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23,978
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17151
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Discharge summary
|
report
|
Admission Date: [**2170-9-6**] Discharge Date: [**2170-9-8**]
Date of Birth: [**2117-10-26**] Sex: M
Service: MEDICINE
Allergies:
Integrilin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Here for elective cath of L iliac artery for poss stenting.
Major Surgical or Invasive Procedure:
Catheterization of L iliac from R side.
History of Present Illness:
: Pt is a 52 yo male with history of diabetes, HTN, depression,
anxiety disorder,CAD s/p MI in [**2160**] PTCA [**2161**] to RPL, cypher
stenting RCA [**2168**] (repeat cath in [**7-/2168**] with no flow limiting
disease), and PVD complaining of worsening LLE pain. Reported
that he could only walk [**1-28**] block without severe pain. He was
seen in Dr.[**Name (NI) 5452**] office found to have ABI of 0.5 on the left
with blunted waveforms and was cheduled for LE angiography. On
arrival to the hospital he was found to be hypotensive to the
60s but was asymptomatic. It was decided to proceed with the
procedure and he was given 5 liters of NS during the procedure
with BPs in high 70's to 90's but asymptomatic. Cath showed 100%
occlusion of L external iliacStress Echo on [**9-3**] showed EF 50 %
which is unchanged from previous. Of note patient was seen in
the ED on [**9-2**] with chest pain at which time he had a CTA chest
was negative and troponins were flat. He said that the chest
pain lasted only a few seconds, was sharp and was in center to
left chest. Denied SOB, N/V or diaphoresis at this time. It was
also noticed that his HCT on [**9-2**] was 46.2 and on admission 36.3.
He was transferred to the CCU as he was hypotensive and had
decreased HCT.
Denies melana, BRBPR, hematemesis, hemoptysis, recent illness,
CP on exertion, SOB, change in bowel habits. Has had some
decreased po intake as he has not been thirsty but has had good
UOP. Currently has no symptoms.
Past Medical History:
1. Coronary artery disease, status post MI in [**2160**], status
post stent in [**2168-5-26**] to the right coronary artery.
[**2168-8-16**] cardiac catheterization: LM and Cx free of disease. LAD
with an 80% ostial stenosis of the D1. RCA with diffuse disease
of the proximal and mid segment with a maximal stenosis of 50%.
The distal RCA stent was widely patent. FFR of mid RCA was 0.88.
[**2169-3-1**] echo: EF 50%, trivial MR, 1+ TR
[**2170-4-18**] Cardiolite stress test: Negative for ischemia.
.
2. Hypertension.
3. Anxiety disorder.
4. PVD with claudication.
5. Major Depressive disorder.
6. Diabetes.
7. Appendectomy
8. Asthma
Social History:
Social History: Has history of smokingPatient is separated and
lives with his 12 year- old son and his mother. [**Name (NI) **] currently
does not work. He was born in [**Country 5881**] and grew up in South
[**Country 480**]. He came to the US in [**2153**].
Family History:
Family History: (+ ) FHx CAD: Mother had MI at the age of 81.
His
60 year-old brother has "problems with his heart".
Physical Exam:
Vitals: BP 98/70 HR 79 R 15 O2 sats 95% RA
General: middle aged male lying in bed in NAD
HEENT: MMM, no JVD, no LAD
CV:nl S1 S2, 2/6 systolic murmur heard best at the apex
Pulm: CTA anteriorly
Abd: Normal BS, soft, NT/ND
Guaiac: negative
Ext: warm, 1+ DP pulse on right, no palpable DP pulse on left,
no edema
Groin: cath site C/D/I with
Neuro: AAox 3, 5/5 strength in upper and lower extremities,
senastion to light touch intact
Labs: see end of note
EKG: NSR, Rate 75, normal intervals, Q wave in III, no st
changes, poor R wave progression
.
Pertinent Results:
[**2170-9-6**] 10:01PM GLUCOSE-128* UREA N-16 CREAT-0.9 SODIUM-144
POTASSIUM-4.0 CHLORIDE-114* TOTAL CO2-21* ANION GAP-13
[**2170-9-6**] 10:01PM CK(CPK)-47 TOT BILI-0.2
[**2170-9-6**] 10:01PM CK-MB-NotDone cTropnT-<0.01
[**2170-9-6**] 10:01PM CALCIUM-9.0 PHOSPHATE-2.6*# MAGNESIUM-1.7
IRON-56
[**2170-9-6**] 10:01PM calTIBC-268 HAPTOGLOB-229* FERRITIN-171
TRF-206
[**2170-9-6**] 10:01PM OSMOLAL-302
[**2170-9-6**] 10:01PM WBC-5.7 RBC-3.99* HGB-13.5* HCT-37.3* MCV-93
MCH-33.9* MCHC-36.3* RDW-15.8*
[**2170-9-6**] 10:01PM NEUTS-55.4 LYMPHS-37.2 MONOS-6.4 EOS-0.9
BASOS-0.2
[**2170-9-6**] 10:01PM MACROCYT-1+
[**2170-9-6**] 10:01PM PLT COUNT-148*
[**2170-9-6**] 10:01PM PT-12.9 PTT-34.1 INR(PT)-1.1
[**2170-9-6**] 03:05PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-113* TOTAL CO2-19* ANION GAP-11
[**2170-9-6**] 03:05PM ALT(SGPT)-17 AST(SGOT)-13 CK(CPK)-36* ALK
PHOS-34* AMYLASE-60
[**2170-9-6**] 03:05PM ALBUMIN-3.1*
[**2170-9-6**] 03:05PM PLT COUNT-137*
[**2170-9-6**] 03:05PM WBC-7.4 RBC-3.83* HGB-12.6*# HCT-36.3* MCV-95
MCH-32.9* MCHC-34.7 RDW-15.9*
[**2170-9-6**] 03:05PM PT-13.6* PTT-36.8* INR(PT)-1.2
[**2170-9-7**] 05:47AM BLOOD Cortsol-6.6
[**2170-9-6**] 10:01PM BLOOD Osmolal-302
[**2170-9-6**] 10:01PM BLOOD calTIBC-268 Hapto-229* Ferritn-171
TRF-206
[**2170-9-7**] 05:47AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-9-6**] 10:01PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-9-7**] 05:47AM BLOOD CK(CPK)-47
[**2170-9-6**] 10:01PM BLOOD CK(CPK)-47 TotBili-0.2
[**2170-9-6**] 03:05PM BLOOD ALT-17 AST-13 CK(CPK)-36* AlkPhos-34*
Amylase-60
.
.
Cath [**9-6**]:
COMMENTS:
1. Access was obtained via the right CFA in a retrograde
fashion.
2. Resting hemodynamics showed normal central aortic pressures.
3. The abdominal aorta had minimal disease.
4. Right lower extremity: patent CIA/EIA as well as the
proximal SFA
and profunda artery.
5. Left lower extremity: the CIA was patent. The EIA had a long
occlusion into the CFA, which reconstituted via collaterals. The
proximal SFA and profunda were patent.
6. Unsuccessful PTA of the left EIA (see PTA comments).
FINAL DIAGNOSIS:
1. Occluded left EIA.
.
.
CXR on admit:IMPRESSION: No evidence of acute cardiopulmonary
process.
Brief Hospital Course:
BRIEF OVERVIEW:
52 yo male with h/o diabetes, HTN, depression, anxiety
disorder,CAD s/p MI in [**2160**] PTCA [**2161**] to RPL, cypher stenting
RCA [**2168**] (repeat cath in [**7-/2168**] with no flow limiting disease),
and PVD complaining of worsening LLE pain. Pt was admitted for
cath for possible stenting of the L iliac artery. He was found
to have a SBP in the 60's on presentation to the cath [**Year (4 digits) **]. The
catheterization was conducted, and the L iliac was totally
occluded. No intervention was performed. S/p LE cath he was
tx'd to the CCU for monitoring. His BP returned to the low
100's and he was tx'd to the floor. He was stable overnight on
the floor and was restarted on a small dose of his home BB and
discharged in good condition.
.
HOSPITAL COURSE BY SYSTEM:
1. Hypotension: The pt was hypotensive in the cath [**Year (4 digits) **]
presenting from home. It was thought that this was most likely
[**2-28**] dehydration as patient said he has been taking decreased PO
and had been NPO after MN for the procedure. However, after
vigorous hydration in the [**Month/Day (2) **] with 5L of saline, he remained
hypotensive. Blood cultures, U/A, urine culture were negative.
Cortisol in AM was 6.6, which is not diagnostic, so a cortisol
stim test was conducted, which revealed a normal response. HCT
remained stable. Iron studies and hemolysis labs revealed no
abnormalities. CE's remained flat. In the CCU, all
antihypertensives were held. Seroquel was also held as it has
been implicated in orthostatic hypotension. No definitive
determination of the cause of the hypotension was revealed, but
the BP was stable and was tx'd to the floor overnight. His BP
remained stable and his metoprolol was restarted at 12.5 [**Hospital1 **], a
much lower dose. It was thought that he was likely dehydrated
when he presented, as well as having taken all of his BP meds
just prior to presentation. F/U was arranged for close
monitoring of his BP and the pt was discharged in good
condition.
.
2. PVD - The pt was brought in for cath of the L iliac via the R
iliac. He was tx'd to the CCU s/p cath with total occlusion of
L ext iliac, no intervention. The pt was continued on ASA,
plavix. At the time of this hospitalization, there was no plan
for OR.
.
3. DM: Hypoglycemics were held post-cath to prevent
hypoglycemia and/or lactic acidosis. The pt was continued on a
RISS and fingersticks were followed.
.
4. Psych: There were no issues at this hospitalization.
Seroquel was held initially and restarted after the first night
in the hospital. He tolerated his home dose well from a BP
point of view. Of note, the pt was noted to have a bilateral
UE/LE tremor throughout his body. This was thought to represent
an EPS. It has been constant and unchanged for years per the
pt.
.
5. Seizure disorder: Anti-epileptics were continued and there
were no issues at this hospitalization.
.
6.Anemia: There was a significant acute decrease in HCT after
the cath [**Last Name (LF) **], [**First Name3 (LF) **] recheck and get hemolysis labs and iron
studies. There were no obvious sites of acute blood loss, and
the patient was guaiac negative. He did not require any
transfusions. It was later thought that this drop in HCT
represented a significant dilutional anemia due to the 5L of
fluid the pt received in the cath [**First Name3 (LF) **].
.
7. Ppx: The patient received mucomyst after his procedure for
kidney protection.
9. Codae status: The patient remained full code during the
course of this hospitalization.
Medications on Admission:
Metformin 500mg [**Hospital1 **]
Glipizide 10mg [**Hospital1 **].
Actos 30mg daily.
Aspirin 325mg daily.
Cardizem CD 240mg daily.
Plavix 75mg daily.
Zestril 10mg daily.
Lorazepam 1mg tid.
Metoprolol 100mg [**Hospital1 **].
Isosorbide 20mg [**Hospital1 **].
Pletal 100mg [**Hospital1 **].
Depakote 1000mg qAM, 1500mg qPM.
Niaspan 1000mg daily.
Folic acid 1mg [**Hospital1 **].
Crestor 10mg daily.
Seroquel 200mg qHS.
Oxycodone 5mg qid.
Zonegran 200mg daily.
Advair diskus 1 puff [**Hospital1 **].
Albuterol 1 puff tid.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO QAM (once a day (in
the morning)).
4. Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig:
Three (3) Tablet, Delayed Release (E.C.) PO QPM (once a day (in
the evening)).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Rosuvastatin Calcium 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Quetiapine Fumarate 200 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
13. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day.
18. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO twice a day. Capsule, Sustained
Release(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
L Internal Iliac Occlusion
DM
Bipolar
Discharge Condition:
Good
Discharge Instructions:
Your blood pressure was low, likely because you were dehydrated.
Your blood pressure medications may be too high, as well. We
have reduced the number and amount of BP medications at this
hospitalization.
.
You should call Dr. [**Last Name (STitle) **] early next week for an appointment.
([**Telephone/Fax (1) 5455**]
.
You should call Dr. [**First Name (STitle) **] for an appointment, as well.
[**Telephone/Fax (1) 11144**]
They will need to measure your blood pressure and check your
basic labs.
.
Be sure to drink plenty of fluids.
.
If you develop lightheadedness, lose consciousness, have chest
pain or shortness of breath, please seek medical attention
immediately.
Followup Instructions:
Dr. [**Name (NI) **] - pt to call for appt.
Dr. [**Name (NI) **] - pt to call for appt.
Completed by:[**2170-9-11**]
|
[
"276.5",
"414.00",
"296.7",
"447.1",
"250.00",
"780.39",
"458.29",
"V45.82",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
11631, 11637
|
5810, 6583
|
330, 371
|
11731, 11737
|
3543, 5672
|
12460, 12579
|
2859, 2962
|
9936, 11608
|
11658, 11710
|
9393, 9913
|
5689, 5787
|
11761, 12437
|
6610, 9367
|
2977, 3524
|
231, 292
|
400, 1886
|
1909, 2549
|
2581, 2827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,900
| 175,958
|
41977
|
Discharge summary
|
report
|
Admission Date: [**2129-10-6**] Discharge Date: [**2129-10-11**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Enteroscopy with [**Hospital1 **]-CAP electrocaudery of AVMs [**2129-10-7**]
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE
87 year-old man with prior GI bleeds from jejunal AVMs in past,
CAD and CHF with EF of 30% s/p ICD and PPM for complete heart
block who presents from OSH with GI bleed.
He was in his usual state of health on until this AM when he
awoke from sleep with acute shortness of breath and sharp chest
pain radiating across chest. Was pleuritic in nature. No fevers,
chills, or cough. Pt was unclear if this was "heart burn" or
cardiac related and tried omeprazole however did not have any
relief. Then tried sublingual nitroglycerin x 1 which relief
however pain then returned. Pt then tried omeprazole again
without relief and then called EMS for further assistance. EMS
gave patient nebulizer treatment which per patient provided good
relief.
At outside hospital ED, patient was noted to have a hct of 25
down. Patient was then transferred to [**Hospital1 18**] for further
evaluation. Of note, per patient, he has had several GI bleeds
and has chronic anemia from GI loss requiring several blood
transfusions. Has long standing history dating back to 2 years
ago. Patient was last admitted at OSH from [**9-26**] to [**9-30**] during
which time an enteroscopy was completed revealing stable AVMs.
However he required 3 units of pRBCs. Per report, if patietn
were to bleed, "spiral enteroscopy" was to be completed.
Additionally, patient was also seen in ED on [**10-2**] for severe
right nare epistaxis. Nasal packing was completed by ENT and
patient was sent home. Since epistaxis, patient has had repeated
episodes of melena however per patient, he has black stools
regularly [**1-26**] iron supplementation. He denies any bright red
blood. No dizziness/LH.
At [**Hospital1 18**] ED, initial VS were 97.3 60 114/61 22 91% 4L. Patient
initially had chest pain and SOB and was given 4mg of morphine.
Several attempts at PIVs failed requiring RIJ placement. Hct was
24 and patient was transfused 1 unit of pRBCs. GI was consulted
in ED. Trop was also elevated to 0.25 however there were no EKG
changes. Cards was also consulted who did not feel this required
any acute intervention. He had one episode of hypotension to 80s
while positioning during CVL placement which prompted ICU
admission. He remained hemodynamically stable in the ICU.
On floor, he appeared well and had no complaints. He did endorse
his usual congestion.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Coronary artery disease s/p MI x 3
- Systolic heart failure with EF of 30%
- Diabetes mellitus, type II
- Jejunal AVMs
- Chronic kidney disease
- Hypertension
- Hyperlipidemia
Social History:
- Tobacco: 55ppd, quit 5 years ago
- Alcohol: occ
- Illicits: denies
Family History:
Mother with ovarian CA, father with renal CA.
Physical Exam:
Vitals: T: 96.0 BP: 126/49 P: 70 R: 22 O2: 93%1L
General: well appearing NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds on left with crackles
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, +2
pitting edema to mid shins
Pertinent Results:
[**9-30**] (from outside hospital):
WBC 6.0, Hct 33, Plt 138
Na 136, K 4.4, Cl 104, HCO2 32, BUN 45, Cr 1.5, Ca 8.7
From [**Hospital1 18**]:
[**2129-10-6**] 08:48PM CK(CPK)-70
[**2129-10-6**] 08:48PM CK-MB-7 cTropnT-0.22*
[**2129-10-6**] 08:48PM IRON-65
[**2129-10-6**] 08:48PM calTIBC-256* FERRITIN-194 TRF-197*
[**2129-10-6**] 08:48PM HCT-26.3*
[**2129-10-6**] 02:25PM PT-13.2 PTT-27.7 INR(PT)-1.1
[**2129-10-6**] 02:05PM GLUCOSE-141* UREA N-44* CREAT-1.7* SODIUM-139
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16
[**2129-10-6**] 02:05PM estGFR-Using this
[**2129-10-6**] 02:05PM CK-MB-8 cTropnT-0.25*
[**2129-10-6**] 01:45PM WBC-8.6 RBC-2.45* HGB-8.3* HCT-24.8* MCV-101*
MCH-33.7* MCHC-33.3 RDW-19.8*
[**2129-10-6**] 01:45PM NEUTS-86* BANDS-0 LYMPHS-9* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2129-10-6**] 01:45PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-OCCASIONAL
[**2129-10-6**] 01:45PM PLT SMR-NORMAL PLT COUNT-160
ENTEROSCOPY [**2129-10-7**]:
- Clotted blood on a background of dry oropharynx was noted. No
active bleeding
- Diffuse friability, erythema and nodularity of the mucosa with
contact bleeding were noted in the antrum and stomach body. Cold
forceps biopsies were performed for histology
- At least 20 small AVMs were noted extending from D1 to distal
Jejunum. Treated successfully with [**Hospital1 **]-CAP Electrocautery.
- Otherwise normal Enteroscopy to distal Jejunum
PATHOLOGY:
Stomach, antrum, biopsy [**2129-10-7**]:
1. Chronic inactive gastritis with intestinal metaplasia.
2. H. pylori immunostain is negative with adequate controls.
Brief Hospital Course:
87 year-old man with history of CAD, systolic HF (EF 30%), DM,
recurrent GI bleeds presenting with chest pain, SOB and drop in
HCT. The patient was taken to enteroscopy and found to have
numerous AVMs. Caudery was used to ablate the AVMs that were
seen. HCT was monitored post-procedure and HCT was
downtrending, but very slowly. It is very probable that the
patient has other AVMs that were not visualized and may still be
oozing blood. He had no frank blood in stool. His discharge
hematocrit was 29.7. Patient was not short of breath and did
not have angina on the day of discharge.
PROBLEM LIST:
#. Gastrointestinal bleeding from AVMs. The patient received a
total of 4 units of PRBC transfusion (2 on [**10-6**] on [**10-8**],
and 1 on [**10-10**]). He had push enteroscopy with electrocaudery of
AVMs on [**2129-10-7**].
#. Anemia secondary to blood loss s/p caudery of AVMs [**2129-10-7**].
#. Chest pain/SOB: with elevated troponin concerning for demand
ischemia v. ongoing new ischemia. EKG unrevealing in setting of
paced rhythm. Could be related new ischemic event versus
ischemia in setting of anema. Cards was consulted in ED who did
not feel he required acute intervention. CP did resolve after
blood transfusion. SOB improved after receiving Lasix. Ranexa
continued to prevent anginal symptoms. Nebulizer meds were
effective in controlling cardiac wheeze.
#. CAD/CHF: EF 30% per report. S/P ICD/PPM placement for primary
prevention. On Ranexa for refractory angina. Lisinopril not
given because of low blood pressure.
#. Epistaxis: Packed right nostril. Packing removed after
several days. Epistaxis did not recur.
#. Hypotension secondary to hypovolemia from hemorrhage.
Resolved after transfusion. Lisinopril held throughout
hospitalization.
#. DM: No A1c on file. Insulin sliding scale given while in
hospital. Glipizide restarted at discharge.
# DVT prophylaxis: pneumoboots
# Code: DNR/DNI (confirmed)
TRANSITIONAL ISSUES:
- Recheck HCT within 5-7 days; transfuse as indicated
- Titrate glipizide dose
- Restart Lisinopril if BP can tolerate
Medications on Admission:
Medications on Transfer:
- Glipizide 5mg [**Hospital1 **]
- Lasix 120mg daily
- Lasix 40mg QHS
- Lipitor 10mg
- Ranexa 500mg [**Hospital1 **]
- Omeprazole 20mg daily
- Sublingual nitroglycerin prn
- Lisinopril 10mg daily (patient states that he does not take
this when his BP is lower)
Discharge Medications:
1. Nebulizer
Provide a nebulizer machine for delivering nebulized
medications. Indication: reactive airway disease
2. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) unit dose Inhalation every four (4)
hours as needed for shortness of breath or wheezing.
Disp:*30 units* Refills:*0*
3. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
4. furosemide 40 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
5. furosemide 40 mg Tablet Sig: Two (2) Tablet PO every evening.
6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes as needed for chest pain: if you
still have chest pain after 3 doses, seek immediate medical
attention.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
- Arterio-venous malformations in jejunum
- Anemia, chronic gastrointestinal blood loss
- Coronary artery disease
- Systolic heart failure
- Diabetes mellitus, type II
- Chronic kidney disease
- Cardiac wheezing
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 transferred to the [**Hospital1 18**] for management of your
gastrointestinal bleeding that is caused by AVM (arterio-venous
malformation). You underwent a procedure called Enteroscopy and
multiple AVMs were treated with caudery.
After the procedure you were monitored for rebleeding. Your
hematocrit did slowly trickle downward, but you did not
demonstrate any visible blood in your stools. Your discharge
hematocrit level is 29.7.
MEDICATION INSTRUCTIONS:
1. DuoNeb one unit dose nebulized every 4 hours as needed for
shortness of breath or wheezing.
2. STOP Lisinopril 10 mg daily until you see your regular
doctor. This was not given because your blood pressure was lower
during the hospitalization.
3. REDUCE DOSE Glipizide 2.5 mg twice daily for blood sugar
control. If your sugars are consistently higher than 150mg,
then you can go back to your previous dose of 5 mg twice daily.
4. Continue all other medications unchanged.
HEART FAILURE INSTRUCTIONS:
- Weigh yourself every morning. If you have greater than 3 pound
weight gain, call your doctor.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Street Address(2) **], STE#6, [**Location (un) 91155**],[**Numeric Identifier 33731**]
Phone: [**Telephone/Fax (1) 91156**]
Appointment: Monday [**2129-10-17**] 1:45pm
Name: [**Doctor First Name **],MAMDOUH M.
Address: [**Male First Name (un) 71692**] UNIT 2A, [**Location (un) **],[**Numeric Identifier 58635**]
Phone: [**Telephone/Fax (1) 48385**]
Appointment: Tuesday [**2129-10-18**] 2:45pm
|
[
"280.0",
"535.10",
"458.9",
"786.07",
"414.8",
"796.3",
"784.7",
"537.89",
"250.00",
"276.52",
"537.82",
"V45.02",
"428.22",
"428.0",
"414.01",
"585.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.16",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
9057, 9118
|
5599, 6193
|
263, 341
|
9373, 9373
|
3886, 5576
|
10650, 11226
|
3312, 3359
|
8023, 9034
|
9139, 9352
|
7713, 7713
|
9555, 10000
|
3374, 3867
|
7567, 7687
|
2765, 3009
|
213, 225
|
369, 2746
|
6207, 7546
|
10025, 10627
|
9388, 9531
|
7738, 8000
|
3031, 3210
|
3226, 3296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,564
| 151,705
|
24057
|
Discharge summary
|
report
|
Admission Date: [**2128-3-18**] Discharge Date: [**2128-3-24**]
Date of Birth: [**2082-11-9**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 61190**] is a 45-year-old
gentleman who presented to the emergency room approximately 1
month prior with complaints of chest pain occurring off and
on for several months. He was stabilized. He ruled out for a
myocardial infarction. He had a Cardiolite stress test which
showed inferior reversible ischemia. He eventually had a
cardiac catheterization with the following results; a 70% LAD
lesion, a 70% diagonal 1 lesion, an 80% circumflex lesion, a
60% OM lesion, an 80% RCA lesion, a 70% PDA lesion, an
ejection fraction of 61%.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Non-insulin-dependent diabetes mellitus.
4. History of prior smoking.
5. Obesity.
PAST SURGICAL HISTORY: Includes ventral incisional hernia
repair, open cholecystectomy, and partial colectomy for
diverticulitis.
MEDICATIONS PRIOR TO ADMISSION: Aspirin 325 mg p.o. once a
day, Lipitor 10 mg p.o. once a day, Toprol XL 100 mg p.o.
once daily, glyburide 2.5 mg p.o. once a day, sublingual
nitroglycerin p.r.n.; and the patient was unsure but thought
he was on Protonix (dose unknown).
HABITS: The patient quit smoking 1 month ago and had a 1
pack per day x a 15-year history. He had only rare use of
alcohol.
PHYSICAL EXAMINATION ON ADMISSION: He was 6 feet 0 inches
tall, 275 pounds. In no apparent distress. His exam was
unremarkable. The lungs were clear bilaterally without any
rales or rhonchi. The heart was regular in rate and rhythm
with S1 and S2 tones. No murmurs, rubs, or gallops. His
abdomen was soft, nontender, and nondistended with positive
bowel sounds. No rebound or guarding. He had healed abdominal
incisions. His extremities were warm and well perfused with
2+ bilaterally femoral and radial pulses and 1+ bilateral DP
and PT pulses. He had spider veins with some superficial
varicosities on his bilateral lower extremities, but no
obvious large varicosities. He was alert and oriented x 3
with a nonfocal neurologic exam. He had no carotid bruits.
PREOPERATIVE LABORATORY DATA: White count of 9.7, hematocrit
of 39.7, platelet count of 230,000. PT of 12.8, PTT of 26.1,
INR of 1.0. Urinalysis was negative. Sodium of 138, K of 4.1,
chloride of 100, bicarbonate of 27, BUN of 13, creatinine of
0.7, with a blood sugar of 120. ALT of 39, AST of 26,
alkaline phosphatase of 72, total bilirubin of 0.5. Total
protein of 7.5. Albumin of 4.6. Globulin of 2.9. HbA1C of
8.7%.
RADIOLOGIC STUDIES: Preoperative chest x-ray showed no acute
cardiopulmonary process.
Preoperative EKG showed a sinus rhythm at 81 with no acute
ischemic events.
HOSPITAL COURSE: The patient was referred to Dr. [**Last Name (STitle) **] for
coronary artery bypass grafting. The patient was admitted to
the hospital on [**2128-3-18**] and underwent coronary artery
bypass grafting x 3 by Dr. [**Last Name (STitle) **] with a LIMA to the LAD, a
vein graft to the PLV, and a vein graft to the OM. He was
transferred to the cardiothoracic ICU in stable condition.
On postoperative day 1, the patient had been extubated
overnight. He was started on some epinephrine for support.
Briefly, he remained on a Neo-Synephrine drip at 2 and an
epinephrine drip at 0.02. A repeat chest x-ray was done for a
hazy picture of his left lung, and diuresis was begun.
On postoperative day 2, the patient was hemodynamically
stable. Epinephrine was off. Neo-Synephrine was weaned down
to 0.7 mcg/kg/min. He continued his Lasix diuresis and
finished his perioperatively Keflex. His mediastinal chest
tubes were removed. His pleural tube remained in place.
On the 17th the patient was transferred out to floor and
switched over to p.o. Percocet for pain management. He began
ambulating with the nurses and physical therapist. He was
transfused 2 units of packed red blood cells. His hematocrit
rose to 28. He had an episode of sinus tachycardia of
approximately 118 with a stable blood pressure of 113/60. On
postoperative day 3, he started low-dose Lopressor 12.5 twice
a day. His Foley was discontinued, and he was transferred out
to [**Hospital Ward Name 121**] Two.
On postoperative day 4, he was in a sinus rhythm. He also
began his aspirin therapy and was started back on his oral
diabetic medication. His exam was unremarkable. He had a
small amount of necrotic material at his chest tube sites.
Two sites were open approximately 1 cm x 1 cm deep. His
pacing wires remained in place. He had developed a red rash
on his back and on his leg just behind the saphenous harvest
site, on the calf, and his abdomen, and upper thigh. His
pacing wires were discontinued later in the day. His chest
tube sites received wet-to-dry dressing changes, and he was
given topical treatment for his rash to his leg and back. He
was doing very well with the nurses and physical therapist
and did a level 4. He was seen by dermatology, and their
evaluation and recommendations were appreciated for
evaluation of his rash. He continued with Sarna lotion and
was given Atarax p.r.n. as well as triamcinolone ointment
b.i.d.
On postoperative day 5, he refused his blood draw in the
morning. He was in sinus tachycardia at 117. He had decreased
breath sounds at the bases. He complained of some right hand
weakness, but his ulnar and radial nerves were intact. Upon
exam, he had full range of motion with 4+ strength. His chest
tube sites continued to have dressing changes with a scant
amount of serosanguineous drainage. He was tachycardic
slightly with his ambulation, and his heart rate slowed down
when he began to rest. His Lopressor was increased to 75 p.o.
b.i.d., and he continued with his aspirin therapy.
On postoperative day 6, the date of discharge, the patient
continued to be somewhat tachycardic. His medications were
changed Toprol XL. He continued to be treated for his rash.
His tachycardia was discussed with Dr. [**Last Name (STitle) **], and he was
discharged on his home dose of Toprol XL. He continued with
the steroid cream, and dermatology's recommendations were
relayed to the patient. He was followed up by Dr. [**First Name4 (NamePattern1) 402**]
[**Last Name (NamePattern1) **] from dermatology prior to his discharge.
DISCHARGE STATUS: The patient was discharged to home in
stable condition on [**2128-3-24**].
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 3.
2. Hypertension.
3. Hypercholesterolemia.
4. Non-insulin-dependent diabetes mellitus.
5. History of prior smoking.
6. Obesity.
MEDICATIONS ON DISCHARGE:
1. Enteric coated aspirin 81 mg p.o. once daily.
2. Colace 100 mg p.o. twice daily (x 1 month).
3. Lasix 20 mg p.o. twice daily (x 7 days).
4. Percocet 5/325 1 to 2 tablets p.o. q.4-6h. p.r.n. (for
pain).
5. Glyburide 2.5 mg p.o. twice daily.
6. Protonix 40 mg p.o. once daily.
7. Hydroxyzine hydrochloride 25-mg tablets 1 to 2 tablets
p.o. q.6h. p.r.n. (for itching).
8. Toprol XL 100 mg p.o. once daily.
9. Lipitor 10 mg p.o. once daily.
10. Potassium cholesterol 20 mEq p.o. twice daily (for 7
days).
11. Sarna anti-itch 0.5% lotion 1 application topically
t.i.d. p.r.n. (for itching).
12. Clobetasol propionate 0.05% lotion 1 application
topically b.i.d. (x 2 weeks).
DISCHARGE INSTRUCTIONS: The patient was instructed to follow
up with Dr. [**Last Name (STitle) **] in the office for his postoperative
surgical visit in 3 to 4 weeks; to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 28678**] (his cardiologist) in 1 to 2 tablets; and to follow up
with Dr. [**Last Name (STitle) 3617**] in 1 to 2 (his primary care physician). He was
also instructed to call Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **] in the [**Hospital 2652**]
Clinic if his rash worsened, and the number was given to the
patient ([**Telephone/Fax (1) 26578**]).
DISCHARGE DISPOSITION: The patient was discharged to home
with VNA services on [**2128-3-24**].
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2128-4-21**] 14:39:14
T: [**2128-4-23**] 09:45:32
Job#: [**Job Number 61191**]
|
[
"401.9",
"411.1",
"278.01",
"250.00",
"E930.8",
"693.0",
"272.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7987, 8061
|
6423, 6604
|
6630, 7334
|
2769, 6402
|
7359, 7963
|
894, 1002
|
1035, 1421
|
165, 719
|
1436, 2751
|
741, 870
|
8086, 8331
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,204
| 106,313
|
9779
|
Discharge summary
|
report
|
Admission Date: [**2117-8-21**] Discharge Date: [**2117-9-6**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
female with a history of rheumatoid arthritis and
hypertension who was in the process of preoperative
evaluation for a right knee replacement. She was found to
have a urinary tract infection on routine urinalysis on
[**8-11**]. She was therefore started on Bactrim. Since
then the patient reports nonspecific complaints including
increasing fatigue and occasional lightheadedness but denied
any chest pain, shortness of breath, nausea, vomiting, or
diaphoresis. She does report that her urine did become
[**Location (un) 2452**] in color. She experienced a decrease in urine output
times two days prior to admission without any dysuria or
hematuria.
She had laboratories drawn at an outside hospital on
[**8-18**] which demonstrated an increased white blood cell
count with 3 bands. In addition, her creatinine had
increased from a baseline of 1 to 2.7. While she was at her
primary care physician's office getting her laboratories
drawn she continued to complain of lightheadedness and
dizziness.
She was seen in the clinic on [**8-20**] for followup. She
was found to have a blood pressure of 110/64 and physical
examination revealed no bibasilar crackles. Her
electrocardiogram showed no acute changes, and a chest x-ray
was negative by report. Her creatine kinase enzymes and
creatinine were found to be elevated and she was sent to the
Emergency Department to evaluate for acute renal failure and
to rule out for myocardial infarction.
In the Emergency Department, the patient was afebrile with
stable vital signs. Her creatine kinases were cycled, and
her troponin was negative. Her second creatine kinase had an
elevated MB fraction. The patient was questioned again about
chest pain, angina, shortness of breath, nausea, vomiting,
diaphoresis; and she denied all. She was noted at that time
to have a maculopapular rash.
In the Emergency Department, she was given Lasix 20 mg, and
aspirin, as well as 1 unit of packed red blood cells. She
was admitted for further evaluation of her acute renal
failure and to rule out myocardial infarction.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis.
2. Osteoporosis.
3. Hypertension.
4. History of vertigo.
5. No history of coronary artery disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 25 mg p.o. q.d.,
Bactrim 1-week total (to be completed on [**10-20**]),
Fosamax 10 mg p.o. q.d., Plaquenil 200 mg p.o. b.i.d.,
Ultra-Cal, Vioxx 25 mg p.o. b.i.d., meclizine 25 mg p.o. q.d.
p.r.n.
SOCIAL HISTORY: The patient lives alone is very independent.
She walks regularly for exercise. She denies any alcohol or
tobacco use. Her daughter is her contact at phone
number [**Telephone/Fax (1) 32941**].
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were blood
pressure 108/48, heart rate 58, respiratory rate 26, satting
97% on 2 liters oxygen. In general, pleasant, in no acute
distress. HEENT revealed extraocular muscles were intact.
Pupils were equal, round, and reactive to light. The
oropharynx was without lesions. Cardiovascular had a regular
rate and rhythm, a 2/6 systolic ejection murmur at the left
sternal border radiating to the axilla. No jugular venous
distention. Pulmonary revealed crackles appreciated at the
lower one-third on the left and lower one-half on the right.
Abdomen was distended and tympanitic with positive bowel
sounds, soft and nontender. No suprapubic tenderness. No
costovertebral angle tenderness. Foley in place with light
yellow urine. Extremities had 2+ pitting edema to the feet
bilaterally. Skin had maculopapular rash over the chest,
arms, legs; nonpruritic. Neurologically, nonfocal.
LABORATORY DATA ON PRESENTATION: White blood cell count 6.9,
hematocrit 27.5, platelets 154. Sodium 128, potassium 4.2,
chloride 95, bicarbonate 22, BUN 57, creatinine 3.5, glucose
of 111. ALT 15, AST 30, alkaline phosphatase 79, total
bilirubin 0.2. Creatine kinase 263 with an MB fraction
of 21, giving an index of 8%. Urinalysis was nitrite
negative, protein negative, blood negative, 5 red blood
cells, 1 white blood cell, no bacteria, 1 epithelial cell.
RADIOLOGY/IMAGING: Electrocardiogram revealed sinus rhythm
at 56 beats per minute, primary AV block, normal axis, T wave
inversions in leads III and aVF.
HOSPITAL COURSE: The patient is an 84-year-old female with
rheumatoid arthritis with a recent bump in her creatinine and
a new rash following initiation of Bactrim therapy, who was
also presenting with a complaint of malaise, positive
creatine kinases, negative troponin.
Her acute renal failure seemed likely secondary to Bactrim
initiation as well as possibly having been contributed by
dehydration and Vioxx therapy. The role of her positive
creatine kinase enzymes was unclear. She also seemed to be
demonstrating a mild congestive heart failure at the time of
admission.
The patient was ruling in by myocardial enzymes for a
myocardial infarction given her elevated enzymes. She was
therefore started on an aspirin and Lopressor, and her ACE
inhibitor was held. The patient was started on telemetry,
and serial electrocardiograms were followed.
The patient was also suffering nonoliguric acute renal
failure which was thought secondary to Bactrim, possibly
exacerbated by dehydration. Therefore, the Bactrim was held.
A Renal consultation was obtained, who said that the sediment
of the urine did show white cells. They felt like her
symptomatology could be consistent with Bactrim-induced renal
insufficiency. They recommended gentle hydration and
withholding of offending agents with consideration for
steroid treatment should her renal function worsen.
Over the course of the next few days the patient's creatinine
trended downward as the patient diuresed. The patient
remained cardiovascularly stable with creatine kinase enzymes
trending downward as well. She remained chest pain free over
the next few hospital days. Her beta blocker, aspirin, and
nitrates were continued.
However, the patient's pulmonary function continued to worsen
over the next few days. She continued to have low oxygen
saturations and required increasing amounts of oxygen to
maintain her saturation. In addition, she continued to have
rales on examination despite avid diuresis. Therefore, it
was felt that congestive heart failure was an unlikely reason
for the patient's pulmonary problems. A CT scan was obtained
which was not consistent with pulmonary embolus. As her
pulmonary situation continued to deteriorate, it was felt
that she was likely developing acute respiratory distress
syndrome. She was therefore evaluated by the Medical
Intensive Care Unit team for possible transfer.
By [**8-27**], the patient was requiring 10 liters to 15
liters by face mask to maintain oxygen saturations of greater
than 90%. As part of the workup of her hypoxia, an
echocardiogram revealed an ejection fraction of 50% with
moderate pulmonary hypertension, and her CT angiogram while
demonstrating no evidence of pulmonary embolus did
demonstrate increased interstitial infiltrates and areas of
ground-glass opacifications. She was therefore transferred
to the Medical Intensive Care Unit on [**8-27**] for
management of what appeared to be a noncardiogenic
interstitial infiltrate of unclear etiology. She was
continued on levofloxacin 250 mg p.o. q.d. and was started on
Solu-Medrol 60 mg intravenously q.8h.
A bronchoalveolar lavage was planned to evaluate for
infectious etiology of the patient's pulmonary issues as well
as to obtain a tissue sample for evaluation of possible
hypersensitivity pneumonitis. Pending these results, the
patient was continued on empiric antibiotic therapy as well
as empiric Pneumocystis carinii pneumonia coverage and
empiric steroids. Her saturations remained stable on a
nonrebreather over the next few days; however, the patient
did not show any improvement in her pulmonary situation.
Results from the bronchoalveolar lavage did not demonstrate
any etiology of the patient's pulmonary pathology.
Therefore, Thoracic Surgery was contact[**Name (NI) **] for evaluation for
possible open lung biopsy.
Over the course of the next few days the patient's pulmonary
situation continued to worsen. On [**8-30**], it was felt
that the patient was becoming fatigued and could not longer
support her own breathing. Therefore, she was intubated and
sedated to decrease her work of breathing. Levofloxacin and
Solu-Medrol were continued. The patient has remained
hemodynamically stable; however, after initiating sedatives
for placement of the endotracheal tube, her pressure dropped
and responded well to fluid boluses.
On [**9-1**], a central line was placed in preparation for a
lung biopsy. This resulted in a subsequent pneumothorax
which was treated with chest tube placement. The patient
tolerated the procedure without difficulty. A lung biopsy
was performed later that afternoon. Results from the lung
biopsy demonstrated extensive fibrosis with virtually no
pulmonary architecture remaining. Therefore, it was felt
that the patient was suffering end-stage fibrosis possibly
secondary to a usual interstitial pneumonitis versus an acute
interstitial pneumonitis.
Over the course of the next few days the patient's oxygen
requirements and ventilatory support need increased. A
family discussion was held to discuss the patient's poor
prognosis given the extent fibrosis found on lung biopsy. It
was determined that the only possible course of treatment
left was a short course of intensive high-dose steroids. The
patient's family agreed to this treatment, and the patient
was treated with 1 g of Solu-Medrol intravenously q.d. times
three days. Over the course of those three days, the patient
remained hemodynamically stable but with decreasing blood
pressure and had to be started on pressors. She also
required increasing ventilatory support and was kept sedated
as well as paralyzed. Serial blood gases demonstrated
increasing acidosis. In addition, the patient's peak
pressures increased to well over 40.
Therefore, at the end of three days of high-dose steroids it
was felt that the patient's pulmonary situation had not
improved. This was discussed at length with the patient's
family who agreed that in this situation the patient would
not want to be on a ventilator for the rest of her life.
Therefore, the focus of care was switched to comfort measures
only. The patient was provided with adequate sedation and
pain medication.
The patient was found to be unresponsive in the afternoon of
[**2117-9-6**]. Telemetry demonstrated no electrocardiac
activity. The patient was found to have pupils fixed and
dilated with absent reflexes, absent heart sounds, and absent
breath sounds. The patient was pronounced dead at 4:30 p.m.
on [**2117-9-6**]. The patient's family was in attendance
at the time of death. The attending, Dr. [**First Name (STitle) **], and the
patient's covering primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], were
contact[**Name (NI) **]. The patient deferred an autopsy at the time of
death.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2117-10-14**] 17:06
T: [**2117-10-17**] 10:08
JOB#: [**Job Number **]
(cclist)
|
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"599.0",
"580.89",
"584.9",
"E931.0",
"276.1",
"512.1",
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icd9cm
|
[
[
[]
]
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[
"96.6",
"96.72",
"96.04",
"34.04",
"33.23",
"38.93",
"33.28"
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icd9pcs
|
[
[
[]
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2426, 2632
|
4429, 11544
|
110, 2209
|
2231, 2399
|
2649, 4410
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 199,008
|
2557
|
Discharge summary
|
report
|
Admission Date: [**2127-9-17**] Discharge Date: [**2127-9-26**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Meropenem / Penicillins / Carbapenem
Attending:[**First Name3 (LF) 11356**]
Chief Complaint:
Change in mental status.
Major Surgical or Invasive Procedure:
Hemodialysis
Lumbar puncture under fluorscopic guidance
Pulmonary intubation for respiratory distress
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 12731**] is an 83 year old man with a past medical
history of multiple medical problems including ESRD on HD, CAD
s/p MI, GIBs, Afib not on anticoagulation, multiple previous [**Known lastname 12916**]
(MRSA, ESBL E. coli, VSE) s/p fall with C2 fracture [**4-28**]. He
ultimately required admission for surgical repair for
progressive collapse s/p ORIF C2 and posterior instrumentation
C1-C5 and left iliac crest bone graft placement [**7-31**]. He was
recently readmitted ([**Date range (3) 12950**]) for treament of iliac
crest bone graft site infection and discharged to rehab on a six
week course of ertapenem. He presents today from dialysis with
reports of intermittent confusion and drowsiness at HD followed
by a short episode of tremor/shaking with decreased
responsiveness. Patient's family and rehab reportedly endorsed a
history of intermittent confusion over the last few days.
.
In the ED, initial vitals were T 98.6, BP 127/70, HR 80, RR 16,
O2 sat 98% 2L. CT head, CXR, EKG were unrevealing. Labs were
notable for troponin 0.04 (baseline), WBC 6.4, HCT 38 (above
baseline), Cr 1.8, and LFTs within normal limits. His exam
revealed no new focal neurologic deficits and no evidence of
confusion. He received no interventions prior to admission to
the medicine service.
.
On arrival to the floor patient denies any specific health
complaints. He states he fell asleep at HD and was told that he
was shaking so they brought him to the hospital. He states that
they told him his words were garbled. He denies feeling any
confusion now and is oriented x 3. He denies any changes in his
health since his recent discharge from [**Hospital1 18**]. He denies chest
pain, abdominal pain, diarrhea, dark or bloody stools,
constipation, fevers, chills, nausea, vomiting, shortness of
breath, cough, headache, rash, dysuria, pelvic pain. He is
unaware of any recent changes in his medications. He does not
believe he missed any dialysis sessions. He denies any falls or
traumas. He reports his pain is well controlled. He reports the
only recent change has been his decreased sleep. He states that
a few days ago he got a new roommate at rehab who requires alot
of assistance and keep him awake all hours of the night. He
thinks its been three days since he's gotten any significant
sleep.
.
Review of sytems: Per HPI
Past Medical History:
- Multiple episodes blood stream infections thought to be line
related.
- MRSA in [**2125-9-6**] treated for 6 weeks of vanc given possible
clot in fistula. Line removed. TTE negative for vegetation. TEE
not performed.
- ESBL E.coli bacteremia in [**2125-9-26**] thought to be line related.
Line removed. Treated with 2 weeks of gentamicin at HD.
- ESBL E.coli bacteremia in [**2125-11-26**]. Thought to be line
related. s/p total 4-week course of meropenem/ertapenem
([**Date range (1) 12915**]) for likely endovascular infection in setting of R
IJ clot.
- ESBL E.coli x 2 types, E. faecium [**Name (NI) 12916**] unclear source despite
extensive work-up([**2126-6-27**]). s/p 4 weeks of Vancomycin and
Meropenem.
- ESBL E. coli and E. faecium [**Month/Day/Year 12916**] ([**2126-7-28**]) thought to be line
related s/p 2 weeks Vancomycin/Meropenem.
- Pansusceptible Klebsiella pneumoniae [**Month/Day/Year 12916**] thought [**1-21**] 7mm CBD
stone. s/p ERCP and stenting. Due for repeat ERCP.
- Multiple UTIs, including VRE and klebsiella.
- Atrial fibrillation NOT ON COUMADIN CURRENTLY
- h/o GI bleed, diverticulitis
- C. Diff colitis
- CVA [**28**] years ago w/ right-sided weakness; 2nd stroke 5 years
ago
- h/o nephrolithiasis w/ stent and nephrostomy tube (now
removed)
- CAD s/p MI
- sleep apnea not on CPAP
- depression
- PFTs [**2117**] with mild restrictive ventilatory defect
- Anemia with h/o iron deficiency
- ESRD on HD
.
PAST SURGICAL HISTORY:
- [**2127-7-31**] - C2 fracture dislocation with progressive collapse
s/p ORIF C2 and posterior instrumentation C1-C5 and left iliac
crest bone graft placement.
- [**2127-4-28**] - Right popliteal thrombosis s/p popliteal and tibial
embolectomy and R below the knee popliteal and tibial vein path
angioplasty
- L cataract surgery [**11/2117**],R shoulder surgery [**6-19**]
- R ureteral stent placement [**5-25**]
- L knee surgery
- I&D R wrist [**5-25**]
- cataract surgery [**4-26**]
- L AV brachiocephalic fistula [**5-27**]
- LUE fistulogram and balloon angioplasty of central venous
stenosis [**7-27**]
- LUE fistulagram [**10-27**]
- L UE fistulogram/angioplasty [**8-28**]
- R AVF placement [**1-29**]
- CURRENTLY HAS L subclavian HD line
Social History:
Patient recently has been at rehabilitation since fall and C2
fracture.
Lives with wife [**Name (NI) **], daughter lives downstairs, h/o smoking
[**12-21**] PPD for 50 years, quit 20 years ago, occasional beer, none
recently, no drugs.
Family History:
Non-contributory.
Physical Exam:
VS: T 99.9(tc/tmax), BP 106/64, HR 80, RR 16, O2 sat 96% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Speech
difficult to understand.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry mm.
NECK: soft collar in place, appropriate erythema and induration
surrounding posterior neck incision site, no drainage.
CARDIAC: distant heart sounds, RR, normal S1, S2. No m/r/g. No
thrills, lifts.
LUNGS: [**Last Name (un) **] chest, coarse breath sounds in upper airway that
improve with cough, clear to auscultation anteriorly, resp were
mildly labored, no accessory muscle use. No wheezes, scattered
rhonchi.
ABDOMEN: Soft, NTND. + bs
EXTREMITIES: Trace edema bilaterally, no clubbing, no cyanosis.
1+DPP
SKIN: Scattered small ecchymoses, no rashes, no erythema
LINES: L subclavian HD cath with dressing c/d/i. R PICC line
without surrounding erythema, tenderness, or exudate.
Pertinent Results:
ADMISSION LABS:
[**2127-9-17**] 07:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2127-9-17**] 07:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-SM
[**2127-9-17**] 07:10PM URINE RBC-0-2 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2127-9-17**] 05:30PM GLUCOSE-88 UREA N-7 CREAT-1.8*# SODIUM-142
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-31 ANION GAP-14
[**2127-9-17**] 05:30PM ALT(SGPT)-9 AST(SGOT)-25 ALK PHOS-120 TOT
BILI-0.4
[**2127-9-17**] 05:30PM cTropnT-0.04*
[**2127-9-17**] 05:30PM CALCIUM-8.4 PHOSPHATE-2.4* MAGNESIUM-1.9
[**2127-9-17**] 05:30PM WBC-6.1 RBC-4.31* HGB-11.6* HCT-38.4* MCV-89
MCH-27.0 MCHC-30.3* RDW-19.5*
[**2127-9-17**] 05:30PM NEUTS-74.1* LYMPHS-17.1* MONOS-5.0 EOS-3.2
BASOS-0.6
[**2127-9-17**] 05:30PM PLT COUNT-104*#
[**2127-9-17**] 05:30PM PT-13.3 PTT-33.7 INR(PT)-1.1
.
.
[**2127-9-25**] BLOOD WBC-5.2 RBC-4.61 Hgb-12.5* Hct-41.5 MCV-90
MCH-27.0
MCHC-30.1* RDW-19.8* Plt Ct-102*
.
[**2127-9-25**] Glucose-138* UreaN-12 Creat-2.9* Na-137 K-4.0 Cl-100
HCO3-24 AnGap-17
.
[**2127-9-19**] ALT-11 AST-24 LD(LDH)-232 CK(CPK)-38* AlkPhos-119
TotBili-0.4
[**2127-9-25**] Calcium-9.2 Phos-2.1* Mg-2.0
[**2127-9-22**] Type-ART pO2-98 pCO2-46* pH-7.41 calTCO2-30 Base XS-3
.
MICRO:
.
[**2127-9-17**] BLOOD CX: No growth
[**2127-9-19**] BLOOD CX: No growth
[**2127-9-21**] BLOOD CX: pending
.
[**2127-9-17**] URINE CX: No growth
[**2127-9-21**] URINE CX:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
.
[**2127-9-19**] CSF Cryptococcal Antigen: Negative
[**2127-9-19**] CSF Cx: No Growth
.
IMAGING:
.
EKG [**2127-9-17**]: Probable sinus tachycardia with ventricular
premature beat. Consider left atrial abnormality. Modest right
ventricular conduction delay pattern may be incomplete right
bundle-branch block. Left anterior fascicular block. Modest low
amplitude right precordial lead T wave changes are non-specific.
Since the previous tracing of [**2127-6-7**] the rate is faster and
ventricular ectopy is seen.
.
CT head [**2127-9-17**]: FINDINGS: This study is limited by motion,
which persisted on three attempts at acquiring study. Allowing
for this limitation, there is no intracranial hemorrhage, mass
effect, shift of midline structures or edema. [**Doctor Last Name **]-white matter
differentiation is normally preserved. Bifrontal CSF spaces
remained prominent, consistent due to frontotemporal predominant
parenchymal atrophy. Periventricular regions of hypoattenuation
are consistent with chronic small vessel ischemic disease.
.
Allowing for motion degradation of the study, no fractures are
identified. The mastoid air cells are clear. A right maxillary
sinus anterior retention cyst is unchanged. Cervical spine
fusion hardware is incompletely imaged.
.
IMPRESSION: Limited study due to patient motion. No intracranial
hemorrhage or edema.
.
CXR [**2127-9-17**]: FINDINGS: AP upright and lateral views of the
chest were obtained. There is a left subclavian dialysis
catheter in place, which is unchanged from prior exam with tip
in the expected location of the superior vena cava. A stent is
also again noted within the left brachiocephalic vein. There is
no evidence of pneumonia or CHF. The heart remains enlarged.
Mediastinal contour is prominent, though this is stable and
likely due to an unfolded thoracic aorta. Hilar configuration is
stable. Bones appear intact and degenerative changes are again
noted at the left shoulder. Right shoulder prosthesis is noted.
.
IMPRESSION: No acute findings. No evidence of pneumonia.
.
.
[**2127-9-25**] C-spine X-ray:
There has been posterior fixation and fusion from S1 through C5.
There is
straightening of the normal cervical lordosis. Hardware is
intact. There is sclerosis at the fracture site with increased
osseous bridging since the prior study from [**2127-8-18**].
Osteophytes are present at C4-5 and C5-6 with loss of disc
height. Prevertebral soft tissues are quite prominent. A collar
is present. Marked degenerative changes are present.
Brief Hospital Course:
83 year old man with a past medical history of multiple medical
problems including ESRD on HD, multiple previous [**Year (4 digits) 12916**] (MRSA, ESBL
E. coli, VSE) s/p fall with C2 fracture [**4-28**] with progressive
collapse s/p ORIF C2 and posterior instrumentation C1-C5 and
left iliac crest bone graft placement [**7-31**]. He was recently
admitted ([**Date range (3) 12950**]) for treament of iliac crest bone
graft site infection and discharged to rehab on a six week
course of ertapenem. He presented from HD after reported
intermittent confusion and brief episodes of shaking. He
progressed to respiratory distress during fluroscopic guided LP,
which required a transfer to the MICU for respiratory
assistance, then returned to the general medical floors with
resolution of respiratory issues. His shaking/confusion
resolved with switching of his antibiotics.
#. Altered mental status: On admission Mr. [**Known lastname 12731**] was mildly
agitated but communciating and AOx3. Speech was garbled and
patient was aggressive, cursing at doctors and refusing [**Name5 (PTitle) 12951**],
demanding to go home. Additionally, he had shaking episodes
consisting of jerking movements of is arms and legs, especially
when he closed his eyes. He had a workup consisting of CT head,
EKG, troponins, CXR, UA with UCx's and blood cx's, all which
were negative for any new acute pathology. Electrolytes at
baseline were within normal limits and the patient did not have
a fever. Initial thoughts were possible seizures vs medication
(ertapenem/meropenem) side effect, as he recently started taking
ertapenem for his iliac crest infection on [**2127-8-29**]. The
patient's symptoms progressed on HD2, with increased shaking,
agitation and slurred speech. He continued to need 2 L O2
supplementation for 94% sat. By HD3, the patient's clinical
presntation continued to decompensate, with constant
shaking/fasiculations, agitation, slurred incomprehensible
speech. He was also found to have a fixed dilated right pupil.
He remained afebrile, and was able to follow commands.
Neurology and ID were consulted. Patient scheduled for head CT
angio, neck CT for possible pharyngeal abscess, and IR guided LP
for r/o meningitis. He received his LP, but during the
procedure he required 1mg of Ativan for sedation. He acutely
desaturated requiring nonrebreather and suction. Stat CXR
showed worsening consolidation, especially in the patient's
right lung. Patient was disoriented and lethargic. MICU
consulted and patient transferred for management of respiratory
distress from the IR suite. CT angio and neck CT were never
pursued.
.
MICU Course: Patient was intubated for respiratory failure and
airway protection. He remained intubated, but his mental status
started to improve once he was off carbopenem antibiotics and
switched to aztreonam. He had two sessions of hemodialysis while
in the ICU, which he tolerated well while intubated. He was
sussessfully weaned off the ventilator and was mentating well.
He was started on regular diet and then transferred to the
medicine floor.
.
Back on the general medical floor, the patient's mental status
had drastically improved. He was alert and oriented x3 with
pleasant demeanor and very cooperative with staff. He was
tolerating PO diet well. His PICC line became displaced
requring reinsertion on [**2127-9-26**]. The patient did have episodes
of mild sundowning/delirium, but was easily reoriented and never
required sedating medications. His acute mental status changes
were felt to be due to administartion of carbopenems, given his
rapid recovery off these medications.
.
# History of Iliac crest infection: Patient started on a six
week course of Ertepenem on [**2127-8-29**]. Switched to meropenem on
HD2 due to potential for seizure activity/neurologic
complications with ertapenem. No focal erythema or signs of
gross infection seen. Patient remained afebrile. Switched to
Aztreonam while in the ICU. Mental status drastically improved,
and patient continued to be afebrile and without leukocytosis.
Continue Aztreonam as recommended by ID. Follow up with ID
scheduled for [**2127-10-13**].
.
# C2-Dens cervical spine fracture: pt remained in soft cervical
collar throughout duration of hospitalization. He was evaluated
by ortho spine prior to discharge and received cervical spine
xrays. His injury was stable, and ortho spine reccommended he
stay in the soft collar for another 2 months until he is
reevaluated by his orthopedist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Follow up
appointment scheduled for [**2127-10-27**].
.
# Isolated Thrombocytopenia: Platets in the low 100's on
presentation down from baseline 180. Likely a medication effect.
Continued to trend platelets which remained stable. Patient had
no evidence of active bleeding or clotting and no further
inpatient workup was pursued.
.
#. ESRD on HD: Resume prior HD schedule on discharge. Last HD
session [**2127-9-26**].
.
# Depression: No active symptoms currently. Continued
fluoxetine.
.
# CAD s/p MI: No recent anginal symptoms. Continued
atorvastatin. ASA held for potential interventions and history
of GIB. No issues during hospitalization.
.
# COPD: Patient required ipratropium and albuterol inhalers on
prior admissions. Rec'd albuterol/ipratropium nebs PRN for
respiratory congestion.
.
# GERD: Continued daily omeprazole.
.
# CODE: FULL
.
# EMERGENCY CONTACT: [**Name (NI) **] (wife)
[**Telephone/Fax (1) 12520**] (home)
[**Telephone/Fax (1) 12945**] (cell)
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Ertapenem *NF* 500 mg IV DAILY Duration: 6 Weeks Start:
[**2127-8-29**]
.
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed
for constipation.
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. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical PRN as needed for
pain: 12 hours on/ 12 hour off.
Disp:*qs Adhesive Patch, Medicated(s)* Refills:*2*
8. aztreonam in dextrose(iso-osm) 1 gram/50 mL Piggyback Sig:
Five Hundred (500) mg Intravenous every eight (8) hours:
Continue up to and including [**2127-10-10**] (total 6 weeks of
antibiotics. Start date of ertapenem [**2127-8-29**]).
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO once a day.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**5-27**]
hours as needed for pain.
13. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
14. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO three
times a day: Take with meals (3 times a day with meals).
15. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary:
Altered Mental Status
Ischial [**Doctor First Name **] Infection
.
Secondary:
Recent fall with C2 dens fracture with anterior displacement
End stage renal disease requiring hemodialysis
Atrial fibrillation (not on anticoagulation due to GI bleeds)
Diverticulosis
History of stroke with residual right-sided weakness
Coronary artery disease
History of myocardial infarction
Sleep apnea (not on CPAP)
Depression
Anemia with history of iron deficiency
Delirium during hospital admissions
Chronic obstructive pulmonary disease
Restrictive lung disease
Urinary tract infections
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for changes in mental status.
You were at your rehabilitation center when you started becoming
confused, agitated, and having a hard time communciating. You
also began having muscle twitches throughout the day in your leg
and arms. While in the hospital, we checked for a stroke, new
infection, and meningitis, which were all negative. On your
third hospital day, you went to have a procedure known as a
lumbar puncture, and you began having much difficulty breathing,
requiring you to be transfered to the intensive care unit. You
had a machine to help you breath for several days
("intubation"), and recovered. Your mental status changes and
twitching behavior stopped once you stopped taking the
antibiotic ERTAPENEM.
.
Ertapenem is in a class of antibiotics known as CARBOPENEMS
(other example drugs are IMIPENEM and MEROPENEM). For future
reference, you should inform your health care providers about
this reaction you have had to ERTAPENEM so in the event you get
an infection, other antibiotics can be employed if possible.
.
Some of your home medications have changed:
.
STOP TAKING:
ERTAPENEM 500 mg IV daily (an antibiotic)
.
START TAKING:
AZTREONAM 500 mg IV every 8 hours (an antibiotic)
duration- please continue taking up to and including [**2127-10-10**]
.
It has been a pleasure taking care of you [**Known firstname **]!
Followup Instructions:
You have follow up appointments with the following specialties
and physicians. Please note, when you are preparing for
discharge from your rehabilitation facility, please make sure to
schedule a follow up appointment with your primary care
physician [**Name Initial (PRE) 176**] 10 days of discharge.
.
SCHEDULED APPOINTMENTS
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2127-10-13**] at 10:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: ORTHOPEDICS
When: MONDAY [**2127-10-27**] at 12:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: SPINE CENTER
When: MONDAY [**2127-10-27**] at 12:40 PM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"287.5",
"412",
"427.31",
"530.81",
"E930.8",
"280.9",
"414.01",
"496",
"311",
"518.81",
"585.6",
"349.82",
"998.59",
"780.57",
"780.79",
"V45.11",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"96.71",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
19127, 19221
|
10720, 11608
|
322, 426
|
19848, 19848
|
6319, 6319
|
21433, 22699
|
5322, 5341
|
17436, 19104
|
19242, 19827
|
16311, 17413
|
20031, 21410
|
4304, 5052
|
5356, 6300
|
258, 284
|
2811, 2821
|
454, 2793
|
6335, 10697
|
19863, 20007
|
2843, 4281
|
5068, 5306
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,106
| 170,024
|
464
|
Discharge summary
|
report
|
Admission Date: [**2103-11-2**] Discharge Date: [**2103-11-21**]
Date of Birth: [**2058-7-4**] Sex: M
Service: MEDICINE
Allergies:
Bleomycin / Bactrim / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Mechanical ventilation ([**Date range (1) 3927**]/08)
History of Present Illness:
45 yo M with PMH of recurrent Hodgkin's lymphoma (since [**2094**])
s/p auto and allogeneic transplant with recurrence, last
chemotherapy (gemcitabine, navelbine, decadron [**2103-8-30**]), ? of
bleomycin toxicity recently discharged after prolonged
hospitalization with MICU stay, [**Month/Day/Year 1065**] pneumonia, complicated by
renal failure requiring temporary hemodialysis, who presented
with SOB. He states this feels like an asthma exacerbation.
.
Was febrile when seen in clinic to 102, 88% on RA, was noted to
be wheezing and tachycardic. Received 2 gm cefepime,
posiconazole, and solumedrol 20mg IV (takes 10mg prednisone at
baseline). Pt was admitted to BMT. He was continued on cefepime
and vancomycin was added to abx coverage. Pt became
progressively tachypneic and [**Hospital Unit Name 153**] was called to evaluate
patient.
.
On eval, patient was in respiratory distress, using accessory
muscles, tachypneic to the 40s, O2 sat of 90% on 6L with HR in
the 140s. ABG was 7.23/36/59/16. Lactate 1.7. He was transferred
to the [**Hospital Unit Name 153**] for further management. He was intubated on arrival
without complication
ROS: Denies any recent sick contacts. Notes mild pleuritic chest
pain and nausea. No emesis, abdominal pain, diarrhea, brbpr,
urinary complaints.
Past Medical History:
- Hodgkin's lymphoma. Dx [**12/2094**]. S/p multiple courses of chemo
complicated by bleomycin lung toxicity and relapse of disease.
S/p autogeneic stem cell transplant in [**2097**] and allo BMT in
[**2098**]. Undergoing monthly chemo with gemzar, navelbine and
decadron. Complete onc history available in onc admit note.
- Prior severe pneumonias, including likely prior [**Year (4 digits) 1065**]
infection.
- Hypothyroidism
- Asthma
- HBV core Ab positive
- S/p biliary stent
Social History:
On disability. Previously employed as a child psychologist for
[**Location (un) 3915**] public school system. Divorced with a son. Denies
EtOH, tobacco or drug use.
Family History:
Father had "lymphoma of bone," DM, HTN.
Physical Exam:
VS: T 102 BP 79/55 (normotensive prior to intubation) HR 129 97%
on AC 24x450 PEEP 5 FiO2 50%
GEN: NAD, intubated, sedated
HEENT: PERRL, OP clear, MMM, conjunctiva pink, sclera anicteric
NECK: unable to assess JVP
CHEST: CTAB anteriorly and laterally
CV: RRR, normal S1 and S2, no m/r/g
ABD: soft, NT, NT, no masses, or organomegaly
EXT: WWP, LUE significant 3+ edema, other ext no c/c/e
SKIN:
NEURO: PERRL, responds to verbal stimuli but does not follow
commnands
Pertinent Results:
CXR [**11-1**]: 1. Right middle and lower lobe consolidation,
concerning for infection. 2. Slight decrease in small left
pleural effusion and unchanged small right pleural effusion. 3.
Otherwise no significant change when compared to the previous
radiograph.
CXR [**11-9**]: In comparison with the study of [**11-8**], the
endotracheal and
nasogastric tubes have been removed. No change in the appearance
of the
central venous catheter. Patchy opacification in the right mid
lung may be
slightly less. Otherwise, little change.
CT W/O CONTRAST [**11-5**]: 1. No pulmonary edema. Multifocal
pneumonia progressed since [**2103-10-24**] Chest CT, but
improved when chest radiographs are reviewed between [**11-2**]
and [**11-5**]. 2. Right infrahilar mass decreased in size since
[**2103-1-30**], retroperitoneal adenopathy and left adrenal mass
decreased since [**2103-10-5**]. These areas may represent
treatment response of lymphoma. 3. Conventional chest
radiography should be sufficient to chart the course of
intrathoracic findings over the near future.
Brief Hospital Course:
45 yo M with a long history of recurrent Hodgkin's lymphoma s/p
allogeneic transplant with recurrence admitted with fever,
hypoxia and new pulmonary infiltrates, intubated given
respiratory distress.
RESPIRATORY DISTRESS & ICU COURSE: Transferred to MICU the
morning after admission on [**11-3**] and intubated for respiratory
distress. Intubated on presentation to ICU for respiratory
distress. Thought initially to have pneumonia - infiltrates in
RUL and RML. For empiric coverage, posaconazole, vancomycin,
meropenem, and levofloxacin were started per ID recommendations.
BAL was performed. Bronchoscopy demonstrated mild erythema of
airways but no visible obstruction. PCP, [**Name10 (NameIs) 1065**], and viral
cultures were negative. AFB, legionella, galactomann negative.
Cryptococcus antigen, CMV viral load negative. Urine legionella
negative. Sputum, blood, and urine cultures negative.
Beta-glucan was positive, although patient did not improve on
anti-[**Name10 (NameIs) 1065**] alone.
With lack of success with antibiotics, thought then switched to
possibility of fluid overload. Diureses with Lasix with rapid
resolution of symptoms. Vigileo showed CO=9.6, CI=5.8,
indicating hypervolemia with good cardiac function. Pulmonary
[**Last Name (un) **]-occlusive disease was considered to be etiology -
diagnostic work up would include right heart catheterization.
Patient does not want any invasive procedures at this time.
On [**11-5**], he was given IVIG. A TTE demonstrated preserved EF
with new TR gradient. On [**11-6**], vancomycin was stopped per ID
and BMT recs. He was started on furosemide 20mg IV x2 with good
urine output and then on a lasix drip on [**11-7**]. On [**11-8**], he was
extubated. A sputum gram stain showed 1+ GPC in pairs, chains,
and clusters, and vancomycin was restarted. On [**11-9**], he was
extubated and satting well on only on 2L NC. He was called out.
HYPOXIA/PNEUMONIA - Hypoxia was thought to be either from a
[**Month/Year (2) 1065**] infection that returned following the discontinuation of
posaconazol, or from a new bacterial pneumonia. Levoquin
(started [**11-3**]) and Vancomycin were stopped when called out
([**11-9**]). All diagnostic studies were negative except for some
pleural gram stains showing GPC and a positive b-glucan (drawn
before IVIG). Standing PO Lasix was stopped and he continued to
breath well with even I/Os. He was continued on solmeterol,
ipatroprium, prednisone 10 mg daily.
A repeat beta-glucan was elevated (> 500), but as this was drawn
after IVIG, this was of unclear significance.
He had a low-grade temp to 100 and mild hypotension on [**11-14**]
concerning for infection. Vancomycin was added back. ID was
reconsulted. Repeat chest CT showed interval improvement.
Fevers resolved. On [**11-17**], Vancomycin was discontinued and
meropenem was stopped on [**11-18**]. He remained afebrile with
normal pressures off antibiotics. Mild fevers and hypotension
were thought not to be related to infection
** Posaconazole needs to be continued, start date [**2103-11-2**].
# HODGKIN'S LYMPHOMA. Recurrent, last chemotherapy with
Gemcitabine, Navelbine, and Decadron on [**2103-8-30**]. Given acute
respiratory failure and possible infection, further treatment
was delayed. He was continued on acyclovir prophylaxis.
# DECONDITIONING - His multiple hospitalizations and chronic
disease have left him severly deconditioned. He was seen by
physical therapy. Following several days of active physical
therapy he was able to walk with a walker again, but still
unable to stand from sitting. He was discharged to a facility
where he can continue active physical therapy.
# ACUTE RENAL FAILURE. This was felt to be due to contrast.
Falling since last admission when patient was suspected of
having renal failure secondary to contrast. Last admission which
required HD; had renal biopsy at that time with findings
consistent with ATN. Good urine production > 100/hour while on
lasix with stable creatinine. Medications renally dosed. His
creatinine continued to improve following discharge from the
MICU, when his lasix was discontinued. His creatinine on
discharge was 1.6
# HISTORY OF BLEOMYCIN TOXICITY. Goal to limit oxygen
supplementation to less than 2L to prevent further lung
toxicity.
# HYPOTHYROIDISM. He was continued on home levothyroxine.
# HBV core Ab positive. He was continued on lamivudine therapy.
# FEN: Regular diet. Magnesium and Potassium sliding scales
# Prophylaxis: PPI, ambulation, bowel regimen.
Inhaled pentamadine was last given on [**2103-10-18**]
# Access: R portacath
# Contact: HCP, [**Name (NI) 3924**] [**Name (NI) 3925**], father of patient,
[**Telephone/Fax (1) 3926**].
# Code: Full. Discussed with patient [**2103-11-2**].
Medications on Admission:
-Levothyroxine 75 mcg PO Daily
-Salmeterol 50 mcg/Dose Inhalation Q12H
-Lorazepam 0.5- 1mg PO Q6H prn anxiety, insomnia, nausea
-Oxycodone 5-10 mg PO Q6H PRN
-Olanzapine 2.5 mg PO HS prn
-Ipratropium Bromide 1 Inhalation [**Hospital1 **]
-Pantoprazole 40 mg PO Q24H
-Albuterol INH 1-2 Puffs Q4H
-Lamivudine 100 mg PO Daily
-Acyclovir 400 mg PO Q12H
-Methyl Salicylate-Menthol 15-15 % Ointment topical PRN
-Prednisone 10mg PO daily
Discharge Medications:
1. Posaconazole 200 mg/5 mL Suspension Sig: Five (5) ml PO QID
(4 times a day).
2. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q6hrs () as needed for prn wheeze.
3. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety, nausea.
8. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for pain.
9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation QID (4 times a day).
11. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g
PO DAILY (Daily).
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
13. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
14. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) inh
Inhalation every twelve (12) hours.
15. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
HYPOXIC RESPIRATORY FAILURE
PNEUMONIA
HODGKIN'S LYMPHOMA
DECONDITIONING
ACUTE RENAL FAILURE
HYPOTHYROIDISM
Discharge Condition:
T 97.5 HR 102 BP 130/85 RR 18 Sat 95/RA
Well appearing. Severly deconditioned but able to walk with a
walker.
Discharge Instructions:
You were admitted for respiratory distress, which was thought to
be caused by a [**Hospital6 1065**] pneumonia as well as fluid in your lungs.
You were restarted on posaconazole for this and should continue
this medication.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2103-11-26**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 60**]
Date/Time:[**2103-12-6**] 9:00
Completed by:[**2103-11-21**]
|
[
"279.00",
"070.30",
"484.7",
"V42.82",
"276.0",
"E947.8",
"493.90",
"V45.89",
"276.6",
"201.90",
"276.4",
"244.9",
"564.00",
"284.1",
"458.9",
"518.81",
"117.9",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"99.04",
"96.04",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
10704, 10751
|
4033, 8811
|
329, 384
|
10902, 11015
|
2949, 4010
|
11287, 11643
|
2406, 2447
|
9292, 10681
|
10772, 10881
|
8837, 9269
|
11039, 11264
|
2462, 2930
|
269, 291
|
412, 1705
|
1727, 2208
|
2224, 2390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,792
| 152,092
|
37323
|
Discharge summary
|
report
|
Admission Date: [**2168-11-21**] Discharge Date: [**2168-11-29**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2168-11-23**]: Coronary Artery Bypass Graft Surgery x 3 with LIMA -->
LAD, reverse saphenous vein graft to obtuse marginal, posterior
descending artery, tissue aortic valve replacement
History of Present Illness:
89 yo male has had a year of decreasing exercise tolerance. This
has progressed at a faster pace in the past few months and he
has had to stop walking the 9
hole golf course, dancing and walking his several miles daily.
Echo has previously demonstarted critical AS, preserved LV and
mod-severe pulmonary hypertension. He was admitted for right and
left heart catherization which revealed a three-vessel coronary
artery disease. The LMCA had a 60% calcified stenosis. The LAD
was heavily calcified with a long 80% proximal stenosis. The
LCX had an 80% stenosis at its origin. OM1 had an 80% proximal
stenosis. The RCA was 100% occluded in the proximal segment
with left to right and right to right collaterals supplying the
distal vessel. He was scheduled for aortic valve replacement and
coronary artery bypass graft surgery.
Past Medical History:
HTN,hyperlipidemia,NIDDM, skin CA,migraines
Past Surgical History: TURP, nasal skin Ca excision
Social History:
Race:caucasian
Last Dental Exam:letter in office
Lives with:[**Hospital3 **] facility(has rehab attached)
Occupation:retired
Tobacco:no
ETOH:rare
Family History:
Non contributory
Physical Exam:
Pulse:60 Resp:12 O2 sat:98%(RA)
B/P Right:160/56 Left:160/64
General:WDWN in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur3-4/6 SEM at base/apex
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: N Left:N
Pertinent Results:
Pre Bypass: The left atrium is mildly dilated. The left atrium
is elongated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is mild regional
left ventricular systolic dysfunction with inferior and
inferoseptal hypokinesis throughout. The remaining left
ventricular segments contract normally. Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. The descending thoracic
aorta is mildly dilated. There are complex (>4mm) atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-18**]+) central mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
Post Bypass: A tissue prosthesis is seen in the aortic poisition
which appears well seated. No AI. Peak gradient 27, mean 18 mm
Hg with cardiac index 2.2. No perivalvular leaks seen. LVEF and
wall motion unchanged. Aortic contours intact. Remaining exam is
unchanged. All findings discussed with surgeons at the time of
the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2168-11-23**] 14:36
[**2168-11-29**] 05:30AM BLOOD WBC-11.1* RBC-3.41* Hgb-10.5* Hct-31.9*
MCV-94 MCH-30.8 MCHC-32.9 RDW-14.2 Plt Ct-313#
[**2168-11-29**] 05:30AM BLOOD PT-13.0 PTT-27.9 INR(PT)-1.1
[**2168-11-29**] 05:30AM BLOOD Plt Ct-313#
[**2168-11-29**] 05:30AM BLOOD Glucose-120* UreaN-32* Creat-1.4* Na-135
K-4.4 Cl-98 HCO3-28 AnGap-13
[**2168-11-29**] 05:30AM BLOOD Mg-2.6
[**2168-11-21**] 11:30AM BLOOD %HbA1c-6.4*
Brief Hospital Course:
89 yo admitted with progressive shortness of breath for right
and left heart catherization - previous echo has previously
demonstarted critical AS, preserved LV and mod-severe pulmonary
hypertension. The catherization revealed 3 vessel coronary
artery disease and the patient was taken to the operating room
for a coronary artery graft bypass surgery and aortic valve
replacement.
The patient had a coronary artery bypass graft x 3 and an aortic
valve replacement on [**2168-11-23**]. Total bypass time 114 minutes,
cross clamp time 92 minutes. See operative note for full
details. The patient was transferred to the CVICU in stable
condition on Neosynephrine and propofol. The Neosynephrine was
weaned off postoperative day 1 and the patient was extubated
that morning without incident. He was started on beta blockers,
which were titrated up for better blood pressure control. He
became somewhat disoriented with Percocet and all narcotics were
discontinued. Neurology was consulted secondary to confusion
and word finding issues. Head CT was done and was negative for
acute ischemic event. Mental status was back to baseline at the
time of discharge.
Chest tubes and pacing wires were discontinued per cardiac
surgery protocol. He went into a rate controlled atrial
fibrillation on post operative day 3. Amiodarone was given as a
bolus and he was started on po amiodarone as well as continued
on beta blockers. Amio discontinued for a 1.9 sec pause. He was
started on low dose coumadin on post operative day 5 for atrial
fibrillation greater than 48 hours.Cleared for discharge to
rehab on POD #6.
Target INR 2.0-2.5 for A Fib.
Medications on Admission:
Atenolol 100mg [**Hospital1 **]
ASA 325mg [**Hospital1 **]
ISMN 180mg daily
Ranolazine 500mg [**Hospital1 **]
Simvastatin 40mg daily
Androgel 1% 1 packetd daily
Lisinopril 10mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses: 2 mg dose for [**11-29**] ; daily dosing per provider;target
INR 2.0-2.5 for A Fib.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
9. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous QAC and HS.
10. Lopressor 50 mg Tablet Sig: 1 [**12-18**] Tablet PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
river [**Last Name (un) **]
Discharge Diagnosis:
Coronary artery disease, aortic stenosis s/p AVR/CABG
HTN
hyperlipidemia
postop A Fib
NIDDM
migraines
skin CA
prior TURP
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol prn
Discharge Instructions:
***Target INR 2.0-2.5 for A Fib *** next INR draw on [**2168-11-30**]
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] on [**12-30**] at 1:15 PM [**Telephone/Fax (1) 170**]
Primary Care Dr [**Last Name (STitle) 68779**] in [**12-18**] weeks [**Telephone/Fax (1) 83960**]
Cardiologist Dr [**Last Name (STitle) **] in [**12-18**] weeks [**Telephone/Fax (1) 42006**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2168-11-29**]
|
[
"997.1",
"272.4",
"V45.89",
"424.0",
"250.00",
"427.31",
"416.8",
"346.90",
"348.30",
"E878.2",
"440.0",
"285.9",
"V10.83",
"414.01",
"401.9",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"39.61",
"88.56",
"36.15",
"37.23",
"36.12",
"35.21",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7083, 7137
|
4252, 5899
|
290, 480
|
7302, 7397
|
2315, 4229
|
8008, 8474
|
1642, 1661
|
6133, 7060
|
7158, 7281
|
5925, 6110
|
7421, 7985
|
1431, 1462
|
1676, 2296
|
231, 252
|
508, 1341
|
1363, 1408
|
1478, 1626
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,126
| 109,880
|
51404+51405
|
Discharge summary
|
report+report
|
Admission Date: [**2140-6-28**] Discharge Date: [**2140-7-12**]
Date of Birth: [**2083-10-9**] Sex: F
Service: MICU
CHIEF COMPLAINT: Chest pain and shortness of breath.
HISTORY OF THE PRESENT ILLNESS: This is a 56-year-old female
with a history of sickle cell hemoglobin SC disease with a
baseline hematocrit between 17 and 21, also with chronic
renal failure due to FSGS as well as diastolic CHF, as well
as cirrhosis due to iron overload, who was in her usual state
of health until four to five days prior to admission when she
started to feel increased shortness of breath and
intermittent "band-like" nonpleuritic chest pain. According
to the patient's daughter, the chest pain was nonradiating
with a question of nausea that was present. The patient did
received a blood transfusion on the day prior to admission.
On the next day, the day of admission, the shortness of
breath was worse with increased dyspnea on exertion, making
it difficult to walk more than a few steps. The patient had
chest pain again which was relieved by supplemental 02. In
the Emergency Room, she had a temperature of 99.8 with a
blood pressure of 199/101, pulse 97, respirations 24, 100% on
nonrebreather. There, in the Emergency Room, she was given
Lasix and started on a nitroglycerin drip. She was then
transferred to the medical floor where she became acutely
dyspneic and was found to be extremely hypoxic. She had a
blood gas on face mask which was 7.30 with a PC02 of 52 and a
P02 of 99. She continued to get more somnolent and was
intubated for respiratory failure and was admitted to the
MICU.
PAST MEDICAL HISTORY:
1. Sickle cell hemoglobin SC disease for 20 years.
2. Pulmonary hypertension, on home 02, with pulmonary
infarcts present on chest CT.
3. Diastolic CHF with an EF of 70%, 1+ MR, 2+ TR.
4. Chronic renal failure secondary to focal segmental
glomerulosclerosis.
5. Cirrhosis secondary to iron overload with ascites but no
history of spontaneous bacterial peritonitis.
6. Gout.
7. Hypertension.
8. Depression.
9. Reactive airways disease.
10. History of neutropenia due to hydroxyurea.
11. Status post cholecystectomy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Celexa.
2. Norvasc.
3. Folate.
4. Albuterol.
5. Hydralazine 40 q.i.d.
6. Protonix.
7. Sodium bicarbonate 1,300 q.d.
8. Senna.
9. Ursodiol 300 q.d.
10. Hydroxyurea 1,000 mg q.d.
11. Renagel 800 mg p.o. t.i.d.
12. Calcitriol.
13. Morphine sulfate immediate release p.r.n.
14. Ultram p.r.n.
15. Colace 100 b.i.d.
16. Epo 10,000 units three times a week.
17. Tylenol p.r.n.
SOCIAL HISTORY: The patient lives with her granddaughter.
She denied alcohol or smoking.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.8, blood pressure 140/80, pulse 106, respirations 24, 02
saturation 93% on 5 liters. General: This is an elderly
woman who appeared tachypneic and uncomfortable initially and
became somnolent after being sedated and intubated. HEENT:
The pupils were equally round and reactive to light with
muddy sclerae. Her neck veins revealed JVP that was
difficult to assess but appeared elevated. Cardiovascular:
Rapid but regular rate with normal S1, S2, with a grade
III/VI systolic murmur. Lungs: Remarkable for crackles at
the bases one-third of the way up bilaterally. Abdomen:
Large and distended but soft with some shifting dullness.
There was no guarding or rebound. Extremities: There was 2+
pitting edema, 2+ dorsalis pedis pulses bilaterally.
Neurologic: The patient was initially alert and oriented
times three, became increasingly somnolent and at the time of
admission to the MICU was sedated for intubation.
LABORATORY/RADIOLOGIC DATA: A chest x-ray revealed a
cardiomegaly with prominent pulmonary arteries as well as
pulmonary vascular engorgement and pleural effusions. There
was also persistent patchy linear opacities of lung bases and
at the retrocardiac region.
An EKG was done which showed a normal sinus rhythm at a rate
of 91 beats per minute with evidence of LAD, LVH, and poor R
wave progression. T wave inversions were present in leads I,
aVL, V5 and V6, as well as lead II which was unchanged from
[**2140-5-26**].
White count 9.7, hematocrit 18.5, platelets 86,000 with an
MCV of 96, neutrophils 72%, 48% nucleated RBCs. The Chem-7
was 141, potassium 5.1, chloride 108, bicarbonate 23, BUN 62,
creatinine 3.7, glucose 89. CK 24, troponin less than 0.3.
Her coagulation studies were normal. A U/A was significant
for 400 mg/deciliter of protein on the urinalysis.
HOSPITAL COURSE: 1. RESPIRATORY FAILURE: The patient was
presumed to have a diastolic CHF. It was noted that several
admissions ago, the patient had been discontinued off her
standing Lasix with the thought that it may contribute to
more rapid worsening of her renal failure. It seems to be
that the patient has been admitted a few more times since
that time in [**Month (only) 547**] when she presented with increased ascites
and CHF. Her chest x-ray did seem consistent with cardiac
failure and she was placed on Lasix boluses which did not
result in a negative net diuresis. She then was tried on a
Lasix drip with Zaroxolyn as well as Diuril. All of these
treatments also failed to make her negative.
The Heart Failure Service was consulted and she was tried on
a Nisiritide drip for four days. She did urinate roughly
1,500 cc per day on this regimen. However, she did not make
herself net negative even while her medications were
maximally concentrated by the pharmacy. She continued to
progress in worsening of her creatinine clearance.
The Renal Service was consulted to ask the question whether
dialysis should be instituted. After trying to optimize the
blood pressures and trying medical diuresis, it was
determined that the patient's respiratory status depended on
her fluid overload and both teams agree that the patient
should go to hemodialysis for fluid removal. She was kept on
assist control for most of this time on the mechanical
ventilator and improved her respiratory status after
hemodialysis was initiated.
While on the ventilator, she did develop secretions and
fevers and later grew out Acinetobacter and MRSA from the
sputum for which she had been treated with vancomycin and
ceftazidime. There appeared to be a correlating left lower
lobe infiltrate that seemed to be the focus of the pneumonia.
After the third dialysis, the patient did become length of
stay negative and was prepared for weaning and extubation.
She was finally extubated on [**2140-7-10**] and tolerated this well
and immediately did well on 2 liters of nasal cannula. She
will continue to be treated for a total of 14 days of
vancomycin and ceftazidime for the Acinetobacter and MRSA
pneumonia. She has been afebrile for the past 48-72 hours in
the MICU and will be transferred to the medical floor when a
bed becomes available.
2. CONGESTIVE HEART FAILURE: As mentioned, the patient's
respiratory failure was thought to be due mostly to fluid
overload and diastolic dysfunction. She did have episodes of
labile hyper and hypotension; mainly hypertension which was
controlled by intermittent labetalol and nitroglycerin drips.
In addition, she did have a troponin leakage in the face of
renal failure and hypertension. She initially had been
started on Hydralazine and then later was switched to her
usual Norvasc which is what she was taking at home. She did
have some episodes of hypotension and in order to protect
renal perfusion, all hypertensives were discontinued until
the patient went on dialysis.
At this time, the patient is now back on a beta blocker for
heart failure. For the troponin leak, she was put on a
low-dose aspirin, although keeping a vigilant eye on the
thrombocytopenia she presented with, the aspirin use should
be monitored, especially given the fact that the patient had
a normal coronary catheterization in [**2136**] showing normal
coronary arteries.
In addition, the Renal Service will be asked whether starting
an ACE inhibitor would be okay at this time given that she
does have heart failure and might benefit from this regimen.
3. RENAL FAILURE: As mentioned, the patient did progress in
terms of her worsening of creatinine clearance. The
patient's daughter was notified and was aware that the
patient would need renal replacement in the coming one to two
months irrespective of this acute episode. The patient did
start hemodialysis using a temporary femoral Quinton
catheter. This was discontinued on after her third
hemodialysis. She then received a tunnel dialysis catheter
on [**2140-7-11**] without any incident. She is now, I
believe, scheduled to undergo regular renal replacement
therapy to be dictated by the Nephrology Team and her
nephrologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She will be started on Renagel
as she is now tolerating a diet and appears to be
hyperphosphatemic. She should undergo eating a
phosphate-restricted diet where the potassium is strictly in
her diet which seems to be less crucial for her since she has
been on the hypokalemic side. She will also continue her
Calcitriol and Epo administration starting on dialysis.
PhosLo should be instituted at this time given the latest
renal recommendations.
4. SC DISEASE AND THROMBOCYTOPENIA: The patient's
thrombocytopenia was puzzling because on admission the
platelets were between 60s and 70s and the liver synthetic
function appeared to be fine. Given that the patient had a
history of pancytopenia due to hydroxyurea, Hematology was
consulted and they recommended discontinuing the Hydroxyurea
and famotidine which she was receiving in the ICU for
prophylaxis. She did continue to have low-grade
thrombocytopenia that did not resolve immediately after
discontinuation of those medicines. She did receive a
platelet transfusion for initiation of a femoral Quinton
catheter for dialysis and since then her platelets have
remained above 100,000 with no clinical signs of bleeding.
As mentioned, aspirin has been started but she may require
discontinuation of this medicine depending on how the
Hematology/Oncology Team feels about her thrombocytopenia.
5. FEVERS: As mentioned, the patient did spike fevers
throughout her hospital course. She did receive
ultrasound-guided paracentesis of which only 8 cc of
peritoneal fluid was removed and the fluid analysis was not
consistent with spontaneous bacterial peritonitis. It was
also felt that her peripheral IVs could be contributing to
fevers and those were discontinued in place of a new left
subclavian catheter which was inserted without difficulty.
She also did undergo right DVT ultrasound to look for
evidence of clot because right IJ was initially attempted and
this was not successful. The study showed no evidence of
clot.
When she initially spiked fevers, she was started empirically
on vancomycin, ceftazidime, and Flagyl. She has had diarrhea
which has been negative for C. difficile times three. Her
antibiotic regimen was paired down to just vancomycin and
ceftazidime. A CT scan of the belly was done prior to dispo
from the ICU to look for evidence of intra-abdominal abscess
or ongoing infection given that her previous abdominal
ultrasound was negative and that LFTs were mildly elevated at
one point. A right upper quadrant ultrasound showed absence
of gallbladder and normal hepatopetal flow in the portal
vein. She also had no evidence of abscesses in the abdomen.
As mentioned, the fevers were likely due to a
ventilator-associated pneumonia as the Gram's stain on the
sputum did return Acinetobacter and MRSA for which she is now
being treated and has been afebrile.
This dictation including discharge diagnoses and medicines
will be dictated at a later date.
DR [**First Name (STitle) **] CLARY12.AEW
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2140-7-11**] 01:05
T: [**2140-7-11**] 13:46
JOB#: [**Job Number 106567**]
Admission Date: [**2140-6-28**] Discharge Date: [**2140-7-14**]
Date of Birth: [**2083-10-9**] Sex: F
Service: MICU
ADDENDUM:
HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED):
1. SICKLE CELL C DISEASE AND THROMBOCYTOPENIA ISSUES:
Hematology was consulted again regarding the resumption of
the hydroxyurea. At this time, they are recommending that we
continue to hold off on the hydroxyurea. The patient has an
appointment with her hematologist (Dr. [**First Name (STitle) **] Samoan) on
[**2140-7-14**] and will continue to follow up with him in the
clinic regarding this issue.
2. RENAL FAILURE ISSUES: The final Renal recommendations
were to start the patient both on Phos-Lo and Renagel for
phosphate binding.
She had a trough vancomycin level of 15.3 on [**2140-7-12**]
and was dosed with 1 g of vancomycin on [**2140-7-13**]. She
should continue to be therapeutic until at least [**2140-7-17**]. She will undergo midline placement for administration
of her ceftazidime which should still be administered every
day until [**2140-7-17**].
3. ALTERED MENTAL STATUS ISSUES: Briefly, during the
Intensive Care Unit stay before the patient was extubated and
after the patient had begun dialysis, she still remained very
sleepy and difficult to arouse.
Because of the setting of the low platelets, the patient was
sent for a computed tomography scan of the head to insure
that there was no intracranial process accounting for her
decreased level of consciousness. The computed tomography of
the head showed an essentially normal computed tomography
scan; although, there was a question of a hypodensity within
the frontal lobes bilaterally, which was not specific in
pathology but was potentially consistent with a hypoxic
injury.
The patient did wake up fully after extubation and dialysis
and continued to be appropriate. She was conversing
appropriately with her family, and no further studies were
done to follow up on that radiographic finding.
4. NUTRITION ISSUES: The patient did have a Speech and
Swallow evaluation and was found to pass her video swallow
test. Therefore, the patient was placed on a soft diet with
thin liquids.
DISCHARGE DIAGNOSES:
1. End-stage renal disease (on hemodialysis).
2. Diastolic heart failure.
3. Sickle cell/hemoglobin H disease.
4. Pulmonary hypertension (on home oxygen).
5. Cirrhosis secondary to iron overload.
6. Gout.
7. Hypertension.
8. Depression.
9. Reactive airway disease.
10. History of neutropenia secondary to hydroxyurea.
11. Status post cholecystectomy.
12. Ongoing Acetobacter and methicillin-resistant
Staphylococcus aureus pneumonia; under treatment.
13. Recent Klebsiella urinary tract infection in the
Intensive Care Unit.
MEDICATIONS ON DISCHARGE:
1. Ursodiol 300 mg p.o. once per day.
2. Nephrocaps one tablet p.o. once per day.
3. Aspirin 81 mg p.o. once per day.
4. Metoprolol 25 mg p.o. twice per day.
5. Captopril 12.5 mg p.o. three times per day.
6. Phos-Lo 1334 mg p.o. three times per day (with meals).
7. Renagel 800 mg p.o. q.a.c.
8. Vancomycin (dosed by level when trough is less than 15;
to be given by dialysis).
9. Ceftazidime 1 g intravenously q.24h. (to end on [**7-17**]).
10. Home oxygen nasal cannula at 2 to 4 liters per minute.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to have a follow-up appointment with Dr.
[**First Name (STitle) **] Samoan in Hematology/Oncology on [**7-14**].
2. The patient also had an appointment with Dr. [**Last Name (STitle) 106568**] in
the Liver Center on [**2140-7-15**].
DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2140-7-13**] 13:59
T: [**2140-7-13**] 14:13
JOB#: [**Job Number 106569**]
|
[
"571.5",
"276.1",
"584.9",
"482.41",
"287.5",
"428.30",
"427.31",
"518.81",
"282.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"00.13",
"96.04",
"54.91",
"96.72",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14226, 14773
|
14800, 15320
|
4603, 14204
|
2243, 2626
|
15353, 15832
|
155, 1619
|
2753, 4585
|
1641, 2220
|
2643, 2738
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,938
| 179,620
|
38700+58233
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-3-26**] Discharge Date: [**2130-4-4**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2130-3-29**]
1. Coronary artery bypass grafting x5 with the left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery and sequential reverse saphenous vein
graft to the first and second obtuse marginal artery and
a reverse saphenous vein graft to the diagonal artery
which is Y-grafted to the sequential vein graft.
2. Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] Epic
tissue valve.
3. Left atrial appendage resection.
[**2130-3-30**] re-exploration mediastinum
History of Present Illness:
88 year old male admitted to [**Hospital 5279**] Hospital with ACS from
[**Date range (1) 85977**]. Cardiac catheterization at that time revealed
coronary artery and mitral regurgitation. He was transferred to
[**Hospital1 69**] for surgical evaluation.
Past Medical History:
Atrial fibrillation
NSTEMI [**2-15**]
Vertebral fx([**2063**])
Macular degeneration/legally blind
[**Doctor Last Name 9376**] syndrome
Benign Prostatic Hypertrophy
Hypertension
Bilateral knee arthritis
Social History:
Lives alone
Occupation: retired dairy farmer and historic house restorer
Tobacco: remote-quit many years ago, previously smoked 1ppd
ETOH:[**1-11**] glasses of wine/week
Family History:
Brother-afib and heart failure;
father and sister CVA
Physical Exam:
Pulse: 65 Resp: 14 O2 sat:
B/P Right: 130/60
Height: 5'6" Weight:163lbs.
