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64,407
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23191
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Discharge summary
|
report
|
Admission Date: [**2169-12-26**] Discharge Date: [**2170-1-6**]
Date of Birth: [**2110-5-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Central Venous Line
Arterial Line
Lumbar Puncture
Intubation
Extubation
Hemodialysis
History of Present Illness:
59 year old male with ESRD on HD, dilated
cardiomyopathy, DM, HTN, ETOH abuse presents with respiratory
distress. Per the family, this evening he began to have
nausea/vomtiing, diaphoresis, chest discomfort and shortness of
breath. The shortness of breath/Chest pain came on relatively
suddenly; the family subsequently called EMS. On arrival EMS
noted him to be in respiratory distress,SBP 190s and
diaphoretic. The notes show that the monitior showed ?
elevations; SPO2 52% and put on NRB and then he became
bradycardic, PEA arrested; ventilated him and he regained
pulses, pulses regained en route to hospital. He was taken to
[**Hospital3 **], IO line placed en route. He was intubated on
arrival, found to have K of 8.1, received Ca
Gluconate/D50/insulin/sodium bicarbonate, 100mg IV lasix, and
started on nitro gtt for hypertension (SBP 200s). ABG was
7.04/64/118/17. He was subsequently transferred to [**Hospital1 18**] ED.
Upon arrival his vitals were 95.6 HR 80 BP 163/92 RR 21. An EKG
showed widening QRS (118) with peaked T waves. He was given
additional calcium gluconate 2mg,1 amp sodium bicarbonate, D50,
10U regular insulin, kayexlate 30g. He was continued on nitro
gtt for BP control in ED briefly for hypertension. CXR was done
which showed ET tube in the correct position as well as
pulmonary edema. His WBC was elevated at 30, blood cultures were
sent and Vancomycin/Zosyn were given. Renal was called for
urgent HD.
.
On arrival, pt sedated and intubated, unable to obtain further
history.
.
.
Past Medical History:
DM- no on insulin
ESRD on HD
HTN- on 2 meds unknown
Dilated cardiomyopathy
Left bundle branch block
Normal Cardiac Cath [**2164**]
Anxiety
Depression
Social History:
+1.5ppd, uses oxycodone daily, denies illicits or IVDA, history
of ETOH use
Lives with wife
Family History:
NC
Physical Exam:
GENERAL: Sedated and intubated
HEENT: Pupils are pinpoint, sclera anicteric, ET tube in place
CARDIAC: RRR, no murmurs appreciated
LUNG: Crackles bilaterally
ABDOMEN: Soft, NT, ND +BS throughout
EXT: Perfused, no edema
NEURO: sedated, unable to assess fully
Pertinent Results:
==================
ADMISSION LABS
==================
[**2169-12-26**] 12:34AM BLOOD WBC-31.5* RBC-4.20* Hgb-13.9* Hct-42.0
MCV-100* MCH-33.0* MCHC-33.0 RDW-13.9 Plt Ct-338
[**2169-12-26**] 12:34AM BLOOD Neuts-90* Bands-0 Lymphs-7* Monos-1*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2169-12-26**] 12:34AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2169-12-26**] 12:34AM BLOOD PT-12.0 PTT-28.6 INR(PT)-1.0
[**2169-12-26**] 12:34AM BLOOD Glucose-90 UreaN-73* Creat-11.0* Na-141
K-8.8* Cl-103 HCO3-19* AnGap-28*
[**2169-12-26**] 12:34AM BLOOD ALT-43* AST-52* CK(CPK)-105 AlkPhos-115
[**2169-12-26**] 12:34AM BLOOD cTropnT-0.02*
[**2169-12-26**] 12:34AM BLOOD Albumin-4.1 Calcium-11.2* Mg-2.3
[**2169-12-26**] 03:23AM BLOOD Type-ART pO2-271* pCO2-43 pH-7.30*
calTCO2-22 Base XS--4 Comment-GREEN TOP
[**2169-12-26**] 12:34AM BLOOD Lactate-2.6*
[**2169-12-26**] 03:23AM BLOOD freeCa-1.38*
CHEST X-RAY: ([**2169-12-26**] 12:22 AM)
FINDINGS: An endotracheal tube is seen with tip positioned 4.4
cm above the level of the carina and a nasogastric tube is seen
with sideport and tip coursing below the diaphragm. Severe
bilateral air space consolidation has a generally symmetric
perihilar distribution, with interstitial abnormality,
consisting of thick septal lines and possible micronodulation,
at its periphery. There is no mediastinal venous engorgement,
cardiomegaly, or pleural effusion. The descending pulmonary
arteries are normal caliber; but the margins of the upper poles
of both hila are obscured by adjacent abnormal lung and could
[**Hospital1 **] adenopathy, particularly the left.
IMPRESSION: Although severe pulmonary consolidation and
interstitial
abnormality should be treated as largely or at least partially,
edema, the
absence of other features of heart failure, and the presence of
micronodularity, and possible hilar adenopathy, raise multiple
other
possiblities, including extensive malignancy, pneumonia and
pulmonary
hemorrhage. Repeat radiographs should be obtained after
treatment for
presumptive edema, and, if abnormalities persist, CT scanning
would be more definitive then.
.
ECHO [**2169-12-28**]
The left atrium is moderately dilated. Left ventricular systolic
function is hyperdynamic (EF 70-80%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
.
MRI head [**12-29**]:
IMPRESSION: No evidence of acute infarct, mass effect, or
hydrocephalus
identified.
.
[**1-1**] CXR:
Indwelling devices remain in standard position, and
cardiomediastinal contours are stable in appearance. Lungs are
clear except
for minimal patchy opacity in the left retrocardiac area, likely
atelectasis.
.
[**1-6**] ECG:
Sinus bradycardia. Left axis deviation. Left bundle-branch
block. Poor R wave
progression in the anterior precordial leads likely normal
variant. Compared to
the previous tracing of [**2170-1-5**] the findings are similar.
.
Discharge labs:
Hct 30.1
WBC 10.5
Cr 7.5
K 4.0
Brief Hospital Course:
59 yo male with DM, ESRD on HD, dilated cardiomyopathy & HTN
presented to OSH for shortness of breath and found to have
hyperkalemia with QRS changes, hypertension and pulmonary edema,
successfully weaned overnight however with persistant agitation
and hypertension
#Agitation- Patient persistantly agitated once extubated and off
of sedation, he was requiring large amounts of haldol; and in
order to better evaluate his mental status with imaging he was
reintubated and sedated. Per pts PCP he takes 30mg oxycodone at
home per day. Unclear if agitation due to withdrawal from
opiates given strong ETOH/? Drug abuse history. Other ddx may
include stroke vs viral encephalopathy. Patients family
interviewed again, have not found any evidence of other
substance use. Other Ddx considerations include embolic
phenomena from atrial fibrillation of unknown duration,
encephalitis (viral), withdrawal, etc. A CT head was negative. A
Lumbar Puncture was alsonegative. MRI done also without
evidence of anoxic brain injury or other acute pathology.
Psychiatry was consulted; sedation was changed from propofol to
Precedex. He was initially treated with Haldol for agitation
been changed to zyprexa after QT was prolonged to 500.
Acyclovir was given empirically pending HSV PCR. Patient
extubated on [**1-1**] with significant improvement in mental status
however with persitently high requirement; psychiatry was
consulted. He was changed to zyprexa for agitation and this
improved over the course of his stay. On the floor, held all
mood-altering agents and saw patient's agitation resolve. Likely
[**12-26**] anoxia s/p PEA arrest, plus medication-induced (multiple
high-dose antipsychotics and sedative given in ICU) plus ICU
delirium; needed time for meds to clear and mental status to
clear. Resolved. Disorientation improved.
.
#Respiratory Distress-Initially most likely due to volume
overload and pulmonary edema in setting of malignant
hypertension and missing HD session. Now intubated for airway
protection and agitation. Vent settings at minimum. He was
treated for pneumonia with positive sputum cultures with
Vanc/zosyn. On the floor, improved respiratory status.
# ESRD/Hyperkalemia ?????? Resolved now. On presentation Presumed [**12-26**]
to patient missing HD session over the weekend. His EKG was
consistent with hyperkalemia; widened QRS and peaked T waves. He
was initially treated with Ca gluconate, insulin, kalexlate and
bicarbonate followed by urgent dialysis in the ICU. His
potassium improved and EKG changes improved as well. Renal
continued to follow and he received HD per protocal. He was
started on Phoslo.
#Low Grade [**Name (NI) 59639**] Initially pt had low grade temp, presumed [**12-26**]
pneumonia seen on CXR. His sputum was growing 1+ GP cocci in
pairs/chains/clusters and 1+ GP rods. Blood cultures NGTD and
C.Diff neg. Overnight low grade 99.9.
-Continue vanc/zosyn to complete 8 day course (complete on [**1-2**])
# s/p PEA [**Name (NI) 59640**] Unclear if patient truly had PEA arrest;
documented that he lost pulse briefly but no CPR was done; pt
given supplemental Oxygen/NRB and pulses regained without
intervention. PEA documented at 2204 this evening. Differential
includes hyperkalemia vs hypoxia (pulmary edema/respiratory
distress) vs cardiac (initial symptoms of Chest pain, EKG
changes). 3 sets of cardiac enzymes negative. Not clear events
that occurred.
# Atrial fibrillation: Noted during agitation overnight, not
documented to have this in the past. Pt does have h/o dilated
cardiomyopathy. ECHO showed hyperdynamic EF 70% otherwise was
unrevealing. Previous Cardiac cath in [**2164**] without evidence of
coronary disease. Pt was started on PO diltiazem with diltiazem
gtt; this was subsequently weaned off and po meds in place
instead. Apparently appears to go into afib when getting HD but
then resolves.
# [**Name (NI) 12329**] Pt with hypertensive urgency at OSH on nitro gtt; now
weaned off; not clear if combination of medication
non-compliance and/or missing HD session. On multiple
medications to treat HTN.
# Normocytic anemia, w/large RDW: perhaps [**12-26**] renal disease, or
nutritional deficiency. Perhaps mixed picture.
# ESRD on HD - regular HD sessions resumed.
# Eosinophilia: resolved. unclear etiology. perhaps
medication-induced.
Medications on Admission:
unknown by patient:
home meds, per [**Location (un) **] HD: ([**Telephone/Fax (1) 59641**]:
amlodipine 5mg daily
ASA 81mg daily
levothyroxine 75 mcg daily
lorazepam 1mg daily prn
metoclopramide one tab tid
nadolol 40mg daily
omeprazole 20mg daily
prochlorperazine 10mg daily
tums 500mg tid with meals
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for nausea.
9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- PEA arrest secondary to hyperkalemia.
- Acute diastolic heart failure
- Agitated delirium
- Paroxysmal atrial fibrillation
- Haldol related QTc prolongation
- Diabetes mellitus type II
Secondary:
- CKD stage IV on hemodialysis
- Alcohol related cardiomyopathy (resolved)
- Left bundle branch block
- Hypertension
- Hypothyroidism
- Anemia of chronic kidney disease
- Chronic low back pain
Discharge Condition:
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Mental Status: Alert and oriented x3. Appropriate.
Discharge Instructions:
You were admitted to the hospital with respiratory distress.
This was felt to be due to fluid volume overload as a result of
having missed a dialysis session. Your potassium was also
extremely high and was affecting your heart's conduction system,
also because of having missed dialysis. With fluid removal and
correction of your electrolytes through dialysis, these issues
resolved. Prior to arriving at our hospital, your heart was
reported to have stopped beating, likely secondary to the low
oxygen level you were experiencing due to fluid overload. This
did not re-occur once your respiratory status improved. You also
suffered from agitation and disorientation while in the ICU,
likely secondary to the brain's loss of oxygen before arrival at
the hospital. Once medications to help with agitation washed out
of your system, and you were back on a regular dialysis
schedule, your agitation and disorientation improved. Your heart
rhythm had an irregularity to it likely secondary to medications
given to you in the ICU - we monitored your heart rhythm closely
to ensure your safety.
.
Please call your doctor or return to the hospital if you develop
chest pain, lightheadedness, shortness of breath, chest
palpitations, or other symptoms that concern you.
.
It is very important that you go to all your regularly-scheduled
hemodialysis sessions.
.
We made the following changes to your medications:
We STOPPED the following medications: Lorazepam, Reglan
(Metoclopramide), and TUMS
We STARTED the following medications: Clonidine for blood
pressure and Sevelamer to bind phosphate instead of TUMS.
Nicotine patch to help you quit smoking.
We INCREASED the doses of the following medications: Aspirin and
Amlodipine.
Followup Instructions:
It is very important that you go to all your regularly-scheduled
hemodialysis sessions (Tuesday, Thursday, Saturday).
.
We recommend that you see your primary care doctor in the next
week. Please call Dr.[**Name (NI) 29049**] office to arrange an appointment
([**Telephone/Fax (1) 18203**]). You will need to discuss the risk and benefits
of taking blood thinner medications for your atrial fibrillation
with your doctor.
Please follow up with your nephrologist, Dr. [**First Name (STitle) **] at you dialysis
session on Tuesday. Please call to arrange an appointment.
Completed by:[**2170-2-19**]
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"507.0",
"428.0",
"427.31",
"250.00",
"787.91",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11326, 11332
|
5825, 10148
|
333, 420
|
11777, 11863
|
2562, 5753
|
13687, 14291
|
2264, 2268
|
10500, 11303
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11353, 11756
|
10174, 10477
|
11940, 13316
|
5769, 5802
|
2283, 2543
|
13345, 13664
|
274, 295
|
448, 1965
|
11878, 11916
|
1987, 2139
|
2155, 2248
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,523
| 197,826
|
54012
|
Discharge summary
|
report
|
Admission Date: [**2158-2-11**] Discharge Date: [**2158-2-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
S/p fall at home
Major Surgical or Invasive Procedure:
Suturing of right hand wound, facial laceration, staples to
scalp laceration
History of Present Illness:
Patient is a [**Age over 90 **] y/o with hx of cervical DJD, right arm weakness
who prsents s/p fall in his home this afternoon.
The patient reports that has not been feeling well for the last
few days; he has had what feels like chest congestion with a
cough that is not bringing anything up. Denies fevers, chills,
chest pain, increased weakness, shortness of breath, seizure
like activity, loss of bladder or bowel continence. He reports
that he woke up this morning because he was not feeling well, he
did not eat anythign. In the early afternoon he was walking
through bedroom, he stumbled and hit his head and face in either
the night stand or the headboard. He reports that he was not
able to get up and could not reach the phone. He denies loss of
consciousness. He says he recalls most of the time he was lying
there. finally, he was able to get up and called his son and
daughter. His daughter, who lives close by came over and called
the ambulance. The patient denies preceding chest pain,
lightheadedness, leg weakness. He does reports that his is
unstead on his feet and has poor balance and had for some time
now.
Of note, in the ER, the patient reported that he felt
lightheaded and may have tripped, but doesnt remember anything
afterthat. To me, he reports remembering lying in bedroom not
able to get up.
In the ER, his intial vitals were, HR 49, BP 139/65, RR 16,
O2sat 94% on RA. He recieved 1.5 L NS, Td booster. He had nasal
laceration and scalp laceration sutured and stapled,
respectively. He had a trauma spine consult. Head CT was
negative. Skull CT showed nondisplaced nasal fracture. CT C
Spine showed retropulsed C5 vertebral body in the setting of
known severe Cervical DJD.
Past Medical History:
Mitral regurgitation
Myelopathy and a question of ALS
Severe cervical spondylosis
Hyperlipidemia
BPH
HTN
Gilberts syndrome
Hearing loss
Sciatica
Osteoarthritis
Herpes Zoster
Cataracts
Carpal Tunnel
Social History:
Graduated from [**University/College **]. Widowed and retired, used to work in the
real state business; Quit smoking 50 years ago. Rare alcohol.
Sister lives nearby.
Family History:
Brother may have died of an MI (not sure)
Physical Exam:
Physical exam on admission:
Vitals: T: 98.5 BP: 132/68 P: 59 RR: 18 O2Sat 94% ra
Gen: uncomfortable looking gentleman with [**Location (un) **] J collar in
place. tried blood all over head, and sutured laceration above
eyebrown
HEENT: Clear OP, MMM
NECK: [**Location (un) 2848**] J collar in place
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA laterally
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, except right
upper extremity, [**2-17**].
PSYCH: Listens and responds to questions appropriately, pleasant
Physical exam on transfer from MICU:
T 96.3, BP 118/60, HR 73, RR 23, O2sat 97% on 4L
Gen: NAD
HEENT: MMM
NECK: supple, no lymphadenopathy
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: decreased breath sounds at bases bilaterally, no
expiratory wheezes
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, except right
upper extremity, [**2-17**].
PSYCH: Listens and responds to questions appropriately, pleasant
Physical exam on discharge:
T 97.8, BP 115/59, HR 98, RR 24,
Pertinent Results:
Chemistry:
[**2158-2-11**] 05:25PM GLUCOSE-138* UREA N-16 CREAT-1.0 SODIUM-125*
POTASSIUM-5.1 CHLORIDE-91* TOTAL CO2-27 ANION GAP-12
[**2158-2-22**] 06:40AM GLUCOSE-99 UREA N-13 CREAT-0.7 SODIUM-135
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-27 ANION GAP-8
Hematology:
[**2158-2-11**] 05:25PM WBC-8.4 RBC-3.78* HGB-12.0* HCT-35.3* MCV-93
PLT-187
[**2158-2-11**] 05:25PM NEUTS-79.7* LYMPHS-13.6* MONOS-5.8 EOS-0.4
BASOS-0.4
[**2158-2-11**] 05:25PM PT-13.7* PTT-29.1 INR(PT)-1.2*
[**2158-2-22**] 06:40AM WBC-12.5 RBC-2.99* HGB-9.5* HCT-28.7* MCV-96
Cardiac:
[**2158-2-11**] 05:25PM CK-MB-11* MB INDX-2.3 cTropnT-0.04*
[**2158-2-20**] 04:38AM cTropnT-0.06* proBNP-1090
Other:
[**2158-2-12**]: T4-6.3
[**2158-2-19**]: TSH-1.9
[**2158-2-19**]: Cortisol-14.8
[**2158-2-13**]: Fe-29 TIBC-178 Hapto-89 Ferritin-67 TRF-137
Urinalysis:
[**2158-2-12**]: negative in detail
[**2158-2-19**]: negative in detail
[**2158-2-14**] Na 58 Osmol 476
CT c-spine w/o contrast [**2158-2-11**]:
There is no definite evidence of fracture. There is significant
degenerative disease. A grade 1 anterolisthesis of C4 relative
to [**Name (NI) **] is
noted. There is also significant degenerative disc disease with
complete loss of disc space at C5-6 and C6-7. Facet disease is
noted with multilevel neural foraminal stenosis, most notable
through the mid cervical spine. CT is not able to provide
intrathecal detail compared to MRI. Prevertebral soft tissues
appear normal. Given the malalignment at C4-5, the lack of prior
imaging for comparison, ligamentous injury cannot be entirely
excluded. Nuchal ligament ossification is noted. Pooling of
secretion is noted in the region of the hypopharynx. Thyroid
gland appears unremarkable. There is significant pleural
parenchymal scarring at the lung apices.
CXR Portable [**2158-2-11**]: The study is slightly limited by the
obscuration from the underlying trauma board. Allowing for the
limitation,
there is no acute displaced fracture, pneumothorax or pleural
effusions. A
vertical lucent line is seen projecting over the right lateral
lung is
compatible with a skin fold. The cardiomediastinal silhouette is
within normal limits. There is a tortuous descending aortic
arch. An asymmetric elevation of the right hemidiaphragm is
noted.
XRAY Right Hand [**2158-2-11**]: AP, lateral, oblique views of the right
hand are obtained. There is soft tissue gas in the region of the
thenar eminence without evidence of foreign body or bony
fracture. Degenerative disease is notable in the basal joint,
first MCP joint and second through fifth DIP joints, compatible
with osteoarthritis. There is also diffuse bony
demineralization. Within the bones of the carpus, osteoarthritis
is noted, most notable along the triscaphe joint with
subchondral cysts. There is also proximal migration of the
capitate, likely on the basis of a SLAC wrist. Radiocarpal
osteoarthritic changes are also noted with joint space loss and
articular surface irregularity.
MRI C-spine [**2158-2-12**]:
1. Severe multilevel, multifactorial degenerative disease with
extensive
chronic alignment abnormalities, among them significant
retrolisthesis of C5 on its neighbors; however, the overall
alignment is not significantly changed since the MR examination
of [**2157-2-26**], with no acute alignment abnormality identified.
2. As above, there is no abnormal STIR-hyperintensity in the
paraspinal
ligaments or other soft tissues to suggest acute injury.
3. Related to above, severe spinal canal stenosis at the C4-5
through C5-6
levels with maximal AP canal diameter of only 5 mm and cord
compression; there is stable abnormal T2-hyperintensity within
the cord at this site,
representing established myelomalacia.
4. Unremarkable diffusion-weighted sequence with, again, no
finding to
specifically suggest acute spinal cord injury.
5. Global cerebral and cerebellar atrophy.
Right Shoulder XRAY [**2158-2-12**]:
Three views of the right shoulder show mild superior and
anterior
subluxation, but no fracture or dislocation. Since there is no
erosion of the underside of the acromion this could be an acute
rotator cuff injury.
Adjacent ribs, scapula, and left clavicle are intact.
CT Head w/o contrast [**2158-2-11**]: Non-contrast head CT with coronal
and sagittal reformations provided. There was no hemorrhage,
edema, shift of normally midline structures, or evidence of
acute major vascular territorial infarction. Encephalomalacia is
noted in the right frontal lobe along the high convexity,
appears chronic. Mild involutional changes and ventricular
prominence is compatible with age-appropriate atrophy. Mucosal
thickening is noted within the paranasal sinuses. Nasal bone
deformity is compatible with an acute fracture, better assessed
on the concurrently performed CT of the facial bones. The
mastoid air cells and middle ear cavities are well aerated.
Vascular calcification along the carotid siphon is noted. The
calvarium is intact. There is an old burr hole along the right
frontal bone along the high convexity. Skin staples are noted
along the right high frontal scalp region with an underlying
hematoma.
CXR PA and Lateral [**2158-2-14**]:
New consolidation at the base of the left lung obscures the
diaphragmatic
pleural interface consistent with pneumonia. Milder
abnormalities of the
right base could be atelectasis alone due to lower lung volumes.
Small left
pleural effusion is presumed. Heart size is normal.
CXR Portable [**2158-2-19**]
COMPARISON STUDY: [**2158-2-17**].
FINDINGS:
There is eventration of the right hemidiaphragm. There is
minimal atelectasis at the right lung base. Aorta is mildly
tortuous. Heart is within normal. There is mild retrocardiac
opacity. The remainder of the lungs are otherwise clear.
Essentially no change from prior study.
EKG: NSR, leftward axis. RBBB. no st changes. unchaged from
prior.
Chest X-ray [**2158-2-20**]
IMPRESSION: AP chest compared to [**2-19**].
Heart is normal size, but larger and mediastinal vasculature and
pulmonary
vessels are engorged, probably due to volume overload or cardiac
decompensation. Obscuration of the right diaphragmatic surface
is probably
due to a layering pleural effusion. No pneumothorax.
Echocardiogram [**2158-2-20**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**12-17**]+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is an anterior space which
most likely represents a fat pad.
Compared with the report of the prior study (images unavailable
for review) of [**2154-8-16**], the severity of mitral regurgitation is
slightly increased. Left ventricular systolic function remains
dynamic. Is there a history of high output syndrome (e.g.,
anemia, thyrotoxicosis, thiamine deficiency, peripheral shunt).
Microbiology:
Legionella Urinary Antigen [**2158-2-13**] negative
Urine culture [**2158-2-13**]: contaminated
Urine culture [**2158-2-20**]: negative
MRSA screen [**2158-2-22**]: negative
Blood cultures [**2158-2-19**]: negative
Brief Hospital Course:
[**Age over 90 **] year-old man with hx of cervical DJD, right arm weakness who
presented on [**2-11**] s/p fall in his home. The patient presented
with hyponatremia (Na 125) and hypovolemia. Volume
resuscitation was successful and initially Na level was
increasing, but on hospital day 3, the Na level dropped to 120.
Subsequent CXR showed a developing pneumonia in the left lung
base. Urine electrolytes were suggestive of an SIADH etiology
of hyponatremia. Na levels went from 120->137 after 3 days of
fluid restriction. The SIADH was attributed to the pneumonia.
On hospital day 7 ([**2158-2-17**]) the patient was stable, sodium level
normal, oxygenating well on room air, so he was deemed medically
stable for transfer to rehab. In the afternoon he was to
transfer, he developed acute hypoxemia with increased coughing.
It was thought that he may have developed a mucous plug. Chest
PT was given, respiratory therapy optimized. 48 hours later he
was not improving, rather was becoming hypotensive as well. His
antibiotics were broadened to cover for hospital acquired
pneumonia and the patient was transferred to the MICU for higher
level of care on hospital day 9.
In the MICU, he did well with broadened antibiotics, IVF
resuscitation. His respiratory symptoms were slightly improved
and the patient was transferred back to the floor on hospital
day 10. Over the next two days, the patient's respiratory
status continued to improve, but still required supplemental
oxygen. He was ultimately discharged to [**Hospital1 **], a long-term
acute care hospital for further management and rehabilitation.
PROBLEM LIST:
# [**Name2 (NI) **]: He sustained a nasal laceration and scalp laceration
that were sutured and stapled, respectively, in the ED. It is
unclear whether there was any loss of consciousness, as he
endorsed LOC in the ED but denied it on the floor. Possible
reasons for the fall include mechanical or orthostatic
hypotension. Infection may have contributed to general weakness
and instability, as he had a cough and had not been feeling well
for several days. Seizure activity is unlikely given lack of
seizure history and no loss of bowel or bladder, and ACS or
arrhythmia are unlikely given negative enzymes, normal EKG, and
lack of chest pain. The patient was initially placed in a [**Location (un) 2848**]
J collar until MRI ruled out vertebral injury. There was a
nondisplaced fracture of the nasal bone, for which the patient
will receive an outpatient ENT evaluation. He was placed on
telemetry given the possibility that arrhythmia may have
contributed, but no events were noted. Physical therapy
evaluated the patient and ultimately recommended rehab. He will
need to have the sutures in his hand removed on [**2158-2-24**].
# Hypotensive episode: During this admission, patient required
MICU transfer for hypotension. Most likely etiology was felt to
be worsening pneumonia as patient improved with hydration and
broadened antibiotic coverage. Other potential etiologies
included dehydration. At the time of discharge to rehab his
home antihypertensives continued to be held. All cultures during
this admission were negative.
# Hyponatremia: Patient's serum sodium on admission as 125.
Urine electrolytes were consistent with SIADH with elevated
urine sodium and urine osms. He was started on fluid
restriction and his serum sodium improved. Etiology was most
likely related to his pneumonia. Fluid restriction was
discontinued during the later portion of his hospitalization and
remained stable. His sodium should be rechecked within 2-3 days
of transfer to rehab.
# Pneumonia: Patient was diagnosed with pneumonia during this
hospitalization. He was initially treated with ceftriaxone and
azithromycin but when he developed hypotension this was
broadened to vancomycin, cefepime and ciprofloxacin to cover
hospital acquired pathogens. He did well with this regimen. He
will require four more days of antibiotics to complete his
course. He was treated with albuterol and cough suppressants for
symptoms. At the time of rehab transfer he was breathing in the
high 90s on 3L nasal cannula. This should be weaned at rehab.
# Elevated CK: On presentation patient was noted to have an
elevated CK. This was initially attributed to rhabdomyolysis
and he was treated with IV hydration. His home statin was also
held. His CK level returned to [**Location 213**] with these interventions.
At no time did he develop signs of renal insufficiency.
# Hypertension: As noted above, patient developed hypotension
during this admission. His home antihypertensives were being
held at the time of discharge.
# Hyperlipidemia: Patient's statin was discontinued during this
admission out of concern that it may be contributing to his
elevated CK level. His primary care physician can consider
restarting this as an outpatient.
# Coronary Artery Disease: No active issues. His beta blocker,
ace-inhibitor and statin were discontinued as above. His
aspirin was continued.
# Code status: DNR (okay to intubate)
# Contact: [**Name (NI) **], son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 110726**]
Medications on Admission:
Lasix 10mg every other day
Imdur 30mg daily
Lisinopril 2.5mg daily
Pindolol 2.5mg daily
KDur 10mEq daily
Simvastatin 10mg daily
Aspirin 162mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours.
3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed for cough.
4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for Low Hct, Fe/TIBC<18%.
6. Cefepime 2 gram Recon Soln Sig: One (1) Intravenous every
twelve (12) hours for 4 days.
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 4 days.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours.
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to groin and perianal region.
14. Vancomycin 750 mg Recon Soln Sig: One (1) Intravenous twice
a day for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses:
Pneumonia
Hypotensive episode
Hyponatremia [**1-17**] SIADH
S/p fall
Mild elevation of creatinine kinase likely [**1-17**] dehydration
Secondary Diagnoses:
Benign Hypertension
Hyperlipidemia
Coronary Artery Disease
Mitral regurgitation
Myelopathy and a question of ALS
Severe cervical spondylosis
BPH
Gilberts syndrome
Hearing loss
Sciatica
Osteoarthritis
Herpes Zoster
Cataracts
Carpal Tunnel Syndrome
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 for evaluation of your fall, low sodium level,
and cough. Your lacerations on your face and right hand were
repaired with stitches, and your scalp laceration was repaired
with stables. You were placed in a neck collar, which was
removed after MRI ruled out injury to your vertebral column.
Your cough improved with antibiotics, and your low sodium
improved with restricted water intake.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take cefepime 2g intravenously every 12 hours for four
more days
2. Please take vancomycin 1000mg intravenously every 12 hours
for four more days
3. Please take ciprofloxacin 500mg by mouth every 12 hours for
four more days
4. Please hold your simvastatin until you are seen by your
primary care physician (stopped because of high muscle enzyme
levels)
5. Please use albuterol nebulizers as needed every 4 hours for
cough, wheezing
6. Please use ipratropium nebulizers as needed every 6 hours for
cough, wheezing
7. You can use robitussin as needed for cough
8. Please hold your lasix, imdur, lisinopril, pindolol, and
potassium until you are seen by your primary care physician.
9. You were started on iron supplements for anemia
10. Please take benzonatate 100mg by mouth three times a day
You have a follow-up appointment for evaluation of your nasal
fracture in the Plastic Surgery Clinic at the [**Hospital3 **]
Deaconness [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) 470**], on Friday
[**2-24**] at 1:00pm.
Please keep all your follow up appointments as scheduled.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
within 1-2 weeks of discharge from rehab. The office phone
number is [**Telephone/Fax (1) 250**].
You have the following appointment scheduled for evaluation of
your nasal fracture, on the [**Location (un) 470**] of the [**Hospital Ward Name 23**] Building,
[**Hospital1 69**] [**Hospital Ward Name 516**]:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2158-2-24**] 1:00
You also have the following appointment scheduled:
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2158-3-28**] 2:40
|
[
"873.20",
"458.9",
"721.1",
"424.0",
"272.4",
"401.9",
"728.88",
"486",
"E885.9",
"873.0",
"882.0",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.81",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
18190, 18256
|
11414, 13035
|
279, 357
|
18722, 18722
|
3894, 11391
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|
2116, 2315
|
2331, 2498
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,018
| 186,423
|
47008
|
Discharge summary
|
report
|
Admission Date: [**2175-12-29**] Discharge Date: [**2176-1-4**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
This [**Age over 90 **] yo female presents with lethargy.
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Pt is [**Age over 90 **] yo f with HTN, HOCM, dementia, ? COPD, L hip fracture
several months ago who presented on [**12-29**] from [**Hospital1 1501**] with fatigue
and confusion, found to have a worsening effusion, ? PNA, and a
UTI. She was treated with levofloxacin, and has been afebrile.
At 2 AM today, pt triggered for desaturation into 70's on 2L O2,
and was responsive only to sternal rub. Suctioning only returned
thin secretions. She had been getting IVF, which were then
stopped. Her O2 sat improved to 98% on 100% NRB. ABG at 7 AM on
40% FM showed 7.15/104/77. She was then weaned down on her O2 to
3L with sats remaining in mid 80's. Attending physician spoke to
son, who confirmed DNR/DNI status, but agreed to a trial of
non-invasive ventilation in the ICU. Repeat ABG at 10am on 3L O2
showed 7.27/76/51.
.
Pt currently is moaining intermittently, but is not responsive
to verbal commands. Appears to be in mild respiratory distress.
.
Past Medical History:
1. Hypertension
2. Atrial flutter
3. LVH with outflow obstruction (last ECHO [**9-12**])/HOCM
4. Hypercholesterolemia
5. Osteoporosis
6. Hx breast cancer (dx [**9-12**], grade I infiltrating ductal
carcinoma txed with wide excision)
7. Hx lymphoma resection from L groin; with resultant LE edema
8. Mild dementia
9. Glaucoma
10. Hx cataracts
11. Hx fractures humerus ([**2171**]) and wrist ([**2168**])
12. Hx chest lipoma
13. recent open reduction and internal fixation of Left
intertrochanteric fracture
14. recent PNA
15. recent surgical intubation
16. ? COPD
Social History:
[**Hospital1 1501**]. [**1-10**] ppd smoking for "years." denies other drugs or EtOH.
Family History:
nil of note.
Physical Exam:
ADMISSION:
Gen: appears comfortable
neck supple, no jvd
rrr, nl s1+s2, no m/r/g
bilateral poor air entry, worse on the right
[**Last Name (un) 103**] soft, non tender, nl bs
no o/c/c
pt's very drowsy, able to nod head, not following command.
.
ON TRANSFER TO ICU:
Vitals: T 96.5 BP 162/56 HR 62 RR 16 O2 85% on 3L NC
Gen: occasionally moaning, not responsive to verbal commands,
mild resp distress
HEENT: R pupil min reactive, L pupil reactive. OP very dry.
Cardio: RRR, nl S1S2, 3/6 systolic murmur throughout precordium
(loudest at apex)
Resp: decreased BS of entire R side, decreased BS at L base,
poor insp effort
Abd: soft, nt, nd, +BS
Ext: trace BL LE edema
Neuro: responsive to painful stimuli, but not verbal commands.
Moves all 4 ext.
.
Pertinent Results:
[**2175-12-29**] 12:25PM WBC-8.4 RBC-3.58* HGB-11.0* HCT-33.5* MCV-94
MCH-30.8 MCHC-33.0 RDW-14.1
[**2175-12-29**] 12:25PM PLT COUNT-332
[**2175-12-29**] 12:25PM NEUTS-79.6* LYMPHS-17.2* MONOS-2.1 EOS-0.8
BASOS-0.3
[**2175-12-29**] 12:25PM GLUCOSE-144* UREA N-26* CREAT-0.9 SODIUM-147*
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-38* ANION GAP-9
[**2175-12-29**] 12:25PM ALBUMIN-3.9
[**2175-12-29**] 12:25PM ALT(SGPT)-10 AST(SGOT)-22 ALK PHOS-55
AMYLASE-68 TOT BILI-0.2
[**2175-12-29**] 12:25PM LIPASE-50
[**2175-12-29**] 02:15PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.011
[**2175-12-29**] 02:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2175-12-29**] 02:15PM URINE RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-[**3-13**] RENAL EPI-3.5
[**2175-12-29**] 02:15PM URINE HYALINE-0-2
[**2175-12-29**] 03:16PM LACTATE-1.3
.
.
ECG ([**12-29**]) - Normal sinus rhythm. Voltage for left ventricular
hypertrophy. Atrial premature complexes. No significant change
since the previous tracing of [**2175-3-30**].
.
CXR ([**12-29**])
FINDINGS: AP upright portable chest radiograph is obtained.
There is interval increase in right-sided pleural effusion,
moderate in size. There is fluid noted in the minor fissure on
the right as well. Hazy opacity at the right lung base may
reflect tapered fluid, though underlying pneumonia cannot be
excluded. There is increased left retrocardiac density which may
be on the basis of atelectasis versus pneumonia. Heart size is
difficult to assess but appears grossly unchanged. Mediastinal
contour is unremarkable. There is no pneumothorax. Old right
humeral neck fracture is noted. Calcifications in the left
humeral head may represent bone infarct. Diffuse
demineralization of bone is noted with degenerative changes in
the spine. Bowel gas pattern is unremarkable.
IMPRESSION: Increased right basilar pleural effusion. Increased
haziness at the right lung base may represent fluid versus
pneumonia. Left retrocardiac density may reflect atelectasis
versus pneumonia.
.
CT Head ([**12-29**])
CT HEAD WITHOUT IV CONTRAST: There is no evidence of acute
intracranial hemorrhage, mass, edema, or acute large vascular
territorial infarction. There are global age-related parenchymal
involution changes with proportionate prominence of the
ventricles and sulci. Regions of hypoattenuation in the
periventricular white matter are consistent with chronic
microvascular ischemic changes. No fractures are evident.
Mastoid air cells, external auditory canals, and visualized
paranasal sinuses are clear. Patient is status post bilateral
lens placement.
IMPRESSION: No evidence of acute intracranial process. Unchanged
appearance from [**2175-2-17**].
.
CXR ([**1-3**])
FINDINGS: In comparison to the previous examination from
[**2176-1-2**]. The extent of the right-sided pleural effusion shows
further increase. Just a small portion of the apical right lung
parenchyma is still normally ventilated. In the left lung, signs
of progressive fluid overload are seen. Progressive retrocardiac
atelectasis.
IMPRESSION: In comparison to [**2176-1-2**], further increase of the
right-sided pleural effusion and of the signs of fluid overload
evident in the left lung.
.
Brief Hospital Course:
91-yo F with HTN, HOCM, dementia, ? COPD, who presented with UTI
and ?pna, now with respiratory failure.
.
#. Hypercarbic respiratory failure - Pt has a possible history
of COPD which is likely contributing to her hypercarbia, and she
is also known to have a large and worsening right-sided pleural
effusion, although these are unlikely to have caused her acute
respiratory failure. Pt was noted to become very hypertensive
and desaturate, raising the probability of flash pulmonary edema
that may have caused acute respiratory failure, as well as a
possible aspiration episode and pneumonia. We are unable to
rule-out an underlying pneumonia, especially given the acute
rise in her WBC with left-shift, which is resolving now while on
Vancomycin, Aztreonam, and Flagyl in addition to her
Levofloxacin. She had been transferred to the ICU for a trial of
BiPap, which she failed because of her agonal breathing as she
was unable to time her breaths well on BiPap, and she had
worsening of her ABG on BiPap as well. She continues to maintain
her vital signs well, although she continues to have worsening
ABGs. Discussion with family regarding goals of care are
consistent with not elevating the current level of care, but not
backing off on current measures either. She was continued on
her antibiotics: Levofloxacin (day 6), Vancomycin (day 3),
Aztreonam (day 3), and Flagyl (day 2). She was also treated with
nebulizers and morphine as needed.
.
#. Hypertension - Pt noted to have an episode of hypertension
with SBP 200s. Timing associated with desat to 70s, possibly
contributing to flash pulmonary edema as above, but also raising
possibility of prior stroke to account for pt's current mental
status. Given morphine 1mg IV x1 with good effect. She has had
no acute hypertensive episodes since. She was treated with
morphine 1mg IV PRN.
.
#. UTI - Urine Cx growing Gram +, alpha-hemolytic bacteria, c/w
alpha-Strep vs. Lactobacillus. Pt afebrile, but with increased
WBC and left-shift, now trending downward. She was treated with
Levofloxacin and other antibiotics as above.
.
#. Acute renal failure / hypernatremia - Pt with Cr 1.8 today,
up from 0.8 on admission after stopping IVF. Pt appears dry on
exam today, also with hypernatremia to 149 yesterday, at which
point she received a 250cc free water bolus, with today's Na at
146 (stable). She was started on gentle IVF hydration: D5-1/2NS
@ 50cc/hr.
.
Medications on Admission:
1. Atorvastatin 10 mg
2. Timolol Maleate 0.5 % Drops [**Hospital1 **]
3. Brimonidine 0.15 % Drops [**Hospital1 **]
4. Vitamin E 400 unit Capsule Sig: Two (2) Capsule PO BID
5. Calcium Carbonate 500 mg PO BID
6. Hexavitamin Tablet PO DAILY
7. Atenolol 25 mg PO DAILY
8. Zolpidem 5 mg PO HS
9. Mirtazapine 15 mg PO HS
10. Furosemide 20 mg Tablet PO DAILY
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
17. Aspirin 81mg po daily.
.
Discharge Medications:
Expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
|
[
"401.9",
"305.1",
"272.0",
"365.9",
"486",
"V10.3",
"427.32",
"276.0",
"294.8",
"584.9",
"272.4",
"733.00",
"427.31",
"V10.79",
"V58.66",
"518.81",
"496",
"599.0",
"425.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9074, 9083
|
6077, 8494
|
277, 284
|
9135, 9145
|
2768, 6054
|
9202, 9213
|
1972, 1986
|
9041, 9051
|
9104, 9114
|
8520, 9018
|
9169, 9179
|
2001, 2749
|
180, 239
|
312, 1266
|
1288, 1853
|
1869, 1956
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,711
| 193,902
|
33049+57832+57833
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2127-3-16**] Discharge Date: [**2127-3-28**]
Date of Birth: [**2051-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2127-3-19**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Ramus, SVG to OM1 to OM2), Mitral Valve Replacement (31mm St.
[**Male First Name (un) 923**] Porcine Valve), Atrial Septal Defect Closure
History of Present Illness:
75 y/o male with significant cardiac history since [**2122**]. Since
that time he has been followed for his mitral regurgitation and
coronary disease. He developed atrial fibrillation in [**8-28**] with
episodes of congestive heart failure requiring diuresis. His
most recent cath revealed three vessel coronary disease and echo
showed severe mitral regurgitation.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction w/
stenting/PTCA [**1-23**], Mitral Regurgtation, Atrial Fibrillation s/p
Cardioversion [**12-28**], Hyperlipidemia, Hypertension, Diabetes
Mellitus, Congestive Heart failure, Chronic Obstructive
Pulmonary Disease, Stroke [**2114**], Renal Insufficiency, Back pain,
s/p ICD/PPM placement, s/p Lens implant OU [**3-27**], s/p bilaterala
inguinal hernia repair, s/p polypectomy
Social History:
Quit smoking 15 yrs ago after [**1-22**] ppd x 50 yrs. 1 ETOH drink/wk.
Family History:
NC
Physical Exam:
Vitals: 60 16 98/50 70" 178#
General: WDWN pale appearing male in NAD
Skin: Pale, w/d intact
HEENT: Oropharynx benign, EOMI, NCAT
Neck: Supple, FROM, no JVD
Lungs: Diminished BS at bases, delayed exp
Heart: Regular rate and rhythm 1-2/6 late systolic murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, trace to 1+ edema
Pulses: [**1-22**]+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2127-3-16**] 04:55PM BLOOD WBC-5.8 RBC-3.39* Hgb-9.8* Hct-30.4*
MCV-90 MCH-28.8 MCHC-32.1 RDW-18.6* Plt Ct-204
[**2127-3-16**] 04:55PM BLOOD PT-17.9* PTT-42.2* INR(PT)-1.6*
[**2127-3-16**] 04:55PM BLOOD Glucose-137* UreaN-67* Creat-2.4* Na-144
K-4.9 Cl-104 HCO3-30 AnGap-15
[**2127-3-16**] 04:55PM BLOOD ALT-30 AST-35 AlkPhos-115 Amylase-82
TotBili-0.4
[**2127-3-16**] 04:55PM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.7 Mg-2.4
[**2127-3-16**] 04:55PM BLOOD %HbA1c-6.3*
[**2127-3-16**] Chest X-ray: Heart is mildly enlarged, pulmonary
vasculature is mildly engorged, and there is no pulmonary edema
or pleural effusion. Four transvenous leads represent right
atrial pacer, right ventricular pacer, left ventricular pacer
and right ventricular pacer defibrillator leads each terminating
in standard location, but continuity cannot be traced
equivocally to the left axillary pacemaker, except for the right
atrial lead because the lines are indistinguishable.
[**2127-3-17**] Carotid Ultrasound: Right ICA with 60% to 69% stenosis.
Left ICA with 40% to 59% stenosis.
[**2127-3-17**] Echocardiogram: The left atrium is elongated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is
0-10mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is mild regional
left ventricular systolic dysfunction with basal
inferior/infero-lateral hypokinesis. There is no ventricular
septal defect. with mild global free wall hypokinesis. 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. There is no mitral
valve prolapse. An eccentric, posteriorly directed jet of at
least moderate (2+) mitral regurgitation is seen (ischemic MR is
suggested). The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
[**2127-3-22**] Chest X-ray: 1. Stable bilateral pleural effusions left
greater than right. 2. New left infrahilar opacity may be
secondary to underlying fluid less likely reflects underlying
atelectasis and/or edema. Edema and associated atelectasis
cannot be entirely excluded.
Brief Hospital Course:
Mr. [**Name14 (STitle) 76853**] was admitted for heparinization and routine
preoperative evaluation. Carotid ultrasound was notable for mild
to moderate disease of both internal carotid arteries(see result
section). Preoperative echocardiogram revealed 2+ mitral
regurgitation and an LVEF of 50-55%(see result section). Surgery
was initially delayed secondary to elevated prothrombin time.
Vitamin K was given with improvement in coagulation. On [**3-19**], Dr. [**First Name (STitle) **] performed coronary artery bypass grafting along
with mitral valve replacement and atrial septal defect closure.
See operative note for additional surgical details. Following
the operation, he was brought to the CVICU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated without incident. On postoperative day one, he
transferred to the SDU for further care and recovery. He was
restarted on Warfarin and dosed for a goal INR between 2.0 -
3.0. He was transfused with PRBC to maintain hematocrit near
30%. Pacemaker interrogation showed complete heart block and he
remained v-paced. Over several days, he continued to make
clinical improvements with diuresis. He was eventually cleared
for discharge to rehab on postoperative day 5.
Medications on Admission:
Amiodarone 200mg qd, Norvasc 5mg qd, Aspirin 81mg qd, Calcium,
Combivent, Digoxin .125mg qd, Iron, Flovent, Folbic 2/2.5mg qd,
Humulin N, Humulin R, Lasix 80mg qd, Lipitor 80mg qd, Lisinopril
10mg qd, Lopressor 50mg TID, Omeprazole 40mg qd, Coumadin
(stopped prior to admission)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
13. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) Units Subcutaneous once a day.
15. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous AC & HS: BS 150-200 = 4U
201-250 = 6U
251-300 = 8U
301-350 = 10 U.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Convalescent
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Mitral Regurgtation s/p mitral Valve Replacment
Atrial Septal Defect s/p Closure
Atrial Fibrillation
PMH: s/p Myocardial Infarction w/ stenting/PTCA [**1-23**],
Cardioversion [**12-28**], Hyperlipidemia, Hypertension, Diabetes
Mellitus, Congestive Heart failure, Chronic Obstructive
Pulmonary Disease, Stroke [**2114**], Renal Insufficiency, Back pain,
s/p ICD/PPM placement, s/p Lens implant OU [**3-27**], s/p bilaterala
inguinal hernia repair, s/p polypectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**Hospital Ward Name 121**] 6 for wound check in 2 weeks
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 61691**] in [**2-23**] weeks
Dr. [**Last Name (STitle) **] in [**2-23**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2127-3-24**] Name: [**Known lastname 12513**],[**Known firstname 947**] J Unit No: [**Numeric Identifier 12514**]
Admission Date: [**2127-3-16**] Discharge Date: [**2127-3-28**]
Date of Birth: [**2051-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
Addendum:
pt. has chronic systolic CHF as evidenced by echo.
Also, pt. had failed a voiding trial, requiring replacement of
his Foley. He was subsequently started on flomax, and should
have his Foley removed within the next 24-48 hours for another
voiding trial.
Brief Hospital Course:
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Convalescent
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2127-3-24**] Name: [**Known lastname 12513**],[**Known firstname 947**] J Unit No: [**Numeric Identifier 12514**]
Admission Date: [**2127-3-16**] Discharge Date: [**2127-3-28**]
Date of Birth: [**2051-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Mr. [**Known lastname 12515**]' discharge was delayed secondary to an acute
decline in renal function and supratherapeutic prothrombin time.
His postop creatinine peaked to 3.6. Renal ultrasound was
unremarkable and he did not experience oliguria. All medications
were titrated accordingly and by discharge, his renal function
improved. His renal function should continue to improve after
discharge.
He was also quite sensitive to Warfarin. His INR became
supratherapeutic, peaking to 6.1. Warfarin was held for several
days with improvement in prothrombin time. At discharge, his INR
was 3.6 and very low dose Warfarin was resumed. His goal INR is
between 2.0 - 3.0.
Pertinent Results:
[**2127-3-28**] 06:05AM BLOOD WBC-6.1 RBC-3.10* Hgb-9.0* Hct-27.4*
MCV-88 MCH-29.0 MCHC-32.8 RDW-18.3* Plt Ct-253
[**2127-3-27**] 05:45AM BLOOD WBC-6.6 RBC-3.01* Hgb-8.8* Hct-26.7*
MCV-89 MCH-29.3 MCHC-33.0 RDW-18.4* Plt Ct-254#
[**2127-3-23**] 07:30AM BLOOD WBC-7.3 RBC-3.14* Hgb-9.3* Hct-27.1*
MCV-86 MCH-29.7 MCHC-34.5 RDW-18.7* Plt Ct-124*
[**2127-3-22**] 07:10AM BLOOD WBC-8.8 RBC-2.55* Hgb-7.7* Hct-22.3*
MCV-88 MCH-30.0 MCHC-34.3 RDW-20.0* Plt Ct-107*
[**2127-3-28**] 06:05AM BLOOD PT-34.6* INR(PT)-3.6*
[**2127-3-27**] 05:45AM BLOOD PT-33.9* INR(PT)-3.6*
[**2127-3-26**] 08:45PM BLOOD PT-29.6* INR(PT)-3.0*
[**2127-3-26**] 01:25PM BLOOD PT-53.0* INR(PT)-6.1*
[**2127-3-26**] 05:35AM BLOOD PT-51.2* INR(PT)-5.9*
[**2127-3-25**] 07:14PM BLOOD PT-50.0* INR(PT)-5.7*
[**2127-3-25**] 11:00AM BLOOD PT-45.8* INR(PT)-5.1*
[**2127-3-24**] 09:15AM BLOOD PT-24.9* INR(PT)-2.4*
[**2127-3-23**] 07:30AM BLOOD PT-15.4* PTT-31.9 INR(PT)-1.4*
[**2127-3-22**] 07:10AM BLOOD PT-14.4* PTT-31.9 INR(PT)-1.3*
[**2127-3-28**] 06:05AM BLOOD Glucose-165* UreaN-77* Creat-2.3* Na-141
K-4.8 Cl-101 HCO3-31 AnGap-14
[**2127-3-27**] 05:45AM BLOOD Glucose-69* UreaN-82* Creat-2.9* Na-140
K-4.3 Cl-101 HCO3-27 AnGap-16
[**2127-3-26**] 05:35AM BLOOD UreaN-85* Creat-3.6* K-4.4
[**2127-3-24**] 05:35AM BLOOD UreaN-68* Creat-2.9* K-4.2
[**2127-3-23**] 07:30AM BLOOD Glucose-80 UreaN-65* Creat-2.9* Na-138
K-4.8 Cl-101 HCO3-26 AnGap-16
[**2127-3-22**] 07:10AM BLOOD Glucose-69* UreaN-59* Creat-2.9* Na-139
K-4.8 Cl-103 HCO3-27 AnGap-14
[**2127-3-21**] 06:45AM BLOOD Glucose-183* UreaN-48* Creat-2.3* Na-139
K-5.8* Cl-104 HCO3-28 AnGap-13
[**2127-3-20**] 03:35AM BLOOD Glucose-122* UreaN-40* Creat-1.7* Na-143
K-5.1 Cl-110* HCO3-27 AnGap-11
[**2127-3-16**] 04:55PM BLOOD Glucose-137* UreaN-67* Creat-2.4* Na-144
K-4.9 Cl-104 HCO3-30 AnGap-15
[**2127-3-27**] Discharge Chest x-ray: There has been interval decrease
in size in small right pleural effusion. Moderate left pleural
effusion is grossly unchanged. Bibasilar atelectasis greater on
the left side are persistent. There is no pneumothorax.
Cardiomediastinum is unchanged. Left transvenous pacemaker leads
terminate in standard positions. Patient is post median
sternotomy and CABG.
Brief Hospital Course:
See previous discharge summary. See addendums.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
12. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) Units Subcutaneous once a day.
14. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous AC & HS: 111-139 = 2U
140-159 = 4U
160-179 = 6U
180-199 = 8U
200-219 = 10U
220-239 = 12U
240-260 = 14U.
15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
16. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO qpm: Adjsut to
maintain INR between 2.0 - 3.0. Daily dose may vary.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Convalescent
Discharge Diagnosis:
Chronic Systolic Congestive Heart Failure
Coronary Artery Disease, Mitral Regurgtation, Atrial Septal
Defect
Atrial Fibrillation
Postop Acute Renal Insufficiency, Chronic Renal Insufficiency
Hyperlipidemia
Hypertension
Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
History of Stroke [**2114**]
Discharge Condition:
Good
Discharge Instructions:
- Please shower daily. No baths or swimming for at least one
month.
- Monitor wounds for infection - redness, drainage, or increased
pain
- Report any fever greater than 101
- Report any weight gain of greater than 2 pounds in 24 hours or
5 pounds in a week
- No creams, lotions, powders, or ointments to incisions
- No driving for approximately one month
- No lifting more than 10 pounds for 10 weeks
- Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
Followup Instructions:
[**Hospital Ward Name **] 6 for wound check in 2 weeks
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 11152**] in [**2-23**] weeks
Dr. [**Last Name (STitle) 12516**] in [**2-23**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2127-3-28**]
|
[
"427.31",
"433.30",
"745.5",
"428.0",
"V45.01",
"V12.54",
"412",
"424.0",
"E878.2",
"584.9",
"997.5",
"414.01",
"272.4",
"428.22",
"496",
"426.0",
"403.90",
"250.00",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"35.23",
"36.13",
"35.71",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
14664, 14724
|
13014, 13062
|
340, 549
|
15072, 15079
|
10776, 12991
|
15603, 15932
|
1497, 1501
|
13085, 14641
|
14745, 15051
|
5593, 5873
|
15103, 15580
|
1516, 1964
|
281, 302
|
577, 943
|
965, 1392
|
1408, 1481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,138
| 116,049
|
4540
|
Discharge summary
|
report
|
Admission Date: [**2169-9-25**] Discharge Date: [**2169-9-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 year old female with questioned history of renal artery
stenosis and hypertension, presents with shortness of breath.
The patient went to the bathroom this morning and felt short of
breath. It seemed to improve with rest, but then occurred again
soon after, and she called 911. She denies any chest pain or
pressure, dizziness, or changes in vision during that time. In
the ED her blood pressure was found to be 206/107, HR of 120,
with O2Sa of 88% on RA. She was placed on Bipap with good
results. Lasix 80mg IV was given, morphine 2mg x2 and a nitro
drip was started. There were questioned ST depressions in V4-V6;
cardiology was consulted and believed they were rate related
changes. Troponin was 0.05 and CK-MB of 3.
.
Patient was brought to the CCU with a BP of 135/57 and O2Sa of
97% on 4L NC. In the CCU, patient stated much improved shortness
of breath and denied chest pain. She had no vision changes or
lightheadedness. She denies any recent changes in her
medications, has been taking them as prescribed except for her
clonidine patch which she has not had since Thursday [**2169-9-21**] but
has supplemented with clonidine PO. Denies recent change in her
diet. She denies nausea, vomiting, change in appetite, fevers,
chills, or dysuria.
.
Patient was admitted in [**Month (only) **] at [**Hospital1 2025**] for similar symptoms.
Patient had very elevated BP while at a physicians office,
became dyspnic and was admitted to the ICU with flash pulmonary
edema. She was intubated for 2 days during that stay. Patient
also has history of renal artery stenosis diagnosed
approximately one year ago, although ultrasound done in [**Month (only) **] did
not show any evidence of stenosis.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. Patient does have baseline level of edema on her
lower extremities R>L, and there has been no change recently.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: No history of MI
3. OTHER PAST MEDICAL HISTORY:
Hypertension (up to SBP211 on clinic visit on
CRI (baseline 1.5-1.7)
?Renal Artery Stenosis (L 60-90%)
Hypothyroidism, s/p thyroidectomy
Hip dislocation as child with subsquent growth defect in
effected leg
Thrombocytosis
Admission in [**2169-8-1**] at [**Hospital1 2025**] for hypertensive urgency with
pulmonary edema and respiratory distress requiring intubation
Social History:
Occupation: Retired
Drugs: na
Tobacco: distant history
Alcohol: na
Other: Lives in [**Location **], manages all ADLs, retired secretary,
widowed.
Family History:
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. No evidence of flame
hemorrhage. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm. Right external jugular vein line
CARDIAC: PMI located in 5th intercostal space, lateral
clavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. Diffuse
wheezes with rales at the bases. Decreased breath sounds
particularly at the bases bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ pedal on the left, 2+ on the right. Left leg
shorter than the right. No femoral bruits.
SKIN: Some mild erythematous change on the right shin, no change
per patient
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Neuro: CNII-XII intact, stregnth equal bilaterally, no gross
sensory deficits
Pertinent Results:
[**2169-9-25**] 09:30AM BLOOD WBC-13.9* RBC-3.15* Hgb-8.7* Hct-28.1*
MCV-89 MCH-27.8 MCHC-31.1 RDW-17.8* Plt Ct-417
[**2169-9-26**] 02:14AM BLOOD WBC-6.7# RBC-2.94* Hgb-8.3* Hct-25.3*
MCV-86 MCH-28.1 MCHC-32.7 RDW-17.8* Plt Ct-323
[**2169-9-27**] 06:15AM BLOOD WBC-5.4 RBC-2.82* Hgb-8.1* Hct-24.3*
MCV-86 MCH-28.8 MCHC-33.4 RDW-17.3* Plt Ct-301
[**2169-9-28**] 06:45AM BLOOD WBC-3.8* RBC-2.53* Hgb-7.1* Hct-21.9*
MCV-86 MCH-28.1 MCHC-32.5 RDW-17.4* Plt Ct-364
.
[**2169-9-25**] 09:30AM BLOOD Neuts-84.9* Lymphs-7.3* Monos-6.8 Eos-0.4
Baso-0.6
[**2169-9-26**] 12:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
.
[**2169-9-25**] 09:30AM BLOOD PT-11.9 PTT-22.2 INR(PT)-1.0
[**2169-9-26**] 12:20PM BLOOD Fibrino-613*
[**2169-9-26**] 12:50PM BLOOD Ret Aut-2.4
.
[**2169-9-25**] 09:30AM BLOOD Glucose-267* UreaN-58* Creat-1.8* Na-135
K-6.6* Cl-96 HCO3-27 AnGap-19
[**2169-9-25**] 04:38PM BLOOD Glucose-109* UreaN-60* Creat-2.1* Na-139
K-5.3* Cl-98 HCO3-30 AnGap-16
[**2169-9-26**] 02:14AM BLOOD Glucose-101* UreaN-61* Creat-2.0* Na-139
K-4.4 Cl-97 HCO3-29 AnGap-17
[**2169-9-27**] 06:15AM BLOOD Glucose-95 UreaN-65* Creat-1.7* Na-138
K-4.1 Cl-98 HCO3-33* AnGap-11
[**2169-9-28**] 06:45AM BLOOD Glucose-96 UreaN-72* Creat-1.9* Na-139
K-4.3 Cl-100 HCO3-33* AnGap-10
.
[**2169-9-25**] 04:38PM BLOOD CK(CPK)-99
[**2169-9-26**] 02:14AM BLOOD CK(CPK)-95
[**2169-9-25**] 09:30AM BLOOD CK-MB-3 proBNP-[**Numeric Identifier 19353**]*
[**2169-9-25**] 09:30AM BLOOD cTropnT-0.05*
[**2169-9-25**] 04:38PM BLOOD CK-MB-5 cTropnT-0.10*
[**2169-9-26**] 02:14AM BLOOD CK-MB-4 cTropnT-0.06*
.
[**2169-9-25**] 09:30AM BLOOD Calcium-8.0* Phos-6.0* Mg-2.7*
[**2169-9-25**] 04:38PM BLOOD Calcium-8.4 Phos-5.1* Mg-2.7*
[**2169-9-26**] 02:14AM BLOOD Calcium-8.3* Phos-5.3* Mg-2.6
[**2169-9-26**] 12:20PM BLOOD Iron-13*
[**2169-9-27**] 06:15AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.6
[**2169-9-28**] 06:45AM BLOOD Calcium-7.6* Phos-4.6* Mg-2.5
.
[**2169-9-26**] 12:20PM BLOOD calTIBC-230* Hapto-154 Ferritn-135
TRF-177*
[**2169-9-25**] 09:30AM BLOOD %HbA1c-6.3* eAG-134*
.
[**2169-9-25**] 09:30AM BLOOD TSH-0.77
[**2169-9-25**] 09:56AM BLOOD Glucose-254* K-4.8
.
[**2169-9-25**] 1:35 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2169-9-28**]**
MRSA SCREEN (Final [**2169-9-28**]): No MRSA isolated.
.
[**2169-9-25**] 08:15AM URINE RBC-[**4-14**]* WBC-0-2 Bacteri-0 Yeast-NONE
Epi-0-2 TransE-0-2
[**2169-9-25**] 08:15AM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2169-9-25**] 08:15AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
.
ECG [**9-25**] 0739
Sinus tachycardia. Left atrial abnormality. Left ventricular
hypertrophy.
Non-specific QRS widening and diffuse non-diagnostic
repolarization
abnormalities. No previous tracing available for comparison.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
131 118 112 296/420 74 0 116
.
ECG [**9-25**] 1300
Sinus rhythm. Compared to the previous tracing deep T wave
inversion in the
anterior precordial leads is now present. Heart rate is now
reduced.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
73 148 108 426/448 48 -3 5
.
Chest Xray [**9-26**] 0745
AP UPRIGHT RADIOGRAPH OF THE CHEST: There has been marked
interval
improvement in the parenchymal aeration suggesting improving
pulmonary edema.
There is mild residual, right greater than left. Retrocardiac
consolidation
is either atelectasis or pneumonia. There are small bilateral
pleural
effusions.
Marked kyphoscoliosis of the thoracolumbar spine and related DJD
is noted.
There is a moderate-sized cardiac enlargement with dense
atherosclerotic
aortic calcifications. Surgical clips are seen in the neck.
IMPRESSION:
1. Improving parenchymal aeration with mild residual pulmonary
edema and
small bilateral pleural effusions.
2. LLL atelectasis and/or pneumonia.
Brief Hospital Course:
#Hypertensive Urgency: Patient had similar episode in [**Month (only) **] or
[**Month (only) 205**] with hypertensive urgency and flash pulmonary edema, but
little support for RAS. Likely similar etiology to current
shortness of breath and pulmonary edema. BP responded quickly to
nitro drip. Will maintain blood pressure at 140s, as patient's
baseline is in 170s and if decreased too quickly may get
decreased perfusion. Patient shows no obvious end organ damage
of the hypertension. No change in mental status, no vision
changes or neurologic deficits, creatinine close to baseline.
Patient has history of hypertension with evidence of LVH. Likely
etiology of exacerbation of essential hypertension appears to be
transition from clonidine patch to po. Unknown if PO dose was
adequate or if pt was taking medication properly. Possible
rebound hypertension in setting of inappropriate clonidine
dosing. No recent change in diet.
Pt has a questionable history of renal artery stenosis per OSH
records, however ultrasound in [**Month (only) **] was negative and per
nephrologist, he does not believe she has RAS. Given conflicting
record, would prefer not to start an ACEi. TSH was normal. BPs
well controlled morning after admission with home medication
regimen, no longer requiring nitro gtt. She was started on
Amlodipine, metoprolol succinate, and continued on the clonidine
patch. Hydralazine was discontinued for lack of ease of
administration.
.
#Pulmonary Edema: Acute elevation of BP decreasing forward flow,
likely caused flash pulmonary edema; similar to previous episode
in [**Month (only) **]. Denies chest pain, cardiac enzymes negative (troponin
minimally elevated in setting of CRI), perfusion scan on [**2169-8-7**]
was normal. Does have some EKG changes possibly suggestive of
ischemia, although more likely related to LV strain. Symptoms of
SOB have improved and patient appears less volume overloaded
than on admission after over 2L negative. O2Sa stable on 3L NC.
CXR questioned possible pneumonia in right lobe on [**2169-9-25**], but
afebrile and no history of cough, leukocytosis has resolved. CXR
this morning does not show opacity in RUL and improved vascular
congestion. Clinical picture appears to coincide with pulmonary
edema secondary CHF and proBNP elevated to [**Numeric Identifier 19353**]; however, will
monitor for signs of infection. No further diuresis will be done
today as patient had good response yesterday, is a petite women,
and will begin to mobilize fluid into her vasculature.
.
# CRI - Baseline creatinine of 1.5-1.7. Mildly elevated to 1.8
upon admission and up to 2.1 today. Will continue to monitor and
should improve with improved forward flow. Also has proteinuria
on UA. Could be secondary to hypertensive nephropathy, HbA1c at
6.3%. Pt will follow with her outpatient nephrologist who was
contact[**Name (NI) **] during her admission.
.
# Anemia - Patient has baseline Hct in high 20s, however did
decrease to 23.8 this AM. No obvious source of bleeding, guiac
negative, no abdominal complaints, no hematuria. Patient had
similar decrease in Hct during previous admission for similar
episode. [**Month (only) 116**] be secondary to dilution as increase mobilization
of fluid into vasculature. Microangiopathic hemolytic anemia can
be seen with hypertensive urgency, however less likely. Anemia
will be followed as outpatient by heme.
.
#Hypothyroidism: If over treated with medication, could cause
hypertensive urgency. Will continue current synthroid dose. TSH
normal.
.
# Thrombocytosis - has been treated with anagrelide. Will
continue anagrelide
.
#Diabetes Mellitus: questioned history of DM with previous HbA1c
at 7, it is 6.5% here. Monitor as an outpatient.
Medications on Admission:
Metoprolol 75mg PO BID
Vit D 800 daily
Hydralazine 10mg PO QID
Anagrelide 1mg PO BID
Clonidine Patch 0.3mg/24hrs transdermal qweek
Lasix 20mg daily
Synthroid 88mcg daily
Metronidazole cream. 0.75% [**Hospital1 **] to affected area
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
Disp:*4 Patch Weekly(s)* Refills:*2*
2. Outpatient Lab Work
Please check chem 7 and CBC on [**2169-10-2**] and call results to [**First Name8 (NamePattern2) 717**]
[**Last Name (NamePattern1) **] or Dr. [**Last Name (STitle) 19354**] at [**Telephone/Fax (1) 19355**]
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):
Hold for loose stools.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
12. Metronidazole 0.75 % Cream Sig: One (1) application Topical
as directed.
13. Anagrelide 1 mg Capsule Sig: One (1) Capsule PO twice a day:
Please check with the previously prescipbing physician for [**Name Initial (PRE) **]
refill.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive urgency
Flash Pulmonary Edema
Chronic Renal Insufficiency
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had another episode of hypertensive urgency that led to
fluid backing up into your lungs. We think this is because you
had trouble with your medicines at home. We have now simplified
your medicine regimin after talking with Dr. [**Last Name (STitle) 19356**].
Medication changes:
1. Stop taking Hydralazine
2. start taking Amlodipine (Norvasc) to treat your high blood
pressure
3. Continue taking your clonidine patch, you have a new
prescription for this.
4. Increase the Metoprolol to 200 mg once a day (NOT twice a
day)
5. Start taking Iron (ferrous sulfate) to treat your anemia with
colace to prevent constipation
6. The visiting nurses can check labs on [**10-3**] so that [**First Name8 (NamePattern2) 717**]
[**Last Name (NamePattern1) **] NP has the information when she sees you on [**10-4**].
7. Start aspirin daily (take chewable baby aspirin)
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 19354**] if weight goes
up more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Name: NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital3 **] [**Hospital3 **]
Address: [**Age over 90 19357**], [**Location (un) **],[**Numeric Identifier 19358**]
Phone: [**Telephone/Fax (1) 19355**]
Appointment: Wednesday [**2169-10-4**] 11:20am
We are working on a follow up appointment in Nephrology with Dr.
[**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 19356**] within 16-30 days. The office will contact you at
home with an appointment. If you have not heard or have any
questions please call [**Telephone/Fax (1) 10574**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"585.9",
"280.9",
"244.0",
"428.0",
"404.91",
"428.33",
"440.1",
"285.21",
"238.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
13801, 13858
|
8338, 12060
|
282, 289
|
13980, 13980
|
4173, 8315
|
15187, 15911
|
2980, 3102
|
12342, 13778
|
13879, 13959
|
12086, 12319
|
14165, 14429
|
3117, 4154
|
2376, 2394
|
14449, 15164
|
223, 244
|
317, 2272
|
13995, 14141
|
2426, 2800
|
2317, 2356
|
2816, 2964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,647
| 111,181
|
1743
|
Discharge summary
|
report
|
Admission Date: [**2192-9-17**] Discharge Date: [**2192-9-22**]
Date of Birth: [**2145-12-6**] Sex: F
Service: Plastic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old
female with extensive ductal carcinoma in situ on the right
breast, first noted on mammogram on [**2192-5-21**]. The
patient underwent right breast biopsy on [**2192-6-15**], which
showed ductal carcinoma in situ. The patient presented for a
right mastectomy with a TRAM flap reconstruction. The
patient has no family history of breast cancer.
PAST SURGICAL HISTORY: 1. Right breast biopsy. 2.
Tonsillectomy.
PAST MEDICAL HISTORY: Negative.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Paxil 20 mg p.o.q.d.
PHYSICAL EXAMINATION: On physical examination, the patient
was in no acute distress. Chest: Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm.
Abdomen: Soft, nontender, nondistended.
HOSPITAL COURSE: The patient was admitted on [**2192-9-17**]
and underwent a right modified radical mastectomy with
reconstruction with a free TRAM flap. Immediately
postoperatively, the patient was admitted to the Intensive
Care Unit for frequent flap checks. The patient continued to
have good Doppler flow through the flap overnight. The
patient's postoperative hematocrit was noted to be 26.9.
On postoperative day number one, the patient's TRAM flap was
warm, pink, had a good capillary refill and a strong Doppler
signal. The patient complained of pain but was otherwise
doing well. On postoperative day number two, the patient
began oral intake and fluids were Hep-Locked. The patient
was able to get out of bed to the chair and she was
transferred to the floor.
The patient's epidural was discontinued on postoperative day
number two and the patient was started on oral Percocet. On
postoperative day number three, the patient's Foley was
removed and she was ambulating. On postoperative day number
four, the patient complained of some headache and nausea but
was otherwise doing well. She continued to ambulate.
On postoperative day number five, the patient's left
abdominal drain was removed. The patient was discharged to
home on postoperative day number five with follow-up to be
with Dr. [**First Name (STitle) **] on Tuesday.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2192-9-22**] 10:37
T: [**2192-9-24**] 08:23
JOB#: [**Job Number 9906**]
|
[
"233.0",
"174.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.43",
"85.7",
"85.31"
] |
icd9pcs
|
[
[
[]
]
] |
734, 756
|
989, 2603
|
574, 619
|
779, 971
|
173, 550
|
642, 707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,788
| 142,359
|
26515
|
Discharge summary
|
report
|
Admission Date: [**2173-9-3**] Discharge Date: [**2173-9-10**]
Date of Birth: [**2098-6-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Prednisone / Plaquenil
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
cavitary LLL lung lesion
Major Surgical or Invasive Procedure:
s/p left Video-assisted wedge resection and Left lower lobectomy
flexible bronchoscopy
Thorascopic mediastinal lymph node disection x2
History of Present Illness:
74-
year-old woman, with significant smoking history, who was
found to have a left lower lobe ground-glass opacity
surrounding a bulla as an incidental finding during a lower
GI bleed. In addition, she had a hazy opacity in the right
upper lobe. Given these 2 findings, there was a question
whether or not these represented inflammatory lesions versus
bronchoalveolar carcinoma in one or both. We followed these
lesions with serial CT scans including a PET/CT scan. There
was no FDG uptake within either lesion. There was uptake
within a porta hepatis lymph node which we followed on serial
CT scans and proceeded with esophagoscopy with gastric
ultrasound. It was not visible on ultrasound, and it did not
change on serial follow-up CT scans. Ultimately, both
lesions, the left lower lobe and the right upper lobe lesion,
did not disappear. Therefore, we elected to take her forward
for surgical resection. Our plan was to perform a generous
wedge excision, and if it represented a well-differentiated
bronchoalveolar carcinoma to consider that adequate treatment
for the left lower lobe lesion. Alternatively, if it
represented a more aggressive form of lung cancer, we would
perform a left lower lobectomy.
Past Medical History:
cavitary Left lower lobe lung lesion s/p left Video-assisted and
Left lower lobectomy
Coronary artery disease s/p CABG x 3 and LIMA-LAD stent, s/p IVC
filter.
Carotid stenosis, hx hyponatremia, gastritis, duodenitis w/ Gi
Bleed [**2-22**] requiring transfusions, on protonix therapy.
Social History:
frail, lives w/ husband in [**Name (NI) **], MA.
uses cane and walker at home.
significant smoking hx
etoh- 2 drinks/day
Family History:
n/a
Physical Exam:
General-frail elderly female
HEENT- no cervical or supraclavicular adenopathy
Resp-clear, course upper airway sunds
Cor- RRR, no murmur
Abd- non distended, soft, non- tender
Ext- no clubbing,cyanosis or edema.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2173-9-6**] 06:50AM 10.2 3.21* 10.5* 30.7* 96 32.7* 34.2 13.1
324#
BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct
[**2173-9-6**] 06:50AM 324#
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2173-9-6**] 06:50AM 126* 8 0.5 131* 4.51 91* 27 18
MODERATELY HEMOLYZED
1 HEMOLYSIS FALSELY ELEVATES K
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2173-9-4**] 05:02AM 1028*
ADD ON
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2173-9-4**] 05:02AM 9 <0.011
ADD ON
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2173-9-5**] 11:44 AM
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman s/p LLL lobectomy s/p removal of remaining
chest tube.
REASON FOR THIS EXAMINATION:
Please assess for pneumothorax or effusion. Please do at noon.
HISTORY: Status post left lower lobe lobectomy and removal of
remaining chest tube. Compared with one day earlier, a
left-sided chest tube has been removed. There is a moderately
large left pleural effusion tracking along the left chest wall,
with underlying left lower lobe collapse and/or consolidation.
The left hemidiaphragm is also elevated, with near filled
gastric fundus below. Some crowding of vessels is seen left
lung. There is curvilinear density superimposed over the left
lung apex suggesting the presence of a small left pneumothorax.
In retrospect, this may have been present on the film from [**9-4**]
and [**9-3**]. The differential diagnosis includes vascular
calcification superimposed over the left lung apex. There also
appears to be a small mesh stent in this area. Review of a chest
CT from [**2173-7-15**] shows a densely calcified left subclavian
artery, which is contributing to the appearance on today's
x-ray.
IMPRESSION: Left pleural effusion, unchanged. Equivocal small
left apical pneumothorax, in the setting of a calcified left
subclavian artery crossing the apex of the left lung.
Brief Hospital Course:
Patient admitted [**2173-9-3**] SDA for above procedure. Pt tolerated
procedure well, transferred to PACU in stable
condition,extubated, CT x2 to suction. PACU course complicated
by need for IVF (4L) and neo gtt for BP/hemodynamic support. Pt
transferred to ICU on new for observation BP/ hemodynamic
monitoring.
POD#1-BP stablilized, neo weaned to off, atenolol and lisinopril
resumed; OOB w/ assist x1 w/ cane or walker, PT consulted; Ant
CT d/c w/o complication. Pain control w/ vicodin an toradol w/
good effect. REsp- productive of mod amt thick secretions w/
weak cough, required NT sx x1 overnight. Diuresis. R/O'd MI in
setting of low BP, low u/o. EKG unchanged. CT d/c, [**Doctor Last Name 406**] tube to
bulb suction w/o complication by CXRY.
POD#2-Diuresis w/ fair response, adequate u/o, no evidence of
pulmonary edema, NT suctioning assist w/ secretion clearance.
Foley d/c, plavix and ASA restarted.
Some sig pain and anxiety w/ BP^200, resolved w/ pain med and
reassurance. Transferred to floor in evening. [**Doctor Last Name 406**] drain d/c
POD#3- MOderate amt secretions requiring NT sx occassionally-
q8h for airway clearance, aggressive pulmonary toilet, CPT,
ambulation. Dispo planning for REhab initiated. Labs WNL- WBC
10.2; HCT 30.7.
D/C summary continued by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from this point forward.
POD#4 Pt noted to be in rapid afib-hemodyanamically stable. Did
mot respond to boulses of Iv lopressor or amiodarone gtt. Also
noted to be confused after rec'ing morphine. Pt also
experiencing urinary retention and thus a foley was replaced and
she will need out patient [**Last Name (NamePattern1) **] eval.
POD#5 remained in rapid afib-rebolused w/ amiodarone. confusion
cleared.
cardiology consulted- pt had echo cardiogram -see results
section. Not a candidate for cardioversion or anticoagulation
d/t history of massive GIB on coumadin in [**Month (only) **] per her
cardiologist at [**Last Name (un) 1724**]. Pt will be managed w/ rate control using
dilt and lopressor. she remains on her plavix and Asa for her
stent. Her HR has improved and is now 80 w/ rare bursts of 120's
which are self limited and asymptomatic.
Medications on Admission:
Atenolol 25, zestril 5, aciphex, plavix 75', ASA 81'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection [**Hospital1 **] (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-18**]
Puffs Inhalation Q6H (every 6 hours) as needed.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO four times
a day.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location 4288**]
Discharge Diagnosis:
cavitary Lleft lower lobe lung lesion s/p left Video assisted
and Left lower lobectomy
Coronary artery disease s/p CABG x 3 and LIMA-LAD stent, s/p IVC
filter; carotid stenosis, hx hyponatremia, gastritis, duodenitis
w/ GI bld in pais requiring transfusions, on protonix. Hx etoh-
2 drinks/day
Post op afib
Discharge Condition:
fair-deconditioned
Discharge Instructions:
Call Thoracic Surgery, [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) **] office for any post
surgical issues. [**Telephone/Fax (1) 170**].
call your cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] [**Telephone/Fax (1) 5985**] regarding
any cardiac questions/issues.
call the [**Telephone/Fax (1) **] clinic at [**Hospital1 18**] [**Telephone/Fax (1) 164**].
Followup Instructions:
Call Thoracic Surgery, [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) **] office for follow-up
appointment when released from Rehabilitation facility.
[**Telephone/Fax (1) 170**].
Call [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] clinic for follow up
appointment regarding your urinary retention-[**Telephone/Fax (1) 164**]
Completed by:[**2173-9-10**]
|
[
"414.00",
"427.31",
"V45.81",
"512.8",
"162.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.4",
"33.22",
"40.3",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8039, 8104
|
4442, 6644
|
321, 458
|
8455, 8476
|
2410, 3096
|
8936, 9335
|
2159, 2164
|
6747, 8016
|
3133, 3206
|
8125, 8434
|
6670, 6724
|
8500, 8913
|
2179, 2391
|
257, 283
|
3235, 4419
|
486, 1697
|
1719, 2005
|
2021, 2143
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,856
| 155,343
|
54932
|
Discharge summary
|
report
|
Admission Date: [**2146-8-5**] Discharge Date: [**2146-8-6**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Right SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a [**Age over 90 **] year old woman who was transferred from [**Hospital 6136**]
Hospital ([**Location (un) 34973**])for evaluation of subdural hematoma. We were told that
she had a mechanical fall that day.. She was at her PCPs office
when she reported a mild headache. A CT scan was done at the
outside hospital which revealed an acute on chronic subdural
hematoma. Patient was given mannitol and intubated. There is no
other significant injury identified on their exam. Her CT scan
of her C-spine is negative for fracture. Upon arrival to [**Hospital1 18**],
neurosurgery was consulted for evaluation.
Past Medical History:
PMH: anemia (?bone marrow failure, transfused monthly), CAD,
CHF, CRF
PSH: hysterectomy, ear surgery
Social History:
Daughter [**Name (NI) 1439**] ([**Telephone/Fax (1) 112190**]
[**Name2 (NI) **]r social hx is unknown
Family History:
Unknown
Physical Exam:
On admission:
Initial exam: No EO, no gag, weak cough, + bilateral corneals, R
pupil 3-2mm reactive, L pupil 2mm nonreactive, no BUE movement
to noxious, LLE triple flexion, RLE weak withdrawl.
Repeat exam: Unchanged but R pupil 5mm NR, L pupil 3mm NR.
Pertinent Results:
CT Head [**2146-8-5**]:
IMPRESSION:
1. Enlarging right subdural hematoma with worsening leftward
midline shift, increased bihemispheric sulcal effacement,
worsening effacement of the right lateral ventricle, left
lateral ventricle entrapment, and moderate suprasellar and mild
quadrigeminal cistern effacement. No tonsillar herniation.
2. Slightly increased soft tissue gas near the right TMJ and
posterior to the right maxillary sinus, but no obvious fracture.
[**2146-8-5**] CXR
1. Low endotracheal tube, as above, recommend withdrawal by [**1-7**]
cm.
2. Pulmonary edema, asymmetric, right greater than left, may be
neurogenic in origin
Brief Hospital Course:
This is a [**Age over 90 **] year old woman with a right SDH and midline shift.
She was intubated and medflighted to [**Hospital1 18**] from [**Hospital3 **]. She
did not require any sedation during [**Location (un) **]. Upon arrival to
the ER, she was intubated but not sedated. On initial
examination, R pupil was 3-2mm and L pupil was 2mm nonreactive.
There was no gag but a weak cough, + bilateral corneals, no BUE
movement to noxious, no EO, LLE triple flexion, RLE weak
withdraw. Her head CT from the OSH showed a R sided SDH with
midline shift, the SDH is acute on chronic. Patient was on ASA
and Plavix and did not receive any reversal agents prior to
transport. Given that her exam did not correlate to her imaging,
interval of time from OSH head CT, and anticoagulation, a CT
head was repeated. The CT showed the R SDH had worsened and the
midline shift progressed and was 15mm vs. 10mm on initial CT.
She received platelets and Desmopressin. She was also bolused
with Dilantin. Her VS remained stable. A contact number for her
daughter was found in OSH records. The daughter confirmed she
was DNR, and given the prognosis and family wishes- the family
wanted no aggressive treatment. She was made CMO. Patient was
kept intubated and transferred to the ICU. Family expressed they
were unable to get to the hospital at that time, but would be
able to the next day.
The family was again contact[**Name (NI) **] on [**2146-8-6**] to identify the patient
and were informed that if they did not arrive prior to
expiration that they would have to unfortunately identify her in
the morgue. They did not arrive prior to her expiration that
evening.
Medications on Admission:
allopurinol, aloe vesta, aquaphor, ASA 325mg, lipitor, celexa,
plavix, colace, lasix, prevacid, zestril, metoprolol, nitro,
miralax, ranexa, tylenol, bisacodyl, maalox, MOM
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
Right subdural hematoma with midline shift
Cerebral edema
Respiratory failure
Hyponatremia
Discharge Condition:
Expired on [**2146-8-6**]
Discharge Instructions:
N/A
Followup Instructions:
Expired
Completed by:[**2146-8-6**]
|
[
"518.51",
"585.9",
"432.1",
"428.0",
"348.4",
"427.31",
"285.9",
"414.01",
"348.5",
"V49.86",
"E885.9",
"V58.66",
"V88.01",
"250.00",
"852.21",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4045, 4054
|
2141, 3795
|
261, 268
|
4189, 4217
|
1470, 2118
|
4269, 4307
|
1171, 1180
|
4019, 4022
|
4075, 4168
|
3821, 3996
|
4241, 4246
|
1195, 1195
|
212, 223
|
296, 911
|
1210, 1451
|
933, 1036
|
1052, 1155
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,331
| 178,932
|
2509
|
Discharge summary
|
report
|
Admission Date: [**2182-9-9**] Discharge Date: [**2182-10-16**]
Service: MED
Allergies:
Captopril
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
[**Age over 90 **] yo Russain speaking M with history of CAD s/p CABG, COPD, CHF
(EF 30-35%) and recent MICU admission for PNA, sepsis requiring
intubation, now presenting with SOB, tachypnea, temperature to
102F with desaturation to 79% on room air. His saturation
improved to 97% with a non rebreather and he was then
transferred to the ED from NH. Per pt's son, [**Name (NI) **], the pt has
been more SOB and not tolerating po's over the past 2 days at
[**Hospital3 2558**]. He was recently admitted [**2182-6-24**] for aspiration
PNA and sepsis requiring intubation. He failed swallow study at
that time but was d/c'd to rehab reportedly tolerating po's. In
the ED, the pt was febrile to 102F and given lasix 20mg iv x 1
for slight CHF on CXR. ABG on 70% FM was 7.38/45/60 and BP was
borderline low. The patient was started on ceftriaxone, flagyl
and azithromycin. He was admitted to the unit for close
monitoring of blood pressure and pulmonary function.
Past Medical History:
CAD s/p CABG
CHF
recent MICU admx for PNA, sepsis
HTN
s/p CVA
hypothyroidism
anemia
s/p prostate surgery
h/o C.diff
h/o a.flutter
Social History:
Russian immigrant
60 p-y tobacco
occ EtOH
Physical Exam:
NAD, alert, oriented to person and hospital
mmm, no JVD, EOMI
heart RRR without m/r/g
pulm rales at bilateral bases. l>r
abdomen soft, nt/nd. No HSM
2+ankle edema, 1+dp pulses bilat, warm
EOMI, Pupils 4-->2mm bilat,sensation and strength intact,
dysarthric, eomi.
Pertinent Results:
[**2182-9-18**] 10:07 pm SPUTUM **FINAL REPORT [**2182-9-21**]**
GRAM STAIN (Final [**2182-9-19**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2182-9-21**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES PERFORMED ON CULTURE # 174-8437E [**2182-9-18**].
YEAST. SPARSE GROWTH.
[**2182-9-18**] 10:07 pm BLOOD CULTURE Site: A LINE **FINAL REPORT
[**2182-9-24**]**
AEROBIC BOTTLE (Final [**2182-9-24**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2182-9-22**]):
ENTEROCOCCUS FAECALIS
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ =>16 R =>16 R
LEVOFLOXACIN---------- =>8 R =>8 R
PENICILLIN------------ 16 R 16 R
VANCOMYCIN------------ <=1 S <=1 S
[**2182-9-15**] 5:31 am BLOOD CULTURE**FINAL REPORT [**2182-9-18**]**
AEROBIC BOTTLE (Final [**2182-9-18**]):KLEBSIELLA PNEUMONIAE
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 RANAEROBIC BOTTLE (Final [**2182-9-18**]):
KLEBSIELLA PNEUMONIAE.
Brief Hospital Course:
In the [**Hospital Unit Name 153**], the patient was treated with flagyl, azithro, and
ceftriaxone to cover both aspiration and nursing home acquired
pneumonia. He failed a trial of 5L nasal cannulae with
desaturation, but showed improvement on 40% FIO2 by facemask.
Chest PT was performed with emphasis to the site of the left
lower lobe pneumonia. He was supported with bronchodilators and
steroids with a plan to wean his steroids only if he required a
prolonged duration of therapy. A discussion was undertaken
about the benefit of NG tube placement with transition to PEG,
in order to limit future aspiration events. A discussion was
undertaken with the daughter and son, who agreed that this
procedure could be performed pending the patient's approval and
with the assurance of speech and swallow that the patient's
dysphagia would not improve with a temporary rest from
swallowing. The patient decided to take time to think about
whether or not to have the PEG placed, but agreed to placement
of an NG tube in the interim. He did have new EKG changes in
V5/V6 with tachycardia. This resolved after fluid resuscitation
and resoution of tachycardia. A CXR was not impressive for
signs of pulmonary edema. Fluids were otherwise kept even with
lasix as needed to prevent volume overload. The patient
appeared to have a mixed respiratory and metabolic acidosis with
no anion gap. He is perhaps unable to compensate with this
acute insult in light of his COPD and moderate renal
insufficiency.
The patient was transferred to the medicine floor [**9-18**] and later
that day developed acute respiratory distress with sat 90% on a
nonrebreather mask, respiratory acidosis, and hypotension with
BP90/50 likely due to repeat aspiration He was intubated and
returned to the ICU on the same day. He was bradycardic HR 48,
thrombocytopenic, and had digitalis toxicity. Digitalis was
permanently discontinued and thought to be the cause of the
bradycardia. Beta blockade was temporarily held for bradycardia.
The patient completed a 5 day course of stress dose steroids for
hypotension and klebsiella, enterobacter bacteremia. He received
dopamine for the hypotension and bradycardia. The patient did
well after extubation on [**9-23**] and he returned to the medicine
floor without hemodynamic instability or respiratory distress.
He was readmitted to the ICU for hypercarbic and hypoxic
respiratory failure due to aspiration, and also suffered severe
hypotension with suspected sepsis.
In ICU pt continued to be hypercarbic despite attempts at
multiple ventilator settings and O2 saturations hovered in the
high 80's. He continued to be hypotesive despite max dose
vasopressin and norepinephrine and required frequent normal
saline boluses. Pt developed acute on chronic renal failure and
became anasacic due to multiple fluid boluses resulting and
diffuse skin breakdown along with digit dry gangrene due to
vasopressors. A family meeting was called and it was decided
that the pt would be made CMO. The pt was given morphine as
needed to make respiration comfortable and he was removed from
the ventilator on [**10-15**] and pt expired the next morning.
Medications on Admission:
Regular insulin-sliding scale.
Aspirin 81 q.d.
Atorvastatin 10 mg q.h.s.
Folic acid 1 mg p.o. q.d.
Levothyroxine 75 mcg p.o. q.d.
Acetaminophen prn.
Dextromethorphan/guaifenesin 5 mL p.o. q.6h. if needed.
Solu-Medrol 50 mcg dose disk with one disk q.12h.
Inhaled fluticasone 110 mcg aerosol two puffs b.i.d.
Polyvinyl Alcohol drops 1-2 drops ophthalmic prn as
needed.
Liquid omeprazole.
Therapeutic multivitamin one cap p.o. q.d.Senna.
Docusate p.o. b.i.d.
Amiodarone 200 mg p.o. b.i.d.
Ipratropium inhalation q.6h. as needed.
Captopril now increased to 50 mg p.o. t.i.d. and
hold for systolic blood pressure less than 120.
Metoprolol 12.5 mg p.o. t.i.d.
Carbamide peroxide drops eyedrops 5-10 drops p.o.
b.i.d. for the next four days.
Furosemide 20 mg p.o. q.d., hold for systolic blood
pressure less than 110.
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxic and hypercarbic respiratory failure
Discharge Condition:
Death
|
[
"038.49",
"008.45",
"518.84",
"707.0",
"428.0",
"287.4",
"286.7",
"507.0",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"43.11",
"96.72",
"38.93",
"96.04",
"99.05",
"38.91",
"33.24",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7521, 7530
|
3479, 6646
|
232, 247
|
7617, 7625
|
1755, 3456
|
7551, 7596
|
6672, 7498
|
1470, 1736
|
173, 194
|
275, 1243
|
1265, 1396
|
1412, 1455
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,883
| 143,690
|
9490
|
Discharge summary
|
report
|
Admission Date: [**2179-6-29**] Discharge Date: [**2179-7-13**]
Date of Birth: [**2112-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
ICD discharge
Major Surgical or Invasive Procedure:
Intubation
Attempted VT ablation
L heart catheterization
Endocardial VT ablation
History of Present Illness:
Pt is a 67 year old man with history of CAD s/p inferolateral
MI, CHF (EF <20%), s/p ICD for primary preventions followed by
VT episodes s/p ablation presenting with ICD firing. Pt was
recently admitted after having his ICD fire.
Today pt reports that his ICD fired x1 this evening. Pt was at
rest, had prodrome of fluttering and burning in chest [**3-20**] secs
before ICD fired. Had 1.5 hrs of chest and neck tightness
following ICD fire, typical for him post-ICD fire, which was
resolved on arrival to ED.
During his prior admissions ICD was interrogated by EP and
showed episodes of fast VT with CL 300-320 msec with similar
morphology, some of which responded to ATP while others required
shock. Felt likely to have scar mediated VT from an inferior
origin. At this time there were no signs or symptoms suggestive
of an acute ischemic trigger, and patient was continued on his
home meds of ASA, statin, beta blocker, and ACE-I. The ICD
setting was changed from burst to a more agressive sequence, and
his sotalol was increased from 120 mg [**Hospital1 **] to 160 mg [**Hospital1 **]. Pt
discharged on [**6-28**].
.
On arrival to the ED his initial vital signs were T 98.4, HR 81,
BP 156/95, RR 18, O2 sat 97% RA.
.
He underwent an attempted VT ablation on [**2179-7-1**]. However the
catheters could not be passed through the aortic valve. He was
recovering well from the procedure. However, the patient
experience recurrent VT with appropriate shocks at ~430pm. He
was evaluated by the EP service. He was bolused with amiodarone
(150mg), and lidocaine (200 mg) and transferred to the CCU. Also
prior to transfer his pacer was decreased to VVI at 40 bpm to
limit V-pacing.
.
On arrival to the CCU he is without serious complaint. He has
mild chest discomfort following the shocks. He has no shortness
of breath. He has some ringing in his ears following the
lidocaine infusion.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. Occassionally snores,
but no witnessed apneas. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion with 3 flight of stair, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope. \
Past Medical History:
1. Coronary artery disease status post MI x3 ages 39, 42, 45.
2. Inducible VT on EP study [**2171-9-15**].
3. Status post Guidant Ventale prism implantable cardioverter
defibrillator in 10/00 for nonsustained V-tach. S/p ICD
generator change to a PRIZM DR.
4. Hyperlipidemia.
5. VT ablation [**2174-6-10**].
6. Amiodarone-induced thyrotoxicosis
.
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, -Hypertension
.
Cardiac History: CABG: NA
.
Pacemaker/ICD placed in [**Company 1543**] Virtuoso dual-chamber ICD
originally placed [**9-/2171**] generator change [**2178-5-15**]
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Quit smoking 14 years
ago (previously 1 ppd). Lives with his wife. [**Name (NI) 1403**] for [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
Pain developing pastries, breads, soups.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father w/ CVA x 3 and MI x 4 (first at age 60,
d 89). 2 brothers with hx of CAD and s/p CABG.
Physical Exam:
VS: 99.1 69 135/68 16 95%RA
Gen: WDWN obese middle aged male in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRLA, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with flat JVP
CV: PMI located in 5th intercostal space, midclavicular line.
distant heart sounds. RRR, normal S1, S2.
Chest: device implanted in left chest. non-tender oversight. No
other chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. bilateral femoral access sites
with eccymoses. small hematoma in left groin.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro:
MS- alert, oriented x3. coherent response to interview
CN- II-XII intact
Motor- moving all 4 extremities symmetrically
[**Last Name (un) **]- light tough intact over face/hands/feet
Pertinent Results:
[**2179-6-28**] 07:01AM BLOOD WBC-6.0 RBC-4.69 Hgb-14.6 Hct-42.0 MCV-90
MCH-31.1 MCHC-34.7 RDW-13.7 Plt Ct-178
[**2179-6-29**] 07:40PM BLOOD PT-12.2 PTT-30.8 INR(PT)-1.0
[**2179-6-28**] 07:01AM BLOOD Glucose-88 UreaN-19 Creat-1.0 Na-142
K-4.2 Cl-104 HCO3-30 AnGap-12
[**2179-6-28**] 07:01AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
[**2179-6-29**] 07:40PM BLOOD CK(CPK)-69
[**2179-6-30**] 05:45AM BLOOD CK(CPK)-59
[**2179-7-5**] 11:33AM BLOOD CK(CPK)-55
[**2179-7-6**] 03:56AM BLOOD CK(CPK)-43
[**2179-6-29**] 07:40PM BLOOD cTropnT-<0.01
[**2179-6-30**] 05:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-7-5**] 11:33AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-7-6**] 03:56AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-7-7**] 09:40AM BLOOD %HbA1c-5.9
[**2179-7-7**] 09:40AM BLOOD ALT-12 AST-12 AlkPhos-84 Amylase-28
TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2179-7-1**] 05:35AM BLOOD TSH-4.0
EKG [**2179-6-28**]: Sinus rhythm with first degree A-V delay. Left
atrial abnormality. Intraventricular conduction delay. Inferior
infarct, age indeterminate - may be old. Q-Tc interval appears
prolonged but is difficult to measure. Nonspecific ST-T
abnormalities. Clinical correlation is suggested. Since previous
tracing of [**2179-6-26**], ventricular ectopy absent.
ECHOCARDIOGRAM [**2179-6-30**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is moderate regional left
ventricular systolic dysfunction with thinning/akinesis of the
inferior and inferolateral walls and hypokinesis of the
anterolateral wall. The remaining segments contract well
(suboptimal technical quality). Right ventricular chamber size
is normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be quantified. There is an anterior space which most likely
represents a fat pad.
Compared with the prior study (images reviewed) of [**2177-6-5**],
the left ventricular cavity size is smaller. Regional and global
left ventricular systolic dysfunction is similar (was regional
on the prior study and global LVEF was underestimated.) LVEF
30-35%.
LEFT LENI [**2179-7-2**]: Findings consistent with a left-sided common
femoral artery AV fistula. No pseudoaneurysm.
CT PELVIS W/WO CONTRAST [**2179-7-5**]: 1. Aneurysm of the left common
iliac artery. 2. No evidence of AV fistula.
LEFT HEART CATHETERIZATION [**2179-7-7**]:
1. Selective coronary angiography of this right dominant system
demonstrated 2 [**Month/Day/Year 12425**] coronary artery disease. The LMCA and LAD
showed no significant angiographically apparent cad. The LCx
had a 70%
proximal stenosis and a 100% mid-stenosis with left to left
collaterals
to the OM2. The RCA had a 70% proximal stenosis and a 100%
mid-stenosis
with left to right collaterals to the distal RCA.
2. Limited resting hemodynamic measurements showed elevated left
sided
filling pressure (LVEDP 20mmHg). The systemic arterial pressure
was
normal (104/57 mmHg). There was no significant gradient on
pullback
from the left ventricle to the ascending aorta.
3. Left ventriculography showed an ejection fraction of 30%.
There was
an extensive area of inferobasal dyskinesis and severe
hypokinesis of
the anterolateral and inferoapical walls. There was no mitral
regurgitation.
FINAL DIAGNOSIS:
1. Severe two [**Month/Day/Year 12425**] coronary artery disease, without
significant change
from prior cath of [**2178-9-23**].
2. Mild left ventricular diastolic dysfunction.
3. Severe left ventricular systolic dysfunction
B/L UPPER EXTREMITY LENI [**2179-7-9**]
Likely catheter-associated partially occlusive thrombus in the
right subclavian vein. Extension into right internal jugular
vein not
excluded.
SPUTUM [**2179-7-7**]
GRAM STAIN (Final [**2179-7-7**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2179-7-9**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Brief Hospital Course:
Multiple ICD firings: He was thought to have scar mediated VT
from his underlying CAD and his thinned akinetic ventricle. VT
was initially well controlled on IV amiodarone and IV
lidocaine. A repeat VT ablation was attempted but was
unsuccessful due to inability to cross the aortic valve. An
attempt was made to switch him to PO amiodarone and to wean him
off the IV lidocaine, however, he then began to experience
episodes of VT. Initially, this led to resumption of IV
lidocaine, however, when the frequency of VT episodes and ICD
firings worsened, he was electively intubated and started on IV
amiodarone. During these episodes of VT, he was noted to have ST
changes on EKG and chest pain that responded to nitroglycerin,
thought to be collateral insufficiency in the setting of
tachycardia. He was noted to have episodes of slow VT, below the
detection threshold of his ICD, so the detection threshold was
reduced to 118 and he was started on an esmolol drip for tighter
regulation of heart rate. Amiodarone and lidocaine were
continued per EP. Pt had cath with 3 sites of ablation for
Vtach. Patient then developed ew morphology vtach and was
restarted on amidoarine, lido and esmolol drips. He was then
been transitioned off IV to po meds for rate control -
metoprolol, amiodarone and mexiletine and was without vtach for
72 hours prior to discharge. Plan was to taper his amiodarone
over the next month from TID to qd dosing with outpt EP followup
arranged.
CHF: EF 30-35%. Initially somewhat overloaded, responded to
diuresis. Apparently euvolemic on discharge.
CAD: No acute ischemia. He was on ASA, atorvastatin, and
metoprolol.
.
Respiratory: He was electively intubated for repeated VT
episodes and ICD discharges and was successfully extubated. He
had MSSA growing in his sputum and was initially tx'ed with IV
cefazolin and transitioned to Keflex on [**7-12**]. He was discharged
on Keflex for a projected 7 day course. Speech and swallow
evaluation deemed him able to tolerate food and thin liquids, no
large pills.
.
L femoral bruit: Had a bruit following L groin arterial access
which resolved. CT showed L common iliac aneurysm with no AV
fistula. He was discharged with follow up with vascular
surgery. Per vascular surgery, will need f/u with Dr. [**Last Name (STitle) **] in
one month.
.
R subclavian clot: Pt noted to have clot, thought to be
provoked by R IJ. Coumadin was begun with heparin bridge. On
discharge pt was still subtherapeutic on Coumadin and was given
Lovenox teaching. He was discharged on Lovenox with [**Hospital 197**]
clinic followup. Plan was to continue anticoagulation for 6
months.
.
Hx of Amiodarone-induced thyrotoxicosis: TFT's were normal
during this admission and it was it was determined that it would
be safe to restart amiodarone if needed as the risk of AIT is
approximately 10%. Thus, he was restarted on amiodarone.
Endocrine had been consulted during his previous admission and
were aware. TFTs were normal during this admission and. He
was discharged with followup with Dr. [**Last Name (STitle) **] and plan for
monthly TFTs
.
GERD: Home PPI regimen was continued
Medications on Admission:
Omeprazole 20 mg PO BID
Atorvastatin 40 mg PO DAILY
Aspirin 325 mg PO DAILY
Ramipril 10 mg PO DAILY
Amlodipine 5 mg PO DAILY
Toprol XL 150 mg PO DAILY
Sotalol 160 mg PO BID
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
6. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for Pneumonia for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
11. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y
(120) mg Subcutaneous Q12H (every 12 hours): You will be on this
medication, which you must inject twice daily, until your INR
(Warfarin level) is therapeutic.
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM for 10 days: Dr. [**Last Name (STitle) 32296**] will further advise you on dosing
this medication. You will be on Warfarin for 6 months.
Disp:*20 Tablet(s)* Refills:*1*
13. Amiodarone 200 mg Tablet Sig: As Directed Tablet PO As
directed: This medication is being tapered from its current
dose. Please take 400 mg three times daily for 7 days (through
[**2179-7-22**]); then 400 mg twice daily for 14 days (through [**2179-8-5**]);
then continue on 400 mg daily as your regular dose.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary:
Ventricular tachycardia with prior ICD placement
Recurrent defibrillator firing
MSSA pneumonia
Upper extremity DVT
VT ablation
Severe left ventricular systolic dysfunction
Secondary:
Hyperlipidemia
Gastroesophageal Reflux
History of prior Myocardial infarction
Discharge Condition:
Hemodynamically stable, afebrile, no ICD firing x 72 hours.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for multiple ICD discharges. Your
medications were adjusted but you continued to have your ICD
fire. You underwent catheterization which showed severe two
[**Hospital1 12425**] coronary artery disease, without significant change from
prior cath of [**2178-9-23**]. It also revealed mild left
ventricular diastolic dysfunction and severe left ventricular
systolic dysfunction.
You subsequently underwent attempted to ablation, but your ICD
continued to fire for ventricular tachycardia. Thus, your
medications were further adjusted and you are now being
dishcarged home after 72 hours of no ICD firing.
While inpatient, you were also intubated. You were found to
have a bacterial infection which you are on antibiotics for.
You must take all antibiotics as directed.
You were also found to have a clot (deep venous thrombosis) for
which you are being anticoagulated (medications to decrease your
blood clotting). You may bruise more easily on these
medications. If you fall or strike your head or have a deep
cut, you should be evaluated by a physician for further
bleeding.
You were started on the following medications:
- Amiodarone 400 mg PO three times daily with planned taper
- Mexiletine 200 mg PO three times daily
- Warfarin 4 mg PO DAILY
- Hydrochlorothiazide 25 mg PO DAILY
- Cephalexin 500 mg PO Q6H
- Enoxaparin Sodium 120 mg SC Q12H
- Spironolactone 25 mg PO DAILY
The following medications were stopped:
- Amlodipine 5 mg daily
- Sotalol 160 mg twice daily
The following medications were changed:
- Metoprolol is now 75 mg three times daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L daily
Keep all outpatients appointments.
Seek medical advice if you notice fevers, chills, difficulty
breathing, weight gain greater than 3 lbs, chest pain, increased
leg swelling, palpitations or for any other symptom that is
concerning to you.
Followup Instructions:
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2179-7-19**] 11:00AM
Provider [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 32296**], MD Phone: [**Telephone/Fax (1) 32297**] Date/Time:
[**2179-7-20**] at 10:45AM. Dr. [**Last Name (STitle) 32296**] will continue to manage your
Warfarin (Coumadin) dosing. The VNA will draw your labs at home
and fax them to Dr. [**Last Name (STitle) 32296**] who will advise you on any medication
changes.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Phone: ([**Telephone/Fax (1) 2037**] Date/Time:
[**2179-8-5**] 2:40PM
Provider VASCULAR [**Month/Day/Year **] Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2179-8-10**]
2:15PM
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2179-8-10**] 2:45PM
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2179-7-13**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,414
| 175,270
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48772
|
Discharge summary
|
report
|
Admission Date: [**2187-10-23**] Discharge Date: [**2187-11-7**]
Date of Birth: [**2135-4-29**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Sulfonamides
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
S/p fall with large pannus hematoma.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
52yof w/CHF (EF 15-20%), AFib (s/p cardioversion x2, currently
on amio), presented to ED s/p fall. Pt. was home alone morning
of admission, fell forward while trying to get off of the
toilet. She broke her fall with her hands, and there was no LOC
or head trauma. She reports that her knees buckled and that
following the fall she could not get up, so she crawled to her
bedroom and called 911.
.
At baseline, she is ambulatory at home, but over the last
several weeks, she (and her sister) have noted increasing
SOB/DOE, leg edema, general malaise/fatigue, and a ?new fine
resting tremor involving her digits and lips. On ROS, she denies
HA, chest pain or pressure, cough, nausea/vomiting,
diarrhea/constipation, fever/chills, dysuria,
melena/hematochezia, recent illness.
.
Her only recent medication change was an increase in lasix from
40 to 80 PO BID on [**2187-10-19**].
.
In the [**Name (NI) **], Pt. found to have a Hct drop from baseline mid-30s to
27.8 to 20.8 and an INR of 5.7. She was initially admitted to
the floor but given her decreased hematocrit was transferred to
the CCU team.
Past Medical History:
1. non-ischemic dilated cardiomyopathy, EF 15-20%
2. hypertension
3. paroxysmal AFib (dx in [**2181**], s/p CV x2, currently on amio)
4. obesity
5. reactive airway disease
6. restrictive lung disease
7. bilateral knee surgeries
8. obstructive sleep apnea
Social History:
Patient is not married and has lived in [**Hospital1 778**] for many years.
She works for the city. She quit tobacco 30 yrs ago, quit EtOH
in [**2182**] (occasional beer), no drugs.
Family History:
Mother died (MI in her 60's)
Brother with CAD in 50's
CA
CVA
[**Name (NI) 1568**] brother, nephew, father
Physical Exam:
PE: VS: T 96.9 | 168/98 | 74 | 28 | 94% on RA
gen: NAD, Sitting up comfortably in chair.
HEENT: no LAD, OP clear, MMM, no carotid bruit, unable to see
JVD, no carotid bruit, no neck masses
skin: no rashes
CV: irreg irreg, nl s1s2, distant heart sounds, no murmurs
chest: distant breath sounds, decr. at bases, no crackles or
wheezes.
abd: Morbidly obese with abdominal binder in place, large
ecchymosis involving RLQ/inguinal area to midline, morbidly
obese, tender to palpation esp. on L, +bs, no organomegaly.
extr: warm, no cyanosis, venous stasis changes in LE including
excoriation on L inner ankle. 2+ LE b/l edema, 1+ radial & dp
pulses. neuro: a&ox3, cn ii-xii intact, motor sensory
coordination and language grossly intact/nonfocal.
rectal: guaic negative
Pertinent Results:
Echo [**2187-10-30**]: LVEF=25%. The left atrium is markedly dilated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed. [Intrinsic left ventricular
systolic function may be more depressed given the severity of
valvular regurgitation.] The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. Right
ventricular systolic function is borderline normal. [Intrinsic
right ventricular systolic function may be more depressed given
the severity of tricuspid regurgitation.] There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. The aortic
valve is not well seen. There is mild aortic valve stenosis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. The mitral regurgitation jet is eccentric. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate to
severe [3+] tricuspid regurgitation is seen. There is at least
mild pulmonary artery systolic hypertension. Compared with the
prior study (tape reviewed) of [**2187-9-5**], left ventricular
systolic function appears slightly more vigorous now in the
setting of tachycardia. The pulmonary artery systolic pressure
was elevated in the prior study (not noted in the prior report)
and remains significantly elevated.
.
CXR [**2187-10-30**]: Marked cardiomegaly. Absence of overt pulmonary
congestion and significant pleural effusion speak in favor of
appropriate clinical management.
.
CT abd [**2187-10-29**]: 1. More superior portion of large hematoma of
the right flank and anterior abdominal wall has become more
homogeneous in appearance on today's exam. This suggests further
interval bleeding. This portion of hematoma now measures 19.5 x
10.6 cm in greatest axial dimensions. 2. More inferior portion
of hematoma of the anterior abdominal wall measures up to 19.4 x
10.0 cm in maximum dimension on today's exam. It is difficult to
compare to [**10-23**], as the hematoma may have extended beyond
the Gantry on both of these exams, but this portion is likely
not significantly changed. 3. The liver appears dense on these
non-contrast images. This may reflect prior amiodarone use or
iron overload. Clinical correlation again recommended.
.
CT abd [**2187-10-23**]: There is a large soft tissue hematoma within
the right flank and anterior abdominal wall, measuring 17 x 11
cm in maximum dimension. 2. The liver appears dense on these
non-contrast enhanced images. This may reflect prior amiodarone
use or iron overload - clinical correlation is recommended.
.
CXR [**2187-10-23**]: Stable cardiomegaly. This may be consistent with
cardiomyopathy.
.
ECG [**2187-10-23**]: AFib with RVR (110s), nl. axis, low precordial
voltages, no ST-T changes.
.
Echo [**2187-9-5**]: 1. The left atrium is markedly dilated. The left
atrium is elongated. The right atrium is markedly dilated. 2.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed. Severe
global hypokinesis. 3. Right ventricular chamber size is normal.
Right ventricular systolic function is normal. 4. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. 5. The mitral valve leaflets are mildly thickened. At
least moderate (2+) mitral regurgitation is seen. 6. Moderate
[2+] tricuspid regurgitation is seen. 7. The estimated pulmonary
artery systolic pressure is normal. 8. There is no pericardial
effusion.
.
Cath [**2186-4-10**]: 1. Resting hemodynamics reveaeld elevated rigth
sided filling pressures (RA mean 11 mm Hg, RVEDP 14 mm Hg). The
PA pressures were significantly elvated (PA 62/30 mm Hg, mean PA
42 mm Hg). The PCWP was significantly elevated (mean PCWP 30 mm
Hg). 2. Left ventriculography revealed an EF of 30% with severe
global hypokinesis. There was no significant mitral
regurgitation. 3. Selective coronary angiography revealed a
right dominant system. The LMCA was angiographically normal. The
LAD had a 30% distal stenosis. The LCX was angiographically
normal. The RCA was the dominant vessel and was angiographically
normal.
Brief Hospital Course:
A 52yoF with Afib, s/p fall with large abdominal hematoma and 10
point Hct drop.
.
On admission, Pt. was transferred to the CCU for management of
enlarging pannus hematoma, SOB/DOE, and anemia, all in the
setting of severe CHF, and AFib with supratherapeutic INR. In
the CCU, the Pt. was transfused with FFP (6 units), pRBCs (12
units), and vit. K (10 mg x 2) and her blood counts slowly
stabilized (Hct 29.5, INR 1.3). Surgery team was consulted and
agreed with reversing her coagulopathy and suggested applying an
abdominal binder. The Pt. did not tolerate the binder. The Pt.
was also evaluated by EP and was initially scheduled to have a
cardioversion but this was deferred given the reversal of her
anti-coagulation. The current plan is to attempt cardioversion
after 1 month load of amiodarone, which the Pt. began on [**11-4**].
.
The Pt. was transferred out of the unit, and was initially
restarted on a heparin bridge to coumadin, but unfortunately a
rescan of her pannus hematoma showed extension of the bleeding,
so all anticoagulation was stopped. During this time, the
patient had several episodes of hypotension (SBPs in 80-90s).
Small boluses of IVF were given for resuscitation, but these did
not normalize SBP. Larger boluses were not given due to concern
for pulmonary edema and 3rd-spacing due to very poor LVEF. The
Pt. became oliguric during this time, but her Cr remained
normal. Hypotension persisted, and due to blood pressure holding
parameters on diuretics and AFib meds, the patient could not
take these meds. Further lack of response to fluid boluses and
unclear etiology of hypotension (no evidence of sepsis, so
either cardiogenic or distributive most likely) led to transfer
to MICU. In the MICU, Pt. was given a total of seven liters of
fluid and was able to tolerate it well despite her severe CHF.
She developed mild pulmonary edema after about 5-7L of fluid and
was diuresed with lasix. Her BB and ACE-i were restarted on
[**10-30**] and the ACE-i was slowly titrated up to achieve afterload
reduction.
.
Back on the medical floor, on examination the Pt. was found to
be total body fluid overloaded but was also likely
intravascularly dry. She tolerated gentle diuresis (40 IV lasix
QD), and her SOB/dyspnea improved during this time. Goal net
output was 0.5-1.0 L/d. During this time, the Pt. was
encouraged to sit up and transfer from bed to chair as much as
possible, and plans for d/c to rehab were initiated.
.
The Pt. was found to have an Enterococcus UTI by
urinalysis/culture on [**10-26**], associated with her foley; she was
treated with ciprofloxacin for a two week course. The foley was
switched but kept in due to the need to carefully monitor ins
and outs. The foley was d/c'd at the time of discharge.
.
Daily weights and ins/outs monitoring will be essential to
monitor diuresis as Pt. clearly has a small window of euvolemia
with tendencies toward both hypotension on the one hand, and
pulm. edema/volume overload on the other hand. The Pt. is back
on her home doses of BB and ACE-i, and has had good bp control.
.
The Pt. will restart coumadin on [**11-14**], with frequent INR
checks, in preparation for cardioversion in approximately 1
month.
Medications on Admission:
1. coumadin 2.5 mg p.o. qhs
2. albuterol inh Q6H, flovent 110 2 puffs [**Hospital1 **], flonase inh [**11-19**]
[**Hospital1 **]
3. iron sulfate 325 mg p.o. [**Hospital1 **]
4. amiodarone 300 mg p.o. daily
5. lasix 80 mg p.o. daily
6. lisinopril 10 mg p.o. daily
7. spironolactone 25 mg p.o. daily
8. Toprol-XL 50 mg p.o. b.i.d.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
7. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two
(2) Spray Nasal [**Hospital1 **] (2 times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): please do not inject into abdomen
(Pt. has large hematoma).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day): hold for HR<55 or SBP<90 .
12. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please hold for SBP <90 .
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
16. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
17. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
PLEASE DO NOT START UNTIL [**11-14**].
18. Outpatient [**Name (NI) **] Work
Pt. will start taking coumadin on [**11-14**]. Please check INR every
2-3 days starting on [**11-14**], and adjust INR dose for goal
2.0-3.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Right pannus hematoma secondary to supratherapeutic coumadin
level
2. CHF
3. AFib
Discharge Condition:
Fair, stable.
Discharge Instructions:
Please continue to take all of your medications exactly as
prescribed. If you experience fevers, chest pain, shortness of
breath, or abdominal pain, please call your PCP or return to the
hospital.
.
Your coumadin was stopped because your INR level was too high.
Your coumadin will be restarted on [**11-14**]. Please make sure to
check your INR frequently.
.
You had a urinary tract infection, which we treated with
antibiotics, you will take 3 more days of antibiotics after
discharge.
.
Please weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight > 3
lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) 11298**], RN,BSN,MSN Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-11-7**] 12:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2188-2-12**] 1:00
Completed by:[**2187-11-8**]
|
[
"780.57",
"V43.65",
"428.0",
"428.23",
"285.1",
"401.9",
"584.9",
"427.31",
"493.20",
"996.64",
"425.4",
"E884.6",
"397.0",
"922.2",
"959.12",
"599.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.91",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
12832, 12911
|
7353, 10568
|
324, 331
|
13040, 13056
|
2858, 7330
|
13707, 14055
|
1951, 2058
|
10947, 12809
|
12932, 13019
|
10594, 10924
|
13080, 13684
|
2073, 2839
|
248, 286
|
359, 1458
|
1480, 1736
|
1752, 1935
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,755
| 164,278
|
31659
|
Discharge summary
|
report
|
Admission Date: [**2151-11-15**] Discharge Date: [**2151-11-19**]
Date of Birth: [**2085-9-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2151-11-15**] - 1. Left subclavian to left common carotid artery
bypass with 8-mm PTFE graft. 2. A left common carotid to right
common carotid artery bypass using 8-mm ring PTFE graft. 3.
Exposure of left axillary artery. 4. Ultrasound-guided access of
right common femoral artery. 5. Exposure of left common femoral
artery. 6. Bilateral placement of catheter into the aorta. 7.
Selective catheterization of coronary artery bypass graft. 8.
Coronary angiogram.
9. Aortogram. 10.Endovascular stent graft repair of ascending
thoracic pseudoaneurysm with Talent 40 x 40 x 46-mm endograft.
11.Perclose closure of right common femoral arteriotomy.
[**2151-11-17**] - Ultrasound-guided left thoracentesis.
History of Present Illness:
65 year old male with known
coronary disease, status post coronary artery bypass grafting
surgery in [**2137**]. He is an active smoker and has severe COPD
confirmed by PFT and recent CT scan. On his recent CT scan,
there
was an incidental finding of a focal aneurysmal outpouching of
his ascending aorta along with a left lingula mass. Further
review by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] thought it looked like a penetrating
atherosclerotic plaque that had ulcerated and that it was only
covered by a very thin aortic wall and thus was at risk for
rupture. Given the above findings, he was referred for surgical
evaluation. Had left thoracentesis for one liter of pleural
fluid yesterday by Dr. [**Last Name (STitle) 22882**], with some improvement in
breathing, but has continued cough.
Past Medical History:
Past Medical History:
- Coronary Artery Disease
- COPD
- Hyperlipidemia
- Hypertension
- Calcified aorta
- New finding of Left lingula lung mass
- Bilateral Pleural Effusions; s/p left thoracentesis [**2151-11-8**]
- Hypothyroidism
- Trauma to lower extremities
- Emphysema
Past Surgical History:
- coronary artery bypass grafting surgery x5 in [**2137**] - [**Hospital3 **] Dr.[**Name (NI) 43096**]
- Polypectomy [**2151**]
- Right elbow seroma, s/p debridement and drainage
- Appendectomy
Social History:
Occupation: retired
Last Dental Exam:has only 2 native teeth; no recent dental care
Lives with wife in [**Name (NI) 1411**]
Race:Caucasian
Tobacco:[**1-15**] cigarettes daily
ETOH:[**4-18**] glasses of wine daily
Family History:
Brothers with CAD. One brother died of MI at age 57, another
brother with CABG in early 50's.
Physical Exam:
Pulse: 51 Resp: O2 sat:
B/P Right: Left: 147/75
Height: 69" Weight:200#
General:coughs periodically,clear sputum
Skin: Dry [x] intact []warm, dry, chronic venous stasis changes
BLE
HEENT: PERRLA [x] EOMI [x]injected sclera; OP unremarkable;
fair repair of teeth
Neck: Supple [x] Full ROM [x]no JVD
Chest: right lung CTA; left lung clear to lower-mid, with
basilar
rales; well-healed sternotomy scar
Heart: RRR [x] Irregular [] Murmur- none
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [x] Edema: trace BLE
Varicosities: None [] chronic venous stasis changes bilat.
Left GSV surgically absent from open saphenectomy.
Right GSV may have been disrupted below knee due to trauma.
Multiple incisions along R GSV tract below knee. Thigh may be
usable.
Neuro: Grossly intact, nonfocal exam, MAE [**5-18**] strengths
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: NP Left: NP
PT [**Name (NI) 167**]: trace Left:trace
Radial Right: 2+ Left: 2+
Carotid Bruits :none
Pertinent Results:
[**2151-11-15**] ECHO
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. The right ventricular cavity is moderately dilated with
normal free wall contractility. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque.. There are complex (>4mm) atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
There is no pericardial effusion.
[**2151-11-15**] Cardiac Catheterization
1. Three vessel coronary disease.
2. Patent LIMA-LAD, RIMA-PDA, SVG-D1. Occluded SVG-OM1, SVG-OM2.
3. Graft position obtained for repair of thoracic aortic
aneurysm.
[**2151-11-15**] 04:11PM BLOOD PT-14.7* PTT-38.7* INR(PT)-1.3*
[**2151-11-18**] 06:00AM BLOOD Glucose-120* UreaN-23* Creat-1.0 Na-133
K-4.5 Cl-99 HCO3-27 AnGap-12
[**Known lastname 73523**],[**Known firstname 21376**] [**Medical Record Number 73524**] M 66 [**2085-9-18**]
Radiology Report CHEST (PA & LAT) Study Date of [**2151-11-18**] 2:38 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2151-11-18**] 2:38 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 74382**]
Reason: check L effusion
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p thoracentesis, aortic stent
REASON FOR THIS EXAMINATION:
check L effusion
Final Report
INDICATION: 66-year-old man status post thoracentesis, aortic
stent, check
left effusion.
COMPARISON: [**2151-11-17**]; [**2151-11-9**]; CT of [**9-28**], [**2151**].
CHEST, TWO VIEWS: Median sternotomy wires are unchanged. An
aortic stent is
in place. Heart size is probably normal, although obscured. The
aorta is
calcified and mildly tortuous. Hilar contours are normal. There
is a
persistent small right and small-moderate left effusion. Round
atelectasis in
the left mid lung persists, stable from the pre-operative study
and CT of
[**2151-9-28**]. There is no pneumothorax. Upper lungs are
clear.
Surgical clips are seen.
Overall unchanged.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2151-11-15**] for surgical
management of his thoracic aortic arch aneurysm. He was taken to
the operating room where he underwent endostenting of his aortic
aneurysm as well as left subclavian to left common carotid
artery bypass and a left common carotid to right common carotid
artery
bypass. Please see operative note for details. Postoperatively
he was taken to the intesnive care unit for monitoring. Given
his severe COPD, he was slow to extubate. Eventually he awoke
neurologically intact and was extubated. The Otolaryngology
service was consulted for a hoarse voice however his voice
returned without issue. The thoracic surgery service was
consulted for a large recurrent pleural effusions. A left
thoracentesis was performed which drained 1500cc's of fluid.
Multiple studies were sent on the fluid. Mr. [**Known lastname **] continued to
make steady progress and was discharged [**Last Name (un) **] on [**2151-11-19**]. He will
follow-up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], Dr.[**Last Name (STitle) 914**],
his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Lipitor 80mg daily, Lisinopril 10mg daily, Synthroid 137mcg
daily, Lasix 20mg daily, Atenolol 50mg daily, Aspirin 81mg
daily, Proventil inhaler prn.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 MDI* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
5. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: After 7 days, resume Lasix 10 mg PO daily.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Descending thoracic aortic aneurysm
- Coronary Artery Disease
- COPD
- Hyperlipidemia
- Hypertension
- Calcified aorta
- New finding of Left lingula lung mass
- Bilateral Pleural Effusions; s/p left thoracentesis [**2151-11-8**]
- Hypothyroidism
- Trauma to lower extremities
- Emphysema
- coronary artery bypass grafting surgery x5 in [**2137**] - [**Hospital1 3343**] Dr.[**Name (NI) 43096**]
- Polypectomy [**2151**]
- Right elbow seroma, s/p debridement and drainage
- Appendectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Monitor blood pressure. Maintain systolic blood pressure less
then 130mmHg.
3) Wash incisions daily with soap and water.
4) No driving for 2 weeks or while ever using narcotic pain
medicine.
Followup Instructions:
Scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2151-12-8**] 11:30, [**Last Name (un) 2577**] Building. [**Hospital Unit Name 74383**]. [**Location (un) 86**] Mass.
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2151-11-25**] 2:30
.
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-16**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 5292**] in [**2-16**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please contact all providers for appointments.
Completed by:[**2151-11-19**]
|
[
"458.29",
"305.1",
"401.9",
"786.2",
"244.9",
"285.9",
"496",
"V45.81",
"997.79",
"E878.2",
"511.9",
"414.00",
"272.4",
"440.0",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"39.73",
"39.66",
"88.42",
"34.91",
"37.22",
"39.22"
] |
icd9pcs
|
[
[
[]
]
] |
9245, 9303
|
6411, 7600
|
330, 1036
|
9834, 9841
|
3851, 5516
|
10176, 10897
|
2654, 2750
|
7799, 9222
|
5556, 5604
|
9325, 9813
|
7626, 7776
|
9865, 10153
|
2210, 2406
|
2765, 3832
|
283, 292
|
5636, 6388
|
1064, 1891
|
1935, 2187
|
2422, 2638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,597
| 177,893
|
33842
|
Discharge summary
|
report
|
Admission Date: [**2132-6-11**] Discharge Date: [**2132-6-17**]
Date of Birth: [**2069-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**6-11**] cardiac catherization and intra aortic balloon insertion
[**6-12**] Coronary artery bypass graft x2 (left internal mammary
artery > anterior descending, saphenous vein graft > obtuse
marginal)
History of Present Illness:
63 yo M s/p motorcycle MVC 10 days ago, treated for road rash
and bruising as well as dehydration and dc'd home. One week
later was found ashen, SOB, nauseas and weak, went to see PCP
who sent him to ED. Troponin 0.25, transferred for cath which
showed 90% LM. IABP inserted and patient referred for surgery.
