subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
16,893
| 122,322
|
21505
|
Discharge summary
|
report
|
Admission Date: [**2192-8-31**] Discharge Date: [**2192-9-2**]
Date of Birth: [**2192-8-29**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: The infant is a full-term 3,430
gram female newborn who was admitted from the Newborn Nursery
after a fall from the mother's bed onto the floor.
The infant was born to a 24-year-old gravida I, para 0 now I
mother. The prenatal screens were A positive, antibody
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune. GBS screening positive
(received greater than four hours of intrapartum
antibiotics). No other perinatal sepsis risk factor
concerns.
Maternal history significant for obesity, diaphragmatic
hernia, and obstructive sleep apnea. Pregnancy unremarkable.
The infant was delivered via vaginal delivery on [**2192-8-29**]. Meconium stained amniotic fluid. Apgar scores were
eight at one minute and nine at five minutes.
The infant had been doing well in the newborn nursery without
any concerning issues. Early in the a.m. of [**2192-8-31**], the mother was breast feeding the infant and fell
asleep. The infant fell off the mother's chest onto the
floor. The infant cried immediately.
PHYSICAL EXAMINATION: On admission, the infant was pink,
active, alert, in no distress. The anterior fontanelle was
open and flat. The cranium was without bumps, bruises or
step-offs. Positive red reflex of both eyes. Equal and
reactive pupils. Palate intact with good suck. The lungs
were equal bilaterally. No murmurs. Regular rate and
rhythm. Femoral pulses equal. The abdomen was soft,
positive bowel sounds. The extremities were pink and well
perfuse. Moving all extremities equally, good tone and
strength. Positive suck. Positive plantar reflex.
Symmetric Moro.
HOSPITAL COURSE:
RESPIRATORY: The patient remained in room air throughout
this hospitalization. Respiratory rates were 40s-60s. The
infant has not had any apnea, bradycardia, or desaturations
this hospitalization.
CARDIOVASCULAR: No murmur, hemodynamically stable this
hospitalization.
FLUIDS, ELECTROLYTES, AND NUTRITION: Birth weight 3,430
grams. Most recent weight 3,490 grams. The infant is
currently breast feeding ad lib and has been breast feeding
ad lib without issues.
GASTROINTESTINAL: No issues.
HEMATOLOGY: No blood transfusions this hospitalization.
NEUROLOGY: On [**2192-8-31**], due to the fall, the infant
received a CAT scan of the head which revealed a posterior
fossa subdural hematoma, interhemispheric blood, and a
parietal subdural hematoma, all of which were small in volume.
Neurosurgery from [**Hospital3 1810**] was consulted and they
recommended a head ultrasound 48 hours from the head CAT scan
and observation in the NICU. Head ultrasound on [**2192-9-2**] was within normal limits, no intraventricular
hemorrhage, no other blood noted. Neurosurgery recommended a
follow-up appointment in four to six weeks. The phone number
is [**Telephone/Fax (1) 56723**]. The infant's neurological examination has
been normal.
SENSORY: Hearing screen was performed with automated
auditory brain stem responses. The infant passed in both
ears.
PSYCHOSOCIAL: The parents are involved.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Phone number: [**Telephone/Fax (1) 56724**].
CARE AND RECOMMENDATIONS: Feedings at discharge: Breast
feeding ad lib. Medications: None. Immunizations: The
infant received hepatitis B vaccine in the Newborn Nursery on
[**2192-8-30**].
DISCHARGE DIAGNOSES:
1. Full-term female.
2. Evaluation for cranial fractures, ruled out.
3. Small right parietal and posterior fossa subdural bleeds
with interhemispheric blood.
FOLLOW UP: The patient is to follow-up with Neurosurgery at
[**Hospital3 1810**] in four to six weeks. Phone number: [**Telephone/Fax (1) 56725**]. Follow-up with pediatrician.
Of note, the last name of the infant after discharge will be
[**Last Name (un) 56726**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2192-9-3**] 04:23:32
T: [**2192-9-3**] 07:26:26
Job#: [**Job Number **]
|
[
"V05.3",
"E884.4",
"V30.00",
"852.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55"
] |
icd9pcs
|
[
[
[]
]
] |
3265, 3427
|
3644, 3804
|
1800, 3217
|
3454, 3463
|
3816, 4315
|
1221, 1783
|
3478, 3623
|
163, 1198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,656
| 111,419
|
40580
|
Discharge summary
|
report
|
Admission Date: [**2118-5-10**] Discharge Date: [**2118-5-15**]
Date of Birth: [**2093-7-22**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
left jaw pain and swelling
Major Surgical or Invasive Procedure:
extra-oral I&D of L submandibular, L lateral pharyngeal space
infection with placement of 1 penrose drain tracing to the L
lateral pharyngeal space
History of Present Illness:
25 yo woman with no signif past medical history who presents
with swelling and pain in her left jaw. She had undergone
extraction of her wisdom teeth on wed, [**5-4**] and has had pain
and swelling since [**5-5**]. She presented to [**Hospital3 6592**] on [**5-7**]
and was subsequently sent to [**Hospital1 336**] for further evaluation. Was
reportedly given steroids, and also had a CT scan which
reportedly showed a fluid collection near left mandible,
possible hematoma. She was observed for a brief period and sent
home with pain medications, tylenol, motrin and percocet. She
has also been taking clindamycin by mouth and chlorhexidine
rinse. However, after mild improvement, she again began to feel
worse. Unable to swallow pain pills. Also noted shortness of
breath and hoarse voice. She then presented to [**Hospital3 **],
received clindamycin and decadron and was transferred to [**Hospital1 18**].
In ED, seen by ENT for airway, who felt it was patent. Also
examined by OMFS who noted trismus on exam and on internal exam:
No significant edema, no purulence, FOM soft/nonelevated,
tender to palpation of posterior FOM/lateral pharyngeal area, no
deviation of uvula, no edema of lateral pharyngeal space,
extraction sockets healing, no evidence of alveolar osteitis,
[**Last Name (un) **]
approximately 20 mm
They recommended IV fluids, antibiotics, NPO for now.
The patient reports significant pain in left jaw and left ear
(pain shoots to ear). Throat also feels sore on the left, right
side feels fine. Denies fevers or chills, but has been taking
tylenol/motrin frequently.
Difficulty opening mouth.
Also notes soreness in upper abdomen, as if she had been doing
abdominal exercises. Also having chest pressure. Has leg
swelling in bilateral lower extremities, also feels like fingers
are swollen.
Otherwise, ROS negative in detail.
Past Medical History:
MVC 8 yr ago, metal plate in right jaw/reconstruction
S/p tonsillectomy
s/p c section
Social History:
Lives with boyfriend and 2 yr old daughter. [**Name (NI) **] [**Name2 (NI) **] contacts.
[**Name (NI) 1403**] as a restaurant manager. Smokes cigarettes on occasion,
infrequent alcohol. Also smokes MJ, no other drug use.
Family History:
no family history of throat problems
Physical Exam:
Admission
T 97 bp 117/84 p 70 r 18 100% ra
Gen pleasant woman in pain but no acute resp distress
HEENT perrl, o/p unable to visualize beyond tongue and anterior
teeth due to trismus, only able to open mouth about 1 inch
Neck + swelling over left mandible, no parotid enlargement, +
scattered [**Doctor First Name **] in submandibular space.
Chest CTA bil
CV RRR, sl bradycardic
Abd soft, mild discomfort throughout.
Ext 1+ edema in bilateral lower extremities, mild swelling in
hands
Skin flushed over anterior chest (later in afternoon developed
more macular rash over back, upper chest, arms
Neuro alert and oriented x 3. moves all extremities well
.
Discharge:
afebrile 106/75 56 18 100RA
Incision L neck, stitches in place. Draining small amt purulent
drainage. No surrounding erythema.
Pertinent Results:
CT neck [**2118-5-10**] ([**Hospital1 18**])
1. Empty mandibular third molar sockets bilaterally, with air in
the right
socket. No evidence of mandibular erosion.
2. 2.3 x 1.3 cm hypodensity extending from the left mandibular
third molar
socket into the medial pterygoid, minimally denser than fluid,
which suggests
a phlegmon, though a developing abscess cannot be excluded.
Please correlate
with clinical examination. These findings were discussed with
Dr. [**Last Name (STitle) 88822**]
(oromaxillofacial resident) at 7:10 am on [**2118-5-10**] in person by
Dr. [**Last Name (STitle) 88823**].
3. Swelling of the left lateral oropharyngeal and laryngeal
walls, with
effacement of the left vallecula and pyriform sinus. Swelling of
the left
submandibular gland. Prominent left level 1b, level 2 and
retropharyngeal
nodes. These findings are likely reactive.
[**2118-5-10**] 03:50AM BLOOD WBC-5.1 RBC-3.39* Hgb-10.5* Hct-30.3*
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.3 Plt Ct-157
[**2118-5-15**] 07:35AM BLOOD WBC-3.8* RBC-3.17* Hgb-9.6* Hct-27.1*
MCV-86 MCH-30.2 MCHC-35.3* RDW-12.5 Plt Ct-182
[**2118-5-14**] 05:15AM BLOOD Glucose-77 UreaN-7 Creat-0.4 Na-138 K-3.6
Cl-104 HCO3-26 AnGap-12
[**2118-5-12**] 03:30AM BLOOD ALT-215* AST-29 AlkPhos-89 TotBili-0.5
[**2118-5-14**] 05:15AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.7
[**2118-5-11**] 04:29PM BLOOD Triglyc-434*
.
U/A negative
.
[**2118-5-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2118-5-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2118-5-11**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2118-5-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2118-5-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
[**2118-5-11**] 11:17 am SWAB Site: PHARYNX
LEFT LATERAL PHARYNGEAL ABSCESS.
GRAM STAIN (Final [**2118-5-11**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2118-5-13**]):
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):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
Brief Hospital Course:
25 yo woman with recent tooth extraction bilaterally, now with
swelling over left mandible as well as hypodensity near third
molar, edema of laryngeal and pharyngeal walls on CT scan. Pt
was evaluated by Oral Surgery, and pt went to OR on [**2118-5-11**] for
extra-oral I&D of L submandibular, L lateral pharyngeal space
infection with placement of 1 penrose drain tracing to the L
lateral pharyngeal space. Pt was left intubated overnight while
allowing the swelling to improve. The pt was extubated without
complications on [**2118-5-12**]. Due to fevers on [**5-12**] antibiotics were
changed from clinda to vanco/flagyl/levoflox. She clinically
continued to improve with decreasing pain and swelling, and she
gradually began to improve her ability to speak and eat. ID was
consulted for antibiotic recommendations considering her
surgical hardware from her remote reconstructive surgery s/p
MVA. Pt was discharged on Levofloxacin (or moxifloxacin if
preferable to insurance) and flagyl for 7-14 days, with the
total duration of therapy to be determined at outpt OMFS follow
up. ID had raised question of a possible venous blood clot in
area of the inflammation/infection. Discussed area of concern
with Radiology, who stated that appearance likely flow
limitation due to lack of venous phase contrast, however could
not conclusively rule out a clot in the area. The vein in
question is superficial, and was unable to palpate a cord on
exam. Discussed with OMFS, who will consider further at outpt
follow up, with consideration of venous duplex US.
Discharged to home.
Discharge Medications:
1. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days: Take either Levofloxacin OR Moxifloxacin,
NOT both. (according to insurance coverage).
Disp:*10 Tablet(s)* Refills:*0*
2. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days: Take either Levofloxacin OR Moxifloxacin, NOT both.
(according to insurance coverage).
Disp:*10 Tablet(s)* Refills:*0*
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
5. ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
# L submandibular, L lateral pharyngeal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with an infection in your neck for which you
had surgical drainage. You were treated with antibiotics and
your infection and swelling have been improving. Please
continue your course of antibiotics as prescribed. The total
duration of antibiotics will be determined in outpatient follow
up with Oral Surgery.
Followup Instructions:
Next Wednesday ([**5-18**]) with OMFS with Dr. [**Last Name (STitle) **] at
[**Hospital6 **] at [**Hospital 88824**] Clinic in the
basement
of Moakley building on [**Last Name (NamePattern1) **]., [**Location (un) 86**], [**Numeric Identifier 25248**]
(clinic phone # [**Numeric Identifier 88825**]). Appointment time is will be given
on
Monday [**5-16**] via phone.
Please obtain a PCP. [**Name10 (NameIs) **] you would like to receive primary care
at [**Hospital1 18**], please call [**Telephone/Fax (1) 250**].
|
[
"781.0",
"998.59",
"782.1",
"682.0",
"478.29",
"784.2",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"27.0"
] |
icd9pcs
|
[
[
[]
]
] |
8540, 8546
|
6210, 7792
|
299, 449
|
8638, 8638
|
3557, 6051
|
9142, 9660
|
2689, 2727
|
7815, 8517
|
8567, 8617
|
8789, 9119
|
2742, 3538
|
233, 261
|
477, 2326
|
6090, 6187
|
8653, 8765
|
2348, 2435
|
2451, 2673
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,597
| 130,164
|
36049
|
Discharge summary
|
report
|
Admission Date: [**2129-1-10**] Discharge Date: [**2129-2-4**]
Date of Birth: [**2049-2-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2129-1-10**] Coronary Artery Bypass Graft x 2 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
obtuse marginal), Aortic Valve Replacement (21mm CE magna
tissue)
[**2129-1-20**] Left Side Thoracentesis
[**2129-1-25**] Placement of Left Chest Tube
[**2129-1-28**] Flexible Bronchoscopy
History of Present Illness:
Mrs. [**Known lastname 2643**] is a 79 year old female with known aortic stenosis
and coronary artery disease. Prior to surgical intervention, she
complained of dyspnea on exertion and one pillow orthopnea.
Surgery was previously delayed for retinal bleed and
conjunctivitis which has now improved with medical clearance
from her local opthamologist.
Past Medical History:
Coronary Artery Disease
Aortic Stenosis/Aortic Insufficiency
Congestive Heart Failure - chronic, diastolic
History of Myocardial infarction
Hypertension
Hypercholesterolemia
Peripheral vascular disease
Right Renal Artery Stenosis
Cerebrovascular disease, History of TIA, Carotid Disease
Chronic obstructive pulmonary disease
Non insulin dependent diabetes mellitus
Chronic renal insufficiency
Hypothyroidism s/p thyroidectomy
Gout
Osteoporosis
Macular degeneration
s/p bilateral cataract surgery
s/p appendectomy
s/p tonsillectomy
s/p hysterectomy
Social History:
Retired.
Quit smoking 3 yrs ago with a 60+ pack /year/history.
Social ETOH use.
Family History:
Sister died from CVA. Brother s/p AVR.
Physical Exam:
Admission:
VS: 66 177/72, 64", 140#
Gen: No acute distress
Skin: Unremarkable w/ well-healed thyroid scar
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear lungs bilat.
Heart: Regular rate and rhythm, 4/6 systolic murmur
Abd: Soft, non-tender, non-distended +bowel scars, healed scar
Ext: Warm, ewll-perfused, -edema
Neuro: Grossly intact
Pertinent Results:
[**1-10**] Echo: Pre Bypass: 1. The left atrium is moderately dilated
with Mild spontaneous echo contrast is present in the left
atrial appendage. 2. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. 3.
There is mild regional left ventricular systolic dysfunction
with mild to moderate anteroapical hypokinesis. 4. 4. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
5. There are simple atheroma in the aortic root with focal
calcification of the sinus of valsalva. There are simple
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. 6. There is severe aortic valve stenosis
(area <0.8cm2). 7. The aortic regurgitation vena contracta is
>0.6cm. Severe (4+) aortic regurgitation is seen. 8. The mitral
valve leaflets are moderately thickened. There is severe mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
Post Bypass: 1. Patient is being AV paced and on an infusion of
phenylephrine and epinephrine. 2. Anterior wall, septum,
anterior septum are hypokinetic. LVEF 35% 3. RV function is
normal. 4. Bioprosthetic valve seen in the aortic position.
Valve appears well seated and the leaflets move well. Trace
central aortic insufficiency seen. 5. Unable to obtain
transgastric views to check for gradient across the aortic
valve.
[**1-11**] Head CT: 1. Hypodensity involving the right middle frontal
gyrus, which may represent infarct, age indeterminant, or
chronic microangiopathic small vessel ischemic changes. MRI with
diffusion-weighted imaging is more sensitive and is recommended
to further assess. 2. Left parietotemporal subgaleal fluid
collection. MRI with and without contrast or CT with contrast is
recommended to further assess for rim enhancement which may be
seen in abcess. Alternatively, this may represent a simple
subgaleal fluid collection. 3. Air fluid levels in the
bilateral, left greater than right, maxillary sinuses may
represent acute sinusitis. 4. Moderate microangiopathic small
vessel ischemic changes. Mild diffuse parenchymal volume loss.
[**1-21**] Echo: Suboptimal image quality. Moderate echo filled
pericardial effusion most c/w pericardial hematoma. Mild
symmetric left ventricular left ventricular hypertrophy with
good global biventricular systolic function. Normal functioning
aortic bioprosthesis. Mild pulmonary artery systolic
hypertension.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81804**] F 79 [**2049-2-18**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2129-2-4**] 8:42
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2129-2-4**] 8:42 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 81805**]
Reason: eval for pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
79 year old woman s/p CABG/AVR
REASON FOR THIS EXAMINATION:
eval for pneumothorax
Provisional Findings Impression: JRld [**Name2 (NI) **] [**2129-2-4**] 11:03 AM
Improved, almost complete resolution of fluid overload.
Persistent left lower
lobe opacity is likely due to a combination of pleural effusion
and
atelectasis.
Preliminary Report !! PFI !!
Improved, almost complete resolution of fluid overload.
Persistent left lower
lobe opacity is likely due to a combination of pleural effusion
and
atelectasis.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
PFI entered: [**Last Name (NamePattern4) **] [**2129-2-4**] 11:03 AM
Imaging Lab
[**2129-2-4**] 07:00AM BLOOD WBC-9.0 RBC-3.27* Hgb-10.0* Hct-30.9*
MCV-95 MCH-30.6 MCHC-32.4 RDW-17.0* Plt Ct-432
[**2129-1-10**] 06:55PM BLOOD WBC-10.2 RBC-3.29* Hgb-10.8* Hct-30.0*
MCV-91# MCH-32.9* MCHC-36.1* RDW-18.7* Plt Ct-231
[**2129-2-4**] 07:00AM BLOOD PT-16.3* INR(PT)-1.5*
[**2129-1-10**] 05:32PM BLOOD PT-16.3* PTT-48.6* INR(PT)-1.5*
[**2129-2-4**] 07:00AM BLOOD Glucose-116* UreaN-49* Creat-1.4* Na-138
K-4.5 Cl-98 HCO3-30 AnGap-15
[**2129-1-11**] 02:07AM BLOOD Glucose-83 UreaN-22* Creat-0.9 Na-141
K-4.1 Cl-118* HCO3-20* AnGap-7*
Brief Hospital Course:
[**2129-1-10**] Mrs.[**Known lastname 2643**] underwent Coronary artery bypass graftingx
2(left internal mammary artery grafted to the left anterior
descending artery, Saphenous vein grafted to the Obtuse
Marginal)/Aortic Valve Replacement (#21mm CE Magna Tissue
valve). Cross clamp time:108 minutes/CardioPulmonary Bypass
time:134 minutes. Please refer to Dr.[**Name (NI) 9379**] operative report
for further details.She tolerated the procedure well and was
transferred to the CVICU stable but in critical condition
requiring Epinephrine and Propofol drips. Postoperative course
will now be broken down by systems:
NEURO: Mrs.[**Known lastname 2643**] experienced seizure like activity on
postoperative day one. Head CT scan showed hypodensity involving
the right middle frontal gyrus, which may represent infarct, age
indeterminant, or chronic microangiopathic small vessel ischemic
changes and moderate microangiopathic small vessel ischemic
changes,with mild diffuse parenchymal volume loss-per radiology.
Initially post seizure, Mrs.[**Known lastname 2643**] showed upper left extremity
weakness which fully resolved during her hospital admission by
day 7. [**1-11**] Neurology was consulted and recommended maintaining
systolic blood pressures around 140 mmHg. Warfarin and Aspirin
were continued. No further seizure activity was noted for the
remainder of her hospital stay and remains neurologically intact
without gross sensory/motor deficits.
CARDIAC: Developed atrial fibrillation following extubation on
postoperative day three. Despite treatment with Amiodarone, beta
blockade and calcium channel blockers, atrial fibrillation
persisted. She was started on Warfarin for Anticoagulation. Her
arrythmia revealed [**12-17**] second asymptomatic pauses for which
Amiodarone and calcium channel blockers were discontinued. The
EP service was consulted and did not recommend cardioversion
given pulmonary status and less than one month of adequate
anticoagulation. EP continued to titrate nodal agents.
Amiodarone was eventually resumed along with low dose beta
blockade. Warfarin was titrated for a goal INR between 2.0 -
2.5.
PULMONARY: Extubated on postoperative day three due to prior
inabilty to maintain airway due to possible neurologic event.
She continued to experience signficant peristent hypoxemia
secondary to fluid overload and bilateral pleural effusions. She
was aggressively diuresed. Aggressive pulmonary toilet was
performed along with frequent nebulizer therapies. Once her INR
allowed, left sided thoracentesis was performed on postoperative
day ten in which 600 cc of fluid was removed without
complication. Following thoracentesis, CPAP/BiPAP trials were
initiated. A left sided chest tube was eventually placed for a
recurrent left sided pleural effusion on postopeative day 15.
Diagnostic and therapeutic bronchoscopy was performed on
postoperative day 18. This revealed moderate to severe
tracheobronchial malacia with significant mucous secretions.
Bronchoalveolar lavage of her left lower lobe grew out MRSA for
which Vancomycin (Dr.[**Doctor Last Name 81806**] recommended 10 day course) was
initiated. Subsequently her need for supplemental oxygen
decreased and she was requiring nasal cannula at 2liters at time
of discharge.
RENAL: Postoperative acute renal insuffciency. Creatinine peaked
to 2.1 on postoperative day 18. Medications were titrated
accordingly and by discharge, creatinine had improved to 1.4.
ID: Started on Cipro for postoperative urinary tract infection.
Culture grew out Citrobacter and Enterococcus. She remained
afebrile . On [**1-29**] she was started on Vancomycin for MRSA
aspirated during bronchoscopy alveolar lavage(see above):10 day
course recommended by ID.
WOUND: Wet to dry dressings were applied to leg incision
secondary to erthymatous site that was unroofed for possible
drainage. Sternal wound inferior pole appears erythematous on
POD# 22. Vancomycin on board until [**2-8**].
HEMATOLOGY: Postoperative anemia, intermittently transfused with
PRBC to maintain hematocrit near 30%. Anticoagulation with
Coumadin for INR goal 2-2.5 secondary to Afib.
On POD#24 Mrs.[**Known lastname 2643**] continued to progress and was ready for
discharge to rehab for further increase in endurance and
strength. All follow up appointments were advised, specifically
wound check in 1 week.
Medications on Admission:
Fosamax 70mg qSat
Allopurinol 100mg [**Hospital1 **]
Amlodipine 10mg qd
Atorvastatin 40mg qd
Carvedilol 40mg qd
Lasix 80mg qAM and 40mg qPM
Synthroid 100mcg qd
Aspirin 81mg qd
Multivitamin and calcium, Tylenol
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Warfarin 1 mg Tablet Sig: [**Name8 (MD) **] MD Tablet PO DAILY (Daily) as
needed for Afib .
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
12. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed.
16. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
19. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
20. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML
Injection Q8H (every 8 hours) as needed for line flush.
21. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day: x 4 days, dc after dose administered [**2-8**]**check
trough level [**2-6**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease/Aortic Stenosis - s/p AVR/CABG
Nosocomial Pneumonia - MRSA positive
Postoperative Respiratory Failure
Postoperative Pleural Effusions
Postoperative Atrial Fibrillation - persistent
Postoperative Seizure
Postoperative Anemia
Postoperative Urinary Tract Infection
Chronic Diastolic Heart Failure
Chronic obstructive pulmonary disease
Hypertension
Hypercholesterolemia
Cerebrovascular disease/Peripheral vascular disease
Non insulin dependent diabetes mellitus
Chronic renal insufficiency
Discharge Condition:
Stable
Discharge Instructions:
no lotions , creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage or weight
gain greater than 2 pounds in 2 days
no driving for one month
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] in [**1-18**] weeks
Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 81807**] in [**12-17**] weeks ([**Telephone/Fax (1) 14967**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
please call for appointments
Completed by:[**2129-2-4**]
|
[
"427.31",
"362.52",
"440.0",
"285.9",
"250.00",
"428.0",
"599.0",
"733.00",
"403.90",
"518.0",
"585.9",
"412",
"482.42",
"428.32",
"511.9",
"274.9",
"414.01",
"272.4",
"244.9",
"E878.2",
"997.1",
"V12.54",
"424.0",
"518.5",
"748.3",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"39.61",
"36.11",
"35.21",
"34.91",
"34.04",
"36.15",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13235, 13307
|
6590, 10949
|
339, 662
|
13862, 13871
|
2158, 3692
|
14173, 14576
|
1726, 1766
|
11209, 13212
|
5209, 5240
|
13328, 13841
|
10975, 11186
|
13895, 14150
|
1781, 2139
|
280, 301
|
5272, 6567
|
690, 1042
|
3701, 5169
|
1064, 1613
|
1629, 1710
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,653
| 181,284
|
35474
|
Discharge summary
|
report
|
Admission Date: [**2125-2-19**] Discharge Date: [**2125-2-28**]
Date of Birth: [**2049-12-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Nitroglycerin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional angina
Major Surgical or Invasive Procedure:
[**2125-2-19**] left heart Catheterization, coronary angiography
[**2125-2-19**] Emergent Coronary Artery Bypass Grafting Surgery X 3
(left internal mammary artery to left anterior descending
artery, with vein grafts to PDA and ramus)
History of Present Illness:
Mrs. [**Known lastname **] is a 75 year old female with known coronary disease
and multiple cardiac risk factors. Over the last year, she had
noticed intermittent exertional chest discomfort. Despite
medical therapy, her angina persisted. She underwent cardiac
cathterization in [**2125-1-21**] at [**Hospital3 417**] which revealed
a mid 50% and distal 80% lesion in the right coronary while the
LAD and circumflex had only mild disease. She was therefore
admitted for angioplasty/stenting of the right coronary artery.
During attempts at this, there was acute dissection of the right
coronary artery and emergent revascularization was undertaken.
Past Medical History:
Coronary Artery Disease
Prior MI with History of PTCA in [**2107**]
Hypertension, Dyslipidemia
Type II Diabetes Mellitus
Obesity, Vertigo
s/p thyroidectomy
s/p hysterectomy
s/p hernia repair
s/p appendectomy
s/p breast lump removal
s/p cataract surgery with right eye lens implant
Social History:
Married, lives with husband. Quit tobacco in [**2107**].
Family History:
No family history of premature coronary disease.
Physical Exam:
Admit Vitals: BP 168/59, HR 79, RR 16, SAT 95% RA
General: Elderly female in no acute distress
Neck: supple, no JVD
Lungs: clear bilaterally
Heart: regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen: obese, soft, nontender, nondistended with normoactive
bowel sounds
Ext: warm, trace edema
Neuro: alert and oriented, no focal deficits noted
Pulses: 1+ distally
Pertinent Results:
[**2125-2-19**] 12:00PM BLOOD WBC-8.9 RBC-3.79* Hgb-10.9* Hct-32.8*
MCV-87 MCH-28.6 MCHC-33.1 RDW-13.5 Plt Ct-280
[**2125-2-19**] 12:00PM BLOOD Glucose-176* UreaN-11 Creat-0.7 Na-135
K-4.0 Cl-100 HCO3-26 AnGap-13
[**2125-2-19**] 12:00PM BLOOD ALT-10 AST-15 CK(CPK)-39 AlkPhos-87
Amylase-83 TotBili-0.5
[**2125-2-19**] 02:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2125-2-19**] 12:00PM BLOOD Albumin-3.4
[**2125-2-19**] Cardiac Cath:
1. Limited angiogaphy of this right dominant system
demonstrated multivessel coronary artery disease. The right
coronary artery was diffusely diseased and heavily calcified
with a tight 90% lesion just proximal to the PDA bifurcation.
The left system was not engaged but prior films demonstrated
disease in the proximal LAD and LCX. 2. Attempted PTCA and
stenting of the mid RCA complicated by proximal/ostial vessel
dissection. Rescue PTCA and stenting of the proximal/ostial to
mid RCA with three (3) overlapping Xience drug eluting stents
with incomplete expansion of the distal stent despite multiple
inflations with multiple non-compliant balloons.
[**2125-2-19**] Intraop TEE:
PRE-BYPASS: The interatrial septum is aneurysmal. No atrial
septal defect is seen by 2D or color Doppler. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. No thoracic aortic dissection is seen. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. No aortic regurgitation is seen. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
An epiaortic scan was performed that showed simple atheroma in
the ascending aorta with no extension of the hematoma seen in
the cath lab. POST-CPB: On infusion of dopamine, phenylephrine.
AV pacing. Preserved biventricular systolic function on
inotropic support. Trace MR. Aortic contour is normal post
decannulation.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted for planned percutaneous intervention
of the right coronary artery. The procedure was complicated by
proximal/ostial vessel dissection of the right coronary artery.
She left the cath lab pain free with no significant ST
elevation. She was emergently brought to the operating room for
emergency coronary artery bypass grafting surgery. Please see
operative note for details. Following the operation, she was
brought to the CVICU for invasive monitoring. Early postop, she
remained hypoxic which did not allow for extubation. She
concomitantly experienced fevers and was empirically started on
broad spectrum antibiotics for a presumed pneumonia.
Bronchoalveolar lavage and sputum cultures grew out Haemophilus
influenzae. Antibiotics were titrated accordingly. Blood and
urine cultures remained negative. Patient remained in the ICU
d/t issues of ongoing hypoxia. She was transferred from the ICU
to the floor on [**2-26**] when her oxygen requirement decreased and
her oxygen saturation remained above 90% consistantly. By
post-operative day nine she was ready for discharge to rehab for
IV antibiotics and pulmonary therapy.
Medications on Admission:
Imdur 60 qd, Levothyroxine 125 mcg qd, Starlix 120 tid,
Metformin 1000 [**Hospital1 **], Diovan 160 [**Hospital1 **], Amlodipine 10 qd, Plavix 75
qd, Toprol XL 25 qd, Aspirin 81 qd, HCTZ 12.5 qd, Crestor 20 qd
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation four times a day.
Disp:*1 mdi* Refills:*2*
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
9. oxygen
2 liters continuous via Nasal cannula. Conserving device for
portability.
10. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: [**12-22**]
Inhalation three times a day as needed for shortness of breath
or wheezing.
Disp:*qs * Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Ampicillin-Sulbactam 1.5 gram Recon Soln Sig: One (1) Recon
Soln Injection Q6H (every 6 hours) for 8 days: complete course
on [**2125-3-8**] for H.influenza in sputum culture 3/9/9.
Disp:*32 Recon Soln(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease
RCA Dissection
s/p Emergent Coronary Artery Bypass Grafting Surgery
Postoperative Pneumonia
Hypertension, Dyslipidemia
Type II Diabetes Mellitus
Obesity
Discharge Condition:
good
Discharge Instructions:
Shower daily, no baths. No lotions, creams or powders to
incisions.
No driving for 4 weeks and off all narcotics.
No lifting more than 10 pounds for 10 weeks.
Report any redness of, or drainage from incisions.
Report any fever greater than 100.5
Report any weight gain greater than 2 pounds a day or 5 pounds a
week
Take all medications as directed
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24522**] (PCP)in [**12-22**] weeks ([**Telephone/Fax (1) 50242**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in [**1-23**] weeks ([**Telephone/Fax (1) 8725**])
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (pulmonology) in 4 weeks ([**Telephone/Fax (1) 7769**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
please call for appointments
Completed by:[**2125-2-28**]
|
[
"414.01",
"998.2",
"250.00",
"413.9",
"440.0",
"518.5",
"486",
"401.9",
"997.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"96.6",
"37.22",
"36.07",
"00.47",
"36.15",
"00.40",
"88.56",
"38.93",
"39.61",
"33.24",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
7028, 7100
|
4212, 5381
|
312, 549
|
7321, 7328
|
2081, 4189
|
7725, 8375
|
1623, 1673
|
5641, 7005
|
7121, 7300
|
5407, 5618
|
7352, 7702
|
1688, 2062
|
255, 274
|
577, 1228
|
1250, 1533
|
1549, 1607
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,833
| 135,556
|
11103
|
Discharge summary
|
report
|
Admission Date: [**2191-9-2**] Discharge Date: [**2191-9-8**]
Date of Birth: [**2125-8-6**] Sex: M
Service:
ID/CHIEF COMPLAINT: This is a 66 year old man who has a
history of tobacco use and chronic obstructive pulmonary
disease and hyperlipidemia, who presented to the [**Hospital1 346**] CCU after an elective cardiac
catheterization for increasing shortness of breath over the
past four and one half years.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease, recently diagnosed
with his history of shortness of breath on exertion, however,
no documented pulmonary function tests.
2. Hyperlipidemia.
3. Recent diagnosis of sleep apnea.
ADMISSION MEDICATIONS:
1. Accupril.
2. Lasix.
3. Metoprolol.
4. Combivent.
5. Flovent.
6. Aspirin.
7. Vitamin E.
ALLERGIES: No known drug allergies.
HISTORY OF PRESENT ILLNESS: This patient presented to Dr.[**Name (NI) 35819**] office on [**2191-7-29**], with a history of shortness of
breath on exertion over the past 4.5 years. The patient
stated that the shortness of breath had worsened over the
past three to four months. Prior to five years ago, the
patient was capable of walking approximately six miles per
day.
The patient subsequently underwent a stress echocardiogram
for evaluation of this shortness of breath. Apparently there
was evidence of mitral regurgitation but no ischemia on the
study. Two years ago, the patient underwent repeat exercise
stress test which was apparently "OK" according to the
patient.
On [**2191-8-24**], the patient presented to [**Hospital 21242**] [**Hospital 107**]
Hospital with dyspnea on exertion. He stated that walking
from the parking lot to the Emergency Department he needed to
stop after walking twenty feet. The patient was diagnosed
with congestive heart failure and underwent an echocardiogram
on [**2191-8-24**], which apparently showed mildly decreased left
ventricular function with an ejection fraction of 50%. There
was also concentric left ventricular hypertrophy. The
patient was started on Accupril and Lasix and was referred
for cardiac catheterization today as an outpatient.
On cardiac catheterization, the patient had normal coronary
angiography. On left ventriculography, the patient had
severe global hypokinesis with an ejection fraction of 10%
and mild mitral regurgitation. His hemodynamics at that time
included a cardiac index of 1.4, pulmonary artery wedge
pressure of 40 and left ventricular end diastolic pressure of
30. His pulmonary artery pressure was noted to be 44/24.
The patient was treated with Dobutamine and intravenous
Nitroglycerin and given 40 mg of intravenous Lasix. His
mixed venous oxygen saturation improved from 49 to 75 without
intervention. The patient was subsequently transferred to
the CCU for further management.
During the preceding months, the patient denied any unusual
symptoms. He denied any history of rashes, arthralgias,
cough, upper respiratory infection, fevers.
SOCIAL HISTORY: The patient has a history of tobacco use and
quit sixteen years ago. He uses alcohol rarely and does not
use illicit drugs. He is a happily married man.
PHYSICAL EXAMINATION: On examination in the CCU, the patient
was afebrile with a heart rate of 109, respiratory rate 19,
blood pressure 96/55 with oxygen saturation of 97% on three
liters nasal cannula. On examination, the patient was awake,
alert and comfortable in no apparent distress. His sclera
were anicteric. On cardiovascular examination, he was noted
to have jugular venous distention with normal S1 and S2,
regular rhythm and no S3 or S4. He had no murmurs, rubs or
gallops. He had 2+ bilateral dorsalis pedis pulses. He had
mild 1+ pitting edema in his ankles. His abdominal
examination was benign and his right groin arterial sheath
was intact and not bleeding.
LABORATORY DATA: The patient's white blood count was 10.1
with a hematocrit of 44.5 and platelets of 282,000. Chem7
revealed sodium 137, potassium 4.4, chloride 101, bicarbonate
27, blood urea nitrogen 23, creatinine 1.4, glucose 65. He
had CK and troponin from [**Hospital 21242**] Hospital which were negative.
His prothrombin time and partial thromboplastin time were
within normal limits and his arterial blood gas was 7.40, 42,
86 in room air.
Electrocardiogram showed the patient to be in sinus rhythm at
110 beats per minute with left axis deviation, occasional
premature ventricular contractions and low limb voltages.
His lateral T waves were flat and he did not have any Q
waves.
His postcatheterization film was unchanged from his
precatheterization film.
HOSPITAL COURSE: The patient, on [**2191-9-3**], was noted to have
an 18 beat run of nonsustained ventricular tachycardia
without any symptoms. He was maintained on his Dobutamine
and Nitroglycerin drip and Captopril 3.125 mg t.i.d. was
titrated. The patient subsequently had a troponin done at the
[**Hospital1 69**] which was less than 0.3
The patient also had a PPD done which was negative. His
chest x-ray was unremarkable with no evidence of pulmonary
edema.
The patient was aggressively diuresed with Lasix and his
Dobutamine drip and Nitroglycerin drip were weaned off
on [**2191-9-4**]. He also begun on anticoagulation due to his low
ejection fraction. On [**2191-9-4**], the patient was started on
Aldactone and his Captopril was titrated upward. He was
subsequently transferred to the floor after his groin
Swan-Ganz catheter was discontinued.
The patient also had a workup for hemochromatosis which was
negative and a serum protein electrophoresis was normal. His
ESR was noted to be 25 and [**Doctor First Name **] was negative. His TSH was
within normal limits.
On [**2191-9-6**], the patient was noted to have a run of
accelerated idioventricular rhythm which was again
asymptomatic. Due to his recurrent arrhythmias, the
electrophysiology service was consulted. They recommended
starting the patient on Amiodarone and with discharge
follow-up using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor.
The patient continued to be diuresed with Lasix and Aldactone
and underwent an echocardiogram on [**2191-9-7**]. On that study,
the patient was noted to have an ejection fraction of 20%
with left atrial enlargement and lipomatous hypertrophy of
his interatrial septum. He had normal left ventricular
thickness and cavity size. There were no thrombi
demonstrated in his left ventricle. His left ventricular and
right ventricular systolic function were both depressed.
There was a degree of mitral regurgitation present but it was
unable to be quantified. He had 1+ to 2+ tricuspid
regurgitation and a small pericardial effusion. There was
also a note of mild to moderate pulmonary hypertension.
During his hospital stay, the patient also was evaluated and
treated by the physiotherapist. He was also begun on
Coumadin for outpatient anticoagulation. On [**2191-9-8**], the
patient's dyspnea and his congestive heart failure had
improved to the point that the patient was stable and ready
for discharge.
The patient was discharged home on [**2191-9-8**], with
instructions to follow-up with his primary care physician
early in the next week for checking of his INR. He was also
instructed to follow-up with Dr. [**Last Name (STitle) 120**] in two weeks with
regards to his congestive heart failure. The patient's wife
was able to pick up [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor and was
instructed on its use.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o. q.d.
2. Lisinopril 20 mg p.o. q.d.
3. Aldactone 50 mg p.o. q.d.
4. Digoxin 0.25 mg p.o. q.d.
5. Lasix 40 mg p.o. q.d.
6. Carvedilol 3.125 mg p.o. b.i.d.
7. Coumadin 2 mg p.o. q.d.
8. Vitamin E 400 units p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Combivent two puffs t.i.d.
11. Flovent four puffs b.i.d.
At the time of discharge, the patient still had some
outstanding tests pending for his workup of his
cardiomyopathy including [**Location (un) **] B viruses and
Enteroviruses.
[**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**]
Dictated By:[**Name8 (MD) 26201**]
MEDQUIST36
D: [**2191-9-8**] 16:41
T: [**2191-9-11**] 09:56
JOB#: [**Job Number 35820**]
|
[
"458.0",
"496",
"593.9",
"416.0",
"427.1",
"428.0",
"425.4",
"424.0",
"110.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
7550, 8302
|
4624, 7527
|
695, 831
|
3173, 4606
|
145, 428
|
860, 2977
|
450, 672
|
2994, 3150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,287
| 147,245
|
34584
|
Discharge summary
|
report
|
Admission Date: [**2189-9-23**] Discharge Date: [**2189-9-28**]
Date of Birth: [**2151-10-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Video-assisted thoracic surgery left lower lobe
wedge resection (req general anesthesia, intubation)
History of Present Illness:
Patient is 37 yo male with a history of asthma who presents
shortness of breath. Patient states that his dyspnea began in
[**2187-12-21**]. He had an URI at this time with night sweats,
for which he saw his PCP. [**Name10 (NameIs) **] [**2188-12-20**], the patient
developed another URI. He was still able to play tennis and
maintained his normal activities until [**2189-3-21**].
.
At this time, he noticed dyspnea while golfing with friends.
[**Name (NI) **] then noticed that he had SOB when walking up stairs and
would often "pass out" on the top flight. Patient visited his
PCP who gave him a prescription for Pulmicort. Despite this
intervention, he still remained dyspneic on exertion and
returned to his PCP one week later, at which time he desated to
80% on exertion. Patient was referred to pulmonary and was
bronched on [**9-11**]. BAL was negative for malignant cells but
showed pulm macrophages, lymphocytes, and squamous cells.
.
Patient states that he dyspnea has become progressively worse
over the past two weeks. He is no longer able to walk to his
car without becoming short of breath. He has been having fevers
and chills for the past two weeks, and he has lost 30 lbs over
the past three months. He states that he has had night sweats
since his first URI in [**2187**], and he has had a cough productive
of yellow sputum for the past 3 months.
.
Review of systems is notable for frequent headaches, diarrhea
daily, and a rash on his upper arms bilaterally for the last
three months. Patient denies leg swelling, bruising,
constipation, dysphagia, increased urinary frequency. He
endorses palpitations.
.
In the emergency department, patient's VS were T 98.6, P 114, BP
126/77, R 18, O2 90% on RA. He was placed on 3L of O2. He was
started on Vanc and Levo and then transferred to the [**Hospital1 **] (CC7)
for further workup and evaluation.
Past Medical History:
-mild intermittent asthma since childhood, previously only on
albuterol; one hospitalization as a child
-Allergies to dust, cats, grass
Social History:
Patient lives with his wife in [**Name (NI) 1110**], MA. He does not smoke or
drink alcohol. He occasionally smoke marijuana. Patient has an
18 mo daughter and has another one on the way. He sells office
furniture to the government. Patient denies any recent travel
(he works in [**Location (un) 86**] and [**Location (un) 7349**] and only vistited the SW eighteen
years ago), occupational exposures, pet exposures. He states
that he went to the petting zoo with his daughter 6 months ago.
He recently went to [**Hospital3 **].
Patient lives with his wife in [**Name (NI) 1110**], MA. He does not smoke or
drink alcohol. He occasionally smoked marijuana. Patient has an
18 mo daughter and has another one on the way. He sells office
furniture to the government. Patient denies any recent travel
(he works in [**Location (un) 86**] and [**Location (un) 7349**] and only vistited the SW eighteen
years ago), occupational exposures, pet exposures. He states
that he went to the petting zoo with his daughter 6 months ago.
He recently went to [**Hospital3 **].
Family History:
[**Name (NI) **] father and sisters are alive and well. [**Name (NI) **]
mother recently died from lung cancer
Physical Exam:
VS: T=98.4, BP 134/90, HR 94, R 22, O2 97% on 4L
GEN: Pleasant, young man, in NAD
HEENT: PERRL, EOMI, No conjunctival pallor. No scleral icterus.
OP clear.
NECK: Supple, no LAD, no thyromegaly
CARDIAC: Tachycardic. RRR. Normal S1, S2. No murmurs, rubs or
[**Last Name (un) 549**].
LUNGS: Diffuse rhonchi bilaterally. L>R. Poor air movement
bilaterally.
ABD: Soft, NT, ND. No HSM
EXT: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial
pulses.
SKIN: Macular rash on medial aspect of upper extremities
bilaterally.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-21**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
Pertinent Results:
[**9-23**] CT
Rapid progression of diffuse consolidation, most prominent in
LLL, RLL and lingula. This suggests acute infection superimposed
on a chronic process (hilar lymph nodes suggests sarcoid).
Alternatively, a continuing occupational exposure could be
considered.
[**9-23**] CXR
There is interval increase in the bilateral linear and nodular
opacities throughout both lungs. There is no pleural effusion or
pneumothorax. The cardiomediastinal silhouette is unchanged.
1. No pneumothorax.
2. Significant interval increase in the diffuse reticular
nodular
opacities seen throughout both lungs.
[**9-11**] CXR
There is no pneumothorax. Linear and nodular opacities with the
lower lobe predominance have improved in extent, compared to the
prior radiograph. No large pleural effusion is present.
Pulmonary
vascularity is not increased.
[**2189-9-23**] 01:37PM ANCA-NEGATIVE B
[**2189-9-23**] 01:15PM SED RATE-81*
[**2189-9-23**] 01:15PM GLUCOSE-84 UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2189-9-23**] 01:15PM CK(CPK)-31*
[**2189-9-23**] 01:15PM cTropnT-<0.01
[**2189-9-23**] 01:15PM WBC-9.3 RBC-4.73 HGB-14.3 HCT-41.0 MCV-87
MCH-30.2 MCHC-34.8 RDW-12.1
[**2189-9-23**] 01:15PM NEUTS-81.8* LYMPHS-12.9* MONOS-4.0 EOS-1.1
BASOS-0.2
[**2189-9-23**] 01:15PM PLT COUNT-393
[**2189-9-23**] 01:15PM PT-14.6* PTT-25.8 INR(PT)-1.3*
Brief Hospital Course:
Patient is a 37 yo man with a history of asthma who presented
with progressive hypoxia. Ddx included idiopathic lung disease,
pneumonia, PE. Pulmonary embolism seemed unlikely given that
the patient is on DVT prophylaxis and had been having these
progressive CT changes.
HYPOXIA
He underwent diagnostic VATS on [**2189-9-25**] which he tolerated well
with minimal EBL. Chest tube was removed on the morning of
[**2189-9-26**]. Intial pathology read was consistant with Hamman-[**Doctor First Name **]
syndrome. He was started solumedrol 250 mg q6 on [**9-24**].
On the floor he required 3-6L NC to keep his sats >93%. On the
morning of MICU transfer ([**9-27**]) he was rolling to his side to use
a bedside urinal and had increased hypoxia with O2sats ~85%. He
was placed on a NRB with improvement in his sats and subjective
feeling of dyspnea. A repeat CXR was done. He received an
empiric dose of lasix (20 mg IV x1) with adequate urine output.
He had transient improvement in oxygenation and was transferred
to the MICU on NRB.
In the MICU his oxygen saturation was supported 50-80 % facemask
with waxing and [**Doctor Last Name 688**] requirement. Pressure support
ventilation was not required.
Combivent nebs given Q6 PRN.
POSSIBLE INFECTION
Given then patient's tenuous residual lung function and acute
decompensation, he was also started on emperic pneumonia
treatment with Vanc/Levo on [**9-23**]. Cultures were negative for
AFB, PCP, [**Name10 (NameIs) 14616**], bacteria. His vanc was discontinued on
[**2189-9-24**] and restarted on [**2189-9-27**]. He was placed on prophylactic
Bactrim while on high dose steroids.
TRANSFER TO [**Hospital1 112**]
When path returned as consistent with AIP, we discussed his case
with the transplant service at our sister hospital, [**Name (NI) **], as well as with their critical care team. We arranged
for urgent transfer for expedited evaluation for possible
transplantation, since we felt that this provided the best
balance of risks and benefits.
Medications on Admission:
On admission:
Ibuprofen prn
Albuterol prn
Upon transfer to MICU on [**9-27**]:
Medications on Transfer:
atrovent neb q6
tylenol 325-650 mg q6prn
albuterol neb q6prn
levofloxacin 750 mg daily (start [**2189-9-23**])
methylprednisolone 125 mg q6
pantoprazole 40 mg daily
dilaudid PCA bolus 0.12 mg, q6min:prn, lockout 2 mg daily. no
basal
heparin 5000 sc tid
insulin sliding scale
bactrim DS 1 tab 3x/week
ambien 5-10 mg qhs:prn
trazodone 25 mg qhs:prn
Discharge Medications:
HYDROmorphone (Dilaudid) 0.125 mg IV Q4H:PRN Hold for RR<12,
sedation
Senna 1 TAB PO BID constipation
Lorazepam 0.5 mg PO/IV Q6H:PRN anxiety
MethylPREDNISolone Sodium Succ 250 mg IV Q6H
Calcium Carbonate 500 mg PO BID
Vancomycin 1000 mg IV Q 12H
Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR)
Zolpidem Tartrate 5-10 mg PO HS:PRN
Heparin 5000 UNIT SC TID
traZODONE 25 mg PO HS:PRN
Pantoprazole 40 mg PO Q24H
Insulin SC
Ipratropium Bromide Neb 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Levofloxacin 750 mg PO Q24H
Docusate Sodium 100 mg PO BID
Acetaminophen 325-650 mg PO Q6H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Acute Interstitial Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Transferred to [**Hospital1 112**] for continued care and transplant evaluation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2189-9-28**]
|
[
"515",
"799.02",
"493.90",
"300.00",
"790.29",
"285.1",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.20"
] |
icd9pcs
|
[
[
[]
]
] |
8961, 9004
|
5825, 7835
|
293, 396
|
9076, 9084
|
4407, 5802
|
3552, 3664
|
8337, 8938
|
9025, 9055
|
7861, 7861
|
9108, 9348
|
3679, 4388
|
234, 255
|
424, 2303
|
7875, 7941
|
7966, 8314
|
2325, 2462
|
2478, 3536
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,866
| 128,631
|
25907
|
Discharge summary
|
report
|
Admission Date: [**2120-7-8**] Discharge Date: [**2120-8-1**]
Date of Birth: [**2054-6-13**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Lipitor
Attending:[**First Name3 (LF) 13017**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient seen and examined, agree with house officer admission
note by Dr. [**Last Name (STitle) **] with additions below.
66 year old Female with diabetes, CVA, and ESRD on HD M/W/F who
presented to ED from hemodialysis after developing fever and
chills. History is difficult to obtain, as the patient is
minimally conversive at baseline, but was not noted to have any
coughing, vomiting, or diarrhea per report.
In the ED, initial VS were 100.2 85 [**Telephone/Fax (2) 64431**]% RA. On exam,
she was noted to have a waxing and [**Doctor Last Name 688**] mental status, and was
oriented only to self. At times, she was not responsive to
verbal stimuli and had increased oral secretions. She also was
noted to have diminished breath sounds bilaterally, though this
was felt to be secondary to poor inspiratory effort. Labs
notable for WBC 6.1 with 78.7% neutrophils and no bands. UA not
suggestive of infection.A chest x-ray was performed which was
concerning for RLL PNA. Vancomycin and ceftriaxone were started,
and she was admitted to Medicine for treatment of HCAP. Transfer
VS were 99.3 83 18 100% 2L NC.
On the floor, the patient is oriented only to person. She is
unable to answer most questions and is not cooperative with
exam. Of note, she was recently admitted [**Date range (1) 64432**] with lethargy
and abdominal pain. She had a waxing and [**Doctor Last Name 688**] mental status
during the admission, felt to be multifactorial in nature
secondary to hypoglycemia, exacerbation of previous stroke/neuro
deficits, and possible UTI (though culture only positive for
mixed flora). She did not have any other infectious sources
identified. CT head during that admission did not show any acute
process, and EEG suggested a toxic-metabolic encephalopathy
(possibly secondary to her underlying ESRD). Seizure was felt to
be unlikely. Per notes, she was alert but still dioriented at
time of discharge.
Past Medical History:
1. Coronary artery disease
- s/p cath ([**8-24**]): Mild epicardial disease, collalateral flow
to distal inferior wall, no intervention
2. Hypertension
3. Hyperlipidemia
4. Diabetes: complicated by retinopathy, neuropathy, and
nephropahy
5. ESRD on HD MWF
6. Stroke: left frontal MCA and occipital PCA stroke
7. Impaired memory s/p MVA
8. Anemia
9. History of MSSA PNA, [**3-25**]
10. Treated for presumptive endocarditis, [**12-27**]
11. H/o Upper GI bleed NOS, gastritis, duodenitis
Social History:
Born in [**Country **]. Denies tobacco, EtOH. Lives independently but
has visiting aids come home x3/day. Her two daughters also stop
by a few times a week. She is able to toilet and shower
independently. Meds are prepared by care takers. Meals are also
prepared by aids and family.
Family History:
-Father died in his 70's with heart disease
-Siblings (two sisters) with diabetes mellitus (type II).
Physical Exam:
Physical Exam on Admission:
VSS: 97.9, 147/57, 77, 18, 99%
GEN: Sleepy
Pain: 0/10
HEENT: b/l surgical pupils, Left Ptosis, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: Oriented to self only, moving extremities
Physical Exam on Discharge:
waxing and [**Doctor Last Name 688**] alertness--intermittently arouses to voice,
other times to sternal rub; sometimes follows simple commands
(raise your hands), but rarely; occasionally gives 1 word
answers "yes, no, I don't know"
L pupil surgical, R 1-->0.8mm
L ptosis/facial droop
moves all 4 extremities to noxious stimuli
Pertinent Results:
Labs on Admission:
[**2120-7-8**] 08:51PM TYPE-ART PO2-64* PCO2-45 PH-7.42 TOTAL CO2-30
BASE XS-3
[**2120-7-8**] 07:07PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2120-7-8**] 07:07PM LACTATE-1.0
[**2120-7-8**] 07:00PM GLUCOSE-144* UREA N-19 CREAT-3.3*# SODIUM-137
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2120-7-8**] 07:00PM estGFR-Using this
[**2120-7-8**] 07:00PM CALCIUM-9.1 PHOSPHATE-2.6*# MAGNESIUM-1.8
[**2120-7-8**] 07:00PM WBC-6.1 RBC-3.33* HGB-10.4* HCT-31.7* MCV-95
MCH-31.3 MCHC-32.9 RDW-13.6
[**2120-7-8**] 07:00PM NEUTS-78.7* LYMPHS-15.0* MONOS-5.4 EOS-0.9
BASOS-0.1
[**2120-7-8**] 07:00PM PLT COUNT-204
[**2120-7-8**] 07:00PM PT-10.4 PTT-35.7 INR(PT)-1.0
[**2120-7-8**] 05:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2120-7-8**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2120-7-8**] 05:30PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
Relevant Labs:
[**2120-7-17**] 05:10AM BLOOD %HbA1c-6.2* eAG-131*
[**2120-7-17**] 06:26AM BLOOD Triglyc-212* HDL-60 CHOL/HD-2.7
LDLcalc-59
[**2120-7-21**] 06:00AM BLOOD Phenyto-6.8* Phenyfr-1.5 %Phenyf-22*
[**2120-7-20**] 05:05AM BLOOD Phenyto-5.6* Phenyfr-1.0 %Phenyf-18*
[**2120-7-22**] 05:40AM BLOOD Phenyto-6.3*
[**2120-7-26**] 04:30AM BLOOD Phenyto-3.6*
[**2120-7-26**] 06:26AM BLOOD Phenyto-2.9*
[**2120-7-17**] 03:48PM BLOOD LEVETIRACETAM (KEPPRA)-6.9
[**2120-7-17**] 05:10AM BLOOD LEVETIRACETAM (KEPPRA)-31
CHEST (PA & LAT) Study Date of [**2120-7-8**]
IMPRESSION:
1. New right lower lobe opacity worrisome for pneumonia in the
appropriate setting, although other etiologies such as
atelectasis associated with a small pleural effusion could
explain the finding.
2. Widespread mild interstitial abnormality with new pleural
effusion and thickened fissures, suggesting vascular congestion.
EEG [**2120-7-12**]
IMPRESSION: This telemetry captured no pushbutton activations.
He background appeared very slow and encephalopathic throughout,
but with additional higher voltage slowing on the left side.
After the first hour or so, there was nearly continuous slowing
mixed with 1.5-2 Hz generalized sharp and slow activity, without
clinical signs of seizure on video. The record is difficult for
making the distinction between severe encephalopathy and
seizure, but the somewhat rhythmic, nearly 2 Hz sharp and slow
activity suggests strongly the possibility of nonconvulsive
seizure activity.
EEG [**2120-7-13**]
IMPRESSION: This telemetry captured no pushbutton activations.
This is a
markedly abnormal video EEG telemetry with no normal waking or
sleep activity seen. Background rhythms at best demonstrated a
moderated to severe encephalopathy. There continues to be
interspersed periods of time with 1.5-2 Hz sharp and slow wave
generalized activity concerning for periods of NCSE as well as
more focal left hemisphere sharp and slow discharges at 2 Hz for
variable lengths of time during recording. No clinical correlate
was observed during these periods with persistent epileptiform
activity.
EEG [**2120-7-20**]
MPRESSION: This telemetry captured no pushbutton activations.
This is a
markedly abnormal video EEG telemetry with no normal waking or
sleep activity seen. Background rhythms at best demonstrated a
moderate to severe
encephalopathy. There continues to be interspersed periods of
time with
1.5-2 Hz sharp and slow wave generalized activity as well as
more focal left frontotemporal and right central epileptiform
activity in prolonged runs. No significant change from prior
days' recording.
CT head [**2120-7-10**]
Hypodensity in the left parietal lobe adjacent to the posterior
lateral
ventricle which was not seen on prior exam, unclear if this is
due to
differences in slice selection versus new hypodensity. If
clinical suspicion for ischemia is high, could consider an MRI
for better evaluation.
CT head [**2120-7-22**]
Increased extent of cytotoxic edema in the left parietal lobe
since [**2120-7-10**] suggests an evolving infarct. No significant
mass effect. No hemorrhagic transformation. MRI could be
useful for further evaluation, if not contraindicated.
Bilateral carotid US
Less than 40% stenosis, bilateral internal carotid arteries
Labs on Discharge:
[**2120-7-31**] 04:20AM BLOOD WBC-7.3 RBC-2.96* Hgb-9.3* Hct-29.5*
MCV-100* MCH-31.6 MCHC-31.7 RDW-14.8 Plt Ct-441*
[**2120-7-31**] 04:20AM BLOOD Glucose-193* UreaN-64* Creat-6.3*# Na-136
K-4.6 Cl-91* HCO3-31 AnGap-19
[**2120-7-31**] 04:20AM BLOOD Calcium-9.6 Phos-5.2* Mg-2.7*
[**2120-7-31**] 04:20AM BLOOD Phenyto-8.9* Phenyfr-1.9 %Phenyf-21*
[**2120-7-31**] 04:20AM BLOOD Phenyto-8.9*
[**2120-7-30**] 04:30AM BLOOD Phenyto-8.5* Phenyfr-1.7 %Phenyf-20*
Brief Hospital Course:
66yo woman with a h/o hypertension, DM, hyperlipidemia, afib not
on coumadin, multiple prior CVAs, CAD, and ESRD on HD MWF
admitted to the hospital on Monday [**7-8**] with fevers / chills,
thought to be secondary to HCAP, who developed high blood
pressure and confusion at an HD session; she was transferred to
the ICU a second time for management of status epilepticus.
# Neurology: The stroke team was initially consulted while Ms.
[**Known lastname 64426**] was on the medicine service when she developed decreased
responsiveness and complete disorientation after hemodyalysis.
At that time, her confusion was most likely due to an underlying
infectious and/or metabolic issue, including an episode of
hypertension and hypoxia with O2 sats in the 70s. A new ischemic
event was also considered as a cause. Her head CT demonstrated a
possible new parietal hypodensity that was of uncertain
significance but may represent a new intracerebral process.
Patient had no new focal deficits, however, exam was limited due
to noncompliance. At that time, thought ?parietal hypodensity
was was likely due to cut of the CT. Patient transiently became
more interactive, but continued to be disoriented and aphasic.
Of note, patient was transferred to the ICU at that time for
hypertension control. Following stabilization of her blood
pressures in the ICU, patient returned to the medicine floor.
She developed twitching of her left arm and eyelid, along with
lip smacking and decreased responsiveness, all attributed to
status epilepticus, in HED. She was treated lorazepam 0.5 mg IV
x1, and transferred to the medical ICU for EEG and airway
monitoring. She maintained her airway throughout the episode.
Upon discharge from the MICU, she was transferred to the
Neurology service. She was on LTM and her EEG showed diffuse
encephalopathy as well as intermittent epileptiform discharges.
Her AEDs were adjusted multiple times. On discharge, she was
maintained on Keppra 1000mg qhs and 500mg per HD protocol as
well as Dilantin 175mg tid. Of note, head CT was repeated given
the ?of new parietal hypodensity as above. On repeat head CT,
it was clear that she did indeed have a new infarct in that
area. Most likely, this stroke was embolic in the setting of
afib and no anticoagulation (hand caudate hemorrhage in [**2117**] so
coumadin was stopped) vs. a hypertensive etiology. Carotid b/l
ultrasounds were obtained which did not show significant
stenosis. Did not make any changes to medications as cannot
anticoagulate and she is already on plavix. Controlled HTN as
below. On discharge, patient was more interactive, but waxing
and [**Doctor Last Name 688**] as per discharge exam.
# HCAP: On presentation, the patient's fever/chills were likely
secondary to HCAP given new RLL opacity on CXR. She did not have
a leukocytosis, but did have neutrophil predominance. She was
started on vancomycin and cefepime. Significant interval
worsening in CXR from admission to present with episode of
hypoxia (desat to 70%) likely represents fluid overload. Patient
dialyzed prior to MICU transfer with removal of 3L of fluid. In
the MICU, her respiratory status was monitored and remained
stable. Initial Bcx x3 (drawn on [**7-8**]) show NGTD. Repeat
cultures drawn [**7-10**] secondary to change in mental status, also
show no growth. Urine legionella antigen negative. She was
continued on vanc/cefepime for HCAP.
# Hypertension: Initially, patient's systolic blood pressures
ranged 160s-180s while on the medicine floor. At the time of
her episode of pulmonary edema with desaturation, systolics rose
to the 200s, and this was unresponsive to ultrafiltration of 3L
in dialysis. She was given a labetalol push, and transferred to
the medical ICU. In the ICU, she was continue on her home
medications of Lisinopril 40mg q24h, Lopressor 50mg TID, and
amlodipine 5mg. She continued to be hypertensive o the 180s
systolic, so amlodipine was increased to 10 mg daily. She was
also started on hydralazine 75mg PO tid. Despite these chages,
she continued to be hypertensive, so she underwent dialysis to
remove volume. This normalized her blood pressure to 150-160s
systolic.
# Chronic renal insufficiency: She is on scheduled HD MWF. Her
hypertension was thought to be volume dependent, so she
underwent suscessful ultrafiltration on [**7-11**]. We continued her
sevelamer for phso-binding. Other acute interventions with
regard to her kidney function were not acutely indicated.
# Anemia: Her hemoglobin and hematocrit are low, but similar to
prior levels. Her anemia is most likely due to her chronic renal
insufficiency and/or chronic disease. There was no evidence of
acute bleeding.
# Type 2 DM, uncontrolled: Patient is a brittle diabetic
complicated by retinopathy, neuropathy, and nephropathy. She
was continued on an ISS.
# History of Stroke: She is s/p left frontal MCA and occipital
PCA stroke. Her plavix was continued.
# Atrial Fibrillation: Was on warfarin in past, but not
anticoagulated at present. Warfarin discontinued [**2118-11-29**] due to
caudate hemorrhage. Stopped aspirin in [**8-/2116**] due to infarcts.
In the MICU, she was rate controlled with toprol-xl.
# Coronary artery disease: Stable. Continue continue plavix,
beta blocker, statin, ACE inhibitor
# Hyperlipidemia: continue pravastatin
# Nutrition: Patient was intermittently awake enough to swallow.
Had NG tube in place, pulled it out several times. Discussed
possibility of PEG tube with the family who decided against it.
Patient is able to eat with assistance, so NG tube was
discontinued.
TRANSITIONS OF CARE:
- should follow up in epilepsy clinic with Dr. [**Last Name (STitle) 851**].
- will continue AEDs as above
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Succinate XL 150 mg PO DAILY
3. Docusate Sodium 200 mg PO BID
4. Pravastatin 40 mg PO DAILY
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. Epoetin Alfa 2200 units SC 2X/WEEK (MO,FR)
Monday, [**Last Name (STitle) 2974**]
7. Clopidogrel 75 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
2. Docusate Sodium 200 mg PO BID
3. Metoprolol Succinate XL 150 mg PO DAILY
4. Epoetin Alfa 2200 units SC 2X/WEEK (MO,FR)
Monday, [**Last Name (STitle) 2974**]
5. Clopidogrel 75 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Pravastatin 40 mg PO DAILY
9. Amlodipine 5 mg PO DAILY
10. HydrALAzine 75 mg PO Q8H
hold for SBP<120
RX *hydralazine 25 mg 3 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
11. LeVETiracetam Oral Solution 500 mg PO HD PROTOCOL
To be given after HD
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth per HD
Disp #*30 Tablet Refills:*2
12. LeVETiracetam Oral Solution 1000 mg PO QHS
RX *levetiracetam [Keppra] 1,000 mg 1 by mouth at bedtime Disp
#*30 Tablet Refills:*2
13. Phenytoin (Suspension) 175 mg PO Q8H
RX *phenytoin [Dilantin Infatabs] 50 mg 3.5 by mouth three times
a day Disp #*330 Tablet Refills:*2
14. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Healthcare associated pneumonia
Seizure disorder
New ischemic infarct
Secondary:
Coronary Artery Disease
Hypertension
Diabetes
End-Stage Renal Disease
Strokes
Anemia
Atrial fibrillation
Gastritis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 64426**],
You were recently admitted to [**Hospital1 18**] with fevers and confusion.
While you were here, you had evidence for a pneumonia, and were
treated with intravenous antibiotics.
You also demonstrated jerking movements, which were seizures,
confirmed also by EEG. We started you on medication to control
your seizures and they worked well. You will need to take per
rectum diazepam if you have any seizures lasting more than 5
minutes, or more than 3 short seizures in one hour. A repeat
CAT scan of your brain showed that you recently had a new
stroke. Most likely, it is from your irregular heart rate or
your high blood pressure. You are already on optimal medical
therapy for stroke prevention so we did not change any of these.
You were continued on hemodialysis while you were here, and it
is important that you continue to go to dialysis as an
outpatient. Your blood pressure was quite high and we adjusted
you medicines.
We have made a number of changes to your medications, the
updated list is included.
Please follow up in neurology clinic as scheduled below.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2120-8-27**] at 9:45 AM
With: DRS. [**Name5 (PTitle) **] & [**Last Name (un) 22698**] [**Telephone/Fax (1) 857**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2120-8-1**]
|
[
"V58.67",
"427.31",
"482.9",
"345.3",
"V58.61",
"285.21",
"250.42",
"V45.11",
"784.3",
"357.2",
"518.4",
"583.81",
"781.94",
"362.01",
"349.82",
"403.11",
"250.52",
"585.6",
"518.81",
"348.5",
"414.01",
"438.89",
"250.62",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.6",
"38.97",
"89.19"
] |
icd9pcs
|
[
[
[]
]
] |
15895, 15966
|
8606, 14196
|
288, 295
|
16216, 16216
|
3819, 3824
|
17556, 17951
|
3061, 3164
|
14848, 15872
|
15987, 16195
|
14351, 14825
|
16352, 17533
|
3179, 3193
|
3469, 3800
|
239, 250
|
8127, 8583
|
323, 2236
|
3838, 8107
|
16231, 16328
|
14217, 14325
|
2258, 2744
|
2760, 3045
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,282
| 132,174
|
42629
|
Discharge summary
|
report
|
Admission Date: [**2109-8-2**] Discharge Date: [**2109-8-17**]
Date of Birth: [**2054-8-18**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old man
who is paraplegic with a longstanding sacral decubitus ulcer,
status post multiple debridements and multiple courses of
antibiotics, also a history of multiple episodes of
urosepsis. He presented to the Emergency Department
complaining of nausea, weakness, malaise, and hyperglycemia
times one day. He denies vomiting or shortness of breath.
REVIEW OF SYSTEMS: Positive for chest tightness times many
weeks. There were no acute changes. Review of systems is
also positive for pain in the feet for many weeks, no acute
changes. The patient denies any fevers prior to admission.
PAST MEDICAL HISTORY: Significant for sacral decubitus Stage
IV ulcer since [**2108-2-7**], he is a paraplegic times nine
years which occurred after a thoracotomy procedure, bladder
rupture, recurrent urinary tract infections, diabetes
mellitus Type 2 with neuropathy, osteomyelitis and history of
Clostridium difficile colitis, scrotal fissure/gangrene,
congenital nystagmus, depression with suicidal ideations,
hypoaldosteronism, hypomania and questionable history of
gastrointestinal bleed.
PAST SURGICAL HISTORY: Significant for diverting colostomy
in [**2108-10-7**], urostomy in [**2105**], sacral
debridement and multiple adhesions, left orchiectomy with
perineal debridement, inguinal debridement, thoracotomy and
attempted repair of kyphosis.
SOCIAL HISTORY: The patient denies the use of tobacco or
alcohol.
ALLERGIES: The patient is allergic to Haldol, Morphine and
Erythromycin.
MEDICATIONS ON ADMISSION: Paxil 100 mg q.d., Primidone 12.5
q.h.s., Oxycontin 40 mg b.i.d., Neurontin 300 mg t.i.d.,
Insulin NPH 25 units q. AM, 33 units q. PM, with a regular
insulin sliding scale, Kayciel 40 mg q.d., Prevacid 30 mg
q.d., Heparin subcutaneously b.i.d., Florinef 0.2 mg q.d.,
Ambien 10 mg q.h.s., iron sulfate, also Topamax, Trileptal
and Ativan prn.
PHYSICAL EXAMINATION: On admission temperature was 99.6,
blood pressure 96/56, heartrate 74, respirations 16, 97% on
room air. General, the patient was lying on his side,
speaking very softly. Cardiac examination, normal S1 and S2,
regular rate and rhythm, no murmurs, rubs or gallops. There
was chest pain reproducible on palpation. Lung examination,
clear to auscultation bilaterally. Abdomen had diffuse
tenderness, normoactive bowel sounds. Colostomy bag. There
was brown stool and urostomy present. Extremities, the
patient had contractures of both legs and there were necrotic
areas on multiple toes. Extremities were warm with no edema.
Back, sacral decubitus ulcer about 10 cm in diameter with
vacuum dressing in place.
LABORATORY DATA: On admission white blood count 11.4,
hematocrit 37.3, platelets 369, sodium 137, potassium 4.4,
chloride 102, bicarbonate 20, BUN 20, creatinine 0.7, glucose
240. Chest x-ray was negative for pneumonia or congestion.
Electrocardiogram was normal sinus rhythm.
HOSPITAL COURSE: 1. Infectious disease - The patient was
afebrile with all of his admission blood cultures pending.
Two days after admission the patient spiked a temperature of
101.2 and developed an elevated white blood cell count. At
this time it was unknown if the source of the fever was
urinary tract infection versus possible osteomyelitis in his
sacral region as he has had osteomyelitis in the past. The
patient was empirically started on antibiotics at that time.
It was found that the patient had gram negative rods growing
in his urine, however, he has chronic colonization so it was
unknown if this was infection versus colonization. A few
days later the patient developed decrease in his oxygen
saturation and chest x-ray revealed the right lower lobe and
right middle lobe pneumonia. Over the course of the next
couple of days, the patient decompensated from the
respiratory standpoint and had to be sent to the Medicine
Intensive Care Unit. He was cared for in the Intensive Care
Unit for one day during which time he did not have to be
intubated. He then returned to the floor and continued to
clinically improve until the time of discharge. In terms of
the possible sacral osteomyelitis, magnetic resonance was
done which showed some edema in the pelvic bones, not
definitive for osteomyelitis but incidentally found a right
femur fracture. Orthopedics was consulted and the decision
was made for conservative management at that time.
2. Diabetes mellitus - The patient was initially started on
regular insulin sliding scale. His home NPH was held
initially and was reinstituted on [**8-15**] with good control
of his blood sugar.
3. Pain - The patient was continued on his previous doses of
Oxycontin, Neurontin, Topamax, Trileptal and Oxycodone was
added prn. The patient continued to complain of mild pain in
his feet throughout this hospital stay and Neurontin was
slowly increased up to a discharge dose of 900 mg t.i.d.
4. Sacral decubitus ulcer - On admission the patient had a
vacuum dressing in place which repeatedly fell off during the
admission. The Plastics Department was kind enough to
replace his dressing prn.
5. Psychiatry - Although the patient's affect most of the
time was hypomanic with grandiose plans at times during his
hospital stay he became extremely depressed. Psychiatry
consult was called. They continued to see him on a daily
basis but there were no recommendations for change in
medications.
6. Code status - The patient was initially
Do-Not-Resuscitate, Do-Not-Intubate on admission at the time
in which he decompensated and needed to be sent to the unit.
He reversed his code status to full code and then after he
recovered from his acute illness he is leaning now again
towards Do-Not-Resuscitate, Do-Not-Intubate but no final
decision has been made. This is an issue which will be
discussed with his primary doctor at a later date.
MEDICATIONS ON DISCHARGE:
1. Insulin NPH 20 units q. AM, 27 units q.h.s. to be
adjusted accordingly and regular insulin sliding scale.
2. Neurontin 900 mg p.o. t.i.d.
3. Heparin 5000 units subcutaneously q. 12 hours
4. Vancomycin 1 gm intravenously q. day times 5 more days
5. Ativan 1 mg p.o. t.i.d. prn
6. Vitamin C 500 mg p.o. b.i.d.
7. Zinc Sulfate 220 mg p.o. q.d.
8. Guaifenesin 10 ml p.o. q. 6 hours
9. Simethicone 80 mg p.o. t.i.d. prn
10. Topiramate 75 mg p.o. q.d.
11. Vitamin D4 100 units p.o. q.d.
12. Calcium carbonate 500 mg p.o. t.i.d.
13. Zolpidem Tartrate 10 mg p.o. q.h.s. prn
14. Oxycodone 5 mg p.o. q. 6 hours prn for breakthrough pain,
hold for sedation or respirations less than 12 per minute
15. Acetaminophen 650 mg p.o. prn q. 4-6 hours
16. Oxycontin 40 mg p.o. q. 12 hours, hold for sedation or
respirations less than 12
17. Ferrous Sulfate 325 mg p.o. q.d.
18. Albuterol nebulizer one q. 4-6 hours prn
19. Zosyn 4.5 mg intravenously q. 6 hours times five more
days
20. Oxcarbazepine 150 mg p.o. q.d.
21. Paxil 100 mg p.o. q. AM
22. Florinef 0.2 mg p.o. q.d.
23. Lansoprazole 30 mg p.o. q.d.
24. Primidone 12.5 mg p.o. q.h.s.
FOLLOW UP: The patient is to follow up with his primary
doctor, Dr. [**Last Name (STitle) **] in one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Last Name (NamePattern1) 92182**]
MEDQUIST36
D: [**2109-8-16**] 16:15
T: [**2109-8-16**] 17:25
JOB#: [**Job Number 92183**]
|
[
"820.22",
"V44.6",
"V44.3",
"344.1",
"707.0",
"780.79",
"311",
"486",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6013, 7149
|
1712, 2055
|
3092, 5987
|
1307, 1543
|
7161, 7537
|
2078, 3074
|
567, 787
|
169, 547
|
810, 1283
|
1560, 1685
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,995
| 109,362
|
32593
|
Discharge summary
|
report
|
Admission Date: [**2189-2-9**] Discharge Date: [**2189-2-25**]
Date of Birth: [**2110-12-14**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
monitoring s/p mechanical thrombectomy and extensive venous
angioplasty LE DVTs by IR [**2189-2-9**].
Major Surgical or Invasive Procedure:
Mechanical thrombolysis/angioplasty of DVT w/ repositioning of
IVC filter ([**2-7**], [**2-10**])
Transfusion of 2U FFPs and 2U PRBCs
XRT
History of Present Illness:
78 y.o male h.o intradural extramedullary mass (adenocarcinoma)
(originally presented as sudden back pain, progressively
worsening ascending paralysis) s/p thoracic laminectomy T4-7 and
mass resection [**2189-1-8**], surgery complicated by hemorrhage
resulting in paraplegia, s/p IVC filter for PE ppx. Pt underwent
attempted retrieval of IVC filter [**2189-2-6**], however femoral and
common iliac veins were seen to be thrombosed and procedure was
aborted. Pt went to rad onc today (brain/spine radiation) at
whic time he was noted to have worsening scrotal and LE edema
and decision was made to have pt come in for thrombolysis to
recannulize the femoral/iliac vessels with potential IVC filter
retrieval/replacement. Pt transferred to medicine for monitoring
of hematuria, HCT, monitor for PE.
.
Of note, he has been on coumadin 4mg and Dalteparin [**Hospital1 **] and INR
was noted to be 3.5 preprocedure.
.
In IR pt had extensive thrombectomy with recanalization of
thrombosis in popliteal, femoral, iliac, and IVC with mechanical
device using AngioJet and balloon angioplasty. There was good
angiographic result with some residual thrombosis. No
thrombolytics were used. His IVC filter was left in place.
During the procedure, his SBPs ranged from 120s-140s and HR in
the 80s-90s.
.
Initially, upon admission to the medicine service, SBP was
112/64. However, soon after being admitted to the medicine
service he triggered for hypotension with blood pressure as low
as 80/P. On the floor, he was also noted to be persistently
tachycardic 104-108. A stat hct was sent and revealed a drop
from 29.5 immediately post procedure to 23.6. He received 1L
Normal saline bolus with transient increase in sbps to 90s, then
returning to high 80s. Although b/l lower extremities were
swollen, there was no clear e/o hematoma in popliteal regions
nor in groin. T+S was sent and he was ordered for FFP and prbcs
and transferred to the ICU for further monitoring and care.
.
Upon arrival to the MICU a portable u/s showed no trauma to the
popliteal veins in the popliteal fossa.
.
Initally on the floor, the patient reported nausea which has
since resolved, band-like numbness across abdomen (unchanged)
and paresthesias of b/l LE (unchanged.) He denied abdominal pain
and leg pain, although sensation limited as above. Otherwise, no
fevers, chills, SOB, CP, palpitations, abdominal pain,
V/D/dysuria, +notable hematuria, -joint pains, -headache, -new
paresthesias.
Past Medical History:
- Recently diagnosed with Adenocarcinoma
(intradural/extramedullary). Mets to brain (mult cystic
enhancing lesions seeon on MRI.) CT torso showing mult densities
in the lungs, diffuse metastatic bony disease. Thought to be
from lung primary vs.prostate.
- Paraplegia (from hemorrhagic complication of thoracic
laminectomy)
- s/p IVC filter placement
- Prostate Ca s/p XRT, horomonal therapy (approximately
[**2180**]-[**2181**])
Social History:
The patient was last at a rehab facility. Formerly lived at
home with his wife. Family very involved in his care. Oldest
son, [**Name (NI) **] ([**Telephone/Fax (1) 75974**]) is his health care proxy. [**Name (NI) **] is a
retired fisherman. No tobacco use. No ethanol use.
Family History:
His mother died of blood dyscrasias, while his
father died of an unspecified cancer. He has 6 brothers and 3
sisters and they are healthy. His 6 sons are healthy.
Physical Exam:
gen-lying in bed, NAD, cooperative
vitals-T 100.3, BP 112/64 HR 110, RR 18, Sat 97% on 2L
HEENT-NC/AT, L.eye appears larger than R. PERRLA, EOMI,
anicteric, MMM.
neck: No JVD, no LAD
chest-b/l AE no W/C/R
heart-S1S2 RRR no m/r/g
abd-+bs, +multiple ecchymotic areas ([**3-14**] fragmin?), soft, NT,
ND, -guarding/rebound.
groin-R.groin-no masses, no bruits, bandage C/D/I
ext-no C/C [**3-15**]+edema up to pelvis. +b/l ankle boots in place.
0/5 motor strenght, but sensation intact to touch. 1+palpable DP
pulses, warm extremities. +compression stockings over popliteal
area.
neuro-AAOx3, CN 2-12 intact, motor [**6-15**] B/L UE.
Pertinent Results:
Admit Labs:
------------
[**2189-2-9**] 06:00PM WBC-6.0 RBC-3.22* HGB-10.0* HCT-29.5* MCV-92
MCH-31.1 MCHC-34.0 RDW-12.7
[**2189-2-9**] 06:00PM PLT COUNT-277
[**2189-2-9**] 12:26PM PT-33.6* INR(PT)-3.5*
[**2189-2-10**] 01:48AM BLOOD Glucose-136* UreaN-18 Creat-0.6 Na-136
K-6.0* Cl-103 HCO3-28 AnGap-11
[**2189-2-10**] 01:48AM BLOOD ALT-29 AST-84* LD(LDH)-1258* AlkPhos-100
TotBili-2.2*
[**2189-2-10**] 01:48AM BLOOD Calcium-7.9* Phos-4.8* Mg-2.1
[**2189-2-10**] 03:21AM BLOOD Hapto-40
[**2189-2-10**] 01:09AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.024
[**2189-2-10**] 01:09AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-MOD
[**2189-2-10**] 01:09AM URINE RBC-[**12-31**]* WBC->50 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2189-2-10**] 01:09AM URINE CastGr-0-2 CastHy-0-2
[**2189-2-10**] 1:09 am URINE Source: Catheter.
**FINAL REPORT [**2189-2-13**]**
URINE CULTURE (Final [**2189-2-13**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
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
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S <=0.5 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- <=0.25 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
Other Labs:
------------
[**2189-2-11**] 11:22AM BLOOD Cortsol-5.2
[**2189-2-11**] 01:24PM BLOOD Cortsol-25.4*
[**2189-2-11**] 04:37AM BLOOD PSA-5.7*
[**2189-2-20**] 04:20PM
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT)
Fibrinogen, Functional 516* mg/dL 150 - 400
D-Dimer 1699* ng/mL 0 - 500
[**2189-2-20**] 04:20PM
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT)
Fibrin Degradation Products 0-10 ug/mL 0 - 10
HEPARIN DEPENDENT ANTIBODIES POSITIVE
COMMENT: Positive for Heparin PF4 Antibody by [**Doctor First Name 1059**].
(optical density 2.3)
.
[**Numeric Identifier 75975**] PTA VENOUS [**2189-2-9**] 1:48 PM
PROCEDURE AND FINDINGS: After explaining the risks and benefits
of the procedure, informed consent was obtained from the patient
(after translation) and from his healthcare proxy (son). The
patient was placed prone on the angiographic and both popliteal
areas were prepped and draped in standard sterile fashion. A
preprocedure timeout was performed.
After injection of 1% lidocaine and using ultrasound guidance,
access was gained into the right popliteal vein with a
micropuncture needle. A 0.018 guidewire was advanced through the
micropuncture needle into the distal superficial femoral vein
under fluoroscopic guidance. A micropuncture needle was
exchanged for a 4.5 French micropuncture sheath. Venogram was
obtained with injection of contrast through the micropuncture
sheath, which demonstrated thrombosis extending from the
popliteal vein to the femoral vein. A 0.035 Bentson guidewire
was advanced through the micropuncture sheath into the high IVC
under fluoroscopic guidance. A micropuncture sheath was
exchanged for a 6 French vascular sheath. A 5 French Kumpe
catheter was advanced into the iliac vein and SVC and a venogram
was obtained, which demonstrated thrombosis in the right iliac
vein and IVC, below the IVC filter.
After injection of 1% lidocaine and using ultrasound guidance,
access was gained into the left popliteal vein with a
micropuncture needle. A 0.018 guidewire was advanced through the
micropuncture needle into the femoral vein. A micropuncture
needle was exchanged for a 4.5 micropuncture sheath. A venogram
was obtained with injection of contrast through the
micropuncture sheath, which demonstrated thrombosis extending
from the popliteal to femoral vein. A 0.035 [**Last Name (un) 7648**] wire was
advanced through the micropuncture sheath into the high IVC
under fluoroscopic guidance. A micropuncture sheath was
exchanged for a 6 French vascular sheath.
Mechanical thrombectomy was performed from the IVC to both
popliteal veins with the AngioJet thrombectomy device. Venogram
after mechanical thrombectomy was obtained with injection of
contrast through right vascular sheath, which demonstrated
multiple stenoses/residual mural thrombosis of the left
popliteal and left femoral vein. It was decided to do balloon
dilatation from IVC to both popliteal veins. Balloon dilatation
was performed from both iliac veins to both popliteal veins with
6 mm x 4 cm balloons. After then, balloon dilatation was again
performed from the IVC to both femoral veins with 8 mm x 4 cm
balloons.
Venograms after balloon dilatation was obtained with injection
of both popliteal veins sheaths, which demonstrated marked
interval improvement of venous flow with small residual mural
thrombosis. Iliac venogram was then obtained through a 5 French
Omniflush catheter which was placed in the left common iliac
vein, which demonstrated marked improvement in the thrombosis
and venous flow from the iliac vein into the IVC.
Popliteal vein sheaths were removed and manual compression was
held for 10 minutes until hemostasis was achieved. A compression
dressing was applied at both popliteal vein puncture sites.
Moderate sedation was provided by administering divided doses of
25 mcg of fentanyl and 0.5 mg of Versed throughout the total
intraservice time of 55 minutes during which the patient's
hemodynamic parameters were continuously monitored.
COMPLICATION: Hematuria developed right after the procedure and
is likely due to hemolysis from the Angiojet thrombectomy. Good
hydration should be mantained and creatinine checked.
IMPRESSION: Thrombosis involving the bilateral popliteal,
femoral and iliac veins and IVC, below the IVC filter.
Successful recanalization of thrombosis in popliteal, femoral,
iliac, and IVC with mechanical thrombectomy using AngioJet and
balloon angioplasty, with good angiographic result and some
residual mural thrombosis.
.
CT LOW EXT W/O C BILAT [**2189-2-10**] 12:02 AM
CT OF THE ABDOMEN WITH NO IV CONTRAST ADMINISTRATION: The
visualized portion of the lung bases demonstrate dependent
atelectatic changes and a small bilateral pleural effusion.
Small axial hiatal hernia is also visualized. The visualized
portion of the heart and great vessels appear normal.
The liver, spleen, left adrenal gland, gallbladder, pancreas,
common bile duct, stomach, and loops of small bowel and large
bowel appear normal. The right adrenal gland contains an adenoma
measuring 18 x 17 mm. Both kidneys contain multiple hypodense
lesions which most likely represents cysts. The aorta has normal
appearance. The IVC stent is noted in the infrarenal region.
Contrast is still noted in IVC suggesting residual clot. Both
kidneys are excreting the contrast material. The patient
demonstrates signs of fluid overload.
CT OF PELVIS WITH NO IV CONTRAST ADMINISTRATION: The bladder has
thickened wall and contains a Foley catheter. The prostate is
normal in appearance. The rectum and sigmoid colon contain oral
contrast. Small amount of free fluid is noted within the pelvis.
No evidence of retroperitoneal bleeding is visualized.
CT OF THE Lower extemity: There is significant amount of fluid
accumulation within the scrotum and penis related to venous
obstruction.
Diffuse fluid accumulation in soft tissues are noted.
BONE WINDOWS: No concerning lytic or sclerotic lesions are seen.
IMPRESSION:
1. No retroperitoneal bleeding is noted.
2. There is copious fluid accumulation in the soft tissues and
most prominantly in the scrotum. This is most likely related to
venous occlusion.
Persistent contrast in the venous system is most likely related
to the residual clot.
3. Right adrenal adenoma as described.
4 . Axial Hiatal hernia..
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2189-2-19**] 3:27 PM
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture with no focal lesions. There is no intra- or
extra-hepatic biliary dilation. The portal vein is patent with
anterograde flow. The common duct measures 4 mm. There is no
ascites. Sludge layers within the gallbladder, with no echogenic
gallstones identified. The gallbladder wall is not thickened,
and the gallbladder is only mildly distended. There is no
pericholecystic fluid.
IMPRESSION:
1. Gallbladder sludge without evidence of acute cholecystitis.
2. Normal hepatic echotexture. No evidence of biliary
dilatation.
.
Discharge Labs:
---------------
[**2189-2-25**] 07:20AM
COMPLETE BLOOD COUNT
White Blood Cells 9.4 K/uL 4.0 - 11.0
Red Blood Cells 3.85* m/uL 4.6 - 6.2
Hemoglobin 11.8* g/dL 14.0 - 18.0
Hematocrit 34.7* % 40 - 52
MCV 90 fL 82 - 98
MCH 30.7 pg 27 - 32
MCHC 34.1 % 31 - 35
RDW 13.9 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 292 K/uL 150 - 440
[**2189-2-25**] 07:20AM
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 12.9 sec 10.4 - 13.4
NOTE NEW REFERENCE RANGE AS OF [**2188-12-24**] 12:00A
PTT 30.3 sec 22.0 - 35.0
INR(PT) 1.1 0.9 - 1.1
[**2189-2-25**] 07:20AM
RENAL & GLUCOSE
Glucose 102 mg/dL 70 - 105
Urea Nitrogen 16 mg/dL 6 - 20
Creatinine 0.4* mg/dL 0.5 - 1.2
Sodium 136 mEq/L 133 - 145
Potassium 4.2 mEq/L 3.3 - 5.1
Chloride 100 mEq/L 96 - 108
Bicarbonate 29 mEq/L 22 - 32
Anion Gap 11 mEq/L 8 - 20
CHEMISTRY
Albumin 2.8* g/dL 3.4 - 4.8
Calcium, Total 8.0* mg/dL 8.4 - 10.2
Phosphate 3.9 mg/dL 2.7 - 4.5
Magnesium 2.0 mg/dL 1.6 - 2.6
Alanine Aminotransferase (ALT) 33 IU/L 0 - 40
Asparate Aminotransferase (AST) 18 IU/L 0 - 40
Stool C. Diff ([**2-14**]) - positive
Blood Cx ([**2-18**]) - negative x 2 sets
Brief Hospital Course:
78 y.o man with recently diagnosed adenocarcinoma (unclear
primary, lung vs. prostate likely) s/p T4-7 laminectomy c/b
hemorrhage, resulting in paraplegia, s/p IVF filter, with
increased LE/scrotal edema today now s/p mechanical
thrombolysis/angioplasty of DVT and repositioning of IVC filter.
.
1) Hypotension
Patient had decreased bp after procedure, necessitating ICU
transfer. Likely related to peri-procedural complication given
time course and acute blood loss. No clear source of aneurysm or
hematoma b/l popliteal and right groin on bedside U/S performed
by IR. CT scan done and did not show RP bleed. BP improved
after fluid and blood transfusion (got 2U PRBCs and 2U FFP).
Had cosyntropin stim test which did not show any evidence of
adrenal insufficiency. BP fluctuated intermittently during
course of hospitalization. He did receive intermittent doses of
lasix (IV and PO) which also affected blood pressure. On
discharge, SBP was in mid-90s to low-100s. Patient did not have
symptoms of lightheadedness of dizziness.
.
2) Hematuria
Had hematuria post-procedure which is common occurrence due to
jets in thrombectomy which can cause hemolysis. This
subsequently resolved. Hematuria later recurred after he
received Lepirudin (see below). He was seen by the urology
service who recommended intermittent flushes or CBI (250-500cc
up to twice a day as needed). Upon discontinuation of
Lepirudin, hematuria resolved and further flushes were not
needed. He will need follow up with urology after discharge.
.
3) Extensive Lower extremity DVTs/Heparin-induced
thrombocytopenia
Although IVC filter had been replaced and mechanical
thrombectomy achieved some level of success, the patient had
extensive residual clot burden from IVC filter to the popliteal
veins. Further interventions were discussed with interventional
radiology. They felt that repeat mechanical thrombectomy would
not be beneficial. Only definitive treatment would be
thrombolytics, however these would be contraindicated given
brain mets. Case also discussed with vascular surgery who did
not feel there would be a surgical option. Given the likely
failure of coumadin (INR was therapeutic when clot developed),
coumadin was stopped and the patient was placed on Lovenox at
the recommendation of the heme-onc service. A Factor Xa level
was checked and was therapeutic. However, over the course of
his Lovenox therapy, the patient's platelet count decreased from
264 to 125 over the course of 8 days. Lovenox was stopped and
the patient was started on Lepirudin and Heparin Dependent
Antibodies were sent off. The patient developed the hematuria
(as above) on Lepirudin, however his Hct was stable. Heparin
antibody subsequently came back positive (optical density of 2.3
which is grossly positive). Given these findings, the patient
should never be given heparin products. He was switched over to
Fondaparinux, which he tolerated well (no evidence of a decrease
in blood clots).
.
4) Lower Extremity and Scrotal Edema
This is secondary to extensive clot burden. Legs and scrotum
were elevated and TEDS were used. Lasix was started to try to
mobilize some fluid. Although patient had good urine output
with Lasix, edema was essentially unchanged. Lasix had to be
intermittently stopped due to low blood pressures. He should
continue with compression stockings and Lasix as tolerated to
help with the edema.
.
5) Metastatic adenocarcinoma - unclear primary (lung vs.
prostate) w/ paraplegia
Mets involving brain, spine, bone. He completed his radiation
therapy of the brain and spine and completed the . He was also
continued on dexamethasone. A PSA was checked and was 5.7. Per
report, it was <1 sometime last year. This was discussed with
oncology, who did not necessarily feel this indicated recurrence
of the prostate ca. The patient will need to follow up in
thoracic oncology, the Brain Tumor Center, and Urology (either
his primary urologist, Dr. [**Last Name (STitle) 11789**] or Urology at [**Hospital1 18**]).
Prior to discharge, he was seen by his neuro-oncologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] who will also follow up with him as an outpatient. In
discussing the case with Dr. [**First Name (STitle) 13014**] of Radiation oncology, the
plan will be to do a slow taper of the patient's dexamethasone
over the next few weeks. He is currently on 1mg [**Hospital1 **], and will
be decreased by 0.5mg per week unless directed otherwise by the
doctors in the [**Name5 (PTitle) **] Tumor Center.
.
6) Sacral Decub/Scrotal skin breakdown
The patient had a stage II sacral decubitus ulcer as well as
some scrotal skin breakdown. He was seen by the wound care
nurse who made recommendations on wound care which were
implemented.
.
7) Urinary Tract Infection - MSSA/Pseudomonas
He was diagnosed with a urinary tract infection and treated with
a 2-week course of Ciprofloxacin (last dose on [**2-24**]).
.
8) Anemia
After his transfusion, the patient's Hct remained stable between
34-36.
.
9) C. diff Colitis
The patient developed diarrhea while on antibiotics. Stool for
C. Diff was positive. The patient was started on Flagyl 500mg
tid for C. Diff. He should remain on this until [**3-9**] (2 weeks
after last dose of Cipro was given). The patient had
intermittent passage of jelly-like stool, thought to be
secondary to the infection.
.
10) Goals of care
Discussions held with multiple members of the family, including
son [**Name (NI) **], who is the health care proxy, regarding overall
goals of care. The palliative care team was also involved.
Overall disease process/prognosis was also discussed with
patient via the hospital interpreter. The patient will be
discharged [**Hospital 6595**] Rehabilitation Nursing Center in
[**Hospital1 **]. During the course of this rehabilitation and through
further discussions with the patient's team of doctors [**First Name (Titles) **] [**Name5 (PTitle) 75976**], the family will decide about home hospice. This will
be facilitated through the palliative care service here.
Medications on Admission:
tylenol
MOM
fleet enema
dulcolax supp
celexa 10mg daily
dexamethasone 1mg [**Hospital1 **]
MVI
colace 100mg [**Hospital1 **]
fragmin [**Numeric Identifier 14900**] units SC BID
coumadin 3mg daily
percocet 5/325 1 q4hprn
protonix 40mg daily
ambien 10mg qhs
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Dexamethasone 0.5 mg Tablet Sig: as directed Tablet PO as
directed for 4 weeks: Take 1mg [**Hospital1 **] for 7 days. Then take 1mg in
the morning and 0.5mg in the evening for 7 days. Then take
0.5mg [**Hospital1 **] for 7 days. Then take 0.5mg once daily for 7 days.
Then stop medication.
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks: Last dose on [**3-9**].
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for sbp<95.
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
18. Aquaphor Ointment Sig: moderate amount Topical twice a
day: dry tissue, forehead, left upper chest, b/l lower
extremities. Also to scalp as needed for discomfort. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Rehab
Discharge Diagnosis:
1) Lower extremity deep venous thrombosis
2) Lower extremity and scrotal edema secondary to above
3) Adenocarcinoma of unclear primary with lesions in lung,
spine, and brain
4) Urinary Tract Infection (MSSA/Pseudomonas)
5) Stage II Sacral Decubitus Ulcer w/ skin breakdown of scrotum
6) Prostate Cancer
7) Hematuria
8) C. Diff Colitis
9) Hypotension - intermittent
10) Scalp pain - likely secondary to XRT
11) Heparin-Induced Thrombocytopenia
Discharge Condition:
Afebrile, vital signs stable. Still with significant lower
extremity and scrotal edema.
Discharge Instructions:
You have an extensive blood clot going down most of the lower
half of your body. Due to this clot blocking the return of
blood flow from your legs and scrotum, you have developed
significant leg and scrotal swelling. Attempts to remove the
clot through mechanical means were only partially successful.
The definitive treatment of thrombolysis can't be done because
you have metastatic lesions in your head and would be at very
high risk for bleeding. It appears that the coumadin you were
previously taking did not work to prevent the spread of clots.
Therefore, you were switched to a diffent blood-thinning
medications, Lovenox. Unfortunately, you developed a reaction
to this medicine (decrease in your platelet counts - Heparin
Induced Thrombocytopenia), for this reason you were changed to
another medication, Fondaparinux. You will need to remain on
this medication indefinitely. You will need to watch for signs
of bleeding, such as blood in your urine or stool.
.
You were treated for a urinary tract infection with
Ciprofloxacin for 2 weeks. As a result of receiving necessary
antibiotics, you developed C. Difficile colitis (an infection in
your colon). You were started on another antibiotic for this
(Flagyl). This antibiotic will need to be continued until [**3-9**]
(2 weeks after your Cipro was stopped).
.
You completed the course of radiation therapy to the brain and
spine. You will need to follow up in the Brain tumor clinic as
well as the thoracic oncology clinic.
.
Call your doctor or return to the emergency room if you should
develop chest pain, shortness of breath, worsening headache,
blurry vision, increased weakness or numbness, or significant
bleeding.
Followup Instructions:
Thoracic [**Hospital **] Clinic: [**0-0-**]. Please call to set up a
follow-up appointment.
.
Brain Tumor/Radiation Oncology: You will be contact[**Name (NI) **] by the
Brain [**Hospital 341**] Clinic for a follow up appointment on [**3-9**].
Alternatively, if you do not hear from the clinic, you can call
[**Telephone/Fax (1) 1844**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] of
Radiation oncology and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] of Neuro-Oncology.
.
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]. [**Telephone/Fax (1) 8572**]. Please call to
arrange follow up after discharge from rehab.
.
Urology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11789**]. ([**Telephone/Fax (1) 75977**]. You will need to
set up a follow up appointment with him to follow up on your
hematuria (blood in urine), management of your foley catheter,
and your elevated PSA found during this hospitalization.
Alternatively, if you would like to consolidate all of your care
at [**Hospital1 18**], you can schedule an appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3748**], ([**Telephone/Fax (1) 8791**].
.
Palliative Care: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**]. ([**Telephone/Fax (1) 75978**]. Can call to
further discuss options for palliative care.
|
[
"287.4",
"E934.2",
"V10.46",
"458.29",
"V66.7",
"285.1",
"V12.51",
"V45.89",
"227.0",
"576.8",
"608.86",
"E878.8",
"453.2",
"599.0",
"344.1",
"198.5",
"041.7",
"553.3",
"784.0",
"790.92",
"782.3",
"008.45",
"198.3",
"041.11",
"453.41",
"197.0",
"599.7",
"707.03",
"199.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"88.66",
"39.50",
"00.43"
] |
icd9pcs
|
[
[
[]
]
] |
23350, 23402
|
14953, 21042
|
376, 516
|
23888, 23978
|
4602, 6807
|
25720, 27203
|
3770, 3937
|
21349, 23327
|
23423, 23867
|
21068, 21326
|
24002, 25697
|
13806, 14930
|
3952, 4583
|
235, 338
|
544, 3003
|
3025, 3456
|
3472, 3754
|
6819, 13790
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,566
| 101,484
|
45824
|
Discharge summary
|
report
|
Admission Date: [**2106-9-22**] Discharge Date: [**2106-9-29**]
Date of Birth: [**2059-9-20**] Sex: M
Service: MEDICINE
Allergies:
Epoetin Alfa
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever and chills
Major Surgical or Invasive Procedure:
1. Revision left total knee replacement (polyethylene exchange).
2. Extensive irrigation, debridement and extensive synovectomy
left septic knee.
3. Temporary hemodialysis line placement and removal
4. Tunneled hemodialysis catheter placement
History of Present Illness:
47 year old male with ESRD, DM and HTN with chief complaint of
not feeling well for one week. Pt. has had chills, fever,
feeling hot, diarrhea, n/v on [**9-19**]). Feeling worse over this
past weekend. Pt. has a R IJ tunneled HD catheter and a L AVF
that is not mature. Still had chills todat at HD. In addition,
the catheter was not functioning at dialysis this am. Blood
cultures done at HD on [**2106-9-14**]. These came back positive for
gram positive cocci in pairs in both the aerobic and anaerobic
bottles, were confirmed enterococcus faecalis. Pt was initially
treated with cefazolin at HD until the sensitivities. He was
changed to vancomycin and received 1 gm vanc on Sat [**9-18**] and 500
mg vanc today. Yesterday noted onset of left knee swelling and
pain. Had temp of 101.8 at HD today.
He did not complete scheduled hemodialysis today (only 2 hrs
total). Last complete HD was Saturday.
Past Medical History:
1. Diabetes mellitus type I, on insulin, complications include
in neuropathy, a left toe amputation, and retinopathy.
2. Chronic renal insufficiency, started on HD [**2106-7-30**].
3. Peripheral vascular disease.
4. History of syncopal episodes.
5. Status post left toe amputation.
6. Autonomic neuropathy.
7. Degenerative joint disease.
8. Anemia of chronic inflammation.
9. History of orthostatic hypotension.
10. Hypertension.
11. Chronic diarrhea thought to be secondary to diabetic
enteropathy.
12. HCV.
13. History of left knee replacement secondary to trauma, [**2105**]
at [**Hospital1 112**].
Social History:
There is a prior history of IV drug abuse nine years ago. No
alcohol. Quit tobacco two years ago. Lives in a house with wife
and owns a shoe store. Has several grown children, all in good
health.
Family History:
Mother died of heart attack in early 50's. h/o DM, sister has
DM.
Physical Exam:
Vitals: Tc 98.6 BP 105/59 HR 79 RR 20 O2 sat 96%RA
Gen: NAD, alter, oriented
HEENT: PERRL, nl conjunctiva, clear mucous membranes
Neck: no LAD
Lungs: bibasliar crackles
Cor: RR, nls1 and s2, 2-3/6 systolic ejection murmur
Abd: +BS, NT, ND
Ext: Left knee swollen, warm to touch, pain with movement, no
petechia, splinter hemorrhages, or oslers node on fingers
Neuro: wnl
Pertinent Results:
[**2106-9-21**] 01:45PM BLOOD WBC-20.0*# RBC-2.97* Hgb-8.1* Hct-25.4*
MCV-86 MCH-27.3 MCHC-31.8 RDW-14.1 Plt Ct-352
[**2106-9-23**] 10:40AM BLOOD WBC-13.6* RBC-2.67* Hgb-7.3* Hct-22.7*
MCV-85 MCH-27.3 MCHC-32.1 RDW-14.6 Plt Ct-404
[**2106-9-24**] 05:15AM BLOOD WBC-14.6* RBC-2.97* Hgb-8.3* Hct-24.8*
MCV-84 MCH-27.8 MCHC-33.3 RDW-14.4 Plt Ct-388
[**2106-9-21**] 01:45PM BLOOD Glucose-251* UreaN-33* Creat-5.9* Na-134
K-4.1 Cl-96 HCO3-26 AnGap-16
[**2106-9-23**] 10:40AM BLOOD Glucose-56* UreaN-46* Creat-7.3* Na-138
K-3.5 Cl-100 HCO3-26 AnGap-16
[**2106-9-24**] 05:15AM BLOOD Glucose-130* UreaN-51* Creat-7.5* Na-135
K-3.9 Cl-98 HCO3-25 AnGap-16
[**2106-9-21**] 01:45PM BLOOD Vanco-11.5*
[**2106-9-22**] 05:45PM BLOOD Vanco-34.4
[**2106-9-23**] 10:40AM BLOOD Vanco-22.1*
CATHETER TIP-IV RT. IJ GRAM NEGATIVE ROD
Brief Hospital Course:
1. Bacteremia: The patient was admitted with fevers, chills, and
blood cultures growing enterococcus, with his HD catheter being
the culprit source. The line was discontinued and the line tip
and swab from the line swab grew enteroBACTER, pan-sensitive.
The patient was continued on vancomycin, with levels followed
for target trough of 15-20, for enterococcus as well as
levofloxacin for enterobacter, in addition to gentamicin. TTE
showed 1+ MR, no other valvular abnormalities. He is discharged
with five weeks of Vancomycin to complete a six-week course. He
is also being discharged on Levofloxacin and Gentamicin.
.
2. Knee pain/swelling- The patient was diagnosed with a septic
prosthetic knee, with joint fluid that grew enterococcus.
Orthopedic surgery was consulted and performed a knee wash out
in the OR on [**2106-9-22**] with polyethylene exchange. X-ray on
admission showed femoral periosteal thickening which raised the
question of chronic osteomyelitis; this is of uncertain activity
without prior films. No findings to suggest acute osteomyelitis,
but pt may need knee replacement or further debridement. HV in
place until [**9-25**]. The plan is for the patient to eventually have
the hardware replaced in his knee, once his infectious disease
issues resolve.
.
3. HCV- The patient was previously scheduled for a liver biopsy
but this was cancelled until bacteremia resolved.
.
4. ESRD: Renal followed the patient throughout his admission.
His creatinine steadily increased throughout the start of his
hospitalization. Renal attempted to use his new fistula on [**9-23**]
(placed [**8-11**]), but did the fistula did not function properly. A
tunnelled HD line was placed by IR on [**2107-9-28**] and the patient
reinitiated dialysis.
.
5. Anemia: The patient was noted to have a hematocrit that
trended down to 23.2, down from a baseline around 26. Per the
recommendation of Renal, the patient was given 1U PRBC with
lasix (pt does have some urine output).
.
6. DM- The patient was continued on a regular insulin sliding
scale
Medications on Admission:
Vancomycin
insulin sliding scale
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed.
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO QOD for 1
weeks.
[**Date Range **]:*4 Tablet(s)* Refills:*0*
6. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
QOD for 5 weeks: Will be dosed by level at Hemodialysis. Please
give this prescription to the hemodialysis nurse.
[**Last Name (Titles) **]:*15 -* Refills:*0*
7. Gentamicin 10 mg/mL Solution Sig: 0.7 mg/kg Intravenous QOD
for 2 weeks: Please check trough before hemodialysis. If less
than 1, give 0.7mg/kg dose. Please hand this prescription to
hemodialysis nurse.
[**Last Name (Titles) **]:*6 -* Refills:*0*
8. Insulin
NPH 12U, Regular 10U in AM
9. OxyContin 80 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO twice a day.
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
1. Enterobacter associated line infection
2. Enterococcus bacteremia
3. Enterococcus septic prosthetic knee
Secondary diagnoses:
1. Diabetes Mellitus
2. End stage renal disease on HD
3. Hypertension
Discharge Condition:
Good
Discharge Instructions:
You are discharged to home and should continue all medications
as prescribed. Please contact your primary care physician or
present to the ER if you experience fevers, chills, night
sweats, increased knee swelling or tenderness or other concerns.
You have many important follow-up appointments- please attend
every one.
Followup Instructions:
[**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2106-10-5**] 2:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-10-8**] 10:10
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX) PODIATRY Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2106-10-11**] 11:00
You have a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] on [**2106-10-13**] at 10:00. [**Telephone/Fax (1) 1792**]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-10-13**] 1:40
You have a follow-up appointment with Orthopedic surgeon Dr.
[**First Name (STitle) **] on [**2106-11-3**] at 10:30am. [**Telephone/Fax (1) 1113**]
Hemodialysis three times/week:
Vancomycin trough drawn and dosed at HD for five weeks
Gentamicin trough checked before each HD session. If less than
1, please give 0.7mg/kg dose for two weeks
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"996.66",
"250.51",
"790.7",
"711.06",
"070.70",
"250.61",
"996.62",
"337.1",
"403.91",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.95",
"81.55",
"80.76",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6953, 6959
|
3628, 5676
|
289, 534
|
7222, 7229
|
2791, 3605
|
7598, 8997
|
2319, 2386
|
5759, 6930
|
6980, 7108
|
5702, 5736
|
7253, 7575
|
2401, 2772
|
7129, 7201
|
233, 251
|
562, 1464
|
1486, 2089
|
2105, 2303
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,952
| 112,643
|
5119
|
Discharge summary
|
report
|
Admission Date: [**2128-3-2**] Discharge Date: [**2128-3-15**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Clotted AV graft, DKA.
Major Surgical or Invasive Procedure:
Thrombectomy of AV graft times two.
History of Present Illness:
56 year-old man with DM1 with insulin autoantibody receptor
syndrome, ESRD, PVD, chronic diastolic CHF, poor historian with
numerous admissions for hypoglycemia who presents from HD with
hyperglycemia. Pt presented for HD today which was unable to be
performed due to a clotted AVG. He was found to have a FSBS
>450. He also reported nausea and small amounts of vomiting
beginning this afternoon. Per his sister, he had been more
lethargic starting on Saturday. He denies any fevers, chills,
cough, chest pain, diarrhea, or dysuria.
.
In the ED, initial VS were: T 98, P 106, BP 185/111, RR 24,
O2sat 100. Labs showed WBC 12.7 (no bands but neut predominant),
K 5.4, bicarb 24, gluc 580, anion gap 23. EKG was without
peaked t waves but was notable for new TWI in V4-V6. Added on
CE with nl CK & CK-MB but trop 0.33 in setting of Cr 6.8. CXR
showed a RLL opacity. PIV 20g x 2 placed. Pt was given
insulin 10 units, then started on a gtt at 7 units/hour. He was
also given IVF at 150 cc/h (conservative as not dialyzed today
and limited UOP ~ once weekly) and started on vanc/zosyn for
PNA. Lactate initially 2.8 -> 1.8. He was evaluated by Surgery
re: HD access. Renal was made aware with plan for HD tmrw
pending access. On transfer, vitals: 98. 108, 28, 143/97, 100%
1L. ABG: 7.43/24/144/16 with lytes on that Na 144, K 1.9*, Cl
121, Glc 259, question if drawn near running IVF.
.
On the floor, pt is lethargic. He is responsive to voice and
does sit up to pull on more blankets and complains of feeling
cold but variably answering questions although responses
appropriate when he does. Does admit to noncompliance with his
insulin. No vomiting since earlier this afternoon.
Past Medical History:
1. Type 1 diabetes with insulin autoantibody receptor syndrome
-since age 16 on insulin, followed by Dr. [**Last Name (STitle) 10088**]
[**Name (STitle) 21002**] hypoglycemic episodes, has required intubation for
altered MS in the past
-high level of anti-insulin Ab
-complicated by nephropathy
-complicated by retinopathy (s/p right eye laser surgery,
repeated [**8-2**])
-on immunosuppression ?? no records at [**Hospital1 18**]
2. End-stage renal disease on dialysis
3. Diastolic heart failure
4. Hypertension
5. Hyperlipidemia
6. Peripheral vascular disease
7. Hypothyroidism
8. Anemia
9. Recent burn on his left upper extremity, now s/p skin graft
10. S/p left first toe distal phalangectomy in [**2127-9-28**]
11. Pancreatic lesions seen on an abdominal CT done in [**2127-5-28**]
Social History:
He states that he currently lives with his parents. Several
other relatives also live there at different times. He worked in
construction but was laid off. He denied alcohol tobacco, or
illicit drug use.
Family History:
Per OMR, history of DM (Type 1 and 2), RA and HTN.
Mother - Type 2 Diabetes [**Year (4 digits) **], Rheumatoid Arthritis
Maternal Aunt - Type 2 Diabetes [**Name (NI) **]
Nephew - Type 1 Diabetes [**Name (NI) **]
Physical Exam:
Vitals: T 96.4, P 108, BP 130/79, P 24, RR 99 2L.
General: Alert, oriented, no acute distress. Arousable to voice,
responds appropriately but selectively to questions.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, unable to assess JVD, no LAD
Lungs: Coarse BS b/l
CV: Regular rate, tachyardic, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Complete Blood Count:
[**2128-3-2**] 01:30PM BLOOD WBC-12.7*# RBC-4.28* Hgb-11.9* Hct-36.8*
MCV-86 MCH-27.8 MCHC-32.3 RDW-14.8 Plt Ct-333#
[**2128-3-3**] 06:00AM BLOOD WBC-11.8* RBC-4.07* Hgb-11.6* Hct-34.7*
MCV-85 MCH-28.6 MCHC-33.5 RDW-15.0 Plt Ct-372
[**2128-3-4**] 03:35PM BLOOD WBC-9.5 RBC-3.62* Hgb-10.6* Hct-31.1*
MCV-86 MCH-29.3 MCHC-34.0 RDW-14.8 Plt Ct-317
[**2128-3-5**] 12:00PM BLOOD WBC-9.7 RBC-3.54* Hgb-9.9* Hct-30.1*
MCV-85 MCH-28.0 MCHC-33.0 RDW-15.2 Plt Ct-207
[**2128-3-6**] 05:14AM BLOOD WBC-7.5 RBC-3.34* Hgb-9.6* Hct-29.1*
MCV-87 MCH-28.6 MCHC-32.9 RDW-14.9 Plt Ct-178
[**2128-3-8**] 07:10AM BLOOD WBC-5.4 RBC-3.61* Hgb-10.5* Hct-31.6*
MCV-88 MCH-29.0 MCHC-33.1 RDW-15.1 Plt Ct-171
[**2128-3-9**] 07:00AM BLOOD WBC-6.1 RBC-3.67* Hgb-10.5* Hct-32.1*
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.6* Plt Ct-204
[**2128-3-10**] 06:45AM BLOOD WBC-5.0 RBC-3.57* Hgb-10.2* Hct-31.5*
MCV-88 MCH-28.7 MCHC-32.5 RDW-15.7* Plt Ct-197
[**2128-3-11**] 07:10AM BLOOD WBC-3.5* RBC-3.41* Hgb-9.9* Hct-30.0*
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.9* Plt Ct-171
[**2128-3-12**] 07:45AM BLOOD WBC-3.9* RBC-3.32* Hgb-9.8* Hct-29.4*
MCV-89 MCH-29.6 MCHC-33.4 RDW-15.6* Plt Ct-176
[**2128-3-13**] 07:00AM BLOOD WBC-4.3 RBC-3.67* Hgb-10.7* Hct-32.3*
MCV-88 MCH-29.1 MCHC-33.0 RDW-16.1* Plt Ct-173
[**2128-3-14**] 10:05AM BLOOD WBC-4.4 RBC-3.78* Hgb-11.0* Hct-34.0*
MCV-90 MCH-29.0 MCHC-32.3 RDW-15.8* Plt Ct-170
[**2128-3-15**] 07:30AM BLOOD WBC-4.4 RBC-3.76* Hgb-10.9* Hct-33.9*
MCV-90 MCH-29.0 MCHC-32.2 RDW-15.9* Plt Ct-156
[**2128-3-2**] 01:30PM BLOOD Neuts-84.6* Lymphs-12.1* Monos-2.4
Eos-0.7 Baso-0.1
.
Basic Metabolic Profile:
[**2128-3-2**] 01:30PM BLOOD Glucose-580* UreaN-33* Creat-6.8*# Na-143
K-5.4* Cl-96 HCO3-24 AnGap-28*
[**2128-3-2**] 07:32PM BLOOD Glucose-273* UreaN-35* Creat-7.4* Na-146*
K-3.5 Cl-106 HCO3-20* AnGap-24*
[**2128-3-2**] 07:32PM BLOOD Glucose-636* UreaN-31* Creat-6.6* Na-134
K-2.8* Cl-95* HCO3-25 AnGap-17
[**2128-3-3**] 12:00AM BLOOD Glucose-53* UreaN-34* Creat-7.2* Na-149*
K-3.6 Cl-109* HCO3-29 AnGap-15
[**2128-3-3**] 06:00AM BLOOD Glucose-113* UreaN-33* Creat-7.3* Na-146*
K-3.8 Cl-104 HCO3-30 AnGap-16
[**2128-3-4**] 03:35PM BLOOD Glucose-298* UreaN-34* Creat-7.7* Na-138
K-3.3 Cl-102 HCO3-26 AnGap-13
[**2128-3-5**] 12:00PM BLOOD Glucose-279* UreaN-36* Creat-8.3* Na-140
K-4.2 Cl-101 HCO3-21* AnGap-22*
[**2128-3-6**] 05:14AM BLOOD Glucose-64* UreaN-16 Creat-4.7*# Na-142
K-4.0 Cl-102 HCO3-29 AnGap-15
[**2128-3-8**] 07:10AM BLOOD Glucose-50* UreaN-10 Creat-4.4* Na-142
K-3.9 Cl-102 HCO3-32 AnGap-12
[**2128-3-9**] 07:00AM BLOOD Glucose-94 UreaN-9 Creat-3.8* Na-142
K-3.9 Cl-102 HCO3-30 AnGap-14
[**2128-3-10**] 06:45AM BLOOD Glucose-85 UreaN-8 Creat-3.2* Na-144
K-4.2 Cl-104 HCO3-32 AnGap-12
[**2128-3-11**] 07:10AM BLOOD Glucose-190* UreaN-11 Creat-4.1* Na-140
K-4.2 Cl-102 HCO3-29 AnGap-13
[**2128-3-12**] 07:45AM BLOOD Glucose-175* UreaN-12 Creat-3.3* Na-140
K-4.4 Cl-102 HCO3-31 AnGap-11
[**2128-3-13**] 07:00AM BLOOD Glucose-277* UreaN-19 Creat-4.0* Na-137
K-4.7 Cl-98 HCO3-31 AnGap-13
[**2128-3-14**] 10:05AM BLOOD Glucose-158* UreaN-17 Creat-3.4* Na-142
K-4.9 Cl-99 HCO3-34* AnGap-14
[**2128-3-15**] 07:30AM BLOOD Glucose-293* UreaN-25* Creat-4.0* Na-136
K-5.1 Cl-98 HCO3-30 AnGap-13
.
[**2128-3-2**] 07:32PM BLOOD Calcium-8.9 Phos-2.7# Mg-1.9
[**2128-3-2**] 07:32PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.7
[**2128-3-3**] 12:00AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8
[**2128-3-3**] 06:00AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.4
[**2128-3-5**] 12:00PM BLOOD Calcium-8.1* Phos-4.9*# Mg-2.1
[**2128-3-6**] 05:14AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.8
[**2128-3-8**] 07:10AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6
[**2128-3-9**] 07:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7
[**2128-3-10**] 06:45AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7
[**2128-3-11**] 07:10AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.7
[**2128-3-12**] 07:45AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7
[**2128-3-13**] 07:00AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.8
[**2128-3-14**] 10:05AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.1
[**2128-3-15**] 07:30AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1
.
Cardiac Enzymes:
[**2128-3-2**] 01:30PM BLOOD CK(CPK)-126
[**2128-3-2**] 07:32PM BLOOD CK(CPK)-84
[**2128-3-2**] 07:32PM BLOOD CK(CPK)-71
[**2128-3-3**] 06:00AM BLOOD CK(CPK)-70
[**2128-3-3**] 03:25PM BLOOD CK(CPK)-68
[**2128-3-2**] 01:30PM BLOOD cTropnT-0.33*
[**2128-3-2**] 07:32PM BLOOD CK-MB-NotDone cTropnT-0.31*
[**2128-3-2**] 07:32PM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2128-3-3**] 06:00AM BLOOD CK-MB-5 cTropnT-0.31*
[**2128-3-3**] 03:25PM BLOOD CK-MB-NotDone cTropnT-0.31*
.
[**2128-3-2**] 07:32PM BLOOD TSH-4.9*
[**2128-3-3**] 06:00AM BLOOD Free T4-1.3
[**2128-3-2**] 07:32PM BLOOD Cortsol-20.8*
.
[**2128-3-2**] 04:55PM BLOOD Type-MIX pO2-144* pCO2-24* pH-7.43
calTCO2-16* Base XS--5 Comment-[**Known lastname **] TOP
[**2128-3-2**] 07:47PM BLOOD Type-ART pO2-142* pCO2-19* pH-7.73*
calTCO2-26 Base XS-7
[**2128-3-3**] 12:16AM BLOOD Type-[**Last Name (un) **] pO2-60* pCO2-38 pH-7.52*
calTCO2-32* Base XS-7
[**2128-3-2**] 01:33PM BLOOD Glucose-GREATER TH Lactate-2.8* K-5.4*
[**2128-3-2**] 04:55PM BLOOD Glucose-259* Lactate-1.4 Na-144 K-1.9*
Cl-121*
.
ECG ([**2128-3-2**]): Sinus tachycardia. Left anterior fascicular block.
Anterolateral T wave abnormalities are non-specific but cannot
exclude myocardial ischemia. Clinical correlation is suggested.
Since the previous tracing of [**2128-1-30**] further precordial T wave
changes are now present.
.
Chest Radiograph ([**2128-3-2**]): IMPRESSION: Given the volume loss,
the hazy basilar opacity in the right lung is felt most likely
to represent atelectasis. It is difficult to entirely exclude an
early developing pneumonia and clinical correlation is
recommended. There is likely a small pleural effusion on the
right as well. No signs of fluid overload.
.
Chest Radiograph ([**2128-3-4**]): Lung volumes are much improved and
there is no consolidation any longer at the right lung base.
Mild peribronchial opacification in the left lower lobe is
comparable in appearance to [**3-2**] and could be either
atelectasis or a very small focus of pneumonia. The upper lungs
are clear. Fullness in the upper mediastinum could be due to
venous engorgement in the supine position. Would recommend
upright views when feasible for clarification. Heart size is
normal. No pneumothorax or pleural effusion is evident on the
supine view.
.
Chest Radiograph ([**2128-3-6**]): FINDINGS: Upright portable chest
x-ray compared with [**2128-3-5**]. There is resolution of the
right lower lobe consolidation. There is new small left pleural
effusion with minimal atelectasis. No focal consolidation is
seen. There is no pneumothorax. Cardiomediastinal silhouette is
normal.
IMPRESSION:
1. No evidence of pneumonia in the right lower lobe.
2. New small left pleural effusion with linear atelectasis.
Brief Hospital Course:
56 yo man with a h/o DM I with insulin autoantibody receptor
syndrome, ESRD, PVD, chronic diastolic CHF (last echo [**7-5**]) who
presented originally with DKA and clotted AV graft.
.
# DKA: Patient found to be in DKA secondary to insulin
noncompliance, which has been a pattern illustrated by numerous
prior hospitalizations. Also with history of extremely labile
blood sugars. He was started on an insulin drip and intravenous
fluids. His gap (initially 23) closed with normalization of his
glucose and patient was transitioned to subcutaneous insulin
with improvement in blood sugar control. [**Last Name (un) **] Diabetes
service was consulted and followed sugars daily with uptitration
in insulin as needed. At the time of discharge, was changed to
levemir insulin 8 units in the AM supplemented with insulin
sliding scale with meals. No clear infectious precipitant.
Patient was continued on his PO steroids 10mg daily, though it
remains unclear whether this has improved glycemic control.
Patient will be discharged home with VNA to ensure proper
medication administration and compliance. Will follow up with
PCP and [**Name9 (PRE) 1944**] clinic closely.
.
# AV graft thrombus: With stabilization of DKA, patient was
taken to OR for RUE AV graft thrombectomy. The venous
anastamosis was successfully revised, which required repeat
thrombectomy due to rethrombosis. He was able to continue HD
successfully after this procedure.
.
# ESRD: Patient continued HD as an inpatient and will follow up
as an outpatient with no changes to his HD schedule.
.
# Diarrhea: Patient reported several episodes during his
hospitalization that resolved spontaneously. Was without
chills, leukocytosis, or abdominal pain.
.
# Cognitive dysfunction and inability to care for self: Several
team meeting held throughout hospital course with family, legal,
case management, social work, and primary care physician.
[**Name10 (NameIs) 15421**] [**Name11 (NameIs) 21030**] evaluation on [**2128-3-4**], reported that given
patient's cognitive dysfunction, it would be best to have a
guardian appointment for medical decision making (not just
admitted to a nursing facility) given his processing
difficulties and repeated problems with poor self care. Ethics
team was consulted and it was deemed safe for patient to be
discharged home, as was the wish of the patient and his son, the
temporary legal guardian in regards to placement. The
patient's father is currently contemplating full guardianship
for medical decision making.
.
# HTN: Patient was continued on home dose of metoprolol 50mg PO
TID. Diltiazem was decreased to 180mg PO daily with plan to
uptitrate as an outpatient as needed.
.
# Pneumonia: With radiographic suggestion of PNA on admission.
Patient was initially treated with vanco/zosyn for three days
before antibiotics were stopped due to low suspicion given that
patient remained afebrile, with no leukocytosis, or cough.
.
# Chronic diastolic CHF: Patient was euvolemic on exam.
.
# Hypothyroidism: Stable, continued outpatient levothyroxine.
.
# Anemia: Stable. He continued epo at HD.
Medications on Admission:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for n/v.
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
15. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
17. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Ten (10)
Subcutaneous QAM.
18. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6)
Subcutaneous QPM.
19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
21. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
22. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for toe pain.
23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
capsule, Delayed Release(E.C.) PO DAILY (Daily).
24. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units
Subcutaneous four times a day: Please check fingersticks QID and
administer insulin based on the attached sliding scale.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO twice a
day.
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four
times a day as needed for nausea.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
15. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO twice a day.
16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO once a day as needed for constipation.
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
20. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
21. Humalog 100 unit/mL Cartridge Sig: as directed Subcutaneous
four times a day: Please check fingersticks four times a day and
administer insulin based on the attached sliding scale.
22. Levemir 100 unit/mL Solution Sig: 8 units Subcutaneous qAM.
Disp:*1 month supply* Refills:*2*
23. Insulin Lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous AS DIR: Please take as directed with insulin
sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Diabetic Ketoacidosis
DM1 with insulin autoantibody receptor syndrome
.
Secondary:
ESRD
Diastolic congestive heart failure
Hypertension
Hyperlipidemia
Hypothyroidism
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 at [**Hospital1 827**]. You were admitted to the hospital due to very
high sugars and a condition called diabetic ketoacidosis. You
initially were treated in the Intensive Care Unit with insulin.
As your sugars stabilized, you were transferred to the medicine
floor for further monitoring. Your AV graft for dialysis was
also surgically repaired. Your sugars remain stable and you are
medically cleared to return home. You will have a visiting
nurse who will be able to help make sure that you are taking
your medications properly.
.
We have made the following changes to your medications:
--> decreased diltiazem to 180mg by mouth daily
--> decreased prednisone to 10mg by mouth daily
--> changed levemir to 8 units in the morning
--> changed your insulin sliding scale. Please see attached
chart.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2128-3-19**] at 3:10 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2128-3-29**] at 3:25 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: MONDAY [**2128-4-5**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"244.9",
"250.53",
"362.01",
"486",
"585.6",
"428.32",
"403.91",
"V45.11",
"285.9",
"250.43",
"428.0",
"250.13",
"348.30",
"996.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.49",
"39.42"
] |
icd9pcs
|
[
[
[]
]
] |
18341, 18399
|
10688, 13797
|
291, 328
|
18618, 18618
|
3880, 7918
|
19636, 20536
|
3098, 3311
|
16123, 18318
|
18420, 18597
|
13824, 16099
|
18769, 19373
|
3326, 3861
|
19402, 19613
|
7935, 10665
|
229, 253
|
356, 2049
|
18633, 18745
|
2071, 2860
|
2876, 3082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,849
| 173,832
|
46932
|
Discharge summary
|
report
|
Admission Date: [**2171-6-25**] Discharge Date: [**2171-7-24**]
Date of Birth: [**2108-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
R IJ central line
PICC line placed for long term IV access for intravenous
antibiotics.
Cholecystostomy tube placed by radiology
Foley catheter
History of Present Illness:
Mr. [**Known lastname 99500**] is a 62 year old gentleman with history of multiple
sclerosis, [**Known lastname 862**] disorder, dementia, and chronic indwelling
foley with recurrent UTIs (including ESBL klebsiella) presented
from his nursing home with altered mental status. In
communication with his PCP and [**Name9 (PRE) **] [**Last Name (Titles) **], the patient's
baseline mental status is alert and talkative(occasionally
rambling), but he became lethargic and somnolent beginning the
day prior to admission at the nursing home. He reportedly had a
U/A and culture sent 3 days prior to admission which revealed
VRE (reportedly only sensitive to macrodantin) and proteus. His
nurse practitioner felt he was likely colonized with VRE and
proteus was sensitive to ampicillin, thus he was started on
ampicillin at that time. At that time, he was also felt to be
fecally obstructed, so he was given a fleets enema to which he
responded well. On the evening prior to admission, in addition
to his change in mental status, he was found to be tachycardic
to the low 100s. He was, however, afebrile and systolic blood
pressures were consistently in the 100s-120s. His mental status
declined overnight at the nursing home and he was transferred to
the ED for further evaluation and management.
.
In the ED, his initial vitals revealed: HR 107 BP 98/28 RR 14
O2sat 100%on NRB-->RA; no temperature was recorded. He was
noted to have abdominal discomfort and suprapubic fullness. His
foley was found to be obstructed and when resolved, was noted to
drain frank pus from his bladder. Labs demonstrated WBC count
of 27 with 16% bandemia and an elevated lactate to 10.5 which
decreased to 8.6 with IV fluids. A CT abd/pelvis was obtained
to rule out bowel ischemia and surgery was consulted. CT
abd/pelvis did not reveal ischemia of the gut, but did note
thickening of perirectal and sigmoid wall believed consistent
with chronic laxative use vs. infectious/inflammatory etiology.
A CXR showed a retrocardiac opacity thought to represent
atelectasis vs. consolidation. Blood and urine cultures were
sent and he received vanco/levofloxacin/flagyl. Given his
altered mental status, a head CT was obtained which was negative
for hemorrhage and mass effect.
.
Although it is not clearly documented, he reportedly received 7L
NS IV fluid resuscitation. His ED course was complicated by
multiple attempts at central venous access and he was initially
started on peripheral dopamine to maintain his blood pressure.
A right IJ was then placed and MAPs remained in the low 50s so
levophed was started in addition to dopamine prior to his
transfer to the ICU.
.
ROS: Unable to obtain secondary to altered mental status.
Past Medical History:
# Secondary Progressive MS: first symptoms in [**2125**]; received
courses of steroids in the past; diagnosed at [**Hospital1 2025**]; now with
dementia, decreased vision, paraplegia and decreased function UE
L>R, unable to ambulate for the past 6 yrs; Foley;
# [**Hospital1 **] Disorder: no seizures since [**2168**], has been on PHT and
tegretol
# Frequent UTIs (Klebsiella ESBL in past)
# [**Year (4 digits) **] retention
# Trigeminal Neuralgia
# GERD
# decub ulcers back and feet
# decreased vision (20/400)
# Temporomandibular Joint pain
# Thoracic spine stage IV decubitus ulcer
Social History:
Sister very involved in care and health care proxy. [**Hospital 8304**]
Nursing home resident.
Full code.
Family History:
Non-contributory.
Physical Exam:
PE: T 97.3 HR 115 BP 106/44 RR 15 O2sat 100% NRB CVP 8-9
Gen: Pale, unresponsive to sternal rub, withdraws LUE when
attempting ABG, moving left LE spontaneously, unresponsive to
simple commands
Neck: No carotid bruits appreciated
HEENT: Dry MM, PERRL, gaze conjugate, no roving eye movements
CV: sinus tachy, no mrg appreciated
Resp: CTA anteriorly, clear posteriorly, but not moving large
amounts of air
Abd: +BS, soft, distended, no palpable masses, does not respond
to deep palpation of abdomen
Back: Stage 2 ulcer on thoracic spine, no evidence of purulence
nor surrounding cellulitis, dressed with duoderm
Ext: Toes cool b/l, but with good DP/PT pulses b/l, upper limit
normal capillary refill time
Neuro: See above.
Pertinent Results:
[**2171-6-25**]
9:43p
Source: Line-aline
141 108 31 128 AGap=21
3.3 15 1.1
Ca: 7.5 Mg: 1.7 P: 3.4
[**2171-6-25**]
8:00p
pH
7.36 pCO2
31 pO2
155 HCO3
18 BaseXS
-6
Type:Art; Not Intubated; Cool Neb; FiO2%:70; Temp:36.7
Lactate:4.7
Comments: Lactate: Verified
[**2171-6-25**]
5:07p
Source: Line-central line
SLIGHTLY HEMOLYZED
142 109 32 130 AGap=19
3.7 18 1.2
Comments: K: Hemolysis Falsely Elevates K
CK: 2496 MB: 44 MBI: 1.8 Trop-T: 0.03
Comments: CK(CPK): Verified By Dilution
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 6.8 Mg: 1.7 P: 3.5
Comments: Mg: Hemolysis Falsely Elevates Mg
[**2171-6-25**]
5:00p
Lactate:4.9
Comments: Lactate: Verified
O2Sat: 75
[**2171-6-25**]
2:20p
ALB & CARBA ADDED [**6-25**] @ 15:49; MODERATELY HEMOLYZED SPECIMEN
ALT: AP: Tbili: Alb: 2.7
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Carbamaz: 2.4
Other Blood Chemistry:
Cortsol: 43.7
Comments: Cortsol: Normal Diurnal Pattern: 7-10am 6.2-19.4 /
4-8pm 2.3-11.9
[**2171-6-25**]
2:16p
pH
7.27 pCO2
33 pO2
128 HCO3
16 BaseXS
-10
Type:Art; Temp:36.1
Na:140
K:3.5
Cl:115 Glu:169
Lactate:6.6
Comments: Lactate: Verified
[**2171-6-25**]
1:50p
DIL ADDED 2:32PM; SLIGHTLY HEMOLYZED SPECIMEN
Phenytoin: 9.4
Other Blood Chemistry:
Cortsol: 39.8
Comments: Cortsol: Normal Diurnal Pattern: 7-10am 6.2-19.4 /
4-8pm 2.3-11.9
[**2171-6-25**]
1:00p
Other Blood Chemistry:
Cortsol: 30.1
Comments: Cortsol: Normal Diurnal Pattern: 7-10am 6.2-19.4 /
4-8pm 2.3-11.9
Other Urine Chemistry:
UreaN:246
Creat:17
Na:93
Osmolal:308
Other Hematology
FDP: 160-320
PT: 17.9 PTT: 35.5 INR: 1.7
Fibrinogen: 486 D
Other Hematology
D-Dimer: 6786
[**2171-6-25**]
10:22a
Lactate:5.9
Comments: Lactate: Verified
[**2171-6-25**]
10:20a
Trop-T: 0.02
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
142 109 41 160 AGap=23
3.9 14 1.7 D
Comments: HCO3: Notified [**Location (un) **] At 1155am On [**2171-6-25**]. Pfr
CK: 2067 MB: 32 MBI: 1.5
Ca: 6.2 Mg: 1.7 P: 4.2
ALT: AP: Tbili: Alb:
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Vit-B12:1051 Folate:19.6
Other Blood Chemistry:
Iron: 8
calTIBC: 186
Ferritn: 304
TRF: 143
95
32.3 10.9 D 214
32.0 D
N:76 Band:16 L:4 M:2 E:0 Bas:0 Metas: 2
Comments:
Neuts: DOHLE BODIES
Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Burr: 1+
Retic: 1.0
PT: 17.5 PTT: 36.5 INR: 1.6
[**2171-6-25**]
09:40a
pH
7.24 pCO2
40 pO2
52 HCO3
18 BaseXS
-9
Comments: pH: No Calls Made - Not Arterial Blood
Type:[**Last Name (un) **]
[**2171-6-25**]
07:01a
Green Top
Lactate:8.6
Comments: Lactate: Verified
[**2171-6-25**]
05:30a
Color
Yellow Appear
Cloudy SpecGr
1.020 pH
7.0 Urobil
Neg Bili
Neg
Leuk
Mod Bld
Lg Nitr
Neg Prot
100 Glu
Neg Ket
Neg
RBC
[**10-15**] WBC
>50 Bact
Many Yeast
None Epi
[**1-28**]
Other Urine Counts
3PhosX: Many
[**2171-6-25**]
03:51a
pH
7.19 pCO2
41 pO2
51 HCO3
16 BaseXS
-11
Comments: pH: Verified
pH: Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:[**Last Name (un) **]; Green Top Tube
Na:140
K:3.9
Cl:111 Glu:154
Lactate:10.5
[**2171-6-25**]
03:45a
PT: 16.4 PTT: 35.4 INR: 1.5
[**2171-6-25**]
01:50a
135 98 55 163
>10.0 15 3.2
Comments: K: Hemolysis Falsely Elevates K
K: Hemolyzed, Grossly
K: Notified [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-Ed 3:05 A.M. [**2171-6-25**]
estGFR: 20/24 (click for details)
CK: 1178 MB: 12 MBI: 1.0 Trop-T: 0.05
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 8.3 Mg: 2.5 P: 3.5
ALT: 48 AP: 88 Tbili: 0.6 Alb:
AST: 117 LDH: Dbili: TProt:
[**Doctor First Name **]: 614 Lip: 51
Comments: AST: Hemolysis Falsely Increases This Result
97
27.1 15.9 306
47.7
N:72 Band:16 L:4 M:3 E:0 Bas:0 Metas: 5
Poiklo: 1+ Tear-Dr: 1+
Plt-Est: Normal
Comments: Plt-Smr: Large Plt Seen
.
MICROBIOLOGY:
[**2171-6-25**] 3:45 am BLOOD CULTURE **FINAL REPORT [**2171-6-27**]** ([**2-27**]
bottles)
PROTEUS MIRABILIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
SENSITIVITIES: MIC expressed in
MCG/ML
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2171-6-25**] 5:30 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2171-6-27**]**
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
[**2171-6-25**] 8:08 pm CATHETER TIP-IV Source: Midline.
**FINAL REPORT [**2171-6-28**]**
WOUND CULTURE (Final [**2171-6-28**]):
DUE TO MIXED BACTERIAL TYPES ( >= 3 COLONY TYPES) NO
FURTHER WORKUP
WILL BE PERFORMED.
PROTEUS MIRABILIS. >15 colonies.
Isolate(s) identified and susceptibility testing
performed because
of concomitant positive blood culture(s).
Comparison of the susceptibility patterns may be
helpful to assess
clinical significance.
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2171-6-27**] 2:49 pm BLOOD CULTURE Source: Line-aline.
PENDING......
[**2171-6-28**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
.
[**2171-6-26**] 3:49 am STOOL
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final [**2171-6-28**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2171-6-26**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
.
IMAGING:
Head CT [**6-25**]: 1. No acute intracranial hemorrhage. No
significant change compared to CT of [**2171-5-12**] with multiple
chronic findings as described above. 2. Soft tissue density
material within the external auditory canals bilaterally, most
likely cerumen. Correlation with physical exam is recommended.
.
Portable abdomen [**6-25**]: 1. Marked gastric distention. Dilated
nonspecified loops of bowel. Obstruction cannot be excluded. 2.
Suggestion of markedly distended bladder.
.
CT abdomen/pelvis [**6-25**]: Detailed evaluation of the
intra-abdominal and pelvic organs is limited secondary to lack
of intravenous contrast administration and artifact secondary to
patient arm positioning.
1. No acute intra-abdominal or intra-pelvic pathology.
2. Thickening of the rectal and sigmoid walls may be secondary
to chronic use of laxatives. Infectious proctitis and
inflammatory bowel disease also remain in the differential
diagnosis. Vascular etiologies are considered less likely. If
abdominal symptoms persist, consider follow up exam with oral
and IV contrast.
3. Mild bilateral hydronephrosis. Small bladder diverticulum.
4. Diffuse osteopenia with contiguous compression fractures of
the thoracic and lumbar spine as described above of, age
indeterminate, but overall chronic in appearance.
5. Right femoral head subchondral sclerotic line could represent
a stress fracture versus early avascular necrosis.
.
portable CXR [**6-25**]: 1. Right internal jugular central venous line
tip likely terminates in the cavo-atrial junction. 2. Increased
left retrocardiac opacity may represent atelectasis or
consolidation.
portable CXR [**6-26**]: Cardiac silhouette is obscured and is probably
at the upper limits of normal in size. Bibasilar atelectasis and
possible small effusion. No vascular congestion and I doubt the
presence of consolidations. Tip of the right IJ line lies in the
right atrium. Allowing for technical differences, there is
little change from exam 24 hours ago, including the IJ line
placement. Tip of NG tube in stomach.
.
EKG [**6-25**] 2:29 am: Baseline artifact. Sinus tachycardia. Low QRS
voltage in the limb leads. Diffuse T wave flattening which is
non-specific. Compared to tracing of [**2171-5-12**] significant sinus
tachycardia is new. Clinical correlation is suggested.
Rate PR QRS QT/QTc P QRS T
132 118 92 322/400 56 56 57
EKG [**6-25**] 12:29 pm: Sinus tachycardia with slight ST segment
elevations in leads I and aVL. New T wave inversion in leads
V1-V4 with ST-T wave flattening in leads V5-V6. These findings
are consistent with acute anterolateral ischemic process.
Followup and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
108 152 92 364/427.57 30 -5 9
WBC scan - Decision:
Following the injection of autologous white blood cells labeled
with In-111,
images of the whole body were obtained.
These images show no abnormal foci of tracer accumulation.