General:
Skin: Dry [x] intact [x] Old well-healed incision across left
abdomen
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur II/VI SEM across
pre-cordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:[x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2130-4-4**] 05:50AM BLOOD WBC-10.5 RBC-3.43* Hgb-10.4* Hct-30.6*
MCV-89 MCH-30.3 MCHC-34.0 RDW-15.4 Plt Ct-162
[**2130-3-26**] 02:43PM BLOOD WBC-6.6 RBC-3.78* Hgb-11.7* Hct-33.9*
MCV-90 MCH-30.8 MCHC-34.4 RDW-13.9 Plt Ct-218
[**2130-4-4**] 05:50AM BLOOD Plt Ct-162
[**2130-4-4**] 05:50AM BLOOD PT-17.8* INR(PT)-1.6*
[**2130-3-26**] 02:43PM BLOOD Plt Ct-218
[**2130-3-26**] 02:43PM BLOOD PT-18.3* PTT-40.7* INR(PT)-1.7*
[**2130-4-4**] 05:50AM BLOOD Glucose-104* UreaN-35* Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-28 AnGap-13
[**2130-3-26**] 02:43PM BLOOD Glucose-91 UreaN-25* Creat-1.2 Na-136
K-4.3 Cl-96 HCO3-29 AnGap-15
[**2130-3-26**] 02:43PM BLOOD ALT-21 AST-20 LD(LDH)-225 CK(CPK)-189
AlkPhos-101 Amylase-62 TotBili-1.3
[**2130-3-26**] 02:43PM BLOOD Lipase-29
[**2130-3-26**] 02:43PM BLOOD cTropnT-0.04*
[**2130-4-4**] 05:50AM BLOOD Mg-2.1
[**2130-4-1**] 02:52AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1
[**2130-3-27**] 02:52AM BLOOD %HbA1c-5.9 eAG-123
Final Report
CHEST RADIOGRAPH
INDICATION: Status post CABG, evaluation for interval change.
COMPARISON: [**2130-4-1**].
FINDINGS: As compared to the previous radiograph, the lung
volumes have
increased. Small bilateral pleural effusions. Moderate
cardiomegaly. No
pulmonary edema. The right venous introduction sheath has been
removed.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: SUN [**2130-4-2**] 4:40 PM
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *8.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Stroke Volume: 72 ml/beat
Left Ventricle - Cardiac Output: 4.99 L/min
Left Ventricle - Cardiac Index: 2.72 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.16 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 10 < 15
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - E Wave deceleration time: 170 ms 140-250 ms
TR Gradient (+ RA = PASP): *39 to 41 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Marked LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Mildly dilated aortic arch.
AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened
aortic valve leaflets. Moderate AS (area 1.0-1.2cm2)
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is markedly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic arch is
mildly dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate aortic stenosis. Preserved regional and
global biventricular systolic function. Moderate to severe
tricuspid regurgitation. Moderate pulmonary hypertension.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2130-3-28**] 16:54
Brief Hospital Course:
Transferred in from [**Doctor First Name 5279**] in NH on [**3-26**] for surgery. He
required IV heparin and NTG pre-operatively. Pre-operative
workup completed and he underwent surgery on [**3-29**] with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
epinephrine, phenylephrine, and propofol drips. Had developed
tamponade and returned to the OR for re-exploration on the
following morning [**3-30**]. Extubated later that afternoon without
complications. Coumadin restarted for Atrial fibrillation.
Transferred to the floor on POD #3 to begin increasing his
activity level. Chest tubes and pacing wires removed per
protocol. Gently diuresed toward his preop weight. He had
urinary retention which required foley reinsertion and being
discharged with foley to rehab on ampicillin until foley
removed. He was ready for discharge to rehab [**4-4**]. He was
discharged to rehab at Pleasantview in [**Location (un) **] [**Location (un) 3844**].
Medications on Admission:
Aspirin 81 daily
Lasix 40 daily
Lisinopril 10 daily
Metoprolol XL 50 daily
Ocuvite
Macrobid 100 daily
Simvastatin 20 daily
Flomax 0.4 QHS
Nitroglycerin-prn
Coumadin
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: due
for INR check [**4-6**] - goal INR 2.0-2.5 dose to be adjusted based
on lab results .
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 5 days: or until foley removed .
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): continue twice a day for 10 days then decrease to once a
day .
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours): twice a day with lasix for 10 days then decrease to once
a day .
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Outpatient Lab Work
please check cr/bun, potassium, magnesium twice a week while on
twice a day lasix
Discharge Disposition:
Extended Care
Facility:
Pleasant View
Discharge Diagnosis:
aortic stenosis
coronary artery disease
PMH:
Afib(coumadin), Vertebral fx([**2063**]), Macular
degeneration/legally blind, [**Doctor Last Name 9376**] syndrome, Benign Prostatic
Hypertrophy, Coronary Artery Disease, Hypertension, Bilat knee
arthritis
Discharge Condition:
Alert and oriented x3 nonfocal
gait ***
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*** Target INR 2.0-2.5 for A Fib; first blood draw at rehab
after transfer please.
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Wed [**4-19**] @ 1:15 PM- please
reschedule from rehab if still receiving high-level care
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 85978**] in 6 weeks
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 55499**] in 4 weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2130-4-4**] Name: [**Known lastname **],[**Known firstname **] E Unit No: [**Numeric Identifier 13634**]
Admission Date: [**2130-3-26**] Discharge Date: [**2130-4-4**]
Date of Birth: [**2041-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 135**]
Addendum:
AS was noted in the initial discharge summary the patient had a
second procedure because he had large volume out from his chest
tubes and hemodynamic compromise on the morning of POD1. The
procedure was mediastinal exploration, at that time the surgical
team found mediastinal bleeding with tamponade.
His discharge diagnosis should include:
Discharge Diagnosis:
aortic stenosis s/p AVR
coronary artery disease s/p CABG and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] atrial appendage
ligation.
Tamponade-now resolved after mediastinal exploration and clot
evacuation
PMH:
Afib(coumadin), Vertebral fx([**2063**]), Macular
degeneration/legally blind, [**Doctor Last Name 13635**] syndrome, Benign Prostatic
Hypertrophy, Coronary Artery Disease, Hypertension, Bilat knee
arthritis
Discharge Disposition:
Extended Care
Facility:
Pleasant View
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2130-4-21**]
|
[
"410.72",
"401.9",
"041.04",
"423.3",
"788.20",
"414.01",
"V58.61",
"369.4",
"427.31",
"599.0",
"458.29",
"277.4",
"424.1",
"397.0",
"413.9",
"600.01",
"998.11",
"362.50",
"715.36",
"E878.2",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"36.15",
"35.21",
"37.36",
"34.03",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12643, 12840
|
7141, 8126
|
278, 879
|
10184, 10268
|
2352, 7118
|
10890, 12167
|
1593, 1649
|
8342, 9825
|
12188, 12620
|
8152, 8319
|
10292, 10867
|
1664, 2333
|
228, 240
|
907, 1163
|
1185, 1389
|
1405, 1577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,358
| 122,578
|
40564+58383
|
Discharge summary
|
report+addendum
|
Admission Date: [**2108-6-1**] Discharge Date: [**2108-6-12**]
Date of Birth: [**2040-8-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Thiazides / Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2108-6-4**]
Insertion of IABP
[**2108-6-5**]
1. Urgent coronary artery bypass grafting x3 on IABP, with left
internal mammary artery, left anterior descending coronary;
reverse saphenous vein single graft from aorta to the first
obtuse marginal coronary artery; reverse saphenous vein single
graft from aorta to the distal right coronary artery.
2. Epiaortic duplex scanning.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
This is a 67 year old female who was recently discharged from
[**Hospital6 3105**] following neurology workup when she
was admitted with transient disorientation. She later returned
to the ED with chest pain described as a dull, heavy weight on
her mid chest radiating to the right as well as both arms
associated with weakness and shortness of breath and
palpitations. Had serial
enzymes where the troponin went up to 0.58. She had an abnormal
stress test and was scheduled for a cardiac cath today. Had been
having chest pain on and off which was relieved after receiving
Nitroglycerin and Morphine. Catheterization revealed 80% left
main lesion and multivessel disease. She was subsequently
transferred to [**Hospital1 18**] for surgical revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Morbid Obesity
Diabetes Mellitus
Chronic Kidney Disease
Peripheral Vascular Disease
s/p right carotid endarterectomy [**2103**]
s/p hernia repair
s/p hysterectomy
s/p tonsillectomy
s/p wrist surgery
Social History:
Denies history of tobacco and ETOH.
Family History:
Denies premature coronary artery disease.
Physical Exam:
ADMISSION EXAM:
BP 122/78 Pulse: 60 Resp: 18 O2 sat: 93% on RA
.
Height: 5ft 2" Weight: 87kg
.
General: Obese female in no acute distress.
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Midline incision, hernia
Extremities: Warm [x], well-perfused [x] Edema +1
Varicosities: +2 None []
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: =2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2108-6-12**] 03:17AM BLOOD WBC-7.1 RBC-3.71* Hgb-9.4* Hct-30.8*
MCV-83 MCH-25.5* MCHC-30.7* RDW-15.7* Plt Ct-279
[**2108-6-11**] 06:34AM BLOOD WBC-7.2 RBC-3.67* Hgb-9.4* Hct-30.8*
MCV-84 MCH-25.5* MCHC-30.4* RDW-15.8* Plt Ct-261
[**2108-6-12**] 03:17AM BLOOD Glucose-123* UreaN-41* Creat-1.6* Na-141
K-4.2 Cl-103 HCO3-31 AnGap-11
[**2108-6-11**] 06:34AM BLOOD Glucose-80 UreaN-42* Creat-1.7* Na-140
K-4.4 Cl-102 HCO3-29 AnGap-13
[**2108-6-10**] 06:06AM BLOOD UreaN-40* Creat-1.8* Na-138 K-4.4 Cl-102
[**2108-6-9**] 09:16AM BLOOD UreaN-39* Creat-2.0* Na-140 K-4.3 Cl-103
[**2108-6-1**] WBC-6.0 RBC-3.58* Hgb-9.0* Hct-29.3* RDW-16.7* Plt
Ct-217
[**2108-6-1**] PT-13.3 PTT-35.6* INR(PT)-1.1
[**2108-6-1**] Glucose-115* UreaN-43* Creat-1.2* Na-139 K-5.1 Cl-110*
HCO3-21*
[**2108-6-1**] Calcium-7.4* Phos-2.3* Mg-2.6
[**2108-6-1**] %HbA1c-6.5* eAG-140*
[**2108-6-1**] CK-MB-9 cTropnT-0.30*
[**2108-6-2**] CK-MB-16* MB Indx-10.3* cTropnT-0.38*
[**2108-6-3**] CK-MB-7 cTropnT-0.56*
[**2108-6-4**] CK-MB-4 cTropnT-0.57*
.
[**2108-6-2**] Echocardiogram: The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 10-15mmHg. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with inferior/infero-lateral hypokinesis. No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
[**2108-6-3**] Head MRI:
1. Punctate foci of slow diffusion in the right centrum
semiovale and two further foci, in the right occipital and left
parietal lobe suggestive of acute infarcts. No large territorial
infarction. 2. Small focus of susceptibility artefact likely
from a prior hemorrhage in the right frontal lobe.
.
[**2108-6-4**] Carotid Ultrasound:
1. Findings are consistent with 60-69% left sided ICA stenosis.
2. No significant right-sided ICA stenosis is identified.
.
[**2108-6-5**] Intraop TEE:
Prebypass: No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. There is
mild regional left ventricular systolic dysfunction with
hypokinesia of the apical and midportions of the inferior and
inferoseptal walls.. Overall left ventricular systolic function
is mildly depressed (LVEF= 45 %). The right ventricular cavity
is mildly dilated with normal free wall contractility. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. Tip of IABP 2 cms below the left subclavian artery.
Post bypass: Patient is A paced and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Trivial mitral regurgiation persists. Aorta is intact post
decannulation.
CXR:
[**2108-6-7**]: No pneumothorax. Increased bibasilar atelecatsis and
small bilateral pleural effusions.
Brief Hospital Course:
Ms. [**Known lastname 88804**] was admitted from an outside hospital with
symptomatic multi-vessel coronary artery disease. Pre-operative
testing began. An intra-aortic balloon pump was placed for
continued chest pain. She was seen by neurology for
pre-operative neurological clearance secondary to
confusion/mental status change and an MRI revealed acute
infarcts. On [**6-5**] she underwent an urgent coronary artery bypass
grafting times three. Please see the operative note for
details. She tolerated this procedure well and was transferred
in critical but stable condition to the surgical intensive care
unit. By the following day she was extubated and the balloon
pump was removed. She was placed on ciprofloxacin for a urinary
tract infection. A rise in her creatinine suggested acute renal
injury so her diuresis was slowed. Her chest tubes and
epicardial wires were removed. She was transferred to the
surgical step down floor.
Respiratory: aggressive pulmonary toilet, nebs, incentive
spirometer her oxygen requirements improved to 97% 1L via NC
Cardiac: postoperative hemodynamically stable, sinus rhythm
80-90's, one brief episode of atrial fibrillation. Beta-blockers
were titrated. Blood pressure 110-140's. Aspirin and statin
continued.
GI: H2 blockers, bowel regimen. tolerated diabetic diet.
Developed diarrhea- C-diff negative.
Renal: Stage 4 chronic kidney disease baseline CRE 1.5-2.1.
gently diuresed with good urine output. Electrolytes replete as
needed
Endocrine: Home dose Glipizide and insulin sliding scale were
titrated to maintain BS < 150.
Pain: Tramadol and acetaminophen with good pain control.
Disposition: She was followed by physical therapy who
recommended rehab. She continue to make steady progress and was
discharged to [**Hospital6 **] Hospital in [**Location (un) 246**]. She will
remain on telemetry in the setting of brief post-op a-fib and
pre-op embolic event.
Medications on Admission:
ASA 325mg daily
Atenolol 50mg daily
FeSO4 325mg PO daily
Hydralazine 25mg PO BID
Simvastatin 20mg PO Qhs
Cardura 2mg PO daily
Theophylline 300mg PO BID
Glypizide 5mg PO BID
Plavix - last dose: 300mg on [**2108-6-1**]
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. theophylline 100 mg Tablet Extended Release 12 hr Sig: Three
(3) Tablet Extended Release 12 hr PO BID (2 times a day).
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin and breast rash.
5. Outpatient Lab Work
CBC, Chem 7 on [**6-18**]
6. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. doxazosin 4 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
13. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
17. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
18. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sliding scale.
19. Telemetry
Patient requires telemetry for recent, pre-op embolic event and
brief episode of post-op a-fib
20. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Hypertension
Hyperlipidemia
Morbid Obesity
Diabetes Mellitus
Chronic Renal Insufficiency
Peripheral and CerebroVascular Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
2+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call 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:
Wound check on [**2108-6-12**] at 11:30am in [**Hospital Ward Name **] [**Hospital Unit Name **] [**First Name8 (NamePattern2) **] [**Location (un) 86**], [**Telephone/Fax (1) 170**]
Surgeon: Dr.[**Last Name (STitle) 914**] on [**2108-6-26**] at 3:00pm [**Hospital Unit Name **] [**Hospital Unit Name **]
[**Last Name (NamePattern1) **], [**Location (un) 86**]
Cards: Please have PCP recommend [**Name Initial (PRE) **] Cardiologist for you
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] in [**3-27**] weeks, [**Telephone/Fax (1) 81482**]
.
**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:[**2108-6-12**] Name: [**Known lastname 14098**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 14099**]
Admission Date: [**2108-6-1**] Discharge Date: [**2108-6-12**]
Date of Birth: [**2040-8-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Thiazides / Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors
Attending:[**First Name3 (LF) 1543**]
Addendum:
The patient was discharged on Toprol XL 150mg daily instead
Lopressor.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. theophylline 100 mg Tablet Extended Release 12 hr Sig: Three
(3) Tablet Extended Release 12 hr PO BID (2 times a day).
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin and breast rash.
5. Outpatient Lab Work
CBC, Chem 7 on [**6-18**]
6. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. doxazosin 4 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
13. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
17. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sliding scale.
18. Telemetry
Patient requires telemetry for recent, pre-op embolic event and
brief episode of post-op a-fib
19. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks.
20. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2108-6-12**]
|
[
"403.90",
"410.71",
"278.01",
"250.00",
"272.4",
"434.11",
"443.9",
"584.9",
"433.30",
"585.9",
"112.3",
"433.10",
"437.9",
"414.01",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"97.44",
"36.12",
"37.61",
"38.93",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
14921, 15153
|
6316, 8246
|
336, 772
|
10609, 10818
|
2648, 6293
|
11742, 13043
|
1882, 1925
|
13066, 14898
|
10424, 10588
|
8272, 8491
|
10842, 11719
|
1940, 2629
|
286, 298
|
800, 1562
|
1584, 1813
|
1829, 1866
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,016
| 110,371
|
45537
|
Discharge summary
|
report
|
Admission Date: [**2155-2-9**] Discharge Date: [**2155-2-18**]
Date of Birth: [**2086-12-2**] Sex: M
Service: MEDICINE
Allergies:
Morphine Sulfate / Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
s/p CABGx3(LIMA->LAD, SVG->Ramus/OM, RCA)/AVR(21mm tissue)
[**2155-2-13**]
History of Present Illness:
68 y/o male with prior cardiac history and multiple risk factors
who presented who acute onset of shortness of breath and chest
pain. Was initially treated in the emergency room and eventually
underwent a cardiac catheterization. Cath revealed three vessel
coronary disease. Echo showed moderate to severe aortic stenosis
and moderate aortic regurgitation. He was then referred for
surgical revascularization and aortic valve replacement.
Past Medical History:
Coronary Artery Disease s/p MI x 2 s/p PTCA of LAD
Hypertension
Diabetes Mellitus
L4-L5 spondylolisthesis
h/o Congestive Heart Failure
s/p right Rotator Cuff Repair
s/p bilateral Ulnar nerve transposition
s/p post. and ant. cervical disk procedures and fusions
s/p iridectomy
s/p right total knee replacement
Physical Exam:
General: WD/WN male in NAD
HEENT: NC/AT, PERRLA, EOMI, OP benign
Neck: Supple, FROM, -lymphadenopathy, Carotid 2+ w/ Bilat.
radiation murmur
Lungs: CTAB -w/r/r
CV: RRR, +S1,S2 with SEM
Abd: Soft, NT/ND, +BS without masses
Ext: - C/C/E pulses 2+ throughout
Neuro: Non-focal, MAE, A&O x 3
Pertinent Results:
[**2155-2-9**] 05:30AM BLOOD WBC-13.4*# RBC-4.27* Hgb-12.5* Hct-37.0*
MCV-87 MCH-29.4 MCHC-33.9 RDW-14.3 Plt Ct-637*#
[**2155-2-15**] 05:00AM BLOOD WBC-11.5* RBC-3.36* Hgb-10.2* Hct-29.1*
MCV-87 MCH-30.4 MCHC-35.1* RDW-15.4 Plt Ct-155
[**2155-2-15**] 05:00AM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.0
[**2155-2-17**] 05:15AM BLOOD Glucose-35* UreaN-12 Creat-0.8 Na-136
K-4.5 Cl-97 HCO3-28 AnGap-16
[**2155-2-10**] 04:33PM BLOOD ALT-11 AST-14 AlkPhos-105 Amylase-61
TotBili-0.4
[**2155-2-17**] 05:15AM BLOOD Mg-2.3
[**2155-2-9**] 05:40AM BLOOD %HbA1c-7.3* [Hgb]-DONE [A1c]-DONE
[**2155-2-14**] 10:11AM BLOOD freeCa-1.12
[**2155-2-9**] 05:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
As mentioned in the HPI, pt was initially seen by cardiac
surgery following his cardiac cath. Patient was eventually
consented for surgery and on [**2155-2-13**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 3 and aortic valve replacement. Please see op note for
surgical details. Patient tolerated the procedure well and was
transferred to the CSRU in stable condition receiving
Neo-Synephrine, Dobutamine, and Levophed drips. Later on op day
sedation was weaned and patient awoke neurologically intact. He
was then weaned from mechanical ventilation and extubated. He
was weaned from all Inotropes/Pressors on post op day one and
was then transferred to the cardiac step-down unit. B Blockers
and Diuretics were initiated and patient was gently diuresed
towards his pre-op weight. Chest tubes and Foley catheter were
removed on post op day two. And epicardial pacing wires were
removed on post op day three. Pt was followed by physical
therapy during his entire post op course for strength and
mobility. Patient had a relatively uncomplicated post op course
and was at level 5 by post op day five. His exam and labs were
stable on post op day five and he was discharged home with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
Glyburide 5mg [**Hospital1 **]
Cimetidine 400mg [**Hospital1 **]
Indural LA 160mg qd
Indural XR 30mg
Advicor 500/20
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO HS (at bedtime).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-8**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Tagamet 400 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease/Aortic regurgitation s/p Coronary Artery
Bypass Graft x 3 and Aortic Valve Replacement
Diabetes Mellitus
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1270**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2155-2-19**]
|
[
"V45.82",
"719.41",
"486",
"424.1",
"416.0",
"272.0",
"412",
"401.9",
"411.1",
"414.01",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.12",
"93.90",
"37.23",
"39.61",
"99.04",
"35.21",
"88.72",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4699, 4756
|
2270, 3553
|
309, 385
|
4941, 4947
|
1507, 2247
|
5180, 5352
|
3719, 4676
|
4777, 4920
|
3579, 3696
|
4971, 5157
|
1200, 1488
|
250, 271
|
413, 853
|
875, 1185
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,081
| 166,252
|
49848
|
Discharge summary
|
report
|
Admission Date: [**2125-2-19**] Discharge Date: [**2125-3-14**]
Date of Birth: [**2052-9-15**] Sex: M
Service: MEDICINE
Allergies:
Sporanox / Ace Inhibitors / Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
altered mental status, acute on chronic renal failure
Major Surgical or Invasive Procedure:
Colonoscopy and esophagogastroduodenoscopy [**2125-3-1**]
Hemodialysis
Right brachial venous PICC placement [**2125-3-5**]
History of Present Illness:
(per admission note [**2125-2-20**] by Dr. [**First Name (STitle) 1022**]
72 yo male with PMH sig for CRI s/p kidney transplant in [**2121**],
CHF (35-40%), CAD s/p CABG, [**Hospital 11491**] transferred from [**Location (un) 620**] ICU
for concern of ARF and change in mental status. Pt recently
discharged from [**Location (un) 620**] on [**1-31**] and [**1-26**] for worsening dyspnea
thought to be secondary to CHF and COPD exacerbation. He sent to
rehab on 40mg IV lasix, 10 day course of levofloxacin, and
prednisone taper. He presented on [**2125-2-16**] with worsening SOB
thought to be secondary to COPD exacerbation and/or CHF
exacerbation. There was also quesiton of LL lobe pneumonia and
was started on Vancomycin/levofloxacin and IV steriods. He was
also diuresed with IV lasix. His respiratory status improved
with these interventions. CXR was consistent with CHF
exacerbation and BNP was >15,000. U/S of the abdomen was
performed that was unremarkable and LENI were negative for DVT.
CE negative x3. His renal function ranged btw 3.5-3.6. The
patient also received 1U pRBC for Hb 8. The patient had
increasing somnolence and given concern of tranplant failure he
was transferred to [**Hospital1 18**].
.
On the floor the patient was unable to give a clear history. He
was oriented x3, but was slow and confused regarding his
symptoms and clinical course. He denied fevers, chills, chest
pain, SOB, or pain.
Past Medical History:
ESRD [**2-12**] FSGS s/p CRT [**4-15**] c/b chronic rejection
CAD s/p 3V CABG [**5-13**] (SVG to OM, SVG to PDA, LIMA to LAD)
Chronic diastolic CHF
Mild MR
COPD
E. coli pelvic abscess
HTN
Hyperlipidemia
Angiodysplasias in stomach, duodenum and colon
VZV c/b PHN
Gout
BCC
Umbilical hernia repair
BPH
Social History:
Retired HMS physiologist. He has been living at rehab since
recent discharge. Quit smoking in [**1-19**]. Former heavy ETOH use,
now rare use.
Family History:
Father had CAD and died of a CVA. Mother died of an unknown
cancer that had metastasized to the liver. One brother has CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM (per admission note [**2125-2-20**] by Dr. [**First Name (STitle) 1022**]:
V/S: T:96.1 BP:160/62 HR:61 RR:10 O2 98% 4L
Gen: NAD/ pt somnolent, slow to respond to questions, difficulty
concentrating, orient x3. Pt stares off into space
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor,
MMM, clear oropharynx, no erythema, no exudates no rhinorrhea/
discharge, no sinus tenderness
NECK: supple, trachea midline, no LAD, no thyromegaly
LUNG: + crackles to mid lung fields
CV: S1&S2, [**First Name (STitle) 8450**], II/VI SEM no G/M
JVD: 5cm
Carotid: no bruit
ABD: Soft/+BS/ NT/ ND/no rebound/ no guarding/ palpable
transplant kidney in RLQ
EXT: No C/C/ +1 lower ext edema, +asterixsis
+2 pulses radial, DP, PT b/l & symetrical
NEURO: AAOx3, although slow to answer questions. poor
concentration
CN II-XII grossly intact and non-focal b/l
5/5 strength in upper and lower ext b/l
Sensation to pain, temp, position intact b/l
poor finger/nose, poor rapid/alternating coordination
deferred gait.
Pertinent Results:
[**2125-2-19**] 5:00 pm BLOOD CULTURE
**FINAL REPORT [**2125-2-25**]**
Blood Culture, Routine (Final [**2125-2-25**]): NO GROWTH.
.
[**2125-2-19**] 5:15 pm URINE Source: Catheter.
**FINAL REPORT [**2125-2-20**]**
URINE CULTURE (Final [**2125-2-20**]): NO GROWTH.
.
[**2125-2-19**] 5:15 pm URINE
**FINAL REPORT [**2125-2-20**]**
Legionella Urinary Antigen (Final [**2125-2-20**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
Cardiology Report ECG Study Date of [**2125-2-19**] 10:49:48 PM
Sinus rhythm. Probable left ventricular hypertrophy with
repolarization
change. Compared to the previous tracing of [**2122-9-8**] no change.
.
[**2125-2-19**] CXR
FINDINGS: In comparison with study of [**2122-9-7**], there is
increasing size of
the cardiac silhouette given the PA rather than AP view.
Increasing pulmonary vascular congestion. Silhouetting of one of
the hemidiaphragms is consistent with lower lung consolidation.
.
[**2125-2-19**] RENAL U/S
Transplant renal kidney in the right lower quadrant measures 9.9
cm, and has unremarkable [**Doctor Last Name 352**]-scale appearance. There is no
hydronephrosis or mass. There is no perinephric fluid
collection.
Color Doppler evaluation of the transplant renal vasculature
shows normal flow and waveforms, with resistive indices ranging
from 0.7 to 0.75 in the
segmental arterial branches. Diastolic flow in the main renal
artery is very slightly diminished, but main renal artery
waveform is otherwise normal, with brisk systolic upstroke. Main
renal vein has normal flow and waveforms.
IMPRESSION: Unremarkable transplant renal ultrasound.
.
[**2125-2-20**] CXR
FINDINGS: As compared to the previous radiograph, the
pre-existing pulmonary edema has markedly increased in severity.
There is now clear evidence of moderate-to-massive
intra-alveolar and interstitial fluid accumulation. The size of
the cardiac silhouette and the absence of pleural effusions is
unchanged. There is no evidence of focal parenchymal opacity
suggestive of pneumonia.
.
[**2125-2-21**] TTE
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
moderate hypokinesis of the septum and mild hypokinesis of the
basal to mid inferior segments. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Borderline dilatation of the left ventricle with
regional LV systolic dysfunction. Diastolic dysfunction. Mild
mitral regurgitation. Mild pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of [**2122-9-10**],
wall motion abnormalities are probably new (prior echo images
were suboptimal). Diastolic dysfunction can now be clearly
determined. The degree of mitral regurgitation has increased
slightly.
.
[**2125-2-21**] CXR FINDINGS: As compared to the previous examination,
the signs suggestive of pulmonary edema have moderately
decreased. They are, however, still present. Unchanged moderate
cardiomegaly. No evidence of right pleural effusion, the left
sinus is not shown on today's image.
.
[**2125-2-23**] CXR
AP PORTABLE CHEST: The heart size is mildly enlarged but stable.
The aorta
is mildly tortuous with calcifications noted of the arch. The
patient is
status post sternotomy. Pulmonary edema has significantly
improved and there is now mild residual interstitial edema.
There is mild subsegmental
atelectasis at the left lung base on this image which does not
fully include the costophrenic sulcus. There is no pneumothorax
or evidence of pneumonia.
IMPRESSION: Significant improvement in pulmonary edema with now
mild residual interstitial edema. Mild subsegmental atelectasis
at the left lung base.
.
[**2125-3-3**] LOWER EXTREMITY DOPPLER U/S
FINDINGS: [**Doctor Last Name **]-scale and color Doppler images of the left and
right common
femoral, superficial femoral, popliteal and peroneal veins were
performed.
There is absence of color flow and non-compressibility of the
left peroneal vein, otherwise, there is normal color flow,
compressibility and augmentation. Left Bakers' cyst is seen.
IMPRESSION: Findings compatible with thrombus in the left
peroneal vein.
.
[**2125-3-6**] TTE
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is top normal/borderline dilated. There is mild regional
systolic dysfunction with hypokinesis of the inferior wall and
likely the inferior septum (image quality suboptimal). Overall
left ventricular systolic function is mildly depressed (LVEF= 40
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**1-12**]+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is indeterminate. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with focal regional systolic dysfunction
consistent with coronary artery disease. Mild to moderate aortic
regurgitation.
Compared with the prior study (images reviewed) of [**2125-2-21**],
the estimated pulmonary artery pressures are now indeterminate.
.
[**2125-3-9**] LOWER EXTREMITY DOPPLER U/S
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of the left
common femoral,
superficial femoral, popliteal and tibial veins were performed.
There is
normal flow, compression and augmentation seen in all of the
vessels including
the two left peroneal vessels. No DVT is identified today. Again
seen is [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 4675**] cyst in the left popliteal fossa.
IMPRESSION: No evidence of deep vein thrombosis in the left leg
with
resolution of the thrombosis recently seen in the left peroneal
pain. Left
[**Hospital Ward Name 4675**] cyst.
.
[**2125-3-9**] RENAL TRANSPLANT U/S
FINDINGS: The renal transplant is identified in the right lower
quadrant and
measures 10.1 cm in length. There is no hydronephrosis and no
perinephric
collections are identified.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained. Abnormal arterial waveforms are identified in the main
renal artery
and in the intraparenchymal renal arteries. There is no
diastolic flow
identified on any of the tracings. This appearance is consistent
with
rejection. Appropriate venous flow is identified in the main
renal vein.
IMPRESSION:
1. Abnormal arterial waveforms in the transplant kidney with no
diastolic
flow identified. This appearance is consistent with rejection.
Normal venous
flow identified in the hilum of the transplant kidney.
2. No hydronephrosis and no perinephric collections identified.
Brief Hospital Course:
#DVT/PE - Lower extremity doppler U/S on [**2125-3-3**] revealed
thrombus in the left peroneal vein. The patient was started on
heparin gtt. Due to concomitant hypoxemia, a presumptive
diagnosis of PE was made. V/Q scan was deferred due to
underlying COPD and a baseline abnormal CXR, and CTA chest was
deferred due to renal insufficiency. Repeat U/S [**3-9**] showed
resolution of DVT. Coumadin was started [**3-9**] after hematocrit
had remained stable (goal INR 2-2.5). He will likely require [**3-16**]
months of therapeutic anticoagulation. Goal INR is at the lower
end of the therapeutic range due to his GI AVM's, prior bleeding
and risk for re-bleeding.
.
#Acute on chronic systolic and diastolic heart failure -
Attributed to a combination of discontinuation of diuretic
medication, alterations in the antihypertensive regimen, and
acute on chronic renal insufficiency. Treated with hemodialysis
and medical diuresis. TTE [**2-21**] revealed LVEF 35-40%, moderate
septal hypokinesis, and mild hypokinesis of the basal to mid
inferior segments. He demonstrated adequate room air oxygenation
prior to discharge. He will be discharged on aspirin,
metoprolol, furosemide, metolazone, and isosorbide mononitrate
for afterload reduction. An ACEi was not prescribed due to
allergy. He was advised to record daily weights and to adhere to
a low sodium diet with 2 L fluid restriction.
.
#Acute on chronic renal insufficiency - Due to intravascular
volume depletion in the setting of CHF exacerbation and
antihypertensive therapy, as evidenced by an extremely low
urinary sodium on admission. Initial renal ultrasound was
unremarkable, but repeat exam on [**3-9**] revealed evidence of
rejection. Serum tacrolimus level was therapeutic. He was
advised to adhere to a low sodium/potassium/phosphorus diet. Per
the Transplant Nephrology team, the initial plan will be twice
weekly HD when he is discharged to the rehabilitation facility.
He has a f/u app't at his primary nephrologist's office in 4
weeks (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10083**]). At that time, he will be seeing the
NP, who will make arrangements for an app't with Dr. [**First Name (STitle) 10083**]
soon after (this was due to scheduling availability).
.
#Acute blood loss anemia - The patient had guaiac positive
stools without overt evidence of bleeding. The patient was
transfused a total 5 U PRBC. He was treated with IV iron and
erythropoetin. Colonoscopy [**2125-3-1**] revealed a proximal ascending
colon AVM which was treated with argon thermal therapy.
Endoscopy on that date showed non-bleeding erosions in the
stomach and proximal jejunum. He will continue on twice daily
PPI. Outpatient capsule endoscopy was recommended. Has been on
IV iron therapy and will need 3 more days (started [**3-10**] for an 8
day course). Please remove his R PICC line after IV iron therapy
is completed.
.
#Toxic encephalopathy - Attributed to effects of medications, as
mental status improved after the discontinuation of prednisone
and oral narcotics. Delirium did not seem to improve following
hemodialysis, making uremic encephalopathy unlikely. Infectious
workup was unremarkable. ABG was not suggestive of profound
hypercarbia or hypoxia. EKG did not reveal evidence of new
ischemia or arrhythmia. Electrolytes, glucose, and LFT's were
within normal limits. Mental status returned to baseline prior
to discharge, as corroborated by the patient's wife.
.
#Status post cadaveric renal transplant - Sirolimus was changed
to tacrolimus at the recommendation of the transplant nephrology
team. Serum tacrolimus level was therapeutic. Continued MMF and
bactrim prophylaxis. The patient will be seen in close follow up
in transplant clinic following discharge.
.
#Post-herpetic neuralgia - Continued fentanyl patch and
nortriptyline. At the recommendation of the chronic pain
service, lyrica was added with subsequent resolution of
symptoms.
.
#Mood disorder - The patient was seen in consultation by
psychiatry who recommended the addition of mirtazapine with a
subsequent improvement in mood and sleep. It was recommended
that the patient consider formal neuropsychological testing in
the future to evaluate for memory or cognitive deficits.
.
#Coronary artery disease - No acute issues. Aspirin,
betablocker, and statin were continued, as above.
.
#Chronic obstructive pulmonary disease - No acute issues.
Continued advair and nebulized bronchodilators as needed.
.
#Hypertension - Blood pressure was well-controlled on a regimen
of metoprolol and isosorbide mononitrate.
.
#Dyslipidemia - Continued simvastatin.
Medications on Admission:
Ferrous Gluconate 325mg [**Hospital1 **]
Lyrica 200mg daily
Restoril 15mg qHS
ASA 81mg daily
Prednisone 5mg daily
Zocor 40mg daily
Florastor 250mg [**Hospital1 **]
calcitriol 0.5 mg qhs
CellCept 500mg [**Hospital1 **]
Hydral 75mg [**Hospital1 **]
Lopressor 50mg daily
Advair [**Hospital1 **]
Albuterol 2 puffs QID
Atrovent 2 sprays QID
Bactrim DS 0.5 tab Daily
Norvasc 10mg daily
Sirolimus 1mg daily
Pamelor 10mg daily
Imdur 30mg daily
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) INH Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours)
as needed for pain: Remove after 12 hours. .
11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for sbp<100.
13. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
14. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
16. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
18. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a
day.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
grams PO DAILY (Daily).
21. Na Ferric Gluc Cplx in Sucrose 12.5 mg/mL Solution Sig: One
(1) Intravenous DAILY (Daily) for 3 days.
22. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
23. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
24. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
25. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
26. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
27. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
28. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) mL
Injection QMOWEFR (Monday -Wednesday-Friday).
29. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
30. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
31. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
32. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary
1) Acute on chronic systolic and diastolic heart failure
2) Acute on chronic renal insufficiency
3) Pulmonary embolus
4) Deep vein thrombosis
5) Acute blood loss anemia
6) Colonic angiodysplasia
7) Toxic encephalopathy
8) Post-herpetic neuralgia
9) Mood disorder
Secondary
1) Status post cadaveric renal transplant
2) Chronic allograft nephropathy
3) Coronary artery disease
4) Chronic obstructive pulmonary disease
5) Hypertension
6) Dyslipidemia
Discharge Condition:
- stable
Discharge Instructions:
You were admitted to the hospital with shortness of breath in
the setting of worsening renal failure and congestive heart
failure. Fluid was removed with hemodialysis and diuretic
medication.
Please record your weight daily and contact your physician if
your weight increases by more than 3 pounds.
Please adhere to a diet containing less 2 grams of sodium, 2
grams of potassium, and 1 gram of phosphorus daily. Please
adhere to a 2 liter daily fluid restriction.
You had a colonoscopy which showed an arteriovenous malformation
(AVM) in the large intestine. This was treated with argon
thermal therapy. Upper endoscopy showed multiple non-bleeding
erosions in the stomach and small intestine. Please call
[**Telephone/Fax (1) 13545**] or [**Telephone/Fax (1) 463**] to schedule an outpatient capsule
endoscopy study at your earliest convenience.
The following medication changes were recommended:
1) Sirolimus was changed to a similar medication tacrolimus 0.5
mg twice daily.
2) Lasix was increased, but at discharge was back at 80 mg twice
daily.
3) Isosorbide mononitrate (Imdur) was increased to 60 mg daily.
4) Amlodipine (Norvasc) was discontinued.
5) Hydralazine was discontinued.
6) Pregabalin (Lyrica) was decreased to 75 mg twice daily.
7) Temazepam (Restoril) was replaced with Mirtazapine (Remeron).
8) Pantoprazole (Protonix) was increased to 40 mg twice daily.
Please call your physician or return to the Emergency Department
if you experience fever, chills, sweats, dizziness,
lightheadedness, chest pain, palpitations, cough, wheezing,
shortness of breath, abdominal pain, vomiting, diarrhea, bloody
or dark stools, or difficulty with urination.
Followup Instructions:
1) Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: Wednesday, [**5-16**] @11AM
Location: [**Street Address(2) **], [**Location (un) 620**]
Phone number: [**Telephone/Fax (1) 4105**]
.
2) MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 104155**], NP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP)
Specialty: Nephrology
Date and time: Wednesday, [**4-11**], @11AM
Location: [**Hospital **] Clinic, One [**Last Name (un) **] Place
Phone number: [**Telephone/Fax (1) 2378**]
.
Please follow up with Dr. [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) **] 2-3 days after your
discharge from [**Hospital1 **] [**Hospital1 **]. The phone number is
[**Telephone/Fax (1) 6163**].
|
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14,873
| 194,786
|
2306
|
Discharge summary
|
report
|
Admission Date: [**2174-5-15**] Discharge Date: [**2174-5-29**]
Date of Birth: [**2108-5-17**] Sex: F
Service: MEDICINE
Allergies:
Dyazide / Prozac / Nsaids / Inderal / Cefazolin
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
MSSA bacteremia
Major Surgical or Invasive Procedure:
EJ placement
Hemodialysis
History of Present Illness:
HPI: 65F w/ MMP including DM2, CAD, CHF, s/p CVA, ESRD s/p
transplant still on HD (MWF) s/p admission for nausea/vomiting
after LUE angioplasty for stenosis in her HD fistula, found to
have WBC 19 with 5% bands. However, 2 subsequent CBCs showed
normal WBC with no bands. Patient without fever or localizing
symptoms, so d/ced home [**5-14**]. Nightfloat was called when blood
cultures grew out GPC in pairs and clusters. Pt was then called
and asked to return to the ED for IV abx admission.
.
In the ED, afebrile. VSS. given 1g of vancomycin. Pt then
developed itching in her R.arm after infusion of vanco. She did
not develop skin rash/hives/wheezing or SOB. She was given a
dose of benedryl.
.
Pt currents states that she feels "jumpy", "sleepy", and that
her stomach is "edgy". However, she denies fevers/chills,
HA/LH/dizziness, URI symptoms, SOB/CP/palp, abd
pain/n/v/d/c/melena/brbpr, dysuria/hematuria, joint pains or
skin rash.
.
Past Medical History:
-ESRD s/p cadaveric renal transplant in [**2168**] back on HD at
[**Last Name (un) **] [**Location (un) **] M-W-F. (continues on prednisone). Post
transplant course c/b c.dif infection, polyoma virus infection
-DM II with retinopathy, neuropathy, neuropathy
-Hyperlipidemia
-Hypertension
-s/p mult CVA's (recently [**2173-8-23**])
-CHF [**12-25**] diastolic function-last echo [**2173**]. mild [**Last Name (un) 6879**]
-CAD s/p cath [**2-26**]-LAD 50% stenosed; 2 vessel CAD
-Pulmonary artery hypertension
-s/p cataract extraction
-PNA treated at [**Hospital3 2568**] in [**11-28**]
-s/p thrombectomy LUE graft
-hyperparathyroidism
-L2 compression fracture
-depression
-anemia
Social History:
Lives with daughter. Retired nurses aid. No tobacco or EtOH use.
Walks with cane for balance. Born in [**Country **]. HD at [**Location (un) **]
[**Location (un) **] M/W/F.
Family History:
Father w/ DM and kidney disease and mother w/ HTN
Physical Exam:
Physical Exam:
Vitals - T98.5, BP 138/42, HR 58, RR 24, sat 100% RA, wt 76.8kg
GENERAL: lying in bed, appears stated age, NAD
SKIN: no rashes, no hives, palpable thrill in L AV fistula
HEENT: NC/AT, PERRLA, EOMI, anicteric
CARDIAC: s1s2 rrr +4/6 systolic murmur loudest in RUSB. no r/g
LUNG: b/l ae no w/c/r
ABDOMEN: +bs, soft, NT, ND
EXT: No c/c/e 2+pulses
NEURO: AAOx2 (did not know date), CN II-XII intact
Pertinent Results:
Blood Culture, Routine (Final [**2174-5-20**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Please contact the Microbiology Laboratory ([**5-/2472**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SULFA X TRIMETH sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R
TRIMETHOPRIM/SULFA---- =>320 R
Anaerobic Bottle Gram Stain (Final [**2174-5-15**]):
REPORTED BY PHONE TO DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12078**] AT 1:30 ON [**2174-5-15**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2174-5-15**] 11:20AM LACTATE-1.4
[**2174-5-15**] 11:15AM GLUCOSE-118* UREA N-52* CREAT-5.9* SODIUM-143
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-31 ANION GAP-18
[**2174-5-15**] 11:15AM WBC-9.5 RBC-4.67 HGB-13.2 HCT-41.8 MCV-89
MCH-28.3 MCHC-31.6 RDW-14.6
[**2174-5-15**] 11:15AM NEUTS-77.8* LYMPHS-13.5* MONOS-5.0 EOS-3.4
BASOS-0.3
[**2174-5-14**] 09:40AM ALT(SGPT)-19 AST(SGOT)-23 CK(CPK)-121 ALK
PHOS-120* AMYLASE-198* TOT BILI-0.4
[**5-13**] - EKG Probable ectopic atrial rhythm. Borderline right axis
deviation with modest right ventricular conduction delay.
Diffuse non-specific T wave flattening. Compared to the previous
tracing of [**2173-12-23**] ectopic atrial rhythm is new.
.
Imaging:
[**5-17**] ECHO - IMPRESSION: No definite evidence of endocarditis in
the setting of structurally thickened valves. Moderate symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Diastolic dysfunction. Mild
resting left ventricular outflow tract obstruction. Mild aortic
stenosis. Moderate aortic regurgitation. Mild mitral
regurgitation.
Compared with the prior report (images unavailable for review)
of [**2173-12-24**], the LVOT gradient has decreased. Aortic
regurgitation has increased.
[**5-19**] CT IMPRESSION: 1. No evidence of intra-abdominal or
intrapelvic source of infection. 2. Cholelithiasis without
evidence of cholecystitis. 3. Sub-4-mm pleural-based pulmonary
nodules in the right lower lobe.
.
[**5-18**] ultrasound right arm - Findings consistent with a
predominantly thrombosed pseudoaneurysm of the mid
graft as above.
.
[**5-23**] - tagged WBC scan - IMPRESSION: No abnormal foci of tracer
uptake.
Brief Hospital Course:
Impression and plan: 65 yo F w/ MMP incld ESRD s/p renal tx. on
HD (MWF), DM, CHF, CAD presents 1 day after discharge after
having been found to have +MSSA blood cultures. Now on
Cefazolin dosed at dialysis and is s/p cefazolin desensitization
in the MICU.
1. Bacteremia
- blood cultures negative since [**2174-5-18**]; requires total of 6
weeks of antibiotics
- Prior antibiotics Vanco [**Date range (1) 12079**], x1 [**5-25**] Nafcillin [**Date range (1) 12080**],
Cefazolin 1g IV with HD (1.5g on Fridays) ([**5-26**]-
- as of [**5-25**]- on Cefazolin so that it can be dosed at dialysis as
outpatient: final ID recs are Cefazolin 1 gram M/W and 1.5 gram
on Frdiay
- tagged WBC scan today without specific foci of uptake
- CT of abdomen with contrast showed no acute or infectious
process.
-TEE not tolerated by patient and will not be further pursued
(would require general anesthesia)so cannot rule out bacterial
endocarditis as potential source therefore will treat for full
course 6 weeks
- pt will not need graft removed as tagged wbc scan does not
show evidence of overwhelming uptake in that region
- history of cefazolin allergy s/p desensitization, had +
swelling over left eye [**5-26**] concerning for reaction , however
swelling has improved and patient has received furthur dosing
today.
- if pt tolerates antibiotic today would consider d/c tomorrow,
will require home visiting nurses services
- also if stable tomorrow, can remove EJ before discharge
2. ESRD: The patient is s/p cadaveric renal transplant in [**2168**]
back on HD.
-on Tacrolimus, Bactrim DS, prednisone, nephrocaps, and
cinacalcet, continue dialysis
.
3. Type 2 Diabetes:
-Pt sometimes hypoglycemic after dialysis.
-pt frequently hypoglycemic during this hospital stay, holding
half of NPH dose
.
4. Chronic Diastolic CHF:
- Currently euvolemic, fluid management as per dialysis,
continue ACEI/BB, on [**Year (4 digits) **], statin, b-blocker
.
5. CAD: Continue on [**Year (4 digits) **], statin, beta-blocker, ACE-I.
6. Hypercholesterolemia: Continue statin.
7. Anemia of Chronic Kidney Disease: H/H is 11/34
-continue epogen during HD and outpt PO iron.
8. Diahrrea: pt with profuse water bowel movements
- stool negative x3 for c. diff, so likely non-infectious, will
reccomend outpatient symptomatic treatment, increasing fiber in
diet etc
.
#FEN-cardiac/DM
#PPX-hep SC, bowel reg
#)PT - consulted, either home with services vs. rehab pending
their eval tomorrow AM
#CODE-full
Medications on Admission:
Medications per recent discharge:
Aspirin 81 mg po qdaily
Atorvastatin 40 mg PO DAILY
Paroxetine HCl 10 mg PO DAILY
Gabapentin 100 mg PO WITH HD
Pantoprazole 40 mg PO Q24H
B Complex-Vitamin C-Folic Acid 1 mg Capsule PO DAILY
Cinacalcet 30 mg PO DAILY
Senna prn
Docusate prn
Trimethoprim-Sulfamethoxazole 160-800 mg PO MWF
Metoprolol Tartrate 25 mg PO BID
Prednisone 1 mg PO TID
Lisinopril 10 mg PO DAILY
Tacrolimus 0.5 mg PO DAILY
Bisacodyl 5 mg prn
Epogen with HD
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 38 U qAM
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 5 U qPM
Ferrous Sulfate 325 mg (65 mg Iron) Tablet PO DAILY
.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Prednisone 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-24**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
constipation.
15. Epoetin Alfa 10,000 unit/mL Solution Sig: As directed
Injection ASDIR (AS DIRECTED): To be administered during
dialysis.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous with Breakfast.
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous at Bedtime.
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. Cefazolin 1 gram Recon Soln Sig: One (1) gram Intravenous
every Monday and Wednesday: Dosed at HD. Last dose to be [**2174-6-29**].
21. Cefazolin 1 gram Recon Soln Sig: 1.5 grams Intravenous every
Friday: Dosed at HD. Last dose to be [**2174-6-29**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis: MSSA bacteremia
Secondary Diagnosis: ESRD on HD, s/p cadaveric renal transplant,
h/p CVA, CAD, DM2
Discharge Condition:
Fair.
Discharge Instructions:
You were admitted to the hospital with a diagnosis of bacteremia
(staph aureus). You were treated with several different
antibiotics including Vancomycin, Nafcillin, and most recently
Cefazolin. In order to give you the Cefazolin you [**Location (un) 1834**]
desensitization in the medical ICU. After the procedure was
complete you were treated with Cefazolin, which will continue to
be dosed at hemodialysis for the next 5 weeks. Your last dose of
Cefazolin will be on Wednesday, [**2174-6-29**].
.
You need to have your counts monitored while on the antibiotic.
These labs can be drawn during Hemodialysis. At HD should check
CBC, Electrolytes, and LFTs. Please fax all lab results to
Infectious disease R.N. at ([**Telephone/Fax (1) 6313**], [**First Name9 (NamePattern2) 5035**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12081**]
MD. Questions regarding outpatient antibioitcs should be
directed to ID R.N.s at ([**Telephone/Fax (1) 11581**]
.
You should continue to take your medications as prescribed
below. You should also follow-up at the appointments listed
below. If you develop any concerning symptoms including fevers,
chills, chest pain, shortness of breath, abdominal pain,
vomiting, or diarrhea, you should call your doctor or go to the
Emergency Room immediately.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5537**]
Date/Time:[**2174-6-9**] 10:30 (Interventional [**Month/Day/Year **])
.
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2174-6-15**]
2:30
.
Called Dr.[**Name (NI) 12083**] answering service, will contact the patient
regarding need for follow-up appointment in [**11-24**] weeks by phone
after Monday [**2174-5-30**]
.
[**Hospital **] clinic - [**6-15**] at 2:30 pm
Completed by:[**2174-5-28**]
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|
2039, 2215
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,461
| 155,465
|
21258
|
Discharge summary
|
report
|
Admission Date: [**2107-3-26**] Discharge Date: [**2107-3-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from OSH for tachycardia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is an 88 year-old male with a history of atrial
fibrillation, PVD, among others, who presents with tachycardia,
hypotension and respiratory distress.
Per wife, he was in his usual state of health and when going to
be he was found to have very "labored breathing". He had no
symptoms today of chest pain, chest pressure, or passing out.
Initial vitals by EMS were 02 sat 84%m HR 110, BP 160/106. He
was given lasix 80 mg IV and nitroglycerin spray.
On arrival to the [**Location (un) 620**] ED, he was found to have t 99.7 P 103,
rr40, 208/97, 02 sat 89% on NR. Initially he was placed on CPAP
with nitroglycerin. He intermittently would have pain and was
given morphine. His BP decreased and nitro drip was stopped.
Dopamine was started but then transitioned to levophed as
patient was tachycardic. Additionally, he had complaints of
abdominal pain and possible distension and was given morphine
with episodes of pain which helped with the respiratory distress
as well. For hyperkalemia, he was given calcium gluconate. For
eval of abd pain, he had a CT that was negative. While in the ED
he had approx 600 cc urine output [**First Name8 (NamePattern2) **] [**Location (un) 620**] physician. [**Name10 (NameIs) 227**]
that the patient had a new LBBB, he was started on heparin IV
for possible ACS and patient was transferred for possible
catherization.
Prior to transfer patient was apparently placed on peripheral
levophed and non-rebreather prior to transfer.
On arrival to the CCU, he was combative and seemed to be in
respiratory distress. He was immediately placed on CPAP and
restrained.
Past Medical History:
1. Atrial fibrillation x 20 years (chronic anticoagulation)
2. Peripheral artery disease
3. Thrombocytosis
4. Vertebral compression fractures
5. Hypercholesterolemia
6. Aortic calcification
7. Squamous cell carcinoma of scalp
8. Internal hemorrhoids
9. ?Hypertension
PAST SURGICAL HISTORY:
1. s/p vertebroplasty L4-5
2. s/p scalp cancer resection [**7-11**]
3. s/p femoral stenting (right superificial femoral)[**6-8**]
4. s/p TURP [**4-9**]
5. s/p Appendectomy [**8-7**]
Social History:
Mr. [**Known lastname **] lives with his wife at [**Location (un) **] ([**Hospital3 **]).
He has a remote history of 3-pack per day cigarette smoking,
having stopped over 50 years ago, and is a rare social drinker.
Mr. and Mrs. [**Known lastname **] have 2 children and 3 grandchildren, 1 of
whom is adopted.
Family History:
NC
Physical Exam:
Blood pressure was 148/68 mm Hg while seated. Pulse was 96
beats/min and regular, respiratory rate was 27 breaths/min. T
102 (rectal) Initial 02 sat on CPAP was 100%.
Generally the patient was elderly male, somnolent, initially
combative, and mildly jaundiced.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple. JVD
not elevated. The carotid waveform was normal. The were no chest
wall deformities, scoliosis or kyphosis. The respirations was
labored. Posteriorly, he had diffuse crackles up to apices with
high pitched sounds anteriorly and crackles. There were no
thrills, lifts or palpable S3 or S4. The heart sounds revealed a
normal S1 and the S2 was normal. There were no rubs, murmurs,
clicks or gallops, though was difficult to assess given lung
sounds.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and ?mildly distended. The extremities had no cyanosis, clubbing
or edema. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, or xanthomas.
Pulses:
Right: Carotid 2+ DP tr-1+ PT 2+
Left: Carotid 2+ DP tr-1+ PT 2+
Pertinent Results:
ADMIT LABS ([**2107-3-26**]):
CBC:
WBC-5.1 RBC-3.49* Hgb-13.5* Hct-40.8 MCV-117*# MCH-38.6*
MCHC-33.1 RDW-20.2* Plt Ct-228
COAGS:
PT-29.9* PTT-67.2* INR(PT)-3.1*
CHEMISTRIES:
Glucose-95 UreaN-25* Creat-1.2 Na-134 K-4.0 Cl-98 HCO3-22
AnGap-18
Calcium-8.9 Phos-4.6* Mg-2.1
LFTS:
[**2107-3-28**] ALT-29 AST-36 LD(LDH)-280* AlkPhos-49 TotBili-1.7*
DirBili-0.6* IndBili-1.1
CARDIAC ENZYMES:
[**2107-3-26**] 03:49AM CK-MB-4 cTropnT-0.06* CK(CPK)-128
[**2107-3-26**] 01:00PM CK-MB-5 cTropnT-0.03* CK(CPK)-151
[**2107-3-27**] 05:00AM CK-MB-5 cTropnT-0.02*
[**2107-3-27**] 06:16AM CK-MB-5 cTropnT-0.02* CK(CPK)-166
DIC LABS:
[**2107-3-28**] Fibrino-793*
[**2107-3-28**] FDP-0-10
ANEMIA LABS:
[**2107-3-26**] VitB12-592 Folate-GREATER TH
[**2107-3-29**] calTIBC-217* Hapto-164 Ferritn-618* TRF-167*
ABG:
[**2107-3-26**] 04:05AM Type-ART pO2-355* pCO2-39 pH-7.36 calTCO2-23
Base XS--2
[**2107-3-26**] 05:31PM Type-ART Rates-/35 FiO2-50 pO2-115* pCO2-33*
pH-7.44 calTCO2-23 Base XS-0 Intubat-NOT INTUBA
Comment-NEBULIZER
ECHO ([**2107-3-26**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
0-5mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and 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. The aortic valve leaflets
are moderately thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Mild mitral
regurgitation. Aortic valve sclerosis.
CT Abd/pelvis ([**2107-3-28**]):
1. No evidence for small-bowel obstruction or ileus with
contrast identified within the rectum.
2. Small right pleural effusion and trace left effusion.
Bibasilar atelectasis.
3. NGT with side port at the gastroesophageal junction.
Recommend advancement 5-10cm for optimal positioning.
4. Extensive degenerative changes within the lumbar spine
without evidence of acute fracture. Generalized osteopenia.
.
CXR [**3-28**]: Cardiac silhouette is enlarged but stable in size.
Bilateral lower lobe opacities, right greater than left are
again demonstrated with difficult comparison to recent portable
radiograph due to positional differences, but slight worsening
in the left lower lobe and slight improvement in the right lower
lobes since the earlier radiograph of [**2107-3-26**]. As
reported previously, this may be due to an aspiration pneumonia
given the clinical suspicion for this entity.
.
CXR [**3-30**]: Single upright AP chest, comparison [**2107-3-28**],
demonstrates interval increase in the retrocardiac opacity with
blurring of the hemidiaphragm and aortic interface. The linear
opacities at right base are not significantly changed. Minimal
apical pleural thickening is unchanged. Mild cardiomegaly and
tortuous aorta are unchanged.
Brief Hospital Course:
1. Hypoxic respiratory distress:
Likely multifactorial. Patient may have had a hypertensive
crisis causing acute pulmonary edema, with resulting aspiration
pneumonia. Also may have had a brewing pneumonia which left him
febrile and decompensated, resulting in pulmonary edema. The
patient was initially admitted to the CCU and placed on CPAP
with resulting redistribution of the fluid back into the
vasculature. He was also given Lasix IV x1 in the ED and had
good UOP response to it. An echo did not show any new wall
motion abnormalities or CHF. Cardiac enzymes were cycled and he
was ruled out. CXRs showed no recurrence of pulmonary edema but
persistent lower lobe consolidations.
For the pneumonia, he was treated with levaquin, in addition to
flagyl (given the possibility of aspiration). He had copious
secretions, requiring aggresive suctioning and chest PT in the
CCU. He improved over the first 48 hours without requiring
intubation and his oxygen requirement steadily decreased. As
his respiratory status improved, he was transferred to the floor
(on [**3-29**]); at that time, he was on room air. He received chest
PT to help with his secretions as well as an incentive
spirometer. He remained afebrile on antibiotics without white
count. He also had evidence of bronchospasm on exam, likely from
the pneumonia, and was treated with albuterol and atrovent
nebulizers which were changed to MDIs prior to discharge.
Patient continued to have excellent O2 saturationsm, was
afebrile, and was discharged to rehab with levofloxacin/flagyl
to finish a course of 10 days for his aspiration pneumonia.
.
2. Abdominal distension:
On HD#3, developed progressive abdominal distension with initial
concern for SBO despite the patient having flatus and passing
BMs. A KUB initally confirmed concern for SBO, and general
surgery were consulted. A CT abdomen/pelvis was recommended.
The CT demonstrated contrast reaching the rectum with no
evidence of an SBO. Serial exams revealed improving distension,
patient had multiple bowel movements, and patient was tolerating
PO diet at time of discharge.
.
3. Atrial fibrillation with RVR:
Initially, beta-blocker was held as the patient was NPO with a
well controlled rate. As he began to take PO, beta-blocker was
restarted at the home dose (and later titrated up from 25mg
daily to 50mg daily). He presented on coumadin, which was held
given an initially supratherapeutic INR (3.1, 3.8, 4.0).
Etiologies for the elevated INR included medication interaction
(given levofloxacin/flagyl), decreased gut bacteria in the
setting of antibiotics and poor PO given that the patient was
initially NPO. Labs were not consistent with DIC. He was given
2mg of SC vitamin K and his INR decreased to 2.2. Coumadin was
restarted [**3-29**] and INR remained subtherapeutic at 1.7. However,
he was not given additional coumadin above home dose as he was
continuing on flagyl which can inhibit coumadin metabolism.
.
4. CAD:
Ruled out acute MI with serial cardiac enzymes. Continued
BBlocker (as above) and statin. He did not present on aspirin;
PR aspirin was used while NPO, transitioned to PO.
.
5. Pump:
Clinical exam initially consistent with left sided heart failure
and has some improvement after aggressive diuresis. However echo
with no obvious ventricular systolic or diastolic dysfunction
with an LVEF >50%. Responded well to a one time dose of IV
Lasix and did not require further diuresis once his BP was
controlled.
.
6. Altered mental status:
Was initially delirius in setting of sedating meds and
infection. Per wife, has early dementia (oriented to person,
place, but often not time). Over the CCU course, he improved
greatly at was back to baseline at the time of floor transfer.
Mental status was stable throughout the rest of his hospital
course.
.
7. Thrombocytosis:
Has history of thrombocytosis, likely essential. There is,
however, no documentation of that diagnosis. Has been treated
with hydroxyurea - continued during this admission with normal
platelet levels. There was a question whether he should be on
once daily or twice daily dosing. He was treated with once
daily dosing while in house but should discuss appropriate
dosing with his primary doctor as an outpatient.
.
8. Elevated Indirect bilirubinemia:
There were no signs of cholecystitis on exam or imaging. Does
have history of cholelithiasis. However given that it is
indirect, may be secondary to mild hemolysis in the setting of
hydrea. His hematocrit remained stable throughout and there
were no signs of significant hemolysis. His Tbili trended down
throughout admission with normal LFTs throughout and no
abdominal pain.
.
9. Anemia:
Macrocytic. Macrocytosis was felt to be, at least in part, due
to hydrea therapy. Ferritin was elevated with a normal iron and
low TIBC; could be partly due to anemia of inflammation. Hct
was stable throughout.
.
10. Hyperlipidemia:
Continued statin.
.
11. Hypertension:
Titrated up beta blocker (as above).
12. Code status:
Presented as DNR/DNI; this was discussed with the family
(including daughter who is HCP) and patient. Status was changed
to FULL CODE.
Medications on Admission:
Warfarin 2.5 mg p.o. daily
Lipitor 20 mg p.o. daily
Hydrea 500 mg p.o. [**Hospital1 **]
Metoprolol 25 mg p.o. daily
Mirtazapine 15 mg p.o. daily.
Requip 1.5 tabs/day
Vitamins
Calcium
Discharge Medications:
1. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Requip 1 mg Tablet Sig: 1.5 Tablets PO once a day.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*2*
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*6000 mg* Refills:*2*
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath or wheezing.
Disp:*2 inhalers* Refills:*0*
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*2 inhalers* Refills:*0*
15. Outpatient Lab Work
Please check PT/INR every 2-3 days while on Flagyl and until
stable. Results to Dr. [**Last Name (STitle) **] for further Coumadin management.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Retirement House
Discharge Diagnosis:
Primary Diagnosis:
1. Aspiration Pneumonia
2. Acute pulmonary edema
Secondary Diagnosis:
1. Atrial Fibrillation
2. Hypertension
3. Peripheral vascular disease
4. Hypercholesterolemia
5. Restless Leg Syndrome
Discharge Condition:
Hemodynamically stable; saturating >90% on room air; ambulatory
with walker.
Discharge Instructions:
You were diagnosed with pneumonia and pulmonary edema (fluid in
the lungs). You were treated with antibiotics (Levaquin and
Flagyl) - you should be sure to finish the course as instructed
below. Your Toprol XL was increased to 50mg daily. You were
started on hydrochlorothiazide for your blood pressure. You have
been given prescriptions for albuterol and atrovent inhalers to
help with your breathing. You have also been given
prescriptions for Colace and Senna to help with constipation.
.
Please discuss with your Primary doctor whether you should be on
your Hydroxyurea once a day or twice a day. You are currently
receiving it once a day and your platelets have been stable.
.
Please follow up with your primary doctors as listed below:
.
If you develop chest pain, fever/chills, shortness of breath,
worsening cough, difficulty breathing, or any other concerning
symptom, please call your doctor or report to the nearest ER.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**2107-4-6**] at 10:15am unless you
are still at the rehab facility.
.
Have your PT/INR checked on Friday, [**2107-4-1**]. Further monitoring
per the physicians at rehab.
.
Previously scheduled appointments:
1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3833**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2107-5-24**] 10:15
.
2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2107-6-21**]
9:30
Completed by:[**2107-3-31**]
|
[
"507.0",
"427.31",
"443.9",
"599.0",
"238.71",
"401.9",
"272.0",
"333.94",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
14377, 14441
|
7302, 10793
|
296, 304
|
14694, 14773
|
4057, 4431
|
15757, 16346
|
2799, 2803
|
12687, 14354
|
14462, 14462
|
12479, 12664
|
14797, 15734
|
2272, 2456
|
2818, 4038
|
4448, 7279
|
222, 258
|
332, 1959
|
14552, 14673
|
14481, 14531
|
10808, 12453
|
1981, 2249
|
2472, 2783
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,778
| 198,082
|
26358
|
Discharge summary
|
report
|
Admission Date: [**2158-3-11**] Discharge Date: [**2158-3-16**]
Date of Birth: [**2083-11-21**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
chest pain, SOB
.
Major Surgical or Invasive Procedure:
Cardiac catheterization ([**2158-3-15**])
.
History of Present Illness:
Mr. [**Known lastname 34808**] is a 74 yoM w/ a h/o htn, hypercholesterolemia,
PVD, ESRD on HD, AS s/p AVR who is transferred from [**Hospital3 **] for chest pain and SOB. Patient reports being in his
usual state of health until 2 weeks ago after having skin
resections for skin cancer. The following day, patient went to
HD and following HD felt extremely fatigued and generally
unwell. Over the next 2 weeks, he has had DOE w/ 1 flight of
stairs and half a mile. Prior to 2 weeks ago, he was able to do
stairs and walk a couple of miles w/o SOB. He has been spending
a significant amount of time in bed due to fatigue and SOB over
the last two weeks and also endorses 2 pillow orthopnea which is
also new.
.
Approximately 3 days ago, he developed episodes of chest pain
while at rest at work. This pain was associated with pain under
his arms as well as SOB but no nausea, diaphoresis, or
lightheadedness. The episodes lasted 1-1.5 hours and resolved
spontaneously. Over the last 3 days he has had ~ 5 episodes.
Then yesterday evening, he was awoken from sleep with 10/10
chest pain again ass. w/ pain under the arms and SOB. His wife
called 911 and he was brought to OSH ED. He received 3 SL NTG in
transport and by the time of arrival to the ED, his CP had
resolved. Patient estimates ~1 hr of chest pain. Per pt's
friend, he may have been complaining of chest pain >1 week ago
although he did not report to his family.
.
In the OSH ED, patient was chest pain free. By report, although
not available, ECG showed NSR w/ nonspecific ST-TW changes,
inferior QWs. CKs were negative but troponins were mildly
elevated at 0.16. He was evaluated by Cardiology, started on
heparin and NTG gtt for possible unstable angina/ACS. CXR showed
moderate CHF and he was dialyzed w/ 2 kgs removed. He was then
transferred to [**Hospital1 18**].
.
Upon arrival, patient appears comfortable. He denies any further
chest pain since his last episode was relieved w/ SL NTG prior
to arrival at [**Hospital3 **]. He reports his breathing improved
since his dialysis. He is otherwise without complaint. On review
of symptoms, he denies any fevers, chills, nightsweats,
abdominal pain, diarrhea, constipation, or urinary complaints.
As above, he does note DOE and orthopnea. He denies any recent
LE swelling, syncope, or presyncope.
.
Past Medical History:
# Aortic Stenosis s/p Aortic Valve Replacement [**2156-1-9**]
- (#[**Street Address(2) 65216**]. [**Male First Name (un) 923**]
# ESRD [**2-25**] htn on Hemodialysis T/Th/Sat thru L AVF
# Hypertension
# Hypercholesterolemia
# s/p AAA repair in ?[**2150**] @ [**Hospital1 336**]
# s/p right aortoiliac bypass
# R knee surgery
# R aorti iliac bypass
# Peripheral Vascular Disease
# Anxiety/depression
# s/p R quad repair
# Benign Prostatic Hypertrophy
# s/p L lung biopsy
.
Social History:
Lives in [**Location 38640**], MA with his wife. 2 children. Works as a
security guard. Former 2 ppd smoker. ~ 96 pk/yr hx. Quit in
[**2144**]. Drinks [**1-25**] glasses of wine/day. No h/o heavy EtOH use.
.
Family History:
Denies any family h/o early CAD or other heart problems.
.
Physical Exam:
PHYSICAL EXAMINATION:
VS: AF, BP 137/65, HR 69, RR 19, O2 100% on NRB
Gen: Elderly male in no significant respiratory distress sitting
upright on NRB. Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of ~8 cm H2O.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. [**3-1**] holosys murmur at apex
Chest: Resp were unlabored, no accessory muscle use. Crackles
1/3 up bilaterally.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: LUE fistula w/ palpable thrill. No LE edema.
Skin: Bandage over RLE covering recent surgical incision CDI
Pulses:
Right: Carotid 2+ w/ bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ w/ bruit; Femoral 2+ without bruit; dopplerable
DP
.
Pertinent Results:
MEDICAL DECISION MAKING
.
ECG [**2158-3-11**]: NSR @ 70. LAD. QWs in II, III, aVF, V1-3. TWI aVL.
J point elevation V3. < [**Street Address(2) 4793**] depressions in V6. Compared to
prior ECG [**2156-1-9**], nonspecific STTW changes are new.
.
[**2155-6-20**] Echo: Abnormal study c/w mild to moderate calcific AS
with mild AI and mild LVH. Mitral and tricuspid valves appear
normal.
.
[**2155-6-4**] ETT: Patient exercised for 10:51 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol to an APHR of 94%. No EKG changes. No chest pain.
Images revealed normal regional wall motion. LVEF 67%.
.
CARDIAC CATH performed on [**2155-12-29**] demonstrated:
1. Selective coronary angiography in this right dominant
patient revealed no angiographically significant coronary artery
disease. The LMCA had a mild distal 20% taper. The LAD was
normal.
The LCX had mild luminal irregularities. The RCA also had mild
luminal irregularities.
2. Resting hemodynamics revealed elevation of left sided filling
pressures with a LVEDP of 20mmHG and a PCWP of 15mmHG. There was
mild pulmonary hypertension with a mean PA pressure of 25mmHG.
The cardiac index was preserved at 2.72l/m2/min
3. There was a severe aortic stenosis gradient with mean
gradient of 41mmHG and calculated [**Location (un) 109**] of .79cm2. The aortic
valve appeared calcified on fluoroscopy.
.
LABORATORY DATA:
.
[**Hospital 2079**] Hospital:
WBC 13.3, Hct 38.2, plts 280
Na 143, K 3.8, Cl 103, CO2 28, BUN 34, Cr 4.2, glu 97
AST 18, ALT 19, Tbili 0.4, alb 3.8
CK 50->42->36
MB NDx3
TnT 0.12->0.15->0.16
.
.
.
.
.
.
[**2158-3-11**] 06:08PM WBC-16.6*# RBC-4.31*# HGB-13.0*# HCT-38.2*#
MCV-89 MCH-30.3 MCHC-34.2 RDW-13.6
[**2158-3-11**] 06:08PM NEUTS-61 BANDS-0 LYMPHS-10* MONOS-4 EOS-24*
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2158-3-11**] 06:08PM PLT SMR-NORMAL PLT COUNT-275
[**2158-3-11**] 06:08PM PT-13.7* PTT-30.6 INR(PT)-1.2*
[**2158-3-11**] 06:08PM GLUCOSE-89 UREA N-33* CREAT-4.0* SODIUM-143
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-18
[**2158-3-11**] 06:08PM ALBUMIN-3.9 CALCIUM-9.7 PHOSPHATE-3.2
MAGNESIUM-2.1
[**2158-3-11**] 06:08PM ALT(SGPT)-19 AST(SGOT)-21 LD(LDH)-243
CK(CPK)-41 ALK PHOS-105 TOT BILI-0.8
[**2158-3-11**] 06:08PM CK-MB-4 cTropnT-0.21*
.
.
.
CXR-portable AP ([**2158-3-11**]) - Cardiac size is top normal. The
mediastinal contours are unchanged. The patient is post median
sternotomy. There are low lung volumes. There is mild
interstitial pulmonary edema. Small bilateral pleural effusions
are greater in the right side. Left upper lobe opacity abutting
the pleural surface with loss of volume is grossly unchanged.
IMPRESSION: Mild interstitial pulmonary edema. Chronic changes
in the left upper lobe.
.
ECHO-TTE ([**2158-3-14**]) - The left atrium is mildly 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 moderately dilated. A bioprosthetic aortic valve
prosthesis is present. The transaortic gradient is higher than
expected for this type of prosthesis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
.
CARDIAC-CATHETERIZATION ([**2158-3-15**]) -
1. Coronary angiography in this right-dominant system revealed
only
mild angiographically apparent disease in the native vessels.
--the LMCA had mild angiographically apparent disease.
--the LAD had mild angiographically apparent disease.
--the LCx had mild angiographically apparent disease.
--the RCA had mild angiographically apparent disease.
2. Left ventriculography revealed normal wall motion and mild
mitral
regurgitation. There was a mild gradient of 20 mmHg across the
aortic
valve upon pullback of the angled pigtail catheter from LV to
ascending
aorta.
3. Aortic stenosis study revealed
4. Aortography revealed a dilated and tortuous aorta with no
AI, small
aneurysm in the abdominal aorta as well as left iliac artery,
and a
patent stent in the right iliac artery.
5. Resting hemodynamics revealed high-normal right-sided
filling
pressures with RVEDP 11 mmHg. Left-sided filling pressures were
elevated, with LVEDP 24 mmHg. There was moderate pulmonary
arterial
systolic hypertension, with PASP in the high 50s. The cardiac
output
was preserved with cardiac index 3.6 L/min/m2.
FINAL DIAGNOSIS:
1. Minimal coronary artery disease.
2. Pulmonary hypertension.
3. Mild gradient across aortic valve.
4. Recommend Aspirin
5. Recommend CTA to further assess abdominal aorta/iliacs/PVOD
extent.
.
.
Brief Hospital Course:
The patient is a 74-yo man with history of hypertension,
hyperlipidemia, PVD, ESRD on HD, aortic stenosis s/p porcine AVR
[**2155**], who presents with symptoms of chest pain and shortness of
breath.
.
#. Fluid overload (pump) - The patient presented with symptoms
concerning for a possible new cardiomyopathy. Given that he has
ESRD on HD, fluid was removed via ultra-filtration while at HD.
TTE showed no evidence of a cardiomyopathy, and the patient was
noted to have a preserved EF of 60%. Cardiac catheterization
confirmed the patient's preserved EF at about 50%. The Renal HD
team was following while the patient was admitted, and he was
dialyzed on his normal home dialysis schedule, with additional
ultra-filtration for fluid removal.
.
#. CAD (ischemia) - The patient presented with symptoms
concerning for unstable angina. His ECG showed evidence of a
prior septal and inferior MI, although it had no acute ischemic
changes and was unchanged since [**2155**]. His cardiac enzymes were
also negative. It was believed that he may have had a missed
event 10-14 days prior to his presentation, at the onset of his
symptoms of chest pain and shortness of breath. He had a TTE
that was not suspiscious of ischemic disease, and a cardiac
catheterization that revealed normal coronary arteries with mild
disease. He had been treated with aspirin, plavix, metoprolol,
high-dose atorvastatin, and Imdur while inpatient, but he was
resumed on his home outpatient medications on discharge.
.
#. AS s/p porcine AVR - The patient has a history of AS s/p
porcine AVR in [**2155**]. He now presented with chest pain and
shortness of breath. Evaluation by TTE showed a new elevated
trans-aortic gradient and velocity with decreased valve area.
Per the TEE team, TEE would be unlikely to provide more
information regarding the aortic valve, as TTE allows for better
views of the aortic valve. Cardiac catheterization was done to
evaluate the stenosis, which revealed only a mildly elevated
trans-aortic gradient and otherwise normal bio-prosthetic valve.
.
#. Rhythm - The patient was in NSR during his hospitalization,
with one episode of idio-ventricular NSVT noted.
.
#. ESRD on HD - The patient's ESRD is likely due to his
hypertension, and he is on hemodialysis every Tuesday, Thursday,
and Saturday. The Renal HD team was following while the patient
was admitted, and he was dialyzed on his normal home dialysis
schedule, with additional ultra-filtration for fluid removal.
.
#. Leukocytosis - The patient had no obvious evidence of
infection, and no left shift but a significant eosinophilia on
his differential. He noted recently starting a new medication,
Erythromycin, approximately 2 weeks prior to his admission, for
his skin graft surgery on his left leg. The eosinophilia was
believed to be a drug reaction, although no clear allergy
symptoms were elicited. He was changed from Erythromycin to
Keflex during this hospitalization, and continued on Keflex
throughout. He completed his planned course of prophylactic
antibiotics while inpatient.
.
#. Peripheral Vascular Disease - Cardiac catheterization and
aortography revealed a dilated and tortuous aorta with a small
aneurysm in the abdominal aorta and the left iliac artery, and a
patent stent in the right iliac artery. A CT-Angiogram was
recommended for further evaluation of the abdominal aorta, iliac
arteries, and extent of peripheral vascular occlusive disease.
The patient was advised to discuss this with his primary care
physician / cardiologist as an outpatient, and to follow-up
after the CT-Angiogram with either his primary vascular surgeon
or with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**]. Dr.[**Name (NI) 8664**] office is
available at [**Telephone/Fax (1) 5003**]. The CT-Angiogram will need to be
scheduled with respect to the patient's home hemodialysis
schedule.
.
Medications on Admission:
asa 325 mg daily
atenolol 50 mg daily
norvasc 5 mg daily
lipitor 10 mg daily
renagel
.
Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
6. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Acute diastolic heart failure
2. Fluid overload
3. End-stage renal disease
4. Eosinophilia
.
Secondary Diagnoses:
- Aortic stenosis s/p porcine AVR
- Coronary artery disease
- Idio-ventricular NSVT
- Hypertension
.
Discharge Condition:
afebrile, vital signs stable, asymptomatic
.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2158-3-11**] for congestive heart failure that was noted at [**Hospital 7912**]. You underwent dialysis at [**Hospital6 33**]
prior to your transfer to take off some of the fluid on your
lungs, and you were admitted to the CCU here. You resumed your
normal dialysis schedule and continued to do well. You had an
Echo of your heart which had some findings concerning for
tightening of your aortic valve prosthesis but was otherwise
normal. You then had a cardiac catheterization which showed that
your aortic valve prosthesis was actually normal as well, and
that you still had extra fluid on your lungs. You were stable
for discharge on [**2158-3-16**]. Your symptoms of shortness of breath
and chest pain were likely due to you having too much fluid in
your system, which put a strain on your heart and caused
congestive heart failure, giving you shortness of breath. You
should continue to take the medications as prescribed below, and
you should follow-up at the appointments listed below.
.
If you experience any worsening chest pain, shortness of breath,
or palpitations, you should call your doctor immediately or go
to the Emergency Room.
.
Given your peripheral vascular disease, also noted on the
cardiac catheterization, it was recommended that you have a
CT-Angiogram to evaluate your abdominal aorta, iliac arteries,
and extent of disease. You should discuss this with your primary
care physician / cardiologist as an outpatient. You should
follow-up with Dr. [**Last Name (STitle) **] in about 2-3 weeks time, after the
CT-Angiogram is done. Dr.[**Name (NI) 8664**] office will call you with
regards to an appointment date and time for the CT-Angiogram and
for the follow-up appointment.
.
Followup Instructions:
You have an appointment scheduled to see your primary care
physician and cardiologist, Dr. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**], on Monday, [**3-20**], [**2158**], at 12:45PM. At this appointment you should discuss
with him the need for an outpatient CT-Angiogram to evaluate
your abdominal aorta, iliac arteries, and extent of your
peripheral vascular disease.
You should also follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] here at [**Hospital1 18**] in
about 2-3 weeks time, after the CT-Angiogram is done. Dr. [**Name (NI) 65218**] office will call you with regards to an appointment date
and time for the CT-Angiogram and for the follow-up appointment.
His office's phone number is [**Telephone/Fax (1) 5003**], and his office is
located on [**Hospital Ward Name **] 4 of the [**Hospital Ward Name 517**] at [**Hospital1 18**].
.
You should also follow-up with your surgeons for your left leg
as already scheduled.
.
|
[
"428.31",
"428.0",
"414.01",
"V42.2",
"427.1",
"403.91",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.23",
"39.95",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13735, 13741
|
9252, 13147
|
297, 343
|
14022, 14069
|
4387, 9007
|
15866, 16848
|
3424, 3485
|
13285, 13712
|
13762, 13877
|
13173, 13262
|
9024, 9229
|
14093, 15843
|
3500, 3500
|
13898, 14001
|
3522, 4368
|
239, 259
|
371, 2687
|
2709, 3183
|
3199, 3408
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,073
| 152,717
|
7865
|
Discharge summary
|
report
|
Admission Date: [**2118-12-13**] Discharge Date: [**2118-12-27**]
Date of Birth: Sex:
Service: MICU
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: This is a 75 year old woman with
a history of chronic obstructive pulmonary disease,
hypertension, supraventricular tachycardia and nonsustained
ventricular tachycardia who was admitted to an outside
hospital on [**2118-12-9**] with respiratory distress.
Reportedly, the patient had been short of breath at home for
several days with productive cough, yellow sputum, and low-
grade temperature. The patient did not report any chest
pain. She did, however, report nausea and diarrhea just
prior to admission, as well as worsening shortness of breath
at home the night prior to admission. Emergency Medical
Services found her to be "cyanotic and mottled," and
intubated her in the field. In the outside hospital
Emergency Room, the patient was repleted for presumed chronic
obstructive pulmonary disease flare and received Solu-Medrol,
Albuterol and Atrovent nebulizers and Mucomyst nebulizers as
well as Levofloxacin. Cardiac enzymes were cycled and the
patient ruled in for an myocardial infarction. Her troponin
was 4.14. Initially, the patient received Lasix, but
attributed hypotension upon receiving intravenous fluids was
noted to have increased dyspnea. She was treated with Lasix
and Natrecor which 3 liters diuresis but reported chest pain
and was transferred to [**Hospital6 256**]
for cardiac catheterization.
At the [**Hospital6 256**], the patient had
coronary angiography which demonstrated 70 percent lesions in
the left anterior descending coronary artery and a 95 percent
focal mid lesion in the left circumflex coronary artery as
well as 70 percent lesion in the right coronary artery. The
patient received stenting of the mid left circumflex coronary
artery with 2.0 times 13 mm pixel bare-metal stent. After
the cardiac catheterization, the patient was extubated but
because of respiratory distress, she could not tolerate BiPAP
and was reintubated on [**2118-12-14**]. Echocardiogram on
[**2118-12-14**], showed overall left ventricular systolic
function severely depressed with anterior, apical, septal,
inferior and lateral severe hypokinesis/akinesis. Ejection
fraction was less than 20 percent.
PAST MEDICAL HISTORY:
1. Hypertension. 2. Chronic obstructive pulmonary disease
with 2 liters of oxygen requirement at home. 3. History
of supraventricular tachycardia-history of nonsustained
ventricular tachycardia, on Amiodarone. 4.
Gastroesophageal reflux disease. 5. Gastritis. 6.
Hypercholesterolemia. 7. Anxiety and depression.
MEDICATIONS AT HOME: Serevent, Verapamil, Ativan,
Prednisone, Aspirin, Elavil, Combivent, Flovent, Zantac,
Nitropatch, Lasix.
ALLERGIES: No known drug allergies, but the patient does not
relate well to codeine, Protonix and SSRIs.
SOCIAL HISTORY: She lives at home with her husband. She has
a 60 pack year history of tobacco use. She denies alcohol
and intravenous drug use.
PHYSICAL EXAMINATION: Physical examination upon admission to
the Coronary Care Unit after the cardiac catheterization,
revealed vital signs temperature 97.9, heart rate 108, blood
pressure 128/63, respiratory rate 14, oxygen saturation 94
percent. In general in no acute distress, alert and oriented
times three. Head, eyes, ears, nose and throat, pupils
equal, round and reactive to light, extraocular movements
intact, mucous membranes moist. Cardiovascular, regular rate
and rhythm, S1 and S2, no murmur, rubs or thrills. Lungs
with diffuse mild wheezes bilaterally. Abdomen, soft,
nontender, nondistended with normoactive bowel sounds.
Extremities without edema. Neurologic, alert and oriented
times three and mentating fairly well. Follows commands.
LABORATORY DATA: White blood cell count 14.4, hematocrit
37.1, platelets 256, BUN 30, creatinine 0.5. Chest x-ray,
reveals cardiomegaly and severe emphysema.
HOSPITAL COURSE: As mentioned above, the patient was
transferred to [**Hospital6 256**] from an
outside hospital and immediately received coronary
catheterization and stenting. She was subsequently
transferred to the Coronary Care Unit and then to the
Medicine Intensive Care Unit Service. There, her
hospitalization course was as follows, by system.
Respiratory - The patient was extubated after the coronary
catheterization but did not tolerate BiPAP well and was
reintubated on [**12-15**]. As she was failing spontaneous
breathing trials, a tracheostomy was placed. She started
doing better on her spontaneous breathing trials on [**12-23**]. The plan was to gradually increase her time off the
ventilator, as tolerated. On the day of discharge, the
patient had two spontaneous breathing trials for over three
hours. The patient was maintained on Albuterol and Atrovent
nebulizers, as well as Prednisone for her chronic obstructive
pulmonary disease. It was noted on [**12-18**], the patient
was noted to have left lower lobe pneumonia. The Vancomycin
was added to her regimen of Levofloxacin. The patient was to
finish a course of 14 days of Levofloxacin and 7 days of
Vancomycin.
Coronary artery disease - As mentioned, the patient underwent
cardiac catheterization and stenting. She had no
complications and she was maintained on aspirin, Plavix and
beta blockers throughout her hospital course. Her
echocardiogram showed an ejection fraction of 20 percent.
The patient was maintained euvolemic during this
hospitalization and even to 3500 cc ins and outs goal. The
patient remained in normal sinus rhythm during this
hospitalization and the Lopressor was titrated to keep her
heart rate stable.
Hypertension - The patient was maintained on Metoprolol and
Captopril without complications.
Fluids, electrolytes and nutrition - The patient had a
percutaneous endoscopic gastrostomy placed on [**12-22**],
and tube feedings were started on [**2118-12-22**]. The
patient tolerated the tube feeds well without problems or
limitations.
Endocrine - Since the patient was on steroids for her chronic
obstructive pulmonary disease, initial sliding scale was used
during this hospitalization.
Prophylaxis - Heparin subcutaneously, proton pump inhibitor,
aspiration precautions.
Code status - Full.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Ranitidine 150 mg p.o. b.i.d.
3. Prednisone 30 mg p.o. q.d.
4. Nystatin oral suspension 5 ml p.o. q.i.d. prn/
5. Metoprolol 37.5 mg p.o. b.i.d.
6. Lorazepam 0.5 to 2 mg p.o. q. 4-6 hours prn.
7. Heparin 5000 units subcutaneously q. 8 hours.
8. Captopril 75 mg p.o. t.i.d.
9. Lipitor 10 mg p.o. q.h.s.
10. Enteric coated aspirin 325 mg p.o. q.d.
11. Albuterol nebulizers 1 nebulizer inhaled q. 4 hours
prn.
12. Albuterol 1 to 2 puffs inhaled q. 6 hours prn.
13. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn.
14. Insulin sliding scale.
15. Ipratropium Bromide nebulizer, one nebulizer inhaled
q. 6 hours.
16. Ipratropium Bromide metered dose inhaler 2 puffs
inhaled q.i.d.
DISCHARGE INSTRUCTIONS: Follow up - The patient was advised
to follow up with her primary care physician in one to two
weeks.
Diet - Tube feeding, Probalance full strength.
Post discharge services - Home oxygen, physical therapy and
respiratory therapy.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 6327**]
Dictated By:[**Last Name (NamePattern1) 26045**]
MEDQUIST36
D: [**2119-6-28**] 18:42:42
T: [**2119-6-28**] 19:40:54
Job#: [**Job Number 28330**]
|
[
"401.9",
"300.00",
"518.81",
"428.0",
"414.01",
"530.81",
"410.71",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"36.01",
"88.56",
"88.53",
"36.06",
"37.23",
"96.72",
"31.1",
"99.20",
"33.22",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
6426, 7171
|
4021, 6321
|
7196, 7678
|
2717, 2930
|
3101, 4003
|
149, 172
|
201, 2334
|
2356, 2695
|
2947, 3078
|
6346, 6403
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,540
| 163,861
|
31662
|
Discharge summary
|
report
|
Admission Date: [**2160-4-18**] Discharge Date: [**2160-4-22**]
Date of Birth: [**2093-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 66 yo male with a h/o metastatic NSCLC, currently
undergoing chemosensitization with weekly [**Doctor Last Name **]+taxol (cycle 2,
day 12) who presents following a witnessed syncopal event at
home. His daughter states that he was on the commode having a
bowel movemement when he became unresponsive. He did not fall.
She lowered him onto the ground and initiated CPR. The family
called EMS. She states that he regained consciousness in less
than five minutes. She states that she did not feel for a pulse
prior to initiating CPR. Mr. [**Known lastname **] [**Last Name (Titles) **] any symptoms
immediately preceding his loss of consciousness.
<br>
Mr. [**Known lastname **] reports worsening dyspnea on exertion since initiation
of chemotherapy. He currently feels as though he is working hard
to breath. He states that he sleeps on his left side on one
pillow. He [**Known lastname **] PND, chest pain, or palpitations. He has a dry
non-productive cough. He reports fevers as high as 104 (via oral
thermometer) for the past one week at home, accompanied by
chills and myalgias. He reports mild diarrhea for the past day.
He has never received the flu shot. He reports tingling in his
extremities. He [**Known lastname **] any sick contacts.
<br>In the [**Hospital Unit Name 153**], he remained stable overnight. Influenza ruled
out wiht negative DFA. There was some suspicion for tamponade on
exam because of pulsus alternans noticed on telemetry. His heart
sounds were muffled with elevated JVP and sinus tachycardia. His
vitals were stable. A stat bedside echo was performed that was
negative for effusion.
<br><br><B>PAST ONCOLOGIC HISTORY:</B>
========================
- [**2147**]: diagnosed with left renal cell carcinoma and underwent
nephrectomy.
- [**2151**]: moved to US
- [**10/2157**]: CXR showed a "spot" on his right lung. serial CT scans
showed growth of this lesion (1->3.5cm).
- [**1-/2159**]: PET-CT showed multiple foci of uptake in right lung,
and subcarinal adenopathy and right liver lesion. He deferred
biopsy at that time.
- [**8-/2159**]: hospitalized at [**Hospital1 18**]. CT showed a 4.4 x 2.7cm right
lower lobe lesion and right hilar lymphadenopathy and 7.6cm low
density liver lesion. FNA of the lung mass positive for NSCLC.
Core biopsy showed adenocarcinoma (CK-7 and 20 positive, TTF-1
negative). Bone scan showed abnormality in T10. MRI brain showed
an enlarged pituitary consistent with macroadenoma, but
metastasis could not be ruled out. Chemotherapy was recommended,
but the patient needed to travel abroad to secure his assets.
- Treated to Dubai with alternative therapies until [**Month (only) 1096**]
[**2159**]
- [**Date range (2) 74388**]: Back at [**Hospital1 **] with CTA revealing marked
progression of disease and new right adrenal metastasis. Bone
scan [**2160-2-13**] with known T10 lesion. bronchoscopy with mechanical
resection of tumor in the RLL and RML.
- He has completed XRT to lung mass followed by two cycles of
[**Doctor Last Name **]/Taxol chemosensitization.
Past Medical History:
Metastatic NSCLC, as below
h/o RCC s/p nephrectomy in [**Country 9819**] [**2147**]
h/o abdominal ventral hernia
SIADH
Social History:
The patient immigrated to the United States in [**2151**] as a refugee
from [**Country 16160**]. He [**Country **] tobacco, alcohol, and drug use.
He lives at home with his wife and children. He has 13 children.
He works in import/export from [**Country 651**].
Family History:
No known cancers in the family. Father died of swelling in the
throat possibly related to either infection or cancer.
Physical Exam:
GENERAL: laying in bed, NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent
nares, MMM, good dentition, supple neck, no LAD, JVD to jawline.
CARDIAC: RRR, S1/S2, no mrg, somewhat distant heart sounds
LUNG: prolonged expiratory phase. wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
[**2160-4-18**] AP UPRIGHT CHEST X-RAY: The tip of the right subclavian
catheter projects over the mid SVC. There is no pneumothorax or
evidence of acute cardiopulmonary process, with multiple lung
nodules/masses partially visualized and better evaluated on
previous CT. Heart size is normal. A tortuous aorta is
unchanged.
IMPRESSION: No evidence of pneumothorax or new infiltrate.
<br>
[**2160-4-18**] LOWER EXTREMITY ULTRASOUND: No evidence of deep vein
thrombosis of the right or left lower extremity.
<br>
[**2160-4-18**] CT HEAD:
1. No evidence of major vascular territorial infarct, although
MRI with diffusion-weighted imaging remains more sensitive for
this indication.
2. Expanded sella with enlarged pituitary gland is better
evaluated on MRI brain performed [**2159-8-15**] and is unchanged since
that time.
Brief Hospital Course:
Mr. [**Known lastname **] is a 66 yo male with metastatic NSCLC who presents
following a witnessed syncopal event now anemic
.
Hospital Course by Problem:
.
Patient was intially admitted to the MICU where flu was ruled
out by DFA. otherwise stable there.
.
Syncope: Patient with likely vasovagal and/or hypovolemic
syncope. Patient without prior cardiac risk factors aside from
age and enzymes/EKG are negative. CT head negative for
metastatsis. Patient's Cr slightly increased from baseline
suggesting hypovolemia. Patient had this event in the setting of
a bowel movement, which would suggest vasovagal activity. Both
hypovolemia and vasovagal likely contributed. Tamponade was
also suspected because pt had pulsus alternans and a pulsus of
15 as well as distant heart sounds. A stat bedside echo showed
no effusion. Patient was monitored on telemetry for 24 hours
with no events. Transthoracic echo was within normal limits.
Patient was transfused 2 units pRBCS and felt much better.
.
Febrile neutropenia: Fever of unclear etiology and no suspected
source. Patient no longer neutropenic once on oncology floor.
Patient was initially started in cefepime 2mg q8 hours. He was
afebrile for over 48 hours and ANC improved, so he was taken off
antibiotics. Cultures remained negative.
ARF: Patient with increased Cr, likely pre-renal given FeNa <1%.
This likely contributed to syncope. s/p 2 units prbcs
Respiratory distress: Patient with respiratroy distress prior to
admission by report. CXR has been negative, although may this
may be due to viral syndrome or bacterial etiology. PE also in
differential, cannot get CTA because of ARF. This resolved
before admission to ICU.