Past Medical History:
Hyperlipidemia, DM, OSA (CPAP), Obesity, s/p motorcycle MVC- 10d
ago, Cerebellar atrophy, GERD, s/p bil knee repl, s/p nasal
septum repair after trauma
Social History:
cemetary/farm worker
denies tobacco, etoh
Family History:
NC
Physical Exam:
HR 66 RR 18 BP 118/69
NAD
multiple abrasions both arms; multiple ecchymosis groin, back
lungs CTAB
heart RRR, distant, IABP
Abdomen Benign, obese
Extrem warm, no edema, 2+ pulses t/o
Pertinent Results:
[**2132-6-16**] 05:19AM BLOOD WBC-10.4 RBC-2.77* Hgb-7.9* Hct-24.1*
MCV-87 MCH-28.5 MCHC-32.7 RDW-15.4 Plt Ct-280
[**2132-6-11**] 03:08PM BLOOD WBC-6.8 RBC-3.77* Hgb-10.6* Hct-31.7*
MCV-84 MCH-28.1 MCHC-33.4 RDW-14.0 Plt Ct-269
[**2132-6-11**] 03:08PM BLOOD Neuts-67.4 Lymphs-25.8 Monos-4.0 Eos-2.3
Baso-0.5
[**2132-6-16**] 05:19AM BLOOD Plt Ct-280
[**2132-6-16**] 05:19AM BLOOD PT-11.7 INR(PT)-1.0
[**2132-6-12**] 11:29AM BLOOD Fibrino-407*
[**2132-6-16**] 05:19AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-136
K-4.0 Cl-101 HCO3-29 AnGap-10
[**2132-6-11**] 03:08PM BLOOD Glucose-118* UreaN-14 Creat-0.9 Na-140
K-4.1 Cl-105 HCO3-28 AnGap-11
[**2132-6-11**] 03:08PM BLOOD ALT-52* AST-31 CK(CPK)-102 AlkPhos-94
TotBili-0.8
[**2132-6-11**] 03:08PM BLOOD CK-MB-3 cTropnT-0.04*
[**2132-6-15**] 02:55AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0
[**2132-6-11**] 04:35PM BLOOD %HbA1c-6.4*
CHEST (PA & LAT) [**2132-6-16**] 3:53 PM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
STUDY: PA and lateral chest radiograph.
INDICATION: Status post CABG. Please evaluate size of effusion.
COMPARISON: [**2132-6-15**].
FINDINGS: Right internal jugular central venous catheter tip
terminates at the cavoatrial junction. There is mild bibasilar
discoid atelectasis. Small bilateral effusions remain. There is
mild cardiomegaly. Median sternotomy wires remain intact. No
focal consolidation or evidence of acute pulmonary edema
detected.
IMPRESSION:
1. Mild bibasilar discoid atelectasis.
2. Cardiomegaly and small bilateral pleural effusions. No acute
pulmonary edema detected.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: MON [**2132-6-16**] 5:00 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78222**] (Complete)
Done [**2132-6-12**] at 11:25:38 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2069-3-9**]
Age (years): 63 M Hgt (in): 72
BP (mm Hg): 119/53 Wgt (lb): 300
HR (bpm): 76 BSA (m2): 2.53 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 410.91, 786.51
Test Information
Date/Time: [**2132-6-12**] at 11:25 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 5. The
mitral valve appears structurally normal with trivial mitral
regurgitation.
Dr. [**Last Name (STitle) 914**] was notified in person of the results
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
Sinus rhythm
1. Biventricular function is preserved.
2. Aorta is intact post decannulation
3. IABP appears appropriately positioned 2-3 cm below take-off
of left subclavian artery
3. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2132-6-12**] 16:05
Brief Hospital Course:
He was admitted to the CCU after cardiac catherization that
revealed coronary artery disease. He was seen by cardiac surgery
and was taken to the operating room on [**6-12**] where he underwent a
CABG x 2. He was transferred to the ICU in stable condition.
IABP was dc'd post op. He was extubated on POD #1. He was seen
by skin care for his multiple abrasions. He was started on
amiodarone for afib. He was transferred to the floor on POD #3.
He did well postoperatively and was seen by physical therapy and
was cleared for discharge home. He was ready for discharge on
POD #5.
Medications on Admission:
prilosec, crestor, prozac, motrin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
please take 400mg daily for 10 days then decrease to 200mg once
daily and follow up with cardiologist.
Disp:*60 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease s/p cabg
Post operative atrial fibrillation
Unstable angina
Elevated cholesterol
Diabetes mellitus
Obstructive sleep apnea
Gastroesophageal reflux disease
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name (STitle) 1356**] in 1 week ([**Telephone/Fax (1) 40833**]) please call for appointment
Dr [**Last Name (STitle) 10543**] in [**2-10**] weeks ([**Telephone/Fax (1) 4475**]) please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2132-6-17**]
|
[
"410.71",
"E878.8",
"518.0",
"E849.8",
"327.23",
"458.29",
"250.00",
"414.01",
"427.31",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.22",
"88.56",
"97.44",
"99.04",
"38.93",
"37.61",
"36.15",
"36.11",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8905, 8960
|
6590, 7169
|
323, 530
|
9183, 9190
|
1341, 2303
|
9702, 10161
|
1118, 1122
|
7253, 8882
|
2340, 2370
|
8981, 9162
|
7195, 7230
|
9214, 9679
|
1137, 1322
|
280, 285
|
2399, 6567
|
558, 868
|
890, 1043
|
1059, 1102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,335
| 150,523
|
15090
|
Discharge summary
|
report
|
Admission Date: [**2154-10-1**] Discharge Date: [**2154-10-19**]
Date of Birth: [**2077-3-14**] Sex: F
Service: SICU
CHIEF COMPLAINT: Chronic constipation.
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
female with hypertension and hypercholesterolemia who
presented with chronic constipation, malaise, weight loss and
anorexia for 6-7 months. The patient was initially admitted
to [**Hospital6 1597**] on [**9-29**]. During that hospitalization
a CT scan of her abdomen was obtained which showed pelvic
mass, omental studding and chronic lung disease. In
addition, KUB revealed small bowel obstruction. She was
transferred to Obstetrics/Gynecology service at [**Hospital1 346**] on [**2154-10-1**] for possible laparotomy
and debulking.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
sensorineural hearing loss, villous adenoma removed during
colonoscopy in [**9-13**], status post bowel resection in [**2145**] for
incarcerated hernia.
MEDICATIONS: On admission, Atenolol, Hydrochlorothiazide.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission, generally somewhat
confused elderly cachectic female lying in bed. Temperature
97.3, pulse 93, blood pressure 130/75, respiratory rate 16,
O2 saturation 97% on two liters nasal cannula. Heart was
regular rate and rhythm. Lungs were clear to auscultation
bilaterally. There was an NG tube in place. Abdomen was
soft, distended, with ventral mass, question of fluid shift
and decreased bowel sounds. Extremities showed no edema, 2+
distal pulses, no cyanosis or clubbing.
LABORATORY DATA: On admission white count 14.7, hematocrit
32.3, sodium 140, potassium 4.8, chloride 101, CO2 24, BUN
12, creatinine 0.6, glucose 86, albumin 2.8, calcium 9.3,
phosphorus 2.5, magnesium 1.8, INR 1.2, PTT 20.8. Urinalysis
showed moderate blood, 30 protein, more than 80 ketones,
small bilirubin, negative nitrites and occasional bacteria.
HOSPITAL COURSE: On [**2154-10-3**] the patient went to operating
room for tumor debulking. She underwent omentectomy,
extensive tumor debulking, small bowel resection with
re-anastomosis, resection of sigmoid colon, total abdominal
hysterectomy and bilateral salpingo-oophorectomy, debulking
of the disease and colectomy with Hartmann's pouch as well as
drainage of the ascites. During the surgery patient received
four units of packed red blood cells and 8 liters of
crystalloid. Following the surgery the patient was
transferred to SICU for further management.
While in SICU she initially needed pressors for blood
pressure support. The pressors were weaned off and
echocardiogram was obtained which revealed normal ejection
fraction and 4+ TR with no other significant valvular
disease. She developed multiple atrial tachycardia for which
she required Lopressor intermittently for rate control.
While in the SICU the patient was noted to spike fevers up to
101.8. She was pancultured and her sputum grew pseudomonas
aeruginosa for which she was started on Ceftazidime. In
addition, she received Vancomycin and Flagyl course for
purulent discharge at the ostomy site.
For nutritional support throughout the hospitalization, the
patient was maintained on TPN.
Initially patient required full ventilatory support. With
time she was slowly weaned off the vent and was extubated on
[**2154-10-16**]. According to the prior discussions with the patient
as well as some discussions with her family, the patient's
code status was changed to DNR/DNI. Initial two days
following extubation the patient was ventilating relatively
well with good oxygenation. Diuresis was continued for
presumed pulmonary edema. On [**2154-10-18**] the patient was found to
be much less responsive and on ABG was found to be in acute
respiratory acidosis with PCO2 at 86. The focus of her care
was shifted towards comfort measures to prolong her life, and
patient died on [**2154-10-19**] at 12:10. The immediate cause of
death was hypoxia and hypercarbia. Secondary causes of death
are pneumonia, congestive heart failure, and ovarian cancer.
The family was notified and request for autopsy was declined
by patient's daughter.
FINAL DIAGNOSIS:
1. Hypoxic hypercarbic respiratory failure.
2. Ovarian cancer.
3. Anemia status post four units of packed red blood cell
transfusion.
4. Congestive heart failure.
5. Pseudomonas pneumonia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 16-403
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2154-10-19**] 18:52
T: [**2154-10-27**] 18:06
JOB#: [**Job Number **]
|
[
"560.89",
"197.4",
"997.1",
"518.81",
"183.0",
"197.6",
"482.1",
"197.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"54.4",
"46.10",
"65.61",
"45.75",
"99.15",
"45.63",
"96.04",
"68.4",
"54.59",
"54.29",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1973, 4179
|
4196, 4623
|
1107, 1955
|
152, 175
|
204, 773
|
796, 1084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,727
| 144,851
|
51919
|
Discharge summary
|
report
|
Admission Date: [**2154-5-9**] Discharge Date: [**2154-5-19**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
abdominal pain and vomiting
Major Surgical or Invasive Procedure:
Tunnelled hemodialysis catheter placement
AV fistula
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 107485**] is a 57 yo male with a h/o chronic pancreatitis,
CHF, and polysubstance abuse who presented with 3 days of
abdominal pain and vomiting. Epigastric pain similar to prev.
pancreatitis flare. + emesis (nonbloody and non-billious). Poor
po intake for a few days. He says he has felt intermittent
fevers and chills as well. He denies diarrhea. He says that he
had one drink on the day prior to admission but denies drinking
very much over the past week aside from this one drink.
.
The pt went to the ED at his girlfriend's urging. On arrival,
his vital signs were: T98.3, P118, BP200/94, R18, O2sat 92% on
room air. He was placed on a nitro drip for his hypertension.
His O2 sat dropped to 83% on room air and he was placed on a
non-rebreather-->O2 sats rebounded to the high 90's. He was
found to have elevated pancreatic enzymes and a cxr suggestive
of CHF vs. pneumonia. He was given Zofran 4mg IV, Lasix 60mg IV,
Atarax 25mg po for pruritis, Levaquin 500mg IV and Flagyl 500mg.
He was transferred to the [**Hospital Unit Name 153**] for management of hypertensive
urgency.
.
On review of systems, pt complains of productive cough x many
weeks (since discharge in late [**2154-3-14**] for pneumonia). He
says he brings up greenish sputum that occasionally contains
blood. He also complains of vague chest pain that "comes and
goes" and has been going on for an undefined period of time. He
says he has been compliant with his meds. He does admit to
smoking crack 1 day PTA.
Past Medical History:
DM2
HTN
CAD s/p MI, MIBI in [**11-18**] showed inf/lat reversible defect
CHF with EF 20-30% and severe global hypokinesis
Dyslipidemia
Atrial Fibrillation
H/o GI bleed: Duodenal, jejunal, and gastric AVMs, s/p thermal
therapy; sigmoid diverticuli
Chronic Pancreatitis
Hepatitis C
GERD
CRI, baseline 3.9-5.3
Gout, s/p Arthroscopy with medial meniscectomy [**5-/2149**]
Depression, s/p multiple hospitalizations due to SI
Polysubstance abuse-- crack cocaine, EtOH, tobacco
Erectile dysfunction, s/p inflatable penile prosthesis [**5-/2148**]
Social History:
Pt lives in [**Location 686**] with his wife. [**Name (NI) **] used to be an
electrician for [**Company 31653**] for 30 years, but has been on disability.
Tob: 45 pack-yr
EtOH: history of abuse with hospitalizations for delirium
[**Company 107492**] and detoxification. Admits to 1 drink 1 day PTA.
Illicits: 15 yr h/o Crack cocaine use, last used 1 day PTA.
Family History:
His father with alcoholism, an uncle who committed suicide by
hanging, and a cousin with [**Name2 (NI) 14165**] cell anemia. His mother died
of renal failure at age 58. He states that his twin brother and
his son also have kidney disease.
Physical Exam:
T 98 BP 131/70 P 121 RR 20 O 93%3L
Gen: elderly male lying in bed in nad.
HEENT: PERRL, dry mucous membranes, sclera anicteric.
Neck: supple, no LAD, JVP 8cm
Lungs: Soft, CTAB
Chest: RRR. II/VI mumor at apex.
Abd: soft, mild epigastric tenderness.
Extrem: WWP. no edema.
Neuro: AOx3. CN II-XII intact. [**5-18**] UE and distal LE strength bl
Pertinent Results:
[**2154-5-9**] 04:00PM BLOOD WBC-8.2 RBC-2.64* Hgb-6.5* Hct-19.9*
MCV-75* MCH-24.7* MCHC-32.8 RDW-16.6* Plt Ct-353
[**2154-5-9**] 04:00PM BLOOD Neuts-87.5* Lymphs-5.7* Monos-4.3 Eos-2.2
Baso-0.3
[**2154-5-9**] 04:00PM BLOOD PT-11.8 PTT-24.5 INR(PT)-1.0
[**2154-5-9**] 04:00PM BLOOD Glucose-402* UreaN-50* Creat-4.7* Na-133
K-4.3 Cl-99 HCO3-22 AnGap-16
[**2154-5-9**] 04:00PM BLOOD ALT-10 AST-10 AlkPhos-129* Amylase-701*
TotBili-0.3
[**2154-5-9**] 04:00PM BLOOD Lipase-2089*
[**2154-5-9**] 04:00PM BLOOD CK-MB-7 cTropnT-0.15*
[**2154-5-10**] 12:43AM BLOOD CK-MB-7 cTropnT-0.16*
[**2154-5-10**] 05:20AM BLOOD CK-MB-6 cTropnT-0.17*
[**2154-5-9**] 04:00PM BLOOD Albumin-3.7 Calcium-9.8 Phos-4.0 Mg-2.1
[**2154-5-13**] 01:24PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2154-5-14**] 04:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2154-5-13**] 01:24PM BLOOD HCV Ab-NEGATIVE
[**2154-5-14**] 04:30PM BLOOD HCV Ab-NEGATIVE
[**2154-5-9**] 05:44PM BLOOD Lactate-1.1
.
[**5-9**] cxr: Again, there is significant cardiac enlargement.
Marked perivascular haze is consistent with pulmonary congestion
in the pulmonary circulation. Bilaterally, the diaphragmatic
contours are
obliterated by pleural densities more on the right than the
left. When comparison is made with the next previous examination
([**4-9**], frontal view) the degree of pleural effusion and
pulmonary congestion appears more marked. Possibility of
inflammatory processes on the lung bases obscured by the pleural
effusion cannot be excluded.
.
EKG: Supraventricular tachycardia with atrial rate 230,
ventricular rate 116. Normal QRS axis. IVCD w/ RBBB morphology.
1mm ST segment depressions in leads II, III, aVF.
.
Echo [**1-20**] -
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is 16-20
mmHg. There is moderate symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is moderate to
severe global left ventricular hypokinesis (ejection fraction 30
percent). No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular free wall
is hypertrophied. The right ventricular cavity is dilated. Right
ventricular systolic function appears depressed. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is at least moderate (possibly severe) pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. Compared with the findings of the prior study (images
reviewed) of [**2153-10-3**], the pulmonary artery systolic
pressure is increased. The right ventricle appears more dilated
and hypocontractile now; the left ventricular ejection fraction
may be somewhat further reduced. The mitral and tricuspid
regurgitation are increased.
Brief Hospital Course:
57 yo male with h/o pancreatitis, chf and polysubstance abuse
admitted with hypertensive urgency and pancreatitis.
.
1) Pancreatitis - On admision with Amylase 701, Lipase 2089, and
abdominal pain c/w prior pancreatitis flares all consistent with
acute-on-chronic pancreatitis. Likely etiology is alcohol (pt
admits to drinking PTA and has h/o polysubstance abuse). He was
made NPO, pain control with tylenol and dilaudid, and diet
advanced slowly as tolerated (patient was repeatedly
non-adherent to dietary restrictions while NPO, frequently seen
eating chocolate and sandwiches from the kitchen).
.
2) Acute renal failure: This was acute on chronic (long-standing
DM and HTN), with baseline Cr ~4.0-5.0. Creatinine was at
approximate baseline on admission, then doubled with minimal
urine output likely due to ATN as muddy brown casts observed in
sediment; possible compounded by cocaine and NSAID use. Renal
was consulted. A tunneled HD line was placed and dialysis was
initiated without complications. Urine output improving and Cre
returned to near baseline in the setting of HD. An AV fistula
was placed by the Transplant surgery team. He will start MWF
dialysis at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] and received epoetin alfa and zemplar
dosed at HD. An ACEi was restarted prior to discharge.
.
3) HTN: Hypertensive urgency on admission with SBPs 190's-200's
in ED, admitted to the ICU and treated with nitro gtt with
improvement. Started on diltiazem and hydralazine. Added
amlodipine briefly then stopped per renal recommendations.
.
4) Pulmonary infiltrates: CHF vs. PNA on cxr. Residual RLL
infiltrate and resolving CHF noted on repeat CXR. Completed 7
day course CTX/azithromycin. Also received 1 dose vancomycin to
cover staph as patient had been frequently in hospital. Blood
cultures were NGTD. Legionella urinary antigen negative. Volume
management performed per HD.
.
5) Anemia: Chronic anemia likely [**2-15**] CKD. He has received
multiple transfusions in the past. Hct in low-mid 20's since
[**2154-1-14**]. Iron studies [**2154-4-9**] showed iron deficiency and
iron supplementation was started, which was then discontinued
per renal and he was started on erythropoetin. Transfused 2
units pRBC during hospitalization.
.
6) Hyperglycemia: Type 2 diabetic with known history of poor
glycemic control. FS over 400 on multiple occasions (significant
dietary indiscretion). While in the ICU, he received an insulin
gtt and then was transistioned to NPH with sliding scale. His
home insulin regimen was restarted prior to discharge and his
blood glucose control was improved.
.
7) Chest pain: Unclear of the exact nature and duration of CP
based on the vague history. ECG was without signs of ischemia
and cardiac enazymes with elevated trop of 0.17 likely due to
renal failure +/- demand from decompensated heart failure. The
patient was not started on ASA given h/o GI bleeding and not
started on a beta-blocker given h/o cocaine use.
.
8) Tachycardia: h/o parox a-fib. ECG on presentation with SVT
with 2:1 block atrial tachycardia. Reverted to sinus rhythm.
Continued diltiazem for rate control. Anticoagulation was not
started given his h/o GI bleeding and significant anemia.
.
9) Pruritis: The patient complained of pruritis for 7-8 months,
possible related to uremia/hyperphosphatemia from his chronic
renal disease. There was no visible rash. LFT's were checked
and were within normal limits. He was given atarax prn, sarna
lotion, and dialyzed; his symptoms resolved.
.
10) h/o EtOH abuse: Reported that his last drink was a glass of
brandy on Tuesday PTA. Patient became over-sedated with dose of
valium coupled with Dilaudid in the setting of renal failure,
and required a dose of Narcan for reversal. No further evidence
of EtOH withdrawal and did not require more benzodiazepines.
Medications on Admission:
Lasix 160 mg po DAILY
Calcium Acetate 1334 mg PO TID W/MEALS
Ferrous Sulfate 325 mg PO BID
Atorvastatin 20 mg PO DAILY
Lisinopril 10 mg PO DAILY
Pantoprazole E.C. 40 mg PO Q24H
Calcitriol 0.25 mcg PO DAILY
Epoetin Alfa 8,000 units qMonday -Wednesday-Friday
Hydralazine 25 mg PO Q6H
Thiamine HCl 100 mg PO DAILY
Insulin NPH 30U qAM, 20U qPM
Novolog sliding scale
Diltiazem HCl (sustained release) 360 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
[**Month/Day/Year **]:*90 Tablet(s)* Refills:*2*
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Epoetin Alfa 10,000 unit/mL Solution Sig: 8000 (8000) units
Injection qMWF: dosed at HD.
11. Iron Sucrose 100 mg/5 mL Solution Sig: One (1) dose
Intravenous qMWF: dosed at HD.
12. Zemplar 2 mcg/mL Solution Sig: One (1) dose Intravenous
qMWF: dosed at HD.
13. Novolog 100 unit/mL Solution Sig: One (1) sliding scale
Subcutaneous four times a day.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous qam.
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous qpm.
16. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous as directed.
[**Month/Day/Year **]:*30 pens* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pancreatitis
End-stage renal disease - started on hemodialysis
Systolic heart failure with EF 20-30% and severe global
hypokinesis
.
Secondary:
DM2
HTN
CAD s/p MI
Dyslipidemia
Atrial Fibrillation
H/o GI bleed due to AVMs and sigmoid diverticuli
Chronic Pancreatitis
Hepatitis C
GERD
Gout, s/p Arthroscopy with medial meniscectomy
Depression, s/p multiple hospitalizations due to SI
Polysubstance abuse-- crack cocaine, EtOH, tobacco
Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**]
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid restriction: 1500 ml
Please take all medications as prescribed.
New medications: Sevelamer, Zemplar, Iron sucrose
Discontinued medications: Lasix, Ferrous Sulfate, Calcitriol
.
Stay away from alcohol and cocaine.
.
You will need to start attending hemodialysis on Mondays,
Wednesdays, and Fridays at the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis Center ([**Last Name (NamePattern1) 107496**], [**Location (un) 669**], [**Numeric Identifier 18406**], ([**Telephone/Fax (1) 107497**]). Your first
session will be on Monday [**2154-5-20**].
.
You should return to the hospital if you are experiencing
dizziness, chest pain, palpitations, fevers, or shortness of
breath.
Followup Instructions:
You should follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 216**]. Please call [**Telephone/Fax (1) 250**] to schedule an appointment.
.
You should follow-up with your Nephrologist Dr. [**Last Name (STitle) 4090**] in 2
weeks.
.
You are [**Last Name (STitle) 1988**] for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-5-23**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2154-9-4**] 10:20.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"305.90",
"584.9",
"428.0",
"403.01",
"250.00",
"070.54",
"427.31",
"585.6",
"428.20",
"285.21",
"577.1",
"414.01",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.27",
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
12566, 12572
|
6708, 10562
|
295, 363
|
13126, 13133
|
3473, 6685
|
13991, 14912
|
2853, 3096
|
11024, 12543
|
12593, 13105
|
10588, 11001
|
13157, 13968
|
3111, 3454
|
228, 257
|
391, 1897
|
1919, 2460
|
2476, 2837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,718
| 132,829
|
21690
|
Discharge summary
|
report
|
Admission Date: [**2138-1-2**] Discharge Date: [**2138-1-3**]
Service: MEDICINE
Allergies:
Plavix / Shellfish
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Elective admit for R carotid stent
Major Surgical or Invasive Procedure:
R ICA stent
History of Present Illness:
80 yo F w/ hx of PVD, bilateral carotid dz, left CEA x3 ('[**12**] x
2, '[**27**] p/w L side TIA), right CEA x1 ('[**27**]), HTN, hyperlipidemia,
suspected subclavian steal, and multiple TIAs who is admitted
for elective R carotid stent. In [**October 2137**], she had a TIA with sx
of left hand/arm weakness. No diplopia, dysarthria, dysphagia,
aphasia, gait instability, or other focal deficits. She was
worked up at an OSH with MRI/MRA showing significant R carotid
lesion. Duplex ultrasaound showed right carotid restenosis >90%.
She was started on Plavix for stroke prevention and was
discharged with planned elective right CEA. She went to
[**Location (un) 1110**]/[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital for attempted right CEA but with
significant complications from anestheia. She was given the
option of re-CEA or carotid angioplasty/stent and decided to go
for carotid stent. She had a second TIA involving right
amaurosis fugax like "black curtain over the eye" lasting 5 min.
This occurred after she stopped taking Plavix secondary to
itching. Angiography revealed diffuse abdominal aortic disease
with 70% tubular lesion at the level of the renal arteries,
bilateral iliac disease with 80% ostial right and modest ostial
left, 70% tubular left subclavian lesions before vertebrals and
>90% right carotid disease at origin. Also with 70% right
vertebral, 99% focal left vertebrals in CEA segment. Pt
underwent PCA/stenting R carotid w/ 0% residual. Of note,
central aortic SBP range 30-40 mg Hg above R arm cuff pressure.
Pt denies CP, SOB, dysarthria, weakness, parasthetic, headache,
visual changes.
Neurological Hx: She has asymmetric BP in UE. She gets dizzy
when she reaches up, suspicious for sublcavian steal.
Brain/Neck MRA showed 80-80% stenosis of R ICA; 40 % stenosis of
L ICA. Hypoplastic right A1 segment. Carotid duplex in [**September 2137**] showing 40-60% R ICA stenosis
Past Medical History:
PVD
s/p bilateral CEAs (L CEA '[**19**] w/ redo in '[**30**]; R CEA [**October 2128**] w/
redo in [**April 2129**])
COPD
GERD
mild CRI
s/p hysterectomy
s/p appendectomy w/ hypertensive crisis [**5-27**]
C5-6 lami [**2132**]
right L4-5 lami [**2132**]
s/p AAA repair
Social History:
She is retired at age 63. Previous occpuations: drafting
engineer and working on computers. Pt is divorced and lives
alone. Pt is a former smoker x 35 years. No alcohol or illicit
drug use.
Family History:
Mother deceased 84, hx of Alzheimer's. Father deceased 55 from
accident.
Physical Exam:
VS: BP 134/58 HR 81 RR 17 95% RA
GEN: Lying in bed in NAD, appears comfortable.
HEENT: NC/AT: PERRL, EOMI, nl OP, tongue midline, neck supple,
no JVD, + carotid bruits R > L, 2+ carotid pulses
COR: RRR, S1, S2, III/VI SEM @ LUSB
LUNGS: Clear to auscultate anteriorly
ABD: +BS, soft, NTND, no guarding
EXT: bilateral femoral bruit, 1+ femoral pulses, 2+ DP
bilaterally
NEURO: Alert and oriented x3, CN II-XII intact, strengths
grossly [**5-29**]. Nonfocal. Good repetition, good 3 objects recall.
No word finding difficulties. No apraxis.
Pertinent Results:
EKG: NSR @ 73 BPM, nl intervals, nl axis. TWI V2, no LVH by
criteria. No ST, T-wave changes.
CATH:
. Access was retrograde via the right CFA to the selective
carotid and
vertebral arteries.
2. Abdominal aorta: Severe diffuse disease at the level of the
renals
with a tubular 70% lesion. The thoracic aorta was a bovine Type
I.
3. Renal arteries: Bilaterally single without evidence of
ostial
disease.
4. RLE: There was an ostial 80% CIA lesion.
5. LLE: The CIA had modest ostial disease.
6. Subclavians: The LSCA had a tubular 70% lesion before the
vertebral
and [**Female First Name (un) 899**] take-offs with a mean 10 mmHg gradient across the
lesion.
7. Carotid/vertebral arteries: The right vertebral had a 70%
origin
lesion. The vertebral filled the cerebellar and PCA vessels
without
lesions. The left vertebral had a moderate origin lesion with
competitive flow at the basilar from the contralateral artery.
The LCCA
was normal. The [**Doctor First Name 3098**] was widely patent and filled the
ipsilateral ACA,
MCA and the contralateral ACA. The [**Country **] had a 99% lesion in the
CEA
segment with ipsilateral filling of the MCA only.
8. Stenting of the [**Country **] was performed with a tapered [**8-30**] x 30
mm
Acculink stent.
Brief Hospital Course:
1. Carotid disease: [**Doctor First Name 3098**] was widely patent and filled the
ipsilateral ACA,
MCA and the contralateral ACA. The [**Country **] had a 99% lesion in the
CEA
segment with ipsilateral filling of the MCA only which was
stented with
a tapered [**8-30**] x 30 mm Acculink stent. Pt has allergy to
shellfish so she was premedicated with benadryl, H2-blocker, and
steroid prior to cath. Pt's BP was controlled with IV
nitroprusside post-cath, and was weaned as BP was controlled
with oral agents: metoprolol 50 mg po bid, Norvasc 10 mg po qd,
Accupril 10 mg po qd. Pt was started on ticlodipine 250 mg po
bid as she can not tolerate Plavix.
2. HTN: Pt's R cuff pressure is ~30 mmHg < then the central
pressure. Since pt has undergone multiple CEA's she was not
prone to carotid sensitivity from stent placement. As above, BP
initially controlled with nitroprusside to keep arm SBP 80-100.
She was started on metoprolol 50 mg po bid and Norvasc 10 mg po
qd. She continued her Accupril 10 mg po qd.
3. PVD: Cath showed L subclavian artery had a tubular 70% lesion
before the vertebral and [**Female First Name (un) 899**] take-offs with a mean 10 mmHg
gradient across the lesion. Pt will be scheduled for left
subclavian stent in the future. She was continued on ASA and
Lipitor.
4. CHF: Hx of diastolic dysfunction. Pt gets lasix prn at home.
Lasix was held initially. But after post-cath hydration, pt
found to have small crackles on exam, so IV lasix 20 mg was
given once prior to discharge.
Medications on Admission:
ASA 81 mg po qd, Ativan 0.5 mg tid prn, nadolol 20 mg po qd,
Accupril 10 mg po qd, Lipitor 20 mg po qpm, ranitidine 300 mg
qpm, Combivent inh qid: prn, Lasix 30 mg po prn.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ticlopidine HCl 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day.
6. Accupril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Amlodipine Besylate 10 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day
as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral carotid disease
Discharge Condition:
Hemodynamically and neurologically stable.
Discharge Instructions:
Patient was instructed to take all of the medications as
directed. Pt was instructed to seek medical attention (Dr.
[**First Name (STitle) **], PCP, [**Last Name (NamePattern4) **]) if she develops dizziness, blindness, weakness,
numbness, gait instability, trouble with speech, or any other
concerning neurological symptoms. Patient needs to follow up
with PCP [**Last Name (NamePattern4) **] [**1-25**] weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-3-18**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2138-3-18**] 3:00
You should follow up with your PCP [**Name Initial (PRE) 176**] 1 week for BP check.
Completed by:[**2138-1-3**]
|
[
"401.9",
"433.30",
"272.4",
"447.1",
"530.81",
"443.9",
"496",
"428.0",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
7287, 7293
|
4721, 6242
|
259, 272
|
7363, 7407
|
3430, 4698
|
7869, 8321
|
2778, 2853
|
6464, 7264
|
7314, 7342
|
6268, 6441
|
7431, 7846
|
2868, 3411
|
185, 221
|
300, 2262
|
2284, 2551
|
2567, 2762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,695
| 108,174
|
29196
|
Discharge summary
|
report
|
Admission Date: [**2193-7-23**] Discharge Date: [**2193-9-22**]
Date of Birth: [**2149-3-7**] Sex: F
Service: MEDICINE
Allergies:
Sulfasalazine / Zosyn
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
cardiac Catheterization with placement of BMS X2 to RCA
central venous line placements
IR guided exchange of HD catheter over wire
IR guided arterial line placement
Skin biopsy
Bone marrow biopsy
Kidney biopsy
History of Present Illness:
Patient is a 44 yo F with h/o asthma who presented to [**Hospital1 5979**] ER with dyspnea, found to have possible pneumonia and
asthma exacerbation, was intubated and found to have NSTEMI. Pt
is currently intubated and sedated. Per her family, her niece
visited her on [**7-22**] and found the patient feeling unwell and
short of breath. Her niece had called 911 and the patient was
taken to [**Hospital3 **] ER. VS were: 124/71, pulse 107, RR
30, O2 sat 84% on RA. On exam, she was noted to be diaphoretic
and have expiratory wheezing. CXR revealed bilateral airspace
opacities, bilateral infiltrates v. pulmonary edema, which were
noted to be rapidly increasing overal serial CXRs. Pt was
started on Bipap and admitted to the ICU. She failed Bipap and
was then intubated. Pt was treated with ceftriaxone,
azithromycin, and solumedrol. Tmax was 100.4. Sputum gram
stain showed few polys, few GPCs in pairs, rare GPCs in
clusters; sputum cx grew scant normal respiratory flora.
Further workup revealed increasing cardiac enzymes, CK of
153->1143, CKMB of 11->150, Troponin T of 0.06->2.03
(0.01-0.04). BNP was 1753. Preliminary ECHO work-up showed EF
of 30-35%, severe inferior wall hypokinesis, 2+ MR. [**Name13 (STitle) **] report,
EKG showed SR at rate of 100, with Q waves in lead III and AVF
and non-specific ST-T wave changes. She was treated with IV
Lasix, nitro gtt, heparin gtt, and plavix and transferred here.
.
In the cardiac cath lab, she was found to have 100% stenosis of
distal RCA, which was stented with 2 BMS. Resting hemodynamics
revealed elevated right and left ventricular filling pressures
with RVEDP of 27 mmHg and PCW of 25 mmHg.
.
Per family, ROS was positive intermittent substernal chest pain
for the past 2 years. Per sister, she had normal stress tests,
perhaps a year ago. Per PCP, [**Name10 (NameIs) **] had presented with pedal edema
and weight gain 3 months ago. She also has a chronic productive
cough. She had been hospitalized for pneumonia twice in the
last year and may have required intubation. Last
hospitalization was in [**2193-2-26**].
Past Medical History:
Asthma
Obesity, s/p gastric bypass in [**2187**]
Depression
s/p cesarean sections x2
Social History:
Patient is divorced with 2 sons. She is a nurse. Social
history is significant for [**11-28**] ppd x 30 years. There is history
of alcohol use, [**1-29**] drinks per day. Family is unaware of any
withdrawal issues.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 99.7, BP 107/76, HR 83, RR 27, O2 100% on AC 600x14, FiO2
100%
Gen: Middle aged female, intubated and sedated.
HEENT: Sclera anicteric. PERRL, EOMI. Mucous membranes moist.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. No S4, no S3. No murmurs.
Chest: No chest wall deformities, scoliosis or kyphosis. RLL
crackles. No wheezes.
Abd: Obese. Normoactive bowel sounds, soft, NT/ND, no HSM. No
abdominial bruits.
Ext: No edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+; 1+ DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+; 1+ DP/PT (but
undopplerable?)
Pertinent Results:
ADMISSION LABS:
[**2193-7-23**] 01:31PM BLOOD WBC-13.8* RBC-4.33 Hgb-12.7 Hct-38.9
MCV-90 MCH-29.4 MCHC-32.7 RDW-15.9* Plt Ct-322
[**2193-7-23**] 01:31PM BLOOD Neuts-92.0* Lymphs-6.1* Monos-1.8*
Eos-0.1 Baso-0
[**2193-7-23**] 01:31PM BLOOD PT-15.3* PTT-70.1* INR(PT)-1.4*
[**2193-7-23**] 01:31PM BLOOD Plt Ct-322
[**2193-7-23**] 01:31PM BLOOD Glucose-181* UreaN-18 Creat-1.7* Na-144
K-4.5 Cl-108 HCO3-22 AnGap-19
[**2193-7-23**] 08:59PM BLOOD K-5.9*
[**2193-7-23**] 01:31PM BLOOD CK(CPK)-2738*
[**2193-7-23**] 08:59PM BLOOD ALT-54* AST-375* LD(LDH)-1728*
CK(CPK)-3323* AlkPhos-82 TotBili-0.5
[**2193-7-23**] 01:31PM BLOOD CK-MB-276* MB Indx-10.1* cTropnT-7.82*
[**2193-7-23**] 08:59PM BLOOD CK-MB-185* MB Indx-5.6
[**2193-7-23**] 01:31PM BLOOD Calcium-7.6* Phos-4.7* Mg-1.7
[**2193-7-23**] 08:59PM BLOOD Cholest-150
[**2193-7-23**] 01:31PM BLOOD %HbA1c-5.5
[**2193-7-23**] 08:59PM BLOOD Triglyc-283* HDL-57 CHOL/HD-2.6
LDLcalc-36
[**2193-7-24**] 10:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.3
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-7-23**] 01:40PM BLOOD Type-ART Tidal V-550 FiO2-100 pO2-104
pCO2-31* pH-7.43 calTCO2-21 Base XS--2 AADO2-597 REQ O2-95
Intubat-INTUBATED
[**2193-7-23**] 04:11PM BLOOD Lactate-2.3*
[**2193-7-24**] 09:21PM BLOOD Glucose-130* Lactate-1.2
.
.
[**2193-9-19**] 04:45AM BLOOD WBC-14.6* RBC-2.84* Hgb-8.7* Hct-27.2*
MCV-96 MCH-30.7 MCHC-32.1 RDW-22.7* Plt Ct-148*
[**2193-9-21**] 06:39AM BLOOD WBC-17.5* RBC-2.97* Hgb-9.0* Hct-29.7*
MCV-100* MCH-30.2 MCHC-30.2* RDW-23.1* Plt Ct-70*
[**2193-9-22**] 04:16AM BLOOD WBC-16.9* RBC-1.75*# Hgb-5.5* Hct-17.8*#
MCV-102* MCH-31.6 MCHC-31.0 RDW-22.6* Plt Ct-35*
[**2193-8-11**] 04:00AM BLOOD WBC-29.3* RBC-2.45* Hgb-7.3* Hct-23.3*
MCV-95 MCH-29.7 MCHC-31.2 RDW-18.1* Plt Ct-168
[**2193-8-13**] 11:34AM BLOOD WBC-25.3* RBC-2.74* Hgb-8.0* Hct-25.9*
MCV-94 MCH-29.1 MCHC-30.8* RDW-19.4* Plt Ct-104*
[**2193-8-18**] 03:51AM BLOOD WBC-18.8* RBC-2.36* Hgb-7.3* Hct-23.5*
MCV-100* MCH-30.8 MCHC-30.9* RDW-26.6* Plt Ct-65*
[**2193-9-20**] 03:36AM BLOOD PT-17.3* PTT-26.7 INR(PT)-1.6*
[**2193-9-21**] 03:39AM BLOOD PT-19.3* PTT-31.2 INR(PT)-1.8*
[**2193-9-21**] 10:23PM BLOOD PT-24.2* PTT-150* INR(PT)-2.4*
[**2193-9-22**] 04:16AM BLOOD PT-31.4* PTT-150* INR(PT)-3.2*
[**2193-7-27**] 12:04PM BLOOD Fibrino-667* D-Dimer-5093*
[**2193-8-15**] 04:28PM BLOOD Fibrino-121* D-Dimer-6300*
[**2193-8-16**] 03:26AM BLOOD Fibrino-106* D-Dimer-6475*
[**2193-9-17**] 02:02AM BLOOD QG6PD-19.1*
[**2193-8-3**] 05:30AM BLOOD ACA IgG-3.6 ACA IgM-7.6
[**2193-7-27**] 10:10PM BLOOD ACA IgG-3.2 ACA IgM-6.9
[**2193-9-21**] 10:23PM BLOOD Glucose-215* UreaN-20 Creat-0.7 Na-147*
K-5.3* Cl-98 HCO3-8* AnGap-46*
[**2193-9-22**] 04:16AM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-139
K-5.0 Cl-91* HCO3-10* AnGap-43*
[**2193-9-21**] 04:42PM BLOOD Glucose-260* Na-140 K-6.6* Cl-105 HCO3-<5
[**2193-9-21**] 03:39AM BLOOD Glucose-151* UreaN-26* Creat-0.9 Na-141
K-2.8* Cl-109* HCO3-20* AnGap-15
[**2193-9-20**] 03:36AM BLOOD ALT-32 AST-16 AlkPhos-79 TotBili-1.0
[**2193-9-21**] 10:23PM BLOOD ALT-205* AST-302* LD(LDH)-1137*
CK(CPK)-66 AlkPhos-79 Amylase-834* TotBili-1.0
[**2193-9-10**] 05:36AM BLOOD ALT-108* AST-27 LD(LDH)-596* AlkPhos-193*
TotBili-1.3
[**2193-9-21**] 10:23PM BLOOD Lipase-49
[**2193-8-20**] 03:55AM BLOOD cTropnT-1.50*
[**2193-9-21**] 06:50PM BLOOD CK-MB-NotDone cTropnT-0.68*
[**2193-9-21**] 10:23PM BLOOD CK-MB-NotDone cTropnT-0.56*
[**2193-9-22**] 04:16AM BLOOD CK-MB-8 cTropnT-0.41*
[**2193-8-18**] 04:16PM BLOOD CK-MB-123* MB Indx-2.2
[**2193-9-22**] 04:16AM BLOOD CK(CPK)-153*
[**2193-9-21**] 10:23PM BLOOD Calcium-10.6* Phos-6.1*# Mg-2.5
[**2193-9-22**] 04:16AM BLOOD Calcium-12.2* Phos-5.5* Mg-2.4
[**2193-9-21**] 10:23PM BLOOD Hapto-26*
[**2193-9-9**] 04:11AM BLOOD calTIBC-273 Ferritn-96 TRF-210
[**2193-8-13**] 04:55AM BLOOD TSH-6.1*
[**2193-9-9**] 09:41AM BLOOD PTH-365*
[**2193-7-29**] 02:12AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2193-7-29**] 10:33AM BLOOD ANCA-NEGATIVE B
[**2193-7-24**] 10:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.3
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-9-22**] 08:01AM BLOOD Type-ART pO2-241* pCO2-28* pH-7.49*
calTCO2-22 Base XS-0
[**2193-9-22**] 04:21AM BLOOD Type-ART pO2-300* pCO2-17* pH-7.44
calTCO2-12* Base XS--9
[**2193-9-22**] 03:19AM BLOOD Type-ART Temp-33.3 pO2-411* pCO2-14*
pH-7.43 calTCO2-10* Base XS--11
[**2193-9-22**] 01:20AM BLOOD Type-ART Temp-33.3 Rates-0/20 pO2-68*
pCO2-37 pH-7.08* calTCO2-12* Base XS--18 Intubat-NOT INTUBA
[**2193-9-21**] 10:41PM BLOOD Type-ART Rates-/20 FiO2-40 pO2-117*
pCO2-31* pH-7.11* calTCO2-10* Base XS--18 Intubat-NOT INTUBA
[**2193-9-21**] 07:46PM BLOOD Type-ART pO2-111* pCO2-27* pH-6.94*
calTCO2-6* Base XS--26
[**2193-9-21**] 05:27PM BLOOD Type-ART Rates-20/ pO2-111* pCO2-22*
pH-6.87* calTCO2-4* Base XS--30 Intubat-NOT INTUBA
[**2193-9-21**] 04:59PM BLOOD Type-ART pO2-108* pCO2-24* pH-6.88*
calTCO2-5* Base XS--29 Intubat-NOT INTUBA
[**2193-9-21**] 11:15AM BLOOD Type-ART Temp-35.2 Rates-/22 pO2-83
pCO2-29* pH-7.33* calTCO2-16* Base XS--9 Intubat-NOT INTUBA
[**2193-9-21**] 03:51AM BLOOD Type-ART pO2-139* pCO2-35 pH-7.38
calTCO2-22 Base XS--3
[**2193-9-20**] 06:00PM BLOOD Type-ART pO2-115* pCO2-37 pH-7.38
calTCO2-23 Base XS--2
[**2193-9-20**] 12:26PM BLOOD Type-ART pO2-114* pCO2-31* pH-7.40
calTCO2-20* Base XS--3
[**2193-9-13**] 04:20AM BLOOD Lactate-3.1*
[**2193-9-13**] 11:28AM BLOOD Lactate-2.0 calHCO3-30
[**2193-9-19**] 04:58AM BLOOD Lactate-1.8
[**2193-9-19**] 11:05AM BLOOD Lactate-2.2*
[**2193-9-21**] 03:51AM BLOOD Lactate-2.3*
[**2193-9-21**] 05:27PM BLOOD Lactate-12.9*
[**2193-9-21**] 07:46PM BLOOD Lactate-15.* K-5.3
[**2193-9-21**] 10:41PM BLOOD Lactate-16.7*
[**2193-9-22**] 01:20AM BLOOD Lactate-14.7*
[**2193-9-22**] 03:19AM BLOOD Lactate-18.8*
[**2193-9-22**] 04:21AM BLOOD Lactate-20.2*
[**2193-9-22**] 08:01AM BLOOD Lactate-20.8*
[**2193-9-22**] 08:01AM BLOOD Hgb-3.1* calcHCT-9
[**2193-9-21**] 03:51AM BLOOD O2 Sat-98
[**2193-9-21**] 06:24PM BLOOD O2 Sat-24
[**2193-9-21**] 12:36PM BLOOD O2 Sat-27
[**2193-9-17**] 02:45PM BLOOD O2 Sat-49
[**2193-9-16**] 11:58PM BLOOD O2 Sat-83
[**2193-9-18**] 03:22PM BLOOD O2 Sat-98
[**2193-9-17**] 02:02AM BLOOD ANTI-PLATELET ANTIBODY-TEST
[**2193-9-5**] 06:26PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2193-9-3**] 03:43AM BLOOD ADAMTS13 ACTIVITY AND INHIBITOR-ADAMTS13
A
[**2193-8-27**] 08:18PM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-Test Name
[**2193-8-27**] 01:51PM BLOOD RIBOSOMAL P ANTIBODY-Test
[**2193-8-27**] 01:51PM BLOOD PURKINJE CELL (YO) ANTIBODIES-Test
[**2193-8-27**] 01:51PM BLOOD NEURONAL NUCLEAR ([**Doctor Last Name **]) ANTIBODIES-Test
[**2193-8-17**] 06:00PM BLOOD ADAMTS13 ACTIVITY AND INHIBITOR-ADAMTS13
A
[**2193-8-14**] 04:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2193-8-13**] 04:55AM BLOOD MI-2 AUTOANTIBODIES-Test
[**2193-8-7**] 03:30PM BLOOD SM ANTIBODY-Test
[**2193-8-7**] 03:30PM BLOOD RNP ANTIBODY-Test
[**2193-8-7**] 03:30PM BLOOD ALDOLASE-Test
[**2193-8-6**] 10:22AM BLOOD PROTHROMBIN MUTATION ANALYSIS-
[**2193-8-6**] 10:22AM BLOOD FACTOR V LEIDEN- T
[**2193-8-3**] 05:50AM BLOOD IGG SUBCLASSES 1,2,3,4-Test
[**2193-7-31**] 05:18AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-Test
[**2193-7-25**] 06:56AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2193-7-25**] 06:56AM BLOOD B-GLUCAN-Test
PERTINENT LABS/STUDIES:
.
EKG demonstrated NSR with q waves in III and AVF, TWI in II,
III, AVF, 1 mm STE in V1, STD in V3, V4.
.
2D-ECHOCARDIOGRAM performed on [**2193-7-23**] demonstrated:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. There is mild regional left ventricular
systolic dysfunction with inferior/inferolateral akinesis.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] EF 45%.
Right ventricular chamber size is normal and free wall motion
is probably normal (views suboptimal). The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion.
.
CARDIAC CATH performed on [**2193-7-23**] demonstrated:
The LMCA, LAD, LCX showed no obstructive coronary artery
disease. The RCA showed a distal discrete 100% stenosis with
left to right collaterals.
.
CXR [**2193-7-23**]
AP single view of the chest is obtained with patient in supine
position. The patient is intubated, the ETT terminating in the
trachea some 3 cm above the level of the carina. An NG tube has
been placed and reaches far below the diaphragm. There is marked
cardiac enlargement configuration indicating a prominence of the
left ventricular contour as well as a beginning double contour
and widening of the tracheal bifurcation indicative of left
atrial enlargement. There is no pneumothorax. There are
bilateral mostly
centrally located parenchymal densities consistent with
pulmonary edema.
The lateral pleural sinuses are free. Possibility of some
bilateral pleural effusions layering in the posterior pleural
spaces in this patient in supine position can, however, not be
excluded.
.
MRA Head. [**2193-7-28**].
CONCLUSION: Findings remain suspicious for multiple infarcts,
shown to be
subacute in age.
.
Renal Biopsy. [**2193-8-2**].
Comment:
1. There is no evidence of an immune complex
glomerulonephritis.
2. The focal vascular changes noted are insufficient for a
definite diagnosis of a thrombotic microangiopathy. Clinical
correlation is indicated.
.
Skin biopsy:
Multiple thrombi within small vessels in dermis with overlying
ischemic epidermal changes consistent with thrombotic
microangiopathy.
No vasculitis is seen.
Echo [**9-19**]: The left atrium is markedly dilated. The right
atrium is markedly dilated. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with severe hypokinesis/akinesis of the inferior and
inferolateral walls. Transmitral Doppler imaging is consistent
with Grade III/IV (severe) LV diastolic dysfunction. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets do not fully coapt.
Severe (4+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2193-9-4**],
the severity of tricuspid regurgitation has decreased. Severe
ischemic mitral regurgitation resulting from the mitral leaflets
failing to coapt is unchanged.
Echo [**9-21**]: The left and right atrium are markedly dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild to moderate regional left ventricular
systolic dysfunction with akineis of the inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 40 %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
moderate global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The aortic valve leaflets
appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. At least moderate to severe (3+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is an anterior space which most likely represents a
fat pad.
Compared with the prior study (images reviewed) of [**2193-9-19**],
the findings are similar.
[**9-18**] Renal Ultrasound: FINDINGS: The right kidney measures 10.9
cm, and the left kidney measures 10.2 cm. No hydronephrosis is
identified in either kidney. The cortical thickness appears
normal bilaterally. No cysts or solid masses are identified.
IMPRESSION: No hydronephrosis. Normal cortical thickness
bilaterally.
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
MILDLY HYPOCELLULAR ERYTHROID DOMINANT BONE MARROW WITH
DYSERYTHROPOIESIS AND DYSMEGAKARYOPOIESIS.
Note: The findings are not inconsistent with the effects of
gangcyclovir +/- viremia. A primary myelodysplastic syndrome
appears less likely, but can not be entirely ruled out. Special
stains for microorganisms (Acid-fast, GMS, PAS) are negative.
By immunohistochemistry, T-cell markers CD3 and CD5 highlight
lymphocytes singly and in clusters. CD20 is immunoreactive in a
small subset. CD138 highlights plasma cells in interstitial and
perivascular distribution, which by Kappa/Lambda light chain
immunostaining appear polytypic.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes show
significant anisopoikilocytosis with polychromatophils,
macrocytes, target cells, echinocytes, dacrocytes, microcytes,
ovalocytes and basophilic stippling. A peripheral blood smear
was not submitted. Numerous nucleated RBC's are seen, some with
irregular nuclear contours and asymmetric nuclear budding. The
white blood cell count appears normal. Neutrophils with toxic
vacuolization are prominent and include hypogranular forms.
Platelet count appears normal. Large forms are seen.
Occasional Giant forms are present. Differential count shows
91% neutrophils, 3% monocytes, 8% lymphocytes, 1% other
myelocyte.
Aspirate Smear:
The aspirate material is inadequate for evaluation due to lack
of spicules.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation and consists of
two pieces of fragmented core biopsy with partial aspiration
artifact measuring 0.6 cm in aggregate. The marrow is variably
cellular, overall 20-30%. Interstitial debris and macrophages
appear prominent.
The M:E ratio estimate is decreased. Erythroid precursors are
relatively increased in number and show occasional dysplastic
forms (asymmetric nuclear budding and irregular nuclear
contours). Myeloid elements are decreased and show
full-spectrum maturation.
Megakaryocytes are present in normal number and are focally
present in clusters.
There is an interstitial infiltrate of plasma cells /
lymphoplasmacytic cells occurring singly and in small clusters
occupying 10% of marrow cellularity. Marrow clot section is
similar to the biopsy.
Special Stains:
Iron stain is inadequate for evaluation due to lack of spicules.
Brief Hospital Course:
In summary, Ms. [**Known lastname 62766**] is a 44 year old female admitted
initially to an OSH for multifocal pneumonia, found to have an
NSTEMI, s/p BMS to RCA on admission. Hospital course further
complicated by multiorgan system failure.
.
NSTEMI. Patient transferred to [**Hospital1 18**] due to NSTEMI. Found to
have mild regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis on echo. She had cardiac cath
and was found to have 100% stenosis of distal RCA, which was
stented x2 with BMS. She was started on aspirin, atorvastatin,
and plavix. The patient remained hypotensive after cardiac
catheterization, and was found to have mitral regurgitation.
Her mitral regurgitation worsened thoughout her hospital course
and she developed cardiogenic shock dependent on dobutamine.
Her dobutamine was weaned off over several weeks, but she was
unable to tolerate hemodialysis while off dobutamine.
.
Respiratory failure. Patient was initially admitted to [**Hospital1 **] after presenting with a multifocal pneumonia. Upon
transfer to [**Hospital1 18**], patient had daily fevers in spite of broad
spectrum antibiotics and negative cultures. Her CXR improved,
however, she had persistent altered mental status and tachypnea
thought be secondary to a central process preventing extubation.
She was given steroids for a short period. However, given her
persistent respiratory alkalosis and cheynes-[**Doctor Last Name 6056**] breathing,
she underwent tracheostomy. Due to her distorted anatomy
secondary to gastric bypass, a PEG was not performed at the same
time. During her hospital course, she had episodes of small
amounts of hemoptysis. The patient eventually progressed to
being weaned off the vent entirely, and was breathing
comfortably on the trach mask.
.
Altered mental status. Following cardiac catheterization,
patient found to have several embolic strokes. Patient had
serial TTEs and a TEE looking for a source, but was not found.
She remained minimally responsive and with cheynes-[**Doctor Last Name 6056**]
breathing. EEG x 2 showed toxic-metabolic patterns. Patient
was ultimately started on dialysis in hopes that improvemento
her uremia might improve her mental status. Over time, her
mental status improved, and she began to follow commands.
.
Renal Failure. Patient developed renal failure during her
hospital course. Etiology of her renal failure was not clear.
A renal biopsy could not rule out thrombotic microangiopathy,
but was felt to be consistent with ATN. She was started on
dialysis. There was concern for TTP given thrombocytopenia that
developed three weeks into her hospital stay, but the decision
was made against empiric plasmapharesis after consultation with
transfusion medicine. Patient was given 2 units of
cryoprecipitate for increasing DIC picture, and also started on
heparin gtt without bolus for concern of TTP and increasing
ischemia in lower extremities. She was dialyzed with CVVH, then
hemodialysis. The patient progressed with hemodialysis for
several weeks. During the week of [**9-18**] she became intolerant to
fluid shifts during hemodialysis and would become hypotensive
either during or shortly after hemodialysis. She was reaching
the point where she was requiring fluid boluses after every
hemodialysis session. On [**9-20**], she was restarted on CVVH.
.
DIC/TMA. Patient developed thrombocytopenia, elevated fibrin
split products, low fibrinogen, thought to be consistent with
DIC. She had a biopsy of her skin consistent with thrombotic
microangiopathy. She had decreased perfusion to her feet as
well. This was felt to be due to DIC in adition to levophed.
She was transfused cryoprecipitate and other blood products as
needed. Her coagulopathy was treated with IV heparin. Her
thrombocytopenia and coagulation abnormalities resolved,
however, the patient suffered ischemia of her distal extremities
with resulting necrosis. The patient was left with stable dry
gangrene of her left foot up to her ankle, her toes of her right
foot, and several fingers on each hand. Vascular surgery was
consulted and they recomended pursuing ampuation of her feet
after the patient regained better functioning status after a
stay at rehab.
.
Fevers. Patient initially presenting with daily fevers. She
was treated with broad spectrum antibiotics but continued to
have daily fevers. Given yeast in multiple sites (lung, urine),
but never in blood, patient was started on caspofungin. She
was also given steroids for bronchospasm. In spite of broad
spectrum antiobiotics and steroids, she had daily fevers. Her
fevers resolved after discontinuation of steroids and
antibiotics. She subsequently developed a line infection
treated with seven days of vancomycin. The patient develped
numerous other infections during her stay. She developed
C.Difficile colitis and was treated with flagyl and oral
vancomycin. She developed a CMV viremia and was treated with
ganciclovir. She had an acitenobacter vent associated pneumonia
and completed a course of augmentin. In addition, she developed
multiple other fevers which were attributed to line infetions,
treated with vancomycin. Her central lines were changed by
interventional radiology on multiple occasions.
.
Rhabdo. Patient developed rhabdo during her hospital stay. CK
reached levels greater than 10,000. This was thought to be due
to decreased mobility secondary to her altered mental status.
Her CK trended down to normal levels.
.
Pain Control: The patient experienced continuous pain from her
necrosed and gangrenous feet and fingers. She was treated with
IV fentanyl to treat her pain. The family raised concerns that
fentanyl administration was causing increased drowsiness of the
patient, and requested that it be curtailed. The patient's pain
was continuously evaluated by the nursing staff and physicians
and treated appropriately with fentanyl. The patient was
eventually transitioned to a fentanyl patch with the idea of
weaning off her IV fentanyl administration. Despite the
fentanyl patch she was still requiring additional IV fentanyl.
.
Shock. The patient developed shock on [**7-27**] and remained in shock
for the majority of her hospitalization. Initially attributed to
septic etiology; she was treated with broad spectrum antibiotics
and placed on neosinephrine, vasopressin, and levophed. Her
neosinephrine and vasopressin was discontinued and she
eventually remaned on levophed for blood pressure support. On
[**9-1**], TTE findings of 4+ MR, plus low central venous O2
saturations rasied the concern for a cardiogenic componenet.
Her levophed was discontinued and dobutamine was begun. Her
blood pressure, lactate levels, and central venous O2
saturations improved with initiation of dobutamine. She
remained in cardiogenic shock, dependent on dobutamine until
[**9-18**]. Her dobutamine was weaned off and she was able to
maintain a mean arterial pressure over 60. She continued with
periods of hypotension, most notable during or immediately after
hemodialysis, and required fluid suport during these periods.
After one such hypotensive episode [**9-20**] she was not responsive
to fluids and was restarted on levophed. her CVVH was restarted
on [**9-20**].
The afternoon of [**9-21**] @4pm her routine ABG showed a pH of 6.87,
a bicarbonate of 4, and a lactate of 12.9. These results came as
a surprise as an ABG at noon [**9-21**] showed a pH of 7.33, with a
bicarbonate of 16, and a lactate of 2.0. She remained otherwise
hemodynamically stable during this period without alterations in
her baseline blood pressure or heart rate. Her CVVH fluid was
immediately changed to provide the maximum amount of
bicarbonate. She slowly became hypotensive and was started on
vasopressin, in addition to levophed. She was bolused with a
total of 15 amps of sodium bicarbonate over the next 10 hours,
in addition to tromethamine which is a bicarbonate alternative.
ABGs showed her pH slowly improving to 7.1, with bicarbonate
levels improving to 9, however her lactate continued to rise to
a peak of 20.9. The cause of her acte lactic acidois and
electrolyte abnormaities were unknown, but it was thought that
she may be in worsening cardiogenic shock from a new myocardial
infarction, cardiac tamponade, or massive pulmonary embolism,
she may have been in septic shock, or she have suffered an
insult to another organ system such as acute bowel ischemia.
Stat cardiac echo did not show cardiac tamponade, or new wall
motion abnormalities suggestive of pulmonary embolism or
myocardial infarction. Cardiac enzymes were trended and were
flat. She was started on broad spectrum antibiotics with
vancomycin and meropenem to cover for possible infection causing
shock, in addition to coverage for clostridial species with
flagyl, PO vancomycin, and clindamycin. Physical examination
revealed a distended abdomen. Liver enzymes showed elevated
transaminases consistent with ishemic liver, normal bilirubin
and alkaline phosphatase, normal lipase, but an elevated amylase
to 853. The acuity of the patient's deterioration, in addition
to rising lactate, elevated amylase, and distended abdomen, led
us to believe that the patient was experiencing bowel ischemia.
this would not be surprising in a patient with an underlying
coagulopathy of uncertain etiology. The family was spoken to at
9pm and told of her grave prognosis. The family was fixated on
the patient's fentanyl use, and believed that her depressed
mental status was due to fentanyl. It was explained to her
family that her current condition was not secondary to fentanyl
administration, and that an acute unidentified event occured
which is causing the patient's deterioration. They were told
that this event was most likely mesenteric ischemia but that it
was uncertain, because the patient was too ill to be imaged.
At 4am the patient PEA arrested. CPR was initiated for 90
seconds. She was given epinephrine and atropine, and begun on
neosinephrine and dopamine. Her blood pressure increased and
her pulse returned. Her sister [**Name (NI) **] was called and told of
the events. She was told that the cause of her impaired cardiac
contractility was her underlying acidosis, and that nothing
medically could be done to stop the acidosis from worsening.
[**Doctor First Name **] requested the patient remain full code. The patient
progressed to apnea and was placed on the ventilator. She
underwent a second PEA arrest at 5am, progressing to torsades de
pointes. She was defibrillated once with return to her
junctional rhythm. She underwent another round of CPR lasting
90 seconds. She was given epinephrine, atropine, and sodium
bicarbonate and her blood pressure returned. her sister [**Name (NI) **]
was notified once again after this second PEA arrest. again,
she was told of her grave prognosis, and that her acidosis could
not be alleviated. She again requested that the patient remain
full code. She requested the patient remain full code so that
she could contact family members, and have them arrive to the
hospital so they could see the paitient while she was still
alive. From the hours of 6am through 8:30am the patient was
given epinephrine, atropine, and sodium bicarbonate in order to
stabilize her blood pressure. The patient's hematocrit dring
this time decreased from 18.0 to 9.0, possibly from
intrabdominal hemorrhage from perforated bowel as a result of
bowel ischemia. At 8:30 am the patient's extended family had
arrived. After they had a chance to see the patient alive they
requested she be made DNR. All resuscitative efforts ceased and
the patient passed away at 9am.
The following day the family requested an autopsy be performed.
Medications on Admission:
HOME MEDICATIONS:
Albuterol prn
.
MEDICATIONS ON TRANSFER:
ASA 325 mg
Azithromycin 500mg IV daily
Ceftriaxone 1 gm daily
Plavix 75 mg
Combivent 2 puffs QID
Lasix 40 mg IV BID
ISS
Methylprednisolone 80 mg IB [**Hospital1 **]
Heparin gtt
Nitro gtt
Propofol gtt
Lorazepam 1 mg IV q2 hrs prn
Morphine 2 mg IV q1 hr prn
Discharge Disposition:
Expired
Discharge Diagnosis:
NSTEMI
Cardiogenic Shock
Septic shock
CMV viremia
Disseminated Intravascular Coagulation
Thrombotic Microangiopathy
Dry gangrene of feet, fingers
Ventilator associated pneumonia
Cerebral infarcts
C.Diff colitis
Line infections
Likely Bowel Ischemia
Discharge Condition:
expired
|
[
"410.71",
"E879.8",
"995.92",
"424.0",
"278.00",
"414.01",
"249.00",
"518.81",
"790.8",
"311",
"584.5",
"428.0",
"E932.0",
"305.1",
"786.3",
"728.88",
"285.9",
"785.51",
"286.6",
"349.82",
"999.31",
"078.5",
"785.52",
"434.11",
"486",
"997.31",
"428.21",
"008.45",
"493.92",
"453.8",
"V45.86",
"785.4",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.56",
"31.29",
"96.05",
"00.46",
"36.06",
"39.95",
"97.71",
"41.31",
"00.40",
"37.23",
"38.93",
"38.91",
"88.72",
"38.95",
"99.20",
"96.6",
"00.66",
"33.24",
"55.23",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
30699, 30708
|
18597, 30334
|
300, 512
|
31000, 31010
|
3839, 3839
|
3007, 3089
|
30729, 30979
|
30360, 30360
|
3104, 3820
|
30378, 30394
|
241, 262
|
540, 2645
|
3856, 18574
|
30419, 30676
|
2667, 2754
|
2770, 2991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,537
| 128,113
|
18916
|
Discharge summary
|
report
|
Admission Date: [**2116-8-23**] Discharge Date: [**2116-9-6**]
Date of Birth: [**2037-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
DC cardioversion for atrial fibrillation
History of Present Illness:
Pt is a 79yoM with pmh CAD, s/p DES to ramus and mid circ in
[**2112**], COPD, htn s/p L renal artery stent, PUD who presented on
[**2116-8-19**] to OSH with sudden onset SOB, fever, found to have
NSTEMI as well as likely pneumonia with resultant COPD
exacerbation. Pt states SOB started day of pres, occurred
acutely shortly after feeling leg cramps. Denies chest pain at
that time, states that when he did have an MI back in [**2112**], he
experienced epigastric pain. On route to OSH pt had one episode
vomitting. At the OSH pt was treated for pneumonia and
klebsiella bacteremia with Zosyn, anti-coagulated with
heparin/statin/aspirin for NSTEMI, IV solumedrol for COPD. His
clinical status was improving, was off heparin and symptom free,
stress testing was planned, however on [**2116-8-23**] pt developed
acute SS chest pain, SOB with hypoxia to 80%s on 4L NC. He was
treated with nitroglycerin, morphine, IV lasix for CHF given
clinical/cxr c/w pulmonary edema. EKG was concerning for lateral
STD v4-v6. Pt did improve temporarily but again desaturated and
required non invasive ventillation. At this point he was
restarted on heparin drip.
.
He is currently CP free and feels his breathing has improved
significantly.
.
ROS: denies cough, headache, abd pain, diarrhea, melena,
hematochezia
Past Medical History:
1)CAD
-MI in [**2112**], followed by planned PCI with DES to mid circ,
ramus, also showed 60% LAD disease
2)RAS
-stent to L RA in [**7-/2113**]
3)HTN
4)PUD
5)GIB
6)L knee replacement
7)Gout
Social History:
former tob, current alcohol, married
Family History:
non-contributory
Physical Exam:
t 97.9 HR 67 BP 154/67 RR 18 95% mask hi flow fio2 60%
Gen: tachypneic, labored/abdominal breathing, diaphoretic, skin
w/ pallor
HEENT: No icterus, dry mucous membranes
NECK: Supple, no LAD, +JVD >10. No thyromegaly, no carotid
bruits
CV: nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: rales, crackles bilaterally w/ wheezing transmitted to
all fields
ABD: Soft, ND. hypoactive BS. No HSM
EXT: palpable pulses BL, no edema in LE
SKIN: No rashes/lesions, ecchymoses
NEURO: pt not alert or oriented x 3
Pertinent Results:
[**2116-8-23**] 11:59PM GLUCOSE-262* UREA N-43* CREAT-1.6* SODIUM-143
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16
[**2116-8-23**] 11:59PM ALT(SGPT)-31 AST(SGOT)-30 CK(CPK)-62 ALK
PHOS-78 TOT BILI-0.5
[**2116-8-23**] 11:59PM CK-MB-NotDone cTropnT-1.25* proBNP-[**Numeric Identifier 51719**]*
[**2116-8-23**] 11:59PM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-2.1
[**2116-8-23**] 11:59PM WBC-19.8* RBC-3.14* HGB-10.7* HCT-30.7*
MCV-98 MCH-33.9* MCHC-34.7 RDW-14.5
[**2116-8-23**] 11:59PM PLT COUNT-195
[**2116-8-23**] 11:59PM PT-12.5 PTT-50.9* INR(PT)-1.1
.
Imaging studies:
CHEST (PORTABLE AP) [**2116-8-24**] 1:23 AM
Mild pulmonary edema is new. Mild cardiomegaly unchanged. Left
pleural thickening is stable. No pneumothorax. Widening of the
superior mediastinum is comparable probably due to combination
of mediastinal fat and thyroid enlargement.
.
ECG Study Date of [**2116-8-24**] 12:52:42 AM
Sinus rhythm
Right bundle branch block
Inferior/lateral ST-T changes
Since previous tracing, no significant change
.
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion.
.
CHEST (PORTABLE AP) [**2116-8-28**] 7:13 AM
Lung volumes are lower than on [**8-26**], which may account in
part for intensification of perihilar edema and more pronounced
left lower lobe consolidation. Pneumonia cannot be excluded. The
heart is top normal in size, unchanged. Small left pleural
effusion persists. No pneumothorax.
.
CHEST (PA & LAT) [**2116-8-30**] 9:54 AM
Compared to the prior film, there is improved aeration and less
density in the paracentral regions suggesting some diminution in
pulmonary edema. However, there is residual airspace density and
no evidence for pleural effusion. No new focal consolidation is
seen. An area of atelectasis is noted in the frontal view
adjacent to the left heart border which is subsegmental in
nature.
.
IMPRESSION: Improving appearance of the chest with no new
consolidations.
Brief Hospital Course:
79yo M w/ diastolic heart failure, hypoxia [**12-26**] COPD exacerbation
and pneumonia, NSTEMI w/ STD v1-v4, klebsiella bacteremia,
nasopharyngeal bleed vs GI bleed, new onset a. fib s/p
cardioversion, now in NSR.
.
CARDIAC
# LV function
Pt w/ dilated heart failure p/w CHF exacerbation. Echo w/ EF
>55%, AR/MR, normal LV size. Volume overload with pulm edema,
extremities warm, BP normotensive. IV lasix switched to PO on
[**8-31**], decreased to 80 PO QD from [**Hospital1 **] on [**9-2**], decrease to 40mg
QD on [**9-5**]. Will continue with 40mg QD on d/c home.
- isosorbide, lasix 40 PO qd, lisinopril 40mg, norvasc 10mg
- fluid balance goal -500, monitor UOP, fluid restrict 1L
- Compression stockings for LE edema
- proBNP elevated on admission 15,939, on d/c 2912
.
# Ischemia
Presented w/ NSTEMI. Elevated troponins in setting of CHF,
pneumonia, possible PE, EKG changes with pain on morning of
transfer. Not candidate for cath at this time, cont medical
management. Lipid panel w/ LDL 37, HDL 47, cholesterol 107, TG
116.
- aspirin, atorvastatin 40 qd
.
# Rhythm
New onset of atrial fibrillation on [**8-25**], no hx of Afib in past.
Received amiodarone load and 18hr infusion for rhythm
conversion. PFTs [**2-/2115**] c/w COPD, mild airway obstruciton,
LFTs/TFTs wnl. ?Long QT on ECG on [**8-30**], however will allow for
some prolongation due to RBBB. Placed on heparin drip [**8-26**],
continued for 1 week. D/c'd on [**9-1**]. s/p cardioversion on [**8-27**],
now NSR. Given amiodarone 400mg [**Hospital1 **] ([**Date range (1) 51720**]), 400mg qd
(started [**Date range (1) 51721**]), switched to 200mg QD on [**9-5**] for
prolonged QT.
- Continue diltiazem SR 300mg qd, amio 200mg QD
.
PULMONARY
# Hypoxia:
Multifactorial CHF, COPD, recent PNA. Minimal hemoptysis.
- treat pulmonary edema secondary to CHF w/ diuresis
.
# COPD:
Goal o2 sat 93%, stable on RA at rest and with ambulation, lung
exam w/ persistent wheezing. RR increases with ambulation.
- continue nebs, advair, spiriva
- oral prednisone with taper, 30mg qd starting [**8-29**], 20mg QD on
[**8-31**], 10mg QD on [**9-3**]. Will send patient home on 7.5mg for one
week.
.
RENAL
# ARF:
Fe Urea was 45, so not likely pre-renal etiology. Cr elevation
may be due to bactrim.
- monitor creatinine, currently stable.
- Will need f/u Cr after discharge, off abx.
.
HEME
# Anemia:
Secondary to GI/oropharyngeal bleed vs. hemolysis, monitor
serial Hct. Haptoglobin <20, elevated LDH however may be normal
rxn in patient receiving multiple transfusions. EGD showed only
mild gastritis, no obvious source of bleed. Was given 4U over
this admission.
- Continue [**Hospital1 **] PPI
.
ID
# Leukocytosis:
WBC decreasing, now afebrile. [**Month (only) 116**] be secondary to C. diff vs UTI
vs steroids. C. diff negative x2. CXR wnl. UCx + for
enterococcus, yeast.
- Empiric treatment for c diff with flagyl x 14days (Day 1
[**8-30**]). Will give 14 days from date of last abx which was [**9-4**].
D/c on 2 wks flagyl.
- Completed 7 day course Bactrim for 7 days for complicated UTI
.
# Klebsiella septicemia
Blood cx NGTD.
- completed zosyn course which was begun at OSH
- monitor leukocytosis as above
.
# Pneumonia:
CXR on [**8-28**] showed LLL consolidation, no improvement from prior
study on [**8-25**]. Repeat CXR on [**8-30**] showed improving appearance of
the chest with no new consolidations.
- sputum gram stain with 1+ gram + cocci, 1+ GNR. Culture + for
klebsiella sensitive to zosyn
- completed Zosyn, 10 day course (ended [**2116-8-29**])
.
FEN
monitor K w/ diuresis important in light of prolonged QT, check
PM lytes
- repleted lytes as necessary
.
ENDOCRINE
# DM
now off insulin drip, on RISS
- monitor [**Last Name (LF) 13866**], [**First Name3 (LF) **] remain elevated due to infection/cardiac
stress/steroids
.
DISPO:
Followed by PT, to home once clinically stable. PT did not feel
pt was able to be d/c'd to home on [**9-5**] due to increased RR to
30s on ambulation. He will require VNA follow up to ensure med
compliance and free water restriction.
- f/u with PCP [**Last Name (NamePattern4) **] 1 week.
Medications on Admission:
Transfer med;
nitro drip
heparin drip
lasix 40 iv qd
Riss
solumedrol 80 iv q8
advair 500/50 [**Hospital1 **]
spiriva
zosyn 2.25 mg iv q6
advair
lipitor 80
asa 325
protonix 40
allopurinol 200 qd
morphine 2-4 mg iv q4hr prn
.
Home meds:
lisinopril 80 mg po qd (per osh recs)
Kcl 20 qd
allopurinol 200 mg po qd
atenolol 50 mg po qd
aspirin 81
norvasc 10
lasix 80
clonidine 0.1 mg qd
protonix 40 qd
lipitor 10
imdur 30 qd
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**11-25**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day) as needed
for shortness of breath or wheezing.
Disp:*1 Disk with Device(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: [**11-25**] Inhalation Q4H
(every 4 hours) as needed for shortness of breath or wheezing.
Disp:*1 * Refills:*2*
4. Ipratropium Bromide 0.02 % Solution Sig: [**11-25**] Inhalation Q6H
(every 6 hours) as needed for shortness of breath or wheezing.
Disp:*1 * Refills:*2*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. 1 Box Lancets
Use as directed.
No refills.
14. TrueTrack Glucometer
Dispense #1
15. TrueTrack Glucometer Strips
Dispense 1 box
16. BD Ultrafine Insulin Syringe
30 Unit Syringes
9 bags
17. Humulin R (10 ml bottle)
Dispense one bottle.
No refills.
18. INSULIN
Sliding scale:
Before breakfast if finger stick > 200 give 2 units of insulin.
Before lunch and dinner if finger stick 120-160 give 2 units, if
fingerstick > 160 give 4 units.
19. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
20. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
21. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
22. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnoses:
Non-ST elevated MI
COPD exacerbation
Atrial fibrillation
Pneumonia/klebsiella septicemia
Enterococcal urinary tract infection
Mild gastritis
.
Secondary diagnoses:
1)CAD
-MI in [**2112**], followed by planned PCI with DES to mid circ,
ramus, also showed 60% LAD disease
2)RAS
-stent to L RA in [**7-/2113**]
3)HTN
4)PUD
5)GIB
6)L knee replacement
7)Gout
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for chest pain, shortness of breath, and a
bacterial blood infection with fevers. You had a mild heart
attack and emphysema exacerbation that was treated with
steroids, nebulizers, and chest physical therapy. Your
pneumonia and blood infection were treated with antibiotics.
You were also found to have a urinary tract infection and
diarrheal infection which were treated with bactrim and flagyl,
respectively. You will need to take two more weeks of flagyl at
home.
.
You continued to have productive coughing blood-tinged sputum
that did not appear to come from the lungs, but more likely from
your nose or throat. You were transfused with blood to keep
your red blood cells at a stable level given your coronary heart
disease. You also had blood in your stools requiring
gastrointestinal evaluation with a upper GI scope study. It
showed mild inflammation of the stomach.
.
You had fluid in your lungs and lower extremities due to heart
failure and were given lasix, a diuretic to decrease your volume
overload. Your daily weights were monitored to track amount of
fluid retention in your body and effectiveness of lasix to
decrease it. Your fluid intake was restricted to no more than 1
liter per day and you were also placed on a low-salt, cardiac
healthy diet. These measures reduced the fluid retention
secondary to heart failure and improved your respiratory
function with decreased requirement for supplemental oxygen.
The same blood pressure medications you take at home were
restarted, which include lisinopril, norvasc and isosorbide.
.
You had new onset of a heart rhythm problem called atrial
fibrillation a week into your hospital stay and were placed on
diltiazem for rate control and amiodarone to maintain regular
rhythm. You had cardioversion within 24 hours of onset of atrial
fibrillation and your heart returned to [**Location 213**] sinus rhythm. You
were briefly placed on anticoagulation with heparin, a blood
thinner, to reduce the risk of clot formation due to atrial
fibrillation. You will continue the amiodarone and diltiazem
once discharged.
.
At home, you should take your medications as prescribed. You
will be setup with home VNA service to help with understanding
and remaining compliant with your medications, and monitoring
fluid status with regular weight checks given the heart failure.
.
Finally, you had high blood sugars, possibly because of the
steroids you were on. You will need to check your finger blood
sugar at home and keep a record of this. The visiting nurse
will help you with this.
.
You may need a treadmill stress test in the future to evaluate
your heart function during physical activity to determine
whether it receives enough oxygen. You cardiologist will
determine an appropriate time to do this assessment.
.
Please followup with your PCP and return to the ED if you
experience chest pain, shortness of breath, or increase in lower
extremity swelling.
Followup Instructions:
Please follow-up with your PCP for medical management. We spoke
with her and she said that her office will contact you to
schedule an appointment, if you do not hear from them by
Wednesday, please call her office.
.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 29557**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**]
Referring: [**Last Name (LF) 51722**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 3183**]
|
[
"428.0",
"491.21",
"535.41",
"599.0",
"041.04",
"584.9",
"428.30",
"401.9",
"280.0",
"V45.82",
"038.49",
"482.0",
"427.31",
"414.01",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"99.69"
] |
icd9pcs
|
[
[
[]
]
] |
12162, 12217
|
5068, 9162
|
324, 367
|
12634, 12643
|
2548, 3121
|
15630, 16059
|
1978, 1996
|
9630, 12139
|
12238, 12400
|
9188, 9607
|
12667, 15607
|
2011, 2529
|
12421, 12613
|
274, 286
|
395, 1695
|
1717, 1908
|
1924, 1962
|
3138, 5045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,753
| 177,003
|
25949
|
Discharge summary
|
report
|
Admission Date: [**2185-12-8**] Discharge Date: [**2185-12-24**]
Date of Birth: [**2150-12-8**] Sex: M
Service: SURGERY
Allergies:
Unasyn / Penicillins
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Motor Cycle Crash
Major Surgical or Invasive Procedure:
[**2185-12-8**] Exploratory Lap with Colostomy; Rectal wound irrigation
[**2185-12-8**] ORIF Right femur
[**2185-12-8**] Flexible cystoscopy with foley catheter insertion
[**2185-12-10**] ORIF right wrist
[**2185-12-12**] IVC filter placement
[**2185-12-14**] ORIF Pelvic fracture
History of Present Illness:
35 yo male driver s/p motor cycle crash; found ~60 feet away
from motorcycle, unconscious. Intubated at scene; blood pressure
60's. Patient briefly taken to referring facility for blood
tansfusion and was transferred via [**Location (un) 7622**] to [**Hospital1 18**] for trauma
care.
Past Medical History:
Hyperlipidemia
h/o previous Motorcycle crash x2
Social History:
Employed as an auto mechanic
Quit tobacco
Denies Etoh or illicit drug use
Family History:
Noncontributory
Physical Exam:
VS upon admission to trauma bay:
T 98 BP 119/80 HR 118
GEN: intubated
HEENT: TM's clear, laceration on nose
Pertinent Results:
[**2185-12-8**] 10:06PM TYPE-ART PO2-99 PCO2-41 PH-7.34* TOTAL CO2-23
BASE XS--3
[**2185-12-8**] 10:06PM GLUCOSE-120* LACTATE-3.3* NA+-142 K+-4.3
CL--113*
[**2185-12-8**] 10:06PM HGB-11.6* calcHCT-35 O2 SAT-97
[**2185-12-8**] 08:25PM PLT COUNT-124*
[**2185-12-8**] 08:25PM PT-13.6* PTT-29.1 INR(PT)-1.2
[**2185-12-8**] 05:45PM WBC-15.2* RBC-4.50* HGB-14.0 HCT-37.7* MCV-84
MCH-31.2 MCHC-37.2* RDW-13.8
[**2185-12-8**] 03:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Imaging:
PELVIS IMPRESSION:
1. Right dorsally angulated femoral neck fracture without
femoral head dislocation.
2. Comminuted fracture of the right superior ramus and
nondisplaced fracture of the inferior ramus.
3. Extensive subcutaneous, intramuscular, and extraperitoneal
pelvic emphysema.
4. Partial reduction of prior pubic symphysis diastasis and
persistent right sacroiliac joint diastasis.
.
Head CT negative.
.
EEG, IMPRESSION: This is a mildly abnormal EEG due to the
presence of
intermittent mixed frequency theta slowing along with
generalized bursts
of theta slowing. No sharp or epileptiform features were
observed.
These findings are consistent with a mild encephalopathy. Common
causes
of encephalopathy include medications, metabolic causes, and
infectious
processes.
.
MRI, IMPRESSION: Two small areas of diffusion abnormality with
associated signal changes in FLAIR and gradient-echo as
described. Possibilities include axonal injury or small
nonvascular territory infarcts.
.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedics, Urology,
Plastic Surgery all were consulted initially because of
patient's injuries. He was immediately taken to the operating
room for exploratory lap with colostomy and irrigation of rectal
tear. Orthopedics placed external fixator to pelvic fracture;
ORIF of right femoral neck fracture performed. Intraoperative
Vascular Surgery consult obtained because of cold right foot. An
arteriogram was performed, findings revealed no arterial injury.
Urology consulted intraoperatively as well, flexible cystoscopy
performed and revealed normal urethra and no evidence traumatic
injury; a foley catheter was subsequently placed.
.
The remainder of Mr [**Known lastname 64519**] hospital course was largely
unremarkable; he was extubated without complication [**2185-12-16**] and
transferred to the floor. He experienced episodic agitation and
some mental status changes attributed to Haldol. Pt is
maintained on Olanzapine for agitation at this time, and haldol
should be avoided.
.
Mr [**Known lastname **] also had transiently increased LFTs which upon
discharge were trending down, but he will need follow up for
this with his primary care doctor. In addition, he developed an
asymptomatic thrombocytosis which will need to be followed as an
outpatient. He will be NWB for 6 weeks.
Medications on Admission:
None.
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
2. Fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever/pain.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing.
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Hold for increased sedation.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
s/p Motor Cycle Crash
Pelvic fracture
Right wrist fracture and median nerve entrapment
Right femur fracture
Left renal laceration
Rectal tear
Discharge Condition:
Stable
Discharge Instructions:
*DO NOT BEAR ANY WEIGHT ON EITHER LOWER EXTREMITY FOR THE NEXT 6
WEEKS
*Continue with your Lovenox injections until follow up with
Orthopedics.
*Follow up with Othopedics, Behavioral Neurology and Plastic
Surgery
*Follow up with your primary doctor after your discharge from
rehab
Followup Instructions:
Call for an appointment with Dr. [**Last Name (STitle) 1005**], Orthopedics
[**Telephone/Fax (1) 1228**]. You will need to be seen in 2 weeks.
.
Call for an appointment with Plastic Surgery Hand Clinic
[**Telephone/Fax (1) 4652**]. You will need to be seen in 2 weeks.
.
Call for an appointment with Dr. [**First Name (STitle) **], Neurology
[**Telephone/Fax (1) 1690**]. You will need to be seen in [**1-28**] weeks.
.
You will also need to follow up in the [**Hospital1 18**] Trauma Clinic
within 2 weeks ([**Telephone/Fax (1) 2007**], and we recommend you also follow
with your primary care doctor in [**12-30**] weeks.
|
[
"518.5",
"354.0",
"866.02",
"820.8",
"693.0",
"E816.2",
"958.7",
"863.45",
"808.3",
"883.0",
"E930.0",
"850.9",
"821.01",
"879.7",
"814.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.32",
"88.48",
"96.6",
"86.28",
"54.11",
"03.31",
"79.35",
"79.33",
"79.39",
"38.7",
"78.19",
"86.59",
"81.79",
"46.03",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5091, 5149
|
2778, 4112
|
303, 586
|
5335, 5344
|
1241, 2755
|
5676, 6302
|
1078, 1095
|
4168, 5068
|
5170, 5314
|
4138, 4145
|
5368, 5653
|
1110, 1222
|
242, 265
|
614, 900
|
922, 971
|
987, 1062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,213
| 138,069
|
52405
|
Discharge summary
|
report
|
Admission Date: [**2202-8-20**] Discharge Date: [**2202-8-23**]
Date of Birth: [**2168-10-6**] Sex: F
Service: MEDICINE INTENSIVE CARE UNIT
CHIEF COMPLAINT: Diabetic ketoacidosis.
HISTORY OF PRESENT ILLNESS: Patient is a 33-year-old woman
with a history of insulin dependent-diabetes mellitus type 1,
complicated by gastroparesis and also history of frequent
admissions for repeated diabetic ketoacidosis and poor
compliance with medical followup presenting with nausea and
vomiting. The patient was recently admitted for diabetic
ketoacidosis and discharged on [**2202-8-13**] from the Medicine
Intensive Care Unit. At that time, she had also
guaiac-positive emesis.
In the Emergency Department, she was found to have initially
a fingerstick of 299. She stated she had taken her evening
dose of Lantus which is 16 units. In the Emergency
Department, she received 2 liters of normal saline, Lantus 20
units, Humalog insulin 10 units x1, and then was started on
an insulin drip at 5 units an hour. She also received Zofran
and Reglan with mild improvement in her nausea. Her second
fingerstick was 316 and then 327. Her anion gap increased
from 16 to 25 with standing therapy with IV fluids and
insulin drip during a three hour span.
Patient was therefore, transferred to the Intensive Care Unit
for further management of her diabetic ketoacidosis. The
patient denied any recent fever, chills, abdominal pain,
chest pain, cough, shortness of breath, diarrhea, dysuria, or
increased vaginal discharge. She had an appointment on the
day that she presented to the Emergency Department, which she
missed because she claims she was having nausea and vomiting.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes type 1 since age 8.
2. Gastroparesis.
3. Hypertension.
4. Asthma.
5. Chronic renal failure with creatinine baseline at 1.5-2.0.
6. Status post [**Doctor First Name **]-[**Doctor Last Name **] tear.
7. Hyperlipidemia.
8. Neuropathy.
9. Left ventricular hypertrophy.
MEDICATIONS:
1. Lantus 20 units q.p.m.
2. Humalog sliding scale.
3. Protonix 40 mg p.o. q.d.
4. Zestril 30 p.o. q.d.
5. Atenolol 50 p.o. q.d.
6. MVI.
7. Nitroglycerin prn.
8. Nicotine patch.
ALLERGIES:
1. Aspirin which causes tongue swelling.
2. Beef and pork insulin.
3. Compazine.
4. Codeine.
5. Barium dye.
SOCIAL HISTORY: The patient has a tobacco history of 10 pack
years. She currently smokes a half a pack a day. She denies
any alcohol use or abuse, and any IV drug abuse. She lives
with her fiancee and her four daughters at ages 17, 13, 7,
and 2.
PHYSICAL EXAM ON ADMISSION: Temperature 99.1, pulse 93,
blood pressure 178/94, oxygen saturation 100% on room air
with a respiratory rate of 17. General appearance: Lying in
bed, moaning and complaining when approached. HEENT: Moist
mucosal membranes, EOMI. Neck is supple, no LAD, and no
thyromegaly. Heart: Regular, rate, and rhythm, S1, S2,
there is a 3/6 systolic murmur and [**1-7**] diastolic murmur.
Lungs are clear to auscultation bilaterally. No wheezes,
crackles, or rhonchi. Abdomen is soft, nontender,
nondistended with no hepatosplenomegaly and with some active
bowel sounds. Extremities: No edema. Dorsalis pedis are
palpable bilaterally. There were several skin lesions
suggesting of previous scarring. Neurologic: Is alert and
oriented times three.
LABORATORIES ON ADMISSION: Chem-7 is sodium 144, potassium
3.6, chloride 102, bicarb 17, BUN 48, creatinine 2.2, glucose
327 with a gap of 25, acetone large. White count 12.2,
hematocrit 29.3, platelets 596. ABG was 7.38, 34, 98, 21.
ALT 12, AST 16, LD 180, alkaline phosphatase 201, amylase
121, lipase 47.
EKG: Normal sinus rhythm at 82, normal axis, normal
intervals, no ST elevations or depressions. There is a U
wave in leads V2, V3, and V4.
BRIEF HOSPITAL COURSE: Patient is a 33-year-old woman with
insulin dependent diabetes complicated by gastroparesis and
multiple admissions for diabetic ketoacidosis, who presented
with nausea and vomiting, and was found to be in diabetic
ketoacidosis.
Diabetic ketoacidosis: Upon arrival to the SICU, her
fingerstick was 67, her gap was 25, and her pH was 7.38. Her
IV fluids were switched to D5 normal saline and after 1 liter
to D5 [**12-3**] normal saline, she required 3 liters before her gap
would close. She was continued on the insulin drip. After
18 hours, her gap had closed, however, she was still not able
to take any p.o. because of her underlying nausea. She was
transferred to the floor on the insulin drip with a
requirement of q1h fingerstick and because of her requirement
for her high level of care, she was transferred back to the
Intensive Care Unit [**Unit Number **] hours after.
Her electrolytes remained within normal limits and her gap
also remained normal between 12 and 9. She eventually became
able to tolerate p.o. She was advanced on a solid diabetic
diet. Her IV fluids were stopped, and she was transitioned
to regular insulin 4 units q.6h.
Myocardial infarction as a possible trigger for the event of
diabetic ketoacidosis was ruled out by cycling her cardiac
enzymes which remained negative 12 hours apart. A urinalysis
was also checked given her history of previous UTI and was
found to be abnormal.
Urinary tract infection: The patient was found to have a UTI
with many white blood cells and bacteria in her urine. Urine
culture is still pending at the time of her discharge. She
was, however, started on levofloxacin 250 mg p.o. q.d. and
will be continued for a total seven day course.
Right foot ulcer: The patient has a chronic right foot
ulcer. At the time of admission, the ulcer did not look
erythematous or actively draining pus. The ulcer was treated
with wet-to-dry dressings and she will follow up with Dr.
[**Last Name (STitle) **], who is her podiatrist.
Hypertension: Patient was restarted on her outpatient
medications, which were documented as lisinopril and
atenolol, however, she claimed were lisinopril and Lopressor.
Occasionally, her blood pressure remained elevated in the
170-180 and she required Lopressor 5 mg IV especially given
the fact that she was probably not absorbing the p.o.
Noncompliance and recurrent admissions: Given her history of
recent multiple admissions for diabetic ketoacidosis, the
question of poor social support, and the question was raised,
Psychiatry team was called to evaluate the patient. They
also contact[**Name (NI) **] her mother, and they agreed that patient
probably needed more social support. However, at this point,
she has a social worker involved in her case especially with
her [**Hospital1 **] care, and they do not find her to be
depressed.
Gastroparesis: The patient claimed that Reglan did not help
with her gastroparesis. I contact[**Name (NI) **] Gastroenterology
fellows, who did not have any additional suggestions and
recommended to contact Dr. [**Last Name (STitle) **]. I have emailed Dr. [**Last Name (STitle) **],
and I am waiting for his suggestions. I will e. mail the
suggestion to the patient's primary care doctor, who is Dr.
[**Last Name (STitle) **].
DISPOSITION: The patient was discharged home, where she will
restart her Lantus 20 units IV q.p.m. and Humalog sliding
scale.
FOLLOW-UP INSTRUCTIONS: She will follow up with Dr. [**First Name4 (NamePattern1) 2398**]
[**Last Name (NamePattern1) **] at the [**Last Name (un) **] and with her primary care physician, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DISCHARGE MEDICATIONS:
1. Lantus 20 units q.p.m.
2. Humalog insulin-sliding scale.
3. Lisinopril 30 mg p.o. q.d.
4. Lopressor 25 p.o. b.i.d.
5. Levofloxacin 250 mg p.o. q.d. for four days.
DISCHARGE STATUS: Good.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 19227**]
MEDQUIST36
D: [**2202-8-23**] 14:14
T: [**2202-8-23**] 14:24
JOB#: [**Job Number 108295**]
|
[
"403.91",
"355.9",
"493.90",
"707.15",
"599.0",
"272.0",
"250.13",
"536.3",
"429.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3831, 7239
|
7552, 8023
|
179, 203
|
232, 1690
|
3381, 3807
|
7264, 7529
|
1712, 2320
|
2337, 2585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,034
| 157,954
|
32727
|
Discharge summary
|
report
|
Admission Date: [**2170-2-8**] Discharge Date: [**2170-2-14**]
Date of Birth: [**2116-4-16**] Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived / Corn / Tomato / Bean Pod / Onion / Nut
Flavor
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 year old gentleman with a history of melanoma and asthma
presented to OSH ED on [**2170-2-8**] with complaint of seven days of
dyspnea. Had initially seen PCP with this complaint one week
ago. Described feeling short of breath with exertion. Believed
he was having pneumonia which he has had twice before. No
fevers or chillls, only a mild non-productive cough. At PCP
office, x-ray and laboratories were normal. He tried taking his
albuterol inhaler more often and, though this resulted in some
relief, his symptoms worsened. He returned to PCP [**Name9 (PRE) 76262**]
this time he could only walk a couple steps before feeling
dyspneic. At the office an EKG revealed inverted T waves. He
was then taken by ambulance to [**Hospital6 33**] ED.
Reportedly hemodynamically stable on presentation. A D-dimer
was elevated. A CT torso was performed and revealed saddle
embolus and multiple segmental PE. Aspirin, plavix were given
along with a heparin bolus of 5,000 units and drip at 1000 units
an hour. CK, CK-MB and troponin T normal.
Patient was subsequently transferred to [**Hospital1 18**] where, in ED, HR's
80 BP 117/86 O2 96 on 2L. PTT 52.2 on presentation Heparin
re-bolused and dose adjusted to 1500 units/hour. Pt
subsequently admitted to MICU.
Currently, patient is without complaints. He does say he feels
he will get dyspneic if he tries to move.
On review of systems, the patient denies chest pain. He says he
gets lower leg cramps intermittently over several years. No
recent travel or prolonged period of immobilization. No trauma.
No weight loss or anorexia recently.
Past Medical History:
1) Melanoma. S/p excision of melanoma on L arm.
2) Multiple food allergies--result in anaphylactic reaction. Pt
carries epi-pen.
3) Asthma, uses albuterol occasionally
4) Esophageal stricture, has undergone dilatation twice, most
recently in 3/[**2169**].
5) Status post excision of colon polyps. Reportedly not
malignant
6) Family hx of clotting disorders
Social History:
Married, three grown children. Works as warehouse manager. No
history of tobacco use. Occasional alcohol use on social
occasions.
Family History:
Parents with no known medical conditions. On maternal side,
multiple relatives with malignancies including melanoma, lung
cancer, colon cancer, ovarian and breast cancer.
Pt recently learned (during hospitalization) that he has a
family history of clotting disorders with at least 3 relatives
with medically recognized clot. Of note, he had an uncle who
passed away from a pulmonary embolism.
Physical Exam:
T 98.9; BP 124/87; P 84; RR 24; O2% 94 on 2L
Gen: WD/WN male Caucasian, diaphoretic appearing. Alert,
pleasant.
Head: NCAT
Mouth: MMM
Neck: JVP to 7 cm, no HJR
Chest: Lungs with decreased breath sounds on R. No heave.
Cor: RR, nl S1S2, no murmur, rub, gallop.
Abd: Non-tender
Ext: Negative Homans sign, no cords. Nl distal pulses. No edema.
Neurol: Alert, moves all extremities.
Skin: Diaphoretic.
Pertinent Results:
BILAT LOWER EXT VEINS [**2170-2-9**] 4:24 PM: Partially occlusive
thrombus within the left popliteal vein which does not appear to
extend proximally into the superficial femoral vein.
.
EKG: Sinus rhythm. Compared to the previous tracing of [**2169-2-9**]
no significant change in previously noted inferior and anterior
T wave abnormalities and lateral ST-T wave changes. Clinical
correlation is suggested.
.
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%). The right
ventricular cavity is moderately dilated. There is severe global
right ventricular free wall hypokinesis. There is abnormal
systolic septal motion/position consistent with right
ventricular pressure overload. There is no mass/thrombus in the
right ventricle. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated right ventricle with severe global systolic
dysfunction and signs of acute pulmonary hypertension. Preserved
left ventricular size and systolic function.
.
Labs on admission:
[**2170-2-8**] GLUCOSE-106* UREA N-16 CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
[**2170-2-8**] WBC-9.1 RBC-5.12 HGB-15.3 HCT-44.3 MCV-87 MCH-29.8
MCHC-34.5 RDW-13.7 // NEUTS-57.3 LYMPHS-32.5 MONOS-4.9 EOS-3.9
BASOS-1.3
[**2170-2-8**] PLT COUNT-317
[**2170-2-8**] PT-14.1* PTT-52.2* INR(PT)-1.2*
[**2170-2-8**] CK-MB-NotDone cTropnT-<0.01 proBNP-853*
[**2170-2-8**] CK(CPK)-97
.
On discharge his INR was 4.4 ([**2-14**])
Brief Hospital Course:
Assessment/Plan: 53 year old gentleman with a history of
melanoma and asthma presents with dyspnea on exertion and is
found to have pulmonary saddle embolus. Hemodynamically stable,
mild hypoxia. Transferred from OSH for further management.
.
1) Pulmonary embolic disease. The patient was transferred to
[**Hospital 18**] medical ICU after CT Chest at OSH showed a saddle embolus
and multiple segmental PEs. He was hemodynamically stable on
admission (and throughout his hospital course) and was placed on
a heparin drip. Cardiac enzymes were trended and found to be
normal. He had an echocardiogram which showed signs of right
heart strain, consistent with his diagnosis of PE. He received
supplemental oxygen. After a short period of observation in the
ICU, he was transferred to the medicine floor. At that time he
had significant improvement in his dyspnea and after 2 days no
longer required supplemental oxygen and was able to ambulate the
corridors while maintaining on O2 sat of >90% on room air. He
was started on warfarin on [**2-10**] and received two days of 10mg,
then one day of 5mg. On [**2-13**] his INR was 4.9 and his dose was
held. After a total of 5 days of IV heparin and an overlap of at
least 48 hours of a therapeutic INR, his heparin drip was
discontinued on [**2-14**] and he was discharged with instructions to
take 5mg Coumadin on the day of discharge. He was established
with the [**Hospital 191**] [**Hospital3 **] and will get his INR checks
in [**Location (un) 3320**] at [**Hospital3 3583**] which is closer to home.
Of note, while he was in the hospital he learned that he had
multiple family members in [**Name (NI) 4754**] with medical history of
clotting disorders and in particular had an uncle who passed
away from a pulmonary embolism. As a result of this he would
benefit from a hereditary coagulopathy workup as an outpatient.
.
2) Food allergies. Pt reports fairly recent hx of new food
allergies resulting in anaphylaxis. An EpiPen was maintained at
bedside, but the patient did not have any allergic reactions
during his hospitalization. He reports that he has 3 EpiPens at
home and carries one with him at all times.
.
3) History of melanoma. The patient reports having a small
melanoma excised 2 years ago, would benefit from outpatient
follow-up.
Medications on Admission:
Albuterol inhaler prn
Discharge Medications:
1. Outpatient Lab Work
Please test PT/INR and fax results to [**Hospital 191**] [**Hospital3 **]
at fax # [**Telephone/Fax (1) 3534**]
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia for 10 doses.
Disp:*10 Tablet(s)* Refills:*0*
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take 1-2 tablets as directed at 4pm .
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1.) Pulmonary Embolism
2.) Deep Venous Thrombosis
Discharge Condition:
afebrile, displaying normal vital signs, tolerating a regular
diet, ambulating with O2 sats > 90%
Discharge Instructions:
You were admitted to the hospital for shortness of breath and
found to have a blood clot in your lungs called a pulmonary
embolism. The likely source was from a clot that had developed
in your left leg. You were monitored in the ICU for a short time
and then to the medicine floor. You were treated with IV heparin
and then Coumadin prior to discharge. You were also weaned off
of oxygen. You will need to have frequent blood draws at first,
starting on Thursday at the lab at [**Hospital3 3583**] (phone
[**Telephone/Fax (1) 76263**]). Because of your family history of clotting
disorders you should talk with Dr. [**Last Name (STitle) **] upon discharge regarding
a work-up for an inherited cause.
.
You should continue to take your albuterol inhaler as you need
it and keep your EpiPen with you at all times in the event of an
allergic reaction. You should take your Coumadin daily at
approx. 4pm, and have your Coumadin level checked and adjust
your dose as instructed by the [**Hospital 191**] [**Hospital3 **]. On
the day of discharge (Wednesday [**2-14**]) you should take a
total of 5mg of Coumadin, then do as instructed by the [**Hospital 191**]
[**Hospital3 **] after you get your INR checked on
Thursday.
.
If you experience new shortness of breath, chest pain, leg pain,
an allergic reaction, throat tightness, blood in your urine or
stool, easy bruising, any new bleeding, or if your condition
worsens in any way, seek immediate medical attention.
Followup Instructions:
You should have your blood drawn at [**Hospital3 3583**] on Thursday,
[**2-15**].
.
You have a follow-up appointment with Dr. [**Last Name (STitle) **] on [**2-21**] at
3pm.
.
Provider: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2170-2-21**] 3:00
|
[
"415.19",
"530.3",
"493.90",
"V10.82",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8200, 8206
|
5310, 7607
|
333, 339
|
8309, 8409
|
3358, 4818
|
9919, 10287
|
2528, 2923
|
7679, 8177
|
8227, 8288
|
7633, 7656
|
8433, 9896
|
2938, 3339
|
286, 295
|
367, 1979
|
4832, 5287
|
2001, 2362
|
2378, 2512
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,321
| 197,549
|
40731
|
Discharge summary
|
report
|
Admission Date: [**2114-6-5**] Discharge Date: [**2114-6-19**]
Date of Birth: [**2047-11-24**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
wound drainage
Major Surgical or Invasive Procedure:
Aspiration of right frontal CSF collection [**6-8**], [**6-9**], [**6-11**]
History of Present Illness:
This is a 66 year old man who underwent craniotomy for resection
of
frontal tumor on [**2114-4-27**]. He had been doing well but for two
weeks he has noticed drainage on his pillow when he awakes in
the morning. His wife also noted a fluid collection for about
one week. He has had no fevers and there is no erythema along
his incision.
Past Medical History:
HLD
Hypothyroidism
Seizures
Craniotomy for tumor
Social History:
Past tobacco use (1 ppd x 34 years, quit 20 years
ago). Drinks vodka nightly. Denies illicit drug use. Manages a
landscaping firm. Married and lives with his wife.
Family History:
No seizures. CAD (mother). Prostate cancer
(father, died at age 60). COPD (brother, died at age 65).
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs Full
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-9**] throughout. No pronator drift
Sensation: Intact to light touch
Wound-Fluctuant R frontal fluid collection. No erythema or
active
drainage. Small area of scabing with granulation tissue present.
On Discharge:
GEN: elderly male sitting in bed in NAD
HEENT: healing R frontal fluid collection, minimally
erythematous.
CV: RRR
PULM: CTAB
ABD: soft, NT, ND
EXT: trace peripheral edema at ankles bilaterally
NEURO:
MS - AAOx3, can follow commands, language is intact
CN - PERRL 3->2, EOMI, tongue midline, face symmetrical, facial
sensation intact
MOTOR - [**5-10**] in bilateral IPs, otherwise [**6-9**] throughout. Mild R
pronator drift
SENSATION - intact to light touch throughout
Pertinent Results:
[**6-5**] CT head noncontrast: 1. New subgaleal fluid collection in
the scalp overlying the right craniotomy site.
2. Post-right frontal lobectomy, with resolved post-operative
pneumocephalus. No superimposed acute intracranial process
detected.
[**2114-6-6**] CXR
As compared to the previous radiograph, the patient has received
a
right pectoral Port-A-Cath. The Port-A-Cath is in correct
position. There
are no complications, notably no pneumothorax.
Otherwise, the radiograph is unchanged. No acute lung
parenchymal changes. No pleural effusions. No pneumonia, no
pulmonary edema. Normal hilar and mediastinal contours, normal
size of the cardiac silhouette.
[**2114-6-7**] CSF cytology
NEGATIVE FOR MALIGNANT CELLS.
[**2114-6-8**] CXR
The right Port-A-Cath is again visualized. There is no
pneumothorax. There is a new area of opacity in the left lower
lung that
could represent volume loss or infiltrate. Small amount of
volume loss in the right lower lung as well. Overall, the
appearance has worsened compared to the study from two days
prior
[**2114-6-9**] CT head
1. Unchanged size of a subgaleal fluid collection communicating
with the
epidural space, however, neighboring increased soft tissue
swelling is
present.This may represent a pseudomeningocele.
2. Post-right frontal craniotomy changes. No superimposed acute
intracranial process detected. No new mass effect.
[**2114-6-9**] CT head
Unchanged appearance of a right frontal
pseudomeningocele/extra-axial fluid collection. There is
expected mild enhancement of the overlying subcutaneous soft
tissues, with some stranding and swelling posteriorly. No
abnormal intracranial enhancement is detected. While no
definite signs of an abscess are seen, infection/inflammation of
this
collection cannot be excluded by imaging alone.
[**2114-6-11**] ECG
Sinus tachycardia, rate 106. Left atrial abnormality. The
tracing is
otherwise, within normal limits
[**2114-6-11**] CT head
Stable to slightly decreased right frontal extra-axial fluid
collection, with minimally increased size of right frontal
subgaleal fluid
collection.
[**2114-6-11**] CTA chest
Tiny, non-occlusive, marginal, filling defects in the
subsegmental branches of right upper and left lower lobe are
likely small pulmonary emboli, not necessarily acute. No
evidence of emboli in main, lobar, and segmental branches.
[**2114-6-12**] CXR
In comparison with study of [**6-8**], there is a little overall
change.
Continued opacification at the left base with poor visualization
of the
costophrenic angle is consistent with atelectatic changes in the
left lower lobe and possibl small effusion. No vascular
congestion or acute focal pneumonia. Port-A-Cath position is
unchanged.
[**2114-6-12**] LE US
No evidence of deep vein thrombosis in either leg
[**2114-6-13**] CXR
Cardiac size is top normal accentuated by low lung volumes. Left
lower lobe atelectasis has improved. There is mild vascular
congestion. There is no pneumothorax. Right Port-A-Cath tip is
in unchanged position. There are no enlarging pleural effusions.
[**2114-6-15**] CXR
REASON FOR EXAM: Fever and low saturations.
Cardiac size is top normal. The lungs are clear. There is no
pneumothorax or pleural effusion. The right Port-A-Cath tip is
in the right atrium, which is difficult to visualize.
ADMISSION LABS:
[**2114-6-5**] 07:30PM BLOOD WBC-5.3 RBC-4.16* Hgb-13.3* Hct-40.3
MCV-97 MCH-32.0 MCHC-33.0 RDW-13.4 Plt Ct-260
[**2114-6-5**] 07:30PM BLOOD PT-10.6 PTT-26.9 INR(PT)-1.0
[**2114-6-5**] 07:30PM BLOOD ESR-21*
[**2114-6-5**] 07:30PM BLOOD Glucose-151* UreaN-20 Creat-0.9 Na-141
K-4.0 Cl-101 HCO3-29 AnGap-15
[**2114-6-5**] 07:30PM BLOOD Calcium-9.3 Phos-4.5# Mg-2.2
[**2114-6-5**] 07:30PM BLOOD CRP-1.6
Brief Hospital Course:
Mr. [**Known lastname 89057**] was admitted from clinic on [**6-5**] for draining right
craniotomy site. CT head demostrated a large subgaleal fluid
collection. Aspiration of the collection was performed on [**6-7**] at
the bedside in a sterile fashion. He head was wrapped with
Coban. The gram stain showed no poly's and no organisms. On 5.4
the colelction had reaccumulated so ti was again tapped and the
fluid was sent. the head was then wrapped again. the fluid
showed 2+ GPCs in clusters and staph aureus. He was started on
vancomycin and ceftaz and ID was consulted. His mental status
declined and his head wrap was loosened.
On [**6-9**] he was febrile to 102 and he was panculutred. He had a
head CT with adn without contrast which showed no suigns of
infection but persistent fluid collection. On 5.6 he had
periorbital edema and a vanomycin rough of 15. He had blood
cultures sent as well and his vancomycin was discontinued and he
was started on Nafcillin.
On [**6-11**] his O2 sats decreased to the 80's, was febrile to 102
axillary, and tachycardic to 117. He had a CTA chest and head CT
and was sent to the unit. Prelim reads of his CTA chest showed
PE so he was started on a heparin gtt. Final read of the CTA
Chest showed RUL and LLL subsegmental non-occlusive PE likely
subacute/chronic. On [**6-12**] his exam was improved and had LENIS
which were negative and his heparin gtt was stopped.
On [**6-13**] and [**6-16**] he was neurologically stable on Q2 hr neuro
check. He had some intermittent delirium. He was on nafcillin
per the ID team.
On [**6-19**] the ID team recommended adding rifampin to pt's ABx
regimen. He was given one dose in house and tolerated it well.
He was set up with ID follow-up appointments, and they will
determine the end of his ABx course for the rifampin and
nafcillin. He will be discharged to rehab. he was given
instructions for followup.
PENDING RESULTS:
CSF acid fast stain [**2114-6-12**]
Medications on Admission:
1. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 12hrs ().
2. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
12. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
13. Nafcillin 2 g IV Q4H mssa infection per ID
14. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
CSF collection
Fever
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your wound daily for signs
of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Please contact your doctor or go to the nearest Emergency Room
if you experience any of the below listed Danger Signs.
We made the following changes to your medications:
1) We STARTED you on OXYCODONE 5-10mg every 6 hours as needed
for pain.
2) We STARTED you on TYLENOL 325-650mg every 6 hours as needed
for pain.
3) We STARTED you on BISACODYL 10mg once a day as needed for
constipation.
4) We STARTED you on DOCUSATE 100mg twice a day to help prevent
constipation.
5) We STARTED you on SENNA 8.6mg twice a day as needed for
constipation.
6) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three
times a day to prevent a DVT while you are in rehab. You should
not need to take this medication when you go home from rehab.
7) We STARTED you on NAFCILLIN. You will continue to take this
until your infectious disease doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] to stop.
8) We STOPPED your DEXAMETHASONE because of your infection.
Dexamethasone may be restarted by your neuro-oncology doctors in
the future.
9) We STARTED you on RIFAMPIN 300mg every 8 hours. You will
continue this until your infectious disease doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] to
stop.
Please continue to take your other medications as previously
prescribed.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need an MRI of the brain with and without contrast.
Dr.[**Name (NI) 9034**] secretary can help you make this appointment.
Please call [**Telephone/Fax (1) 1844**] (Brain [**Hospital 341**] Clinic) to arrange for an
appointment with neuro-oncology after you have your MRI in 4
weeks.
Please contact the [**Hospital **] clinic alter this week at ([**Telephone/Fax (1) 4170**]
to get your follow up appointment information. They will be
setting this up however it was not finalized at the time of
discharge.
Completed by:[**2114-6-19**]
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70,393
| 111,964
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55078+59645
|
Discharge summary
|
report+addendum
|
Admission Date: [**2172-9-27**] Discharge Date: [**2172-10-22**]
Date of Birth: [**2124-5-25**] Sex: M
Service: SURGERY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 14255**]
Chief Complaint:
Acute Fulminant Liver Failure
Major Surgical or Invasive Procedure:
[**2172-9-30**]: Orthotopic liver transplant
History of Present Illness:
Patient is a 48M with h/o mental retardation, seizures and
previous MV repair in [**5-1**] who had two witnessed GTC seizures
while at his group home. He was promptly sent to an OSH. En
route
he received 4.5 mg of versed. His dilantin level was 8 so he was
loaded with dilantin (1.4g) and 2L NS. He was noted to be
febrile
at 101.2 and was given gentamycin (has prosthetic mitral valve).
On the evening of admission ([**9-25**]) WBC was 20.8 his liver
enzymes
were mildly elevated (ALT 51, AST 57, AP 150, TB 0.7) but
progressively rose over the next 24 hours to ALT [**2173**], AST 2400,
AP 117, TB 2.9 DB 1.8. His INR was noted to be INR 4.2. His
lactate had fallen from 6.2 on admission to 2.9.
Dilantin level was 26 (after bolus). Both Acetaminophen and
Salicylate levels were less than 10. CPK was elevated at 2564.
Troponin I was 0.50 and rose to 2.74. Creatinine was elevated at
1.6 but trended down to 1.16 (BUN 22).
He was noted to be lethargic with slurred speech. DDx was
post-ictal and/or encepalopathy [**2-27**] liver failure. An U/S was
performed showing "hepatitis but no clotting". He was started on
IV NAC.
He was transferred to [**Hospital1 18**] for further eval of his liver
failure. Upon arrival he is accompanied by staff from his group
home. The patient is responsive, knows he is at a hospital, and
is c/o thirst. Per his caretaker, this is his baseline. He will
interact with others but really is unable to verbalize much. His
speech is more slurred than usual and he appears more fatigued
since his seizure.
Based on his labs, he is a Child Class B, MELD of 25.
Past Medical History:
Mitral valve prolapse, hypothyroidism, cerebral AVM (per
OSH notes, patient had abnormal CTOH in [**2163**] but since then all
others WNL. ? embolic CVA from mitral valve?), cholelithiasis,
anxiety, Lyme disease, mental retardation
PShx: MV replacement [**5-1**] (Bovine)
Social History:
Lives in group home, elderly mother involved with decisions
[**Name (NI) **] [**Name (NI) **], mother: [**Telephone/Fax (1) 112398**]
Group Home: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Ctr [**Telephone/Fax (1) 112399**], Case [**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Doctor First Name 112400**] Tevares
Family History:
Unknown
Physical Exam:
PE: 99.5, 120 (ST), 124/78, 23, 95RA
[**Last Name (LF) **], [**First Name3 (LF) 2995**] X 4, will obey some commands
no carotid bruits
tachycardic, systolic/diastolic murmur heard best in LUSB
CTAB
Soft NT, mildly distented, +BS
no c/c/e
Pulses palp (radial, femoral, DP b/l)
Pertinent Results:
[**2172-10-21**] 05:40AM BLOOD WBC-9.1 RBC-3.20* Hgb-10.4* Hct-32.0*
MCV-100* MCH-32.7* MCHC-32.7 RDW-18.8* Plt Ct-243
[**2172-10-22**] 06:20AM BLOOD WBC-8.4 RBC-3.39* Hgb-11.0* Hct-33.2*
MCV-98 MCH-32.5* MCHC-33.2 RDW-19.1* Plt Ct-231
[**2172-10-19**] 06:05AM BLOOD PT-12.8* PTT-29.1 INR(PT)-1.2*
[**2172-10-21**] 05:40AM BLOOD Glucose-132* UreaN-39* Creat-0.7 Na-132*
K-5.1 Cl-101 HCO3-23 AnGap-13
[**2172-10-22**] 06:20AM BLOOD Glucose-148* UreaN-40* Creat-0.9 Na-133
K-4.6 Cl-99 HCO3-22 AnGap-17
[**2172-10-20**] 05:10AM BLOOD ALT-114* AST-33 AlkPhos-172* TotBili-2.3*
[**2172-10-21**] 05:40AM BLOOD ALT-103* AST-44* AlkPhos-175*
TotBili-2.3*
[**2172-10-22**] 06:20AM BLOOD ALT-100* AST-44* AlkPhos-176*
TotBili-2.1*
[**2172-10-22**] 06:20AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.5*
[**2172-9-27**] 03:09AM BLOOD calTIBC-179 Ferritn-[**Numeric Identifier 112401**]* TRF-138*
[**2172-10-2**] 04:09AM BLOOD Triglyc-199*
[**2172-10-15**] 05:55AM BLOOD TSH-14*
[**2172-9-27**] 12:55AM BLOOD TSH-1.7
[**2172-10-16**] 06:15AM BLOOD Free T4-0.68*
[**2172-10-21**] 05:40AM BLOOD tacroFK-7.2
[**2172-10-3**] 7:10 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2172-10-3**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2172-10-5**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 353-8754M
[**2172-9-30**].
LEGIONELLA CULTURE (Final [**2172-10-10**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Final [**2172-10-19**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2172-10-5**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2172-9-27**] for an orthotopic
liver transplant for acute liver failure of unknown etiology. He
was admitted to the SICU.
Neuro:
The patient has mental retardation at baseline. His presenting
complaint at the OSH was seizures. Upon admission to the
hospital, staff from his group home reported that his speech was
more slurred than usual. Neurology evaluated the pt for
recommendations on seizure prophylaxis. Ativan was discontinued
and Keppra started per neurology recs for seizures. On [**9-28**], he
became increasingly somnolent. On [**2172-9-29**] a bolt was placed to
monitor intracranial pressures. And he was placed on continuous
EEG monitoring. After 2 days of normal pressures, Bolt was
removed on [**10-1**]. On [**10-2**] continuous EEG monitoring was stopped. On
[**10-6**] Head CT showed mildly dilated ventricles w/o evidence of
bleed. On [**2172-10-11**] a MRI showed cortical volume loss/cerebellar
atrophy, no acute ischemic changes.
Liver Failure:
LFTs continued to rise. JP output was bilious. FFP was given for
elevated INR 4.0. Head CT was negative for acute intracranial
hemorrhage. L femoral CVL was placed. He was tachycardic. IVF
boluses were given without improvement. UOP increased w/ albumin
x 1. LFTs continue to trend into 10,000. IV Zosyn and Vancomycin
were given empirically. Acyclovir IV was also started for
herpetic lesions on lip. Transplant team was notified.
Expedited liver transplant ensued and on [**9-29**] he was listed for a
liver transplant for acute liver failure. On [**2172-9-30**], a liver
donor offer was accepted and he underwent orthotopic deceased
donor liver transplant (piggyback), portal vein to portal vein
anastomosis, common hepatic artery (donor) to proper hepatic
artery (recipient) common bile duct to common bile duct
anastomosis. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted by Dr.
[**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. Please refer to operative note for details.
Postop, he went back to the SICU for management. He received
blood products per pathway and remained hemodynamically stable.
IV lasix was given with good urine output. Immunosuppression
consisted of tapering steroids and cellcept. Prograf was started
on postop day 1. Acyclovir was stopped on [**10-1**]. Continuous EEG
continued. Head CT was negative. Rhythmic rights-sided movements
noted,
He spiked fevers on [**10-3**] and was pancultured. Sputum isolated
rare growth of staph coag positive. IV Meropenem was added. On
[**10-4**] a-line was re sited on right, removed a-line on left and
sent tip for culture. Lateral JP was removed on [**10-4**]. On [**10-5**],
vanco was stopped. LFTs were elevated. Hepatic duplex was done
demonstrating patent vessels, mild biliary dilation. TPN was
started for nutrition.
On [**10-7**] LFTs were notable for increasing Tbili. Hepatic
ultrasound revealed a dilated common bile duct. An ERCP was
completed and a stent was placed across a stricture near the
biliary anastomosis (a pre-cut was required to place the stent).
After ERCP, a CT scan of the abdomen was undertaken to evaluate
for possible abscess in the abdomen/torso. Scan revealed
possible RLL pneumonia, but no active intraabdominal process.
Dobhoff was removed during ERCP. During his ERCP, his
temperature spiked and he was pan-cultured (blood, urine and
sputum cultures). These cultures remained negative.
On [**10-8**], he was extubated. Post pyloric feeding tube was placed
in IR. DHT advanced in IR and TF were started. TPN was dc'd.
Neuro exam was improving. On [**10-10**], head MRI was done to evaluate
upper extremity weakness. Speech and swallow evaluated.
On [**10-11**] meropenem was dc'd and he was pan-cultured for
increasing WBC. These cultures remained negative. Lasix was
given for generalized edema.
[**10-12**] was replaced. Dobhoff placed and tube feeds were given.
Insulin was required for elevated glucoses form steroids and
tube feeds.
He was transferred out of the SICU on [**10-14**] to the
medical-surgical unit. Lateral JP drain was removed on [**10-14**].
Speech and swallow evaluation noted soft signs of aspiration.
He was kept NPO and reevaluated on [**10-15**]. He was cleared for PO
diet of thin liquids and ground solids, understanding aspiration
had not been fully ruled out. Repeat evaluation on [**10-16**] noted
coughing with ground solids. Therefore, the following
recommendations were made to switch to thin liquids and pureed
solids. Meds were crushed with pureed solids with 1:1
supervision for meals and meds. Tube feeds continued with water
flushes.
Physical therapy and occupational therapy were consulted.
Evaluations established that he required rehab as he was
impaired motor function, impaired transfers,
impaired knowledge, and was functioning far below his baseline.
He requires
multi disciplinary rehab with intensive daily OT/PT and SLP to
maximize functional recovery for eventual return to group home.
He requires [**Doctor Last Name **] lift to get out of bed. Of note, TSH was
elevated at 14 with free T4 of .68. Levothyroxine was increased
on [**10-20**] to 225mcg daily. Repeat TSH should be done in 6 weeks.
Immunosuppression consisted of tapering steroid per transplant
protocol, cellcept 1 gram [**Hospital1 **], and Prograf which was adjusted
based on trough Prograf levels.
Urine was collected by condom catheter to protect skin from
incontinence. Sacrum was pink, but intact. Criticaid was
applied. He was having BMs (x2 on [**10-21**]).
He will transfer to [**Hospital 5503**] Rehab today.
Medications on Admission:
Levothyroxine 200' (per notes, 300' for two days of the week),
Prozac 60', amoxicillin [**2160**] (during dental work), remeron 30
qPM, Compazine 5 PRN, Dilantin ER 300 qM, Effexor 100"
Discharge Medications:
1. Famotidine 20 mg PO Q12H
2. Fluconazole 400 mg PO Q24H
3. Fluoxetine 60 mg PO DAILY
4. Heparin 5000 UNIT SC Q 8H
5. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
6. LeVETiracetam 1000 mg PO BID
7. Levothyroxine Sodium 225 mcg PO DAILY
check TSH in 6 weeks
8. Metoprolol Tartrate 50 mg PO BID Tachycardia
Hold for HR < 60bpm or SBP < 100mmHg
9. Miconazole Powder 2% 1 Appl TP TID:PRN scrotum
10. Mycophenolate Mofetil Suspension 1000 mg PO BID
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. PredniSONE 17.5 mg PO DAILY
13. Sulfameth/Trimethoprim Suspension 10 mL PO DAILY
14. Tacrolimus 3 mg PO Q12H
On lab draw days, hold medicaitn until trough level drawn
15. ValGANCIclovir Suspension 900 mg PO DAILY
16. Venlafaxine 100 mg PO BID
17. Outpatient Lab Work
Stat labs every MOnday and Thursday for cbc, chem 10, ast, alt,
alk phos, tbili, ua and trough prograf level.
fax results to [**Hospital1 18**] Transplant Center [**Telephone/Fax (1) 697**] attn: RN
coordinator
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Acute Fulminant liver failure likely drug/toxin induced
(phenytoin)
s/p orthotopic liver transplant
Discharge Condition:
Mental Retardation at baseline
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] if the patient
develops fever > 101, chills, nausea, vomiting, diarrhea,
constipation, complaint of increased abdominal pain, incisional
redness, drainage or bleeding, dislodgement or clogging of the
feeding tube or other concerning symptoms.