The above findings are consistent with no radiologic evidence of
any fever
focus.
However, the sensitivity of the study for detection of occult
infection is
decreased by prolonged antibiotic use.
IMPRESSION: No radiologic evidence of any focal fever source
with limitations as
noted above.
PICC change - IMPRESSION: Successful exchange of a previously
placed PICC line over the wire with a new placement of 35 cm
double-lumen line PICC line with tip in the distal part of the
SVC. The line is ready for use.
CXR [**7-22**] - Lung volumes remain quite low. Subsegmental
atelectasis in the left mid lung is unchanged since [**7-16**],
new since [**7-8**]. Upper lungs clear. No pneumonia or
pulmonary edema. Small bilateral pleural effusion may be
present. Heart size normal. Tip of the right PIC catheter
projects over the superior cavoatrial junction.
UPEP - pending
Rib XR- IMPRESSION:
1. Several old healed rib fractures on the right lower inferior
rib cage. The right sixth rib laterally may be acute.
2. A biliary drain identified.
3. Small bilateral pleural effusions and atelectasis at the lung
bases.
LENI bilaterally - CONCLUSION: No evidence of DVT.
CT [**2171-7-14**]: CT OF THE CHEST WITH IV CONTRAST: The heart and
great vessels are unremarkable. There is no pericardial
effusion. No pulmonary nodules or opacities are identified.
There are small, bilateral pleural effusions with associated
atelectasis which are overall unchanged in appearance compared
to [**2171-7-3**].
CT OF THE ABDOMEN WITH IV CONTRAST: The patient is status post
cholecystostomy with a pigtail drain coiled within the
gallbladder fossa in good position. The gallbladder itself is
overall decompressed. There is no evidence of intra- or
extra-hepatic biliary dilatation. The liver is normal in
appearance without focal lesion. The spleen, pancreas, adrenal
glands, stomach and abdominal portions of the large and small
bowel are unremarkable. A small, 3-mm low-attenuation lesion
within the mid pole of the left kidney is too small to
characterize but likely represents a simple renal cyst (2:59).
There are a few, sub 5-mm low-attenuation lesions within the
right kidney which are also too small to characterize but likely
represent simple cysts. There is no free air or free fluid
within the abdomen. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes identified. There are few prominent
mesenteric lymph nodes present.
CT OF THE PELVIS WITH IV CONTRAST: There is mild wall thickening
of the rectum and sigmoid colon which overall is improved in
appearance compared to the previous examination. A Foley balloon
is present within the bladder which is relatively decompressed.
The bladder wall is mildly thickened and this is also unchanged
compared to the previous evaluation. There is no free fluid in
the pelvis. There are no pathologically enlarged inguinal or
pelvic lymph nodes.
OSSEOUS STRUCTURES: Diffuse osteopenia is unchanged. Old
fractures of the right superior and inferior pubic rami are also
unchanged. Contiguous compression fractures of the entire
thoracolumbar spine are present and unchanged. There are no
suspicious lytic or blastic lesions.
IMPRESSION:
1. Status post cholecystostomy with pigtail drain placed within
the gallbladder fossa in good position. No intraabdominal fluid
collections.
2. Stable appearance of bilateral pleural effusions and adjacent
atelectasis.
GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL DRAINA
Reason: Place a cholecystostomy tube
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with HIDA scan positive for cholecystitis. Poor
surgical candidate for GB removal and fevers despite antibiotics
REASON FOR THIS EXAMINATION:
Place a cholecystostomy tube
INDICATION: Acute cholecystitis on HIDA scan. Poor surgical
candidate.
COMPARISON: HIDA, [**2171-7-9**].
PROCEDURE/FINDINGS: A prominent dilated gallbladder with a few
intraluminal shadowing stones is appreciated. After explaining
the risks and benefits of the procedure, informed written
consent was obtained. The patient was placed supine on the table
and a timeout was performed to confirm patient name, location,
and procedure. The patient was prepped and draped in the usual
sterile fashion and 1% lidocaine was used for local anesthesia.
Under constant ultrasound guidance, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4300**] needle was
percutaneously placed into the gallbladder. An 8 French dilator
was used and an 8 French pigtail catheter was subsequently
threaded into the gallbladder lumen. 100 cc of dark bile was
aspirated and sent for culture.
The patient tolerated the procedure well and there were no
complications. Mild sedation was used including 25 mcg of
Fentanyl IV. The attending, Dr. [**First Name (STitle) **] [**Name (STitle) **], was present and
performed the entire procedure.
Post-procedure orders were placed in CareWeb.
IMPRESSION: Successful ultrasound-guided drainage and catheter
placement within gallbladder.
ECHO - Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler. The estimated right atrial pressure is 0-5mmHg.
Left
ventricular wall thickness, cavity size and regional/global
systolic function
are normal (LVEF >55%) There is no ventricular septal defect.
Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no
aortic regurgitation. No masses or vegetations are seen on the
aortic valve.
The mitral valve leaflets are structurally normal. No mass or
vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
There is mild
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen.
PORTABLE CHEST OF [**2171-7-8**].
COMPARISON: [**2171-7-2**].
INDICATION: Fever.
New right PICC line terminates in the superior vena cava.
Cardiac and mediastinal contours are stable in appearance.
Worsening bibasilar retrocardiac opacities are present, probably
related to atelectasis, although underlying infectious process
is not excluded. Small pleural effusions, right greater than
left, are not substantially changed.
MRI L, T spine - IMPRESSION: No evidence of spondylodiscitis or
epidural or paraspinal abscesses of the thoracolumbar spine.
Degenerative changes of the thoracolumbar spine without canal
stenosis.
Partially imaged are degenerative changes of the cervical spine
with likely mild-to-moderate canal stenosis at the C3/4 and C4/5
levels.
Large right pleural effusion.
RIGHT FEMUR ON [**7-6**]
HISTORY: Fever. Possible AVN.
Five views of the upper and lower femur show no abnormality of
the femoral head, neck, trochanteric region are normal. There is
some demineralization of the mid shaft and heterogeneous
mineralization of the condyles of the femur and possibly tibial
plateau. I would recommend routine views of the knee for better
characterization.
KUB [**2171-6-25**] - IMPRESSION:
1. Marked gastric distention. Dilated nonspecified loops of
bowel. Obstruction cannot be excluded.
2. Suggestion of markedly distended bladder.
CT head: IMPRESSION:
1. No acute intracranial hemorrhage. No significant change
compared to CT of [**2171-5-12**] with multiple chronic findings as
described above.
2. Soft tissue density material within the external auditory
canals bilaterally, most likely cerumen. Correlation with
physical exam is recommended.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2171-7-23**] 06:07AM 7.1 2.98* 8.9* 27.6* 93 30.0 32.4 15.0
880*
Source: Line-PICC
[**2171-7-22**] 05:00AM 8.6 2.86* 8.7* 26.5* 92 30.4 32.9 14.6
850*
Source: Line-PICC
[**2171-7-21**] 04:26AM 6.9 2.82* 8.5* 26.0* 92 30.0 32.5 14.5
779*
Source: Line-PICC
[**2171-7-20**] 05:44AM 7.2 2.73* 8.1* 25.6* 94 29.8 31.8 14.4
842*
Source: Line-L PICC
[**2171-7-19**] 06:00AM 7.2 2.74* 8.6* 25.7* 94 31.4 33.4 14.5
806*
Source: Line-PICC
[**2171-7-17**] 03:15PM 8.5 3.09* 9.5* 29.1* 94 30.6 32.4 14.7
975*
Source: Line-PICC
[**2171-7-17**] 06:08AM 7.1 3.10* 9.5* 29.1* 94 30.6 32.6 14.4
873
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos Plasma
[**2171-7-23**] 06:07AM 62 0 23 11 1 2 1* 0 0
MISCELLANEOUS HEMATOLOGY ESR
[**2171-7-15**] 05:47AM 86*
Source: Line-PICC
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-7-22**] 05:00AM 105 11 0.6 136 4.1 102 28 10
Source: Line-PICC
[**2171-7-21**] 04:26AM 9 0.6 133 4.1 98 28 11
Source: Line-PICC
[**2171-7-19**] 06:00AM 84 9 0.6 137 4.9 101 30 11
Source: Line-PICC
[**2171-7-17**] 06:08AM 86 10 0.6 131* 4.8 93* 29 14
[**2171-7-15**] 05:47AM 86 7 0.6 138 4.0 103 29 10
Source: Line-PICC
[**2171-7-13**] 12:08AM 78 9 0.6 139 4.3 103 29 11
Source: Line-PICC
[**2171-7-12**] 04:54AM 71 7 0.5 136 3.9 101 27 12
Source: Line-picc
[**2171-7-11**] 05:30AM 91 9 0.7 137 4.3 100 29 12
Source: Line-PICC
[**2171-7-10**] 04:45AM 6 0.6 138 3.8 100 31 11
Source: Line-picc
[**2171-7-9**] 05:32AM 85 5* 0.5 139 3.7 100 32 11
Source: Line-PICC
[**2171-7-8**] 05:27AM 78 5* 0.5 142 3.1* 104 32 9
Source: Line-PICC
[**2171-7-7**] 05:20AM 3* 0.5 141 3.4 102 31 11
Source: Line-PICC
[**2171-7-6**] 12:27PM 78 3* 0.5 141 3.5 103 29 13
Source: Line-PICC
[**2171-7-5**] 06:00AM 76 4* 0.5 140 4.21 103 27 14
SLIGHT HEMOLYSIS
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
[**2171-7-4**] 08:10AM 87 5* 0.6 137 4.2 101 30 10
[**2171-7-3**] 12:50PM 83 8 0.6 137 4.2 99 28 14
[**2171-7-2**] 05:04AM 138* 10 0.7 133 4.0 97 27 13
Source: Line-RIJTLC
[**2171-7-1**] 05:39AM 88 9 0.5 139 3.9 104 32 7*
Source: Line-TLIJ
[**2171-6-30**] 04:21AM 127* 8 0.6 140 4.0 106 29 9
[**2171-6-29**] 05:19AM 79 9 0.5 141 3.1* 105 32 7
Source: Line-R EJ
[**2171-6-28**] 04:25AM 73 14 0.5 142 3.5 109* 26 11
Source: Line-aline
[**2171-6-27**] 02:25PM 88 18 0.5 141 3.9 110* 24 11
Source: Line-PICC
[**2171-6-27**] 04:28AM 77 20 0.6 143 2.9*1 111* 25 10
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2171-7-19**] 06:00AM 54
Source: Line-PICC
[**2171-7-17**] 03:15PM 150 0.4
Source: Line-PICC
[**2171-7-15**] 05:47AM 17 15 68 0.3
Source: Line-PICC
[**2171-7-13**] 12:08AM 20 14 69 0.4
Source: Line-PICC
[**2171-7-12**] 04:54AM 24 14 72 71 0.6
Source: Line-picc
[**2171-7-11**] 05:30AM 30 14 82 88 0.5
Source: Line-PICC
[**2171-7-10**] 04:45AM 35 15 169 85 0.6
Source: Line-picc
[**2171-7-7**] 05:20AM 67* 23 97 72 0.7
Source: Line-PICC
[**2171-7-5**] 06:00AM 98*1 241 232 110 110* 0.7
SLIGHT HEMOLYSIS
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
[**2171-7-4**] 08:10AM 125* 24 102 122* 0.8
[**2171-7-3**] 12:50PM 162* 29 117 162* 0.8
[**2171-7-2**] 09:50AM 207* 30 111 185* 0.7
Source: Line-R IJ
[**2171-6-30**] 04:21AM 374* 65*
[**2171-6-29**] 05:19AM 596* 150* 199 122* 1.4
Source: Line-R EJ
[**2171-6-28**] 04:25AM 890* 334* 213
Source: Line-aline
[**2171-6-27**] 04:28AM 1361*1 896* 314* 87 1.0
Source: Line-aline
1 VERIFIED BY REPLICATE ANALYSIS
[**2171-6-26**] 04:57PM 1759* 1590* 838* 84 0.9
Source: Line-aline
[**2171-6-25**] 05:07PM 2496*1
SLIGHTLY HEMOLYZED
1 VERIFIED BY DILUTION
[**2171-6-25**] 10:20AM 2067*
[**2171-6-25**] 01:50AM 48* 117*1 1178* 88 614* 0.6
Lipase 411 ([**2171-7-2**])
HEMATOLOGIC calTIBC VitB12 Folate Hapto Ferritn TRF
[**2171-7-17**] 03:15PM 378*
Source: Line-PICC
[**2171-6-26**] 04:57PM 179* GREATER TH1 GREATER TH2 GREATER
TH1 138*
Source: Line-aline
1 GREATER THAN [**2163**]
2 GREATER THAN 20 NG/ML
[**2171-6-25**] 10:20AM 186* 1051* 19.6 304 143*
PSa 1
CRP 88
HIV - negative
NEUROPSYCHIATRIC Phenyto
[**2171-7-1**] 05:39AM 13.5
Source: Line-TLIJ
[**2171-6-25**] 01:50PM 9.4*
DIL ADDED 2:32PM; SLIGHTLY HEMOLYZED SPECIMEN
TOXICOLOGY, SERUM AND OTHER DRUGS Carbamz
[**2171-7-1**] 05:39AM 6.6
Source: Line-TLIJ
[**2171-6-25**] 02:20PM 2.4*
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2171-7-18**] 08:50PM Yellow Clear 1.014
Source: Catheter
[**2171-7-14**] 12:25PM Straw Clear 1.010
Source: Catheter
[**2171-7-5**] 09:03PM Straw SlHazy 1.005
Source: Catheter
[**2171-6-25**] 05:30AM Yellow Cloudy 1.020
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
[**2171-7-18**] 08:50PM TR NEG TR NEG NEG NEG NEG 6.5 NEG
Source: Catheter
[**2171-7-14**] 12:25PM TR NEG NEG NEG NEG NEG NEG 8.0 NEG
Source: Catheter
[**2171-7-5**] 09:03PM TR NEG NEG NEG NEG NEG NEG 7.0 NEG
Source: Catheter
[**2171-6-25**] 05:30AM LG NEG 100 NEG NEG NEG NEG 7.0 MOD
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2171-7-18**] 08:50PM 0 2 NONE NONE 0
Source: Catheter
[**2171-7-14**] 12:25PM 2 0 OCC NONE <1
Source: Catheter
[**2171-7-5**] 09:03PM 0 6* NONE NONE 0
Source: Catheter
[**2171-6-25**] 05:30AM [**10-15**]* >50 MANY NONE [**1-28**]
URINE CRYSTALS 3PhosX
[**2171-6-25**] 05:30AM MANY
OTHER URINE FINDINGS Mucous
[**2171-7-14**] 12:25PM RARE
Source: Catheter
MISCELLANEOUS URINE Eos
[**2171-7-14**] 12:25PM NEGATIVE 1
Source: Catheter
1 NEGATIVE NO EOS SEEN
[**2171-7-9**] 05:34PM POSITIVE 1
Source: Catheter
1 POSITIVE RARE EOS
Chemistry
URINE CHEMISTRY Hours UreaN Creat Na TotProt Prot/Cr
[**2171-7-17**] 03:15PM RANDOM 86 100 1.2*
Source: Catheter
[**2171-6-25**] 01:00PM RANDOM 246 17 93
[**2171-6-25**] 05:30AM RANDOM
OTHER URINE CHEMISTRY U-PEP IFE Osmolal
[**2171-7-17**] 03:15PM MULTIPLE P1 NO MONOCLO2
Source: Catheter
1 MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING
BASED ON IFE (SEE SEPARATE REPORT),
NO MONOCLONAL IMMUNOGLOBULIN SEEN
NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
2 NO MONOCLONAL IMMUNOGLOBULIN SEEN
NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
[**2171-6-25**] 01:00PM 308
Time Taken Not Noted Log-In Date/Time: [**2171-7-22**] 4:28 pm
CATHETER TIP-IV RIGHT PICC TIP.
**FINAL REPORT [**2171-7-24**]**
WOUND CULTURE (Final [**2171-7-24**]): No significant growth.
Brief Hospital Course:
#Urosepsis - ICU course: On presentation the patient met
criteria for SIRS and sepsis: WBC of 27, tachycardic and a
source of infection, thought to be most likely urosepsis given
frank pus drainage from the bladder, history of recurrent
infections and his foley found to be obstructed. In review of
past culture data, UTIs in the past have grown pansensitive E.
Coli and ESBL resistant klebsiella previously sensitive to
meropenem, imipenem, zosyn. Per nursing home report, urine
cultures from 3 days PTA grew VRE (sensitivities unknown) and
proteus. He has also had multiple wound swabs that revealed MRSA
and pseudomonas, thus, it was thought also reasonable to
initially cover for MRSA. His wounds, however, do not appear to
be infected and were thought unlikely to be a contributing
source of sepsis. The CT of the abdomen did not appear
consistent with bowel ischemia, but the patient was initially
started on flagyl given colonic thickening. Upon arrival to the
ICU, his CVP initially was [**7-4**], on a dopamine, levophed and
vasopressin drip. A cortisol stimulation test was negative for
adrenal suppression. With input from ID, the patient was started
on meropenem and daptomycin and flagyl was continued. We were
able to wean the dopamine to off on day 1 in the ICU, and
levophed and vasopressin were weaned on day 2. CVP was
maintained between [**7-5**] with 500cc LR boluses on day 3, and the
patient did not require additional boluses on day 4. By day 4 he
was assessed as stable, recovering from the septic picture, and
fit to be called out to the floor. Blood cultures grew GNRs
which were identified as proteus on day 3 (sensitivities above)
([**2171-6-27**]). Based on sensitivities, IV meropenem was continued and
Daptomycin was discontinued.
On the floor, meropenem was continued. However he started having
fevers again and hence flagyl was restarted. Multiple tests done
to identify source of infection - MRI spine - no abscess or
osteomyelitis, ECHO no IE. Cultures neg. no C diff. No PICC
infection, Foley changed. ID was consulted and CT abd, HIDA done
that confirmed acute cholecystitis. Surgery deemed the patient a
poor surgical candidate and hence a cholesystostomy tube was
placed by IR. Abx were changed to aztreonam. WBC scan prior to
dc was normal. Patient finally remained afebrile for > 4 days
prior to discharge. He is to complete a 2 wk course of IV
aztreonam - day 1 [**2171-7-15**]. Flagyl was stopped after about a 3 wk
course. Patient advised a follow up appointment with Dr
[**Last Name (STitle) 4020**] from infectious disease in 2 weeks as well as on
[**2171-7-26**] - patient should get a CBC, chem 7 for monitoring and
results to be faxed as stated below to Dr [**Last Name (STitle) 4020**] who will
check the results. Brief Ca work up as a fever source (PSA,
SPEP, UPEP) normal.
Acute retention of urine was resolved after foley was placed.
Patient may be advised if an SPC is desired to see Dr [**Last Name (STitle) 770**] in
clinic given recurrent UTIs and [**Last Name (STitle) 27285**] obstruction due to MS.
[**Last Name (STitle) **] disorder: The patient had a tonic-clonic [**Last Name (STitle) 862**] on the
first night of admission, that resolved spontaneously within 2
minutes. This was likely exacerbated by his septic state. His
phenytoin and carbamazapine levels were normal. He has been
[**Last Name (STitle) 862**]-free since then. He was maintained on his outpatient
doses of phenytoin and carbamazapine.
After a speech and swallow evaluation, his diet was advanced as
below. Regular diet per second swallow evaluation.
Acute renal failure: Baseline creatinine is 0.4-0.9. Initial
bump in creatinine most likely was secondary to obstruction, but
also given hemoconcentration and response to fluids, appeared to
be prerenal as well. Given frank pus from bladder, ascending b/l
pyelo was a concern, but CT A/P, albeit without contrast, did
not show evidence of this. Creatinine back to baseline 2-3 days
after initiation of volume resuscitation.
Coagulopathy: INR was elevated to 1.5, then 2.2 in the absence
of blood thinning agents. Given his poor nutritional status, may
be a result of vit K deficiency, but certainly was concerning in
the setting of sepsis. Platelet count was normal. D-dimer
decreasing steadily, stable fibrinogen reassuring that DIC is
unlikely.
- INR normalized with 3 daily doses of vitamin K
.
# EKG changes: T wave inversions in septal leads most likely
reflected lead placement, but new from most recent EKG. MB index
negative x2. Ruled out for MI by cardiac enzymes, cardiac
ischemia was unlikely. No events were seen on tele during the
ICU stay. Patient remained CP free.
.
# Elevated LFTs: Initially the process could be related to the
sepsis. However, later he did have acute cholecystitis refer
above. LFT continued to trend down during admission. Normal at
discharge.
# Pancreatitis attributed to Ileus from MS - developed slight
elevation of lipase in setting of ileus attributed to MS. Made
NPO for two days. Repeat CT abdomen without evidence of
pancreatitis, but GB distension and edema with stones. Diagnosed
with cholecystitis as above. Golytely given 2 L per day for two
days with tap water enemas twice daily for two days. Ileus was
aggressively treated and resolved. No acute mech bowel
obstruction was noted.
# Facial rash consistent with fungal infection - stated
miconazole cream.
# Noted anemia and thrombocytosis both of which were stable at
discharge. Please recheck another CBC in a month to be deferred
to the PCP.
Patient has a new PICC dated [**2171-7-22**] and to complete aztreonam
as above. To make appt with IR for biliay drain removal as
below. ID, surgery to follow up.
Medications on Admission:
Meropenem 500 mg IV Q6H
Bisacodyl 10 mg PO/PR DAILY:PRN
Carbamazepine 200 mg PO QID
Docusate Sodium (Liquid) 100 mg PO BID
Pantoprazole 40 mg IV Q24H
Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
Phenytoin 100 mg PO TID
Heparin 5000 UNIT SC TID
Phytonadione 5 mg PO DAILY
Insulin SC (per Insulin Flowsheet)
Senna 1 TAB PO BID
Lorazepam 2 mg IV PRN [**Month/Day/Year 862**]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) mL PO TID (3
times a day).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): to the face rash.
6. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection PRN (as
needed) as needed for [**Hospital1 862**]: [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 862**].
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): hold for diarrhea.
10. Polyethylene Glycol 3350 17 g (100%) Powder in Packet Sig:
One (1) Powder in Packet PO hs (): hold for diarrhea.
11. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)) as needed for constipation.
14. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
16. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours): last day [**2171-7-30**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Bacteremia (Proteus sp.) due to [**Location (un) 27285**] tract infection
Acute [**Location (un) 27285**] retention
Fevers from acute cholecystitis
Ileus
Pancreatitis
Seizures
Thrombocytosis
Anemia of chronic disease
Delerium
Transaminitis
Acute renal failure
Multiple sclerosis
Discharge Condition:
Stable
Discharge Instructions:
Return to the hospita;l if you develop fevers, chills, abdominl
pain, vomiting, nausea or any other symptoms of concern to you.
You will have to complete a course of IV antibiotics for the
gall bladder infection.
Dr [**Last Name (STitle) 1699**] - your primary doctor will further care for your
medical needs.
Followup Instructions:
Your PCp [**Name Initial (PRE) **] [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 608**] to follow up at the
NH.
Urology - Dr [**Last Name (STitle) 770**] : [**Telephone/Fax (1) 2906**]- please call to schedule
appointment for a SPC
[**Last Name (LF) **], [**First Name3 (LF) **]: RADIOLOGY: [**Telephone/Fax (1) 5546**]. Call after
anibiotics is completed for removal of the biliary drain.
Surgery - Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**] - Dial # : [**Telephone/Fax (1) 2998**] . Please
call to make a follow up appointment in the next 2-3 weeks.
ID - Dr [**First Name8 (NamePattern2) 59674**] [**Last Name (NamePattern1) 4020**] - Call [**Telephone/Fax (1) 457**] to make an
appointment in next 2 weeks for follow up. Fax the results of
CBC, chem 7 to Dr [**Last Name (STitle) 4020**] on [**2171-7-26**] at [**Telephone/Fax (1) 1419**].
|
[
"707.03",
"V02.59",
"276.2",
"E849.8",
"574.00",
"511.9",
"564.00",
"733.13",
"788.20",
"584.9",
"790.7",
"263.1",
"560.1",
"599.0",
"285.29",
"041.6",
"707.09",
"799.02",
"340",
"733.90",
"996.62",
"350.1",
"591",
"V09.0",
"596.3",
"E879.8",
"593.4",
"733.00",
"518.0",
"238.71",
"276.52",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"34.91",
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
36253, 36323
|
28423, 34125
|
338, 483
|
36646, 36655
|
4756, 17412
|
37016, 37947
|
3979, 3998
|
34555, 36230
|
17449, 17579
|
36344, 36625
|
34151, 34532
|
36679, 36993
|
4013, 4737
|
277, 300
|
17608, 21127
|
511, 3229
|
21136, 28400
|
3251, 3840
|
3856, 3963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,146
| 124,174
|
33071
|
Discharge summary
|
report
|
Admission Date: [**2108-12-29**] Discharge Date: [**2109-1-4**]
Date of Birth: [**2028-2-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Percocet / Percodan / Darvocet A500
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increased DOE
Major Surgical or Invasive Procedure:
[**12-31**] AVR (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) **] tissue valve)
History of Present Illness:
80 yo F with known history of AS followed by echo. Recent echo
showed worsening AS which corresponded to increased shortness of
breath. Referred for surgery.
Past Medical History:
chronic AF, AS/CAD, CHF, ^lipidemia, PVD, pulmonary
hypertension, hypothyroidism, B inguinal hernias, GERD, vertigo,
sciatica, B varicosities, osteoporosis, R leg fx
Social History:
part time town [**Doctor Last Name **] worker
lives alone
quit tobacco 27 years ago
1 drink/day
Family History:
NC
Physical Exam:
NAD
Lungs CTAB
Heart RRR 3/6 SEM -> carotids
Abdomen benign
Extrem war, no edema, BLE varicosities
Neuro grossly intact
Pertinent Results:
[**2109-1-4**] 05:15AM BLOOD WBC-7.4 RBC-3.02* Hgb-9.5* Hct-26.9*
MCV-89 MCH-31.4 MCHC-35.2* RDW-14.5 Plt Ct-128*
[**2109-1-4**] 05:15AM BLOOD Plt Ct-128*
[**2109-1-4**] 05:15AM BLOOD Glucose-93 UreaN-13 Creat-0.6 Na-141
K-3.8 Cl-106 HCO3-29 AnGap-10
Brief Hospital Course:
On [**12-31**] of [**2108**] Ms. [**Known lastname 4217**] [**Last Name (Titles) 1834**] an aortic valve
replacement with a St. [**Male First Name (un) 923**] Epic tissue valve. This procedure
was performed by Dr. [**Last Name (STitle) **]. She tolerated the procedure
well and was transferred in critical but stable condition to the
surgical intensive care unit. Her pressors were weaned and her
chest drains removed. She was transferred to the floor. Ms.
[**Known lastname 76885**] wires were removed and she was gently diuresed. Her
coumadin was restarted for her chronic atrial fibrillation.
Beta blockers were titrated up to control her heart rate and
blood pressure. She was seen in consultation by the physical
therapy service. By post operative day four she was ready for
discharge in stable condition to rehab.
Medications on Admission:
unithyroid 112 mcg
lasix 20
metoprolol 100 [**Hospital1 **]
norvasc 5
digoxin 0.25
coumadin 2.5 alternating with 5
simvastatin 80
celebrex 200
ambien 10 HS
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day:
take 2 tablets (40mg) for 7 days, then decrease to 1 tablet (20
mg) ongoing.
Disp:*120 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO once
a day: take 2 packets for 7 days, then decrease to one packet
daily ongoing.
Disp:*60 Packet(s)* Refills:*0*
6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO daily ().
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take one tablet (2.5mg) every other day alternating with two
tablets (5mg) titrated to an INR goal of [**1-5**].5 for atrial
fibrillation.
Disp:*30 Tablet(s)* Refills:*0*
10. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day.
11. Ambien 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
AS now s/p AVR
PMH: chronic AF, CAD, CHF, ^lipidemia, PVD, pulmonary
hypertension, hypothyroidism, B inguinal hernias, GERD, vertigo,
sciatica, B varicosities, osteoporosis, R leg fx
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 27267**] 2 weeks
Dr. [**Last Name (STitle) 20222**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2109-1-4**]
|
[
"V15.82",
"443.9",
"414.01",
"427.31",
"416.8",
"530.81",
"424.1",
"733.00",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
3787, 3817
|
1366, 2195
|
326, 426
|
4044, 4052
|
1091, 1343
|
931, 935
|
2401, 3764
|
3838, 4023
|
2221, 2378
|
4076, 4328
|
4379, 4535
|
950, 1072
|
273, 288
|
454, 613
|
635, 802
|
818, 915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,944
| 187,587
|
51365
|
Discharge summary
|
report
|
Admission Date: [**2143-5-4**] Discharge Date: [**2143-5-11**]
Date of Birth: [**2098-12-27**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
HA, seizure, hypertension
Major Surgical or Invasive Procedure:
arterial line placement
lumbar puncture
endotracheal intubation
History of Present Illness:
History was derived from the medical chart and the pt's wife.
.
Mr. [**Known lastname 784**] is a 44 yo man with ESRD [**1-12**] reflux nephropathy s/p
failed LRRT in [**2134**], HTN, PUD who awoke on the morning of
admission at ~4 a.m. with a severe headache. He had associated
nausea and vomiting. He was also mily disoriented, slurring his
words and even walked into a wall because he did not see it. The
pt's wife then called EMS. When EMS arrived, he reportedly ahd a
GTC seizure that lasted ~2 minutes that resolved without
intervention.
.
At the OSH, he underwent head CT, which did not demonstrate any
hemorrhage. His intial CBC was WBC 4.4, Hgb 10.2, Plt 105. His
BP was controlled with labetalol 20 mg IV x1 (down to 170/95).
.
He was transferred to [**Hospital1 18**] for further care.
.
In the ED at [**Hospital1 18**], his initial VSs were 99.9, 87, 233/125, 32,
99%. He underwent LP, which demonstrated no leukocytosis and 42
RBCs in Tubes 1 and 4. He received ceftriaxone 2g IV, ampicillin
2g IV, vancomycin 1g IV, acetaminophen, lorazepam 4mg IV total,
haloperidol 10mg IV total, hydralazine 20 mg IV, labetalol 20 mg
IV and was eventually started on a nitroprusside drip.
.
No further history was obtained from the pt [**1-12**] delirium.
Past Medical History:
- ESRD secondary to chronic ureterovesical junction obstruction
leading to bilateral hydronephrosis, on hemodialysis
- s/p renal transplant [**2134**] ([**Name (NI) 106515**] brother)
- Severe hypertension
- Gout
- Peptic Ulcer disease
- Bladder neck stricture
- Atypical chest pain
Social History:
40py, quit 2 yrs ago. No EtOH or other drugs. Lives in apartment
building with his wheelchair-bound wife where he works as
superintendent.
Family History:
Father had MI mid 50s. No DM. Brother had cancer of jaw which
was resected.
Physical Exam:
Vitals: T: 100.6 BP: 246/104 P: 85 R: 28 SaO2: 100%
General: Unarousable, jittery, does not follow commands
HEENT: NCAT, PERRL, no scleral icterus, MMM
Neck: supple, no significant JVD, no neck stiffness
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, ND, normoactive bowel sounds
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes noted.
Neurologic: Unarousable, does not follow commands. PERRL. Normal
bulk. No abnormal movements noted. Moves all extremities. 2+
reflexes at the patella and biceps. Plantar response was flexor
bilaterally.
Pertinent Results:
Admission labs:
[**2143-5-4**] 11:50AM WBC-5.3 RBC-3.52* HGB-10.0* HCT-31.4* MCV-89
MCH-28.5 MCHC-31.9 RDW-15.7*
[**2143-5-4**] 11:50AM NEUTS-88.1* LYMPHS-9.2* MONOS-2.4 EOS-0.2
BASOS-0.2
[**2143-5-4**] 11:50AM PLT COUNT-145*
[**2143-5-4**] 11:50AM PT-13.4 PTT-32.4 INR(PT)-1.1
[**2143-5-4**] 11:50AM GLUCOSE-103 UREA N-17 CREAT-6.4* SODIUM-140
POTASSIUM-6.5* CHLORIDE-103 TOTAL CO2-25 ANION GAP-19
[**2143-5-4**] 11:50AM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.6
MAGNESIUM-2.4
[**2143-5-4**] 11:50AM ALT(SGPT)-9 AST(SGOT)-67* LD(LDH)-885* ALK
PHOS-73 TOT BILI-0.7
[**2143-5-4**] 11:59AM GLUCOSE-101 LACTATE-1.6 NA+-140 K+-4.1
CL--100 TCO2-30
[**2143-5-4**] 11:50AM AMMONIA-LESS THAN
[**2143-5-4**] 11:50AM TSH-1.0
[**2143-5-4**] 11:50AM T4-7.8 FREE T4-1.1
[**2143-5-4**] 11:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-5-4**] 12:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2143-5-4**] 01:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-43
GLUCOSE-59
[**2143-5-4**] 01:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-42*
POLYS-20 LYMPHS-60 MONOS-20
[**2143-5-4**] 01:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-42*
POLYS-0 LYMPHS-0 MONOS-0
Brief Hospital Course:
44-year-old man with ESRD on HD and difficult-to-control
hypertension presented with seizures, found to be hypertensive
to 233/125.
# Hypertensive emergency: Patient continued on valstartan,
carvediol, clonidine, hydralazine, lisinopril, and nifedepine.
In the MICU his BP was controlled with labetolol and nitro gtts.
Nicardipine gtt was eventually used. He was converted from
nicardipine to nifedipine on [**2143-5-9**]. Blood pressure were in the
150's with the drips and were slightly higher on the nifedipine
but with maintained diastolics in the 80-90's. He was
transitioned back to PO home meds while in the MICU and then
transferred to the floor. He was electively intubated for airway
protection. He self-extubated and was reintubated, and was
eventually extubated without incident. His BP on the floor
remained in the 150-160/80-90 range. Further workup of the
etiology of his refractory chronic HTN was deferred for his
outpatient care providers given that laboratory test results
would have taken a week to return and he did not require
inpatient level of care.
# Neurology: Patient's mental status improved gradually. He was
initially treated with acyclovir pending CSF HSV PCR, but it was
discontinued when CSF was found to be HSV negative. Neurology
signed off and indicated no need for further neurologic f/u.
# Respiratory failure: Patient extubated without any respiratory
difficulty.
# ID: Patient afebrile off of all antibiotics. An infectious
etiology for his presentation was felt to be unlikely.
# ESRD s/p failed transplant: He had HD every Mon, Wed, Fri.
Tacrolimus was discontinued due to concern for PRES.
Mycophenolate was increased to 1000 [**Hospital1 **]. He was continued on PCP
prophylaxis with TMP/SMX. His medications were renally dosed.
# GERD/PUD: continued on outpatient pantoprazole.
# Code status: FULL CODE
Medications on Admission:
Lisinopril 40 mg [**Hospital1 **]
Carvedilol 12.5 mg [**Hospital1 **]
Valsartan 80 mg daily
Nifedipine SR 30 mg [**Hospital1 **]
Clonidine 0.3 mg/24 hr Patch
Tacrolimus 2 mg [**Hospital1 **]
Mycophenolate Mofetil 1000 mg [**Hospital1 **]
Trimethoprim-Sulfamethoxazole 80-400 mg daily
Pantoprazole 40 mg daily
Sevelamer HCl 800 mg tid with meals
B Complex-Vitamin C-Folic Acid 1 mg daily
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
Disp:*4 Patch Weekly(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Mycophenolate Mofetil 250 mg Capsule Sig: Four (4) Capsule PO
BID (2 times a day).
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
11. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
13. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
15. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Major: Hypertensive emergency
PRES
seizure
.
Minor:
acute renal failure
Discharge Condition:
stable
Discharge Instructions:
You were admitted for severely elevated blood pressure. You were
found to have a neurologic condition called PRES which was
thought to be related to your high blood pressure. PRES results
in your thinking being confused and is life threatening. It is
very important to keep your blood pressure under control. Your
blood pressure is under better control. It is important that you
take all of your medications as prescribed. You were also
evaluated by neurology.
If you develop fevers, chills, confusion, weakness,
numbness/tingling in your extremities, or find blood pressures
>160 at home you should call your doctor.
Please take all of your medications as prescribed and follow up
with the appointments below.
MEDICATIONS:
Your Carvedilol and Valsartan has been increased to better
control your blood pressure.
Your Nifedipine dose has been decreased to help control your
blood pressure.
Hydralazine has been STARTED to treat your high blood pressure.
Your TACROLIMUS has been STOPPED as you do not need this drug
any longer.
Followup Instructions:
Please call your PCP to set up a follow-up appointment within
the next two weeks. Dr.[**Name (NI) 29254**] telephone number is
[**Telephone/Fax (1) 250**].
Please continue to follow-up with your outpatient hemodialysis
program and your outpatient nephrologist per your usual
schedule.
You do not need a follow-up appointment with neurology. However,
if you would like to reach the neurology clinic, please call
[**Telephone/Fax (1) 8302**].
|
[
"403.91",
"518.81",
"V45.1",
"584.9",
"585.6",
"348.39",
"345.10",
"533.90",
"274.9",
"530.81",
"996.81",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.91",
"39.95",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7994, 8000
|
4148, 6005
|
300, 366
|
8116, 8125
|
2892, 2892
|
9203, 9649
|
2132, 2209
|
6443, 7971
|
8021, 8095
|
6031, 6420
|
8149, 9180
|
2224, 2873
|
235, 262
|
394, 1652
|
2908, 4125
|
1674, 1960
|
1976, 2116
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,077
| 132,686
|
53159
|
Discharge summary
|
report
|
Admission Date: [**2145-8-23**] Discharge Date: [**2145-9-13**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old
woman who was observed by her husband to slump over while
doing the dishes and became unresponsive. She was
unresponsive at the scene and was intubated, sedated and
transferred to [**Hospital1 69**] where a
head CT showed diffuse subarachnoid hemorrhage with
ventricular dilatation. Blood pressure range was 64 to 180
on an off Nipride, pulse was 40 to 60, intubated and sedated.
Pupils were 2.5 mm and briskly reactive, face was symmetric.
She had positive dolls eyes, positive corneal, positive gag,
minimal withdraw and flexion in the upper and triple flexion
in the bilateral lowers, the toes were mute, reflexes are 2+
bilaterally.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Asthma.
LABORATORY: White blood cell count 9, hematocrit 36.2,
platelets 278, sodium 141, K 4.1, 105/27, 16/.8 and 157.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for close observation and then taken to angio where
she was diagnosed with bilateral posterior cerebral artery
aneurysms, which were coiled with good occlusion. The
patient tolerated the procedure well and was taken to the
Intensive Care Unit post coiling. The patient was
unresponsive on Propofol. She was intubated, off sedation,
she remained unresponsive. Pupils are 1.5 bilaterally with
minimal reaction to light. No corneal. No cough to deep
suctioning. She was flaccid times four in all extremities to
painful stimuli and she was not breathing over the
ventilator. The following day her pupils were 1.5
bilaterally with no reaction. She had negative dolls eyes.
She had positive gag. She withdrew to pain in the upper
extremities and minimal triple flexion in the lower
extremities. Head CT showed coil artifact with no obvious
new hemorrhage. On [**2145-8-26**] the patient made the family a
DNR, although her condition had been unchanged and spiked a
temperature to 101.9 on the 29th. Klebsiella and H flu was
cultured from her sputum. She was started on Vanco, Levo and
Gentamycin. On the 30th she opened her eyes half way,
grimaced symmetrically localizing on the right upper, left
upper had trace movement to pain, withdrew minimally to the
pain in the lower extremities. A head CT showed a right
thalamic infarct. She remained with a drain in place at 15
cm above the tragus. On [**2145-9-1**] she had an episode
where she dropped her pressure. An echocardiogram on the
30th showed an EF of greater then 75% with an outflow
obstruction and trivial mitral regurgitation.
Electrocardiogram was normal sinus rhythm. [**2145-9-1**] she had
an electrocardiogram changes. CPKs and enzymes were sent.
She had a positive troponin at .27. Cardiology was consulted
due to the fact that the patient could not have heparin.
There was little, but blood pressure control, the patient
could have from a cardiology standpoint. Medically the
patient's condition continued to wax and wane. She ruled in
for a large myocardial infarction. She developed a clot in
the left IJ, which did not require any treatment. She
continued to have difficulty weaning from the ventilator and
went into respiratory distress on [**2145-9-5**]. She also had
severe leukocytosis and ultimately when into renal failure
requiring dialysis. She coded on [**2145-9-12**] and was chemically
coded without success and the patient expired on [**2145-9-12**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2145-9-13**] 10:26
T: [**2145-9-13**] 10:43
JOB#: [**Job Number 109464**]
|
[
"V46.1",
"430",
"410.71",
"434.91",
"486",
"518.81",
"453.8",
"276.6",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"38.95",
"96.72",
"02.2",
"38.93",
"88.41",
"89.64",
"39.95",
"39.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
994, 3762
|
126, 795
|
817, 976
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,902
| 170,956
|
5903+55707+55708
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2189-8-6**] Discharge Date: [**2189-8-12**]
Date of Birth: [**2131-5-18**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 58 year-old
African American female with a past medical history
significant for chronic obstructive pulmonary disease, atrial
fibrillation, chronic renal failure and morbid obesity who
was admitted to the MICU at the [**Hospital1 188**] [**Hospital Ward Name 516**] from home with a one day history of fever
and mental status changes. She had been home for only one
day after a five and a half month rehab stay at Towers [**Doctor Last Name **]
[**Hospital **] hospital. She presented to the Emergency
Department with what was a one day course of fever and mental
status changes. She was difficult to arouse and was
lethargic. The patient presented with a temperature of 102.7
degrees Fahrenheit, respiratory rate 34 and an O2 saturation
of 71%. She was given oxygen nonrebreather and her O2 sats
responded to 95%. She had a chest x-ray done, which was poor
quality, but showed an enlarged heat with evidence of a left
lung base infiltrate versus atelectasis. She had a CAT scan
of the head, which showed prominence to the right side of the
midline gyrus. She was treated with nebulizers and was given
one dose of Ceftriaxone 2 grams intravenous. On hospital day
one the patient's mental status improved and she was began on
Levofloxacin 250 mg intravenous q 48. Upon further
questioning she denies dysuria prior to admission, but did
report increased urinary frequency. The patient also had a
vague history of hemoptysis over the last two weeks and she
reported one episode of hemoptysis while in the Emergency
Room. She also reported a history of blood per rectum for
which she was given a colonoscopy in the past, which
demonstrated no lesions or etiology of bleeding source. This
colonoscopy was done in [**2189-5-12**].
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Congestive heart failure with an ejection fraction of
approximately 20 to 30%.
3. Chronic obstructive pulmonary disease. She ahs O2 at
home and her home O2 requirement is 3 liters. She is also on
BiPAP for obstructive sleep apnea. Her settings are 15 and
8.
4. Gastroesophageal reflux disease.
5. Coronary artery disease status post stenting of the right
coronary artery.
6. Diabetes mellitus.
7. Atrial fibrillation for which she is on Coumadin 3 mg po
q.d. and Amiodarone 200 mg po q.d.
8. Status post V fibrillation arrest on previous admission
and she is not a candidate for ICD placement secondary to her
body habitus.
9. Pulmonary hypertension.
10. Anemia of chronic disease.
11. Chronic renal failure with a baseline creatinine of
approximately 2.2.
SOCIAL HISTORY: Significant for a 40 pack year history. She
quit in [**Month (only) 958**] of last year. She lives at home with her
boyfriend.
FAMILY HISTORY: Her mom passed away of multiple myeloma and
her dad past away and had a history of diabetes.
LABORATORIES ON ADMISSION: White blood cell count of 7.2,
hematocrit 31.3, platelet count of 274. She had an mean
corpuscular volume of 88 and she had a slight left shift with
81 polymorphonuclearocytes. Chemistries, sodium 138,
potassium 5.5, chloride 97, bicarb of 27, BUN 59, creatinine
of 3.1 and a platelet count of 111. She had an INR of 2.1
and a PTT of 33.2. She had an ALT of 12, AST 27, alkaline
phosphatase 148, total bili of 1.4, lipase 15, amylase 24.
She had a CK of 40 and a troponin of .5. She had a blood gas
done, which showed a pH 7.4. In terms of imaging studies she
had a chest x-ray, which showed an enlarged heart, poor
quality and they could not rule out a basilar infiltrate as
mentioned previously. Head CT demonstrated no hemorrhage, no
shifts and a prominence of the mid right side frontal gyrus
and the electrocardiogram demonstrated normal sinus rhythm
with left axis deviation. Right bundle branch block. She
did have an echocardiogram in [**2188-3-14**], which showed
an ejection fraction between 20 and 30%, mild left
ventricular hypertrophy, moderate left ventricular dilation
and severe global hypokinesis and mild mitral regurgitation.
HOSPITAL COURSE: 1. Urinary tract infection: The patient
was admitted with a urinary tract infection. She was given
one dose of Ceftriaxone 2 grams in the Emergency Room and
then she was started on Levofloxacin renal dosing, which is
250 mg q 48 intravenous for ten days. With the improvement
of the patient's mental status she was switched over to a po
dosing and with further discussion with the attending her
duration of antibiotics therapy was increased from 10 days to
14 days. On the day of discharge it is day 6 of 14 of
antibiotics coverage and she is taking antibiotics every
other day for that 14 day period. The cultures grew out two
isolates of estrichia coli, which was sensitive to
Levofloxacin.
2. History of hemoptysis: The patient reported an
approximate two week history of hemoptysis prior to admission
and one episode in the Emergency Room. While in the MICU and
on the medicine floor she had no further episodes of
hemoptysis. Sputum gram stain demonstrated white cells and
epithelial cells, but no red cells and sputum culture was
contaminated. I spoke to the nursing staff at Towers [**Doctor Last Name **]
Rehab Hospital where she stayed and they denied noticing any
episodes of hemoptysis there. The patient had a chest CT
done at this hospital, which revealed no masses, no
infiltrates and no focal etiologies for hemoptysis.
3. Chronic obstructive pulmonary disease/obstructive sleep
apnea: Initially the patient was having difficulty with
breathing. Over the course of her hospital stay she has been
maintained on her standing Albuterol ipratropium inhales and
she has been getting Albuterol ipatropium nebulizers prn,
which she has been responding to. Her lung examination have
improved from having diffuse expiratory wheezing. Today the
day of discharge her lungs were clear bilaterally. She has
been maintained on her BiPAP machine with settings at 15 and
8 for which she has had no difficulties.
4. Acute on chronic renal failure: She has had creatinines
in the high 2s approximately 2.7, 2.8, 2.6 over the last
several days. We believe her baseline creatinine to be 2.2.
In working up the acute on chronic renal failure we obtained
a FENA, which was less then 1% leading us to believe that the
cause of her renal failure was a prerenal source in a setting
with a patient with baseline congestive heart failure with a
low ejection fraction in the setting of dehydration and
presepsis with already baseline poor renal function. It is
possible that this patient might have had an episode of
hypotension prior to the admission and it is possible that
the creatinine in the high 2s may be a new baseline secondary
to some ischemic injury or acute tubular necrosis that might
have occurred secondary to poor perfusion. The patient has
been taking good po over the last five days and the
creatinines have remained stable.
5. Diabetes mellitus: The patient initially had elevated
finger sticks early on in the course of her hospital stay
with finger sticks in the high 190s to low 200s. Upon
reviewing on line medical records we determined that the
patient's home diabetes regimen included insulin 70 NPH 30
regular 40 units in the morning and 30 units in the evening.
The patient was started on half this dose 20 units in the
morning, 15 in the evening. She responded appropriately.
Her finger sticks had been maintained between the 80s and
100s over the last three days. We obtained a hemoglobin A1C,
which was normal at 5.6.
6. Bilateral foot pain: Two days prior to discharge the
patient complained of bilateral pain over the dorsal surfaces
and lateral aspects of her feet. She described this pain as
achy with occasional shooting pains up toward her hips. The
patient was admitted in [**2189-1-11**] with a similar
complaint. At that time it was not believed that this pain
was neuropathic in nature and instead was attributed to
trauma. The patient on this hospital admission had x-rays of
her feet done, which demonstrated no acute fractures, diffuse
osteopenia and osteophyte formations. On the previous
hospital admission the patient was started on Neurontin and
Nortriptyline, but this treatment was discontinued after a
short period of time. The patient was given only one dose of
Neurontin 300 mg, but the etiology of the pain is not certain
that it is neuropathic in the setting of a hemoglobin A1C of
5.6, which demonstrates relatively good control of her blood
glucoses levels over the past several months. This foot pain
might be related to chronic stasis of her lower extremities
secondary to her morbid obesity, congestive heart failure and
her diabetes. The patient's pain was well controlled on
Acetaminophen 500 mg po q 4 hours standing with Oxycodone 5
mg po q 4 hours prn pain.
7. Congestive heart failure: The patient has denied any
symptoms of orthopnea or paroxysmal nocturnal dyspnea during
this hospital stay. She has not reported any increased work
of breathing or shortness of breath above and beyond her
baseline chronic obstructive pulmonary disease and
obstructive sleep apnea. Due to her acute on chronic renal
failure the patient's Lasix, Aldactone and Prinivil were held
and she was discharged with these medications still being
held and we recommended follow up with her primary care
physician as to restarting these medications. Although the
patient did deny symptoms of orthopnea and paroxysmal
nocturnal dyspnea, she did have lower extremities pitting
edema 2+ bilaterally up to the mid thighs.
8. Atrial fibrillation: She has been in and out of atrial
fibrillation throughout this hospital course. She is
maintained on Coumadin 3 mg po q.d. and an INR was obtained
early on in the course of her hospital stay, which was 2.7.
9. Gastroesophageal reflux disease: She has not had any
complaints or symptoms of heartburn and she has been
maintained on Protonix 40 mg po q.d.
10. Anemia of chronic disease: This has been worked up in
the past and it has been stable and her hematocrit has been
stable through this admission.
11. Depression: She has been maintained on her Sertraline
50 mg po q.d. and has not complained of or demonstrated any
symptoms of depressed behavior during this hospital stay.
The patient will be discharged to an extended care facility.
The exact ECF has yet to be determined. I will call back
with that information.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 23310**]
MEDQUIST36
D: [**2189-8-12**] 10:12
T: [**2189-8-12**] 10:22
JOB#: [**Job Number 23311**]
Name: [**Known lastname 1012**], [**Known firstname **] Unit No: [**Numeric Identifier 3955**]
Admission Date: [**2189-8-6**] Discharge Date: [**2189-8-12**]
Date of Birth: [**2131-5-18**] Sex: F
Service:
The patient is being discharged to [**Location (un) 3956**] Subacute Extended
Care Facility [**Location (un) 3957**], which is outside of [**Location (un) 42**],
[**State 1145**]. Patient was restarted on Prinivil 10 mg po q
day and it is Lasix 60 mg po bid and aldactone 25 mg po q
day, which are being held. The Prinivil's usual home dose is
20 mg po q day, but we elected not to go to her full home
dose because of the resolving acute on chronic renal failure.
It will be important for her primary care physician to
[**Name9 (PRE) 587**] her congestive heart failure medications and to
re-evaluate starting her up again on her Lasix 60 mg po bid
and her aldactone 25 mg po q day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-735
Dictated By:[**Last Name (NamePattern1) 1566**]
MEDQUIST36
D: [**2189-8-12**] 13:54
T: [**2189-8-12**] 18:06
JOB#: [**Job Number 3958**]
Name: [**Known lastname 1012**], [**Known firstname **] Unit No: [**Numeric Identifier 3955**]
Admission Date: [**2189-8-6**] Discharge Date: [**2189-8-12**]
Date of Birth: [**2131-5-18**] Sex: F
Service:
The previous discharge summary job number [**Numeric Identifier 3963**].
I left out some information which I would like to add on.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To extended care facility.
PRIMARY DIAGNOSIS: Urinary tract infection.
SECONDARY DIAGNOSES:
1. Diabetes type 2 controlled.
2. Chronic obstructive pulmonary disease.
3. Chronic renal failure.
4. Congestive heart failure.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg po q day.
2. Sertraline 50 mg po q day.
3. Pantoprazole 40 mg po q day.
4. Fluticasone 110 mcg two puffs inhalation [**Hospital1 **].
5. Miconazole nitrate powder applied to skin-folds [**Hospital1 **].
6. Metoprolol 50 mg po bid.
7. Capsaicin 0.025% cream applied to arthritic joints tid.
8. Hydralazine 20 mg po q8h.
9. Isosorbide dinitrate 20 mg po tid.
10. Warfarin 3 mg po q day.
11. Albuterol/ipratropium inhalers 103 and 18 mcg two puffs
q6h.
12. Albuterol 0.83 mg/ml inhalation q6 prn.
13. Ipratropium 0.2 mg/ml two puffs q6 prn.
14. Montelukast 10 mg po q day.
15. Oxybutynin chloride 10 mg po q day.
16. Levofloxacin 250 mg po q48h for the next eight days for a
total course of 14 days.
17. Acetaminophen 500 mg po q4h.
18. Oxycodone 5 mg po q4-6h prn pain.
19. Insulin 70/30 20 units q am, 15 units q pm.
FOLLOW-UP PLANS: An appointment with her primary care
physician, [**First Name8 (NamePattern2) 3964**] [**Name11 (NameIs) **], on [**8-25**] at 3 pm in the [**Doctor Last Name **]
Building, [**Location (un) 3965**] of the [**Hospital3 **] Hospital, and she is
also supposed to call [**Hospital 3966**] Clinic here at the [**Hospital3 **] Hospital for suggestions on weight loss.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-735
Dictated By:[**Last Name (NamePattern1) 1566**]
MEDQUIST36
D: [**2189-8-12**] 10:54
T: [**2189-8-12**] 11:01
JOB#: [**Job Number 3967**]
|
[
"491.21",
"250.00",
"530.81",
"585",
"427.31",
"428.0",
"599.0",
"584.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.27"
] |
icd9pcs
|
[
[
[]
]
] |
2895, 3002
|
12653, 13491
|
4190, 12355
|
12501, 12630
|
13509, 14100
|
159, 1915
|
12454, 12480
|
3017, 4172
|
1937, 2731
|
2748, 2878
|
12380, 12434
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,844
| 185,366
|
25456
|
Discharge summary
|
report
|
Admission Date: [**2133-4-15**] Discharge Date: [**2133-7-3**]
Date of Birth: [**2095-9-5**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides) / Reglan
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
SOB, Tachycardia, Hypotension
Major Surgical or Invasive Procedure:
Exploratory laparotomy, lysis of adhesions (4
hours enterectomy enteroenterostomy) resection of desmoid
times 1 of the abdominal wall with enterectomy, closure of
enterotomy and enteroenterostomy.
History of Present Illness:
37F with complex medical history well known to Dr. [**Last Name (STitle) 957**] who
presents with a 6 day history of SOB that limited her ADLs. She
was evaluated in the ER at [**Hospital **] Hospital where she underwent an
extensive workup revealing no problems. INR was 1.1. She then
underwent a V/Q scan which was negative and was started on
Lovenox [**Hospital1 **] per her oncologist Dr. [**First Name (STitle) **]. She reported to Dr. [**Name (NI) 7012**] clinic for a routine follow-up and was found to have
continued SOB, tachycardia, and hypotension.
Past Medical History:
Gardners Syndrome
Uterine fibroid s/p myomectomy- [**2118**]
Desmoid tumor resection- [**2121**]
Right Breast mass, s/p excision- [**2125**]
Total Colectomy w/ ileostomy- [**2126-8-5**]
s/p port-a-cath placment
Atrial tachycardia secondary to doxarubacin toxicity
h/o DVT LLE- [**2127**]
h/o Hodgkins, s/p MOPP chemo- [**2117**]
GERD
Social History:
Pt is single, w/o children. Lives in [**State 531**], works as an
insurance account represenative. Denies tobacco and drinks ETOH
rarely.
Family History:
Father, 65, w/ prostate ca
Mother, 66, w/ breast ca, sister w/ lupus
Physical Exam:
Admission PE- [**2133-4-15**]
96.8 106 90/68 20 100%RA
Resting comfortably in no cardiorespiratory distress.
Neck: Port in place on right side. Supple
CV: rrr, s1s2, no murmurs, rubs, gallps
Chest: CTABL
Abd: scaphoid appearance with 3 ostomy appliances in place. Left
ostomy bag draining liquid stool contents. 2 other ostomy bags
on right draining a milky colored fluid. Abdomen is firm and
tender to superficial palpation. (+)BS on auscultation.
Neuro: grossly intact. CNII-XII intact
Pertinent Results:
[**2133-6-29**] 11:50AM URINE RBC->50 WBC->50 Bacteri-OCC Yeast-FEW
Epi-0-2 TransE-0-2
[**2133-6-26**] 04:18AM BLOOD WBC-15.7*# RBC-2.75* Hgb-8.1* Hct-24.0*
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.4 Plt Ct-422
Brief Hospital Course:
[**Known firstname 1154**] [**Known lastname **] was admitted to the surgery service on [**2133-4-15**]
under the care of Dr. [**Last Name (STitle) 957**]. She received IV hydration and two
doses of albumin for tachycardia/hypotension with good response.
Admission labs showed WBC 10.7; INR 1.2; BUN 34; Creat 1.7; Alb
3.5; TRF 160. She was started on antibiotics for empiric
coverage. A new draining site was noted on exam in proximity to
her old midline fistula site. This was pouched. Admission weight
showed that she had lost 10 pounds since last admission. She was
placed on a regular diet; calorie counts were started with goal
of 1800 cal per day. A KUB was completed to evaluate renal
stent position b/c she was complaining of urinary frequency.
This showed no migration of the stent. Dr. [**Last Name (STitle) 13534**] was notified
and reviewed the film. At HD 2 the SOB had resolved. AT HD 4 she
was afebrile and doing well. BUN 14; Creat 1.2; INR 1.6; WBC
5.8. Fistula sites had increased drainage. At HD 7 a
fistulagram was completed which showed no clear relationship
between the abscess and the bowel. At HD 10 she was taken to CT
for attempted drainage of the abdominal abscess. She was found
to have a proximal small bowel obstruction and the procedure was
not performed. At HD 11 she was (+) bilious vomiting. KUB
showed evidence of small bowel obstruction. She was made NPO and
IV fluids were started. Abdominal pain was increased and a PCA
was provided for pain management. Her diet was later advanced
as tolerated. At HD 14 the abdominal abscess formed a fluctuent
area which was drained of purulent fluid via aspiration and sent
for culture. At HD 16 abx coverage was adjusted for wound
culture (+) yeast/enterococcus/MRSA. At HD 17 she was (+)
emesis. She was made NPO. A PICC line was placed. TPN was
started. CT scan of the abdomen/pelvis was performed which
showed a high-grade obstruction of the proximal jejunum with
transition point in the mid abdomen. She was managed
conservatively with NGT decompression, which was removed at HD
25 due to decreased output and patient discomfort. At HD 35 she
continued to show obstruction per KUB. Ostomy output waxed and
waned. She continued to have emesis each morning, but did not
want the NGT replaced. She was supported on TPN. On [**6-9**] she
underwent an exploratory laparotomy, lysis of adhesions (4 hours
enterectomy enteroenterostomy), resection of desmoid times 1, of
the abdominal wall with enterectomy, closure of enterotomy and
enteroenterostomy by Dr. [**Last Name (STitle) 957**]. On [**6-15**] the path report
showed skin and subcutaneous tissue with mets described as well
to moderately differentiated adenocarcinoma. Likewise there was
adenocarcinoma involving the wall of the small intestine/desmoid
tumor. Cells where positive for CK20 and CDX2, negative for
CK7, suggesting an intestinal primary site.
[**6-15**] Path: Skin and subcutaneous tissue with mets
well/mod-differentiated adenocarcinoma. Metastatic well- to
moderately-diff'd adenoCA involving wall of small
intestine/desmoid tumor. Cells positive for CK 20 and CDX2,
negative for CK 7 -> suggestive of an intestinal primary site.
She had an upper gi with small bowel follow through which
visualized the tumor in the 2nd and 3rd portions of the
duodenum. The patient then developed a fever. Urine analysis
showed yeast in the urine for which she was placed on diflucan.
Cultures eventually showed 10,000-100,000 yeast/ml. She also
had a CT scan to rule out any abdominal source for the fever.
The CT scan showed some old contrast from the upper gi, but no
evidence of a current leak. The patient remained afebrile after
this point and was tolerating PO intake.
Medications on Admission:
Coumadin
tamoxifen 120mg
Prevacid 30mg
Paxil 60mg
Flonase
Lovenox 60mg [**Hospital1 **]
Discharge Medications:
1. Zinc Sulfate 220 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
2. Imodium A-D 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. Flagyl 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day
for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
5. Diflucan 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once a day for
1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Megace Oral 40 mg/mL Suspension [**Hospital1 **]: One (1) PO once a day.
Disp:*20 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Desmoid with intestinal obstruction and gastrointestinal
cutaneous fistula.
2. Duodenal adenocarcinoma
3. Abdominal Abscess
4. Dehydration
Iron deficient anemia
Malnutrition
Discharge Condition:
Stable
Discharge Instructions:
Please return if:
1. Fever >101
2. Nausea, vomitting or the inability to pass stool
3. Abdominal Pain
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] in his clinic on Friday, [**7-24**] at 2:45.
Please follow up with you regular oncologist for INR monitoring
and evaluation as discussed.
|
[
"453.8",
"567.22",
"238.1",
"198.2",
"V10.79",
"211.3",
"568.0",
"199.1",
"263.9",
"569.81",
"276.51",
"197.4",
"V58.61",
"998.11",
"286.7",
"593.3",
"112.2",
"560.89",
"V55.2",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.3",
"45.16",
"43.19",
"99.07",
"99.15",
"45.91",
"88.03",
"45.62",
"99.05",
"99.04",
"54.59",
"99.06",
"38.93",
"96.08"
] |
icd9pcs
|
[
[
[]
]
] |
7055, 7061
|
2479, 6209
|
331, 530
|
7282, 7291
|
2252, 2456
|
7441, 7638
|
1653, 1723
|
6347, 7032
|
7082, 7261
|
6235, 6324
|
7315, 7418
|
1738, 2233
|
262, 293
|
558, 1121
|
1143, 1479
|
1495, 1637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,028
| 166,371
|
3849
|
Discharge summary
|
report
|
Admission Date: [**2109-8-18**] [**Month/Day/Year **] Date: [**2109-9-16**]
Date of Birth: [**2040-4-7**] Sex: M
Service: MEDICINE
Allergies:
Augmentin / Heparin Agents
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
fever, respiratory failure, hypotension
Major Surgical or Invasive Procedure:
Bronchoscopy
Chest Tube placement
History of Present Illness:
69 y/o M w/ striatonigral degeneration, nonverbal and minimally
communicative, recurrent aspiration w/ tracheostomy with
multiple infectious complications including MRSA, VRE, C. Diff,
pseudomonas, GERD, diastolic dysfunction, ischemic bowel s/p j
tube, recent admit to [**Hospital Unit Name 153**] in [**6-28**] with hypoxia, UTI, who is now
being transferred from an outside hospital after being admitted
there for acute hypercarbic respiratory failure on [**8-14**]. The
patient presented with hypercarbic respiratory failure on [**8-14**]
(ABG 6.97/200/105), and this was felt secondary to obstruction
of his tracheostomy tube and possibly from his neurological
disease. He was also in acute renal failure with hyperkalemia.
Patient was admitted to OSH and had bronchoscopy which showed
occlusion of the tracheostomy orifice by the posterior
membranous trachea. He had 2 trach changes while there but
patient still intermittently seemed to occlude the trach and
develop high PIPs. This was mostly positional. Patient was at
least in part transferred for
Other events during this brief OSH hospitalization were a PAC
with PCWP 18, PAP 45/26 RAP 18. His initial hematocrit was only
19 but improved and stabilized with 3 units of PRBC (no source
found for this blood loss). Patient's stool was also + for C.
Diff. His renal failure improved. Patient had low grade fevers
with a bld cx that grew 1/2 bottles GPR thought to possibly be a
contaminant. He was treated with PO Vanco for C. diff, Cefepime,
and flagyl.
On transfer to the [**Hospital1 **], patient was found to be hypotensive with
MAPs in the low 50s, systolics in the 70s. He improved slightly
with 1.9 L of IVF but then declined again and required
initiation of Levophed.
Past Medical History:
1. Striatonigral degeneration.
2. History of methicillin-resistant Staphylococcus aureus.
([**11-27**] stool)
3. History of vancomycin-resistant Enterococcus.
4. History of multiple aspiration pneumonias.
5. GERD.
6. Diverticulosis.
7. Prostate cancer status post prostatectomy.
8. Hypothyroidism.
9. Tracheostomy.
10. History of bullous pemphigus.
11. History of upper GI bleed.
12. Jejunostomy tube placement.
Hospitalizations:
[**2108-3-24**]: Pseudomas in sputum txt with zosyn then changed to
gent
[**2108-4-24**]: Bronch to adjust trach placement and sputum
[**2107-11-24**]: fever, hypoxia, inc. secretions txt with ceftaz
[**2108-9-24**]:pseudomonas pna, wound infection
[**2109-6-24**] fever, UTI, coag negative staph blood infection
Social History:
Lives with wife, bed bound; no etoh/drugs/smoking. Has personal
care attendent.
Family History:
NS
Physical Exam:
PE: Tc on admit 103.9 HR 74 BP 77/46 RR 22 O2 sat 94%
AC 40% TV 300 RR 18 PEeP 5
GEN: extremely contracted elderly male, chronically ill
appearing, nonverbal
HEENT: o/p and nose with yellowish secretions, poor dentition,
trach in place
NECK: fully contracted to left, trach in place, intermittent
cuff leak
CV: RRR S1S2 no mrg
LUNG: coarse rhonchi on both sides, L>R
ABD: sl distended, nontender, bs+, j tube with erythema
surrounding it
EXT: 1+ edema, good radial pulses
NEURO: increased tone, difficult to assess rest of exam due to
severe contraction and nonverbal/relatively unresponsive
existence, IS responsive to pain
Pertinent Results:
[**2109-8-18**] 09:53PM GLUCOSE-129* UREA N-65* CREAT-1.8*
SODIUM-150* POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-38* ANION
GAP-12
[**2109-8-18**] 09:53PM ALT(SGPT)-6 AST(SGOT)-22 ALK PHOS-69 TOT
BILI-0.8
[**2109-8-18**] 09:53PM CALCIUM-8.0* PHOSPHATE-1.7* MAGNESIUM-2.1
[**2109-8-18**] 09:53PM WBC-11.2* RBC-3.28* HGB-9.0* HCT-29.3* MCV-89
MCH-27.5 MCHC-30.8* RDW-18.5*
[**2109-8-18**] 09:53PM NEUTS-90.3* BANDS-0 LYMPHS-5.6* MONOS-3.7
EOS-0.2 BASOS-0.1
[**2109-8-18**] 09:53PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2109-8-18**] 09:53PM PLT SMR-NORMAL PLT COUNT-133*
[**2109-8-18**] 09:53PM PT-13.7* PTT-24.5 INR(PT)-1.3
OSH micro: [**8-16**] bld cx 1/2 bottles gPR
[**8-15**] bronch sputum, few pseudomonas, sesnsitive to
amikacin/gent/tobra/imipenem
[**8-14**] sputum: similar rare psudomonas
[**8-15**] stool + for CDif
Echo OSH: LA 4.8 cm, EF 65%, rV normal, mild AS, mild AI, no LVH
CHEST (PORTABLE AP): [**2109-9-13**]
Reason: evaluate for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with tracheostomy, s/p resolved ptx with
ncreased secretions
REASON FOR THIS EXAMINATION:
evaluate for infiltrate
INDICATION: Status post resolving pneumothorax, evaluate for
infiltration.
COMPARISON: Study from [**2109-9-8**].
PORTABLE AP CHEST RADIOGRAPH: There is limited evaluation
secondary to poor positioning of the patient. There appears to
be a tracheostomy positioned with the tip positioned within the
trachea. A right-sided PICC line is seen, with the tip
positioned in the upper SVC. There is an opacity overlying the
mediastinum, which is curved, and likely represent structures
outside the body. There is obscuration of the left
hemidiaphragm, suggesting likely atelectasis. There is slightly
increased prominence of the pulmonary vasculature consistent
with some pulmonary vasculature congestion.
IMPRESSION: Mild pulmonary vasculature congestion. Minimal
probable atelectasis at the left lung base.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on [**Doctor First Name **] [**2109-8-29**] 12:29 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 17273**]
Service: Date: [**2109-8-26**]
Date of Birth: [**2040-4-7**] Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
PROCEDURE: Rigid bronchoscopy.
LOCATION: Operating theater.
ASSISTANT: [**Last Name (NamePattern4) 17275**], M.D.
DESCRIPTION OF PROCEDURE: After informed consent was
obtained from under Mr. [**Known lastname 17276**] Health Care Proxy, he was
brought to the operating theater where general anesthesia was
employed. Due to Mr. [**Known lastname 17276**] profound contractures and
difficult anatomy, the tracheoscope was unable to be inserted
through the mouth and had to be inserted through his
tracheostomy stoma site. With great difficulty, the rigid
tracheoscope was inserted through the trachea stoma site to
the level above the carina. At this angle and due to the very
small nature of the tracheoscope, we were unable to deploy a
wide stent. At this point in the procedure, given the fact
that we could not safely deploy a stent, and there were no
therapeutic options which could performed in the safe
fashion, given the tortuous nature of his trachea and the
extreme difficulty in positioning this patient, given his
current contractures and given his profound underlying
medical problems, the procedure was aborted at this point. A
#8 [**Last Name (un) 295**] TTS tracheostomy tube was replaced through his
tracheal stoma.
FINDINGS: Tortuous trachea, extremely difficult positioning,
great difficulty passing tracheoscope.
Procedure aborted secondary to not being able to safely
deploy stent into the airway.
SPECIMENS OBTAINED: None.
COMPLICATIONS: None.
DICTATED BY:[**Last Name (NamePattern4) 17277**]
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**]
Dictated By:[**Name8 (MD) 17278**]
MEDQUIST36
D: [**2109-8-28**] 09:40:17
T: [**2109-8-28**] 10:04:20
Job#: [**Job Number 17279**]
[**2109-8-25**] 10:10 am SPUTUM Source: Induced.
**FINAL REPORT [**2109-8-30**]**
GRAM STAIN (Final [**2109-8-25**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2109-8-30**]):
THIS IS A CORRECTED REPORT ([**2109-8-29**]).
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] AT 09:45AM ON [**2109-8-29**].
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PREVIOUSLY REPORTED AS ([**2109-8-27**]) NON-FERMENTER, NOT
PSEUDOMONAS
AERUGINOSA.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
VANCOMYCIN VERIFIED BY SENSITITRE.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- 8 S 8 S
CEFTAZIDIME----------- 8 S 4 S
CIPROFLOXACIN--------- <=0.5 S =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I <=0.5 S 8 I
IMIPENEM-------------- 2 S =>8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 4 S 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 16 S 16 S
PIPERACILLIN/TAZO----- <=8 S 8 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 4 S <=1 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
A/P: 69 y/o M w/ MMP, including most signicantly a striatonigral
neurodegenerative disease resulting in severe contraction and
requiring trach for frequent aspiration, presented with
respiratory failure, sepsis and pseudomonal pneumonia,
transferred for possible trach change, successfully weaned from
vent while at [**Hospital1 18**].
1. Respiratory Failure:
Patient has been having significant problems with tracheostomy.
He is followed by IP/[**Doctor First Name **] [**Doctor Last Name **].
-IP was consulted and an attempt was made to place a y stent to
improve respiratory status. Attempt was unsuccessful, but a
[**First Name9 (NamePattern2) 17280**] [**Last Name (un) 295**] trach was placed.
-Pt was able to be weaned from the vent and was placed on trach
mask, with good sats and ABG.
-Sputum grew MRSA that was vanc sensitive and Pseudomonas the
was meroperem sensitive. pt was treated with a 10 day course on
Meropenem and Vancomycin for probable PNA vs. Tracheitis vs.
colonization. On [**Last Name (un) **] sputum was decreased in amount and
less concerning in color.
.
For ongoing respiratory care at the time of [**Last Name (un) **], Pt. was
prescribed frequent tracheal suctioning every 2-4 hours;
inexsufflator treatment: 30/30 - 40/40 as tolerated; X 2 cycles
prn for secretions, and BIPAP was recommended as follows:
inspiratory pressure: 10 cm/h2o, expiratory pressure: 5 cm/h2o
Supp O2: 4 L/min, to be applied at night only. Also, frequent
tracheal suctioning, every 2-4 hours.
.
2. Shock: Patient presented hypotensive. Responded initially to
fluids but required levophed. Initially with fem TLC, access was
converted to PICC by IR. Most likely patient was septic given
fever, wbc, multiple sources of infection. [**Last Name (un) **] stim was wnl.
PT continued to have episodes of night time drops in BP while
sleeping, but these events spontaneously resolved with or
without fluid boluses, on [**Last Name (un) **] the patient had no signs of
sepsis or shock.
3. ID: Patient had low grade fevers at OSH, with high fever here
on admit. Had two lines (new L SC and OLD PICC line) removed and
cultured showing only coag neg staph. Pt also with Hx of C. Diff
colitis and history of resistant bugs. Pt was treated with
Vanco and Meropenem for 10 days and was afebrile after finishing
course. Course of oral Vanc was completed for CDiff colitis
without further symptoms.
4. Renal Insufficiency: Baseline Cr is 0.8, was elevated.
Improved with rehydration and resolved over course of hospital
stay.
5. CHF: History of diastolic CHF with suppportive ECHO here at
[**Hospital1 18**]. Takes lasix at home. Was given lasix 20mg QAM while in
the hospital and was discharged on 40 PO QD.
6. Hematology: Had a Hct drop at OSH without clear source. Here
required PRBCs x1. Based on iron studies seems to be anemia of
chronic disease. PT had a hx of heparin-induced
thrombocytopenia.
7. FEN: J tube was replaced by IR as it was clogged on
admission. Tube feedings were continued and Pt. was followed by
nutrition.
8. GERD: Pt. has severe reflux disease with essentially no [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]. Had large episode of bilious vomiting when his head was
in trendelenberg. Was treated with Lansoprazole and HOB
elevation to > 45 degrees.
9. Neurological Disease: Continued his sinemet and mirapex.
10. Hypothyroid: Continued his levoxyl.
11. PPX: During his stay he wore pneumoboots and had a PPI and
bowel reg.
12. Access: While in house he had a new picc line placed for
access.
13. Full Code.
Medications on Admission:
On transfer:
mirapex 1.5 po ngt [**Hospital1 **]
miconazole powder to groin [**Hospital1 **]
ativan 1 q8
combivent 8 puffs q6
lansoprazole 30 po bid
levoxyl 100 mcg qd
sinemet 25/250 one at 8 AM, [**11-25**] tab at 1 pm and 6 pm
motillin 10 qid
vancomycin 125 PO 4x/day (started [**8-16**])
D5Q
cefepime/flagyl [**Date range (1) 11879**]
[**Date range (1) **] Medications:
1. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO 8
AM ().
3. Carbidopa-Levodopa 25-250 mg Tablet Sig: 0.5 Tablet PO 6 PM
().
4. Carbidopa-Levodopa 25-250 mg Tablet Sig: 0.5 Tablet PO 1 PM
().
5. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Mirapex Oral
7. Docusate Sodium 150 mg/15 mL Liquid Sig: 100mg PO BID (2
times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Date range (1) **] Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
[**Hospital **] Diagnosis:
Pneumonia, sepsis, tracheal stenosis
[**Hospital **] Condition:
Fair
[**Hospital **] Instructions:
Follow Interventional Pulmonologies recommendations regarding
trach care, take medications as perscribed and be sure to
folllow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].
Followup Instructions:
Follow up with your primary care doctor and your neurologist
regarding further lab work and adjustment of your medications.
Follow up with Interventional Pulmonology with any concerns
regarding the trach tube.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
Completed by:[**2109-9-16**]
|
[
"038.9",
"041.19",
"008.45",
"996.69",
"333.0",
"041.04",
"285.29",
"518.0",
"519.02",
"482.1",
"427.31",
"244.9",
"996.59",
"512.8",
"530.81",
"276.52",
"585.9",
"428.30",
"996.62",
"V64.1",
"428.0",
"995.92",
"807.09",
"785.52",
"518.81",
"519.1",
"276.0",
"041.11",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.21",
"93.90",
"97.23",
"34.04",
"99.04",
"38.93",
"33.23",
"97.03"
] |
icd9pcs
|
[
[
[]
]
] |
10375, 13940
|
338, 374
|
3686, 4721
|
15319, 15675
|
3021, 3025
|
4758, 4835
|
13966, 15296
|
3040, 3667
|
259, 300
|
4864, 10352
|
402, 2140
|
2162, 2908
|
2924, 3005
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,683
| 145,527
|
9903
|
Discharge summary
|
report
|
Admission Date: [**2133-1-26**] Discharge Date: [**2133-2-3**]
Date of Birth: [**2049-5-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Shellfish Derived / Aspirin
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 year old female with a history of HTN, CKD, anemia presents
to the ER with worsened bilateral hip pain. Apparently she fell
on Friday and was seen at [**Hospital3 **] and discharged
home after she had slipped on ice. She now has worsening
bilateral hip pain and also R knee and right scapula pain since
her fall. Has been immobile since accident.
In the ER her vitals 99.5, 88, 86/62, 20, 92% RA
102/57 when seen by ER resident, then to 80s, FAST negative.
Getting a TTE being done currently. A right IJ was placed and
started on Levophed. Received 2 liters of IVF. Non operative
fractures.
She received vancomycin, levofloxacin, ASA, morphine, ativan and
was started on Levophed for hypotension. A blood cx was sent and
a non contrast CT Torso was obtained which showed a non
displaced fracture of the right inferior pubic ramus, body of
pubis and possible fracture at anterior lip of right acetabulum.
In the ICU patient looks fatigued but has no dyspnea or chest
pain. Her only complaint is pain in the hips.
Past Medical History:
Hypertension
Chronic kidney disease
Normocytic anemia [**2-3**] CKD
s/p CCY
infrarenal AAA
GERD
Social History:
NC
Family History:
Father died in his 80's of a CVA after a long history of
hypertension
Mother with kidney disease
Physical Exam:
Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2133-1-30**] 06:40AM BLOOD WBC-9.0 RBC-3.45* Hgb-10.1* Hct-31.2*
MCV-91 MCH-29.3 MCHC-32.3 RDW-14.7 Plt Ct-177
[**2133-1-29**] 05:20AM BLOOD WBC-8.9 RBC-3.50* Hgb-10.5* Hct-31.4*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.8 Plt Ct-173
[**2133-1-28**] 11:19PM BLOOD WBC-7.8 RBC-3.71* Hgb-10.8* Hct-32.8*
MCV-88 MCH-29.2 MCHC-33.0 RDW-14.6 Plt Ct-167
[**2133-1-28**] 09:30AM BLOOD WBC-6.5 RBC-3.17* Hgb-9.5* Hct-28.2*
MCV-89 MCH-30.0 MCHC-33.9 RDW-14.6 Plt Ct-165
[**2133-1-27**] 04:06PM BLOOD WBC-6.5 RBC-2.66* Hgb-7.7* Hct-24.1*
MCV-91 MCH-29.1 MCHC-32.0 RDW-14.8 Plt Ct-167
[**2133-1-27**] 05:59AM BLOOD WBC-6.7 RBC-2.80* Hgb-8.2* Hct-25.5*
MCV-91 MCH-29.2 MCHC-32.0 RDW-14.5 Plt Ct-150
[**2133-1-26**] 01:15PM BLOOD WBC-10.8 RBC-3.51* Hgb-10.5* Hct-31.9*
MCV-91 MCH-30.0 MCHC-33.1 RDW-14.8 Plt Ct-195
[**2133-1-26**] 01:15PM BLOOD PT-12.4 PTT-26.4 INR(PT)-1.0
[**2133-1-30**] 06:40AM BLOOD Glucose-102* UreaN-60* Creat-2.2* Na-140
K-4.9 Cl-109* HCO3-19* AnGap-17
[**2133-1-28**] 09:30AM BLOOD Glucose-125* UreaN-62* Creat-2.3* Na-138
K-5.1 Cl-110* HCO3-19* AnGap-14
[**2133-1-27**] 05:59AM BLOOD Glucose-84 UreaN-66* Creat-2.6*# Na-140
K-5.3* Cl-113* HCO3-15* AnGap-17
[**2133-1-26**] 01:15PM BLOOD Glucose-101* UreaN-78* Creat-3.7*# Na-137
K-5.6* Cl-104 HCO3-21* AnGap-18
[**2133-1-30**] 06:40AM BLOOD CK(CPK)-144
[**2133-1-29**] 05:20AM BLOOD CK(CPK)-182
[**2133-1-28**] 11:19PM BLOOD CK(CPK)-249*
[**2133-1-27**] 04:06PM BLOOD CK(CPK)-350*
[**2133-1-27**] 05:59AM BLOOD CK(CPK)-464*
[**2133-1-26**] 01:15PM BLOOD ALT-13 AST-22 CK(CPK)-468* AlkPhos-74
TotBili-0.7
[**2133-1-26**] 01:15PM BLOOD Lipase-23
[**2133-1-30**] 06:40AM BLOOD CK-MB-4 cTropnT-0.24*
[**2133-1-29**] 05:20AM BLOOD CK-MB-5 cTropnT-0.24*
[**2133-1-28**] 11:19PM BLOOD CK-MB-6 cTropnT-0.24*
[**2133-1-27**] 04:06PM BLOOD CK-MB-5 cTropnT-0.14*
[**2133-1-27**] 05:59AM BLOOD CK-MB-5 cTropnT-0.12*
[**2133-1-26**] 01:15PM BLOOD CK-MB-4 cTropnT-0.11*
[**2133-1-30**] 06:40AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.0
[**2133-1-28**] 09:30AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1
[**2133-1-27**] 05:59AM BLOOD Calcium-7.8* Phos-3.9 Mg-1.9
[**2133-1-26**] 05:25PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2133-1-26**] 05:25PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2133-1-26**] 05:25PM URINE RBC-[**3-6**]* WBC-[**3-6**] Bacteri-FEW Yeast-NONE
Epi-[**6-11**]
.
.
[**2133-1-27**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT - NEGATIVE
[**2133-1-26**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **], negative to date
.
.
TTE
The estimated right atrial pressure is 0-10mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the distal 2/3rds of the anterior septum and
distal anterior wall. The remaining segments contract normally
(LVEF = 40-45%). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal with
focal hypokinesis of the apical free wall. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
left and right ventricular dysfunction suggestive of CAD.
Pulmonary artery systolic hypertension.
CLINICAL IMPLICATIONS:
Based on [**2130**] 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.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2133-1-26**] 17:31
.
.
CT Torso
Final Report
INDICATION: 83-year-old woman with known AAA with worsening
groin pain,
hypotension, evaluate for AAA or leak.
COMPARISON: CT of the torso from [**2131-9-3**].
TECHNIQUE: MDCT images were acquired from the thoracic inlet
down to the
pubic symphysis without IV contrast. Multiplanar reformations
were obtained
and reviewed.
CT OF THE CHEST WITHOUT CONTRAST: The thyroid gland is
unremarkable. There
is no axillary or mediastinal lymphadenopathy. There is mild
biapical
scarring. Also noted are small subpleural blebs and emphysema.
There is
bilateral mild interstitial pulmonary edema evidenced by septal
prominence.
There is a pectus excavatum deformity of the chest wall.
The trachea is patent centrally. There is significant aortic
valvular, mitral
annular and coronary artery calcification. The heart size is
normal. There is
relative [**Name (NI) 33214**] of the myocardium compared to the
blood pool, likely
due to anemia.
CT OF THE ABDOMEN WITHOUT CONTRAST: The noncontrast appearance
of the liver,
spleen, adrenals, kidneys and pancreas is unremarkable. There is
mild
nonspecific right perinephric stranding. The patient is status
post
cholecystectomy. The abdominal aorta is tortuous and dilated
measuring up to
37 x 37 mm in its largest dimension. This is essentially
unchanged in size
from prior studies and there is no evidence of aortic rupture.
No fluid
collection is present in the visualized abdomen. The small and
large bowel
are unremarkable. No free air or free fluid is present. There is
no
abdominal, mediastinal or retroperitoneal lymphadenopathy.
CT OF THE PELVIS WITHOUT CONTRAST: The uterus, bladder, and
rectum are
unremarkable. There is no pelvic or inguinal lymphadenopathy
present.
OSSEOUS STRUCTURES: An acute fracture of the right inferior
pubic ramus and
right pubic body. Also present is a small right superior sacral
alar non
displaced fracture. A small anterior lip fracture cannot be
excluded at the
right acetabulum (2:104). There is no significant associated
hematoma.
There is minimal degenerative joint disease with endplate
sclerosis and vacuum
phenomena at the L5-S1 level. Incidental note is made of
bilateral sacral
Tarlov cysts.
IMPRESSION:
1. Right inferior pubic ramus and right pubic body fractures.
Right sacral
ala fracture and possible anterior right acetabulum fracture.
2. No hematoma or evidence of AAA rupture.
These findings including the change from the wet read were
communicated to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD at ~5 pm on [**2133-1-26**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: [**First Name8 (NamePattern2) **] [**2133-1-29**] 3:53 PM
.
.
Final Report
EXAM: Chest single portable AP view.
CLINICAL INFORMATION: 83-year-old female with history of new
right IJ.
COMPARISON: [**2133-1-26**] at 14:53.
FINDINGS: There has been interval placement of a right internal
jugular
central venous line with distal tip in the mid superior vena
cava. No
evidence of pneumothorax is seen. Diffuse interstitial
prominence is again
seen, which given differences in technique, may be slightly
increased. The
cardiac and mediastinal silhouettes are unchanged with
enlargement of the
cardiac silhouette. The aorta remains heavily calcified.
IMPRESSION:
1. Interval placement of a right internal jugular central venous
catheter
with distal tip in the mid SVC, without evidence of
pneumothorax.
2. Diffuse interstitial prominence, given differences in
technique, may be
slightly increased.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2483**]
Approved: [**First Name8 (NamePattern2) **] [**2133-1-27**] 10:21 AM
.
.
Final Report
INDICATION: 83 year-old woman with CHF with several pelvic
fractures.
COMPARISON: CT torso performed [**2133-1-26**] and chest radiograph
performed
[**2133-1-27**].
AP UPRIGHT CHEST RADIOGRAPH: A right internal jugular catheter
with its tip
in the lower SVC is stable. Pulmonary vascular engorgement has
improved .
There are new small bilateral pleural effusions. The lungs are
otherwise
clear without pneumothorax or consolidation. The heart size
remains slightly
enlarged.
IMPRESSION: Minimal mprovement in CHF. Small bilateral pleural
effusions are
new since two days prior.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: [**First Name8 (NamePattern2) **] [**2133-1-29**] 2:55 PM
.
..
.
Final Report
STUDY: AP pelvis, [**2133-1-27**].
HISTORY: An 83-year-old woman with fracture.
FINDINGS: Comparison is made to the prior CT scan from [**1-26**], [**2133**].
There is a fracture involving the right inferior pubic rami,
similar to the
prior CT scan. The small fracture seen off of the right anterior
acetabulum
is not well seen. There is minimal joint space narrowing of
bilateral hip
joints. Extensive vascular calcifications are present.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**First Name8 (NamePattern2) **] [**2133-1-27**] 6:22 PM
.
.
Cardiology Report ECG Study Date of [**2133-1-26**] 2:44:50 PM
Normal sinus rhythm. Low voltage in the standard leads. Poor R
wave progression
in leads V1-V3. Compared to the previous tracing of [**2131-9-3**] there
is no
diagnostic interim change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 174 80 364/416 76 74 -24
CTA chest [**2133-1-3**] (preliminary read): No PE. Mild CHF.
Brief Hospital Course:
83 F with HTN s/p recent [**Last Name (un) **] with right hip fracture admitted
to MICU in setting of hypotension likely secondary to volume
depletion and medications.
# Hypotension - Occurred upon getting information from the
patient and family it was teased out that she has had minimal
oral intake over the past 48-72 hours in the setting of pain and
nausea from the pain medications. The etiology of her
hypotension is most likely secondary to volume depletion and
blood pressure medications. The history of fall and
immobilization is concerning for a pulmonary embolus but given
she is asymptomatic currently and a TTE performed in the ER
showed no RV strain to suggest saddle pulmonary embolus although
small embolus is not ruled out. Also need to include sepsis
(although no localizing source) and NSTEMI. Pressures improved
once transferred to the floor and blood culture remained neg, pt
was afebrile, no WBC so no abx were necessary. Her home BP meds
(Triamterene/HCTZ, losartan) were held due to low normal BP and
they may be restarted as an outpatient. Of note, patient
underwent CTA prior to discharge that was negative for PE.
# Right acetabular hip fracture - Non operative per orthopedics;
pain improved, pt was discharged to rehab on oxycodone for pain
with orthopedic clinic f/u.
# NSTEMI / demand ischemia: found to have trp/CK leak but
unclear if nstemi vs demand given acute renal failure. her CKs
trended down and trp plateaud. the pt had some chest discomfort
which was thought to be due to panic attack / generalized
anxiety. TTE during admission showed EF 40 with hypokinesis of
the distal 2/3rds of the anterior septum and distal anterior
wall. we started metoprolol 12.5 [**Hospital1 **] and continued home ASA 325,
simvastatin 40. we have decided to hold ACE-i for now given pt's
renal failure and low normal BP.
# Anxiety: pt very anxious at baseline regarding her husband and
her own condition. although her hip pain is controlled she is
very anxious (crying) about the thought of PT or having pain in
the future. she admits that her 'nerves are getting to her'.
psych was consulted and recommended her starting celexa 10mg
daily for likely generalized anxiety disorder. we also initiated
ativan 0.25mg po q6prn which seemed to alleviate sx. she should
also have potential psych followup in the future for further
treatment of her anxiety.
# Anemia: Acute on chronic likely secondary IV hydration on top
of CKD. She has echymoses on Right buttock, but no other signs
of bleeding, however, Hct down to 24 but stable at 31 after 2U
transfusion.
# Acute on chronic kidney injury - Cr returned down to 2.2 which
appears near baseline.
# Anemia - [**2-3**] CKD, monitor given no evidence of bleeding.
# Hypertension - Currently hypotensive, hold home meds.
# GERD - Continue outpatient lansoprazole.
Medications on Admission:
Percocet
Atenolol 50mg daily
Triamterene/HCTZ 50/25mg once daily
Lansoprazole 30mg once daily
Losartan 50mg once daily
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every
6 hours).
3. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
5. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
7. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Woodbriar - [**Location (un) 4444**]
Discharge Diagnosis:
Primary:
Right acetabular fracture
generalized anxiety disorder
.
Secondary:
chronic anemia
CKD
hypertension
Discharge Condition:
afebrile, stable vitals, tolerating POs
.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted due to a right hip fracture which you did not
need surgery for. You were initially in the ICU for low blood
pressure which improved and you were transferred to the floor.
You were found to have anemia which improved with blood
transfusion. You were also seen by psychiatry due to your
persistant anxiety. You were started on celexa 10mg daily and
ativan 0.25mg to be taken sparingly as needed for acute anxiety.
Please take a lidocaine patch, and oxycodone as needed for your
pain. We started you on metprolol 12.5 mg twice a day, you
should stop taking atenolol. We are currently holding your blood
pressure medications (Triamterene/HCTZ, Losartan) since your
blood pressure is low normal. These may be restarted in the
upcoming weeks by your PCP.
.
Please take all medications as prescribed.
Please followup with all appointments.
Please do not hesitate to return to the hospital if you have any
concerning symptoms at all.
.
Followup Instructions:
Please follow up with the following providers:
.
Please schedule an appointment to see Dr. [**Last Name (STitle) 16258**], [**Telephone/Fax (1) 19196**]
.
Please schedule an appointment to see psychiatry in 4 weeks, Dr. [**Name (NI) 33161**] office can give you a referral or you may call, ([**Telephone/Fax (1) 33215**]
.
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5322**]
Specialty: Orthopaedics
Date/ Time: Wednesday [**2133-2-11**] at 10 AM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) 551**]
Orthopaedics
Phone number: ([**Telephone/Fax (1) 2007**]
Completed by:[**2133-2-3**]
|
[
"427.89",
"403.90",
"584.9",
"410.71",
"428.22",
"805.6",
"276.2",
"276.52",
"300.02",
"338.11",
"808.0",
"530.81",
"285.21",
"E885.9",
"785.59",
"458.29",
"E942.6",
"585.9",
"441.4",
"808.2",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16122, 16185
|
12019, 14855
|
337, 343
|
16338, 16380
|
2157, 5726
|
17520, 18199
|
1547, 1645
|
15024, 16099
|
16206, 16317
|
14881, 15001
|
16550, 17497
|
1660, 2138
|
5749, 11996
|
286, 299
|
371, 1392
|
16394, 16526
|
1414, 1511
|
1527, 1531
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,626
| 149,195
|
10343
|
Discharge summary
|
report
|
Admission Date: [**2107-6-11**] Discharge Date: [**2107-6-15**]
Date of Birth: [**2074-6-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain and LE weakness
Major Surgical or Invasive Procedure:
mid thoracic laminectomy and spinal abscess washout
History of Present Illness:
The patient is a 31yo man who reports lower back pain and
lower extremity weakness beginning on wednesday [**6-8**]. The day
prior to the onset of symptoms, the patient moved a heavy piece
of furniture but reported no symptoms until the next morning.
Then he experienced moderate low back pain with increasing
weakness of the lower extremities bilaterally. He was started on
vicodin by his PCP. [**Name10 (NameIs) **] the following morning ([**6-9**]) the patient
was unable to walk, although his back pain had decreased. He
denies dizziness, HA, N/V. He reports no fever or chills at
home
but was febrile on admission to the ED. His last void and BM
was
on [**6-9**]. Since then he has had sensation of increasing bladder
discomfort and fullness but has been unable to void. he denies
bladder and bowel incontinence.
Past Medical History:
HTN
Depression
Social History:
occasional cigarette smoking and ETOH
profession: attorney
Family History:
Both parents alive and well, father with HTN. No h/o
neurological disease.
Physical Exam:
O: T: 102.1 BP: 144/87 HR: 100 R 16 O2Sats 99
Gen: lying in bed, mild discomfort but NAD.
HEENT: Pupils: PERRL 3-2mm bilaterally EOMs intact, full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, bladder distended and tender to palp prior to
foley placement
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
B T IP Q AT G
R 5 5 2 2 2 2
L 5 5 2 2 4 4
Sensation: Intact to light touch throughout except decreased
sensation on lateral aspect of R thigh. Proprioception intact
bilaterally
Reflexes: muted bilaterally, patellar and biceps
Toes downgoing bilaterally
Rectal exam: decreased tone
MRI lumbar spine shows no apparent compression of the spinal
cord.
Pertinent Results:
[**2107-6-10**] 10:30PM PT-11.6 PTT-23.2 INR(PT)-1.0
[**2107-6-10**] 10:30PM WBC-12.0* RBC-4.82 HGB-15.3 HCT-43.4 MCV-90
MCH-31.7 MCHC-35.2* RDW-13.8
[**2107-6-10**] 10:30PM NEUTS-88* BANDS-7* LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2107-6-10**] 10:30PM GLUCOSE-127* UREA N-15 CREAT-1.0 SODIUM-135
POTASSIUM-3.6 CHLORIDE-94* TOTAL CO2-26 ANION GAP-19
[**2107-6-11**] 04:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 POLYS-76
LYMPHS-15 MONOS-0 MACROPHAG-9
[**2107-6-11**] 04:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-327*
GLUCOSE-58 LD(LDH)-27
[**2107-6-11**] 10:38AM HGB-13.1* calcHCT-39
[**2107-6-11**] 10:38AM TYPE-ART PO2-131* PCO2-38 PH-7.47* TOTAL
CO2-28 BASE XS-4 INTUBATED-INTUBATED
[**2107-6-11**] 05:49PM WBC-10.2 RBC-3.57*# HGB-11.1*# HCT-32.4*#
MCV-91 MCH-31.1 MCHC-34.4 RDW-13.1
MRI:
([**2107-6-10**], with and without contrast): The study is normal. There
is no evidence of cauda equina compression, disk protrusion or
infection.
([**2107-6-11**], with contrast): Limited study due to the absence of
intravenous contrast due to prior administration earlier in the
day. There is a posterior epidural collection extending from
approximately T4 to T10. This is suspicious for an epidural
abscess.
([**2107-6-12**], with and without contrast): No definite residual
abnormal material. However, possible anterior epidural
enhancement in the lower thoracic spine.
Brief Hospital Course:
Mr. [**Known lastname 34333**] presented to the hospital on [**2107-6-10**] with lower back
pain, urinary retention, and lower extremity weakness. On
work-up, the patient was noted to have an epidural mass vs.
abscess on T spine MR, and was taken to the operating room for a
laminectomy and spinal abscess washout. He was put on
antibiotics, and following the surgery, has resolution of his
leukocytosis and improved lower extremity motor function. He
went from the recovery room to the intensive care unit
post-operatively. His pain was well controlled with Dilaudid
initially, then by oxycontin and percocet once he tolerated PO.
On the second post-operative day, he was transferred to the
floor in stable condition, and his drain was removed. A PICC
line was placed on [**6-14**] for IV antibiotics after discharge
(vancomycin and ceftriaxone) for 6 weeks.
At the time of discharge, on physical exam, the patient had full
strength in b/l quads, hamstrings, and extensor hallucis longus;
his strength was 4+/5 in his right iliopsoas and [**2-24**] in his
anterior tibialis; both were full on the left. The patient was
otherwise neurologically intact.
On discharge, the patient was swell, tolerating a regular diet,
with vital signs stable, and pain well managed.
Medications on Admission:
Zoloft 100 mg daily
Atenolol 100 mg daily
HCTZ 10 mg (? - per pt's report) daily
Ibuprofen 800 mg q8h prn
Hydrocodone prn since [**6-8**], unknown dose
Unknown muscle relaxant prn since [**6-8**]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-23**]
Tablet, Delayed Release (E.C.)s PO Daily, PRN as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Outpatient Lab Work
CBC, BUN/Cr, LFTs, vancomycin levels. Fax Dr. [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**] at
[**Telephone/Fax (1) 1419**]
9. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) 2 g/50 mL Piggyback Intravenous Q24H (every 24 hours) for 6
weeks.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
15. Morphine 2 mg/mL Syringe Sig: 2-4 mg Injection Q4H (every 4
hours) as needed for pain: Administer for breakthrough pain
only.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: (100 units/ml) 2 ml
IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
.
17. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) ML
Injection DAILY (Daily) as needed: Peripheral IV - Inspect site
every shift .
18. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 6 weeks.
Disp:*QS Recon Soln(s)* Refills:*2*
19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Epidural abscess
Discharge Condition:
Stable
Discharge Instructions:
Return to ER for return of headache, nausea, vomiting,
dizziness, visual changes, difficulty with speech, increased
weakness or numbness, incontinence or urinary retention, or
fever > 38.5 C.
?????? Do not smoke
?????? Keep wound clean and dry / No tub baths or pools until seen in
follow up. Begin daily showers [**2107-6-15**].
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? 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
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
PLEASE RETURN TO THE OFFICE IN [**9-4**] DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES OR HAVE REMOVED AT REHAB
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 548**] in 4 weeks with an thoracic MRI with
and without gadolinium; please call [**Telephone/Fax (1) 2992**] to make an
appointment.
PLEASE RETURN TO DR.[**Doctor Last Name **] OFFICE IN [**9-4**] DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURES OR HAVE REMOVED AT REHAB
Follow up with ID, on [**2107-7-19**] at 9am. You must get weekly blood
work, which should be faxed to [**Telephone/Fax (1) 1419**] (Provider: [**Name10 (NameIs) **] [**Name8 (MD) 34334**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**] Date/Time:[**2107-7-19**] 9:00)
|
[
"311",
"401.9",
"788.20",
"324.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
7627, 7739
|
3796, 5067
|
345, 399
|
7800, 7809
|
2369, 3773
|
9384, 9970
|
1384, 1461
|
5314, 7604
|
7760, 7779
|
5093, 5291
|
7833, 9361
|
1476, 1813
|
279, 307
|
427, 1251
|
1828, 2350
|
1273, 1290
|
1306, 1367
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,647
| 154,179
|
25017
|
Discharge summary
|
report
|
Admission Date: [**2121-11-16**] Discharge Date: [**2121-11-17**]
Date of Birth: [**2082-5-27**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
upper endoscopy
History of Present Illness:
39 year old male with CAD s/p stent in [**2118**] (on ASA/plavix),
past EGD in [**2118**] for melena (only mild gastritis) p/w melena on
Wednesday and this morning. Pt felt lightheaded which made him
go to the ED but he denies any N/V, epigastric pain, CP, SOB.
Also no recent NSAIDs or EtOH.
.
In the ED, he was HD stable (T89.5, 126/55, HR80, 99%RA) but
found to be guaiac positive. He received PPI IV x1. His Hct
dropped from 39 (in [**2118**]) to 23. Repeat Hct was 25. NGL with BRB
did not clear after 1L lavage. 2 large bore IVs were placed. He
received 2U of PRBC. GI has evaluated the patient and plans to
scope the pt in the ICU.
.
On arrival in the ICU, he was HD stable but still draining dark
content from the OGT.
Past Medical History:
- Posterolateral MI with stenting of OM in [**Month (only) 205**] 200, on
ASA/plavix
- H/o melena in [**2118**], EGD in [**2118**] with very mild gastritis
- H/o EtOH abuse
Social History:
2-3 beers per night, previous more heavy alcohol abuse. No IVDU.
No cigarettes.
Family History:
non-contributory
Physical Exam:
VS: Temp: 100.5 BP: 135/63 HR: 94 RR: 15 O2sat: 100% on 2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM
NECK: supple, no jvd, no carotid bruits
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, 2/6 SEM at USB
ABD: nd, ++b/s, soft, nt, no masses
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Moves all extremities
RECTAL: Guaiac pos in ED
Pertinent Results:
[**2121-11-16**] 12:00PM GLUCOSE-121* UREA N-39* CREAT-1.3* SODIUM-142
POTASSIUM-5.4* CHLORIDE-110* TOTAL CO2-24 ANION GAP-13
[**2121-11-16**] 12:00PM estGFR-Using this
[**2121-11-16**] 12:00PM WBC-10.0 RBC-2.67*# HGB-8.0*# HCT-23.2*#
MCV-87 MCH-29.9# MCHC-34.4 RDW-14.5
[**2121-11-16**] 12:00PM NEUTS-73.5* LYMPHS-20.7 MONOS-3.6 EOS-2.0
BASOS-0.2
[**2121-11-16**] 12:00PM PT-12.7 PTT-23.0 INR(PT)-1.1
[**2121-11-16**] 10:00PM POTASSIUM-4.4
Brief Hospital Course:
Summary: 39 year old male with CAD s/p stent in [**2118**] (on
ASA/plavix), past EGD in [**2118**] (only gastritis) p/w melena, found
to have UGIB with Hct drop to 23 (from 39 in [**2118**]), no active
bleeding on emergent upper endoscopy.
.
# UGIB: DDx included PUD, gastritis, erosive esophagitis,
variceal bleed, [**Doctor First Name 329**]-[**Doctor Last Name **] tear or AVMs. The patient denied
any recent N/V, NSAIDs, excessive EtOH. His ASA and Plavix were
held given concern for continued bleeded. Emergent upper
endoscopy in ICU showed duodenal ulcer w/ no active bleeding
although NGT lavage demonstrated bright red blood without
clearing w/ 1L lavage. He was hemodynamically stable throughout
his hospital course, though he did complain of some
lightheadedness. The patient was transfused a total of 2u PRBCs.
His HCT trended upwards and remained stable. At the time of
discharge, the patient was able to tolerate PO. He was sent home
on PO PPI [**Hospital1 **] with instructions to follow-up for his H. Pylori
testing results. His antihypertensives were held at the time of
discharge with instructions to restart in coordination with the
patient's PCP.
.
# CAD: The patient is s/p MI in [**2118**] and stenting. In the
setting of his bleeding his ASA, BB and ACEI were held; the
patient was instructed to discuss restarting these with his PCP.
[**Name10 (NameIs) **] statin was continued.
.
# Elevated Cr: The patient's creatinine was the same as a prior
baseline in [**2118**]. It was thought this may be due to muscle mass
versus mild CKD. His ACEI was held in the setting of GIB.
.
# Hyperlipidemia: The patient's statin was continued.
.
# H/o EtOH abuse: Now only 2-3 beers per night lately. Did not
require ativan per CIWA scale.
Medications on Admission:
metoprolol 100 mg b.i.d.
Accupril 40 mg daily
Plavix 75 mg daily
aspirin 81 mg daily
Lipitor 80 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
6 weeks.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*5*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*5*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Duodenal Ulcer
SECONDARY:
CAD
EtOH
Discharge Condition:
Good; hemodynamically stable, HCT trending upwards, able to
tolerate PO intake.
Discharge Instructions:
-You must continue to take your anti-reflux medication
(Protonix) for at least six weeks until you are seen at the [**Hospital **]
clinic.
-Contact your primary care physician to discuss when to re-start
your high blood pressure medications.
Followup Instructions:
- Contact your Primary Care Doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up
appointment within one to two days of being discharged. You will
need to get your blood count re-checked. You should discuss with
them when to restart your high-blood pressure medications and
results of tests that were pending at the hospital when you were
discharged (H. Pylori blood test).
- Contact the [**Hospital 18**] [**Hospital **] Clinic at ([**Telephone/Fax (1) 2233**] to [**Telephone/Fax (1) **] a
follow-up appointment for six weeks from now.
- Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2122-3-26**] 2:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"272.4",
"V45.82",
"285.1",
"532.40",
"414.01",
"412",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4562, 4568
|
2345, 4095
|
320, 338
|
4657, 4738
|
1868, 2322
|
5028, 5854
|
1404, 1422
|
4250, 4539
|
4589, 4636
|
4121, 4227
|
4762, 5005
|
1437, 1849
|
266, 282
|
366, 1094
|
1116, 1290
|
1306, 1388
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,551
| 160,312
|
49045
|
Discharge summary
|
report
|
Admission Date: [**2120-8-11**] Discharge Date: [**2120-8-14**]
Date of Birth: [**2059-6-26**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
male with a past medical history of hypertension,
gastroesophageal reflux disease, anxiety with cardiac risk
factors of age, gender, hypertension, borderline
hypercholesterolemia who presented to [**Hospital1 190**] at 3:00 a.m. on [**2120-8-11**] after onset acutely of
chest pain at 10:00 p.m. [**2120-8-10**]. The chest pain was 8 out
of 10 in severity, radiating down the patient's left arm, not
associated with any nausea, vomiting, diaphoresis. There was
no relief with antacids or rest. In the Emergency
Department, electrocardiogram showed inferior ST elevations
and high lateral depressions of 1, AVL. In the Emergency
Department the patient received aspirin 325 mg, Lopressor 5
mg intravenous, started on nitroglycerin drip, heparin drip
and Integrilin drip. The patient arrived at the
catheterization laboratory at approximately 4:45 a.m. with
continued chest pain. Cardiac catheterization showed acute
inferior myocardial infarction due to occlusion of left
dominant circumflex after first marginal. This was
successfully reperfused and stented. During catheterization
the patient had a prominent and transient Bezold-Jarisch
reflex that occurred with reperfusion. This required
transient right ventricular pacing. It also required
Atropine and low dose transient Dopamine. The patient did
not have any recurrence of this reaction throughout the rest
of the catheterization case. Catheterization also showed a
20% proximal lesion of the left anterior descending coronary
artery with a 70 to 80% lesion in the mid left anterior
descending coronary artery. Left ventriculogram was
performed throughout the catheterization, which showed an
ejection fraction of 64%. Also showed focal inferior basal
hypokinesis. The patient was then transferred to the
Coronary Care Unit for further monitoring.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gastroesophageal reflux disease.
3. Situational anxiety.
4. Borderline hypercholesterolemia.
ALLERGIES: The patient reports an allergy to iodine and
shellfish, unknown reaction.
MEDICATIONS PRIOR TO ADMISSION:
1. Aspirin 81 mg po q.d.
2. Atenolol 25 mg po q.d.
3. Prevacid 30 mg po q.d.
SOCIAL HISTORY: The patient lives alone. Reports occasional
alcohol use consistent of one to two martinis, half bottle of
red wine nightly. Denies any recreational drug use or
tobacco use.
FAMILY HISTORY: The patient's mother died of myocardial
infarction in her 60s. Father deceased at old age secondary
to complications of bronchitis.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature
97.9. Pulse 84. Blood pressure 116/55. Respiratory rate
18. O2 saturation 97% on 4 liters nasal cannula. General
appearance, well developed, well nourished, white male,
sleeping comfortably and in no acute distress. HEENT
normocephalic, atraumatic. Sclera anicteric. Pupils are
equal, round and reactive to light and accommodation. Oral
mucosa moist. Neck supple, no masses or lymphadenopathy. No
jugulovenous distention or elevated jugulovenous pressure
noted. Lungs clear to auscultation bilaterally. No rhonchi,
wheezes or rales. Cardiovascular regular rate and rhythm.
S1, S2 heart sounds auscultated. No murmurs, rubs or
gallops. Abdomen soft, nontender, nondistended. Positive
bowel sounds. No hepatosplenomegaly. Groin femoral
catheterization bandage site, clean, dry and intact. No
serosanguinous discharge noted. Extremities no clubbing,
cyanosis or edema noted. Extremities warm and dry. 2+
dorsalis pedis pulses peripherally bilaterally.
PERTINENT LABORATORIES/X-RAY STUDIES: Complete blood count
on admission showed a white blood cell of 6.4, hematocrit
42.2, platelet count 228. Serum chemistries showed sodium
140, potassium 3.9, chloride 103, bicarbonate 27, BUN 16,
creatinine 0.8, glucose 119. Coagulation profile showed a PT
12.5, PTT 23.4, INR 1.0. Cardiac enzymes on admission showed
CK 301, CKMB 7, troponin 0.05. Peak CK was 1401, peak
troponin 3.10. Electrocardiogram on admission showed normal
sinus rhythm at 75 beats per minute, normal axis and
intervals. No evidence for atrial ventricular enlargement.
No evidence for a bundle branch block. 0.5 to [**Street Address(2) 4793**]
elevations noted in leads 2, 3, AVF. 0.[**Street Address(2) 1755**] depressions
noted in leads 1, AVL, V5-V6. Right sided electrocardiogram
showed no ST elevation in lead V4R. Chest x-ray on admission
showed no evidence of congestive heart failure or pneumonia.
Echocardiogram performed [**2120-8-12**] showed left ventricular
ejection fraction 60%. Left atrium is moderately dilated.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal. Small basal
posterior hypokinesis is present. The aortic valve leaflets
(3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. Persantine stress test
([**2120-8-2**]), the patient exercised for a total of four minutes
with a 55% maximal heart rate achieved. No chest, back, neck
or arm discomfort was reported during the procedure. No
significant ST segment changes were noted from baseline. The
rhythm was sinus with no ectopy noted. The hemodynamic
response to the Persantine effusion was appropriate. The
patient had no anginal symptoms or electrocardiogram changes
from baseline. The nuclear portion of this examination
showed stress images with normal left ventricular cavity
size. There was a small, severe, intense defect in the base
of the inferior wall, which was fixed on resting perfusion
images. Ejection fraction calculated from gated wall motion
images obtained after Dipyridamole administration was 50%.
There was normal wall motion. The overall impression was
that of a small, severe, fixed defect in the base of the
inferior wall.
HOSPITAL COURSE: 1. Coronary artery disease: The patient
was status post inferior myocardial infarction, status post
left circumflex percutaneous intervention with stent
placement in left circumflex. On arrival to the floor he was
continued on aspirin, Plavix, Integrilin. Integrilin was
discontinued after 18 hours. Initially beta blocker and ace
therapy were held secondary to hemodynamic instability,
history of Bezold-Jarisch reaction while in the
catheterization laboratory. On arrival to the floor he was
on a Dopamine drip and this was weaned as tolerated by his
blood pressure. As his blood pressure improved we added beta
blocker and ace inhibitor back to his medication regimen and
this was tolerated well. Cardiac enzymes were cycled with
peak value of CK 1401, troponin T 3.10. While the patient's
left circumflex was felt to be the vessel involved in his
inferior myocardial infarction, we were also concerned due to
his left anterior descending coronary artery lesions on
coronary catheterization. Therefore once he was stabilized
he underwent Persantine stress testing with results as above.
Namely there was a small severe intensity defect in the base
of the inferior wall, which was fixed on resting perfusion
images. The patient was discharged on a medication regimen
of aspirin, Plavix, Metoprolol, Lisinopril, Lipitor. He was
instructed that he is to continue aspirin and Plavix daily
for the next nine months status post percutaneous stent
placement.
2. Possible alcohol abuse: During this admission the
patient was monitored on CIWA scale for signs and symptoms of
alcohol withdraw. If he exhibited evidence of withdraw he
was to be administered Lorazepam. However, he did not
exhibit any signs or symptoms of withdraw during this
hospitalization. He was counseled as to his alcohol intake
and instructed to cut down his level of intake. The patient
was amenable to this discussion and agreed to monitor his
alcohol intake more closely.
CONDITION ON DISCHARGE: Stable. The patient was cleared by
physical therapy for discharge to home without any additional
services or physical therapy needed. He was ambulatory
independently. He was chest pain free.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES:
1. ST elevation myocardial infarction.
2. Hypertension.
3. Gastroesophageal reflux disease.
4. Situational anxiety.
5. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po one po q.d.
2. Plavix 75 mg one po q.d.
3. Lipitor 10 mg one po q.d.
4. Lisinopril 10 mg one po q.d.
5. Lansoprazole 30 mg one po q.d.
6. Toprol XL 100 mg 1.5 po q.d.
FOLLOW UP PLANS: The patient was instructed to call his
doctor or return to the Emergency Room if he had recurrent
chest pain, chest pressure, difficulty breathing, dizziness
or weakness. He was instructed to take all of his
medications as prescribed particularly that he is required to
take his aspirin and Plavix daily for the next nine months.
He was also instructed to limit his daily alcohol intake to
one drink per day. He was counseled on a low cholesterol,
low fat diet. He was instructed to participate in a cardiac
rehabilitation program and to start an exercise program with
the guidance of his cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He is told
to call and see his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in
one to two weeks. He was finally instructed to call
[**Telephone/Fax (1) 3512**] to schedule an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
for a cardiology follow up. She will manage his
cardiovascular care and schedule an exercise stress test in
six weeks.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2120-8-15**] 05:13
T: [**2120-8-18**] 09:20
JOB#: [**Job Number 102926**]
cc:[**Name8 (MD) 4990**]
|
[
"291.81",
"458.2",
"303.90",
"401.9",
"427.5",
"V70.7",
"530.81",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.06",
"88.53",
"36.01",
"37.23",
"39.64",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
2560, 2715
|
8313, 8460
|
8483, 10100
|
6053, 8016
|
2269, 2350
|
161, 2010
|
2730, 6035
|
2032, 2237
|
2367, 2543
|
8041, 8292
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,740
| 135,148
|
36290
|
Discharge summary
|
report
|
Admission Date: [**2135-4-19**] Discharge Date: [**2135-4-21**]
Date of Birth: [**2060-8-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin / Heparin Agents / Erythromycin Base /
Codeine
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
transfer for new HD line placement
Major Surgical or Invasive Procedure:
replaced HD tunneled line
placed PICC line
RIJ removed
History of Present Illness:
This is a 74 year old F with ESRD on dialyis, CAD s/p CABG,
COPD, HIT+ on coumadin, recently s/p a prolongued course of
pneumonia s/p intubation followed by trach/PEG who had been at
[**Hospital **] Rehab. She is transfered from [**Hospital1 **] for dialysis
catheter replacement. Per [**Hospital1 **] physician, [**Name10 (NameIs) **] dialysis
[**Last Name (un) **] has been unusable on the last 2 dialysis sessions despite
TPA. Her last dialysis session was 5 days ago. She is edematous
but has no pulmonary edema, no increased O2 requirement (35%
Fio2) and K yesterday was 4.1.
Past Medical History:
Pseudomonas PNA
Respiratory Failure, on vent, weaning at [**Hospital1 **]
HIT +, no thrombosis
COPD
ESRD on dialysis
CAD s/p CABG
PVD
Depression
PAF
Gastroparesis
Social History:
Married, lives with Husband. Daughter is RN and involved in care
Family History:
NC
Physical Exam:
General Appearance: No acute distress, Thin
Head, Ears, Nose, Throat: Normocephalic, trached
Cardiovascular: (S1: Normal), (S2: Normal, Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Wheezes : exp, Diminished: bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Trace, Left: Trace
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2135-4-20**] WBC-7.8 RBC-3.24* Hgb-8.6* Hct-28.9* MCV-89 MCH-26.7*
MCHC-29.9* RDW-17.5* Plt Ct-227
[**2135-4-20**] Glucose-84 UreaN-108* Creat-3.3* Na-131* K-4.4 Cl-93*
HCO3-26
[**2135-4-20**] 04:45AM BLOOD PT-36.7* PTT-40.7* INR(PT)-3.9*
[**2135-4-20**] 04:45AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.5 Iron-15*
[**2135-4-20**] 04:45AM BLOOD calTIBC-199* Ferritn-32 TRF-153*
[**2135-4-20**] 04:45AM BLOOD PTH-22
CXR - FINDINGS: A double-lumen catheter is introduced over the
left internal jugular vein. A standard central venous access
line is placed in the right internal jugular vein, the tip of
the left catheter projects over the brachiocephalic vein, the
tip of the right catheter projects over the azygos vein.
Right-sided tracheostomy tube. Small bilateral pleural
effusions. Mild cardiomegaly and right-sided perihilar haze
could be indicative of mild pulmonary fluid overload. Bilateral
subtle fibrotic changes, most obvious in the retrocardiac lung
areas, could represent fibrotic scars after old infection. No
evidence of recent infectious lung disease.
PICC placement - IMPRESSION: Uncomplicated ultrasound and
fluoroscopically guided single lumen PICC line placement via the
right brachial venous approach. Final internal length is 41 cm,
with the tip positioned in SVC. The line is ready to use.
Brief Hospital Course:
74 year old F with ESRD on dialyis, CAD s/p CABG, COPD, HIT+ on
coumadin, chronically ventilated, trach/PEG who is transfered
from [**Hospital1 **] for dialysis catheter replacement.
.
# HD line change: Pt was transferred for intermittently working
HD line. On CXR, line appeared short, which may be contributing
to mechanical difficulties. There was also some thought that
patient may have a persistant SVC also contributing to line
difficulties. IR guided change of line was performed after INR
was reversed with FFP. She was restarted on coumadin at
discharge. INR was 2.2 on day of discharge, her goal was [**2-1**].
.
# ESRD on HD: Per pt's daughter, she had some mild CRI of
unknown etiology prior to recent hospitalizations, followed by
PCP. [**Name10 (NameIs) **] became HD dependent after recent prolongued
hospitalization. She received 1 HD session with 2kg removal. She
did received 4000 units Epo with HD on [**2135-4-20**]. On day of
discharge, [**4-21**], she underwent another HD session and the new HD
line was working very well.
.
# Respiratory Failure: She remained on the Vent without issues.
Of note, meropenam was stopped as [**Hospital1 **] note stated that she
should have 10 day course and first dose received on [**2135-4-6**]
(last should be [**4-16**]). Flagyl was continued as per [**Hospital1 **]
records. The need for continued Flagyl should be re-addressed at
[**Hospital1 **], as this can likely be stopped as well if it was also
started for aspiration pneumonia.
.
# PICC line placement: Pt arrived with RIJ. After discussion
with family, family was amenable to switching to single lumen
PICC. As she has stopped her IV meropenam, she may not have
long-term needs for PICC line and we recommend that this be
removed in favor of peripheral IV once needs for IV antibiotics
are clarified.
.
# COPD: She continued spiriva and nebs. Her predinsone 15 mg
daily was continued. It was unclear how long her taper was
supposed to be. We recommend follow-up regarding duration of
prednisone taper and if she will be chronically on higher
steroid doses, she may benefit from ppx with bactrim.
.
# HTN: She continued clonidine, labetalol, isordil, lisinopril
.
# Gastroparesis: continued reglan
.
# Depression/Anxiety: continued paxil and seroquel
.
# Prophylaxis: PPI, therapeutic INR, bowel regimen
.
# Code Status: Full
Medications on Admission:
Calcium Carbonate 1250mg daily
Cholrhexidine
Clonidine patch 0.3mg q friday
Darbepoetin 200 mcg with dialysi
Ferrous sulfate 300mg [**Hospital1 **]
Advair q12 hrs
Folic acid 1mg daily
Isordil 60mg daily
Labetalol 400mg [**Hospital1 **]
Lansoprazole 30mg daily
Linsiopril 10mg daily
Meropenem 500mg [**Hospital1 **]
Miconazole topically
Nystatin swich and spit
Paroxetine 10m q daily
Quetiapine 12,5mg [**Hospital1 **]
Simethicone drips 80mg TID
Soidum Bicarbonate 8.4% vial to be mixed with lansoprazole
Tiotropium 10cg daily
Vitamin D 400 units daily
Coumadin 2.5mg daily
Flagyl 500mg TID
Tylenol 650mg daily PRN
Albuterol PRN
Klonpin 0.5mg q 12 prn
Loperamid 2mg prn
Reglan 5mg pRN
Morphine 1mg q 6hrs PNR
Nitro 2% paste PRN CP
Discharge Medications:
1. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension [**Hospital1 **]:
Three (3) PO DAILY (Daily).
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane QID (4 times a day).
3. Clonidine 0.3 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly
Transdermal QFRI (every Friday).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO BID (2 times a day).
5. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Isosorbide Dinitrate 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO
TID (3 times a day).
7. Labetalol 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day) as needed.
12. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
13. Prednisone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily): on a prednisone taper [**Name6 (MD) **] [**Name8 (MD) **] MD's.
14. Quetiapine 25 mg Tablet [**Name8 (MD) **]: 0.5 Tablet PO BID (2 times a
day).
15. Simethicone 80 mg Tablet, Chewable [**Name8 (MD) **]: One (1) Tablet,
Chewable PO TID (3 times a day).
16. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Name8 (MD) **]:
One (1) Cap Inhalation DAILY (Daily).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Name8 (MD) **]: One (1)
Tablet PO DAILY (Daily).
18. Metronidazole 500 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO Q8H
(every 8 hours).
19. Acetaminophen 160 mg/5 mL Solution [**Name8 (MD) **]: [**12-31**] PO Q6H (every 6
hours) as needed.
20. Clonazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID PRN ()
as needed for anxiety.
21. Loperamide 1 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO QID (4 times a
day) as needed.
22. Metoclopramide 10 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO TID PRN () as
needed for vomiting.
23. Warfarin 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Once Daily at
4 PM.
24. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed.
25. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
26. Darbepoetin Alfa In Polysorbat 200 mcg/0.4 mL Pen Injector
[**Month/Day (2) **]: One (1) Subcutaneous MWF: with dialysis.
27. Nitropaste 2%
appply [**12-31**] inch PRN chest pain
28. PICC
PICC line care as per protocol, flush with saline
- no heparin as patient is HIT positive
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Occluded dialysis catheter
end stage renal disease
respiratory failure, ventilator dependent
Discharge Condition:
stable
Discharge Instructions:
You were admitted for replacement of your dialysis catheter.
This was replaced and you had one successful dialysis session.
You also had your right central line replaced with a PICC line.
We have stopped you IV meropenam as you have completed a 12 day
it.
.
Please restart all medications as they were at [**Hospital1 **] prior to
transfer to [**Hospital1 18**]. The only medication change was: discontinued
Meropenem as course was finished.
Followup Instructions:
FOllow up with PCP [**Name9 (PRE) 78033**],[**Name9 (PRE) **] [**Telephone/Fax (1) 45347**] as necessary.
|
[
"V46.11",
"496",
"V44.1",
"414.00",
"518.83",
"289.84",
"V45.81",
"V58.61",
"427.31",
"585.6",
"V44.0",
"482.1",
"300.4",
"536.3",
"996.73",
"443.9",
"403.91",
"E879.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"38.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9380, 9459
|
3313, 5663
|
364, 420
|
9605, 9614
|
1979, 3290
|
10104, 10213
|
1316, 1320
|
6444, 9357
|
9480, 9584
|
5689, 6421
|
9638, 10081
|
1335, 1960
|
290, 326
|
448, 1031
|
1053, 1218
|
1234, 1300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,755
| 151,669
|
2106
|
Discharge summary
|
report
|
Admission Date: [**2125-2-9**] Discharge Date: [**2125-2-23**]
Date of Birth: [**2078-7-15**] Sex: F
Service: MEDICINE
Allergies:
Vicodin / Sustiva
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
acute renal failure and pneumonia (transfer from outside
hospital)
Major Surgical or Invasive Procedure:
bronchoscopy, lumbar puncture x2
History of Present Illness:
Pt 46 y/o female with PMHx significant for HIV who presented to
Good [**Hospital 5159**] Hospital on [**2125-2-5**] with cough, fever, and
diarrhea. She had visited her freind in the hospital with PNA 2
weeks prior to presentation. Patient was initially put on 5 day
course of Zithromax outpatient but did not improve and was
admitted to the hospital. On admission her CXR was significant
for right sided pneumonitis. Patient was admitted and being
treated for CAP with levofloxacin and ceftriaxone when she
apparently decompensated from a respiratory standpoint on [**2-8**],
requiring intubation. At that point she had CT chest which
showed dense consolidation of RUL with b/l ground glass air
space disease throughout both lobes. Patient was put on
respiratory isolation for concern for TB and [**Month/Year (2) 11381**] x2 sent, fist
one [**2125-2-6**] came back negative.
.
While at the OSH patient also developed ARF with Cre going from
2.7 on admission to 5.5 on day of transfer. Renal was consulted
and felt could be secondary to volume depleation from diarrhea.
She underwent renal U/S at OSH which was negative. She was
started on bicarb gtt for treatment of metabolic acidosis. On
[**2-9**] patient started on steroids and pentamidine given concern
for PCP [**Name Initial (PRE) 11091**]. She also become hypotensive at OSH and was started
on neo and transferred to [**Hospital1 18**].
.
Also during admission at OSH patient found to have 7mm left
posterior parietal hemorrhage on head CT without mass effect.
She was seen by neurosurgery at OSH who felt hemorrhage unlikely
after repeat head CT showed no change in mass. Patient also
noted to have severe sinusitis.
Past Medical History:
1. HIV diagnosed in [**2108**]; CD4 675 HIV VL 209 in [**2124-12-22**].
presented with CMV retinitis
2. H/O CMV retinitis of R eye
3. s/p TAH with BLO in [**2118**]
4. HTN
5. History of brain cancer/meningioma
6. hyperlipidemia
7. h/o chronic diarrhea since starting HAART in [**2108**]. Has had
many GI w/u and colonoscopy in the last year
8. Rectal cancer: [**2121**] had XRT, chemo, and surgery. since her
cancer has had BRBPR
Social History:
Lives at home with sister, denies etoh use, states quit smoking
4 days prior to admit at OSH. Denies any IV drug use .
Family History:
Maternal grandparents died of cancer (unknown type) in their 60s
or 70s. Her parents are alive in their 70s. No other known
cancer in the family. Paternal grandmother diet of cirrhosis.
Physical Exam:
T 96.0 BP 116/68 P 64 RR 22 O2 95 on 2L FS 131 Wt 153 lbs
Gen: NAd, tired appearing
Heent: PERRL, sclera anicteric
Chest: decreased breath sound at bases, breathing comfortably
Cardiac: RRR S1/S2 no murmurs
Abd: soft non-distended
Ext: Patient with erythema of all toe-nails at nail-bed where
nail meets skin; no edema, R subclavin IV in place
Neuro: alert and awake interactive, appropriate
Pertinent Results:
[**2125-2-9**] 07:27PM WBC-14.3* RBC-2.80* HGB-9.6* HCT-28.1*
MCV-100* MCH-34.3* MCHC-34.3 RDW-15.0
[**2125-2-9**] 07:27PM NEUTS-99.0* LYMPHS-0* MONOS-1.0* EOS-0
BASOS-0
[**2125-2-9**] 07:27PM PLT SMR-NORMAL PLT COUNT-343
[**2125-2-9**] 07:27PM PT-13.6* PTT-29.5 INR(PT)-1.2*
HIT ANTIBODY: NEGATIVE
.
IRON 53, TIBC 183, FERRITIN 980, FOLATE 14.3, B12 [**2028**]
ABS CD4 30->195
.
[**2125-2-9**] 07:27PM GLUCOSE-137* UREA N-83* CREAT-5.3* SODIUM-135
POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-17* ANION GAP-13
[**2125-2-9**] 07:27PM ALT(SGPT)-30 AST(SGOT)-68* LD(LDH)-531* ALK
PHOS-106 AMYLASE-119* TOT BILI-0.7 DIR BILI-0.6* INDIR BIL-0.1
[**2125-2-9**] 07:27PM LIPASE-51
[**2125-2-9**] 07:27PM ALBUMIN-2.4* CALCIUM-7.1* PHOSPHATE-5.3*
MAGNESIUM-2.9*
.
CSF
[**2125-2-12**] TOTAL PROTEIN 22, GLUCOSE 69
[**2125-2-21**] TOTAL PROTEIN 42, GLUCOSE 43
EBV, HSV PCR: NEGATIVE
FLOW CYTOMETRY FROM [**2125-2-21**]: PENDING (prelim negative for
evidence of CNS lymphoma)
.
HIV VL: PENDING
.
[**2125-2-9**] 07:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2125-2-9**] 07:30PM URINE RBC-15* WBC-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2125-2-9**] 07:30PM URINE EOS-NEGATIVE
.
FUNGAL BLOOD CX: NO GROWTH TO DATE
BLOOD CX: NO GROWTH TO DATE
CATH TIP CX: NEGATIVE
CMV VL: UNDETECTABLE
RAPID RESPIRATORY VIRAL SCREEN: NEGATIVE, VIRAL CULTURE: PENDING
URINE LEGIONELLA ANTIGEN: NEGATIVE
.
[**2125-2-10**] 12:07 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2125-2-10**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2125-2-13**]):
~[**2117**]/ML OROPHARYNGEAL FLORA.
YEAST. ~3000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
LEGIONELLA CULTURE (Final [**2125-2-17**]): NO LEGIONELLA
ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2125-2-11**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Final [**2125-2-23**]):
YEAST.
ACID FAST SMEAR (Final [**2125-2-12**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
.
[**2125-2-21**] 8:02 pm CSF;SPINAL FLUID Source: LP.
GRAM STAIN (Final [**2125-2-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
.
[**2125-2-12**] 6:24 pm CSF;SPINAL FLUID TUBE 3. R/O HSV.
GRAM STAIN (Final [**2125-2-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2125-2-15**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
.
[**2125-2-9**] CXR: 1. Right upper lobe consolidation, likely
pneumonia.
2. Moderate interstitial abnormality is likely pulmonary edema,
though viral pneumonia is also possible.
3. Possible mediastinal lymphadenopathy - recommend Chest CT for
further evaluation on a nonemergent basis.
.
[**2125-2-11**] CXR: Markedly improved airspace process in the right
upper lobe and mildly improving interstitial edema.
.
[**2125-2-12**] MR HEAD: 1. Abnormal FLAIR sulcal hyperintensity ,
differential includes any leptomeningeal process. In a patient
with HIV, meningitis is not excluded and correlation with lumbar
puncture is recommended. Also, contrast enhanced study could be
performed if patient's renal function improves, or hemodialysis
can be arranged.
2. A 6 mm lesion within the left occipital cortex, which may
represent a meningioma, but is incompletely characterized. A
hemorrhage in this area is not entirely excluded, and short
interval followup with non-contrast CT was recommended.
3. Pansinus opacification.
.
[**2125-2-12**] CXR: Cardiac size is top normal. ET tube is in the
standard position. NG tube is in the stomach. Right subclavian
vein catheter terminates in the cavoatrial junction. There has
been mild interval worsening of mild-to-moderate pulmonary
edema. Right upper lobe consolidation is stable. Ill-defined
right lower lobe perihilar opacity is new. This could be due to
asymmetric pulmonary edema, but infection cannot be completely
excluded.
.
[**2125-2-12**] SPINAL FLUID: NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes and monocytes.
.
[**2125-2-13**] CXR: Mild improvement in the degree of pulmonary edema
as well as the previously noted right upper and lower lung field
consolidations.
.
[**2125-2-13**] EEG: This is an abnormal EEG due to the right greater
than left
central sharp waves, the bursts of generalized slowing and the
slow and
disorganized background rhythm. The first two abnormalities
suggest
dysfunction of deep subcortical midline structures, while the
slow
background suggests a mild to moderate encephalopathy. An
encephalopathic picture may result from infections, toxic
metabolic
abnormalities or medication effect.
.
[**2125-2-14**] CT HEAD: 1. Unchanged hyperdensity along the left
occipital convexity likely represents meningioma, but a
hemorrhage cannot be entirely excluded. Unchanged from prior
examinations.
2. Pansinusitis.
.
[**2125-2-15**] SINGLE AP PORTABLE VIEW OF THE CHEST: Cardiomediastinal
contour is unchanged. Right subclavian vein catheter terminates
in the SVC. There is no pneumothorax or pleural effusion.
Diffuse mild interstitial abnormality has improved since [**2-12**], [**2124**]. Right upper lung consolidation is increasing.
.
[**2125-2-16**] UNILAT UP EXT VEINS US RIGHT: No evidence for DVT.
.
[**2125-2-18**] CT ABD/PELVIS: 1. No intra-abdominal source of fever
identified. Diffuse anasarca with interval increase in small
amount of simple free fluid noted within the cul- de- sac.
2. Mild stranding/wall thickening of the distal rectum/anus
consistent with known history of anal carcinoma. Wall thickening
may also be related to post- radiation changes in correct
clinical setting.
3. Marked improvement in multifocal pneumonia with interval
appearance of small simple right pleural effusion. Incidental
note is also made of a mucous-filled left lower lobe bronchus.
4. Diffuse enlargement to kidneys bilaterally. Findings
suggestive underlying renal dysfunction may be due to HIV
nephropathy.
.
[**2125-2-18**] CT HEAD: 1. No significant change from most recent CT
examination; however, current examination is limited due to
motion artifact.
2. Stable appearance to left occipital density, likely
representing a meningioma.
3. Stable appearance to opacification of sphenoid sinus with
mild improvement to opacification within the ethmoid air cells.
Maxillary sinuses were not included on current study. If high
clinical suspicion for sinus disease as a source of fever, may
be better evaluated with dedicated sinus CT.
.
[**2125-2-18**] CXR: Improvement in the appearance of the interstitial
process together with the right upper lobe airspace disease
since the prior examination.
.
Brief Hospital Course:
# Multifocal pneumonia: Patient required intubation at the
outside hospital. Bronchoscopy here with sputum negative for
PCP. [**Name10 (NameIs) 11381**] negative x 3, urine legionella antigen negative, and
viral screen negative. Swallow evaluation was done during her
admission due to her poor mental status and showed no evidence
of aspiration. Patient improved on zosyn/vanco and finished a
total of 12 days of antibiotics on levo/vanco. At the time of
discharge she was stable on room air and received the pneumovax
prior to discharge.
.
# Drug fever: At the end of patient's course of antibiotics for
her pneumonia, she began to have fevers as high as 103 but was
also noted to have developed a rash. Suspect drug reaction to
either acyclovir (started for ? HSV meningitis but discontinued
once PCR negative) versus zosyn. Her fevers resolved off all
antibiotics. Work-up was otherwise negative, including CT abd,
CT head to reevaluate for progressive sinusitis, and repeat
cultures. She did grow yeast in her urine, so her foley was
discontinued and she received a single dose of diflucan. Her
subclavian line was also discontinued, despite negative
cultures. The tip culture was negative.
.
# Abnormal MRI: MRI done for altered mental status while in the
ICU showed an abnormal FLAIR sulcal hyperintensity and an
occipital density, thought to be a meningioma. Neurology was
consulted and followed along during the patient's stay. They
suspect the occipital lesion is a meningioma given it is stable
compared to a prior MRI in [**7-26**]. However, they have requested a
follow-up MRI as an outpatient and will also see her in
outpatient follow-up. As for the meningeal enhancement, concern
raised for possible CNS lymphoma. Hematology was consulted and
followed along. Patient found to have EBV in her CSF with rare
atypical cells on cytology. A repeat LP was done to send CSF
for flow. Preliminary flow does not suggest lymphoma. Repeat
cytology is pending.
.
# Acute renal failure: Renal followed along. Suspect acute
tubular necrosis. Creatinine improved to 2.0 by the time of
discharge. She had no severe electrolyte disturbances.
Medications were renally dosed. Patient will be following up
with renal as an outpatient.
.
# HIV: ID followed throughout the admission. At discharge,
given persistent renal dysfunction and complaints of diarrhea on
kaletra, her HAART regimen was adjusted. She will follow-up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11382**] for continued care. Repeat CD4 and HIV
viral load sent prior to discharge. Bactrim prophylaxis
deferred given CD4 count has been steadily climbing. This can
be started at her ID follow-up if her CD4 remains < 200. She
did require nystatin for oropharyngeal +/- esophageal
candidiasis.
.
# Neutropenia: Suspect medication-induced given onset during
her stay. Following the discontinuation of all antibiotics, ANC
recovered and patient no longer neutropenic at the time of
discharge.
.
# History of anal cancer: Patient will discuss with her ID
provider whether she can do screening anal paps. If not,
patient will need referral to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] for this reason.
Patient given Dr.[**Name (NI) 3377**] name for future reference.
.
# Anemia: Folate and B12 normal. High ferritin suggests anemia
of chronic disease. Certainly renal failure will be a
contributing factor.
.
# Altered mental status: Likely due to residual effects of
sedating meds administered while intubated. MRI issues
discussed above. LP did not suggest infectious etiology. EEG
showed no evidence for seizures. Patient had a normal mental
status at the time of discharge.
.
# FEN: regular diet, nutrition recommended supplement [**Hospital1 **]
.
# Dispo: discharged home with services (PT and home safety
evaluation)
Medications on Admission:
Acyclovir 800mg [**Hospital1 **]
albuterol MDI prn
didanosine 250mg daily
Diflucan 100mg qam and 150mg afternoon
Flonase
Fuzeon [**Hospital1 **]
Kaletra 200/50 [**Hospital1 **]
Lipitor 80mg qhs
Lodine 500mg [**Hospital1 **]
Loratadine 10mg daily
oxycodone 50mg q6
Pepcid 20mg daily
Prednisone 10mg daily
Premarin 0.625mg daily
Reyataz 150mg [**Hospital1 **]
Tricor 145mg daily
Truvada 1 tab daily
Zithromax 150mg daily
motin for back pain
Discharge Medications:
1. Didanosine 200 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. Fuzeon 90 mg Kit Sig: One (1) injection Subcutaneous twice a
day.
Disp:*60 prefilled syringes* Refills:*0*
3. Atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day:
MUST TAKE WITH RITONAVIR, DO NOT TAKE WITH ANY ANTACIDS.
Disp:*30 Capsule(s)* Refills:*0*
4. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO once a day:
MUST TAKE WITH ATAZANAVIR.
Disp:*30 Capsule(s)* Refills:*0*
6. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day for 7 days.
Disp:*1 inahler* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 7 days.
Disp:*140 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
primary:
multifocal bacterial pneumonia
neutropenia
HIV, symptomatic
likely meningioma but needs follow-up MRI to confirm stability
EBV in CSF - preliminary work-up does not suggest CNS lymphoma
but final cytology pending
acute renal failure due to acute tubular necrosis
anemia of chronic disease
drug fever
encephalopathy - resolved prior to discharge
hypokalemia
secondary:
history of anal cancer
Discharge Condition:
good: afebrile, ANC steadily improving, stable on room air
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience temperature > 101, worsening cough or shortness of
breath, chest pain, or other concerning symptoms.
Please continue to take a nutritional supplement twice daily to
improve your nutritional status.
Please note your new HIV medication regimen.
Please monitor for signs and symptoms of abacivir
hypersensitivity and call Dr. [**Last Name (STitle) 11382**] if you notice any of the
following:
anaphylaxis, fever, rash, fatigue, diarrhea, abdominal pain,
sore throat, shortness of breath, cough, headache, muscle or
joint pain, swelling in your arms or legs, numbness in your arms
or legs, nausea and vomiting, mouth ulcerations, eye irritation,
or gland swelling
Followup Instructions:
1. Provider: [**Name10 (NameIs) 11383**],[**Name11 (NameIs) 11384**] OB/GYN PPS CC8 (SB) Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2125-3-13**] 1:00. [**Hospital Ward Name **] [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**Location (un) **].
2. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11385**], MD (new primary care doctor)
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-3-19**] 3:30. [**Hospital Ward Name 23**] Building,
[**Hospital Ward Name **] [**Hospital1 18**] [**Location (un) **].
3. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] (nephrology) Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2125-3-1**] 3:00. [**Hospital Ward Name **] [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**Location (un) **] Medical Specialties.
4. You have an MRI of your head scheduled on Tuesday [**2125-3-6**] at
4:45 in the [**Hospital Ward Name 517**] basement.
5. You have an appointment scheduled with Dr. [**First Name (STitle) 640**] [**MD Number(4) 747**] [**Name8 (MD) **],
M.D. (neurology) Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2125-3-8**] 2:00.
[**Hospital Ward Name 516**] [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**Location (un) **].
6. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11382**] on Wednesday, [**2-28**], [**2124**] at 9:00 AM. Phone: ([**Telephone/Fax (1) 4170**]. [**Hospital1 18**], [**Last Name (NamePattern1) **]., Suite GB (ground level)
|
[
"272.4",
"518.81",
"112.84",
"225.4",
"482.9",
"288.00",
"V10.06",
"042",
"276.8",
"276.2",
"075",
"458.9",
"401.9",
"584.5",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"96.6",
"03.31",
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
15921, 15972
|
10360, 13837
|
344, 378
|
16417, 16478
|
3310, 5543
|
17259, 18807
|
2692, 2882
|
14740, 15898
|
15993, 16396
|
14276, 14717
|
16502, 17236
|
2897, 3291
|
6062, 8347
|
5572, 5748
|
238, 306
|
406, 2086
|
9671, 10337
|
13853, 14250
|
2108, 2540
|
2556, 2676
|
5780, 6029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,673
| 137,646
|
13551
|
Discharge summary
|
report
|
Admission Date: [**2105-3-24**] Discharge Date: [**2105-4-3**]
Date of Birth: [**2035-9-3**] Sex: F
Service: CCU
CHIEF COMPLAINT: Chest pain.
The patient is a 69-year-old female with a history of
hypertension and increased cholesterol who was in her usual
state of health until approximately 8 p.m. when she noted the
sudden onset of ripping chest pain radiating to her back.
The patient fell to the floor; however, she denies any loss
of consciousness.
Emergency Medical Service arrive at the scene and found her
diaphoretic with a blood pressure of 60/palp, heart rate
of 55, saturations of 98% on room air. The patient was given
2 liters of normal saline bolus and was brought to the
Emergency Room.
At that time, her blood pressure was 100/palp in the
Emergency Room at [**Hospital6 3105**]. The patient
with chest pain. Blood pressure was 70/palp, heart rate of
80s to 90s. Electrocardiogram with ST elevations in II, III,
and aVF. The patient was given Retavase 10 mg/10 cc at
8:45 p.m. and was started on a dopamine drip; initially at 7
and increased to 10. The patient was given a heparin
4000-unit bolus and was started on 900 units per hour; at
which point, given persistent chest pain and ST elevations,
the patient was given a second dose of Retavase 10 mg/10 cc
at 9:15. Subsequently, she had reperfusion ectopy with five
seconds of atrial fibrillation and was shocked at 300 joules
into sinus rhythm. The patient was given an amiodarone bolus
at 150 mg and was started on an amiodarone drip at 1 mg per
minute. Given her persistent hypotension and need for
dopamine was increased to 20.
The patient was taken to the catheterization laboratory for
an intra-aortic balloon pump placement; at which time the
blood pressure and heart rate improved, and the patient was
transferred to [**Hospital1 69**].
HOSPITAL COURSE: On arrival to the [**Hospital1 **]
catheterization laboratory (at approximately 1:30 a.m.), the
patient with a blood pressure of 120/60 and heart rate of 80.
The patient was noted to have a brisk bleed from her groin;
at which time fluoroscope revealed a kink in a sheath in the
arterial balloon pump, and the patient's intra-aortic balloon
pump was removed and pressure was held.
At this time, the electrocardiogram on arrival showed
resolution of the ST elevations in II, III, and aVF.
Vascular Surgery was consulted when there was noted absent
pulses in the right lower extremity. Subsequent to this
pressure applied to the groin the patient became bradycardic
with 2:1 block and hypotensive and was started on atropine
and dopamine, and a transvenous pacing wire was placed; at
which point 4-mm to 5-mm ST elevations were noted in the
inferior leads. The patient was prepped for cardiac
catheterization.
Left cardiac catheterization revealed total occlusion of the
proximal right coronary artery; at which time a 2.5-mm X
18-mm stent was placed with good flow achieved distally. The
patient developed ventricular tachycardia times two on the
table and was bolused with lidocaine and started on a
lidocaine drip. Amiodarone was discontinued. The patient
had a right heart catheterization at this time also which
revealed pulmonary artery pressures of 37/24, wedge of 25,
right atrial mean of 25, right ventricular of 35/19,
pulmonary artery saturation of 48%, cardiac output of 2.9,
cardiac index of 1.7, and systemic vascular resistance
of 800. An intra-aortic balloon pump was placed in the left
groin, and dopamine and Levophed were started. The patient
with persistent junctional rhythm and hypotension.
The patient was transferred to the Coronary Care Unit after
the catheterization laboratory. In the Coronary Care Unit,
the patient had a pulse of 70.
PHYSICAL EXAMINATION ON PRESENTATION: An elderly white
female, intubated and sedated, afebrile, pulse of 70, blood
pressure of 68/37, satting 100% on AC 40%, tidal volume
of 600, rate of 14, positive end-expiratory pressure of 5.
Intra-aortic balloon pump with assisted systole of 64,
augmented diastole of 53, set at 1:1. The patient on
dopamine at 20, Levophed at 20, and lidocaine at 2. On head,
eyes, ears, nose, and neck examination pupils were equally
round and reactive to light. The oropharynx was clear with
an endotracheal tube in place, jugular venous pulse not
visualized. Chest examination showed scattered wheezes and
coarse breath sounds bilaterally. Cardiovascular revealed a
regular rate. No murmurs. The abdominal examination
revealed bowel sounds positive, soft and nontender.
Extremities revealed there was a right groin hematoma, and
the right lower extremity dorsalis pedis and posterior
tibialis pulses were dopplerable but not palpable. On
neurologic examination, the patient was sedated. Pupils were
reactive. Left groin had a Swan and an intra-aortic balloon
pump in place.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission from the outside hospital revealed a white blood
cell count of 11.3, hematocrit of 46, platelets of 280.
Troponin there was 0.2 with a creatine kinase of 77. SMA-7
with sodium of 140, potassium of 3.3, chloride of 103,
bicarbonate of 24, blood urea nitrogen of 17, creatinine
of 1.3, glucose of 240. Liver function tests were slightly
elevated. Laboratories at 2:30 a.m. showed a hematocrit
of 31.3, at 3 a.m. showed a hematocrit of 26. The patient's
SMA-7 at 2:30 a.m. revealed a bicarbonate of 16 with an anion
gap of 12. Arterial blood gas revealed pH of 7.28, PCO2
of 31, PO2 of 240. The patient's lactate level was 8.9,
glucose to 578.
RADIOLOGY/IMAGING: Electrocardiogram at 8:20 revealed sinus
bradycardia at 48, frequent premature atrial contractions, ST
elevations in II, III, and aVF, V4 to V6, ST elevations in V1
and V2.
Electrocardiogram at 1:30 a.m. revealed sinus rhythm at 85, Q
waves in III and aVF, T wave inversions and resolution of ST
elevations to 1-mm in II, III, and aVF.
Electrocardiogram at 4:45 a.m. again revealed T wave
inversions, and Q waves, 2-mm to 3-mm ST elevations in II,
III, and aVF.
IMPRESSION: The patient is a 69-year-old female admitted
with an acute inferior myocardial infarction complicated by
cardiogenic shock; now status post right coronary artery
stent with an intra-aortic balloon pump in place, on
pressors.
1. CARDIOVASCULAR: (a) Ischemia: The patient with an
acute myocardial infarction, status post right coronary
artery stent. The patient's creatine kinases were cycled.
Maximum creatine kinase in the 3000 range; which maximized on
day two and then subsequently trended back to normal. The
patient was started on aspirin, and Plavix, and Lipitor.
When blood pressure tolerated, the patient was weaned off the
intra-aortic balloon pump and pressors. The patient was
started on Lopressor, and eventually the patient was started
on captopril. The patient able to tolerate this regimen.
The patient was chest pain free throughout her stay. She did
not require any further nitroglycerin.
(b) Pump: The patient with cardiogenic shock secondary to
inferior wall infarct and right ventricular failure. The
patient initially with an intra-aortic balloon pump placed at
the outside hospital which was removed in the catheterization
laboratory, and an intra-aortic balloon pump was placed in
our catheterization laboratory. The patient was also on
Levophed initially for pressor support. The patient was
heparinized for the intra-aortic balloon pump. The patient
remained on the balloon pump for two to three days.
Eventually, the patient was able to wean off her Levophed.
Echocardiogram on the following morning revealed an ejection
fraction of 20% to 30% with inferior and septal hypokinesis.
The patient was initially kept positive to insure an good
blood pressure; however, eventually the patient was
overloaded and needed to be diuresed. The patient was given
Lasix p.r.n. but eventually was able to manage an auto
diuresis, maintaining maps above 60 off pressors. The
patient's cardiogenic shock improved, and the patient
eventually was able to be restarted on blood pressure
medications such as Lopressor and captopril prior to
discharge. Heparin was discontinued after platelets started
to fall and the intra-aortic balloon pump was removed.
(c) Electrophysiology: The patient initially with
ventricular fibrillation at the outside hospital, status post
cardioversion. The patient was then in ventricular
tachycardia in the catheterization laboratory. The patient
was started on a lidocaine drip which was eventually turned
off. On hospital day three, the patient went into atrial
fibrillation with rapid ventricular rate into the 160s. The
patient was loaded with amiodarone, attempted direct current
cardioversion time two unsuccessfully. However, after the
patient was switched over to an amiodarone drip, the patient
converted into sinus rhythm. The patient was eventually
converted to p.o. amiodarone 400 mg b.i.d. times five days
then 400 mg p.o. q.d. The patient will be discharged on
amiodarone 200 mg p.o. q.d. times six week. The patient was
able to maintain a normal sinus rhythm throughout the rest of
her hospital course.
2. PULMONARY: The patient was intubated at the outside
hospital. On arrival, the patient was mechanically
ventilated at AC 700, rate of 12, 100%, no positive
end-expiratory pressure. The patient's course, pulmonary
wise, was also complicated by thick secretions and a question
of aspiration pneumonia. The patient was initially started
on Levaquin and clindamycin intravenously and eventually grew
out Staphylococcus aureus in her sputum which was sensitive
to both Levaquin and clindamycin. The patient continued
intubated when multiple weaning trial were unsuccessful
secondary to increased oxygen demand, secondary to thick
secretions and pneumonia.
However, after approximately six days on the ventilator (on
hospital day six), the patient was successfully weaned and
extubated. Post extubation was complicated by some stridor
with laryngeal edema. The patient was started on intravenous
Solu-Medrol with some helio oxygen for further oxygen
delivery, and the patient was eventually switched over to
p.o. prednisone with a rapid taper. The patient will
continue this rapid taper as an outpatient supplemented with
albuterol nebulizers and meter-dosed inhaler. The patient
continued to be treated for her pneumonia with Levaquin and
clindamycin. Upon discharge, the patient was maintaining
stable saturations on 2 liters nasal cannula
3. INFECTIOUS DISEASE: The patient was initially afebrile
on arrival; however, after intubation on hospital day three,
the patient spiked fevers to 102.4. The patient was
pan-cultured and eventually started on Levaquin empirically.
Given the patient's persistent fevers, clindamycin was
supplemented. The patient eventually grew out Staphylococcus
aureus in her sputum and Escherichia coli in her urine, which
were both pan-sensitive. The patient was treated for her
Staphylococcus pneumonia and Escherichia coli urinary tract
infection with a 14-day course of Levaquin and clindamycin;
to be continued and finished as an outpatient. The patient
was afebrile for the last three days of her hospital stay.
4. HEMATOLOGY: The patient with a drop in her hematocrit
from 46 to 31 upon arrival. The patient with an expanding
hematoma in her right groin. The patient was transfused 3
units STAT upon arrival to the floor and an additional 2
units to 3 units during her hospital course to maintain her
hematocrits. The patient eventually had a CT scan of her
abdomen and pelvis to rule out a retroperitoneal or femoral
hematoma. No retroperitoneal hematoma was found; however,
the patient was found to have a 5-cm right common femoral
artery pseudoaneurysm. The patient was taken to
Interventional Radiology for an ultrasound-guided thrombin
injection of the pseudoaneurysm with good result. The
patient's hematocrit remained stable throughout her stay.
Vascular was following; however, they did not intervene. The
patient to have a repeat femoral ultrasound prior to
discharge. The patient regained good pulses in her lower
extremities and with no loss of sensation or neurologic
function.
The patient's platelets were initially 200 on arrival and
dropped precipitously to 70, then 50, then 40.
Heparin-induced thrombocytopenia antibody was sent. Heparin
was discontinued. However, as the intra-aortic balloon pump
was pulled on hospital day four, the patient's platelets
improved; likely thrombocytopenia was secondary to
intra-aortic balloon pump; heparin-induced thrombocytopenia
antibody had yet to return upon discharge.
5. FLUIDS/ELECTROLYTES/NUTRITION: The patient was initially
intubated. The patient started tube feeds. Nutrition was
consulted. The patient maintained on tube feeds while
intubated. When the patient was extubated, the patient was
slowly able to start taking clears and eventually a
mechanical soft diet prior to discharge.
6. ENDOCRINE: The patient with elevated sugars in the
setting of an acute myocardial infarction. The patient was
initially started on an insulin drip; however, after 24 hours
was switched over to regular insulin sliding-scale with
normalization of her sugars status post myocardial
infarction.
7. LINES: The patient initially with a right internal
jugular triple lumen, femoral Swan. The Swan was pulled on
hospital day two. The right internal jugular triple lumen
also pulled while the patient was febrile. Radial arterial
line also pulled. All cultures were negative. The patient
was eventually switched over to peripherals and discharged
without any lines in place, as antibiotics were switched over
to p.o. prior to discharge.
DISCHARGE DIAGNOSES: (In addition to her diagnoses on
arrival)
1. Acute inferior wall myocardial infarction; complicated by
right ventricular failure and cardiogenic shock.
2. Aspiration pneumonia.
3. Escherichia coli urinary tract infection.
4. Extubation complicated by laryngeal/tracheal edema.
5. Right common femoral artery pseudoaneurysm.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. (times 30 days).
3. Lipitor 10 mg p.o. q.d.
4. Lopressor 25 mg p.o. b.i.d.
5. Zestril 10 mg p.o. q.d.
6. Albuterol and Atrovent meter-dosed inhaler.
7. Albuterol and Atrovent nebulizers p.r.n.
8. Prednisone taper 30 mg p.o. q.d. times two days; then
20 mg p.o. q.d. times two days; then 10 mg p.o. q.d. times
two days.
9. Levaquin 500 mg p.o. q.d. times six more days (to
complete a 14-day course).
10. Clindamycin 300 mg p.o. q.6h. times six more days (to
complete a 14-day course).
11. Regular insulin sliding-scale.
12. Kayexalate p.r.n.
13. Protonix 40 mg p.o. q.d.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DATE: [**2105-4-3**].
DISCHARGE DISPOSITION: The patient was to be discharged to
[**Hospital 5130**] Rehabilitation Center for further physical
therapy and pulmonary rehabilitation.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-153
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2105-4-2**] 16:17
T: [**2105-4-2**] 16:22
JOB#: [**Job Number 40943**]
|
[
"507.0",
"997.3",
"998.2",
"785.51",
"427.1",
"414.01",
"410.21",
"997.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"36.01",
"37.23",
"36.06",
"37.78",
"37.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
14866, 15221
|
13744, 14074
|
14101, 14757
|
1868, 13722
|
14772, 14842
|
152, 1850
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,784
| 195,188
|
5632
|
Discharge summary
|
report
|
Admission Date: [**2137-4-2**] Discharge Date: [**2137-4-22**]
Date of Birth: [**2059-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest burning and dyspnea on exertion
Major Surgical or Invasive Procedure:
[**4-3**] Cardiac catheterization
[**4-12**] Aortic Valve Replacement (23mm CE Magna Tissue Valve),
Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to PDA w/
y-grafts to OM and Ramus)
History of Present Illness:
77 year old patient with severe aortic stenosis who has been
asymptomatic until he presented today to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16643**]
office at [**Company 191**] ([**Hospital Ward Name 23**]) with complaints of chest pain and
dyspnea, primarily with exertion.
.
Patient reports worsening chest burning and SOB with exertion
starting about 2-3 weeks ago. Now also occuring at rest. His
chest burning "feels like acid" but is not relieved by tums. It
can last 3-4 minutes up to 30 minutes, resolves with rest and
deep breaths, and does not radiate. It is not associated with
nausea or diaphoresis. He says it is only associated with
shortness of breath when he exerts himself. He has not had
lightheadedness, visual changes, palpitations. He notes that
over the last 6 months or so he has had decreased energy,
normally he is very active. He has a chronic cough productive of
white to yellow sputum that is unchanged from baseline. No
fevers, chills, vomiting, diarrhea, BRBPR, abdominal pain.
.
EKG in clinic (unavailable) per report had minor ST depressions
c/w prior. Pt was directly admitted to [**Hospital Ward Name **] 3 for cath with Dr.
[**Last Name (STitle) **].
Past Medical History:
--Severe aortic valve stenosis (area <0.8cm2).
--COPD
--Hyperlipidemia -> TC 159, LDL 95, HDL 48, TG 78.
--AAA s/p endovascular repair with stent [**2133**]
--Ulcerative colitis
--H/O bladder cancer (presumably in remission)
--Gastric mass with 4/07 biopsy which showed intestinal
metaplasia and Paneth cell metaplasia, the [**Doctor Last Name 6311**] stain is
focally positive for organisms consistent with H. pylori.
Social History:
Social history is significant for the absence of current tobacco
use. 100 pack year history (quit 2 years ago). There is no
history of alcohol abuse. He drinks ETOH 1 beer/day.
Family History:
Father MI in 40s and fatal MI at 75, sister lung cancer
Physical Exam:
VS - 96.6 115/66 85 16 95%RA 75kg
Gen: WDWN pleasant elder male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP, not elevated.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. crescendo SEM radiating to carotids. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. mild expiratory wheezes
on right in all fields.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. 2+DPs
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**4-3**] Cath: 1. Three vessel coronary artery disease. 2. Severe
aortic stenosis. 3. Mild global left ventricular contractile
dysfunction. 4. Biventricular diastolic dysfunction. 5. Mild
pulmonary arterial hypertension. 6. Mild systemic arterial
systolic hypertension.
[**4-4**] Chest CT: 1. Extensive calcifications of the [**Month/Year (2) 5236**] as
described involving the most proximal anterior part of the
ascending [**Month/Year (2) 5236**]. Heavy aortic valve calcifications,
hemodynamically significant. 2. Extensive atherosclerosis of the
coronary arteries. 3. Emphysema, predominantly affecting the
upper lungs. 4. Bronchial wall thickening consistent with
bronchitis. Focal area of impaction of lingular bronchi, most
likely due to secretions. Followup with chest CT in three to six
months is recommended to exclude the possibility of endoluminal
neoplasm. 5. New small pericardial effusion. 6. Increased but
low in density left hepatic lobe lesion. This lesion as well as
the bilateral adrenal neoplasm stable in size, might be
evaluated with MR of the abdomen. 7. Aortic stent. 8. Stable
enlargement of left thyroid with a low-density 2.5 x 1.8 cm
lesion. This finding giving its long-term stability is most
likely benign but evaluation with thyroid ultrasound would be
recommended for the possibility of malignancy.
[**4-4**] CNIS: Less than 40% stenosis of the internal carotid
arteries bilaterally. This is a baseline examination at the
[**Hospital1 18**].
[**4-8**] Thyroid U/S: Large left lower lobe thyroid nodule which
would be amenable for biopsy.
[**4-9**] Abd MRI: 1. Several liver cysts, the largest of which is in
segment II of the left lobe of liver with no concerning
features. 2. Bilateral adrenal adenomas incompletely assessed on
MRI in view of susceptibility from the aortic graft. 3. Gastric
cardia soft tissue mass unchanged from previous CT allowing for
difference in technique.
[**4-12**] Echo: Pre-CPB: No spontaneous echo contrast is seen in the
left atrial appendage. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). There is moderate symmetric left ventricular
hypertrophy. Right ventricular chamber size and free wall motion
are normal. The ascending [**Month/Day (2) 5236**] is very heavily calcified. There
are simple atheroma in the descending thoracic [**Month/Day (2) 5236**]. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post-CPB: NSR with phenylephrine infusing. A prosthetic aortic
valve is well-seated and functioning. No AI, no leak. Mean
residual gradient = 10. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Good
biventricular systolic fxn.
[**4-17**] Liver U/S: Mildly distended gallbladder with sludge.
Gallbladder wall thickness at the upper limits of normal and not
significantly changed when compared with the study from [**2133**]. If
there is a clinical concern for cholecystitis, a nuclear HIDA
scan can be obtained for further evaluation to assess for cystic
duct obstruction.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2137-4-22**] 05:15AM 10.1 3.59* 10.5* 32.0* 89 29.3 32.9 16.0*
208
COAGS:
[**2137-4-22**] 05:15AM 18.7* 32.4 1.7*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2137-4-22**] 05:15AM 88 25* 0.7 145 4.0 106 33* 10
RADIOLOGY Final Report
CHEST (PA & LAT) [**2137-4-21**] 8:17 AM
CHEST (PA & LAT)
Reason: increase in left pleural effussion
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with with left plueral effussion / would like PA
and LAt to better asses
REASON FOR THIS EXAMINATION:
increase in left pleural effussion
TWO-VIEW CHEST [**2137-4-21**]
COMPARISON: [**2137-4-19**].
INDICATION: Left pleural effusion.
Moderate left and small right pleural effusions are not
substantially changed allowing for positional and technical
differences of the examinations. Heart is upper limits of normal
in size. Areas of atelectasis are present adjacent to the
effusions, left greater than right. Note is made of prior median
sternotomy and aortic valvular replacement.
IMPRESSION: Moderate left and small right pleural effusion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SUN [**2137-4-21**] 10:11 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 22566**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 22567**]
(Complete) Done [**2137-4-12**] at 1:15:35 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2059-5-19**]
Age (years): 77 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: AVR/CABG
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2137-4-12**] at 13:15 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW3-: Machine: AW3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
[**Last Name (NamePattern4) **] - Ascending: 2.7 cm <= 3.4 cm
[**Last Name (NamePattern4) **] - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *80 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Moderate symmetric LVH.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Last Name (NamePattern4) **]: Simple atheroma in descending [**Last Name (NamePattern4) 5236**].
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage. There is mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
There is moderate symmetric left ventricular hypertrophy.
Right ventricular chamber size and free wall motion are normal.
The ascending [**Last Name (NamePattern4) 5236**] is very heavily calcified. There are simple
atheroma in the descending thoracic [**Last Name (NamePattern4) 5236**]. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
Post-CPB:
NSR with phenylephrine infusing.
A prosthetic aortic valve is well-seated and functioning. No AI,
no leak. Mean residual gradient = 10.
Trace MR.
[**First Name (Titles) **] [**Last Name (Titles) 5235**].
Good biventricular systolic fxn.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2137-4-12**] 13:35
Date: [**2137-4-22**]
Signed by [**Doctor First Name **] [**Doctor Last Name **], CCC,SLP on [**2137-4-22**] Affiliation:
[**Hospital1 18**]
REPEAT OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Thin liquid,
Nectar-thick
liquid, honey thick liquid, pureed consistency barium, and
ground
up cookies mixed with pudding were administered. Results follow:
ORAL PHASE:
Bolus formation and bolus control were mildly impaired with
premature spill over before the swallow. AP tongue movement was
moderately impaired with tongue pumping to transport the bolus.
He piecemealed pureed & ground solids. Oral transit was
prolonged
with ground solids, but was much better with pureed
consistencies
compared with last week, when it took him
between 8-9 seconds to transport liquids an 12-14 seconds for
purees. Today, he swallowed one bite of puree in 7 seconds, but
it took him 38 seconds to chew & swallow one bite of ground
solids.
PHARYNGEAL PHASE:
Swallow initiation was mildly delayed. Palatal elevation was
complete, but laryngeal elevation was mildly reduced with mildly
incomplete valve closure. Epiglottic deflection was improved
with
use of a chin tuck and an efforful swallow. Pharyngeal transit
was timely with adequate bolus propulsion. Only a trace coating
of residue was seen in the valleculae after the swallow. UES
opening appeared wfl at the height of the swallow.
ASPIRATION/PENETRATION:
The pt had penetration during the swallow with one sip of
nectar thick liquid and with all sips of thin liquid despite use
of a chin tuck. He stripped some, but not all of the penetration
was cleared during the swallow, and so he had trace aspiration
after the swallow with thin liquids only. He was not sensate to
the trace aspiration and cued coughs were weak and ineffective
at
clearing the aspirate material. However, he did not aspirate
with
nectar thick liquid during today's study.
TREATMENT TECHNIQUES:
Use of a chin tuck plus an effortful swallow were successful in
reducing penetration during today's study and eliminating
aspiration with nectar thick liquids.
SUMMARY:
Mr. [**Known lastname **] presents with improved oral and pharyngeal
swallowing ability with penetration of thin liquids during the
swallow and trace aspiration of thin liquids after the swallow.
However, he was able to swallow nectar thick liquids and ground
or pureed solids without penetration or aspiration when he
swallowed efforfully with his chin tucked toward his chest. He
was able to safely swallow ground solids, but one bite took 38
seconds to completely swallow where puree took only 7 seconds.
Therefore, he may be at increased nutritional risk on a ground
solid diet.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of level 4, mild to moderate
dysphagia.
RECOMMENDATIONS:
1. Suggest diet of nectar-thick liquids and pureed solids.
2. Swallow efforfully with chin tucked to chest
3. Small pills may be taken whole w/nectar thick liquid;
larger pills can be broken or crushed in puree
4. Nutrition consult to evaluate caloric intake, but expect
intake will be limited and he may need to have supplemental
nutrition.
5. Recommend repeat videoswallow at rehab in one week to see if
his diet can be safely upgraded to include ground or soft
solids & /or thin liquids
These recommendations were shared with the patient, the nurse
and
the medical team.
___________________________________
[**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 19916**] [**Doctor Last Name 3748**], M.S., CCC-SLP
Pager # [**Numeric Identifier 22568**]
Face time: 10:00-11:00 AM
Total time: 120 minutes
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was a direct admit from
Dr. [**Last Name (STitle) **] office following new onset chest pain and
shortness of breath which started 2 weeks ago. He underwent a
cardiac cath on [**4-3**] which revealed severe three vessel coronary
artery disease and confirmed severe aortic stenosis. Mr.
[**Known lastname **] required an extensive work-up prior to surgical
intervention. Which included multiple diagnostic studies and
Hematology, Pulmonary, and GI consultations. During this time he
was medically managed by the cardiology service. He was finally
cleared for surgery and on [**4-12**] he was brought to the operating
room where he underwent a coronary artery bypass graft x 4 and
aortic valve replacement. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. He required
multiple blood transfusions d/t post-operative bleeding. In
approximately 24 hours after surgery he was weaned from
sedation, awoke neurologically [**Month/Day (2) 5235**], and extubated. On post-op
day two he was started on beta blockers and diuretics. Chest
tubes and epicardial pacing wires were removed on post-op day
three. He required aggressive pulmonary toilet d/t his pulmonary
disease. On post-op day three he was c/o difficulty swallowing
and a swallow evaluation was performed. His PO intake was
advanced as tolerated with constant f/u with speech and [**Hospital 22569**] service. On post-op day five his LFT's increased and a
Liver/GB U/S was performed (see results). Later on this day he
had an episodes of rapid atrial fibrillation and was treated
with Amiodarone and Lopressor. He was cardioverted on post-op
day six into sinus rhythm, but eventaully converted back in AF.
Later on this day he was transferred to the telemetry floor for
further care.
He continued to have swallowing issues and had a video swallow
on [**4-22**] which showed that he can eat nectar thick liquids and
ground diet. He needs strict calorie counts at rehab. On
POD#10 he was discharged to rehab in stable condition.
Medications on Admission:
Prevalite 4gm packet [**Hospital1 **], Aspirin 81mg once a day, Omeprazole
20mg once a day, Terazosin 5mg once a day, Asacol 800mg TID
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Terazosin 5 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
3. Asacol 400 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO three times a day.
4. Cholestyramine-Sucrose 4 gram Packet [**Hospital1 **]: One (1) Packet PO
BID (2 times a day).
5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
6. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: 1.5 Tablets PO TID (3
times a day).
10. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Tablet,Rapid
Dissolve, DR(s)
12. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day) for 5 days.
13. Amoxicillin 250 mg Capsule [**Last Name (STitle) **]: Four (4) Capsule PO Q12H
(every 12 hours) for 5 days.
14. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day) for 5 days: Decrease to 400 mg PO daily for 7 days when
[**Hospital1 **] dose complete, then decrease to 200 mg PO daily after 400 mg
dose completed.
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed.
18. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
19. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
20. Coumadin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day:
Dose for INR goal of [**1-12**].5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4860**] - [**Location (un) 4310**]
Discharge Diagnosis:
Severe Aortic Stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Post-op Atrial Fibrillation
Emphysema
Thyroid Nodule
PMH: Hyperlipidemia, Gastroesophageal reflux, GI Bleed,
Ulcerative colitis, Benign Prostatic Hypertrophy, Bladder
cancer, Endovascular AAA repair
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 for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Hospital Ward Name 121**] 6 in 2 weeks for wound check
Dr. [**First Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] in [**1-13**] weeks
Dr. [**First Name (STitle) **] in 4 weeks
Already scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2137-5-8**] 1:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2137-8-19**]
1:00
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2137-8-19**] 2:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2137-4-22**]
|
[
"V10.51",
"790.5",
"784.7",
"600.00",
"998.11",
"997.1",
"E878.2",
"511.9",
"041.85",
"787.20",
"424.1",
"537.89",
"V15.82",
"287.5",
"280.9",
"241.0",
"272.4",
"535.50",
"492.8",
"440.0",
"427.31",
"414.01",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"88.53",
"36.13",
"88.56",
"45.13",
"37.23",
"35.21",
"89.60",
"99.61",
"36.15",
"99.04",
"39.61",
"00.40",
"38.14"
] |
icd9pcs
|
[
[
[]
]
] |
20251, 20325
|
15629, 17757
|
357, 545
|
20681, 20687
|
3228, 6984
|
21000, 21750
|
2443, 2500
|
17942, 20228
|
7021, 7110
|
20346, 20660
|
17783, 17919
|
20711, 20977
|
2515, 3209
|
280, 319
|
7139, 15606
|
573, 1789
|
1811, 2231
|
2247, 2427
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,994
| 154,956
|
3326
|
Discharge summary
|
report
|
Admission Date: [**2174-7-23**] Discharge Date: [**2174-8-2**]
Date of Birth: [**2107-3-10**] Sex: F
Service: SURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Abdominal pain with free on abdominal scan
Major Surgical or Invasive Procedure:
[**2174-7-24**] Right hemicolectomy, mucous fistula,
[**Doctor Last Name **] ileostomy.
History of Present Illness:
67F with ESRD [**12-30**] SLE maintained on chronic prednisone
recently started [**Hospital **] transferred from [**Hospital3 3583**] for free
air
on CT Abd/pelvis. Details of her hospital course are limited and
the patient is not a reliable historian. Apparently the patient
underwent a C-scope and polypectomy 4 weeks ago. Patient does
not
recall any complications afterwards but 3 weeks ago, she
underwent an ex-lap for signs of "bowel perforation" (it appears
that the patient had signs of SBO, underwent a CT scan showing
perforation). The laparotomy was negative for a source. She was
in the hospital for almost 2 weeks and was discharged on [**7-8**].
She returned back to [**Hospital1 46**] on [**7-12**] for left thigh pain and was
found to have a hematoma [**12-30**] supratherapeutic INR (5.6). Of note
she had a right rectus abdominal wall hematoma last admission.
These bleeds required reversal of coumadin and multiple blood
transufsions. On [**7-12**] a LLE US was performed showing no evidence
of DVT in the fem, [**Doctor Last Name **] and calf veins.
Since being in the hospital, the patient has had a FTT picture.
She has enterococcus and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] UTIs and was started
on
Vanco and Gent. It was mentioned that she would start
Amphotericin but per her OMR, this was not given. She was stared
on HD last Friday for hyperkalemia. Most recently in the last
2-3
days, she has been c/o increasing abdominal pressure/pain,
nausea, and poor PO intake. She is unable to tolerate clears
very
well [**12-30**] nausea. She states she had a BM in the AM but since
then
has not passed flatus. Per transfer summary, after this BM she
had signficant abdominal pain with peritoneal signs. A CT scan
was performed showing free air.
Access: right tunneled HD line, L IJ triple lumen
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
Cardiac Cath at [**Hospital1 3278**] in [**11/2172**]: DES to RCA
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Severe Aortic Stenosis
Systemic Lupus Erythematosis
TIA
PVD (65% stenosis in carotid arteries)
HLD
L vocal chord dysfunction
GERD
COPD
MVR (mild)
DVT (s/p anticoagulation with coumadin discontinued
approximately three weeks ago in [**1-/2173**])
Carpal Tunnel Syndrome
CKD baseline Cre 1.2->1.7
Retrosternal calcification (chronic)
Social History:
Married. Retired hairdresser. Lives in [**Location 3320**].
-Tobacco history: 20 ppy smoking hx, quit 27 years ago
-ETOH: [**11-29**] EtOH drinks weekly
-Illicit drugs: denies
Family History:
Father died at 75 from CAD. Aunt died of MI at 49. Sister with a
pacemaker.
Physical Exam:
Admission PE:
99.5 78 161/733 18 98RA
Gen: Supine in bed, appears comfortable, answers appropriately,
A+OX3
CV: RRR, soft systolic murmur heard
Resp: CTAB
Abd: TTP with rebound tenderness in RUQ and RLQ, no HSM, no TTP
on left side, previous ex-lap midline scar healing
DRE: Not performed given pain during examination
Ext: Left LE swollen [**12-30**] hematoma, TTP posterior thigh, 2+
pitting LE edema
Pulses: 2+ radial b/l, Right fem 1+, left fem 2+, faintly palp
DP
pulses b/l
Pertinent Results:
[**2174-7-23**] 10:15PM BLOOD WBC-10.7# RBC-3.83*# Hgb-12.0 Hct-36.3#
MCV-95 MCH-31.4 MCHC-33.2 RDW-18.0* Plt Ct-148*
[**2174-7-24**] 05:13AM BLOOD WBC-12.4* RBC-3.58* Hgb-10.9* Hct-34.4*
MCV-96 MCH-30.5 MCHC-31.7 RDW-17.9* Plt Ct-130*
[**2174-7-25**] 05:05AM BLOOD WBC-13.4* RBC-2.79* Hgb-8.5* Hct-27.3*
MCV-98 MCH-30.5 MCHC-31.2 RDW-17.8* Plt Ct-124*
[**2174-8-2**] 07:41AM BLOOD WBC-9.2 RBC-2.68* Hgb-7.8* Hct-25.8*
MCV-96 MCH-29.2 MCHC-30.3* RDW-16.3* Plt Ct-194
[**2174-7-31**] 05:40AM BLOOD PT-18.7* PTT-37.3* INR(PT)-1.8*
[**2174-8-1**] 06:31AM BLOOD PT-23.5* PTT-42.7* INR(PT)-2.2*
[**2174-8-2**] 07:41AM BLOOD PT-24.9* PTT-43.3* INR(PT)-2.4*
[**2174-7-23**] 10:15PM BLOOD Glucose-65* UreaN-25* Creat-2.4* Na-134
K-4.0 Cl-98 HCO3-30 AnGap-10
[**2174-7-30**] 03:35AM BLOOD Glucose-69* UreaN-56* Creat-4.2* Na-132*
K-4.6 Cl-100 HCO3-25 AnGap-12
[**2174-8-2**] 07:41AM BLOOD Glucose-82 UreaN-26* Creat-2.6* Na-135
K-4.1 Cl-99 HCO3-29 AnGap-11
[**2174-7-24**] 05:13AM BLOOD ALT-13 AST-25 AlkPhos-161* TotBili-1.0
[**2174-7-25**] 05:05AM BLOOD ALT-11 AST-21 AlkPhos-99 TotBili-1.0
[**2174-8-2**] 07:41AM BLOOD Calcium-7.4* Phos-3.2 Mg-1.7
[**2174-7-26**] 05:12AM BLOOD C3-80* C4-24
[**2174-7-27**] 11:33AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2174-7-27**] 11:33AM BLOOD HCV Ab-NEGATIVE
[**2174-7-24**] 5:32 pm SWAB Source: Rectal swab.
**FINAL REPORT [**2174-7-27**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2174-7-27**]):
ENTEROCOCCUS SP..
Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
[**2174-7-30**] Blood cultures: pending
[**2174-7-24**] 1:30 am SWAB PERITONEAL FLUID.
A swab is not the optimal specimen collection to evaluate
body
fluids.
GRAM STAIN (Final [**2174-7-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2174-7-26**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2174-7-28**]): NO GROWTH.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
Brief Hospital Course:
67F with SLE maintained on chronic steroids, ESRD recently on HD
here with free air seen on CT scan. Rebound tenderness was
appreciated on PE. She was taken to the OR by Dr. [**First Name (STitle) **] W.
[**Doctor Last Name **] after cardiology was consulted and cleared her for OR. She
underwent right hemicolectomy, mucous fistula, [**Doctor Last Name **] ileostomy
for microperforation of the distal sigmoid colon and stercoral
perforation of the right colon(hepatic flexure). Postop, she did
well from GI standpoint. Ileostomy was working. Diet was slowly
advanced over several days and tolerated. Mucous fistula
appeared edematous and had a small amount of clear fluid
draining. An ostomy pouch was applied. Please refer to
enterostomal note. Abdominal incision had staples. Abdomen was
distended. An ultra sound was done to assess for ascites given
h/o cirrhosis. A small loculated fluid pocket with septations in
the right lower quadrant containing multiple bowel loops was
noted. This was not adequate for paracentesis. Incision had a
small amount of clear fluid drainage. Dry gauze dressing was
changed twice on [**8-1**]. Drainage was scant on [**8-2**]. She was also
noted to have a stage 2 decubitus on her sacrum which was
covered by Mepilex and changed every 3 days.
She received a total of 4 days of Vanco and Zosyn for coverage
for GI organisms.Blood cultures remained negative to date. Blood
cultures were un finalized at time of discharge to rehab.
Pain was initially managed with IV Dilaudid. This was switched
to po Dilaudid once diet was tolerated. She averaged 4mg po
approximately 3 times per day for abdominal incision/back and
leg pain.
Hct decreased over over the initial postop days then was stable
at 25-26. Renal was consulted for acute on chronic renal
failure. Urine output decreased with increase in creatinine.
Acute kidney injury was secondary to hypotension/blood loss. She
was initially managed with Lasix. However, she was very
edematous and had very low urine output. Hemodialysis was
performed on [**7-30**] removing 1.95kg. Dialysis was repeated on [**8-1**]
with 3 liters removed and again on [**8-2**] with 1.5 liters removed.
She tolerated the treatments well with SBP in the 140s and heart
rates in 88-95 range. It was felt that her [**Last Name (un) **] would resolve and
that she would not require chronic dialysis. The plan was for
her to be assessed on a daily basis. Urine output for 24 hours
was up to 300ml/day on [**8-1**]. A right tunnelled line was present
(previously placed at OSH).
PT was consulted recommended rehab for strengthening. Two person
assist with rolling walker was necessary. Mobility improved over
subsequent days. She required dilaudid
Coumadin for h/o Lupus anticoagulant was resumed on [**7-31**] at 3mg.
INR was 2.4 on [**8-2**] and Coumadin was decreased to 2.5mg.
Prednisone continued for SLE management.
The plan was for her to continue on dialysis at least 2-3 times
a week until renal function improved. Of note, vein mapping was
done while hospitalized at [**Hospital1 18**].
She was accepted at N.E. [**Hospital1 **] in [**Location (un) 701**] and will transfer
there today.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient medications brought in by
husband.
1. Ascorbic Acid 1000 mg PO DAILY
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Ferrous Sulfate 325 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Pravastatin 40 mg PO DAILY
6. Amlodipine 10 mg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN back pain
8. Warfarin 5 mg PO DAILY16
as directed for inr [**12-31**]
9. Calcium Carbonate 500 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. ALPRAZolam 0.5 mg PO QHS:PRN insom
12. Sodium Bicarbonate 650 mg PO QID
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
14. HydrALAzine 50 mg PO Q6H
15. Omeprazole 40 mg PO DAILY
16. PredniSONE 5 mg PO DAILY
17. Warfarin 1 mg PO DAILY16
as directed for inr [**12-31**]
18. Calcium Acetate 667 mg PO TID W/MEALS
19. Vitamin D 1000 UNIT PO DAILY
20. Aspirin 81 mg PO DAILY
21. Cyanocobalamin 1000 mcg IM/SC Q MONTH
22. Hydrochlorothiazide 12.5 mg PO DAILY
23. chlorzoxazone *NF* 500 mg Oral TID back pain
24. Carvedilol 25 mg PO BID
25. Deep Sea Nasal *NF* (sodium chloride) 0.65 % NU q 6 hours
26. fluticasone *NF* 50 mcg/actuation NU 2 sprays [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. ALPRAZolam 0.5 mg PO QHS:PRN insom
3. Amlodipine 10 mg PO DAILY
4. HydrALAzine 50 mg PO Q8H
hold for SBP < 100
5. Carvedilol 25 mg PO BID
6. Omeprazole 40 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
9. Tiotropium Bromide 1 CAP IH DAILY
10. fluticasone *NF* 50 mcg/actuation NU 2 sprays [**Hospital1 **]
11. Nephrocaps 1 CAP PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Pravastatin 40 mg PO DAILY
16. Cyanocobalamin 1000 mcg IM/SC Q MONTH
17. Fluticasone Propionate NASAL 1 SPRY NU DAILY
18. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
19. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
20. Calcium Carbonate 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
-Microperforation of the distal sigmoid colon and stercoral
perforation of the right colon(hepatic flexure).
-Acute on CRF
-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:
Please call Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 673**] if you
have any of the following:
temperature of 101 or greater, chills, nausea, vomiting,
increased abdominal distension, ileostomy output stops or stool
output is greater than 2 liters per day, incision
redness/bleeding/drainage, dialysis access malfunctions.
Change ileostomy pouch every 3 days and prn
Hemodialysis 3x per week
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-8-10**] 11:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2174-8-2**]
|
[
"V45.82",
"998.2",
"289.81",
"V43.3",
"584.5",
"272.4",
"V58.61",
"V58.65",
"707.03",
"585.3",
"578.9",
"276.7",
"E870.8",
"403.90",
"707.22",
"V12.51",
"530.81",
"496",
"710.0",
"443.89",
"414.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"39.95",
"46.23"
] |
icd9pcs
|
[
[
[]
]
] |
11519, 11591
|
6322, 9488
|
341, 432
|
11763, 11763
|
3717, 6003
|
12537, 12866
|
3123, 3201
|
10716, 11496
|
11612, 11742
|
9514, 10693
|
11946, 12514
|
3216, 3698
|
2415, 2549
|
6039, 6299
|
259, 303
|
460, 2307
|
11778, 11922
|
2580, 2913
|
2329, 2395
|
2929, 3107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,192
| 179,885
|
42481
|
Discharge summary
|
report
|
Admission Date: [**2117-3-17**] Discharge Date: [**2117-3-23**]
Date of Birth: [**2041-10-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Quinine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
asymptomatic lung mass noted on CXR
Major Surgical or Invasive Procedure:
[**2117-3-17**]
Video-assisted thoracic surgery (VATS) right lower lobectomy,
mediastinal lymph node dissection and bronchoscopy with
bronchoalveolar lavage.
[**2117-3-20**]
Bronchoscopy with bronchoalveolar lavage
History of Present Illness:
Mr. [**Known lastname 91948**] is a 75yo male with
unremarkable PMH who presents today for evaluation after a
screening CXR revealed a new 4-5cm mass in the right lower lobe.
This was further evaluated with CT scan which was reviewed at
today's visit. He denies any symptoms currently, specifically
denying cough, shortness of breath, hemoptysis, weight loss,
chest pain, or fever/chills. Ofnote, on a PET CT, there was an
incidental finding of a 6-cm abdominal aortic aneurysm for which
he will undergo repair after this hospitalization. A
transbronchial biopsy with pathology
demonstrating non-small cell carcinoma was done and subsequent
cervical mediastinoscopy revealed negative nodes. He presents
now for surgical excision.
Past Medical History:
DM2, HL, HTN, PE ([**2094**]), Knee surgery ([**2094**]), Appendectomy as a
child, Rigid esophagus, [**2117-3-12**] cervical mediastinoscopy
Social History:
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:_50_
quit: _2008__
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:
Marital Status: [ ] Married [x] Single
Lives: [x] Alone [ ] w/ family [ ] Other:
Family History:
non contributory
Physical Exam:
BP: 127/72. Heart Rate: 95. Weight: 250.8. Height: 70.5. BMI:
35.5. Temperature: 97.9. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 99.
Gen: alert and oriented, well appearing in no acute distress
CV: RRR
Pulm: prolonged expiratory phase
Abd: Soft NT ND
Ext: WWP
Pertinent Results:
[**2117-3-17**] 05:23PM WBC-17.2*# RBC-4.19* HGB-13.3* HCT-37.3*
MCV-89 MCH-31.7 MCHC-35.7* RDW-12.6
[**2117-3-17**] 05:23PM PLT COUNT-380
[**2117-3-17**] 05:23PM CALCIUM-9.1 PHOSPHATE-4.8* MAGNESIUM-1.8
[**2117-3-17**] 05:23PM GLUCOSE-217* UREA N-16 CREAT-1.1 SODIUM-137
POTASSIUM-5.5* CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
[**2117-3-19**] CTA :
1. No pulmonary embolus detected to the subsegmental levels. No
aortic
dissection.
2. Complete mucus impaction of the right middle lobe bronchus,
with resulting right middle lobe collapse. A small collection of
air and fluid may be a small consolidation. Abscess is unlikely
given short timecourse.
3. Left focal consolidations and ground-glass opacities
throughout the left upper and lower lobes, compatible with
multifocal pneumonia or aspiration.
4. Reexpansion pulmonary edema within the right upper lobe.
5. Mild post-surgical air and fluid within the right pleural
cavity.
6. Extensive subcutaneous emphysema extending along the right
chest wall and lower right neck, as seen on prior radiographs.
[**2117-3-23**] CXR :
1. Slightly improved right lung aeration, but persistent
moderate asymmetric edema is unusual for this long postoperative
course.
2. Unchanged moderate right pleural effusion.
3. Improved subcutaneous emphysema overlying the right chest
wall.
4. Small residual right basilar pneumothorax
Brief Hospital Course:
Mr. [**Name14 (STitle) **] was admitted to the hospital and taken to the
Operating Room where he underwent a right VATS with right lower
lobectomy. He tolerated the procedure well and returned to the
PACU in stable condition. He maintained stable hemodynamics
after fluid resuscitation and his pain was in adequate control.
Following transfer to the Surgical floor his epidural catheter
was removed on post op day #1 and he was able to cough and use
his incentive spirometer effectively but his volumes gradually
decreased and eventually desaturated to the mid 80's. He has a
chest CTA done to rule out PE which was negative but he had
right middle lobe collapse due to secretions. He was
transferred to the SICU for close observation and vigorous
pulmonary toilet.
He eventually required bronchoscopy and lavage to remove his
secretions and following that was able to maintain saturations
in the 94% range on 2.5 to 3 liters. He remained afebrile and
his WBC gradually decreased from 15K to 10K. He was transferred
back to the Surgical floor to complete his recovery. He has an
effective cough and continues to use his incentive spirometer.
Due to his prolonged hospitalization he was evaluated by the
Physical Therapy service due to his prolonged oxygen needs as
well as his limited mobility. They felt that he was able to go
home with VNA, home PT and oxygen. His ambulatory saturations
off of oxygen was 85%. He eventually was able to maintain
saturations of 96% on 2 liters of oxygen.
His right chest port sites were healing well and he was
tolerating a regular, diabetic diet with blood sugars in the
170-190 range. His metformin will be restarted. He was
discharged to home on [**2117-2-22**] on home O2 and VNA services. He
will follow up in the Thoracic Clinic in [**2-19**] weeks.
Medications on Admission:
Metformin 1000", Amlodipine 5', simvastatin 40', ASA81
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Respiratory Therapy
Oxygen at 2 liters/min via nasal cannula, continuous
Pulse dose for portability
Dx : Lung cancer, Right middle lobe collapse
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right lower lobe lung cancer.
Right middle lobe collapse
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 lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2117-4-15**] at 2:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the [**Location (un) **] Radiology Department in the [**Hospital Ward Name 23**] Clinicla Center for a
chest xray.
Completed by:[**2117-3-23**]
|
[
"V15.82",
"V45.79",
"518.0",
"458.9",
"441.4",
"401.9",
"E912",
"272.4",
"162.5",
"934.1",
"934.8",
"250.00",
"V12.55"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"32.41",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
6266, 6324
|
3561, 5367
|
311, 530
|
6425, 6425
|
2164, 3538
|
8145, 8628
|
1845, 1863
|
5473, 6243
|
6345, 6404
|
5393, 5450
|
6608, 8122
|
1878, 2145
|
236, 273
|
558, 1290
|
6440, 6584
|
1312, 1455
|
1471, 1829
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,830
| 107,918
|
14759
|
Discharge summary
|
report
|
Admission Date: [**2181-3-14**] Discharge Date: [**2181-3-21**]
Date of Birth: [**2122-8-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient had a routine medical appointment here at the
hospital earlier today. On his way home, he was involved in a
lateral impact MVC. The patient lost consciousness and was
transported to an outside hospital where a CT scan of the head
and plain films of the chest and C-spine were obtained. The head
CT revealed a small intraparenchymal hemorrhage and the patient
was transferred
here for further evaluation.
Past Medical History:
-Hep C cirrhosis and HCC s/p liver [**First Name3 (LF) **] [**4-1**]
-Hernia repair and lysis of adhesions [**12-2**] with liver bx showing
F2 fibrosis 6 months after transplantation.
-Liver bx on [**2179-6-15**], showing mild mixed inflammation, no
evidence of rejection, focal bile duct epithelial damage, mild
centrivenular hemorrhage and congestion, mild mixed steatosis,
consistent with recurrent viral hepatitis C and no significant
change in the grade of inflammation.
-DM, on insulin, being titrated down due to wt loss s/p
[**Date Range **]
-s/p right colectomy [**12-29**], for toxic colitis
-Herpes simplex 1, pt unsure of this hx
-hx of EBV
-s/p appendectomy
-hyptertension
Social History:
Married. Lives with wife and 13 y.o. son from a prior
relationship. Is a Jeweler. No tobacco use. Very occasional beer
use. No current drug use, but had used drugs as a young adult.
Family History:
no liver disease in family
Physical Exam:
Temp:98.5 HR:80 BP:152/80 Resp:20 O(2)Sat:100 Normal
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits, C-spine nontender
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, mild left upper quadrant
tenderness to palpation. There are no peritoneal findings.
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent, moves all extremities
Psych: Mental status somewhat diminished according to the
patient's wife
Pertinent Results:
[**2181-3-14**] 02:30PM WBC-1.1* RBC-3.22* HGB-10.3* HCT-32.8*
MCV-102* MCH-32.1* MCHC-31.5 RDW-14.7
[**2181-3-14**] 02:30PM NEUTS-70.4* LYMPHS-16.0* MONOS-6.5 EOS-6.9*
BASOS-0.2
[**2181-3-14**] 02:30PM PLT COUNT-64*
[**2181-3-14**] 02:30PM PT-12.4 INR(PT)-1.0
[**2181-3-14**] 02:30PM tacroFK-5.3
[**2181-3-14**] 02:30PM UREA N-24* CREAT-0.9 SODIUM-134 POTASSIUM-4.9
CHLORIDE-101 TOTAL CO2-25 ANION GAP-13
[**2181-3-14**] 02:30PM ALT(SGPT)-37 AST(SGOT)-27 ALK PHOS-94 TOT
BILI-0.4
[**2181-3-14**] 02:30PM ALBUMIN-3.7 CALCIUM-8.2* PHOSPHATE-2.9
MAGNESIUM-1.9
[**2181-3-14**] 08:35PM WBC-2.6*# RBC-2.98* HGB-9.8* HCT-29.4*
MCV-99* MCH-32.8* MCHC-33.2 RDW-15.4
[**2181-3-14**] Head CT :
1. Trace SAH in left parietal region.
2. Small amount of intraventricular hemorrhage in right
occipital [**Doctor Last Name 534**].
[**2181-3-14**] CT Torso :
1. Left rib fractures, detailed above. Left distal clavicle
fracture.
2. Small amount of hemoperitoneum, source unclear though
possibly from subtle splenic injury.
3. Liver [**Month/Day/Year **], with hepatosplenomegaly, extensive varices,
and
gallbladder fossa seroma.
4. Increase in supraumbilical ventral hernia, containing
transverse colon
without evidence of obstruction.
[**2181-3-15**] Head CT :
Unchanged appearances of the intracranial hemorrhage compared to
the prior CTA examination of [**2181-3-14**]. No new hemorrhage or
hydrocephalus seen.
[**2181-3-15**] Left shoulder :
Non-displaced fracture distal left clavicle. Acromioclavicular
joint intact.
[**2181-3-17**] Head CT :
Stable right parietooccipital subarachnoid hemorrhage with
possible slight
redistribution. A hyperdense focus in the left frontal lobe is
unchanged and could be a small focus of intraparenchymal
hemorrhage, which is unchanged. No new worrisome findings.
Brief Hospital Course:
Mr. [**Known lastname 43406**] was evaluated by the Trauma team in the Emergency
Room and his imaging was reviewed. He was also seen by the
Neurosurgery service as he had a SAH and a right occipital IVH.
He was admitted to the hospital for further observation and
testing.
He was treated prophylactically with Keppra for a 10 day course
and had no seizure activity. He had 2 subsequent Head CT's
which showed no interval change in his intracranial hemorrhages
but his wife felt that he was not at his baseline mental status.
He was evaluated by the Occupational Therapy service on
multiple occasions and they found deficits in memory and recall
and felt that he would benefit from both a short term rehab and
a follow up visit with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive
Neurology.
[**Last Name (NamePattern1) 1326**] surgery was following the patient during his
hospitalization and made recommendations regarding his
immunosuppressive regimen.
He underwent pulmonary toilet specifically incentive spirometry,
to ensure deep breathing and coughing and prevent pneumonia due
to his multiple rib fractures. He needed much encouragement but
was compliant. The Physical Therapy service concurs that a short
term rehab prior to returning home would be helpful for
increasing mobility safely as well as stamina.
Medications on Admission:
Ribavirin 200 mg Tab 3 tablets in the am and 2 in the evening
Procrit 40,000 unit/mL Injection inject 1mL once a week
Neupogen 300 mcg/mL Injection 300mcg weekly
Infergen 15 mcg/0.5 mL Sub-Q 15mcg once a day in place of
pegasys
Viagra 100 mg Tab 0.5 (One half) Tablet(s) by mouth as needed
Citalopram 20 mg Tab 1 Tablet(s) by mouth once a day
Prograf 1 mg Cap, twice daily 2 Capsule(s) by mouth twice a day
ergocalciferol (vitamin D2) 50,000 unit Cap once a week
sulfamethoxazole-trimethoprim 400 mg-80 mg Tab
1 Tablet(s) by mouth once a day NOT TAKING for now while on
interferon and Ribavirin
Lisinopril 5 mg Tab daily
Amlodipine 10 mg Tab once a day
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): thru [**2181-3-24**].
Disp:*14 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. insulin regular human 100 unit/mL Solution Sig: home dose
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
Neuro-Rehabilitation Center - [**Location (un) 7740**]
Discharge Diagnosis:
S/P MVC
1. L parietal SAH
2. Tiny IVH in R occ [**Doctor Last Name 534**]
3. Mildly diplaced left lateral 9th rib fx
4. Nondisplaced left 4th-8th rib fx
5. Intraabdominal hemorrhagic free fluid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive (fluctuating).
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* Your injury caused rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
* You bled into a portion of the brain and a repeat Head CT
showed no extension. The Occupational Therapist recommends that
you follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive
Neurology for a full evaluation. In the mean time you are on
Keppra which is a drug to prevent seizures. You will stay on
that for a total of 10 days for prophylaxix.
* If you develop any new symptoms that concern you please call
your doctor or return to the Emergency Room.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**12-28**] weeks.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1669**] for a follow up appointment in 8
weeks with a repeat Head CT. The secretary can arrange that for
you.
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive Neurology at
[**Telephone/Fax (1) 1690**] for a follow up appointment in [**1-26**] weeks.
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2181-4-25**] 1:40
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"401.9",
"852.06",
"284.1",
"E849.9",
"996.82",
"571.5",
"V10.07",
"810.00",
"250.00",
"807.05",
"868.03",
"E812.0",
"E878.0",
"070.54",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7043, 7124
|
4183, 5542
|
310, 317
|
7362, 7362
|
2348, 4160
|
9273, 9970
|
1688, 1716
|
6247, 7020
|
7145, 7341
|
5568, 6224
|
7559, 9250
|
1731, 2329
|
263, 272
|
345, 763
|
7377, 7535
|
785, 1472
|
1488, 1672
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,189
| 153,399
|
52494
|
Discharge summary
|
report
|
Admission Date: [**2172-6-27**] Discharge Date: [**2172-6-30**]
Date of Birth: [**2104-11-2**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Aspirin / Prednisone
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGD/colonoscopy
History of Present Illness:
67 yo M with history of diverticulosis, s/p partial
sigmoid-colectomy in [**2157**] for diverticular bleed, presented to
the ED with blood in his stool. He was last admitted in [**Month (only) 958**]
[**2170**] for a GI bleed with Hct of 28 without a clear source
identified, but it resolved spontaneously. His hematocrit
continued to improve over the course of the year with iron
supplementation, most recently 47.2 in 12/[**2170**]. Yesterday
evening he had 2 episodes of blood in his stool and he went to
the ED at [**Hospital **] Hospital where his Hct was found to be 41. He
had 3 more episodes of stool with more blood, and he was
subsequently transferred to [**Hospital1 18**].
In the ED, initial vitals 97.6 102 126/72 16 97%. He had no
bowel movements overnight. He was asymptomatic and his
hematocrit was found to be 42. Around 4am, he became bradycardic
and hypotensive to the 50s. He was given a 2L bolus of NS and
his pressures and heart rate improved over the course of an
hour. On transfer, his vitals were 116/74 85 15 98%RA.
On arrival to the [**Hospital Unit Name 153**], he feels well and is without complaints.
He has no urge to defacate.
Review of systems:
(+) Per HPI
(-) No lightheadedness, no dizziness, no syncope, no abdominal
pain, no nausea, vomiting, no GERD or gastritis type symptoms.
Past Medical History:
BPH
diverticulosis and diverticulitis s/p partial sigmoidectomy [**2157**]
GERD
Hyperlipidemia
Hypertension
OSA
hypogonadism
hypothyroidism
prediabetes
S/p appendectomy
s/p right inguinal hernia repair
s/p right shoulder surgery
Social History:
Works in business development. Lives in [**Location **] with his son.
[**Name (NI) 1139**] - none
EtOH - 1 beer/work
Drugs - occasional marijuana
Family History:
Colon Ca in brother, Father with CAD and DM2.
Physical Exam:
Vitals: temp 98.4, HR 91, BP 124/87, O2 sat 99% 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: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2172-6-27**] 07:42AM GLUCOSE-118* UREA N-18 CREAT-1.3* SODIUM-138
POTASSIUM-4.9 CHLORIDE-111* TOTAL CO2-20* ANION GAP-12
[**2172-6-27**] 07:42AM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-1.9
[**2172-6-27**] 07:42AM HGB-13.6* HCT-39.8*
[**2172-6-27**] 02:50AM GLUCOSE-122* UREA N-22* CREAT-1.4* SODIUM-136
POTASSIUM-4.1 CHLORIDE-114* TOTAL CO2-17* ANION GAP-9
[**2172-6-27**] 02:50AM estGFR-Using this
[**2172-6-27**] 02:50AM WBC-7.4# RBC-4.50*# HGB-14.9# HCT-42.2#
MCV-94 MCH-33.2* MCHC-35.5* RDW-13.8
[**2172-6-27**] 02:50AM NEUTS-65.2 LYMPHS-26.8 MONOS-4.0 EOS-3.0
BASOS-0.9
[**2172-6-27**] 02:50AM PLT COUNT-233
07/0CT Abd: no source of bleeding
CT Abd: no source of bleeding
Brief Hospital Course:
67 yo M with history of multiple GI bleeds, presenting with
BRBPR.
# Hypotension
Appears to be a vagal episode in the ED, with bradycardia,
hypotension and diaphoresis. This may have been related to a
brisk bleed vs. vasovagal, especially given short time frane and
spontaneous resolution. The episode resolved quickly, he was
given 2L of NS and he has remained hemodynamically stable.
- EKG
- monitor pressures closely and transfuse or replete fluids PRN
# GI Bleed
About 5 bloody bowel movements overnight, last one at about 1am
at [**Location (un) **] Hopsital. His Hct in the ED is 42, which is very
close to his most recent baseline of 47. Now Hct 39.8, may be
from further bleeding or dilutional. He had a likely vagal
episode in the ED of unclear etiology, but may have been related
to a brisk bleed or a bowel movement. Etiology of GI bleed
includes diverticular or anastamotic bleed, or a brisk upper
source such as an ulcer. He received 1u pRBC and after
significant hydration, his Hct has remained stable at 34.
CTA of the abd revealed no active extravasation into the
colon.
He underwent a colonoscopy - which revealed diverticulosis
but no evidence of acute bleed. The anastomotic site was normal
with no evident ulcer/bleed. An EGD was performed to follow up
on a past EGD report of Barretts Esophagus. The EGD showed an
irregular Z-line but no clear evidence of Barretts this time
through. A biopsy was at the site was obtained nevertheless.
To minimize diverticular disease, he was advised to increase
fiber intake and assure regularity of bowel movement.
# Hypercholesterol
- continue pravastatin
# BPH
- Tamsulosin was held temporarily and reinitiated on discharge.
# Prophylaxis: protonix, no SC heparin
# Access: 2 large bore PIVs
# Communication: Patient
# Code: Full
Medications on Admission:
EPINEPHRINE - 0.3 mg/0.3 mL (1:1,000) Pen Injector - Inject one
pen SC once as needed for allergic reaction.
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays nas once a day
LORAZEPAM - 0.5 mg Tablet - 1/2-1 Tablet(s) by mouth once a day
as needed for anxiety
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day
PRAVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by
mouth once a day
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day Take while using narcotics; hold for loose stools
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**12-23**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
5. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for anxiety.
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticular Bleed (LGIB)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for lower gastrointestinal bleeding presumably
due to a diverticular bleed. You received 1 unit packed red
blood cells and underwent a colonoscopy and an EGD (upper
scope). The reports were provided to you. There are no changes
to your medications and we recommend that you increase your
fiber intake if possible.
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: WEDNESDAY [**2172-11-25**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
|
[
"327.23",
"403.90",
"V45.72",
"562.12",
"585.3",
"600.00",
"244.9",
"458.9",
"257.2",
"272.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
6815, 6821
|
3428, 5239
|
302, 320
|
6891, 6891
|
2708, 3405
|
7401, 7798
|
2102, 2150
|
6056, 6792
|
6842, 6870
|
5265, 6033
|
7042, 7378
|
2165, 2689
|
1529, 1669
|
256, 264
|
348, 1510
|
6906, 7018
|
1691, 1922
|
1938, 2086
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,255
| 138,581
|
6368
|
Discharge summary
|
report
|
Admission Date: [**2194-3-25**] Discharge Date: [**2194-4-2**]
Date of Birth: [**2124-12-11**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Naprosyn
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal Pain
Nausea/Vomiting
Major Surgical or Invasive Procedure:
1. Diagnostic laparoscopy.
2. Open cholecystectomy with intraoperative cholangiogram.
History of Present Illness:
69F, well-known to Dr. [**Last Name (STitle) **], with PMH of gallstone
pancreatitis/ERCP pancreatitis/DM/HTN/hypercholesterolemia with
who presents to [**Hospital1 18**] ER for 72 hours RUQ abdominal pain and 48
hours N/V
Past Medical History:
PMH:
DMII
HTN
Gallstone Pancreatisit ([**2191**])
OA
PSH:
ERCP [**11-30**]
Appendectomy
Right breast lumpectomy
Bilateral Knee Replacements
Social History:
Occ ETOH, No tobacco, Married
Physical Exam:
Admission PE- [**2194-3-25**]
99.1 80 132/70 18 98%RA
HEENT: anicteric, NAD, MMM, No JVD/Bruit
Cor: Reg, S1S2
Pulm: Diminished BS but clear no crackles
Abd: soft obese, (+)[**Doctor Last Name **], no hernia, no mass
Ext: no C/C/ 1+ ext edema
Pertinent Results:
Admission Labs
------------------
[**2194-3-25**] 03:45PM BLOOD WBC-14.1*# RBC-4.68 Hgb-14.3 Hct-42.6
MCV-91# MCH-30.6 MCHC-33.6 RDW-13.8 Plt Ct-215
[**2194-3-25**] 03:45PM BLOOD Neuts-85.1* Lymphs-9.3* Monos-4.4 Eos-1.1
Baso-0.1
[**2194-3-25**] 03:45PM BLOOD Plt Ct-215
[**2194-3-25**] 03:45PM BLOOD Glucose-166* UreaN-12 Creat-0.7 Na-137
K-4.6 Cl-98 HCO3-28 AnGap-16
[**2194-3-25**] 03:45PM BLOOD ALT-21 AST-37 AlkPhos-71 TotBili-1.3
[**2194-3-26**] 07:10AM BLOOD ALT-14 AST-17 LD(LDH)-222 AlkPhos-65
Amylase-23 TotBili-1.3 DirBili-0.4* IndBili-0.9
[**2194-3-25**] 03:45PM BLOOD Lipase-24
[**2194-3-26**] 07:10AM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.5 Mg-1.8
Discharge Labs
-------------------
[**2194-4-1**] 03:49AM BLOOD WBC-7.7 Hct-28.6* Plt Ct-406
[**2194-4-1**] 03:49AM BLOOD Plt Ct-406
[**2194-4-1**] 03:49AM BLOOD Glucose-111* UreaN-9 Creat-0.4 Na-143
K-3.6 Cl-98 HCO3-37* AnGap-12
[**2194-3-30**] 03:15AM BLOOD Lipase-19
[**2194-3-29**] 02:35AM BLOOD CK-MB-6 cTropnT-0.25*
[**2194-3-29**] 08:13AM BLOOD cTropnT-0.40* proBNP-3711*
[**2194-3-29**] 10:06AM BLOOD CK-MB-11* MB Indx-3.2 cTropnT-0.35*
[**2194-3-29**] 06:40PM BLOOD CK-MB-10 MB Indx-3.4
[**2194-3-30**] 03:15AM BLOOD cTropnT-0.33*
[**2194-3-30**] 09:46AM BLOOD CK-MB-7 cTropnT-0.33*
[**2194-3-30**] 03:48PM BLOOD CK-MB-6 cTropnT-0.30*
[**2194-4-1**] 03:49AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.8 Mg-2.1
Operative Note
-------------------
PREOPERATIVE DIAGNOSIS: Acute cholecystitis.
POSTOPERATIVE DIAGNOSIS: Acute and chronic cholecystitis
with cystic duct obstruction secondary to stone.
OPERATION:
1. Diagnostic laparoscopy.
2. Open cholecystectomy with intraoperative cholangiogram.
ASSISTANTS: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) 15738**] [**Name (STitle) 24629**].
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: Mrs. [**Known lastname 24630**] is a 69-year-old
lady with a history of non-insulin-dependent diabetes mellitus,
hypertension, and gallstone pancreatitis status post
sphincterotomy in [**2191**] who presented with a 3-day history of
right upper quadrant pain. She had a fever and leukocytosis and
normal liver function tests. Given the duration of her symptoms
we attempted conservative treatment with bowel rest and
intravenous antibiotics. After 24 hours, she continued to have
fevers and right upper quadrant tenderness and leukocytosis.
Accordingly, I advised a cholecystectomy. I explained that given
the duration of the symptoms there would be a high likelihood of
conversion to an open cholecystectomy but that we would attempt
a
laparoscopic approach. The risks and benefits of the procedure
were discussed with the patient and she consented to proceed.
INTRAOPERATIVE FINDINGS:
1. Upon diagnostic laparoscopy there was serous fluid in the
right upper quadrant. The omentum was firmly adherent to
the liver edge and gallbladder. Limited inspection of the
fundus of the gallbladder showed it to be ischemic with
a portion of the wall necrotic. Accordingly, we elected
to convert fairly quickly to open cholecystectomy.
2. An attempted cholangiogram was unsuccessful. We were
unable to successfully pass a cholangiocatheter beyond
the cystic duct/common duct junction. Upon opening this
further, it was clear that there was a stone impacted
here which we could not safely retrieve. We did not wish
to further dissect the common bile duct given the
tremendous edema of the tissues.
DESCRIPTION OF PROCEDURE IN DETAIL: The patient was identified
in the preoperative holding area and taken to the operating room
where she was positioned supine on the operating room table.
After the adequate induction of general endotracheal anesthesia,
her abdomen was widely sterilely prepped and draped in the usual
fashion. Intravenous Unasyn was administered. A timeout was
performed identifying the patient and the procedure to be
performed.
The infraumbilical space was anesthetized with 0.5% Marcaine
plain. A vertical midline incision was made here and the
fascia was opened in the midline and the peritoneal cavity
entered bluntly without incident. #0 Vicryl sutures were
placed in the fascia and the [**Last Name (un) 24631**] trocar secured. A carbon
dioxide pneumoperitoneum was achieved. An angled 30 degree
laparoscope was inserted. Limited inspection of the lower
abdomen and left upper quadrant was unremarkable. Inspection
of the right upper quadrant showed a large amount of serous
fluid about the liver and an omentum firmly adherent to the
gallbladder and liver edge. Additional local anesthetic was
infiltrated in the epigastrium and a 12-mm transverse incision
was made and a 12-mm port placed. A smooth grasper was placed
via
this port. It was clear that the omentum was firmly tethered to
an ischemic, if not necrotic, gallbladder. An additional 5-mm
port was placed in the right subcostal space in the
mid-clavicular line to facilitate better retraction of the
omentum and inspection of the gallbladder. The omentum was
bluntly taken off the fundus and body of the gallbladder, and
there was a portion of the gallbladder wall which appeared
necrotic. It was clear that we could not safely complete this
operation laparoscopically and so the ports were removed and
the pneumoperitoneum evacuated. We elected to convert at this
time to an open procedure.
A right subcostal incision was made, joining our two previous
port incisions. This was carried down through the subcutaneous
tissues and fascia with the cautery. The rectus muscle was
divided with the cautery. Peritoneal cavity was entered without
incident. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24412**] retractor system was placed. A malleable
retractor was placed on a lap pad and retracted the duodenum and
colon caudally. We then placed a right angle retractor on the
subcostal margin cranially. There was some bleeding from the
liver edge near the fundus of the gallbladder which was
successfully cauterized. We scored the wall of the gallbladder
approximately 3 mm away from the liver bed. We mobilized the
gallbladder from the fossa by staying in this plane, leaving a
fairly significant rind of tissue on the liver surface. We
carried this dissection all the way down toward the neck of the
gallbladder. We placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1356**] clamp on the fundus of the
gallbladder as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1356**] clamp on the neck of the
gallbladder to aid in retraction. The cystic artery was
identified and cauterized.
At this point we identified what we believed to be the cystic
duct with the cystic duct lymph node; however, there was an
extensive amount of inflammation and edema of the tissues. We
dissected some of this edematous tissue from the anterior
aspect in the porta and exposed what we believed to be the
common bile duct. However, we did not persist a great deal in
this dissection given an increased potential risk of injury
to structures here. Accordingly, we elected to perform a
cholangiogram. An opening was made in the neck of the
gallbladder
and we attempted to place a cholangiocatheter but met resistance
after passing it only 1-2 cm. A clip was placed on the opening
and we attempted a cholangiogram with half-
strength Conray. This filled the infundibulum of the
gallbladder and potentially the proximal cystic duct, but we
were unable to opacify the biliary ductal system or duodenum.
Accordingly, I aborted this procedure. I consulted Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] intraoperatively. We elected to transect what we
believed
to be the cystic duct and passed the gallbladder off the field.
We then explored the cystic duct stump with a Schnidt and
identified a gritty structure which appeared to be a stone at
the
cystic duct/common bile duct junction. With Potts scissors we
opened up the cystic duct stump to better visualize this. Given
its gritty nature, we were somewhat concerned about possible
carcinoma at this site. Accordingly, a biopsy was taken of the
cystic duct and sent for frozen section. This returned as only
fibrosis. We were unable to safely retrieve the stone. Given
that
we were quite close to the common bile duct, we did not wish to
open up the cystic duct any further and risk encroaching upon
the
common bile duct lumen. Thus, we simply closed the cystic duct
stump with two figure-of-eight 3-0 PDS sutures,tacking a flap of
edematous fatty tissue over this repair with an additional 3-0
PDS. There was no leakage of bile from this stump at any point
during the
exploration, again suggesting that the cystic duct was indeed
obstructed.
The right upper quadrant was copiously irrigated and
hemostasis was assured. There appeared to be a small leakage
of bile from the liver bed at the lower aspect of the
gallbladder fossa, and this was extensively cauterized with good
effect and after observation for several minutes was noted to
be free from bile leakage. A #19 [**Doctor Last Name 406**] drain was placed in
the right upper quadrant and brought out through a separate
stab incision lateral to our incision. The fascia was then
closed in two layers with running #1 looped PDS sutures.
Subcutaneous tissues were irrigated and the skin was closed
with staples. A sterile dressing was applied. The patient
tolerated the procedure well. There were no complications.
Given the amount of fluids and narcotics the patient received,
she was kept intubated and transferred to the PACU in stable
condition.
INTRAOPERATIVE FLUIDS: 4 liters of crystalloid.
URINE OUTPUT: 170 cc.
ESTIMATED BLOOD LOSS: 50 cc.
ABDOMEN U.S. (COMPLETE STUDY)
Reason: H/O OF GALLSTONES, NOW WITH RUQ PAIN, R/O CHOLECISTITIS
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman with h/o gallstones now with RUQ pain
REASON FOR THIS EXAMINATION:
r/o choley
ABDOMINAL ULTRASOUND [**2194-3-25**] AT 17:09 HOURS.
HISTORY: History of gallstones with right upper quadrant pain.
COMPARISON: [**2192-4-6**].
FINDINGS: There are multiple echogenic foci, predominantly in
the central portal triad with relative dirty acoustic shadowing
highly suggestive of air. There is a marked hyperechoic focus
extending the length of the common bile duct. These findings
suggest an indwelling biliary stent or may be result of
pneumobilia from prior sphincterotomy. Portal venous gas is felt
much less likely given distribution. The liver echotexture is
relatively echogenic, which is likely, in part, due to body
habitus. The portal vein is normal in diameter with hepatopetal
flow with a normal Doppler waveform. The common bile duct
measures between 4 and 7 mm. The head of the pancreas is not
visualized. The body is seen and there is no evidence of
pancreatic ductal dilatation.
The gallbladder is distended. No overt wall thickening is seen.
There may be trace pericholecystic fluid. At least one small
gallstone is noted at the gallbladder neck. No movement is seen
on decubitus views suggesting possible impaction. The patient
was focally tender over the gallbladder during the examination.
The right kidney measures 11.7 cm in length. The left kidney
measures 10.3 cm in length. Both kidneys demonstrate normal
echotexture with no hydronephrosis or stones identified. The
spleen is normal in size at approximately 9.4 cm in length.
IMPRESSION:
1. Distended gallbladder with questionable impacted small stone
and minimal- to-trace pericholecystic fluid. Given tenderness
over gallbladder at the time of examination (positive [**Doctor Last Name **]
sign), acute cholecystitis remains in the differential
diagnosis. If further imaging correlation is required based on
equivocal clinical examination, consider HIDA scan.
2. Apparent pneumobilia as above. Correlate with prior procedure
and surgical history. Does the patient have indwelling biliary
stent or history of prior sphincterotomy?
Results were immediately posted to the ED dashboard and
discussed with Dr. [**Last Name (STitle) 4281**], ER resident, at time of dictation.
ECHO
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: 0.39 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Arch: *3.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *2.6 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 27 mm Hg
Aortic Valve - Mean Gradient: 16 mm Hg
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 168 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Overall
normal LVEF
(>55%). Transmitral Doppler and TVI c/w Grade II (moderate) LV
diastolic
dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Mildly dilated aortic arch.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Minimally increased
gradient c/w minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions:
The left atrium is mildly dilated. There is symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is normal (LVEF>55%). Transmitral
Doppler and
tissue velocity imaging are consistent with Grade II (moderate)
LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal.
The aortic arch is mildly dilated. The aortic valve leaflets are
moderately
thickened. There is a minimally increased gradient consistent
with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic
pressure could not be determined. There is a trivial/physiologic
pericardial
effusion.
Brief Hospital Course:
[**Known firstname 24632**] [**Known lastname 24630**] was admitted to the surgery service on [**2194-3-25**]
under the care of Dr. [**Last Name (STitle) 5182**]. RUQ ultrasound was consistent
with cholecystitis. WBC count was 14.1. LFTs were WNL. (+) UTI.
She was made NPO. IV fluids and Unasyn were started. At HD 2
she had decreased urine output. Fluid boluses were provided. At
HD 3 she was febrile to 101.4. CXR showed slightly increased
fluid overload, with no evidence of pneumonia. She continued
with RUQ abdominal pain and leukocytosis. She was taken to the
operating room where she underwent diagnostic laparoscopy, open
cholecystectomy; cystic duct biopsy; and cholangiogram. Upon
diagnostic laparoscopy there was serous fluid in the right upper
quadrant. The omentum was firmly adherent to the liver edge and
gallbladder. Limited inspection of the fundus of the gallbladder
showed it to be ischemic with a portion of the wall necrotic. It
seemed that there was an impacted stone at the common/cystic
duct junction and this was opened with the finding of a gritty
material which was concerning for carcinoma. A biopsy was taken
from the site. (See operative note). She tolerated the
procedure well. Given the amount of fluid and narcotics the
patient received during surgery she remained intubated and
monitored in the PACU overnight. At POD 2 she was extubated
without event and returned to the floor. Later that night she
was intubated for respiratory distress r/t pulmonary edema and
taken to the ICU. She was febrile to 102.7. WBC count was
elevated at 16.2. Troponins were elevated. ECG was negative for
ischemia. BNP was elevated. Cardiology was consulted and felt
that the elevation of cardiac labs was r/t acute pulmonary
edema. An ECHO was performed which showed LVEF>55% (see
report). At POD 3 she was afebrile and was undergoing diuresis.
She was extubated without event. At POD 5 she was transferred
from the floor. She was afebrile and WBC count was 7.7. Blood
and urine cultures were negative. She was tolerating a regular
diet. At POD 6 she was complaining of left hand pain. Xray
negative for acute process/fracture. Plastic surgery was
consulted and recommended splint. She was discharged to Pine
[**Hospital **] Rehab in good condition. She was to follow up with Dr.
[**Last Name (STitle) 1924**] and Hand clinic.
Medications on Admission:
ASA 81'
Atenolol 50'
Avandia 2'
Compazine
Diovan 40'
Lipitor 40'
Metformin
Vicodin/NSAIDS/Tylenol
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs qs* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
Disp:*30 Lozenge(s)* Refills:*2*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. 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*
10. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection per sliding scale: per sliding scale.
Disp:*qs qs* Refills:*0*
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day: [**Month (only) 116**] discontinue when walking at
least 2-3 times per day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 21957**] Center
Discharge Diagnosis:
acute calculous cholecystitis
Discharge Condition:
stable
Discharge Instructions:
Please return or contact for:
* Fever (> 101 F) or chills
* Abdominal Pain
* Nausea or vomiting
* Inability to pass gas or stool
* Redness or drainage from incision site
* Any other concerns
You may continue your previous medications as prescribed. You
may shower. Gently wash incision and pat dry. No lifting over
[**9-8**] pounds or abdominal stretching exercises for 4-6 weeks.
Followup Instructions:
Please call Dr[**Name (NI) 12822**] office for a follow up appointment ([**Telephone/Fax (1) 13446**].
Please follow up in [**11-26**] weeks in Hand Clinic. Please call for an
appointment. The number is ([**Telephone/Fax (1) 7138**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2194-4-2**]
|
[
"428.0",
"401.9",
"V64.41",
"574.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"51.22",
"51.51",
"96.71",
"87.53",
"51.13"
] |
icd9pcs
|
[
[
[]
]
] |
20202, 20257
|
15995, 18355
|
315, 404
|
20331, 20340
|
1150, 10965
|
20771, 21143
|
18503, 20179
|
11002, 11058
|
20278, 20310
|
18381, 18480
|
20364, 20748
|
882, 1131
|
245, 277
|
11087, 15972
|
432, 656
|
678, 820
|
836, 867
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,921
| 128,083
|
15764
|
Discharge summary
|
report
|
Admission Date: [**2171-6-25**] Discharge Date: [**2171-6-26**]
Date of Birth: [**2111-9-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 yo M homeless w/ PMH of COPD, alcohol dependence with recent
admission on [**6-19**] for COPD exacerbation, alcohol withdrawal who
left AMA presented today to the ED for shortness of breath. He
has a recent history of multiple admissions and ED evaluations
for shortness of breath. Of note he has been worked up for RML
collapse with concern of mass causing an obstruction s/p rigid
bronchoscopy in [**3-/2171**] with negative cytology.
On admission today, patient came in complaing of dyspnea. Per
ED report, he was unable to explain more about why he was coming
in in the ED. He denied alcohol intake however smelled of
alcohol and had an blood alcohol of 338. Denied chest pain,
denied fevers, chills, cough. Required sternal rub to wake up.
88% on RA and not moving good air bilaterally. His oxygenation
improved to 96% on 3L and a VBG on 3L was 7.40/49/122. CXR
showed RLL consolidation. He received IV methylprednisolone
given his inability to take PO, 3 rounds of duonebs, and a dose
of IV levofloxacin. He was transferred to the unit due to his
altered mental status and poor respiratory status with this
depressed mental status however he was able to talk so it was
felt htat he did not require intubation for airway
protection/hypoxia.
On arrival to the MICU he complained of a knife like feeling in
his back that was worsened with deep breath but no change in his
cough or production of sputum. He denied any recent fevers or
chills. He could not recall why he was at the hospital or how he
got there.
Past Medical History:
COPD
PNA
Alcohol abuse
HTN
Multiple musculskeletal surgeries including facial
reconstruction
Splenectomy s/p [**Year (4 digits) 8751**] 10 years ago
Chronic pain on methadone
Hx hypercarbic respiratory failure
Social History:
Homeless, squatting on a floor in an old building. Smoking
currently (unclear amount), current alcohol use (does not recall
last drink). Denies other drugs
Family History:
unknown
Physical Exam:
Admission Exam:
VS: 97.8, 97, 100/62, 13, 96%4L NC
General: Somnulent, nodding off mid sentence, older than stated
age male, thin with multiple areas of scab over, in no acute
distress. Mildly agitated when awakened but cooperative when
awake.
HEENT: Sclera anicteric,PEERL of 4mm and reactive. Unable to
perform EOM exam to assess for nystagmus. MMM, unable to open
mouth wide to assess oropharynx.
Neck: supple, JVP not elevated, no LAD, no retractions
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Moving good air bilaterally. Coughing with deep
inspiration, nonproductive. Wheezing inspiratory and expiratory
bilaterally. No dullness to percussion. Pt did not cooperate
with egophany
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ DP pulses bilaterally. no edema.
multipel areas of healing , no clubbing, cyanosis or edema
Neuro: limited neuro exam given his level of consciousness.
A+Ox1.5 (knew year but not date, did not know location and knew
name). Unable to recall previous president. Moving all
extremities. Tongue midline, symmetric smile. Finger to nose
deferred until sober
Pertinent Results:
Admission Labs:
[**2171-6-25**] 07:50PM BLOOD WBC-5.7 RBC-4.43* Hgb-14.3 Hct-44.4
MCV-100* MCH-32.2* MCHC-32.1 RDW-15.3 Plt Ct-157
[**2171-6-25**] 07:50PM BLOOD Neuts-26* Bands-0 Lymphs-55* Monos-7
Eos-10* Baso-1 Atyps-1* Metas-0 Myelos-0
[**2171-6-25**] 07:50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2171-6-25**] 07:50PM BLOOD PT-10.2 PTT-31.6 INR(PT)-0.9
[**2171-6-25**] 07:50PM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-144
K-3.7 Cl-101 HCO3-31 AnGap-16
[**2171-6-25**] 07:50PM BLOOD ASA-NEG Ethanol-332* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-6-25**] 08:16PM BLOOD Type-[**Last Name (un) **] pO2-122* pCO2-49* pH-7.40
calTCO2-31* Base XS-4 Comment-GREEN
Micro
Blood culture [**2171-6-25**]- PENDING
Imaging:
CXR [**2171-6-25**]: Streaky airspace opacities within the lung bases,
slightly worse in the left lung base when compared to the prior
study. These could reflect areas of bibasilar atelectasis but
infection particularly in the left lung base cannot be excluded.
Emphysema.
Brief Hospital Course:
59 yo M w/ PMH of COPD (no PFTs in our system) and alcohol
intoxication presented intoxicated complaining of shortness of
breath and admitted to the ICU for altered mental status and
concern for pneumonia vs. COPD exacerbation.
#Hypoxia- patient has baseline COPD and it is unclear if he
takes his medications as an outpatient. he complained of some
shortness of breath on admission and was sating 89% on RA in no
respiratory distress. He received multiple rounds of nebulizers
with improvement in airmovement in his lungs. His VBG on 3L of
NC was unremarkable. He was admitted to the ICU for monitoring
of his respiratory status while he had altered mental status.
As his mental status improved, his respiratory status remained
stable with O2 sat 92 on Room Air, which appears to be his
baseline.
#Altered mental status- patient was intoxicated on admission
with a blood alcohol level of 332. The morning after admission
he was A+Ox3 with a nonfocal neurological exam. Initially there
was concern that he may have had hypercarbia causing his AMS,
however as his EtOH intoxication decreased, his mental status
improved.
#Alcohol dependence-Patient has had many admissions/ED visits
for alcohol intoxication. He has no history of withdrawal
seizures but has had problems with respiratory depression in the
setting of preventing his withdrawal with diazepam. On this
admission because of his inability to take in po, he was started
on IV ativan. over the first night he recieved 2 mg IV ativan
for agitation. Social work was consulted while he was here given
his frequent admissions for this. As he was able to take PO in
the morning, he was given a total of 15mg of Diazepam for CIWA
>10. Discharge to a detox facility was discussed, however Mr.
[**Known lastname 7710**] stated he did not want to quit drinking and would go back
to drinking after going to rehab. Decision was made not to send
him to rehab and to discharge directly from ICU.
#Hypertension- patient has a history of hypertension however on
admission his BPs ranged in the low 100s. He was unable to
verify his home regimen and his antihypertensives were held.
While in the MICU, his SBP ranged from 100-140s. No anti
hypertensives were started.
TRANSITIONAL ISSUES
-Pt. was counseled on alcohol cessation, he should continue to
be encouraged to quit drinking.
-Pt. should be further counseled to take his COPD medications
-Pt. would benefit from social work assistance
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheeze
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Enalapril Maleate 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheeze
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Enalapril Maleate 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
EtOH intoxication
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 7710**],
You were treated at [**Hospital1 18**] for intoxication and difficulty
breathing. As you became more sober, your difficulty breathing
was improved. We strongly recommend you enter a detoxification
program and stop drinking. We also recommend that you take your
medications that are prescribed to you.
Followup Instructions:
Please see your PCP [**Last Name (NamePattern4) **] [**1-28**] days
Please enter an alcohol detox program
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2171-6-26**]
|
[
"305.1",
"401.9",
"V45.79",
"303.01",
"338.29",
"491.21",
"V12.61",
"V60.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7624, 7630
|
4614, 7063
|
299, 305
|
7697, 7697
|
3524, 3524
|
8212, 8485
|
2282, 2291
|
7408, 7601
|
7651, 7676
|
7089, 7385
|
7848, 8189
|
2306, 3505
|
240, 261
|
333, 1859
|
3540, 4591
|
7712, 7824
|
1881, 2092
|
2108, 2266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,040
| 127,586
|
23750+57370
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-7-19**] Discharge Date: [**2120-8-30**]
Date of Birth: [**2068-6-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
laparoscopic & thoracoscopic esophagogastrectomy [**7-19**]
percutaneous tracheostomy [**8-20**]
mulitple cardioversions for rapid AF
bronchoscopy with lavage [**8-9**]
diagnostic paracentesis [**8-11**]
History of Present Illness:
52M with stage T3 esophageal cancer s/p chemo/XRT, with marked
diminuition of the primary tumor, presented [**7-19**] for elective
resection of the tumor. His symptoms included marked dysphagia,
solid > liquid. He had undergone a lap jejunostomy in [**3-16**] to
provide nutritionduring his adjuvant treatments. During his
treatments, he has had decreased dysphagia & has begun to
maintain his caloric requirements via oral feedings.
Past Medical History:
Hepatitis C
esophageal CA s/p chemo/XRT
COPD
GERD
chronic lower back pain
s/p feeding J tube
s/p appy
s/p portacath
Social History:
+cigs, +etoh
Family History:
noncontributory
Physical Exam:
AVSS
AOx3
RRR, no murmurs
no [**First Name9 (NamePattern2) **] [**Doctor First Name **]
CTA B
soft NT
1+ LE
Pertinent Results:
[**8-26**] CXR: Small pleural effusions continue to resolve. The
diffuse infiltrative pulmonary abnormality has not improved,
although its heterogeneous texture suggest the development of
interstitial pulmonary emphysema. There is no pneumomediastinum
or pneumothorax. Heart is normal sized. Tracheostomy tube and
right internal jugular and right subclavian venous catheters are
in standard placement, unchanged. A drain projects over the
thoracic inlet to the left of midline.
[**8-7**] CT chest: No evidence of pulmonary embolism. Extensive
bilateral interstitial and ground glass opacities, most
pronounced in the bases, which could be consistent with acute
atypical pneumonia, pulmonary edema versus ARDS.
[**8-5**] UGIS: No evidence of leakage at the anastomotic site.
Initial delay in contrast emptying at pylorus but filling of
duodenum was subsequently demonstrated.
[**7-26**] CXR: Bilateral small pneumothoraces; Dilatation of the
stomach, which is fluid filled. New asymmetric consolidations in
the lungs (left > right).
[**7-24**] UGIS: No evidence of leak at the anastomotic site.
Brief Hospital Course:
[**7-19**] Admitted to colorectal surgery service following
uncomplicated esophagogastrectomy.
[**7-20**] Extubated
[**7-21**] Transferred to floor
[**7-22**] APS consult: dilaudid PCA
[**7-24**]: negative swallow study. Started on clears
[**7-25**]: Desaturation & increasing O2 requirements. CXR showed
markedly distended gastric bubble & bilateral infiltrates
[**7-26**]: Taken to OR for replacement of NGT under direct
visualization, and readmitted to SICU
[**7-27**]: Developed rapid atrial fibrillation requiring electrical
cardioversion. Cardiac enzymes & echo neg
[**8-5**]: Repeat barium swallow negative. Given sips of clears
[**8-6**]: Transferred to floor in good condition after tolerating
PO's without complication
[**8-7**]: Transferred to TSICU after developing respiratory distress
(pO2 48)
[**8-9**]: Reintubated for bronchoscopy
[**8-12**]: cardioverted for rapid a fib
[**8-14**]: started steroid pulse for empiric treatment for pulmonary
fibrosis
[**8-16**]: cardioverted for rapid a fib
[**8-20**]: percutaneous tracheostomy
[**8-21**]: cardioverted for rapid a fib
NEURO: Acute on chronic pain issues. Currently treated with
methadone, clonidine & prn ativan
CV: intermittent rapid A fib, requiring cardioversion because of
recalcitrant hypotension. followed by cardiology. rate
controlled with lopressor & digoxin. anticoagulated with
coumadin (INR 2-2.5) & aspirin. avoiding amiodarone due to
pulmonary issues.
RESP: severe respiratory failure, presumably from pulmonary
fibrosis (etiology aspiration pneumonitis vs amio toxicity vs
occult infection)
FEN/GI: sustained by tube feeds & on meds via LUQ J tube. lyte
repletion. prevacid for GI prophylaxis.
HEME: hct stable on coumadin 7.5qd. check at least biweekly INR
& adjust coumadin doses accordingly (goal 2-2.5).
ID: no active infective issues
END: prednisone tape (currently 7.5qd), RISS
PROPH: Duoderm for lumbar & sacral skin breakdown, P boots
DISP: To vent rehab ([**Hospital1 **]), full code, HCP [**Name (NI) **] [**Name (NI) **]
(wife [**Telephone/Fax (1) 60665**] or [**Telephone/Fax (1) 60666**])
Medications on Admission:
dilaudid, Klonopin 1"", protonix, fentanyl patch 75', aldactone
50', kelfex 500""
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
check INR twice weekly & adjust coumadin doses as needed (goal
INR 2-2.5).
Disp:*30 Tablet(s)* Refills:*2*
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*120 Tablet(s)* Refills:*2*
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) dose PO DAILY (Daily).
Disp:*30 doses* Refills:*2*
7. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): wean off as tolerated.
Disp:*90 Tablet(s)* Refills:*2*
8. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q1-2H () as
needed.
Disp:*30 mg* Refills:*2*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*5*
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*1 inhaler* Refills:*5*
11. Acetaminophen 160 mg/5 mL Solution Sig: One (1) teaspoon PO
Q6H (every 6 hours) as needed.
Disp:*250 ML* Refills:*3*
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*qs container* Refills:*2*
13. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons
PO BID (2 times a day): to prevent constipation.
Disp:*500 ML* Refills:*2*
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*250 ML(s)* Refills:*2*
16. Lorazepam 2 mg/mL Syringe Sig: One (1) ML Injection Q1-2H ()
as needed.
Disp:*60 ML* Refills:*6*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
hepatitis C
esophageal adenocarcinoma
COPD
GERD
s/p appendectomy
s/p feeding jejunostomy
respiratory failure
ARDS
aspiration pneumonitis
pulmonary fibrosis
rapid atrial fibrillation
blood loss anemia requiring RBC transfusion
depression
anxiety
Discharge Condition:
requiring mechanical ventilation. otherwise, stable
Discharge Instructions:
as directed
Followup Instructions:
Contact Dr.[**Name (NI) 1482**] office at [**Telephone/Fax (1) 2981**] to arrange a
follow up appointment.
Contact [**Name2 (NI) 60667**] office at [**Telephone/Fax (1) 170**] to arrange a follow
up appointment at the same time.
Completed by:[**2120-8-30**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 11052**]
Admission Date: [**2120-7-19**] Discharge Date: [**2120-8-30**]
Date of Birth: [**2068-6-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 203**]
Addendum:
Respiratory Status:
Mr. [**Known lastname 2306**] has been supported with mechanical ventilation
during the majority of his inpatient stay. He has most recently
tolerated trach collar for about 3 hours on the penultimate day
of his admission (up from 1 hour on [**8-27**]). For the rest of
[**8-29**], he received pressure control ventilation (settings fiO2
50%, PEEP 5, DP 32, TV 475, RR 20). His ABG on the day of
discharge was 7.41/62/141/41/12, which is typical of his
baseline CO2 retainer status.
Vent Wean:
At vent rehab, I would hope that he should tolerate about 1
additional hour per day of trach collar. If he does not
tolerate trach collar, please reverse to CPAP or PCV as
tolerated by Mr [**Known lastname 2306**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2120-8-30**]
|
[
"496",
"536.1",
"427.31",
"150.5",
"507.0",
"515",
"070.54",
"512.1",
"789.5",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"42.52",
"96.6",
"33.24",
"54.91",
"96.04",
"31.1",
"00.17",
"40.3",
"99.69",
"42.42",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
8586, 8822
|
2471, 4572
|
332, 538
|
7069, 7123
|
1349, 2448
|
7183, 8563
|
1189, 1206
|
4704, 6678
|
6801, 7048
|
4598, 4681
|
7147, 7160
|
1221, 1330
|
275, 294
|
566, 1004
|
1026, 1143
|
1159, 1173
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,075
| 196,132
|
41924
|
Discharge summary
|
report
|
Admission Date: [**2174-11-9**] Discharge Date: [**2174-12-2**]
Date of Birth: [**2111-3-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
ventricular tachycardia arrest/dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2174-11-11**] - Aortic valve replacement with 19-mm St. [**Hospital 923**] Medical
Regent mechanical heart valve, aortic root enlargement with
bovine pericardium.
[**2174-11-9**] - Cardiac catheterization
History of Present Illness:
The patient is a 63 male with multiple medical problems
including critical aortic stenosis who is admitted to CCU
following ventricular tachycardia arrest during cardiac
catheterization. He was in his normal state of health until this
past fall when he developed progressive dyspnea with exertion.
He denies symptoms concerning for angina. On exam, he was noted
to have a murmur consistent with aortic stenosis. He underwent a
surface echocardiogram that revealed aortic valve area by
continuity equation of 0.7 cm2 (trileaflet). He was referred to
[**Hospital1 18**] cardiac surgery for evaluation for aortic valve
replacment.
On the day of admission, he underwent left heart catheterization
to evaluate coronary anatomy. He was in his normal state of
health before case. Arterial access obtained through right
radial without issue (3:10PM). He then started to complain of
his right arm hurting him and became very anxious and said he
felt claustrophobic. His systolic blood pressure drifted down to
the 60s with heart rate in the fifties (3:16PM). He was given
atropine and started on dopamine.
He felt warm, diaphoretic, and restless. His blood pressure and
heart rate were variable, with narrow complex tachycardia up to
140s. The left circulation was injected (3:28). He was noted to
have increasing PVCs on telemetry and then at 4:02PM developed
polymorphic ventricular tachycardia with loss of pulse. CPR was
initiated and he was shocked x2 with return of pressure. CPR
done for approximately 1 minute. He was intubated w/ fent/midaz
and still agitated so paralyzed. Initial ABG 7.17/46/180/18.
Catheterization showed no significant CAD, mean wedge 16,
cardiac index of 3.92. Right groin venous sheath placed. TTE
w/out effusion. Repeat ABG 7.22/40/290/17. He was given at least
1.4L IVF during the case. Given dose of Ancef.
On review of systems, s/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. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
-Aortic stenosis
-Hyperlipidemia
-Hypertension
-Morbid obesity
-Asthma
-GERD
-Cholelithiasis
-Degenerative joint disease
-Arthritis
-Anxiety
-Cholecystectomy [**77**] years ago
Social History:
-Marine biology teacher [**Location (un) 1411**] high school
-Former smoker during college
-several drinks per week
-denies illicit drug use
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died CAD in early 60s
- Father: died CAD, heart failure in mid 60s
- Brother: diagnosis of peripheral artery disease
Physical Exam:
Admission exam:
VS: BP:89/62 HR: 82 RR: 14 100%
Vent settings: AC 550 RR:14 PEEP: 8 cm/h2o FIO2: 100
GENERAL: Intubated, raising both hands
HEENT: NCAT. Sclera anicteric. pupils 2mm -> 1mm bilaterally,
EOMI. Conjunctiva were pink, no pallor of the oral mucosa. No
xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: S1, S2 appreciated, ejection click not appreciated,
loud, nearly holosystolic murmur RUSB radiate to carotids
LUNGS: No chest wall deformities, faint crackles at bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits, right groin venous
access sheath in place
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:
Admission labs:
[**2174-11-9**] 12:56PM BLOOD WBC-7.7 RBC-4.34* Hgb-12.9* Hct-37.5*
MCV-86 MCH-29.8 MCHC-34.5 RDW-13.2 Plt Ct-244
[**2174-11-9**] 12:56PM BLOOD Neuts-65.2 Lymphs-27.8 Monos-5.6 Eos-1.0
Baso-0.5
[**2174-11-9**] 12:56PM BLOOD PT-12.6* PTT-150* INR(PT)-1.2*
[**2174-11-9**] 12:56PM BLOOD Glucose-85 UreaN-21* Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-22 AnGap-16
[**2174-11-9**] 12:56PM BLOOD ALT-27 AST-35 AlkPhos-53 TotBili-0.7
[**2174-11-9**] 12:56PM BLOOD %HbA1c-5.5 eAG-111
[**2174-11-9**] 04:37PM BLOOD Type-ART Rates-/14 Tidal V-550 PEEP-5
FiO2-1 pO2-180* pCO2-46* pH-7.17* calTCO2-18* Base XS--11
Intubat-INTUBATED
[**2174-11-9**] 05:03PM BLOOD Type-ART Rates-/14 Tidal V-550 PEEP-5
FiO2-100 pO2-290* pCO2-40 pH-7.22* calTCO2-17* Base XS--10
AADO2-402 REQ O2-69 Intubat-INTUBATED
[**2174-11-9**] 09:37PM BLOOD Type-ART pO2-200* pCO2-34* pH-7.39
calTCO2-21 Base XS--3
Imaging/procedures:
-Cardiac cath ([**2174-11-9**]) - 1. Coronary angiography of this right
dominant system demonstrated one
vessel coronary artery disease. The LMCA was short and patent.
The LAD
had a proximal 40 % and 50% D1 stenosis. The LCX had a mid 30%
stenosis.
The RCA had a proximal 30% and distal 40% stenosis.
2. Resting hemodynamics revealed mildly elevated right and left
sided
filling pressures, with RVEDP 14 mmHg and PCW 16 mmHg. There was
moderate pulmonary arterial hypertension at rest, with PASP 46
mmHg. The
cardiac output was preserved at rest, with cardiac index 3.9
L/min/m2.
3. Event summary: Initial access obtained in right radial artery
using a
5 F sheath. After passing catheter centrally to ascending aorta,
patient
started feeling very estless, and felt hot and non-specifically
agitated. Denied chest pain or SOB, but initial central BP low
with SBP
88 mmHg, and then dropping down to 65 mmHg despite IV fluid
boluses.
Patient diaphoretic and HR 55/min. Given 0.5 mgIV atropine, with
increase HR but no improvement in BP. Then dopamine infusion was
started. Patient became intermittently agitated and tachycardic
with HR
increase to 150 bpm transiently and associated drops in BP to
SBP 70's.
When he would calm down, HR would decrease and SBP would improve
even
off dopamine. Initial angiography left coronary selective in the
LCX,
but no evient LMCA disease or dissection in thoracic aorta on
limited
contrast puffs. Decided to withdraw catheter from body, and
stabilize
patient clinically. He has no other feature to suggest allergic
response, but still very anxious. Called Dr [**Last Name (STitle) 45821**] of Ct
surgery to
discuss situation. Patient still too agitated to perform
coronary
angiography. While monitoring patient, he developed some mild
chest
tightness and PVC's and then had VF cardiac arrest. CPR
immediately
initiated and then quickly underwent successful DC cardioversion
with
restoration of pulse. With CPR and cardioversion, sheath
dislodged from
right radial artery, and TR band placed over the site. After [**12-5**]
minutes, he had another VF cardiac arrest with very brief CPR
and almost
inmmediate cardioversion. Anesthesia called stat, and patient
sedated
and intubated. Now more hemodynamically stable with better BP,
and
dopamine stopped. Access then obtained in right CFA and CFV and
coronary
angiography and RHC performed. At end of case, patient
hemodynamically
quite stable with BP 140/80 off pressors, good cardiac output,
and PCWP
16. Right CFA access site closed using AngioSeal device.
FINAL DIAGNOSIS:
1. one vessel coronary artery disease.
2. Hypotension and VF cardiac arrest likely secondary to
vasovagal
episode in the context of severe aortic stenosis. Echocardiogram
performed stat at end of case showed preseved LVEF and no
pericardial
effusion. He is s/p DC cardioversion x 2 and CPR. Intubated and
ventilated.
3. Moderate pulmonary hypertension.
-TTE ([**2174-11-9**]) - There is mild regional left ventricular
systolic dysfunction with probable hypokinesis of the distal
anterior septum. Right ventricular chamber size and free wall
motion are normal. Significant aortic stenosis is present (not
quantified). Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Aortic stenosis is probably severe. At least
moderate aortic regurgitation. Image quality is suboptimal. The
mid to distal anterior septum is probably mildly hypokinetic.
-CXR ([**2174-11-9**]) - The tip of the endotracheal tube projects 3.5
cm above the carina. The nasogastric tube shows a normal
course. Moderate cardiomegaly with mild pulmonary edema. No
pleural effusions. No pneumonia. Minimal retrocardiac
atelectasis. There is no evidence of rib fractures on the
current radiograph. If clinically relevant, a dedicated rib
series should be obtained.
-CXR ([**2174-11-10**]) - As compared to the previous radiograph, there
is no relevant change. Low lung volumes, intubation, moderate
cardiomegaly, and mild fluid overload. No pleural effusions. No
evidence of pneumonia.
- ECHO [**2174-11-11**]
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-45 %). Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
to moderate ([**12-5**]+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
an epinephrine infusion. Right ventricular function on initial
post-bypass images appears moderately depressed, then improves
back to baseline after chest closure. Left ventricular function
is unchanged. There is a well-seated, well-positioned mechanical
prosthetic valve in the aortic position. No paravalvular leak is
seen. Characteristic washing jets are seen. There is a mean
gradient of 21 mmHg at a cardiac output of 4.1 L/min. Mitral
regurgitation is unchanged. The aorta is intact
post-decannulation.
- Abdominal U/S
Extremely limited ultrasound due to the patient's body habitus.
Despite diligent effort, the gallbladder could not be
identified. If further evaluation of the gallbladder is
indicated, CT, MR, or nuclear medicine scan could be obtained.
Brief Hospital Course:
The patient is a 63 male with multiple medical problems
including critical aortic stenosis who is admitted to CCU
following ventricular tachycardia arrest during cardiac
catheterization. Due to the initial complexity of his
hospitalization, his course will be broken down into systems
until the time of his aortic valve replacement.
#VT ARREST: Patient developed hemodynamically unstable
polymorphic ventricular during cardiac catheterization. EKG from
earlier in the day with normal QT interval with no conduction
abnormalities. Postulated mechanism his ventricular arrhythmia
include ischemia, excess catecholamines, of vagal event during
procedure causing hypotension resulting in ischemia. Upon
admission to the CCU, he was initially requiring dopamine which
was weaned at the same time he was extubated and sedation was
turned off.
#RESPIRATORY FAILURE: Patient intubated in the setting of VT
arrest. ABG with increased A-a gradient most likely due to VQ
mismatch from atelactasis and mild/moderate pulmonary vascular
congestion. He was extubated without difficulty on ICU day 2 and
maintained good oxygen saturation.
#AORTIC STENOSIS: Patient with progressive dyspnea on exertion
found to have trileaflet aortic valve with aortic valve area of
0.7 by continuity equation on recent echocardiogram.
#RIGHT ARM PROXIMAL WEAKNESS - After he was extubated and
sedation wore off, he was unable to lift his right arm but had
intact hand movement. This was presumed to be from a brachial
plexus injury which may have occurred during his cardiac cath
which was performed through the right radial artery. Neurology
was consulted and felt that there was no evidence of a central
process. He will follow up as an outpatient with neurology and
had his arm placed in a sling during this admission.
On [**2174-11-10**], Mr. [**Known lastname 13257**] [**Last Name (Titles) 5058**] neurologically intact and the
decision was made to proceed with his surgery. On [**2174-11-11**], Mr.
[**Known lastname 13257**] was taken to the operating room where he underwent
enlargement of his aortic root with replacement of his aortic
valve using a 19mm St. [**Male First Name (un) 923**] mechanical valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. He required blodd
transfusions for postoperative anemia. He developed right heart
failure and remained intubated, sedated and on inotropes. He was
diuresed aggressively. He developed hepatic congestion with
elevation of his LFT's. A right upper quadrant ultrasound was
negative. His creatinine gradually increased and the renal
service was consulted for evaluation of an acute kidney injury.
Acute tubular necrosis in the setting of hypoperfusion was
suspected and he was started on CVVHD for fluid removal. His
creatinine slowly improved. He also became thrombocytopenic and
a hematology consult was obtained. Argatroban was started and
all heparin products were stopped. An original HIT screen was
negative but a serotonin assay was sent which returned positive.
Leukocytosis was noted and vancomycin and zosyn were started for
broad coverage. A central line culture grew coag negative staph
and the infectious disease service was consulted. He will
continue on Vancomycin only until the 8 AM dose on [**12-3**]. Tube
feeds were started for nutritional support. Coumadin started
[**11-23**] for mechanical valve while bridged with argatroban. An MRI
of the brain was ordered for lingering right sided weakness of
both the upper and lower extremities and for limited horizontal
gaze. It showed multiple small white matter infarctions, but
neurology felt these findings did not explain Mr. [**Known lastname **]
deficits. Over the next week he began to make slow neurologic
improvement. By post-operative day 21 he was ready for
discharge to [**Hospital3 **].
Medications on Admission:
-Protonix 40mg once daily
-albuterol every 6 hours prn
-Lisinopril 20mg once daily
-Zocor 40mg once daily
-Aspirin 81mg daily
Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital3 **]: One (1) gm
Intravenous Q 12H (Every 12 Hours): for coad negative staph in
IV line. last dose 12/31 at 8AM.
2. simvastatin 10 mg Tablet [**Hospital3 **]: One (1) Tablet PO HS (at
bedtime).
3. lisinopril 5 mg Tablet [**Hospital3 **]: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet [**Hospital3 **]: Three (3) Tablet PO TID
(3 times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital3 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
9. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for
1 doses: Continue coumadin dosing for goal INR of [**1-6**] for a
mechanical aortic valve.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Aortic stenosis
Hyperlipidemia
acute renal failure
heparin-induced thrombocytopenia
Hypertension
Morbid obesity
Asthma
GERD
Cholelithiasis
Degenerative joint disease
Arthritis
Anxiety
Cardiac arrest
Discharge Condition:
Alert and oriented x3 nonfocal
Stands with max assist
Right sided weakness 4/5 both upper and lower extremities,
limited horizontal gaze
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace lower extremity
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) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**1-11**] at 1PM
Cardiologist: Dr. [**Last Name (STitle) **] on [**12-28**] at 9:10AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve
Goal INR 2-3.0
First draw [**12-3**]
Completed by:[**2174-12-2**]
|
[
"V17.3",
"424.1",
"584.5",
"416.8",
"414.01",
"276.2",
"300.00",
"493.90",
"518.52",
"401.9",
"378.71",
"955.7",
"E879.0",
"998.01",
"997.1",
"289.84",
"285.1",
"V85.41",
"427.5",
"573.0",
"272.4",
"427.1",
"428.0",
"997.09",
"278.01",
"E878.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"35.22",
"35.39",
"39.61",
"96.72",
"39.95",
"88.56",
"96.6",
"99.62",
"37.21",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
16791, 16834
|
11456, 15326
|
332, 542
|
17077, 17340
|
4560, 4560
|
18314, 18902
|
3420, 3666
|
15502, 16768
|
16855, 17056
|
15352, 15479
|
8023, 11433
|
17364, 18291
|
3681, 4541
|
3037, 3037
|
242, 294
|
570, 2943
|
4576, 8006
|
3068, 3246
|
2965, 3017
|
3262, 3404
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,634
| 131,358
|
16214
|
Discharge summary
|
report
|
Admission Date: [**2195-3-24**] Discharge Date: [**2195-3-27**]
Date of Birth: [**2135-2-7**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 60 year-old male with
coronary artery disease, coronary artery bypass graft times
ten years ago who developed nausea and vomiting and
diaphoresis after shoveling snow this morning. He also
described a pressure across his anterior chest. He took tons
of baking soda without relief. He called 911 and took
aspirin. The pain was relieved somewhat by nitroglycerin. He
was taken to [**Hospital6 33**] and was given additional
aspirin. He was started on heparin and given 300 mg of
Plavix, morphine and started on a nitro drip. He was then
transferred to [**Hospital1 69**] for
catheterization.
His electrocardiogram demonstrated acute ST elevations. His
cardiac anatomy was saphenous vein graft to obtuse marginal
one and posterior descending coronary artery, saphenous vein
graft to left anterior descending coronary artery and
saphenous vein graft to ramus.
Catheterization revealed a right dominant system with
evidence of native disease plus saphenous vein graft to left
circumflex and obtuse marginal one to posterior descending
coronary artery with TIMI two flow and a large thrombus,
which was stented. He was bradycardic much of the procedure.
In the holding area he vomited bright red blood times two
and Integrilin and heparin were discontinued. He was given
Dopamine for bradycardia and transferred to the Coronary Care
Unit for monitoring. His wedge pressure was 28.
PAST MEDICAL HISTORY:
1. Coronary artery disease with a coronary artery bypass
graft ten to twelve years ago.
2. Sleep apnea.
3. Status post tonsillectomy and adenoidectomy.
4. Status post pilonidal cyst.
approximately ten years.
ALLERGIES: No known drug allergies.
MEDICATIONS: He was on aspirin 325 once a day, however, he
was not compliant with this.
SOCIAL HISTORY: He has a history of tobacco use. One pack
per day times twenty five years. He quit after his coronary
artery bypass graft. He has rare alcohol use. No
intravenous drug abuse and lives alone.
FAMILY HISTORY: Significant for father who died at age 59 of
a heart attack and likely hypertension.
PHYSICAL EXAMINATION ON ADMISSION: His temperature was 98.
Blood pressure 125/73. Pulse 60. Respirations 15. 100% on
2 liters nasal cannula. He is a pleasant man in no acute
distress. Pupils are equal, round and reactive to light and
accommodation. Extraocular movements intact. His mucous
membranes were dry. His heart had a regular rate and rhythm
with no appreciable murmurs, rubs or gallops. He had no
elevated JVP. His lungs were clear anteriorly and
bilaterally. Abdomen he had hyperactive bowel sounds, but
his abdomen was benign. His femoral sheath was intact. He
had no hematoma. Extremities were warm with no clubbing,
cyanosis or edema. Positive dorsalis pedis pulses
bilaterally.
LABORATORY: White blood cell count 11.6, hematocrit 36.3,
platelets 205, PT 12.9, PTT 29.6, INR 1.1. Differential 86.9
neutrophils, 0 basophils, 9.4 lymphocytes, 3.2 monocytes, .2
eosinophils, .3 basophils. Sodium 143, creatinine 4.2,
chloride 105, bicarb 25, BUN 15, creatinine 1, glucose 136.
His CK was 243 and then 178.
HOSPITAL COURSE: He is admitted to the Coronary Care Unit
with close follow up as he is in with a gastrointestinal
bleed in the setting of heparin and Integrilin. He had no
further episodes of emesis. His hematocrit remained stable
overnight. He had initially frequent ectopy on telemetry
including nonsustained ventricular tachycardia all within 48
hours of his myocardial infarction. The frequency of these
decreased with aggressive electrolyte repletion. He was
started on low dose Metoprolol, however, his heart rate was
down into the 40s. He was asymptomatic with this. He was
maintained on intravenous Protonix b.i.d. He was started on
Plavix 75 mg q day and Lipitor. Additional laboratory work
included triglyceride of 56, HDL of 56, LDL of 230 and a
ratio of 5.3. ALT 44, AST 225, alkaline phosphatase is 74,
total bilirubin .7. His CKs peaked at [**2204**] and began to
trend downward. His troponin was registered as greater then
50. His hematocrit remained stable with only a slight trend
downward.
He was seen by physical therapy who deemed it safe for him to
go home without any further physical therapy needs. He had
an echocardiogram, which revealed an EF of 35 to 40%, normal
left atrium size, elongated left atrium with an left
ventricular mildly dilated, hypokinesis, akinesis of inferior
septum and inferior wall and posterolateral walls, left
ventricular function, right ventricular function depressed.
Trace aortic regurgitation and 1+ mitral regurgitation.
The patient was given much encouragement to follow up with
his physician. [**Name10 (NameIs) **] reestablished care with Dr. [**Last Name (STitle) 46260**] who
could serve both as his primary care physician and his
primary cardiologist. Dr.[**Name (NI) 46261**] office was contact[**Name (NI) **] and
updated on the [**Hospital 228**] hospital stay with suggestion for
referral for gastroenterology for further evaluation of
gastrointestinal bleed.
DISCHARGE MEDICATIONS:
1. Nitroglycerin .3 mg tab sublingual take one tab
sublingual as needed for chest pain.
2. Plavix 75 mg one tablet po q day times 90 days.
3. Aspirin 325 mg one tablet po q day.
4. Atorvastatin 20 mg tablet one tablet po q day.
5. Metoprolol 12.5 mg po b.i.d.
6. Captopril 6.25 mg t.i.d.
7. Pantoprazole one tablet p.o. q. day.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 21307**]
MEDQUIST36
D: [**2195-3-27**] 10:55
T: [**2195-3-27**] 13:28
JOB#: [**Job Number 42811**]
|
[
"578.0",
"414.01",
"458.2",
"427.89",
"414.02",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.64",
"99.20",
"88.55",
"37.23",
"36.01",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
2151, 2258
|
5244, 5856
|
3292, 5221
|
160, 1558
|
2273, 3274
|
1580, 1921
|
1938, 2134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,355
| 109,323
|
8302+55930
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-1-28**] Discharge Date: [**2160-2-2**]
Date of Birth: [**2133-5-22**] Sex: F
Service: [**Company 191**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 26-year-old
female with a complicated past medical history including
vasculitis, GI dysmotility, status post a total colectomy,
multiple intravascular thromboses, and line infections on
chronic TPN, who presented to the Emergency Department with
change in mental status. According to the patient's mother,
she was in her usual state of health until the morning od
[**2160-1-28**] when the family noted decreased mental
status and increased agitation. She was mumbling words and
not making sense. Her mother does think that she did have
some odd behavior the night before. They deny any recent
fevers, chills, nausea, vomiting, headache, sick contacts,
URI symptoms, no change in medications or recent substance
use was elicited in the history. The patient denied recent
falls or head trauma.
On arrival to the ED, she was afebrile and hemodynamically
stable. An infection workup was instituted including blood
cultures, urine culture, head CT, chest x-ray, and LP, none
of which elucidated a potential cause. She was admitted to
the ICU for further management and treatment of electrolyte
abnormalities.
PAST MEDICAL HISTORY:
1. Neuropathic vasculitis incompletely characterized but
extensively worked up; treatments in the past include
steroids, however, those were discontinued several years ago.
2. Gastrointestinal dysmotility syndrome diagnosed in [**2144**],
status post subtotal colectomy in [**2147**] with resultant short
gut syndrome on TPN since [**2148**]. Multiple line thromboses and
difficult intravenous access issues.
3. Central line infections including Staphylococcus
epidermidis, [**Female First Name (un) 564**], and Klebsiella.
4. Poorly characterized pulmonary scarring and infiltrate.
5. Status post cholecystectomy.
6. Anemia of chronic disease.
7. Reflux sympathetic dystrophy with chronic pain.
8. Bladder atony, status post suprapubic catheter placement
in [**2150**].
9. Status post dental extraction.
10. Status post salpingo-oophorectomy of the left.
11. History of VRE in urine.
12. Question of somatization disorder.
13. Status post GJ tube placement for decompression.
14. Status post multiple vascular stents including right IJ,
left brachiocephalic, left iliac and SVC.
15. Chronic pain syndrome.
16. Muscle spasms.
ADMISSION MEDICATIONS:
1. Reglan 10 mg IV q. 12.
2. Famotidine 40 mg IV b.i.d.
3. Lorazepam 3 mg q. three hours p.r.n.
4. Benadryl 100 mg q. three hours p.r.n.
5. Enoxaparin 60 mg subcutaneously b.i.d.
6. Hydromorphone PCA 4 mg per hour with 4 mg bolus q. ten
minutes, lockout of 28.
7. Albuterol p.r.n.
8. Total parenteral nutrition.
SOCIAL HISTORY: The patient lives at home with her family.
She is wheelchair bound. The family and the patient denied
any injection of illicit drug use. No alcohol or tobacco
use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.9, heart rate 100-110, BP 125/80, respiratory rate 16,
saturating 100% on 2 liters nasal cannula. General: The
patient was chronically ill appearing, pale, but comfortable.
HEENT: Anicteric sclerae. Pale conjunctivae. The pupils
were 2 mm and reactive. No nystagmus present. The
oropharynx was clear. The lips were dry. The neck was
supple. JVP, no carotid bruits, no thyromegaly. There is no
lymphadenopathy. The heart revealed a regular rate and
rhythm, normal S1, S2, no murmurs, rubs, or gallops. The
lungs revealed poor effort, clear to auscultation
bilaterally. Decreased breath sounds at the bases. The
abdomen was scaphoid, gastrostomy tube in place, and
suprapubic catheter in place. Bowel sounds soft but present.
Nondistended, nontender. Carotid, radial, femoral, and
dorsalis pedis pulses are equal and intact. Extremities
revealed no rash or edema. Mental status on admission
revealed that the patient was alert and oriented to person
but not place and time, inattentive, unable to assess short
and long-term memory. Grossly full visual fields. Cranial
nerves were intact, II through XII. Motor tone was normal.
Would not cooperate with assessment of strength. However,
moving all four extremities.
LABORATORY/RADIOLOGIC DATA: On admission, white count 2.2,
67 neutrophils, 23 lymphs, 6 monos, 2 eosinophils, crit of
31.7, platelets 138,000. Chem-7 was normal. Calcium,
magnesium, and phosphorus were normal. ALT 15, AST 18, INR
1.3. ESR 75. The tox screen was negative for benzos,
barbiturates, amphetamines, methadone, positive for opiates,
LT acellular, 21 protein, glucose 67. TSH 1.9. ABGs 7.37,
20, 207. Lactate initially 10, repeat 4.
The EKG revealed sinus tachycardia at 157 with normal
intervals, right axis deviation, poor R wave progression,
nonspecific T wave changes.
Chest x-ray showed venous stents in the left subclavian,
right brachiocephalic vein, and superior vena cava, unchanged
in appearance, right Hickman catheter is also apparent,
improvement in previously noted bilateral air space
opacifications. No focal consolidation, effusion,
pneumothorax, or failure.
CT of the head was negative for mass lesions, bleed, or
shift.
HOSPITAL COURSE: 1. MENTAL STATUS: The patient was
admitted to [**Hospital Ward Name 332**] ICU for close monitoring. She was
initially started on broad spectrum antibiotics, Flagyl,
vancomycin, and levofloxacin pending culture workup as it was
thought that her mental status change was due to infection.
Blood cultures, urine culture, U/A, chest x-ray, CSF
examination were all normal and did not point to source of
infection. The patient remained afebrile. The antibiotics
were discontinued. She was noted to have hypomagnesemia and
hypokalemia and these were aggressively repleted. According
to the family, she has had mental status changes in the past
when her electrolytes were abnormal.
Psychiatry consult was obtained and they felt that her
bizarre behaviors were consistent with delirium. There was
also concern that her baseline high doses of narcotics,
benzodiazepines, and anticholinergics could be causing her
confusion. These medications were initially held without
much improvement in her mental status. Further discussion
with the family raised concern that in the past she has done
poorly off these medications and so they were restarted.
Her mental status slowly cleared to near baseline by the
fourth hospital day. She was awake, alert, and oriented
times three, conversant, able to participate in care,
although occasionally using nonsensical speech.
2. FLUIDS, ELECTROLYTES, AND NUTRITION: TPN was initially
held as line infection was being ruled out. Wound cultures
were negative. TPN was restarted on [**2160-1-31**]. Electrolytes
were aggressively repleted as needed.
3. TACHYCARDIA: The patient had intermittent bouts of
tachycardia on the first three hospital days. On hospital
day number four, the patient developed a persistent sinus
tachycardia in the 130s. Initially, this was felt possibly
due to dehydration or pain. Her Dilaudid PCA was titrated
back up to home dose and she was bolused with several liters
of IV fluid. This was not successful in fixing her
tachycardia. PE was considered, however, felt to be unlikely
given the lack of hypoxia or tachypnea. She also continues
to be on Lovenox 60 mg b.i.d. for previous thromboses so it
is already being treated. There is concern for RV strain and
then volume overload. However, at the time of dictation,
tachycardia persists.
Please see addendum for further hospital course and discharge
status.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADF
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2160-2-2**] 03:45
T: [**2160-2-2**] 15:54
JOB#: [**Job Number 29422**]
Name: [**Known lastname 5132**], [**Known firstname **] A Unit No: [**Numeric Identifier 5133**]
Admission Date: [**2160-1-28**] Discharge Date: [**2160-2-7**]
Date of Birth: [**2133-5-22**] Sex: F
Service: [**Company 112**]
ADDENDUM: This addendum covers the hospital course from
[**2160-2-3**] through [**2160-2-7**].
1. MENTAL STATUS: The patient's mental status gradually
improved over the remainder of her stay. She was felt to be
at baseline per family on the day prior to admission. On the
day of admission, the patient said that she felt well and
wanted to go home. Other than the electrolyte abnormalities
noted, the cause of her mental status change is not obvious.
She was followed by psychiatry who certainly felt that there
could be a component of somatization involved and continued
to recommend on a long-term basis an attempt be made to wean
her from her high-dose narcotics, Benadryl and
benzodiazepines. However, this was not undertaken during
this hospitalization.
Of note, the patient did have one episode of "seizure-like
activity", in which she appeared stiff as a board and then
was slumped over in her bed; however, there was no postictal
state and this was not felt to be a seizure. She had no
other episodes like this.
2. TACHYCARDIA: The patient continued to be tachycardiac
from 100-130 during the remainder of her admission. A CT
angiogram was performed to evaluate for pulmonary embolism
given decreased right ventricular systolic function on
echocardiogram on [**2160-2-4**] and nonspecific EKG changes. The
CT angiogram was negative for pulmonary embolism and at no
time did the patient's blood pressure drop nor did she have
any trouble with oxygenation.
Blood cultures were also drawn to evaluate whether the
patient had an impending infection and these were no growth
to date at the time of discharge.
3. PAIN CONTROL: The patient was continued on her Dilaudid
PCA with a basal rate of 4 mg per hour and lockout of 5.2 mg
per hour. Her pain was well controlled by the end of
admission on this regimen. She is discharged on a similar
but more extensive Dilaudid regimen, that is 4 mg per hour
basal with 1-5 mg boluses every eight minutes as needed. She
has been stable on this regimen for quite some time.
4. CHRONIC SPASMS: These were treated with Benadryl 100 mg
every three hours, also with Ativan 3 mg every three hours
and also with Hyoscyamine sublingual tablets p.r.n.
5. ANTICOAGULATION: The patient was continued on her
Lovenox 60 mg b.i.d. given her history of stenosed and
thrombosed vasculature related to her central venous access.
6. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
continued on her home TPN regimen with adjustments made for
electrolyte values p.r.n. This includes lipids in the mix on
Tuesdays and Thursdays. Her Reglan and Pepcid were included
in her TPN.
7. DISPOSITION: The patient remained resistant to
psychiatric care on an outpatient basis. The patient
expressed no desire to attempt to transition from her TPN to
any kind of p.o. or G tube feedings. The patient clearly
desired to return home with the exact same regimen that she
had been admitted with. The patient's case was discussed in
depth with her primary care physician who is aware of her
current admission. She was also followed by psychiatry while
in the hospital.
DISCHARGE DISPOSITION: Home with services.
DISCHARGE INSTRUCTIONS:
1. The patient should follow-up with her primary care doctor
in one to two weeks.
2. The patient should see Dr. [**Last Name (STitle) 1180**] within one week to have
chemistries and laboratories checked to make adjustments to
TPN.
3. The patient should continue on medications as before
admission.
4. Continue with TPN as before admission.
5. See Pulmonary Function Laboratory on [**2160-2-27**]. Next
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1112**] on [**2160-2-27**].
DISCHARGE MEDICATIONS:
1. Lovenox 60 mg q. 12 hours.
2. Hyoscyamine 0.125 mg tablets sublingual every six hours
p.r.n.
3. Benadryl 100 mg IV q. three hours.
4. Zofran 10 mg IV q. four hours up to five times per day
for nausea.
5. Pepcid 40 mg IV b.i.d.
6. Reglan 10 mg q. 12 hours.
7. Dilaudid 10 mg per milliliter solution: 4 mg per hour
continuous infusion with a bolus of [**2-4**] mg q. eight minutes
as needed.
8. Ativan 3 mg every three hours.
DISCHARGE DIAGNOSIS:
1. Altered mental status/delirium.
2. Malnutrition.
3. Gastroparesis.
4. Vasculitis.
5. Abdominal pain.
6. Limb pain.
CONDITION ON DISCHARGE: Similar to her baseline condition.
Discharged on Dilaudid drip and TPN.
[**Last Name (LF) **],[**Name8 (MD) **], m.d. 12.adf
Dictated By:[**Last Name (NamePattern1) 2223**]
MEDQUIST36
D: [**2160-2-7**] 02:20
T: [**2160-2-7**] 19:36
JOB#: [**Job Number 5147**]
|
[
"536.3",
"263.0",
"447.6",
"276.8",
"337.20",
"427.89",
"293.0",
"275.2",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11302, 11323
|
11890, 12327
|
12348, 12473
|
5275, 5279
|
11347, 11867
|
2488, 2809
|
3029, 5257
|
8274, 11278
|
1329, 2465
|
2826, 3014
|
12498, 12795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,614
| 111,449
|
51625
|
Discharge summary
|
report
|
Admission Date: [**2136-11-18**] Discharge Date: [**2136-11-21**]
Date of Birth: [**2085-2-15**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain, SOB, nausea
Major Surgical or Invasive Procedure:
percutaneous angioplasty PL branch of RCA
History of Present Illness:
Mr [**Known lastname **] is a 51yoM with h/o HIV/AIDS (in [**7-/2136**], CD4 582, HIV
VL non-detectable), pulmonary HTN (on sildenafil), HCV, who
presents with chest pain and STEMI in distal RCA. He initially
presented to [**Hospital1 18**] ED with 3 hours of severe ([**9-12**])substernal
burning chest pain/pressure radiating to his left arm.
Associated with nausea and shortness of breath. No pleuritic
component. No recent fevers, chills, or cough. Unable to
describe whether it is exertional because he has not really
exerted himself during the symptoms. The patient had gotten up
early in the morning and gone to church then participated in
church activities. He put his feet up when he got home and
began to experience the chest pain. No prior similar episodes.
No syncope or dizziness. No focal weakness, numbness, or
tingling. No recent catheterization or a stress test. He did
have a cardiac cath in [**2129**], that showed disease in LMCA and
LAD, but none in RCA.
Past Medical History:
1. CARDIAC RISK FACTORS: no Diabetes, no Dyslipidemia, no
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- prior cath [**2129-8-3**] (report is below): disease to LMCA and
LAD
- HIV/AIDS: last counts on [**7-/2136**], CD4 was 582, HIV VL non-
detectable, on Truvada/Kaletra.
- h/o disseminated [**Doctor First Name **]
- h/o rectal herpes
- Hepatitis C-completed 1 yr of ribavirin/PEG-IFV therapy; HCV
viral load undetectable in [**2130**]
- Pulmonary hypertension-on sildenafil
- HPV (perirectal) with anal dysplasia- He underwent transanal
microscopially assisted laser destruction of anal condyloma
excisional on [**2132-4-11**]. The path report of 2 biopsied lesions
demonstrated high grade squamous intraepithelial lesion (anal
intraepithelial neoplasia II-II) extending to peripheral
specimen margins. Initiated topical aldara therapy.
- Schatzki's ring - esophageal dilitation
Social History:
He lives with his non-[**Name (NI) 106973**] husband. They have been in a
monogamous in the relationship for over ten years. The patient
works at the front desk in his husband's hair salon in [**Location 9104**]. His husband is a world-reknowned hair colorist. He has
a prior history of smoking. He smoked 1 PPD for 15 years and
quit 20 years ago. He denies any current alcohol as it
interferes with his medications. No prior history of alcohol
abuse. He denies any present drug use. Distant marijuana use
- Tobacco history: former
- ETOH: none
- Illicit drugs: none
Family History:
- Adopted. Unknown history.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: 96.9, 76, 121/77, 16, 97%/2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Mildly
uncomfortable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-11**] holosystolic murmur best heard at
apex. 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. Post-cath cuff on
right wrist without any TTP or hematoma.
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+
.
PHYSICAL EXAMINATION ON DISCHARGE:
Vitals - Tm/Tc: 98.2 HR: 66 (53-66) BP: 102/64 (84-107/44-69)
RR: 16 02 sat: 94%RA (94-98% RA)
In/Out: not recorded
Weight: 83.5 kg
Tele: SR, no events
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Very
pleasant.
HEENT: NCAT. MMM.
NECK: Supple with JVP 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-11**] holosystolic murmur best heard at
apex. No thrills, lifts. No S3 or S4. no carotid bruits
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness. + bowel sounds
EXTREMITIES: No c/c/e. No femoral bruits. Dressing over RRA
C/D/I. No hematoma or oozing.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
[**2136-11-18**] 06:20PM WBC-7.7 RBC-4.51* HGB-16.1 HCT-47.3 MCV-105*
MCH-35.8* MCHC-34.1 RDW-12.2
[**2136-11-18**] 06:20PM GLUCOSE-87 UREA N-15 CREAT-0.9 SODIUM-135
POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-22 ANION GAP-17
[**2136-11-18**] 06:20PM NEUTS-49.3* LYMPHS-40.8 MONOS-7.5 EOS-1.9
BASOS-0.5
[**2136-11-18**] 06:20PM PT-12.6 PTT-28.3 INR(PT)-1.1
[**2136-11-18**] 06:20PM cTropnT-<0.01
.
Relevant labs:
[**2136-11-19**] 03:17 CK 485/CK-MB 63/TropnT 0.52
[**2136-11-19**] 09:11 CK 563/CK-MB 75/TropnT 0.73
[**2136-11-19**] 15:33 CK 372/CK-MB 52/TropnT 0.69
[**2136-11-20**] CK 153/CK-MB 18/TropnT 0.57
.
Labs on discharge:
[**2136-11-21**] WBC 6.5/RBC 4.08/Hgb 14.7/Hct 42.5/Plt 224
[**2136-11-21**] Gluc 92/BUN 19/Crea 1.1/ Na 134/K 4.0/Cl 99/HCO3 25/Ca
9.1/Mg 2.0/Phos 2.6
.
TTE:
[**2136-11-19**]
The left atrium is mildly elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). 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. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
CARDIAC CATH:
[**2136-11-18**]
1. Selective coronary angiography of this right dominant system
demonstrated three vessel coronray disease. The LMCA had 40%
distal
stenosis. The LAD had 40% mid-vessel stenosis. The LCx had 60%
mid and 60% distal stenosis. The RCA had 50% mid-vessel
stenosis, 50% PDA
stenosis and 100% occlusion of the posterolateral branch.
2. Limited resting hemodynamics revealed normotension.
3. Perfusion of a small RPL branch successfully treated by PTCA
with 2.25 mm balloons.
Diagnosis: 3 vessel cardiac disease
.
[**2129-8-3**]
1. Selective coronary angiography demonstrated a right-dominant
circulation with mild coronary artery disease. LMCA had a
distal 40%
stenosis. LAD had a proximal 50% stenosis. LCx was diminutive,
and had no angiographically-apparent flow-limiting stenoses.
RCA was a large, dominant vessel without
angiographically-apparent stenoses.
2. Left ventriculography demonstrated no significant mitral
regurgitation, normal wall motion and EF of 60%.
3. Resting hemodynamics with patient breathing ambient air
demonstrated severe pulmonary hypertension (mean PA 51 mmHg).
Right-
and left-sided filling pressures were normal (mean RAP 3 mmHg,
RVEDP 7 mmHg, mean PCWP 3 mmHg). Cardiac output at baseline was
3.9 L/min with cardiac index of 1.9 L/min/m2. Baseline PVR was
calculated to be 2106 dynes-sec/cm5. After 15 minutes with
patient breathing 100% oxygen via a face mask, repeat
hemodynamics demonstrated no significant change in pulmonary
pressure. Cardiac output increased to 5.1 L/min, and calculated
PVR decreased to 1286 dynes-sec/cm5. After 15 minutes with
patient breathing nitric oxide at 40 ppm, repeat hemodynamics
demonstrated minimal reduction in pulmonary pressures (mean PA
45 mmHg), but no further increase in cardiac output, or decrease
in PVR beyond what was seen with 100% oxygen.
.
CXR:
[**2136-11-20**]
Previous mild interstitial pulmonary edema has improved. There
is no
consolidation or appreciable pleural effusion. Marked pulmonary
artery
dilatation and azygous distention are longstanding, evidence of
pulmonary
arterial hypertension and possible central venous hypertension.
Extensive
calcific hilar adenopathy as demonstrated by CT scanning is not
readily
appreciated on conventional radiographs.
.
[**2136-11-18**]
Single semi-erect AP portable view of the chest was obtained. No
evidence of a pneumothorax is seen. The right costophrenic angle
is not fully included on the image, however no large pleural
effusion is seen. There is no focal consolidation. Prominence of
the hila and AP window persists, stable. Cardiac and mediastinal
silhouettes are stable.
Brief Hospital Course:
Mr [**Known lastname **] is a 51yoM with h/o HIV/AIDS (in [**7-/2136**], CD4 582, HIV
VL non-detectable), pulmonary HTN and HCV presenting with chest
pain, SOB and nausea, found to have an inferior STEMI with 100%
occlusion of the RPLA, which was opened with balloon
angioplasty.
.
.
ACTIVE ISSUES:
# STEMI: A prior cath in [**2129**] showed mild CAD in LAD (50%) and
LMCA (40%) but otherwise his cardiac history is negative. This
was his first episode of chest pain. The only major known risk
factors being prior tobacco use and HIV infection. On admission
his EKG showed an inferoposterior STEMI with a negative Troponin
T. The patient was directly taken to the cath lab on [**2136-11-18**]
where 100% occlusion of RPL was found and opened by angioplasty.
Notably he was also found to have 40% stenosis in the LMCA and
LAD, 60% in the LCx, and 50% in the RCA and PDA. Prior to
catheterization, he had been treated with bivalirudin, which may
carry a significantly decreased risk of bleeding complications
(40% less than heparin + integrillin) after cath. He tolerated
the procedure well with resolving EKG changes after the
intervention. The cardiac markers where elevated up to a peak of
CK 563/CK-MB 75/TnT 0.73, finally trending down again prior to
discharge. However he had ongoing throbbing chest pain on day 1
post-cath which was responsive to 4mg Morphine but not to
Nitroglycerin. Several EKGs were obtained during these episodes
but did not support the idea of persistent ischemia and showed
normal sinus rhythm. A TTE on [**2136-11-19**] showed normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function (LVEF >55%). The thoracic aorta
was mildly dilated at sinus level. The patient was started on
Aspirin 325mg daily (for 2 weeks), Plavix 75mg daily (for 2
weeks), Metoprolol succinate 12.5mg daily, Lisinopril 2.5mg
daily and Atorvastatin 80mg daily (LDL goal: 70). Concerning the
work up of further risk factors his lipid panel showed
cholesterin 174/LDL 116/HDL 42/triglycerides 81. His HbA1c is
5.5%.
.
.
CHRONIC ISSUES:
# HIV/AIDS: The patient is compliant with home medications and
has excellent follow-up with his PCP, [**Name10 (NameIs) 1023**] manages his
antiretrovirals, Kaletra and Truvada. As of [**2136-7-30**], his CD4
was 582 and viral load <50. During this admission, his Kaletra
and Truvada were continued, but the patient's PCP may consider
changing antiretroviral regimen to medications with fewer
cardiac/metabolic side effects.
.
# Pulmonary Hypertension: Documented history of this problem,
which has been stable. The patient's sildenafil (with which he
has been treated since [**2129**]) was held for two days secondary to
hypotension, and restarted upon discharge.
.
# Depression/Anxiety: Documented history of this problem, for
which he was treated with citalopram and lorazepam prior to
admission. During this admission, he demonstrated a normal QTc
on EKG, so his citalopram was continued with low concern for
induction of Torsades de pointes.
.
.
TRANSITIONAL ISSUES:
- recommend reassessment of sildenafil therapy by PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] Aspirin 325mg for 2 weeks, then change to 81mg
- continue Plavix 75mg for 2 weeks
- PCP may consider changing antiretroviral regimen to
medications with fewer cardiac/metabolic side effects
Medications on Admission:
HOME MEDICATIONS: confirmed with patient
- albuterol 90mcg HFA inhaler 1-2 puffs INH [**Hospital1 **] PRN (takes [**2-5**]
x/week)
- citalopram 20mg PO qday
- truvada 200mg/300mg PO qday
- fexofenadine 60mg PO BID
- Kaletra 200-50mg 2 tablets PO BID
- Lorazepam 1mg QID and 2mg QHS
- Ranitidine 300mg [**Hospital1 **]
- Sildenafil 25mg TID (last at noon)
- Triancinolone groin prn
- Zolpidem 6.25 mg Tablet,Ext Release Multiphase QHS
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation twice a day as needed for shortness of
breath or wheezing.
7. ammonium lactate 12 % Lotion Sig: One (1) application Topical
twice a day.
8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for anxiety: [**Month (only) 116**] take additional pill at bedtime.
10. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. sildenafil 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
12. zolpidem 6.25 mg Tablet,Ext Release Multiphase Sig: One (1)
Tablet,Ext Release Multiphase PO at bedtime as needed for
insomnia.
13. lidocaine 4 % Cream Sig: One (1) application Topical twice a
day.
14. triamcinolone acetonide 0.1 % Lotion Sig: One (1)
application Topical twice a day.
15. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
17. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation myocardial infarction
Pulmonary hypertension
Dyslipidemia
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 at [**Hospital1 18**].
You had chest pain and a heart attack. A cardiac catheterization
was performed and found a 100% blockage in an artery that is an
extension of the right coronary artery. A balloon agioplasty was
performed to open the artery but no stent was placed. You also
had moderate blockages in the left anterior descending artery,
the left main artery and the right coronary artery itself. It is
important that you take all of your medicines as prescribed to
try to prevent these blockages from getting worse and causing
another heart attack.
We made the following changes to your medicines:
1. Start aspirin and plavix (clopidogrel) to help to prevent a
clot in your coronary arteries. Dr. [**Last Name (STitle) 911**] may stop the plavix
but you need to take an aspirin for the rest of your life.
2. Start taking Atorvastatin (Lipitor) every day to lower your
cholesterol
3. Start taking metoprolol to lower your heart rate and help
your heart recover from the heart attack.
4. Start taking lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
.
Please note that nitroglycerin interacts with the Sildenafil and
should be avoided.
Followup Instructions:
***Dr. [**Last Name (STitle) **] needs to know about your heart attack before this
test is performed.
Department: ENDO SUITES
When: TUESDAY [**2136-12-11**] at 10:00 AM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2136-12-11**] at 10:00 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
Please call Infectious Disease where you see your primary care
physician and book an urgent care appointment within 1 week of
hospital discharge.