Medications on Admission:
Cefepime 2 g IV Q12H (Day 1: [**2160-4-19**])
Oseltamivir Phosphate 75 mg PO BID
---
Megestrol Acetate 800 mg PO QAM
Acetaminophen 650 mg PO Q6H:PRN
Ondansetron 4 mg IV Q8H:PRN nausea
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN
OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID:PRN
Heparin 5000 UNIT SC TID
Pyridoxine HCl 50 mg PO DAILY
Influenza Virus Vaccine 0.5 ml IM ASDIR
Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Medications:
1. Megace Oral 40 mg/mL Suspension Sig: One (1) tablespoon PO
once a day.
2. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for chills, discomfort.
5. Motrin 400 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
6. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Metastatic non small cell lung cancer
syncope
anemia from blood loss
secondary:
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital after fainting. You had also had a
cough. The fainting was most likely secondary to low blood
volume. You recieved a blood transfusion and felt much better
afterward.
You were also checked for the flu. You did not have the flu.
Please call your doctor or return to the hospital if you faint,
have chest pain, high fevers, or any other concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] Phone:[**0-0-**]
Date/Time:[**2160-4-29**] 10:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-4-29**] 12:00
Completed by:[**2160-4-27**]
|
[
"288.00",
"162.5",
"584.9",
"198.7",
"V10.52",
"280.0",
"780.2",
"780.6",
"198.5",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8310, 8316
|
5423, 5550
|
323, 330
|
8450, 8459
|
4578, 5105
|
8891, 9228
|
3854, 3973
|
7663, 8287
|
8337, 8429
|
7131, 7640
|
8483, 8868
|
3988, 4559
|
276, 285
|
5578, 7105
|
358, 3417
|
5114, 5400
|
3439, 3559
|
3575, 3838
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,818
| 167,958
|
3948+3949
|
Discharge summary
|
report+report
|
Admission Date: [**2128-9-14**] Discharge Date: [**2128-9-21**]
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
male diabetic who presented for a stress test, which was
proven to be positive.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o.q.d., Zestril 30
mg p.o.q.d., Glucophage 850 mg p.o.b.i.d., Zocor 10 mg
p.o.q.d. and Lasix 20 mg p.o.q.d., however, patient reports
not having taken the Lasix.
PHYSICAL EXAMINATION: On physical examination, the patient
was afebrile with stable vital signs. Lungs: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm. Abdomen: Benign. Extremities: Warm and well
perfused.
ALLERGIES: The patient has no known drug allergies.
HOSPITAL COURSE: The patient was transferred to the
cardiothoracic service for coronary artery bypass grafting.
The patient was taken to the Operating Room on [**2128-9-16**]. The patient was transferred to the CSRU
postoperatively, where he did well.
Postoperatively, the patient was slowly weaned from the
ventilator and extubated. He was transferred to the floor
and his chest tubes were removed. The patient had episodes
of confusion and attempted to removal his Foley. A new Foley
was placed, urology was consulted. Physical therapy was also
consulted for mobility and for function. He continued to do
well.
The patient continued to do well on the floor. He was given
Haldol for his confusion and improved. Sitters were stopped
on [**2128-9-21**] and the patient continued to do well.
His oxygen was weaned and he was up and ambulating. He is
being discharged to a rehabilitation facility in stable
condition.
DISCHARGE MEDICATIONS:
Lasix 20 mg p.o.b.i.d.
Metformin 500 mg p.o.b.i.d.
Simvastatin 10 mg p.o.b.i.d.
Clopidogrel 75 mg p.o.q.d.
Vicodin one to two tablets p.o.q.4h.p.r.n.
Enteric coated aspirin 325 mg p.o.q.d.
Potassium 20 mEq p.o.q.d.
Lopressor 12.5 mg p.o.b.i.d.
FOLLOW-UP: The patient was instructed to follow up in one to
two weeks with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
CONDITION ON DISCHARGE: The patient was discharged to a
rehabilitation facility in stable condition.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2128-9-21**] 15:05
T: [**2128-9-21**] 16:26
JOB#: [**Job Number **]
Admission Date: [**2128-9-14**] Discharge Date: [**2128-10-4**]
Service:
This is a 78-year-old male who has a history of high
cholesterol, and hypertension, and chronic renal
insufficiency who was seen at cardiac catheterization
laboratory and found to have multivessel disease.
On examination, he had a long history of chest discomfort for
several months and had anginal symptoms. His past medical
history is significant for chronic renal insufficiency,
benign prostatic hypertrophy, diverticulitis, mild
hyperparathyroidism, hypertension, hyperlipidemia. He is
status post TURP, status post right carotid.
He had no known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin, Zestril, and Glucophage
80 mg, Lasix, multivitamins, Zocor.
He was taken to the operating room on [**2128-9-16**] where a
coronary artery bypass graft was performed, off pump. He was
slowly weaned from his ventilator postoperatively. He was
started on beta blockers and diuretics postoperatively and
continued to improve. Physical therapy was consulted for
ambulation and he did well. He was transferred to the floor
on [**2128-9-17**], continued to improve. His chest tube was
removed. His Foley was kept in place. He had episodes of
confusion at that time which he pulled his Foley and his
pacing wires.
Urology was consulted for placement of a new Foley due to
inability to void and the Foley was kept in place for 48
hours. He was then started on Haldol on a standing dose with
some improvement. His Foley was removed after 48 hours and
the patient did well. Sitter was started to monitor his
mental status and his agitation. He began diuresis.
However, he continued to have changes in his mental status
and Psychiatry was consulted, which felt that he was having
delirium. However, he did not have clearing of his mental
status, his Haldol was causing extra-parametal symptoms, so
it was reduced to 2 mg standing dose, and it was found that
his extraparametal symptoms improved. However, he needed to
continue to be monitored.
He postoperatively developed urinary tract infection which
also developed bacteremia from that and was started on
levofloxacin. His white count was 26.1 and his creatinine
rose all the way to 3.7. His metformin and Lasix were
stopped, and the patient was switched to Avandia. Renal
consult was taken at that time and a renal ultrasound showed
no extrinsic disease. There is some slight subcortical
thinning, but no hydronephrosis. He continued on renal dose
of levofloxacin for a total of 10 day course and mental
status began to improve. Patient's creatinine dropped back
down to 2.6 and was consistent with urinary electrolytes were
normal and patient continued to be followed and improved.
PT was reconsulted at that time to assess his ambulation due
to his multiple medical issues. He is unable to be assessed.
PT felt comfortable sending the patient home for ambulatory
abilities and his mental status continued to improve. His
primary care physician is also following along and was kept
abreast of all of these issues. Sitter was removed and
patient was felt to be capable enough to go home with VNA on
[**2128-10-4**]. On [**2128-9-24**] the patient was discharged with VNA
services.
DISCHARGE MEDICATIONS: Levofloxacin 250 mg po q day x2 more
days, Avandia 2 mg po bid, Lopressor 25 mg po bid,
simvastatin 10 mg po q day, Plavix 75 mg po q day x3 months,
EC-ASA 325 po q day, and Colace 100 mg po bid.
The patient is discharged home in stable condition.
Instructed to followup with Dr. [**Last Name (STitle) **] in [**1-21**] weeks and Dr.
[**Last Name (STitle) 1537**] in [**4-24**] weeks. Patient is discharged home in stable
condition.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2128-10-4**] 11:13
T: [**2128-10-4**] 11:23
JOB#: [**Job Number 17537**]
|
[
"790.7",
"998.59",
"401.9",
"414.01",
"599.0",
"276.5",
"584.9",
"293.0",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
5745, 6456
|
3161, 5721
|
757, 1667
|
464, 739
|
125, 235
|
2126, 3134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,442
| 143,410
|
53648
|
Discharge summary
|
report
|
Admission Date: [**2164-3-17**] Discharge Date: [**2164-3-19**]
Date of Birth: [**2092-10-1**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Intracerebral [**Hospital 110177**] transfer from [**Hospital3 14565**].
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs [**Known lastname **] is a 71-year-old left-handed woman presenting with the
above on a background of Coumadin for likely AF and numerous
medical problems.
[**Doctor First Name **], her son, cooked dinner. Her granddaughter brought food
down to her in her down-stairs apartment at about 7:30 PM last
night. At 8:50 she called on the phone to upstairs to talk and
was fine (she has a cell phone downstairs), said that she was
full. At about 11 PM, [**Doctor First Name **] was going to bed. He could hear
someone yelling. He didn't know who it was, intially, but they
then heard Mrs. [**Known lastname **] yelling for help. They rushed downstairs.
Mrs. [**Known lastname **] had vomited and defecated. She was in her bed. She
said that she couldn't sit. Then when helped up she said she
couldn't find her feet. She then asked where he was when he was
standing right in front of her ith bright lights on. She seemed
to be unable to see. He was going to call 911, but Mrs. [**Known lastname **]
asked for [**Doctor First Name **] to call her daughter, [**Name (NI) 1022**]. [**Name2 (NI) **] called [**Doctor Last Name 1022**] and
then [**Doctor Last Name 1022**] asked to speak with her. [**Doctor First Name **] had to place the phone
in
her hand. Mrs. [**Known lastname **] spoke to [**Doctor Last Name 1022**] and said "I can't go to the
bathroom". 911 was called. She became increasingly incoherent,
still able to speak, forming words that where irrelevant for
EMS.
She was taken to [**Hospital3 **]. CT scan was performed at [**Hospital3 14565**] at about 1 AM. A large hemorrhage was seen. She was
intubated at 2 AM given that she was not interactive and she
kept
slumping down (concern about airway). She was transported to
[**Hospital1 18**] at 5:30 AM by ambulance. She was given vitamin K and two
units FFP at [**Hospital3 **], also loaded with Dilantin. She was
hypertensive to 222/100 at [**Hospital3 **], rate 83, then 245
systolic at 4:58 AM before transfer (HR not recorded), other
vitals normal. INR 2.2 at [**Hospital3 **] before reversed, UA clear,
creatinine 0.6, CBC with leukocytosis to 14.9, K 3.2, otherwise
normal labs.
Neurosurgery saw the patient in the ED, but did not think
intervention was indicated in any way at this time. Neurology
was
called.
[**Hospital1 18**] ED:
Today 06:05 Nitroprusside Sodium 25mg/mL-2mL 1 [**Last Name (LF) 33474**], [**First Name3 (LF) **]
Today 06:07 Nitroprusside Sodium 25mg/mL-2mL Return 1 [**Last Name (LF) 33474**],
[**First Name3 (LF) **]
Today 06:09 Labetalol 100 mg / 20 mL Vial 1 [**Last Name (LF) 110178**], [**First Name3 (LF) 6177**]
Today 07:27 Propofol 1000mg/100mL Vial 1 [**Last Name (LF) **],[**First Name3 (LF) **] A.
Takes medications faithfully. Has been well lately. Review of
systems negative except as above.
Past Medical History:
Per Son and HCP:
- Hypertension
- [**Name (NI) **]
- On Coumadin, likely AF (INR every two weeks)
- Pacreatitis (?) with surgery - common duct obstrcution
- Varices, hiatal hernia (?)
- Diabetes, type II, on insulin
- Hypothyroidism
- Iron deficiency anemia
- Osteopenia (?)
Per [**Hospital3 **] notes, also:
- Splenectomy, thrombocytopenia before
- Renal Failure
Social History:
Llives with son, [**Name (NI) **], and her grandchildren. Independent, but
for help with food shopping, climbs stairs slowly. No alcohol,
smoking.
Family History:
Sons think heart disease in her family, her brothers.
Physical Exam:
At admission:
Vitals: T 97.9 F, CMV 14 x 0.4, FiO2 0.4, 138/70, HR 88 SR, 100%
General Appearance: Intubated, lying flat, occasional irregular
and asymmetric, alternating shaking of arms and legs.
HEENT: NC, AT, intubated.
Neck: Supple.
Lungs: CTA bilaterally/vent sounds.
Cardiac: Regular, SEM upper sternal.
Abdominal: Soft.
Extremities: Cool peripheral pulses 1+.
Neurologic:
Mental status:
Movement to pain.
Cranial Nerves:
I: Not tested.
II: Pupils miotic and unreactive.
III, IV, VI: Doll's intact.
V, VII: Face symmetric, corneals intact.
VIII: Hearing cannot be tested.
IX, X: Gag intact.
[**Doctor First Name 81**]: Not tested.
XII: Intubated.
Posture normal and no truncal ataxia.
Tone normal throughout. Normal bulk.
Power
Reflexes and pain withdrawal intact.
Reflexes: B T Br Pa Ac
Right 2 2 2 1 0
Left 2 2 2 1 0
Toes upgoing.
Sensation intact to pain with withdrawal.
Pertinent Results:
[**2164-3-17**] 03:16PM CK-MB-3 cTropnT-<0.01
[**2164-3-17**] 03:16PM CK(CPK)-124
[**2164-3-17**] 03:16PM GLUCOSE-263* UREA N-16 CREAT-0.7 SODIUM-143
POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12
[**2164-3-17**] 09:11PM OSMOLAL-322*
[**2164-3-17**] 09:11PM SODIUM-145 POTASSIUM-3.4 CHLORIDE-109*
[**2164-3-17**] 03:16PM CALCIUM-8.2* PHOSPHATE-2.3* MAGNESIUM-1.5*
[**2164-3-17**] 03:16PM OSMOLAL-308
[**2164-3-17**] 03:16PM WBC-10.9 RBC-3.56* HGB-10.6* HCT-33.1* MCV-93
MCH-29.9 MCHC-32.1 RDW-13.2
[**2164-3-17**] 03:16PM PLT COUNT-133*
[**2164-3-17**] 03:16PM PT-14.8* PTT-28.8 INR(PT)-1.4*
[**2164-3-17**] 06:55AM PO2-194* PCO2-29* PH-7.58* TOTAL CO2-28 BASE
XS-6
[**2164-3-17**] 06:25AM GLUCOSE-307* UREA N-17 CREAT-0.7 SODIUM-143
POTASSIUM-3.0* CHLORIDE-101 TOTAL CO2-23 ANION GAP-22*
[**2164-3-17**] 06:25AM PHENYTOIN-18.7
[**2164-3-17**] 06:25AM WBC-12.0* RBC-3.70* HGB-11.3* HCT-33.7*
MCV-91 MCH-30.5 MCHC-33.5 RDW-13.2
[**2164-3-17**] 06:25AM NEUTS-88.8* LYMPHS-6.9* MONOS-3.4 EOS-0.7
BASOS-0.3
[**2164-3-17**] 06:25AM PLT COUNT-142*
[**2164-3-17**] 06:25AM PT-14.1* PTT-28.4 INR(PT)-1.3*
[**2164-3-17**] 06:25AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2164-3-17**] 06:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2164-3-17**] 06:25AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2164-3-17**] NCHCT:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the left occipital,
parietal and
temporal lobes with extension into the left lateral ventricle,
third
ventricle, and fourth ventricle and with a subdural component
along the
tentorium.
2. Severe left cerebral hemispheric mass effect, midline shift
to the right by 12 mm, and uncal herniation as well as
effacement of the left-sided basilar cistern and the ambient
cisterns.
3. Comparison to the outside hospital CT is not possible since
the only one images of the study was uploaded onto the PACS
system.
[**2164-3-17**] CXR:
IMPRESSION: Appropriately placed lines and tubes.
[**2164-3-18**] NCHCT:
IMPRESSION: Left-sided intraparenchymal hemorrhage with
surrounding edema,
sulcal effacement, midline shift, and intraventricular
extension. There is
severe mass effect and midline shift with the uncus displaced
into the ambient
cistern, similar in appearance compared to [**2164-3-17**]; no new
areas of
hemorrhage.
[**2164-3-18**] CXR:
Orogastric tube terminates in the proximal stomach, but side
port is above
this level and the tube could be advanced for standard
positioning.
Otherwise, no relevant changes since recent study except for
slight improved aeration at the left lung base.
Brief Hospital Course:
71-year-old left-handed woman with a-fib on coumadin who
presents with left temp-parietal lobar hemorrhage while lying in
bed, admitted to the Neuro-ICU. Exmaination is consistent with
intact brainstem, left posterior cortical dysfunction,
Wernicke's progressed to mutism. This seems likely spontaneous.
Antecents may have been hypertension or angiopathy, with
Coumadin also present (INR 2.2). Family meeting on [**2164-3-18**] came
to make the patient CMO. The patient passed away quietly on
[**2164-3-19**] while in the Neuro-ICU.
Medications on Admission:
- Folic acid, 1 mg
- Nadolol 40 mg QD
- Furosemide 20 mg QD
- Levothyroxine 75 ug QD
- Enalapril maleate 20 mg QD
- Pravastatin 40 mg QHS
- Vitamin D 50,000 QWeek
- Coumadin 1-2 mg (alternating days, most likely)
- Citracal caltrate 630 mg QD
- Iron 65 mg QD
- Inulins:
- Levemir 12 units QAM
- Novolog before meals
Discharge Medications:
na
Discharge Disposition:
Expired
Discharge Diagnosis:
na
Discharge Condition:
deceased
Discharge Instructions:
na
Followup Instructions:
na
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"272.0",
"348.5",
"403.90",
"V58.61",
"784.3",
"585.9",
"250.00",
"280.9",
"342.90",
"244.9",
"348.4",
"518.81",
"431",
"V58.67",
"427.31",
"733.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8442, 8451
|
7504, 8039
|
378, 384
|
8497, 8507
|
4778, 7481
|
8558, 8655
|
3779, 3834
|
8415, 8419
|
8472, 8476
|
8065, 8392
|
8531, 8535
|
3849, 4231
|
265, 340
|
412, 3211
|
4281, 4759
|
4246, 4265
|
3233, 3599
|
3615, 3763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,345
| 148,385
|
45836
|
Discharge summary
|
report
|
Admission Date: [**2159-5-24**] Discharge Date: [**2159-6-1**]
Date of Birth: [**2082-11-10**] Sex: M
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
gentleman with a history of CAD, hypertension, high
cholesterol, chronic renal insufficiency, and idiopathic
restrictive cardiomyopathy, possibly secondary to amyloid,
who presents with increase in shortness of breath. The
patient was recently hospitalized for worsening CHF during
which he had a thoracentesis and a fat pad biopsy. He
reports since then increased shortness of breath, dyspnea on
exertion with 10-15 feet. He also notes decreased urine
output overnight and he has no urine output on the morning of
admission. The patient presented to the Emergency Room with
an O2 saturation of 73% on room air and a systolic blood
pressure in the 70's and no urine output after a Foley
catheter was placed. He was given 500 cc of normal saline
bolus and started on Dopamine. The patient initially
required a non rebreather but was eventually stable on nasal
cannula O2. He had a right IJ catheter placed in the
Emergency Room and a Swan Ganz placed later in the day. The
patient had a thoracentesis of a recurrent right pleural
effusion with ultrasound guidance also upon arrival in the
CCU.
PAST MEDICAL HISTORY: 1) Coronary artery disease status post
CABG in [**2142**]. 2) Cardiomyopathy, infiltrative, currently
being worked up for amyloidosis. 3) Recurrent transudative
pleural effusions. 4) Hyperlipidemia. 5) Chronic renal
insufficiency with a baseline creatinine of 1.5 to 2.0. 6)
Hypertension. 7) Status post hernia repair. 8) Penile
implant.
MEDICATIONS: On admission, Toprol 50 mg q d, Aldactone 25 mg
q d, Lasix 120 mg q d, Zocor 20 mg q d, Aspirin 325 mg q d,
Colestipol 5 mg q d and Zestril 2.5 mg q d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone, family nearby,
DNR/DNI, no tobacco, no alcohol.
REVIEW OF SYSTEMS: No fevers, weight is stable, positive non
productive cough. The patient notes increased abdominal
girth, no nausea, vomiting, diarrhea or bright red blood per
rectum, good appetite, no dysuria or frequency.
PHYSICAL EXAMINATION: On admission, T current 97.8, pulse
79, blood pressure 91/40, respiratory rate 18, O2 saturation
94% on Dopamine. General, patient is a pleasant, elderly
male in no acute distress, who is alert and oriented times
three. HEENT: Pupils are equal, round, and reactive to
light and accommodation, extraocular movements intact,
scleral icterus, oropharynx clear, dry mucus membranes. Neck
supple with JVD of about 12. Lungs, decreased breath sounds
at the bases with bibasilar rales. Cardiovascular, regular
rate and rhythm, normal S1 and S2, no murmurs, rubs or
gallops. Abdomen soft, nontender, non distended, positive
bowel sounds. Extremities, no pedal edema, 1+ DP pulses
bilaterally. Neuro, patient is a alert and oriented times
three, cranial nerves intact, moving all extremities.
LABORATORY DATA: On admission white count 11.1, hematocrit
35.2, platelet count 231,000, PT 14.7, INR 1.5, sodium 127,
potassium 5.3, chloride 89, CO2 27, BUN 47, creatinine 2.5,
glucose 126, urinalysis showed large blood and nitrites,
greater than 300 protein, small bilirubin, [**3-6**] whites,
greater than 50 RBC, ALT 20, AST 22, LDH 196, total bilirubin
2.4, total protein 2.2, albumin 3.9, CK 65, troponin 1.0,
calcium 9.1, magnesium 2.2, pleural fluid showed protein 3.0,
glucose 131, LDH 90, PH 7.49. Chest x-ray showed right sided
pleural effusion and mild CHF. EKG was V paced with rate of
66. Abdominal biopsy was negative for amyloid.
Echocardiogram [**4-27**] showed left atrial moderately dilated,
symmetric LVH, right myocardium with speckled pattern, LVEF
30-35. Cath on [**2158-8-10**], SVG to OM1 patent, LIMA to LAD
patent, RA19 wedge 34.
HOSPITAL COURSE: The patient is a 76-year-old gentleman with
a history of CAD, hypertension, high cholesterol,
infiltrative cardiomyopathy being worked up for amyloid, who
came in with hypotension and hypoxia.
1. Cardiovascular: Patient with a restrictive
cardiomyopathy thought to be secondary to amyloid. He came
in with hypotension, required Dopamine which was eventually
weaned off. The patient had a Swan Ganz catheter placed
which initially showed an output of 6.5, an index of 3.23 and
SVR of 714. These numbers decreased slightly when the
Dopamine was weaned off. The patient underwent a biopsy of
his endomyocardium and results at this time are pending. The
H&E stain was suggestive for amyloid but the
for definitive amyloid diagnosis is
pending at this time. The patient was not restarted on any
of his cardiac medications and was discharged home not on any
medications. His pacer was checked by EP and the rate was
increased to 80.
2. Pulmonary: Patient is status post tap of recurrent
transudative effusions, likely secondary to congestive heart
failure. The patient underwent pleuroscopy with pleurodesis
and pleural biopsy on the 29th. He had a chest tube that was
removed prior to discharge. He did well and will follow-up
with Dr. [**Name (NI) **].
3. GI: The patient had elevated alkaline phosphatase and
bilirubin on admission. He had an abdominal ultrasound that
showed minimal ascites with distended hepatic veins
consistent with right heart failure. He had some gallstones
without any evidence of cholecystitis. His LFTs became more
normal prior to discharge.
4. Renal: The patient admitted with elevated creatinine,
decreased urine output and worsening renal failure. He had
recently been started on ACE inhibitor. This was
discontinued. Urine output and creatinine improved while on
Dopamine. His numbers continued to be stable and on day of
discharge had actually started to go up and on day of
discharge creatinine was 2.1. He had potassium of 6.1 on day
of discharge for which he received Kayexalate and Lactulose
and those numbers will be repeated the day after discharge by
home VNA.
5. Endocrine: Patient with hyponatremia, pattern consistent
with heart failure, his urine lytes were not consistent with
SIADH. An endocrine consult was obtained and they agreed
that heart failure was the likely etiology. There is also
concern over adrenal insufficiency and an a.m. Cortisol was
checked and was 25. This ruled out adrenal insufficiency.
Of note, his thyroid functions were also checked and his TSH
was 12 and his free T4 was 1.4. But given the fact that he
had received some Dopamine which could suppress his TSH,
these may not be accurate numbers. Endocrine also noted that
the free T4 is not very helpful in an acute hospitalized
setting. He has repeat TFTs and T3 and T3 uptake pending at
time of discharge. This needs to be followed up by Dr. [**Last Name (STitle) **].
6. GU: The patient had some dysuria and bladder spasm with
his Foley catheter. He received Levsin prn for those spasms.
Also of note, patient has penile implants and had a condom
catheter that caused increased swelling of his penis. He was
seen by GU who helped deflate his implants and his symptoms
improved.
DISPOSITION: The patient will be discharged home, with home
VNA services. He does not want to pursue further care and is
DNR/DNI at this time. They will arrange home hospice as they
are interested. The patient is discharged home on no
medications. He will have labs checked on day after
discharge. He will follow-up with Dr. [**Last Name (STitle) **] in one week and
Dr. [**Name (NI) **] in one week.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Restrictive cardiomyopathy.
3. Congestive heart failure.
4. Renal failure.
5. High cholesterol.
6. Recurrent pleural effusions.
7. Status post pleurodesis.
DISCHARGE MEDICATIONS: None.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.12-abz
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2159-6-1**] 10:57
T: [**2159-6-1**] 11:09
JOB#: [**Job Number 43154**]
|
[
"401.9",
"428.0",
"277.3",
"272.0",
"425.7",
"276.1",
"585",
"511.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.24",
"34.92",
"34.04",
"34.91",
"37.25"
] |
icd9pcs
|
[
[
[]
]
] |
7833, 8082
|
7614, 7809
|
3924, 7593
|
2248, 3906
|
2016, 2225
|
149, 171
|
200, 1331
|
1354, 1905
|
1922, 1996
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,200
| 153,506
|
44388
|
Discharge summary
|
report
|
Admission Date: [**2187-6-28**] Discharge Date: [**2187-7-5**]
Service: CARDIOTHORACIC
Allergies:
Tetanus Toxoid, Fluid
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2187-6-28**] Emergent CABG x3 on IABP(LIMA-Diag, SVG-LAD, SVG-OM)
[**2187-6-28**] Cardiac Catheterization/Placement of IABP
[**2187-6-29**] RE-exploration for Bleeding
History of Present Illness:
The patient is an 84-year-old woman who presented with an acute
myocardial infarction and angina of several days' duration.
Catheterization was performed which showed very tight left main
and LAD disease in addition to severe left sided coronary artery
disease. She is status post right coronary artery stenting and
there was only mild disease in this vessel. She had received 600
mg of Plavix several hours prior to the procedure and an
intra-aortic balloon pump was placed. But she had [**11-9**] chest
pain on the balloon pump and therefore was taken emergently to
the operating room for bypass surgery.
Past Medical History:
CAD s/p IMI/PCI-RCA, HTN, ^chol, Cataracts, Uterine CA s/p TAH,
Appy, Rt elbow fx
Social History:
Quit smoking [**2142**]. Admits to approx 20 pack year history.
Family History:
No family history of premature coronary disease
Physical Exam:
126/61, 64, 18, 99% 4L
Elderly female, supine, IABP in place
No acute distress
Oropharynx benign
Neck supple, no JVD. Carotids 2+ without bruits.
Lungs with bibasilar crackles.
Heart with regular rate and rhythm. Normal s1s2. No murmur or
rub.
Abdomen benign
Ext warm without edema
Non-focal neuro exam.
Pertinent Results:
ADMIT LABS:
[**2187-6-28**] 09:05AM BLOOD WBC-9.9 RBC-3.89* Hgb-12.4 Hct-36.4
MCV-94 MCH-31.9 MCHC-34.1 RDW-13.1 Plt Ct-263
[**2187-6-28**] 09:05AM BLOOD PT-11.8 PTT-24.7 INR(PT)-1.0
[**2187-6-28**] 09:05AM BLOOD Glucose-124* UreaN-14 Creat-0.8 Na-134
K-5.2* Cl-98 HCO3-26 AnGap-15
[**2187-6-28**] 09:05AM BLOOD cTropnT-<0.01
[**2187-6-28**] 09:05AM BLOOD CK-MB-3
[**2187-6-28**] Cardiac Cath:
1. Coronary angiography in this right-dominant system revealed
severe
left-main and multivessel CAD:
--the LMCA had an 80% distal stenosis
--the LAD had a 95% ostial stenosis. D2 had a 60% stenosis.
--the LCX had a 60% proximal stenosis
--the RCA had a 50% proximal stenosis.
2. Left ventriculography revealed measured LVEF 77%, normal LV
systolic
function and no mitral regurgitation.
3. Limited resting hemodynamics revealed elevated left-sided
filling
pressures, with LVEDP 16 mmHg. Systemic arterial systolic
pressures
were normal, with SBP 132 mmHg. There was no gradient across
the aortic
valve upon pullback of the angled pigtail catheter from LV to
ascending
aorta.
4. Patient had severe angina after angiography. A 30cc IABP
was placed
with resolution of the chest pain.
[**2187-6-28**] Intraop TEE:
PRE-BYPASS:
1. The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Acute severe hypokinesis
noted in the mid to apical septum and mid to apical anterior and
anterolateral wall. This resolved with heart rate control and
pericardial opening.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are three aortic valve leaflets. No aortic
regurgitation is seen. Aortic sclerosis is seen, [**Location (un) 109**] is around
2.1 cm2 by planimetry.
5. Mild (1+) mitral regurgitation is seen.
POST-BYPASS:
For the post-bypass study, the patient was receiving vasoactive
infusions including phenylephrine and is being AV paced.
1. Biventricular function is preserved.
2. Aorta is intact post decannulation
DISCHARGE LABS:
[**2187-7-4**] 06:05AM BLOOD Hct-31.5*
[**2187-7-3**] 05:18AM BLOOD WBC-12.9* RBC-3.46* Hgb-10.6* Hct-30.7*
MCV-89 MCH-30.6 MCHC-34.5 RDW-14.7 Plt Ct-134*
[**2187-7-4**] 06:05AM BLOOD Glucose-86 UreaN-23* Creat-0.7 Na-137
K-3.4 Cl-93* HCO3-38* AnGap-9
[**2187-7-3**] 05:18AM BLOOD Glucose-96 UreaN-30* Creat-0.9 Na-137
K-3.5 Cl-94* HCO3-37* AnGap-10
[**2187-7-2**] 05:20AM BLOOD Glucose-82 UreaN-30* Creat-1.1 Na-139
K-4.4 Cl-99 HCO3-31 AnGap-13
Brief Hospital Course:
Given left main lesion and persistent chest pain, Mrs. [**Known lastname **]
was emergently taken to the operating room where Dr. [**Last Name (STitle) **]
performed coronary artery bypass grafting surgery. She returned
to the operating room later that night for postoperative
bleeding. She was also given multiple blood products. For
surgical details, please see seperate dictated operative notes.
Following the operation, she was brought to the CVICU for
invasive monitoring. On postoperative day one, she weaned from
Epinephrine. By postoperative day two, the IABP was removed and
she was extubated without incident. She had an episode of SVT
which broke with Adenosine. She also experienced episodes of
paroxsymal atrial fibrillation and was started on Amiodarone. By
postoperative day three, she converted back to a normal sinus
rhythm. She otherwise maintained stable hemodynamics and
transferred to the SDU on postoperative day four. Over several
days, she continued to make clinical improvements with diuresis.
She remained in a normal sinus rhythm without further episodes
of atrial fibrillation. Medical therapy was optimized and she
was medically cleared for discharge to rehab on postoperative
day seven.
Medications on Admission:
Cauduet 5/40'
Fosamax 70'
Lisinopril 40'
Metoprolol 175"
ASA 162'
Norvasc 5'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: then drop to 200mg daily. Please hold for heart rate
less than 60.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily):
Hold SBP<110 mmHg .
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days: Then titrate accordingly to preoperative weight of 65kg.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days:
Take with Lasix. Titrate accordingly.
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**7-8**]
hours as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Extended Care
Discharge Diagnosis:
Coronary Artery Disease - s/p Emergent CABG
Postop Bleeding - s/p Re-expoloration
Postop Atrial Fibrillation
Acute Myocardial Infarction
History of IMI [**2175**], s/p PCI/Stenting to RCA [**2175**]
Hypertension
Elevated Cholesterol
History of Uterine CA s/p TAH
Discharge Condition:
Stable
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 911**] 2 weeks - call for appt
Dr. [**Last Name (STitle) **] 4 weeks - call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2429**] 2 weeks - call for appt
Completed by:[**2187-7-5**]
|
[
"427.31",
"286.9",
"E849.7",
"427.89",
"401.9",
"272.0",
"410.81",
"E878.2",
"996.72",
"414.01",
"V10.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"88.56",
"36.15",
"97.44",
"88.72",
"37.61",
"38.93",
"34.01",
"36.12",
"38.91",
"39.61",
"38.85",
"99.06",
"37.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
6658, 6715
|
4266, 5484
|
245, 418
|
7022, 7031
|
1644, 3780
|
7330, 7569
|
1256, 1305
|
5611, 6635
|
6736, 7001
|
5510, 5588
|
7055, 7307
|
3796, 4243
|
1320, 1625
|
195, 207
|
446, 1054
|
1076, 1159
|
1175, 1240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
561
| 105,399
|
18799
|
Discharge summary
|
report
|
Admission Date: [**2113-7-25**] Discharge Date: [**2113-7-28**]
Date of Birth: Sex:
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 51472**] was a 63 year old
man who was found in his bathroom around noon on the day of
admission. He was found to be minimally responsive to
questions. After he was transferred to the [**Hospital1 346**], he progressively got worse in his
mental status and could only respond to noxious stimuli.
Initially, he was brought to a local hospital where a CT
confirmed a large bleed inside his brain. Cervical spine was
cleared and the patient was intubated before being transferred to
the [**Hospital1 69**].
Neurologic examination at the time of admission: The patient
was unresponsive and could only respond with withdrawal to deep
noxious stimuli. He did not respond to any other
stimulation. His cranial nerve examination revealed severe
papilledema with pupils one to two mms bilaterally. The tone
of his musculature was normal in all limbs and no rigidity
was noted. His reflexes were spread and crossed in the lower
extremity, especially when it was applied to the right
patella. No reflexes could be seen on the left. His toes
were upgoing on both sides.
HOSPITAL COURSE: At the time of admission, CAT scan of his
head showed a large, acute, intracranial hemorrhage with
surrounding edema centered in the left basal ganglion. The
area of acute hemorrhage measured six by four cms. The edema
extended anteriorly to the left frontal lobe. This created a
mass effect on the left lateral ventricle and there was a
rightward shift of the midline by approximately one cm. No
skull fracture was noticed.
Mr. [**Known lastname 51473**] condition gradually deteriorated and on [**7-28**], the patient's status was changed to comfort measures
only. He expired a little later that day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-279
Dictated By:[**Doctor Last Name 51474**]
D: [**2113-9-12**] 08:30
T: [**2113-9-13**] 03:34
JOB#: [**Job Number 51475**]
|
[
"431",
"401.9",
"305.1",
"412",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1270, 2094
|
162, 1252
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,847
| 122,837
|
52090
|
Discharge summary
|
report
|
Admission Date: [**2170-10-20**] Discharge Date: [**2170-10-29**]
Date of Birth: [**2105-4-22**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 65-year-old
man with a history of coronary artery disease, peripheral
vascular disease, chronic obstructive pulmonary disease, and
hypertension, who presented to [**Hospital3 3583**] with
increasing shortness of breath. He had recently been
admitted to the same hospital with pneumonia complicated by
respiratory failure requiring intubation, and had been
discharged a couple of weeks prior. After discharge, he had
mild baseline dyspnea which began to worsen until he
developed shortness of breath with minimal exertion. He
denied fevers and cough, but reported occasional chills. He
denied nausea, vomiting, or chest pain.
PAST MEDICAL HISTORY: Coronary artery disease status post
myocardial infarction, peripheral vascular disease status
post bilateral lower extremity revascularization, chronic
obstructive pulmonary disease, chronic renal insufficiency
with a baseline creatinine of 2.0, and hypertension.
MEDICATIONS AT HOME: Norvasc 10 mg once a day, minoxidil 2.5
mg three times a day, Clonidine .1 mg three times a day,
aspirin 81 mg once a day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with wife at home. 50 year smoking
history, quit recently.
SUMMARY OF OUTSIDE HOSPITAL COURSE: Upon presentation to
[**Hospital3 3583**], Mr. [**Known lastname **] was found to have wheezing on
examination. His oxygen saturations were 97% on room air. A
chest x-ray showed a right upper lobe pneumonia. He was
started on levofloxacin, Solu-Medrol, and nebulizer
treatments. His blood pressure on admission was 240/133, and
this was treated aggressively. He was continued on his usual
regimen of minoxidil and Clonidine. In addition, he was
given Verapamil sustained release 240 mg once a day,
Terazosin 2 mg once a day, and Cozaar 50 mg once a day. With
this regimen, his blood pressure dropped to as low as 107/43.
The rapidity of this decline is unknown.
After his blood pressure fell to this level, his Verapamil
and Cozaar were held, however, the Clonidine, minoxidil and
Terazosin were continued. His creatinine began rising to a
maximum of 6.1 at the time of discharge from [**Hospital3 3583**].
An MRA there showed an atrophic right kidney, a tiny and
stenosed right renal artery, and a high-grade stenosis at the
origin of the left renal artery. By the time of discharge,
the patient was anuric and making minimal urine. Quantities
were not specified in outside hospital records.
During his hospitalization at [**Hospital3 3583**], he also
developed lower extremity weakness, which initially began on
the right side but progressed to bilateral involvement.
These symptoms were attributed at first to anxiety, but
continued to worsen, and he was transferred to [**Hospital1 346**] for further workup and neurologic
imaging.
At the time of transfer, he had a chief complaint of
bilateral leg weakness and moderate shortness of breath. He
denied chest pain, fevers, chills, nausea, vomiting,
diarrhea, abdominal pain, dizziness or lightheadedness.
PHYSICAL EXAMINATION: Temperature 98.4, blood pressure
98/58, heart rate 81, respirations 22, oxygen saturation 96%
on 2 liters. In general, he was in no apparent distress,
alert and oriented x 3. His pupils were equally round and
reactive to light, extraocular movements intact, oropharynx
with small white exudate on uvula, otherwise clear. Lungs:
Crackles at the right base, good air movement. Cardiac:
Regular rate and rhythm, I/VI systolic murmur at the upper
sternal borders, no gallops or rubs. Abdomen: Soft,
slightly distended, nontender, no hepatosplenomegaly, no
masses, normal active bowel sounds, guaiac negative.
Extremities: No edema, 1+ distal pulses bilaterally.
Neurological examination: Fluent speech, normal
comprehension, cranial nerves II through XII intact. Upper
extremities: 5/5 strength bilaterally, with 2+ reflexes, no
pronator drift. The patient was unable to feel his Foley
catheter, positive rectal tone. Lower extremities: 0/5
strength bilaterally, areflexic, toes equivocal. T11-12
pinprick and temperature level, intact proprioception and
light touch.
LABORATORY DATA: White count 9, hematocrit 23.6, platelets
290. Sodium 131, potassium 6.2, chloride 96, bicarbonate 17,
BUN 86, creatinine 6.9, glucose 156, anion gap 24. CK 250,
CK/MB 14, MB index 5.6, troponin 5.6. Electrocardiogram
showed ST depressions in I, AVL, V4 through V6, which were
new compared with an electrocardiogram from the outside
hospital.
HOSPITAL COURSE:
1. Neurology: Bilateral leg weakness. An MRI of the head
was obtained to rule out watershed infarcts. The MRI was
negative for acute process. A MRI of the whole spine was
obtained to rule out compression or infarct. The study was
negative, but limited due to technical aspects. Neurology
was consulted, and it was felt that the patient's symptoms
were most consistent with an anterior spinal artery
distribution and that his hypotensive episode had
precipitated a spinal infarct resulting in paraplegia, with
poor prognosis for any type of meaningful recovery. He was
started on aspirin and Plavix after bleeding was ruled out by
imaging studies.
2. Renal: Bilateral renal artery stenosis. The patient's
blood pressure was low (100/60) on admission, and he was in
anuric renal failure at the time of presentation, with an
anion gap acidosis and hyperkalemia. The Renal team was
notified and did not feel that dialysis was indicated. He
was treated accordingly for his hyperkalemia, and given
bicarbonate.
3. Pulmonary: He was continued on levofloxacin for the
right upper lobe pneumonia, and continued on nebulizers and
oral steroids for chronic obstructive pulmonary disease
exacerbation.
4. Cardiovascular: Hypotension. His blood pressure
medications were held. He was given calcium gluconate in an
attempt to reverse the effects of Verapamil received at the
outside hospital.
5. Hematology: Decreased hematocrit. The patient received
transfusions of packed red blood cells given his history of
coronary artery disease and hematocrit of 23.6.
ASSESSMENT: It was felt that the patient had multiple
iatrogenic problems due to hypotension secondary to
aggressive treatment of high blood pressure at the outside
hospital. These included spinal infarct, acute anuric renal
failure, demand cardiac ischemia. Per the patient, his
baseline blood pressure was around 180 and, given his
relative hypotension at the time of admission, it was felt
that his blood pressure needed to be raised in order to
improve perfusion.
He was transferred to the Intensive Care Unit and received
intravenous fluids with careful monitoring, as well as
Levophed. During his Medical Intensive Care Unit course, his
blood pressure came back to the 150s, and he began to make
urine. His neurological examination remained unchanged. His
cardiac enzymes remained within normal limits with a peak MB
index of 5.6. These elevations were attributed to demand
ischemia vs. small myocardial infarction. His CK did rise to
13,000, and this was attributed to his neuromuscular
injuries.
He was transferred back to the floor, where he continued to
do well from a renal standpoint. His creatinine trended down
from a maximum of 8.3 to close to baseline by the time of
discharge. On [**10-28**], his creatinine was 2.4. His
baseline creatinine is 2.0.
His neurological examination at the time of discharge remains
unchanged. He remains paraplegic and with 0/ strength in his
lower extremities. He and his family are both aware of the
poor prognosis for recovery of neurological function, and
they are also aware of the etiology of his recent medical
complications.
DISCHARGE STATUS: Discharged to spinal rehabilitation unit.
DISCHARGE TREATMENT:
1. Goal blood pressure 150 to 160. The patient's
hypertension should not be aggressively treated below 150, as
he has shown intolerance of low blood pressure. He is
currently on Lopressor 25 mg twice a day and lasix 20 mg once
a day, and these should be titrated slowly.
2. The patient will need careful follow up of bowel and
bladder function, given his paraplegia. He is currently
being straight catheterized intermittently every eight hours
to prevent the infectious risk of a permanent indwelling
Foley catheter, and aggressive bowel regimen should be
maintained to ensure that the patient stools regularly.
3. Frequent turning, out of bed as tolerated, physical and
occupational therapy.
4. Replete electrolytes as needed.
DISCHARGE DIET: Regular.
DISCHARGE MEDICATIONS: Aspirin 81 mg by mouth once a day,
Tums two tablets by mouth three times a day, heparin 5000
units subcutaneously twice a day, Protonix 40 mg by mouth
once a day, Plavix 75 mg by mouth once a day, albuterol and
Atrovent metered dose inhalers as needed, Lipitor 10 mg by
mouth once a day, Ambien 5 mg by mouth daily at bedtime as
needed, Lopressor 25 mg by mouth twice a day, potassium
chloride as needed, miconazole powder twice a day as needed,
Colace 100 mg by mouth twice a day, Lactulose 30 cc by mouth
as needed, soapsuds enema per rectum as needed, lasix 20 mg
by mouth once a day (additional lasix as needed), magnesium
oxide as needed, calcium gluconate as needed.
DISCHARGE DIAGNOSIS:
1. Spinal infarct resulting in paraplegia
2. Anuric renal failure, resolving
3. Cardiac demand ischemia
(All of above attributed to hypotensive episode.)
4. Right upper lobe pneumonia
5. Chronic obstructive pulmonary disease exacerbation
6. Anemia
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 4925**]
MEDQUIST36
D: [**2170-10-29**] 01:55
T: [**2170-10-29**] 02:09
JOB#: [**Job Number 107812**]
|
[
"486",
"410.71",
"440.1",
"336.1",
"491.21",
"584.9",
"414.01",
"276.7",
"344.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8739, 9413
|
9434, 9953
|
4700, 8715
|
1156, 1319
|
3238, 4683
|
184, 845
|
869, 1134
|
1337, 1423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,043
| 108,686
|
47384+47385
|
Discharge summary
|
report+report
|
Admission Date: [**2165-9-9**] Discharge Date: [**2165-9-19**]
Date of Birth: [**2107-3-17**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
female with a prior cardiac history of severe mitral
regurgitation and severe tricuspid regurgitation, as well as
dilated cardiomyopathy with biventricular failure and an
ejection fraction of 25 to 30%, with complaint of increasing
leg edema, increasing abdominal distention times the last two
weeks. She denies fever, chills, shortness of breath,
positive cough with production of green brown sputum and
nausea always present at baseline. No vomiting, no
palpitations, no diaphoresis. She was admitted for
preoperative diuresis prior to a scheduled mitral valve
replacement and tricuspid valve repair scheduled for
[**2165-9-12**].
PAST MEDICAL HISTORY: Significant for:
1. Myocarditis at age 11.
2. Dilated cardiomyopathy with biventricular failure.
3. Severe tricuspid regurgitation.
4. Severe mitral regurgitation.
5. Atrial fibrillation with cardioversion and placement of a
DDD pacer on [**5-12**], currently in VVI mode.
6. Hypertension.
7. Chronic renal insufficiency with a baseline creatinine of
1.4 to 2.0.
8. Hypothyroidism.
9. Iron deficiency anemia.
10. Methicillin resistant Staphylococcus aureus pneumonia.
11. Peptic ulcer disease.
12. Migraine headaches.
13. Chronic sinusitis.
14. Panic disorder.
15. Malnutrition/anorexia.
16. Status post Billroth II in [**2153**].
17. Status post roux-en-y in [**2156**].
18. Status post volvulus with hemicolectomy and ileosigmoid
anastomosis in [**2160**].
19. Status post perforated small bowel obstruction.
ALLERGIES: Gentamicin, Bactrim, Chloramphenicol and
Penicillin.
MEDICATIONS ON ADMISSION:
1. Lasix 80 mg twice a day.
2. Zaroxolyn 2.5 mg twice a day.
3. Captopril 12.5 mg three times a day.
4. Amiodarone 200 mg once daily.
5. Coumadin 7.5 mg once daily which was discontinued as of
[**2165-9-3**].
6. Synthroid 125 mcg once daily.
7. Actigall 300 mg twice a day.
8. Calcium one gram once daily.
9. Protonix 40 mg once daily.
10. Klonopin 1 mg three times a day.
11. Prozac 80 mg once daily.
12. Fioricet p.r.n.
13 [**Doctor First Name **] 60 mg twice a day.
14. Nasacort Spray p.r.n.
15. Compazine suppository 25 mg twice a day p.r.n.
16. Multivitamin one once daily.
17. Potassium Chloride 80 meq twice a day.
SOCIAL HISTORY: The patient lives with fiancee. Positive
tobacco use, quit several years ago. Former benzodiazepine
addiction.
PHYSICAL EXAMINATION: At the time of admission, vital signs
revealed temperature 97.6, blood pressure 102/64, heart rate
86, respiratory rate 16, oxygen saturation 100% in room air.
In general, the patient is a very thin, small frame woman in
no distress. Head, eyes, ears, nose and throat - The
oropharynx is pink. Mucous membranes are moist. The tongue
is moist. Extraocular movements are intact. Cardiovascular
regular rate and rhythm, paced, II/VI systolic murmur and
soft distant heart sounds. The chest reveals good
inspiratory effort, bilaterally clear to auscultation,
occasional crackles in bibasilar area. No wheezes and no
rhonchi. The abdomen is soft, positive bowel sounds, no
distention, nontender, no guarding. Extremities - bilateral
lower extremity edema 2 to 3+ from the dorsal foot up to the
patella, unable to palpate pulses secondary to edema, no
cyanosis.
LABORATORY DATA: White count 6.1, hematocrit 25.3, platelets
315,000. Sodium 133, potassium 3.0, chloride 95, CO2 22,
blood urea nitrogen 51, creatinine 1.4, glucose 181. Albumin
3.0.
HOSPITAL COURSE: The patient was admitted to the Medical
service. The heart failure service and cardiology service
were both consulted and the patient was vigorously diuresed
over the several days prior to her scheduled surgery. She
was also seen and cleared by the dental service while she was
an inpatient.
On [**2165-9-12**], the patient was brought to the operating room
for scheduled surgery. Please see the operative report for
full details. In summary, the patient underwent a mitral
valve replacement with a #29 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valve and
tricuspid valve repair with a #32 [**Doctor Last Name **] annuloplasty ring.
She tolerated the operation well and was transferred from the
operating room to the Cardiothoracic Intensive Care Unit. At
the time of transfer, she had Neo-Synephrine at 2.0
mcg/kg/minute, Dobutamine at 5 mcg/kg/minute and Propofol at
50 mcg/kg/minute. The patient did well in the immediate
postoperative period following her arrival in the
Cardiothoracic Intensive Care Unit. Her anesthesia was
reversed. She was weaned from the ventilator and
successfully extubated.
Postoperative day one, the Electrophysiology service was
consulted and the patient's intrinsic pacer seemed to be
missensing and misfiring. Also on postoperative day one, the
patient was weaned from her Dobutamine and Neo-Synephrine.
During that time, she remained hemodynamically stable despite
being in accelerated junctional rhythm.
On postoperative day two, the patient had been on all
cardioactive drugs 24 hours. She was started on Lasix,
Lopressor and Aspirin as well as Coumadin and transferred to
the floor for continuing postoperative care and cardiac
rehabilitation.
Over the next several days, the patient remained
hemodynamically stable. Her active level was advanced with
the assistance of the nursing staff and physical therapy.
The patient continued to be followed by the heart failure
service as well as the electrophysiology service. She did
show no further evidence of pacemaker malfunction.
On postoperative day five, the pacemaker was again
interrogated by electrophysiology and was found to be
functioning at the same level as it had been prior to her
surgery, and therefore the plan to electively reposition
wires postoperatively was aborted. Electrophysiology service
signed off with the plan to follow-up with the patient as an
outpatient in Device Clinic on [**2165-10-1**].
The patient is to be restarted on Coumadin at this point
given her mechanical mitral valve and history of atrial
fibrillation. Her goal INR will be 3.0. It is anticipated
that the patient will be stable and ready for discharge
within the next two days.
At this time, the patient's physical examination is as
follows: Vital signs revealed temperature 97.1, heart rate
90, atrial fibrillation, blood pressure 100/60, respiratory
rate 18, oxygen saturation 97% in room air. Preoperative
weight was 110 pounds and discharge weight is 106.7 pounds.
Laboratory data as of [**2165-9-17**], is white blood cell count
10.0, hematocrit 27.3, platelet count 268,000. Sodium 135,
potassium 3.2, chloride 96, CO2 23, blood urea nitrogen 59,
creatinine 1.6, glucose 112.
The patient is alert and oriented times three, moves all
extremities, follows commands. Breath sounds, scattered
crackles, diminished at the bases bilaterally.
Cardiovascular regular rate and rhythm, S1 and S2, with
positive mechanical click. The abdomen is soft, nontender,
minimally distended. Extremities are warm, perfused with 2+
edema bilaterally. Sternal incision is stable, clean and
dry, open to air, closed with staples, no erythema.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement with #29 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
mechanical valve.
2. Status post tricuspid valve repair with #32
[**Last Name (un) 3843**]-[**Doctor Last Name **] annuloplasty ring.
3. Cardiomyopathy.
4. Atrial fibrillation.
5. Hypertension.
6. Chronic renal insufficiency.
7. Hypothyroidism.
8. Anemia.
9. Peptic ulcer disease.
10. Migraines.
11. Sinusitis.
12. Panic disorder.
13. Anorexia.
14. Status post Billroth II.
15. Status post roux-en-y.
16. Status post volvulus with hemicolectomy and an
ileosigmoid anastomosis.
17. Perforated small bowel obstruction.
18. Methicillin resistant Staphylococcus aureus pneumonia.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 5 mg once daily.
2. Lasix 80 mg twice a day.
3. Potassium 20 meq twice a day.
4. Amiodarone 200 mg once daily.
5. Metoprolol 12.5 mg twice a day.
7. Fioricet one to two tablets q4hrs p.r.n.
8. Clonazepam 0.5 mg three times a day.
9. Fluoxetine 80 mg once daily.
10. Actigall 300 mg twice a day.
11. Levothyroxine 125 mcg once daily.
12. Colace 100 mg twice a day.
13. Ranitidine 150 mg twice a day.
14. Coumadin 5 to 7.5 mg once daily to reach a goal INR of
2.0 to 3.0.
15. Ambien 5 mg q.h.s. p.r.n.
The patient is to be discharged to home with VNA and home
rehabilitation services. She is to have follow-up in the
[**Hospital **] Clinic on [**2165-10-1**], at 1:30 p.m. in the [**Hospital Ward Name 23**]
Building. She is also to have follow-up with the Heart
Failure Clinic. She is to have follow-up in [**Hospital 409**] Clinic in
two weeks. She is to have follow-up with Dr. [**Last Name (STitle) **] in three
to four weeks and follow-up with her primary care physician
also in three to four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2165-9-17**] 17:42
T: [**2165-9-17**] 18:21
JOB#: [**Job Number 18104**]
Admission Date: [**2165-9-9**] Discharge Date: [**2165-9-19**]
Date of Birth: [**2107-3-17**] Sex: F
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
female with prior cardiac history significant for severe
mitral regurgitation as well as severe tricuspid
regurgitation, dilated cardiomyopathy with biventricular
failure, and an estimated left ventricular ejection fraction
of approximately 30%. She recently presented complaining of
increased leg edema, increased abdominal distention, and
weight gain for a few weeks. She has a history of a DDD
pacemaker device placement. The patient denies any shortness
of breath currently. She denies any palpitations or
diaphoresis or chest pain. The patient was originally
admitted to the Medicine service.
PAST MEDICAL HISTORY:
1. Myocarditis at age 11
2. Dilated cardiomyopathy with biventricular failure and
estimated ejection fraction of 30%
3. Severe tricuspid regurgitation
4. Severe mitral regurgitation
5. Atrial fibrillation/flutter with DDD pacer placed in [**5-12**]
6. Hypertension
7. Chronic renal insufficiency
8. Hypothyroidism
9. Iron-deficiency anemia
10. History of methicillin resistant staphylococcus aureus
pneumonia
11. Peptic ulcer disease
12. Migraine headaches
13. Chronic sinusitis
14. Panic disorder
PAST SURGICAL HISTORY:
1. Billroth II in [**2153**]
2. Roux-en-Y in [**2156**]
3. Volvulus status post hemicolectomy and ileosigmoid
anastomosis in [**2160**]
4. Perforated small bowel obstruction
ALLERGIES:
1. Gentamicin
2. Bactrim gives the patient headaches and pruritus.
3. Chloramphenicol
4. Penicillin
MEDICATIONS ON ADMISSION:
1. Lasix 80 mg by mouth twice a day
2. Captopril 12.5 mg by mouth three times a day
3. Amiodarone 200 mg by mouth once daily
4. Coumadin 7.5 mg by mouth once daily (discontinued on
[**2165-9-3**])
5. Synthroid 125 mcg by mouth once daily
6. Actigall 200 mg by mouth twice a day
7. Zaroxolyn 2.5 mg by mouth twice a day
8. Prozac 80 mg by mouth once daily
9. Fioricet as needed
10. [**Doctor First Name **] 60 mg by mouth twice a day
11. Nasacort spray as needed
12. Multivitamin
13. Potassium chloride 80 mEq twice a day
SOCIAL HISTORY: Former smoker.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.6, blood
pressure 102/64, heart rate 86, respiratory rate 16, oxygen
saturation 100% on room air. The patient appeared to be a
rather thin woman in no apparent distress. Head, eyes, ears,
nose and throat examination within normal limits.
Cardiovascular examination regular rate and rhythm, II/VI
systolic ejection murmur, soft heart sounds. Chest: Good
inspiratory effort, clear to auscultation bilaterally,
occasional crackles bibasilarly. Abdominal examination:
Bowel sounds present, abdomen soft, nontender, nondistended.
Extremities: Bilateral pitting edema, extremities otherwise
warm and well perfused, no pulses palpable secondary to
edema.
LABORATORY DATA: Hematocrit 29.9, white blood cell count
9.2. PT 13.9, PTT 150. Glucose 90, BUN 56, creatinine 1.8,
potassium 4.4. An electrocardiogram obtained on [**2165-9-10**]
showed a probable accelerated junctional rhythm.
HOSPITAL COURSE: The patient was originally admitted to the
Medicine service. She was placed on intravenous heparin.
She was continued on amiodarone. The patient was also
started on amoxicillin for endocarditis prophylaxis. The
patient was transfused with two units of packed red blood
cells. The patient was diuresed. At the time, Cardiac
Surgery was consulted about a possible surgical intervention,
given valvular disease.
On [**2165-9-12**], the patient underwent tricuspid valve repair (#32
[**Doctor Last Name **] annuloplasty ring) and mitral valve repair (#29 St.
[**Male First Name (un) 1525**] mechanical valve). The procedure was without any
complications. Please see the full operative note for
details.
The patient was transferred to the Intensive Care Unit in
stable condition. The patient continued to be in accelerated
junctional rhythm. No ectopy was noted. Electrophysiology
service was consulted. Their opinion was that both the A and
the V leads were malfunctioning. The patient was extubated
on postoperative day one. The patient tolerated extubation
well. Physical Therapy was consulted to follow the patient
throughout the hospitalization. The chest tubes and the
urine catheter were removed. The patient was continued on
intravenous heparin and she was also given a dose of Coumadin
on postoperative day three.
Electrophysiology service was following the patient
throughout the hospitalization. The patient's pacemaker was
re-interrogated on postoperative day four. Their opinion was
that the pacing leads are not functioning well, but overall
system is adequate with VVI pacing. They thought that lead
revision would very likely be a long procedure without
guarantee of improving quality of right atrial or right
ventricular leads. Given the fact that the patient is not
pacemaker dependent, the decision was made to not proceed
with lead revision but to follow the patient clinically.
The patient was also seen in-house by the congestive heart
failure attending, who recommended changes to the diuresis
regimen. The patient continued to do well. She continued to
be in junctional rhythm with some ectopy. On [**2165-9-18**], the
patient had one run of ventricular tachycardia (four beats),
which was not repeated. In addition, the patient's potassium
level was measured at 2.1. It was adequately replenished
with oral and intravenous potassium at the time. The
patient's repeat potassium was stable at 4.2.
The patient was discharged to a rehabilitation facility on
[**2165-9-19**] in stable condition.
CONDITION ON DISCHARGE: Good
DISCHARGE DISPOSITION: Rehabilitation facility
DISCHARGE DIAGNOSIS:
1. Valvular disease status post mitral valve repair and
tricuspid valve repair
2. Congestive heart failure
3. Atrial fibrillation
4. Cardiomyopathy
5. Hypertension
6. Chronic renal insufficiency
7. Anemia
DISCHARGE MEDICATIONS:
1. Lisinopril 5 mg once daily
2. Lasix 80 mg twice a day
3. Potassium chloride 20 mg twice a day
4. Amiodarone 200 mg once daily
5. Metoprolol 12.5 mg twice a day
6. Metolazone 5 mg once daily
7. Fioricet one to two tablets every four hours as needed
8. Clonazepam 0.5 mg by mouth three times a day
9. Fluoxetine 80 mg by mouth once daily
10. Ursodiol 300 mg by mouth twice a day
11. Synthroid 12.5 mcg by mouth once daily
12. Colace 100 mg by mouth twice a day
13. Ranitidine 150 mg by mouth twice a day
14. Coumadin to be adjusted to the INR goal of 2.5 to 3.0
15. Ambien 5 mg daily at bedtime as needed
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with her surgeon, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], in approximately four weeks.
2. The patient is to follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] (the
congestive heart failure specialist) in approximately one
week.
3. The patient is to follow up with her primary care
physician within the next one to two weeks.
4. Anticoagulation instructions: The patient's Coumadin
level is to be adjusted accordingly to maintain an INR level
of 2.5 to 3.0.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 10097**]
MEDQUIST36
D: [**2165-9-19**] 01:56
T: [**2165-9-19**] 02:52
JOB#: [**Job Number 100277**]
|
[
"424.2",
"276.8",
"280.9",
"263.9",
"425.4",
"E878.1",
"424.0",
"996.01",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"42.23",
"88.72",
"35.33",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
15153, 15178
|
7326, 8026
|
15435, 16051
|
15199, 15412
|
8052, 9495
|
11031, 11562
|
12554, 15098
|
16075, 16911
|
10710, 11005
|
11618, 12536
|
9524, 10157
|
10179, 10687
|
11579, 11595
|
15123, 15129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,664
| 155,471
|
4729
|
Discharge summary
|
report
|
Admission Date: [**2168-2-9**] Discharge Date: [**2168-2-17**]
Date of Birth: [**2093-3-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Hydrochlorothiazide / Biaxin / Ciprofloxacin /
Thiazides / Darvocet-N 100 / Demerol
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Febrile neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74F w/ with a recent diagnosis of non-small cell lung CA who was
seen in clinic on the day prior to admission with epistaxis,
fatigue and oral ulcers. She reports that she has epistaxis
frequently, but that it was much worse than usual, (dripping
blood, used 3 boxes of kleenex, passing several clots). She
reports the fatigue is stable x 3 weeks. Oral
ulcers/inflammation of her lips has been present x 2 weeks; it
is uncler if this is due to HSV vs a side effect of chemo. She
received a platelet transfusion and was started on acyclovir
(for presumptive oral HSV).
.
The patient returned to clinic in follow up on the day of
admission; she was found to be febrile to 100.4 with
neutropenia. She was therefore transferred to OMED for direct
admission.
Past Medical History:
Non small cell lung CA of LUL -left superior anterior
mediastinum diagnosed in [**11-29**] as part of w/u for worsening sob-
Well-differentiated adenocarcinoma of mucinous type, stains
consistent with primary lung carcinoma. Dr [**Last Name (STitle) **] in thoracic
surgery felt that the mass was not operable to the the location
adjacent to the branch vessels of the aorta - s/p 2 cycles of
carboplatin and Taxol, complicated by an episode of acute
shortness of breath, nausea, myaglgias and significant
neuropathy; s/p 1 cycle of carboplatin AUC 6 and gemcitabine
1000 mg/m2 days one
and eight, complicated by epistaxis, thrombocytopenia.
.
Coronary artery bypass graft x2 vessels [**2164**]
Aortic valve replacement in [**4-/2165**], a tissue valve
Chronic back pain with sciatica
Diastolic CHF requiring hosp x 2 ([**2164**], [**2166**]); recent echo
showed LVEF of 75%, LVOT Obstruction
Hypertension results in pulmonary edema
Hypotension results in syncope
History of right-sided pulmonary nodules
Cholecystectomy
TAH and BSO (unclear why)
Cataract surgery
Thyroid cancer ([**2112**], radical surgery and radiation therapy)
Social History:
She is married. She formerly worked as a freelance writer. She
smoked about one cigarette per day for 30 years and has not
smoked in the last 20 years. She does not drink alcohol.
.
Family History:
Her mother died at age 83 of senile dementia and CHF. Her father
died at age 86 of emphysema. He was a smoker. She has a brother
age 73 in good health with the exception of diabetes and sister
age 77 and a sister age 69. She has two maternal aunts with
breast cancer in her early 60s but, otherwise, there is no
family history of cancer.
Physical Exam:
Vitals- T 98.6 BP 91/52 HR 90 RR 22 O2Sat 91% RA
Gen: Comfortable, NAD
Heent: + oral ulcer on lip. mmm.
Lungs: decreased BS at L base. scattered exp wheezes.
Cardiac: RRR
Abd: +bs, soft, nt/nd.
Ext: no edema
Skin: intact, no rashes
Neuro: Awake and alert
Pertinent Results:
[**2168-2-8**] 04:49PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+
[**2168-2-8**] 04:49PM NEUTS-53.0 BANDS-2.0 LYMPHS-40.0 MONOS-3.0
EOS-2.0 BASOS-0
[**2168-2-8**] 04:49PM WBC-1.5*# RBC-2.96* HGB-8.7* HCT-25.1* MCV-85
MCH-29.5 MCHC-34.8 RDW-16.3*
[**2168-2-8**] 04:49PM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-2.2*
MAGNESIUM-1.5*
[**2168-2-8**] 04:49PM GLUCOSE-117* UREA N-12 CREAT-0.7 SODIUM-129*
POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-27 ANION GAP-14
[**2168-2-9**] 09:53AM GRAN CT-410*
.
EKG:
Sinus tachycardia
Possible left atrial abnormality
Late R wave progression - probable normal variant
Since pervious tracing, heart rate faster
.
[**2-9**] CXR: 1. Bibasilar opacities are concerning for
consolidation or atelectasis. 2. Left hemidiaphragm elevation
and left pleural effusion are unchanged. 3. Left superior
mediastinal mass has increased in size which may be due to tumor
extension, atelectasis surrounding the tumor, or
post-obstructive consolidation.
.
[**2-12**] TTE
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular
systolic function is hyperdynamic (EF>75%). There is a severe
resting left
ventricular outflow tract obstruction. A mid-cavitary gradient
is identified.
There is no ventricular septal defect. Right ventricular chamber
size and free
wall motion are normal. A bioprosthetic aortic valve prosthesis
is present.
The aortic prosthesis appears well seated, with normal
leaflet/disc motion and
transvalvular gradients. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. There is moderate to severe
mitral annular
calcification. There is a minimally increased gradient
consistent with trivial
mitral stenosis. Mild to moderate ([**11-24**]+) mitral regurgitation is
seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is
moderate to severe pulmonary artery systolic hypertension. There
is no
pericardial effusion.
Brief Hospital Course:
74 female with NSCLC admitted for febrile neutropenia,
transferred to [**Hospital Unit Name 153**] for 24 hours with sudden respiratory failure
due to pulmonary edema, then transferred back to OMED where her
course was complicated by pneumonia and recurrent pulmonary
edema due to diastolic failure.
.
When patient arrived to the floor on admission she was initially
stable, breathing comfortably with a lung exam notable for only
decreased sounds in the LLL. However, shortly after arrival, she
developed acute respiratory distress with tachypnea and
shortness of breath. VS were significant for BP of 190s/100s,
HR: 160s. Her lung exam revealed diffuse crackles and rales. Her
ABG was 7.33/57/71 on facemask. CXR showed cephalization and
some consolidation at the left hemidiaphragm. Lasix 40 mg IV was
given x3. Nebs were given. Nitropaste (1 inch) was applied.
Hydrocortisone 40 mg IV was given. Bipap was started. The
patient was emergently transferred to the [**Hospital Unit Name 153**] for Bipap and
closer monitoring.
.
In the ICU patient was still very tachypneic and in respirtory
distress so given 4mg of morphine. After morphine given patient
respiratory status improved however her blood pressure dropped
to SBP 60s and she was then given IVF bolus which she responded
to. Her Bipap was able to be removed shortly afterwards. She
remained stable overnight and was then called out to the floor
for further management. She again had respiratory distress
secondary to pulmonary edema triggered by HTN and tachycardia on
[**2-10**]; this event was managed on the floor with Lasix and
Lopressor IV.
.
On the floor, the following issues were addressed.
.
#Pulmonary edema/Diastolic Dysfunction: The patient's
respiratory failure was thought to be due to sudden pulmonary
edema due to tachycardia and hypertension in the setting of
severe diastolic heart failure and LVOT obstruction. Cardiology
was consulted. Her betablocker was titrated up to 75mg TID by
discharge with marked improvement in her heart rate (120's on
admission, down to 100's by discharge). Her Valsartan was
discontinued. She will follow up with cardiology after discharge
for further management of her severe diastolic disfunction and
consideration of AV nodal ablation. Additionally, albuterol was
d/c'd and levalbuterol started to minimize the side effect of
tachycardia.
.
#PNA: The patient was found to have b/l PNA on CXR; several
aspiration events were witnessed throughout her hospitalization.
She was initially treated with cefepime and vancomycin for
febrile neutropenia; this was changed to Zosyn for broader
coverage given her aspiration events. She required supplemental
O2 via non-rebreather then shovel mask for the first several
days of her admission; this was weaned as her O2 sats improved.
She was discharged on levofloxacin for a total of a 2 week
course.
.
# Febrile Neutropenia - Mrs[**Known lastname 19892**] counts quickly improved
as she had received Neulasta prior to her hospitalization. She
remained afebrile throughout her admission. Blood and urine
cultures were negative at the time of discharge.
.
#Aspiration Risk: The patient has known L vocal cord paralysis
and had witnessed aspiration events on two occasions. She has
previously failed a speech and swallow eval. Speech and swallow
were again consulted; however, the patient refused to
participate in an evaluation. She stated full understanding of
her ongoing aspiration and of the associated risks of that. She
refused to modify her diet or swallowing techniques in any way.
.
#HSV: The patient had extensive perioral HSV ulcerations on
admission. She was treated with acyclovir. Her ulcerations
improved as her counts recovered. She was discharged with [**Hospital1 **]
acyclovir.
.
# Non-small cell lung CA - No therapy at present. Supportive
care was provided. She will follow up as an outpatient.
.
# Cardiovascular: The patients statin and ASA were discontinued
in an effort to minimize her pill burden given her difficulty in
swallowing.
.
# Hypothyroidism -The patient was continued on synthroid.
.
# Diarrhea - the day prior to discharge the patient had some
loose stool. C diff was negative and she remained afebrile for
more than 24 hours with a decrease in her white count. She was
advised that if her diarrhea did not resolve within 36-48 hours
to call her primary oncologist.
Medications on Admission:
Ambien 5mg qhs
Atenolol 31.25 qhs
Compazine 10mg q8 prn
Cozaar 12.5mg qam
Fish Oil
Lipitor 10mg qhs
Synthroid 0.125mg qam
NTG 0.4mg SL prn
Premarin 0.3mg qam
Ativan 0.5mg prn
Lomotil prn
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q3H PRN ().
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed.
7. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation q6h () as needed for SOB or wheezing.
Disp:*1 inhaler* Refills:*0*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
12. Folic Acid 400 mcg Tablet Sig: Three (3) Tablet PO once a
day.
Disp:*90 Tablet(s)* Refills:*2*
13. Acyclovir 200 mg/5 mL Suspension Sig: Five (5) mL PO twice a
day.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Primary: diastolic heart failure, pulmonary edema, febrile
neutropenia and pneumonia
Secondary: NSCLC
Discharge Condition:
Fair
Discharge Instructions:
During this admission you have been treated for diastolic heart
failure, pulmonary edema, febrile neutropenia and pneumonia.
Please continue to take all of your medications as prescribed.
It is very important to take your Metoprolol 75mg three times
daily, as controlling your heart rate will be key in avoiding
the breathing problems you were admitted with.
If you develop shortness of breath, chest pain, rapid heart
rate, fever, or any other concerning symptoms please seek
immediate medical care.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2168-2-18**]
1:00pm
.
You will also be scheduled for a follow up appointment with Dr.
[**First Name (STitle) **] on Thursday [**2-18**]. The office will contact you to let
you know what time this appointment is.
.
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2168-3-16**] 10:00
.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2168-3-18**] 8:10
|
[
"451.82",
"276.1",
"780.6",
"934.1",
"486",
"428.0",
"V42.2",
"493.20",
"E912",
"287.5",
"416.8",
"054.9",
"244.0",
"162.9",
"V10.87",
"518.81",
"428.30",
"288.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11183, 11244
|
5334, 9705
|
373, 379
|
11390, 11397
|
3165, 5311
|
11947, 12589
|
2535, 2874
|
9943, 11160
|
11265, 11369
|
9731, 9920
|
11421, 11924
|
2889, 3146
|
314, 335
|
407, 1163
|
1185, 2318
|
2335, 2519
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,417
| 156,284
|
39868
|
Discharge summary
|
report
|
Admission Date: [**2186-12-1**] Discharge Date: [**2186-12-11**]
Date of Birth: [**2122-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization [**2186-12-1**]
Coronary artery bypass graft x3 (left internal mammary artery >
let anterior descending, saphenous vein graft > obtuse marginal,
saphenous vein graft > posterior descending) [**2186-12-5**]
History of Present Illness:
64 year old male with medically managed MI in [**2161**], HTN and
dyslipidemia complaining of exertional angina ongoing since
[**2186-2-13**]. He began noticing
pain while out running for exercise in [**Month (only) 958**] and notes pain has
been progressively worsening over the last few months. Stress
test on [**2186-4-24**] revealed medium area of myocardial scar with
mild peri- infarct ischemia in PDA distribution. He presents
today for cardiac catheterization to further evaluate.
Past Medical History:
s/p MI medically managed [**2161**] at [**Hospital 8**] Hospital
Dyslipidemia
Chronic back pain
s/p R Hernia repair
s/p Hydrocele
Hypertension
Social History:
Lives with:alone
Occupation:executive in a pharmaceutical company
Tobacco:quit 35yrs ago, smoked for 10 yrs 5-6 packs per day
ETOH:2 beers every Friday
Family History:
mom MI [**25**]'s, brother MI [**15**]'s
Physical Exam:
Pulse:71 Resp:16 O2 sat:96/Ra
B/P Right:123/82 Left:149/75
Height:5'[**86**]" Weight:274 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
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaqu. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
Biventricular systolic function remains preserved. The MR is now
trace. The study is otherwise unchanged from the prebypass
period.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2186-12-5**] 12:51
Brief Hospital Course:
Presented for cardiac catheterization and was found to have
significant coronary artery disease. He was admitted and
underwent preoperative workup and on [**2186-12-5**] was brought to the
operating room and underwent coronary artery bypass graft
surgery, see operative report for further details. He received
vancomycin for perioperative antibiotics and was transfered to
the intensive care unit for post operative management. In the
first twenty four hours he was weaned from sedation,
neurologically intact, and was extubated without complications.
Post operative day one he continued to progress and was
transferred to the floor. Physical therapy was consulted for
strength and mobility. Gently diuresed toward his preop weight
-had 1+ lower extremity bilaterally at the time of discharge.
Chest tubes and pacing wires removed per protocol. Developed A
Fib on [**12-9**] and amiodarone started. Anticoagulated with
coumadin for afib. Cleared for discharge to home with VNA
services on [**2186-12-11**] by Dr. [**Last Name (STitle) **].
Medications on Admission:
HYDROCHLOROTHIAZIDE 25 mg daily
LISINOPRIL 20 mg daily
SIMVASTATIN 80 mg daily
ASCORBIC ACID 500 mg twice a day
ASPIRIN 325 mg daily
GINKGO BILOBA 60 mg twice a day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
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. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
9. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): take 400mg for 5 days then 400mg daily for 7 days then
200mg daily.
Disp:*120 Tablet(s)* Refills:*2*
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. warfarin 5 mg Tablet Sig: as directed Tablet PO once a day:
coumadin dosing based on INR for afib
INR goal 2.0-2.5.
Disp:*60 Tablet(s)* Refills:*2*
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
14. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
15. Outpatient Lab Work
INR draw on [**2186-12-12**] and call results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3530**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
postop A Fib
Dyslipidemia
Chronic back pain
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Oxycodone and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2186-12-28**] 2:45
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**3-20**] weeks [**Telephone/Fax (1) 3530**]
Cardiologist: Dr [**Last Name (STitle) 2257**] [**Telephone/Fax (1) 2258**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw [**2186-12-12**] Results to Dr. [**Last Name (STitle) **] phone [**Telephone/Fax (1) 3530**]
Completed by:[**2186-12-11**]
|
[
"427.31",
"V15.82",
"413.9",
"414.01",
"412",
"E878.2",
"997.1",
"V17.3",
"272.4",
"285.9",
"401.9",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.12",
"88.56",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6433, 6490
|
3160, 4207
|
323, 555
|
6624, 6876
|
2138, 3137
|
7717, 8437
|
1428, 1471
|
4424, 6410
|
6511, 6603
|
4233, 4401
|
6900, 7694
|
1486, 2119
|
272, 285
|
583, 1074
|
1096, 1242
|
1258, 1412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,258
| 103,434
|
18719
|
Discharge summary
|
report
|
Admission Date: [**2200-4-23**] Discharge Date: [**2200-4-30**]
Date of Birth: [**2126-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Shortness of breath, fatigue.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 73 y/o M with CMML who was admitted on [**2200-4-2**] at
[**Location (un) 5871**] for splenic rupture where he underwent emergent
splenectomy on [**4-2**], course complicated by intra-abdominal staph
infection. There is no discharge summary available but per the
patient the procedure was without complications, no pressor
requirement per operative report. Culture of hematoma revealed
coagulase negative staphylococcus with multiple resistances but
sensitive to vancomycin. He was started on vancomycin for this.
Per pt he also had diarrhea related to c. diff infection and
flagyl was started. He was discharged from the OSH to complete a
course of vancomycin and flagyl. Since discharge the patient
reports that he has generally remained somewhat tired and
occasionally has felt some soreness in his ankles. This morning
he reports feeling much more tired and noticed that,
intermittently, he has felt some shortness of breath. No
associated chest pain or diaphoresis. The patient was taken by
hospital to the oncology clinic. There he was afebrile and
hemodynamically stable; however, his O2 saturation was noted to
be 90 on room air. He was subsequently admitted to the hospital.
Currently the patient reports he doesn't feel short of breath
except with exertion. He believes his diarrhea has resolved.
Past Medical History:
myelodysplastic syndrome
diverticulosis
AML 12 years ago(treated with chemo and recovered)
HTN
Social History:
Married, two children, does not smoke, having stopped some time
ago. Social alcohol. Perhaps two glasses of wine per day. Coffee
none. He is retired, having worked at D.E.C.
Family History:
Notable for coronary disease and diabetes mellitus.
Physical Exam:
VS: T 98.9 P 80 BP 112/80 RR 20 O2 95 on 2L
Gen: Elderly Caucasian gentleman in NAD.
Head: NCAT.
Eyes: PERRL, EOMI, anicteric,
Mouth: Small black spot on L lateral tongue, otherwise MMM, no
other lesions
CV: RR, nl S1S2, 3/6 systolic murmur at LLSB
Lungs: Slightly diminished at R base, otherwise fair air
movement with no adventitial sounds heard.
Abdomen: Purpuric bruising at abdomen LUQ and LLQ. Non-tender,
non-distended, normoactive BS,
Extrem: no c/c/e
Pertinent Results:
WBC 38 (was 23.1 on [**4-1**]), monocytic predominance
Hct 39.6
Plt 54
Cr 3.3 (baseline 2.1 to 2.4)
K 3
CK/CK MB nl. Trop 0.07
Microbiology
urinalyisis: negative for LE, nitrates. Few bacteria.
from OSH
LUQ hematoma: coag negative staphylococcus PCN resistant but
vancomycin sensitive.
Brief Hospital Course:
This is a 73 year old man with CMML with recent admission to OSH
for emergent splenectomy after splenic rupture who is admitted
for hypoxemia and worsening bilateral ground glass opacities.
He was treated aggressively on the floor with antibiotics and
other etiologies (PE, MI, etc) were appropriately addressed. He
was fluid resusitated and continued on his CMML regimen.
Despite this, the patient became progressively hypotensive and
was transfered to the ICU for further care.
In the ICU the patient continued to deteriorate and developed
progressive hypotension and acidosis despite aggressive fluid
repletion, pressor support, and bicarbonate drip. He received >
8L NS, 8amps bicarb, pressor support w/ levophed and
vasopressin, and maximum ventilatory support. Despite these
measures, his lactate continued to trend upwards and he became
progressively more hypotensive on the PEEP settings required to
adequately oxygenate him. Furthermore, the patient developed
tumor lysis syndrome in the setting of his chemotherapy and
became anuric producing only 40cc of urine over 8hr. Renal
service was called emergently to consider dialysis but the
family elected to change his code status to DNR/DNI and focus
care on comfort as a priority, after discussion w/ his
oncologist Dr [**First Name (STitle) 1557**] and to defer more aggressive therapy.
Medications on Admission:
MED Danazol 200 mg PO BID Start: 4 pm
MED Folic Acid 1 mg PO DAILY
MED Pantoprazole 40 mg PO Q24H
MED Atenolol 25 mg PO DAILY Start: In am
Please hold for SBP less than 100, HR less than 55.
MED Prednisone 12.5 mg PO DAILY Start: In am
MED Metronidazole 500 mg PO TID
MED Hydroxyurea 1500 mg PO DAILY
MED Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
CMML, splenic rupture, hypotension
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2200-9-23**]
|
[
"286.9",
"519.4",
"998.12",
"205.10",
"V58.65",
"584.9",
"300.00",
"V45.79",
"403.91",
"790.7",
"401.9",
"428.0",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"00.17",
"54.91",
"96.71",
"99.05",
"99.25",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4666, 4675
|
2890, 4240
|
345, 351
|
4753, 4762
|
2578, 2867
|
4815, 4976
|
2029, 2082
|
4637, 4643
|
4696, 4732
|
4266, 4614
|
4786, 4792
|
2097, 2559
|
276, 307
|
379, 1700
|
1722, 1819
|
1835, 2013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,718
| 162,712
|
26435
|
Discharge summary
|
report
|
Admission Date: [**2158-2-2**] Discharge Date: [**2158-2-7**]
Date of Birth: [**2106-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
51 yo M with no significant past medical history admitted with
PE found at OSH. Patient thought he had some "congestion" which
developed over a week ago. He took Robitussin and then Mucinex
w/out relief. He then started to feel short of breath with
exertion, after going to the bathroom and walking from his car
to the office. Patient then went to his PCP who prescribed
Albuterol prn for shortness of breath also with little relief.
Patient was then seen at work by [**Name8 (MD) **] RN who found that he was
hypoxic. His PCP then referred him to the ED at an OSH ([**Hospital1 **]).
At the OSH: VS HR 125 BP 129/84 R 36 O2 sat 91% RA. ABG
7.5/29/59. EKG showing sinus tach with TWI V2-V3 (new compared
to prior EKG). A CT was performed which reveiled a saddle PE,
Dimer >1050 and he was started on IV Heparin w/out lysis. He was
then transfered to [**Hospital1 18**] for further management.
ROS - Patient denies any feelings of sob prior to this, very
occasionally used Albuterol in the past, no feelings of
palpitations, dizziness, no chest pain or pressure, no pleuritic
chest pain. No cough, sputum production, no hematemesis,
fevers/chills. Patient reports, however, not being able to
expand his chest enough and not being able to fill his lungs
with enough air. He also reports a funny sensation as though
"something were stuck in there" behind his left knee, no frank
leg swelling or tenderness. He states that his calves are always
very hard and stiff. No history of any long bone fractures or
any trauma. Recent >10 lb weight loss [**2-16**] to social stressors.
In the MICU - Patient admitted to MICU overnight, continued on
IV Heparin, CE negative x 1, ECHO done (preliminary) showing RV
strain, elevated PA pressures to ~70, significant TR with RV
pressure overload.
Past Medical History:
1. Right orbital fracture with titanium floor plate s/p MVA
2. Gout
Social History:
Heavy tobacoo use x since age 17, heavy drinking [**6-22**] drinks per
night (beers)
ETOH: 8 beers per day for past 3 years.
Works at [**Company 1475**] Correctional Complex.
Complex social situation with recent death of his 46 yr old
ex-wife [**8-19**] and now dispute over custody of his two children,
20 yr old daughter who wants to leave home and 15 yr old son who
was in car accident that killed ex-wife.
Family History:
Father - recent admission to [**Hospital1 **] for CAD - to get 4 vessel CABG
Mother passed away from complications of parkinsons.
No bleeding discrasias or clots in family
Physical Exam:
T: 98 HR: 90 BP: 95-108/50-60, RR: 15-20 O2 sat 91-93% 4L
GEN: lying in bed, pale, NAD, very talkative
HEENT: NC/AT, EOMI, PERRL, o/p clear, mmm
NECK: distended superficial neck veins, JVP to jaw at 30%,
supple
Chest: CVA b/l no wheezes/rales/rhonchi
CVS: no heaves/thrills, no palpable P2, nl S1 S2, regular, no
m/r/g appreciated, distant heart sounds
ABD: soft, flat, BS+, NT/ND
EXT: No edema, calves soft and symmetric, non tender, no
erythema/swelling
NEURO: A&O x3, non focal, circumstantial
Pertinent Results:
[**2158-2-2**] WBC-9.2 RBC-4.20* Hgb-13.7* Hct-37.5* MCV-89 RDW-13.6
Plt Ct-165
[**2158-2-7**] WBC-7.7 RBC-3.79* Hgb-12.7* Hct-35.2* MCV-93 RDW-13.7
Plt Ct-157
[**2158-2-2**] PT-13.5* PTT-62.3* INR(PT)-1.2
[**2158-2-7**] PT-12.5 PTT-30.7 INR(PT)-1.0
[**2158-2-7**] Lupus-PND ACA IgG-PND ACA IgM-PND
[**2158-2-2**] Glucose-130* UreaN-18 Creat-1.0 Na-139 K-3.8 Cl-106
HCO3-22 AnGap-15
[**2158-2-3**] Calcium-9.3 Phos-3.3 Mg-1.9
ECG: Sinus rhythm. Non-diagnostic repolarization abnormalities.
No previous tracing available for comparison.
TTE [**2-3**]:
MEASUREMENTS:
Left Atrium - Four Chamber Length: 4.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.9 cm (nl <= 5.0 cm)
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
TR Gradient (+ RA = PASP): *50 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Depressed LVEF. LV dysnchrony is present.
RIGHT VENTRICLE: Normal RV wall thickness. Markedly dilated RV
cavity. Severe global RV free wall hypokinesis. Abnormal septal
motion/position.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA
systolic
hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. LV systolic function appears
depressed, at least moderately and possibly severe. The views
are limited to make an accurate assessment. Left ventricular
dysnchrony is present.
3.The right ventricular cavity is markedly dilated. There is
severe global right ventricular free wall hypokinesis. There is
abnormal septal
motion/position.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve insufficiency
seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation
seen.
6. Moderate to severe [3+] tricuspid regurgitation is seen.
7.There is moderate pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
LENIs [**2158-2-5**]: IMPRESSION: Intraluminal thrombus identified
within the right popliteal vein, and extending into the distal
most aspect of the right superficial femoral vein.
Brief Hospital Course:
51 yo man with no significant past medical history admitted with
shortness of breath and hypoxia found to have a saddle PE with
severe right heat strain, initially admitted to MICU for close
monitoring given the extent of his PE.
1) Pulmonary Embolus: He was immediately started on IV heparin
with PTT kept 60-100. He had no significant events in the MICU,
with oxygen saturation stable on 2-4L in the mid-90s. He was
transfered to the floor after one night in the MICU. He had an
echocardiogram on [**2-3**] which demonstrated severe R heart strain
with 3+ TR, marked dilation and hypokinesis of the RV, as well
as secondary compromise of LV function, with moderately to
severely depressed LVEF. Despite this, the patient was able to
be quickly weaned off of O2 completely, with ambulatory sat 95%
on RA on the day of discharge. He never had hemodynamic
instability, and it was therefore decided not to proceed with
lysis. He had a LENI which demonstrated extensive RLE DVT, the
presumed source for his PE.
In terms of his risk factors, he does smoke heavily and was
encouraged to quit. He will follow up with Dr. [**Last Name (STitle) 6160**] at
[**Hospital1 18**] for hypercoagulable workup. Some of the workup was
initiated in house, however some of the assays are unreliable in
the presence of coumadin. It should also be noted that the
patient was on folate when homocysteine was checked in our
system, therefore this result is unreliable.
He was discharged on lovenox which should be continued for at
least 48 hours after his INR is therapeutic on coumadin (goal
[**2-17**], 2.5-3.5 if APA positive). He will take 10 mg coumadin for
2 days after discharge, and thereafter his PCP will instruct him
on the dose depending on his INR. He will have his INR checked
with his PCP 2 days after discharge.
He should have another echocardiogram to monitor his LVEF and R
heart function in about 3-4 weeks after discharge, which should
be set up by his PCP.
2) Gout: He complained of R knee swelling, pain, and tenderness
starting the day prior to discharge, which he says is his
"gout." Exam was consistent with gout and he also had some R
metatarsal pain. He was discharged on a 6 day course of
prednisone for presumed mild gout flare. He will take protonix
for GI prophylaxis while on high dose steroids.
3) ETOH Abuse: No evidence of withdrawl during the
hospitalization. He was given folate/MVI/thiamine, which were
d/c'ed on discharge.
Medications on Admission:
Mucinex
albuterol
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 7 days.
Disp:*14 doses* Refills:*3*
2. Coumadin 5 mg Tablet Sig: Two (2) Tablet PO once a day for 2
days: Please take 10 mg (2x5mg tablets) for the first two days
after you leave the hospital. You will then have your INR
checked by Dr. [**Last Name (STitle) **] who will tell you how much to take
thereafter.
Disp:*4 Tablet(s)* Refills:*0*
3. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: To be
combined with 2.5 mg tablets as directed by Dr. [**Last Name (STitle) **] to achieve
desired dose.
Disp:*30 Tablet(s)* Refills:*2*
4. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: To
be combined with 5 mg tablets to achieve desired dose as
determined by Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*2*
5. Prednisone 10 mg Tablets, Dose Pack Sig: One (1) Tablets,
Dose Pack PO once a day for 6 days: Take 30 mg on days 1 and 2,
20 mg on days 3 and 4, then 10 mg on days 5 and 6, then done.
Disp:*12 Tablets, Dose Pack(s)* Refills:*0*
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 6 days: To be
taken while you're taking the prednisone.
Disp:*6 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Submassive pulmonary embolism
Right heart failure
Deep venous thrombosis of right lower extremity
Acute gout flare
Alcohol abuse
Discharge Condition:
Good, normal oxygen saturation on room air, ambulating with only
minor pain in right knee.
Discharge Instructions:
As you know we have started you on a new medication called
coumadin, which you will be on for at least 3 months. You will
be on Lovenox via an injection twice a day for at least the next
few days. Your primary care doctor will tell you when you can
safely stop these injections (they will need to be continued for
2 more days after your INR level in your blood is between [**2-17**]).
You will also be on a prednisone taper for your gout flare for
the next 6 days. While taking prednisone we have placed you on
protonix which protects your stomach.
You should make sure Dr. [**Last Name (STitle) **] sets you up with a repeat
echocardiogram to take another look at your heart in [**3-18**] weeks
or so.
Please seek medical attention if you experience any shortness of
breath, chest pain, blood in your sputum, worsening leg pain or
swelling, or anything of concern to you.
You have the appointment listed below with your PCP, [**Name10 (NameIs) 3**] well as
with Dr. [**Last Name (STitle) 6160**], a hematologist, for further workup of why
you developed this clot.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-3-13**] 11:30
Dr. [**Last Name (STitle) **] on Thursday [**2158-2-9**] at 1:10 p.m. Please call his
office with any questions.
|
[
"453.41",
"584.9",
"415.19",
"303.91",
"274.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9710, 9716
|
5877, 8341
|
321, 328
|
9888, 9980
|
3383, 5854
|
11100, 11337
|
2676, 2850
|
8409, 9687
|
9737, 9867
|
8367, 8386
|
10004, 11077
|
2865, 3364
|
274, 283
|
356, 2140
|
2162, 2232
|
2248, 2660
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,889
| 141,731
|
20302
|
Discharge summary
|
report
|
Admission Date: [**2182-12-3**] Discharge Date: [**2183-1-10**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: This 71 year old female has a
history of critical aortic stenosis and mitral stenosis and
is preopped for an AVR. She had a recent catheterization at
[**Hospital1 69**] on [**11-21**] which revealed
clean coronaries and she now presents for surgery. She has
had increased shortness of breath and dyspnea on exertion.
Also, on her catheterization, she had an ejection fraction of
57%. Her aortic valve had a 37 mm gradient and was .54 cm
squared. Mitral valve had a 20 mm gradient and was 0.59 cm
square. She had 1+ aortic insufficiency as well. She is now
admitted for AVR/MVR.
PAST MEDICAL HISTORY: Significant for a history of critical
aortic stenosis. History of hypertension. History of
diabetes. History of chronic atrial fibrillation and status
post hysterectomy.
MEDICATIONS ON ADMISSION:
Vitamin E 400 units q. day.
Wolfram 7 mg p.o. q. day.
Spironolactone 25 mg p.o. three times a day.
Clochlor 10 meq p.o. q. day.
Glucotrol XL 10 mg p.o. q. day.
Furosemide 80 mg p.o. q. day.
Fosamax 7 mg subcutaneous q. week.
ALLERGIES: She is allergic to Quinine. She gets welts.
SOCIAL HISTORY: She lives alone in [**Hospital3 4634**]. She does
not smoke cigarettes and does not drink alcohol.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: She is an elderly, white female in no
apparent distress. Vital signs stable, afebrile. HEAD,
EYES, EARS, NOSE AND THROAT: Normal cephalic, atraumatic.
Extraocular movements intact. Oropharynx benign. Neck was
supple, full range of motion, no lymphadenopathy or
thyromegaly. Carotids 2+ and equal bilaterally with
radiating murmurs. Neck was supple. Full range of motion.
No lymphadenopathy or thyromegaly. Lungs had bibasilar
crackles. Cardiovascular examination: Irregular rate and
rhythm with a 3/6 systolic ejection murmur and a [**2-28**]
diastolic murmur. Abdomen was soft, nontender, with positive
bowel sounds. No masses or hepatosplenomegaly. Extremities:
2+ pulses bilaterally throughout. No clubbing, cyanosis or
edema. Neurologic examination was nonfocal.
HOSPITAL COURSE: On [**12-4**], she underwent a AVR/MVR Maze
procedure with stapling of the left atrial appendage. Her
aortic valve was replaced with a 19 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial valve. Her mitral valve was replaced with a 25
mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. Cross clamp time
was 175 minutes. Total bypass time was 150 minutes. She was
transferred to the CSRU on Milrinone, Epinephrine and
Nitroglycerin.
She was extubated on postoperative day number one and
continued to have chest tube output. She had increased PA
pressures and remained on the Milrinone. Also, her white
count went up to 20,000. She was started on Levofloxacin.
She remained on the Milrinone drip in the unit for quite some
time, with an elevated white count. All her cultures were
negative. She had an increased amylase and lipase eventually
and was n.p.o. She also started to have a rising creatinine
and was seen by renal. They recommended holding her
diuretics. She still remained on the Milrinone and remained
in preoperative atrial fibrillation. She was treated with
Vancomycin and Levo for awhile with no positive cultures.
She was seen by renal. She also had hyponatremia of unknown
etiology. She went down as low as 116 and was treated with
hypertonic saline. She has not had a recurrence of that.
She had a negative cortisol stimulation test.
She continued to remain in the unit with a white count around
20,000. She was eventually weaned off her Milrinone on
postoperative day number 10. She was very slow to progress
with any ambulation or physical activity. She was beginning
to be stable until postoperative day number 12 when she
became hypothermic. She had a profound acidosis and had to
get reintubated. She again did not grow out any positive
cultures. She had a head CT that was negative. Neurology
saw her. They did not feel that it was due to her correction
of her sodium because that was done over several days,
therefore, that was not the issue. She remained intubated.
She was started on tube feeds. She has had a chronic
elevated amylase of around 200 which does not change if we
feed her. She does not have abdominal pain with that. General
surgery feels that it is not a pancreatitis.
She remained intubated and was eventually treated with
Fluconazole, Flagyl, Levofloxacin. She continued to have
chest tubes during this entire time, as she had continuous
serous drainage from those. She was eventually extubated
again on postoperative day number 19. She was slowly
recovering and started eating. She did have a few abdominal
ultrasounds and abdominal CT's which were negative for any
pancreatitis. She did have large gallstones which is all she
had with that. She continued to remain in the unit and slowly
progressed. She had a triple lumen catheter placed in her
right subclavian on postoperative day number 30. She was
stable from the line. Her heparin was restarted and a day
later, her PTT was 78 and that evening she became diaphoretic
and tachypneic. She became acidotic and was reintubated.