-Blood draw on Mondays and Thursdays for transplant lab
monitoring Continue tube feeds via post pyloric feeding tube and
encourage oral intake as tolerated.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2172-10-28**] 9:00. [**Hospital **] Medical Office Building, [**Location (un) **] [**Last Name (NamePattern1) **], [**Location (un) 86**], MA
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2172-11-5**] 2:00 [**Hospital **] Medical Office Building, [**Location (un) 436**]
[**Last Name (NamePattern1) **], [**Location (un) 86**], MA
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2172-11-11**] 9:20 [**Hospital **] Medical Office Building, [**Location (un) 436**]
[**Last Name (NamePattern1) **], [**Location (un) 86**], MA
Completed by:[**2172-10-22**] Name: [**Known lastname 18436**],[**Known firstname **] J Unit No: [**Numeric Identifier 18437**]
Admission Date: [**2172-9-27**] Discharge Date: [**2172-10-22**]
Date of Birth: [**2124-5-25**] Sex: M
Service: SURGERY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2214**]
Addendum:
the patient's coagulopathy was from fulminant liver failure.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] [**Hospital **] Hospital - [**Location (un) 2653**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2216**] MD [**MD Number(2) 2217**]
Completed by:[**2172-11-16**]
|
[
"785.0",
"345.10",
"288.60",
"344.00",
"507.0",
"V12.54",
"787.22",
"V12.61",
"244.9",
"E936.1",
"E878.0",
"728.88",
"249.00",
"576.2",
"300.00",
"572.2",
"317",
"996.82",
"570",
"054.9",
"V42.2",
"784.51",
"286.7",
"482.41",
"747.81",
"584.5",
"728.87",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.19",
"99.15",
"38.91",
"50.12",
"50.59",
"01.10",
"38.93",
"51.87",
"96.04",
"96.6",
"96.72",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
14218, 14474
|
5015, 10713
|
300, 346
|
12222, 12372
|
3115, 4927
|
12887, 14195
|
2794, 2803
|
10949, 11957
|
12099, 12201
|
10739, 10926
|
12396, 12864
|
2818, 3096
|
4963, 4992
|
231, 262
|
374, 1971
|
1993, 2268
|
2284, 2778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,183
| 171,331
|
15038
|
Discharge summary
|
report
|
Admission Date: [**2178-9-26**] Discharge Date: [**2178-10-6**]
Date of Birth: [**2142-5-20**] Sex: M
Service: Blue Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43972**] is a 36-year-old
male with a past medical history of Hodgkin's lymphoma
treated approximately 15 years ago with staging laparotomy,
splenectomy and nodal sampling followed by x-ray radiation
therapy, the subsequent diagnosis two years ago of ITP with
evidence of splenosis by CT scan, which was treated with
Prednisone IgG, and recently treated with Rituxan with good
effect. He presented approximately one month ago with severe
abdominal pain and was diagnosed with portal vein thrombosis and
started on coumadin after being heparinized. He presented to the
Emergency Room at [**Hospital1 69**] on
[**2178-5-27**] with 2-3 day history of increasing abdominal pain on
the right side. At this time he denies nausea, vomiting,
positive flatus and still had a bowel movement at that time.
CT scan was obtained from an outside hospital which
demonstrated a focal area of small bowel wall thickening, portal
vein thrombosis and superior mesenteric vein thrombosis. It was
felt at that time that patient was experiencing worsening
mesenteric ischemia and was admitted for exploratory
laparotomy to assess the viability of his small bowel.
PAST MEDICAL HISTORY: 1) Hodgkin's lymphoma diagnosed 15
years ago. 2) ITP diagnosed two years ago treated with IgG
and Prednisone, recently treated with Rituxan approximately
one week prior to admission. 3) Portal vein thrombosis
diagnosed approximately one month ago. 4) Hypothyroidism.
5) Restless leg syndrome. 6) Anxiety.
MEDICATIONS: Dilaudid 4 mg q 4 hours, Prevacid 30 mg q day,
Levoxyl 250 mcg q day, Mysoline 125 mg q d, Paxil 40 mg q
day, Permax .015 mg q day, Coumadin 5 mg q day.
SOCIAL HISTORY: A [**3-15**] pack per day smoker times
approximately 15 years, denies current alcohol use.
PHYSICAL EXAMINATION: Temperature 97, blood pressure 172/91,
respiratory rate 22, oxygen saturation 93% on room air. He
is an uncomfortable white male in apparent distress.
Respiratory exam was clear to auscultation bilaterally.
Cardiac, regular rate and rhythm, S1 and S2 appreciated.
Abdominal exam showed a firm abdomen with right sided
tenderness, no shake tenderness, no cough tenderness.
Extremities were warm with palpable pulses distally. His
rectal showed normal tone, and was guaiac negative at that
time.
LABORATORY DATA: On admission the patient had a white count
of 13.1, hematocrit of 39.1, platelet count 148,000.
Electrolytes, sodium 141, potassium 3.3, BUN and creatinine
14 and 0.9, glucose 112. At the time of admission
prothrombin time of 23.3 and INR was 2.0. His liver function
tests were all within normal limits with albumin of 3.2. The
CAT scan on admission from the outside hospital again showed
small bowel wall thickening, portal vein thrombosis and
superior mesenteric vein thrombosis.
HOSPITAL COURSE: The patient was admitted on [**2178-9-26**] for
emergent exploratory laparotomy. He was evaluated by the
general surgery service and the vascular surgery
service. On admission the patient was begun on a Heparin drip,
IV antibiotics. The patient was taken for a repeat CT angiogram.
This scan showed new free fluid within the abdomen with the same
focal area of small bowel showing signs of ischemia. Given the
severe pain and clinical exam as well as CT findings, consent was
obtained to proceed with the exploratory laparotomy. Exploratory
laparotomy was performed with the preoperative diagnosis of
ischemic bowel. Approximately a 50 cm segment of small bowel was
found to be thickened/congested in the mid to distal ileum. It
was found that all other small and large bowel was viable . The
patient was admitted postoperatively from the
operating room to the surgical ICU. The patient was left
intubated following his operation, given his bowel edema and
otherwise guarded status. Upon admission to the surgical
Intensive Care Unit the patient was noted to have laboratory
values of white count 16.3, hematocrit 33.1, platelet count
99,000. [**Name (NI) 2591**], PT 15.5, PTT 29.2, INR 1.7, BUN and
creatinine were stable as were his liver function tests.
Once admitted to the surgical ICU the patient was sedated on
Morphine and Propofol. Systolic blood pressure was
maintained with fluid boluses and he was left intubated. He
was admitted with an NG tube, central venous access. His
coag values were followed q 6 hours and Heparin drip was
begun on the patient.
Overnight in the surgical ICU from [**2178-9-26**] to [**2178-9-27**] the
patient was left intubated on Morphine and Propofol drip. It
was decided during the morning of [**2178-9-27**] to begin to wean
his sedation. At that time it was also decided to pursue
extubation of the patient. The patient's sedation was
weaned. His ventilator support was weaned as well. In the
surgical ICU on [**2178-9-27**] values drawn at midnight showed a PT
of 16.1, PTT 29.9, INR 1.8. On the patient's Heparin drip PT
was found to increase at 4 a.m. to 12.0, PTT was found to be
39.9 and the patient's INR was 2.0. On [**2178-9-27**] hematology
consult was obtained. Hematology/Oncology was asked to see
the patient for management of his portal vein and splenic
vein thrombosis and his new diagnosis of superior mesenteric
vein thrombosis given his history of Hodgkin's disease and
ITP. At that time hematology/oncology service recommended
continuation of the Heparin drip for anticoagulation. It was
unclear at this time why the patient developed spontaneous
portal vein and splenic vein thrombosis. At that time they
also decided to obtain the patient's outpatient records from
[**Hospital **] Hospital and spoke with his hematologist, Dr. [**First Name (STitle) **].
At that time the patient's goal PTT should be 55, to maintain
adequate anticoagulation given his venous thrombosis.
Overnight from [**2178-9-27**] to [**2178-9-28**] the patient was extubated
and began to complain of pain at incision. He was also
transferred from the ICU to the floor overnight between
[**2178-9-27**] to [**2178-9-28**]. On exam the morning of [**2178-9-28**] the
patient was found to be stable, good urine output, we
continued to check hematocrit q 6 hours. It was decided at
this time to start TPN on the patient to increase his Heparin
to maintain a goal PTT of 55 to 70. Heparin previously at
1400 units had only elevated his PTT to a value of 45.2. The
patient was also noted to have a declining platelet count
from 88 to 66. There is concern at this time that given the
patient's history of prior exposure to Heparin, his current
Heparin drip, the patient might be experiencing Heparin
induced thrombocytopenia. Complicating this picture was also
the patient's history of ITP. Hematology/Oncology was again
asked to address this issue. At this time a Heparin induced
thrombocytopenia panel was obtained. This was eventually
shown to be negative. The patient continued to do well the
day of [**2178-9-28**] with continued complaints of incisional pain.
At this time the patient's Dilaudid PCA was increased to
cover his pain. On exam the patient's abdomen was found to
be markedly distended. The plan at the time was just to
await return of bowel function with this patient. We
continued to check his hematocrit q 6 hours which was found
to be fairly stable throughout his hospitalization. During
the day, however, his platelet count continued to decline to
a value in the 50's.
Overnight from [**2178-9-28**] to [**2178-9-29**] the patient was noted to
have a mild amount of delirium. The patient spontaneously
pulled his nasogastric tube which was replaced on the floor
without difficulty. It was felt at the time the delirium was
probably secondary to the Ativan that was being given at that
time and to hold the Ativan. On [**2178-9-29**] laboratory values
demonstrated a platelet count of 30 with [**Date Range **] demonstrating
an adequate PTT of 55. Given the concern about the patient's
possible platelet decline being due to Heparin induced
thrombocytopenia, the patient was begun on Lepirudin on
Tuesday, [**2178-9-28**] and was continued to [**2178-9-29**]. At this time
patient's PTT value of 55 was found to be adequate with a
prudent anticoagulation. On day of [**2178-9-29**] the patient
continued to do well, his pain was better controlled with
increased PCA dose. Dressing was removed. The incision was
found to be dry and intact. The patient continued with good
urine output, had a moderate amount of NG output. The NG
tube was putting out approximately 640 cc on the 19th, 350 cc
overnight from [**9-28**] to [**2178-9-29**] after the tube was replaced.
Overnight from [**2178-9-29**] to [**2178-9-30**] the patient continued to do
well. The patient's platelet count, however, was noted to be
declining to a value of 16 from 20 from the previous check.
The patient's PTT was also found to be declining to a value
of 49 and it was decided at this point to increase the
patient's Lepirudin dose. Also on [**2178-9-30**] the patient's
Heparin induced thrombocytopenia came back negative and it
was decided to restart his Heparin at that time. The
patient's NG tube continued to have a moderate amount of
output, putting out approximately 1220 cc total overnight
from [**2178-9-29**] to [**2178-9-30**]. The patient was also noted to be
coughing up a small amount of bright red blood on [**9-30**] and it
was felt at this time this was old clot and did not represent
active bleeding in this patient. The patient's hematocrit
continued to be stable at 26.3. On [**2178-9-30**] the patient's
negative Heparin induced thrombocytopenia panel was felt that
his platelet drop was most likely due to recurrence of his
ITP and it was decided at that time to give IVIG of 1 gm/kg
in a divided dose over approximately two days.
Overnight from [**2178-9-30**] to [**2178-10-1**] the patient continued to do
well. He was comfortable, however, his bowel function was
slow to return. He was still without flatus. His pain
control continued to be with a Dilaudid PCA. Half his dose
of IVIG was given on [**2178-9-30**] with the other half given on
[**2178-10-1**]. The patient's platelet count was found to respond
to this IVIG regimen increasing to a value of 53. The
patient was also restarted on his Heparin drip which was
elevated to 1800 units per hour at which time was found to
have a PTT of 47.9 and it was decided at this point to
increase Heparin dose to [**2176**] units per hour. On the day of
[**10-1**] the patient continued to do well, however, his bowel
function was again found to be slow to return. He denied
flatus over the day of [**2178-10-1**]. His NG output was noted to
be moderately decreased over the day and it was decided at
that point to discontinue his Foley catheter and continue to
try and get his Heparin to a therapeutic PTT value.
Overnight from [**2178-10-1**] to [**2178-10-2**] the patient continued to do
well, however, he was still found to be without flatus. He
was burping with NG tube clamped. He was having low
residuals from his NG tube, however, his abdomen was still
distended. His platelets continued to respond well to the
IVIG treatment increasing to a value of 86 from 53 the day
before. It was felt at that time that his low platelets were
truly consistent with ITP. On [**2178-10-2**] the patient continued
to do well. However, complained of increased abdominal
distention during the day. He was having low residuals from
his clamped NG tube but it was at that time just replaced
back to continue suction. After replacing the tube to
continuous suction approximately 200 cc of bilious fluid was
obtained.
Overnight from [**2179-10-2**] to [**2178-10-3**] the patient continued to do
well. He was found to be more comfortable although he was
still without flatus. The morning of [**2178-10-3**] the patient was
given a Dulcolax suppository which induced good bowel
function. The patient had a bowel movement shortly after
insertion of the Dulcolax suppository.
Overnight from [**2178-10-3**] to [**2178-10-4**] the patient continued to do
well, continued to have bowel movements, was reporting good
flatus. It was decided on the morning of [**2178-10-4**] to
discontinue the patient's NG tube. The patient's Heparin
dose was running at a value of 2100 units per hour, PTT was
found to be value of 52.2. The patient was showing good
signs of bowel function and it was decided at that time to
also start the patient on a clear liquid diet. The patient
was noted to have elevated white count to a value of 24 on
[**2178-10-4**]. It was decided at that time to change his central
line to check a clostridium difficile toxin assay. The
patient was also started on Flagyl 500 mg tid. The patient's
central line was changed on [**2178-10-4**]. Culture of the central
line tip was negative. Additionally, the patient's
clostridium difficile toxin assay was negative. Following
changing the patient's central line, chest x-ray was
obtained. This demonstrated the new central line to be
positioned within the right atrium. The line was withdrawn 3
cm and was used again. Following the patient's procedure,
central line was changed. The patient's Heparin was stopped
for approximately two hours. Laboratory values after
changing this line demonstrated PTT of 26.3 and the patient
was restarted on his usual dose of Coumadin. A recheck of
the patient's PTT several hours later demonstrated a value of
46. It was decided at this time to increase the patient's
Heparin drip to a value of 2400 units per hour, rechecking
the laboratory values on the morning of [**2178-10-5**] demonstrating
PTT of 60.6. The patient's hematocrit was again noted to be
stable. The patient was tolerating his clear liquid diet.
On the morning of [**2178-10-5**] it was decided to advance the
patient's diet to a full liquid diet with a regular house
diet to begin that evening. The patient continued to do
well, continued to pass flatus and bowel function was thought
to be good. At this time the patient was started on his home
medications of Paxil and Permax.
On the evening of [**2178-10-5**] it was also decided to begin
patient back on his dose of Coumadin for consideration of
long-term anticoagulation. The patient was given a dose of
7.5 mg of Coumadin this evening.
Overnight from [**2178-10-5**] to [**2178-10-6**] the patient continued to do
well. He was tolerating a solid diet and it was decided at
this time to discharge the patient home on Lovenox and
Coumadin with follow-up until his Coumadin is therapeutic.
The patient is to continue taking his Lovenox. The patient
demonstrated good bowel function. On [**2178-10-6**] the patient's
staples were taken out and the plan was discussed with
Hematology Oncology for long-term anticoagulation in this
otherwise complex patient.
CONDITION ON DISCHARGE: Good. He was tolerating full liquid
diet, his pain control is with oral pain medications, he is
therapeutic on a Heparin drip with a PTT value of 84 this
morning.
By review of systems:
1. From a GI standpoint the patient is status post
exploratory laparotomy with resection of 50 cm of mid to
distal ileum for mesenteric ischemia, most likely induced by
venous congestion. The patient is currently taking a regular
diet with good bowel function. Pathology showed no evidence of
recurrent lymphoma.
2. Hematology: The patient has ITP. The patient had a low
platelet count down into the value of the teens. This was
treated with IVIG with good response. The patient was to
follow-up with his regular hematology oncologist as an
outpatient for consideration of Rituxan treatment.
3. From an anticoagulation standpoint the patient was noted
to have PTT value with a slightly elevated stay into the
80's. It was decided that the patient will need long-term
anticoagulation given his history of a portal venous splenic
vein thrombosis and superior mesenteric vein thrombosis.
This will be accomplished with Coumadin as per the hematology
oncology service who has been in touch with his regular
hematologist, Dr. [**First Name (STitle) **]. Currently the patient has just begun
on his dose of Coumadin.
The patient is to be discharged on a dose of 1 mg/kg,
approximately 120 mg of Lovenox q 12 hours to be injected
subcutaneously. Until his Coumadin dose is therapeutic with
an INR of 2.5. The patient is to follow-up at [**Hospital **]
Hospital for laboratory draws tomorrow. The patient has a
follow-up appointment with his hematologist, Dr. [**First Name (STitle) **] on
Thursday morning at approximately 7:15.
The patient's wife has demonstrated proficiency with
administering the subcutaneous Lovenox in the past. She has
administered this to both the patient's father and the
patient. The patient was given his first dose of Lovenox
here in the hospital. The patient's wife demonstrated that
she was able to give the dose to the patient with the nurse
present. It was decided at this time the patient will not
need VNA services for administration of Lovenox. He is to
follow-up with his regular hematologist tomorrow.
DISCHARGE MEDICATIONS: Percocet 5/325 mg 1-2 tabs po q 4
hours prn pain, Colace 100 mg po bid prn constipation,
Lovenox 120 mg q 12 hours to be administered subcutaneously,
Coumadin 5 mg q day, Protonix 40 mg q day. Patient's home
medications which he is to begin taking again include Paxil
40 mg q day, Permax .01 mg q day, Levoxyl 250 mcg q day.
FOLLOW-UP: With Dr. [**First Name (STitle) 2819**] and Dr. [**First Name (STitle) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Doctor Last Name 43973**]
MEDQUIST36
D: [**2178-10-6**] 11:56
T: [**2178-10-12**] 19:57
JOB#: [**Job Number 43974**]
cc:[**Telephone/Fax (1) 43975**]
|
[
"557.0",
"567.2",
"201.90",
"287.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"38.93",
"45.62",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
17243, 17960
|
2989, 14952
|
1970, 2971
|
15163, 17219
|
169, 1337
|
1360, 1838
|
1855, 1947
|
14977, 15144
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,202
| 146,581
|
264
|
Discharge summary
|
report
|
Admission Date: [**2140-3-5**] Discharge Date: [**2140-3-16**]
Service:
CHIEF COMPLAINT: Bright red blood per rectum.
PAST MEDICAL HISTORY: Aortic stenosis, hypertension, spinal
stenosis, hemorrhoids, peptic ulcer disease, history of
gastrointestinal bleed, status post laminectomy, status post
right hip replacement, status post salivary calculus removal
in the [**2087**].
OUTPATIENT MEDICATIONS: Zantac 150 mg p.o. b.i.d.; MS Contin
30 mg p.o. b.i.d.; Imdur 30 mg p.o. q. day; Desipramine 20 mg
p.o. q.h.s.; Ambien 10 mg p.o. q.h.s.; Colace 100 mg p.o.
b.i.d.; Senna one tablet p.o. b.i.d.; Lorazepam .5 mg p.o.
b.i.d.; Lasix 30 mg p.o. q. day, recently increased from 20
mg p.o. q. day; Milk of magnesia 2 to 3 Tbsp p.o. q.h.s.;
Clindamycin 600 mg one hour before dental procedures; on
[**2140-3-1**], Mavik 1 mg p.o. q. day and Aldomet 500 mg
p.o. b.i.d. were discontinued
ALLERGIES: By report beta blocker causes insomnia and
dizziness. Calcium channel blocker causes insomnia and
lightheadedness, Darvocet causes confusion and delirium,
Penicillin causes tongue swelling. Ultram causes dry mouth.
Erythromycin causes dyspepsia and Levaquin causes an unknown
reaction.
SOCIAL HISTORY: The patient lives with his wife. The
patient's daughter lives in the same town. Remote tobacco
history, quit 30 to 40 years ago, at the time was using one
pack per day for 15 years. No recent alcohol use. Only
drank socially when he was younger. Denies intravenous drug
use.
PHYSICAL EXAMINATION: Admission physical examination
Vital signs: Temperature 97.4, pulse 85, respirations 21,
blood pressure 128/58. Respiratory oxygen saturation 95% on
room air.
General: In no acute distress.
Neurological: Alert and oriented times three with no focal
neurological deficits.
Cardiovascular: Regular rate and rhythm with III/VI
holosystolic, crescendo/decrescendo murmur auscultated along
the left sternal border and precordium.
Pulmonary: End inspiratory bibasilar crackles one third of
the way up.
Abdomen: Soft, nontender, nondistended, no hepatomegaly and
no splenomegaly, bowel sounds normal. No palpable masses.
Neck: No jugulovenous distension.
Extremities: 2 to 3+ pitting edema of the lower extremities
bilaterally below the knees.
Head, eyes, ears, nose and throat: No icterus, no pallor.
Mucous membranes moist, no oropharyngeal exudate.
HOSPITAL COURSE: The patient initially presented to the
Emergency Room after noticing a small amount of blood on the
toilet paper, after having a bowel movement after being
constipated for two days which is not uncommon. He denies
gross blood in the toilet, melena or maroon stools. He
denies hemoptysis or hematemesis. He denies dizziness or
headache.
The patient reports experiencing decreased exercise tolerance
for the two months prior to admission. He describes this as
shortness of breath after 5 to 10 feet of walking as opposed
to 50 to 100 feet of walking. He also reports a generalized
drowsiness and discomfort. He reports increasing bilateral
leg edema for the last two weeks but denies chest pain,
palpitations and paroxysmal nocturnal dyspnea as well as
orthopnea. He denies fever, chills, nausea, vomiting or
abdominal pain.
The patient was initially admitted to [**Location (un) **] to monitor his
hematocrit given his history of gastrointestinal bleed. The
hematocrit remains stable and no intervention was performed.
The gastrointestinal bleed was attributed to his hemorrhoids.
There was no repeat bleeding in-house.
A cardiology consult was placed to evaluate the patient's
symptoms of increasing heart failure and history of critical
aortic stenosis. The decision was made to take the patient
to the Catheterization Laboratory. Per the Catheterization
Laboratory report, findings at catheterization are as
follows: Severe pulmonary hypertension and severely elevated
left-sided filling pressures, cardiac index severely reduced
at 1.2 liters/minute/meter square, focal 50% left anterior
descending stenosis with calcified left anterior descending
as well as a distal 70% left anterior descending stenosis.
Mild diffuse disease in the circumflex, 60% diffuse disease
in the right coronary artery. Valvuloplasty of the aortic
valve was performed, increasing the valve area from baseline
0.29 cm squared to 0.41 cm squared. The patient tolerated
the procedure well. He was treated post-valvuloplasty with
Dobutamine and Lasix, right ventricular pressure 90/20,
pulmonary capillary wedge pressure and he was subsequently
given a trial of Milrinone which failed, 35. The patient was
then transferred to the Cardiology Floor Service. Aortic
blood pressure was 170/90 and he was administered Nutracort
for 24 hours. The patient was started on ACE inhibitor which
was gradually increased. His Imdur was discontinued and he
was started on daily p.o. Lasix. At the time of discharge,
the patient was hemodynamically stable and breathing
comfortably without any distress. The patient was able to
start ambulating with the help of physical therapy. Right
after admission it was also noted that the patient had
elevated liver function tests which subsequently resolved.
This transient rise was attributed to passive hepatic
congestion. He was also ruled out for myocardial infarction
upon presentation.
DISCHARGE STATUS: The patient is stable for discharge to
rehabilitation.
DISCHARGE MEDICATIONS: Lasix 40 mg p.o. q.d.; Lisinopril 20
mg p.o. q. day; Dulcolax 10 mg p.r. q.h.s. prn; Ambien 5 to
10 mg p.o. q.h.s. prn; Desipramine 20 mg p.o. q.h.s.; Colace
100 mg p.o. b.i.d.; Morphine Sulfate sustained release 30 mg
p.o. q. 12 hours; enteric coated aspirin 81 mg p.o. q. day;
Protonix 40 mg p.o. q. day; Lactulose 30 ml p.o. q.i.d. prn;
Senna one tablet p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Critical aortic stenosis, status post valvuloplasty
2. Congestive heart failure
3. Hypertension
4. Hemorrhoids
5. Spinal stenosis
6. Peptic ulcer disease with a history of gastrointestinal
bleed
7. Status post laminectomy
8. Status post right hip replacement
9. Status post salivary calculus removal in the [**2087**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2140-3-16**] 08:36
T: [**2140-3-16**] 08:42
JOB#: [**Job Number 2583**]
|
[
"424.1",
"573.3",
"401.9",
"455.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"35.96",
"88.56",
"00.13",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
5411, 5781
|
5802, 6411
|
2392, 5387
|
415, 1196
|
1517, 2374
|
101, 131
|
154, 390
|
1213, 1494
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,239
| 125,055
|
208+209
|
Discharge summary
|
report+report
|
Admission Date: [**2189-3-17**] Discharge Date: [**2189-3-25**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
woman with a history of coronary artery disease with recent
CCU stay and autoimmune hemolytic anemia who presented again
to the CCU after being admitted to the floor with a two-day
history of weakness, increased shortness of breath, decreased
She had stent to the left anterior descending at an outside
hospital in [**2188-11-25**]. She then represented to [**Hospital6 1760**] on [**2189-2-18**], with her
anginal equivalent (epigastric pain) and was found to have ST
elevations on her electrocardiogram in leads V2-V5. She had
a complicated emergent catheterization. The catheterization
placed on Dopamine and intubated.
On catheterization, the patient had in stent restenosis of
the left anterior descending, and she received percutaneous
transluminal coronary angioplasty. A lesion of the ramus
intermedius was stented as well. Intra-aortic balloon pump
was initiated at that time.
She had a four-day stay in the CCU when she was able to be
taken off the balloon pump and ventilatory support. She did
have an episode of acute hypoxia after transfer to the floor
that improved with diuresis and nitrates. She was discharged
two weeks to this current admission to a nursing home.
On presentation to the Emergency Department the patient had a
heart rate of around 100, and systolic blood pressure in the
80-90s. Hematocrit was down to 24.5. Hematocrit on
discharge from her prior hospitalization was 33; however, her
baseline hematocrit is in the mid 20s. She was transfused 1
U of packed red blood cells in the Emergency Department. She
had no electrocardiogram changes on arrival to the Emergency
Department.
Upon arrival to the floor, she had acute decrease in oxygen
saturations to the low 80s with tachypnea and tachycardia to
the 150s. She was given intravenous Nitroglycerin drip,
intravenous Lasix, and intravenous Lopressor 2.5 mg, as well
as IV Morphine 2 mg. Her ABG showed a pH of 7.19, and a pCO2
of 48, and a pO2 of 56. The patient was intubated and
transferred to the CCU. Her electrocardiogram showed sinus
tachycardia with unchanged segment elevations in V2-V4
compared with baseline. Her chest x-ray was consistent with
increasing congestive heart failure compared with earlier in
the day.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post myocardial infarction in [**2189-1-23**]. Catheterization in
[**2188-11-25**] with stent to the proximal to the left anterior
descending, and PTCA to the ramus and diagonal, 80% proximal
right coronary artery lesion. Catheterization in [**2189-1-23**]
showed 100% proximal left anterior descending in stent
stenosis, and PTCA was performed, as well as 100% OM1 lesion,
as well as an 80% ramus lesion which was stented.
Catheterization was complicated by hypotension and
respiratory distress as described in the HPI. 2. Systolic
dysfunction a left ventricular ejection fraction of 20-25% by
echocardiogram earlier this month showing mild symmetric left
ventricular hypertrophy as well. Echocardiogram also showed
near akinesis of the entire septum and anterior wall of the
left ventricle, as well as distal inferior and distal lateral
wall akinesis. The apex was aneurysmal as well. 3.
Hypertension. 4. History of GI bleed. The patient had an
admission during [**2189-1-23**] for GI bleed. 5. Autoimmune
hemolytic anemia followed by Hematology/Oncology at [**Hospital6 1760**] diagnosed in [**2188-11-25**].
6. Diabetes mellitus thought to be steroid induced. 7.
Hypothyroidism.
MEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d., Captopril
12.5 mg t.i.d., Ambien 5 mg q.h.s., Prevacid 30 mg b.i.d.,
Timoptic 0.5% eye drops, Xalatan eyedrops, NPH Insulin 4 U
b.i.d., sliding scale Insulin regular, Synthroid 0.25 mg
q.d., Plavix 75 mg q.d., Lopressor 50 mg t.i.d., Aspirin 81
mg q.d., Prednisone taper currently at 30 mg q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient resides at [**Hospital 582**] Nursing Home.
Denies tobacco. Occasional alcohol. She is a retired hair
dresser.
PHYSICAL EXAMINATION: Vital signs: On admission temperature
was 100.0??????, heart rate 100, blood pressure 118/51, oxygen
saturation 100% on 60% FIO2 on vent setting AC 12 x 550 FIO2
60% .............. to 7.5. General: The patient was
intubated, awake, responsive. The patient was in no acute
distress. Cardiovascular: Regular, rate and rhythm. No
murmurs. Audible over breath sounds. Respirations: Diffuse
anterior crackles. Extremities: Trace bilateral lower
extremity edema. Abdomen: Positive bowel sounds. Soft,
nontender, nondistended. Guaiac negative in the Emergency
Department. Neck: There was 9 cm JVP.
LABORATORY DATA: White count 12.4, hematocrit 29.4 up from
24.5 in the Emergency Department, platelet count 290; INR
1.1, PTT 23.4; potassium 3.4, BUN 28, creatinine 1.4, glucose
172, magnesium 1.7, albumin 3.1; CKs serially 41, 36, 39,
troponin 1.3 on the morning of admission.
ASSESSMENT: This was an 83-year-old woman with known
congestive heart failure and ischemic coronary disease
presenting flash pulmonary edema in the setting of blood
transfusion.
HOSPITAL COURSE: 1. Cardiovascular/ischemia: The patient
underwent repeat cardiac catheterization while intubated.
The catheterization showed instant restenosis of her left
anterior descending stent at 40%; however, distal to the
stent, there was an 80% focal lesion which was ballooned and
stented. Her ramus stent were patent with associated ostial 40%
lesion. Her known 80% right coronary artery lesion remained
unchanged. Right heart catheterization showed a pulmonary wedge
pressure of 30, RA pressure of 12, PA pressure of 61/34, RV
pressure of 61/16. Cardiac output was 4.4 with an index of 2.9.
Mixed venous saturation in the Catheterization Lab was 57.6 from
the pulmonary artery.
The patient did well postcatheterization and was able to be
extubated. She was placed on Aspirin and Plavix for life.
Beta-blocker was re-added, and Lopressor was titrated up 50
mg b.i.d. Ace inhibitor was also added. Her statin was
continued as well. She remained chest-pain free and free of
shortness of breath throughout the rest of her
hospitalization.
2. Cardiovascular/pump: The patient's ejection fraction was
known to be 20%. Heart catheterization confirmed her fluid
overload and congestive heart failure physiology. She did
not respond to Lasix on initially arriving in the CCU;
however after catheterization, she diuresed well to Lasix
with general improvement in her PA diastolics and improvement
of her kidney function. She was able to be extubated without
difficulty after adequate diuresis was achieved.
Upon arrival to the floor from the CCU, the CHF Service was
consulted. They recommended initiating Digoxin, low-dose
nitrate, and standing p.o. Lasix which was done. She was
discharged with plans to follow-up with the CHF Service for
continued medical management of her congestive heart failure.
3. Pulmonary: The patient was able to be initially
extubated on the second hospital day; however, on the day
after initial extubation, her status remained tenuous with
increasing Nitroglycerin drip and p.r.n. Morphine required to
reduce her preload enough to maintain oxygenation. On the
night after initial extubation, she required emergent
reintubation due to acute hypoxia. Chest x-ray prior to
intubation demonstrated white-out of the lower two-thirds of
the right lung; however, film 3-4 hours postintubation showed
resolution of the opacity throughout the right lung
consistent with acute mucous plugging. It was therefore
thought that that episode of hypoxia was not due to
congestive heart failure but to mucous plugging. The patient
was reextubated without difficulty status post
catheterization and maintained satisfactory oxygenation
throughout the remainder of her hospital stay.
She was also started on Levofloxacin on admission due to
suspicion of right upper lobe infiltrate. Levofloxacin was
switched to Ceftriaxone and Azithromycin on the third
hospital day. She remained afebrile throughout her hospital
course but did however start to develop a cough toward the
end of her hospital stay. She was continued on the
Ceftriaxone through the hospital stay with the plan for a
total 14-day course along with her Azithromycin.
4. Infectious disease: As above, the patient was treated
for suspicion of pneumonia. Of note, she had an isolated
positive blood culture growing gram-positive cocci in pairs
and clusters from [**2189-3-19**]; however, she was afebrile
throughout the time surrounding this culture. Repeat
cultures were drawn on [**2189-3-24**], and were pending at
the time of this dictation.
5. Heme: The patient has a history of autoimmune hemolytic
anemia with a baseline hematocrit in the mid 20s. As noted
in the HPI, she was transfused 1 U prior to her episode of
flash pulmonary edema. Hematology Service was [**Name (NI) 653**], and
they felt that it would be acceptable to transfuse the
patient as needed. The patient was transfused with one
additional unit of blood during her hospital stay. Due to
her steroids and autoimmune hemolytic anemia, she was
restarted on stress dose steroids as she had been on her
previous admission. These were quickly tapered to a
discharge dose of Prednisone 10 mg q.d. The patient had
stable blood pressure and hematocrit on this dose.
6. Fluids, electrolytes, and nutrition: The patient
developed hypernatremia toward the end of her hospital stay
with a peak sodium of 151. It was thought that this was due
to inadequate p.o. intake and free-water intake, and she was
encouraged to maintain p.o. intake. A Nutrition consult was
obtained as well. Follow-up labs of her sodium were pending
at the time of this dictation.
DISPOSITION: The patient was discharged to acute
rehabilitation in stable condition.
DISCHARGE MEDICATIONS: Enteric Coated Aspirin 325 mg p.o.
q.d., Plavix 75 mg p.o. q.d., Timoptic 0.5% eye drops 1 drop
per eye q.d., Xalatan 0.005% solution 1 drop to each eye
q.d., Folate 1 mg p.o. q.d., NPH Insulin 4 U subcue b.i.d.,
Synthroid 250 mcg p.o. q.d., Azithromycin 250 mg p.o. q.d.,
Protonix 40 mg p.o. q.d., Prednisone 10 mg q.d., Ceftriaxone
1 g IV q.24 hours to be discontinued on [**4-1**], Lopressor 50
mg p.o. q.d., Onalopril b.i.d., Ambien 5 mg p.o. q.h.s.
p.r.n., Lasix 20 mg p.o. q.d., Imdur 30 mg p.o. q.d., Digoxin
0.125 mg p.o. q.d.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post new stent to the left
anterior descending.
2. Congestive heart failure complicated by flash pulmonary
edema requiring intubation.
3. Pneumonia.
4. Autoimmune hemolytic anemia.
DR.[**First Name (STitle) **],[**Last Name (un) 2060**] 12-953
Dictated By:[**Name8 (MD) 2061**]
MEDQUIST36
D: [**2189-3-24**] 14:52
T: [**2189-3-24**] 15:19
JOB#: [**Job Number 2062**]
Admission Date: [**2189-3-17**] Discharge Date: [**2189-3-27**]
Service: CCU
ADDENDUM:
DISCHARGE MEDICATIONS: 1. Enalapril 15 po b.i.d. 2. Lasix
40 po q.d. 3. Digoxin .125 po q.d. 4. Imdur 30 po q.d.
5. Prednisone 10 po q.d. 6. Tylenol prn. 7. Prevacid 30
po q.d. 8. Synthroid 250 micrograms po q day. 9. Aspirin
325 mg po q.d. 10. Plavix 75 po q.d. for life. 11. Folate
1 mg po q.d. 12. Timoptic .5 solution one drop each eye
q.d. 13. Zalatan .005% solution one drop each eye q.d. 14.
Lopressor 50 mg po b.i.d. 15. Ambien 5 po q.h.s. prn. 16.
NPH 4 units b.i.d. and then regular insulin sliding scale.
17. K-Dur 10 mg po q.d.
DISCHARGE INSTRUCTIONS: The patient should have potassium
followed in a couple of days and monitored closely and her
potassium dose adjusted as needed. She should have daily
weights and monitored for signs of congestive heart failure.
The patient should follow up with Congestive Heart Failure
Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2067**] in one week. The phone number is
[**Medical Record Number 2068**]. She should also follow up with her primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] in one week as well.
[**Last Name (LF) 1870**],[**First Name3 (LF) **] 12.953
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2189-3-27**] 13:26
T: [**2189-3-27**] 13:45
JOB#: [**Job Number 2070**]
1
1
1
R
|
[
"519.1",
"V45.82",
"486",
"244.9",
"251.8",
"414.01",
"428.0",
"996.72",
"283.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"88.55",
"38.93",
"36.06",
"36.01",
"37.21",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11137, 11684
|
10567, 11113
|
3661, 4020
|
5275, 9986
|
11709, 12546
|
4186, 5257
|
117, 2378
|
2401, 3634
|
4037, 4163
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,538
| 176,351
|
46643
|
Discharge summary
|
report
|
Admission Date: [**2200-9-29**] Discharge Date: [**2200-10-1**]
Date of Birth: [**2133-7-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Pt is a 67yo F w/ a PMH of CHF, HTN, CRI and COPD who was
found at her [**Hospital1 1501**] to be acutely SOB this AM. On exam, she was
found to be wheezing, her O2 sats were 66% and only improved to
72% on 3L. Rest of her VS were: temp of 96.3, BP was 200/80, HR
124, and RR 24. Pt states that she was trying to go to the
bathroom when she became acutely SOB. Per documentation, she had
had a large amount of loose stool at the time (she is
incontinent of both stool and urine at baseline). Denies any CP,
palp, dizziness, LH, arm or jaw pain, diaphoresis, nausea or
vomiting. EMS was called and on arrival, applied a NRB with
improvement in her sats to 99%. On arrival to the ER, her SBP
was still elevated in the 210s and her HR was 110s. She was felt
to have [**1-14**] word dyspnea. Labs and blood cx were sent. She was
given nitropaste w/o effect. She was started on CPAP and was
given IV lasix. Lactate returned at 4.9 and she was given CTX,
azithromycin, and vancomycin. BNP returned at 31,089. CXR was
c/w pulmonary edema. Her SBP remained in the 190s-200s, so a
nitro gtt was started with improvement in her SBP to the 170s.
After 2 hrs, CPAP was discontinued and the patient was able to
maintain her O2 sats of 98-100% on 3L by nc. In total, she made
650cc of UOP. She was transferred to the ICU from the ED once
her respiratory status was stable, as she was still on a
nitroglycerin gtt.
.
ROS: denies fevers, chills, CP, palp, jaw or arm pain,
dizziness, LH, n/v, + mild abd pain, ? diarrhea (pt denies, but
likely per [**Hospital1 1501**] report); denies dysuria or hematuria but pt
incontinent; denies URI sx; denies LE edema, orthopnea or PND;
denies recent use of O2
Past Medical History:
# CHF - EF 25-30% by ECHO in [**7-19**]
# HTN
# CVA x2-3 (per patient) - has residual R sided LE weakness
# COPD
# CRI - baseline Cr ~2.0
# DM
# Depression
# Hypercholesterolemia
# GERD
# Glaucoma
# Legal blindness b/l (? post stroke)
# s/p lithotripsy for kidney stone
# s/p oophorectomy
# s/p cholecystectomy
Social History:
2 ETOH drinks daily, until CVA triggered nursing home residency.
Pt denies tobacco use but records indicate smoking. Former
bartender. Still married to husband [**Name (NI) 449**].
Family History:
Father died at 66 y, DM. Mother died when pt was infant. No
known diseases in siblings.
Physical Exam:
VS - 99.7, BP 170-177/76-82, HR 83-92, RR 17-22, O2 sats 96-97%
on 3L nc
nitro gtt: 5 mcg/kg/min
Gen: WDWN older female in NAD. Lying in bed, cooperative,
pleasant, answers questions appropriately.
HEENT: Sclera anicteric. Pupils nonreactive to light
bilaterally, opacified bilaterally.
CV: RR, normal S1, S2. No m/r/g.
Lungs: Crackles [**1-14**] way up bilaterally, with decreased BS at
bases bilaterally.
Abd: Soft, NTND. + BS. No masses, no HSM.
Ext: No edema. 2+ DP pulses bilaterally.
Neuro: Difficult to assess EOM due to blindness. Remaining
cranial nerves (V-XII) appear intact. Strength is [**4-17**] in UE
bilaterally, both distally and proximally. Strength on
dorsiflexion and plantarflexion was [**5-17**] bilaterally. Could not
assess patellar reflexes or ankle reflexes. No clonus. Toes
equivocal bilaterally.
Pertinent Results:
Admission Laboratories:
Hematology:
CBC: WBC-10.1# RBC-3.80*# HGB-11.4*# HCT-35.0*# MCV-92 MCH-30.1
MCHC-32.7 RDW-15.1 PLT COUNT-260
Differential: NEUTS-68.7 LYMPHS-26.6 MONOS-3.1 EOS-1.3 BASOS-0.3
PT-12.0 PTT-23.5 INR(PT)-1.0
.
Chemistries:
GLUCOSE-284* UREA N-38* CREAT-2.3* SODIUM-142 POTASSIUM-5.0
CHLORIDE-108 TOTAL CO2-19* ANION GAP-20
CALCIUM-8.6 PHOSPHATE-6.2*# MAGNESIUM-2.3
.
Other:
[**2200-9-29**] 07:00AM CK-MB-3 proBNP-[**Numeric Identifier 99043**]*
[**2200-9-29**] 07:28AM LACTATE-4.9*
[**2200-9-29**] 03:59PM LACTATE-1.7
.
Cardiac Enzymes:
[**2200-9-30**] 05:27AM BLOOD CK(CPK)-70 CK-MB-4 cTropnT-0.18*
[**2200-9-29**] 11:13PM BLOOD CK(CPK)-83 CK-MB-5 cTropnT-0.22*
[**2200-9-29**] 02:48PM BLOOD CK(CPK)-108 CK-MB-7 cTropnT-0.19*
.
MICRO:
[**2200-9-29**] blood cultures - no growth as of [**2200-10-1**].
.
IMAGING:
EKG [**2200-9-29**]: rate of 112, LBBB, ? ST depressions in II, III, aVF
(new from old), TWI in V5, V6 (old)
.
CXR [**2200-9-29**]: There is hazy bilateral patchy airspace process
that likely represents pulmonary edema. There is a left pleural
effusion. There is unchanged cardiomegaly. There is no
pneumothorax. IMPRESSION: Findings consistent with fluid
overload.
Brief Hospital Course:
A/P: 67yo F w/ a PMH of CHF, HTN, CRI and COPD who was found at
her [**Hospital1 1501**] to be acutely SOB this AM, likely due to flash pulmonary
edema.
.
# CHF: Patient was admitted with shortness of breath and
pulmonary edema in the setting of hypertensive crisis. The
etiology of her pulmonary edema was unclear but was felt to be
secondary to her high blood pressure. She received lasix and
BiPAP in the ER and was transferred to the MICU. Upon arrival
to the MICU she was no longer significantly short of breath and
was satting well on 3 L nasal cannula. She was placed on a
nitroglycerine drip for immediate control of her blood pressure
and was slowly started back on her home antihypertensive
medications. She was noted to have a slightly elevated troponin
which peaked at 0.22 but she did not complain of any chest pain
and had no EKG changes. She was quickly weaned off of
supplemental oxygen. Her chest xray on discharge showed
interval improvement in her pulmonary edema. A number of
changes were made to her medication regimen. Her hydralazine
was switched from a TID dosing to a QID dosing. Her lisinopril
was decreased from 10 mg TID to 10 mg [**Hospital1 **]. Her lasix was
increased to 40 mg PO daily from 40 mg PO every other day. She
was tolerating this medication regimen well on discharge with
blood pressures ranging from 130s to 140s systolic.
.
# Hypertensive Emergency: On admission the patient was noted to
have a systolic blood pressure in the 200s with evidence of a
mild troponin elevation and CHF consistent with hypertensive
emergency. Her renal function was at her baseline and she had
no evidence of encephalopathy. She was started on a
nitroglycerine drip and her outpatient hypertensive regimen was
altered as described above. Her blood pressure was stable on
this regimen for the remainder of her hospital course.
.
# Elevated Lactate: On admission the patient was noted to have
a lactate of 4.9 with evidence of an anion gap metabolic
acidosis. It was thought that this was likely due to
hypoperfusion in the setting of hypertensive crisis. Following
intervention to decrease her blood pressure this decreased to
1.7.
.
# COPD: The patient has a history of COPD. On admission she had
no evidence of COPD exacerbation. She was written for nebulizer
treatments PRN but did not require these.
.
# Chronic Renal Insufficiency: The patient has a baseline
creatinine of 2.3 which was her creatinine on presentation. Her
medications were renally dosed for decreased GFR.
.
# Diabetes: The patient has a history of type II diabetes for
which she takes oral hypoglycemics. During her MICU course she
was maintained on an insulin sliding scale with good control of
her blood sugars. She was discharged on her home diabetes
regimen.
.
# Prophylaxis: She received subcutaneous heparin for DVT
prophylaxis.
Medications on Admission:
glucerna shakes 1 can PO BID
furosemide 40mg PO QOD
isosorbide MN ER 60mg PO QD
effexor XR 37.5mg PO QD
lipitor 20mg PO QD
aspirin 325mg PO QD
senna 2 tabs PO QD
ferrous sulfate 325mg PO BID
lactulose 30mL PO BID
coreg 12.5mg PO BID
betoptic 0.25% O/S 1 drop in R eye [**Hospital1 **]
prilosec OTC 20mg PO QD
hydralazine 25mg PO TID (hold for SBP <110)
lisinopril 10mg PO TID (hold for SBP <110)
ntg SL prn
tylenol 650mg PO Q4 prn
[**Male First Name (un) **]-tussin SF 10mL PO Q4 prn cough
[**Name (NI) **]
MOM 30mL PO QHS prn
Fleet's enema 1 PR QD prn constipation
O2 at 2l/min via NC prn
Discharge Medications:
1. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed.
7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day:
Please hold for SBP < 110 or HR < 60.
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] (2 times a day).
12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Please hold for SBP < 110 .
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: Please hold for
SBP < 110 .
15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
four times a day: Please follow insulin sliding scale.
17. Humalog Insulin Sliding Scale
Insulin sliding scale for breakfast, lunch, dinner:
< 60 - give [**Location (un) 2452**] juice and crackers
60-150 - give 0 units
151-200 - give 2 units
201-250 give 4 units
251-300 - give 6 units
301-350 - give 8 units
351-400 - give 10 units
>400 - give 12 units and recheck within 1 hour
.
At Bedtime please give half of the dose for meal time sliding
scale.
18. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q5 minutes x 3 as needed for chest pain: Please take
for chest pain. Can take up to three tablets total. Please
call 911. .
19. Milk of Magnesia 7.75 % Suspension Sig: 30 mL PO once a day
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Primary:
Hypertensive Emergency
Congestive Heart Failure
.
COPD
Diabetes type II
Hypercholesterolemia
GERD
Glaucoma
Discharge Condition:
Good
Discharge Instructions:
You were seen and evaluated for your shortness of breath. You
were found to have an elevated blood pressure and evidence of
fluid in your lungs. You were treated with medications for your
blood pressure as well as for the fluid in your lungs.
.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take lasix 40 mg every day instead of every other day.
2. Please take hydralazine 25 mg every six hours instead of
every 8 hours.
3. Please take lisinopril 10 mg two times a day instead of three
times a day.
.
Please keep all your follow up appointments. You have an
appointment scheduled with your cardiologist Dr. [**Last Name (STitle) 2357**] on
[**10-30**]. You should also follow up with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within one week fo discharge.
.
Please seek immediate medical attention if you experience any
chest pain, shortness of breath, fevers > 101.5 degrees,
lightheadedness, diziness, numbness or tingling or any other
concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2200-10-31**] 12:00
.
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
[**Name (STitle) **] within one week of disharge. The office phone number is
[**Telephone/Fax (1) 6019**].
|
[
"530.81",
"428.0",
"250.00",
"403.00",
"438.89",
"585.9",
"496",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10452, 10528
|
4777, 7633
|
319, 325
|
10688, 10695
|
3548, 4093
|
11825, 12203
|
2597, 2688
|
8274, 10429
|
10549, 10667
|
7659, 8251
|
10719, 11802
|
2703, 3529
|
4110, 4754
|
276, 281
|
353, 2044
|
2066, 2379
|
2395, 2581
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,864
| 138,587
|
18829+56996
|
Discharge summary
|
report+addendum
|
Admission Date: [**2127-6-11**] Discharge Date: [**2127-6-24**]
Service: Neurosurgery
HISTORY OF THE PRESENT ILLNESS: The patient is an
89-year-old gentleman admitted to an outside hospital on
[**2127-6-5**] for recurrent left ear bleeding and epistaxis. The
bleeding required 2 units of packed red blood cells to be
transfused. An MRI demonstrated an opacification of the
mastoid suggestive of a soft tissue mass consistent with
blood clot. Ultimately, angiography demonstrated a left ICA
pseudoaneurysm. The patient was transferred to Dr.[**Name (NI) 9224**]
service for a left ICA stent placement.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Syncope. Carotid ultrasound, head CT, and MRI were all
negative in [**2126-8-27**].
3. Gout.
4. Emphysema.
5. Chronic renal insufficiency.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
pleasant, awake, alert, and oriented times three, afebrile.
Vital signs: BP was 114/57, heart rate 91, respiratory rate
27. HEENT: The patient had left ear packing in place.
Neurologic: Nonfocal. He was awake, alert, and oriented
times three. Moving all extremities. Cranial nerves II
through XII were intact. Cardiovascular/respiratory: Chest
was clear to auscultation. Regular rate and rhythm.
Abdomen: Soft, nontender, nondistended.
HOSPITAL COURSE: The patient was admitted with a left ICA
pseudoaneurysm with significant bleeding requiring
transfusion at an outside hospital. He was admitted to the
Neurosurgery Service. The patient was admitted to the ICU
for close neurologic evaluation and underwent an arteriogram
with stent placement.
On [**2127-6-12**], the patient underwent left ICA stent placement
for pseudoaneurysm. Post procedure, he was monitored in the
ICU. He tolerated the procedure well. He was transferred to
the regular floor on [**2127-6-14**]. He was in stable condition.
He was seen by the Cardiology Service for episodes of SVT.
It was recommended to start him on metoprolol 25 mg p.o.
b.i.d. and titrate for rate control. His vital signs
remained stable throughout his stay on the floor and he was
seen by Physical Therapy and Occupational Therapy and felt to
require rehabilitation.
He was also seen by the Hematology/Oncology Service for
workup of his anemia, although they felt that the extensive
workup could be done as an outpatient and it was not
necessary to do it is an inpatient.
On [**2127-6-18**], the patient was taken back to the Angio Suite
for stent placement for the ICA pseudoaneurysm. He was
admitted to the ICU post procedure. He was awake, alert, and
oriented times three. Pupils 5 down to 4. He had strong
grasp. Motor strength in all muscle groups was [**3-31**]. His
visual fields were full to confrontation. He continued to
have some oozing from the right groin from the sheath. He
had a crit which was trending downwards. It was 29.7 on [**2127-6-19**]. His IV heparin was discontinued. The sheath was
pulled in the afternoon. The patient's crit continued to
trend down and the patient had a firm right hip and groin
area.
The patient was taken for an abdominal CT on [**2127-6-20**] which
demonstrated a hematoma in the retroperitoneal space and
iliopsas. The aspririn dose was reduced to 81mg for 3 days and
the Hct remained stable until discharge and after restarting back
on ASA 325 mg.
He was again seen by Cardiology for problems with SVT and was
on some IV Neo while in the unit to keep his blood pressure
above 100. These were discontinued and the patient was
transferred to the regular floor on [**2127-6-23**]. He continued
on metoprolol 25 mg p.o. b.i.d. and it was titrated to keep
his heart rate less than 100 and keep his blood pressure
above 100. He continues to remain neurologically stable. He
continues back on the Plavix and aspirin.
He was transferred to the regular floor. He has been seen by
Physical Therapy and Occupational Therapy and found to
require rehabilitation.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q .d.
2. Plavix 75 mg p.o. q.d.
3. Propanolol 20 mg p.o. q. 24 hours.
4. Miconazole powder topically q.i.d. p.r.n.
5. Colace 100 mg p.o. b.i.d.
6. Ferrous sulfate 325 p.o. t.i.d.
7. Pantoprazole 40 mg p.o. q. 24 hours.
8. Hydrochlorothiazide 25 mg p.o. q.d.
CONDITION ON DISCHARGE: Stable at the time of discharge.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1132**] in three
to four weeks time and should continue on Plavix for 3 more
weeks and aspirin indefinitely.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2127-6-24**] 10:46
T: [**2127-6-24**] 10:58
JOB#: [**Telephone/Fax (2) 51544**]
Name: [**Known lastname 9606**], [**Known firstname **] Unit No: [**Numeric Identifier 9607**]
Admission Date: Discharge Date: [**2127-6-25**]
Date of Birth: Sex: M
Service:
Patient's discharge was delayed one day due to lack of rehab
bed. Patient did have one episode of heart rate into the
130s this morning with no change in blood pressure and no
change in mental status. He received 2.5 mg of IV Lopressor
and his heart rate came down to the 70s. He remains
neurologically stable. His vital signs are stable, and he is
ready for discharge to rehab with followup with Dr. [**Last Name (STitle) 365**] on
[**7-14**] at 2 pm.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2127-6-25**] 13:16
T: [**2127-6-25**] 13:17
JOB#: [**Job Number 9608**]
|
[
"998.12",
"274.9",
"430",
"285.1",
"401.9",
"E878.8",
"427.89",
"492.8",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.90",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
3983, 4273
|
1334, 3960
|
842, 1316
|
640, 827
|
5493, 5756
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,960
| 110,273
|
5817+5818
|
Discharge summary
|
report+report
|
Admission Date: [**2148-2-20**] Discharge Date: [**2148-2-29**]
Date of Birth: [**2104-4-9**] Sex: F
Service: MICU-B
HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old
female with a past medical history significant for severe
COPD ([**12-15**] - FEV1 0.36 and FVC 1.13), asthma, anxiety,
recently hospitalized at [**Hospital3 **] [**Date range (1) 23086**]. The
patient presented at that time with shortness of breath and
hypoxia. She was intubated for hypercapnic respiratory
failure. Unsuccessful weaning trials from ventilator, and
tracheostomy placed. The patient was reported to have a
episodes in which she became dyssynchronous from the
ventilator and required paralysis for adequate ventilation.
The etiology of episodes unknown. The patient was placed on
standing doses of BNZ. In addition, the patient had frequent
episodes of tachycardia and hypertension which were thought
to be secondary to anxiety. Also, MSSA bacteremia secondary
to line placement developed and was treated with oxacillin.
Discharged [**2-11**] to [**Hospital1 **] for slow wean from ventilator.
At [**Hospital1 **], the patient had multiple episodes of respiratory
distress. On day of discharge, the patient was noted to be
tachycardic to the 140s, but in sinus. She was also
tachypneic while on pressure support on the ventilator. Her
blood gas at that time was 7.40/45/55 and satting 88%. Vent
settings were not recorded. On exam, the patient had poor
air movement. She was difficult to bag. She was transferred
to [**Hospital1 18**] for further management. Prior to transfer, she was
given continuous nebs and Solu-Medrol 60 mg IV x 1.
In the Emergency Department, the patient was difficult to
bag. She was asynchronous with the vent while on pressure
support. Her tidal volumes were in the 100s. She was given
ativan 4 mg IV without effect. Fentanyl 100 mcg without
effect. She was started on propofol drip with improved
compliance, but transient blood pressure drop developed.
In the Intensive Care Unit on pressure support with poor
tidal volumes, the patient was given 2 mg of dilaudid IV. It
was discovered that repositioning the trach by hyperextending
the neck improved compliance and patient's tolerance of
pressure support.
In addition, white blood cell count 22, from 8.7 at time of
last discharge. The patient was given a dose of vancomycin,
Levaquin and Flagyl. A chest x-ray was without pneumothorax
or pneumonia. There was presence of left basilar
atelectasis. ECG showed only sinus tachycardia.
PAST MEDICAL HISTORY: 1) COPD/asthma, 2) Anxiety, 3) Mitral
valve prolapse, 4) Hypertension, 5) Positive PPD, treated
with INH x 6 months.
MEDICATIONS ON ADMISSION: 1) prednisone 15 mg po qd, 2)
fentanyl 25 mcg patch q 72 h, 3) risperidone 2 mg po bid, 4)
ativan 1 mg po q 6 h and q 4 h prn, 5) cardizem 30 mg po q 6
h, 6) Ambien 5 mg po q hs prn, 7) Celexa 60 mg po qd, 8) iron
sulfate 300 mg po qd, 9) potassium chloride 20 mEq po qd, 10)
captopril 50 mg po tid, 11) Singulair 10 mg po qd, 12)
Flovent MDI 110 mcg 2 puffs [**Hospital1 **], 13) nafcillin 2 mg IV q 6 h
through [**2148-2-21**].
ALLERGIES: Compazine.
SOCIAL HISTORY: Patient is estranged from her husband, with
one son, age 5. [**Name2 (NI) 6961**] are very involved in her care. She
has a history of tobacco use. She is a full code.
PERTINENT DATA ON ADMISSION - LABS: White blood cell count
12.8, hematocrit 27.2, platelets 314, 94% neutrophils, 0
bands, INR 1.3. Urinalysis negative. BUN 13, creatinine
0.5, potassium 4.1, magnesium 1.5. Arterial blood gas showed
pH 7.38, PCO2 42, PAO2 423 on R8 TV800 PEEP 20 and FIO2 100%.
HOSPITAL COURSE - 1) PULMONARY: The patient was continued on
around-the-clock nebulizers, MDI Flovent and Singulair. She
was started on Solu-Medrol 60 mg IV q 8 h and then was
changed on hospital day two to prednisone 60 mg po qd, and
was immediately started on a quick taper back to 15 mg po qd.
She was maintained on the vent on pressure support with PEEP,
and at the time of discharge was tolerating well pressure
support 10&5 with a FIO2 of 40%. Positioning of her head
which would cause occlusion of the opening to her trach tube
was found to be the source of her acute episodes of dyspnea
and anxiety. A new trach piece was ordered, and on the day
of transfer the patient was dilated by interventional
pulmonology and fitted with this new trach. For her anxiety,
she was maintained on Valium 5 mg q 6 h which was increased
to 7.5 mg IV q 6 h, with extra Valium prn.
2) INFECTIOUS DISEASE: The patient grew pan sensitive
Klebsiella in [**2-17**] blood culture bottles. Blood cultures were
drawn because of the patient's elevated white blood cell
count which was most likely secondary to steroids and/or
stress reaction. She was started on Levofloxacin and
ceftazidime. PICC line was pulled on the morning of
[**2148-2-22**]. Urine culture also grew greater than 100,000
[**Last Name (LF) 23087**], [**First Name3 (LF) **] the patient's Foley was changed, and she was
treated with oral fluconazole, her last dose of which was on
[**2148-2-25**].
3) CARDIOVASCULAR: The patient was maintained on diltiazem
and captopril for blood pressure and heart rate control.
4) GASTROINTESTINAL: The patient was maintained on tube
feeds.
DISCHARGE STATUS: The patient is stable for discharge back
to [**Hospital1 **], after placement of her new trach.
DISCHARGE MEDICATIONS: 1) Levofloxacin 500 mg po qd to
complete a 14-day course; her last dose should be on
[**2148-3-6**], 2) prednisone taper 15 mg po qd x 7 days, started
on [**2148-2-26**], then 10 mg po qd x 7 days, then 5 mg po qd x 7
days, 3) Valium 7.5 mg po q 6 h; maximum Valium given should
not exceed 30 mg in 8 h, 4) captopril 50 mg po tid, 5)
citalopram 40 mg po qd, 6) iron sulfate 325 mg po qd, 7)
risperidone 2 mg po bid, 8) fluticasone 110 mcg 2 puffs [**Hospital1 **],
9) Montelukast 10 mg po qd, 10) diltiazem 30 mg po qid, 11)
heparin 5,000 U subcu q 12 h, 12) Zantac 150 mg po bid, 13)
Atrovent nebulizer 1 nebulizer q 6 h prn, 14) albuterol
nebulizers 1 nebulizer q 3-4 h prn, 15) Atrovent MDI 2 puffs
qid, 16) albuterol MDI 1-2 puffs q 6 h prn, 17) salmeterol
inhaler 2 puffs [**Hospital1 **].
DISCHARGE DIAGNOSES: 1) Respiratory distress secondary to
mechanical obstruction of tracheostomy. 2) Anxiety. 3)
Gram-negative bacteremia. 4) [**Female First Name (un) 564**] urinary tract
infection.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**MD Number(1) 23088**]
MEDQUIST36
D: [**2148-2-27**] 10:15
T: [**2148-2-27**] 09:07
JOB#: [**Job Number 23089**]
Admission Date: [**2148-2-20**] Discharge Date: [**2148-2-29**]
Date of Birth: [**2104-4-9**] Sex: F
Service:
ADDENDUM: This is a STAT Discharge Summary Addendum to the
previously dictated Discharge Summary for the admission
[**2148-2-20**].
Interventional Pulmonology was unable to dilate for
tracheostomy placement at the bedside, so the patient was
taken to the operating room where her tracheostomy stoma was
dilated and a new tracheostomy tube was inserted. During the
procedure, it was noted that the patient had a tracheal
ulceration over the posterior wall 2 cm below the tracheal
stoma.
The patient tolerated this procedure well and reported being
able to breath easier with the new tracheostomy.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AEW
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2148-2-29**] 08:14
T: [**2148-2-29**] 08:31
JOB#: [**Job Number 23090**]
|
[
"493.20",
"519.1",
"790.7",
"041.3",
"519.02",
"300.00",
"518.83",
"112.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"31.99",
"96.6",
"97.23",
"33.21",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6268, 7655
|
5450, 6246
|
2722, 3177
|
167, 2554
|
2577, 2695
|
3194, 5426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,193
| 144,086
|
9448
|
Discharge summary
|
report
|
Admission Date: [**2165-9-23**] Discharge Date: [**2165-9-27**]
Date of Birth: [**2096-5-8**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Atenolol / Tegaderm
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Gastrointestinal Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 year old female with h/o GIB secondary to PUD, extensive CAD
with recent percutaneous angioplasty and stenting of SVG to RCA
conduit and OM1 on chronic plavix and ASA presenting with
hematchezia.
.
Pt recently hospitalized in CCU from [**Date range (1) 32223**] for treatment of
cardiogenic shock. On arrival patient noted to be persistently
hypotensive. ECHO on admission showed depressed EF of 20-25%,
diffuse WMA and elevated RA pressures. Echo was grossly
unchanged from baseline (7/[**2165**]). EKG was also unchanged from
baseline. Patient was cathed which showed new distal occlusions
in the OM1 and 90% stenosis of the RCA-ACG bypass, DES were
placed in both. Placed on Pepcid for GIB ppx.
.
Her [**9-3**] - [**9-20**] Hospital course was complicated:
1. Fluid overload/Kidney Failure necessitating CVVH. She
started on on CVVH with intermittent need for phenylephrine to
maintain sufficient MAPs. Phenylephrine was difficult to wean
but ultimately pt was started on midodrine, sudafed and
fludrocortisone to assist in raising SVR. In total ~20 L were
removed with CVVH. A new tunneled dialysis catheter was placed
prior to discharge with plan to continue dialysis in rehab and
ultimately resume outpatient HD.
2. Leukocytosis/Line Infection. During stay her right tunneled
dialysis line on the right was noted to be erythematous.
Cultures were sent from the line and 1 of 2 bottles grew gram
positive rods, gram negative rods and gram postive cocci in
pairs and chains. She was started on empiric Vancomycin and
Zosyn antibiotic tx and completed a 10 day.
.
Patient discharged to rehab on [**9-20**]. NOted this morning to pass
several maroon color stools with clots. EMS called; en route
SBPs noted to be SBP of 85 (per last d/c summary SBPs 80s-90s).
.
In the ED, initial VS: 97.7 91 84/41 18 98% 6L Nasal Cannula.
SBPs increased to 110s prior to IV hydration. Patient underwent
NG lavage which demonstrated scant clots with predominantly
bilious fluid; all clots resolved after flush with 500cc of IVF.
GI consulted and recommended transfusion and initiation of PPI
ggt, CT angio. Patient transfused 2units of uncrossed RBCs and
1u of platelets. Decision made to admit to MICU for further
mgmt.
.
On the floor, patient overall feeling "lousy". Denies abdominal
pain, nausea, vomiting, hematemesis. Reports acute worsening of
chronic non-productive cough. Reports stable 2 pillow
orthnopnea, stable edema. Denies fevers, chills, sweats.
Past Medical History:
- CAD s/p 4V CABG '[**51**] (LIMA to LAD, SVG to diag, SVG to Cx, SVG
to RCA), DES x3 to OM1 ([**2164-8-11**]), BMS to OM1 ([**2164-5-1**]), BMS x3
to LCX/OM ([**1-/2165**])
- TIA `97 or `98
- paroxysmal afib/flutter s/p multiple cardioversions '[**55**]/'[**56**];
d/c'd coumadin ~4yrs ago [**2-6**] GIB
- ESRD
- COPD on 3L home O2 (non compliant)
- Morbid obesity
- Hypertension
- Hyperlipidemia
- PVD s/p angioplasty of anterior tibial artery ([**9-11**]), s/p
angioplasty of right dorsal pedis ([**11-11**])
- s/p L5 amp & [**4-9**] metatarsal head resections
- GIB from PUD ~4 yrs ago
- OSA
- Chronic anemia (baseline ~ 32)
- C. diff colitis, toxin positive, in the absence of diarrhea
- Hypothyroidism
- Asthmatic bronchitis
- Sciatica
- Vertigo
- MRSA hx
Social History:
Lives in [**Location 86**], at home with her son, [**Name (NI) **]. She uses a
wheelchair at baseline and is on 2 liters O2. She formerly
worked as a homemaker and in meat wrapping.
-Tobacco history: quit smoking 30 years ago, smoked 2.5 ppd x
25yrs
-ETOH: no current alcohol use, none in past that she reports
-Illicit drugs: denies
Family History:
Mother died of breast cancer at age 60; sister died at 60 of
glioblastoma; father died of lung cancer at 73; and sister died
at 60 of heart disease; son died at [**Hospital1 18**], diabetic, of massive
MI in [**2160**]
Physical Exam:
On Admission:
General: Alert, sleeping but arousable, chronic hacking
non-productive cough
HEENT: Sclera anicteric, MMM, oropharynx clear without exudates,
lesions
Neck: supple, JVP hard to assess in setting of bilateral lines,
no palpable 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
TLD
-- right tunnelled line
-- left triple lumen
.
On Discharge:
T 96.6, BP 120/61, HR 92, RR 18, SO2 93% RA
Chest: erythema surrounding dialysis line
Exam otherwise as above
Pertinent Results:
Admission Labs:
[**2165-9-23**] 09:00PM BLOOD WBC-14.6* RBC-2.74* Hgb-7.1* Hct-22.3*
MCV-81* MCH-25.9* MCHC-31.8 RDW-18.8* Plt Ct-173
[**2165-9-23**] 09:00PM BLOOD Neuts-86.1* Bands-0 Lymphs-8.2* Monos-4.6
Eos-1.0 Baso-0
[**2165-9-23**] 09:00PM BLOOD PT-13.6* PTT-32.4 INR(PT)-1.2*
[**2165-9-23**] 09:00PM BLOOD Glucose-65* UreaN-21* Creat-2.5*# Na-140
K-3.7 Cl-102 HCO3-31 AnGap-11
[**2165-9-24**] 12:32AM BLOOD CK-MB-3 cTropnT-0.16*
[**2165-9-25**] 03:29AM BLOOD CK-MB-4 cTropnT-0.18*
[**2165-9-26**] 05:05AM BLOOD CK-MB-4 cTropnT-0.19*
[**2165-9-24**] 12:32AM BLOOD Calcium-8.0* Phos-2.3*# Mg-1.9
.
CTA
1. Slightly decreased wall thickening at the hepatic flexure of
the colon
consistent with improving colitis. Focal areas of colonic
mucosal enhancement but no definite areas of active
extravasation into the GI tract to suggest a site for GI
bleeding.
2. Hypodense lesion in the pancreatic head which may represent a
cystic
lesion or dilated side branch. Recommend follow up MRI in 1
year.
3. Bilateral pleural effusions, stable from prior study.
4. Moderate narrowing at the origin of the left renal artery.
.
CXR
IMPRESSION: Since [**2165-9-19**], right effusion has
increased and now is moderate in quantity. Bilateral lower lung
atelectasis left more than right is stable as is left pleural
effusion. Stable, moderate to severe
cardiomegaly.
.
Discharge Labs:
[**2165-9-27**] 04:50AM BLOOD WBC-6.7 RBC-3.04* Hgb-8.5* Hct-26.2*
MCV-86 MCH-28.0 MCHC-32.4 RDW-19.6* Plt Ct-183
[**2165-9-27**] 04:50AM BLOOD Glucose-91 UreaN-24* Creat-4.0*# Na-135
K-3.8 Cl-96 HCO3-30 AnGap-13
[**2165-9-27**] 04:50AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1
Brief Hospital Course:
69 year old female with h/o GIB secondary to peptic ulcer
disease, extensive CAD s/p CABG and ischemic cardiomyopathy with
chronic systolic heart failure with recent DES of SVG-RCA
conduit and OM1 one month ago on Plavix and ASA, and ESRD on HD
admitted with hematchezia. Course was notbable for ICU admission
for atrial fibrillation with rapid ventricular response.
.
#Gastrointestinal hemorrhage:
The patient was initially admitted to the ICU for atrial
fibrillation but hemoatocrit was stable. A NG lavage was
performed with no obvious bleeding but ?scant coffee ground. Pt
was managed with a PPI and a CT was performed which showed
improved hepatic flexure colitis. The patient was transfused
3units PRBCs and 1 units platelets and hematocrit remained
stable. GI was consulted as was the patient's Cardiologist Dr.
[**Last Name (STitle) **]. ASA and Plavix were continued given recent stent placment
and endoscopy was deferred given low likelihood of an
intervenable lesion and the patients somewhat tenuous
cardiopulmonary status. The patient was transferred to the floor
and hematocrit remained stable without further evidence of
hematochezia. PPI was discontinued and patient was placed back
on H2blocker therapy as the most likely source of bleeding was
felt to be mild hepatic flexure ischemic colitis on the
background of dual anti-platelet therapy.
.
# A.Fib CHADS score 4: not previously anticoagulated due to h/o
recurrent GI bleeds. Patient had been started on amiodarone on
last CCU admission, but given rapid Afib the patient was
reloaded with amiodarone with conversion to sinus rhythm.
Patient was then transitioned to 200 mg by mouth daily which
should be continued after discharge.
.
# Acute on Chronic Cough. Etiology includes pulmonary edema,
COPD exacerbation and PNA (less likely) although felt most
likely to be due to volume overload. Patient treated with
supportive care and HD intiatated on HD3. Sputum cultures were
sent which grew only normal upper respiratory flora.
.
#Acute on chronic systolic heart failure: TTE [**9-15**] showed severe
regional left ventricular systolic dysfunction and severe hypo
to akinesis of the entire septum, anterior wall, and distal [**2-7**]
of the left ventricle. At time of discharge on [**9-21**] pt's weight
had decreased from 143kilos to 119 kilos. Chest Xray showed
worsening bilateral pleural effusions. Fluid was managed with
hemodialysis and Fludracortisone dosage was reduced as the
patient was not hypotensive and tolerated hemodialysis well.
.
# CAD. Patient with extensive CAD history. [**9-13**] Cath with new
distal occlusions in the OM1 and 90% stenosis of the RCA-ACG
bypass and patient s/p DES to occlusions. Currently patient
without complaints of chest pain or anginal equivalent. Patient
continued on ASA, Plavix due to risk of instent thrombosis.
Cardiac enzymes cycled and were consistent with baseline. During
ICU stay patient without signs or symptoms of active angina and
she remained asymptomatic on the floor.
.
# COPD. On home 3L NC. During last admission patient started on
advair, ipratropium and albuterol nebs. She completed a short
course of solumedrol, and a prednisone taper (finished on [**9-22**]).
O2 sats were in low to mid 90's on RA at time of discharge.
Currently patient saturating 90-595% at baseline requirement of
3L.
.
# DM. Home 70/30; 30 in AM, 20u qhs with regular ISS. Home
regimen continued. Patient also continued on Gabapentin for
treatment of peripheral neuropathy.
.
# Hypothyroidism. TSH and free T4 were WNL on last admission.
Continued on home levothyroxine 100mcg.
#ESRD on HD: Patient was continued on hemodialysis for
management of volume and continued on midodrine and
fludracortisone. Fludracortisone dose was reduced during
admission. Given probable ischemic colitis the dose of midodrine
could be down titrated as tolerated by blood pressure to reduce
risks of end organ ischemia.
Transitional Issues:
1. Incidental hypodense lesion on pancreatic head identified on
abdominal imaging with recommended follow-up in one year.
2. Follow-up with gastroenterologist as an outpatient.
3. Fludricortisone dose was decreased from 0.2 to 0.1 mg at
discharge. Pt should be gradually tapered off over the next few
weeks as tolerated. She should receive one week of 0.1 mg, then
one week of 0.05 mg, then off. Start date of taper is [**2165-9-27**].
Medications on Admission:
x 70/30: 30u qAM
x ISS
x Levothyroxine 100mcg QD
x Midodrine 10mg TID
x Omega 3 Fish Oils 1000mg [**Hospital1 **]
x Tiotropium Bromide 18mcg/cap inhalation
x Vitamin B Complex 1cap QD
x Bupropion XL 150mg QD
x Guaifenesin 100 TID
x Albuterol neb Q6hrs
x Amiodarone 400mg TID thru [**9-24**]
x Amiodarone 200mg QD (start on [**9-25**])
x ASA 325mg QD
x Atorvastatin 40mg qhs
x Plavix 75mg QD
x Famotidine 20mg [**Hospital1 **]
x Fludrocortisone 0.2mg QD
x Fluticasone/Salmeterol 250/50 1puff [**Hospital1 **]
Discharge Medications:
1. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Thirty (30) units Subcutaneous QAM.
2. Humalog 100 unit/mL Solution Sig: ASDIR units Subcutaneous
ASDIR: Please use as directed by her prescribing physician. .
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. bupropion HCl 150 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
8. guaifenesin 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation Q6H (every 6
hours) as needed for SOB.
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
15. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM.
18. heparin (porcine) 1,000 unit/mL Solution Sig: ASDIR ASDIR
Injection PRN (as needed) as needed for line flush.
19. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
20. senna 8.6 mg Capsule Sig: Two (2) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Gastrointestinal Bleed
Congestive Heart Failure
End-Stage Renal Disease
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 32090**]:
.
You were admitted to [**Hospital1 18**] with a gastrointestinal bleed that
was most likely due to inflammation in your colon. There was
initially concern that you would need a procedure called a
colonoscopy but this was deferred as you were in the ICU. The
bleeding gradually stopped and it was felt that you were safe to
return to rehab. You may continue to pass occasional blood clots
for several days.
.
The following changes were made to your medications:
1. Your dose of Fludricortisone was decreased to 0.1 mg by mouth
daily.
2. Stop taking Amiodarone 400 mg by mouth twice a day. Your only
Amiodarone dose at this time should be 200 mg by mouth once a
day.
3. Stop taking your Omega-3 supplement as this can increase your
risk of bleeding.
4. Start taking Nephrocaps 1 cap by mouth daily.
5. Your Aspirin was changed to a 325 mg enteric coated
formulation. Continue to take 1 tablet by mouth daily.
6. Stop taking Coumadin.
.
No other changes were made to your medications and you should
continue taking all other medications as previously prescribed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
No appointments were made for you as you are being discharged to
a rehabilitation facility. Please have the rehabilitation
facility make an appointment for you with your primary care
doctor and also Dr. [**Last Name (STitle) **].
Completed by:[**2165-9-28**]
|
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
500
| 141,591
|
27100+57522
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-3-14**] Discharge Date: [**2200-4-4**]
Date of Birth: [**2140-8-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
- aorto-biliac aortic aneurysm repair with supraceliac cross
clamping
- insertion of swan catheter
- CVL placement
History of Present Illness:
59 y/o M underwent a cardiac evaluation early in [**2199**] that
showed a 5.6cm aortic aneurysm. This was confirmed on a CT scan
just days later. He had no previous history of this aneurysm.
Past Medical History:
1. CAD s/p CABG in [**2192**]
a. [**2199-8-8**] cardiac catheterization - torturous right iliac,
unable
to evaluate the graft site for AAA surgery. The LM had a 100%
stenosis and is s/p CABG (LIMA-LAD, SVG-OM) at [**Hospital3 **] [**Hospital1 107**].
b. [**2198**] stress test - exercised 5'[**21**]" of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol to 60%
APMR stopping d/t leg pain. EKG showed 1-2.5mm info lateral ST
depressions which resolved 10 minutes into recovery. Nuclear
images showed a significant inferoapical and posterior, mostly
reversible defect.
c. [**5-26**] echo -concentric LVH with no wall motion abnormalities.
EF
60-65%. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. LA enlargement. There is a 5.4cm AAA.
[**12/2182**] CABG - (LIMA-LAD, SVG-OM)
2. high cholesterol
3. HTN
4. AAA 5.6 cm, last US [**2200-1-9**]
5. obesity
6. tobacco abuse
Social History:
Married for 10+ with two from a previous
marriage. He works full time night shifts as a security guard.
His wife will drive him to and from the hospital. 50 pyr smoking
hx, occ ETOH (beers), no IVDU
Family History:
[**Name (NI) 41900**] CAD Father had angina at age 59 and died at age 69
of MI, stroke. M died at 71 from liver cancer
Physical Exam:
vitals: 98.7 58 116/54 20 95%
generally well appearing in no acute distress
oriented to place and person, flat affect
ctab, no w/c/r
rrr, no m/r/g
soft, nt, nd, nabs, incision clean/dry/intact and well healed
no c/c/e, pulses 2+ x4
Pertinent Results:
[**2200-4-3**] 07:05AM BLOOD WBC-11.3* RBC-3.39* Hgb-9.9* Hct-30.0*
MCV-89 MCH-29.2 MCHC-33.0 RDW-13.4 Plt Ct-678*
[**2200-3-21**] 01:56AM BLOOD Neuts-78.7* Lymphs-9.7* Monos-5.0
Eos-6.5* Baso-0.1
[**2200-4-3**] 07:05AM BLOOD Plt Ct-678*
[**2200-3-30**] 03:08AM BLOOD PT-14.2* PTT-26.3 INR(PT)-1.3*
[**2200-3-14**] 08:08PM BLOOD Fibrino-100*
[**2200-4-3**] 07:05AM BLOOD Glucose-85 UreaN-33* Creat-1.6* Na-140
K-5.1 Cl-105 HCO3-22 AnGap-18
[**2200-4-3**] 08:35AM BLOOD ALT-112* AST-60* AlkPhos-229* Amylase-93
TotBili-0.7
[**2200-3-23**] 09:05AM BLOOD CK(CPK)-121
[**2200-4-3**] 08:35AM BLOOD Lipase-104*
[**2200-4-3**] 08:35AM BLOOD Albumin-3.3*
[**2200-4-3**] 07:05AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.7
[**2200-4-3**] 08:35AM BLOOD VitB12-1105* Folate-18.6
[**2200-3-23**] 03:00AM BLOOD TSH-1.5
[**2200-3-30**] 03:32AM BLOOD freeCa-1.25
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2200-4-2**] 5:15 PM
Reason: please eval for focal infarct / bleed
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p AAA repair POD 19 with mental status changes
and overall decreased mentation
REASON FOR THIS EXAMINATION:
please eval for focal infarct / bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 59-year-old male status post AAA repair,
postoperative day #19, presenting with mental status changes.
COMPARISONS: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: Study is limited secondary to motion artifacts.
Allowing for this factor, there is no evidence of acute
intracranial hemorrhage, mass effect, shift of normally midline
structures or hydrocephalus. [**Doctor Last Name **]- white matter differentiation
appears well preserved. Basal cisterns are patent. Ventricles,
cisterns and sulci are unremarkable. There are calcifications
within the vertebral and internal carotid arteries,
atherosclerotic in origin. The basilar artery appears tortuous
without definite aneurysmal dilatation. There is opacification
within the visualized superior aspect of the maxillary sinuses
with frothy secretion component. No fractures are identified.
The mastoid air cells are well aerated.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Prominent, tortuous basilar artery without definite
aneurysmal dilatation.
3. Likely maxillary sinus disease. The maxillary sinuses are not
completely imaged on this head CT scan.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**Doctor First Name **] [**2200-4-3**] 8:31 AM
Brief Hospital Course:
The Pt. was admitted after undergoing an open repair of an
abdominal aortic aneurysm. The pt. tolerated the procedure well
and spent the evening in the PACU under ICU observation. The
following day he was taken to the ICU. Please see operative
report for further details. The pt. initially had an episode of
hypostension with a sbp of 80s and MAP of 60 which resolved with
fluid and a dopamine gtt. This gtt was quickly weaned and pt.
was able to maintain satisfactory sbps on his own.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
5. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Succinate 200 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**] Inc.
Discharge Diagnosis:
- s/p open AAA repair
- post operative delerium
- post-operative hypotension
- post-operative anemia
- poast-operative acute renal failure
Discharge Condition:
- stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING AORTIC SURGERY
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
.
There are no specific restrictions on activity other than no
lifting an object heavier than twenty-five (25) pounds for the
first three (3) months. Gradually increase your level of
activity back to normal depending on how you feel. Fatigue is
normal, especially for the first month postoperative. Resume
driving when you feel strong enough and comfortable enough
without needing pain medication.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Severe and worsening abdominal pain .
.
Pain or swelling in one of your legs.
.
Increasing pain, redness or drainage related to your incision(s)
.
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 8 weeks.
.
Resume driving when you feel strong enough and comfortable
enough without needing pain medication .
.
No heavy lifting greater than 20 pounds for 8 weeks.
.
Avoid excessive bending at the hips and stooping for 4 weeks.
.
BATHING/SHOWERING:
.
You may shower immediately if the incision is dry upon coming
home. No baths until sutures / staples are removed. Dissolving
sutures may have been used. In either case, you can wash your
incision gently with soap and water.
.
WOUND CARE:
.
Suture / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.
.
MEDICATIONS:
.
You may resume taking medication you were on prior to your
surgery unless specifically instructed otherwise by your
physician [**Name9 (PRE) **] will be given a new prescription for pain
medication, which should be taken every three (3) to four (4)
hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid heavy lifting (over 20 pounds) for 8 weeks after surgery.
.
No strenuous activity for 4-6 weeks after surgery.
.
DIET:
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:00 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
- you should call Dr.[**Name (NI) 5695**] office to schedule a
follow-up appointments. Please call his office at ([**Telephone/Fax (1) 16580**] to schedule a post-op check up.
- you should also follow-up with your primary care physician for
medication, blood pressure, blood sugar, and routine follow-up
care.
Completed by:[**2200-4-4**] Name: [**Known lastname **],[**Known firstname 1495**] C Unit No: [**Numeric Identifier 11582**]
Admission Date: [**2200-3-14**] Discharge Date: [**2200-4-4**]
Date of Birth: [**2140-8-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1546**]
Addendum:
Hospital Course
The Pt. was admitted after undergoing an open repair of an
abdominal aortic aneurysm. The pt. tolerated the procedure well
and spent the evening in the PACU under ICU observation. The
following day he was taken to the ICU. Please see operative
report for further details.
[**3-15**]
Propofol / vented
ATN noted
lytes followed / replenished / fluid management
ativan for etoh use
[**3-19**]
Vent wean with atteept to decrease peep
[**3-21**]
PRBC
Vent wean with attept to decrease peep
lytes followed / replenished / fluid management
EKG changes with elevated CPK / MB - cardiology consulted.
[**2200-3-22**]
Vent wean with attept to decrease peep
lytes followed / replenished / fluid management
TF started and advanced
[**2200-3-23**]
Vent wean with attept to decrease peep
lytes followed / replenished / fluid management
TF
Pt experiences agitation on atttempted wean
[**2200-3-24**]
Vent wean with attempt to decrease peep
lytes followed / replenished / fluid management
TF
Sinusitis with pos cx'x
IV antibiotics started
Increase sodium / free water given
Creat improves
[**2200-3-25**]
Vent wean with attept to decrease peep
lytes followed / replenished / fluid management
TF
Pt bronched for therapeutic aspiration
[**2200-3-26**] - [**2200-3-27**]
Vent wean with attept to decrease peep
lytes followed / replenished / fluid management
TF
H-flu / AB adjusted
[**2201-3-28**]
Pt extubated
AB / creat improved
[**2200-3-29**]
Pnuemonia / chest PT
Pt OOB
[**2200-3-30**]
Pt transfered to the VICU
lytes followed / replenished / fluid management
TF
creat continues to improve
[**2199-3-31**] - [**2199-4-2**]
OOB / diet advanced / TF DC'd
lytes followed / replenished / fluid management
[**2200-4-1**]
Mentation improves / WBC decreases / creat improves
Lines DC'd
Pt consult
[**2200-4-3**]
Pt transfered to the floor
PT clears to go home with monitering
[**2200-4-4**]
Pt stable for DC
to follow-up with Dr [**Last Name (STitle) **]
Wife agrees
Discharge Disposition:
Home With Service
Facility:
[**Company 720**] Inc.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2200-4-4**]
|
[
"276.0",
"291.81",
"413.9",
"458.29",
"428.0",
"414.01",
"442.2",
"997.5",
"473.8",
"441.4",
"V45.81",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.56",
"96.6",
"38.93",
"38.48",
"38.44",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
14501, 14710
|
4921, 5413
|
339, 456
|
6258, 6268
|
2233, 3192
|
11719, 14478
|
1842, 1962
|
5436, 5999
|
3229, 3326
|
6097, 6237
|
6292, 8020
|
1977, 2214
|
274, 301
|
3355, 4898
|
8032, 11019
|
11042, 11696
|
484, 678
|
700, 1609
|
1625, 1826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,904
| 156,412
|
10535
|
Discharge summary
|
report
|
Admission Date: [**2180-4-5**] Discharge Date: [**2180-4-17**]
Date of Birth: [**2114-3-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Transfer from [**Hospital1 **] s/p MVA ? hemorrhage and cerebellar mass
Major Surgical or Invasive Procedure:
Intubation for MRI due to severe claustrophobia [**2180-4-6**]
R Suboccipital Crani for Mass Resection [**2180-4-14**]
History of Present Illness:
Mr [**Known lastname **] is 66 y/o male with HTN, CAD and PAD. Was in his
normal state of health today, with the exception of feeling
exausted after being up for 72 hours trying to pump out his
basement. He remembers going to [**Company 7546**] and leaving the
parking lot that is the last thing he remembers. He awoke with
the arrival of the EMS, he was found in the parking lot the
details of what he hit are unavailable and there is discrepancy
about whether the air bag deployed. He was brought to [**Hospital **]
hospital and found to have ? cerebellar mass versus stroke and
right occiptal partieal focus of IPH. These appear to be more
concerning for masses than trauma. The patient only complains of
low back pain at this time.
Past Medical History:
CAD, PAD, has had right iliac artery stent and right coronary
artery stent
Social History:
Former smoker 60 pack year hx stopped in [**2171**]. Drinks 3-4
glasses of wine per day. No illicit drug uses. Lives with wife,
works part time installing fire suppression systems.
Family History:
non-contributory
Physical Exam:
Upon admission:
BP:150/81 HR:80 R 18 O2Sats 98%
Gen: WD/WN c/o back pain
HEENT: Pupils: [**4-22**] EOMs full;
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No pronator drift
Motor:
D B T IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 3 5 5 5 5 5
L 5 5 5 3 5 5 5 5 5
Note IP most likely limited by pain
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, unable to test heel
to shin due to back pain.
Patient did not want me to turn him according to trauma there
was lumbar point tenderness. No bowel or bladder incontinence
Upon discharge:
SAME as above. Neurologically intact. Incision Clean, Dry, and
Intact
Pertinent Results:
CT Abdomen with contrast [**2180-4-5**]:
1. Age-indeterminate L3 and L4 compression fractures. Recommend
clinical
correlation. No evidence of acute visceral injury in the abdomen
or pelvis.
2. Esophageal wall thickening and regional gastrohepatic
lymphadenopathy.
Recommend endoscopy for further evaluation. Follow-up and
further evaluation for cause of lymaphdenopathy should be
obtained if endoscopy is negative and no other source
identified.
3. Right lower lobe pulmonary nodule measure up to 6-mm.
Recommend dedicated chest CT for further evaluation. Six-month
followup CT should also be performed to assess stability, given
patient's smoking history.
4. Hypodense hepatic lesion in segment IV. Recommend ultrasound
or MRI for
further characterization.
MRI Brain [**2180-4-6**]:
Numerous enhancing masses throughout the supra- and
infratentorial compartments, without subependymal or
leptomeningeal enhancement. The findings most likely represent
multiple metastatic lesions, likely mucinous adenocarcinoma from
a gastrointestinal primary site, given the MR [**First Name (Titles) **] [**Last Name (Titles) 34702**], as well as the findings on the body CT scan.
CT Chest with contrast [**2180-4-6**]:
1. Right middle lobe lung nodule. Followup in three months is
recommended.
2. Fatty liver with a focal lesion in the left lobe of the
liver. As
recommended in prior CT abdomen, MR could be performed.
3. Soft tissue asymmetry in the right side at the level of the
cricoid. This can be evaluated either with physical exam or
endoscopy.
4. Regional gastrohepatic lymphadenopathy associated with
esophageal wall
thickening as mentioned in prior CT should be evaluated.
5. Coronary calcifications.
Ultrasound of the liver [**2180-4-6**]:
1. No liver lesion to correlate with hypodensity seen on CT scan
identified.
No worrisome lesions identified.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver
disease and more advanced liver disease including significant
hepatic
fibrosis/cirrhosis cannot be excluded on this study.
MRI L-spine with and without contrast [**2180-4-6**]:
1. Multiple subacute compression fractures throughout the
visualized
thoracolumbar spine, corresponding to the findings on the
prompting CT scan. There is no associated soft tissue mass and
there is some normal residual bone marrow within each vertebral
body. Both the MR [**First Name (Titles) **] [**Last Name (Titles) **] appearance suggests that these are most
likely "benign" osteoporotic fractures, without features
suspicious for malignant involvement.
2. Chronic bilateral L5 spondylolysis with associated Grade I
anterolisthesis as detailed, and resultant foraminal narrowing,
more significant on the right.
MRI Brain [**4-14**]:
1. Multiple enhancing lesions, in the brain and the cerebral and
the
cerebellar hemispheres, redemonstrated for surgical planning;
the largest
lesion in the right cerebellar hemisphere measures 2.5 x 2.6 x
2.0 cm. There has been interval evolution of the lesions, with
increased necrosis and more conspicuous rim enhancement on the
present study compared to the prior study of [**4-6**], several new
lesions compared to the prior study of [**2180-4-6**]. This is a
limited study, performed for pre-surgical planning. Complete sMR
tudy is recommended to assess betetr the interval
change/progression.
LABS:
Amdission:
[**2180-4-5**] 01:41PM WBC-13.6*# RBC-4.38* HGB-11.3* HCT-34.3*
MCV-78*# MCH-25.8*# MCHC-33.0 RDW-13.5
[**2180-4-5**] 01:41PM PT-13.7* PTT-28.1 INR(PT)-1.2*
[**2180-4-5**] 01:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2180-4-5**] 03:00PM GLUCOSE-135* UREA N-7 CREAT-0.7 SODIUM-123*
POTASSIUM-3.9 CHLORIDE-87* TOTAL CO2-29 ANION GAP-11
Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2180-4-17**] 05:50AM 10.5 4.23* 10.3* 32.9* 78* 24.4* 31.3
13.6 421
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2180-4-17**] 05:50AM 991 12 0.6 130* 4.8 94* 27 14
Brief Hospital Course:
The patient was transferred to [**Hospital1 18**] from an outside hospital
for evaluation of multiple intracranial massess after an episode
of LOC. Additional work up from the OSH included a CT of the
chest/abdomen that revealed a hypodensity in the liver and a
chronic L2 compression fractures. He was hyponatremic upon
admission and was admitted to the ICU for Q1 hour neuro checks
and q4 hr sodium checks. His neurologic examination was notable
only for mild dysmetria on his right upper extremity.
The patient was placed on hypertonic saline for the first night
and was switched to salt tablets on [**4-6**] when his Na was 130. A
brain MRI was required for the work up but the patient could not
tolerate the study due to severe claustrophobia. Ultimately, he
required intubation for the study. The MRI revealed multiple
brain lesions. MRI of the lumbar spine was negative for any
metastasis. Additionally, he had a liver ultrasound to further
evaluate a hypodensity seen on CT scan. The ultrasound was
negative for any concerning lesions.
The case was reviewed in the BTC. It was felt that the right
cerebellar lesion was of a sufficient size as to warrant
resection before whole brain radation can be safely
administered. Since the patient had been on ASA, the plan was
to discharge the patient to have him return as an outpatient for
his surgery. However, the patient failed PT eval, requiring
additional hospital stay. Ultimately, the patient was taken to
the OR prior to discharge. On [**4-14**], the patient underwent a
right suboccipital craniotomy for tumor resection. He tolerated
the procedure well. He was closely monitered in the ICU for the
following 36 hours and then transferred to to the floor.
Post-operatively, he remained neurologically unchanged relative
to his preoperative examination. He was OOB independently and
had very little post operative pain. He was seen by Physical
Therapy, who recommended that he was fine to return to home
without services.
He was discharged to home on [**4-17**]. Appointments were made for
the patient in terms of radiation therapy and GI endoscopy in
accordance to the patient's request. He will follow up with Dr. [**Name (NI) 34703**] office in [**4-25**] weeks. He will resume his ASA use 1 month
after surgery.
Medications on Admission:
ASA 325mg, Diova 160mg QD,
Lopressor 50mg [**Hospital1 **], Vitoran 1080 QD
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Meds
Please continue to take your home medications Diovan and
Vytorin.
Discharge Disposition:
Home With Service
Facility:
VNA of the [**Location (un) 1121**]
Discharge Diagnosis:
Multiple brain lesions
Cerebellar mass - Metastesis of unknown origin
SIADH
Discharge Condition:
Neurologically stable
Discharge Instructions:
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.
?????? 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.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc. FOR ONE MONTH
?????? 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:
You have an appointment in the Brain [**Hospital 341**] Clinic on [**5-1**] at
2:00pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Be sure you notify your Primary care Doctor regarding the
pulmonary nodule that was found on your Chest CT. You should
have a repeat CT of your lungs in 3 months.
Also, you should have a repeat check of your sodium level next
week with your PCP. [**Name10 (NameIs) **] should stay on a strict 1.2L fluid
restriction until you see him/her.
Completed by:[**2180-4-17**]
|
[
"780.39",
"253.6",
"401.9",
"443.9",
"733.13",
"198.3",
"V45.82",
"199.1",
"431",
"414.01",
"300.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
10350, 10416
|
7326, 9613
|
391, 512
|
10536, 10560
|
3227, 7303
|
12335, 13107
|
1592, 1610
|
9740, 10327
|
10437, 10515
|
9639, 9717
|
10584, 12312
|
1625, 1627
|
279, 353
|
3136, 3208
|
540, 1278
|
2012, 3120
|
1641, 1760
|
1775, 1996
|
1300, 1377
|
1393, 1576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,407
| 120,997
|
38914
|
Discharge summary
|
report
|
Admission Date: [**2158-1-25**] Discharge Date: [**2158-2-2**]
Date of Birth: [**2115-3-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endoscopy
Banding of Esophageal Varices
Blood Transfusion
History of Present Illness:
42 yo M with history of ETOH and HCV cirrhosis with new
hematemesis and melena since the day prior to admission.
Initially presented to [**Hospital1 8**] ED the morning of admission.
Had NGT placed with reportedly 600cc of bloody return. Alcohol
level 21 at [**Hospital1 8**], last drink about 24 hours ago. Two 18g
IVs were placed, 2L NS were given, Protonix, Zofran 8mg,
Dilaudid 1mg IV and he was transferred to [**Hospital1 18**]. Initial ED VS
97.4, 127, 145/71, 18, 96/RA. Abdomen tender in epigastrum. Hct
initially 40/37 on simultaneous lab draws. Given 1.5L and put on
Protonix gtt. NG lavage with coffee ground and brown clot. Given
Valium 5mg x 2, A&O x 3 but sleepy. Given Octreotide gtt,
Protonix bolus & gtt, Ciprofloxacin 400mg IV x 1. VS upon
transfer 140/80, (lowest 125/70), HR 110s (Peak 130s).
.
On the floor, patient confirms new bloody vomit starting at
midnight. No prior hematemesis, melena. Does use Ibuprofen
intermittently and drinks 6-12 beers/daily. Confirms h/o alcohol
detox stays with tremulous and palpitations. No h/o
hallucinations or seizure with alcohol withdrawl.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
EtOH Abuse
Cirrhosis
Hepatitis C: No prior treatment
Diabetes Mellitus 2 - 20 + years
Tobacco Use
Depression
Hypertension
GERD
Pancreatitis
Diverticulitis
Hemorrhoids
Atypical chest pain
Social History:
- Tobacco: 1 ppd x 20+ years
- Alcohol: 6-12 beers daily
- Illicits: None
Family History:
No history of bleeding disorders or abdominal bleeding. Both
parents still living.
Physical Exam:
Vitals: T: 97 BP: 127/54 P: 112 R: 18 18 O2: 96/RA
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:
[**2158-1-25**] 07:29AM BLOOD WBC-14.3* RBC-4.42* Hgb-12.5* Hct-37.0*
MCV-84 MCH-28.4 MCHC-33.9 RDW-13.4 Plt Ct-176
[**2158-1-25**] 09:59AM BLOOD Hct-31.7*
[**2158-1-25**] 03:25PM BLOOD Hct-32.8*
[**2158-1-25**] 07:45PM BLOOD Hct-40.4
[**2158-1-26**] 02:30AM BLOOD WBC-7.5 RBC-4.34* Hgb-12.8* Hct-36.7*
MCV-85 MCH-29.5 MCHC-34.9 RDW-13.4 Plt Ct-75*#
[**2158-1-27**] 05:45AM BLOOD WBC-6.2 RBC-4.58* Hgb-12.6* Hct-38.2*
MCV-83 MCH-27.6 MCHC-33.1 RDW-13.7 Plt Ct-72*
[**2158-1-29**] 06:00AM BLOOD WBC-4.0 RBC-4.71 Hgb-13.2* Hct-39.2*
MCV-83 MCH-27.9 MCHC-33.6 RDW-14.1 Plt Ct-83*
[**2158-2-2**] 04:45AM BLOOD WBC-6.8 RBC-5.06 Hgb-14.1 Hct-42.4 MCV-84
MCH-28.0 MCHC-33.3 RDW-13.8 Plt Ct-108*
[**2158-1-25**] 07:29AM BLOOD PT-15.8* PTT-31.2 INR(PT)-1.4*
[**2158-2-2**] 04:45AM BLOOD PT-15.4* PTT-35.6* INR(PT)-1.4*
[**2158-1-25**] 07:29AM BLOOD Glucose-128* UreaN-23* Creat-0.6 Na-138
K-3.8 Cl-99 HCO3-31 AnGap-12
[**2158-2-2**] 04:45AM BLOOD Glucose-380* UreaN-10 Creat-0.8 Na-133
K-4.1 Cl-96 HCO3-29 AnGap-12
[**2158-1-25**] 07:29AM BLOOD ALT-122* AST-163* CK(CPK)-411*
AlkPhos-145* TotBili-1.2
[**2158-2-2**] 04:45AM BLOOD ALT-161* AST-154* LD(LDH)-172
AlkPhos-183* TotBili-1.0
[**2158-1-27**] 05:45AM BLOOD Lipase-26
[**2158-1-25**] 07:29AM BLOOD cTropnT-<0.01
[**2158-1-25**] 07:29AM BLOOD Albumin-3.8
[**2158-2-2**] 04:45AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.6 Mg-1.8
[**2158-1-27**] 05:45AM BLOOD AFP-4.4
Imaging
CXR [**1-25**]
FINDINGS: Nasogastric tube has been advanced into the body of
the stomach. The exam is otherwise not appreciably changed
allowing for technical differences
CXR [**1-25**]
IMPRESSION: Left side port and tip of NG tube beyond the GE
junction.
[**1-25**] Abdominal Ultrasound
IMPRESSION:
1. Mild gallbladder distension with questionable area of focal
thickening.
No definite evidence of gallstones or biliary dilatation.
2. Patent portal vein.
3. Left kidney cyst.
4. Splenomegaly.
[**2158-1-25**] EGD
Impression: Varices at the lower third of the esophagus and
gastroesophageal junction
Stomach covered in dark blood and clot. No clear varices
visualized but again unable to assess mucosa given blood in
stomach. No bright red bleeding.
Dark blood and clot in duodenum. No clear ulceration.
Otherwise normal EGD to second part of the duodenum
Recommendations: Grade II-III esophageal varices without
stigmata of recent bleeding. Blood noted throughout entire
stomach without active source visualized. No banding as concern
for aspiration of blood contents given that patient is not
intubated. Recommend continue octreotide gtt, PPI IV, abx,
aspiration precaution. NG tube placement. IV erythromycin. Trend
hct. If active bleeding intubation will be required prior to
banding. If all stable, will re attempt endoscopy once blood has
cleared.
[**2158-1-27**] EGD
Impression: Varices at the lower third of the esophagus and
gastroesophageal junction
Erythema, congestion and mosaic appearance in the whole stomach
compatible with portal hypertensive gastropathy
Otherwise normal EGD to third part of the duodenum
Recommendations: Please continue octreotide and PPI. No active
bleeding identified currently. No gastric source identified. Due
to withdrawel symptoms patient will be set up for EGD with
banding under MAC anesthesia.
[**2158-1-31**] EGD
Impression: Grade III esophageal varices (ligation)
Portal Hypertensive Gastropathy
Otherwise normal EGD to third part of the duodenum
Additional notes: Recommend:
1) Carafate for 7 days
2) High dose PPI
2) Repeat EGD and banding in 2 weeks, (anesthesia case)
Brief Hospital Course:
Mr. [**Known lastname **] is a 42 year old man with hepatitis C and alcoholic
cirrhosis who presented with hematemesis.
.
# GI bleed: Mr. [**Known lastname **] was initially admitted to the MICU
following transfer from an OSH. He had an NG tube placed which
returned coffee ground material. He underwent an emergent EGD
which showed grade II-III varices. He was on an octreotide and
pantoprazole gtt. He required a total of four units of pRBC's
upon admission. Following the transfusions, his hematocrit
remained stable. He underwent a second EGD for banding, but
could not tolerate the procedure. A third EGD was planned with
anesthesia, but had to be rescheduled multiple times because he
was eating despite being told multiple times that he had to be
NPO. He underwent the banding procedure and was told to follow
up for a repeat in two to three weeks. He was started on
nadolol. This was uptitrated to 40 mg, but had to be decreased
to 20 mg because of bradycardia. He was placed on sucralfate for
a total of seven days. He received ciprofloxacin following the
first EGD.
.
# Cirrhosis: His AFP was within normal limits. He received a
lactulose enema in the MICU for confusion. He was restarted on
rifaximin. He was not placed on lactulose because of intolerance
noted in an OSH discharge summary. He had no ascites.
.
# Alcohol abuse: His last drink was 24 hours prior to
presentation. He continually scored on the CIWA protocol. He
required diazepam every two hours. This was eventually tapered.
He was counseled multiple times not to drink any alcohol again.
He was placed on thiamine and folic acid.
.
# Diabeted mellitus: He was intially placed on an insuling
sliding scale while NPO. As his diet was restarted, glargine was
added. He had multiple episodes of elevated blood glucose.
Although on a diabetic diet, he was found eating candy on
multiple occasions. He was discharged on his home regimen.
.
# Tobacco Use: He was given a nicotine patch. Smoking cessation
was encouraged.
.
# Depression: His medication was held while NPO. It was
restarted when he was able to eat.
.
# Hypertension: His lisinopril was held in the setting of an
acute bleed. It was later restarted. He had several episodes of
elevated blood pressure likely related to his withdrawal.
.
# Thrombocytopenia: This was at his baseline per documentation
from previous hospital summaries that were obtained.
.
# Prophylaxis: He was on pneumoboots and ambulated.
Medications on Admission:
Lisinopril 5 mg daily
Lantus 80 units daily
Humalog SS 10U QAC
Trazodone 200 mg QHS
Seroquel 300 mg QHS
Amantadine HCl 100 mg po BID
ASA 81 mg daily
Paroxetine 30 mg daily
MVI (per PCP)
Seroquel 25 mg TID
Ultram 50 mg PRN
Vitamin D 800 units daily
Gabapentin 800 mg TID
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
10. Quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Humalog Subcutaneous
13. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
15. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Esophageal Varices
Hepatitis C
Alcohol Abuse
Cirrhosis
Secondary Diagnosis:
Diabetes Mellitus
Musculoskeletal Pain
Discharge Condition:
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Mental Status: Clear and coherent
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital after vomiting blood. You have severe
liver disease caused by Hepatitis C and alcohol. You must stop
drinking alcohol. While you were in the hospital, you had an
endoscopy with banding which helps close some of the blood
vessels in your esophagus that are at risk for bleeding. You
need to have a repeat procedure in two-three weeks.
Your sugars were elevated while you were in the hospital. On the
day of discharge, [**2158-2-2**], we gave you the lantus earlier than
your usual time. So please do not take lantus the evening on
[**2158-2-2**] as you were already given a dose. Please restart taking
your evening lantus dose on [**2158-2-3**], that is, tomorrow night and
thereafter. Besides this small change, you should continue your
insulin regimen as prescribed by your regular care doctor.
Please measure you sugars at home and notify your regular care
doctor if your sugar is elevated despite insulin.
Please discontinue ASPIRIN while recovering from your bleeding
episode. Please discuss with your regular doctor when to restart
this medications.
We have added several new medications to your list: Nadolol,
pantoprazole, thiamine, folate and sucralfate.
Followup Instructions:
Please follow up with your regular care doctor, Dr. [**Last Name (STitle) 86335**], on
[**2-8**], at 2:30 pm. Please call [**Telephone/Fax (1) 7538**] if you have
questions.
|
[
"456.20",
"303.90",
"287.5",
"572.3",
"305.1",
"571.2",
"577.1",
"250.00",
"V65.49",
"401.9",
"070.54",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10638, 10695
|
6511, 8955
|
325, 385
|
10874, 10962
|
2943, 6488
|
12300, 12477
|
2305, 2389
|
9275, 10615
|
10716, 10716
|
8981, 9252
|
11022, 12277
|
2404, 2924
|
1536, 1986
|
274, 287
|
413, 1517
|
10812, 10853
|
10735, 10791
|
10977, 10998
|
2008, 2197
|
2213, 2289
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,765
| 166,883
|
2510
|
Discharge summary
|
report
|
Admission Date: [**2191-1-14**] Discharge Date: [**2191-1-21**]
Date of Birth: [**2125-1-6**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Patient was admitted on [**2191-1-14**]
with end sage liver disease here for liver transplant.
HISTORY OF PRESENT ILLNESS: This is a 65 year-old female,
Cantonese speaking, with chronic hepatitis B virus cirrhosis
with the history of hepatoma x2, status post radiofrequency
ablation x2. Patient denied any fever, night sweats. She did
admit to a recent cough approximately 10 days ago treated
with antibiotics by the primary care physician. [**Name10 (NameIs) **] was
unable to state which antibiotics. She complaints of chronic
nasal stuffiness, uses Sudafed for this. She denied any sore
throat. Denied headache, malaise, fatigue. She did admit to a
cough and a small amount of yellow phlegm noted in the
morning since the treatment with antibiotics. She denied any
abdominal pain, nausea, vomiting, diarrhea, melena, shortness
of breath, chest pain. She complains of nervousness.
PAST MEDICAL HISTORY: Hepatitis B virus, latent tuberculosis
infection, status post treatment with INH for 1 year upon
arrival to the U.S. in [**2175**].
PAST SURGICAL HISTORY: Tubal ligation in [**2158**], appendectomy
in [**2158**], removal of ovarian tumor in approximately [**2158**].
Gallstones, cholecystectomy.
MEDICATIONS UPON ARRIVAL: Entecavir 1 mg p.o. q.d., adefovir
10 mg p.o. q.d., clotrimazole 10 mg 5x a day lozenge.
FAMILY HISTORY: Born in [**Country 651**], immigrated to the United
States in [**2175**]. Two children. Does not work. No pets. Works
in her garden.
SOCIAL HISTORY: Denies history of alcohol use, smoking or
illicit drugs.
ALLERGIES: No known drug allergies.
Denied any recent travel outside the U.S. within the last 5
years.
PHYSICAL EXAMINATION: Alert and oriented. Head, eyes, ears,
nose and throat: Pupils equal, round and reactive to light
and accommodation, extraocular movements intact. No jugular
venous distension. Trachea is in midline. No lymphadenopathy.
No maxillary tenderness. Nasal mucosa was pink. Lungs were
clear bilaterally. Cardiac: S1, S2, II/VI systolic ejection
murmur at the apex. Abdomen large, nontender, positive bowel
sounds. Vascular: 3+ dorsalis pedis and posterior tibials
bilaterally. No carotid bruits. Neurologic: Alert and
oriented x3. No asterixis. Sense equal [**4-8**], gait steady.
Preoperative chest x-ray demonstrated right upper lobe
scarring. No evidence of active infection. There was
elevation of the minor fissure with associated volume loss on
the right secondary to right upper lobe scarring. No
pneumothorax, no pleural effusions. Preoperative
electrocardiogram demonstrated no acute changes.
HOSPITAL COURSE: She was prepped for the operating room,
taken to the operating room on [**2190-1-14**]. She
underwent cadaveric liver transplant with duct to duct
biliary construction over a T tube. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]
assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) **] [**Name (STitle) **] and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Estimated blood loss was 700 cc. There were no
complications. She was taken to the SICU postoperatively for
recovery. She had 2 [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 12828**], a nasogastric tube and a
T tube. She was intubated. She was in stable condition. She
was placed on IV Unasyn. During intraoperative she received
induction and immunosuppression with Solu-Medrol 500 mg,
CellCept 1 gram. Her Swan catheter was removed on
postoperative day 1. Her liver function tests trended down.
Preoperatively AST was 2,08, ALT 1434, alkaline phosphatase
150 and total bilirubin 0.4. Liver function tests trended
down daily. She was extubated without incident. Hematocrit
was stable at 33.2. Her blood pressure was a little bit
elevated, 154/92 to 138/58. She was started on Lopressor.
This was increased to 75 mg b.i.d. She had a slight increase
in her ALT up to 1398 from 1184. A Duplex ultrasound was
done. This demonstrated unremarkable examination. A small
right pleural effusion was noted. The main hepatic artery,
right hepatic artery and left hepatic artery had indices of
0.6, 0.56 and 0.53 respectively. There were no intra- or
extrahepatic biliary dilatations noted. The main portal vein,
the left portal vein and the right portal veins were also
seen and were patent. She was transferred out to the medical
surgical unit where her diet was gradually advanced. Abdomen
appeared soft with mild tenderness. Her Foley catheter was
removed. She complained of discomfort at the incision site
but was reluctant to take pain medication. She continued
receive hepatitis B immune globulin 5,000 units q.d. on
postoperative days 1 through postoperative day 5. She had
received 10,000 units intraoperatively during the anhepatic
phase before surgery. She received daily hepatitis C surface
antigen and hepatitis B surface antibody laboratories.
Preoperatively her hepatitis B surface antigen was positive.
Her antibody level was negative. Subsequent laboratories
demonstrated HBFAG negative and hepatitis B surface antibody
titers between 450 and greater than 450 MIU/ml.
The patient was followed by physical therapy during this
hospital course. Additional physical therapy needs were
identified. Rehabilitation was suggested. Social work
followed the patient as well.
Her vital signs were stable. Urine output was excellent. Her
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 12828**] were removed without incident. Her T-tube was
capped after she underwent a gravity cholangiogram on
postoperative 5. This demonstrated no evidence of obstruction
or leak. There was mild narrowing at the anastomotic site,
likely related to the postoperative edema. This was
nonobstructing. Two to three small ovoid filling defects in
the distal native common duct, nonobstructing and of unclear
etiology were noted. The T tube was capped on postoperative
day 5. Liver function tests continued to trend down and on
postoperative day 7 she was ready for discharge to [**Hospital3 12829**] Hospital and accepted as a patient. She was
tolerating a regular diet, comfortable. Incision appeared
clean and dry without erythema, drainage. Her T tube was
capped. The site was also clean and dry. AST on postoperative
day 7 was 77, ALT 484, alkaline phosphatase 169 and a total
bilirubin of 0.5. Creatinine remained stable at 0.5. White
blood cell count was 15.2 with a hematocrit of 28. She was
ambulatory with assist. Of note, she did complain of loose
stool around postoperative day 4. A C difficile culture was
sent off. This was subsequently found to be negative. Her
Solu-Medrol was tapered down and transitioned to p.o.
prednisone 20 mg p.o. q.d. Prograf was initiated on
postoperative day 2 at 1 mg p.o. b.i.d. This was increased to
2 mg p.o. b.i.d. The follow up level was 16.5 and Prograf was
readjusted to 1 mg p.o. b.i.d. The Prograf level on [**1-20**] was 12.3. Goal range 10.
DISCHARGE MEDICATIONS: Included heparin 5,000 units SV
b.i.d., prednisone 20 mg p.o. q.d., adefovir 10 mg p.o. q.d.,
Protonix 40 mg p.o. q.d., metoprolol 25 mg tablets 3 tablets
p.o. b.i.d. to hold for systolic blood pressure less than 110
or heart rate less than 50. CellCept [**Pager number **] mg p.o. q.i.d.,
Colace 100 mg p.o. b.i.d., Bactrim Single Strength p.o. 1
tablet p.o. q.d., Percocet 5/325 mg tablet 1 tablet p.o.
p.r.n. q 4 to 6 hours, entecavir 1 mg p.o. q.d., fluconazole
400 mg p.o. q.d., hepatitis B immune globulin 5 ml IM once a
week with 3 doses on [**2-4**], [**2-11**] and [**2-18**], Prograf
1 mg p.o. b.i.d., magnesium oxide 400 mg p.o. b.i.d. for 2
days starting [**2191-1-21**], Valsate 900 mg p.o. q.d.
Insulin regular sliding scale per q.i.d. blood sugar checks.
Patient should follow up with the [**Hospital1 190**] transplant office in 1 weeks time. Please call
to make arrangements for follow up visit, [**Telephone/Fax (1) 673**].
DISCHARGE PLAN: Includes laboratory work every Monday and
Thursday for CBC, chem-10, AST, ALT, alkaline phosphatase,
total bilirubin, albumin and a trough Prograf level with
results to be faxed to the transplant office at [**Telephone/Fax (1) 697**].
Patient may shower. She should receive physical therapy,
occupational therapy, nutrition consult as well as social
service for follow up at rehabilitation.
DISCHARGE DIAGNOSES: Hepatitis B cirrhosis.
Hepatocellular carcinoma, status post radiofrequency ablation
x2.
Liver transplant [**2191-1-14**].
Glucose intolerance since steroid initiation.
CONDITION ON DISCHARGE: Patient was in stable condition on
the day of discharge. Vital signs were stable. She was
tolerating a regular diet. She was ambulating with assist.
She demonstrated slow and steady functional gain. Blood sugar
ranged between 99 and 220.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2191-1-21**] 15:14:54
T: [**2191-1-21**] 16:50:01
Job#: [**Job Number 12830**]
|
[
"070.32",
"V10.07",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"50.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1513, 1648
|
8557, 8727
|
7182, 8126
|
2767, 7158
|
1237, 1496
|
1852, 2749
|
171, 267
|
296, 1057
|
8143, 8535
|
1080, 1213
|
1665, 1829
|
8752, 9250
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,936
| 147,105
|
1208
|
Discharge summary
|
report
|
Admission Date: [**2102-10-31**] Discharge Date: [**2102-11-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 y/o Russian speaking male with extensive PMH including
metastatic nonsmall cell lung CA s/p lobectomy and XRT, DM,
orthostasis, mild diastolic CHF and chronic renal insufficiency
presenting with SOB. Pt has had difficulty breathing for the
past several years, especially increasing about 1.5 years ago
after segmental resection of a right lung mass. At that time he
also developed increasing pain in his back around the site of
his surgery, which increases on inspiration, is present at rest
and does not increase with exertion. He was last discharged from
[**Hospital1 18**] for COPD exacerbation [**2102-9-30**]. In general, the patient
has not been eating or drinking as much as he used to and has
lost weight. Currently, he describes gradual increase in
viscosity of sputum and decreased total volume over the last
month. He feels it difficult to breathe with these secretions.
He continues to have lateral chest pain on deep inspiration. He
denies palpitations, nausea, vomiting, hemoptysis, night sweats,
assymetric leg or arm swelling.
In the ED, the patient was treated BiPAP, CXR obtained
(interstial infiltrates) and antibiotics given (after sputum was
collected).
Past Medical History:
1. Metastatic nonsmall cell lung cancer - s/p RUL lobectomy
[**2100**], radiation tx to pleural based nodule [**12/2101**]
2. CAD
3. PVD, s/p left femoral stent in [**2091**]
4. Type II DM
5. Chronic Renal Insufficiency
6. COPD
7. Depression
Social History:
The patient was born in [**Country 532**] and moved to the United States in
[**2091**]. He speaks no English. He currently lives in [**Location 86**] with
his wife. His granddaughter is his health care proxy. [**Name (NI) **] has a
60-90 pack per year history of tobacco use. He quit smoking 1.5
years ago. He denied alcohol use.
Family History:
noncontributory
Physical Exam:
98.4 138/65 87 18 (slightly labored) 95% 3L NC
Brief Hospital Course:
1. Dyspnea: Pt was noted to be producing thick secretions and
having difficulty expectorating them. CXR revealed diffuse
interstitial infiltrates and CT revealed an interval increase in
the # and size of the pt's innumerable pulmonary nodules,
indicating progression of intrapulmonary metastatic disease. Pt
was initially treated with ceftriaxone and azithromycin
empirically to cover for CAP, later switched to just
azithromycin for bacterial tracheobronchitis--he will complete a
7 day course. Mr.[**Known lastname 7640**] was also started on mucolytics and
nebulizers for symptom relief. Chest physiotherapy also helped
to mobilize the patient's secretions. His butamide was
increased from 2 to 3mg po qD to aid in decreasing any
concurrent pulmonary edema and drying out his secretions.
Pulmonary was consulted and felt no cure was feasable for the
patient, and he should be treated palliatively. Scopolamine
patch started to decrease secretions.
2. Code Status: Palliative care consult was obtained and
Dr.[**Last Name (STitle) **] met with the patient and grandaughter (health care
proxy). Goals of care were discussed and it was decided that
shifting from the goal of cure to the goal of maximizing comfort
was most appropriate. He was made DNR/DNI. He needs chest
physiotherapy and aggressive pulmonary toilet. Plans were made
for home services with bridge to hospice care, but the patient
subsequently deteriorated (see below).
3. Pneumonia: On [**11-2**], we were informed by Micro lab that
patient's sputum was growing Nocardia. This raised the
possibility that some of his radiographic findings were
attributable to this infection as opposed to advancing
metastatic disease. The Infectious Disease service was consulted
& the patient was started on the appropriate abx immediately.
4. respiratory failure: Pt deteriorated on [**11-3**], and after
discussion with his family, he was transferred to the MICU where
he was stabilized with NIPPV. Etiology was likely
multifactorial, including advanced lung ca, COPD, Nocardiosis.
After a couple of days, he returned to the medicine floor, where
he again had severe respiratory compromise, along with
increasing lethargy. The family requested transfer back to MICU
for another trial of NIPPV, and shortly after his arrival there,
the family agreed to change the goals of care to comfort
measures only. He was started on a morphine drip and expired
comfortably on [**11-7**].
Discharge Medications:
N/A
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Stage 4 Squamous Cell Lung Cancer
COPD
Nocardiosis
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2102-11-2**]
|
[
"311",
"428.32",
"197.0",
"518.81",
"428.0",
"491.22",
"414.01",
"250.00",
"198.5",
"V10.3",
"593.9",
"039.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4732, 4807
|
2230, 4681
|
266, 272
|
4902, 4907
|
4959, 5116
|
2113, 2130
|
4704, 4709
|
4828, 4881
|
4931, 4936
|
2145, 2207
|
223, 228
|
300, 1484
|
1506, 1749
|
1765, 2097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,559
| 125,740
|
31590
|
Discharge summary
|
report
|
Admission Date: [**2112-10-13**] Discharge Date: [**2112-10-20**]
Date of Birth: [**2043-7-2**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Morphine Sulfate
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Syncope, torsades de pointes
Major Surgical or Invasive Procedure:
Cardiac cath and drug-eluting stent placement [**2112-10-17**]
History of Present Illness:
Ms. [**Known lastname **] is a 69 yo woman with ESRD secondary to DM and HTN,
CHF, hx of TIA, presented to ED after syncopal episode. She had
been in her usual state of health until she began having
syncopal episodes about 1.5 weeks ago. Prior to today, she has
had 2 episodes of passing out for a few seconds, once at home
and once at her son's. Of note, she also felt lightheaded after
dialysis on Monday, which resolved later in the day with rest.
She denies any recent medication changes, except for switch to
Celexa from Lexapro more than 6 months ago.
.
This morning, patient had left in the morning around 6am for a
nephrology appointment at [**Hospital1 18**]. She felt well upon awakening
but had not eaten breakfast. She was sitting in the backseat of
the T Ride when she suddenly lost consciousness for [**11-10**]
minutes. Her daughter was with her at the time and did not note
any head trauma or shaking. Denies any chest pain, numbness or
tingling in her arms, palpitations, diaphoresis, or shortness of
breath prior to or after the syncope episode. Patient awoke in
the ambulance and was transported to the [**Hospital1 18**] ED.
.
On review of systems, patient has had TIA x 2 without residual
neuro deficits. S/he denies any prior history of stroke, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. 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. Positive for syncope and
lightheadedness.
.
In the ED, initial vitals were HR 70s, BP 90s/50s, AF. EKG on
admission showed QT prolongation. Patient had torsades de
pointes x 2, lasting < 1 min each and was unresponsive. Prior to
torsades, she was eating lunch and felt slightly lightheaded.
Central line was placed in R femoral and Mag 5 mg IV was given.
Neuro was consulted and felt cause of syncope is unlikely
neurogenic given head CT that was negative for bleed and more
likely cardiac or from hypoperfusion.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CHF
- A-fib
- Hypercholesterolemia
3. OTHER PAST MEDICAL HISTORY:
- ESRD, on M/W/F HD
- DM2 x >20 yrs
- HTN
- hx of uterine CA, s/p TAH-BSO in [**2098**]
- TIA x 2
- L AV graft
Social History:
-Tobacco history: rarely
-ETOH: ocassional (<1 drink/wk)
-Illicit drugs: denies
Lives with daughter, daughter's boyfriend, and grandson. [**Name (NI) **]
good support system at home for ADL's.
Family History:
Mother and GM died of cancer in their 80's. DM in grandfather.
Daughter had [**Name2 (NI) **] CA and son had oral CA. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
VS: T=98 BP=104/61 HR=74 RR=15 O2 sat=96% on RA
GENERAL: WDWN female 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.
Poor dentition.
NECK: Supple with JVP to angle of jaw. No carotid bruits
CARDIAC: RR, normal S1, S2. 2/6 systolic cresc-decresc murmur.
No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, mild
bibasilayr crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Large, reducible
ventral hernia
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 1+ PT 1+
Left: Radial 2+ DP 1+ PT 1+
Pertinent Results:
Labs on admission:
[**2112-10-13**] 08:55AM PT-43.2* PTT-31.5 INR(PT)-4.6*
[**2112-10-13**] 08:55AM PLT COUNT-208
[**2112-10-13**] 08:55AM NEUTS-82.8* LYMPHS-12.2* MONOS-2.7 EOS-1.8
BASOS-0.6
[**2112-10-13**] 08:55AM WBC-11.1* RBC-4.84# HGB-14.2 HCT-47.6# MCV-98
MCH-29.3 MCHC-29.8* RDW-17.2*
[**2112-10-13**] 08:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2112-10-13**] 08:55AM CALCIUM-9.0 PHOSPHATE-2.4*# MAGNESIUM-1.7
[**2112-10-13**] 08:55AM CK-MB-NotDone
[**2112-10-13**] 08:55AM cTropnT-0.20*
[**2112-10-13**] 08:55AM CK(CPK)-96
[**2112-10-13**] 08:55AM estGFR-Using this
[**2112-10-13**] 08:55AM GLUCOSE-153* UREA N-28* CREAT-5.5* SODIUM-142
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-29 ANION GAP-21*
[**2112-10-13**] 03:28PM TSH-1.0
.
Labs on discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2112-10-20**] 04:49AM 7.1 3.30* 10.2* 32.5* 98 31.0 31.5 17.2*
160
Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2112-10-20**] 04:49AM 86 31* 4.4*# 140 4.9 101 30 14
PT/INR 12.8/1.1
.
EKG [**2112-10-12**]: NSR @ 60bpm, no ectopy, LAD, PRWP (new since
[**2111-3-25**]), normal PR and QRS intervals, QTc prolonged at 620ms,
no LVH, no ST elevations/depresions.
.
TELEMETRY: Episodes of R on T and torsades noted on tele.
.
CHEST XRAY [**2112-10-13**]:
PA and lateral chest radiograph. The mildly enlarged
cardiomediastinal silhouette is stable. Again noted are aortic
calcifications, most prominent at the aortic knob. There is
interval removal of the dual-lumen dialysis catheter. The
pulmonary vasculature is mildly engorged and increased
interstitial markings bilaterally are unchanged, compatible with
mild interstitial edema. There are no pleural effusions. The
lungs are otherwise grossly clear without new focal
consolidations. In the low thoracic spine there is an apparent
new anterior wedge deformity, which is not seen a year and a
half ago. Degenerative changes are noted in the thoracic spine.