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2136-12-5**] at 12:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2136-12-5**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2136-12-26**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"414.2",
"530.81",
"416.8",
"410.31",
"300.00",
"V12.09",
"042",
"414.01",
"311",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.20",
"00.40",
"00.66",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
14427, 14433
|
8884, 9168
|
294, 337
|
14547, 14547
|
4760, 4765
|
15942, 17569
|
2914, 2943
|
12720, 14404
|
14454, 14526
|
12261, 12261
|
14698, 15919
|
2958, 2979
|
1457, 1491
|
12280, 12697
|
3982, 4741
|
11941, 12235
|
231, 256
|
9183, 10950
|
5415, 8861
|
365, 1344
|
4779, 5396
|
14562, 14674
|
1522, 2306
|
10966, 11920
|
1366, 1437
|
2322, 2898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,191
| 170,843
|
42154
|
Discharge summary
|
report
|
Admission Date: [**2138-9-30**] Discharge Date: [**2138-10-13**]
Service: SURGERY
Allergies:
Tetanus / barbituates
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
weakness, decreased appetite
Major Surgical or Invasive Procedure:
[**2138-10-2**]: IR for drain placment into subhepatic periduodenal
stump space
History of Present Illness:
HPI: 89M s/p open cholecystectomy on [**2138-9-18**] presents with
persistent poor appetite, po intolerance, and weakness. Patient
was admitted from [**Date range (1) 91425**] for choledocholithiasis and
underwent ERCP on [**2138-8-1**] with sphincerotomy and 1cm stone
extraction. Patient was discharged home on 14days of Augmentin
and presented on [**2138-9-18**] for elective interval cholecystectomy.
Laparoscopic approach was abandoned due to dense adhesions from
his prior operations and his gallbladder was removed
uneventfully. Patient recovered well postoperatively and was
discharged home on POD#3.
Since discharge, patient notes poor po tolerance and appetite.
He denies nausea or vomiting. His energy never returned to
baseline; he normally swims at the [**Company 3596**] but has been unable to
do anything outside to his home since his operation. Patient
denies fevers,chills, drainage from wound, or pain in abdomen.
His main complaint is profound weakness and malaise. He denies
diarrhea
and has been passing flatus with normal bowel movements. In
ED,patient received cipro, flagyl, and
Past Medical History:
hypertension, BPH
Social History:
quit smoking ~ 25 years ago
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2138-9-29**]
Temp: 99.7 HR: 108 BP: 128/78 Resp: 18 O(2)Sat: 99 Normal
Constitutional: ill, nontoxic
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nondistended, Nontender, Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Physical examinatiion upon discharge: [**2138-10-13**]:
General: NAD
vital signs: t=97.3, hr=61 irregular, bp=126/85, oxygen
saturation 100% room air
CV: Irreg, ns1, s2, -s3, -s4
LUNG: Decreased bs right side, left clear
ABDOMEN: Soft, non-tender, DSD to right sided abdominal wound,
staples intact lower half wound, no erythema
EXT: Edematous lower extremities, weak dp bil., no calf
tenderness bil.
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
[**2138-10-13**] 06:33AM BLOOD WBC-11.5* RBC-3.86* Hgb-11.8* Hct-37.8*
MCV-98 MCH-30.7 MCHC-31.3 RDW-15.3 Plt Ct-266
[**2138-10-12**] 05:30AM BLOOD WBC-10.2 RBC-3.79* Hgb-11.9* Hct-38.3*
MCV-101* MCH-31.5 MCHC-31.2 RDW-15.9* Plt Ct-223
[**2138-10-10**] 05:30AM BLOOD WBC-9.9 RBC-3.51* Hgb-11.4* Hct-36.0*
MCV-102* MCH-32.4* MCHC-31.6 RDW-16.0* Plt Ct-217
[**2138-9-29**] 06:17PM BLOOD WBC-20.8*# RBC-3.94* Hgb-12.6* Hct-39.7*
MCV-101* MCH-31.9 MCHC-31.7 RDW-13.5 Plt Ct-520*#
[**2138-10-3**] 12:18AM BLOOD Neuts-85.4* Lymphs-11.0* Monos-3.4
Eos-0.1 Baso-0.1
[**2138-9-29**] 06:17PM BLOOD Neuts-90.5* Lymphs-6.4* Monos-2.7 Eos-0.1
Baso-0.3
[**2138-10-13**] 06:33AM BLOOD Plt Ct-266
[**2138-10-13**] 06:33AM BLOOD PT-36.2* PTT-41.1* INR(PT)-3.6*
[**2138-10-12**] 05:30AM BLOOD Plt Ct-223
[**2138-10-12**] 05:30AM BLOOD PT-29.1* PTT-52.4* INR(PT)-2.8*
[**2138-10-11**] 10:10AM BLOOD PT-24.6* PTT-94.3* INR(PT)-2.3*
[**2138-10-10**] 05:30AM BLOOD PT-19.6* PTT-80.1* INR(PT)-1.8*
[**2138-10-13**] 06:33AM BLOOD Glucose-84 UreaN-30* Creat-1.2 Na-142
K-4.3 Cl-102 HCO3-32 AnGap-12
[**2138-10-12**] 05:30AM BLOOD Glucose-98 UreaN-31* Creat-1.1 Na-142
K-3.6 Cl-102 HCO3-31 AnGap-13
[**2138-10-10**] 05:30AM BLOOD Glucose-104* UreaN-32* Creat-1.1 Na-142
K-4.8 Cl-107 HCO3-29 AnGap-11
[**2138-10-8**] 01:28AM BLOOD ALT-141* AST-65* AlkPhos-119 TotBili-0.4
[**2138-10-7**] 05:42AM BLOOD ALT-171* AST-88* LD(LDH)-214 AlkPhos-100
TotBili-0.4
[**2138-10-3**] 07:12AM BLOOD CK-MB-3 cTropnT-0.03*
[**2138-10-3**] 12:18AM BLOOD CK-MB-3 cTropnT-0.04*
[**2138-10-2**] 09:48PM BLOOD CK-MB-3 cTropnT-0.04*
[**2138-10-13**] 06:33AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.0
[**2138-10-7**] 05:42AM BLOOD Vanco-19.3
[**2138-10-4**] 12:54AM BLOOD Lactate-1.4
[**2138-9-29**] 08:17PM BLOOD Lactate-2.1*
[**2138-10-4**] 12:54AM BLOOD freeCa-1.25
[**2138-10-1**] 6:00 pm ABSCESS
**FINAL REPORT [**2138-10-5**]**
GRAM STAIN (Final [**2138-10-1**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
FLUID CULTURE (Final [**2138-10-5**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2138-10-5**]): NO ANAEROBES ISOLATED.
[**2138-10-3**] 1:25 am SWAB Source: RLQ ccy incision.
**FINAL REPORT [**2138-10-7**]**
GRAM STAIN (Final [**2138-10-3**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final [**2138-10-7**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2138-10-7**]): NO ANAEROBES ISOLATED.
[**2138-9-29**]: EKG:
Atrial flutter with a ventricular rate of 106. RSR' pattern in
leads V1-V2.
Tendency toward low voltage in the limb leads. Compared to the
previous
tracing of [**2138-9-18**] no diagnostic interval change.
[**2138-9-29**]: Chest x-ray:
IMPRESSION: Patchy opacity in the right lung base may reflect
an area of
infection. Trace bilateral pleural effusions.
[**2138-9-30**]: cat scan of abdomen/pelvis:
IMPRESSION:
1. Large amount of free air and heterogeneous material along the
undersurface
of the right hepatic lobe. The appearance is concerning for a
fistulous
connection with the bowel with extraluminal material and air.
Clinical
correlation and correlation with operative history recommended.
Linear
hypodensity in the adjacent liver suggests focal portal venous
clot which may
be causing a perfusion abnormality.
2. 4.8 x 2.5 cm fluid and air collection deep to the incision
along the
anterior abdominal wall could represent infection/developing
abscess.
3. Superficial air and fluid adjacent to surgical staples.
4. Opacity at the right lung base could represent chronic
aspiration/fibrotic
change.
[**2138-9-30**]: UGI:
IMPRESSION: Limited study due to inability of patient to take
enough p.o.
contrast due to risk of aspiration with esophageal dysmotility.
Unable to
determine duodenal perforation. Recommend NG tube placement with
subsequent contrast injection into the stomach and duodenum to
better assess for leak.
[**2138-10-1**]: IR drain placement:
IMPRESSION: Successful son[**Name (NI) 493**] and fluoroscopic guided
placement of the abscess drainage in the subhepatic periduodenal
stump space.
[**2138-10-2**]: chest x-ray:
IMPRESSION: Right lower lobe hazy infiltrates most likely
representing
pneumonia. Followup examination is recommended.
[**2138-10-3**]: ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The
estimated cardiac index is depressed (<2.0L/min/m2). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic root is mildly dilated at
the sinus level. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a very small pericardial effusion.
[**2138-10-3**]: chest x-ray:
IMPRESSION: Worsening right lower lobe opacification,
compatible with
worsening severe right lower lobe pneumonia, or hemorrhage in
the appropriate clinical setting.
[**2138-10-4**]: echo:
Conclusions
The left and right atria are moderately dilated. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis with apical sparring.. Mild (1+) aortic
regurgitation is seen. Severe [4+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension
(CVP of 20 mmHg). There are signs of right ventricular pressure
and volume overload.
Compared with the findings of the prior study (images reviewed)
of[**2138-10-3**] there is no significant change,
CLINICAL IMPLICATIONS: Signs of right ventricular volume and
pressure overload. Severe pulmonary [**Last Name (un) **] hypertension. Normal
left ventricular systolic function however cardiac index is low
most probably due to the right ventricular failure.
[**2138-10-4**]: cat scan of abdomen and pelvis:
1. Stable ground glass in the right lower lobe may represent
aspiration,
pneumonia, hemorrhage or focal edema.
2. Increasing bilateral small pleural effusions.
3. Subhepatic fluid and air collection in the region of the
right-sided
pigtail catheter containing extravasated oral contrast material
has decreased in size. There has been no further leak.
[**2138-10-5**]: Bil. lower ext. vein ext:
IMPRESSION:
1. Limited assessment of the left peroneal and right calf veins.
Otherwise,
no bilateral lower extremity DVT.
2. Diffuse subcutaneous edema.
[**2138-10-7**]: chest x-ray:
FINDINGS: In comparison with the study of [**10-5**], respiratory
motion greatly degrades the image. Diffuse bilateral areas of
opacification are consistent with elevated pulmonary venous
pressure and pleural effusions. The possibility of superimposed
pneumonia would have to be considered in the appropriate
clinical setting. Central catheter remains in place.
[**2138-10-7**]: Cat scan of the chest:
IMPRESSION: Bilateral, but right predominant, non-completely
recent PE.
Large right and small left pleural effusion, non-characteristic
right lower lobe parenchymal changes. Right heart enlargement
without ventricular bulging
[**2138-10-10**]: ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The anterior and antero-septal wall are mildly hypokinetic. The
right ventricular cavity is markedly dilated The ascending aorta
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened. Trace aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Severe [4+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
Brief Hospital Course:
89 year old gentleman re-admitted to the acute care service s/p
open cholecystectomy with weakness and decreased appetite. Upon
admission, he was made NPO, given intravenous fluids, and
underwent radiographic imaging. The cat scan of the abdomen
showed large amount of free air and heterogeneous material along
undersurface of
right hepatic lobe. He was started on empiric antibiotic
coverage with Vancomycin/Zosyn. He proceeded to undergo
percutaneous drainage under fluoroscopy on [**10-1**] with placement
of a 10F catheter. Initial abscess fluid GS showed 2+ GNR, 1+
yeast. On [**10-2**], patient became progressively tachycardic to
120s and hypotensive to SBP 70s. He was noted to have decreasing
UOP and a rising Cr (1.4 from 1.1). He was transfered to the
TSICU for concern for hypovolemia versus sepsis. Of note, he was
found to be in atrial flutter with [**Month/Year (2) 5509**], for which Cardiology was
consulted.
Neuro: The patient's pain was well controlled during his
hospital stay. He was initially managed on IV pain medications
while NPO, but this was transitioned to po tylenol and dilaudid
with good pain relief.
CV: The patient was transferred to the unit tachycardic and with
SBP 70s. He was given several liters of fluid for concern of
sepsis. He was initially found to be in aflutter with [**Last Name (LF) 5509**], [**First Name3 (LF) **]
cardiology was consulted. Cardiac enzymes were negative. On
[**10-3**] a TTE was performed that showed severe right heart
dysfunction with pulmonary HTN and right heart overload. Lasix
was given with good response. Low dose levophed was required to
maintain MAP > 60. On [**10-4**], repeat ECHO confirmed previous
findings and milrinone gtt was started to help with cardiac
ionotropy. Neo was still required to keep MAP elevated. On
[**10-5**], repeat echo showed no improvement with milrinone, so this
was discontinued. Pressors were weaned off and BP remained
stable. Cardiology recommended digoxin loading and patient
received 2 doses. CHF specialist was consulted and recommended
getting a CTA chest for concern of pulmonary embolus.
PULM: The patient remained stable from a pulmonary standpoint
and was maintained on low dose nasal cannula. On [**2138-10-7**], CTA
chest was performed for concern of PE and this showed bilateral
pulmonary emboli. The patient was started on heparin gtt and
bridged to coumadin during his hospitalization. He has a strong
cough and raises thick brown sputum. He has received intruction
in use of incentive spirometry.
GI: The patient was initially kept NPO as patient was presumed
to be septic and there was concern that operation would be
needed. Patient's diet was ultimately advanced to regular and
tolerated well without issues. The abdominal drain intially was
putting out significant amount of purulent fluid, however this
quickly decreased and minimal output was seen. Repeat CT on
[**10-5**] showed that the fluid collection was still present, but
had decreased signifcantly in size. Scant yellow drainage still
seen on [**10-8**].
GU: The patient's urine output remained marginal for much of his
stay. He was in acute renal failure with rise in Cr up to max
1.7. His urine output was variable and at times improved with
fluid resuscitation and pressors. Foley was kept in place for
close urine output monitoring, and electrolytes were checked and
repleted daily. Foley was discontinued on [**10-9**], and patient did
not have difficulty voiding.
WOUND: Right subcoastal incision, consisting of wet to dry
dressing. Scant serosanguinous drainage noted.
HEME: HCT remained stable with no issues. Because of his
standing AF, and prolonged bed rest, he underwent a cat scan of
the chest which showed bilateral, but right predominant,
non-completely recent PE. On [**10-7**] the patient was started on
heparin gtt for pulmonary emobli, and low dose coumadin was
started as well. His heparin drip was discontinued and he has
been maintained on coumadin. His last INR is 3.6 and his dose
of coumadin for [**10-13**] is being held. He will resume aspirin
when off coumadin.
ENDO: No issues, Insulin sliding scale
ID: The patient was started on empiric vanc, zosyn, and
fluconazole for presumed enteral leak. He was kept on this
regimen until [**2138-10-8**] when abx were changed to po
cipro/flagyl/fluconazole. His wound was opened on admission for
purulent drainage and concern for wound infection. This was
packed with wet/dry and is healing well. Staples are present on
half the incision and will be removed on follow-up visit. The
patient's WBC peaked at 16, and pan cultures revealed mixed
bacteria. His ciprofloxacin and flagyl were discontinued on
[**10-13**]. He will continue on fluconazole to complete the full
course. His white blood cell count is 11.5
DISPO: He was evaluated by physical therapy and recommendations
made for discharge to an extended care facility where he can
further regain his strength and mobility.
Medications on Admission:
Colace 100'', omeprazole 20'', aspirin 81', senna prn, terazosin
1', finasertide 5', lisinopril 5', HCTZ 25'
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for Pain.
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for HR <60, systolic blood pressure <110.
7. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA): please monitor INR..PLEASE HOLD COUMADIN
DOSE 10/31.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 13 days: started [**10-9**].
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
HOLD until follow-up visit with PCP.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: HOLD.....RESUME
WHEN OFF COUMADIN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Skilled Nursing Center - [**Location (un) 1456**]
Discharge Diagnosis:
intra-abdominal fluid collection
atrial fibrillation/flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - needs assistance
Discharge Instructions:
You were re-admitted to the hospital with decreased appetite and
weakness after you had your gallbladder removed. You had a cat
scan of the abdomen which showed a fluid collection deep in the
wound. Because there was a concern for a duodenal perforation,
you underwent a cat scan of the abdomen which showed a
intra-abdominal fluid collection. You had a drain placed in your
abdomen for the fluid collection. During your hospitalization,
you had changes in your blood pressure and heart rate and you
were transferred to the intensive care unit for monitoring.
Once your vital signs stablilized, you returned to the surgical
floor. The concern was raised for blood clots in your lungs and
you underwent a cat scan. You were started on a heparin drip
and have been converted to coumadin. You were seen by physical
therapy and recommedations made for dicharge to a rehabilitation
facility. Your vital signs have stabilized and you are now
preparing for discharge.
Followup Instructions:
Please follow-up with the acute care service in 1 week. You can
scheudle your appointment 24 hours after discharge by calling #
[**Telephone/Fax (1) 600**] at that time you will have the staples removed.
Please follow up with your primary care provider [**Last Name (NamePattern4) **] 1 week, Dr.
[**Last Name (STitle) 73983**]. The telephone number #[**Telephone/Fax (1) 79695**]. If he feels that
you need follow-up with a cardiologist, he will refer you to
one.
Completed by:[**2138-10-13**]
|
[
"427.32",
"428.33",
"600.00",
"507.0",
"995.91",
"038.9",
"427.31",
"567.22",
"584.9",
"416.0",
"401.9",
"E878.6",
"415.19",
"428.0",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18417, 18526
|
12170, 17126
|
257, 340
|
18631, 18631
|
2638, 9794
|
19775, 20276
|
1577, 1595
|
17287, 18394
|
18547, 18610
|
17152, 17264
|
18786, 19752
|
1610, 1633
|
9817, 12147
|
189, 219
|
2189, 2619
|
368, 1473
|
1648, 2172
|
18646, 18762
|
1495, 1515
|
1531, 1561
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,082
| 145,143
|
20377
|
Discharge summary
|
report
|
Admission Date: [**2129-3-14**] Discharge Date: [**2129-3-14**]
Date of Birth: [**2099-6-20**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 29-year-old male with
history of fibrosing mediastinitis which was diagnosed in
[**2119**], status post a left main metallic stent on [**2129-1-19**] who
presented to the MICU status post stent removal and resultant
intrabronchial hemorrhage. The patient arrived from [**State **]
for stent removal today from his left main, which resulted in
bleeding and a 10 mm tear. The patient remained intubated
for airway protection and epinephrine and normal saline was
injected into the lesion. During the bronchoscopy, the left
main was ballooned x2 and a biopsy was taken. The patient
also was noted to have a right bronchial occlusion with a
right upper lobe pinhole opening. The patient has had farm
and chicken care exposure in the past, which is thought to be
the cause of his fibrosing mediastinitis.
PAST MEDICAL HISTORY: Fibrosing mediastinitis diagnosed in
[**2119**], status post stent to left main on [**2129-1-19**] with semi-
patent right main bronchus. No other past medical history.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Doxycycline.
2. Tylenol With Codeine.
SOCIAL HISTORY: The patient is from [**State **]. He is an
engineer. He is married with one new baby. [**Name (NI) **] is a
nonsmoker.
FAMILY HISTORY: There is no history of fibrosis in his
family.
PHYSICAL EXAMINATION: Temperature 97.6 degrees, heart rate
92, blood pressure 125/66. The patient, initially in the
ICU, was on AC 400 x 18, PEEP of 10, FIO2 of 50. The patient
was 100 percent oxygen saturated on these settings. The
patient was intubated and sedated. The patient's ETT was
discharging bright red blood. HEENT: PERRL. ETT in place.
Neck: No JVD. Lungs: Decreased breath sounds on the right
with fair aeration of the right upper lobe. Good aeration on
the left. Cardiovascular: Regular rate and rhythm. Normal
S1 and S2. No murmurs, rubs, or gallops. Abdomen: Soft,
nontender, and nondistended; bowel sounds present.
Extremities: No cyanosis, clubbing, or edema. Pneumoboots,
bandage was clean, dry, and intact in his right groin.
Neuro: Intubated, sedated, no withdrawals to pain.
LABORATORY DATA: Labs and studies were significant for an
ABG on low settings of 7.37, 52, and 134.
RADIOGRAPHIC STUDIES: The patient's chest x-ray showed no
pneumothorax, patchy right upper lobe opacity. Right
mediastinum shift and right-sided volume loss and very wide
mediastinum.
HOSPITAL COURSE: The patient spiked a temperature overnight
following the bronchoscopy and Zosyn was started. The
patient was again bronchoscoped on the night of admission for
troubled breathing and was suctioned. Chest x-ray showed
almost whiteout of the right lung, but this was thought to be
expected with the patient's recent intervention. The patient
was sedated deeply in order to prevent further trauma and
suction tube was not passed to prevent also further trauma in
the bronchi. The patient was extubated on [**2129-3-16**] without
problems. [**Name (NI) **] was continued to be treated with Zosyn for two
weeks. He was called out to the floor without problems and
remained comfortable with normal breathing. The patient was
to be observed over the weekend, but it was decided that the
patient could be discharged earlier and follow up with Dr.
[**Last Name (STitle) **] for further intervention and with Dr. [**Last Name (STitle) 952**] for
discussion of possible thoracic surgery.
DISCHARGE DISPOSITION: To home.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS: Fibrosing mediastinitis, status post
left bronchial stent removal.
DISCHARGE MEDICATIONS: Cefuroxime 500 mg 1 p.o. b.i.d. x18
days.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**]
Dictated By:[**Last Name (NamePattern1) 2864**]
MEDQUIST36
D: [**2129-6-1**] 17:29:11
T: [**2129-6-2**] 06:16:12
Job#: [**Job Number 54637**]
|
[
"519.3",
"998.11",
"519.1",
"998.2",
"780.6",
"996.59",
"934.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.91",
"98.15",
"33.22",
"39.98",
"33.99",
"96.05",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3608, 3618
|
3640, 3647
|
1426, 1474
|
3762, 4038
|
3669, 3738
|
2600, 3584
|
1497, 2582
|
165, 981
|
1004, 1269
|
1286, 1409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,773
| 149,695
|
4549
|
Discharge summary
|
report
|
Admission Date: [**2155-6-6**] Discharge Date: [**2155-6-9**]
Date of Birth: [**2083-9-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted with 12 hours of abdominal pain and chills.
Major Surgical or Invasive Procedure:
Laparoscopic Appendectomy
History of Present Illness:
71 year old male admitted with abdominal pain. The pain started
approximately 12 hours ago upon awakening this morning. Pain i
slocalized to epigastrum, achy, constant, never migrating.
Patient with some chills today as well. Sllight decrease in
appetite. Two small bm's today, nonbloody, normal for him.
Past Medical History:
Hypertension
Benighn prostatic Hypertrophy,
gallstones,
sciatica,
cardiomegaly
Social History:
Lives with wife. [**Name (NI) 1403**] at plumbing business. Occasional alcohol,
no tobacco quit 20 years ago.
Family History:
NC
Physical Exam:
Vital signs: 98.7 81, 150/76 Respiratory rate 16. 95% on room
air.
No apparent distress
Comfortable
NCAT
RRR
Resp. clear to auscultation bilaterally
Abd: Non distended, normal active bowel sounds, soft tender RLQ
without rebound or guarding. No scars or hernias.
Rectal: guiac negative. normal tone, no masses
Pertinent Results:
[**2155-6-5**] 04:45PM BLOOD WBC-11.3* RBC-4.99 Hgb-14.4 Hct-42.1
MCV-84 MCH-28.8 MCHC-34.2 RDW-14.0 Plt Ct-244
[**2155-6-9**] 01:59AM BLOOD WBC-7.0 RBC-4.52* Hgb-13.1* Hct-38.0*
MCV-84 MCH-29.0 MCHC-34.5 RDW-13.7 Plt Ct-233
[**2155-6-5**] 04:45PM BLOOD Glucose-152* UreaN-18 Creat-1.1 Na-138
K-4.3 Cl-100 HCO3-28 AnGap-14
[**2155-6-9**] 01:59AM BLOOD Glucose-149* UreaN-23* Creat-1.0 Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
[**2155-6-5**] 04:45PM BLOOD ALT-36 AST-24 CK(CPK)-74 AlkPhos-56
TotBili-0.8
[**2155-6-9**] 01:59AM BLOOD CK(CPK)-21*
[**2155-6-5**] 04:45PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-214
[**2155-6-8**] 04:09AM BLOOD CK-MB-2 cTropnT-<0.01
[**2155-6-8**] 11:49AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-6-9**] 01:59AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-6-6**] 10:10AM BLOOD Calcium-9.6 Phos-2.9 Mg-1.8
[**2155-6-9**] 01:59AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.3
[**2155-6-5**] 04:45PM BLOOD TSH-1.0
[**2155-6-5**] CT Scan
Fluid filled and dilated appendix measuring up to 1.3 cm with
adjacent fat stranding consistent with uncomplicated
appendicitis.
[**2155-6-8**] CXR
IMPRESSION: No acute cardiopulmonary process - stable.
[**2155-6-9**] Echo
The left atrium is normal in 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 aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No diastolic dysfunction, pulmonary hypertension or
significant valvular disease seen.
Compared with the report of the prior study (images unavailable
for review) of [**2152-1-20**], the degree of LVH and aortic
dilatation may be slightly reduced on the current study.
Brief Hospital Course:
Patient admitted on [**2155-6-5**] with abdominal pain. CT scan
confirmed appendicitis. On [**2155-6-6**] patient went to the operating
room for a laparoscopic appendectomy without complications. He
tolerated the procedure well. He was progressing well
postoperatively until [**2155-6-8**] when he was noted to be in a rapid
afib. He was given two additional doses of beta blocker with
resulting hypotension. Patient was transferred to the intensive
care unit. He was monitored and enzymes checked times 3. They
were all negative. Cardiology was consulted. Cardiology
recommends beta blocker, full dose asa, 1/2 dose of valsartan.
Patient is now in normal sinus rhythm. [**Month/Day/Year **] completed,
Showing little change from previous.
Discharge Plans:
1. Follow up with Dr. [**Last Name (STitle) **] in a couple of weeks.
2. Follow up with pcp (Dr. [**Last Name (STitle) **]. White) in one week.
Medications on Admission:
diovan 160mg po daily,
HCTZ 25mg po daily,
terazosin 5mg po daily
metoprolol XL 50mg po daily,
ibuprofen PRN
saw [**Location (un) 6485**] 500mg po bid
prilosec OTC 20mg daily
fish oil
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for PAIN.
Disp:*30 Tablet(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 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day: for
one week.
Disp:*14 Tablet(s)* Refills:*0*
7. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day: for one week.
Disp:*21 Tablet(s)* Refills:*0*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
9. Diovan 160 mg Tablet Sig: [**1-8**] Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
New Onset Afib.
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* 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.
Activity:
No heavy lifting of items [**10-22**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**6-20**] at 1:15 [**Hospital Ward Name 23**] building [**Location (un) 470**].
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2155-10-22**]
11:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2155-10-30**] 1:20
Completed by:[**2155-6-9**]
|
[
"401.9",
"427.31",
"997.1",
"724.3",
"278.00",
"429.3",
"V15.82",
"530.81",
"600.00",
"540.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.01"
] |
icd9pcs
|
[
[
[]
]
] |
5480, 5486
|
3465, 4368
|
371, 399
|
5559, 5568
|
1328, 3442
|
7162, 7546
|
978, 982
|
4603, 5457
|
5507, 5538
|
4394, 4580
|
5592, 6793
|
997, 1309
|
271, 333
|
6805, 7139
|
427, 733
|
755, 835
|
851, 962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,756
| 100,168
|
2948
|
Discharge summary
|
report
|
Admission Date: [**2103-5-19**] Discharge Date: [**2103-5-27**]
Date of Birth: [**2080-7-19**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Back pain for one day
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 14164**] is a 22 year-old African-American woman with known
[**Known lastname 14165**] cell disease, who presents with a 1-day history of
right-sided posterior chest pain.
She notes that she was well until 4-days prior to admission when
she developed URI symptoms, including headache, rhinorrea, and
generalized fatigue. She subsequently developed a cough,
productive of small amounts of dark yellow sputum. Yesterday,
she developed right-sided posterior chest pain, pleuritic in
nature, worse with coughing, deep breathing and lying on the
culprit side. She reports only mild SOB. She felt warm over the
past few days, but did not measure her temperature. She denies
chills. She is unsure whether she has received Pneumovax and
Influenza vaccines.
ROS is otherwise negative for other joint pain. No GI or urinary
complaints. No lightheadedness, no dizziness.
In the ED, vitals initially T 99.4, HR 80, BP 119/58, RR 16,
oxygen saturation 95% on 3L, 88% on room air. A CXR revealed a
RLL infiltrate. She was given Ceftriaxone 1 gm IV X1 and
Azithromycin 500 mg PO QD. She was also given Morphine 1 mg IV
X1, Benadryl 25 mg X1, and Dilaudid for pain control.
Past Medical History:
1. [**Known lastname **] cell disease, with 1 admission per year since [**2100**] for
acute pain crisis.
2. History of gonorrhea
3. Prior pneumonia versus acute chest syndrome in [**2100**]
4. History of pre-eclampsia during her first pregnancy
5. Known multiple RBC allo-antibodies and difficult cross-match
Social History:
She lives with her 2 children aged 4 and 2 years-old. She is an
active smoker, and smokes about 5 cigarettes per day. She quit
for about 3 years, but restarted last year. No EtOH consumption.
She also denies illicit drug use.
Family History:
She lived in a [**Doctor Last Name **] home from the age of 5 onwards. Per OMR
records, both her mother and father have [**Name2 (NI) 14165**] cell trait. Both
her children have [**Name2 (NI) 14165**] cell trait.
Physical Exam:
Physical examination on admission:
VITALS: T 99.4, HR 100, BP 110/55, RR 20, Sat 99% on 3 liters
via NC.
GEN: Sleepy. Scratching all over. Uncomfortable with motion.
HEENT: Anicteric. EOMI. PERRL. Frontal bossing.
LN: No cervical lymphadenopathy.
RESP: Dullness to percussion at right base. Decreased air entry
at right base, with basilar crackles. No bronchial breathing. +
egophony, + whispered pectoriloquy.
CVS: PMI not displaced. Normal S1, physiologic splitting of S2.
No S3, S4. Soft, late systolic murmur at apex, non-radiating.
GI: BS NA. Abdomen soft and non-tender.
EXT: Strong pedal pulses. No pedal edema.
Pertinent Results:
Relevant laboratory data on admission:
CBC:
WBC 11.1, Hb 6.9, Hct 19.9, Platelet 552
NEUTS-54 BANDS-1 LYMPHS-35 MONOS-7 EOS-2 BASOS-1 ATYPS-0 METAS-0
MYELOS-0 NUC RBCS-1
HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-3+ MACROCYT-2+ MICROCYT-1+
POLYCHROM-NORMAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-2+ [**Name2 (NI) **]-2+
Chemistry:
Na 138, K 4.7, Cl 106, HCO3 24, BUN 8, Creat 0.7, Glucose 0.7
Relevant imagind studies:
[**2103-5-19**] CXR: Stable cardiac contours. Interval development of
patchy opacity in right lower lobe, no pleural effusion.
[**2103-5-20**] CXR: Heart size is within normal limits and there is no
evidence for CHF. There is consolidation in the right middle and
right lower lobes with an associated small right pleural
effusion, increased when compared with the prior film of [**5-19**], 05. There is atelectasis at the left lung base as previously
demonstrated. There is probably some associated collapse of the
right lobe.
IMPRESSION: Increase in extent of right middle lobe and right
lower lobe consolidation with small right pleural effusion. Left
basilar atelectasis.
[**2103-5-21**] CXR: The cardiac silhouette is upper limits of normal
in size and there is slight increase in pulmonary vascularity,
consistent with the patient's known [**Year/Month/Day 14165**] cell status. There
are multifocal areas of consolidation involving the right middle
and both lower lobes, which have progressed in the interval.
There are also bilateral probable small pleural effusions.
IMPRESSION: Worsening multifocal consolidation suggesting
multifocal pneumonia. [**Year/Month/Day **] cell lung is in the differential
diagnosis if there are not infectious symptoms present.
[**2103-5-22**] CXR: No significant interval change.
[**2103-5-23**] CXR: Increased mild to moderate left pleural effusion.
Persistent right middle and lower lobe infiltrate with right
pleural effusion, stable.
[**2103-5-24**] CXR: Slight interval improvement in right middle lobe
aeration. Slight improvement in right pleural effusion. Stable
left pleural effusion with left lower lobe retrocardiac
atelectasis.
[**2103-5-26**] CXR: Improving right middle lobe and left lower lobe
opacities. There is a small left-sided pleural effusion
unchanged.
********
[**2103-5-22**] ECHO: The left atrium is mildly elongated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is trivial mitral regurgitatino. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
22 year-old African-American woman with [**Year/Month/Day 14165**] cell disease
admitted with respiratory symptoms and right-sided back pain,
found to have RLL infiltrate + hypoxemia.
1) Pneumonia +/- acute chest syndrome: CXR on admission revealed
a RLL infiltrate suspicious for pneumonia, although acute chest
syndrome can not be ruled out. Examination was also remarkable
for hypoxemia, with saturation in the low 80s. She was
empirically started on Ceftriaxone and Azithromycin for coverage
of Mycoplasma, Chlamydia, Hemophilus and pneumococcus, and
hydrated. She was afebrile on admission, but subsequently
developed a fever in hospital with rising WBC up to 34.6 on
[**5-21**]. She also developed worsening hypoxemia on [**5-21**] with
increasing SOB in the setting of decreasing hematocrit to 15.5,
then 14.3. An ABG revealed pH 7.41/38/70. A repeat CXR was
performed and remarkable for worsening RML/RLL pneumonia. Given
the above as well as inability to transfuse PRBCs [**3-21**] no
available cross-matched blood (multiple allo-antibodies), Ms.
[**Known lastname 14164**] was transferred to the ICU on [**5-20**].
In the ICU, supportive care was provided. She was continued on
Ceftriaxone and Azithromycin. Sputum cultures returned as OP
flora, without predominance of organisms (can not rule out
Chlamydia or Mycoplasma). Blood and urine cultures all returned
negative. Serial CXRs initially revealed worsening picture, with
interval development of a LLL infiltrate consistent with
multilobar process, and bilateral pleural effusions. An echo was
performed that showed normal EF>60%. The effusions were
ultimately felt most likely [**3-21**] fluid overload in the setting of
aggressive IVF administration, and she was diuresed with Lasix
on [**5-23**] and [**5-24**]. She eventually improved and defervesced,
with decreasing oxygen requirements and improved radiographic
picture. Antibiotics were changed to PO Levofloxacin on [**5-24**],
Ceftriaxone D/C'd on [**5-24**] (received 6 days), and Azithromycin
D/C'd on [**5-25**] (received 7 days). She will complete a 14-day
course (total) of Levofloxacin (last dose on [**2103-6-1**]).
Of note, the effusions persist at discharge, stable in size. She
also has persistent leukocytosis with WBC 16.2 at discharge.
Both should improve with time. She will need follow-up imaging
after completion of her antibiotic course to document complete
resolution of infiltrate/effusion, as well as repeat WBC. If the
effusions persist, then a thoracentesis would be indicated to
rule out a parapneumonic effusion. She was given Pneumococcal,
Meningococcal and Hib vaccines prior to discharge. She will
follow-up with her PCP [**Name Initial (PRE) 176**] 1 week of discharge.
2) [**Name Initial (PRE) **] cell disease: Hematocrit on admission was 19.9 (around
baseline), down to 15.3 on [**5-20**] with 2+ [**Month/Year (2) 14165**] cells on
peripheral smear, then a nadir of 14.3 on [**5-21**]. The hematology
service was consulted. Ms. [**Known lastname 14164**] has multiple allo-antibodies
and HRB absent which is rare except in some African-Americans.
The blood bank was unable to provide matched blood. She was
transfused 1 unmatched unit on [**5-22**] after pre-medication with
Prednisone 60 mg PO QD, without response. Further transfusion
was therefore held. Per hematology, folate was increased to 5 mg
PO QD. Her hematocrit slowly trended up to 22 at discharge. Of
note, ferritin was sent to rule out concomitant iron deficiency,
and returned elevated at 791. She had appropriate
reticulocytosis to 22% in the setting of her anemia.
She will follow-up with Dr. [**Last Name (STitle) **] in Hematology within 1 week of
discharge. Treatment with hydroxyurea should be addressed.
3) Pain control: Pain control was achieved with Dilaudid IV prn
and pre-medication with Benadryl. She was switched to PO
OxyContin 10 mg PO BID and oxycodone for breakthrough on [**5-26**],
with fair pain control. Tylenol around the clock and Naproxen
were also added. She was discharged on
OxyContin/Oxycodone/Naproxen/Tylenol + bowel regimen.
4) Bacterial vaginosis: Ms. [**Known lastname 14164**] was diagnosed with bacterial
vaginosis prior to admission, treated with Flagyl. She completed
a 5-day course of Flagyl in hospital, with resolution of her
symptoms ([**5-22**] --> [**5-26**]).
5) Oral lesions: While in hospital, she developed oral lesions
suspicious for oral HSV. She was started on Valtrex 1 gm PO TID
with plan to complete 3 days. She will complete her course as an
out-patient (last doses on [**2103-5-28**]).
Medications on Admission:
Folate 2 mg PO QD
Metronidazole (has been taking only intermittently for bacterial
vaginosis)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
Disp:*150 Tablet(s)* Refills:*1*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Please take while on Oxycontin.
Disp:*60 Capsule(s)* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: Start on [**5-28**], last dose on [**6-1**].
Disp:*5 Tablet(s)* Refills:*0*
4. Valacyclovir HCl 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for HSV for 3 doses: Please take 1 pill
tonight, 1 pill tomorrow morning and 1 pill tomorrow night. .
Disp:*6 Tablet(s)* Refills:*0*
5. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*25 Tablet Sustained Release 12HR(s)* Refills:*0*
6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
[**Month/Year (2) **] cell disease
Anemia
Pneumonia
RBC antibodies
Secondary diagnoses:
Bacterial vaginosis
Probable oral herpes simplex
Discharge Condition:
Patient discharged home in stable condition. Saturation 94-96%
on room air. Hematocrit 22.5.
Discharge Instructions:
Please return to the hospital or call your PCP if you develop
worsening respiratory symptoms, including increasing shortness
of breath, or increasing cough. You should also return if you
develop a fever.
Please continue to take Levofloxacin daily, last dose on [**6-1**].
This is to treat your pneumonia. Start on [**5-28**].
Please note that we have also increased folate to 5 mg daily.
Please take Oxycontin 10 mg twice daily for pain control. You
can also take oxycodone 5 mg as needed every 4 to 6 hours for
breakthrough pain.
Note that we have given you 3 vaccines (Haemophilus influenza,
Pneumococcal, and Meningococcal vaccines)
Followup Instructions:
Please call your PCP (Dr. [**Last Name (STitle) 14166**] [**Telephone/Fax (1) 14167**] and schedule an
appointment to see him within 1 week of discharge. You will need
a repeat CXR in the next 2 weeks.
Please call Dr.[**Name (NI) 220**] office (Hematology) [**Telephone/Fax (1) 9645**], and
schedule an appointment to see him within 1-2 weeks of
discharge.
Completed by:[**2103-5-27**]
|
[
"041.9",
"282.62",
"276.6",
"305.1",
"054.9",
"517.3",
"511.9",
"486",
"616.10",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11609, 11615
|
5837, 10409
|
302, 308
|
11815, 11909
|
2980, 3005
|
12597, 12985
|
2111, 2326
|
10554, 11586
|
11636, 11723
|
10435, 10531
|
11933, 12574
|
2341, 2362
|
11744, 11794
|
241, 264
|
336, 1520
|
3019, 5814
|
1542, 1852
|
1868, 2095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,436
| 195,581
|
45528
|
Discharge summary
|
report
|
Admission Date: [**2190-2-23**] Discharge Date: [**2190-4-8**]
Date of Birth: [**2116-4-12**] Sex: F
Service: SURGERY
Allergies:
Codeine / Demerol / Penicillins / Ranitidine
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Nausea, vomiting, severe abdominal pain.
Major Surgical or Invasive Procedure:
Colonoscopy
Right colectomy
Percutaneous drainage of intra-abdominal abscess
History of Present Illness:
73 yo F with PMH sig for CAD s/p CABG '[**69**], CVA/TIA's, GERD,
hypercholesterolemia, recently hospitalized ([**Date range (1) 97126**]/5) for
RLL PNA, p/w abdominal pain since [**2190-2-22**] 8.00 pm. Her PNA had
been improving. Epigastric pain [**11-8**], which she says is her
anginal equivalent, + nausea, no
F/C/V/SOB/diaphoresis/diarrhea/constipation/BRBPR/LE edema. Took
2 sl NTG and morphine w/o any relief, then called EMS.
In the [**Name (NI) **], pt was hypotensive to the 50s, received 3 lt NS but
SBP still in the 80s. Pt mentating well, refused pressors.
Received GI cocktail for h/o GERD, ?esophageal spasm.
Past Medical History:
1) CAD s/p CABG [**69**]??????, S/P left main, left circumflex, and
SVG-diag stents in [**3-/2187**] with re-look in [**7-1**] showing 10%
stenosis in left main, proximal LAD occlusion, RCA occlusion
with collaterals.
2) Right CFA aneurysm
3) Hypercholesterolemia
4) GERD
5) CVA/TIA??????s
Social History:
1 pack/week tobacco x 50 years, quit in [**2155**]. Lives alone in
[**Location (un) **]. Independent in ADLs. Never married. Has multiple
siblings. On sister who lives in [**Name (NI) 1727**] is her HCP.
Family History:
Mother, father, and brother with CAD.
Physical Exam:
VS Afebrile, BP 83/52, P 88, R 20, O2 sat 98% RA
Gen: talkative, pleasant elderly woman, uncomfortable
HEENT: OP clear, MMM
Neck: supple, no LAD or masses
Card: RRR, nl S1, S2 no R/M/G
Pulm: RLL crackles
Abd: hyperactive BS, soft, ND, diffusely TTP, esp on the R side.
+ rebound. Guaiac +.
Ext: no c/c/e
Skin: No rashes.
Neuro: AOX3, CN II-XII intact
Pertinent Results:
[**2190-2-22**] 10:30PM BLOOD WBC-6.4 RBC-3.87* Hgb-12.4 Hct-35.9*
MCV-93 MCH-32.1* MCHC-34.6 RDW-12.9 Plt Ct-232
[**2190-3-24**] 04:15AM BLOOD Neuts-70 Bands-23* Lymphs-1* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2190-2-22**] 10:30PM BLOOD Glucose-119* UreaN-20 Creat-1.5* Na-136
K-4.3 Cl-98 HCO3-25 AnGap-17
[**2190-4-6**] 06:16AM BLOOD Glucose-92 UreaN-13 Creat-1.8* Na-141
K-4.0 Cl-104 HCO3-33* AnGap-8
[**2190-2-22**] 10:30PM BLOOD ALT-23 AST-22 CK(CPK)-41 AlkPhos-80
Amylase-87 TotBili-0.5
[**2190-2-22**] 10:30PM BLOOD Lipase-49
[**2190-2-22**] 10:30PM BLOOD cTropnT-<0.01
CT ([**2190-2-26**]):
1) Bibasilar infiltrates consistent with pneumonia.
2) Cecal colitis, which is likely due to c diff. given the
patient's recent antibiotic course. Other less likely etiolgies
include cecal diverticulits, ischemia or neoplasm. Follow up CT
scan is recommended to exclude neoplasm in the area.
3) Intra and extra hepatic biliary ductal dilatation with low
attenuations
within the pancreas. To evaluate for IPMT an MR is recommended.
3) Bilateral renal cysts.
4) Questionable wall thickening within the cecum vs. fecal
material and lack of contrast distention.
MRCP ([**2190-2-28**]): 1) Mild intra and extrahepatic biliary ductal
dilatation without definite enhancing mass or calculus related
to the biliary tree. There is associated mild dilatation of the
pancreatic duct. This could be related to ampullary stenosis
which can be seen following chronic pancreatitis.
2) Unusual serpiginous fluid attenuation structure along the
anterior inferior margin of the liver, probably a biliary duct
with a more central stricture. Please see comments above.
3) Possible dominant dorsal pancreatic duct. 1.4 cm cystic
structure within the pancreatic head communicating with the duct
of Wirsung, which most likely represents sequela of chronic
pancreatitis and less likely IPMT.
4) Colitis. Unchanged since the CT scan.
5) Please refer to the MR angiography report of the previous day
for details on the vascular structures.
CT ABDOMEN W/CONTRAST ([**2190-3-6**]):
1. Unchanged appearance of small, bilateral pleural effusions.
2. Stable appearance of previously described cecal colitis
without evidence of free air or obstruction.
3. Stable mild biliary ductal dilatation.
4. Unchanged appearance of pancreatic and renal cysts.
5. Stable appearance of 3.6-cm infrarenal abdominal aortic
aneurysm and aneurysmal dilatation of the right femoral artery.
Bx of Colon [**2190-3-10**]: Chronic active colitis with ulceration and
prominent granulation tissue.
Path from surgery [**2190-3-15**]: Ileum and proximal resection margin:
No diagnostic abnormalities recognized. Appendix: No diagnostic
abnormalities recognized. Colon: a) Cecal chronic active
colitis, with mucosal-submucosal ulcers; focal deep mural
inflammation, abscess formation, and fibrosis (slides S and T);
extensive serosal fibrosis and adhesions. b) Distal colon and
distal resection margin: No diagnostic abnormalities recognized.
c) Sampling of pericolic lymph nodes (23): Reactive changes. d)
No granulomas or fistulas identified. e) No thrombi,
atheroemboli, or primary vasculitis identified.
CT abdomen [**2190-3-24**]: 1) Multiple abscesses within the right
abdomen and pelvis.
2) Findings consistent with a post-ileus.
3) Small bilateral pleural effusions.
4) Stable mild biliary ductal dilatation.
5) Stable pancreatic and renal cysts.
6) Stable infrarenal abdominal aortic aneurysm and aneurysmal
dilatation of the right femoral artery.
7) Pigtail catheter placed in large intra-abdominal fluid
collection
Fistulogram/Sinogram [**2190-3-29**]: No fistula identified between the
abscess cavity within the right lower quadrant and the bowel.
CT Abd [**2190-4-1**]: Overall, the appearances show marked improvement
in the large collection on the right flank. A deep pelvic
collection is seen, unchanged or marginally smaller in size from
previous. An ectatic aorta is seen, with stable infrarenal
aneurysm and stable aneurysm of the right SFA. There is now an
increase in the amount of anasarca and pleural effusions.
Sinogram [**2190-4-7**]: Pig-tail catheter seen positioned within the
abscess cavity in the right lower quadrant, which appears
similar to the abscess cavity seen on recent CT scan from
[**2190-4-1**].
Brief Hospital Course:
73 y/o female with PMH significant for CAD s/p CABG in [**2169**] and
relook cath in [**3-/2187**]; GERD; and hypercholesterolemia admitted
with abdominal pain. Pt was hypotensive following taking several
SL NTG at home for "chest pain" and did not respond initially to
fluid resucitation.
Pt's right lower quadrant pain was associated with rebound and
gaurding since admission. Pt initially declined surgical
intervention, so she was managed expectantly (NPO, IVF,
antibiotics, serial abdominal exams). CT scans on admission and
repeated [**3-6**] indicated cecal colitis of unclear etiology
(infectious v. ischemic); colonoscopy on [**2190-3-10**] confirmed
ischemic colitis, and pt was scheduled for R colectomy on [**3-15**].
The procedure itself was uncomplicated, and is further detailed
in the operative note dated [**3-15**] dictated by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Of note, the pt was ruled out for MI on admission. During her
admission she continued to complain of intermittent L arm
heaviness not associated with CP; serial EKGs were unchanged and
cardiac enzymes were negative. Cardiology was consulted and
recommended transfusing to maintain Hct above 30; pt received
several units of blood and was noted on [**3-26**] to have converted
to [**Doctor Last Name 5239**] antibody positive, indicating that she would be very
likely to have a hemolytic transfusion reaction; thus no further
transfusions were administered. She was advised to have a
postop echo and continue ASA and statin.
Postoperatively the pt's course was complicated by the
following:
1. Ileus: resolved by POD#7
2. Sepsis/Intra-abdominal abscess: MRSA+, treated with Vanco.
Two abscesses located on CT, the more superficial andn larger of
which was addressed with placement of a perc drain, and remains
in place at time of discharge. The smaller, deeper collection
is not amenable to perc drainage, and will be addressed with
linezolid.
3. C. difficile infection: treated with flagyl x16 days,
resolved at time of discharge
4. Wound abscess: Erythema noted at superior aspect of wound on
POD#6. Staples removed and small seroma evacuated. Similar
erythema noted at inferior aspect of wound on POD#9; staples
were removed and another seroma evacuated. Wounds cultured,
revealing MRSA. Wound has been packed open with [**Hospital1 **] dressing
changes, now shows healthy granulation tissue in both areas.
5. Renal failure with Cr rising from baseline of 0.8 to a peak
of 2.0 in the setting of administration of IV contrast. Urine
output fell precipitously when she became septic, and she
developed bilateral pleural effusions and anasarca. Her urine
output increased to a normal level after antibiotics were
instituted, and has remained normal since then; her Cr is
trending downwards, and is 1.5 at the time of discharge.
On [**2190-4-8**], she was deemed stable and suitable for discharge.
She was discharged with pigtail catheter and instructed to have
it flushed [**Hospital1 **]. PICC line and foley were removed on day of
discharge.
Code- DNR/DNI, confirmed with PCP.
Medications on Admission:
Home Meds:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
3. Moexipril HCl 7.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Isosorbide Dinitrate 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*100 ML(s)* Refills:*0*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation four times a day.
Disp:*3 MDIs* Refills:*0*
.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
3. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhaler
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
5. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 30 days.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed. Tablet(s)
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
11. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
once a day.
12. Moexipril HCl 15 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Isosorbide Dinitrate 5 mg Tablet Sig: One (1) Tablet PO
three times a day.
14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed.
15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN.
16. Guaifenesin 100 mg/5 mL Syrup Sig: [**6-8**] ml PO every six (6)
hours as needed for cough.
17. Outpatient Lab Work
CBC to be drawn every week and faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 97127**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
1. Cecal Colitis
2. Intra-abdominal abscess
3. MRSA bacteremia
4. Acute renal failure
5. Dilated biliary ducts, extra and intrahepatic
6. CAD s/p CABG '[**69**] with redo [**2187**]
7. Right CFA aneurysm
8. Hypercholesterolemia
9. GERD
10. h/o CVA/TIAs
Discharge Condition:
Stable, improving
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all your follow up appointments.
3. Seek medical attention for chest pain, shortness of breath,
fever or chills, worsening abdominal pain, diarrhea, bright red
blood in your stools, dark stools, increasing drainage from your
wound, or any other concerning symptoms.
Flush pigtail drain with saline twice a day.
Followup Instructions:
Call Dr.[**Name (NI) **] office for an appointment in 2 weeks:
[**Telephone/Fax (1) 3201**].
Keep the following appointment with your PCP:
[**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] Where: [**Name12 (NameIs) **] Date/Time:[**2190-5-3**] 9:00
Completed by:[**2190-4-8**]
|
[
"568.0",
"557.0",
"998.13",
"459.81",
"584.5",
"567.2",
"276.6",
"413.9",
"V45.81",
"560.1",
"486",
"008.45",
"576.1",
"998.59",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.25",
"54.59",
"99.04",
"99.15",
"38.93",
"45.73",
"47.19"
] |
icd9pcs
|
[
[
[]
]
] |
12282, 12352
|
6387, 9493
|
344, 423
|
12668, 12687
|
2059, 6364
|
13107, 13440
|
1632, 1672
|
10621, 12259
|
12373, 12373
|
9519, 10598
|
12711, 13084
|
1687, 2040
|
264, 306
|
451, 1079
|
12392, 12647
|
1101, 1393
|
1409, 1616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,812
| 190,481
|
48156
|
Discharge summary
|
report
|
Admission Date: [**2127-3-7**] Discharge Date: [**2127-3-12**]
Service: MEDICINE
Allergies:
Mercury,Ammoniated / Shellfish / Cefepime
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
nausea, vomiting, diarrhea, syncope
Major Surgical or Invasive Procedure:
central line and arterial line placement
History of Present Illness:
[**Age over 90 **]-year-old woman with history of Alzheimer's, OA, osteopenia,
prior C. diff infection presented from home with multiple
episodes of nausea, vomiting, loose stools, syncope. According
to her son who lives with her, patient had been doing well with
no complaints, attending her regular daycare program yesterday.
She got home, helped her son [**Name (NI) **] dinner, ate dinner, went to
bed. At around 7 pm, she woke up, went to the bathroom, had
loose stools, vomited, and syncopized onto the bathroom floor
for a very brief period of time. Son helped her move back to
bed. Shortly afterwards he heard her falling on the bedroom
floor. She was unresponsive for about 30 seconds and when she
came back, reporting that she was feeling the need to go to the
bathroom again but felt dizzy and fell. Back to bed. Shortly
later, her son then found her vomiting in bed while lying on her
bed, choking on her vomitus. The son turned her on her side. She
was not very responsive at this time. The son called 911.
.
At baseline patient usually has "runny nose" per son with some
mild, mostly nonproductive coughs. Last night she was noted to
have productive coughs. No subjective or objective fever at
home.
.
In the ED, initial VS: T 98, HR 80, BP 142/70, RR 20, 95%RA. Her
head and neck CT was negative. CXR showed atelectasis vs. LLL
pna. Cardiac enzymes were not elevated, and ECG showed no acute
ST/T changes. Her lipase was elvated at 188, and patient
underwent an abdominal/pelvic CT that was unremarkable. During
the ED car, she became tachy to the 120s, rigoring, spiking to
101.7. Her lactate was 3.4 after 2L fluid. She received
vancomycin 1 gm IV x 1, levofloxacin 750 mg IV x 1. Before being
transferred to the MICU, her vitals were T 101, HR 120, BP
122/76, RR 18, 95-98% 2L.
Past Medical History:
- Alzheimer's dementia - mild
- Right hip fracture s/p ORIF in [**2125-7-10**] status post fall.
- C. difficile, refractory since [**2125-8-10**]
- Depression.
- OA
- s/p wrist fracture
- Osteopenia
- cataract surgery
Social History:
No active tobacco, etoh. Lives near 5children who are very
involved in care. Independent with ADLs, walks with walker, goes
to day care 5x/week.
Family History:
+HTN
no significant illness that are contributory
Physical Exam:
GENERAL: elderly woman lying in bed in NAD
Neuro: oriented to name and place only, not able to recall what
happened at home
HEENT: EOMI, OP moist, no lesion
CARDIAC: JVP not distended, normal S1/S2, [**3-15**] pansystolic murmur
loudest at RUSB with radition to both carotids
LUNG: bibasilar crackles, no wheezing, good aeration bilaterally
ABDOMEN: soft, NT, ND, bowel sounds present
EXT: no c/c/e
On Discharge notable changes:
Patient oriented to person place and year, mild confusion.
mild rash on right antecubital fossa
remainder of exam unchanged
Pertinent Results:
[**2127-3-7**] 02:00AM WBC-10.9# RBC-4.27 HGB-13.3 HCT-39.7 MCV-93
MCH-31.0 MCHC-33.4 RDW-13.4
[**2127-3-7**] 02:00AM NEUTS-88.3* LYMPHS-8.8* MONOS-1.4* EOS-1.4
BASOS-0.1
[**2127-3-7**] 02:00AM PLT COUNT-283
[**2127-3-7**] 02:00AM PT-11.4 PTT-19.7* INR(PT)-0.9
[**2127-3-7**] 02:00AM GLUCOSE-152* UREA N-24* CREAT-1.3* SODIUM-136
POTASSIUM-7.9* CHLORIDE-101 TOTAL CO2-24 ANION GAP-19
[**2127-3-7**] 02:00AM ALT(SGPT)-28 AST(SGOT)-86* CK(CPK)-162 TOT
BILI-0.4
[**2127-3-7**] 02:00AM LIPASE-188*
Head CT: There is no evidence of acute intracranial hemorrhage
or shift of
normally midline structures. The ventricles and sulci are
prominent
consistent with age-related atrophy. There is periventricular
white matter
hypodensity and subcortical white matter hypodensity consistent
with chronic small vessel ischemic changes. The basilar cisterns
are preserved. There is no definite evidence of acute fracture.
The visualized paranasal sinuses demonstrate mild mucosal
thickening in the left maxillary sinus.
C-spine CT: There is no definite evidence of acute fracture. The
vertebral
body heights are preserved. Multilevel degenerative changes are
identified
including severe disc space narrowing and marginal osteophyte
formation. There is grade 1 anterolisthesis of C7 on T1. There
is no prevertebral soft tissue swelling. Calcification posterior
to the spinous process of C7 is identified and may represent
sequelae of prior trauma. The visualized lung apices are clear.
RUQ u/s: There is increased echogenicity of the liver consistent
with fatty infiltration. There is no intrahepatic or
extrahepatic biliary dilatation. The common bile duct measures
3 mm. The gallbladder is normal in appearance. There is no
evidence of cholelithiasis, pericholecystic fluid or gallbladder
wall thickening. The pancreas demonstrates mild ductal
dilatation measuring up to 3 mm. The tail is obscured by
overlying bowel gas.
Abd/pel CT: There is bibasilar atelectasis with patchy opacities
that may
represent aspiration. There is a hiatal hernia with a dilated
upstream
esophagus. There is no pericardial or pleural effusion. A
calcified
granuloma in the left lobe of the liver is identified. The
spleen, adrenal
glands, gallbladder and kidneys are unremarkable. There is
moderate
pancreatic ductal dilatation measuring up to 5 mm in diameter.
No definite
pancreatic mass is identified, although this study is not
tailored for this evaluation. There is no mesenteric or
retroperitoneal lymphadenopathy. Small bowel loops are normal in
caliber and without focal wall thickening. Calcifications of
the descending aorta and its branches are noted. There is no
free fluid or free air.
Incidental note is made of an anterior abdominal wall
fat-containing hernia (3, 54). Extensive atherosclerotic
calcification of the aorta and its branches are noted.
CT OF THE PELVIS: There is extensive diverticulosis without
evidence of acute diverticulitis. The appendix is normal. The
bladder contains a Foley
catheter. The uterus is unremarkable.
BONE WINDOWS: There are extensive degenerative changes
identified. No focal lytic or sclerotic lesion noted. Periosteal
amorphous new bone formation posterior to the right inferior
pubic ramus is noted. However the cortex is intact. Similar
changes to the left side are also identified to a lesser degree.
These are likely post-traumatic in nature.
Brief Hospital Course:
[**Age over 90 **]-year-old woman with history of Alzheimer's, OA, osteopenia,
prior C. diff infection presented from home with multiple
episodes of nausea, vomiting, loose stools, syncope.
# Pneumonia: with septic picture on admission, most likely due
to PNA (?aspiration). Unlikely from abdominal source given no
abdominal exam and unremarkable abdominal imaging studies. Viral
swab negative. Zosyn and vancomycin were started empirically.
(Vancomycin PO was added for c diff prophylaxis given hx of
such. She will need to continue this for 2 weeks after
antibiotics complete.) She was initially hypotensive and
required IVF resuscitation as well as pressors for ~4 hours.
Subsequently she was normotensive. Sputum, blood, and urine cx
were negative. She recieved vanc and zosyn in the ICU which was
changed to levofloxacin and flagyl on the medical floor. She
was discharged on levo/flagyl and PO vanc.
# Acute kidney injury: Creatinine bumped to 1.3 on admission,
improved to baseline after fluid resusucitation.
# Alzheimer's: Donepezil, mirtazapine, and memantine were
continued.
# Gastroenteritis: Patient with improving diarrhea in house.
Likely her aspiration pneumonia related to emesis in the setting
of a gastroenteritis. She was C. diff negative x2. Her
diarrhea improved on the medical floor although was still
present at the time of discharge. However patient was taking in
good POs and not getting dehydrated.
# Dispo: patient was seen by physical therapy and was cleared
for home with 24 hour care which can be provided by family.
Patient will schedule with her PCP.
Medications on Admission:
MEDICATIONS (at home):
calcitonin 200 units/spray 1 spray in alternate nostrils daily
donepezil 10 mg qhs
memantine 10 mg [**Hospital1 **]
mirtazapine 15 mg qday
calcium + D3
MVI
omega 3
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Spray Nasal once a day: Alternate nostrils daily.
3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qhs ().
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Take 4 times a day for next 4 days. When done with
Levofloxacin take 2 times a day for two weeks.
Disp:*44 Capsule(s)* Refills:*0*
11. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
12. Guaifenesin 50 mg/5 mL Liquid Sig: One (1) PO every [**4-15**]
hours as needed for cough for 2 weeks.
Disp:*1 Bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] VNA
Discharge Diagnosis:
Viral Gastroenteritis
Aspiration Pneumonia
Dementia
Secondary:
C. diff
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital because of nausea, vomiting
and diarrhea. We determined that you developed a pneumonia in
the setting of vomiting. You were treated in the intensive care
unit initially and improved and were sent to a medical floor.
On the floor you improved and were able to switch to oral
antibiotics. Because of your history of C. diff infections you
were given oral vancomycin while on other antibiotics. You will
need to take the vancomycin as directed below. You were seen by
physical therapy who felt it was safe for you to go home given
your attentive family. Please be very careful when walking and
always have a family member present.
MEDICATION CHANGES:
Levofloxacin 500mg for 4 more days
Flagyl 500mg three times a day for 4 more days
Vancomycin capsules 125mg four times a day for 4 more days and
twice a day for two weeks.
Followup Instructions:
Please call gerontology office at [**Telephone/Fax (1) 719**] to schedule an
appointment with your PCP.
|
[
"995.92",
"331.0",
"294.10",
"008.8",
"780.2",
"285.9",
"584.9",
"311",
"785.52",
"733.90",
"507.0",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9759, 9814
|
6624, 8225
|
284, 326
|
9930, 9930
|
3216, 3725
|
10965, 11072
|
2574, 2625
|
8463, 9736
|
9835, 9909
|
8251, 8440
|
10080, 10749
|
2640, 3197
|
10769, 10942
|
209, 246
|
354, 2152
|
3734, 6601
|
9945, 10056
|
2174, 2395
|
2411, 2558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,222
| 186,965
|
40866
|
Discharge summary
|
report
|
Admission Date: [**2198-5-31**] Discharge Date: [**2198-6-28**]
Date of Birth: [**2128-11-29**] Sex: F
Service: SURGERY
Allergies:
aspirin
Attending:[**First Name3 (LF) 14255**]
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
[**2198-6-1**] Diagnostic Paracentesis
[**2198-6-21**] EGD: feeding tube placement, duodenal polyp biopsy
[**2198-6-22**] EGD: duodenal stalk identified as source of melena,
endoclip placed
History of Present Illness:
Patient is a 69yo F with history of schistosomiasis cirrhosis
c/b diuretic refractory ascites, portal hypertension and
encephalopathy currently on transplant list, IDDM, HTN and HLD
who was directly admitted from home by Dr. [**Last Name (STitle) **], outpatient
Hepatologist for acute renal failure. Patient was recently
discharged from [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service on [**2198-5-25**] where she was
admitted for abdominal distension. During that admission LVP was
performed and SBP ruled out. Diuretics were not restarted and no
medication changes were made. Patient is s/p 3 liter LVP this
week. Diuretics were discontinued [**2198-5-9**] because acute renal
failure. No documentation of creatinine on admission as labs
drawn at another facility and faxed to Dr.[**Name (NI) 9920**] office.
Patient denies recent fevers, chills, nausea, vomiting,
diarrhea, confusion. Patient does endorse occasional
lightheadedness and occasional back pain.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Schistosomiasis complicated by cirrhosis and ascites requiring
multiple large-volume paracenteses
- Hepatic encephalopathy
- Hypertension
- IDDM
- Dyslipidemia
- Nephrolithiasis
Social History:
Originally from [**Male First Name (un) 1056**], moved to the US in [**2157**]. Currently
living with husband, independent in her ADLs. Denies tobacco,
alcohol or drugs.
Family History:
no FH of liver disease
Physical Exam:
On Admission:
VS: 98.1 154/56 88 18 99%RA
GENERAL: Chronically ill but currently well appearing 69yo F who
appears older than her stated age. She is comfortable,
appropriate and in good humor. Tanned and mildly jaundice with
some sclera icterus
HEENT: Sclera slightly icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly.
Caput over umbilicus.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
[**Location (un) **]. No asterixis
Discharge Exam: Expired
Pertinent Results:
Admission Labs:
[**2198-5-31**] 08:12PM BLOOD WBC-4.7 RBC-2.65* Hgb-8.4* Hct-27.2*
MCV-103* MCH-31.5 MCHC-30.7* RDW-18.0* Plt Ct-92*
[**2198-5-31**] 08:12PM BLOOD PT-21.4* PTT-41.8* INR(PT)-2.0*
[**2198-5-31**] 08:12PM BLOOD Glucose-184* UreaN-28* Creat-2.0* Na-128*
K-5.0 Cl-97 HCO3-22 AnGap-14
[**2198-5-31**] 08:12PM BLOOD ALT-30 AST-69* LD(LDH)-282* AlkPhos-199*
TotBili-6.1*
[**2198-5-31**] 08:12PM BLOOD Albumin-3.7 Calcium-9.8 Phos-2.7 Mg-2.2
Paracentesis Fluid:
[**2198-6-1**] 02:51PM ASCITES WBC-250* RBC-2825* Polys-21* Lymphs-16*
Monos-62* Mesothe-1*
[**2198-6-1**] 02:51PM ASCITES TotPro-1.0 Albumin-LESS THAN
Discharge Labs: Expired
*****************
Reports:
Chest x-ray [**2198-6-13**]
Moderate to severe pulmonary edema. Retrocardiac opacity may
represent atelectasis and/or consolidation.
ECG: NSR, normal axis, no ST changes, nl QRS and PR intervals.
TTE [**2198-6-14**]
The left atrium is mildly dilated. 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 diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-15**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion.
Brief Hospital Course:
Patient is a 69yo F with history of schistosomiasis cirrhosis
c/b diuretic refractory ascites, portal hypertension and
encephalopathy currently on transplant list, IDDM, HTN and HLD
who was directly admitted from home for acute renal failure.
# Acute Renal Failure: Baseline Cr < 1.5. Admitted with
creatinine of 2.0, FeNa on admission 0.28% indicating pre-renal
state. No evidence of infection on admission without fevers,
chills, nausea, vomiting, suprapubic tenderness or dysuria, UA
with epis and does not indicate UTI. Patient received albumin
1g/kg (62.5grams) on HD 1 and morning after creatinine improved
to 1.7. On HD 2 H/H was low so instead of albumin patient was
volume challenged with 1 unit PRBCs and 25grams of albumin (1
unit PRBCs=25 grams albumin). Diagnostic paracentesis ruled out
SBP. Creatinine worsened after initial volume challenge and did
not respond to second round of 1g/kg albumin. After failed
improvement diagnosis of hepatorenal synrome was made and
midodrine/octreotide were started and uptitrated without
improvement in creatinine. Cr steadily continued to rise,
patient became oliguric and was volume overloaded. The renal
team was consulted. Initially, plan was for pt to have HD line
placed in IR and start dialysis. However, given active bleeding
(see below), she was trasferred to SICU and started on CVVH.
# Cirrhosis: Chronic, related to schistosomiasis complicated by
diuretic refractory ascites, chronic renal failure, portal
hypertension, thrombocytopenia, prior SBP and encephalopathy.
MELD 20 on admission with Childs Class C. Without evidence of
encephalopathy, hepatic decompensation or asterixis on
admission. Continued Rifaximin 550mg PO BID and Lactulose TID
for HE prophylaxis. Continued Ciprofloxacin for SBP prophylaxis.
Diagnostic paracentesis was performed and ruled out SBP. No GI
endoscopy in our system but patient being evaluated for
transplant, cannot be on transplant list without endoscopy so
presumably completed somewhere. MELD rose to >30 in setting of
hepatorenal syndrome and patient was listed for ABO incompatible
liver. As HRS progressed, MELD score was at 40 on transfer to
the SICU.
# Pulmonary edema: Pt w/ pulm edema on CXR on [**6-13**] and mildly
symptomatic. Initially, pt subjectively some SOB, but O2 low to
mid 90s on RA. After 2 days, developed O2 requirement.
Overload most likely in the setting of rapidly deteriorating
renal function. Less likely cirrhosis induced cardiomyopathy.
Last TTE [**8-/2197**] with normal EF. Repeat TTE with still normal EF
but new moderate PA systolic HTN. Attempted to diurese with
Lasix 20 iv then 80, put out very small amt of urine,
incontinent. In setting of rapidly progressive HRS, pt became
oliguric and was unable to mobilize fluid. Plan was made for
dialysis as above.
# Hard palate bleed: On [**6-15**] at ~6am, pt developed bleed right
hard palate. This was likely [**2-15**] mild oral trauma in the
setting of coagulopathy--INR 3.6, platelets 75. Initially,
attempted to stop by applying pressure, unsuccessful. Per
discussion with ENT and OMFS, attempted to stop the bleed with
afrin soaked gauze, topical thrombin, silver nitrate,
aminocaproic acid. Also transfused with platelets, FFP, and
RBCs (as hct was 22 down from 25 at last check). Held continuous
pressure for ~3 hours. As soon as pressure was released, active
bleeding was visualized. Tamponaded bleed for ~10 minutes, but
again continued to have uncontrollable bleed and was transferred
to SICU on the transplant surgery service for elective
intubation and packing. The lesion was cauterized and the
bleeding was controlled. She was initially successfully
extubated at transferred to the floor.
# Hyponatremia: Hypervolumic hyponatremia from cirrhosis. Did
not diurese patient given [**Last Name (un) **]. Albumin and PRBCs given for
intravascular volume and patient kept on 1.5L fluid restricted
diet. She remained hyponatremic so fluid restricted further to
1.2L with improvement in Na.
# Acute anemia: Patient with chronic anemia related to cirrhosis
though with acute drop on HD 2. Unclear etiology without GIB
during admission. Unknown if patient has varices without
endoscopy in our system and is not on beta-blocker so presumably
none on prior endoscopy. Possible hct drop was in setting of
volume challenge overnight and dilutional effect though WBC and
platelets unchanged. She was transfused 1 unit PRBCs both for
anemia and volume challenge. Hct remained stable following
transfusion.
# DM: Insulin Dependent, Type II. Hyperglycemic during admissin.
Continued Glargine 12 units qHS and HISS
# HLD: Chronic, stable, continue zetia
TRANSITIONAL ISSUES:
- Continue holding diuretics
- Recommend tracking down endoscopy report, unknown where
completed
ICU Course ([**2198-6-22**] to [**2198-6-28**], date of death)
Ms [**Known lastname 89252**] was transferred to the surgical ICU the morning of
[**2198-6-22**] after developing worsening melena. She had an EGD the day
prior for the purpose of Dobhoff feeding tube placement, and
during that EGD a duodenal polyp was noted and biopsied. Of
note, she had an INR of 2.5 and fibrinogen of 59 prior to the
procedure so snare removal of the polyp was deferred. The
evening following the EGD, she had several episodes of melena
thus prompting transfer to the ICU to facilitate repeat emergent
EGD. The EGD [**6-22**] showed a lot of old blood around the polyp, but
no active bleed from the stalk.
The first few days in the SICU she remained HD stable, but
continued to have melena with an unstable hematocrit. We
transfused RBC, FFP, platelets and cryo to goal Hct of 30 and
correct her coagulopathy. We were unable to completely correct
her, and she began having significant oral bleeding. By [**2198-6-25**],
she was coughing blood, had an increased oxygen requirement. She
remained encephalopathic and was not protecting her airway
sufficiently so she was intubated. After intubation she had a
pressor requirement which remained until time of death. She was
started on broad spectrum antibiotics (vanc/zosyn/mica) and a CT
torso showed severe pneumonia with very little residual aerated
lung volume.
On [**6-26**] she was begun on CVVH for acidosis and had increased
pressor requirement with the addition of vasopressin. We
continued to transfuse RBC/FFP/cryo to maintain blood levels.
On [**6-27**] she had increased pressor requirement and markedly
increased oral bleeding. It was estimated she bleed 600cc
periorally this day. Transfusions continued and she remained on
high dose levo/vaso, though her pressor requirement was slightly
less than the day prior. A family meeting was held. It was
decided she would not want to be on full life support for more
than 5 days. As it had been 3 days to this point, we decided to
make a final decision Friday unless she acutely worsened.
On [**6-28**], the day of her death, she acutely worsened during the
day. She became hypotensive despite increasing her pressor
doses. Melena and oral bleeding increased and she grew
increasingly tachycardic. She was not responding hemodynamically
to significant product transfusion, and her ventilator settings
were increased with more oxygen needed. Another family meeting
was held and we discussed that she was decompensating rapidly
and likely had an unsurvivable condition. The family present was
receptive and understanding. She was transitioned to comfort
care at 7pm, though the endotracheal tube was left in to prevent
aspirating blood which we felt would cause her too much
discomfort. She was started on a morphine drip. Her heart rate
and blood pressure gradually declined and asystole occured at
9:28pm. She was declared at 9:30pm. The family declined an
autopsy.
Medications on Admission:
- Ciprofloxacin 250 mg daily.
- Ezetimibe 10 mg Tablet PO DAILY
- Insulin glargine Twelve (12) units SC QHS
- Humalog 100 unit/mL sliding scale
- Lactulose 10 gram/15 mL 30 ML PO TID
- Pantoprazole 40 mg Tablet PO Q12H
- Rifaximin 550 mg Tablet PO BID
- Calcium 500 + D (D3) Oral
- Omega 3 Fish Oil Oral
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"348.1",
"V45.11",
"272.4",
"518.81",
"041.49",
"286.7",
"578.1",
"276.69",
"789.59",
"599.0",
"427.31",
"507.0",
"572.3",
"572.4",
"287.5",
"276.2",
"585.6",
"584.9",
"572.2",
"V58.67",
"276.1",
"571.5",
"570",
"V49.83",
"250.00",
"V12.09",
"995.94",
"785.59",
"211.2",
"403.91",
"572.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"27.31",
"96.71",
"45.30",
"54.91",
"38.95",
"33.24",
"45.16",
"96.6",
"39.95",
"29.11"
] |
icd9pcs
|
[
[
[]
]
] |
12804, 12813
|
4684, 9343
|
289, 480
|
12864, 12873
|
3090, 3090
|
12925, 12931
|
2155, 2179
|
12772, 12781
|
12834, 12843
|
12444, 12749
|
12897, 12902
|
3730, 4661
|
2194, 2194
|
3062, 3071
|
9364, 12418
|
230, 251
|
508, 1748
|
3106, 3714
|
2208, 3046
|
1770, 1952
|
1968, 2139
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,554
| 163,754
|
38356
|
Discharge summary
|
report
|
Admission Date: [**2173-8-27**] Discharge Date: [**2173-9-6**]
Date of Birth: [**2125-3-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2173-8-28**]
History of Present Illness:
48 M h/o non-traumatic splenic rupture ([**7-22**]) c/b large
peri-splenic hematoma requiring percutaneous drainage ([**8-10**]) and
recurrent left pleural effusion requiring intermittent drainage.
Pt now returns with increasing SOB over the past 24 hours.
Until
today he was feeling well; afebrile, eating well and ambulating.
This AM he felt sluggish and SOB. His VNA noted decreased
breath
sounds on the left and recommended he come to [**Hospital1 18**]. He reports
having a fever today as well.
ROS:
(+) per HPI
(-) Denies pain, chills, fatigue/malaise/lethargy, changes in
appetite, nausea, vomiting, hematemesis, bloating, cramping,
melena, BRBPR, dysphagia; chest pain, cough, edema; urinary
frequency, urgency
Past Medical History:
PMH: atraumatic splenic rupture, HTN, DM
PSH: none
Social History:
SH: Works as director of facilities at a private school.
Married.
Former smoker, 50 pack year history, quit 19 months ago.
Occational EtOH. No other drug use.
Family History:
FH: Mother with hypertension, father with DM, renal failure,
COPD
Physical Exam:
On Admission:
Physical Exam:
98.5 F 108 148/97 24 92% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation on the right, decreased breath
sounds
at the left base, No W/R/R
ABD: obese, soft, nondistended, nontender, no rebound or
guarding, normoactive bowel sounds, no palbable masses
Ext: mild LE edema, LE warm and well perfused
Brief Hospital Course:
Patient evaluated in emergency department by surgical team and
admitted to ACS service. CTA chest done revealed recurrent left
pleural effusion, now loculated, after splenic rupture. He also
had an increased temp and WBC. He was admitted to surgery for
splenectomy and thoracic surgery was consulted for chest tube
placement. On [**8-28**] he underwent left-sided chest tube
placement, exploratory laparotomy, splenectomy, abscess washout.
He tolerated the procedure well and remained intubated
overnight. His vent was weaned and he was extubated on [**8-29**]
without event. He was transferred to the floor.
He had significant pain control issues requiring high dose of
intravenous narcotics. Once his chest tube was removed his pain
seemed to diminish; an abdominal binder was also used which
seemed to contribute significantly to his comfort. He is being
discharged on oral pain regimen and bowel medications.
He was closely followed by Physical therapy and initially
recommended for rehab but given that he progressed rapidly once
his pain was better controlled he was recommended for home with
services.
By the time of discharge he was tolerating a regular diet and
ambulating with a cane.
he will follow up in ACS and Thoracic clinic as an outpatient.
He will also require follow up with his primary providers.
Medications on Admission:
motrin PRN, lisinopril, statin, glyburide, metformin
Discharge Medications:
1. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metformin 500 mg Tablet Sig: [**2-13**] Tablet PO twice a day.
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
1. Splenic rupture, infected, perisplenic hematoma
2. Left-sided pleural effusion
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 a splenectomy (removal of
our spleen) and placment of a chest tube in oreder to drain
fluid from your chest performed in the operating room on [**8-28**].
Resume your home medications as prescribed by your providers.
General Discharge Instructions:
You have had an abdominal operation. This sheet goes over some
questions and concerns you or your family may have. If you have
additional questions, or [**Male First Name (un) **]??????t understand something about your
operation, please call your surgeon.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside. But avoid traveling long distances until you
see your surgeon at your next visit.
[**Male First Name (un) **]??????t lift more than 10 pounds for next 6 weeks. (This is about
the weight of a briefcase or a small bag of groceries.) This
applies to lifting children, but they may sit on your lap.
You should start some light exercise such as walking 3-4 times
daily sor short periods astolerated.
You may shower but will need to stay out of bathtubs or swimming
pools for a time while your incision is healing. Ask your doctor
when you can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or ??????washed out?????? for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All these feelings and reactions are normal and should go away
in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that, it??????s OK.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.
Followup Instructions:
Follow up with [**Hospital 2536**] clinic next week to have your staples
removed. Please call [**Telephone/Fax (1) 600**] to make an appointment.
Follow up with Dr. [**Last Name (STitle) **], [**First Name3 (LF) 1092**] Surgery in [**2-13**] weeks;
call ([**Telephone/Fax (1) 17398**] for an appointment.
Follow up with your primary care providers in the next 1-2 weeks
for ongoing managment of your medical conditions. You will need
to call for an appointment.
Completed by:[**2173-9-6**]
|
[
"E878.8",
"415.11",
"250.00",
"511.89",
"E849.7",
"289.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"88.49",
"54.19",
"34.04",
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
4090, 4165
|
1861, 3188
|
317, 334
|
4291, 4291
|
7265, 7760
|
1357, 1425
|
3292, 4067
|
4186, 4270
|
3214, 3269
|
4472, 4729
|
1469, 1838
|
4761, 7242
|
273, 279
|
362, 1088
|
1454, 1454
|
4306, 4448
|
1110, 1164
|
1180, 1341
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,498
| 125,710
|
48609+48610
|
Discharge summary
|
report+report
|
Admission Date: [**2172-2-18**] Discharge Date: [**2172-2-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Mr. [**Known firstname 6107**] [**Known lastname **] Sr. is an 85-year-old gentleman with a history
of systolic heart failure (EF 30% on [**2172-2-4**]), atrial
fibrillation, aortic stenosis ([**Location (un) 109**] 0.8-1.0 cm2), HTN, Burkitt's
lymphoma, who presents with altered mental status and
dehydration. Patient was recently admitted to the CCU for a-fib
with [**Location (un) 5509**], Klebsiella UTI, and altered mental status. His mental
status improved by discharge. He was treated with a course of
antibiotic and was discharged to rehab on metoprolol 125 mg TID.
.
Per Rehab notes and family he had been having episodes of
shortness of breath and agitation that lasted 2-3 minutes. He
was also found very confused in the morning of [**2172-2-18**], A&Ox2
with periods of AMS, restless with HR 110, RR 36, BP 139/98, T
98.7. His metoprolol was increased to QID. Patient finished
today his treatment for UTI. There is no history of cough,
dysuria, frequency, abdominal pain, diarrhea, skin rash. Patinet
has only been mildy constipated (based on medications at Rehab).
.
In the ER patient had TT 97.8 F, BP 149/115, HR 149, RR 28, SpO2
95% on 3 L NC. Patient was wax and [**Doctor Last Name 688**], confused, but was
able to give part of a story. He was found to be on AFib with
[**Doctor Last Name 5509**]. Patient had a head CT scan that did not show intra-craneal
bleed or acute pathology, CXR with mild right pleural effusion
and basal atelectases. Urine analysis was unremarcable, urine
culture pending. EKG did not show any ST-T wave abnormalities.
CEs neg x 2.
.
.
Past Medical History:
1. Aortic stenosis, valve siz 0.8-1cm2
2. Congestive heart failure, systolic
3. paroxysmal atrial fibrillation
4. hypertension
5. atypical Burkitt's lymphoma diagnosed [**4-9**] and treated with
chemotherapy; lymphoma complicated by a pathologic right
proximal femur fracture treated with right proximal femur
replacement [**2168-7-28**]; following his surgery, he underwent XRT to
both femurs
6. benign prostatic hyperplasia s/p transurethral
photo-vaporization of the prostate gland [**9-10**]
7. glaucoma
8. cataracts
9. moderate degenerative joint disease (osteoarthritis)
10. OSA: uses BiPap at night for sleep
Social History:
He moved back home 3.5 weeks ago after living in an [**Hospital 4382**] facility for years. He lived alone and reports he does
all of his own cooking, cleaning, and shopping, although others
pitch in to help out. However, after last hospitalization he was
still at Rehab. Two of his three sons live in [**State 350**].
Patient used to smoke in his teens and twenties quitting many
years ago. Does not remember date. He has history of ~10
pack-year smoking. He denies tobacco, alcohol, or illicit drug
use.
Family History:
Parents died when he was 12 of unknown cause. He has no data
regarding his father's family. His grandmother died when she was
in her 80s of unknown etiology. Patient denies history of
premature CAD, cancer, DM.
Physical Exam:
On admission-
VITAL SIGNS - Temp 96.9 F, BP 102/62 mmHg, HR 96 BPM, RR 22 X',
O2-sat 99% RA 2 L NC
GENERAL - sick-appearing man, intermittently tachypneic,
oriented x 3 but lethargic
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, 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 - PMI non-displaced, RRR, no MRG, nl S1-S2, no s4 or s3
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, rectal exam normal with good sphincter tone
and guaiac negative
EXTREMITIES - WWP, no c/c/e, 1+ peripheral pulses (radials),
legs with venous stasis changes, dopplerable pulses, but not
palpable, good capilary refil
SKIN - no rashes or lesions, cold, clamy
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox2 (place), CNs II-XII grossly intact, muscle
strength 5/5 throughout, sensation grossly intact throughout,
DTRs 2+ and symmetric, cerebellar exam intact, gait unable to
eval
Pertinent Results:
Admission labs:
[**2172-2-18**] 11:35AM WBC-12.3*# RBC-4.74 HGB-14.5 HCT-43.7 MCV-92
MCH-30.6 MCHC-33.1 RDW-17.8*
[**2172-2-18**] 11:35AM NEUTS-74.8* LYMPHS-13.6* MONOS-10.0 EOS-1.3
BASOS-0.3
[**2172-2-18**] 11:35AM cTropnT-0.01
[**2172-2-18**] 11:35AM CK(CPK)-61
[**2172-2-18**] 11:35AM GLUCOSE-165* UREA N-55* CREAT-2.2*#
SODIUM-143 POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-22 ANION GAP-21*
.
Discharge labs:
[**2172-2-26**] 06:06AM BLOOD WBC-4.5 RBC-4.29* Hgb-13.0* Hct-41.5
MCV-97 MCH-30.3 MCHC-31.3 RDW-21.1* Plt Ct-114*
[**2172-2-26**] 06:06AM BLOOD Plt Ct-114*
[**2172-2-26**] 06:06AM BLOOD Glucose-124* UreaN-37* Creat-1.5* Na-146*
K-4.5 Cl-112* HCO3-25 AnGap-14
[**2172-2-26**] 06:06AM BLOOD ALT-111* AST-77* LD(LDH)-355*
AlkPhos-863* TotBili-2.9*
[**2172-2-24**] 05:21AM BLOOD GGT-1097*
[**2172-2-26**] 06:06AM BLOOD Albumin-3.2* Calcium-8.2* Phos-2.8 Mg-2.5
.
CXR:
A small right pleural effusion with associated relaxation
atelectasis at the right lung base. Minimal left base
atelectasis. Large
globular heart, question possible underlying pericardial
effusion
TTE: [**2172-2-20**]
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-20mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is moderate global left ventricular hypokinesis (LVEF = 35 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
estimated cardiac index is depressed (<2.0L/min/m2). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is moderate to severe aortic valve stenosis
(area 0.8 cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Severe (4+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion appears loculated (mostly posterior to the LV).
.
CT head [**2172-2-18**]
IMPRESSION:
1. No acute intracranial hemorrhage or large territorial
infarct.
2. Unchanged microvascular ischemic disease.
KUB [**2172-2-19**]
FINDINGS: There is no free air. There is a nonspecific bowel gas
pattern,
without evidence of ileus or obstruction. There is an S-shaped
scoliosis in the lumbar spine.
IMPRESSION: No ileus, obstruction or free air.
Right UE ultrasound [**2172-2-25**]
FINDINGS: [**Doctor Last Name **]-scale and color son[**Name (NI) 493**] imaging of the right
internal
jugular, subclavian, axillary, brachial, basilic, and cephalic
veins was
performed. The left subclavian vein was examined for comparison
purposes. The right internal jugular vein demonstrates normal
flow and compressibility. Flow and waveforms in the bilateral
subclavian veins appear symmetric. There is no intraluminal
thrombus identified within the right subclavian vein. The right
axillary, brachial, and basilic veins demonstrate lack of normal
compressibility, with echogenic intramural thrombus surrounding
the indwelling venous catheter. Flow in the right basilic is
absent, while minimal residual flow is seen in the right
axillary vein adjacent to the intramural thrombus.
IMPRESSION: Acute deep venous thrombosis involving the right
axillary,
brachial, and basilic veins. The right subclavian vein appears
uninvolved.
Abdominal RUQ utlrasound [**2-25**]
IMPRESSION:
1. Obscuration of the left liver lobe. Visualized liver
parenchyma appears
normal.
2. Decompressed gallbladder, with no stones, sludge, wall
thickening, or
pericholecystic fluid. Mild gallbladder wall thickening
appreciated on the
prior examination has resolved.
3. No biliary dilatation.
4. Unchanged pleural effusion.
.
Brief Hospital Course:
85 year old male admitted with altered mental status and had
afib with [**Month/Year (2) 5509**]. He was briefly on the cardiology floor before
being transferred to the CCU.
.
# AMS - Altered mental status improved modestly with IV fluids.
Ongoing confusion was thought to be likely from an infectious
process (pna vs. UTI vs. C. diff colitis). Head CT was
unremarkable. No evidence of stroke or seizure. No evidence of
CHF exacerbation on exam, no HTN encephalopathy. No evidence of
hypoxia or hypercarbia. Elevated LFTs likely shock liver during
last admission, which might have contributed to the altered
mental status. Patient intermittently had delirium in CCU, and
his mental status was still impaired, but improving at
discharge. He was intermittently A x O 3, but still confused.
.
# Atrial fibrillation - Patient had baseline afib, with [**Month/Year (2) 5509**] to
the 130s shortly after admission. He received digoxin with some
improvement. He was transferred to the ccu given multiple
medical comorbidities. Heart rate was controlled with PO
metoprolol and diltiazem. The decision had been made previously
by his CPC not to anticoagulate him given a history of multiple
falls and hx of difficultly controlling his INR as an out pt.
However, on [**2-26**] Lovenox was started [**3-9**] UE DVT to continue
during rehab admission. He may need to transitioned to coumadin
instead after discharge as per PCP [**Name Initial (PRE) 10245**]. Pt discharged on
diltiazem XR 120 [**Hospital1 **] and metoprolol tartrate 100 [**Hospital1 **]
.
# Pneumonia: CXR showed RLL consolidation. Given a rising
lactate and multiple medical co-morbidities, he was transferred
to the ccu. Because he was from a nursing home, but without
MDR risk factors, he was initially treated with pip-tazo. Blood
and sputum cultures as well as urinary legionella antigen were
negative. As he was improving clinically, antibiotics were
changed to levofloxacin for a 10 day course that will be
complete on [**2172-2-28**].
.
# Diarrhea/abdominal pain: C diff was considered given recent
antibiotics. He was initially treated with metronidazole. KUB
did not show free air or dilated loops. Stool tests for c diff
toxin were negative x 2. Abdominal pain resolved.
Metronidazole was discontinued.
.
# Systolic heart failure/severe aortic stenosis: Patient had a
history of systolic heart failure, EF 30% on [**2172-2-4**]. He had no
evidence of acute heart failure this admission, with stable BP.
Repeat echo showed slightly improved EF at 35% and worsening of
valve disease (severe mitral and tricuspid regurgitation and
moderate to severe aortic stenosis with valve area .8%).
Euvolemia was maintained. Attending had discussion with family.
Pt is not a canidate for valve replacement. However, if his
mental status imporves in the future, he can be evaluated for a
palliative valvuloplasty. This issue is to be readdressed in as
out patient in [**Hospital 102258**] clinic.
.
# Coronaries: no chest pain, negative CEs. No active issues.
.
# Acute on Chronic Renal failure: Patient had a history of CKD
with baseline creatinine in ~1.5. Creatinine rose to 2.2 with
hyaline casts and FeNA <1% suggesting pre-renal and ATN combined
picture. He was hydrated, and creatinine improved.
.
# Elevated LFTs: AST and ALT were lower than last admission but
AP and tbili higher, likely due to shock liver from hypotension.
He had already had an unrevealing hepatitis and autoimmune
workup during last admission. LFTs trended down except AP
remained elevated, ultrasound of RUQ on [**2-25**] was unrevealing.
Showed improvement of gallbladder thickness from last admission.
LFTs should be rechecked as an outpatient, however, no acute
intervention is indicated.
.
# Elevated INR: INR was initially 2.6, up from 1.3 at discharge
on [**2172-2-11**]. This was likely [**3-9**] liver disease and malnutrition.
There were no signs of active bleeding. INR trended toward
baseline.
.
# Hypertension: Metoprolol was continued with the addition of
diltiazem as above. He was normotensive.
.
# OSA: Patient was on CPAP at night as an outpatient. This was
continued. Pt has [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing intermittently while
asleep, which is likely [**3-9**] heart failure.
.
# Right arm edema/DVT: PICC was placed in the right arm, and it
was subsequently swollen. Ultrasound showed extensive upper
extremity thrombis involving the axillary, brachial, and basilic
veins. Line was removed, new PICC placed in other arm. Pt placed
on Lovenox [**Hospital1 **]. Coumadin not started due to hx of difficult to
control INR, and concurrent liver disease which elevated INR. In
the future, pt's PCP may want to try transitioning to Coumadin.
He will need platelets checked on [**2-29**], (3 days after starting
lovenox).
.
# Code status: The patient was full code based on extensive
discussions with family, HCP- [**Name (NI) 6107**], his son. [**Name (NI) **] did not
have capacity during his admission.
.
He was discharged to a rehab facility. He will have follow up
with his PCP and cardiology.
Medications on Admission:
Milk of magnessia 30 cc PO Daily PRN
Dulcolax 10 mg PR PR constipation
Fleet enema 1 PR PRN Daily
ASA 325 mg PO Daily
Citalopram 20 mg PO Daily
MVI 1 PO Daily
Latanoprost 0.005% Left eye QHS
Calcium carbonate 500 mg PO q8hrs
VHC 90 ml PO TID
VItamin c 500 mg PO Daily
Zinc sulfate 220 mg PO Daily
Metoprolol 125 mg PO TID
Docusate 100 mg PO BID
Senna 1 PO BID PRN
Ipratropium 0.02% 3ml QID PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): hold if HR <60 or if SBP <90
.
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): for 6 months starting on [**2172-2-26**].
8. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 2 days: 10 day course completed on [**2172-2-28**].
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed: hold for loose stool.
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day): Please hold
for SBP < 100 or HR < 60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Pneumonia
Severe aortic stenosis
Acute on chronic renal failure
Atrial fibrillation with rapid ventricular response
Upper extremity deep vein thrombosis, right side
.
Obstructive sleep apnea
Chronic systolic heart failure
Hypertension
Elevated liver function testes secondary to shock liver
Discharge Condition:
Hemodynamically stable, afebrile, confused, requiring BiPAP at
night
Discharge Instructions:
You were admitted to [**Hospital1 18**] due to confusion. You were found to
have a pneumonia and increased heart rate with your atrial
fibrillation. You were given antibiotics for your infection.
Your medications were adjusted to control your heart rate. You
also had dehydration that had worsened your kidney fuctin, this
was treated with IV fluids. You developed a blood clot in your
right arm veins, for which you were started on lovenox to thin
your blood. In the future, the cardiologist will reevaluate you
and see if you need a valvuloplasty to temporarily increase the
size of your aortic valve.
.
Please keep your follow up appointments as detailed below.
.
Take your medications as instructed. Several changed were made
to your medications:
1. started diltiazem extended-release 120mg twice daily
2. decreased metoprolol to 100mg twice daily
3. started enoxaparin 80mg subcutaneous injections twice daily,
you should continue getting these shots while you are in rehab.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
You should have your liver function test (AST, ALT, Alk phos,
total bili) checked one week after discharge from the hospital.
Followup Instructions:
PCP- [**Last Name (NamePattern4) **]. [**First Name (STitle) **], please call [**Telephone/Fax (1) 250**], to schedule a
follow-up appointment once you leave the rehab
.
Cardiology- This appointment is also with Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], need to
discuss possible vavuloplasty
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2172-4-16**] 1:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2172-4-16**]
11:00
Completed by:[**2172-2-28**] Admission Date: [**2172-2-27**] Discharge Date: [**2172-3-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 14062**]
Chief Complaint:
altered breathing pattern
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] was re-admitted on [**2172-2-27**] for an altered breathing
pattern on arrival to rehab after being discharged that same
day. Following is the history of his recent admission
[**Date range (1) 102259**]:
Mr. [**Known lastname **] [**Known firstname 6107**] Sr. is an 85-year-old gentleman with a history
of systolic heart failure (EF 30% on [**2172-2-4**]), atrial
fibrillation, aortic stenosis ([**Location (un) 109**] 0.8-1.0 cm2), HTN, Burkitt's
lymphoma, who presents with altered mental status and
dehydration. Patient was recently admitted to the CCU for a-fib
with [**Location (un) 5509**], Klebsiella UTI, and altered mental status. His mental
status improved by discharge. He was treated with a course of
antibiotic and was discharged to rehab on metoprolol 125 mg TID.
.
Per Rehab notes and family he had been having episodes of
shortness of breath and agitation that lasted 2-3 minutes. He
was also found very confused in the morning of [**2172-2-18**], A&Ox2
with periods of AMS, restless with HR 110, RR 36, BP 139/98, T
98.7. His metoprolol was increased to QID. Patient finished
today his treatment for UTI. There is no history of cough,
dysuria, frequency, abdominal pain, diarrhea, skin rash. Patinet
has only been mildy constipated (based on medications at Rehab).
.
In the ER patient had TT 97.8 F, BP 149/115, HR 149, RR 28, SpO2
95% on 3 L NC. Patient was wax and [**Doctor Last Name 688**], confused, but was
able to give part of a story. He was found to be on AFib with
[**Doctor Last Name 5509**]. Patient had a head CT scan that did not show intra-craneal
bleed or acute pathology, CXR with mild right pleural effusion
and basal atelectases. Urine analysis was unremarcable, urine
culture pending. EKG did not show any ST-T wave abnormalities.
CEs neg x 2.
.
Patient received almost 2 L of NS with urine output of 600 cc
over 22 hours. His mental status is reportedly improving slowly
with the IVF. He received digoxin 0.125 mg x 1 with HR
decreasing from the 130-140s to 110s. Given his multiple medical
problems and [**Name2 (NI) 28645**] lactate (3.1 from 2.2), he was transferred
to the CCU.
.
Patient had very diffcult access and arrived to the floor with
only a small IV in the left thumb. Pt received 500 cc NS bolus
in the ER. The medical team placed an EJ and PICC was placed on
[**2-19**].
Past Medical History:
1. Aortic stenosis, valve siz 0.8-1cm2
2. Congestive heart failure, systolic
3. paroxysmal atrial fibrillation
4. hypertension
5. atypical Burkitt's lymphoma diagnosed [**4-9**] and treated with
chemotherapy; lymphoma complicated by a pathologic right
proximal femur fracture treated with right proximal femur
replacement [**2168-7-28**]; following his surgery, he underwent XRT to
both femurs
6. benign prostatic hyperplasia s/p transurethral
photo-vaporization of the prostate gland [**9-10**]
7. glaucoma
8. cataracts
9. moderate degenerative joint disease (osteoarthritis)
10. OSA: uses BiPap at night for sleep
Social History:
He moved back home 3.5 weeks ago after living in an [**Hospital 4382**] facility for years. He lived alone and reports he does
all of his own cooking, cleaning, and shopping, although others
pitch in to help out. However, after last hospitalization he was
still at Rehab. Two of his three sons live in [**State 350**].
Patient used to smoke in his teens and twenties quitting many
years ago. Does not remember date. He has history of ~10
pack-year smoking. He denies tobacco, alcohol, or illicit drug
use.
Family History:
Parents died when he was 12 of unknown cause. He has no data
regarding his father's family. His grandmother died when she was
in her 80s of unknown etiology. Patient denies history of
premature CAD, cancer, DM.
Physical Exam:
GENERAL - sick-appearing man, intermittently tachypneic,
oriented x 3 but lethargic
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, 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 - PMI non-displaced, RRR, no MRG, nl S1-S2, no s4 or s3
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, rectal exam normal with good sphincter tone
and guaiac negative
EXTREMITIES - WWP, no c/c/e, 1+ peripheral pulses (radials),
legs with venous stasis changes, dopplerable pulses, but not
palpable, good capilary refil
SKIN - no rashes or lesions, cold, clamy
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox2 (place), CNs II-XII grossly intact, muscle
strength 5/5 throughout, sensation grossly intact throughout,
DTRs 2+ and symmetric, cerebellar exam intact, gait unable to
eval
Pertinent Results:
Admission labs:
[**2172-2-26**] 06:06AM WBC-4.5 RBC-4.29* HGB-13.0* HCT-41.5 MCV-97
MCH-30.3 MCHC-31.3 RDW-21.1*
[**2172-2-26**] 06:06AM GLUCOSE-124* UREA N-37* CREAT-1.5*
SODIUM-146* POTASSIUM-4.5 CHLORIDE-112* TOTAL CO2-25 ANION
GAP-14
[**2172-2-26**] 06:06AM ALT(SGPT)-111* AST(SGOT)-77* LD(LDH)-355* ALK
PHOS-863* TOT BILI-2.9*
EKG [**2-27**]:
Atrial fibrillation. Non-specific ST-T wave changes. Compared to
the previous tracing the rate is slower.
Brief Hospital Course:
85 yo man with CHF, AS, afib, multiple recent admissions for
altered mental status, now re-admitted for [**Last Name (un) 6055**]-[**Doctor Last Name **]
breathing.
Please see recent discharge summary for history [**Date range (1) 102259**] for
detailed recent medical history. Patient was re-admitted the
day of discharge for [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing.
Altered breathing pattern: Likely [**Last Name (un) 6055**]-[**Doctor Last Name **] secondary to
congestive heart failure. At his baseline he has periods of
apnea lasting several seconds but resumes breathing
spontaeneously. He generally maintained normal O2 sats,
although sometimes dropping into the upper 80s. BiPap was
continued at night.
Altered mental status: Likely delirium secondary to multiple
recent hospital admissions. Mental status was unchanged from
prior admission and waxing and [**Doctor Last Name 688**]. Generally A&O x 2.
Aortic stenosis: Patient has known AS with valve area ~1.0 cm2.
He and his family are considering valvuloplasty for palliation.
He will follow-up as an outpatient for further consideration.
Atrial fibrillation: Rate control was improved with titration
of calcium channel blocker and beta blocker. Rate is generally
90-100. He will continue anticoagulation with lovenox as long
as he is at rehabilitation. He and his primary care physician
can decide whether anticoagulation is warranted after that.
CHF: He was euvolemic this admission.
Elevated liver enzymes: This was also noted on prior admission.
It is most likely secondary to poor cardiac pump function
causing hepatic congestion.
Medications on Admission:
ASA 325 mg PO Daily
Metoprolol 125 mg PO TID
Citalopram 20 mg PO Daily
MVI 1 PO Daily
Latanoprost 0.005% Left eye QHS
Calcium carbonate 500 mg PO q8hrs
VHC 90 ml PO TID
VItamin c 500 mg PO Daily
Zinc sulfate 220 mg PO Daily
Ipratropium 0.02% 3ml QID PRN
Docusate 100 mg PO BID
Senna 1 PO BID PRN
Milk of magnessia 30 cc PO Daily PRN
Dulcolax 10 mg PR PR constipation
Fleet enema 1 PR PRN Daily
Discharge Medications:
1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
2. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
primary: chronic systolic congestive heart failure, altered
mental status
secondary: aortic stenosis, paroxysmal atrial fibrillation,
hypertension, Burkitt's lymphoma
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you had an unusual
breathing pattern at the rehabilitation facility. This is likely
because of your heart disease.
The antibiotics for your pneumonia finished while in the
hospital. Also, the diltiazem was increased to better control
your heart rate.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
PCP- [**Last Name (NamePattern4) **]. [**First Name (STitle) **], please call [**Telephone/Fax (1) 250**], to schedule a
follow-up appointment once you leave the rehab
.
Cardiology (This appointment is also with Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] to
discuss possible vavuloplasty.): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2172-4-16**] 1:00
[**Year/Month/Day **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2172-4-16**]
11:00
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2172-6-8**] 1:40
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5004**] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 14063**]
Completed by:[**2172-3-3**]
|
[
"428.22",
"327.23",
"276.51",
"486",
"403.90",
"202.80",
"585.9",
"453.8",
"401.9",
"427.31",
"428.0",
"424.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
25980, 26059
|
23052, 23798
|
17828, 17834
|
26270, 26279
|
22565, 22565
|
26742, 27585
|
21398, 21610
|
25141, 25957
|
26080, 26249
|
24722, 25118
|
26303, 26719
|
4782, 8405
|
21625, 22546
|
17763, 17790
|
17862, 20219
|
22582, 23029
|
23814, 24696
|
20241, 20858
|
20874, 21382
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,759
| 151,565
|
2478
|
Discharge summary
|
report
|
Admission Date: [**2110-11-9**] Discharge Date: [**2110-11-13**]
Date of Birth: [**2066-8-30**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Imitrex / Morphine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hanging attempt
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 44yoF with a history of depression, anxiety,
previous suicide attempts, chronic pancreatitis with G tube
placement due to CFTR gene, migraines, pain disorder on chronic
opiates who is transferred to the MICU for further management of
her airway s/p hanging attempt.
.
She was initially admitted to Deac4 from the [**Hospital1 18**] ED on [**2110-10-31**]
due to suicidal ideation in the context of a chronic
pancreatitis flare. She was recently admitted to Deac4 for
similar complaints [**Date range (1) 12703**]. Since then, plans were in place for
opiate detox with plans to transition from methadone to
[**Date range (1) 12695**].
.
Per psychiatry note: Patient today [**2110-11-9**] had requested more
Seroquel but was found sedated by nursing and was told that it
was not possible at this time. Approximately 5-6 minutes later,
patient was found hanging from the top of her bathroom door
using a bed sheet to hang herself. She was elevated above ground
and was unresponsive when initially found. Her J tube was found
on the floor. She was initially poorly responsive, but breathing
and responsive to pain. Pt's initial vitals were HR 110 Bp
144/70 RR 16, spO2 was 100% on RA. FSG 127. She demonstrated
fasciculations of the toungue and jaw, later the extremities. IO
placed by code team after failed PIV though poor draws and pain
elicited upon use. Upon transfer to MICU, patient guarding her
airway and screaming.
.
Upon arrival to the MICU, her inital VS were T95.2 axillary,
P95, BP 147/72, RR18, Sat 100NRB. She was awake and screaming in
response to manipulation of her IO line. She noted abdominal
pain, though felt no difficulty breathing and she was moving
adeqaute air on physical exam. Her I/O was d/c'd due to
malfunction.
.
Of note, she was recently admitted to the medical floor and
again attempted to hang herself from a bedsheet noose due to
inadequate pain control.
.
Review of systems could not be elicited due to lack of patient
cooperation.
Past Medical History:
-Chronic Pancreatitis - Diagnosed in [**2102**]. She is s/p J-tube
placement in [**2103**] for poor nutrition. She is s/p dozens
admissions for abdominal pain.
- Left upper extremity DVT in [**2105**]
- Left axillary and proximal brachial vein thrombus on U/S from
[**2109-11-14**]; and also new found clot in right IJ thought to be old
- Migraine headaches
- Prior cardiomyopathy: EF 30% which improved to 50% in [**2103**]
- Iron deficiency anemia
- H/o GNR bacteremia and multiple line infections, most recent
bacteremia [**5-12**] felt to be [**3-5**] dental caries
- Vitamin D deficiency
.
Past Surgical History:
Jtube replaced [**11-6**]
L PICC in midline position placed [**11-4**]
h/o R PICC
s/p Cholecystectomy
s/p Hysterectomy s/p endometriosis in [**2096**]
s/p Bilateral lumpectomies with benign pathology
s/p Tonsillectomy in [**2079**]'s
.
PAST PSYCHIATRIC HISTORY:
-Diagnoses: Depression, pain disorder with both a general
medical
condition and psychological factors, anxiety. First had
depression around age 18.
-Prior Hospitalizations: Four hospitalizations on [**Hospital1 **] 4
since [**2110-8-1**]. No other psychiatric hospitalizations.
-History of assaultive behaviors: Denies
-History of suicide attempts or self-injurious behavior: Yes,
attempted hanging on medical floor as per HPI. Per Dr.[**Name (NI) 3757**]
note of [**7-9**], reported 1 prior admission and 1 suicide attempt
using family car in garage.
-Prior med trials: At 18, treated with fluoxetine which caused
"anxiety and feeling disorganized." Recently, has had trials of
Wellbutrin and Zoloft.
-Therapist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12704**] [**Telephone/Fax (1) 12685**]
-Psychiatrist: Dr. [**Last Name (STitle) 12696**] ([**Last Name (STitle) **] maintenance prescriber who is
also a psychopharmacologist)
Social History:
- The patient lives in [**Location 12670**] with her female partner
([**Name (NI) **]) and their son [**Name (NI) **], who is [**Name (NI) 12705**] biological
son.
- Partner helps with ADLs.
- Adopted at age 5.
- Recalls early mistreatment prior to adoption. Was adopted
along with older half-sister. One older brother, biological
child of adoptive family. Completed college at [**Hospital 12706**], worked in accounting for a while, then left to do
bartending and working at [**Company 12679**]. Liked job at [**Company 12679**]
but left after son's birth due to her medical issues.
Family History:
Adopted. Aware that biological mother and father are
heterozygous for CFTR gene mutation. [**Name (NI) **] mother had breast
cancer and ovarian in 30s.
Physical Exam:
Physical Exam on arrival to MICU
Vitals: T95.2 axillary, P95, BP 147/72, RR18, Sat 100NRB
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, erythematous
skin around neck, no stridor, hard collar in place.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: tachycardic rate and normal rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: G tube site mildly eerythematous, pain on palpation of
abdomen, normal BS
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
- SUPINE ABDOMEN X-RAY [**2110-11-10**]
Preliminary Report !! WET READ !!
Little contrast injected, reportedly due to high resistance [**Name8 (MD) **]
RN. Faint
opacification of SB loops in LUQ, compatible with jejunal
location.
- CERVICAL SPINE CT WITHOUT INTRAVENOUS CONTRAST [**2110-11-9**]
There is no evidence of fracture, malalignment, or prevertebral
soft tissue swelling. The lateral masses of C1 are symmetric
about the dens. Minimal osteophyte formation is [**Year (4 digits) 12681**]
superior to the anterior arch of C1, and appears similar
compared to prior examination from [**2110-7-23**]. Otherwise,
normal cervical lordosis is preserved. Disc space height is
normal without evidence of significant endplate degenerative
change. The visualized outline of the thecal sac is within
normal limits without critical canal stenosis.
The thyroid gland appears homogeneous without focal nodule. The
imaged lung apices are clear.
IMPRESSION: No acute fracture, malalignment or prevertebral soft
tissue
swelling.
NOTE ADDED AT ATTENDING REVIEW: They thyroid gland demonstrates
an apparent nodule in the left lobe. This was obscured by
artifact on the prior study, but allowing for this, it appears
unchanged.
- CT HEAD WITHOUT CONTRAST [**2110-11-9**]
Evaluation of the skull base is limited due to patient motion.
However, there is no evidence of hemorrhage, mass, mass effect,
or infarction. The ventricles and sulci are normal in morphology
and configuration. [**Doctor Last Name **]-white matter differentiation is grossly
preserved throughout. There is no evidence of fracture. The
visualized paranasal sinuses and mastoid air cells appear well
aerated.
IMPRESSION: No acute intracranial process.
- ABDOMEN, SUPINE AND LEFT LATERAL DECUBITUS - [**2110-11-7**]
Gas pattern is unremarkable. There is no evidence of free air.
Soft tissues are normal.
Brief Hospital Course:
Ms. [**Known lastname 12667**] is a 44yoF with depression, anxiety, pain syndrome,
polysubstance abuse, chronci pancreatitis with J tube who was
transferred from Deac4 where she was hosptialized for SI to
MICU7 for further airway management after an attempted hanging.
1. ATTEMPTED HANGING: Patient with attempted hanging on Deac4
with 3-5 minutes of suspension by the cervical spine. At no
point has she demonstrated signs of airway compromise including
hypoxia/desaturation, stridor, secretion pooling, coughing,
cyanosis. Her examination revealed excellent air movement and
her robust voice was reassuring. She was not intubate. She
remained NPO with serial examinations. CT head and neck were
done and ruled out soft and bony tissue trauma. Her diet was
liberalized when imaging showed no airway edema, and she resumed
all PO meds. She retained a 1:1 sitter while in ICU. Lab was
difficult to obtain given poor access. She was cleared medically
to go to Psychiatry.
2. J-TUBE REMOVAL: patient with abdominal pain related to her
self-D/C of J tube. Per patient and HCP, no desire to continue J
tube, and she could not cooperate with initial replacement
attempt due to pain. J tube was replaced on [**2110-11-10**] with
good positioning but difficulty with flushing given the kink and
despite use of soda to declog it. It was replaced again on
[**2110-11-12**] by surgery, and the J tube study showed that it was
normal. However there was difficulty with flushing tube so
surgery replaced on [**2110-11-13**]. Patient will need a J tube study
in order to confirm placement. In order to order the study, POE
should be accessed. Under the "Radiology" tab, click on "General
XRAY." In that tab, in the "Other Exam:" enter "G" and click on
"G/GJ/GI TUBE CHECK." In addition, the J tube should be flushed
after each feed.
3. POLYSUBSTANCE ABUSE/OPIATE DEPENDENCE: Gave IV methadone then
PO when cleared for oral intake. PRN dilaudid given for
breakthrough pain.
4. CHRONIC PANCREATITIS: Currently without appetite, restarted
pancrelipase when taking po diet
5. ACUTE AGITATION: Patient was acutely agitated around the time
of coding and unit transfer though calmed down thereafter.
Received a dose of haldol 2.5mg IV for anxiety/agitation, but
was later able to take PO meds. Initially had planned to limit
benzos per psych recommendation, though after speaking with
patient's HCP, planned to generally keep patient comfortable in
unit.
6. DEPRESSION: Patient with complex depression on aggressive
psychiatric regimen including buspar, seroquel, amitryptiline,
and clonidine.
7. TRANSAMINITIS: Chronic in nature.
Medications on Admission:
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO/NG Q8H:PRN pain/headache/fever not
to exceed 4g/day of tylenol
Amitriptyline 50 mg PO/NG HS
Acetaminophen-Caff-Butalbital [**2-2**] TAB PO Q12H:PRN headache not
to
exceed 4 g of acetaminophen per day
BusPIRone 20 mg PO TID
CloniDINE 0.1 mg PO BID Start: In am
Ferrous Sulfate 325 mg PO/NG TID
Gabapentin 400 mg PO/NG TID
Ibuprofen 600 mg PO Q6H:PRN pain
Lisinopril 10 mg PO/NG DAILY Start: In am
Lorazepam 1 mg PO/NG Q12H:PRN severe anxiety
Methadone 10 mg PO/NG QID Hold for oversedation
Metoprolol Succinate XL 25 mg PO DAILY
Mirtazapine 30 mg PO/NG HS
Pantoprazole 40 mg PO Q24H Start: In am
Pancrelipase 5000 2 CAP PO QIDWMHS
Promethazine 25 mg PO/NG Q4H:PRN nausea
Promethazine 25 mg IM Q8H:PRN nausea
Quetiapine Fumarate 100 mg PO TID:PRN agitation
Sertraline 50 mg PO/NG [**Hospital1 **]
Tizanidine 8 mg PO/NG HS:PRN pain
Tizanidine 2 mg PO/NG QAM:PRN pain Start: In am
TraMADOL (Ultram) 25 mg PO Q12H:PRN pain
Zolpidem Tartrate 5 mg PO HS:PRN insomnia [**Month (only) 116**] repeat x 1
Allergies:
Imitrex, Morphine, Prochlorperazine, Reglan
Discharge Medications:
1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
5. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. methadone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
10. sertraline 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-2**]
Tablets PO Q4H (every 4 hours) as needed for headache.
14. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**] (Genesis) TCU - [**Hospital Ward Name 517**] (West Contact)
Discharge Diagnosis:
Severe Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you were attempt to hurt yourself. You
were in the ICU for close observation. You were observed and
were found ready to go back to the psychiatry unit.
While you were in the medical unit, we had surgery see you see
in order to replace your J tube. It was replaced and is working
well.
No changes were made to your medications.
Followup Instructions:
Please be sure to keep the following appointments:
Department: PAIN MANAGEMENT CENTER
When: TUESDAY [**2110-12-2**] at 10:20 AM
With: [**Name6 (MD) 12672**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2110-11-13**]
|
[
"346.90",
"577.1",
"338.29",
"296.34",
"E953.0",
"286.9",
"304.00",
"V62.84",
"V48.9",
"569.62",
"280.9",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.32"
] |
icd9pcs
|
[
[
[]
]
] |
12541, 12646
|
7475, 10103
|
312, 318
|
12708, 12708
|
5584, 7452
|
13238, 13757
|
4805, 4959
|
11253, 12518
|
12667, 12687
|
10129, 11230
|
12859, 13215
|
2969, 4187
|
4974, 5565
|
257, 274
|
346, 2327
|
12723, 12835
|
2349, 2946
|
4203, 4789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,982
| 123,358
|
20073
|
Discharge summary
|
report
|
Admission Date: [**2197-10-29**] Discharge Date: [**2197-11-9**]
Date of Birth: [**2139-6-11**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient was admitted on
[**2197-10-29**], who is a 58-year-old gentleman who was an
unrestrained driver car versus tree, who sustained a C2-C3
subluxation as well as a right acetabular fracture with
posterior dislocation and a positive peroneal nerve injury.
Patient was transferred to [**Hospital1 188**] for care.
Patient arrived to [**Hospital1 69**] in
stable, not vented, moving all extremities. C collar was in
place and his right leg was reduced in the Emergency Room
under conscious sedation placed under femoral pin traction.
Patient was taken for four vessel angio which
showed patent vessels, small amount of vasospasm in the left
ICA. The patient was brought to the Trauma SICU for frequent
neuro checks, Solu-Medrol drip, and monitoring while waiting
halo.
PAST MEDICAL HISTORY:
1. Lymphadenopathy.
2. Lymphedema of the right lower lobe.
3. Lung cancer status post chemotherapy and radiation
treatment.
4. Pneumonectomy.
SOCIAL HISTORY: Quit smoking three years ago. Extensive
alcohol, first history of [**1-31**] scotches each night.
PHYSICAL EXAMINATION: The patient was alert and oriented
times three. Right hip pain. Moves extremities, however,
has a right footdrop. Lungs are clear to auscultation. Sats
were 100% on 2 liters. Cardiovascular: Heart rate in the
70s-80s without ectopy. Pneumoboots for DVT prophylaxis.
GI: Abdomen is soft, hypoactive bowel sounds, no nausea,
NPO. ID: The patient was afebrile and received dose of
antibiotics in the Emergency Room.
ASSESSMENT: C2 fracture and right acetabular fracture,
dislocation upon admission.
Orthopedics was consulted regarding spine and regarding his
acetabular fracture. Specialized two days film were got and
patient received [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], which will be on for six weeks'
duration. Halo was placed in the unit without incident.
Patient continued to be stabilized by the Trauma service
while his halo was placed for the cervical spine fracture.
Patient was transferred from the Trauma service as his
injuries were mainly orthopedic related and his acetabular
fracture underwent open reduction internal fixation on [**11-2**].
His C2-C3 subluxation continued to be stabilized with a halo.
Patient was placed on Ancef, Lovenox 40, and his right lower
extremity was touchdown weightbearing with his hip being able
to flex 70 degrees.
During the operative fixation of the acetabular fracture, the
patient went into AFib, however, his enzymes were cycled and
he returned to sinus, and it was decided that patient could
meet discharge criteria to be discharged to rehab facility on
[**11-8**]. This was undertaken along with Social Work, and
patient was discharged to rehab in stable condition.
MAJOR DIAGNOSES:
1. Right acetabular fracture, repaired open reduction
internal fixation. Range of motion 70 degrees of hip flexion
with touchdown weightbearing status.
2. C2-C3 subluxation stabilized with halo. Halo will remain
in place for six weeks' duration.
3. Atrial fibrillation.
4. Rule out myocardial infarction. Myocardial infarction was
ruled out by cardiac enzymes and atrial fibrillation resolved
after perioperative period.
CONDITION ON DISCHARGE: Stable.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 740**]
MEDQUIST36
D: [**2197-11-8**] 09:43
T: [**2197-11-9**] 11:57
JOB#: [**Job Number 54035**]
|
[
"427.31",
"808.0",
"805.02",
"956.3",
"E849.5",
"E816.0",
"E878.1",
"997.1",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.94",
"93.41",
"79.39",
"88.41",
"79.75"
] |
icd9pcs
|
[
[
[]
]
] |
1244, 3351
|
161, 939
|
961, 1104
|
1121, 1221
|
3376, 3638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,586
| 165,567
|
12672
|
Discharge summary
|
report
|
Admission Date: [**2104-9-22**] Discharge Date: [**2104-10-29**]
Date of Birth: [**2047-1-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
Dobhoff tube (for feeding)
Nasogastric Tube placement
PICC (longer IV line) x 2
History of Present Illness:
57 year old woman with known history significant for spinal
stenosis, IBS, and GERD who presents via [**Hospital 1263**] Hospital with 2
days of abdominal pain and vomiting. Initial diagnosis at [**Hospital 1263**]
hospital was pancreatitis with persistent tachycardia. She
reports nausea and dry heaves with upper abd pain since Saturday
night. No fevers, T 95.3 at home. On the day of admission, she
had a syncopal episode at home with LOC while going to the
bathroom, but denies head strike. Lowered to ground by her
husband. EMS was called; initially patient with SBP 50 and HR
130s. At [**Doctor Last Name 1263**], received 3L IVF and no significant improvement
in HRs. CT showed pancreatic edema and ascites on imaging; no
gallstones seen.
The patient was transferred to the medical ICU and later
transitioned to the medical floor.
Denies history of alcohol use aside from 0-1 drink each day
while on vacation over the past week and prior to that 2
drinks/month. No new medicines or supplements. No family hx of
pancreatitis.
Labs at OSH: WBC 16.4, Na 135, K 3.5, Ca 8.2, Cr 2.67, Amylase
1661, Lipase 758. Denies prior history of pancreatitis or
gallbladder conditions.
Past Medical History:
spinal stenosis
exercise induced asthma (no intubations)
hypertension
vaginal dryness
hepatitis A [**2060**]
ear surgery
appendectomy [**2074**]
c-section
tonsillectomy
GERD
IBS s/p recent c-scope, EGD reported per pt as "normal"
normal stress test w/in last 5 yrs for palpations
Social History:
- Tobacco: quit over 30 years ago
- Alcohol: reports less than 2 drinks / month, 0-1 drink /day x
5 days while on vacation
- Illicits: denies
Family History:
Denies pancreatic or hepatic conditions in her family.
Physical Exam:
Admission Exam to ICU:
Vitals: 98.7 126 156/58 19 97 RA
General: Alert, oriented, appears uncomfortable but NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: mild rales at bases B/L, nonlabored breathing
CV: regular rhythm, tachy, no M/R/G
Abdomen: soft, no shake tenderness, mild guarding, diffuse
tenderness to moderate palpation, no rebound tenderness,
GU: foley in place
Ext: warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
CT report from OSH (oral contrast, no IV): no gallstones seen,
but GB distended and likely "sludge" no ductal dilitation,
"severe" pancreatitis, w/ extensive extrahepatic inflammation in
abdominal pelvic mesentary, moderate pancreatic ascites,
thickening of wall of descending colon.
RUQ US [**9-24**]
1. No evidence for gallstones or sludge in the gallbladder.
2. The common bile duct is mildly dilated to 8 mm, a region for
this such as choledocholithiasis is not identified on this scan;
however, cannot be
excluded as the distal portions of the common bile ducts are not
visualized.
Therefore, MRCP is recommended.
3. Moderate amount of ascites and small right pleural effusion.
.
CXR [**9-27**]
FINDINGS: There is improved aeration in the region of the right
mid/upper
lung described previously. There continue to be bilateral
pleural effusions, but these are somewhat smaller compared to
prior. There is volume loss at both bases. An underlying
infectious infiltrate cannot be excluded at the bases.
.
CT abdomen [**9-30**]-IMPRESSION:
1. Worsening acute pancreatitis, with areas of necrosis, as well
as
surrounding edema and fluid. There is no well formed fluid
collection on this study.
2. Reactive changes of the duodenum and left colon.
3. Large bilateral pleural effusions with adjacent atelectasis.
4. Moderate amount of abdominal ascites.
.
[**9-30**] MRI abdomen-
IMPRESSION:
1. Heterogenous signal intensity of the pancreas consistent with
patient's
known pancreatitis. A small region of necrosis at the neck
cannot be excluded.
2. Peripancreatic fluid, some hemorrhagic or proteinaceous
fluid. Likely
early pseudocyst formation, however, no drainable collection
seen.
3. Moderate perihepatic ascites.
4. Bilateral pleural effusions, larger on the right.
The study and the report were reviewed by the staff radiologist.
.
KUB [**10-3**]-IMPRESSION: Dobhoff tube with tip projecting over the
proximal jejunum. Bilateral pleural effusions.
.
CT abdomen [**10-8**]-IMPRESSION:
1. Evolving pancreatic pseudocyst formation.
2. Evidence of SMV thrombosis with accompanying mucosal edema of
the
ascending colon.
3. No evidence of hemorrhagic pancreatitis.
4. No evidence of pancreatic necrosis.
5. Improving right pleural effusion, stable left pleural
effusion
.
Head CT [**10-1**]-IMPRESSION:
No acute intracranial hemorrhage or mass effect. Small amount of
fluid and
mucosal thickening in the left side of sphenoid sinus- correlate
given the
symptoms.
.
Abd CT [**10-15**]
INDICATION: Severe pancreatitis, now with fevers and bacteremia.
Evaluate
for evidence of bleeding or further infection of pseudocyst to
explain
fever/bacteremia.
TECHNIQUE: MDCT images were obtained from the lung bases to the
pelvic outlet
without intravenous contrast. Coronal and sagittal reformats
were obtained.
COMPARISON: CT of the abdomen and pelvis on [**2104-10-13**]
and [**10-7**], [**2104**].
FINDINGS:
CT OF THE ABDOMEN: Bilateral pleural effusions are again noted
and appear
enlarged from prior examination, particularly on the right side.
The
visualized portions of the heart are normal in size and there is
no
pericardial effusion.
The liver has a slightly nodular contour to the right lobe
without caudate
lobe enlargement. There also appears to be a partially
recanalized umbilical
vein that is visualized on prior examination. There are no focal
liver
lesions and the hepatic and portal veins are patent. The
gallbladder is again
noted to be edematous similar to a prior study on [**2104-10-13**].
On this non-contrast CT the pancreas is not high density and not
suggestive of
hemorrhage in the pancreatic parenchyma. A pancreatic pseudocyst
with likely
internal hemorrhage is again noted (2:45). Grossly the
pancreatic pseudocysts
appear similar in size and distribution. However an anterior
pancreatic
pseudocyst that measured 5.8 cm on prior examination appears
smaller on
today's examination, measuring approximately 4.9 cm (2:43). The
exact
delineation of these collections is unclear but they do not
appear to have
worsened. There is no gas noted in any of the pancreatic
pseudocysts to
suggest infection.
The stomach and small bowel appear are unremarkable. An NG tube
is noted
coursing into the fundus of the stomach. The ascending and
transverse colons
are edematous. There is more ascites than on prior study
tracking
perihepatically and into the left paracolic gutter. There is
more third
spacing into the subcutaneous fat throughout the mesentery and
into the
transverse mesocolon. The spleen, adrenal glands and kidneys are
unremarkable. There are no renal stones. There is no
intra-abdominal
lymphadenopathy. There is no free air.
CT OF THE PELVIS: The distal transverse, descending and sigmoid
colon and
rectum are all collapsed, unchanged. An unchanged amount of
pelvic free fluid
is again noted. The uterus and adnexa are unremarkable. A Foley
catheter is
noted in the bladder, which is unremarkable. There is no free
air.
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic
lesions.
IMPRESSION:
1. Worsening bilateral pleural effusions particularly on the
right.
2. No overt worsening of pancreatic pseudocysts. The pancreatic
pseudocyst
in the region of the transverse mesocolon appears slightly
smaller. There is
no gas within the pseudocyst to suggest infection.
3. Increased amount of ascites.
4. Nodular contour to right lobe of the liver with a partially
recanalized
umbilical vein.
5. Ascending and transverse colon mucosal edema, likely
secondary to
pancreatitis.
6. Gallbladder wall edema likely secondary to pancreatitis.
7. No evidence of hemorrhagic pancreatitis.
.
KUB [**10-28**]: Final Report
INDICATION: C-diff colitis, complaining of worsening abdominal
pain and
discomfort, evaluate for megacolon.
COMPARISON: [**2104-10-20**].
FINDINGS: One supine frontal view of the abdomen was obtained.
There is mild
distention of the transverse colon. There is no dilation of
small bowel.
There is no free air. The osseous structures are unremarkable.
There are no
soft tissue calcifications.
IMPRESSION: No radiologic evidence of toxic megacolon.
MICROBIOLOGY-
[**2104-10-12**] URINE URINE CULTURE-PENDING INPATIENT
[**2104-10-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2104-9-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-30**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2104-9-27**] URINE URINE CULTURE-FINAL INPATIENT
[**2104-9-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2104-9-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-26**] STOOL OVA + PARASITES-FINAL INPATIENT
[**2104-9-25**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2104-9-25**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL INPATIENT
[**2104-9-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-25**] URINE URINE CULTURE-FINAL INPATIENT
[**2104-9-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-9-23**] URINE URINE CULTURE-FINAL INPATIENT
[**2104-9-22**] URINE NOT PROCESSED INPATIENT
[**2104-9-22**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2104-9-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2104-9-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL
**FINAL REPORT [**2104-9-25**]**
Blood Culture, Routine (Final [**2104-9-25**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
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----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2104-9-23**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2104-9-23**] AT
0315.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2104-9-23**]): GRAM NEGATIVE
ROD(S).
[**2104-10-12**] 08:32AM BLOOD Hct-24.3*
[**2104-10-12**] 05:13AM BLOOD WBC-14.4* RBC-2.32* Hgb-7.0* Hct-21.0*
MCV-91 MCH-30.3 MCHC-33.5 RDW-15.0 Plt Ct-419
[**2104-10-10**] 06:45AM BLOOD WBC-11.5* RBC-2.70* Hgb-8.2* Hct-24.5*
MCV-91 MCH-30.4 MCHC-33.5 RDW-15.1 Plt Ct-453*
[**2104-10-9**] 05:08AM BLOOD WBC-9.7 RBC-2.65* Hgb-8.1* Hct-23.6*
MCV-89 MCH-30.5 MCHC-34.2 RDW-15.2 Plt Ct-463*
[**2104-10-8**] 06:05AM BLOOD WBC-12.5* RBC-2.90* Hgb-8.9* Hct-26.1*
MCV-90 MCH-30.8 MCHC-34.2 RDW-15.2 Plt Ct-505*
[**2104-10-7**] 08:54PM BLOOD Hct-23.4*
[**2104-10-7**] 01:10PM BLOOD Hct-24.7*
[**2104-10-7**] 05:50AM BLOOD WBC-13.8* RBC-2.93* Hgb-9.0* Hct-26.4*
MCV-90 MCH-30.8 MCHC-34.1 RDW-15.4 Plt Ct-558*
[**2104-10-6**] 05:11AM BLOOD WBC-13.5* RBC-3.36*# Hgb-10.2*#
Hct-30.2*# MCV-90 MCH-30.5 MCHC-33.8 RDW-15.3 Plt Ct-491*
[**2104-10-1**] 10:50AM BLOOD WBC-25.6* RBC-3.01* Hgb-9.3* Hct-27.3*
MCV-91 MCH-30.9 MCHC-34.1 RDW-14.6 Plt Ct-391
[**2104-9-25**] 07:32AM BLOOD WBC-8.7 RBC-3.19* Hgb-10.1* Hct-28.6*
MCV-90 MCH-31.6 MCHC-35.3* RDW-13.9 Plt Ct-115*
[**2104-9-24**] 04:58AM BLOOD WBC-8.4 RBC-3.98* Hgb-12.5 Hct-34.7*
MCV-87 MCH-31.4 MCHC-36.0* RDW-13.2 Plt Ct-145*
[**2104-9-22**] 02:00PM BLOOD WBC-13.2* RBC-6.01* Hgb-18.7* Hct-52.9*
MCV-88 MCH-31.0 MCHC-35.3* RDW-12.9 Plt Ct-210
[**2104-9-29**] 07:55AM BLOOD Neuts-93* Bands-1 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2104-9-23**] 12:32AM BLOOD Neuts-65 Bands-15* Lymphs-10* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2104-10-12**] 05:13AM BLOOD PT-15.1* PTT-84.1* INR(PT)-1.3*
[**2104-10-8**] 06:05AM BLOOD Plt Smr-HIGH Plt Ct-505*
[**2104-9-27**] 05:25AM BLOOD PT-13.7* PTT-22.1 INR(PT)-1.2*
[**2104-9-26**] 04:07AM BLOOD Fibrino-1254*
[**2104-9-25**] 07:44AM BLOOD Fibrino-1258*
[**2104-10-12**] 05:13AM BLOOD Glucose-105* UreaN-13 Creat-0.5 Na-138
K-4.0 Cl-103 HCO3-26 AnGap-13
[**2104-10-7**] 05:50AM BLOOD Glucose-132* UreaN-12 Creat-0.5 Na-137
K-3.9 Cl-102 HCO3-26 AnGap-13
[**2104-9-28**] 04:59AM BLOOD Glucose-136* UreaN-22* Creat-0.8 Na-140
K-3.8 Cl-101 HCO3-30 AnGap-13
[**2104-9-26**] 04:07AM BLOOD Glucose-107* UreaN-24* Creat-0.8 Na-142
K-3.0* Cl-99 HCO3-32 AnGap-14
[**2104-9-24**] 04:58AM BLOOD Glucose-144* UreaN-25* Creat-0.8 Na-141
K-3.6 Cl-106 HCO3-26 AnGap-13
[**2104-9-22**] 02:00PM BLOOD Glucose-137* UreaN-48* Creat-1.8* Na-136
K-3.8 Cl-98 HCO3-25 AnGap-17
[**2104-9-22**] 09:00PM BLOOD Glucose-116* UreaN-42* Creat-1.5* Na-139
K-4.3 Cl-106 HCO3-18* AnGap-19
[**2104-9-23**] 12:32AM BLOOD Glucose-130* UreaN-38* Creat-1.2* Na-136
K-4.0 Cl-108 HCO3-18* AnGap-14
[**2104-10-7**] 05:50AM BLOOD ALT-22 AST-25 AlkPhos-85 TotBili-0.3
[**2104-10-6**] 05:11AM BLOOD ALT-23 AST-27
[**2104-9-28**] 04:59AM BLOOD ALT-20 AST-28 LD(LDH)-416* AlkPhos-115*
Amylase-91 TotBili-0.6
[**2104-9-24**] 04:58AM BLOOD ALT-17 AST-31 AlkPhos-48 Amylase-438*
TotBili-0.6
[**2104-9-22**] 02:00PM BLOOD ALT-24 AST-33 AlkPhos-75 TotBili-0.5
[**2104-10-9**] 05:08AM BLOOD Lipase-45
[**2104-10-8**] 06:05AM BLOOD Lipase-61*
[**2104-10-7**] 05:50AM BLOOD Lipase-58
[**2104-10-6**] 05:11AM BLOOD Lipase-59
[**2104-10-2**] 10:38AM BLOOD Lipase-42
[**2104-9-28**] 04:59AM BLOOD Lipase-67*
[**2104-9-25**] 04:30AM BLOOD Lipase-98*
[**2104-9-24**] 04:58AM BLOOD Lipase-200*
[**2104-9-22**] 02:00PM BLOOD Lipase-1193*
[**2104-10-12**] 05:13AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.9
[**2104-9-25**] 02:35PM BLOOD VitB12-752 Folate-17.2
[**2104-10-3**] 10:35AM BLOOD Triglyc-152*
[**2104-9-22**] 02:00PM BLOOD Triglyc-177*
[**2104-9-25**] 02:35PM BLOOD TSH-1.6
[**2104-10-6**] 05:11AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2104-9-25**] 04:30AM BLOOD IgG-460*
[**2104-9-25**] 03:59AM BLOOD IgG-445*
[**2104-9-25**] 04:30AM BLOOD IgG-460*
[**2104-9-25**] 03:59AM BLOOD IGG SUBCLASSES 1,2,3,4-Test
.
[**2104-10-22**] 05:17AM BLOOD WBC-28.7* RBC-3.02* Hgb-9.1* Hct-26.2*
MCV-87 MCH-30.3 MCHC-35.0 RDW-15.7* Plt Ct-462*
[**2104-10-22**] 05:17AM BLOOD PT-14.5* PTT-23.9 INR(PT)-1.3*
[**2104-10-22**] 05:17AM BLOOD Glucose-93 UreaN-19 Creat-0.4 Na-134
K-4.0 Cl-99 HCO3-24 AnGap-15
[**2104-10-22**] 05:17AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
[**2104-10-17**] 12:55AM STOOL CLOSTRIDIUM DIFFICILE TOXIN, PCR-
positive
Blood Culture ([**2104-10-12**]):
**FINAL REPORT [**2104-10-18**]**
Blood Culture, Routine (Final [**2104-10-18**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
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----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
LATEST LABS
[**2104-10-29**] 05:40AM BLOOD WBC-16.0* RBC-2.83* Hgb-8.4* Hct-25.8*
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.4 Plt Ct-425
[**2104-10-29**] 05:40AM BLOOD Glucose-120* UreaN-11 Creat-0.4 Na-131*
K-3.8 Cl-99 HCO3-25 AnGap-11
[**2104-10-28**] 07:53AM BLOOD AlkPhos-142*
[**2104-10-27**] 06:04AM BLOOD ALT-8 AST-14 AlkPhos-130* TotBili-0.3
[**2104-10-27**] 06:04AM BLOOD Lipase-28
[**2104-10-29**] 05:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.7
[**2104-10-29**] 05:40AM BLOOD Triglyc-78
[**2104-9-25**] 02:35PM BLOOD TSH-1.6
Brief Hospital Course:
Patient is a 57 year old woman with known spinal stenosis, GERD,
and IBS who presented to the medical ICU via an outside
hospital with 2 days of abdominal pain and vomiting w/ found to
have severe acute pancreatitis of unclear etiology.
.
ACUTE ISSUES:
.
# Acute Pancreatitis and C. Diff colitis:
-Pt tranferred to the [**Hospital1 18**] ICU from OSH. Initially presented
with leukocytosis with bandemia, severe pain, and positive blood
culture for gram negative rods, on IV zosyn and aggressively
hydrated. Made NPO with bowel rest and TPN intially. Following
NJ tube placement by IR, started tube feeds (which she did not
tolerate at the time). GI, ID, and surgery were consulted.
.
The etiology of pancreatitis remained unclear. OSH CT scan
showing distended GB and RUQ showed mild CBD dilatation at 8mm
but no stone/sludge. MRCP showed extensive pancreatitis,
ascites, and fluid around the liver but no biliary dilitation.
Pt is social drinker, no FMH of pancreatitis or hyperCA,
hypertriglyceremia. Autoimmune serologies were sent and
unremarkable. No new meds, structural or anatomic abnormalities.
Given recent use of thiazides, this was entertained as a
possible cause of pancreatitis. Thiazides were discontinued.
.
Transferred from ICU on [**9-28**] to floor. Placed on dilaudid PCA.
Had an acute rise in WBC while on Zosyn (attribued to continued
waxing and [**Doctor Last Name 688**] flare). Switched to cefipime and covered
empirically for C. Diff for a few days on Po Vanc and IV Flagyl
which were later discontinued after C. Diff PCR returned
negative. Repeat CT Abdomen showed mild area of necrosis.
GI/Pancreatitis team consulted (Dr. [**First Name (STitle) 908**] - felt there was no
need for invasive intervention.
.
TPN was initiated on [**10-1**] and PICC was placed on [**10-2**]. TF's were
slowly started on [**10-3**]. The patient did not tolerate tube feeds
once they were advanced on [**9-10**] and they were again
stopped. She remained on TPN for nutrition at this time. Tube
feeds were never restarted. Due to continued abdominal pain,
distented abdomen, and woresening anemia, pt underwent a repeat
CT scan on [**10-7**] that showed evolving pancreatic pseudocyst, new
SMV thrombosis with edema of the ascending colon, no evidence of
hemorrhagic pancreatitis or necrosis. [**10-8**] pt's symptoms
improved.Pt was started on clears [**10-10**] and her diet was
successfully advanced to a BRAT diet on [**10-11**]. Dobhoff was
removed on [**10-12**]. She continued to have abd pain and was
evaluated by pancreas team in the ICU. A PICC line was placed
and the plan was to start TPN. On [**10-13**] pt developed rigors,
fever, and was developed a GNR bacteremia. On [**10-14**] her Hct
dropped to 20 and she received 2 units of PRBCs. She triggered
on [**10-15**] with Temp of 102, worsening abdominal discomfort,
increased respiratory distress. She was then transferred to the
[**Hospital Unit Name 153**]. Her CT was repeated and showed no change in the pancreas,
but increse in pleural effusion on the right side. Surgery was
consulted and there were no acute surgical intervention done.
There was concern for C.diff given that pt had diarrhea on the
onset of antibiotics and she started on PO vanco in addition to
IV Flagyl. She then had worsen abd distention and decreased BS
which were concerning for ileus. She did have C.Diff toxin
positive stool at that point. She was placed on PPN given that
her PICC was removed. Her symptoms improved and she was
transferred back to the floor on [**10-17**]. A PICC line was
re-inserted on that date and TPN restarted. GI and ID continued
to follow her.
.
Since transfer back to the floor, her abdominal pain has slowly
improved (though she still has pain), and her nausea has
improved. Her NGT was removed, and PO diet was slowly
reintroduced. On the day of discharge, she ws still receiving
TPN. She was taking in small amounts of oral liquids. GI
continued to see her through the day of discharge. They
recommended advancing diet as tolerated (avoiding high-fat
foods), and follow-up with Dr. [**First Name (STitle) 908**] of Gastroenterology in his
clinic within the next 2 weeks (they are working on an
appointment - the phone number for the GI division is
[**Telephone/Fax (1) 463**]). They recommended no other changes in her
management at this time, and on [**2104-10-29**] agreed with the plan for
discharge to LTAC.
.
# E. coli bacteremia:
-OSH BCx with E. Coli bacteremia. Pt initially on zosyn and
later transitioned to cefepime (when WBC increased to 28K, later
attributed to pancreatitis and not bactermia). Source of E. Coli
unclear. Potential sources were transient cholangitis from
blocked CBD stone, or translocation from a thickened descending
colon found on abdominal CT scan. Patient completed a course of
cefepime on [**10-6**]. 2 week course of therapy. Blood cultures from
[**10-12**] grew E. coli as well and at this time pt. was transferred
back to [**Hospital Unit Name 153**] in setting of fever. She was put on Zosyn for this
for a planned 2 week course ([**10-13**] - [**10-27**]). PICC line was
replaced [**10-17**]. After transfer back to the floor, the pt was
placed on Tigecycline for better coverage of her C. diff in the
setting of a rising WBC (up to 35K) despite PO/PR Vanco and IV
Flagyl. As the E.coli is also sensitive to tigecylcine, the
Zosyn was discontinued. Multiple sets of blood cultures since
[**10-12**] have been negative. Total of 2 week of
course of Tigecycline was completed on [**2104-10-27**].