She was found to have a right hemothorax.
On postoperative day number 32, she had a right VAC procedure
with evacuation of a hemothorax. She tolerated that well and
recovered from that. On postoperative day number 33, she had
a tracheostomy. The next day, she had a percutaneous
endoscopic gastrostomy placed. She tolerated all of this
well. She also was treated with Natrecor for diuresis and was
followed by the heart failure service. We discontinued the
Natrecor on postoperative day number 36 and switched her to
her preoperative Aldactone 25 mg three times a day and put
her on 60 of intravenous Lasix twice a day. Upon discharge
to rehabilitation, she is on C-Pap with a pressure support of
12. She is tolerating that well. She is also on Pro-Balance
tube feeds at 50 an hour, tolerating that well.
MEDICATIONS ON DISCHARGE:
Tylenol prn.
Colace 100 mg p.o. twice a day.
Nystatin swish and swallow four times a day.
Glipizide 10 mg p.o. twice a day.
Glucotrol 10 mg p.o. q. day.
KCl 40 meq p.o. twice a day.
Lasix 60 mg intravenous twice a day. This should remain
intravenous. She will not diurese well with p.o.
Spironolactone 25 mg p.o. three times a day.
Fosamax 70 mg subcutaneous q. week.
Coumadin .5 mg p.o. q h.s.
Subcutaneous heparin 5000 units subcutaneous twice a day.
She should have an INR goal of 2 to 2.5.
LA[**Last Name (STitle) **]RY DATA: White count 7,200; hematocrit 29.2;
platelets 127. Sodium 149; potassium 4; chloride 113; BUN
33; creatinine 0.5; blood sugar 146. She will be followed by
Dr. [**Last Name (Prefixes) **] as soon as she is discharged from
rehabilitation and by Dr. [**Last Name (STitle) **] when she is discharged from
rehabilitation. She needs to have her vent weaned and is to
work with physical therapy for ambulation.
She was discharged to [**Location (un) 4480**] [**Hospital 4094**] Rehabilitation on
postoperative day number 37.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2183-1-10**] 07:20
T: [**2183-1-10**] 04:12
JOB#: [**Job Number 54492**]
|
[
"276.1",
"584.9",
"511.8",
"396.0",
"518.5",
"398.91",
"998.11",
"276.2",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"33.22",
"39.31",
"89.68",
"00.13",
"99.04",
"35.21",
"35.23",
"31.1",
"96.6",
"96.04",
"43.11",
"39.61",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
6148, 7472
|
959, 1243
|
2216, 6122
|
1414, 2198
|
1380, 1391
|
152, 737
|
760, 933
|
1260, 1360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,257
| 164,421
|
28561
|
Discharge summary
|
report
|
Admission Date: [**2116-10-3**] Discharge Date: [**2116-10-14**]
Date of Birth: [**2097-9-3**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Severe nausea and vomiting
Major Surgical or Invasive Procedure:
-Plasmapheresis
-Intubation
-Right internal jugular venous catheter (removed [**2116-10-14**])
History of Present Illness:
19yo female admitted on [**2116-10-3**] w/ severe nausea and vomiting.
The patient was seen in ED on [**2116-9-29**] with bloody diarrhea and
crampy abdominal pain. Stool cultures sent were negative,
including E coli. CT showed colitis. She was admitted
overnight & sent home with po flagyl/cipro.
.
Following discharge she felt progressively better & diarrhea
decreased in volume. However, 2days prior to admission, she
developed severe nausea and retching. When she presented on
[**2116-10-4**], she was found to have thrombocytopenia, hemolytic
anemia (with schitocytes on smear), and renal failure.
Past Medical History:
None
Social History:
She is a freshman at [**First Name4 (NamePattern1) 1663**] [**Last Name (NamePattern1) 1688**]. Her aunts and grandmother
live in the area; however, her parents are in [**State 622**]. The
patient is a nonsmoker. She does not drink significant amount of
alcohol.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Temperature 97.9, blood pressure 134/72, pulse 96, respiratory
rate 16, oxygen saturation 100% on room air.
Gen- pleasant though somewhat anxious young woman lying in bed
HEENT- PERRL, anicteric, EOMI, dry mucus membrane, oropharynx is
clear, however, palatal petechia noted. no cervical
lymphadenopathy,
CV- regular rhythm and rate, no rubs/mmurmur/gallop
RESP- lungs clear bilaterally
ABDOMEN- Active bowel sounds. Non-distended. Mild
periumbilical tenderness. No guarding; no hepato- nor
splenomegaly.
EXT- [**1-13**]+ pedal edema, pedal pulses 2+ and equal bilaterally.
NERUO- Alert and oriented x3, CNII-XII intact, moving all limbs
spontanesouly, sensation grossly intact
SKIN- no rashes, no bruises (except at sites of blood draws)
Pertinent Results:
[**2116-10-3**] 09:40PM BLOOD Glucose-95 UreaN-30* Creat-1.2* Na-135
K-3.6 Cl-102 HCO3-23 AnGap-14
[**2116-10-3**] 09:40PM BLOOD WBC-6.3 RBC-3.50* Hgb-10.8* Hct-29.3*
MCV-84 MCH-30.7 MCHC-36.7* RDW-13.9 Plt Ct-15*#
[**2116-10-3**] 10:40PM BLOOD LD(LDH)-877*
[**2116-10-3**] 10:40PM BLOOD calTIBC-226* Hapto-<20* Ferritn-735*
TRF-174*
.
[**2116-10-4**] 08:15AM BLOOD ADAMTS13 ACTIVITY 49%
.
[**2116-10-12**] 04:58AM BLOOD WBC-5.6 RBC-2.67* Hgb-8.4* Hct-23.8*
MCV-89 MCH-31.5 MCHC-35.3* RDW-14.3 Plt Ct-274
[**2116-10-13**] 05:23AM BLOOD WBC-6.1 RBC-2.66* Hgb-8.0* Hct-24.1*
MCV-91 MCH-30.2 MCHC-33.4 RDW-14.5 Plt Ct-373
[**2116-10-14**] 06:00AM BLOOD WBC-6.2 RBC-2.62* Hgb-8.1* Hct-23.8*
MCV-91 MCH-31.0 MCHC-34.2 RDW-14.7 Plt Ct-408
.
[**2116-10-12**] 04:58AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-141 K-3.7
Cl-104 HCO3-29 AnGap-12
[**2116-10-13**] 05:23AM BLOOD Glucose-89 UreaN-11 Creat-1.0 Na-139
K-3.8 Cl-106 HCO3-26 AnGap-11
[**2116-10-14**] 06:00AM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-142
K-3.9 Cl-109* HCO3-25 AnGap-12
.
[**2116-10-12**] 04:58AM BLOOD LD(LDH)-262*
[**2116-10-13**] 05:23AM BLOOD LD(LDH)-283*
[**2116-10-14**] 06:00AM BLOOD LD(LDH)-315*
.
[**2116-10-13**] 05:23AM BLOOD Hapto-<20*
[**2116-10-14**] 06:00AM BLOOD Hapto-22*
.
[**2116-10-13**] 05:23AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.8 Mg-1.9
.
[**2116-10-9**]
COMPARISON: CT abdomen and pelvis with contrast [**2116-9-28**].
CT OF THE ABDOMEN WITH CONTRAST: Since the prior examination,
there has been interval development of bilateral lower lung lobe
air space consolidation primarily along the bronchovascular
bundles, most prominently at the right lower lung. There is
moderate-sized bilateral pleural effusions with associated
subsegmental atelectasis. The heart is normal in size. The liver
is unremarkable. There are no focal liver lesions or biliary
ductal dilatation identified. The gallbladder, pancreas, spleen,
and adrenal glands are normal in appearance. The kidneys enhance
symmetrically and excrete contrast normally. There is no
evidence of hydronephrosis or hydroureter. The stomach and
intra-abdominal loops of small and large bowel are normal in
appearance and caliber. There is no pathologically enlarged
mesenteric or retroperitoneal lymphadenopathy. The visualized
aorta is normal in caliber.
CT OF THE PELVIS WITH CONTRAST: Since the prior examination,
there has been interval improvement in the diffuse bowel wall
thickening throughout the colon. A segment of thickened bowel
remains which most likely is within the terminal ileum. However,
the bowel wall thickening within the large bowel has resolved.
There has been interval increase in the amount of intrapelvic
free fluid, although no focal fluid collections or abscess is
identified. A Foley is seen within an otherwise collapsed
bladder. The uterus and adnexa are unremarkable. There is
diffuse subcutaneous fat stranding consistent with anasarca.
There is no pathologically enlarged inguinal or pelvic
lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Interval resolution in the degree of colonic and sigmoid
colon wall thickening has resolved, however a small segment of
what looks to be terminal ileum is now thickened. There is
interval increase in the amount of intrapelvic free fluid but no
focal fluid collections or abscesses.
2. Bilateral lower lung lobe pneumonia, right greater than left.
Moderate- sized bilateral pleural effusions.
.
CHEST (PORTABLE AP) [**2116-10-11**]
A single AP view of the chest is obtained [**2116-10-11**] at 11:53 and
is compared with a prior radiograph of [**2116-10-8**]. Cardiac size
remains unchanged. Mediastinal contour is also unremarkable.
Right-sided pulmonary infiltrates appear to have increased,
particularly in the right base. There also is an increase in the
left base with a left pleural effusion. Ill-defined infiltrate
is developing in the left upper lobe. The patient has been
extubated. A right-sided IJ line is in unchanged position.
IMPRESSION:
Persistent multifocal airspace disease, which appears more
widespread with extension to the left upper lobe. Left pleural
effusion increasing since prior examination.
Brief Hospital Course:
#TTP-HUS: Upon admission, the pt was diagnosed w/ TTP-HUS given
her thrombocytopenia, hemolytic anemia (with schitocytes), and
renal failure. She was admitted to the [**Hospital Unit Name 153**]. The hematology
and transfusion medicine services were consulted and started on
plasmapheresis ([**10-4**]). She underwent a total of 8 sessions of
plasmapheresis (the last on [**2116-10-12**]) with good therapeutic
response. Her platelet count returned to [**Location 213**] levels and
eventually her hematocrit stabilized as well, though she still
anemic (23.8) and with evidence of hemolysis on the day of
discharge (LDH 381 and haptoglobin 22). The pt's renal failure
resolved with the therapy (peak creatinine 1.4 and discharge
creatinine 0.8). She never had mental status changes during
hospitalization. The etiology of the TTP-HUS was not determined
during her stay. It may have resulted from E. coli
0157:H7-associated TTP (Shiga toxin was negative). It could
have been due to Idiopathic-TTP, though ADAMTS13 activity was
only mildly depressed. She identifies no precipitant foods,
specifically denies eating raw spinach, undercooked meat, or
drinking tonic (quinine) water.
.
#Respiratory Distress: on the second day of plasmapheresis the
pt developed respiratory distress, requiring intubation. The
cause of her respiratory distress was thought to be due to
volume overload or acute lung injury from the plasmapheresis.
Imaging was consistent with both of these possible diagnoses.
As well, the pt began spiking temperatures with the
plasmapheresis therapy. These fevers were thought to be the
result of transfusion reactions; however, because of her tenuous
state and chest imaging suggestive of pneumonia she was started
on a course of levofloxacin empirically (subsequently changed to
azithromycin given rash). Infectious workup (blood, sputum,
stool, and urine cultures) were unrevealing. The pt was
extubated successfully three days following intubation, and
transferred to the floor. She was weaned off oxygen and by the
time of discharge was ambulating without dyspnea.
.
#Colitis/Terminal Ileitis: The patient did have some abdominal
pain during admission; particularly in the right lower quadrant.
She had no further bouts of bloody diarrhea, though she did
have some intermittent loose stool. CT of the abdomen showed
wall thickening of the terminal ileum. The patient's infectious
workup was negative. There was question of new onset IBD;
however, this was not worked up in the acute setting. Given the
TTP-HUS diagnosis, the cipro and flagyl (started for the bloody
diarrhea she had had days prior to admission) were discontinued.
The pt's abdominal pain resolved during her hospitalization. It
was recommended that she undergo an outpatient colonoscopy to
evaluate for possible underlying intestinal pathology such as
IBD.
.
#Headache: The patient noted mild, focal left temporal
headaches throughout stay, associated with no focal neurological
changes, nor any aura. They spread over her head and were
associated with pain to palpation over the affected areas. The
HA's were responsive to tylenol. They were thought to be
tension headaches.
.
#Rash: While receiving empiric levofloxacin (for possible
pneumonia) the patient developed, a small, pruritic rash on the
right arm (on day four of treatment). Because of concern for
allergic reaction to the antibiotic, the levofloxacine was
discontinued and azithromycin was started. The patient will
complete a total of 7 days of empiric anti-pneumonia therapy.
Medications on Admission:
Ciprofloxacin
Flagyl
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Do not take more than 4grams of tylenol
(ie, acetaminophen) daily.
2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days.
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-13**] Sprays Nasal
PRN (as needed) as needed for nasal dryness.
4. Outpatient Lab Work
Obtain serial CBC blood work as per Dr. [**Last Name (STitle) **]
5. Outpatient study
Obtain outpatient colonoscopy as per Dr. [**Last Name (STitle) **]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Thrombotic Thrombocytopenia Purpura-Hemolytic Uremic Syndrome
-Acute Renal Failure
-Pneumonia vs. Transfusion Associated Acute Lung Injury
Discharge Condition:
Good
Discharge Instructions:
Watch for bruising, rashes, shortness of breath/difficulty
breathing, return of bloody diarrhea, non-bloody diarrhea
lasting >3 days, or general worsening of symptoms. If any of
these occur, you should call your primary care doctor [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9643**] ([**Telephone/Fax (1) 250**]) immediately or go to the emergency room.
-You should have your blood drawn two to three times a week to
check your blood tests.
Followup Instructions:
A follow-up appointment has been arranged with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] (Internal Medicine) on Thursday [**10-15**] @ 8:20AM in the
Atrium Sweet on the [**Location (un) 453**] of the [**Hospital Ward Name 23**] Clinical Center of
the [**Hospital1 18**] [**Hospital Ward Name 516**]. The office phone number is([**Telephone/Fax (1) 6301**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
|
[
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"283.11",
"558.9",
"584.9",
"784.0",
"446.6",
"780.6",
"787.02",
"564.1",
"E879.8",
"275.41",
"458.8",
"276.2",
"482.9",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.76",
"38.93",
"96.71",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10593, 10599
|
6406, 9961
|
305, 402
|
10802, 10809
|
2190, 6383
|
11320, 11830
|
1362, 1380
|
10032, 10570
|
10620, 10620
|
9987, 10009
|
10833, 11297
|
1395, 1405
|
1427, 2171
|
239, 267
|
430, 1038
|
10639, 10781
|
1060, 1066
|
1082, 1346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,768
| 132,275
|
29802
|
Discharge summary
|
report
|
Admission Date: [**2149-5-1**] Discharge Date: [**2149-5-12**]
Date of Birth: [**2081-2-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Fever, rigors
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
68 F w/ metastatic NSCLC, known mets to brain s/p whole brain
[**First Name3 (LF) 16859**] for numerous foci and s/p craniotomy for R temporal lobe
mass resection [**2149-4-10**] who was found to be more somnolent at
rehab.
Tumor hx includes a mediastinoscopy and biopsy followed by
carboplatin and Taxol for 8 cycles. She developed right facial
droop in summer [**2148**] and a head MRI showed 5 enhancing lesions
suggestive of brain metastases. She then received whole brain
cranial irradiation from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. She then developed
right lower extremity swelling caused by a deep vein thrombosis.
She then developed a R temporal lobe mass w/ surrounding edema
that was felt to be not amenable to [**Last Name (LF) 16859**], [**First Name3 (LF) **] surgery was
performed [**4-10**] for palliation. Pt w/ post-op dysarthria.
Discharged to [**Hospital **] Rehab [**2149-4-15**].
Ms. [**Known lastname **] presented from [**Hospital **] Rehab on [**2149-5-1**] with fever
to 103 and rigors. On presentation, pt was noted to be poor
historian, but denied fever; reported dyspnea, cough, chest pain
(states has had in past, not new), rigors, x 1 day. Denied
headaches, back pain.
In ED febrile to 102.8. CXR showed RML and RLL infiltrate; CT
suggestive of post-obstructive PNA on R. Mildly hypoxemic and
borderline BP ~100. Received decadron 10 mg IV in ED.
Patient was admitted to MICU initially for management. She was
treated with zosyn and vancomycin for a post-obstructive pna. A
bronchoscopy with stent placement was considered, but position
of obstruction not ideal for stenting, and pt's clinical
condition improved with antibiotics alone. She currently is
stable on NC oxygen, hemodynamically stable. She is therefore
transferred to floor (OMED service).
.
On admission to the OMED service, the patient is again a poor
hisotrian. Review of systems was difficult to obtain, but the
patient does complain of a sore throat.
Past Medical History:
ONCOLOGY HISTORY:
1. Metastatic non-small lung CA:
- stage 4B with spread to contralateral lung and brain:
- tumor hx includes a mediastinoscopy and biopsy followed by
carboplatin and Taxol for 8 cycles.
- developed right facial droop in summer [**2148**] and a head MRI
showed 5 enhancing lesions suggestive of brain metastases. She
then received whole brain cranial irradiation from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
M.D.
- developed right lower extremity swelling caused by a deep vein
thrombosis.
- developed a R temporal lobe mass w/ surrounding edema that was
felt to be not amenable to [**Last Name (LF) 16859**], [**First Name3 (LF) **] surgery was performed [**4-10**] for
palliation. Pt w/ post-op dysarthria.
PAST MEDICAL HISTORY:
1. Right LE DVT (noted during previous hospital course in
[**2149-3-15**])
- s/p IVC filter placement (no anticoagulation due to brain
mets, recent craniotomy)
Social History:
She was smoking 1.5 packs of cigarettes per day for 8 years; she
stopped in [**2119**]. She does not drink alcohol or use illicit
drugs.
Family History:
Her mother died of an unspecified cancer while her father passed
away from a heart attack. She has 11 siblings and 3 of them are
alive; a sister died of ovarian cancer, another sister died of
breast cancer, and a brother died of an
unspecified typed of cancer. She has 3 daughters and 2 sons,
and they are healthy.
Physical Exam:
Vitals - 98F 110/81 HR 98 R 18 99%5L NC
Gen - Comfortable in bed, fidgeting, NAD
HEENT - Pupils minimally reactive. MMM. Unable to examine OP
Resp - Decreased BS on R, Crackles RML.
CVS - Tachy. RRR.
Abd - Obese, soft, nt/nd
Ext - RLE: 2+ pitting edema to the knee
[**Name (NI) 298**] Pt noncooperative w/ exam. Unable to assess CN, strength
or sensation. Oriented to hospital, [**2149-4-10**].
Pertinent Results:
ADMISSION LABS ([**2149-5-1**]):
CBC:
WBC-10.0# RBC-2.76*# Hgb-8.5* Hct-24.1*# MCV-88 MCH-30.7
MCHC-35.1* RDW-19.8* Plt Ct-218#
Neuts-93.4* Bands-0 Lymphs-4.8* Monos-1.4* Eos-0.3 Baso-0.1
COAGS:
PT-15.3* PTT-150* INR(PT)-1.4*
CHEMISTRIES:
Glucose-120* UreaN-11 Creat-0.4 Na-132* K-3.9 Cl-97 HCO3-24
AnGap-15
Calcium-8.1* Phos-2.6* Mg-1.7
MISC:
calTIBC-105* Ferritn-1256* TRF-81*
CTA CHEST ([**2149-5-1**]):
1. Large right hilar mass consistent with known history of lung
cancer invading adjacent mediastinal structures. Mass narrowss
the bronchus intermedius and occludes the right upper lobe
bronchus. There is near complete consolidation of the entire
right middle and right lower lobes.
2. Probable metastatic nodules in the left lower lobe and right
upper lobe. Multiple mediastinal lymph nodes.
3. No evidence of pulmonary embolism.
CXR ([**2149-5-1**]):
1) New large right middle and lower lobe consolidation,
aspiration or pneumonia, with small left- sided pleural effusion
representing atelectasis vs pneumonia.
2) Right paratracheal density corresponds to lung mass on same-
day CT.
CT HEAD ([**2149-5-2**]):
There appears to be a small amount of subarachnoid blood
remaining in the posterior right frontal lobe. There appears
resolution in the minimal mass effect. There has been resolution
over the previously noted areas of hemorrhage. The remainder of
the exam is stable.
ECHO ([**2149-5-7**]):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
1. Post obstructive pneumonia: Patient presented with fevers,
rigors, dyspnea, cough, hypotension found to have large RML and
RLL post obstructive pneumonia on CXR and Chest CT. Urine
culture were negative and blood cultures showed no growth as
well. Once on Zosyn and Vancomycin, she initially showed
clinical improvement with stable hemodynamics. Pulmonology was
constuled to determine if a bronchoscopy and possible stend
would be worthwhile. It was felt that the area of pneumonia did
not have a large blockage in the upstream bronchus and that the
bronchus that appeared obstructed did not have an associated
pneumonia. Given this, it was their feelign that stent
placement would be of little value. On the evening of [**2149-5-6**],
the patient was found to be acutely hypoxic to the low 90%s with
a NRB mask. She was intubated in the [**Hospital Unit Name 153**] and anesthesia noted
food in her oropharynx suggestive of an aspiration event. She
underwent bronchoscopy in the [**Hospital Unit Name 153**] on [**2149-5-7**] which showed no
evidence of bronchial obstruction. A right IJ CVL was placed
for monitoring and medication administration on [**2149-5-7**]. The
patient was empirically treated with vanco/Zosyn/azithromycin
but, in spite of these antibiotics, her respiratory failure
continued to worsen and she developed ARDS and septic shock.
She required vasopressin and norepinephrine for blood pressure
support but developed progressively worsening oliguria. After
numerous discussions with the family, they chose to make her DNR
and, eventually, comfort-measures-only given the severity of her
ARDS and septic shock in the setting of her advanced lung
cancer. She was put on a morphine drip for comfort and expired
on [**2149-5-12**].
Medications on Admission:
Vancomycin 1 gram IV q24H
Dexamethasone 2 mg PO BID
Darbepoetin Alfa 60 mcg qWednesday
Lansoprazole 30 mg PO BID
Pantoprazole 40 mg PO daily
Phenytoin 300 mg PO qHS
Heparin SC 5000 U [**Hospital1 **]
Insulin Sliding Scale
Senna 2 tablets PO qHS
Colace 100 mg PO BID
dulcolax 10 mg PO daily
acetaminophen prn
artificial tears prn
lactulose 20 gm PO daily prn
milk of magnesia prn
odansetron 4 mg PO/SL q8H prn nausea
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
aspiration pneumonia with subsequent ARDS
septic shock secondary to aspiration pneumonia
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"486",
"285.22",
"276.51",
"934.1",
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"785.59",
"453.8",
"V15.3",
"E912",
"198.3",
"518.0",
"276.1",
"518.81",
"428.0",
"162.8",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"00.17",
"86.05",
"96.6",
"96.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8711, 8720
|
6448, 8216
|
328, 340
|
8852, 8861
|
4241, 6425
|
8913, 8919
|
3491, 3810
|
8683, 8688
|
8741, 8831
|
8242, 8660
|
8885, 8890
|
3825, 4222
|
275, 290
|
368, 2359
|
3157, 3319
|
3335, 3475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,616
| 175,273
|
36663
|
Discharge summary
|
report
|
Admission Date: [**2144-7-3**] Discharge Date: [**2144-7-9**]
Date of Birth: [**2066-6-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Keppra
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
[**7-3**] Right Craniotomy for evacuation of R SDH
dialysis
History of Present Illness:
Patient came from rehab facility for a complaint of left
extremity weakness. He usually ambulates with a rolling walker
and was seen to drag his left leg. He has a previous history of
fall resulting in bilateral SDH in [**Month (only) **] of 09. He underwent left
burr holes. He states that he weakness has occurred within the
past two days. He also reported some uninary frequency and
frequency.
Past Medical History:
HTN, CAD, DM
Social History:
Married, lives with wife
Family History:
NC
Physical Exam:
O: T: 96.9 BP:107 / 61 HR: 86 R 30 O2Sats 95% on R/A
Gen: WD/WN, comfortable, NAD.
HEENT: Prior Burr hole site well healed. Pupils: 2.5mm to 2.0mm
bil EOMs Full to Confrontation.
Conjugate gaze.
Neck: Supple. No upstrokes or bruits noted
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Trace pedal edema present
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Primary language Greek but speaks \English well.
Orientation: Oriented to person, place, and date.
Recall: [**2-18**] objects at 5 minutes.
Language: Speech is slow and deliberate with good comprehension
.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2.5mm to
2.0 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. Strength full power 5-/5 throughout both upper
extremities. Right LE with 5/5 throughout. The Left LE is 4+/5
through the entire extremity. There is 3Beats Clonus Bilat,No
pronator drift
Sensation: Intact to light touch and propioception, bilaterally.
Coordination: Slowed on finger-nose-finger
Gait not observed.
Exam upon discharge: alert and oriented x3, slight weakness L
LE, wound with slight erythema
Pertinent Results:
[**2144-7-7**] 12:00PM BLOOD WBC-10.0 RBC-3.21* Hgb-8.4* Hct-27.9*
MCV-87 MCH-26.1* MCHC-30.0* RDW-17.0* Plt Ct-204
[**2144-7-3**] 10:10AM BLOOD Neuts-68.3 Lymphs-23.0 Monos-5.7 Eos-2.3
Baso-0.7
[**2144-7-7**] 12:00PM BLOOD Plt Ct-204
[**2144-7-7**] 12:00PM BLOOD Glucose-191* UreaN-57* Creat-6.0* Na-135
K-4.7 Cl-95* HCO3-26 AnGap-19
[**2144-7-4**] 03:11AM BLOOD Amylase-206*
[**2144-7-3**] 04:11PM BLOOD Glucose-115* Lactate-1.0 Na-139 K-4.6
Cl-99*
Head CT [**2144-7-3**]:IMPRESSION: Bilateral acute on chronic subdural
hemorrhages with associated extrinsic mass compression on the
bilateral frontal and parietal lobes. A now interval progression
in size with a 26-mm in transverse diameter right subdural
collection and a 14-mm in diameter left subdural collection.
Interval improvement in left-sided pneumocephalus in expected
postoperative appearance of left-sided pneumocephalus.
Head CT 7/19IMPRESSION:
1. Interval decrease in size of left predominantly iso to
hypodense subdural collection. The collection persists overlying
the left hemisphere at the vertex.
2. Slight decrease in size of the right subdural collection with
slight
decrease in pneumocephalus about the surgical site.
3. No shift of midline structures. No evidence for herniation.
4. No evidence for new hemorrhage.
Head CT [**2144-7-6**] IMPRESSION: Status post right parietal
craniotomy, stable right-sided subdural hemorrhage with
pneumocephalus and stable left-sided subdural hemorrhage, both
with a few linear areas of hyperdense material which are likely
cortical veins and unchanged; however, close f/u study to be
considered to exclude hemorrhage. No interval increase in size.
Brief Hospital Course:
Mr [**Known lastname 82927**] was admitted to the neurosurgery service and
underwent right sided craniotomy for subdural evacuation. Post
operatively he was monitored in the ICU he was extubated on post
op day 1, he was receiving Dilantin for seizure prophylaxis. He
had some difficulty with hypotension thought to be related to
post dialysis fluid removal. He was started on Midrodrine which
helped raised his blood pressure. He was transferred to the
neurostep down on post op day 1. Follow up CT showed interval
decrease in size of left subdural collection, predominantly
isodense with a small focal hyperdensity, predominantly at the
vertex. He was noted to have some right sided leg weakness post
operatively. Physical therapy recommened the patient should go
to rehab. On discharge he was tolerating a regular diet, his
blood pressure was maintained in the low 100's. He was noted to
have a slight right drift and facial asymmetry. His last
dialysis was on [**7-9**]. He required bolus of dilantin [**7-9**] for low
level and standing dosages was increased and this should be
followed at rehab to maintain therapeutic level. his incision
looked slightly erythematous on [**7-9**] and keflex was started for
7 day course. Staples should be removed [**2144-7-10**].
Medications on Admission:
Tylenol 650mg po Q6hrs;prn, Anusol
Supp 1Supp [**Hospital1 **];PRN, Atorvastatin 20mg QD,Cholecalciferol VIT D
1000U QDay, Miconazole powder 2% top [**Hospital1 **], Digoxin 0.125mg
Q48hrs,
Colace 100mg [**Hospital1 **], Erythropoietin 20,000Units SC PRN Dialysis,
Ferrous Gluconate 125mg IV; PRN Dialysis, Finasteride 5mg PO
Daily, Lasix 40mg [**Hospital1 **], Amaryl 1mg PO QAM, Heparin 5000u SQ
Daily,
Reg. Insulin Sliding Scale,Latanoprost 0.005% Opth 1drop each
eye
QHS, Ativan 1mg po QHS PRN anxiety or sleep, MVI Nephrocaps 1
Cap
Non-STD, Metoprolol SR 25mg PO Daily, Pilosec 20mg daily,
Percocet PRN, Miralax 17GM Po daily, Psyllium Metamucil 5.85GM
Daily; PRN constipation, Flomax 0.4mg po QHS, Venlafaxine SR
37.5mg po daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Headache.
2. Hemorrhoidal Cream 0.25-1 % Cream Sig: One (1) Rectal twice
a day as needed for Hemmorroids.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO Q48HRS ().
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO Qam () as
needed for Anti diabetes.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO NON DIALYSIS DAYS ().
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
15. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO DAILY (Daily).
16. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
21. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
22. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO TID (3 times a day).
23. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days: take thru [**2144-7-16**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Bilateral SDH
chronic renal disease
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing in one
week. Please have results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office or have your staples out at rehab
on [**7-10**]
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks. You need to have a CT at that
time
??????
Completed by:[**2144-7-9**]
|
[
"414.01",
"852.21",
"V45.11",
"250.00",
"403.91",
"412",
"458.21",
"585.6",
"E888.9",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"38.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8373, 8453
|
4258, 5532
|
289, 350
|
8533, 8557
|
2569, 4235
|
10094, 10416
|
873, 877
|
6318, 8350
|
8474, 8512
|
5558, 6295
|
8581, 10071
|
892, 1259
|
230, 251
|
378, 777
|
1603, 2453
|
1274, 1587
|
799, 814
|
830, 857
|
2474, 2550
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,358
| 111,330
|
38731
|
Discharge summary
|
report
|
Admission Date: [**2115-4-10**] Discharge Date: [**2115-4-18**]
Date of Birth: [**2075-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
39yM with alcoholic cirrhosis presents from outside hospital for
further management of upper GI bleed.
Presented to OSH on [**2115-4-9**] with nosebleed x 2 days and
requesting detox. Alcohol level 355 there. Put on thiamine,
folate, and ativan per detox protocol. Platelets of 15,
transfused 15 unit of platelets. On the medical floor, dry
heaving and retching, vomited x1 coffee grounds. Hct dropped
from 38.6 to 26.9 this AM. Today, transfused 2U and underwent
EGD, showing recently bleeding gastric varices but no active
bleeding, in addition to portal hypertension and small
esophageal varices. Remained on octeotride gtt and IV protonix.
Transferred to [**Hospital1 18**] for consideration of TIPS vs. fibrin glue.
Transfused 2 more additional units of platelets.
Drinks [**1-19**] pints of vodka daily. Last drink on morning of [**4-9**].
Has been taking 10-15mg Q8h of oxycodone for the past several
weeks. Of note, patient underwent right elbow fusion 3 weeks
prior to presentation after falling down stairs and hitting
forehead.
On transfer, vitals signs stable with BP 126/83, HR 94, RR 16
97% on 2L NC. + Midepigastric and periumbilical pain, constant
but sometimes sharp, radiates laterally. + [**7-27**] right elbow pain
s/p surgical fusion of R elbow after fall 3-4 weeks ago.
Past Medical History:
EtOH abuse--2 pints of vodka daily
Hx of alcohol withdrawal
Thrombocytopenia [**2-19**] liver cirrhosis
Cirrhosis x 2 years
Hx of biliary sludge
S/p fusion of right elbow 3-4 weeks ago
S/p remote jaw surgery
Social History:
Lives alone, recently feels lonely. States that family lives
close by. Drinks [**1-19**] pints of vodka daily. Currently does not
work, retired from department of corrections.
Family History:
Mother with hypertension and osteoporosis
Physical Exam:
T 97.3, HR 89, BP 126/83, 97% on 2L
Gen: Tired, alert, oriented, appropriate
HEENT: NCAT. Pupils 2mm, equal, round and reactive to light with
accommodation. + mild scleral icterus. Dried blood in right
nostril, no signs of active bleeding. Oral mucosa moist,
jaundice noted on tongue.
Neck: Thyroid symmetric, no nodules. Soft anterior cervical
lymph nodes, mobile and nontender. No other posterior cervical,
submental, supraclavicular lymphadenopathy.
CV: RRR. Mild I/VI systolic murmur at RUSB
Lungs: Poor inspiratory effort (difficult secondary to abdominal
pain), but clear to ausculation posteriorly and anteriorly.
Abdomen: soft, nondistended. Bowel sounds hyperactive.
Tenderness to palpation in epigastric region with some volumtary
guarding. No rebound. Liver percussed 4cm from costal margin. No
fluid wave or evidence of ascites.
R elbow: flexed, moderately tender to palpation. Restricted
range of motion.
Extremities: warm and well-perfused. 2+ DP pulses bilaterally.
No edema
Wrist tremor, but no asterixes.
Pertinent Results:
On admission:
[**2115-4-10**] 10:39PM BLOOD WBC-3.9* RBC-3.43* Hgb-11.0* Hct-31.2*
MCV-91 MCH-32.2* MCHC-35.4* RDW-15.3 Plt Ct-35*
[**2115-4-10**] 10:39PM BLOOD Neuts-58.1 Lymphs-35.1 Monos-5.7 Eos-0.8
Baso-0.4
[**2115-4-10**] 10:39PM BLOOD PT-14.7* PTT-29.0 INR(PT)-1.3*
[**2115-4-10**] 10:39PM BLOOD Glucose-117* UreaN-12 Creat-0.8 Na-137
K-4.2 Cl-100 HCO3-28 AnGap-13
[**2115-4-10**] 10:39PM BLOOD ALT-20 AST-146* LD(LDH)-178 AlkPhos-139*
TotBili-4.2*
[**2115-4-10**] 10:39PM BLOOD Albumin-3.4* Calcium-7.9* Phos-3.0
On discharge:
[**2115-4-17**] 03:40PM BLOOD Hct-27.8*
[**2115-4-17**] 06:30AM BLOOD WBC-5.9 RBC-2.77* Hgb-9.1* Hct-27.0*
MCV-98 MCH-32.8* MCHC-33.5 RDW-15.7* Plt Ct-74*
[**2115-4-17**] 06:30AM BLOOD PT-16.1* PTT-33.5 INR(PT)-1.4*
[**2115-4-17**] 06:30AM BLOOD Plt Ct-74*
[**2115-4-17**] 06:30AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-135
K-3.8 Cl-99 HCO3-29 AnGap-11
[**2115-4-17**] 06:30AM BLOOD ALT-13 AST-78* LD(LDH)-166 AlkPhos-155*
TotBili-2.7*
[**2115-4-17**] 06:30AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8
MICRO:
Blood cultures negative from [**4-11**]
Two cultures from [**4-14**] with no growth to date
RUQ ultrasound
1. Reversed flow direction in the portal system with varices.
2. Marked splenomegaly.
3. Cholelithiasis.
Elbow
Three views. Positioning is suboptimal. The patient is status
post open
reduction and internal fixation of fracture of the olecranon
process of the
ulna. Fracture fragments are transfixed by a screw and wire.
There is mild
diastasis at the fracture site. Cortices appear otherwise
intact. There is
no evidence of dislocation. Mineralization appears normal. Soft
tissue
swelling is present over the fracture site.
IMPRESSION: Status post ORIF
EGD [**4-12**]:
Varices at the lower third of the esophagus (ligation)
Small hiatal hernia
Schatzki's ring
Activate bleeding and an erosion in the gastroesophageal
junction compatible with [**Doctor First Name 329**] [**Doctor Last Name **] tear
Granularity, friability and mosaic appearance in the whole
stomach compatible with portal hypertensive gastropathy
Varices at the fundus (injection)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
39 year old man with alcoholic cirrhosis and EtOH abuse presents
with upper GI bleed.
#. Upper GI Bleed: Pt with one episode of coffee ground emesis
with associated Hct 12 point Hct drop at the OSH. Received 1U
pRBC and underwent EGD that showed stigmata of prior variceal
bleed and gastropathy. Hct has remained stable after transfer,
but an EGD performed [**4-12**] showed active bleeding from a
[**Doctor First Name **]-[**Doctor Last Name **] tear, bleeding portal gastropathy, and esophageal
varices were banded. He was started on carafateand pantoprazole.
He received five days of ceftriaxone. He is scheduled for repeat
EGD and hematocrt check as an outpatient.
#. EtOH Cirrhosis:
LFTs trended down over hospitalization. Nadolol and diuretics
were held.
Encouraed to drink boost supplements.
#. EtOH Abuse:
Pt reported 1 pint of vodka per day. He was monitored on a CIWA
scale and started on thiamine, folate and a multivitamin. He was
seen by social work.
- CIWA scale with Valium dosing for CIWA>10
- Thiamine, folate, MV
- SW Consult to develop plan to ensure sobriety on d/c
#. Thrombocytopenia:
s/p 15U plts at the other hospital. Likely secondary to
splenomegaly, and bone marrow suppression from alcohol.
#. Right elbow fracture s/p fall and ORIF - Patient pain
currently controlled, but with reduced range of motion. He was
seen by orthopedic surgery. THe fracture was felt to be slowly
healing and no intervention was neccessary during this
hospitalization. Lidocaine patch and oxycodone for pain.
# Conjuntivitis
Allergic versus viral. Started erythromycin ointment.
#. Code - Full Code
Medications on Admission:
Furosemide 20mg PO QD
Folic acid 1mg PO QD
Nadolol 20mg PO QD
Spironolactone 50mg PO BID
Omeprazole 20mg PO QD
Lactulose 15ml PO TID
Ativan 1mg Q4h prn alcohol withdrawal--takes 1mg QD
Oxycodone 5mg PO BID prn (taking 10-15mg Q8h for last several
weeks).
Discharge Medications:
1. Folic Acid 1 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. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to 3 BM per day.
Disp:*2700 ml* Refills:*2*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Erythromycin 5 mg/g Ointment Sig: 0.5 in Ophthalmic QID (4
times a day).
Disp:*1 tube* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: do not drive or operate machinery.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastrointestinal bleed, esophageal varices, portal
hypertensive gastropathy, [**Doctor First Name 329**] [**Doctor Last Name **] tear, alcoholic
hepatitis
Secondary: alcohol abuse, status post right elbow fracture,
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted with bleeding from your esophagus and stomach.
You underwent endoscopy twice to repair the bleeding. You no
longer had any evidence of bleeding, but will need to have a
repeat EGD as an outpatient on [**2115-4-23**]. The bleeding occured as
a complication of your liver diease due to alcohol. It is
important that you no longer drink alcohol.
The following changes were made to your medications:
1) You were started on thiamine, folic acid and multivitamin
2) You were started on lactulose 30ml three times a day and
titrate to 3 bowel movements per day
3) You were started on a lidocaine patch that you should wear
for 12 hours and then take off for 12 hours.
4) You were started on sucralfate 1g four times a day
5) You were started on pantoprazole 40mg twice a day
6) You were started on erythromycin ointment to your eyes four
times a day
7) You were started on oxycodone 5mg every 6 hours as needed for
pain. You should avoid driving or operating machinery.
You should follow-up with the appointments below.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2115-4-23**]
3:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2115-4-23**] 3:00
Please follow-up with your outpatient [**Year/Month/Day 86055**] within the
next week. If you are unable to contact your [**Name2 (NI) 86055**] you
can schedule on appointment at [**Hospital1 18**]: Phone: ([**Telephone/Fax (1) 2007**]
|
[
"V54.11",
"372.39",
"571.1",
"305.01",
"287.4",
"456.20",
"572.3",
"571.2",
"285.1",
"530.3",
"530.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
8457, 8463
|
5380, 6993
|
334, 339
|
8742, 8742
|
3208, 3208
|
9985, 10469
|
2107, 2150
|
7298, 8434
|
8484, 8721
|
7019, 7275
|
8890, 9962
|
2165, 3189
|
3744, 5357
|
280, 296
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367, 1664
|
3222, 3729
|
8757, 8866
|
1686, 1897
|
1913, 2091
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,458
| 130,840
|
36
|
Discharge summary
|
report
|
Admission Date: [**2137-3-7**] Discharge Date: [**2137-3-16**]
Date of Birth: [**2060-10-8**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo male w/PMHx sx for chronic kidney disease, cirrhosis [**1-31**]
NASH vs. PSC with resultant ascites and Grade II esophageal
varices, DM2, PSC, and CAD who presents with acute worsening of
creatinine. Patient has chronic kidney disease with baseline
creatinine of 1.8, now elevated to 4.8 with potassium 5.8. His
CKD is thought [**1-31**] HTN and DM2. He recently received therapeutic
paracentesis with removal of 3.5L of fluid, negative for SBP. He
states that he has noticed increasing abdominal distension and
fatigue over the past several weeks. He has not noticed
increased pruritus, confusion, delta MS.
.
He has taken recent antibiotics, and states that his po intake
has been poor due to lack of appetite. He says that his urine
output has been about the same as prior. Denies use of NSAIDS at
home. He has not been able to walk long distances because of his
LE swelling. Denies CP/SOB/DOE/F/C/N/V/BRBPR/melena.
Past Medical History:
1) Right Popliteal DVT. (s/p IVC filter)
2) DM type 2; Uncontrolled with Complications: Hypoglycemia
1) Cirrhosis ??????NASH
2) Grade 2 Esophageal Varices
3) Possible Primary Sclerosing Cholangitis ?????? (Rule Out diffuse
Cholangiocarcinoma)
4) CKD
5) Anemia
6) Thrombocytopenia
7) Splenomegaly
8) CAD- known mild reversible inferior defect (MIB [**1-3**]),
preserved ejection fraction
9) Hypoalbuminemia
Social History:
Lives at home with his wife. Retired [**Company 378**] manager. No alcohol,
smoking, or drugs.
Family History:
Mother died from MI @ 75, no renal dz, no DM
Physical Exam:
VS: 97.0 HR 67 BP 106/54 RR 16 O2sat 95% RA
GENERAL: AA male, appears mildly cachectic with protruding
abdomen
HEENT: PERRL, EOMI, left eye wandering. No scleral icterus.
Mucous membranes dry.
LUNGS: Clear to auscultation and percussion bilaterally. No
decreased BS.
CARDIAC: RRR w/o MRG
ABDOMEN: +BS, distended abdomen, +fluid wave, tympanic,
umbilical hernia. Rectal: external hemorrhoids. Guaiac negative.
EXTREMITIES: [**2-1**]+ pitting edema to the midthigh.
SKIN: Skin excoriations and hyperpigmented macules.
Neuro: no asterixis
Pertinent Results:
132 100 94 / 211 AGap=20
-------------
5.8 18 4.7 \
Ca: 8.0 Mg: 2.8 P: 6.9
.
97
6.6 \ 11.5 / 115
-------
35.3
N:73.1 Band:0 L:19.5 M:4.1 E:2.7 Bas:0.6
Anisocy: 2+ Poiklo: 1+ Macrocy: 3+ Spheroc: 1+ Target: 1+
Plt-Est: Low
PT: 15.0 PTT: 24.6 INR: 1.3
NDICATION: Low-grade fever and cough.
The lung volumes are low. Allowing for this factor, the heart
size is normal, but demonstrates left ventricular configuration.
The pulmonary vascularity is normal. There is some crowding of
vessels in the lower lung zones likely related to the low lung
volumes. A slightly more patchy area of opacity is seen in the
infrahilar region on the lateral view likely due to crowding of
vascular structures. No pleural effusions are identified.
Within the imaged portion of the upper abdomen, there is a
paucity of bowel gas suggesting underlying ascites.
IMPRESSION:
1. Low lung volumes. No definite pneumonia, but repeat study may
be helpful to fully exclude basilar pneumonia on this low lung
volume radiograph.
2. Probable ascites.
.
INDICATIONS: 76-year-old man with renal failure and cirrhosis.
COMPARISONS: Ultrasound from [**2137-2-28**].
TECHNIQUE: Renal ultrasound examination.
FINDINGS: The right kidney measures 10.5 cm in length, the left
10.9 cm. Both kidneys appear normal without stones, masses, or
hydronephrosis. There is a large amount of ascites, as seen on
the recent ultrasound as well. The liver is coarse and nodular
consistent with cirrhosis.
IMPRESSION: No evidence of hydronephrosis. Large amount of
ascites.
.
Reason: Please place temporary IJ dialysis catheter on [**2137-3-11**]
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with NASH cirrhosis s/p GI bleed now requires
dialysis
REASON FOR THIS EXAMINATION:
Please place temporary IJ dialysis catheter on [**2137-3-11**]
CLINICAL INFORMATION: 76-year-old man with cirrhosis of the
liver, status post GI bleed, renal failure, needs temporal
dialysis catheter placement for hemodialysis.
PROCEDURE/FINDINGS: The procedure was performed by Dr. [**First Name (STitle) 379**] [**Name (STitle) **]
and Dr. [**Last Name (STitle) 380**]. Dr. [**Last Name (STitle) 380**], the attending radiologist, was
present and supervising throughout the procedure.
After the risks and benefits were explained to the patient,
written informed consent was obtained. The patient was placed
supine on the angiographic table. The right neck was prepped and
draped in the standard sterile fashion. Ultrasound confirmed the
right internal jugular vein was patent and compressible. A
preprocedure timeout was obtained to confirm the patient's name,
procedure, and the site. 5 cc of 1% lidocaine was applied for
local anesthesia. Under ultrasonographic guidance, a 21-gauge
needle was used to access the right internal jugular vein. A
0.018 guide wire was placed through the needle under
fluoroscopic guidance with the tip in the superior vena cava.
The needle was exchanged for a 4-French micropuncture sheath.
The wire was exchanged for a 0.035 guide wire under fluoroscopic
guidance with the tip in the inferior vena cava. The
micropuncture sheath was removed. The venous access was dilated
by using 12- and 14-French dilators. A 20-cm hemodialysis
catheter was placed over the wire with the tip in the right
atrium. The wire was removed. Two lumens were flushed, and the
catheter was secured with skin with sutures.
The patient tolerated the procedure well, and there were no
immediate complications.
During the procedure, two ultrasound films were taken.
IMPRESSION: Successful placement of a 20-cm, temporal
hemodialysis catheter through right internal jugular vein with
the tip in the right atrium. The catheter is ready to use.
.
[**2137-3-8**] 5:26 pm PERITONEAL FLUID
**FINAL REPORT [**2137-3-14**]**
GRAM STAIN (Final [**2137-3-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2137-3-11**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2137-3-14**]): NO GROWTH.
Brief Hospital Course:
76 yo male w/PMHx sx for DM2, HTN, CKD, cirrhosis [**1-31**] NASH vs.
PSC who presented with acute on chronic renal failure, thought
[**1-31**] hepatorenal syndrome, complicated by an UGIB from esophageal
varices. Patient was transferred to the MICU on [**2137-3-8**], with
banding of esophageal varices and transfusion of 4u pRBC, now
stable and s/p placement of hemodialysis catheter and has
dialysis intiiated, also received large volume paracentesis with
removal of 1.1 L. His clinical status deteriorated due to
worsening cirrhosis and renal failure, and he was made CMO prior
to transfer to hospice.
.
#. Acute on chronic renal failure. Patient likely had ARF from
hepatorenal syndrome, triggered by intravascular volume
depletion from large volume paracentesis done several days prior
to admission, with contribution from UGIB during his admission.
Renal ultrasound has been negative for obstruction, urine
electrolytes [**Location (un) 381**] sodium c/w HRS, and urine sediment bland.
Urine eosinophils negative, less concerning for ATN as cause.
Patient received 500cc NS challenge on day of admission, with no
improvement in his renal function. Patient was initiated on
hemodialysis and received three sessions with minimal
improvement in renal function. He was placed on nephrocaps, and
given octreotide and midodrine for treatment of HRS. He was
given albumin 12.5 mg twice daily. His diuretics were held.
.
#. GI bleeding. Patient had an episode of coffee grounds emesis
in the ED, with hx Grade II esophageal varices. He again had an
episode of upper GI bleeding while on the floor, and was
transferred to the MICU.
In the MICU, the patient received 2 units of blood and underwent
gastric banding for variceal bleeds. He was continued on
octreotide gtt for 5 days and started on carafate. After the
banding, pt did not develop any further hematemasis, however, pt
received two more units for hct drop. He was started on full
liquid diet. He was then transferred to the floor, where he was
stable for the next several days. He had an active T&S, and was
on protonix and carafate, scheduled for repeat endoscopy two
weeks later. On day prior to discharge, patient again started
vomiting up guaiac positive material. KUB showed an ileus, with
likely vomiting of feculent material mixed with blood. There was
no indication of active bleeding.
#. Scrotal edema. Patient c/o pain and tenderness at Foley
insertion site, and his foley was discontinued. He was not
having any urine output and received intermittent straight
catheterizations with minimal urine output. These were
discontinued as well due to patient discomfort. Bladder scan was
not reliable for urine in bladder due to increased ascites.
Patient's pain was controlled with morphine, viscous lidocaine,
and scrotal elevation with warm packs.
.
#. Cirrhosis [**1-31**] NASH vs. PSC. MELD score calculated at 32.
Patient received diagnostic paracentesis for SBP which was
negative, with final cx showing no growth, and was placed on SBP
prophylaxis with levofloxacin. He also received a large volume
paracentesis wtih removal of 1.1L . His nadolol was held. He had
a fluid restriction of 1500cc/day and his I/Os were monitored
closely. He was given lactulose for hepatic encephalopathy. His
spironolactone and furosemide were held due to concerns over
hypotension. He was continued on ursodiol. Liver consult
followed the patient throughout his hospital stay. He was given
Vit K SC for his coagulopathy.
#. Hyperkalemia. Likely [**1-31**] ARF. His hyperkalemia resolved with
kayexelate and dialysis.
.
#. Diabetes type 2. Patient was continued on home insulin
regimen until decision was made to make patient CMO.
.
#. PPx. Incentive spirometer. Senna/colace. PPI.
.
#. Code status: Patient was made CMO. A palliative care consult
was obtained. He was given a fentanyl patch with morphine elixir
for pain, and given ativan and dolasetron as well. He was
discharged to hospice.
.
#. Communication: Wife [**Name (NI) 382**]- [**Name (NI) 383**] [**Known lastname 384**] (h)-[**Telephone/Fax (1) 385**] and
(w)-[**Telephone/Fax (1) 386**]
Medications on Admission:
CIPRO 250 mg--1 tablet(s) by mouth twice daily
FERGON 240MG--One twice a day [**First Name8 (NamePattern2) **] [**Last Name (un) 387**]. dr [**First Name4 (NamePattern1) 388**] [**Last Name (NamePattern1) **]
HUMALOG 100 U/ML--Sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) 387**]
INSULIN SYRINGE 30GX0.312"--Use as directed
INSULIN SYRINGE 30GX0.375"--Use as directed
LANCETS --As directed for glucometer monitoring
LANTUS 100 U/ML--16 units at bedtime
LASIX 40MG--[**12-31**] by mouth twice a day
NADOLOL 20MG--One by mouth every day
ONE TOUCH GLUCOMETER STRIPS --As directed.
PROCRIT [**Numeric Identifier 389**] U/ML--Take one ml (20,000 units) every week
SPIRONOLACTONE 25MG--[**12-31**] by mouth every day
SYRINGE,DISPOSABLE --Use one ml syringe for the procrit
TEDS HOSE - KNEE HIGH 2 PAIR--Wear daily
[**Last Name (un) 390**] FORTE 500MG--one tablet(s) by mouth three times a day per
liver unit
Discharge Medications:
1. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed) as needed for foley manipulation.
2. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Morphine Concentrate 20 mg/mL Solution Sig: Ten (10) mg PO
Q3H (every 3 hours).
Disp:*150 cc* Refills:*2*
5. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1-2H
() as needed.
6. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
q3h as needed for dyspnea or pain.
Disp:*150 cc* Refills:*0*
7. Other
Ativan 5 mg/ml
0.25 to 2 mg under the tongue q4-6h prn anxiety or nausea
Not to exceed 8 mg/25 hours
Disp: 30 ml
8. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours as needed for increased secretions.
Disp:*1 box* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
1. Hepatorenal syndrome
2. Acute renal failure requiring dialysis
3. Upper GI bleeding from esophageal varices
4. Cirrhosis with ascites
5. Scrotal edema
6. Ileus
7. Hyperkalemia
8. Diabetes mellitus type 2
9. Thrombocytopenia
10. External hemorrhoids
Discharge Condition:
Poor
Discharge Instructions:
You will be going to an inpatient hospice center where your pain
will be controlled. If you develop increased trouble breathing,
nausea, or pain, please let your doctors [**Name5 (PTitle) 393**].
Followup Instructions:
Provider: [**Name Initial (NameIs) 394**]/[**Name8 (MD) 395**] M.D. Date/Time:[**2137-3-28**] 11:15
Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2137-4-9**] 11:00
|
[
"414.01",
"585.9",
"572.2",
"276.2",
"276.7",
"285.1",
"572.4",
"287.5",
"584.9",
"250.40",
"560.1",
"276.50",
"789.5",
"403.91",
"456.20",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"54.91",
"99.07",
"38.95",
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12489, 12569
|
6483, 10594
|
289, 295
|
12865, 12872
|
2434, 4032
|
13116, 13371
|
1815, 1861
|
11566, 12466
|
4069, 4140
|
12590, 12844
|
10620, 11543
|
12896, 13093
|
1876, 2415
|
230, 251
|
4169, 6460
|
324, 1251
|
1273, 1687
|
1703, 1799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,548
| 151,940
|
22456
|
Discharge summary
|
report
|
Admission Date: [**2173-5-24**] Discharge Date: [**2173-5-30**]
Date of Birth: [**2112-2-9**] Sex: F
Service: MED
Allergies:
Percocet / Vicodin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with tissue biopsy, cardiac catheterization
History of Present Illness:
61yo F with HTN, hypercholesterolemia who developed hemoptysis
last night. Several TSP--presented to OSH. CXR with RML nodule
and CT with RML mass. Bronch with friable lesion in R bronchus
intermedius.
HCT stable, some increase in hemoptysis after bronch with
passing of clots. No h/o exposure to TB, no travel exposures.
Past Medical History:
borderline HTN, hyperchol, s/p R knee arthroscopy, s/p tubal
ligation
Social History:
Pt is nurse [**First Name (Titles) **] [**Last Name (Titles) 58344**], no h/o tobacco use, no h/o TB exposure
Family History:
father died MI age 72, grandfather with possible gastric CA
Physical Exam:
T 97.7 P 91 BP 144/100 RR 19 SpO2 96%
Gen: awake, alert, anxious
HEENT: PERRL, EOMI, no JVD, no oral lesions
CV: S1, S2 no S3,S4/M/R
Pulm: symmetrical to percussion, clear BS with no W/C/R
Abd: soft, NT, BS+
Ext: warm, 2+ R/DP, pulses BL, no edema
Pertinent Results:
[**2173-5-28**] 04:26AM BLOOD WBC-7.4 RBC-3.59* Hgb-10.7* Hct-31.4*
MCV-88 MCH-29.8 MCHC-34.0 RDW-12.5 Plt Ct-167
[**2173-5-27**] 03:16AM BLOOD WBC-8.8 RBC-3.51* Hgb-10.3* Hct-30.3*
MCV-86 MCH-29.5 MCHC-34.2 RDW-12.9 Plt Ct-126*
[**2173-5-26**] 01:54AM BLOOD WBC-12.7* RBC-3.84* Hgb-11.3* Hct-32.7*
MCV-85 MCH-29.6 MCHC-34.7 RDW-12.5 Plt Ct-227
[**2173-5-25**] 06:58AM BLOOD Hct-36.2
[**2173-5-24**] 10:19PM BLOOD WBC-9.7 RBC-4.62 Hgb-13.7 Hct-39.4 MCV-85
MCH-29.6 MCHC-34.7 RDW-12.9 Plt Ct-214
[**2173-5-24**] 10:19PM BLOOD Neuts-76.6* Lymphs-17.6* Monos-4.9
Eos-0.6 Baso-0.3
[**2173-5-28**] 04:26AM BLOOD Plt Ct-167
[**2173-5-28**] 04:26AM BLOOD PT-12.3 PTT-24.3 INR(PT)-1.0
[**2173-5-27**] 03:16AM BLOOD Plt Ct-126*
[**2173-5-27**] 03:16AM BLOOD PT-13.2 PTT-27.5 INR(PT)-1.2
[**2173-5-26**] 01:54AM BLOOD Plt Ct-227
[**2173-5-24**] 10:19PM BLOOD PT-12.4 PTT-27.6 INR(PT)-1.0
[**2173-5-27**] 03:16AM BLOOD Glucose-96 UreaN-11 Creat-0.8 Na-143
K-3.5 Cl-112* HCO3-23 AnGap-12
[**2173-5-26**] 01:54AM BLOOD Glucose-129* UreaN-10 Creat-0.8 Na-139
K-3.7 Cl-108 HCO3-23 AnGap-12
[**2173-5-25**] 06:44PM BLOOD K-3.6
[**2173-5-24**] 10:19PM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-143
K-3.7 Cl-108 HCO3-26 AnGap-13
[**2173-5-27**] 03:16AM BLOOD CK(CPK)-120
[**2173-5-26**] 07:28PM BLOOD CK(CPK)-163*
[**2173-5-26**] 12:24PM BLOOD CK(CPK)-187*
[**2173-5-26**] 01:54AM BLOOD CK(CPK)-216*
[**2173-5-27**] 03:16AM BLOOD CK-MB-2 cTropnT-0.31*
[**2173-5-26**] 07:28PM BLOOD CK-MB-3 cTropnT-0.26*
[**2173-5-26**] 12:24PM BLOOD CK-MB-5
[**2173-5-26**] 01:54AM BLOOD CK-MB-14* MB Indx-6.5*
[**2173-5-25**] 06:44PM BLOOD CK-MB-NotDone cTropnT-0.28*
[**2173-5-28**] 04:26AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9 Iron-21*
[**2173-5-28**] 04:26AM BLOOD calTIBC-222* Ferritn-171* TRF-171*
[**2173-5-25**] 12:00AM BLOOD ANCA-NEGATIVE B
[**2173-5-25**] 06:50PM BLOOD Type-ART Temp-36.1 Rates-9/ Tidal V-650
O2-100 pO2-258* pCO2-41 pH-7.36 calHCO3-24 Base XS--1 AADO2-429
REQ O2-73 -ASSIST/CON Intubat-INTUBATED
[**2173-5-25**] 03:48PM BLOOD Type-ART pO2-379* pCO2-32* pH-7.44
calHCO3-22 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2173-5-25**] 06:50PM BLOOD K-3.4*
[**2173-5-25**] 03:48PM BLOOD Glucose-168* Lactate-1.8 Na-139 K-3.0*
[**2173-5-25**] 03:48PM BLOOD Hgb-12.4 calcHCT-37
[**2173-5-25**] 03:48PM BLOOD freeCa-1.14
Brief Hospital Course:
ICU course:
61 yo F with HTN and hyperlipidmia who underwent rigid
bronchoscopy with cauterization for hemoptysis and was noted to
have ST-elevations inferioly on the EKG and a short bradycardic
arrest. She was stabilized and referred for emergent cardiac
cath. Coronary angiography of this right-dominant circulation
showed no flow-limiting CAD. The LMCA, LAD and LCX had mild
luminal irregularities. The RCA had a 30% proximal and a 40% mid
vessel stenosis with normal flow and myocardial blush.2. Resting
hemodynamics showed normal LV filling pressures. 3. Left
ventriculography showed no wall motion abnormalities and an EF
of 69%. There was no mitral regurgitation. And the final
diagnosis was: 1. Coronary arteries without flow-limiting
disease. 2. Normal ventricular function. A follow-up echo was
done and it showed: The left atrium is normal in 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. Left
ventricular systolic function is hyperdynamic (EF>75%). There
is a moderate
resting left ventricular outflow tract obstruction. 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. Moderate to severe (3+) eccentric posteriorly
directed mitral
regurgitation is seen. There is no pericardial effusion. Pt
re-admitted to ICU, developed some HTN, controlled with
Diltiazem. Pt also developed LLE pain in ICU; doppler [**5-27**]
showed no evidence of DVT. Pain improved with incr mobility.
Floor Course:
1. Cardiology: Pt was transferred to floor where she had no
further cardiac issues. She was arranged to have f/u with a
repeat Echo in the future, as it was not felt by Cardiology that
her MR was related to papillary muscle dysfxn or another urgent
issue.
2. Pulmonary: Pt had scant blood-streaked sputum while on
floor, which was felt by IP to be nl considering the friability
of her lesion. They were not worried, as it was a tiny amt of
blood. Biopsy was still pending on d/c, and pt had f/u arranged
with thoracic surgery, with repeat chest CT/PET.
3. PT: Pt was evaluated by PT before d/c, who felt that she was
stable to be discharged home by herself. She was weak but able
to ambulate through the halls.
Medications on Admission:
ASA, Lescol, ibuprofen PRN
Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD (once a day).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
3. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for cough.
Disp:*1 MDI* Refills:*0*
4. Robafen AC 10-100 mg/5 mL Syrup Sig: One (1) PO every six
(6) hours as needed for cough.
Disp:*1 100cc* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary mass, Inferior Myocardial infarction
Discharge Condition:
Stable
Discharge Instructions:
Please call your PCP or return to the hospital with increasing
hemoptysis, fevers, cough productive of greenish sputum, chest
pain, or shortness of breath.
Followup Instructions:
F/U with PMD: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 58345**] [**Telephone/Fax (1) 58346**]
Provider: [**Name10 (NameIs) **] THORACIC MULTI SPEC-CC9 MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2173-6-10**] 3:30
Please call radiology at [**Telephone/Fax (1) 327**] for appt confirmation for
chest CT/PET scan on Tuesday [**6-1**]
Please call Cardiology at [**Telephone/Fax (1) 58347**] for apppt for
echocardiogram
|
[
"515",
"786.3",
"272.0",
"427.5",
"424.0",
"E879.8",
"997.1",
"401.9",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.72",
"33.27",
"32.29",
"96.71",
"88.53",
"99.60",
"37.23",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6705, 6711
|
3611, 6107
|
282, 347
|
6802, 6810
|
1283, 3588
|
7014, 7496
|
935, 996
|
6184, 6682
|
6732, 6781
|
6133, 6161
|
6834, 6991
|
1011, 1264
|
232, 244
|
375, 698
|
720, 792
|
808, 919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,481
| 168,351
|
2976
|
Discharge summary
|
report
|
Admission Date: [**2111-1-31**] Discharge Date: [**2111-2-18**]
Date of Birth: [**2031-10-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Neurosurgery was consulted for an abnormal head CT
Major Surgical or Invasive Procedure:
Intubation and subsequent extubation
PICC line placement and removal
History of Present Illness:
79 year old female reportedly found down at the bottom of
her stairs by her husband. She was vomiting upon arrival to the
ER. Initially her SBP was in the 130s and then it dropped to the
70s. She was paralyzed, intubated and started on a neo drip. The
ER reported that her left pupil was 3mm and her right was 1mm.
Her head CT showed bilateral SDHs so a neurosurgery consult was
called.
Past Medical History:
- DM2 w/retinopathy and neuropathy
- Arthritis
- Right Hip fracture [**2108**]
Social History:
Previously lived at home with her husband, one -two drinks per
night, no tobacco, walked with a walker
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM UPON ADMISSION:
T:97.9 BP:99/51 HR:85 RR:18 O2Sats:100% vented
(Examined initially just after the patient was intubated and
paralytics were still on board. The following exam reflects my
second exam after paralytics wore off.)
Gen: intubated, sedated
HEENT: Pupils: Left 1mm, surgical, Right 2-1mm
EOMs- unable to test
Has an open laceration on the occipital region of her head.
Neck: In cervical collar. Does not appear to have tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: No eye opening, not following commands.
(+) gag with suctioning
Cranial Nerves:
I: Not tested
II: Pupils: left 1 mm, surgical, right 2-1mm
III-XII: unable to test
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Localized bilaterally with upper extremities. Withdraws
bilateral lower extremities to noxious.
Sensation: Appears to be intact bilaterally.
Toes upgoing bilaterally
Pertinent Results:
Head CT [**2111-1-30**]:
FINDINGS: Right frontal parenchymal hemorrhage is noted which
measures 2.0 x 1.4 cm on axial view. A second focus of right
frontal parenchymal hemorrhage closer to the vertex measures 10
x 8 mm. There is a small amount of subarachnoid hemorrhage of
both frontal lobes. Also noted are bilateral subdural hematomas,
which appear to be acute on chronic, with a hyperdense component
indicating acute blood. These layer around both cerebral
convexities. On the left maximal thickness of the subdural
collection is 6 mm and on the right maximal thickness also 6 mm.
Subdural blood layers along the tentorium. There is no
appreciable shift of normally midline structures or mass effect.
The basilar cisterns are not effaced. There is an acute fracture
of the right temporal bone with extension through the right
mastoid air cells, which contain blood. There is mild depression
of the squamous portion of the right temporal bone. The temporal
bone fracture extends into the lesser sphenoid [**Doctor First Name 362**] on the
right. There is also a fracture through the right occipital bone
with over-riding of bone fragments by about 6 mm. There is
subcutaneous and intramuscular emphysema as well as a small
amount of pneumocephalus near the temporal fracture sites. There
is a small amount of blood layering in the right maxillary
sinus. The nasal cavity is opacified, probably due to blood. The
sphenoid sinus is opacified with heterogeneous material
suggesting chronic opacification secondary to inspissated
secretions. However, there is probably a small amount of blood
in the sphenoid sinus as well. The globes are intact. There is
soft tissue swelling of the right periorbital region. The
patient is intubated with terminus out of view.
IMPRESSION:
1. Parenchymal contusion of the frontal lobes, right greater
than left.
2. Bifrontal subarachnoid hemorrhage.
3. Bilateral subdural hematomas with mix densities.
4. Fractures through the right temporal and occipital bones.
Head CT [**2111-1-31**]:
FINDINGS: The right frontal parenchymal hemorrhage has
significantly worsened over the short interval, now measuring
approximately 5.6 x 3.7 cm, previously 2.0 x 1.4 cm. There is
new mass effect with shift of the anterior midline structures to
the left by approximately 5 mm and partial effacement of the
frontal [**Doctor Last Name 534**] of the right lateral ventricle. There has also been
worsening in left frontal subarachnoid hemorrhage and
parenchymal contusion. Redemonstrated are bilateral subdural
hematomas, which layer around both cerebral convexities and
along the tentorium, which are similar in volume to the prior
study. The basilar cisterns are not effaced. There is no new
major vascular territorial infarction. The temporal and
occipital bone fractures are similar to the prior study. There
remains blood in the right mastoid air cells. There remains
small fluid levels in both maxillary sinuses and the left
sphenoid sinus air cell. Opacification of the right sphenoid
sinus air cell is probably due to a combination of acute blood
and chronic secretions. Several of the ethmoid air cells are
opacified.
IMPRESSION:
1. Significant short interval worsening in right frontal
intraparenchymal hemorrhage with new mass effect, which causes
shift of the anterior midline structures to left by about 5 mm
and mild effacement of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle.
2. Worsening in left frontal subarachnoid hemorrhage and
contusion.
3. No appreciable change in subdural hematomas of the bilateral
cerebral convexities and along the tentorium.
4. Redemonstration of temporal and occipital fractures.
CT head [**2111-2-1**]:
FINDINGS: The right frontal mixed attenuation parenchymal
hemorrhage appears relatively stable in size measuring
approximately 5.4 x 3.6 cm with increased effacement of the
ipsilateral frontal [**Doctor Last Name 534**] of the lateral ventricle. No change in
shift of anterior midline structures by approximately 5 mm
detected. There is relatively stable appearance to bilateral
subdural hematomas layering around both cerebral convexities and
along the tentorium. There is no evidence of
uncal/transtentorial or tonsillar herniation. There is large
amount of intraventricular hemorrhage within the occipital horns
of the lateral ventricles bilaterally with unchanged degree of
mild hydrocephalus. The temporal and occipital bone fractures
are similar to prior study. There is stable opacification in
bilateral mastoid air cells, right maxillary sinus and sphenoid
sinuses. Several ethmoid air cells are also opacified.
IMPRESSION:
1. Large right frontal mixed attenuation parenchymal hemorrhage
with increased effacement of the ipsilateral frontal [**Doctor Last Name 534**]
however size and associated midline shift appears stable.
2. No appreciable change in bilateral subdural hematomas. There
is no evidence of uncal/transtentorial or tonsillar herniation.
3. Re-demonstration of temporal and occipital fractures.
4. Unchanged opacification of sinus opacification.
5. Large amount of intraventricular hemorrhage with unchanged
degree of mild ventricular dilatation.
CT head [**2111-2-4**]:
FINDINGS: Redemonstrated is the large right frontal
intraparenchymal hemorrhage which is similar in size compared to
[**2111-2-1**] at 9:12 a.m. There has been interval evolution with the
periphery of the hemorrhage now hypodense relative to brain
parenchyma consistent with edema/infarction. Effacement of the
frontal [**Doctor Last Name 534**] of the right lateral ventricle is similar to the
prior study. There remains slight shift of the anterior midline
structures to the left by about 5 mm, not changed. Left frontal
parenchymal contusion and subarachnoid hemorrhage has not
appreciably changed. Subdural hematomas which layer around the
bilateral cerebral convexities and along the tentorium are
similar to the prior study. The volume of blood layering within
the occipital horns of the lateral ventricles has diminished.
The size and configuration of the ventricular system is stable.
There is no effacement of the basilar cisterns. There remains a
fluid level in the sphenoid sinus. The right temporal and
occipital fractures are similar to the prior study.
IMPRESSION:
1. Evolution of right frontal intraparenchymal hemorrhage with
surrounding edema/infarction. No appreciable change in mass
effect with effacement of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle and shift of the anterior normally midline structures
to the left by about 5 mm. Similar appearance of left frontal
parenchymal contusion and subarachnoid hemorrhage.
2. No significant change in bilateral subdural hematomas.
3. Diminished amount of blood layering within the occipital
horns of the lateral ventricles. No change in ventricular size
or configuration.
4. Right temporal and occipital fractures redemonstrated.
CT head [**2111-2-5**]:
FINDINGS: There is a large right frontal intraparenchymal
hemorrhage of similar size with a similar moderate amount of
surrounding edema exerting mild leftward shift of the midline
approximately 4 mm, unchanged compared to prior study. There is
an unchanged right temporal subdural hematoma and unchanged
bifrontal subdural hematomas. There is an unchanged left frontal
hypodensity consistent with contusion. Subarachnoid blood within
the left frontal and posterior temporal lobe are stable. There
is no hydrocephalus. Blood is layering within both occipital
horns to a small degree, right greater than left.
There is hyperdense fluid within the sphenoid sinuses with right
skull base fractures again demonstrated that are unchanged.
IMPRESSION:
1. Unchanged head CT.
2. Unchanged large right intraparenchymal hemorrhage.
3. Unchanged bifrontal and right temporal subdural hematomas.
4. Unchanged left frontal and posterior temporal subarachnoid
hemorrhage.
5. Unchanged left frontal contusion.
6. Similar blood layering within the occipital [**Doctor Last Name 534**] of
ventricles with no evidence of hydrocephalus.
7. No change in mild leftward shift of the midline
.
PA & LATERAL VIEW, CHEST [**2111-2-4**]:
Mild bilateral pleural effusions and vascular plethora more
prominent at lung bases. There is also evidence of retrocardiac
opacity suggestive of either left lower lobe atelectasis or
aspiration. Old rib fracture in the posterior 9th left rib is
noted. There is no pneumothorax, hilar contours are normal.
Pulmonary vasculature demonstrates mild engorgement.
Cardiomediastinal silhouette and heart size is within normal
limits.
IMPRESSION: Interval development of small bilateral pleural
effusion and mild vascular plethora, suggestive of volume
overload. Retrocardiac opacification could be due to left lower
lobe partial atelectasis or aspiration.
.
EEG Study Date of [**2111-2-14**]
MPRESSION: Abnormal EEG due to the mildly slow and disorganized
background and due to the occasional left hemisphere sharp wave
discharges (very rarely on the right). The first abnormality
signifies
a widespread encephalopathy affecting cortical structures
broadly.
Metabolic disturbances, infection, and medications are among the
most
common causes. There were no areas of prominent and persistent
focal
slowing. Sharp waves indicate cortical hypersychrony and raised
the
possibility of an epileptogenic focus, but there were no simple
discharges to suggest ongoing seizures.
Brief Hospital Course:
A/P: 79 yo female with DM found down with bilateral subdural
hemorrhage, also developed DKA during her stay.
.
# Subdural hemorrhage: The patient was admitted to the SICU
under the neurosurgery service for bilateral SDHs and a right
frontal contusion. She was moving all extremities when her
sedation was off but she was intubated initially. On [**2111-1-31**] her
CT showed increased hemorrhagic contusion, but her neuro exam
remained stable. She had an MRI of the c-spine which showed no
injury. She had multiple CTs during the remainder of her stay,
all of which were stable. She was initially managed on
dilantin, but because of a rash, was transitioned to keppra.
She had an episode of seizure like activity, after which her
keppra was titrated up to her discharge dose. She has follow-up
with Dr. [**Last Name (STitle) **] of neurosurgery on [**2111-3-10**] at 3pm. Dr.[**Name (NI) 9034**]
office will call [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with date/time of CT head and MR
head (w and w/o contrast). Dr.[**Name (NI) 9034**] phone: [**Telephone/Fax (1) 1669**]
.
# DM/DKA: The patient was extubated on [**2-3**] and was transferred
to the floor. On [**2-4**] the patient became more lethargic and she
was hyperglycemic with a glucose of 408. She had another CT scan
which was stable with no increase in hemorrhage. Her sugars
continued to be elevated overnight an [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was
obtained on [**2-5**]. She was transferred to TSICU team for DKA, and
then transferred to the MICU. Her anion gap closed while in the
MICU and she was tranferred to the floor where [**Last Name (un) **] continued
to follow and titrate her standing and sliding scale insulin.
Her blood sugar should be followed and titrated as needed. She
may benefit from an ace-I as an outpatient, but was not started
during this admission. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with [**Last Name (un) **]
for any questions on her blood sugar control. [**Hospital1 18**] [**Numeric Identifier 14231**],
phone: [**Telephone/Fax (1) 2490**]
.
# PNA: On [**2-5**] the patient's CXR revealed "small bilateral
pleural effusion and mild vascular plethora, suggestive of
volume overload. Retrocardiac opacification could be due to left
lower lobe partial atelectasis or aspiration." She was started
on vanc and zosyn for nosocomial pna, which she received a 7 day
course and finished on [**2-12**].
.
# UTI-UCx enterococcus sensitive to vanc. difficult to assess
symptoms given mental status. Initially on cipro, d/c'd on 9th.
Finished vanc course as above.
.
# Urinary retention: foley was discontinued during her stay, but
had to be replaced given residual urine over 400cc. An attempt
should be made to take her foley catheter out again while in
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
.
# fever/leukocytosis: ? cdiff given recent antibiotics. She was
cdiff negative x 3 during her stay. No witnessed aspiration and
tube feeds without residual, so doubt aspiration. Antibiotics
d/c'd on [**2111-2-13**]. Her WBC trended down during the last week of
her stay and nadired at 12-14.
.
#Hct- stable around 25, though continues to be inconsistent.
Hapto wnl. Guaiac positive stools. s/p overall normal EGD when
PEG tube placed. Iron studies consistent with chronic disease.
.
# FEN: she was given a PEG tube and her tube feeds were titrated
to goal per nutrition recs.
.
# Access - PICC, PEG
.
# PPx: she should have sc heparin and bowel regimen.
.
# Code: per family wishes, she was transitioned to DNR/DNI
during her stay.
.
# Dispo and follow-up: She was transferred to a rehab facility
on [**2-18**] for further PT/OT, nutrition feedings, and ongoing
neurological recovery. She will f/u with her PCP as needed
after discharge from rehab. Follow-up with neurosurgery as
above.
Medications on Admission:
Insulin (NPH and sliding scale regular)
Fosamax
Discharge Medications:
1. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: Ten (10) mL PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: 5000 (5000)
units Injection TID (3 times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Year (2) **]: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Year (2) **]: One (1)
Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID
(2 times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: As per
sliding scale below units Subcutaneous every six (6) hours.
11. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Five (5) mL PO QAM
(once a day (in the morning)).
12. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Ten (10) mL PO QPM
(once a day (in the evening)).
13. Lantus 100 unit/mL Cartridge [**Last Name (STitle) **]: Thirty (30) units
Subcutaneous at bedtime.
14. Loperamide 2 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO QID (4 times
a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Bilateral SDHs
Right frontal contusion
SAH
DKA now resolved
Nosocomial Pneumonia
Discharge Condition:
Stable for discharge to her rehab facility
Discharge Instructions:
You were admitted to the hospital after a fall and developed
bleeding in the fronal lobes bilaterally. You also developed
diabetic ketoacidosis and are now on a stable insulin regimen.
You were treated for a full course of hospital acquired
pneumonia. And you also had a feeding tube placed for
nutrition.
.
Please take medications as instructed below.
.
If you develop fevers, worsening cough, abdominal pain, vomiting
or diarrhea, or any other concerning symptoms, please call your
doctor or report to the nearest ER.
.
Followup Instructions:
You have follow-up with Dr. [**Last Name (STitle) **] on [**2111-3-10**] at 3pm. Dr. [**Name (NI) 14232**] coordinator will call [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with times for a
follow-up MRI (with and without contrast) and CT head. Dr. [**Name (NI) 14232**] phone: [**Telephone/Fax (1) 1669**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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"801.26",
"780.6",
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"250.12",
"800.26",
"E880.9",
"357.2",
"362.01",
"250.62",
"285.29",
"780.39",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"99.04",
"96.72",
"96.04",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17230, 17303
|
11597, 15526
|
366, 437
|
17428, 17473
|
2155, 11574
|
18045, 18474
|
1094, 1112
|
15624, 17207
|
17324, 17407
|
15552, 15601
|
17497, 18022
|
1127, 1143
|
276, 328
|
465, 854
|
1810, 2136
|
1157, 1699
|
1714, 1794
|
877, 958
|
974, 1078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,530
| 189,421
|
42274
|
Discharge summary
|
report
|
Admission Date: [**2170-7-11**] Discharge Date: [**2170-7-30**]
Date of Birth: [**2113-7-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2170-7-16**]
1. Coronary artery bypass grafting x4, left internal
mammary artery to left anterior descending coronary
artery; reverse saphenous vein single graft from the
aorta to the ramus intermedius coronary artery; reverse
saphenous vein single graft from the aorta to the first
obtuse marginal coronary artery; reverse saphenous vein
single graft from the aorta to the distal right coronary
artery.
2. Left anterior descending patch angioplasty with a piece
of reverse saphenous vein graft.
[**2170-7-11**]
Cardiac Catheterization
History of Present Illness:
57 year old male with hypertension and dyslipidemia awoke this
morning with chest discomfort around 5:30, the pain traveled to
his left arm and he presented to [**Hospital3 3583**]. He received O2
and Nitroglycerin and the pain
subsided. One set of cardiac enzymes, troponin was 0.04. He was
transferred to [**Hospital1 18**] for cardiac catheterization to further
evaluate. He was found to have coronary artery disease upon
cardiac catheterization and is now being referred to cardiac
surgery for revascularization.
Past Medical History:
Primary Diagnosis:
Coronary Artery Disease
Past Medical History:
Hypertension
Dyslipidemia
TIA [**2170-3-16**]
GERD
Arthritis
BPH
Past Surgical History:
s/p femur fracture repair
Social History:
Patient lives alone, but his son stays with him frequently.
Works for [**Name (NI) **] Brothers.
[**Name (NI) 1139**]: quit [**2170-3-16**], prior to that smoked 1pack/ week.
ETOH: 4 drinks/ week. Patient denies any illicit drug use.
Family History:
father died at 77 of MI
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 123/80, 62, 18, 98%RA
General: Appears anxious, mild distress
Skin: Warm and dry
HEENT: No neck masses, thyromegaly, jaundice, cyanosis, R eye
lid swelling
Heart: JVP not elevated, RRR, PMI not displaced, NL S1S2, no
M/G/R
Lungs: Clear in axillae
Abd: Soft, nontender, + BS, no fluid, liver not enlarged, no
palpable masses
EXT: Right radial approach, no bleeding/hematoma/ ecchymosis
noted. 2+ radial and ulnar pulses, + CSM right hand. 2+ DP/PT,
no pedal edema
Neurologic: A+Ox3, speech clear, normal affect, no gross motor
abnormalities.
Pertinent Results:
Labs on admission:
[**2170-7-11**] WBC-8.0 RBC-4.42* Hgb-13.8* Hct-39.0* MCV-88 MCH-31.3
MCHC-35.5* RDW-13.6 Plt Ct-269
[**2170-7-11**] Neuts-77.1* Lymphs-18.0 Monos-3.1 Eos-1.3 Baso-0.5
[**2170-7-11**] PT-12.1 PTT-43.9* INR(PT)-1.0
[**2170-7-11**] Glucose-135* UreaN-12 Creat-0.7 Na-135 K-3.2* Cl-100
HCO3-25
[**2170-7-11**] ALT-23 AST-20 AlkPhos-62 TotBili-1.1
[**2170-7-11**] CK-MB-4 cTropnT-<0.01 CK-MB-3 cTropnT-<0.01 [**2170-7-11**]
CK(CPK)-93
[**2170-7-12**] CK-MB-3 cTropnT-<0.01 CK(CPK)-81 CK-MB-2 cTropnT-<0.01
[**2170-7-15**] CK(CPK)-51
[**2170-7-11**] Albumin-4.4 Cholest-205*
[**2170-7-11**] %HbA1c-5.5 eAG-111
[**2170-7-11**] Triglyc-164* HDL-47 CHOL/HD-4.4 LDLcalc-125
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2170-7-13**]
No evidence of deep venous thrombosis in the lower extremities
bilaterally.
[**2170-7-16**]
Conclusions
PRE-CPB: 1. The left atrium and right atrium are normal in
cavity size. No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No mass/thrombus is
seen in the left atrium or left atrial appendage. No thrombus is
seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. LVEF = 55%.
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. A-pacing briefly.
Well-preserved biventricular systolic function post-cpb. MR
remains trace. No AI. The aortic contour is preserved post
decannulation.
[**2170-7-23**] 07:30AM BLOOD WBC-15.6*# RBC-3.28* Hgb-9.9* Hct-29.9*
MCV-91 MCH-30.2 MCHC-33.0 RDW-14.2 Plt Ct-495*
[**2170-7-23**] 07:30AM BLOOD UreaN-14 Creat-1.2 Na-135 K-4.5 Cl-98
[**2170-7-30**] 05:26AM BLOOD WBC-10.2 RBC-3.05* Hgb-9.2* Hct-26.5*
MCV-87 MCH-30.1 MCHC-34.6 RDW-13.8 Plt Ct-813*
[**2170-7-29**] 05:00AM BLOOD WBC-9.9 RBC-2.99* Hgb-9.1* Hct-26.6*
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.8 Plt Ct-800*
[**2170-7-30**] 05:26AM BLOOD Glucose-108* UreaN-12 Creat-0.8 Na-137
K-4.5 Cl-99 HCO3-28 AnGap-15
[**2170-7-29**] 05:00AM BLOOD Na-135 K-4.6 Cl-98
Brief Hospital Course:
Mr.[**Known lastname 91618**] was brought to the Operating Room on [**2170-7-16**] where he
underwent Coronary artery bypass grafting x4,(left internal
mammary artery to left anterior descending coronary artery;
reverse saphenous vein single graft from the aorta to the ramus
intermedius coronary artery; reverse saphenous vein single graft
from the aorta to the first obtuse marginal coronary artery;
reverse saphenous vein single graft from the aorta to the distal
right coronary artery. Left anterior descending patch
angioplasty with a piece of reverse saphenous vein graft) with
Dr. [**Last Name (STitle) 914**]. Please refer to the operative report for further
surgical details. Cardiopulmonary Bypass Time:133 minutes.
Crossclamp time: 111 minutes. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
intubated and sedated in stable but critical condition. He
awoke neurologically intact and was extubated without incident.
He weaned off pressor support, was hemodynamically stable.
Beta blocker/Statin/Aspirin/ and diuresis was initiated. He was
gently diuresed toward the preoperative weight. All lines and
drains were discontinued per protocol. The patient was
transferred to the telemetry floor for further recovery. He
developed a post-op anemia with Hematocrit drop to 19%. He
received 2 units of PRBC with appropriate rise in hematocrit to
25%. Echo was performed to rule out tamponade and revealed a
trivial pericardial effusion. His Hct continued to trend down
and required another transfusion. The source was felt to be his
operative leg due to the amount of ecchymosis/swelling and
drainage. A compression wrap was placed on the donor leg. His
Hct stabilized after several days, he remained on his ASA and
Plavix. Physical therapy service was consulted for evaluation of
strength and mobility. He was started on Cefazolin for
cellulitis of the left leg.
Leg did not improve and ID was consulted. Culture was drawn and
would grow Serratia. Antibiotics were adjusted accordingly. He
was eventually treated on a course of IV Vancomycin and PO
Ciprofloxacin. White blood count returned to [**Location 213**] and the
patient was afebrile. Cellulitis turned to ecchymosis and pain
decreased.
By the time of discharge on POD 14 the patient was ambulating
with assistance, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to [**Hospital 8220**] Center in [**Location (un) 3320**] in good condition with appropriate
follow up instructions. Antibiotics will continue through [**8-14**],
at which time he will follow-up with ID and the need for further
antibiotics will be determined at this visit.
Medications on Admission:
Norvasc 10mg daily
Gabapentin 300mg daily
Lisinopril 20mg daily
Lovastatin 10mg daily
Omeprazole 20mg [**Hospital1 **]
Tramadol 50mg PRN (arthritis pain)
ASA 325mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Vancomycin 1000 mg IV Q 8H
check level before 4th dose
12. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed for dry nares.
15. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasms or anxiety .
Disp:*30 Tablet(s)* Refills:*0*
16. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
18. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
21. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
22. magnesium citrate Solution Sig: Three Hundred (300) ML
PO ONCE (Once) as needed for constipation.
23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
24. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
25. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 3320**]
Discharge Diagnosis:
Coronary Artery Disease
Past Medical History:
Hypertension
Dyslipidemia
TIA [**2170-3-16**]
GERD
Arthritis
BPH
Past Surgical History:
s/p femur fracture repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance- difficult to bear weight on LLE due
to pain
Incisional pain managed with Dilaudid and Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - very ecchymotic total length of leg, mild serosang
drainage from distal SVH site.
Edema- trace left leg
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Infectious Diseases: Dr. [**Last Name (STitle) **] (for Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 457**],
[**2170-8-14**] 11:30am [**Doctor First Name **], basement
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] on [**2170-8-21**] 2:30 in the [**Hospital **]
medical office building ([**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 5310**] [**Telephone/Fax (1) 5315**] on [**8-10**] at 2pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 82558**] in [**3-20**] 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:[**2170-7-30**]
|
[
"998.12",
"E878.2",
"401.9",
"414.01",
"041.85",
"285.9",
"V15.82",
"998.59",
"410.71",
"272.4",
"511.9",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"38.97",
"37.22",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10744, 10826
|
5387, 8104
|
288, 862
|
11031, 11359
|
2516, 2521
|
12198, 13024
|
1878, 1904
|
8324, 10721
|
10847, 10871
|
8130, 8301
|
11383, 12175
|
10982, 11010
|
1919, 1929
|
1951, 2497
|
238, 250
|
890, 1409
|
1450, 1474
|
2535, 5363
|
10893, 10959
|
1627, 1862
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,264
| 127,038
|
54596
|
Discharge summary
|
report
|
Admission Date: [**2154-6-24**] Discharge Date: [**2154-7-1**]
Date of Birth: [**2103-1-17**] Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
FTT
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
THis is a 51 yo F with metastatic cholangiocarcinoma who was
transferred from [**Hospital3 3583**] for FTT. The patient was
admitted to [**Hospital3 **] [**1-24**] N/V and abd pain. + coffee
ground emesis. She was not capable of taking her PO pain meds.
Her pain had markedly increased in the past few weeks. THe
patient was exeriencing increasing nausea and vomiting secondary
to her chemotherapy (last round two weeks ago). At [**Hospital1 **] the patient was hydrated. Her initial CXR was
unremarkable as was her CBC. The doctors [**First Name (Titles) **] [**Hospital3 **]
spoke to the patient about her poor ultimate prognosis. At that
point, the patient decided to come to [**Hospital1 18**] to be seen by her
oncologist Dr. [**First Name (STitle) **]. Currently the patient complains of mild
nausea, + cough, shortness of breath, and whitish sputum, occ
diarrhea [**1-24**] lactose intolerance. + abd pain when laying down.
On review of systems, the pt. denied recent fever or chills. No
night sweats. + 30 lb weight loss. Denied headache, sinus
tenderness, rhinorrhea or congestion. Denied chest pain or
tightness, palpitations. Denied vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Etoh abuse
ONC HX:
metastatic cholangiocarcinoma:
TREATMENT HISTORY: Ms. [**Known lastname 29571**] was diagnosed with
cholangiocarcinoma in [**2153-4-22**] with peritoneal and omental
metastases. She has been treated with biliary stenting with
resolution of jaundice. She completed 8 cycles gemcitabine and
CPT11 in [**2153-12-23**] until relapse and was started on xeloda
1000mg [**Hospital1 **] for 14 days of 21 day cycles.
s/p stent 8x6 cm metal stent traversing the stricture from the
CBD to the left main hepatic duct
s/p exploratory laparoscopy with omental and peritoneal biopsies
s/p chemotherapy with gemcitabine and CPT-11 x 3 doses
Social History:
Etoh abuse. 25 pack-year tobacco history. Daily marijuana use.
Lives with her boyfriend. Currently unemployed.
Family History:
Maternal uncle with stomach cancer; grandmother with AML.
Physical Exam:
T 99.2, HR 85, BP 102/74, RR 18, O2 sat 92% 3L
Gen: awake, alert, oriented. No apparent distress. Cachectic and
fatigued
HEENT: PERRL, EOMI, sclera anicteric. MM dry. + whitish plaque
on tongue and palate. No erythema.
Neck: no lad, supple.
CV: regular rate and rythym III/VI SEM at apex. (old)Nl S1 and
s2. No rubs/clicks.
Pulm: + crackles b/l. Decreased BS at bases.
Ab: mildly distended, + TTP in epigastrium. No rebound or
guarding. + abd mass palpated. diminished BS.
Ext: warm, well perfused, [**1-25**]+ pitting edema b/l. 2+ pulses.
Skin: stage I decub ulcer.
Brief Hospital Course:
Mrs. [**Known lastname 29571**] was tolerating POs with liberal use of
anti-emetics. Her pain was controlled with a morphine drip. Pt.
had an acute onset of shortness of breath and was transferred to
the ICU. After a long discussion with Dr. [**First Name (STitle) **], the pt and
family decided to reconsider code status, which was intially
full code. While in the ICU, Mrs. [**Known lastname 29571**] and her family
decided to change her goals of care to comfort measures only.
Her morphine drip was titrated to pain and dyspnea-free. the
patient passed away on [**2154-7-1**].
Medications on Admission:
dilaudid, lorazepam, metoclopramide, zelnorm, senna, ranitidine,
promethazine, zofran, morphine drip.
Discharge Disposition:
Expired
Discharge Diagnosis:
cholangiocarcinoma
Discharge Condition:
pt. expired during hospital stay
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2154-8-19**]
|
[
"261",
"276.51",
"197.6",
"599.0",
"038.49",
"112.0",
"707.03",
"995.91",
"156.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3799, 3808
|
3063, 3647
|
269, 276
|
3870, 3904
|
3957, 3992
|
2395, 2454
|
3829, 3849
|
3673, 3776
|
3928, 3934
|
2469, 3040
|
226, 231
|
305, 1574
|
1596, 2246
|
2262, 2379
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,389
| 136,610
|
39139
|
Discharge summary
|
report
|
Admission Date: [**2119-2-14**] Discharge Date: [**2119-2-15**]
Date of Birth: [**2048-4-6**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
lower GI bleed
Major Surgical or Invasive Procedure:
R femoral cordis placement
Endotracheal intubation
L radial arterial line placement
Femoral artery cannulation and mesenteric angiography
History of Present Illness:
70M with history of metastatic and locally recurrent colon
cancer s/p LAR and multiple subsequent resections and history of
GI bleeds from sites of recurrent tumor, presenting from OSH
with large LGIB. He appeared to be very actively bleeding there
with clots. He was transfused 2 units PRBCs at OSH. Dopamine
was started for hypotension and NGT was placed.
.
He was transferred to [**Hospital1 18**] for further management. Initial BP
83/p and he apparently had a seizure in triage. He was
hypotensive at times to the 50s systolic. He had a R femoral
Cordis placed and was intubated. In the ED massive transfusion
protocol was initiated. He received at least 12 units PRBCs, 4
FFP, 1 cryo, 1 platelets, 6 liters of NS. Hct after 9 units was
17. Also received antihistamines and steroids for contrast
allergy and likely need for IR intervention. GI was consulted
and noted limited ability to intervene given rapid bleed.
Surgery was consulted and felt patient would be poor surgical
candidate and recommended IR intervention. IR discussed
possible intervention with family, who wished to proceed with
potential angio and coiling.
.
Patient went to the IR suite for attempt at angiography. Upon
arrival to IR patient hypotensive to 60s-80s systolic. Rapidly
required max doses of dopamine, neosynephrine, and levophed in
addition to blood and saline products via rapid infuser. Approx
10 units PRBCs, 3 FFP, 1 platelets were given in addition to >12
L saline. MICU attending met with family and decision was made
for patient to be DNR in event of cardiac arrest.
Unfortunately, IR could not localize bleeding in SMA or [**Female First Name (un) 899**].
Family was notified with plans to bring patient up to MICU for
transition to comfort care. Further blood product transfusions
stopped and he was supported with saline.
Past Medical History:
- Colon adenocarcinoma with mets, s/p LAR and subsequent
resections with at least 2 GIBs ([**5-/2118**] and [**9-/2118**]) resulting
from recurrent tumor and ulcerations. Diagnosed in [**2113**]. Had
adjuvant chemo with continued progression.
- COPD
- Hyperlipidemia
- HTN
- Bells palsy
- DM
- CAD s/p MI and PCI with stenting in [**2111**]
Social History:
Lives with wife. [**Name (NI) **] current smoking or EtOH use.
Family History:
unknown
Physical Exam:
(upon arrival to MICU, following angio)
HR 109, BP 77/42, R30, 80% on FiO2 1, PEEP 5.