IMPRESSION:
1. Mild interstitial pulmonary edema.
2. Mild anterior wedge deformity in a low thoracic vertebral
body, new in the interval.
.
HEAD CT [**2112-10-13**]:
There is no acute intracranial hemorrhage or fracture. No large
territorial infarct, edema or mass effect are noted. The midline
structures are normal. The ventricles and sulci are prominent,
compatible with age-appropriate atrophy. There is
periventricular and subcortical white matter disease, compatible
with chronic small vessel ischemia. Again noted is a punctate
calcific density in the right sylvian fissure, unchanged, and
may represent a calcified granuloma, sequela of prior
neurocysticercosis, or be vascular etiology. A non- aggressive-
appearing lucent lesion is unchanged in the left frontal bone,
previously thought to be a hemangioma.
There is significant calcification in the distal vertebral
arteries as well as the cavernous portions of the internal
carotid arteries bilaterally The visualized paranasal sinuses
and mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
.
TTE [**2112-10-14**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 20 %) secondary to extensive anterior, septal,
and apical akinesis. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. Right
ventricular chamber size is normal. with depressed free wall
contractility. There are focal calcifications in the aortic
arch. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis. Mild to moderate ([**1-29**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. There is severe mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Impression: extensive anterior, septal, and apical akinesis with
moderate-to-severe tricuspid regurgitation and at least mild
mitral regurgitation; moderate aortic stenosis.
.
Cardiac Cath [**2112-10-18**]:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had no
angiographically
apparent disease. The LAD had a hazy 80& stenosis right after
the first
septal branch. D1 had a proximal 60% stenosis. The Cx had no
angiographically apparent disease. The RCA had a 50% stenosis in
the mid
portion of the vessel.
2. Successful PCI of the proximal LAD with a 3.0x18mm Promus
DES.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PCI of the LAD with DES.
Brief Hospital Course:
Ms. [**Known lastname **] is a 69 yo woman with ESRD/HD secondary to DM and HTN,
CHF, paroxysmal atrial fibrillation, hx of TIA, who presented to
ED after a syncopal episode. In the ED she was found to have
prolonged QTc with episodes of symptomatic torsades de pointes.
The patient was discharged home with appropriate cardiac
follow-up.
.
# RHYTHM: Syncope of recent onset was thought to be due to QT
prolongation and pause-dependent torsades de pointes of unclear
etiology. Given patient age and lack of syncope history prior to
recent episodes, prolonged QT syndrome was thought unlikely to
be purely secondary to congenital channelopathy. Due to concern
that torsades de pointes could be medication-induced, Celexa was
discontinued. Electrolyte imbalance was also considered due to
patient's ESRD and HD, although electrolytes were only
borderline low (K 3.8, Mg 1.7). Potassium was repleted prn in
diasylate with goal of 5.0, and magnesium repleted to goal of
high-normal. Ischemia from possible ACS may also have
contributed to [**Known lastname 74264**] (see below). Patient had brief recurrence of
torsades de pointes on [**2112-10-14**] during HD that self-terminated
and did not require isoproterenol or temp pacing. EKG was
monitored daily and showed persistent QT prolongation that did
improve over the course of her hospitalization from 620ms to
469ms. EP was consulted and recommended initiation of verapamil,
which the patient tolerated well. ICD placement was deferred due
to patient's ESRD, stable condition, and improvement with
medical mangement of prolonged QT. Other than episodes of [**Name (NI) 74264**],
pt was in NSR throughout hospitalization. Coumadin was initially
held due to supratherapeutic INR of 4.6 on admission but later
resumed for her history of atrial fibrillation.
.
# PUMP: Patient had unclear history of congestive heart failure
based on TTE and TEE done 3 yrs ago at OSH. TTE performed
[**2112-10-14**] showed LVEF of 20% with extensive anterior, septal, and
apical akinesis, moderate-to-severe tricuspid regurgitation, at
least mild mitral regurgitation, and moderate aortic stenosis.
Based on cardiac cath findings, wall motion abnormalities and
systolic heart failure was consistent with ischemic
cardiomyopathy. Patient was fluid restricted and kept on
low-salt diet. Daily weights and I/O's were monitored. No ACE-I
was given due to ESRD. On discharge, patient was 64.2kg and had
net fluid balance of about positive 600 mL. She anuric and
dependent on HD for fluid removal.
.
# CORONARIES: Patient had no known coronary artery disease prior
to admission but had chemical stress test in [**2111-7-28**] that was
normal per patient history. EKG during admission showed loss of
R waves in in precordial leads and diffuse ST elevations that
were both new compared with EKG from 2/[**2111**]. Cardiac enzymes
were initially elevated and trended until peak of CK 1044, MB
50, TropT 4.50 on [**10-14**] afternoon. It was unclear whether the
cardiac enzyme leak was secondary to global ischemia from [**Month/Year (2) 74264**] or
due to primary ACS event that may have led to [**Month/Year (2) 74264**]. The patient
was treated with ASA 325, Plavix 75 mg, heparin gtt, and
continued on simvastatin 40 mg. She underwent non-emergent left
cardiac cath on [**2112-10-18**] that showed a hazy 80% stenosis in the
LAD just distal to takeoff of first septal, in addition to 60%
stenosis in proximal D1 and 50% stenosis in mid-RCA. Promus
drug-eluting stent was placed in LAD with good effect.
.
# ESRD: Patient continued to receive M/W/F hemodialysis via left
AV graft. Patient has been essentially anuric. Electrolytes have
been stable since admission. Dialysate adjusted to maintain
potassium around 5.0 due to [**Date Range 74264**] arrhythmia. Renal tabs and
PhosLo were continued. Patient is on Epo for anemia of chronic
disease.
.
# R FEMORAL HEMATOMA: Hematoma developed around R femoral line
placed emergently in ED, likely [**2-29**] supratherapeutic INR.
Resolved after administration of vitamin K and pressure
dressings. LFT's were not indicative of coagulopathy from liver
disease.
.
# HYPOTHYROIDISM: Due to concern of hypothyroidism contributing
to [**Month/Day (2) 74264**], TSH was checked and wnl (1.0). Levothyroxine was
continued at home dose throughout hospital stay.
.
# DM2: Blood sugars were well-controlled. Patient is not on any
insulin or oral hypoglycemics at home. Diabetic diet and
sliding-scale insulin was given for glycemic control.
.
# CODE: FULL
Medications on Admission:
- coumadin 5 mg daily
- levothyroxine
- ASA 81 mg
- Celexa
- Acidophilus
- PhosLo 3 tabs qac
- simvastatin 40 mg daily
- nifedepine on T/R/Sat/Sun
- renal vitamins
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): You should take this medication for at least 12 months.
Disp:*30 Tablet(s)* Refills:*2*
2. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): Please skip your morning dose on days you receive
hemodialysis.
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
Please have your INR blood test done at your dialysis center on
Monday [**2112-10-24**] and have the results forwarded to Dr. [**Last Name (STitle) **] as
well as your Dr. [**Last Name (STitle) 74265**] (fax# [**Telephone/Fax (1) 74266**]) for monitoring
your Coumadin (warfarin) dose.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Please resume the 81 mg baby aspirin after you finish with 1
month of 325 mg aspirin.
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO three
times a day: take with meals.
10. Acidophilus 500 million cell Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Ventricular Tachycardia with prolonged QTc
STEMI
.
Secondary Diagnoses:
End stage renal disease on HD (M,W,F)
Diabetes Mellitus
Hypertension
Chronic systolic CHF
Paroxysmal Atrial Fibrillation
Discharge Condition:
Good; hemodynamically stable and improved
Discharge Instructions:
You were admitted to the hospital with an abnormal heart rhythm,
called torsades de pointes, possibly related to some of your
home medications, as well as changes to your electrolytes. We
treated you by stopping some of your home medications (Celexa),
and repleting your electrolytes. While you were an inpatient,
you had changes to your ECG and blood tests concerning for a
myocardial infarction (commonly known as a heart attack).
Consequently, you underwent a cardiac catheterization and a
drug-eluting stent was placed in your LAD (one of the major
arteries supplying blood to your heart).
.
At your outpatient hemodialysis in the future, it is important
that they monitor your electrolytes closely and adjust dialysis
for a goal potassium greater than 4.5 and goal magnesium greater
than 2.
.
The following changes were made to your medications:
STOP Celexa
STOP Nifedepine
START Verapamil 40 mg three times daily. Do not take your
morning dose of verapamil on days you receive dialysis.
START Aspirin 325 mg once daily for 1 month then resume aspirin
81 mg once daily.
START Plavix 75 mg. You should take this medication for at least
12 months.
.
If you experience any further episodes of dizziness or "spells,"
chest pain, palpitations, shortness of breath, dark tarry
stools, abnormal bleeding or other concerning symptoms, please
call 911 or your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74265**] at [**0-0-**].
.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Cardiology) on Tuesday, [**2112-11-8**] at
1:00 pm
[**Hospital1 18**] - Cardiac Services
[**Location (un) 830**], [**Hospital Ward Name 23**] 7
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Dr. [**First Name4 (NamePattern1) 24592**] [**Last Name (NamePattern1) 74265**] (PCP) on Thursday, [**2112-11-3**] at 9:15
am
Phone: [**0-0-**]
You should have your INR blood test drawn on Monday at your
dialysis clinic and have the results forwarded to Dr. [**Last Name (STitle) **]
for management of your coumadin dose.
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64,043
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46294
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Discharge summary
|
report
|
Admission Date: [**2184-1-29**] Discharge Date: [**2184-2-2**]
Date of Birth: [**2125-7-17**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Tricor
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58-year-old man with ESRD secondary to type I DM s/p living
unrelated renal transplant on [**2179-6-16**] presenting with DKA in
setting of gastroenteritis and insulin noncompliance. Pt reports
3 days of nausea and NBNB emesis, poor appetite, and diarrhea.
Denies abdominal pain or fevers. Wife had similar symptoms one
day prior to pt's presentation. Symptoms began after [**Holiday **]
gathering at friend's place. Pt states that he felt too unwell
to go upstairs to retrieve his medications and thus did not take
his medications, including his insulin, for the last three days.
Prior to this, he reports good medication compliance, including
compliance with his insulin (recently changed to humulin R U 500
30 units/meal).
.
He presented to OSH ED where he was noted to be in DKA and
started on IV insulin drip at 2units/hr. He was then transferred
to [**Hospital1 18**] ED for further care. At [**Hospital1 18**] ED, he received Regular
insulin 10units and placed on drip at 10units/hr. He also
received zofran, morphine and hydrocortisone prior to transfer
to ICU.
.
On arrival to the ICU, pt complaining of continued nausea and
back pain. States that he has had back pain since [**Month (only) **]. He
had been hospitalized for ulcers in his feet and had been
wheelchair bound and discharged to rehab. He began to have back
pain when he started to walk again. Denies urinary/fecal
incontinence/retention and saddle anesthesia.
.
Review of systems:
(+) Per HPI; also reports bifrontal headaches (now resolved),
rhinorrhea, cough occasionally productive, occasionally SOB
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies chest pain, chest pressure, palpitations, or
weakness. Denies dysuria, frequency, or urgency. Denies
myalgias. Denies rashes or skin changes.
Past Medical History:
- DM type I complicated by peripheral neuropathy
- ESRD s/p renal transplant
- Hypertension
- Hyperlipidemia
- Morbid obesity
- ?CAD: stress test [**11-6**] that demontrated some mild ischemia in
the posterior wall and some hypokinesis. Cardiac Cath-no
significant disease requiring intervention
- Hypothyroidism
- Sarcoid, based on granuloma on lung scan
Social History:
Lives with wife [**Name (NI) 55745**] and 1 dog. Has a daughter in college who
is currently visiting. Quit tobacco in the [**2142**]. Denies alcohol
use and recreational drug use.
Family History:
Mother: pancreatic cancer
Physical Exam:
ADMISSION EXAM:
Vitals: 97.2, 152/93, 98, 21, 100%RA
General: Alert, oriented x 3, appears fatigued, no acute
distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 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+ DP/PT pulses, no clubbing, cyanosis
or edema; ulcer on dorsum of medial side of left foot appears
clean with good granulation tissue, no drainage
.
DISCHARGE EXAM:
VS - Tm98.1 Tc 96.5 F, BP 130s/50-60s, HR 66-93, R 16-20, O2-sat
96-98% RA
GENERAL - Comfortable appearing male in NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - PMI non-displaced, irregular rhythm, no MRG, nl S1-S2
ABDOMEN - obese, NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Right foot with superficial ulcer on medial aspect,
dressed.
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
[**2184-1-29**] 06:00PM BLOOD WBC-7.5 RBC-5.06 Hgb-14.8 Hct-45.6 MCV-90
MCH-29.2 MCHC-32.4 RDW-13.9 Plt Ct-198
[**2184-1-29**] 06:00PM BLOOD Neuts-92.2* Lymphs-5.4* Monos-2.1 Eos-0.2
Baso-0.2
[**2184-1-29**] 06:00PM BLOOD Glucose-646* UreaN-55* Creat-2.2* Na-131*
K-5.7* Cl-92* HCO3-9* AnGap-36*
[**2184-1-29**] 09:01PM BLOOD Calcium-8.5 Phos-4.3 Mg-2.3
[**2184-1-29**] 07:35PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
[**2184-1-29**] 07:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
PERTINENT LABS:
[**2184-1-29**] 09:10PM BLOOD CK-MB-7 cTropnT-0.02*
[**2184-1-30**] 03:05AM BLOOD CK-MB-6 cTropnT-0.01
[**2184-1-29**] 09:10PM BLOOD CK(CPK)-229
[**2184-1-30**] 03:05AM BLOOD CK(CPK)-199
[**2184-1-29**] 09:24PM BLOOD Lactate-2.6*
[**2184-1-30**] 03:21AM BLOOD Lactate-1.3
[**2184-1-29**] 06:00PM BLOOD %HbA1c-10.3*
.
DISCHARGE LABS:
[**2184-2-1**] 05:35AM BLOOD WBC-5.7 RBC-4.45* Hgb-13.1* Hct-37.9*
MCV-85 MCH-29.4 MCHC-34.6 RDW-13.7 Plt Ct-179
[**2184-2-2**] 05:45AM BLOOD Glucose-68* UreaN-33* Creat-1.8* Na-137
K-3.9 Cl-101 HCO3-23 AnGap-17
.
EKG:
NSR, rate 90s, NA, T wave flattening V4-6; no ischemic ST
changes
.
IMAGING:
[**2184-1-29**] CXR: Frontal and lateral views of the chest are
obtained. There has been interval removal of a previously seen
right central venous catheter. No focal consolidation, pleural
effusion, or evidence of pneumothorax is seen. The cardiac
silhouette is top normal to mildly enlarged. The aortic knob is
calcified. No overt pulmonary edema is seen.
IMPRESSION: No findings to suggest pneumonia.
Brief Hospital Course:
58 year-old man with ESRD s/p type DM I s/p living unrelated
renal transplant on [**2179-6-16**] presenting with DKA in setting of
gastroenteritis and insulin noncompliance.
.
# DKA: Pt with blood glucose initially in 600s, anion gap 30,
and glucose/ketones in urine consistent with DKA. Likely
triggered by recent gastroenteritis and subsequent insulin
noncompliance. Other workup for infectious etiology, including
CXR and U/A unrevealing for source of infection and patient
remained afebrile w/o leukocytosis. EKG w/o ischemic changes and
cardiac enzymes were negative. Patient was continued on insulin
gtt and the anion gap closed. When glucose decreased to 250 he
was started on D5 1/2NS, and after starting POs the D5 1/2NS was
stopped. [**Last Name (un) **] was consulted and recommended starting his home
insulin regimen at a decreased dose (100units Q8h rather than
150units Q8h). Despite this lower dose he had occasional blood
sugars in the 60s believed to be from eating a lower
carbohydrate diet than his normal diet. Insulin was further
reduced to 80units Q8 hours. This may need to be increased as an
outpatient.
.
# ESRD s/p renal transplant: Pt was previously followed by Dr
[**Last Name (STitle) **] but was last seen in [**2181**]. Creatinine was reportedly
3s at OSH ED, now downtrended to 1.8 on discharge. Per wife,
baseline Cr ranges [**2-2**]. Per renal we continued tacrolimus 5mg
[**Hospital1 **], prednisone 5mg daily, and bactrim prophylaxis, and changed
MMF to 1000mg [**Hospital1 **]. Upon discharge patient will need outpatient
f/u with Dr. [**Last Name (STitle) **].
.
#Volume overload: Mr. [**Known lastname 4901**] was clinically volume overloaded
after receiving significant IVF. His furosemide was increased
from 40 mg daily to 40 mg [**Hospital1 **]. This should be readdressed as an
outpatient when he is euvolemic.
.
Chronic Issues:
# Foot ulcers: Pt with peripheral neuropathy and ulcers [**3-4**]
diabetes. Ulcer on left foot appears clean with good granulation
tissue. No signs of infection.
.
# HTN: Patient remained normotensive. Continued home doses of
metoprolol and isosorbide mononitrate. Restarted lasix at 40 [**Hospital1 **]
for volume overload (see above)
.
# Hyperlipidemia: Continued home doses of zetia, rosuvastatin.
Patient reported having allergy to fenofibrate so this was held.
This should be re-addresses by his PCP.
.
# Hypothyroidism: Continued levothyroxine.
.
Transitional Issues:
.
#Insulin dose: While in the hospital his insulin was decreased
from his home dose of 150units TID to 80units of TID because of
hypoglycemia with higher doses. This is likely from eating less
carbohydrates while in the hospital. This should be readdressed
as an outpatient.
.
#Renal follow up: Will need to continue follow up with Dr.
[**Last Name (STitle) **].
.
#Fenofibrate: This medication is listed in his current
medications but also as an allergy. This should be addressed as
an outpatient.
.
#Volume overload/furosmidedose: Mr. [**Known lastname 4901**] was clinically volume
overloaded after receiving significant IVF. His furosemide was
increased from 40 mg daily to 40 mg [**Hospital1 **]. This should be
readdressed as an outpatient when he is euvolemic.
.
Medications on Admission:
1. Folic acid 1mg [**Hospital1 **]
2. Bactrim SS 1 tablet daily
3. Metoprolol Succ 25mg QAM, 12.5mg QPM
4. Fenofibrate 200mg daily
5. Levothyroxine 100mcg daily
6. Isosorbide mononitrate ER 30mg daily
7. Crestor 20mg daily
8. Tacrolimus 5mg [**Hospital1 **]
9. Prednisone 5mg daily
10. Zetia 10mg daily
11. Lasix 40mg daily
12. Aspirin 325mg daily
13. MMF 1000mg [**Hospital1 **]
14. Vicodin prn back pain
15. Humulin R U500 150 units/meal
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO QAM (once a day (in the
morning)).
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO HS (at bedtime).
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*0*
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
14. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
15. insulin regular hum U-500 conc 500 unit/mL Solution Sig:
Eighty (80) units Injection three times a day: with meals.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 4901**],
You were in the hospital because you had a medical condition
from very high blood sugar called diabetic ketoacidosis. This
happened because you were not taking your insulin and you had an
infection called gastroenteritis. We are glad that you are
feeling better. We made some changes in your insulin schedule.
You should make sure to continue taking your insulin as directed
(see below). You should also keep taking all other medications
as you have been. Make sure to follow up with your primary
doctor, your endocrinologist (diabetes doctor), and your
nephrologist (kidney doctor). Thank you for coming to [**Hospital1 1535**].
Medication Changes Summary:
Please take Humulin R U500 80 units/meal
Please take tacrolimus 5mg twice a day
Please increase your furosemide (Lasix) to 40mg twice a day
until you see your PCP, [**Name10 (NameIs) 1023**] will decide whether to go back to
your home dose.
Please stop taking fenofibrate (tricor) because you may have an
allergy to this medicine. Please confirm with your primary
doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**].
Please continue to take all other medications as you have been.
Followup Instructions:
Please call your PCP's office tomorrow to schedule a follow up
appointment for Thursday or Friday so they can decide what to do
about your Lasix (furosemide) dosing.
Name: [**Last Name (LF) 98448**],[**First Name3 (LF) 1112**] J.
Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 34354**]
Fax: [**Telephone/Fax (1) 98449**]
.
Please call your endocrinologist to schedule the soonest
available follow up (within the next 7-10 days).
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
[**Street Address(2) **]
[**Hospital1 **], [**Numeric Identifier 20777**]
Phone: ([**Telephone/Fax (1) 98450**]
.
Please call your nephrologist (kidney doctor), Dr. [**Last Name (STitle) **],
to set up an appointment within 7-10 days.
[**Hospital1 18**] - Division of Nephrology
[**Last Name (NamePattern1) 439**], LMOB #7
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 673**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]
|
[
"E878.0",
"707.15",
"517.8",
"V58.69",
"585.9",
"V58.65",
"V58.67",
"250.13",
"250.43",
"584.9",
"276.69",
"724.5",
"244.9",
"278.01",
"996.81",
"403.90",
"V15.81",
"357.2",
"135",
"250.63",
"008.8",
"250.83"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10780, 10786
|
5675, 7532
|
280, 286
|
10852, 10852
|
4014, 4014
|
12220, 13347
|
2705, 2732
|
9383, 10757
|
10807, 10831
|
8919, 9360
|
11003, 12197
|
4949, 5652
|
2747, 3415
|
3431, 3995
|
8417, 8893
|
8122, 8406
|
1770, 2112
|
237, 242
|
314, 1751
|
4030, 4600
|
10867, 10979
|
4616, 4933
|
7548, 8101
|
2134, 2491
|
2507, 2689
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,105
| 141,597
|
16324
|
Discharge summary
|
report
|
Admission Date: [**2130-1-26**] Discharge Date: [**2130-2-3**]
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This is an 81 year old
gentleman who had a past medical history significant for
hypertension, chronic anemia, chronic renal insufficiency and
noninsulin dependent diabetes mellitus. He recently
developed increasing shortness of breath and fatigue.
Echocardiogram showed moderate to significant aortic
stenosis. He was referred in for cardiac catheterization in
preparation for aortic valve replacement.
Cardiac catheterization showed that he had moderate aortic
stenosis and moderate coronary artery disease.
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes mellitus.
2. Chronic anemia.
3. Chronic renal insufficiency.
4. Renal calculi ten years ago.
5. Hypercholesterolemia.
MEDICATIONS ON ADMISSION:
1. Lisinopril 30 mg p.o. q. day.
2. Atenolol 50 mg p.o. q. day.
3. Aspirin 325 mg p.o. q. day.
4. Lipitor 40 mg p.o. q. day.
5. Hydrochlorothiazide 25 mg p.o. q. day.
6. Glyburide 5 mg p.o. q. day.
7. Terazosin 2 mg p.o. q. day.
8. Allopurinol 300 mg p.o. q. day.
ALLERGIES: He was allergic to intravenous dye which causes
skin rash.
SOCIAL HISTORY: He had no tobacco history and social
alcohol use.
PHYSICAL EXAMINATION: On admission he was in sinus rhythm
with a blood pressure of 140/80. His skin was clear. His
neck was supple with no jugular venous distention. He had
two plus palpable carotid pulses with no bruits, no
lymphadenopathy. His heart has a regular rate and rhythm
with a normal S1 and S2 and a Grade III/VI systolic ejection
murmur. Lungs are clear to auscultation bilaterally. His
abdomen was soft, nontender, nondistended, and obese with no
hepatosplenomegaly or other palpable masses. Extremities
were warm and well perfused with pedal edema and no
varicosities. His neurological examination showed he was
alert and oriented times three, with gross motor and sensory
intact and two plus palpable radial, femoral, dorsalis pedis
and posterior tibialis pulses bilaterally.
LABORATORY: On admission, of note his creatinine was 1.4.
His EKG showed normal sinus rhythm.
HOSPITAL COURSE: He was admitted to the Operating Room
where he underwent aortic valve replacement with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] with a 21 millimeter bovine pericardial valve and a
coronary artery bypass graft times one. Please refer to the
operative note.
He tolerated surgery well and without complication and was
transferred to Cardiothoracic Intensive Care Unit on a
Nitroglycerin drip at 0.5 mics per kilo per minute for blood
pressure control and a propofol drip. He was extubated later
that evening without incident.
On postoperative day one he was weaned off all drips. He had
a heart rate of 75 in normal sinus. He had a couple of short
limited episodes of ectopy with some PACs while in sinus
tachycardia and one brief self-resolving run of ventricular
tachycardia. He remained, however, mainly in sinus rhythm
with a heart rate of between 70 and 80. Chest tubes were
removed on postoperative day three and he was started on
Lopressor for pressure and heart rate control. He
additionally required intravenous Hydralazine for further
blood pressure control.
On postoperative day four, he was deemed stable and ready for
transfer to the regular floor. On postoperative day five, he
went into persistent atrial flutter which soon began to
alternate with atrial fibrillation. His rate was
persistently in the 120 to 130 range. He was given
intravenous Lopresor and intravenous amiodarone. His rate
was eventually able to be controlled between 85 and 95 on 100
mg twice a day of oral Lopressor and 400 mg three times a day
of oral amiodarone.
He remained hemodynamically stable and asymptomatic
throughout the period. Despite all the medication he did not
convert into sinus rhythm and was started on low dose of
intravenous heparin. Once therapeutic on this heparin the
decision was made to cardiovert the patient as it was felt
that due to his age he would not be an ideal candidate for
Coumadin. He was then successfully cardioverted on
postoperative day seven and has remained in normal sinus
rhythm since that time with the heart rate in the 70s.
Following overnight observation on Telemetry after his
cardioversion, he was deemed ready and stable for transfer to
the extended care facility.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o. twice a day times seven days, then
400 mg q. day times one month.
2. Enteric-coated aspirin 325 mg p.o. q. day.
3. Zantac 150 mg p.o. q. day.
4. Colace 100 mg p.o. twice a day.
5. Percocet one tablet p.o. p.r.n. q. four to six hours for
pain.
6. Glyburide 5 mg p.o. q. day.
7. Allopurinol 300 mg p.o. q. day.
8. Atorvastatin 40 gm p.o. q. day.
9. Terazosin hydrochloride 2 mg p.o. q. h.s.
10. Norvasc 10 mg p.o. q. day.
11. Ferrous gluconate 300 mg p.o. q. day.
12. Ascorbic acid 500 mg p.o. twice a day.
13. Lopresor 100 mg p.o. twice a day.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement and coronary artery
bypass graft times one.
2. Moderate aortic stenosis.
3. Chronic anemia.
4. Noninsulin dependent diabetes mellitus.
5. Chronic renal insufficiency.
6. Hypercholesterolemia.
7. Renal calculi.
DISPOSITION: He was discharged to an extended care facility
on a cardiac heart healthy diet with 1800 calorie American
Diabetic Association limit with activity as tolerated.
DISCHARGE INSTRUCTIONS:
1. He was instructed to follow-up with his cardiologist in
the next one to two weeks.
2. He was instructed to follow-up with his primary care
physician in one to two weeks.
3. He was instructed to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], his
surgeon, in about four weeks.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2130-2-10**] 14:30
T: [**2130-2-10**] 16:48
JOB#: [**Job Number 46515**]
|
[
"424.1",
"E878.8",
"427.32",
"428.0",
"997.1",
"414.01",
"427.31",
"274.9",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"88.72",
"35.21",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5048, 5483
|
4448, 5027
|
843, 1189
|
2176, 4425
|
5507, 5828
|
1282, 2157
|
125, 638
|
660, 817
|
1207, 1258
|
5854, 6138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,529
| 183,002
|
36151
|
Discharge summary
|
report
|
Admission Date: [**2200-12-24**] Discharge Date: [**2201-1-4**]
Date of Birth: [**2125-2-2**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
transfer for IPH
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
75 yo male with h/o amyloid angiopathy with microbleed,
alzheimer's dementia who presents as a transfer from an OSH with
large LEFT ICH. Patient was walking outside on his drive way
when
his wife [**Name (NI) 81986**] him on the ground at approximately 2pm. She
did not see him fall, so it was unclear if it was a mechanical
vs
another etiology. However, he did get up from the ground and
went up stairs. Patient, who had visual deficits from a prior
stroke, then told his wife he could no longer see at all. At
this point she called EMS. Patient was seen at [**Hospital3 **] at
4:30pm where exam notable for alert, speaking full sentences,
mildly confused, MAE, imaging notable for large LEFT ICH with
3mm
shift. Patient was loaded with 1 gram of fosphenytoin.
Transferred via [**Location (un) 7622**] to [**Hospital1 18**], intubated enroute for GCS
change 15 to 5. Given Fentanyl 300, versed 5 mg. On arrival to
[**Hospital1 18**] patient was noticed to have full body shaking and
nonresponsivenes. Patient was given Keppra 1400mg. Trauma
workup
otherwise unremarkable. Urology consulted for blood at urethral
meatus s/p foley placement by their service. Neurosurgery
recommended no operative intervention. At this point neurology
was consulted.
Past Medical History:
Hyperlipidemia
An MRI scan of the brain in [**2196**] (copy sent to the ED) showed
multiple hemorrhages, and he was diagnosed with amyloid
angiopathy - he had left occipital hemorrhages
Seizures?
Residual left hemiparesis
Melanoma excision (location unknown)
Basal Cell cancer excision (location unknown
Gout
Social History:
Lives with his wife, retired [**Name2 (NI) 31869**], they have a son. no
smoking, etoh, or illicit drug use
Family History:
not known
Physical Exam:
Physical Exam on Admission:
vitals: 98.7 BP: 120 / 60 HR:79 R 18 O2Sats 100%
Gen: Intubated. .
HEENT: Pupils: right 1 mm NR, Left 1mm NR
Neck: in C collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: bradycardic
Extrem: Warm and well-perfused.
Neuro:
MS:Off sedation. On ventilator, not breathing above the vent.
Grimaces to noxious, but does not open eyes
Cranial Nerves:
corneals + bilaterally,
Pupils. Midline, no bobbing. 1 mm BL, non reactive
unable to elicit occulocephalic reflex, however limited
secondary
to C-collar
Gag absent but grimaces
not breathing above vent
Sensory/Motor: Patient withdrew to noxious, in left upper and
lower. Withdrew to noxious in RLE. No withdrawal in RUE.
reflexes:2+ throughout Toes upgoing bilaterally.
Pertinent Results:
Labs on Admission:
[**2200-12-23**] 08:30PM WBC-11.4* RBC-3.81* HGB-12.0* HCT-34.0*
MCV-89 MCH-31.4 MCHC-35.2* RDW-13.4
[**2200-12-23**] 08:30PM PLT COUNT-184
[**2200-12-23**] 08:30PM PT-12.8 PTT-23.0 INR(PT)-1.1
[**2200-12-23**] 09:01PM GLUCOSE-144* LACTATE-2.4* NA+-141 K+-4.3
CL--101 TCO2-26
[**2200-12-23**] 08:30PM UREA N-20 CREAT-1.5*
[**2200-12-23**] 08:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
IMAGES:
NCHCT: Large left temporal intraparenchymal hemorrhage with
surrounding edema, mass effect including sulcal effacement and
compression of the posterior left ventricle with subsequent
prominence of the right temporal [**Doctor Last Name 534**]. 5-mm of rightward midline
shift. Intraventricular hemorrhage, as above, involving the left
ventricular body, possibly posterior [**Doctor Last Name 534**] of the left temporal
of the left ventricle, and posterior [**Doctor Last Name 534**] and atrium of the
right ventricle; Possible small focus of subarachnoid hemorrhage
in the right frontoparietal region, as above; Right occipital
encephalomalacia with internal linear high density, which may
represent calcification or additional focus of acute hemorrhage
EEG: abnormal routine EEG due to the presence of a
diffusely slow background which reached a maximum of 6 Hz. This
is
representative of a mild to moderate encephalopathy such as can
be seen
with diffuse ischemia, infection, toxic/metabolic, among other
etiologies. There were no clear epileptiform discharges or
electrographic seizures noted.
Brief Hospital Course:
Mr. [**Known lastname 81983**] is a 75 y/o man with h/o amyloid angiopathy who was
transferred from OSH with large left IPH; initial ICH score of
4. This is believed to be secondary to his amyloid angiopathy.
He was evaluated by the neurosurgery service, who beleived that
given his baseline functional status and dominant hemispheric
hemorrhage, they would not surgically intervene and recommended
medical mangament. He was then admitted to the Neuro ICU for
supportive care; including vent management, BP control, and tube
feeds. He was maintained on ventilator support to protect his
airway as he was never able to open his eyes or respond to
commands. While in ICU, he developed Enterococcus UTI and was
treated with 3 days of Vanco for this. He was initially able to
move his left upper extremity spontaneusly, but eventually he
was only able to withdraw it to noxious stimuli. At the time of
this change in his neurologic exam, a repeat head CT was
performed, which showed worsening midline shift, believed to be
secondary to increasing edema around the hemorrhage.
Neurosurgery was alerted about this change and recommended
medical management. He was started on Mannitol. Shortly after
this change was made, the family decided to change the goals of
care and proceed with comfort measures. He was extubated and
started on a Morphine drip for comfort.
Medications on Admission:
Aricept 10 mg daily
simvastatin 20 mg daily
allopurinol 100 mg daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
L intraperenchymal hemorrhage
amyloid angiopathy
Discharge Condition:
n/a
Discharge Instructions:
Mr. [**Known lastname 81983**] presented with large L IPH secondary tp amyloid
angiopathy. He remained on supportive care during hospital
course, but given poor prognosis and lack of meaningful recovery
possible, decision made by family to make him CMO.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2201-2-20**]
|
[
"348.4",
"V85.0",
"331.0",
"348.5",
"E885.9",
"294.10",
"459.9",
"V49.86",
"853.01",
"277.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5991, 6000
|
4483, 5843
|
321, 327
|
6093, 6099
|
2896, 2901
|
6401, 6551
|
2090, 2101
|
5963, 5968
|
6021, 6072
|
5869, 5940
|
6123, 6378
|
2116, 2130
|
265, 283
|
355, 1615
|
2500, 2877
|
2916, 4460
|
1637, 1948
|
1964, 2074
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,124
| 118,410
|
47006
|
Discharge summary
|
report
|
Admission Date: [**2137-3-3**] Discharge Date: [**2137-3-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Chest Pain/Shortness of Breath
CHF,demand ischemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 85 year old man recently admitted to [**Hospital1 18**] in
[**2137-1-20**] for bilateral lower lobe pneumonia complicated by a
NSTEMI. Patient has reported history of untreated multiple MIs
in the [**2111**] and has diagnoses of HTN, CKD, CHF, DVT,and bipolar
disorder. On last admission, the patient had an echocardiogram
that revealed an EF 40-50% with global LV hypokinesis. The
cardiology service was consulted at this time with
recommendation that the patient was likely a poor cath candidate
given his multiple comorbidities and CKD with creatinine of 2.5
The patient was discharged back to his home at Heathwood NH with
decision to manage patient's cardiac disease medically. Per
notes from E.D. the patient is reported to have experienced
chest pain and dyspnea early this a.m. that was relieved at that
time with SL-NTG x1. The patient's symptoms recurred and was
treated again with nitropaste as well as lasix 120mg PO, without
resolution of symptoms this time. Given his symptoms, the
patient was trasnferred to [**Hospital1 18**] where he was found to be
tachypnic and dyspneic on arrival. In the ED, the patient was
treated with ASA 325mg, 80mg IV lasix, O2, NTG gtt and was
started on non-invasive ventilation, with reported resolution of
pain. The patient was treated with an additional 160mg IV lasix
without good initial response. Upon transfer to the CCU, the
patient had produced only 300cc urine.
.
Allergies: NKDA
Past Medical History:
1. HTN
2. CKD: Cr from office visit last year w/ Cr 1.8
3. bipolar disorder - on lithium previously, recently
experienced toxicity
4. hyperlipidemia
5. prostrate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not
know details.
7. Urinary incontinence
8. MI ([**2111**]) and a recent NSTEMI in [**Month (only) **]/06
9. DVT
10. CHF
Social History:
Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. The patient is reported to be
independent of ADLs. He receives prepared meals twice daily via
the home facility. He reports that at baseline he is able to
ambulate although only with the aid of a walker on wheels. He
denies any drinking history and has very remote tobacco use. Has
2 grown children, one is [**State **] and one in [**State 760**]. Dr.
[**Last Name (STitle) 1266**] is the patient's PCP and his wife his HCP. Dr.
[**Last Name (STitle) 1266**] has been very involved with this patient regarding
code status and goals of care. Currently, the patient is full
code as was established on last admission and confirmed this
admission. Given patient's overall prognosis and expectation
that the patient will require more and more frequent
hospitalization, conversation is ongoing with regards to overall
management strategies.
Full code. Wife is his health care
proxy.
.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: BP: 118/59 HR: 77 (NSR) RR: 31-32 O2 Sat: 96% on 4L
NC
.
Gen: Patient is an elderly male, sitting upright in bed in
moderate respiratory distress, with use of accessory muscles
when breathing and audible wheezes.
HEENT: NC, patient with small dry blood over left lower lip. MM:
dry
Neck: prominent EJ, + JVD
Chest: Noteable for use of sternocleidomastoids and intercostal
muscles with breathing. Patient with audible expiratory wheezes
from upper airway, asucultation of lung fields without
significant wheezes. Rapid breathing with small tidal volume,
poor airmovement throughout. Small crackles at left lower base
Cor: RRR, no obvious M/R/G
Abd: Obese, soft, NT. +NABS
Ext: 2+ pedal edema, 1+ pitting edema to knees. Chronic
hyperpigmentation of lower extremities bilaterally. Distal
pulses 2+ bilaterally.
Pertinent Results:
Admission Labs:
.
[**2137-3-3**] 11:40AM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2137-3-3**] 11:40AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2137-3-3**] 11:40AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.011
[**2137-3-3**] 11:40AM PT-43.1* PTT-31.8 INR(PT)-4.9*
[**2137-3-3**] 11:40AM NEUTS-95.2* BANDS-0 LYMPHS-3.1* MONOS-1.5*
EOS-0.2 BASOS-0
[**2137-3-3**] 11:40AM WBC-16.8* RBC-3.53* HGB-11.0* HCT-32.6*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.7
[**2137-3-3**] 11:40AM VALPROATE-11*
[**2137-3-3**] 11:40AM CALCIUM-8.9 PHOSPHATE-6.1*# MAGNESIUM-2.4
[**2137-3-3**] 11:40AM CK-MB-4
[**2137-3-3**] 11:40AM cTropnT-0.13*
[**2137-3-3**] 11:40AM CK(CPK)-170
[**2137-3-3**] 11:40AM GLUCOSE-121* UREA N-45* CREAT-2.5* SODIUM-138
POTASSIUM-7.0* CHLORIDE-107 TOTAL CO2-18* ANION GAP-20
[**2137-3-3**] 12:00PM ALBUMIN-4.0
[**2137-3-3**] 12:00PM POTASSIUM-4.4
[**2137-3-3**] 12:03PM LACTATE-1.7
[**2137-3-3**] 12:03PM COMMENTS-GREEN TOP
[**2137-3-3**] 03:12PM %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
[**2137-3-3**] 05:40PM CK-MB-22* MB INDX-10.4* cTropnT-0.48*
[**2137-3-3**] 05:40PM CK(CPK)-212*
[**2137-3-3**] 07:23PM O2 SAT-97
[**2137-3-3**] 07:23PM K+-4.0
[**2137-3-3**] 07:23PM TYPE-ART PO2-87 PCO2-33* PH-7.43 TOTAL CO2-23
BASE XS-0
[**2137-3-3**] 08:04PM CALCIUM-8.9 MAGNESIUM-2.1
[**2137-3-3**] 08:04PM POTASSIUM-4.0
Pertinent Labs/Studies
.
CK: 170 -> 212 -> 224 -> 138
CK-MB: 4 -> 22 -> 23 -> 13
Trop: < .01 -> .48 -> .13
.
Creatinine: 2.5 -> 2.6 -> 2.7 -> 2.9
.
[**2137-3-3**]: HbA1c - 5.4%
[**2137-3-3**]: Valproate - 11
[**2137-3-3**]: CCU admission ABG: 7.43/33/87/23
.
.
Imaging:
[**2137-3-3**]: Portable Chest - There is stable cardiomegaly. The
left
costophrenic angle is excluded from the radiograph. There is
slight
prominence of the pulmonary vasculature centrally but no overt
edema. Again identified is bibasilar opacification persisting
at the lung bases slightly increased in the left lower lobe
compared to the prior study which could be residual edema or
atelectasis. The possibility of mild volume overload or
developing infection cannot be excluded. No pneumothorax is
identified. The soft tissue and osseous structures are stable.
IMPRESSION: Slight increase in opacification at the lung bases
reflecting
bibasilar atelectasis or possible developing infection/mild
volume overload.
.
[**2137-3-5**]: Chest Pa/Lat - pending
.
.
Microbiology:
Urine Cultures:
[**2137-3-3**]: UA: Leuks Mod, Nit neg, WBC > 50, Bact - mod
[**2137-3-5**]: UA: Leuks Mod, Nit neg, WBC [**3-24**], Bact - few
[**2137-3-3**]: Urine Cx: >100K Coag Pos Staph
[**2137-3-5**]: Urine Cx: pending
.
Blood Cultures:
[**2137-3-3**]: Blood Cultures x 4: NGTD
[**2137-3-5**]: pending
Discharge Labs:
Brief Hospital Course:
Assessment: Patient is an 85 year old male with past CAD hx who
presents with CHF exacerbation and enzyme leak likely secondary
to demand ischemia.
.
Cardiovascular:
CHF: The patient presented to the hospital with symptoms of
decompensated CHF including dyspnea, rales on exam and
peripheral edema. The patient additionally reported chest pain
on admission that was initially responsive to nitrate therapy,
then refractory. In the ED the patient was assessed to be in CHF
and was treated with lasix, 120mg IV in total, nitro gtt, and
additionally given aspirin given chest pain and history of CAD.
The patient was noted on admission to have an supratherapeutic
INR of 5.1 on admission for which additional anticoagulation
with Heparin gtt or Lovenox was held. The patient's ECG on
admission was remarkable for an old LBBB with some non-specific
TWI in I and aVL, poor R wave progression but no significant or
acute ST changes. The patient was admitted to the CCU for
ongoing diuresis with additional monitoring of enzymes for
potential NSTEMI. Of note, in the ED the patient was initially
treated with non-invasive mask ventilation with good effect.
Attempted diuresis prior to admission only yielded an output of
300cc net negative. Despite this, the patient was transferred to
the floor without need for non-invasive ventilation and was
oxygenating well with 5L NC. The patient was placed on a lasix
gtt with good effect with negative diuresis 2.5-3.0 liters since
admission. The patient remains mildly fluid overloaded with goal
additional diuresis of approximately one more liter, which will
be performed now with lasix boluses. Further diuresis beyond one
liter may be limited by the patient's renal function given rise
in creatinine from 2.5 to 2.9 as well as blood pressure. The
patient has had a steady oxygen requirement of 2.0 L NC with
some improvement in subjective symptoms. It is thought that
patient may do well on discharge with combination
Hydralazine/Nitrate for afterload/preload reduction as his
creatinine will not tolerate an ACE inhibitor.
.
CAD: As noted, on admission the patient was known to reportedly
have had multiple MIs in the 80's without intervention. The
patient's initial cardiac enzymes on admission were CK-170,
MB-4, Trop- .13 with peak values of 224/23/.48. Rise in
patient's enzymes were thought most likely to be secondary to
demand ischemia in the setting of decompensated CHF although a
small NSTEMI can not be [**Month/Day/Year 20003**] out. Trying to illicit the
precipitating event was unsuccessful. The patient on admission
was maintained on ASA and Plavix (which he was previously
taking). Heparin was not started given patient's elevated INR on
admission and coumadin was held. Patient was maintained on high
dose Atorvastatin for secondary prevention. The patient remained
chest pain free for the remainder of his admission. The patient
had an echocardiogram performed in [**Month (only) 404**] during his last
admission which demonstrated an EF of 40-50% with global LV
hypokinesis. Given there was no evidence for large infarct,
there was no expectation of any great change from previous, so a
repeat echocardiogram was not performed. Pt in the past has not
been able to tolerate an ACEi due to worsening renal function
every time an ACE is started.
.
Rhythm: The patient on admission was in NSR without significant
ectopy during his hospital course. The patient however was noted
to develop afib on [**2137-3-4**] without clear precipitant. The
patient was normotensive without ongoing evidence of ischemia at
this time. The patient has no chart diagnosis of Afib but it is
possible or likely that he has paroxysmal afib that has not
previously been recognized. THe patient is currently already
anticoagulated for an indication of DVT. Given his age and
medical status, the patient is thought likely to be a poor
candidate for cardioversion. Therefore, current strategy is to
continue anticoagulation (INR goal 2.0-3.0) and rate control.
Currently the patient has had fair rate control with HR ranging
from 60-110. The patient's dose of hydralazine was decreased to
50mg po 6h to allow increase in metoprolol to 75mg po tid for
increased rate control. His rate is now well controlled with a
heart rate ranging from 60-80s.
.
#. ID - The patient remained afebrile without elevated white
count on admission. On previous admission the patient was
treated for PNA. On admission to CCU, patient was noted to have
+UA as well as questionable left lower lobe consolidation worse
than previous for which levo/Flagyl was started. Flagyl was
discontinued the following day given no evidence for aspiration
or PNA and the patient was continued on levofloxacin for pna to
complete a ten day course. Urine culture from [**2137-3-3**] grew Coag
+ Staph, sensitivity pending. Given foley, it was thought this
more likely represented contaminant or colonizer so abx regimen
was not changed. The patient's foley catheter was changed and
repeat UA/UCx ordered. The patient had one set of blood culture
without growth and a repeat was ordered to ensure there was no
seeding of urine from blood. The bacteria was later identified
as MRSA and patient was treated with 2 days of IV Vancomycin,
and transitioned to Linezolid PO to complete a 1 week course.
.
#. Heme: On admission the patient was noted to have a
supratherapeutic INR of 5.1 for which coumadin was held. Despite
this, the patient's INR continued to rise to 7.0 over two days.
This was thought most likely to be nutritional and the patient
was given 5mg PO Vitamin K on [**2137-3-5**]. Also of note the patient
had a HCt drop from 32.6 on admission to 27.7. However, repeat
Hct have been relatively stable and the patient is without any
obvious source of bleeding (no bowel movements yet this
admission). INR dropped to 1.4 after administration of Vit K and
patient was restarted on his coumadin at a dose of 4mg po qhs.
Pt is have his INR monitored by his PCP and dose will be
titrated as needed to maintain goal of [**2-22**].
.
#. CKD: Patient is noted to have baseline creatinine of 2.0-2.8.
On admission the patient had a creatinine of 2.5 which has been
rising, most recently 2.9 in the setting of diuresis. Patient's
meds have been reneally dosed and current diuresis plans are to
remove approximately one additional liter given rising
creatinine and potential for hypotension. Pt's creatinine
eventually peaked at 3.1, and with continued diuresis, pt's Cr
dropped to 2.6 on day of discharge, which is patient's baseline.
.
#. FEN: Patient was maintained on a Cardiac Healthy/Low Na diet.
Patient had a S+S eval which cleared his as appropriate for thin
liquids and puree solids with appropriate aspiration precautions
and assistance with feeding. Patient is being fluid restricted <
1200 given CHF.
.
#. Code: Full.
# DISPO: Patient to be discharged to rehabilitation for short
term rehab.
Medications on Admission:
Depakote: 250mg EC qhs, 125mg qam
Lasix 60mg po qd
Norvasc 10mg po qd
Plavix 75mg po qd
Hydralazine 75mg po qd
Protonix 40mg po qd
Lipitor 80mg po qd
ASA 81mg po qd
Coumadin 5mg po qhs
Toprol XL 225mg po qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Divalproex 250 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO HS (at bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO three
times a day: with meals.
17. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
18. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. Decompansated CHF
2. ? Demand ischemia vs. small NSTEMI
3. UTI (MRSA)
Secondary:
4. Coronary artery disease
5. Hypertension
6. Chronic renal insufficency
7. Anemia
8. DVT
Discharge Condition:
Afebrile, pain free, stable to be discharged home
Discharge Instructions:
1. Please report to the nearest emergency department if you
have
fever, shortness of breath, chest pain or loss of consciousness.
2. Please weigh yourself daily. Please call Dr. [**Last Name (STitle) 1266**] if
you gain more than 3 lbs.
3. Please limit your fluid intake to 1200 ml daily
4. Please follow up with the following providers:
A. Primary Care
Please make an appointment to followup with Dr. [**Last Name (STitle) 1266**] within
the next 2 weeks. You can reach his office at [**Telephone/Fax (1) 608**].
B. Cardiology: Please call to schedule an appointment to be seen
within 1 month ([**Telephone/Fax (1) 62**]) for follow-up of congestive heart
failure
C. [**Telephone/Fax (1) **] Surgery
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) (see
appointment time below)
D. Podiatry
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2137-3-15**] 10:00
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2137-4-26**] 2:20
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2137-7-30**] 10:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Completed by:[**2137-3-8**]
|
[
"427.31",
"486",
"410.72",
"428.23",
"V58.61",
"403.91",
"584.9",
"285.9",
"296.7",
"410.71",
"599.0",
"428.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15785, 15855
|
6981, 13880
|
311, 317
|
16081, 16132
|
4128, 4128
|
17227, 17889
|
3240, 3258
|
14137, 15762
|
15876, 16060
|
13906, 14114
|
16156, 17204
|
6958, 6958
|
3288, 4109
|
221, 273
|
345, 1795
|
4144, 6941
|
1817, 2220
|
2236, 3224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,631
| 100,040
|
40674
|
Discharge summary
|
report
|
Admission Date: [**2193-6-27**] Discharge Date: [**2193-6-30**]
Date of Birth: [**2162-12-8**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
chest, lower back and hip pain, s/p crush injury
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 88968**] is a 30 year old man with untreated hypertension who
suffered a crush injury to his chest (tractor loaded with weight
rolled onto his chest) requiring extraction with a fork lift.
He denied any LOC; VS were stable during [**Location (un) **]. Upon ED
presentation, he c/o hip and low back pain, yet denied chest
pain, dyspnea, abdominal pain, headache or neck pain.
Cardiology was consulted given concern for contusion, cardiac
injury. He was noted to have a new RBBB on ECG with TWI. The
patient has a CPK of 1464 and TnT<0.01. MB 5. Pt's chest pain
improved with narcotics. He also denied dyspnea, although it
hurts to take a deep breath.
He stopped taking anti-hypertensives because lack of insurance.
He had atypical chest pains in the past and was evaluated at
[**Hospital1 **] with an ECG. Denies any exertional chest symptoms. No
orthopnea or PND. Remaining ROS positive for back pain and pain
in the hips. All other ROS are negative.
Past Medical History:
HTN (not currently treated)
Social History:
Married (wife, [**Name (NI) **] [**Name (NI) 88969**], [**Telephone/Fax (1) 88970**] is emergency contact).
Non-smoker, no alcohol. No illicits.
Family History:
No premature CAD.
Physical Exam:
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Neuro: Speech fluent
Pertinent Results:
[**2193-6-27**] 02:03PM BLOOD WBC-5.0 RBC-5.25 Hgb-15.0 Hct-42.7
MCV-81* MCH-28.6 MCHC-35.2* RDW-14.0 Plt Ct-225
[**2193-6-27**] 02:10PM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.0
[**2193-6-27**] 02:03PM BLOOD Plt Ct-225
[**2193-6-27**] 09:36PM BLOOD Glucose-111* UreaN-7 Creat-1.0 Na-140
K-3.2* Cl-108 HCO3-23 AnGap-12
[**2193-6-27**] 09:36PM BLOOD Glucose-674* UreaN-7 Creat-1.0 Na-136
K-2.6* Cl-102 HCO3-28 AnGap-9
[**2193-6-27**] 02:03PM BLOOD UreaN-10 Creat-1.3*
[**2193-6-27**] 09:36PM BLOOD CK(CPK)-909*
[**2193-6-27**] 02:03PM BLOOD ALT-40 AST-42* CK(CPK)-1464* AlkPhos-64
TotBili-0.6
[**2193-6-27**] 02:03PM BLOOD Lipase-48
[**2193-6-27**] 09:36PM BLOOD CK-MB-5 cTropnT-<0.01
[**2193-6-27**] 02:03PM BLOOD cTropnT-<0.01
[**2193-6-27**] 09:36PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9
[**2193-6-27**] 09:36PM BLOOD Calcium-6.8* Phos-1.8* Mg-1.6
[**2193-6-27**] 02:03PM BLOOD Calcium-9.1
[**2193-6-27**] 02:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-6-27**] 02:10PM BLOOD Glucose-105 Lactate-1.5 Na-145 K-3.5
Cl-107
[**2193-6-27**] 02:10PM BLOOD Hgb-14.8 calcHCT-44
.
[**2193-6-27**] 09:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2193-6-27**] 02:24PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2193-6-27**] 09:36PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2193-6-27**] 02:24PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
[**2193-6-27**] 09:36PM URINE RBC-12* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2193-6-27**] 02:24PM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2193-6-27**] 02:24PM URINE Mucous-RARE
[**2193-6-27**] 02:24PM URINE Hours-RANDOM
.
[**2193-6-27**] 9:36 pm MRSA SCREEN; Source: Nasal swab.
(Final [**2193-6-30**]): No MRSA isolated.
.
[**2193-6-28**] 11:25AM BLOOD WBC-4.3 RBC-5.24 Hgb-15.1 Hct-44.0 MCV-84
MCH-28.8 MCHC-34.2 RDW-14.4 Plt Ct-228
[**2193-6-28**] 11:25AM BLOOD Plt Ct-228
[**2193-6-28**] 11:25AM BLOOD Glucose-133* UreaN-5* Creat-1.0 Na-142
K-3.6 Cl-109* HCO3-25 AnGap-12
[**2193-6-28**] 11:25AM BLOOD CK(CPK)-718*
[**2193-6-28**] 04:47AM BLOOD CK(CPK)-827*
[**2193-6-28**] 11:25AM BLOOD CK-MB-5 cTropnT-<0.01
[**2193-6-28**] 04:47AM BLOOD CK-MB-5 cTropnT-<0.01
[**2193-6-28**] 11:25AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.2
[**2193-6-28**] 04:50AM BLOOD Type-[**Last Name (un) **] pH-7.32*
[**2193-6-28**] 04:50AM BLOOD freeCa-1.11*
.
[**2193-6-28**] 09:57AM URINE Hours-RANDOM
[**2193-6-28**] 09:57AM URINE Myoglob-PRESUMPTIVE
.
[**2193-6-29**] 05:55AM BLOOD WBC-5.9 RBC-5.40 Hgb-15.2 Hct-44.6 MCV-83
MCH-28.2 MCHC-34.2 RDW-14.2 Plt Ct-220
[**2193-6-29**] 05:55AM BLOOD Plt Ct-220
[**2193-6-29**] 05:55AM BLOOD
[**2193-6-29**] 05:55AM BLOOD Glucose-87 UreaN-15 Creat-1.2 Na-141
K-3.6 Cl-107 HCO3-25 AnGap-13
[**2193-6-29**] 05:55AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1
.
[**2193-6-27**] Cardiology ECG
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Probable left ventricular hypertrophy. No
previous tracing available for comparison.
Rate 67, PR 192, QRS 170, QT/QTc 424/436, P 65, QRS -72, T -26
.
[**2193-6-27**] 1:45 PM, TRAUMA #2 (AP CXR & PELVIS PORT)
IMPRESSION: No acute intrathoracic or pelvic injury.
.
[**2193-6-27**] 1:59 PM, CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial injury or skull fracture.
.
[**2193-6-27**] 2:00 PM, CT ABD & PELVIS WITH CONTRAST, CT CHEST
W/CONTRAST
IMPRESSION: No acute injury in the chest, abdomen or pelvis. No
acute
fracture.
.
[**2193-6-27**] 2:00 PM, CT C-SPINE W/O CONTRAST
IMPRESSION: No acute fracture or malalignment.
.
[**2193-6-27**] 5:01 PM, MR CERVICAL SPINE W/O CONTRAST
[**2193-6-27**] 5:01 PM, MR L SPINE W/O CONTRAST
[**2193-6-27**] 5:01 PM, MR THORACIC SPINE W/O CONTRAST
IMPRESSION:
1. No evidence of fracture or ligamentus injury.
2. Mild degenerative changes of the spine.
.
[**2193-6-28**] at 10:02:43 AM, ECHO, Portable TTE (Complete)
IMPRESSION: No RV systolic dysfunction or pericardial effusion
to suggest significant cardiac contusion. Symmetric left
ventricular hypertrophy with mild global systolic dysfunction.
Dilated thoracic aorta with mild functional aortic
regurgitation. Mild mitral regurgitation.
These findings are most consistent with hypertensive heart
disease.
.
[**2193-6-28**] Cardiology ECG
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Compared to the previous tracing no change.
Brief Hospital Course:
Mr. [**Known lastname 88968**] is a 30 year old man with untreated hypertension who
suffered a crush injury to his chest (tractor loaded with weight
rolled onto his chest) requiring extraction with a fork lift.
He denied any LOC; VS were stable during [**Location (un) **]. Upon ED
presentation, he c/o hip and low back pain, yet denied chest
pain, dyspnea, abdominal pain, headache or neck pain.
Cardiology was consulted, given concern for cardiac contusion,
injury. Assesment: chronic RBBB from HTN versus RV contusion
with conduction delay in the RV. LV function appeared
normal. Hx not c/w acute coronary syndrome. He was noted to
have a new RBBB on ECG with TWI. CPK of 1464 and TnT<0.01, MB 5,
AST 42, Ca 9.1, 3 RBC in the urine, Cr 1.3, Hct 42.7.
The patient was initially managed in the TICU for close fluid
status monitoring. The patient was hemodynamically stable. He
received agressive hydration with a goal Uop of >100cc/hr. The
patient's pain was controlled and on HD2, patient was doing
better. His CKs were cycled and trending down. His Creatinine
normalized, so IVF rate was cut back. The patient's diet was
advanced and he was transitioned to po pain meds and transferred
to the floor.
On the floor, he tolerated a regular diet, was ambulating with
physical therapy. He continued to have intermittent muscular
pain in his chest, lower back, and hips, unchanged from previous
days. His pain was controlled on oral narcotic pain medications.
CT imaging and MRI of spine showed no fracture or ligamentous
injury, CT did not show any acute injury or fracture in chest,
abdomen, or pelvis. He was ready for discharge on [**2193-6-30**] to
home.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for muscle spasm.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
rhabdomyolysis
muscular pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ACS service. You did not have any
fractures or organ injuries seen on imaging. You may feel a lot
of muscular aches in the next couple of weeks as your body
heals. Please resume all home medications. You can take the
prescribed narcotic for pain, but do not drive or operate heavy
machinery while taking the medication. You can also take tylenol
or ibuprofen for pain, but do not exceed 4g of tylenol per day.
Followup Instructions:
Follow-up at the acute care surgery clinic as needed:
[**Telephone/Fax (1) 600**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2193-6-30**]
|
[
"728.88",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8535, 8541
|
6473, 8136
|
351, 358
|
8614, 8614
|
1961, 6450
|
9225, 9446
|
1593, 1612
|
8191, 8512
|
8562, 8593
|
8162, 8168
|
8765, 9202
|
1627, 1942
|
263, 313
|
386, 1364
|
8629, 8741
|
1386, 1415
|
1431, 1577
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,793
| 127,282
|
21345
|
Discharge summary
|
report
|
Admission Date: [**2120-8-6**] Discharge Date: [**2120-8-14**]
Date of Birth: [**2049-8-3**] Sex: M
Service: SURGERY
Allergies:
Plavix / Coumadin / Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
[**2120-8-6**]: Open repair of a suprarenal abdominal aortic aneurysm.
History of Present Illness:
This is a man with an enlarging aneurysm just
above the previously repaired infrarenal aortic aneurysm.
The current aneurysm involves the visceral segment of the
aorta. He is status post left retroperitoneal repair of the
infrarenal aorta with multiple bowel obstructions and
abdominal operations with hernia repair with mesh.
Therefore, we chose to approach this through a right
retroperitoneal approach. Because of the complexity, I asked
Dr. [**Last Name (STitle) **] for assistance, as this was beyond the level
of experience of the available resident.
Past Medical History:
PMHx:
CAD - cardiac cath [**4-27**] - RCA patent stents minimal dz LM, LAD,
LCx
Dislipidemia
PAF
HTN
AAA (h/o prior repair in '[**10**] now with supragraft aneurysm)
Non small cell lung cancer s/p chemo/XRT/RULobectomy with brain
mets
CVA [**2108**] with right sided involvement
OA
Diverticuli
prostate cancer
kidney stones
traumatic hip dislocation in [**2063**], status post fusion
Hepatits A
Heart murmur NOS
depression/anxiety
PSHx:
s/p Hartmann's then colostomy reversal '[**07**]
s/p right upper lung lobectomy [**2112**]; LUL VATWR [**11-25**]
s/p left occipital craniotomy [**8-22**]
s/p AAA repair [**2110**]
s/p radical prostatectomy [**2109**]
s/p ventral hernia repait [**2109**]
s/p left hip fusion [**2063**]
s/p right TKR [**2117**]
s/p Herniorrhaphy in [**2075**] with recurrent midline and left flank
incisional hernias
s/p appendectomy
s/p tonsillectomy
Social History:
Former pack a day smoker; quit 6 years ago
Denies ETOH at present ("heavy" drinker about 15 years ago)
He lives part-time in [**Location (un) 86**] with his current wife and part-time
in [**Name (NI) 37452**] where he owns a home. He is independent in
adls. He is a high school graduate, currently retired. He has
two daughters in their 20's from his first marriage.
used to work with restaurant equipment
Family History:
Atherosclerotic cardiovascular disease, prostate and colon
cancer, and hypertension
His father died at 64 of a "[**Last Name **] problem" that the patient does
not recall, and his mother died at 42 of rheumatic fever.
Sister died of colon cancer at a young age
Physical Exam:
Gen: WDWN chronically ill-appearing elderly gentleman in no
acute distress. CV: RRR
Lungs: CTA bilat
Abd: obese, soft, no m/o, tender over incision site
Incision: clean/dry/intact with staples in place
Extremities: Warm and well perfused without edema bilat. He has
had bilateral hip surgeries and his left foot is externally
rotated and about 4" shorter than the right.
Pulses: Femoral - palp bilat DP - palp on left, dop on right PT
- dop bilat
Pertinent Results:
Admission:
[**2120-8-6**] 02:33PM BLOOD WBC-10.5 RBC-4.38* Hgb-13.7* Hct-39.0*
MCV-89 MCH-31.4 MCHC-35.2* RDW-14.3 Plt Ct-135*
[**2120-8-6**] 02:33PM BLOOD PT-13.1 PTT-33.2 INR(PT)-1.1
[**2120-8-6**] 02:33PM BLOOD Glucose-152* UreaN-25* Creat-1.0 Na-138
K-4.6 Cl-111* HCO3-20* AnGap-12
[**2120-8-6**] 02:33PM BLOOD ALT-30 AST-39 LD(LDH)-187 CK(CPK)-101
AlkPhos-60 TotBili-1.8*
[**2120-8-6**] 02:33PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.4*
Discharge:
[**2120-8-14**] 07:35AM BLOOD WBC-7.7 RBC-3.95* Hgb-12.2* Hct-35.9*
MCV-91 MCH-30.9 MCHC-34.0 RDW-14.2 Plt Ct-238
[**2120-8-14**] 07:35AM BLOOD PT-11.6 PTT-24.2 INR(PT)-1.0
[**2120-8-14**] 07:35AM BLOOD Glucose-115* UreaN-28* Creat-1.2 Na-139
K-4.5 Cl-107 HCO3-24 AnGap-13
[**2120-8-14**] 07:35AM BLOOD Calcium-9.8 Phos-2.8 Mg-1.9
Other pertinent labs:
[**2120-8-6**] 02:33PM BLOOD CK-MB-5 cTropnT-<0.01
[**2120-8-6**] 10:45PM BLOOD CK-MB-8 cTropnT-<0.01
[**2120-8-7**] 05:52AM BLOOD CK-MB-9 cTropnT-<0.01
[**2120-8-9**] 11:40AM BLOOD CK-MB-3 cTropnT-<0.01
[**2120-8-9**] 08:14PM BLOOD CK-MB-2 cTropnT-<0.01
[**2120-8-10**] 04:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2120-8-11**] 03:53PM BLOOD CK-MB-1 cTropnT-<0.01
[**2120-8-11**] 11:50PM BLOOD CK-MB-1 cTropnT-<0.01
[**2120-8-12**] 08:50AM BLOOD CK-MB-1 cTropnT-<0.01
[**2120-8-6**] 2:33 pm MRSA SCREEN SOURCE:NASAL SWAB.
**FINAL REPORT [**2120-8-8**]**
MRSA SCREEN (Final [**2120-8-8**]): No MRSA isolated.
Brief Hospital Course:
The patient was admitted to the Vascular Surgical Service for
evaluation and treatment of AAA.
Vascular: Underwnt open repair of a suprarenal abdominal aortic
aneurysm, transferred to the CVICU. Pt NPO, On IV fluids, Foley
catheter, NG tube and Lumber drain. The patient was
hemodynamically stable. He did not require pressors. He was
extubated with out complications. The NG tube was also removed
without sequelae
He was transferred to the VICU when stable from the acute
setting. In the VICU he remained stable. Acute pain service was
following the patient. They stopped his SQ heparin. His Lumbar
drain was pulled without sequelae. PT did see the patient,
recommended Rehab. On DC pt is taking PO, Urinating, has had BM.
Neuro: The patient received pain medications through lumbar
drain, This was removed without sequelae. He did receive
Hydromorphone PCA, This was weaned, On DC he is taking PO pain
medications with good effect and adequate pain control.
CV: The pt did have an episode of sustained asymptomatic VTACH
and several episodes of non - sustained VTACH. A cardiology
consult was obtained. Pt was hemodynamically stable at all
times. He was given IV amiodarone bolus at the initial event and
converted to sinus rhythm. He was loaded with an amio gtt and
then converted to PO amiodarone. Dr [**Last Name (STitle) **] followed his throughout
his hospitalization. Pt was r/o out for MI. The patient
remained stable from a cardiovascular standpoint; vital signs
were routinely monitored. He was in sinus rhythm without issues
for over 48 hours prior to discharge. He is discharged on oral
amiodarone, with 2 more days of the load (400mg tid thru [**8-15**])
and then starting 400mg daily. He will follow up with cardiology
as an outpt.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO with IV fluids.
Diet was advanced when appropriate, which was well tolerated. Pt
did have a NG tube. This was removed when pat started to have
flatulence. He was on a bowel regime. He has had a BM on this
admission.
GU: Patient's intake and output were closely monitored, and IV
fluid was adjusted when necessary. His Foley was DC'ed. He is
urinating without difficulty. He remains on oxybutynin chloride
5 mg
FEN: Electrolytes were routinely followed, and replete when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound care include dry
bandage, He received pre-op antibiotics. There were no ID
processes during this hospital stay.
Endocrine: The patient's blood sugar was monitored throughout
his stay; There were no abnormalities detected
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
atenolol 50'; folic acid 1'; lisinopril 20'; omeprazole 20';
oxybutynin chloride 5'; probiotic 4 '; aspirin 81';
multivitamin'; omega-3 fatty 1,000''
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 5 days: Stop [**8-16**], then start 400 qd. Dr [**Last Name (STitle) **] will
manage amiodarone.
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. Ditropan XL 5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) m l
Injection [**Hospital1 **] (2 times a day): until fully ambulatory.
10. amiodarone 400 mg Tablet Sig: One (1) Tablet PO three times
a day for 2 days: last dose, pm of [**8-15**].
11. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day:
please start this on [**8-16**] am, after pt has finished load.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
AAA
V TACH
HTN, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**4-24**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-21**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2120-9-11**] 10:45
Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 7960**], [**2120-9-2**]. 1530 hrs. [**Doctor Last Name **] Partk, [**Location (un) 56415**]. This is to discuss your V tach episode that you
had after your operation
Completed by:[**2120-8-14**]
|
[
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
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9466, 9551
|
4544, 7978
|
318, 391
|
9627, 9627
|
3070, 3851
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275, 280
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419, 980
|
3874, 4521
|
9642, 9754
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1002, 1877
|
1893, 2301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,238
| 117,451
|
4781
|
Discharge summary
|
report
|
Admission Date: [**2152-11-28**] Discharge Date: [**2152-12-10**]
Date of Birth: [**2086-5-31**] Sex: F
Service: CCU SERVICE
HISTORY OF PRESENT ILLNESS: This is a 66 year old female
with paroxysmal atrial fibrillation, status post prior
ablation and cardioversion with a recent recurrence of her A
fib who is admitted for a reablation procedure. She had
hypotension during the procedure to the 60s systolic. She
was found to have a hematocrit drop from 41 to 29 at this
time and was found to have a retroperitoneal bleed and a
rectus sheath bleed on CT scan done emergently.
The patient was transfused two units of blood and placed on a
Dopamine drip with good blood pressure response to the 120s
to 150s and was transferred to the CCU for her critical care
intubated. The patient had been intubated electively prior
to the procedure. Her Heparin was reversed with Protamine
after her drop in hematocrit.
PAST MEDICAL HISTORY: Paroxysmal atrial fibrillation
starting in [**2133**], status post ablation in [**9-/2152**],
cardioversion in 12/[**2151**]. She has been treated in the past
with Sotalol and Cardizem.
Echocardiogram on [**2152-11-28**] showing an ejection fraction of
greater than 55%, mildly dilated left atrium and a small
secundum atrial septal defect. Also a history of
hypertension, dyslipidemia, mitral valve prolapse, status
post hysterectomy, appendectomy, right leg vein ligation.
Also status post a recent left eye hemorrhage and a right
ankle fracture.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Accupril 10 p.o. q d.
2. Propafenone 300 mg q a.m., 225 mg q noon time and q p.m.
3. Coumadin 2.5 mg p.o. q hs which was stopped two days
prior to admission.
4. Multivitamin.
5. Atenolol 25 mg p.o. q d.
SOCIAL HISTORY: The patient is a part time teacher. No
tobacco, no alcohol. No drug use. She is divorced. She has
four grown children.
PHYSICAL EXAMINATION ON ADMISSION TO THE CCU: Temperature,
94.8; pulse, 87; blood pressure, 130/76; saturation, 100% on
ventilator of AC, 614; PEEP, 5; FIO2, 0.4. General, she is
intubated and sedated on Propofol. Head, eyes, ears, nose
and throat, pupils were mid size and sluggish. Anicteric
sclera. Mucous membranes, dry. Left subconjunctival
hemorrhage. Neck, without jugular venous distention. Chest,
clear to auscultation. Vented breath sounds anterolaterally.
Cardiac, regular rate and rhythm. S1, S2. No rubs, gallops
or murmurs. Abdomen, soft, hypoactive but present bowel
sounds. Left rectus abdominal mass. No ecchymoses.
Extremities, there is a cast on her right lower extremity.
Pulses are 1+ in the left dorsalis pedis with good capillary
refill. Extremities are cool. No edema. Mild cyanosis of
her nail beds. The patient had a left femoral A line and two
right groin venous lines and one femoral venous line. Her
popliteal pulse on the right leg was intact.
LABORATORY ON ADMISSION TO THE CCU: Show a white blood count
of 12; hematocrit, 32; platelets, 173. INR, 1.3; PTT, 30.
Sodium, 143; potassium, 3.7; chloride, 112; bicarbonate, 20;
BUN, 17; creatinine, 0.7. Glucose, 219. Calcium, 6.8.
Magnesium, 1.3. Free calcium, 0.98. Initial blood gas,
7.28/41/473. Lactate, 3.0. Subsequent blood gas of
7.48/26/200 on FIO2 of 40%.
CT of abdomen shows left rectus sheath hematoma 4.9 x 7 cm.
Pelvic CT shows 5.5 x 4.7 right pelvic and 7.8 x 6 cm
hematoma which is likely bleeding from the left common
femoral vein.
HOSPITAL COURSE: This is a 66 year old female with
paroxysmal atrial fibrillation which is recurrent, status
post past ablation procedures in cardioversion and trials of
antiarrhythmics, now with large retroperitoneal bleed status
post atrial fibrillation ablation with hypotension.
The [**Hospital 228**] hospital course was complicated by a demand
ischemic event to her myocardium with elevation in her CK and
troponin, a right common and superficial femoral deep venous
thrombosis with subsequent multiple small pulmonary emboli
and urinary tract infection.
1. Hypotension - The patient was hypovolemic status post
large bleed with good response to Dopamine and blood, status
post a bleed. Her blood pressure normalized after this
volume repletion and the patient actually became hypertensive
later in her hospital course.
2. Atrial fibrillation - The patient had a history of
recurrent atrial fibrillation with completed ablation this
admission. She did have brief episodes of atrial
fibrillation and atrial tachycardia on one to two occasions
during this hospital admission. She was started on
Flecainide which was discontinued status post her myocardial
infarction and started on Sotalol which was also
discontinued. She will just be continued for now on
Metoprolol 100 mg p.o. b.i.d. for rate control. She will
follow up with the EP Service with Dr. [**Last Name (STitle) **] for further
management of her atrial fibrillation.
3. Right lower extremity deep vein thrombosis/pulmonary
embolus - The patient began having increased right lower
extremity edema after being transferred to the Floor from the
Unit. This is the leg in which she has a cast for her right
ankle fracture. Lower extremity ultrasound showed a common
femoral and superficial femoral deep vein thrombosis in her
right leg. Because the patient was still showing evidence of
decreasing hematocrit at this time and had a contraindication
to anticoagulation initially with this decreasing hematocrit,
an IVC filter was placed. This was placed through the left
femoral vein without rebleed. The patient tolerated this
procedure well.
One day after placement of the IVC filter, the patient
started to complain of feeling short of breath and began to
require O2 via nasal cannula to keep her sats in the 90%,
with her room sat being in the high 80 percents. A trial CT
scan done at that time showed multiple small pulmonary emboli
in the second and third order pulmonary arteries. At this
time her hematocrit had been stable and she was started on
Heparin with a goal PTT of 50 to 60.
After 72 hours of a stable hematocrit on the Heparin GTT, she
was started on Coumadin for her deep vein thrombosis,
pulmonary emboli and atrial fibrillation. She was given 5 mg
q d and finally reached therapeutic Coumadin level on the
26th. She will be discharged on her former Coumadin dose of
2.5 mg p.o. q hs with follow up of her INRs with her Primary
Care Physician in [**Location (un) 3844**].
4. Myocardial ischemia - The patient did show evidence of
myocardial infarction in the setting of her bleed. This was
most likely a low flow demand infarct rather than an acute
coronary syndrome. Her peak CK was 300 and she did rule in
by index.
5. Pump function - An echocardiogram done after her rule in
showed a decrease in her ejection fraction from 55% to 50%.
She had normal PA pressures of 18 mm of Mercury. She did
have evidence of global right ventricular free wall
hypokinesis which was most likely secondary to her multiple
small pulmonary emboli.
6. Urinary tract infection - The patient was found to have a
urinary tract infection after complaining of abdominal pain.
She was started on a three day course of Ciprofloxacin and
tolerated this well.
DISCHARGE PLAN: The patient was discharged after
demonstrating a stable hematocrit while being therapeutic on
her Coumadin for 24 hours. She will follow up with her
Primary Care Doctor [**First Name (Titles) **] [**Last Name (Titles) 766**], which is in 24 hours after
discharge, for checking of her INR. She will follow up with
Dr. [**Last Name (STitle) **] to follow up on her atrial fibrillation and
ablation this week.
She has decided to keep her IVC filter in place. It had the
option of being a removable IVC filter, however, she felt
that she would feel more comfortable leaving the IVC filter
in place and remaining on her anticoagulation as she would
need to anyway.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Atrial fibrillation.
2. Deep venous thrombosis with pulmonary embolism.
3. Urinary tract infection.
4. Hypertension.
5. Demand ischemic myocardial infarction.
MEDICATIONS ON DISCHARGE:
1. Accupril 20 mg p.o. q d.
2. Coumadin 2.5 mg p.o. q hs as dose per INR.
3. Metoprolol 100 mg p.o. b.i.d.
4. Ciprofloxacin.
5. .................... 40 mg p.o. q d.
6. Senna.
7. Colace.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**First Name3 (LF) 20049**]
MEDQUIST36
D: [**2152-12-13**] 16:40
T: [**2152-12-13**] 18:43
JOB#: [**Job Number 20050**]
|
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icd9cm
|
[
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icd9pcs
|
[
[
[]
]
] |
7966, 8134
|
8160, 8641
|
1573, 1785
|
3500, 7231
|
175, 933
|
7248, 7913
|
956, 1547
|
1802, 3482
|
7938, 7945
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,125
| 176,175
|
4503
|
Discharge summary
|
report
|
Admission Date: [**2104-1-5**] Discharge Date: [**2104-1-11**]
Service: [**Doctor Last Name **] Medicine Firm
HISTORY OF PRESENT ILLNESS: This is an 89-year-old female
with COPD (requiring home oxygen and nebulizers) and a
history of multiple exacerbations, found down in bathroom
with a respiratory rate of 6. Per family, patient was noted
to have progressive respiratory difficulty one week prior to
admission. She responded well to a nebulizer at the time.
Family members increased O2 requirement from 1-2 liters by
nasal cannula and patient seemed to be doing well.
On the day of admission, she was found down in the bathroom
with a respiratory rate between [**5-13**]. EMS arrived and placed
an oral airway and bagged the patient. Noted the entitle CO2
to be approximately 60 and the decision was made to intubate
the patient. The patient received Versed and propofol for
sedation; subsequently systolic blood pressure dropped to the
30s. She was treated at the time with an IV fluid bolus and
dopamine, and responded well. At this time, her vitals were
temperature of 97.0, blood pressure 130/40, respiratory rate
of 20, and O2 saturation at 99%.
In the ED, her temperature was 97.2, pulse of 84, blood
pressure 140/30, respiratory rate of 12, and O2 saturation of
100%. Lungs were noted to be rhonchorous with crackles
bilaterally. An ABG after starting ventilator showed a pH of
7.24, pO2 of 274 and a pCO2 of 74. Head CT showed no acute
hemorrhage. Chest x-ray showed only emphysematous changes.
Cardiac enzymes showed a troponin leak. EKG was unchanged
from prior. Blood cultures and urine cultures were obtained.
In the MICU, the patient was maintained on sustained
mechanical ventilation, started on IV Solu-Medrol,
ipratropium, and albuterol nebulizers, and levofloxacin. She
failed several attempts of weaning off the ventilator, was
successfully extubated on the day of transfer to ICU (ICU day
#5). She was initially receiving tube feeds, but upon
transfer was tolerating p.o. well. Given her history of
SIADH, she was on free water restriction. Sodium initially
was at 132, by transfer day, had increased to 136.
Upon transfer to the [**Doctor Last Name **] Medicine Firm, the patient
denies any fevers, chills, nausea, vomiting, diarrhea, chest
pain, shortness of breath, or abdominal pain. She states
that her breathing is back to baseline and is tolerating p.o.
well.
PAST MEDICAL HISTORY:
1. COPD: Emphysema. Pulmonary function tests on [**2103-1-7**] show a FEV1 of 0.64 (52%), FVC 0.74 (37%). Chronic CO2
retainer, with a baseline pCO2 between 70-80. Requires home
oxygen.
2. SIADH: Thought to be secondary to COPD. Usually treated
with free water restriction.
3. Seizures secondary to hyponatremia.
4. Question of CAD: Multiple admissions for acute
respiratory failure secondary to COPD, had shown troponin
leaks. An echocardiogram in [**2103-1-7**] showed left
ventricular systolic function is hyperdynamic with an
ejection fraction of more than 75% with mild left atrial
dilatation. Have never undergone a stress test. She is on
medical management.
5. Hypertension.
6. Colon cancer status post resection in [**2097**].
7. Dementia.
8. Degenerative joint disease.
9. Iron deficiency anemia.
SOCIAL HISTORY: Patient lives at home with four children.
Smoking history of 20 pack years, quit four years ago.
Denies any alcohol use. Active second-hand [**Year (4 digits) **] from her
children.
FAMILY HISTORY: Noncontributory.
ALLERGIES: Doxycycline.
MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Detrol 1 mg p.o. q.d.
3. Flovent prn.
4. Albuterol prn.
5. Combivent prn.
6. Multivitamins one tablet p.o. q.d.
7. Tums 500 mg p.o. b.i.d.
8. Vitamin D 400 units p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: In general, she is a
female appearing her stated age, laying in bed comfortable in
no apparent distress. Very cooperative. Vitals show a
temperature of 97.1 with a pulse of 77 beats per minute and
regular, blood pressure of 154/62 with a respiratory rate of
22, and O2 saturation of 92% on 3 liters nasal cannula. Her
weight is 108 pounds. She is normocephalic, atraumatic with
pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Red reflex
is present, anicteric sclerae. Oropharynx is clear. Dry
mucous membranes. Her neck is supple with no nodules,
lymphadenopathy, or tenderness. Trachea was midline. No
JVD. Carotid pulses were 2+ with no bruits. Thyroid was not
palpable. Lungs show decreased breath sounds throughout with
poor air movement. There is scattered inspiratory crackles
throughout. No wheezes or rhonchi noted. Her heart was
regular, rate, and rhythm with a normal S1, S2, no murmurs,
rubs, or gallops. Her abdomen was soft, nondistended, and
nontender with normoactive bowel sounds and no bruits. It
was tympanic to percussion with no masses or ascites noted.
Liver edge was palpable on inspiration, it was soft. Spleen
tip was unpalpable. No costovertebral angle tenderness was
noted. Her infraumbilical midline scar is well healed. Both
lower extremities were cool to touch with no clubbing,
cyanosis, or edema. Her dorsalis pedis pulse was 1+, PT
pulse was unpalpable. She had no jaundice or rashes.
Patient was alert and oriented to person, place, and time.
Patient made good eye contact throughout the interview.
Cranial nerves II through XII were intact. Had normal tone
throughout. She had 3/5 strength and appropriate for age.
Reflexes were 1+ at the knees and ankles. Her sensory
examination was intact to vibration at hallux bilaterally.
She had normal finger-to-nose testing, appropriate to age,
and gait was not assessed.
LABORATORY VALUES ON PRESENTATION: Sodium of 136, potassium
3.8, chloride 95, bicarb of 39, BUN of 12, creatinine of 0.3,
glucose of 108. White count of 10.9, hemoglobin of 10.6,
hematocrit of 33.2, and platelets of 268. Calcium was 7.9,
magnesium was 1.8, and phosphate was 2.0. Blood cultures
showed no growth to date. Urine cultures showing no growth
to date.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. Acute respiratory failure secondary to COPD exacerbation:
Upon presentation to the floor, the patient had been started
on a prednisone taper at 40 mg taking her down to 0 in two
weeks. She was receiving O2 via nasal cannula with an O2
saturation goal between 90-95% given her history of chronic
CO2 retention. Her nebulizers were continued and spaced to
q.4-6h. She was continued on levofloxacin for a total of 10
days. Upon discharge, the patient stated that she was
returning back to baseline.
2. Question of coronary artery disease: The patient did have
a positive troponin while in-house of 3.2. She was started
on a beta blocker in the ICU. However, due to her severe
chronic obstructive pulmonary disease and per PCP's
recommendation, it was discontinued on hospital day #3. She
was continued on aspirin and an ACE inhibitor.
Because of her debilitated state and severe chronic
obstructive pulmonary disease, she would not be a candidate
for any cardiac intervention, so the plan was made to
medically manage her to the best possibility as noted
previously.
3. Syndrome of inappropriate secretion of antidiuretic
hormone: The patient's sodium was followed while in-house.
Fluid restrictions were maintained. Her sodium improved
while in-house and was normal at the time of discharge.
4. Hypertension: The patient's hypertension was stable on
ACE inhibitors throughout the hospitalization.
5. Dementia: Her dementia remained at baseline throughout
her hospital stay.
6. Hyperglycemia: Likely secondary to steroid taper. She
was started on regular insulin-sliding scale. At the time of
discharge, her sugars have been well managed.
7. Anemia: Patient's hematocrit levels were followed and
they remained stable throughout the hospitalization.
8. Prophylaxis: The patient received prophylaxis,
subcutaneous Heparin for deep venous thrombosis, with
ranitidine for gastrointestinal ulcer prophylaxis, and
continued on calcium and vitamin D for steroid-induced
osteoporosis prophylaxis.
9. Physical Therapy: Evaluated patient, ambulated well,
desatting only to the high 80s. She was recommended to be
discharged to home with visiting nurse services. Family
expressed concern as they do not want her to go an extended
care facility.
10. Fluids, electrolytes, and nutrition: The patient was
fluid restricted. She tolerated a regular diet. Her
electrolytes were repleted as needed. Speech and Swallow
team was consulted. She has been evaluated in the past.
They noted no aspiration risk. She was continued on house
diet.
DISCHARGE DISPOSITION: Given the patient's baseline clinical
condition, the decision was made to discharge the patient to
home.
DISCHARGE STATUS: To home with visiting nurse services.
DISCHARGE MEDICATIONS:
1. Lisinopril 2.5 mg p.o. q.d.
2. Levofloxacin 500 mg p.o. q.d. for a total of 10 days.
3. Prednisone taper from 40 mg down to 10 mg in two weeks as
noted.
4. Albuterol one nebulizer treatment q.4h. as needed.
5. Ipratropium bromide one nebulizer treatment q.6h. as
needed.
6. Zantac 150 mg p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Acute respiratory failure secondary to acute exacerbation
of chronic obstructive pulmonary disease.
2. Syndrome of inappropriate secretion of antidiuretic
hormone.
3. Acute bronchitis.
4. Hypertension.
CODE STATUS: Full.
DISCHARGE FOLLOWUP: Patient is to followup with her primary
care physician in two weeks or earlier if needed.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 17681**]
MEDQUIST36
D: [**2104-1-15**] 14:15
T: [**2104-1-17**] 07:43
JOB#: [**Job Number 19230**]
|
[
"491.21",
"518.84",
"280.9",
"294.8",
"V10.05",
"253.6",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8690, 8854
|
3479, 6076
|
9202, 9429
|
8877, 9181
|
8146, 8666
|
6109, 8127
|
9450, 9851
|
149, 2422
|
2444, 3261
|
3278, 3462
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,637
| 185,357
|
40159
|
Discharge summary
|
report
|
Admission Date: [**2183-11-4**] Discharge Date: [**2183-11-5**]
Date of Birth: [**2119-11-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / IV Dye, Iodine Containing Contrast
Media
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
carboplatin desensitization
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63F with stage IIIC poorly differentiated primary peritoneal
serous carcinoma, now with disease recurrence and participating
in a [**Company 2860**] clinical trial, admitted to the ICU for cycle 5 of
[**Doctor Last Name **]/taxol therapy with carboplatin desensitization.
One third of the way through infusion of carboplatin during
cycle 2 of chemotherapy on [**2183-9-2**], she developed an intense
feeling of heat and generalized body tingling, numbness and
tingling of the lips, and chest tightness. Carboplatin was
discontinued and she received 100 mg hydrocortisone and 50 mg of
Benadryl IV. Her vital signs remained stable, but she later had
vomiting and headache. Given her allergic reaction, she was
admitted to the ICU to receive cycles 3 and 4 of carboplatin per
the desensitization protocol. She has tolerated the treatments
without incident.
Today, she is directly admitted to the ICU again for carboplatin
desensitization for cycle 5 of chemotherapy. On arrival to the
MICU, patient's VS: T 91, BP 122/71, HR 82, RR 19, SpO2 93% RA.
She denies any complaints, feels fine without pain, fever,
nausea, vomiting, abdominal pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, headache, congestion,
shortness of breath, cough, chest pain, palpitations, abdominal
pain.
Past Medical History:
- Stage IIIC poorly differentiated primary peritoneal serous
carcinoma
- Thalassemia
- Hypertension (per patient never treated with home medication,
only when in hospital or seeing doctors)
- Gastritis/Reflux
Oncologic history
- CT abd/pelvis on [**2182-2-28**] revealed a large mass centered in the
sigmoid colon with pelvic lymphadenopathy, retroperitoneal
lymphadenopathy, and peritoneal carcinomatosis.
- A colonoscopy revealed a fungating, ulcerated mass within the
sigmoid colon causing a partial obstruction. The biopsy of this
mass revealed adenocarcinoma with papillary formation,
suggestive of an ovarian primary.
- [**2182-3-14**] underwent exploratory laparotomy, hysterectomy,
bilateral salpingo-oophorectomy, rectosigmoid resection with
colorectal re anastomosis and diverting loop ileostomy. This
was a suboptimal tumor debulking. Intra-operatively, the uterus
and bilateral adnexal were unremarkable. Extensive firm
retroperitoneal lymphadenopathy was appreciated. There was no
evidence of carcinomatosis. The tumor was noted to involve the
sigmoid colon and rectum. Pathology examination revealed serous
carcinoma involving full thickness of the rectal wall. Seven of
eight lymph nodes were positive for malignancy. Uterus, cervix,
fallopian tubes, and ovaries were negative for malignancy.
- [**Date range (3) 88205**]: 5 cycles of chemotherapy with Carboplatin q21
days and weekly Taxol, [**2182-8-15**] 6th cycle of chemotherapy with
Carboplatin and Taxotere in place of Taxol due to neurotoxicity
- [**2183-7-12**]: MRI of the L-spine shows new retroperitoneal
lymphadenopathy consistent with disease recurrence.
- [**2183-8-11**] started chemotherapy according to the clinical trial
[**Company 2860**] #11-228 (Phase II, multi-center, double-blind, placebo
controlled, randomized study of ombrabulin in patients with
platinum-sensitive recurrent ovarian cancer treated with
Carboplatin/Paclitaxel)
Social History:
Immigrated from [**Country 3587**] in youth. Formerly employed in retail
sales. No children, husband lives in [**Country 3587**]. Sister and
[**Name2 (NI) 802**] live in [**Name (NI) 86**] area.
- Tobacco: Never
- EtOH: Denies
- Illicits: Denies
Family History:
Mother and father lived to their 70s. Family history of
thalassemia. Uncle with diabetes. She denies family history of
cancer, CAD, or hypertension.
Physical Exam:
Admission physical exam:
Vitals: T 91, BP 122/71, HR 82, RR 19, SpO2 93% RA
General: NAD, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVD appreciated, no LD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding, epigastric hernia that is reducible, two
large healed surgical scar from resection of cancer and
cholecystectomy
Ext: Warm, well perfused, 2+ pulses, 1+ edema up to knees
Neuro: CNII-XII intact, downgoing babinski
Discharge physical exam:
Vitals: T 98.4, BP 119/68, HR 80, RR 23, SpO2 94% RA
General: NAD, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVD appreciated, no LD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding, epigastric hernia that is reducible, two
large healed surgical scar from resection of cancer and
cholecystectomy
Ext: Warm, well perfused, 2+ pulses, 1+ edema up to knees
Neuro: CNII-XII intact
Pertinent Results:
Admission labs:
[**2183-11-3**] 10:05AM BLOOD WBC-3.7*# RBC-3.84* Hgb-8.9* Hct-27.8*
MCV-72* MCH-23.1* MCHC-32.0 RDW-20.1* Plt Ct-211
[**2183-11-3**] 10:05AM BLOOD Neuts-48.9* Lymphs-42.6* Monos-7.1
Eos-1.3 Baso-0.2
[**2183-11-3**] 10:05AM BLOOD PT-11.2 INR(PT)-1.0
[**2183-11-3**] 10:05AM BLOOD UreaN-21* Creat-0.8 Na-143 K-3.6 Cl-105
[**2183-11-3**] 10:05AM BLOOD Glucose-182*
[**2183-11-3**] 10:05AM BLOOD TotProt-6.9 Albumin-4.3 Globuln-2.6
Calcium-8.9 Phos-3.8 Mg-1.6
[**2183-11-3**] 10:05AM BLOOD ALT-36 AST-32 AlkPhos-103 TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2183-11-4**] 01:48PM BLOOD ALT-35 AST-29 LD(LDH)-267* AlkPhos-112*
TotBili-0.3
[**2183-11-3**] 10:05AM BLOOD CA125-40*
Discharge labs:
[**2183-11-5**] 04:18AM BLOOD WBC-7.1# RBC-3.68* Hgb-8.2* Hct-26.1*
MCV-71* MCH-22.4* MCHC-31.5 RDW-21.0* Plt Ct-202
[**2183-11-5**] 04:18AM BLOOD Glucose-156* UreaN-23* Creat-0.9 Na-141
K-4.3 Cl-105 HCO3-24 AnGap-16
[**2183-11-5**] 04:18AM BLOOD ALT-33 AST-29 AlkPhos-93 TotBili-0.4
[**2183-11-5**] 04:18AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.7
Studies: None
Micro: None
Brief Hospital Course:
63F with stage IIIC poorly differentiated primary peritoneal
serous carcinoma, now with disease recurrence and participating
in a [**Company 2860**] clinical trial, admitted to the ICU for cycle 5 of
[**Doctor Last Name **]/taxol therapy with carboplatin desensitization.
# Carboplatin desensitization: Cycle 2 was complicated by an
allergic reaction after infusion of carboplatin which included a
feeling of heat, generalized body tingling, numbness of the
lips, chest tightness, nausea, and headache. Patient was
admitted to the ICU for cycles 3 and 4 with carboplatin
desensitization per protocol, and tolerated both cycles well.
She underwent carboplatin desensitization per protocol for cycle
5 of [**Doctor Last Name **]/taxol and tolerated well. At discharge, she was
feeling well, able to eat and denied any pain, fevers, tingling.
# Stage IIIc poorly differentiated primary peritoneal serous
carcinoma: Status post sub-optimal debulking surgery ([**2182-3-14**])
and 6 cycles of chemotherapy ([**4-/2182**]/[**2182**]); five cycles with
Carboplatin and weekly Taxol and 1 cycle with Carboplatin and
Taxotere. CT torso on [**7-24**] documented disease recurrence. On
[**8-11**], she started chemotherapy according to the clinical trial
[**Company 2860**] #11-228 (Phase II, multi-center, double-blind, placebo
controlled, randomized study of ombrabulin in patients with
platinum-sensitive recurrent ovarian cancer treated with
Carboplatin/Paclitaxel). The second cycle was complicated by an
allergic reaction to carboplatin (see above), but cycles 3 and 4
were administered per the carboplatin desensitization protocol
without complication. Restaging CT torso performed on [**10-11**] showed
no new lesions, but there is mild interval enlargement of right
retroperitoneal lymph nodes and left external iliac chain lymph
node which could reflect progression of metastatic disease. She
completed cycle 5 of chemotherapy during this admission per [**Company 2860**]
clinical trial #11-228 and tolerated desensitization well
(above). QTc was monitored while receiving high doses of
ondansetron and remained within normal limits.
# Prophylaxis: heparin sq
# Communication: Patient
# Code: Full code
# Transitional Issue:
-patient has follow up with heme/onc on [**2183-11-11**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Ondansetron 8 mg PO BID:PRN nausea
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Carboplatin desensitization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 47639**],
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 18**]. You were hospitalized to make sure that you did not
have an adverse reaction while receiving your chemotherapy
medications. You received your medications without any problems.
Please follow up with your cancer doctors.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2183-11-11**] at 8:45 AM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2183-11-11**] at 9:30 AM
With: [**First Name8 (NamePattern2) 4617**] [**Last Name (NamePattern1) 26978**], RN [**Telephone/Fax (1) 9644**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2183-11-24**] at 7:45 AM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2183-11-5**]
|
[
"196.2",
"V07.1",
"282.46",
"158.8",
"V58.11",
"401.9",
"V70.7",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
9071, 9077
|
6489, 8775
|
359, 365
|
9148, 9148
|
5389, 5389
|
9667, 10569
|
3929, 4080
|
9098, 9127
|
8801, 9048
|
9298, 9644
|
6093, 6466
|
4120, 4741
|
1554, 1700
|
291, 321
|
393, 1535
|
5405, 6077
|
9163, 9274
|
1722, 3649
|
3665, 3913
|
4766, 5370
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,851
| 111,571
|
6886
|
Discharge summary
|
report
|
Admission Date: [**2199-1-25**] Discharge Date: [**2199-1-31**]
Service:
DATE OF DEATH: [**2199-1-31**]
The patient is an 83-year-old patient with multiple medical
problems who presented to [**Hospital1 188**] on [**2199-1-25**], with complaint of intermittent diarrhea,
nausea following a viral URI (treated with Zithromax). The
patient initially went to an outside hospital where she was
noted to have a K of 10. She transferred here for a possible
hemodialysis. At [**Hospital1 69**], the
patient was treated with Kayexalate, bicarbonate, calcium,
D50, insulin and Lasix. She was also noted to be in acute
renal failure, BUN and creatinine were 122 and 3.4
respectively with a K of 10 and bicarbonate of 9.
The patient is without history of renal insufficiency, it was
thought that the patient's metabolic acidosis was secondary
to severe diarrhea and acute renal failure, was prerenal in
etiology. In the MICU, K and acidemia improved with
hydration. The patient also underwent abdominal CT, which
was within normal limits. The patient was called out of the
MICU on [**2199-1-26**], noted to have improved renal function.
Spironolactone was restarted shortly thereafter on the floor.
The patient's systolic blood pressure was around 90-100 on
the afternoon of [**2199-1-29**], did spike a temperature to 101
associated with shortness of breath and rigors. Chest x-ray
showed no evidence of CHF or infiltrate. She was
pancultured. EKG showed increased rate with no other
changes. In the evening of [**2199-1-29**], she was noted to be
hypotensive with the BP in the 60s, given fluid boluses,
started on low-dose dopamine and transferred to the MICU.
EKG noted for new onset atrial fibrillation.
PAST MEDICAL HISTORY: CHF, EF of 30 percent on 3 liters of
home O2.
Bilateral CEA.
CAD status post CABG, [**2190**].
Dyslipidemia.
Pacemaker placement status post syncope.
AICD placement status post Vtach, [**2193**].
Hypertension.
OA.
Hypothyroidism.
Pulmonary hypertension.
ALLERGIES: No known drug allergies.
TRANSFER MEDICATIONS: Included Lipitor, sotalol, furosemide,
KCl, metoprolol, levothyroxine, docusate, ASA,
spironolactone, amlodipine, pantoprazole, and heparin.
PHYSICAL EXAMINATION: Elderly-appearing female,
uncomfortable. Temperature was 98.0 degrees, blood pressure
73/30, heart rate 109, respiratory rate 29, O2 saturation was
96 percent on room air and 100 percent on nonrebreather.
HEENT: Normocephalic, atraumatic, PERRL. Mucous membranes
were moist. Sclerae were anicteric. Neck was supple with no
lymphadenopathy, no carotid bruits, right subclavian line.
CARDIOVASCULAR: Tachy, irregular, S1, S2 with 2/6 systolic
ejection murmur. Lungs were clear to auscultation
anterolaterally. Abdomen was obese, soft and nontender,
nondistended with no hepatosplenomegaly. EXTREMITIES: No
CCE. NEUROLOGIC: Alert and oriented x3. Cranial nerves II
to XII are grossly intact, moved all extremities well.
LABORATORY FINDINGS: Relevant data on MICU transfer included
CBC which was essentially within normal limits with the
exception of a creatinine of 1.8. UA with moderate bacteria
with 42 white blood cells and urine and blood cultures were
pending. Etiology data was reviewed essentially above.
ASSESSMENT, PLAN AND HOSPITAL COURSE: An 83-year-old female
with history of cardiac disease admitted to MICU on [**2199-1-25**]
with hyperkalemia, acidemia, and acute renal failure, was
readmitted to the MICU with new onset of atrial fibrillation
with RVR and associated hypotension. Lab data notable for
UTI and leukocytosis.
Hypotension: Differential initially included sepsis,
hypovolemia, diuresis, poor forward flow in the setting of
adrenal insufficiency and MI. The patient was continued on
pressors, and she was originally placed on rule out sepsis.
Plan in addition, urine culture came back positive for fecal
contamination and blood cultures showed gram positive cocci
in clusters and pairs. Thus she was started on vancomycin
and Levaquin and Flagyl for ? C-difficile after Zithromax.
Left subclavian line was removed and a new line was inserted.
The patient was given a cortisol test, which was not in
keeping with adrenal insufficiency. No labs are going to be
drawn given family preference given the hypotension and poor
prognosis of this septic patient; this was in context of a
family meeting, [**2199-1-30**], to discuss the plan. The family
decided on yes antibiotics and supportive care; no lab draws,
no pressors; DNR/DNI. The patient had been kept on pressors
until this point.
Sepsis: The fever began to trend down with the treatment
with antibiotics. Blood cultures were positive in 5 out of 6
bottles. Levaquin was continued for ? UTI, Flagyl for ? C.
difficile and vancomycin was continued as well.
Atrial fibrillation: The patient was continued on
amiodarone. She had the pacer but the ICD was disabled per
family interest and patient's comfort and to avoid shocking
this very ill patient.
Coronary artery disease: The patient was continued on
aspirin and statin, followed on telemetry.
GI: Clostridium difficile assay was attempted although the
patient did not have a bowel movement in the final days of
her life and comfort was the main key here.
FEN: Ad lib given goal of patient comfort.
PPI: PPX, subcutaneous heparin, PPI.
Communication was with the patient and the daughter.
Respiratory failure: The patient was hypoxemic and kept on
face mask to keep comfortable. She did not tolerate BiPAP or
nonrebreather well. Given the better articulated family
goals and patient's goal, the patient was maintained on
facemask.
DISPOSITION: Plan was initially to transfer the patient to
the floor, but after a brief stay in the MICU and transfer of
antibiotics to oxacillin on the day of her death. The
patient was kept in the MICU just for the sake of comfort and
lack of disruption and she passed away on the night of
[**2199-1-31**] with her family and friends at the bedside.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25971**] [**Name8 (MD) **], MD
Dictated By:[**Last Name (NamePattern1) 25972**]
MEDQUIST36
D: [**2199-5-28**] 18:37:50
T: [**2199-5-29**] 23:37:53
Job#: [**Job Number 25973**]
|
[
"244.9",
"995.91",
"599.0",
"996.62",
"276.2",
"428.0",
"038.11",
"276.7",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3304, 6269
|
2237, 3286
|
2072, 2214
|
1747, 2049
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,370
| 132,680
|
14567
|
Discharge summary
|
report
|
Admission Date: [**2173-6-8**] Discharge Date: [**2173-6-23**]
Date of Birth: [**2100-12-24**] Sex: F
Service:
This is a 72-year-old female with a history of type 2
diabetes, hypertension, hypercholesterolemia, and asplenia
who was admitted on [**2173-6-8**] with fever, cough, and dyspnea,
found to be septic from Streptococcus bovis bacteremia. She
was admitted to the MICU, started on broad-spectrum
antibiotics, resuscitated with IV fluids, briefly required
pressors. She was maintained in the unit for approximately 2
weeks with minimal change in her clinical status. She was
unable to be weaned from the vent. She developed ATN and had
slow recovery of her creatinine, but no resolution of her
BUN, concerning for ongoing renal dysfunction. She developed
pancreatitis and abnormal LFTs. There were attempts to
determine the etiology of the Streptococcus bovis, concern
being an abdominal process or GI malignancy; however, she was
unable to undergo CAT scan given marked edematous during her
hospital stay. She was followed by the Infectious Disease
Team and the Nephrology Team as well as Gastroenterology Team
and ERCP. She developed an obstructive cholestatic picture,
however, was unable to undergo ERCP secondary to the risk
given her comorbidities and poor prognosis. A family meeting
was held on [**2173-6-23**] to discuss her grave prognosis. Family
decided this was not within her wishes as the patient was
initially DNR/DNI and had previously stated that she did not
want to be trached or on long-term ventilatory support.
Therefore, care was withdrawn on [**2173-6-21**]. She was placed on
the morphine drip and extubated. She died at 7:45 p.m. on
[**2173-6-23**]. The family was notified and an autopsy was
declined.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 39096**]
Dictated By:[**Doctor Last Name 42976**]
MEDQUIST36
D: [**2173-6-23**] 22:32:25
T: [**2173-6-24**] 04:07:53
Job#: [**Job Number 42977**]
|
[
"785.52",
"577.0",
"486",
"518.5",
"287.5",
"584.5",
"038.0",
"428.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"88.72",
"99.15",
"00.11",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,346
| 189,811
|
50835
|
Discharge summary
|
report
|
Admission Date: [**2144-2-7**] Discharge Date: [**2144-2-10**]
Date of Birth: [**2087-10-2**] Sex: M
Service: MEDICINE
Allergies:
Clonidine / Trazodone / Bactrim / Morphine / Ultram / Ambien /
Ditropan
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Passing out
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 year old man with past medical history significant for
cirrhosis, chronic bronchitis, depression, anxiety, alcohol
abuse, presenting from home with episodes of "passing out".
.
Patient is profoundly somonolent and responding few questions.
Reports having these episodes today, not eating well for past
few weeks. Denies knowingly taking more medications but reports
"it is quite possible". Reports having passing out spells while
sitting down. No chest pain, diaphoresis, shortness of breath.
No vomiting, no hematemesis. No further history can be obtained
at this time.
.
Of note, patient has been recently evaluated for cough and
significant weight loss as well as worsening depression. He had
a chest x-ray which revealed patchy opacities, plan was for 2
week course of ciprofloxacin.
In the ED, vital signs were initially: 97 72 94/64 16 100,
however shortly thereafter HR decreased to 60's and 50's with
SBP in the 80's to 90's. Patient received 4 liter NS and was
trasnferred to MICU for further evaluation.
.
Immediately on arrival, patient noted to be bradycardic to 30's
with SBP in 130's. ECG confirmed sinus bradycardia. IV Glucagon
5mg was administered immediately with improvement in HR to the
50's.
.
Past Medical History:
1) Chronic Bronchitis with asthma and intubation (intubation was
several years ago)
2) Rheumatoid arthritis
3) Depression/anxiety
4) Chronic neck pain, headache (used to be drug seeking)
5) Alchohol abuse (quit for 10 years and then restarted. sober
since [**2136**])
6) Diverticulosis
7) Barrett's Esophagus
Social History:
Per records, history of EtOH abuse, recently sober and followed
by psychiatry. No IV drugs, lived with daughter who recently
left for college.
Family History:
N/C
Physical Exam:
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-29**], and BLE [**4-29**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
Pertinent Results:
CT HEAD:
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-29**], and BLE [**4-29**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
Brief Hospital Course:
# BRADYCARDIA/INTOXICATION : Patient felt to have acute
intoxication of Nadolol which caused bradycardia. He was started
on a glucagon gtt which improved his HR and mental status.
Toxicology was consulted who felt that in the setting of renal
failure the nadolol would persist for 48 hours. His HR improved
after initial 12 hours. Psychiatry was consulted and offered him
inpatient psychiatric evaluation, which he refused. He was
eventually discharged back on his nadolol with follow-up in a
partial day program.
#MENTAL STATUS CHANGES-Initially presumed secondary to
ingestion. CT head done [**2-7**] negative. Resolved before transfer
to floor.
# BRONCHITIS: Unclear if patient completed treatment course
recently but no active pulmonary symptoms. Initial concern for
TB in the MICU given ETOH history and previous CT findings and
current CXR with RUL findings, however a documented PPD was
negative 2 weeks prior. No need to r/o for TB.
.
# ACUTE RENAL FAILURE- Creatinine 2.8 (baseline 0.8); FENA 1.04;
The patient was felt to be profoundly dehydrated and after
fluids/PO intake this all improved to baseline. Resolved on the
floor with rehydration and return of cardiac output.
.
#Elevated cardiac enzymes- Patient has bradycardia/hypotension,
EKG on arrival with new TW flattening anterolaterally; Troponin
markedly elevated in ED to 0.26 but has acute renal failure;
enzymes trended down. They were unconcerning on the floor.
Medications on Admission:
ACYCLOVIR [ZOVIRAX] - 5 % Cream - apply every few hours to HSV
until healed on lips
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every four (4) hours as needed for shortness of
breath, cough or wheezing
CLINDAMYCIN PHOSPHATE [CLEOCIN T] - 1 % Solution - apply to
face,
chest, back, arms and legs up to twice daily
CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth three times a
day
ERYTHROMYCIN [E-MYCIN] - 333 mg Tablet, Delayed Release (E.C.) -
one Tablet(s) by mouth three times a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays intranasal
once
daily
LACTULOSE - 10 gram/15 mL Solution - 15 cc by mouth three times
daily for three BM per day
LEVOTHYROXINE - 100 mcg Tablet - 1 (One) Tablet(s) by mouth once
a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METRONIDAZOLE [METROCREAM] - 0.75 % Cream - [**Hospital1 **] to face
MUCUS CLEARING DEVICE [ACAPELLA] - Device - use as instructed
daily per pulmonary rehab. Dx=bronchiectasis.
MUPIROCIN CALCIUM [BACTROBAN] - 2 % Ointment - apply to open
areas daily
NADOLOL - 80 mg Tablet - 1 Tablet(s) by mouth once a day
OXYCODONE - 5 mg Tablet - 2 Tablet(s) by mouth twice a day as
needed for chronic foot pain. Total dose is 10mg [**Hospital1 **]. NOT TO BE
FILLED UNTIL [**2144-1-13**].
SERTRALINE [ZOLOFT] - 100 mg Tablet - 2 Tablet(s) by mouth po
qam
SOLIFENACIN [VESICARE] - 10 mg Tablet - 1 Tablet(s) by mouth
once
a day
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth daily
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - as directed three times
per week to itchy spots on skin.
CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day
CANE - Device - use as directed dx: Rheumatoid Arthritis
COMPRESSION STOCKINGS - Misc - use as directed once a day
FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65 mg
Elemental Iron) Tablet - [**1-29**] Tablet(s) by mouth once a day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 2 Tablet(s) by mouth twice a day
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
Nadolol Overdose
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital after you were found
unresponsive by your family. It was found that you had taken
too much of your nadolol and likely your klonopin. You required
an extended stay in the ICU where life saving measures were
provided. Eventually you were moved to the floor where you did
well from a medical standpoint and were cleared for discharge.
.
You were seen by our experts in psychiatry who offered you
inpatient psychiatric hospitalization which you refused. You
were offered several other options and eventually settled upon.
The following changes were made to your medications:
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2144-2-20**] 3:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2144-2-20**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2144-2-20**] 4:00
Completed by:[**2144-2-11**]
|
[
"401.9",
"327.23",
"300.4",
"244.9",
"427.89",
"571.5",
"714.0",
"292.81",
"338.29",
"530.85",
"530.81",
"723.1",
"562.10",
"493.90",
"276.51",
"600.00",
"584.9",
"784.0",
"458.29",
"305.03",
"E939.4",
"E941.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.65"
] |
icd9pcs
|
[
[
[]
]
] |
7828, 7889
|
3434, 4878
|
342, 348
|
7950, 7950
|
2773, 2773
|
8733, 9193
|
2105, 2110
|
6993, 7805
|
7910, 7929
|
4904, 6970
|
8099, 8710
|
2125, 2754
|
291, 304
|
376, 1596
|
2782, 3411
|
7964, 8075
|
1618, 1929
|
1945, 2089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,140
| 165,582
|
24089
|
Discharge summary
|
report
|
Admission Date: [**2117-3-20**] Discharge Date: [**2117-4-9**]
Date of Birth: [**2059-1-14**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
male with history of peripheral vascular disease, status post
right AKA in [**4-14**] after failed right fem distal (for
revisions for thrombosis). The patient had a prolonged course
at Rehab and was recently admitted to [**Hospital3 45967**] on
[**3-17**] for black discoloration MRA with right femoral occlusion
and mild dehydration according to the primary care physician
and was to get vascular follow-up. The patient then developed
nausea and vomiting and fevers, called PCP and PCP referred
to [**Hospital1 69**] on [**2117-3-20**].
PAST MEDICAL HISTORY: Peripheral vascular disease, status
post multiple revisions, failed femoral distal bypass,
history of hyperglycemia, diet controlled. Coronary artery
disease, status post CABG in [**2102**].
CURRENT MEDICATIONS:
1. Bisoprolol
2. Plavix
3. Aspirin
4. OxyContin or Oxycodone
5. Vytoran
6. Neurontin
7. Klonopin
8. Flomax
9. Micro K
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Used tobacco, the patient is a heavy smoker.
PHYSICAL EXAMINATION: On admission the patient was 99.1, 93,
116/76, 16 and 100% on room air. Generally he is in no acute
distress, cachectic. Cardiovascular: Regular rate and rhythm.
Chest is decreased breath sounds. Abdomen was soft,
nontender, nondistended. Extremities: Left lower extremity
had some rubor pallor edema to mid-shin, small 2 cm
ulceration on the medial malleolus with dry eschar. Right
lower extremity is right stump with dry gangrene, no evidence
of erythema or edema. Pulses: Right femoral is nonphasic,
popliteal, dorsalis pedis, posterior tibial, AT peroneal
obviously were all gone because of the amputation on the left
and biphasic femoral monophasic, popliteal, dorsalis pedis
and biphasic PT.
LABORATORY FINDINGS: On admission was white count 6.6, crit
34, platelets 237. Chemistry: Sodium 139, potassium 4.5,
chloride 100, bicarbonate 28, BUN 6, creatinine .5. Glucose
128, PT 113, PTT 31.8, INR 1.2.
The patient was admitted to medicine and placed on IV fluids,
blood cultures were drawn. The patient underwent cardiac
workup, he had pain control and left ulcer was debrided.
Right AK stump was also debrided. The patient was admitted to
the medicine service and hospital course was as follows.
The patient had a cardiac evaluation hospital day 2 that
showed stress electrocardiogram and echocardiogram with acute
myocardial infarction unlikely since electrocardiogram showed
no ST elevation but maybe some chronic ischemia because
Troponin was somewhat elevated. The patient was kept on
aspirin and placed on Plavix to hold prior to surgery. By
hospital day 2 the patient's nausea and vomiting had
resolved. On [**2117-3-23**] the patient had gastrointestinal follow-
up because the patient started having some melanotic stools.
The patient had dropped a crit from 34 to 29, placed into the
intensive care unit and they were planning to do an EGD when
the patient was stable. Angio was held. The patient was
hypotensive during this and on [**2117-3-23**] was transferred to the
MICU.
On [**2117-3-23**] the patient had CT scan of the abdomen that showed
colonic intussusception at the level of hepatic flexure with
large cecal mass, pneumonia within the right upper lobe and
fatty liver and chronic pancreatitis. The patient also had
emphysematous changes of the periphery, bilateral lung
fields, small bilateral pleural effusions and moderate intra-
abdominal free fluid. Because of this finding General Surgery
was consulted. The Gastroenterologists strongly felt that the
intussusception was the etiology of the patient's G.I. bleed and
did not feel a preoperative colonoscopy was required. The patient
was taken to the operating room for exploratory laparotomy to
evaluate and possibly was done under general endotracheal
anesthesia. However, no intussusception (felt to have reduced
spontaneously) nor bowel mass was found and in this malnourished
patient with thin bowel, it was felt best not to do an
intraoperative colonoscopy (right sided lesion likely) nor
resection. The patientwas taken back to the ICU where he remained
stable and did well postoperatively. On [**2117-3-26**] the patient was
transferred to the floor, NG tube was discontinued on the
16th,postoperative day three. Physical therapy continued to see
the patient throughout and deemed him to need rehabilitative
care. The patient was transferred back to the surgical intensive
care unit on [**2117-3-28**] for respiratory distress and was intubated
on [**2117-3-28**]. On [**2117-3-29**], postop day four,
Lopressor was changed to intravenous. The patient was
attempted to wean to extubate, was kept in negative liter and
was transfused one unit of packed cells. However, he failed
extubation time two and then on postoperative day seven had a
bronchoscopy which was negative for any pathology or gross
secretions. Tube feeds were started on [**2117-3-31**] and up to goal
on [**2117-4-1**]. Thoracic surgery was consulted on [**2117-4-1**] and the
patient had failed extubation twice and then self-extubated
the third time and failed that as well so he had a Trach
placed on [**2117-4-1**]. Did well from the Trach. On postoperative
day 7, the patient continued to do well, weaned off of the
vent, some Trach mask for most of [**4-7**] and [**2117-4-8**]. However,
had some episodes of hypernatremia for which was treated with
free water boluses. The patient was transferred to
rehabilitation center on [**2117-4-9**] in good health, stable on
tube feeds and on Trach mask. The patient was doing well and
was instructed to follow-up with Dr. [**Last Name (STitle) **] in follow-up, he
should call for an appointment.
DISCHARGE DIAGNOSIS:
1. Peripheral vascular disease
2. Respiratory distress
3. Status post negative exploratory laparotomy for
intussusception.
4. Status post tracheostomy.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. twice a day
2. Percocet elixir.
3. Albuterol
4. Plavix
5. Aspirin
6. Tylenol
7. Prevacid
8. Colace
9. Milk of Magnesia
10. Atrovent
11. Insulin sliding scale
12. Heparin subcutaneously
13. Zinc sulfate
14. Multivitamins
15. Pepane area spray
16. Lipitor
17. Azinamide.
Patient's condition is good.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 14981**]
Dictated By:[**Doctor Last Name 9174**]
MEDQUIST36
D: [**2117-4-9**] 10:53:52
T: [**2117-4-9**] 11:56:12
Job#: [**Job Number 61248**]
|
[
"V45.81",
"785.59",
"707.05",
"518.5",
"250.00",
"440.24",
"790.7",
"285.1",
"263.9",
"273.8",
"276.6",
"560.0",
"578.9",
"255.4",
"997.69",
"707.13",
"995.94",
"353.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.6",
"99.04",
"54.11",
"99.15",
"86.28",
"96.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
6040, 6662
|
5860, 6017
|
1231, 5839
|
987, 1145
|
182, 751
|
774, 966
|
1162, 1208
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,937
| 180,123
|
47276
|
Discharge summary
|
report
|
Admission Date: [**2190-10-1**] Discharge Date: [**2190-10-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 W, CAD s/p CABG, CHF with EF of <20%, who presents to the ED
with dyspnea. Of note, patient was recently hospitalized from
[**Date range (1) 23456**] for atypical chest pain.
.
Per NH report, patient was having difficulty breathing with
audible wheezes and rales on exam. Her oxygen saturation was
96-97% on 12L via simple mask. RR was 32 and patient was
described as diaphoretic. Denied CP. She was then sent to the ED
for evaluation. During transport she was switched to NRB on 10
LPM with sat of 100% and she received 80 mg IV lasix and 1 SL
NTG.
.
In the ED, a foley catheter was placed and patient was treated
with albuterol nebs, nitro gtt, and got 1 dose of levofloxacin.
She was started on BiPAP ventilation. She was on the biPap for <
1 hour when she pulled the mask off herself. When the MICU HO
arrived to assess the patient, she was already being prepared
for transport and was noted to be satting 96% on 2 L by NC, in
no apparent distress.
.
This history was almost entirely obtained via records as patient
is deaf and legally blind.
.
Patient transferred to medicine on [**10-2**] after remaining
hemodynamically stable in ICU. No increase in oxygen
requirements and BP stable. Difficult to obtain information from
patient due to her hearing/visual impairment. However, patient
repeatedly saying she wanted to 'get out of here' and go back
apparently to her nursing facility.
Past Medical History:
HTN
CAD s/p CABG
Cardiomyopathy with EF <20% on Echo in [**2185**]
Colon cancer s/p partial colectomy
Social History:
No smoking, no alcohol, no drugs
Family History:
Non-contributory
Physical Exam:
VS: afebrile, VSS O2sat: 96& 2 L
GEN: NAD
HEENT: MMM, neck supple
RESP: crackles in lower lung fields, diminished sounds in upper
lung fields
CV: RRR, S1 and S2 wnl, I/VI soft systolic murmur
ABD: soft, NT, ND, + BS, tympanic
EXT: no edema, 2+ DP pulses
Pertinent Results:
[**2190-10-1**] 08:46AM BLOOD WBC-10.9# RBC-3.92* Hgb-12.9 Hct-37.9
MCV-97 MCH-33.0* MCHC-34.2 RDW-16.2* Plt Ct-244
[**2190-10-3**] 07:35AM BLOOD WBC-5.7 RBC-3.16* Hgb-9.9* Hct-30.3*
MCV-96 MCH-31.3 MCHC-32.6 RDW-16.1* Plt Ct-190
[**2190-10-1**] 08:46AM BLOOD Neuts-95.4* Bands-0 Lymphs-3.4*
Monos-1.0* Eos-0.1 Baso-0.1
[**2190-10-1**] 08:46AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2190-10-1**] 08:46AM BLOOD PT-11.9 PTT-23.1 INR(PT)-1.0
[**2190-10-1**] 08:46AM BLOOD Glucose-152* UreaN-28* Creat-0.9 Na-143
K-4.8 Cl-105 HCO3-27 AnGap-16
[**2190-10-3**] 07:35AM BLOOD Glucose-97 UreaN-28* Creat-0.9 Na-141
K-3.7 Cl-103 HCO3-30 AnGap-12
[**2190-10-3**] 07:35AM BLOOD ALT-15 AST-22 LD(LDH)-245 AlkPhos-76
TotBili-0.5
[**2190-10-1**] 08:46AM BLOOD cTropnT-0.09*
[**2190-10-3**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2190-10-2**] 01:42AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.4
[**2190-10-3**] 07:35AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.5
[**2190-10-2**] 01:49PM BLOOD calTIBC-299 Ferritn-51 TRF-230
[**2190-10-1**] 10:11AM BLOOD Type-ART pO2-151* pCO2-47* pH-7.39
calTCO2-30 Base XS-3
[**2190-10-1**] 09:42AM BLOOD Lactate-2.9*
[**2190-10-1**] 08:55AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2190-10-1**] 08:55AM URINE RBC-[**4-11**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2190-10-1**] 08:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
.
MICROBIOLOGY
[**2190-10-1**] 8:50 am BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Preliminary):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 100087**] CC7A [**Numeric Identifier 100088**] [**2190-10-3**]
17:28PM.
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. BEING
ISOLATED.
FURTHER IDENTIFICATION TO FOLLOW.
.
CHEST (PORTABLE AP) [**2190-10-1**] 8:30 AM
IMPRESSION: AP chest compared to [**9-12**] through 12:
Extensive pleural thickening or small effusion adjacent to
multiple rib fractures in the left mid and lower chest is
unchanged. Chest CT on [**9-19**] showed that the majority of
these fractures are not acute. There is no pneumothorax. Mild
pulmonary edema has recurred. Moderate-to-severe cardiomegaly
and large pulmonary arteries are longstanding.
Brief Hospital Course:
86 W, CAD s/p CABG, CHF with EF of <20%, admitted for dyspnea
and transferred to ICU, now hemodynamically stable and called
out to medicine service.
.
#SOB/CHF:
Per patient's last echo in [**2185**], EF is < 20 %. It is likely even
lower than that she has had a positive stress test and has
medically-managed CAD. Obviously she is at very high risk for
dyspnea from fluid shifts. Per last d/c summary there was some
concern for PNA on CT, but patient was never dx'd or treated for
PNA. No evidence of PNA on current CXR.
- cont lasix, monitor UOP for goal of even
- oxygen support, no increase in O2 requirement
- CXR revealed mild pulmonary edema and unchanged pleural
effusion
.
#HTN:
Patient was stable upon transfer to the medicine service but
became hypotensive into SBP 80s the following morning on [**10-3**].
She had received her diuretics the night prior and may have been
volume-depleted in combination with fluid restriction and
decreased PO intake while inpatient. She was gently rehydrated
and BP, which is normally low at baseline, trended up and her
mentation remained intact. Patient was also complaining of chest
pain and EKG was unchanged from prior. Cardiac enzymes were sent
and pending. Patient has a tenuous fluid balance status due to
CHF and must be careful not to over diurese. Lasix will be
decreased to 20 PO daily as she does not have signs of volume
overload and lungs are clear on exam.
- Cont meds to optimize BP control
- on metoprolol, isorbide mononitrate and lisinopril; hold for
low BP
- lasix 20mg PO daily
.
# CAD
No complaints of CP. Elevated cardiac enzymes due to
stress/demand ischemia. No need for further followup given
patient's co-morbidities and code status. No ST changes on EKG.
- hold ASA in setting of low Hct and concern for bleeding
- cont statin
.
#Anemia:
Patient had intial drop in Hct on admission with serial Hct
remaining unchanged. Patient guiaic negative and no GI
intervention necessary. Iron studies normal.
.
# F/E/N:
NPO, aggressively replete lytes
.
# PPx:
PPI, pneumoboots
.
#Access:
PIV
.
# CODE STATUS:
DNR/DNI
.
# Comm:
[**Name (NI) **] [**Name (NI) 2852**], husband, notify him of plans prior to discharge
as he is able to effectively communicate with wife. Phone
[**Telephone/Fax (1) 100089**].
.
# Dispo:
DC to rehab on [**10-4**] if she remains stable and if bed available
at facility. Patient will be followed by Dr. [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) **]
at rehab.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily):
please hold for SBP<90.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO Qam as needed
for wt>93 lb: please give if am weight is > 93 lbs.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QHS (once a day (at bedtime)).
9. Salsalate 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
10. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO QAM.
13. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
17. Lidocaine 5 % Cream Sig: One (1) Appl Topical PRN (as
needed) as needed for pain: apply TP prn for pain.
18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2
Drops Ophthalmic QID (4 times a day).
19. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day): please apply to Right eye only.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QAM (once a day (in the morning)).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily): Hold
for SBP<90 or HR<60.
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily):
Hold for SBP<90.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO qAM: Hold for
SBP<90.
8. Senna 8.6 mg Tablet Sig: 8.6 Tablets PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day as needed
for pain.
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for pain.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed.
15. Salsalate 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-8**]
Ophthalmic four times a day.
17. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic four
times a day: Right eye only.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
1. CHF exacerbation
.
Other Diagnoses:
HTN
CAD s/p CABG
CHF with EF <20% on Echo in [**2185**]
Colon cancer s/p partial colectomy
anemia
ARF
Legally blind
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for shortness of breath and were admitted to
the intensive care unit for close monitoring. You were diuresed
with lasix and your respiratory status improved back to
baseline.
.