.
# C Diff colitis: Severe. treated with PO and PR Vancomyinc as
well as IV TIgecycline. PR Vanco discontinued [**10-23**]. She will
complete PO Vancomycin 500 mg q6h on [**2104-11-4**].
.
# Acute Kidney injury:
Creatinine was 1.8 at the time of admission. This was likely
secondary to hypoperfusion. She responded well to fluid
resuscitation and her creatinine rapidly corrected. Cr 0.4 on
the day of discharge
.
# Metabolic Encephalopathy:
Pt presented A0x3 and became confused and agitated on
[**9-4**] with hallucinations of her cousin in the room,
and although orientated largely to time, person and place,
became agitated and pulled out her picc line and ng tube. This
later completely resolved and she quickly returned to her
pleasant baseline with normal cognition.
.
# Respiratory distress:
This evolved initially following aggressive fluid resuscitation.
Pt was started on vancomycin (and zosyn) to cover for HCAP, but
these were discontinued after one day given her rapid clinical
improvement following diuresis with furosemide. There was also
significant bilateral pleural effusion from likely pancreatic
effusion. Pt was later weaned to room air and then developed
respiratory distress on [**10-15**] and was transferred to the [**Hospital Unit Name 153**].
TTE showed low normal LVEF, 1+ MR, borderline elevated PASP.
Hypoxia was felt to be due to volume overload and she was
diuresed with furosemide 20mg IV with good effect. It resolved.
.
# Hypertension:
held home bp medications initially due to concerns for
SIRS/spesis. However, her vitals stabilised and she
subsequently became hypertensive with SBP in the 200s. Her
hypertension was controlled initially with labetalol, and then
with PO metoprolol. When made NPO the pt was transitioned to IV
Metoprolol around the clock. When able to take PO, IV was
discontinued and pt was started on diltiazem 30mg QID
(equivalent to her home dose of 120mg daily). When unable to
take PO again, she was started on metoprolol IV QID. She was
transitioned back to Metoprolol PO on [**2104-10-24**] (no diltiazem),
with doses titrated based on BP and HR.
.
# Question of SMV thrombosis.
GI requested hematology involvement. This is considered to be a
provoked event and 3-6 months of anticoagulation would be
recommended. Pt was started on IV heparin without an initial
bolus. This was stopped on the day of the transfer back to the
ICU, as repeat abdominal imaging was obtained, and upon further
review by Radiology and GI, it was determined that the patient
most likely did NOT have an SMV thrombosis, and that the
occlusion in the SMV was due to extrinsic compression, most
likely due to significant underlying inflammation and edema from
her pancreatitis. Anticoagulation was stopped.
.
# Spinal stenosis: At home, was controlled with ibuprofen 2 tabs
[**Hospital1 **]
- Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain. Narcotics were
limited due to her severe ileus. She did not complain of severe
back pain, but as she begins rehabilitation this may flare up
again.
.
# Exercise induced asthma: At home was on singulair 10mg daily.
In the hospital she received:
- Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath
- Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
.
# GERD: At home was on ranitidine 300mg daily.
- Continued on Pantoprazole 40 mg IV Q12H until she started
taking PO, then transitioned to oral form\
.
# Elevated Alk Phos: unclear cause and significance, perhaps
medication-related. AlkPhos 142 on [**10-28**].
.
# Hyponatremia: likely related to fluid shifts and limited
nutrition. Na 131 on the day of discharge.
.
#Weakness
-Due to prolonged hospitalization and severe illness. No focal
findings. Needs inpatient physical therepy and rehabiliation
before returning home.
Medications on Admission:
diltiazem 120mg daily
hctz 12.5mg daily
singulair 10mg daily
ranitidine 300mg daily
flovent 110 mcg 2 puffs daily
fluticasone prop 50 mcg 2 puffs per nostril daily as needed
pro air 90 mcg as needed
vagifem vag tab 25 mcg 1-2x weekly
loratadine calcium w/ vitamin D 2 tabs 2x daily
probiotic MV1 daily
ibuprofen 2 tabs [**Hospital1 **]
dulcolax daily
fibercom 2 daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every 4-6 hours.
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily) as needed for congestion.
3. ipratropium bromide 0.02 % Solution Sig: One (1) PUFF
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for shortness of breath.
6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
11. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
12. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours): THROUGH [**2104-11-4**].
13. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for pain, anxiety, nausea.
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
17. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
eight (8) hours as needed for nausea.
18. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5 mg Injection Q3H
(every 3 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis
- Acute pancreatitis
- Ecoli bacteremia
- Hypertension
- Severe C. diff infection
Minor
spinal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: independent
Discharge Instructions:
You were admitted on [**9-22**] to the medical intensive care unit for
significant pancreatitis and inflammation. You also were found
to have bacteremia (bacteria in the blood) which was likely
related to your pancreatitis. Multiple images here revealed
that the pancreas was significantly inflamed. You were treated
with antibiotics for the bacteremia and also for possible
pancreatic necrosis. The cause of the pancreatitis remains
unclear and may have been due to a passed stone. Due to the
pancreatitis, you were not able to eat. You had a nasal feeding
tube placed, but were not able tolerate tube feedings. You were
then transferred back to the ICU with new infections, bacteria
(E.Coli) in your blood stream and bacteria (C.Diff) in your
colon. Due to inability to tolerate PO intake, you had PICC
line placed and you were started on IV nutrition (TPN). You
have completed a course of antibiotics for the E coli
bloodstream infection. You will need to complete a course of
antibiotics for the C diff colon infection (continue oral
vancomycin through [**2104-11-4**]).
Followup Instructions:
It is recommended that you see Dr. [**First Name (STitle) 908**] of Gastroenterology in
his clinic within the next two weeks. They are working on an
appointment. If you do not hear from them, you can call [**Hospital1 18**]
Gastroenterology at [**Telephone/Fax (1) 463**].
After discharge from the LTAC, please make an appointment with
your primary care doctor to be seen within 7 days.
|
[
"401.9",
"780.79",
"577.2",
"008.45",
"285.9",
"238.71",
"530.81",
"348.31",
"276.1",
"724.00",
"518.82",
"276.8",
"577.0",
"564.1",
"790.5",
"790.7",
"041.49",
"493.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"96.6",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
29161, 29233
|
17393, 26762
|
319, 401
|
29399, 29399
|
2661, 17370
|
30643, 31034
|
2090, 2146
|
27181, 29138
|
29254, 29378
|
26788, 27158
|
29536, 30620
|
2161, 2642
|
267, 281
|
429, 1610
|
29414, 29512
|
1632, 1914
|
1930, 2074
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,348
| 121,950
|
24423
|
Discharge summary
|
report
|
Admission Date: [**2187-5-28**] Discharge Date: [**2187-6-10**]
Date of Birth: [**2110-8-3**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 11041**] is a 76-year-old
woman transferred to cardiac surgery at [**Hospital1 190**] for evaluation for CABG. The patient was
admitted to the [**Hospital3 45967**] on [**5-22**] with a complaint
of left-sided chest pain with no associated nausea or
vomiting. However, she did complain of mild dyspnea on
exertion and fatigue. This had been going on for several
weeks.
The patient had a previous exercise tolerance test which was
negative. The patient had a CPK of 91 with a troponin of
0.05. EKG with a right bundle branch block, left anterior
fascicular block, and ST-T wave changes. The Cardiac cath
done at [**Hospital3 35813**] Center on the day of transfer
revealed normal LV function with a 60% left main, a 70% LAD,
a 60% first diagonal, a 60% ramus, and a 100% proximal RCA
with good collateralization.
PAST MEDICAL HISTORY: Significant for hypertension, type 2
diabetes mellitus, Zollinger-[**Doctor Last Name 9480**] syndrome, status post
partial gastric pancreatectomy and on chronic suppression,
hypercholesterolemia, peripheral vascular disease, CAD, a
stroke 40 years prior, and left CEA.
MEDICATIONS AT HOME: Include Zocor 40 daily, Nexium 120
daily, Cartia XT 180 daily, lisinopril 10 daily, Plavix 75
daily, Atacand 16 daily, and Actos 15 daily.
MEDICATIONS ON TRANSFER: She was transferred with a heparin
drip at 800 units per hour, Colace 100 mg b.i.d., Isordil 60
mg daily, prednisone 60 mg daily, and Ambien p.r.n.
ALLERGIES: The patient states an allergy to ASPIRIN,
PENICILLIN, SULFA, and IV CONTRAST.
SOCIAL HISTORY: She lives with her sister-in-law. Smoked 2
packs per day until 13 years ago; at which time she quit. She
denies alcohol use.
FAMILY HISTORY: Significant for 5 or 6 family members who
have heart disease.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed a
temperature of 97.8, heart rate of 65, blood pressure of
140/70, respiratory rate of 18, and O2 saturation of 96% on
room air. Height of 5 feet 1.5 inches. Weight of 170 pounds.
In general, in no acute distress. HEENT revealed anicteric
and noninjected. No JVD. No lymphadenopathy. A right-sided
bruit. No bruit on the left. Cardiovascular revealed a
regular rate and rhythm with a 3/6 systolic ejection murmur.
The lungs were clear to auscultation bilaterally. The abdomen
was soft, nontender, and nondistended with a well-healed
scar. The extremities were warm and well perfused with no
clubbing, cyanosis, or edema. Neurologically, a nonfocal
exam. The pulses were 2+ throughout.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**]. She was scheduled for a carotid
ultrasound as well as an abdominal CAT scan. On the day
following admission, the carotid ultrasound showed a right
with 70% to 90% stenosis and the left with less than 40%
stenosis. The abdominal CAT scan was scheduled to rule out
abdominal masses and revealed no metastatic disease. The
patient was status post splenectomy and distal
pancreatectomy.
On [**6-1**], the patient was brought to the operating room for
coronary artery bypass grafting. Please see the OR report for
full details. In summary, the patient had a CABG x 3 with a
LIMA to the LAD, a saphenous vein graft to OM, and a
saphenous vein graft to the PDA. Her bypass time was 60
minutes with a cross-clamp time of 51 minutes. She tolerated
the operation well and was transferred from the operating
room to the cardiothoracic intensive care unit. At the time
of transfer, the patient was A paced at 80 beats per minute
with a mean arterial pressure of 84 and a PAD of 18. She had
propofol at 20 mcg/kg/min and a Neo-Synephrine infusion at 5
mcg/kg/min.
The patient did well in the immediate postoperative period.
Her anesthesia was reversed. However, she was slow to wake
and remained too weak to successfully extubate on the day of
surgery. She was, however, successfully extubated on
postoperative day 1. She remained hemodynamically stable
during this period. However, she did require a Neo-Synephrine
infusion to maintain an adequate blood pressure.
On postoperative day 2, the patient continued to do well.
However, hemodynamically she continued to require a Neo-
Synephrine infusion to maintain an adequate blood pressure.
Her chest tubes were removed, and she stayed in the intensive
care unit due to her requirement for Neo-Synephrine drip.
Over the next several days several attempts were made to wean
the patient from her Neo-Synephrine drip. Each time the
patient would become hypotensive, and her infusion would be
restarted.
Ultimately, on postoperative day 5, the patient was able to
be successfully weaned from her Neo-Synephrine infusion and
at that time she was transferred to the floor for continuing
postoperative care and cardiac rehabilitation. Over the next
several days the patient had an uneventful postoperative
course. Her activity level was increased with the assistance
of the nursing staff as well as physical therapy staff. It
was felt on postoperative day 7 that she would be ready to
discharge within the next 24 to 48 hours.
At that time, the patient's physical exam was as follows. A
temperature of 98.6, heart rate of 66 (sinus rhythm), blood
pressure of 106/55, respiratory rate of 20, and O2 saturation
of 92% on room air. In general, in no acute distress.
Neurologically, alert and oriented x 3. Moved all extremities
and followed commands. A nonfocal exam. Pulmonary revealed
diminished in the bases (left greater than right). Cardiac
revealed a regular rate and rhythm, S1 and S2, with no
murmurs. The sternum was stable. Incision with staples
without erythema or drainage. The abdomen was soft,
nontender, and nondistended with normal active bowel sounds.
The extremities were warm and well perfused with no edema.
Left leg incision from endoscopic vein harvesting with Steri-
Strips was open to air, clean, and dry.
Lab data revealed a sodium of 135, potassium of 5.3, chloride
of 98, CO2 of 30, BUN of 15, creatinine of 1.1, glucose of
129, and hematocrit of 33.
DISCHARGE DISPOSITION: The patient is to be discharged home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE FOLLOWUP: She is to follow up with her
cardiologist in [**State 792**]in 3 to 4 weeks and to follow up
with Dr. [**Last Name (STitle) **] in 4 weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post coronary artery
bypass grafting x 3 (with a left internal mammary artery
to the left anterior descending, a saphenous vein graft to
the obtuse marginal, and saphenous vein graft to the
posterior descending artery).
2. Hypertension.
3. Diabetes mellitus type 2.
4. Zollinger-[**Doctor Last Name 9480**] syndrome.
5. Hypercholesterolemia.
6. Status post left carotid endarterectomy.
7. Status post splenectomy and partial pancreatectomy.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 12.5 mg b.i.d.
2. Lasix 20 mg daily (x 2 weeks).
3. Colace 100 mg b.i.d. (while taking pain medication).
4. Plavix 75 mg daily
5. Lipitor 10 mg daily.
6. Actos 15 mg daily.
7. Tylenol No. 3 1 to 2 tablets every 4 to 6 hours as needed
(for pain).
8. Nexium (resume preoperative schedule).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2187-6-8**] 16:39:52
T: [**2187-6-8**] 18:07:14
Job#: [**Job Number 61824**]
|
[
"443.9",
"413.9",
"272.0",
"401.9",
"414.01",
"251.5",
"433.10",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.15",
"36.12",
"39.61",
"99.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6190, 6229
|
1882, 1966
|
6446, 6936
|
6962, 7538
|
2706, 6166
|
1316, 1456
|
6284, 6425
|
164, 1000
|
1981, 2688
|
1482, 1722
|
1023, 1294
|
1739, 1865
|
6254, 6263
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,257
| 155,111
|
45700
|
Discharge summary
|
report
|
Admission Date: [**2161-1-4**] Discharge Date: [**2161-1-8**]
Date of Birth: [**2079-5-20**] Sex: M
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Decreased urine output
Major Surgical or Invasive Procedure:
Placement of a central venous catheter
History of Present Illness:
81M with h/o dementia, aortic stenosis, chronic renal
insufficiency, CVA, hypothyroidism, fungating SCC c/o increased
swelling of legs and scrotum.
.
The patient has CRI. his Cr has wavered between 1.7 and 2.3 for
> 5 years. additionally, he often has K > 5.1, with several
non-hemolyzed K 5.1-5.6 since [**55**]/[**2159**]. The patient has been seen
at [**Hospital1 18**] frequently, largely for falls. Of note, during one of
these admissions, a fungating mass ultimately determined to be
SCC was discovered on his shoulder that was later excised in the
OR in [**10-26**].
Per [**Hospital3 2558**] records, patient's Lasix 20 mg PO daily was
d/c'd 6 days ago. d/w nurse, notes show it was d/c'd due to
concern re: worsening renal failure. CH drew labs and found Cr
2.4 and K of 6.4 at 2pm.
.
In the ED, presenting VS: 97.7 65 175/101 16 98%. Initial EKG
had peaked T waves and PR 226 (baseline 286). Patient was found
to have hyperkalemia (K of 6.8). Could not get peripheral
access, so ED placed R IJ triple lumen. He received 10 u of
insulin, kayexalate, calcium gluc 2g. He has phymosis and
scrotal swelling. Urology was involved. They attempted to place
a foley with plans for a suprapubic catheter if failure. A
repeat EKG showed less peaking of T's. He received colace, metop
25 and neurontin. Transfer VS: 96.3, 60, 172/79, 14, 100% on RA.
I went to the ED to evaluate patient and found that he was
tachycardic to 120, hypertensive to 180/100 and his R IJ site
was very bloody. Additionally, he had a foley placed under
(necessarily) unsterile circumstances that put out 215 cc. His
Right IJ had been stitched for bleeding previously; his dressing
was replaced and a very slow trickle was noticed from the line
site. His atrial tachycardia would break spontaneously and
relapse. His blood gluc was 41 on a blood draw before transfer.
he received 1 amp of d50
Past Medical History:
-Dementia
-6x5 fungating SCC removed from shoulder in [**10-26**]
-Seizure [**2156**]
-Aortic Stenosis
-Hyponatremia: admitted for Na of 121 in [**7-24**]
-Hypothyroidism
-Hypertension
-Hx old left pontine lacunar infarct, no residual weakness
-Alcohol abuse
-Dementia
-Chronic Renal insufficiency
-Anemia of Chronic Disease
-Gout
-Depression
-Actinic Keratoses
Social History:
Lives with wife at [**Hospital3 2558**]. The patient is a retired
police officer/firefighter. He has a distant tobacco history and
a chart diagnosis of past alcohol abuse.
Family History:
Non-contributory in this 79 year old man
Physical Exam:
Triage VS: 97.7 65 175/101 16 98%
Transfer VS: 96.3, 60, 172/79, 14, 100% on RA
General: An elderly male laying supine, eyes closed,
occasionally saying "please please no" and "I'm a good man". He
is oriented to self, [**Hospital1 18**] and sunday.
HEENT:Pupils not visualized patient uncooperative, MMM,
oropharynx clear, edentulous
Neck: R IJ in place with bloody gauze.
Lungs: Clear to auscultation bilaterally in anterior fields, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, grade II/VI SEM best heard over
LUSB no gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: 3+ pitting edema to the Groin bilaterally; Warm, well
perfused, 2+ pulses BL, no cyanosis.
Skin: right hand with ecchymosis
GU: grossly edematous, swollen penis with foley
Neuro: arousable intermittently, localizes to pain, holds eyes
tightly close and does not allow us to open them, moving all
extremities
Pertinent Results:
Admission Labs:
[**2161-1-4**] 07:00PM BLOOD Glucose-86 UreaN-49* Creat-2.5* Na-128*
K-7.4* Cl-100 HCO3-15* AnGap-20
[**2161-1-4**] 08:00PM BLOOD Glucose-86 UreaN-50* Creat-2.6* Na-130*
K-6.8* Cl-100 HCO3-18* AnGap-19
[**2161-1-5**] 03:31AM BLOOD Glucose-112* UreaN-48* Creat-2.4* Na-133
K-5.1 Cl-101 HCO3-19* AnGap-18
[**2161-1-5**] 03:31AM BLOOD Calcium-8.4 Phos-5.9*# Mg-1.9
[**2161-1-4**] 08:00PM BLOOD WBC-4.1 RBC-3.17* Hgb-9.8* Hct-30.7*
MCV-97 MCH-31.0 MCHC-31.9 RDW-15.5 Plt Ct-169
[**2161-1-5**] 03:31AM BLOOD WBC-4.0 RBC-2.82* Hgb-8.9* Hct-26.8*
MCV-95 MCH-31.6 MCHC-33.4 RDW-15.5 Plt Ct-137*
.
Discharge Labs:
[**2161-1-7**] 06:36AM BLOOD WBC-3.9* RBC-3.11* Hgb-9.8* Hct-29.8*
MCV-96 MCH-31.4 MCHC-32.8 RDW-15.5 Plt Ct-157
[**2161-1-7**] 06:36AM BLOOD Glucose-106* UreaN-49* Creat-2.2* Na-136
K-4.3 Cl-103 HCO3-22 AnGap-15
.
Urine Studies:
[**2161-1-5**] 12:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2161-1-5**] 12:50AM URINE Blood-NEG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2161-1-5**] 12:50AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2161-1-5**] 12:50AM URINE Hours-RANDOM Creat-53 Na-79 K-50 Cl-70
.
Micro Data
[**2161-1-5**] Urine Culture negative
.
CXR [**2161-1-4**]: IMPRESSION: Appropriate position of right IJ
central venous catheter. Stable cardiomegaly.
Brief Hospital Course:
81M with h/o dementia, aortic stenosis, chronic renal
insufficiency, CVA, hypothyroidism, fungating SCC admitted with
increased swelling of legs and scrotum and hyperkalemia
following the recent discontinuation of lasix. Hospital course
by problem list:
.
# Hyperkalemia: High baseline (5.2) with acute elevation and
possible cardiotoxicity with mildly peaked T waves on ECG. The
cause was likely due to the acute kidney injury, recent
discontinuation of lasix, and lisinopril. In the [**Name (NI) **] pt received
10 u of insulin, kayexalate, calcium gluc 2g. Serial potassium
levels confirmed that hyperkalemia was resolving. The pt's
lisinopril was discontinued this admission and should not be
restarted. Potassium level on discharge was 4.3.
.
# Acute kidney injury: At 2.6 on admission, pt was not much
above his baseline cr (~ 2-2.3). Pt had good urine output with
foley placement and 1L NS resuscitation in ED and urine
electrolytes were unrevealing. UA and culture were negative.
He did receive 1 dose of Cipro due to unsterile foley insertion.
Lisinopril was held and the nephrology service was consulted.
Nephrology recommended restarting his home Lasix. He was given
one dose of Lasix 20mg IV x 1 on [**2161-1-5**] and then restarted on
Lasix 20mg PO daily. His creatinine improved to 2.2 on
discharge.
.
# Lower extremity edema and phimosis: Likely related to stopping
pt's lasix. Lasix was restarted on day 2 of admission. Urology
saw the patient and placed foley in ED. The foley was removed
on [**2161-1-6**] and he was able to void. Urology was called and did
not recommend further management for his phimosis. This is
likely chronic from peripheral edema.
.
# Hypertension: Patient with aortic stenosis and htn at
baseline. His Lisinopril was stopped due to hyperkalemia. His
metoprolol was increased to 50mg PO BID. He was started on
Amlodipine 5mg PO daily. His blood pressure should be checked
daily and his Amlodipine can be increased as needed. Nitrates
and hydralazine should be avoided due to his aortic stenosis.
.
# Tachycardia: Patient noted to have tachycardia to 130 in the
ED. On rhythm tracing, he appears to have a shorter PR. DDx is
Sinus tach versus atrial tach. This rhythm resolved in ED, and
on subsequent ECGs he was bradycardic. This atrial tachycaria
may have been related to his hyperkalemia.
.
# Seizure disorder: His Gabapentin dose was decreased to 300mg
PO qHS for his seizure disorder. After discussion with his son,
his seizures were all in the setting of alcohol withdrawal. His
Gabapentin should remain at 300mg PO qHS due to his creatinine
clearance < 30.
.
# Dyslipidemia / CAD: Continued on Simvastatin and aspirin.
.
# Hypothyroidism: Continued on Levothyroxine
.
# Dementia: The patient has end-stage dementia, ? due to
excessive alcohol use in the past. He was given Trazodone
during this admission. Atypical anti-psychotics were not given
due to a history of prolonged QTC on ECGs during prior
admissions. His QTC was 440 this admission. He had frequent
episodes of shouting, yelling out and agitation. He was
reoriented, his foley was removed and tele discontinued. He was
calm prior to discharge and off restraints.
.
Code: DNR/DNI, confirmed by HCP, son [**Name (NI) **] [**Name (NI) 4318**]
--[**Telephone/Fax (1) 97393**] (Pager) or [**Telephone/Fax (1) 97399**]
Medications on Admission:
1. Simvastatin 10 mg q6pm
2. Metoprolol Tartrate 25 mg [**Hospital1 **]
3. Docusate Sodium 100 mg [**Hospital1 **]
4. Folic Acid 1 mg qd
5. Furosemide 20 mg qd (dc'd on [**12-29**])
6. Levothyroxine 100 mcg qd
7. Aspirin 81 mg Tablet qd
8. Omeprazole 20 mg Capsule qd
9. Thiamine HCl 100 mg qd
10. Lisinopril 5 mg qd
11. Gabapentin 600 mg Capsule qHS
12. Alendronate 70 mg qMon
13. Senna 8.6 mg [**Hospital1 **] prn
14. Sodium Bicarbonate 650 mg TID
15. Natural Balance 0.4 % Drops qd
16. Robafen 100 mg/5 mL Liquid qdprn cough
17. Trazodone 12.5 mg TID:PRN agitation
18. Fleet Enema 19-7 gram/118 mL Enema qd:prn constipation
19. Ketorolac 0.4 % TID
(20. Seroquel 37.5 mg q7pm ) might not be taking
21. Tylenol 325 mg q4hrs:prn
22. Artificial Tears Drops
23. Melatonin 3 mg Tablet qhs
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for itchy eyes.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed for agitation.
12. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal rash.
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Hyperkalemia
2. Acute on Chronic Renal Failure
3. Hypertension
Secondary Diagnoses:
4. Hypothyroidism
5. Dementia
6. Seizure Disorder
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 with high potassium levels and
worsening of your kidney function. You were monitored overnight
in the ICU. You were initially treated with fluids, then lasix.
You were treated with medications for your high potassium.
Your labs improved and you were discharged.
The following medication changes were made this admission:
STOP Lisinopril 5mg by mouth daily
START Amlodipine 5mg by mouth daily
INCREASE Metoprolol to 50mg by mouth twice a day
START Artificial Tears Ointment as needed for dry eyes
DECREASE Gabapentin to 300mg daily for your seizure disorder
No other changes were made to your medications.
Followup Instructions:
Please see your primary care doctor at your nursing home.
Completed by:[**2161-1-8**]
|
[
"403.90",
"605",
"272.4",
"V12.54",
"274.9",
"311",
"244.9",
"276.2",
"427.89",
"V49.86",
"585.4",
"608.86",
"285.21",
"424.1",
"584.9",
"V10.83",
"294.8",
"276.7",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10974, 11044
|
5229, 5470
|
291, 331
|
11245, 11245
|
3832, 3832
|
12088, 12176
|
2821, 2864
|
9415, 10951
|
11065, 11065
|
8604, 9392
|
11420, 12065
|
4454, 5206
|
2879, 3813
|
11172, 11224
|
229, 253
|
359, 2228
|
3848, 4437
|
5484, 8578
|
11084, 11151
|
11260, 11396
|
2251, 2615
|
2631, 2805
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,056
| 187,861
|
2297+2298
|
Discharge summary
|
report+report
|
Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-8**]
Date of Birth: [**2071-2-22**] Sex: F
Service: MEDICINE/ICU
This covers hospital course through [**2148-5-6**].
HISTORY OF PRESENT ILLNESS: This is a 77 year old female
with past medical history that includes recent C2 fracture
and resultant quadriparetic state, multiple infectious
complications over the last one half year that have included
Methicillin resistant Staphylococcus aureus pneumonia and
Methicillin resistant Staphylococcus aureus endocarditis as
well as a sacral decubitus ulcer complicated by
osteomyelitis, who presents from [**Hospital3 7**] with
respiratory failure following an aspiration of tube feeds.
The patient was apparently doing well at the [**Hospital3 5090**] until the morning of admission when she was turned
for a dressing change and was noted to become agonal, thick
fluid was later noted to be suctioned from her lungs. The
patient was noted to desaturate and had a SAO2 of 68% and a
blood pressure of 80/palpable and a heart rate of 100 at
[**Hospital1 **]. She was given 100% nonrebreather where her SAO2 was
noted to increase to 98% and arterial blood gas was drawn at
[**Hospital1 **] and was noted to be 7.3/47/96. The patient was
transferred to the [**Hospital1 69**] for
further evaluation and treatment.
On Emergency Department admission to the [**Hospital1 346**], the patient was found to be
hypotensive and in further respiratory distress. Out of
concern for her hypertension, the patient was initiated on
sepsis protocol and was intubated for respiratory failure in
the Emergency Department. A left subclavian line was placed
and the patient received three liters of fluid in the
Emergency Department. The patient was restarted on empiric
antibiotics given her known history of Methicillin resistant
Staphylococcus aureus and colonization with Acinetobacter.
In the Emergency Department, the patient was also noted to
become unresponsive and fingerstick glucose was 28. The
patient was also noted to have a temperature of 101.8 and a
lactate of 2.2. She was started on Levophed and admitted to
the Medical Intensive Care Unit for further evaluation.
PAST MEDICAL HISTORY:
1. Status post fall in [**10-4**], in which she suffered a C2
type II odontoid fracture and subdural hematoma. She is
status post evacuation of hematoma/craniotomy which was done
at [**Hospital6 1129**]. Status post fall, she is
quadriparetic. Her hospital course at [**Hospital6 1130**] was a complicated three month course that included
several infectious complications, Methicillin resistant
Staphylococcus aureus endocarditis, thrush, pneumonia, for
which she received eight weeks of Vancomycin and had last
positive blood culture on [**2148-1-11**], while at [**Hospital6 2121**], as well as several other infectious
complications. The patient was transferred to [**Hospital3 6373**] on [**2147-12-31**], however, was readmitted to
[**Hospital6 1129**] on [**2148-2-2**], with worsening
renal failure in the setting of hypotension following a large
gastrointestinal bleed. The patient has since become
hemodialysis dependent. She, however, received a
percutaneous endoscopic gastrostomy and tracheostomy at
[**Hospital6 1129**] and the tracheostomy is now
decannulated.
2. The patient also has a history of VRE urinary tract
infection.
3. Stage IV sacral decubitus ulcer involving the sacrum and
coccyx that is complicated by osteomyelitis for which she has
received an extended course of antibiotics that included
Imipenem and later Meropenem, Linezolid and Amikacin.
4. The patient also had a recent Methicillin resistant
Staphylococcus aureus PICC line infection. The PICC line was
removed shortly prior to this current admission.
5. As noted, the patient had a gastrointestinal bleed in
[**2148-1-1**], at [**Hospital1 **]. We do not have records that
indicate the location of this gastrointestinal bleed although
the patient has apparently had no further bleed since that
time.
6. Hypertension.
7. Diabetes mellitus type 2.
8. Hypothyroidism.
9. Asthma.
10. Hyperlipidemia.
11. Anemia.
12. Hypercalcemia which is thought to be secondary to a
secondary hyperparathyroidism and the patient has recently
been started on Zemplar (that is, Paricalcitol) which she
receives with hemodialysis.
13. The patient also developed Clostridium difficile colitis
recently and was treated with p.o. Flagyl.
14. The patient has malnutrition and received tube feeds.
15. The patient also has neurologic impairment and thought to
have a waxing and [**Doctor Last Name 688**] encephalopathy for which she is
given Lactulose.
16. The patient also suffered a radial artery pseudoaneurysm
and is status post repair.
17. Depression.
ALLERGIES: Iodine and iodine containing dyes, Mevacor,
Lipitor, Hydrochlorothiazide and Unasyn.
MEDICATIONS ON TRANSFER FROM [**Hospital1 **]:
1. Hydralazine 25 mg three times a day.
2. Epogen 4000 Monday, Wednesday and Friday.
3. Labetalol 300 mg three times a day.
4. Sertraline 25 mg once daily.
5. Norvasc 5 mg once daily.
6. Levoxyl 112 mcg once daily.
7. Heparin subcutaneously.
8. Keppra 500 mg twice a day.
9. NPH insulin 10 units twice a day.
10. Albuterol and Atrovent nebulizers q2hours p.r.n.
11. Albuterol and Atrovent nebulizers q4hours standing.
12. Bisacodyl 10 mg p.r.n.
13. Lactulose 20.
14. Fluconazole 100 mg twice a day. (apparently started after
workup for fever did not reveal source at [**Hospital1 **]).
SOCIAL HISTORY: The patient is recently widowed, denies any
alcohol or tobacco use. She lives at [**Hospital3 7**]
currently and was very active prior to her fall in [**2147-10-2**].
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission, temperature was 98.4,
pulse 70, blood pressure 101/33. The patient was intubated
and had a SAO2 of 100% on assist control ventilation with
tidal volume of 400, PEEP of 5, respiratory rate 18. On
physical examination, the patient was intubated and sedated
and unresponsive. Right pupil was pin point and left was 3.0
millimeters and reactive. The patient was noted to have an
absence of cervical lymphadenopathy, had brisk carotid
upstrokes, had well healed site of former tracheostomy. Her
heart had a regular rate and rhythm with no murmurs, rubs or
gallops. Chest was rhonchorous anterolaterally. The abdomen
was soft with gastrostomy tube in place, nontender,
nondistended, positive bowel sounds. Extremities were warm,
no cyanosis and no edema. The patient has a sacral decubitus
ulcer which is Stage IV and which has a purulent discharge.
The patient is sedated and was not moving extremities
spontaneously. She did respond to pain.
LABORATORY DATA: On admission, white blood cell count was
11.7, hematocrit 32.0, platelet count 370,000. Sodium 132,
potassium 5.9, chloride 97, bicarbonate 23, blood urea
nitrogen 72, creatinine 4.0, glucose 89, ALT 13, AST 18,
amylase 51, lipase 18, alkaline phosphatase 434. Troponin T
0.8 with CK of 20. Calcium 11.4, magnesium 2.3, phosphorus
1.9. Urinalysis (urine withdrawn by straight catheter, the
patient is anuric) shows greater than 50 red cells, greater
than 50 white cells. Arterial blood gas reveals 7.24/59/55
that improved with intubation to 7.28/48/323.
Electrocardiogram shows normal sinus rhythm with left axis
deviation, no significant changes from prior
electrocardiogram of [**10-4**].
Chest film shows multilobar infiltrates involving the right
upper lobe, right middle lobe and left upper lobe with a left
subclavian central venous line that is properly positioned
and endocardial tube that is also properly positioned. CT of
the head does not show any mass or hemorrhage.
Sputum reveals greater than 25 polymorphonuclear cells with
less than 10 epithelial cells and 1 positive gram positive
cocci in pairs.
HOSPITAL COURSE:
1. Aspiration/respiratory failure - The patient as noted was
intubated on arrival to the Emergency Department for hypoxic
respiratory failure in the setting of tube feed aspiration.
The patient was maintained on a ventilator from admission in
the Emergency Department through the [**2148-5-4**], when she was
successfully extubated. The patient was given meter dose
inhalers as well as empiric antibiotics for aspiration
pneumonia that included Linezolid and Meropenem given the
patient's known colonization with Methicillin resistant
Staphylococcus aureus and Acinetobacter. Given the patient's
recent history of Clostridium difficile colitis on
antibiotics, the patient was also maintained on p.o. Flagyl.
Sputum culture revealed coagulase positive Staphylococcus
aureus that was pansensitive. The patient's infiltrates were
noted to improve somewhat over the course of hospitalization
on chest film. The possibility of replacement of the
patient's tracheostomy was discussed with the patient's
family given her risk for further aspiration. However, the
[**Hospital 228**] health care proxy (her son) decided that he did not
want to pursue a tracheostomy for protection against further
aspiration as he felt that this would not merit the decrement
and quality of life for her and felt that the problem was
caused by a malpositioned percutaneous endoscopic gastrostomy
tube (see below).
2. Sepsis - The patient was admitted with hypotension and
fever. She was noted to have greater than 100,000
Acinetobacter in fluid withdrawn from her bladder on
admission (the patient is anuric). It is felt that the
patient was likely not uroseptic from this source as all
blood cultures were negative during the hospitalization.
However, the patient's PICC line was removed on Emergency
Department admission and the catheter tip on [**2148-4-29**], did
reveal greater than 15 colonies of Methicillin resistant
Staphylococcus aureus. In addition, it was felt that the
patient has ongoing osteomyelitis (see below). The patient
was maintained on broad spectrum antibiotics that included
Meropenem and Linezolid and Flagyl and infectious disease
consultation was obtained. The patient's hypotension
improved over the course of hospitalization and the patient
was weaned off pressors shortly after admission. The patient
also had a significant bandemia on admission that disappeared
over the course of hospitalization.
3. Osteomyelitis/sacral decubitus ulcer - The patient is
known to have a Stage IV sacral decubitus ulcer that is
colonized by Acinetobacter and Methicillin resistant
Staphylococcus aureus. The Acinetobacter is resistant to
multiple antibiotics though is sensitive to Meropenem and the
patient had been treated with Meropenem up until several days
prior to this admission. The patient was recently started on
Meropenem as above as well as Linezolid as above. Wound
culture again revealed the Methicillin resistant
Staphylococcus aureus and Acinetobacter as well as VRE.
Plastic surgery was consulted for possible wound debridement
as well as consideration for placement of a VAC dressing on
the wound since it has been slow to heal. However, it was the
opinion of plastic surgery consultation that the location of
the wound was too close to the anus for a VAC dressing. The
VAC dressing would likely become contaminated with fecal
material. Furthermore, it was felt that no debridement was
indicated and the patient was continued on antibiotics as
above. The patient was turned every two hours to promote
wound healing of this pressure sore. The patient was
maintained on a Triadyne bed and the patient's wound dressing
was changed twice a day.
4. Chronic renal insufficiency/hemodialysis - The patient
was maintained on hemodialysis. The patient received Zemplar
with dialysis. The patient remained anuric while in the
hospital.
5. Diabetes mellitus - The patient was initially maintained
on insulin sliding drip and transitioned to a regular insulin
sliding scale.
6. Asthma - The patient was maintained on Albuterol and
Atrovent inhalers while ventilated and later on Atrovent and
Albuterol nebulizers.
7. Anemia - The patient had a hematocrit on admission of
32.2, though with hydration this decreased to 25.0. The
patient was transfused a total of three units of blood with
hemodialysis over the course of the hospitalization.
8. Hypertension - The patient's antihypertensive regimen was
held on admission in the setting of hypotension, however,
after several days of admission, the patient was weaned off
pressors and became hypertensive and her antihypertensive
regimen of Amlodipine, Hydralazine and Labetalol was
restarted.
9. Seizure disorder - The patient was maintained on Keppra
for prophylaxis of seizures.
10. Hypercalcemia - As mentioned above, the patient has
secondary hyperparathyroidism and was maintained on Zemplar
with dialysis. Her calcium remains elevated though it is
felt that it will take longer for the Zemplar to exert its
full effect.
11. Hypothyroidism - The patient was maintained on
Levothyroxine.
12. Depression - The patient was maintained on Zoloft.
13. Fluid, electrolytes and nutrition - The patient was
admitted with a gastrostomy tube that was apparently placed
at the [**Hospital6 1129**] over a prior admission
and that had apparently recently been changed and replaced
with a Foley catheter while at [**Hospital3 7**]. The
patient was taken to interventional radiology where it was
found that her gastrostomy tube was placed high in the
stomach (in the fundus) and was oriented cranially. Initial
attempts to redirect the catheter caudally were unsuccessful.
The patient underwent further evaluation by interventional
radiology in which the Foley was removed and was converted to
a PEJ tube over a wire. A 16.5French [**Location (un) 12056**]/Talzote/Coombs
gastrojejunostomy tube was placed over a wire such that there
are now two ports; a blue port is present in the jejunum and
a red port is present in the stomach and can be used for
suction. The patient was restarted on tube feeds on [**2148-5-4**]
(her jejunostomy was placed on [**2148-5-3**]), and tube feeds were
increased subsequently on [**2148-5-5**].
14. Elevated alkaline phosphatase - As noted on a previous
admission in [**Month (only) 956**], the patient's alkaline phosphatase
increased over the course of hospitalization after TPN was
begun. Her alkaline phosphatase increased from admission
value of 434 up to a maximum of 414 on [**2148-5-3**]. TPN was
discontinued and the patient's alkaline phosphatase was 1063
on [**2148-5-5**]. Her transaminases did not elevate significantly
over the course of hospitalization, nor did the bilirubin
(maximum bilirubin was 0.4 on admission). The patient
underwent ultrasound examination of the right upper quadrant
which again revealed adenomyomatosis of the gallbladder wall
(which was seen on ultrasound in [**2147-5-2**]) and there was no
evidence of cholelithiasis or choledocholithiasis.
15. Prophylaxis - The patient was maintained on proton pump
inhibitor as well as subcutaneous Heparin and bowel regimen.
16. Mental Status - The patient was noted to have waxing and
[**Doctor Last Name 688**] mental status though at times was interactive with the
staff and with her family and could follow commands. At other
times, the patient was more somnolent and less interactive
with the staff.
CONDITION ON DISCHARGE: The patient is discharged in stable
condition.
DISCHARGE DIAGNOSES:
1. Hypoxic respiratory failure.
2. Aspiration pneumonia.
3. Fever.
4. Sepsis.
5. Sacral Stage IV decubitus ulcer.
6. Osteomyelitis (sacral/coccygeal).
7. End stage renal disease, hemodialysis dependent.
8. Hypertension.
9. Encephalopathy.
10. Asthma.
11. Hypothyroidism.
12. Depression.
13. Anemia.
14. Hypercalcemia/secondary to hyperparathyroidism.
MEDICATIONS ON DISCHARGE:
1. Levetiracetam 500 mg p.o. twice a day.
2. Levothyroxine 112 once daily.
3. Zinc Sulfate 220 mg once daily.
4. Sertraline 25 mg once daily.
5. Thiamine 100 mg p.o. once daily.
6. Bisacodyl p.r.n. once daily.
7. Ascorbic Acid 500 mg once daily.
8. Linezolid 600 mg twice a day.
9. Meropenem 500 mg once daily.
10. Flagyl 500 mg p.o. twice a day.
11. Acetaminophen 650 mg q4hours p.r.n.
12. Hydralazine 10 mg three times a day.
13. Labetalol 300 mg p.o. three times a day.
14. Amlodipine 5 mg p.o. once daily.
15. Lactulose q8hours p.r.n.
16. Albuterol and Atrovent nebulizers q4hours.
17. Albuterol and Atrovent nebulizers q2hours p.r.n.
18. Regular insulin sliding scale.
19. Nephrocaps.
20. Subcutaneous Heparin 5000 units twice a day.
CONDITION ON DISCHARGE: The patient is discharged in stable
condition.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 11363**]
MEDQUIST36
D: [**2148-5-5**] 13:14
T: [**2148-5-5**] 14:22
JOB#: [**Job Number 12057**]
cc:[**Hospital1 12058**] Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-8**]
Date of Birth: [**2071-2-22**] Sex: F
Service: PULMONARY
ADDENDUM - 1) PULMONARY ISSUE/ASPIRATION PNEUMONIA: The
patient has maintained good O2 sats on face tent and her
respiratory status has been stable. She still sounds
rhonchorous on exam anteriorly, and chest x-ray from [**2148-5-7**] appeared slightly worsened on the left side. However,
repeat chest x-ray on [**5-8**] appeared slightly improved, and
indicates that the patient most likely has atelectasis and
possibly some mucous plugging as well. The patient has been
stable with her oxygenation and her secretions have lessened
somewhat in their amount, and secretions are mostly whitish
in color. Suctioning has been performed q 4 h, and the
patient will need to continue with the suctioning q 4 h, or
may need to increase frequency if patient sounds more
rhonchorous. She will also need frequent chest PT,
especially on the left side, given her atelectasis and thick
secretions. As mentioned in the previous discharge summary,
her G-tube was converted to a J-tube to prevent further
aspiration events, and she will be maintained on
broad-spectrum antibiotics for sacral decub osteomyelitis
that also empirically covers her aspiration pneumonia.
2) SEPSIS/ID: The patient's leukocytosis continues to
improve. Per ID recs, the patient will remain on
broad-spectrum antibiotics, meropenem and linezolid, for
sacral decub osteomyelitis for an indefinite period of time.
The patient has an ID follow-up appointment in 2 weeks
(Please see page 1), and further antibiotic coverage will
have to be decided at that time. In the meantime, while
patient remains on meropenem and linezolid, she will also
remain on C. diff prophylaxis with Flagyl [**Hospital1 **] until these
antibiotics are discontinued. The patient is having a PICC
line placed for an extended course of antibiotics (She
previously had a left subclavian which will be discontinued
prior to discharge.).
3) FEN: The patient's sodium has improved on the day of
discharge, but this should continue to be monitored every few
days following discharge to insure that the patient has
adequate intake of free water.
4) END-STAGE RENAL DISEASE: The patient is on a Tuesday,
Thursday, Saturday schedule for hemodialysis, and she should
continue this as an outpatient. She should receive her dose
of meropenem as directed daily, but on days of hemodialysis
should receive the medication after hemodialysis. The
patient has a right tunneled IJ catheter for hemodialysis.
5) CODE STATUS: The patient is still full code, as has been
discussed with the family on numerous occasions with the MICU
team, as well as Dr. [**Last Name (STitle) 217**]. They state that their
mother would want this, and they are aware that she may need
to be reintubated in the future, despite her probable poor
outcome.
6) NEURO/PSYCH: Per family, the patient is at her baseline
mental status. It appears that the patient's behavior is
often volitional, but often speaks in full sentences to her
family. Psych was consulted on this admission and do not
feel that there is a component of depression involved in her
neuro status and recommended discontinuation of the Zoloft.
DISCHARGE MEDICATIONS: Same as on the previous discharge
summary, except Zoloft 25 mg po qd has been discontinued.
DISCHARGE STATUS: To [**Hospital **] Rehab. Please see page 1 for
follow-up appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2148-5-8**] 13:52
T: [**2148-5-8**] 14:00
JOB#: [**Job Number 12059**]
|
[
"780.39",
"730.28",
"038.9",
"263.9",
"995.92",
"584.9",
"518.81",
"707.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"44.32",
"96.04",
"38.91",
"96.72",
"99.15",
"00.14",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5694, 5712
|
15359, 15720
|
20116, 20564
|
15746, 16495
|
7859, 15266
|
5735, 7842
|
225, 2192
|
2214, 5491
|
5508, 5677
|
16520, 20092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,827
| 185,747
|
50910
|
Discharge summary
|
report
|
Admission Date: [**2150-4-27**] Discharge Date: [**2150-5-5**]
Date of Birth: [**2080-12-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2150-4-27**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Epic Tissue
Valve)
History of Present Illness:
This is a 69 year old female with long-standing aortic stenosis.
Over the past several months, she has experienced worsening
dypsnea on exertion. Most recent echocardiogram showed severe
aortic stenosis with an valve area of 0.9 cm2. She also
underwent cardiac catheterization which confirmed severe aortic
stenosis(valve area 0.67 cm2, mean gradient 31mmHg) and revealed
normal coronary arteries. She was therefore referred for aortic
valve replacement.
Past Medical History:
-Aortic Stenosis
-Dyslipidemia
-Hypertension
-History of Pulmonary Embolus and Acute Renal Insufficiency
following Total Abd Hysterectomy
-Left Total Knee Replacement
-Open cholecystectomy
-Appendectomy
Social History:
30 pack year history, quit tobacco 20 years ago. Drinks ETOH
socially. Lives alone. Retired.
Family History:
No premature coronary artery disease. Mother valve replacement
in her 80's.
Physical Exam:
Admission:
Vitals: 151/79, 80, 14
General: obese female in no acute distress
Skin: warm, dry. no rashes
HEENT: oropharynx benign
Neck: supple, no jvd
Chest: clear breath sounds bilaterally
Heart: regular rate and rhythm, s1s2, 3/6 systolic ejection
murmur heard throughout the precordium and carotid region
Abdomen: benign
Extremities: warm, no edema
Neuro: grossly intact
Pulses: 1+ distally
Pertinent Results:
[**2150-4-27**] Intraop TEE:
PREBYPASS
1. The left atrium is mildly dilated. A patent foramen ovale is
present with left-to-right shunt across the interatrial septum
is seen at rest. 2. Left ventricular wall thicknesses and cavity
size are normal. Overall left ventricular systolic function is
normal (LVEF>55%). 3. Right ventricular chamber size and free
wall motion are normal. 4. There are simple atheroma in the
aortic arch and descending thoracic aorta. 5. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis
(area<0.8cm2). Moderate (2+) aortic regurgitation is seen. 6.
The mitral valve is mildly thickened, with trivial mitral
regurgitation.
POSTBYPASS
1. Patient is on phenylephrine infusion.2. There is a well
seated, well functioning tissue valve seen in the aortic
position. Mean gradient is 22 mmHg 3. The right ventricle is
moderately dysfunctional. Air is seen by the [**Month/Day/Year 5059**] in the
right coronary artery. Epinephrine started with good results,
the RV function is improved 4. The LV function remains good 5.
The aortic contours remain smooth after decannulation
Brief Hospital Course:
Mrs. [**Last Name (STitle) **]' [**Known lastname **] was admitted and taken to the OR for AVR (21mm
St. [**Male First Name (un) 923**] epic porcine). See operative note for details. Mrs. [**Last Name (STitle) 105826**] was transported intubated and on phenylephrine and
propofol drips to the cardiac ICU. Mrs.[**Known lastname **] was extubated
on POD#1. Betablockers and diuresis was initiated. Mrs.[**Last Name (STitle) 105827**]
developed post operative afib on POD#2 which responded to
amiodarone and she converted to sinus rhythm. Chest tubes and
pacing wires were removed per cardiac surgery post op protocol.
Mrs.[**Last Name (STitle) 105827**] was transferred from the ICU on POD#3. Shr required
aggressive pul tiolet and diuresis to wean from oxygen. On POD#6
Mrs.[**Last Name (STitle) 105827**] complained of blurry vision in right eye. She was
seen by opthalmology and thought to have retinal artery
occlusion likelt due to emboli. No anticoagulation was
recommended per opthalmology. It was recommended that she follow
up with her opthalmologist in one month. A carotid ultrasound
was obtained and revealed no significant stenosis.
She was seen by physical therapy and was cleared for discharge
to home on POD#8.
Medications on Admission:
Lipitor 10 qd, Atenolol 25 qd, Aspirin 81 qd, Spiriva, Albuterol
prn, Lisinopril 10 qd, Glucosamine/Chondroitin, Tylenol prn
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*65 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
Disp:*1 mdi* Refills:*2*
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. 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*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
2 tabs twice daily for 7 days then two tablets daily for one
month.
Disp:*70 Tablet(s)* Refills:*1*
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
.[**Location (un) 932**] VNA
Discharge Diagnosis:
Aortic Stenosis, s/p Aortic Valve Replacement
Dyslipidemia
Hypertension
History of Pulmonary Embolus
Central retinal artery occlusion of right eye possibly due to
embolic event
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
8) If the vision in your right eye worsens, see your
opthalmologist immediately or report to the emergency room.
Followup Instructions:
call to schedule the following appointments:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 8579**] in [**3-10**] weeks
Dr. [**Last Name (STitle) 32496**] in [**3-10**] weeks
Wound check with [**Hospital Ward Name **] 6 nurses in 2 weeks
Follow up with your opthalmologist Dr. [**Last Name (STitle) 18520**] in 1 month.
Completed by:[**2150-5-5**]
|
[
"362.31",
"427.32",
"272.4",
"997.1",
"427.31",
"790.29",
"424.1",
"E878.1",
"V43.65",
"V12.51",
"491.21",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5883, 5942
|
2945, 4174
|
298, 400
|
6163, 6170
|
1742, 2922
|
7063, 7433
|
1237, 1314
|
4349, 5860
|
5963, 6142
|
4200, 4326
|
6194, 7040
|
1329, 1723
|
239, 260
|
428, 884
|
906, 1111
|
1127, 1221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,729
| 137,533
|
27806
|
Discharge summary
|
report
|
Admission Date: [**2170-7-18**] Discharge Date: [**2170-7-26**]
Date of Birth: [**2116-1-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Intraoperative Ultrasound
Distal Pancreatectomy with Splenectomy
Mobilization of Splenic Flexure
Repair of Duodenotomy
Primary Umbilical Hernia Repair
Open Cholecystectomy
Cardioversion
History of Present Illness:
This 54-year-old woman is in relatively good health but has
recently had abdominal pain. She reports three months of
abdominal and back pain and a poor appetite. A workup for this
has revealed an umbilical hernia but more
worrisome, a CAT scan was performed and this showed a 2.5 x 3
centimeter mass in the body of the pancreas, most suspicious for
pancreatic neuroendocrine tumor. This was biopsied by an
endoscopic ultrasound and this biopsy was indeterminate. This
lesion had some dystrophic calcification in it as well. It
had the typical hypervascular appearance of a neuroendocrine
tumor. Furthermore, there was suggestion of a hyperemic lesion
in segment III of the liver.
Past Medical History:
Hypercholesterolemia
Hypertension
Social History:
Is [**Location 7972**] speaking. Works as a cleaner.
She reports no smoking or alcohol use.
Family History:
`
Physical Exam:
VS: 97.4, 65, 102/51, 18, 99%RA
Gen: WNL, NAD
Head: anicteric, PERRLA
Neck: no adenopathy
CV: RRR, S1, S2, no murmur
Pulm: WNL, CTA bilat.
Abd: nontender, nondistended, no masses. Ventral Umbilical
Hernia - Reducible.
Ext: no edema, +2 pulses bilat.
Pertinent Results:
US INTR-OP 60 MINS [**2170-7-18**] 7:26 AM
US INTR-OP 60 MINS
Reason: Distal pancreatectomy with splenectomy and
cholecystectomy;
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with
REASON FOR THIS EXAMINATION:
Distal pancreatectomy with splenectomy and cholecystectomy; IOUS
INTRAOP ULTRASOUND
Intraoperative ultrasound guidance was provided during distal
pancreatectomy to evaluate an abnormality seen on recent CT scan
in the left lobe of the liver. The ultrasound study confirms the
presence of a calcified hypoechoic mass in the tail of the
pancreas. The liver is diffusely echogenic consistent with fatty
replacement. Areas of sparing are noted in the left lobe. No
discrete lesion is identified in the left lobe of the liver
corresponding to the abnormality seen on CT apart from areas of
fatty sparing.
IMPRESSION: No solid mass noted in the left lobe of the liver.
CHEST (PA & LAT) [**2170-7-21**] 9:53 AM
CHEST (PA & LAT)
Reason: Interval change
[**Hospital 93**] MEDICAL CONDITION:
Asymmetric smooth pleural thickening at the left apex
REASON FOR THIS EXAMINATION:
Interval change
CHEST, SINGLE VIEW ON [**7-21**]
HISTORY: Asymmetric pleural thickening at the left apex,
question interval change.
REFERENCE EXAM: [**7-20**].
FINDINGS: There has been no significant interval change in the
right IJ line with tip at the cavoatrial junction. The heart
size is mildly enlarged. There is increased retrocardiac opacity
likely due to pleural effusion, although underlying infiltrate
and volume loss cannot be excluded. There is some patchy volume
loss in the right lower lung as well.
Baseline artifact
Atrial fibrillation with rapid ventricular response
Modest nonspecific low amplitude T wave changes
No previous tracing available for comparison
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
121 0 86 322/394.14 0 37 -24
Brief Hospital Course:
She was admitted to [**Hospital1 18**] on [**2170-7-18**]. Post-operatively she was
NPO, had a NGT, and was on IV fluids.
Pain: She was being followed by the Pain service for the
epidural. POD 1, she was comfortable on APS 10 at 4cc/h. On POD
2, herepidural was capped and she was put on a Dilaudid PCA. POD
6, she was switched to a PO Percocet with good pain control.
Abd/GI: POD 2, her NGT was D/C'd. She was started on sips POD 3.
Her diet was advanced over the next few days as she had return
of bowel function and she was tolerating a regular diet at time
of discharge. Her drain will remain in place and be removed at a
follow-up appointment. Her JP Amylase was 1891. Her incision was
clean, dry and intact. The staples will remain in place until
her follow-up appointment.
Radiology: A CXR on [**2170-7-18**] revealed asymmetric smooth pleural
thickening at the left apex. Follow-up CXR on [**7-20**] and [**7-21**]
showed some mild pleural effusion.
CV: The patient went in to Atrial fibrillation on POD 4, with a
modest ventricular rate 90-100. She was PT given multiple
boluses of Diltiazem and Metoprolol without converting. she
wasthen admitted to the ICU for a Diltiazem drip and heart rate
management. On POD 5 ([**2170-7-23**]) she was successfully cardioverted
to NSR. She will stay on Lopressor 25 mg TID.
Immunizations: She received immunizations x 3 on POD 5.
Medications on Admission:
amlodipine, prevacid
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 4 weeks.
Disp:*40 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Insulin Glargine 100 unit/mL Solution Sig: 10 Units
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
6. Humalog 100 unit/mL Solution Sig: Sliding Scale Subcutaneous
four times a day: Dose according to Sliding Scale.
Check blood glucose 4 times per day at meals and at bedtime.
Disp:*qs * Refills:*2*
7. Insulin Needles (Disposable) Needle Sig: One (1)
Miscell. four times a day.
Disp:*qs * Refills:*2*
8. Insulin Testing Strips Sig: One (1) four times a day.
Disp:*qs * Refills:*2*
9. Lancets Misc Sig: One (1) Miscell. four times a day.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
Pancreatic Tail Lesion
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
Please make all follow-up appointments.
No lifting >10 lbs for 4 weeks.
Your drain will remain in place and be removed at your follow-up
appointment.
You may wash and shower your incision. Pat dry and leave open to
air. No swimming or tub baths for 6 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 week.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2170-8-3**] 9:45
Completed by:[**2170-8-6**]
|
[
"251.3",
"427.31",
"577.9",
"997.1",
"530.81",
"553.1",
"401.9",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"52.59",
"53.49",
"51.22",
"46.71"
] |
icd9pcs
|
[
[
[]
]
] |
6261, 6320
|
3658, 5043
|
328, 539
|
6387, 6394
|
1719, 1853
|
6862, 7106
|
1430, 1433
|
5114, 6238
|
2731, 2785
|
6341, 6366
|
5069, 5091
|
6418, 6839
|
1448, 1700
|
274, 290
|
2814, 3635
|
567, 1248
|
1270, 1305
|
1321, 1414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,197
| 146,066
|
27548
|
Discharge summary
|
report
|
Admission Date: [**2172-6-7**] Discharge Date: [**2172-6-15**]
Date of Birth: [**2111-2-14**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Keflex
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Endotracheal intubation
EGD x2, one with dermabond and lipiodol injections
PRBC transfusions
FFP transfusions
History of Present Illness:
61 year-old man with history of cirrhosis [**3-4**] EtOH and possibly
NASH with known esophageal, gastric, and rectal varices,
mechanical AV valve on anticoagulation, presenting with four
days of dark stools, which are now black. He notes that he has
become increasingly weak over past four days. He endorses
lightheadedness, fatigue, and general malaise. Patient had been
in [**State 1727**] and given dark stool he stopped taking coumadin several
days ago. Of note, the patient has had a URI over the past
several weeks. He was seen by his PCP [**Last Name (NamePattern4) **] [**5-26**]. Labs at that
visit were significant for a new renal failure with a creatinine
of 2.9.
.
In the ED, initial vs were: T 97.2 P 101 BP 92/56 R 18 O2 sat
100% on RA. Exam was notable for conjunctival pallor and black
stool on rectal exam. Labs were notable for HCT of 30.3 down
from 34 one week ago and 41 in [**2172-1-1**], BUN of 132,
Creatinine of 2.9, INR of 3.2. Patient's SBPs went down into
70s, but improved to 90s - 100s prior to transfer. Patient
received 4L NS, vancomycin, levofloxacin, and was started on
protonix and octreotide gtt. Patient was found to be
hyperkalemic and received insulin, calcium gluconate. He did
not receive kayexelate given GI bleeding. Patient underwent NG
lavage, which was negative. Hepatology was consulted and
recommended treating with ceftriaxone - patient received start
of dose of ceftriaxone, but it was stopped as patient has
cephalosporin allergy. Patient was ordered 2 units PRBC and 2
units of FFP, but this was not started prior to transfer from
ED. Patient has 3 18 gauge peripheral IVs. Transfer vitals are
P 56, BP 101/49, R 14, O2 sat 100% on RA.
.
On the floor, patient is comfortable. He feels tired, but has
not had any further melena. He refuses to have a foley catheter
placed because he has had difficulty with foley placement in the
past. He does not currently feel like he has to urinate. He
denies chest pain, shortness of breath.
Past Medical History:
* Cirrhosis (possibly [**3-4**] NASH), complicated by esophageal,
gastric and rectal varices. Last EGD in [**12/2171**] showed 1 cord of
Grade I esophageal varices at lower third of esophagus. Patient
with fatty liver and splenomegaly on RUQ ultrasound.
* Varices at the lower third of the esophagus
* Portal hypertensive gastropathy and stomach varices
* Endocarditis from dental abscess s/p AVR [**2167**] with mechanical
valve
* Hypertension
* Diabetes Mellitus Type II (last HgbA1c 7.4% in [**5-/2172**])
* Hyperlipidemia
* Anxiety
* Peripheral Neuropathy
* Atrial fibrillation s/p DCCV now on dronedarone
* Diastolic CHF EF - 55%, grade II diastolic dysfunction
* History of transient systolic cardiomyopathy with global EF of
30 - 35%, now back to EF of 55% with grade II diastolic
dysfunction
Social History:
Retired Mechanical engineer, [**Location (un) 32775**], MA, Married to wife
[**Name (NI) **]. [**Name2 (NI) **] children
- Tobacco: 20 pack year smoking history. Quit in [**2151**]. Current
cigar smoking
- Alcohol: 3 beers per day. Used to be about 6 pack per day.
- Illicits: Denies
Family History:
Mother pancreatic CA, deceased
Father alcoholism, deceased
Brother with CABG, CVA.
Physical Exam:
On admission:
Vitals: T:95.9 BP: 117/56 P: 59 R: 15 O2: 99% RA
General: Alert, oriented, in no acute distress
HEENT: Sclera anicteric, dry mucus membranes
Neck: supple, JVP not elevated, no LAD
Lungs: Respirations unlabored, speaking in full sentences,
Bibasilar crackles
CV: Brady, S1, mechanical S2, no murmurs/rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, trace edema, wearing pneumoboots
Pertinent Results:
Admission labs:
===============
[**2172-6-7**] 02:00PM BLOOD WBC-7.9 RBC-3.58*# Hgb-10.9* Hct-30.3*
MCV-85 MCH-30.4# MCHC-35.9* RDW-14.2 Plt Ct-189
[**2172-6-7**] 02:00PM BLOOD Neuts-71.9* Lymphs-21.4 Monos-4.6 Eos-1.2
Baso-0.9
[**2172-6-7**] 02:00PM BLOOD PT-32.1* PTT-29.3 INR(PT)-3.2*
[**2172-6-7**] 02:00PM BLOOD Glucose-144* UreaN-132* Creat-2.9*
Na-130* K-7.3* Cl-104 HCO3-16* AnGap-17
[**2172-6-7**] 02:00PM BLOOD ALT-22 AST-45* AlkPhos-37* TotBili-0.4
DirBili-0.1 IndBili-0.3
[**2172-6-7**] 02:00PM BLOOD Lipase-56
[**2172-6-7**] 02:00PM BLOOD cTropnT-<0.01
[**2172-6-7**] 08:40PM BLOOD Calcium-7.7* Phos-4.1 Mg-2.1
[**2172-6-7**] 02:25PM BLOOD K-6.1*
[**2172-6-8**] 04:32PM BLOOD Glucose-162* Lactate-1.2 Na-138 K-5.1
Cl-113*
.
Discharge labs:
===============
[**2172-6-15**] 05:30AM BLOOD WBC-4.6 RBC-3.21* Hgb-9.7* Hct-27.6*
MCV-86 MCH-30.1 MCHC-35.0 RDW-13.5 Plt Ct-75*
[**2172-6-14**] 05:00AM BLOOD Neuts-72.2* Lymphs-15.3* Monos-8.8
Eos-3.0 Baso-0.6
[**2172-6-15**] 05:30AM BLOOD PT-31.1* PTT-31.1 INR(PT)-3.1*
[**2172-6-14**] 05:00AM BLOOD ESR-75*
[**2172-6-15**] 05:30AM BLOOD Glucose-75 UreaN-28* Creat-1.6* Na-138
K-3.6 Cl-100 HCO3-29 AnGap-13
[**2172-6-15**] 05:30AM BLOOD ALT-31 AST-31 AlkPhos-107 TotBili-1.3
[**2172-6-15**] 05:30AM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.0 Mg-1.8
[**2172-6-12**] 09:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2172-6-12**] 09:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2172-6-10**] 05:37PM URINE Hours-RANDOM UreaN-750 Creat-71 Na-30
K-45 Cl-26
Imaging:
========
[**2172-6-8**] TTE: The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The right atrial pressure is indeterminate.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no ventricular septal defect. RV with normal free wall
contractility. The ascending aorta is mildly dilated. A
mechanical aortic valve prosthesis is present. The prosthetic
aortic valve leaflets appear normal The transaortic gradient is
higher than expected for this type of prosthesis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2171-8-23**],
the AVR gradient is slightly higher. Moderate pulmonary
hypertension is now detected (was not measured on the prior
study).
.
RUQ U/S: Normal abdominal ultrasound, specifically no thrombus
seen in the portal or splenic veins.
.
Hepatic venogram with pressures prior to attempted TIPS
procedure:
1. Right heart pressure 20 mmHg.
2. Cardiomegaly.
3. Portosystemic gradient at 5 mmHg.
IMPRESSION: Based on the elevated right heart pressure (20 mmHg)
and
relatively low portosystemic gradient (5 mmHg), and after
discussion between Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] and [**Name5 (PTitle) 4154**], no TIPS was
performed.
.
CXR [**2172-6-11**]:
Mild cardiomegaly is unchanged. Mediastinal and hilar contours
are also stable. The patient is status post valve replacement
and multiple median sternotomy wires appear intact. Possible
small bilateral pleural effusions appear unchanged. Dense
opacities seen in both lungs appear new since [**6-9**] though
unchanged from one day prior, possibly areas of aspirated
barium. Pulmonary vascular congestion has improved.
.
CXR [**2172-6-12**]:
PA AND LATERAL VIEWS OF THE CHEST: Moderate cardiomegaly is
unchanged in
severity. Mediastinal and hilar contours are normal. Note is
again made of
multiple median sternotomy wires as well as an aortic valve
prosthetic. There
is no pneumothorax or pulmonary edema. There are small bilateral
pleural
effusions which are unchanged.
Multiple round and branching hyperdense foci are seen in the
lungs
bilaterally, unchanged from the most recent comparisons, though
new since [**6-9**]. Notably, the patient underwent gastric variceal
sclerotherapy with
Lipiodol on that same date and has not ingested an barium. For
that reason,
these opacities are presumed to represent areas of embolic
lipiodol within the
pulmonary arteries. Recommend further evaluation via CT. This
recommendation
was discussed via telephone by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 14804**] with Dr. [**First Name4 (NamePattern1) 2398**]
[**Last Name (NamePattern1) **] at
15:47 on [**0-0-0**]
.
CT [**2172-6-13**]
FINDINGS: Multifocal linear high-density nodules are present in
the lungs, which are distributed along the course of the
pulmonary arteries. The findings would be in keeping with
lipiodol emboli in the pulmonary arteries. Patchy areas of
ground-glass opacification are also present, particularly in the
apical segment of the lower lobes, middle lobe and lingula. The
distribution of the ground-glass opacification is not
consistently related to the high-density material, suggesting
that the ground glass change does not represent early
infarction. Interlobular septal thickening is also noted.
There is extensive bilateral pleural thickening, more
predominant in the lower lobes. Tiny pleural effusions are also
present. Linear atelectasis is noted. Multiple mediastinal lymph
nodes are present, the largest measuring 14 mm in station 7
(subcarinal). There is coronary artery calcification and a
calcified aortic valve.
There are numerous upper abdominal varices. High-density
material is noted in the gastric fundus likely lipiodol from the
recent intervention. The liver is nodular in keeping with
cirrhosis. No significant ascites.
Bone review is unremarkable.
IMPRESSION:
1. There are multiple high-density nodules within the lungs,
which are
distributed along the course of the pulmonary arteries, in
keeping with
lipiodol emboli.
2. Patchy areas of ground-glass opacification are also noted.
These features are not suggestive of pulmonary infarcts and more
consistent with interstitial pulmonary edema. Extensive
bilateral pleural thickening is also present with small pleural
effusions.
PENDING LABS: BLOOD CULTURES X4 (ALL Previous 4 cultures were
negative. Urine culutres negative as well as sputum cultures)
Brief Hospital Course:
Mr. [**Known lastname 12056**] is a 61 year-old man with history of cirrhosis with
esophageal, gastric, and rectal varices, mechanical aortic valve
on anticoagulation presenting with melena, hypotension, HCT drop
likely secondary to UGIB from gastric varices.
.
# Upper GI Bleed: Patient has a known history of esophageal and
gastric varices and is currently anticoagulated on coumadin for
mechanical AV. He was hypotensive in ED with SBPs in 70s, but
was hemodynamically stable after coming to the MICU. HCT dropped
from 33 to 22 from ED and patient received 2 units PRBCs. He had
an EGD on [**2172-6-7**] which showed varices in the esophagus and
funuds with blood in the fundus as well as duodenitis and
hypertensive gastropathy, with no acitve bleeding. He was
started on an octreotide and PPI infusion and planned for a TIPS
procedure to relieve the portal hypertension. He underwent a TTE
which showed elevated TR gradient and he went down for hepatic
venogram with pressures which showed significantly elevated
right sided pressures. Given this, a TIPS could not be done and
he was transferred back to the MICU while intubated for diuresis
in an attempt to decrease right sided pressures. His HCT
remained stable and he remained intubated overnight and self
extubated the following day. He had a repeat EGD on [**6-9**] to
inject dermabond into the varices as TIPS procedure was not
possible. He spiked a fever to 101 and per hepatology was
started empirically on vanco/zosyn. His nadolol was restarted
and HCT continued to be stable. His platelets dropped from 189
on admission to 68 and his protonix was changed to sucralfate.
Coumadin and heparin were continued for his AVR as there was no
evidence of active bleeding. Patient continued to be diuresed
adequately. Patient did develop some oozing around R IJ (TIPS
procedure) site and IR recommended applying pressure. He
developed a superficial hematoma around the area and HCT was
stable. Patient was transferred to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] service
where HCT's were trended. HCT remained stable in the 25-27
range. No transfusions required on the general medical floors.
*Repeat endsocopy within 6 weeks of discharge
.
# Respiratory failure: Patient had pulmonary edema in setting of
volume overload after receiving blood products. Patient was
intubated during TIPS procedure, but self extubated on [**6-9**]. He
had pulmonary edema on his CXR and was diuresed with a lasix
drip as above, to decrease right sided pressures. His lasix drip
was converted to lasix boluses. On the general floors, was
diuresed intravenously and placed back on oral regimen prior to
discharge.
.
# Dermabond emboli: Patient had lipoidal injections per above
during EGD. After fever spikes, CXR showed peculiar radiodense
lesions. CT scan was pursued which indicated probable lipoidal
emboli throughout pulmonary arterial vasculature. Deemed to be
benign finding. Patient without pulmonary symptomatology at
that time.
*Repeat chest xray in 6 months time for monitoring.
.
# Fever: Patient spiked fever [**6-9**]. Unclear etiology, though
differential includes GI sources after EGD, pneumonia,
post-dermabond of varices. He was empirically started on
vancomycin and zosyn (day 1 = [**6-9**]) and hepatology recommended
considering TEE to evaluate for endocarditis given history of
AVR. Blood and urine cultures were sent and showed no growth to
date at time of transfer. TEE not pursued given paucity of
symptomatology and lack of recurrent fevers. Low grade fever of
100.6 on [**6-11**]. Pancultures were negative. Had CT scan for
incidental CXR findings of dermabond embolization. CT confirmed
lack of pneumonia and antibiotics were discontinued. Remained
afebrile for rest of hospital course.
.
# Acute renal failure: Patient with acute renal failure with
creatinine of 2.9 on admission, up from baseline 1.1 - 1.5.
Patient had elevated creatinine of 2.9 at PCP visit on [**2172-5-26**].
Unclear etiology, possibly pre-renal etiology from medication
side effect as patient is on lasix and lisinopril. Patient could
also have pre-renal or ATN as cause of renal failure from GI
bleed. Urine lytes showed FeUrea of 45% which is less consistent
with pre-renal. Lisinopril was held and Cr was trended. Trended
down with diuresis to 1.6. Restarted ACE-I prior to discharge.
*Should have CMP repeated to assess improvement in renal
function
.
# Cirrhosis: Patient with history of alcoholic vs NASH cirrhosis
complicated by esophagel, gastric, and rectal varices. His
variceal bleed was managed with dermabond as he was not a TIPS
candidate, as above. Nadolol restarted prior to discharge.
.
# Mechanical Aortic Valve: Patient with mechanical aortic valve
replacement. He is anticoagulated on coumadin with goal IRN
between 2.5 and 3.5. Coumadin was held in setting of EGD and he
was bridged with heparin drip. His coumadin was restarted after
there was no more signs of active bleeding.
*Follow up INR within 1 week of discharge.
.
# Hypotension: Patient with hypotension in ED with SBPs in 70s.
Improved following 4L of IVF in ED. Likely secondary to acute
blood loss from upper GI bleed. But also concern for infection,
sepsis causing hypotension. Improved after sedation was weaned
s/p extubation. He was empirically started on vanco/zosyn as
above for empiric coverage in setting of fever. Cultures were
sent and pending at time of transfer. No growth at time of
discharge with 4 pending blood cutlures.
*Follow up pending blood culture data.
.
# Chronic Diastolic CHF: Patient with EF of 55%. Patient with
some evidence of volume overload on exam and on CXR following
IVF. He was diuresed as above with lasix drip and eventually
transitioned back to PO diuresis.
.
# Atrial Fibrillation: Patient with h/o a. fib s/p cardioversion
now on Dronedarone 400 mg [**Hospital1 **]. He was continued on his
anticoagulation and INR trended.
.
# Diabetes Mellitus: Patient with home insulin. Most recent
HgbA1c 7.4. Continued lantus and humalog sliding scale in house.
Discharged with insulin and metformin.
.
# Depression: Continued Cymbalta 60 mg daily.
.
TRANSITIONAL ISSUES: Please see individual above issues.
PENDING LABS: Blood cultures x 4.
Medications on Admission:
Dronedarone 400 mg [**Hospital1 **]
Cymbalta 60 mg daily
Lasix 80 mg [**Hospital1 **]
Humalog 10 - 20 units before [**Hospital1 16429**] TID
Insulin glargine
Lisinopril 40 mg daily
Metformin 850 mg [**Hospital1 **]
Nadolol 20 mg PO daily
Spironolactone 100 mg PO daily
Coumadin 8 - 9 mg daily
Ferrous sulfate 325 mg TID
Discharge Medications:
1. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. warfarin 4 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
9. ferrous sulfate 325 mg (65 mg iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
10. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. insulin lispro 100 unit/mL Insulin Pen Sig: 10-20 units
Subcutaneous three times a day: before [**Last Name (LF) 16429**], [**First Name3 (LF) **] sliding scale.
13. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: One
Hundred (100) units Subcutaneous once a day: in the morning.
14. Outpatient [**Name (NI) **] Work
PT/INR
Please have results faxed to [**Last Name (LF) 2903**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] at [**Telephone/Fax (1) 7922**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
UGIB (esphageal and gastric variceal bleed)
Liver cirrhosis secondary to NASH
Secondary:
Hypertension
Diabetes Mellitus Type II (last HgbA1c 7.4% in [**5-/2172**])
Hyperlipidemia
Anxiety
Peripheral Neuropathy
Atrial fibrillation s/p DCCV now on dronedarone
Diastolic CHF EF - 55%, grade II diastolic dysfunction
AVR on coumadin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] because you black stools for 4
days. This was due to bleeding varices in your esophagus and
stomach which you have had in the past. You were initially
admitted to the ICU and treated with IV fluids, blood
transfusions, plasma transfusions, antibiotics and other
medications that would help stop this bleeding. Two upper
endoscopies were done to evaluate this bleeding and during the
second one a medication was injected to stop the bleeding. This
caused you to have fevers and due to this received antibiotics
that were subsequently stopped. You were later transferred to
the hepatology floor where everything remained stable and you
had no more episodes of bleeding. You had an abdominal
ultrasound that revealed no acute changes.
.
MEDICATION CHANGES:
START: PANTOPRAZOLE 40 mg daily
No othe changes were made to your medications
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**State **]When: THURSDAY [**2172-6-25**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: LIVER CENTER
When: THURSDAY [**2172-6-25**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ENDO SUITES
When: WEDNESDAY [**2172-7-8**] at 9:30 AM
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2172-7-8**] at 9:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], 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
|
[
"285.1",
"401.9",
"427.31",
"428.0",
"E849.7",
"250.00",
"E930.9",
"571.5",
"V58.61",
"572.3",
"V43.3",
"V64.1",
"428.32",
"456.20",
"276.7",
"518.81",
"780.61",
"537.89",
"455.6",
"287.5",
"458.9",
"578.1",
"535.60",
"584.9",
"356.9",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"88.64",
"44.43",
"45.13",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
18742, 18748
|
10646, 16787
|
289, 401
|
19130, 19130
|
4203, 4203
|
20277, 21340
|
3570, 3654
|
17251, 18719
|
18769, 19109
|
16906, 17228
|
19281, 20064
|
4956, 10623
|
3669, 3669
|
16808, 16880
|
20084, 20254
|
243, 251
|
429, 2425
|
4219, 4940
|
3683, 4184
|
19145, 19257
|
2447, 3249
|
3265, 3554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,150
| 199,416
|
44866
|
Discharge summary
|
report
|
Admission Date: [**2177-7-26**] Discharge Date: [**2177-8-23**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 74655**] is an 87 year-old
female who was transferred from [**Hospital 4415**]
with recent onset of left CN III palsy and headache. An MRA
performed at [**Hospital1 336**] had revealed the presence of a left bilobed
PCOM aneurysm. On arrival to [**Hospital1 69**]
she was awake, arousable, followed commands. She did have a
ventricular drain that was placed at [**Hospital 4415**].
She was brought to the angio suite on [**2177-7-26**] where she had
partial treatment of her wide-necked bilobed aneurysm.
Postoperatively, the patient's vital signs were heart rate 89
blood pressure 167/60, 100%, 17 respirations, 97.6. She was
arousable, following commands, unable to open her left eye.
Heart rate was regular rate and rhythm. Lungs were clear.
She had an A line in place. She was receiving Nipride for
her blood pressure control.
PAST MEDICAL HISTORY: Coronary artery bypass graft done in
[**2172**]. She had a right lobectomy in her right lung. She has
had back surgery. Questionable hypertension and
incontinence.
MEDICATIONS ON ADMISSION:
1. Imdur.
2. Vasotec.
3. Prilosec.
4. Lasix.
PHYSICAL EXAMINATION: Her arterial blood gas postoperatively
was 7.48, 34, 26. Neurological examination she obeys
commands, intubated, moving all four extremities, opens eyes
to voice, sleepy, but easily arousable, alert to person and
place not time. Full fields in right eye. Left eye ptosis,
irregular pupil on the left eye. Right pupil was 4 to 2
brisk, full extraocular movements intact on the right,
dysconjugate gaze and III nerve palsy. Good grasp.
LABORATORY: Hematocrit 29, white blood cell count 6.7,
platelets 146, sodium 139, potassium 3.8, chloride 107, CO2
24, 10 for BUN, creatinine .7, 155.
HOSPITAL COURSE: On the [**5-27**] in the morning the
patient did appear to be having some decreased mental status,
however, she was awake, not alert and oriented. Speech was
somewhat garbled. Her right pupil was reactive. CT of the
head showed no hemorrhages or early signs of infarction. She
was felt maybe to have sundowning. In the morning
of the 17th she was found to have a complete ptosis of the
left eye. She did have confused confabled speech. Her blood
pressures were kept in the 120s to 140s. She received an MRI
with DWI images that day. She was continued to be monitored
in the Intensive Care Unit given her decrease in mental
status. The patient was kept in the Intensive Care Unit.
The MRI that was done earlier in the day showed an acute
parietal left middle cerebral artery territorial infarct
along with chronic lacunar infarcts in the basal ganglion. The
patient was kept in the Intensive Care Unit through the 21st.
She had dysarthria and aphagia. She also seemed to be having
some delirium where psychiatry was involved. Her blood
pressures were kept below the 140 range. She was given
supportive care during this time. She was seen by physical
therapy and began a rehab plan. On the [**6-1**] when she
was on the floor she was afebrile. Heart rate was 80s. Blood
pressure 170s/90s. Seemed to follow some commands. Seemed
to be neurologically improved. Her blood pressure was
aggressively controlled. She did have a speech and swallow
test, which she did not pass and she continued to receive
nasogastric tube feedings. Psychiatry was following her for
her delirium, which was felt to be secondary to her recent
cerebral infarction. She was also found to have a urinary
tract infection at this time. On the [**6-4**] the
patient was found to be arousable, but very sleepy, still
aphasic. CT of the head was done on the 25th and was still a
stable area of infarct. No further infarct was noted. The
patient also had a more of a metabolic workup that showed her
electrolytes to be all within normal limits and her white
blood cell count was 7.7, hematocrit 34.9, liver function
tests were normal. Her TSH was also normal. Her metabolic
workup was felt to be negative at this time.
The patient did have a MRI on the 27th that showed slight
anterior flow increase. The comparison on the MRI from [**7-27**]
again noted there is a left temporal posterior insular
subacute infarction. There is no change in the appearance of
this abnormalities and no new areas of infarction were
identified. No focal microvascular infarction. There was
overall stable appearance of the brain. The patient also had
an electroencephalogram evaluation and was continued on tube
feedings. She had a gastrointestinal consult, however, the
family was not in agreement about starting PEG tube feedings.
They continued with the nasogastric tube feedings. The
patient continued to wax and wane as far as her mental
status. She was not following commands, however, was
attentive and opened her eyes. Her vital signs had been
stable. On the [**5-12**] the patient had not made up
their mind regarding PEG tube placement. Social work did get
involved with the family. On the 3rd there was a family
meeting with Dr. [**Last Name (STitle) 1132**] and the quality of life was discussed
for the patient and the family decided to hold off on any
discharge or rehab planning and PEG tube feedings at that
time. On the [**5-22**] Dr. [**Last Name (STitle) 1132**] discussed with the
family who decided given the patient's quality of life that
she would not want to continue to live in her current status
and not want to have a feeding tube in. The family decided
to make her DNR/DNI and comfort measures only. The patient
passed away on [**2177-8-23**] at 2:25 p.m. on a morphine drip with
her family at her bedside.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 32961**]
MEDQUIST36
D: [**2177-8-23**] 04:54
T: [**2177-8-25**] 09:31
JOB#: [**Job Number 95976**]
|
[
"599.0",
"784.3",
"401.9",
"997.02",
"V66.7",
"437.3",
"787.2",
"V45.81",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
1200, 1250
|
1884, 5967
|
1273, 1866
|
124, 983
|
1006, 1174
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,498
| 148,144
|
46369
|
Discharge summary
|
report
|
Admission Date: [**2105-1-8**] Discharge Date: [**2105-1-11**]
Date of Birth: [**2052-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with thrombectomy to bare metal stent in
the left coronary artery
History of Present Illness:
Mr. [**Known lastname 49486**] is a 52 year-old male with a PMH of CAD s/p PCI
in [**2102**], HTN, NIDDM admitted with anterior STEMI. The patient
presented with complaints of three hours of [**2-28**] chest pain with
radiation to his left arm. He had associated nausea and SOB. He
called his PCP who instructed him to go to the ED. His previous
presentation prior to his last cath was of increasing dyspena on
exertion. He denied having a history of chest pain.
.
In the ED, initial vitals were T 96.4, HR 96, BP 199/117, RR 20,
O2 98%. ECG demonstrated ST elevations I, II, AVL, V2-V6 with ST
depressions AVR. He was given Clopidogrel 600mg, Metoprolol 5mg
IV, Nitroglycerin SL and gtt started, ASA 81mg, Morphine 2mg IV
and Eptifibatide gtt was started. CK 302 with troponin 0.14. He
was taken emergently to the cardiac cath lab.
.
At cath he was found to have 100% proximal stent thrombosis of
the LAD. LCx and RCA were normal. He underent thrombectomy and
PTCA of the stent with good result except for a residual cutoff
to the distal diagnoal. He was given a loading dose of plavix
600 mg and continued on the eptifibatide gtt and nitro gtts. He
was also given 3 200 mcg boluses of nicardipine.
.
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 admits to awakening occasionally with
about an hour of subjective fevers/chills, but has had no
persistent fevers. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of dyspnea
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
3. OTHER PAST MEDICAL HISTORY:
CAD s/p bare metal stent to the proximal LAD placed 2 years ago
NIDDM
Hypertension
Social History:
He works at a sausage cart vendor [**Hospital1 98542**]. He admits to
smoking 3ppd for 35 years. He denies alcohol or drug use.
Family History:
Significant for his father dying from a MI at age 76.
Physical Exam:
GENERAL: Middle-aged male, somewhat anxious lying in bed in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP not able to be visualized.
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.
EXTREMITIES: No edema. Right femoral area has bandage with some
blood present in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Femoral 2+ DP 1+ PT 1+
Left: Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2105-1-8**] 06:05AM WBC-13.7* RBC-5.67 HGB-17.6 HCT-52.2* MCV-92
MCH-31.1 MCHC-33.8 RDW-13.5
[**2105-1-8**] 06:05AM NEUTS-85.0* LYMPHS-9.8* MONOS-4.2 EOS-0.4
BASOS-0.6
[**2105-1-8**] 06:05AM GLUCOSE-317* UREA N-26* CREAT-1.2 SODIUM-137
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2105-1-8**] 06:05AM CALCIUM-10.1 PHOSPHATE-4.2 MAGNESIUM-1.8
[**2105-1-8**] 06:05AM CK-MB-12* MB INDX-4.0
[**2105-1-8**] 06:05AM cTropnT-0.14*
[**2105-1-8**] 06:05AM PT-11.9 PTT-25.1 INR(PT)-1.0
[**2105-1-8**] EKG: Sinus rhythm. Anterolateral myocardial infarction
with ST-T wave configuration consistent with acute process.
[**2105-1-8**] CCATH: COMMENTS: 1. Coronary angiography in this right
dominant system demonstrated single vessel coronary disease. The
LMCA, LCx, and RCA were without angiographically apparent
disease. The LAD had 100% proximal in-stent thrombosis. 2.
Limited resting hemodyanmics revealed systemic arterial
normotension. 3. [**Month/Day/Year 18583**] percutaneous thrombectomy (utilizing
the Export catheter), and serial PTCA of the proximal LAD
thrombotic occlusion with 3.5, 4.0 and 4.5 mm balloons. Final
angiography showed an excellent result in the treated lesion
with no residual stenoses, residual thrombus or flow-limiting
dissection. TIMI 3 flow was evident throughout the LAD system
with a cut off (emboli) to the distal diagonal branch.
4. IVUS of the proximal LAD (including the old stent and the
whole
segment), showed an MLD of 4.3 mm and well apposed stent without
residual thrombus or dissection. 5. Successful deployment of a
6F Angioseal to the RCFA. 6. Due to the patient's body habitus,
access was moderately difficult advancing the J wire
retrogradely, requiring Magic Torque wire. FINAL DIAGNOSIS: 1.
Single vessel coronary artery disease with ST elevation MI from
acute thrombotic occlusion of the proximal LAD consistent with
very-late stent thrombosis. 2. Percutaneous thrombectomy of the
thrombotic proximal LAD lesion with Export catheter. 3.
[**Name (NI) 18583**] PTCA of the proximal LAD lesion (including the stent)
with 3.5, 4.0, and 4.5 mm balloons with excellent final result.
4. IVUS of the proximal LAD showed excellent PTCA result. 5.
Successful closure of the RCFA with 6F Angioseal. 6. Embolic
occlusion of the distal diagonal . Monitor renal function and
switch to renal dose if GFR < 50. 7. Prasugrel (Not Plavix)
starting in AM with 60 mg bolus then 10 mg daily. 8. Complete
smoking cessation, weight loss (minimum of 10% of current
weight), and best medical management for secondary prevention
(target BP < 130/80, LDL <70, HDL>45, TG<150).
[**2105-1-8**] TTE: The left atrium is elongated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with akinesis of the
anterior wall, septum and apex. The remaining segments contract
normally (LVEF = 25-30%). Anterior wall and septum appear
slightly edematous, suggesting a recent MI. No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a very small pericardial
effusion. The effusion appears circumferential.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w recent LAD-territory myocardial infaction. Very
small pericardial effusion.
Brief Hospital Course:
Mr. [**Name14 (STitle) 98543**] is a 52 year-old male with pmh of hypertension,
HL, CAD s/p bare metal stent in [**2102**] admitted with a STEMI
secondary to an instent thrombosis s/p thrombectomy.
#. CORONARIES/STEMI: The patient presented with chest pain and
STE in V2-V6, I, II, aVL. Cardiac catheterization showed instent
thrombosis of the proximal LAD bare metal stent (previously
placed around 2 years prior). He had the thrombosis removed and
was admitted to the CCU. The patient was initially plavix loaded
and was given integrillin and was continued on aspirin,
simvastatin, nitroglycerin gtt. The patient was soon started on
metoprolol tartrate for blood pressure and heart rate control.
Initially the plan was to start prasugrel, however, the patient
was unable to attain the medication at a pharmacy near his
house. Thus, he was started on plavix 150mg daily. An ACE
inhibitor was also added. The patient had a TTE which showed
apical akinesis and a depressed ejection fraction. He was
started on warfarin and lovenox 150mg [**Hospital1 **]. He was counselled on
smoking cessation. He was discharged with follow up with Dr.
[**Last Name (STitle) **].
#. Decrease ejection fraction: The patient was started on ACE
inhibitor and metoprolol tartrate as described above. The
patient will follow up with Dr. [**Last Name (STitle) **] as an outpatient.
#. Hypertension: The patient was continued on lisinopril 20mg
[**Hospital1 **] and started on metoprolol succinate 50mg daily. He had good
blood pressure control as an inpatient.
#. Diabetes Type II: The patient was started on an insulin
sliding scale. He was switched back to his oral medications as
an outpatient.
#. Anxiety: The patient presented and was very anxious. He
denies history of alcohol abuse. It is likely related to
nicotine withdrawal. He was given nicotine patch and nicorette
gum prn for withdrawal sypmtoms.
Medications on Admission:
Glipizide XL 10 mg po daily
Metformin 1000 mg qam, 500 mg qpm
Simvastatin 80 mg po daily
Niaspan 1000 mg po daily
Lisinopril 20 mg po bid
Hydrochlorothiazide 12.5 mg po daily
ASA [**11-22**] tablet
? Metoprolol (not mentioned in the last note, but per Dr. [**Last Name (STitle) **]
he was on this)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO every
morning.
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Niaspan 1,000 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
10. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Lovenox 150 mg/mL Syringe Sig: One (1) ml Subcutaneous twice
a day.
Disp:*10 syringes* Refills:*2*
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety: do not drive while taking this medication.
Disp:*7 Tablet(s)* Refills:*0*
13. Lovenox 150 mg/mL Syringe Sig: One (1) ml Subcutaneous twice
a day for 2 doses.
Disp:*2 syringes* Refills:*0*
14. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Acute systolic Dysfunction with EF 25%
Hypertention
Diabetes mellitus type 2
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a clot in your stent that caused a heart attack. The
clot was removed and there is now good blood flow through the
stent. You will need to restart your plavix to protect your
heart. Your heart is also weak after the heart attack. this
increases your risk of blood clots. You will need to inject
lovenox twice daily to keep your blood thin and take couamdin
for at least a few months until your heart function improves.
Dr. [**Last Name (STitle) **] will monitor your labs and tell you when you can stop
taking the injections. You are also at risk for fluid retention
because of your heart fucntion. 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.
.
Medication changes:
1. Start taking Plavix 150mg daily
2. Start taking Enoxaparin (lovenox) 150mg under the skin twice
daily.
3. Start taking coumadin to prevent blood clots. Please check
your INR on [**1-12**] at Dr.[**Name (NI) 11325**] office.
4. Increase your aspirin to 325 mg daily
5. Stop taking Hydrchlorothiazide
6. Start taking Metoprolol to lower your heart rate and help
your heart recover from the heart attack.
7. Use the nicotine patch to help you quit smoking. This is the
most important thing you can do for your health.
Followup Instructions:
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] B. Phone: [**0-0-**] Date/time: Please call the
office on Monday morning to arrange a blood test for the
coumadin level and to schedule a follow up appt for 2 weeks.
|
[
"996.72",
"410.01",
"414.2",
"401.9",
"250.00",
"305.1",
"414.01",
"300.00",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"00.41",
"00.66",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
10800, 10806
|
7074, 8967
|
310, 402
|
10962, 10962
|
3419, 5159
|
12399, 12626
|
2574, 2629
|
9316, 10777
|
10827, 10941
|
8993, 9293
|
5176, 7051
|
11107, 11837
|
2644, 3400
|
2258, 2296
|
11857, 12376
|
265, 272
|
430, 2168
|
10976, 11083
|
2327, 2413
|
2190, 2238
|
2429, 2558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,436
| 190,374
|
14923
|
Discharge summary
|
report
|
Admission Date: [**2166-12-11**] Discharge Date: [**2166-12-17**]
Date of Birth: [**2093-6-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2166-12-12**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending artery;
vein grafts to obtuse marginal and posterior descending artery.
[**2166-12-11**] Cardiac catheterization
History of Present Illness:
This is a 73 year old female with multiple cardiac risk factors.
She recently complained of chest pain which she described as
left sided pressure sensation which was related to emotional
stress. She subsequently underwent stress testing which was
notable for 1 mm upsloping ST segment depressions that resolveed
10 minutes into recovery. Perfusion imaging showed reversible
defects in the apex, anterior, lateral, and inferior walls.
Gated images revealed mild distal anterior and apical
hypokinesis with an LVEF of 66%. She was therefore referred for
cardiac catheterization.
Past Medical History:
Hypertension, Diabetes Mellitus, Depression, Renal cell tumor,
Hypothyroidism - s/p right and left thyroidectomy, Peptic Ulcer
Disease, GERD, Sciatic Pain
Social History:
Denies history of tobacco and ETOH. She lives alone.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: Temp 96.4, BP 140/60, HR 61, RR 18, SAT 95% on room air
General: elderly female in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD, no carotid bruit
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2166-12-15**] 07:10AM BLOOD WBC-11.5* RBC-3.36* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.8 MCHC-34.6 RDW-13.6 Plt Ct-195
[**2166-12-14**] 02:08AM BLOOD PT-12.6 PTT-25.1 INR(PT)-1.1
[**2166-12-15**] 07:10AM BLOOD Glucose-150* UreaN-24* Creat-0.8 Na-142
K-3.9 Cl-102 HCO3-30 AnGap-14
[**2166-12-15**] 07:10AM BLOOD ALT-14 AST-19 AlkPhos-74 Amylase-23
TotBili-0.6
[**2166-12-12**] 12:56AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2166-12-11**] CXR
Mild cardiomegaly, clear lungs. No acute process.
[**2166-12-13**] CXR
Cardiomegaly. No evidence of CHF.
[**2166-12-12**] EKG
Sinus rhythm. Low precordial lead voltage. Compared to the
previous tracing of [**2166-12-11**] no diagnostic interim change.
[**2166-12-11**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant system
demonstrated severe three (3) vessel coronary artery disease.
The LMCA
demonstrated mild disease throughout. The LAD had a total
occlusion in
the mid portion of the vessel. The LCX was diffusely diseased
with a
70% OM lesion. The RCA was diffusely diseased with a 90% mid
vessel
stenosis.
2. LV ventriculography demonstrated mildly depressed systolic
function
with an estimated ejection fraction of 55%. Several LV focal
wall
motion abnormalities were noted including - anteriolateral and
apical
hypokinesis. No mitral regurgitation noted.
3. Bilateral renal angiography demonstrated no significant
atherosclerosis.
4. Limited resting hemodynamics demonstrated an elevated
central aortic
pressure (175/77 mm Hg) along with an elevated left filling
pressure
(LVEDP 25 mm Hg). There was no significant gradient across the
aortic
valve upon pullback from the left ventricle.
[**2166-12-17**] 06:50AM BLOOD Hct-29.3*
[**2166-12-17**] 06:50AM BLOOD K-4.3
Brief Hospital Course:
Ms. [**Known lastname 43737**] was admitted and underwent cardiac
catheterization. Selective coronary angiography demonstrated a
right dominant system with severe three vessel coronary artery
disease. The LMCA demonstrated mild disease throughout. The
LAD had a total occlusion in the mid portion of the vessel. The
LCX was diffusely diseased with a 70% OM lesion. The RCA was
diffusely diseased with a 90% mid vessel stenosis. Left
ventriculography demonstrated mildly depressed systolic function
with an estimated ejection fraction of 55%. No mitral
regurgitation was noted. Bilateral renal angiography
demonstrated no significant atherosclerosis. Based on the above
results, cardiac surgery was consulted and further evaluation
was performed. Workup was relatively unremarkable and she was
cleared for surgery.
On [**12-12**], Dr. [**Last Name (STitle) **] performed three vessel coronary
artery bypass grafting. The operation was uneventful and she was
brought to the CSRU in stable condition. Within 24 hours, she
awoke neurologically intact and was extubated. She maintained
stable hemodynamics and weaned from inotropic support without
difficulty. Low dose beta blockade was resumed as well as
aspirin therapy. On postoperative day two, she transferred to
the SDU for further recovery. On post-operative day three, Ms.
[**Known lastname 43737**] went into Atrial fibrillation and responded well to IV
Lopressor and converted back into sinus rhythm. She was gently
diuresed towards her preoperative weight. The [**Last Name (un) **] diabetes
service was consulted for assistance with her diabetes
medication management. Low dose lantus was started and diabetes
teaching was initiated. Ms. [**Known lastname 43737**] continued to make steady
progress and was discharged home on postoperative day five. She
will follow-up with Dr. [**Last Name (STitle) **] and her primary care physician
as an outpatient. Her primary care physician will obtain an
outside cardiologist for Ms. [**Known lastname 43737**].
T 99.6 HR 75 SR 154/76 RR 20 99% RA sat.
Medications on Admission:
Lipitor, Protonix 40 qd, Metformin 1000 [**Hospital1 **], Nefedical 30 qd,
Atenolol 25 qd, Synthroid 112 mcg daily,
Prandin one tab qAM and HS,2 tabs qPM
Aspirin 81 mg daily
Actos 30 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Hospital1 **]:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
2. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
[**Hospital1 **]:*120 Tablet(s)* Refills:*1*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
[**Hospital1 **]:*45 Tablet(s)* Refills:*0*
7. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days: Take for 5 days with potassium and then stop.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
10. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5
days: Take with lasix and stop when lasix stopped.
[**Hospital1 **]:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Lantus 100 unit/mL Solution Sig: Six (6) Units Subcutaneous
at bedtime: Take as directed by physician.
[**Name Initial (NameIs) **]:*1 1 months supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Family care Extended Inc
Discharge Diagnosis:
Coronary Artery Disease - s/p Coronary Artery Bypass Graft
Hypertension
Diabetes Mellitus
Depression
Renal cell tumor
Hypothyroidism - s/p right and left thyroidectomy
Peptic Ulcer Disease
Gastroesophageal Refulx Disease
Sciatic Pain
Discharge Condition:
Good
Discharge Instructions:
1) Patient may shower, no baths until wound has healed.
2) No creams, lotions or ointments to incisions until it has
healed.
3) No driving for at least one month. No lifting more than 10
lbs for at least 10 weeks from the date of surgery.
4) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
5) Mointor finger stick blood sugars before meals and at
bedtime. Keep a log for Dr. [**Last Name (STitle) 3357**] to review at your postop
visit.
6) Take lasix for 5 days with potassium and then stop.
7) Report any weight gain of more then 2 pounds in 24 hours or 5
pounds in one week.
8) Please call with any concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-29**] weeks. ([**Telephone/Fax (1) 1504**]
Local PCP/cardiologist, Dr. [**Last Name (STitle) 3357**] in [**1-26**] weeks.
Please call above providers for appointments.
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2166-12-31**]
1:45
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2167-1-7**] 9:00
Dr. [**Last Name (STitle) 12746**] at [**Hospital **] Clinic in 2 weeks.
Completed by:[**2167-1-5**]
|
[
"414.01",
"V10.52",
"411.1",
"311",
"724.3",
"427.31",
"250.00",
"401.9",
"530.81",
"244.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.53",
"88.55",
"36.12",
"36.15",
"37.22",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8060, 8115
|
3750, 5819
|
334, 574
|
8392, 8398
|
1896, 3727
|
9113, 9699
|
1444, 1487
|
6062, 8037
|
8136, 8371
|
5845, 6039
|
8422, 9090
|
1502, 1877
|
284, 296
|
602, 1180
|
1202, 1358
|
1374, 1428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,932
| 126,267
|
15104
|
Discharge summary
|
report
|
Admission Date: [**2159-5-7**] Discharge Date: [**2159-5-22**]
Date of Birth: [**2093-11-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Right hand clumsiness
Major Surgical or Invasive Procedure:
[**5-9**]->Left Craniotomy for mass resection
[**5-14**]->Right Craniotomy for mass resection
History of Present Illness:
65 y/o male who has had right arm weakness/clumsiness
characterized by dropping of objects difficulty with position
sensation, went to [**Hospital6 **] on [**5-7**] when symptoms
became worse. Ct of the head showed an area of hemorrhage in the
left temp/ parietal lobe and an MRI revealed two lesions one in
the right and one in the left temp. parietal regions. He was
then transferred to [**Hospital1 18**] for definitive neurosurgical care
Past Medical History:
Melanoma lesion on left posterior neck resected two years ago
with clear margins.
Diverticulosis
s/p partial bowel resection
Social History:
Married, One glass of wine/day, remote smoking history 30 years
ago for 20yrs/pk/day
Family History:
father-leukemia
[**Name (NI) 44090**] CA
Physical Exam:
Exam upon admission:
T:98.6 BP: 153 /100 HR: 80 R:18 O2Sats:98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: L 7mm flicker, R 6 to 4 brisk EOMs: intact
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-27**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, as above. Visual
fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Right hand grip
strength
4/5, finger to nose dysmetria and pronator drift. No abnormal
movements. Left arm strength full.
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
No clonus
Exam on Discharge:
The patient is dysarthric. He is oriented x 3. He has a slightly
flattened left nasal labial fold. Pupils are PERRL. He has
persistant right upper extremity weakness, and left upper
extremity weakness that is steroid dose dependent. His
distal(LE) strength is full. Sensation is intact. Both wounds
are clean, dry and intact; without erythema or drainage. Sutures
have been removed.
Pertinent Results:
Labs on Admission:
[**2159-5-7**] 12:20AM BLOOD WBC-10.3 RBC-4.61 Hgb-13.9* Hct-40.4
MCV-88 MCH-30.2 MCHC-34.5 RDW-13.2 Plt Ct-361
[**2159-5-7**] 12:20AM BLOOD Neuts-87.4* Lymphs-9.2* Monos-2.2 Eos-0.8
Baso-0.4
[**2159-5-7**] 12:20AM BLOOD PT-14.1* PTT-27.5 INR(PT)-1.2*
[**2159-5-7**] 03:30AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.1
Labs on Discharge:
XXXXXXXXXXX
Imaging:
CT Torso [**2159-5-7**]:
CT CHEST: The left thyroid is enlarged and heterogeneous without
focal
lesion. A 2.9 x 2.1 cm left lower lobe subpleural lung mass
(3:42) and a 5 mm right upper lobe nodule (3:40) are noted.
Calcified nodule near the right hilum (3:33) likely represents
sequela of prior granulomatous disease. There is no mediastinal
adenopathy. Several enlarged right axillary lymph nodes measure
up to 25 x 22 mm (3:22). Heart size is normal. There is no
pericardial effusion. The pulmonary arteries are patent to the
segmental level.
CT ABDOMEN: The gallbladder, spleen, adrenals, and pancreas are
unremarkable. Well-circumscribed hypodense subcentimeter liver
lesion in segment III (3:50) likely represents a cyst but is not
fully characterized. The liver is otherwise unremarkable without
evidence of intra- or extra-hepatic biliary dilatation or focal
lesion. Both kidneys demonstrate several subcentimeter well-
circumscribed lesions which likely represent cysts but are not
fully characterized. There is extensive descending and distal
transverse colon diverticulosis without evidence of
diverticulitis. The intra-abdominal loops of large and small
bowel are otherwise unremarkable without evidence of
pneumatosis, free air, or obstruction. There is no mesenteric or
retroperitoneal lymphadenopathy.
CT PELVIS: The bladder, rectum, and prostate are unremarkable.
There is
extensive sigmoid diverticulosis without evidence of
diverticulitis.
Bone windows demonstrate no lesion that is concerning for
metastasis or
infection. Mild multilevel degenerative changes are noted.
IMPRESSION:
1. Left lower lobe lung mass likely represents metastasis,
although tissue
diagnosis can be obtained if indicated.
2. Right axillary lymphadenopathy likely reflects metastatic
recurrence.
3. Heterogeneous left thyroid should be further evaluated on
thyroid
ultrasound.
4. Extensive diverticulosis without evidence of diverticulitis.
Head CT [**5-7**]:
FINDINGS: In the right frontotemporal region, there is a 2.5 x
3.3 cm
hypodensity with fine hyperdense rim and surrounding vasogenic
edema (series 2, image 19). This is essentially identical in
size to the lesion defined on the MR (2.6 x 3.3 cm). There is
slight effacement of the subjacent body of the right lateral
ventricle but no significant shift of the midline structures. At
the left frontovertex, there is 2.2 x 3.0 cm hyperdense lesion,
with mild surrounding vasogenic edema and overlying subarachnoid
hemorrhage, similar in size to the lesion defined on the MR (2.0
x 2.7 cm). At the posterolateral aspect of this process, there
is an ovoid isodense focus measuring 1.2 x 0.9 cm (2:24),
corresponding to the enhancing peripheral nodule on the MR. [**Name13 (STitle) **]
other foci of acute hemorrhage are seen. There is no fracture.
There is no osteolytic or- blastic lesion. Mastoid air cells and
paranasal sinuses are clear. No subcutaneous nodules are
demonstrated.
IMPRESSION: Unchanged appearance of right frontotemporal lesion
and left
frontovertex hemorrhagic lesion, likely metastases (for further
details,
please refer to the MR [**First Name (Titles) 767**] [**Hospital6 1597**]).
MRI Head [**5-11**](post-rsxn):
FINDINGS: The patient is status post left parietal craniotomy,
in comparison with the prior study, the previously described
left frontal lobe mass lesion, has been resected. The T1
sequence without contrast demonstrates a nodular area of
hyperintensity signal, likely consistent with blood products and
apparently unchanged after the administration of gadolinium
contrast. Restricted diffusion is noted adjacent in the
posterior margin of the surgical area, blooming artifacts and
magnetic susceptibility changes are visualized in the surgical
bed. The pattern of vasogenic edema is unchanged. The right
frontoparietal deep white matter lesion is unchanged and
demonstrates again thick rim enhancement as well as mural
enhancement as described in the prior examination. Normal flow
void signal is identified in the major vascular structures, the
orbits, the paranasal sinuses and mastoid air cells are
unremarkable.
IMPRESSION: 1. Status post left parietal craniotomy, there is a
nodular area of hyperintensity signal in the surgical bed and
posterior surgical margin, likely consistent with blood
products, however residual mass lesion is a consideration,
follow-up is recommended.
2. Similar pattern of vasogenic edema, the right frontoparietal
deep white
matter lesion is unchanged.
Head CT [**5-14**](post-rsxn)
FINDINGS: Again noted are left parietal craniotomy changes, with
air seen
within the surgical bed, similar in appearance to prior study.
Residual
vasogenic edema within the left frontal and parietal lobes are
again noted.
Minimal focus of hemorrhage within the surgical bed is also
unchanged. In the interim, there has been interval right frontal
craniotomy, with post-surgical changes seen, with
pneumocephalus, small foci of hemorrhage. There is residual
vasogenic edema. Additionally, there is pneumocephalus overlying
the right frontal lobe, as well as small subdural collections
bilaterally. No new foci of hemorrhage are identified.
Ventricles and sulci are normal in caliber and configuration.
There is no shift of normally midline structures. Visualized
paranasal sinuses are normally aerated.
IMPRESSION:
1. Interval right frontal craniotomy, with expected
post-surgical changes
within the surgical bed, with pneumocephalus, small amount of
hemorrhage.
2. Stable post-surgical changes within the left parietal lobe,
following
surgical resection.
Head CT [**5-16**]:
NON-CONTRAST HEAD CT: There has been no significant interval
change since one day prior. There are bilateral craniotomies
with post-surgical changes in the left parietal lobe, including
a tiny amount of pneumocephalus, residual postoperative
hemorrhage and vasogenic edema. Within the right temporal and
parietal resection bed, there is pneumocephalus, hemorrhage and
edema. Postoperative hemorrhage is stable measuring 5.7 x 4.1
cm. There is stable minimal shift of midline structures, of
approximately 3 mm leftward shift. No new foci of hemorrhage are
identified. The visualized paranasal sinuses and mastoid air
cells are clear.
IMPRESSION: No significant change in the right temporoparietal
lobe resection bed hemorrhage and additional postoperative edema
and pneumocephalus within the left cerebral hemisphere.
Head CT [**5-17**]:
FINDINGS: Patient is status post bilateral craniotomies. Within
the surgical bed in the right temporal and parietal lobes, there
is residual hemorrhage, pneumocephalus, and vasogenic edema.
Compared to the prior study, there has been no interval change
in size of the residual hemorrhage. Postoperative changes in the
left parietal lobe with tiny residual hemorrhage,
pneumocephalus, and vasogenic edema are also stable. There is a
minimal leftward shift of normally midline structures of
approximately 3 mm, unchanged. There are no new foci of
hemorrhage. Ventricles and sulci are normal in caliber and
configuration without evidence of hydrocephalus. Visualized
paranasal sinuses and mastoid air cells are normally aerated.
IMPRESSION:
1. No significant interval change from the prior study in the
postoperative hemorrhage within the right temporoparietal lobe
resection bed.
2. Stable post-surgical changes with the left parietal resection
bed.
LENIS [**5-15**]:
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and color
Doppler imaging of the right and left common femoral,
superficial femoral and popliteal veins demonstrate normal
compressibility, augmentation, waveforms and flow. The peroneal
veins are unremarkable.
IMPRESSION: No lower extremity DVT.
EKG [**5-7**]:
Sinus rhythm
Modest ST junctional depression is nonspecific and may be within
normal limits, but clinical correlation is suggested No previous
tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 156 98 366/416 28 -25 5
Brief Hospital Course:
The patient was admitted to the neurosurgery service on [**5-7**]. On
[**5-9**] he went to the operating room for a left sided craniotomy
to resect the first of two brain lesions. Post-operatively he
was monitored in the ICU for 24hrs without incident. He was then
transferred to the neurosurgery floor for continued planning for
the resection of the right sided lesion. During his hospital
stay, neuro oncology and radiation oncology were consulted for
this patient. On 4.20, he underwent right sided craniotomy for
debulking of said lesion prior to cyberknife therapy could be
started. Post operatively, he was again transferred to the ICU
for continued monitoring. On POD#1 he was found to have new
weakness in the left upper extremity, and to be more lethargic.
A head CT was immediately done and there was new bleeding
identified in the right sided resection cavity, as well as
increased vasogenic edema. He did not worsen neurologically that
day, so head CT was again repeated on [**5-16**]. Vasogenic edema was
again noted, and lethargy persisted. It was decided to increase
the dose of his steroids from 4mg three times daily to 6mg four
times daily.
The patient was improving neurologically and was transferred to
the stepdown unit on [**2159-5-17**]. He was evaluated by neuro-oncology
and was scheduled for a Brain [**Hospital 341**] Clinic appointment. PT and
OT evaluated the patient and recommended rehab placement.
His diet was advanced to regular and he tolerated that well. His
steroids were initially decreased to 3mg QID, but had recurrance
of left upper extremity weakness. The steroids were again
increased to 4mg QID; and to remain at this dose until WBR
therapy was initiated and could have this re-evaluated.
On [**5-21**],he was transported to the [**Hospital1 18**] [**Hospital Ward Name **] to receive
mapping planning for WBR. He tolerated this well, and was
returned to the [**Hospital Ward Name **]. He was then discharged to an
appropriate rehab facility on [**2159-5-22**] with follow up scheduled
in the brain tumor clinic.
Medications on Admission:
[**Hospital1 **] Benadryl prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
11. Regular Insulin Sliding Scale
Regular Insulin Sliding Scale per nursing flow sheet
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right fronto-temporal, and left frontovertex brain lesions
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may shower and wash your head normally, as your sutures
have been removed prior to discharge.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-3**] days (from your 2nd
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic with Dr. [**Last Name (STitle) 724**]
[**Telephone/Fax (1) 1844**]. It is on [**2159-6-4**] at 2:00 pm. The Brain [**Hospital 341**]
Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], on [**Hospital Ward Name 23**] 8.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization
Completed by:[**2159-5-22**]
|
[
"V10.82",
"197.0",
"196.3",
"348.5",
"431",
"198.3",
"997.02",
"562.10",
"E878.8",
"781.3",
"V15.82",
"787.20",
"729.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
14376, 14455
|
11236, 13297
|
299, 395
|
14558, 14582
|
2895, 2900
|
16399, 17199
|
1133, 1176
|
13377, 14353
|
14476, 14537
|
13323, 13354
|
14606, 16376
|
1191, 1198
|
237, 261
|
3244, 8860
|
423, 866
|
1727, 2473
|
2492, 2876
|
8869, 11213
|
2914, 3225
|
1449, 1711
|
888, 1014
|
1030, 1117
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,098
| 164,266
|
3342
|
Discharge summary
|
report
|
Admission Date: [**2194-8-29**] Discharge Date: [**2194-9-3**]
Date of Birth: [**2138-2-10**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Iodine
Attending:[**First Name3 (LF) 15519**]
Chief Complaint:
Labile blood pressure
Major Surgical or Invasive Procedure:
Arterial line placement [**8-29**]
History of Present Illness:
56F with h/o Stage IV Ovarian CA , recurrent DVTs, morbid
obesity and HTN who was sent to the ED from Oncologist's office
with Creatinine of 3.2 after five days out from an Abd CT with
IV contrast on [**2194-8-25**] to evaluate for peritoneal mets. She was
also taking increasing doses of MSContin for pain as her kidney
fxn was declining. She has been mildly somnelent for few days
PTA with occasional nausea and headache. No fevers, chills,
diarrhea, hematuria, SOB. She does report decreased urine output
over the past several days.
.
In ED, she did not have accurate blood pressure measurements
secondary to her obesity and an inability to find an extra large
BP cuff. Systolic BPs were recorded from the 50s to the 160s,
though she had no clinical evidence of hypotension. Cardiology
was called for Echo which revealed no evidence of tamponade,
with nml EF. Pt received a total of 4L NS. A left radial A line
was placed, she had persistent hypotension, with her blood
pressure supported with pressors and IVF in the MICU. Of note,
she had a prompt response to Narcan, so it was thought her
change in mental status was [**3-19**] both contrast nephropathy and a
decreased ability to metabolize opioids while she was increasing
her dose at home. Renal was consulted, and incr her renal
perfusion with pressors, IVF, lasix challenges. As obstruction
was considered, a renal ultrasound on [**8-29**] demonstrated no evid
of hydronephrosis. Her Creatinine continued to improve, and at
the time of her transfer to the floor, her Cr was 1.2, down from
6.6 on [**8-30**].
.
She was started on a heparin drip given her h/o UE DVT in the
right axillary and subclavian veins, previously managed with
lovenox. A LE doppler on [**8-29**] demonstrated no DVTs. It is
unclear why the pt was not on coumadin at home. At transfer to
floor, she was changed from heparin drip to sq lovenox.
.
Heme-onc also followed the pt, she is s/p 5 cycles of
[**Doctor Last Name **]/taxol with resistant disease and will be switched to Doxil
per Dr. [**Last Name (STitle) 15520**]. She has persistently low Hct/plt, which
heme/onc feels is a likely side effect of chemo. She is
DNR/DNI.
Past Medical History:
1. Diabetes mellitus type 2
2. Stage IV ovarian/peritoneal CA dx'd [**5-20**] after presentation
wtih new ascites and DOE, exudative pleural effusion returned as
adenocarcinoma. Elevated CA-125. Status post 3 cycles of taxol
and Carboplatin (last [**7-7**]). Oncologist = [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**]
3. Morbid obesity
4. H/o recurrent RLE DVTs following trauma to RLE, s/p IVC
filter >6 yrs ago. Had been off anticoagulation X 6 years prior
to current DVT. Started on Lovenox on [**7-16**].
5. Hypertension
6. Hypercholesterolemia
7. Osteoporosis
8. s/p c
Past surgical history:
s/p cholecystectomy
s/p TAH (ovaries left in place)
Has right port-o-cath
Social History:
She used to work as a computer programmer. History of IVDU
(heroin), none in a number of years. History of heavy alcohol
consumption. Ex-smoker, she quit about 10 years ago. She used to
smoke about [**3-20**] ppd X years. Disabled from leg injury in past.
Family History:
Mother with history of stomach cancer. Brother with Hepatitis.
Father in good health.
Physical Exam:
PE: BP: AF 90's/70's P:67 RR: 14 Oxygen sat: 94%RA
GEN: Chronically ill. A&O X 3.
HEENT: Left eye down and out. Left ptosis. PERRL.
NECK: Swelling or right arm swelling. The right Port-A-Cath is
okay.
LUNGS: Show diminished breath sounds at the bases, left greater
than right.
CARDIAC: Regular rate and rhythm, no murmur, rub or gallop.
ABDOMEN: Obese with normal bowel sounds. Exam limited by body
habitus.
EXTREMITIES: Warm without rash.
Neuro: Non-focal other than left eye esotropia and ptosis. No
papilledema. Normal gait. Strength 5/5 upper and lower
extremities. Sensation intact throughout.
Pertinent Results:
CT OF THE CHEST WITH IV CONTRAST: There is interval decrease in
the left-sided pleural effusion with interval improved aeration
of the left lung. There is residual left-sided atelectasis.
Multiple calcified granuloma at the left lung base are again
demonstrated and unchanged. The airways appear patent to the
level of the segmental bronchi bilaterally. The heart,
pericardium, and great vessels are unremarkable.
CT OF THE ABDOMEN WITH IV CONTRAST: Multiple intra-abdominal
fluid collections are again demonstrated and not significantly
changed in size or distribution compared to the prior study. The
appearance of a high density, thin, rim surrounding many of
these collections is again seen and unchanged. The liver,
spleen, adrenal glands, kidneys, stomach, small bowel, and large
bowel are unremarkable. The pancreas is poorly visualized and
appears atrophic. An IVC filter is in place. Multiple
gastrohepatic ligament nodes measuring 11 and 12 mm in short
axis diameter are stable. No free air is seen.
CT OF THE PELVIS WITH IV CONTRAST: The bladder, distal ureters,
rectum, and sigmoid colon are unremarkable. There is no pelvic
or inguinal lymphadenopathy.
CT Head: No obvious mass or midline shift or other evidence
increased ICP. (unofficial read).
CXR [**2194-9-3**]: IMPRESSION: Resolving left lower lobe opacity
which may relate to resolving atelectasis or improving
pneumonia. Persistent small left pleural effusion.
ECHO [**2194-8-30**]: Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
A/P: 56F with h/o Stage IV Ovarian CA, recurrent DVTs, morbid
obesity and HTN with acute renal failure [**3-19**] contrast
nephropathy, and altered mental status [**3-19**] increasing opioid
doses in setting of failing kidneys (kidneys not able to clear
MSContin).
.
1. Acute renal failure, Contrast Nephropathy: Given temporal
relationship to contrast study, we felt this was most likely
contrast nephropathy. Her FENa was calculated to be 0.4% which
can be consistent with renovascular constriction from contrast
in the setting of DM. Her renal ultrasound was without evidence
of obstruction. We held her ACEI given ARF, and increased her
renal perfusion in the ICU with IVF, pressors and lasix
challenges. Her Creatinine responded appropriately, and her
renal function demonstrated a downward trend in creatinine. She
urinated well, with discharge Cr at 1.2 (her baseline). Renal
was consulted and followed pt throughout her hospital course.
.
2. Cardiovascuar/Hypotension:
The etiology of her presenting hypotension was unclear, given
she had no active infection and this was not a septic picture.
She had +MRSA sputum with ?PNA.
Her echo on admission demonstrated EF=60%, but suboptimal [**3-19**]
anterior fat pad, so tamponade could not initially be ruled
out. She did not have a pulsus parodoxicus or elevated JVP.
.
3. Change in Mental Status secondary to uremia vs oversedation,
with decreased clearance of MSContin. Following admission to the
ICU, she developed worsening mental status, that responded well
to 0.4 mg Narcan. Of note, her MSContin dose recently increased
to 100 mg PO BID, so we felt that she had decreased clearance in
setting of ARF. Her Head CT was wnl; and the pt was refusing
MRI (to look for carcinomatous meningitis). She can follow up
as an outpatient with Dr. [**Last Name (STitle) 15520**] regarding MRI for staging
workup of the brain. At discharge, her mental status is clear.
.
4. Pulmonary: During her stay, she had a left pleural effusion
with left lower lobe opacification, suggesting atelectasis
versus consolidation on CXR. Furthermore, her sputum cx came
back positive for MRSA. This could be due to colonization vs.
MRSA PNA. She has remained afebrile, however, satting 100% on
RA. This was resolving on subsequent CXRs.
.
5. Chronic anemia. Her Hematologist/Oncologist felt this is
likely secondary to treatment with the [**Doctor Last Name **]/taxol regimen. Pt
is s/p 5 cycles. We followed serial HCTs, without need for
transfusion. This will be monitored as outpatient.
.
6. Right dilated pupil: Question with regards to the chronicity
as pt reports having this in the past, but it is not documented
in prior notes. Initial Head CT negative. Pt does not want
further imaging studies despite our explaining our concern for
increased intracranial pressure or carcinomatous meningitis.
- F/U with MRI with Dr. [**Last Name (STitle) 15521**], if pt agrees.
.
6. RUE DVT: Dx with thrombus in right axillary and subclavian
veins, previously managed with Lovenox. Unclear why pt was not
on Coumadin. The pt is now on sQ Lovenox 120mg SQ QAM, 150mg SQ
QHS. She was on a heparin gtt while in the MICU.
.
7. DM: Continue present outpatient management. On SSI in the
hospital.
.
8. Code status: Pt is DNR/DNI. Partner's sister is patient's
HCP.
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs MDI* Refills:*0*
4. 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:*2*
5. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*2*
7. Enoxaparin Sodium 120 mg/0.8 mL Syringe Sig: One (1)
Subcutaneous QAM (once a day (in the morning)).
Disp:*qs 120mg/0.8mL syringes* Refills:*2*
8. Enoxaparin Sodium 150 mg/mL Syringe Sig: One (1) 150mg/mL
syringes Subcutaneous QPM (once a day (in the evening)).
Disp:*qs 150mg/mL syringes* Refills:*2*
9. Flovent 110 mcg/Actuation Aerosol Sig: 2 puffs Inhalation
q4-6h prn wheezing.
Disp:*1 MDI* Refills:*2*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
4 times per day prn as needed for pain: Can take an additional 4
pills total throughout the day for breakthrough pain. Max per
day: 8 pills.
Disp:*40 Tablet(s)* Refills:*0*
11. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
6 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
1. acute renal failure secondary to intravenous
contrast/contrast-induced nephropathy
2. opioid ingestion in setting of acute renal failure leading
to altered mental status
3. pneumonia
4. Stage IV Ovarian cancer
5. Type II Diabetes Mellitus
6. Morbid obesity
7. h/o recurrent deep venous thrombosis
8. hypertension
9. hypercholesterolemia
10. osteoporosis
Discharge Condition:
Stable
Discharge Instructions:
If you experience any chest pain, shortness of breath, decreased
urine output, nausea or vomiting, please report to the ER
immediately.
Please take all of your medications.
Please follow up with your physicians (appts listed below).
Followup Instructions:
1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-9-8**] 12:00
2. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] Date/Time:[**2194-9-8**] 12:30
3. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-9-8**] 12:30
4. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Her office number
is [**Telephone/Fax (1) 250**]. Please call this number as soon as possible to
schedule a follow-up appointment.
Completed by:[**2194-9-28**]
|
[
"183.0",
"197.6",
"486",
"401.9",
"E850.2",
"965.09",
"584.9",
"285.22",
"733.00",
"250.00",
"197.2",
"272.0",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10983, 11050
|
6109, 9417
|
299, 336
|
11461, 11469
|
4269, 5437
|
11751, 12500
|
3544, 3631
|
9440, 10960
|
11071, 11440
|
11493, 11728
|
3180, 3255
|
3646, 4250
|
238, 261
|
364, 2537
|
5446, 6086
|
2559, 3157
|
3271, 3528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,968
| 125,987
|
29688
|
Discharge summary
|
report
|
Admission Date: [**2192-2-15**] Discharge Date: [**2192-2-24**]
Date of Birth: [**2124-2-15**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Upper endoscopy X 2 with 3 endoclips placed in the middle third
of the esophagus, colonoscopy, capsule endoscopy
History of Present Illness:
67 year old male with recent admission for GI bleed presents
with recurrent rectal bleeding. The patient was admitted to
[**Hospital1 18**] [**Date range (1) 15078**] with a GI bleed. An EGD [**2192-2-9**] showed a duodenal
dieulafoy lesion, which was treated with epinephrine as well as
surgical clips with good hemostasis. He required a total of 15
units PRBCs during that hospitalization and had stabilization of
his HCT at 30 upon discharge on [**2192-2-12**]. He visited his PCP on
day of admission for dysuria and increased urinary frequency. He
hadn't had a BM for two days and also denied N/V. While at the
PCP, [**Name10 (NameIs) **] noted blood in the rectal vault and sent him to the
ED. In the ED the patient had an NGT placed with fresh blood
return; he was given 2 units pRBC and admitted to the medical
ICU.
Past Medical History:
- GI bleed in setting of high dose aspirin use for sciatica [**2173**]
- Blood clot in rectum after having surgery [**2155**]
- duodenal dieulafoy lesion as above
- ? VonWillebrand Disease
- GI bleed [**2-7**] due to a duodenal Dieulafoy lesion, as above
Social History:
Drank several ETOH jello shots this past week, but no ETOH
otherwise. No past of present smoking history. No IVDU. Lives
with his wife in community duplex.
Family History:
Daughter with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] disease, discovered upon profuse
bleeding during tonsillectomy. No other family members have been
tested.
Physical Exam:
Physical exam on admission:
VS: 96.3 79 128/67 14 98 @ RA
GEN: a+ox3, NAD
HEENT: op clear, eomi
NECK: supple, no LAD, ? enlarged thyroid
LUNGS: CTAB
HEART: RRR no murmurs
ABD: s/nt, mild distention, +BS
EXTR: w/wp, no edema
Pertinent Results:
Laboratory tests on admission:
[**2192-2-14**]
WBC-13.0 HGB-7.7 HCT-22.1 MCV-89 RDW-18.6 PLT COUNT-360
NEUTS-83.8* BANDS-0 LYMPHS-11.8* MONOS-2.6 EOS-0.9 BASOS-0.9
GLUCOSE-113* UREA N-25* CREAT-0.9 SODIUM-138 POTASSIUM-4.4
CHLORIDE-107 TOTAL CO2-25
CALCIUM-7.9* PHOSPHATE-2.8 MAGNESIUM-2.3
U/A: BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG RBC-0 WBC-0-2
BACTERIA-FEW YEAST-NONE EPI-0
Laboratory tests on discharge:
[**2192-2-24**]
WBC-3.9 Hgb-10.3 Hct-30.0 MCV-90 RDW-16.7 Plt Ct-392
Neuts-56.1 Lymphs-32.0 Monos-8.5 Eos-2.6 Baso-0.8
Glucose-87 UreaN-11 Creat-1.1 Na-139 K-4.2 Cl-104 HCO3-29
ALT-101 AST-59* LD(LDH)-793* AlkPhos-62 TotBili-1.3
Other tests
[**2192-2-16**] FacVIII-336 VWF Ag >200, VWF CoF 320
[**2192-2-20**] TSH-7.1 Free T4-1.1
HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE
HCV Ab-NEGATIVE
[**2192-2-19**] Parietal antibody-NEGATIVE
[**2-14**] EKG: [**2-14**] EKG: Sinus rhythm. Inferior T wave changes are
nonspecific
Early R wave progression. Since previous tracing, no significant
change
Radiology:
[**2-16**] abd U/S: The right lobe of the liver appears unremarkable
without evidence of focal lesions or intrahepatic biliary
dilatation. The left lobe of the liver is not well seen due to
overshadowing bowel gas. The gallbladder contains several sludge
balls but no definite stones. There is no evidence of
cholecystitis. The pancreas is not well seen due to the
overlying bowel gas. The common bile duct measures 3.6 mm. The
right kidney measures 10.2 cm in length. The left kidney
measures 11 cm in length, and contains a 1.9 x 1.7 cm simple
cyst in the interpolar region. In addition, adjacent to the
simple cyst there appears to be an approx. 1.2-cm complex lesion
with hyperechoic rim and isoechoic center. No significant
internal Doppler flow is seen. No evidence of hydronephrosis or
nephrolithiasis is seen in either kidney. The spleen measures 11
cm in greatest diameter and appears unremarkable. The visualized
portion of the aorta is normal in caliber. No ascites is seen.
Portal veins, hepatic veins, and hepatic arteries demonstrate
normal Doppler flow and waveforms.
[**2-23**] GI Bleeding scan: No evidence of GI bleeding.
[**2-20**] MRI Abdomen: Susceptibility artifact is demonstrated within
the region due to metallic device. Visualized aspects of the
liver, spleen, gallbladder, and left adrenal glands, and
pancreas are unremarkable. The right adrenal gland is not
visualized due to susceptibility artifact from the metallic
device. Multiple T1 hypointense, T2 hyperintense, nonenhancing
lesions are demonstrated within the left kidney, the largest
which is interpolar and contains a single thin septation, this
lesion measures 2 cm. A total of three cysts are seen within
this kidney. There is no evidence of solid mass. There is no
evidence of nodularity within the cysts. On the right, there is
a tiny simple cyst, which measures 6 mm at the upper to mid
kidney. Visualized bowel is unremarkable. There is no
lymphadenopathy or ascites. The bones demonstrate no suspicious
lesions.
[**2-23**] KUB: Interval progression of the endoscopy capsule which
now projects over the mid descending colon. Several smaller
capsule fragments appear unchanged in position within the mid
right abdomen. No evidence of obstruction or free
intraperitoneal air
Brief Hospital Course:
67 year old male with a recent GI bleed due to a duodenal
Dieulafoy lesion (s/p sclerotherapy [**2192-2-9**]) presents with BRBPR
and HCT 22.
1) Gastrointestinal bleed: The patient underwent an EGD [**2192-2-15**],
which showed friability and nodularity in the middle third of
the esophagus with a visible venous vessel that was oozing. 3
clips were placed; no bleeding was noted from the previously
treated Dieulafoy's lesion. A non-bleeding stomach body erosion
was also noted. Given the patient's hematocrit was stable
following transfusion, he was transferred to the general medical
floor. On [**2-20**], he had increased frequency of maroon stool; a
repeat EGD was performed which was negative. He subsequently
underwent a bleeding scan [**2-20**], which was without evidence of
bleeding. On [**2-21**], he underwent a colonoscopy, which showed
diverticulosis of the descending colon and sigmoid colon, but no
source of bleeding. A repeat colonoscopy is recommended in 5
years. He then underwent a capsule endoscopy on [**2-21**], the
results of which are pending at the time of discharge. The
patient will be contact[**Name (NI) **] by the gastroenterology service within
2 weeks with the results. At the time of discharge, the
patient's hematocrit is stable without further evidence of
gastrointestinal bleeding.
2) Acute blood loss anemia: The patient's hematocrit was 22.1 on
admission; over the course of his hospital stay, he was
transfused 6 units of blood (the last [**2192-2-19**]). At time of
discharge, the patient's hematocrit was stable at 30. The
patient was continued on a multivitamin and folate.
3) Hemolysis: The patient was noted to be hemolyzing (high LDH,
hapto <20, elevated bilirubin). Direct comb's test was positive,
with antibody indentification of ant-c, E, and Jka. The
hematology service was consulted, who felt this was consistent
with and intravascular allo-Ab hemolytic anemia. He most likely
had an acute hemolytic
reaction to emergency release blood he received in the ED on
[**2-15**] (1 unit was c positive, 1 was jka positive). The patient's
hemolysis labs gradually trended down, although haptoglobin
remained <20; given repeat direct comb's test was negative,
hematology did not recommend further work-up at this time. The
patient should inform all his physicians that he has a history
of acute hemolytic reaction.
4) Possible [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) **] disease: Given positive family
history, the patient had a factor VIII, vWF coF, and vWF
checked, all of which were elevated, not consistent with VW
disease.
5) Transaminitis: The patient's ALT peaked at 198, AST 202, an
elevation that may have been related to mild liver hypoperfusion
at the time of his GI bleed. A RUQ ultrasound (see results)
showed gallbladder sludge without stones and normal doppler
studies. HCV antibody was negative, HBV panel was consistent
with prior immunization, and HAV IgM was negative. The patient's
iron/TIBC ratio was >50% (116/173), but ferritin was not
significantly elevated at 105 to suggest iron overload. The
patient's LFTs were trending down at time of discharge (ALT 101,
AST 59). These should be monitored as an outpatient, and further
work-up (such as liver biopsy) pursued at the discretion of the
patient's PCP.
6) Vitamin B12 deficiency: The patient was treated with IM
vitamin B12 for 5 days then transitioned back to oral regimen.
An intrinsic factor antibody was negative.
7) Nausea, vomiting, diarrhea: On the evening of [**2-21**], the
patient developed watery diarrhea, nausea and vomiting. A KUB
showed no evidence of obstruction, with the endoscopy capsule
having passed into the large bowel. C. diff toxin assay (-) X 1.
The patient's symptoms resolved within 24 hours, indicating that
they may have been due to a gastroenteritis.
8) H. pylori: The patient was noted to be H. pylori antibody
positive. He will complete a 2 week course of clarithromycin,
metronidazole, and PPI.
9) Leukopenia: On [**2-23**], the patient's wbc was 2.9, with a normal
differential. This rose to 3.9 on discharge. This may have been
due to a viral illness (gastroenteritis as above). The patient's
wbc should be repeated as an outpatient to ensure stability.
10) Renal mass: On the patient's abdominal ultrasound showed a
1.2-cm lesion in the left kidney with echogenic center and
hypoechoic rim. A follow-up MRI showed bilateral renal cysts,
the largest on the left containing a thin septation, however,
there was no evidence of suspicious solid masses and no evidence
of internal nodularity. The patient should have a repeat imaging
study (abd CT/MRI) in 6 mos to evaluate for change in
size/character.
11) Enlarged thyroid: The patient had an elevated TSH, but free
T4 was normal. These should be repeated once the patient has
recovered from this acute episode. He should also have an
outpatient thyroid ultrasound to evaluate for nodules.
12) Hypertension: The patient remained normotensive off
lisinopril. His blood pressure should be monitored as an
outpatient and lisinopril restarted as needed by his PCP.
13) Full code
Medications on Admission:
B12 2000mcg daily
lisinopril 10mg daily
pantoprazole 40mg [**Hospital1 **]
Discharge Medications:
1. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: upper gastrointesintal bleed
Secondary: gastroenteritis, hemolysis, H. pyloir infection,
vitamin B12 deficiency renal cysts, thyromegaly, hypertension,
transaminitis.
Discharge Condition:
Stable
Discharge Instructions:
1) Please follow-up as indicated below
2) Please take all medications as prescribed. Do not restart
lisinopril until directed to do so by your primary care
physician. [**Name10 (NameIs) **] will complete 5 more days of antibiotics to treat
H. pylori
3) Please come to the emergency room if you develop bleeding,
lighthededness, change in your urine color, nausea, vomiting,
abdominal pain, lightheadedness, diarrhea, or other symptoms
that concern you.
4) You were found to have anti-c, e, and jka antibodies in your
blood; please inform your physicians that you have a history of
hemolytic reaction to a transfusion.
Followup Instructions:
Primary care: Please follow-up with your primary care physician
[**Name Initial (PRE) 176**] 1 week following discharge
- please discuss scheduling a thyroid ultrasound to better
evaluate your enlarged thyroid gland
- please discuss schedule an abdomen CT to evaluate for change
in the renal cysts seen on your MRI
- you should have a repeat CBC (white blood cell count,
hematocrit, and platelets) checked at that time to ensure
stability.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2192-2-25**]
|
[
"537.84",
"535.40",
"530.82",
"790.4",
"041.86",
"285.1",
"401.9",
"593.9",
"562.10",
"266.2",
"283.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.13",
"45.19"
] |
icd9pcs
|
[
[
[]
]
] |
11524, 11530
|
5570, 10680
|
300, 415
|
11750, 11759
|
2182, 2199
|
12425, 13018
|
1735, 1922
|
10806, 11501
|
11551, 11729
|
10706, 10783
|
11783, 12402
|
1937, 1951
|
2653, 5547
|
233, 262
|
443, 1267
|
2213, 2639
|
1289, 1546
|
1562, 1719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,362
| 157,722
|
8368
|
Discharge summary
|
report
|
Admission Date: [**2145-3-8**] Discharge Date: [**2145-3-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Possible PEA Arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 89 yo male with a history of DM2, HTN, slow
AFib, and poor functional capacity who presents to [**Hospital1 18**] after
sustaining a questionable PEA arrest at his opthomologist's
office on [**2145-3-8**]. Per the patient's daughter, after hurrying
him across the road because of oncoming traffic, he acutely
developed lethargy and went to sit down in a hunched over
position. He was apparently unresponsive for 2-3 minutes and
then [**Name8 (MD) **] RN came by and called EMS, which arrived within 3
minutes per the patient's daughter.
.
When EMS arrived, their initial documented HR [**Location (un) 1131**] was a
pulse of 26. After transfer to the stretcher, he was reportedly
pulseless and CPR was initiated (5 min), his monitor reported
pulse in the 20s and he was given atropine for presumed PEA. Per
report, he was also apneic, and hence was intubated int he
field. His HR subsequently rose to 58 and then was 110 on his
arrival to the [**Hospital1 18**] ED (AFib). He was reportedly also agitated
from his intubation.
On arrival to [**Hospital1 18**], his HR was in the 80s. He was started on
propofol gtt (as he was not sedated in the field). His pressure
dropped to 75/25, and his HR dropped to 55. It was presumed that
his BP decrement was due to the bradycardia, and thus was given
atropine and the propofol discontinued. He was given a 2nd mg of
atropine because his HR was still in the 50s; and started on
fentanyl gtt and versed for sedation.
He had a femoral line placed and dopamine infusion was begun b/c
of of BP in the 80s-90s and hr in the 40s.
.
Cardiology was consulted in the ED; he had an ECHO which showed
R heart strain; however, a subsequent PE protocol CT did not
find evidence of an acute PE; evidence of chronic PE was found.
He was intubated for altered mental status and undertook a trip
to the cardiac catheterization laboratory which found him to
have:
- elevated RV and PA pressures.
- he was also started on heparin gtt and given ASA 325.
.
Of note, he was taken off of his ASA for 4 days prior to his
opthamologic surgery. He was also not being anticoagulated for
his known AFib.
Past Medical History:
CAD (s/p CABG) - unclear anatomy
Anticardiolipin (+) in past - no follow up antibody tests.
CHF (unclear if diastolic or systolic)
DM2
Hypertension
Hypothyroidism
Atrial Fibrillation - not on warfarin because he is a high fall
risk - per son ([**Name8 (MD) **] MD)
Hearing impairment
Prostate Cancer s/p prostatectomy
Retinopathy
b/l cataract surgery
OA of cervical and lumbar spine
Osteoporosis
Bladder cancer
Hyperlipidemia
Social History:
Family denied tobacco or alcohol abuse. Recently moved in with
daughter. [**Name (NI) **] has low functional capacity; has difficulty walking
long distances; cannot climb a flight of stairs. Gets SOB with
moderate exertion. Has a walker, but does not use it to walk.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T: 97.4 , BP: 161/83 , HR: 40s-50s (Irregular) , Intubated:
AC 550 x 18 with FiO2 of 50%, PEEP: 5 , 100% O2 % on
Gen: Elderly male who is sedated and intubated.
HEENT: NCAT. Sclera anicteric. Pupils irregular and equal and
minimally responsive to light, EOMI.
Neck: Supple with JVP to mid neck at 30 degrees.
CV: +s1+s2 irregularly irregular. No murmurs
Chest: No crackles, wheeze, rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. R sheath in place. L groin line in place. Cool
feet, but with dopplerable pulses
Pertinent Results:
ADMISSION LABS:
[**2145-3-8**] 11:25AM BLOOD WBC-12.9* RBC-3.32* Hgb-11.2* Hct-34.0*
MCV-103* MCH-33.7* MCHC-32.9 RDW-14.0 Plt Ct-102*
[**2145-3-8**] 11:25AM BLOOD Neuts-65.7 Lymphs-30.8 Monos-2.5 Eos-0.5
Baso-0.6
[**2145-3-8**] 11:25AM BLOOD Plt Ct-102*
[**2145-3-8**] 11:25AM BLOOD PT-14.4* PTT-52.5* INR(PT)-1.3*
[**2145-3-9**] 04:51AM BLOOD ACA IgG-28.5* ACA IgM-57.4*
[**2145-3-10**] 10:13AM BLOOD Heparin-0.29*
[**2145-3-8**] 11:25AM BLOOD Glucose-325* UreaN-37* Creat-2.0* Na-137
K-4.6 Cl-106 HCO3-16* AnGap-20
[**2145-3-8**] 06:10PM BLOOD ALT-38 AST-65* LD(LDH)-349* AlkPhos-140*
TotBili-1.7*
[**2145-3-8**] 11:25AM BLOOD CK(CPK)-135
[**2145-3-8**] 11:25AM BLOOD Calcium-9.0 Mg-2.8*
.
CARDIAC ENZYMES:
[**2145-3-8**] 11:09PM BLOOD CK-MB-13* MB Indx-5.2 cTropnT-0.31*
[**2145-3-9**] 02:06PM BLOOD CK-MB-6 cTropnT-0.38*
[**2145-3-12**] 05:00AM BLOOD CK-MB-5 cTropnT-0.13*
.