Intubated, sedated. Not responding.
Tachycardic, regular.
Abdomen obese, no mass appreciated.
Extrem cool without appreciable edema.
Large active bright red blood from rectum (saturating towels
underneath patient; dripping from angio table during IR
procedure)
Pertinent Results:
[**2119-2-14**] 09:10PM
WBC-9.6 HGB-6.3* HCT-19.7* MCV-97 MCH-31.0 MCHC-31.9 RDW-16.4*
NEUTS-89.7* LYMPHS-6.8* MONOS-3.4 EOS-0.1 BASOS-0.1
PLT COUNT-122*
PT-16.3* PTT-150* INR(PT)-1.4*
GLUCOSE-335* UREA N-19 CREAT-1.1 SODIUM-140 POTASSIUM-4.8
CHLORIDE-112*
TOTAL CO2-18* ANION GAP-15
ALBUMIN-2.1* CALCIUM-6.6* PHOSPHATE-2.9 MAGNESIUM-1.7
ALT(SGPT)-4 AST(SGOT)-10 CK(CPK)-32* ALK PHOS-39* TOT BILI-1.1
LIPASE-11
cTropnT-0.05* CK-MB-NotDone
.
CXR: ETT slightly low, no cardiopulmonary process.
ECG: sinus tach, NANI.
Brief Hospital Course:
70 M with advanced locally recurrent and metastatic colon cancer
with history of multiple bleeds from sites of recurrence,
presenting with large, brisk lower GI bleed, presumed from same
source. He arrived to [**Hospital1 18**] with low Hct, significant
coagulopathy (likely consumption), and hemodynamic instability.
GI, surgery, and IR were consulted. GI unable to intervene
given briskness of his bleed. Patient too unstable and
coagulopathic for surgical intervention. IR was pursued at last
attempt/heroic measures. Unfortunately no bleeding was seen and
thus no embolization was possible. Throughout his course at the
two hospitals, he received at least 24 units PRBCs, 7 FFP,
platelets, cryo, calcium, and at least 20 liters of saline.
Despite these measures he continued to show evidence of
refractory hemorrhagic shock, requiring maximum doses of 3
pressors. The gravity of the situation was discussed with the
family before and during angiography, and they understood that
beyond IR there were no options. The inability to embolize was
discussed with the family and patient was thus supported with
non-blood products until arrival to the MICU in order to spend
last moments with family. As saline infusions were stopped,
with continued full pressor and vent support but knowledge that
patient would pass within minutes, patient went into asystolic
arrest. He was pronounced dead at 3:05am. Autopsy was declined
by family and ME.
Medications on Admission:
Gllyburide 5 mg [**Hospital1 **]
Simvastatin 40 mg daily
toprol xl 50 mg daily
diovan 160 mg daily
protonix 40 mg daily
senna prn
Citrucel 1000 mg QAM
proair 90mcg 2 puffs q4h prn
vit b12 1000 mcg daily
uroxatrol 10 mg daily
percocet prn
oxycontin 20 mg Q12hrs
ambient 10 mg HS
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Hemorrhagic shock
Lower GI bleed
.
Coagulopathy
Anemia of acute blood loss
Metastatic colon cancer
Respiratory failure
THrombocytopenia
Lactic acidosis
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"401.9",
"250.00",
"286.9",
"285.1",
"578.9",
"272.4",
"V45.82",
"496",
"276.2",
"V10.05",
"287.5",
"780.39",
"785.59",
"518.81",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"88.47",
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5537, 5546
|
3729, 5181
|
310, 449
|
5741, 5750
|
3174, 3706
|
5801, 5898
|
2780, 2789
|
5510, 5514
|
5567, 5720
|
5207, 5487
|
5774, 5778
|
2804, 3155
|
256, 272
|
477, 2316
|
2338, 2683
|
2699, 2764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,870
| 136,095
|
49161
|
Discharge summary
|
report
|
Admission Date: [**2103-3-3**] Discharge Date: [**2103-4-22**]
Date of Birth: [**2022-2-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Central Venous Line Placement
Arterial Line Placement
Intubation
Mechanical Ventilation
Percutaneous gallbladder drain placement
History of Present Illness:
Mr. [**Known lastname **] is an 81 year-old man with a history of atrial
fibrillation on warfarin, DM2, HTN, hyperlipidemia, prior
pulmonary TB, who presents with 2 days of worsening abdominal
pain. He had been in his USOH until he noted lower abdominal
pain two days ago, worse with movement and palpation. He had
never had pain like this before. He reports decreased urine
output and increased thirst, but was not having worsened pain
with eating. He has not had fevers. He came to the ED today
because of the pain and was noted to be hypoxic to 91% on room
air upon arrival. He was given approx 1.5 L of hydration in the
ED, after a CT abdomen showed acute pancreatitis. He has been
afebrile with SBPs 100-110 and has not been tachycardic.
He was admitted to the medical floor, and more aggressive fluid
resuscitation (2L NS) was given. He began to have respiratory
distress and was noted to have O2 sat 88% on 4L nc. He was
transferred to the MICU for worsening respiratory status. On
arrival, he began to vomit and had a witnessed aspiration event.
He was intubated for airway protection and respiratory
distress.
ROS:
No fevers. (+) constipation
Past Medical History:
1. Diabetes mellitus type II
2. Hypertension
3. Atrial fibrillation
4. Hypercholesterolemia
5. Left inguinal hernia now s/p repair ([**2101-1-28**])
6. Congestive heart failure
7. Glaucoma
8. History of nephrolithiasis
9. Diverticuli
10. History of intermittent pyuria
11. History of hematuria likely secondary to stones
12. Sexual dysfunction
13. ?Nummular eczema
14. Anemia
15. Right lower lobe lung nodule s/p mediastinal lymphadenopathy
with pathology showing necrotizing granuloma
16. Status post right inguinal hernia repair
17. Status post right masteroidectomy and tempanoplasty
18. Status post cholesteatoma
19. Status post bilateral cataract surgery
[**15**]. Pulmonary TB s/p 4-drug rx with persistent stable 18 mm lung
21. Bladder cancer s/p transurethral resection
Social History:
Ex-smoker, quit 50 years ago, 10 pack-year smoking history. No
EtOH. He has 6 children in [**Location (un) 686**]. He is currently a
resident at [**Hospital3 2558**], independent with ADL.
Family History:
7 healthy children, mother h/o DM, father h/o EtOH use
Physical Exam:
ON ADMISSION:
=============
T 97.9 BP 107/68 HR 90 RR 20 Sat 91% on 2 L/min, 98% on 4 L/min
General: NAD
HEENT: no icterus, dry MM
Neck: jugular veins flat
Chest: rales 1/3 up bilaterally
CV: rrr, no m/r/g
Abdomen: distended, soft, (+) guarding and rebound in RUQ
Extremities: 2+ edema to midshins, 1+ PT pulses, warm
Skin: no rashes or jaundice
Neuro: alert, appropriate
UPON TRANSFER TO MICU:
======================
T 94.4 BP 124/43 HR 85 RR 20 Sat 89% initially on vent,
increasing to 100%
VENT: AC at 600x16, PEEP 5, 100% FiO2
General: Intubated, sedated.
HEENT: PERRL, anicteric, dry MM, ETT in place
Neck: jugular veins flat
Chest: coarse breath sounds bilaterally
CV: rrr, no m/r/g
Abdomen: distended, soft, decreased BS.
Extremities: Warm, 2+ edema, 2+ PT pulses.
Pertinent Results:
ADMISSION LABS:
===============
[**2103-3-3**] 10:50PM TYPE-ART PO2-86 PCO2-40 PH-7.31* TOTAL CO2-21
BASE XS--5
[**2103-3-3**] 07:20PM TYPE-ART PEEP-15 O2-70 PO2-61* PCO2-46*
PH-7.30* TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2103-3-3**] 07:20PM GLUCOSE-65* LACTATE-1.1
[**2103-3-3**] 03:24PM GLUCOSE-44* UREA N-30* CREAT-1.1 SODIUM-140
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
[**2103-3-3**] 03:24PM ALT(SGPT)-30 AST(SGOT)-32 LD(LDH)-276* ALK
PHOS-61 AMYLASE-712* TOT BILI-0.7
[**2103-3-3**] 03:24PM LIPASE-255*
[**2103-3-3**] 03:24PM CALCIUM-7.9* PHOSPHATE-2.7# MAGNESIUM-2.5
[**2103-3-3**] 03:24PM WBC-11.7* RBC-4.41* HGB-11.9* HCT-38.2*
MCV-87 MCH-27.1 MCHC-31.3 RDW-17.3*
[**2103-3-3**] 03:24PM PLT COUNT-179
[**2103-3-3**] 03:24PM PT-31.2* PTT-41.3* INR(PT)-3.2*
MICROBIOLOGY: Limited sample
=============
Bile: FLUID CULTURE (Final [**2103-4-21**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE
GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 103133**] ([**2103-4-14**]).
VRE Swab: VANCOMYCIN------------ >256 R
Urine: AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
STUDIES:
========
CT Abd/Pelvis:
IMPRESSION:
1. Marked inflammatory changes about the head of the pancreas is
consistent with acute pancreatitis. No drainable fluid
collections are identified. An underlying mass or necrosis of
the pancreas cannot be excluded on this non- contrast study. The
duodenum is secondary inflammed and fluid extending into the
deep presacral space via the right flank.
2. Esophagus dilated with oral contrast. The patient could be at
risk for aspiration. Underlying esophageal disorder cannot be
excluded.
3. Patchy bilateral opacities, right greater than left with
superimposed atelectasis. This is nonspecific, but could
possibly represent microaspiration.
4. Diverticulosis.
ABDOMINAL ULTRASOUND: There is mobile sludge/[**Doctor Last Name 5691**] layering
within the gallbladder with no discrete shadowing stones. The
[**Doctor Last Name 5691**] measures 1.4 cm in diameter. There is no gallbladder wall
edema or pericholecystic fluid to suggest cholecystitis. The
portal vein is patent with anterograde flow. The common duct
measures 6 mm and there is no intra- or extra-hepatic biliary
ductal dilatation. No focal hepatic lesions are identified. The
pancreas is not seen due to overlying bowel gas.
ECHO:
The left atrium is moderately dilated. 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. The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The aortic valve leaflets
appear structurally normal with good leaflet excursion. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis and moderate pulmonary artery systolic hypertension.
This constellation of findings is suggestive of a primary
pulmonary process (pulmonary embolism, COPD, pneumonia, etc.).
CT Abd/Pelvis:
1. Compared to prior exam from [**2103-3-16**], there is
worsening consolidation within the right lower lobe. Bilateral
pleural effusions are present, left greater than right.
2. Extensive fluid and stranding surrounding the pancreatic head
consistent with pancreatitis, not significantly changed from
prior exam. Non-contrast technique limits evaluation of adjacent
vessels.
3. A percutaneous cholecystostomy tube is identified within the
gallbladder. There is interval decompression of gallbladder
which contains small stones.
4. Small amount of perihepatic and perisplenic ascites,
marginally increased compared to prior exam. Mild-to-moderate
amount of fluid within the pelvis. Diffuse body wall anasarca.
CXR: IMPRESSION: AP chest compared to [**3-24**] through [**4-15**]:
Diffuse severe infiltrative pulmonary abnormality more
pronounced in lower lungs has not changed appreciably in nearly
a month, accompanied by moderate right and left pleural
effusions which have increased recently but not since [**4-15**].
ET tube, right jugular line and feeding tube are in standard
placements. No pneumothorax. Heart size obscured by adjacent
pleural and parenchymal abnormalities.
Brief Hospital Course:
81 year old man originally admitted to the hospital with severe
acute pancreatitis of unclear etiology. He initially met met
four of five [**Last Name (un) **] criteria. The patient received aggressive
fluid resuscitation as well as pain control. He was transferred
to the MICU for worsening oxygenation.
Upon transfer to the MICU, the patient was intubated after a
witnessed aspiration event, a central and A-line were placed,
both to monitor hemodynamics and for fluid resuscitation. The
patient was initially treated with meropenem for aspiration
pneumonia. Vancomycin was added.
His hospital course was complicated by sepsis with hypotension,
ARDS, requiring pressor and ventilatory support with
percutaneous drain placement for acalculous cholecystitis. His
vancomycin was discontinued and he was started on Zosyn for
broad spectrum coverage.
The patient was extubated on [**3-21**] after tolerating a SBT. He
required re-intubation for respiratory distress. He was
initiated on a Lasix drip to attempt to mobilize some of his
anasarca for extubation. His diuresis was limited by his
hypotension.
The patient eventually went into multiorgan system failure
manifested by anuria as well as a two pressor requirement. He
also required increasing amount of PEEP and FiO2 of 1.0 to
maintain oxygenation. The patient became increasingly acidotic.
In keeping with the desire of his family, the patient was
treated with pressors, antibiotics and ventilator support but
was made DNR with no further escalation of care.
The patient expired in the intensive care unit with his daughter
and son-in-law at the bedside.
Medications on Admission:
warfarin 1 mg daily
amiodarone 200 mg daily
enalapril 5 mg [**Hospital1 **]
furosemide 40 mg daily
glyburide 5 mg daily
metformin 250 mg daily
nifedipine 60 mg daily
KCl 20 mEq daily
pantoprazole 40 mg daily
atorvastatin 80 mg daily
UPON TRANSFER TO MICU:
warfarin 1 mg daily
amiodarone 200 mg daily
enalapril 5 mg [**Hospital1 **]
furosemide 40 mg daily
glyburide 5 mg daily
metformin 250 mg daily
nifedipine 60 mg daily
KCl 20 mEq daily
pantoprazole 40 mg daily
atorvastatin 80 mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Septic Shock
ARDS
Acalculous cholecystitis
Pancreatitis
Acute renal failure with anuria
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"276.0",
"038.9",
"401.9",
"785.52",
"250.00",
"995.92",
"518.81",
"272.0",
"286.9",
"427.31",
"507.0",
"V10.51",
"577.0",
"560.1",
"575.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.6",
"38.91",
"96.72",
"99.15",
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
10394, 10403
|
8197, 9826
|
335, 465
|
10543, 10552
|
3543, 3543
|
10604, 10746
|
2678, 2734
|
10366, 10371
|
10424, 10522
|
9852, 10343
|
10576, 10581
|
2749, 2749
|
281, 297
|
493, 1652
|
3559, 8174
|
2763, 3524
|
1674, 2455
|
2471, 2662
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,719
| 182,222
|
7573
|
Discharge summary
|
report
|
Admission Date: [**2128-3-10**] Discharge Date: [**2128-3-19**]
Date of Birth: [**2094-10-21**] Sex: M
Service: MEDICINE
Allergies:
Voriconazole
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
fever, chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33-year-old man with AML on day 16 of his fourth cycle of HiDAC
who presents with fever. Over the course of the day on [**2128-3-9**]
the patient felt increasingly fatigued and, in the evening,
developed fever to 102F with chills. He denies any cough but
claims somewhat chronic mild nasal congestion with minimal
post-nasal drip. No dysuria or diarrhea. He reports a dull
frontal headache with mild photophobia but no neck stiffness or
any focal neurologic symptoms. No mylagias. No recent travel or
sick contact. [**Name (NI) **] influenza vaccination.
.
In the ED, T 104.4, HR 122, BP 168/98, RR 16, 100% RA. Exam,
including neuro exam, was unremarkable. His ANC was 40. CXR
negative. Patient was given empiric cefepime and vancomycin.
.
Review of Systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies sinus tenderness.
Denies chest pain or tightness, palpitations, lower extremity
edema. Denies cough, shortness of breath, or wheezes. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies abnormal bleeding,
bruising, lymphadenopathy. Denies dysuria, stool or urine
incontinence. Denies arthralgias or myalgias. Denies rashes or
skin breakdown. No numbness/tingling in extremities. All other
systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
DIAGNOSIS: Acute myeloid leukemia, myelomonocytic
differentiation with inversion 16. Treated w/ C2D1 High dose
Cytarabine pmn [**12-21**]. The patient presented with three weeks of
fatigue, sore throat, preauricular pain and two days of a
headache on [**2127-10-9**]. Laboratory studies revealed a white blood
cell count of 57,000 with 30% others, hematocrit of 36.1, and
platelet count of 54,000. He underwent a bone marrow aspirate
and biopsy and pathology demonstrated acute myelogenous leukemia
with myelomonocytic differentiation that was positive for the
inversion 16 mutation. He initiated therapy with standard 7+3
including Daunorubicin at 90 mg/m2 and cytarabine 100 mg/m2. His
course was complicated by pulmonary edema during induction
requiring ICU transfer, febrile neutropenia and respiratory
bronchiolitis. He was discharged from the hospital on day +30
bone marrow was without leukemia. He began postremission therapy
with high dose cytarabine on [**2127-11-17**]. Cycle 1 was complicated
by fever/neutropenia requiring admission. On [**12-14**] he had
dendritic cell collection (vaccine trial protocol #09-412).
Cycle 2 ([**Date range (1) 27630**]) was uncomplicated, as was Cycle 3 (D1 was
[**2128-1-26**]).
.
OTHER PAST MEDICAL HISTORY:
- asthma
- allergies
- motor vehicle accident in [**2126-7-24**], in which he hit his head
Social History:
Mr. [**Known lastname 27628**] is engaged and his fiancee just gave birth to a
baby girl named [**Name (NI) 27631**] on [**1-16**]. He worked as a financial
officer and account manager. He is trained as a chef and
continues to work in the food service industry and with
catering.
Tobacco: Pt started smoking at age 18 ~1 pack per week
currently, but did smoke more heavily in the past. He has since
quit and does not plan to resume smoking.
EtOH: Pt drinks alcohol socially, never on a regular basis. No
EtOH since [**2127-9-24**]
Drugs: Pt denies hx of illicit drug use.
Family History:
His father died of kidney cancer in his 40s.
Maternal grandmother had melanoma. His mother has high blood
pressure, high cholesterol, thyroid lesion, and alopecia.
Physical Exam:
ADMISSION EXAM:
VS: T 101.5, BP 104/58, HR 118, RR 20, 97%RA
GEN: Young man lying in bed in NAD, awake, alert.
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesions.
NECK: Supple, no JVD.
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present.
MSK: Normal muscle tone and bulk.
EXT: WWP. No c/c/e, 2+ DP/PT bilaterally.
SKIN: Small cut on left shin, no erythema or drainage.
NEURO: Oriented x 3, normal attention, CN II-XII intact, no
nuchal rigidity
PSYCH: Appropriate, pleasant.
.
DISCHARGE EXAM:
VS: T 98, BP 124/70, HR 80, RR 16, 94-99%RA
GEN: NAD, awake, alert.
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesions.
NECK: Supple, no JVD.
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present.
MSK: Normal muscle tone and bulk.
EXT: WWP. No c/c/e, 2+ DP/PT bilaterally.
SKIN: No lesions or rash.
NEURO: Oriented x 3, normal attention, CN II-XII intact, motor
and sensory function intact.
PSYCH: Appropriate, pleasant.
Pertinent Results:
ADMISSION LABS:
[**2128-3-10**] 12:04AM BLOOD WBC-0.3* RBC-2.95* Hgb-9.5* Hct-24.6*
MCV-83 MCH-32.0 MCHC-38.4* RDW-15.5 Plt Ct-32*
[**2128-3-10**] 12:04AM BLOOD Neuts-13.0* Bands-0 Lymphs-79.1*
Monos-5.4 Eos-1.8 Baso-0.7
[**2128-3-10**] 12:04AM BLOOD PT-12.1 PTT-23.0 INR(PT)-1.0
[**2128-3-10**] 12:04AM BLOOD Gran Ct-40*
[**2128-3-10**] 12:04AM BLOOD Glucose-109* UreaN-20 Creat-1.2 Na-139
K-3.6 Cl-99 HCO3-27 AnGap-17
[**2128-3-10**] 12:04AM BLOOD ALT-42* AST-27 LD(LDH)-187 AlkPhos-107
TotBili-0.6
[**2128-3-10**] 12:04AM BLOOD Calcium-9.9 Phos-3.1 Mg-2.0
.
PERTINENT LABS:
[**2128-3-12**] Aspergillus Galactomannan Ag: negative
[**2128-3-12**] B-Glucan: negative
[**2128-3-14**] Coccidioides Ab: negative
[**2128-3-14**] Adenovirus PCA: negative
[**2128-3-14**] Blastomycosis Ab: pending
.
DISCHARGE LABS:
[**2128-3-19**] 12:00AM BLOOD WBC-6.6 RBC-3.06* Hgb-8.9* Hct-25.5*
MCV-83 MCH-29.1 MCHC-34.9 RDW-14.6 Plt Ct-119*
[**2128-3-19**] 12:00AM BLOOD Neuts-56 Bands-0 Lymphs-21 Monos-17*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-4* NRBC-2*
[**2128-3-19**] 12:00AM BLOOD PT-13.8* PTT-26.1 INR(PT)-1.2*
[**2128-3-19**] 12:00AM BLOOD Gran Ct-4067
[**2128-3-19**] 12:00AM BLOOD Glucose-90 UreaN-17 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2128-3-19**] 12:00AM BLOOD ALT-69* AST-31 LD(LDH)-326* AlkPhos-78
TotBili-0.5
[**2128-3-19**] 12:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3
................................................................
MICROBIOLOGY:
[**2128-3-10**] Blood Cx: Strep viridans (4/4 bottles)
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
[**2128-3-10**] Urine Cx: no growth x2
[**2128-3-10**] Rapid Resp Viral Screen: negative
[**2128-3-11**] Blood Cx: negative
[**2128-3-11**] Urine Legionella Ag: negative
[**2128-3-12**] Blood Cx: negative
[**2128-3-12**] Stool Cx: no C.diff
[**2128-3-13**] Blood: CMV VL not detected
[**2128-3-13**] Blood Cx: negative
[**2128-3-14**] Blood Cx: NGTD
[**2128-3-14**] Blood: Cryptococcal Ag not detected
[**2128-3-14**] Stool Cx: negative
[**2128-3-16**] Blood Cx: NGTD
................................................................
IMAGING:
[**2128-3-10**] CXR: No acute intrathoracic process.
.
[**2128-3-11**] TTE: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly to
moderately depressed (LVEF=40-45%) with mild global hypokinesis
(and inferior near akinesis). There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with mild
global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2127-10-15**], the LVEF/RVEF have decreased (c/w toxic/metabolic
process). The patient is now tachycardic. No valve vegetations
are/were seen.
.
[**2128-3-12**] Lower Extremity U/S: no DVT in either leg
.
[**2128-3-12**] CT Chest w/o con: Widespread infiltrative pulmonary
abnormality, infection and/or pulmonary hemorrhage. Some
component of edema is likely.
.
[**2128-3-12**] RUQ U/S: Mild gallbladder wall edema and sludge but no
evidence of stones, pericholecystic fluid and the [**Doctor Last Name 515**] sign
is negative. Therefore, acute cholecystitis is unlikely,
however, clinical correlation is recommended. If there is high
clinical concern, nuclear medicine hepatobiliary scan might be
considered.
.
[**2128-3-14**] CXR: There has been no change since [**3-12**] in the
extensive peribronchial infiltration, worse in the right lung
than the left. Heart is normal size. Pulmonary vasculature is
normal, although mediastinal veins are mildly distended. There
is no pleural effusion. Given the appearance of the chest CT
performed concurrently with the most recent prior chest
radiograph, I do not believe this is pulmonary edema and favor
atypical pneumonia or pulmonary hemorrhage instead.
Brief Hospital Course:
33 year old man with AML on day 16 of his fourth cycle of HiDAC
who presented with neutropenic fever, found to have Strep
viridans bacteremia and pneumonia.
.
# Neutropenic fever: Upon admission, CXR and UA were both
negative and the patient denied any URI, GI, or meningeal
symptoms. No lines. He was noted to have a small cut on his left
lower extremity which did not appear infected. He was
empirically started on vanc/cefepime + oseltamivir. Rapid
respiratory viral screen was negative so the oseltamivir was
stopped. He continued to experience fevers to 104 and
desaturation to the low 90s, so voriconazole and levofloxacin
were added. Blood cultures returned positive for Strep viridans
(4/4 bottles), so antibiotics were changed to
vanc/meropenem/vori. A TTE showed depressed LVEF and RVEF
compared to a prior study in [**9-/2127**], c/w a toxic/metabolic
process. No vegetations were seen. He remained hypoxic, so LENI
was done which showed no DVT. Due to an increasing O2
requirement, he was transferred to the ICU for close monitoring
and oxygen through face mask. CT chest showed a widespread
pulmonary infiltrate suspicious for infection or pulmonary
hemorrhage, as well as some component of pulmonary edema. He was
diuresed with good effect and his O2 requirement slowly
declined. Azithromycin was added to his antibiotic regimen to
cover atypical organisms, though a urine legionella antigen was
negative. The patient experienced diarrhea and was empirically
started on PO vancomycin. C. diff returned negative and the PO
vanc was then stopped. He was treated with several days of
Neupogen. All fungal and viral cultures returned negative and
all repeat blood cultures were negative. His clinical status
continued to improve and he was eventually transferred back to
the floor on vanc/meropenem/azithro/vori. The patient
experienced hallucinations on the voriconazole so this was
switched to micafungin. A PICC was placed and the patient was
discharged home on vanc/meropenem for a total 7-day course for
pneumonia (to be completed on [**3-22**]). He will then complete an
additional 3 days of ceftriaxone for a total 10-day course for
the bacteremia (to be completed on [**3-25**]).
.
# Chest pain: The patient complained of mild chest pain during
his ICU stay. Troponins were initially slightly elevated, but
the CK-MBs were flat and he did not have any EKG changes. The
pain resolved spontaneously and was felt to be due to his
underlying pneumonia.
.
# Blurry vision: The patient reported several days of blurry
vision in his right eye. He was evaluated by ophthalmology which
revealed a macular hemorrhage with multiple cotton wool spots in
the right eye and multiple intraretinal hemorrhages in the left
eye, likely from his underlying AML. He will follow up with
ophthalmology next week.
.
# AML: The patient is s/p induction with 7+3 and subsequently
underwent 4 cycles of HiDAC. He was neutropenic upon admission
and received several days of Neupogen while in the ICU, which
was discontinued on the floor since he was no longer
neutropenic. ANC upon discharge was 4067.
.
# Full code
Medications on Admission:
1. acyclovir 400 mg q8h
2. albuterol inh prn wheezing
3. ciprofloxacin 500 mg [**Hospital1 **] x 14 days (day 1 = [**2128-2-29**])
4. fluconazole 200 mg daily x 14 days (day 1 = [**2128-2-29**])
5. prednisolone acetate 1% 1 drop TID
6. prochlorperazine 10 mg q8h prn nausea
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
5. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day: Administer 1 gram daily from [**Date range (1) 27632**].
Disp:*4 days supply* Refills:*0*
6. vancomycin 10 gram Recon Soln Sig: 1250 (1250) mg Intravenous
every eight (8) hours: Administer 1250mg every 8 hours from
[**Date range (1) 27632**].
Disp:*4 days supply* Refills:*0*
7. ceftriaxone 1 gram Piggyback Sig: One (1) gram Intravenous
once a day: Administer 1g daily from [**Date range (1) 9237**].
Disp:*3 days supply* Refills:*0*
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary:
- Bacteremia
- Pneumonia
.
Secondary:
- Acute myelogenous leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 27628**],
You were admitted with fevers and were found to have an
infection in your blood and lungs which we are treating with
antibiotics. You also reported blurry vision in your right eye.
The ophthalmologists evaluated you and it is likely that this is
from your leukemia.
.
We have made the following changes to your medications:
- STARTED vancomycin and ertapenem (antibiotics) which you will
take through [**2128-3-22**]
- STARTED ceftriaxone (antibiotic) which you will take from
[**Date range (1) 27633**] after you finish the vancomycin and ertapenem
- STOPPED ciprofloxacin
Followup Instructions:
Please call ([**Telephone/Fax (1) 6179**] to arrange a follow up appointment
with Dr. [**Last Name (STitle) **].
.
Please call ([**Telephone/Fax (1) 18621**] to arrange a follow up appointment
with the ophthalmologist.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2128-3-21**]
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27,171
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47035
|
Discharge summary
|
report
|
Admission Date: [**2105-1-28**] Discharge Date: [**2105-2-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
altered mental status, respiratory distress
Major Surgical or Invasive Procedure:
endotracheal intubation
central venous line placement
arterial line placement
History of Present Illness:
83-year-old gentleman with a h/o microfollicular thyroid adenoma
and recent diagnosis of hepatocellular/colon cancer who
presented to the ED with mental status changes and increasing
confusion. He also reported dizziness, weakness, and shortness
of breath stating that he felt like he was going to "pass out."
He was noted to be diffusely jaundiced. STAT FSBG was 24. He was
given glucagon and D50. Family reported increasing confusion at
home.
.
In ED, vitals on presentation: T 98.5 HR 91 BP 129/60 RR 16
99%NRB. He was given vancomycin, levofloxacin, and flagyl. He
was sent for a CT abdomen and pelvis. After returning from CT
scan, he developed respiratory distress. The ED was concerned
about possible allergic reaction from IV contrast and he was
given nebs, solumedrol, pepcid, and benadryl. His respiratory
status did not improve and he was intubated for increased work
of breathing. A right femoral line was placed and levophed was
started for hypotension (BP 88/47) after intubation. He was also
given lactulose down his OGT that was placed after intubation.
He was also noted to be guaiac positive on rectal exam.
.
Of note, he was recently discharged after admission for 30-pound
weight loss, nausea after eating with occasional vomiting,
jaundice and epigastric pain and was found to have several liver
lesions on CT. Given the multiple liver lesions, suspicious
lymph nodes, possible carcinomatosis of the omentum, and poor
liver function, the patient was noted to be stage IV. Final
pathology was pending at time of discharge. He was seen in
oncology clinic on [**2105-1-23**]. Liver biopsy returned with
adenocarcinoma with a staining profile c/w colon cancer. Concern
for a primary hepatocellular carcinoma along with another
primary cancer metastatic to the liver, likely colon. His
prognosis is poor per recent oncology visit.
Past Medical History:
Recent diagnosis of hepatocellular and colon cancer, felt to
have 2 different primary cancers per notes and biopsy reports
Right microfollicular adenoma s/p resection 4/[**2096**].
Paralyzed left hemidiaphragm (FEV1/FVC of 88%). - per OMR.
T2DM
Hypertension.
Hypercholesterolemia
Social History:
Emigrated from [**University/College **] ~35 years, and is a retired welder and
electrician. Divorced, has 5 children. Lives alone in [**Location (un) 583**],
and family is far away. Distant history of tobacco and EtOH ~40
years ago. No illicit drug use.
Family History:
Father died of liver cancer at age 66.
Physical Exam:
Gen: intubated and sedated, profoundly jaundiced
HEENT: PERRLA, sclerae icteric, poor dentition, ETT in place
Neck: moderately distended JVD
Cor: RRR, no 2/6 SEM
Resp: decreased BS at L base, notherwise CTAB
Abd: protuberant and jaundiced, soft non-tender, + BS
Ext: 2+ b/l pitting edema
Pertinent Results:
[**2105-1-28**] Admission Labs
WBC-12.7* RBC-3.85* Hgb-11.6* Hct-34.1* MCV-89 MCH-30.1
MCHC-34.0 RDW-17.9* Plt Ct-416 Neuts-80.7* Lymphs-14.6*
Monos-4.4 Eos-0.2 Baso-0.1
.
PT-16.7* PTT-29.5 INR(PT)-1.5*
.
Glucose-20* UreaN-36* Creat-0.6 Na-127* K-4.1 Cl-91* HCO3-25
AnGap-15 Calcium-8.1* Phos-3.4 Mg-2.9*
.
ALT-206* AST-425* AlkPhos-746* TotBili-26.7* Albumin-2.8*
.
CK(CPK)-150 CK-MB-4 cTropnT-<0.01
.
Cortsol-39.2*
.
Ammonia-57*
.
Salient results After arrival to ICU
[**2105-1-29**]
WBC-8.1 RBC-3.15* Hgb-9.5* Hct-29.0* MCV-92 MCH-30.2 MCHC-32.8
RDW-18.0* Plt Ct-399
.
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
CK 108 CK-MB-4 cTropnT-<0.01
.
[**2105-1-31**]
WBC-10.3 RBC-3.18* Hgb-9.6* Hct-28.6* MCV-90 MCH-30.3 MCHC-33.7
RDW-17.7* Plt Ct-421
.
PT-22.1* PTT-33.4 INR(PT)-2.1*
.
Glucose-113* UreaN-42* Creat-1.2 Na-130* K-4.3 Cl-99 HCO3-21*
AnGap-14
.
Glucose-186* UreaN-50* Creat-2.1* Na-134 K-4.4 Cl-100 HCO3-18*
AnGap-20
.
ALT-275* AST-631* AlkPhos-944* TotBili-22.6*
.
CK-MB-4 cTropnT-0.03*
.
**************MICRO************
admission bcx, ucx all negative
sputum culture with sparse oropharyngeal flora
.
*************RADIOLOGY********************
[**1-28**] CT abd/pelvis
IMPRESSION:
1. Overall no significant interval change from [**2105-1-13**]
with slight improvement in nonspecific jejunal wall thickening.
2. Multiple hepatic masses in a cirrhotic liver with thrombosis
of the left portal vein and partial thrombosis of the right
posterior portal vein. Small ascites.
3. Bibasilar atelectasis
.
[**1-28**] CT head
IMPRESSION: No intracranial hemorrhage or mass effect
.
[**1-29**] CXR
FINDINGS: In comparison to the previous examination, the lung
volumes have further decreased. The size of the cardiac
silhouette is overall unchanged. Increase of vascular markings
which could be due to a combination of reduced lung volumes and
slight increase of pulmonary edema. The pre-existing right-
sided pleural effusion is unchanged.
IMPRESSION: Lower lung volumes with increase of vascular
markings that could partly be due to slight increase of
pulmonary edema.
.
[**1-31**] CXR
IMPRESSION: AP chest compared to [**1-28**] through 22:
Moderate right pleural effusion, and bibasilar atelectasis have
worsened since [**1-28**]. Stomach is severely distended with
gas and may account in part for low lung volumes. Cardiac
silhouette is largely obscured, probably not appreciably
enlarged though mediastinal and pulmonary vascular engorgement
suggests a component of volume overload or cardiac
decompensation. Subsequent radiograph 8:08 a.m. on [**2-1**]
available at the time of this dictation showed improvement in
cardiac status and resolution of gastric distention.
Brief Hospital Course:
83-year-old gentleman with a h/o recent diagnosis of
hepatocellular/colon cancer who presented to the ED with mental
status changes and increasing confusion, found to be obtunded in
the setting of severe hypoglycemia (FSBG 20) and intubated for
respiratory failure c/b hypotension on levophed.
.
# Respiratory failure - unclear reason for intubation as pt was
never documented as hypoxic in the ED. ? "increased work of
breathing." An arterial line was placed in the ICU which showed
excellent gas exchange and the pt was easily and rapidly
extubated without complication.
.
# Hypotension - occurred in the setting of intubation, and was
started on levophed in the ED. Within the frst 6 hours of ICU
admission, was easily titrated off of pressors with stable BPs
and resolution of hypotension.
.
# Flash pulmonary edema - after extubation, pt had repeat
episodes of uncontrolled hypertension, acute SOB, paradoxical
breathing, elevated JVP, and hypoxia. CXRs confirmed worsening
pulmonary edema. Was treated aggressively with lasix, morphine,
nitropaste, and BP control with beta blockade. It was unclear
what precipitated these episodes. EKGs were done and on [**1-31**] an
intra-event EKG showed ? of ST elevation in anteroseptal leads.
Treated with ASA and BB as pt not a candidate for heparin or
intervention. Serial enzymes were trended, which were not
revelaing for ACS. An echo was ordered which showed mild focal
left ventricular dysfunction. Mild mitral regurgitation.
Patient continued to have hypoxia in the setting of
hypertension, with shorntess of breath relieved with nitropaste
and IV morphine. Aspirin ultimatly discontinued once patient
made CMO. He was placed on Morphine and Nitro paste to help
improve his respiratory status. Levsin 0.125mcg or a scopolamine
patch can be added to help with secretions.
.
# Acute renal failure - in setting of fluid restriction and
aggressive diuresis pt had acute renal failure. FE urea was
consistent with prerenal etiology. Was not volume rescusitated
given tendency to go into pulmonary edema. Likely secondary to
poor intravascular volume with low serum albumin. [**Month (only) 116**] also have
suffered ATN from hypotension during peri-intubation period.
Urine Eosinophils were negative.
.
# Metastatic hepatocellular/colon cancer - tumor markers were
revealing for a very elevated AFP, CEA within normal limits, and
slightly elevated CA-19-9. Hepatitis serologies were revealing
for negative for HBsAg, negative HBsAb, positive HBcAb, and
negative HCV Ab. An ultrasound guided liver biopsy was done
during last admisison and initial cytology results were positive
for malignanct cells consistent with a poorly-differentiated
carcinoma. Oncology communicated this to pt during recent
outpatient appointment, and the topic of home hospice was
discussed. Due to the patients declining status with
multisystem failure and limited therapeutic options, the patient
was made CMO.
.
# Portal vein thrombosis - known, chronic. Not a candidate for
treatment.
.
# Guiaic positive stools/h/o melena - was scheduled for
outpatient colonoscopy on day of admission. Serial HCTs were
stable.
.
# Microfollicular thyroid adenoma s/p resection [**3-/2097**] - was
very hypothyroid per clinical presentation on recent admission,
discharged on levothyroxine. Still within 6 weeks of intial
therapy so TFTs not checked.
.
# Hyponatremia - stable, most likely a hypervolemic hyponatremia
[**1-10**] to liver dysfunction and resultant constitutive activation
of ADH axis. Was maintained on a fluid restriction.
.
# Hypoglycemia/ DM-II - was recently begun on an oral insulin
secretagogue which is likely responsiible for altered mental
status at home and presentation hypoglycemia in the ED. Due to
severe hepatic impairment, his gluconeogenesis is certainly
dysfucntional. Was persistently hypoglycemic in the ICU despite
no insulin administration initially. Eventually, sugars
rebounded to elevated levels, and repsonded quite vigorously to
cautious ISS. Patient was followed by [**Last Name (un) **] consult until
decision made to make patient CMO. At that point, fingersticks
and insulin were discontinued to help with patient comfort.
.
# Hypertension - treated with standing beta blockade. This was
continued for patient comfort since he had periods of
tachycardia which caused discomfort.
.
# FEN - ate a heart healthy diabetic diet.
.
# Code - DNR/DNI
.
# Comm - [**Name (NI) 1116**] [**Name (NI) 7086**], HCP and son, [**Telephone/Fax (1) 99736**] (cell),
[**Telephone/Fax (1) 99737**] (home)
.
# Dispo - Patient transferred from ICU to medical floor on [**2-5**]
morning and then discharged to a skilled nursing facility as CMO
patient.
Medications on Admission:
Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mL PO
q1hour as needed for Pain or Respiratory distress: Can titrate
dose up to keep respiratory rate <20.
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
3. Nitroglycerin 2 % Ointment Sig: 0.5 inches Transdermal Q8H
(every 8 hours) as needed for respiratory distress: Hold for
sbp<95.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR<60 or sbp<100.
5. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tab
Sublingual every four (4) hours as needed for secretions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Hepatocellular carcinoma
Colon Cancer
Hypoxemia
NSTEMI
Acute Renal Failure
Hypoglycemia
Hypotension
Hypothyroid
DM-II
Discharge Condition:
Afebrile. Tachypnic. Not in pain.
Discharge Instructions:
You have cancer of the liver (hepatocellular carcinoma) and
cancer of the colon. Based on the overall poor prognosis, you
have chosen to pursue purely palliative care. Therefore you are
going to a skilled nursing facility.
Followup Instructions:
Oncology: [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2105-2-6**]
9:30
Oncology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2105-2-6**] 9:30
|
[
"572.4",
"197.7",
"578.9",
"572.2",
"250.80",
"276.52",
"153.8",
"197.6",
"401.9",
"452",
"155.0",
"272.0",
"584.9",
"276.0",
"518.81",
"244.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11557, 11629
|
5946, 10641
|
304, 383
|
11790, 11827
|
3216, 5923
|
12100, 12365
|
2852, 2892
|
10861, 11534
|
11650, 11769
|
10667, 10838
|
11851, 12077
|
2907, 3197
|
221, 266
|
411, 2259
|
2281, 2563
|
2579, 2836
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,975
| 127,571
|
31771
|
Discharge summary
|
report
|
Admission Date: [**2109-9-18**] Discharge Date: [**2109-10-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
CC:[**CC Contact Info 40789**]
Major Surgical or Invasive Procedure:
Intramedullary nailing right femur shaft
Mechanical ventilation
History of Present Illness:
HPI: Mrs. [**Known lastname **] is a [**Age over 90 **] year old female with h/o CHF, a. fib,
s/p MIx2, s/p MVAs, h/o TIAs, fell at home after slipping and
falling on her right hip in the kitchen. Taken to [**Hospital1 **] noted to have right femur fracture and was transferred
to [**Hospital1 18**] for ORIF. In the ambulance given morphine became
hypotensive Upon arrival to the ED, she was given 3 LNS. Her
INR was found to be 3.4, so she was given 2 units FFP and
Vitamin K. She was hypotensive and unresponsive and there was
concern for septic shock versus hemorrhagic shock (due to hip
fracture). She was given one dose os vanco/ceftriaxone and 3L
IVF. He received narcan 0.4mg.. She later got dilaudid and
toradol for pain control.
.
She was admitted to the TICU ahd her course is outlined below.
# Respiratory failure - She was initially intubated on [**9-18**] for
airway protection and started on fentanyl/versed drip. After
going to the OR on [**9-20**], the drips were stopped. She remained
minimally responsive until receiving flumazenil on ? with
improvement. After discussion with family planned for
extubation and no reintubation. Underwent succesful extubation
on [**9-23**] at 11AM.
.
# Hypotension. She required pressors (phenylephrine) during icu
course until [**9-21**], likely due to blood loss as a result of the
surgery in addition to lasix drip and beta blocker use for A.
Fib rate control.
.
# A. Fib. Patient initially in A. Fib with RVR. She was given
metoprolol PRN but this contributed to hypotension, so was given
IV Digoxin. Currently not on digoxin due to ?elevated digoxin
levels and is on standing metoprolol 25 tid at time of transfer.
.
# Right femur fracture. On [**9-18**], she underwent traction pin.
On [**9-19**], R femur CMN. On [**9-23**], the wound was found to have a
large amount of [**Last Name (LF) 74594**], [**First Name3 (LF) **] it was sutured with 2 nylons.
.
Upon arrival to the floor from the ICU on [**9-28**], patient is
minimally interactive and so unable to elicit further history.
Past Medical History:
PMH:
HTN
CAD s/p MI
s/p CVAs
cognitive impairment
Atrial fibrillation on coumadin at home
.
Social History:
Social Hx: lives at home with husband in a 2 bedroom appt,
husband caregiver. walks with a cane. recently admitted to
rehab with chf exacerbation and previous to this admission
required walker.
Family History:
Family Hx: Noncontributory.
Physical Exam:
Physical Exam:
Vitals: Tm 98.1 Tc96.1, 116/50 (100-142/50-80), HR 81 (70-98),
RR 24, O2 94%3L
General: lying in bed sleeping, NGT present
HEENT: temporal wasting, dry mucous membranes
Pulm: CTA anteriorly, no wheezes or crackles
CV: RRR, normal S1, S1, no murmurs/rubs/gallops
Abd: soft, NT, ND, bowel sounds present
ext: no LE edema
Neuro: minimally responsive
Pertinent Results:
CXR [**9-24**]. Severe cardiomegaly with particular left atrial
enlargement is longstanding. Consolidation in the right mid
lung which arose between [**9-20**] and 23 has improved
consistent with clearing pneumonia. Mild generalized
interstitial abnormality and low lung volumes are longstanding.
Pulmonary edema if present is minimal and not appreciably
changed recently.
.
Echo [**9-24**]. IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global biventricular systolic
function. Pulmonary artery systolic hypertension. Moderate to
severe tricuspid regurgitation. Right ventricular cavity
enlargement with preserved systolic function. These findings
are suggestive of a primary pulmonary process (chronic or acute
on chronic; COPD, pulmonary embolism, bronchospasm, etc.).
.
Right Hip Films [**9-18**]. Acute, comminuted, spiral fracture of the
proximal right femoral shaft, with varus angulation.
.
Brief Hospital Course:
In summary, Mrs. [**Known lastname **] is a [**Age over 90 **] yo female with CAD, HTN, s/p CVAs,
A.Fib, dementia s/p Right femur fracture whose post-op course
was complicated by prolonged intubation secondary to altered
mental status.
.
Hip Fracutre. Patient underwent intramedullary nailing of right
hip on [**9-19**]. She remained intubated for several days following
surgery, likely due to accumulation of benzodiazepines after
being on a Versed drip for several days and pulmonary edema due
to fluid overload. She improved with diuresis and flumazenil
and was eventually extubated. Her staples at Right hip will
need to be removed on post-op day 14 ([**2109-10-4**]).
.
Altered Mental status. Patient was intially minimally
responsive only to sternal rub, however, she improved with
flumazenil. She may be have an infection (?Aspiration
pneumonia) which may have contributed to her mental status. She
was put on standing tylenol (rather than opioids) for pain
control. Upon discharge, she was speaking intermittently and
more alert.
.
Possible aspiration pneumonia. Patient is unable to clear her
oral secretions well. Her WBC was rising and her oxygen
requirements were increasing. She was started on Zosyn/ Vanco
for presumed aspiration pneumonia. Course is scheduled to be
completed on [**10-3**], however these were stopped because the
decision was made to make her comfort measures only care.
Nutrition. Patient is malnurished with most recent albumin of
2.1. Was seen by speech and swallow on [**9-24**] and again on [**9-30**]
who recommended NPO with NG tube and tube feeding. Tube feeds
were continued until [**10-2**], when the decision was made to make
patient hospice care.
.
DNR/DNI. The family decided to send patient to hospice. Would
recommend that patient get Roxonal and sublingual ativan for
shortness of breath or discomfort.
Medications on Admission:
Medications on transfer:
Insulin SC Sliding Scale
Acetaminophen 650 mg PR Q6H:PRN
Metoprolol 25 mg PO TID
Bisacodyl 10 mg PR HS:PRN
Morphine Sulfate 0.5-1 mg IV Q2H:PRN
Olanzapine 2.5 mg PO ONCE:PRN max 2.5 mg qd for aggitation
Enoxaparin Sodium 30 mg SC Q 24H
Furosemide 20 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
2. Ativan 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as
needed.
3. Roxanol Concentrate 20 mg/mL Solution Sig: One (1) 20 ml PO
q1 hour as needed for shortness of breath or wheezing.
4. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tab
Sublingual every four (4) hours as needed for increased
secretions.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 7661**] House
Discharge Diagnosis:
right hip fracture
Discharge Condition:
poor
Discharge Instructions:
You were admitted for a hip fracture. You were taken to surgery
to repair the hip. You and your family decided to send you to
hospice in order to make you most comfortable.
Followup Instructions:
Your primary care physician is [**Name9 (PRE) 74595**] [**Name9 (PRE) 63252**], MD. Please
call with any questions. Ph [**Telephone/Fax (1) 34574**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
|
[
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"412",
"821.01",
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"486",
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
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] |
icd9pcs
|
[
[
[]
]
] |
6810, 6867
|
4176, 6048
|
292, 357
|
6930, 6937
|
3221, 4153
|
7161, 7444
|
2793, 2823
|
6383, 6787
|
6888, 6909
|
6074, 6074
|
6961, 7138
|
2853, 3202
|
223, 254
|
385, 2448
|
6099, 6360
|
2470, 2564
|
2580, 2777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,313
| 138,828
|
29857
|
Discharge summary
|
report
|
Admission Date: [**2176-11-22**] Discharge Date: [**2176-12-4**]
Date of Birth: [**2145-5-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
transfer for evaluation of transaminitis, possible endocarditis
Major Surgical or Invasive Procedure:
ERCP
left knee irrigation and debridement; evacuation of a large
hematoma; synovial biopsy and partial synovectomy
History of Present Illness:
Mr. [**Known lastname **] is a 31 y/oM with h/o DM1 on HD, ESRD on HD, and
bipolar disorder which has led to inconsistent HD adherence in
the past (most recently hospitalized at [**Hospital1 18**] from [**2176-8-12**] -
[**2176-9-3**] for ESRD/Bipolar c/b fistula bleeding and need for HD
line) now transferred from [**Hospital1 **] with fevers, polymicrobial
bacteremia, and transaminitis.
In brief, patient was admitted to the [**Hospital1 **] ICU with fever
and hypoxemia after [**Hospital1 2286**] on [**11-4**]. Blood cx's from his
tunnelled subclavian HD line grew out S. aureus. His tunnelled
line was removed, and a temporary femoral line was placed. He
was covered with Vancomycin until blood cx's grew out [**Month/Year (2) 8974**] and
he was switched to Nafcillin. TTE on [**11-6**] without evidence of
vegetations. However, patient spiked T to 101.4 one week later,
and blood cx's drawn from his temp HD line grew Enterococcus
raffinous and micrococcus on [**11-14**] and VRE (E. Facecium) on
[**11-17**]. Peripheral blood cx's were negative. ID was consulted and
patient was receiving linezolid 600 mg IV BID, flagyl 500 mg IV
BID, cefepime 1 gram q24h. The day of transfer a new systolic
murmur was heard. In addition, patient was noted to have
worsening transaminitis (bili 7.6, AP 674, GGT 572, AST 60 ALT
50) with some RUQ abdominal pain. Patient was subsequently
transferred to [**Hospital1 18**] for further evaluation of possible
endocarditis and transaminitis.
In the ED, vital signs were initially: 98.7 94 155/73 16 100.
Got cefepime and nafcillin IV in the ED. Surgery consulted on
patient, RUQ showed no evidence of acute cholecystitis, so
patient was deemed not a surgical candidate.
Patient allowed examination but declined to be interviewed on
admission to the floor, and would only answer a few questions
regarding social history (as stated below). He denied abdominal
pain and admitted to some diarrhea.
Past Medical History:
PAST MEDICAL HISTORY:
Type 1 DM (diagnosed 13 years ago), managed by Dr. [**Last Name (STitle) 7537**] [**Name (STitle) 58216**]
ESRD: CKD stage 5 (on hemodialysis since [**3-16**]) M/W/F
Diabetic retinopathy
Diabetic neuropathy
Diabetic myonecrosis ([**3-16**])
Chronic ulcer at right foot
Hypertension
Mood disorder, NOS--[**6-15**] inpatient psychiatric admission.
Notes indicate an escalation in erratic behavior with "mood
instability, irritability/lability."
Proximal tibia fracture [**6-15**]-closed reduction
h/o C.difficle infection
Fistula Bleeding [**8-15**] requiring operative management and temp HD
cath
Social History:
Not currently working, lives with family. Reports marijuana use,
no alcohol, denies IVDU, occasional tobacco.
Patient's legal guardian responsible for medical decisions is
his mother, [**Name (NI) **] [**Name (NI) **], Primary# cell:[**Telephone/Fax (1) 71405**],
Secondary# house:[**Telephone/Fax (1) 71406**]. His brother [**Name (NI) **] can be
reached on his cell [**Telephone/Fax (1) 71407**] or work [**Telephone/Fax (1) 71408**].
Family History:
Extensive family history of DM. No family hx of CAD or
psychiatric conditions.
Physical Exam:
VS: 98.6 148/89 72 20 97% on RA
GEN: covering head with blanket. poor hygeine.
SKIN: Crusted blood underneath fingernails. No nail splinter
hemorrhages or [**Last Name (un) 1003**] lesions.
HEENT: No JVD, neck supple. No mucosal petechiae. bloody nose.
CHEST: Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; +[**4-12**] SM heard best along left sternal
border and apex.
ABDOMEN: distended, tympanitic, minimal BS. no g/rt.
EXTREMITIES:no peripheral edema, warm without cyanosis.
+xerosis. no apparent open ulcers. blood under fingernails.
NEUROLOGIC: Alert and oriented to person, place, time, and
president. disgruntled. states 'my thinking feels clear'. unable
to do neuro exam due to patient non-compliance. +asterixis.
Pertinent Results:
STUDIES:
On Admission:
[**2176-11-21**] 09:15PM NEUTS-67.0 LYMPHS-10.3* MONOS-4.9 EOS-17.3*
BASOS-0.5
[**2176-11-21**] 09:15PM WBC-14.7*# RBC-3.30* HGB-8.6* HCT-26.5*
MCV-81* MCH-25.9* MCHC-32.2 RDW-22.4*
[**2176-11-21**] 09:15PM CRP-261.6*
[**2176-11-21**] 09:15PM LIPASE-42
[**2176-11-21**] 09:15PM ALT(SGPT)-40 AST(SGOT)-33 ALK PHOS-549* TOT
BILI-4.8* DIR BILI-4.2* INDIR BIL-0.6
[**2176-11-21**] 09:15PM GLUCOSE-165* UREA N-60* CREAT-10.0*#
SODIUM-136 POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-24 ANION GAP-21*
[**2176-11-21**] 09:42PM LACTATE-1.1
[**2176-11-22**] 09:50AM PT-16.7* PTT-30.0 INR(PT)-1.5*
On Discharge:
[**2176-12-4**] 07:00AM BLOOD WBC-13.4* RBC-3.08* Hgb-9.2* Hct-29.1*
MCV-95 MCH-29.8 MCHC-31.6 RDW-20.9* Plt Ct-582*
[**2176-12-3**] 07:05AM BLOOD Neuts-63.6 Lymphs-16.7* Monos-4.9
Eos-13.4* Baso-1.3
[**2176-12-1**] 06:30AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-OCCASIONAL Polychr-OCCASIONAL Target-1+
[**2176-12-4**] 07:00AM BLOOD Plt Ct-582*
[**2176-12-4**] 07:00AM BLOOD Glucose-83 UreaN-27* Creat-8.0*# Na-140
K-4.0 Cl-96 HCO3-29 AnGap-19
[**2176-12-4**] 07:00AM BLOOD ALT-26 AST-37 AlkPhos-1170* TotBili-4.3*
[**2176-12-4**] 07:00AM BLOOD Calcium-10.0 Phos-5.1* Mg-2.2
IMAGING:
RUQ U/S: tiny fluid seen adjacent to GB, but no stones/sludge
seen in non-distended
gallbladder to suggest acute cholecystitis.
CXR: [**2176-11-21**]
1. New massive enlargement of the cardiac silhouette without
evidence of CHF could represent dilated cardiomyopathy or
pericardial effusion.
2. Left lower lobe likely atelectasis.
ECHO: [**11-23**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. No vegetations are seen. There
is no mitral valve prolapse. Very mild (1+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is a very small circumferential pericardial effusion.
Compared with the prior study (images reviewed) of [**2176-5-31**], a
very small circumferential pericardial effusion and mild
pulmonary artery systolic hypertension are now identified.
Is there a history to suggest pericarditis?
CT Abdomen and Pelvis:
1. No CT findings of acute pancreatitis or of complictations of
pancreatitis.
2. Small bilateral effusions, right greater than left, but
decreased from [**2176-6-8**]. Residual bibasilar pulmonary
nodules, markedly improved from the previous study.
3. Enlargement and heterogeneity of the liver, consistent with
hepatic congestion in the setting of right heart failure.
Left Knee X-ray: [**11-26**]
Worsening appearance of the left knee with new
erosions,increased sclerosis, and fragmentation. Findings are
concerning for infection given the clinical history although
they could also be seen in progressive Charcot arthropathy.
ERCP: [**11-27**]
1 fluoroscopic spot images were obtained during ERCP without
presence of a radiologist and submitted for review. Images
demonstrate cannulation and opacification of proximal portion of
the pancreatic duct which appears prominent. Subsequent
cannulation and opacification of the biliary tree reveal
normal-sized CBD, intra- and extra-hepatic biliary ducts, and
cystic duct as well as the gallbladder without evidence of
filling defects or strictures. For further details please refer
to full procedural note in OMR.
Brief Hospital Course:
31 yo M with h/o of DMI, ESRD on HD, bipolar now transferred
from OSH for polymicrobial bacteremia and transaminitis.
1. Elevated liver enzymes, cholestatic pattern: The ddx
includes but not limited to cholangitis (given fever,
leukocytosis, and possible partially treated process at OSH that
worsened with discontinuation of gram negative/anaerobic
coverage), cholestasis from sepsis, medication-induced
hepatotoxicity (i.e. nafcillin given peripheral eosinophilia),
and vanishing bile duct syndrome. Patient was initially covered
for possible cholangitis with linezolid/cefepime/flagyl though
he denied any abdominal pain. RUQ showed tiny fluid adjacent to
the gallbladder, a non-specific, otherwise without evidence of
cholelithiasis or acute cholecystitis. HIDA scan showed
markedly poor hepatic uptake of radiotracer compatible with
severe hepatocellular dysfunction; no evidence of central
biliary obstruction. MRCP and subsequent ERCP showed no intra-
or extra-hepatic bile duct dilatation nor evidence of
cholelithiasis. Both hepatology, ERCP, and general surgery
followed the patient. Liver enzymes peaked on [**11-30**] with ALT 30
AST 50 ALP 1739 total bili 11.6. Enzymes started to trend down
spontaneously and at time of discharge were ALT 26 AST 37 ALP
1170 tbili 4.3. Hepatology deferred inpatient liver biopsy
given his improvement in LFTs. Further evaluation for biopsy
will be deferred to outpatient hepatology. The patient should
have liver function tests every 2-3 days initially to ensure
that enzymes are still trending downwards.
2. Bacteremia: Patient with [**Month/Year (2) 8974**] on [**11-4**] -[**11-6**], enterococcus and
micrococcus on [**11-14**] and VRE on [**11-17**] catheter blood cx.
Peripheral cx have been negative. Pt orginally had a tunneled
HD catheter, which was then taken out when [**Month/Year (2) 8974**] was discovered.
and blood cultures cleared (first negative culture [**11-7**]). TTE
[**11-6**] negative for
vegetations. Pt then had a temporary HD line in R groin, which
grew enterococcus raffinosis and micrococcus in one sample, but
no others. Blood cultures from his
fem line on [**11-17**] grew VRE faecium. This line was removed and
he had a second temporary HD line placed. Patient was switched
from antibiotic regimen of vancomycin, nafcillin, and cefepime
to linezolid on [**11-22**]. His blood cultures remained negative
during his entire admission. New tunnelled hemodialysis line was
placed on [**11-28**]. Linezolid was switched to daptomycin for
greater efficiacy against endocarditis. TEE was deferred as
patient had recent history of [**First Name8 (NamePattern2) 329**] [**Last Name (NamePattern1) **] tear, and the risk
of procedure were felt to outweigh benefits. Given patient's
multiple episodes of bacteremia and new murmur on physical exam,
the infectious disease team recommended treating patient with
full 6 week course of daptomycin (end date [**1-3**]) from last
positive culture for presumed endocarditis. He had defervesced
x 3 days before discharge. He will have weekly CKs measured
while on daptomycin.
3. Unhealed left proximal tibia fracture: Patient presented with
left knee swollen and warm. Knee is not weight-bearing although
patient was known to be non-complaint with recommendations.
Aspirate showed 70,000 WBCs, 330,000 RBCs, and gram stain was
negative in the setting of longterm antibiotics. Patient went
to surgery on [**2176-11-28**] for a washout which was consistent with
an old hematoma/hemarthrosis per the surgeon, but did not look
grossly purulent. Cultures were negative. Patient tolerated
the procedure well, without any acute complications. At time of
discharge, patient is non-weight bearing pending further
evaluation at orthopedic clinic.
4. ESRD on HD: Patient had a line holiday from [**Date range (1) 71409**].
New tunnelled catheter placed on [**11-28**]. He was otherwise
continued on HD.
5. Diabetes Type I: His glucose was well controlled on Lantus
and RISS. [**Last Name (un) **] followed the patient.
6. Bipolar Disorder: This was stable on his psych medications.
Olanzapine was held due to possible side effect of cholestasis
and restarted on [**2176-11-27**]. Patient required several doses of
halidol during hospitalization for agitation, but this resolved
by the time of discharge.
7. Toxic-metabolic encephalopathy: This was likely to due to
infection and progressive hyperbilirubinemia, hyperammonemia as
well as renal failure. Head CT at OSH and at [**Hospital1 18**] showed no
acute pathology. He was treated with lactulose, rifaximin for
empiric treatment of hepatic encephalopathy. Patient's mental
status returned to baseline. Lactulose and rifaximin were
stopped by time of discharge.
8. Acute on chronic anemia of iron-deficiency and CKD: His
baseline Hct ~28%. His HCT had trended down to 20. He received
a total of 3 units of PRBCs following evacuation of septic
hematoma on [**11-28**].
9. Eosinophilia: Etiology is unclear, but this is chronic since
[**4-15**]. Pt had eosinphilia (up to 20%) in the past. Strongyloides
Ab was pending at time of discharge and had normal cortisol
level. He will need outpatient hematology evaluation for this.
10. HTN: He was continued on his home Labetalol, Amlopdipine.
Medications on Admission:
TRANSFER MEDICATIONS: (per discharge summary from [**Hospital1 **])
Nafcillin 1 gram IV q4h
Cefpime 1 gram IV q24H
Linezolid 600 mg IV BID
Flagyl 500 mg IV TID
Labetolol 200 mg PO BID
Norvasc 10 mg PO daily
Zocor 40 mg PO daily
Aspirin 81 mg PO daily
Neprhocaps 1 cap PO daily
CAlcium Acetate 667 mg PO TID
Zyprexa 10 mg PO QHS
Neurotin 300 mg PO BID
Percocet 1 tab PO q6H:prn pain
Benadryl 25 mg PO q6H:prn pruritis
Kayexalate 15 mg PO BID qTuThSATSUN
Thiamine 100 mg PO daily
Epogen 20,000 U SQ with HD
Discharge Medications:
1. Docusate Sodium 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day) as needed for constipation.
2. Labetalol 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
5. Calcium Acetate 667 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritis.
7. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Nicotine 14 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
10. Lanthanum 500 mg Tablet, Chewable [**Hospital1 **]: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection PRN (as needed) as needed for line flush.
12. Olanzapine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
13. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4H (every 4
hours) as needed for pain.
14. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
15. Ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day).
16. Daptomycin 500 mg Recon Soln [**Hospital1 **]: 400mg Recon Solns
Intravenous Q48H (every 48 hours): End date: [**1-3**].
17. Insulin Glargine 100 unit/mL Cartridge [**Month/Year (2) **]: Eight (8) units
Subcutaneous at bedtime.
18. Insulin Lispro 100 unit/mL Cartridge [**Month/Year (2) **]: according to
sliding scale Subcutaneous after measuring blood glucose:
please see attached sliding scale.
19. Outpatient Lab Work
Please draw LFTs with other hemodialysis labs every 2-3 days and
review with physician at rehabilitation [**Name9 (PRE) 71410**].
Please draw CK weekly while on on daptomycin and fax results to
[**Hospital **] clinic: [**Telephone/Fax (1) 432**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
Recurrent Bacteremia
Transaminitis of unclear etiology
left knee septic hematoma
Secondary Diagnoses:
type I Diabetes Mellitus
End- Stage Kidney Disease on [**Location (un) **]
partially healed left tibial fracture
Discharge Condition:
stable, afebrile for more than 72 hours; hemodynamically stable
Discharge Instructions:
You were transferred from an outside hospital with recurrent
fevers and an elevation of your liver enzymes. We did many
tests to determine what the source of the infection and why your
liver enzymes were elevated. Your left knee also became very
swollen from a large collection of blood. The orthopedic
doctors took [**Name5 (PTitle) **] to the operating room to drain the blood from
your knee. You tolerated this procedure well. You must not
walk on your left leg until you are seen by the orthopedic
doctors in a follow up appointment (see below).
Eventually your liver enzymes started to return back to normal,
but you will need to be followed by the liver clinic as an
outpatient (see below). We treated your fevers with
antibiotics- you will need to take Daptomycin for a total of 6
weeks (end date [**1-3**]). You will also need to follow with the
infectious disease physicians as an outpatient.
We made several changes to your medication regimen. Please see
the attached sheet for your complete medication list.
It is important for you to take Daptomycin 500mg every 48hrs for
a total of 6 weeks (end date [**1-3**]). While you are on this
medication, you must have your muscle enzymes checked every
week.
Please call your physician or return to the emergency room if
you develop any additional fevers, chest pain, shortness of
breath, increased swelling your leg or any other complaint.
Followup Instructions:
Please follow up with your primary care physician, [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7538**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2176-12-11**] 10:30
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2176-12-17**] 10:40
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2176-12-17**] 10:20
|
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"570",
"250.61",
"585.6",
"999.31",
"790.7",
"250.51",
"296.80",
"V58.67",
"286.7",
"421.0",
"733.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"80.76",
"51.10",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16250, 16323
|
8161, 13461
|
380, 497
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16602, 16668
|
4446, 4456
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3580, 3660
|
14017, 16227
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16344, 16445
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13487, 13487
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16692, 18099
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3675, 4427
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16466, 16581
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5081, 8138
|
277, 342
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13509, 13994
|
525, 2465
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4470, 5067
|
2509, 3107
|
3123, 3564
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,887
| 146,310
|
36545
|
Discharge summary
|
report
|
Admission Date: [**2143-9-2**] Discharge Date: [**2143-9-5**]
Date of Birth: [**2074-11-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
LE edema
Major Surgical or Invasive Procedure:
Transfusion of 1 unit of packed red blood cells on [**2143-9-4**].
History of Present Illness:
68 y/o F with hx of CAD, CHF, HTN, DM and PVD with recent DVT
and IVC filter and GI bleed presented with worsening LE edema
and blisters. She also had been just seen by nephrologist who
was concerned about anemia, and possible decompensated heart
failure as cause of LE edema.
She has had worsening of her LE edema, and chronic pain in her
legs. No fevers, chills. She has severe PVD and R toe necrosis
and well as bilateral heel ulcers. She had an IVC filter placed
approximately 1 week ago. She denied any chest pain, shortness
of breath, abdominal pain, nausea, vomiting, fevers, chills. She
had not noticed any blood in her stool or urine. She came in
from rehab, hated it, and had been having worsening depression.
On review of systems, she denied any fever, chills, night
sweats, headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
PVD: s/p R fem-[**Doctor Last Name **] bypass (approx 10yrs ago), L aorto-iliac
bypass (approx 8yrs ago), R common femoral endarterectomy ([**6-1**])
Obesity
GI bleed (in [**7-/2143**] at [**Hospital6 **])
diastolic CHF
HTN
PVD
Obstructive sleep apnea
obesity
renal artery stenosis s/p left renal stenting [**2-1**]
history of UTI [**4-1**] treated levaquin
history of left arm hematoma with left brachial pseudoaneurysm
thrombin, left arm median nerve neuropathy
coronary artery disease s/p MI12/08,s/p CABG"S x4
DM2 w neuropathy,insulin dependant
Social History:
Currently coming from rehab. Has family in the area whom she
sees often but still is very depressed and just wantes to go
home. Former smoker with a 20+ pack/yr history. No alcohol
use.
Family History:
Non-contributory.
Physical Exam:
On admission to the floor, vitals were: temperature 99, blood
pressure 147/58, heart rate 74, respiratory rate 20, oxygen
saturation 98% on room air. General examination revealed an
obese, elderly lady in no acute distress. Her jugular venous
pressure was less than 10 and her cardiac exam showed regular
rate and rhythm, without rubs, murmurs or gallops. Exam of the
lower extremities revealed 2+ edema and right 1st-3rd toes with
necrotic black tissue, no warm or surrounding erythema, no
lymphangetic spreading; bilateral heel ulcers also without
erythema or signs of infection; L dorsum of foot with multiple
vesicles, L lateral shin with skin tear and scant weeping and
bleeding. The remainder of the exam, including pulmonary,
neurologic and abdominal components, was normal.
Pertinent Results:
LABS ON ADMISSION
[**2143-9-2**] 08:20PM BLOOD Neuts-77.6* Lymphs-16.6* Monos-4.2
Eos-1.2 Baso-0.4
[**2143-9-2**] 08:20PM BLOOD PT-12.2 PTT-21.4* INR(PT)-1.0
[**2143-9-2**] 08:20PM BLOOD Glucose-356* UreaN-53* Creat-1.4* Na-138
K-4.9 Cl-101 HCO3-25 AnGap-17
[**2143-9-2**] 08:20PM BLOOD CK(CPK)-42
[**2143-9-2**] 08:20PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2143-9-2**] 08:20PM BLOOD cTropnT-0.02*
[**2143-9-2**] 08:20PM BLOOD Iron-49
[**2143-9-2**] 08:20PM BLOOD calTIBC-225* VitB12-403 Folate-7.1
Ferritn-539* TRF-173*
PERTINENT INTERVAL LABS
calTIBC 225 / VitB12 403 / Folate 7.1 / Ferritin 539 / TRF 173
LABS AT DISCHARGE
CBC: 6.0 WBC / 28.3 Hct / 266 Plts
Lytes: Na 139 / K 4.3 / Cl 99 / HCO3 29 / Urea 47 / Cr 1.3 /
Glu 96
Ca 8.9 / Phos 4.8 / Mg 2.6
TESTING
[**2142-9-5**] LENIs: Partial thrombus is again seen in the right
common femoral vein and occlusive thrombus is again seen in the
right superficial femoral vein. On today's exam, there is
incomplete compression of the left common femoral vein
demonstrating nonocclusive thrombus. Images of the left
superficial femoral vein demonstrate no flow on color Doppler
imaging and this vein does not compress. This is consistent with
deep vein thrombosis. IMPRESSION: 1. Stable appearing DVT in the
right superficial femoral vein with non-occlusive thrombus in
the right common femoral vein. 2. New deep vein thrombosis
identified within the left superficial femoral vein and new
nonocclusive thrombus seen within the left common femoral vein.
[**2143-9-2**] EKG: Sinus rhythm. Short P-R interval. Late R wave
progression. ST-T wave abnormalities. Since the previous tracing
of [**2143-8-15**] probably no significant change.
[**2143-9-2**] CXR: The cardiomediastinal silhouette is mildly
enlarged. There is mild pulmonary vascular congestion. No pleura
effusion or pneumothorax is seen. There is a stable, rounded
retrocardiac opacity, best seen on the lateral view, which is
unchanged since [**2143-5-21**], and felt to represent focal
dilatation of the esophagus as seen on prior CT. Median
sternotomy wires and clips in the epigastric region are
unchanged. No acute osseous abnormalities are noted. IMPRESSION:
1. Mild cardiomegaly with mild pulmonary vascular congestion. 2.
Stable retrocardiac opacity, consistent with esophageal
dilatation seen on prior CT.
[**2143-8-14**] LENIs: 1. Extensive deep venous thrombus extending from
the right common femoral vein through the posterior tibial vein
on the right side.
2. Normal left deep venous system without evidence of DVT.
[**2143-5-28**] ECHO: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. The overall left
ventricular ejection fraction is normal (LVEF 60%). However, the
basal anterior septum is fibrotic and akinetic, and the basal
inferior septum and apex are hypokinetic. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
focal wall motion abnormalities in the left ventricle with a
normal ejection fraction
Brief Hospital Course:
68F with hx of CAD, CHF, DM, PVD and DVT who presents with
worsening LE edema in setting of IVC filter placement 2 weeks
ago for RLE DVTs as well as low hematocrit at 26.6 on admission
found to have new LLE DVTs. Her hospital course is detailed
below:
Lower extremity edema/new LLE DVTs: Worsening lower extremity
edema was thought to be attributable to increased clot burden in
the lower extremities, with possible contributions from heart
failure (with elevated BNP). Bilateral lower extremity venous
ultrasound on [**2143-9-5**] revealed new deep vein thrombosis
within the left superficial femoral vein and new nonocclusive
thrombus within the left common femoral vein. Vascular therapy
was consulted, and no further therapy initiated at this time as
anticoagulation is contraindicated due to recent history of a
severe gastrointestinal bleed, and the patient already has an
IVC filter in place. Patient has follow up with Dr. [**Last Name (STitle) 1391**]
from vascular surgery. Educated to use waffle boots at night,
compression stockings, and leg elevation.
Anemia: Patient had a normocytic anemia with a hematocrit of
26.6 on admission, down significantly from her baseline around
31.7 on [**2143-8-15**]. Guaiac testing was negative, and iron
studies were not suggestive of deficiency. She likely has
anemia of chronic disease. She was transfused 1 unit of packed
red blood cells on [**2143-9-4**] with a good response (3 point
increase in hematocrit). She may benefit from treatment with
erythropoeitin as an outpatient, in the setting of chronic renal
insufficiency.
Decompensated diastolic congestive heart failure: Patient given
Lasix with a good response: diuresed over 1L on night of
admission and lower extremity edema improved slightly. She had
no symptoms of respiratory discomfort, and she ruled out for MI
by cardiac enzymes. She has been directed to conitnue on her
home dose of torsemide on discharge. She may also benefit from
ACE inhibitor therapy in the outpatient setting.
Necrotic toe ulcers: Patient has severe peripheral vascular
disease including right toe necrosis and bilateral heel ulcers.
Legs were kept elevated, and compression stockings and waffle
boots were used as tolerated.
Diabetes mellitus: Patient was hyperglycemic with a glucose of
344 on admission. Her glucose levels responded well on her home
NPH dosing and a Humalog sliding scale; her glucose was 96 at
discharge.
Chronic renal insufficiency: Creatinine remained around her
baseline (1.3-1.5) through the course of her hospital stay. BUN
has been mildly elevated from baseline. Her sevelemer was
continued at her outpatient dosing. She may benefit from
erythropoeitin in the outpatient setting, as outlined above.
Depression: Patient was tearful during multiple interviews; her
depression severe and is obviously limiting patient's ability to
work well with physical therapy. She was continued on her home
dosing of sertraline. Outpatient follow-up for depression
recommended.
Medications on Admission:
tegretol 100mg TID
ativan 1mg QHS
nitrostat 0.4mg SL PRN
NPH 28U SQ QAM and 20U QPM
novolog RISS
ultram 50mg Q4hr PRN
colace 100mg [**Hospital1 **]
miralax 17gm QD
torsemide 60 mg daily
simvastatin 40 mg daily
renagel 800mg TID
iron 325 QD
sertraline 75 mg qHS
neurontin 600mg [**Hospital1 **]
neurontin 300mg qHS
lopressor 75 [**Hospital1 **]
prilosec 40 QD
zofran PRN
Discharge Medications:
1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
3. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5min as needed for chest pain.
Disp:*1 bottle* Refills:*0*
4. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: 28 units in the morning, 20 units at night units
Subcutaneous four times a day.
Disp:*QS units* Refills:*2*
5. Novolog 100 unit/mL Solution Sig: As directed SC Subcutaneous
2-4 times/day: Per attached sliding scale.
Disp:*QS units* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablet PO
DAILY (Daily) as needed for constipation.
Disp:*QS powder* Refills:*0*
9. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
14. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a
day.
Disp:*120 Capsule(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
17. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Disp:*1 tube* Refills:*0*
19. Neurontin 300 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary Diagnosis: peripheral vascular disease
Secondary Diagnoses:
decompensated congestive heart failure (diastolic)
anemia
peripheral vascular disease
chronic renal insufficiency
diabetes mellitus
depression
Discharge Condition:
Stable, with some improvement in lower extremity edema and
improvement in red blood cell count (hematocrit).
Discharge Instructions:
You were admitted with worsening swelling of your lower
extremities and a low red blood cell count (hematocrit). An
ultrasound of your legs revealed two areas of new clot formation
in your left leg. You already have a filter in a large vessel
to prevent blood clots spreading upwards when you had blood
clots in your right leg. The clots in your right leg were
stable. You were treated with diuretics, [**Male First Name (un) **] stockings, and
waffle boots, and showed some improvement in your leg swelling.
You were transfused 1 unit of packed red blood cells on [**9-4**], [**2143**], with an improvement in your red blood cell count after
the transfusion.
Please continue to take your home medications as prescribed.
- continue your home torsemide dose at 60mg daily and follow up
with your primary care about management of your heart failure
It is also very important for you to keep your legs elevated,
use the compression stockings at all times, and also the waffle
boots when you are in bed. This will help prevent new clots and
help the swelling in your legs.
If your develop worsening leg swelling again, or if other
symptoms develop that concern you, please return to the hospital
or contact your primary care physician.
Followup Instructions:
Please follow-up with vascular surgery, Dr. [**Last Name (STitle) 1391**] ([**Telephone/Fax (1) 29063**] on [**10-23**] at 10:30am in his [**Location (un) 12595**] office.
Please follow up with your nephrologist, Dr. [**Last Name (STitle) 7674**] within [**2-27**]
weeks of discharge from the hospital. ([**Telephone/Fax (1) 39385**]. The office
should be calling you with an appointment, but if you do not
hear back from them within 2 days, please call for appointment.
- At this appointment, please follow up on whether you would
benefit from an additional medication called Epo to help with
your red blood cell count
Please follow-up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 63259**],
within 1-2 weeks of discharge from the hospital. The office
should be calling you with an appointment, but if you do not
hear back from them within 2 days, please call for appointment.
|
[
"585.4",
"428.33",
"440.1",
"327.23",
"250.62",
"428.0",
"453.41",
"440.23",
"707.15",
"285.21",
"357.2",
"311",
"707.14",
"403.90",
"V58.67",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12357, 12440
|
6600, 9602
|
279, 348
|
12695, 12806
|
3005, 6577
|
14091, 15039
|
2165, 2184
|
10022, 12334
|
12461, 12461
|
9628, 9999
|
12830, 14068
|
2199, 2986
|
12530, 12674
|
231, 241
|
376, 1369
|
12480, 12509
|
1391, 1943
|
1959, 2149
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,826
| 104,229
|
9486
|
Discharge summary
|
report
|
Admission Date: [**2155-7-13**] Discharge Date: [**2155-7-21**]
Date of Birth: [**2088-5-22**] Sex: F
Service: MEDICINE
Allergies:
Lidocaine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
67 yo woman with h/o NHL s/p CHOP [**2153**], myelodysplasia, hep C,
PUD, eosinophilia with recent admits on [**4-2**] with RLL PNA
and [**Date range (1) 32291**] for a fib with RVR now comes in with chest pain
and shortness of breath. Patient's english is only fair, but she
declines the use of an interpreter.
States she was discharged recently. Since her discharge, she has
been very tired and weak. She has shortness of breath that
started with exertion, but then progressed to sob at rest. The
exact timing of this is not clear. She sleeps on one pillow and
has no PND. No [**Date range (1) 5162**], or chills, weight changes. She may have
slight ankle swelling that is new.
She has also had some intermittent chest pains. The exact timing
of these is difficult to elicit. It appears to occur at rest and
with exertion. It is not associated with the sob, n/v, abd pain,
lh, or diaphoresis. The pain lasts from seconds to 25 minutes.
Last episode was yesterday. It does not appear pleuritic in
nature.
Past Medical History:
NHL s/p CHOP in [**2153**]-[**2154**].
Myelodysplasia dx in [**2154**]. ? resulted from her chemotherapy
Chronic hepaitis C
h/o duodenal ulcer
GERD
depression
?angioedema/eosinophilia
atrial fibrillatio: dx [**6-12**]. no coumadin due to myelodysplasia
Social History:
Married
2 children
No tobacco or ETOH
On disability
Originally from [**Location (un) 3156**]. Taught lab medicine while there?
Family History:
NC
Physical Exam:
on admission:
Vitals : T 99.4, 58, 123/55, 17, 98% 2L, 94 % RA
Gen: alert and oriented x 3, NAD
HEENT: PERRL, OP clear, no LAD, conjunctival pallor
CV: RRR, no m/r/g
Lungs: RLL decreased breath sounds with dullness to percussion,
left CTA
Abd: soft, NTND +BS
Ext: 1+ bilateral LE edema, 2+DPs
Skin: no rashes
Pertinent Results:
[**2155-7-13**] 11:00AM WBC-2.5* RBC-2.41*# HGB-7.1*# HCT-20.8*#
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.6*
[**2155-7-13**] 11:00AM PLT SMR-VERY LOW PLT COUNT-26*
[**2155-7-13**] 11:00AM NEUTS-54 BANDS-5 LYMPHS-28 MONOS-6 EOS-1
BASOS-0 ATYPS-6* METAS-0 MYELOS-0 NUC RBCS-3*
[**2155-7-13**] 11:00AM PT-13.6* PTT-25.0 INR(PT)-1.2
[**2155-7-13**] 11:00AM GLUCOSE-144* UREA N-26* CREAT-0.9 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-22 ANION GAP-15
[**2155-7-13**] 11:00AM CK(CPK)-17*
chest x ray: diffuse haziness in right lung base with probable
effusion and possible posterior layering. No pna or chf
CTA: airways patent. mild-large right pleural effusion with mild
atelectasis. Slight left pleural effusion. Mild septal
thickening and ground glass c/w volume overload. Right PNA
improving. left base nodule not well seen. no axillary lad.
persistent, but unchanged, mediastinal adenopathy. No PE. Upper
abdomen without abnormalities. bone windows are unremarkable.
Brief Hospital Course:
This patient is a 67 year old female with NHL s/p CHOP, MDS, Hep
C, recently diagnosed afib [**6-12**] transfered to MICU for hypoxia
on floor accompanied by [**Month/Year (2) 5162**], frequent episodes of afib with
RVR, also hypotension originally thought to be consistent with
sepsis.
1)SIRS/ Sepsis: Patient had episodes of fever and hypotension
(during tachycardia and not during tachycardia), lactate 1.5,
temp most likely related to pna
-patient placed on vanco, levo, flagyl originally- changed to
vanc and zosyn since patient continued to spike [**Month/Year (2) 5162**]. Patient
also had her line changed in the unit as she continued to spike
[**Month/Year (2) 5162**]. Plan was to consider tap of pleural effusion if patient
remained febrile. The though was that patients underlying MDS
and ?functional neutropenia was impairing her ability to clear
her pna. Her clinical status continued to decline.
2) Hypoxia: Unclear how hypoxic patient was while on the floor,
but likelyw as due to pna and tachycardia. was on a 6.0 liter nc
in the unit
3) Hypotension: related to her underlying infection and afib
with rvr
4) CV: patient had intermittent episodes of afib with rvr,
responded well to lopressor but difficult situation given her
low bp. Cardiology was consulted and she was started on amio and
digoxin. We attemped to use PO metoprolo for rate control.
Patient was not being anticoagulated as she is a fall risk and
platelets very low with high inr. Echo with mild sysytolic
dysfuction, likely with some doastolic dysfuction.
5) Anemia/ thrombocytopenia: heme onc thinks this was a
manifestation of MDS in setting of being infected, no evidence
of hemolysis on peripheral smear
6) Elevated bili: workup with RUQ and HIDA scan was been
negative
------
Patient resp and clinical status continued to decline. She
became septic and hypotensive on three pressors. She was
intubated. A family meeting was held and she was made cmo. Her
tube was pulled and she passed away shortly after.
Medications on Admission:
Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
prn
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
amiodarone 400 mg po qd x 2 weeks, then 200 mg po daily
indefinitely
Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2155-7-22**]
|
[
"286.7",
"284.8",
"518.81",
"486",
"276.5",
"276.1",
"584.9",
"038.9",
"995.92",
"427.31",
"428.40",
"070.54",
"202.80",
"785.52",
"593.9",
"238.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"00.17",
"96.71",
"99.05",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5587, 5596
|
3141, 5147
|
302, 313
|
5655, 5672
|
2140, 3118
|
5736, 5782
|
1790, 1794
|
5547, 5564
|
5617, 5634
|
5173, 5524
|
5696, 5713
|
1809, 1809
|
231, 264
|
341, 1352
|
1824, 2121
|
1374, 1629
|
1645, 1774
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,791
| 181,156
|
7437
|
Discharge summary
|
report
|
Admission Date: [**2134-11-1**] Discharge Date: [**2134-11-8**]
Date of Birth: [**2075-2-18**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
[**First Name8 (NamePattern2) **] [**Known lastname 1968**] comes to [**Hospital1 18**] for definitive treatment of Left knee.
Major Surgical or Invasive Procedure:
Left TKR [**2134-11-1**]
Past Medical History:
PMH: HTN, depression/anxiety, obesity (BMI 50)
PSH: [**2132-10-23**] rotator cuff surgery
Social History:
NC
Family History:
NC
Physical Exam:
On discharge:
Afebrile, All vital signs stable
General: Alert and oriented, No acute distress
Resp: Reg even rate no audible wheeze
Cardiac: rrr, no rubs, murmurs, gallops
Extremities: left lower/upper Incision: intact, no
swelling/erythema/drainage Dressing: clean/dry/intact
Sensation intact to light touch, Neurovascular intact distally,
Capillary refill brisk, 2+ pulses, Weight bearing: full weight
bearing
Pertinent Results:
[**2134-11-1**] 02:30PM BLOOD WBC-16.3*# RBC-2.91* Hgb-9.0* Hct-26.7*
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.6 Plt Ct-285
[**2134-11-4**] 07:15AM BLOOD WBC-8.1 RBC-2.81* Hgb-8.6* Hct-26.1*
MCV-93 MCH-30.7 MCHC-33.0 RDW-13.5 Plt Ct-183
[**2134-11-1**] 08:36PM BLOOD PT-14.1* PTT-23.3 INR(PT)-1.2*
[**2134-11-4**] 07:15AM BLOOD PT-14.2* PTT-24.8 INR(PT)-1.2*
[**2134-11-1**] 02:30PM BLOOD Glucose-133* UreaN-23* Creat-1.3* Na-137
K-5.1 Cl-103 HCO3-28 AnGap-11
[**2134-11-4**] 07:15AM BLOOD Glucose-118* UreaN-19 Creat-1.2* Na-136
K-4.7 Cl-101 HCO3-30 AnGap-10
[**2134-11-1**] 02:30PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.8
[**2134-11-4**] 07:15AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2
[**2134-11-1**] 05:18PM BLOOD pO2-161* pCO2-66* pH-7.22* calTCO2-28
Base XS--2
[**2134-11-3**] 09:34AM BLOOD Type-ART pO2-95 pCO2-43 pH-7.44
calTCO2-30 Base XS-4
Brief Hospital Course:
Mrs. [**Known lastname 1968**] was admitted to [**Hospital1 18**] on [**2134-11-1**] for an elective
left total knee replacement. Pre-operatively, she was consented,
prepped, and brought to the operating room. Intra-operatively,
she was closely monitored and remained hemodynamically stable.
She tolerated the procedure well without any complication.
Post-operatively, she was transferred to the PACU and floor for
further recovery. On the floor, post operative stay in pacu she
was noted to have periods of apnea obstructive and was
reintubated, she was slightly hypotensive with a hct of 26 and
seh received 2 units blood. On post operative day 2 she was
extubated and transfered to the ortho floor with hct of 26.8,
inr 1.4. On post op day three hct was 26.1, she was noted to
have low grade temps and a u/a c+s was ordered as recent chest
xrays were clear. Early post operative day 3 she was noted to
have low SBP with oxygen sats of 82%, she was treated with fluid
bolus and awakening bps improved as well as saturation. A
respitory consult was placed for CPAP. Later that night her hct
was noted to be 24.8, chest xray clear, and low urine output
with a rise in creatinine to 2.2 she was given another fluid
bolus, with a repeat in desat and SBP therefor was transfered to
the ICU. She was determined to be overly sensitive to the
narcotics and her sats remained normal, received one unit prbc
with a follow up hct of 27 creat 1.8. The following day her
creat improved to 1.2 with hct 27.1 she was transferred back to
ortho floor. On [**11-7**] some errythema noted at knee
incision was started on Keflex for a 10 day course,then she
remained hemodynamically stable. Her pain was controlled. She
progressed with physical therapy to improve her strength and
mobility. She was discharged today in stable condition.
Medications on Admission:
amitriptyline, atenolol, Celebrex, Celexa, Neurontin,
OxyContin, Vicodin, lisinopril
All: asa->stomach upset
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg/0.3 ml
Subcutaneous Q12H (every 12 hours) for 3 weeks.
Disp:*42 30mg/0.3 ml* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
13. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
15. Amitriptyline 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp less than or equal to 90.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 7168**]
Discharge Diagnosis:
OA Left knee
Discharge Condition:
Stable
Discharge Instructions:
If you experience any shortness of breath, new redness,
increased swelling, pain, or drainage, or have a temperature
>101, please call your doctor or go to the emergency room for
evaluation. You may bear weight on your left leg. Please use
your crutches for ambulation. You may resume all of the
medications you took prior to your hospital admission. Take all
medication as prescribed by your doctor. You have been
prescribed a narcotic pain medication. Please do not drive or
operate any machinery while taking this medication. Feel free
to call our office with any questions or concerns.
* Continue your Lovenox injections as prescribed to help prevent
blood clots. Please finish all of this medication. Please take
an aspirin daily to help prevent blood clots. Please start this
medication after completing your course of Lovenox injections.
Physical Therapy:
Activity: Out of bed w/ assist
Treatments Frequency:
Keep your incision clean and dry. Apply a dry sterile dressing
daily as needed for drainage or comfort. Keep your knee dry for
5 days after your surgery. After 5 days you may shower, but
make sure that you keep your incision dry. Your skin staples may
be removed 2 weeks after your surgery or at the time of your
follow up visit.
If you experience any shortness of breath, new redness,
increased swelling, pain, or drainage, or have a temperature
>101, please call your doctor or go to the emergency room for
evaluation. You may bear weight on your left leg. Please use
your crutches for ambulation. You may resume all of the
medications you took prior to your hospital admission. Take all
medication as prescribed by your doctor. You have been
prescribed a narcotic pain medication. Please do not drive or
operate any machinery while taking this medication. Feel free
to call our office with any questions or concerns.
* Continue your Lovenox injections as prescribed to help prevent
blood clots. Please finish all of this medication. Please take
an aspirin daily to help prevent blood clots. Please start this
medication after completing your course of Lovenox injections.
Physical Therapy:
Activity: Out of bed w/ assist
Treatments Frequency:
Keep your incision clean and dry. Apply a dry sterile dressing
daily as needed for drainage or comfort. Keep your knee dry for
5 days after your surgery. After 5 days you may shower, but
make sure that you keep your incision dry. Your skin staples may
be removed 2 weeks after your surgery or at the time of your
follow up visit.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 3996**] [**Last Name (NamePattern1) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2134-11-16**]
3:10
Completed by:[**2134-11-8**]
|
[
"E879.9",
"458.29",
"276.7",
"518.4",
"518.5",
"276.2",
"584.9",
"278.00",
"715.96",
"998.11",
"V85.4",
"285.1",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.91",
"81.54",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5699, 5787
|
1901, 3728
|
409, 436
|
5844, 5853
|
1047, 1878
|
8419, 8616
|
586, 590
|
3889, 5676
|
5808, 5823
|
3755, 3866
|
5877, 6731
|
605, 605
|
8008, 8041
|
8063, 8396
|
620, 1028
|
243, 371
|
458, 550
|
566, 570
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,885
| 153,107
|
23516
|
Discharge summary
|
report
|
Admission Date: [**2185-10-3**] Discharge Date: [**2185-10-10**]
Date of Birth: [**2124-3-26**] Sex: F
Service: MEDICINE
Allergies:
Naproxen / Iodine
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
fever/hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61yo woman with h/o metastatic mesothelioma s/p her cycle 2 of
Alimta 10 days prior to admission initially presented with 10
days of nausea/vomiting, diarreha, fever and hypotension in the
ED. Her initial review of systems was also significant for a
diffuse rash over her chest and stomach after chemotherapy which
had improved.
.
In ED, her vitals were significant for fever to 101, hypotension
with
sbp to 80's, rr 18, sat 97% on RA. Her bp improved to 90's
systolic after 2L NS, but dropped again to 80's and required
peripheral neosynephrine to maintain pressure. Labwork revealed
lactate 2.0, pancytopenia, hyponatremia, hypochloremia. CXR c/w
prior imaging unchanged b/l opacities c/w known mesothelioma.
U/A neg. KUB neg for obstruction.
.
At time of transfer from ED to MICU, pt had been given a total
of 5L NS, vanc 1 gm, cefepime 2 gm, continued on neo.
.
Her MICU course was notable for the following:
.
Central venous access was obtained, broad spectrum abx with
vancomycin and cefepime were continued, hemodynamics improved
and
pressors were weaned off, and cultures were followed - with
urine and blood cultures no growth to date.
Past Medical History:
-Mesothelioma dx [**2174**]: s/p multiple rounds of multiple different
chemo regimens, BCG instillation. Had been on Gleevec, but
stopped prior to her son's wedding
-H/o C. diff colitis in [**2174**]
-Hypothyroidism
PSH:
-CCY
-Excision of chest wall masses
Social History:
Lives with her husband, former psych nurse. No tobacco,
alcohol, or illegal/illicit drug use. No sick contacts.
Family History:
NC
Physical Exam:
vs: 96.6, 81, 20, 133/74, 97% RA
.
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - diminished breath sounds on right with crackles [**1-17**] way
up.
CV - RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr -No edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, non-focal
Skin - diffuse rash scattered dark brown patches with red
borders over chest abdomen and back
Pertinent Results:
[**2185-10-3**] 07:40AM GRAN CT-1880*
[**2185-10-3**] 07:40AM PLT COUNT-118*#
[**2185-10-3**] 07:40AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2185-10-3**] 07:40AM NEUTS-85* BANDS-1 LYMPHS-6* MONOS-2 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 HYPERSEG-3*
[**2185-10-3**] 07:40AM WBC-2.4*# RBC-3.42* HGB-9.4* HCT-26.9*
MCV-79* MCH-27.4 MCHC-34.8 RDW-21.1*
[**2185-10-3**] 07:40AM CALCIUM-8.3*
[**2185-10-3**] 07:40AM GLUCOSE-167* UREA N-20 CREAT-1.2* SODIUM-129*
POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-23 ANION GAP-17
[**2185-10-3**] 07:58AM LACTATE-2.0
[**2185-10-3**] 08:15AM CORTISOL-30.8*
[**2185-10-3**] 08:15AM CK-MB-1
[**2185-10-3**] 08:15AM cTropnT-<0.01
[**2185-10-3**] 08:15AM CK(CPK)-30
[**2185-10-9**] 07:05AM BLOOD WBC-4.6 RBC-3.75* Hgb-10.1* Hct-28.4*
MCV-76* MCH-26.9* MCHC-35.4* RDW-19.0* Plt Ct-85*
[**2185-10-9**] 07:05AM BLOOD Gran Ct-2820
[**2185-10-9**] 07:05AM BLOOD Glucose-90 UreaN-7 Creat-0.9 Na-140 K-4.2
Cl-105 HCO3-28 AnGap-11
[**2185-10-9**] 07:05AM BLOOD Calcium-7.4* Phos-2.6* Mg-1.7
[**2185-10-4**] 01:02PM BLOOD calTIBC-133* Ferritn-GREATER TH TRF-102*
[**2185-10-4**] 01:02PM BLOOD Cortsol-40.4*
[**2185-10-3**] 07:58AM BLOOD Lactate-2.0
__________________________
CXR:
FINDINGS: Since prior study dated [**2185-8-2**], there has been
no
significant interval changes. Stable appearance of the large
right lung opacity, and right-sided chest wall increase density
with several right-sided ribs periosteal reaction consistent
with known extensive mesothelioma. The left lung demonstrates
multiple nodular opacities consistent with metastatic disease,
unchanged when compared to prior study.