Weigh yourself every morning, please notify MD at rehab if
weight change is >3 lbs. Your weight at discharge is 90lbs.
.
Adhere to 2 gm sodium diet
.
Fluid Restriction: 1500 ml
.
Take all medications as directed. Do not stop or change your
medications without first speaking to the doctor at rehab.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2190-10-20**] 11:20
2. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2190-10-20**] 2:15
3. You have a stress test scheduled for [**2190-10-12**] at 11am. The
location is [**Last Name (NamePattern1) **]. Your cardiologist (Dr. [**Last Name (STitle) 100044**] is
aware.
|
[
"413.9",
"369.4",
"389.9",
"428.0",
"V45.81",
"458.29",
"425.4",
"401.9",
"V10.05",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10514, 10586
|
4548, 7020
|
270, 277
|
10785, 10794
|
2199, 3737
|
11338, 11857
|
1892, 1910
|
8848, 10491
|
10607, 10764
|
7046, 8825
|
10818, 11315
|
1925, 2180
|
223, 232
|
3767, 4525
|
305, 1699
|
1721, 1825
|
1841, 1876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,365
| 154,590
|
5301+55660
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-2-16**] Discharge Date: [**2185-3-2**]
Date of Birth: [**2119-9-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
1. Intubated on [**2185-2-17**] & extubated [**2185-2-18**]
2. [**2185-2-23**]: Ipsilateral first order catheter placement,
unilateral extremity angiogram, abdominal angiogram.
3. [**2185-2-25**]: 1. Right below knee popliteal. 2. Posterior tibial
artery bypass with reverse saphenous vein graft. 3.
Intraoperative angioscopy and valve lysis.
History of Present Illness:
Mr. [**Known lastname 7749**] is a 65 yo M with a h/o uncontrolled DMII, ESRD on PD,
CAD, CHF w/ an EF of 25% and Waldenstrom's macroglobulinemia who
presents with altered mental status x 1 day. Patient was
discharged Tuesday night following admission for SBP and foot
infection; family states that he was slightly confused at time
of discharge. Wife states that he was disoriented and unable to
eat or drink during the day on Wednesday. Per family, he was
unable to perform PD as usual. Wife states that he was
requiring constant supervision and that she was afraid he would
fall. She called daughter who states that he was somnolent,
unable to complete a sentence, and unable to stand. Wife denies
any fevers or rigors at home. Daughter reports that he has been
increasingly somnolent with incoherent thoughts since last week.
.
In ED, HR 74, BP 101/65, RR 21, SpO2 100% on NRB. A CXR and CT
head were performed. Blood, urine, and peritoneal fluid were
sent for culture, and he received a dose of vancomycin and
zosyn. Given his somnolence, patient was intubated in ED for
airway protection. He received normal saline 2 L, ASA 325 mg
PR, Vancomycin 1 g, and Zosyn 4.5 g. Following intubation,
blood pressure dropped to 78/50 and levophed gtt was initiated.
.
Past Medical History:
Waldenstrom's macroglobulinemia, diagnosed 8-9 years ago,
started on chemotherapy in [**2-22**].
Status post 7 cycles of Rituxan, vincristine, cyclophosphamide,
and prednisone.
Hypertension.
Diabetes mellitus, poorly controlled.
History of possible renal failure and neuropathy from diabetes.
Coronary artery disease status post left anterior descending
angioplasty x 2 in 12/89 and [**8-/2167**].
Chronic renal insufficiency secondary to diabetes mellitus,
hypertension, and renal atrophy.
History of atrophy of one kidney.
Hypercholesterolemia.
Sleep apnea, using CPAP at home
Gout.
GERD.
History of gallstones.
Status post arthroscopic procedure to his right knee
approximately 5-7 years ago for torn cartilage.
Social History:
The patient denies tobacco use. He has not drunk alcohol for the
last 2 months and he states that he quit in order to lose
weight. Prior to that, he was drinking [**1-23**] alcoholic beverages
per day. He is married and he states that his wife is an
alcoholic. He is semi-retired. He used to be the Director of
Human Relations and Vice President of Hospital. The patient was
also a lawyer and does a small amount of law practice on the
side. He has 4 grown children who are healthy.
Family History:
The patient's father died of colon cancer at age 55; mother is
alive in her late 80s with hypertension, status post CABG for an
MI, and with history of stroke.
Physical Exam:
PE:
Vitals: 98.2 97.6 80 122/70 20 95%
NAD. A&Ox3.
Anicteric. MMM.
No bruits.
RRR.
CTAB.
Soft. NT. ND. PD cath LLQ.
Multiple b/l heal fissures and ischemic ulcers with dry eschar
on
digits and right lateral midfoot, largest b/t 1&2 digits on R.
Also lesions on L foot. +paronychia right medial hallux.
Erythema
of the forefoot and lateral foot on the R. Some dependent rubor
of B feet. Sensation and motor intact.
Pulses:
car rad fem [**Doctor Last Name **] pt dp
R +2 +1 +1 tri [**Hospital1 **] mono
L +2 +1 +1 tri tri mono
Labs:
137 95 41 /
------------ 157
3.6 28 8.6 \
Ca: 8.2 Mg: 1.8 P: 5.6
\ 8.3 /
6.6 ---- 282
/25.7 \
Pertinent Results:
[**2185-2-19**] 04:05AM BLOOD WBC-7.4 RBC-2.56* Hgb-7.8* Hct-23.7*
MCV-93 MCH-30.4 MCHC-32.9 RDW-15.4 Plt Ct-304
[**2185-2-15**] 07:10AM BLOOD WBC-6.8 RBC-2.63* Hgb-7.7* Hct-24.3*
MCV-92 MCH-29.3 MCHC-31.7 RDW-16.0* Plt Ct-253
[**2185-2-19**] 04:05AM BLOOD PT-16.6* PTT-32.0 INR(PT)-1.5*
[**2185-2-19**] 04:05AM BLOOD Glucose-169* UreaN-47* Creat-8.9* Na-135
K-3.7 Cl-96 HCO3-27 AnGap-16
[**2185-2-15**] 07:10AM BLOOD Glucose-118* UreaN-58* Creat-8.4* Na-134
K-3.9 Cl-93* HCO3-30 AnGap-15
[**2185-2-17**] 02:23PM BLOOD CK(CPK)-67
[**2185-2-17**] 06:04AM BLOOD CK(CPK)-82
[**2185-2-16**] 09:55PM BLOOD CK(CPK)-124
[**2185-2-17**] 02:23PM BLOOD CK-MB-5 cTropnT-0.52*
[**2185-2-17**] 06:04AM BLOOD CK-MB-7 cTropnT-0.53*
[**2185-2-16**] 09:55PM BLOOD cTropnT-0.65*
[**2185-2-17**] 06:37AM BLOOD proBNP-[**Numeric Identifier 21602**]*
[**2185-2-19**] 04:05AM BLOOD Calcium-8.2* Phos-6.2* Mg-1.6
[**2185-2-17**] 06:37AM BLOOD Cortsol-23.7*
[**2185-2-19**] 04:05AM BLOOD Vanco-17.7
[**2185-2-16**] 10:03PM BLOOD Lactate-4.7*
[**2185-2-17**] 02:36PM BLOOD Lactate-1.2
[**2185-2-16**] 10:35 pm BLOOD CULTURE VENIPUNCTURE #2.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2185-2-18**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
ECHO [**2185-2-17**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = 20-30 %).
There is no ventricular septal defect. The right ventricular
cavity is dilated with depressed free wall contractility. 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. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2184-7-5**], the left ventricle is
more dilated. The mitral regurgitation is reduced.
CXR [**2185-2-19**]: A single portable image of the chest was obtained
and compared to the prior examination dated [**2185-2-18**]
demonstrating no significant interval change. An enlarged
cardiac silhouette associated with pulmonary vascular congestion
is again seen. There is a left retrocardiac opacity likely
secondary to underlying atelectasis, difficult to exclude
pneumonia. No new focal opacities are seen. The right central
venous line is grossly unchangedand terminates within the
expected region of the cavoatrial junction. The endotracheal
tube and nasogastric tube had been removed in the interim.
Brief Hospital Course:
65 yo M with a h/o uncontrolled DMII, ESRD on PD, CAD, CHF w/ an
EF of 20-30% and Waldenstrom's macroglobulinemia who presents
after recent discharge with altered mental status x 1 day and
continuing chronic bilateral lower extremity ischemia.
.
#) Altered mental status: etiology unclear, but hyperviscosity
secondary to Waldentrom's is unlikely given serum viscosity of
1.3 (nl 1.4-1.8). After careful review, it appears patient has
been experiencing increasing lower extremity pain and has self
increased pain medication dosing. After metabolic etiologies
were excluded, it appears both altered mental status and
hypercarbic respiratory arrest were medicaiton induced. Patient
was re-evaluated by podiatry regarding foot ulcers, as these
seem to be the source of his severe pain. For details, please
see under Foot ulcers below.
.
#) Hypotension: on adm, pt met 1 of SIRS criteria (afebrile, HR
74, WBC 7.9, RR 21) but required levophed for BP support
following intubation. Only definitive culture data is ?????? bottles
+ for GPCs. Essentially unchanged ECHO and CE flat. Septic
shock was still most likely etiology pt hypotension on
admission. No evidence of sepsis or infection in our system.
Patient was quickly weaned off pressors and was transferred to
the floor, where he has been normotensive.
.
#) Foot ulcers: As above, these are likely cause of severe pain.
Patient has known severe vascular disease with prior superficial
femoral artery angioplasty. Podiatry re-evaluated case and
requested doppler studies of lower extremities, which confirmed
severe disease. Vascular surgery was consulted and decided to
perform angiogram which revealed severe occlusive disease of the
right lower extremity. After discussion with patient, he decided
to undergo femoral-popliteal bypass. Patient was transferred to
vascular surgery after procedure.
.
#) ESRD: We Continued PD, per renal recs. Goal to run net
negative.
.
#) Cardiac:
(a) Vessels: Pt p/w mild troponin leak, likely due to demand
ischemia in setting of sepsis and renal disease. Patient
remained asymptomatic and serial ECG's showed return to
baseline.
.
(b) Chronic Systolic Heart Failure: Severe global left
ventricular hypokinesis with relative preservation of apical
systolic function suggestive of non-ischemic etiology; ECHO [**2-17**]
essentially unchanged with LVEF 20-30%. We resumed Ace-I and
beta-blocker, patient tolerated them well
.
c) Atrial Fibrillation: Pt noted to be in A.Fib with HR in low
100s on [**2185-2-19**], with return to sinus rhythm.
.
#) Anemia: likely [**1-22**] ESRD.
- continue Procrit
.
#) DM2: Poorly controlled, HbA1c>13%. Patient maintained on
sliding scale insulin.
.
#) OSA: pt with h/o OSA on CPAP, but has not been using for
months now
- will monitor overnight & apply supplemental oxygen prn
- encourage family to bring in home machine
.
#) Waldenstrom's Macroglobulinemia: serum viscosity essentially
stable, no acute issues
.
Prophylaxis:
# DVT: Heparin sc TID
# Stress ulcer: PPI
.
# Code status: Patient remained FULL CODE during this
admission.
.
===========================================
Vascular Surgery:
Pt was transferred to the Vascular Surgery service on [**2185-2-26**]
following a Right popliteal to posterior tibial artery bypass
with Right Saphenous vein graft. There were no complications
intraoperatively and the patient tolerated the procedure well.
He was extubated in the OR and transferred to the PACU for
recovery. Ultimately he was transferred to [**Hospital Ward Name 121**] 5 for recovery.
.
[**2185-2-27**] POD1 The patient was seen by the Renal service and
recommendations were made to continue his peritoneal dialysis at
1.5% dextrose, [**2176**] cc volume, Q6hrs, with PO KCL 15mEq [**Hospital1 **]. Pt
was seen by PT/OT and declined evaluation on this day.
.
[**2185-2-28**] POD2 Pt passed a single Guaic (+) BM. Pt was seen by the
[**Hospital **] clinic and home insulin dosing was adjusted. Pt was seen
and evaluated by PT/OT and recommendations were made for rehab.
Pt was also seen by OT and recommendations were again made for
rehab.
.
[**2185-3-1**] POD3 Pt with a K of 3.4 (down from 3.6) and was given a
single dose of 40mEq KCL PO per Renal consult service. Pt will
continue current peritoneal dialysis, insulin, and home
medication regimen at rehab.
Medications on Admission:
Toprol XL 25 mg [**Hospital1 **]
Allopurinol 75 mg daily
Levothyroxine 75 mcg daily
Nexium 40 mg daily
Niaspan ER 500 mg daily
ICap [**Hospital1 **]
Humulin R 5 units [**Hospital1 **]
Humulin N 30 units qAM, 25 units qPM
Lipitor 20 mg daily
Lisinopril 20 mg daily
Iron 65 mg daily
ASA 81 mg daily
Effexor XR 150 mg daily
Lorazepam 1 mg qHS
Ambien 10 mg qHS
Procrit 6000 units qweek
Fosrenol 100 mg TID w/ meals
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
2. Allopurinol 300 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO daily ().
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 7 days.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for PRN insomnia.
13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. Humulin R 5 units [**Hospital1 **]
18. Humulin N 30 units qAM, 25 units qPM
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital 21603**] hospital
Discharge Diagnosis:
1. Altered mental status
2. DMII
3. ESRD on PD
4. CAD s/p angioplasty '[**65**] & '[**66**]
5. CHF with LVEF of 25%
6. HTN
7. PVD
8. Hypercholesterolemia
9. Obstructive Sleep Apnea
10. GERD
11. Gout
12. Hypothyroidism
13. Waldenstrom's Macroglobulinemia
14. Chronic Bilateral Lower Extremity Ischmia s/p Right [**Doctor Last Name **]-PT
bypass with reversed SVG
Discharge Condition:
Stable, to rehab
Discharge Instructions:
Please report to the ER for temperature greater than 101.0F,
increasing confusion, persistent fever/chills, nausea and/or
vomiting, increasing pain to your wound sites and/or drainage,
bleeding, or foul smell, increasing redness to wound site or
obvious signs of infection.
Followup Instructions:
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2185-5-19**] 1:40
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Phone: [**Telephone/Fax (1) 1393**]
Please follow up with him in 2 weeks. Please call to schedule an
appointment.
Name: [**Known lastname 2534**],[**Known firstname **] F Unit No: [**Numeric Identifier 3602**]
Admission Date: [**2185-2-16**] Discharge Date: [**2185-3-2**]
Date of Birth: [**2119-9-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2185-3-2**] patient required adjustment in his insuin dosing
secondary to hypoglycemia related diminished po intake and renal
failure. [**Hospital1 **] NPH adjusted to qam dosing and reg insulin sliding
scale at breakfast,dinner and HS.
patient's beta blocker was initally increased during the
postoperative period for rate control.But this dosing developed
drop in systollic b/d. dosing adjusted today from 37.5mgm to
25mgm tid lopressor.
d/c to rehab stable.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital 3603**] hospital
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2185-3-2**]
|
[
"583.81",
"518.81",
"414.01",
"V58.67",
"440.4",
"965.8",
"276.8",
"458.29",
"250.42",
"427.31",
"274.9",
"780.97",
"V16.0",
"428.0",
"V17.49",
"V45.82",
"428.22",
"327.23",
"250.72",
"V45.1",
"403.91",
"440.24",
"272.0",
"273.3",
"518.0",
"585.6",
"285.21",
"E850.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.29",
"88.47",
"88.48",
"54.98",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15435, 15662
|
7130, 7387
|
334, 679
|
13906, 13925
|
4151, 5277
|
14247, 15412
|
3240, 3401
|
11904, 13406
|
13522, 13885
|
11469, 11881
|
13949, 14224
|
3416, 4132
|
5321, 7107
|
273, 296
|
707, 1985
|
7402, 11443
|
2007, 2723
|
2739, 3224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,537
| 190,612
|
54062
|
Discharge summary
|
report
|
Admission Date: [**2164-9-1**] Discharge Date: [**2164-9-3**]
Date of Birth: [**2111-5-18**] Sex: F
Service:
CHIEF COMPLAINT: Change in mental status.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
female with a past medical history of chronic obstructive
pulmonary disease, pulmonary embolism in [**2159**], obstructive
sleep apnea, as well as schizoaffective disorder, borderline
personality disorder, and posttraumatic stress disorder who
was found to have decreased mental status at her group home.
She was brought to the [**Hospital1 69**]
Emergency Department and found to be somnolent but arousable
and was given Narcan 0.4 mg intravenously with improvement in
her mental status. Per report, the patient was switched from
her Percocet for chronic chest wall pain to MS Contin 15 mg
p.o. b.i.d. approximately four days prior to admission by her
primary care physician at the [**Hospital6 733**] Clinic.
REVIEW OF SYSTEMS: On review of systems, the patient also
reports cough productive of moderate sputum (which she
describes as her chronic baseline). She denies chest pain,
shortness of breath, fevers, chills, nausea; although, she
vomited one time last week. Otherwise, the patient was in
her usual state of health.
On arrival in the Emergency Department, she had an arterial
blood gas which was 7.24/69/56, and after Narcan this was
7.3/59/60 on 2 liters nasal cannula.
PAST MEDICAL HISTORY:
1. Recurrent aspiration pneumonia; status post swallow
study in [**2163-12-23**].
2. Chronic obstructive pulmonary disease with pulmonary
function tests from [**2164-5-21**].
3. Pulmonary embolism in [**2159**].
4. Diabetes mellitus times seven years with peripheral
neuropathy.
5. Chronic pain from chest wall.
6. Obstructive sleep apnea with home CPAP.
7. Gastroesophageal reflux disease.
8. Urinary incontinence.
9. Schizoaffective disorder.
10. Borderline personality disorder.
11. Posttraumatic stress disorder.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Haldol 5 mg p.o. t.i.d.,
Adderall 120 mg p.o. q.d., aspirin 325 mg p.o. q.d.,
multivitamin one tablet p.o. q.d., Glucophage 1000 mg p.o.
q.a.m. and 500 mg p.o. q.p.m., Prilosec 20 mg p.o. b.i.d., MS
Contin 15 mg p.o. b.i.d., Neurontin 900 mg p.o. t.i.d.,
Ambien 10 mg p.o. q.h.s., venlafaxine-XR 187.5 mg p.o. q.d.,
quetiapine 25 mg p.o. b.i.d. and 300 mg p.o. q.h.s., Lidoderm
transdermal patches, Flovent 200 mcg 2 puffs b.i.d.,
Colace 100 mg p.o. b.i.d., lactulose 300 cc p.o. as needed,
Humulin NPH 62 units b.i.d., Vioxx 25 mg p.o. b.i.d.,
Atrovent 2 puffs b.i.d., Serevent 2 puffs b.i.d., albuterol 1
to 2 puffs q.i.d., ipratropium 1 puff q.i.d., clonazepam 1 mg
p.o. b.i.d., Fioricet p.o. as needed.
SOCIAL HISTORY: The patient lives at the Finwood Group Home
(for 10 years). She smoked one pack per day for 60 years.
She has a history of ethanol abuse and abused by her
stepfather.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 95.6, pulse was 109, blood pressure
was 155/71, oxygen saturation was 94% on 4 liters nasal
cannula. In general, the patient was an obese female who was
alert and conversant, in no apparent distress. Head, eyes,
ears, nose, and throat revealed normocephalic and atraumatic.
Sclerae were anicteric. Pupils were equal, round, and
reactive to light. Mucous membranes were moist. Neck was
obese, supple, well-healed scars. Chest revealed decreased
breath sounds bilaterally. Positive wheezing on
end-expiration. No crackles. Cardiovascular examination
revealed a regular rhythm. A systolic ejection murmur at the
border, loud first heart sound. The abdomen was soft,
slightly tenderness to palpation in the right upper quadrant,
obese, normal active bowel sounds, and without masses.
Extremities were without clubbing, cyanosis, or edema.
Distal pulses were 1+. Well-healed scars along the wrist.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
studies revealed white blood cell count was 11.3, hematocrit
was 40.8, platelets were 23. PT and PTT were within normal
limits. Chemistries were significant for a potassium of 4.6.
Blood urea nitrogen and creatinine were 23 and 1. A serum
toxicology screen was negative. A urine toxicology screen
showed positive benzodiazepines, opiates, and amphetamines.
A urinalysis was negative.
RADIOLOGY/IMAGING: A chest x-ray was poor quality, but
preliminarily read as bibasilar patches.
A CT angiogram was negative for evidence of pulmonary
embolism.
ASSESSMENT: This is a 50-year-old woman with chronic
obstructive pulmonary disease with obstructive sleep apnea,
recurrent aspiration, with an increase in narcotic use who
presented with altered mental status, decreased respiratory
rate and cough secondary to the MS Contin.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit overnight for monitoring of her respiratory status
and mental status.
The patient was initially started on levofloxacin and Flagyl
for a question aspiration pneumonia and given 125 mg of
Solu-Medrol in the Emergency Department for question chronic
obstructive pulmonary disease flare. However, while in the
Intensive Care Unit, the patient's respiratory status and
mental status improved to her baseline. Off oxygen, the
patient saturated between 92% to 94% on room air with
occasional desaturations to 88% to 90% on room air.
Given the improvement in her oxygen saturations and her
mental status, her symptoms were attributed to the change
from Percocet to MS Contin. The MS Contin was discontinued,
and the patient was placed on her Percocet for pain.
PLAN:
1. PULMONARY: The patient's decreased respiratory rate was
attributed to her MS Contin. She did well in the Intensive
Care Unit with oxygen saturations as described above without
the need for antibiotics or steroids. She will continue on
her chronic obstructive pulmonary disease regimen via
meter-dosed inhalers. The patient was also prescribed CPAP
at night; however, the patient was noncompliant and may
benefit from its use at home given her obstructive sleep
apnea.
2. PAIN CONTROL: The patient continued to take Percocet
without change in mental status. At this point, the patient
should avoid longer-acting narcotics at this time.
3. ENDOCRINE: The patient's blood sugars ran in the low
100s during this time; probably because she was not engaging
in a regular diet. Her NPH was cut in half to 31 units of
NPH b.i.d. which she will be discharged on until she regains
her regular home diet.
4. PSYCHIATRY: The patient was continued on her psychiatric
medications as before.
MEDICATIONS ON DISCHARGE:
1. Haldol 5 mg p.o. t.i.d.
2. Adderall 120 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Multivitamin one tablet p.o. q.d.
5. Glucophage 1000 mg p.o. q.a.m. and 500 mg p.o. q.p.m.
6. Prilosec 20 mg p.o. b.i.d.
7. Neurontin 900 mg p.o. t.i.d.
8. Ambien 10 mg p.o. q.h.s.
9. Venlafaxine-XR 187.5 mg p.o. q.d.
10. Quetiapine 25 mg p.o. b.i.d. and 300 mg p.o. q.h.s.
11. Lidoderm transdermal patches.
12. Flovent 200 mcg 2 puffs b.i.d.
13. Colace 100 mg p.o. b.i.d.
14. Lactulose 300 cc p.o. as needed.
15. Humulin NPH 31 units q.a.m. and q.p.m.
16. Vioxx 25 mg p.o. b.i.d.
17. Atrovent 2 puffs b.i.d.
18. Serevent 2 puffs b.i.d.
19. Albuterol 1 to 2 puffs q.i.d.
20. Ipratropium 1 puff q.i.d.
21. Clonazepam 1 mg p.o. b.i.d.
22. Fioricet p.o. as needed.
23. Percocet 5/325 mg one to two tablets p.o. q.4-6h. as
needed (for pain).
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharged to Finwood Group Home.
DISCHARGE DIAGNOSES: Mental status changes and respiratory
depression secondary to long-acting narcotic use.
DISCHARGE FOLLOWUP: Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2961**] at
[**Hospital6 733**].
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Name8 (MD) 23851**]
MEDQUIST36
D: [**2164-9-3**] 11:21
T: [**2164-9-6**] 09:11
JOB#: [**Job Number 97949**]
cc:[**Last Name (NamePattern4) 106762**]
|
[
"478.29",
"276.2",
"250.00",
"518.89",
"507.0",
"E935.2",
"780.09",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7668, 7757
|
6674, 7541
|
2042, 2750
|
4831, 6647
|
7556, 7646
|
961, 1417
|
143, 169
|
7778, 8151
|
198, 941
|
1440, 2015
|
2767, 4813
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,912
| 137,012
|
6251
|
Discharge summary
|
report
|
Admission Date: [**2179-12-18**] Discharge Date: [**2179-12-27**]
Date of Birth: [**2157-7-6**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old
white male with history of bipolar disorder who presents
status post self inflicted stab wounds to anterior left
chest. Complains of chest pain. No shortness of breath. No
abdominal pain. Heart rate is 100, blood pressure 100/70, O2
saturation 100%.
PHYSICAL EXAMINATION: Temperature 96.1 F, heart rate 108,
blood pressure 128/palp, respiratory rate 36, 100% on room
air. In general no acute distress. Cardiovascular: Regular
rate and rhythm, no murmurs, rubs, or gallops. Lungs:
Breath sounds bilaterally, clear to auscultation. Abdomen:
Soft, nontender, nondistended. Extremities: Warm. DP and
PTs bilaterally 2+. Rectal: No guaiac. Normal rectal tone.
Neck: No trauma. Back: No trauma, no deformities. Neuro:
Alert. Pupils equal, round and reactive to light and
accommodation bilaterally. Extraocular muscles intact
bilaterally. GCS 15. There is 5/5 strength in the upper and
lower extremities bilaterally.
LABORATORY DATA ON ADMISSION: Hematocrit 31.3. Chem-7:
Sodium 138, potassium 4.6, chloride 110, BUN 13, creatinine
0.5, amylase 47. Urinalysis negative.
Arterial blood gas was 7.33, pCO2 44, pO2 138, bicarbonate
24, base deficit of minus 2.
Toxins are positive for benzodiazepine, barbiturates and
amphetamines.
Chest x-ray showed left pneumothorax / hemothorax.
Fast negative and serial hematocrits were 30, 33 and 33.
Chest x-ray #3 after second chest tube placed showed positive
atelectasis in the left lung. CT Scan of the chest showed
mediastinal hematoma back laying between the aorta and blood
and residual hemothorax and a small pneumothorax.
HOSPITAL COURSE: Patient was admitted to the Trauma Surgical
Intensive Care Unit after placement of two chest tubes and
confirmation of the left pneumothorax dissipating. The
patient remained hemodynamically stable and was placed on
wall suction to decrease bloody drainage for which 600 cc was
drained immediately. The patient was resuscitated in the ICU
receiving 3100 of cc of IV fluid. Psychiatry consult was
obtained at which time the diagnosis was psychosis. A one to
one non-security sitter was assigned to the patient as well
as Effexor 225 mg, Nortriptyline 100 mg p.o. b.i.d. and
Haldol for agitation p.r.n.
The patient did well in the ICU remaining stable and his CIWA
scale continued to be baseline. The CIWA scale was to watch
for benzodiazepine withdraw which the patient did not show
any signs throughout his stay. On the second day of
admission, the patient received two units of packed red blood
cells for a hematocrit of 26.5. Post transfusion hematocrit
was 31.7.
The patient was transferred to the Surgical floor for follow
up. On hospital day #5, the Cardiothoracic Surgery Service
was consulted secondary to a persistent effusion. It was
thought at that time that the patient should go to the
Operating Room to have a left thoracoscopy with evacuation of
pleural fibrin. In addition, Psychiatry started Seroquel.
The patient was preopted on [**12-21**] and brought to the
Operating Room at which time a VAC was performed with
evacuation of fluid. 500 cc of old blood was evacuated from
the pleural space. A 32 French chest tube was placed into
the left pleural space.
Postoperatively, the patient did well and it was recommended
by Psychiatry to taper the Effexor as well as the Seroquel.
The chest tube remained on 20 cm H2O wall suction for 48
hours after which the chest tube was put to water-seal and
subsequent chest x-ray was negative for pneumothorax. The
patient was discharged from Cardiothoracic Surgery Service on
[**2179-12-27**] in good condition. O2 saturations were 98% on
room air.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Transferred to Psychiatry Rehabilitation.
DISCHARGE DIAGNOSES: Self inflicted stab wound to the left
hemithorax secondary to psychosis.
DISCHARGE MEDICATIONS:
1. Dilaudid 2 to 4 mg p.o. q. four to six hours p.r.n. pain.
2. Effexor XR 150 mg times one day then 75 mg times three
days then 37.5 mg times three days.
3. Seroquel 100 mg p.o. q.h.s. times one day then 50 mg
times three days.
4. Senna two tablets p.o. q.h.s.
5. Colace 100 mg p.o. b.i.d.
6. Nortriptyline 25 mg p.o. q.h.s.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2179-12-27**] 12:27
T: [**2179-12-27**] 12:51
JOB#: [**Job Number 24319**]
|
[
"860.5",
"780.39",
"298.9",
"862.39",
"E956",
"296.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"04.81",
"34.21",
"34.1"
] |
icd9pcs
|
[
[
[]
]
] |
3954, 4028
|
4051, 4666
|
1817, 3838
|
480, 1154
|
173, 457
|
1169, 1799
|
3863, 3932
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,733
| 184,830
|
24041
|
Discharge summary
|
report
|
Admission Date: [**2144-3-19**] Discharge Date: [**2144-3-23**]
Date of Birth: [**2087-3-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
57F with history of dyspnea on exertion and nonexertional left
arm numbness for the past several years who had new onset chest
pressure and pain the morning of [**2144-3-19**] accompanied by left arm
heaviness and pain radiating across the chest to the right arm.
This was associated with nausea, diaphoresis, and shortness of
breath. The pain/pressure was partially relieved few hours later
after her husband came home from work and gave her aspirin. In
the ambulance, the pain was fully relieved by SLNGx3; however,
the pressure did not resolve until after getting IV morphine x3
at [**Hospital3 3583**]. CBC w/ WBL 10.8, hct 42, plt 311K, CHEM 7
WNL, creat 0.7, gluc 119. Initial ECG showed <1mm ST elevation
in III and TWI in I, AVL. Remained CP free overnite. By the
morning of [**2144-3-20**], the ST elevation had resolved and TWI now
appeared in III along with ?Q wave development. She had less
severe chest discomfort that resolved with 2'' nitropaste and
morphine. CK was 53 and TnT<0.038 then CK 250/trop 1.57 in the
2nd set. At [**Hospital1 46**], she was also given zofran, nitropaste,
plavix 75, metoprolol 12.5, and lipitor 10 for diagnosis of
"myocardial infarction, calcified trileaflet aortic valve with
mild aortic stenosis."
.
She was tx to [**Hospital1 18**] for emergent cardiac cath. Pt was found to
have severe AS, area 0.7. She had distal total RCA occlusion for
which PCI was unsuccessful. LMCA proximal 20%. Anatomy was right
dominant. Elevated LV and RV filling pressures.
Past Medical History:
chronic low back pain, no prior cardiac history, TAH [**2130**],
Tonsillectomy age 10
Social History:
no tobacco, alcohol, illicit drugs. lives with husband; 2
children; recently returned from vacation in NH about 3 days
ago.
Family History:
mother with CHF and heart murmur, no early MIs
Physical Exam:
Gen:NAD, appropriate
HEENT: PERRL, EOMI, MMMI, OPC
CV: RRR, SEM w/ rad to neck III/VI, JVP 1cm above sternal angle
Abd: S, NT/ND, +BS
Ext: wwp, +2 DP, no edema
neuro: AOx3, motor and sensory grossly intact
wound: R groin sheath intact w/o hemorrhage, hematoma, or bruit
Pertinent Results:
Admission Labs: [**2144-3-19**]
GLUCOSE-126* UREA N-15 CREAT-0.6 SODIUM-140 POTASSIUM-3.6
CHLORIDE-108 TOTAL CO2-27 ANION GAP-9
ALT(SGPT)-23 AST(SGOT)-88* ALK PHOS-52 AMYLASE-39 TOT BILI-0.4
ALBUMIN-3.5
WBC-8.5 RBC-3.47* HGB-10.9* HCT-31.8* MCV-92 MCH-31.4 MCHC-34.3
RDW-13.3
PLT COUNT-221
PT-13.7* PTT-82.0* INR(PT)-1.2
Brief Hospital Course:
1. CAD/Ischemia-NSTEMI (subendocardial, inferior distribution).
Cardiac catheterization showed 100% occlusion of distal RCA
which could not be stented (could not be crossed by wire). Post
procedure TTE showed that her RV was had good systolic motion.
She was continued on ASA, statin BB, ACEI, and she will return
as an outpatient for replacement of her Aortic valve; at this
time, decision will be made whether graft to RCA would be
beneficial. She had no further chest pain while in-house.
2. Pump: TTE post-procedure showed EF=55% with no significant
wall motion abnormalities. She was kept euvolemic with respect
to I/O's while in-house.
3. Severe AS: As per catheterization, AV area was 0.7 cm2.
Peak gradient by TTE was 84 mm HG. CT surgery was consulted,
and the decision was made for AV replacement as an outpatient,
and she will return for this procedure.
4. Rhythmn: NSR on telemetry while in-house.
5. Back Pain-percocet PRN, morphine PRN were used while
in-house.
6. Disposition: She was discharged in good condition, to return
in [**12-15**] weeks for surgery for AV replacement.
Medications on Admission:
Home Meds:
MVI, estrogen ring started about 3 mo ago. \
Meds on transfer:
plavix 75 daily
lopressor 12.5 [**Hospital1 **]
lipitor 10 daily
ECASA 325 daily
tylenolol prn
morphine prn
nitro prn
nitropaste 1 in q 6 hr
magaldrata plus prn dyspepsia
Methocarbamol 750 mg qhs
Etodolac 400 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for pain.
Disp:*100 Tablet, Sublingual(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Cardiac Rehab
Please have your PCP arrange for you to undergo cardiac rehab
under his guidance. You should be aware that you are scheduled
for an open heart surgery in the near and will benefit from
cardiac rehab after the surgery.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Inferior myocardial infarction, Aortic stenosis
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed.
Please note several new medications have been started for your
heart.
1. Aspirin EC 325mg once daily
2. Atorvastatin 80mg once daily at night
3. Metoprolol XL 25mg once daily
4. Lisinopril 5mg once daily
5. Percocet 1-2 tabs as needed for back pain every 8hours
6. Nitroglycerin tablets which should be placed under the
tongue for episodes of chest pain/pressure. Please administer
upto 3 nitroglycerin tablets every 5 minutes for chest pain. If
you experience chest pain, please call your PCP or go directly
to the ED.
7. Docusate 100mg twice daily for constipation. While you are
taking opiates (including percocet) you may become constipated,
please take this medication to prevent development of
constipation.
Follow up with Dr. [**Last Name (STitle) 70**] in the cardiothoracic surgery
clinic on Thursday. Call ([**Telephone/Fax (1) 1504**] to schedule the
appointment with his secretary.
Please follow up with your PCP within two weeks of discharge to
go over all of your medications as well. You should also have
your liver function tests and cholesterol profile monitored
while on this regimen. He can also arrange for cardiac rehab
after your open heart surgery.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 70**] in the cardiothoracic surgery
clinic on Thursday. Call ([**Telephone/Fax (1) 1504**] to schedule the
appointment with his secretary.
Please also arrange to follow up with your PCP within two weeks
of discharge to go over the new medication and to arrange for
follow up care.
|
[
"424.1",
"414.01",
"410.71",
"724.5",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.01",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
5421, 5427
|
2830, 3938
|
303, 329
|
5528, 5534
|
2484, 2484
|
6813, 7139
|
2128, 2176
|
4291, 5398
|
5448, 5507
|
3964, 4020
|
5558, 6790
|
2191, 2465
|
232, 265
|
357, 1860
|
2500, 2807
|
1882, 1970
|
1986, 2112
|
4038, 4268
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,959
| 189,847
|
30217
|
Discharge summary
|
report
|
Admission Date: [**2163-4-11**] Discharge Date: [**2163-4-13**]
Date of Birth: [**2096-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
hypertensive urgency
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
67 yo Male (portugese speaking only) from capperverdean with
PMHx of HTN was admitted to the CCU for management of
hypertensive urgency with an initial BP of around 270/130.
He is visiting his niece from [**Country 37027**] and was not taking his HTN
meds for around a week. He also claims to be consuming more salt
over the last week. He went to a clinic on the DOA with
complains of vague pains in legs and was found to have elevated
BP. He was then transferred to [**Hospital1 18**] for further management.
Upon presentation, his BP was 280/130 with HR of 90 and RR 22
satting at 97%/RA. He was having mild headaches complained of
generalized weakness for the last 2 days. He did not complain of
any Chest pain, SOB, nausea/vomiting, blurriness of vision or
tingling/numbness in extremities.
In the ED, his EKG showed SR @ 76 with LAD, LVH,J point
elevations in V1-V3, TWI in V4-V6; no prior for comparioson; His
trop was 0.03, flat CK; He was intially given labetolol IV 20
mg, hydral 10 mg IV, ASA 325mg, This however did not decrease
his BP significantly and was then started on IV Labetolol at
6mg/min and transferred to the CCU
Past Medical History:
Hypertension
.
Social History:
No family history of SCD
No smoking or drinking history
Family History:
N/A
Physical Exam:
96.6, 159/85, 60, 20, 99%/RA
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: CTA b/l, no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, nt
Skin: warm extremities, no rash
EXT: 2+ DP, 1+ pedal edema bilaterally
Neuro: moving all extremities, 5/5 strength, following commands,
PERRLA, reflexes 2+ b/l
Pertinent Results:
EKG: SR @ 76 with LAD, LVH,J point elevations in V1-V3, TWI in
V4-V6; no prior for comparison
Brief Hospital Course:
# HTN: It was felt that med non-compliance and increased salt
intake lead to severely elevated BP. Per pt, his baseline SBP is
240's. Patient remained asymtomatic during hospital course. He
was initially on labetalol gtt, transitioned to oral meds and
had no evidence of any end organ dysfunction. He was discharged
on Atenolol 50, Lisinopril 20 QD, HCTZ 25. He was instructed to
week to titrate meds. Both he and his family are aware of
importance of medical follow-up.
.
# CAD: no history of CAD; mild trop leak could be from left
heart strain. Evidence of severe LVH. He ruled out for MI.
.
# CKD: Creatinine was 1.2, but he did have mild proteinuria on
U/A likely stage 2 CKD given GFR of 67. ACE inhibitor was
started.
.
# FEN: low sodium diet
.
# DISPO: d/c home today given that he is at his baseline BP
# Code: Full
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications and follow up with your
appointments. Please report to your physician or the emergency
department if you have any headaches, blurriness of vision,
nausea, vomiting, chest pain, palpitations or shortness of
breath.
.
Please note that you have to see your doctor early next week on
[**Hospital1 766**] or Tuesday for your blood pressure check and titration of
your medicines.
Followup Instructions:
Please make an appointment with your doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] ([**4-18**]) for checking your blood pressure.
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 8268**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2163-4-20**]
4:00
|
[
"585.2",
"403.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3481, 3487
|
2181, 3008
|
336, 343
|
3552, 3561
|
2063, 2158
|
4016, 4307
|
1644, 1649
|
3063, 3458
|
3508, 3531
|
3034, 3040
|
3585, 3993
|
1664, 2044
|
276, 298
|
371, 1515
|
1537, 1554
|
1570, 1628
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,325
| 195,343
|
42068
|
Discharge summary
|
report
|
Admission Date: [**2149-11-19**] Discharge Date: [**2149-11-24**]
Date of Birth: [**2072-4-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Biaxin / Erythromycin Base / morphine / Cipro /
Demerol / IV Dye, Iodine Containing Contrast Media / Sulfa
(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2149-11-19**] Aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna
ease aortic valve bioprosthesis.
History of Present Illness:
The patient is a 77yo diabetic female who was hospitalized 4
months ago for dyspnea and was found to be in congestive heart
failure with aortic stenosis. She reports worsening shortness of
breath over the past few months during conversation, and
lightheadedness when getting out of bed, or going from sitting
to standing position. Symptoms increased over last 3 weeks. She
has to stop three times to rest 15min each time to make bed.
Able to go up only 3 stairs, then rest. Near syncopal episodes
daily. After extensive workup, she was cleared to proceed with
high risk aortic valve replacement.
Past Medical History:
- aortic stenosis
- hypertrophic cardiomyopathy (EF 35%)
- CHF
- DVT (LLE [**2-/2149**]) - coumadin d/c'd 2 months ago
- hypercalcemia
- atypical pneumonia (ground glass opacities both lungs)
- DM type 2
- Temporal ateritis (chloroquine, Imuran, prednisone)
- ? lupus (rheum workup in progress)
- abdominal aortic aneurysm s/p repair (Eastern ME Med Ctr)
- HTN
- CKD
- hyporenemic,hyperaldosteronism
- osteoarthritis
- osteoporosis
- dyslipidemia
- reactive airway disease
- bilateral cataract surgery
- TAH/BSO
- cholecystectomy
- vertebroplasty x2 secondary to compression fracture
- colonoscopy ([**2149-6-30**])
- bilateral retinal occlusion (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 91294**] - opthal.,
[**State 1727**])
(Avastin injections q 6 wks)
Social History:
SOCIAL HISTORY: Lives with 86yo husband. [**Name (NI) **] local ([**Name2 (NI) **]), son
in
[**Name (NI) 24402**]( [**Name (NI) **]). Friends assist at home.
Race: caucasian
Last Dental Exam: 1 year ago (Acadia Dental Arts)
Lives with: husband
Occupation: retired postal carrier (27yrs)
Tobacco: quit 40 yrs ago (3/4ppd x 25yrs)
ETOH: none
Family History:
Mother(89) and father (60's) deceased from CAD.
Physical Exam:
Pulse: 85
B/P: Right 137/82 Left
Resp: 18
O2 Sat: 99
Temp: 97.8
Height: Weight:
General: alert pleasant elderly female in wheelchair
Skin: multiple areas of echymosis, turgor poor
HEENT: normocephalic, anicteric, eyeglasses, oropharynx moist,
conjunctiva pink
Neck: referred murmer ausculatated, neck supple, trachea midline
Chest: no obvious deformities/scars
Heart: murmer throughout
Abdomen: soft, nontender, nondistended, well healed midline
incisional scar
Extremities: trace pedal edema
Neuro: alert and oriented, in wheelchair, pleasant asking
questions approp.
Pulses: palpable peripheral pulses
Pertinent Results:
[**2149-11-19**] Intraop TEE
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.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded.
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results before
surgical incision.
.
POST-BYPASS:
Normal RV systolic function.
Poor echo windows does not allow to rule out possible segmental
wall motion abnormalities.
LVEF 55%.
Intact thoraic aorta.
.
[**2149-11-20**] Chest X-ray:
Removal of endotracheal tube and other support and monitoring
devices, with residual right internal jugular vascular sheath
remaining in
place. No visible pneumothorax. Cardiomediastinal contours are
stable in the
postoperative period, improving atelectasis in left lower lobe.
Slight
worsening minor atelectasis at right lung base. Persistent small
left pleural
effusion, but no visible pneumothorax.
LABS
[**2149-11-23**] 06:25AM BLOOD WBC-7.6 Hct-28.4*
[**2149-11-21**] 06:02AM BLOOD WBC-12.9* RBC-3.62* Hgb-10.6* Hct-31.3*
MCV-87 MCH-29.4 MCHC-34.0 RDW-16.3* Plt Ct-150
[**2149-11-23**] 06:25AM BLOOD UreaN-28* Creat-1.0 Na-136 K-4.4 Cl-102
[**2149-11-22**] 10:50AM BLOOD Glucose-252* UreaN-22* Creat-0.9 Na-138
K-3.3 Cl-101 HCO3-30 AnGap-10
[**2149-11-21**] 06:02AM BLOOD Glucose-151* UreaN-23* Creat-1.0 Na-138
K-3.5 Cl-101 HCO3-29 AnGap-12
[**2149-11-20**] 06:10PM BLOOD Na-136 K-4.2 Cl-103
[**2149-11-20**] 01:46AM BLOOD Glucose-113* UreaN-27* Creat-1.1 Na-139
K-5.5* Cl-112* HCO3-22 AnGap-11
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent an aortic valve
replacement by Dr. [**Last Name (STitle) 914**]. Given Penicillin allergy, she
required Vancomycin for perioperative antibiotic coverage. For
surgical details, please see operative note. Following surgery,
she was brought to the CVICU for invasive monitoring. Within 24
hours, she awoke neurologically intact and was extubated without
incident. She maintained stable hemodynamics and transferred to
the cardiac SDU on postoperative day one. She continued to
progress well and worked with physical therapy for strength and
mobility. Her Lopressor and Lisinopril were increased for
better heart rate and blood pressure control. Lantus was also
titrated up for hyperglycemia. On POD5 she was ambulating with
assistance, tolerating a full oral diet and her incisions were
healing well. It was thought that she was safe for transfer to
rehab at this time. Azathrioprine was restarted upon transfer
to [**Hospital6 **] rehab. All follow up appointments were
advised.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
AZATHIOPRINE - (Prescribed by Other Provider) - 50 mg Tablet -
1
Tablet(s) by mouth twice a day
CALCITONIN (SALMON) - (Prescribed by Other Provider) - 200
unit/dose Spray, Non-Aerosol - 1 spray in each nostril once a
day
alternating each nostril
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth qd am
FENTANYL - (Prescribed by Other Provider) - 50 mcg/hour Patch
72
hr - apply topically q72 hrs as needed for prn
FLUDROCORTISONE - (Prescribed by Other Provider) - 0.1 mg
Tablet
- 1 Tablet(s) by mouth once a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 250 mcg-50 mcg/Dose Disk with Device - 1 puff inh
twice a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
HYDROXYCHLOROQUINE - (Prescribed by Other Provider) - 200 mg
Tablet - 1 Tablet(s) by mouth once a day alternate with 200mg
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day as needed for prn sleep
LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth q6hrs as needed for prn anxiety
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day as
needed for prn
PREDNISONE - (Prescribed by Other Provider) - 1 mg Tablet - 6
Tablet(s) by mouth once a day
Discharge Medications:
1. prednisone 5 mg/5 mL Solution Sig: 6 ml PO DAILY (Daily).
2. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once
a day.
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) Nasal DAILY (Daily).
11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*7 Patch 72 hr(s)* Refills:*0*
13. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for anxiety.
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
17. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
19. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
21. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
22. azathioprine 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
23. lantus
30 units SQ daily at B-fast
24. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: d/c when LE edema resolved and at pre-op weight of
60kg.
25. regular insulin
regular insulin per sliding scale based on qid fingerstick
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 8432**] Center [**Hospital **] Rehab
Discharge Diagnosis:
Aortic Stenosis, s/p AVR
Chronic Diastolic Congestive Heart Failure
Hypertrophic Cardiomyopathy
Type II Diabetes Mellitus
Temporal Arteritis
Hypertension
Chronic Kidney Disease
History of DVT
Prior repair of Abd Aortic Aneurysm
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Lower extremities - trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] on [**12-22**] at 1:45pm in the [**Hospital **] medical
office building, [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 91295**] in 3 weeks - office will contact
patient with appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 91296**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13712**] in [**4-8**] weeks [**Telephone/Fax (1) 54951**]
**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:[**2149-11-24**]
|
[
"403.90",
"V12.51",
"446.5",
"272.4",
"V58.61",
"428.0",
"425.18",
"428.32",
"250.00",
"585.9",
"715.90",
"733.00",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
10243, 10319
|
5327, 6363
|
434, 554
|
10591, 10781
|
3053, 5304
|
11652, 12458
|
2361, 2411
|
7888, 10220
|
10340, 10570
|
6389, 7865
|
10805, 11629
|
2426, 3034
|
375, 396
|
582, 1180
|
1202, 1987
|
2019, 2345
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,640
| 195,483
|
51135
|
Discharge summary
|
report
|
Admission Date: [**2147-2-15**] Discharge Date: [**2147-2-22**]
Date of Birth: [**2069-8-26**] Sex: M
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Nausea, vomiting and chest pain
Major Surgical or Invasive Procedure:
Left internal jugular line
Porta-cath removal
History of Present Illness:
77 yo male with transfusion dependant MDS, moderate AS and dCHF
per echo in [**2145**], CAD s/p 2 stents [**2139**] and HTN who presented to
[**Hospital1 **] [**Location (un) **] with nausea, vomiting, diarrhea, malaise, as well as
two episodes of chest pain last night. Pt awoke this morning
was still having lightheadedness, nausea, chest pain and
shortness of breath. Upon arrival to [**Hospital1 **] [**Location (un) 620**] he was found to
have a SBP 60, WBC 17,500 (normally 1,500), lactate 7.4,
troponin 0.462, BNP 5641 and Cr 3.0 (baseline creatinine 1.0).
CXR: showed signiifcant pulmonary edema, placed on BiPAP for
respiratory status with good relief and increase in saturation
to 100%. Pt was tried on dopamine but developed chest pain and
ishemic EKG changes (ST depressions) so was transitioned to
phenylephrine at [**Location (un) 620**] ED. Got vanco, zosyn, one unit of
PRBC's and was transferred to [**Hospital1 18**] ED by [**Location (un) **] ground.
There was discussion of intubation but was not initiated
secondary to concern for further BP drop and improvement with
BiPap.
In the ED labs were notable for a WBC of 25.9 with 41% bands,
BUN/Cr 55/3.0, troponin of 0.83, initial lactate of 2.9. He was
given cefepime and flagyl in the ED. A central line was placed
and levophed was continued. In addition, there was initial
concern for carotid injury, which was subsequently ruled out by
bedside ultrasound.
Past Medical History:
- CAD s/p RCA stent placement (at VA), followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5858**]
- transfusion dependent MDS dignosed in [**2144**], gets 2 u RBCs
every week, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10919**] at [**Hospital1 **] [**Location (un) 620**]
- Hyperlipidemia
- Gout
- HTN
- dCHF (EF of 55%)
Social History:
- Patient is retired, used to run the electronic department at
[**University/College **] Coop. He is married and lives with his wife. They have 3
children and 3 grandchildren.
- Tobacco: rare cigarettes in the past.
- EtOH: social alcohol consumption
- Illicits: denies
Family History:
history of heart disease in family. His sister had stomach
cancer.
Physical Exam:
Vitals: 98.3 124/52 84 20 96% on RA
General: Alert, oriented, no acute distress
Lungs: crackles halfway up bilaterally, no wheezes or rales
CV: Regular rate and rhythm, normal S1 + S2, [**2-7**] holosystolic
murmur throughout the precordium
Abdomen: soft, diffuse tenderness to palpation, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: warm, well perfused, 2+ pulses, 1+ nonpitting edema to the
the level of the ankle
Pertinent Results:
[**2147-2-21**] 07:55AM BLOOD WBC-2.6*# RBC-2.70*# Hgb-8.1*# Hct-24.6*#
MCV-91 MCH-29.9 MCHC-32.8 RDW-14.7 Plt Ct-34*#
[**2147-2-21**] 05:42AM BLOOD Glucose-115* UreaN-28* Creat-1.0 Na-135
K-3.6 Cl-98 HCO3-32 AnGap-9
[**2147-2-20**] 06:33AM BLOOD ALT-78* AST-37 LD(LDH)-368* TotBili-2.1*
[**2147-2-15**] BLOOD CULTURE [**Location (un) **]
- All bottles growing MSSA
[**2147-2-15**] BLOOD CULTURE
STAPH AUREUS COAG +
OXACILLIN------------- S
CT Abdomen and pelvis [**2-15**]:
1. Bilateral airspace consolidations in a predominantly basilar
and
peripheral distribution. Differential is extensive and includes
infectious
etiologies. Mediastinal lymphadenopathy may be reactive.
2. 4-cm gastric submucosal cystic lesion. Differential includes
duplication cyst.
3. No evidence of acute intra-abdominal process. No abscess.
4. Subcutaneous soft tissue stranding anterior to the xyphoid;
clinical
correlation is recommended.
5. Umbilical hernia containing nonobstructed, nonstrangulated
small bowel.
6. Catheter of an accessed right chest wall port terminates in
the right
ventricl
Brief Hospital Course:
77 yo male with transfusion dependant MDS, severe AS and dCHF
per echo in [**2145**], CAD s/p PCA X 2 in [**2139**] who presented to [**Hospital1 **]
[**Location (un) **] with nausea, vomiting, diarrhea, malaise, as well as two
episodes of chest pain, found to be in septic shock with MSSA
bacteremia.
.
# Septic Shock: Pt initially presented to [**Hospital1 **] [**Location (un) 620**] with
systolic blood pressure in the 60s. He was given Vanc, Zosyn,
fluid resuscitated, started on pressors, and medflighted to
[**Hospital1 18**]. He was subsequently transitioned to a levophed gtt and
given Vanc, Cefepime, Levaquin and flagyl given his
immunocompromised state. His blood cultures from [**Location (un) 620**] and
[**Hospital1 18**] on admission grew out MSSA. Infectious disease service was
consulted. The presumed source was pulmonary as there was
evidence of possible pneumonia on chest CT. The other potential
source considered was skin entering through his port-a-cath. The
port-a-cath was removed by general surgery on hospital day 1.
His antibiotics were narrowed to Nafcillin (initially) and
levaquin (covering for pneumonia). Pt also presented with [**Last Name (un) **],
transaminitis and an NSTEMI, all felt to be secondary to sepsis.
With agressive care his creatinine returned to baseline and
LFT's and troponins downtrended. He had a PICC line placed on
[**2-20**] for long term antibiotics. Will need repeat TTE at end of
course of therapy per ID recommendations (to be arranged by ID).
He will also need repeat blood cultures following his antibiotic
course prior to replacing his port ([**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 8817**] [**Last Name (NamePattern1) **] RN).
Nafcillin was stopped on [**2-20**] due to concern of
thrombocytopenia, and he was instead discharged on cefazolin 2gm
q8hr to complete a 4 week course.
.
# Afib with RVR: Pt was noted to be in atrial fibrillation with
rates in the 120's-150's on the first night of the
hospitalization in the setting of sepsis. He was trialed on
metoprolol and esmolol gtt, but both caused profound hypotension
and bradycardia and were therefore discontinued. Cardiology was
consulted and recommended not treating his atrial fibrillation
given his hemodynamic stablility and in the setting of acute
illness. He was not considered to be a candiate for
anticoagulation given his severe MDS. On the medicine floor he
converted to sinus rhythm, where he remains at discharge. His
aspirin was continued and a beta blocker was restarted.
.
# dCHF and severe AS: In the MICU pt had hypoxia with bilateral
crackles with a chest x-ray consistent with pulm edema. We
restarted lasix 40 mg po on transfer to medical floor and at
times gave him additional PO/IV lasix for goal net negative 1L
per day. His oxygen requirement improved by the day of discharge
and currently is satting 88-92 on room air and 97% on 1L nasal
cannula. The patient takes shallow breaths and O2 sat improves
with deep breaths. We encouraged incentive spirometry. He
continues to have bilateral crackles 1/3 up from bases. Would
recommend daily weights. We have increased his lasix to 40mg
twice daily and would recommend this dose for the next several
days. At that time, please reassess and if appears euvolemic
consider down-titrating dose to 40mg daily (home dose prior to
hospitalization) and may consider uptitrating as well if still
volume overloaded. Creatinine and lytes should be checked
regularly and lasix dose adjusted accordingly.
.
# Chest pain/dyspnea
While on the floor, he had intermittent brief episodes of chest
pain and dyspnea, particularly when receiving anitbiotics. This
was short lived and resolved spontaneously. ECG was checked
during and post chest pain, without any noticeable changes. He
reports that this has been a long-standing issue and takes
nitroglycerin PRN at home. The chest pain is thought to be
stable angina or possibly anxiety. While he was never given SLNG
in the hospital as his chest pain resolved spontaneously, would
offer it to him if this recurs at facility.
.
# MDS: He requires weekly RBC's transfusions. He was given 3
units of PRC's during his admission to the MICU. He was also
given one unit of PRBCs on [**2-21**] and one unit on prior to
discharge on [**2-22**]. He will need 1-2x weekly CBC and transfusion
for HCT <24 or platelets <20.
.
#Port-a-cath wound: Patient had port-a-cath removed from left
chest. Initially packed with gauze, which lead to bleeding when
gauze was removed. Per wound care: "The wound bed is grey in
color measuring 1.5 x 3 x 2cm.
Edges are regular but not completely attached - minimal.
Drainage is moderate serosang without odor. There is no
erythema, induration or fluctuance." Wound care recommendations
are: Irrigate ulcer with wound cleanser set to stream and pat
dry
No Sting barrier wipe to periwound tissue, allow to dry fill
wound with aquacel ag rope followed by dry gauze secure with
Medipore H soft cloth tape change daily. Due to MDS, patient
often bleeds with each dressing change and will need direct
pressure to be applied after dressing change. He may also need
his dressing to be changed more frequently than daily if it
becomes saturated.
.
#4-cm gastric submucosal cystic lesion. This was thought to be a
duplication
cyst on imaging. Would recommend outpatient GI follow up.
.
TRANSITIONAL ISSUES
- Still appears volume overloaded, he needs continued diuresis
with Lasix 40mg PO BID. Check lytes and creatinine and adjust
lasix dosing accordingly
- Patient should have surveillance cultures 2 weeks after
completing antibiotics in order to make further decisions
regarding the need for port replacement
- Should have repeat TTE after completion of IV antibiotics
- Can consider prophylaxis if he becomes neutropenic
Medications on Admission:
- Allopurinol 100 mg once a day
- furosemide 40 mg once a day
- metoprolol 12.5 mg once a day
- neomycin/polymyxin eardrops
- niacin 750 mg once a day
- simvastatin 40 mg once a day
- nitroglycerin sublingually p.r.n.
- Tylenol p.r.n.
- vitamin C and aspirin 81 mg every other day.
- aspirin 81mg QOD
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
for 5 days, then 1 tablet daily.
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
4. niacin 750 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days: until [**2-24**].
7. cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection Q8H
(every 8 hours): for at least 3 weeks, until followup with
Infectious Disease.
8. morphine 10 mg Capsule, Ext Release Pellets Sig: One (1)
Capsule PO once a day as needed for prior to dressing change.
Disp:*5 capsules* Refills:*0*
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO every other day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
MSSA Bacteremia
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 7820**],
You were admitted to the hospital with a pneumonia and bacteria
in your blood. You were initially treated in the ICU and then
moved to the medical floor. You will need to have longterm
antibiotics to treat this bloodstream infection.
Medication changes:
Start levofloxacin 750mg orally daily until [**2-24**]
Start cefazolin 2 gram IV every 8 hours for at least 3 weeks
Increase lasix to 40mg PO BID for 5 days
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2147-2-27**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10921**], MD [**Telephone/Fax (1) 38619**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
**Plan to be at this appointment for several hours since you
will be getting a blood transfusion.
Name: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD
Specialty: Primary Care
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3070**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2147-2-28**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2147-3-16**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 32437**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"401.9",
"486",
"584.9",
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"038.11",
"428.32",
"274.9",
"E942.6",
"238.75",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.91",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
11288, 11382
|
4198, 8725
|
299, 346
|
11451, 11451
|
3088, 4175
|
12101, 13617
|
2520, 2589
|
10352, 11265
|
11403, 11430
|
10027, 10329
|
11633, 11900
|
2604, 3069
|
11920, 12078
|
228, 261
|
8737, 10001
|
374, 1810
|
11466, 11609
|
1832, 2217
|
2233, 2504
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,822
| 169,619
|
44027
|
Discharge summary
|
report
|
Admission Date: [**2136-4-20**] Discharge Date: [**2136-5-1**]
Date of Birth: [**2057-4-9**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Ciprofloxacin
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Colonoscopy
PICC placement
History of Present Illness:
79 y/o female with a h/o CAD s/p CABG '[**30**], multiple myeloma not
treated per pts wishes, T2DM, and CHF who presented w/ sepsis of
unclear etiology. She was recently admitted in [**2136-3-28**] for
congestive heart failure. She has a h/o urinary retention for
which she has an indwelling foley. Per VNA she had been having
foul smelling urine for two days prior to her admission. On the
morning of her admission she had shaking chills, unable to take
temperature due to shaking and was brought by family to ED. At
that time noted to have temp of 105 rectal, initial BP 158/80,
and noted to be volume overloaded.
.
Recently the pt came to the ED two days ago, after choking on
"grits" at breakfast. She was administered "heimlich" by
daughter, and resolved. CXR at that time notable for ? CABG
aneurysm, but no PNA.
.
She was given lasix 40 mg IV w/ subsequent BP drop to 80s SBP.
She was given azithromycin, ceftriaxone, and vancomycin for
probable pneumonia. She denied any fevers/chills/n/v/diarrhea.
She denies any SOB, CP, or abdominal pain.
Past Medical History:
1. Coronary artery disease with known 3-vessel disease,
- s/p NQWMI in [**2130-7-9**]
- s/p CABG [**8-8**]
2. T2DM
3. Hypercholesterolemia
4. Gastroesophageal reflux disease
5. Hypertension
6. Multiple myeloma (has continued to defer treatment)
7. Bilateral adrenal adenoma
8. Iron deficiency anemia
9. s/p cholecystectomy
[**39**]. s/p TAH BSO
11. Right-sided carotid stenosis
12. Urinary retention (eval with cystoscopy - found to have
excessive trabeculations c/w poor emptying) - requires straight
cath
13. CHF (systolic dysfunction, MR, TR)
Social History:
She lives with her son. She has 5 living children in [**Location (un) 86**] area
who are involved in her care. She is involved in her church when
she is able for health reasons. Widowed. Never smoked. Used to
drink alcohol socially. No IVDU.
Family History:
Siblings with hypertension. Brother, father with CVA. Mother
with MI and uterine cancer.
Physical Exam:
VS 96.0 124/64 80 16 95% RA
GENERAL: elderly female in NAD
HEENT: EOMI, MMM
NECK: JVP ~12 level of ear, supple, no LAD, no thyromegaly, RIJ
CDI
CARDIOVASCULAR: S1, S2, reg, III/VI systolic M at apex
LUNGS: Good air movement, no wheeze or crackles
ABDOMEN: Soft, ND, obese, Slight RLQ tenderness on palpation.
EXTREMITIES: Warm, 1+ LE edema, no C/C.
NEURO: A/O x2 (not time, follows commands) 4/5 strength
bilaterally
Pertinent Results:
[**2136-4-20**] CXR
Limited examination. There is suggestion of worsening fluid
balance. If clinically feasible, consider PA and lateral views
for more optimal evaluation.
.
[**2136-4-21**] CT Torso
Lobulated mass in the cecum and ascending colon of indeterminate
etiology without bowel obstruction. Possibilities include a
carcinoma, plasmacytoma or lymphoma, but given the clinical
presentation of sepsis, infectious process is in the
differential. Endoscopy is recommended.
Diverticulosis.
Enlarging bilateral adrenal masses.
New bilateral pleural effusions
Anasarca.
.
EKG: Sinus tachy 100, [**Last Name (LF) **], [**First Name3 (LF) **] dep and TWI in V4-V6, II, III.
.
Imaging: CXR: Diffuse haziness, vascularity, cardiomegaly.
Echo: EF 30-35%, 2+MR, 3+TR, 1+AR. Mod global RVHK, global LVHK.
.
[**4-24**] CT head: 1. No evidence of acute major vascular territorial
infarct, hemorrhage, or enhancing lesions. If high clinical
suspicion, MRI would be more sensitive evaluation. 2.
Myelomatous involvement of the skull, with no epidural or other
associated soft tissue mass.
.
[**4-24**] CXR: Compared with [**2136-4-21**], the pulmonary edema has
resolved. There is persistent retrocardiac atelectasis/opacity.
The remainder of the visualized lung fields appear clear.
.
[**4-27**] CT abdomen/pelvis: 1. Cardiomegaly with reflux of contrast
into enlarged hepatic veins suggestive of right heart
dysfunction. 2. Bilateral pleural effusions and adjacent
relaxation atelectasis, right greater than left, unchanged. 3.
Stable bilateral adrenal masses previously characterized as
adenomas. 4. Anasarca. 5. Filling defects within the right colon
seen on prior examination no longer visualized and likely
represented stool that has passed in the interim. 6. Colonic
diverticulosis without evidence of diverticulitis.
.
AEROBIC BOTTLE (Final [**2136-4-25**]):
[**2136-4-23**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 94534**] AT 6:15 AM.
GEMELLA SPECIES.
ORGANISM NON-VIABLE, UNABLE TO PERFORM SENSITIVITIES.
ANAEROBIC BOTTLE (Final [**2136-4-25**]):
GEMELLA SPECIES. IDENTIFICATION PERFORMED FROM AEROBIC
BOTTLE.
.
AEROBIC BOTTLE (Final [**2136-4-24**]):
GEMELLA (STREPTOCOCCUS) MORBILLORUM.
IDENTIFICATION PERFORMED ON CULTURE # 228-1282H
[**2136-4-20**].
ANAEROBIC BOTTLE (Final [**2136-4-24**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 8:30 PM ON
[**2136-4-20**] .
GEMELLA SPECIES.
IDENTIFICATION PERFORMED ON CULTURE # 228-1282H
[**2136-4-20**].
Brief Hospital Course:
ICU COURSE:
.
79 y/o female with a h/o CAD s/p CABG, T2DM, MM, and CHF who
presented with sepsis. She was found to have a lobulated mass in
the cecum and ascending colon on CT torso and [**2-12**] blood cx
bottles growing G+ cocci. The following issues were addressed
during this admission.
.
She was admitted to the MICU on a short course of Levophed. In
the MICU, her blood cultures have grown 2/4 bottles of G+ Cocci,
ucx negative. Her abdominal CT showed lobulated mass in the
cecum and ascending colon concerning for carcinoma. She has been
seen by the GI team who suggested the possibility of
plasmacytoma and lymphoma in the differential. She is to be
scoped by GI on a future date once they deem her stable. Of note
she was transfused with 1 unit of PRBCs for Hct of 24 with
minimal response but no evidence of acute blood loss/hemolysis.
.
GENERAL MEDICINE FLOOR:
.
# Sepsis/bacteremia. [**4-11**] blood cultures grew Gemella, unable to
perform sensitivies. ID consulted for antibiotic coverage; they
recommended vancomycin. All surveillance cultures were negative
to date. The patient declined TEE to rule out endocarditis, so
she will be treated with a six week course of vancomycin to
empirically treat endocarditis. All other cultures were
negative.
.
# Lobulated mass in the cecum and ascending colon. First CT
showed a lobulated mass that was concerning for plasmacytoma vs.
lymphoma vs. primary colon CA. However, on repeat CT, there was
no mass, and the initial mass was likely intracolonic fecal
matter.
.
# CHF. Fluid overloaded on exam (increased JVP, lower extremity
edema, bibasilar crackles on lung exam). Blood pressures have
been within normal limits; will slowly add back cardiac
medications (atenolol, furosemide) and *gentle* diuresis as
blood pressure tolerates. TTE on [**3-24**] demonstrated decreased
ejection fraction of 30-35% and biventricular hypokinesis.
- Oral furosemide according to home regimen
- Start [**Last Name (un) **]
.
# Coagulopathy. Chronic. INR, PTT elevated. Possible clotting
factor inhibitor given malignancy vs. factor deficiency. At the
time of discharge, a mixing study was pending; this should be
followed up as an outpatient.
.
# Diplopia. During the hospitalization, the patient complained
of double vision; her cranial nerve exam was otherwise
unremarkable. CT head showed no evidence of mass, infection, or
infarct to explain the findings. She was seen by ophthalmology
consult, who noted microvascular changes consistent with the
patient's known diabetes and recommended outpatient follow-up.
.
# Hyponatremia. Chronic problem, possibly secondary to multiple
myeloma +/- CHF. No interventions during this hospitalization.
.
# Anemia. Most likely multifactorial in etiology (with history
of multiple myeloma). B12 level pending. Last iron studies
([**2136-3-8**]) consistent with anemia of chronic disease.
Continued outpatient vitamin B12 and folate given macrocytosis.
.
# CAD. Had elevated troponin T on admission with flat CK
(attributable to MI in setting of sepsis). EKG showed resolution
of T-wave and non-specific EKG changes. Continued on aspirin and
beta blocker; [**Last Name (un) **] started at the time of discharge.
.
# Multiple Myeloma. Plasmacytoma previously identified on
sternal biopsy; she was noted on skeletal survey to have
additional lesions in [**2133**] w/ R humerus lesion, L mid femur.
Renal function has been stable, UPEP in [**Month (only) 404**] showed trace IgG
band. Patient has declined treatment. No interventions during
this hospitalization.
.
# Diabetes. Has been normoglycemic. Continued on insulin sliding
scale, with close monitoring of blood glucose levels. Cardiac
and diabetic diet.
Medications on Admission:
ASA 81
Atenolol 50
Lasix 40
NTG
NPH 22/4
KCl 20
Discharge Medications:
1. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed.
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours) for 5 weeks.
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-10**] Sprays Nasal
QID (4 times a day) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for iotching.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
As directed Subcutaneous twice a day: 16 units before breakfast,
2 units before bedtime.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) as
directed Subcutaneous four times a day: According to sliding
scale (attached).
14. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Bacteremia/sepsis
Systolic congestive heart failure
Coagulopathy, malignancy-related
Anemia, chronic
Multiple myeloma
Discharge Condition:
Hemodynamically stable, tolerating PO
Discharge Instructions:
You were admitted with fevers and were found to have positive
blood cultures. You were treated with the appropriate
antibiotics and should remain on IV antibiotics for six weeks'
duration given concern for infection of the heart valves.
.
If you develop worsening shortness of breath, chest pain, fever,
chills, nausea, vomiting, or other concerning symptoms, please
seek medical attention immediately.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] within 1-2 weeks of discharge
from rehab.
.
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2136-5-9**]
9:00
.
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2136-5-10**] 9:20
.
Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2136-5-10**]
9:20
|
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"428.20",
"562.10",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.07",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
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] |
10668, 10723
|
5442, 9135
|
298, 327
|
10885, 10925
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2796, 3609
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3618, 5419
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1429, 1977
|
1993, 2237
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,954
| 106,486
|
53705
|
Discharge summary
|
report
|
Admission Date: [**2201-4-14**] Discharge Date: [**2201-4-28**]
Date of Birth: [**2127-1-28**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Ativan
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
abdominal pain, nausea, emesis
Major Surgical or Invasive Procedure:
[**2201-4-14**] - Endoscopic retrograde cholangiopancreatography
History of Present Illness:
This is a 74 year-old Male with a PMH significant for chronic
lower extremity pain syndrome (on narcotics), HTN, OSA (not on
CPAP), chronic constipation and undefined asymptomatic cardiac
septal defect who presented with acute onset abdominal pain,
nausea and emesis for 1-day who was found to have evidence of
gallstone pancreatitis and transferred from [**Hospital3 3583**] for
further management.
.
The patient notes that he awoke feeling well on [**2201-4-13**] and ate
a hotdog for lunch without issues; however, within an hour of
consumption he felt nausea and generalized malaise with chills.
Following these symptoms, he developed epigastric abdominal pain
that was [**8-4**] in intensity, that was intermittent and achy-dull
in character radiating through to his back. He notes that he had
a similar pain after breakfast a week prior to this episode; but
never before that. The patient also notes associated
non-bilious, non-bloody emesis surrounding his nausea. He denies
fevers. No unintentional weight loss. He notes yellowing of the
skin. He denies headache or vision changes. No loose or bloody
stools, notes recent constipation issues (last BM morning of
admission to OSH was dark, formed and non-bloody). Around 7PM,
his pain worsened and he presented to [**Hospital3 3583**]. Of note,
he has had on-going, bilateral proximal lower extremity pain
issues that has been managed for several months with Percocet
(previously with Celecoxib) and recent he started Prednisone 15
mg PO daily with some improvement.
.
At [**Hospital3 3583**], the patient arrived with VS 98.2 75 169/83
22 94% RA. Exam was notable for epigastric abdominal pain and
yellowing of the skin. Laboratory studies notable for WBC 12.6
(86.9% neutrophilia, no bandemia), HCT 47.5%, PLT 161.
Creatinine 0.87. LFTs: AST 446, ALT 413, AP 59, T-bili 3.8 with
lipase 639. Troponin 0.01. U/A negative. A CT abdomen and pelvis
demonstrated multiple gallstones, a prominent gallbladder
measured to 9-cm with mild stranding. There was also mild
pancreas stranding without evidence of small bowel obstruction.
He received 1L NS x 3, Zosyn 3.375 g IV x 1, Morphine 8 mg IV x
1 and Fentanyl 100 mcg IV x 1 for pain control; he received
Zofran 4 mg IV x 2, Protonix 80 mg IV x 1 with infusion
following. He also received Benadryl 25 mg IV x 1,
Metoclopramide 10 mg IV x 1 and [**Known lastname **] his recent steroid use,
Hydrocortisone 100 mg IV x 1. He was transferred to [**Hospital1 18**] for
further management and ERCP team evaluation.
.
In the [**Hospital1 18**] ED, initial VS 100.5 82 182/84 18 98%RA. Exam
notable for improved abdominal pain. Laboratory data notable for
WBC 9.6 (neutrophilia 89%), HCT 45.7, PLT 173. Creatinine 0.8.
INR 1.2. LFTs: AST 452, ALT 512, AP 73, T-bili 4.1, Albumin 0.8,
lipase 645. Lactate 2.1. An EKG demonstrated NSR @ 85, NA/NI,
IVCD, no ST-changes. ERCP fellow evaluated patient and agreed
with transfer for urgent ERCP needs. He received Dilaudid 2 mg
IV x 1, Zofran 4 mg IV x 1 and a Foley catheter was placed prior
to transfer. He received 1L NS x 2. Vitals prior to transfer,
97.9 149/79 81 15 95%RA.
.
On arrival to [**Hospital Unit Name 153**], he appears non-toxic and stable. He has some
epigastric abdominal complaints with mild nausea.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Chronic proximal lower extremity pain (on chronic narcotic
therapy, has trialed Celecoxib and recently started Prednisone
treatment)
2. Hypertension
3. Chronic constipation ([**Known lastname **] narcotic use)
4. Septal defect in myocardium (stable since childhood, serially
monitored with 2D-Echo)
5. Obstructive sleep apnea (does not tolerate CPAP use)
6. Hypogonadism
7. s/p appendectomy (years prior)
Social History:
Patient lives at home with his wife, [**Name (NI) **]. They have four
children who are grown. He is a retired finance officer. Prior
tobacco use for 20 years (15-20 pack-year); quit 25 years prior.
Recently discontinued alcohol use after his steroid initiation
([**2-27**] mixed drinks daily with 4-5 on weekends). No recreational
substance use.
Family History:
Mother had lung cancer; father with gallstones and aggressive
thyroid carcinoma. No strong cardiovascular history or history
of other malignancies.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 97.9 149/79 81 15 96% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Non-toxic appearing with notable jaundice.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry. Scleral icterus noted.
NECK: supple without lymphadenopathy. JVD difficult to assess
[**Known lastname **] body habitus.
CVS: Regular rate and rhythm, II/VII mid-systolic murmur heard
at LLSB without radiation, no rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases bilaterally without
adventitious sounds. No wheezing, rhonchi or crackles. Stable
inspiratory effort.
ABD: soft, diffusely tender to deep palpation, non-distended,
with normoactive bowel sounds. No palpable masses or peritoneal
signs. Negative [**Doctor Last Name 515**] sign.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
.
Pertinent Results:
.
IMAGING:
[**2201-4-13**] CT ABDOMEN & PELVIS (from [**Hospital3 3583**]) - multiple
gallstones, a prominent gallbladder measured to 9-cm with mild
stranding. There was also mild pancreas stranding without
evidence of small bowel obstruction (per Radiology report).
.
[**2201-4-19**] 05:50AM BLOOD WBC-10.5 RBC-4.50* Hgb-12.6* Hct-38.5*
MCV-86 MCH-28.0 MCHC-32.7 RDW-15.7* Plt Ct-183
[**2201-4-18**] 05:00PM BLOOD Hct-37.2*
[**2201-4-18**] 10:53AM BLOOD WBC-11.3* RBC-4.41* Hgb-12.5* Hct-38.2*
MCV-87 MCH-28.4 MCHC-32.8 RDW-15.7* Plt Ct-141*
[**2201-4-17**] 05:00AM BLOOD WBC-18.1* RBC-4.97 Hgb-14.0 Hct-43.5
MCV-88 MCH-28.2 MCHC-32.2 RDW-15.4 Plt Ct-146*
[**2201-4-16**] 03:35PM BLOOD Hct-43.8
[**2201-4-16**] 04:17AM BLOOD WBC-18.4* RBC-4.78 Hgb-13.1* Hct-41.4
MCV-87 MCH-27.4 MCHC-31.7 RDW-15.9* Plt Ct-149*
[**2201-4-14**] 09:05PM BLOOD WBC-11.8* RBC-5.05 Hgb-13.6* Hct-44.5
MCV-88 MCH-26.8* MCHC-30.5* RDW-15.9* Plt Ct-149*
[**2201-4-14**] 09:05PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL
[**2201-4-17**] 11:35PM BLOOD Neuts-85.6* Lymphs-5.7* Monos-8.2 Eos-0.4
Baso-0
[**2201-4-16**] 04:17AM BLOOD PT-15.2* PTT-34.6 INR(PT)-1.4*
[**2201-4-14**] 06:09AM BLOOD PT-12.7* PTT-28.2 INR(PT)-1.17*
[**2201-4-19**] 05:50AM BLOOD Glucose-98 UreaN-11 Creat-0.6 Na-142
K-2.8* Cl-101 HCO3-30 AnGap-14
[**2201-4-18**] 07:20PM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-143
K-2.7* Cl-103 HCO3-28 AnGap-15
[**2201-4-18**] 10:53AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-146*
K-3.2* Cl-104 HCO3-28 AnGap-17
[**2201-4-17**] 11:35PM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-135
K-3.1* Cl-93* HCO3-27 AnGap-18
[**2201-4-17**] 05:00AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-132*
K-3.4 Cl-93* HCO3-26 AnGap-16
[**2201-4-16**] 07:30AM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-130*
K-3.3 Cl-94* HCO3-26 AnGap-13
[**2201-4-16**] 04:17AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-132*
K-3.5 Cl-98 HCO3-25 AnGap-13
[**2201-4-15**] 06:45AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138
K-3.7 Cl-106 HCO3-22 AnGap-14
[**2201-4-14**] 09:05PM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-140
K-3.9 Cl-109* HCO3-22 AnGap-13
[**2201-4-14**] 06:09AM BLOOD Glucose-119* UreaN-16 Creat-0.8 Na-138
K-4.1 Cl-105 HCO3-22 AnGap-15
[**2201-4-19**] 05:50AM BLOOD ALT-71* AST-18 AlkPhos-54 TotBili-2.5*
[**2201-4-18**] 10:53AM BLOOD ALT-83* AST-22 CK(CPK)-180 AlkPhos-52
TotBili-2.9* DirBili-1.4* IndBili-1.5
[**2201-4-17**] 11:35PM BLOOD ALT-99* AST-25 CK(CPK)-60 AlkPhos-56
TotBili-2.6*
[**2201-4-17**] 11:55AM BLOOD CK(CPK)-83
[**2201-4-17**] 05:00AM BLOOD ALT-148* AST-23 CK(CPK)-86 AlkPhos-57
TotBili-2.6* DirBili-0.8* IndBili-1.8
[**2201-4-16**] 07:30AM BLOOD ALT-225* AST-32 CK(CPK)-109 AlkPhos-65
Amylase-78 TotBili-3.0*
[**2201-4-16**] 04:17AM BLOOD ALT-222* AST-32 AlkPhos-59 Amylase-88
TotBili-2.5*
[**2201-4-15**] 06:45AM BLOOD ALT-332* AST-83* LD(LDH)-291* AlkPhos-71
TotBili-2.4*
[**2201-4-14**] 09:05PM BLOOD ALT-393* AST-139* LD(LDH)-205 AlkPhos-72
TotBili-2.9*
[**2201-4-14**] 06:09AM BLOOD ALT-512* AST-452* AlkPhos-73 TotBili-4.1*
[**2201-4-19**] 05:50AM BLOOD Lipase-37
[**2201-4-17**] 05:00AM BLOOD Lipase-22
[**2201-4-15**] 06:45AM BLOOD Lipase-545*
[**2201-4-14**] 09:05PM BLOOD Lipase-1345*
[**2201-4-14**] 06:09AM BLOOD Lipase-645*
[**2201-4-18**] 10:53AM BLOOD CK-MB-6 cTropnT-<0.01
[**2201-4-17**] 11:35PM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-4-17**] 11:55AM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-4-17**] 05:00AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-3649*
[**2201-4-16**] 07:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-4-19**] 05:50AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.2
[**2201-4-18**] 07:20PM BLOOD Calcium-8.3* Phos-2.2* Mg-2.2
[**2201-4-18**] 10:53AM BLOOD Calcium-8.4 Phos-1.4* Mg-2.2
[**2201-4-17**] 11:35PM BLOOD Calcium-8.6 Phos-1.6* Mg-1.7
[**2201-4-18**] 12:03AM BLOOD Type-[**Last Name (un) **] pO2-140* pCO2-37 pH-7.50*
calTCO2-30 Base XS-5
[**4-14**] ERCP
Impression: Cannulation of the biliary duct was successful and
deep with a sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
The common bile duct was dilated to 12 mm.
There were several filling defects in the mid-CBD consistent
with stones and/or sludge.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sweep x 3 was performed with successful extraction of
copious amounts of sludge and debris.
Final cholangiogram was normal without filling defects.
.
Recommendations: NPO overnight with aggressive IV hydration with
LR at 200 cc/hr.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ([**Pager number 8437**])
Continue aggressive management of pancreatitis.
Continue antibiotics x 7 days.
Consider cholecystectomy.
.
[**4-16**] CT abdomen/pelvis:
IMPRESSION:
1. Findings consistent with reported diagnosis of pancreatitis
with minimally increased peripancreatic and periduodenal fat
stranding as well as interval development of notable
pancreatico-duodenal groove bowel wall thickening likely related
to either groove pancreatitis or duodenal hematoma [**Known lastname **] recent
ERCP. No complications of pancreatitis such as : splenic venous
thrombosis, splenic artery pseudoaneurysm, focal abscess, or
phlegmon formation.
2. New bilateral pleural effusions, both small in size, right
greater than
left.
3. Bilateral hyperdense renal cystic lesions likely represent
hemorrhagic
cysts, could be further evaluated with renal ultrasound.
.
LENI [**4-17**]:
IMPRESSION: No DVT in the left upper extremity.
.
CXR [**4-18**]:
Left PICC line tip is at the mid SVC. NG tube passes below the
diaphragm
terminating most likely in the stomach. There is interval
development of
pulmonary edema on the top of preexisting consolidations in the
lung bases.
Pulmonary hypertension is most likely present [**Known lastname **] the
prominence of
pulmonary arteries.
.
[**4-19**] Head CT:
IMPRESSION: No CT evidence for acute intracranial process.
[**4-19**] CT ABD PELVIS: IMPRESSION:
1. Interval increase in peripancreatic stranding and duodenal
wall
thickening. No pseudocyst or other complication identified.
2. Hypodensities within the portal vein adjacent to the
pancreatic head may
represent flow artifact or less possibly thrombus. Attn on
followup.
3. Poor opacification of SMV does not allow for adequate
assessment.
.
[**2201-4-19**] CXR: FINDINGS: In comparison with the study of [**4-18**],
there is continued
enlargement of the cardiac silhouette with mild improvement in
pulmonary
venous pressure. Prominent pulmonary arteries are again seen
bilaterally.
Little change in the appearance of the nasogastric tube
.
[**4-22**] Video Fluoroscopy:
SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing
videofluoroscopy was
performed in conjunction with the speech and swallow division.
Multiple
consistencies of barium were administered. Barium passed freely
through the
oropharynx without evidence of obstruction. There is penetration
with thin
liquids. There was no gross aspiration. The barium tablet is
held up at the
vallecula but clears with multiple swallows of barium.
Degenerative change is
seen in the cervical spine.
IMPRESSION: Penetration with thin liquids. For details, please
refer to
speech and swallow note in OMR.
[**2201-4-24**] KUB:
FINDINGS: Two upright and two supine frontal views of the
abdomen show
gaseous distention of several loops of small bowel, increased
from [**2201-4-19**].
There is gas in non-dilated loops of large bowel as well as the
rectum. No
air-fluid level or evidence of pneumoperitoneum is detected.
Multiple
calcific densities are noted in the pelvis which may represent
vascular
calcifications seen on recent CT of [**2201-4-19**]. The visualized lung
bases
demonstrate mild atelectasis. The osseous structures are within
normal
limits.
IMPRESSION: Gaseous distention of the small bowel increased from
[**2201-4-19**] most
likely represents ileus; partial small bowel obstruction cannot
be entirely
excluded. No free air.
[**2201-4-25**] KUB
In comparison with the study of [**4-24**], there is gas within mildly
dilated
transverse colon. Remainder of the bowel gas is essentially
within normal
limits, so that the overall pattern most likely reflects
adynamic ileus.
Brief Hospital Course:
74M with a PMH significant for chronic lower extremity pain
syndrome (on narcotics and steroids), HTN, OSA (not on CPAP),
chronic constipation and undefined asymptomatic cardiac septal
defect who presented with acute onset abdominal pain, nausea,
emesis and jaundice for 1-day with CT evidence of obstructing
common biliary duct stone; mild-moderate transaminitis,
hyperbilirubinemia with lipasemia consistent with acute
gallstone pancreatitis now s/p ERCP with successful sludge
extraction. Hospital course was complicated by delirium,
hypertensive urgency with CP but no evidence of ACS. He also
developed pulmonary edema from aggressive hydration for his
pancreatitis, ileus, and required nutritional supplement with
TPN.
.
#Moderate-severe PANCREATITIS, ACUTE/GALLSTONE
PANCREATITIS/CHOLEDOCHOLITHIASIS W/ OBSTRUCTION: Patient
presented with abdominal, nausea, emesis and jaundice for 1-day
with CT imaging evidence of obstructing common biliary duct
stone; mild-moderate transaminitis, hyperbilirubinemia with
lipasemia consistent with gallstone pancreatitis. No prior
history of biliary colic or prior episodes of pancreatitis,
despite significant alcohol history. ERCP evaluated the patient
and felt urgent ERCP was necessary, this was performed with
stone and sludge extraction. Pt was felt to have had a moderate
pancreatitis and the general surgery and ERCP teams followed the
patient. Pt was [**Known lastname **] aggressive IV fluids and zosyn for concern
of possible early cholangitis at OSH prior to admission. Zosyn
was continued for 10 days. Pt was [**Known lastname **] IV narcotics and
antiemetics for pain control. [**Known lastname 227**] continued pain on the
medical floor, pt had a CT scan of the abdomen performed on [**4-16**]
showing concern for possible duodenal hematoma vs. edema from
pancreatitis. Both the ERCP and Surgery teams felt this to be
consistent with edema from pancreatitis [**Known lastname **] stability of Hct.
NG tube was placed [**Known lastname **] ileus. [**Known lastname 227**] prolonged, NPO status PPN
was initiated as there was no central access. Repeat CT scan
showed interval increase in peripancreatic stranding and
duodenal wall thickening. No pseudocyst or other complication
identified. His abdominal pain gradually improved. He had a
PICC line placed for TPN which he pulled out while delirious so
it was replaced and he continued on TPN as his diet was
gradually advanced. He failed a bedside speech and swallow and
underwent video swallow study. Speech and swallow recommended
ground solids and thin liquids. This should also be low fat and
low residue. Unfortunately he re-developed nausea and vomiting
and KUB showed increased gaseous distention. He was made NPO
again. Repeat KUB showed ileus. His diet was slowly advanced,
and he tolerated it well, without nausea or increase in
abdominal pain. At the time of discharge, his diet was low-fat,
no dairy, no coffee (as recommended by GI).
.
#Fever/Leukocytosis-likely due to above. CT scanning showed
acute pancreatitis. No dysuria, diarrhea, or cough to suggest
additional causes. lactate normal. Pt developed fever to 102 on
[**4-19**]. Vancomycin was added to the zosyn regimen. Serial BCX, UCX
were drawn which remained negative. Repeat CXR and CT
Abd/Pelvis did not show any new signs of infection. Vanco was
d/ced on [**4-21**] and the pt was monitored without any further fever
or leukocytosis. Zosyn was d/ced on [**4-24**] after 10 days
(including OSH coverage).
.
#Metabolic encephalopathy-Initially the patient was A&O x 3 but
with developed sundowning and delirium. He denied headache or
signs of meningitis. No evidence for seizures. Etiology was
likely multifactoral related to polypharmacy from opioids,
anti-emetics, age, acute illness, hospitalization. Infectious
work up was unrevealing EKG was not suggestive of ischemia. Pt
was [**Known lastname **] a 1:1 sitter to prevent pulling out of lines. Zyprexa
5mg [**Hospital1 **] was administered. Head CT showed no acute intracranial
abnormalities. His mental status gradually improved and at
discharge he is alert and oriented x3, [**Location (un) 1131**] newspapers.
.
#Chest pain/Hypertensive urgency-Pt developed CP and SOB [**4-16**]
overnight in setting of SBP 180-200. EKG unchanged from prior.
Serial cardiac biomarkers negative. He was [**Known lastname **] aspirin and SL
nitro in that setting. No events were recorded on telemetry.
This was likely due to pain, pulmonary edema and hypertensive
urgency. Pt was placed on standing IV hydralazine and metoprolol
which was later transitioned to PO metoprolol. Lisinopril was
also added later in his hospitalization.
.
#Pulmonary edema/volume overload-Thhis was related to aggressive
fluid resuscitation as recommended for gallstone pancreatitis.
IV fluids were decreased and pt was [**Known lastname **] lasix. He required 2L
of NC but this was weaned off.
.
# POLYMYALGIA RHEUMATICA on SYSTEMIC STEROID THERAPY
CHRONIC LOWER EXTREMITY PAIN - Patient presented with
long-standing history of chronic lower extremity edema which has
been managed with chronic narcotics (Percocet), trial of
Celecoxib and now Prednisone dosing (since [**2201-3-31**]) with
improvement. Pain symmetric and isolated to the proximal lower
extremities concerning for polymylagia rheumatica. His EMG was
reassuring. The differential also includes rheumatoid arhtirits
vs. hypothyroidism vs. spondyloarthropathy vs. fibromyalgia vs.
myopathy. Pt was continued on prednisone 15mg daily which was
converted to hydrocortisone when the pt was NPO. He received
Dilaudid for pain but when his mental status improved, he was
transitioned to oxycodone. He did not have any signs of vascular
compromise. He should follow up with his PCP for further
management.
.
# HYPERTENSION - History of hypertension that has been managed
on ACEI previously, but now only beta-blockers (Atenolol daily).
See above, pt was [**Known lastname **] standing IV hydralazine and metoprolol
but was later restarted on an ACEI. Hydralazine was not
continued.
.
#Duodenal hematoma?-There was concern raised on CT imaging. Hct
remained stable. Other differential included edema related to
acute pancreatitis. Surgery and ERCP teams monitored the
patient.
.
#Acute on chronic CONSTIPATION with ileus - This has been an
on-going issue since his narcotic use for his lower extremity
pain. CT without evidence of bowel obstruction and his last
bowel movement was formed, hard and non-bloody the morning prior
to admission. Aggressive bowel regimen attempted, but pt was
found to have an ileus. NGT was placed and the patient remained
NPO especially as he was also delirious. When his mental status
improved, NGT was d/ced and he was restarted on a PO bowel
regimen. He later developed diarrhea but KUB showed increased
gaseous distention suggestive of an ileus.
.
# Diarrhea - Later in his hospitalization, the pt developed
diarrhea. Cdiff test was negative. Diarrhea improved.
.
#Hyponatremia/hypernatremia - This was managed with IVF
intermittently during his hospitalization.
.
#OSA-does not tolerate CPAP. Outpt f/u.
.
#Thrombocytopenia-could be due to acute illness, vs. medication
effect. Improved.
TRANSITIONAL ISSUES
1. Follow a low-fat diet, avoiding dairy and coffee.
2. Antihypertensives changed to metoprolol 25 mg [**Hospital1 **] and
lisinopril 20 mg daily.
3. Check K and Cr next week (on [**4-26**] here, K was 3.6 and Cr 0.7).
4. Follow-up with Surgery for elective cholecystectomy
5. Other notable labs on last check: Hct 39.4 (borderline low),
ALT 101, AST 41, AlkPhos 65, Total Bili 0.7. Would repeat LFTs
in the outpatient setting.
6. Abd CT on [**4-16**] showed: "Bilateral hyperdense renal cystic
lesions likely represent hemorrhagic cysts, could be further
evaluated with renal ultrasound." Can consider renal ultrasound
in outpatient setting, if clinically indicated.
7. Abd CT on [**4-19**] showed: "Hypodensities within the portal vein
adjacent to the pancreatic head may represent flow artifact or
less possibly thrombus. Attn on followup." Would consider
repeat imaging in follow-up.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient's Pharmacy)
1. Percocet 5/325 mg (1-2 tabs) PO Q6H PRN pain
2. Aspirin 81 mg PO daily
3. Atenolol 50 mg PO daily
4. Prednisone 15 mg PO daily (started [**2201-3-31**])
5. Sennosides 2 tabs PO daily
6. Testosterone (Androgel) 1 application topically daily
7. Citalopram 20 mg PO daily
8. Ergocalciferol 50,000 units PO weekly
9. Lactulose 30 mL ([**1-26**] teaspoons) PO daily
Discharge Medications:
1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day).
Disp:*1 BOTTLE* Refills:*0*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
acute gallstone pancreatitis
choledocholithiasis
delirium
fever
pulmonary edema
ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for further evaluation of gallstone
pancreatitis. For this, you underwent an ERCP which removed
stones from your bile ducts. Ultimately, you will likely need
your gallbladder removed. Your hospital course was complicated
by delirium, fever, hypertension, and ileus. Your symptoms
improved.
.
Medication changes:
1. Lisinopril 20 mg daily for blood pressure
2. Metoprolol 25 mg [**Hospital1 **] for blood pressure (instead of
atenolol).
.
You should have your liver function tests, potassium level, and
creatinine level (kidney function) checked at your visit with
Dr. [**First Name (STitle) **] next week.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: INTERNAL MEDICINE
Address: [**Apartment Address(1) 63839**], [**Location (un) **],[**Numeric Identifier 40624**]
Phone: [**Telephone/Fax (1) 25821**]
Appointment: WEDNESDAY [**5-6**] AT 2:30PM
**Your appointment for Wednesday [**4-29**] has been cancelled
and the appointment above has replaced it.**
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**Last Name (LF) **], [**Name8 (MD) **] MD
When: TUESDAY [**2201-5-26**] at 1:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2201-5-27**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"276.69",
"287.5",
"564.00",
"745.9",
"725",
"574.51",
"577.0",
"338.29",
"729.5",
"276.0",
"257.2",
"276.1",
"401.9",
"V58.69",
"V15.82",
"787.91",
"786.50",
"511.9",
"327.23",
"348.31",
"514",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
23538, 23599
|
14060, 22170
|
315, 381
|
23729, 23729
|
5701, 11682
|
24623, 25795
|
4513, 4662
|
22637, 23515
|
23620, 23708
|
22196, 22614
|
23880, 24190
|
4677, 5682
|
24210, 24600
|
244, 277
|
409, 3669
|
11691, 14037
|
23744, 23856
|
3691, 4134
|
4150, 4497
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,292
| 186,944
|
44116
|
Discharge summary
|
report
|
Admission Date: [**2116-8-28**] Discharge Date: [**2116-8-31**]
Date of Birth: [**2033-12-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscoy [**2116-8-29**] with placement of 3 clips
Arterial line placement [**2116-8-28**]
History of Present Illness:
82M with h/o CAD on ASA, colonic adenomas s/p polypectomy [**8-26**]
presenting with BRPBR x 1 day. Pt underwent colonoscopy [**8-26**] for
f/u of cecal adenoma removed [**6-2**] and was found to have residual
polypoid tissue was seen at site of previous resection in the
cecum. Part of the polyp was adherent to the underlying
submucosa and could not be lifted easily with submucosal
injection of saline and methylene blue. Endoscopic mucosal
resection (EMR) was performed and the polyp was completely
removed piecemeal using a hot snare. A 5 mm sessile polyp in the
sigmoid [**Month/Year (2) 499**] was also removed. The patient tolerated the
procedure well and was discharged home. He resumed his regular
diet and had no bowel movements until the following evening when
he noted dark red blood in the toilet. He reports at least 6
episodes of dark red blood per rectum throughout the night. In
the morning, he passed dark red blood and clots and noted
dizziness while climbing the stairs for which he presented to
the ED. He denied nausea, vomiting, abdominal pain. No chest
pain, palpitations or SOB. Last ASA was 5 days prior to
colonoscopy, denies other anticoagulants.
In the ED, initial VS were 97.0 72 109/66 18 98% RA. +
orthostatic, Hct 32 from 40 at OSH [**8-25**]. BP dropped to 80s/50s
after BRBPR in bathroom. Received 1 unit pRBCs and 2L NS, BP
100s/70s.
On arrival to the MICU, patient's SBP 140s, P 90s, 98% 2L NC. At
approximately 1500, passed 650ml BRBPR at commode, HR 50s and
patient presyncopal. Back on monitor, SBP 110s. Given 1.5L NS
and NGT placed,H/H sent, 2nd unit PRBCs started.
Review of systems:
(+) Per HPI
(-) Denies shortness of breath, chest pressure, palpitations.
Denies abdominal pain, hematemesis, diarrhea
Past Medical History:
-Colonic adenomas: pt reports approximately 6 colonoscopies in
lifetime most recently [**2116-8-26**] and [**6-2**].
-MI: [**2105**], s/p PCI with 2 bare metal stents placed, 81mg ASA at
home stopped 5 days prior to colonoscopy
-Osteoporosis: thought to be secondary to PPIs, on Forteo
injections x 6 months
-BPH
Social History:
Lives in a house, son lives in an apt in the house. Wife died 2
years ago. Retired fire fighter and bus driver. No EtOH, 20p\py
smoking hx quit 30 years ago. No illicits.
Family History:
Older sister had [**Name2 (NI) 499**] CA, deceased age 86. Mother died from ?CA
in her 70s. Father MI, deceased age 65.
Physical Exam:
Vitals: 98.5 P78 150/63 R17 97% RA
General: Pale appearing, 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,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2116-8-28**] 09:30AM BLOOD WBC-11.6* RBC-3.47* Hgb-10.9* Hct-31.6*
MCV-91 MCH-31.5 MCHC-34.5 RDW-13.4 Plt Ct-222
[**2116-8-31**] 06:55AM BLOOD WBC-10.2 RBC-3.15* Hgb-10.0* Hct-28.7*
MCV-91 MCH-31.6 MCHC-34.7 RDW-14.5 Plt Ct-137*
[**2116-8-28**] 09:30AM BLOOD Neuts-70.0 Lymphs-22.7 Monos-5.2 Eos-1.2
Baso-1.0
[**2116-8-31**] 06:55AM BLOOD Glucose-103* UreaN-10 Creat-1.0 Na-141
K-3.8 Cl-105 HCO3-28 AnGap-12
[**2116-8-28**] 11:34PM BLOOD ALT-26 AST-26 LD(LDH)-159 CK(CPK)-221
AlkPhos-38* TotBili-1.2
[**2116-8-31**] 06:55AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.8
CXR: lung volumes remain low. There are no pleural effusions.
Unchanged left pleural calcifications. No pulmonary edema. No
pneumothorax. Moderate cardiomegaly with mild enlargement of
the left ventricle. Moderate tortuosity of the thoracic aorta.
Colonoscopy: A single non-bleeding 2-3 cm ulcer with visible
vessel and fibrin was found in the cecum. Three endoclips were
successfuly applied to the visible vessel and ulcer for the
purpose of hemostasis. Otherwise normal colonoscopy to cecum.
Brief Hospital Course:
Brief Course:
82M with h/o MI s/p polypectomy [**8-26**] presenting with BRPBR x 1
day most likely secondary to his recent polypectomy in setting
of aspirin use. Patient received a total of 5 units PRBCs and IV
fluids and was adequately resuscitated. Colonoscopy was done
with clipping of vessel. He was observed and had no repeat blood
per rectum and a stable hematocrit.
Active Issues:
# BRBPR: The etiology is likely bleeding at site of recent
polypectomry. He did receive 5 u PRBC. He underwent colonscopy
on [**8-29**] that showed an ulcer with visible vessel that wasn't
actively bleeding. 3 clips were placed. HCT was stable after the
procedure. He remained asymptomatic and did not have any
additional blood pre rectum. His aspirin was restarted after
discussion with GI. Diet was advanced to normal. He was given
warning signs and symptoms and has close follow up in his PCPs
office. At the time of discharge his hct was 28.
# Hypoxia: He had a new oxygen requirement. With incentive
spirometry and ambulation he improved with ambulatory O2 sat 95%
on room air.
#CAD: S/p PCI with stent placement [**2105**]. Cardiac enzymes were
negative, EKG did not show acute changes. Restarted aspirin,
atorvastatin, and anti-hypertensives on [**8-30**] after his acute
bleed was stabilized.
Chronic Issues:
#HTN: On 2 agents at home. Initially held antihypertensives
given hemodynamic instability, but restarted home amlodipine and
metoprolol on [**8-30**].
#Osteoporosis: Continue home Forteo
Transitional Care Issues:
1. Code: Full code given acute illness (previously DNR/DNI) =
should be clarified as an outpatient whether he wants to remain
full code or return to DNR/I status.
2. follow hct and O2 levels as an outpatient
Medications on Admission:
. Information was obtained from .
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Forteo *NF* (teriparatide) 20 mcg/dose - 600 mcg/2.4 mL
Subcutaneous [**Hospital1 **]
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Forteo *NF* (teriparatide) 20 mcg/dose - 600 mcg/2.4 mL
Subcutaneous [**Hospital1 **]
6. Tamsulosin 0.4 mg PO HS
7. Metoprolol Tartrate 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: lower gastrointestinal tract bleeding from ulceration
in cecum, acute blood loss anemia
Secondary: colonic adenomas, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You came to the hospital with bleeding from your
gastrointestinal tract. You were admitted to the ICU for close
monitoring, and received a transfusion of 5 units of red blood
cells. You were seen by the gastroenterology doctors, and
underwent a colonoscopy on [**2116-8-29**]. They saw an ulceration in
part of your [**Date Range 499**], and placed 3 clips over a blood vessel in
the ulcer. There were no signs of active bleeding, or other
areas of bleeding. You tolerated the procedure well. Your
blood counts remained stable, and you are now stable for
discharge to home.
You also had some low oxygen sats while you were here. These
resolved with taking deep breaths. There was no evidence of
infection of fluid on your lungs. At the time of discharge you
were saturating well on room air.
It is very important that you follow-up with your primary care
doctor later this week. You should also have your blood count
rechecked this week as well.
Followup Instructions:
Name: NP [**First Name5 (NamePattern1) 1494**] [**Last Name (NamePattern1) 94688**]
Location: NORTHSHORE PRIMARY CARE
Address: [**Apartment Address(1) 94689**], [**Location (un) **],[**Numeric Identifier 41397**]
Phone: [**Telephone/Fax (1) 61159**]
Appointment: Friday [**2116-9-4**] 10:45am
|
[
"998.11",
"569.82",
"412",
"733.09",
"V45.82",
"V12.72",
"E879.8",
"E943.0",
"V58.66",
"578.9",
"285.1",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
6868, 6874
|
4492, 4866
|
311, 406
|
7069, 7069
|
3407, 4469
|
8232, 8528
|
2729, 2851
|
6577, 6845
|
6895, 7048
|
6251, 6554
|
7220, 8209
|
2866, 3388
|
2065, 2187
|
266, 273
|
4881, 5785
|
6016, 6225
|
434, 2046
|
7084, 7196
|
5801, 5990
|
2209, 2524
|
2540, 2713
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,383
| 174,600
|
27978
|
Discharge summary
|
report
|
Admission Date: [**2184-5-16**] Discharge Date: [**2184-5-21**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
80 F fall from wheelchair. PMH of Multiple sclerosis, GCS 3T
on arrival in ED
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 y/o F with long history of MS [**First Name (Titles) **] [**Last Name (Titles) 68122**] was being
pushed in her wheelchair today, seatbelt off and wheels
accidently over top of stairs. Pt. fell from wheelchair and
tumbled about 2 steps onto her head. Pt. with confusion at scene
but no LOC. Pt. intubated in route by EMS without sedation, she
was unresponsive/minimally responsive at scene. In [**Name (NI) **] pt.
initially evaluated w/GCS of 3 however, once in the CT scanner
and after getting IVF the pt. opened eyes spontaneously and
would
localize to voice.
Past Medical History:
Patient has MS. [**Name13 (STitle) **] reports that at baseline she does not move
below the neck and when in a particularly good mood will speak
in full sentences.
Social History:
Husband and two sons at side
Family History:
unknown, NC
Physical Exam:
T: BP: 118/62 HR: 52 R: 18 O2Sats: 100 on vent
Gen: WD/WN, thin, NAD
HEENT: Pupils: ERRL EOMs intact
Neck: in c-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+, ND
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, not cooperative w/exam
Motor: Pt. cannot move below the neck at baseline
Sensation: pt. no responsive at time
Reflexes: B T Br Pa Ac
Right difficult to assess, pt does not relax
Left
Toes downgoing bilaterally
Rectal exam: sphincter tone wnl
Pertinent Results:
[**2184-5-16**] 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2184-5-16**] 04:53PM GLUCOSE-165* LACTATE-2.4* NA+-137 K+-3.7
CL--107 TCO2-21
[**2184-5-16**] 04:50PM CK(CPK)-30 AMYLASE-61
[**2184-5-16**] 04:50PM UREA N-19 CREAT-0.7
[**2184-5-16**] 04:50PM CK-MB-NotDone cTropnT-<0.01
[**2184-5-16**] 04:50PM WBC-4.8 RBC-3.25* HGB-10.7* HCT-29.2* MCV-90
MCH-32.8* MCHC-36.5* RDW-13.2
Brief Hospital Course:
In the ED, CT scans of the cervical spine showed rotary
subluxation of C1 and C2. Pt was admitted to the hospital
DNR/DNI and Neurology was consulted. Pt was admitted intubated
with a C-collar in place. Once in house patient was extubated
and never regained her baseline mental status. Pt did not
receive code level care per the family's wishes. On HD#6 she
expired and was pronounced
Medications on Admission:
ASA
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2184-6-18**]
|
[
"344.00",
"518.5",
"584.9",
"E884.3",
"427.5",
"340",
"276.2",
"486",
"599.0",
"806.00",
"873.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
2714, 2723
|
2242, 2632
|
340, 346
|
2775, 2785
|
1754, 2219
|
2837, 2871
|
1192, 1205
|
2686, 2691
|
2744, 2754
|
2658, 2663
|
2809, 2814
|
1220, 1457
|
221, 302
|
374, 942
|
1472, 1735
|
964, 1130
|
1146, 1176
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,702
| 162,453
|
34902
|
Discharge summary
|
report
|
Admission Date: [**2159-12-11**] Discharge Date: [**2159-12-20**]
Date of Birth: [**2099-5-25**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
expired
History of Present Illness:
60yo with h.o HTN, BL, LVH, CHF recent admitted for SOB/DOE and
elective myocardial biopsy worsening since [**Month (only) 958**]. He was
discharged from [**Hospital1 18**] on Sunday (2 days PTA) and began feeling
SOB shortly after arriving at home. Sunday evening he noted DOE
when walking up a flight of stairs and then Monday he was SOB
all day long. He noted it was worse with laying flat. He called
Cardiology here and was instructed to take an extra dose of
torsemide 20mg. That medication did help his symptoms briefly
but he continued to feel very short of breath and presented to
the ED at [**Hospital1 11485**]. He got lasix there and was transferred here.
He reports a mild cough for the past 3 weeks. He states that it
is productive of yellow sputum in the morning. He denies fevers,
chills, wheezing, chest pain, chest pressure, palpitations,
worsening edema. He does report some dizziness on occasion but
states it is not postural. He denies a sensation that the room
is spinning and he denies feeling faint. He reports that he did
faint approximately 3 weeks ago prior to his last admission. He
denies any dietary indiscretion. pt reports [**12-14**] lb weight gain
since discharge.
Recent w/u included thoracentesis of R.sided pleural effusion
with 500cc of transudative fluid, stress echo, TTE, MRI showing
thickening of LV and subendocardium suggestive of amyloidosis.
He was started on high dose steroids and underwent cardiac cath
with myocardial biopsy which was positive for amyloid.
Per BMT notes, the patient was started on chemotx for Multiple
mylema/amyloid. He was scheduled to get Chemotx today (valcaid &
decadron). Pt not ICD or cardiac xplant candidate 2/2 MM. Pt
wished to be DNR/DNI during last admission.
.
In the ED, his vitals signs were as follows: 96.8 74 105/86 18
98% 2L. He was given aspirin 325mg. His Trop at OSH 0.39; he has
CRI. The ED reported EKG changes STE in V3.
ROS: positive for tongue pain r/t canker sore and mild swelling.
positive for poor appetite and 20 lb weight loss over past 5
months.
negative for nausea vomiting, abdominal pain, brbpr, diarrhea,
constiption, dysuria, hematuria, joint pain or muscle aches.
Past Medical History:
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, +Hypertension
.
Other Past History:
Acute on chronic diastolic heart failure (EF 40%)
Hypertension
Hyperlipidemia
Left ventricular hypertrophy
Moderate mitral regurgitation
Multiple myeloma
Amyloid - cardiac amyloid
Social History:
married with 2 step-children. pt is a financial consultant.
previous tobacco use 15 PY hx, quit 30 years ago. no EtOh in 2
months. previous 2 beers/night. no IV drugs
Family History:
Father with stroke.
Physical Exam:
VITAL SIGNS - Temp 95 axillary, HR 73, BP 108/80 mmHg, RR 20,
SpO2 99% on 1L.
Gen: WDWN middle aged male in NAD. Oriented x3. Mood seems
depressed, with restricted affect
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. OP with mmm, no erythema. Small 4mm shallow ulceration on
left side of tongue
Neck: Supple with JVP of 13 cm. no LAD
CV: RRR, normal S1, S2. No m/r/g. No thrills, lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, CTAB, no crackles, wheezes or rhonchi.
Abd: + scar on abdomen. Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin: No rashes.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2159-12-11**] 08:08AM WBC-7.1 RBC-5.65 HGB-18.2* HCT-51.6 MCV-91
MCH-32.2* MCHC-35.3* RDW-15.5
[**2159-12-11**] 08:08AM NEUTS-76.2* LYMPHS-13.3* MONOS-10.1 EOS-0.3
BASOS-0.1
[**2159-12-11**] 08:08AM PLT COUNT-242
[**2159-12-11**] 08:08AM PT-16.1* PTT-27.0 INR(PT)-1.4*
[**2159-12-11**] 08:08AM GLUCOSE-130* UREA N-80* CREAT-2.2*
SODIUM-128* POTASSIUM-3.8 CHLORIDE-85* TOTAL CO2-28 ANION GAP-19
[**2159-12-11**] 08:08AM cTropnT-0.43*
[**2159-12-11**] 08:08AM CK-MB-7 proBNP-[**Numeric Identifier 79877**]*
[**2159-12-11**] 08:08AM CALCIUM-10.8* PHOSPHATE-5.3* MAGNESIUM-2.6
.
CARDIAC ECHO ([**12-18**]):
There is severe symmetric left ventricular hypertrophy. There is
moderate global left ventricular hypokinesis (LVEF = 30-40 %).
The right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with severe global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
supporting structures of the tricuspid valve are
thickened/fibrotic. There is borderline pulmonary artery
systolic hypertension. The pulmonic valve leaflets are
thickened. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2159-11-27**], right ventricular contractile function is
significantly further reduced.
.
Head CT: ([**12/2159**])
IMPRESSIONS:
1. No evidence of hemorrhage.
2. Prominence of the ventricles out of proportion to sulcal
prominence raises
possibility of noncommunicating hydrocephalus.
.
CArdiac Cath: ([**12/2159**])
COMMENTS:
1. Resting hemodynamics demonstrated markedly elevated right
(RVEDP
21mmHg) and left sided filling pressures (mean PCWP 31 mmHg),
moderate
pulmonary arterial hypertension (56/33/41) and markedly reduced
cardiac
index of 1.2 L/min/m2 (assuming normal O2 consumption). Systemic
arterial pressures were normal.
2. With milrinone infusion up to 0.75mcg/kg/min, cardiac index
increased
to 1.5L/min/m2, with stable pulmonary pressures (54/32/39 mmHg)
and PCWP
(mean 34mmHg).
FINAL DIAGNOSIS:
1. Severe biventricular diastolic and systolic dysfunction.
2. Improved cardiac index but unchanged pulmonary arterial and
wedge
pressures with milrinone.
Brief Hospital Course:
In summary, Mr [**Known lastname 79874**] is a 60-year-old man with amyloid
cardiomyopathy, end-stage diastolic and systolic CHF (EF 20% [**Month (only) **]
[**2158**]) and newly diagnosed multiple myeloma, s/p bortezimib and
dexamethasone, admitted to the hospital w CHF flare in the
setting of fluid retention [**1-14**] chemotx. Pt was transferred to
the CCU with severe dyspnea/hypoxemia for diuresis w milrinone
support.
.
# Dyspnea/Pump: end-stage combined systolic/diastolic CHF [**1-14**]
severe restrictive cardiomyopathy from amyloidosis. S/p right
heart cath [**2158-12-16**], which showed improved CI on milrinone trial.
Transferred to CCU for milrinone gtt and furosemide gtt
treatment with minimal response. Pt and family expressed their
wish to discontinue treatment and pursue comfort measures only.
.
#. CAD: No known CAD & recent cath with clean coronaries.
Troponin elevated in setting of CRI.
.
# Pneumonia: LLL opacity on CXR on [**2158-12-14**]. Levofloxacin 5-day
course completed.
.
# Multiple myeloma: recently diagnosed, followed by heme/onc.
Received chemotx [**2159-12-14**] with reduced dose of decadron.
Allopurinol and melphalan initiated along w supportive measures.
.
# Psych - depression/adjustment disorder [**1-14**] medical illness.
Very flat affect.
On citalopram 20mg daily.
.
# Acute Renal failure [**1-14**] end-stage CHF. Elevated Cr: Cr 2.2,
unclear baseline (? 1.4). Likely from prenal azotemia secondary
to heart failure as well as concurrent furosemide therapy.
Medications on Admission:
Torsemide 20mg per day
Toprol-XL 100 mg per day
Allopurinol 150mg per day
Zolpidem 5-10mg QHS
Docusate 100mg [**Hospital1 **]
Senna 1-2 tabs [**Hospital1 **]
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
Pt was admitted to the CCU in end-stage diastolic heart failure,
was treated with milrinone and lasix drips with minimal success.
Pt decided to stop treatments and receive comfort measures only.
Pt died of respiratory failure on [**12-21**]/9 @ 15:20.
Followup Instructions:
expired
Completed by:[**2159-12-20**]
|
[
"486",
"112.0",
"584.9",
"428.40",
"585.9",
"428.0",
"425.7",
"277.39",
"403.90",
"424.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
7999, 8008
|
6249, 7758
|
301, 311
|
8060, 8070
|
3741, 5345
|
8370, 8410
|
3001, 3022
|
7967, 7976
|
8029, 8039
|
7784, 7944
|
6069, 6226
|
8094, 8347
|
3037, 3722
|
242, 263
|
339, 2513
|
5354, 6052
|
2535, 2801
|
2817, 2985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,654
| 159,434
|
38147
|
Discharge summary
|
report
|
Admission Date: [**2184-9-23**] Discharge Date: [**2184-9-29**]
Date of Birth: [**2102-11-15**] Sex: F
Service: MEDICINE
Allergies:
Hydrocodone Bit / Oxycodone Hcl / Amlodipine Besylate /
Oxycodone Terephthalate / Tolterodine Tartrate / Solifenacin /
Codeine
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 81 year old female with history of CAD s/p CABG x
4, a. fib, and recent open AAA repair with post-op course
complicated by stroke and a. fib transferred from OSH with
worsening hypoxemia. Patient also developed post-operative
dysphagia, and required a PEG tube placement. She was then
transferred to [**Hospital 5130**] Rehab on [**2184-9-18**]. On [**2184-9-22**], the
patient developed sudden onset of shortness of breath, and was
transferred to an OSH for evaluation. At the OSH, she was
evaluated managed for myocardial ischemia. She also received
coverage for an aspiration event with pip/tazo and vanc. She
was then transferred directly to [**Hospital1 18**] ICU for further
management earlier this evening.
.
Upon arrival to the ICU, the patient was complaining of crampy
abdominal pain, which has been going on for weeks. She denies
chest pain/pressure, dyspnea, fevers/chills. Remainder of ROS
as noted below.
Past Medical History:
PAST MEDICAL HISTORY:
- hyperlipidemia
- hypertension
- CAD, s/p CABG x 4
- carotid disease, s/p left CEA
- AAA, s/p repair
- Right frontal lobe infarct
- dementia
- T12 compression fx, s/p kyphoplasty
- right shoulder fracture
- CKD, s/p HD in setting of atheroembolic disease in [**2175**]
- Right renal cyst
- GERD
- overactive bladder
- UTIs
- Raynauds
- Gout
- Hypothyroidism
- uses O2 at night
PAST SURGICAL HISTORY
- Left CEA, [**2173**] - complicated by severed left hypoglossal nerve
- CABG x 4 in [**2175**]
- kidney shunt [**2175**], [**2176**]
- Hysterectomy
- kyphoplasty [**6-/2184**]
- appendectomy
- bladder suspension
Social History:
- married for > 50 years
- had six children (one son deceased - had CP and died from
pneumonia in setting of hamstring surgery)
- retired telephone operator
- She has a 60 pk/yr tobacco history and quit 10 years ago
- Daughter, [**Name (NI) **], is her HCP
Family History:
Noncontributory
Physical Exam:
VS: 174/76 HR 80s 95% on 100% NRB and 6 liters n/c
GA: AOx2 (not date), NAD, no work of breathing
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: diffuse bilateral rales, good air movement
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. well
healed midline scar. PEG tube in place
Extremities: wwp, no edema. DPs, PTs 2+.
Skin:
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
Pertinent Results:
MICRO:
.
[**2184-9-24**] Urine
[**2184-9-24**] CXR:
1. New severe pulmonary edema.
2. Moderate cardiomegaly, unchanged.
.
[**2184-9-25**] CT Torso:
1. Patchy consolidations with diffuse ground-glass opacities
occupying the
entirety of both lungs, compatible with multifocal pneumonia in
the setting of waxing and [**Doctor Last Name 688**] pulmonary edema. Reticular
appearance may have some contribution from interstitial lung
disease as well. Reactive mediastinal lymphadenopathy is
present.
In this acute setting, underlying interestitial lung disease
cannot be
evaluated. Assessment for interstitial lung disease via HRCT
could be
performed after resolution of acute medical issues.
2. Status post gastrostomy tube placement.
3. Stable post-AAA repair.
4. A focal area of fat stranding in the omentum deep to a
subcutaneous and
skin surgical change may represent postsurgical change
inflammation or a small area of omental infarct.
5. Multiple hemorrhagic renal cysts, unchanged.
Brief Hospital Course:
81 year old female with [**Hospital 23789**] transferred from OSH directly to ICU
for worsening hypoxemia.
.
# Hypoxemic respiratory failure: Patient's oxygen requirement of
6L NC with simultaneous 100% face mask remained unchanged.
Patient appears to have multifactorial etiology. Prior imaging
shows evidence of underlying interstitial lung disease. Her
baseline poor pulmonary status was exacerbated by her smoking
history, recent aspiration pneumonia, and subsequent ARDS. She
showed no improvement to nearly 72 hours high dose steroids and
aggressive diuresis. She was treated with 5 days of broad
spectrum antibiotics without improvement. Due to her lack of
improvement a family meeting was held to discuss goals of care.
The family stressed the importance of her returning home and
felt that without any additional options for therapeutic
interventions that they would prefer to focus on comfort
measures at home with the help of Hospice. Hospice was
contact[**Name (NI) **] and accepted patient. Hospice will provide all
medications for symptomatic management.
.
# CAD: Patient with known CAD. She denied chest pain. ECG was
without ischemic changes. She was continued on aspirin and
statin during her admission. These medications were discontinued
after decision to pursue comfort measures only.
.
# Atrial fibrillation: Patient with history of atrial
fibrillation in the post op setting. She was in sinus rhythm on
presentation and remained in sinus rhythm throughout
hospitalization. Due to concern that her worsening lung
function might be related to her amiodarone use this medication
was discontinued. She was continued on metoprolol for rate
control and anticoagulation during admission until the decision
was made to pursue comfort measures only.
.
# HTN: Blood pressure only mildly elevated. Hydralazine was
discontinued and she was continued on metoprolol until the
decision was made to pursue comfort measures only.
.
.
# Renal insufficiency: Creatinine near baseline of 1.8 on
admission.
.
#FEN: NPO, tube feeds and meds via PEJ
.
#PPX: no PPI, bowel regimen, INR therapeutic on coumadin during
admission
#Code: DNR/DNI transition to comfort measures only
#Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter and HCP) [**Telephone/Fax (1) 85106**]
#Dispo: HOME with hospice
Medications on Admission:
Medications at Rehab:
Warfarin 2.5 mg daily
Amiodarone 200 mg Tablet daily
Aspirin 81 mg Tablet daily
Ezetimibe 10 mg daily
Simvastatin 40 mg Tablet daily
Allopurinol 100 mg Tablet daily
Levothyroxine 25 mcg Tablet daily
Lansoprazole 30 mg Tablet,Rapid Dissolve, daily
Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID
Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q4H
Polyethylene Glycol 3350 17 gram/dose Powder [**Telephone/Fax (1) **]: One daily
Tramadol 50 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO Q6H (every 6 hours)
Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL)
Vitamin D 1,000 unit Tablet daily
Paroxetine HCl 40 mg Tablet daily
Hydralazine 25 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO every six hours
Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID
Morphine 10 mg/5 mL Solution [**Telephone/Fax (1) **]: 2.5-5 mg/mL PO Q4H PRN
Enoxaparin 300 mg/3 mL Solution [**Hospital1 **]
.
Medications at OSH upon transfer:
Albuterol neb
Allopurinol 100 mg
Amiodarone 200 mg daily
ASA 81 mg daily
Docusate
Ertapenem 500 mg daily
Ezetimibe 10 mg daily
Furosemide 20 mg daily
Ipratroprium neb
Lansoprazole 30 mg daily
Levothyroxine 25 mcg daily
Methylprednisolone 60 mg QID
Metoprolol 25 mg daily
Ondansetron 4 mg Q6H PRN
Paroxetine 40 mg daily
Simvastatin 10 mg daily
Hydralazine 25 mg daily
Vancomycin 1 gram daily
Discharge Medications:
Medications to be provided by Hospice services for symptomatic
relief.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]Hospice
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Respiratory failure. Heart rate and blood pressure stable.
Discharge Instructions:
You were transferred to [**Hospital1 18**] intensive care unit due to
worsening respiratory status. You were found to have aspiration
pneumonia as well as fluid on your lungs in the setting of
underlying lung disease. You were treated aggressively with
antibiotics (to fight infection), diuretics (to remove excess
fluid), and steroids (to reduce inflammation). You did not
respond to these treatments and continued to require very high
levels of supplemental oxygen. After meeting with you and your
family the decision was made to prioritize your comfort and to
discharge you home with the help of Hospice.
Followup Instructions:
Per Hospice Care
|
[
"244.9",
"403.90",
"274.9",
"530.81",
"585.9",
"443.0",
"276.0",
"V45.81",
"427.31",
"507.0",
"414.01",
"272.4",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7977, 8031
|
4073, 6422
|
408, 414
|
8095, 8156
|
3063, 4050
|
8815, 8835
|
2334, 2351
|
7882, 7954
|
8052, 8074
|
6449, 7859
|
8180, 8792
|
2366, 3044
|
349, 370
|
442, 1384
|
1428, 2043
|
2059, 2318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,825
| 199,925
|
52148
|
Discharge summary
|
report
|
Admission Date: [**2140-2-10**] Discharge Date: [**2140-2-21**]
Date of Birth: [**2054-4-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85M with a pmh of bronchiectasis, HTN, a-fib, s/p CVA, and
neurofibromatosis with a history of aspiration in the past who
presents from [**Hospital1 **] with hypoxia and tachypnea. He was feeling
unwell, with general malaise and low grade temps and became
short of breath, particularly with activity. He has been there
for months for rehab after his stroke in 11/[**2138**]. Found with O2
sat on room air in 80s. He was given a neb and brought in. He
was put on NRB mask on his way in and was satting 97% on
arrival. He denied cough any CP or SOB, cough, chills,
palpitations.
In the ED, initial vs were: T 100.6 P 85 BP 127/50 R 30 O2 97%
sat on NRB. Patient was placed on NRB and was administered
Vancomycin 1g IV x1, Zosyn 4.5g IV x1, and 10mg IV lasix. CXR
was consistent with pulmonary edema. On transfer VS were T 98.8,
P 78, BP 121/58, RR 16, 100% on NRB.
On the floor, Pt is comfortable, tachypneic, ROS revealed: He
denies fever, chills, CP/palps, nausea, vomiting, diarrhea,
dysuria, myalgias, PND, orthopnea and LE edema. He admits to
constipation, malaise, frequency of urination, and low grade
temp. All other review of systems negative.
Past Medical History:
- ischemic stroke, [**10/2139**]
- Hypertension
- Atrial fibrillation on Coumadin
- Neurofibromatosis 1
- Bronchiectasis secondary to mycobacterium avium intracellulare
([**Doctor First Name **]) infection, followed by pulmonology. PFTs [**6-8**] showed FVC
2.55 (68% pred), FEV1 2.36 (99% pred).
- Sleep-disordered breathing diagnosed in [**8-/2130**] (RDI 49.3,
oxygen nadir 88%) with obstruction as well as a pattern of
central breathing with possible [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations. Not
on CPAP.