EKG : AFib with LBBB morphology. Diffuse TWI in inferior leads.
Also V1-V4 with TWI. STD in V3-V4. (A report from OSH [**7-17**]: AFib
with RBBB.
- [**11-16**]: Slow AFib with RBBB
.
TELEMETRY demonstrated: Slow Afib.
.
[**2145-3-8**] TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild symmetric left ventricular
hypertrophy with normal systolic function. Moderately dilated
right ventricle with moderately depressed function and severe
estimated pulmonary artery systolic hypertension.
.
[**8-15**]: ECHO from [**Hospital3 **]
- EF: 65%
- PASP: 39mm Hg
- concentric LVH
.
ETT performed : NA
.
CARDIAC CATH performed on [**2145-3-8**]:
Pulm HTN and moderate elevation of PVR with moderate LV
diastolic dysfunction.
.
HEMODYNAMICS:
CO: 6.55 L/min CI: 3.28 L/min/m^2
RA (mean) : 14
RV: 93/8
PCWP (mean) : 24mm Hg
PA : 93/24 (mean 49)
.
CTA [**2145-3-8**]:
1. No acute PE. Findings suggestive of chronic PE.
2. Endotracheal tube terminates 1.5 cm from the carina. Pull
black is recommended.
3. Acute angulation of bilateral anterior ribs. Recommend
clinical
correlation for acute injury possibly related to recent
resuscitative efforts.
4. Extensive coronary artery disease.
5. Possible interstitial lung disease versus interstitial
engorgement in the setting of recent cardiac arrest. Followup
imaging may be useful once clinically stabilized.
.
[**3-17**] EEG:
Abnormal portable EEG due to the slow and disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathy affecting both cortical and
subcortical
structures. Anoxia is a possible explanation of the
encephalopathy.
Medications, infection, and metabolic disturbances can also
contribute.
There were no areas of persistent focal slowing, and there were
no
epileptiform features.
Brief Hospital Course:
(1) POSSIBLE PEA ARREST
From accounts from EMS, it appeared that Mr. [**Known lastname **] had a PEA
arrest while running across the street. However, it did not take
long to rescucitate the patient in the field, so it is unclear
whether he had an actual arrest. Given his chronic PE and high
PA & RV pressures, it is likely that he could not match the
demand from his episode of exertion, leading to hypoxia which
may have been the predisposing factor to his PEA. In addition,
the patient has poor functional status, and along with his known
CAD and DM, demand ischemia could have potentially led to his
PEA. Given his CKD and dye load with CTA and right heart cath,
detailed inspection of his coronary anatomy was not pursued.
.
He was continued on aspirin and atrovastatin during his
hospitalization. ECHO showed moderately dilated right ventricle
with moderately depressed function and severe estimated
pulmonary artery systolic hypertension.
(2) HYPOXIC BRAIN INJURY
Mr.[**Known lastname **] suffered from severe neurologic impairment from his
cardiac event. Once off sedation for intubation, he was
arousable to voice but otherwise not following commands or
communicating. Neurology was consulted to advise on progrnosis,
and EEG showed encephalopathy c/w anoxic brain injury.
Neurology felt there was little probability of recovery to
baseline functioning. The palliative care team was consulted,
and the patient was made comfort measures only on [**2145-3-18**]. On
the morning of [**2145-3-19**], Mr. [**Known lastname **] passed away in the CCU when
his heart went into asystole.
(3) CHRONIC PULMONARY EMBOLISM
Lovenox
(4) ACUTE ON CHRONIC RENAL FAILURE
Mr. [**Known lastname **] has long-standing diabetes mellitus with likely CKD,
although baseline creatinine is not known. Cr was 2.0 on
admission and then 2.3 several days later, likely secondary to
ATN from hypoperfusion during his event and the dye load from
the catheterization and CTA. Urine output remained good, and
creatinine slowly improved over the hospitalization.
(5) FEVER
Most likely source is pulmonary [**3-13**] aspiration at time of field
intubation; sputum with 3+ GPC and GNR. He was placed on
vancomycin and zosyn for a seven day course, with improvement in
his fevers. Blood cultures were negative except for one vial
which grew coag neg Staph, thought to be a contaminant.
Infection/sepsis was not thought to contribute to the immediate
cause of death.
Medications on Admission:
Benicar 20mg daily
Furosemide 40mg daily
Insulin:
AM: 20U Humalog and 40U Humulin N
PM: 20U Humalog and 20U Humulin N
Levothyroxine: 50mcg
ASA Alternates b/w 162mg/325mg
Fe
MVI
Zantac (? dose)
Lipitor 20 mg PO QHS
Zoladex Q 3 months
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
Pulseless electrical activity
Anoxic brain injury
Discharge Condition:
Patient expired on [**2145-3-19**] in the CCU.
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"427.5",
"276.0",
"584.9",
"416.8",
"585.9",
"403.90",
"428.32",
"428.0",
"244.9",
"507.0",
"518.81",
"415.19",
"250.40",
"276.52",
"V10.51",
"348.1",
"599.0",
"362.01",
"427.31",
"427.89",
"250.50",
"V45.81",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"88.52",
"96.71",
"88.55",
"00.17",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10070, 10079
|
7331, 9786
|
281, 287
|
10192, 10240
|
3852, 3852
|
10291, 10296
|
3221, 3239
|
10100, 10171
|
9812, 10047
|
10264, 10268
|
3279, 3833
|
4562, 7308
|
221, 243
|
315, 2469
|
3868, 4545
|
2491, 2919
|
2935, 3205
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,274
| 145,640
|
43137
|
Discharge summary
|
report
|
Admission Date: [**2132-5-6**] Discharge Date: [**2132-5-12**]
Date of Birth: [**2083-1-21**] Sex: F
Service: VSU
CHIEF COMPLAINT: Nonhealing right fifth toe ulceration.
HISTORY OF PRESENT ILLNESS: This is a patient with multiple
medical problems who has been followed by the podiatry
service for a nonhealing right fifth toe ulceration which has
been refractory to conservative treatment for over the last 6
weeks. The patient denies any claudication or any foot rest
pain. She walks with a walker. She was seen by Dr. [**Last Name (STitle) 1391**] 2
weeks ago and she had at that time only monophasic waveforms
on her right leg. The patient underwent a diagnostic
arteriogram on [**2132-4-28**], and returns now for elective
revascularization.
PAST MEDICAL HISTORY: Medical illnesses of peripheral
vascular disease with right foot ischemia, type 1 diabetes,
status post pancreatic transplant with triopathy, end-stage
renal disease, status post renal transplant x2, failed on
hemodialysis Monday, Wednesday and Friday, history of
hypertension, history of hyperlipidemia, history of chronic
inflammatory demyelinating polyneuropathy, history of toxic
megacolon, status post multiple bowel obstructions, status
post ileostomy with redo, history of coronary artery disease,
status post CABG in [**2124**], ejection fraction 30%-40%, history
of recurrent falls with a left hip fracture, closed
reduction, history of asthma, history of pneumonia recently
treated with Levaquin, history of dysplastic knee, status
post excision, history of VRE, history of herpes zoster,
history of retinopathy secondary to diabetes, legally blind,
history of multiple drug allergies.
ALLERGIES: Multiple drug allergies with Betadine,
nitroglycerin transdermal patch and gabapentin.
MEDICATIONS ON ADMISSION: Prograf 2 mg twice a day,
prednisone 5 mg daily, Imuran 25 mg every other day, aspirin
81 mg daily, folate 1 mg daily, Bactrim single strength
Monday, Wednesday and Friday, Lopressor 75 mg twice a day
p.r.n., enalapril 15 mg twice a day p.r.n., Atrovent nasal
inhaler sprays 2 twice a day, Astelin nasal inhaler sprays 2
twice a day, Flovent inhaler 22 mcg puffs 2 twice a day,
Ventolin inhaler p.r.n., Restasis 0.05% drops 1 both eyes
twice a day which is being held, Pred Forte 1% drops 1 drop
left eye q.3 days, Acular 0.5% 1 drop left eye q.3 days,
Zaditor drops both eyes p.r.n., Alrex drops both eyes p.r.n.,
Benadryl 25 mg p.r.n., Tylenol 1 gram p.r.n., Sudafed 30 mg
p.r.n., Alka-Seltzer 2 p.r.n., Procrit as per protocol,
ferrous sulfate per high hemodialysis protocol, Zemplar per
hemodialysis protocol, all given at dialysis, Fosrenol [**2124**]
mg with meals which is 10 tablets total daily, Ambien 5 mg at
bedtime p.r.n., Compazine 10 mg p.r.n., Claritin 10 mg
q.a.m., [**Doctor First Name **] 60 mg daily p.r.n., ibuprofen 400-800 p.r.n.,
Midrin 7.5 mg twice a day p.r.n. for blood pressure, Imodium
4 to 8 mg 3 times daily, Nephrocap 1 daily, Zyprexa 20 mg at
bedtime, mirtazapine 30 mg at bedtime, Salex 6% cream twice a
day to skin, psyllium husk fiber capsules 2 twice a day, 4
capsules at bedtime, Beano capsules [**12-26**] p.o. with meals,
Lomotil 2-4 mg tablets 3 times daily, Pepcid 10 mg q.a.m.,
simethicone 125 mg 3 times daily, clorazepam 0.5 mg twice a
day p.r.n., hydromorphone 2-4 mg q.4-6 hours p.r.n. for back
pain, cyclobenzaprine 5 mg twice a day, Naprosyn 500 mg twice
a day.
SOCIAL HISTORY: The patient is married, lives with her
spouse. The patient is a former cigarette smoker, has not
smoked since [**2107**]. Denies alcohol use.
PHYSICAL EXAMINATION: Vital signs stable. Alert white female
in no acute distress. Lungs: Clear to auscultation. Heart is
regular rate and rhythm. Abdominal exam is unremarkable.
Pulse exam: Palpable femorals with absent distal pulses on
the right and dopplerable pedal pulses on the left.
Neurological exam: Nonfocal, oriented x3.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2132-5-6**]. She underwent a
right BK [**Doctor Last Name **] to lateral peroneal artery bypass with right
saphenous vein, a fibular resection, angioscopy and valve
lysis. The patient tolerated the procedure well and was
transferred to the PACU in stable condition. The patient did
well postoperative and was transferred to the SICU for
continued monitoring and care. Postoperative day #1, there
were no overnight events. She was afebrile. Physical exam was
unremarkable. She had a dopplerable DP pulse. The patient did
require some Haldol intermittently overnight secondary to
mild confusion. The patient's fluids were Hep-locked. Her
diet was advanced as tolerated. She remained on bedrest and
in the VICU. The renal service followed the patient during
her hospitalization and managed her hemodialysis needs. The
patient was dialyzed every Monday, Wednesday and Friday.
Psychiatry was requested to see the patient for continued
delirium and they felt that the patient was delirious. This
was not controlled with Haldol or Ativan. They are aware
that the patient has a history of delirium after major
surgical procedures. Usually this clears with holding
medications and giving Haldol. The patient was followed by
the ostomy service for management of her ileostomy. The
patient's delirium resolved by postoperative day #4. The
remainder of her hospital course was unremarkable. The
patient was discharged to home in stable condition on [**2132-5-12**], postoperative day #6. The patient will be dialyzed
prior to being discharged to home.
DISCHARGE INSTRUCTIONS: She should follow up with Dr.
[**Last Name (STitle) 1391**] in 2 weeks' time, to call for an appointment at [**Telephone/Fax (1) 13922**]. She may ambulate essential distances. She should
elevate the right leg when sitting in a chair. She may shower
but no tub baths. She should call the office if she develops
fever greater than 101.5 or the wounds become erythematous,
drain or there is groin swelling
DISCHARGE MEDICATIONS: Unchanged from preadmission
medications with the addition of Percocet tablets [**12-25**] q.4-6
hours p.r.n. for pain.
DISCHARGE DIAGNOSES:
1. Ischemic right toe ulceration refractory to conservative
treatment.
2. Postoperative delirium resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2132-5-12**] 10:35:13
T: [**2132-5-12**] 12:15:28
Job#: [**Job Number 92978**]
|
[
"V45.81",
"357.2",
"707.15",
"424.0",
"583.81",
"V42.83",
"272.4",
"250.41",
"403.91",
"357.81",
"250.51",
"362.01",
"250.61",
"585.6",
"397.0",
"440.23",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
6144, 6529
|
6003, 6123
|
1818, 3429
|
3941, 5548
|
5573, 5979
|
3612, 3880
|
3899, 3923
|
153, 193
|
222, 771
|
794, 1791
|
3446, 3589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,355
| 131,364
|
47842
|
Discharge summary
|
report
|
Admission Date: [**2178-9-22**] Discharge Date: [**2178-10-22**]
Date of Birth: [**2104-5-21**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Nitroglycerin
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
74 yo male with AS, AR, MR, [**Hospital **] transferred to CCU for tailored
diuresis prior to valve surgery
Major Surgical or Invasive Procedure:
Cardiac Catheterization with stent placement to RAD
Paracentesis
[**Last Name (NamePattern4) 15255**] of Present Illness:
This 74 year old retired dentist was admitted to a hospital in
[**State 9512**] on [**2178-7-3**] for CHF. He was aggressively diuresed
and referred for cardiac catheterization. His CHF was felt to be
due to significant valvular heart disease. He subsequently came
back to [**State 350**] and was seen by Dr. [**Last Name (Prefixes) **] for
further consultation regarding his cardiac condition. He has a
hx of aortic stenosis, aortic insufficiency and mitral
insufficiency, CAD s/p cath [**8-4**] showing 1VD, afib on coumadin,
CRI, Childs Class A cirrhosis.
.
He was readmitted in early [**2178-8-31**] with volume
overload/ascites, likely secondary to congestion and renal
failure for tailored diuresis prior to pending surgical valve
repair. During this admission, he had an elevated creatinine of
21. and elevated LFTs. He was evaluated by renal and
interventional cardiology who felt no further intervention with
the renal stents was required. Hepatology evaluated him and gave
him a Childs A classification of chronic liver disease and a 5%
risk for surgical complications. He was also seen by cardiology
and Dr. [**Last Name (STitle) **] felt that the patient's overall cachexia gave
him a high surgical risk. His Captopril, Hydralazine, and Lasix
were d/c'd because of his increased creatinine. His Atenolol was
discontinued because of bradycardia. This was discussed at
length with Drs. [**Last Name (STitle) 1290**] and [**Name5 (PTitle) **], and the patient and
family, and it was felt that the patient should have a month of
increased nutrition and no alchohol intake to improve his
surgical outcome. The patient was restarted on coumadin and will
be sent to rehab on Lovenox while he was transitioning back to
coumadin. He was also to have some PT to improve his strength
and endurance. He was planned for readmission on [**10-19**] and
surgery on [**10-21**].
.
On [**9-22**], (this admission), he was readmitted with fluid
overload, markedly increased ascites (approx 10 pound wt gain),
and cirrhosis with some confusion on presentation, a distended
abdomen, LE edema and 2 episodes of syncope after taking BP meds
without noted head trauma. Upon admission, a plan for tailored
diuresis and increased nutrition with subsequent valve repair
was commenced.
Past Medical History:
Past Medical History:
Afib on coumadin
HTN
Aortic stenosis
Mitral regurgitation
hypercholesterolemia
Osteoporosis
Renal artery stenosis, s/p stents, CRI 1.6-1.8
Chronic liver disease, Childs class A
s/p T+A
Social History:
Lives in [**Last Name (LF) 11084**], [**First Name3 (LF) **]. Spends summers in [**Location (un) 3844**]
ongoing pipe smoking
30 pack year history of cig smoking, quit 35 yrs ago
Drinks 4 oz ETOH/day. Hx ETOH abuse per family
Family History:
noncontributory
Physical Exam:
Vitals: Tc 97.9 Tmax 98.4 HR 96 BP 137/65(119-137/54-71)
RR 21 96% 02 on R/A
GEN- WD/WN Male resting in bed in NAD
HEENT- PERRL, EOMI, MMM
NECK- Elevated JVP to angle of jaw
CV- RRR, [**4-5**] high pitched HSM, No R/G S1, S2; 2+ puluses DP, PT,
Radial, Carotid; No carotid bruits.
Lung- Slight Decr. BS RLL
Abd- Markedly distended with periumbilical hernia, + fluid wave,
BSNA, No HSM, No Masses
Ext- 2+ non-pitting edema No C/E
Neuro- A and O x 3. CN II-XII intact, some word finding
difficulty
Pertinent Results:
[**2178-7-31**] echo: moderately dilated LA, mild symmetric LVH with an
EF of 40%. RV systolic function appearing depressed. The
ascending aorta was mildly dilated. There was moderate AS with a
peak gradient of 44 mmHG, mean of 24 mmHG, [**Location (un) 109**] of 0.9cm2. There
was 1+ AI, 2 + MR with severe MAC and mild mitral stenosis.
There
was [**2-1**]+ TR.There was also moderate pulmonary hypertension.
.
[**2178-9-22**] 09:15PM POTASSIUM-5.2*
[**2178-9-22**] 09:15PM CK(CPK)-268*
[**2178-9-22**] 06:07PM GLUCOSE-78 UREA N-59* CREAT-2.1* SODIUM-127*
POTASSIUM-6.0* CHLORIDE-91* TOTAL CO2-20* ANION GAP-22*
[**2178-9-22**] 06:07PM ALT(SGPT)-207* AST(SGOT)-249* LD(LDH)-440*
ALK PHOS-235* TOT BILI-2.2*
[**2178-9-22**] 06:07PM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-4.3
MAGNESIUM-2.3
[**2178-9-22**] 06:07PM NEUTS-73.5* LYMPHS-17.2* MONOS-7.7 EOS-1.1
BASOS-0.6
[**2178-9-22**] 06:07PM NEUTS-73.5* LYMPHS-17.2* MONOS-7.7 EOS-1.1
BASOS-0.6
[**2178-9-22**] 06:07PM WBC-9.8 RBC-4.74 HGB-14.0 HCT-42.6 MCV-90
MCH-29.6 MCHC-33.0 RDW-16.0*
[**2178-9-22**] 06:07PM PLT COUNT-291
[**2178-9-22**] 06:07PM PT-20.3* PTT-38.0* INR(PT)-2.7
[**2178-9-22**] 09:15PM OSMOLAL-288
[**2178-9-22**] 09:15PM CK-MB-11* MB INDX-4.1 cTropnT-0.11*
.
Peritoneal fluid on [**9-24**] NEGATIVE FOR MALIGNANT CELLS.
.
Echo [**9-23**] The left and right atrium are moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and moderate global hypokinesis. [Intrinsic left
ventricular systolic function may be more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is markedly dilated with severe global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The ascending
aorta and aortic arch are mildly dilated. The aortic valve
leaflets are severely thickened/deformed. There is moderate
aortic valve stenosis. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened with
characteristic rheumatic deformity but minimal mitral stenosis.
Moderate (2+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
Compared with the report (tape unavailable for review) of
[**2178-7-31**], the severity of aortic regurgitation and tricuspid
regurgitation are slightly increased.
.
Echo [**10-6**] EF 40-45%. The left and right atrium are moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Resting regional wall motion
abnormalities include focal hypokinesis of the inferior wall.
The remaining segments are mildly hypokinetic. The right
ventricular cavity is moderately dilated with focal hypokinesis
of the basal 2/3rds of the free wall. The aortic valve leaflets
are severely thickened/deformed with severe aortic valve
stenosis. Mild to moderate ([**2-1**]+) aortic regurgitation is seen.
The mitral valve leaflets and supporting structurs are
moderately thickened. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2178-9-23**], the
right ventricle is slightly smaller and free wall motion may be
slightly improved (more regional in dysfunction). Global left
ventricular systolic function is improved with regional
dysfunction now apparent.
.
Cardiac Cath [**10-16**] 1) Resting hemodynamics demonstrated mildly
elevated left and right sided filling pressures with the
RVEDP=13 mmHg and LVEDP=14 with a mean PCWP=17mmHg. The cardiac
output was depressed with a CI=2.0. 2) Interrogation of the
mitral valve demonstrated mild mitral stenosis with a mean
gradient of 6 mmHg with a calculated mitral valve area of 1.2
cm3. The mitral valve gradient was most prominant in early
diastle and may have had a significant contribution from the
mitral regurgitation. There was minimal gradient across the
mitral vavle in late diastle. 3) interrogation of the aortic
valve demonstrated a mean gradient of 17 mmHg at rest which gave
a calculated valve area of 0.8 cm3. With Dobutamine, the cardiac
output did not augment significantly and the gradient rose to 20
mmHg giving a calculated valve area of 1.1 cm3. 4) Selective
coronary angiography was only performed to the right coronary
artery and revealed a 90% proximal stenosis and a 60% distal
stenosis. 5) Left ventriculograpy was not performed so as to
minimize dye load. 6) Successful predilation, stenting using a
Vision 3.0 X 15 BMS and postdilation of the proximal RCA
stensois with lesion reduction from 90% to 10% . Final angiogram
showed TIMI III flow with no evidence of dissection or
embolisation. (see PTCA comments)
Brief Hospital Course:
A: 74 year old man with a hx of AS/AR/MR, CAD s/p cath [**8-4**]
showing 1VD, afib on coumadin, CRI, Childs Class A cirrhosis who
presented with volume overload/ascites, likely [**3-4**] congestion
and renal failure in anticipation of valve repair who underwent
diuresis followed by cardiac catheterization with stent to RAD
and new valve assessments rendering him a poor candidate for
valve surgery.
.
PLAN:
1) CHF- EF 40-45% on last echo. Likely etiology was cessation of
blood pressure meds and lasix after discharge on [**8-4**] in the
setting of his valvulopathies. Pt was given milrinone (which was
eventually weaned) and lasix GTT and transferred to the CCU for
tailored diuresis prior to anticipated valve repair. Due to
marked ascited, he underwent paracentesis with a total of 1
liter of serous fluid removed on [**9-23**] negative on culture and
negative for malignant cytology. He was diuresed 18kg during
this admission (admission wt was 75.5kg, discharge wt 57.7kg).
His distended abdomen improved greatly as a result. He was not
SOB during the admission, nor did he experience symptoms of PND
or orthopnea. After many different dose adjustments, we found
that Dr. [**Known lastname 11679**] diuresed best with PO lasix (120mg PO daily on
discharge) dosing with occasional Zaroxolyn (Metolazone)at
2.5mg. Catheterization revealed little change in aortic valve
gradient with dobutamine which, in combination with cirrhosis
and the patient's overall cachexia, decreased our desire to
aggressively pursue valve repair at this time.
.
2) CAD - Known 1VD and mild 2VD. As noted above, the patient
underwent caridac catheterization with cypher stent placement to
his 90% occluded RAD on [**10-16**] with only 10% residual occlusion.
He will continue ASA, plavix, low dose beta blocker (can be
increased later if pressures and HR tolerate), and aldactone
upon discharge. He had no chest pain at any time during the
admission.
.
3) AFib - The patient has longstanding paroxysmal afib for which
he was prophylaxed with heparin during admission and will be
discharged on coumadin. INR on date of discharge is 1.8 on 4mg
Coumadin (started only 2 days ago) so this will need to be
followed closely at rehab and adjusted accordingly.
.
4) Cirrhosis/GI - Pt had elevated LFTs on admission which
hepatology attributed to a combination of alcohol intake and
congestion. He was given an anti-emetic for nausea when needed
(rarely). In addition, pt began tx with lactulose which
improved his mental status. Diuresis helped his marked ascited
secondary to cirrhosis. While he frequently refused lactulose
and bowel meds, we encouraged the patient to take both.
.
5) Renal - Hx CRI with hx renal artery stenosis s/p stent in
past. Pt admitted with Creat 2.0 which trended to 1.4-1.8 for
the majority of his admission. Probably s/p cirrhosis and also
intravascular volume depletion despite third spacing. FeUrea
calculated was 35 consistent with prerenal etiology on [**10-18**]. 4
days post cath, creatinine peaked at 3.0. The patient was seen
by renal who thought this was due to intravascular hypovolemia
despite third spacing in conjunction with dye load. Creatinine
is trending down at time of discharge to 2.4. Per renal, the
prognosis of a hyponatremic patient unable to clear free water
like Dr. [**Known lastname 11679**] is poor and for this reason, while elevated
creatinine should be trended, please note his baseline of >1.5.
.
7) Coagulation - Pt was off coumadin due to markedly elevated
INR on admission likely due to hepatic congestion (INR now
down). He was on heparin for a fib throughout admission and
restarted on coumadin 2 days prior to discharge with a discharge
INR of 1.8.
.
8) Hypothyroid - Continued throughout admission on
levothyorixine at present dose.
.
11) Bladder spasms- hyoscyamine 0.125 working well TID started
this admission. Will continue post-discharge.
.
13) FEN - Nutrition consult for poor PO intake, we added
supplements to all meals and recommend continuing this as an
outpatient.
.
14) Code status - full code per discussion with patient and
daughter
Medications on Admission:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed.
5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses: GIve for INR goal of [**3-4**].5.
6. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous twice
a day: d/c when INR 2-2.5.
Discharge Medications:
1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*3*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Hyoscyamine Sulfate 0.125 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*5*
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
13. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical TID (3
times a day).
Disp:*1 tube* Refills:*2*
14. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 doses.
Disp:*90 Tablet(s)* Refills:*2*
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
Disp:*1 tube* Refills:*0*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
18. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
19. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Pleasant View Nursing and Rehab
Discharge Diagnosis:
CHF, AR, MR, AS
Discharge Condition:
Stable
Discharge Instructions:
Pls call with any new symptoms including shortness of breath,
chest pain, etc. Take all meds as prescribed below. Continue
to work with PT with a goal of ambulating as much as tolerated.
Low sodium diet. Free water restricted to 2 liters
Followup Instructions:
To be followed by PCP in [**Name9 (PRE) **] at rehab
|
[
"V58.61",
"571.2",
"244.9",
"692.9",
"799.4",
"427.31",
"403.91",
"599.0",
"922.32",
"276.1",
"398.91",
"584.9",
"596.8",
"573.0",
"396.0",
"286.7",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"54.91",
"36.06",
"89.64",
"99.07",
"37.23",
"88.55",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15958, 16016
|
9065, 13174
|
394, 2790
|
16076, 16085
|
3830, 9042
|
16374, 16430
|
3281, 3298
|
13856, 15935
|
16037, 16055
|
13200, 13833
|
16109, 16351
|
3313, 3811
|
247, 356
|
2834, 3021
|
3037, 3265
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,735
| 140,564
|
54549
|
Discharge summary
|
report
|
Admission Date: [**2190-3-16**] Discharge Date: [**2190-3-20**]
Date of Birth: [**2108-5-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / E-Mycin / Flagyl / Pepcid
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy/EGD
History of Present Illness:
The patient is an 81 year old female with a history of critical
aortic stenosis, recent CVA ([**2-23**] after having a cardiac
catheterization) with recent admission for GI bleed.
.
The patient underwent an elective cardiac catheterization on [**2-23**]
with subsequent CVA. She was discharged to [**Hospital3 **] but
was admitted to [**Hospital1 18**] on [**2190-3-3**] for maroon stools and a
hematocrit of 22. While here, she was treated conservatively
with blood transfusions and serial Hct, with Hct stable between
27-30 on discharge. She had no further episodes of dark stool
and was discharged. No procedures were undertaken given recent
CVA and other co-existing illnesses.
.
Since discharge, she has been back at rehab and had been doing
well.
Daughter-in-law reports that her Hct fell to a low of 25 but the
last hct provided at the clinic visit was 27. While her
daughter says her rehab was going well and she did work well
with PT and OT she now has been more "lethargic" over the last
two days. She was awake yesterday evening with a sensation that
she had to defecate despite not being able to have a bowel
movement. She is on a bowel regimen but only a small hard pellet
of stool came out. She also had some abdominal pain. Per the
rehab records her SBP has been 90-100.
.
She presented to [**Hospital **] clinic today and was found to have quite
profound dyspnea on exertion. Given that she looked ill and had
been lethargic prior to evaluation in clinic, she was sent to
the ED for further evaluation. While in the ED, initial vital
signs were T- 98, HR- 86, BP- 110/56, RR- 18, SaO2- 98% on RA.
She was found to have Hct 22.1 with black stools that were
guaiac positive. She was given 2U pRBCs, started on PPI gtt and
given adequate IV access with 18g and 16g peripheral IVs. EKG
showed mild changes from prior with first set of cardiac enzymes
negative. She remained hemodynamically stable while in the ED.
GI was consulted and recommended MICU admission for possible
scope.
.
On arrival to the MICU, vital signs were T- 98.0, HR- 83, BP-
120/61, RR- 15, SaO2- 94% on RA. The patient reports feeling
well, especially since she received the blood transfusion in the
ED. She denies abdominal pain, dizziness, lightheadness, chest
pain, shortness of breath or diarrhea at this time.
Past Medical History:
Critical aortic stenosis [**Location (un) 109**] 0.5cm2, [**2190-2-23**]
R MCA CVA, no residula deficits
"Mediterranean Anemia"
Hypertension
Hysterectomy [**2135**]
Dyslipidemia
GERD
Bladder CA s/p cystectomy [**2165**]
Dysphagia
Neuropathy
Anemia
CCY [**2137**]
Hernia [**2175**]
Back surgery [**2183**]
Cataract removal
Social History:
Lives at home, son lives at home with her. Retired from sewing
business. Tobacco: never. ETOH: denies. Drug
use: denies.
Family History:
Mom passed away age 59 from heart problems. [**Name (NI) **] passed away age
74 from PNA. Sister passed away age 79 had a history of valve
surgery but died from leukemia. Brother passed away age 50 from
cancer. Brother alive age 84 had a valve replacement one year
ago.
Physical Exam:
Vitals: T- 98.0, HR- 83, BP- 120/61, RR- 15, SaO2- 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, [**1-26**] harsh systolic
murmur loundest at RUSB with radiation to carotids, no rubs,
gallops
Lungs: Prominnet kyphosis, clear to auscultation bilaterally, no
wheezes, rales, ronchi
Abdomen: Left sided nephrostomy tube collecting clear urine and
appering clean and not infected. Large left sided distension
which is not painful. Otherwise soft, 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, strength grossly normal, gait deferred.
.
DISCHARGE EXAM
Tm 98.4 Tc 98.3 HR 68 (62-90) BP 106/55(66) {100/44-131/79} RR
18 SpO2: 97%
GEN: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, [**1-26**] harsh systolic murmur loundest at
RUSB with radiation to carotids, no rubs, gallops
Lungs: Prominent kyphosis, clear to auscultation bilaterally, no
wheezes, rales, ronchi
Abdomen: Left sided nephrostomy tube collecting clear urine and
appearing clean and not infected. Large left sided distension
which is not painful. Otherwise soft, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength grossly normal, gait stable
w/walker and PT assist
Pertinent Results:
ADMISSION LABS
[**2190-3-16**] 04:10PM PLT SMR-HIGH PLT COUNT-588*#
[**2190-3-16**] 04:10PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-OCCASIONAL MICROCYT-3+ POLYCHROM-2+ OVALOCYT-2+
TARGET-OCCASIONAL TEARDROP-1+ FRAGMENT-OCCASIONAL
[**2190-3-16**] 04:10PM NEUTS-90* BANDS-0 LYMPHS-7* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2190-3-16**] 04:10PM WBC-13.2* RBC-2.87*# HGB-6.3*# HCT-22.1*#
MCV-77* MCH-22.1* MCHC-28.7* RDW-19.4*
[**2190-3-16**] 04:10PM calTIBC-359 HAPTOGLOB-49 FERRITIN-47 TRF-276
[**2190-3-16**] 04:10PM IRON-38
[**2190-3-16**] 04:10PM LD(LDH)-301* TOT BILI-0.4
[**2190-3-16**] 04:10PM GLUCOSE-148* UREA N-58* CREAT-1.1 SODIUM-142
POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-20* ANION GAP-17
[**2190-3-16**] 06:10PM PT-11.6 PTT-25.3 INR(PT)-1.1
[**2190-3-16**] 06:10PM cTropnT-<0.01
[**2190-3-16**] 06:25PM LACTATE-1.6
.
HCT TREND
[**2190-3-16**] 04:10PM BLOOD Hgb-6.3*# Hct-22.1*#
[**2190-3-17**] 02:03AM BLOOD Hgb-9.0*# Hct-28.7*#
[**2190-3-17**] 07:16AM BLOOD Hgb-8.8* Hct-27.5*
[**2190-3-17**] 12:05PM BLOOD Hct-29.5*
[**2190-3-17**] 09:00PM BLOOD Hct-29.3*
[**2190-3-18**] 02:47PM BLOOD Hct-26.0*
[**2190-3-19**] 05:05AM BLOOD Hgb-9.6* Hct-31.3*
.
DISCHARGE LABS
[**2190-3-19**] 05:05AM BLOOD WBC-12.9* RBC-3.71* Hgb-9.6* Hct-31.3*
MCV-84 MCH-26.0* MCHC-30.8* RDW-19.2* Plt Ct-334
[**2190-3-19**] 05:05AM BLOOD PT-11.7 PTT-28.0 INR(PT)-1.1
[**2190-3-19**] 05:05AM BLOOD Glucose-87 UreaN-17 Creat-0.6 Na-147*
K-2.8* Cl-117* HCO3-20* AnGap-13
[**2190-3-19**] 05:05AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
.
KUB [**3-17**] - Portable and left lateral decubitus abdominal
radiographs. There are multiple gas-filled loops of small bowel
seen in the left abdominal wall hernia. Surgical clips are seen
throughout the pelvis, unchanged from [**2181**]. 11mm calcific
density in the region of the left kidney is unchanged from prior
imaging. There is no evidence of obstruction.
.
CXR [**1-15**] - IMPRESSION: No acute intrathoracic process.
.
[**3-18**] COLONOSCOPY
Findings:
Excavated Lesions Multiple non-bleeding diverticula were seen
in the sigmoid colon. Diverticulosis appeared to be of moderate
severity.
Other Several small AVMs were noted in the proximal ascending
colon. These lesions were treated with APC with successful
obliteration of the AVMs. Additional smaller AVMs in the colon
or small bowel cannot be ruled out. An Argon-Plasma Coagulator
was applied for hemostasis successfully in the proximal
ascending colon.
Impression: Diverticulosis of the sigmoid colon
Several small AVMs were noted in the proximal ascending colon.
These lesions were treated with APC with successful obliteration
of the AVMs. (thermal therapy)
Otherwise normal colonoscopy to cecum
.
[**3-18**] EGD
Findings: Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Lumen: A sliding small size hiatal hernia was seen.
Excavated Lesions A few superficial ulcers ranging in size from
6 mm to 8 mm were found in the Fundus. A pigmented material
suggested recent bleeding. These lesions were most consistent
with [**Location (un) 3825**] ulcers.
Duodenum:
Excavated Lesions A single diverticulum was found near the
ampulla.
Impression: Normal mucosa in the esophagus
Multiple small "[**Location (un) **]-type' ulcers were noted just beneath the
GE junction with pigemented spots but no signs of active
bleeding. These are classically seen in the setting of a large
hiatal hernia, which is not present in this patient.
Nevertheless they may be a contributing source of bleeding.
Small periampullary diverticulum.
Otherwise normal EGD to third part of the duodenum
Recommendations: The [**Location (un) **]-type ulcers are likely a
contributing source to her anemia. They had no high risk
features to them and high dose anti-acid therapy should reduce
the risk of bleeding. However, if the patient is given
anticoagulation there is a risk that these lesions will start
bleeding. Continued anti-acid therapy will reduce this risk to
some degree.
Start pantoprazole 40mg [**Hospital1 **]
Brief Hospital Course:
Primary Reason for Admission: 81F with critical AS with recent
cath complicated by stroke on aspirin who was admitted for
recurrent GIB, found to have multiple [**Location (un) **] ulcers and AVMs on
colonoscopy without active bleeding. pt expected to be
transfusion dependent while awaiting AVR within the next month.
.
Active Problems:
.
# GIB:
Second admission for GI bleed this month. During her first
admission, she was managed conservatively and did well. Now
returns from rehab with recurrent GIB and hct down to 22.1 (from
27-30). Received 2U pRBC in the ED. She was hemodynamically
stable on arrival to the MICU. GI was consulted and performed a
colonoscopy under anaesthesia which showed evidence of [**Location (un) **]
ulcers (superficial) in gastric fundus and no active bleeding.
GI recommend continuing pantoprazole 40mg [**Hospital1 **]. Hematocrit and
hemodynamics were monitored throughout her stay in the MICU. Her
hematocrit dropped slightly on HD 2 and she was transfused total
3U PRBC (2U in ED on arrival, 1U on [**3-18**] for Hct 26, with
appropriate Hct increase to 31). She may require more
transfusions from slow oozing of AVMs while awaiting AVR. Needs
Hct check 3x/week and suggest transfusion for Hct <25. She was
transferred to the floor on [**3-19**] and her repeat HCT on the
morning of discharge was stable at 31. Her ASA was stopped given
her recurrent GIBs and preload dependence in the setting of
critical AS, which was discussed with her PCP and Cardiologist.
Her stroke was iatrogenic in the setting of crossing the aortic
valve, so the indication for ASA in her case is less clear. She
does not have significant CAD on cardiac cath.
.
# CHRONIC ANEMIA
Likely component of blood loss from GI tract as her recent Hct
ranged from 27-30. Reports history of "Mediteranean anemia"
which may mean thalassemia, any prior workup unavailable. Her
MCV is low (60-70s). She takes iron and folate at home. HCT and
hemodynamics were monitored as above. Required 3U total of PRBC
transfusion.
.
# [**Last Name (un) **]
Creatinine elevated to 1.1 from baseline of 0.8. Also had
elevated BUN on arrival to MICU. Thought likely prerenal in
setting of GIB and limited PO intake. Recieved 2U PRBCs in the
ED for GI bleed and 1U of PRBC on hospital day 2. Patient's
fluid status was monitored throughout her stay and was
cautiously bolused as needed. Discharge Cr 0.6.
.
# Critical AS
Valve area 0.5 on last cath, pt awaiting surgical AVR with Dr.
[**Last Name (STitle) **]. Required lasix with transfusions because of mild DOE.
EKG with new TWI on arrival, cardiac enzymes negative.
Outpatient cardiologist Dr. [**Last Name (STitle) **] saw pt in-house and agreed with
plan for endoscopy. Cardiac surgery also aware of
hospitalization. There was discussion of moving up her AVR date
but outpatient plan to continue unchanged.
.
# S/P R MCA stroke
Suffered periprocedure stroke after cardiac cath 2 admissions
ago. Had been living in rehab since for PT/OT. No residual
deficits. On aspirin at home. Prior Carotid US showed <40%
stenosis bilaterally. Aspirin was held in the setting of GI
bleed.
.
TRANSITIONAL ISSUES
1. Recommend close monitoring of Hct, stools. Should get 3x/week
Hct draw by VNA to be followed-up by PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5456**]. [**Month (only) 116**] require
set-up w/outpatient transfusion center if requiring frequent
transfusions.
2. Needs AVR - outpatient follow-up w/cardiac surgeon Dr.
[**Last Name (STitle) **] as pre-arranged.
3. ASA discontinued; PCP [**Name Initial (PRE) 12309**]
Medications on Admission:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO once a
day.
10. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
ml PO once a day: hold for loose stools.
11. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
12. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 10 days.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
ml PO once a day: hold for loose stools.
12. Outpatient Lab Work
Monday [**3-22**]: Chem10, CBC
.
Three times weekly: HCT
.
Results to be followed up by
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) **], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 5457**]
Fax: [**Telephone/Fax (1) 32161**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
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 111600**],
You were admitted to the [**Hospital1 18**] with evidence of a
gastrointestinal tract bleed. You were given a blood transfusion
because of the loss of blood.
The gastroenterologists were consulted and you underwent a
colonoscopy that did not show any evidence of active bleeding.
You should continue to take pantoprazole, which helps prevent
gastric ulcers. Please take as prescribed.
Please note the following changes to your medications:
HELD Aspirin for bleeding
Thank you for allowing us to participate in your care.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) **], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 5457**]
Appointment: Thursday [**2190-3-25**] 1:00pm
Department: NEUROLOGY
When: TUESDAY [**2190-3-23**] at 4:00 PM
With: DRS. [**Name5 (PTitle) **] & HAUSSEN [**Telephone/Fax (1) 1694**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SURGERY
When: WEDNESDAY [**2190-4-7**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
[
"272.0",
"531.40",
"276.0",
"530.81",
"V10.51",
"V13.01",
"569.85",
"562.10",
"285.1",
"255.10",
"455.3",
"280.0",
"414.01",
"282.40",
"584.9",
"424.1",
"V88.01",
"V12.54",
"276.8",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
15332, 15390
|
9210, 12784
|
320, 338
|
15443, 15443
|
5152, 9187
|
16213, 17135
|
3179, 3450
|
13997, 15309
|
15411, 15422
|
12810, 13974
|
15626, 16078
|
3465, 5133
|
16107, 16190
|
271, 282
|
366, 2679
|
15458, 15602
|
2701, 3024
|
3040, 3163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,566
| 113,423
|
52104
|
Discharge summary
|
report
|
Admission Date: [**2157-5-26**] Discharge Date: [**2157-6-6**]
Date of Birth: [**2084-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ([**5-27**]), Interventional Cardiology
[**2157-6-1**]: Coronary artery bypass grafting x3, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein up to the marginal branch and the posterior
descending artery.
History of Present Illness:
72yo man with HTN and DM who
presented to ER with chest pain that occurred at rest. chest
pain
was associated with diaphoresis and mild shortness of breath.
In the ED, patient's initial VS were 97.4 84 220/96 20 94% on
Bipap. The patient was started on Bipap and was given NTG SL x 3
and started on NTG gtt. The patient was also given Lasix 20mg IV
x 1. The patient's ECG was in NSR and showed diffuse ST
depression with elevation in AVR. Patient was started on Hep gtt
and plavix loaded.
Past Medical History:
coronary artery disease, Diabetes, Dyslipidemia, Hypertension,
CRI(1.7), rt arm atrophy
Social History:
He smokes occasional cigars and does drink alcohol. Patient
enjoys fishing
Family History:
Mother: DM
Father: Died of unknown causes
Physical Exam:
VS: 112/63, 67, 20, 97RA
Height: 5ft6in Weight:175lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] rales bases bilat
Heart: RRR [x] Irregular [] Murmur-no
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right:2+(cath)Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right: no Left: no
Pertinent Results:
Labs on Admission:
[**2157-5-25**] WBC-8.7 RBC-4.60 Hgb-13.8* Hct-42.8 MCV-93 Plt Ct-192
[**2157-5-25**] Neuts-54.5 Lymphs-39.4 Monos-4.3 Eos-1.3 Baso-0.6
[**2157-5-25**] PT-11.7 PTT-25.4 INR(PT)-1.0
[**2157-5-25**] Glucose-410* UreaN-20 Creat-1.7* Na-137 K-4.0 Cl-98
HCO3-30
[**2157-5-26**] CK(CPK)-408*
[**2157-5-26**] %HbA1c-9.9* eAG-237*
[**2157-5-25**] cTropnT-0.04*
[**2157-5-26**] proBNP-424*
[**2157-5-26**] cTropnT-0.04*
[**2157-5-26**] CK-MB-39* MB Indx-9.6* cTropnT-0.97*
[**2157-5-26**] CK(CPK)-408*[**2157-6-5**] 09:11AM BLOOD Hct-31.5*
[**2157-6-4**] 04:46AM BLOOD WBC-13.4* RBC-3.63* Hgb-11.0* Hct-32.4*
MCV-90 MCH-30.4 MCHC-34.0 RDW-14.7 Plt Ct-148*
[**2157-6-5**] 09:11AM BLOOD Glucose-205* UreaN-21* Creat-1.0 Na-134
K-4.2 Cl-97 HCO3-32 AnGap-9
[**2157-6-6**] 04:56AM BLOOD UreaN-18 Creat-1.0 K-3.8
Reports:
Cardiac Catheterization:
1. Coronary angiography in this right-dominant system
demonstrated
three-vessel disease. The LMCA had a 30% distal stenosis. The
mid-LAD
had serial 90% stenoses. The LCx was patent, but a large first
obtuse
marginal branch had serial 90% stenoses. The RCA had serial 90%
stenoses
in its proximal and middle portion.
2. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure.
FINAL DIAGNOSIS:
1. Three-vessel coronary artery disease.
.
CXR PA/LAT: Diffuse perihilar opacities and vascular congestion
have resolved. The cardiomediastinal silhouette is normal. There
are no
pleural effusions. Chronic elevation of the right hemidiaphragm
is stable
since [**2148**].
.
ECHO: Overall left ventricular ejection fraction is normal (LVEF
65%). However, the basal segment of the inferior wall and the
apex are hypokinetic. Right ventricular chamber size and free
wall motion are normal. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
Intra-op echo [**2157-6-1**]:
Prebypass
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%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results on [**2157-6-1**] at 1030am.
Post bypass
Patient is on phenylephrine and is AV paced. Biventricular
systolic function is unchanged. Mild mitral regurgitation
present. Aorta is intact post decannulation.
Brief Hospital Course:
The patient is a 72yo gentleman who presented to the ED with a
hypertensive emergency and ruled in for NSTEMI by EKG and
enzymes. Cardiac cath revealed multi-vessel disease and cardiac
surgery consultation was requested. The patient underwent the
routine preoperative workup. He was taken to the operating room
on [**2157-6-1**] where he underwent coronary artery bypass x3
LIMA-LAD, SVG to Oobtuse marginal and SVG to PDA. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Vancomycin was used for surgical
antibiotic prophylaxis. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. He was restarted on his preoperative medication
Lisinopril but at a lower dose given marginal systolic blood
pressure in the 80's.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility.
[**Last Name (un) **] was consulted for blood sugar management and his insulin
regimen was changed to Lantus. He is to follow up Dr. [**Last Name (STitle) 57318**] as
an outpatient for further adjustments in insulin.
By the time of discharge on POD #5 the patient was ambulating
with assistance, the wound was healing and pain was controlled
with oral analgesics. The patient was cleared for discharge to
[**Hospital3 **] rehab in good condition with appropriate follow
up instructions.
Medications on Admission:
Atenolol 100mg daily
Lipitor 40mg daily
HCTZ 25mg Twice Weekly
Isosorbide 15mg daily
Lisinopril 40mg daily
Metformin ER 1000mg Once Daily
Aspirin 81mg daily
Novolog (70-30) 33/17
Discharge Medications:
1. Metformin 1,000 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
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:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous Q AM.
Disp:*QS 1 month * Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 units
Subcutaneous Q BEDTIME.
Disp:*QS 1 month * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
PMH:
Diabetes, Dyslipidemia, Hypertension, CRI(1.7), right arm
atrophy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
sternal incision clean and dry
Left leg harvest site clean and dry with intact steri strips.
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 cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2157-6-30**] 1:15pm
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 132**] C. [**Telephone/Fax (1) 133**] in [**2-12**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-12**] weeks
Endocrinologist at [**Last Name (un) **] Dr [**Last Name (STitle) 57318**] Wed [**6-8**] at 11:00 AM
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2157-6-6**]
|
[
"428.0",
"414.01",
"511.9",
"403.90",
"410.71",
"585.9",
"428.31",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.12",
"39.61",
"88.56",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8238, 8308
|
4848, 6651
|
332, 601
|
8447, 8639
|
2046, 2051
|
9271, 9866
|
1340, 1383
|
6880, 8215
|
8329, 8426
|
6677, 6857
|
3325, 4825
|
8663, 9248
|
1398, 2027
|
282, 294
|
629, 1120
|
2065, 3308
|
1142, 1232
|
1248, 1324
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,702
| 106,995
|
36833
|
Discharge summary
|
report
|
Admission Date: [**2101-9-15**] Discharge Date: [**2101-9-21**]
Date of Birth: [**2050-6-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Chief Complaint:hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 51 y.o male with h.o colon cancer widely mets to lungs
s/p ileostomy, mucous fistula, transferred from [**Hospital 1562**]
Hospital for further eval. Per report, pt noticed clogging,
cloudy outpt from his urostomy tubes 1-2 days ago and 1 episode
of vomiting. He also reportedly denied change in ileostomy
outpt, but was noted to have cloudy outpt from his R.nephrostomy
tube.
.
While at [**Name (NI) 1562**], pt noted to have dirty u/a. Afeb, BP 128/68,
HR 120's, sat 96% on RA at ~9am. Upon transfer was noted to have
BP 84/54, HR 113, sat 100% on 2L. CXR with "L.sided white out".
.
In [**Hospital1 18**] ED, initial vitals T-99.4, 95/61, hr 121, 16, 100% on
2L-cold, clammy on presentation. On exam decreased bowel sounds
on L.side. The patient's abdomen was non-tender, non-distended,
and had b/l nephrostomy tubes with cloudy/turbid outpt.
Upon transfer to the MICU the patient was started on
phenylephrine for pressor support briefly. His coverage was
broadened to cefepime/vanc/cipro. The patient mental status and
hemodynamics improved. Discussions with the patient and sister
resulted in a DNR/DNI discussion. As the patient is now stable
with a diagnosis of urosepsis, organism to be determined he is
called out to the medical floor.
.
At the time of transfer to the general medicine floors, the
patient is resting comfortably with pain controlled. He is
concerned about the cleanliness of his enviroment and the
temperature of his new room.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, melena, hematochezia
Past Medical History:
Metastatic Colon CA: lung, liver, kidneys, bone, throat.
Chronic pain
GERD
Social History:
Pt lives in [**Location **], formerly lived in Hospice facility. Denies
smoking, ETOH, drug use. Ambulates with a cane.
Family History:
Non-contributory
Physical Exam:
Admission physical exam:
Vitals:T. 99.5, BP 101/54, HR 133, RR 22 sat 98% 4L
General: writing in pain, moaning
HEENT: Nc/AT, EOMI, anicteric, poor dentition.
Neck: supple
Lungs: b/l ae, diminished BS, anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, tachycardic
Abdomen: +bs, +multiple areas of tubing/fistula etc.
urine-cloudy.
GU: no foley
Ext: warm, well perfused, 2+ pulses
neuro: somnolent, answers some questions AAOx1
Pertinent Results:
Admission laboratories:
[**2101-9-15**] 03:58PM BLOOD WBC-11.9* RBC-3.65* Hgb-10.7* Hct-33.2*
MCV-91 MCH-29.3 MCHC-32.2 RDW-15.6* Plt Ct-272
[**2101-9-15**] 03:58PM BLOOD Neuts-92.2* Lymphs-5.9* Monos-1.2*
Eos-0.5 Baso-0.1
[**2101-9-18**] 10:11AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.0
[**2101-9-15**] 03:58PM BLOOD Glucose-98 UreaN-24* Creat-1.2 Na-136
K-3.6 Cl-102 HCO3-24 AnGap-14
[**2101-9-16**] 03:37AM BLOOD ALT-24 AST-39 LD(LDH)-651* AlkPhos-238*
TotBili-0.6
[**2101-9-16**] 03:37AM BLOOD Albumin-2.5* Calcium-7.3* Phos-3.3
Mg-1.2*
[**2101-9-15**] 03:58PM BLOOD calTIBC-229* Ferritn-880* TRF-176*
Iron-9*
[**2101-9-16**] 03:37AM BLOOD TSH-0.93
[**2101-9-15**] 04:13PM BLOOD Lactate-1.6
Urinalysis:
[**2101-9-15**] 04:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2101-9-15**] 04:30PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2101-9-15**] 04:30PM URINE RBC-21-50* WBC->50 Bacteri-MANY
Yeast-NONE Epi-0-2
EKG ([**2101-9-15**]): Artifact is present. Sinus tachycardia. Normal
tracing. Compared to the previous tracing there is no
significant change.
Rate PR QRS QT/QTc P QRS T
116 130 70 314/412 61 8 8
Imaging:
CT of the chest/pelvis/abdomen ([**2101-9-15**]):
CT OF THE CHEST WITHOUT IV CONTRAST: A left subclavian catheter
terminating
in the right atrium is noted. There is no axillary, mediastinal,
supraclavicular adenopathy. There is an 8 mm right thyroid lobe
nodule. The patient LUL collapse with a left hilar mass. There
are multiple bilateral pulmonary nodules, consistent with known
history of malignancy, metastatic lung cancer. Evaluation of
hilar structures is limited given lack of IV contrast, however,
there is fullness adjacent to the left upper lobe bronchus with
suggestion of a mass measuring 1.9 x 2.6 cm, may relate to
patient's known malignancy (2:19). There are innumerable
bilateral pulmonary nodules, largest in the right lower lobe,
measuring 2.3 x 1.3 cm and 2.0 x 1.9 cm. There are bilateral
pleural effusions. There is right lower lobe consolidation may
reflect atelectasis given enhancement.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Livery demonstrates fatty
infiltration. The gallbladder, spleen, pancreas are within
normal limits. The right adrenal demonstrates a mass, measuring
2.1 x 1.6 cm, suspicious for adrenal metastases. There are
multiple mesenteric lymph nodes, in the
gastrosplenic ligament, measuring up to 1.2 cm and may reflect
metastatic
nodes. The patient has an indwelling vena caval filter. There
are bilateral nephrostomy tubes. The right kidney is otherwise
unremarkable. The leftkidney demonstrates mild hydronephrosis
and hydroureter, could be due to clogged PCN tube, which is
appropriately positioned in the renal pelvis. There is no
intraperitoneal free fluid or free air.
There is a left paramedian colostomy. There is a right lower
quadrant
ileostomy. Small amount of contrast is noted in the small bowel.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is marked soft
tissue thickening and fullness in the deep pelvis effacing the
normal fat planes and limiting differentiation between bladder,
prostate and residual rectum. It extends from the sacral
promontry to the pubic symphysis. There is no inguinal or
pelvicsidewall adenopathy. The largest inguinal lymph node on
the right measures up to 1 cm.
OSSEOUS STRUCTURES: There are no osteolytic or osteosclerotic
lesions.
IMPRESSION:
1. Innumerable pulmonary nodules, right adrenal metastases,
mesenteric nodes, pelvic soft tissue mass, left peri hilar mass,
and left upper lobe collapse, findings consistent with
metastatic lung cancer.
2. A hydronephrotic left kidney with percutaneous nephrostomy
tube in situ
and moderate left hydronephrosis and hydroureter possibly due to
compression/infiltration from the pelvic mass and clogged PCN
tube.
3. Bilateral Pleural effusions and RLL atelectasis.
4. Fatty Liver
Culture data:
[**2101-9-17**] 2:44 pm URINE Source: Kidney LEFT NEPHROSTOMY.
**FINAL REPORT [**2101-9-20**]**
URINE CULTURE (Final [**2101-9-20**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 2 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
[**2101-9-17**] 2:45 pm URINE Source: Kidney RIGHT NEPHROSTOMY.
**FINAL REPORT [**2101-9-19**]**
URINE CULTURE (Final [**2101-9-19**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 279-0219P [**2101-9-17**].
Brief Hospital Course:
Assessment and Plan: Pt is a 51 y.o male with h.o colon ca who
presents with hypotension found to have sepsis due to UTI.
.
1. Sepsis due to UTI: The patient was stabilized in the ICU with
IV fluids and broad spectrum antibiotics including Vancomycin,
Zosyn, and Cipro. Repeat lactates were normal. Although his
SBP~80, the patient was mentating well initially, but then grew
more somelent. His status improved with antibiotic treatment,
intravenous fluids and brief pressor treatment with Neo. Once
stabilized, he was transferred to the general medicine floors.
The patient had a positive urinanalysis and urine cultures
revealed Pseudomonas growing in both of his nephrostomy tubes
which is sensitive to Cefepime. Vancomycin and Cipro were
discontinued in light of the sensitivities. While on the floors
the patient was normotensive and afebrile without any complaints
of shortness of breath, fevers, chills, or abdominal pain.
Of note, his right nephrostomy bag also grew yeast on the urine
culture. Since he is on antibiotic treatment, he was not covered
for yeast. Once his antibiotic course ends on [**10-6**], if he is
still growing yeast in his urine, one could consider treatment
for his yeast.
The patient had bouts of tachycardia to 120s during his stay on
the floors which responded to high 90s with fluid boluses. He
did not have any episodes of hypoxia, hemoptysis or chest pain
concerning for PE. His pain was well controlled. Of note, the
patient says that he has a baseline tachycardia.
2. Metastatic colon cancer: A CT scan of the chest, abdomen and
pelvis revealed extensive metastases. The patient is s/p bowel
resections with a colostomy, stoma and bilateral nephrostomies.
The patient stated that he is full code and wants chemotherapy
for his disease. Contact was made with the primary oncologist
who thought in [**Month (only) **]/[**Month (only) 205**] that he was not a good candidate for
further chemotherapy treatment. His pain regimen was changed
while in the hospital to Fentanyl patch 100 mg, lidocaine patch,
Morphine Sulfate 4.5 mg SL Q2H:PRN pain, Morphine SR 90 mg PO
Q8H pain, Gabapentin 600 mg PO TID, Naproxen 250 mg PO Q12H:PRN
and Tylenol PRN. He stated that his home pain regimen sedated
him too much.
.
3. Leaking right nephrostomy tube: Interventional radiology
evaluated the tube and said that the tube was not currently
leaking. It might have been leaking secondary to either kinking
or increased debris. Once the debris was flushed, it was not
leaking. If the tube leaks, then interventional radiology would
have to be contact[**Name (NI) **].
.
4. Anemia of chronic disease and iron deficiency anemia: The
patient remains and lab values reveal an anemia of chronic
disease and iron deficiency anemia. His Fe/TIBC ratio is less
than 5% and his iron levels are low (Fe=9). He was started on
iron supplementation. His hematocrit remained stable (Hct on
discharge=28.2).
.
5. Chronic Prednisone use: The patient is on his home dose of
prednisone. He states that his prednisone helps his neuropathy,
but the his primary care physician and oncologist do not know
why he takes prednisone. The use needs to be addressed for its
immunosuppressive effects, especially in light of his recent
infection.
Outpatient followup:
1. Address goals of care for his metastatic cancer.
2. Once antibiotic treatment ends on [**10-6**], check a urine
culture. If the culture still has yeast growing, contact a
physician to consider treating the yeast.
3. Address the reason why the patient uses prednisone.
Medications on Admission:
tylenol prn
ativan q4hrs
roxanol 20mg/ml, 4.5ml SL Q2hrs for pain
naproxen 220 [**Hospital1 **]
zofran
MSIR 90mg q3hrs prn
fentanyl 100mcg/patch
neurontin 600mg QID
lidoderm 5% patch
omeprazole 20mg daily
KCL 40meq in am
zoloft 100mg daily
prednisone 10mg [**Hospital1 **]
Neurontin 600 mg Tab Oral
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6HR:PRN
as needed for fever or pain: Do not exceed 4 grams per day.
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO q4HR: PRN as
needed for anxiety.
3. Roxanol Concentrate 20 mg/mL Solution Sig: 4.5 mL PO Q2HR:PRN
as needed for pain: Sublingually.
4. Naproxen Sodium 220 mg Tablet Sig: One (1) Tablet PO BID:PRN
as needed for pain. Tablet(s)
5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4HR:PRN as needed for nausea.
6. BenGay Ultra Strength [**2102-6-9**] % Cream Sig: One (1)
application Topical PRN as needed for pain: Please apply to
right knee.
7. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
11. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Bacid Capsule Sig: Two (2) Capsule PO twice a day.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day.
15. MS Contin 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO every eight (8) hours.
16. Morphine Concentrate 20 mg/mL Solution Sig: Four (4) mg PO
Q2H (every 2 hours) as needed for pain.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
19. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 15 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 9188**] care and Rehab Ctr
Discharge Diagnosis:
Primary:
1. Sepsis due to UTI
.
Secondary
1. Metastatic colon cancer
2. Anemia
Discharge Condition:
Stable. On room air. Pain well controlled. Ambulating with
assistance.
Discharge Instructions:
You came to the hospital because you were not feeling well. You
were found to have an infection with bacteria called Pseudomonas
growing in your urine. You were first in the ICU and then when
stabilized came to the general medicine floors. While on the
general medicine floors, you did not have a fever or low blood
pressure. You will leave with an antibiotic called Zosyn which
will treat your infection.
.
Your right nephrostomy tube started to leak while in the
hospital. The interventional radiologist came to evaluate you
and said that your tube was fine. It was probably leaking due to
a kink in the tube. If it happens again, you should unkink the
tube. If you are having problems with the tube, you can call the
interventional radiology department at [**Hospital3 **] [**Telephone/Fax (1) **].
At other hospitals, they also have interventional radiology
departments that would help.
You should come back to the hospital or call your primary care
physician if you have any fevers, chills, abdominal pain,
shortness of breath, or chest pain.
Followup Instructions:
We made an appointment with your oncologist to discuss your
goals of care.
Appointment #1
MD: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Specialty: Oncology
Date and time: [**10-3**] at 11am.
Location: [**Location (un) 83209**], [**Apartment Address(1) **]; [**Location 21487**], [**Numeric Identifier 83210**]
Phone number: [**Telephone/Fax (1) 52208**]
|
[
"198.5",
"198.89",
"530.81",
"997.5",
"591",
"V44.3",
"356.9",
"197.7",
"338.29",
"038.43",
"288.60",
"285.22",
"401.9",
"E878.1",
"255.41",
"197.0",
"280.9",
"V10.05",
"493.90",
"V44.2",
"995.91",
"599.0",
"198.0",
"V44.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13768, 13838
|
7824, 11360
|
343, 350
|
13961, 14034
|
2807, 7801
|
15130, 15547
|
2320, 2338
|
11710, 13745
|
13859, 13940
|
11386, 11687
|
14058, 15107
|
2378, 2788
|
292, 305
|
378, 2068
|
2090, 2167
|
2183, 2304
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,805
| 151,145
|
54166+59582
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-10-20**] Discharge Date: [**2182-1-15**]
Date of Birth: [**2147-8-5**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / E-Mycin
Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
Increased seizure frequency
Major Surgical or Invasive Procedure:
IVC filter placement
Bronchoscopy
Intubation
LP
Tracheotomy
PEG placed
History of Present Illness:
34 year-old woman with a history of refractory epilepsy and
[**Doctor Last Name **] encephalitis transferred from OSH with increased
seizure frequency. Unfortunately, pt is unaccompanied and
presently non-verbal so most of history from medical record.
.
Per OSH records, EMS arrived at pt's apt a few minutes after a
generalized convulsion per visiting nurse who was present.
Visiting RN also reported pt had 6 focal seizures in ~35
minutes. Pt had at least 1 more generalized seizure at OSH and
multiple focal right face seizures, and received ativan 1mg x2
and used the VNS magnet as well. She was initially unresponsive
on arrival to OSH, and developed increased alertness while
there but she was using her right arm only minimally and was
non-
verbal, which is atypical for her. Labs and head CT were
unremarkable (see below) except for AED levels that were low-
normal. She was transferred for further management.
.
Pt is unable to tell me how many focal or generlized seizures
she
has had today. She reports having ~30 seizures yesterday. At
baseline per OMR notes she has 5-10 per day.
.
ROS: No fever, chills. +Cough for 2 days. No headache, chest
pain, sore throat.
Past Medical History:
1. Epilepsy. Seizures started at age 11, with remission from age
16 to 22. Has right facial motor seizures daily, exact frequency
unclear. Unclear baseline frequency of GTC. Did well during
pregnancy with seizure control, currently meds being titrated
down. Also with VNS.
2. OSA, previous OMR notes report CPAP 11, unable to verify if
currently using given mental status
3. Multiple injuries [**12-27**] seizures
4. h/o right arm and leg fracture
5. Migraine headache
6. [**Doctor Last Name 73**] encephalitis
7. Cervical cancer s/p laser surgery
Social History:
Has visiting nurse, lives with fiancee and new baby. Uses
wheelchair at home.
Family History:
Adopted, kids with no seizures
Physical Exam:
T 99.9 BP 124/79 HR 90s RR 15 O2 sat 100% 4L NC
(though RR 30 and O2 sat 93% when having focal seizure)
General: Appears stated age, frequent motor seizures
HEENT: NC/AT Sclera anicteric. OP clear
Neck: Supple
Lungs: +Cough, few bibasilar crackles
CV: RRR, nl S1, S2, no murmur.
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema
.
Neurologic Examination:
Mental Status: Awake, somewhat sleepy with yawning, inattentive.
Mostly non-verbal, occasionally moans and rarely says words or
phrases. Answers questions (nods, shakes head, can point to word
or numbers on page but does not write) and follows simple
commands mostly appropriately but is extremely slow to do so. No
obvious neglect.
.
Cranial Nerves: Pupils equally round and reactive to light, 5 to
3 mm bilaterally, brisk. Extraocular movements intact, bilateral
end-gaze nystagmus. Facial sensation intact to light touch.
Right
facial droop, varying severity depending on how far out from
focal seizure. Normal oropharyngeal movement. Tongue midline, no
fasciculations. Has multiple mostly right face motor seizures,
begin with tonic phase and then followed by clonic involving
platysma as well as orbicularis oculus and oris with some tongue
and jaw involvement as well.
.
Motor: Normal bulk and tone bilaterally, fasiculations absent in
upper and lower extremities. No tremor. Formal strength testing
complicated by some inattention, giveway weakness and poor
effort. However, left arm is full strength. Right arm with
pronator drift, and at least 4/5 strength. Legs with bilateral
IP
weakness but at least 3, left dorsiflexion full and right
dorsiflexion at least 4.
.
Sensation was intact to light touch in all 4 extremities.
.
Reflexes: DTRs trace to absent throughout. Toes withdrew.
.
Coordination is normal on finger-nose-finger on left, did not
perform on right.
Gait deferred.
Pertinent Results:
[**2181-10-20**] 06:35AM BLOOD WBC-4.4 RBC-3.54* Hgb-12.0 Hct-35.2*
MCV-99* MCH-33.9* MCHC-34.0 RDW-12.9 Plt Ct-125*
[**2181-10-20**] 05:24PM BLOOD PT-12.8 PTT-23.4 INR(PT)-1.1
[**2181-10-20**] 05:24PM BLOOD Glucose-101 UreaN-7 Creat-0.5 Na-142
K-3.8 Cl-105 HCO3-26 AnGap-15
[**2181-10-20**] 01:44AM BLOOD ALT-15 AST-16 AlkPhos-51 Amylase-55
TotBili-0.4
[**2181-10-20**] 05:24PM BLOOD Calcium-8.6 Phos-3.7 Mg-1.7
[**2181-10-20**] 01:44AM BLOOD Albumin-4.3
[**2181-10-20**] 01:44AM BLOOD Phenoba-39.2
[**2181-10-20**] 12:46PM BLOOD Carbamz-2.6*
[**2181-10-20**] 01:27PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.020
[**2181-10-20**] 01:27PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2181-10-20**] 01:27PM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-<1
[**2181-10-24**] 04:59PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-175*
Polys-7 Bands-3 Lymphs-85 Monos-6
[**2181-10-24**] 04:59PM CEREBROSPINAL FLUID (CSF) TotProt-22 Glucose-98
----
Torso CT 12/01:1. Bilateral lower lobe consolidation and patchy
opacity in the right upper lobe. Given the distribution,
aspiration should be considered.
2. A 9-mm segment of small bowel intussusception, that likely
represents so- called "transient intussusception." There is no
evidence of proximal dilatation or obstruction of small bowel.
----
CT head [**10-26**]:There is opacification of multiple paranasal
sinuses, likely related to the patient's intubation. Again seen
is a left frontoparietal craniotomy defect. Chronic changes of
brain injury are seen in the left hemisphere including
encephalomalacia and ex vacuo ventricular dilitation, with an
associated slight shift of normally midline structures to the
left, unchanged since the prior study. The fluid in the extra-
axial space under the craniotomy flap that was present on the
prior exam has resolved. No areas of intra- or extra- axial
acute hemorrhage are identified. There are no findings to
suggest major vascular territorial infarction. There are post-
surgical changes in the area of the craniotomy, the remaining
soft tissue structures including the orbits appear unremarkable.
----
LENIs [**10-31**]:Nonocclusive thrombus within the left common femoral,
greater saphenous, and mid superficial femoral veins.
----
Head CT [**10-31**]:: Limited study, due to severe image degradation
from beam- hardening and streak artifacts, as detailed above. No
displacement of the normally midline structures, or change in
the configuration of the ventricular system since the prior head
CT. Repeat head CT, without metallic devices, would obviously be
a more sensitive means to assess the brain parenchyma.
----
CTA [**10-31**]:IMPRESSION:
1. Bilateral central pulmonary embolism involving bilateral main
pulmonary arteries, as well as bilateral upper and lower lobe
branches.
2. Associated mosaic perfusion of bilateral lungs.
3. Improving atelectasis.
----
Torso CT [**11-3**]:IMPRESSION:
1. Marked increase in airspace consolidation within the right
and left lungs as described above.
2. Small bilateral pleural effusions.
3. No evidence of hematoma within the chest, abdomen, or pelvis.
.
US RUQ: Normal right upper quadrant ultrasound. No son[**Name (NI) 493**]
evidence of acalculous cholecystitis.
Brief Hospital Course:
1.Neuro:
She was initially admitted to the neuro-stepdown unit to monitor
given her frequent focal motor facial seizures. These initially
improved with a phenobarbital load and she appeared to be
improving. Her phenobarbital level was good at 42 after her
load. She was continued on her home AEDs. Unfortunately, she
then began to have an increase in her facial seizures(6-8/hr)
without complete recovery in between. She was unable to talk in
between seizures and then started to desat into the 80s despite
5LNC oxygen. For this reason, she was intubated, transferred to
the ICU and put on a pentobarb drip. This achieved burst
supression. She was continued in this state for several days,
continued on her home AEDs as well as the pentobarbital. She
had adequate drug levels quickly. The only change was that her
carbamazepine was switched to oral solution so it could be given
through her NGT. This made her levels more unstable so she
required frequent redosing of extra tegretol to keep her levels
up. Initial reasons for her increase in seizure frequency are
unknown and we are not clear as to why she had these events. It
is possible that she missed some medication doses, but she
initially denied this and we can not be sure. No evidence of
infection was discovered on initial survey. This included CXR,
urine and blood cultures, and an LP. The LP showed 6
WBCs(lymphocyte=85%)(which is consistent with a post-status
CSF), pro=22, glu=98She did develop a pneumonia after several
days here, but this is thought to have occured as a result of
hre seizures and possible aspiration and is not likely the cause
of her seizing. After several days, her pentobarbital drip was
attempted to be weaned but this was unsuccessful as she had a
reappearance of frequent spikes that bordered on seizure
activity. This was attempted several more times after
medication changes were made and each time the attempts were
unsuccessful. The changes included increasing her carbamazepine
which became problem[**Name (NI) 115**] due to poor absorption. This was then
stopped. She was switched to IV phenobarbital. Her ativan was
increased without much effect, and then she had dilantin added
to her regimen. She was continued on her pentobarb drip with
several unsuccessful weans as above. She was on continuous
bedside EEG monitoring throughout. From [**Date range (1) **], pentobarb
weaned from 3.5 to 2.5 over 2 days, with more high amplitude,
disorganized eeg activity- sharps present ([**12-29**] bursts in 10 sec
interval), left dominant. There was no ongoing sz activity.
However, on [**11-7**] overnight, she had more generalized spikes
([**11-26**] sec apart), necessitating another increase in the pentobarb
drip. With higher requirement for pentobarb, she was thought to
have barbiturate resistance. By [**11-9**] she was weaned off
pentobarb and started on an ativan drip, which was increased to
3mg/hr. EEG initially showed spikes, but later showed
disorganized activity. Ativan drip was successfully weaned to
about 0.5-1mg/hr, but the patient began to have increasing
spikes and electrographic seizure activity on bedside EEG,
including one event during which she again developed clinical
status epilepticus with facial twitching lasting 35 minutes,
correlating with seizure on EEG; she was rebolused with ativan
and received dilantin for a concurrently low level. Later on,
with adequate dilantin dosing and ativan drip at about 2mg/hr,
she had some witnessed seizure activity with eyebrow twitches
and blinking correlated with right frontal spikes that looked
almost artifactual. It was unclear if this was seizure, as the
EEG was atypical. However, as her ativan drip could not be
further weaned (and despite the risks associated with depakote
and lamictal together), her lamictal dose was halved (after a
level had been sent) and depakote was added and titrated up
slowly to prevent complications of SJS.
.
On [**11-21**], critical illness polyneuropathy was demonstrated by
EMG. She was at the time areflexic throughout with no
spontaneous movement. By [**2181-11-30**], she had trace reflexes in the
right knee and left biceps. Later followed by trace in R
brachioradial.
.
Over the month of [**Month (only) 404**], progressively increased VPA,
decreased dilantin, increased lamictal (level on [**11-30**] was 1.8).
Ativan drip was eventually transitioned to oral ativan. This
was slowly decreased to her usual outpatient dose, 1mg po
q8hours. EEG with less spikes, but persistent left frontocentral
slowing.
.
At the time of discharge, we suspect that she is occasionally
having brief focal motor seizures, which is usual for her at
baseline and were undetected by EEG. She appears to be more
awake at times and is able to follow simple commands such as
sticking out her tongue. She is not able to move her
extremities, but responds to noxious stimuli in her UE with
grimace (no response in LE). She is able to track in the
horizontal plane if she is awake and cooperative, with a clear
nystagmus.
Her anticonvulsant regimen at the time of discharge includes:
-gabapentine 1600 TID PO
-lamotrigine 200 [**Hospital1 **] and 250HS PO
-ativan 1mg q 8hrs PO
-dilantin 300mg PO/MG TID (goal level, corrected for albumin,
around 15 ); uncorrected level [**1-7**]: 10.6; on [**1-8**] 12.8
-VPA 1750 qid PO/NG; level 64 on [**1-7**] (goal 40-60); on [**1-8**]
level was 8; extra iv dose given; please monitor this level very
closely, i.e. daily, and contact Dr. [**Last Name (STitle) 1846**] if the level does
remain under the goal range.
-PB 150 [**Hospital1 **] PO/NG: 56.8, on [**1-8**] 54.3. Goal is to have it drop
to levels of 30-40 (the dose was decreased last week, but due to
the long half life it will take some time for the levels to
drop). Her dilantin, phenobarbital and depakote levels were all
in the therapeutic range. Sertraline was started to treat her
for depression as she would often start crying while being
examined.
.
2.Pulmonary: She was ventilated and did well with this until she
developed difficulty on [**10-31**]. A pu.monary embolus was suspected
so she had a chest CTA which showed bilateral PEs in all main
pulmonary arteries. This was very concerning. She also
required an increase in her pressors at this time as she was
becoming more hypotensive. She was started on heparin
initially, then the decision was made to procede with
thrombolysis. She received IV tpa to lyse her clots and did
well with this. She improved fairly quickly after this
intervention. LENIs at that time showed further LE clot in the
right leg. She also had an esophageal balloon placed to help
guide ventilator management in this setting. She had a
hematocrit drop after the TPA but no source was found on torso
CT. She had no intracranial bleeding either. The hematocrit
stabilized and at that time heparin was restarted. She then had
an IVC filter placed.
Before her PEs, she had spiked a fever and had thick mucous
nasal discharge. A bronchoscopy showed apparent PNA as did her
chest CT. This was treated with vancomycin, then switched to
oxacillin when it returned as MSSA. She continued to spike
frequently, but no other infectious source was found.
Eventually, she defervesed and this may have all been due to an
undertreated PNA. She spiked another fever when she had her
multiple PEs but this was attributed to the clots. She
continued to have thick, dark secretions, but repeat
bronchoscopy was always unrevealing. She was treated with two
courses of levaquin+flagyl+vancomycin.
.
3.Heme: She had a stable hematocrit during her stay, but did
have a drop in her level after getting thrombolysis. A torso CT
and physical exam showed no obvious source of bleeding. Her
hematocrit then stabilized and remained so for the rest of her
stay.
.
4.CV: She required pressors to maintain an adequate BP for much
of her stay. This was thought to be due to the fact that she was
on pentobarbital and that she had a severe infection. The only
positive blood culture was coag neg staph and likely a
contaminant. When she developed her PEs, her pressor
requirement increased greatly. This was probably directly
related to the clots. After lysis, we were able to wean her
back down. She still required this while on the pentobarbital
drip, even when her infection was totally treated. She had a
TEE after her thrombolysis which showed mild pulm HTN, but no
valvular lesions or chamber pathology. Her heart rate remained
in the high 90s-100s (thought related to infection) but her
blood pressure was stable for the remainder of her hospital stay
between late [**10-29**] and [**11-30**]
.
4.ID: She initially spiked very high daily fevers. The only
source of infection was her multifocal PNA which was speciated
as MSSA. This was treated with vancomycin, but this was not
effective, so she was switched to oxacillin(first had to be
desensitized as she has PCN allergy). This was more effective
and her PNA had cleared by the time her PE developed(had a
repeat CT at that time). She did still have fever, but it was
attributed to her clots. She never had positive urine or true
positive blood cultures. She continued to have fevers thought
related to pneumonias. She was treated with two courses of
levaquin + flagyl + vancomycin, though later on, pneumonia was
though to be adequately treated. She continued to have fevers,
and no origin was found through [**Date range (1) 35604**], with brief periods
of defervescence. Her line was empirically resited; gynecology
was consulted for ?[**Last Name (un) **] or vaginal infection that could be
causing temperature spikes; they felt this was unlikely and
recommended discontinuing antifungal agents that had been used
to treat a yeast infection early on. Fever was thought to be
potentially related to either dilantin or vancomycin (though
even off vanco, she had spiked); however, due to her risk of
recurrent status, discontinuing dilantin was not felt to be
indicated. In mid-[**Month (only) 404**], she developed a UTI due to
Klebsiella which was resistant to all antibiotics except
carbapenems. She was successfully treated with a seven day
course of meropenem with effect. This course was repeated
[**Date range (1) 111012**], again with good effect.
.
5.Renal: Her renal function was stable throughout her admission.
She had good urine output.
.
6.GI: She received tube feeds during her stay in the ICU and
tolerated these well. Initially per NGT, later per PEG tube. As
she had complained to her parents of abdominal pain in the days
prior to the hospitalization, a CT was performed early on ([**10-25**])
that showed "transient intussuception;" however, a follow-up CT
performed [**11-3**] was negative. In [**11-30**], she had a RUQ u/s to r/o
cholecystitis as source of fever, which was a negative study.
Medications on Admission:
Lamictal 200/200/400, tegretol XR [**Telephone/Fax (1) 111002**], neurontin
1600 tid, mysoline [**Telephone/Fax (3) 41254**], ativan 1 tid, folate 4, B12
1000, MVI, colace
Discharge Medications:
1. Gabapentin 250 mg/5 mL Solution Sig: One (1) 1600mg PO TID (3
times a day).
2. Acetaminophen 160 mg/5 mL Solution Sig: [**11-26**] PO Q4-6H (every
4 to 6 hours) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) 30mg PO DAILY (Daily).
6. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) 400mg PO Q6H
(every 6 hours) as needed.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Insulin Regular Human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) 90mg Subcutaneous
Q12H (every 12 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours).
13. Levocarnitine 330 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
15. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
16. Lamotrigine 100 mg Tablet Sig: 2.5 Tablets PO HS (at
bedtime): give in hs in addition to doses in qam and afternoon.
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Phenytoin 100 mg/4 mL Suspension Sig: One (1) 300mg PO TID
(3 times a day).
19. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Phenobarbital 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
21. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) 1750mg PO
QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Status epilepticus
Pulmonary Embolism
Deep venous thrombosis
Pneumonia
Urinary tract infection
Critical illness polyneuropathy
Discharge Condition:
Stable: trach and PEG in place; following simple commands with
her facial muscles; not able to move her extremities due to
critical illness polyneuropathy.
Discharge Instructions:
Please administer medication as instructed.
.
Please continue to check levels of phenobarbital, dilantin and
valproic acid.
.
Her anticonvulsant regimen at the time of discharge includes:
-gabapentine 1600 TID PEG
-lamotrigine 200 [**Hospital1 **] and 250HS PEG
-ativan 1mg q 8hrs PEG
-dilantin 300mg PEG TID (goal level, corrected for albumin,
around 15 ); uncorrected level [**1-7**]: 10.6; [**1-8**] 12.8
-VPA 1750 qid PEG; level 64 on [**1-7**] (goal 40-60); level on [**1-8**]
8; extra dose given iv prior to discharge.
-PB 150 [**Hospital1 **] PEG: 56.8 on [**1-7**]; 54.3 on [**1-8**]. Goal is to have it
drop to levels of 30-40 (the dose was decreased last week, but
due to the long half life it will take some time for the levels
to drop).
Her dilantin, phenobarbital were all in the therapeutic range.
Valproate level dropped on the day of discharge to 8 (extra iv
dose given prior to discharge); please follow this level very
closely (check daily) and contact Dr. [**Last Name (STitle) **] (phone number see
below) if the level remains under the goal range.
.
Make sure to treat any raise in temperature with tylenol
immediately.
Followup Instructions:
Please follow up at the [**Hospital 875**] Clinic: Dr. [**Last Name (STitle) 1846**] [**1-17**] at 12.00. [**Hospital Ward Name 860**] Building [**Location (un) **].
.
Please call Dr.[**Name (NI) 1847**] office [**Telephone/Fax (1) 876**] for further
questions.
Completed by:[**2182-1-8**] Name: [**Known lastname 18208**],[**Known firstname 850**] Unit No: [**Numeric Identifier 18209**]
Admission Date: [**2181-10-20**] Discharge Date: [**2182-1-15**]
Date of Birth: [**2147-8-5**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / E-Mycin
Attending:[**First Name3 (LF) 186**]
Addendum:
1) Anti-epileptic drug regimen:
Since the initial discharge summary, the anticonvulsant regimen
has changed, especially with respect to valproic acid that
should be administered in SPRINKLE form only.
Her anticonvulsant regimen at the time of discharge includes:
-Valproic acid 1750mg qid PEG; level 43 on [**1-14**] (goal 40-60);
PLEASE NOTE: SPRINKLES ONLY (syrup or liquid will not be
absorbed and will lead to subtherapeutic levels)
-gabapentine 1600 TID PEG
-lamotrigine 200 [**Hospital1 **] and 250HS PEG
-ativan 1mg q 8hrs PEG
-dilantin 300mg PEG TID (goal level, corrected for albumin,
around 15); uncorrected level [**1-14**]: 11.5
-Phenobarbital 150mg [**Hospital1 **] PEG: 54.3 on [**1-8**]. Goal is to have it
drop to levels of 30-40 (the dose was decreased last week, but
due to the long half life it will take some time for the levels
to drop).
.
Her dilantin, phenobarbital, and valproic acid were all in the
therapeutic range prior to discharge.
.
Please follow valproic acid, phenobarbital and dilantin levels
very closely and contact Dr. [**Last Name (STitle) **] (phone number see below) if
the levels start deviating from the goal range.
.
Make sure to treat any raise in temperature with tylenol
immediately.
.
.
2) Clinical status:
Over the last week, the patient improved dramatically. She is
more awake and is now able to talk via a passy muir valve. She
is able to follow commands, can wiggle her fingers and toes and
has a trace of movement in both knees.
She is able to sit in a chair.
Chief Complaint:
.
Major Surgical or Invasive Procedure:
.
History of Present Illness:
.
Past Medical History:
.
Social History:
.
Family History:
.
Physical Exam:
.
Pertinent Results:
.
Brief Hospital Course:
.
Medications on Admission:
.
Discharge Medications:
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]
Discharge Diagnosis:
Status epilepticus
Pulmonary Embolism
Deep venous thrombosis
Pneumonia
Urinary tract infection
Critical illness polyneuropathy
Discharge Condition:
Stable: trach and PEG in place; able to talk with passy muir
valve; able to move her extremities (distal arms; distal legs,
trace knees) Has critical illness polyneuropathy that is slowly
improving.
Discharge Instructions:
Please administer medication as instructed.
.
Please continue to check levels of phenobarbital, dilantin and
valproic acid.
.
Her anticonvulsant regimen at the time of discharge includes:
-gabapentine 1600 TID PEG
-lamotrigine 200 [**Hospital1 **] and 250HS PEG
-ativan 1mg q 8hrs PEG
-dilantin 300mg PEG TID (goal level, corrected for albumin,
around 15 ); uncorrected level [**1-14**]: 11.5
-Valproic acid 1750mg qid PEG; level 43 on [**1-14**] (goal 40-60);
PLEASE NOTE: SPRINKLES ONLY (syrup or liquid will not be
absorbed and will lead to subtherapeutic levels)
-Phenobarbital 150mg [**Hospital1 **] PEG: 54.3 on [**1-8**]. Goal is to have it
drop to levels of 30-40 (the dose was decreased last week, but
due to the long half life it will take some time for the levels
to drop).
Her dilantin, phenobarbital, and valproic acid were all in the
therapeutic range.
Please follow these levels very closely (check daily) and
contact Dr. [**Last Name (STitle) **] (phone number see below) if the levels start
deviating from the goal range.
.
Make sure to treat any raise in temperature with tylenol
immediately.
Followup Instructions:
Please follow up at the [**Hospital 16210**] Clinic: Dr. [**Last Name (STitle) 18212**] [**1-31**]
at 12.00. [**Hospital Ward Name 8742**] Building [**Location (un) **].
.
Please call Dr.[**Name (NI) 18213**] office [**Telephone/Fax (1) 16212**] for further
questions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 191**] MD [**MD Number(1) 192**]
Completed by:[**2182-1-15**]
|
[
"V10.41",
"416.8",
"482.0",
"511.9",
"995.91",
"415.19",
"041.3",
"453.40",
"326",
"518.0",
"345.01",
"599.0",
"327.23",
"038.9",
"356.9",
"780.09",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"33.24",
"38.91",
"96.04",
"88.72",
"89.19",
"43.11",
"99.10",
"38.93",
"03.31",
"96.72",
"38.7",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
24432, 24506
|
24351, 24354
|
24191, 24194
|
24677, 24878
|
24325, 24328
|
26037, 26463
|
24285, 24288
|
24406, 24409
|
24527, 24656
|
24380, 24383
|
24902, 26014
|
24303, 24306
|
24150, 24153
|
24222, 24225
|
3042, 4183
|
2706, 3026
|
2691, 2691
|
24247, 24250
|
24266, 24269
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,369
| 163,200
|
26250+57494
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-6-21**] Discharge Date: [**2128-6-28**]
Date of Birth: [**2048-4-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2128-6-22**] MV repair (28mm [**Company 1543**] 3D ring)
History of Present Illness:
80 yo female with hx of MR, Afib who reports worsening DOE in
the past few months. TEE showed nl EF with moderate to severe
MR. [**Name14 (STitle) 4452**] cath showed no significant coronary disease. Coumadin
stopped [**6-13**], started lovenox [**6-18**], with last dose 5/10. Admitted
for IV heparin and pre-op workup.
Past Medical History:
mitral regurgitation
atrial fibrillation
hypertension
left LE fx with DVT [**2100**]
cholelithiasis
gastroesophageal reflux disease
anxiety disorder
macular degeneration
skin cancer
osteoarthritis
hypothyroidism
Social History:
denies tobacco use
has bourbon and vermouth daily
Family History:
non-contrib.
Physical Exam:
Hr 75 A fib Rr 18 O2 sat 93% on 1L NC 124/68
65" 104.5 kg
sikn dry and intact
EOMI
neck supple , full ROM, no carotid bruits
CTAB
RRR
soft NT, ND + BS
warm, well-perfused, no edema or varicosities
neuro grossly intact
1+ bil. fem/DPs
2+ radials bil.
PTs non-palp. 2+ edema
Pertinent Results:
[**2128-6-25**] 07:33AM BLOOD WBC-16.2* RBC-3.16* Hgb-9.8* Hct-28.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.8 Plt Ct-169
[**2128-6-25**] 07:33AM BLOOD PT-14.2* INR(PT)-1.2*
[**2128-6-24**] 03:36AM BLOOD Glucose-108* UreaN-15 Creat-0.9 Na-137
K-4.2 Cl-103 HCO3-26 AnGap-12
[**2128-6-21**] 07:58PM BLOOD ALT-53* AST-64* LD(LDH)-235 AlkPhos-63
Amylase-35 TotBili-1.3
[**2128-6-28**] 06:04AM BLOOD WBC-7.9 RBC-2.82* Hgb-8.5* Hct-26.1*
MCV-92 MCH-30.2 MCHC-32.7 RDW-13.7 Plt Ct-299
[**2128-6-28**] 06:04AM BLOOD Plt Ct-299
[**2128-6-28**] 06:04AM BLOOD PT-17.0* INR(PT)-1.5*
[**2128-6-28**] 06:04AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-140
K-3.9 Cl-100 HCO3-31 AnGap-13
[**2128-6-21**] 07:58PM BLOOD %HbA1c-5.8
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 %).
The right ventricular cavity is moderately dilated with
borderline normal free wall function.
There are focal calcifications 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 regurgitation. There is no aortic valve
stenosis.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) central mitral
regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known lastname 65020**] at
8AM.
.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including epinephrine 0.02
mcg/kg/min.
Borderline global hypokinesis of RV and LV. LVEF 45 to 50%.
There is a mitral annular prosthesis in the mitral annular
region c/w with ring, stable, with no residual regurgitation or
stenosis.
Thoracic aortic contour is intact.
Moderate TR..
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2128-6-22**] 10:27
Radiology Report CHEST (PA & LAT) Study Date of [**2128-6-28**] 9:05 AM
Reason: evaluate effusions
Final Report
INDICATION: Status post mitral valve replacement, to evaluate
for effusions.
COMPARISON: [**2128-6-26**].
CHEST, TWO VIEWS: Right internal jugular line is again seen with
tip
projecting in the body of the right atrium. Cardiomediastinal
contours are
stable. Bibasilar atelectasis is slightly progressed on this
study and
bilateral pleural effusions are slightly larger. Median
sternotomy wires are again seen. Osseous structures are grossly
normal.
IMPRESSION:
1. Slight worsening of bibasilar atelectasis and persistent
small bilateral effusions.
2. Central venous catheter with tip projecting in the body of
the right
atrium.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Brief Hospital Course:
Ms. [**Known lastname 65020**] was admitted on [**6-21**] for IV heparin and completion of
her pre-operative workup. She underwent a mitral valve repair
with 28mm [**Company 1543**] 3D ring with Dr. [**Last Name (STitle) **] on [**6-22**]. She
tolerated the procedure well and was transferred to the CVICU in
critical but stable condition on titrated epinephrine and
propofol drips. She was extubated and weaned from her pressors
by post-operative day two. Her chest tubes were removed and she
was transferred to the surgical step-down floor. Her epicardial
wires were removed, her medications were titrated and she was
started on coumadin for atrial fibrillation. She was
aggressively diuresed. She made slow progress in physical
activity capacity and on post-operative day six she was ready
for discharge to rehabilitation at Willow Manor in [**Hospital1 189**].
Medications on Admission:
coumadin 5 mg 5d/wk; 2.5 mg 2d/wk (last dose 5/3)
lovenox (LD [**6-20**])
norvasc 10 mg daily
celexa 40 mg daily
lipitor 10 mg daily
levothyroxine 25 mcg daily
toprol XL 25 mg daily
Vit. D daily
prevacid 30 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed for pain.
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
[**Name8 (MD) **], MD to adjust dose daily for target INR [**3-16**]
Last 4 days doses 5/5/5/2.5.
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Metoprolol Tartrate 25 mg Tablet Sig: .5 Tablet PO twice a
day.
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
15. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Willow Manor - [**Hospital1 189**]
Discharge Diagnosis:
mitral regurgitation s/p MV repair
atrial fibrillation
hypertension
left LE fx with DVT [**2100**]
cholelithiasis
gastroesophageal reflux disease
anxiety disorder
macular degeneration
skin cancer
osteoarthritis
hypothyroidism
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incision dry
no driving for one month and off all narcotics
no lfting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Followup Instructions:
see Dr. [**Last Name (STitle) 11250**] in [**2-13**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
please call for appts.
Completed by:[**2128-6-28**] Name: [**Known lastname 11476**],[**Known firstname 2175**] Unit No: [**Numeric Identifier 11477**]
Admission Date: [**2128-6-21**] Discharge Date: [**2128-6-28**]
Date of Birth: [**2048-4-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
As noted in the discharge summary Ms [**Known lastname **] is an 80 year old
woman s/p mitral regurgitation s/p MV repair(28 [**Company **] ring)
on [**6-22**].
Preoperatively she had experienced worsening shortness of
breath. He preoperative echocardiogram showed moderate to severe
mitral regurgitation most likely due to papillary muscle
dysfunction. Mild regional left ventricular systolic dysfunction
c/w CAD. Mild pulmonary artery systolic hypertension. Although
she had an ejection fraction of 50% this is consistant with
systolic heart failure.
Discharge Disposition:
Extended Care
Facility:
Willow Manor - [**Hospital1 1612**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2128-7-20**]
|
[
"V10.83",
"401.9",
"428.22",
"244.9",
"V58.61",
"427.31",
"428.0",
"362.50",
"530.81",
"V12.51",
"V88.01",
"300.00",
"574.20",
"424.0",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.23",
"88.56",
"88.53",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
9236, 9421
|
4796, 5665
|
341, 403
|
7733, 7740
|
1398, 4773
|
8074, 9213
|
1071, 1085
|
5932, 7379
|
7484, 7712
|
5691, 5909
|
7764, 8051
|
1100, 1379
|
282, 303
|
431, 753
|
775, 988
|
1004, 1055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,920
| 105,405
|
27318
|
Discharge summary
|
report
|
Admission Date: [**2181-11-24**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2103-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea, abdominal distention.
Major Surgical or Invasive Procedure:
Internal jugular line placement.
History of Present Illness:
78 year old female with multiple medical problems, pertinently
including CAD status post CABG, hypertension, and type 2
diabetes, with multiple recent hospitalizations for different
resistant infections, including MSSE, MRSE and strep viridans
bacteremia thought to be secondary to decubitus ulcer with
associated osteomyelitis for which she is on a 6 week course of
vancomycin, last discharged to nursing home on [**2181-11-12**] after a
hospitalization for anemia of chronic inflammation, renal
failure, and an E. Coli UTI resistant to levofloxacin and
treated with a 2 week course of pip-tazo which was completed on
[**11-27**], presenting from the nursing home with a couple of days of
dyspnea and tachypnea with LLL infiltrate on CXR, as well as 1
week of vomiting and abdominal distention.
.
In the ED, labs notable for acute renal failure, leukocytosis,
elevated lactate. Her abdomen was tensely distended. She had
an IJ line placed and code sepsis intitiated. Started on
levophed for hypotension.
Past Medical History:
1) CAD status post CABG [**2169**]
2) Hypertension
3) Type 2 diabetes
4) Pulmonary fibrosis
5) Traumatic Brain Injury: Spring [**2181**], complicated by
subdural, subarachnoid, and intraparenchymal hemorrhages. Since
that time she has been non-verbal and bed bound with a PEG tube
for feedings in a nursing home.
6) Seizure disorder
7) Recurrent DVTs
Social History:
Italian decent, speaks Italian with some English. Now non-verbal
following TBI. Children involved in care. Lives in a [**Hospital1 1501**]/Rehab.
All ADLs done for her. No tobacco, EtOH, or drug use. Widowed
18mo ago, has 3 children.
Family History:
brother w/ hematologic cancer
brother w/ throat cancer
brother w/ lung ca
no known h/o seizures, stroke
Physical Exam:
BP 107/68, HR 70s, RR 28, 90% on NRB.
GENERAL: Agonal appearing obese caucasian female, non-verbal.
HEENT: Moist MM. Anicteric sclerae.
NECK: Flat JVP.
LUNGS: Rhonchi bilaterally.
COR: RR, normal rate, difficult to auscultate over coarse BS.
ABD: Tensely distended, without bowel sounds.
EXTR: [**1-15**]+ edema on left > right.
Pertinent Results:
[**2181-11-24**] 09:25AM BLOOD WBC-20.1*# RBC-3.47* Hgb-10.1* Hct-29.4*
MCV-85 MCH-29.1 MCHC-34.3 RDW-17.3* Plt Ct-429#
[**2181-11-24**] 09:25AM BLOOD PT-17.5* PTT-47.3* INR(PT)-1.6*
[**2181-11-24**] 09:25AM BLOOD Glucose-136* UreaN-115* Creat-3.9*#
Na-140 K-6.5* Cl-94* HCO3-20* AnGap-33*
[**2181-11-24**] 12:50PM BLOOD ALT-29 AST-18 AlkPhos-251* Amylase-138*
TotBili-0.3
[**2181-11-24**] 12:50PM BLOOD Albumin-2.3* Calcium-8.9 Phos-7.0*#
Mg-5.1*
[**2181-11-24**] 12:50PM BLOOD Cortsol-53.9*
[**2181-11-24**] 09:58AM BLOOD Lactate-4.8*
Brief Hospital Course:
78 year old female with multiple medical problems, including CAD
status post CABG, hypertension, and type 2 diabetes, with
multiple recent hospitalizations for different resistant
infections, including MSSE, MRSE and strep viridans bacteremia
thought to be secondary to decubitus ulcer with associated
osteomyelitis, presenting with sepsis. She was agonal on
arrival to the MICU, with audible coarse breath sounds. In
discussion with the family, they were clear about wanting to
keep her comfortable and NOT pursuing any further aggressive
treatments. They understood that treatment would likely entail
continued pressors, possibly dialysis, intubation, etc, and they
understand that without these treatments, Mrs. [**Known lastname **] would
likely pass away relatively soon. Given her deteriorated
quality of life, they opted for comfort measures, which were
pursued with the initiation of a morphine drip, and
discontinuation of levophed. Within an hour of arrival to the
MICU she became apneic, her blood pressure dropped, and she
became bradycardic and then pulseless. She was pronounced dead
at 4 p.m., an hour after arrival to the MICU. Her family was in
the room, as was the Priest.
Medications on Admission:
Not recorded.
Discharge Medications:
N/A.
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Acute renal failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"995.92",
"780.39",
"250.00",
"518.81",
"486",
"E929.3",
"V44.1",
"515",
"584.9",
"V45.81",
"V66.7",
"907.0",
"401.9",
"784.3",
"276.2",
"038.9",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4395, 4404
|
3103, 4302
|
348, 382
|
4474, 4483
|
2542, 3080
|
4535, 4541
|
2063, 2169
|
4366, 4372
|
4425, 4453
|
4328, 4343
|
4507, 4512
|
2184, 2523
|
278, 310
|
410, 1420
|
1442, 1795
|
1811, 2047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,598
| 198,591
|
48527
|
Discharge summary
|
report
|
Admission Date: [**2161-8-22**] Discharge Date: [**2161-9-1**]
Service: MEDICINE
Allergies:
Epinephrine / Sulfa (Sulfonamides) / Aspirin / Coumadin
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Wide complex tachyacardia, V-Fib arrest s/p fall
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
Mr. [**Known lastname 4640**] is a [**Age over 90 **] yo M CAD s/p MI, CHF, A-FIB, CVA and recent
history notable for V-tach with hypotension who presented to OSH
with syncopal fall and hip fracture. Per report, pt was found to
be in wide complex tachycardia (irregularly irregular to 180s),
was given digoxin that put him into pulseless VT arrest at the
outside ED. He was shocked then given amiodarone and
resucitated with no neurological sequalae. After this he was
transferred to [**Hospital1 18**] for hip surgery with support of cardiac
anesthesia.
.
Pt was hospitalized earlier this month for V-tach with
hypotension and was shocked twice. EP was consulted for
possibility of device insertion, however patient refused. Pt was
taking Digoxin at the time, which was discontinued due to
concerns regarding its pro-arrhythmic side effects. Patient was
also noted to be intermittently in a fib/flutter, but was not
anticoagulated due to history of GI bleed and questionable
sensitivity to aspirin.
.
On the evening of [**8-22**], he went into sustained mom[**Name (NI) **] wide
complex tachycardia, felt to be consistent with VT vs. 2:1
block. He received Metoprolol 5 mg IV, amiodarone 150 mg IV x 2,
then Lidocaine 50 mg IV, and Lidocaine 100 mg IV, all without
response. Electrolytes were checked at the time, with K 4.1 and
Mg 1.9; he received 2 grams of IV magnesium sulfate. He then
received a third bolus of 150 mg IV amiodarone and was
transferred to the CCU. He has been hemodyanically stable
throughout with SBP's in mid-80's to 90's.
.
Cardiac review of systems was notable for absence of chest pain,
shortness of breath, palpitations, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, or lightheadedness.
Past Medical History:
CHF
Cardiomyopathy
Atrial Fibrillation
CAD s/p MI [**2129**]
CVA [**2159**]
Goiter (Dr. [**Last Name (STitle) 6467**]
Anemia (Iron Deficiency)
S/P Herpes Zoster w/ post herpetic neuralgia
Diverticulosis
Paget's disease of the Bone
Chronic Sinusitis
GIB [**2148**] + H. Pylori --> treated.
.
Cardiac Risk Factors: No DM, No HTN, No Hyperlipidemia.
.
Social History:
Pt lives with his wife who is very ill. They have 24 hour
nursing assistance.
Quit smoking at age 60.
Family History:
Non-contributory.
Physical Exam:
On Admission:
--------------
VS: T: 99.8, BP: 87/59, HR: 144, RR: 24, SpO2 97% on 3L NC
Gen: Cachectic, elderly male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: Tachy, regular. S1, S2. No S4, no S3.
Chest: No crackles, wheeze, rhonchi.
Abd: soft, NT/ND +BS.
Ext: No c/c/e.
.
On day of discharge the patient's vital signs were T 98.2, BP
116/54, HR 69, RR 30, and O2 Sat of 97% on RA. Exam otherwise
not significantly changed from admission.
Pertinent Results:
<b><u>LABORATORY RESULTS<u><b>
On Admission:
WBC-7.0 RBC-3.22* Hgb-9.6* Hct-28.9* MCV-90 Plt Ct-156
PT-14.1* PTT-32.1 INR(PT)-1.2*
Glucose-142* UreaN-31* Creat-1.1 Na-134 K-4.2 Cl-107 HCO3-19*
AnGap-12
Calcium-8.9 Phos-2.8 Mg-1.9
.
On Discharge:
WBC-10.2 RBC-2.85* Hgb-8.6* Hct-25.5* MCV-89 Plt Ct-199
PT-13.4 PTT-29.3 INR(PT)-1.1
Glucose-102 UreaN-19 Creat-0.9 Na-137 K-4.2 Cl-108 HCO3-24
AnGap-9
Albumin-2.9* Calcium-9.6 Phos-3.0 Mg-2.1
.
Cardiac Enzymes:
CK: 24-14-18
MB: ND-ND-ND
TropT: 0.03-0.03-0.04
.
<b><u>OTHER STUDIES<u><b>
ECG on Presentation [**2161-8-22**]: Regular wide complex tachycardia -
suggests ventricular tachycardia Since previous tracing of the
same date, regular wide complex tachycardia with different QRS
morphology now present
.
ECG on [**2161-8-26**] (day of surgery): Baseline artifact.
Supraventricular bradycardia. Intraventricular conduction delay
of left bundle-branch block type. Low limb lead voltage. Since
the previous tracing of [**2161-8-25**] probably no significant chnge.
.
ECG on [**2161-8-31**] (day prior to discharge) revealed wide complex
sinus rhythm with left axis deviation and aberrant conduction.
Rate was 62. Stable lateral ST depressions.
.
<b><u>RADIOGRAPHIC STUDIES<u><b>
CXR shortly after presentations ([**2161-8-23**]):
IMPRESSION: Stable examination. Persistent nodular density
projected in
lower right lung. Widening of the superior mediastinum
consistent with known goiter.
.
Intraoperative fluoro images during ORIF of L hip [**2161-8-26**]
revealed placement of a short intramedullary rod into the left
femur with a screw
entering the femoral head.
Brief Hospital Course:
Mr. [**Known lastname 4640**] is a [**Age over 90 **] yo male with a h/o ischemic cardiomyopathy,
atrial fibrillation, recurrent VT, and CVA who presents with
left hip fracture, now transferred to CCU in sustained VT
.
1) Rhythm: Patient presented s/p syncope likely due to cardiac
arrhythmia. He arrived to OSH in irreg, irreg rhythm with HR
180's, followed by pulsess VT after administration of IV
digoxin. He was shocked x 1, which resulted in NSR. On arrival
to [**Hospital1 18**], he was in NSR, then in slow atrial fibrillation. The
patient had a history of recurrent VT arrests probably mediated
by scar from old MI. On day of arrival he went into sustained
VT that was refractory to Metoprolol 5 mg IV, amiodarone 150 mg
IV x 2, then Lidocaine 50 mg IV, and Lidocaine 100 mg IV.
Eventually, patient was converted with electrical cardioversion
and started on a procainamide drip. He was continued on this
drip and remained in sinus rhythm. On the day after his ORIF
([**2161-8-27**]) he was converted to dofetilide in the hope of
establishing him on an oral [**Doctor Last Name 360**] that he could take at home.
His QT interval remained stable on this medication, but he did
begin to periodically go into A fib with RVR that was responsive
to IV beta blocker and increases in his oral dose of nodal
agents. Unfortunately, the patient went into a wide complex
tachycardia on [**2161-8-30**] that was initially thought to be afib with
RVR and eventually read as VT. He became hypotensive at this
time so he once again had electrical cardioversion. His
Dofetilide was stopped and he was once again loaded with
amiodarone. He remained stable on this regimen until the day of
discharge with only two periods of NSVT of three to four beats
on the night prior to discharge. Plan is to continue amiodarone
load for total of seven days and then go to a daily dose.
Patient will be discharged on a cardiac monitor to assess for
further VT events. Should the patient continue to have VT
events would proceed to ablation and PPM placement if patient
continued to be willing to do this. Patient had been on
clopidogrel and ASA for CVA prophylaxis given paroxysmal afib,
but clopidogrel was held due to hematuria in the hospital in
setting of multiple anticoagulants (see below).
.
2) CAD: The patient had a history of MI in [**2129**] which was
medically managed. His aspirin and clopidogrel were held for
surgery and restarted afterward. Clopidogrel eventually had to
be held again due to hematuria. Beta blocker was stopped on
presentation due to procainamide and hypotension but was
restarted after surgery. Mr. [**Known lastname **] blood pressure would not
tolerate carvedilol while on additional anti-arrythmics so he
was switched from this to metoprolol during this
hospitalization. Cardiac enzymes were checked at presentation
given arrythmia, but these were completely flat leading the
treating team to be confiden that this arrythmia was not
mediated by an ACS.
.
3) Pump: Patient has chronic ischemic cardiomyopathy with
systolic heart failure. ECHO earlier this month demonstrated EF
30%. Patient appeared euvolemic throughout his hospitalization.
Daily weights were stable. He was maintained on low sodium
diet. His beta blocker and ACEi were initially held due to
hypotension but after surgery these were restarted and well
tolerated.
.
4) Left hip fracture: Given the patient's hip fracture he and
his family were offered palliative ORIF with the understanding
that he would be very high risk given his arrythmia and multiple
arrests. They elected to proceed and ORIF was performed on
[**2161-8-26**] after he had been stable and out of VT for several days.
He tolerated this procedure quite well and was initially put on
PCA for pain control before being switched to PRN morphine doses
and acetaminophen. Patient will be kept on enoxaparin for four
weeks after this surgery for DVT prophylaxis.
.
5) Hematuria: The patient's enoxaparin dose was increased
post-surgically in the context of restarting clopidogrel and
aspirin. He had a foley in place at this time and began to
experience considerable hematuria with clots and maroon colored
urine. This was presumed secondary to foley trauma in the
context of multiple anticoagulants and UA was negative for RBC
casts and signs of infection. Clopidogrel was stopped and
continuous bladder irrigation was initiated for a period of
approximately 24 hours in order to avoid clot obstruction of the
urethra and post-renal failure. On discontinuation of CBI
patient was passing pink urine without clot. Hematocrit was
stable. If patient's hematuria doesn't completely resolve he
was instructed to follow up with his PCP for outpatient work up
of hematuria. Clopidogrel should continue to be held until
enoxaparin course is completed.
.
5) Anemia: Patient has known history of iron-deficiency anemia.
He was continued on PO iron therapy. He received one unit
pRBC's prior to surgery. After a small post surgery drop he
maintained a relatively stable hematocrit.
.
He was fed a cardiac, heart healthy diet. He was maintained on
LMWH for DVT prophylaxis in the setting of hip fracture. He was
DNR/DNI but was willing to accept elective cardioversion. He
will be discharged to acute rehab to recover from his hip
fracture.
Medications on Admission:
Carvedilol 12.5 mg [**Hospital1 **]
Neurontin 200 mg QHS
Plavix 75 mg daily
Furosemide 20 mg daily
Protonix 40 mg daily
Potassium chloride 20 mEq daily
Quinapril 5 mg daily
Ferrous sulfate 325 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks: Continue until [**2161-9-9**].
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for constipation.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): contiinue through [**9-7**]. .
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
13. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days: D/C on [**2161-9-3**].
14. Amiodarone 200 mg Tablet Sig: Three (3) Tablet PO once a
day: Start on [**2161-9-8**].
15. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary diagnosis:
Left hip fracture
Ventricular tachycardia
Hematuria
.
Secondary diagnosis:
Systolic congestive heart failure
Coronary artery disease
Anemia
Discharge Condition:
BP=116/54
HR= 69
Temp= 98.2
O2 sat= 97% on RA
Discharge Instructions:
You had an irregular heart rhythm called ventricular tachcardia
that was not well controlled. We have started you on amiodarone
to try to control this rhythm. You decided that you didn't want
a pacemaker or internal defibrillator.
.
You had a broken hip that was repaired. You will need to return
to get your sutures out in 1 week and will need physical therapy
to increase your mobility and go home. You are on tylenol for
pain control. You will be on Lovenox for 4 weeks total to
prevent blood clots.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000cc
Followup Instructions:
Orthopedic:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2161-9-15**] 11:00
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2161-9-15**] 11:20 for suture removal
.
Endocrinology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**0-0-**] Date/Time:
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
[
"458.29",
"428.0",
"427.31",
"240.9",
"414.8",
"053.19",
"E888.9",
"820.21",
"427.32",
"427.1",
"731.0",
"599.7",
"412",
"280.9",
"414.01",
"428.22",
"473.9",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.48",
"79.35",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
11997, 12080
|
4903, 10209
|
311, 326
|
12283, 12331
|
3262, 3293
|
13041, 13618
|
2591, 2610
|
10462, 11974
|
12101, 12101
|
10235, 10439
|
12355, 13018
|
2625, 2625
|
3508, 3704
|
3721, 4880
|
223, 273
|
354, 2081
|
12195, 12262
|
12120, 12174
|
3307, 3494
|
2103, 2454
|
2470, 2575
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,565
| 170,566
|
35151
|
Discharge summary
|
report
|
Admission Date: [**2100-10-29**] Discharge Date: [**2100-11-8**]
Date of Birth: [**2028-1-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
72M that fell from standing resulting in an intraparenchymal
head bleed.
Major Surgical or Invasive Procedure:
tracheostomy, PEG placement, IVC filter placement
History of Present Illness:
74M with h/o HTN was observed to fall from standing and hit
his head on desk prior to falling on the floor. No evidence of
mechanical fall. Was taken to OSH, was reportedly GCS3-5, was
intubated found to have left frontal IPH, then transferred to
[**Hospital1 18**]. Received 1gm Dilantin prior to transfer. On presentation
patient was reportedly withdrawing all extremities. Pupils were
asymmetric with left 2mm and right was pinpoint.
Past Medical History:
HTN, NIDDM
Social History:
Lives with family, no alcohol or tobacco
Family History:
noncontributory
Physical Exam:
In emergency room
O: T:96.2 BP: 178/86 HR:77 R:16 O2Sats:100% vent
Gen: Intubated, sedated.
HEENT: Pupils: Left 4mm minimally reactive, Rt 3mm->2
EOM unable to abtain, +corneal rt, no corneal reflex on
left, Ecchymosis over left eye lid
Neck: cervical collar
Lungs: on Ventilator.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated
Orientation: unable to obtain.
Language: Intubated and sedated.
Pertinent Results:
Admission CT Head:
1. Bilateral temporal and left frontal intraparenchymal
hemorrhagic
contusions with right temporoparietal subarachnoid hemorrhage
identified.
2. Predominantly left-sided facial fractures as described with a
superior
orbital wall fracture associated with a small extra-conal
hematoma noted in
the superior aspect of the left orbit.
3. No intracranial aneurysm identified.
Echo:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the inferior and inferolateral
walls. The remaining segments contract normally (LVEF = 45 %).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-30**]+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Carotid Duplex:
Mild calcified plaque at the origins of both the left and right
internal
carotid arteries with less than 40% stenosis bilaterally.
CBC at Discharge [**11-8**]: WBC 9.8, HCT 30.8, Platelet count 332
MB, CK [**11-4**]: 6 and 0.73, down from a peak of 44 and 0.82 [**10-30**]
Lower extremity Duplex: No evidence of lower extremity DVT in
either leg.
Brief Hospital Course:
Patient admitted to surgical trauma service with the above
described intraparenchymal hemorrhages and SAH. Patient also
developed a NSTEMI that was followed with serial enzymes. By
system his issues occurred and were managed by system.
Neurologic: Patient arrived intubated due to his mental status
being [**3-3**] on arrival to the other hospital. He then had a
frontal bolt placed here with ICP's measured. The bolt was
removed and the patient then had an MRI that showed likely
diffuse axonal injury. He was maintained on dilantin for a one
week course. He then was following some commands at the time of
discharge and was noted to have 4 out of 5 strength in the RUE,
RLE, but a fairly significant L. sided hemiparesis.
Cardiac: He had EKG changes and enzyme elevations that were
consistent with a NSTEMI and was unable to be anticoagulated due
to his head bleed. The goal then was rate control with beta
blockade. Cardiology followed the patient and we were able to
add aspirin one week into his hospital stay, along with lipitor,
and his home dose of lisinopril. His TTE is described above in
the results section along with his cardiac enzyme levels.
Respiratory: Patient was trached one week into his stay and was
noted to have thick secretions with 4+ gram negative diplococci,
2+ gram negative rods, 1+ gram positive rods noted on a BAL. he
was treated broadly with vanco, zosyn, and cipro until the
culture came back citrobacter and the regimen was tapered to
cipro at the time of discharge.
GI: Tubefeeds started early and patient received PEG at the
time of tracheostomy. Tolerating tubefeeds, having BM's.
GU: Also with UTI with enterobacter and citrobacter sensitive to
cipro. Sent on cipro.
Heme: Heparin SC approved by neurosurgery and started. Patient
also received IVC filter at time of trach and PEG.
Endocrine: Discharged on a sliding scale with BS controlled
between 98-137 last five days of stay on stable tubefeeding
regimen.
ID: To complete a 10 day course of cipro for PNA and UTI.
Medications on Admission:
Lisinopril 10mg QD
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) units
Injection ASDIR (AS DIRECTED): will print out sliding scale for
the paperwork.
7. Acetaminophen 160 mg/5 mL Solution Sig: [**12-30**] PO Q6H (every 6
hours) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
11. Morphine 10 mg/mL Solution Sig: 0.2-0.4 mL Intravenous Q2H
(every 2 hours) as needed for Pain: via G-tube.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
fall, intraparenchymal head bleed, left facial fracture, left
4th rib fracture
Non-ST-elevation MI (NSTEMI)
Discharge Condition:
stable
Discharge Instructions:
Patient to be discharged to rehabilitation facility and to
follow up with the trauma clinic and to have the facility call
to schedule this appointment. Trauma office to be notified if
patient having worsening pains, fevers, chills, nausea,
vomiting, or if there are any questions or concerns.
Followup Instructions:
Patient to be discharged to rehabilitation facility and to
follow up with the trauma clinic and to have the facility call
to schedule this appointment at [**Telephone/Fax (1) 2359**].
Patient to follow up with plastic surgery and to call for
appointment at [**Telephone/Fax (1) 5343**].
Patient to follow up with neurosurgery and to call for
appointment at [**Telephone/Fax (1) 1669**].
|
[
"780.2",
"807.01",
"E888.1",
"486",
"410.71",
"438.20",
"041.85",
"802.4",
"802.8",
"250.00",
"599.0",
"518.5",
"801.10",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"38.7",
"96.6",
"96.72",
"43.11",
"01.10"
] |
icd9pcs
|
[
[
[]
]
] |
6087, 6157
|
3004, 5039
|
388, 440
|
6308, 6317
|
1512, 1522
|
6659, 7051
|
1020, 1037
|
5108, 6064
|
6178, 6287
|
5065, 5085
|
6341, 6636
|
1052, 1390
|
276, 350
|
468, 911
|
1531, 2981
|
1405, 1493
|
933, 946
|
962, 1004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,530
| 129,816
|
6212
|
Discharge summary
|
report
|
Admission Date: [**2116-5-4**] Discharge Date: [**2116-5-18**]
Date of Birth: [**2051-12-5**] Sex: M
Service: SURGERY
Allergies:
Codeine / Percocet
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
[**Doctor Last Name **] syndrome - s/p 2 previous colon cancers in the right colon
and the transverse colon.
Major Surgical or Invasive Procedure:
Open completion abdominal colectomy with ileal pouch to distal
sigmoid
History of Present Illness:
Mr. [**Known lastname 24214**] is a 64-year-old gentleman who has a complicated
past medical
history including a kidney [**Known lastname **] in [**2103**], a colectomy in
[**2112**] for right colon cancer, and a subsequent new colon cancer
in
[**2114**], for which he had a transverse colectomy. He does recall
being told that perhaps he should have his full colon out at
that
time, but elected not to do that at such time. Because of two
cancers within
two years, he was evaluated and found to be positive for [**Doctor Last Name **]
syndrome. His last colonoscopy was in [**2115-10-10**]. He had
gastritis and duodenitis, but no new polypoid lesions in his
colon. Patient presents today for open completion abdominal
colectomy with ileal pouch to distal sigmoid.
Past Medical History:
PMH:
1. polycystic kidney disease,2. HTN
3. Anemia- prior to kidney [**Year (4 digits) **]
2. [**Doctor Last Name **] Syndrome
4. gout
5. previous MI >1 year ago, bare metal stents with 12mo on
plavix
6. GERD
7. Arthritis
8. A flutter
PSH:
1. s/p kidney [**Doctor Last Name **] in [**2103**]
2. s/p right colectomy [**2112**]
3. s/p transverse colectomy [**2114**]
Social History:
Mr. [**Known lastname 24214**] is a prior smoker of 44 pack years.
There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His mother died from brain cancer, and his
father died from cirrhosis.
Physical Exam:
General: Alert, oriented, no acute distress
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, [**Doctor First Name **]
incision, binder in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Access: Rt AVF, protected and marked
Pertinent Results:
ADMISSION LABS:
[**2116-5-5**] 05:22AM BLOOD WBC-7.9# RBC-3.78* Hgb-10.3* Hct-33.8*#
MCV-90 MCH-27.3 MCHC-30.5* RDW-15.4 Plt Ct-149*
[**2116-5-4**] 04:38PM BLOOD Glucose-126* UreaN-30* Creat-2.2* Na-141
K-4.6 Cl-105 HCO3-24 AnGap-17
[**2116-5-7**] 10:15AM BLOOD CK(CPK)-448*
[**2116-5-7**] 10:15AM BLOOD CK-MB-3 cTropnT-0.02*
[**2116-5-4**] 04:38PM BLOOD Calcium-8.8 Phos-2.8 Mg-2.3
[**2116-5-5**] 05:22AM BLOOD Cyclspr-47*
DISCHARGE LABS:
[**2116-5-16**] 06:42AM BLOOD WBC-9.0 RBC-3.64* Hgb-10.2* Hct-31.9*
MCV-88 MCH-28.0 MCHC-32.0 RDW-17.0* Plt Ct-269
[**2116-5-16**] 06:42AM BLOOD PT-21.4* PTT-83.4* INR(PT)-2.0*
[**2116-5-17**] 05:19AM BLOOD PT-27.2* PTT-129.2* INR(PT)-2.6*
[**2116-5-18**] 04:35AM BLOOD PT-29.2* INR(PT)-2.8*
[**2116-5-17**] 05:19AM BLOOD Glucose-119* UreaN-48* Creat-2.5* Na-137
K-4.3 Cl-104 HCO3-22 AnGap-15
[**2116-5-11**] 05:30AM BLOOD ALT-8 AST-18 LD(LDH)-225 AlkPhos-64
TotBili-1.0
[**2116-5-17**] 05:19AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.9
[**2116-5-17**] 05:19AM BLOOD Cyclspr-69*
IMAGING STUDIES:
TEE ([**2116-5-13**]):
No spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. Mild spontaneous echo contrast is present in
the left atrial appendage. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium or the right
atrial appendage. Right atrial appendage ejection velocity is
good (>20 cm/s). No atrial septal defect is seen by 2D or color
Doppler. There is complex (mobile) atheroma in the aortic arch,
and simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
.
IMPRESSION: Mild spontaneous echo contrast in the left atrial
appendage, but no thrombus seen. No spontaneous echo contrast or
thrombus seen in LA/RA/RAA. Complex/mobile atheroma in the
aortic arch Mild mitral regurgitation.
CXR [**2116-5-8**]:
FINDINGS: A radiograph centered at the thoracolumbar junction
was obtained
for evaluation of a nasogastric tube, which terminates within
the proximal
stomach. The side port is not well visualized but may be
proximal to the GE junction. Heart is mildly enlarged, and note
is made of bibasilar patchy and linear atelectasis.
CXR [**2116-5-11**]:
FINDINGS:
An ill-defined opacity in the right infrahilar region is likely
an
atelectasis. There is no evidence to suggest pulmonary edema.
There is no
pleural abnormality. Heart size, mediastinal and hilar contours
are stable.
IMPRESSION: An ill-defined opacity in the right infrahilar lung
is likely an atelectasis. Attention is required on follow up
radiograph if there is any linical concern for lung infection.
Brief Hospital Course:
The patient was taken to the OR for a completion colectomy with
j-pouch ileorectal anastomosis for [**Doctor Last Name **] syndrome. He initially
tolerated the procedure well. See the separately-dictated
operative note for details.
Transfer to the ICU for difficult to control atrial fibrillation
ICU COURSE
NEURO/PAIN: The patient's pain was initially well-controlled on
dilaudid PCA. By POD#4, the PCA was discontinued, and his pain
was controlled on only acetaminophen.
#Atrial Fibrillation: On POD#3, the patient had an episode of
atrial fibrillation with rapid ventricular response, after
having missed a dose of his metoprolol; this resolved with iv
metoprolol, and his po metoprolol was re-dosed to TID to provide
better control. The next day, he went into afib again, and was
rate controlled with iv metoprolol; by this time, the patient
was having nausea and emesis with gastric distension likely
secondary to ileus, and it was thought that his PO metoprolol
was not being absorbed. By POD#5, after continued afib with
occasional tachycardia to the 130s, it was decided to transfer
the patient to the ICU for rate control with esmolol and
diltiazem drips. His HR was well-controlled on these agents, but
he remained in afib. The drips were eventually stopped and the
patient was maxed out on PO metoprolol. He was started on a
heparin gtt in preparation for possible cardioversion.
Cardiology followed and it was recommended that he start an amio
gtt to improve chances of successfull cardioversion. A TEE was
performed on [**2116-5-14**] which was negative for intracardiac
thrombus. He underwent cardioversion on [**2116-5-15**]. He will be
continued on an amiodarone taper until he follows up with his
outpatient cardiologist. Additionally, reccommendations of
placing patient on metoprolol succinate 100 mg daily instead of
50 mg metoprolol tartrate TID.
-Amiodarone taper: 400 mg [**Hospital1 **] for 2 weeks/200 mg PO BID for 2
weeks/100 mg [**Hospital1 **] for 2 weeks. Plan for follow up with Dr.
[**Last Name (STitle) **] in 4 weeks and to continue coumadin.
-currently on heparin gtt bridge while INR becomes therepeutic
# UTI: The patient was found to have low-grade fevers to 100.4
during his ICU stay. He was cultured and was ultimately found
to have a pan-sensitive E. Coli UTI. He was initially started
on IV ceftrixone, but this was switched to PO cefpodoxime for a
planned 2-week course.
-Day 1 of treatment [**2116-5-13**]
# [**Last Name (un) **] on CKD: The patient has a history of renal [**Last Name (un) **] for
APCKD. The patient is status-post renal [**Last Name (un) **], and he was
maintained on his cellcept, cyclosporin, and prednisone in
consultation with the nephrology [**Last Name (un) **] service. His doses
were adjusted appropriately per his cyclosporin levels, and the
routes of administration appropriately changed when his diet
order was changed to NPO: when NPO, his prednisone was changed
to iv methylprednisolone, his cellcept changed to IV, and his
cyclosporin was given as a liquid through the NGT. His baseline
creatinine pre-op was about 2.2, and an elevation
post-operatively was determined to be secondary to pre-renal
ARF; he was hydrated according to recommendations by [**Last Name (un) **]
nephrology. Potentially nephrotoxic home medications
(allopurinol, furosemide, and lisinopril) were held. Urine
output was closely monitored. Methylprednisolone was switched
back to PO prednisone prior to ICU transfer.
-follow renal recommendations for cyclosporine dosing
-follow up cyclosporine level and check with renal whether to
check daily cyclosporine levels.
GASTROINTESTINAL: The patient was NPO following his procedure.
He was advanced to clears on POD#2, but due to intermittent
nausea, he was backed down to sips and then NPO on POD#4, when
he had an episode of emesis. An NGT was placed until POD#5, when
it was clamped for 4 hours with no residual, then discontinued.
Beginning POD#3, the patient had liquid bowel movements with
some expected dark clots. POD#6, he was passing over 2L of
liquid stool, and it was decided to start octreotide to slow
down the output and perhaps also improve his intermittent
nausea. Continued to have loose liquid stools at time of ICU
call out. Added on psyllium wafer to assist with binding,
although patient is not tolerating wafers well.
GENITOURINARY: The patient is status-post renal [**Last Name (un) **], and
he was maintained on his cellcept, cyclosporin, and prednisone
in consultation with the nephrology [**Last Name (un) **] service. His
doses were adjusted appropriately per his cyclosporin levels,
and the routes of administration appropriately changed when his
diet order was changed to NPO: when NPO, his prednisone was
changed to iv methylprednisolone, his cellcept changed to IV,
and his cyclosporin was given as a liquid through the NGT. His
baseline creatinine pre-op was about 2.2, and an elevation
post-operatively was determined to be secondary to pre-renal
ARF; he was hydrated according to recommendations by [**Last Name (un) **]
nephrology. Potentially nephrotoxic home medications
(allopurinol, furosemide, and lisinopril) were held. Urine
output was closely monitored. Noted to have UTI per above with
recommendations for 14 day course.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis. The patient also had sequential
compression boot devices in place during immobilization to
promote circulation. GI prophylaxis was with pantoprazole and
ranitidine.
Patient was transitioned from a heparin gtt to po coumadin by
POD13. Patient progressed well on the floor and diarrhea
decreased with wafers and loperamide. Patient was ambulating
independenly with good urine output and stable vital signs at
time of dischage with adequate po intake. Superior surgical
incision staples were removed from wound and steri-strips were
placed. Vac was removed and wet-to-dry dressings placed for vac
placement by VNA tomorrow in the am. Inferior staples were left
in place to protect incision integrity. Follow up labs for
renal [**Last Name (un) **] will be performed on Wednesday per renal and
should include an INR. Primary care appointment was scheduled
for patient on Wednesday at 11:45 for coumadin management.
Patient was instructed to call the clinic to make an appointment
for follow up with Dr. [**Last Name (STitle) 1120**] early next week. Antiobiotic to be
continued for additional 10 days after discharge. Plan of care
was discussed with patient and wife who demonstrated good
understanding and agreement with above plan for postoperative
follow up.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth once a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE 50 mg 24 hr 1 Tablet(s) by mouth once a day
MYCOPHENOLATE MOFETIL 1 Tablet(s) by mouth twice a day
PRAVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
RANITIDINE HCL - 150 mg Capsule - 1 Capsule(s) by mouth nightly
SIROLIMUS 1 mg Tablet - 2 Tablet(s) by mouth daily
ASPIRIN 81 mg Tablet- 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE-VIT D3-MIN 600 mg-400 unit [**Unit Number **] Tab by mouth
twice
a day
FERROUS SULFATE - 325 mg (65 mg iron) - 1 Tablet(s) by mouth
once a day take separately from Calcium
Discharge Medications:
1. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. ipratropium bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing.
3. psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day).
Disp:*60 Wafer(s)* Refills:*2*
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
5. cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*80 Tablet(s)* Refills:*0*
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once 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. loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. cyclosporine modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
11. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
14. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 7 days.
Disp:*10 Tablet(s)* Refills:*0*
15. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
VNA Carenetwork
Discharge Diagnosis:
[**Doctor Last Name **] Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
S/P Open Colectomy
You were admitted to the hospital after a completion total
colectomy for surgical management of your [**Doctor Last Name **] Syndrome. You
have recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
regarding these results they will contact you before this time.
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 3-4 days. After anesthesia it is not
uncommon for patient??????s to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected however, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonges loose stool, or constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
You were discharged with a VAC in place for post operative
managment of your surgical wound. VNA services were arranged
for you VAC changes and wound management. Your staples are also
in place and will be removed at your postoperative clinic visit.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated.
You will be prescribed a small amount of the pain medication
dilaudid. Please take this medication exactly as prescribed. You
may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 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.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Warfarin (Coumadin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
1. A follow up appointment has been scheduled with your PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 3855**], on WEDNESDAY [**5-20**] at 11:45 for INR measurement
and coumadin dosing. Please call [**Telephone/Fax (1) 3858**] with questions
2. Please have your regular [**Telephone/Fax (1) **] labs drawn for
monitoring of drug levels on Wednesday. Please have an INR
drawn at this time for review at your Wednesday follow
appointment with your primary care physician.
3. Please call and make an appointment for follow up with Dr. [**Name (NI) 14120**] Clinic at ([**Telephone/Fax (1) 3378**] within one week of discharge.
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2116-7-24**] 10:10
|
[
"274.9",
"401.9",
"427.32",
"V10.05",
"530.81",
"412",
"293.0",
"584.9",
"427.31",
"428.22",
"V45.82",
"751.62",
"997.49",
"753.12",
"V50.49",
"428.0",
"V42.0",
"578.1",
"V49.86",
"780.52",
"560.1",
"041.49",
"599.0",
"V84.09",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"99.62",
"46.22",
"38.97",
"88.72",
"45.93",
"45.82"
] |
icd9pcs
|
[
[
[]
]
] |
14284, 14330
|
5215, 11863
|
387, 459
|
14407, 14407
|
2367, 2367
|
23776, 24576
|
1787, 1940
|
12690, 14261
|
14351, 14386
|
11889, 12667
|
14558, 19076
|
2808, 3381
|
19870, 23753
|
1955, 2348
|
19108, 19855
|
238, 349
|
487, 1259
|
2383, 2792
|
14422, 14534
|
1281, 1648
|
1664, 1771
|
3399, 5192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,238
| 191,681
|
34387
|
Discharge summary
|
report
|
Admission Date: [**2146-7-28**] Discharge Date: [**2146-8-9**]
Date of Birth: [**2067-4-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Confusion, Dysphasia/Dysarthria, Bradyphrenia
Major Surgical or Invasive Procedure:
WXRT
History of Present Illness:
79y Russian speaking woman w/ atypical carcinoid tumor,
metastatic to liver and hylum c/o of headache for over 48 h
(started in the occipital region, spreading to frontal area).
Per patient while having her dinner on [**7-27**] she became drowsy.
She then developed imbalance c/o of left arm pain. Mrs [**Known lastname 79094**]
did not complain of nausea or diplopia associated with her
headache but was noted to be dysarthric. However, she did
complain of "vertigo." and symptoms consistent with tinnitus.
This was a sudden change. She was brought to [**Hospital 47**]
hospital.
Hospital course obtained from fellow's note:
"Evaluation at [**Location (un) 47**] [**Hospital1 1281**] revealed a left thalamic
hemorrhagic infarct, and the patient was transferred to the
[**Hospital1 18**]
NSICU for further management. She was given 1g of
dilantin and 10mg of Decadron prior to transfer to [**Hospital1 18**]. On
arrival here, her neurologic symptoms had resolved with the
exception of an inability to ambulate, which the patient
attributes to generalized weakness and exhaustion rather than to
a focal weakness of the lower extremities. She is transferred to
the OMED service for initiation of whole brain radiation
therapy"
As of today ([**2146-7-30**]), patient has received two radiation
treatments which she has tolerated well. She appears in no acute
distress with stable vital signs. Pt denies fevers, chills, HA,
diplopia, dysarthria, dysphagia, localized weakness,
paresthesias or tremors. Her major c/o has been constipation (no
BM x 5 days) and generalized weakness. She denies wt loss,
sweats, SOB, CP, PND, abdominal pain, N/V, cough, hematemesis,
diarrhea, melena, BRBPR. The remainder of the review of systems
is negative in detail.
.
Onc Hx. - Per Fellow note:
"The patient was diagnosed with atypical carcinoid tumor in late
[**2144**] when a hepatic mass was identified, with FNA showing
low-grade neuro-endocrine carcinoma. She underwent a right
middle
lobe wedge resection of a lung mass on [**2145-2-19**], with pathology
revealing a 2cm atypical carcinoid tumor with satellite lesions.
In [**8-1**], a CT showed disease progression with an enlarging right
upper lobe mass, a stable right hilar mass, and a liver mass
that
had increased in size. The patient was treated with
carboplatin/etoposide followed by four cycles of pemetrexed with
evidence of further disease progression. Her most recent CT scan
on [**2146-7-12**] demonstrated a small increase in the size of her
right
lung mass with an increase in both the size and number of her
hepatic metastases. She is now considering treatment with
RAD-001
plus a novel [**Doctor Last Name 360**] on a clinical trial which is expected to open
this summer. In the meantime, she is taking temozolomide 250mg,
with an initial 5-day course given from [**Date range (1) 44736**]. Follow-up
with
Dr. [**Last Name (STitle) **] is planned for [**2146-8-9**]."
Past Medical History:
1. Glaucoma affecting b/l
2. Hypertension Hx
3. Hypothyroidism (Synthroid stopped by her Oncologist).
4. Inflammation of the arachnoid at 20 yo (direct translation)
Social History:
Lives with Daughter in [**Name2 (NI) 47**]. Was independent in ADLs
prior to admission. Distant history of tobacco use, occasional
EtOH use, no illicit drugs.
Family History:
Noncontributory
Physical Exam:
PE EXAMINATION on admission:
temperature 97.6 F, HR 84 bpm, BP 111/56, saturating 96% on room
air, respiratory rate 14
Neurological examination
Cranial nerves I and VIII not formally tested
II: peripheral vision constricted bilaterally, presumed to be
due to her glaucoma. Optic discs were pale and large
bilaterally. PEARL in tact.
III, IV, VI: normal eye movements
Va, b, c : no sensory deficits noted.
IX, X: good palatal movements and a strong cough
[**Doctor First Name 81**]: [**5-30**] power in both the sternocleidomastoid and trapezius
muscles
XII: No tongue deviation.
Upper and Lower limb examinations demonstrated normal tone,
power and reflxes, apart from the L2,3 group where power was
reduced to [**4-30**] bilaterally. No fasciulations were noted, no
clonus was observed. Gait was not formally assessed. Cerebellar
signs were negative. However, proprioception appeared to be
reduced on the [**Last Name (un) 2043**] prominences of her hallux bilaterally.
Pinprick sensation appeared to be reduced in her right leg, her
trunk was not assessed, but the sensation in her arms were in
tact.
Cardiovascular system: Heart sounds were normal, JVD was not
elevated, +1 edema up to her ankles bilaterally
Respiratory: Poor air entry in the right upper zone anteriorly,
otherwise lungs were clear.
Abdomen: Palpable tender liver edge, otherwise soft abdomen with
normal bowel sounds.
PE on OMED transfer ([**2146-7-30**]):
VS T99.9 P94 BP112/75 R18 95%O2 sat on RA
GEN-NAD, amiable russian speaking woman
HEENT-no [**Doctor First Name **],MMM, no icterus, clear conjunctiva
Neck-no [**Doctor First Name **], full ROM
Cor-S1S2 nl, no g/m/r, RRR
Pulm-CTA bl, decreased snds at R base
Abd-soft, NT, ND, No organomegaly
Extrem-no edema, chronic venous statis changes in LE, LUE
antecubital fossa w/ erythematous, macular rash 6x8cm w/
satellite lesions, purulent discharge from site of venipuncuture
Skin- see above
Neuro: PERRL, III - XII intact, VIII not formally tested,
Strength 5/5 throughout, sensation intact throughout except
medial right leg between ankle and MCL, FTN, HTS intact,
babinski negative. Romberg, gate not assessed due patient
weakness. DTRs 2+ [**Name2 (NI) 6028**].
Pertinent Results:
Labss on admission and transfer from ICU to OMED service:
[**2146-7-28**] 02:45AM BLOOD WBC-3.6* RBC-4.22 Hgb-13.2 Hct-38.8
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.8 Plt Ct-232
[**2146-7-29**] 04:49AM BLOOD WBC-6.7# RBC-4.09* Hgb-12.7 Hct-37.8
MCV-93 MCH-31.2 MCHC-33.7 RDW-14.2 Plt Ct-232
[**2146-7-28**] 02:45AM BLOOD Neuts-79.6* Lymphs-17.6* Monos-1.6*
Eos-0.7 Baso-0.4
[**2146-7-30**] 07:30AM BLOOD Neuts-86.0* Bands-0 Lymphs-8.8* Monos-4.1
Eos-0.9 Baso-0.1
[**2146-7-28**] 02:45AM BLOOD PT-13.0 PTT-30.0 INR(PT)-1.1
[**2146-7-28**] 02:45AM BLOOD Glucose-167* UreaN-10 Creat-0.8 Na-144
K-3.9 Cl-109* HCO3-26 AnGap-13
[**2146-7-29**] 04:49AM BLOOD Glucose-104 UreaN-16 Creat-0.7 Na-143
K-4.1 Cl-109* HCO3-25 AnGap-13
[**2146-7-30**] 07:30AM BLOOD Glucose-101 UreaN-14 Creat-0.7 Na-136
K-3.6 Cl-101 HCO3-26 AnGap-13
[**2146-7-28**] 02:45AM BLOOD CK(CPK)-142*
[**2146-7-30**] 10:30PM BLOOD CK(CPK)-81
[**2146-7-28**] 03:15PM BLOOD cTropnT-<0.01
[**2146-7-30**] 10:30PM BLOOD CK-MB-2 cTropnT-<0.01
[**2146-7-31**] 07:08AM BLOOD CK-MB-2 cTropnT-<0.01
[**2146-8-1**] 07:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2146-7-29**] 04:49AM BLOOD Calcium-9.9 Phos-3.4 Mg-2.1
[**2146-7-30**] 07:30AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0
Imaging:
MRI [**7-28**]:
FINDINGS: On T1-weighted sequences without contrast there is
evidence of
multiple hemorrhagic lesions involving both frontal lobes, the
largest lesion
is located on the left thalamic area measuring approximately 1.5
x 2.1 cm in
size in the sagittal projection x 2.2 x 2.0 cm in the axial
view. There is no
evidence of hydrocephalus, this lesion is protruding partially
to the left
side of the third ventricle. Magnetic susceptibility is
demonstrated in these
lesions related with hemorrhagic changes. On FLAIR, no
significant vasogenic
edema is demonstrated. After the administration of gadolinium
contrast
punctate lesions are also visualized suggesting metastatic
infiltration (image
#18 series #12). A punctate focus of magnetic susceptibility is
noted on the
right cerebellar hemisphere (image #6 series #9), mild
restricted diffusion is
demonstrated surrounding these lesions, there is no evidence of
acute ischemic
events. Normal flow void signal is identified in the major
vascular
structures. The orbits, the paranasal sinuses and the mastoid
air cells
appear unremarkable.
IMPRESSION: Multiple hemorrhagic brain lesions most of them
located
supratentorially in both cerebral hemispheres and left thalamic
region as
described above, given the history of lung cancer the
differential include
metastatic hemorrhagic lesions. Some of these lesions
demonstrate magnetic
susceptibility including a small focus of low signal on the
right cerebellar
hemisphere as described above. There is no evidence of
hydrocephalus.
CT - IMPRESSION: Large hemorrhage within the left thalamus with
concern for
noncommunicating hydrocephalus. Subtle hypoattenuation
surrounding the
lateral ventricles may reflect transependymal egress of
cerebrospinal fluid.
NOTE ADDED AT ATTENDING REVIEW: There are other lesions, with
surrounding
edema in the right frontal lobe (series 2, image 26), and left
frontal lobe
(series 2, images 21 and 22). These findings are most suspicious
for
metastatic disease. Recommend MR with contrast if these are not
known lesions.
US UE [**7-31**] - IMPRESSION: Superficial thrombus within the left
cephalic vein limited to the
antecubital fossa consistent with either a partial acute
thrombus or partially
recanalized chonic thrombus. The left basilic vein was not
identified.
CXR [**8-2**] - IMPRESSION: No evidence of acute cardiopulmonary
process.
Right infrahilar opacity consistent with lymphadenopathy
demonstrated on the
outside chest CTs as well as the area of prior lung
resection/biopsy. This area might represent neoplastic
involvment and should
be further evaluated if this was not obtained previously.