IMPRESSION: No significant interval changes when compared to a
scout view from a CT dated [**2185-8-2**].
.
MRI head: IMPRESSION:
1. No evidence for intracranial metastatic disease.
2. Evidence for small chronic right insular infarct.
.
EKG: NSR@96 bpm, nml axis/int, TWF in III, aVF, V2, and V3, TWI
in V1 .
.
Brief Hospital Course:
61yo woman with history of metastatic mesothelioma recently s/p
cycle 2 of Alimta chemotherapy initially presented with
SIRS/sepsis with fever and hypotension requiring volume
resuscitation and pressor therapy; now called out from MICU,
hemodynamically stable and initially on broad spectrum
antibiotics without focal infectious source to date, being
treated for ongoing n/v.
.
1. Hypotension (thought intially to be sepsis): Pt initially
admitted to ICU and was thought to have sepsis supported at
presentation by fever, leukopenia, hypotension requiring volume
resuscitation and pressor therapy. She was treated with empiric
broad spectrum antibiotics, however there has been no clear
focal infectious source identified to date. It may well have
been transient bacteremia in setting of recent chemotherapy,
mucositis, and bacterial translocation across the gut mucosa.
Urine and blood cultures remain negative to date. Stool c diff
toxin negative x1, second pending at time of discharge. We
discontinued cefipime and vanco given afebrile without specific
source ever identified, and vital signs remained stable. The
right IJ catheter was removed with catheter tip sent for
culture, neg to date.
.
2. Nausea/vomiting/diarrhea- Pt initially sent with severe
nausea and vomiting which was likely due to side effect of
recent chemotherapy. She was treated symptomatically and
supported with IV fluids. Both nausea and vomiting were under
better control with compazine. As well diarrhea was treated
with loperamide. Stool cultures/c diff was negative. Still
awaiting final stool studies result. Diet was advanced as
patient tolerated.
.
3. The patient had ARF at presentation, which was felt most
likely pre-renal etiology and resolved.
.
4. Rash: Pt was found to have rash on presentation. This was
thought likely associated with chemo as pt had similar rash [**2-17**]
to cycle #1. Rash improving on day of discharge.
.
5. Metastatic Mesothelioma Pt was not treated while inpatient.
Follow up treatment will be determined by primary oncologists.
.
6. Neuro: vague h/o arm shaking when waking up from sleep while
in ICU. Per report there was no real seizure activity, though
patient convinced she had a seizure. It is thought that the
jerking likely [**2-17**] anxiety. MRI of the head was obtained and
showed no focal lesion that could cause seizures. No further
episodes occured while in the hospital.
.
7. Depression/ anxiety- Pt with continued symptoms at night of
anxiety requesting klonapin. She was afraid that "she might have
another seizure". Reassured patient, will continue with ativan
prn. [**Month (only) 116**] need out pt psych eval to manage current meds (pt
expressed desire to see psychiatrist). She was continued on SSRI
and ativan prn.
.
8. Hypothyroidism: Pt was kept on her home dose of synthroid.
.
9. FEN: She was given a regular diet, pt asked to avoid lactose
containing foods.
.
10. For prophylaxis, the pt was written for pneumoboots. She
did receive heparin for a 1-2 days of hospitalization, but had
decreased platelets and the heparin was stopped.
.
11. Code- DNR/DNI
Medications on Admission:
-Levothyroxine 112mcg daily
-Prozac 20mg daily
-Dronabinol 2.5 mg [**Hospital1 **]
-Compazine 10 mg q6h prn
-restoril 30 mg qhs prn
Discharge Medications:
1. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for rib pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
8. Beds
1 [**Hospital **] hospital bed with split side rails
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Homecare
Discharge Diagnosis:
Metastatic mesothelioma
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for evaluation of low blood pressure,
diarrhea, and vomiting. You were treated with medications to
symtomatically manage these symptoms.
You should call your doctor or return to the ED if you have:
* Increased vomiting or diarrhea
.
You have an appointment with Dr. [**Last Name (STitle) 3274**] on [**2185-10-13**], but should
call his office to change the appointment to see him in in about
one month.
* Passing out
* Fever or chills
* Shortness of breath, chest pain
* Any other concerning symptoms
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2185-10-13**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2185-10-13**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2185-10-13**]
3:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2185-10-10**]
|
[
"288.0",
"171.4",
"785.59",
"536.2",
"584.9",
"E933.1",
"276.1",
"995.94",
"197.0",
"782.1",
"244.9",
"038.9",
"733.90",
"285.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
8594, 8654
|
4610, 7724
|
297, 304
|
8722, 8731
|
2524, 4587
|
9300, 9880
|
1907, 1911
|
7907, 8571
|
8675, 8701
|
7750, 7884
|
8755, 9277
|
1926, 2505
|
240, 259
|
332, 1479
|
1501, 1760
|
1777, 1891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,795
| 126,115
|
19126
|
Discharge summary
|
report
|
Admission Date: [**2131-11-23**] Discharge Date: [**2131-12-11**]
Date of Birth: [**2066-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Lung biopsy [**12-3**]
Bronchoscopy [**11-27**]
History of Present Illness:
Mr. [**Known lastname **] is a 65 yo male with h/o Hodgkin's lymphoma, in CR
with negative PET [**9-26**], pulmonary fibrosis [**12-26**] 4 cycles of
bleomycin(mild restrictive ventilatory pattern) who presents to
ED with increasing SOB. He had been doing well s/p treatment for
bleomycin toxicity (has been off steroids for "a long time")
until this 5 days PTA when you developed pulmonary wheezing L>R.
He presented to his PCP after [**Name9 (PRE) **] he had blood work/CXR. He
was started on levo/albuterol 3 days PTA with little change in
resp symtpoms. He also c/o rhinorrhea and cont wheezing. He
denies cough/palpitations, chest pain. No f/c/ns/n/v.
+constipation. He has chronic LBP since late in chemo course and
has been scheduled for [**Doctor First Name **] [**2131-12-4**]. B/c of back pain(right
sided), he spends inc. time lying on floor, on R side. His
sister became concerned about his resp status and called for him
to come to ED. He also notes 30lb weight loss since [**12-28**] which
he has not been able to put back on despite good appetite.
Past Medical History:
-CAD-
s/p 4-v CABG in [**2117**] (LIMA->LAD, RIMA->RCA, SVG-> OM1/OM2); Had
positive stress tests in [**2126**] and [**2128**], and patient wanted
medical management. Positive stress in [**7-26**] which led to PTCA of
D1, LAD, and LMCA with stenting of the LMCA and LAD. Echo in
[**3-26**] showed an EF of 55% and E/A of 0.56
-Stage III mixed cellularity Hodgkins Lymphoma-
Diagnosed in [**6-25**]. Right neck mass was removed in [**2130-11-23**]
and treated with 6 cycles of ABVD chemo, but taken off Bleomycin
in [**Month (only) 116**] due to lung toxicity after hospitalization for SOB.
Followed by Dr. [**Last Name (STitle) **].
-Bleomycin lung toxicity-
As in HPI. Being followed by Dr. [**First Name (STitle) **]. Started prednisone in
[**Month (only) 116**] and finished prednisone taper 2 weeks ago. Had also been on
Bactrim concurrently.
-Back pain
Had low back surgery in [**2121**] at [**Hospital6 1708**]. A
recent MRI scan demonstrated disc prolaspe at L3 and L4,
posterior displacement of the right L4 nerve root in the lateral
recess, and at L4/L5 with posterior displacement of the left L5
nerve root and mild left-sided channel stenosis associated with
the disc bulge. There was no evidence of lymphomatous
involvement. Has had chronic LBP radiating into RLE, awaiting
Ortho evaluation.
Social History:
Home and Support: He grew up on the [**Hospital3 **] where he worked
for five years as an elementary school teacher. He then became
the school principal for 36 years. He is now retired and lives
in alone in [**Location (un) 3320**]. He is single and has not been married.
His sister, [**Name (NI) **], lives in the [**Hospital3 **] and is his health
care proxy. Animal Exposure: No pets. No exposure known.Travel:
None.Diet/Exercise: Balanced diet. Obstacles to care: None.
Tobacco/Drug Use: None.Alcohol: Occasional.
Family History:
His father had prostate cancer, his mother had a history of
stroke, a sister who has had breast cancer, and another sister
who has had a heart attack. He has two sisters and one brother.
Physical Exam:
T: 99.7/98.1 BP: 110-130/60-80 RR: 20 HR: 89-98 RR: 20 O2: 95%
GEN: Mid age male, resting on right side, speaking in complete
sentences but with labored breathing, NAD
HEENT: PERRL, sclerae anicteric, EOMI, mm-dry, OP - +food
particles, mild erythema of post OP but no lesions, no LAD
Cardiac: rrr, no m/g/r
PULM: crackles at bases bilat otherwise cta, no wheezing
abd: soft, nt/nd +BS
ext: no c/c/e; poor skin turgur
Pertinent Results:
[**2131-11-23**] 06:15PM GLUCOSE-104 UREA N-8 CREAT-0.6 SODIUM-130*
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-29 ANION GAP-13
[**2131-11-23**] 06:15PM WBC-8.7 RBC-3.90* HGB-11.6* HCT-33.9* MCV-87
MCH-29.8 MCHC-34.2 RDW-16.0*
[**2131-11-23**] 06:15PM NEUTS-69.8 LYMPHS-13.8* MONOS-7.9 EOS-8.1*
BASOS-0.4
[**2131-11-23**] 06:15PM PLT COUNT-323
[**2131-11-23**] 06:15PM PT-13.0 PTT-30.2 INR(PT)-1.1
at OSH [**11-13**]
BNP: 152
u/a and blood cx, negative
Chest CT
[**10-14**]: restaging CT: no evidence of dz progression; stable
fibrotic changes
CXR: [**11-18**] bilat. patchy pna
[**11-22**]: bilat prominent interstitial markings with confluent
opacity at right base
Brief Hospital Course:
Mr. [**Known lastname **] is a 65 yo male with Hodgkins lymphoma, now in
chronic remission, with h/o bleomycin toxicity now presenting
with 1 week h/o SOB.
He presented to PCP [**Last Name (NamePattern4) **] [**11-18**] and was found to have B basilar
consolidations c/w PNA and started on levo (day#3 on admit)
without improvement of symptoms. Although he does have h/o
bleomycin toxicity he has been followed by Dr. [**First Name (STitle) **] and had
been stable both clinically and per chest CT on [**10-14**]. Labored
breathing and SOB possibly infectious (although no cough/fever),
recurrence of lymphoma, or progression of bleomycin toxicity.
Admitted on [**2131-11-23**] and treated empirically with ctx and
azithro for presumed community acquired pneumonia; brochoscopy
on [**11-27**] performed to evaluate for other infectious etiologies or
recurrence of lymphoma. He initially did well post-bronchoscopy
but then had an episode of desaturation and hypotension and
transferred to the ICU for further evaluation; intubated [**11-29**] for
persistent respiratory distress and hypoxemia. Started on
levophed [**11-29**] for persistent hypotension which was not responsive
to fluid boluses and antibiotics changed to vanco/zosyn for
broader empiric coverage.
Transferred to the [**Hospital Ward Name **] on [**12-3**] for lung biopsy; post
operatively, Mr. [**Known lastname **] remained intubated given poor
oxygenation; blood pressure remained pressor dependent. Path
report from lung biopsy revealed diffuse alveolar damage/ ARDS
without evidence of lymphoma. Extensive family discussions were
held post-operatively as patient remained ventilator and pressor
dependent and following a family meeting on [**12-11**], aggressive
care was withdrawn the evening of [**12-11**] and patient was extubated
and placed on a moprhine drip. He expired at 21:30 on [**12-11**].
Medications on Admission:
Atorvastatin
Plavix
Toprol XL
Quinapril
Protonix
Aspirin
Senna/Colace
ambien prn
percocet prn
Discharge Disposition:
Home
Discharge Diagnosis:
ARDS
Hodgkin's Lymphoma
Discharge Condition:
Deceased
|
[
"V45.82",
"515",
"201.90",
"276.1",
"410.71",
"038.8",
"722.10",
"428.0",
"995.92",
"785.52",
"518.84",
"V45.81",
"136.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"00.17",
"96.6",
"33.28",
"33.24",
"38.93",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6731, 6737
|
4705, 6586
|
335, 384
|
6805, 6816
|
4006, 4680
|
3362, 3551
|
6758, 6784
|
6612, 6708
|
3566, 3987
|
276, 297
|
412, 1477
|
1499, 2809
|
2825, 3346
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,931
| 102,660
|
52509
|
Discharge summary
|
report
|
Admission Date: [**2181-5-22**] Discharge Date: [**2181-5-24**]
Date of Birth: [**2133-4-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Nausea/Vomiting, DKA.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48F h/o DM1 who presents with DKA. Per the patient, she in USOH
until 2d ago, when she quit smoking. Since then she reports
increased intake of sweets. She has also been "running out of
insulin and trying to make it last." She took 24U of lantus
yesterday, and describes increased n/v yesterday night prompting
her to present to the ED.
.
In ED VS= 98.5 89 140/72 16 100%RA. Labs were notable for
critical high finger stick, HCO3 of 6, pH 7.10/26/61, lactate
5.0, CRE 1.5 (baseline 0.8), GAP 29, corrected NA 146. UA with
rare bacteria, 0 WBC, 0-2 epi. CXR unremarkable. ECG with
?twi/std in 2,3,avf and ?j-point elevation v1-2, was faxed to
cardiology who felt c/w strain. Exam notable for gingival
hyperplasia, otherwise, clinically dry.
.
He received CTX empirically for elevated lactate, and
leukocytosis. 2 PIVs were placed, and he was given 3L IVF, 10U
regular, and insulin gtt started and increased to 6U/hr. She is
awake, mentating well. At the time of transfer, VS= 154/74
100 20 100%RA.
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. DM1 - A1C 10.2 [**1-8**]; multiple ED visits for hypoglcyemia
2. HTN
3. depression
4. bartholin gland abscess s/p I&D
Family History:
History of HTN; no DM, CAD or cancer.
Physical Exam:
Vitals: 98.9 96 161/78 18 100%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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2181-5-23**] 02:23AM BLOOD WBC-12.4* RBC-3.66* Hgb-10.7* Hct-31.4*#
MCV-86# MCH-29.3 MCHC-34.1# RDW-16.0* Plt Ct-230
[**2181-5-22**] 11:00AM BLOOD WBC-16.2*# RBC-4.79 Hgb-13.5 Hct-45.8#
MCV-96# MCH-28.2 MCHC-29.5* RDW-15.4 Plt Ct-332
[**2181-5-22**] 11:00AM BLOOD Neuts-89.0* Lymphs-7.8* Monos-2.8 Eos-0.1
Baso-0.3
[**2181-5-23**] 02:23AM BLOOD Plt Ct-230
[**2181-5-23**] 02:23AM BLOOD PT-12.6 PTT-30.7 INR(PT)-1.1
[**2181-5-23**] 02:23AM BLOOD Glucose-146* UreaN-13 Creat-0.9 Na-142
K-4.1 Cl-116* HCO3-16* AnGap-14
[**2181-5-22**] 09:36PM BLOOD Glucose-181* UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-114* HCO3-18* AnGap-13
[**2181-5-22**] 05:33PM BLOOD Glucose-145* UreaN-13 Creat-0.9 Na-142
K-3.8 Cl-114* HCO3-16* AnGap-16
[**2181-5-22**] 02:00PM BLOOD Glucose-586* UreaN-19 Creat-1.4* Na-139
K-4.9 Cl-115* HCO3-8* AnGap-21*
[**2181-5-22**] 11:00AM BLOOD Glucose-880* UreaN-22* Creat-1.5* Na-134
K-5.4* Cl-99 HCO3-6* AnGap-34*
[**2181-5-22**] 09:36PM BLOOD CK(CPK)-98
[**2181-5-22**] 11:00AM BLOOD CK(CPK)-101
[**2181-5-22**] 11:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2181-5-22**] 09:36PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2181-5-23**] 02:23AM BLOOD Calcium-8.7 Phos-1.1*# Mg-1.9
[**2181-5-22**] 02:04PM BLOOD Type-[**Last Name (un) **] pO2-61* pCO2-26* pH-7.10*
calTCO2-9* Base XS--20 Comment-GREEN TOP
[**2181-5-22**] 06:29PM BLOOD Type-[**Last Name (un) **] Temp-38.3 Rates-/18 pO2-54*
pCO2-31* pH-7.32* calTCO2-17* Base XS--8 Intubat-NOT INTUBA
[**2181-5-22**] 12:44PM BLOOD Glucose-GREATER TH Lactate-5.0*
[**2181-5-22**] 06:29PM BLOOD Lactate-3.0*
.
.
STUDIES:
Brief Hospital Course:
# DKA - The trigger was felt to be likely medication
non-compliance. CXR and UA were not consistent with infection.
She was started on an insulin drip in ED, and arrived on the
floor receiving 6U/hr. She received 3L IVF in ED. Upon arrival
to ICU she was switched to 1/2 NS x 1L given rising corrected
Na. Serial CHEM7 obtained Q4HR revealed gap closed ~11PM on the
night of admission, with FSBS < 250. She was transitioned to
D51/2 NS @ 100/hr, and the insulin drip was discontinued after
she was given 30U of lantus. Gap remained closed, repeat FSBS
up to 273, for which she received 10U, with FSBS down to 70s.
CE negative x2. She was seen by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultant the next
day. Also, on the day following her admission, the patient's
anion gap reopened. She was restarted on the insulin drip. On
the following day, he anion gap closed and the insulin drip was
stopped. She was also seen by the [**Last Name (un) **] consultant, who
increased her Lantus dose and her sliding scale insulin. She
was then discharged home with a prescription for insulin and
follow-up appointments.
# Leukocytosis - This was felt likely to be a stress response.
The urinalysis was unremarkable, the CXR was without focal
infiltrate, and the ECG was without active evidence of ischemia.
# HTN - The patient was continued on her home regimen.
# Depression - The patient was continued on her home regimen of
fluoxetine.
# Smoking - The patient declined a nicotine patch.
Medications on Admission:
- Aspirin 81 mg PO DAILY (Daily).
- Metoprolol Tartrate 100 mg PO BID
- Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
- Nifedipine 30 mg SR PO DAILY.
- Insulin Humalog sliding scale.
- Insulin Lantus 27 UNITS QDAILY.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous once a day.
Disp:*QS ml* Refills:*2*
6. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous QACHS: as per sliding scale.
Disp:*6 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Type I diabetes
Discharge Condition:
Hemodynamically stable with blood sugars controlled on
subcutaneous insulin.
Discharge Instructions:
You were admitted for diabetic ketoacidosis in the setting of
not taking enough insulin. It is essential that you continue to
follow your finger sticks four times per day and dose your
insulin appropriately. We have increased your lantus to 35 units
daily and you have a new sliding scale. Please follow up with
your doctors [**First Name (Titles) **] [**Last Name (Titles) **] at [**Last Name (un) **] for further management of
your diabetes.
Please return to the emergency department or call your [**Last Name (un) **]
physician if you blood sugar rises above 400, you feel confused,
or have any other new concerns.
Followup Instructions:
Please call [**Last Name (un) **] and your primary care physician to schedule [**Name Initial (PRE) **]
follow up appointment with your physician in the next week.
Please also follow up with your therapist as soon as possible.
|
[
"276.51",
"401.9",
"V17.49",
"250.13",
"V15.81",
"V58.67",
"V43.3",
"288.60",
"311",
"787.01",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.17",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
6490, 6496
|
4099, 5619
|
336, 343
|
6578, 6657
|
2509, 4076
|
7324, 7554
|
1945, 1984
|
5902, 6467
|
6517, 6557
|
5645, 5879
|
6681, 7301
|
1999, 2490
|
1406, 1785
|
275, 298
|
371, 1387
|
1807, 1929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,629
| 160,577
|
47536
|
Discharge summary
|
report
|
Admission Date: [**2107-3-1**] Discharge Date: [**2107-3-20**]
Date of Birth: [**2049-12-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
Fixation of left intertrochanteric hip fracture [**2107-3-2**]
History of Present Illness:
This is a 66 y/o M s/p fall from 15 feet onto concrete who now
presents with L. frontal SAH, L. post SDA, ? IPH and basilar
skull fractures. The patient is positive for EtOH and cocaine;
he is a poor historian. The patient complains of right-sided
pain.
Past Medical History:
1) traumatic brain injury after a 15-ft fall onto concrete, with
basilar skull fx, left posterior SDH; left frontal SAH; left
frontal intraparenchymal hemorrhage.
2) right [**5-5**] rib fractures,
3) multiple old R & L rib fx,
4) acute L femoral neck fx ,
5) multiple thoracic and lumbar spine fractures, including fx of
R transverse processes of L1-L5, fx of body of T8, fx of post
processes of T9-T12, L1, L4.
6) Alcohol intoxication
7) Altered mental status
9) Aspiration
10) S/P CVA
[**08**]) S/P cerebral aneurysm clipping
Social History:
Lives alone in a rooming house, has one sister who is supportive
Tobacco + AND CURRENT
ETOH daily
Family History:
non contributory
Physical Exam:
O: T: 97.4 BP:167/102 HR: 86 R 31 O2Sats 100% NRB
Gen: unable to concentrate on examine (received pain medication
prior).
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Right hip tender, right leg
shorter than left
Neuro:
Mental status: fell asleep during the exam, arousable, will open
eyes and answer minimal questions.
Oriented to self.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2
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: did not examine
[**Doctor First Name 81**]: neck collar in place
XII: NRB in place
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength 4/5 throughout. LLE pain on motion consistent
with injuries.
Sensation: Intact to light touch, propioception.
Toes downgoing bilaterally
Pertinent Results:
[**2107-3-1**] 03:52AM WBC-14.1* RBC-4.32* HGB-12.9* HCT-38.5*
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.7
[**2107-3-1**] 03:52AM PLT COUNT-328
[**2107-3-1**] 03:52AM GLUCOSE-118* LACTATE-5.1* NA+-143 K+-4.2
CL--104 TCO2-19*
[**2107-3-1**] 03:52AM ASA-NEG ETHANOL-162* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2107-3-1**] 03:52AM UREA N-32* CREAT-2.1*
[**2107-3-1**] 06:55AM ALT(SGPT)-25 AST(SGOT)-43* ALK PHOS-66
AMYLASE-75 TOT BILI-0.2
[**2107-3-1**] 06:55AM LIPASE-42
[**2107-3-1**] CT C spine : 1. Posterior pharyngeal soft tissue swelling
of the neck . 2. Basilar skull fracture as detailed more fully
on concurrent CT of the head.
3. Multilevel degenerative changes, most prominent at the level
of C5-6 with a posterior disc osteophyte complex resulting in
moderate to sever central canal stenosis. Ligamentous or spinal
cord injury cannot be excluded in this setting and recommend MR
for further evaluation.
[**2107-3-1**] Head CT : 1. Multicompartmental intracranial hemorrhage
including bifrontal subarachnoid hemorrhage, small component of
likely subdural extra-axial hemorrhage seen along the left
cerebellum and possible intraparenchymal hemorrhage seen
overlying the left temporal lobe.
2. Encephalomalaciathe right temporal lobe with adjacent high
attenuation
focus likely representing hemorrhage.
3. Comminuted basilar skull fracture involving the occipetal
bone though
without apparent extension into the carotid canals.
4. Posterior scalp hematoma.
[**2107-3-1**] CT Torso :
1. No acute intrathoracic or intra-abdominal traumatic process.
2. Extensive fractures as described above, with multiple
right-sided acute thoracic rib fractures, acute fracture of the
left femoral neck, and multiple fractures of the vertebral
bodies including an anterior fracture of the T8 vertebral body
and multiple transverse process and posterior spinous fractures.
3. Cholelithiasis without secondary signs of cholecystitis.
[**2107-3-2**] : Left hip : Proximal left femoral trochanteric fracture.
[**2107-3-2**] CTA Head and neck :
1. Comminuted basilar skull fracture, with extension into the
right jugular foramen, and apparent bilateral venous sinus
compression.
2. Status post ACOM aneurysm clipping and right MCA infarct.
Intact
intracranial arterial circulation, with no evidence of new
aneurysm or
thrombus.
3. Evolving hemorrhagic contusions in the bilateral
frontotemporal lobes.
4. Trace left frontal subarachnoid and pericerebellar subdural
hemorrhages
[**2107-3-7**] Head CT :
1. No new intracranial hemorrhage.
2. Evolving hemorrhagic contusions in the left frontal lobe.
3. Old right MCA infarct with evolving internal hemorrhage.
4. Comminuted basilar skull fracture.
[**2107-3-7**] CTA Chest :
1. No evidence of pulmonary embolus.
2. New left lung upper lobe contusion is likely secondary to
slight increase in displacement of a left lateral sixth rib
fracture. Otherwise, there is no change in multiple other rib
and thoracic spine fractures since [**2107-3-1**].
3. Minimal left lower lung aspiration pneumonia.
4. New small bilateral pleural effusions.
[**2107-3-16**] Videoswallow :
Frank aspiration was seen multiple consistencies on lateral
and
AP views. For further details, please refer to the speech
pathology report
OMR.
Brief Hospital Course:
Mr. [**Known lastname 100497**] was evaluated by the Trauma team in the Emergency
Room and admitted to the Trauma ICU for frequent neuro checks
and further management. The Neurosurgery service was consulted
regarding his SAH,SDH and Thoracic spine fractures. A TLSO
brace was recommended and ordered. The Orthopedic service was
also consulted for his left hip fracture.
On [**2107-3-2**] he was taken to the Operating Room for fixation of his
left hip fracture. He tolerated the procedure well and returned
to the ICU in stable condition. His pain was controlled with
Dilaudid and he eventually got out of bed with his TLSO brace.
His neuro status was stable as was his head CT.
Following transfer to the Trauma floor he developed periods of
agitation and confusion along with tachycardia and was placed on
a CIWA protocol. A repeat head CT was done which was unchanged.
His confusion and delirium persisted and eventually he developed
congestion and tachypnea prompting transfer to the ICU for
pulmonary toilet on [**2107-3-7**]. He was eventually intubated and
sedated for pulmonary toilet A CTA was done which ruled out PE
and a bronchoscopy was done which was unremarkable. Tube
feedings were started and pulmonary toilet continued. He was
eventually extubated on [**2107-3-9**].
He was transferred back to the Trauma floor on [**2107-3-10**] and is
making slow progress. His cough is effective though he still
requires chest PT. His mental status is improving and his
agitation is controlled with Zyprexa. He has been seen by the
Physical Therapy service on a daily basis and although he is
improving as far as balance and transfers go, he still requires
assistance as he can be impulsive. He was also evaluated on
multiple occasions by the Speech and Swallow service and
currently is on a regular diet. He actually failed a video
swallow on [**2107-3-16**] possibly due to his mental status. The
following day he was alert, oriented and able to swallow without
any difficulty. His caloric intake will need to be monitored
closely.
After a long hospital day he is being transferred to rehab with
the hope that he will return home and live independently.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection twice a day.
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1) traumatic brain injury after a 15-ft fall onto concrete, with
basilar skull fx, left posterior SDH; left frontal SAH; left
frontal intraparenchymal hemorrhage.
2) right [**5-5**] rib fractures,
3) multiple old R & L rib fx,
4) acute L femoral neck fx ,
5) multiple thoracic and lumbar spine fractures, including fx of
R transverse processes of L1-L5, fx of body of T8, fx of post
processes of T9-T12, L1, L4.
6) Alcohol intoxication
7) Altered mental status
9) Aspiration
10) S/P CVA
[**08**]) S/P Cerebral ameurysm clipping
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance, walking with a
rolling walker. TLSO brace at all times
Discharge Instructions:
* You were admitted to [**Hospital1 18**] to the trauma service after a 15
foot fall onto concrete. You suffered a traumatic brain injury
(bleeding in your brain) and you also sustained multiple
fractures of your spine and ribs.
*You broke your left hip and underwent a surgical procedure to
fix your hip.
*You were also very confused during a majority of your
hospitalization and had difficulty swallowing.
*Please wear the TLSO brace provided whenever you are out of bed
until your follow up with the spine surgeons. It's job is to
protect and support your spine.
During your stay at [**Hospital1 18**] you were diagnosed with alcohol
intoxication either by blood tests or clinical exam. We
encourage you to limit your drinking, as alcohol can damage the
body in many ways. Intoxication can also put you at risk for
motor vehicle collisions, assault, falls, and other injuries or
even death. You should NEVER drive or operate heavy machinery
after drinking. You should also not go to work after drinking.
Recommended guidelines from the US Centers for Disease Control
and Prevention: No more than 2 drinks per day for men and no
more than 1 drink per day for women.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Prolonged nausea
* Vomiting
* Confusion, drowsiness, change in normal behavior
* Trouble walking, or speaking (slurred speech)
* Numbness or weakness of an arm or leg.
* Severe headache
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the orthopedic clinic in 4
weeks. Call [**Telephone/Fax (1) 58181**] for an appointment.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2107-4-6**] 2:30
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2107-4-6**] 3:30 ( Neurosurgery )
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40,736
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5437
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Discharge summary
|
report
|
Admission Date: [**2117-4-12**] Discharge Date: [**2117-4-17**]
Date of Birth: [**2033-4-3**] Sex: F
Service: MEDICINE
Allergies:
Soma / Ciprofloxacin / Epinephrine / Oxycodone
Attending:[**Last Name (un) 20147**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient states that for the past 3 days she has been feeling
weak. She has been unable to ambulate. Her PO intake has been
poor. She states that she has decreased urine output for the
past couple of days. Also complains of pain in her throat which
started yesterday.
.
In the ED, initial vs were: T 96.8 HR 68 BP 152/90 RR 18 SpO2
96% RA. Initial labs were notable for a K of 7.2, as well as a
positive UA. The patient was given insulin and D50, kayexalate,
3 amps of bicarb in D5W. EKG showed peaked T-waves. Otherwise
the patient was treated for positive UA with ceftriaxone. Renal
was consulted to see patient and determined that patient would
benefit from dialysis. Prior to coming to the floor received
calcium to stabilize cardiac membrane.
.
On the floor, the patient arrived with HR 66 BP 160/66 RR 18
SpO2 96% on RA. Repeat labs on arrival to the floor initially
showed a K of 6.9 but on chem 10 was 5.9, repeat green top was
5.8. Since her K was improving, it was decided not to pursue HD
for her hyperkalemia. She currently feels well with no
complaints.
.
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:
CAD s/p CABG in [**2083**], MI in [**2079**], c/b left ventricular aneurysm
and severe infarct-related cardiomyopathy with EF 30%, Vtach and
VF s/p ICD in [**2104**]
afib
htn
Dyslipidemia
Recurrent TIAs
Gerd
Gout
DVT/PE s/p IVC filter
Low back pain and herniated disc s/p multiple back surgeries and
Right-sided sciatica
Basal cell CA on R shin and forehead
s/p CCY
Social History:
Lives with husband in senior citizen complex. Has two children,
several grandchildren and great-grandchildren. Has hx of smoking
3-4ppd; quit in [**2075**]. Drinks 1 cocktail on most nights. No
illicit drug use.
Family History:
Father: bladder cancer
Physical Exam:
On Admission:
Vitals: 96.8 68 152/90 18 96% RA
General: Alert, oriented, no acute distress
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
Vitals: 96.8 68 152/90 18 96% RA
General: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, MMM, good dentition, no erythema, exudate
Neck: supple, JVP not elevated, no LAD, no carotid bruits
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**1-3**] murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Skin: Several ecchymoses on upper arms bilaterally and lower
extremities bilaterally. No visibile rashes, ulcers. Patient has
prominent brusies on shins bilaterally, pt believes due to edema
MSK: 4/5 strength in LE sym, [**4-1**] UE sym, no clubbing, no
cyanosis, no swelling, unable to ambulate
Ext: warm, well perfused, 2+ pulses,
Neuro: AOx3, CN III-XII intact, no pronator drift
Pertinent Results:
Admission labs:
[**2117-4-12**] 07:05PM BLOOD WBC-26.1*# RBC-4.05* Hgb-13.4 Hct-39.9
MCV-98 MCH-33.1* MCHC-33.6 RDW-15.4 Plt Ct-216
[**2117-4-12**] 07:05PM BLOOD Neuts-88* Bands-2 Lymphs-5* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2117-4-13**] 01:33AM BLOOD PT-13.0 PTT-19.0* INR(PT)-1.1
[**2117-4-12**] 07:05PM BLOOD Glucose-221* UreaN-109* Creat-1.7* Na-134
K-7.2* Cl-103 HCO3-18* AnGap-20
[**2117-4-13**] 06:30AM BLOOD CK-MB-3 cTropnT-0.01
[**2117-4-13**] 01:33AM BLOOD Calcium-10.1 Phos-3.9 Mg-2.9*
[**2117-4-12**] 07:05PM BLOOD Digoxin-0.3*
.
Discharge labs:
[**2117-4-17**] 07:00AM BLOOD WBC-18.1* RBC-3.50* Hgb-11.0* Hct-35.7*
MCV-102* MCH-31.3 MCHC-30.7* RDW-15.3 Plt Ct-135*
[**2117-4-16**] 08:20AM BLOOD Neuts-70 Bands-4 Lymphs-15* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-2*
[**2117-4-17**] 07:00AM BLOOD Glucose-125* UreaN-56* Creat-1.1 Na-139
K-5.1 Cl-108 HCO3-18* AnGap-18
[**2117-4-15**] 08:25AM BLOOD VitB12-491 Folate-GREATER TH
.
Images:
CXR [**2117-4-12**]: no acute intrapulmonary process
.
EKG:
peaked T waves, PVCs
.
[**2117-4-15**] Renal ultrasound
IMPRESSION:
1. Mildly atrophic kidneys with thin cortices bilaterally,
compatible with medical renal disease.
2. No hydronephrosis or calculi are present. Probable
atherosclerotic
vascular calcific foci in the hilar fat.
3. Urinary bladder partially contracted with Foley catheter
placement.
.
[**2117-4-16**] CXR:
FINDINGS: As compared to the previous radiograph, there is no
substantial
change. No evidence of pneumonia. Borderline size of the cardiac
silhouette. Tortuosity of the thoracic aorta. Several calcified
granulomas in the right upper lobe. Pacemaker in unchanged
position.
.
Brief Hospital Course:
ICU course:
Ms. [**Known lastname 12528**] is an 84 year-old with history of CAD with
cardiomyopathy who presented with 3 days of weakness, poor PO
intake and was found to have hyperkalemia with peaked T-waves.
.
# Hyperkalemia: The patient recently was started on
spirnolactone which in conjunction with renal hypoperfusion
secondary to being volume depleted as well as taking an ACE
inhibitor could cause an elevated potassium. In the ED patient
received calcium gluconate, insulin with D50, kayexelate. Renal
was consulted and recommended dialysis if her K did not improve
to less than 6 with medical management. Spironolactone and
lisinopril were held.
Patient was admitted to the intensive care unit as she possibly
needed dialysis. Her AM repeat potassium was <6 and she did not
require dialysis. She was treated with lasix for hyperkalemia.
.
# UTI: Urine analysis showed moderate bacteria, mod leuk
esterase, and 22 WBC. The patient has grown out urine cultures
several times before with sensitive E.coli as well as
entercoccus. Patient was started on ceftriaxone IV.
.
# ARF: Likely pre-renal given recent medication addition of
spirnolactone. Could be over-diuresis resulting in renal
hypoperfusion. Otherwise etiology could be also iatrogenic as
patient is on lisinopril, allopurinol although given the fact
the patient has been using this for some time now this is
unlikely.
.
# HTN: Patient recently was started on spirnolactone for high
blood pressure per the patient. Lisinopril and spironolactone
were held in the setting of hyerkalemia. Patient was given
lasix. Continued atenolol. Held isosorbide mononitrate as
patient getting high dose of lasix.
.
# CAD w/ cardiomyopathy: Patient has history of CAD. Continued
home simvastatin and aspirin. Held digoxin as patient had
elevated creatinine.
.
# Gout: Held allopurinol and colchicine given ARF while patient
in ICU.
.
On the medicine floor:
# Hyperkalemia: The patient may ahve been both dehydrated and on
spironolactone. The patient was also hyperglycemic which could
contribute to extracellular shift of potassium. The patient has
had good response in her K+ levels to initial treatment of
insulin, kayexelate, and bicarbonate. Renal does not feel that
dialysis is necessary. The patient's potassium had normalized by
early [**2117-4-15**], and remained within normal limits for the rest of
her hospitalization. Sprinololactone was discontinued, and
lisinopril held. The decision on lisinopril therapy is deferred
to her primary care physician.
.
# UTI: Urine analysis with moderate bacteria, moderate leukocyte
esterase, and leukocytosis. The patient's urine grew
pan-sensitive E. coli. Given allergies to fluoroquinolone and
concern for Bactrim given diominshed kidney function, a
btea-lactam was chosen. She started on ceftriaxone. Ultrasound
not suggestive of pyelonephritis or abscess. The patient was to
continue cefpodoxime for 7-day course.
.
# Leukocytosis: The patient has been afebrile during her
hospital stay, but her WBC count has been out of proportion to a
urinary tract infection, especially one that has been treated
with appropriate antibiotics based on the sensitivities. C.
diff. unlikely given fewer than three bowel movements per day.
Coagulation studies unremarkable. Chest X-ray showed no
pneumonia. Differential showed increasing number of lymphocytes
and atypicals. Dr. [**Last Name (STitle) **] spoke with Dr. [**First Name (STitle) **], who said he would
follow her blood counts as an outpatient and would determine if
any dyscrasia presented itself. Accordingly, initial order of
smear and cytometry were deferred.
.
# Acute kidney injury: Likely pre-renal given recent medication
addition of spironolactone. Could have been over-diuresis
resulting in renal hypoperfusion +/- her concurrent UTI. Renal
ultrasound not suggestive of post-renal cause.Creatinine has
normalized over course of stay.
.
# Hypertension: The patient was started on metoprolol, rather
than atenolol, due to variable kidney function [**Hospital 22034**] hospital
stay. Spironolactone and lisinopril were discontinued. Eventual
home regimen can be determined by her primary care physician.
.
# CAD with cardiomyopathy: Patient has history of CAD and CABG.
Continued aspirin, simvastatin, digoxin.
.
# Gout: Patient not currently symptomatic. Holding allopurinol
and colchicine for now; outpatient physician can decide on
restart
.
Follow up: Follow the patient's white blood cell count and
differential.
Medications on Admission:
1. allopurinol 300 mg PO DAILY
2. atenolol 150 mg PO DAILY
3. colchicine 0.6 mg PO MWF
4. digoxin 62.5 mcg PO DAILY
5. folic acid 2 mg PO DAILY
6. isosorbide mononitrate 60 mg PO DAILY
7. lisinopril 40 mg PO once a day
8. nitroglycerin 0.3 mg PO as needed for chest pain.
9. simvastatin 40 mgPO DAILY
10. aspirin 325 mg PO DAILY
11. aldactone
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: Two (2) Tablet PO once a day.
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain.
7. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Hyperkalemia
Secondary:
Urinary tract infection
Hypertension
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 12528**],
You were admitted after your potassium levels were found to be
dangerously high. These high levels were probably caused by your
blood pressure medications, especially spironolactone (also
called aldactone). That medication was stopped, as was
lisinopril. Your potassium returned to regular levels fairly
quickly and have been stable.
You were also found to have a urinary tract infection. You will
be discharged with an antibiotic, cefpodoxime, to take for three
days. Please take this medication for three more days, even if
you feel better.
We also adjusted your blood pressure medications because of
stopping two previous medications (spironolactone and
lisinopril) because of your potassium and another (atenolol)
because your kidney function was unpredictable. We have started
you on a new medication, metoprolol. Your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], [**First Name3 (LF) **] determine what would be the best
medications for your high blood pressure.
We also stopped your gout medications (allopurinol and
colchicine) because of your unpredictable kidney function. Dr.
[**First Name (STitle) **] will decide whether or not to restart these medications.
START cefpodoxime and take for three days.
START metoprolol.
STOP aldactone (spironolactone).
STOP lisinopril.
STOP colchicine.
STOP allopurinol.
STOP atenolol.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please make an appointment with Dr. [**First Name (STitle) **] to follow up over the
next week.
.
Department: [**Hospital3 249**]
When: MONDAY [**2117-5-24**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2117-6-18**] at 1 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2117-6-18**] at 1:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 20148**]
|
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] |
[] |
icd9pcs
|
[
[
[]
]
] |
11264, 11313
|
5577, 9992
|
314, 321
|
11452, 11452
|
3878, 3878
|
13157, 14240
|
2525, 2549
|
10459, 11241
|
11334, 11431
|
10092, 10436
|
11635, 13134
|
4452, 5554
|
2564, 2564
|
10003, 10066
|
3031, 3859
|
1443, 1890
|
266, 276
|
349, 1424
|
3894, 4436
|
2578, 3017
|
11467, 11611
|
1912, 2279
|
2295, 2509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,203
| 120,726
|
2262
|
Discharge summary
|
report
|
Admission Date: [**2150-11-16**] Discharge Date: [**2150-11-17**]
Date of Birth: [**2101-5-20**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 49-year-old Caucasian
male with a history of familial dysautonomia and metastatic
lung cancer. The patient presented to the Emergency Room
following a brief syncopal episode that was preceded by acute
shortness of breath. The patient states that he had not had
any pulmonary symptoms prior to [**2150-9-6**] when he
developed acute shortness of breath, for which he was seen at
[**Hospital3 **]. He was found to have a large right-sided
pleural effusion at that time. A pleurocentesis yielded a
malignant fluid that was later diagnosed as an
adenocarcinoma. A follow-up CT scan of the chest and abdomen
revealed metastases to the liver. The patient, at that time,
was started on Taxol and carboplatin. He received a second
round of chemotherapy three days prior to this admission.
The morning of admission, the patient states that he was in
his usual state of health. He went to dinner with his
parents and shortly after, he started to complain of
increasing shortness of breath that was not relieved by his
home oxygen. The mother reports that the patient started to
hyperventilate and then briefly passed out. There was no
head trauma, seizure activity, bowel or bladder incontinence.
The patient denies any chest pain, chest tightness. He also
denies any recent weight gain or increased swelling in the
lower extremities. He does report two-pillow orthopnea.
Neither the mother nor the patient were really able to
adequately describe the dyspnea. They were not able to say
whether it was an air hunger, or unable to catch his breath,
or whether he was just unable to catch a deep breath. Their
only description was that the patient just had increased
breathing efforts.
PAST MEDICAL HISTORY: 1) Familial dysautonomia. This is a
rare genetic disorder. It is a progressive sensorimotor
neuropathy where the patient tends to lose reflexes,
hypotonia, decreased perception of pain and temperature,
orthostatic hypotension, and swallowing dysfunction. 2) A
right hip fracture, status post open reduction and internal
fixation in [**2150-6-6**]. 3) Adenocarcinoma of unknown origin,
presumed to be lung cancer with metastases to the liver.
ALLERGIES: Include aspirin.
MEDICATIONS UPON ADMISSION AS FOLLOWS: 1) Valium 2 mg prn,
2) Florinef 0.1 mg q am, 0.2 mg q pm, 3) [**Doctor First Name **] 60 mg qd, 4)
Actonel 35 mg q weekly, 5) artificial eyedrops, 6) compazine
prn, 7) multivitamin, 8) carboplatin and Taxol.
SOCIAL HISTORY: The patient denies any alcohol, IV drug use,
or smoking history. He lives in a group home.
LABS UPON ADMISSION AS FOLLOWS: White blood count 13.6,
hematocrit 32.9, platelet count 209. His differential showed
53% neutrophils, 11% bands, 24% lymphocytes, 6% monocytes, 2%
eosinophils, and 1% basophils. His Chem-7 showed a sodium of
135, potassium 3.8, chloride 93, bicarb 25, BUN 37,
creatinine 0.9, and glucose 182. INR 0.9. His urinalysis
revealed trace proteins and greater than 250 glucose. His
cardiac enzymes were cycled and were negative x 3.
His EKG showed sinus tachycardia at 110 beats per minute;
normal axis; left ventricular hypertrophy; a left atrial
abnormality; T wave inversion in leads III and V6; Q waves in
V4 and V5; normal intervals.
His chest x-ray revealed: Severe kyphoscoliosis, an
ill-defined opacity at the right lung base. CT of the chest
revealed no evidence of pulmonary emboli. A large
consolidation of the right lung base with air bronchograms,
suggestive of pneumonia. Given the dilated, gas-filled
esophagus, aspiration pneumonia should be considered. There
was also a smaller possible left lower lobe pneumonia.
Marked rotary scoliosis of the thoracic spine. Multiple
sclerotic foci in the lower thoracic vertebral bodies that
could represent metastases.
An echocardiogram was also performed. The echocardiogram
results showed a normal left atrium. Left ventricular wall
thickness and left cavity size were normal. Overall left
ventricular systolic function was greater than 55%. Right
ventricular chamber size was normal. There was mild global
right ventricular free wall hypokinesis. The aortic root was
moderately dilated. The aortic valve leaflets were mildly
thickened. No aortic regurgitation was seen. The mitral
valve appeared structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic
pressure was normal. There was trivial pericardial effusion.
PHYSICAL EXAM INCLUDED THE FOLLOWING: His heart rate was
105, blood pressure ranged from 180-65 systolic and from
130-40 diastolic, respiratory rate 32, O2 sats 90% on room
air, 96% on a nonrebreather, temperature upon admission 95.4.
In general, this was a frail-appearing male who appeared
older than his stated age. He was in minor respiratory
distress on a nonrebreather mask. There was audible
gurgling. He was alert and oriented x 3. He had decreased
reflexes in the upper and lower extremities. The patient had
notable JVD to the angle of the mandible. He was anicteric.
He had pinpoint pupils bilaterally. His chest showed severe
kyphoscoliosis. There were rales and rhonchi throughout the
entire right lung. The patient also had egophony on the
right side. He had rales and rhonchi in the lower half of
the left chest. The patient had a palpable PMI. He was in
regular rate and rhythm with a loud S1, S2. His abdomen
showed two well-healed midabdominal scars. He was without
rebound tenderness, or tenderness to deep palpation.
Hepatosplenomegaly could not be appreciated. He had normal
bowel sounds. The patient had +2 edema in the left leg, +1
pedal edema in the right leg.
HOSPITAL COURSE: This was a 49-year-old male with a history
of familial dysautonomia and lung cancer who presented with
an acute onset of dyspnea. The dyspnea appeared to be due to
a number of factors, to include decreased compliance due to
his kyphoscoliosis; a large pleural effusion; possible
aspiration pneumonia; anemia; and questionable myocardial
dysfunction. In the Emergency Room, the patient was given 40
mg of IV lasix, and he responded with approximately 4.5
liters of urine over the next three to four hours. Due to
his autonomic dysfunction, the patient was repleted with
several IV boluses for a total of 2.5 liters. His net loss
was approximately 2 liters in the first 24 hours. Following
the diuresis, the patient's O2 saturation improved and he was
able to be weaned off the nonrebreather to the nasal cannula.
The patient was also started up on Levaquin for a possible
pneumonia.
The patient's white blood count upon admission was 13 with
11% bands. Initially, it was thought that this was due to
his chemotherapy and Neupogen. On the second day of
admission, the patient's white blood count dropped to 2.3.
In discussion with the patient's oncologist, this precipitous
drop was consistent with the nadir expected with his
chemotherapy regimen. The patient was observed and continued
to improve. It was requested that he stay for one additional
night on the general medicine floor for observation, but the
patient insisted on going home. He stated that he would
follow-up with his primary care physician and his oncologist
in the next week. He was discharged home in stable
condition.
DISCHARGE DIAGNOSES: 1) Familial dysautonomia. 2)
Adenocarcinoma, presumed to originate from pulmonary source.
3) Pneumonia. 4) Pulmonary edema believed to be of cardiac
origin.
DISCHARGE MEDICATIONS: 1) Valium 2 mg prn, 2) Florinef 0.1
mg q am, 0.2 mg q pm, 3) [**Doctor First Name **] 60 mg qd, 4) multivitamin,
5) Actonel 35 mg q weekly, 6) artificial eyedrops, 7)
compazine prn, 8) Levaquin 500 qd for 2 weeks, 9) lasix 10 mg
prn for fluid overload.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**MD Number(1) 11938**]
MEDQUIST36
D: [**2150-11-18**] 14:08
T: [**2150-11-23**] 11:25
JOB#: [**Job Number 11939**]
cc:[**Male First Name (un) 11940**]
|
[
"737.30",
"197.7",
"742.8",
"285.22",
"486",
"162.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7427, 7587
|
7611, 8169
|
5805, 7405
|
164, 1863
|
1886, 2612
|
2629, 5787
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
969
| 137,250
|
53542
|
Discharge summary
|
report
|
Admission Date: [**2162-5-3**] Discharge Date: [**2162-5-11**]
Date of Birth: [**2079-10-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cleocin /
Lipitor / Pravachol / dabigatran / Avelox / Captopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Weakness/fatigue
Major Surgical or Invasive Procedure:
PICC line placement for milrinone infusion
PICC line removal
History of Present Illness:
Patient is an 82yo M with PMHx of Stage 4 systolic heart
failure, EF 15%; s/p BiV ICD downgrade to BiV pacemaker; s/p
CABG times 2 who presents after BiV pacemaker downgrade for
management of heart failure.
Patient was last hospitalized for a heart failure exacerbation
at [**Hospital3 24768**] in [**2161-12-15**]. He was diuresed; his wife
reports that since this admission, the patient has steadily
gained weight, particularly in his legs and abdomen. [**Name (NI) **]
wife describes a basketball appearing belly with measured
increases in his abdominal girth- 35inches (at baseline) to
40inches recently. The patient's wife denies poor appetite in
the patient, but reports small portion sizes for meals.
The patient has been taking 80mg po lasix twice daily; however,
given the increased abdominal girth, the patient's outpatient
Cardiologist, Dr. [**Last Name (STitle) 24717**], tried xiroxalin once weekly. However,
the addition of xiroxalin resulted in decreased SBP, as low as
85/55. This augmentation to diuresis was then discontinued.
The patient has orthopnea requiring an elevated head of bed in
addition to 2 pillows. He will have SOB with exertion and with
limited activity (ie walking to the bathroom).
On arrival to the floor, patient denies chest pain and shortness
of breath.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
On review of systems, patient has no history of 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. [**Name (NI) **]
wife denies recent fevers, chills or rigors. All of the other
review of systems were negative.
Past Medical History:
1. HEART FAILURE HISTORY
- Presumed etiology: Ischemic
- Systolic CHF
- Last known EF in year: By report EF 15%
- When was the last known HF admission: None on file at [**Hospital1 18**];
per family last HF admission in [**2161-12-15**].
- Known ??????dry?????? or ??????baseline?????? BNP: unknown
.
2. CARDIAC HISTORY:
- CARDIAC EQUIVALENTS OR RISK FACTORS: (-)diabetes,
(+)dyslipidemia, (-)hypertension, (-)current smoking, (+)family
history of CAD, (-)peripheral arterial disease, (-)stroke
- ANATOMY: CABGx2 [[**2143**] CABG (SVG to LAD, SVG to D1, SVG to Cx
with jump to OM1); [**2151**]: Redo CABG: LIMA to LAD, SVG to OM1,
SVG to PDA]
- PERCUTANEOUS CORONARY INTERVENTIONS: [**12/2155**]: Cypher stenting
of SVG to OM
- PACING/ICD: s/p BiV ICD implant in [**2153-8-14**]; s/p generator
replacement in [**2158**]
- ARRHYTHMIAS:
?????? AFib s/p cardioversion; CHADS score of 2 on coumadin
?????? H/o VTach, VFib, cardiac arrests: NSVT
- HISTORY OF CARDIOTOXIC CHEMOTHERAPY: None
- THORACIC RADIATION FOR CANCER OF: None
.
OTHER PAST MEDICAL HISTORY:
--s/p AAA repair at [**Hospital1 2025**] in [**2151**]
--h/o ulcerative colitis
--Anxiety
--Mohs surgery for basal cell skin cancer (s/p several surgeries
on
different sites of his face)
--Tonsillectomy
--Episodes of epistaxis, requiring an emergency room visit, s/p
cauterization
--Decubitus on buttocks- wife describes this to be the size of a
pencil eraser
.
Social History:
Patient is married with five children. Ambulates with walker. No
history of falls. Sleeps in a hospital bed with head elevated.
Incontinent of both urine and stool, wears depends. Occupation:
Previously was employed as a Tax accountant
--ETOH: none
--Tobacco: none
Home care Services: Physical therapy twice a week, home health
aide daily for several hours.
Family History:
There is no documented family history of dilated cardiomyopathy,
premature atherosclerotic cardiovascular disease, sudden death,
hypertrophic cardiomyopathy, or inborn errors of metabolism
affecting the cardiovascular system
Physical Exam:
Admission physical exam:
Dry wt: Unknown, present weight 150 pounds (68.1kg)
T= 98.3
BP = 99/57 (97-104/57-84)
Pulse = 62
RR and O2 sat: 97% RA
General: Alert, oriented, no acute distress, cachectic appearing
male
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: Engorged IJV; JVP is 6-cm water, with positive
hepatojugular reflux
Lungs: Crackles up to one-third of the lung field posteriorly
without wheezes
CV: Regular rate and rhythm, normal S1 + S2; 2/6 systolic murmur
best appreciated at the RUSB, but heard throughout the
precordium. No rubs, gallops
Abdomen: Distended. Soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: 4+ bilateral lower extremity edema up to 15-cm above the
medial malleolus; chronic venous stasis changes with
hyperpigmentation and stasis dermatitis; warm, well perfused, 1+
pulses in LE bilaterally, no clubbing, cyanosis
Skin: Slight yellowing of the skin, though no scleral icterus.
Neuro: CN??????s [**3-28**] intact, motor function grossly normal, no
notable focal neuro deficits, mood and affect are appropriate
Discharge physical exam: Unchanged from above, except as below:
Discharge weight: 63.2kg
Abdomen: minimal distention, soft/NT, normoactive BS
Ext: 3+ pitting edema in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
Pertinent Results:
Admission labs:
[**2162-5-3**] 10:45AM BLOOD WBC-4.9 RBC-3.38* Hgb-10.4* Hct-33.1*
MCV-98 MCH-30.8 MCHC-31.5 RDW-13.5 Plt Ct-256
[**2162-5-3**] 10:45AM BLOOD PT-20.3* PTT-31.9 INR(PT)-1.9*
[**2162-5-3**] 10:45AM BLOOD Glucose-83 UreaN-61* Creat-2.1* Na-138
K-3.7 Cl-96 HCO3-34* AnGap-12
[**2162-5-3**] 10:45AM BLOOD Albumin-3.4*
[**2162-5-3**] 10:18PM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2
[**2162-5-3**] 10:45AM BLOOD Digoxin-2.3*
.
Discharge labs:
[**2162-5-11**] 07:35AM BLOOD WBC-6.4 RBC-3.29* Hgb-10.0* Hct-32.0*
MCV-97 MCH-30.4 MCHC-31.2 RDW-13.7 Plt Ct-197
[**2162-5-11**] 07:35AM BLOOD PT-21.5* PTT-33.7 INR(PT)-2.0*
[**2162-5-11**] 07:35AM BLOOD Glucose-82 UreaN-64* Creat-2.2* Na-138
K-4.2 Cl-96 HCO3-32 AnGap-14
[**2162-5-11**] 07:35AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.3
.
Microbiology:
[**2162-5-5**] 7:04 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2162-5-8**]**
MRSA SCREEN (Final [**2162-5-8**]): No MRSA isolated.
[**2162-5-9**] 10:05 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Pending):
.
Imaging:
Chest X-ray [**2162-5-3**]:
FINDINGS: As compared to the previous radiograph, the patient
now shows
massive cardiomegaly and perihilar vascular congestion,
pulmonary edema and mild-to-moderate right pleural effusion.
There is unchanged evidence of a left pectoral pacemaker, the
generator has been replaced in the interval.
.
TTE [**2162-5-4**]
The left atrium is dilated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 20 %)
secondary to akinesis of the inferior and posterior walls and
severe hypokinesis of the rest of the left ventricle. The right
ventricle was poorly visualized but appears dilated and
profoundly hypokinetic on very limited imaging (primarily of the
infundibulum/outflow tract). The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**2-15**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] At least moderate [2+] tricuspid regurgitation
is seen. [Due to acoustic shadowing from the defibrillator coil,
the severity of tricuspid regurgitation may be significantly
UNDERestimated, potentially by up to 2 grades.] There is
moderate pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
.
Cardiac catheterization [**2162-5-5**]
COMMENTS:
1) Resting hemodynamics prior to initiation of milrinone therapy
revealed moderate pulmonary arterial hypertension, with a PA
pressure of
62/18 mmHg. The catheter was difficult to wedge at this point.
2) After milrinone therapy was administered (50 mcg/kg bolus
over 10
minutes, followed by 0.375 mcg/kg/min for 10 minutes), the
degree of
pulmonary arterial hypertension was similar, with a PA pressure
of 63/20
mmHg. The wedge pressure was mild-to-moderately elevated at 19
mmHg.
3) Notably, the PA saturation increased from 52% at baseline to
64.5%
after milrinone administration; this corresponded to an increase
in
cardiac index from 1.9 L/min/m2 at baseline to 2.6 L/min/m2
after
milrinone administration.
FINAL DIAGNOSIS:
1. Moderate pulmonary arterial hypertension.
2. Low cardiac index, improved with milrinone without change in
other
parameters.
3. Will transfer to CCU with PA catheter in place and milrinone
continued.
.
TTE [**2162-5-6**]
The left ventricular cavity is dilated. Overall left ventricular
systolic function is severely depressed (LVEF= 25 %). The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are mildly thickened. An
eccentric, posterolaterally directed jet of moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
[Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is no
pericardial effusion.
Compared with the findings of the prior study off milrinone
(images reviewed) of [**2162-5-4**], the current study on
milrinone shows an increased left ventricular ejection fraction.
.
WRIST(3 + VIEWS) RIGHT:
RIGHT WRIST, THREE VIEWS: There is diffuse osteopenia which
limits detection of subtle non-displaced fractures. Within this
limitation, no fracture or dislocation is seen. Degenerative
changes at the first CMC and triscaphe joints consist of
subchondral sclerosis and osteophytosis with associated joint
space narrowing. The soft tissues are unremarkable. Incidentally
noted are atherosclerotic vascular calcifications.
IMPRESSION: No fracture or dislocation. Degenerative changes at
the first
CMC and triscaphe joints.
Brief Hospital Course:
82M history of stage IV systolic heart failure (EF 15%) s/p BiV
ICD downgrade to BiV pacemaker, s/p CABG times 2 who presents
after BiV pacemaker downgrade for management of acute on chronic
systolic heart failure, with initiation of milrinone this
admission.
# Chronic systolic heart failure: Cardiomyopathy is likely
secondary to ischemia. Patient is NYHA class 4. Given his volume
overload upon presentation and low systolic blood pressure, the
patient was started on a lasix drip. Digoxin was discontinued
given the elevated serum level of 2.3 at admission. Patient was
then taken to catheterization lab for right heart
catheterization with milrinone trial that showed that his low
cardiac index improved with milrinone without change in other
parameters. The patient was transferred to the CCU for
monitoring after milrinone trial. Right heart cath showed: Fick
CO/CI 3.4/1.91. With milrinone: 4.6/2.59. Baseline - RA: 19,
Wedge: 27, PA 62/18 (37). With milrinone in lab - PCW: 19, PA
63/20 (34), PVR=270. O2 sat: 52 to 65%. In the CCU, the
patient was monitored carefully, cardiac output and diuresis was
improved on milrinone. On [**5-6**]: RA 14, PA 55/21 (34), CO/CI:
5.5/3, SVR=550. PA catheter was discontinued. His primary
cardiologist recommended keeping him on 0.375 mcg/kg/min IV.
Patient was transitioned from lasix drip to PO torsemide. PICC
line was initially placed so patient can receive home infusion
of milrinone, however he self d/c'd the PICC line while he was
confused. The patient was continued on 60mg oral torsemide and
lisinopril 2.5mg daily (changed from [**Last Name (un) **] on admission with no
adverse effects). Coreg was switched to Toprol by the CCU team
as well. Digoxin was held given supratherapeutic level on
admission and fluctuating renal failure. After family meeting
with the patient, family, and palliative care, the decision was
made that he would not continue home milrinone. This decision
was made in part because it would be difficult for him to keep
the PICC line in place and being on milrinone limited his
options for rehab placement. The patient and his family further
expressed that the priority is for him to be home eventually,
and they in the end, felt too overwhelmed with the prospect of
milrinone at home given his intermittent confusion and lack of
24 hour care. He did diurese well and benefited from the
milrinone infusion while in the hospital. Torsemide should be
titrated after leaving the hospital to allow stable weight and
net even to 500cc negative/day after leaving the hospital.
# Renal insufficiency: Patient with unknown baseline; presented
with a serum creatinine of 2.1 on admission. Serum creatinine
ranged from 1.9-2.2 during this admission. The patient's renal
insufficiency was thought to be from poor forward flow secondary
to the patient's underlying heart failure.
# Status post BiV pacemaker downgrade: Patient previously had a
BiV pacemaker with ICD which was replaced to BiV pacemaker
without ICD by EP (given goals of care, DNR status). The site
remained clean, dry, and intact through the admission. The
patient was placed on clindamycin three times daily for
infectious prophylaxis; the clindamycin was discontinued after 6
days. He will follow-up in device clinic after discharge.
# Atrial fibrillation: CHADS-2 score of 2. Patient on warfarin
with goal INR [**3-19**]. Warfarin was continued through the admission
per home dosing; INR was monitored daily. INR on day of
discharge was therapeutic.
# Diarrhea: Patient with liquid stools after being treated with
Clindamycin for infection prophylaxis after pacer replacement. A
stool C. diff was sent which was negative and his diarrhea
improved. Of note, he has ulcerative colitis.
--Chronic issues--
# Coronary artery disease: Patient status post CABG x2 and PCI
to grafts. Patient denied chest pain through the admission.
Patient not on a statin secondary to leg aches in the past.
Aspirin 81mg daily was continued through the admission.
# Anxiety: Patient's home trazodone 25mg daily was continued
through the admission. He was intermittently anxious through the
hospitalization asking for family members often. When family
members were present, the patient would become less anxious.
# Decubitus ulcer: Patient with decubitus ulcer on buttocks.
Patient was seen by wound care who suggested aloe [**Doctor First Name **] to the
healing area daily.
# Poor appetite/wasting: Continued Megace at home dosing.
# Transitional issues:
-Will not continue on milrinone infusion which was during this
admission because of difficulty keeping a PICC line in after
discharge
-INR will be checked on on [**2162-5-13**]
-Check chemistry 10 on [**2162-5-13**] to assess renal function and
electrolytes, replete K and Mg as needed.
-Daily weights and I/O's monitoring for goal of stable weights
or even to 500cc/day negative. Titrate torsemide dose up as
needed to achieve this in conjunction with outpatient
cardiologist, Dr. [**Last Name (STitle) 24717**].
#Code status: Patient was DNR/DNI during this hospitalization
and palliative care was involved. The family understands Mr.
[**Known lastname 4027**] has an end-stage illness and are receptive to eventually
having hospice involved in his care, possibly when he leaves
rehab and is back home. They were given hospice resources on
discharge.
Medications on Admission:
Medications - Prescription
CARVEDILOL [COREG] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 6.25 mg Tablet - 1 Tablet(s) by mouth
three times a day 1 in a.m and midday. 2 in pm 4 tabs/day
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1
Tablet(s) by mouth 4x/ week ONLY Tuesday/Thursday/Friday/Sunday
FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth every morning, one at noon time Crushed in
applesauce- difficulty swalling
MEGESTROL - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 40 mg Tablet - 1 Tablet(s) by mouth three times a day
Crushed in applesauce-difficulty swallowing
POTASSIUM CHLORIDE [KLOR-CON] - (Prescribed by Other Provider)
-
20 mEq Packet - 1 Packet(s) by mouth daily
TELMISARTAN [MICARDIS] - (Prescribed by Other Provider) - 40 mg
Tablet - [**2-17**] Tablet(s) by mouth daily every morning
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5
(One half) Tablet(s) by mouth every evening
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - one tablet by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 0.4 mg Tablet -
one tablet by mouth once a day
MULTIVITAMIN - (OTC) - Tablet, Chewable - one tablet by mouth
once a day
Discharge Medications:
1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
[**Month/Day (4) **]:*30 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
6. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. megestrol 40 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Apple Rehab
Discharge Diagnosis:
Primary diagnosis:
Chronic systolic heart failure
Dyslipidemia
Discharge Condition:
Mental Status: Confused, sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 4027**],
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**].
After replacement of your pacemaker, you were admitted for
management of your heart failure. The decision was made to start
a medication called milrinone through IV infusion to help your
heart failure symptoms. This medication was stopped before
discharge after a discussion with you and your family.
Take all medications as instructed. Note the following
medication changes:
START Lisinopril 2.5mg daily
START Torsemide 60mg daily. Your rehab facility may increase the
dose as needed.
START Metoprolol succinate 50mg daily
STOP Digoxin
STOP telmisartan
STOP Lasix (furosemide)
STOP Coreg (carvedilol)
STOP potassium (your potassium levels have been good in the
hospital)
Keep all hospital follow-up apppointments. Your up-coming
appointments are listed below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Specialty: INTERNAL MEDICINE/CARDIOLOGY
Address: 27 [**Location (un) 24719**] DR, [**Location (un) **],[**Numeric Identifier 24720**]
Phone: [**Telephone/Fax (1) 24721**]
Appointment: MONDAY [**5-17**] AT 3PM
Department: CARDIAC SERVICES
When: THURSDAY [**2162-5-27**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"V10.83",
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icd9cm
|
[
[
[]
]
] |
[
"00.53",
"37.75",
"37.21",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18649, 18687
|
11115, 15589
|
397, 459
|
18794, 18794
|
5748, 5748
|
19975, 20504
|
4138, 4364
|
17919, 18626
|
18708, 18708
|
16495, 17896
|
9437, 11092
|
18971, 19454
|
6194, 9420
|
4404, 5499
|
2648, 3362
|
19474, 19952
|
341, 359
|
487, 2305
|
5764, 6178
|
18727, 18773
|
18809, 18947
|
15612, 16469
|
3384, 3747
|
3763, 4122
|
5524, 5729
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,086
| 136,077
|
21000
|
Discharge summary
|
report
|
Admission Date: [**2124-5-5**] Discharge Date: [**2124-5-9**]
Date of Birth: [**2071-10-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization: s/p three stents to RCA (jailed SA
nodal artery and acute marginal artery); cath complicated by RV
infarct physiology requiring dobutamine; stable low atrial
escape and junctional escape with intermittent NSR; HD stable
and sx free on discharge
History of Present Illness:
52 yo male with CFR, pripr tobacco use and remote chest XRT for
testicular ca in [**2097**], p/w exertional chest pain and dyspnea for
the past 5 days. Pt reports feeling unwell all week, c/o
flu-like sxs and DOE. Subjective report of fever a day prior to
presentation. Pt called his pCP the day of admission who
recommended ED evaluation. In [**Name (NI) **], pt ruled in for inferior STEMI
(ECG with inferior ST elevations with developemnt of Q waves and
lateral ST depressions. CK 452, MB 14, Tr 3.1--> pt was taken to
cath lab where he was found to have a sub acute
inferior-posterior infarction with extensive posterior MI,
requring dobutamine gtt. Hemodynamics revelaed RA pressure of
19, RV pressure 34/14; PCWP 22 and CI 1.6. Pt was found tro have
a total occlusion on RCA with L-R collaterals. RCA thrombosis
was technically difficult to open; s/p PCI x 3 with Taxus DES.
Procedure was comoplicated by SA nodal arrest with stable
junctional escape rhythm due to jailed SA nodal artery. Pt was
transferred to CCU for further care.
Past Medical History:
testicular lymphoma
Social History:
smoker
Family History:
n/c
Physical Exam:
121/76 HR 105 18 100 % 4lNC
NAD
JVD 5 cm above clavicle
cTA B
RRR; s1/2; split s2, no m/r/g
abd: [**Last Name (un) 17066**]
ext: pulses nl by doppler; no c/c/e
Pertinent Results:
[**2124-5-5**] 09:57PM O2 SAT-79
[**2124-5-5**] 09:58PM HGB-13.7* calcHCT-41 O2 SAT-98
[**2124-5-5**] 11:13PM HGB-12.9* calcHCT-39 O2 SAT-72
[**2124-5-5**] 11:13PM TYPE-MIX
Brief Hospital Course:
1. s/p subacute inferior/post STEMI: pt remained HD stable in
CCU. Dobutamine gtt was weaned off overnight, ASA, Plavix, high
dose statin were continued. ace was added sucessfully. Initially
trasnferred with Swan Ganz catheter, which was d/c'ed after
dobutamine was weaned off.
2. Pump: EF 55% on LV garm, severe RV dysfucntion due to RV
infarction. TTE showed EF >60%; mild symmetric LVH, basal-inf
and mid-inf HK and normal RV.
3. Rhythm: stable low atrial escape after jailed SA nodal artery
during complicated cath. low does beta blocker was started on
hosp day 2. sunsequently, SA node function recovered.
4. Low grade fever: CXR with small B effusions; all cs negative;
no infectious sxs; hct stable, likley related to being post-MI
vs viral infection as fevers precceded this hospitalization. Pt
appeared well, It was decided to d/c py with outopt pcp and
cardiology follow up.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. inferior STEMI: s/p RCA stent
2. low grade fevers: unclear source; ? viral infection
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as directed
Please see your PCP within next week to look into low grade
temperature that you have been having since your trip to [**State 1727**].
Please come to ER if develop chest pain, shortness of breath,
lightheaedednessor persistent fevers
Followup Instructions:
1. please see you primaru care physician within the next week
2. please have your PCP recommend [**Name Initial (PRE) **] local cardiologist in your
area (will need to be seen by cardiologist within next [**12-22**]
weeks)
Completed by:[**2124-9-22**]
|
[
"V15.82",
"414.01",
"410.71",
"780.6",
"V15.3",
"427.89",
"410.81",
"V10.47"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"99.20",
"36.01",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
3789, 3795
|
2155, 3045
|
324, 596
|
3927, 3935
|
1950, 2132
|
4257, 4511
|
1747, 1752
|
3100, 3766
|
3816, 3906
|
3071, 3077
|
3959, 4234
|
1767, 1931
|
274, 286
|
624, 1664
|
1686, 1707
|
1723, 1731
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,328
| 170,578
|
48958
|
Discharge summary
|
report
|
Admission Date: [**2131-9-25**] Discharge Date: [**2131-11-3**]
Date of Birth: [**2054-5-26**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
diffuse large B-cell lymphoma
Major Surgical or Invasive Procedure:
Biopsy of Anterior chest wall mass
Thoracentesis
PICC line placement
History of Present Illness:
77 yo F w/ ho CVA 2 [**Last Name (un) **], afib on coumadin, DM2, CAD, COPD who was
sent to the ED for a persistently elevated INR off of coumadin
for 5 days which was preventing bx of a L knee soft tissue mass.
The pt reports the mass growing over the past 5 months which has
progressed to the point that she cannot walk. An MRI done was
notable for an enhancing mass in the suprapatellar pouch. She
also note a growing chest wall mass that has increased in size
over the last 3 weeks. She denies fevers, chills, night sweats,
weight loss. She does note poor appetite. She denies
cp/sob/cough. She denies rash.
Past Medical History:
PMH:
CVA [**2129**], residual slight aphasia
HTN
AFIB
CAD
DM2
COPD - never formally dx by PFTs
rheumatic heart disease
h/o UGI bleed [**7-30**]
anemia of chronic disease
Colon biopsy c/w collagenous colitis. Hospitalized at [**Hospital1 18**] in
[**1-31**] for diarrhea attributed to collagenous colitis.
Social History:
No EtOH, no drugs, [**11-7**] p-y tobacco,
She is married and lives with her husband.
Family History:
Rheumatic fever
CVA
Sister - Breast [**Name (NI) 3730**]
Physical Exam:
T 99.7 HR 73 BP 127/60 R 23 sat 97% RA
gen: NAD, slightly flat affect, OX3, mild resp distress
HEENT: mmm, subcm bilateral cervical LAD, no thyroid nodules
chest: 4X5 cm firm, fixed nodule over sternum with overlying
ectatic blood vessels, mild tenderness, poor air movement
bilaterally but otherwise CTAb
abd: s/nt/nd +BS no HSM
ext: no edema, swollen, warm L knee, with firm nodular swelling
over superior medial aspect with overlying ectatic blood
vessels, passive flexion limited to only [**11-15**] degrees, 2+ DP
and PT pulses
neuro: CN2-12 intact except slight L lower facial droop,
strength 4/5 [**Doctor Last Name **] and LLE, sensation intact
Pertinent Results:
Labs notable for WBC of 17.8, hct 27.0 (stable from 27.6 on
[**9-17**]), INR 2.4
Cr 1.3 (1.3 on [**9-17**])
[**2131-10-1**] 06:50AM BLOOD WBC-19.6* RBC-3.45* Hgb-9.4* Hct-30.0*
MCV-87 MCH-27.3 MCHC-31.3 RDW-14.9 Plt Ct-175
[**2131-9-30**] 05:30AM BLOOD Neuts-92.2* Lymphs-4.5* Monos-2.7 Eos-0.6
Baso-0.1
[**2131-9-30**] 05:30AM BLOOD Hypochr-2+
[**2131-10-1**] 06:50AM BLOOD Plt Ct-175
[**2131-9-29**] 05:25AM BLOOD PT-13.9* PTT-27.1 INR(PT)-1.3
[**2131-10-1**] 06:50AM BLOOD Glucose-160* UreaN-54* Creat-1.5* Na-132*
K-4.4 Cl-94* HCO3-27 AnGap-15
[**2131-9-27**] 10:00AM BLOOD LMWH-0.36
[**2131-9-30**] 05:30AM BLOOD LD(LDH)-212
[**2131-9-27**] 10:00AM BLOOD proBNP-4625*
[**2131-10-1**] 06:50AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.7 UricAcd-9.0*
[**2131-9-25**] 06:29PM BLOOD Lactate-1.9
.
.
[**2131-9-25**]: CT Chest:
1. Large anterior chest wall mass encasing the manubrium with
evidence of manubrial erosion.
2. Mediastinal and bilateral axillary lymphadenopathy. Small
left paraaortic lymph nodes.
3. Multiple bilateral pulmonary nodules.
4. Probable splenomegaly.
5. Findings consistent with metastatic disease or lymphoma
.
CT Head:
1. No acute hemorrhage or mass effect.
2. Chronic infarctions in the left middle cerebral artery
territory distribution
.
[**2131-9-26**]: Chest wall mass, fine needle aspiration: Diffuse large
B-cell lymphoma. CD 20, 79 +, CD10, BCL2 -
.
[**2131-9-30**]: CT abd/pelvis:
1. Interval increase in size and number of bilateral lower lobe
pulmonary nodules.
2. Enlarged left periaortic lymph nodes.
3. Atrophic kidneys with mild prominence of the collecting
systems bilaterally. The fullness of the collecting systems may
be secondary to marked bladder distention.
4. Possible soft tissue density mass within the left renal
pelvis, however, this is not clearly delineated on this
non-contrast examination. Further evaluation with ultrasound or
contrast-enhanced CT is recommended.
5. Cholelithiasis without evidence of cholecystitis.
6. Multiple ill-defined low density lesions within the posterior
subcutaneous tissues of the back and buttock which may represent
lymphomatous masses.
.
[**2131-10-2**]: TTE:
1. The left ventricular cavity size is normal. Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall
left ventricular systolic function is probably normal
(LVEF>55%).
2. The aortic valve leaflets are moderately thickened. There is
mild aortic
valve stenosis. Mild to moderate ([**1-28**]+) aortic regurgitation is
seen.
3. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension.
.
[**2131-10-24**]: Pleural Fluid:
Non-specific reactive T cell dominant profile; no phenotypic
evidence of B-cell non-Hodgkin lymphoma in specimen
.
[**2131-10-25**]: CT chest:
1. New patchy ground glass opacity and consolidation within the
left lower lobe, concerning for acute infection.
2. New moderate right and small left pleural effusions.
3. Interval decreased size of anterior chest wall mass,
mediastinal and axillary lymphadenopathy, and multiple pulmonary
nodules.
4. High attenuation soft tissue thickening of the inferior
aspect of the posterior right diaphragm and upper abdominal
wall/peritoneal fascia. Given the rapid appearance since
[**2131-9-25**], most likely consideration is retroperitoneal
hemorrhage, perhaps tracking from a lower source. Has there been
any recent intervention on the right side to explain these
findings?
5. Findings suggestive of bronchomalacia. A dedicated CT trachea
study could be performed when the patient is stable, if
clinically warranted, for confirmation.
.
[**2131-10-31**]: CT trachea:
Moderate-to-severe tracheo-bronchomalacia.
Brief Hospital Course:
.
#Diffuse Large Bcell Lymphoma - On admission, coumadin was held
and the patient was placed on lovenox. A biopsy of the anterior
chest mass was performed on [**2131-9-26**] with orthopedics and
thoracics following. A staging Abd/Pelvic CT and echo was
performed. Abd/Pelvic CT showed pulm nodules increased in size
from [**9-25**] and multiple SC masses in back and buttocks. The
biopsy returned consistent with diffuse large B cell lymphoma.
She was started on allopurinol for TLS ppx as her uric acid was
elevated. She was then transferred to the OMED service for
further therapy. She was started on Prednisone. She then
received rituxan [**10-4**] and cytoxan [**10-5**]. She became transiently
neutropenic after the chemotherapy but this resolved with
neupogen. Repeat CT torso was notable for decrease in tumor
burden. She received no more chemotherapy [**2-28**] declining
respiratory status.
.
#Tachypnea/Hypoxia - The patient required 2L O2 to maintain
oxygen sats >95% while on the medicine service. She was on lasix
as an outpatient so this was continued with minimal improvement
in her oxygen saturations despite increasing doses. On the day
of transfer on [**2131-10-1**], she had increased tachypnea and shortness
of breath. She had bibasilar crackles on exam but her CXR was
not consistent with failure. A foley was placed and IV lasix
were given with improvement on clinical exam. A TTE was done
notable for normal EF, mild pulmonary systolic hypertension, and
[**1-28**]+AR. She was also treated for her COPD with nebulizer
therapy. She remained stable from a respiratory standpoint until
she received Rituxan. After that time she became more tachypneic
and hypoxic. A chest CT and CXR were not notable for pneumonia
but notalb for bilateral effusions and evidence of volume
overload. Cardiology was consulted and they recommended
aggressive diuresis. Diuresis was limited by worsening
creatinine and increasing HCO3. On [**10-23**], she was sent to the
MICU for respiratory distress and hypercarbia. Her ABG was
7.31/86/123 on 4L. Pulmonary mechanics were completed and
notable for a NIF of -38cmH2O and VC of 450 CC. Since she was
DNR/DNI, Bipap was attempted. Her ABG on Bipap was 7.5/54/93
compared to 7.4/75/78 on nasal cannula. She had a therapeutic
thoracentesis done the next day. She did not tolerate her Bipap
and it was stopped. She remained stable from a respiratory
standpoint. Neurology was consulted for concern of neuromuscular
weakness contributing to her hypercarbia as she also had
proximal weakness on exam. Neurology did not feel that she has
an inherent NM disorder such as Myasthenia but that her LE
weakness should be further evaluated for a spinal process. The
patient hten had a diaphragm US notable for normal diaphragm
motion. PFTs from [**Hospital1 2025**] were obtained and notable for FEV1-1.1 and
FVC 1.9 c/w COPD. She was transferred back to the floor but
continued to have O2 sats of 88-89% on [**1-28**] L NC. Her CXR was
again c/w CHF. Pulmonary was consulted. She was restarted on
lasix + diamox in order to keep her HCO3 from 30-32. All of her
IV medications were concentrated. She continued therapy for
COPD. She had a CT neck notable for tracheomalacia but a stent
was felt unnecessary as it would only provide minimal palliative
symptom benefit and the patient was a poor surgical candidate.
On [**11-2**], she again developed respiratory distress. She was given
20 mg IV lasix. ABG was notable for 7.2/87/50/36 on 1L. She was
put on a nonrebreather with improvement her oxygen saturations.
She was quickly weaned to a face mask. Her and her family
reiterated that they did not want her to go back to the MICU for
Bipap. She remained tachpneic and hypoxic. The decision was made
to make the patient best supportive measures only. She was
started on a morphine drip make her more comfortable from a
respiratory status. The patient passed on [**11-3**] at 815am.
.
#Fevers - The patient was initially febrile in the emergency
department with a wbc of 20. Blood and urine cultures were sent.
On [**9-29**], she again spiked a temperature to 100.9. Blood cultures
were again sent which grew out [**1-28**] coag negative staph. On
[**2131-9-30**], her temperature was 101.2 so she was started on
vancomycin. She also had increasing LFTs and an abdominal US
notable for sludge. She was started on ceftiraxone and
clindamycin in addition to the vancomycin. She continued to be
febrile so was changed from ceftriaxone to cefepime. She
continued to be febrile so her picc line was removed and grew
pan-sensitive ecoli. She became afebrile on these medications
but she continued to have a leukocytosis. She was then changed
from cefepime/clinda to Unasyn. Her leukocytosis improved on the
Unasyn. Repeat US was notable for cholelithiasis but negative
for cholecystitis. Her LFTs except alk phos also began to
normalize. On [**10-11**], she remained afebrile but developed
increasing wbc count and diarrhea so stool studies were sent
which were negative. Surveillance blood cultures also remained
negative. She again developed low grade temps. Her urine was
notable for yeast despite multiple foley changes. She was
treated with a 10 day course of fluconazole. After her
thoracentesis on [**10-25**], a follow up CT scan was notable for
ground glass opacities and an infiltrate. She was started on
cefepime/flagyl. She remained afebrile on these medications.
.
## elevated alk phos - The patient noted RUQ pain around [**2132-9-30**].
At that time she also developed increasing LFTs including
alkaline phosphatase. Abd US on [**10-3**] di not note duct dilatation
or stones but she was started on cefepime/clindamycin for
concern of cholecystitis. She continued to have abdominal pain
and elevated LFTs. A repeat US on [**10-10**] was notable for
cholelithiasis but no cholecystitis. She continued dilaudid for
the abdominal pain. Over the next week her abdominal pain
improved and her LFTs except alk phos normalized. On [**10-26**] she
had a recurrence of abdominal pain so surgery was consulted and
a HIDA scan was ordered. The patient could not tolerate the
entire scan but what was done seemed negative. She continued to
require pain medication for her abdominal pain.
.
## afib: On admission, her coumadin was stopped and she was
started on lovenox. Around [**10-10**], the lovenox was stopped and she
was changed to a heparin gtt. She remained on a hepartin gtt
until [**10-12**] when she was changed back to lovenox. She remained on
lovenox until after her admission to the intensive care unit.
After being transferred to the floor from the unit, her
hematocrit was noted to drop. She was guaic negative and
hemolysis labs were negative. There was concern that she was
bleeding from her thoracentesis site vs developing an RP bleed
so lovenox was stopped. Her hematocrit stablized and she
remained off of anticoagulation except for ppx w/ subcutaneous
heparin. She was continued on verapamil and lopressor for rate
control.
.
## DM: She was maintained on sliding scale insulin + NPH
throughout the admission.
.
## Code: DNR/I
.
Medications on Admission:
All: sulfa
..
Meds:
lasix 40 mg daily
[**Last Name (un) **] 4-240 mg daily
glipizide 10 mg daily
coumadin 2.5 mg hs(off for last 5 days)
zoloft (? dose)
lovenox sc bid (last 5 days)
CaCO3 1250 mg daily
vytorin
albuterol prn
Discharge Medications:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
1. Diffuse large B-cell lymphoma
2. CHF
3. Atrial fibrillation
4. COPD
Secondary Diagnoses:
1. Diabetes Mellitus
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
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"486",
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"518.84",
"707.8",
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"511.9",
"496",
"250.00",
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icd9cm
|
[
[
[]
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[
"34.91",
"99.25",
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"99.28",
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icd9pcs
|
[
[
[]
]
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13400, 13415
|
6002, 13097
|
321, 391
|
13596, 13606
|
2233, 3361
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1486, 1544
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13371, 13377
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13630, 13636
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1559, 2214
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13551, 13575
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250, 283
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419, 1033
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3370, 5979
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1380, 1469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,848
| 192,720
|
51739
|
Discharge summary
|
report
|
Admission Date: [**2105-4-28**] Discharge Date: [**2105-5-12**]
Date of Birth: [**2026-2-20**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin / Augmentin
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Shortness of breath, PNA
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
Central Line Placement
History of Present Illness:
Pt is a 79 yo F with h/o NSCLC/BAC s/p lobectomy at [**Hospital1 112**] on
Tarceva, COPD/bronchiectasis on intermittent home o2, Pulmonary
MAC in '[**99**] s/p 18 months Rx now with recurrence MAC, IgG
deficiency on IVIG (last on [**2105-4-8**]), who was diagnosed by her
[**Company 2860**] provider at the end of [**Month (only) 958**] with PNA at which time she was
prescribed levaquin ([**4-20**]).
.
Started levofloxacin on [**4-20**] but despite antibiotics had
increased SOB with worsening of her chronic cough. In this
setting she was admitted to [**Hospital3 **] for PNA and COPD
exacerbation.
.
Pt had CT with bilateral infiltrates and possible mucous
plugging and negative for PE. There she was started on cefepime,
azithro, nebs, and solumedrol.
.
Her OSH course was c/b demand ischemia (0.15, that trended down
to 0.1). The pt refused bronch. ID was also consulted, and
thought atypical PNA was possible vs. noninfectious cause, but
recommended continuing abx. Of note treatment for her recurrant
MAC has not been
started as she is currently on Tarceva.
.
She had been doing well on the floor until, shortly after being
examined by the pulmonary consult team on [**4-29**] she acutely
decompensated from a respiratory standpoint. She dropped her
oxygen sats as low as 42%. A respiratory code was called and the
patient was peri-intubation. She was placed on a nebulizer and
given 40mg of IV lasix and her sats came up to the mid-low 90's.
She was transferred to the MICU
.
Upon arrival to the MICU she was initially hypoxic and
tachypneic and was consented for intubation, however after 1
hour on continuous nebulizers her oxygenation came up to 99% on
NRB. VBG at that time revealed 7.46 40. The decision was made to
intubate that patient by [**4-30**]. BAL performed on [**4-30**], which was
repeated on [**5-1**], showed no mucous plugging. Patient finished a 5
day course of azithromycin on [**5-2**], and on [**5-3**] a steroid taper
was started at 30mg QD with a plan for a 10 day total taper.
Patient extubated on [**5-3**] successfully, monitored until [**5-4**] and
sent to the floor.
.
Upon transfer to the floor, patient was comfortable, appropriate
and was only c/o some mild SOB with occasional cough.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
LLL Lung cancer s/p lobectomy at [**Hospital1 112**] on Tarceva
COPD/Bronchiectasis on home O2
Recurrent MAC
IgG deficiency on IVIG
Cellulitis MRSA
Folliculitis [**2-25**] Tarceva
Osteoporosis
T2DM w/periph vasc complications
HLD
CAD
Gout
Basal cell CA
Colonic polyp
Sensorineural hearing loss
TAH in 40s
Social History:
Lives at home with husband, [**Name (NI) **]. Retired, former clerical worker
at police department. She quit smoking tobacco 40yrs ago, smoked
1ppd x30yrs, no illicits. Drinks 2 glasses wine per night.
Family History:
Father - MI
Mother - [**Name (NI) 2481**]
Daughter - IVDU, hepatitis
2 healthy daughters
[**Name (NI) **] history of malignancy
Physical Exam:
ADMISSION PHYSICAL:
VS - Temp 98.6F, BP 184/92, HR 82, R 24, O2-sat 98% 2LNC
GENERAL - cachectic, pleasant, elderly female, appears fatigued,
NAD
HEENT - NC/AT, EOMI, L pupil>R (cataract surgery) sclerae
anicteric, dry, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - use of neck mm to breath, coarse rhonchi throughout
HEART - difficult to appreciate BS over rhonchi, RRR, no
appreciable mumurs, rubs, gallops
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - warm, dry, chronic venous stasis changes
SKIN - several scattered ecchymoses throughout
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities, no gross deficits
.
DISCHARGE PHYSICAL:
97% on 2L
Persistent wheezing and rhonchi on expiration. Breathing
comfortably.
Pertinent Results:
ADMISSION LABS:
[**2105-4-28**] 11:02PM URINE HOURS-RANDOM UREA N-857 CREAT-41
SODIUM-43 POTASSIUM-21 CHLORIDE-22
[**2105-4-28**] 11:02PM URINE OSMOLAL-467
[**2105-4-28**] 11:02PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2105-4-28**] 11:02PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
[**2105-4-28**] 11:02PM URINE RBC-58* WBC-11* BACTERIA-NONE YEAST-NONE
EPI-0
[**2105-4-28**] 08:00PM GLUCOSE-239* UREA N-40* CREAT-1.2*
SODIUM-132* POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-15
[**2105-4-28**] 08:00PM estGFR-Using this
[**2105-4-28**] 08:00PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2105-4-28**] 08:00PM WBC-11.0 RBC-3.66* HGB-10.5* HCT-31.4* MCV-86
MCH-28.8 MCHC-33.6 RDW-14.3
[**2105-4-28**] 08:00PM NEUTS-88.7* LYMPHS-8.8* MONOS-2.3 EOS-0.1
BASOS-0.1
[**2105-4-28**] 08:00PM PLT COUNT-506*
[**2105-4-28**] 08:00PM PT-12.4 PTT-26.3 INR(PT)-1.0
.
MICRO:
[**2105-4-28**] URINE CULTURE: NEGATIVE
[**2105-4-30**] BLOOD CULTURE x2: NGTD
[**2105-5-1**] URINE CULTURE: NEGATIVE
[**2105-5-1**] BLOOD CULTURE X 2: NGTD
.
[**2105-4-30**] 3:14 pm BRONCHOALVEOLAR LAVAGE: Negative
.
Initial CXR:
Chain suture in the right lower lung denotes the region of prior
surgery, but
the details of lobectomy are not obvious from this radiographic
appearance.
There is some pleural thickening at the right base as well as
atelectatic lung
draped over the right heart extending to the diaphragm. Upper
lungs are
clear. Left lung shows diminished vascularity suggesting
emphysema. On the
lateral view, a large elliptical opacity projecting over the
cardiac
silhouette may contain the right middle lobe bronchus but I
can't tell whether
this is atelectasis or thickening in the neo-fissure after
surgery. It could
even be a mass. Evaluation would require comparison to prior
chest imaging
not available to me now and may warrant chest CT scanning.
Left lung is generally clear aside from mild linear scarring or
atelectasis
extending to minimally thickened lateral costal pleural surface.
There is no
layering pleural effusion or evidence of central adenopathy. The
heart is
mildly to moderately enlarged. Atherosclerotic calcification is
heaviest at
the origin of head and neck vessels, less so but extending
throughout the
aortic arch and descending thoracic aorta. Lateral view also
suggests
calcification in the proximal coronary arteries. Dr. [**Last Name (STitle) **] was
paged.
.
Discharge labs:
[**2105-5-12**] 05:15AM BLOOD WBC-11.1* RBC-2.63* Hgb-7.9* Hct-23.3*
MCV-89 MCH-30.1 MCHC-34.0 RDW-16.8* Plt Ct-257
[**2105-5-12**] 05:15AM BLOOD Glucose-106* UreaN-13 Creat-0.6 Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
Brief Hospital Course:
HOSPITAL COURSE:
Pt is a 79yoF with h/o lung CA s/p lobectomy at [**Hospital1 112**], on Tarceva,
COPD/bronchiectasis on home O2 (does not always use), MAC '[**99**]
s/p 18 months Rx, now with recurrent MAC, IgG deficiency on IVIG
(last on [**2105-4-8**]), HTN/CAD, saw her [**Company 2860**] provider at the end of
[**Month (only) 958**] and dx'd with PNA, who presented with dyspnea - was
treated for pneumonia initially. She was transferred to the ICU
early in her course and was intubated for hypoxic respiratory
distress. After extubation, on the floor, she developed a
second infection and was discharged to complete an additional
course of IV antibiotics in addition to a steroid taper.
.
# Dyspnea/hypoxic respiratory failure: On transfer from OSH, the
patient was continued on Vanc/Cefepime/Azithromycin for presumed
pneumonia. She developed acute respirtory distress on HD1 with
transient saturations to the 40s, which spontaneously corrected
with nebulizer treatments. She was transferred then to the MICU
for closer monitoring. Due to worsening work of breathing and
poor saturations in the mid-upper 80s on a non-rebreather, she
was eventually intubated on HD2. She had significant though
transient hypotension to the 60s systolic during the
peri-intubation period, with saturations dropping to the 40s
transiently despite an FiO2 of 100%. She stabilized rapidly
with nebulizer treatments given for high airway resistance
indices on the vent. Received a RIJ and briefly received
levophed for hypotension, which rapidly resolved by HD3.
Bronchoscopy on [**2105-4-30**] showed extremely thick and tenacious
secretions that could not be easily aspirated- so her
respiratory decompensation was attributed to plugging. Lavage
was performed though cultures, including
fungal/AFB/PCP/bacterial, were negative. Repeat bronch was
performed on [**2105-5-1**] to remove any remaining secretions, though
none were found. She was continued on broad spectrum
antibiotics- completed 5 days of azithromycin and finished an 8
day course of vancomycin/cefepime for bilateral lower lobe
opacities seen on CT, ending on [**2105-5-6**]. She was also treated
for potential COPD exacerbation with IV methylprednisone for 2
days, before starting oral steroids, and began a 10 day oral
prednisone taper at 30mg daily on [**2105-5-3**]. She was successfully
extubated on [**2105-5-3**].
.
After transfer to the floor, the patient developed hemoptysis,
occurring 2x a day, TBSP amount of frank blood each time. The
pulmonary c/s team was re-involved and a CXR was done which
showed complete LLL collapse. As such, aggressive chest PT,
ambulation, and the pt's home regimen of a cappella valve after
both ipratropium/albuterol and mucomyst nebs was done. A repeat
CXR showed continued LLL collapse, and as such, the pt was again
bronched which showed tracheal ulcers, likely from ET tube.
Vanc/cefepime were again started on [**2105-5-8**] as the repeat CXR
showed possible PNA in the right middle lung field. The patient
was discharged to complete an additional 8-day course of
vancomycin and cefepime as well as a 2-week course of
prednisone. She was scheduled for follow-up with her oncologist,
pulmonologist, and PCP.
.
# HYPERTENSION: Patient had quite labile blood pressure,
particularly while ventilated, with SBP reaching 190-200
commonly despite restarting home antihypertensives. She had a
high sedative requirement, and her pressures were felt to be
related to anxiety. She was transitioned to metoprolol 100mg
[**Hospital1 **] instead of atenolol, and continue losartan. These were
continued on the floor with good response
.
# Lung cancer: s/p lobectomy. Pt with rash per OSH records
thought to be related to Tarceva. Pt has been on treatment for 4
years now. Tarceva held while on the medicine floor, however was
restarted on discharge
.
# Coronaries: Troponin leak at OSH, pt without chest pain. Most
likely Type II, demand ischemia, given recent illness. No sx of
chest pain, SOB. Continued aspirin and simva, no anginal sx.