- h/o left hemifacial spasms and droop, has received Botox
injections
- h/o left upper lid ptosis
- Melanoma excision for left ear [**2131**]
- Unilateral kidney: s/p nephrectomy for non-functioning kidney
[**2080**]
Social History:
Has been at [**Hospital1 599**] since his stroke for rehab. He lives with his
wife prior to rehab. His son lives nearby, and he is also in
frequent contact with his daughter. [**Name (NI) **] is an electrician by
trade, was working until recently, and still does supervisory
work.
- Tobacco: He formerly smoked cigarettes/cigars/pipes,
but quit 15 years ago
- Alcohol: Denies
- Illicits: Denies
Family History:
Son also with neurofibromatosis
DM and MI
Physical Exam:
Vitals: T: 99.4 BP: 111/62 P: 92 R: 14 O2: 98% on NRB
General: Alert, oriented, mild distress
HEENT: Sclera anicteric, MMM, NRB in place, left ptosis
Neck: supple, JVP not elevated, no LAD
Lungs: Mild respiratory discomfort, tachypneic, bibasilar
crackels, otherwise clear, no wheezes, rales, ronchi
CV: Normal rate, regular rhythm, II/VI holosystolic harsh
ejection murmur at the RLSB, no appreciable rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Skin: Innumerable fibromas covering his entire body with some
trunkal sparing
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, left sided ptosis
Pertinent Results:
Admission labs:
[**2140-2-10**] 05:00PM BLOOD WBC-17.5* RBC-3.75* Hgb-12.1* Hct-35.2*
MCV-94 MCH-32.4* MCHC-34.5 RDW-14.0 Plt Ct-279
[**2140-2-10**] 05:00PM BLOOD Neuts-87.9* Lymphs-7.4* Monos-2.8 Eos-1.5
Baso-0.4
[**2140-2-10**] 05:25PM BLOOD PT-34.8* PTT-27.0 INR(PT)-3.5*
[**2140-2-10**] 05:25PM BLOOD Glucose-132* UreaN-34* Creat-1.3* Na-137
K-4.7 Cl-103 HCO3-27 AnGap-12
[**2140-2-10**] 11:10PM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
[**2140-2-10**] 05:32PM BLOOD Lactate-1.7 K-4.8
Cardiac Biomarkers:
[**2140-2-10**] 05:25PM BLOOD proBNP-1432*
[**2140-2-11**] 06:04AM BLOOD CK-MB-2 cTropnT-0.01
[**2140-2-10**] 11:10PM BLOOD CK-MB-2 cTropnT-<0.01
[**2140-2-10**] 05:25PM BLOOD cTropnT-<0.01
Transfer labs:
[**2140-2-12**] 05:18AM BLOOD WBC-18.1* RBC-3.90* Hgb-12.2* Hct-34.1*
MCV-88 MCH-31.3 MCHC-35.7* RDW-13.5 Plt Ct-243
[**2140-2-12**] 05:18AM BLOOD PT-26.2* PTT-34.4 INR(PT)-2.5*
[**2140-2-12**] 05:18AM BLOOD Glucose-117* UreaN-27* Creat-1.3* Na-135
K-4.2 Cl-101 HCO3-24 AnGap-14
[**2140-2-12**] 05:18AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0
Imaging:
Portable TTE (Complete) Done [**2140-2-11**] at 9:24:02 AM FINAL
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal to borderline -hyperdynamic (LVEF >70%). There is a mild
resting left ventricular outflow tract obstruction. 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.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output and increased
stroke volume due to aortic regurgitation. Mild to moderate
([**12-6**]+) aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Increased transaortic velocity secondary to
high output and increased stroke volume, not aortic stenosis.
Mild to moderate aortic regurgitation. Mild mitral
regurgitation. Indeterminate pulmonary artery systolic pressure.
Compared with the report of the prior study (images unavailable
for review) of [**2133-1-15**], the left ventricular systolic function
is now borderline hyperdynamic. The severity of aortic
regurgitation has increased minimally. The transaortic valvular
velocity was not previously commented upon.
CHEST (PORTABLE AP) Study Date of [**2140-2-10**] 5:00 PM
FINDINGS: There are low lung volumes when compared with prior
and increasing bibasilar opacities. The heart size is top
normal. The mediastinal contours are normal. There is
indistinctness of the pulmonary vasculature, increased compared
with prior. There is no large pleural effusion or pneumothorax.
IMPRESSION: Lower lung volumes with indistinct pulmonary
vasculature consistent with mild pulmonary edema.
.
CXR [**2-12**]-
FINDINGS: As compared to the previous radiograph, there is no
relevant change as to the massive bilateral diffuse parenchymal
opacities, right more than left. No opacities have newly
occurred. Borderline size of the cardiac silhouette. No larger
pleural effusions. No evidence of pneumothorax.
.
EKG-[**Known lastname **],[**Known firstname 1955**] H [**Medical Record Number 107892**] M 85 [**2054-4-24**]
Cardiology Report ECG Study Date of [**2140-2-10**] 5:07:14 PM
Sinus rhythm with first degree atrio-ventricular conduction
delay. Left axis deviation. Left anterior fascicular block.
Compared to the previous tracing of [**2140-1-1**] heart rate is
slower. Otherwise, multiple abnormalities as previously noted
persist without major change.
.
Microbiology:
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2140-2-11**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2140-2-11**]):
Negative for Influenza B.
Blood Culture, Routine (Preliminary): GRAM POSITIVE
COCCUS(COCCI). IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2140-2-11**]): GRAM POSITIVE COCCI
IN CLUSTERS.
Video swallow ([**2140-2-15**]): VIDEO OROPHARYNGEAL SWALLOW: The study
was conducted in collaboration with speech pathology. Various
consistencies of barium were administered by mouth including
thin, nectar, honey, ground, and puree. There is silent
aspiration with thin and nectar consistency. There is a small
amount of penetration or residuals seen with honey consistency.
There is no penetration or aspiration seen with ground or puree
consistency. There is a moderate amount of residue within the
valleculae and piriform sinuses. This cleared with subsequent
dry
swallows. IMPRESSION: Silent aspiration with thin and nectar
consistency. Moderate residue in the valleculae and piriform
sinuses.
Brief Hospital Course:
85M with a pmh of bronchiectasis, HTN, a-fib (on warfarin), s/p
CVA, and neurofibromatosis who presents with hypoxia and
tachypnea requiring NRB for ventilation and ICU stay through
[**2-12**] for hypoxemia. Never hypotensive. Was not intubated.
.
# Hypoxemia-multifactorial, but most likely initiated by
aspiration pneumonia. He was treated on an 8-day course of
vancomycin, cefepime, levofloxacin. He devervesced and improved
clincally. He was ruled out for influenxa. He had some acute
diastolic heart failure with elevated BNP. Initial CXR showed
mild pulmonary edema. He was given IV lasix, and ruled out for
MI (He was contined on metoprolol, ACEi, statin). PE was
considered unlikely in the setting of anticoagulation. Continued
bronchodilators. He was initially ordered an empiric dysphagia
diet. Speech and swallow ordered, and video swallow showed
severe silent aspiration on all liquids, including
honey-thickened. He then was made NPO and arranged for a PEG
tube, which he got on [**2140-2-19**]. Upon discharge, his pulmonary
status was stable, with slowly decreasing WBC and O2 requirement
of 3L.
.
# Aspiration, FEN: See above for aspiration as etiology of
pneumonia. PEG tube was initially tried by IR, but this was
unsuccessful as they did not have an adequate window, as bowel
was overlying his stomach. GI did successfully place the PEG
tube on [**2140-2-19**]. He was then started on tube feeds successfully.
His megace was discontinued once he was made NPO.
.
# Chronic leukocytosis: He has had elevated WBC since at least
[**2132**]. Unclear if that has been worked up. On admission, there
was a left shift with 88% polys, probably due to acute infection
(PNA) currently. 1 bottle of blood cultures from [**2140-2-10**] was
positive for GPCs in clusters - felt to be contaminant.
Treatment for PNA as above. Leukocytosis was trending slowly
down on discharge. If leukocytosis continues or worsens should
consider hematology/oncology consult or further ID w/u.
.
# Paroxysmal A-Fib: Currently in sinus rhythm. On Coumadin at
rehab, however, supratherapeutic INR of 3.5 on admission. Also
received antibiotics in the ED which could have caused further
interaction with coumadin and elevation in INR. Coumadin was
held and INR monitored - goal INR = 2.0 - 3.0. Restarted
coumadin on [**2140-2-12**], which was then held on [**2140-2-16**] as PEG tube
placement was pursued. He was restarted on low-dose coumadin on
[**2140-2-20**], and this may be titrated for goal INR [**1-7**].
.
# CKD II - GFR 52 on adm. Creat improved at 1.2. Cause of renal
failure unclear. [**Name2 (NI) **] had episodic ARF with creat as high as 1.6.
Likely due to infection, poor PO intake. His Creatinine was
mostly stable for several days prior to discharge.
.
# Urinary incontinence: He had urinary incontinence with stage I
ulcer. He was therefore maintained on a condom cath. He denied
any feelings of retention, bladder fullness, or pain. However,
he may be considered for a bladder scan for possible urinary
retention with overflow; if he does have retention, you may
consider flomax.
.
# HTN: continued on metoprolol
.
# DVT PPX-on coumadin and therapeutic
.
# Code: Full (discussed with patient on multiple occasions,
including on [**2140-2-12**] upon transfer to floor)
.
# Prophylaxis: anticoagulated with coumadin
# Access: peripheral IV x 2
# Communication: Patient, Wife [**Name (NI) 794**] ([**Telephone/Fax (1) 107893**], [**Name2 (NI) **]ter
[**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 107894**], Son [**Name (NI) 401**] ([**Telephone/Fax (1) 107895**]
# Code: Full (discussed with patient on multiple occasions,
including on [**2140-2-12**] upon transfer to floor). He was briefly
considered for DNR/DNI in the setting of severe aspiration, but
upon long discussion with him and his family, he opted for PEG
tube.
Medications on Admission:
1. atenolol 25 mg PO DAILY (Daily).
2. simvastatin 10 mg PO DAILY
3. fluticasone 50 mcg/Actuation Spray 1 spray [**Hospital1 **]
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) PO BID
5. trazodone 25 mg PO HS as needed for insomnia
6. acetaminophen 325 mg, 1-2 tabs PO Q6H prn pain, fever
7. calcium carbonate 200 mg (500 mg) PO BID
8. sodium chloride Nasal Spray [**12-6**] TID as needed for irritation.
9. Megace Oral 400 mg/10 mL (40 mg/mL) PO twice a day.
11. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. warfarin 4 mg PO 2X/WEEK (MO,FR).
13. warfarin 2 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA).
14. lactobacillus acidoph & bulgar 1 million cell Tablet PO BID
15. budesonide 0.5 mg/2 mL One neb twice a day prn for SOB or
wheezing.
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please give NG.
2. fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
Inhalation twice a day.
3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia: please give NG.
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day): NG.
5. citalopram 10 mg/5 mL Solution Sig: One (1) PO DAILY
(Daily): NG.
6. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) Inhalation twice a day as needed for shortness of breath or
wheezing.
7. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-6**] Sprays Nasal
TID (3 times a day) as needed for irritation.
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: NG.
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): NG. Tablet(s)
11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): please give NG if NPO.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation: NG.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: NG.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
acute bacterial aspiration pneumonia
atrial fibrillation
bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity status: Ambulatory with assist, needing physical
therapy
Discharge Instructions:
You were admitted from your rehab facility with shortness of
breath and found to have pneumonia. For this, you were initially
treated in the ICU. You were started on antibiotics. Your
symptoms improved slowly. You required 3 liters of oxygen upon
discharge. You had a speech and swallow test which showed severe
aspiration on all types of liquids, including honey-thickened.
You then were not allowed to eat anything by mouth, and we
placed a feeding tube. You will continue to get your nutrition
through your feeding tube, and you should have a repeat speech
and swallow evaluation once your pneumonia is resolved.
.
Medication changes:
1.stopped megace
2.medications for constipation if needed
3.decreased warfarin to 1 mg daily, this may need to be
increased for goal INR [**1-7**]
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please have your rehab facility call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4559**]
[**Last Name (NamePattern1) 58**] at [**Telephone/Fax (1) 107896**] after discharge.
.
Department: BIDHC [**Location (un) **]
When: TUESDAY [**2140-2-23**] at 2:00 PM
|
[
"V45.73",
"V58.61",
"403.90",
"288.60",
"707.03",
"428.0",
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"482.9",
"787.21",
"428.31",
"787.23",
"494.0",
"V85.0",
"427.31",
"237.71",
"535.50",
"584.9",
"262",
"585.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
14492, 14582
|
8503, 12382
|
314, 320
|
14698, 14698
|
3521, 3521
|
15776, 16063
|
2711, 2755
|
13202, 14469
|
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|
12408, 13179
|
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|
2770, 3502
|
7650, 8480
|
15510, 15753
|
266, 276
|
348, 1504
|
3537, 7612
|
14713, 14848
|
1526, 2280
|
2296, 2695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,108
| 117,347
|
23599
|
Discharge summary
|
report
|
Admission Date: [**2194-3-15**] Discharge Date: [**2194-3-15**]
Date of Birth: [**2124-6-30**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
exsanguination
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
69M previously healthy, developed sharp abdominal pain this
morning at gym, and fainted. He was brought to local hospital,
where he was diagnosed with a ruptured AAA & taken to the OR,
where he received an aortic tube graft. Postoperatively, he
developed an increasing pressor requirement & his abdomen became
distended. Concerned for leaking anastomoses, the surgeons at
[**Hospital3 25150**] transferred Mr. [**Known lastname 780**] for further care here
at [**Hospital1 **].
Past Medical History:
none
Social History:
none
Family History:
father died of ruptured AAA at same age
Physical Exam:
Large rpessor requirment to maintain BP
Intubated & sedated
Large distended abdomen
Pertinent Results:
inr 2, hct 26, ck 4350
Brief Hospital Course:
Mr. [**Known lastname 780**] was taken emergently to the OR here, where Dr.
[**Last Name (STitle) **] found approximately 5 liters of clotted blood within his
abdomen upon incision. Almost immediately, CPR was instituted
but Mr. [**Known lastname 780**] could not be resuscitated. Time of death 820pm
Medications on Admission:
none
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
AAA rupture
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2194-3-15**]
|
[
"272.0",
"441.3",
"998.2",
"E878.8",
"274.9",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"37.91",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
1486, 1495
|
1099, 1403
|
310, 316
|
1551, 1560
|
1052, 1076
|
1612, 1647
|
892, 933
|
1458, 1463
|
1516, 1530
|
1429, 1435
|
1584, 1589
|
948, 1033
|
256, 272
|
344, 826
|
848, 854
|
870, 876
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,546
| 175,020
|
37978
|
Discharge summary
|
report
|
Admission Date: [**2146-9-14**] Discharge Date: [**2146-10-28**]
Date of Birth: [**2076-11-26**] Sex: M
Service: SURGERY
Allergies:
Percodan / Codeine / Atorvastatin / Tramadol / Readi-Cat /
Flagyl
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatitis and pseudocyst
Major Surgical or Invasive Procedure:
[**2146-9-14**]:
1. ERCP
[**2146-9-20**]:
1. Open pancreatic necrosectomy and peripancreatic abscess
drainage.
2. Open cholecystectomy with fluoroscopic intraoperative
cholangiography.
3. An 18-French Malecot gastrostomy tube.
4. Feeding jejunostomy tube - 12-French whistle-tip.
[**2146-10-4**]:
1. PTC placement
[**2146-10-17**]:
1. PTC exchange
[**2146-10-19**]:
1. PTC exchange and upsizing
[**2146-10-21**]:
1. Aborted thoracentesis of the right side.
2. Right video-assisted thoracic surgery decortication of
loculated right pleural effusion.
History of Present Illness:
69year old male with complaint of 6 weeks of abdominal pain with
multiple admissions to [**Hospital3 13313**] for pancreatitis.
Has experienced a 37 pound weight loss over this time. Over
this course, amylase has returned to [**Location 213**] following an initial
amylase of 2640. The patient reports doing well when kept NPO,
but the recurrence of sharp abdominal pain with PO intake. Pain
is described as diffusely epigastric, sharp, constant at a [**5-22**],
made worse with PO intake, relieved with narcotic pain meds,
non-radiating. Patient also reports moderate nausea relieved
with Zofran.
Past Medical History:
1. HTN
2. COPD (PFTs in [**6-21**]: FEV1 75% predicted, moderate restrictive
disease, significant response to bronchodilatator)
3. "silent" MI years ago (negative stress test in [**2137**])
4. hypertriglyceridemia
5. legally blind secondary to degenerative visual condition
6. chronic back pain
Social History:
Married. Retired carpenter. Smoked 1 PPD x 45 years; quit in the
[**2127**]. Rare alcohol. No illicits.
Family History:
Father died in his 70s from an MI. Mother lived to her 90s and
died from unclear causes.
Physical Exam:
On Admission:
AVSS/afebrile.
Gen: In NAD.
HEENT: Legally blind. Sclerae anicteric. O-P clear.
CV: RRR; s1s2+
Chest: CTA(B).
Abd: BSx4. Obese, soft, NT, non-rigid. G-J tube in place.
Ext: 1+ ankle edema
NEURO: A+Ox3.
.
At Discharge:
AVSS/afebrile
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **]. No JVD.
LUNGS: Posterior apical and basal chest tubes to [**Doctor First Name 84856**].
Prior CT site at anterior apical with occlussive dressing.
Slightly decreased BS (R) base, otherwise CTA.
COR: RRR; nl S1/S2 w/o m/c/r.
ABD: (L)UQ G-Tube clamped. (L)LQ J-Tube clamped for transport.
Both patent/intact. (R)[**Name (NI) **] PTC drain capped. Tube insertion sites
c/d/i. Abdominal incision well approximated, healing well OTA.
BSx4. Soft/NT/ND.
EXTREM: Mild ankle edema w/o pitting. No cyanosis, pallor.
NEURO: A+Ox3. Legally blind. Otherwise non-focal/grossly intact.
SKIN: WWP.
Pertinent Results:
On Admission:
[**2146-9-14**] 09:38PM GLUCOSE-105 UREA N-8 CREAT-0.5 SODIUM-134
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-14
[**2146-9-14**] 09:38PM ALT(SGPT)-170* AST(SGOT)-187* ALK PHOS-363*
AMYLASE-37 TOT BILI-2.8*
[**2146-9-14**] 09:38PM LIPASE-33
[**2146-9-14**] 09:38PM CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-1.6
[**2146-9-14**] 09:38PM WBC-10.8 RBC-3.66* HGB-9.5* HCT-29.5* MCV-81*
MCH-26.1* MCHC-32.4 RDW-14.9
[**2146-9-14**] 09:38PM PLT COUNT-398
.
IMAGING:
[**2146-9-17**] CT Abd/Pelvis: pancreatitis, pseudocysts, SMV
thrombosis
[**2146-9-17**] CTA Pancr Abd/Pelvis: confirmed SMV thrombosis on
venous phase
[**2146-9-27**] Upper GI no oral contrast is seen beyond the duodenal
bulb .
[**2146-10-22**] CXR patchy consolidation of the RUL, bigger R pleural
effusion
[**2146-10-22**] CXR: large R pleural effusion, additional loculated
pleural fluid
[**2146-10-23**] CXR: large focal consolidation in the right lower lobe
with loculated pleural effusion and multiple chest tubes on the
right, no appreciable change since prior study.Small L pleural
effusion
[**2146-10-23**] CXR: Dense opacification of the right hemithorax with
three chest tubes on the right. The loculated right-sided
pleural effusion appears to be somewhat less dense at the right
periphery and there appears to be mildly improved opacification
of the right lung. Dense effusion at the right lung apex and at
the right lung base. Left lung is relatively clear
[**2146-10-24**] CXR: Right loculated pleural effusion is associated
with small amount of air component, difficult to assess in this
single frontal semi-upright view. This is unchanged from prior.
Right chest tubes remain in place. Cardiomediastinal contour is
unchanged. The left lung is grossly clear besides linear
atelectasis in the base.
[**2146-10-25**] CXR: Substantial right pleural effusion, particularly
basal, persist despite presence of three right pleural tubes,
one at the apex, one along the mediastinum and one coiled at the
right base. Attendant atelectasis is persistent, most severe in
the middle and lower lobes. Left lung clear. Heart size normal.
No endotracheal tube is seen below C7, theupper margin of this
film.
[**2146-10-26**] CXR: The examination is compared to [**2146-10-25**].
The three right-sided chest tubes show an unchanged course and
position. The extent of the lateral pleural opacities have
minimally decreased, the extent of the more medial pleural
opacities are without relevant change. There is no evidence of
pneumothorax. Unchanged blunting of the right costophrenic sinus
suggesting a small pleural effusion. Unchanged opacities along
one of the three chest tubes. The left lung is unremarkable.
[**2146-10-27**] AM CXR: As compared to the previous radiograph, the
position of the right-sided chest tube is unchanged. In the
interval, a minimal decrease of the right pleural fluid has
occurred. The transparency of the right-sided lung parenchyma is
minimally improved. In the left lung, no relevant changes are
seen. No evidence of interval recurrence of focal parenchymal
opacity suggesting pneumonia. No left pleural effusion.
[**2146-10-27**] PM CXR: P....
.
MICROBIOLOGY:
.
[**2146-9-20**] 12:45 pm SWAB PANCREATIC ABSCESS.
**FINAL REPORT [**2146-9-24**]**
GRAM STAIN (Final [**2146-9-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2146-9-23**]):
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 2 S 16 I
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2146-9-24**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
.
[**2146-10-21**] 9:29 pm TISSUE PLEURA RIGHT SIDE.
GRAM STAIN (Final [**2146-10-22**]): 2+ (1-5 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
TISSUE (Preliminary): KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
CITROBACTER FREUNDII COMPLEX. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| CITROBACTER FREUNDII
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S 2 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2146-10-26**]): NO ANAEROBES ISOLATED.
[**2146-9-20**] 12:45 pm SWAB PANCREATIC ABSCESS.
GRAM STAIN (Final [**2146-9-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2146-9-23**]):
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed in MCG/ML
______________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 2 S 16 I
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2146-9-24**]): BACTEROIDES FRAGILIS GROUP.
SPARSE GROWTH. BETA LACTAMASE POSITIVE.
.
MRSA SCREEN (Final [**2146-10-24**]): No MRSA isolated.
Brief Hospital Course:
The patient was admitted to the General Surgical Service [**2146-9-14**]
for further evaluation of pancreatitis and a pseudocyst after
undergoing a failed ERCP. The ERCP demonstrated severe edema of
the distal stomach and bulb causing narrowing with a spontaneous
drainage of pruluent material from the bulb, most likely due to
a large pseudocyst or fluid collection. Unable to pass the ERCP
scope beyond the bulb. He was made NPO, an NG Tube was placed,
started on IV fluid, a foley catheter was placed, and he was
started on IV Unasyn. Routine labwork, CXR, and ECG were
performed. Admission Abdominal/pelvic CT demonstrated findings
consistent with pancreatitis with note a pseudocyst. The study
also showed mild intrahepatic biliary dilation, inflammation of
the duodenum and CBD, as well as raised suspicion for SMV
thrombosis. A PICC line was placed, and TPN was started. A CTA
pancreas protocol was perfomed on [**2146-9-17**], which redemonstrated
pancreatitis with numerous adjacent air and fluid filled
pseudocysts, as well as a filling defect of the upper portion
of the SMV, consistent with SMV thrombosis. There was no
evidence of reactive pseudo-aneurysm formation. The patient was
started on a Heparin infusion, titrated until therapeutic.
.
On On [**2146-9-20**], the patient underwent open pancreatic necrosectomy
and peripancreatic abscess drainage, open cholecystectomy with
fluoroscopic intraoperative cholangiography, and placement of
both a gastrostomy and feeding jejunostomy tubes, which went
well without complication (reader referred to the Operative Note
for details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids
and antibiotics, with a foley catheter, J-Tube and G-Tube to
gravity, a JP drain in place, and a Dilaudid PCA for pain
control. He was continued on IV Unasyn. The patient was
hemodynamically stable. On POD#1, he required multiple IV fluid
boluses totalling 1.5 Liter as well as Metoprolol IV for
tachycardia and low urine output with good response. He
accidentally self-discontinued his NG tube the as well, but did
not require replacement. Otherwise, his initial post-operative
course was unremarkable. Heparin infusion was restarted
post-operatively. He was started on trophic tubefeeds via the
J-tube on POD#6, which were advanced to goal. TPN was continued
until POD#7, then discontinued. He got out of bed with Physical
Therapy. His recovery progressed as expected.
.
On [**2146-10-1**], however, the patient experienced tachycardia,
dyspnea, and BRBPR. A hematocrit was 15.7 down from 28.6 four
days prior. Heparin was stopped. The patient was transferred to
the SICU. He received a total of 5 units of PRBCs, and was
stabilized. Gastroenterology was consulted, recommending holding
heparin, transfuse, continue PPI, and holding off on colonoscopy
as inpatient unless bleeding re-occurs. While in the SICU, the
patient developed parotiditis, which resolved later on the floor
with sucking on [**Doctor Last Name **] drops and [**Last Name (un) **] [**Doctor Last Name 84857**]. Tubefeeds were
restarted toward goal.
.
When hemodynamically stable, the patient was returned to the
floor on [**2146-10-3**]. He experienced increased abdominal pain and
distension, despite venting the G-Tube. Abdominal/pelvic CT
revealed an overall stable appearance of the abdomen and pelvis
with persistent small fluid collection tracking lateral to the
duodenum/posterior to the pancreatic head and small probable
hepatic subcapsular fluid collection. On [**2146-10-4**], the patient
underwent PTC drainage of the perihepatic fluid collection with
drainage catheter placed to gravity. Given history of GIB on
Heparin infusion, it was determined to start subcutaneous
heparin prophylaxis only. At this point, his recovery again
progressed. Foley catheter was discontinued. Staples were
removed with steri-strips placed. G-tube was clamped. Tubefeeds
continued via the J-Tube at goal. The patient continued to work
with Physical Therapy. On [**2146-10-7**], the PTC was capped, but then
later uncapped and G-Tube vented for abdominal pain, nausea and
dyspnea. Tubefeeds were held overnight. By [**2146-10-13**], he was able
to tolerate a clamped G-tube, capped PTC, J-tube feeds, and
sips. The PICC was discontinued on [**2146-10-9**] and the tip sent for
culture for a temperature spike. IV Vancomycin was added to
Unasyn. PICC tip culture was negative.
.
On [**2146-10-17**], the patient underwent IR cholangiogram demonstrating
a stricture of the distal common bile duct, but no signs of bile
leak. The pigtail drain was replaced with a new drain of the
same size for better bile drainage, as the patient did not
tolerate upsizing of the drain at that time. The day after the
procedure, he was restarted on tubefeeds, clear liquids, and the
PTC was capped, which he tolerated. He was also started on IV
Reglan to improve his GI motility. On [**2146-10-19**], he underwent PTC
evaluation in IR, which demonstrated no evidence of ductal
dilatation, again with long area of narrowing in the lower CBD
likely related to mass effect from edema. The PTC this time was
successfully upsized to a 10 French drain. Tubefeedings and diet
were restarted, and the PTC subsequently capped. IV Vancomycin
and Unasyn were discontinued, and discharge planning underway.
.
On [**2146-10-20**], the patient again experienced abdominal pain and
nausea, as well as dyspnea and increased oxygen demand. CXR
revealed a marked increase in the extent of the pre-existing
right pleural effusion, with the effusion occupying about
one-half of the right hemithorax. Also, signs of fluid overload.
Chest CT demonstrated a large multiloculated right pleural
effusion, compressive atelectasis and patchy ground-glass
opacities. On [**2146-10-21**], the patient initially underwent an
unsuccessful thoracentesis attempt of the right side, followed
by a successful right video-assisted thoracic surgery (VATS)
decortication of loculated right pleural effusion (See Operative
Notes for full details). Three chest tubes were placed; anterior
apical, posterior apical, and basilar chest tubes to suction.
The patient was subsequently admitted to the SICU.
.
SICU Course:
Tranferred to SICU for increased WOB. A-line placed. Lasix x2
given with good diuresis. Self-resolved V-tach Approx. 5sec x2,
asymptomatic. Rate controlled.
[**2146-10-23**]: Restarted tubefeeds via J-tube, PCA for pain with good
effect, CXR for this afternoon. Tachycardia responsive to extra
doses of metoprolol. Increased dosing to Q4 hrs. Antibiotic
discontinued. PTC drain clamped. PVC's, repleting electrolytes.
Pleural effusion growing GPR per initial report; Infectious
Disease consulted. Most likely a contaminate. Suggest Flagyl to
cover clostridium if he gets worse or spikes a temperature.
[**2146-10-24**]: Pleural effusions growing GNR (correction from GPR
stated previously), started on Ciprofloxacin. Tachypneic
overnight, ABG 7.41/51/107, CXR stable.
.
On [**2146-10-25**], the patient was transferred back to the inpatient
floor. He was tolerating a full liquid diet PO and tubefeeds at
goal via the J-tube, the G-tube was clamped, PTC drain was
capped, and he had three chest tubes in place 10 15cm suction,
an anterior apical, posterior apical, and basal. He was voiding
without assistance, and ambulating well with assistance due to
legal blind status, and not weakness. He was continued on
Ciprofloxacin. Also, he continued to receive Lasix approximately
every other day for gentle diuresis. On [**2146-10-26**], the culture of
the pleural tissue returned with pan-sensitive Klebsiella
pneumoniae and Citrobacter freundii complex; Flagyl was added to
Cipro for more comprehensive gram negative coverage. All three
chest tubes were placed to water seal, which he tolerated. On
[**2146-10-27**], a CXR revealed a minimal decrease of the right pleural
fluid with minimally improved transparency of the right-sided
lung parenchyma. In the left lung, no relevant changes are seen.
No evidence of interval recurrence of focal parenchymal opacity
suggesting pneumonia. No left pleural effusion. The anterior
apical chest tube was discontinued, and pneumostats were placed
on the remaining chest tubes (posterior apical and basal).
.
The patient had experienced some mild, non-specific pruritus
starting [**2146-10-26**], which developed into a rash and hand
angioedema early overnight into [**2146-10-28**]. Flagyl, intitiated on
[**10-26**], was suspected and stopped. The patient was given
Benadryl, Fexofenadine, and Singulair with symptomatic
improvement. Otherwise, he remained stable. He will continue on
Fexofenadine and Singulair for one week to prevent recurrent
delayed hypersensitivity reaction.
.
At the time of discharge on [**2146-10-28**], the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, albeit not with completely adequate
intake, and tubefeeds at goal via the J-tube, G-Tube was
clamped, PTC was capped, and posterior apical and basal chest
tubes had pneumostats in place. He was ambulating with
assistance due to visual impairment, voiding without assistance,
moving his bowels, and pain was well controlled. Infectious
Disease has recommended that he continue on Ciprofloxacin for at
least 3 weeks, preferably for 2 weeks AFTER all his drains have
been removed. He was discharged home with VNA services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
Atenolol 50mg PO daily.
Prilosec 20mg PO daily.
ASA 81mg PO daily.
Fenofibrate 200mg PO daily.
Spiriva 18mcg 1 tab via inhalation daily.
MVI 1 tab PO daily.
Glucosamine
Calcium+D
Fish Oil
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation: Over-the-counter.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*70 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. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching, redness.
Disp:*1 large bottle* Refills:*2*
9. Fenofibrate Micronized 200 mg Capsule Sig: One (1) Capsule PO
once a day.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Calcium 500 with Vitamin D Oral
12. Fish Oil Oral
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 17 days.
Disp:*34 Tablet(s)* Refills:*0*
14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*0*
15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for pruritus for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
16. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching.
Disp:*30 Capsule(s)* Refills:*0*
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day
for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
18. Nebulizer & Compressor For Neb Device Sig: One (1)
device Miscellaneous As directed.
Disp:*1 unit* Refills:*0*
19. Nebulizer Accessories Kit Sig: One (1) kit with
hand-held nebulizer and tubing Miscellaneous As directed.
Disp:*1 unit* Refills:*2*
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation four times a day as
needed for shortness of breath or wheezing.
Disp:*25 pre-filled nebs* Refills:*4*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] Homecare
Discharge Diagnosis:
1. Complicated gallstone pancreatitis.
2. SMV thrombosis
3. Moderate intrahepatic ductal dilatation and severe common
bile duct dilatation
4. Loculated right pleural effusion.
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-22**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
General Drain Care:
.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water, pat dry, and place
a drain sponge if needed daily and PRN.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Chest Tube with [**Month/Year (2) **] Information
You are ready to go home, but still need your chest tube. A
small device, called an Atrium [**Month/Year (2) **], has been placed on
the end of your chest tube to help you get better.
About The Atrium [**Month/Year (2) **]:
The Atrium [**Month/Year (2) **] is made to allow air and a little fluid to
escape from your chest until your lung heals. The device will
hold 30ml of fluid. Empty the device as often as needed (see
directions below) and keep track of how much you empty each day.
Items Needed for Home Use:
?????? Atrium [**Month/Year (2) **] Chest Drain Valve (provided by hospital)
?????? [**Last Name (un) **]-lock syringes to empty drainage, if needed (provided by
hospital or VNA Nurse)
?????? Wound dressings (provided by hospital or VNA Nurse)
Securing the [**Last Name (un) **]:
Utilize the pre-attached garment clip to secure the [**Last Name (un) **]
to your clothes. It is small and light enough that you won't
even feel it hanging at your side. Make sure to keep the
[**Last Name (un) **] in an upright position as much as possible. Before
lying down to sleep or rest, empty the [**Last Name (un) **] so there will
be no fluid to potentially leak out.
Wound Dressing:
You have a dressing around your chest tube. This should be
changed at least every other day or as prescribed by your
doctor.
Showering/Bathing:
Showering with a chest tube is all right as long as you don't
submerge the tube or device in water. No baths, swimming, or hot
tubs.
Note:
This device is very important and the tubing must stay attached
to the end of your chest tube.
?????? If it falls off, reconnect it immediately and tape it
securely.
?????? If it falls off and you can't get it back together, go to the
closest hospital emergency room.
Warnings:
1. Do not obstruct the air leak well.
2. Do not clamp the patient tube during use.
3. Do not use or puncture the needleless [**Last Name (un) 30342**] port with a
needle.
4. Do not leave a syringe attached to the needleless [**Last Name (un) 30342**] port.
5. Do not connect [**First Name8 (NamePattern2) 691**] [**Last Name (un) 30342**]-lock connector to the needleless
[**Last Name (un) 30342**] port located on the bottom of the chest drain valve.
6. If at any time you have concerns or questions, contact your
nurse [**First Name (Titles) **] [**Last Name (Titles) **].
[**Name10 (NameIs) 84858**] the [**Name10 (NameIs) **]
?????? Keep the [**Name10 (NameIs) **] in an upright position and make sure the
tubing stays firmly attached to the end of your chest tube. Make
sure the [**Name10 (NameIs) **] stays clean and dry. Do not allow the
[**Name10 (NameIs) **] to completely fill with fluid or it may start to leak
out. If fluid does leak out, clean off the [**Name10 (NameIs) **] and use a
Q-tip to dry out the valve.
?????? If the [**Name10 (NameIs) **] becomes full with fluid, empty it using a
[**Last Name (un) 30342**]-lock syringe. Firmly screw the [**Last Name (un) 30342**]-lock onto the port
located on the bottom of the [**Last Name (un) **].
?????? Pull the plunger back on the syringe to empty the fluid. When
the syringe is full, unscrew the syringe and empty the fluid
into the nearest suitable receptacle. Repeat as necessary. If it
becomes difficult to empty the fluid using a syringe, squirt
water through the port to flush out the blockage or consult your
nurse [**First Name (Titles) **] [**Last Name (Titles) **]. [**Name10 (NameIs) **] [**Name11 (NameIs) **] may need to be changed out.
.
Right abdominal PTC drain is capped. If you experiences fever,
uncap the PTC and place to collection bag. Call Interventional
Radiology Fellow for further instructions. Weekdays:
([**Telephone/Fax (1) 84859**] [**Hospital Ward Name 517**]. Nights/Weekends: Interventional
Radiology Fellow/Resident - call page operator ([**Telephone/Fax (1) 84860**] and
ask for pager# [**Serial Number 5603**]. Call the VNA nurse or Dr.[**Name (NI) 9886**] Office
if unsure with carrying out the above procedure, or proceed to
the Emergency Room.
Followup Instructions:
Please call ([**Telephone/Fax (1) 84861**] to arrange a follow-up appointment
with Dr. [**First Name (STitle) **] (PCP) in 2 weeks.
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7542**], MD (Surgery). Phone: ([**Telephone/Fax (1) 471**].
Date/Time: [**2146-11-14**] at 9:45am. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2146-11-8**] 9:00. Location: Chest Disease Center, [**Hospital Ward Name 121**]
Bldg., [**Hospital1 **] I
.
The patient will be contact[**Name (NI) **] [**Name2 (NI) 84862**] by Interventional
Radiology to arrange post-discharge follow-up.
Completed by:[**2146-10-28**]
|
[
"577.0",
"041.85",
"276.1",
"401.9",
"724.00",
"518.81",
"272.1",
"562.12",
"E878.8",
"V15.82",
"E931.5",
"568.0",
"527.2",
"041.3",
"E934.2",
"576.2",
"511.1",
"537.89",
"577.2",
"496",
"557.0",
"574.70",
"997.1",
"285.1",
"998.12",
"369.4",
"427.1",
"995.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.52",
"51.98",
"96.6",
"43.19",
"97.05",
"52.01",
"45.13",
"46.39",
"99.15",
"51.22",
"87.54",
"87.53",
"52.22",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
22090, 22146
|
9970, 19537
|
354, 904
|
22365, 22372
|
3051, 3051
|
29244, 30008
|
1989, 2080
|
19777, 22067
|
22167, 22344
|
19563, 19754
|
22396, 23851
|
23867, 29221
|
2095, 2095
|
2327, 3032
|
287, 316
|
932, 1533
|
3066, 9947
|
1555, 1852
|
1868, 1973
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,511
| 118,904
|
22895
|
Discharge summary
|
report
|
Admission Date: [**2184-3-10**] Discharge Date: [**2184-3-24**]
Date of Birth: [**2107-5-14**] Sex: F
Service: MEDICINE
Allergies:
Latex / Ativan / Xanax / Reminyl
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Central venous line placement
History of Present Illness:
76 yo woman with end stage COPD s/p trach in [**2-3**] and on/off
vent since, transferred here for fever and increased lethargy.
She was recently discharged from hospital to [**Hospital 38**] Rehab on
[**2-19**] after being weaned off vent. However, her mental status had
remained very poor (barely responsive) for the past few week.
She had to go back on vent a week ago due to worsening resp
status. She has various bacteria growing out of her sputum,
urine and blood. She has documented serratia and pseudomonas in
sputum, serratia and coag negative staph in blood, and VRE and
[**Female First Name (un) **] in urine. She has been treated with Amikacin and
levofloxacin for the serratia infection and vancomycin for coag
negative staph. However, she continued to deteriorate with the
treatment and her family requested her to be transferred to
hospital for evaluation. She came to [**Hospital1 18**] as [**Hospital **] Hosp didn't
have an ICU bed.
Past Medical History:
1. End-Stage COPD
2. Tracheostomy, intermittently vent dependent
3. Dementia
4. Type II Diabetes
5. Coronary Artery Disease
6. Congestive Heart Failure
7. Chronic Renal Failure
8. Atrial Fibrillation
Social History:
Has been at vent rehab over last year with intermittent
hospitalizations.
Family History:
non contributory
Physical Exam:
VS. T96.2 82 146/47 PS10/5 350 18 0.5
GENERAL: Minimally responsive,
NECK: Right IJ
CARDIOVASCULAR: S1, S2, [**Last Name (un) **], II/VI LUSB
LUNGS: Soft, coarse sounds bilaterally
ABDOMEN: Soft, NT, ND, obese, no rebound or guarding
EXTREMITIES: [**3-4**]+ UE and LE edema
NEURO: Awake, moving all four extremities, but not following
commands, unable to cooperate with exam.
Pertinent Results:
CT HEAD W/O CONTRAST [**2184-3-10**] 4:32 AM
1) No acute intracranial abnormality visualized.
2) Global brain atrophy, prominent in degree.
3) Mild chronic small vessel ischemic infarcts.
CT TORSO W/CONTRAST [**2184-3-16**] 9:21 PM
1. Diffuse soft tissue edema/anasarca.
2. No focal fluid collections suggestive of abscess.
3. Bilateral loculated pleural effusions.
4. Gallstone without evidence of cholecystitis.
5. Fat stranding surrounding the rectum, which seems
disproportionate to the degree of edema, may represent
inflammatory etiology, although evaluation of the pelvis is
limited by metallic hardware within the hips.
ECHO Study Date of [**2184-3-10**]
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. A focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild(1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
[**2184-3-15**] 10:20 am SPUTUM ENDOTRACHEAL.
**FINAL REPORT [**2184-3-20**]**
GRAM STAIN (Final [**2184-3-15**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2184-3-20**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
OROPHARYNGEAL FLORA ABSENT.
WORK-UP PER DR [**First Name (STitle) **] ([**Numeric Identifier 59176**]).
SERRATIA MARCESCENS. MODERATE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity available on request.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
STENOTROPHOMONAS (XANTHOMON
| | |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- 8 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- 2 S <=1 S
[**2184-3-11**] 8:00 am CATHETER TIP-IV Source: pic.
**FINAL REPORT [**2184-3-13**]**
WOUND CULTURE (Final [**2184-3-13**]):
SERRATIA MARCESCENS. >15 colonies.
Trimethoprim/Sulfa sensitivity available on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- 8 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
[**2184-3-10**] 12:40 am BLOOD CULTURE
**FINAL REPORT [**2184-3-12**]**
AEROBIC BOTTLE (Final [**2184-3-12**]):
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name 10280**] @ 1720 ON [**2184-3-10**].
SERRATIA MARCESCENS. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity available on request.
SENSITIVE TO AMIKACIN <=2MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- 8 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
ANAEROBIC BOTTLE (Final [**2184-3-12**]):
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2184-3-10**] 05:38PM HCT-22.9*
[**2184-3-10**] 05:38PM PT-17.7* PTT-32.0 INR(PT)-2.0
[**2184-3-10**] 01:06PM GLUCOSE-102 UREA N-70* CREAT-0.8 SODIUM-148*
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-35* ANION GAP-7*
[**2184-3-10**] 01:06PM CK(CPK)-27
[**2184-3-10**] 01:06PM CK-MB-NotDone cTropnT-0.21*
[**2184-3-10**] 01:06PM CALCIUM-8.5 PHOSPHATE-1.9* MAGNESIUM-2.4
[**2184-3-10**] 01:06PM PT-25.2* PTT-35.7* INR(PT)-4.0
[**2184-3-10**] 12:42PM VoidSpec-NAME ON SP
[**2184-3-10**] 12:42PM WBC-26.3* RBC-2.82* HGB-8.7* HCT-27.3* MCV-97
MCH-30.9 MCHC-32.0 RDW-18.1*
[**2184-3-10**] 12:42PM PLT COUNT-369
[**2184-3-10**] 12:42PM VoidSpec-DATE NOT R
[**2184-3-10**] 10:58AM TYPE-ART PO2-44* PCO2-54* PH-7.45 TOTAL
CO2-39* BASE XS-11
[**2184-3-10**] 07:50AM GLUCOSE-176* UREA N-72* CREAT-0.9 SODIUM-154*
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-39* ANION GAP-9
[**2184-3-10**] 07:50AM CK(CPK)-26
[**2184-3-10**] 07:50AM CK-MB-NotDone cTropnT-0.23*
[**2184-3-10**] 07:50AM CALCIUM-8.1* PHOSPHATE-1.0* MAGNESIUM-2.1
[**2184-3-10**] 07:50AM WBC-23.3* HCT-25.9*
[**2184-3-10**] 07:50AM PT-27.1* PTT-36.9* INR(PT)-4.6
[**2184-3-10**] 05:25AM TYPE-ART RATES-/13 TIDAL VOL-550 O2-100
PO2-465* PCO2-45 PH-7.53* TOTAL CO2-39* BASE XS-13 AADO2-218 REQ
O2-44 INTUBATED-INTUBATED
[**2184-3-10**] 05:25AM LACTATE-1.8
[**2184-3-10**] 05:25AM freeCa-1.05*
[**2184-3-10**] 02:10AM PT-29.0* PTT-39.1* INR(PT)-5.3
[**2184-3-10**] 01:08AM COMMENTS-GREEN TOP
[**2184-3-10**] 01:08AM LACTATE-3.6*
[**2184-3-10**] 12:40AM GLUCOSE-56* UREA N-78* CREAT-0.9 SODIUM-151*
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-36* ANION GAP-12
[**2184-3-10**] 12:40AM ALT(SGPT)-49* AST(SGOT)-24 CK(CPK)-27 ALK
PHOS-54 AMYLASE-66 TOT BILI-0.2
[**2184-3-10**] 12:40AM LIPASE-26
[**2184-3-10**] 12:40AM cTropnT-0.20*
[**2184-3-10**] 12:40AM CK-MB-NotDone
[**2184-3-10**] 12:40AM ALBUMIN-2.6* CALCIUM-7.8* PHOSPHATE-0.8*
MAGNESIUM-2.2
[**2184-3-10**] 12:40AM ACETONE-NEG OSMOLAL-344*
[**2184-3-10**] 12:40AM DIGOXIN-1.7
[**2184-3-10**] 12:40AM WBC-19.3* RBC-2.61* HGB-8.0* HCT-25.1* MCV-96
MCH-30.7 MCHC-32.0 RDW-17.9*
[**2184-3-10**] 12:40AM NEUTS-85.3* BANDS-0 LYMPHS-11.7* MONOS-2.3
EOS-0.6 BASOS-0.1
[**2184-3-10**] 12:40AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-1+ TEARDROP-OCCASIONAL
[**2184-3-10**] 12:40AM PLT COUNT-297
[**2184-3-10**] 12:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2184-3-10**] 12:40AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2184-3-10**] 12:40AM URINE RBC-[**4-3**]* WBC-[**12-19**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
Brief Hospital Course:
76 yo woman with vent-dependent COPD and multiple organism
growing from blood, urine and sputum, here for fever and poor
mental status.
* MULTIDRUG RESISTANT BACTEREMIA/PNEUMONIA: Sputum, blood
cultures, and PICC tip grew out multiple gram negative rods
(Serratia marascens, Pseudomonas aeruginosa, and
Stenotrophomonas) of nosocomial origin. Patient was continued
on Amikacin as initiated at outside hospital and Meropenem
(directed based upon sensitivities from outside hospital, and
confirmed against [**Hospital1 18**] cultures). Patient was treated with a
full two week course, and remained afebrile following hospital
day 6, with surveillance blood cultures clear following removal
of infected PICC as noted above.
Despite nosocomial pneumonia based on endotracheal sputum
cultures, no radiographic evidence of infiltrate was found,
however small pleural effusions were found, R>L, which did not
appear accessible by thoracentesis. Therefore, these were
managed medically with antibiotic therapy. Patient completed a
fourteen day course of meropenem and amikacin on [**2184-3-24**].
* RESPIRATORY FAILURE: Within 4 days of admission, patient's
ventilatory requirements were minimized, and patient was weaned
to trach mask for several hours a day. However, following two
days of weaning to trach mask, patient's ventilatory
requirements increased again, with unclear etiology (no obvious
bronchospasm, no increased alveolar/arterial gradient).
Increased requirement was based upon subjective appearance of
discomfort and increasing tachypnea rather than objective data.
At the time of discharge, patient was tolerating pressure
support of [**11-3**] for several hours a day, and it appeared that
patient would likely be weaned again to trach mask with time.
* ATRIAL FIBRILLATION: At the time of admission, patient's INR
was elevated at 5.3, and warfarin was held throughout
hospitalization. Of note, patient did have guaiac positive
stools, however gastrointestinal consultants felt that this was
more likely due to supratherapeutic INR as opposed to an
intrinsic source. Indeed, following resolution of INR,
hematocrit was stable and stool was guaiac negative- although
still occasionally guaiac positive secondary to hemorrhoids and
small anal fissures. Therefore, it was felt that benefit of
anticoagulation in the setting of likely poor short term
prognosis of MDR infections did not outweigh risk of bleeding.
In addition, given chronic renal insufficiency, digoxin was also
discontinued for concern of digoxin toxicity, and patient was
rate controlled with metoprolol alone.
* GI BLEED: At the time of admission, patient was thought to
have a GI bleed given guaiac positive stools in setting of
supratherapeutic INR as above. GI consultants recommended
outpatient EGD and colonoscopy for followup given the more
pressing issues of patient's ventilatory status.
* MENTAL STATUS: Although patient was apparently admitted for
mental status change, it is unclear what patient's baseline
mental status was, and patient was never responsive to verbal
stimuli throughout hospitalization. Patient was clearly awake,
tracked visually, and responded to noxious stimuli
appropriately, however throughout hospitalization, despite lack
of clear etiology, patient never gave any evidence of ability to
follow commands or comprehend commands.
* ADVANCED DIRECTIVES: Goals of care were addressed with the
patient's daughter [**Name (NI) 1785**], who is healthcare proxy, given the
fact that patient's quality of life at present seemed fairly
poor and ultimate prognosis poor (given accelerating multidrug
resistant infections). However, daughter was insistent that
patient had recovered in past, and that she did not wish to
change goals from maximum aggressive interventions.
Nonetheless, [**Doctor First Name 1785**] did suggest that patient would ultimately
like "to go home".
At the time of discharge, patient had been afebrile for nearly a
week, required near minimal ventilatory support, and appeared to
be at baseline mental status.
Medications on Admission:
Metoprolol 75 [**Hospital1 **]
Clonidine 0.4
Digoxin 0.125
Levoxyl 125
ASA
Pxil 20
Protonix 40
Colace 100 [**Hospital1 **]
Flovent
Coumadin
Vancomycin 1g [**Hospital1 **]
Amikacin 450
Levofloxacin 500
Lantus 26 HS
RISS
Vit A
Vit C
Neutraphos TID
Prednisone 40
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) ml
PO BID (2 times a day): Hold for loose stools.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
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. Acetaminophen 160 mg/5 mL Elixir Sig: 325-650 mg PO Q4-6H
(every 4 to 6 hours) as needed for pain/fever>101.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous every twelve (12) hours.
13. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Taper - 3 tablets for next 2 days, then 2 tablets for 2
days, then one tablet for 2 days, then stop.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-1**]
Drops Ophthalmic PRN (as needed).
16. Artificial Saliva 0.15-0.15 % Solution Sig: 1-3 MLs Mucous
membrane PRN (as needed) for 1 doses.
17. Hydralazine HCl 20 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours) as needed for SBP>180.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]-[**Hospital1 **]
Discharge Diagnosis:
Respiratory Failure
Ventilator associated Multi-drug resistant pneumonia and
bacteremia
Atrial Fibrillation (not on anticoagulation given concern of GI
bleed)
Hypertension
Discharge Condition:
Fair - continued to require pressure support ventilation.
Mental status: awake, but minimally responsive - not following
commands and not interactive.
Discharge Instructions:
Continue medications as directed.
Continue trach care per protocol.
Followup with primary care physician as needed
Followup Instructions:
Will require outpatient colonoscopy to evaluate for possible
lower GI bleed when ventilatory status stabilized.
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
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[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,020
| 167,285
|
4248
|
Discharge summary
|
report
|
Admission Date: [**2121-3-25**] Discharge Date: [**2121-3-26**]
Date of Birth: [**2071-1-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
headache, blurred vision, hypertension
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 50 year-old Female with a PMH significant for
ulcerative colitis and remote history of migraine headache who
presented with 1-day of headache and right-sided neck pain that
progressed gradually starting the afternoon of [**2121-3-24**] found to
be hypertensive.
.
The patient notes the headache pain was bilateral and constant
with a throbbing quality that gradually progressed since the
afternoon of [**2121-3-24**], while she was at work. She took Ibuprofen
without significant benefit, and while her headache failed to
worsen, it remained into the evening. The patient awoke the day
of admission with a right, posterior neck and shoulder pain that
radiating anteriorly. She checked her blood pressure at home and
it was 180/112 mmHg so she called her primary care physician.
[**Name10 (NameIs) **] was associated with a transient blurry vision which
resolved within minutes. She was referred to the ED given her
hypertension and vision concerns.
.
She has no documented history of hypertension but did have a
blood pressure of 150/90 mmHg on routine [**Name10 (NameIs) 3390**] [**Name Initial (PRE) **] 1-month ago.
Given that finding, she was told to discontinue her OCP (Aviane)
medication (which she has been on for 3-years for dysmenorrhea).
She takes no other medications and no anti-hypertensives. She
denies meningismus, fevers or chills. No current vision changes
or diplopia. She denies chest pain or shortness of breath. She
has no leg swelling. She denies dysuria or hematuria. She has no
nausea, emesis or abdominal pain and denies decreased appetite.
She has no numbness, weakness or tingling. She also denies
seziure history, but has a notable history of remote migraine
headaches without episodes for many years.
.
On arrival to the ED, initial VS 98.6 88 [**Telephone/Fax (2) 18460**]0% RA. Her
exam was notable for TTP over the right trapezius muscle with
normal fundoscopic exam and no papilledema. She had no visual
field deficits and her neurologic exam was non-focal. She was
having some restlessness and reported muscle twitching of her
neck and right shoulder. Her laboratory data were notable for
WBC 7.7, HCT 44.0. Creatinine 0.8. Urine hCG and urinalysis were
negative. An EKG showed NSR @ 81, NA/NI, concern for LVH without
ST-changes or evidence of ischemia. A CTA of the head and neck
demonstrated no acute intracranial process, with the exception
of left sphenoidal sinus disease. There was no evidence of
dissection, aneurysm or vascular malformation. She was started
on a Labetalol infusion and given Diazepam 5 mg PO x 1 for
twitching and her BP improved to 179/111 mmHg with a HR of 80
and improvement in her headache.
.
On arrival to the [**Hospital Unit Name 153**], she had no chest pain or shortness of
breath. She has no vision changes or headaches. Her right neck
and shoulder spasm improved with Diazepam.
.
ROS: Denies vision changes. No cough or upper respiratory
symptoms. Denies chest pain, dizziness or lightheadedness; no
palpitations. Denies shortness of breath. No nausea or vomiting,
denies abdominal pain. No dysuria or hematuria. Denies muscle
weakness, myalgias or neurologic complaints.
Past Medical History:
1. Ulcerative colitis (diagnosed in [**2104**], few episodic flares;
sigmoidoscopy in [**2110**] showing only left-sided colitis)
2. Spasmodic dysphonia (requiring Botox injections, followed by
Dr. [**First Name (STitle) **] from ENT surgery)
3. Migraine headache with aura (remote history, no recent
episodes)
4. Endovenous laser ablation of the left greater saphenous vein
([**2110**])
Social History:
Divorced mother of two. Two to three cups of coffee per day.
Works as a medical assistant for an OB/Gyn. Denies tobacco
history or current use; social alcohol use (1-2 drinks on
weekends); no recreational substance use. She denies dietary
supplements.
Family History:
Father deceased from esophageal cancer; mother with lung cancer
and breast cancer is still living. Maternal side with early
cardiac death in two males of unknown circumstance. No cardiac
dysrrhythmia or early MIs of note.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 80 154/101 17 96% RA
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD not elevated.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No carotid bruits.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. No audible
abdominal bruit.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.
.
DISCHARGE EXAM: unchanged
Pertinent Results:
ADMISSION LABS:
.
[**2121-3-25**] 09:50AM BLOOD WBC-7.7 RBC-4.98 Hgb-15.5 Hct-44.0 MCV-88
MCH-31.2 MCHC-35.3* RDW-12.8 Plt Ct-241
[**2121-3-25**] 09:50AM BLOOD Neuts-79.3* Lymphs-13.9* Monos-3.7
Eos-1.8 Baso-1.3
[**2121-3-25**] 09:50AM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-138
K-6.2* Cl-102 HCO3-22 AnGap-20
[**2121-3-25**] 09:50AM BLOOD CK(CPK)-155
[**2121-3-25**] 09:50AM BLOOD CK-MB-3 cTropnT-<0.01
[**2121-3-25**] 09:50AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2 Cholest-242*
[**2121-3-25**] 02:59PM BLOOD %HbA1c-PND
[**2121-3-25**] 09:50AM BLOOD Triglyc-100 HDL-89 CHOL/HD-2.7
LDLcalc-133*
[**2121-3-25**] 09:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2121-3-25**] 11:38AM BLOOD K-3.7
[**2121-3-25**] 09:50AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003
[**2121-3-25**] 09:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2121-3-25**] 09:50AM URINE UCG-NEGATIVE
[**2121-3-25**] 09:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
DISCHARGE LABS:
.
[**2121-3-26**] 04:29AM BLOOD WBC-6.8 RBC-4.41 Hgb-13.4 Hct-40.1 MCV-91
MCH-30.4 MCHC-33.4 RDW-13.1 Plt Ct-257
[**2121-3-26**] 04:29AM BLOOD Glucose-99 UreaN-19 Creat-0.8 Na-139
K-3.9 Cl-106 HCO3-24 AnGap-13
[**2121-3-26**] 04:29AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
.
MICROBIOLOGIC DATA:
[**2121-3-25**] MRSA screen - pending
.
IMAGING STUDIES:
.
[**2121-3-25**] CTA HEAD W&W/O C & RECO - No CT evidence of acute
intracranial process. Aerosolized secretion in the left
sphenoidal sinus suggest sinusitis. Futher details to be
provided with CTA report. CTA: No evidence of dissection,
aneurysm, vascular malformation or flow-limiting stenosis. Intra
and extracranial anterior and posterior circulation arteries are
patent. Left cavernous carotid is slightly smaller than right.
Mild degenerative changes with disc space narrowing and
disc-osteophyte complexes at C4/5, [**5-18**], and [**6-19**]. No significant
spinal canal
narrowing. Awaiting 3D reformations.
.
[**2121-3-25**] MR HEAD W/O CONTRAST - No evidence of acute infarction.
Fluid in the sphenoid sinus with aerosolized secretions
consistent with acute sinusitis.
.
[**2121-3-25**] CHEST (PA & LAT) - No acute findings. No mediastinal
widening.
Brief Hospital Course:
IMPRESSION: 50F with a PMH significant for ulcerative colitis
and remote history of migraine headache who presented with
headache and transient vision changes found to be hypertensive
to 200/100 mmHg with reassuring CTA head and neck imaging
concerning for hypertensive urgency vs. emergency.
.
# HYPERTENSIVE URGENCY VS. EMERGENCY - The patient presented
with a blood pressure of 150/90 mmHg on routine [**Month/Day/Year 3390**] [**Name Initial (PRE) **]
1-month ago with no prior history of hypertension, certainly a
prior history of uncontrolled essential hypertension is
plausible. She has few modifiable risk factors, she is not
obese, denies excessive alcohol intake, and is physically active
with aerobic activity. She is not on anti-hypertensive
medications and recently discontinued her OCP (Aviane). Her
blood pressure has ranged from 180-200/100-110s mmHg over 2-days
with symptoms of posterior headache and neck pain, involuntary
muscle spasm vs. distal extremity parathesias and twitching as
well as transient vision concerns - despite normal renal
function, no cardiac ischemic changes on EKG, encephalopathy,
papilledema or retinal hemorrhaging. Given this symptomatology,
hypertensive emergency was the concern. Overall her work-up was
reassuring with a negative head and neck CTA and negative head
MR imaging. She also had a reasurring laboratory work-up,
although her EKG did show some chronic LVH changes and
ultimately we attributed her condition to undiagnosed and
uncontrolled essential hypertension. A Labetalol gtt was started
in the ED and she was quickly weaned to PO Labetalol and then
started Lisinopril 10 mg PO daily which will continue as an
outpatient. She will follow-up with her [**Name Initial (PRE) 3390**] [**Last Name (NamePattern4) **] 1-week for
electrolyte monitoring.
.
# NECK SPASM, CERVICAL DYSTONIA - The patient presented with
features of right neck and shoulder pain that has occurred
before, per her daughter. The physical exam findings and
clinical history indicate a primary focal dystonia or cervical
dystonia. Half of patients describe pain in the setting of these
findings. Her CTA did note some degenerative changes with disc
space narrowing and disc-osteophyte complexes at C4/5, [**5-18**], and
[**6-19**] but the symptomatology seemed unrelated. This likely
represents a separate process from her hypertensive urgency and
there is no evidence of a medication-induced effect. She
responded to Tylenol and PRN Valium with symptomatic relief.
.
# ULCERATIVE COLITIS - History of ulcerative colitis that has
been left-colon predominant diagnosed in [**2104**]. She has had prior
flares a few times yearly with rectal bleeding and last
sigmoidoscopy in [**2110**] showed left-sided colitis only. She has
never been on corticosteroid treatment. She was previously on
5-ASA (Rewasa) therapy only intermittently. She has no active
rectal bleeding or abdominal pain symptoms to suggest active
flare.
.
TRANSITION OF CARE ISSUES:
1. Follow-up scheduled with [**Year (4 digits) 3390**] [**Last Name (NamePattern4) **] 1-week with electrolyte
monitoring.
Medications on Admission:
None
Discharge Medications:
1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for fever or pain.
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Outpatient Lab Work
Please have your sodium, potassium and BUN, creatinine checked
as an outpatient, which can be followed by your primary care
physician. [**Name Initial (NameIs) 3390**]: [**Name10 (NameIs) 18461**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 18462**], FAX: [**Telephone/Fax (1) 18463**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Hypertensive urgency vs. emergency
2. Cervical dystonic reaction, muscle spasm
.
Secondary Diagnoses:
1. Ulcerative colitis
2. Hypertension
3. Migraine headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Critical Care Unit service at [**Hospital1 1535**] on the [**Location (un) **] of the [**Hospital Ward Name 332**]
Intensive Care Unit regarding management of you critically high
blood pressure, headache and neck pain. You were treated with IV
blood pressure medications, pain medications and muscle
relaxants with improvement in your symptoms. You were discharged
on a low dose of Lisinopril for blood pressure management and
will follow-up with your primary care physician [**Last Name (NamePattern4) **] 1-week with
electrolyte monitoring in clinic.
.
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
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Lisinopril 10 mg by mouth daily
START: Acetaminophen 325-650 mg by mouth every 4-6 hours as
needed for pain or headache
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Name: [**Last Name (LF) 18461**],[**First Name3 (LF) **] C
Location: [**Hospital **] HEALTH CENTER
Address: 200 [**Last Name (un) 12504**] DR, [**Location (un) **],[**Numeric Identifier 18464**]
Phone: [**Telephone/Fax (1) 18462**]
When: Tuesday, [**4-1**], 2:30 PM
|
[
"V12.79",
"346.90",
"728.85",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11398, 11404
|
7691, 10793
|
343, 371
|
11632, 11632
|
5367, 5367
|
13734, 14003
|
4253, 4477
|
10848, 11375
|
11425, 11528
|
10819, 10825
|
11815, 13711
|
6458, 6788
|
4492, 5321
|
11549, 11611
|
5337, 5348
|
264, 305
|
399, 3555
|
5383, 6442
|
11647, 11759
|
3577, 3967
|
3983, 4237
|
6805, 7668
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,423
| 130,855
|
21278
|
Discharge summary
|
report
|
Admission Date: [**2106-12-29**] Discharge Date: [**2107-1-20**]
Date of Birth: [**2054-12-5**] Sex: M
Service: MEDICINE
Allergies:
Optiray 350 / Shellfish Derived
Attending:[**First Name3 (LF) 21073**]
Chief Complaint:
Biliary obstruction
Major Surgical or Invasive Procedure:
ERCP
External PTC drain
hepaticojejunotomy
re-exploration
cardiac cath and stenting
intraaortic balloon pump
History of Present Illness:
Mr. [**Known lastname **] is a 52M who is 1 year s/p OLT. He began to develop
an increase in his liver enzymes in [**Month (only) **]. A liver biopsy
was performed which revealed drug induced hepatitis, a question
of early recurrent hepatitis C, but no signs of acute rejection.
A hepatitis C viral load was checked and it was negative. 2
weeks ago his bilirubin was noted to be elevated. He underwent
an ERCP today which revealed a complete obstruction at the
biliary anastomosis. He [**Month (only) **] fevers, chills and jaundice. He
is tolerating a normal diet and having normal BMs. He [**Month (only) **]
abdominal pain but has had recent pruritis and dark urine.
Past Medical History:
HTN, HCV cirrhosis, hepatocellular carcinoma,
s/p appy, s/p right inguinal hernia repair, s/p OLT [**12-3**]
Social History:
He emigrated from Viet Nam in [**2090**]. He lives with his
girlfriend and has smoked cigarettes for 35 years, about 0.5
packs per day. He is still smoking 10- 15 cigs per day. He
previously drank alcohol and experimented with IV drugs, but
[**Year (4 digits) **] alcohol or drug use for at least the past 5 years.
Family History:
His father died of old age and his mother died from an injury.
He has two brothers who died from alcohol and substance abuse.
Another brother has liver disease and underwent partial hepatic
resection, while another brother had his
gallbladder removed. Two other brothers, a sister, and a
daughter are alive and well. Mr. [**Known lastname **] [**Last Name (Titles) **] any family history
of blood diseases.
Physical Exam:
PE: 95.5, 55, 120/80, 18, 99% on room air
Gen: no distress, alert and oriented x 3
HEENT: NC/AT, PERLA, EOMi, anicteric, mucous membranes moist
Neck: supple, no LAD
Chest: RRR, no murmurs, lungs clear
Abd: soft, nontender, nondistended, well healed incision
Ext: palpable pulses, no edema
Pertinent Results:
-CBC: 6.9 > 41.6 < 207
-INR 1.0
-LFTs: ALT 331, AST 161, AP 416, TBili 2.5, DBili 1.4, Alb 4.
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2106-12-29**] after ERCP revealed a biliary
stricture. The patient underwent PTC drain placement initially;
however, the drain would not pass the obstruction and therefore
only drained externally. On [**1-6**] the patient underwent a
hepaticojejunostomy to correct the biliary stricture.
On [**1-8**], the patient was noted to have acute onset of
respiratory distress. An ABG showed 7.45/32/57 and the patient
was intubated. CXR was consistent with pulmonary edema. A
bedside echo was performed and showed new anterior hypokinesis
with akinesis of the apex and anterior septum; overall LVEF of
25-35%. Noted to be hypotensive to the 80s, tachycardic to the
120s. He was taken to cardiac catheterization for further
evaluation. Cardiac cath revealed 3 vessel disease. Bare mental
stents were placed in the LAD and RCA. Given persistent shock a
balloon pump was placed in the cath lab and he was brought to
the CCU.
He had been started on vanc and zosyn prior to transfer and
these were continued given concern for sepsis as a cuase for his
persistent hypotension. He was also placed on dopamine for
pressure support. Fluconazole was added for fungal coverage as
the patient is immunosuppressed. The patient's abominal
surgical wound continued to leak bile throughout his stay in the
CCU. An abdominal US was done to evaluate for fluid collection
which showed no large perihepatic fluid collection and a small
right pleural effusion.
A repeat TTE was done on and off the ballon pump on [**1-10**] which
showed improved systolic function but he continued to have
distal inferior wall hypokinesis and distal septal hypokinesis.
The balloon pump removed on [**1-10**]. He was extubated on [**1-11**].
On POD 5 cholangiogram showed a complete obstruction of this
anastomosis. He therefore returned to the operating room on POD
7, for exploration and revision.
On [**1-12**] a HIDA scan was performed which showed a bile leak from
the hepaicojejunostomy anastomosis. He was very confused and
require 1:1 sitters. On [**1-16**] the patient was transferred back
to the transplant floor. A follow up cholangiogram determined
the patient's bile leak to actually have been coming from the
liver edge rather than the anastomosis. The patient therefore
continued to have JP drainage. A CT scan was performed which
showed a 6 x 3 cm collection that was not drainable. The
patient's diet was slowly advanced and tolerated.
On the 24th, the patient had his roux tube capped which was well
tolerated. He was sent home on the 25th on oral levaquin with
JP drainage, a capped roux tube, and with plans to attend
cardiac rehab in the near future.
Medications on Admission:
felodipine 10mg daily, HCTZ 12.5mg daily, MMF 500mg [**Hospital1 **],
prograf 1.5mg [**Hospital1 **], Bactrim SS 1 tab daily, omeprazole 20mg [**Hospital1 **],
sennosides 8.6mg [**Hospital1 **], colace 100mg [**Hospital1 **], tylenol prn
Discharge Medications:
Aspirin 325mg daily, Plavix 75mg daily, Olanzappine 5mg daily
prn, Oxycodone 5-10mg prn, Mycophenolate Mofetil 500 mg [**Hospital1 **],
Bactrim daily, Famotidine 20 mg [**Hospital1 **], Fluconazole 400mg daily,
Levofloxacin 500mg daily, Tacrolimus 0.5mg [**Hospital1 **]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
biliary stricture
Myocardial infarction
Discharge Condition:
good
Discharge Instructions:
Call for fevers >101.4
nausea/vomiting/ constipation or diarrhea
please call for any concerns
please also call for any abdominal pain
Cardiac [**Hospital 15973**] Rehab will be set-up at outpatient visit
Please measure and record
Followup Instructions:
Please Call Dr.[**Name (NI) 1381**] Office for Follow up appointment next
week
([**Telephone/Fax (1) 3618**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 21075**]
|
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"518.81",
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"428.0",
"038.9",
"414.01",
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"410.71",
"997.4",
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icd9cm
|
[
[
[]
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[
"00.66",
"51.94",
"88.56",
"36.06",
"37.23",
"51.98",
"51.37",
"51.10",
"00.46",
"37.61",
"96.04",
"00.41",
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icd9pcs
|
[
[
[]
]
] |
5751, 5809
|
2470, 5168
|
314, 425
|
5893, 5900
|
2352, 2447
|
6178, 6383
|
1617, 2027
|
5456, 5728
|
5830, 5872
|
5194, 5433
|
5924, 6155
|
2042, 2333
|
255, 276
|
453, 1133
|
1155, 1266
|
1282, 1601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,484
| 128,086
|
40470
|
Discharge summary
|
report
|
Admission Date: [**2189-6-27**] Discharge Date: [**2189-6-28**]
Date of Birth: [**2126-2-25**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
History of Present Illness:
63 year old male with history of anxiety presented s/p cardiac
arrest. Per wife, he was sleeping at home tonight, she was awoke
around 9:45pm by the loud snoring. He was unresponsive when wife
tried to arouse him. She called 911 and started CPR immediately.
When EMS arrived, he was intubated and was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
with ACLS protocols enacted. He was asystolic upon arrival to AJ
with an estimated down time 45 minutes per EMS. At AJED, he was
defrillibrated x1, had ROC, received 5 of epi, 3 of bicarb, amp
D50, 1 gm Ca, dopa, and levophed. Arctic sun was initiated
around 11pm. When he arrived to ED, his dopa was stopped due to
ectopy. He was placed on Heparin Sodium, ? Clopidogrel loaded
with 600mg, Atorvastatin 80mg, Aspirin 325mg, and Fentanyl.
Though per ED staff reporting, unclear if patient actually got
the plavix load, atorvastatin, Aspirin due to OG tube unclear
location. Initial ED vitals were: temp of 34, HR of 107, BP of
198/68, RR of 20, Sat 100% on CMV.
.
In ED, Cardiology fellow evaluation noted patient was
unresponsive without any gag reflex, concerned for head bleed,
patient was sent for urgent CT of head for evaluation: prelim
read per report was notable for a large MCA with potential PCA
ischemic infarct with hemorrhagic conversion, left frontal
hemorrhagic area with intraparenchimal and subarachanoid
involvment. Neurosurgery was contact[**Name (NI) **] - recommended repeat CT
of head 6 hours post, no anticoagulations.
.
On review of systems, not able to obtain from patient. Per wife,
patient had periodic palpatation for the past year that had a
negative evaluation (unclear what was involved), was attributed
to anxiety.
.
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: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- anxiety
Social History:
works in the navy yard as a pipe-fitter.
- Tobacco history: quite 30 yrs ago, smoked 10 yrs 2ppd
- ETOH: daily 1-2 drinks
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: T=94 BP=154/100 HR=81 RR=20 O2 sat= 100% CMV
GENERAL: Intubated sedated paralyzed, decerebrate posturing
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma. Pupil 4mm and
5mm.
NECK: Supple
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. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Left IO line in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
LABORATORY RESULTS:
.
[**2189-6-27**] 03:09AM CK-MB-GREATER TH cTropnT-7.63*
[**2189-6-27**] 02:57PM CK-MB-GREATER TH cTropnT-6.71*
[**2189-6-27**] 08:27PM CK-MB-499* MB INDX-15.3* cTropnT-5.66*
[**2189-6-27**] 03:09AM CK(CPK)-3847*
[**2189-6-27**] 08:27PM CK(CPK)-3270*
.
[**2189-6-27**] 03:24AM LACTATE-5.2*
[**2189-6-27**] 05:00AM LACTATE-6.6*
[**2189-6-27**] 03:03PM LACTATE-6.9*
[**2189-6-27**] 06:30PM LACTATE-4.9*
[**2189-6-27**] 08:50PM LACTATE-3.5*
.
[**2189-6-27**] 12:05AM FIBRINOGE-221
[**2189-6-27**] 12:05AM PT-12.7 PTT-27.8 INR(PT)-1.1
[**2189-6-27**] 03:09AM PT-14.7* PTT-87.8* INR(PT)-1.3*
[**2189-6-27**] 09:25AM PT-13.1 PTT-24.0 INR(PT)-1.1
[**2189-6-27**] 02:57PM PT-13.3 PTT-24.0 INR(PT)-1.1
[**2189-6-27**] 12:05AM PLT COUNT-265
[**2189-6-27**] 03:09AM PLT COUNT-313
[**2189-6-27**] 09:25AM PLT COUNT-255
[**2189-6-27**] 02:57PM PLT COUNT-261
.
[**2189-6-27**] 12:05AM WBC-9.5 RBC-5.65 HGB-17.3 HCT-50.7 MCV-90
MCH-30.7 MCHC-34.2 RDW-13.8
[**2189-6-27**] 03:09AM WBC-22.8*# RBC-5.87 HGB-18.3* HCT-52.5*
MCV-90 MCH-31.2 MCHC-34.9 RDW-14.1
[**2189-6-27**] 09:25AM WBC-21.7* RBC-5.70 HGB-17.6 HCT-51.6 MCV-91
MCH-30.8 MCHC-34.1 RDW-14.4
[**2189-6-27**] 02:57PM WBC-15.3* RBC-6.08 HGB-18.6* HCT-54.5* MCV-90
MCH-30.5 MCHC-34.1 RDW-14.1
.
[**2189-6-27**] 12:10AM URINE MUCOUS-RARE
[**2189-6-27**] 12:10AM URINE RBC-47* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
[**2189-6-27**] 12:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2189-6-27**] 12:10AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.006
[**2189-6-27**] 12:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
[**2189-6-27**] 12:11AM freeCa-1.23
[**2189-6-27**] 03:09AM CALCIUM-9.9 PHOSPHATE-4.0 MAGNESIUM-2.2
[**2189-6-27**] 02:57PM CALCIUM-9.9 PHOSPHATE-1.3* MAGNESIUM-1.8
.
[**2189-6-27**] 12:11AM GLUCOSE-207* LACTATE-5.9* NA+-144 K+-3.6
CL--106 TCO2-20*
[**2189-6-27**] 03:09AM GLUCOSE-213* UREA N-26* CREAT-1.5* SODIUM-144
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-22 ANION GAP-22*
[**2189-6-27**] 08:18AM GLUCOSE-201* LACTATE-7.5* NA+-144 K+-2.6*
CL--116*
[**2189-6-27**] 09:25AM GLUCOSE-193* UREA N-34* CREAT-1.7*
SODIUM-148* POTASSIUM-2.8* CHLORIDE-111* TOTAL CO2-15* ANION
GAP-25*
[**2189-6-27**] 02:57PM GLUCOSE-161* UREA N-34* CREAT-1.9*
SODIUM-154* POTASSIUM-3.1* CHLORIDE-113* TOTAL CO2-20* ANION
GAP-24*
[**2189-6-27**] 09:25AM OSMOLAL-318*
[**2189-6-27**] 02:57PM OSMOLAL-323*
[**2189-6-27**] 08:27PM OSMOLAL-328*
.
[**2189-6-27**] 12:11AM TYPE-ART RATES-/20 TIDAL VOL-500 PEEP-5
O2-100 PH-7.26* -ASSIST/CON INTUBATED-INTUBATED COMMENTS-GREEN
TOP
[**2189-6-27**] 05:00AM TYPE-ART PO2-387* PCO2-17* PH-7.51* TOTAL
CO2-14* BASE XS--6
[**2189-6-27**] 08:18AM TYPE-ART PO2-249* PCO2-21* PH-7.39 TOTAL
CO2-13* BASE XS--9
[**2189-6-27**] 03:03PM TYPE-[**Last Name (un) **] PH-7.26*
[**2189-6-27**] 06:30PM TYPE-[**Last Name (un) **] PH-7.27* COMMENTS-PERIPHERAL
.
[**2189-6-27**] 12:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-6-27**] 12:05AM LIPASE-108*
[**2189-6-27**] 12:05AM UREA N-23* CREAT-1.5*
[**2189-6-27**] 09:25AM ALBUMIN-4.0 CALCIUM-9.5 PHOSPHATE-2.6*
MAGNESIUM-2.1
[**2189-6-27**] 02:57PM ALT(SGPT)-143* AST(SGOT)-413* CK(CPK)-4223*
ALK PHOS-53 TOT BILI-0.6
.
IMAGING:
.
CT Head ([**6-27**] 1:43 AM):
1. Probable hemorrhagic conversion of MCA territorial infarct.
PCA
territorial infarct without hemorrhagic conversion.
2. Extensive left hemispheric edema with rightward shift of
midline and mass effect upon the lateral ventricle.
.
CT Head ([**6-27**] 7:36 AM):
IMPRESSION:
1. Increased size of left frontal hemorrhage with increased
surrounding
cytotoxic edema likely secondary to hemorrhagic conversion of an
MCA territory infarct.
2. Increased edema and effacement of the sulci and rightward
shift concerning for increased rightward subfalcine and downward
transtentorial herniation.
3. Newly apparent hypodensities in the basal ganglia and
hippocampi can be
seen in global anoxic injury.
.
Echocardiogram ([**6-27**] 1:03:46 PM)
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is severe
global left ventricular hypokinesis (LVEF = 15-20%). Right
ventricular chamber size is normal. with moderate global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
IMPRESSION: Severe global left ventricular systoilc dysfunction,
most c/w global process (toxic, metabolic, post-arrest, etc.).
Moderate global right ventricular systolic dysfunction.
Technically-difficult study.
.
ECG ([**6-27**] 12:06:08 AM)
Atrial fibrillation with a rapid ventricular response.
Ventricular ectoy
versus aberrant conduction. Non-specific ST-T wave changes. No
previous
tracing available for comparison.
TRACING #1
.
ECG ([**6-27**] 2:04:40 AM)
Sinus tachycardia. Ventricular ectopy. Left atrial abnormality.
Non-specific
ST-T wave changes. Compared to the previous tracing of the same
date sinus
rhythm has replaced atrial fibrillation.
TRACING #2
.
CHEST (PORTABLE AP) ([**6-27**] 12:05 AM)
IMPRESSION:
1. Satisfactory ET tube positioning.
2. NG tube tip within the distal esophagus, requiring further
advancement for optimal positioning.
3. Pulmonary edema and mild cardiomegaly.
.
CHEST (PORTABLE AP) ([**6-27**] 4:27 AM)
An ET tube is present, tip in satisfactory position
approximately 4.2 cm above the carina. An NG tube is present,
tip extending beneath diaphragm off film. The heart is not
enlarged, though there is a left ventricular configuration. The
aorta is calcified and slightly tortuous. No CHF, focal
infiltrate, or effusion is identified. An additional line with
metallic tip overlies the midline of the neck, ?temperature
probe. An additional view includes the tip of the NG tube
overlying the distal stomach.
Brief Hospital Course:
63 yom with minimal past medical history, who was transferred
from an OSH after being found unresponsive, in cardiac arrest
s/p acls and arctic sun, with findings of large ischemic infarct
and hemorrhagic conversion.
.
# Stroke: Patient had CT head in the ED which showed a MCA
territorial infarct w/ likely hemorrhagic conversion, PCA
infarct w/o conversion, and significant edema w/ rightward
midline shift. Patient was evaluated by neurosurgery and
neurology- he was started on hypertonic saline protocol with a
goal Na of 150-155, goal osms 315-320. They predicted a grim
prognosis given the extent of his stroke, edema, and the absence
of brainstem reflexes (no pupillary reflexes, no corneals, no
VOR, no gag to ETT wiggle, no cough to suction). He was started
on keppra 500 mg IV q12hr. Repeat head CT showed increased size
of left frontal hemorrhage with increased surrounding edema as
well as rightward shift concerning for increased rightward
subfalcine and downward transtentorial herniation. In addition,
there were new hypodensities in the basal ganglia and hippocampi
suggestive of global anoxic injury. Neurosurgery felt there was
no role for intervention. Neurology re-evaluated after the
patient had been rewarmed and found no significant changes in
his neurologic exam. They felt that meaningful recovery of any
neurologic function was essentially impossible. A family meeting
was held and the patient's family decided to first stop
escalating care, and then ultimately to terminally extubate
given his overall status. The patient expired on [**2189-6-28**] at
1:30AM.
.
# CAD/Cardiac arrest: EKG was concerning for an LAD lesion,
though the initial event was felt likely to be a stroke. It was
difficult to discern which changes were primary vs. secondary
related to CPR and the shocks he received. Anticogulation and
anti-platelet agents were held given his hemorrhagic stroke and
patient was re-warmed. Echo showed severe global left
ventricular systoilc dysfunction, most c/w a global process. The
patient's prognosis was dictated by his stroke - see above.
Medications on Admission:
Lorazepam 1-2 mg PO BID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2189-6-30**]
|
[
"276.2",
"427.5",
"300.00",
"348.5",
"557.9",
"V15.82",
"427.31",
"430",
"434.91",
"V10.91",
"348.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11962, 11971
|
9775, 11856
|
307, 307
|
12022, 12031
|
3444, 9752
|
12087, 12125
|
2650, 2767
|
11930, 11939
|
11992, 12001
|
11882, 11907
|
12055, 12064
|
2782, 2782
|
2347, 2426
|
247, 267
|
335, 2237
|
2796, 3425
|
2457, 2470
|
2259, 2327
|
2486, 2634
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,786
| 132,293
|
14049
|
Discharge summary
|
report
|
Admission Date: [**2169-12-13**] Discharge Date: [**2169-12-21**]
Date of Birth: [**2090-4-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary atrtery bypass grafts
x4(LIMA-LAD,SVG-DG,SVG-OM,SVG-dRCA) [**2169-12-15**]
left heart catheterization, coronary angiogram [**2169-12-14**]
History of Present Illness:
79 year old female with hx of colon cancer s/p R colectomy on
folfax presented to the ED with chest pain. She reports
intermittent anginal chest pain over the last few months. She
recently saw PCP [**Last Name (NamePattern4) **] [**12-7**] and was c/o severe chest discomfort.
At that time she described the pain as substernal and
nonradiating to arms, jaw or back. The pain woke her from sleep
at times and was usually relieved with warm water and Tums. In
addition, she also endorsed reflux symptoms, and pain associated
with meals. On the morning of presentation patient woke up with
severe chest pain and called EMS. She was found to have coronary
artery disease upon cardiac catheterization and is now being
referred to cardiac surgery for revasculariztion.
Cardiac Catheterization: Date:[**2169-12-14**] Place:[**Hospital1 18**]
LAD: long 95% ostial, 70% mid, 70% major diagonal
LCX: 60% major OM1
RCA: 60% ostial
Past Medical History:
- glaucoma
- CKD/CRI
- chronic hip and low back pain
- See podiatry for foot issues - multiple bumions
- Gout
- shingles [**2168-4-16**]
- Hypothyroidism
- Hypertension
- Hyperlipidemia
- Diabetes Mellitus
- Chronic Kidney Disease (baseline 1.8-2.0)
- Gastritis
- Hypothyroidism
- Glaucoma
- Osteoarthritis
- Stage III (T2 N1a M0) colon (cecal) adenocarcinoma S/p right
hemicolectomy and currently on adjuvant chemotherapy with
FOLFOX.
SurgHx:
status post right ankle surgery
status post right hand surgery
right hemicolectomy [**9-/2169**]
Social History:
Divorced. Lives alone. Has 5 children (4 live nearby).
Previously worked in a laundromat.
-Tobacco history: 30 pack year history - quit 37 years ago
-ETOH: denies
-Illicit drugs: denies
Family History:
Mother with hypertension
maternal grandmother with cancer of unknown primary and diabetes
father had an MI at the age of 98
brother with diabetes
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:74 Resp:16 O2 sat:100/RA
B/P Right:131/58 Left:131/60
Height:5'3" Weight:168 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
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 [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2169-12-13**] 10:40AM BLOOD Neuts-49.7* Lymphs-36.7 Monos-6.7
Eos-6.7* Baso-0.1
[**2169-12-18**] 03:48AM BLOOD WBC-6.8 RBC-3.24* Hgb-9.9* Hct-28.4*
MCV-88 MCH-30.4 MCHC-34.7 RDW-15.5 Plt Ct-92*
[**2169-12-18**] 09:03AM BLOOD PT-15.3* INR(PT)-1.4*
[**2169-12-17**] 12:33AM BLOOD PT-20.1* PTT-34.7 INR(PT)-1.9*
[**2169-12-15**] 03:02PM BLOOD PT-15.6* PTT-26.2 INR(PT)-1.5*
[**2169-12-15**] 02:07PM BLOOD PT-17.4* PTT-22.5* INR(PT)-1.6*
[**2169-12-14**] 02:30PM BLOOD PT-13.1* PTT-57.3* INR(PT)-1.2*
[**2169-12-18**] 03:48AM BLOOD Glucose-102* UreaN-30* Creat-2.4* Na-129*
K-4.3 Cl-94* HCO3-26 AnGap-13
[**2169-12-13**] 10:40AM BLOOD Glucose-230* UreaN-29* Creat-1.8* Na-141
K-3.8 Cl-104 HCO3-28 AnGap-13
[**2169-12-14**] 02:30PM BLOOD ALT-19 AST-34 CK(CPK)-110 AlkPhos-119*
Amylase-54 TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2169-12-14**] 07:33AM BLOOD CK-MB-10 cTropnT-0.93*
[**2169-12-13**] 10:31PM BLOOD CK-MB-17* cTropnT-0.99*
[**2169-12-13**] 10:40AM BLOOD cTropnT-0.44*
[**2169-12-20**] 04:17AM BLOOD WBC-10.8 RBC-3.42* Hgb-10.3* Hct-30.3*
MCV-89 MCH-30.1 MCHC-34.0 RDW-15.0 Plt Ct-183
[**2169-12-19**] 01:58AM BLOOD WBC-8.9 RBC-3.33* Hgb-10.1* Hct-29.1*
MCV-88 MCH-30.4 MCHC-34.7 RDW-15.4 Plt Ct-142*#
[**2169-12-18**] 03:48AM BLOOD WBC-6.8 RBC-3.24* Hgb-9.9* Hct-28.4*
MCV-88 MCH-30.4 MCHC-34.7 RDW-15.5 Plt Ct-92*
[**2169-12-20**] 04:17AM BLOOD Glucose-97 UreaN-30* Creat-1.9* Na-133
K-3.8 Cl-95* HCO3-29 AnGap-13
[**2169-12-19**] 01:58AM BLOOD Glucose-84 UreaN-30* Creat-2.0* Na-133
K-4.1 Cl-95* HCO3-32 AnGap-10
[**2169-12-18**] 03:48AM BLOOD Glucose-102* UreaN-30* Creat-2.4* Na-129*
K-4.3 Cl-94* HCO3-26 AnGap-13
TTE [**12-16**]
PRE-CPB:
The left atrium is markedly dilated. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Mild hypokinesis is seen in
the basal septal and anteroseptal segments. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma with mobile component in the
distal aortic arch, maximum height measuring 1.1cm. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta, maximum height
measuring 0.8cm. No thoracic aortic dissection is seen.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) central aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Trivial
mitral regurgitation is seen.
POST-CPB:
The patient is on a phenylephrine infusion. Left ventricular
systolic function appears mildly improved. Estimated EF>55%.
Right ventricular function is preserved. Valvular function is
unchanged from pre-bypass. There continues to be a PFO now with
bidirectional shunt. The mobile atheroma in the distal arch
appears unchanged. There is no evidence of aortic dissection.
Brief Hospital Course:
Mrs [**Known lastname 6105**] was admitted to the hospital with unstable angina
and after admission she remained pain free. Catherization was
done on [**12-15**] and this revealed 95% osteal LAD and triple vessel
disease. She was referred for surgical revascularization. She
was brought to the operating room on [**12-16**] where the patient
underwent coronary bypass grafting x4 with left internal mammary
artery left anterior descending coronary; reverse saphenous vein
single graft from the aorta to the first
diagonal coronary artery; reverse saphenous vein single graft
from the aorta to the first obtuse marginal coronary; as well as
reverse saphenous vein single graft
from aorta to the distal right coronary artery. See operative
note for full details. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD
1 found the patient extubated and breathing comfortably. She was
lethargic with a tenuous resiratory status initially post op and
therefore kept in the CVICU until POD 4. The patient was
neurologically intact but Percocet was stopped and Ultram was
given for pain medications due to lethargy. She was
hemodynamically stable on no inotropic or vasopressor support.
Her WBC fell to 1.7 initally post op and then rose to 5-6,000
and was normal at discharge. Oncology was consulted given her
recent chemotherapy and recommendations ade to follow ANC and
temperature and to have low index of suspicion for infection.
Heme-Onc outpatient follow up was arranged. The CTs were removed
on POD 2 and wires on POD 3 per cardiac surgery protocol. She
spiked a fever on POD 1 night was pan cultured but all cultures
were negative or pending at the time of discharge. Beta blocker
was initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery with an improved mental and
respiratory status. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD #6 the patient was ambulating with
assistance, the wound was healing well and pain was controlled
with Ultram and Tylenol. The patient was discharged to [**First Name4 (NamePattern1) 41920**]
[**Last Name (NamePattern1) **] rehab in good condition with appropriate follow up
instructions.
Medications on Admission:
COLCHICINE [COLCRYS] - 0.6 mg Tablet - 0.5 (One half) Tablet(s)
by mouth daily
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 20 mg Capsule, Delayed
Release(E.C.) - 1 Capsule(s) by mouth daily
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily
GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth at bedtime
INSULIN GLARGINE [LANTUS] - (Dose adjustment - no new Rx) - 100
unit/mL Solution - 25 units daily at night
INSULIN LISPRO [HUMALOG KWIKPEN] - 100 unit/mL Insulin Pen -
please take according to sliding scale at lunch and dinner
Sliding scale: 150-199 2u 200-249 4u 250-299 6u 300-349 8u > 350
10u
LEVOTHYROXINE - 25 mcg Tablet - one Tablet(s) by mouth daily
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth four times
a
day thirty minutes before meals and at bedtime
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth twice daily
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth Q 8 hour
take q8hour for 2 days after chemotherapy, then as needed for
nausea/vomiting
OXYCODONE - 5 mg Tablet - [**12-18**] Tablet(s) by mouth q4-6 hours as
needed for pain
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth Q
8 hour as needed for nausea/vomiting
SIMVASTATIN - 10 mg Tablet - one Tablet(s) by mouth taken in the
evening
SPIRONOLACTON-HYDROCHLOROTHIAZ - 25 mg-25 mg Tablet - 1
Tablet(s)
by mouth once a day
SUCRALFATE - 1 gram Tablet - 1 Tablet(s) by mouth before each
meal and before bed
ACETAMINOPHEN [ASPIRIN FREE EXTRA STRENGTH] - (Prescribed by
Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth three
times a day
CALCIUM CARBONATE-VITAMIN D3 - (OTC) - 500 mg calcium (1,250
mg)-400 unit Tablet - Tablet(s) by mouth
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. levothyroxine 25 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed for dryness.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
16. colchicine 0.6 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
18. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours).
19. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
20. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
21. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
22. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
23. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
24. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
25. lantus
25 units SQ qam
26. humalog
humalog insulin per sliding scale
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
unstable angina
s/p coronary artery bypass
insulin dependent diabetes mellitus
Stage 3 colon cancer
chronic kidney disease
hypertension
hypothyroidism
gout
s/p right hemicolectomy
glaucoma
osteoarthritis
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram and Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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) 914**] ([**Telephone/Fax (1) 170**]) on [**2170-1-22**] at 1:15pm in the
[**Hospital **] medical office building [**Doctor First Name **] suite2A
Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 62**] Date/Time:[**2170-1-8**]
10:30
Provider: [**First Name11 (Name Pattern1) 1521**] [**Last Name (NamePattern1) 1522**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2170-1-11**] 12:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2170-1-11**] 10:30
Please call to schedule appointments with:
Primary Care: Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]in [**3-22**] 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:[**2169-12-21**]
|
[
"244.9",
"410.71",
"274.9",
"V45.3",
"250.40",
"414.01",
"585.4",
"288.50",
"287.49",
"403.90",
"293.0",
"V58.67",
"V85.31",
"272.4",
"153.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"37.22",
"36.15",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
12485, 12607
|
6157, 8574
|
293, 443
|
12855, 13088
|
3130, 6134
|
14012, 15111
|
2186, 2447
|
10294, 12462
|
12628, 12834
|
8600, 10271
|
13112, 13989
|
2462, 3111
|
243, 255
|
471, 1398
|
1420, 1964
|
1980, 2170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,443
| 170,036
|
29584
|
Discharge summary
|
report
|
Admission Date: [**2111-4-29**] Discharge Date: [**2111-6-3**]
Date of Birth: [**2035-10-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Renal failure and Hyperkalemia
Major Surgical or Invasive Procedure:
Nephrostomy tube replacement X 3 and removal
Pecutaneous Liver bx
Tunneled Hemodialysis Line placement
Nephrogram with balloon tamponade
Renal Angiogram
History of Present Illness:
75 y.o. M with h/o transition cell cancer of the bladder in [**2105**]
s/p resection and treated with postop BCG therapy, who was
diagnosed wtih TCC of the R kidney in [**9-/2110**] when he developed
hematuria. He is s/p resection of R renal mass in [**1-/2111**] with
placement of nephrostomy tube for administration of BCG. (The
patient declined nephrectomy because he did not want to have
dialysis.) Six weeks after the resection he began treatments
with IFN and BCG. After his third weekly treatment, two weeks
ago he developed increased weakness, chills, low grade temps, +
sweats, increased passage of clots in the nephrectomy tube and
the penis. + Dry cough for 3 weeks. These symptoms were thought
to be secondary to the IFN. His last treatment scheduled for [**4-23**] was held [**1-16**] to these sx. Five days prior to admission his
nephrostomy tube stopped draining, he developed a cough, dry
heaves, +anorexia and 10lb weight loss. + difficulty generating
urinary stream. + Motrin use within the last week. Given his
constitutional symptoms, his bloodwork was checked today which
demonstrated a leukocytosis of 30 K, anemia with HCT = 22, Cr =
15.8. His K was 7.2. He was sent to the ED. These symptoms
persisted and thus today in urology clinic his nephrostomy was
changed. ECG in the ED demonstrated NSR without acute changes. A
foley catheter was placed and it drained 200 cc of bloody urine.
He was given ceftriaxone 1 g IV, vancomycin 1 gm IV- prior to
cultures being drawn, insulin 10 U IV, 1 am D50, calcium gluco
On review of systems, the pt. denied pruritis or ocular
swelling. Denied headache, sinus tenderness, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain or
tightness, palpitations. No diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denied arthralgias or myalgias
Past Medical History:
TCC s/p TUR in [**2105**] and 6 treatments of BCG followed with yearly
negative cystoscopies
[**1-21**] s/p Right renal exploration, right pyelotomy, open
excision of right renal pelvic tumor, right ureteral stent
removal and right nephrostomy tube placement.
L atrophic kidney due to likely obstruction and pyelonephrosis
Social History:
Lives with his wife in [**Name (NI) 7658**], MA. Remote history of smoking.
Quit 40 years ago. 20-pack-year smoking history. Retired from
[**Company **] as the head of the flight division. Does his
own finances
Family History:
two sisters have also had bladder cancer
Physical Exam:
Physical Exam on Admission
Tm = 100.6 P 80s BP 149/55 RR O2Sat 99% on RA
GENERAL:Well appearing elderly male who appears his stated age.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. guiac negative stool in ED.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
Pertinent Results:
[**2111-5-15**] 05:25PM BLOOD HCV Ab-NEGATIVE
[**2111-5-15**] 07:15AM BLOOD PEP-NO SPECIFI
[**2111-6-1**] 07:10AM BLOOD CEA-2.5 AFP-<1.0
[**2111-5-15**] 05:25PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2111-5-16**] 08:00PM BLOOD PTH-90*
[**2111-4-30**] 12:43AM BLOOD calTIBC-170* Ferritn-801* TRF-131*
[**2111-4-29**] 07:35AM BLOOD Creat-15.4*#
[**2111-5-21**] 06:45AM BLOOD Glucose-87 UreaN-18 Creat-5.6*# Na-140
K-4.3 Cl-99 HCO3-32 AnGap-13
[**2111-6-1**] 07:10AM BLOOD Glucose-74 UreaN-32* Creat-8.4*# Na-131*
K-4.6 Cl-94* HCO3-25 AnGap-17
[**2111-4-29**] 04:00PM BLOOD Neuts-95.8* Bands-0 Lymphs-1.9*
Monos-1.9* Eos-0.2 Baso-0.2
[**2111-4-29**] 07:35AM BLOOD WBC-29.5*# RBC-2.72* Hgb-7.9*# Hct-24.5*
MCV-90 MCH-28.9 MCHC-32.1 RDW-14.5 Plt Ct-723*
[**2111-4-30**] 05:07AM BLOOD WBC-12.9* RBC-1.96* Hgb-5.8* Hct-17.3*#
MCV-89 MCH-29.4 MCHC-33.2 RDW-14.0 Plt Ct-486*
[**2111-5-1**] 06:31PM BLOOD Hct-25.2*
[**2111-5-8**] 09:10PM BLOOD Hgb-9.8* Hct-30.8*
[**2111-5-26**] 03:30PM BLOOD Hct-24.1*
[**2111-5-30**] 07:00AM BLOOD WBC-10.9 RBC-3.44*# Hgb-10.1*# Hct-31.1*#
MCV-91 MCH-29.5 MCHC-32.6 RDW-15.7* Plt Ct-462*
[**2111-6-1**] 07:10AM BLOOD Hct-26.7*
[**2111-6-1**] 05:10PM BLOOD Hct-29.6*
[**2111-6-2**] 07:30AM BLOOD Hct-29.2*
[**2111-6-3**] 07:45AM BLOOD Hct-24.8*
[**2111-6-3**] 02:00PM BLOOD Hct-26.8*
[**2111-5-14**] 04:53PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
.
[**4-29**] Renal U/S
FINDINGS: The right kidney measures 15.4 cm. A percutaneous
nephrostomy tube is partially visualized. The left kidney is
atrophic and measures approximately 6.7 cm and demonstrates a
3.8 x 2.3 x 2.6 cm peripelvic cyst. No hydronephrosis or mass is
noted.
.
Renal Scan
IMPRESSION:
Minimal function in both kidneys, right slightly greater than
left.
.
MRI Brain
MRI OF THE BRAIN: There is no evidence of acute brain ischemia.
There is mild brain atrophy, resulting in slight sulcal and
ventricular prominence. There is no abnormal signal within the
brain parenchyma. The craniocervical junction appears
unremarkable.
.
There is high T2/FLAIR signal within one of the right frontal
air cells. Magnetic susceptibility artifact is seen in the area
of the medial right maxillary sinus anteriorly, which may relate
to some sort of metal in this localization.
.
MRA OF THE BRAIN: There is no area of hemodynamically
significant stenosis, or aneurysmal dilation within the circle
of [**Location (un) 431**] or its major branches. There is no evidence of
arteriovenous malformation. The right vertebral artery is not
visualized, which is likely a developmental/congenital finding.
.
IMPRESSION:
1. No evidence of acute brain ischemia.
2. Chronic paranasal sinus disease as described above.
3. Metallic artifacts in the right nose/right maxillary sinus.
Please clinically correlate.
4. No evidence of aneurysm or significant stenosis within the
circle of [**Location (un) 431**]
.
MRI Abdomen:
FINDINGS:
There has been interval development of multiple metastatic
lesions throughout all lobes of the liver measuring up to 1.8 cm
in size. There has been interval increase in size of the right
renal mass, which infiltrates the entire right kidney, enlarges
it, and extends beyond it into the adjacent perirenal fat,
measuring 14.2 cm in craniocaudad extent. The collecting system
is nearly entirely replaced by diffuse infiltrative tumor. Tumor
or clot within the collecting system extends down to the level
of the right ureterovesicular junction. Additionally, this tumor
invades the right renal vein and extends superiorly into the
infrahepatic IVC to approximately 2.5 cm below the junction of
the right hepatic vein with the cava. There is no invasion into
the hepatic veins or right atrium. Additionally, there is direct
invasion of tumor through the right renal venous wall into the
surrounding perivenous fat.
.
Right paracolic gutter peritoneal metastasis measures 2.0 cm in
short axis dimension. There are multiple enlarged pericaval and
periaortic lymph nodes, the largest of which is best seen on
series 3, image 8, measuring 2.3 cm in maximal width. There is
no evidence for osseous metastatic disease. There is trace
abdominal ascites.
.
The remainder of the abdominal viscera, the left adrenal gland,
pancreas, and spleen are unremarkable on this limited
non-contrast evaluation. The left kidney is atrophic with a
hydronephrotic collecting system.
.
IMPRESSION:
Marked interval progression of primary tumor with new
metastases. infiltrating expansile right renal transitional cell
carcinoma extending into the right renal vein and the hepatic
IVC approximately 2.5 cm below the venous confluence. There is
also direct extension through the right renal vein and through
the right renal capsule involving the adjacent perinephric fat.
Multiple hepatic metastases, bulky enlarged retroperitoneal
lymph nodes, mesenteric lymph nodes, and at least one peritoneal
deposit is also seen.
.
Metastatic carcinoma, poorly differentiated, consistent with
urothelial origin (see comment). Comment. The tumor resembles
that seen in this patient's prior biopsy, S07-8064 (right renal
pelvic tumor).
Brief Hospital Course:
Acute renal failure due to obstructive uropathy: given elevated
Cr on admission and obstructive uropathy, patient underwent
placement of tunneled HD line. Nephrology followed in house.
Pt will continue TIW HD sessions as an outpatient.
.
Hematuria: main issue during the hospitalization. Underwent
numerous attempts to control massive hematuria, including CBI,
nephrostomy tube exchange, tamponade by IR, and ultimatley
angiogram (which did not show active extravasation).
Eventually, HCT remained stable, and Foley/PCN removed.
Nephrectomy not felt to be an option given metastatic disease.
Will continue to have HCT followed closely as an outpatient.
.
Metastatic bladder transitional cell cancel (to liver,
retroperitoneum): pt underwent U/S guided liver bx which
confirmed metastatic TCC. The MRI of Abdomen also revealed
interval progression of primary tumor with new metastases. In
addition, the tumor extended into the right renal vein and the
hepatic IVC approximately 2.5 cm below the venous confluence.
Bulky enlarged retroperitoneal lymph nodes, mesenteric lymph
nodes, and at least one peritoneal deposit were also seen. Seen
by primary urologist, Dr. [**Last Name (STitle) **], who felt that the patient no
longer had surgical options for resection given metastatic
disease. Dr. [**Last Name (STitle) **] (GU oncology) felt that the risks of
palliative chemotherapy (ie, TCP and subsequent bleeding)
outweighed any benefit that the patient may receive. However,
should the patients bleeding continue to stabilize over a longer
period of time, palliative chemorx may become an option.
Medications on Admission:
blood pressure pill- he does not know the name of it
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*60 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Outpatient Lab Work
CBC, Chem7, Ca/Mg/Phos
Please send to Dr. [**Last Name (STitle) 16968**] office
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute renal failure due to obstructive uropathy
Secondary: Hematuria, Metastatic bladder transitional cell
cancer (to liver, retroperitoneum), chronic blood loss anemia,
urinary tract infection
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with acute renal failure due to urinary
obstruction.
1) Please take all medications as prescribed. You have been
started on Renagel to control your phosphate level.
2) Please follow-up as indicated below.
3) Please contact your primary care doctor or come to the
emergency room if you develop decreased urinary output, blood or
clots in your urine, abdominal pain, fevers, chills, or other
symptoms that concern you.
Followup Instructions:
1) Primary Care: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16968**]
([**Telephone/Fax (1) 34574**]) within 1-2 weeks following discharge. Please get
your blood counts checked on [**6-5**] and faxed to his office.
2. Please call Dr. [**Last Name (STitle) **] as needed
|
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31,502
| 125,192
|
41
|
Discharge summary
|
report
|
Admission Date: [**2174-7-22**] Discharge Date: [**2174-8-5**]
Date of Birth: [**2093-11-17**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
upper endoscopy, dialysis
History of Present Illness:
This is a 80yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]
and recent aortic valvuloplasty [**2174-5-11**] s/p multiple
hospitalizations for CHF exacerbation (last d/c [**2174-7-20**]) who
returns w/SOB x several hours. Her husband noted that she went
home feeling well. She was breathing comfortably, w/o any
episodes of CP/palpitations/SOB. This AM ~2AM, she awoke to use
the bathroom and made good urine. She felt "funny" but denied
SOB at the time. She used the 2L oxygen with which she had been
discharged and felt comfortable until ~4:45AM when she became
acutely SOB. He notes that he has been trying to adhere to 2gm
sodium diet and she was compliant with her medications.
Yesterday she ate: Cheese blintz w/sour cream, shrimp w/small
amount of cocktail sauce, coke, cookie w/22mg sodium, gouda
cheese, salmon w/dill sauce(small portion), protein bar.
.
In the ED, her initial VS were: 97.8 BP 160/110 HR 107. She was
in respiratory distress and required emergent intubation. A CVL
was placed. She was started on a Nitroglycerin drip for
hypertension.
.
On review of symptoms, her husband denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, hemoptysis. She
denies exertional buttock or calf pain. During her prior
admission, she had guiac +stool, but did not have any bowel
movements during her brief stay at home. Her husband denies that
she had fever/chills/cough at home. He does note periods of
apnea when she is asleep.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, +2 pillow
orthopnea at baseline- unchanged, ankle edema, palpitations,
syncope or presyncope.
.
Past Medical History:
- CAD--one vessel disease on cath in [**5-/2174**], s/p stent to LCx
Severe AS s/p valvuloplasty [**4-/2174**] ([**Location (un) 109**] from 0.56->0.74; Grad
from 24->12)
- Chronic systolic CHF, EF 30-40%
- HTN
- strep viridans bacteremia
- CRI with Cr 1.3-2.5 over last month, was on hemodialysis for
one month in [**2174-4-14**]
- Scoliosis with chronic back pain on vicodin
- h/o MRSA from LLE trauma in [**2173-7-14**]
- h/o cholelithiasis
- osteoarthritis
- herpes zoster
- Gastritis
- h/o H. pylori
- Anemia--baseline Hct 26-30
- h/o right inguinal herniorrhaphy in [**2156**]
- Myositis s/p muscle biopsy at [**Hospital1 112**], possibly related to statin
use
- s/p right nephrectomy [**2165**] for renal cell carcinoma
OUTPATIENT CARDIOLOGIST: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**]
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**]
Nephrologist: [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**]
ALLERGIES: statin--myositis
Social History:
Social history is significant for the absence of current tobacco
use; she smoked [**12-15**] PPD from age 18 to age 60. There is no
history of alcohol abuse; she occasionally has wine. Uses a
walker; no recent falls.
Family History:
Father died of a heart valve problem at age 52 and 4 of her
siblings had heart problems (though not valvular disease).
Physical Exam:
VS: T 97.7, BP 108/51, HR 96, RR 20, O2100% on AC 100%500x16
PEEP5
Gen: elderly woman intubated, sedated
HEENT: NCAT. Sclera anicteric. right pupil, small, nonreactive.
left pupil also small, minimally reactive. EOMI. Conjunctiva
were pink
Neck: Supple, unable to assess JVP due to positioning.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: + scoliosis, No chest wall deformities or kyphosis.
Coarse BS bilaterally anteriorly. Resp were unlabored, no
accessory muscle use. No obvious crackles, wheeze, rhonchi.
Abd: Obese, soft, + slightly distended, NT, No HSM or
tenderness. No abdominial bruits. Ecchymoses noted.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
[**2174-7-22**] 06:05AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2174-7-22**] 06:05AM FIBRINOGE-434*
[**2174-7-22**] 06:05AM PLT COUNT-500*
[**2174-7-22**] 06:05AM PT-13.8* PTT-18.7* INR(PT)-1.2*
[**2174-7-22**] 06:05AM WBC-13.2* RBC-4.24 HGB-12.4 HCT-37.7 MCV-89
MCH-29.3 MCHC-33.0 RDW-16.3*
[**2174-7-22**] 06:05AM GLUCOSE-248* LACTATE-4.0* NA+-139 K+-4.8
CL--102 TCO2-20*
[**2174-7-22**] 06:05AM cTropnT-0.01
[**2174-7-22**] 06:05AM CK-MB-NotDone
[**2174-7-22**] 06:05AM CK(CPK)-17* AMYLASE-35
[**2174-7-22**] 06:05AM UREA N-71* CREAT-2.0*
[**2174-7-22**] 06:35AM TYPE-ART TEMP-36.3 RATES-0/14 TIDAL VOL-500
PEEP-5 O2-100 PO2-225* PCO2-47* PH-7.30* TOTAL CO2-24 BASE XS--3
AADO2-437 REQ O2-76 INTUBATED-INTUBATED VENT-CONTROLLED
[**2174-7-22**] 04:35PM MAGNESIUM-3.1*
[**2174-7-22**] 04:35PM UREA N-74* CREAT-2.3* SODIUM-139
POTASSIUM-4.1
[**2174-7-22**] 05:13PM TYPE-ART PO2-75* PCO2-36 PH-7.44 TOTAL CO2-25
BASE XS-0
[**2174-8-1**]: Upper GI Endoscopy - According to the GI Fellow, they
had found several bleeding AVM's at the Gastric and Duodenal
border similar to an endoscopy done a month prior. GI was able
to cauterize 3 of the AVM's.
Brief Hospital Course:
This is a 80yo woman with h/o CAD s/p recent DES to LCX and AS
s/p valvuloplasty admitted on [**7-22**] for another CHF exacerbation,
receiving diuresis/HD, pt course was complicated by GI bleeding,
underwent dialysis prior to leaving. It was decided that the
patient was not a candidate for surgical intervention of the
stenotic valve at this time.
.
# CHF Exacerbation: The patient had several episodes of
desaturation and acute shortness of breath. The patient was
given progressive doses of lasix, typically IV at 100mg. She
became refractory to Lasix dosing and required priming with
diuril. The patient was transferred from CCU to the floor, at
which point she developed both acute shortness of breath and
progressive hematemesis which prompted her return back to the
CCU. She developed renal failure shortly thereafter, and
required hemodialysis. After frequent dialysis, the Pt. is now
satting at 98% on 4L and is fairly comfortable.
.
# Coronary artery disease: DES to LCx in [**2174-5-11**], other
coronaries w/o obstructive dz. No evidence of acute ischemic
changes during admission. The patient had been receiving ASA
and Plavix along with carvedilol, the ASA and plavix were
discontinued after the episode of upper GI bleeding.
.
# Aortic Stenosis: s/p valvuloplasty, not thought to be good
surgical candidate due to large atheroma. No realistic
percutaneous option as patient has 4 exclusion criteria for most
feasible trial. Last TTE [**7-27**] w/aortic valvular area of 0.5
cm2.
.
# ID Issues: Pt recently ended course of Vancomycin for strep
veridins bacteremia. Blood and Urine cultures have been
negative, TTE negative for any endocarditis. Urine cultures
negative with postitive UA. The patient had her foley removed
and she completed a course of cipro for 5 days.
.
# Upper GI Bleed: The patient devleped retching and hematemesis
on [**8-1**], which was similar to an episode a month earlier. At
that time she was scoped and found to have multiple bleeding
AVM's which were cauterized and had a stable Hct. At this time,
the patient was found to again have multiple AVM's which were
bleeding. The patient was transferred back to the ICU after a
hematocrit drop of over 7 to 19, was given 3 units of blood.
She summarily went into flash pulmonary edema with concomitant
renal failure, and had to be dialyzed. The patient was given 1
more unit of blood and placed on Epo before discharge, Hct has
been stable at baseline of 26 for the 48 hours prior to
discharge.
.
# Acute on Chronic Renal Failure: The patient had been
responsive to high doses of lasix (100mg) with diuril priming.
However, when the patient developed hematemesis and had an acute
blood loss, she subsequently developed renal failure, and when
she had a subsequent episode of flash pulmonary edema, she
received urgent dialysis and a tunnelled HD line was placed.
She received dialysis prior to discharge, and had been followed
by Dr. [**Last Name (STitle) 118**].
Medications on Admission:
Aspirin 81 mg
Carvedilol 12.5 mg PO BID
Clopidogrel 75 mg
Camphor-Menthol 0.5-0.5 % Lotion as needed for itching.
Sevelamer HCl 800 mg PO TID W/MEALS
Gabapentin 300 mg PO Q48H
Hydrocodone-Acetaminophen 5-500 mg PO every six hours as needed
Prilosec 20 mg
Sodium Chloride 0.65 % Aerosol, Nasal
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg Tablet
Furosemide 160 mg Tablet DAILY
Fexofenadine 60 mg [**Hospital1 **]
Atrovent HFA 1 Inhalation four times a day.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
4. Ipratropium Bromide 0.02 % Solution Sig: [**12-15**] Inhalation Q6H
(every 6 hours) as needed.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-15**] Inhalation Q6H (every 6 hours) as needed
for sob/wheeze.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**12-15**] Adhesive Patch, Medicateds Topical QD () as needed for pain.
13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for PRN pain relief.
14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**]
Drops Ophthalmic PRN (as needed).
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: [**12-15**] Injection
PRN (as needed) as needed for line flush.
18. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
20. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
21. Morphine Sulfate 1 mg IV Q2H:PRN
22. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
23. Ondansetron 4 mg IV Q8H:PRN
24. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
25. Pantoprazole 40 mg IV Q12H
26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Acute on Chronic Congestive Heart Failure
Aortic Stenosis
Upper Gastrointestinal Atriovenous Malformations
Acute on Chronic Renal Failure
Secondary:
Strep viridans bacteremia
Renal cell carcinoma
Scoliosis
cholelithiasis
osteoarthritis
herpes zoster
Gastritis
Anemia
Myositis
Discharge Condition:
ambulating with marked assistance, tolerating PO feeds, vital
signs stable, hemodialysis dependent
Discharge Instructions:
You were recently admitted to the CCU because of shortness of
breath and during your course at the hospital, an episode of
vomiting blood. An endoscopy of the top portion of your
intestinal tract showed some bleeding vessels, which the GI
doctors were [**Name5 (PTitle) 460**] to coagulate while doing the scope. Also, we
are now dialyzing you to remove the fluid from your body to
prevent the shortness of breath that you've been feeling.
Additionally, you have received several units of blood and
you've been given a medicine to cause your body to make more
blood. You are now going to be transferred the [**Hospital 100**] Rehab
MACU for further care. You will be seen by Dr. [**Last Name (STitle) 118**] at the
rehabilitation center, as you will be able to receive dialysis
there. Also, you are scheduled for two appointments in the
upcoming week, one with Dr. [**Last Name (STitle) **], and one with Dr. [**Last Name (STitle) 120**].
You have a repeat [**Last Name (STitle) 461**] scheduled in early [**Month (only) 462**] as
well. Please attend all of these appointments.
Followup Instructions:
1. Provider: [**First Name4 (NamePattern1) 125**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-8-10**] 9:00 AM
2. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-8-11**] 3:20
3. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-8-18**] 11:00
4. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2174-9-28**] 11:15
Completed by:[**2174-8-5**]
|
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"96.04",
"38.93",
"99.04",
"93.90",
"38.95",
"42.33",
"39.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11804, 11870
|
5701, 8671
|
292, 320
|
12199, 12300
|
4474, 5678
|
13432, 14021
|
3415, 3536
|
9187, 11781
|
11891, 12178
|
8697, 9164
|
12324, 13409
|
3551, 4455
|
233, 254
|
348, 2086
|
2108, 3163
|
3179, 3399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,276
| 111,860
|
28928
|
Discharge summary
|
report
|
Admission Date: [**2168-8-26**] Discharge Date: [**2168-9-6**]
Date of Birth: [**2133-8-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p 15 ft fall
Major Surgical or Invasive Procedure:
[**2168-8-30**] ORIF bilat radius fractures
[**2168-8-27**] Halo placement
[**2168-8-26**] Bilateral retrograde femoral nail
[**2168-9-1**] IVC filter placement
History of Present Illness:
35 yo male s/p 15 ft fall, landing on back; no LOC. Complaining
of bilateral leg pain
Past Medical History:
Denies
Social History:
+EtOH
Family History:
Noncontributory
Physical Exam:
Admission PE:
T: 98.0, HR: 82, BP: 122/77, RR: 18, O2 Sat: 100% RA
Neuro: A&Ox3, GCS 15
HEENT: NCAT, PERRL, C-Collar in place
CV: RRR
Chest: CTAB, no deformities
Abd: Soft/NT/ND. FAST negative
Rectal: good rectal tone
Back: spine non-tender
Extremities: pulses 2+ bilaterally in UE and LE. L wrist
fracture, bilateral LE in traction, bilateral deformities of
femurs
Pelvis: stable
Pertinent Results:
[**2168-8-26**] 08:26PM UREA N-12 CREAT-1.1
[**2168-8-26**] 08:26PM AMYLASE-80
[**2168-8-26**] 08:26PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-8-26**] 08:26PM GLUCOSE-93 LACTATE-1.3 NA+-145 K+-4.3 CL--106
[**2168-8-26**] 08:26PM HGB-12.7* calcHCT-38 O2 SAT-61 CARBOXYHB-2.6
MET HGB-0.2
[**2168-8-26**] 08:26PM WBC-12.5* RBC-5.34 HGB-12.9* HCT-38.0*
MCV-71* MCH-24.1* MCHC-33.9 RDW-14.7
[**2168-8-26**] 08:26PM PLT COUNT-193
[**2168-8-26**] 08:26PM PT-13.0 PTT-22.1 INR(PT)-1.1
CT C-SPINE W/O CONTRAST
Reason: C2 fracture from OSH
[**Hospital 93**] MEDICAL CONDITION:
35 year old man s/p fall
REASON FOR THIS EXAMINATION:
C2 fracture from OSH
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of trauma, status post fall. History of C2
fracture seen on study from an outside hospital.
COMPARISON: None.
TECHNIQUE: Contiguous axial images of the cervical spine were
obtained with coronal and sagittal reconstructions.
CT C-SPINE: There are fractures extending through the transverse
foramen of C2 bilaterally. The left fracture demonstrates
several millimeters of distraction of the fracture fragments.
Additionally, there is associated 3-mm grade I anterolisthesis
of C2 on C3. No other fractures are identified. The dens
articulates normally with the anterior aspect of C1. The
atlantoaxial space is preserved. The lateral masses of C1
articulate normally with the dens. No other fractures are
identified. The spinal canal is widely patent. There is limited
evaluation of intrathecal contents; however, the contour of the
thecal sac is within normal limits.
IMPRESSION: There are fractures extending through the transverse
foramen of C2 bilaterally. There is associated grade I
anterolisthesis of C2 on C3. Given the location of the
fractures, there is concern for associated vertebral artery
injury, and further evaluation with a CTA is recommended.
BILAT LOWER EXT VEINS
Reason: TRAUMA,EVAL FOR DVTS
[**Hospital 93**] MEDICAL CONDITION:
35 year old man with bilateral femur fractures
REASON FOR THIS EXAMINATION:
evaluate for DVTs
INDICATION: Bilateral femur fractures. Evaluate for DVT.
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 867**] of the right common
femoral and superficial femoral veins were performed. The
popliteal veins were not evaluated due to the patient's
bilateral leg fractures. Normal flow, augmentation,
compressibility and waveforms were demonstrated within the
vessels examined. No intraluminal thrombus is identified.
IMPRESSION: No evidence of DVT in the right or left common
femoral or superficial femoral veins. Please note that the
popliteal veins were not examined.
FOOT AP,LAT & OBL BILAT; TIB/FIB (AP & LAT) BILAT
Reason: eval fracture
[**Hospital 93**] MEDICAL CONDITION:
35 year old man with fall
REASON FOR THIS EXAMINATION:
eval fracture
INDICATION: Status post fall.
ELEVEN VIEWS OF THE SPINE, HIPS, AND LOWER EXTREMITIES:
There is no evidence of fracture or malalignment within the
thoracic and lumbosacral spine. There is no fracture or
dislocation within the hips. There are bilateral transverse
overriding medially displaced femoral shaft fractures with
fracture fragments. The knees and ankles demonstrate no evidence
of fracture. Joint spaces of the knees and ankles are preserved.
IMPRESSION:
Bilateral displaced overriding femoral shaft fractures.
FOOT AP,LAT & OBL BILAT; TIB/FIB (AP & LAT) BILAT
Reason: eval fracture
[**Hospital 93**] MEDICAL CONDITION:
35 year old man with fall
REASON FOR THIS EXAMINATION:
eval fracture
INDICATION: Status post fall.
ELEVEN VIEWS OF THE SPINE, HIPS, AND LOWER EXTREMITIES:
There is no evidence of fracture or malalignment within the
thoracic and lumbosacral spine. There is no fracture or
dislocation within the hips. There are bilateral transverse
overriding medially displaced femoral shaft fractures with
fracture fragments. The knees and ankles demonstrate no evidence
of fracture. Joint spaces of the knees and ankles are preserved.
IMPRESSION:
Bilateral displaced overriding femoral shaft fractures.
Brief Hospital Course:
Patient admitted to trauma service. Orthopedic and Spine surgery
were consulted because of his injuries. He was taken to the
operating room for repair of his multiple extremity fractures on
[**8-26**] and [**8-30**]. He can be weight bearing as tolerated LLE; he is
touch-down weight bearing on RLE and must wear [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] brace
at 0-90 degress. He is non-weightbearing for bilat UE's.
He was taken to the operating room by Spine where a Halo was
placed on [**8-27**] for his cervical fracture. Postoperatively he has
done well. His pain is being controlled with Oxycodone.
An IVC filter was placed because of his increased risk for
venous thrombus; he was also placed on daily Lovenox.
Physical and Occupational therapy were consulted and have
recommended short rehab stay.
Medications on Admission:
None.
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day as needed for per sliding scale.
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection of 30
mg Subcutaneous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p 15 ft Fall
Cervical fracture C2
Bilateral Distal Radius Fracture
Bilateral Femoral Fractures
Discharge Condition:
Stable
Discharge Instructions:
You must wear the halo brace at all times, until otherwise
stated by the spine physicians.
You are "touch down weight bearing" on your right leg - i.e.
your toes may touch the ground but no weight should be placed on
it; you should use crutches to keep the weight off that leg.
You need to wear the [**Doctor Last Name **] brace on your right knee locked
between 0 and 90 degrees. You may bear weight as tolerated on
your left leg.
Continue to wear the splints on your arms until otherwise
instructed by orthopedics. You should not bear weight with your
arms.
You will need to continue to take blood thinners for the next 4
weeks.
Follow up with Orthopedics and Spine surgery in the next [**3-4**]
weeks.
You should be seen by a physician/return to an Emergency
Department for:
*if you are unable to move your arms or your legs or develop
weakness in your arms or legs
*difficulty breathing
*numbness or tingling in your arms or your legs
*if you develop swelling in your arms/legs, and/or your
fingers/toes become cold or blue
*worsening pain in your arms or your legs
*other symptoms that concern you.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for an appointment with, Dr. [**Last Name (STitle) 1005**],
Orthopedics in 2 weeks.
Call [**Telephone/Fax (1) 3573**] for an appointment with, Dr. [**Last Name (STitle) 363**], Spine
surgery in [**3-4**] weeks.
Completed by:[**2168-9-6**]
|
[
"805.02",
"813.42",
"821.00",
"E884.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.7",
"79.32",
"93.41",
"78.55",
"93.54",
"02.94"
] |
icd9pcs
|
[
[
[]
]
] |
6857, 6929
|
5248, 6081
|
328, 492
|
7070, 7079
|
1112, 1703
|
8238, 8514
|
676, 693
|
6137, 6834
|
4631, 4657
|
6950, 7049
|
6107, 6114
|
7103, 8215
|
708, 1093
|
274, 290
|
4686, 5225
|
520, 607
|
629, 637
|
653, 660
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,305
| 137,807
|
23158
|
Discharge summary
|
report
|
Admission Date: [**2171-7-15**] Discharge Date: [**2171-7-22**]
Date of Birth: [**2103-2-27**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Dizziness, left face and arm weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 68 year old right handed male with a past
medical history significant for HTN and DM2, who presented from
an OSH with a right basal ganglia hemorrhage.
The patient was somewhat sleepy but able to tell the general
story. There were no other witnesses currently present. The
patient reported that he was at church this Sunday. He felt
most
of the service was uneventful, he could remember getting
particularly upset or excited during the service. He noted at
around 4 the service had ended and he was getting up to leave
and
noted he felt "dizzy" He denied any vertigo but felt like he
was
having difficulties standing upright and was leaning to the
left.
He also noted that he was having difficulty keeping his hat in
his left hand. He thinks someone also noted that he had a
facial
droop and he was sent to the local ED (which was [**Hospital3 **]). About ~1-2 hours later he developed a left sided
headache, which then progressed to involving his whole head.
During this episode he was able to understand everyone around
him
and had no difficulty with communication.