Labs at discharge:
[**2146-8-6**] 05:15AM BLOOD WBC-4.6 RBC-3.69* Hgb-11.3* Hct-33.3*
MCV-90 MCH-30.7 MCHC-34.0 RDW-12.6 Plt Ct-289
[**2146-8-7**] 06:50AM BLOOD WBC-4.2 RBC-3.57* Hgb-11.4* Hct-32.6*
MCV-91 MCH-31.9 MCHC-35.0 RDW-12.5 Plt Ct-240
[**2146-8-8**] 06:35AM BLOOD WBC-4.2 RBC-3.58* Hgb-11.3* Hct-32.3*
MCV-90 MCH-31.5 MCHC-34.9 RDW-12.5 Plt Ct-248
[**2146-8-9**] 06:20AM BLOOD WBC-4.0 RBC-3.64* Hgb-11.6* Hct-32.9*
MCV-90 MCH-31.9 MCHC-35.3* RDW-12.5 Plt Ct-221
[**2146-8-6**] 05:15AM BLOOD Glucose-106* UreaN-9 Creat-0.7 Na-144
K-3.7 Cl-109* HCO3-27 AnGap-12
[**2146-8-7**] 06:50AM BLOOD Glucose-102 UreaN-9 Creat-0.7 Na-143
K-3.7 Cl-108 HCO3-26 AnGap-13
[**2146-8-8**] 06:35AM BLOOD Glucose-98 UreaN-8 Creat-0.7 Na-144 K-3.6
Cl-109* HCO3-26 AnGap-13
[**2146-8-9**] 06:20AM BLOOD Glucose-101 UreaN-9 Creat-0.7 Na-142
K-3.9 Cl-108 HCO3-27 AnGap-11
[**2146-8-7**] 06:50AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.1
[**2146-8-8**] 06:35AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.0
[**2146-8-9**] 06:20AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.0
Brief Hospital Course:
79 yo woman with metastatic atypical carcinoid tumor for which
she is treated at DFCC, now presenting with multiple hemorragic
brain lesions including a left sided thalamic hemorrhage.
Patient transferred from ICU to OMED service on [**2146-7-30**] (see HPI
for summary of ICU care).
.
#) Brain metastases, multiple. There was no evidence of elevated
intracranial pressure on exam or Hx throughout the admission.
The neurologic exam appeared to have returned to baseline.
Patient underwent WXRT (finished 7 of 10 doses), last Tx was is
due on Friday [**8-12**]. The care of patient was discussed with
primary oncologist, Dr. [**Last Name (STitle) **] with whom pt has appt on
[**2146-8-9**]. Patient is to start a steroid taper after completion of
XRT per Dr. [**Last Name (STitle) **]. Pt. may resume temozolomide after XRT,
but this was deferred to the primary oncologist. There were no
changes in the neurologic exam from [**2146-7-30**] at discharge.
#) L antecubital fossa rash. [**Hospital **] hospital stay was
complicated by L antecubital fossa cellulitis, likely allergic
reaction at onset, now cellulitis/thrombophlebitis [**2-26**] puncture
wound. This was noted on [**2146-7-30**]. Patient was started on
Clindamycin PO x 3 days with progression of erythema and edema
(12 x 18 cm erythematous/edematous area). An U/S [**7-31**] showed no
loculation or fluid collection, just superficial
thrombophlebitis. On [**2146-8-3**] patient was started on Vancomycin
IV 1g Q12 hours for MRSA coverage, which was decreased to 750mg
Q12 due to elevated trough. Clindamycin was discontinued.
Erythema and edema continued to progress, repeat U/S showed no
change. By [**8-6**] however, progression of erythema and edema was
arrested. By [**8-8**] the cellulitis nearly resolved. Patient
remained afebrile throughout the hospitalization and on
discharge only minor erythema remained at site of
thrombophlebitis. Vanco was d/ced on [**8-9**] and patient was
discharged home on doxycycline 100mg PO BID for 5 days. BCx
were negative.
.
#) Constipation - patient had BMs EOD on the following regimen:
lactulose, senna, docusate, bisacodyl, miralax. She was
discharged home with this regimen.
.
#) BP control - blood pressure was maintained at 110 to 150 SBP.
Patient required 1 L of NS on 2 separate occasions to maintain
goal SBP 120 - 160.
.
# LLL crackles - noted on exam on [**2146-8-1**]. Most likely
atelectasis, as patient w/o fever, cough, or SOB, thus less
likely PNA. CXR - no evidence of pulm edema, consolidation,
effusion. Resolved by [**2146-8-6**] with spirometry.
.
#) Weakness - likely [**2-26**] proximal myopathy of unknown etiology.
Pt. w/ hitory of hypothyroidism, but pt. is subclinically
hyperthyroid (TSH < 0.02). A myopathy work up was initiated:
anti-Ro, anti-La, LDH, aldolase, a PTH, a vitamin D, an anti-SM,
anti-RNP as well as ANCA were obtained. Also Hepatitis B and
hepatitis C. Patient's physical function improved over hospital
stay. She was able to ambulate independently. Per PT reports -
patient will benefit from home PT 3-4times per week for balance
and daily tasks, she was cleared for home. Patient will f/u as
outpatient w/ Neuro-oncology as above.
.
#) Social situation - Pt's insurance does not cover any home
serices or rehab. Have applied for insurance upgrade, however
this will take over 1mo. Patient has been cleared to go home w/o
services by PT. Case manager will continue to work on the case.
.
#) Glaucoma - continued home treatments, no symptoms.
.
#) Code status: Full
Patient was discharged home in a hemodynamically stable
condition with balance and ambulation at home. She has
appropriate follow up.
Medications on Admission:
Xalatan
Alphagan
Cosopt
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. 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*
5. 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:*2*
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*2 bottles* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 25 days: Start day after completion of radiation.
Take 4 tabs x 5 days, 3 tabs x 5 days, 2 tabs x 5 days, 1 tab x
5 days, [**1-26**] tab x 5 days then stop. .
Disp:*53 Tablet(s)* Refills:*0*
9. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
twice a day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical carcinoid with metastases, now to the brain
Hypothyroidism
Glaucoma
History of Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] for treatment of a bleeding stroke on
the left side of your brain that is most likely due to the
metastases of your lung cancer to the brain. You were treated
in the intensive care unit at [**Hospital1 18**], where you were evaluated by
neurosurgery and radiation oncology doctors for further
treatment. It was felt that best treatment for you would
include whole brain radiation for ten cycles. While in the
hospital you received seven of those treatments. You have
tolerated those treatments well without any adverse effects,
except for transient headaches.
Your stay at the hospital was complicated by an infection and
superficial phlebitis (inflammation of the veins) in your left
forearm. You did not have a blood clot inside deep inside your
arm (deep vein thrombosis). You were treated with antibiotics
(intravenous vancomycin) for seven days. Your infection
improved significantly and rash resolved. You are being
discharged home on additional antibiotic (doxycyline) which you
should take as directed (please see below) for the next five
days.
While you were in the hospital, you were seen by a
neuro-oncologist (brain cancer doctor). You were diagnosed with
a myopathy (a disease of the muscle). The source of this is
unclear at the time of discharge. An appointment with
neuro-oncology was arranged for you (please see below).
Functionally, your mobility improved and you were able to walk
on your own.
In addition, as you complete your last radiation treatment on
Friday, [**8-12**], you should promptly start taking a regimen of
steroid medication prescribed to you at discharge (Prednisone,
see below for detailed instructions).
Should you experience any new pain, confusion, difficulties with
balance, weakness, numbness, tingling, double vision, severe
headache, chest pain, shortness of breath, leg swelling/pain or
any other symptom concerning to you, please contact your primary
care provider or go to the nearest emergency room.
You were discharged home in stable condition. It is strongly
recommended that you should complete your radiation treatments
and follow up with your primary oncologist, Dr. [**Last Name (STitle) **].
Followup Instructions:
Please follow up with your primary oncologist, Dr. [**Last Name (STitle) **]
on [**8-9**] for your regular appointment. Please call ([**Telephone/Fax (1) 79095**] to confirm your appointment or should you have any
questions.
Please follow up for completion of your radiation therapy. Your
next treatment is [**8-9**], at [**Hospital 18**] [**Hospital 79096**] clinic.
Please follow up with Dr. [**Last Name (STitle) **], a neuro-oncologist. An
appointment will be made for you and you will be contact[**Name (NI) **]
directly. Please call to confirm your appointment or if you
have any questions. ([**Telephone/Fax (1) 6574**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
Completed by:[**2146-8-14**]
|
[
"244.9",
"999.2",
"197.7",
"401.9",
"431",
"451.82",
"682.3",
"359.9",
"518.0",
"198.3",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
15858, 15864
|
10833, 14508
|
317, 323
|
16009, 16018
|
5903, 9779
|
18272, 19063
|
3657, 3674
|
14582, 15835
|
15885, 15988
|
14534, 14559
|
16042, 18249
|
3689, 3704
|
232, 279
|
9799, 10810
|
351, 3275
|
3719, 5884
|
3297, 3463
|
3479, 3641
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,835
| 143,282
|
20453+20454+20472+20473
|
Discharge summary
|
report+report+report+report
|
Admission Date: [**2173-3-5**] Discharge Date: [**2173-4-8**]
Date of Birth: [**2096-3-31**] Sex: M
Service:
ADDENDUM: This is a continuation of the STAT Discharge
Summary.
On postoperative day 15 ([**2173-3-24**]), the patient
underwent a tracheostomy without complications. This was
done with the consent and knowledge of his family. He had
some emesis on [**2173-3-26**] and a nasogastric tube was
placed. His white blood cell count was then 7000. He
continued to run a negative fluid balance. He was alert but
not following commands at this time. He had Pseudomonas in
his line.
The patient had bright red blood from his ostomy on [**2173-3-28**]. However, his hematocrit remained stable. He was on
ceftazidime at this point. He was also on total parenteral
nutrition for nutritional support.
He was seen by Physical Therapy who did [**Known lastname **] with him. A
bedside swallow evaluation was done, which the patient
failed. He underwent placement of a percutaneous endoscopic
gastrostomy tube on [**2173-4-2**] after informed consent was
obtained from his family. This was done percutaneously by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient's tube feedings were
advanced over the next few days.
From the time course of [**2173-4-3**] to [**2173-4-8**] the
patient did well. His tube feedings were advanced to goal.
The patient was afebrile and tolerating these well. He had
adequate bowel function out of his ostomy. He was
increasingly alert. His blood cultures were negative at this
time.
FINAL DISCHARGE DIAGNOSES:
1. Fulminant Clostridium difficile colitis.
2. Status post subtotal colectomy.
3. Acute myocardial infarction.
4. Status post tracheostomy placement.
5. Status post percutaneous endoscopic gastrostomy tube
placement.
6. Chronic obstructive pulmonary disease.
7. History of contrast nephropathy.
8. History of subdural hematoma.
9. Pseudomonas pneumonia.
10. Pseudomonas urinary tract infection.
11. Bacteremia.
12. Total parenteral nutrition requirement.
13. Anemia.
14. Hypovolemia.
15. Vasopressor requirement.
16. Septic shock.
17. Requirement for continuous venovenous hemofiltration
dialysis.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**Last Name (STitle) **] after he has been discharged
from his rehabilitation facility.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: To rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Epogen 4000 units two times per week.
2. Albuterol nebulizer q.6h.
3. Ipratropium bromide four times per day as needed.
4. Tylenol 325-mg tablets one to two tablets by mouth
q.4-6h.
5. Hydralazine 25 mg by mouth q.6-8h.
6. Lansoprazole 30 mg by mouth once per day.
7. Lopressor 50-mg tablets 1.5 tablets by mouth twice per
day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**]
Dictated By:[**Last Name (NamePattern1) 54759**]
MEDQUIST36
D: [**2173-4-8**] 15:54
T: [**2173-4-8**] 16:32
JOB#: [**Job Number 54784**]
Admission Date: [**2173-3-5**] Discharge Date: [**2173-4-8**]
Date of Birth: [**2096-3-31**] Sex: M
Service:
PRIMARY DIAGNOSIS:
1. Fulminant C difficile colitis.
2. Subtotal colectomy.
3. Acute myocardial infarction.
4. Status post tracheotomy placement.
5.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D.
[**MD Number(1) 10637**]
Dictated By:[**Last Name (NamePattern1) 54759**]
MEDQUIST36
D: [**2173-4-8**] 15:28
T: [**2173-4-8**] 15:33
JOB#: [**Job Number 54785**]
Admission Date: [**2173-3-5**] Discharge Date: [**2173-4-8**]
Date of Birth: [**2096-3-31**] Sex: M
Service:
PRIMARY DIAGNOSIS:
1. Fulminant C. difficile colitis.
2. Acute myocardial infarction.
3. Chronic obstructive pulmonary disease.
4. History of contrast nephropathy.
5. History of subdural hematoma.
6. History of pseudomonas pneumonia.
7. History of pseudomonas urinary tract infection.
8. History of discitis.
PRIOR PROCEDURES:
1. Subtotal colectomy.
2. Tracheostomy placement.
3. PEG placement.
4. Central venous line placement.
BRIEF ADMITTING HISTORY AND PHYSICAL: The patient was
admitted and surgical consultation was obtained in the early
morning of [**2173-3-6**]. The patient was on vasopressor at
the time of the consultation. He had been transported from
[**Hospital 1562**] Hospital on [**1-6**] with discitis and fat bacteremia.
He had been in rehabilitation on [**Location (un) **] when he developed
colonic distension, crampy abdominal pain, nausea, vomiting
and diarrhea. He was transferred to the [**Hospital 1562**] Hospital
Intensive Care Unit where he was found to have Clostridium
difficile. He has been transferred for septicemia and
fulminant colitis. His past medical history is significant
for chronic obstructive pulmonary disease and hypertension
and now renal failure on hemodialysis. Past surgical history
is significant for a left subdural hematoma evacuation on
[**2-10**]. He has a social history of alcohol abuse. He has
an allergy to Serevent. Medications upon admission were
Vasopressin, Zosyn, Flagyl, Protonix, Solu-Medrol 300 t.i.d.
and Haldol.
Upon examination his temperature was 96.6 with a heart rate
of 90 and a blood pressure of 102/50, satting 96 percent on 2
liters. The abdomen remained extremely distended and
diffusely tender. His extremities were very edematous.
Palpable pedal pulses. A rectal tube was placed and stool
was guaiac negative. His arterial blood gases at the time
was 7.30, 23, 118, 14, minus 7. CT scan obtained at that
time showed colonic thickening with stranding in the left
colon.
Aggressive intravenous fluids were initiated. The patient
was intubated. The patient was continued on antibiotics.
The patient continued to do poorly in the Medical Intensive
Care Unit. He was seen by the renal staff and was in the
Medical Intensive Care Unit. He continued to deteriorate.
His white count was 26,000 with a hematocrit of 27. Calcium
is 6.1. He was seen by Nutrition and they recommended total
parenteral nutrition. A central venous line was placed on
the left subclavian vein on [**2173-3-6**] without complication. At
this time he was in acute renal failure. He continued to be
treated on Vancomycin orally, meropenem and Flagyl. He was
intubated. He was continued on hydrocortisone, Ativan,
Flagyl and meropenem and Vancomycin at that time. He
remained in septic shock. His white count continued to climb
and on [**2173-3-9**] was 36,000. He had increasing abdominal
tenderness. At this time it was felt that his only chance of
survival would be a subtotal colectomy. Informed consent was
obtained and the patient was taken to the operating room on
[**2173-3-9**] for a subtotal colectomy. He continued to have a
large white count approximating 37,000 at that time. He was
ventilated and fluid resuscitated in the Intensive Care Unit.
A left femoral arterial line was placed on [**2173-3-10**] without
complications.
The patient was seen by cardiology at that time. He was on
Levophed at .4 mcg per minute. At that it was found that he
has vasospasm of the LAD. This was in conjunction with
underlying coronary artery disease. The cardiologist
recommended aspirin, weaning the pressors as tolerated, and
Nitropaste and calcium channel blocker. A transthoracic
echocardiogram was done, limited views. There was no
evidence of wall abnormalities at that time. The patient had
an extended course. He did rule in for a myocardial
infarction based on troponin elevation. He was in oliguric
ATN at this time as well with a gap acidosis. He continued
to be on TPN at this time. He continued to be followed by
the cardiology service. He was no Levophed along with
propofol and insulin drip. He was also on Plavix at this
time. He continued on continuous venous hemodialysis. We
were able to remove some fluids starting on approximately
[**2173-3-13**]. He was continued on dialysis. He also had an
episode of atrial fibrillation and atrial flutter which
responded to amiodarone drip. He was continued on
Vancomycin, meropenem and Flagyl. Amiodarone drip was also
continued.
By [**2173-3-15**] the Levophed drip was weaned off. The CVVH was
discontinued on [**3-16**]. He had a line change over a wire
on [**2173-3-16**] of the left internal jugular line. His Cordis was
discontinued as was his Swan. He had a triple lumen catheter
placed without complication. He was started on Nystatin as
well as his other antibiotics. He was continued on
amiodarone. He was transfused a unit of red cells on
[**2173-3-17**]. He was stated on DDAVP for this thrombocytopenia.
He had a respiratory alkalosis at that time. He received two
more units of blood on [**2172-3-17**] to maintain a hematocrit above
30 per cardiology given his small myocardial infarction. He
continued to improve and his respiratory alkalosis resolved.
He was on fluconazole and Vancomycin at this time. He was
off pressors. His ventilator was weaned. His
thrombocytopenia was evaluated and he was found to be HIT
negative. He was started on Presodex in an attempt to
extubate him on [**2173-3-20**]. This was initially unsuccessful.
However, he was not following commands so extubation was
delayed. His right IJ line was discontinued on [**2173-3-21**]. He
was seen by neurology service who recommended an EEG for
correction of his infectious issues. Also sedation was
limited. Also preliminary EEG showed no seizure activity and
was consistent with encephalopathy. His renal function to
improve, status post contrast nephropathy. His white count
also was trending downward.
On [**2173-3-23**] a left subclavian line was placed without
complications. He was continued on TPN.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 54759**]
MEDQUIST36
D: [**2173-4-8**] 15:46
T: [**2173-4-8**] 16:04
JOB#: [**Job Number 54807**]
Admission Date: [**2173-3-5**] Discharge Date: [**2173-4-8**]
Date of Birth: [**2096-3-31**] Sex: M
Service:
PRIMARY DIAGNOSIS:
1. Fulminant C. difficile colitis.
2. Acute myocardial infarction.
3. Chronic obstructive pulmonary disease.
4. History of contrast nephropathy.
5. History of subdural hematoma.
6. History of pseudomonas pneumonia.
7. History of pseudomonas urinary tract infection.
8. History of discitis.
PRIOR PROCEDURES:
1. Subtotal colectomy.
2. Tracheostomy placement.
3. PEG placement.
4. Central venous line placement.
BRIEF ADMITTING HISTORY AND PHYSICAL: The patient was
admitted and surgical consultation was obtained in the early
morning of [**2173-3-6**]. The patient was on vasopressor at
the time of the consultation. He had been transported from
[**Hospital 1562**] Hospital on [**1-6**] with discitis and fat bacteremia.
He had been in rehabilitation on [**Location (un) **] when he developed
colonic distension, crampy abdominal pain, nausea, vomiting
and diarrhea. He was transferred to the [**Hospital 1562**] Hospital
Intensive Care Unit where he was found to have Clostridium
difficile. He has been transferred for septicemia and
fulminant colitis. His past medical history is significant
for chronic obstructive pulmonary disease and hypertension
and now renal failure on hemodialysis. Past surgical history
is significant for a left subdural hematoma evacuation on
[**2-10**]. He has a social history of alcohol abuse. He has
an allergy to Serevent. Medications upon admission were
Vasopressin, Zosyn, Flagyl, Protonix, Solu-Medrol 300 t.i.d.
and Haldol.
Upon examination his temperature was 96.6 with a heart rate
of 90 and a blood pressure of 102/50, satting 96 percent on 2
liters. The abdomen remained extremely distended and
diffusely tender. His extremities were very edematous.
Palpable pedal pulses. A rectal tube was placed and stool
was guaiac negative. His arterial blood gases at the time
was 7.30, 23, 118, 14, minus 7. CT scan obtained at that
time showed colonic thickening with stranding in the left
colon.
Aggressive intravenous fluids were initiated. The patient
was intubated. The patient was continued on antibiotics.
The patient continued to do poorly in the Medical Intensive
Care Unit. He was seen by the renal staff and was in the
Medical Intensive Care Unit. He continued to deteriorate.
His white count was 26,000 with a hematocrit of 27. Calcium
is 6.1. He was seen by Nutrition and they recommended total
parenteral nutrition. A central venous line was placed on
the left subclavian vein on [**2173-3-6**] without complication. At
this time he was in acute renal failure. He continued to be
treated on Vancomycin orally, meropenem and Flagyl. He was
intubated. He was continued on hydrocortisone, Ativan,
Flagyl and meropenem and Vancomycin at that time. He
remained in septic shock. His white count continued to climb
and on [**2173-3-9**] was 36,000. He had increasing abdominal
tenderness. At this time it was felt that his only chance of
survival would be a subtotal colectomy. Informed consent was
obtained and the patient was taken to the operating room on
[**2173-3-9**] for a subtotal colectomy. He continued to have a
large white count approximating 37,000 at that time. He was
ventilated and fluid resuscitated in the Intensive Care Unit.
A left femoral arterial line was placed on [**2173-3-10**] without
complications.
The patient was seen by cardiology at that time. He was on
Levophed at .4 mcg per minute. At that it was found that he
has vasospasm of the LAD. This was in conjunction with
underlying coronary artery disease. The cardiologist
recommended aspirin, weaning the pressors as tolerated, and
Nitropaste and calcium channel blocker. A transthoracic
echocardiogram was done, limited views. There was no
evidence of wall abnormalities at that time. The patient had
an extended course. He did rule in for a myocardial
infarction based on troponin elevation. He was in oliguric
ATN at this time as well with a gap acidosis. He continued
to be on TPN at this time. He continued to be followed by
the cardiology service. He was no Levophed along with
propofol and insulin drip. He was also on Plavix at this
time. He continued on continuous venous hemodialysis. We
were able to remove some fluids starting on approximately
[**2173-3-13**]. He was continued on dialysis. He also had an
episode of atrial fibrillation and atrial flutter which
responded to amiodarone drip. He was continued on
Vancomycin, meropenem and Flagyl. Amiodarone drip was also
continued.
By [**2173-3-15**] the Levophed drip was weaned off. The CVVH was
discontinued on [**3-16**]. He had a line change over a wire
on [**2173-3-16**] of the left internal jugular line. His Cordis was
discontinued as was his Swan. He had a triple lumen catheter
placed without complication. He was started on Nystatin as
well as his other antibiotics. He was continued on
amiodarone. He was transfused a unit of red cells on
[**2173-3-17**]. He was stated on DDAVP for this thrombocytopenia.
He had a respiratory alkalosis at that time. He received two
more units of blood on [**2172-3-17**] to maintain a hematocrit above
30 per cardiology given his small myocardial infarction. He
continued to improve and his respiratory alkalosis resolved.
He was on fluconazole and Vancomycin at this time. He was
off pressors. His ventilator was weaned. His
thrombocytopenia was evaluated and he was found to be HIT
negative. He was started on Presodex in an attempt to
extubate him on [**2173-3-20**]. This was initially unsuccessful.
However, he was not following commands so extubation was
delayed. His right IJ line was discontinued on [**2173-3-21**]. He
was seen by neurology service who recommended an EEG for
correction of his infectious issues. Also sedation was
limited. Also preliminary EEG showed no seizure activity and
was consistent with encephalopathy. His renal function to
improve, status post contrast nephropathy. His white count
also was trending downward.
On [**2173-3-23**] a left subclavian line was placed without
complications. He was continued on TPN.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 54759**]
MEDQUIST36
D: [**2173-4-8**] 15:46
T: [**2173-4-8**] 16:04
JOB#: [**Job Number 54808**]
|
[
"008.45",
"263.9",
"585",
"584.9",
"496",
"038.9",
"410.81",
"427.31",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.73",
"43.11",
"46.21",
"99.04",
"99.15",
"33.24",
"96.72",
"31.1",
"38.91",
"39.95",
"96.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
2463, 2483
|
2509, 3256
|
2268, 2417
|
2432, 2439
|
1609, 2233
|
10339, 16690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,552
| 154,051
|
4379+55574
|
Discharge summary
|
report+addendum
|
Admission Date: [**2155-7-3**] Discharge Date: [**2155-7-13**]
Date of Birth: [**2079-2-22**] Sex: F
Service: CCU
HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old
Russian-speaking female with a history of CAD, status post
CABG in [**2152-12-4**] with graft of LIMA to LAD, saphenous
vein graft to OM1/OM2, saphenous vein graft to right PDA.
Follow-up catheterization in [**3-5**] showed diffuse, severe
three vessel disease, almost totally occluded saphenous vein
graft to PDA. The patient then underwent right coronary
artery PTCA with stent placement. For the past one year she
still complained of limited exercise capacity, more severe
dyspnea, and chest tightness. She denied any severe or
sustained episodes of chest pain, orthopnea, PND,
palpitations, syncope. Her chest tightness with exertion
responded to three sublingual nitroglycerin.
She was referred for coronary catheterization and renal
angiography on [**2155-7-4**]. She was admitted on [**2155-7-3**] for
precatheterization hydration and Mucomyst therapy. We felt
that renal angiography was warranted secondary to her marked
hypertension despite medical management with multiple
medications in order to evaluate for possible renal artery
stenosis. The patient had previously refused renal MRI scan
secondary to anxiety.
Early in the a.m. on [**2155-7-4**], her systolic blood pressure
increased to 212/73. She was started on a nitroglycerin
drip. The drip rate was 0.3 micrograms per kilogram per
minute and was titrated up to 8 cc per hour. She underwent
coronary catheterization on [**2155-7-4**] with cardiac output
5.18, cardiac index 2.70, left ventricular end-diastolic
pressure of 13, mean pulmonary capillary wedge pressure of 7.
Catheterization showed LAD occluded proximally, left
circumflex with nondominant vessel with previous stent patent
with diffuse in-stent restenosis with competitive flow
distally filling the saphenous vein graft. RCA was a
dominant vessel with previous proximal stents patent. Distal
RCA had a 50% lesion. Proximal right PDA 80% lesion.
Saphenous vein graft to RCA occluded proximally. Saphenous
vein grafts to OM1/OM2 patent. LIMA to LAD patent.
Renal angiography showed eccentric 40% lesion in the right
renal artery and no disease in the left renal artery. The
patient was noted to have a large hematoma in her right groin
several hours post catheterization on [**2155-7-4**]. Pressure was
applied by nurses and resulted in hemostatic control. The
heart rate was 66, blood pressure 144/60, peripheral pulses
were Dopplerable. Early on [**2155-7-5**], the patient began to
complain of abdominal pain radiating from her groin to the
epigastrium. Expansion of the right groin hematoma was
noted. Repeat hematocrits showed a decline in her hematocrit
value from 30 to 24.6.
On [**2155-7-5**], she was transfused 2 units of packed red blood
cells along with Lasix. On the morning of [**2155-7-5**] at 6:00
a.m. she began to complain of sharp pain at her groin site.
She had not been out of bed or moved at all. At this time, a
firm swollen area was noted in the center of the hematoma.
The patient was given morphine sulfate for pain control which
resulted in a drop of her systolic blood pressure from 130s
to 90s.
Vascular Surgery was consulted who recommended an ultrasound.
The ultrasound noted an echogenic mass 8.6 times 10.6 cm
consistent with right femoral hematoma with pseudoaneurysm
formation, an arterial venous communication.
The patient was transferred to the Coronary Care Unit for
further monitoring.
PAST MEDICAL HISTORY:
1. CAD, status post non-Q wave MI in 03/00, status post
stent to OM2, status post CABG in [**2152-12-4**] with LIMA
to LAD, SVG to OM1/OM2, SVG to right PDA. Repeat
catheterization in [**3-5**] with diffuse and severe disease,
almost totally occluded saphenous vein graft to PDA. Status
post right coronary PTCA with stent placement.
2. Diabetes mellitus type 2, inulin-requiring, with
retinopathy.
3. Peripheral vascular disease, status post right femoral
popliteal bypass in [**1-4**].
4. Obesity.
5. Hypertension.
6. Hypercholesterolemia.
7. Gastroesophageal reflux disease.
8. Colonoscopy in [**3-5**] with edematous polyps and
diverticuli.
9. Hiatal hernia.
10. History of fecal incontinence.
ALLERGIES: The patient reports allergies to penicillin,
unknown reaction.
MEDICATIONS PRIOR TO ADMISSION:
1. Nitroglycerin patch at 0.4 mg per hour.
2. Demodex 20 mg p.o. q.d.
3. Potassium chloride 20 mEq p.o. q.d.
4. Imdur 60 mg p.o. q.d.
5. Lisinopril 40 mg p.o. q.d.
6. Avandia 8 mg p.o. q.d.
7. Lipitor 10 mg p.o. q.d.
8. Nifedipine 60 mg p.o. q.d.
9. Prilosec 40 mg p.o. q.d.
10. Metformin 1,500 mg p.o. b.i.d.
11. Toprol XL 200 mg p.o. q.d.
12. Aspirin 81 mg p.o. q.d.
13. Insulin 70/30 16 units q.a.m.
SOCIAL HISTORY: The patient is Russian-speaking only. She
lives with family members, denied any history of alcohol,
tobacco, illicit drug use.
FAMILY HISTORY: The patient reports brother deceased from MI
at age 59.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.6, heart rate 85, normal sinus rhythm, blood pressure
124/45, respiratory rate 13, oxygen saturation 91% on room
air. General appearance: Well developed, obese white
female, lying flat, in no acute distress. HEENT:
Normocephalic, atraumatic. Pupils unequal; left pupil
pinpoint, minimally reactive, right pupil with anisocoria,
nonreactive. The oropharynx was clear. The oral mucosa was
dry. Neck: Supple, no masses or lymphadenopathy, 2+ carotid
pulses, no delayed upstroke, no carotid bruits, unable to
asses JVP. Lungs: Clear to auscultation anterolaterally,
well-healed sternotomy scar. Cardiovascular: Regular rate
and rhythm, S1, S2, heart sounds auscultated, questionable S4
heart sound, grade I/VI systolic ejection murmur,
holosystolic at apex. Abdomen: Soft, obese, nontender,
nondistended, positive bowel sounds. Extremities: No
clubbing, cyanosis or edema. Feet cool, left greater than
right. Dorsalis pedis and posterior tibial pulses
Dopplerable bilaterally. Groin: Right groin with 18 by 12 cm
hematoma, purplish skin discoloration, firm to hard
consistency, no bruit auscultated.
PERTINENT LABORATORY DATA/X-RAYS, OTHER STUDIES: Hematocrit
26.0, platelets 245,000. Serum chemistries with potassium
3.7, BUN 26, creatinine 1.8, patient's baseline creatinine
1.1 to 1.3. Coagulation profile: PT 12.5, PTT 22.7, INR
1.0.
EKG: [**2155-7-5**] (normal sinus rhythm at 67 beats per minute),
axis at 0 degrees, T wave inversions in leads II, III, aVF.
Nonspecific lateral changes.
Coronary catheterization on [**2155-7-4**] (native three vessel
disease), left main with no significant obstructive disease,
LAD subtotally occluded in midvessel and filled distally via
LIMA to LAD, left circumflex 30% narrowing proximally, OM2
with diffuse 70% proximal disease, competitive flow from SVG
to OM1/OM2 distally, OM3 70% diffuse disease beyond which had
a competitive flow from saphenous vein graft to OM1/OM2. RCA
with mild diffuse disease and proximal and midvessel. RCA
stents patent. Distal RCA 50% discreet stenosis, right PDA a
small vessel with discreet 80% stenosis proximally and
diffuse disease distally. Saphenous vein graft to OM1/OM2
widely patent, saphenous vein graft to right PDA stump
occluded, LIMA to LAD patent, mean pulmonary capillary wedge
pressure 4, right ventricular end-diastolic pressure 7.
Pulmonary artery pressure elevated at 33/9. Left ventricular
end-diastolic pressure 12. Mild diffuse in abdominal aorta.
Right renal artery with 40% eccentric stenosis at origin.
Left renal artery with no significant obstructive disease.
Femoral ultrasound ([**2155-7-6**]): Large heterogenous echogenic
mass measuring 8.6 by 10.6 cm corresponding to large
hematoma. Within the heterogenous mass there is a focal area
of 2-and-Fro vascular flow measuring 2.8 by 2.5 cm,
consistent with a pseudoaneurysm. The neck of the
pseudoaneurysm measures approximately 8 mm. Adjacent and
superior to pseudoaneurysm, images of vascular flow
demonstrated turbulent color flow pattern, consistent with AV
fistula.
HOSPITAL COURSE: 1. CORONARY ARTERY DISEASE: The patient
is with native three vessel disease, status post CABG, RCA
stent. For her ischemia, plan was made to continue aspirin
325 mg p.o. q.d., beta blockade with metoprolol 75 mg p.o.
b.i.d., and Lipitor 10 mg p.o. q.d. Initially, the patient's
other outpatient hypertensives including ACE inhibitor,
nitrates, calcium channel blockers were held secondary to the
concern for hemodynamic instability in light of her hematoma
formation status post catheterization. Additionally, cardiac
enzymes were cycled and the patient ruled out for myocardial
infarction. Serial EKGs demonstrated no evidence of ischemic
changes.
As the patient's hematoma stabilized and status post vascular
repair of her pseudoaneurysm, it was felt that hemodynamic
stability was no longer a concern. She maintained stable
blood pressures for the first several days of her hospital
course and, thereafter, demonstrated elevated blood
pressures. Therefore, she was started on a beta blocker, ACE
inhibitor, calcium channel blocker, nitrate, diuretic for
blood pressure control. At the time of discharge, she was
maintaining blood pressures in the ranges of
150s-180s/60s-80s on metoprolol 125 p.o. b.i.d., Captopril
100 mg p.o. t.i.d., Amlodipine 10 mg p.o. q.d., Isosorbide
mononitrate 60 mg p.o. q.d., hydrochlorothiazide 25 mg p.o.
q.d.
The patient had a normal ejection fraction on stress
echocardiogram in [**2152-12-4**] prior to CABG. We felt
that an echocardiogram would be useful to assess her current
left ventricular ejection fraction of cardiac function.
Echocardiogram was performed on [**2155-7-7**]. It showed mild
dilatation of the left atrium. Left ventricular wall
thicknesses and cavity size were grossly normal. Left
ventricular ejection fraction 60-70%. There was mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the basal-inferior and inferoseptal walls.
The remaining segments contracted well. The right ventricle
was not well seen. The aortic valve leaflets appeared
structurally normal with good leaflet excursion. There was
no aortic valve stenosis or aortic regurgitation. The mitral
valve leaflets were structurally normal. Mild 1+ mitral
regurgitation was seen. The pulmonary artery systolic
pressure could not be quantified. There was a
trivial/physiologic pericardial effusion.
The patient was monitored throughout her hospital course on
Telemetry. She had no evidence of any arrhythmic events. At
the time of discharge, she was hemodynamically stable.
2. RIGHT GROIN HEMATOMA STATUS POST CATHETERIZATION:
Vascular Surgery consultation was obtained. They recommended
a lower extremity ultrasound, with results as above. The
patient was monitored with serial hematocrits, hemodynamic
monitoring in the Coronary Care Unit, and serial peripheral
pulse evaluation. She required multiple transfusions to
maintain hematocrit values greater than 30. As she was felt
to be unstable, and the pseudoaneurysm contributing to this
blood loss, she underwent surgical repair of her right
femoral hematoma and pseudoaneurysm on [**2155-7-8**].
During this procedure, right groin hematoma was evacuated and
right femoral vessels were repaired. The patient tolerated
this procedure well. Vascular Surgery continued to follow
her status post repair with wound checks and general wound
care. She did require additional blood transfusions status
post surgical repair to maintain hematocrit values greater
than 30. However, at the time of discharge, she was
hemodynamically stable, and hematocrit values were stable for
greater than 72 hours above 33.0.
Per Vascular Surgery, the patient had two [**Location (un) 1661**]-[**Location (un) 1662**]
drains in place status post her surgical repair. Vascular
Surgery wanted these left in place until they stopped
draining. The patient continued to drain minimal amounts of
serosanguinous fluid. At the time of this dictation, drains
were still in place, Vascular Surgery still following the
patient for wound care and Kefzol antibiotic therapy was
started for new onset erythema around the right groin
incisional sites.
3. ACUTE RENAL FAILURE STATUS POST CORONARY CATHETERIZATION:
On admission to the CCU, the patient's creatinine was
evaluated to a value of 1.8, baseline creatinines ranged from
1.1 to 1.3 per the medical record review. Prior to her
catheterization, she received Mucomyst and aggressive IV
fluid hydration therapy. However, evaluation of her urinary
electrolytes and urine studies demonstrated evidence of
prerenal azotemia. Therefore, the patient's outpatient
diuretic doses were held and she was volume resuscitated with
IV fluids and multiple blood transfusions. After she became
euvolemic, her renal function continued to improve.
At the time of discharge, creatinine was down to baseline of
1.0 to 1.1.
4. DIABETES MELLITUS TYPE 2: Status post catheterization,
Metformin was held. The patient was continued on her
outpatient dose of insulin 70/30 16 units q.a.m. She was
monitored with q.i.d. fingerstick blood glucose testing and
covered with regular insulin sliding scale. Several days
into her hospital course, her Avandia was restarted at a dose
of 8 mg p.o. q.d. Fingerstick blood glucose testing on the
Avandia and insulin 70/30 16 units q.a.m. ranged from 80-150.
5. RIGHT UPPER EXTREMITY EDEMA: In the morning of [**2155-7-13**],
the patient complained of edema of the right upper extremity.
The extremity was nontender to palpation, peripheral pulses
were intact. The patient was evaluated with a right upper
extremity ultrasound. Results to follow.
6. ACTIVITY: Status post surgical repair of the patient's
right groin hematoma, she was kept on bed rest for several
days per Vascular Surgery recommendation. After her hematoma
and pseudoaneurysm was stabilized, post surgical repair, her
activity level was advanced as tolerated. She was evaluated
by Physical Therapy who felt that she was a candidate for
inpatient rehabilitation after discharge from this hospital.
Therefore, plans upon discharge include placement in an acute
rehabilitation facility where the patient can increase
mobility functional status, gait, and balance.
DISCHARGE CONDITION: The patient was discharged in good
condition. At the time of discharge, her hematocrit value
was stable above 33 for 72 hours, with transfusion needs
contained. She was hemodynamically stable. She will require
additional physical therapy to increase her functional
status, gait, and mobility and was discharged to an acute
rehabilitation facility.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Postprocedure hemorrhage.
2. Coronary artery disease, native.
3. Precipitous drop in hematocrit.
4. Post catheterization complication.
5. Renal artery atherosclerosis.
6. Right femoral pseudoaneurysm repair.
7. Acute renal failure.
8. Hypertension.
9. Diabetes mellitus type 2.
10. Hypertension, unspecified.
RECOMMENDED FOLLOW-UP: The patient is to call Dr.
[**Last Name (STitle) 1911**] at [**Telephone/Fax (1) 285**] for follow-up appointment within
two weeks. Additionally, she should make a follow-up
appointment with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name5 (NamePattern1) 15139**]
[**Last Name (NamePattern1) 18877**] at [**Telephone/Fax (1) 5308**] within the next seven to
ten days.
DISCHARGE MEDICATIONS:
1. Insulin 70/30 subcutaneously 16 units q.a.m.
2. Lipitor 10 mg one p.o. q.d.
3. Pantoprazole 40 mg one p.o. q.d.
4. Colace 100 mg one p.o. b.i.d.
5. Bisacodyl 5 mg two tablets p.o. q.d. as needed for
constipation.
6. Hydrochlorothiazide 25 mg p.o. q.d.
7. Metoprolol 125 mg p.o. b.i.d.
8. Isosorbide mononitrate 60 mg p.o. q.d.
9. Aspirin 81 mg p.o. q.d.
10. Captopril 100 mg p.o. t.i.d.
11. Amlodipine 10 mg p.o. q.d.
12. Rosiglitazone 8 mg p.o. q.d.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 2064**] 12-ABZ
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2155-7-13**] 03:23
T: [**2155-7-13**] 15:26
JOB#: [**Job Number 18878**]
Name: [**Known lastname 3074**], [**Known firstname 3075**] Unit No: [**Numeric Identifier 3076**]
Admission Date: [**2155-7-3**] Discharge Date: [**2155-7-14**]
Date of Birth: [**2079-2-22**] Sex: F
Service: CCU
ADDENDUM:
CONDITION ON DISCHARGE: Good. Hematocrit stable greater
than 33.0 for the past 72 hours without transfusion
requirement. Hemodynamically stable. Assessed by physical
therapy and felt to require rehabilitation.
DISCHARGE STATUS: The patient was discharged to an extended
care facility.
DISCHARGE DIAGNOSES:
1. Postprocedure hemorrhage.
2. Coronary artery disease, native.
3. Precipitous drop in hematocrit.
4. Post catheterization complication.
5. Renal artery atherosclerosis.
6. Right femoral pseudoaneurysm repair.
7. Acute renal failure.
8. Hypertension.
9. Diabetes mellitus type 2.
10. Hypotension.
MEDICATIONS ON DISCHARGE:
1. Insulin 70/30 16 units subcutaneously q.a.m.
2. Lipitor 10 mg p.o. once daily.
3. Pantoprazole 40 mg p.o. once daily.
4. Colace 100 mg p.o. twice a day.
5. Dulcolax 10 mg p.o. once daily.
6. Hydrochlorothiazide 25 mg p.o. once daily.
7. Metoprolol 125 mg p.o. twice a day.
8. Isosorbide Mononitrate 60 mg p.o. once daily.
9. Aspirin 81 mg p.o. once daily.
10. Captopril 100 mg p.o. three times a day.
11. Amlodipine 10 mg p.o. once daily.
12. Rosiglitazone 8 mg p.o. once daily.
13. Levofloxacin 500 mg p.o. once daily for fourteen days.
The patient instructed to continue dose until follow-up
appointment with Dr. [**Last Name (STitle) **] in two weeks.
FOLLOW-UP PLANS: The patient instructed to call Dr.[**Name (NI) 3077**] office at [**Telephone/Fax (1) 3078**], for follow-up
appointment to monitor her right groin wound status post
femoral pseudoaneurysm repair. She was instructed to see him
within the next two weeks. She was also instructed to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 3079**], for a follow-up appointment.
She was told to see him within the next two weeks.
Additionally, she was instructed to make a follow-up
appointment with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name5 (NamePattern1) 3080**]
[**Last Name (NamePattern1) 3081**], at [**Telephone/Fax (1) 3082**], within the next seven to
ten days. She was instructed to call her primary care
physician or visit an Emergency Department if she experienced
any chest pain, shortness of breath, palpitations, dizziness
or light-headedness. Additionally, she was told to notify
her doctor if she experienced any fevers or chills, increased
pain, redness or drainage from her groin wound site. She was
instructed that several of her medications had been changed.
She was told to disregard any of her old medications at home
and take medications that we had prescribed as directed. In
terms of wound care, her right femoral groin area should be
kept dry. Daily dressing changes are needed, cleaning with
normal saline, dressing with dry gauze. Per vascular
surgery, while the patient is in the rehabilitation facility,
the [**Location (un) 2021**]-[**Location (un) 2022**] drain is to be kept at low wall suction.
[**Location (un) 2021**]-[**Location (un) 2022**] drain may be discontinued after drainage
ceases.
[**Name6 (MD) 2292**] [**Name8 (MD) 2293**], M.D. [**MD Number(1) 2294**]
Dictated By:[**Last Name (NamePattern1) 3083**]
MEDQUIST36
D: [**2155-7-27**] 13:32
T: [**2155-7-27**] 13:53
JOB#: [**Job Number 3084**]
cc: [**Name6 (MD) **] [**Name8 (MD) **], M.D.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
[**First Name11 (Name Pattern1) 255**] [**Last Name (NamePattern4) **], M.D.
[**First Name5 (NamePattern1) 3080**] [**Last Name (NamePattern1) 3081**], M.D.
|
[
"285.1",
"707.0",
"440.1",
"584.9",
"272.0",
"998.12",
"997.2",
"414.01",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"39.52",
"88.45",
"37.22",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
14432, 14860
|
4996, 5074
|
16921, 17229
|
15646, 16608
|
14881, 15623
|
17255, 17923
|
8195, 14411
|
4420, 4833
|
17941, 20146
|
5089, 8177
|
3602, 4388
|
4850, 4979
|
16633, 16900
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,888
| 182,362
|
3413
|
Discharge summary
|
report
|
Admission Date: [**2154-9-13**] Discharge Date: [**2154-10-11**]
Date of Birth: [**2106-8-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Epinephrine / Percocet / Codeine / Latex
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SSCP
Major Surgical or Invasive Procedure:
[**9-14**] RVAD insertion/ECMO decannulation
History of Present Illness:
48 yo F presented to [**Location (un) **] ED [**9-13**] with new onset SSCP, +
STEMI. She was taken emergently to the cath lab, where 3 bare
metal stents were placed in a totally occluded RCA. She became
hypotensive, an IABP was placed, doapmine and levophed were
started. She then suffered a PEA arrest, after ACLS she was
stabilized and transferred with [**Hospital1 18**] for definitive treatment.
Past Medical History:
[**Doctor Last Name 15769**] cardiac valve anomaly (congenital)
Junctional rhythm with reentry
Right heart dilatation with h/o syncopal events and palpitations
Thalassemia minor
Hypothyroidism
Hypertension
Depression
Low back pain
Polycystic ovaries
Glaucoma
Hypertriglyceridemia
Social History:
Pt smokes [**11-19**] ppd. Rarely consumes alcohol
Family History:
Non-contributory
Physical Exam:
Deferred, intubated, sedated, taken emergently to the OR.
Pertinent Results:
[**2154-10-11**] 03:00AM BLOOD WBC-9.3 RBC-3.07* Hgb-9.7* Hct-26.6*
MCV-87 MCH-31.5 MCHC-36.4* RDW-15.8* Plt Ct-48*
[**2154-10-10**] 03:09AM BLOOD WBC-11.4* RBC-3.82* Hgb-11.5* Hct-32.3*
MCV-85 MCH-30.0 MCHC-35.5* RDW-15.6* Plt Ct-68*
[**2154-10-11**] 03:00AM BLOOD PT-17.2* PTT-30.8 INR(PT)-1.6*
[**2154-10-11**] 03:00AM BLOOD Glucose-70 UreaN-103* Creat-2.4* Na-153*
K-4.1 Cl-121* HCO3-25 AnGap-11
[**2154-10-10**] 03:13PM BLOOD UreaN-114* Creat-2.8* Na-150* Cl-118*
HCO3-23
Brief Hospital Course:
She was initially stable after transfer but after 2-3 hours
decompensated and was taken to the cath lab. She was found to
have patent stents, but she continued to deteriorate. She was
placed on ECMO, and then was taken to the OR with vascular
surgery for repair of her Left CFA, CFV, and EIA at the site of
the previous IABP. TEE showed Ebsteins anomaly with markedly
dilated RA/RV with focal RV hypokinesis, severe TR, small LV
with focal inferior hypokinesis with EF > 60%, trace MR, no AI.
On [**9-14**] she was taken to the operating room where she underwent
placement of and RVAD and removal of ECMO. She was transferred
to the SICU on epinephrine, milrinone, levophed and propofol as
well as Nitric oxide. She developed fevers for which she was
cultured and ID was consulted. Cultures remained negative, she
was placed on broad antibiotic coverage. She remained intubated
and paralyzed, with likely ARDS. She was seen by hematology for
difficulty maintaining a therapeutic ptt and thrombocytopenia.
She was HIT -, and the thrombocytopenia was thought to be
secondary to the VAD as well as illness. She was started on tube
feeds. Vascular continued to follow her for her groin incisions,
which eventually required VAC dressing. Her sternal wound
developed purulent draiange, and the wound was opened and a vac
dressing was applied there as well. She remained on vanco, zosyn
and flagyl. CT scan of head/chest abdomen/pelvis on [**9-23**] was
essentially negative for infection with the exception of a 7.3
cm right groin fluid collection. There as no bleed or infarct on
head CT. She was seen by optho for conjunctivitis and placed on
erythromycin ointment. She continued to have fever and white
count, but negative cultures. TEE on [**9-25**] showed no eveidence of
endocarditis. Her respiratory status improved and her sedation
was weaned. CXR showed slow resolution of ARDS. Her zosyn was
changed to meropenum given the continued fevers, as well as
fluconazole for some yeast growth from her wounds. She remained
febrile despite antibiotic change, however her white count began
to improve.
She was taken to the cath lab on [**10-7**] for placement of a PA
cath in preparation for RVAD weaning.
Fevers continued, she remained on vanco, fluc, and ceftaz was
started on [**10-8**].
On [**10-8**] she was found to have melena and HCT drop, and GI was
consulted. Gastric lavage showed maroon/black but no fresh
blood. She was started on a protonix drip. EGD showed blood in
the stomach, and findings consistent with hemorrhagic gastritis.
Her heparin was stopped and she was started on Dextran.
Her LFTs increased, and then began to improve. Her [**Last Name (un) 3041**] was
dc'd. Hepatitis serologies were sent.
Her fever started on improve and at the time of discharge she
was afebrile for about 48 hours.
Medications on Admission:
hydrocodone, omeprazole, levoxyl, lexapro, hctz, kcl, verapamil
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection INFUSION (continuous infusion).
5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. Acetaminophen 160 mg/5 mL Solution Sig: [**11-19**] PO Q4-6H (every
4 to 6 hours) as needed for fever.
7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic Q8H
(every 8 hours) as needed.
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q4H (every 4 hours).
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
12. Potassium Chloride 20 mEq / 50 ml SW IV PRN K<4.4 and CR<2.0
** Concentrated KCL must be given via central line only **
13. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic [**Hospital1 **]
(2 times a day).
14. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for T>102.
15. Pantoprazole 40 mg Recon Soln Sig: Eight (8) Recon Soln
Intravenous INFUSION (continuous infusion).
16. Furosemide 80 mg IV BID
17. Metoclopramide 10 mg IV Q6H:PRN nausea/vomiting
18. Vancomycin HCl 1000 mg IV Q 24H
19. Metoprolol 10 mg IV Q4H
20. Dextran 40 in D5W 500 ml IV 500 ML Q 24
21. CeftazIDIME 1 gm IV Q12H
22. HydrALAZINE HCl 20 mg IV Q6H:PRN sbp>160
23. Morphine Sulfate 1-5 mg IV Q4H:PRN
24. Lorazepam 0.5-1 mg IV Q4H:PRN
25. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous BREAKFAST (Breakfast): 35 units QAM
25 units QPM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2025**]
Discharge Diagnosis:
Acute MI, Cardiogenic shock, RV failure, Recent RCA stents
Ebsteins Anomaly
s/p Left THR 3 weeks ago secondary to AVN ([**2154-8-8**])
Inferior STEMI
lipids
LBP
hypothyroid
thallesemia minor
DM2
PUD
GERD
Glaucoma s/p multiple surgeries
Obesity
tobacco abuse
h/o junctional rhythm
depression
Discharge Condition:
Stable
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2154-10-11**]
|
[
"041.10",
"998.32",
"998.11",
"244.9",
"682.2",
"519.2",
"276.0",
"278.00",
"518.5",
"E912",
"256.4",
"785.51",
"V45.82",
"934.1",
"998.59",
"410.41",
"427.31",
"287.5",
"372.00",
"112.3",
"V43.64",
"401.9",
"535.01",
"746.2",
"282.49",
"584.9",
"305.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"86.22",
"39.32",
"97.44",
"88.43",
"33.24",
"37.66",
"37.23",
"39.65",
"00.12",
"88.56",
"33.22",
"38.93",
"88.72",
"99.69",
"45.13",
"39.31",
"37.21",
"96.6",
"00.13",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
6675, 6722
|
1800, 4616
|
322, 369
|
7057, 7187
|
1299, 1777
|
1188, 1206
|
4730, 6652
|
6743, 7036
|
4642, 4707
|
1221, 1280
|
278, 284
|
397, 799
|
821, 1103
|
1119, 1172
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,337
| 156,022
|
6283
|
Discharge summary
|
report
|
Admission Date: [**2169-11-3**] Discharge Date: [**2169-11-21**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
ischemic left ist toe ulcer
Major Surgical or Invasive Procedure:
none
History of Present Illness:
hospital transfer from [**Hospital3 7571**]hospital for chronic left
foot wound x 6 months which has failed conserative treatment and
antibiotic.Transfered for vascular evaluation
Past Medical History:
history of gout
history of ischemic heart disease ,s/p CABG's,s/p coronary
angioplasty with stenting
history of congestive heart failure, elevated BNP 1260 ([**10-20**])
history of hypertension
history of deep vein thrombosis complicated with pulmonary
embolus, negative factor V Leiden, elevated homocystiene level,
anticoagulated
history of polymyalgia rheumatica-predisone
history of hyperlipdemia
history of drug allergy: codiene
history of tobacco use 110-120 pack years, discontinued
cardiac arrythmia, s/p pacemaker
Social History:
recently widowed( 1.5 months ago
former smoker
denies ETOH use.
He lives alone but has a very involved family with his son and
daughter-in-law
Family History:
unknown
Physical Exam:
vital signs: 96.9-68-18 120/64 O2 sat room air 94%, Wt. 206#
FSBG: 118
gen: no acute distress
HEENT: no bruits
Lungs: [**Last Name (un) **] to auscultatiion
Heart : irregular rythmn
Abd: soft nontender, nondistended
extremity: 2x3cm hematoma on dorsum of left footwith purulent
drainage
Pulses palpable femoral bilaterally , absent popliteal's
bilaterally with dopperable signals pedal pulses bilaterally
Neuro: intact
Pertinent Results:
[**2169-11-3**] 09:25PM GLUCOSE-118* UREA N-83* CREAT-2.9*#
SODIUM-134 POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-29 ANION GAP-18
[**2169-11-3**] 09:25PM CALCIUM-9.2 PHOSPHATE-6.1*
[**2169-11-3**] 09:25PM WBC-13.3* RBC-3.34* HGB-10.8* HCT-31.8*
MCV-95 MCH-32.4* MCHC-34.0 RDW-16.2*
[**2169-11-3**] 09:25PM PLT COUNT-135*#
[**2169-11-3**] 09:25PM PT-32.3* PTT-37.7* INR(PT)-3.5*
Brief Hospital Course:
A/P:83 yo male with h/o CAD, CHF, COPD and DMII admitted for
left foot ulcer secondary to poor blood flow to the leg and DM
who developed acute renal failure in the setting of vancomycin
for the foot ulcer. During his hospital course, the patient
developed worsening CHF requiring diuresis which worsened his
renal failure. His mental status also waxed and waned in the
setting of infection, frequent aspiration, and poor cardiac
output. Vascular surgery wanted to take the patient to the OR
for possible amputation but there was concern on whether Mr.
[**Known lastname 24397**] would survive the surgery. He had a temporary
hemodialysis lined placed for HD and interventional radiology
accidently left the wire in the HD catheter which was removed
one day post procedure with no subsequent medical complications.
He received dialysis x 3 for his worsening renal failure. The
family and the patient had frequent discussions regarding long
term goals for the patient. Mr [**Known lastname 24397**] did not want further
interventions and he was made DNR/DNI. His health continued to
worsening and he went into rapid afib and ventricular
tachycardia with crushing chest pain. Medical management was
initiated but when the family was called, they requested he be
made Comfort Measures Only and the patient was started on a
Morphine drip for pain and comfort. A palliative care consult
was requested who confirmed with the family the patient's
wishes. Mr. [**Known lastname 24397**] was kept comfortable. He passed away on
[**2169-11-21**] 11:10pm and his family was made aware.
Medications on Admission:
Atenolol 25mg daily, Lasix 80 twice a day, prednisone 10mg
atorvstatin 10mg, nitro patch 0.2, coumadin 5mg 2xper week and
2.5 5 xper week, vanco started on [**10-31**] and stopped [**11-8**]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
expired
|
[
"041.11",
"V45.82",
"428.20",
"707.03",
"274.9",
"V58.65",
"293.0",
"707.14",
"507.0",
"403.91",
"V53.31",
"V45.81",
"786.04",
"585.9",
"496",
"584.5",
"725",
"440.24",
"707.13",
"707.15",
"255.4",
"250.00",
"682.7",
"707.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"88.42",
"99.04",
"39.95",
"88.48",
"38.95",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
3896, 3905
|
2050, 3626
|
244, 250
|
3956, 3965
|
1644, 2027
|
4018, 4028
|
1181, 1190
|
3867, 3873
|
3926, 3935
|
3652, 3844
|
3989, 3995
|
1205, 1625
|
177, 206
|
278, 459
|
481, 1005
|
1021, 1165
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,417
| 133,094
|
46895
|
Discharge summary
|
report
|
Admission Date: [**2117-11-12**] Discharge Date: [**2117-11-16**]
Date of Birth: [**2045-3-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Fentanyl / Lactose / Iron
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->OM, Diag) [**2117-11-12**]
Past Medical History:
1. Crohn's disease x 25yrs (s/p transverse colectomy &
ileocecectomy)
2. Prostate cancer s/p L nerve sparing radical prostatectomy
3. Basal cell carcinoma
4. HTN
5. s/p R shoulder arthroscopy
6. CAD s/p MI; most recent EF 60%, negative stress in [**2112**]
7. Sciatica
8. Osteopenia
9. CIS s/p transverse colectomy
Social History:
SH: Lives w/ wife; no children. Denies tobacco/drugs but social
alcohol.
Family History:
FH: Father w/ CAD and mother w/ ALS. Colorectal cancer in
family.
Physical Exam:
Pulse: Resp:16 O2 sat:98%
B/P Right:132/76 Left:124/80
Height:5'9" Weight: 210#
General:AAO x 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Brady Irregular [] Murmur
Abdomen: Soft [x] softly distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema 1+ LLE edema,
trace RLE 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:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2117-11-15**] 03:30AM BLOOD WBC-10.0 RBC-3.77* Hgb-11.9* Hct-34.8*
MCV-92 MCH-31.5 MCHC-34.2 RDW-13.9 Plt Ct-194
[**2117-11-14**] 03:21AM BLOOD PT-13.8* PTT-28.4 INR(PT)-1.2*
[**2117-11-15**] 03:30AM BLOOD Glucose-111* UreaN-15 Creat-0.9 Na-138
K-3.6 Cl-102 HCO3-30 AnGap-10
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2117-11-15**] 3:30 PM
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with cabg
REASON FOR THIS EXAMINATION:
f/u LLL atelect
Final Report
HISTORY: CABG with left lower lobe atelectasis.
FINDINGS: In comparison with the study of [**11-13**], there is
continued low lung volumes with bilateral atelectatic changes,
especially pronounced at the left base. The possibility of
supervening pneumonia cannot be excluded. Upper lung zones are
clear and there is no definite vascular congestion.
Incidental note is dilatation of gas-filled loops of bowel,
consistent with an adynamic ileus.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: MON [**2117-11-15**] 8:05 PM
Echo:
Conclusions
PREBYPASS
The left atrium is normal in size. No spontaneous echo contrast
is seen in the body of the left atrium or left atrial appendage.
No spontaneous echo contrast is seen in the body of the right
atrium. 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%).
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis.
The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is a
focal calcification on one of the aortic valve leaflets, either
the non-coronary or the left-coronary leaflet. There is no
aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
POSTBYPASS
The patient is A-paced on a phenylephrine infusion.
Biventricular systolic function is preserved.
Trace aortic regurgitation and trace mitral regurgitation
persist.
The thoracic aorta is intact after aortic decannulation.
Dr. [**Last Name (STitle) **] was notified in person of the results at the time of
the study.
Brief Hospital Course:
The patient was admitted on [**2117-11-12**] and underwent
CABGx3(LIMA->LAD, SVG->OM, Diag. The cross clamp time was 44
minutes, total bypass time was 65 minutes. He tolerated the
procedure well and was transferred to the CVICU on Propofol in
stable condition. He was extubated on the post op night and his
chest tubes were discontinued on POD#1. He was transferred to
the floor on POD#2 and his epicardial pacing wires were
discontinued on POD#3. He continued to progress and was
discharged to home on POD#4 in stable condition.
Medications on Admission:
ADALIMUMAB [HUMIRA] 40 mg/0.8 mL Kit - one time a week
ATENOLOL 50 mg Tablet 2 Tablet(s) by mouth once daily
ATORVASTATIN [LIPITOR] 5 mg Tablet once a day
CYANOCOBALAMIN (VITAMIN B-12) 1,000 mcg/mL Solution - 1,000 mcg
IM once monthly
FERRAHEME -dosage uncertain,
HYDROCHLOROTHIAZIDE 12.5 mg daily LISINOPRIL 40 mg once a day
LOPERAMIDE 2 mg Capsule - 1 Capsule(s) by mouth 5 2mg capsules
per day
MESALAMINE [PENTASA]500 mg takes 8 x a day NITROGLYCERIN
PANTOPRAZOLE 40 mg once a day
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit Capsule once every
evening CYANOCOBALAMIN (VITAMIN B-12) GLUCOSAMINE
&CHONDROIT-MV-MIN3 - GLUCOSAMINE SULFATE 2KCL LORATADINE 10 mg
Tablet daily
MULTIVITAMIN,TX-MINERALS NATURAL CALCIUM 500 mg Tablet-2 tabs po
take 1000 mg's 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 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO QID (4 times a day).
Disp:*480 Capsule, Sustained Release(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease-s/p CABGx3 [**2117-11-12**]
s/p myocardial infarction
HTN
elevated cholesterol
GERD
Crohn's disease
iron deficiency anemia
Discharge Condition:
Good, ambulating well. Pain controlled with Percocet.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**2117-12-9**] @ 1:15 PM
Cardiologist: Dr. [**Last Name (STitle) **] [**2117-12-17**] 2:00 PM
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 1407**] in [**5-17**] 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:[**2117-11-16**]
|
[
"733.90",
"401.9",
"412",
"280.9",
"413.9",
"272.0",
"414.01",
"555.9",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6390, 6448
|
3951, 4486
|
310, 362
|
6639, 6696
|
1577, 1942
|
7540, 8033
|
808, 876
|
5310, 6367
|
1982, 2008
|
6469, 6618
|
4512, 5287
|
6720, 7517
|
891, 1558
|
255, 272
|
2040, 3928
|
384, 701
|
717, 792
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,596
| 136,107
|
48309
|
Discharge summary
|
report
|
Admission Date: [**2198-5-8**] Discharge Date: [**2198-5-10**]
Date of Birth: [**2115-7-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82yo female who resides at [**Hospital 100**] rehab facility who presents to
[**Hospital1 18**] after sustaining a fall.
Past Medical History:
Dementia
depression with psychotic features
CAD s/p CABG in [**1-/2194**] LIMA-.LAD, SVG->OM1
HTN
RBBB and LAFB
Dyslipidemia
B12 deficiency
Pilynoidal cyst removal
IBS/GERD
Social History:
Per patient, has lived at [**Hospital6 459**] since [**Month (only) **].
Divorced with 3 children with whom she is in close contact. 5
pack year smoking history, quit at age 25. No alcohol.
Family History:
Father with MI and stroke, age 70's
Mother with MI, age 88
Physical Exam:
On admission:
T 97.5 B/P 159/60(in 200's intermittently) HR:60 R20. O2Sat: 96%
on 2L.
HEENT: Left orbital hematoma with sig. edema, dried blood in
oropharynx, no blood or drainage in nares or ears.
Neck: Cervical collar in place
Lungs: CTA bilat.
Cardiac: RRR.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Left knee abrasion, Rt LE edema
Mental status: Drowsy but arousable, cooperative with exam,
normal affect.
Orientation: Oriented to person only. Able to state she lives
in [**Location (un) 1110**].
Language: answers questions in full sentences. no dysarthria
Cranial Nerves:
I: Not tested
II: rt Pupil round and reactive to light, 3 to 2mm. Unable to
assess left [**1-29**] edema of orbit
III, IV, VI: Extraocular movements intact right without
nystagmus. Unable to assess left [**1-29**] edema of orbit
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: Diminished bulk and normal tone bilaterally. intention
tremor UE b/l. Strength diminished globally. Injury to rt
shoulder but antigravity biceps/triceps and [**4-1**] grip. LUE
biceps
[**3-1**], tri [**4-1**], grip [**4-1**]. LE [**4-1**] quad, [**5-1**] plantarflex, [**4-1**]
dorsiflex Left and [**3-1**] dorsiflex rt.
Sensation: Intact to light touch bilaterally/symmetric.
Reflexes: B T Br Pa Ac
Right 1+----------
Left 1+----------
Toes downgoing bilaterally
Upon Discharge:
Patient is oriented x 2 but is confused and has poor short term
memory. She has a large periorbital hematoma on the left but the
swelling is slightly decreased.
PERRL, EOMS intact. Follows commands with all 4 but has
generalized weakness of 5-/5 everywhere. There are sutures over
the left eye.
Pertinent Results:
[**5-8**]: CT Head: Acute subdural hematoma overlying right cerebral
hemisphere, measuring 1 cm in maximal dimensions. No shift of
midline. Scattered foci of subarachnoid hemorrhage. Large left
periorbital hematoma.
[**5-8**]: CT Sinus: No fx. Large left periorbital and preseptal
hematoma/swelling. Globe appears intact.
[**5-8**]: CT C-spine: No fx or malalignment. Multilevel degenerative
changes, may predispose cord to injury with minor trauma. If
high
clinical concern for cord or lig injury, MR is suggested.
[**5-8**]: CT Abd/P: No acute intra-abdominal or intra-pelvic
findings.
Trace free fluid. T11 and T12 compression fractures, chronicity
unknown, but new from [**2194-1-25**]. Old inferior pubic rami
fractures.
[**5-9**]: Head CT:
IMPRESSION:
1. No significant interval change in multifocal,
multicompartmental
intracranial hemorrhage, without evidence of shift of normally
midline
structures.
2. Stable left periorbital, preseptal hematoma.
Brief Hospital Course:
Admitted from ED to Trauma ICU for close neurologic monitoring.
She was also evaluated by Opthamology to address her left eye
eccymosis, edema and orbits. CT imaging has remained stable. On
[**5-9**] follow up head CT was unchanged. Her neuro status improved
and she was more awake and not as lethargic. She was transferred
to the floor. The patient was evaluated by PT and OT who felt
that she was safe to go back to her nursing home. She was
discharged on [**2198-5-10**].
Medications on Admission:
asa 81, buproprion 100', calcium,
vit b12, cholecalciferol, prilosec 20, lopressor 25", risperdal
0.5", simvastatin 80, senna
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Risperidone 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Fever.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for itching.
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day): Continue until follow up appointment.
9. Outpatient Lab Work
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Right Subdural Hematoma/SAH
Left periorbital hematoma
Discharge Condition:
Neurologically improved
Discharge Instructions:
??????Have a friend/family member check your incision daily for signs
of infection and wound breakdown.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no heavy lifting (>10
pounds). You should avoid straining or holding your breath such
as when moving your bowels. Avoid excessive bending.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in 4 days [**5-14**] for removal of
your sutures. Please call ([**Telephone/Fax (1) 88**] to schedule an
appointment with the Nurse Practitioner for this appointment.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks with a noncontrast head CT.
-You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
Completed by:[**2198-5-10**]
|
[
"V45.81",
"266.2",
"921.2",
"852.20",
"E885.9",
"852.00",
"401.9",
"272.4",
"564.1",
"290.0",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5648, 5713
|
3859, 4335
|
327, 334
|
5811, 5837
|
2872, 2883
|
7308, 7963
|
907, 968
|
4512, 5625
|
5734, 5790
|
4361, 4489
|
5861, 7285
|
983, 983
|
279, 289
|
2557, 2853
|
362, 484
|
1573, 2541
|
2893, 3614
|
3623, 3836
|
997, 1328
|
1343, 1557
|
506, 681
|
697, 891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,367
| 139,864
|
51689
|
Discharge summary
|
report
|
Admission Date: [**2183-7-26**] Discharge Date: [**2183-8-13**]
Date of Birth: [**2137-11-1**] Sex: F
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Urokinase / Heparin Calcium
(Porcine) / Aspirin / Penicillins / Streptokinase
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Small Bowel Obstruction
Major Surgical or Invasive Procedure:
Exploratory laparotomy with lysis of adhesions and small bowel
resection [**2183-7-30**]
History of Present Illness:
45 F w/ ESRD secondary to ureterovesical reflex sp LRRT
[**2150**]+[**2160**], CRT [**2155**]+[**2174**] w/ a history of multiple partial small
bowel obstruction presents with recurrent small bowel
obstruction.
Past Medical History:
PMH-ESRD secondary to ureterovesical reflex, HTN, pancreatitis,
chronic constipation, pSBO [**2178**], Hep C+, CMV+, EBV+
PSH-LRRT [**2150**]+[**2160**], CRT [**2155**]+[**2174**], multiple AV grafts with PTFE,
TAH/BSO, appy, ex lap LOA
Social History:
SOCIAL HISTORY: No history of tobacco use. No h/o alcohol use.
married and lives with husband.
Family History:
FHx: epilepsy
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T 98.6 P 109 BP 162/84 R 12 Sat 95%RA
GEN: Pt sitting up in bed with NGT in place, appears in good
spirits, NAD, cushingoid in appearance
HEENT: dry MM, PERRL, conjunctivae slightly injected, no
cervical LAD, soft tissue mass on R side of neck anteriorly s/p
permacath, no carotid bruits, NGT in place to gravity
CV: RRR, no m/r/g
PULM: mild LLL rales, otherwise CTA, multiple varicosities on
chest wall
ABD: slightly distended, multiple varicosities, tender to
palpation in epigastrium with +rebound and voluntary guarding,
other quadrants nontender to palp, pain elicited with moving the
bed, NABS, kidney transplants palpable in bilateral lower
quadrants, +midabdominal surgical scars, no percussible or
palpable HSM
EXT: emaciated extremitites, 2+ DP/PT pulses, warm and well
perfused
SKIN: scales on anterior shins bilaterally
NEURO: a and o x 3, moving all 4 extrem
Pertinent Results:
[**2183-7-26**] 02:00PM BLOOD WBC-10.8 RBC-4.57 Hgb-13.0 Hct-39.4
MCV-86# MCH-28.4 MCHC-32.9 RDW-14.2 Plt Ct-256
[**2183-8-1**] 07:00AM BLOOD WBC-11.7* RBC-3.20* Hgb-9.1* Hct-28.4*
MCV-89 MCH-28.5 MCHC-32.1 RDW-14.2 Plt Ct-233
[**2183-8-2**] 05:37AM BLOOD WBC-9.1 RBC-2.84* Hgb-8.1* Hct-25.1*
MCV-88 MCH-28.6 MCHC-32.4 RDW-14.2 Plt Ct-219
[**2183-8-4**] 06:00AM BLOOD WBC-11.5* RBC-3.89* Hgb-11.5* Hct-33.9*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.1 Plt Ct-200
[**2183-8-11**] 12:37PM BLOOD WBC-12.0* RBC-3.30* Hgb-9.5* Hct-29.6*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.0 Plt Ct-369
[**2183-8-12**] 05:30AM BLOOD WBC-10.8 RBC-2.99* Hgb-8.5* Hct-26.8*
MCV-89 MCH-28.3 MCHC-31.6 RDW-15.0 Plt Ct-330
[**2183-8-13**] 05:00AM BLOOD WBC-10.9 RBC-3.07* Hgb-8.9* Hct-28.0*
MCV-91 MCH-28.9 MCHC-31.7 RDW-15.2 Plt Ct-367
[**2183-7-26**] 02:00PM BLOOD PT-11.8 PTT-21.2* INR(PT)-0.9
[**2183-7-28**] 08:30AM BLOOD Glucose-100 UreaN-32* Creat-1.2* Na-145
K-4.9 Cl-113* HCO3-19* AnGap-18
[**2183-8-4**] 06:00AM BLOOD Glucose-126* UreaN-37* Creat-0.9 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2183-8-8**] 09:11PM BLOOD Glucose-58* UreaN-43* Creat-2.4* Na-131*
K-4.9 Cl-101 HCO3-17* AnGap-18
[**2183-8-9**] 06:00AM BLOOD Glucose-64* UreaN-43* Creat-2.7* Na-135
K-4.3 Cl-105 HCO3-17* AnGap-17
[**2183-8-11**] 04:56AM BLOOD Glucose-79 UreaN-39* Creat-3.1* Na-138
K-4.0 Cl-109* HCO3-16* AnGap-17
[**2183-8-13**] 05:00AM BLOOD Glucose-73 UreaN-26* Creat-2.5* Na-139
K-4.6 Cl-109* HCO3-17* AnGap-18
[**2183-8-5**] 08:41AM BLOOD Vanco-34.5
[**2183-8-6**] 06:00AM BLOOD Vanco-51.9*
[**2183-8-7**] 05:50AM BLOOD Vanco-30.7
[**2183-8-8**] 06:07AM BLOOD Vanco-25.8*
[**2183-8-10**] 05:00AM BLOOD Vanco-25.7*
[**2183-8-13**] 05:00AM BLOOD Vanco-13.2*
Brief Hospital Course:
On admission, the patient was noted to be in mild acute renal
failure. She was made NPO status and placed on IVF. NGT was
placed. A CT scan of the abdomen showed dilated proximal small
bowel, decompressed distal small bowel. On [**7-27**], Urine cx grew
gram positive bacteria-not speciated and antibiotics were
started. On [**7-28**], a RIJ central venous catheter was placed
secondary to inadequate IV access. The pt continued to be
ditended with high NGT output. As a result, on [**7-29**], TPN was
started. A repeat urine cx was obtained on [**8-1**], which showed
resolution of the pt's UTI.
The pt's clinical condition had not improved with conservative
management. On [**7-30**], an exploratory laparotomy, lysis of
adhesions, and small bowel resection was performed. Please see
the operative note for details. The pt had an unremarkable post
operative course and her NGT was DC'd on POD # 2.
On [**8-2**], the pt was transferred to the ICU after having a
temperature of 103.0, persistent tachycardia, ECG changes and
positive cardiac enzymes. The am of [**8-2**], the pt's hct drifted
down to 25 and she was transfused 2U RBC's. Cardiology was
obtained and they agreed with the management of the surgical
team's management. A TTE was obtained which showed:
There is moderate global left ventricular hypokinesis (ejection
fraction 30 percent). Right ventricular systolic function is
borderline normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Severe (4+)
mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension.
Broad spectrum antibiotics were started. Presumed diagnosis of
pneumonia was made secondary to expectorated brown/purulent
looking sputum and a questionable infiltrate on CXR. CT abd was
obtained which showed no free fluid or air and no bowel wall
thickening. After transfusion, resusitation and resolution of
fever, the pt's hr was well controlled and her ecg changed
resolved. She was transferred to the floor in a stable
condition on [**8-3**].
The pt's PE improved and her bowel function returned. On [**8-6**],
her diet was advanced and tpn was weaned off. On [**8-7**], the pt's
wound was noted to be slightly erythematous. The superior
aspect of her wound was opened and packed and her Gram stain was
negative. On [**8-8**], her antibiotics were DC'd. HEr vanco had
been held secondary to high levels. In addition, her
cyclosporin levels were noted to be slightly elevated and her
BUN/Cr increased. Her cyclo level was adjusted accordingly. A
Renal US was obtained which was unremarkable; resistive indices
0.66-0.76. Her renal function improved and upon discharge, she
was AVSS with an unremarkable PE. She had a temperature of
101.0 on [**8-11**]. The urine culture grew > 100,000 EColi. She
was DC'd on 7 days of levofloxacin. The superior aspect of her
wound was opened up for 2 cm. She will be DC'd with VNA to help
with dressing changes and medication overview. Upon discharge
on [**8-13**], she was AVSS and tolerating a regular diet, ambulating
and voiding without difficulty.
Medications on Admission:
Neoral 50/25, pred 10', cellcept [**Pager number **]"', NaHCO3 1300", protonix
40', dilt 120', lasix 40', levoquin 250 MWF, premarin 0.3',
lipitor 10', kristalose 10 g packet Q week, metamucil
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
TID (3 times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours). (dose to be adjusted per level).
9. Levofloxacin 500mg- one tab qday X 5 days.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
small bowel obstruction
s/p exploratory laparotomy with lysis of adhesions and small
bowel resection [**2183-7-30**]
MI
DM
mitral& tricuspid regurgitation, pulmonary hypertension
Acute renal insufficiency s/p kidney transplant [**2174**]
cyclosporin toxicity
wound infection
Discharge Condition:
stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability
to take medications, abdominal pain, decreased urine output,
edema, 3 pound weight gain in 1 day, shortness of breath, chest
pain, or any redness/bleeding or pus at abdominal incision.
Labs every Monday & Thursday for cbc, chem 7, ast, t.bili,
albumin, calcium, phosphorus, urinalysis and trough cyclosporin
level. Results should be fax'd to [**Telephone/Fax (1) 673**] as soon as
available.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2183-9-1**] 1:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule
appointment in 1 week
Call to schedule follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 107087**] (Cardiology)
[**Telephone/Fax (1) 107088**]
Completed by:[**2183-8-13**]
|
[
"560.81",
"584.9",
"070.70",
"410.71",
"998.32",
"424.0",
"996.81",
"428.21",
"280.0",
"599.0",
"401.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"45.62",
"96.07",
"99.15",
"99.04",
"54.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8226, 8301
|
3797, 7088
|
389, 480
|
8620, 8629
|
2066, 3774
|
9150, 9672
|
1111, 1128
|
7331, 8203
|
8322, 8599
|
7114, 7308
|
8653, 9127
|
1143, 1143
|
1165, 2047
|
326, 351
|
508, 720
|
742, 982
|
1014, 1095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,377
| 176,842
|
14963
|
Discharge summary
|
report
|
Admission Date: [**2146-8-16**] Discharge Date: [**2146-8-23**]
Date of Birth: [**2107-12-30**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
female transferred from an outside hospital for acute liver
failure. Per the patient's family and notes, the patient had
a six week illness associated with nausea and vomiting with a
questionable hematemesis and diarrhea as well as occasional
abdominal pain. This had begun shortly after the patient had
eaten seafood out of the home.
The patient was seen by her primary care physician and her
laboratory studies were presumably normal. At that time, she
was treated with Flagyl. The patient was then found by her
boyfriend on the morning of [**2146-8-16**]. There are
conflicting reports as to whether she was confused and
irritable or unresponsive.
The patient was taken to an outside hospital and found to be
unresponsive. She required intubation, with arterial blood
gases revealing a pH of 7.39 and a CO2 of 26, oxygen 607.
Laboratory data were significant for a white blood cell count
of 16.3 with 93% neutrophils, an ammonia of 274, AST 1,919,
ALT 3,926, prothrombin time 19.7, INR 2.46, partial
thromboplastin time within normal limits, total bilirubin
2.1. Repeat ALT six hours later revealed a value of 2,589,
AST 944, CPK 143, MB 15, MB index 10.4.
At the outside hospital, the patient was given Rocephin,
morphine and Protonix. Nasogastric tube aspirate was notable
for heme positive material. A chest x-ray, KUB, head CT and
CT of the abdomen and pelvis were negative for any
abnormalities. At this time, she was transferred to the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Intensive Care Unit for
further management.
At the time of evaluation, the patient was intubated and
sedated. A history of the etiology of the patient's
unresponsiveness was quite unclear. The patient had not had
any alcohol intake for two years, no history of intravenous
drug use, positive tatoos, occasional Tylenol use.
PAST MEDICAL HISTORY: 1. Depression. 2. Anxiety. 3. Low
back pain.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Effexor and Xanax; intrauterine
pregnancy in place.
FAMILY HISTORY: There is no family history of liver disease,
positive history of deep vein thrombosis and pulmonary
embolus.
SOCIAL HISTORY: The patient smokes. She currently lives
with her boyfriend and two children.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 100.7, pulse 130s, blood pressure
137/68. Patient intubated and sedated. No evidence of
scleral icterus, no spider angiomata. Pulmonary: Clear to
auscultation anteriorly. Cardiovascular: Tachycardia.
Abdomen: Hepatomegaly, no splenic tip palpable, no
appreciable fluid wave. Head, eyes, ears, nose and throat:
Large pupils, 7.5 mm bilaterally, equal, round and responsive
to light, however, pupils did deviate to the left.
LABORATORY DATA: Admission white blood cell count was 12,
hematocrit 33.4, platelet count 274,000, differential with
89% neutrophils, 4% lymphocytes, 1% monocytes, 1% atypicals
with evidence of hypersegmented nucleated cells, occasional
teardrops, 1+ target cells, 2+ anisocytosis on smear,
prothrombin time 18.8, INR 2.5, partial thromboplastin time
30.7, sodium 149, potassium 3.1, chloride 118, bicarbonate
18, BUN 25, creatinine 0.5, glucose 193, anion gap 13,
calcium 9.7, phosphorous 0.3, magnesium 2.6, ALT 2,327, AST
756, LD 325, CK 84, alkaline phosphatase 208, albumin 3.3,
amylase 135, lipase 548, total 3.5, troponin 0.6, CPK 84.
Urinalysis revealed trace leukocyte esterase, positive
nitrites with 3 white blood cells, trace blood, 2 red blood
cells, trace protein, 15 ketones. Urine toxicology screen
was positive for benzodiazepines and positive for opiates.
Serum toxicology screen was negative. Arterial blood gases
revealed a pH of 7.5, pO2 327, pCO2 25, oxygen saturation 99.
Right upper quadrant ultrasound revealed normal flow in the
portal vein, hepatic vein and hepatic arteries with normal
liver parenchyma.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit. An electroencephalogram revealed wide
spread encephalopathy in the cortical and subcortial regions.
The patient was given a three to four day course of
n-acetylcysteine for a presumed Tylenol ingestion per family,
as the patient was taking this medication for abdominal pain.
The patient had an ICP monitor placed by the neurosurgical
service to monitor intracranial pressure. The patient was
treated with lactulose for hepatic encephalopathy. The
patient was evaluated by the transplant surgery team for
possible liver transplant, and was added to the liver
transplant list.
On the second day of admission, the patient was placed on
ceftazidime and vancomycin for infectious disease prophylaxis
as she had a persistently elevated white blood cell count as
well as a fever but no identifiable source. An ethics
consult was obtained regarding performing HIV testing for
possible liver transplantation.
The patient did quite well in the Medical Intensive Care
Unit. She received supportive care with proton pump
inhibitor, electrolyte support, blood transfusion, mechanical
ventilation and antibiotics. The the patient liver function
tests continued to trend downward.
The patient was transferred to the medicine service on [**2146-8-20**] after her liver function tests had trended downward.
She had significantly improved encephalopathy. The patient
had been extubated. She did, however, remain with an
elevated white blood cell count of 22.8 and a mild low grade
fever.
The patient was seen by psychiatry, who deemed that she was
not an immediate risk to herself. Further history elicited
possible Tylenol # or Tylenol P.M. ingestion by patient,
however, she did not appear to have any depressed mood. She
does have an outpatient psychiatrist for a history of
"chemical depression".
The patient had an esophagogastroduodenoscopy which showed
esophagitis, multiple small antral ulcers and mild
duodenitis. Her overall condition improved dramatically and
the patient was eventually discharged to home with follow-up
with her primary care physician as well as the Liver Clinic.
CONDITION AT DISCHARGE: Quite stable.
FOLLOW-UP: The patient needs to have scalp sutures removed
from her neurosurgical procedure. She will see her primary
care physician on [**Name9 (PRE) 766**], [**2146-8-29**].
DISCHARGE MEDICATIONS:
Protonix 40 mg p.o.q.d.
Once she leaves the hospital, the patient will be living at
her mother-in-law's house. She appears to have a good social
support system. Her husband and children will also be living
with her. Ultimately, it was thought that Tylenol ingestion,
unintentionally, as well as possible Kava supplement
ingestion chronically led to fulminate hepatic failure, with
resolution with supportive treatment and n-acetylcysteine.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2146-9-15**] 18:06
T: [**2146-9-21**] 15:37
JOB#: [**Job Number 43810**]
|
[
"570",
"530.11",
"276.0",
"577.0",
"518.81",
"E850.4",
"965.4",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.04",
"96.71",
"38.93",
"01.18"
] |
icd9pcs
|
[
[
[]
]
] |
2330, 2440
|
6602, 7307
|
2260, 2313
|
4204, 6370
|
2559, 4186
|
6385, 6579
|
167, 2105
|
2128, 2233
|
2457, 2536
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,225
| 187,093
|
4296
|
Discharge summary
|
report
|
Admission Date: [**2171-5-6**] Discharge Date: [**2171-5-8**]
Date of Birth: [**2147-8-13**] Sex: F
Service: [**Hospital1 212**]
CHIEF COMPLAINT: Hypoxia, hemoptysis, fever.
HISTORY OF PRESENT ILLNESS: This is a 23 year old woman with
SLE, lupus nephritis, end stage renal disease on
hemodialysis, warm antibody hemolytic anemia on 50 mg of
prednisone times one month who was in her usual state of
health until Friday, [**2171-5-3**], when she developed a cough.
She was otherwise well and was able to undergo all her normal
weekend activities until the morning of [**5-6**] when she
developed fever, chills, a few teaspoons of hemoptysis and
right upper quadrant pain. She was brought to the emergency
room where she had sats of 82% in room air which then
improved to 97% on 4 liters. She has respiratory rate in the
50s and T-max up to 102. She was given ceftriaxone,
Lopressor 25 and Tylenol. Right upper quadrant and shortness
of breath improved.
PAST MEDICAL HISTORY: Notable for SLE which was diagnosed in
3/97 and treated with prednisone, .................... and
cyclophosphamide. Warm antibody hemolytic anemia diagnosed
in [**4-9**] on prednisone taper initially of 60 mg times one
month, now on 50 mg. End stage renal disease on hemodialysis
since [**2166**]. Pneumococcal sepsis in 10/97 status post
intubation. Sickle cell trait. Status post VSD repair in
3/97. Status post LSO secondary to [**Last Name (un) **] in 1/97. History of
C.diff. Hypertension.
ALLERGIES: Demerol from which she gets angioedema.
Vancomycin.
MEDICATIONS: Include prednisone 50 mg q.d., Nephrocaps one
tab q.d., Rocaltrol, Epogen 15,000 units IV Monday,
Wednesday, Friday at hemodialysis, Procardia XL 60 mg q.d.,
Prilosec 20 mg p.o. q.d., Tums 1 gm p.o. t.i.d. with meals,
InFeD 50 mg IV q.Wednesday at hemodialysis.
PHYSICAL EXAMINATION: On [**5-7**] on transfer to the medical
service vitals were temperature of 99.1, heart rate 110,
respiratory rate 20, blood pressure 140/100, O2 96% in room
air. Generally she was comfortable looking, cushingoid
facies. HEENT: throat was clear, no erythema. Moist mucous
membranes. No cervical or inguinal lymphadenopathy. CV
tachycardic, normal S1, S2, no murmur. Pulmonary: rales
bilaterally half way up, no egophony, positive dullness at
right base. Abdomen was soft, slightly tender in the right
upper quadrant with deep palpation, positive bowel sounds.
Extremities had no edema or rash.
LABORATORY DATA: Notable for white count of 18.4, hemoglobin
12.0, hematocrit 39.3, platelets 56. Differential showed 77
neutrophils, 1 band, 15 lymphocytes, 5 monos, 2 eosinophils.
Sodium was 138, potassium 5.7 with repeat of 5.3, chloride
102, CO2 19, BUN 39, creatinine 8.9, glucose 109. ALT was
232, AST 96, alka phos 93, lipase 25, total bili 0.03.
Legionella antigen was negative. Sputum showed greater than
25 polys, 3+ gram positive cocci, 3+ gram negative rods.
Chest x-ray showed right lower lobe dense infiltrate with
small effusion. Abdominal ultrasound showed liver diffusely
hypoechoic, focal echogenicity relative around the portal
triad in a starry [**Hospital Ward Name **] pattern, no focal mass, no intrahepatic
biliary ductal dilatation. Common bile duct measured 4.
Gallbladder was abnormal with thickened wall and edematous.
No fluid collection. Impression was hepatitis.
HOSPITAL COURSE: The patient was initially admitted to the
MICU where she did well overnight. Her O2 was weaned and in
the a.m. on [**5-7**] she was sating 96% in room air. On [**5-7**]
a.m. she was transferred to the medical floor at which time
she continued to improve on levofloxacin 250 mg. She
received the first dose of levofloxacin on [**5-6**]. She
received the second dose of 250 mg on [**5-7**] and because of
hemodialysis, the next dose was scheduled for [**5-9**].
By the morning of [**5-8**] the patient was well appearing, sating
97% in room air, eating well. The right upper quadrant pain
had largely resolved. The patient only complained of mild
tenderness on deep palpation. Transaminases began trending
down. ALT dropped to 170, AST to 46. Blood cultures were
pending at the time of discharge. Urine culture was
negative. The patient was discharged home on [**5-8**] after
hemodialysis with plans to follow up with Dr. [**Last Name (STitle) **] on [**5-14**].
Issues at time of discharge included (1) community acquired
pneumonia. Plan is for the patient to finish a 14 day course
of levofloxacin. (2) Cardiac issues. The patient was
stable. Blood pressure was adequately controlled on
Procardia XL. Tachycardia resolved and was likely secondary
to infection. EKG on admission showed no changes. (3) GI.
The patient was tolerating full diet with no complaints of
abdominal pain. Dr. [**Last Name (STitle) **] will follow up the patient's
transaminases as an outpatient. Hepatitis serologies for
hepatitis A and C were ordered and will be followed up by
Dr. [**Last Name (STitle) **]. (4) Hematology. Anemia of mixed etiology warm
antibody hemolytic anemia and anemia secondary to chronic
disease followed by Dr. [**Last Name (STitle) **]. The patient will continue to
take iron, Epogen and prednisone.
The patient was discharged in stable condition. The patient
was discharged home.
DISCHARGE DIAGNOSIS: Community acquired pneumonia.
[**Doctor First Name 306**] C- [**Name8 (MD) 308**], M.D. [**MD Number(1) 11871**]
Dictated By:[**Doctor Last Name 18598**]
MEDQUIST36
D: [**2171-5-8**] 22:34
T: [**2171-5-10**] 15:24
JOB#: [**Job Number 18599**]
|
[
"401.9",
"285.21",
"582.81",
"710.0",
"481",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5323, 5604
|
3389, 5301
|
1868, 3371
|
164, 193
|
222, 976
|
999, 1845
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,195
| 109,365
|
20275
|
Discharge summary
|
report
|
Admission Date: [**2161-8-27**] Discharge Date: [**2161-9-4**]
Date of Birth: Sex:
Service:
DIAGNOSIS: Metastatic carcinoma and respiratory failure.
HISTORY OF PRESENT ILLNESS: The patient is a delightful 73-
year-old gentleman who was diagnosed with metastatic squamous
cell carcinoma of the lung. He underwent chemoradiotherapy
with his final doses of chemotherapy being 2 to 3 weeks prior
to admission. He subsequently developed dyspnea and was
treated with steroids. He continued to have respiratory
deterioration requiring intubation, and was transferred from
[**Hospital 1562**] Hospital in complete respiratory failure on a
mechanical ventilator. He was transferred for the purposes
of a lung biopsy to determine the etiology and define further
treatment.
HOSPITAL COURSE: The patient was taken to the operating room
and underwent an open lung biopsy. The pathology was
consistent with organizing pneumonia, acute lung injury, and
pulmonary embolisms. The patient continued to do poorly,
and he was made comfort measures. he died on [**2161-9-4**].
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern4) 54269**]
MEDQUIST36
D: [**2162-2-18**] 17:03:27
T: [**2162-2-19**] 11:10:35
Job#: [**Job Number 54435**]
|
[
"518.82",
"459.2",
"V15.82",
"401.9",
"V10.46",
"V15.3",
"780.6",
"515",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.28",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
819, 1372
|
210, 801
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,801
| 125,317
|
46238
|
Discharge summary
|
report
|
Admission Date: [**2102-3-10**] Discharge Date: [**2102-3-28**]
Date of Birth: [**2036-7-29**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
female with a history of bipolar disorder, ovarian carcinoma
and hyponatremia who presents complaining of one month of
hemoptysis with blood-streaked sputum, abdominal pain,
shortness of breath and dyspnea on exertion. The patient
states that she has some abdominal bloating and mild right
lower quadrant pain. She also notes some blood-streaked
sputum with clots for the past month which is small volume.
The patient notes weakness, occasional back pain, occasional
headache, no fevers or chills, no dysuria, no rash, no
jaundice, no bilateral lower extremity edema.
In the Emergency Department the patient was found to have a
temperature of 100, pulse 114, blood pressure 163/92,
respiratory rate 18, saturating 96% on room air. She had a
chest x-ray that was significant for compression of the right
lower lobe bronchus and multiple diffuse pulmonary nodules.
She had a KUB which showed no evidence of small bowel
obstruction. She also had an abdominal CT which was
significant for a subacute liver hematoma which was 6 x 10 cm
in size. The patient also had a chest CT which showed
multiple pulmonary nodules and a small right-sided pleural
effusion.
The patient was seen by the surgical consultation service who
stated that there was no role for immediate intervention of
the liver hematoma at this time.
MEDICATIONS ON ADMISSION: 1. Tylenol [**1-12**] p.o. q. 4 hours
p.r.n. pain. 2. Loxapine 25 mg p.o. q.h.s. 3. Risperdal 1
mg p.o. q.h.s.
ALLERGIES: Prolixin, Stelazine, Flonase, Ativan, Dimetapp,
Trilafon, lithium, aspirin, Persantine, Relafen, ranitidine,
Prilosec, Procardia, strawberries, Sudafed, tofu.
PAST MEDICAL HISTORY: 1. Bipolar disorder, question of
history of schizoaffective disorder on loxapine and
Risperdal. 2. Ovarian carcinoma status post total abdominal
hysterectomy and bilateral salpingo-oophorectomy in [**2096**] and
status post chemotherapy. Low anterior resection of the
rectosigmoid. Excision of cul-de-sac and completion
hysterectomy with partial vaginectomy. 3. Bright red blood
per rectum with diverticulosis status post low anterior
resection. 4. History of prolonged QT syndrome in the past
secondary to Mellaril. 5. Onychodystrophy of toenails. 6.
Hyponatremia in the past secondary to increased fluid intake,
however the patient has had low sodium in the past without
any symptoms.
FAMILY HISTORY: Uncle with some sort of cancer which is
unknown.
SOCIAL HISTORY: The patient lives alone, is divorced and has
a restraining order out on her ex-husband. She denies any
history of alcohol or tobacco use.
PHYSICAL EXAMINATION: Weight 199.2 pounds, temperature 99.8,
pulse 112, blood pressure 138/76, respiratory rate 28, pulse
oximetry 95% on room air. General: Sleepy, confused,
disheveled female in no apparent distress. Neck: No
lymphadenopathy. HEENT: Moist mucous membranes, oropharynx
clear. Cardiovascular: Normal S1 and S2, regular rate and
rhythm, no murmurs, gallops, or rubs. Pulmonary: Clear to
auscultation bilaterally, poor respiratory effort. Abdomen:
Positive bowel sounds, soft, nondistended, mild right upper
quadrant and right lower quadrant tenderness, obese.
Extremities: Nonpitting edema, obese, good pulses.
LABORATORY DATA: At the time of admission her white blood
cell count was 20, hematocrit 30 (down from 42 in [**2102-2-11**]), platelet count 291, MCV 85, sodium 119, potassium 4.5,
chloride 81, bicarbonate 21, BUN 15, creatinine 0.7, glucose
139, urine osmolality 544, urine sodium less than 10.
Differential on the white blood cell count showed neutrophils
89%, lymphocytes 6.8%, monocytes 4.4%, eosinophils 0.1%.
EKG: Normal sinus rhythm, rate of 100, QTC 414, right bundle
branch block, slight left axis deviation.
Abdominal CT, chest CT as noted in history of present
illness.
HOSPITAL COURSE: 1. Hyponatremia: Patient with a history of
psychogenic polydipsia in the past, however given that her
urine osmolalities are high, question of syndrome of
inappropriate diuretic hormone secondary to pulmonary
metastases, however low urine sodium also points to potential
prerenal or intravascular volume etiology. The patient was
initially treated with fluid restriction with gradual
improvement of her sodium. It remained within the 125 to 135
range and oscillated with treatment with intravenous fluids
and p.o. status for multiple procedures. The patient was
asymptomatic and seemed to maintain a sodium between 125 and
135. No further aggressive treatment of the hyponatremia was
continued. The patient had her urine sodium and osmolality
checked on multiple occasions and her urine sodium was
usually low and urine osmolalities were usually high.
2. Shortness of breath: The patient was intermittently
treated with oxygen via nasal cannula and maintained oxygen
saturations greater than 92% during her hospital course. The
etiology of her shortness of breath was likely secondary to a
combination of her liver hematoma and abdominal extension and
obesity causing elevation of her diaphragm and subjective
shortness of breath as well as her diffuse pulmonary nodules.
The patient also had a small right-sided pleural effusion
which then increased in size and formed a right
hydropneumothorax. The patient initially had a bronchoscopy
by the interventional pulmonary service, however the biopsy
results showed scant fragment sof bronchial mucosa and
alveolated parenchyma without evidence of malignancy.
However this biopsy seemed to be insufficient for diagnosis.
The patient was seen by the CT surgery service and eventually
had a video-assisted thoracoscopic procedure with drainage of
a right hydropneumothorax, pleurodesis, pulmonary biopsy and
two chest tubes that were placed. The procedure was
uncomplicated. The patient had good resolution of her
shortness of breath secondary to drainage of the fluid. The
patient had her chest tubes pulled on [**2102-3-25**] and
chest x-ray showed no evidence of pneumothorax or residual
fluid.
Preliminary results of the pulmonary biopsy revealed a
carcinoma that was likely not pulmonary in etiology and it
was likely metastatic from her ovarian cancer. This was per
a preliminary discussion with the pathologist who had
reviewed some of her prior biopsy results. However, full
report is still pending at the time of dictation.
3. Pneumonia: On the patient's initial chest x-ray and chest
CT the patient had a question of a right lower lobe collapse
versus consolidation. She was initially treated with a
five-day course of azithromycin (patient has a history of
prolonged QT and we did not want to use levofloxacin). The
patient had multiple sputum Gram stains which were possibly
contaminated with oral flora and which did not grow out any
specific pathogens. Her pleural fluid Gram stain and culture
were also negative. However, given the development of right
hydropneumothorax it is possible that the patient redeveloped
consolidation of the right lower lobe and thus she was
treated with intravenous Zosyn for a full seven-day course.
4. Hemoptysis: The patient had persistent small amounts of
blood-streaked sputum at the beginning of her hospital
course. This gradually disappeared for some time and
recurred around [**2102-3-27**] with small amounts of
recurrent hemoptysis. This was clearly thought to be
secondary to her known diffuse metastatic pulmonary nodules.
5. Liver hematoma: The patient's abdominal pain was
secondary to her known liver hematoma. She was followed by
the surgery service. She had a benign abdominal examination
with only minimal amounts of right upper and right lower
quadrant tenderness. The patient had a repeat abdominal CT
on [**2102-3-15**] which showed that the patient was actively
bleeding from her hematoma into her peritoneum. The patient
was treated with supportive blood transfusions and was kept
on strict bedrest for this. Of note, the patient did slip
and fall which may have contributed to the rupture of the
acute liver hematoma. The patient did quite well from this
perspective and had no further acute abdominal pain and had a
stable hematocrit. She received a total of eight units of
packed red blood cells for the fall in her hematocrit. The
patient subsequently did not need blood after [**2102-3-16**]
and the surgery service signed off.
6. Bipolar disorder: The patient was continued on her home
dose of loxapine and Risperdal with no complications.
7. Infectious disease: The patient initially grew out one
out of four bottles of Gram positive cocci and a second set
of one out of two bottles of Gram positive cocci, found to be
coagulase negative staphylococcus and question of Port-a-Cath
infection. The infectious disease service and surgery
services were consulted for question of potential removal of
the Port-a-Cath if indeed it was infected. However,
subsequent blood cultures remained negative that were drawn
from the Port-a-Cath and the patient was treated with
intravenous vancomycin. Her Port-a-Cath remained in place
with no further complications.
8. Gradually increasing white blood cell count: The patient
initially had a gradual decrease in her white blood cell
count on the azithromycin, however her white blood cell count
started to rise and was 22 on [**3-16**], gradually increasing
to a maximum of 45 on [**2102-3-23**]. There was concern for
potential C. difficile infection even though the patient was
not having diarrhea or any loose stools at that time. The
patient was started on Flagyl 500 mg p.o. t.i.d. and will
complete a full 14-day course of this medication. She did
have one stool for C. difficile which was sent subsequent to
the initiation of antibiotics, which was negative for C.
difficile. However given that the patient had improvement in
the white blood cell count on Flagyl, however was
concomitantly on Zosyn, it is unclear which antibiotic was
contributing to her decreasing white blood cell count and the
decision was made with consultation of the infectious disease
service, to continue full courses of both the Zosyn and the
Flagyl.
9. Acute renal failure: The patient had a stable creatinine
throughout her hospital course however subsequent to her
video-assisted thoracoscopic procedure and subsequent to
being n.p.o. for several days and on fluid restriction, the
patient had an elevated creatinine of 1.6, was found to be
prerenal. As the patient was intravascularly volume depleted
the patient was treated with intravenous fluid hydration and
eventually her creatinine improved to 1.0 which is her
baseline. After fluids the etiology was felt to be prerenal.
10. Oncology: Discussion with the patient's family was had
regarding preliminary biopsy results. Previously discussion
was had with Dr. [**Last Name (STitle) **] regarding plan of care. If
pulmonary biopsy result returned as ovarian carcinoma plans
for outpatient chemotherapy with carboplatin would be
initiated. If pulmonary biopsy revealed secondary primary
metastatic cancer the patient would likely be made comfort
care.
Preliminary biopsy results returned as ovarian carcinoma.
This was conveyed to Dr. [**Last Name (STitle) 3274**] who was covering for Dr.
[**Last Name (STitle) **]. Appointment was made with Dr. [**Last Name (STitle) **] for
Monday, [**4-3**] at 10 AM for the patient to discuss these
findings with Dr. [**Last Name (STitle) **] and to consider outpatient
chemotherapy. The patient was agreeable to this.
The patient is being screened for placement to skilled
nursing facility/rehabilitation facility and will likely be
discharged to a facility with outpatient chemotherapy.
The patient was deconditioned at the time of discharge and
will need physical therapy for rehabilitation.
CONDITION ON DISCHARGE: Fair, deconditioned, needs physical
therapy.
DISCHARGE MEDICATIONS:
1. Tylenol p.o. p.r.n.
2. Miconazole powder t.i.d. p.r.n.
3. Risperdal 1 mg p.o. q.h.s.
4. Loxapine succinate 25 mg p.o. q.h.s.
5. Flagyl 500 mg p.o. t.i.d. for a full 14-day course.
6. Colace 100 mg p.o. b.i.d.
7. Senna 2 tablets p.o. b.i.d. p.r.n.
8. Dulcolax 10 mg p.o. or p.r. q. day p.r.n.
DISCHARGE DIAGNOSES:
1. Metastatic ovarian carcinoma.
2. Right hydropneumothorax.
3. Right lower lobe pneumonia.
4. Liver hematoma.
5. Hyponatremia.
6. Coagulase-negative staphylococcus bacteremia.
7. Bipolar disorder.
8. Acute renal failure with resolution.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2102-3-28**] 11:19
T: [**2102-3-28**] 11:41
JOB#: [**Job Number 98303**]
cc:[**Last Name (NamePattern1) 48222**]
|
[
"790.7",
"197.0",
"568.81",
"584.9",
"486",
"285.1",
"276.1",
"197.2",
"295.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.21",
"34.92",
"33.28",
"33.27",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
2562, 2612
|
12315, 12826
|
11998, 12294
|
1541, 1827
|
4013, 11904
|
2792, 3995
|
167, 1514
|
1850, 2545
|
2629, 2769
|
11929, 11975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,568
| 143,687
|
52101
|
Discharge summary
|
report
|
Admission Date: [**2191-7-12**] Discharge Date: [**2191-7-19**]
Date of Birth: [**2117-8-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Known abdominal and bilateral common
iliac artery aneurysms.
Major Surgical or Invasive Procedure:
Resection and repair of aneurysm with 20 x 10
bifurcated Dacron aortobi-iliac graft [**2191-7-12**]
History of Present Illness:
This 73-year-old gentleman has been followed
some time with abdominal and bilateral common iliac artery
aneurysms. His aorta is 5.2 cm but his right common iliac is
6.4 cm and his left common iliac is 2.8 cm. He was advised to
have aortobi-iliac repair to prevent possible rupture.
Past Medical History:
# RCA Stent [**2188**]
# AAA (5.3cm aneurysm of distal infrarenal aorta)
# R Common Iliac Aneurysm (6.2cm), L Common Iliac (3.2cm)
# R Lobectomy for lung CA [**2188**]
# HTN
# Appendectomy
# Herniorrhaphy
# Tonsilectomy
# R Rotator cuff repair
Social History:
Social history is significant for quitting smoking 6 years ago.
Pt drinks 2-3 per month. Works as a sports announcer for the
[**Location (un) 86**] Celtics.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His father had an MI in his late 60's. Mother
had CABG at age 81.
Physical Exam:
VS T 97 P 56 BP 156/85 97% 3LNC
Gen: AAOx3, NAD
HENT: wnl
Lungs: CTA b/l
Heart: RRR
Abd: soft, non-tender
Ext:
Pulses: Fem DP PT
Rt 2+ 2+ 2+
Lt 2+ 2+ 2+
Pertinent Results:
[**2191-7-17**] 07:30AM BLOOD WBC-9.2 RBC-3.91* Hgb-11.2* Hct-33.7*
MCV-86 MCH-28.6 MCHC-33.2 RDW-15.2 Plt Ct-350
[**2191-7-16**] 05:05AM BLOOD WBC-9.9 RBC-3.88* Hgb-11.2* Hct-33.3*
MCV-86 MCH-28.9 MCHC-33.7 RDW-15.2 Plt Ct-307
[**2191-7-15**] 05:04AM BLOOD WBC-7.0 RBC-3.79* Hgb-11.2* Hct-32.4*
MCV-86 MCH-29.5 MCHC-34.5 RDW-14.8 Plt Ct-243
[**2191-7-17**] 07:30AM BLOOD Plt Ct-350
[**2191-7-16**] 05:05AM BLOOD Plt Ct-307
[**2191-7-15**] 05:04AM BLOOD Plt Ct-243
[**2191-7-17**] 07:30AM BLOOD Glucose-119* UreaN-31* Creat-1.2 Na-144
K-3.4 Cl-112* HCO3-21* AnGap-14
[**2191-7-16**] 05:05AM BLOOD Glucose-138* UreaN-27* Creat-1.2 Na-143
K-3.3 Cl-109* HCO3-22 AnGap-15
[**2191-7-15**] 05:04AM BLOOD Glucose-140* UreaN-22* Creat-1.4* Na-140
K-3.7 Cl-107 HCO3-22 AnGap-15
[**2191-7-14**] 09:04PM BLOOD Glucose-146* UreaN-22* Creat-1.4* Na-140
K-3.7 Cl-107 HCO3-23 AnGap-14
[**2191-7-15**] 05:04AM BLOOD CK(CPK)-1653*
[**2191-7-14**] 01:36PM BLOOD CK(CPK)-927*
[**2191-7-15**] 05:04AM BLOOD CK-MB-10 MB Indx-0.6 cTropnT-0.04*
[**2191-7-14**] 09:04PM BLOOD CK-MB-8 cTropnT-0.03*
[**2191-7-14**] 01:36PM BLOOD CK-MB-7 cTropnT-0.03*
[**2191-7-17**] 07:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3
[**2191-7-16**] 05:05AM BLOOD Calcium-8.6 Phos-3.7# Mg-2.2
ECG Study Date of [**2191-7-14**] 11:16:16 AM
Sinus rhythm. Intraventricular conduction delay. Leftward axis.
Early
R wave transition. Compared to the previous tracing of [**2191-7-7**]
the
findings are similar.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2191-7-14**] 9:18
AM
Final Report
Single AP chest radiograph compared to [**2191-7-12**] shows left
basilar opacity resulting in partial obscuration of the left
hemidiaphragm, which is most compatible with a lower lobe
pneumonia. Lateral radiograph would be helpful. The right lung
is clear. The cardiomediastinal contour is probably within
normal limits. The left hemidiaphragm remains slightly elevated.
Right IJ vascular sheath terminates just proximal to the
confluence of the brachiocephalic vein and SVC.
IMPRESSION: Left basilar opacity, most compatible with left
lower lobe
pneumonia. Lateral radiograph would be helpful.
The study and the report were reviewed by the staff radiologist.
ECG Study Date of [**2191-7-15**] 10:40:48 AM
Sinus rhythm. Compared to tracing #1 the findings are similar.
Brief Hospital Course:
This 73-year-old gentleman who comes in today for admission for
scheduled surgery for repair of a known abdominal and bilateral
common iliac artery aneurysms.
[**2191-7-12**] Patient is admitted via holding room to Vascular
Surgery/Dr. [**Last Name (STitle) **] service, taken to OR and underwent a
successful Resection and repair of aneurysm with 20 x 10
bifurcated Dacron aortobi-iliac graft, was transfused with 2
units PRBc's intra-op. Patient recovered in CVICU overnight.
Patient was had a PA line for hemidynamic monitoring, placed on
Nitro gtt and Lopressor IV for BP and HR control.
[**2191-7-13**] Ptaient was hymodynamically stable transferred to [**Hospital Ward Name 121**] 5
VICU. Nitro gtt was d/c'd. NG tube was also d/c'd and started
with sips.
[**2191-7-14**] VSS. Patient had episodes of confusion was placed on 1:1
observation.Psych consulted, thought to have Delirium secondary
to multiple factors-recommeded Haldo and trial of Zyprexa. Nitro
gtt re-started for hypertension. Autodiuresing, foley d/c'd.
Pre-op UA came back positive for UTI started on Cipro.
Cardiology consulted for BP control recommeded IV metoprolol.
[**2191-7-15**] Patient remains disoriented/agitated, requiring
sedation. A-line d/c'd. Nitro gtt off, started Hydralazine IV
for BP control. Now on PO Lopressor.
[**2191-7-16**] Agitation resolving mostly alert and oriented, tapered
sedation. BP control still an issue still getting IV
Hyadralazine, Cardiology recommended Norvasc. Patient out of
bed.
[**2191-7-17**] Patient is still mildly hypertensive BP
140's-150's/80-90. AAOx3 and appropraite.
[**2191-7-18**] VSS overnight, discharged to home in good condition.
[**2191-7-18**] Blood pressure was still an issue overnight, patient
recieved Hydralazine IV prn. Cardiology recommended at add
Lisinopril.
[**2191-7-19**] BP more stable. Cardiology recommended to d/c Lisinopril
and start Hydrochlorthiazide. Patient d/c'd on Metoprolol,
Norvasc and Hydrochlorthiazide, FU set with PCP.
Medications on Admission:
Allopurinol 300 mg qd
ASA 325 mg qd
Atenolol 100 mg qd
Folate 1 mg qd
Lipitor 20 mg qd
MVI qd
Nexium 40 mg qd
Tricor 145 mg qd
Plavix 75 mg [**Hospital1 **]
Wellbutrin 300 mg qd
Nitroquick 0.3 PRN
Lysine 500mg po qd
Mag 250 mg qd
advair prn
proventil prn
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 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.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Wellbutrin SR 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO once a day.
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lysine 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PVD
Hypercholesterolemia
CAD
arthritis/gout
DM
CRI
lung mass
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**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
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and [**Month/Day (3) **] dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 3121**]
Need to Follow-up in 1 wk for suture/staples removal
Provider:[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 25832**]
Date/Time: [**8-4**], 9:45 AM
Completed by:[**2191-7-26**]
|
[
"250.00",
"401.9",
"E939.3",
"V10.11",
"441.4",
"292.81",
"272.0",
"585.9",
"599.0",
"244.9",
"442.2",
"E939.2",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.46",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
7562, 7620
|
3902, 5894
|
333, 435
|
7725, 7732
|
1549, 3879
|
10592, 10922
|
1206, 1355
|
6199, 7539
|
7641, 7704
|
5920, 6176
|
7756, 10159
|
10185, 10569
|
1370, 1530
|
232, 295
|
463, 747
|
769, 1015
|
1031, 1190
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,157
| 107,489
|
41178+58426
|
Discharge summary
|
report+addendum
|
Admission Date: [**2109-3-6**] Discharge Date: [**2109-3-19**]
Date of Birth: [**2041-12-10**] Sex: F
Service: NEUROLOGY
Allergies:
Latex
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Called by emergency department to
evaluate difficulty breathing in the patient with myasthenia
[**Last Name (un) 2902**].
Major Surgical or Invasive Procedure:
Intubation
Placement of a pheresis line with four sessions of
plasmapheresis
History of Present Illness:
The patient is a 67-year-old
right-handed woman with a past medical history significant for
myasthenia [**Last Name (un) 2902**], diabetes, hypertension, hyperlipidemia, who
is
presenting with four days of worsening dysarthria, dysphagia,
and
respiratory difficulty concerning for a myasthenic crisis.
The patient first noted mild symptoms of difficulty breathing on
Friday night. She reports that this was very mild sensation
that
she was not able to take a full deep breath; however, it was not
very bad and did not trouble her significantly. The patient
noted the following day what she termed flu-like symptoms, which
she described as aching muscles, mild neck pain and mild joint
pain. She indicated that this sensation lasted for most of the
day. She denies having any fevers or chills. There was no
nausea or vomiting or any other symptoms. She did not have any
rhinorrhea or other symptoms concerning of a viral process. The
patient noted on that day (Saturday) that she was having
increasing difficulty chewing her food. She noted that she was
unable to close her jaw fully and felt that her mouth would hang
open. She needed to use her hand to fully help her close her
jaw. This difficulty with chewing got so bad that she was
unable
to eat solid foods and was eating only pureed foods and milk
shakes. The patient was able to use her lips to suck food from
a
straw; however, believes that this ability decreased over the
course of the next two days.
By Sunday she had significant difficulty swallowing any whole
food. If she swallowed whole food she noticed that she would
need to cough and was concerned that she would choke on it. She
was unable to chew very well at all. The patient on Sunday also
started to notice a worsening of her breathing. She again
describes this as an inability to take full deep breaths. She
felt like she was always out of breath and needed to take many
more smaller breaths. The patient also was complaining of some
mild diplopia predominantly in the afternoon. In addition, she
felt that her speech was slurred and abnormal. She felt she was
having difficulty moving her mouth to make the sounds as well as
difficulty with sounds produced by her tongue and pharynx. The
patient believed that her breathing was slightly improved when
she was sitting up as opposed to lying flat. As these symptoms
progressed, she called her neurologist on Tuesday who based on
the worsening of her symptoms, recommended that she go to her
local emergency department. The patient presented to [**Hospital2 **]
[**Hospital3 **] Emergency Room where they evaluated her and then transferred
her to [**Hospital3 **] for further evaluation.
The patient denies significant cough over the last few days.
She
did note that she had an episode of coughing after she was given
a breathing treatment at [**Hospital3 **] Hospital, but does not believe
that there has been any difficulty with coughing during these
last four days. She does have an occasional cough, which she
attributes to long history of smoking, but this is not a daily
event. The patient denies any change in her medication. She
has
been taking her Mestinon reliably; she has been taking it
approximately four to five times a day. She has not recently
changed her dose. The patient denies any recent medication
change of any type. She did not believe she was started on any
antibiotics recently. The patient has had no recent surgeries
or
other particular life stressors.
The patient reports that her myasthenia was diagnosed
approximately two years ago. The symptoms that she noted at the
time of diagnosis was double vision and which worsened in the
afternoon as well as muscle weakness in both her arms and legs
which additionally worsened in the afternoon. She notes that
she
is very good after a night's sleep and reports that she is very
active and energetic in the morning; however, this abates by
early afternoon. The patient is not completely clear of the
workup, she got the diagnosis of myasthenia, but she does
remember getting a multiple blood tests as well as an EMG and
she
has been started on Mestinon for at least two years now. She
did
not remember if she had a trial of steroids but did not believe
so during this interview. The patient reports that she is
well-controlled on Mestinon usually. She will get tired and
feel
fatigued before the next dose; however, the dose usually kicks
in
about 15 minutes and relieves most of her symptoms. She reports
that she will occasionally have diplopia when the dose wears
off.
She has never had a crisis requiring intubation in the past.
She has never had any difficulty with breathing or other
respiratory problems such as asthma.
On neuro ROS, the pt denies headache, loss of vision, she
reports
diplopia, dysarthria, dysphagia. She denies lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. Denies difficulty with gait - but
gets
tired easily
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Reports
very rare cough, significant shortness of breath. Denies chest
pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies rash. She did
have
arthralgias and myalgias last Saturday.
Past Medical History:
- MG - diagnosed about 3 years ago with body weakness, diplopia,
dysarthria, has only been on Mestinon 60 mg QID
- DM
- HTN
- HLD
Social History:
Lives at home with a husband but she indicated that
their relationship was strained. The number that she provided is
not in service. She was intubated before we could get a HCP or
next of [**Doctor First Name **]. She is a long term smoker, smoked 1PPD for 50
years, has cut down to 1/4 pack over last few years. No etoh,
no
drugs
Family History:
No family history of MG or other neurological
diseases. Some DM in the family.
Physical Exam:
Vitals: T:98.6 P:88 R: 28 on my exam, went to 40 before
intubation BP:167/76 SaO2: 95 on 4L
General: Awake, cooperative, tachypneic, feels out of breath,
She
was able to speak in full sentences initially, but then would
have to take breaths every [**2-8**] words. Using accessory muscles,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: mild expiratory wheezes througout
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**2-7**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Has diplopia on upgaze
after 5 seconds.
V: Facial sensation intact to light touch. Has jaw weakness on
opening jaw, unable to fully close jaw against gravity
VII: No facial droop, mild ptosis of right eyelid, facial
musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. Has difficulty with
lingual and palatal sounds
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Can count to 20 on one breath initially
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5- 5- 5- 5- 5 5 5- 5 5 5 5
R 5- 5- 5- 5- 5 5 5- 5 5 5 5
on 10 pumps of deltoid she fatigues to a 4.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
Admission Labs:
Blood:
[**2109-3-6**] 07:25PM BLOOD WBC-13.7* RBC-4.71 Hgb-14.6 Hct-42.7
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.9 Plt Ct-272
[**2109-3-6**] 07:25PM BLOOD Neuts-81.8* Lymphs-10.7* Monos-5.9
Eos-1.1 Baso-0.5
[**2109-3-7**] 02:30AM BLOOD PT-12.8 PTT-22.3 INR(PT)-1.1
[**2109-3-12**] 12:55PM BLOOD Fibrino-412*
[**2109-3-6**] 07:25PM BLOOD Glucose-131* UreaN-15 Creat-0.7 Na-142
K-3.8 Cl-103 HCO3-27 AnGap-16
[**2109-3-6**] 07:25PM BLOOD ALT-18 AST-17 AlkPhos-80 TotBili-0.3
[**2109-3-6**] 07:25PM BLOOD Albumin-4.6 Calcium-9.4 Phos-4.0 Mg-2.2
[**2109-3-7**] 02:30AM BLOOD TSH-2.3
[**2109-3-6**] 07:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2109-3-6**] 10:42PM BLOOD freeCa-1.23
Urine:
[**2109-3-6**] 07:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2109-3-6**] 07:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2109-3-6**] 07:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2109-3-6**] 10:07PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2109-3-11**] 05:15AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.026
[**2109-3-11**] 05:15AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-8.5* Leuks-LG
[**2109-3-11**] 05:15AM URINE RBC-69* WBC-497* Bacteri-MOD Yeast-NONE
Epi-0
Cultures:
[**2109-3-11**] URINE URINE CULTURE-FINAL {PROTEUS
MIRABILIS, ENTEROCOCCUS SP.} INPATIENT
[**2109-3-8**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL INPATIENT
[**2109-3-6**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2109-3-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2109-3-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Chest X-Ray [**3-13**]
IMPRESSION: AP chest compared to [**3-9**] through 5:
Generalized infiltrative pulmonary abnormality which developed
after [**3-10**] has improved, probably edema either cardiac or
related to drug or blood product administration. Small left
pleural effusion is unchanged and small right pleural effusion
is presumed although not imaged directly. Heart size is normal.
ET tube is in standard placement, nasogastric tube passes below
the diaphragm and out of view, and a right internal jugular line
ends in the upper SVC. No pneumothorax.
Brief Hospital Course:
Mrs. [**Known lastname **] was diagnosed with myasthenia [**Last Name (un) 2902**] as described
above. She had been maintained on Mestinon alone, without prior
immunosuppression or steroid treatment. This time she presented
with severe respiratory compromise, resulting in NIF's less than
-20. She was intubated and maintained on ventilator CPAP support
while plasmapheresis treatment was conducted. She underwent four
sessions of pheresis with clear improvement in strength on
clinical examination and NIF, allowing eventual extubation on
[**2109-3-13**]. Cellcept was started at 500 mg [**Hospital1 **] and Mestinon
restarted at 30 mg QID (half her home dose). The fifth planned
session of plasmapheresis was cancelled. When extubated and
stable she was transferred to the floor service.
While in the ICU, she also developed a UTI with proteus
mirabilis, initially intended as a three day course of
ciprofloxacin. This was changed to Bactrim on [**2109-3-14**], and she
should continue this through [**2109-3-20**].
Given Cellcept, weekly CBC will be necessary.
Dyslipidemia - Low dose statin was continued.
Medications on Admission:
- ASA 81
- Diovan 160mg qd
- Mestinon 60mg QID
- Metformin 500mg [**Hospital1 **]
- Pravastatin 10mg qd
- Lumigan 0.03 % Eye Drops qd qhs
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q6H (every 6 hours) as needed for Headache.
7. Senna Herbal Laxative 12 mg Capsule Sig: One (1) Tablet PO
BID (2 times a day) as needed for constipation.
8. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
twice a day.
9. pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days: Last dose [**2109-3-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
Myasthenia [**Last Name (un) **] flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a myasthenic flare, requiring intubation
and plasma exchange. You improved greatly, and were started on
the immunosuppressant medicine CellCept, which you should
continue. Please continue on this medicine as well as your other
medicines you were taking prior to arrival. Please stop smoking.
Please see your PCP if you need help with this.
Followup Instructions:
Please follow up with your neurologist on the [**Hospital3 **].
Completed by:[**2109-3-16**] Name: [**Known lastname 14204**],[**Known firstname 2803**] [**Doctor Last Name 2062**] Unit No: [**Numeric Identifier 14205**]
Admission Date: [**2109-3-6**] Discharge Date: [**2109-3-19**]
Date of Birth: [**2041-12-10**] Sex: F
Service: NEUROLOGY
Allergies:
Latex
Attending:[**First Name3 (LF) 542**]
Addendum:
Ms. [**Known lastname **] was also started on steroids prior to discharge and
these will be titrated to a goal dose of 60mg daily. This will
provide coverage until the Cellcept begins to be effective in
several months. We also spoke with her primary neurologist Dr.
[**Last Name (STitle) 14206**] and Ms. [**Known lastname **] will follow up with her in the next [**12-9**]
months.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q6H (every 6 hours) as needed for Headache.
7. Senna Herbal Laxative 12 mg Capsule Sig: One (1) Tablet PO
BID (2 times a day) as needed for constipation.
8. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
twice a day.
9. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days: Last dose [**2109-3-20**].
10. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Hospital3 709**] ([**Hospital **]
Hospital of [**Location (un) 776**] and Islands)
Discharge Instructions:
You were admitted with a myasthenic flare, requiring intubation
and plasma exchange. You improved greatly, and were started on
the immunosuppressant medicine CellCept, which you should
continue. You were also started on steroids and the dose will
increase over the next several weeks. Please continue on this
medicine as well as your other medicines you were taking prior
to arrival. Please stop smoking. Please see your PCP if you need
help with this.
Followup Instructions:
Please follow up with your neurologist on the [**Hospital3 413**] in [**3-13**]
weeks. You steroids (prednisone) will need to be increased
every three days by 10mg until you reach the target dose of 60mg
daily.
[**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**] MD [**MD Number(1) 545**]
Completed by:[**2109-3-19**]
|
[
"599.0",
"401.9",
"518.81",
"305.1",
"300.00",
"250.00",
"780.52",
"041.6",
"272.4",
"518.0",
"358.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.71",
"96.6",
"96.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
16829, 16962
|
11654, 12767
|
390, 468
|
14155, 14155
|
9291, 9291
|
17464, 17836
|
6477, 6559
|
15560, 16806
|
14093, 14134
|
12793, 12933
|
16986, 17441
|
7836, 9272
|
6574, 7205
|
228, 352
|
496, 5955
|
9308, 11631
|
14170, 14282
|
5977, 6109
|
6125, 6461
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,899
| 122,304
|
44603
|
Discharge summary
|
report
|
Admission Date: [**2127-12-16**] Discharge Date: [**2127-12-23**]
Date of Birth: [**2068-5-1**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Codeine / Red Dye / Vioxx / ibuprofen / Bactrim DS /
Glucophage / simvastatin / Crestor / Allopurinol
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
[**2127-12-16**]: s/p Complex left hip girdle stone resection
arthroplasty of infected native hip with interpositional
antibiotic spacer.
[**2127-12-20**]: blood transfusion
[**2127-12-17**]: PICC line placement
History of Present Illness:
Pt is a 59 yo female who in [**2127-2-8**] dev left hip pain and was
dx'ed with OA.
In [**2127-9-8**], she has sig worsening of pain in left hip and
sought care at [**Hospital1 **] ED on [**2127-9-20**]. Had IR guided arthrocentesis
c/w septic joint. Taken to OR for washout on [**2127-9-21**] and cx's
showed strep anginosus. Blood cx's taken after initiation of abx
were neg. TTE neg then and she had repeat washout on [**2127-9-24**].
She had imaging c/w osteo. She was seen by ID and she was
treated initially with vanco alone, then ceftriaxone added and
when her strep was [**Last Name (un) 36**] to pen-G, she was switched to Pen G to
complete 6 wks of abx therapy.
On [**2127-10-21**], she was dc'ed to home. She represented 3 days later
with n/v and CP. She was switched from pen G to ceftriaxone
given poss of nause due to pen G.
She was dc'ed on [**2127-10-27**].
She was seen as outpt in [**Hospital **] clinic by Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] on [**2127-11-5**]
and she was nauseated and c/o loose stools. She had completed 6
wks of abx and her inflamm markers were still elevated and she
was still having mobility probs. ID decided to cont treating her
with ceftriaxone 2G iv q 24.
On [**2127-11-21**], she was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from ortho and
he proposed surgery given concern she was failing abx therapy.
on [**2127-12-2**], her ceftriaxone was stopped to max opportunity for
positive cx at time of surgery.
On [**2127-12-16**], she had resection arthroplasty, deep tissue
synovectomy and removal of necrotic tissue with insertion of
vanco/tobra spacer. Post op, she developed hypotension which led
to admission to [**Hospital Unit Name 153**]. She received 5L of LR and 250cc 5% albumin
in PACU.
ICU course - her hct has drifted down to 23. Her blood pressure
has improved but does occasionally drop down which the ICU team
believes is related to her bolus doses of dilaudid.
Past Medical History:
CAD
[**10-11**]: C. cath performed for exertional dyspnea and chest
heaviness with occasional symptoms at rest as well. ETT at
[**Hospital 882**] Hospital was abnormal by report, and echocardiogram
[**2119-9-26**] showed moderate global hypokinesis. She is referred for
right and left heart catheterization for evauation of filling
pressures and coronary anatomy.
[**6-/2127**]: TEE/DCCV cardioversion due to atrial fibrillation.
[**2127-8-5**]: Cavo-tricuspid and coronary sinus RFA for
atrial flutter on [**2127-8-5**]
* DMII
* bilateral knee replacements
* h/o acute renal failure in setting of knee surgery
* osteoarthritis
* Idiopathic Cardiomyopathy diagnosed [**2119**]
* depression
* anemia
* obesity s/p LAGB ([**2126**])
Social History:
SOCIAL HISTORY: Lives in [**Hospital1 6930**] with daughter. Had a difficult
separation from
her husband of 30 [**Name2 (NI) 1686**] about a year ago. Worked as a mammographer
at the [**Hospital1 882**]; recently laid off. Two adult children.
-Tobacco history: never
-ETOH: very rare
-Illicit drugs: none
Family History:
Father died of MI at age 65. Mother had major CVA at 72. Three
sisters with breast cancer, one who recently suffered bilateral
PEs. Mother and 2 sisters with DM.
Physical Exam:
[**2127-12-18**] [**2046**]
T 98 BP 114/60 HR 82 O2 sat 96%RA
Pt is a & O x 3
HEENT - PERRLA
CV - RRR
lungs - CTA
Abd - soft, NT, nbs
ext - left hip surgical wound clean; bilat lenis on, old scars
over both knees
neuro - [**3-22**] intact; gait not tested; nl strength and sensation
Pertinent Results:
Admission labs:
[**2127-12-16**] 07:41PM BLOOD WBC-8.5 RBC-3.64* Hgb-10.2* Hct-31.6*
MCV-87 MCH-28.1 MCHC-32.4 RDW-15.3 Plt Ct-235
[**2127-12-17**] 06:04AM BLOOD Glucose-123* UreaN-32* Creat-1.3* Na-137
K-4.5 Cl-103 HCO3-26 AnGap-13
[**2127-12-17**] 06:04AM BLOOD Calcium-7.9* Phos-4.2# Mg-1.7
.
Differential
[**2127-12-18**] 07:17PM BLOOD Neuts-57.6 Lymphs-21.9 Monos-4.7
Eos-15.4* Baso-0.5
[**2127-12-18**] 03:56AM BLOOD calTIBC-204* Ferritn-147 TRF-157*
.
Vanco trough 23.4 on [**12-19**].
.
Micro:
Blood cx [**12-19**], [**12-18**] - NGTD. Blood cx [**12-17**] no growth.
MRSA screen negative
[**12-16**] operative cultures X 7, 2+ PMNS, cultures negative,
universal PCR pending
Urine Cx [**12-22**] pending
.
[**2127-12-23**] 05:21AM BLOOD WBC-4.9 RBC-3.09* Hgb-8.7* Hct-25.8*
MCV-84 MCH-28.2 MCHC-33.8 RDW-16.0* Plt Ct-180
[**2127-12-23**] 05:21AM BLOOD Neuts-47.3* Lymphs-36.2 Monos-5.9
Eos-9.9* Baso-0.7
[**2127-12-22**] 05:03AM BLOOD Neuts-50.6 Lymphs-31.7 Monos-5.4
Eos-12.0* Baso-0.4
[**2127-12-20**] 04:56AM BLOOD Neuts-43.0* Lymphs-35.2 Monos-7.0
Eos-13.8* Baso-1.0
[**2127-12-18**] 07:17PM BLOOD Neuts-57.6 Lymphs-21.9 Monos-4.7
Eos-15.4* Baso-0.5
[**2127-12-23**] 05:21AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-142 K-3.6
Cl-105 HCO3-30 AnGap-11
[**2127-12-23**] 05:21AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.8
[**2127-12-22**] 05:03AM BLOOD Vanco-19.3
Brief Hospital Course:
Ms. [**Known lastname **] is a 59 y/o female with left hip osteoarthritis
unresponsive to 6 week course of ceftriaxone, now s/p left hip
resection arthroplasty complicated by hypotension post
operatively.
.
ACUTE ISSUES
# Osteomyelitis, s/p resection, complicated by pain: The patient
is s/p Left hip resection arthroplasty and antibiotic spacer
placement. She had previously completed a 6 week course of
ceftriaxone with continued fevers and elevated inflammatory
markers. She was placed back on vancomycin and ceftriaxone and
ID followed. Eosinophilia was present, felt to be secondary to
ceftriaxone and therefore her antibiotics were changed to
Vancomycin only. She will need 6 weeks of antibiotic therapy
with Vancomycin ([**2127-12-17**] - [**2128-1-27**]). Operative cultures
were negative at discharge but pending. Universal PCR was also
sent and is pending. Pain control was acheived with oxycontin
20 mg po bid and dilaudid 2-4 mg po q3 hours. Anticoagulation
is maintained with lovenox 30 mg sc bid while she is restarting
on coumadin. Goal INR 2 - 2.5. Lovenox can be stopped once INR
therapeutic. She will follow-up in [**Hospital 5498**] clinic and
Infectious Disease clinic. The overall plan is to continue on 6
weeks of antibiotic therapy, have a joint aspirate checked after
off antibiotics for 2 weeks, and if negative for infection, to
proceed with a total hip replacement.
.
She will require weekly labs for monitoring of her IV therapy.
This includes weekly Chem-10, CBC, CRP, ESR, and Vanco trough.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient
antibiotics should be directed to the infectious disease R.Ns.
.
# Acute post op anemia: Prior to [**Month (only) 216**], she had baseline hct
37-39, since then has been relatively stable at 27-29. Possibly
secondary to anemia of chronic disease in setting of
osteomyelitis. Post op, she had a Hct of 23. She received 2
units of blood. Hct at discharge was 25.8.
.
# Hypotension, in the setting of usual hypertension: Patient on
metoprolol and lisinopril at home. She had hypotension post op,
requiring [**Hospital Unit Name 153**] stay. The Hypotension resolved with fluids, and
she did not require pressors. She was evaluated by the
Cardiology Consult service after her BP stabilized, and Toprol
XL was restarted at reduced dose of 50mg daily, home dose had
been 150mg. She was also restarted on Lasix 40mg daily with
potassium supplementation. She will be followed in Cardiology
Clinc as an outpatient. If her blood pressure remains elevated
>130/80 at rehab, lisinopril can also be restarted at 2.5mg
daily. Can also consider increasing Toprol XL to 100mg daily if
BP >130/80 and HR >80. Otherwise, addition of ACEi will be
re-evaluated at her outpatient Cardiology appointment. She
should have weekly Chem-10 checked to monitor her diuresis and
results can be faxed to outpatient Cardiology at [**Telephone/Fax (1) 3341**],
attention Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 31469**].
.
CHRONIC ISSUES
# A fib/flutter: Currently in sinus rhythm. She was maintained
on amiodarone. Dr.[**Name (NI) 26896**] fellow saw her while she was
hospitalized. She also had her Toprol restarted at a reduced
dose. She is currently on anticoagulation with [**Hospital1 **] Lovenox, but
Coumadin can be restarted with a goal INR of 2 - 2.5, and
Lovenox can be stopped once INR at goal.
.
# Diabetes: Last A1C 6.4% in 2/[**2127**]. On detemir at home, changed
to lantus and sliding scale here. Her blood sugars were well
controlled.
.
# Depression: She was continued on home dose of sertraline, and
seen by social work.
.
# Code: Full (discussed with patient)
.
Pending labs:
Universal PCR on operative cultures from [**12-16**]
Operative cultures 11/8
Blood cultures 11/10, [**12-19**]
Urine Culture [**12-22**]
.
Transitional Issues:
1. Continue on IV antibiotics for total of 6 weeks, with weekly
monitoring labs to be followed by ID. ID will also monitor her
operative cultures, including universal PCR and determine need
to adjust antibiotics.
2. She will need to have weekly labs checked to monitor her
diuresis, and this can be followed by outpatient Cardiology
Clinic as described above.
3. She will need to be re-initiated on Coumadin and have daily
INR checks till INR at goal of 2 - 2.5, at which time her
Lovenox can be stopped.
4. She will need her BP monitored, if persistently >130/80, can
start lisinopril 2.5mg daily. Can also consider increasing
Toprol XL to 100mg daily if her BP >130/80 and HR >80.
.
Medications on Admission:
insulin (novlog and levemir)
amiodarone
metoprolol
furosemide
coumadin
sertraline
dilaudid
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sertraline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
6. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 6 weeks:
[**2127-10-9**].
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Outpatient Lab Work
please check weekly CBC, Chem-10, Vanco trough, ESR, CRP, fax to
Outpatient [**Hospital **] clinic at [**Telephone/Fax (1) 1419**].
please also fax the Chem-10 to Cardiology Clinic, attn: Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 3341**].
please start lab checks this week on [**12-26**] (Friday).
15. Outpatient Lab Work
please check daily INR till INR at goal and stable. goal INR is
2 - 2.5
16. Humalog 100 unit/mL Solution Sig: sliding scale coverage
Subcutaneous with meals and before bed time (QAC and QHS):
Please check fingersticks QAC and QHS.
.
150, do not administer Humalog. FS 151 - 200, humalog 2 units
SQ, FS 201 - 250, Humalog 4 units SQ, FS 251 - 300, Humalog 6
units SQ, FS 301 - 350, Humalog 8 units SQ, FS >350, Humalog 10
MD. FS 71 - 200, do not administer Humalog. FS 201 - 250,
Humalog 1 unit SQ, FS 251 - 300, Humalog 2 unit SQ, FS 301 -
350, Humalog 3 unit SQ, FS > 350, Humalog 4 unit SQ and [**Name8 (MD) 138**] MD.
.
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
please continue at this dose till seen by Cardiology Clinic in
follow-up.
18. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO once a day: do not give if K>5.
19. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
20. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**]
Discharge Diagnosis:
Chronic osteomyelitis of left femoral head and hip
Hypotension
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 may not drive a car until cleared to do so by your surgeon.
.
Please keep your wounds clean. You may shower starting five (5)
days after surgery, but no tub baths or swimming for at least
four (4) weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by Dr. [**Last Name (STitle) **] two weeks after your surgery.
.
Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
Continue [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
.
WOUND CARE: Please keep your incision clean and dry. It is okay
to shower five days after surgery but no tub baths, swimming, or
submerging your incision until after your four (4) week checkup.
Please place a dry sterile dressing on the wound each day if
there is drainage, otherwise leave it open to air. Check wound
regularly for signs of infection such as redness or thick yellow
drainage. Staples will be removed by the visiting nurse or rehab
facility in two (2) weeks.
.
VNA (once at home): Home PT/OT, dressing changes as instructed,
wound checks, and staple removal at two weeks after surgery.
.
ACTIVITY: [**Month (only) 116**] progress to partial weight bearing after obtaining
L external shoe lift. No strenuous exercise or heavy lifting
until follow up appointment.
.
You were admitted for a surgery for your left hip infection.
You are now going to rehab. After surgery, your blood pressure
was low, but it improved with fluids. Some medication changes
were made to your cardiac medications. You were also started on
IV antibiotics for your chronically infected left hip and will
continue for a total of a 6 week course. You will be discharged
to rehab and will follow-up with your doctors as listed below.
Please take your medications as described below. Major
medication changes during this admission include:
1. Decreased TOPROL XL dose.
2. Started LASIX.
3. Started POTASSIUM CHLORIDE.
4. Started VANCOMYCIN IV.
5. Started LOVENOX.
6. Stop LISINOPRIL.
7. Started LANTUS.
8. Stop DETEMIR
.
Followup Instructions:
.
Department: ORTHOPEDICS
When: FRIDAY [**2128-1-16**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], PA [**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: INFECTIOUS DISEASE
When: WEDNESDAY [**2128-1-7**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2128-1-12**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
After your are discharged from rehab, you should contact your
PCP office and schedule an appointment to be seen in 1 - 2
weeks.
.
|
[
"250.00",
"425.4",
"288.3",
"V58.67",
"V43.65",
"427.31",
"584.9",
"285.1",
"285.29",
"730.15",
"458.29",
"564.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.85",
"38.97",
"84.56"
] |
icd9pcs
|
[
[
[]
]
] |
13037, 13083
|
5589, 9496
|
388, 602
|
13189, 13189
|
4202, 4202
|
15501, 16653
|
3721, 3884
|
10350, 13014
|
13104, 13168
|
10235, 10327
|
13372, 13966
|
3899, 4183
|
9517, 10209
|
335, 350
|
13978, 15478
|
630, 2627
|
4218, 5566
|
13204, 13348
|
2650, 3382
|
3414, 3705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,695
| 166,255
|
398
|
Discharge summary
|
report
|
Admission Date: [**2177-2-20**] Discharge Date: [**2177-2-25**]
Date of Birth: [**2115-9-8**] Sex: M
Service: MEDICINE
Allergies:
Unasyn
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hypotension, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61y/o M w/ DM2, CHF s/p ICD, CRI, and atrial fibrillation
presenting today with altered mental status and hypotension. The
patient was recently admitted to [**Hospital1 18**] in mid-[**Month (only) 1096**] with a
perirectal abscess complicated by hypotension and a MICU
admission. His course was further complicated by renal failure
and a transaminitis attributed to unasyn therapy. He was
discharged to a rehab facility on [**1-10**] and had recently left
that facility and returned home last week. According to his
wife, he has been more sedated since discharge from the hospital
but otherwise has been doing relatively well at home. He
endorses chronic knee and LE pain but denies any recent CP, SOB,
abdominal pain, N/V, poor PO intake, progressive weakness,
paresthesias, HA, melena, or BRBPR. He has noticed some
intermittant painless shaking in his hands that has occasionally
caused him to drop objects. He and his wife note good compliance
with his medications though she had held his coreg until
yesterday given slow HR at home. She feels that his altered
mental status can be directly attributed to the doses of
narcotics that he was discharge on as this was a new medication
for him. He has been eating well at home but did not take good
PO today despite receiving his regular dose of insulin.
.
Today he presented to a neurology appointment for further
evaluation of his hand shaking and there was noted to be
somnolent. His blood pressure was in the 80s systolic and he was
sent to the ED for further evaluation. There he was seen to be
bradycardic to the low 50s and somnolent. His glucose level was
33 and he received D50 and promptly awoke and was appropriate
per report. His bradycardia was treated with atropine to which
his HR increased to the 70s and his relative hypotension
(systolic ~90) improved. EP was contact[**Name (NI) **] and reportedly felt
that no intervention was indicated at this time. He was admitted
to the ICU because his HR dipped to the low 50s for ~25 seconds
and it was felt that he merited intensive monitoring.
Past Medical History:
1. Diabetes mellitus type 2, insulin dependent
2. Non-ischemic Cardiomyopathy, EF ~20%
3. ICD placement ([**11-3**]) primary prevention of SCD
4. Elevated transaminases, unknown etiology
5. Chronic atrial fibrillation
6. Chronic renal insufficiency
7. Umbilical hernia repair, [**8-/2175**]
8. Gallstone pancreatitis s/p ERCP ([**2176-6-28**])
9. Internal hemorrhoids
10. Hemoglobin C carrier
Social History:
Lives with his wife, has four grown children. Not currently
working, on disability. Wife works at [**Hospital1 18**]. Used to work in
contruction. No tobacco, alcohol, or illicits. originally from
[**Country 3515**]. had planned to head home early this coming week
Family History:
No family history of heart disease. father died at 93 from old
age. one uncle lived to 103.