.
# Acute renal failure: Cr 1.2 on admission, 1.1 from OSH. Most
likely prerenal as pt appears dry, hypovolemic, and had been
diuresed at OSH. Creatinine quickly returned to baseline.
.
# Dysuria: symptoms reported on ROS, of occasional burning, no
other syx. UA suggestive of infection, though urine culture
negative. Received broad spectrum abx for pneumonia.
.
# T2DM: on no medication at home. BG high here, but likely [**2-25**]
corticosteroids. Continued on insulin sliding scale. As steroids
were tapered, patient had minimal insulin requirement and was
discharged off insulin.
.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP:
- PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **]
[**Name Initial (NameIs) **] ONCOLOGY
3. Hct check scheduled for [**5-14**] after Hct 23 on day of discharge
Medications on Admission:
MEDICATIONS on admission to [**Hospital1 2436**]:
Ativan 1mg po qhs
Atrovent 0.5mg via neb tid
Albuterol 3mg via neb tid
Acetylcysteine 10% via neb tid
Tarceva 100mg po daily
Singulair 10mg po qhs
Zocor 80mg daily
Atenolol 100mg po daily
Combivent 18mcg/103mcg
Avapro 300mg po daily
Prilosec 20mg po daily
Symbicort 2puffs [**Hospital1 **]
Flonase 50mg nu daily
vitamin D3
MVI 1 tab daily
robitussin prn
.
Abx regimen at [**Hospital1 2436**]:
Azithromycin 500mg IV qhs x1 on [**2105-4-26**], and 250mg daily
Cefepime 2g IV q24hrs started [**2105-4-26**], received one dose 4/3,
[**4-27**], [**4-28**]
Methyprednisolone 60mg IV q6hrs
Duoneb q6hrs
Albuterol 2.5mg neb q2hr prn
Omeprazole SR 20mg daily
Montelukast 10mg qhs
Irbesartan 300mg daily
Acetaminophen 650mg prn
Atenolol 100mg daily
Hycodan 5mL po x4 daily prn
Lorazepam 0.5mg po tid prn
Simvastatin 80mg po qhs
ASA 325mg po daily
Heparin 5000 units tid
Nitro inch top q6hrs prn
Symbicort 160/4.5 twice daily
Mucinex 1200mg po twice daily
Lasix 40mg IV twice daily*** - unclear if receiving
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation three times a day.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation three times a day as
needed for SOB.
4. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb
Miscellaneous three times a day: 15 minutes after
atrovent/proair. Should be followed with use of a cappella
valve.
Disp:*1 bottle* Refills:*2*
5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for secretions.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. prednisone 5 mg Tablets, Dose Pack Sig: 1-2 Tablets PO once a
day for 14 days: Take 2 pills [**5-13**] through [**5-19**]; take 1 pill (5
mg) [**5-20**] through [**5-26**], then stop. .
Disp:*21 Tablets* Refills:*0*
10. Flonase 50 mcg/Actuation Spray, Suspension Nasal
11. Tarceva 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
13. Combivent 18-103 mcg/Actuation Aerosol Inhalation
14. Symbicort Inhalation
15. Vitamin D-3 Oral
16. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Physical Therapy
Pulmonary rehab three times weekly
18. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 4 days: Last day of
antibiotics is [**2105-5-15**].
Disp:*6000 mg* Refills:*0*
19. cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q12H
(every 12 hours) for 4 days: Last day is [**2105-5-15**].
Disp:*8 gram* Refills:*0*
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. Outpatient Lab Work
Please draw CBC on [**2105-5-14**] and fax to patient's PCP [**First Name8 (NamePattern2) 1785**]
[**Last Name (NamePattern1) **].
fax: [**Telephone/Fax (1) 6808**]
phone: [**Telephone/Fax (1) 31019**]
22. lorazepam 1 mg Tablet Sig: [**1-25**] Tablet PO three times a day
as needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
COPD/bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization. You were admitted to [**Hospital1 18**] from another
hospital because of a possible pneumonia and difficulty
breathing from your COPD and bronchiectasis. You completed a
course of antibiotics, were intubated in the ICU, and underwent
a procedure called "bronchoscopy." The breathing tube was
safely removed, and you returned to the floor where the
pulmonary team continued to see you. You had some episodes of
coughing up blood, but we felt this was from your intubation and
not too concerning. You also had an X-ray that showed a
collapse of one of the lobes of your lung, so we continued
aggressive chest physical therapy to help reinflate your lung.
A repeat x-ray showed improvement. Finally, we started a
steroid taper for your breathing and you will complete an
additional 8-day course of antibiotics (last day is [**2105-5-15**]).
.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- COMPLETE the prednisone taper as prescribed
- START taking TOPROL XL 200 mg by mouth daily
- STOP taking ATENOLOL
- CHANGE aspirin to 81 mg per day
- Start Cefepime and Vancomycin (antibiotics) to be continued
until [**2105-5-15**]
.
Please follow up with your physicians as indicated below.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) 2270**] [**Last Name (NamePattern4) 90572**],MD
Specialty: Medical Oncology
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**], 4th FL
Phone: [**Telephone/Fax (1) 3468**]
When: Wednesday, [**5-20**] at 10AM
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 107181**],MD
Specialty: Primary Care
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 31019**]
When: You will be called at home with an appoinmtnet. If you do
not hear in two business days, please call above number.
We are working on a follow up appointment in Pulmonary with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2 weeks. The office will contact you at
home with an appointment. If you have not heard within 2
business days or have any questions please call [**Telephone/Fax (1) 2296**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.6",
"96.71",
"38.91",
"33.24",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15437, 15503
|
7168, 7168
|
345, 394
|
15567, 15567
|
4429, 4429
|
17002, 18165
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3442, 3572
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13110, 15414
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15524, 15546
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12038, 13087
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7185, 12012
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15718, 16979
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6929, 7145
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3587, 4410
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281, 307
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422, 2877
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4445, 6913
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15582, 15694
|
2899, 3206
|
3222, 3426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,304
| 137,801
|
1832+55324+55325
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2138-9-12**] Discharge Date: [**2138-9-19**]
Service: SURGERY
Allergies:
Tomato / Cranberry Juice / Apple Juice
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Metastatic colon cancer to liver.
Major Surgical or Invasive Procedure:
Exploratory laparotomy with segment V and VI hepatic resection.
History of Present Illness:
Mr. [**Known lastname 10239**] is an 84-year-old man with a history of colon
cancer. In [**2137-4-18**] he had an ileocecectomy performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for adenocarcinoma and 0/20 nodes were positive
for disease. He had been doing well until [**2138-7-18**], when
he developed melena associated with a supertherapeutic INR on
Coumadin. As part of the evaluation for melena, a CT scan of
the abdomen was performed on [**7-18**] and demonstrated two
lesions in Segment V and Segment VI of the liver that were new
compared to a CT scan dated [**2137-6-28**]. An
ultrasound-guided biopsy was attempted, but visualization was
impossible. The lesions were also seen on an MRI done [**7-20**], [**2137**]. His CEA is now 3.0, compared to 2.0 at the time of his
colon resection. He
says he has had epigastric discomfort that he describes as "gas
pains" and has had a weight loss of approximately 5 lbs. He
denies any fevers, chills, nausea, or vomiting. His bowel
movements are somewhat irregular, alternating between
constipation and diarrhea.
Past Medical History:
1. Colon cancer
2. Hypertension
3. Hyperlipidemia
4. Basal-cell carcinoma of the skin
5. Atrial fibrillation
6. Congestive heart failure
7. ST-elevation myocardial infarction in [**2126**]
Social History:
He denies any use or abuse of tobacco or illicit drugs. He
drinks an occasional glass of wine.
Family History:
His family medical history is significant for his mother who
died of "old age." The patient does not know any medical
history regarding his father or the cause of his death.
Physical Exam:
On Discharge:
VS: Temp 99.4, HR 87, BP 125/69, RR 18, O2 sat 92% on room air
Gen: no acute distress, alert and oriented x 3
CV: RRR, no murmurs, gallops, or rubs
Pulm: clear bilaterally
Abd: soft, nontender, nondistended, (+) bowel sounds
Wound: incision clean, dry, and intact, no erythema or drainage
Ext: no calf tenderness, no edema, 2+ pulses
Pertinent Results:
Post-operative labs while in the PACU
[**2138-9-13**] 12:57AM BLOOD WBC-10.8# RBC-3.37* Hgb-10.7* Hct-31.3*
MCV-93 MCH-31.7 MCHC-34.2 RDW-13.6 Plt Ct-164
[**2138-9-13**] 12:57AM BLOOD PT-15.5* PTT-29.8 INR(PT)-1.4*
[**2138-9-13**] 12:57AM BLOOD Glucose-117* UreaN-23* Creat-1.3* Na-143
K-4.0 Cl-111* HCO3-25 AnGap-11
[**2138-9-13**] 12:57AM BLOOD ALT-173* AST-205* AlkPhos-65 TotBili-1.1
[**2138-9-13**] 12:57AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.8*
Peak LFTs on POD2
[**2138-9-14**] 02:19AM BLOOD ALT-639* AST-486* AlkPhos-77 Amylase-72
TotBili-0.6
Discharge labs:
[**2138-9-17**] 04:34AM BLOOD WBC-4.3 RBC-2.88* Hgb-9.2* Hct-27.2*
MCV-95 MCH-32.0 MCHC-33.8 RDW-13.9 Plt Ct-143*
[**2138-9-17**] 04:34AM BLOOD Glucose-99 UreaN-31* Creat-1.4* Na-138
K-4.4 Cl-109* HCO3-22 AnGap-11
[**2138-9-17**] 04:34AM BLOOD ALT-193* AST-67* AlkPhos-105 TotBili-0.5
[**2138-9-17**] 04:34AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.7 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 10239**] was admitted on [**2138-9-12**] and underwent a successful
resection of segments V and VI of his liver for metastatic colon
cancer. He was transferred to the ICU post-operatively where a
pulmonary artery catheter was placed to better monitor his
cardiovascular status. He was extubated without difficulty.
While in the ICU he was given sips of clear liquids and his
intravenous fluids were minimized. His pain was well controlled
with intravenous morphine injections. On POD2 he was
transferred to the floor where all of his home medications were
restarted and his diet was advanced to a regular house diet. He
is currently tolerating his diet and having regular bowel
movements. His pain is well controlled on oral pain
medications. His foley catheter was discontinued and he is
voiding independently. On post-op days 5 and 6 his lateral and
medial [**Doctor Last Name **] drains were removed respectively. Over the course
of his hospital stay his LFTs peaked on POD2 and have steadily
trended downward since. A physical therapy consult was obtained
and their recommendation was discharge with home physical
therapy. He is discharged in good condition with appropriate
follow up and home services.
Medications on Admission:
1. Lasix 20mg daily
2. Lopressor 50mg daily
3. Protonix 40mg daily
4. Diovan 80mg daily
5. Flonase 1 puff each nostril daily
6. ASA 81mg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (LF) 10246**], [**First Name3 (LF) 10247**]
Discharge Diagnosis:
Metastatic colon cancer to the liver.
Discharge Condition:
Good
Discharge Instructions:
Call your physician if you experience:
- fever > 101.5
- persistent abdominal pain not relieved by your medication
- inability to eat or drink
- increasing redness or drainage from your incisions
- yellowing of your skin or your eyes
- chest pain or shortness of breath
- any other concerns you may have
Continue to take all of your home medications.
Do not swim or take tub baths. You may shower.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week. Call his office at ([**Telephone/Fax (1) 10248**] to schedule your appointment.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-10-3**]
1:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2138-11-5**] 10:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-12-10**] 10:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Name: [**Known lastname 1442**],[**Known firstname **] Unit No: [**Numeric Identifier 1443**]
Admission Date: [**2138-9-12**] Discharge Date: [**2138-9-19**]
Date of Birth: [**2053-10-15**] Sex: M
Service: SURGERY
Allergies:
Tomato / Cranberry Juice / Apple Juice
Attending:[**First Name3 (LF) 48**]
Addendum:
Mr. [**Known lastname **] [**Last Name (Titles) 1444**] concerns to the night nursing staff on
[**2138-9-17**] about going home alone. Due to these concerns he was
screened by various rehabilitation facilities on [**2138-9-18**] and was
offered a bed by one of them. He opted to decline this bed
offer and requested to go to a rehab facility closer to his
home. On [**2138-9-19**] he was offered a bed by [**Date Range 1445**] [**Location 1446**], which he accepted. He is discharged in good condition.
He is to follow up with Dr. [**Last Name (STitle) **] on [**2138-9-24**] at 10:40am.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (LF) 1445**], [**First Name3 (LF) 1447**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2138-9-19**] Name: [**Known lastname 1442**],[**Known firstname **] Unit No: [**Numeric Identifier 1443**]
Admission Date: [**2138-9-12**] Discharge Date: [**2138-9-19**]
Date of Birth: [**2053-10-15**] Sex: M
Service: SURGERY
Allergies:
Tomato / Cranberry Juice / Apple Juice
Attending:[**First Name3 (LF) 48**]
Addendum:
Mr [**Known lastname **] carries a diagnosis of CHF.
An echo completed on [**2138-9-13**] in preparation for liver resection
showed an ejection fraction of 25-30%. The left atrium is mildly
dilated. Left ventricular wall thicknesses and cavity size are
normal. There is moderate regional left ventricular systolic
dysfunction with akinesis of the inferior wall and inferior
septum and moderate hypokinesis of the remaining segments. The
remaining left ventricular segments are hypokinetic. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2137-6-21**], the
findings are similar.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (LF) 1445**], [**First Name3 (LF) 1447**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2138-10-15**]
|
[
"998.2",
"197.7",
"427.31",
"V45.81",
"428.0",
"401.9",
"412",
"E878.6",
"272.4",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.22",
"46.73",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9257, 9493
|
3328, 4570
|
278, 344
|
5466, 5473
|
2381, 2931
|
5922, 7504
|
1821, 1998
|
4763, 5278
|
5405, 5445
|
4596, 4740
|
5497, 5899
|
2947, 3305
|
2013, 2013
|
2027, 2362
|
205, 240
|
372, 1478
|
1500, 1691
|
1707, 1805
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,293
| 199,898
|
34288
|
Discharge summary
|
report
|
Admission Date: [**2134-8-16**] Discharge Date: [**2134-8-31**]
Date of Birth: [**2061-6-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Refractory Hypertension
Major Surgical or Invasive Procedure:
bronchoscopy with biopsy
History of Present Illness:
This is a 73 year-old female with a history of hypertension,
coronary artery disease, migraine headaches, who was transferred
from [**Hospital3 10377**] hospital for neurosurgical
evaluation after a right parietal intracranial hemorrhage was
noted on CT scan performed for evaluation of headache. Patient
presented initially due to persistent headache for 3 weeks. She
denied any focal weakness, gait instability, visual disturbance,
dysarthria, nausea, vomitting, or any other symptoms. She
initially felt the headache was secondary to migraine and took
Fioricet with minimal relief. Eventually, she let her primary
care physician know, and he referred her to the emergency room.
At [**Hospital3 417**] ED, right parietal hemorrhage was noted and
patient was referred for neurosurgical evaluation. She was also
treated with labetalol 5mg IV x 4. At [**Hospital1 18**], Preliminary [**Location (un) 1131**]
of repeat head CT demonstrated right parietal calcifications,
with no cerebral oedema, mass effect, or midline shift. Patient
continued to have marked hypertension (190/50) in the emergency
room and was started on labetalol continuous infusion. She was
admitted to MICU for further management of refractory
hypertension. She reports she has been adherent to all her
anti-hypertensive medications.
.
In the ED, initial blood pressure was 205/85. She received total
labetalol IV total of 20mg, then started on continuous infusion.
She was also given potassium chloride 50mEq for hypokalemia and
was admitted for further management. Neurosurgery was consulted
and recommended conservative management, blood pressure control,
and no need for seizure prophylaxis.
.
On review of systems, patient denies any fevers, chills, chest
discomfort, shortness of breath, abdominal pain, diarrhea,
conspipation, lower exremity oedema, dysuria, or rashes.
Past Medical History:
#. Hypertension
#. Coronary artery disease, S/P MI in [**2130**]
#. Migraine headaches
#. Hyperlipidemia
#. Hypothyroidism secondary to partial thyroidectomy for nodule
#. Low-back surgery
Social History:
The patient lives at home alone in [**Hospital1 1474**]. She is divorced,
with 5 children whom live locally. She previously worked for
[**Company 78921**] but is now retired.
Tobacco: [**1-13**] pack daily x 50 years, still smoking
ETOH: No use
Illicts: No use
Family History:
Father - died age 58 MI
Brother - died age 58 MI
Mother - died age 39 ??
Physical Exam:
On admission to the ICU , PE was as follows:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Laboratories [**8-17**]: Notable for potassium of 2.5 and
creatinine of 1.5. ECG: Sinus rhythm at 70 bpm, normal axis,
normal PR, QRS intervals. QT is 452mm intervals, normal R-wave
progress, LVH, no ST or T-wave changes, Q-waves in inferior
leads.
Imaging:
Head CT [**8-17**]:
IMPRESSION: Three rounded foci, 1-2 mm in size within the right
frontoparietal region and a second focus in the left temporal
lobe most likely represent calcium, possibly sequelae from prior
infection or inflammation. These calcifications could also be
associated with an underlying vascular abnormality. If
clinically indicated, an MRI could be performed to further
characterize this finding.
Air-fluid level within the left maxillary sinus may represent
acute sinusitis. Clinical correlation recommended.
_____
[**2134-8-18**] Radiology MRA CHEST W&W/O CONTRAS
IMPRESSION:
1. Right lung mass with subcarinal and right paratracheal
lymphadenopathy,
highly suspicious for metastatic lung cancer. Dedicated
evaluation with chest CT is recommended.
2. Severe narrowing of the origin and 3.5 cm distal to the
origin of the left subclavian artery. A small filling defect at
the origin of the left
subclavian may represent thrombus superimposed on athersclerotic
plaque.
3. Moderate-to-severe stenosis of the left common carotid
origin.
4. Probable aortic stenosis and regurgitation. Further
evaluation with
echocardiography is recommended.
5. Atrophic left kidney.
6. Small vertebral lesion, which may represent a hemangioma but
not fully
characterized on this exam.
_____
[**2134-8-19**] ECHO: normal biventricular systolic function
_____
[**2134-8-19**] Radiology CT CHEST W/CONTRAST
IMPRESSION:
1. Large heterogeneous mass in the right upper and middle lobes
with
associated hilar and mediastinal lymphadenopathy, highly
concerning for
bronchogenic carcinoma. No pleural effusion or chest wall
invasion.
2. Additional pulmonary nodules in the right middle and lower
lobes,
measuring up to 8 mm each.
3. Small segmental pulmonary embolus within the anterior segment
of the right lower lobe pulmonary artery.
4. Extensive atherosclerotic disease within the aorta and
moderate
calcification in the LAD.
5. Moderately severe centrilobular emphysema.
6. Left adrenal hyperplasia without focal nodule.
_____
[**2134-8-20**] Radiology MRA ABDOMEN W&W/O CONTR
IMPRESSION:
Bilateral high-grade stenoses of the proximal renal arteries,
left greater
than right, with bilateral renal atrophy, also left greater than
right. The function of the left kidney is likely quite imparied
and could be quantified with nuclear medicine, if needed.
_____
FNA, right paratracheal lymph node:
Positive for malignant cells, consistent with metastatic
adenocarcinoma.
_____
Brief Hospital Course:
She is a 73 year-old female with a history of hypertension,
hyperlipidemia, coronary artery disease and previous stroke who
presents with 3 week course of headache and intracranial
densities concerning for ICH vs. previous insult.
1. NON SMALL CELL LUNG CANCER -patient originally transferred
for evalutation of hypertensive urgency, headache, and
?intracranail bleed. Due to marked blood pressure differential,
MRI/A was obtained to rule out dissection, which ultimately
diagnosed a RML lung mass. Patient underwent bronchoscopy with
biopsy confirming adenocarcinoma. Oncology was consulted. MRI
head was obtained for staging purposes and to follow up
?calcifications noted on head ct, now with new diagnosis of lung
cancer. MRI showed possible leptomeningeal metastases.
Outpatient follow up in Thoracic [**Hospital **] clinic was arranged,
and she will be called with an appointment time. She was seen by
the palliative care service while she was inpatient to address
goals of care. She was DNR/DNI throughout her stay. She will not
need a PET/CT given her brain metastases, and presumed Stage IV
diagnosis.
2. RENAL ARTERY STENOSIS -Patient initially admitted with
difficult to control blood pressure and evidence of atrophic
kidney. MRI abdomen confirmed high grade renal artery stenosis,
Left greater than Right. Her blood pressure was eventually
controlled on 3 agents, however, due to impending nephrotoxic
chemotherapy agents, and plan for long term anticoagulation,
consideration was given to intervention on arterial stenosis
this admit, while she was on a heparin drip. Cardiology was
consulted and evaluation and intervention was recommended, on
both her stenosed/occluded subclavian arteries and bilateral
renal arteries, to 1. provide better information of her true
central pressures, since hypertensive urgency was her presenting
complaint and 2. to attempt to maximize her renal preservation
in the setting of probable nephrotoxic chemotherapy. Patient and
family were agreeable to proceding with procedure, which patient
underwent [**2134-8-26**], and had stent placed in her subclavian and
renal arteries. She had a small hematoma after the procedure
without bruit.
3. PULMONARY EMBOLISM - small segmental pulmonary embolism was
identified on chest ct. Patient remained hemodynamically stable
and had no respiratory symptoms. Heparin drip was initiated
without complication, and continued until possible inpatient
procedures were completed. Renal function was borderline for
consideration of lmwh for discharge, however Ms. [**Known lastname 15532**] [**Last Name (Titles) 3139**] attempts at home management and administration,
therefore, she remained hospitalized on heparin drip until
coumadin, INR therapeutic. At time of discharge, she had an INR
of 3.3, and was instructed to hold one dose, and restart at a
lower dose of 3 mg daily. She had hematuria while on heparin and
coumadin, which resolved with the discontinuation of the
heparin.
4. CKD (III) -kidney function remained stable during admission,
patient found to have renal artery stenosis as discussed above.
patient underwent cath/stenting.
5.CAD(NATIVE VESSEL) -asymptomatic during hospitalization, no
chest pain in setting of hypertensive urgency, asa/bb/statin
continued.
Medications on Admission:
Metoprolol 50mg [**Hospital1 **]
Levothyroxine 100mcg daily
HCTZ 50mg daily
Atorvastatin 10mg daily
Potassium Chloride
Fioricet PRN for Migraine hx
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 2 weeks: take
aspirin 81 mg a day while you are taking plavix. .
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: start taking this
dose once you are no longer taking plavix.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
Start taking this dose tomorrow night. Please have your INR
checked on Thursday or Friday.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
NON SMALL CELL LUNG CANCER
HTN, MALIGNANT/REVOVASCULAR
PULMONARY EMBOLISM
CAD (NATIVE VESSEL)
CKD III
RENAL ARTERY STENOSIS
HEMATURIA
ACUTE BLOOD LOSS ANEMIA
Discharge Condition:
Stable
Discharge Instructions:
You had initially gone to [**Hospital3 10377**] Hospital for a
persistent headache. Due to concern for a possible bleed in
your brain, you were transferred to [**Hospital1 827**]. After a repeat CT showed that you did not have
an acute bleed in your brain, you were transferred to our
intensive care unit for the treatment of high blood pressure,
which was discovered in the emergency department. During the
course of your evaluation, a lung mass and a blood clot in the
lung were discovered as well as severe narrowing of your renal
arteries, subclavian arteries, and carotid artery. Further
evaluation by CT, MRI, and biopsy of the lung mass led to the
diagnosis of non-small cell lung cancer that showed evidence of
spread to other parts of your body. You were being followed by
the Oncology service and Pulmonary service for this during your
stay.
.
You were then transferred to the Cardiology service for stenting
of your narrowed right renal artery and left subclavian artery.
This was completed without complications, and your blood
pressure improved following the stenting of your arteries.
.
You were given medication for your pulmonary embolus. Please
watch for signs of increased bleeding, shortness of breath,
nausea, chest pain, or increased confusion.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **] on
[**Last Name (LF) 766**], [**9-6**] at 12:45 pm.
You should go to clinic on Thursday or Friday to have your INR
checked. Dr.[**Name (NI) 65062**] office will call you and set this up.
Today you should hold your coumadin dose, and tomorrow start
taking 3 mg daily.
You will need to follow up with oncology and with
radiation-oncology to discuss treatment of your cancer. The
number for thoracic oncology clinic is [**0-0-**]. They will
call you to make the appointment.
You will need to follow up with Dr. [**First Name (STitle) **] in cardiology in [**3-16**]
for the stent that was placed in your artery. The number to call
to make this appointment is [**Telephone/Fax (1) 42006**].
|
[
"305.1",
"E879.8",
"196.1",
"404.00",
"415.11",
"447.1",
"285.1",
"433.10",
"599.7",
"414.01",
"244.0",
"198.3",
"E849.7",
"162.8",
"440.1",
"346.90",
"424.1",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"00.41",
"39.50",
"40.11",
"00.46",
"33.27",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
10956, 10962
|
6365, 9631
|
338, 365
|
11164, 11173
|
3598, 6342
|
12492, 13262
|
2751, 2825
|
9830, 10933
|
10983, 11143
|
9657, 9807
|
11197, 12469
|
2840, 3579
|
275, 300
|
393, 2242
|
2264, 2457
|
2473, 2735
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,357
| 140,040
|
18061
|
Discharge summary
|
report
|
Admission Date: [**2105-2-24**] Discharge Date: [**2105-3-4**]
Date of Birth: [**2022-4-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Transfer for eval of aortic stenosis
Major Surgical or Invasive Procedure:
[**2105-2-26**] - CABGx1 (Vein->Diagonal artery), AVR (23mm pericardial
valve)
[**2105-2-25**] - Cardiac Catheterization
History of Present Illness:
This is an 82-year-old male with a history of hyperlipidemia,
hypertension , aortic stenosis and CAD. He underwent a cardiac
catheterization on [**2104-9-16**] where he was found to have a
90% lesion in his proximal large diagonal branch and a 50%
lesion in the distal RCA. He subsequently had a stent to his
diag . He returned to the [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **] on [**2105-2-16**] by ambulance
after he almost fell due to dizziness. He had also been having
worsening shortness of breath for approximately 2 weeks. He
was found on CXR in the ED to have pneumonia and CHF. His BNP
was 3466 on admission. He was admitted, diuresed and given
antibiotics, which he finished prior to discharge. He was felt
to be stable and essentially baseline upon discharge with marked
improvement. A repeat echo at [**Hospital1 46**] showed a new EF of 20% and
severe AS although echos have traditionally overestimated
gradient and underestimated his valve area. Case in point, an
echo in [**7-18**] showed: concentric LVH, LVEF 60%. a peak gradient
of 77 mmHG, mean of 50 mmHG, maximum velocity 4.4 m/s,[**Location (un) 109**]
0.5cm2. However, cardiac catheterization in [**9-17**] showed a peak
to peak gradient of 20 mm Hg and a calculated aortic valve area
of 1.24 cm2. Thus at that time was not referred to aortic valve
replacement. He was referred here from [**Hospital1 46**] for evalation of
his coronaries and his valve area, as either may be the cause of
his newly worsened heart failure.
The patient notes slowly progressive decrease in functional
status, with DOE after ascending one flight of stairs. The
patient also endorses occasional PND without orthopnea. He also
notes positional lightheadedness but no syncope or exertional
lightheadness. He denies chest discomfort, either exertional or
at rest. He has previously been scheduled for possible AVR but
has failed to meet criteria based on his catherizations.
Past Medical History:
CAD, s/p LAD/D1 stenting in [**2100**] and BMS to D1 in [**9-17**]
Hypertension
Hyperlipidemia
Aortic stenosis
Mild Renal artery stenosis
GERD
Prostate cancer s/p XRT approximately four to five years ago
Right knee replacement
Appendectomy
Skin cancer resection
Bilateral Cataract surgery
Possible hemorrhoids- occasional blood noted on toilet tissue
? diastolic dysfuction
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient is widowed
and lives alone. He has three children who live out of state.
His emergency contact is his son [**Name (NI) **] at [**Telephone/Fax (1) 49978**]. His
brother in law is [**Name (NI) **] [**Name (NI) 5279**]. His home number is [**Telephone/Fax (1) 49979**].
-Patient worked as an engineer.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T: 96.8 P: 64 BP: 155/95 O2: 96% RA
Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect
appropriate. Mildly cachectic.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP not appreciated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, minimal S2. Soft, mid peaking 1/6 SEM heard
throughout precordium. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses: Parvus et Tardus
Right: Carotid 2+ Femoral 2+ Popliteal 0+ DP 1+ PT 0+
Left: Carotid 2+ Femoral 2+ Popliteal 0+ DP 1+ PT 0+
Pertinent Results:
[**2105-3-4**] 05:25AM BLOOD WBC-8.9 RBC-3.72* Hgb-11.2* Hct-33.0*
MCV-89 MCH-30.1 MCHC-33.9 RDW-14.6 Plt Ct-193
[**2105-3-3**] 02:02AM BLOOD WBC-8.0 RBC-3.47* Hgb-11.0* Hct-30.4*
MCV-88 MCH-31.6 MCHC-36.0* RDW-14.7 Plt Ct-144*
[**2105-3-4**] 05:25AM BLOOD PT-13.6* INR(PT)-1.2*
[**2105-3-4**] 05:25AM BLOOD Plt Ct-193
[**2105-3-3**] 02:02AM BLOOD PT-13.4 PTT-33.9 INR(PT)-1.1
[**2105-3-2**] 03:18PM BLOOD PT-12.9 PTT-33.6 INR(PT)-1.1
[**2105-3-4**] 05:25AM BLOOD Glucose-133* UreaN-29* Creat-1.0 Na-140
K-3.9 Cl-100 HCO3-33* AnGap-11
[**2105-2-25**] 05:40AM BLOOD ALT-22 AST-29 LD(LDH)-223 AlkPhos-83
Amylase-67 TotBili-1.6*
TTE:
The left and right atrium are moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe global left ventricular hypokinesis (LVEF = 25 %).
Systolic function of apical segments is relatively preserved.
The estimated cardiac index is depressed (<2.0L/min/m2). No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size is normal with borderline normal free
wall function. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <<0.8cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets and supporting structures are
mildly thickened. Mild to moderate ([**2-11**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Normal left
ventricular cavity size with severe global hypokinesis with
relative sparing of apical segments (suggestive of a
non-ischemic etiology). Mild-moderate mitral regurgitation.
Pulmonary artery systolic hypertension.
CXR:
The only comparison study is from [**2100-6-29**]. As on this
examination, there is marked hyperexpansion of the lungs with
enlargement of the cardiac silhouette and tortuosity of the
aorta. Mild prominence of interstitial markings could reflect
chronic lung disease, elevated pulmonary venous pressure, or
both. Some atelectatic change is seen at the left base. Blunting
of both costophrenic angles is consistent with bilateral pleural
effusions or scarring from previous inflammatory changes.
Specifically, no evidence of acute pneumonia.
[**2105-2-25**] Chest CT Scan
1) Significant calcification of the aortic valve and to a lesser
degree of the aortic annulus. However, the calcification
bypasses the ascending aorta by at least 11 cm.
2) A lesion in the right lobe of the liver requires evaluation.
Consider a dedicated liver CT with contrast or MRI.
3) Calcified cyst-like structure in the spleen. The differential
would include a traumatic cyst, epidermoid, or parasitic cyst.
Evaluation with US or Abdominal CT is recommended.
4) Prominent interstitial thickening seen in the lung bases left
more than right which could be attributed to infection and/or
aspiration. Please clinically correlate.
[**2105-2-26**] ECHO
PRE-BYPASS:
1. The left atrium is dilated. Moderate spontaneous echo
contrast is seen in the body of the left atrium.
2. The left atrial appendage emptying velocity is depressed
(<0.2m/s).
3. A patent foramen ovale is present. A left-to-right shunt
across the interatrial septum is seen at rest.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 15-20 %).
5. Right ventricular chamber size is normal. with moderate
global free wall hypokinesis.
6. The aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The ascending aorta is
moderately dilated. There are simple atheroma in the aortic
arch. The descending thoracic aorta is moderately dilated. There
are simple atheroma in the descending thoracic aorta. Mild
Spontaneous Echo contrast is noted in the Descending aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Trace aortic regurgitation is
seen.
8. The mitral valve leaflets are moderately thickened. There is
mild valvular mitral stenosis (area 1.5-2.0cm2), no flow
proximal acceleration. Unable to demonstrate a gradient across
the mitral valve.. Mild (1+) mitral regurgitation is seen.
9. The tricuspid valve leaflets are mildly thickened.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including epinephrine, milrinone
and phenylephrine infusions. The patient is being AV paced.
1. . A well-seated bioprosthetic valve is seen in the aortic
position with normal leaflet motion and gradients (mean gradient
= 5 mmHg). The valve is well seated; there is no aortic
regurgitation or paravalvular leak.
2. Right ventricular function has modestly improved. Left
ventricular function has also modestly improved with LVEF
20-25%.
3. Aortic contours are intact post-decannulation.
4. No intervention to the mitral valve. Post-bypass, Mitral
valve leaflets with improved excursion. Mean gradient across the
valve 2.3mmHg. No proximal flow acceleration.
Brief Hospital Course:
Mr. [**Known lastname 1007**] was admitted to the [**Hospital1 18**] on [**2105-2-24**] for further
management of his aortic valve disease. He underwent a cardiac
catheterization which revealed single vessel coronary artery
disease and severe aortic stenosis. Given the severity of his
disease, the cardiac surgical service was consulted for surgical
management. Mr. [**Known lastname 1007**] was worked up in the usual preoperative
manner. On [**2105-2-26**], Mr. [**Known lastname 1007**] was taken to the operating room
where he underwent coronary artery bypass grafting to one vessel
and an aortic valve replacement with a tissue prosthesis. Please
see operative report for details. Postoperatively he was taken
to the cardiac surgical intensive care uniit for monitoring. On
postoperative day one Mr. [**Known lastname 1007**] [**Last Name (Titles) 5058**] neurologically intact and
was extubated. He developed atrial fibrillation which was
treated with amiodarone and was started on coumadin. On
postoperative day three, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength an mobility. He
was ready for discharge to rehab on POD #6.
Medications on Admission:
Medications on Transfer:
Toprol XL 12.5 mg daily
Lasix 20 mg 1 tab daily
Nebs q 8 hrs
KCL 20 mEq daily
Protonix 40 mg [**Hospital1 **]
Diovan 80 mg [**Hospital1 **]
Lovenox 30 mg daily
Plavix 75mg daily
Zocor 10mg daily
Norvasc 5mg daily
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
2 doses: Check INR [**3-6**], goal INR 2-2.5 for atrial fibrillation.
14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): to sacrum.
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center of [**Location (un) 3320**]
Discharge Diagnosis:
CAD/AS
Hyperlipidemia
Hypertension
Mild renal artery stenosis
GERD
Prostate cancer s/p XRT
right knee replacement
Appendectomy
Skin cancer resection
Bilateral cataract surgery
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact surgeon at ([**Telephone/Fax (1) 4044**] with any wound issues.
2) Report any fever greater then 100.5
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
one week.
4) No driving for 1 month.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 5310**] in 2 weeks. [**Telephone/Fax (1) 5315**]
Follow-up with Dr. [**First Name (STitle) 45874**] in [**3-15**] weeks. [**Telephone/Fax (1) 49980**]
Call all providers to make appointments.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2105-3-4**]
|
[
"424.1",
"401.9",
"427.31",
"V15.3",
"428.31",
"V43.65",
"V10.83",
"V10.46",
"272.4",
"997.1",
"440.1",
"998.11",
"414.01",
"V45.82",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"89.60",
"35.21",
"39.61",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
12881, 12961
|
9782, 11079
|
308, 431
|
13181, 13190
|
4324, 9759
|
13623, 14065
|
3269, 3351
|
11369, 12858
|
12982, 13160
|
11106, 11106
|
13214, 13600
|
3366, 4305
|
232, 270
|
459, 2419
|
11131, 11346
|
2441, 2817
|
2833, 3253
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,727
| 145,929
|
53100
|
Discharge summary
|
report
|
Admission Date: [**2192-7-11**] Discharge Date: [**2192-7-16**]
Date of Birth: [**2134-4-9**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
revision Right total hip replacement - acetabular component
History of Present Illness:
Mr [**Known lastname **] had a right total hip replacement in [**2177**]. He did well
until the components failed in [**2188**]. At that point, he had a
revision right total hip arthroplasty of all components. He
continued to have pain and xray demonstrated mild to moderate
protrusion of the acetabular components into the pelvis. For
this, he elects for definitive treatment.
Past Medical History:
HTN, dyslipid, ischemic heart disease, h/o NSTEMI, OSA, OA,
gout, MS, h/o stroke, glaucoma, restless leg, psoriasis, h/o
MRSA
Social History:
nc
Family History:
nc
Physical Exam:
well appearing 58 year old male
alert and oriented
no acute distress
RLE:
-dressing-c/d/i
-incision-c/d/i, no erythema, minimal serosanguinous drainage
-+AT, FHL, [**Last Name (un) 938**]
-SILT
-brisk cap refill
-calf-soft, nontender
-NVI distally
Pertinent Results:
[**2192-7-11**] 04:20PM BLOOD WBC-6.6 RBC-4.19* Hgb-13.1* Hct-40.2
MCV-96 MCH-31.2 MCHC-32.5 RDW-13.5 Plt Ct-228
[**2192-7-11**] 08:25PM BLOOD WBC-12.0*# RBC-3.35* Hgb-11.0* Hct-32.8*
MCV-98 MCH-32.8* MCHC-33.6 RDW-14.1 Plt Ct-164
[**2192-7-12**] 03:56AM BLOOD WBC-10.9 RBC-2.85* Hgb-9.4* Hct-27.1*
MCV-95 MCH-32.8* MCHC-34.5 RDW-14.1 Plt Ct-171
[**2192-7-15**] 06:00AM BLOOD WBC-11.1* RBC-3.30* Hgb-9.9* Hct-29.9*
MCV-91 MCH-30.0 MCHC-33.0 RDW-16.3* Plt Ct-225
[**2192-7-13**] 06:50AM BLOOD Glucose-102* UreaN-7 Creat-0.6 Na-138
K-3.4 Cl-101 HCO3-27 AnGap-13
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. [**Hospital Unit Name 153**] admission - Because the patient has multiple
co-morbidities and lost a fair amount of blood intraoperatively,
Mr [**Known lastname **] was initially admitted to the [**Hospital Unit Name 153**] for observation. He
remained intubated for approximately 18 hours after surgery. He
was hypotensive. He responded well to blood transfusion and
fluid resusitation. He was extubated and doing well when
transferred to 12 [**Hospital Ward Name **] on POD 1.
2. Post-op delerium - on the night of POD 1 and into POD 2, Mr
[**Known lastname **] was noted to be paranoid, confused, and anxious. He was
unable to verbalize the causes for this. Consults for medicine
and social work were called. His medication was adjusted -
psychotropics and narcotics were minimized. On POD 3, he was
clear and coherent.
Otherwise, pain was initially controlled with IV dilaudid
followed by
a transition to oral pain medications on POD#2. The patient
received lovenox for DVT prophylaxis pre-operatively for one
week prior to surgery and was restarted on this on the morning
of POD#1. The foley was removed on POD#3 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity. Posterior hip precautions.
No active abduction x 6 weeks
Mr [**Known lastname **] is discharged to rehab in stable condition with
prescriptions for lovenox and dilaudid.
Medications on Admission:
atenolol, baclofen, celexa, clonazepam, folic acid, lisinopril,
neurontin, nicotine patch, provigil, timolol eye drops, alphagan
eye drops, plavix, simvastatin
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
Disp:*21 syringe* Refills:*0*
2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
13. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
14. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO daily ().
15. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
16. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
17. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
19. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day:
**please resume once you've finished your course of lovenox**.
20. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
21. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 6560**] Care & Rehab Center - [**Location (un) 86**]
Discharge Diagnosis:
failed Right Total Hip replacement - acetabular component
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed. DO
NOT RESUME PLAVIX UNTIL YOU'VE COMPLETED YOUR COURSE OF LOVENOX.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for three weeks
after leaving the hospital to help prevent deep vein thrombosis
(blood clots). After completing the lovenox, please resume your
home dose of plavix.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four week
checkup. Please place a dry sterile dressing on the wound each
day if there is drainage, otherwise leave it open to air. Check
wound regularly for signs of infection such as redness or thick
yellow drainage.
Staples will be removed by the rehab facility in two weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. No strenuous exercise or heavy lifting until follow
up appointment. Posterior hip precautions. NO ACTIVE ABDUCTION
X 6 WEEKS.
Physical Therapy:
Weight bearing as tolerated on the operative extremity.
Posterior hip precautions. NO ACTIVE ABDUCTION X 6 WEEKS. No
strenuous exercise or heavy lifting until follow up appointment
Treatments Frequency:
Please keep your incision clean and dry. It is okay to shower
five days after surgery but no tub baths, swimming, or
submerging your incision until after your four week checkup.
Please place a dry sterile dressing on the wound each day if
there is drainage, otherwise leave it open to air. Check wound
regularly for signs of infection such as redness or thick yellow
drainage.
Staples will be removed by the rehab facility in two weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2192-8-10**] 10:40
Completed by:[**2192-7-16**]
|
[
"333.94",
"327.23",
"V02.54",
"340",
"285.1",
"E878.1",
"274.9",
"412",
"731.3",
"V12.54",
"276.52",
"458.29",
"996.42",
"293.0",
"414.01",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.71",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6361, 6454
|
1868, 4270
|
331, 393
|
6556, 6556
|
1284, 1845
|
10387, 10619
|
990, 994
|
4480, 6338
|
6475, 6535
|
4296, 4457
|
6739, 8924
|
1009, 1265
|
9720, 9903
|
9925, 10364
|
277, 293
|
8936, 9702
|
421, 804
|
6571, 6715
|
826, 954
|
970, 974
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,394
| 140,942
|
51562
|
Discharge summary
|
report
|
Admission Date: [**2166-8-20**] Discharge Date: [**2166-9-12**]
Date of Birth: [**2113-10-15**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Toprol Xl / Lipitor / Levofloxacin / Compazine /
Vancomycin
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
endotracheal intubation and extubation
central venous catheter placement
History of Present Illness:
55 yo F with h/o CAD s/p CABG, HTN, DM2, PVD, CRI with h/o
episodes of ARF, h/o hyperkalemia BIBA due to lethary. Patient
was feeling generally unwell since discharge from [**Hospital1 18**] for
episode of ARF with Cr was 2.3 (from baseline 1.1) and K 6.8 and
LE pain [**12-26**] PVD. Per her son who has been staying with her since
her discharge she was ambulatory. He reports that 2-3 days ago
she started to become more lethargic, noted to be sleeping a
lot, falling asleep during conversation then waking up and
mumbling inconherently. Her visiting nurse suggested she seek
medical attention two days prior but patient refused to come
back to the hospital. Last night patient noted to be worsening
per her son, c/o persistent pain, more lethargic, unable to
walk, having to carry her to the bathroom and to the bedroom.
This AM when nurse came they convinced her to come to ED via
EMS. Per her son she has been eating a little, drinking water,
urinating normally. He has not noted any fevers, chills, cough,
nausea/vomiting or diarrhea.
.
In the ED, VS: 95.0 60 120/70 16 100% NRB. Given 0.4 narcan with
no response. K hemolyzed but elevated to 7.8 given
insulin/dextrose, calicum and kayexalate with improvement to
5.6. Renal consult placed, no need for urgent dialysis. Given 1
gram ceftriaxone for UTI. CPAP noninvasive ventilation
attempted. ABGs 7.24-7.26/55-64/100-200. Given Solumedrol 125 mg
x 1, Albuterol/Atrovent nebs.
.
Upon arrival to the ICU, patient off CPAP, sating 90-92% 4->2L
NC. Very difficult to arrouse, requires frequent prompting,
states she felt unwell since discharge from hospital, denies CP,
sob, denies pain.
Past Medical History:
1. PVD: prior work-up at the [**Hospital1 112**]
2. CAD s/p CABG in [**2160**] at [**Hospital1 112**]
3. DM 2
4. h/o CVA - c/b residual numbness/weakness of left arm and leg
5. HTN
6. Hyperlipidemia
7. Elevated LFTs, unknown etiology (?NASH)
Social History:
She works for the Department of Mental Retardation. She lives
alone. Her son lives in the same building. She smokes [**11-25**] ppd
(used to be more) for ~15 years. She denies a history of
alcohol/drug use.
Family History:
(+)HTN, DM; no FH cancer
Physical Exam:
VS: 97.0 BP 108/89 HR 70 RR 20 90% 2L
Gen: obese, somnolent, opens eyes with repeated prompting, speak
in one-two word sentences, falls asleep, snoring, mumbling
occasionally
Neck: obese, supple, unable to asses JVD
Heent: marked periorbital edema, PERRL, anicteric, MMM
Chest: Diffuse rhonchi, no wheezing/rales
CVS: nl S1 S2, distant heart sounds, no m/r/g appreciated
Abd: obese, distended but soft, no HSM appreciated, no
rebound/guarding, BS +
Ext: warm, dry atrophic skin with several crusted ulcerations
(all appear old), [**12-27**]+ pitting edema to below the knee
Neuro: A+Ox3 with prompting, moves all four extremities, not
compliant with exam due to somnolence, responds to painful
stimuli/prompting, appropriate to questions, mumbles
intermittently
Pertinent Results:
[**2166-8-20**] 06:30PM GLUCOSE-88 UREA N-50* CREAT-4.7* SODIUM-135
POTASSIUM-5.6* CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2166-8-20**] 06:30PM ALT(SGPT)-81* AST(SGOT)-98* ALK PHOS-158*
AMYLASE-58 TOT BILI-0.6
[**2166-8-20**] 06:30PM ALBUMIN-3.3* CALCIUM-9.4
[**2166-8-20**] 06:30PM TSH-1.2
[**2166-8-20**] 05:02PM GLUCOSE-154* LACTATE-1.4 NA+-130* K+-6.1*
CL--99*
[**2166-8-20**] 04:45PM WBC-7.9 RBC-2.92* HGB-8.8* HCT-27.5* MCV-94
MCH-30.2 MCHC-32.0 RDW-15.7*
[**2166-8-20**] 04:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-8.9
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Micro:
RPR non-reactive
Blood Cultures [**2166-8-22**]: negative
.
[**2166-8-19**]
CT head: There is no acute intracranial hemorrhage. There is no
mass effect or shift of normally midline structures. The
ventricles, sulci, and cisterns are unremarkable. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. Visualized paranasal
sinuses are clear. The orbits are unremarkable. No acute
fractures are identified.
.
TTE
[**2166-8-22**]: The left atrium is moderately dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (ejection fraction 40-50 percent) secondary to
hypokinesis of the basal segments of the inferior and posterior
walls. Tissue velocity imaging E/e' is elevated (>15) suggesting
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. There is moderate
aortic valve stenosis. Mild to moderate ([**11-25**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial 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.
Compared with the findings of the prior report (images
unavailable for review) of [**2159-9-25**], moderate aortic
stenosis is now present.
.
[**2166-8-21**]: RIJ HD catheter placement: Uncomplicated ultrasound and
fluoroscopically guided triple lumen temporary dialysis catheter
placement via the right internal jugular vein approach with the
tip positioned in the right atrium.
.
[**2166-8-25**]: RUQ ultrasound: The study is significantly limited
secondary to patient body habitus. Limited views of the liver
show no focal lesions. The common bile duct is presumed to be
patent and measures approximately 2 mm. The polyp seen within
the gallbladder on the previous exam is not seen on today's
study. Evaluation of the main portal vein with Doppler shows
hepatopetal flow, appropriately, but there are periods of
intermittent neutral flow which could reflect portal
hypertension. There is some fluid present in Morison's pouch.
Brief Hospital Course:
In brief, the patient is a 52 year old woman with history of CAD
s/p CABG, diabetes, hypertension, morbid obesity, chronic kidney
disease (type 4 RTA), and PVD who presented with subacute change
in mental status.
.
# Decreased Mental Status: The patient presented with decreased
consciousness following a low impact fall at home. An initial
head CT was negative for mass effect or bleeds. The etiology of
her change in mental status was likely multifactorial secondary
to obesity hypoventilation leading to hypercapnea and hypoxia,
severe sleep deprivation from OSA, worsening renal failure, +/-
small contribution from hyperammonenia. Other diagnostic
possibilities that were negative included screen for drug
intoxication, sepsis, thyroid dysfunction, or seizure. The
patient was evaluated by the neurology service who thought the
change was likely a toxic-metabolic picture. The endocrinology
service was consulted and ruled out thyroid disfunction. The
patient was found to have a mildly elevated ammonia level, but
the remainder of her synthetic liver function was normal. She
received lactulose titrated to [**11-25**] bowel movements per day.
Regarding her renal impairment, a renal consult was obtained and
initiated hemodialysis after adequate access was acheived. The
patient will need to have a sleep study as an outpatient to
confirm the diagnosis of sleep apnea and to titrate CPAP. In
patient attempts at CPAP were unsuccessful due to claustraphobia
once the patient was more awake. Upon transfer to the medical
floor, the patient was awake and answering questions
appropriately. She has had a normal mental status on the floor
off all sedating meds.
.
# Resp: The patients initial hypercapnea was thought secondary
to COPD and hypoventilation. She received nebulized
bronchodilators according to her outpatient regimen. The patient
did suffer a PEA arrest likely triggered by worsening hypoxia of
unclear etiology. CPR was initiated according to ACLS
guidelines. She regained her blood pressure quickly following
one round of epinephrine and atropine. She was intubated and
mechanically ventilated, blood gases were monitored. She was
weaned and extubated without complication. By time of transfer
from the ICU she was maintaing a normal O2sat on room air.
Attempts at CPAP initiation were unsuccessful as described
above. She has remained stable on room air while on the floor.
.
# Acute on Chronic RF. The patient's underlying chronic kidney
disease is likely [**12-26**] HTN/DM, type 4 RTA on last admission, with
concomitant UTI (found on presentation). The acute worsening of
her renal function was somewhat unclear as the time course was
quite rapid of a decline, however, no triggering toxic exposure
was identified. She completed a course of antibiotics for her
UTI. Her urine output continued to decrease and a temporary HD
catheter was placed. She was evaluated by the renal service who
managed the dialysis sessions. She is currently on a qTues,
Thurs, Sat schedule and is set up as an outpatient at [**Last Name (un) 106879**]
[**Location (un) **] to continue hemodialysis once she has completed her
rehab stay. She is on a nephrocap and her electrolytes have
been stable.
.
# HD catheter line infection:
Patient noted to have purulent discharge from her hemodialysis
catheter site during hemodialysis. Swab was sent and cultures
were drawn off the line and peripherally but all culture data is
negative to date. She received IV gentamicin which was
discontinued given negative gram stain. She was continued on 7
days daptomycin for empiric treatment. Suspect early diagnosis
to explain negative cultures versus sterile seroma but opted to
treat to protect new line placed on the left. The catheter on
the right was discontinued. Continue bacitracin cream to the
incision site, which will need removal of stitches in the next
couple of days.
.
# Hypotn/hypoxia on HD:
Patient had an episode of transient hypotension and hypoxia
while on hemodialysis on the day of the diagnosis of a suspected
line infection. Her blood pressure improved with a 200 cc bolus
and her hypoxia resolved spontaneously. Suspect transient
bacteremia versus vancomycin allergic reaction (onset after 25
of 200 cc of vancomycin) versus overdialyzed. No recurrent
episodes.
.
# CAD s/p CABG. There were no acute issues during her ICU stay
as the patient denied CP and the EKG was non specific. Unclear
anatomy, ?grafts. Currently not on optimal CAD treatment due to
past adverse reactions to beta-blockers and statins. The TnT was
slightly elevated at 0.02, which was likely [**12-26**] renal
dysfunction. TTE with new AS and CHF on exam (pitting edema,
unable to assess JVD d/t body habitus). She received aspirin.
Volume management was controlled by ultrafiltration. She was
started on a low dose ACEI on the floor given low EF and ESRD on
hemodialysis (discussed with renal prior to initiation).
.
# DM. Very poorly controlled as outpatient, last HbA1C was 9.8%
on [**6-29**]. On high dose Glargine at home. During the hospital
stay the patient had both hypo- and hyper-glycemia. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consult was obtained. On the floor, her glargine has been
increased based on her daily regular insulin requirement.
.
# Anemia: Patient has a baseline anemia with labs suggestive of
iron deficiency. She is s/p 2 doses of IV iron and will need 3
more doses to correct her iron deficit. She will follow-up with
her PCP to schedule an outpatient colonoscopy. Folate/B12 were
normal. SPEP and UPEP this admission negative. Her admission
was complicated with bleeding associated with a hemodialysis
line placement. She required 2 U PRBC for resuscitation.
.
# PPx. SC Heparin, PPI, bowel reg
.
# FEN: DM, cardiac diet
.
# Dispo:
# Code: Full (confirmed)
.
# Access: PIV, subclav HD cath
.
# Communication: Son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 106880**]; [**Telephone/Fax (1) 106881**], son
trying to get POA (temporary) to be able to pay her bills.
Medications on Admission:
Lasix 20 mg po daily
- Dipyridamole-Aspirin 200-25 mg PO BID
- Hydrocodone-acetaminophen 10-325 one tablet po q4h:prn
- Docusate Sodium 100 mg Capsule po bid
- Senna 8.6 mg TabletBID
- Gabapentin 100 mg po qHS
- Glyburide 10 mg PO BID
- Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H x 7 days
[**8-15**]
- Ipratropium Bromide 2 Puff Inhalation QID
- Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
- Fludrocortisone 0.1 mg po daily
- Glargine 37 U SQ qhs
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
7. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) puff
Inhalation twice a day.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain: max = 2 grams per day.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
10. Neomycin-Bacitracin-Polymyxin Ointment Sig: One (1) Appl
Topical QID (4 times a day): to right neck prn.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 1230**]y (450)
mg Intravenous ONCE for 1 days: PLEASE GIVE ONE DOSE [**2166-9-12**]
AFTER HEMODIALYSIS (then course complete).
13. Ferric Gluconate
125 mg qd x 3 days (may be given with hemodialysis)
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. glargine
38 units SQ qhs
16. humalog insulin
per sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
primary:
obesity hypoventilation
acute on chronic renal failure
urinary tract infection
hyperkalemia
type 2 diabetes with poor control
transaminitis
s/p mechanical fall
hemodialysis line infection
secondary:
history of coronary artery disease
history of peripheral vascular disease
history of poorly controlled type 2 diabetes, with complications
Discharge Condition:
good: alert, lytes stable, tolerating hemodialysis
Discharge Instructions:
Please monitor for temperature > 101, change in mental status,
low or high blood sugars, bleeding at hemodialysis catheter
site, or other concerning symptoms.
You may have an allergy to vancomycin, please avoid this
medication in the future.
Followup Instructions:
[**Last Name (un) **] Clinc [**9-30**] at 10:30 AM, with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Phone:
[**Telephone/Fax (1) 2384**]
Dr. [**Last Name (STitle) **] on Wed [**2166-9-17**] at 1:00pm, [**Hospital Unit Name **], [**Hospital Ward Name 12837**], [**Location (un) **] [**Hospital Unit Name **]. Phone: [**Telephone/Fax (1) 2395**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 106882**] on [**9-22**], 4pm. [**Hospital Ward Name 23**] 1. Phone:
[**Telephone/Fax (1) 250**]
|
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41,897
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45076
|
Discharge summary
|
report
|
Admission Date: [**2143-3-3**] Discharge Date: [**2143-4-8**]
Date of Birth: [**2071-9-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Missed [**First Name3 (LF) 2286**]
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy x2
Multiple episodes of [**First Name3 (LF) 2286**]
History of Present Illness:
Mr. [**Known lastname **] is a 71 yo with ESRD on HD, and depression, bipolar
w/ current auditory hallucinations who presented 4 days post
discharge to the ED since he missed HD. Pt was admitted last
week for chest discomfort on the setting of missing HD which
resolved. He also had an admission on [**2-17**]-31 for AV fistula
repair/thrombectomy done by vascular surgery. He presented to
the ED after missing his HD yesterday. He had sign a contract
with psych that he would not miss HD and was brought to the ED
yesterday. In the ED he was found to be very pale and had a Hct
of 16.6 from 29 4 days prior on the day of his admission. He
denies having any abd pain, melena or hematemesis. However pt
continues to be delusional and not fully answering questions.
.
In the ED his vitals were 97.4, 83/40->93/49 (with baseline of
SBP 140s-160s), HR 52, 100% on 4 L. His repeat HCT was 13 and he
was found to have + guaiac. He was given 1 unit of PRBCs. K was
5.5, BUN of 135, creat 167.
.
On arrival to the floor, pt appeared extremely pale with BP in
the 80s/40s-50s, HR in 60s (in the setting of receiving BB in
the AM). Pt is alert and O x 3, however dellusional and needing
to redirect. NG lavage was done and he had coffee ground/BRB via
NG that did not clear with 1 L lavage. He was ordered 3 units
blood and GI was called to evaluate pt.
.
ROS: unable to give hx given pt is dellirius.
Past Medical History:
-Mood disorder, previously dx bipolar
(outpt therapist Dr. [**Last Name (STitle) 96334**] [**Telephone/Fax (1) 96336**])
-ESRD [**2-20**] lithium exposure and chronic interstitial nephritis on
HD (Tue/[**Doctor First Name **]/Sat)
-DI from Lithium toxicity
-Normal pressure hydrocephalus s/p drain at [**Hospital1 112**] in [**2138**] (no
shunt seen on imaging)
-Hypertension
-Anemia of chronic disease
-H/o endocarditis
-Pulmonary lymphadenopathy
Past Surgical History:
-CABG x 4, resection of tumor from left ventricular outflow
tract [**2141-1-27**]
-Left brachiocephalic AV fistula placed [**2139-9-23**]
-Left forearm radiocephalic AV fistula [**2139-5-12**]
-Appendectomy
-Tonsillectomy
Social History:
He denied using tobacco but endorsed occasional alcohol use. He
denied recreational drug use. He lives in an apartment by
himself. His niece is his HCP.
Family History:
History of depression in his father.
Physical Exam:
On Admission:
VS - 97.4, 83/40->93/49 (with baseline of SBP 140s-160s), HR 52,
100% on 4 L
GENERAL - thin man, very pale, in no acute distress, inattentive
HEENT - NC/AT, poor dentition, dry MM
NECK - supple, LAD, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - LUE AV graft with erythema surrounding sutures,
some warmth, swelling of LUE. Very faint thrill palpable over
graft. 1+ lower extremity edema
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, inattentive
.
On Discharge
VS: 96.0, 160/90, 80, 20, 97%RA
GENERAL - thin man, NAD
HEENT - NC/AT
NECK - No JVD
LUNGS - CTAB
HEART - Systolic murmur heard best at RUSB
CHEST - Indwelling catheter line in place on right C/D/I
ABDOMEN - soft, +BS, NT, ND
EXTREMITIES - LUE AV graft in place with decreasing LUE
swelling; steri-strips in place; thrill palpated, persistent
left lower extremity swelling.
Pertinent Results:
ADMISSION LABS:
[**2143-3-3**] 11:10AM WBC-5.8 RBC-1.62*# HGB-5.4*# HCT-16.6*#
MCV-102* MCH-33.3* MCHC-32.6 RDW-15.1
[**2143-3-3**] 11:10AM NEUTS-72.1* LYMPHS-21.0 MONOS-3.7 EOS-2.5
BASOS-0.6
[**2143-3-3**] 11:10AM PLT COUNT-288
[**2143-3-3**] 11:10AM GLUCOSE-71 UREA N-135* CREAT-6.7*# SODIUM-135
POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-21* ANION GAP-24*
[**2143-3-3**] 11:10AM ALT(SGPT)-14 AST(SGOT)-23 ALK PHOS-69 TOT
BILI-0.1
[**2143-3-3**] 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-3-3**] 01:24PM PT-15.1* PTT-28.6 INR(PT)-1.3*
DISCHARGE LABS:
[**2143-4-8**] 06:00AM BLOOD WBC-8.0 RBC-2.61* Hgb-8.4* Hct-24.6*
MCV-94 MCH-32.3* MCHC-34.3 RDW-16.6* Plt Ct-391
[**2143-4-8**] 06:00AM BLOOD Glucose-88 UreaN-61* Creat-5.9* Na-139
K-4.3 Cl-94* HCO3-32 AnGap-17
[**2143-4-8**] 06:00AM BLOOD Calcium-9.5 Phos-6.3* Mg-2.3
[**2143-3-26**] 07:05AM BLOOD calTIBC-215* Ferritn-1176* TRF-165*
______________
STUDIES:
[**2143-3-3**] EKG: Sinus rhythm. Right bundle-branch block/left
anterior fascicular block. Consider prior anterior myocardial
infarction. Compared to the previous tracing of [**2143-2-22**] the
findings are similar.
[**2143-3-3**] CXR: As compared to the previous radiograph, the patient
has received a nasogastric tube. The tip of the tube projects
over the pyloric region. Unchanged position and course of the
right hemodialysis catheter. Unchanged partly organized left
pleural effusion with subsequent left areas of atelectasis. No
newly appeared focal parenchymal opacities.
[**2143-3-3**], EGD: edematous and friable stomach with evidence of
recent
bleeding. Epinephrine given and endoclips x2 were placed.
[**2143-3-14**], EGD: no active bleeding, linear esophageal erosions.
Endoclips no longer present.
[**2143-3-28**], CT Head:
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Soft tissue swelling overlying the left frontal calvarium,
with no
subjacent fracture.
3. Prominent ventricles, compatible with history of normal
pressure
hydrocephalus, unchanged since the [**2139-12-16**] CT
examination. No shunt seen. Correlate clinically.
4. Mild mucosal thickening in the ethmoid air cells and sphenoid
sinus.
[**2143-4-4**] CXR:
IMPRESSION: No new focal airspace consolidation to suggest acute
pneumonia. Improved left lung base aeration but with persistent
loculated pleural effusion and atelectasis. New small right
pleural effusion.
Brief Hospital Course:
Mr. [**Known lastname **] is a 71 year old man with a history of ESRD, on HD,
and multiple cardiac problems, s/p graft revision/thrombectomy
who presented after missing HD and was found to have upper GI
bleed. He was initially admitted to the MICU. He underwent NG
lavage with bright red blood and underlying significant anemia.
GI did urgent EGD that showed edematous and friable stomach with
evidence of recent bleeding, but no discrete ulcers. Received
epi injection and 2 endo clips. Plan was to continue PPI with
eventual repeat EGD. In setting of volume resuscitation and
transfusion, patient required intubation [**2-20**] volume overload.
Had two [**Month/Day (2) 2286**] sessions with removal of nearly 4 liters of
fluid and was successfully extubated on [**3-5**]. The patient's
psychiatric history also played a significant role in his
course. He missed his [**Month/Year (2) 2286**] session secondary to an
irrational dislike of his [**Month/Year (2) 2286**] center per his outpatient
psychologist and was sectioned to the hospital against his will.
He was seen by psychiatry in house who deemed him without
capacity to make decisions regarding his well being and
recommended chemical restraints (haldol, ativan) in the setting
of his agitation and threatening behavior. He was transferred
to the floor for further care, and his floor course is as
follows:
# Refusal of care: Pt intermittently refusing care, including
hemodialysis and repeat endoscopy, labs, and vital sign checks.
Per psychiatry, pt has never been in a stable enough frame of
mind to competently refuse [**Month/Year (2) 2286**], and some conflicting
messages from patient, especially since has also expressed
strident desire "to live" as recently as this admission (e.g. pt
is full code). After [**3-9**] (following emergent HD for uremia),
Mr. [**Known lastname **] was more cooperative, although still refusing HD on
occasion, VS checks, and lab draws. The medical, psychiatry,
and renal teams met and decided to pursue emergency
guardianship given that without HD, pt's clinical and mental
state decompensate. The HCP was notified regarding intermittent
refusal of care, that this refusal is against his best interest,
and that emergency guardianship is being pursued. The HCP has
had no questions, and urged us to call her if she can help in
any way. Social work and psychiatry continued to follow patient
throughout his admission. Initially, his niece, the HCP was
going to be his gaurdian, but then at the last minute she backed
out secondary to recently strained relationships with Mr.
[**Known lastname **]. Mr. [**Known lastname 96343**] therapist/case worker, Mr. [**Last Name (Titles) **], wanted
to be the patient's gaurdian. Mr [**Name13 (STitle) **] is intricately involved
in the patient's care and he called frequently to discuss issues
related to the patient. He spoke with the medical as well as
the legal team frequently. Ultimately we felt there was a
conflict of interest to have Mr. [**Name14 (STitle) **] be the patient's gaurdian
given her was also being payed by the patient for other
services. It was also vague as the the actual role Mr. [**Name14 (STitle) **]
played in the patient's life. Mr. [**Known lastname **] was appointed a
independent gaurdian Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3647**] who can be reached at
[**Telephone/Fax (1) 96344**]. I spoke with Mr. [**Name13 (STitle) 3647**] prior to discahrging the
patient and he will receive a finalized copy of this discharge
summary.
.
# Psych: Patient with history of severe depression with previous
trials of ECT and treatment with lithium. He was followed by
psychiatry. As per prior admission note there is increased
concern for auditory hallucinations, and patient expressed that
these hallucinations tell him to refuse [**Name13 (STitle) 2286**]. Started on
oral Haldol standing dose 1mg [**Hospital1 **], Ativan 0.5mg TID.
Venlafaxine was held. The patient was repeatedly evaluate by
psychiatry and they felt he was doing better on this regiment at
the time of discharge. He was sent home with follow up with his
therapist Mr. [**Name14 (STitle) **] and referred to a day program at [**Last Name (un) 16093**].
.
# Upper GI bleed s/p 5U pRBCs: pt with significant anemia on
admission. HCT remianed relatively stable following transfusion
and EGD, but patient continued to pass dark, guaiac positive
stools. Repeat endoscopy did not reveal active bleeding. He
was started on an oral PPI twice daily for 8 weeks. His H/H
continued to trend down throughout his stay, but his guaiac was
negative on repeat exam. We spoke with [**Last Name (un) 2286**] and it seemed
that he was not receiving his EPO shots as prescribed. They
restarted EPO injections. However, since his Hct had trended
down to such an extent, 22.4, he was given 2 units of blood
prior to transfer. After 8 weeks he will need to be
transitioned daily PPI and follow-up in [**Hospital **] clinic.
.
# Pt fell out of bed while sleeping during the last week of his
prolonged hospital stay. He sustained small scratches on his
forehead and CT head w/o contrast was negative. He was
initially placed on fall precautions, but that was discontinued
in the setting that he had been walking around with his walker
and very stable for over a month. The incident occured while
sleeping and had little to do with deconditioning, imbalance or
syncope. The patient had no other events throughout his
hospital stay.
.
# ESRD [**2-20**] lithium toxicity: pt requiring HD, but due to his
psychiatric comorbidities, he has intermittently missed HD.
Renal followed the patient while he was hospitalized. He will
need to follow-up with vascular surgery in regards to his new
fistula. Chem panel was trended as best as able given patient's
intermittent lab refusal.
.
# Hypertension: Continued metoprolol and lisinopril.
.
# CAD: continued simvastatin, but held aspirin given bleed risk.
.
# Code: Full
.
Gaurdian: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3647**] [**Telephone/Fax (1) 96344**]
Medications on Admission:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
9. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*540 Tablet(s)* Refills:*2*
11. clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Vitamin B Complex Capsule Sig: One (1) Capsule PO once a
day.
3. cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO once a day.
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID w/
Meals.
9. haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
12. Vitamin C 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Nizhoni
Discharge Diagnosis:
Primary:
-Upper gastrointestinal bleed
.
Secondary:
-Mood disorder
-End-stage renal disease
-Hypertension
-Anemia
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 **],
You were hospitalized at [**Hospital1 18**] because you had a bleed in your
stomach and your blood level was very low. We had to give you a
large blood transfusion, as well as have the gastroenterologists
look into your digestive tract with a camera
(esophagogastroduodenoscopy, EGD). While you were hospitalized,
you were resumed on your normal hemodialysis schedule.
Occasionally, you would refuse care, and for this reason, we
spoke with the courts about how to best care for you. After
speaking with the legal department here we felt that it would be
best to pursue gaurdianship. You remained in the hospital while
this was being established and on [**4-5**] a guardian was
appointed for you. This gaurdian will help you make medical
decisions if you are unable to, but in no way will the gaurdian
interfere with personal or financial matters. You are being
discharged from the hospital with plan to resume [**Month (only) 2286**] and
follow up with your PCP. [**Name10 (NameIs) 2172**] Guardians name is [**Name (NI) **] [**Name (NI) 3647**]
at [**Telephone/Fax (1) 96344**].
.
Please also give the SAGE program a call and set up to join the
day program at [**Hospital 16093**] hospital. I think that it would be
valuable to go to this on days that you are not at [**Hospital **].
.
Please take your medications as prescribed.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] PRIMARY PHYSICIANS
Address: [**Street Address(2) **], [**Apartment Address(1) 22976**], [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 8894**]
Appt: Friday, [**4-12**] at 10:45am
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2143-4-17**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"348.39",
"585.6",
"V45.81",
"280.0",
"285.1",
"296.80",
"414.01",
"285.21",
"785.59",
"578.9",
"403.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"42.33",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14521, 14559
|
6266, 12365
|
304, 385
|
14717, 14717
|
3798, 3798
|
16292, 16895
|
2710, 2748
|
13378, 14498
|
14580, 14696
|
12391, 13355
|
14900, 16269
|
4407, 5604
|
2300, 2523
|
2763, 2763
|
230, 266
|
413, 1806
|
5613, 6243
|
3814, 4391
|
2777, 3779
|
14732, 14876
|
1828, 2277
|
2539, 2694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,178
| 152,065
|
41873+58485
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-7-29**] Discharge Date: [**2160-8-15**]
Date of Birth: [**2083-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
IVH
Major Surgical or Invasive Procedure:
[**2160-7-29**] External Ventricular drain placement
[**2160-8-1**] Stereotactic biopsy of brain lesion
History of Present Illness:
This is a 77 year old man who was in usual state of health when
he had the
sudden onset of suboccipital / upper cervical neck pain and a
sense of fullness in his ears bilaterally. He felt faint and
nauseated, so EMS was called by family. He was taken to an OSH
where a CT head was done showing a right parietal lobar
hemorrhage with extension into the right lateral ventricle. He
was referred to [**Hospital1 18**] for further management. He was seen in
the
ED where he described persistent suboccipital pain, frontal
headache, and nausea. He was actively vomiting during
assessment. He desctribes no vision changes, numbness,
weakness.
Past Medical History:
BPH
HTN
Social History:
Social Hx:
Married, retired. Former smoker. Minimal EtOH consumption.
Family History:
NC
Physical Exam:
On admission
T:97.9 BP: 138/65 HR:76 R:18 O2Sats:100/2L
Gen: withdrawn. ill appearing.
Neck: Meningismus.
Awakes to voice
Cooperative with
Oriented to person, place, and date
Language: Speech fluent with good comprehension and repetition
Pupils equally round and reactive to light
Extraocular movements intact and conjugate without nystagmus
Facial strength intact and symmetric
Palatal elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally.
Tongue midline without fasciculations.
Normal bulk and tone bilaterally
Left pronator drift
Intact to light touch x 4 extremities
Toes downgoing bilaterally
On Disharge: patient is AO x3, PERRL, face symmetric, tongue
midline. left hemiparesis.
Pertinent Results:
CT head [**2160-7-29**]: IMPRESSION:
1. Moderate- Large hemorrhage centered in the right frontal
lobe, with
edematous/hemorrhagic appearance of the adjacent left frontal
lobe with
surrounding edema. This pattern is concerning for amyloid
angiopathy and/or
underlying mass/vascular cause. Recommend MR imaging following
resolution of
acute hemorrhage for further characterization if not
contra-indicated.
2. Surrounding vasogenic and diffuse cerebral edema, causing
right
ventricular compression and 3-mm leftward shift.
3. Diffuse intraventricular hemorrhage, predisposes to
obstructive
hydrocephalus, though comparison to prior imaging is requested.
CT head [**2160-7-29**] post EVD:
1. Right frontal EVD terminates beyond the foramen of [**Last Name (un) 2044**] at
the anterior part of the third ventricle.
2. Otherwise, no change from the prior exams.
3. No new hemorrhage or evidence of hydrocephalus, over 14 hour
interval
[**2160-7-30**] MRI with and without contrast
IMPRESSION: Heterogenous contrast enhancement of the mass in the
splenium of the corpus callosum, substantiating the presumed
diagnosis of a butterfly glioma with secondary hemorrhage.
CT head [**2160-7-30**]
1. Stable appearance of right frontal-approach ventriculostomy
catheter with its tip in the region of the foramen of [**Last Name (un) 2044**].
2. Mass effacing the right lateral ventricle with hemorrhagic
components, better appreciated on the comparison MRI study.
[**2160-8-2**] CT head post biopsy:
IMPRESSION: Hemorrhagic mass centered in the splenium, and
extending to the bifrontal lobes. Minimally increased
surrounding vasogenic edema. Persistent intraventricular and
subarachnoid hemorrhage. No significant change in hemorrhage,
edema or ventricular size.
[**2160-8-4**] CT Head:
1. Size of ventricles are unchanged. No evidence of
hydrocephalus.
2. Hemorrhagic mass lesion centered in the corpus callosum
splenium largely unchanged in size and character. Appearance of
this mass is suggestive of neoplasm.
3. No evidence of infarct, herniation or new hemorrhage.
[**2160-8-7**] CT Head:
1. No significant change in ventricular size compared to [**8-4**], [**2159**]. No evidence of hydrocephalus.
2. Hemorrhagic mass centered in the right thalamus and corpus
callosum, not significantly changed. See details on prior MR
study.
3. Minimal subarachnoid hemorrhage overlying the left parietal
lobe. No new intracranial hemorrhage or evidence of acute large
vascular territorial
infarction.
[**2160-8-8**] CT Head:
No change from previous scan.
LENS [**2160-8-8**]
No evidence of bilateral lower extremity DVT.
Brief Hospital Course:
Mr. [**Known lastname 54563**] was admitted to the ICU for Q1 hour neurochecks and
systolic blood pressure control less than 140 in the setting of
Intraventricular hemorrhage and hydrocephalus. His exam
remained stable overnight however during the day on [**7-29**] he
became more lethargic. STAT head CT demonstrated progressive
hydrocephalus and an External Ventricular Drain was placed at
the ICU beside. He tolerated the procedure well. Post
procedure CT head demonstrated catheter within the right lateral
ventricle terminating within the 3rd ventricle without new
hemorrhage.
MRI with contrast was completed on [**7-30**] which demonstrated a
enhancing mass within the splenium of the corpus callosum.
Overnight, pt had pulled his EVD. Subsequently, a right EVD was
replaced in routine fashion without complication at the bedside.
Post procedure CT scan showed a R EVD placement without new
hemorrhages or infarct.
On [**8-1**] the patient was noted to be more lucid during the AM
hours. There were episodes of right arm tremors which were
thought to possibly be focal seizures. His dilantin level was 11
so he was given a bolus with a goal in the upper teens. In the
afternoon he was brought to the OR for a stereotactic biopsy.
Postoperativel he remained neurologically stable. Post-op CT
head on [**8-2**] showed no new hemorrhage.
Pt remained over the next 2 days with a fluctuating neurological
exam. Head CT on [**8-4**] demonstrated stable ventricular size
without evidence of new hemorrhage. His mental status began to
improve and so on [**8-5**] he was transferred out of the ICU to the
Step Down unit and an EVD wean was inititated, the drain was
raised to 20cm above the tragus. ICPs remained stable and EVD
output diminished. On [**8-6**] the patient's mental status
continued to improve: the patient was AOx3 and he was retelling
complex jokes. EVD was further challenged and raised to 25cm
above the tragus. A CT head was done in the am of [**8-7**] and was
stable. The drain was clamped. He had some elevated ICP's to the
30's but this was when he was OOB.
A CT head was done on [**8-8**] and showed no change in ventricular
size. His EVD was removed without complication. His exam
remained stable.
He was seen and evaluated by Physical therapy and Occupational
therapy and it was recommended that he be discharged to rehab.
Clamping trials with the foley catheter were initiated but
unsuccessful. On [**8-11**] he was transferred to the floor and
continued to await transfer to rehab. A decadron wean was
initiated. Dr. [**Last Name (STitle) **] continued to follow the patient as well.
Pt now has a schedule treatment plan. He is set for discharge
to rehab and will follow-up accordingly.
Medications on Admission:
Flomax 0.4 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
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. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO Q8H (every 8 hours).
5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for nasal conjestion.
12. insulin regular human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): see sliding scale flow
sheet.
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12hrs ()
for 30 days.
15. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
16. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
Discharge Diagnosis:
Bilatteral corpus callosum lesion
Intraventricular hemorrhage
Hydrocephalus
Seizures
Glioblastoma Multiforme
Dysphagia
Malnutrition
Post-op Delirium
Hypertension
hyponatremia
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:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Continue to take Keppra and Dilantin as prescribed. Follow up
with laboratory blood drawing of a dilantin level in one week.
This can be drawn at your PCP??????s office, but please have the
results faxed to [**Telephone/Fax (1) 87**].
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic, [**Name6 (MD) 640**] [**Name8 (MD) 15756**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2160-8-14**] 11:00. 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.
Completed by:[**2160-8-15**] Name: [**Known lastname 14350**],[**Known firstname **] Unit No: [**Numeric Identifier 14351**]
Admission Date: [**2160-7-29**] Discharge Date: [**2160-8-15**]
Date of Birth: [**2083-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 599**]
Addendum:
Disregard BTC appt on [**8-14**]
Follow-Up Appointment Instructions
?????? You have an appointment on Monday [**8-18**] at 10am with
Radiation-Oncology Dr. [**Last Name (STitle) 1285**] for mapping for you radiation
treatments' Radiation Oncology is on the [**Hospital Ward Name 600**] [**Hospital Ward Name **]
building on the [**Location (un) 3896**].
?????? You will also be scheduled for future radiation treatments
after your mapping session. Please call [**Telephone/Fax (1) 14352**] with
questions.
- You will also need to see Dr. [**Last Name (STitle) **] from Neuro-oncology in
the Brain [**Hospital 26**] Clinic to start your chemotherapy treatments. An
appointment has been scheduled for you. Please call [**Telephone/Fax (1) 602**]
with questions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2160-8-15**]
|
[
"401.9",
"191.8",
"438.20",
"345.90",
"263.9",
"276.1",
"348.5",
"600.00",
"293.0",
"438.82",
"348.4",
"787.20",
"331.4",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
13184, 13372
|
4607, 7338
|
300, 406
|
9203, 9203
|
1971, 3742
|
11466, 13161
|
1216, 1220
|
7409, 8910
|
9005, 9182
|
7364, 7386
|
9386, 11443
|
1235, 1952
|
256, 262
|
434, 1079
|
4485, 4584
|
9218, 9362
|
1101, 1111
|
1127, 1200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,809
| 113,923
|
48877
|
Discharge summary
|
report
|
Admission Date: [**2131-2-15**] Discharge Date: [**2131-2-20**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Polyuria/Polydypsia
Major Surgical or Invasive Procedure:
R femoral line placement
History of Present Illness:
Briefly, patient is a 52 yo lady with DM1, Graves' disease, HTN,
chronic migraines, Hep C, asthma, [**Hospital **] transfered from the MICU
with DKA in setting of medication non compliance. Patient self
d/ced all her meds over a week ago due to polyuria and fatigue,
stating she just "didn't feel like taking them" and wanted to
lie still. Patient had been having a typical URTI with cough,
rhinorrhea, also with N/V/D x 3-4 days prior to admission.
Patient then developed shortness of breath which prompted her to
come to the hospital. In the ED, FS was critically high, AG of
37-->admitted to MICU for DKA, given 10 U regular insulin IV and
started on insulin drip. She was hydrated with 3L NS in the ED.
.
In the MICU, gap closed with NPH/Humalog SS, continued
NS->D51/2NS x 1L, now taking POs, [**Last Name (un) **] consult placed.
.
On the floor, patient has multiple complaints, ROS positive for
chronic headaches, +migraine history, a "pulling" sensation in
her chest x several months, localized to the left, diffuse in
nature, radiates to her neck, left arm with tingling/numbness on
occasion with these episodes, also radiating down her left leg.
She says that these episodes occur mostly with exertion when she
is cleaning the house or walking. Patient also c/o crampy
abdominal pain periumbilical and pelvic in location, similar to
when she had her babies, these are no associated with menses.
She says that she always has this pain but that it is currently
worse. She also c/o burning and sharp pains in ther legs b/l
which is also chronic in nature. Patient is taking POs but often
gets nauseous and vomits. Patient also says that she has
intermittent fresh blood in her stools, on the toilet paper and
in the bowel which she thinks is associated with straining, also
with occasional dark black stools x several months.
Past Medical History:
1. Type 1 diabetes mellitus diagnosed in [**2125**].
2. Hypertension.
3. [**Doctor Last Name 933**] disease.
4. Asthma.
5. Hepatitis C.
6. GERD.
7. Obesity.
8. Rheumatoid arthritis.
9. Recent bilateral knee arthroscopy in [**2129-5-26**].
10. Migraines.
11. Status post TAH and pelvic floor surgery with bladder lift.
Social History:
The patient denies tobacco or alcohol use. Lives with a
22-year-old daughter. Currently has home VNA.
Family History:
Non contributory
Physical Exam:
VS: 98.4 BP 126/74 HR 84 R 18 O2 sat 100% RA FS 86 194 lbs
Gen: middle aged lady, NAD, talkative
HEENT: moist, edentulous, anicteric, EOM full
Neck: supple, JVP flat
Chest: CTA b/l, no wheezing or rales
CVS: nl S1 S2, split S2, no m/r/g appreciated
Abd: soft, mildly tender diffusely, no rebound or guarding, BS
present but trace, no HSM
Ext: warm, dry, 1+ dp pulses b/l, no chronic skin
changes/rashes, R fem line in place, clean/dry/intact, no
swelling, non tender, full range of motion of LE b/l; deformity
of fingers b/l, slightly contracted/curled inward
Neuro: A&O
Pertinent Results:
[**2131-2-15**] 11:00PM TYPE-[**Last Name (un) **] PO2-73* PCO2-20* PH-7.10* TOTAL
CO2-7* BASE XS--21
[**2131-2-15**] 11:00PM GLUCOSE-528*
[**2131-2-15**] 10:30PM GLUCOSE-535* UREA N-25* CREAT-1.3*
SODIUM-130* POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-6* ANION GAP-33*
[**2131-2-15**] 07:50PM GLUCOSE-817* UREA N-30* CREAT-1.6*
SODIUM-127* POTASSIUM-6.4* CHLORIDE-85* TOTAL CO2-<5 VERIFIE
[**2131-2-15**] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-2-15**] 07:50PM URINE HOURS-RANDOM
[**2131-2-15**] 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2131-2-15**] 07:50PM WBC-15.4*# RBC-5.11# HGB-15.3# HCT-46.9#
MCV-92# MCH-29.9 MCHC-32.6 RDW-12.2
[**2131-2-15**] 07:50PM NEUTS-86.2* LYMPHS-10.5* MONOS-3.1 EOS-0.1
BASOS-0.1
[**2131-2-15**] 07:50PM HYPOCHROM-1+
[**2131-2-15**] 07:50PM PLT COUNT-359
[**2131-2-15**] 07:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2131-2-15**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2131-2-15**] 07:30PM URINE HOURS-RANDOM
[**2131-2-15**] 07:30PM URINE GR HOLD-HOLD
[**2131-2-15**] 06:41PM GLUCOSE-767*
.
CHEST SINGLE PORTABLE: Comparison is made to [**2130-12-3**].
Heart size is normal. The mediastinal and hilar contours are
unremarkable. The lungs are clear. There are no pleural
effusions or pneumothorax. Visualized osseous structures are
unremarkable.
.
IMPRESSION: No evidence of acute cardiopulmonary process
Brief Hospital Course:
Ms. [**Known lastname 18741**] is a 52 yr old female with type 1 DM, HTN, Asthma,
chronic migraines, RA, HTN admitted with DKA in setting of med
non compliance.
# DKA: Patient reports not taking her meds [**2-22**] depression,
recent illness and simply not wanting to continue taking
medication. No clear source of infection, neg UA, clear CXR. ?
abd source given localized abd pain radiation to back. Other
possible exacerbating factors include CAD, hyperthyroidism.
Cardiac enzymes were negative x 3 however patient with evidence
of lateral ischemia with TWI on EKG associated with tachycardia,
noted in lateral leads I, avL, V5-6. Patient also with vague
complaints of ?angina, chest discomfort with exertion. Patient
likely needs an outpatient stress test in the near future for
further work up. Patient was initially managed in the MICU with
insulin gtt, FS q 1 hr and aggressive IVF hydration with closure
of the anion gap. After one night in the unit, patient was
transfered to the floor with good control. Patient followed by
[**Last Name (un) **] who managed the patient with NPH insulin and Humanlog
sliding scale. At the time of discharge, she was achieving
decent sugar control on her consistent carbohydrate diet. She
will follow up with [**Last Name (un) **] as an outpatient. At the time of
discharge, the patient voiced understanding that she really
needed to maintain good sugar control to prevent another
occurrence of the events leading to this hospitalization.
.
# Chest Pain - Patient with new EKG changes, TWI in lateral
leads I, aVL, V5-6, ?demand ischemia in setting of tachycardia
vs. new ischemic event precipitating DKA. CE negative x 1 on
admission. Patient relays symptoms somewhat suggestive of
angina, chest tightness on exertion with sob, diaphoresis,
radiation to arm. ?difficult to interpret in setting of DM, as
well as the patient's inconsistent reports. Repeat enzymes
remained flat. The patient will need to follow up as an
outpatient for stress testing and coronary risk stratification.
.
# Abd Pain: Ongoing complaints x many months, crampy pain,
periumbilical and pelvic, likely fibroids vs. pancreatitis vs.
PUD. Lipase elevated on admission to 245, trending down to
normal likely in setting of DKA, tolerating POs but with
relatively poor intake. Continued on PPI. Her intake improved
somewhat leading up to discharge. She expressed awareness that
she needed to keep her PO intake consistent to prevent problems
with her glucose management. She was instructed to follow up
her abdominal pain as an outpatient with EGD/colonoscopy, and
possible pelvic ultrasound. Patient experienced some
improvement with Reglan during her stay.
.
# Neuropathic pain/Neuropathy - patient c/p
burning/tingling/numbness in legs, also ?gastroparesis given
history of vomiting. Continued on Tramadol, started Neurontin
[**Hospital1 **]. This medication will likely take time to work, and
effectiveness of this regimen can be evaluated and titrated as
an outpatient.
.
#. Graves' Disease: Patient taking methimazole as outpatient,
although there is concern regarding her medication compliance.
This could account for her elevated free T4 on screening in
house. Will continue current methimazole dose for now, will need
to recheck as outpatient.
.
#. GERD: Will continue PPI for now. This may help her abdominal
pain as well. Giving NSAIDS (tramadol) currently.
.
#. Asthma: Continuing with current outpatient regimen. No
evidence for asthma exacerbation at this time.
.
#. HTN: Patient on antihypertensives as an outpatient. Have been
holding these since admission for her DKA. Currently BP has been
running wnl, so will continue to hold. With resumption of
outpatient dietary habits may creep back up. Will need to follow
up as outpatient.
.
#. Seronegative polyarthritis: Continue sulfasalazine, NSAID prn
for now. Patient has been followed by Dr. [**Last Name (STitle) **] in [**Hospital 2225**]
clinic for this problem.
.
#. Hepatitis C: Patient is not taking any antiviral therapy.
Seen by Dr. [**Last Name (STitle) **] in Hepatology. Genotype is 1A, biopsy
revealed Grade I inflammmation. Decision was made not to pursue
antiviral therapy.
.
#. Migraine headaches: The patient experienced several headaches
that fit her usual migraine pattern during her stay. These
headaches were responsive to sumatriptan in house, along with
oxycodone. Her headaches had improved by the time of discharge.
She was sent home with a small amount of sumatriptan for any
additional headaches prior to her next outpatient visit.
Medications on Admission:
* Methimazole 10 mg tid
* Cyclobenzaprine 10 mg [**Hospital1 **]
* Pantoprazole 40 mg qd
* Diazepam 5 mg [**Hospital1 **]
* Montelukast 10 mg qd
* Salmeterol q12
* Fluticasone 110 mcg, 2 puffs [**Hospital1 **]
* Hyoscyamine Sulfate 0.375 mg [**Hospital1 **]
* Albuterol 1-2 puffs q6hrs prn
* Losartan 100mg qd
* Hydrochlorothiazide 25 mg qd
* Aspirin 81 mg qd
* Sulfasalazine 1500 mg [**Hospital1 **]
* 70-30 unit/mL 80U qam
* 70-30 unit/mL 90U qhs
Discharge Medications:
1. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*2*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
10. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
Disp:*1 small bottle* Refills:*2*
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*2*
15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID PRN
as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
16. Imitrex 100 mg Tablet Sig: One (1) Tablet PO once a day as
needed for migraine.
Disp:*10 Tablet(s)* Refills:*0*
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Six (36) units Subcutaneous qAM with breakfast.
Disp:*qs qs* Refills:*2*
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Six (26) units Subcutaneous qPM with dinner.
Disp:*qs qs* Refills:*2*
19. Humalog 100 unit/mL Solution Sig: Per sliding scale units
Subcutaneous four times a day.
Disp:*qs qs* Refills:*2*
20. Lancets Misc Sig: One (1) lancet Miscell. four times a
day.
Disp:*qs qs* Refills:*2*
21. test strips Sig: One (1) glucometer test strip four times
a day.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
Diabetic ketoacidosis
Type 1 diabetes mellitus
.
Secondary:
Hypertension
Hepatitis C virus infection
Chronic arthritis
Migraine headaches
Chronic abdominal pain
Discharge Condition:
stable, tolerating PO and ambulating without assistance.
Discharge Instructions:
Please continue to take all medications as prescribed. It is
extremely important that you continue to take your diabetes
medications and check your blood sugars with every meal and
before bedtime. You should call Dr. [**Last Name (STitle) **] at [**Last Name (un) **] if your
blood sugars are above 300 at any time. If you experience new
chest pain, shortness of breath, fevers, chills, nausea,
vomiting, or any other concerning symptoms, contact your
physician or return to the emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 7176**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2131-3-12**] 4:00 (Rheumatology)
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-5-2**]
9:40 (Liver doctor)
.
Please call your primary care doctor to make an appointment
within the next 2-4 weeks. You need to schedule an outpatient
exercise MIBI stress test for your heart. Your physician will
make this appointment for you.
.
If you would like outpatient psychiatric follow up, you can call
Dr. [**Last Name (STitle) 10166**], who you have seen before, at ([**Telephone/Fax (1) 32356**] to set up
an appointment.
.
You should contact Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 16687**] to arrange an
outpatient colonoscopy and discuss a possible outpatient upper
endoscopy.
.
You have an appointment at [**Last Name (un) **] with Dr. [**Last Name (STitle) **] on [**3-1**], at 9:00 AM to discuss your diabetes management. Please make
every effort to keep this appointment.
Completed by:[**2131-3-12**]
|
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icd9cm
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77,053
| 103,702
|
41137
|
Discharge summary
|
report
|
Admission Date: [**2153-8-19**] Discharge Date: [**2153-8-22**]
Date of Birth: [**2089-5-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
variceal bleed
Major Surgical or Invasive Procedure:
Endotracheal intubation
Upper GI endoscopy with variceal banding
Femoral central venous catheter placement
History of Present Illness:
Mr. [**Known lastname **] is a 64 year old man with hx of known cirrhosis,
complicated by esophageal varices and HCC, recently placed on
home hospice, presenting today for hematemesis. He was
reportedly feeling tired and nauseated all day and had 3 small
episodes of bloody and black hematemesis. Reported feeling
significantly worse later during the day, experienced large
volume hematemesis at home, after which he called EMS himself.
SBP was reportedly 80/palp in the field.
.
In the ED, lowest SBP was in 90s. He had another episode of
hematemesis 800cc bright red with black clots in the ED. He was
noted to be just mildly encephalopathic, but mentating well
enough to confirm that he would want intubation in the temporary
setting to protect his airway for upper endoscopy. When
preparing to do an IJ, pt had another large volume hematemesis.
Pt was intubated with racuronium and etomidate; racuronium was
used in the setting of elevated K to 6.8. A PIV was placed in
hand and sterile Right Femoral Cordis placed as well. Patient
received 3u pRBCs as well as 1300cc total NS in EMS and ED. He
was started on octreotide bolus + gtt as well as pantoprazole
bolus + gtt. He is on fentanyl and versed for sedation. Vitals
in the ED prior to transfer to MICU were as follows: 76 145/76
FiO2 100% PEEP 5 Vt 500 RR 14.
Past Medical History:
Onc Hx:
-[**2150-11-19**]: resection of 4x4x3.8cm liver lesion in segment 5.
Pathology consistent with HCC. No lymphovascular invasion
-[**2151-5-20**]: resection of 1.8cm lesion in segment 5
-[**2152-2-14**]: chemoembolization of a branch of right hepatic artery
with taxotere and embospheres for two right lobe lesions
measuring 1.5 and 0.5 cm along with microwave ablation of the
1.5cm lesion
-had been on transplant list when MRI [**2152-8-11**] showed 2.4 x 4.3cm
lesion in segment 8 and thrombosis of a portal vein branch.
Underwent biopsy of the lesion which revealed a moderately
differentiated hepatocellular carcinoma with tumor embolus in
the portal vein branch. AFP started rising, 232ng/mL. Delisted
from transplant list.
-attempt to enroll in SEARCH trial. However, pt had anemia
(despite d/c-ing internferon and ribavarin), making him
ineligible from study
-began radiation in [**11/2152**] and finished 01/[**2153**]. Since [**2153-1-22**]
he has been on sorafenib 400mg [**Hospital1 **]. AFP steadily increasing over
last 5 months to 3000s.
-required large volume paracentesis twice [**2-/2153**] (7.6L and
7.8L). Episodes of anemia secondary to GI bleeding. EGD and
colonoscopy performed, revealing esophageal varices, hemorrhoids
and mild portal gastropathy.
-hospital admission [**2153-3-5**] for drop in Hct for which he
received PRBCs. No site of bleeding identified.
.
Other Past Medical History:
- HTN
- ? CHF
- Hepatitis C as above, felt to be obtained on the job due to
numerous episodes of bleeding and other injury.
- h/o back spasms for which he takes narcotics.
.
Past surgical history:
- s/p cholecystectomy.
- s/p appendectomy.
- s/p tonsillectomy.
- s/p procedure for shoulder dislocation
Social History:
Recently moved from [**State 531**] to [**Location (un) 86**] to be near his son. Lives
alone but son lives ten minutes away. Worked in the past as
sheet metal worker but now retired. Denies hx of smoking, EtOH
or illicit drug use, including IV drugs.
Family History:
Father: Cirrhosis, EtOH.