At [**Hospital3 4107**] he was noted be hypertensive (180/100) and to
have face/arm and leg weakness. He also was left alone briefly
and apparently had a fall. He stated he was reaching for his
wallet and fell forward hitting his head on the floor. He then
had a head CT which showed the right sided basal ganglia
hemorrhage. He was then sent to [**Hospital1 18**] for further evaluation.
On neuro ROS, the pt reports a bifrontal headache. He denies
any
loss of vision, blurred vision, diplopia. He has notable
dysarthria. No lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- DM2
- HTN
- history of ?blood clot in legs (unclear -> he is possibly just
describing varicosities, had a laser treatment in last few
years)
Social History:
Patient lives in an apartment by himself, but right
above his daughter. [**Name (NI) **] is a retired iron worker. He has no
etoh, tob or drug use history. His wife is deceased.
Family History:
Some diabetes and HTN in the family, no known history
of stroke. 2 brothers died of complication of diabetes
Physical Exam:
Vitals: T:97.3 P:83 R: 16 BP:189/98 SaO2:97
General: Sleepy, will awake and answer [**1-31**] questions but will
fall back asleep if not continually stimulated, otherwise
cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: mild LE and venous stasis changes at feet
bilaterally.2+ radial b/l
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Sleepy, requires continued stimulation but can
answer two-three part questions. Alert, oriented x 3. Somewhat
inattentive, able to name DOW backwards with constant prompting
Language is dysarthric but 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. Able to follow both midline and
appendicular commands. Poor recall 0/3 in 5 minutes. Appears to
neglect left side.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. Difficult to determine if field
cut, appears to see in all visual fields to motion, will not pay
attention for confrontation testing.
III, IV, VI: EOMI without nystagmus. Normal saccades. R
exotropia
V: Facial sensation intact to light touch.
VII: L sided facial droop, forehead spared
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, slightly increased tone in legs.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 4 5- 4+ 4+ 5 4 4+ 5 5- 5- 5 5-
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Decreased sensation to light touch on left leg to
around knee but no clear level, decreased to pin on left
hemibody. Decreased proprioception at left toe. Extinction to
DSS on left side.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was upgoing on left, down on right
-Coordination: With right hand normal FNF/HKS, unable to perform
on R
-Gait: Deferred
Pertinent Results:
[**7-14**] EKG
Sinus rhythm with probable sinus arrhythmia and atrial premature
beats. Low amplitude lateral lead T wave changes are
non-specific. Since the previous tracing of [**2165-11-26**] atrial
ectopy is present and T wave abnormalities have decreased.
[**7-14**] CT Head
Acute 4 x 2 cm right lentiform nucleus hemorrhage with
surrounding edema and mild adjacent mass effect, as above. No
prior for
comparison. Findings are most likely due to hypertensive
hemorrhage, although underlying mass can not be entirely
excluded. Consider further evaluation with MRI if no
contraindication.
[**7-15**] CT Head
No interval change in right lentiform nucleus hemorrhage. No new
hemorrhage.
[**7-18**] ECHO
Moderate left ventricular hypertrophy with normal systolic
function.
[**7-19**] CT Head
Unchanged right lentiform nucleus hemorrhage. No new hemorrhage
or fractures.
[**7-19**] Renal U/S
1. No evidence of renal artery stenosis.
2. Moderate left hydronephrosis; CT recommended to Dr. [**Last Name (STitle) 19825**]
(covering for Dr. [**Last Name (STitle) **].
3. Right polar cyst 1cm
Brief Hospital Course:
ICU Course: patient was admitted with R putamen hemorrhage in
the setting of HTN, DM2 and medication noncompliance. Exam was
somnolent but arousable to voice, L arm weakness in UMN pattern
and minimal L leg weakness. L facial droop was present. The
patient's blood pressure was controlled on nicardopine drip and
he was transitioned to oral agents (lisinopril 30 mg daily,
amlodipine 10 mg daily and hctz 25 daily). His sugars were
controlled on insulin drip until he was transitioned to his home
regimen of NPH 28 units [**Hospital1 **]. He had repeat CT imaging which
showed no changes, and was transferred to floor.
His BUN and Creatinine were rising on the floor, and his
lisinopril was discontinued and he was given IVF. A renal
artery doppler showed moderate left-sided hydronephrosis without
arterial or venous abnormalities. A TTE showed mild left
ventricular hypertrophy and a calcified mitral valve.
His mild hydronephrosis (seen on Renal U/S as above) should be
re-evaluated with a CT-a/p with contrast after his GFR returns
to baseline.
Medications on Admission:
- patient stated he was on insulin, and a medication for his
blood pressure but was not sure of the type or dose, was not
able
to provide his pharmacy (OMR medications date from [**2165**])
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP<100mmHg.
3. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily): hold for SBP<100mmHg.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
7. insulin sliding scale
Insulin (Regular) sliding scale - Please refer to the sliding
scale sheet printed out with the discharge paper work
8. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty Eight (28) Units Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right basal ganglia hemorrhage
Hyperlipidemia
Hypertension
Left Ventricular Hypertrophy
Calcified Mitral Valve
Discharge Condition:
LEFT-sided hemiplegia, mild right facial droop (old), and
stable/baseline left anisocoria
Discharge Instructions:
You were admitted to the hospital with weakness of the left side
of your body. This was caused by a bleed deep within the right
side of your brain. This bleed was likely caused by high blood
pressure over a long period of time. Many people with
hemorrhages make significant improvements within the first 6
months, and this is dependent on proper physical rehabilitation.
In the hospital we started you on several different medications
including:
1) Simvastatin 20mg daily (to control cholesterol)
2) Hydrochlorothiazide 25mg daily (a water pill/diuretic)
3) Amlodipine 10mg daily (to control blood pressure)
Followup Instructions:
1. Stroke [**Hospital 878**] clinic (Dr. [**Last Name (STitle) 1693**]
Tuesday [**2171-8-27**] at 4:00pm
2. PCP [**Name9 (PRE) **] [**Name10 (NameIs) **] call for appointment at your earliest
convenience with your own primary care practicioner.
Completed by:[**2171-7-22**]
|
[
"431",
"V15.81",
"V15.88",
"401.9",
"V58.67",
"342.92",
"272.4",
"250.00",
"424.0",
"591",
"781.94",
"429.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8757, 8827
|
6651, 7705
|
354, 360
|
8982, 9074
|
5534, 6628
|
9734, 10011
|
2925, 3037
|
7946, 8734
|
8848, 8961
|
7731, 7923
|
9098, 9711
|
4189, 5515
|
3052, 3647
|
277, 316
|
388, 2543
|
3662, 4172
|
2565, 2710
|
2726, 2909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,244
| 122,450
|
54658
|
Discharge summary
|
report
|
Admission Date: [**2148-6-3**] Discharge Date: [**2148-6-12**]
Date of Birth: [**2079-9-28**] Sex: F
Service: MEDICINE
Allergies:
Egg White / gluten / Amitriptyline / Corn Oil / lactose /
fluconazole / Garlic Oil / Levofloxacin / latex / guava flavor /
Sulfa(Sulfonamide Antibiotics) / Poison Sumac Extract / soy
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
transferred for bright red blood per rectum
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
68 y/o F with history of colonic polyps s/p multiple
colonoscopies (last in [**2147-9-26**] showing diverticula and internal
hemorrhoids) was admitted to [**Hospital **] on [**2148-5-30**],
Thursday, after she experienced lower abdominal cramping and an
episode of BRBPR mixed with stool. This was followed by an
episode of non-bloody, non-bilious vomiting and lightheadedness.
Of note, the day prior to presentation at OSH, she was
constipated [**2-22**] to opoid use and took some miralax to help with
her BM. Had normal BM that day and does not report any
straining. She went to the ED for eval. On presentation to ER,
vitals were stable. She denied fever, chills, Dyspnea, Chest
pain, recent travel, she had had a meal at a work function
recently, but otherwise has not eaten out at restaurants. Hct on
admission to OSH was 39 and dropped to 27 with hydration and
also continued BRBPR. She received 3 units of PRBC over weekend.
She said that Friday she had a few episodes of BRBPR not as
severe as the day of admission, but significant. Saturday, she
had a BM that was coated in blood, but no other episodes.
Sunday, did not have a BM. Today, she had another large bloody
diarrhea and hct 23.7. She received 2 units of pRBC prior to
transfer.
Of note, the patient was seen by GI at OSH. Initially thought to
be diverticular and would self resolve so did not work up
further with [**Last Name (un) **] or imaging. However, on day of transfer plan
was to perform a bleeding scan. They did not have the
radioactive material to conduct study and delay in testing led
patient and family to request transfer. The patient's sister is
on the board here at [**Hospital1 18**] and requested transfer to our
institution for further management.
On the floor,
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, constipation, hematochezia, dysuria,
hematuria.
Past Medical History:
HTN,
kidney stones,
allergic rhinitis,
colonic polyps h/o tubular adenoma
DJD
Chronic LBP
Social History:
Is a nun, works at a nursing home, no smoking, rare EtOH, no
illicit drug use.
Family History:
Mother with diverticulitis c/b diverticular abscess requiring
surgery, no GI neoplasms or IBD, Grandmother with Diabetes,
mother with CAD, HTN, HLD; father with
Physical Exam:
Admission PE:
VS: 98.9, 115/61, 78, 18, 97%RA
GENERAL: Well-appearing in NAD, comfortable, appropriate.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD, supra/infraclavicular LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact,
Discharge PE:
Pertinent Results:
Admission labs:
[**2148-6-4**] 01:13AM BLOOD WBC-10.0 RBC-3.10* Hgb-9.9* Hct-29.5*
MCV-95 MCH-31.9 MCHC-33.6 RDW-15.2 Plt Ct-184
[**2148-6-4**] 10:35AM BLOOD Hgb-9.7* Hct-29.2*
[**2148-6-4**] 07:48PM BLOOD Hct-29.5*
[**2148-6-4**] 01:13AM BLOOD PT-12.7* PTT-26.0 INR(PT)-1.2*
[**2148-6-4**] 01:13AM BLOOD Glucose-96 UreaN-16 Creat-0.6 Na-137
K-3.7 Cl-105 HCO3-22 AnGap-14
[**2148-6-4**] 01:13AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.8
LENIs
IMPRESSION:
1. Acute, occlusive thrombus in both right posterior tibial
veins. The
remainder of the right lower extremity veins are patent.
2. No left lower extremity DVT.
Brief Hospital Course:
Ms. [**Known lastname **] is a 68F with history of diverticulosis, internal
hemorrhoids who is being transferred here for BRBPR.
# diverticular bleed: The patient was transferred to [**Hospital1 18**] for
persistent BRBPR, which was thought to be [**2-22**] diverticular
bleed. While at the OSH she received 5U PRBC in total. While
at [**Hospital1 18**], the patient's crits were trended and her vital were
monitored. The patient remained stable while she was here and
did not rebleed. She was seen by GI who decided that no active
intervention was needed at the time, as the patient was not
bleeding. Recent history of bleed led to brief ICU stay for
monitoring while heparin started for DVT (see below). Hct was
stable despite initiation of heparin drip. By the end of the
hospitalization, the patient was having normal bowel movements,
without any evidence of bright red blood; her stools were also
occult blood negative.
# RLE DVT: The patient was found to have new RLE DVT. Discussion
was had with patient about whether or not to start
anticoagulation given the fact that the DVT was all distal to
the knee and she had the recent history of bleeding. Decision
was made for initiation of anticoagulation as there were several
factors favoring possible/likely progression of her distal DVT,
including multiple veins involved, ongoing immobility, recent
horomone therapy. Given the need for anticoagulation in the
setting of recent GI bleed, it was decided that the patient be
transferred to the MICU for treatment of DVT with heparin drip
for close observation in the event of possible repeat bleeding,
however, the GI team (Dr. [**Last Name (STitle) 3315**] felt that the chance of
repeat bleeding was very low. Was stable overnight on heparin
drip and transferred to the floor the next day with plan to
start warfarin.
While on the [**Hospital1 **], the patient was continued on warfarin and
heparin drip. The heparin drip was later stopped and the
patient was discharged on lovenox bridge until coumadin is
therapeutic with INR ranging from [**2-23**]. She was discharged on
warfarin and lovenox. Once the INR is [**2-23**] for at least 24
hours, the lovenox can be discontinued.
# HTN: The patient's home metoprolol was initially held given
concern for masking physiologic tachycardia in the seting of
acute bleeding. However, once she was no longer actively
bleeding, her metoprolol was restarted.
# Allergic rhinitis: The patient was continued on her home
Flonase.
# Chronic LBP: The patient's home exalgo was converted to its
morphine equivalent and she was continued on 30 mg MS contin
daily while in house. The patient was instructed to stop her
home meloxicam, as it can increase her risk of bleeding.
# menopausal symptoms: The patient was taking hormone
replacement therapy (Prempro) for symptomatic hot flashes.
Because of her development of RLE DVT, she was instructed to
stop all hormonal therapy, as it can increase her risk of
clotting.
Transitional Issues:
- The patient will have to continue Coumadin for at least three
months for RLE DVT. She will need repeat ultrasound in the
three months to assess for resolution of clot, at which time if
resolution if proven, consideration can be given to cessation of
anticoagulation, this decision will need to be made by her
primary care physician.
- The patient was discharged on lovenox which will have to be
continued until INR is therapeutic, ranging from [**2-23**]. once INR
is therapeutic (ranging between [**2-23**]) for at least 24 hours,
please stop lovenox.
- Please STOP meloxicam and Prempro.
Medications on Admission:
Calcium 1,000ng PO Daily
Ciclopirox (8% nail solution) apply daily
estrogen/medroxypr 3/1.5 1 tab Daily
Flonase 1 spray each nostril daily
Glucosamine 1,000mg 2 tab PO BID
Meloxicam 15mg PO Daily
Metoprolol tartrate 25mg PO BID
MVI w/ minerals Daily
trazadone 100mg PO QHS
Exalgo 12 mg daily
Discharge Medications:
1. calcium 500 mg Tablet Sig: Two (2) Tablet PO once a day.
2. ciclopirox 8 % Solution Sig: One (1) Topical once a day:
apply daily to affected toe nail.
3. Flonase 50 mcg/actuation Spray, Suspension Sig: One (1)
Nasal once a day.
4. Glucosamine 500 mg Tablet Sig: Four (4) Tablet PO twice a
day: [**2136**] mg twice daily .
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Exalgo ER 12 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
9. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
titrate to INR [**2-23**]
10. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg
Subcutaneous every twelve (12) hours: please stop once INR is
between 2 and 3 for at least 24 hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 68422**] Home - [**Location (un) 5503**]
Discharge Diagnosis:
primary diagnosis:
diverticular bleed
right lower extremity deep vein thrombosis
secondary diagnosis:
chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were transferred to the [**Hospital1 **] because you were
having continued bright red blood per rectum. We monitored your
vital signs and blood levels closely. We also had the
gastroenterologists evaluate you as well; they felt that
repeating a colonoscopy was not necessary.
We advanced your diet slowly, and upon discharge, you were
eating well and having normal bowel movements, without any
blood.
During this hospitalization, you were found to have a venous
thrombosis in your right leg. We started you on a blood
thinning medication for this. Because there was concern that
you could start bleeding again, we were transferred to the
intensive care unit briefly. You tolerated the blood thinning
medication well.
Please check daily INRs with goaL INR between [**2-23**]. Once INR is
therapeutic (between [**2-23**]) for at least 24 hours, please stop
Lovenox.
We made the following changes to your medications:
STOP Meloxicam --> this increases your risk of bleeding
STOP Prempro --> hormones can increase your risk to develop
blood clots
START Coumadin 3 mg daily
START Lovenox 90 mg injections subcutaneously every 12 hours
Followup Instructions:
Please see your primary care doctor within one week of leaving
the rehab facility.
|
[
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"724.2",
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"788.64",
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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|
4077, 7056
|
486, 494
|
9147, 9147
|
3441, 3441
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9003, 9003
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9162, 9274
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2598, 2679
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
634
| 193,607
|
15630
|
Discharge summary
|
report
|
Admission Date: [**2116-8-3**] Discharge Date: [**2116-8-6**]
Date of Birth: [**2053-12-21**] Sex: M
Service: BLUE [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
male status post hepaticojejunostomy for Mirizzi syndrome
recently discharged from [**Hospital1 69**]
on [**2116-7-26**]. Upon discharge from [**Hospital1 190**] patient was doing well. He followed in clinic
with Dr. [**Last Name (STitle) **]. On the night prior to admission patient
noticed blood tinged bile and clot in his bile bag. Patient
had an urge to defecate and passed a large amount of liquidy
tarry stool and fainted with loss of consciousness briefly.
Patient presented to [**Hospital3 **] Hospital where he was found to
be hypotensive with guaiac positive stool. At that time
there was no bright red blood per rectum and no melena.
Patient was transferred to [**Hospital1 188**].
PAST MEDICAL HISTORY: Significant for CAD status post stent,
status post CABG. Type 2 diabetes. Hypertension. Chronic
renal insufficiency.
PHYSICAL EXAMINATION: On presentation to the E.R., the
patient was afebrile at 97.8, pulse 98, blood pressure 99/58,
respiratory rate 25, 98% saturation in room air. At that
time patient had already received 2 liters of crystalloid at
[**Hospital3 **] Hospital, 800 cc of crystalloid and two units of
PRBC at [**Hospital1 69**]. Patient was
ill appearing and pale, but alert and oriented times three.
Sclerae were anicteric. No JVD. Cardiovascular exam was not
significant. Lung exam was not significant. Abdominal exam
showed right PTC bag filled with bile and blood clots. Left
PTC was capped at that time. Patient's surgical wound was
intact and had no evidence of infection. Rectal exam showed
guaiac positive stool. Extremities were warm. There was no
pedal edema.
HOSPITAL COURSE: The patient was immediately admitted to the
ICU. Laboratory values on admission were white count of
14.7, hematocrit 26.7, platelets 335. Differential on the
white count was 81.5% neutrophils, 1% bands, 9% lymphocytes.
Chemistry at that time was sodium 130, potassium 5.8,
chloride 103, CO2 18, BUN 56, creatinine 2.6, glucose 71.
AST 27, ALT 12, alka phos 98, t-bili 0.2, amylase 171, lipase
251, total protein 7.4, albumin 2.8. PT 14.4, PTT 27.2, INR
1.4. In the ICU patient received two additional units of
PRBC and a total of 5 liters of crystalloid resuscitation and
made adequate urine of 1000 cc over 24 hours and maintained a
normotensive blood pressure.
The patient underwent emergent tube cholangiogram to study
his biliary system to try to identify a potential source of
bleeding. The tube cholangiogram study showed no evidence of
active bleeding at that time. It also showed dilatation of
the biliary system consistent with previous studies. By
hospital day two patient was adequately resuscitated and was
able to be transferred to the floor. He remained under close
observation and supervision on the floor without
complications, without evidence of any bleeding. The patient
remained afebrile throughout his stay. He was discharged on
hospital day four.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleeding.
2. Mirizzi syndrome status post hepaticojejunostomy.
3. Hypertension.
4. Type 2 diabetes.
5. Coronary artery disease status post coronary artery
bypass graft, status post stent.
6. Chronic renal insufficiency.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg one tablet p.o. q.24.
2. Calcium carbonate 1 gm q.12 for one week and then 500 mg
p.o. b.i.d.
3. Bicitra 30 cc p.o. q.d.
4. Lopressor 25 mg p.o. b.i.d.
5. Protonix 40 mg p.o. b.i.d.
FOLLOWUP: The patient is to follow up with Dr. [**First Name (STitle) **] or
Dr. [**Last Name (STitle) **] in the office in one week. Patient also needs
renal followup and patient prefers to follow up with a
nephrologist referral from his PCP. [**Name10 (NameIs) **] also has the
phone number of the [**Hospital1 69**]
nephrologist, Dr. [**Last Name (STitle) 118**], and is able to make an appointment
if needed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 45150**]
MEDQUIST36
D: [**2116-8-6**] 10:33
T: [**2116-8-6**] 11:00
JOB#: [**Job Number 45151**]
|
[
"285.9",
"576.2",
"401.9",
"276.5",
"250.00",
"578.9",
"276.7",
"593.9",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
3243, 3490
|
3513, 4415
|
1867, 3148
|
1089, 1849
|
193, 922
|
945, 1066
|
3173, 3222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,107
| 161,512
|
27001+27051
|
Discharge summary
|
report+report
|
Admission Date: [**2110-9-26**] Discharge Date: [**2110-10-8**]
Date of Birth: [**2028-12-19**] Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending:[**Last Name (un) 11220**]
Chief Complaint:
The patient was actually continuously admitted between [**2110-9-26**]
and [**2110-10-8**]. He was erroneously "discharged" on [**2110-9-30**].
Please see the discharge summary dated [**2110-10-8**] for details of
the hospitalization.
Major Surgical or Invasive Procedure:
See [**2110-10-8**] discharge summary.
History of Present Illness:
See [**2110-10-8**] discharge summary.
Past Medical History:
See [**2110-10-8**] discharge summary.
Social History:
See [**2110-10-8**] discharge summary.
Family History:
See [**2110-10-8**] discharge summary.
Physical Exam:
See [**2110-10-8**] discharge summary.
Pertinent Results:
See [**2110-10-8**] discharge summary.
Brief Hospital Course:
See [**2110-10-8**] discharge summary.
Medications on Admission:
See [**2110-10-8**] discharge summary.
Discharge Medications:
See [**2110-10-8**] discharge summary.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
See [**2110-10-8**] discharge summary.
Discharge Condition:
See [**2110-10-8**] discharge summary.
Discharge Instructions:
See [**2110-10-8**] discharge summary.
Followup Instructions:
See [**2110-10-8**] discharge summary.
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Completed by:[**2110-10-21**] Admission Date: Discharge Date:
Date of Birth: [**2028-12-19**] Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending:[**Last Name (un) 11220**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Right ureteroscopy with laser lithotripsy and stent
exchange([**2110-9-30**])
History of Present Illness:
81 yo M with recurrent UTIs, DM, afib, CP, sent to the ED from
his [**Hospital1 1501**] with fever. He has a chronic indwelling foley and was
recently admitted for klebsiella urosepsis. At his [**Hospital1 1501**], fever
workup revealed a UTI with reported klebsiella, as well as
diarrhea concerning for C. diff. He was asymptomatic. Mr.
[**Known lastname 66369**] lives at [**Location 66462**] Altenheim [**Hospital1 1501**] ([**Telephone/Fax (1) 66463**].
In the ED, initial vitals 98.7 86 157/81 16 99%, and he then
spiked to 101.0. He was given meropenem and flagyl. On
admission, vitals were 99.1 85 119/57 23 99%.
This morning, the patient feels well and is without complaints.
He denies any abdominal pain or suprapubic tenderness. He also
denies HA, blurry vision, chest pain, or cough. He states that
he has had his urinary catheter in for "a long time" but is
unable to be more specific. He states that it was supposed to
be removed soon.
Past Medical History:
- T2DM
- Hypotonic hyposensitive bladder with urinary retention and
chronic indwelling foley
- Atrial fibrillation (CHADS2 = 4. Not on coumadin due to fall
risk)
- Cerebral palsy
- dCHF (LVEF 55% [**2110-8-4**])
- Hypertension
- Dyslipidemia
Social History:
Patient is a limited historian. Lives in [**Location 66367**] facility.
Wheelchair bound. Non-smoker. Does not drink alcohol.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: Tc 99.4 Tm 99.9 BP 170/60 HR 92 RR 18 SaO2 98% on RA
General: Alert, oriented, no acute distress. Speech difficult
to understand.
CV: irreg irreg, no murmrs
LUNGS: CTA b/l
ABD: soft, non tender, non distended
GU: foley in place
EXT: no edema
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.0 144/78 HR 76 RR 20 SaO2 96% on RA
Afebrile since [**10-3**]
General: Alert, oriented, no acute distress. Speech difficult
to understand due to dysarthria.
CV: Irregularly irregular, no m/r/g
LUNGS: CTAB, moving air well, respirations are unlabored.
ABD: Obese, soft, non tender, non distended
GU: Foley in place. (+) scrotal edema. no bowel sounds
auscultated. no "bag of worms" sign. Suture coming out of
urethra.
EXT: Trace pitting edema
[**Name8 (MD) **] RN notes: Stage 2 sacral ulcer present.
Pertinent Results:
MICROBIOLOGY
============
[**2110-9-28**] 12:36 pm URINE Source: Catheter.
**FINAL REPORT [**2110-9-29**]**
URINE CULTURE (Final [**2110-9-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2110-10-2**] 1:26 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2110-10-8**]**
Blood Culture, Routine (Final [**2110-10-8**]): NO GROWTH.
BLOOD CULTURE ([**10-2**]): Pending
CBC TREND
=========
[**2110-9-29**] 07:15AM BLOOD WBC-8.5 RBC-3.41* Hgb-10.6* Hct-30.5*
MCV-89 MCH-31.0 MCHC-34.7 RDW-14.5 Plt Ct-356
[**2110-9-30**] 07:40AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.3* Hct-29.7*
MCV-89 MCH-30.6 MCHC-34.5 RDW-14.5 Plt Ct-349
[**2110-9-30**] 10:00PM BLOOD WBC-22.8*# RBC-3.33* Hgb-10.5* Hct-29.5*
MCV-89 MCH-31.4 MCHC-35.4* RDW-14.3 Plt Ct-295
[**2110-10-1**] 05:56AM BLOOD WBC-18.3* RBC-3.24* Hgb-10.3* Hct-29.6*
MCV-91 MCH-31.9 MCHC-34.9 RDW-14.4 Plt Ct-198
[**2110-10-2**] 04:51AM BLOOD WBC-17.0* RBC-3.12* Hgb-9.7* Hct-27.7*
MCV-89 MCH-31.1 MCHC-35.1* RDW-14.6 Plt Ct-158
[**2110-10-3**] 06:40AM BLOOD WBC-13.2* RBC-3.09* Hgb-9.5* Hct-28.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.9 Plt Ct-194
[**2110-10-4**] 06:25AM BLOOD WBC-11.3* RBC-3.17* Hgb-9.9* Hct-29.0*
MCV-92 MCH-31.1 MCHC-34.0 RDW-14.9 Plt Ct-239
[**2110-10-5**] 05:40AM BLOOD WBC-13.3* RBC-3.19* Hgb-10.1* Hct-29.6*
MCV-93 MCH-31.5 MCHC-34.0 RDW-15.2 Plt Ct-236
[**2110-10-6**] 07:20AM BLOOD WBC-12.2* RBC-3.21* Hgb-10.3* Hct-29.6*
MCV-92 MCH-32.0 MCHC-34.6 RDW-15.5 Plt Ct-274
[**2110-10-7**] 06:45AM BLOOD WBC-9.5 RBC-3.07* Hgb-9.7* Hct-28.8*
MCV-94 MCH-31.7 MCHC-33.7 RDW-15.6* Plt Ct-280
[**2110-10-8**] 05:37AM BLOOD WBC-8.6 RBC-3.11* Hgb-9.7* Hct-28.9*
MCV-93 MCH-31.3 MCHC-33.6 RDW-15.9* Plt Ct-300
CHEMISTRY TREND
===============
[**2110-9-29**] 07:15AM BLOOD Glucose-190* UreaN-15 Creat-0.8 Na-133
K-4.3 Cl-99 HCO3-25 AnGap-13
[**2110-9-30**] 07:40AM BLOOD Glucose-192* UreaN-16 Creat-0.8 Na-135
K-4.5 Cl-103 HCO3-23 AnGap-14
[**2110-10-1**] 05:56AM BLOOD Glucose-299* UreaN-24* Creat-1.2 Na-135
K-6.0* Cl-103 HCO3-15* AnGap-23*
[**2110-10-2**] 04:51AM BLOOD Glucose-188* UreaN-31* Creat-1.4* Na-137
K-3.7 Cl-106 HCO3-19* AnGap-16
[**2110-10-2**] 05:30PM BLOOD Glucose-161* UreaN-31* Creat-1.3* Na-135
K-3.7 Cl-102 HCO3-21* AnGap-16
[**2110-10-4**] 06:25AM BLOOD Glucose-197* UreaN-27* Creat-1.1 Na-133
K-3.9 Cl-104 HCO3-19* AnGap-14
[**2110-10-5**] 05:40AM BLOOD Glucose-178* UreaN-23* Creat-0.9 Na-132*
K-3.5 Cl-103 HCO3-20* AnGap-13
[**2110-10-6**] 07:20AM BLOOD Glucose-169* UreaN-18 Creat-0.8 Na-139
K-3.7 Cl-107 HCO3-22 AnGap-14
[**2110-10-7**] 06:45AM BLOOD Glucose-148* UreaN-15 Creat-0.8 Na-137
K-4.7 Cl-109* HCO3-18* AnGap-15
[**2110-10-8**] 05:37AM BLOOD Glucose-104* UreaN-14 Creat-0.8 Na-136
K-3.8 Cl-104 HCO3-27 AnGap-9
[**2110-10-1**] 06:27AM BLOOD Lactate-6.1*
[**2110-10-2**] 05:01AM BLOOD Lactate-2.3
LIVER ENZYMES TREND
===================
[**2110-9-30**] 10:00PM BLOOD ALT-32 AST-80* CK(CPK)-85 AlkPhos-72
TotBili-0.3
[**2110-10-1**] 11:19AM BLOOD CK(CPK)-289
[**2110-10-2**] 04:51AM BLOOD ALT-1703* AST-3740* AlkPhos-76
TotBili-0.4
[**2110-10-3**] 06:40AM BLOOD ALT-1010* AST-802* LD(LDH)-403*
AlkPhos-82 TotBili-0.5
[**2110-10-4**] 06:25AM BLOOD ALT-702* AST-303* LD(LDH)-270* AlkPhos-86
TotBili-0.5
[**2110-10-5**] 05:40AM BLOOD ALT-490* AST-125* LD(LDH)-229 AlkPhos-86
TotBili-0.6
[**2110-10-6**] 07:20AM BLOOD ALT-393* AST-62* LD(LDH)-274* AlkPhos-87
TotBili-0.5
[**2110-10-7**] 06:45AM BLOOD ALT-285* AST-53* LD(LDH)-473* AlkPhos-84
TotBili-0.4
CARDIAC ENZYMES TREND
=====================
[**2110-9-30**] 10:00PM BLOOD CK-MB-2 cTropnT-0.37*
[**2110-10-1**] 05:56AM BLOOD CK-MB-3 cTropnT-0.33*
[**2110-10-1**] 11:19AM BLOOD CK-MB-3 cTropnT-0.31*
[**2110-9-26**] CXR: There is mild cardiomegaly. The aorta is unfolded.
No CHF, focal infiltrate, or effusion is identified.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION
==================================
Mr. [**Known lastname 66369**] was admitted with fever and suspected to have UTI.
Although no culture-proven urinary pathogen isolated, we decided
to treat given history of catheter-associated UTIs. Given
previous multi-drug resistent UTIs, was given IV meropenem and
he improved. Was set to be discharged on [**9-30**] but had a
previously-scheduled outpatient urological procedure (stent
exchange and lithotripsy), so we decided to allow for this while
in house. Unfortunately, he became septic in the PACU following
the procedure and had rapid ventricular response to his atrial
fibrillation requiring a two day stay in the ICU which was
complicated by acute kidney injury, acute liver injury, and
cardiac demand ischemia. Upon returning to the floor, he was
treated with IV antibiotics for urosepsis and PO antibiotics for
c. diff colitis and he improved, with details as below.
#) UROSEPSIS: As above, met multiple SIRS criteria
(hypotension, tachycardia, fever) while in PACU on [**9-30**] so was
transferred to the ICU for treatment. His course was
unfortunately complicated by acute liver injury, acute kidney
injury, and elevated troponins all likely from his hypotension
which are resolving or resolved at the time of discharge
(creatinine back to baseline, liver enzymes downtrending,
troponins returned to [**Location 213**].) Returned to the floor on [**10-3**].
Although no blood or urine cultures grew definitive pathogens,
treated for presumptive bacteremia, given previous MDR UTIs,
indwelling foley, and systemic inflammatory response syndrome
following urological instrumentation, a transient bacteremia was
suspected. Given IV meropenem from [**9-26**] with a 14 day course
ending [**10-10**].
#) CATHETER-ASSOCIATED URINARY TRACT INFECTION: No urinary
pathogen isolated on this admission (cultures grew > 3,
suggestive of contamination) Given recent history of previous
admission for multi drug resistant klebsiella UTI resulting in
urosepsis, we treated him empirically with meropenem. Also has
a prior history of vancomycin sensitive enterococcus. Cultures
growing mixed flora from [**Hospital1 1501**] and [**Hospital1 18**] could possibly be true
results rather than contamination given chronic indwelling
foley. Monitored for return of symptoms since [**07**]% of klebsiella
CA-UTIs are resistent to carbapenems, but he steadily improved.
#) C. DIFFICILE COLITIS: C. diff negative at [**Hospital1 1501**] but positive at
[**Hospital1 18**] [**9-28**]. Reported diarrhea at [**Hospital1 1501**], but this has much improved
over the course of his hospitalization. Given PO metronidazole
but switched to PO vancomycin at the suggestion of ID. Planned
for course lasting two weeks after finishing other antibiotics,
finishing
#) ATRIAL FIBRILLATION: Had episode of rapid ventricular reponse
in setting of sepsis with resolved with treatment. Continued on
digoxin while here. Not on coumadin due to fall risk per Atrius
records. CHADS2 score is 4. Given thromboembolic risk of 8.5%
per year, would consider starting anticoagulation. A recent
prospective study at the [**Hospital1 756**] showed that "patients on oral
anticoagulants at high risk of falls did not have a
significantly increased risk of major bleeds." ("Risk of Falls
and Major Bleeds in Patients on Oral Anticoagulation Therapy."
The American Journal of Medicine. [**2109**].)
#) DIABETES MELLITUS: Glipizide and metformin held in setting of
sepsis. Started on insulin drip [**10-1**] for elevated blood sugars
with an anion gap and ketonuria concerning for DKA. Anion gap
closed and patient was transitioned over to an insulin sliding
scale. Upon return to the floor, was restarted on PO meds and
insluin was discontinued with good response in blood sugars.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Aspirin 325 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Digoxin 0.25 mg PO EVERY OTHER DAY
5. Furosemide 20 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 10 mg PO DAILY
10. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
11. Vitamin D 400 UNIT PO BID
12. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
13. Finasteride 5 mg PO DAILY
14. GlipiZIDE 10 mg PO BID
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Milk of Magnesia 30 mL PO Q6H:PRN constipation
17. Tamsulosin 0.4 mg PO HS
18. traZODONE 25 mg PO HS:PRN insomnia
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Aspirin 325 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Digoxin 0.25 mg PO EVERY OTHER DAY
5. Finasteride 5 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. GlipiZIDE 10 mg PO BID
8. Lisinopril 5 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Simvastatin 10 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
16. traZODONE 25 mg PO HS:PRN insomnia
17. Vitamin D 400 UNIT PO BID
18. Meropenem 500 mg IV Q6H
19. Vancomycin Oral Liquid 125 mg PO Q6H CDI failed flagyl
20. Acetaminophen 650 mg PO Q6H:PRN fever
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] center
Discharge Diagnosis:
Urosepsis
Acute kidney injury
Acute liver injury
Cardiac demand ischemia
Nephrolithiasis
Sacral ulcer
Clostridium difficile colitis
Atrial fibrillation
Diabetes mellitus
Cerebral palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 66369**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with a fever and were found
to have a urinary tract infection. You were improving, but you
likely developed an infection in your blood after your
urological procedure which transiently damaged your kidneys,
liver, and heart, which are recovering upon discharge. Please
follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] urology as scheduled.
Followup Instructions:
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Department: [**Location (un) 2274**]- [**Location (un) **] Urology
Address: [**Location (un) 4363**] [**Location (un) 86**], [**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 2284**]
Appointment: Tuesday [**2110-10-14**] 2:15pm
Name: [**Last Name (LF) 38584**],[**First Name3 (LF) **] P.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
|
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14,226
| 131,900
|
7177
|
Discharge summary
|
report
|
Admission Date: [**2191-10-11**] Discharge Date: [**2191-10-28**]
Date of Birth: [**2126-3-15**] Sex: F
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This is a 65 year old female
with known coronary artery disease. She presented to [**Hospital3 6265**] Emergency Room on [**2191-10-10**] with chest pain
and shortness of breath. The patient experienced progressive
shortness of breath and hypoxia and required intubation.
Chest x-ray showed pulmonary edema. The patient was admitted
to the Coronary Care Unit and treated for congestive heart
failure with Lasix and Nitroglycerin. On hospital day #2 the
patient ruled in for myocardial infarction by enzymes. The
patient experienced a ventricular fibrillation arrest, was
cardioverted times one to sinus rhythm and was transferred to
[**Hospital6 256**] for cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease
2. Status post percutaneous transluminal coronary
angioplasty and stent to left anterior descending
3. Positive stress test in [**2187**]
4. Noninsulin dependent diabetes mellitus
ALLERGIES: No known drug allergies
PREOPERATIVE MEDICATIONS:
1. Norvasc 5 mg p.o. b.i.d.
2. Atenolol 50 mg p.o. q. day
3. Naprosyn prn
4. Lasix 40 mg p.o. q. day
5. Potassium chloride
6. Meclizine prn
7. Lipitor 20 mg p.o. q. day
8. Glucophage 500 mg p.o. b.i.d.
9. Isordil 40 mg p.o. t.i.d.
10. Alprazolam 1 mg p.o. b.i.d.
11. Voltaren 75 mg p.o. b.i.d.
12. Axid prn
13. Glucotrol 10 mg p.o. q. day
14. Enteric coated Aspirin 1 p.o. q. day
15. Multivitamin q. day
16. Glucosamine
17. Vitamin B12 injections
18. Calcium supplements
PHYSICAL EXAMINATION: Initial physical examination revealed
the patient to be intubated. Carotids were without bruits.
Lungs were clear. Heart regular rate and rhythm. Abdomen
markedly obese. Extremities warm and well perfused.
HOSPITAL COURSE: The patient was taken to the cardiac
catheterization laboratory. Results of the cardiac
catheterization were a 95% left main lesion, moderate left
anterior descending disease, 100% obtuse marginal lesion,
100% right coronary artery lesion. The patient was given an
intra-aortic balloon pump and emergently taken to the
Operating Room for a coronary artery bypass graft times three
by Dr. [**Last Name (STitle) **]. Saphenous vein graft to obtuse marginal,
supraventricular tachycardia to posterior descending artery,
saphenous vein graft to left anterior descending. The
patient was transferred to the Intensive Care Unit in stable
condition on a Neosynephrine drip, Milrinone drip,
intra-aortic balloon pump 1:1. Intraoperative
transesophageal echocardiogram showed an ejection fraction of
45% with mild to moderate mitral regurgitation, mild to
moderate tricuspid regurgitation and mild aortic
insufficiency. In the Intensive Care Unit on postoperative
day #1 the patient was continued on her inotropic support.
The patient was started on an Amiodarone infusion for atrial
fibrillation prophylaxis. FVO2 was monitored due to the
patient's tricuspid regurgitation. The patient required a
moderate amount of volume resuscitation. On postoperative
day #2 the patient went into atrial fibrillation with rapid
ventricular response and converted to normal sinus rhythm
with Lopressor and Amiodarone boluses. The Milrinone
infusion was attempted to be weaned off and was restarted
secondary to a decrease in the cardiac index. The patient
continued to experience periods of atrial fibrillation. On
postoperative day #3 the intra-aortic balloon pump was
removed. The patient was weaned and extubated from
mechanical ventilation and continued to have problems with
atrial fibrillation with rapid ventricular response. The
Milrinone infusion was weaned to off on postoperative day #3.
The patient was noted to have a decrease in her platelet
count to 81,000. A heparin antibody panel was sent which was
subsequently negative. The patient required an insulin
infusion for control of her blood sugars. On postoperative
day #4 the patient required increased pulmonary toilet and
nebulizer treatments for increased secretions and wheezing.
On postoperative day #5 the patient was noted to have a
elevated white blood cell count to 21,000 which rose to
25,000 on postoperative day #6. The patient was pancultured
at that time. On postoperative day #6 the patient
experienced increasing respiratory distress with shortness of
breath and hypoxia. The patient was reintubated.
Bronchoscopy was performed at the time of reintubation which
was essentially clear with scant loose secretions. Shortly
after the bronchoscopy was performed the patient
self-extubated and required emergent reintubation due to
decreased oxygen saturation. Also on postoperative day #6
the patient again experienced problems with atrial
fibrillation with rapid ventricular response. After being
reintubated the patient was cardioverted times one into sinus
rhythm. Chest x-ray done after reintubation showed a right
pleural effusion for which a chest tube was placed with 600
cc of serosanguinous fluid. The patient's cultures from
postoperative day #6 had multiple organisms. Urine culture
was positive for Klebsiella. Sputum culture was positive for
Hemophilus influenza beta lactamase positive. Blood cultures
were positive for Methicillin-sensitive Staphylococcus
aureus, Hemophilus influenza as well as coagulase negative
Staphylococcus. The patient was started on Levaquin for the
urinary tract infection and was subsequently started on
Vancomycin for the coagulase positive Staphylococcus in her
blood. On postoperative day #7 the patient required
intravenous Diltiazem infusion to control the ventricular
rate of her atrial fibrillation. Postoperative day #8 the
patient self-extubated again and again was emergently
reintubated due to decreased oxygen saturation and was
reintubated. White blood cell count was noted to be elevated
and due to the positive blood cultures a new central line was
placed. The patient required cardioversion again on
postoperative day #8 and cardioverted to a junctional rhythm.
The patient remained in the Intensive Care Unit for diuresis
with Lasix and Diamox and slow ventilatory wean, antibiotic
therapy. On [**10-21**], postoperative day #10 the patient
was weaned and extubated from mechanical ventilation. Her
chest tube was removed on postoperative day #11. The patient
required aggressive pulmonary toilet and nebulizer treatments
for secretions and wheezing. The patient was started on a
heparin drip to anticoagulate her for her recurrent atrial
fibrillation. On [**10-25**], postoperative day #14, the
patient was transferred from the Intensive Care Unit to the
floor. On [**10-26**], the patient underwent
electrophysiology study for her preoperative history of
ventricular fibrillation. The study was negative for
inducible ventricular tachycardia and the arrhythmia service
recommended continuing the Amiodarone for the history of
atrial fibrillation. The patient had remained in sinus
rhythm for over 72 hours continuing on her heparin drip.
After her electrophysiology study the patient was started on
Coumadin therapy. The patient is currently awaiting bed
availability in a rehabilitation facility. The patient is
awaiting a PICC line placement for continued oxacillin for
her Methicillin-sensitive Staphylococcus aureus bacteremia
for a total of 14 days and the patient will be discharged to
rehabilitation in stable condition.
CONDITION AT DISCHARGE: Temperature maximum is 98.4, pulse
76 in sinus rhythm, blood pressure 118/60, oxygen saturation
on 2 liters of nasal cannula is 98%. Weight is 107.4 kg
which is 1 kg less than her admission weight. Blood sugars
on insulin sliding scale are 150s to 200s. The patient is
neurologically intact. Cardiovascular is regular rate and
rhythm without rub or murmur. Extremities are warm and well
perfused. Respiratory, lungs with coarse breathsounds
bilaterally with minimal secretions, good cough effort, now
requiring only as needed nebulizer treatments. Abdomen is
large, positive bowel sounds, nontender, nondistended. The
patient has 2 to 3+ peripheral edema.
Laboratory data shows hematocrit of 28.5, platelet count 230,
PT 15.8, INR 1.7, on [**2191-10-27**], potassium 3.6, BUN 13,
creatinine 0.6. Last chest x-ray showed small bilateral
pleural effusions, bilateral retrocardiac opacities probably
atelectasis and a resolution of a previously noted small
right apical pneumothorax. Sternal incision is clean and dry
with staples intact. The patient has a small amount of
erythema surrounding the staples which appears to be a local
staple reaction. Saphenectomy site is clean and dry.
Steri-strips are intact without erythema or drainage.
DISCHARGE DIAGNOSIS:
1. Status post emergent coronary artery bypass graft
2. Postoperative atrial fibrillation
3. Noninsulin dependent diabetes mellitus
4. Postoperative bacteremia
DISCHARGE MEDICATIONS:
1. Percocet 5/325 one to two tablets p.o. q. 4-6 hours prn
2. Multivitamin one p.o. q. day
3. Lipitor 20 mg p.o. q.h.s.
4. Combivent MDI 2 puffs q. 4 hours prn
5. Oxacillin 1 gm q. 4 hours to continue through last dose
[**10-31**]
6. Protonix 40 mg p.o. q. day
7. Colace 100 mg p.o. b.i.d.
8. Lasix 40 mg p.o. b.i.d.
9. Kayciel 20 mg p.o. b.i.d.
10. Lopressor 100 mg p.o. b.i.d.
11. Amiodarone 400 mg p.o. b.i.d. through [**11-3**] and
then decrease to 400 mg p.o. q. day
12. Captopril 6.25 mg p.o. b.i.d.
13. Enteric coated Aspirin 325 mg p.o. q. day
14. Glucotrol 5 mg p.o. q. day
15. Regular insulin sliding scale for blood sugar 150 to 200
give 3 units subcutaneously, for blood sugar 201 to 250 give
6 units subcutaneously, for blood sugar 251 to 300 give 9
units subcutaneously
16. Coumadin daily dose to be determined by that day's
PT/INR. After discharge from rehabilitation facility the
patient's Coumadin is to be monitored and dosed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] of [**Location (un) 3320**], phone [**Telephone/Fax (1) 26647**].
DISCHARGE INSTRUCTIONS: The patient's staples are to be
removed at the rehabilitation facility on [**2191-11-1**].
Coumadin is to be titrated for a goal INR of 2.0. The
patient is to schedule an appointment with Dr. [**Last Name (STitle) **] upon
discharge from rehabilitation. The patient is to schedule an
appointment with Dr. [**First Name (STitle) **] upon discharge from
rehabilitation.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2191-10-27**] 17:14
T: [**2191-10-27**] 17:36
JOB#: [**Job Number 26648**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
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] |
icd9pcs
|
[
[
[]
]
] |
8972, 10066
|
8784, 8949
|
1897, 7496
|
10091, 10727
|
1164, 1645
|
1668, 1879
|
7511, 8763
|
179, 867
|
889, 1138
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,384
| 114,474
|
9792
|
Discharge summary
|
report
|
Admission Date: [**2136-9-20**] Discharge Date: [**2136-9-26**]
Date of Birth: [**2099-9-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Infected transhepatic catheter
Clotted right brachial-to-right atrial arteriovenous graft.
Major Surgical or Invasive Procedure:
[**2136-9-21**]: Angioplasty and stent of right brachial artery-to-
right atrium arteriovenous graft.
History of Present Illness:
Patient was seen in clinic for evaluation of Right arm dialysis
graft and was noted to be febrile and ill-appearing. The
transhepatic catheter that was being used for hemodialysis was
noted to have copious amounts of pus at the insertion site. Due
to fever and septic appearance she was admitted through the ER
to the SICU for catheter removal and medical management
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD due to IgA nephropathy
2. Schizoaffective disorder
3. Depression
4. Anemia
5. GERD
6. Cardiomyopathy
7. Hypothyroidism
8. GI bleed
9. Coagulase negative staph infection
10. RLE DVT
11. Seizures x 2 [**8-11**]
PAST SURGICAL HISTORY:
s/p L upper & lower AV fistula - failed
s/p R AV fisula basilic v transposition - failed
s/p R forearm AV graft - failed
s/p PD catheter '[**27**] - failed
central venous stenosis - R brachiocephalic v.
occlusion of inominate v.
s/p R arm brachial->axilla AV graft ([**2133-10-9**])
s/p thrombectomy & angioplasty of outflow stenosis ([**2133-10-11**])
s/p thrombectomy ([**2133-10-23**])
s/p thrombectomy and revision of R arm AV graft ([**2133-11-12**])
s/p thrombectomy of R arm AV graft ([**2133-11-16**], [**2133-12-15**])
s/p excision of infected R arm AV graft ([**2133-12-25**])
[**2136-8-2**] right brachial artery to right atrium graft
[**2136-8-3**] rue graft thrombectomy
7/-/07 Trache
[**2136-8-13**] RUE exploration -seroma
[**2136-8-31**] UTI, pseudomonas
[**2136-9-8**] replacement of transhepatic hemodialysis catheter
Social History:
Currently a patient at [**Hospital6 **], unemployed, no
tobacco, alcohol, or recreational drug use. Estranged from
mother [**Name (NI) **] ([**Telephone/Fax (1) 32972**])
Family History:
Non-contributory.
Physical Exam:
VS: 102.2-104, 115, 80/48, 22, 100% 12L trach,mask
Gen: Shaking, awake but appears sleepy
Card: Sinus tach, regular
Lungs: CTA, on trach mask
Abd: Soft, ND, NT, pus at insertion site of catheter
Pertinent Results:
On Admission: [**2136-9-20**]
WBC-10.3# RBC-2.66* Hgb-8.7* Hct-26.4* MCV-99* MCH-32.6*
MCHC-32.8 RDW-17.2* Plt Ct-275
PT-17.5* PTT-31.5 INR(PT)-1.6*
Glucose-116* UreaN-40* Creat-5.0* Na-143 K-4.8 Cl-104 HCO3-25
AnGap-19
ALT-14 AST-20 AlkPhos-137* Amylase-86 TotBili-0.3
TotProt-7.0 Calcium-8.5 Phos-4.2 Mg-1.9
On Discharge: [**2136-9-26**]
WBC-4.7 RBC-2.41* Hgb-7.6* Hct-23.4* MCV-97 MCH-31.4 MCHC-32.3
RDW-16.8* Plt Ct-199
PT-25.6* INR(PT)-2.6*
Glucose-82 UreaN-38* Creat-5.1*# Na-142 K-3.5 Cl-102 HCO3-29
AnGap-15
Calcium-8.4 Phos-3.7 Mg-1.7
Brief Hospital Course:
Patient admitted to the SICU due to the severity of the fever
and infected transhepatic catheter that had copious pus at the
insertion site. The catheter was removed. Cultures of Blood,
urine and sputum were ordered. Blood cultures grew Coag+ Staph,
(MRSA) as well as the catheter tip. She was started on Vanco and
Gentamycin on admission, the gentamycin was withdrawn once
culture data received.
She underwent thrombectomy and stent placement to the dialysis
graft on [**2136-9-21**] with Drs [**Last Name (STitle) 816**] and [**Name5 (PTitle) 32976**].
Initial arteriographic images revealed occlusion and thrombus
near the anastomosis with no blood flow to the heart. After a
successful balloon dilation of the graft and advancing of the
wire into the right atrium, there was evidence of blood flow and
the area of the anastomosis of the right atrium was discovered.
There was
successful deployment of self-expandable stent in the graft
followed by another deployment of a stent from the prior stent
into the right atrium. The post-stenting images reveal
excellent patency of the graft and flow immediately through
the graft into the right atrium and into the right ventricle.
She was placed on a heparin drip, and was then converted back to
Coumadin which she will be discharged on.
She was dialyzed using the Right graft with 350 blood flows.
She was dialyzed again on [**9-24**] and [**9-26**]. On [**9-26**] she received 1
unit pRBCs for hct of 23.4%
Of note the patient remains on the trach with O2 via trach mask.
Laryngoscopy done on [**9-18**] just prior to this admission shows
mild collapse medially of left arytenoid and omega shaped
epiglottis. Patnet airway. Their recommendation is that
respiratory therapy can try plugging the trach during the day
and see how she tolerates. They recommend follow-up in 3 months
with [**First Name4 (NamePattern1) 9317**] [**Last Name (NamePattern1) **] MD ([**Telephone/Fax (1) 32977**]) Please see attached report
from ENT.
Patient should continue to receive Vanco at hemodialysis and
then PO Flagyl for 2 weeks following Vanco completion.
Follow PT/INR per facility protocol, Coumadin is for thrombus
management
Of note, a cardiac echo was performed on [**9-25**]: there was no
evidence of vegetations, EF > 55%
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
5. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
6. Fluphenazine HCl 1 mg Tablet Sig: Five (5) Tablet PO LUNCH
(Lunch).
7. Mirtazapine 15 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime).
8. Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp <100 and HR <55.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
14. Fluphenazine HCl 1 mg Tablet Sig: Five (5) Tablet PO
BREAKFAST (Breakfast).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed: Sarna for pruritus.
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain / fever.
2. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Midodrine 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Through [**11-7**].
6. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
8. Fluphenazine HCl 10 mg Tablet Sig: 0.5 Tablet PO Q AM WITH
BREAKFAST ().
9. Fluphenazine HCl 10 mg Tablet Sig: 0.5 Tablet PO Q LUNCH ().
10. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
11. Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Mirtazapine 15 mg Tablet Sig: 2.5 Tablets PO HS (at
bedtime).
16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Check PT/INR per facility protocol.
17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): Give throughSept 19.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**]
Discharge Diagnosis:
Infected transhepatic dialysis catheter/removed
Thrombectomy Right arm dialysis graft
Discharge Condition:
Fair
Discharge Instructions:
Continue hemodialysis schedule T-Th-S
Use Right AVG dialysis graft for hemodialysis. Check bruit and
thrill daily. Please call [**Telephone/Fax (1) 673**] if unable to appreciate
bruit/thrill
No constrictive clothing, blood pressures, blood draws or IV's
to Right arm
Continue medications as directed
Vanco for one additional month at hemodialysis
Flagyl for 6 weeks
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2136-10-4**] 9:50
[**First Name4 (NamePattern1) 9317**] [**Last Name (NamePattern1) **] MD: 3 month follow-up ([**Telephone/Fax (1) 32977**])
Completed by:[**2136-9-26**]
|
[
"038.9",
"996.73",
"V44.0",
"295.70",
"285.9",
"530.81",
"995.91",
"583.9",
"311",
"585.6",
"996.62",
"425.4",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"39.90",
"39.50",
"39.95",
"39.49",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
8364, 8408
|
3153, 5422
|
493, 596
|
8538, 8545
|
2585, 2585
|
8961, 9259
|
2335, 2355
|
6895, 8341
|
8429, 8517
|
5448, 6872
|
8569, 8938
|
1293, 2130
|
2370, 2566
|
2909, 3130
|
362, 455
|
624, 992
|
2599, 2895
|
1036, 1270
|
2146, 2319
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,685
| 165,993
|
6115
|
Discharge summary
|
report
|
Admission Date: [**2126-1-29**] Discharge Date: [**2126-1-31**]
Service: [**Hospital1 **]
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This is an 86 year old female
with coronary artery disease and colon cancer status post
resection in [**2125-11-13**], who presented to the emergency
department with bright red blood per rectum times two that
began one hour prior to presenting to the E.D. While in the
E.D. patient had three additional episodes during which she
had lower abdominal cramping that felt like a "menstrual
cycle." In the emergency department patient was evaluated by
surgery who felt that there should be no surgical
intervention at this time. In addition, interventional
radiology was contact[**Name (NI) **] who declined intervention secondary
to the high risk of precipitating mesenteric ischemia.
Vasopressin was also considered, but was contraindicated due
to her coronary artery disease.
PAST MEDICAL HISTORY: Colon cancer status post hemicolectomy
at [**Hospital6 1708**] in [**2125-11-13**], no mets.
Coronary artery disease. Hypercholesterolemia.
Hypertension. Hemorrhoids.
OUTPATIENT MEDICATIONS: Lopressor 100 mg b.i.d., Isordil 60
mg q.day, aspirin, Dyazide 50 mg q.day, Lipitor 20 mg q.day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco or ethanol.
FAMILY HISTORY: Positive for colon cancer.
PHYSICAL EXAMINATION: On admission temperature was 98.2,
pulse 70, blood pressure 99/54, respiratory rate 18, O2 sat
98% in room air. Patient was alert and in no acute distress.
HEENT and neck unremarkable. Cardiovascular normal S1, S2
with a [**3-21**] holosystolic murmur heard best at apex. Lungs
clear bilaterally. Abdomen protuberant, well healed midline
scar, no hepatosplenomegaly. Extremities trace pedal edema.
LABORATORY DATA: On admission included hematocrit of 32.3
which was down from 36.8 the day prior. White count 6.3,
platelets 372. Coags INR 1.0, PT 12.2, PTT 27.7. UA
remarkable only for trace ketones. Electrolytes within
normal limits. ALT and AST within normal limits. Alka phos,
amylase, t-bili and lipase all within normal limits.
HOSPITAL COURSE:
1. The patient was given the usual type and screen as well
as IV fluids. She was transfused two units of packed red
blood cells for a goal hematocrit of greater than 27%.
Patient was admitted to the medical intensive care unit. She
was continued on IV fluids. She had refused two units of
packed red blood cells in the emergency department. She went
for a GI bleeding study which showed increased tracer
activity within the rectum that suggested a rectal source for
the bleeding. GI was subsequently consulted. She underwent
sigmoidoscopy the day of admission. There was blood in the
sigmoid colon, descending colon and transverse colon. There
was also diverticulosis of the proximal sigmoid colon and
descending colon that GI felt was likely the source of
bleeding. After the two units of packed red blood cells
repeat hematocrit remained stable at 32. No further blood
loss occurred.
2. Cardiology. During these episodes there were no cardiac
complications. EKG on admission showed sinus rhythm at 79
beats per minute, left axis deviation, old inferior infarct,
possible prior anterior MI. However, there were no changes
when compared with [**2125-12-12**]. She was continued on
telemetry throughout her hospital course and revealed no
events.
DISCHARGE STATUS: The patient was discharged to home.
FOLLOWUP: The patient is to follow up with primary care
physician on [**Name9 (PRE) 766**].
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.day.
2. Lopressor 50 mg p.o. b.i.d.
3. Aspirin 325 mg p.o. q.day.
4. Lipitor 20 mg p.o. q.day.
Her other cardiac medications including Dyazide and Isordil
were held. Patient's blood pressure was around 120/50, heart
rate 70s to 80s. She is to follow up with her primary care
physician to reinstate these medications given ability of
blood pressure to tolerate.
DISCHARGE DIAGNOSES: Lower GI bleed, likely diverticulosis.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 5838**]
Dictated By:[**Last Name (NamePattern1) 23941**]
MEDQUIST36
D: [**2126-1-31**] 15:02
T: [**2126-1-31**] 15:13
JOB#: [**Job Number **]
|
[
"401.9",
"411.1",
"285.1",
"414.01",
"562.12",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
1369, 1397
|
4036, 4333
|
3620, 4014
|
2184, 3597
|
1175, 1311
|
1420, 2167
|
120, 150
|
179, 957
|
980, 1150
|
1328, 1352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,423
| 186,792
|
10833
|
Discharge summary
|
report
|
Admission Date: [**2179-8-26**] Discharge Date: [**2179-9-3**]
Date of Birth: [**2142-10-8**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old
gentleman with a history of alcoholism, who was transferred
from an outside hospital with alcohol-induced pancreatitis.
While there, he was aggressively hydrated. He was febrile to
101.4??????F and was started on imipenem and Levaquin. He was
borderline hypoxic on four liters of oxygen by nasal cannula
and was transferred to [**Hospital1 69**]
for further management of pancreatitis as well as
questionable impending adult respiratory distress syndrome.
COURSE IN MEDICAL INTENSIVE CARE UNIT: When he arrived at
the medical intensive care unit, the patient was felt to have
some component of volume overload and was diuresed with
improvement in the chest x-ray alveolar infiltrate pattern
and weaning of his oxygen requirement. He was started on
empiric Levaquin and Flagyl for possible aspiration. He was
noted to have a coagulopathy and was started on vitamin K. A
DIC panel was checked and he was found to have an elevated
D-dimer of greater than [**2177**] and a fibrinogen that was normal
at 285.
Over [**2179-8-27**], the patient became increasingly tachypneic
and dropped his oxygen saturations to the 80s and low 90s on
two liters by nasal cannula. An arterial blood gas was
obtained, which showed the appearance of acute respiratory
alkalosis with a pH of 7.50, pCO2 of 29 and pO2 of 53 on two
liters of oxygen by nasal cannula.
The patient had been bed-bound for approximately one week at
the outside hospital and was not on any prophylaxis. Given
his A-a gradient, high D-dimer and worsening respiratory
symptoms, a CT angiogram was done, which revealed bilateral
subsegmental filling defects and diffuse ground glass
opacities consistent with fluid overload versus adult
respiratory distress syndrome. At this time, the patient was
started on heparin for bilateral subsegmental pulmonary
embolism.
The patient did well in the medical intensive care unit. He
remained hemodynamically stable and his respiratory status
improved consistently, allowing him to be discharged to the
floor on [**2179-8-29**].
PAST MEDICAL HISTORY:
1. Alcohol abuse.
2. Left hip arthrotomy.
3. History of pancreatitis.
MEDICATIONS ON TRANSFER:
1. Banana bag.
2. Protonix 40 mg intravenous q.d.
3. Nicoderm 21 mg patch every 24 hours
4. Levaquin 500 mg p.o. q.d.
5. Flagyl 500 mg p.o. t.i.d.
6. Neutra-Phos two packets p.o. t.i.d.
7. Vitamin K 10 mg p.o. q.d. times three days.
8. Ativan 2 mg p.o./intravenous/intramuscular every four
hours standing times three doses.
9. Albuterol and Atrovent nebulizers.
10. Heparin drip.
ALLERGIES: There were no known drug allergies.
SOCIAL HISTORY: The patient lived with his wife, [**Name (NI) **]. [**Name2 (NI) **]
was unemployed and a former plumber. He smoked one and a
half packs per day and drank 12 cans of beer per day. His
last drink was five days prior to admission. He had used
cocaine in the past, but denied any current use.
FAMILY HISTORY: The patient had a father with lung
carcinoma, who died at the age of 63 and was positive for
alcohol abuse. The patient had a mother with a myocardial
infarction at the age of 58.
PHYSICAL EXAMINATION: Upon arrival to the floor, the patient
had a temperature of 102.1??????F, a blood pressure of 136/80, a
heart rate of 118-122 and an oxygen saturation of 97% on five
liters by nasal cannula. In general, he was in no acute
distress. He was alert and oriented. On head, eyes, ears,
nose and throat examination, the extraocular movements were
intact. The pupils were equal, round and reactive to light
and accommodation. The sclerae were anicteric. The
oropharynx was clear. The neck was supple without any
jugular venous distention.
The lungs were clear to auscultation bilaterally with
bilaterally decreased breath sounds at the bases. The
cardiovascular examination was a regular rate and rhythm with
a normal S1 and S2 and no murmurs. The abdomen was soft,
nontender and nondistended with positive bowel sounds. The
extremities had no edema, cyanosis or clubbing. On
neurological examination, cranial nerves II through XII were
grossly intact. Strength was [**5-1**] in all major muscle groups
bilaterally. The examination was otherwise nonfocal.
LABORATORY DATA: On admission, the patient had a white blood
cell count of 13,700, hematocrit of 34.9 and platelet count
of 244,000. Chemistries showed a sodium of 134, potassium of
3.5, chloride of 101, bicarbonate of 20, BUN of 4, creatinine
of 0.6 and glucose of 149. Anion gap was 13. The patient
had a prothrombin time of 15, INR of 1.5 and partial
thromboplastin time was 58.2. Lipase was 53.
RADIOLOGY DATA: A chest x-ray showed bilateral perihilar
densities, right greater than left, which were improved from
the prior examination.
HOSPITAL COURSE ON FLOOR: The patient was transferred out of
the medical intensive care unit on [**2179-8-29**], once his
respiratory status had improved. From a gastrointestinal
standpoint, the patient's pancreatitis was resolving. His
lipase was noted to be 53, down from the 800s at the outside
hospital, and he was able to tolerate p.o. intake without
difficulty. He did not require any pain medication. He
initially complained of diarrhea, which resolved within a few
days on its own. Stool studies were negative for Clostridium
difficile and fecal leukocytes. Stool cultures were negative
as well. At the time of discharge, the patient did not have
any active acute gastrointestinal issues.
The patient had recurrent fever spikes as well as an elevated
white blood cell count. A CT scan of the abdomen and pelvis
did not reveal any evidence of abscess or phlegmon. It was
notable for a small amount of pancreatitis ascites, but was
otherwise unremarkable. The patient had multiple cultures of
his blood, urine and stool, all of which were nondiagnostic.
At this time, the patient was on Levaquin and Flagyl with a
downward trend in the white blood cell count and frequency of
his fevers. Once a gastrointestinal source was ruled out,
the patient was maintained on Levaquin alone with a continued
response. No focus of infection was ever determined, but the
patient was continued on a two week course of Levaquin, given
his sustained improved. On the day of discharge, the patient
had been afebrile for the past 24 hours.
From a pulmonary standpoint, the patient's respiratory status
improved consistently throughout his stay. He was maintained
on Lovenox while we waited for his Coumadin to become
therapeutic. The patient had a normal transthoracic
echocardiogram with no right wall motion abnormalities or
increased pulmonary artery pressures. At the time of
discharge, the patient's oxygen saturation was 100% in room
air and he was ambulating without difficulty.
Given the patient's recent history of alcohol withdrawal, he
was followed by the psychiatry service. He came to us on
high doses of standing Ativan. This was switched to Valium
per the psychiatry service and was carefully weaned. The
patient did not manifest any further evidence of alcohol
withdrawal while on the floor. The patient had agreed to
participate in an outpatient alcohol rehabilitation program
and will be followed by outpatient psychiatry. He was
started on Serzone for management of anxiety and depression.
DISCHARGE MEDICATIONS:
Levaquin 500 mg p.o. q.d. to complete a 14 day course.
Lovenox.
Coumadin 5 mg p.o. q.d.
Serzone 15 mg p.o. b.i.d.
FOLLOW UP: The patient will follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 4640**], to have his INR checked. In the
meantime, the patient will be maintained on Lovenox. He has
been instructed as to the use of the injections. The patient
will also follow up with outpatient psychiatry and has agreed
to participate in an outpatient alcohol rehabilitation
program.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**]
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2179-9-3**] 15:09
T: [**2179-9-3**] 15:25
JOB#: [**Job Number 35333**]
|
[
"415.19",
"291.81",
"507.0",
"276.3",
"300.4",
"303.90",
"428.0",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3109, 3291
|
7470, 7585
|
7597, 8264
|
3314, 7447
|
159, 2220
|
2341, 2780
|
2242, 2316
|
2797, 3092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,753
| 190,880
|
22339
|
Discharge summary
|
report
|
Admission Date: [**2128-7-16**] Discharge Date: [**2128-7-23**]
Date of Birth: [**2099-6-14**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old
woman with history of headache who was seen by Dr. [**Last Name (STitle) 1132**] in
his office last Friday and noted to have severe headache.
She had a CT scan, which showed a question of a subarachnoid
hemorrhage. The patient was admitted and had an angiogram,
which showed a right MCA aneurysm that was not amenable to
coil embolization. The patient was, therefore, admitted to
the ICU and taken to the OR. On [**2128-7-18**], the patient was
taken to the OR for clipping of a right MCA aneurysm without
intraoperative complication. Postoperative, the patient's
vital signs were stable. She was afebrile. Pupils were 3
down to 2 mm bilaterally. She did have right periorbital
edema. Her grasps and her IPs were full strength. She did
have a slight left drift. She remained in the ICU for close
neurologic observation. Her vital signs remained stable.
She remained neurologically intact. She had a repeat
angiogram, which showed good placement of the clip. The
patient was awake, alert, oriented x3. Pupils equal, round,
and reactive to light with no drift. Grasps and IPs were
full. The patient has a past medical history of asthma,
anxiety, reflux disease, and hypertension. Past surgical
history of tubal ligation, excision of tumor in the right
hand and back. She remained neurologically stable and was
transferred to the regular floor on [**2128-7-20**]. She has
remained neurologically intact with just complaints of
headache. She had a repeat head CT on the day of discharge,
which was stable. She was discharged to home in stable
condition with follow up with Dr. [**Last Name (STitle) 1132**] in one week for
staple removal.
MEDICATIONS: Medications at the time of discharge,
1. Nicotine 14 mg patch, change q.24 h.
2. Fluoxetine 20 mg p.o. q.d.
3. Hydromorphone 1 to 3 tablets p.o. q.4 h. p.r.n. for
headaches, 2 mg tablets were prescribed.
4. Advair for her asthma 150 mcg dose 1 to 2 puffs q.12 h.
DISCHARGE CONDITION: The patient's condition was stable at
the time of discharge.
FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 1132**] on [**2128-7-30**] at
10:30 am. Her condition was stable at the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2128-7-23**] 13:51:50
T: [**2128-7-23**] 21:27:44
Job#: [**Job Number 58175**]
|
[
"401.9",
"437.3",
"300.00",
"493.90",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"03.31",
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
2155, 2217
|
2229, 2625
|
165, 2133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,677
| 110,246
|
48605
|
Discharge summary
|
report
|
Admission Date: [**2150-7-27**] Discharge Date: [**2150-8-1**]
Date of Birth: [**2085-9-6**] Sex: F
Service: MEDICINE
Allergies:
Benadryl / Penicillins / Morphine
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
bilateral flank pain
Major Surgical or Invasive Procedure:
Left percutaneous nephrostomy placement ([**2150-7-27**])
History of Present Illness:
Ms. [**Known lastname 17301**] is a 64 yo female h/o urinary retension, stroke,
cardiac arrest, hypertension who presents from her [**Hospital 4382**] facility with bilateral flank pain. This pain began on
[**7-25**] and has progressively worsened. She also noted subjective
fevers and chills and mild nausea though no vomiting. Patient's
aid called 911 given concern.
.
In the ED, vitals were: 101.4 128/80 87 24-28 97% RA. CT
ABD/PELV showed Left UPJ and UVJ stones, with associated left
mild hydroureter and mild pelvocaliectasis with surrounding
stranding. Seen by urology who recommended percutaneous
nephrostomy tube by IR. She received 1 L NS and Cipro IV x 1 an
flagyl. Highest fever was 101.4.
.
On the floor, patient describes mainly L sided flank pain.
Otherwise feeling thirsty.
Past Medical History:
MEDICAL HISTORY:
1. hypertension
2. gait disorder s/p CVA
3. urinary incontinence x12 months
4. hydronephrosis
5. chronic kidney disease: crt low to mid 2's
6. post-menopausal vaginal bleeding with thickened endometrial
stripe
7. remote deep venous thrombosis
8. hypothyroidism s/p partial thyroidectomy
9. cardiac arrest 1/05 per report
10. depression
11. pvd ?: seen by Dr. [**Last Name (STitle) **] of vascular surgery [**8-27**] but no
note from that visit, arterial studies normal [**4-/2146**]
12. Basal cell carcinoma of the left upper lip, s/p Mohs'
surgery
in [**1-/2149**]
Social History:
The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist. She lives alone in a
facility for handicapped senior citizens; her boyfriend lives
two blocks away. She denies tobacco, alcohol, or illicit drug
use or abuse.
Family History:
She was adopted; her mother died when she was very young, and
her father abused alcohol.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, 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, + LLQ tenderness and mild RLQ tenderness,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, 2+ LE edema, no clubbing or
cyanosis
Neuro: AOx3, CN II-XII grossly intact, 5/5 strength bilateral
UEs, [**3-24**] in RLE, 4+/5 LLE
CHANGES ON DISCHARGE
1) Left Nephrostomy in place
2) Less tender abdomen
Pertinent Results:
Labs on admission:
[**2150-7-27**] 02:45PM GLUCOSE-83 UREA N-66* CREAT-4.0* SODIUM-133
POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-17
[**2150-7-27**] 11:20AM WBC-32.7*# RBC-4.73 HGB-13.2 HCT-40.3 MCV-85
MCH-28.0 MCHC-32.9 RDW-13.4
[**2150-7-27**] 11:20AM NEUTS-96.1* LYMPHS-2.3* MONOS-0.8* EOS-0.4
BASOS-0.3
[**2150-7-27**] 11:20AM PLT COUNT-207
[**2150-7-27**] 11:20AM PT-14.9* PTT-29.6 INR(PT)-1.3*
[**2150-7-27**] 11:20AM ALT(SGPT)-23 AST(SGOT)-43* CK(CPK)-205* ALK
PHOS-77 TOT BILI-0.5
[**2150-7-27**] 11:50AM URINE RBC-[**4-29**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2150-7-27**] 11:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
LABS ON DISCHARGE:
[**2150-7-29**] 08:20AM BLOOD WBC-15.4* RBC-4.00* Hgb-11.2* Hct-34.3*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.1 Plt Ct-182
[**2150-7-28**] 05:08AM BLOOD PT-13.3 PTT-26.8 INR(PT)-1.1
[**2150-7-29**] 08:20AM BLOOD Glucose-94 UreaN-68* Creat-3.8* Na-138
K-3.3 Cl-103 HCO3-25 AnGap-13
Micro:
[**2150-7-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2150-7-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2150-7-27**] 10:44 pm FLUID,OTHER NEPHROSTOMY FLUID.
GRAM STAIN (Final [**2150-7-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PROBABLE ENTEROCOCCUS. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary):
[**2150-7-27**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2150-7-27**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2150-7-27**] 12:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2150-7-27**] URINE URINE CULTURE-PENDING EMERGENCY [**Hospital1 **]
Imaging:
CT abd/pelvis ([**2150-7-27**]):
IMPRESSION
1. Left UPJ and UVJ stones, with associated left mild
hydroureter and mild
pelvocaliectasis.
2. Left perinephric and periureteric inflammatory stranding.
3. Cholelithiasis without evidence of cholecystitis.
CXR ([**2150-7-28**]):
Left lower lobe opacity. Considerations include atelectasis,
infection, or combination of the two.
Percutaneous Nephrostomy ([**2150-7-27**]):
Successful replacement of left percutaneous nephrostomy with
8-French Flexima nephrostomy tube under fluoroscopic guidance.
Mild left hydronephrosis and hydroureter noted. There is a
partially obstructing left UVJ stone and nonobstructing left UPJ
stone.
Brief Hospital Course:
IN SUMMARY
This is a 64 yo female with a history of urinary retention and
indwelling foley who presents with bilateral flank pain and
found to have L obstructing ureteral stones, leukocytosis to 32,
fever and acute on chronic renal failure. She has responded to
Meropenem and nephrostomy placement. That nephrostomy was not
putting out, so she had a nephrostogram that showed no problems
with the system but confirmed a large obstructing stone
BY PROBLEM
# Pyelonephritis/Peri-Urosepsis: The reason for her
presentation. Related to obstructing ureteral stones. Given the
stones seen on CT, her high WBC (33) and ARF (4.0 from 2.2) in
the setting of her multiple medical problems, she received ICU
care. She [**Last Name (un) **] required pressors. She was started on cipro and
flagyl and given PCN allergy was transitioned to Meropenem.
Cultures of urine and blood were positive for enterococcus and
ecoli. These were sensitive to ciprofloxacin. The patient was
kept on meropenem because of penicillin allergy and transitioned
to cipro. Surveilance cultures were negative. Pt defervesced
rapidly and WBC fell slowly.
.
# L ureteral stones: Seen by urology who rec urgent
decompression of L collecting system with PCN by IR. PCN blocked
up on [**2150-7-28**], IR assessed with nephrostogram that confirmed the
stone. She require more definitive management after this
emergent intervention. She will f/u on [**8-10**]. She was
discharged with a PCN that drained clear, bloody fluid.
.
# Acute on Chronic Renal Failure: Baseline 2-2.6. Acutely
related to ureteral stone obstruction in setting of poor renal
reserve vs pre-renal or even ATN in setting of evolving
infection and continued diuresis. She fell from 4.0 to 2.8 by
the time of discharge.
.
# HTN: Pressures currently in the 110's systolic, baseline
around 150's in setting of peri-sepsis. Continue Labetalol and
Furosemide on d/c or outpatient; was held inpatient
.
# LLL Opacity: CXR read as infection vs atelectasis. Very
possible this represents atelectasis given pt describes
splinting past few days. Could also be a sympathetic effusion.
No cough, hypoxia. Most likely atelecasis
.
# Depression: Mood stable. Cont outpt regimen of sertraline and
nortriptyline.
.
ISSUES TO BE RESOLVED OUTPATIENT
1) Pyelonephritis - cipro 500 mg until [**8-11**]
2) Kidney Stones - Urology appointment on [**8-10**]
3) Hypertension - Labetalol and furosemide were held inpatient.
[**Month (only) 116**] consider restarting if clinically indicated.
Medications on Admission:
Lasix 160 mg TID
Labetolol 300mg TID
Nortriptyline 25mg QAM, 50mg QPM
Sertraline 100mg daily
ASA 81 mg daily (not compliant)
Ergocalciferol 50,000 IU qmonthly
Discharge Medications:
1. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
standard injection Injection TID (3 times a day): As long as
immobile .
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Transport
Patient will need transportation to medical appointments on
[**2150-8-6**] and - especially - [**2150-8-10**]
8. Outpatient Physical Therapy
If indicated after rehab discharge, patient will need physical
therapy outpatient
9. Outpatient Lab Work
Please check chemistry (sodium, potassium, BUN, creatinine) on
Monday, [**8-3**].
If less than 2.0, can switch to 750 mg Ciprofloxacin daily until
[**2150-8-11**]
10. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 10
days: Last Day is [**2150-8-11**].
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
12. Labetalol 300 mg Tablet Sig: One (1) Tablet PO three times a
day: THIS MEDICATION WAS HELD FOR SEPSIS AND THEN PERSISTENT
NORMOTENSION. Can restart if clinically indicated.
13. Lasix 80 mg Tablet Sig: Two (2) Tablet PO three times a day:
WAS HELD THIS ADMISSION FOR SEPSIS AND THEN ACUTE RENAL FAILURE.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4860**] - [**Location (un) 4310**]
Discharge Diagnosis:
PRIMARY
Pyelonephritis
Ureteral Stone
SECONDARY
Diarrhea
s/p Stroke
Discharge Condition:
afebrile, stable, left nephrostomy draining some bloody urine
Discharge Instructions:
You were admitted with flank pain. This was caused by a serious
kidney infection related to a stone blocking the flow of urine.
You received antibiotics and a procedure to relieve the
blockage. You did well. You will have to follow up with a
urologist to address the stone.
.
NEW MEDICATION
CIPROFLOXACIN - this is the antibiotic, take it as directed
SARNA LOTION - this will help with your rash and itch
.
Return to the hospital if you experience high fevers, severe
pain or any symptoms that concern you.
.
Follow ups:
1: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2150-8-10**]
10:15
2: After being discharged, follow up with [**Company 191**] POST [**Hospital 894**]
CLINIC Phone:[**Telephone/Fax (1) 250**]
Followup Instructions:
Upon discharge, please follow up with [**Company 191**] POST [**Hospital 894**] CLINIC
Phone:[**Telephone/Fax (1) 250**]
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2150-8-10**] 10:15
Completed by:[**2150-8-1**]
|
[
"787.91",
"584.9",
"585.9",
"518.0",
"244.0",
"590.10",
"041.4",
"592.1",
"403.90",
"788.30",
"591",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.03",
"87.72"
] |
icd9pcs
|
[
[
[]
]
] |
10614, 10688
|
6388, 8884
|
313, 372
|
10800, 10864
|
2887, 2892
|
11710, 12025
|
2082, 2172
|
9094, 10591
|
10709, 10779
|
8910, 9071
|
10888, 11687
|
2187, 2868
|
4925, 6365
|
253, 275
|
3634, 4259
|
400, 1193
|
2907, 3615
|
4709, 4881
|
1215, 1800
|
1816, 2066
|
4294, 4675
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,303
| 168,845
|
5558+55682
|
Discharge summary
|
report+addendum
|
Admission Date: [**2171-9-27**] Discharge Date: [**2171-10-10**]
Date of Birth: [**2093-4-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Oxycodone
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
R Knee tightness and pain
Major Surgical or Invasive Procedure:
[**2171-9-28**]: R Knee I+D, washout
[**2171-10-3**]: R knee gastroc flap and wound closure
Past Medical History:
Right total knee replacement ([**2169**])but did not gain full ROM so
underwent a patellectomy and lateral release [**2171-5-8**]. This was
then complicated by infection with MRSA and MRSA bacteremia. The
knee prosthesis was removed on [**2171-5-26**] and an antibiotic spacer
was placed. She was treated with a 6 week course of vancomycin.
The spacer was felt to be causing irritation and tenting on the
skin and thus it was removed with debridement of devitalized
tissue and VAC application on [**2171-6-14**]. On [**2171-7-5**], she was
returned with dehiscence of right knee incision. Multiple
debridements were subsequently performed with growth primarily
of Enterobacter as well as one culture positive of VRE and one
of CNS. She was treated with Meropenem and Daptomycin and
ultimately was changed to oral Cipro for the Enterobacter and
continued on Daptomycin for the VRE/CNS. She then underwent R
knee fusion on [**2171-9-18**] by Dr. [**Last Name (STitle) **]. In this stay she was
complicated by a VRE/MRSA+ knee cultures.
CAD s/p MI x 2 (25 years ago)
Colon Cancer ([**2162**]) s/p 5-FU and partial colectomy
Anemia
Urge incontinence
HTN
Cervical cancer
Tonsilectomy
Appendectomy,
Rectosigmoidectomy
Wrist ORIF ([**2166**]) & right prosthetic knee infection as above.
.
Social History:
Recently widowed over the past year and lost her son. Lives
alone at home. She does not currently smoke, quit 30 years ago,
[**6-8**] year history of 3 packs/week. She does not drink coffee.
No ETOH. No IVDU.
Family History:
[**Name (NI) **] father died in his 90s of an MI, and the patient's
mother died of unknown causes.
Physical Exam:
GEN: NAD
HEENT: EOMI, PERRL, sclera anicteric
OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
CV: RRR
PULM: Lungs CTAB
ABD: Soft, NT, ND, +BS.
EXT: Right knee skin with overstiching very tight, no drains,
significant swelling and hemarthroses. Able to move toes on LLE
and RLE, strength 4.5 in
Right foot. DP Pulses 1+ bilaterally.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2171-10-7**] 03:57AM BLOOD Hct-32.2*
[**2171-10-6**] 05:04PM BLOOD Hct-31.9*
[**2171-10-6**] 05:30AM BLOOD Hct-27.9*
[**2171-10-5**] 02:07PM BLOOD WBC-3.7* RBC-3.08* Hgb-9.1* Hct-26.9*
MCV-87 MCH-29.4 MCHC-33.6 RDW-16.5* Plt Ct-233
[**2171-10-5**] 04:31AM BLOOD WBC-3.9* RBC-2.99* Hgb-8.9* Hct-26.2*
MCV-88 MCH-29.8 MCHC-34.1 RDW-16.6* Plt Ct-198
[**2171-10-4**] 04:30AM BLOOD WBC-6.5# RBC-3.53* Hgb-10.5* Hct-30.6*
MCV-87 MCH-29.8 MCHC-34.4 RDW-16.3* Plt Ct-220
[**2171-10-3**] 04:50AM BLOOD WBC-3.9* RBC-3.58* Hgb-10.7* Hct-30.7*
MCV-86 MCH-29.9 MCHC-34.8 RDW-16.4* Plt Ct-185
[**2171-10-2**] 05:07AM BLOOD WBC-4.5 RBC-3.54* Hgb-10.6* Hct-30.2*
MCV-85 MCH-29.9 MCHC-35.0 RDW-17.0* Plt Ct-171
[**2171-10-1**] 05:10PM BLOOD WBC-4.3 RBC-3.62* Hgb-10.7* Hct-31.0*
MCV-86 MCH-29.6 MCHC-34.6 RDW-17.5* Plt Ct-165
[**2171-10-1**] 05:10AM BLOOD WBC-4.6 RBC-3.39* Hgb-10.1* Hct-28.6*
MCV-84 MCH-29.7 MCHC-35.2* RDW-17.1* Plt Ct-147*
[**2171-9-30**] 09:42AM BLOOD Hct-29.0*
[**2171-9-30**] 01:55AM BLOOD WBC-5.5 RBC-3.30*# Hgb-10.0*# Hct-27.4*#
MCV-83 MCH-30.2 MCHC-36.3* RDW-16.5* Plt Ct-105*
[**2171-9-29**] 03:40PM BLOOD WBC-5.2# RBC-2.63* Hgb-7.8* Hct-21.6*
MCV-82 MCH-29.6 MCHC-36.0* RDW-16.6* Plt Ct-121*
[**2171-9-29**] 05:02AM BLOOD WBC-11.5* RBC-3.18* Hgb-9.1* Hct-25.7*
MCV-81* MCH-28.7 MCHC-35.5* RDW-17.2* Plt Ct-163
[**2171-9-29**] 12:06AM BLOOD WBC-14.6*# RBC-2.88* Hgb-8.5* Hct-23.9*
MCV-83 MCH-29.4 MCHC-35.4* RDW-17.4* Plt Ct-211#
[**2171-9-28**] 09:00PM BLOOD Hct-28.3*
[**2171-9-28**] 03:55PM BLOOD Hct-27.2*
[**2171-9-28**] 06:35AM BLOOD WBC-3.5* RBC-2.82* Hgb-8.4* Hct-24.5*
MCV-87 MCH-29.8 MCHC-34.2 RDW-15.6* Plt Ct-80*
[**2171-9-27**] 05:30PM BLOOD WBC-3.8* RBC-2.60* Hgb-7.6*# Hct-22.0*
MCV-85 MCH-29.3 MCHC-34.6 RDW-16.3* Plt Ct-93*
[**2171-9-27**] 05:30PM BLOOD Neuts-81.1* Lymphs-12.6* Monos-5.5
Eos-0.6 Baso-0.1
[**2171-10-5**] 02:07PM BLOOD Plt Ct-233
[**2171-10-5**] 04:31AM BLOOD Plt Ct-198
[**2171-10-4**] 04:30AM BLOOD Plt Ct-220
[**2171-10-3**] 04:50AM BLOOD Plt Ct-185
[**2171-10-3**] 04:50AM BLOOD PT-14.3* PTT-29.5 INR(PT)-1.2*
[**2171-10-2**] 05:07AM BLOOD Plt Ct-171
[**2171-9-29**] 03:34PM BLOOD PT-16.0* PTT-31.9 INR(PT)-1.4*
[**2171-9-29**] 05:02AM BLOOD Plt Ct-163
[**2171-9-29**] 05:02AM BLOOD PT-17.4* PTT-31.9 INR(PT)-1.6*
[**2171-9-29**] 12:06AM BLOOD Plt Ct-211#
[**2171-10-5**] 04:31AM BLOOD Glucose-101 UreaN-11 Creat-0.9 Na-138
K-4.4 Cl-102 HCO3-31 AnGap-9
[**2171-10-4**] 04:30AM BLOOD Glucose-151* UreaN-10 Creat-0.7 Na-132*
K-4.8 Cl-97 HCO3-30 AnGap-10
[**2171-10-3**] 04:50AM BLOOD Glucose-103 UreaN-9 Creat-0.5 Na-136
K-3.9 Cl-100 HCO3-34* AnGap-6*
[**2171-10-2**] 05:07AM BLOOD Glucose-94 UreaN-8 Creat-0.5 Na-134 K-4.2
Cl-98 HCO3-32 AnGap-8
[**2171-10-1**] 05:10PM BLOOD Glucose-121* UreaN-10 Creat-0.5 Na-134
K-4.4 Cl-99 HCO3-31 AnGap-8
[**2171-9-30**] 01:55AM BLOOD Glucose-131* UreaN-15 Creat-0.7 Na-136
K-3.3 Cl-105 HCO3-27 AnGap-7*
[**2171-9-29**] 12:06AM BLOOD ALT-26 AST-69* LD(LDH)-363* CK(CPK)-54
AlkPhos-49 Amylase-50 TotBili-1.5
[**2171-9-29**] 12:06AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2171-10-5**] 04:31AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8
[**2171-10-4**] 04:30AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.6
[**2171-10-3**] 04:50AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.9
[**2171-10-2**] 05:07AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8
[**2171-10-3**] 06:23PM BLOOD Type-[**Last Name (un) **] pO2-41* pCO2-49* pH-7.41
calTCO2-32* Base XS-4 Intubat-INTUBATED
[**2171-9-30**] 07:30AM BLOOD Type-ART pH-7.41
[**2171-9-29**] 12:43AM BLOOD Type-ART pO2-114* pCO2-32* pH-7.42
calTCO2-21 Base XS--2
[**2171-10-3**] 06:23PM BLOOD Glucose-117* Lactate-2.0 Na-132* K-4.3
Cl-94*
[**2171-9-27**] 05:41PM BLOOD Lactate-.7
Brief Hospital Course:
The patient was admitted on [**9-27**] with significant swelling of
her old R knee incision with sig hemarthroses to R knee. She was
taken to the OR on [**9-28**] for a R knee I+D with VAC placement. She
tolerated the procedure well and was brought to the PACU. In the
PACU, she was worked up for hypotension and low UOP with
continued drainage into her R knee, she was given 4u pRBC and 2u
FFP as well as a 500cc NS bolus. She had a central line placed
for access and was transferred to the SICU for acute fluid
management and pressors. As her vac was with continued excess
drainage, it was clamped on POD 1 in the SICu and re-attached to
suction later that day with significantly decreased drain
output. She was transferred to the floor on [**9-30**] from the ICU in
stable condition with continued RLE swelling.
On [**10-3**] she underwent a gastrocnemius flap to her wound. She
tolerated the procedure well and no STSG was needed. The patient
remained immobile for 5 days per PRS and was discharged with
minimal swelling, though she needed 1u pRBC on [**10-6**]. She was
discharged with both drains in place and will be discharged on
Keflex.
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Anticoagulation: the patient will be discharged on 40 Lovenox
daily which will be followed up at her first post op visit in 2
weeks.
Antibiotics: As the knee did not show any signs of infection and
simply was swollen [**3-2**] hemarthrosis, the paitent will not
receive outpatient Abx (same as her last discharge)
Dispo: to rehab
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day: take until drains are pulled at your follow up appointment
with plastic surgery.
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) as needed for constipation.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO TID (3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Nursing Home - [**Location (un) 3146**]
Discharge Diagnosis:
R knee effusion, bleeding, hypotension, exposed hardware R knee
Discharge Condition:
Good
Discharge Instructions:
Continue to be touchdown weight bearing on your R knee without
flexion. Wear your knee brace at all times.
Take all medications as prescribed.
Keep your drains in place per the plastic surgery team and
record their output daily in a drain journal log.
If you experience wound redness, fevers >101.4, chest pain,
shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] significant bleeding, or anything else
that concerns you, call Dr. [**Last Name (STitle) 67**] office or go to the emergency
room.
Physical Therapy:
TDWB RLE, NO ACTIVE/PASSIVE RANGE OF MOTION EXERCISES AT RIGHT
KNEE (Knee is fused), WBAT LLE
Treatments Frequency:
JP drain care, plastic surgery will discontinue drains at follow
up appointment. daily dressing changes with sterile dry gauze.
elevation of RLE
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 4599**] [**Last Name (NamePattern1) 9856**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2171-10-18**] 10:20
Follow up with Plastic Surgery Clinic in [**1-30**] weeks by calling
([**Telephone/Fax (1) 7138**]
Completed by:[**2171-10-7**] Name: [**Known lastname 3734**],[**Known firstname **] Unit No: [**Numeric Identifier 3735**]
Admission Date: [**2171-9-27**] Discharge Date: [**2171-10-10**]
Date of Birth: [**2093-4-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Oxycodone
Attending:[**First Name3 (LF) 370**]
Addendum:
Pt was planned for discharge few days earlier, but we decided to
keep her inhouse while her JP drains are in place. She was
stable throughout the additional hospital stay. The amount of
drainage in JP slowly decreased to approximately 10cc/day and
was d/c'd by PRS. ID was also consulted and pt was given bactrim
and vancomycin while drain was in place. Antibx (bactrim and
vanc) will continue for 14 days. Wound was c/d/i and pt was
AVSS. Pt's R knee fusion will be followed by Ortho, and plastic
surgery will manage her surgical wound site and gastroc flap.
She will continue to follow up with [**Hospital **] clinic to ensure no new
infection occurs. Pt can be d/c to rehab.
FOLLOW-UP INSTRUCTIONS:
1) ORTHOPAEDIC SURGERY: [**First Name8 (NamePattern2) 3736**] [**Last Name (NamePattern1) 3737**] [**MD Number(3) 1117**]:[**Telephone/Fax (1) 809**]
Date/Time:[**2171-10-18**] 10:20
2) Plastic Surgery Clinic (Dr. [**Last Name (STitle) 3738**] [**Name (STitle) **]) in 1 weeks by
calling [**Telephone/Fax (1) 3739**]
3) [**Hospital **] clinic: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3740**] in 2 weeks by calling
[**Telephone/Fax (1) 496**]
New set of instructions can be seen on page 1, but briefly:
ANTICOAGULATION: Please take lovenox injections (40mg) once a
day x 3
weeks and then take aspirin 325 mg twice a day x 3 weeks. [**Month (only) 412**]
discontinue all blood thinners 6 weeks post-operatively. Please
call [**First Name9 (NamePattern2) 3741**] [**Doctor Last Name **] at [**Telephone/Fax (1) 3742**]
with any questions.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after
POD#5 but do not tub-bath or submerge your incision. Please
place a
dry sterile dressing to the wound each day if there is drainage,
leave
it open to air. Check wound regularly for signs of infection
such as
redness or thick yellow drainage. Sutures should not be removed
until follow-up with PRS in 1 week.
ACTIVITY: Weight bearing as tolerated to operative leg; no ROM
of R knee; No strenuous exercise or heavy lifting
until follow up appointment, at least.
VNA (after home): Home PT/OT, dressing changes as instructed,
and routine vitals and wound check; routine PICC line care w/
antibx administration if discharged from rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3743**] Nursing Home - [**Location (un) 3744**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 372**] MD [**MD Number(2) 373**]
Completed by:[**2171-10-10**]
|
[
"V10.41",
"V10.05",
"276.52",
"998.12",
"041.89",
"719.16",
"711.06",
"E878.8",
"788.31",
"401.9",
"414.01",
"458.29",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"86.74",
"80.16",
"83.82",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12996, 13238
|
6309, 7875
|
310, 404
|
9196, 9203
|
2624, 6286
|
10043, 11382
|
1960, 2060
|
7898, 8979
|
9109, 9175
|
9227, 9740
|
2075, 2605
|
9758, 9852
|
9874, 10020
|
245, 272
|
12283, 12973
|
11406, 12271
|
426, 1714
|
1730, 1944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,048
| 120,991
|
18651
|
Discharge summary
|
report
|
Admission Date: [**2158-7-6**] Discharge Date: [**2158-7-10**]
Date of Birth: [**2087-9-7**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
gentleman with a history of hypercholesterolemia, history of
exertional angina for about a year, who originally presented
to [**Hospital3 3583**] with the onset of chest pain and tightness
at rest and subsequently was transferred to [**Hospital1 346**] for cardiac catheterization.
Patient states that over the course of the last year he has
had exertional angina when taking long walks, but over the
course of three weeks the episodes got more frequent. He
describes them as chest tightness and dyspnea in the
mid-chest. He had a similar episode at rest lasting 1 1/2
hours. Episode resolved, followed by another one that made
him eventually go to the hospital. EKG showed sinus
bradycardia, [**Street Address(2) 1755**] depressions in leads V1 to V4, ST
elevation in V6. Patient was diagnosed with acute posterior
MI and received two doses of Retavase 20 minutes after
arrival. He was also started on heparin drip, nitro drip and
was given metoprolol. He was subsequently asymptomatic after
2 mg of morphine en route to [**Hospital1 188**]. Upon arrival to [**Hospital1 18**] emergency department, ST
depressions on EKG were improved and patient was asymptomatic
and hemodynamically stable. Chest x-ray was normal per
outside hospital report.
PAST MEDICAL HISTORY: BPH. Hypercholesterolemia diet
controlled.
PAST SURGICAL HISTORY: Rotator cuff repair. Left carpal
tunnel repair. Left hernia repair.
MEDICATIONS: Hytrin.
ALLERGIES: Typhoid vaccine.
SOCIAL HISTORY: The patient is married, lives with his wife.
[**Name (NI) **] a son. Retired. Used to be very active, now activities
limited by exertional angina. No history of tobacco or
illicit drug use. Occasional alcohol use.
PHYSICAL EXAMINATION: Vital signs were temperature 98.4,
blood pressure 80s to 110 over 50s to 60s, pulse 60,
respirations 16, O2 sat 99% on 2 liters by nasal cannula. In
general, the patient was a pleasant gentleman in no apparent
distress. HEENT pupils were equal, round, and reactive to
light and accommodation. Extraocular muscles were intact.
Normal oropharyngeal mucosa. Neck no bruits, jugular venous
pressure approximately 4 cm above the clavicles. Pulmonary
clear to auscultation bilaterally, no wheezing, crackles or
rhonchi. Cardiovascular regular rate and rhythm, normal S1,
S2, no murmurs, gallops or rubs. Abdomen positive bowel
sounds, soft, nondistended, nontender, no organomegaly.
Extremities no cyanosis, clubbing or edema.
LABORATORY DATA: White count 9.7, hemoglobin 12.4,
hematocrit 36.9, platelets 194. INR 1.1. Labs from the
outside hospital CK 174, troponin I 0.024.
HOSPITAL COURSE: The patient was transferred to the CCU
after being evaluated in the emergency room. Patient is
status post posterior MI, status post Retavase thrombolytic
treatment times two at the outside hospital.
1. Cardiovascular. Acute coronary syndrome, status post
acute MI with EKG changes suggestive of posterior wall MI.
Asymptomatic upon arrival to the CCU. EKG suggestive of
resolution of ischemia and good reperfusion after lytic
therapy. Patient was continued on aspirin, heparin drip.
Was restarted on metoprolol 12.5 b.i.d., on a statin and on a
nitro drip. Patient remained chest pain free overnight.
Patient was taken to the cardiac catheterization lab in the
morning. During cath his pulmonary capillary wedge pressure
(PCWP) was 18. Patient was found to have mid-RCA total
occlusion with collaterals and OM1 lesion, both of which were
stented. After cardiac catheterization patient had a brief
episode of hypotension with systolic blood pressure of 80.
Patient was subsequently given atropine and dopamine and
returned to the CCU. Upon return to the CCU, patient had
nausea and had an episode of hematemesis. Nasogastric lavage
was performed and it did not clear with 2 liters of normal
saline. The lavage fluid was grossly bloody and nonbilious.
Integrilin was held. Patient was started on IV Protonix.
Serial hematocrits were stable at 36. GI consult was called
and it was felt that patient was hemodynamically stable and
had gastrointestinal bleeding in the setting of
anticoagulation and lytic therapy. Therefore, it was
prompted to carefully monitor the patient with serial
hematocrits and not to do endoscopy at that time. From the
cardiovascular standpoint, patient has done extremely well.
Patient was transferred to the regular floor and has not had
any subsequent episodes of chest pain. Patient was treated
with aspirin, Plavix, atenolol, lisinopril and a statin which
was transitioned to patient's outpatient regimen. Patient
has had no alarming rhythms on telemetry.
2. GI. The patient had an episode of acute gastrointestinal
bleeding in the setting of being anticoagulated with two
doses of lytic therapy at the outside hospital as well as
Integrilin post cardiac catheterization. Integrilin was
held. Patient has had stable hematocrits and no further
episodes of bleeding. It was decided that since this was in
the setting of anticoagulation, patient would, however,
benefit from being treated with Protonix and being followed
in the outpatient gastroenterology office four to six weeks
after discharge for probable endoscopic evaluation.
3. Pulmonary. The patient has maintained good oxygen
saturation and has not required supplemental O2 since
transfer from the cardiac intensive care unit.
4. Renal. The patient has had stable creatinine and
received appropriate post cardiac catheterization hydration.
5. Endocrine. The patient has a good lipid profile,
however, since patient is status post MI and status post
stent, he will continue to be on statin therapy as an
outpatient.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is to be discharged to home.
DISCHARGE DIAGNOSES:
1. Acute posterior myocardial infarction.
2. Gastrointestinal bleeding in the setting of treatment
with thrombolytics.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Nitroglycerin 0.3 mg sublingual p.r.n.
3. Plavix 75 mg p.o. q.d. times nine months.
4. Pantoprazole 40 mg p.o. q.d.
5. Tamsulosin 0.4 mg p.o. q.h.s.
6. Atenolol 25 mg p.o. q.d.
7. Lisinopril 5 mg p.o. q.d.
8. Lovastatin 40 mg p.o. q.d.
FOLLOWUP: The patient is to follow up with his primary care
physician in one week. The patient also is to follow up with
Dr. [**Last Name (STitle) **] in two weeks. Dr.[**Name (NI) 15020**] office is to
contact the patient with an appointment date. Patient is to
have an echocardiogram four weeks after discharge. Patient
is also to follow up with gastroenterologist to be
recommended by patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], in four to six weeks.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Doctor Last Name 51186**]
MEDQUIST36
D: [**2158-7-23**] 19:12
T: [**2158-7-28**] 09:23
JOB#: [**Job Number 51187**]
cc:[**Last Name (NamePattern1) 51188**]
|
[
"V15.82",
"401.9",
"272.0",
"600.0",
"396.3",
"998.11",
"414.01",
"429.9",
"410.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.07",
"37.23",
"88.53",
"99.20",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5968, 6090
|
6113, 7253
|
2818, 5854
|
1535, 1659
|
1918, 2800
|
159, 1443
|
1466, 1511
|
1676, 1895
|
5879, 5947
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,133
| 137,143
|
35643
|
Discharge summary
|
report
|
Admission Date: [**2157-3-23**] Discharge Date: [**2157-3-28**]
Date of Birth: [**2087-3-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
hypotension, mental status changes,diarrhea
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
This is a 70 female with HTN, hyperlipidemia who was admited to
MICU with altered mental status, platelet count of 5, ARF,
hypotension after having vomiting and diarrhea over one week.
She experienced upper respiratory symptoms associated with
diarrhea over several days. She was given immodium but this did
not help her much. She was having approximately 8 episodes per
day that were non bloody. Because her mental status was altered
and she was brought to the ED and a head CT was negative for
bleed. She received ceftriaxone and vancomycin x1 dose in the
ED. Her mental status has improved since she was admitted
yesterday.
In the ED she was noted to be hypotensive and was given IVF. She
required levophed for pressure support but this has been
discontinued and she has been able to mantain normal BP with
IVF. A CXR was performed and showed diffuse patchy infiltrates
and mediastinal widening (?lymphadenopathy). A chest CT showed
diffuse GGOs with ?consolidation at the bases. A [**Name (NI) 5283**] sono was
performed and was negative for cholecystitis. UA was positive
and she was started on levofloxacin. Her UCx grew low number of
GNR.
On presentation she was noted to have ARF with cre elevated at
4.0 She has been geting IVF and her Cre has improving to 2.6.
Her outpatient cre was ?1.5. FeNa 0.7. Initially she had AG of
22 and HCO3 of 19. After fluids AG is 16 and HCO3 is 16.
Hematology was consulted for TCP. Smear was negative for
schistos, LDH was elevated but hapto was normal. The patient
denied any fever prior to presentation. Review of outpatient
record shows that she was TCP in [**10-20**] with plt of 7. Per
daughter, the patient has been told she has "clumping
platelets". Blue tube [**Last Name (un) **] have been employed in the hospital.
Folate and B12 were negative. No evidence of bleeding since the
patient has been hospitalized and she denies any bleeding PTA.
Past Medical History:
HTN
H-cholesterolemia
Seasonal allergies
Social History:
lives with husband, one daughter is a lab tech, does
not smoke or drink.
Family History:
NC
Physical Exam:
Vitals: 97 132/90 101 18 95%
General: no acute distress, able to relate element of her
presentation, oriented to self, [**Location (un) **], hospital, month, day
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated
Lungs: limited exam due to position, but no crackes or wheeze
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, obesity
Ext: edema to thighs, no pettechia are evident
Pertinent Results:
[**2157-3-23**] 07:15PM BLOOD WBC-2.8* RBC-5.16 Hgb-14.8 Hct-43.6
MCV-85 MCH-28.7 MCHC-34.0 RDW-15.1
[**2157-3-25**] 01:48AM BLOOD WBC-9.7 RBC-4.30 Hgb-11.9* Hct-36.8
MCV-86 MCH-27.6 MCHC-32.3 RDW-15.6* Plt Ct-19*
[**2157-3-27**] 05:30AM BLOOD WBC-12.8* RBC-4.02* Hgb-11.4* Hct-35.2*
MCV-88 MCH-28.4 MCHC-32.5 RDW-15.8* Plt Ct-77*#
[**2157-3-28**] 06:15AM BLOOD WBC-9.2 RBC-3.68* Hgb-10.2* Hct-30.9*
MCV-84 MCH-27.6 MCHC-32.9 RDW-15.6*
[**2157-3-23**] 07:15PM BLOOD Neuts-86.2* Lymphs-11.0* Monos-2.2
Eos-0.6 Baso-0.1
[**2157-3-26**] 07:40AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-4 Eos-1
Baso-0 Atyps-5* Metas-0 Myelos-0
[**2157-3-24**] 03:01AM BLOOD Fibrino-829*# D-Dimer-As of [**12-14**]
[**2157-3-24**] 03:00AM BLOOD FDP-10-40*
[**2157-3-23**] 07:15PM BLOOD Fibrino-1170*
[**2157-3-23**] 07:15PM BLOOD Ret Aut-0.6*
[**2157-3-28**] 06:15AM BLOOD Glucose-100 UreaN-21* Creat-0.9 Na-140
K-3.8 Cl-109* HCO3-22 AnGap-13
[**2157-3-27**] 05:30AM BLOOD Glucose-105 UreaN-34* Creat-1.5* Na-142
K-4.2 Cl-113* HCO3-18* AnGap-15
[**2157-3-23**] 07:15PM BLOOD Glucose-102 UreaN-102* Creat-4.4* Na-138
K-3.4 Cl-100 HCO3-19* AnGap-22*
[**2157-3-25**] 01:48AM BLOOD Glucose-112* UreaN-67* Creat-2.6* Na-142
K-3.6 Cl-114* HCO3-16* AnGap-16
[**2157-3-26**] 07:40AM BLOOD ALT-40 AST-48* LD(LDH)-214 AlkPhos-207*
TotBili-1.0
[**2157-3-25**] 01:48AM BLOOD ALT-33 AST-54* LD(LDH)-339* AlkPhos-162*
TotBili-2.2*
[**2157-3-24**] 03:01AM BLOOD ALT-22 AST-27 LD(LDH)-217 AlkPhos-148*
TotBili-2.9* DirBili-2.7* IndBili-0.2
[**2157-3-23**] 07:15PM BLOOD ALT-29 AST-27 LD(LDH)-225 AlkPhos-179*
TotBili-1.8*
[**2157-3-24**] 12:11PM BLOOD proBNP-6429*
[**2157-3-23**] 07:15PM BLOOD Lipase-23
[**2157-3-28**] 06:15AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
[**2157-3-24**] 12:11PM BLOOD VitB12-GREATER TH Folate-14.9
[**2157-3-23**] 07:15PM BLOOD Hapto-374*
[**2157-3-24**] 03:01AM BLOOD Hapto-292*
[**2157-3-24**] 12:11PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2157-3-24**] 03:19AM BLOOD Type-[**Last Name (un) **] pO2-46* pCO2-28* pH-7.31*
calTCO2-15* Base XS--10
[**2157-3-24**] 02:44PM BLOOD Type-ART pO2-90 pCO2-31* pH-7.35
calTCO2-18* Base XS--7
[**2157-3-24**] 04:25PM BLOOD Type-CENTRAL VE pO2-49* pCO2-33* pH-7.32*
calTCO2-18* Base XS--8
[**2157-3-25**] 02:14AM BLOOD Type-ART pO2-180* pCO2-32* pH-7.34*
calTCO2-18* Base XS--7
[**2157-3-26**] 11:11AM BLOOD Type-ART pO2-103 pCO2-35 pH-7.39
calTCO2-22 Base XS--2 Intubat-NOT INTUBA
[**2157-3-23**] 07:42PM BLOOD Lactate-3.1*
[**2157-3-24**] 02:44PM BLOOD Lactate-1.1
[**2157-3-26**] 11:11AM BLOOD Lactate-1.6
Head CT: negative
[**Month/Day/Year 5283**] US: 1. Dilated gallbladder, but no evidence for acute
cholecystitis.
2. Right hydronephrosis
Renal US: Moderate right hydronephrosis persists. Left kidney
appears
unremarkable.
Chesst CT [**2157-3-24**]:
1. Mild pulmonary edema.
2. Collapse of bibasilar segmental bronchi, could be due to
bronchomalacia. Marked peribronchovascular thickening, could be
atelectasis alone or in infiltrative process such as sarcoid or
lymphadenopathy. Repeat chest CT is recommended after resolution
of the acute edema with perfect coaching about deep inspiration.
3. Granulomatous nodal calcification.
4. Mild aortic valvular calcification, of unknown hemodynamic
significance.
Moderate mitral annulus calcifications. Scattered coronary
artery
calcifications. Cardiomegaly.
5. Small hiatal hernia.
CXR
[**2157-3-23**]
Right IJ central venous catheter tip in the expected location of
the cavoatrial junction.
Low lung volumes limit evaluation. Left basilar atelectasis,
mild CHF.
Widened appearance of the mediastinum for which clinical
correlation is
advised.
---
[**2157-3-25**]
As compared to the previous examination, there is marked
improvement of the chest radiograph. The size of the cardiac
silhouette has decreased, the lung volumes have increased. The
preexisting evidence of overhydration has markedly decreased,
although the aspect of the hilar
structures still suggests minimal remnant central edema. There
also is a
marked decrease of the pre-existing predominantly left mid lung
and right
basal areas of atelectasis. There is no evidence of pleural
effusion. No
focal parenchymal opacity suggestive of pneumonia. Mild
tortuosity of the
thoracic aorta, the central venous catheter is unchanged in
position.
---
[**2157-3-26**]
Comparison is made to the prior day. Cardiac and mediastinal
contours are unchanged. There are areas of minor atelectasis at
the lung bases associated with low lung volumes, but no
congestive heart failure, pleural effusion or pneumothorax
ECHO
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). The
right ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Hyperdynamic left ventricular systolic function.
Mildy dilated right ventricle with normal systolic function.
Brief Hospital Course:
In brief this is a 70 year old female with HTN, hyperlipidemia
who was admited to MICU with diarrhea, altered mental status,
platelet count of 5, ARF, hypotension, CT finding concerning for
PNA as well as UA concerning for UTI. She has been doing well in
the MICU and is transfered to the floor, with improved mental
status, resolved hypotension, improved ARF and currently being
treated for PNA and UTI with levofloxacin and being followed by
hematology for TCP.
# Diarrhea: Most likely this was the precipitant for
hypovolemia. Stool cultures were negative. Most likely etiology
is viral gastroenterits. Resolved during hospitalization.
# Hypotension: She was noted to have E Coli bacteremia on OSH.
Most likely source is urine, given UA finding concerning for
UTI. She was started on broad spectrum antibiotics on
presentation which were consolidated to levofloxacin. She was
discharged on a 14 day course of this medication. Initially
treated with levophed and IVF. The patient was able to mantain
normal BP after these interventions were discontinued. She was
monitored for several days without complications. Her atenolol
was held and can be restarted on an outpatient basis.
# Altered mental status: Most likely related to hypovolemia and
or infective illness. Head CT negative. This resolved with
correction of BP and antibiotic therapy.
# ARF: FeNa consistent with volume depletion. Fluid responsive
and returned to baseline with IVF. On presentation she had AGMA;
notably AG closed with IVF but HCO3 continued to decrease. This
suggests a NAGMA which most likely was related to the diarrhea.
As the diarrhea improved the HCO3 returned to [**Location 213**] level.
# Thrombocytopenia (TCP): Differential included ITP (but no
large platelets on smear), vitamin deficiency (B12/folate were
normal) or viral infection-related process (but EBV and CMV were
positive for chronic but not acute infection, ). Other
etiologies such as as drug-induced processes were considered.
She has been taking prilosec (although it is not clear if the
onset of prilosec fits with the development of TCP). Prilosec
was discontinued. MDS is a remote possibility as well. She
received one platelet transfusion and her platelet count
increased through the hospitalization. The patient was refered
to outpatient hematology for further work up.
# Mild transaminitis: Followuing her hypotension she developed
mild transaminits which was attributed to hepatic hypoperfusion.
These improved following restoration of blood pressure. Her
statin was held and can be restarted as outpatient. If her
transaminases remain elevated she may require further work up.
Medications on Admission:
Prilosec
Atenolol 50mg qd
Simvastatin 40 mg qd
Zyrtec 10 mg qd
HCTZ 37.5 qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
twice a day as needed for shortness of breath or wheezing.
Disp:*1 bottle* Refills:*0*
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day as needed for shortness of breath or
wheezing.
Disp:*1 bottle* Refills:*0*
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Zyrtec
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] VNA
Discharge Diagnosis:
acute renal failure
thrombocytopenia
bacteremia
Discharge Condition:
Good
Discharge Instructions:
You were admitted with low blood pressure, kidney failure and
low platelet count. The cause for the low blood pressure was
infection of your urine which was complicted by infection
spreading to your blood. We are treating you with antibiotics
for this reason.
You were also were noted to have kidney failure which was also
related to the low blood pressure. We gave you intravenous
fluids which helped your kidney function.
Your low platelet number was evaluated by our blood doctor
specialist. The exact cause remains unclear and you will require
further work up of this condition on an outpatinet basis. You
may need a bone marrow biopsy, which you should discuss with
your regular doctor or with the blood doctor that we are
refering you to.
Please call your regular doctor or return to the ED if you have
any concerning symptoms.
Followup Instructions:
regular doctor: PEARL,[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 9674**] on [**2157-4-4**] at
10:30 am.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2157-4-12**]
|
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[
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16,468
| 144,622
|
9279
|
Discharge summary
|
report
|
Admission Date: [**2151-5-27**] Discharge Date: [**2151-6-15**]
Date of Birth: [**2103-7-30**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: The patient presented to the SICU with
pancreatitis.
HISTORY OF PRESENT ILLNESS: A 47-year-old male with a
history of cadaveric renal transplant in [**2149**] who was
transferred from [**Hospital3 417**] Medical Center with
pancreatitis on [**5-26**] complaining of abdominal pain.
Abdominal CT showed pancreatitis. The patient was confused,
combative, hallucinating. He was afebrile. He was sent to the
EW. He vomited. He was sedated with Versed and propofol and
intubated. The patient was treated with Kayexalate, D-5-W,
insulin for hyperkalemia. He was transferred to the [**Hospital1 18**] and
admitted to the SICU where he remained intubated. The patient
continued to be agitated, associated with hallucinations. He
required IV sedation.
PAST MEDICAL HISTORY: Significant for end-stage renal
disease secondary to hypertension, hepatitis C, gout, HSV,
history of motor vehicle accident with right tibia fracture,
head injury, exploratory laparotomy and tracheostomy, history
of CHF.
PAST SURGICAL HISTORY: Cadaveric renal transplant on
[**2150-1-21**] with ACR on [**2150-2-18**], exploratory
laparotomy, tracheostomy in [**2134**], left AV fistula x2.
MEDICATIONS ON ADMISSION: CellCept [**Pager number **] mg p.o. b.i.d.,
Prograf 4 mg p.o. b.i.d., Bactrim single strength 1 tablet
p.o. daily, Protonix 40 mg p.o. daily, amlodipine 10 mg p.o.
daily, atenolol 75 mg p.o. daily, Diovan 160 mg p.o. daily,
clonidine 0.3 mg p.o. t.i.d., Tricor 48 mg p.o. daily and
oxycodone p.r.n..
ALLERGIES: The patient was allergic to PENICILLIN, VICODIN
and MOTRIN.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.7, heart
rate 80, BP 172/79, respiratory rate 30, 100% intubated,
sedated. The patient moved all extremities. Responded to
pain. HEENT: Within normal limits. COR: Regular rate and
rhythm. No murmurs, regurg, gallops. LUNGS: Coarse
bilaterally. ABDOMEN: Distended and soft. EXTREMITIES: No
C/C/E. Peripheral IV x2 in the right upper extremities.
Intake and output at outside hospital 1220 cc in and 625 out.
LABORATORIES ON ADMISSION: White count 14.4, hematocrit
41.8, platelets 124, 90.5% PMNs, sodium 139, potassium 6.6,
BUN 30, creatinine 3.3, chloride 121, bicarbonate 12, amylase
1240, lipase 829, alkaline phosphatase 156, AST 20, ALT 16,
direct bilirubin 0.4, indirect bilirubin 0.3, CK 193, CK-MB
2.4, troponin 0.2. ABGs 7.25/25.9/415.2/11.3, ammonia was 35.
Tox screen was positive for cocaine on [**5-27**].
BRIEF HOSPITAL COURSE: The patient was admitted to the SICU.
Abdominal CT demonstrated diffusely enlarged pancreatitis
with infiltration of surrounding fat, renal transplant right
iliac fossa. Head CT demonstrated no evidence of hemorrhage,
midline shift or mass effect. He was treated with a beta
blocker for hypertension. Remained intubated. He was n.p.o.
with IV fluid hydration. Nephrology was consulted and
followed throughout this hospital course. Renal ultrasound
demonstrated normal renal transplant ultrasound. Chest x-ray
on [**5-27**] demonstrated satisfactory position of NG tube and
ETT tube. Mild pulmonary edema was noted with possible right
lower lobe pneumonia. EKG demonstrated sinus rhythm with a
rate of 80, with possible left ventricular hypertrophy, with
late transition. An ultrasound of the gallbladder was done.
This demonstrated extrahepatic biliary dilatation without
intra-hepatic biliary dilatation. The patient was status post
cholecystectomy, but the degree of biliary dilatation was
more than would have been expected for a patient of this age.
Given the presence of pancreatitis, a distal duct calculus or
lesion was amongst the possible diagnoses. Correlation with
cross sectional imaging preferably MRI was recommended to
evaluate the distal duct, per radiology. The patient had a
central line placed, new right subclavian central venous
catheter tip terminated in the superior right atrium. No
pneumothorax occurred. The patchy opacity in the right lower
lobe was thought to represent atelectasis. The patient had
serial chest x-rays that demonstrated development of vascular
engorgement, and perihilar haziness was developing
asymmetrical airspace disease within the right lung as well
as a lingering right pleural effusion. Post pyloric feeding
tube was placed with the tip in the distal duodenum. He was
started on post pyloric feedings. His amylase and lipase
decreased. The patient experienced intermittent bouts of
hypertension up into the 180s with stimulation with heart
rate in the 90 to100s with occasional PVCs. He continued to
be treated with Versed and fentanyl drip for DTs and
continued on a CIWA scale, ranging from 5 to 12. The patient
was administered Ativan for extreme agitation with a good
result. Lung sounds remained clear into the bases. He was
suctioned for moderate amounts of thick tan secretions from
the ETT tube and bloody secretions from the supraepiglottis
tube. The patient was given TPN. He received fluid boluses
for low CVP. Blood cultures were drawn as well as urine
cultures. These were subsequently found to be negative. The
patient continued to be hypertensive. This was treated with
hydralazine and Lopressor. Hematocrit remained stable. The
patient was extubated on [**5-30**]. He tolerated this without
event. He received aggressive pulmonary toilet. He was out of
bed.
He also received clonidine 0.2 mg. t.i.d.. He experienced
acute renal failure, most likely due to third spacing and
pancreatitis as well as contrast effect. His creatinine was
3.2. On [**2151-5-30**] the patient required rapid sequence
intubation with cricoid pressure for respiratory distress. O2
saturations were 89% and respiratory was 40. Pa02 was 60,
down from 88 after diuresis of 20 of Lasix.
On [**2151-6-5**] a bilateral upper extremity venous ultrasound
was done to evaluate left arm edema. Chronic nonocclusive
neural calcification of the superficial left brachial vein
was noted. Otherwise, vasculature was patent of the bilateral
upper extremities. On [**5-30**] the patient continued to
demonstrate increasing symptoms of DTs. CIWA scale was
monitored hourly. The patient required a one-to-one sitter.
He was agitated, anxious, and diaphoretic, and tachycardia to
110 despite q.2h. Ativan and fentanyl drip as well as
clonidine patch. He remained on a nitro drip for BP control
as well as Ativan for DTs and fentanyl drip for pain. He was
given Lopressor, hydralazine and clonidine as well as
Norvasc. Blood pressure decreased to 130s to 150s. He was on
AC with increased peak to 10.
On [**5-31**], the first chest x-ray demonstrated consolidation
more on the right. A bronchoscopy was done at the bedside,
cultures were sent to the lab. Sputum culture demonstrated
greater than 25 PMNs and less than 10 epithelial cells as
well as 3+ budding yeast with pseudohyphae. He remained on IV
vancomycin and cefepime. The patient also experienced
herpetic lesions on his penis. Acyclovir was started. His
white blood cell count was 5.2. Hematocrit was stable in the
27 to 28 range. He remained intubated.
Infectious disease followed the patient making
recommendations that included sending a swab of the penile
lesions for GC and chlamydia. These were subsequently
negative. Ciprofloxacin 500 mg IV was started x1 and then 250
mg IV daily, as well as Flagyl 500 mg IV q.8h.. A nasal
aspirate was sent for viral pathogens. These were
subsequently negative. Acyclovir was held. A VRE rectal swab
as well as MRSA screening were both negative. An RPR was
checked. This was negative. The patient was felt to have
community-acquired pneumonia plus or minus aspiration.
Levaquin, Flagyl, vancomycin and cefepime were recommended.
CellCept was decreased to 1 gram q.12h. per Dr. [**Last Name (STitle) **]. His
Prograf was adjusted as well. Repeat blood cultures were
done. These were negative. The patient remained intubated and
sedated. He continued on a pulse pyloric feeding tube, using
Peptamen at 65 cc an hour. TPN was weaned off. IV sedation
was weaned as well as vent settings. His amylase and lipase
continued to decrease. Amylase of 5 and lipase 204. LFTs were
within normal limits. Creatinine remained in the 3.0 to 3.1
range. White blood cell count 5.3, hematocrit 27. He was
treated with IV Lasix drip to keep 2 liters negative for
fluid overload. He was extubated without event, and
creatinine decreased to 2.6.
He was transferred from the SICU to the medical surgical unit
where he gradually improved. His mental status was concerning
for lack of return to baseline. A neuro consult was obtained.
A head CT was done. This demonstrated no evidence of
hemorrhage or mass effect. An RPR was sent. This was
negative. TSH was normal. Ammonia level was normal. A
fentanyl patch had been applied prior to leaving the SICU.
This was removed. Patient's mental status gradually improved.
Psychiatry was consulted for concern for delirium. The
patient had also been receiving lorazepam. This was deceased
to minimize benzodiazepine anticholinergics effects. A one-to-
one sitter was present. He was given Haldol 0.5 mg b.i.d. The
patient's mental status improved. He requested pain
medication for chronic leg pain. He was given a minimal
amounts of Percocet with decreased complaints of leg pain
The patient continued to improve. A KUB was done. The abdomen
appeared somewhat distended. There was no evidence of
obstruction. Ossification in the paraspinal tissues was noted
on the left. A CT of the abdomen was done that demonstrated
peripancreatic stranding consistent with pancreatitis. There
was no evidence of pseudocyst or pancreatic calcifications.
The patient's amylase and lipase had returned to [**Location 213**].
Creatinine was down to 2.1. The patient continued to be
hyperkalemic with a potassium of 5.9. He received treatment
for this with insulin, dextrose, Kayexalate. This was
repeated x2. The patient was found to be drinking Boost
supplements. He was instructed not to drink these given
potassium in the Boost supplement. Potassium decreased to
5.5. Gradually the patient was taking in increased amounts of
p.o. fluid. His abdomen was nondistended, nontender. He was
ambulatory. Alert and oriented. His Prograf remained in the
range of 8.4 on 6 mg b.i.d.. He continued on CellCept.
Physical therapy cleared him for discharge.
DISCHARGE STATUS: The patient was discharged home off
antibiotics. He completed a 10-day course for aspiration
pneumonia. Vital signs were stable.
DISCHARGE FOLLOWUP: The patient was scheduled to follow up
in the outpatient clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 1
week. He was instructed to make a follow-up appointment.
DISCHARGE MEDICATIONS: He was discharged home on clonidine
0.3 mg per 24-hour patch to be changed weekly on Fridays,
Protonix 40 mg p.o. daily, folic acid 1 mg p.o. daily,
Thiamine 100 mg p.o. daily, CellCept [**Pager number **] mg p.o. b.i.d.,
amlodipine 10 mg p.o. daily, Percocet 5/325-mg tablets 1
tablet p.o. p.r.n. q.4-6h. as needed for leg pain with 20
tablets being dispensed, Prograf 1 mg p.o. b.i.d., Lasix 20
mg p.o. daily, bicarbonate 1300 mg p.o. b.i.d., Florinef 0.1
mg p.o. daily was initiated and a script given as well as
Kayexalate 30 grams p.o. for p.r.n. use per transplant office
if potassium is high.
DISCHARGE DIAGNOSES: Pancreatitis, aspiration pneumonia,
genital herpetic lesions, chronic pain, and cocaine abuse.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 3762**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2151-6-22**] 15:47:01
T: [**2151-6-24**] 11:11:41
Job#: [**Job Number 31799**]
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74,340
| 145,774
|
49240+59160
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-4-7**] Discharge Date: [**2159-4-10**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo F s/p mechanical fall, she remembers she tripped in the
bathroom and fell from standing position, did not lose
consciousness. Patient was taken to outside hospital where CT
head showed SDH. Patient was transferred to [**Hospital1 18**].
On arrival to [**Hospital1 18**] patient is alert and oriented, denies
confusion, headache, dizziness and vertigo. She complains of
left sided body pain. Denies chest pain
and shortness of breath.
Patient had a recent syncopal episode, patient was hospitalized
recently. EEG negative, per family report work up for syncope
was
negative. Patient was recently discharge from rehab.
Past Medical History:
PMH:
1. HTN
2. Osteoperosis
3. Cardiomyopathy
4. Cervical spondylosis
5. Degenerative joint disease
6. CHF with LVEF 20%
PSH:
1. Bilateral hip replacements
2. Bilateral cataract surgery
Social History:
She is widowed. She has three children. She lives at home
with nursing care from daughters. She is using a walker for
ambulation. She does not smoke nor consume alcohol.