Physical Exam:
PE: 96.8, 100-110/65-85, 60-80, 20, 98%RA
I/O 24hr: [**Telephone/Fax (1) 3522**]
Gen: Eating, answers all questions appropriately; A+Ox3
Heent: MMM, elevated JVP to ears
CV: Irregular, no M/R/G appreciated
Lungs: Mild basilar crackles, no wheezes, rhonchi
Abd: S/NT/ND, +BS, midline infraumbilical surgical scar
Ext: 2+ LE edema bilaterally, WWP
Neuro: Responding appropriately to questions and moving all
extremities spontaneously, AAO x 3
Skin: No rash or skin breakdown noted
Pertinent Results:
[**2177-2-20**] 04:15PM PT-25.8* PTT-50.0* INR(PT)-2.5*
[**2177-2-20**] 04:15PM PLT SMR-LOW PLT COUNT-147*
[**2177-2-20**] 04:15PM HYPOCHROM-NORMAL ANISOCYT-2+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+
TARGET-OCCASIONAL
[**2177-2-20**] 04:15PM NEUTS-33* BANDS-0 LYMPHS-59* MONOS-3 EOS-5*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2177-2-20**] 04:15PM WBC-5.1 RBC-3.89* HGB-11.9*# HCT-34.0* MCV-88
MCH-30.6 MCHC-34.9 RDW-20.5*
[**2177-2-20**] 04:15PM ASA-NEG
[**2177-2-20**] 04:15PM PHENOBARB-<1.2* PHENYTOIN-<0.6* LITHIUM-0.2*
VALPROATE-<3.0*
[**2177-2-20**] 04:15PM DIGOXIN-1.1 THEOPHYL-<0.8*
[**2177-2-20**] 04:15PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.7
MAGNESIUM-2.3
[**2177-2-20**] 04:15PM cTropnT-<0.01 proBNP-5727*
[**2177-2-20**] 04:15PM LIPASE-273*
[**2177-2-20**] 04:15PM ALT(SGPT)-41* AMYLASE-149* TOT BILI-2.2*
[**2177-2-20**] 04:15PM estGFR-Using this
[**2177-2-20**] 04:15PM GLUCOSE-27* UREA N-17 CREAT-1.2 SODIUM-135
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
[**2177-2-20**] 04:28PM LACTATE-1.8 K+-4.6
.
CXR: 1. Cardiomegaly with mild pulmonary edema. 2. Ill-defined
retrocardiac opacity, likely reflects atelectasis. However, if
there is a clinical suspicion for pneumonia, recommend repeat PA
and lateral views after diuresis.
.
RUQ u/s: 1. The liver demonstrates no focal or textural
abnormality.
2. The gallbladder contains sludge. No definite stones or
evidence of acute cholecystitis.
Brief Hospital Course:
61 year old man with CHF (EF 20%) and Afib admitted for altered
mental status and hypotension.
.
# HYPOTENSION: Found to have BP of 80/60 at Neurologist's office
and then sent to the ED. In the ED, he got atropine with
improvement of his heart rate and his BP. In the MICU, his BP
ranged from 100-110/65-85. The thought is that he was
bradycardic and had decreased cardiac output resulting in low
BP.Not infected so not likely septic hypotension. Peripherals
warm and well perfused so not likely cardiogenic hypotension.
Patient was monitored on telemetry. Heart rate and BP remained
within normal limits for duration of inpatient stay. Patient
was restarted on coreg and diovan prior to discharge with good
blood pressure control and normal heart rate.
.
# BRADYCARDIA: Found to have heart rates in the 40's in the ED.
Received atropine with improvement. In the MICU, coreg held and
HR ranged from 60-80. Unclear why he became bradycardic when
he's been taking coreg chronically. He has ICD with pacemaking
capabilities; threshold set to 40. EP was consulted regarding
threshold setting and felt no changes needed to be made. Patient
was restarted on coreg without difficulty. Continued on digoxin.
Monitored on telemetry with no events.
.
# ALTERED MENTAL STATUS: Likely from hypotensive episode, or
from narcotics. Resolved.
.
# HYPOGLYCEMIA: Fingerstick was 33 at ED. Responded to D50.
Unclear why hypoglycemia. Possibly from poor PO intake at home,
although he denies. Possibly from incorrect insulin dosing,
especially since he recently switched brands of novalog.
Restarted on NPH 5 units in AM decreased from prior regimen of
NPH 15units QAM/8units QPM. Covered with Humalog sliding scale.
FS monitored and had good control for duration of stay.
.
# CHF: Non ischemic cardiomyopathy with acute exacerbation of
congestive heart failure and EF 20%. Currently volume overloaded
with elevated JVP to jaws, peripheral edema and crackles in
lungs. Initailly treated with IV lasix for diuresis and
transitioned to PO regimen of 80 mg daily with improvement in
peripheral edema and lung exam. Directed to maintain low salt
diet, and check daily weights. Restarted on coreg and diovan
.
# Atrial fibrillation: in afib currently w/ rate ~ 80s.
Continued coumadin, digoxin, restarted coreg with good effect.
.
# Chronic renal insufficiency: at baseline.
.
# LFT elevation: Elevated since previous admission in setting of
both unasyn reaction and stones in the CBD. He is s/p pancreatic
stenting and stent removal. LFTs trended downward. Possible
contribution from liver congestion from CHF. RUQ obtained to
evaluate for stone which was negative.
.
# Myoclous: Intermittently has shaking movements of his left
arm. Arranged to have outpatient neurology follow up.
.
FULL CODE
Medications on Admission:
1. Lidoderm patch daily to knees
2. Tylenol prn
3. Lasix 80mg daily
4. Oxycodone prn
5. Oxycontin 20mg [**Hospital1 **]
6. Glucosamine/Chondroitin 500/400mg daily
7. Senna/Docusate
8. Multivitamin daily
9. Coreg 3.125mg [**Hospital1 **]
10. Digoxin 0.125mg daily
11. Diovan 80mg daily
12. Coumadin 5.5mg (3x/wk) and 5mg (4x/wk)
13. NPH 15u qAM, 8u qPM
14. Humalog sliding scale
15. Protonix 40mg daily
Discharge Medications:
1. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA): Alternating with Coumadin 5.5mg PO daily 3x/week
(MON,WED,FRI).
2. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Glucosamine-Chondroitin 500-400 mg Tablet Sig: One (1) Tablet
PO once a day.
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5)
units Subcutaneous once a day: At breakfast.
10. Insulin Aspart 100 unit/mL Solution Sig: Administer
subcutaneously per home insulin sliding scale subcutaneous
Subcutaneous four times a day.
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*0*
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Valsartan 40 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:
Final diagnosis
Hypotension
Bradycardia
Hypoglycemia
Secondary diagnosis
Diabetes mellitus type II
Chronic atrial fibrillation
Cardiomyopathy
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for low blood pressure, low heart rate, and
low blood sugar levels. You were initially admitted to the
intensive care unit as your blood pressure and heart rate were
very low and required extra monitoring. Some of your blood
pressure medications were held, and your blood pressure and
heart rate stabilized. Your insulin was also held and restarted
at a lower level and your blood sugars were stable on discharge.
Please continue your home medications with the following
additions and changes.
- Continue your diovan and coreg at the new dose directed.
- you can continue to take your lasix and digoxin at home dosing
- also, we changed your insulin dosing to a lower dose. Please
continue this and measure your fingersticks 4 times a day with
coverage with insulin sliding scale and readdess this with your
primary care provider.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
2,000ml
Please call your primary care provider or return to the hospital
if you feel any symptoms of lightheadness, dizziness, nausea,
vomiting, palpitations, chest pain, shortness of breath, or any
new or worrisome symptoms.
Followup Instructions:
Please make an appointment with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name (STitle) 3510**], within 1-2 weeks of discharge from the hospital.
[**Telephone/Fax (1) 3511**]
Please keep your appointment with your cardiologist as below. It
will be important to follow up on your blood pressure and heart
rate control and whether to continue some of your blood pressure
medications. Please call to change your appointment to an
earlier date within 2 weeks of discharge. Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2177-3-10**] 9:00
.
We have scheduled an appointment for you with Neurology.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 3523**] [**Name (STitle) 3524**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2177-3-24**] 9:30
Other scheduled appointments include:
Provider [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2177-3-25**] 1:00
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2177-3-28**]
8:20
|
[
"427.89",
"250.00",
"425.4",
"428.0",
"585.9",
"427.31",
"V45.02",
"V58.61",
"428.33",
"458.9",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9832, 9890
|
5182, 6435
|
282, 289
|
10077, 10087
|
3700, 5159
|
11333, 12590
|
3092, 3185
|
8414, 9809
|
9911, 10056
|
7987, 8391
|
10111, 11310
|
3200, 3681
|
226, 244
|
318, 2376
|
6450, 7961
|
2398, 2793
|
2809, 3076
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,198
| 193,744
|
33408
|
Discharge summary
|
report
|
Admission Date: [**2189-5-28**] Discharge Date: [**2189-5-30**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
hemoptysis during CT-guided placement of fiducial by
interventional radiology
Major Surgical or Invasive Procedure:
CT-guided placement of fiducial by interventional radiology
History of Present Illness:
87 yo F with history of HTN, lung adenocarcinoma who was
admitted after hemoptysis during an IR procedure. On day of
admission, pt visited interventional radiology for a fiducial
seed placement for upcoming cyberknife therapy. During the
procedure, she began to cough up bright red blood, hemoptysized
50-100cc bright red blood. Her oxygen saturations dropped to
the 70s, and came up on a non rebreather to 91%. With this
episode, she was hypertensive to the 200s, which resolved
without intervention. Her heart rate also went from the 60's to
the 120s as well. CT of the chest showed no evidence of
pneumothorax, but did show hemorrhage around biopsy site, and
new bilateral pleural effusions.
On evaluation in the radiology suite, she complained of
shortness of breath and sleepiness while denying chest pain,
headache, or palpitation. Her BP was 140's /90s, HR in the
120's. She was satting 93% on RA, and 100% on 4L face mask.
Pt was then transferred to the MICU for observation following
the procedure. On arrival to MICU, she went into rapid
afib/flutter, which was controlled w/ diltiazem.
Past Medical History:
Poorly differentiated adenoCA of the LUL (s/p CT guided bx [**1-24**],
PET [**2188-10-23**] with no uptake in lung desion. [**3-18**] flex bronch,
cevical mediastinscopy, left VATs, evacuation of pleural
effusion, LN all negative but LUL lung nodule PET(+))
Hypertension
TKR, right [**8-23**]
TAH
Cholecystectomy [**2183**]
Social History:
Patient smoked for 30 years, started age 18. Drinks 1 cocktail
nightly before dinner. She does not currently work. She lives
alone in Fishkill, NY, and drove to [**Location (un) 86**] w/ her daughter for
treatment of the lung cancer. Has a supportive daughter, who
lives nearby.
Family History:
No history of cancer or heart disease
Physical Exam:
Vitals: 97.1, 78 (60-80s), 110-150s/40-50s, 22, 98% on RA
Gen: Comfortable, pleasant elderly lady in NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: Tachycardic. NL S1, S2. No murmurs, rubs or gallops
appreciated
LUNGS: Crackles throughout, worse on left side, worse at bases
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-19**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
LABS
[**2189-5-28**] 08:00AM WBC-3.7* RBC-3.64* Hgb-12.0 Hct-34.7* MCV-95
MCH-32.9* MCHC-34.5 RDW-14.0 Plt Ct-305
[**2189-5-28**] 01:32PM WBC-5.9# RBC-3.24* Hgb-10.8* Hct-31.5* MCV-97
MCH-33.3* MCHC-34.2 RDW-13.5 Plt Ct-274
[**2189-5-28**] 09:14PM Hct-30.7*
[**2189-5-29**] 05:32AM WBC-3.9* RBC-2.89* Hgb-9.8* Hct-27.6* MCV-96
MCH-34.1* MCHC-35.7* RDW-14.1 Plt Ct-244
[**2189-5-29**] 06:55PM Hct-30.2*
[**2189-5-30**] 06:40AM WBC-3.0* RBC-3.07* Hgb-10.3* Hct-29.1* MCV-95
MCH-33.6* MCHC-35.5* RDW-13.9 Plt Ct-270
[**2189-5-28**] 01:32PM BLOOD Glucose-108* UreaN-21* Creat-0.9 Na-142
K-3.9 Cl-103 HCO3-28 AnGap-15
[**2189-5-30**] 06:40AM BLOOD Glucose-91 UreaN-20 Creat-0.9 Na-141
K-3.9 Cl-103 HCO3-29 AnGap-13
CYTOLOGY
[**2189-6-1**] SPECIMEN RECEIVED: [**2189-5-28**] CYTOPATHOLOGY SMEARS,
NON-GYN
Touch prep of core, lung, left upper lobe: Positive for
malignant cells, consistent with adenocarcinoma.
ECG
Study Date of [**2189-5-28**] 11:30:10 AM
Probable sinus tachycardia. Extensive ST segment depressions
most prominent in the inferolateral leads which may be due to
myocardial ischemia. Compared to the previous tracing of
[**2189-3-17**] the rate is markedly faster and inferolateral ST segment
changes are more prominent. QTc interval is also shorter in the
setting of a rapid heart rate.
TRACING #1 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
125 146 86 298/411 -122 53 -102
IMAGING STUDIES
CT INTERVENTIONAL PROCEDURE, LEFT UPPER LOBE LUNG NODULE BIOPSY
UNDER CT
FLUOROSCOPIC GUIDANCE [**2189-5-28**]
IMPRESSION: Core biopsy of the left upper lobe speculated
mass.Planned
fiducial seed placement could not be performed due to hemopysis
and
deterioration in patient condition. The patient developed
hemoptysis and the post- procedure CT scan demonstrated possible
aspiration. The patient was transferred to the medical ICU for
further care.
CHEST (PORTABLE AP) Study Date of [**2189-5-29**] 3:49 AM
IMPRESSION: AP chest compared to [**3-19**] through [**5-28**]:
Heavy asbestos-related pleural calcification obscures larger
areas of both
lungs. Allowing for differences in patient position, there are
no lung
findings to suggest pneumonia. Bilateral pleural effusion and/or
pleural
scarring is unchanged. Heart size is normal. Moderate-sized
hiatus hernia is longstanding.
Brief Hospital Course:
Aspiration Pneumonitis: Patient had a witnessed aspiration event
during the IR lung bx. CXR was consistent with aspiration
pneumonitis, as was CT scan. Imaging also showed hemorrhage
around bx site. Pt initially had O2Sat in the 70s, but
eventually tolerated RA with sats 94%. Repeat CXR on [**5-29**] did
not show significant worsening.
Afib/flutter: Pt w/o history of known afib/flutter. She was
rate controlled with diltiazem and spontaneously converted. MI
was ruled out with cardiac markers x3 (0.04, 0.04, 0.02). After
10mg IV diltiazem patient's HR decreased to high 60s, then
remained in high 50s-mid 60s on the afternoon/night of [**5-28**].
Anticoagulation was discussed with the patient; she was not
interested in initiating therapy during hospital stay. She is
to discuss it with her PCP.
Hemoptysis: Patient hemoptysized 50-100cc per IR team in the
setting of lung biopsy. There was evidence of hemorrhage around
bx site, with per IR is normally seen after biopsy. Hct was
31.5 immediately post-procedure. Repeat hct dropped to 29 and
was stable on discharge. This drop with thought to be primarily
from the hemoptysis.
Lung Mass: Previous biopsy showed poorly differentiated adenoCA.
The plan is for cyberknife radiation which the patient is to
receive following discharge.
Hypertension: Patient was intially hypertensive, but then
stabilized after diltiazem. She was continued on her home
diltiazem 240mg QD and HCTZ 50mg QD.
Acute Renal Failure: Patient's Cr rose from 0.9 at admission to
1.3 on morning of [**5-29**]. Likely prerenal due to low volume
(little PO intake day of admission). She was given a 500mL NS
bolus and Cr was followed. It was 0.9 on discharge.
CODE: full code
Medications on Admission:
Cardizem 240mg daily
HCTZ 50mg daily
Centrum silver
iron
Discharge Medications:
1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
primary: adenocarcinoma of the lung
secondary: hypertension, atrial fibrillation, anemia
Discharge Condition:
Good and stable.
Discharge Instructions:
You were admitted for a procedure to prepare for cyberknife
therapy for your lung cancer. The procedure was complicated by
blood loss and hemoptysis (coughing up blood). You were
monitored in the ICU following the procedure. During this
period, your blood pressure was elevated at times as high as
190s. You heart also exhibited an abnormal heart rhythm called
atrial flutter/fibrillation. This was treated with diltiazem,
and your blood pressure and heart rate improved. On discharge,
your heart rhythm was normal and your blood pressure had
improved to systolic in the 150s.
As discussed, you should review with your new PCP these issues,
particularly treatment of your blood pressure and evaluation for
the irregular heart rhythm atrial flutter/fibrillation, since
recurrent episodes of this can lead to stroke.
Your blood count (hematocrit) did decrease following the
procedure you underwent. Prior to the procedure your hematocrit
was 34 and following the procedure it was 30. You should have
your blood count rechecked within the week. You should also
continue taking your iron pills.
If you develop any shortness of breath, chest pain, abdominal
pain, blood in your stools, nausea, vomiting, fever, chills,
palpitations, or any other concerning symptoms, please call your
primary care physician or immediately proceed to the emergency
department at the nearest hospital.
Followup Instructions:
Please follow up with your primary care provider and doctors.
Provider: [**Name10 (NameIs) 77521**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 77522**] Call to schedule
appointment
|
[
"427.32",
"E878.8",
"401.1",
"584.9",
"785.0",
"162.8",
"511.9",
"998.11",
"285.1",
"V64.1",
"507.0",
"427.31",
"997.3",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.41",
"00.31",
"33.26"
] |
icd9pcs
|
[
[
[]
]
] |
7410, 7416
|
5223, 6941
|
298, 360
|
7550, 7569
|
2850, 5200
|
9006, 9237
|
2156, 2195
|
7048, 7387
|
7437, 7529
|
6967, 7025
|
7593, 8983
|
2210, 2831
|
180, 260
|
388, 1494
|
1516, 1842
|
1858, 2140
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,648
| 110,118
|
19678
|
Discharge summary
|
report
|
Admission Date: [**2123-12-25**] Discharge Date: [**2124-1-7**]
Date of Birth: Sex: F
Service: [**Hospital1 139**]
CHIEF COMPLAINT: The patient is a 77-year-old woman with
unresectable pancreatic cancer with pulmonary embolism and
small-bowel obstruction.
HISTORY OF PRESENT ILLNESS: The patient presented to an
outside hospital on [**12-24**] after her daughter noticed
increased somnolence and vomiting.
She was taken to [**Hospital3 15174**] and was found to
be unresponsive. She was intubated for airway protection. A
computed tomography scan showed a small-bowel obstruction.
BRIEF SUMMARY OF HOSPITAL COURSE: She was transferred to
[**Hospital1 69**] Intensive Care Unit.
Upon arrival a repeat abdominal computed tomography showed
ascites and partial small-bowel obstruction and enlargement
of the pancreatic head. The patient was evaluated by Surgery
who felt that the mass was unresectable. The small-bowel
obstruction was managed medically. The patient was
extubated.
Her course was then complicated by development of a
non-ST-elevation myocardial infarction.
The patient was transferred to the medical floor on [**2123-12-28**] where she desaturated to 85% on 4 liters. It was
thought that the patient had vomited and aspirated. A
computed tomography angiogram was performed which showed
bilateral pulmonary emboli. Lower extremity Doppler studies
also revealed bilateral deep venous thrombi. The patient was
started on heparin intravenously and an inferior vena cava
filter was placed. The patient subsequently developed
heparin-induced thrombocytopenia syndrome. Her platelets
dropped from 150 to 98. Heparin was stopped.
At that point, the patient realized her diagnosis and
prognosis. The patient stated that she was not interested in
radiation or chemotherapy. Code discussions were held with
the patient and her family. She was made comfort measures
only.
The patient was transferred to the medical floor. The
hospital course the following day, on transfer to the medical
floor, the patient passed away while on a morphine drip. The
family were notified and declined autopsy.
CONDITION AT DISCHARGE: Expired.
DISCHARGE STATUS: Not applicable.
DISCHARGE DIAGNOSES:
1. Pulmonary embolism.
2. Deep venous thromboses.
3. Pancreatic cancer.
4. Small-bowel obstruction.
5. Aspiration pneumonia.
6. Heparin-induced thrombocytopenia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**]
Dictated By:[**Name8 (MD) 53260**]
MEDQUIST36
D: [**2124-2-26**] 10:20
T: [**2124-2-26**] 10:38
JOB#: [**Job Number 53261**]
|
[
"157.0",
"276.5",
"410.71",
"415.19",
"789.5",
"560.9",
"518.81",
"507.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"38.91",
"38.7",
"96.6",
"96.72",
"99.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2240, 2674
|
651, 2158
|
2173, 2219
|
161, 286
|
315, 622
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,001
| 179,090
|
45555
|
Discharge summary
|
report
|
Admission Date: [**2166-12-6**] Discharge Date: [**2166-12-7**]
Date of Birth: [**2093-3-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Right IJ CVL
Left Arterial line
History of Present Illness:
This is a 73 F with advanced ovarian cancer with peritoneal
carcinomatosis, h/o atrial fibrillation, recurrent episodes of
SBO (nonsurgical candidate), who presented to the ED earlier
yesterday s/p fall at home. Per family, patient began vomiting 1
day PTA and sustained a fall at home due to dizziness, hitting
her head. She had no other symptoms at the time, including
fevers/chills, chest pain, SOB, diarrhea or dysuria. +abdominal
pain that also began 1 day PTA, diffuse in nature and consistent
with her prior presentations of SBOs. She was brought into the
ED for further evaluation.
.
In the ED, patient was hypotensive to the 70's systolic,
requiring titration up to three pressors after IVF, although SBP
still remained in the 70's. Right IJ and A-line were also
placed. She was tachypneic and became increasingly acidemic
throughout her ED course: 7.44->7.34->7.29. She received 4.5 L
NS with CVP responding at 9, and then started on pressors (levo,
dopa, vasopression). She also received Cefepime, flagyl, and
repletion of her low K and low Mg. Cardiology performed a
bedside TTE to rule out pericardial effusion/tamponade as an
etiology of her hypotension. OB/gyn, heme-onc, and surgery were
made aware of her admission. She was deemed to be a nonsurgical
candidate.
Past Medical History:
Stage I breast cancer (right), s/p mastectomy
Ovarian cancer, stage IIIb-IV with peritoneal carcinamatosis
atrial fibrillation
h/o atrial septal defect s/p CABG and repair
HTN
h/o bradycardia s/p pacemaker
Social History:
Lives at home with her husband, no tobacco/EtOH/illicits.
Family History:
The patient's father had multiple myeloma.
Physical Exam:
VS: Tc 95.9, BP 74/49, HR 70, RR 32, SaO2 87%/NRB
General: critically-ill appearing female in respiratory
distress, moaning from abdmoninal discomfort
HEENT: PERRL, EOMI. +NRB in place
Neck: supple, +right IJ with oozing
Chest: diffuse expiratory wheezes with crackles at the bases b/l
CV: RRR no m/g/r
Abd: firm, distended with TTP diffusely. +voluntary guarding.
Decreased BS.
Ext: no c/c/e, +left radial A-line
Pertinent Results:
[**2166-12-6**] CT abd/pelvis -
1. Limited examination.
2. Findings concerning for small-bowel obstruction secondary to
mass in the terminal ileum.
3. Ventral wall hernia involving segment III of the liver.
4. Right adnexal mass.
5. Hyperdense subcapsular metastasis has increased in size.
.
[**2166-12-6**] CXR -
Single bedside AP examination labeled" "upright" with extreme
right
CP angle excluded from the film, and tubing overlying the
thorax. The study is compared with similar examination dated
[**2166-9-17**]; the overall appearance is essentially unchanged. The
patient is status post median sternotomy [**2164**] apparently intact
sternal cerclage wires. Left-sided unipolar pacemaker appears
to terminate in the RV apex, unchanged (single view) evidence of
denuding of a short, 6 mm segment of wire installation,
representing "sheath separation" at the costoclavicular
intersection, a finding unchanged on serial
studies dating to [**10-9**]. The heart size is unchanged, with no
specific evidence of CHF. No focal consolidation is seen.
.
[**2166-12-6**] CT head - No ICH or mass effect.
.
Brief Hospital Course:
This is a 73 y/o female with advanced ovarian CA with peritoneal
carcinomatosis, recurrent SBO, who presented with abdominal pain
and refractory hypotension, hypothermia, leukopenia with
bandemia, and tachypnea. She fit criteria for septic shock and
was admitted to the MICU for further management. Upon admission,
she was on 4 vasopressors with SBP's in the 70's. Presumed
source was her abdomen (likely ischemic bowel with
superinfection) and surgery was consulted while she was in the
ED for her SBO. She was deemed not to be an operative candidate
given her extensive abdominal involvement from the ovarian
cancer. Her urine and CXR were unremarkable. She was continued
on broad-spectrum antibiotics to cover all potential sources and
was also started on IV steroids due to profound refractory
hypotension on 4 pressors.
She had a severe metabolic acidosis on admission due to lactic
acidosis and respiratory support measures (i.e. NIV and
intubation) were discussed with the patient and her family.
Given her profund septic shock, we explained to the family and
the patient that once she were intubated, the chance of being
extubated was low. The patient and family understood and
expressed wishes for the patient to be a DNI/DNR. An extensive
discussion was held with the family regarding the patient's grim
prognosis, given her septic shock, non-operable status, and need
for maximal medical support. A decision with the MICU attending
present was made to make the patient comfort measures only, as
she was rapidly declining on maximal medical support. She was
kept comfortable with morphine IV prn and fentanyl IV prn for
her abdominal pain and respiratory status. She expired
approximately 4 hours after arrival to the MICU with her family
present. The case was discussed with medical examiner, who
declined the case. The family declined autopsy as well.
Medications on Admission:
1. Coumadin 3 mg daily
2. Ranitidine 150 mg [**Hospital1 **]
3. Dyazide 1 tab daily
4. Compazine prn
5. Femara 2.5 mg daily
6. Neurontin 900 mg tid
7. Megace 400 mg daily
8. Digoxin - dose unclear
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2166-12-9**]
|
[
"584.9",
"427.31",
"197.6",
"414.00",
"785.52",
"183.0",
"038.9",
"V45.81",
"995.92",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5762, 5771
|
3620, 5485
|
327, 360
|
5822, 5831
|
2483, 3597
|
5884, 5919
|
1989, 2033
|
5733, 5739
|
5792, 5801
|
5511, 5710
|
5855, 5861
|
2048, 2464
|
276, 289
|
388, 1669
|
1691, 1898
|
1914, 1973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,145
| 188,266
|
46347
|
Discharge summary
|
report
|
Admission Date: [**2117-11-15**] Discharge Date: [**2117-11-19**]
Date of Birth: [**2048-10-26**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / Erythromycin Base / Vicodin
Attending:[**First Name3 (LF) 87305**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Femoral Line with pressor support
ICU admission
History of Present Illness:
69F w/hx of lung adenocarcinoma metastatic to bone presenting
with hypoxia, increased increased oxygen requirement and cough.
Developed over the last day or two. Patient was hypoxic to the
80s on her home 2L. Expereicned increased lethargy. Notable
negatives: no CP, fever, chills.
Patient was recently admitted from [**Date range (1) 29694**]/11 with anemia
[**1-13**] chemo and/or bony mets and an elevated white count. She was
transfused 2UPRBC. In addition, she started taxotere therapy the
day of discharge.
.
In the ED inital vitals were temp of 99.4 HR 98 BP 88/54 RR 22
satting 100% on Non-Rebreather. Labs were notable for white
count of 18.7 (21.2 on [**2117-11-11**]) and Hct 23.3 down from 27.7,
troponin <0.01 and lactate 1.7. Urinalysis had trace leuks, neg
nitrates and WBC 14 with few bacteria. She was given vancomycin
1g IV, cefepime 1g IV, and pulse dose of methylprednisone 125mg
IV. Blood pressures dropped to systolic 80s. She was bolused 3L
NS without improvement, so a femoral line was placed and
levophed was started. She was unable to be weaned off of
non-rebreather and so was transferred to the ICU for further
management. Vital signs prior to transfer were T 98.6, 109,
107/55, NRB @ 99%. CXR was read as extensive metastatic disease
to the lungs with right pleural effusion and right basal
consolidation.
.
The team spoke with pt's oncologist Dr. [**First Name (STitle) 3459**] who was concerned
this pleural effusion could be due to radiation pneumonitis, rec
adding solumedrol to her regimen. Agreed with admission to [**Hospital Unit Name 153**].
.
On arrival to the ICU, VS were 97.9 98 90/61 22 satting 98% on
NRB @ 15L.
Past Medical History:
Oncology History:
Ms. [**Known firstname **] [**Known lastname **] is a 68-year-old woman diagnosed with
pneumonia in [**2117-6-11**]. She failed to improve after multiple
courses of antibiotics and eventually a CT scan of the chest on
[**2117-7-27**] demonstrated consolidation of the right lower lobe
and right middle lobe with narrowing of the bronchus
intermedius.
[**2117-7-29**]: saw Dr. [**Last Name (STitle) 34792**] and eventually underwent a first
attempt at bronchoscopy on [**2117-8-10**], which was nondiagnostic and
then a second bronchoscopy on [**2117-8-13**] by Dr. [**Last Name (STitle) **] at the
[**Hospital3 **], which was nondiagnostic. However, there was
extensive extrinsic
compression.
[**2117-8-20**]: underwent a third bronchoscopy, biopsy revealed
adenocarcinoma with LVI, and pathology from 4 lymph nodes also
contained adenocarcinoma. The patient had a CT pulmonary
angiogram to rule out PE for complaints of worsening shortness
of breath and it revealed substantial consolidation in the right
middle lobe with the right lower mass, now measuring up to 15
cm, although some of that may
have been collapse of the right lower lobe.
[**2117-8-30**]: initial Cncology consult. Referred for staging
studies.
[**2117-9-2**]:PET scan at the [**Hospital3 **] revealed extensive bony
metastases in the large right lung mass, also there is an FDG
avid adrenal nodule.
[**2117-9-3**]: MRI of the brain was negative.
The patient and family expressed an interest in outpatient
management close to their home in [**Location (un) 1110**], [**State 350**].
Therefore, she was referred to [**Hospital3 1196**]. She
was seen by Dr. [**First Name8 (NamePattern2) 3460**] [**Last Name (NamePattern1) **] of Radiation Oncology and chest
simulation was planned for
[**Date range (1) 98517**]/11: While inpatient at [**Hospital1 18**] evalulation of R hip
demonstrated intramedullary tumor in the femur, but the cortex
was intact.
[**2117-9-9**]: Started radiation
[**2117-9-8**] Week #1 carboplatin AUC2 and paclitaxel 60mg/m2
(inpatient [**Hospital1 18**])
[**2117-9-13**] Discharge home
[**2117-9-15**] Week #2 carboplatin AUC2 and paclitaxel 60mg/m2
([**Location (un) **]) and Zometa
[**2117-9-22**] Week #3 carboplatin AUC2 and paclitaxel 60mg/m2-reacted
with chest pain
[**2117-9-27**] Follow up and fluids
[**2117-9-29**] Week #4 carboplatin AUC2, taxol held due to reaction
[**2117-9-30**] Complete XRT
[**2117-10-6**] Cycle #1 carboplatin AUC 5 and pemetrexed 500mg/m2
[**2117-10-13**] Zometa 4mg/ IVF, nadiring, low H/H and PLTS, developed
epistaxis and brief episode of chest pain resolved with mylanta,
sent to [**Hospital1 18**] ER
PAST MEDICAL HISTORY:
Bone metastases
Lung cancer
RLL pneumonia
Hypokalemia
Osteoporosis
TOBACCO DEPENDENCE
HYPERTENSION - ESSENTIAL
ANXIETY STATES, UNSPEC
HYPERCHOLESTEROLEMIA
Social History:
The patient smoked 1 pack per day since age 30 and she is trying
to quit. She is married. Her husband is [**Name (NI) **]. She has a son
and a daughter. The daughter has two children. She is a
retired special education classroom assistant for the town of
[**Location (un) 13040**].
Family History:
Mother died secondary to a brain tumor. Son also had a brain
tumor which was successfully treated. Father had CAD and alcohol
abuse.
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral crakcles, most pronounced in right base
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
97.7, 155/91, 118, 22-26, 91 5LNC
GENERAL: very anxious, pale, redirectable but scattered
SKIN: cool, no excoriations or lesions, no rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera
CARDIAC: RRR, S1/S2, no mrg
LUNG:Crackles through out with diminished breath sounds on the
right side. rapid breating with accessory muscle use.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Admission labs:
WBC-18.7* RBC-2.62* HGB-7.8* HCT-23.3* MCV-89 MCH-29.9 MCHC-33.6
RDW-19.7*
NEUTS-90* BANDS-0 LYMPHS-3 MONOS-2 EOS-2 BASOS-0 ATYPS-0
METAS-2* MYELOS-1*
HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL
MICROCYT-1+ POLYCHROM-OCCASIONAL [**Name (NI) 98521**]
[**Name (NI) 98522**]
PT-15.8* PTT-31.6 INR(PT)-1.5*
LACTATE-1.7
cTropnT-<0.01
proBNP-1143*
DISCHARGE LABS: [**2117-11-17**] 05:49AM BLOOD WBC-10.6 RBC-2.70*
Hgb-8.2* Hct-25.0* MCV-93 MCH-30.5 MCHC-33.0 RDW-18.5* Plt
Ct-118*
Microbiology:
Blood cultures ([**2117-11-15**])- x 2, no growth to date
Urine culture ([**2117-11-15**])- urine legionella antigen negative, no
growth
Aspergillus galactomannan- pending
Beta-glucan- pending
Imaging:
CXR ([**2117-11-15**])- Overall stable exam with extensive metastatic
disease to the lungs with right pleural effusion and right basal
consolidation.
CTA chest ([**2117-11-16**])- As compared to the previous examination
from [**2117-10-27**], there is no relevant change. No
pulmonary embolism. Large mass in the right lung with invasion
of the hilar and the mediastinum. Innumerable metastatic lung
nodules. An area of consolidation at the left lung base has
minimally increased. Multiple osteodestructive lesions.
Brief Hospital Course:
69 yof with metastatic NSCLC presenting with shortness of
breath, hypoxia and hypotension.
RESPIRATORY DISTRESS- Patient was on non-rebreather on arrival
to the ICU. Overnight on the day of admission, she was weaned
to nasal cannula. There was concern for radiation pneumonitis,
and so patient was started on steroids. CTA showed no pulmonary
embolism, and no evidence of radiation pneumonitis, and so
steroids were discontinued on HD2. She was treated broadly with
vancomycin, cefepime and levofloxacin for concern for HCAP given
recent admission to the hospital, however, cultures were all
negative and she improved, so these mediactions were
discontinued after 48 hrs. Patinet's respiratory status
continued to decline over the course of her stay from
progression of her malignancy. The decision was made that the
patient wanted to have comfort measures only and be transitioned
to home hospice. She was discharged to home.
.
HYPOTENSION- Patient was initially hypotensive to the 80s
requring central venous access and pressor support. No clear
etiology was discovered as CTA was negative for PE, her cardiac
function appeared intact and no evidence of sepsis was observed.
Paitent was rapidly weaned from pressors and her BPs
normalized.
.
NON SMALL CELL LUNG CANCER ?????? CTA showed stable diffuse pulmonary
infiltrates without progression of disease. Patient was started
on bactrim prophylaxis which was discontinued when patient
elected for comofort focused care.
.
ANEMIA - chronic component, with additional decline. No
evidence for acute blood loss. Patient was transfused 2U PRBC
with good response.
GOALS OF CARE- family meeting took place on HD1 with patient and
husband. Determined that patient would be DNR/DNI and elected
to focus on comfort based care. the patient was discharged home
with hospice.
.
TRANSITIONAL ISSUES:
patient is a DNR/DNI
patient is not to be readmitted to the hospital
patient is home with hospice care
Medications on Admission:
1. alum-mag hydroxide-simeth 200-200-20 mg/5 mL PO QID as needed
for chest pain/dysphagia.
2. oxycodone 60 mg Extended Release PO Q12H
3. oxycodone 5 mg PO Q3H prn pain
4. omeprazole 20 mg Delayed Release(E.C.) PO DAILY
5. atenolol 12.5 mg PO DAILY
6. lorazepam 0.5 mg PO Q4H prn
7. folic acid 1 mg PO DAILY
8. prochlorperazine maleate 10 mg PO Q6H prn
9. docusate sodium 100 mg PO BID
10. dexamethasone 4 mg PO DAILY
11. sucralfate 1 gram PO QID
12. gabapentin 300 mg PO HS
13. senna 8.6 mg PO BID prn
14. ondansetron 8 mg Tablet, Rapid Dissolve PO Q8H prn
Discharge Medications:
1. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Senna Lax 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*30 Tablet(s)* Refills:*2*
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
4. OxyContin 60 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every twelve (12) hours.
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2*
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for wheeze.
Disp:*30 * Refills:*2*
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*2*
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*30 * Refills:*2*
10. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
Fifteen (15) ML PO TID (3 times a day) as needed for heartburn.
Disp:*30 suspensions* Refills:*2*
11. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
Disp:*30 * Refills:*2*
12. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane every four (4) hours as needed for sore throat.
Disp:*60 * Refills:*2*
13. oxyfast 20 mg/mL Sig: 1-20 mg/mL q1h as needed for pain.
Disp:*100 mL* Refills:*2*
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*30 Tablet(s)* Refills:*2*
15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*120 Tablet(s)* Refills:*0*
16. oxycodone 5 mg/5 mL Solution Sig: [**4-20**] mL PO every four (4)
hours as needed for pain: Use if patient unable to tolerate oral
medications.
Disp:*300 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
PRIMARY:
Respiratory Distress
Hypotension
Lung cancer
Secondary:
Osteoporosis
TOBACCO DEPENDENCE
HYPERTENSION - ESSENTIAL
ANXIETY STATES, UNSPEC
HYPERCHOLESTEROLEMIA
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 while you were in the
hospital. You were admitted for evaluation of your respiratory
distress and sent to the intensive care unit. You received IV
antibiotics, steroids and medications to improve you blood
pressure. Your clinical status improved rapidly and you were
transfered to the regular oncology floor. Given the progressive
nature of your cancer you elected to focus your care on your
comfort rather than [**Hospital 17073**] medical treatments. You were
discharged home with hospice care to better meet these needs.
The following changes were made to your medications:
START Albuterol Neb every 6 hours as needed
START oxycodone liquid 5-10mL by mouth every 4 hours as needed
for pain if unable to tolerate pills
START Ondansetron by mouth 4 mg every 8 hours as needed for
nausea
START Dexamthasone by mouth 4 mg every 12 hours
START ipratropium-albuterol nebulizer every 4-6 hours as needed
START Oxyfast 20 mg/mL 1-20 mg by mouth every 1 hour as needed
for pain
CONTINUE Docusate by mouth 100 mg twice daily
CONTINUE Senna 8.6 by mouth mg twice daily
CONTINUE lorazepam 0.5 mg Tabletby mouth every 6 hours
CONTINUE lorazepam 0.5mg tablet by mouth every 4 hours as needed
for anxiety
CONTINUE oxycodone 60 mg Tablet Extended Release 12 hr Sig: One
(1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
CONTINUE omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig:
Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
CONTINUE sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4
times
a day).
CONTINUE petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Stop atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Followup Instructions:
None
|
[
"198.5",
"338.3",
"300.00",
"530.81",
"305.1",
"V87.41",
"V15.3",
"707.03",
"300.01",
"162.8",
"272.0",
"401.9",
"707.22",
"799.02",
"733.00",
"785.59",
"196.1",
"285.9",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12527, 12605
|
7685, 9519
|
325, 375
|
12816, 12816
|
6414, 6414
|
14700, 14708
|
5251, 5386
|
10255, 12504
|
12626, 12795
|
9671, 10232
|
12967, 14677
|
6808, 7662
|
5426, 5881
|
9540, 9645
|
266, 287
|
403, 2067
|
6430, 6791
|
12831, 12943
|
4771, 4928
|
4944, 5235
|
5906, 6395
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,709
| 173,305
|
45264
|
Discharge summary
|
report
|
Admission Date: [**2171-9-14**] Discharge Date: [**2171-9-19**]
Date of Birth: [**2089-4-28**] Sex: F
Service: MEDICINE
Allergies:
Plaquenil / Daypro / Atenolol / Keppra
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
Left hemiarthroplasty
History of Present Illness:
Ms. [**Known lastname 96713**] is an 82-year-old female with severe diastolic
heart failure, moderate pulmonary hypertension, afib on
anticoagulation, rheumatoid arthritis, and chronic anemia who
was admitted to the orthopedics service for a left femoral neck
transverse fracture which occured in the setting of a mechanical
fall while cleaning her house on [**2171-9-14**]. She denied any chest
pain, palpitations, pre-syncopal, or syncopal episodes prior to
the fall. She denied any LOC or any head trauma.
.
After ortho surgery she was extubated. She was intitially
satting well on 4LNC. She became progressively more hypoxic,
hypertensive, tachycardic (A fib to 130s) and tachypneic. She
was placed on NRB and an ABG was obtained which showed
hypercarbic and hypoxic respiratory failure. A CXR showed
pulmonary edema. She was given lasix and nitropaste and put out
300 ccs of urine. She was then placed on BIPAP. While on BIPAP,
she was noted to have a focal motor (arm) seizure which was new
to her which resolved prior to receiving any medications. She
developed a second right arm focal motor seizure
post-operatively and was given 2 mg of ativan IV. She was
hypoxic during the event and was bagged by anesthesia. She was
then placed back on BIPAP. Patient was transferred to the MICU.
.
Patient was diuresed in the MICU. She had a head CT due to
seizure activity that was negative. She had an echo that showed
diastolic HF and moderate pulmonary hypertension. Also post op
was given 1 unit RBCs. Patient was transferred to the floor and
she has been stable
Past Medical History:
1. Non-ischemic cardiomyopathy
-TTE [**11-14**]: EF 50-55%, LVH, with now more mod-severe diastolic
CHF compared to prior echos
-Cardiac Cath [**6-12**] with 40% LAD stenosis
-Difficult to manage, is hospitalized for exacerbations often
2. Moderate pulmonary HTN
-3+ TR on [**7-14**] echo
3. Hypertension
4. Paroxysmal atrial fibrillation on coumadin
5. Rheumatoid arthritis on methotrexate
6. Macrocytic Anemia
7. Osteoarthritis
8. Gout
9. Osteoporosis
10. Pancreatic cyst: Already worked up by heme-onc, and adressed
by PCP and GI, no further work up at this time recommended.
11. Failure to thrive: decreased appetite, managed currently
with ensure.
Social History:
She is married and lives in a house with her husband, son, and
daughter in law. Retired from [**Male First Name (un) 96714**] stores this year. Her
husband is well. She denies drugs and alcohol. 50-pack year
smoking history, occasionally smokes now.
Family History:
Mom - DM, arthritis
Dad - no health problems
[**Name (NI) **] family history of premature CAD or SCD.
Physical Exam:
VS: HR 80, BP 104/48, 98% on Bipap, RR 20,
Gen: somnolent, opens eyes to voice/sternal rub, follows simple
commands
HEENT: bipap in place
CV: RRR, no m/r/g
Pulm: Crackles [**2-9**] way up bilaterally, no wheezes/crackles
Abd: soft, NT, ND, bowel sounds present
Ext: LLE with bandage with small amount of blood, mild edema,
cool extremities
Neuro: somnolent, follows simple comands
Pertinent Results:
[**2171-9-14**] 11:52PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2171-9-14**] 11:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2171-9-14**] 11:52PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2171-9-14**] 09:45PM TYPE-ART TEMP-37.0 O2-80 PO2-218* PCO2-47*
PH-7.33* TOTAL CO2-26 BASE XS--1 AADO2-318 REQ O2-57
INTUBATED-NOT INTUBA
[**2171-9-14**] 07:20PM TYPE-ART PO2-152* PCO2-50* PH-7.29* TOTAL
CO2-25 BASE XS--2
[**2171-9-14**] 07:20PM LACTATE-4.3*
[**2171-9-14**] 06:42PM GLUCOSE-171* UREA N-23* CREAT-1.3* SODIUM-134
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-20* ANION GAP-18
[**2171-9-14**] 06:42PM CK(CPK)-191*
[**2171-9-14**] 06:42PM CK-MB-10 MB INDX-5.2 cTropnT-0.03*
[**2171-9-14**] 06:42PM CALCIUM-7.8* PHOSPHATE-3.8 MAGNESIUM-1.6
[**2171-9-14**] 06:42PM WBC-9.7 RBC-3.05* HGB-11.1* HCT-36.0 MCV-118*
MCH-36.3* MCHC-30.8* RDW-14.9
[**2171-9-14**] 06:42PM NEUTS-94.1* LYMPHS-4.6* MONOS-1.1* EOS-0.1
BASOS-0.1
[**2171-9-14**] 06:42PM PLT COUNT-140*
[**2171-9-14**] 06:42PM PT-15.2* PTT-24.7 INR(PT)-1.3*
[**2171-9-14**] 05:56PM TYPE-ART TEMP-36.9 PO2-77* PCO2-51* PH-7.32*
TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA
[**2171-9-14**] 05:56PM GLUCOSE-173* LACTATE-2.1* NA+-139 K+-4.6
[**2171-9-14**] 03:18PM GLUCOSE-131* UREA N-24* CREAT-1.4* SODIUM-139
POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2171-9-14**] 03:18PM CK(CPK)-165*
[**2171-9-14**] 03:18PM CK-MB-8 cTropnT-0.03*
[**2171-9-14**] 03:18PM CALCIUM-8.8 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2171-9-14**] 03:09PM WBC-13.5* RBC-3.29* HGB-12.0 HCT-38.3
MCV-116* MCH-36.5* MCHC-31.4 RDW-14.9
[**2171-9-14**] 03:09PM PLT COUNT-138*
[**2171-9-14**] 03:09PM PT-22.7* INR(PT)-2.1*
[**2171-9-14**] 06:15AM GLUCOSE-99 UREA N-23* CREAT-1.3* SODIUM-142
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-27 ANION GAP-16
[**2171-9-14**] 06:15AM CALCIUM-8.4 PHOSPHATE-4.5# MAGNESIUM-2.0
[**2171-9-14**] 06:15AM WBC-9.5# RBC-3.02* HGB-11.0* HCT-35.5*
MCV-118* MCH-36.5* MCHC-31.0 RDW-14.9
[**2171-9-14**] 06:15AM PLT COUNT-146*
[**2171-9-14**] 06:15AM PT-18.4* PTT-25.7 INR(PT)-1.7*
[**2171-9-13**] 10:20PM URINE HOURS-RANDOM
[**2171-9-13**] 10:20PM URINE GR HOLD-HOLD
[**2171-9-13**] 10:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2171-9-13**] 10:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2171-9-13**] 10:20PM URINE RBC-0-2 WBC-[**4-11**] BACTERIA-MOD YEAST-NONE
EPI-0
[**2171-9-13**] 10:20PM URINE HYALINE-0-2
[**2171-9-13**] 08:15PM GLUCOSE-143* UREA N-19 CREAT-1.3* SODIUM-138
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
[**2171-9-13**] 08:15PM estGFR-Using this
[**2171-9-13**] 08:15PM cTropnT-0.02*
[**2171-9-13**] 08:15PM DIGOXIN-0.7*
[**2171-9-13**] 08:15PM WBC-6.3 RBC-3.02* HGB-11.6* HCT-34.4*
MCV-114* MCH-38.5* MCHC-33.8 RDW-15.2
[**2171-9-13**] 08:15PM NEUTS-81.6* LYMPHS-12.9* MONOS-4.9 EOS-0.5
BASOS-0.2
[**2171-9-13**] 08:15PM PLT COUNT-188
[**2171-9-13**] 08:15PM PT-21.5* PTT-25.0 INR(PT)-2.0*
FOLLOWING LABS FROM [**2171-9-19**]
White Blood Cells 6.8
Red Blood Cells 2.50*
Hemoglobin 9.0*
Hematocrit 27.9*
MCV 112*
MCH 36.1*
MCHC 32.4 %
RDW 17.5*
Platelet Count 140*
Glucose 88
Urea Nitrogen 32*
Creatinine 1.0
Sodium 138
Potassium 4.5 mEq/L
Chloride 100 mEq/L
Bicarbonate 32
PT 18.6*
PTT 27.1
INR(PT) 1.7*
CT Head:
Unchanged appearance of the brain without evidence of acute
intracranial
abnormalities. MRI would be more sensitive for evaluation of new
seizures, if clinically indicated.
Brief Hospital Course:
Ms. [**Known lastname 96713**] is an 82 yo female with severe chronic diastolic
HF, afib on coumadin, HTN, moderate pulmonary hypertension,
rheumatoid arthritis, chronic anemia who is s/p hip replacement
for mechanical fall complicated by post-op hypoxia.
.
SHORTNESS OF BREATH: SOB is likely secondary to diastolic CHF
given that she is known to have significant diastolic CHF and
has had several admissions for CHF exacerbations. She reportedly
got only 1L NS in the OR and 2 units of FFP. Additionally her
post-op pain may have contributed to tachycardia and worsening
diastolic dysfunction. Patient was transferred to the MICU
post-op and diuresed with lasix. A dilt drip was started for HR
control and blood pressure was controlled with nitropast/drip.
An a-line was placed in the MICU for frequent abgs. Home
digoxin and spironolactone were continued. Patient was
stablized and transferred to the floor on [**2171-9-17**]. On the floor
she has not complained of shortness of breath. She was on
oxygen upon transfer, but has not required O2 for the past 2
days; she is satting well on room air.
.
SEIZURE: Family denies history of seizure though patient has a
keppra allergy suggesting seizure at some point. Patient states
that her doctor thought she had a seizure a few years back but
then changed his mind. CT head was negative for any acute
change. She should seek neuro follow-up and EEG as an
outpatient.
.
HIP REPLACEMENT: Patient post-op for hip replacement. Per neuro,
able to weight bear fully on both legs now. Patient started
lovenox 40units every night for DVT prophylaxis after ortho
surgery. Her coumadin was also started and her INR is climbing
up. It was 1.7 on day of discharge. She is also receiving
tylenol round the clock and morphine 7.5mg every 4 hours as
needed. Her fosamax, calcium, and vitamin D should be continued
as an outpatient for osteoporosis.
.
AFIB WITH RVR: with RVR. Patient with A. fib with RVR
post-operatively leading to diastolic CHF exacerbation. She is
now on Digoxin, metoprolol 25mg [**Hospital1 **] and comadin. Her INR is 1.7
on discharge. She has had no episodes of RVR on the floor.
Please continue with current treatment.
.
CAD. Cardiac enzymes mildly elevated post-operatively without
ischemic changes on EKG. This was likely secondary to demand
ischemia. We continued aspirin and statin. Beta-blocker was
discontinued at first but restarted upon transfer to the floor.
Patient came in on Toprol XL but has done well with metorolol
25mg [**Hospital1 **] in house. We will continue with metoprolol 25mg [**Hospital1 **]
upon discharge.
.
HYPERTENSION: Patient was hypertensive in the MICU and was
controlled with dilt drip and nitro paste/drip. She has done
well on the floor without any episodes of hypertension. Please
continue her current anti-hypertensive regimen including
metoprolol 12.5mg twice a day, furosemide 10mg 4x/week,
lisinopril 2.5mg at night, spironolactone 12.5mg every day.
.
RHEUMATOID ARTHRITIS: Patient is chronically on methotrexate
and 5 mg of prednisone. She did not receive methotrexate in
hospital. Please continue methotrexate 5mg every Thursday.
Please continue prednisone 5mg daily.
.
OSTEOPOROSIS: Continue calcium, vitamin D, alendronate.
.
GOUT: Continue allopurinol.
.
CONSTIPATION: Patient states that she has not had a bowel
movement in a week nor passed gas in 4 days. A radiograph of
her abdomen was performed, which showed a large amount of stool
and was negative for obstruction. She was given a ducolax
suppository today, a Fleets enema, and lactulose. Upon
discharge she had not had a BM. Rehab made aware.
.
Patient stated that she wanted to be full code. She had
peripheral IV access while on the floor. Her contact is her
husband, daughter, or daughter-in-law. ([**Name (NI) **] - HCP)
[**Telephone/Fax (1) 96712**]
Medications on Admission:
Alendronate 35 mg [**Telephone/Fax (1) 20515**]
Allopurinol 150 mg daily
Digoxin 125 mcg 4/week (tues/thurs/sat/sun)
Folic Acid 1 mg daily
Furosemide 10 mg 4x/wk (tues/thurs/sat/sun)
Lisinopril 2.5 mg QHS
Methotrexate 5 mg every thursday
Toprol XL 25 mg QHS
Pravastatin 10 mg QHS
Prednisone 5 mg daily
Spironolactone 12.5 mg daily
Trazadone 25 mg QHS
Warfarin 2.5 mg 6x/week, 5 mg on thurs
Acetaminophen 650 mg [**Hospital1 **] PRN pain
Citracal + D 1500 mg/200 units [**Hospital1 **]
Ensure 1 can QHS
Guar gum QHS
Multivitamin 1 tab daily
Ocuvite 1 tab [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Multivitamin [**Hospital1 8426**] Sig: One (1) Cap PO DAILY (Daily).
3. Calcium Carbonate 500 mg [**Hospital1 8426**], Chewable Sig: One (1)
[**Hospital1 8426**], Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit [**Hospital1 8426**] Sig: One (1)
[**Hospital1 8426**] PO DAILY (Daily).
5. Allopurinol 100 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
6. Folic Acid 1 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
7. Pravastatin 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO HS (at
bedtime).
8. Prednisone 5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
9. Spironolactone 25 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO DAILY (Daily).
10. Digoxin 125 mcg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
QPM (once a day (in the evening)).
12. Warfarin 2.5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO QPM (once a
day (in the evening)).
13. Aspirin 81 mg [**Hospital1 8426**], Chewable Sig: One (1) [**Hospital1 8426**], Chewable
PO DAILY (Daily).
14. Metoprolol Tartrate 25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID
(2 times a day).
15. Acetaminophen 500 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Q6H
(every 6 hours).
16. Furosemide 20 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO QTUES, THURS,
SAT, SUN ().
17. Morphine 15 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO Q4H (every 4 hours)
as needed for pain.
18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily): Until patient has a bowel movement.
19. Senna 8.6 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation: Until patient has a bowel movement.
20. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis: Left femoral Neck fracture
Acute on Chronic diastolic heart failure
Atrial Fibrillation with rapid ventricular response
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters
You were admitted with a femoral fracture. You were taking to
the operating room where they fixed your fracture, but
afterwards you developed shortness of breath and were taken to
the MICU where you had fluid taken off of your lungs. You
improved, and were taken to the medical floor where you were
seen by physical therapy, and you were cleared for
rehabilitation. You will need to complete a short course of
antibiotics as listed below. You will need follow up with Dr.
[**Last Name (STitle) **] as scheduled below.
The following changes were made to your medications:
Cephalexin 500 mg three times a day for 7 days
Please keep all scheduled appointments
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pains, fevers, chills,
shortness of breath, nausea, vomiting, diarrhea, or
pain/swelling/redness or discharge from your leg wound.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**2171-10-4**] 10:00 AM- [**Location (un) 1385**] [**Hospital Ward Name **]
Please schedule a followup appt with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1683**]
[**Telephone/Fax (1) 1144**] for followup in [**3-13**] weeks.
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - [**Last Name (NamePattern1) **] MEDICINE (SB)
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2171-10-16**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2171-10-16**] 3:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2171-10-28**] 2:40
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"584.9",
"305.1",
"428.33",
"416.8",
"733.00",
"E885.9",
"401.9",
"714.0",
"274.9",
"428.0",
"427.31",
"518.5",
"715.90",
"425.4",
"820.8",
"564.09",
"345.50",
"V58.61",
"285.29",
"577.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13639, 13709
|
7083, 10938
|
312, 336
|
13892, 13901
|
3416, 6874
|
14976, 15880
|
2895, 2999
|
11559, 13616
|
13730, 13730
|
10964, 11536
|
13925, 14953
|
3014, 3397
|
259, 274
|
364, 1935
|
6883, 7060
|
13749, 13871
|
1957, 2612
|
2628, 2879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,905
| 115,900
|
11963
|
Discharge summary
|
report
|
Admission Date: [**2141-5-6**] Discharge Date: [**2141-5-23**]
Date of Birth: [**2064-10-30**] Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
s/p cardiopulmonary arrest
Major Surgical or Invasive Procedure:
Mechanical Ventilation (previously trached)
Central venous Catheter
R SC placed [**5-6**] -> d/c'd and changed to PICC line
left femoral A-Line placed [**5-6**]
Chest tube removal
History of Present Illness:
This is a 76 y/o male with with history of large right MCA and
MCA/PCA watershed infarct in [**2-15**], likely cardioembolic due to
his history of atrial fibrillation; cardiomyopathy with EF 15%;
s/p MRSA pneumonia, now with E.coli pleural effusion; C.diff
infection; and s/p recent trach and PEG on [**4-28**] for inability to
wean vent from recurrent aspirations; found unresponsive at the
[**Hospital1 **] Facility this morning. Patient is interactive but
non-verbal ([**1-13**] trach) at baseline, but it is not clear from
records when he was last seen normal.
.
This morning at rehab, at approximately 7:20 am he was found to
be unresponsive and pulseless, but had a blood pressure of at
least 100/60. He was given CPR for 8 minutes, although the
records document a pulse at one minute, and he received
epinephrine, after which he had Vtach at 192, for which pt was
loaded with amiodarone and started on amiodarone gtt. Per
patient's sister, he has been having increased secretions from
trach +/- bloody secretions, requiring increased suctioning.
This is not documented in NH records.
.
He was then transferred to the [**Hospital1 18**] ED, with stable BP in
120's/70's and HR in 70's. Initial VS in ED were Tc 98.4, BP
124/70, HR 80's, RR 18, SaO2 100%/vent. He was continued on
amiodarone and given levofloxacin for abx coverage. He had blood
and urine cx sent, CXR, CT head (negative), and CT torso done.
Upon initial exam, he was noted to flex his limbs to noxious
stimuli, but his eyes were deviated up and to the left, and he
had a "resting tremor" of the left arm, which was described as
intermittent twitches of the arm that were not sustained or
rhythmic. He was then transferred to the MICU for further
management. Just before he was transported his nurse in the ED
noticed more pronounced left arm twitching. The ED resident
evaluated him and then called Neurology for a consult
re:?seizure, while the patient was being taken to the ICU.
.
Upon arrival to the MICU, pt's VS were stable, however he was
noticed to have left arm twitching and blood at the corner of
his mouth. Upon opening his mouth, the tongue was found to be
bitten and macerated, with tongue fasiculations. An oral airway
was placed. Patient was given 4 mg IV ativan total and loaded
with 1 gm dilantin.
Past Medical History:
- Hypertension
- hypercholesterolemia
- disc bulge L4-5 w/o herniation
- hx of osteomyelitis T12-11 [**2136**]
- screening carotid study '[**37**]: bilateral mild to moderate
carotid stenosis
- s/p laminectomy thoracic spine
- Cardiomyopathy with LVEF 10-15%
- Ischemic MCA CVA [**2-15**]
- Paroxsymal Afib
- History of GI bleed
- Aspiration PNA (patient failed speech and swallow in past)
- CRI with baseline Cr 1.8-2.2
- s/p trach/PEG [**4-29**]
Social History:
From [**Hospital **] rehab. No history of tobacco, history of heavy
alcohol use (2 pint/day) but has been less recently. Retired
biochemist.
Family History:
NC
Physical Exam:
VS: Tc 95.6, BP 129/79 ->80's/40/s with dilantin, HR 83-100, RR
19, SaO2 100%/AC 450 x 14, FiO2 50%, PEEP 5.
General: Unresponsive male with rightward eye gaze, biting down
on tongue
HEENT: Pupils pinpoint and non-reactive. No doll's eye reflex.
+tongue biting and fasiculations. Oral airway in place. Trached.
Neck: supple, unable to assess JVD
Chest: Diffue coarse rhonchi, right chest tubes in place
CV: RRR s1 s2 distant, no murmurs appreciated
Abdomen: obese, soft, active bowel sounds, PEG c/d/i
Ext: +2 edema in LE and UE b/l; heel ulcer
Neuro: Unresponsive except to noxius stimuli, pupils pinpoint
and NR, trace corneal reflex. +tongue fasiculations.
+hyperactive DTR's, +clonus, +upgoing toes.
Pertinent Results:
[**2141-5-6**] 11:45AM BLOOD WBC-15.6* RBC-2.92* Hgb-8.1* Hct-24.8*
MCV-85 MCH-27.5 MCHC-32.5 RDW-20.4* Plt Ct-336
[**2141-5-6**] 11:45AM BLOOD Neuts-84* Bands-0 Lymphs-3* Monos-11
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1*
[**2141-5-6**] 11:45AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Target-1+
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
[**2141-5-6**] 11:45AM BLOOD Glucose-128* UreaN-70* Creat-1.6* Na-147*
K-3.6 Cl-106 HCO3-32 AnGap-13
[**2141-5-8**] 04:24AM BLOOD Glucose-140* UreaN-84* Creat-2.3* Na-144
K-4.1 Cl-106 HCO3-26 AnGap-16
[**2141-5-10**] 03:21AM BLOOD Glucose-124* UreaN-92* Creat-2.7* Na-145
K-3.5 Cl-108 HCO3-26 AnGap-15
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
[**2141-5-6**] 07:56PM BLOOD Phenyto-13.8
[**2141-5-9**] 04:04AM BLOOD Phenyto-12.5 Phenyfr-2.7* %Phenyf-22*
[**2141-5-10**] 03:21AM BLOOD Phenyto-12.1 Phenyfr-2.6* %Phenyf-21*
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT TorsoW/CONTRAST [**2141-5-6**]
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
CT CHEST WITH IV CONTRAST: The patient has a tracheostomy tube
with tip that terminates at the thoracic inlet. There are
multiple mediastinal and axillary lymph nodes, none of which are
pathologically enlarged. The aorta is moderately calcified along
with coronary artery calcifications. There is a right-sided
pleural effusion that is small in size and decreased compared to
prior study. Two chest tubes are seen within the effusion. There
is a small amount of associated pneumothorax. There is also
atelectasis of the right lower lobe; the possbility of
superimposed airspace disease cannot be excluded. Both air and
fluid are decreased compared to prior study. There is a tiny
left pleural effusion. Within the lung parenchyma, there is
ground glass opacity diffusely thoughout the left lung,
nonspecific, although the possibility of infection cannot be
excluded. Subcutaneous emphysema is seen along the chest tube
tracts.
CT ABDOMEN WITH IV CONTRAST: Within the liver, there is a focal
hypodense hepatic cyst within the left lobe measuring 19 mm.
Within the caudate lobe of the liver, there is an additional 8 x
14 mm hypodensity also likely representing hepatic cyst. The
gallbladder contains a small amount of fluid. There is a small
amount of perihepatic fluid. There is thickening of the aderenal
glands bilaterally without evidence of focal lesion. The
pancreas, spleen, and kidneys are unremarkable. The small and
large bowel are within normal limits. There is no evidence of
obstruction. There is a small- to- moderate amount of fluid
within the pelvis. Calcifications extend along the course of the
aorta into the iliac and common femoral arteries.
CT PELVIS WITH IV CONTRAST: The urinary bladder, prostate, and
rectum are unremarkable. There is a rectal tube in place. There
is a moderate amount of soft tissue edema throughout the entire
torso, most notable within the pelvis and proximal thighs. There
is a lipoma in the distal psoas muscle, incidentally noted.
BONE WINDOWS: There are no suspicious lytic or sclerotic bony
lesions. There is fusion of T10/T11 with an angular kyphosis,
unchanged and either postinfectious, postraumatic, or congenital
in etiology. Multilevel degenerative change of the thoracolumbar
spine are seen.
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT HEAD W/O CONTRAST [**2141-5-6**] 12:58 PM
FINDINGS: Again demonstrated is a large low-density area within
the right MCA distribution consistent with a subacute/chronic
infarction which is not significantly changed compared to prior
study from [**2141-3-21**]. There are also linear hyperdense foci
near the vertex of the posterior temporal region likely
representing cortical mineralization secondary to the infarct.
There is no evidence of acute intracranial hemorrhage. The
ventricles are similar in size. There is no shift of the
midline.
IMPRESSION: Stable head CT with no evidence of new intracranial
hemorrhage. Stable right MCA territorial chronic/subacute
infarction.
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Neurophysiology Report EEG Study Date of [**2141-5-7**]
FINDINGS:
PUSHBUTTONS: Five events were identified for periods of rhythmic
eye-blinking. Apart from eye-blink artifact, no other changes in
the
EEG were seen. The eye-blinking lasts for many seconds at a
time, and
in short periods between the eye-blinking, the EEG does not show
signs
of epileptiform activity. When the eye-blinking stops, no
epileptiform
changes are seen.
AUTOMATED INTERICTAL EPILEPTIFORM ACTIVITY: Background activity
consists of very low amplitude [**2-13**] Hz mixed delta and theta
frequency
slowing. Throughout, EKG artifact is seen as a rhythmic change
in the
EEG.
AUTOMATED SPIKE DETECTION: This algorithm captured 141 events,
all for
eye-blink artifact.
AUTOMATED SEIZURE DETECTION: This algorithm captured no events.
SLEEP: No normal sleep or wake transitions were seen.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 120 bpm.
IMPRESSION: This is an abnormal 24 hour bedside telemetry due to
the
presence of extremely suppressed background activity. The
episodes of
eye-blinking do not appear to be ictal, but clinical correlation
is
suggested. Automated algorithms have failed to identify any
epileptiform activity.
.
146 105 73 179 AGap=15
3.5 30 1.8
CK: 62 MB: Notdone Trop-T: 0.20
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 9.0 Mg: 2.8 P: 3.5
ALT: AP: Tbili: Alb: 2.9
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Phenytoin: 13.8
Source: Line-art
85
14.4 8.5 406
26.5
Source: [**Name (NI) 37626**]
PT: 18.1 PTT: 34.2 INR: 1.7
Source: Catheter
Color
Yellow Appear
Clear SpecGr
1.023 pH
5.0 Urobil
Neg Bili
Neg
Leuk
Neg Bld
Sm Nitr
Neg Prot
30 Glu
Neg Ket
Neg
RBC
0 WBC
0 Bact
None Yeast
None Epi
<1
[**2141-5-6**]
6:08p
pH
7.42 pCO2
48 pO2
98 HCO3
32 BaseXS
5
Type:Art; Temp:35.8
[**2141-5-6**]
11:55a
Na:147
K:3.6
Cl:106 TCO2:32
Glu:124
Lactate:1.1
[**2141-5-6**]
11:45a
147 106 70 128 AGap=13
3.6 32 1.6
estGFR: 42/51 (click for details)
CK: 46 MB: Notdone Trop-T: 0.18
Comments: cTropnT: Notified Whitehead,E Ew 5.26 At 1.30p
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 9.0 Mg: 3.0 P: 3.4
ALT: 17 AP: 63 Tbili: 0.5 Alb: 2.6
AST: 19 LDH: Dbili: TProt:
[**Doctor First Name **]: 70 Lip: 18
85
15.6 8.1 336
24.8
N:84 Band:0 L:3 M:11 E:1 Bas:0 Myelos: 1 Nrbc: 1
Comments: Hct: Notified [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 37627**] 12:19pm [**2141-5-6**]
Plt-Ct: Verified By Smear
Plt-Ct: Occ Large Plt Present
Hypochr: 3+ Anisocy: 2+ Poiklo: 1+ Microcy: 2+ Polychr:
OCCASIONAL Target: 1+
Plt-Est: Normal
PT: 17.9 PTT: 40.0 INR: 1.7
[**2141-5-6**]
11:20a
Color
Yellow Appear
Clear SpecGr
1.016 pH
5.0 Urobil
Neg Bili
Neg
Leuk
Tr Bld
Neg Nitr
Neg Prot
30 Glu
Neg Ket
Neg
RBC
[**5-21**] WBC
[**2-13**] Bact
Few Yeast
None Epi
0-2
Brief Hospital Course:
76 y/o male with PMH significant for MCA stroke, s/p recent
trach/PEG, s/p chest tubes for recent empyema, now presenting
from rehab s/p cardiac arrest and in status epilepticus.
.
# s/p cardiac arrest - PEA primary rhythm, thought to be
secondary to hypoxia from mucous plugging or blood clots in
trachea. He had no signs of sepsis and blood cultures were all
negative. Troponin was elevated in the setting of renal failure
but had no ECG changes. The patient was initially was
dobutamine and dopamine for pressor support and then later to
levophed which was discontinued after 2nd hospital day. He was
continued on hydrocortisone and fludrocortisone for 7 days for
presumed adrenal insufficiency which was started prior to
arrival to the MICU. He was initially amiodarone but was stopped
after 24 hours. The patient had no further cardiac arrhthymia
during his MICU stay.
.
# Seizure/anoxic brain injury/stroke - Most likely [**1-13**] anoxic
brain injury in setting of cardiac arrest and hypoperfusion to
brain as well as later repeat MRI brain on [**5-10**] showed a new
right posterior temporal/superior parietal/occipital regions,
posterior to the chronic infarct, which was the culprit for
seizure/twitching. He was loaded with 1gm of dilantin initially
and was continued on 100mg iv q8h which achieved a good
therapeutic dilantin level. His twitching improved with dilantin
but still continued to have intermittent eye twitching. After 5
days of not showing any evidence of meaninful and/or purposeful
responsiveness over the course of the MICU stay, neuro
consultant felt that his prognosis for recovery was poor. Pt
was continued on ASA. Pt was switched to po dilantin on [**5-16**] and
repeat dilantin level after 2 days of po dilantin was 12.4.
Continue current dilantin dosing.
- Free dilantin level goal of [**1-13**].3 to correlate with a total of
13-15.
.
# Respiratory failure - in setting of recurrent aspiration [**1-13**]
CVA, now trached and pegged. Continued ventilation and
aggressive chest PT and pulmonary toilet. Chest tube to
suction, and IP injected tPA x 4 days break up to loculation and
further facilitate drainage.
- Pt was continue on Aztreonam 1 gm q8 for E.coli PNA c/b
empyema during last admission, course until [**2141-5-28**]. Sputum was
also growing MRSA and started vancomycin on [**2141-5-6**], last day at
least [**2141-5-28**]. Vancomycin was held on [**2141-5-22**] with plans for
dosing by level given renal insufficiency. Hold dose for level
>15.
- Chest tube # 2 was removed on [**2141-5-19**] after confirming no air
leak and no further drainage. Repeat CXR after #2 removed
showed no changes in hemopneumothorax. However, Chest tube #1
continued to have air leak and drainage. The right sided chest
tube was placed to water seal on [**2141-5-22**] with a chest xray that
showed a stable pneumothorax and no significant change or
worsening with re-expansion of the right lung. Please continue
to keep chest tube in place until there is no longer an air leak
present. The Chest tube may be removed at that time. Please
continue IV Vanco and IV Aztreonam for 2 additional weeks (end
date [**2141-6-6**]) to complete a total of a 6 wk course of Abx for
his empyema. Please monitor daily Vanco levels and give an
Vancomycin 1g prn for vanco trough <15. His Vanco trough on day
of discharge ([**5-23**]) was 22.4.
.
# h/o CHF - EF 15%, was on afterload agents including BB,
Isordil, digoxin, hydralazine. Initially, all were held given
pressor-dependent hypotension.The patient was restarted on BB
and was aggressively diuresed with IV lasix and lasix gtt. The
lasix gtt was discontinued on [**2141-5-22**] and the patient was
transitioned to lasix 100 mg IV TID and diuril 500 mg IV BID
with goal -500 to 1 liter each day. In the future, this high
dose of lasix may not be beneficial and consideration should be
made for bumex + diuril.
.
# Anemia- The patient required intermittent blood transfusion
for drifting down hct which was partially attributed to
phlebotomy. However, he had bleeding from trach site for which
he underwent bronch on [**5-15**] and showed suction trauma with
granulation tissues at the carina without any active bleeding.
He was given vitamin K. IP repeated bronch on [**5-16**] which only
showed slight trach displacement with was repositioned and only
saw granuation tissues. He did have guaiac positive stool on [**4-19**]
but lavage from PEG was negative for any coffee ground materials
or blood. The patient may have swallowed blood resulting in
melena. However, H2 blocker was switched to iv PPI.
- His hematocrit remained low at 24 but stable with no active
issues.
.
# h/o C diff colitis - Flagyl was discontinued on arrival to the
ICU given its ability to lower the seizure threshold. He had no
more recurrence of diarrhea and negative C. Diff cultures from
[**2141-5-10**].
.
# A fib - The patient was in normal sinus rhythm on transfer.
Anticoagulation was held given the low hematocrit and concern
for GI bleed in addition to acute stroke, ? hemorrhagic. The
patient is on ASA 325 mg.
.
# CRI - Cr now stable at 1.5-1.6. Continue to monitor with
diuresis.
# F/E/N - with G tube on tube feeds, monitor lytes
.
# PPx - heparin SC, famotidine
.
# Access - R SC placed [**5-6**] -> d/c'd and changed to PICC line,
left femoral A-Line [**5-6**] d/c'd
.
# Code - FULL
.
# Communication - sister [**Name (NI) 382**], [**Name (NI) **]) [**First Name4 (NamePattern1) **] [**Name (NI) **] [**Telephone/Fax (1) 37628**]
.
Medications on Admission:
1. Digoxin 125 mcg qod
2. Lansoprazole 30 mg qd
3. Ascorbic Acid 90 mg/mL drops [**Hospital1 **]
4. Therapeutic Multivitamin Liquid qd
5. Heparin SC tid
6. Ferrous Sulfate 300 mg/5 mL liquid qd
7. Isosorbide Dinitrate 10 mg tid
8. Senna 8.8 mg/5 mL [**Hospital1 **]
9. Docusate Sodium 50 mg [**Hospital1 **]
10. Hydralazine 50 mg q8 hrs
11. Albuterol nebs prn
12. Ipratropium nebs prn
13. Metoprolol 100 mg tid
14. Aspirin 325 mg qd
15. Aztreonam [**2133**] mg IV Q8H
16. Flagyl 500 mg tid
Discharge Medications:
1. Senna 8.8 mg/5 mL Syrup [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a
day) as needed. Tablet(s)
2. Mineral Oil-Hydrophil Petrolat Ointment [**Year (4 digits) **]: One (1) Appl
Topical TID (3 times a day) as needed.
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Year (4 digits) **]: One (1)
Appl Ophthalmic PRN (as needed).
4. Aspirin 325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: One (1) PO BID (2
times a day).
6. Phenytoin 100 mg/4 mL Suspension [**Year (4 digits) **]: One (1) PO Q8H (every
8 hours).
7. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO TID
(3 times a day).
8. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Year (4 digits) **]: 4-6 Puffs
Inhalation Q4H (every 4 hours) as needed.
9. Albuterol 90 mcg/Actuation Aerosol [**Year (4 digits) **]: 4-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
10. Insulin Lispro (Human) 100 unit/mL Solution [**Year (4 digits) **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
11. Nystatin 100,000 unit/mL Suspension [**Year (4 digits) **]: Five (5) ML PO QID
(4 times a day).
12. Bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal
DAILY (Daily).
13. Famotidine 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q24H (every
24 hours).
14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
15. Lorazepam 2-4 mg IV Q1-2H:PRN seizure
16. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
18. Chlorothiazide 500 mg IV BID
19. Furosemide 100 mg IV TID
20. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
21. Zinc Sulfate 220 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily) for 14 days.
22. Ascorbic Acid 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
23. Chlorothiazide 500 mg IV BID
Please give 30 mins prior to Lasix.
24. Aztreonam in Dextrose(IsoOsm) 1 g/50 mL Piggyback [**Year (4 digits) **]: One
(1) gram Intravenous every eight (8) hours for 2 weeks: End date
[**6-6**].
25. Vancocin 1,000 mg Recon Soln [**Month/Year (2) **]: One (1) gram Intravenous
once a day for 2 weeks: End date [**6-6**]. Dose by levels as
patient has renal failure.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Anoxic brain injury
Cerebrovascular accident
Congestive heart failure, EF 15%
Empyema s/p chest tube
Air leak in chest tube from likely bronchopleural fistula
Discharge Condition:
Poor prognosis for neurologic recovery, non-purposeful movement
of eyes. Does not follow commands.
Discharge Instructions:
Please check dilantin level in 5 days and dose accordingly.
Please monitor electrolytes and creatinine with IV diuresis.
Please have chest tube removed once there is no air leak
present. Please continue IV Vancomycin/IV Aztreonam for 2 more
additional weeks to treat his empyema. His Vancomycin has been
dosed by daily levels as his renal failure has required q48 hour
dosing.
Followup Instructions:
Please follow up with your neurologist, Dr. [**Last Name (STitle) 851**], in 4
weeks.
Please follow up with your pulmonogist in 4 weeks.
|
[
"518.83",
"428.0",
"V09.0",
"E928.8",
"V58.61",
"348.1",
"427.1",
"041.4",
"V12.59",
"585.9",
"434.91",
"427.31",
"873.64",
"510.0",
"584.5",
"519.09",
"707.03",
"707.07",
"255.4",
"E879.8",
"482.41",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"33.21",
"96.72",
"00.17",
"96.6",
"96.05",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
20153, 20224
|
11373, 16894
|
293, 474
|
20427, 20528
|
4185, 11350
|
20957, 21098
|
3440, 3444
|
17435, 20130
|
20245, 20406
|
16920, 17412
|
20552, 20934
|
3459, 4166
|
227, 255
|
502, 2793
|
2815, 3265
|
3281, 3424
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,507
| 181,945
|
38434
|
Discharge summary
|
report
|
Admission Date: [**2173-5-26**] Discharge Date: [**2173-6-4**]
Date of Birth: [**2096-3-4**] Sex: F
Service: MEDICINE
Allergies:
Strawberry
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Chest pain and diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient was transferred to [**Hospital Unit Name 196**] from the SICU on [**2173-5-30**] for
management of volume overload, rate controlled Afib, valvular
disease, and other medical issues.
Of note, she was recently in the OSH twice. She was admitted to
[**Hospital3 **] on [**5-12**] for abdominal pain, which they thought
could be due to ischemic bowel in the rectum and sigmoid (based
on imaging), and it was managed medically. At the same time,
patient was + for C. diff colitis. She was found to be anemic
with Hct 25 and got 1 pRBC transfusion. [**Name6 (MD) **] baseline Crt is
1.3. Nephrology thought that this could be pre-renal or ATN.
Readmitted to [**Hospital3 **] [**2173-5-18**] for hypotension, requiring
pressors. At that last admission, she was worked up for
possible cholecystitis. Her Hct was 27. WBC was 8.1. LFT was
wnl. She was going to be transferred for possible sepsis from
cholecystitis vs. colitis to [**Hospital1 2025**] on Reglan, Metoprolol, Zofran,
Flagyl, Zosyn (unclear reasons), [**Name (NI) 85572**], possible [**Name (NI) **], [**First Name3 (LF) **],
imdur, meclozine regularly for management of possible
cholecystitis. However, she was consequently transfererd to
[**Hospital1 18**].
.
While in [**Hospital1 18**], they noted patient had anginal symptoms at rest
which had only been non-exertional angina. Troponin was found
to be positive at that time with EKG changes in STD in
anterolateral leads. She reported stable anginal and several
episodes of syncope over the last few months with increasing LE
edema. There was no SOB or orthopnea. It was thought that this
could be due to CHF exacerbation. She was managed medically on
[**Hospital1 **], BB, statin, Imdur for the event and then heparin gtt for
AF. Her C. diff was managed with flagyl and vanco and
improving. Patient was also diuresed with furosemide after she
became hemodynamically stable. She is still net positive 5 L.
Past Medical History:
- CAD s/p CABG [**2164**] (LIMA-LAD, SVG-D1, SVG-OM, SVG-RCA)
- Aortic stenosis
- Hypertensive crisis with worsening mitral regurgitation
- Paroxysmal atrial fibrillation (not on coumadin @ home)
- Hypercholesterolemia
- Diabetes c/b neuropathy, nephropathy
- non healing L ankle ulcer
- h/o endometrial CA s/p TAH/BSO
- OA s/p bilateral TKT
- h/o GI bleed
- h/o MRSA +
- h/o C. diff in [**2173-4-20**]- [**2173-5-20**]
Social History:
- used to live at home prior to these hospitalizations
- thinks that it might be helpful to go to a nursing home
afterward
- retired
- never smoked
- no EtOH
- no illicit drugs
Family History:
- mother CABG 60s
- [**Name2 (NI) **] FH or arrhythmia or SCD
Physical Exam:
- VS -
- Gen: not in acute distress. oriented to people, place, and
time. flat affect
- HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
- Neck: supple, difficult to examine given body habitus.
- CV: irregular HR, normal S1 and S2, did not appreciate any
m/r/g, no thrills, lifts. Difficult to assess S3 or S4 given
irregular HR.
- Chest: + sternal scar from past CABG, respiration was
unlabored. + wheeze, no crackles or rhonchi appreciated in the
anterior lung fields.
- Abd: obese, soft, NT, ND, + BS. No HSM apprecaited. Fecal
tube in place with dark green/black watery stool.
- GU: + foley, clear pale yellow urine
- Ext: No cyanosis, clubbing. +2 dependent edema up to the
hips. SCD bilaterally. Difficult to palpate pulses in the feet
due to the edema. 2+ in radial pulses bilaterally.
- Skin: Pale, no stasis dermatitis or xanthomas.
Pertinent Results:
[**2173-5-26**] 03:16PM CK-MB-2 cTropnT-1.08*
[**2173-5-26**] 07:57AM CK-MB-2 cTropnT-1.15*
[**2173-5-26**] 01:42AM CK-MB-2 proBNP-[**Numeric Identifier 85573**]*
2D-ECHOCARDIOGRAM performed on [**2173-5-27**] demonstrated: The left
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
moderate to severe global left ventricular hypokinesis (LVEF =
30 %). There is considerable beat-to-beat variability of the
left ventricular ejection fraction due to an irregular
rhythm/premature beats. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
depressed free wall contractility. 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).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
ETT: no record in [**Hospital1 18**] or OSH record
CARDIAC CATH: no record in [**Hospital1 18**] or OSH record
HEMODYNAMICS: no record in [**Hospital1 18**] or OSH record
.
OTHER TESTING:
- [**5-18**] CT abd: pneumonia in the right lung base, b/l trace
pleural effusion, cardiomegaly, severe atherosclerosis, no
ischemic colitis, milk of calcium vs. tiny GB stone in the GB,
status post hysteretomy
- [**5-18**] abd U/S- no GB wall thickening, possible + [**Doctor Last Name **] sign
- [**5-22**] CT abd pelvis (OSH)- b/l pleural effusion, atelectasis,
cholelithiasis, + ascites, levocurvature of the lumbar spine,
coronary atherosclerosis and calficication of the abdominal
aorta.
- [**5-20**]- C diff +
- [**5-26**] CT ABDOMEN ([**Hospital1 18**]): There are bilateral moderate pleural
effusion and bibasilar mild atelectasis. The heart and
pericardium appear normal. The liver enhances homogeneously
without focal lesion. There is no intra- or extra-hepatic
biliary dilatation. The gallbladder is nondistended with minimal
pericholecystic fluid likely due to third spacing. There is no
evidence of acute cholecystitis. Hyperdensity layering in the
gallbladder wall likely represent small stones as seen on prior
study (ultrasound [**2173-5-26**]). The spleen, pancreas, adrenals,
stomach, loops of small and large bowel appear unremarkable.
Bilateral renal hypodensities likely represent simple cysts. The
largest on the right measures 1.4 cm (2:37). There is no
hydronephrosis or stones. There
is no free intraperitoneal air. There is a small amount of
ascites. There is no pathologically enlarged mesenteric or
retroperitoneal lymph nodes.
- [**5-26**] PELVIC CT ([**Hospital1 18**]): A Foley catheter is noted in the
bladder. The bladder, distal ureters, rectum and sigmoid appear
unremarkable. Small amount of pelvic free fluid is noted. There
is no free air or lymphadenopathy. There is diffuse calcified
atherosclerosis throughout the abdominal aorta and both iliacs
with no significant stenosis or aneurysm formation. BONE
WINDOWS: There are multilevel degenerative changes throughout
the thoracic and lumbar spine without osseous lesions concerning
for infection or malignancy. IMPRESSION: 1. No CT findings to
explain patient's symptoms. No CT evidence of
cholecystitis or colitis. 2. Bilateral moderate pleural
effusion, small amount of ascites and anasarca.
[**2173-5-30**]: CXR IMPRESSIONS: Unchanged moderate bilateral pleural
effusions, with likely
progressing multiple bilateral consolidations. Given history of
sepsis,
locule of gas in the left retrocardiac region raises concern for
loculated
effusion or pulmonary cavitation. CT chest with IV contrast is
recommended
for further assessment.
[**2173-5-31**] CT chest:IMPRESSION:
1. No lung abscess or cavity. Conventional radiographic
abnormalities
explained by a small area of aeration in the otherwise collapsed
basal left
lower lobe.
2. Moderate bilateral nonhemorrhagic pleural effusion, right
greater than
left, probably chronic given the relative high attenuation,
responsible for
substantial bibasilar atelectasis.
3. Mild-to-moderate cardiomegaly and probable pulmonary
hypertension.
4. Severe atherosclerotic plaque or mural thrombus, thoracic
aorta, ulcerated
at the level of the aortic arch.
5. Large goiter.
6. Cholelithiasis and possible cholecystitis. Clinical
evaluation is
advised.
Brief Hospital Course:
Patient admitted to SICU from outside hospital ICU for further
managment of colitis and possible cholecystitis. She was
started on antibiotics for her known C.diff collitis.
[**2173-5-18**] RUQ US: CBD 4.4 mm. + sludge. No GB wall thickening or
[**2173-5-21**] HIDA: Mild delay bile transit time from liver to GB.
Negative for cystic or CBD obstruction.
ICU Course:
Neurologic: No acute issues, patient A x3. Tylenol for pain.
Cardiovascular: Pt with [**Last Name (LF) 7792**], [**First Name3 (LF) **] depressions in anterolateral
leads, troponin elevation 1.15->1.08-0.93. cont BB, statin, [**First Name3 (LF) **],
Imdur. Patient in atrial fibrillation, started heparin gtt. TTE
performed showed depressed EF of 30%. Increased metoprolol to
75mg TID dosing.
Pulmonary: No acute issues
Gastrointestinal / Abdomen: Patietn tried on PO's and did well.
She was continued on her antibiotic treatment for C. diff
colitis (on Flagyl, oral vanco). HIDA scan negative for
cholecystitis. Surgery recommends no intervention at this time.
Nutrition: DAT
Renal: Cr 1.5, unclear baseline though patient with h/o
nephropathy from DM. Follow Cr with repeat labs.
Hematology: No acute issues.
Infectious disease: Originally treated with unasyn (and later
switched to cipro) for possible cholecystitis however this was
discontinued after imaging and further evaluation revealed no
evidence fo cholecystitis. Continued on Flagyl, oral vanco for
C. diff.
Endocrine: DM2, hold glipizide, RISS goal BG >150
The patient was ruled out for cholecystitis clinically and on
imaging. There was no need for surgical intervention or further
ICU care. Given her co-morbidities (including A fib, CHF) and
her infectious colitis she was transferred to the medical team
for further treatment.
Pt transferred to cardiology service [**2173-5-30**].
P: #. CAD, s/p CABG in the past. Had likely troponin leak from
possible CHF exacerbation in the setting of sepsis or
hypovolemia (given the labs showed hemoconcentration). We
continued her aspirin but decreased it from 325mg to 81mg,
continued her BB, continued her statin and lisinopril. We
monitored pt on tele and she did not have any further episodes
of chest pain while on the cardiology floor.
.
#. Pump. LVEF 30%. Fluid overloaded with lots of dependent
edema. ProBNP [**Numeric Identifier 85573**]. +5 L since admission, now with about 7L
down from admission. We diuresed pt with increasing doses of
lasix IV until settling on a regimen of 80mg IV lasix TID.
However, pt is to be discharged on torsemide 40mg [**Hospital1 **]. Pt was
borderline hypokalemic on multiple occasions and was repleted
with oral potassium. Pt continued on spironolactone 25mg QD.
#. Rhythm. AF. Rate controlled on 150mg toprol XL- however
increased to 200mg to make it a 1 pill dose. Pt hasd HRs in the
80's so had room for increased BB. Pt anticoagulated on
coumadin. However, pt's coumadin and flagyl likely interacted
[**2173-6-1**] pt had an INR of 10.0, was given 10 units of vit K and
INR the next day was 1.3, so pt was placed on a heparin drip
while coumadin increased again back to therapeutic level.
# ID - pt has UA positive for yeast, consulted ID who
recommended replacing the Foley and re-culturing from fresh
Foley. We completed this and the UA from the fresh foley was
also positive for yeast and bacteria. ID recommended starting a
3-day course of fluconazole, which pt got her first dose of
[**2173-6-3**] and can be stopped after she gets her dose on
[**2173-6-5**].
# Mental status changes. Pt had some episodes of somnolence and
confusion. We investigated for possible causes of infection.
We did a CXR [**2173-5-31**] which showed a question of a lung
consolidation, so we did a CT chest also [**2173-5-31**] which showed
bilateral pleural effusions with compressive atelectasis. We
also did a U/A, and UCx (see above). Per ID recs we increased
oral vancomycin to 250mg Q6H from 125mg. Pt the next day was
less somnolent and confused. She never spiked a fever with the
mental status changes. Upon discharge pt was alert and
oriented.
#. Diarrhea [**12-22**] C. Diff. Improved over the course of the
hospitalization. We continued vanco po and metronidazole IV.
Per ID recs, we determined that pt needed a 14 day course. As
started in OSH on [**2173-5-26**], both antibiotics can be stopped
after [**2173-6-9**]. Stool guiac positive, likely secondary to
C-diff irritation of intestinal lining, however, did not
definitively r/o GIB. Pt's HCT has been stable and running at
baseline (which is low - see anemia below) of 25-26, and diarrhe
has improved from a black color to a brown color.
#. Hypertension. Pt running in SBP 140's throughout admission,
so increased lisinopril from 2.5mg to 5mg then ([**2173-6-3**]) to
10mg. We continued her metoptolol (and increased it from
150-200) and her imdur. Pt's BP now in the 130's.
#. T2 DM - we put patient on an inpatient sliding scale and
monitored BS regularly. No hypoglycemic episodes or severe
hypoglycemic episodes throughout admission.
#. Anemia. Unclear the cause of anemia, possibly from GIB given
dark looking stool or from chronic disease. Stool guiac was
positive. Lactate was 1.7 so less concerned for complication of
ischemic bowel. As pt's HCT is now stable but still low, will
defer work-up of anemia to PCP.
.
#. Flat affect. Mood appears depressed. Possibly due to recent
hospitalization and difficult to manage DM according to patient,
however on 2 occasions she said she wanted to die. We involved
social work who recommended active listening to the patients
problems and a psych consult if pt's mood did not improve when
her medical illnesses did. We started pt on 10mg of celexa and
the next day increased it to 20mg.
#. INR. Pt had high of 10.6, then gave vit K and INR then became
1.3, pt was then placed on heparin drip until could become
therapeutic on warfarin.
.
#. FEN
- nutrition consult
- heart healthy diabetic
- f/u electrolytes and replete as necessary
.
#. Access:
- PIV
.
#. PPx:
- SCD
- hep gtt
- incentive spirometry
.
#. Code:
- DNR/DNI
- health care proxy- brother- [**Name (NI) **] [**Known lastname 85574**] cell [**Telephone/Fax (1) 85575**],
home [**Telephone/Fax (1) 85576**].
.
#. Dispo:
- to LTAC
- will need to have PCP f/u on incidental finding of the right
lung nodule
Medications on Admission:
Norvasc, [**Telephone/Fax (1) **], Clonidine , [**Telephone/Fax (1) **], Colace, Isosorbide
mononitrate,
metoprolol, simvastatin, glipizide, ISS
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Ipratropium Bromide 0.02 % Solution Sig: [**11-21**] Inhalation Q6H
(every 6 hours) as needed for wheeze.
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**11-21**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for CP.
6. Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-21**] Inhalation Q6H (every 6 hours) as needed
for wheeze.
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: Please discontinue this after [**2173-6-9**].
12. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Please check INR and adjust dose accordingly.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Fluconazole 200 mg Tablet Sig: 0.5 Tablet PO Q24H (every 24
hours) for 3 days: Please discontinue this medication after
[**2173-6-5**].
17. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 7 days: Please
discontinue this medication after [**2173-6-5**].
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea: Please
discontinue this medication when pt leaves rehab.
19. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One Hundred (100) units Intravenous per sliding
scale: Please continue heparin bridge until pt is therapeutic on
coumadin.
20. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
21. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary: heart failure, C. Diff colitis
Secondary:
- Paroxysmal atrial fibrillation
- Hypercholesterolemia
- Diabetes
- non healing L ankle ulcer
- OA s/p bilateral TKT
- h/o GI bleed
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were seen in the hospital for chest pain and you were
medically managed for this issue. In addition you had severe
diarrhea from a bacteria called Clostridium Difficle. We
managed your many medical problems and transferred you to
rehabilitation for further management.
Medication Changes:
1. We started you on an antifungal called fluconazole. You will
only take this until [**2173-6-5**]
2. We started you on an anitidepressant called Celexa.
3. We started you on a heart medication called lisinopril.
4. We started you on coumadin.
5. We increased your metoprolol XL dose to 200mg once a day.
6. WE started you on an antibiotic called vancomycin which you
will only take until [**2173-6-9**]
7. We started you on a diuretic medicine called torsemide.
8. We started you on a medication to help with acid refulcx
symptoms called ranitidine.
9. We stopped your norvasc.
10. We stopped your glipizide while in hopspital, but you can
continue this when you are released from rehab.
11. We decreased your aspirin dose from 325mg to 81mg a day.
12. We started you on a heart medication that is also a diuretic
called spironolactone.
13. We started you on some breathing medications called
albuterol and ipratropium
14. We started you on an antibiotic called metronidazole that
you have to take intravenously until [**2173-6-9**].
Please keep all of your follow-up appointments and take your
medications exactly as prescribed.
You will need to follow-up on your incidentally found R-lung
nodule with your PCP.
If you experience any of the warning signs listed below, please
tell the doctors at the facility you are going to, or go to your
nearest emergency room.
It was a pleasure taking care of during this hospitalization.
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5423**],MD
Location: [**Location (un) **] CARDIOLOGY
Address: [**Street Address(2) **], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 10768**]
Phone: [**Telephone/Fax (1) 5424**]
Please have the rehab contact your cardiologist above to make an
appointment for follow up care once you are discharged from
rehab. You will need to be seen by your cardiologist.
|
[
"707.13",
"428.33",
"428.0",
"357.2",
"427.31",
"410.71",
"008.45",
"V02.9",
"790.92",
"V10.42",
"V58.67",
"424.1",
"V43.65",
"583.81",
"250.60",
"V45.81",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17576, 17676
|
8734, 15073
|
294, 300
|
17904, 17904
|
3953, 8711
|
19841, 20331
|
2926, 2989
|
15269, 17553
|
17697, 17883
|
15099, 15246
|
18084, 18360
|
3004, 3934
|
18380, 19818
|
231, 256
|
328, 2273
|
17919, 18060
|
2295, 2716
|
2732, 2910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,756
| 178,816
|
46418
|
Discharge summary
|
report
|
Admission Date: [**2182-8-6**] Discharge Date: [**2182-8-21**]
Date of Birth: [**2100-3-18**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
HD tunneled line catheter insertion ([**2182-8-9**]) and removal.
History of Present Illness:
Mr. [**Known lastname **] is a 82yoM with multiple medical problmes including
CAD, CHF (EF 30-35%), CKD (Cr 3.2 on admission to rehab) who was
brought to the ED from rehab with SOB and confusion. In the ED,
he was combative and initially refusing vital signs. Initial
vitals: 97.8 74 136/53 18 96% 4L np. While in the ED, he calmed
but was noted to be delerious. When he fell asleep, O2 sats
dropped. He he was temporarily placed on a non-rebreather, but
when awoken was easily weaned back to nasal canula. On exam in
the ED, crackles were noted in the in right base. In the ED, UA
was done and was negative. Head CT negative. CXR was notable for
new R-sided opacity. No consults were called in the ED. VItal
prior to transfer: 154/63, P76, RR18, 100% on 3L NC
.
In her ED call-in, PCP was concerned about uremia. Pt has a
documented "cognitive impairment," but it is unclear what this
entails from the notes in OMR. Otherwise, the patient had been
quite functional at home prior to his [**2182-5-22**] admission, after
which he went to rehab where he has been since. Of note, last
admission, poor responsse to 120mg Lasix with metolazone 5mg.
.
On the floor, pt is unable to articulate words and not following
commands.
.
Review of systems: Unable to obtain
Past Medical History:
CAD ([**Doctor Last Name **]- cath '[**66**] - LAD -> stent)
HTN
CHF (EF = 30-35% in [**6-1**] 2+ MR, 2+ AI, 2+ TR)
renal cancer ([**Doctor Last Name **])
CRI (2.4-2.7) ([**Doctor Last Name 4883**])
hyperlipidemia,
Prostate cancer ([**Doctor Last Name **])([**Hospital1 656**])
h/o colitis,
cataracts,
seasonal allergies,
bilateral knee OA,
GERD,
iron deficiency anemia,
cervical and lumbar DJD,
right testicular atrophy secondary to mumps
Social History:
He lives alone. He is a retired barber. Originally from [**Country 5976**].
Denies tobacco, recreational drugs, or alcohol excess. Per
nephew drinks 2 shots of schnapps nightly.
Family History:
Father died at 41 of nephritis. Mother with aortic stenosis.
Physical Exam:
Admission Physical Exam:
154/63, P76, RR18, 100% on 3L NC
General: AxO x 0, speech difficult to understand, copious
bruises noted across body. No Fentanyl patch noted.
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: limited exam [**1-23**] patient positioning and mental status,
CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended
GU: no foley
Ext: warm, well perfused, bilateral [**12-23**]+ edema to the knees.
Erythema to above the ankle on the left. Both ankles are
bandaged with Kerlix.
Neuro: Unable to engage in coversation, not following comands,
no focal deficit, but jerking of the B/L UE
.
Discharge Physical Exam:
Vitals: [**Doctor First Name **] protocol
Gen: NAD AOx2
HEENT: EOMI, PERRL, oropharynx clear
CV: RRR s1/s2 -m/r/g
R: minor bibasilar rales, otherwise CTA b/l -w/r/
A: +BS soft NTND -HSM
Ext: -c/c/e
Skin: -rash/new lesions, diffuse echymoses over his arms and
legs.
Neuro: AOx2-3, follows commands.
Pertinent Results:
Admission Labs:
[**2182-8-6**] 01:30PM BLOOD WBC-9.7 RBC-4.03* Hgb-11.3* Hct-34.2*
MCV-85 MCH-27.9 MCHC-32.9 RDW-20.9* Plt Ct-161
[**2182-8-6**] 01:30PM BLOOD ALT-18 AST-32 CK(CPK)-95 AlkPhos-84
TotBili-1.0
[**2182-8-6**] 01:30PM BLOOD Calcium-8.6 Phos-6.2* Mg-1.8
[**2182-8-12**] 06:27AM BLOOD VitB12-1567* Folate-17.7
[**2182-8-12**] 06:27AM BLOOD TSH-24*
[**2182-8-6**] 01:30PM BLOOD TSH-13*
[**2182-8-12**] 06:27AM BLOOD Free T4-0.57*
[**2182-8-10**] 07:21AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2182-8-17**] 06:20AM BLOOD WBC-11.8* RBC-3.81* Hgb-10.9* Hct-33.0*
MCV-87 MCH-28.6 MCHC-33.0 RDW-20.2* Plt Ct-121*
[**2182-8-16**] 06:35AM BLOOD WBC-8.4 RBC-3.66* Hgb-10.4* Hct-31.1*
MCV-85 MCH-28.6 MCHC-33.6 RDW-20.2* Plt Ct-108*
[**2182-8-8**] 07:45AM BLOOD Neuts-87* Bands-0 Lymphs-4* Monos-9 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
Discharge Labs:
[**2182-8-17**] 06:20AM BLOOD PT-16.1* PTT-38.0* INR(PT)-1.4*
[**2182-8-17**] 06:20AM BLOOD Glucose-100 UreaN-30* Creat-2.5* Na-140
K-4.0 Cl-98 HCO3-28 AnGap-18
[**2182-8-16**] 06:35AM BLOOD Glucose-98 UreaN-52* Creat-3.2* Na-137
K-3.9 Cl-98 HCO3-27 AnGap-16
[**2182-8-15**] 06:20AM BLOOD Glucose-106* UreaN-36* Creat-2.5* Na-137
K-3.8 Cl-97 HCO3-28 AnGap-16
[**2182-8-14**] 06:36AM BLOOD Glucose-112* UreaN-59* Creat-3.1* Na-139
K-3.6 Cl-97 HCO3-30 AnGap-16
[**2182-8-17**] 06:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
Studies:
CXR ([**2182-8-6**])
Limited study due to rotation demonstrates bilateral pleural
effusions with bibasilar airspace opacities, worst on the left
than the right, possibly due to atelectasis though infection is
not excluded.
CT HEAD W/O CONTRAST ([**2182-8-6**])
No acute intracranial process.
RENAL U.S. ([**2182-8-7**])
1. Stable large left mid-to-lower pole renal mass.
2. Mild stable left-sided pelviectasis.
3. Unchanged atrophic, slightly echogenic right kidney.
LIVER OR GALLBLADDER US ([**2182-8-7**])
1. Trace perihepatic ascites.
2. Doppler assessment of the hepatic portal veins and inferior
vena cava (retrohepatic and mid) shows patency and appropriate
directionality of flow. No evidence of thrombus.
TTE ([**2182-8-8**])
there is a mobile echodensity seen in the left atrium at the
base of the mitral leaflet, near the aorto-mitral fibrous
continuity. This could be a vegetation or part of the myxomatous
mitral valve. A TEE would help clarify, if clinically relevant.
Moderate focal LV systolic dysfunction. Dilated and depressed
right ventricle. Mild to moderate mitral regurgitation. Mild to
moderate aortic regurgitation. Moderate to severe pulmonary
artery hypertension.
MR HEAD W/O CONTRAST ([**2182-8-15**])
1. No evidence of new hemorrhage, edema, masses, mass effect or
infarction. Study is somewhat limited by motion artifacts.
2. Small focus of altered signal intensity, unchanged from
previous study, likely representing hemorrhagic residuum in
right frontal lobe.
3. Increasing confluence of FLAIR hyperintensities seen in the
periventricular white matter, most likely indicating progression
of chronic small vessel infarction.
Brief Hospital Course:
Assessment and Plan: 82yo M with CKD, CHF (EF 30-35%), and CAD
who was brought to the ED with AMS and hypoxia and admitted to
the ICU and later transfered to the medical floor and
hemodialysis was intiated.
# AMS:
The patient's altered mental status was thought to be possibly
due to delirium from an infection or toxic metabolic cause or
due to his uremia secondary to worsening chronic renal failure.
He was found to have LLE cellulitis and RLL PNA and was started
on broad antibiotics for these (initially vanc/zosyn then
changed to vanc cefepime). His mental status improved
dramatically on the antibiotics. An LP was considered, but not
performed as it was thought his pneumonia accounted for the
source of infection. It was felt that while his uremia was not
the cause of such an acute change in his mental status, it was
felt that this was at least contributing to his apparent
baseline confusion. His mental status continued to fluctuate
between AOx1 to AOx2-3, with obvious inattention and confusion
at times.
# Acute on chronic renal failure:
The patient was found to have a high BUN:Cr, although his feUrea
was not consistent with pre-renal. The patient also had
recently started on colchicine which was inappropriately dosed
for his GFR. He was resuscitated with IVF and his renal
function improved somewhat. Renal was consulted and recommended
hemodialysis be started. His feelings towards dialysis were not
fully known and it was determined that he did not have capacity
at this time to make the decision. It was felt that by
initiating hemodialysis on this admission, the correcting of his
uremia may help his mental status to the point where Mr. [**Known lastname **]
could make his wishes known. His health care proxy consented to
begin hemodialysis.
The patient underwent HD and tolerated it well. Aggressive
amounts of fluids were removed. The patient became more alert
and awake, indicating that HD was helping with his overall
mental status, however he also began to endorse visual
hallucinations and paranoid delusions. He was typically only
oriented to self, but occasionally also to place. After
thorough discussion, it was felt that given the patients
multiple complex medical problems continued hemodialysis was not
recommended.
Two family meetings were held with the healthcare proxy to
discuss goals of care. Ultimately it was decided that Mr [**Known lastname **]
would be transitioned to hospice care, as his multiple
comorbidities and likely untreated renal cell carcinoma would
shorten his overall prognosis regardless of HD.
# Dementia
While his functioning prior to this episode was not entirely
clear, multiple report indicated that this was a relatively
rapid decline in Mr. [**Known lastname **]. He was reported as ambulatory and
interactive as late as the spring. While it was clear that he
was delirious due to his infection and uremia, it also became
clearer that his underlying dementia was more significant than
was thought. A work up for possible reversible causes of
dementia was done, including thyroid studies, syphilis testing,
vitamin B12 and folate levels, and a MRI of the brain. The only
revealing study was an elevated TSH, however he was treated for
this during this admission.
# Pulmonary hypertension
As the patient was significantly volume overloaded, and
transthoracic echocardiogram was done which revealed pulmonary
artery hypertension. The pulmonary service was consulted who
said that they felt that this was most likely due to his
significant left sided heart disease leading to pulmonary venous
hypertension. The recommended volume reduction through HD and
diuresis. Also, a mobile echodensity was incidentally seen in
the left atrium at the base of the mitral leaflet; the echo
report felt that this could be a vegetation or part of the
myxomatous mitral valve. Further work up was deferred due to
his concurrent kidney failure and worsening mental status.
# Renal mass
An renal ultrasound was done in order to rule out obstructive
causes of kidney failure. It did not show obstruction, however
it did show the persistence of a known renal mass that was felt
to be increasing in size. In his medical chart, it appears to
suggest that Mr. [**Known lastname **] knew this was likely a malignancy and did
not chose to take action at that time. While it is not known
what his cognitive status was at that time, given his multitude
of medical problems, further work up of this mass was deferred
to see if dialysis might have improved his mental status.
# Decreasing platelets
The patient was noted to have a decreasing platelet count from
161k to 105k. The diagnosis of heparin induced thrombocytopenia
was considered. Heparin dependant antibodies were negative.
# Hypernatremia:
The patient was found to be hypernatremic on admission. This
was likely a result of his AMS rather than the etiology. The
patient was replete with free water and his sodium levels
improved.
# Depression:
The patient's antidepressants were held in the setting of
altered mental status.
# Hypothyroidism:
The patient was continued on his home levothyroxine, the dose of
which was increased
# CAD:
The patient was continued on his home medications.
___________________________________________
.
Goals of Care:
A meeting was held with the [**Hospital 228**] health care proxy to
discuss what Mr. [**Known lastname **] would have wanted going forward.
Hemodialysis was initiated to see if resolving the patient's
uremia may have helped his mental status improve to the point
that he would be able to fully express his wishes. This was not
the case however, and while it did help the patient to be more
awake and alert, he continued to lack capacity to make medical
decisions. The futility in continuing with hemodialysis was
discussed in light of his multiple organ dysfunction - dementia,
ESRD, severe pulmonary hypertension, and likely malignancy. It
was decided to discontinue hemodialysis and Mr. [**Known lastname 4675**] code
status was made DNR/DNI. Goals of care were discussed a second
time with the HCP, and the decision was confirmed to transition
to hospice care.
Medications on Admission:
Per last d/c summary
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. balsalazide 750 mg Capsule Sig: Three (3) Capsule PO twice a
day.
8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
.
List from rehab:
ASA 81
balsalazide 750mg 3 tablets [**Hospital1 **]
Seoquel 50mg qHS
acetaminophen 325 2 tablets q6 hours PRN
bisacodyl 10mg suppository
Fleet enema 1 daily PRN
MoM 30ml daily PRN
citalopram 20mg daily
fluticasone 1 spray per nostril daily
furosamide 80mg [**Hospital1 **]
metolazone 2.5mg 30 mins before Lasix
metop succinate 50mg daily
MVI
niferex-150 cap daily
omeprazole 20mg daily
Colcrys 0.6mg po TID ([**2182-8-1**])
levothyroxine 37.5mcg qAM (recent increase from 25mg on [**2182-8-1**])
Renvela 800mg 1 tab TID
Keflex 250mg tab TID x 7 days (start [**2182-8-5**])
Fentanyl 12.5mcg patch (started [**2182-8-6**])
.
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do not exceed 8 tablets daily.
7. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO once a day as needed for constipation.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Renvela 800 mg Tablet Sig: One (1) Tablet PO three times a
day: Please take with meals.
10. haloperidol lactate 5 mg/mL Solution Sig: One (1) 0.25mg
Injection [**Hospital1 **] (2 times a day) as needed for agitation/anxiety.
11. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for agitation.
12. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
End stage renal disease
Secondary Diagnoses:
Pneumonia
Cellulitis (left lower extremity)
Demenita
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization. You were admitted because you were having
difficulty breathing and you were confused. When you arrived,
we found that you had pneumonia in your lungs as well as an
infection in the skin of your legs. You were treated with
antibiotics. We also found that your kidneys were no longer
functioning well enough. You continued to be confused and very
tired and we felt that this may have been due to your kidneys
not functioning. We started you on temporary dialysis, however
we do not recommend continued dialysis.
Followup Instructions:
None
|
[
"530.81",
"294.8",
"276.0",
"348.30",
"V45.11",
"244.9",
"682.6",
"403.91",
"593.9",
"585.6",
"428.0",
"272.4",
"416.0",
"584.9",
"428.20",
"V10.46",
"707.03",
"715.36",
"486",
"280.9",
"707.25"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15240, 15330
|
6496, 12653
|
290, 358
|
15501, 15501
|
3415, 3415
|
16317, 16325
|
2321, 2384
|
14053, 15217
|
15351, 15351
|
12679, 14030
|
15678, 16294
|
4283, 6473
|
2424, 3071
|
15416, 15480
|
1628, 1646
|
229, 252
|
386, 1609
|
3431, 4267
|
15370, 15395
|
15516, 15654
|
1668, 2109
|
2125, 2305
|
3096, 3396
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,185
| 107,093
|
6396
|
Discharge summary
|
report
|
Admission Date: [**2104-4-8**] Discharge Date: [**2104-4-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] y/o M w/DM, CHF, who presented to the ED tonight c/o weakness
and falls x 2 days. His wife brought him in, stating that the
past 2 nights, she has heard him fall. He hasn't lost
consciousness, but has been unable to get up after falling. His
wife also notes that he has been coughing for the past couple of
days, and she doesn't think he has been himself. She's noted
that he is confused when he wakes up in the mornings, for the
past 2 mornings, but this has resolved over the course of each
day. However, she brought him to the ED today due to his falls
and weakness.
.
In the ED, his vitals were 100.6, BP mostly 90s/50s but as low
as 86/44, P 60s, RR 18-22, O2 sat 89%RA and 100%3L. He had a
head/C-spine CT which were negative for any acute process. CXR
showed a new LLL infiltrate superimposed on a chronic-appearing
reticular process. A CVL was placed, with an initial CVP of 8.
He was given 500 cc NS (vs 2 L NS, unclear documentation), CVP
improved to 11. He was given tylenol and levofloxacin, and
admitted to the MICU.
.
Currently, Mr. [**Known lastname **] has no complaints other than he is thirsty.
He denies any headache, neck pain, chest pain, shortness of
breath, cough, nausea, vomiting, abd pain.
Past Medical History:
1. Type 2 DM
2. CHF, EF >55% on TTE [**2100**]
3. Symptomatic bradycardia s/p PPM [**2096**]
4. HTN
5. Gout
6. Glaucoma
7. s/p appy
8. s/p cataract surgery
9. Chronic dyspnea: Has been seen in Pulmonary [**10-8**], who felt
that his limitation in exertion was more related to
musculoskeletal problems. O2 sat at that time 94%RA, crackles
[**2-6**] way up on exam, likely IPF vs burnt-out sarcoid (had
respiratory illness in [**Country 651**] in his 20s) but since it was not
limiting him, did not pursue further treatment/workup.
10. Degenerative disc disease: severe at L5-S1 seen on plain
film [**12-9**]
11. ?prostate cancer: PSA elevated at 7.8 in [**4-8**]
Social History:
Lives with his wife in [**Name (NI) **]. Is a former accountant. No hx
of tobacco use. No EtOH.
Family History:
father died at [**Age over 90 **] y/o from CHF. Mother died at 64 of cancer.
Brother died of aspiration pna.
Physical Exam:
T: 97.7 BP: 111/59 P: 72 R: 16 O2 sat: 99%2L CVP: 4
Gen: pleasant elderly gentleman in NAD. oriented to person,
knows it is [**2104-4-3**] but not which day, thinks he is at his
apartment. Knows his phone number.
HEENT: NC, AT, conjunctivae noninjected, MM very dry
Neck: supple, no LAD, JVD at 5 cm
Lungs: coarse crackles halfway up bilaterally
CV: RRR, I/VI systolic ejection murmur at RUSB
Abd: soft, nt/nd, +bs
Ext: no edema, 1+ distal pulses bilaterally
Neuro: Strength 5/5 x4, pt unable to cooperate with reflex exam
Pertinent Results:
[**2104-4-9**] 04:04AM BLOOD WBC-6.1 RBC-2.96* Hgb-11.7* Hct-34.9*
MCV-118* MCH-39.5* MCHC-33.5 RDW-14.4 Plt Ct-126*
[**2104-4-9**] 04:04AM BLOOD Neuts-76.2* Lymphs-16.6* Monos-7.0 Eos-0
Baso-0.1
[**2104-4-9**] 04:04AM BLOOD PT-14.2* PTT-65.4* INR(PT)-1.3*
[**2104-4-9**] 04:04AM BLOOD Glucose-102 UreaN-20 Creat-1.2 Na-140
K-3.7 Cl-106 HCO3-25 AnGap-13
[**2104-4-9**] 04:04AM BLOOD CK(CPK)-1328*
[**2104-4-8**] 02:39PM BLOOD CK(CPK)-1594*
[**2104-4-8**] 02:39PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-1313*
[**2104-4-8**] 02:49PM BLOOD Lactate-2.0
.
EKG: v-paced
.
CXR [**2104-4-8**]: FINDINGS: The heart is again seen at the upper
limits of normal. A left-sided pacemaker is seen with leads in
standard position over the right atrium and right ventricle.
Bibasilar reticular opacities again identified consistent with
underlying interstitial lung disease such as IPF or collagen
vascular disease. A new opacity is identified in the left lower
lung field obscuring the left hemidiaphragm.
IMPRESSION:
1. New opacity within the left lower lung field with partial
obscuration of the hemidiaphragm consistent with pneumonia.
2. Bibasilar reticular opacities likely representing chronic
interstitial lung disease such as IPF or collagen vascular
disease.
.
Head CT [**2104-4-8**]: There is no hemorrhage, mass effect, shift of
the normally midline structures, or major vascular territorial
infarct. There are age-appropriate involutional changes.
Moderate periventricular white matter hypodensity is consistent
with chronic microvascular ischemia. A hypodensity in the right
basal ganglia likely represents a chronic lacunar infarct. The
overlying soft
tissues are unremarkable. The osseous structures are
unremarkable. There is _____ mucosal thickening of the frontal,
ethmoid, and maxillary air cells. Mild mucosal thickening as
well as likely air-fluid levels are seen within the sphenoid
sinus.
IMPRESSION:
1. No hemorrhage or mass effect.
2. Chronic microvascular ischemic changes.
3. Right basal ganglia lacunar infarct, likely chronic.
4. Paranasal sinus mucosal thickening as well as air-fluid
levels within the sphenoid sinuses which can be seen in the
setting of acute sinusitis.
.
C-spine CT [**2104-4-8**]: On sagittal images from the skull base to the
T2 vertebral bodies is clearly visualized. There are no
prevertebral soft tissue abnormalities. There is no fracture.
There is loss of the normal cervical lordosis. Mild grade 1
retrolisthesis of C5 on C6 and C6 on C7 is likely degenerative.
Moderate to severe degenerative changes are noted of the
cervical spine manifested less prominently at the C4 through C6
vertebral body levels by disc
space narrowing and large anterior osteophytes. At C2
uncovertebral joint, hypertrophy results in left neural
foraminal narrowing. Bilateral neural foraminal narrowing is
also noted at the C5 and C6 levels as well as mild spinal canal
stenosis. Scattered cervical chain lymph nodes do not meet CT
criteria for pathologic enlargement. Small bullae are seen at
the right lung
apex.
Again seen are air-fluid levels within the sphenoid sinus and
maxillary mucosal thickening.
IMPRESSION:
1. No fracture.
2. Moderate-to-severe degenerative changes of the cervical spine
resulting in multilevel neural foraminal narrowing and mild
spinal canal stenosis.
3. Air-fluid levels in the sphenoid sinuses, which can represent
acute sinusitis in the proper clinical setting.
4. Loss of normal cervical lordosis.
Brief Hospital Course:
A/P: [**Age over 90 **] y/o M w/DM, CHF, who presents with weakness, confusion,
and cough, found to be hypotensive in the ED.
.
1. Hypotension/Pneumonia: It was thought that his hypotension
was due to volume depletion in the setting of infection
(pneumonia) and his anti-hypertensives. His BP improved with
IVF. CXR showed a LLL PNA and he was treated with levofloxacin.
He should complete a 7 day course for CAP. A chest CT was done
as CXR showed evidence for pulmonary fibrosis that was confirmed
on CT. He should follow up in pulmonary clinic with Dr. [**First Name (STitle) 216**]
on [**2104-6-27**] at 3:00.
.
2. Confusion: Initially confused on arrival. Likely secondary to
hypovolemia +/- infectious process as patient's mental status
returned to baseline with return of blood pressure and treatment
with levofloxacin for pneumonia. He was alert and oriented upon
discharge.
.
3. Hypoxia: Oxygen saturation was 89% on RA in ED, but returned
to 99% on room air with improvement of hypotension and
antibiotic therapy. He did have occasional brief desaturations
while sleeping but would rapidly return to baseline. the patient
likely has some component of obstructive sleep apnea in addition
to his chronic lung disease.
.
4. Frequent falls: Per clinic notes, pt is very unsteady on his
feet, and ambulates with a walker at home. [**Month (only) 116**] have been
somewhat confused, and fell in setting of not using walker.
Given low BG levels, hypoglycemia may have also played a role.
The patient denies loss of conciousness or syncope. However, it
remains an unclear picture as the pt is not a great historian.
Head CT and C-spine are negative, no other signs of trauma on
exam. Seen by physical therapy who cleared him for home with 24
hour care. As his BG levels were low on his oral hypoglycemic
[**Doctor Last Name 360**], this was discontinued. The patient was advised to follow
up with his PCP upon discharge.
.
5. Elevated CK: Likely related to falls. MB and troponin were
negative.
.
6. ARF: Baseline creatinine 1.1-1.3, and was elevated to 1.4.
Given the hypotension and return to baseline with fluids, his
ARF was attributed to a pre-renal physiology.
.
7. CHF: Does not appear volume overloaded on exam, neck veins
flat, no edema, crackles at baseline per OMR notes, CVP 4. BNP
elevated but may be secondary to R heart strain from pulmonary
disease. Antihypertensives were held on discharge as patient
admitted with low SBPs. Will follow-up with PCP to determine
reintroduction of these medications.
.
8. Macrocytic anemia: Has undergone w/u as outpatient. Vitamin
B12 is normal in 600s, folate normal, methylmalonic acid high
(which can indicate b12 defic.) and homocysteine normal. Will
follow-up w/PCP for further [**Name Initial (PRE) **]/u if necessary.
.
The patient's case was discussed with his daughter throughout
his stay. He is being discharged home with 24 hour nursing care.
Medications on Admission:
aldactone 25 mg daily
allopurinol 150 mg daily
aspirin (enteric coated) 81 mg daily
glyburide 1.25 mg [**Hospital1 **]
hctz 25 mg daily
nitroglycerin prn
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO once a day.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as previously directed as needed for chest pain.
4. home care
Patient requires a home semi-electric bed with side rails
5. home care
Patient will need a home 3-in-1 commode
6. home care
patient will need wheelchair with elevated leg rests and
removable arm rests
7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumonia
Respiratory Distress
ARF
.
Secondary:
Type 2 DM
CHF
HTN
Gout
Glaucoma
Discharge Condition:
Good.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of
breathingdifficulties. The CAT scan of your chest whoed signs of
possible chronic infection and interstitial lung disease. You
should continue to take one pill of 750 mg Levofloxacin every 48
hours for a total of 7 days.
.
The CAT scan also showed some chronic changes that you should
have followed up by a Pulmonogist as an outpatient.
We would like you to stop taking your hydrochlorothiazide,
aldactone, and glyburide. Please see your PCP upon discharge to
address the issue of restarting these medications.
.
Please return to the ER if you experience shortness of breath,
worsening fever or cough or any other symptoms that concern you.
.
Please follow up with your PCP upon discharge.
Followup Instructions:
Please follow up with your primary care physician upon
discharge.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2104-5-1**]
10:30
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2104-5-1**] 11:00
With Pulmonary Clinic within 2 weeks.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-6-27**]
3:00
Completed by:[**2104-4-10**]
|
[
"428.0",
"276.50",
"V45.01",
"728.88",
"401.9",
"584.9",
"250.00",
"515",
"486",
"799.02",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10257, 10315
|
6501, 9408
|
270, 277
|
10444, 10452
|
3027, 6478
|
11249, 11744
|
2357, 2467
|
9613, 10234
|
10336, 10423
|
9434, 9590
|
10476, 11226
|
2482, 3008
|
222, 232
|
305, 1542
|
1564, 2228
|
2244, 2341
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,770
| 138,200
|
8175
|
Discharge summary
|
report
|
Admission Date: [**2200-1-23**] Discharge Date: [**2200-2-1**]
Date of Birth: [**2113-10-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
unstable, postinfarction angina
Major Surgical or Invasive Procedure:
emergent redo cornary artery bypass grafts, open chest insertion
itra aortic balloon [**2200-1-25**]
chest closure [**2200-1-29**]
left heart catheterization coronary and graft angiography
History of Present Illness:
This 86 year olf white female is s/p CABG [**2188**] (LIMA-LAD,
SVG-RCA/PDA) and porcine MVR. She has chronic atrial
fibrillation ,on Coumadin. She was admitted to [**Hospital3 **]
with chest pain and transferred here for cardiac
catheterization. She has noted increased fatigue with household
activities over the past few weeks, accompanied by brief "chest
twinges" that resolved with rest. At 2:30am, the day prior to
admission, while watching TV, pt noted sudden onset of severe,
10/10 chest pain. This was not relieved by TUMS and was
accompanied by nausea and diaphoresis.
She received sublingual nitroglycerin and aspirin in the ED. The
EKG was concerning for VT v. Afib with RVR with ST depression
in V4-V6 and ?STE in lead III. A Heparin infusion was begun.
Labs were notable for troponins of 0.02->0.07->0.09, MB49
creatinine of 1.6 (baseline), INR 2.7, BNP 2043. CXR negative
for congestion or infiltrate. Vitals on transfer HR85, RR18,
BP177/53, 100%on 2L.
She was transferred [**Last Name (un) **] for further intervention.
Past Medical History:
s/p coronary artery bypass, mitral valve replacement
chronic obstructive pulmonary disease
polymyalgia rheumatica
hypertension
Hypothyroidism
Gout
Social History:
Lives with daughter, daughter's husband, granddaughter, and
great grandchildren in Onset. Quit smoking 30 yrs ago, 1/2-1
ppd, not sure how long. No EtOH. Denies illicit drug use.
Family History:
Brother with CAD, lung cancer. status post PTCA and stent. Aunt
with CAD. Daughter with breast CA.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: BP=139/94 HR=91 RR=18 O2 sat=98%RA
GENERAL: pleasant elderly woman in NAD
NECK: Supple with JVP of 10 cm. No carotid bruits.
CARDIAC: irregular, normal S1, S2. No m/r/g. No lifts.
LUNGS: Resp were unlabored. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM.
EXTREMITIES: Cool feet but 2+ DPs bilaterally. Left-sided
femoral bruit. 1+ ankle edema R>L
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
.
DISCHARGE PHYSICAL EXAMINATION:
Pertinent Results:
Admission Labs:
[**2200-1-23**] 08:03PM BLOOD WBC-9.0 RBC-4.00* Hgb-11.3* Hct-35.0*
MCV-88 MCH-28.2 MCHC-32.3 RDW-15.1 Plt Ct-238
[**2200-1-23**] 08:03PM BLOOD PT-29.4* PTT-150* INR(PT)-2.8*
[**2200-1-23**] 08:03PM BLOOD Glucose-197* UreaN-42* Creat-1.6* Na-137
K-4.7 Cl-101 HCO3-26 AnGap-15
[**2200-1-23**] 08:03PM BLOOD cTropnT-0.07*
[**2200-1-23**] 08:03PM BLOOD Calcium-9.3 Phos-3.0 Mg-2.2
Carotid series ([**1-24**]):
Impression: Right ICA <40% stenosis.
FINDINGS:
Cardiac catheterization
1. Two vessel CAD.
2. Distal LMCA disease (FFR 0.82)
3. Patent SVG-RCA. Functionally occluded LIMA-LAD.
4. Severe systemic arterial hypertension.
5. Mildly elevated left-sided filling pressure and mild
pulmonary hypertension.
6. Successful closure of the right femoral arteriotomy site with
an
Angioseal VIP device.
Brief Hospital Course:
She was admitted and underwent catheterization as noted.
Referral was made for reoperative bypass grafting. The morning
of surgery she had rest angina and, therefor, was taken to the
Operating Room for emergent bypass surgery.
Grafts to the LAD with a the RIMA was performed and repair of
the radial artery graft as well. She had episodic VT and
hypotension in the Operating Room. An intra aortic balloon was
placed and she was observed for sometime with relatively stable
hemodynamics on Epinephrine and nitroglycerin and later
Milrinone. The chest remained open with an Esmark dressing in
place.
Post operatively she required a lot of volume and blood products
as she was on Plavix. the IABP waqs removed on [**1-26**] due to
rupture of the device. She remained oliguric and CVVH was
instituted on [**1-27**]. She was hemodynamically quasi stable on
pressors and after CVVH the chest was closed without problems on
[**1-29**]. She was gradually weaned from Epinephrine and Milrinone
while the Levophed remained on.
She had stable hemodynamics on Levophed and CVVH and the PA
catheter was removed. On [**1-31**] nights she required volume
repletion and titration of pressor. A CXR showed a LUL
infiltrate and antibiotics for VAP were begun.
At about 1450 she acutely dropped her BP to 70 and heart rate to
40, the 30. Epinephrine, atropine, bicarbonate and calcium were
administered. She developed runs of NSVT. The family were in
attendance at the bedside and no defibrillation nor compressions
were given at their request. Dr. [**First Name (STitle) **] was called and spoke
with the family who reiterated their desires. \
She had sustained VT and was pronounced dead at 1505. No
autopsy was allowed. dr. [**First Name (STitle) **] was aware.
Medications on Admission:
[**Last Name (un) **]
atorva 40mg
bumex 1mg
Caltrate 600 2 tabs daily
Flarex 1 drop left eye daily
Flovent 250 mcg 1 puff [**Hospital1 **]
Folate 1 tab daily
Mucinex 600mg daily
hydrocodone-acetaminophen 10/325 daily
levothyroxine 88mcg daily
metoprolol tartrate 50mg daily
MVT
Procardia XL 90mg daily
prilosec 20mg daily
prednisone 10mg daily (part of a taper by Dr. [**Last Name (STitle) 11679**] per
patient, normally on [**6-3**].5mg alternating)
coumadin 2mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Unstable, postinfarction angina
s/p redo sternotomy,coronary artery bypass, intraaortic balloon
placement, open chest
s/p closure chest
acute renal failure
polymyalgia rheumatica
hypertension
hypothyroidism
chronic obstructive pulmonary disease
s/p coronary bypass,mitral valve replacement [**2188**]
Discharge Condition:
expired
Discharge Instructions:
None
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2200-2-1**]
|
[
"V58.61",
"998.11",
"244.9",
"997.31",
"414.01",
"401.9",
"996.09",
"398.90",
"998.01",
"584.5",
"V42.2",
"427.1",
"416.8",
"E878.1",
"E878.2",
"272.4",
"427.31",
"414.04",
"410.71",
"496",
"725",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.59",
"36.15",
"34.79",
"39.61",
"88.57",
"96.6",
"96.72",
"39.95",
"88.56",
"37.61",
"34.03",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
5795, 5804
|
3483, 5244
|
341, 535
|
6149, 6159
|
2646, 2646
|
6212, 6338
|
1993, 2096
|
5766, 5772
|
5825, 6128
|
5270, 5743
|
6183, 6189
|
2111, 2121
|
2627, 2627
|
270, 303
|
563, 1607
|
2662, 3460
|
1629, 1778
|
1794, 1977
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,034
| 176,205
|
33675
|
Discharge summary
|
report
|
Admission Date: [**2172-5-26**] Discharge Date: [**2172-5-28**]
Date of Birth: [**2118-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
vfib/vtach arrest
Major Surgical or Invasive Procedure:
Atrial fibrillation and PVI/ablation
Coronary Artery Catheterization
Cardiac Arrest
History of Present Illness:
This is a 53 year old gentleman with hypertension and history of
atrial fibrillation. He was rate controlled and started on
anticoagulation therapy. He underwent a successful
cardioversion in [**2171-7-5**] but reverted to atrial fibrillation
within four days. He found when he was in regular rhythm he had
more energy, an increased exercise tolerance and a reduction in
his dyspnea.
He was started on Propafenone and underwent another
cardioversion but sinus rhythm was not successfully restored.
The patient was seen in consultation with Dr. [**Last Name (STitle) 3321**] for his
arrhythmia and ablation was discussed as an alternative to other
medications. He has elected to undergo the procedure.
.
He reports in addition to dyspnea, fatigue and a decreased
exercise tolerance he has associated
palpitations,lightheadedness and profuse sweating. He reports
episodes have awaken him from sleep.
.
His afib ablation was successful until the end of the procedure
when he went into vtach arrest. Reportedly, he received an
asynchronous emergency shock which put him into vfib which was
refractory to 3 360J external shocks and required an internal
defibrillation for restoration of sinus rhythm. His total time
in VT and VF was 2 minutes 26 seconds. He was put on a neo and
epi drip for BP support. The cause of his vtach was thought to
be from triggered activity from the catecholamines he was on for
the procedure. His neo, epi and dopamine was stopped and he was
maintained in sinus rhythm with amio and lidocaine drip. His
coronaries were imaged and there was no thrombus. Echo showed
no tamponade, no gross wall motion abnormality, and mildly
depressed RV function. He was then transferred to the ICU
intubated. Reportedly, he recovered consciousness and was
appropriate before being sedated again.
.
ROS: Unable to obtain ROS because patient is intubated and
sedated.
Past Medical History:
PMH:
Atrial fib
Colon polyps
Umbilical hernia
.
Cardiac History:
CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD placed: none
Social History:
He is married, has five children and works as a lineman for
NSTAR as well as runs a horse ranch. He does not smoke and
drinks 2-3 alcoholic beverages daily.
Family History:
N/A
Physical Exam:
VITALS: 96.3, 107/64, 79, 99% 100%FiO2, AC 700x18, PEEP 8
Ht: 6 ft 3 in
Wt: 275 lbs
Admission
GEN: intubated and sedated
HEENT: intubated
NECK: obese, unable to assess JVP
CV: RRR, no M/G/R
PULM: Coarse respirator sounds, no w/r/r
ABD: Obese, soft, NT, ND, +BS
EXT: No peripheral edema
PULSES: 1+ DP and PT pulses bilaterally
.
Discharge
VITALS: 98.3, 126/64, 79, 100% RA
GEN: Aox3, in NAD
HEENT: benign OP
NECK: obese, unable to assess JVP
CV: RRR, no M/G/R
PULM: CTAB, no labored breathing
ABD: Obese, soft, NT, ND, +BS
EXT: No peripheral edema, right thigh numbness across
anterior-lateral thigh from hip to just above the knee, strength
[**6-8**], warm distal extremeties, distal sensation intact; mild
bruising at right groin but no hematoma or bruit; left groin
without hematoma, bruising or bruit
PULSES: 1+ DP and PT pulses bilaterally
Pertinent Results:
2D-ECHOCARDIOGRAM: [**2172-5-26**]:
Overall left ventricular systolic function is low normal (LVEF
50-55%). There is depressed right ventricular free wall
contractility. There is no pericardial effusion.
.
CXR
In comparison with study of [**5-20**], there are lower lung volumes.
This plus the AP technique may account for much of the increased
prominence of the cardiac silhouette and fullness of the
mediastinum. No gross evidence of pulmonary edema. Some
atelectatic changes are seen at the left base. Although this
certainly could well represent something on the patient, the
possibility of a foreign body must be excluded.
Endotracheal tube tip is in place with the tip at the upper
clavicular level, approximately 6.5 cm above the carina.
.
CBC
[**2172-5-26**] 07:15AM BLOOD WBC-4.8 RBC-5.09 Hgb-16.7 Hct-45.8 MCV-90
MCH-32.9* MCHC-36.5* RDW-13.2 Plt Ct-162
[**2172-5-26**] 05:32PM BLOOD WBC-10.3# RBC-4.37* Hgb-14.4 Hct-40.1
MCV-92 MCH-32.9* MCHC-35.8* RDW-13.4 Plt Ct-159
[**2172-5-26**] 10:30PM BLOOD WBC-9.6 RBC-4.35* Hgb-14.4 Hct-39.9*
MCV-92 MCH-33.2* MCHC-36.2* RDW-13.5 Plt Ct-163
[**2172-5-27**] 04:14AM BLOOD WBC-9.1 RBC-4.25* Hgb-13.7* Hct-39.4*
MCV-93 MCH-32.3* MCHC-34.8 RDW-13.7 Plt Ct-159
[**2172-5-28**] 06:05AM BLOOD WBC-5.5 RBC-3.86* Hgb-12.7* Hct-36.1*
MCV-93 MCH-32.8* MCHC-35.1* RDW-13.6 Plt Ct-131*
.
Coag
[**2172-5-26**] 05:32PM BLOOD PT-17.9* PTT-73.4* INR(PT)-1.6*
[**2172-5-26**] 10:30PM BLOOD PT-15.4* PTT-23.0 INR(PT)-1.4*
[**2172-5-27**] 06:00AM BLOOD PT-16.4* PTT-62.4* INR(PT)-1.5*
[**2172-5-28**] 06:05AM BLOOD PT-17.2* PTT-26.1 INR(PT)-1.6*
[**2172-5-28**] 06:05AM BLOOD Plt Ct-131*
.
Chem 7
[**2172-5-26**] 07:15AM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-140
K-4.5 Cl-105 HCO3-25 AnGap-15
[**2172-5-26**] 05:32PM BLOOD Glucose-162* UreaN-20 Creat-1.1 Na-138
K-4.9 Cl-106 HCO3-23 AnGap-14
[**2172-5-26**] 10:30PM BLOOD Glucose-151* UreaN-18 Creat-1.0 Na-140
K-4.8 Cl-107 HCO3-23 AnGap-15
[**2172-5-27**] 04:14AM BLOOD Glucose-151* UreaN-17 Creat-1.0 Na-142
K-4.7 Cl-108 HCO3-22 AnGap-17
[**2172-5-28**] 06:05AM BLOOD Glucose-94 UreaN-16 Creat-1.0 Na-139
K-4.7 Cl-102 HCO3-30 AnGap-12
Brief Hospital Course:
53 M with hypertension and afib s/p 2 failed DCCV admitted for
elective PVI complicated by post-procedural vtach/vfib arrest
now stablized in the CCU.
.
# Vtach/Vfib arrest: Vtach occured at the end of Afib PVI after
isoproterenol administration. It was likely triggered activity
from catacholemines. After Vtach/Vfib arrest he underwent
cardiac cath which showed no coronary lesions. Peri-code echo
ruled out tamponade. CTA of the chest performed after the
procedure ruled out PE. Head CT was negative for acute stroke or
bleeding. He received amiodarone and lidocaine drip during the
code. These were sequentially discontinued with no recurrance of
Vtach. Atenolol was restarted. Digoxin was permanently
discontinued. He was monitored on telemetry when in the CCU and
on the floor and remained in NSR. He was discharged with a
[**Doctor Last Name **]-of-hearts with close EP follow up. Per EP, he will need a
cardiac MRI in one month.
.
# Afib: Afib s/p PVI. The patient remained in NSR after he was
transfered to the CCU. Coumadin with lovenox bridging was
intiated. He was also start on ASA 325mg. He was discharged with
a KOH monitor with EP f/u in 2 weeks. Per EP, he will need a
cardiac MRI in one month.
.
# Ant/Lateral right leg numbness: The morning after his
proceedure he complained of right thigh numbness, w/o distal
numbness, no weakness. On physical exam, his leg numbness was
localized to the L3/4 dermatone with purely sensory deficity,
distal ext with strength 5/5, good sensation and DP 2+
consistent with lateral cutaneous femoral nerve compression
(meralgia parastetica). It is unclear exactly why he developed
these symptoms but it most likely due to nerve compression while
lying on his right side overnight. Alternatively, he had had a
mild rt femoral arterial groin bleed with resolved with pressure
to the groin; however, right groin U/S showed no hemamatoma or
pseudoaneurysm. MRI L-spine showed no nerve compression.
.
# Pleuritic CP: Pt only has CP when taking a deep breath, EKG
w/o ischemic changes. CXR nl w/o. Peri-code echo r/o tamponade.
CP is likely MSK [**3-7**] to chest compressions during code and mild
pericarditis [**3-7**] to procedure. He was started on Ibuprofen 600mg
q 8hrs for two weeks.
.
# Incidental lymphadenopathy on CT: A large right hilar lymph
node was seen on CTA performed for PE. The patient and [**Month/Day (2) 3390**]'s
office was informed of this finding. The patient was scheduled
for a repeat CT in 3 months although it might be valuable to
perform at PET scan as an outpt prior to that. This decision was
defered to his [**Month/Day (2) 3390**].
.
# Communication: wife home [**Telephone/Fax (1) 77957**], cell [**Telephone/Fax (1) 77958**]
Medications on Admission:
Atenolol 25 mg 1 tab daily
Coumadin 2 mg 1 day alternating with 4 mg every other day LD
[**2172-5-22**]
Digoxin 0.125 mg 1 tab daily
Lovenox 120 mg x 3 doses
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day) for 7 days.
Disp:*14 injections* Refills:*0*
4. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO once a day: 2mg
alternating with 4mg every other day.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 3
days: take on [**2172-5-28**],[**2172-5-29**] and [**2172-5-30**] and then switch to
your regular coumadin dosing.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Vtach/ Vfib arrest
Meralgia Parasthetica
Discharge Condition:
improved
Labs: INR 1.6
Discharge Instructions:
Post atrial fibrillation ablation wound, activity and medication
guidelines. Please report chest pain, shortness of breath,
groin concerns (bleeding, redness, swelling) to Dr. [**Last Name (STitle) 2232**]. You
will also be sent home with a heart monitor. In addition, you
will need to restart coumadin; your coumadin level (INR) is
currently low. Until your INR is 2.0, you will need to inject
lovenox to prevent stroke. You will need to arrange to have your
INR followed by your coumadin clinic. You should have your INR
drawn on [**2172-6-1**].
.
On your CT scan of your chest, there was an enlarged lymph node.
This may not be abnormal. You will need a repeat CT scan of
your chest in 3 weeks to see if this changes. Please see
instructions below.
.
The following changes have been made your your medications:
1. Coumadin was restarted. You should take coumadin 5mg for the
next 3 days, then start taking your usual dose of 4mg
alternating with 2mg or as directed by your coumadin clinic.
2. You should take aspirin 325mg daily.
3. You will need to take lovenox 60mg twice a day until your INR
is 2.0.
4. You should stop taking digoxin.
5. You can take Ibuprofen 600mg three times a day for two weeks.
Then as needed for chest pain.
Followup Instructions:
You will need your INR checked frequently. Please have your INR
draw on [**2172-6-1**].
.
You will need a cardiac MRI in one month and then a follow up
appointment with Dr. [**Last Name (STitle) 2232**]. Dr.[**Name (NI) 11369**] office will call you
with the appointment for the cardiac MRI.
.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**2172-7-1**] 11:00
Provider: [**Name10 (NameIs) 3390**] [**Name11 (NameIs) **],[**Name12 (NameIs) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 13254**] on [**2172-6-12**] 11:45. He
will need to follow up in the a repeat chest CT in 3 months. He
may also consider sending you for PET scan.
On your CT scan of your chest, there were some enlarged lymph.
Please get a repeat CT scan of chest at 10:30am on [**2172-8-27**]
located on [**Location (un) 861**] of the [**Hospital Ward Name 23**] Building. You should talk
about these results with your [**Hospital Ward Name 3390**]. [**Name10 (NameIs) 357**] call [**Telephone/Fax (1) 327**] if
you need to reschedule.
|
[
"355.1",
"785.6",
"401.9",
"427.31",
"427.5",
"427.1",
"427.41",
"V45.81",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.26",
"37.28",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
9351, 9357
|
5727, 8439
|
333, 418
|
9462, 9487
|
3578, 5704
|
10778, 11932
|
2693, 2698
|
8648, 9328
|
9378, 9441
|
8465, 8625
|
9511, 10755
|
2713, 3559
|
276, 295
|
446, 2335
|
2357, 2502
|
2518, 2677
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.