Family History:
Her family history is noted for a sister who died of breast
cancer. Another sister died of ruptured aortic aneurysm. Her
father had [**Name2 (NI) **] strokes. Her mother died at age [**Age over 90 **].
Physical Exam:
On arrival to [**Hospital1 18**]:
Vitals: 98.3 84 139/66 17 94% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR's
PULM: Decrease [**Hospital1 **] basilar respiratory sounds.
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused. No bone deformities
Strength 4/5 Bilateral upper and lower extremities.
On discharge:
Vitals: 96.6 61 144/70 18 100% RA
GEN: A&O, NAD
CV: RRR, normal S1S2
Pulm: Breath sounds dimished bilaterally
Abd: Soft, nontender, nondistended
Extr: No LE edema, warm, pink and well perfused.
Neuro: A&O X [**3-2**], +MAE and follows commands, PERRLA, speech
clear and coherent
Pertinent Results:
Labs on admission:
[**2159-4-7**] 09:51PM WBC-10.8 RBC-3.57* HGB-11.4* HCT-33.8* MCV-95
MCH-31.9 MCHC-33.8 RDW-12.6
[**2159-4-7**] 09:51PM NEUTS-87.3* LYMPHS-8.5* MONOS-3.5 EOS-0.4
BASOS-0.4
[**2159-4-7**] 09:51PM PLT COUNT-202
[**2159-4-7**] 09:51PM PT-12.2 PTT-24.6* INR(PT)-1.1
[**2159-4-7**] 09:51PM GLUCOSE-125* UREA N-68* CREAT-1.7* SODIUM-138
POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-31 ANION GAP-14
[**2159-4-7**] 09:51PM cTropnT-0.02*
[**2159-4-7**] 10:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-4-7**] 10:08PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
Labs at discharge:
[**2159-4-9**] 05:02AM BLOOD WBC-8.1 RBC-3.20* Hgb-10.2* Hct-30.1*
MCV-94 MCH-31.8 MCHC-33.8 RDW-12.6 Plt Ct-171
[**2159-4-10**] 04:55AM BLOOD Glucose-84 UreaN-69* Creat-1.9* Na-133
K-5.0 Cl-97 HCO3-29 AnGap-12
[**2159-4-10**] 04:55AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.9
[**2159-4-10**] 04:55AM BLOOD cTropnT-0.04*
[**2159-4-7**] CT head w/out contrast:
IMPRESSION:
1. Left subdural collection of uniform low density, likely
represents a
subdural hygroma or chronic subdural hematoma with mild
rightward shift of
midline structures.
2. Prominent extra-axial space overlying the right frontal lobe
mixed density between intermediate and lower density suggesting
a subdural hematoma which is likely either subacute or older.
[**2159-4-7**] CT spine w/out contrast:
IMPRESSION: No acute fracture or malalignment. Stable
degenerative changes. Dilated esophagus and small left pleural
effusion, also better evaluated on chest CT.
[**2159-4-7**] CT chest/abd/pelvis w/out contrast:
IMPRESSION:
1. Multiple displaced comminuted left-sided rib fractures with a
left-sided pleural effusion and small foci of air which are
loculated in the pleural or extrapleural space near the
fractures and also along the outer chest wall, although there is
no substantial pneumothorax at this time.
2. Cardiomegaly.
3. Dilated esophagus suggesting an abnormality of motility.
4. Mildly prominent left supraclavicular lymph node, probably
reactive.
[**2159-4-7**] Left femur xray (AP & LAT), pelvis xray (AP only):
IMPRESSION: Findings suggesting prior injury. Bilateral total
hip
replacements, which appear intact.
[**2159-4-7**] HUMERUS (AP & LAT) LEFT; ELBOW (AP, LAT & OBLIQUE) LEFT;
SHOULDER 1 VIEW LEFT
FINDINGS: The bones appear demineralized. Left-sided rib
fractures are
better characterized on CT torso examination from the same day.
There is no evidence for fracture, dislocation, or bone
destruction involving the
shoulder, humeral shaft or elbow. At the elbow, there is
prominent calcified enthesiopathy along both the medial and
lateral epicondyles.
IMPRESSION: Left-sided rib fractures, better characterized on CT
imaging of the same day.
[**2159-4-7**] ECG
Normal sinus rhythm with marked intra-atrial conduction
abnormality. Left
anterior hemiblock. Left ventricular hypertrophy with secondary
repolarization abnormality. Left bundle-branch block. Abnormal
tracing. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 166 160 458/473 80 -59 130
[**2159-4-9**] SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT:
Mild glenohumeral DJD. Partially visualized lateral rib
fracture.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted initially to the ICU under the acute care
service for monitoring. Her imaging was reviewed and neurosurgey
was consulted for her SDH. It was determined that her head CT
findings were not acute, and that findings were consistent with
L frontal lobe SDH vs. hygroma without mass effect and R chronic
SDH. She remained without neurologic defecits, and no
intervention was needed. It was determined she was safe to start
on DVT prophylaxis with SC heparin. She was scheduled for
neurosurgery follow up and a repeat head CT prior to discharge.
Of note, cardiac enzymes were cycled on admission given the fall
and patient's cardiac history. Troponins were slightly elevated
at 0.02, 0.02 and 0.04; however this was in the setting of
chronic renal insufficiency and elevated creatinine (1.7-1.9).
ECG was obtained as well which showed normal sinus rhythm with
marked intra-atrial conduction abnormality but no evidence of
acute myocardial infarction or ischemia. She remained without
chest pain, palpitations, shortness of breath, or syncopal
symptoms.
She was admitted on a regular diet. She was also started on a
bowel regimen given her decreased mobility and administration of
narcotics. She was noted to have no repsiratory issues. She has
a known EF of 20% so her fluid status was watched closely. After
being monitored overnight in the ICU wihtout any issues she was
transferred to the floor on HD #1.
On the floor her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. Her oxygen
saturations remained within normal limits on room air. Her home
cardiac medications were restarted including her plavix,
metoprolol, aspirin, and lasix; however, her spironolactone was
held due to persisent mild hyperkalemia 5.5 on admission (5.0 at
discharge). Her electrolytes were monitored and repleted as
needed. Her pain medications were adjusted to adequately control
her pain level and ensure her ability to use incentive
spirometry. She was also started on standing nebulizer
treatments to optimize her respiratory function. Her neuro
status remained unchanged.
Physical therapy and occupational therapy were consulted to
assess her mobility and safety given her injuries and history of
falls, who recommended to discharge a rehab facility when
medically cleared.
On [**2159-4-10**] she is afebrile and hemodynamically stable. Her pain
is well controlled and she is tolerating a regular diet and
making adequate amounts of urine. She is being discharged to a
rehab facility to continue her recovery.
Patient's anticipated length of stay at rehab is less than 30
days.
Medications on Admission:
1 Lopressor 100mg [**Hospital1 **]
2 Lasix 10 mg daily
3 Spironolactone 12.5 mg daily
4 Plavix 75 mg daily
5 Calcium 1500 mg daily
6 Vit D 1000 IU daily
7 Vit B 12 1000 dialy
8 Sertraline 12.5 mg daily
9 MVI
10 Imodium prn
11 Tylenol prn
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. sertraline 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
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 BID (2 times a
day) as needed for constipation.
5. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
13. 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, wheezing.
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
s/p fall
Injuries: Left [**8-7**] rib fractures
Secondary:
Chronic left frontal lobe subdural hematoma vs. hygroma
Chronic right subdural hematoma
Hyperkalemia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital after suffering a fall. You
sustained broken ribs on your left side from the fall. There was
a small amount of blood noted on the CT scan of your head, but
upon review it was determined that this was old blood and you
have no acute injury to your head. It is recommended that your
follow up with neurosurgery in 1 month for a repeat head CT scan
to re-evaluate this chronic bleed in your brain.
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths.
If the pain medication is too sedation, take half the dose and
notify your physician.
[**Name10 (NameIs) **] 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 samll
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.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
Please resume all of your regular home medications EXCEPT your
spironolactone. This medication has been held because you had
elevated potassium levels while in the hospital. Your potassium
levels will be rechecked at rehab.
Followup Instructions:
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 103219**],MD
Specialty: Primary CAre
Location: [**Hospital6 **]
Address: [**Apartment Address(1) 25834**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 19752**]
When:Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2159-5-3**] at 1 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
We are working on a follow up appointment in the Neurosurgery
Department with Dr. [**Last Name (STitle) **] in the next month. The Rehab will be
called with the appointment. If you have not heard or have
questions, please call [**Telephone/Fax (1) 1669**].
Completed by:[**2159-4-10**] Name: [**Known lastname 16698**],[**Known firstname 13139**] Unit No: [**Numeric Identifier 16699**]
Admission Date: [**2159-4-7**] Discharge Date: [**2159-4-10**]
Date of Birth: [**2066-5-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 844**]
Addendum:
The patient has an appointment with Dr. [**Last Name (STitle) **] on [**2159-5-22**]
at 2 pm, and an appointment for a CAT scan at the [**Location (un) 16700**] on the same day at 1:15 pm.
Discharge Disposition:
Extended Care
Facility:
Charwell House
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**] MD [**MD Number(1) 846**]
Completed by:[**2159-4-10**]
|
[
"852.21",
"E885.9",
"428.0",
"781.2",
"807.04",
"733.00",
"585.9",
"403.90",
"425.4",
"V43.64",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14066, 14262
|
5650, 8293
|
264, 270
|
10271, 10393
|
2316, 2321
|
12279, 14043
|
1356, 1562
|
8582, 9940
|
10078, 10250
|
8319, 8559
|
10456, 12256
|
1577, 2002
|
2017, 2297
|
209, 226
|
3008, 5627
|
298, 939
|
2335, 2989
|
10408, 10432
|
961, 1150
|
1166, 1340
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,199
| 138,831
|
11889
|
Discharge summary
|
report
|
Admission Date: [**2139-10-14**] Discharge Date: [**2139-10-26**]
Date of Birth: [**2077-2-3**] Sex: M
Service: SURGERY
Allergies:
clindamycin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Hepatitis C, here for liver [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**2139-10-15**]: Orthotopic Liver [**Month/Day/Year 1326**]
[**2139-10-16**]: Exploratory Lap, Liver Biopsy, Roux en Y
Hepaticojejunostomy
[**2139-10-18**]: Exploratory Lap, Hepatic Artery Thrombectomy
History of Present Illness:
62 y/o male diagnosed with HCV in [**2130**] and has progressed to HCC
and is now here to possibly receive a liver from a donor who had
HCV. The patient states that he has felt well recently and has
no unusual symptoms besides occasional intermittent
constipation. The patient has been eating and drinking normally,
and using the bathroom normally. The patient has no other
complaints. He denies fevers, chills, nausea, vomiting,
abdominal pain, melena, any bleeding.
He has no confusion, disorientation, no jaundice, no light
stools.
Past Medical History:
Hepatitis C complicated by cirrhosis and esophageal varices,
now w likely hcc s/p RFA, Knee pain, Dysphoria, GERD, Erectile
dysfunction, L thumb verrucae.
Social History:
Married, with grown children, works as a building contractor
continues to build his own home in [**State 1727**]. No smoking
cigarrettes, but does have a cigar occasionally, quit ETOH
(wine) 10 months ago, although no reported abuse. He feels his
work is quite active and does not do other exercise.
Family History:
Non-Contributory
Physical Exam:
Vitals:95.8 132/74 58 18 100%RA
HEENT: anicteric sclerae, MMM, NC AT.
CV: RRR Ns1s2 no mrg
Lungs CTAB
Abdomen: soft, NT, ND, no guarding
Extremities: warm, well perfused, pulses palpable bilaterally,
no
edema.
Skin: no jaundice.
Pertinent Results:
On Admission: [**2139-10-14**]
WBC-2.8* RBC-4.14* Hgb-14.9 Hct-42.8 MCV-103* MCH-36.0*
MCHC-34.8 RDW-13.9 Plt Ct-46*
PT-17.3* PTT-33.8 INR(PT)-1.5*
Glucose-115* UreaN-8 Creat-0.8 Na-138 K-4.3 Cl-104 HCO3-28
AnGap-10
ALT-35 AST-86* AlkPhos-196* TotBili-4.5*
Albumin-3.2* Calcium-9.3 Phos-2.9 Mg-1.8
AFP-49.7* (Trending down since RFA)
HIV Ab-NEGATIVE
At Discharge [**2139-10-26**]
WBC-6.3 RBC-2.71* Hgb-9.1* Hct-25.1* MCV-93 MCH-33.7* MCHC-36.4*
RDW-18.2* Plt Ct-148*
PT-12.6 PTT-27.0 INR(PT)-1.1
Glucose-112* UreaN-20 Creat-0.9 Na-136 K-3.7 Cl-104 HCO3-25
AnGap-11
ALT-148* AST-89* AlkPhos-251* TotBili-1.2
Calcium-8.5 Phos-3.7 Mg-1.5*
tacroFK-8.1
Brief Hospital Course:
62 y/o male admitted for liver [**Month/Day/Year **]. The patient was taken
to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. During the initial
transplantation the patient received large volumes of FFP and
platelets and 3 units RBCs. The right hepatic artery was noted
to be of concern in the operative note, please see the OR note
for surgical detail. Also of note there was initially congestion
in the liver which was relieved with side-to-side caval
cavostomy in the infrahepatic location for additional venous
outflow. The liver was pink with good arterial flow that was
only pulsatile, and pulsatility
in both the left and the replaced right hepatic artery. He was
transferred to the SICU in stable condition.
The initial post day zero ultrasound showed patent vasculature.
Late on POD 1, another ultrasound was performed, and this time
there was a marked change in the hepatic arteries, with
diminished peak velocity and lack of diastolic flow in the main
hepatic artery. No right or left intrahepatic artery was
identified despite diligent effort. Additionally there was bile
noted in the patients' medial JP drain, and so was taken to the
OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for an Exploratory laparotomy, Roux-en-Y
hepaticojejunostomy and a liver biopsy. It was noted that there
was evidence of a bile leak from a slit in the anterior wall of
the bile duct anastomosis. The bile
duct itself was not necrotic. A Roux-en-Y hepaticojejunostomy
was performed, with a Roux tube left in place. Reagrding the
artery, there was a strong pulse throughout the artery although
no thrill, consistent with his examination during the
[**Last Name (NamePattern1) **] procedure. The GDA was religated and the
side-to-side cavostomy from during his original procedure did
not have evidence of outflow obstruction.
A CTA was performed on POD 2, AST and ALT, initially
down-trending were going back up. This study showed two kinks
within the proximal donor hepatic artery with abrupt diameter
change into an attenuated but patent left hepatic artery. An
extremely
diminutive segment of the right hepatic artery branch is also
seen, likely
secondary to an extremely tight stenosis or alternatively the
RHA flow may be
from collateralization from the left hepatic artery. He was
again taken to the OR, this time with Dr [**First Name (STitle) **]. The
hepaticojejunostomy was patent with no evidence of leak,
however, there was just a pulsatile flow within the hepatic
artery, and the
replaced right hepatic artery was obviously thrombosed. The
liver looked viable without evidence of necrosis. The distal
portion of the SMA just distal to the takeoff of the replaced
right hepatic artery was opened and an extensive clot was found
in that segment. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18096**] catheter, TPA and heparin were all
utilized to clear the clot.
Daily ultrasounds for the next three days were obtained. There
was some concern for elevated velocity in the main hepatic vein,
and there was mild elevation in the LFTs, and bilirubin,
however, without intervention, all values were down-trending
daily and no further surgery was done.
A CTA was done on POD 6 showing patency of donor celiac to
receipient prior hepatic artery, distal to GDA. The previously
noted kinks in donor celiac artery less apparent and there was
dimunitive but patent L hepatic artery, RHA is diminutive but
patent and IVC and PV anastomosis are patent.
Cholangiogram obtained of the existing Roux done per pathway on
POD 5 does not demonstrate the drain sitting within the roux
limb. The drain has been capped.
The patient received routine induction immunosuppression, and
daily prograf levels and medication adjustments were made. The
patient was tolerating the cellcept, and prednisone taper was
slightly accelerated and he was discharged to home on 15 mg
prednisone.
The patient was placed on aspirin and plavix to maintain patency
of the vasculature as these were arterial issues, although he
was initially maintained on a heparin drip through POD 8.
He was tolerating diet and ambulating with assistance and had
return of bowel function.
Hep C viral load was sent showing 304,000 copies. Liver biopsies
collected during both post operative surgeries showed no
evidence of rejection, and no necrosis.
Medications on Admission:
bupropion HCl ER 100, cipro 250', clotrimazole 10''''',
ergocalciferol 50K, omeprazole 20, propranolol 20''', rifaximin
550'', tadalafil 20 PRN, ursodiol 300 qAM, 600 qPM, Vit C
[**2128**]'', Ca-Vit D3'', Vit E
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. sodium polystyrene sulfonate Powder Sig: Four (4) tsps
PO As direct by [**Year (4 digits) **] clinic as needed for hyperkalemia:
Only take as directed by [**Year (4 digits) **] clinic.
14. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
15. FreeStyle Lite Strips Strip Sig: One (1) strip
Miscellaneous four times a day.
Disp:*2 bottles* Refills:*5*
16. Lancets,Ultra Thin Misc Sig: One (1) lancet
Miscellaneous four times a day.
Disp:*2 bottles* Refills:*5*
17. Alcohol Prep Pads Pads, Medicated Sig: One (1) swab
Topical four times a day: to prep skin.
Disp:*1 box* Refills:*3*
18. NPH insulin human recomb 100 unit/mL Suspension Sig: Six (6)
units Subcutaneous once a day: per scale.
Disp:*2 bottles* Refills:*5*
19. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Follow Sliding scale.
Disp:*2 bottles* Refills:*5*
20. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
21. insulin syringe-needle U-100 0.3 mL 30 x [**2-8**] Syringe Sig:
One (1) syringe Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
home health of southern [**State **]
Discharge Diagnosis:
HCV cirrhosis now s/p liver [**State **]
Bile Leak
Hepatic Artery Thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the [**State **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, yellowing of skin or eyes, incisional redness,
drainage or bleeding, inability to tolerate food, fluids or
medications or other concerning symptoms.
You will have your labs drawn every Monday and Thursday per the
[**Telephone/Fax (1) **] clinic guidelines.
Please monitor your finger stick blood sugars and record values.
Please bring record of finger sticks with you to clinic and also
call the [**Telephone/Fax (1) **] clinic if you are repeatedly getting values
greater than 200. You have been started on insulin, please be
sure to record all values and doses given
You may shower, no tub baths or swimming until notified you may
do so
No heavy lifting
No driving until notified you may do so
You have one small capped drain left in place. This drain should
remain covered, with no tape directly on drain to skin or drain
to dressing. PLease keep "sandwiched" between drain sponge and
dry gauze dressing. After showering you can change dressing.
Should be changed once daily and site monitored for redness,
drainage or bleeding
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2139-11-2**] 9:40
Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2139-11-2**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2139-11-9**] 10:00
Completed by:[**2139-10-26**]
|
[
"996.82",
"607.84",
"571.5",
"456.21",
"530.81",
"997.4",
"287.5",
"724.2",
"444.89",
"780.52",
"790.29",
"155.0",
"070.54",
"576.8",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"51.37",
"50.59",
"00.93",
"99.10",
"38.06",
"88.47",
"50.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9438, 9505
|
2563, 6942
|
323, 528
|
9624, 9624
|
1891, 1891
|
10990, 11438
|
1608, 1626
|
7204, 9415
|
9526, 9603
|
6968, 7181
|
9775, 10967
|
1641, 1872
|
232, 285
|
556, 1093
|
1905, 2540
|
9639, 9751
|
1115, 1272
|
1288, 1592
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,846
| 170,715
|
29613
|
Discharge summary
|
report
|
Admission Date: [**2101-2-20**] Discharge Date: [**2101-3-3**]
Date of Birth: [**2040-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain with Syncopal episode
Major Surgical or Invasive Procedure:
[**2101-2-24**] Aortic Valve Replacement with 21mm St. [**Male First Name (un) 923**] Mechanical
Valve, Closure of ASD
History of Present Illness:
This is a 61 yo male w/ h/o hypertension, hyperlipidemia, and
DM2 (diet controlled) who recently developed chest pain and had
syncopal episode today. TTE from 1 wk prior revealed Aortic
Stenosis with a valve area 0.8cm2 (ordered [**2-25**] PCP noting [**Name Initial (PRE) **]
louder AS murmer on physical exam). Transferred from Caritas
[**Hospital3 **] for further management and cardiac catheterization.
Past Medical History:
Hypertension, Hyperlipidemia, Diabetes Mellitus (diet
controlled), s/p R. Arthroscopic knee surgery, s/p
tonsillectomy, s/p R. finger repair
Social History:
Lives with his wife. On disability after injury to R knee on
the job (was a heavy laborer). No EtOH. Former smoker (quit 10
yrs ago with approx 80 pk yrs).
Family History:
Mother had a stroke at 84, no family history of heart disease or
murmurs. 2 healthy daughters.
Physical Exam:
Vitals: T: 96.2 P: 94 BP: 132/70 R: 18 SaO2: 95% on RA
General: Overweight, Awake, alert, NAD.
HEENT: 9 cm scap lac with staples, PERRL, EOMI without
nystagmus, no scleral icterus noted, MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, IV/VI blowing systolic murmur heard best
over RUSB but heard over precordium; decreases with valsalva
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally.
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.
Skin: lac as above.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
Pertinent Results:
[**2101-2-22**] Cath: 1. Selective coronary angiography of this right
dominant system demonstrated normal LMCA, LAD, RCA, and LCX. A
small conus branch had 70% proximal stenosis. 2. Left
ventriculography was deferred. 3. Limited hemodynamic assessment
revealed normal systemic blood pressure (118/60 mmHg).
[**2101-2-23**] CNIS: Normal carotid study.
[**2101-2-24**] Echo: POST-CPB: Normal biventricular systolic function.
There is a bileaflet prosthesis in the aortic position. It is
well seated and both leaflets can be seen moving. Though no
images showing such were captured, there was trace valvular AI.
A small perivalvular leak could not be completely ruled out.
There was a maximum gradient of 40 mm Hg across the valve with a
mean pressure of about 35 mm Hg. The secundumn ASD was still
present with left to right flow still evident. An area of
pledgets could be seen in the RA wall near the ASD but they did
not occlude flow. There was persistent microbubbles seen in the
left atrium, left ventricle and thoracic aorta. They appeared to
eminate from the pulmonary veins.
[**2101-3-1**] Head CT: There is no evidence of acute intracranial
hemorrhage, shift of normally midline structures, or
hydrocephalus. [**Doctor Last Name **]-white matter differentiation appears grossly
preserved. Hypodensity in the periventricular white matter of
both cerebral hemispheres is seen, suggesting chronic
microvascular ischemia. Right frontal subgaleal hematoma is seen
close to the vertex. There is also evidence of hematoma in the
subcutaneous tissue in the left orbital region. Visualized
paranasal sinuses appear normally aerated.
[**2101-3-3**] 04:41AM BLOOD WBC-20.3* RBC-3.44* Hgb-9.8* Hct-30.2*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.2* Plt Ct-508*
[**2101-3-3**] 11:00AM BLOOD PT-19.5* PTT-62.1* INR(PT)-1.9*
[**2101-3-3**] 04:41AM BLOOD Plt Ct-508*
[**2101-3-2**] 09:00AM BLOOD Glucose-138* UreaN-13 Creat-0.7 Na-137
K-4.4 Cl-98 HCO3-28 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 70983**] was transferred from OSH and underwent an echo
followed by a cardiac cath. Both revealed severe aortic stenosis
but cath showed no coronary artery disease. Cardiac surgery was
consulted for surgical management of his AS. Appropriate
pre-operative work-up was preformed and then on [**2-24**] she was
brought to the operating room where he underwent an Aortic Valve
Replacement and ASD closure. Please see operative report for
surgical details. Following surgery he was transferred to the
CSRU for invasive monitoring in stable condition. He had some
post-operative bleeding which required several blood products.
Later on op day he was weaned from sedation, awoke
neurologically intact and was extubated. On post-op day one his
chest tubes were removed and he was started on beta blockers and
diuretics. He was gently diuresed towards his pre-op weight.
Later on this day he was transferred to the telemetry flood and
[**Last Name (un) **] was consulted for diabetes management. [**Last Name (un) **] followed
patient during entire post-op course. Epicardial pacing wires
were removed on post-op day three and he was started on Coumadin
with Heparin bridge. Coumadin titrated for a goal INR between
2.0-3.0. He continued to have low HCT post-operatively and was
started on Iron and Vit. C. Late on post-op day five, he was
found on the floor with a laceration over his left eye. Heparin
was initially held and a Head CT ruled out intracranial
hemorrhage. On post-op day seven Heparin was restarted, along
with Coumadin. He was ready for discharge on POD #8.
Medications on Admission:
Lisinopril 10 mg po daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*0*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
10. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO at bedtime: 7.5 mg
[**3-3**], check INR [**3-4**] with results to cardiac surgery.
Disp:*60 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) for 10 days.
Disp:*60 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 10 days.
Disp:*40 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Diabetes Mellitus (prior diet controlled, now on medication)
PMH: Hypertension, Hyperlipidemia, Diabetes Mellitus (diet
controlled), s/p R. Arthroscopic knee surgery, s/p
tonsillectomy, s/p R. finger repair
Discharge Condition:
good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks. Tel ([**Telephone/Fax (1) 1504**].
Dr. [**Last Name (STitle) **] in 2 weeks. Tel ([**Telephone/Fax (1) 70984**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2101-3-4**]
|
[
"424.1",
"780.2",
"E884.4",
"401.9",
"272.4",
"745.5",
"998.11",
"250.00",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.71",
"37.22",
"39.61",
"88.52",
"35.22",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
7362, 7445
|
4100, 5690
|
352, 472
|
7740, 7746
|
2129, 3225
|
8064, 8340
|
1265, 1362
|
5766, 7339
|
7466, 7719
|
5716, 5743
|
7770, 8041
|
2095, 2110
|
1377, 1999
|
280, 314
|
500, 909
|
3234, 4077
|
2014, 2078
|
931, 1073
|
1089, 1249
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,644
| 184,074
|
1276
|
Discharge summary
|
report
|
Admission Date: [**2132-5-17**] Discharge Date: [**2132-6-25**]
Date of Birth: [**2062-6-29**] Sex: F
Service: MEDICINE
Allergies:
Phenergan
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
cuff leak
Major Surgical or Invasive Procedure:
bronchoscopy with Y stenting
repeat bronchoscopy [**5-29**]
History of Present Illness:
69F Hx COPD, CHF, lung Ca s/p RUL lobectomy, s/p trach brought
from [**Hospital1 **] (baintree) resp rehab for ? tracheal misplacement.
She was initially admitted to a community hospital in [**State 108**] in
[**2130**] for CHF. She improved and was transferred to [**Hospital1 7932**] (at family's request) for further rehabilitation care.
Upon arrival to [**Hospital1 **], she was intubated for respiratory
distress. After 3 weeks of ventilation, she was admitted to [**Hospital 2586**] Medical Center for tracheostomy/PEG placement. She
did well post-operatively, and was transferred back to [**Hospital1 **]
for Vent weaning. Her initial tracheostomy was changed to a
Bavona on [**2-4**]. She did well until one week PTA, when she was
noted to have increased work of breathing and dyspnea. The MDs
at [**Hospital3 **] decided to change her tracheostomy tube for
a longer one. This was done at [**Hospital3 5365**] 4 days PTA.
Postoperatively, she had significant respiratory distress, did
not tolerate the vent, and was noted to have lower tidal
volumes, hypoxia with saturations to the low 90s, cyanosis and a
significant cuff leak. She was started on Ceftazidime at her
facility for ? PNA.She was thus transferred to the [**Hospital1 18**] for
further evaluation/intervention. En route, she was very anxious
and given 2mg IV ativan.
In the ER, she was noted initially to have slight perioral
cyanosis with RR 46. Her initial ABG was 7.39/59/70. She then
had an episode of significantly decreased tidal volumes. A
flexible bronch was done by Dr. [**Name (NI) **] in the ED, which
showed a posterior tracheal ulceration at the distal end of the
[**Last Name (un) **], with > 98% occlusion of the distal ostia of the tube by
the ulcer wall as well as granulation tissue. The bronchoscope
was passed through the obstruction, and the patient's O2
saturations, tidal volumes improved. She had two similar
episodes in the ED, which improved with upright positioning,
cough, and vocalizations. She had a persistent cuff leak. In th
ED, she also recieved Vanco 1g IV, Ceftazidime 2gm, Solumedrol
40mg IV and ativan 2mg IV.
Past Medical History:
1. CHF s/p respiratory failure s/p trach
2. COPD - O2 dependent
3. NSCLC s/p LUL lobectomy [**2126**], s/p chemo (Iressa)/XRT, s/p ?
pleurodesis
4. DM II
5. Anemia, thrombocytopenia
6. Hx recurrent bacteremias
7. Hx [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] fungemia
8. s/p L THR
9. s/p cataract surgery
[**35**]. s/p TAH
11. paroxysmal afib
Social History:
Lived in [**State 108**] w/ husband, moved to [**Name (NI) 38**] in [**Month (only) **] to live
at [**Hospital1 **] [**Location (un) 38**]. + Hx tobacco (uncertain duration). No
EtoH, illicits. Very involved, supportive family.
Family History:
non-contributory
Physical Exam:
VS- 97.9 78 104/54 20 96%
GEN- s/p trach, somnolent but arousable, able to speak despite
trach
SKIN - cool, diffuse anasarca w/ ecchymoses
HEENT - PERRL, OP clear, trach in place at 12cm
COR - RRR no m/r/g
PULM - coarse bilateral w/ diffuse wheeze and rhonchi
ABD - obese, NT, ND
EXTR- 4+ lower extremity pitting edema, anasarca
NEURO - MAE x 4, responds to command
Pertinent Results:
[**2132-5-17**] 01:12PM BLOOD WBC-19.2* RBC-3.46* Hgb-10.6* Hct-35.3*
MCV-102* MCH-30.6 MCHC-30.0* RDW-19.0* Plt Ct-246
[**2132-5-18**] 03:02AM BLOOD WBC-13.6* RBC-2.91* Hgb-9.1* Hct-28.9*
MCV-99* MCH-31.3 MCHC-31.5 RDW-19.6* Plt Ct-162
[**2132-5-21**] 03:46AM BLOOD WBC-11.7* RBC-3.13* Hgb-9.7* Hct-30.3*
MCV-97 MCH-30.9 MCHC-31.9 RDW-19.4* Plt Ct-164
[**2132-5-17**] 01:12PM BLOOD Neuts-82* Bands-2 Lymphs-10* Monos-4
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-2*
[**2132-5-17**] 01:12PM BLOOD PT-14.2* PTT-21.2* INR(PT)-1.3*
[**2132-5-19**] 04:00AM BLOOD PT-16.7* PTT-21.9* INR(PT)-1.5*
[**2132-5-17**] 01:12PM BLOOD Glucose-244* UreaN-26* Creat-0.7 Na-138
K-5.0 Cl-97 HCO3-31 AnGap-15
[**2132-5-21**] 03:46AM BLOOD Glucose-108* UreaN-24* Creat-0.6 Na-145
K-2.9* Cl-100 HCO3-34* AnGap-14
[**2132-5-18**] 03:02AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.2
[**2132-5-21**] 03:46AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.9
[**2132-5-17**] 02:45PM BLOOD Type-ART Temp-37.4 Tidal V-500 FiO2-50
pO2-70* pCO2-54* pH-7.39 calHCO3-34* Base XS-5 Intubat-INTUBATED
[**2132-5-21**] 01:53PM BLOOD Type-ART Temp-37.9 Rates-/14 Tidal V-600
PEEP-5 FiO2-50 pO2-136* pCO2-48* pH-7.48* calHCO3-37* Base XS-11
-ASSIST/CON Intubat-INTUBATED
.
CXR: Lung volumes are quite low. Tracheostomy tube has standard
appearance. Heart is normal size, shifted slightly to the right.
A dense band of radiopacity parallels the minor fissure, which
is either a fissural pleural fluid on the right or unusual
distribution of atelectasis. Just superior to that is an oval
region of consolidative lung with an appearance suggesting prior
radiation. It could explain right infrahilar consolidation and a
vertically oriented that to radiodensity projects lateral to the
upper descending thoracic aorta
.
Echo [**5-19**]: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function appears normal (LVEF>55%). Right
ventricular systolic function appears normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve is not well seen.
The pulmonary artery systolic pressure could not be determined.
The main pulmonary artery is dilated. There is no pericardial
effusion.
.
[**5-21**] CXR: 1. Improving pulmonary edema and bibasilar
atelectasis. Stable bilateral pleural effusions.
2. Continued right upper lobe opacity of uncertain etiology.
This could represent post-radiation change, superimposed
infection, or possibly active tumor in this area. The finding
was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7933**], who indicates a history
of prior upper lobectomy of uncertain laterality that is
followed in an outside hospital. Clinical correlation is
necessary.
.
ECHO [**5-29**]: normal LVEF, severe [**2-2**] diastolic dysfunction.
.
[**5-27**] blood cultures: + for seratia marscens (sensitive to
zosyn).
[**5-29**] bronch sputum gram stain: +GNR.
Brief Hospital Course:
67 yo F with history of COPD, CHF, chronic trach originally
presented with increased respiratory distress, cyanosis,
hypoxia.
.
HYPOTENSION/SEPSIS:
Pt has been intermittently hypotensive s/p aggressive diuresis
over the course of her admissing to the MICU. These episodes
have typically resolved with IVF boluses. On [**5-28**] she developed
respiratory distress felt [**1-3**] aspiration of liquids, and
developed hypotension requiring pressor support (levo/vaso,
changed to neo/vaso). In addition to her underlying
intravascular depletion, a septic and cardiogenic etiology were
considered. Cardiac enzymes were found to be elevated, and
NSTEMI was diagnosed. Troponins peaked at 0.19, and trended
downward. A repeat ECHO showed no change in LVEF, and severe
diastolic dysfunction. Pt was not felt to be a candidate for
angioplasty or beta blockers [**1-3**] her hypotension, but was
treated with aspirin. Blood Cultures from [**5-27**] showed GNR
(serratia marscens), and sputum gram stain also showed GNR. Pt
was begun on a course of zosyn ([**5-28**]) and levaquin ([**5-30**]). The
patient was persistently hypotesive even after resolution of
sepsis. The patient was switched from prednisone (for COPD) to
dexamethasone in order to perform an accurate [**Last Name (un) 104**] stim test. As
above, pt was started on a dopamine drip for hypotension during
diuresis. However, even after the lasix drip was discontinued,
pt remained hypotensive and required dopamine. The decision was
made to [**Last Name (un) 104**] stim the patient but given that she was already on
prednisone, she was switched to decadron and fludrocort and a
[**Last Name (un) 104**] stim was done 48 hrs later. This was positive and she
received a total of 5 days of fludrocortisone and
hydrocortisone. Following cessation of her high dose steroids,
she was started on a slow prednisone taper. This should be
slowly tapered over the next 2 weeks, ending in [**Month (only) 216**]. She was
started on midodrine for BP support given her persistant low
vascular tone and difficulty weaning off pressors.
Neosynephrine was successfully weaneded off the neosynephrine
and tolerated boluses of lasix to keep her fluid status even to
negative.
RESPIRATORY FAILURE:
Initial bronchoscopy on admission was concerning for
peritracheal ulceration and granulation tissue with some
tracheal obstruction and leakage of the the tracheal cuff. Pt
was unable to lie flat for airway CT, and was taken to the OR on
[**5-20**] for rigid bronchoscopy revealing severe left mainstem
bronchus and trachel malacia without ulceration. A Y stent was
placed with [**Last Name (un) 295**] trach in the proximal end of the stent. Pt
was subsequently oxygenating and ventilating well on AC
ventilatory support. Trials of PS were intermittently
succesful, although pt continued to experience episodes of
respiratory distress [**1-3**] ongoing tracheal secretions, and volume
overload which required her to be placed on AC ventilation. In
addition to albuterol, atrovent, and flovent, pt was started on
a course of solumedrol ([**5-23**]) tapered to prednisone for COPD
exacerbation. On [**2132-5-29**] pt was found to be in respiratory
distress with frothy pink sputum suctioned from the trachea.
She was diagnosed with a serratia pneumonia and treated with
unasyn and levaquin x 14 days. Following resolution of her
pneumonia, she was placed on pressure support and weaning trials
were attempted daily. She is currently on pressure support of 10
and PEEP 10. During two trach collar traials she became
tachypneic but ABG's remained stable. Please try to wean off PS
further.
The patient should follow-up in about 4 weeks as an outpatient
at the [**Hospital1 18**] for a bronchoscopy.
.
Serratia sepsis / pseudomonas & acinetobacter pneumonia: The
patients blood cultures from [**5-28**] grew out serratia. Sputum also
grew serratia and acinetobacter. She was treated with
unasyn/levofloxacin for a 14 day course. Due to persistent
hypotension, she was recultured, including a bronchscopy which
grew out pseudomonas and acinetobacter sensitive to cefepime.
She will complete a 14-day course of cefepime on [**6-29**].
CHF/NSTEMI: Pt continued to appear severly volume overloaded on
clinical exam, although she is intravascularly volume depleted
as evidenced by low UOP and drops in BP with attempts to
diureses. Repeated attempts to diurese have been initially
successful (removing ~1L), but ultimately resulted in
hypotension. Cardiac enzymes were found to be elevated on [**5-28**]
and an NSTEMI was diagnosed. Troponins peaked at 0.19, and
trended downward. A repeat ECHO showed no change in LVEF, and
severe diastolic dysfunction. Pt was not felt to be a candidate
for angioplasty or beta blockers [**1-3**] her hypotension, but was
treated with aspirin.
AFIB: Pt had atrial fibrillation with increasing rate on
levophed so she was transitioned to neosynephrine for BP support
while septic. When stable, she could not tolerate BB or CCB for
rate control so she was restarted on digoxin. She tolerated
this well.
DMII: Controlled with insulin gtt initially, now controlled with
SQ insulin.
ANEMIA: Originally felt to be [**1-3**] tracheal secretions, and
chronic disease. Pt initially on EPO, discontinued as anemia
not likely related to EPO deficiency. Her hct remained stable
and then slowly began to trend down. She was transfused PRBC for
a goal hct of >21.
FEN: pt had been eating prior to arrival while being ventilated
with AC ventilation. She was seen by speech and swallow consult
once transitioned to PS ventilation, and cleared for clear
liquids after a video swallowing study. However, she
subsequently developed respiratory distress and PNA felt [**1-3**] to
aspiration, and was thus made NPO by mouth. She has been
receiving TF via NGT since [**5-29**]. The family is opposed to the
placement of a PEG at the time of this summary.
Psych: Towards the end of the [**Hospital **] hospital stay, pt started
having delusions. It seemed to coincide with the initiation of
high dose steroids. She was not started on any anti-psychotics
as she was not a harm to herself or others. She was continued
on her antidepressants.
Code: full
Medications on Admission:
KCL 20 mEq [**Hospital1 **]
Lasix 40 [**Hospital1 **]
Ceftaz 2gm q8hr (day [**3-7**])
Solumedrol 40mg q 12h (day [**1-5**])
ISS
Reglan 5mg po tid
Protonix 40mg po qd
Paxil 20mg po qd
Epogren 20,000U q fri
Digoxin 0.125 qd
ASA 325 qd
Colace 100 qd
Senna 2 tabs [**Hospital1 **]
Florinef 0.1 mg qd
Lactulose 30 ml [**Hospital1 **]
Combivent MDI 6 puffs QID
Flovent 110 mcg 4 puffs [**Hospital1 **]
albuterol nebs q2h prn
Morphine 2 mg q 4 prn
Tylenol
Lidocaine 2% gel to trach stoma prn
Ambien 5mg po qhs prn
Ativan 1 mg q4hrs prn
Allergies: Phenergan
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Five (5) Puff
Inhalation Q4H (every 4 hours).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
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. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
10. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H
(every 8 hours): last day [**6-29**].
11. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
15. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
18. Atrovent 18 mcg/Actuation Aerosol Sig: Five (5) puffs
Inhalation every six (6) hours.
19. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight
(8) units
units Subcutaneous twice a day.
20. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
units Subcutaneous four times a day: per sliding scale.
21. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Taper off 10mg every three days.
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): hold for MAP<55.
23. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Primary: Broncho-tracheomalacia
Diastolic CHF
COPD
Pneumonia
Secondary:
Diabetes type II
Hx lung CA
Discharge Condition:
stable, oxygenating well on pressure support
Discharge Instructions:
To care providers: please pursue aggressive respiratory rehab.
Plan follow up with interventional pulmonology at [**Hospital1 18**]
([**Telephone/Fax (1) 3020**]in [**2-2**] weeks for a flexible bronchoscopy to ensure
correct stent placement / lack of granulation tissue.
.
Please continue to try and wean pressure support and PEEP with
goal of trach mask. Please try and aggressively decrease both
PS and PEEP.
.
Assess fluid status, measure daily weights, fluid intake and
output and give lasix as needed to keep negative. Her baseline
BP is 90's/40's. Adjust lasix dose as needed.
.
She needs to finish a 14 day course of antibiotics (last day of
cefepime should be [**6-29**])
.
Please taper her PO steroids slowly over the next 2 weeks. Today
is day 2 of 30mg Prednisone.
Followup Instructions:
Please follow-up with your regular physician
.
Please follow up with interventional pulmonology at [**Hospital1 18**]
([**Telephone/Fax (1) 3020**]in [**2-2**] weeks for a flexible bronchoscopy.
Completed by:[**2132-6-25**]
|
[
"250.00",
"276.52",
"255.4",
"995.92",
"293.0",
"428.0",
"491.21",
"V58.67",
"V10.11",
"482.83",
"519.09",
"285.29",
"410.71",
"507.0",
"785.52",
"518.84",
"038.44",
"519.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.05",
"96.6",
"96.72",
"33.24",
"33.23",
"33.21",
"00.17",
"97.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15679, 15760
|
6636, 12876
|
279, 341
|
15904, 15951
|
3569, 6613
|
16779, 17005
|
3149, 3167
|
13477, 15656
|
15781, 15883
|
12902, 13454
|
15975, 16756
|
3182, 3550
|
230, 241
|
369, 2492
|
2514, 2888
|
2904, 3133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,675
| 186,935
|
9346
|
Discharge summary
|
report
|
Admission Date: [**2131-12-30**] Discharge Date: [**2132-1-8**]
Service: [**Location (un) **] Medicine
HISTORY OF PRESENT ILLNESS: This is an 89 year old gentleman
with a history of chronic obstructive pulmonary disease on
home oxygen, atrial fibrillation, Type 2 diabetes, recently
discharged from [**Hospital6 256**] on
[**2131-12-12**], status post T3 through T7 laminectomy.
His hospital course was complicated by T4 epidural hematoma
evacuation. The patient was discharged to [**Hospital3 7558**] for three days at which point the nursing
staff noticed increased secretions as well as decreased
oxygen saturations. Of note, the patient had been treated
with pneumonia approximately one month prior to this
admission. Additionally, there was some report that the
patient had decreased p.o. intake at rehabilitation and a
questionable history of Methicillin-sensitive resistant
Staphylococcus aureus. The patient does report a flu shot in
[**2131-11-26**]. He is currently denying any fevers, chills,
nightsweats, nausea, vomiting or diarrhea. The patient's
treatment at rehabilitation primarily consisted of nebulizer
treatments with suctioning for the chronic obstructive
pulmonary disease as well as diuresis for probable congestive
heart failure. In the Emergency Department, the patient was
noted to be hypotensive with a blood pressure of 63/94
associated with hypoxia. The patient was initially
transferred to the Medicine Intensive Care Unit for BiPAP and
for intravenous fluid resuscitation. At that point the
patient was initially started on Ceftriaxone, Azithromycin as
well as Clindamycin. After aggressive intravenous fluids
hydration the patient's blood pressure normalized to
approximately 110/48. His arterial blood gases at the time
was 7.46, 45, 66, after BiPAP 7.48, 44, 115. The chest x-ray
was consistent with a right middle lobe pneumonia. He was
stabilized over night in Medicine Intensive Care Unit and
transferred to the regular floor for further treatment and
evaluation.
PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary
disease on home oxygen, associated with a chronic cough; 2.
Atrial fibrillation, no recent history of Coumadin use; 3.
Status post laminectomy complicated by epidural hematoma
evacuation; 4. Type 2 diabetes; 5. Coronary artery disease
and congestive heart failure with an ejection fraction of 55%
in [**2131-11-26**], 3+ tricuspid regurgitation; 6. Status
post recent pneumonia, approximately one month ago, treated
with Levofloxacin at rehabilitation, status post flu shot in
[**2131-8-27**]; 7. History of Escherichia coli infection;
8. Neurogenic bladder.
MEDICATIONS ON TRANSFER:
1. Azithromycin 250 mg p.o. q.d.
2. Ceftriaxone 1 gm intravenously q.d.
3. Calcium carbonate 500 t.i.d.
4. Vitamin D 400 q.d.
5. Multivitamin
6. Prednisone 60 mg p.o. q.d.
7. Digoxin .25 mg p.o. q.d.
8. Clindamycin 600 mg intravenously q. 8 hours
9. Protonix 40 mg p.o. q.d.
10. Tylenol prn
11. Atrovent/Albuterol nebulizers q. 4 hours prn
12. Heparin subcutaneously t.i.d.
13. Percocet prn for back pain
SOCIAL HISTORY: The patient prior to recent surgery was
independent of activities of daily living, however, post
surgery has been quadriplegic. Currently the patient lives
with his wife, however, he spent time at [**Hospital3 7558**] postoperatively. The patient is an ex-tobacco
user and quit in [**2093**] with a 35 pack year history. The
patient reports approximately 2 glasses of alcohol a day. He
denies any intravenous drug abuse. He is a retired engineer.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature maximum 99.4,
pulse 74, blood pressure 53/94 after intravenous fluid
resuscitation, increased to 112/60, respiratory rate 32,
oxygen saturation 95% on BiPAP with pressure support of 10
and a positive end-expiratory pressure of 5. Generally, the
patient is an elderly cachectic male described as being in
mild to moderate respiratory distress on BiPAP. Head, eyes,
ears, nose and throat: Moist mucous membranes. Pupils
equal, round and reactive to light and accommodation. No
scleral icterus. Neck examination, no jugulovenous
distension. Cardiac examination, normal S1 and S2,
tachycardiac, regular rate. Pulmonary examination: Clear to
auscultation anterolaterally with rhonchi in the upper
airways, abdominal examination benign. Extremity
examination, trace bilateral lower extremity pitting edema.
The patient was able to withdraw from pain. Sensation intact
in the lower extremities, however, unable to voluntarily move
lower extremities against resistance.
LABORATORY DATA: Laboratory data from admission, white blood
cell count 14.4 with a differential of 91% neutrophils, no
bands, 3% lymphocytes. Hematocrit 38.9, baseline hematocrit
34 to 36, platelets 126, MCV 101. Chem-10 remarkable for a
bicarbonate of 35, BUN 26, creatinine 0.7, cardiac enzymes
negative. Lactate 1.9. Coagulation studies normal.
Arterial blood gases, 7.46/45/66, on BiPAP 7.48/44/115.
Chest x-ray from admission, right heart border was obscured
secondary to right middle lobe density, left lung base with
opacification, officially read as possible right middle lobe
pneumonia.
HOSPITAL COURSE: 1. Respiratory distress - The patient was
initially transferred to the Medicine Intensive Care Unit for
a 24 hour period of time during which he received BiPAP over
night as well as nebulizer treatment and suctioning,
antibiotic treatment was initiated with Clindamycin,
Azithromycin and Ceftriaxone. The patient was transferred
back to the floor the following day, off of BiPAP saturating
fine on nasal cannula. During the [**Hospital 228**] hospital course
he persistently mucous plugged, particularly at bedtime while
lying in the supine position, during which time he saturation
would decrease significantly down to 60s or 70s. The
patient's oxygen saturation improved dramatically post
suctioning, respiratory therapy. The chest x-rays were
notable for worsening infiltration on both sides, however,
there was no evidence of overt congestive heart failure. The
patient remained hypoxic on room air with an oxygen
saturation of 80%, however, he was able to be weaned down to
4 liters of nasal cannula with an oxygen saturation greater
than 90% without any evidence of respiratory distress.
2. Infectious disease - The patient has a history of
pneumonia. He is status post treatment for Levofloxacin
given the right middle lobe infiltrate. The patient was
broadly covered with antibiotics, however, during his
hospitalization he had had a right subclavian line placed and
subsequently developed an Methicillin-sensitive resistant
Staphylococcus aureus bacteremia, one out of four bottles
were positive for Methicillin-sensitive resistant
Staphylococcus aureus with negative seromas cultures. The
catheter tip was sent, growing gram positive cocci and the
patient was started on Vancomycin therapy. She will be
discharged with a PICC line with follow up treatment as an
outpatient with Vancomycin. Additionally, the patient had an
echocardiogram to evaluate for any vegetations. A
transthoracic echocardiogram was performed which revealed no
vegetations. An ejection fraction of 75 to 80%, the left
ventricle was described as being hyperdynamic. There was 2+
tricuspid regurgitation. There were no other obvious wall
motion abnormalities or other valvular abnormalities. The
patient was treated initially for presumed bacteremia without
evidence of endocarditis or osteomyelitis, however, given his
known back surgery and inability to move his lower
extremities voluntarily, the decision was made to follow up
with his vascular surgeon and obtain an magnetic resonance
imaging scan as an outpatient to evaluate for any suspicious
lesions of the surgical site which would warrant prolonged
antibiotic therapy.
3. Coronary artery disease - The patient does have a history
of coronary artery disease, however, no recent cardiac
catheterization confirmed that. The patient did have a
positive troponin while he was in the Medicine Intensive Care
Unit, however, creatinine kinase were flat. The patient was
maintained on Digoxin for rate control and Coumadin
anticoagulation was initiated during his hospitalization,
after obtaining clearance from Neurosurgery.
4. Activities/neurologic - The patient was seen by
Neurosurgery during this hospitalization with recommendations
for the patient to use his back brace while out of bed.
Additionally, the patient can resume physical therapy with
this brace on. Follow up magnetic resonance imaging scan is
scheduled for two weeks post discharge. The patient is
instructed to follow up with his neurosurgeon.
5. Code status - Discussion regarding cardiac resuscitation
as well as intubation, was initiated during this
hospitalization. The patient clearly stated that he wanted
to be full code, however, he would not want prolonged
mechanical ventilations.
DISCHARGE CONDITION: The patient is stable on 3 liters of
nasal cannula, saturating greater than 90%. He has a PICC
line in place for intravenous antibiotics as an outpatient.
DISCHARGE STATUS: The patient will be discharged to [**Hospital3 7558**] to pursue ongoing physical therapy and to
finish his antibiotic course for bacteremia.
DISCHARGE MEDICATIONS:
1. Coumadin 2.5 mg p.o. q.d.
2. Vancomycin 1250 mg intravenously q.d.
3. Albuterol nebulizer q. 4 hours
4. Salmeterol discus 1 puffs q. 12 hours
5. Aspirin 325 mg p.o. q.d.
6. Senna
7. Colace
8. Metronidazole 500 mg p.o. t.i.d.
9. Levofloxacin 500 mg p.o. q.d.
10. Percocet prn
11. Protonix 40 mg p.o. q.d.
12. Atrovent nebulizers 1 nebulizer q. 4 hours
13. Calcium carbonate 500 mg p.o. t.i.d.
14. Vitamin D 400 units p.o. q.d.
15. Multivitamin one capsule p.o. q.d.
16. Digoxin .25 mg p.o. q.d.
17. Tylenol prn
The patient is instructed to complete a total of two weeks of
Vancomycin, Metronidazole and Levofloxacin, this will be
outlined on the discharge medication sheet upon transfer to
[**Hospital3 4419**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 1600**]
MEDQUIST36
D: [**2132-1-5**] 14:21
T: [**2132-1-5**] 16:14
JOB#: [**Job Number 31942**]
|
[
"486",
"427.31",
"790.7",
"038.9",
"707.0",
"996.62",
"491.21",
"397.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8987, 9306
|
3577, 3617
|
9329, 10294
|
5239, 8965
|
144, 2028
|
3632, 5221
|
2675, 3090
|
2051, 2650
|
3107, 3560
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,801
| 172,010
|
38036
|
Discharge summary
|
report
|
Admission Date: [**2194-10-6**] Discharge Date: [**2194-10-14**]
Date of Birth: [**2135-11-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cardizem / Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea and increasing fatigue/palpitations
Major Surgical or Invasive Procedure:
s/p AVR(#25 On-X mech)/Maze/LAA ligation [**10-7**]
History of Present Illness:
58 year old male with known aortic stenosis and history of
atrial fibrillation since [**2193-6-25**]. Over the last year, he has
undergone four cardioversions, his most recent in [**2194-7-26**] in
which he reverted back to AFib within 48 hours. He has failed
therapy with sotalol. He is currently on Amiodarone. Given his
aortic stenosis and persistent AFib, he has been referred for
AVR/Maze.
Past Medical History:
Atrial Fibrillation
Aortic stenosis
Hypertension
Dyslipidemia
Obesity
Left Knee Meniscus
Social History:
Occupation: VP/CEO at UConn
Lives with: wife, children and [**Name2 (NI) 12496**]
Race: caucasian
Tobacco: Denies
ETOH: Social
Family History:
Maternal Grandfather died of MI in his 60's.
Mother suffered stroke at age 82. Father died of prostate
cancer.
Physical Exam:
Pulse: 88 Resp: 16 BP Left: 126/76
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 systolic ejection
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [x]
Neuro: Grossly intact - intention tremors noted on upper
extremities
Pulses:
Femoral Right: +1 Left: +1
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: trans murmur Left: trans murmur
Discharge:
T; T 99.0 HR: 73 SR BP: 117/68 Sats: 95% RA WT: 132 kg
preop: 137 kg
General: sitting in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR normal S1,S2 good click
Resp: clear breath sounds bilateral
GI: obese, benign
Extr: warm trace edema
Incision: sternal clean, dry intact. no erythema
Neuro: non-focal
Pertinent Results:
PRE-CPB:1. The left atrium is moderately dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. The left atrial appendage emptying velocity is depressed
(<0.2m/s). A probable thrombus is seen in the left atrial
appendage. A 3-D echo confirmed mobile mass of apparent
different density than LAA wall.
2. No thrombus is seen in the right atrial appendage No atrial
septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %).
4. The right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with borderline normal free
wall function.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Trace aortic
regurgitation is seen directed eccentrically toward the anterior
leaflet of the mitral valve.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
8. There is a small to moderate sized pericardial effusion.
There are no echocardiographic signs of tamponade.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. A pacing for slow sinus
rhythm. Well-seated mechanical valve in the aortic position. No
AI. Preserved biventricular function. Left atrial appendage is
obliterated post Maze procedure. Aortic contour is normal post
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
[**2194-10-10**] WBC-8.6 RBC-2.69* Hgb-8.5* Hct-25.2* Plt Ct-131*
[**2194-10-6**] WBC-7.4 RBC-4.16* Hgb-13.0* Hct-39.0* Plt Ct-238
[**2194-10-12**] PT-15.1* PTT-27.8 INR(PT)-1.3*
[**2194-10-11**] PT-14.6* PTT-23.0 INR(PT)-1.3*
[**2194-10-11**] PT-14.4* PTT-23.0 INR(PT)-1.2*
[**2194-10-11**] PT-13.5* PTT-20.2* INR(PT)-1.2*
[**2194-10-10**] Glucose-123* UreaN-35* Creat-1.2 Na-133 K-4.7 Cl-99
HCO3-29
[**2194-10-6**] Glucose-157* UreaN-27* Creat-1.2 Na-135 K-4.6 Cl-98
HCO3-29
[**2194-10-9**] Mg-2.2
Brief Hospital Course:
Admitted [**10-6**] for IV heparin and pre-op workup completion.
[**2194-10-7**] he was brought to the operating room and underwent
aortic valve replacement, MAZE procedure. See operative report
for further details. He was transfered to the intensive care
unit for hemodynamic management. He was weaned from sedation,
awoke neurologicaly intact and was extubated without
complications. On post operative day one he was started on
coumadin and transferred to the floor. On post operative day
two his pacing wires and chest tubes were removed. While
walking with physical therapy he blacked-out and fell to floor
after feeling dizzy. He incurred a nose bleed and laceration to
the forehead. His heart rate was continuous monitoring and
showed no ectopy sinus rhythm 70. His neuro status was
monitored very closely with no deficits. He was gently diuresed
toward his preop weight. Once the INR was 2.0 he was discharged
to home with his wife. His pain was well controlled with PO
pain medication, he tolerated a regular diet. He will follow-up
with the [**Hospital **] [**Hospital 197**] clinic for coumadin dosing.
Medications on Admission:
COUMADIN- last dose [**2194-10-3**]
amiodarone 200 mg daily
lisinopril 40 mg daily
metoprolol 50 mg [**Hospital1 **]
norvasc 2.5 mg daily
HCTZ 25 mg daily
simvastatin 40 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) 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. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days: then talk with PCP about resuming HCTZ.
Disp:*10 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:*0*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. sleep study
Please follow up with outpatient primary care physician for
outpatient sleep study due to risk of sleep apnea
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: please take 5 mg [**10-14**] and [**10-15**] then have INR checked on
[**10-16**] for further dosing .
Disp:*60 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Labs: PT/INR for coumadin dosing with goal INR 2.5-3.0 for
mechanical Aortic valve - first draw [**10-16**] with results to UCon
coumadin clinic 1-[**Telephone/Fax (1) 84956**] fax [**Telephone/Fax (1) 84957**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 84958**] Home Health
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Atrial fibrillation s/p MAZE
Hypertension
Hyperlipidemia
obesity
Discharge Condition:
Good
Discharge Instructions:
Take medications as directed on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 10 weeks.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>100.5, sternal drainage,redness, or
weight gain of 2 pounds in 2 days or 5 pounds in one week
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 84959**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.[**Telephone/Fax (1) 170**]
Please follow up with outpatient primary care physician for
outpatient sleep study due to risk of sleep apnea
Labs: PT/INR for coumadin dosing with goal INR 2.5-3.0 for
mechanical Aortic valve - first draw [**10-16**] with results to UCon
coumadin clinic 1-[**Telephone/Fax (1) 84956**] fax [**Telephone/Fax (1) 84957**]
Completed by:[**2194-10-14**]
|
[
"278.00",
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"E849.7",
"746.4",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
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|
4593, 5719
|
333, 387
|
7708, 7715
|
2288, 4570
|
8193, 8789
|
1086, 1199
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5949, 7489
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5745, 5926
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7739, 8170
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1214, 2269
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250, 295
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415, 812
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834, 925
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941, 1070
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 107,751
|
43041+43042
|
Discharge summary
|
report+report
|
Admission Date: [**2187-2-26**] Discharge Date: [**2187-2-28**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
PICC line placement and removal
History of Present Illness:
38 y/o man, well known to dept. Medicine, with DMI and severe
gastroparesis and hypertension, [**Name6 (MD) 2091**] on RRT (o/p HD tiw)
frequently admitted for abdominal pain crises with n/v,
resulting in uncontrolled HTN given fact that cannot take po
meds during these episodes. Has had innumerate admissions for
the same here. He presents overnight with 1 day of nausea and
several epsiodes of vomitting. Sxs are typical of prior
episodes. Denies CP/SOB/diarrhea/f/c/URIsx.
.
In the ED he was found to be afebrile, hr 70-80s, hypertensive
to 160s systolic, and sating 99% on RA. EKG was significant for
worsening ST elevations in V1-V4, pseudonormalization of TW in
v2, v3 and new TWI in v6. Per ED report Interventional cards
attending was consulted who felt that this was possibly
developing LV aneurysm and declined to bring him to cath.
.
Of note, during admission from [**Date range (1) 92864**], cardiology was
consulted for ST elevations that were seen on his EKG s/p a
recent STEMI in [**2186-12-14**] elevations were
persistent (possibly due to evolving aneurysm) and that no
further work up would be necessary unless there are further
changes on future EKGS. They also reviewed his recent
echocardiograms which showed akinetic segments of his LV.
However, it was decided to defer anticoagulation since his EF
was relatively preserved.
.
In the ED, labs were significant for a potassium of 6.7, repeat
of 6.4. He received calcium gluc, kayexalate, labetalol 20mg,
ativan 2mg IV x 2, dilaudid 2mg IV x 2 and 4U Reg Insulin. Renal
was consulted and he went to HD.
.
He was evaluated by Merit at HD. There his BP was slightly low
during dialysis and he was very lethargic. It was difficult to
get a full story due to drowsiness.
Past Medical History:
#. DMI uncontrolled with complications
#. CAD s/p STEMI [**12-21**] in setting of cocaine use, s/p cath with
bare metal stent to LAD
#. Recurrent flash pulmonary edema since STEMI [**12-21**]
chronic systolic heart failure
#. [**Month/Year (2) 2091**] stage V on HD since [**2-/2184**] (T/Th/Sat), followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
#. Recurrent line sepsis, coag negative staph, klebsiella,
enterobacter
#. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
#. History of AV fistula clot
Social History:
Patient has a prior history of tobacco and marijauna use, but he
does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. 2 sisters, one with diabetes. 6 brother, one with
diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
V: Post HD 97.3, BP 167/114, P78, R16, 99%RA
Gen: Drowsy but arousable, middle-aged AA man
HEENT: PERRL, OP clear, MMM
CV: RRR no m/r/g, HD cath in place with no erythema, warmth or
tenderness surrounding
Pulm: CTAB
Abd: decreased BS, NTND
Ext: no edema
Pertinent Results:
[**2187-2-26**]
WBC-8.5# HGB-10.3* HCT-34.6* MCV-82 RDW-18.1* PLT COUNT-343
NEUTS-64.6 LYMPHS-21.3 MONOS-7.0 EOS-6.4* BASOS-0.7
GLUCOSE-292* UREA N-60* CREAT-8.8* SODIUM-137 POTASSIUM-6.3*
CHLORIDE-95*
TOTAL CO2-24 ANION GAP-24*
CALCIUM-10.4* PHOSPHATE-7.5* MAGNESIUM-2.1
CK(CPK)-165 CK-MB-7
cTropnT-0.38* -> 0.37 -> 0.40 -> 0.33
.
CXR: no acute process
.
ECG: Sinus rhythm, ST elevations V1-V4 not significantly changed
from previous. TWIs laterally, not significantly changed from
previous.
Brief Hospital Course:
A/P: 38 year old male with DMI, ESRD on HD, gastroparesis, CAD
s/p STEMI 2 months ago, presenting with nausea, vomiting similar
to prior gastroparesis flares.
.
# Nausea/Vomiting - Likely secondary to gastroparesis, as with
prior admissions. His usual regimen if IV reglan, dilaudid, and
ativan was started. This resulted in significant improvement
and he was able to tolerate POs by the following morning. He
stated he was feeling improved and expressed his intentions to
leave on [**2187-2-28**] AM. At this time he denied abdominal pain and
was tolerated PO intake well.
.
# HTN - Hypertensive prior to HD with some hypotension during
it. Was also labile on the floors, intermittently with elevated
BP but then falling into 100's systolic range. Still able to
tolerate HD. Med compliance as an outpatient is complicated by
N/V and inability to hold down PO meds. Got IV meds (metoprolol,
captopril) overnight, but then able to take in PO meds.
Clonidine patch had come off also; that was replaced. No
evidence of sepsis or cardiac changes.
.
# Hyperkalemia - With ESRD. Had HD on the day of admission and
then again the following day to keep with schedule. K improved
following HD.
.
# CAD - Recent STEMI s/p stent. He was ruled out for MI here
(stable unchanging troponin elevations). EKG with persistent ST
changes as above, ? possible evolving aneurysm per past
cardiology evaluation. Last echo [**2-3**] still without evidence of
aneurysm. Cardiology has previously been involved during
admissions; have felt no further workup needed unless acute
changes in EKG or symptoms. Case was discussed with cards in the
ED. He was scheduled with cardiology as an outpatient. Aspirin,
[**Month/Year (2) **], beta blocker and ACE inhibitor were continued.
.
# DM type I - Given NPH (patient using at home) and regular SS
coverage.
.
# ESRD on HD: Has HD on day of admit and then again the
following day to keep him on schedule and to get him to dry
weight. Lanthanum was continued. Attempted to obtain urine tox
given transplant candidate status, but patient unable to give
urine sample (though does void).
.
# Full code
Medications on Admission:
#. Aspirin 325 mg DAILY
#. Clopidogrel 75 mg DAILY
#. Atorvastatin 80 mg DAILY
#. Clonidine 0.2 mg/24 hr Patch Weekly (every Tuesday)
#. Clonidine 0.1 mg PO BID
#. Lisinopril 40 mg DAILY
#. Labetalol 300 mg [**Hospital1 **]
#. Prochlorperazine Maleate 10 mg Q6PRN
#. Insulin 5U NPH [**Hospital1 **] and RISS for FS>150.
#. Metoclopramide 10 mg QIDACHS
#. Lorazepam 1 mg Q4H PRN nausea
#. Omeprazole 40 mg Daily
#. Lanthanum 500 mg 2 tabs TID QAC
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times
a day: with meals and at bedtime.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for nausea.
11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: with meals.
13. Insulin
Insulin as you have been doing at home: NPH 5 units in the
morning and evening. Regular insulin for fingerstick sugar
above 150 as you have been doing at home.
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea/vomiting
Gastroparesis
Hypertensive urgency
Diabetes mellitus
End stage renal disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with nausea, vomiting, abdominal pain, and
inability to hold down food or liquids. This was likely due to
gastroparesis from diabetes as before. We treated you with pain
and nausea medications and you have improved. We have offered
to have you stay to ensure that your symptoms do not return, but
you have indicated that you would like to leave the hospital at
this time.
.
Please call your doctor or return to the hospital if you have
worsening abdominal pain, nausea, vomiting, inability to hold
down liquids, chest pain, dizziness, or any new symptoms that
you are concerned about.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed. We have not made any
changes to you medications since you were admitted.
Followup Instructions:
You have several upcoming appointments at [**Hospital1 18**]:
.
1. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD (Neurology) Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2187-3-13**] 10:00
2. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS (Internal Medicine) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-3-27**] 12:00
3. [**Company 191**] CLINICAL PHARMACIST Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-3-27**]
1:00
4. Transplant team (Dr. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) 10801**] [**Last Name (NamePattern1) **]); [**2187-4-9**]
starting at 2:00 pm.
5. Dr. [**Last Name (STitle) **] (heart specialist); [**2187-4-9**] at 4:00 pm.
.
You should continue dialysis as usual on Tuesdays, Thursdays,
and Saturdays.
.
You will also need followup with your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) in the future. In the
meantime, you have an appointment with one of the clinic's nurse
practitioners ([**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**]) as above.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Admission Date: [**2187-3-1**] Discharge Date: [**2187-3-5**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
s/p left femoral line placement and removal
hemodialysis, PICC line placement and removal
History of Present Illness:
38 year old male with a past medical history significant for
over 40 admissions in the past year to the hospital, diabetes
mellitus type 1 complicated by severe gastroporesis, coronary
artery disease status post ST segment elevation myocardial
infarction with placement of bare metal stent [**2186-12-17**], endstage
renal disease on hemodialysis who presented with a one hour
history of sharp cramping generalized abdominal pain which awoke
him from sleep. The abdominal pain induced per patient nausa and
vomiting; therefore, he called the ambulance to take him to the
hospital. Of note for dinner prior to this episode of pain, the
patient ate a cheeseburger and soup. Also he was recently
discharged from [**Hospital1 18**] [**2187-2-28**] in order to make a court
appearance. He states that he has continued to take his
antihypertensives and antinausea medications at home. He states
that this pain is typical of his abdominal pain crises. He
states this is unlike the chest pain he developed in the setting
of cocaine use prior to his myocardial infarction in [**12-21**].
Patient had recent post ST segment elevation myocardial
infarction in [**12-21**] that presented with L-sided chest tightness
radiating to L arm with associated diaphoresis. During that
admission he was found to have occlusion of distal left anterior
descending artery to D1 with bare metal stent placement.
.
In the ED: He was found to be hypertensive to 177/123-> 220/134
-> started on a nitro paste, then nitro gtt when a femoral line
was placed. He was given ativan 2mg IM x 3 and dilaudid 2mg
IM/IV x 3 for nausea. He was given aspirin 325mg. He was
transferred to the CCU due to lack of floor beds.
.
CCU Course: His nitro ggt was weaned off as pain control was
achieved with ativan 1mg intravenous 2-4 hours and dilaudid 2mg
intravenous every 2-4 hours. His blood pressure medications were
gradually restarted with good effect. He underwent hemodialysis
[**2187-3-1**] for ultrafiltration of 2.2 liters and the removal of 1.7
liters. Patient was started on Lantus 6 units in the evening and
has a BG on 51 in the am that was treated. The patient is
schedeuled to undergo placement of a PICC by IR [**2187-3-2**].
.
ROS (on transfer): No chest pain, shortness of breath, nausea,
vomiting, constipation, diarrhea, pruritis, changes in skin or
eye color, diaphoresis. No fevers, chills. +diffuse abdominal
pain, non radiating, crampy
Past Medical History:
DIABETES MELLITUS:
-- gastroparesis, complicated by chronic abdominal pain
-- end-stage renal disease on hemodialysis since [**2-/2184**]
HYPETENSION
CAD s/p STEMI on [**2186-12-17**] in setting of cocaine use with bare
metal stent placement to the LAD, unable to cross d1 lesion.
history of line sepsis, coag negative staph most recently
[**2187-1-10**] and priors with klebsiella/enterobacteremia
AUTONOMIC DYSFUNCTION
-- hypertensive emergency
-- orthostatic hypotension
history of substance abuse (cocaine, marijuana, alcohol)
history of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
history of AV fistula clot
CVA?
Social History:
Patient has a prior history of tobacco and marijauna use, but
he does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use *1 per patient. He states he does not currently use
cocaine.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. 2 sisters, one with diabetes. 6 brother, one with
diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
VS: 97.1, 143/100, 83, 20, 96% RA, pain [**5-24**], BG 69
.
Gen: young male in NAD, resp or otherwise. Oriented x 2 (missed
date by one day). Mood, affect appropriate. Pleasant.
HEENT: NCAT. anicteric sclera. CNII-XII grossly intact
Neck: Supple no JVD, no cervical LAD.
CV: RRR, no r/g, SEM best heard RUSB/LUSB, does not radiate to
carotids.
Chest: Respirations unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi. RUQ tunneled HD line dressing c/d/i.
Abd: soft, ND, No HSM. No abdominial bruits. No tenderness to
palpation, no rebound, no guarding.
Ext: Left groin triple lumen catheter c/d/i. 4/5 strength hip
flexors, 4+/5 biceps, triceps, deltoids
Pertinent Results:
CARDIAC CATH [**12-21**] demonstrated: LMCA - no disease, LAD - LAD
occluded proximally after D1. The D1 had a chronic total
occlusion, LCx was a non-dominant vessel without lesions, RCA
was not injected.
.
ECG (from ED): Sinus tachy at 118. STE V1-V4 unchanged from
[**2187-2-26**]. TWIs in I, aVL, V5-V6 unchanged from previous.
.
[**2187-2-2**] TTE: EF=45%, distal septum, anterial wall, apex HK.
The left atrium is elongated. There is mild symmetric LVH. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the distal septum, distal anterior wall and apex.
(LVEF = 45%). PASP 36.
Brief Hospital Course:
38 year old male with diabetes mellitus complicated by
gastroparesis, hypertension, autonomic dysfuction, coronary
artery disease status post myocardial infarction [**12-21**] with
stent placement presents with abdominal pain, nausea, vomiting
and discovered to be hypertensive.
.
1) Hypertensive: The patient has chronic hypertension and is on
clonidine, labetalol, lisinopril. Notes from multiple prior
admission indicated that he becomes very hypertensive in the
setting of pain. Patient's underlying abdominal pain was treated
with ativan iv prn and a dilaudid PCA. On a diabetic and renal
diet with the pain control the patient's pain resolved. Patient
was continued on his home blood pressure medications including
labetalol, clonidine, lisinopril. Patient was transitioned to
dilaudid oral and ativan prn.
.
2) Diabetes Mellitus: Patient on admit transitioned to Lantus
and dose was adjusted. The patient will be discharged home on
Lantus and an insulin sliding scale. Patient had one episode
where he consumed an entire jug of [**Location (un) 2452**] juice raised his
potassium to 6 with flipped Ts V4/V6. Patient was treated with
calcium gluconate, kayexelate and insulin. Repeat ECG showed
resolution of the flipped t-waves. Patient was discharged home
with antiemetics prn for his gastroporesis.
.
3) Coronary Artery Disease: status post bare metal stent for
anterior ST segment elevation myocardial infarction. Continued
patient aspirin, [**Location (un) 4532**] and ace inhibitor.
.
4) End Stage Renal Disease: Patient continued on his tuesday,
thursday, saturday hemodialysis. Appreciated renal hemodialysis
recommendations.
.
5) Pain management - Patient has history of diabetic
gastroparesis and abdominal pain. His abdominal pain can be
attributed to poor food choices prior to this episode. Labile
blood pressure appeared to depend upon his level of pain
control. The pain service was consulted. Patient has responded
well the PCA, standing tylenol and new neurontin and no longer
requires ativan. Patient's intravenous dilaudid requirement was
transitioned to oral dilaudid.
== Patient to go home new standing tylenol, neurontin and
dilaudid po.
.
6) FEN: diabetic/cardiac/renal diet maintained while in the
hospital.
.
7) ACCESS: Patient had a femoral line placed for access which
was removed when the patient had a PICC placed for access.
Patient continues to have hemodialysis catheter for hemodialysis
access.
.
8) Code: FULL CODE.
Medications on Admission:
Aspirin 325 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Atorvastatin 80 mg PO once a day.
Clonidine 0.1 mg PO BID
Clonidine 0.2 mg/24 hr Patch Weekly QMON (every Monday).
Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day.
Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a
day: with meals and at bedtime.
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for nausea.
Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Lanthanum 1,000 mg Tablet, PO three times a day: with meals.
Insulin as you have been doing at home: NPH 5 units in the
morning and evening. Regular insulin for fingerstick sugar above
150 as you have been doing at home.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
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 QIDACHS
(4 times a day (before meals and at bedtime)).
11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
Disp:*25 Tablet(s)* Refills:*0*
13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
14. Lantus 100 unit/mL Solution Sig: Four (4) units Subcutaneous
at bedtime: as directed.
15. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QTUTHSA
([**Doctor First Name **],MO,WE,FR).
16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUTHSA
(TU,TH,SA).
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection subcutaneously as previously directed: per insulin
sliding scale.
18. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive urgency
gastroparesis
diabetes mellitus
secondary diagnosis:
end stage renal disease on hemodialysis
coronary artery disease
Discharge Condition:
stable, ambulating, tolerating po's
Discharge Instructions:
You were admitted to the hospital for abdominal pain and high
blood pressure. You were treated with in intravenous pain
medication which was converted to pills so that you could
acheive better pain control at home. Upon discharge your blood
pressure was under good control; it is important that you take
these medications daily.
.
Please call your primary care physician or call 911 if you
experience chest pain, nausea, vomiting, increased abdominal
pain, fevers, headache or other concerning symptoms.
.
Please resume your home medications as previously instructed.
Followup Instructions:
Please call the [**Hospital 191**] clinic at [**Telephone/Fax (1) 250**] to set up an
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next 1-2 weeks to
follow-up. If he is not available, ask for the next available
appointment.
.
You have the following previously scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2187-3-13**] 10:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-3-27**] 12:00
Provider: [**Name10 (NameIs) 191**] CLINICAL PHARMACIST Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-3-27**] 1:00
|
[
"414.01",
"536.3",
"585.6",
"412",
"250.63",
"403.01",
"V45.82",
"337.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
20647, 20653
|
15547, 18006
|
10490, 10582
|
20836, 20874
|
14910, 15524
|
21490, 22250
|
13995, 14206
|
18941, 20624
|
20674, 20728
|
18032, 18918
|
20898, 21467
|
14221, 14891
|
10436, 10452
|
10610, 13029
|
20749, 20815
|
13051, 13700
|
13717, 13979
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,694
| 153,533
|
29121
|
Discharge summary
|
report
|
Admission Date: [**2111-1-20**] Discharge Date: [**2111-2-24**]
Date of Birth: [**2048-12-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
[**Doctor First Name **]
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Respiratory failure secondary to severe tracheobronchomalacia
and recent Stenotrophomonas multophilia/Serratia maracesans
pneumonia
GERD
Major Surgical or Invasive Procedure:
[**2111-1-22**] Rigid Bronchoscopy, placement of a 14mm Y-stent
[**2111-2-4**] Rigid bronchoscopy, removal of Y stent, and placement of
Bovona trach
[**2111-2-6**] Nissen fundoplication
History of Present Illness:
62yo F w/ admission to St. Vincents for complaints of a several
days of increased SOB/sputum change. Ultimately, the patient
required vent support and work-up at the OSH discovered severe
TBM. The pulmonary service at the OSH sent the patient to [**Hospital1 18**]
for definitive management. She completed a course of bactrim
for a Stenotrophomans and Serratia PNA (?CAP vs VAP). Upon
transfer, she was on the vent but tolerating oral feeds., HD
normal with no new culture or temparture findings.
Past Medical History:
Respiratory failure
GERD
Asthma
DVT/PE
^lipidemia
Depression
Anxiety
Tracheobronchomalacia status post resection,
Vocal cord dysfunction presumably from GERD s/p tracheostomy in
[**2105**]
Social History:
married, no EtOH, no tobacco
Family History:
N/C
Physical Exam:
98.1 68 (SR) 108/72 (BP) 22 (RR) 100% (on CPAP/PS), FS = 176
HEENT: anicteric, MMM, no adenopathy
Cor: Regular no m/r/g
Pulm: CTA anteriorly, diminished at the bases
Abd: soft, NT, ND +BS
Ext: trace edema, calves soft, 1+DP/PT, trace-1+ edema
Pertinent Results:
[**2111-1-20**] 08:26PM TYPE-ART PO2-124* PCO2-39 PH-7.38 TOTAL
CO2-24 BASE XS--1 INTUBATED-INTUBATED
[**2111-1-20**] 08:26PM freeCa-1.19
[**2111-1-20**] 06:05PM GLUCOSE-91 UREA N-14 CREAT-0.8 SODIUM-142
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14
[**2111-1-20**] 06:05PM estGFR-Using this
[**2111-1-20**] 06:05PM PLT COUNT-179
[**2111-1-20**] 06:05PM PLT COUNT-179
Brief Hospital Course:
The patient was admitted to the CSRU where initial work-up
included an airway CT scan and a bedside flexible bronchosopy.
She was deemed a non-surgical candidate given her functional
status and likely prior tracehal resection. On HD3, the patient
had a 14mm Y-stent and within 12 hours, she was able to
extubate. Speech and swallow as well as ORL saw the patient.
They agreed that the patient does have paradoxic movement of her
cords -- continuance of her usual diet of soft solids & thin
liquids.
Early on the morning of HD 5 the patient had an episode of acute
respiratory distress for which she was bronched. Thick
secretions were suctioned and the patient improved. Later that
day a second bronchoscopy was performed with revealed an almost
completely plugged L mainstem bronchus and distal portion of the
Left limb of the stent. This plug was removed with a much
suctioning and ultimately the patient coughed it out. Upon
replacing the scope the stent was visualized to be in good
position and now clear of secretions. She was started on
mucomyst nebs and Ciprofloxacin for 7 days.
Over the ensuing 72 hours, she was given aggressive pulmonary
care and appeared quie stable clincally. Her secretions were
more easily managed and discussions were held between the
Interventional Pulmonology service and the Thoracic Surgical
Service as to whether or not the Y-stent was a tenable solution
for long-term palliation of her severe tracheobronchomalacia.
Although not entirely documented, she appears to have had prior
tracheal surgery/reconstruction and it is unclear if her
recurrent laryngeal nerves were injured at this time,
nonetheles, she does in fact have paradoxic cord motion and
severe tracheobronchomalacia in the setting of prior tracheal
reconstruction with the background of a prolonged
hospitalization for respiratory failure and pneumonia. She is
not an ideal surgical candidate, particularly since she has a
high risk of recurrence/failure in the setting of where a major
reconstruction would be the only realistic chance for potential
palliation (i.e. thoracotomy, tracheal resection, bronchoplasty
+/- mesh prosthesis).
However, the patient continued to be suctioned for large amounts
of thick yellow secretions. She also developed severe cough and
chest tightness after the stent placement. She had a bedside
bronchoscopy on [**2111-1-26**] with suction of large amounts of
secretions. The patient was started on prednisone because of
the possibility of an asthmatic component contributing to her
cough and mucous production. The patient was re-bronched [**2111-1-28**]
to evaluate the Y stent as well as the secretions because it did
not appear as if she was tolerating the stent. It was
determined that the Y-stent was in the appropriate position with
only minimal secretions noted and distal granulation tissue
forming at the left bronchial limb of the Y-stent. However even
though the patient is not an ideal surgical candidate, her
tracheal malacia was so severe that it required treatment and
surgery remained the only and best option for her. Because a
tracheobronchoplasty can result in proximal esophageal motility
disorder, which can worsen acid reflux leading to aspiration and
further vocal cord dysfunction, it is imperative that she
undergo definitive surgical treatment for her reflux before the
tracheoplasty is performed. As part of her GERD workup, the
patient had an esophageal manometry study on [**2111-1-29**] which showed
diffuse esophageal spasm and a slightly hypotensive lower
esophageal sphincter. The patient had repeat bronchoscopies on
[**2111-1-30**] and [**2111-2-2**] for therapeutic aspirations. On [**2111-2-4**], the
patient went to the OR for a rigid bronchoscopy with granulation
tissue excission, stent removal, and tracheostomy tube change
which she tolerated well and improved the patient's symptoms.
Two days later, the patient went to the OR again for a
laparoscopic Nissen fundoplication.
The patient's post-operative course was uneventful as she was
soon able to tolerate a regular diet. She was started on
Lovenox for DVT prophylaxis. After a recovery period of a week,
the patient returned to the OR on [**2111-2-15**] for tracheoplasty. Pt
recovered well from tracheoplasty and post bronch revealed good
repair. She was maintained on empiric keflex for tracheal mesh.
Coumadin was resumed and lovenox was d/c'd once INR was
therapeutic. Her main issue post op was pain control-requiring
prolonged use of parenteral narcotics. she is currently on po
pain med and using parenteral narcotics for break thru.
she requires ongoing hospital level of care at [**First Name8 (NamePattern2) **] [**Hospital3 6783**]
Hospital and then transition to home.
Medications on Admission:
prevacid 30 mg [**Hospital1 **]
singulair 10 mg daily
combivent inhaler Q6hr prn
sertraline 200mg daily
klonopin 1mg TID
senna [**Hospital1 **]
colace 100 mg TID
lidocaine TD'
Discharge Medications:
1. Sertraline 50 mg Tablet [**Hospital1 **]: Four (4) Tablet PO DAILY
(Daily).
2. Clonazepam 0.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times
a day) as needed.
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed.
9. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: [**1-27**] Inhalation Q6H
(every 6 hours).
10. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours).
11. Acetylcysteine 10 % (100 mg/mL) Solution [**Month/Day (2) **]: One (1)
Miscellaneous [**Hospital1 **] (2 times a day).
12. Lidocaine HCl 0.5 % Solution [**Hospital1 **]: One (1) ML Injection Q1H
(every hour) as needed for cough.
13. Heparin Lock Flush 100 unit/mL Solution [**Hospital1 **]: One (1) ML
Intravenous DAILY (Daily) as needed.
14. Lorazepam 2 mg/mL Syringe [**Hospital1 **]: .5-1 mg Injection Q4H (every
4 hours) as needed for anxiety.
15. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Outpatient Lab Work
Please check PT/INR with your PCP
18. Cefazolin 1 g Piggyback [**Last Name (STitle) **]: One (1) gm Intravenous every
eight (8) hours for 3 weeks.
19. Coumadin 1 mg Tablet [**Last Name (STitle) **]: 1 [**1-27**] Tablet PO once a day: goal
INR 2.5-3.
20. Hydromorphone 2 mg/mL Syringe [**Month/Day (2) **]: .5 mg Injection Q3-4H
(Every 3 to 4 Hours) as needed.
Discharge Disposition:
Extended Care
Facility:
St Vincents [**Hospital3 17921**] Center
Discharge Diagnosis:
1-Severe tracheobronchomalacia
2- Remote history of respiratory failure/chronic paradoxic vocal
cord movement
3- Tracheostomy/recurrent pneumonia (history since [**2105**])
4- GERD
5- Asthma
6- H/o DVT/PE (remote w/ IVC filter, on chronic anticoagulation)
7- Hyperlipidemia
8- Depression/Anxiety
9- tracheoplasty
Discharge Condition:
deconditioned, tolerating a soft consistency/thin liquid diet,
able to manage secretions, off the ventilator.
pain control remains ongoing issue.
INR therapeutic
Discharge Instructions:
Patient can follow-up with her pulmonologist/PCP as needed.
Patient can follow-up with her pulmonologist/PCP as needed.
continue Kefzol x 3 weeks (total 4 weeks course)
continue coumadin
Followup Instructions:
See above
Completed by:[**2111-2-24**]
|
[
"518.84",
"625.6",
"V12.51",
"701.5",
"466.0",
"934.1",
"530.81",
"478.74",
"493.20",
"272.4",
"996.59",
"530.5",
"V46.11",
"E912",
"V44.1",
"478.30",
"519.19",
"519.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"96.6",
"44.67",
"96.72",
"96.05",
"31.5",
"45.13",
"31.79",
"89.32",
"03.90",
"33.21",
"97.23",
"32.01",
"98.15"
] |
icd9pcs
|
[
[
[]
]
] |
9257, 9324
|
2123, 6867
|
436, 624
|
9681, 9845
|
1711, 2100
|
10080, 10121
|
1428, 1433
|
7093, 9234
|
9345, 9660
|
6893, 7070
|
9869, 10057
|
1448, 1692
|
260, 398
|
652, 1154
|
1176, 1366
|
1382, 1412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,637
| 157,427
|
40160
|
Discharge summary
|
report
|
Admission Date: [**2183-11-25**] Discharge Date: [**2183-11-26**]
Date of Birth: [**2119-11-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / IV Dye, Iodine Containing Contrast
Media
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Desensitization
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 47639**] is a 63F with stage IIIC poorly differentiated
primary peritoneal serous carcinoma, now with disease recurrence
and participating in a [**Company 2860**] clinical trial, admitted to the ICU
for cycle 6 of [**Doctor Last Name **]/taxol therapy with carboplatin
desensitization.
One third of the way through infusion of carboplatin during
cycle 2 of chemotherapy on [**2183-9-2**], she developed an intense
feeling of heat and generalized body tingling, numbness and
tingling of the lips, and chest tightness. Carboplatin was
discontinued and she received 100 mg hydrocortisone and 50 mg of
Benadryl IV. Her vital signs remained stable, but she later had
vomiting and headache. Given her allergic reaction, she was
admitted to the ICU to receive cycles 3 and 4 of carboplatin per
the desensitization protocol. She has tolerated the treatments
without incident. She was readmitted to the ICU earlier this
month [**Date range (1) 57529**] for desensitization for cycle 5 again without
incident.
Today, she is directly admitted to the ICU again for carboplatin
desensitization for cycle 6 of chemotherapy. On arrival to the
MICU, patient's VS: 97.8, 85, 131/78, 18, 100% RA
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies
constipation, abdominal pain, diarrhea, dark or bloody stools.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
- Stage IIIC poorly differentiated primary peritoneal serous
carcinoma
- Thalassemia
- Hypertension (per patient never treated with home medication,
only when in hospital or seeing doctors)
- Gastritis/Reflux
Oncologic history
- CT abd/pelvis on [**2182-2-28**] revealed a large mass centered in the
sigmoid colon with pelvic lymphadenopathy, retroperitoneal
lymphadenopathy, and peritoneal carcinomatosis.
- A colonoscopy revealed a fungating, ulcerated mass within the
sigmoid colon causing a partial obstruction. The biopsy of this
mass revealed adenocarcinoma with papillary formation,
suggestive of an ovarian primary.
- [**2182-3-14**] underwent exploratory laparotomy, hysterectomy,
bilateral salpingo-oophorectomy, rectosigmoid resection with
colorectal re anastomosis and diverting loop ileostomy. This
was a suboptimal tumor debulking. Intra-operatively, the uterus
and bilateral adnexal were unremarkable. Extensive firm
retroperitoneal lymphadenopathy was appreciated. There was no
evidence of carcinomatosis. The tumor was noted to involve the
sigmoid colon and rectum. Pathology examination revealed serous
carcinoma involving full thickness of the rectal wall. Seven of
eight lymph nodes were positive for malignancy. Uterus, cervix,
fallopian tubes, and ovaries were negative for malignancy.
- [**Date range (3) 88205**]: 5 cycles of chemotherapy with Carboplatin q21
days and weekly Taxol, [**2182-8-15**] 6th cycle of chemotherapy with
Carboplatin and Taxotere in place of Taxol due to neurotoxicity
- [**2183-7-12**]: MRI of the L-spine shows new retroperitoneal
lymphadenopathy consistent with disease recurrence.
- [**2183-8-11**] started chemotherapy according to the clinical trial
[**Company 2860**] #11-228 (Phase II, multi-center, double-blind, placebo
controlled, randomized study of ombrabulin in patients with
platinum-sensitive recurrent ovarian cancer treated with
Carboplatin/Paclitaxel)
Social History:
Immigrated from [**Country 3587**] in youth. Formerly employed in retail
sales. No children, husband lives in [**Country 3587**]. Sister and
[**Name2 (NI) 802**] live in [**Name (NI) 86**] area.
- Tobacco: Never
- EtOH: Denies
- Illicits: Denies
Family History:
Mother and father lived to their 70s. Family history of
thalassemia. Uncle with diabetes. She denies family history of
cancer, CAD, or hypertension.
Physical Exam:
Admission exam:
Vitals: 122/75 HR 84 95%/RA
General: Alert, oriented, well appearing female pleasant in no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
edentulous with top dentures in place
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,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge exam:
Tmax: 37 ??????C (98.6 ??????F)
Tcurrent: 36.6 ??????C (97.9 ??????F)
HR: 68 (68 - 93) bpm
BP: 117/62(76) {99/51(63) - 138/80(90)} mmHg
RR: 17 (15 - 23) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
General: Alert, oriented, well appearing female pleasant in no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
edentulous with top dentures in place
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, RUSB 2/6 systolic
ejection murmur, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
Admission labs:
[**2183-11-24**] 08:45AM BLOOD WBC-4.4 RBC-3.65* Hgb-8.4* Hct-26.3*
MCV-72* MCH-23.1* MCHC-32.0 RDW-20.7* Plt Ct-188
[**2183-11-24**] 08:45AM BLOOD Neuts-49.1* Lymphs-42.2* Monos-6.3
Eos-1.7 Baso-0.7
[**2183-11-24**] 08:45AM BLOOD PT-10.8 INR(PT)-1.0
[**2183-11-24**] 08:45AM BLOOD Plt Ct-188
[**2183-11-24**] 08:45AM BLOOD UreaN-18 Creat-0.8 Na-142 K-3.8 Cl-106
[**2183-11-24**] 08:45AM BLOOD Glucose-110*
[**2183-11-24**] 08:45AM BLOOD ALT-39 AST-36 AlkPhos-111* TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2183-11-24**] 08:45AM BLOOD TotProt-7.4 Albumin-4.4 Globuln-3.0
Calcium-9.6 Phos-3.5 Mg-1.5*
[**2183-11-24**] 08:45AM BLOOD CA125-41*
[**2183-11-24**] 08:42AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003
[**2183-11-24**] 08:42AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2183-11-24**] 08:42AM URINE Hours-RANDOM Creat-20 TotProt-<6
Discharge labs:
[**2183-11-26**] 06:14AM BLOOD WBC-7.0 RBC-3.46* Hgb-7.9* Hct-25.0*
MCV-72* MCH-22.7* MCHC-31.4 RDW-20.8* Plt Ct-172
[**2183-11-26**] 06:14AM BLOOD Glucose-124* UreaN-24* Creat-0.9 Na-141
K-4.1 Cl-106 HCO3-27 AnGap-12
[**2183-11-25**] 01:30PM BLOOD ALT-38 AST-33 LD(LDH)-253* AlkPhos-102
TotBili-0.3
[**2183-11-26**] 06:14AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.7
Pertinent micro: none
Pertinent imaging: none
Brief Hospital Course:
64F with history of stage IIIc primary peritoneal carcinoma who
presents for desensitization to carboplatin prior to cycle # 6
of treatment with paclitaxel and carboplatin.
ACTIVE ISSUES:
# CARBOPLATIN ALLERGY: Patient has a history of reaction to
treatment (heat and generalized body tingling, numbness and
tingling of the lips, and chest tightness) during cycle 2 of
treatment. Has subsequently undergone desensitization prior to
treatment for cycles [**4-7**] without incident. Presented for
desensitization today prior to cycle 6. Desensitization protocol
was implemented per pharmacy/oncology recs (protocol prepared by
pharmacy, signed by oncology as this is chemotherapy not ordered
by housestaff). The patient was premedicated 30-60 minutes prior
to initiation of chemotherapy with the following:
Diphenhydramine 25 mg IV, Famotidine 20 mg IV, Ondansetron 8 mg
IV, Dexamethasone 10 mg IV. Chemotherapy (desensitization to
carboplatin): Paclitaxel 330.8 mg IV, Carboplatin 5.897 mg IV,
Carboplatin 58.97 mg IV, Carboplatin 589.7 mg IV (full
therapeutic dose). She did not require any epinephrine and did
not exhibit signs or sx of an allergic reaction.
The patient tolerated desensitization well and had no adverse
reactions.
# STAGE IIIC PRIMARY PERITONEAL SEROUS CARCINOMA: Patient
currently undergoing chemotherapy as above; oncology history as
above. Plan for outpatient CT scan for re-staging on [**12-8**] with
premedication for contrast allergy.
INACTIVE ISSUES:
# Thalassemia: stable, no changes
# Hypertension ("white coat;" not on treatment): stable, no
treatment required
# Status post cholecystectomy: asymptomatic, stable
# Gastritis/Reflux: stable
TRANSITIONAL ISSUES:
# Chemo: patient should be followed closely for any reactions
Medications on Admission:
- Dexamethasone as directed
- Vicodin 5-500 mg [**2-3**] tablet(s) by mouth Q4-6 hours as needed
for pain (up to 8 tablet)
- Lorazepam 0.5 mg tablet [**2-3**] Tablet(s) by mouth every eight (8)
hours as needed for nausea or anxiety
- Ondansetron HCl 8 mg by mouth twice daily as needed for nausea
- Prednisone 50 mg tablet: Take 1 tablet 13, 7 and 1 hour prior
to CT scan
- Prochlorperazine maleate 10 mg tablet by mouth twice daily x 3
days after chemotherapy
- Diphenhydramine [**Last Name (un) **]-Cap 25 mg capsule 2 capsule(s) by mouth
once 1 hour prior to CT scan
- Colace
- Senna
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- chemotherapy desensitization
- peritoneal serous carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 47639**],
It was a pleasure caring for you while you were hospitalized at
the [**Hospital1 **]. As you recall, you were admitted for
desensitization to one of your chemotherapeutic agents. You
tolerated this well without any allergic event.
There is no change to your medications.
Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] below.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2183-12-1**] at 8:45 AM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2183-12-1**] at 9:30 AM
With: [**First Name8 (NamePattern2) 4617**] [**Last Name (NamePattern1) 26978**], RN [**Telephone/Fax (1) 9644**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2183-12-8**] at 9:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2183-11-26**]
|
[
"V70.7",
"196.2",
"V58.11",
"158.8",
"530.81",
"282.40",
"V07.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
9955, 9961
|
7381, 7555
|
356, 362
|
10085, 10085
|
5997, 5997
|
10672, 11697
|
4256, 4407
|
9781, 9932
|
9982, 9982
|
9168, 9758
|
10236, 10649
|
6950, 7358
|
4422, 5098
|
5114, 5978
|
9078, 9142
|
1615, 2027
|
301, 318
|
7570, 8844
|
390, 1596
|
8861, 9057
|
6014, 6933
|
10001, 10064
|
10100, 10212
|
2049, 3976
|
3992, 4240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,887
| 175,660
|
36885
|
Discharge summary
|
report
|
Admission Date: [**2161-8-11**] Discharge Date: [**2161-8-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
left arm pain and atrial flutter
Major Surgical or Invasive Procedure:
[**2161-8-11**] Left brachial thromboembolectomy
[**2161-8-11**] Right PICC placement
[**2161-8-12**] Left forearm fasciotomy
History of Present Illness:
[**Age over 90 **] y/o lady with h/o aflutter presented to OSH with cold left
arm. She was found to be aflutter with RVR and was started on
dilt drip and heparin drip. She was transfered to [**Hospital1 18**] for
surgical eval. Patient underwent left brachial thrombectomy by
vascular surgery. During surgery her HR was in 60-70s per
Anesthesia however rebounded to 120s in PACU. She was given 15
mg IV dilt bolus and was started on a dilt drip in PACU. She was
transferd to the floor for further managment.
.
On arrival to the floor patient was found to be unresponsive to
verbal stimuli. She will occasionally open her eyes. She did not
have a gag reflex and had diffuse rhonchi. She was triggered.
She received 10 of IV morphine (total) and some dilaudid in
PACU. ABG was 7.24/58/236 c/w respiratory acidosis. She received
narcan IV 0.5 mg once and her mental status and gag reflex
improved. She was complaining of left upper extremity pain.
.
Patient was recently seen at OSH with a possible eye infection
and might have left AMA. The records are not available
currently. Patient has memory confusion problems at baseline,
however could ambulate and dress herself at home.
.
Patient is a poor historian and unable to give a good history.
Past Medical History:
CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection
?S/p left eye surgery
Social History:
Lives with son and daughter-in-law. Unattended during day when
family at work although a family member will usually check in at
lunchtime. H/o smoking, quit in her 60s. No EtOH or drug use.
Family History:
N/C
Physical Exam:
On discharge:
VS: BP 148/64 HR 84 RR 16 O2 sat 95% RA
GENERAL: in NAD, difficult to understand speech, A and O x 1
HEENT: MMM, oropharynx clear
NECK: supple, no JVD
CARDIAC: S1S2 RRR
LUNGS: CTA bilaterally
ABDOMEN: Soft, NTND.
EXTREMITIES: LUE swollen, radial pulse 2+ on left, dressed with
erythema/ecchyosis over anterior aspect of LUE; 2+ pulses
throughout
NEURO: CN II-XII intact, moves all four extremites spontaneously
Pertinent Results:
[**2161-8-19**] WBC-10.2 RBC-2.85* Hgb-8.9* Hct-26.4* MCV-93 MCH-31.3
MCHC-33.7 RDW-16.7* Plt Ct-309
[**2161-8-19**] Plt Ct-309
[**2161-8-19**] PT-24.7* PTT-31.2 INR(PT)-2.4*
[**2161-8-19**] Glucose-138* UreaN-86* Creat-3.3* Na-140 K-3.7 Cl-101
HCO3-25 AnGap-18
[**2161-8-12**] CK(CPK)-[**Numeric Identifier 83288**]*
[**2161-8-17**] CK(CPK)-1874*
[**2161-8-19**] Calcium-9.8 Phos-3.6 Mg-2.3 Iron-PND
TTE - Mild calcific aortic stenosis. Normal global biventricular
systolic function. Mild pulmonary hypertension.
Brief Hospital Course:
[**Age over 90 **] yo woman with history of dementia, coronary artery disease,
paroxysmal atrial flutter who was transferred to [**Hospital1 18**] for left
upper extremity thrombectomy and atrial flutter with rapid
ventricular response complicated by worsening renal failure,
rhabdomyolysis status post left upper extremity fasciotomy.
# Left brachial thrombus complicated by compartment syndrome,
Rhabdomyolysis
- The patient was found to have cool, pulseless left arm
extremity and taken to the operating room by Vascular Surgery on
[**2161-8-11**] for left brachial thromboembolectomy. The patient
developed decreasing arm sensation and strength over [**2161-8-12**] with
development of compartment syndrome, likely due to reperfusion
injury, and was taken to the operating room by Plastics for
fasciotomy. Following the fasciotomy, the patient was followed
by plastics for wound management, and received heparin for
anti-coagulation. The patient was transitioned to oral
anti-coagulation, and INR at discharge was 2.4 on warfarin 2 mg
daily. The patient will be followed by the hand clinic at
rehab.
# Atrial flutter
- The patient has a histroy of atrial flutter and was found to
be in rapid ventricular response prior to transfer to [**Hospital1 18**] and
was started on a diltiazem drip. The rate improved in the
operating room on sedation; following transfer to the cardiac
unit post-operatively, the patient again had rapid ventricular
response. The patient was transitioned back to home metoprolol
as rate controlled off diltiazem drip. The patient's home
digoxin was discontinued as digoxin level rose to 2.8 in setting
of acute renal failure, and decreased to 2.4 after
discontinuation of digoxin. Of note, digoxin reportedly was
started only 1 month ago and may have been supratherapeutic as
patient had described vision changes although dig level only 0.7
on admit. The patient's rate remained well controlled following
transfer to the general medical floor on home metoprolol
regimen.
# Acute renal failure
- The patient's baseline was unknown but was 1.2 on admission.
The creatinine continued to rise with declining urine output
progressing to anuria in setting of difficulty obtaining
intravenous access and rhabdomyolysis from the compartment
syndrome. The urine sediment consistent with ATN. Duloxetine,
gabapentin, and digoxin was discontinued, and not restarted at
time of discharge. Given rising creatinine despite initiation
of aggressive intravenous fluids once PICC was placed,
hemodialysis was considered and family amenable. However, the
patient was responsive to diuresis with diuril and high dose
lasix with improvement in urine output that was greater than 100
cc/hour. Following transfer from the ICU, intravenous fluids
and diuresis was discontinued, the patient was started on a
dysphagia diet, the creatinine continued to improve with
adequate urine output. Creatinine at time of discharge was 3.3
and down-trending from a peak of 4.8.
# Rhabdomyolysis
- The patient reportedly was found in bed with left arm pain per
her son although circumstances leading up to this unclear.
Creatinine kinase was 1405 on admission but increased rapidly as
initially unable to obtain vascular access. Interventional
radiology-guided PICC was placed successfully, and the patient
was hydrated aggressively first with normal saline, then
switched to normal bicarbonate. Peak creatinine kinase was
[**Numeric Identifier 83288**] on evening of [**2161-8-12**] and was downtrending at 1874 on
[**2161-8-17**].
# Hypocalcemia
- Patient had low calcium levels in the setting of
rhabdomyolysis, and calcium was repleted throughout the hospital
course.
# CAD Native Vessel
- The patient has an unspecified history of coronary artery
disease per her son. It was felt that the elevated cardiac
enzymes were difficult to interpret in the setting of worsening
renal failure, and acute coronary syndrome was considered
unlikely. The patient may have had some demand ischemia in the
setting of atrial flutter with rapid ventricular response.
Cardiac markers were decreasing during hospitalization,
metoprolol, aspirin, and heparin/coumadin were given, and
transthoracic echo showed no wall motion abnormalities with
preserved biventricular systolic function, with an estimated
ejection fraction of 55%.
# Delerium, Dementia - Senile
- The patientt has dementia at baseline, and there were no acute
findings on CT head. The patient was thought to be somnolent in
setting of OR sedation with some improvement after receving
Narcan. Again noted to be somnolent after second OR procedure
although improved back to baseline without Narcan and with
continued improvement of above medical problems. The TSH was
normal.
# Conjunctivitis
- The patient had a purported eye infection and was continued on
the antibiotic ointment used prior to transfer.
# Mild Malnutrition
- Following nasogastric tube removal, a speech and swallow
evaluation 2 days prior to discharge cleared the patient for a
dysphagia diet with close one to one supervision. The patient
was taking PO at discharge.
Medications on Admission:
Aspirin 325 mg daily
Metoprolol 50 mg [**Hospital1 **]
Digoxin 0.125 mg daily
Cymbalta 40 mg daily
Gabapentin 300 mg [**Hospital1 **]
Erythromycin eye ointment
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
Sea View Retreat
Discharge Diagnosis:
Primary Diagnoses:
left brachial thrombus s/p thrombectomy
compartment syndrome s/p fasciotomy
a. flutter with RVR
rhabdomyolysis
acute renal failure
Secondary Diagnoses:
CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection
Discharge Condition:
stable and improved
Discharge Instructions:
You were admitted to the hospital for left arm pain. A blood
clot was found in your arm, and you had surgery to remove the
clot. During the recovery process, your arm developed high
pressures, and you had to have surgery to release that pressure.
At this time, your kidney function declined, and you needed IV
fluids and medication. You stayed in the ICU for a short amount
of time, and then you were transferred to the general medicine
floor. There, you continued to improve, and you were discharged
on [**2161-8-19**] to an extended care facility for continued care.
You will follow up with the hand clinic, see appointment below.
Dr. [**Last Name (STitle) 8448**], your regular doctor, will see you in the rehab
center.
Please have the staff at the rehab center call Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8448**] at [**Telephone/Fax (1) 83289**] to set up an appointment.
You were discharged on a new medication, coumadin, and your
cymbalta and neurontin were discontinued when you left the
hospital.
Please call or have your caretakers call if you develop left arm
pain/numbness/weakness or your arm becomes cold, fevers or
chills, or any other concerning medical symptoms.
Followup Instructions:
Please have the staff at the rehab center call Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8448**] at [**Telephone/Fax (1) 83289**] to set up an appointment.
Dr.[**Name (NI) 27488**] appointment:
Specialty: Plastic Surgery Clinic
Date and time: [**8-28**] at 1pm
Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 4652**]
Special instructions if applicable:
|
[
"780.97",
"E942.1",
"796.0",
"276.2",
"275.41",
"728.88",
"584.5",
"414.01",
"427.32",
"E935.8",
"350.1",
"276.6",
"372.30",
"787.22",
"263.1",
"290.0",
"311",
"788.5",
"998.89",
"V15.82",
"729.71",
"E878.8",
"444.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"38.03",
"83.14"
] |
icd9pcs
|
[
[
[]
]
] |
9082, 9125
|
3133, 8243
|
295, 422
|
9506, 9528
|
2593, 3110
|
10791, 11239
|
2126, 2131
|
8453, 9059
|
9146, 9297
|
8269, 8430
|
9552, 10768
|
2146, 2146
|
9318, 9485
|
2160, 2574
|
223, 257
|
450, 1693
|
1715, 1903
|
1919, 2110
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,193
| 103,431
|
34218
|
Discharge summary
|
report
|
Admission Date: [**2135-4-27**] Discharge Date: [**2135-5-3**]
Date of Birth: [**2116-3-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Multiple gunshot wounds
Major Surgical or Invasive Procedure:
[**4-29**] ORIF L proximal femur
[**4-29**] IVC filter
History of Present Illness:
19 yo male s/p multiple gunshot wounds to head, chest, spine,
and lumbar region. He was intubated at scene and transferred to
[**Hospital1 18**] via [**Location (un) 7622**] for further care.
Past Medical History:
Denies
Social History:
Has one child
Family History:
Noncontributory
Physical Exam:
ON ADMISSION:
96.1 100 165/p 20 99% on vent
pupils 1.5mm b/l, unreactive
vented
decreased L breath sounds
abd distended, FAST neg
pelvis stable
GSW wounds to L and R occiput, L upper chest, spine, L buttock
Pertinent Results:
Upon admission:
[**2135-4-27**] 08:30PM TYPE-ART PO2-329* PCO2-52* PH-7.29* TOTAL
CO2-26 BASE XS--1
[**2135-4-27**] 08:30PM GLUCOSE-124* LACTATE-1.6 NA+-139 K+-3.6
CL--107
[**2135-4-27**] 08:30PM HGB-11.4* calcHCT-34 O2 SAT-100 MET HGB-0.5
[**2135-4-27**] 08:25PM WBC-17.5* RBC-4.25* HGB-11.1* HCT-34.9*
MCV-82 MCH-26.1* MCHC-31.8 RDW-12.8
[**2135-4-27**] 08:25PM PLT COUNT-254#
[**2135-4-27**] 08:25PM PT-13.6* PTT-28.1 INR(PT)-1.2*
[**2135-4-27**] 08:25PM FIBRINOGE-162
[**2135-4-27**] 08:09PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CHEST (PORTABLE AP) [**2135-5-2**] 8:18 AM
FRONTAL CHEST RADIOGRAPH: Persistent left-sided pneumothorax is
identified, unchanged in appearance from prior study. There is
decreasing opacity consistent with improving contusion.
Improving left basilar atelectasis is also seen. There has also
been interval decrease in amount of subcutaneous emphysema
noted. Multiple punctate radiodense foci again seen projecting
over the left chest suggesting small foreign body fragments.
This appearance is unchanged from prior. Right lung remains
relatively clear.
IMPRESSION: Improving left lung contusion and atelectasis.
Persistent pneumothorax.
CT HEAD W/O CONTRAST [**2135-4-27**] 8:02 PM
IMPRESSION:
1. No intracranial injury or fracture.
2. Scalp hematoma at the vertex with bullet fragments and air.
Small right subgaleal hematoma.
CT C-SPINE W/O CONTRAST [**2135-4-27**] 8:03 PM
IMPRESSION:
1. No fracture or dislocation.
2. Gunshot injury to the left upper chest with hemorrhage in the
left lung apex, bullet fragments traversing the left apex and
large subcutaneous emphysema. This is better evaluated on the
subsequently acquired contrast enhanced torso CT.
CT CHEST W/CONTRAST [**2135-4-27**] 8:03 PM
IMPRESSION:
1. Gunshot wound to left upper chest with left upper lobe
collapse and parenchymal hemorrhage. Multiple small metallic
fragments are located in close proximity to the left subclavian
artery, although there is no direct evidence of arterial injury.
Small left anterior pneumothorax status post chest tube
placement.
2. Two bullets in the lumbar spine, one located in the central
spinal canal at L2, the other located in the vertebral body of
L3 with associated L3 fracture.
3. Bullet located at the lateral aspect of the left femoral neck
without apparent femoral neck fracture, although visualization
in this region is limited due to streak artifact.
Brief Hospital Course:
Upon arrival to the Emergency room he was evaluated by the
Trauma team, and a left chest tube was immediately placed with
return of 280 cc blood. He had several gunshot wounds to his
posterior head, chest, spine, and left buttock. His head wounds
were superficial and did not penetrate the skull. Bullets were
discovered in his spinal canal at L2 and in the vertebral body
of L3. His left buttock gunshot wound penetrated his left
femoral head resulting in fracture and he was taken to the
operating room by Orthopedics for repair of this.
The remainder of his hospital course by systems as follows:
Neuro
Neurosurgery was consulted for his spine injuries and the
decision was made to manage conservatively. Initially he had no
lower extremity movement; only recently has he had quadriceps
movement 1/5 strength. As for his mental status he is awake,
alert oriented x3. Ativan prn was prescribed for anxiety. He is
on prn Oxycodone for pain.
Cardiac
Initially tachycardic on the scene, resolved during the rest of
his admission. There have been no active cardiac issues.
Respiratory
His chest tube output decreased over time, and was placed to
water seal and was removed on HD4. A post-pull CXR showed
residual pulmonary contusions but no pneumothorax. He has not
required any supplemental oxygen for the remainder of his
hospital stay.
FEN/GI
He is tolerating a regular diet and is on a bowel regimen.
GU
He has an indwelling Foley and is making adequate urine.
Heme
His hematocrits have remained stable; lowest value of 25 on
[**4-29**]; most recent 26.6 on [**5-1**] with no signs of any active
bleeding.
An IVC filter for DVT prophylaxis was placed on [**4-29**].
ID
He was on Ancef x48h for antibiotic prophylaxis following his
IVC filter and left femur repair. He is no longer on
antibiotics. Endo
No major issues.
Social work was closely involved with his care throughout his
stay for emotional support. He was also evaluated by Physical
and Occupational therapy who have recommended rehab post acute
hospital stay.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
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 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 for
constipation.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Multiple gunshot wounds
Small subgleal hematoma posterior right ear
Left hemothorax
L3 fracture
Left femoral neck fracture
Discharge Condition:
Good
Discharge Instructions:
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 2 weeks, call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery, in 4 weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.
Completed by:[**2135-5-3**]
|
[
"860.5",
"861.31",
"882.0",
"E965.4",
"820.9",
"300.00",
"806.5",
"867.9",
"877.0",
"873.1",
"920"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"34.04",
"96.71",
"38.7",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
6391, 6461
|
3441, 5479
|
340, 397
|
6632, 6639
|
955, 957
|
6687, 6972
|
695, 712
|
5534, 6368
|
6482, 6611
|
5505, 5511
|
6664, 6664
|
727, 727
|
273, 302
|
425, 618
|
972, 3418
|
640, 648
|
664, 679
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,485
| 145,259
|
12839
|
Discharge summary
|
report
|
Admission Date: [**2179-3-26**] Discharge Date: [**2179-5-8**]
Date of Birth: [**2123-10-23**] Sex: M
Service: SURGERY
Allergies:
Vitamin E / Heparin Agents
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
End stage liver disease
Major Surgical or Invasive Procedure:
Intubation for mechanical ventilation
Laporatomy
Abdominal paracentesis
History of Present Illness:
55yoM Hep C etoh cirrhosis currently being evaluated for
transplant, s/p VATS for further w/u of SOB and pulmonary
nodules, presented on 2 days with generalized fatigue and mild
confusion, now transferred to MICU as per recs of liver
attending for worsening renal function and worsening mental
status. In ED on admission, no paracentesis performed, begun on
empiric azithro/ceftriaxone therapy for both SBP +/- infection
from left VATs discharge from previous admission. On floor,
noted to have worsening renal function with creatinine from 0.8
to 2.7 with urinary sodium 78, decreasing UOP.
Discharged [**3-22**], had VATS for "SOB" and "pulmonary nodules"
evaluation, has been feeling ill since this discharge. ROS prior
to admission was negative for CP, palps, cough, fever, chills,
diarrhea, dysuria, headache, vision changes, black tarry stools,
BRBPR, or hematemesis. Had noted increased LE edema as well as
increased abdominal girth, but no abdominal pain prior to
admission. On transfer, ROS essentially unchaged, difficult to
take a full ROS [**3-13**] mental status.
.
Now [**4-3**], pt readmitted from floor with increasing O2
requirements over the previous day, now on 6l nc to 8l face
mask. Vital signs stable, with sbp 120/70, rr 24. Pt received
40iv lasix x2 on floor, with total of 300cc UOP since 5am
through transfer at 3pm. CXR showing worsening pulmonary edema
since [**4-1**] cxr, suggestive of chf. Glucoses on floor elevated at
250-350. Vanco was started on floor [**4-2**] for concern for
pneumonia (given o2 requirement increase) as well as G+ coverage
L vats.
Past Medical History:
1. pulmonary nodules - BAL [**1-16**] which grew out [**Name (NI) 8974**] (unclear if
ever got treated) ss/p recent lung biopsy
2. hepatitis C genotype 1: s/p monotherapy
3. hepatitis B cirrhosis - gII/III esophageal varices, a small
gastric varix and portal gastropathy.
4. diabetes
5. hypertension
6. hypothyroidism
7. history of positive PPD.
Social History:
Lifetime nonsmoker, works in construction. He lives alone,
reportedly at the [**Company 3596**]. He was a previous heavy alcohol user,
but quit about 20 years ago and he notes exposure to asbestos.
Family History:
Mother who picked up some sort respiratory condition after
traveling to [**State 15946**] and his father has question of esophageal
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - BP 125/63, P 65, RR 20, 96%6L face mask
Gen - older than stated age, mild tachypnea, mental status
abnormal - responsive to commands but intermittently. Requires
arm/sternal rubbing intermittently to elicit response. Knew in
[**Hospital 86**] hospital, [**2179**].
HEENT - clear OP, MMM, no jaundice appreciated
NECK - supple, no LAD, no JVD
CV - distant, RRR, no murmurs, rubs or [**Last Name (un) 549**]
LUNGS - decreased effort, decreased BS throughout
ABD - soft, mildly distended, +fluid wave. +spiders
EXT - 1+ edema to knees. 2+ DP pulses BL, +dependant edema
SKIN - VATS incision with mild erythema around edges, slightly
warm, drainage from sites.
NEURO: oreiented to hospital and person and month.
CN 2-12 grossly intact but difficult to assess.
Pertinent Results:
ADMISSION LABS:
[**2179-3-26**] 02:45PM BLOOD WBC-4.9 RBC-3.86* Hgb-10.9* Hct-32.6*
MCV-84 MCH-28.2 MCHC-33.5 RDW-16.1* Plt Ct-132*
[**2179-3-26**] 02:45PM BLOOD Neuts-78.0* Lymphs-12.8* Monos-7.1
Eos-2.0 Baso-0.1
[**2179-3-26**] 02:45PM BLOOD PT-16.9* PTT-35.2* INR(PT)-1.5*
[**2179-3-26**] 02:45PM BLOOD Glucose-275* UreaN-11 Creat-0.8 Na-133
K-5.0 Cl-97 HCO3-28 AnGap-13
[**2179-3-26**] 02:45PM BLOOD ALT-11 AST-36 CK(CPK)-23* AlkPhos-123*
TotBili-1.9*
[**2179-3-26**] 02:45PM BLOOD Lipase-23
[**2179-3-26**] 02:45PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-416*
[**2179-3-26**] 02:45PM BLOOD TotProt-7.4 Calcium-8.0* Phos-3.2 Mg-1.6
[**2179-3-26**] 05:20PM BLOOD Ammonia-42
[**2179-3-30**] 04:15AM BLOOD TSH-0.15*
[**2179-3-30**] 04:15AM BLOOD T3-45* Free T4-1.2
[**2179-4-27**] 07:36PM BLOOD Cortsol-28.6*
[**2179-3-30**] 12:29PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:160
[**2179-3-30**] 04:15AM BLOOD RheuFac-3
IMAGING:
[**2179-3-26**] HEAD CT:
This study is limited by motion artifact, despite repeat
acquisition. There is no evidence of acute intracranial
hemorrhage, shift of normally midline structures, or
hydrocephalus. [**Doctor Last Name **]-white matter differentiation is grossly
preserved. Hypodensity in the periventricular white matter of
both cerebral hemispheres consistent with moderate chronic
microvascular infarction. There is complete opacification of
the right frontal and right ethmoid sinuses. The remaining
visualized paranasal sinuses and mastoid air cells appear
normally aerated. IMPRESSION: 1. No evidence of intracranial
hemorrhage. 2. Sinus disease, as described.
[**2179-3-26**] CXR:
Increased opacity of the left lower lung, at least in part due
to
increased loculated pleural fluid. Difficult to exclude
superimposed
consolidation. Increased pulmonary vascular engorgement,
suggesting
contribution of volume overload, but assessment of
cardiovascular status is also limited due to low lung volumes.
[**2179-3-26**] ABD US:
1. Cirrhotic-appearing liver with small-to-moderate amount of
ascites. Patent portal vein.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Splenomegaly
[**2179-3-28**] TTE:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a small to moderate sized circumferential pericardial
effusion most prominent along the inferolateral wall of the left
ventricle and around the right atrium with minimal effusion
anterior to the left and right ventricles. There are no
echocardiographic signs of tamponade. Compared with the prior
study (images reviewed) of [**2178-12-15**], the pericardial effusion
is new.
[**2179-4-5**] TTE:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade. Compared with the
prior study (images reviewed) of [**2179-3-28**], the effusion is now
small.
[**2179-4-11**] RENAL US:
1. No evidence of hydronephrosis.
2. Marked splenomegaly and ascites.
[**2179-4-11**] PERITONEAL FLUID: NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
END STAGE LIVER DISEASE
Mr. [**Known lastname **] [**Known lastname 39505**] has cirrhosis and a history of HCV and HBV.
Unfortunately this hospital course was complicated by hepatic
encephalopathy, hepatorenal syndrome and spontaneous bacterial
peritonitis. He was initially admitted on [**2179-3-26**] after a VATS
on [**2179-3-19**] for evaluation of pulmonary nodules and SOB; he
presented with fatigue and malaise and was admitted to the floor
for presumptive SBP and pneumonia. He had three transfers from
the floor to the MICU throughout his hospitalization. The first
was on 2//08 for worsening mental status and renal failure. The
second ICU adission was on 2//08 for hypoxemic respiratory
failure requiring intubation. The third admission was on
[**2179-4-27**] for worsening mental status and renal failure.
In terms of management of his ESLD, he was maintained on
lactulose, rifaximin,
ASCITES/SBP
MENTAL STATUS/CONFUSION
RENAL FAILURE
55yoM with history of cirrhosis, HCV, HBV, s/p VATS [**2179-3-19**] for
w/u of pulmonary nodules and SOB, presented with fatigue and
malaise, admitted to floor for presumptive SBP and pneumonia,
transferred to MICU for worsening mental status and renal
failure, called out to floor with subsequent readmission to MICU
for hypoxemic respiratory failure and intubation.
.
# confusion - ddx throughout hospital course included infection
(pneumonia, cellulitis of L VATs, SBP without diagnostic
paracentesis), hepatic encephalopathy, toxic metabolic
encephalopathy, medication effect with decreased clearance of
methadone, renal failure with uremia, hypercarbia. Patient was
initially treated with ceftriaxone for presumptive SBP and
pneumonia, finishing 8-d course. Upon retransfer to MICU on
hospital day#8, initiated on vancomycin and cefepime for concern
for hospital acquired pneumonia, but subsequently discontinued
after 2-day course due to negative sputums and improved chest
xray. Patient was continued on liberal lactulose and rifaxim
regimen throughout his course, with moderate improvement.
Patient methadone was held throughout his course. Patient did
show improvement intermittently with narcan (1 dose) and
improvement with hypercarbia while on cpap or intubation.
.
# Cardiovascular - Initially on floor, showed no hemodynamic
compromise, but upon first transfer to MICU, showed periods of
hypotension, with SBPs to mid-80s, which improved with fluid
resuscitation. A bedside echocardiogram was performed on
[**Hospital **] transfer to MICU for concern for tamponade, given
worsened cardiomegaly upon from [**11-16**] through [**3-19**], with
moderate pericardial effusion on [**2179-3-19**] ct scan. Tamponade
physiology was not identified, but given worsened pericardial
effusion, pericardiocentesis thought indicated in mid-term, as
may be underlying issue with hypoxemia and renal failure.
Initial work-up initiated with tsh, rf, [**Doctor First Name **]. Upon retransfer to
MICU after fluid resuscitation on floor for renal failure,
patient showed signs of pulmonary edema and subsequently
diuresed.
.
# ARF - Patient had recurrent bouts of acute renal failure
throughout his course, with significant urine output compromise.
Due to concern for hepatorenal syndrome initially, was started
on octreoteide and midodrine, which, in addition to IVF,
improved urine output and renal failure. But with worsening
cardiovascular status and pulmonary edema, pt showed acute renal
failure episodes with diuresis. Renal consult followed patient
throughout his course. Patient did not receive any route of
hemodialysis.
.
# Cirrhosis - Patient had history of grade II/III varices and
his nadolol was held intermittently throughout his course due to
his cardiovascular status. Patient had worsening abdmonial
fluid collection and subsequently had an abdominal paracentesis
on [**4-5**]?. As above, patient was continued on lactulose and
rifaximin. Liver consult followed patient throughout his
course. To be evaluated for liver transplant as outpatient.
.
# Respiratory failure - as above, initially concern for
pneumonia on CXR with increasing pulmonary edema. Was treated
with ceftriaxone for 8 days (for SBP), then was on 2-day course
of vanco and cefepime, then discontinued. Sputum cultures
remained negative throughout his course. Was subsequently
intubated on retransfer to MICU [**4-2**] for hypoxemic respiratory
failure thought secondary to pulmonary edema, but had persistent
hypercarbia on ABGs, with transient improvement in mental status
when pCO2 lower with assitance from ventilation.
.
# Hx substance abuse - pt's methadone held throughout his
course.
.
# fEN - patient intermittently had nasogastric tube in place
with tube feedings, but intermittently was able to maintain
mental status to take medications on his own.
.
# CODE - FULL code.
.
# [**Name (NI) **] - HCP is Brother [**Name (NI) **] [**Telephone/Fax (3) 39506**]
ADDENDUM:
The patient was taken to the OR [**2179-4-29**] for exploratory
laparotomy and lysis of adhesions for possible SBO.
Post-operatively, the patient never fully recovered. Ventilator
settings remained high. He self-extubated on POD2 and was
re-intubated that day for respiratory failure. POD7-9 he became
hypotensive requiring vasopressor support. He was not
responding off of all sedation. On POD9, he precipitously
decompensated with sharp increase in vasopressor requirement,
development of UGI bleeding. It was determined at this time
after discussion with the surgical attending, the intensive care
attending, the hepatology attending, and the family that the
situation was unsalvageable. After family members made their
last visit, the patient was removed from vasopressor support and
expired shortly thereafter.
Medications on Admission:
Lasix 40 daily
insulin
Synthroid 150 daily
lisinopril 5 daily
Ativan 1 mg PRN
methadone 68 mg daily
nadolol 40 daily
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
Primary DIagnoses:
Cirrhosis
Diabetes
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"572.3",
"070.32",
"560.81",
"571.2",
"349.82",
"584.9",
"572.4",
"423.9",
"070.54",
"518.81",
"567.23",
"486",
"780.01",
"995.92",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.72",
"39.95",
"54.59",
"33.24",
"96.6",
"54.91",
"99.15",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13434, 13440
|
7480, 13239
|
310, 383
|
13522, 13531
|
3563, 3563
|
13583, 13589
|
2601, 2742
|
13406, 13411
|
13461, 13501
|
13265, 13383
|
13555, 13560
|
2782, 3544
|
247, 272
|
411, 1999
|
4525, 7457
|
3579, 4516
|
2021, 2369
|
2385, 2585
|
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