Physical Exam:
Admission:
Vitals: T: BP: 115/59 P: 76 R: 15 O2: 100% on AC FI02 100%
General: Intubated and sedated; general wasting
HEENT: Sclera icteric; OG tube in place
Neck: JVP not elevated, no LAD
Lungs: Vented breath sounds with transmitted upper airway noises
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: tensely distended; tympanic to percussion; normoactive
bowel sounds present; anus with erythematous, bulging
hemorrhoids. Skin surrounding anus with small amount of dried
red blood.
GU: foley in place
Skin: Jaundiced
Ext: cool, doughy; 1+ DP and PT pulses
.
Transfer to the floor from the MICU
Vitals: R [**10-26**]
General: Extubated; general wasting
HEENT: Sclera icteric; MM dry
Neck: JVP not elevated, no LAD
Lungs: CTAB with transmitted upper airway noises
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: tensely distended; tympanic to percussion; +BS
GU: foley in place
Skin: Jaundiced
Ext: cool, no edema
Pertinent Results:
ADMISSION
[**2153-8-19**] 09:38PM GLUCOSE-81 UREA N-44* CREAT-2.0* SODIUM-132*
POTASSIUM-6.8* CHLORIDE-104 TOTAL CO2-13* ANION GAP-22*
[**2153-8-19**] 09:38PM ALT(SGPT)-52* AST(SGOT)-89* ALK PHOS-194* TOT
BILI-10.1*
[**2153-8-19**] 09:38PM LIPASE-16
[**2153-8-19**] 09:38PM ALBUMIN-2.2* CALCIUM-8.5 PHOSPHATE-6.0*#
MAGNESIUM-1.9
[**2153-8-19**] 09:38PM WBC-12.2*# RBC-2.53* HGB-9.0* HCT-27.2*
MCV-108* MCH-35.7* MCHC-33.2 RDW-23.4*
[**2153-8-19**] 09:38PM NEUTS-83.9* LYMPHS-9.3* MONOS-6.4 EOS-0.1
BASOS-0.3
[**2153-8-19**] 09:38PM PLT COUNT-153
[**2153-8-19**] 09:38PM PT-22.8* PTT-37.1* INR(PT)-2.1*
[**2153-8-19**] 09:17PM PH-7.35
[**2153-8-19**] 09:17PM GLUCOSE-65* LACTATE-6.5* NA+-131* K+-6.3*
CL--109 TCO2-13*
[**2153-8-19**] 09:17PM HGB-7.8* calcHCT-23 O2 SAT-95
.
LAST LABS
[**2153-8-20**] 12:00AM BLOOD WBC-11.1* RBC-3.35*# Hgb-11.5*# Hct-34.0*
MCV-102* MCH-34.4* MCHC-33.8 RDW-23.2* Plt Ct-107*
[**2153-8-20**] 12:00AM BLOOD Glucose-97 UreaN-45* Creat-2.0* Na-129*
K-6.5* Cl-101 HCO3-14* AnGap-21*
[**2153-8-20**] 12:00AM BLOOD Calcium-8.4 Phos-6.0* Mg-2.0
[**2153-8-20**] 12:30AM BLOOD Lactate-5.4* K-6.4*
[**2153-8-20**] 12:30AM BLOOD freeCa-1.09*
Brief Hospital Course:
64M with known history of cirrhosis, complicated by HCC and
esophageal varices, recently placed on Hospice, presenting with
large volume variceal bleed.
.
# Goals of Care
Patient was admitted with hematemesis due to an upper
gastrointestinal bleed secondary to bleeding varicies status
post variceal banding. Discussion with family led to a decision
of transitioning goals of care to comfort measures only. Patient
was then transferred from the MICU to the floor and the patient
was kept comfortable with morphine and scopolamine. Patient
passed away about 48 hours after transfer to the floor. Family
was notified and came to the hospital shortly thereafter.
.
# Variceal Bleed
Pt was admitted with hematemesis secondary to variceal bleed and
underwent emergent upper endoscopy with variceal banding while
in the ICU. He received a total of four units of red cells, and
was started on pantoprazole and octreotide drips. Patient with
known history of HCV cirrhosis, complicated by variceal bleeding
in the past, and last banded in [**11/2152**], per son. Previously
received medical care in [**State 531**]. Further observation and
treatment were held as the patient was made CMO.
.
# Hyperkalemia
Likely due to constipation, and also likely due to acute kidney
injury. No significant acidemia on VBG. No EKG changes.
Kayexelate was offered, but the family declined as the patient
was made CMO.
.
# Acute Renal Failure
Likely prerenal etiology in setting of large volume upper GI
bleed. However, as patient has elevated lactate, hypoperfusion
may have been severe enough for acute kidney injury to be due
acute tubular necrosis. His creatinine was 2.0 upon transfer,
but further treatment was held.
.
# Anion gap metabolic acidosis
Likely due to lactic acidosis, though etiology unclear.
Possibly due to hypoperfusion from gastrointestinal bleed.
However, as patient has elevated WBC count, sepsis also
possible. Per son, patient may also have GI obstruction
evidenced by constipation. Lactate peaked at 7 but fell to 5.4
when his last set of labs were checked. No further treatment as
patient was made CMO.
.
#Hyponatremia - Likely hypovolemic hyponatremia in the setting
of hypoperfusion/decreased effective circulating volume.
Baseline in the mid 130s. This was monitored and was stable at
129 upon transfer.
.
#HCV Cirrhosis
Patient has a history of HCV cirrhosis with multifocal
hepatocellular carcinoma, complicated by portal vein thrombosis,
esophageal varices, and hepatic encephalopathy. Prior to
intubation, patient mildly encephalopathic and reportedly had
not stooled for 36 hours prior to admission. Lactulose was
stopped as patient was made CMO.
.
#Leukocytosis
Infectious etiology broad in this patient with HCV cirrhosis
with variceal bleed, and status post intubation. Patient has
been afebrile and hemodynamically stable since admission. He
may have had a primary pneumonia, or may have had an aspiration
event. Must also consider SBP in this patient. Urinalysis
negative for UTI. As concern for intestinal obstruction, may
consider infectious GI complication or perforation, but no
evidence of sepsis. As patient afebrile, leukocytosis may also
be reactive. White counts were trending down when his last set
of labs were checked. No further treatment or evaluation as the
patient was made CMO.
Medications on Admission:
1. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for back spasm.
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Take [**1-15**] doses daily with a goal of 3 bowel
movements per day.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Intubation
Right Femoral Central Venous Catheter Insertion
Upper Endoscopy status post Variceal Banding x4
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Completed by:[**2153-8-26**]
|
[
"276.1",
"V49.86",
"571.5",
"276.7",
"584.9",
"789.59",
"070.71",
"456.0",
"155.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
10150, 10159
|
6077, 9400
|
321, 430
|
10310, 10322
|
4870, 6054
|
3826, 3852
|
10120, 10127
|
10180, 10289
|
9426, 10097
|
10346, 10386
|
3434, 3540
|
3867, 4851
|
266, 283
|
458, 1791
|
3237, 3411
|
3556, 3810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,560
| 180,763
|
36557
|
Discharge summary
|
report
|
Admission Date: [**2195-4-27**] Discharge Date: [**2195-5-4**]
Date of Birth: [**2139-1-6**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Metformin
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Transfer from OSH for BRBPR and abdominal pain
Major Surgical or Invasive Procedure:
Colonoscopy
Insertion of right internal jugular central venous line
History of Present Illness:
This is a 56 yo man with hx of Diverticulitis s/p partial
colectomy x 2, hx of multiple herniorraphy's, recent diagnosis
of Crohn's disease who was transferred from OSH for BRBPR and
abdominal pain. Patient states he has had chronic abdominal pain
for "years". One month ago he went for routine colonoscopy and
was diagnosed with Crohn's disease. Last week he began to
experience chills, sweats and BRBPR. He was seen at [**Hospital 1562**]
Hospital and had a workup done including CT scan of the ABD
which was negative. Over the past week, diarrhea has continued
with 4-6 bloody BMs per day. He states he is passing only clots
and blood for the past 4 days. Also had temp to 102 one day last
week. He has history of bloody diarrhea in the past with
aspirin. He was seen at [**Hospital6 **] and he was
noted to have a HCT drop from 40 to 33 over the past week. He
was transferred to [**Hospital1 18**] for further management. Of note,
patient also with right groin fistula.
.
In the emergency department, initial vitals: Temp 97.8, BP
137/92, HR 93, RR 20 100% RA. Patient was given Cipro 400mg IV x
1, Flagyl 500mg IV once, Pantoprazole 40mg IV x 1, morphine 4mg
IV x 2. GI notified and will see in AM, recommended to hold
steroids for now, start cipro/flagyl. CT abd/pelvis with no
abscess or evidence of other acute intra-abdominal pathology.
Initially, the plan was for the patient to be admitted to the
medical floor, however while in the ED the patient became
hypotensive to 70-80s and tachycardic to 120s. R IJ was placed.
SBP improved to 100-110s after IVF resuscitation with ~1.5L NS.
Admitted to the MICU for close monitoring.
.
On arrival the ICU, the patient complains of dry mouth,
exhaustion, HA, sore back, and nausea (no vomiting). Had large
bloody bowel movement shortly afterward.
Past Medical History:
Crohn's disease
DM2
Arthritis
HTN
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Social History:
Occasional EtOH use, prior hx of Alcohol Abuse over 15 years
ago. Denies tobacco or illicit drug use. Lives in [**Location 7453**], has a significant other x 19 years. On disability [**1-26**]
L hand crush injury, former mechanic.
Family History:
No family hx of Crohn's disease. Mother passed away from PNA,
also had HTN.
Physical Exam:
99.8; 92; 117/80; 95% RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM
Neck - Supple
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - Quiet heart sounds ([**1-26**] body habitus); RRR, normal S1/S2;
no murmurs
Abdomen - Obese; midline hernia appreciated; normoactive bowel
sounds; soft; diffuse TTP
Ext - Warm, well perfused, radial and DP pulses 2+; trace lower
extremity edema to knees
Neuro - Moving all extremities
GU - Right of scrotum a small (2-3mm) perforation with
clear/yellowish serous drainage
Pertinent Results:
[**2195-4-27**] 09:45PM BLOOD WBC-11.1* RBC-4.13* Hgb-11.5* Hct-34.3*
MCV-83 MCH-27.8 MCHC-33.5 RDW-13.9 Plt Ct-563*
[**2195-4-27**] 09:45PM BLOOD Neuts-84.0* Lymphs-10.2* Monos-5.6 Eos-0
Baso-0.1
[**2195-4-27**] 09:45PM BLOOD PT-13.5* PTT-24.7 INR(PT)-1.2*
[**2195-4-30**] 03:20AM BLOOD ESR-87*
[**2195-4-27**] 09:45PM BLOOD Glucose-175* UreaN-49* Creat-1.3* Na-135
K-4.3 Cl-102 HCO3-24 AnGap-13
[**2195-4-27**] 09:45PM BLOOD ALT-12 AST-10 CK(CPK)-89 AlkPhos-64
TotBili-0.3
[**2195-4-27**] 09:45PM BLOOD Lipase-16
[**2195-4-27**] 09:45PM BLOOD CK-MB-NotDone
[**2195-4-27**] 09:45PM BLOOD cTropnT-<0.01
[**2195-4-28**] 09:22AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2195-5-3**] 10:26AM BLOOD %HbA1c-6.9*
[**2195-4-30**] 03:20AM BLOOD CRP-181.6*
[**2195-5-4**] 05:30AM BLOOD WBC-11.6* RBC-3.43* Hgb-9.8* Hct-28.8*
MCV-84 MCH-28.5 MCHC-33.9 RDW-14.2 Plt Ct-513*
[**2195-5-4**] 05:30AM BLOOD Glucose-142* UreaN-32* Creat-2.0* Na-142
K-3.8 Cl-107 HCO3-26 AnGap-13
[**2195-5-4**] 05:30AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.2
[**2195-4-27**] 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-4-27**] 09:45PM PT-13.5* PTT-24.7 INR(PT)-1.2*
[**2195-4-27**] 09:45PM WBC-11.1* RBC-4.13* HGB-11.5* HCT-34.3*
MCV-83 MCH-27.8 MCHC-33.5 RDW-13.9
[**2195-4-27**] 09:45PM PLT COUNT-563*
[**2195-4-27**] 09:45PM LIPASE-16
Blood Cx:
Blood Culture, Routine (Final [**2195-5-5**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
[**4-28**], [**4-29**], [**4-29**], [**4-29**], [**4-29**] NO GROWTH
Urine Cx: [**4-28**], [**4-29**], [**4-30**] NO GROWTH
FECAL CULTURE (Final [**2195-4-29**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2195-4-30**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2195-4-29**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare. .
MANY RBC'S. .
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2195-4-30**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-4-29**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
FECAL CULTURE (Final [**2195-5-2**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2195-5-2**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-4-30**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
OVA + PARASITES (Final [**2195-4-30**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare. .
MANY RBC'S. .
MANY POLYMORPHONUCLEAR LEUKOCYTES.
CT ABDOMEN W/CONTRAST Study Date of [**2195-4-28**] 12:32 AM:
IMPRESSION:
1. No evidence of colitis or intra-abdominal abscess.
2. Multiple abdominal wall hernias, containing loops of small
and large bowel
as detailed above, without evidence of obstruction.
3. Right adrenal nodule, incompletely characterized, but likely
reflects an
adrenal adenoma. Recommend comparison with outside studies to
assess for
interval changes in size.
4. Left renal cyst.
5. Diverticulosis, without evidence of diverticulitis.
Colonoscopy Wednesday, [**2195-4-29**]:
Impression: Ulceration, granularity, exudate and erythema in the
cecum, ascending colon, transverse colon, descending colon and
sigmoid colon compatible with Crohn's disease, Diverticulosis of
the sigmoid colon and descending colon, Otherwise normal
colonoscopy to cecum
Recommendations: Please obtain MRI to evaluate for
abscess/fistula. If this does not show evidence of abscess, will
proceed to treatment with IV steroids +/- remicaid.
Monitor HCT.
Please resend stool x 2 for c.diff.
Send ESR/CRP.
CT abd/pelvis: [**4-28**]
IMPRESSION:
1. No evidence of colitis or intra-abdominal abscess.
2. Multiple abdominal wall hernias, containing loops of small
and large bowel
as detailed above, without evidence of obstruction.
3. Right adrenal nodule, incompletely characterized, but likely
reflects an
adrenal adenoma. Recommend comparison with outside studies to
assess for
interval changes in size.
4. Left renal cyst.
5. Diverticulosis, without evidence of diverticulitis.
MRI: Pelvis
IMPRESSION: Small track, measuring 14 mm in depth, extending
from the skin of
the right thigh to the fascia abutting the gracilis, with no
evidence of
deeper extension and no evidence of fistula or abscess, as
questioned. Trace
bilateral hydroceles.
X-ray Foot:
FINDINGS: There is general soft tissue swelling. The
mineralization of the
bones appears normal. Mild-to-moderate degenerative disease at
the tibiotalar
joint and talonavicular joint. Small plantar spur. There is no
secure sign
of cortical disruption indicative of fracture.
Brief Hospital Course:
56 year-old male with diverticulitis s/p partial colectomy x 2,
history of multiple herniorraphies, recent diagnosis of Crohn's
disease transferred from OSH for BRBPR and abdominal pain on
[**2195-4-27**]. In the ED, he was hypotensive and tachycardia and
required a brief stay in the MICU, after which he was
transferred to the medicine service.
MICU COURSE
===========
# Crohn's Disease: Patient found to have severe crohn's dz on
colonoscopy. An MRI was done showing no fistulas or abscesses.
Patient was started on solumedrol along with Cipro and Flagyl
prior to transfer to the floor per GI recommendations. In
addition, stool O&P along with C. Diff toxin sent. C. difficile
was negative.
# Hypotension/Sinus tachycardia: Likely secondary to hypovolemia
in the context of bleeding, decreased PO intake, fever.
Hypotension resolved with fluid boluses.
# BRBPR: Pt with significant bleeding causing hemodynamic
instability. Hct drop 40-->33, was been stable in MICU despite
multiple bloody BM's in ED. Likely lower GI bleed given
description of BRB with clots. Differential would include
Crohn's disease, diverticulosis, AVM, infectious. Also uses
chronic NSAIDS so could represent a brisk UGI bleed. Patient
started on IV protonix and Hct observed Q6H.
# Fever: Pt had fever to 102 at home and now with low-grade
temp. No leukocytosis. Raised concern for infectious or
inflammatory process-- especially given history of
diverticulitis and Crohn's-- however no signs of abscess,
colitis, or pericolic fat stranding on CT.
# Elevated creatinine: No history of chronic kidney disease.
Most likely represents prerenal acute renal failure in the
setting of BRBPR. Cr increased to 1.7 from 1.4, received a
contrast dye load and is also prerenal given low FeNa. Unclear
etiology, possibly a component of both ATN and pre-renal
azotemia. Continued to monitor and adminstered fluid.
MEDICINE COURSE
===============
On transfer to the medicine service, patient was transitioned to
prednisone for Crohn's flare. He did not have any episodes of
BRBPR. He remained hemodynamically stable and did not require
blood transfusions. PPD was checked for possible initiation of
Remicade as outpatient; PPD was negative. TMPT, checked to
assess for ability to tolerate azathiprione therapy, was pending
on discharge. On discharge, patient was scheduled for
appointment with outpatient gastroenterologist. He was sent out
with a steroid taper and PPI. His antibiotics were 10 day course
of ciprofloxacin and flagyl.
As his blood glucose was not well-controlled with steroid
therapy, [**Last Name (un) **] was consulted. He was maintained on his home
dose of Lantus and started on an aggressive Humalog sliding
scale insulin regimen which should be titrated concurrently with
steroids on an outpatient basis.
Patient's creatinine improved after transfer from ICU.
Acute kidney injury was likely secondary to contrast-induced
nephropathy. His creatinine should be rechecked within one week
of discharge.
On MRI patient was also noted to have a 14mm track
extending from is right thigh to the underlying muscle. He
report serous drainage. There was no fecal output. This was
dressed daily, and the wound team was consulted for further
recommendations (given risk of infection based on location). He
was sent home with VNA and wound care.
On day prior to discharge patient also complained of right
foot pain. He injured the right ankle approximately 1.5 years
ago; did not seek medical attention, and pain improved.
Worsening pain on plantar surface, medially of right foot
throughout hospital course. Also with ?small effusion inferior
to lateral malleolus. Most likely pain from soft tissue edema
secondary to steroid use. Plain film of the film showed no
evidence of fracture. The patient should have outpatient
follow-up with the pain persists.
Medications on Admission:
Naproxen 400mg [**Hospital1 **]
Lantus 30 units qHS
Tramadol 50mg PO daily
Lisinopril unknown dose
Glyburide unknown dose
Actos unknown dose
Prednisone 30mg daily with plan for slow taper, started last
week
Discharge Medications:
1. 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*
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: generic for tylenol.
7. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Four (24) units Subcutaneous daily at breakfast time: will be
tapered based on prednisone dosing.
Disp:*QS 1 month* Refills:*2*
9. Insulin Lispro 100 unit/mL Solution Sig: AS DIR units
Subcutaneous four times a day: see attached sliding scale for
dosing based on fingerstick before meals and at bedtime.
Disp:*QS 1 month* Refills:*2*
10. Dressing Care
Commercial wound cleanser or normal saline to irrigate/cleanse
right groin wound.
Pat the tissue dry with dry gauze.
Pack loosely with [**Doctor Last Name 12536**] AMD [**12-26**]" packing strip moistened with
normal saline.
Cover with dry gauze
Change dressing daily.
Secure dressing in underclothes or minimal softcloth tape
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Association
Discharge Diagnosis:
Primary:
- Crohn's flare
- Acute kidney injury, likely secondary to contrast exposure
Secondary:
- Epidermal retention cyst with draining tract in groin
- Diabetes mellitus, type II
- Right foot
Discharge Condition:
Hemodynamically stable; without blood in stools; ambulating
without problem; afebrile
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2195-4-27**] due to blood in your stools due to a flare of your
Crohn's disease. You had a brief stay in the ICU, and then were
transferred to the medical [**Hospital1 **] for further care; you did not
require any blood transfusions. The gastroenterology service was
involved in your care. You were treated with steroids and
antibiotics. You were also noted to have a worsening of your
kidney function; this is likely related to contrast which your
received for a CT scan, and should improve over time.
Your medication regimen has changed. Please review your
medication list closely. Note that we have stopped your diabetic
pills, because of the acute renal failure (resolving) and the
increased blood sugars due to prednisone. Discuss restarting the
pills (Actos and glyburide) with Dr [**Last Name (STitle) **] when your kidneys have
fully recovered and you are off of prednisone. We also stopped
your lisinopril. You should continue to drink fluid and maintain
good hydration.
In the meantime, you are on two new forms of insulin in addition
to lantus. One is called NPH, which is intermediate-acting. You
will take this at breakfast time to counter-act prednisone. If
any changes are made in your prednisone dosing, you need to
discuss with your doctor how to change the insulin-NPH dosing,
because with less prednisone, you will need less NPH.
The other new insulin is insulin-lispro, or Humalog. You will
take doses of this based on your fingerstick value at meal time
to adjust the blood sugar. Attached is a copy of the sliding
scale of doses, based on pre-meal blood sugar, that we recommend
for now; discuss this with Dr [**Last Name (STitle) **], as it will need to be
refined going forward, especially if you are able to restart the
pills for blood sugar control.
It is important that you follow up with your physicians as
listed below.
Please call your physician or return to the emergency department
for increasing abdominal pain, blood in your stools, dark tarry
stools, fever, or for any other symptoms which are concerning to
you.
Followup Instructions:
You have an appointment with your PCP, [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 29822**]), to make sure the kidneys are functioning
normally and diabetes care follow-up.
Date and time: [**5-8**] at 11am
Location: [**Location (un) **]
Phone number: [**Telephone/Fax (1) 29822**]
You have an appointment with Dr [**Last Name (STitle) **], your gastroenterologist,
to discuss starting either remicade or other medications to
achieve remission of the Crohn's disease.
MD: Dr [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
Specialty: GI
Date and time: [**5-11**] at 3pm
Location: [**Hospital1 1562**]
Phone number: [**Telephone/Fax (1) 82746**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2195-5-13**]
|
[
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"V58.67",
"780.60",
"555.1",
"578.1",
"250.00",
"782.3",
"401.9",
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"729.5",
"716.90",
"584.9",
"458.0",
"562.10",
"785.0",
"276.52",
"216.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
14316, 14387
|
8659, 12520
|
330, 400
|
14627, 14715
|
3289, 8636
|
16862, 17737
|
2620, 2697
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12778, 14293
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14408, 14606
|
12546, 12755
|
14739, 16839
|
2712, 3270
|
244, 292
|
428, 2229
|
2251, 2356
|
2372, 2604
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,002
| 162,289
|
2571
|
Discharge summary
|
report
|
Admission Date: [**2110-5-9**] Discharge Date: [**2110-5-28**]
Date of Birth: [**2027-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
IVC filter placement
ERCP s/p sphincterotomy and stent placement in common bile duct
IR guided liver biopsy
Thoracentesis
History of Present Illness:
82-year-old female with a history of HTN, Hyperthyroidism,
likely cholangiocarcinoma, recent PE/DVTs on coumadin p/w
progressive dyspnea. Patient was recently admitted for dyspnea
on [**2110-4-6**] and found to have RUL segmental branch PE on CTA. CTA
also showed a liver lesion with scattered pulmonary nodules
concerning for malignancy. Subsequent MRI showed a large
ill-defined
heterogeneous mass concerning for an intrahepatic
cholangiocarcinoma with multiple satellite nodules. Biopsy not
done due to need for anticoagulation for acute stage of PE. She
was seen in oncology clinic today and was felt to not be a
candidate for chemotherapy given her low performance status. She
was noted to be sob in clinic and was admitted for further
evaluation.
Notably, patient c/p progressive dyspnea since her last
admission. She felt OK initially and using supplemental oxygen
intermittently. Over the course of the past 3-4 days she has had
increasing dyspnea on exertion, where walking [**9-2**] feet caused
significant dyspnea. Once she rested, her breathing improved.
She denies cp, cough, fevers, chills N/V/D/C. She does admit to
decreased appetite, abdominal fullness, and persistent right leg
swelling. She has been taking all of her medications and her
last INR was 2.5 2 days prior, and notably has never been
subtherapeutic since starting this coumadin.
On the floor, the patient appears quite dyspneic, but after
sitting for some time, her tachypnea and dyspnea improved.
Patient states she has problems with her liver, but per her
family is not aware she has cancer. Per the family, she cannot
understand her disease process so they are trying not to tell
her to much detail.
Past Medical History:
-Lower extremity DVT
-PE anticoagulated on Coumadin
-Pulmonary nodules
-Live mass concerning for malignancy
-Hypertension
-Hypothyroidism status post thyroidectomy on levothyroxine
-Cholecystitis status post cholecystectomy
-Scoliosis
-Hypersensitivity to heparin
-H/o intracranial and cervical spinal meningioma s/p posterior
fossa decompression, C1-C2 laminectomies, tumor resection and
grafting([**2107-12-17**])
Social History:
Patient is origally from [**Country 651**]. She lives in a senior housing
apartment. She has been independent with her ADLs until recently
including cooking and grocery shopping. She has no history of
alcohol or tobacco use.
Family History:
-No family history of cancer
-No family history of liver disease
Physical Exam:
GEN: Chachectic appearing female in mild respiratory distress
VS: 102/58 93 26 94% RA
HEENT: Dry MM
CV: Irregular, RR, no m/g/r
PULM: decreased breath sounds at left base, clear otherwise, no
w/r/r
ABD: soft, NT/ND, positive bowel sounds
LIMBS: warm, well perfused, 1+ pitting edema in RLE, no edema on
left.
SKIN: dark, no rashes; scoliosis noted
NEURO: CN 2-12 grossly in tact, no gross neurological
abnormalities, moving all extremities
Pertinent Results:
[**2110-5-9**] 05:10PM PT-24.4* PTT-29.4 INR(PT)-2.3*
[**2110-5-9**] 11:00AM UREA N-21* CREAT-0.9 SODIUM-136 POTASSIUM-3.9
CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
[**2110-5-9**] 11:00AM ALT(SGPT)-13 AST(SGOT)-35 CK(CPK)-47 ALK
PHOS-257* TOT BILI-0.6
[**2110-5-9**] 11:00AM CK-MB-2 cTropnT-0.01 proBNP-3016*
[**2110-5-9**] 11:00AM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-1.8
[**2110-5-9**] 11:00AM WBC-9.9 RBC-4.03* HGB-10.8* HCT-34.1* MCV-85
MCH-26.8* MCHC-31.7 RDW-15.0
[**2110-5-9**] 11:00AM NEUTS-84.5* LYMPHS-8.6* MONOS-3.8 EOS-2.8
BASOS-0.2
Studies:
[**2110-5-21**]: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
Moderate (2+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is a small to
moderate sized pericardial effusion. No right ventricular
diastolic collapse or overt tampoande is seen. There is brief
right atrial diastolic invagination. Compared with the prior
study (images reviewed) of [**2110-4-7**], the pericardial effusion
appears larger. There remains no overt tamponade. The degree of
pulmonary hypertension detected has slightly increased. The
degree of AR and the LVEF are similar.
[**2110-5-24**] CXR: 1. Apparent slight increase in right pleural
effusion with predominantly
subpulmonic distribution. Persistent collapse of right middle
and right lower lobes. 2. Persistent peripheral left mid lung
opacity probably due to infarct in the setting of known
pulmonary embolism.
[**2110-5-20**] Pleural Fluid: POSITIVE FOR MALIGNANT CELLS consistent
with metastatic adenocarcinoma.
[**2110-5-19**] ECG: Normal sinus rhythm, rate 86. Frequent atrial
premature beats. Low voltage in the standard leads. Generalized
non-specific repolarization abnormality. Delayed precordial R
wave progression of indeterminate significance. Compared to the
previous tracing of [**2110-5-2**] atrial ectopy appears somewhat more
frequent and the overall ventricular rate is marginally
increased.
[**2110-5-16**] Liver Biopsy: A. Liver, left lobe lesion, core needle
biopsy: Adenocarcinoma, moderately differentiated, see note. B.
Liver, hilar lesion, core needle biopsy: Adenocarcinoma,
moderately differentiated, see note. Note: Immunostains for CK7
and CK19 are positive. CD10 is focally positive. CD20 and
HepPar1 are negative. CEA is non-contributory. The
immunophenotype and morphology are consistent with a tumor of
pancreatico-biliary origin in the appropriate clinical setting.
[**2110-5-9**] CT Head: No acute intracranial process. No evidence of
metastases or acute hemorrhage. Findings were discussed with Dr.
[**First Name (STitle) **] [**Name (STitle) **] at 12:35 am on [**2110-5-10**].
[**2110-5-9**] CT Abdomen/Pelvis: . New pulmonary embolism within a
segmental left pulmonary artery extending to the left lower
lobe. Stable appearance of the posterior right upper lobe
segmental artery pulmonary embolism. 2. Large thrombus in the
lower infrarenal IVC extending into the proximal bilateral
common iliac veins. 3. Right common femoral, superficial
femoral, and deep femoral veins thrombosis as seen on recent
lower extremity ultrasound. This thrombus does not extend
superiorly into the right external iliac vein. Short segment of
left common femoral vein thrombus. 4. Stable appearance of
multiple nodules throughout the lungs, concerning for metastatic
disease. Stable appearance of moderately sized right pleural
effusion and adjacent compressive atelectasis. 5. Stable
appearance of known cholangiocarcinoma with intrahepatic biliary
dilatation. Stable dilatation of the common bile duct and
pancreatic duct. 6. Moderate ascites. 7. Stable pericardial
effusion.
Brief Hospital Course:
Ms. [**Known lastname 13004**] is an 82 year old Cantonese speaking female with
history of DVT, PE, pulmonary nodules, and liver lesions
concerning for malignancy who presented with progressive dyspnea
found to have extensive thrombus burden despite therapeutic INR.
#. Dyspnea: Likely related to her numerous and progressive PE's
in setting of therapeutic INR. Patient's right leg appeared
quite swollen on presentation and an ultrasound was performed.
This showed extensive clot burden and the superior aspect of the
thrombus could not be appreciated by ultrasound as it extended
into the patient's pelvis. A CT torso was then performed which
showed extensive clot burden with a large thrombus in the lower
infrarenal IVC extending into the proximal bilateral common
iliac veins. A new pulmonary embolus was also noted. Since the
patient was continuing to develop thrombus in the setting of a
therapeutic INR, it was felt an IVC filter should be initiated
immediately. Vascular was consulted placed an IVC filter from
the left IJ approach overnight. The patient was started on
lovenox [**Hospital1 **] and tolerated the procedure well. Regarding the
patient's left pleural effusion that may be contributing mildly
to dyspnea, IP was consulted. She acutely decompensated from a
respiratory standpoint and required transfer to the ICU. She
was tachypneic and required 6L NC to maintain sats. A CXR
revealed progressive accumulation of effusion and she requires a
thoracentesis which drained 1.2 Liters of transudative effusion.
She was then able to be weaned to 2L oxygen to maintain her
sats and was transferred back to the floor. On the floor her
respiratory status remained stable on 1-2L O2. She was
continued on Lovenox with an IVC filter. Pleurex catheter
placement was considered for a subsequent right-sided pleural
effusion but it was felt there was not enough pleural fluid to
warrant placement. She was also diuresed after returning to the
floor with Lasix and her SOB improved, although oxygenation
remained stable.
#. Cholangiocarcinoma: She had a new diagnosis of
cholangiocarcinoma on this admission. Given the need to
decompress the patient's bile ducts to reduce the risk of
cholangitis with a liver guided biopsy, an ERCP was performed
[**5-14**]. Sphincterotomy performed as well as a stent placement in
the common bile duct. On [**5-16**], patient underwent an IR guided
liver biopsy without any complications. Biopsy showed
adenocarcinoma consistent with pancreatico-biliary origin. She
was not felt to be a candidate at this time for chemotherapy
given her respiratory status and overall weakness. She was
discharged to rehab with plans to readdress goals of care and
chemotherapy in 2 weeks with her primary oncologists.
#. HTN: Stable, Continued home Amlodipine and lisinopril.
#. Hypothyroidism: Her dose of levothyroxine was increased due
to a high TSH. She will need repeat thyroid studies in 6 weeks.
Medications on Admission:
Lisinopril 20 mg daily
Omeprazole 20 mg daily
Levothyroxine 100 mcg daily
amlodipine 5 mg daily
coumadin 2 mg daily
home oxygen
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation .
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob/wheezing.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for sob/wheezing.
12. Morphine Sulfate 0.5 mg IV Q4H:PRN pain/sob
hold for sedation or rr < 12
13. Levothyroxine 125 mcg Capsule Sig: One (1) Capsule PO once a
day.
14. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous Q12H (every 12 hours).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis:
Cholangiocarcinoma
DVT/PE
Pleural Effusion
Secondary:
Hypertension
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 because of shortness of breath. You were found
to have extensive blood clots in your body, especially your
lungs. This is why it is so difficult to breathe. A filter was
placed in your large vein to prevent further clots from reaching
your lungs. You were started on a blood thinner called lovenox.
You should continue to take this medication until your
oncologist tells you otherwise.
You were also found to have fluid around your right lung. You
had a procedure where this fluid was drained and it improved
your breathing.
You also had a sample of tissue taken from your liver mass. The
results show that you have a type of cancer called
cholangiocarcinoma.
You should continue to take all of your medications as
prescribed. These are the changes to your medications:
START Lovenox 50 mg injections to be taken every 12 hours.
START Lasix 20mg by mouth daily
CHANGED levothyroxine to 125mcg by mouth daily
You should also have thyroid studies checked in approximately 6
weeks.
Followup Instructions:
You are to follow up with Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 13005**] in 2
weeks. You have the following appointment scheduled:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/[**First Name (STitle) 13005**]
Date/Time: [**Last Name (LF) 2974**], [**2110-6-13**] at 9:30am
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, Floor 9
Phone: [**Telephone/Fax (1) 13006**]
You should also have an appointment with the intervential
pulmonary doctors to follow the fluid around your lung. You
will be called with an appointment. If you do not hear from
their clinic, please call [**Telephone/Fax (1) 3020**] to schedule an
appointment.
|
[
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"155.1",
"415.19",
"453.2",
"789.59",
"244.0",
"576.2",
"401.9",
"V58.61",
"511.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"38.7",
"50.11",
"88.51",
"34.91",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
12536, 12635
|
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|
321, 445
|
12766, 12766
|
3398, 6501
|
13976, 14749
|
2857, 2923
|
10840, 12513
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12656, 12656
|
10688, 10817
|
12949, 13713
|
2938, 3379
|
13742, 13953
|
274, 283
|
473, 2160
|
6511, 7691
|
12675, 12745
|
12781, 12925
|
2182, 2599
|
2615, 2841
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,708
| 146,685
|
33670
|
Discharge summary
|
report
|
Admission Date: [**2143-3-31**] Discharge Date: [**2143-4-30**]
Service: NEUROLOGY
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
L frontal ICH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 84 M PMH dementia, NIDDM, HTN, hyperchol and GI ulcers
transferred from OSH ED after being found by wife at 2am in
reclining chair having trouble making words. Wife checked SBP
and noted >200, called EMS. OSH Head CT revealed a 5.5cm L
frontal lobe ICH with blood in left frontal, b/l occipital horns
and with 5mm midline shift to the right.
At OSH, VS [**Telephone/Fax (2) 77945**]6-97% 2L NC. GCS 14. Not oriented to
place or time and was confused but able to follow commands.
nitro drip started -> BP 187/80. Rec'd metoprolol and zofran.
EKG RBBB.
Upon arrival to ED, 97.9 52 163/74 16 97% 3L. Per nrse
note,
pt alert, oriented to person only, slow to react but able to
follow commands and answer most simple questions.
BP elevated to 202/101 started on nitro gtt with subsequent dip
in BP to 88/42. Pt became pale with decreased resp, nitro
stopped and pt intubated for resp distress with Lido, Vec,
Etomidate and Succinylcholine. Also, rec'd fentanyl 100mg IV
for
sedation. Vitals recovered to 138/49 62. Rec'd atropine 1amp
also given for HR 32, pt placed on pacer pads.
Repeat NCHCT repeated and reviewed with Nsurg attg showing
stable
bleed, no significant change in size. Nsurg consulted and felt
that no surgical intervention indicated at this time given
amount
of atrophy allowing for minimal mass effect of bleed and
stability of bleed and baseline status of patient which was
discussed with family who agreed.
ROS: At OSH, denied vision changes, HA or recent falls.
Past Medical History:
dementia
hypercholesterolemia
HTN
NIDDM
bleeding ulcers s/p "stomach operation"
s/p appy
Denies prior stroke.
Social History:
Lives with wife in [**Name (NI) 7661**]. At baseline, oriented x2 not to
place, walks without assistance. Daughter in the area. No tob,
etoh or drugs.
Family History:
nc
Physical Exam:
Exam: On propofol gtt for BP control and sedation.
T- 97.9 BP- 130/40 HR- 44 RR- vented 100 O2Sat
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema, in two pt restraints
Neurologic examination:
Mental status: Responds to noxious stim only and spontaneously
moving legs bilaterally but not opening eyes or following
commands. Per nurse when light on propofol, bites on ETT and
moves to pull tube L>R arm.
Cranial Nerves:
Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. +Corneals and grimaces to nasal tickle
bilaterally.
Unable to elicit EOMs partial alertness or assess facial assym
[**3-16**] tube.
Motor/Sensory
Increased tone in legs bilaterally, mildly decreased in right
arm. Extends to noxious stim in legs bilaterally and left arm.
Internally rotates the right arm to noxious stim. Normal bulk
bilaterally. No observed myoclonus or tremor.
Reflexes:
+2, maybe slightly brisker on the right and absent achilles.
Toes downgoing bilaterally.
Coordination/Gait/Romberg: Unobtainable.
Pertinent Results:
[**2143-4-23**] 5:24 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2143-4-26**]**
GRAM STAIN (Final [**2143-4-23**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2143-4-26**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**4-24**] CT torso without contrast.
COMPARISON: [**2143-4-13**].
A tracheostomy tube tip projects approximately 6 cm from the
carina. A left-sided PICC terminates at the SVC/brachiocephalic
junction. There is CT evidence of anemia. Coronary artery
calcification and calcific atherosclerotic plaque within the
thoracic aorta is again noted.
There is moderate cardiomegaly. Large mediastinal lymph nodes
again noted, most prominent measuring 1.5 cm in short axis
(2:22). Bibasilar
consolidations and small-to-moderate pleural effusions again
noted
bilaterally. There are moderate centrilobular emphysematous
changes within
the lung apices bilaterally.
CT ABDOMEN WITHOUT CONTRAST: Intra-abdominal and intrapelvic
organs cannot be well evaluated given lack of intravenous
contrast administration. No gross liver lesion is detected.
The spleen, adrenal glands, right kidney, and large and small
bowel are grossly unremarkable. There is calcific
atherosclerotic plaque throughout the abdominal aorta and its
branches. No free fluid or free air is detected within the
abdomen. There is colonic diverticulosis diffusely. The left
kidney again demonstrates a hypoattenuating lesion in the
interpolar region which cannot be further characterized given
lack of intravenous contrast administration. A gastrostomy tube
is detected within the stomach.
CT PELVIS WITHOUT CONTRAST: Air and urine is detected within
the urinary
bladder. There is prostatic enlargement with coarse
calcification within the prostate centrally. A large amount of
stool is present within the rectum. There is a right inguinal
hernia with a small amount of nonobstructed small bowel and
mesenteric fat within.
OSSEOUS STRUCTURES: There are numerous healed rib fractures in
the
anterolateral aspects consistent with prior trauma. There are
multilevel
degenerative changes within the lumbar spine.
IMPRESSION:
1. Bibasilar consolidations in which an infectious process
cannot be
excluded. Moderate bilateral pleural effusions.
2. No intra-abdominal or intrapelvic fluid collections are
detected to
suggest abscess, however, evaluation is limited given lack of
intravenous
contrast administration.
3. Cardiomegaly, coronary artery calcifications and
pathologically enlarged mediastinal lymph nodes.
4. Right nonobstructive inguinal hernia with small bowel
within.
5. Moderate centrilobular emphysematous change.
[**2143-3-31**] 09:48PM CK(CPK)-234*
[**2143-3-31**] 09:48PM CK-MB-4 cTropnT-0.03*
[**2143-3-31**] 05:39PM CK(CPK)-154
[**2143-3-31**] 05:39PM CK-MB-4 cTropnT-0.02*
[**2143-3-31**] 05:39PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2143-3-31**] 05:39PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-3-31**] 05:39PM URINE RBC-[**4-17**]* WBC-[**4-17**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2143-3-31**] 05:39PM URINE GRANULAR-[**4-17**]* HYALINE-[**7-23**]*
[**2143-3-31**] 04:47PM TYPE-ART PO2-122* PCO2-40 PH-7.42 TOTAL
CO2-27 BASE XS-1
[**2143-3-31**] 12:36PM TYPE-ART PO2-554* PCO2-38 PH-7.44 TOTAL
CO2-27 BASE XS-2
[**2143-3-31**] 10:00AM ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-57 ALK
PHOS-150* TOT BILI-0.7
[**2143-3-31**] 10:00AM LIPASE-23
[**2143-3-31**] 10:00AM cTropnT-0.01
[**2143-3-31**] 10:00AM ALBUMIN-3.4 CALCIUM-8.5 PHOSPHATE-4.9*
MAGNESIUM-2.3
[**2143-3-31**] 10:00AM PHENYTOIN-13.8
[**2143-3-31**] 10:00AM WBC-12.7* RBC-3.66* HGB-11.1* HCT-33.1*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.3
[**2143-3-31**] 10:00AM NEUTS-88.0* BANDS-0 LYMPHS-7.2* MONOS-4.1
EOS-0.4 BASOS-0.3
[**2143-3-31**] 10:00AM PT-12.9 PTT-25.1 INR(PT)-1.1
[**3-31**]: Very large left frontal intraparenchymal hemorrhage with
extension into the ventricles. There is mass effect, with
rightward shift by approximately 7 mm. Underlying mass cannot be
entirely excluded.
[**4-1**]: Allowing for positional differences, no significant change
seen compared to prior study, with large left frontal
hemorrhage, with extension to the ventricles again seen.
[**4-7**]: CTH: No significant change in large left frontal
intraparenchymal hemorrhage and similar rightward shift of the
midline.
[**4-7**]: CT neck: 1. Acute parotitis with no definite evidence of
abscess. Exam is somewhat limited due to lack of intravenous
contrast.
[**4-11**]: In comparison with study of [**4-7**], there is continued
enlargement of the cardiac silhouette. The pulmonary vascularity
has decreased and is now virtually within the normal range.
Blunting of the costophrenic angles with a streak of atelectasis
at the left base persists. Tracheostomy tube remains in place.
[**4-11**]: RUQ U/S:
1. Normal-appearing gallbladder.
2. Tiny right pleural effusion.
Brief Hospital Course:
Pt admitted to ICU as intubated for airway protection. repeat
CTH stable on [**4-1**] from initial.
Neuro: Upon extubation and removal of sedation, he was
responsive intermittently to commands, but not speaking. He had
decreased lateral gaze to the R. He was moving all his
extremities, although L>R with increased strength on L.
Reflexes were increased on R. However, after reintubation, pt
with decreased responsiveness, such that he was no longer
following commands, with decreased spontaneous movements of his
R side (only withdrawing to noxious in both RUE/LE). he
continued to have L gaze preference with increased reflexes on
R. Decreased responsiveness/exam felt to be secondary to
infection as CT scans were stable on [**4-5**] and [**4-7**]. pt
continued to have stable exam - alert to voice, + BTT
bilaterally, with EOMI, R facial droop, spont movement of LUE
and LE (UE>LE), with withdrawal of R side to noxious. R toe up,
L toe down.
CV: BPs initially requiring a nicardipine gtt for BP control.
pt started on metoprolol, allowing for nicardipine to be weaned
off. however, on [**4-3**], increased BPs requiring norvasc which was
increased to 20 QD. nicardipine was restarted with continued
elevated BPs. FLP with LDL <70. BPs controlled on amlodipine 10,
metoprolol 50 TID, hydralazine 20 Q6. statin held with elevated
LFTs.
Resp: Pt extubated, which patient tolerated well requiring O2 by
face tent initially. however, pt had acute desat event [**3-16**]
mucous plugging on [**4-3**] with resulting bradycardia. pt was given
atropine x 1 with relief of bradycardia and patient was
reintubated. pt continued on vent support, until tracheostomy
performed on [**4-9**]. ventilator support discontinued on [**4-10**];
however, pt with increased secretions and resp distress
requiring vent support. taken off vent on [**4-11**]. pt with Aa
gradient. pt requiring frequent suctioning requiring stay in
ICU. pt required bronchoscopy on [**4-14**] with removal of
significant mucous plugging. pt stable on trach mask with
decreased suctioning prior to discharge.
Endo: A1c elevated 6.9. DSticks elevated. RISS and NPH needed
to maintain sugar control. stable by discharge.
ID: He with temperature elevation >101 on [**4-1**]. cultures were
sent - remained negative. CXR on [**3-31**] was wnl. CXR on [**4-2**] and
[**4-5**]: with bibasilar atelectasis. found on [**4-6**] to have
parotitis with neck swelling and rising WBC with fever. pt was
started on vanco and cipro with sputum also growing GPC and GNR.
neck swelling improved and pt became afebrile, but pt continued
to have rising WBC up to 22.4 on [**4-10**]. LFTs also elevated.
concern for cholecystitis - RUQ u/s wnl. statin held. LFTs
decreasing. WBC continued to be elevated on [**4-13**] - 2.
bronchoscopy with purulent discharge with GPCs on gram stain.
pt continued on vancomycin after bronchoscopy with declining
WBC. ciprofloxacin stopped after 10 day course for parotitis.
pt continued on additional 10D course of vancomycin with coag +
staph PNA (to be finished on [**4-25**]).
Heme: H/H decreased to 23 with hydration and with somewhat blood
tinged bronchoscopy. HCT stabilized. pt started on iron on
[**4-17**]/8.
FEN/GI: PEG placed [**4-9**] with prolonged intubation and inability
to manage his airway. BUN/Creat decreased to 52/1.2 on [**4-17**] with
PEG feeds and H2O boluses. Pt with elevated K and phos while on
probalance. Feeds switched to diluted nutren renal with
improvement in his electrolytes and continued improvement in
BUn/Creat.
Access: PICC placed [**4-8**].
COURSE ON [**Hospital1 **]:
84 yo M s/o large L frontal ICH, likely related to amyloid
angiopathy, residual R hemiparesis (should wear AFO for R foot
drop), trach and PEG. Was on Vanco for MRSA pneumonia recovered
from bronchoscopy.
On [**4-24**], he had a clinical deterioration, febrile, WBC up to 30,
so pancultured including C.diff, which have been negative other
than Staph Aureus in his sputum. Medicine consulted. Chest CT
showed persistent pleural effusions. RUE DVT somewaht improved
on f/u US, we are elevated that arm. Added Zosyn to the Vanco to
complete 14-day course (some doses have been held when Vanc
trough above 20). During that deterioration he was hypoglycemic,
requiring D50W and glucagon, so his long-acting insulin was
discontinued. He has required PRBC transfusions, Hct recently
stable at 24, however stools mildly guiaic positive, so should
monitor Hct level. He had some [**Last Name (un) 103**] pain, KUB, AST/ALT/lipase
were normal. His WBC remains elevated at 15.6 but afebrile and
he is clinically improved, requiring suctioning Q4hrs. SBP goal
120-140. [**Hospital 77946**] rehabilitation as albumin is only 2.
Medications on Admission:
glucophage
lipitor
namenda
amlodipine
atenolol
quinapril
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: max 4 g daily.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO once a day.
4. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 g Intravenous Q8H (every 8 hours) for 10 days.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb
Miscellaneous Q6H (every 6 hours) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units SC Injection TID (3 times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**7-21**]
Puffs Inhalation Q4H (every 4 hours).
14. Insulin Lispro 100 unit/mL Solution Sig: scale scale
Subcutaneous ASDIR (AS DIRECTED).
15. 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.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: as
directed as directed Intravenous DAILY (Daily) as needed.
17. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 24H (Every 24 Hours) for 10 days: PLEASE
MONITOR TROUGH LEVEL AND HOLD FOR LEVEL > 20
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
1)Large lobar R frontal intracranial hemorrhage
2)RUE DVT
3)MRSA Pneumonia
Discharge Condition:
stable
Discharge Instructions:
You have been hospitalized for a large bleed in your brain. Due
to this you should avoid at all times medications such as
aspirin, other antiplatelet agents, or anticoagulants, as these
may cause further bleeding. Your blood pressure needs to be
well-controlled.
Please attend all your follow-up appointments as directed.
Followup Instructions:
NEUROLOGY: Dr. [**First Name (STitle) **] [**Name (STitle) **] Date/Time:[**2143-6-4**] 5:30
Phone:[**Telephone/Fax (1) 2574**]
PLEASE CALL RADIOLOGY AT [**Telephone/Fax (1) 327**] TO SCHEDULE A FOLLOW-UP CT
SCAN OF YOUR BRAIN WITHOUT CONTRAST PRIOR TO YOUR [**Hospital **]
CLINIC APPOINTMENT; THIS COULD BE DONE EARLIER THAT AFTERNOON.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2143-4-30**]
|
[
"482.41",
"790.5",
"431",
"263.9",
"527.2",
"511.9",
"584.9",
"933.1",
"285.29",
"277.39",
"401.9",
"453.8",
"427.31",
"799.1",
"V09.0",
"272.0",
"507.0",
"250.82",
"518.81",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"96.04",
"38.93",
"96.71",
"34.91",
"96.6",
"96.05",
"33.24",
"31.1",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
16128, 16198
|
9382, 14124
|
247, 253
|
16316, 16324
|
3338, 9359
|
16694, 17154
|
2108, 2112
|
14232, 16105
|
16219, 16295
|
14150, 14209
|
16348, 16671
|
2127, 2473
|
194, 209
|
281, 1787
|
2725, 3319
|
2512, 2709
|
2497, 2497
|
1809, 1921
|
1937, 2092
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,192
| 177,920
|
2174
|
Discharge summary
|
report
|
Admission Date: [**2101-11-10**] Discharge Date: [**2101-11-16**]
Date of Birth: [**2037-3-10**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
left hip arthritis
Major Surgical or Invasive Procedure:
left tha
History of Present Illness:
64 y/o with OA of right hip,presents for surgical management of
pain. His hematology team was consulted for pre and post
operative care.
infusion, high risk bleeding, high risk thrombosis
.
History of Present Illness: 64 y/o male with chronic hepatitis B
infection with grade [**3-31**] cirrhosis (presently suppressed),
antithrombin III deficiency and superior mesenteric thrombosis
[**2095**](managed by Dr. [**Last Name (STitle) 2805**], on coumadin),
thrombocytopenia/macrocytosis, esophageal varices, and
hypertension who is POD #0 s/p left total hip replacement with
Dr. [**Last Name (STitle) **].
.
From surgical perspective, blood loss estimated to be 750 cc and
procedure was uncomplicated. Patient received 3L LR, 50 mL 25%
albumin, 2 mg versed, 8 mg decadron, 250 mcg fentanyl, total of
6 mg dilaudid, 4 g cefazolin. UOP was 240 cc during procedure.
.
From hematology perspective, patient presented with several days
of abdominal pain and bloating in [**2095-4-28**]. He underwent a CT
can at [**Hospital1 18**] on [**2095-5-19**], which demonstrated a nonocculusive
endoluminal thrombus within the superior mesenteric vein with
extension into more distal branches and extending into the main
portal vein. Work up at the time revealed low Protein C and
antithrombin III levels (Antithrombin III 48%, normal range 80
to 120%; Protein C antigen 31%, protein C functional 46%). On
[**2095-8-3**], the antithrombin III levels were determined was 54%
and the antithrombin antigen was 65%, both below the range of
normal. Further testing revealed he was negative for prothrombin
gene mutation, factor V Leiden, and anticardiolipin. He was
placed on coumadin therapy indefinitely with goal INR of [**3-2**].
.
In anticipation of his upcoming surgery, he was recently seen in
[**Hospital **] clinic on [**2101-9-16**]. At that time he was informed that hip
replacement surgery is associated with a very high risk of
developing thrombotic complications. For this reason, he was
recommended to stop coumadin 5 days prior to surgery and start a
Lovenox bridge (150 mg daily) until the day before his surgery.
He had low antithrombin III levels on [**2101-9-16**] (66%), although
these levels were all checked while he was still on Coumadin.
For this reason, he was recommended to receive ATIII repletion
therapy to correct the deficiency prior to having the procedure.
IVC filter was also considered for DVT prophylaxis, but he had a
relatively contraindication to its use with a prior history of
SMV thrombosis, and it was felt that collateral thrombosis could
further put that vascular tree at risk.
.
With regard to his AT3 deficiency, patient received 1 dose
before surgery to keep level > 100%. Level at baseline is
approximately 55%.
.
Prior to transfer, HR 84 and BP 144/89. Access 2 piv - 16 guage
x 2. Unable to obtain A-line as catheter would not thread.
Past Medical History:
1. Superior mesenteric vein thrombosis ([**4-/2095**]) secondary to
ATIII deficiency, on coumadin
2. macrocytosis/thrombocytopenia (thrombocytopenia and
macrocytosis were thought [**3-1**] liver disease from hepatitis B. He
was ruled out for myelodysplastic because his smear lacked
characteristic Pelger [**Last Name (un) 11605**] cells, ovalomacrocytes or microcytic
anemia)
3. Splenomegaly (per U/S in [**2100**])
4. hepatic cirrhosis (grade III/IV)
5. HTN on Naldolol
6. Esopageal varicies (An EGD done in [**2099-7-28**] showed grade 1
and 2 esophageal varicies)
7. Gall bladder polyps
8. Hepatitis B, unknown source of exposure(genotype D, with
precore and BCP mutations (basal core promoter mutation) on
tenofovir
9. Oral HSV on Valcyclovir
10. Hematuria-one episode as a childhood of unclear etiology
11. Colonic Adenoma [**2089**]--> s/p polypectomy. Repeat negative
colonoscopy in [**2094**].
Social History:
NC
Family History:
NC
Physical Exam:
well appearing, well nourished 64 year old male
alert and oriented
no acute distress
LLE:
-dressing-c/d/i
-incision-c/d/i -> no erythema or drainage. DIFFUSE ecchymosis
throughout entire LLE. mild edema
-+AT, FHL, [**Last Name (un) 938**]
-SILT
-brisk cap refill
-calf-soft, nontender
-NVI distally
Pertinent Results:
[**2101-11-10**] 07:12PM BLOOD WBC-11.2*# RBC-3.94* Hgb-13.7* Hct-39.7*
MCV-101* MCH-34.8* MCHC-34.5 RDW-13.7 Plt Ct-118*
[**2101-11-11**] 04:52AM BLOOD WBC-9.4 RBC-3.53* Hgb-12.6* Hct-35.6*
MCV-101* MCH-35.7* MCHC-35.4* RDW-14.6 Plt Ct-127*
[**2101-11-11**] 03:12PM BLOOD Hct-33.7*
[**2101-11-11**] 08:40PM BLOOD WBC-12.1* RBC-3.13* Hgb-10.6* Hct-31.8*
MCV-102* MCH-34.0* MCHC-33.4 RDW-13.5 Plt Ct-113*
[**2101-11-12**] 08:10AM BLOOD WBC-8.6 RBC-2.75* Hgb-9.8* Hct-28.4*
MCV-103* MCH-35.8* MCHC-34.6 RDW-14.8 Plt Ct-109*
[**2101-11-13**] 06:15AM BLOOD WBC-7.4 RBC-2.41* Hgb-8.4* Hct-24.2*
MCV-100* MCH-34.8* MCHC-34.7 RDW-13.7 Plt Ct-104*
[**2101-11-14**] 05:55AM BLOOD WBC-5.2 RBC-2.16* Hgb-7.8* Hct-22.3*
MCV-103* MCH-36.0* MCHC-34.9 RDW-14.7 Plt Ct-115*
[**2101-11-15**] 01:56AM BLOOD WBC-6.0 RBC-2.65* Hgb-9.3* Hct-26.4*
MCV-100* MCH-35.1* MCHC-35.2* RDW-16.2* Plt Ct-120*
[**2101-11-15**] 06:10AM BLOOD WBC-5.4 RBC-2.58* Hgb-8.9* Hct-25.4*
MCV-98 MCH-34.6* MCHC-35.2* RDW-15.8* Plt Ct-108*
[**2101-11-15**] 07:33PM BLOOD Hct-28.6*
[**2101-11-16**] 06:30AM BLOOD WBC-6.4 RBC-2.75* Hgb-9.6* Hct-27.9*
MCV-101* MCH-34.9* MCHC-34.5 RDW-16.7* Plt Ct-161
[**2101-11-10**] 07:12PM BLOOD Neuts-86.8* Lymphs-9.6* Monos-2.3 Eos-0.9
Baso-0.3
[**2101-11-11**] 04:52AM BLOOD Neuts-78.1* Lymphs-14.4* Monos-7.0
Eos-0.2 Baso-0.3
[**2101-11-15**] 01:40PM BLOOD PT-16.7* PTT-31.7 INR(PT)-1.5*
[**2101-11-16**] 06:30AM BLOOD PT-16.9* PTT-29.2 INR(PT)-1.5*
[**2101-11-14**] 12:21PM BLOOD LMWH-0.28
[**2101-11-10**] 01:59PM BLOOD AT-118
[**2101-11-11**] 04:52AM BLOOD AT-91
[**2101-11-12**] 08:10AM BLOOD AT-72
[**2101-11-13**] 06:15AM BLOOD AT-73
[**2101-11-14**] 05:55AM BLOOD AT-95
[**2101-11-10**] 07:12PM BLOOD Glucose-146* UreaN-16 Creat-0.8 Na-137
K-4.8 Cl-105 HCO3-24 AnGap-13
[**2101-11-11**] 04:52AM BLOOD Glucose-162* UreaN-18 Creat-0.7 Na-135
K-4.2 Cl-104 HCO3-24 AnGap-11
[**2101-11-12**] 08:10AM BLOOD Glucose-130* UreaN-19 Creat-0.8 Na-136
K-3.5 Cl-103 HCO3-28 AnGap-9
[**2101-11-14**] 12:21PM BLOOD Glucose-163* UreaN-17 Creat-0.7 Na-138
K-3.9 Cl-106 HCO3-26 AnGap-10
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. please see below
2. heme consulted for antithrombin III deficiency. follows with
Dr [**Last Name (STitle) 2805**]
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#2 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior hip
precautions.
Mr [**Known lastname 11606**] is discharged to home with services in stable
condition.
Assessment and Plan
Mr. [**Known lastname 11606**] is a 64-year-old male with history of liver
cirrhosis, hepatitis B, SMV/PV thrombosis and antithrombin III
deficiency (on coumadin), who is s/p left total hip replacement
and POD day 0. Admitted to [**Hospital Unit Name 153**] for administration of AT-3
# s/p left total hip replacement: POD #1. Uncomplicated surgery
per discussion with orthopedics, with estimated blood loss 750
cc. Pain well controlled currently.
- cefazolin per orthopedics recs (total of 3 doses)
- pain control with standing naproxen, tylenol and prn morphine
- written for dilaudid PCA per orthopedics, which can be
consolidated to morphine IV or PO regimen in next 24-48 hours
- monitor [**Hospital1 **] Hct for now and can transition to daily once
stable
- hip plain film per ortho on [**11-10**] and [**2101-11-12**]
- ROM Restictions post surgical hip precautions per ortho
.
# AT III deficiency: hip replacement surgery is associated with
a very high risk of developing thrombotic complications. Given
Mr. [**Known lastname 11607**] ATIII deficiency, underlying liver disease, and
previous history of venous thromboses, he is at high risk for
perioperative thrombosis. Prior to the OR, he received Thrombate
(antithrombin III) at a dose of 3864U IV x1 and his AT level
rose to 118%.
- appreciate hematology/oncology recommendations
- per heme/onc goal is an AT level >75% (ideally 80-120). This
morning??????s level was 91 so will get dose of 1656 U today
- he should have levels checked daily for at least the next
three days and will be dosed with additional Thrombate prn (at a
dose of 1656U IV daily).
- For DVT prophylaxis, has satarted Lovenox 30mg SC BID 12 hours
after surgery (orthopedics team aware). Currently not on
treatment dose heparin bridge per heme recs. Will touch base
about when to formally bridge to coumadin
- Continue coumadin
# Anemia: Hct 39.7--> 35.6 with baseline of 46-47. Unlikely to
be dilutional given lack of dilution of platelets. Other
possibility includes surgical site bleeding. Less likely B12,
folate, Fe deficiency, or anemia of chronic disease.
- trend with [**Hospital1 **] Hcts
- B12, folate, iron studies all pending
- will guaiac stool
# Hepatitis B: unknown source of exposure(genotype D, with
precore and BCP mutations (basal core promoter mutation) on
tenofovir.
- continue tenofovir per home regimen
# Oral HSV
- continue valacyclovir per home regimen
# HTN: BP currently stable.
- continue nadalol per home regimen
# Thrombocytopenia: stable and at baseline, per review of OMR
and per discussion with hematology.
- trend daily
Medications on Admission:
NADOLOL - 20 mg Tablet - one Tablet(s) by mouth daily
TENOFOVIR DISOPROXIL FUMARATE - 300 mg Tablet - 1 Tablet(s) by
mouth daily
VALACYCLOVIR - (Prescribed by Other Provider) - 500 mg Tablet -
1 Tablet(s) by mouth once a day
WARFARIN - 5 mg Tablet - 1-1.5 Tablet(s) by mouth once a day
Patient to take 7.5 mg daily 6 days per week and 5 mg daily 1
day
per week (Sunday).
Medications - OTC
GLUCOSAMINE SULFATE [GLUCOSAMINE] - (Prescribed by Other
Provider) - Dosage uncertain
OMEGA-3 FATTY ACIDS - (OTC) - Dosage uncertain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous twice
a day: until inr 2.0 -2.5.
Disp:*10 * Refills:*0*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
goal INR [**3-2**]. Follow by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**].
Disp:*30 Tablet(s)* Refills:*2*
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
left hip osteoarthritis
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool
softener (such as colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox twice a day and
coumadin 7.5 until your INR is therapeutic to help prevent deep
vein thrombosis (blood clots). After your INR is therapeutic
([**3-2**]) you may stop lovenox injections. Please follow up with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] on Friday.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four week
checkup. Please place a dry sterile dressing on the wound each
day if there is drainage, otherwise leave it open to air. Check
wound regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. posterior precautions. mobilize frequently. No
strenuous exercise or heavy lifting until follow up appointment.
Physical Therapy:
post hip precautions
wbat
Treatments Frequency:
daily dressing changes as needed
ice as tolerated
staples out 2 weeks from surgery
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2101-12-9**] 12:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2101-12-1**]
10:20
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2101-12-1**] 8:30
Completed by:[**2101-11-16**]
|
[
"054.9",
"287.5",
"V58.61",
"571.5",
"289.81",
"401.9",
"715.35",
"070.32",
"285.9",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"00.77"
] |
icd9pcs
|
[
[
[]
]
] |
12357, 12415
|
6648, 10865
|
338, 349
|
12483, 12483
|
4554, 6625
|
15559, 16034
|
4207, 4211
|
11437, 12334
|
12436, 12462
|
10891, 11414
|
12666, 14607
|
4226, 4535
|
15404, 15430
|
15452, 15536
|
280, 300
|
14619, 15386
|
596, 3245
|
12498, 12642
|
3267, 4171
|
4187, 4191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,728
| 135,702
|
26171
|
Discharge summary
|
report
|
Admission Date: [**2166-2-23**] Discharge Date: [**2166-2-26**]
Date of Birth: [**2117-10-5**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
45M unrestrained driver in MVC car v tree. + Airbags deployed,
unknown LOC, found face down in snow. GCS on EMS arrival to
scene [**6-21**], hemodynamically stable during transport.
Past Medical History:
Unknown
Social History:
Pt consumes alcohol on a daily basis.
Family History:
NC
Physical Exam:
Vitals 99 hr 84 bp 142/90 sats 100%
Pt not responsive, notably intoxicated
rrr
ctab
.
laceration over r orbit
sntnd + bs, FAST negative
pelvis stable, guaiac negative, decreased rectal tone
MAE
Pertinent Results:
[**2166-2-23**] 09:42PM TYPE-ART PO2-241* PCO2-35 PH-7.38 TOTAL
CO2-22 BASE XS--3
[**2166-2-23**] 09:42PM GLUCOSE-90 LACTATE-4.6* K+-3.5
[**2166-2-23**] 02:45PM UREA N-7 CREAT-0.8
[**2166-2-23**] 02:45PM ASA-NEG ETHANOL-161* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2166-2-23**] 02:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2166-2-23**] 02:45PM WBC-9.5 RBC-4.73 HGB-16.2 HCT-45.1 MCV-95
MCH-34.2* MCHC-35.9* RDW-12.5
[**2166-2-23**] 02:45PM PLT COUNT-227
[**2166-2-23**] 02:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
Mr [**Known lastname 34850**] was uneventfully intubated in the ED for airway
protection and management. He was then transferred to the Trauma
SICU for further evaluation of his condition. Initial films all
negative for traumatic pathology in the emergency department.
Head CT suggestive of possible frontal shear or cribiform palte
injury, however, on repeat head CT, there was no evidence of
these injuries. He was cleared from a neurosurgical perspective
early in his hospitalization.
.
Pt was weaned from the ET tube on HD 2 without difficulty and
transferred to the regular hospital floor. He was evaluated by
Pt who cleared him for discharge. By HD 3 ([**2166-2-25**]), pt was
stable and cleared without any acute intervention required for
his injuries. Due to his social situation, he was kept in the
hospital awaiting placement.
.
On HD 4 ([**2166-2-26**]), pt endorsed SI with a plan. For this reason,
psychiatric consult was obtained, who beleived the patient to be
suicidal and recommended transfer to a facility for psychiatric
stabilization.
.
He was discharged from [**Hospital1 18**] medically stable to HRI in
[**Location (un) **] on [**2166-2-26**]. Notably, he had a WBC count of 13,
however, without fever or evidence of systemic infection and
stable vital signs, there was no intervention required. In
addition, UA and CXR were previously clear.
Medications on Admission:
None.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
5. Folic Acid plus B12 1-0.8 mg Tablet Sig: One (1) Tablet PO
once a day.
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Transdermal
DAILY (Daily).
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary Diagnoses
1. s/p mvc
2. suicidal ideation
Discharge Condition:
Good.
Discharge Instructions:
Return to the ER or call a doctor if you should experience
numbness, tingling, weakness, visual changes, increased pain,
fever, chills or any other worrisome symptoms.
Followup Instructions:
With the trauma surgery clinic in [**2-17**] weeks, you can call
[**Telephone/Fax (1) 2756**] to be connected with the clinic to arrange an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"V71.4",
"V60.0",
"719.43",
"E815.0",
"311",
"873.42",
"303.00",
"V62.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"96.04",
"96.71",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
3493, 3512
|
1544, 2912
|
284, 310
|
3606, 3614
|
857, 1521
|
3830, 4114
|
624, 628
|
2968, 3470
|
3533, 3585
|
2938, 2945
|
3638, 3807
|
643, 838
|
241, 246
|
338, 522
|
544, 553
|
569, 608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,667
| 171,998
|
27118+57526
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-11-27**] Discharge Date: [**2159-11-30**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
low hematocrit, melena, left arm pain (?angina)
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
[**Age over 90 **] y/o full code male, resident of [**Hospital 100**] Rehab, with aortic
mechanical valve secondary to Listeria endocarditis (on
coumadin), Coombs positive autoimmune hemolytic anemia (warm
autoantibody, on prednisone), CAD s/p NSTEMI [**7-11**], CKD stage
III, chronic CHF (likely diastolic with EF 50%), and history of
GIB, who presented to the [**Hospital1 18**] ED with weakness and was noted
to have a hematocrit of 19 (Hct was 32 two weeks ago). Per the
ED, there was concern for acute bleed (given history consistent
with melena) vs hemolysis.
.
In the ED, initial vs were: 97.6, 80, 106/55, 16, 94%, pain
[**4-11**]. Patient reported left arm pain concerning for ?angina.
Patient was guaiac positive. He denied hemoptysis, hematemesis,
or brisk LGIB. Labs notable for Hct 18, INR 5.9. Cardiac enzymes
pending. Patient was evaluated by GI and plan is for upper
endoscopy tomorrow. GI stated that NG lavage should be deferred.
Received 5 mg vitamin K, pantoprazole 80 mg x 1, and was ordered
for 2u pRBC and FFP (did not receive). Blood bank following
patient closely.
.
In the ED, EKG notable for atrial fibrillation, RBBB, ?LAFB, no
ST changes. Access includes one 16G and one 20G PIV. PICC line
reported to be non-functional. VS on transfer: 97.6, HR 80-90,
BP 106/55, RR 16, 94-96% 2L NC.
.
On the floor, patient denies dyspnea and chest pain. He reports
pain in his palate.
.
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:
# Anemia from GI bleed of gastric ulcer vs. hemolytic anemia
# Autoimmune hemolytic anemia (Coomb's +, warm autoantibody),
previously on prednisone [**11-9**]
# Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped
due to hemolytic anemia
# Aortic mechanical valve, recently Coumadin resistant so on
Lovenox bridge
# hx recent GI bleeds: colonoscopy [**9-9**]: noted normal colon,
hemorrhoids
# GERD: EGD [**7-11**] with non-bleeding ulcers in
esophagus and stomach
# H/o presyncope
# CKD Cr 1.6-2.0 Stage III
# CAD s/p NSTEMI [**7-11**]
# Chronic CHF, likely diastolic, on diuretics ([**9-10**] EF=50%)
# Hyperlipidemia
# Hypertension
# Depression vs adjustment disorder after death of brother
# Prostate cancer- s/p radiation
# Bladder/bowel incontinence
# Right lateral malleolus stage 1 pressure ulcer
# Dementia
Social History:
Never smoked, no EtOH or other drugs. Born in NY and has been a
book binder all of his life. Moved to [**Location (un) 86**] to be closer to
his son, who is a Rabbi [**First Name8 (NamePattern2) 151**] [**Last Name (Titles) **] PhD. Currently living at
[**Hospital 100**] Rehab. Uses walker or wheelchair typically. Requires a
significant degree of assistance in all his ADLs and IADLs.
Family History:
No bleeding diatheses. Father had stomach cancer. No other
cancers including colon.
Physical Exam:
On Admission:
Vitals: T: 95.4, HR 87, BP 98-105/52-61, 21, 100% 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: occasional crackles at left base, improved with coughing,
otherwise clear
CV: irregular, mechanical S1 and 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
Guaiac: black, tarry, strongly guaiac positive, ext hemorrhoids
Pertinent Results:
On Admission:
[**2159-11-27**] 01:51PM BLOOD WBC-7.2 RBC-1.57*# Hgb-5.9*# Hct-18.0*#
MCV-115* MCH-37.2* MCHC-32.5 RDW-21.7* Plt Ct-193
[**2159-11-27**] 01:51PM BLOOD Neuts-90* Bands-1 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-1*
[**2159-11-27**] 01:51PM BLOOD PT-53.5* PTT-34.7 INR(PT)-5.9*
[**2159-11-27**] 01:51PM BLOOD Ret Man-10.8*
[**2159-11-27**] 01:51PM BLOOD Glucose-148* UreaN-41* Creat-1.5* Na-141
K-4.5 Cl-106 HCO3-26 AnGap-14
[**2159-11-27**] 01:51PM BLOOD ALT-16 AST-22 LD(LDH)-295* CK(CPK)-36*
AlkPhos-39* TotBili-0.6
[**2159-11-27**] 01:51PM BLOOD CK-MB-7 cTropnT-0.29*
[**2159-11-27**] 01:51PM BLOOD Hapto-<5*
[**2159-11-27**] 06:50PM BLOOD TSH-1.6
[**2159-11-27**] 11:54PM BLOOD Lactate-1.6
[**2159-11-27**] AP CXR - No radiopaque central venous line is evident.
Heart is mildly enlarged. Lungs are clear. Small left pleural
effusion is stable. Thoracic aorta is markedly tortuous,
probably explains rightward tracheal deviation.
Brief Hospital Course:
[**Age over 90 **] y/o full code male, resident of [**Hospital 100**] Rehab, with mechanical
aortic valve secondary to Listeria endocarditis (on coumadin),
Coombs positive autoimmune hemolytic anemia (warm autoantibody,
on prednisone), CAD s/p NSTEMI [**7-11**], CKD stage III, chronic CHF
(likely diastolic with EF 50%), and history of GIB, who
presented to the [**Hospital1 18**] ED with weakness and was noted to have a
hematocrit of 19 and melena on guaiac exam.
# Acute on chronic anemia/hct drop. Chronic anemia with
baseline Hct 25-30 secondary to warm autoimmune hemolytic anemia
(on prednisone, managed by heme/onc), stage III CKD, and
myelodysplasia. Acute hematocrit drop to Hct 16 was initially
suspected to be from UGIB vs. LGIB given melena on guaiac exam
(especially considering his history of esophageal
erosions/gastritis/lymphangiectasias). Differential also
included acute on chronic hemolysis from his warm hemolytic
anemia. He was hemodynamically stable in the ICU. He received
vitamin K with improved INR, a total of 4 units of PRBC, was
initially placed on an a pantoprazole drip which was later
transitioned from IV to PO omeprazole 40mg [**Hospital1 **]. He received an
upper GI endoscopy that did not reveal an active source of
bleeding, a non-bleeding duodenal polyp and a small hiatal
hernia were found. He continued on home iron, folate, MVI, and
alternating prednisone of 20 mg and 15 mg. Heme/Onc and GI were
consulted. He was transitioned to a PO diet which he tolerated
upon discharge.
# CAD/left arm pain. Likely result of demand ischemia given
acute drop in Hct, there were no ST/T changes on EKG and
although his troponin level was mildly elevated on discharge, it
trended down and his pain resolved with oxygen improvement of
his anemia. He was continued on home simvastatin.
# Aortic mechanical valve, on coumadin. Goal INR 2.5-3.5. He
was found to have INR 5.9 on admission, coumadin was held and he
received 5mg PO vitamin K in the ED with reversal of his INR to
2.2 in the setting of a potential GI bleed. Due to this rapid
reversal, there was suspicion that the initial INR was a
laboratory error. He was placed on a heparin drip (mechanical
valve) and was restarted on coumdain on [**2159-11-30**]. He will
continue on heparin drip until INR is at goal 2.5-3.5.
# Autoimmune hemolytic anemia. Heme/Onc was consulted. He
continued with home prednisone regimen and was started on
bactrim for PCP [**Name Initial (PRE) 1102**].
# Stage III CKD: Slight acute on chronic renal failure, likely
secondary to hypovolemia in setting of anemia. Resolved and
creatinine returned to baseline with improvement in his
hematocrit and volume status.
# Subclinical Hypothyroidism: TSH was normal. He continued
with home levothyroxine dose 75 mcg daily.
# Tinea corporis: Topical Clotrimazole was started for likely
tinea on his right foot. This should be continued for 7 days.
The patient was full code for this admission. His son was his
point of contact. [**Name (NI) **] will be discharged to [**Hospital1 100**] Home MACU
where he will continue on heparin drip and his INR should be
checked daily. A CBC should be checked in 1 week to ensure his
anemia and thrombocytopenia is stable.
Medications on Admission:
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 4
(Four) Tablet(s) by mouth daily
IPRATROPIUM BROMIDE - (Prescribed by Other Provider) - 0.2
mg/mL
(0.02 %) Solution - 0.5 (One half) mg inhaled every four hours
as
needed for SOB
LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet
-
1 Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by
mouth twice a day
PREDNISONE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 10 mg Tablet - 2 (Two) Tablet(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider; Dose adjustment -
no new Rx) - 40 mg Tablet - 1 Tablet(s) by mouth every evening
WARFARIN [COUMADIN] - (Prescribed by Other Provider; Dose 4.5
mg
daily) - Dosage uncertain
.
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 650 mg Tablet
-
1 Tablet(s) by mouth every 6 hours as needed for pain
BISACODYL [DULCOLAX] - (Prescribed by Other Provider) - 5 mg
Tablet, Delayed Release (E.C.) - 2 Tablet(s) by mouth every two
days
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg Tablet
-
2 (Two) Tablet(s) by mouth daily
GUAIFENESIN - (Prescribed by Other Provider) - 100 mg/5 mL
Liquid - 10 ml's by mouth every six (6) hours as needed for
cough
.
Allergies: Amoxicillin
.
Discharge Medications:
1. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: 0.5 mg Inhalation
every four (4) hours as needed for shortness of breath.
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. prednisone 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. prednisone 5 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
8. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO every 2 days.
11. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4)
Tablet PO DAILY (Daily).
12. guaifenesin 50 mg/5 mL Liquid Sig: Ten (10) mL PO every six
(6) hours as needed for cough.
13. heparin (porcine) in D5W 10,000 unit/100 mL Parenteral
Solution Sig: 1000 (1000) units Intravenous qhour: please
continue until INR at goal [**3-7**].
14. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
15. Clotrimazole Foot 1 % Cream Sig: One (1) application Topical
twice a day for 7 days: apply to rash on right foot.
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
capful PO DAILY (Daily) as needed for constipation.
17. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
every twenty-four(24) hours: for left midline.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Anemia: from either lower intestinal gastrointestinal source or
due to acute exacerbation of chronic warm hemolytic anemia
Mechanical valve: due to history of listeria endocarditis, on
coumadin
GERD
Chronic kidney disease: Stage III
Hypertension
Hyperlipidemia
Coronary Artery Disease
Subclinical hypothyroidism
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 66590**],
You came to the hospital because you were anemic (your blood
counts were much lower than normal) and we suspected possible
bleeding from your gastrointestinal tract. You had an upper
endoscopy which did not show any source of bleeding. You also
have an autoimmune disease which causes you to be anemic, this
disease was also likely contributing to your lower blood counts.
You received several units of blood, you improved, and were
stable for transfer back to your [**Hospital3 **].
Due to your anemia, we stopped your coumadin and you are
temporarily on heparin. We are restarting your coumadin and
once your INR is at goal, the heparin will be stopped.
Please follow up with your physicians as indicated below.
Please make an appointment to meet with your primary care doctor
at the [**Hospital1 100**] Home within the next 2 weeks to follow up on your
anemia.
Please make the following changes to your medications:
- Start Bactrim SS 1 tab daily (this is to prevent a lung
infection while you are on prednisone)
- Start Clotrimazole cream 1% apply moderate amount to rash on
right foot two times daily for 7 days
- Start Heparin IV infusion 1000 Units/hr until INR is at goal
2.5-3.5
- Start miralax 17grams (1 capful) daily as needed for
constipation
If you develop any signs of gastrointestinal bleeding including
black or bloody stools, nausea and vomitting black or bloody
fluids, please seek emergency care immediately.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2159-12-4**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2159-12-4**] 1:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2159-12-10**] 4:30
Please follow up with your [**Hospital1 100**] Home primary care doctor
within the next 2 weeks. Please discuss potential GI follow-up
appointments as well.
Completed by:[**2159-11-30**] Name: [**Known lastname 11583**],[**Known firstname 11584**] Unit No: [**Numeric Identifier 11585**]
Admission Date: [**2159-11-27**] Discharge Date: [**2159-11-30**]
Date of Birth: [**2069-10-9**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 5448**]
Addendum:
Labs upon discharge:
[**2159-11-30**]: HCT 26.9, Platelets 108, WBC 8.4, INR 1.1, PTT 44.9,
BUN 29, Cr 1.5,
Procedures:
EGD report [**2159-11-29**]: Small hiatal hernia
No gastric ulcer identified.
Polyp in the proximal part of the second part of the duodenum
Normal appearing ampulla of Vater.
Otherwise normal EGD to third part of the duodenum
Imaging:
CXR [**2159-11-27**]: No radiopaque central venous line is evident.
Heart is mildly enlarged. Lungs are clear. Small left pleural
effusion is stable. Thoracic aorta is markedly tortuous,
probably explains rightward tracheal deviation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**]
Completed by:[**2159-11-30**]
|
[
"276.52",
"427.31",
"585.3",
"553.3",
"428.0",
"110.5",
"578.9",
"V43.3",
"V58.61",
"403.90",
"283.0",
"V58.65",
"211.2",
"428.32",
"244.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
15202, 15426
|
5166, 8412
|
270, 275
|
11860, 11860
|
4177, 4177
|
13534, 14585
|
3449, 3537
|
9817, 11415
|
11525, 11839
|
8438, 9794
|
12036, 12970
|
3552, 3552
|
12999, 13511
|
1725, 2172
|
182, 232
|
14602, 15179
|
303, 1706
|
4191, 5143
|
11875, 12012
|
2194, 3023
|
3039, 3433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,731
| 187,718
|
38926
|
Discharge summary
|
report
|
Admission Date: [**2201-2-13**] Discharge Date: [**2201-2-23**]
Date of Birth: [**2139-8-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Left cerebellar stroke
Major Surgical or Invasive Procedure:
[**2201-2-13**]: Emergent Suboccipital decompressive craniotomy
[**2201-2-20**]: PEG
History of Present Illness:
The patient is a 52 year-old male with a h/o HTN, diabetes
transferred from [**Hospital3 **] intubated with a diagnosis of
left cerebellar hemorrhage. Per transfer report, he presented
to the emergency room per EMS after vomiting at home coffee
ground emesis with sudden onset severe occipital headache.
During
transport, he was noted to have SBPs in the 200s. While in the
emergency room, he vomited coffee ground emesis and an NGT was
placed with return of 200cc of coffee ground emesis. He was
noted to have difficulty controlling his left arm, unable to do
LUE finger to nose with expressive aphasia and left sided facial
droop. Following a CT scan of the head which demonstrated a
large cerebellar hemorrhage with mass effect on the 4th
ventricle, the patient became increasing dyspneic and agitated
and was intubated for blood pressure control and airway control.
Tox screen was negative.
In the emergency room on presentation, he had spontaneous
movement of his LUE and withdrawal to noxious stimuli of BLE
without movement of his RUE. Gag reflex intact. He was
transfered to the ICU.
Past Medical History:
- HTN
- DM
- Asthma
- Alcoholism (although pt's brother does not think he has had
anything to drink for years, unaware of whether pt had DTs, szs,
etc)
- Chronic abdominal distress
Social History:
7SOCIAL HISTORY:
- lives with wife who is Chinese (speaks [**Name (NI) 8230**]) and their 3
year-old son [**Name (NI) **]
- serves as a boss of parking garages
Family History:
FAMILY HISTORY:
- negative for seizure, stroke
- positive for heart disease, DM (father)
Physical Exam:
On Admission:
BP:151/100 HR:111 RR:21 O2Sats: 100 on vent
Gen: NAD, intubated and sedated on propofol.
HEENT: Pupils: PERL, EOMs unable to be assessed.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Unable to assess.
Orientation: Unable to assess.
Recall: Unable to assess.
Language: Unable to assess.
Naming intact. Unable to assess.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to [**2-10**] and 3-2
mm bilaterally. Unable to assess visual fields.
III, IV, VI: Unable to assess.
V, VII: Unable to assess.
VIII: Unable to assess.
IX, X: Palatal elevation symmetrical. Gag reflex intact.
[**Doctor First Name 81**]: Unable to assess.
XII: Unable to assess.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Unable to assess strength.
Sensation: Unable to assess.
On Discharge:
Alert and oriented x3. Left facial droop. PERRL, EOM intact. At
times a slight left pronator drift and dysmetria is noted. MAE
[**4-15**].
Pertinent Results:
Labs on Admission:
[**2201-2-12**] 10:23PM BLOOD WBC-21.9* RBC-5.66 Hgb-15.2 Hct-45.1
MCV-80* MCH-26.9* MCHC-33.8 RDW-13.7 Plt Ct-318
[**2201-2-12**] 10:23PM BLOOD PT-12.5 PTT-18.4* INR(PT)-1.1
[**2201-2-12**] 10:23PM BLOOD UreaN-12 Creat-0.7
[**2201-2-12**] 10:23PM BLOOD ALT-39 AST-30 AlkPhos-127 TotBili-0.8
[**2201-2-13**] 08:12AM BLOOD CK(CPK)-163
[**2201-2-12**] 10:23PM BLOOD Albumin-4.1
[**2201-2-13**] 08:12AM BLOOD CK-MB-4 cTropnT-<0.01
Labs on Discharge:
[**2201-2-23**] 06:05AM BLOOD WBC-10.7 RBC-5.10 Hgb-13.7* Hct-40.9
MCV-80* MCH-26.8* MCHC-33.5 RDW-13.2 Plt Ct-445*
[**2201-2-23**] 06:05AM BLOOD Plt Ct-445*
[**2201-2-23**] 06:05AM BLOOD Glucose-248* UreaN-17 Creat-0.9 Na-137
K-3.7 Cl-100 HCO3-27 AnGap-14
[**2201-2-23**] 06:05AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
-------------
IMAGING:
-------------
NCHCT [**2-12**]:
IMPRESSION: Large space-occupying process in the left posterior
fossa with
mass effect on the fourth ventricle, perimesencephalic cisterns,
and possible mild left tonsillar herniation. Given the
heterogeneity of the lesion, subacute blood products are not
excluded, but no definite acute blood products are identified.
[**Month (only) 116**] represent subacute infarct, hemorrhage, underlying mass
lesion or infection is not excluded and an MRI is recommended
for further evaluation if there is no contraindication.
MRI HEAD [**2-13**](Post-op):
Area of restricted diffusion with blood products in the left
cerebellum with enhancement along the folia. The differential
diagnosis
includes a disease such as intravascular lymphoma vs. an acute
infarct. The enhancement along the brainstem and internal
auditory canal could be due to leptomeningeal disease or due to
blood products within the subarachnoid space. There is tonsillar
herniation seen due to mass effect from the fourth ventricular
swelling and compression of the cerebellum and hydrocephalus
identified. Correlation with CSF findings when the mass effect
has reduced would help for further assessment.
NCHCT [**2-13**](Post-op):
Expected post-surgical changes of left occipital craniectomy
with
residual blood products and air within the resection bed.
Persistent but mild improvement of effacement of fourth
ventricle and foramen magnum crowding. No new hemorrhage. No
midline shift.
Echo [**2201-2-14**]:
Normal global biventricular systolic function. No pulmonary
hypertension or clinically-significant valvular disease seen.
Limited study.
MRA Brain [**2201-2-17**]:
1. Mild intracranial atherosclerotic disease. No vascular
malformation or
aneurysm.
2. Asymmetric nonvisualization of the left AICA and superior
cerebellar
arteries and nonvisualization of the PICA bilaterally.
Video Swallow eval [**2201-2-18**]:
SWALLOWING VIDEO FLUOROSCOPY: Oropharyngeal swallowing video
fluoroscopy was performed in conjunction with the speech and
swallow division. Multiple consistencies of barium were
administered. Barium passed freely through the oropharynx and
esophagus without evidence of obstruction. There was evidence of
penetration and gross aspiration with thin liquids and nectar.
IMPRESSION: Gross aspiration with thin liquids and nectar.
KUB [**2201-2-22**]:
FINDINGS:
Oral contrast is visualized in the large bowel, demonstrating
diverticulosis and a filled appendix. While there is a paucity
of air in the small bowel, I do not see dilated loops nor
abnormal air-fluid levels. The psoas margins are sharply
delineated. There is no evidence for pneumatosis or free air. A
PEG tube is seen, with the balloon component just to the left of
the L1 vertebral body pedicle.
IMPRESSION: Nonspecific nonobstructed bowel gas pattern.
Brief Hospital Course:
Mr. [**Name13 (STitle) 449**] was admitted to [**Hospital1 18**] intubated and was brought
emergently to the OR with Dr. [**Last Name (STitle) 739**]. He had a posterior
decompressive craniectomy. He returned to the SICU intubated and
post-op CT head was satisfactory. Off sedation he was following
commands with all 4 extremities, right grasp was weaker. He was
on a PPI drip for his coffee ground emesis per GI. His SBP goal
was <140 per Stroke Team. He was being weaned toward sedation in
the afternoon on [**2201-2-13**]. He was extubated on the [**2-14**], his
Protonix drip was transitioned to Po bid, neurologically he was
intact with a left facial and some serosanguinous drainage from
wound. He required frequent pulmonary toilet including deep
nasal suctioning which required him to remain in the ICU. SQH
was started on [**2-17**]. Neurology recommended an MRA and this was
ordered. The patient removed his NG tube twice. A Dobbhoff was
placed. He had tachycardia requiring IV Lopressor throughout the
day. His oral metoprolol was not able to be given during day due
to difficulty with Dobbhoff placement. The pm dose will be
given.
He continued to have some serous drainage at his incision. A
small leak was noted at the superior aspect of his incision and
2 staples were placed at the bedside in the pm of [**2201-2-17**]. He
removed his Dobhoff. He was getting prn Lopressor for
tachycardia. He did not get any medication sthrough dobhoff
before he pulled it out. He had no further respiratory or wound
issues overnight. On [**2-18**] transfer orders for the floor with
telemetry were ordered.
A Sp/Swallow re-eval was performed with video study on [**2-18**].
They recommended a PEG with modified [**Month/Year (2) **] for pleasure. He was
cleared for nectar thick piquids, purees, meds in puree, strict
aspiration precuations., Will all po's he needs to utilize a
left head turn and chin tuck.
GI was called with these recommendations. They scheduled him for
a PEG and this was done on [**2201-2-20**]. SQH was being held. His
Foley was discontinued on [**2201-2-19**]. On [**2-21**] he had an episode of
coffee grain emesis a KUB was done which was unremarkable but
did show diverticulosis.
PT/OT was consulted. They recommended rehab and the patient was
cleared for discharge on [**2201-2-23**].
Medications on Admission:
Unknown
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no
bm 48 hrs.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp>100/HA.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for HTN.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab
Discharge Diagnosis:
Left cerebellar infarct
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Name10 (NameIs) **]
Usually no special [**Name10 (NameIs) **] is prescribed after a craniotomy. A
normal well balanced [**Name10 (NameIs) **] is recommended for recovery, and you
should resume any specially prescribed [**Name10 (NameIs) **] you were eating
before your surgery.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this on after clearance from Dr.
[**Last Name (STitle) 739**].
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you
are awake.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please follow-up with Dr. [**Last Name (STitle) 739**] 4 weeks after
discharge. You will need a Head CT w/o contrast. Please call
Paresa to set up this appointment [**Telephone/Fax (1) 1272**]
?????? Please follow-up with your PCP after discharge. You should
also set up a outpatient GI appointment as your KUB showed
Diverticulosis.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2201-2-23**]
|
[
"V58.67",
"787.22",
"305.03",
"530.10",
"781.3",
"998.32",
"578.0",
"781.94",
"250.02",
"348.4",
"493.22",
"401.9",
"518.81",
"E878.8",
"729.89",
"784.3",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.71",
"96.6",
"38.91",
"04.42",
"01.39",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
10487, 10537
|
6811, 9131
|
341, 428
|
10605, 10629
|
3143, 3148
|
13467, 13971
|
1969, 2044
|
9189, 10464
|
10558, 10584
|
9157, 9166
|
10653, 13444
|
2059, 2059
|
2984, 3124
|
279, 303
|
3610, 6788
|
457, 1554
|
2498, 2970
|
3162, 3591
|
2345, 2482
|
1576, 1759
|
1792, 1937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,902
| 145,768
|
10102
|
Discharge summary
|
report
|
Admission Date: [**2183-8-16**] Discharge Date: [**2183-8-18**]
Date of Birth: [**2134-2-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 yo M discharged from ED this morning for EtOH intoxication
who was BIBA for seizure. Long history of EtOH abuse and
innumerable ED visits for the same. Per patient, drinks 2-3
pints vodka/day, in addition to an unknown number of beers. Last
drink was evening of [**8-14**].
In ED: VS on presentation: bp: 144/85 HR: 116 RR: 16 Sat: 97%on
RA
No labs were drawn. Head CT negative on prelim read. No EKG
done. Was a/o x3, and appropriate. Neuro exam was unremarkable.
Placed on CIWA, received total of 50 iv valium.
VS prior to transfer: BP:132/84 HR:86 RR: sat:97%.
Head CT: No ICH, No shift. Pt has total of 23 head CTs & 15
C-spine CTs since [**2181-6-19**]!
On transfer to the unit patient reports feeling nauseous, had
mild HA and mild back pain. Denies CP or SOB.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Alcohol abuse with history of withdrawal seizures
Epilepsy
HTN
GERD
s/p ORIF left ankle
H pylori
Hemorrhoids
Barrett's esophagus
Social History:
Homeless. Sometimes stays with brother or a female friend.
[**Name (NI) **]-term EtOH abuse, ongoing, cannot quantify amount. Most
recent drink yesterday. Denies IV drug use. Smokes 1 ppd. 3
children.
Family History:
From the records:
Pt. does not remember the cause of death of his mother or
father. [**Name (NI) **] states fateher died in [**2145**]. Mother may be alive,
but states "I do not know a lot about my mother". Many siblings
- unclear if illnesses.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented to person, place, time and purpose. In
no acute distress
HEENT: NC/AT. Sclera anicteric, dry mm, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTp throughout, mildly distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ pedal edema
Neuro: cn 2-12 intact, strength 5/5 throughout, gait not
assessed, mild tremor in hand R/L but no asterixis
Skin: multiple hyperpigmented plaques on LE of vaious sizes,
appear chronic, mildly TTP
Pertinent Results:
[**2183-8-16**] 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2183-8-16**] 12:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2183-8-16**] 12:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2183-8-16**] 12:40AM WBC-3.1* RBC-3.66* HGB-10.9* HCT-34.5* MCV-95
MCH-29.9 MCHC-31.6 RDW-18.7*
[**2183-8-16**] 12:40AM NEUTS-64.4 LYMPHS-31.9 MONOS-2.3 EOS-0.9
BASOS-0.5
[**2183-8-16**] 12:40AM GLUCOSE-85 UREA N-4* CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16
[**2183-8-16**] 07:52AM ALBUMIN-3.6 CALCIUM-8.2* PHOSPHATE-2.7
MAGNESIUM-1.5*
[**2183-8-16**] 07:52AM ALT(SGPT)-49* AST(SGOT)-136* ALK PHOS-70 TOT
BILI-0.8
[**2183-8-16**] 07:52AM PT-13.4 PTT-26.7 INR(PT)-1.1
CT HEAD:
FINDINGS: There is no intracranial hemorrhage, loss of
[**Doctor Last Name 352**]-white matter
differentiation, mass effect, or edema. The ventricles, sulci,
and cisterns
are of normal configuration and size for age. There is no
fracture. Post-
surgical changes are seen in the right supraorbital region,
stable. The
mastoid air cells and visualized paranasal sinuses are clear.
IMPRESSION: No acute intracranial hemorrhage, cerebral edema or
skull
fracture. Stable global, particularly bifrontal cortical,
atrophy, which may
relate to the history above.
CT C-SPINE: FINDINGS: There is no acute fracture or malalignment
of the cervical spine. Atlantodental and craniocervical junction
are normal. The prevertebral tissues are normal. Facet joints
are normally aligned. Lateral masses of C1 are well-seated on
C2. The dens appears normal. Mild degenerative changes are seen
at C5 anteriorly, appear unchanged. There is no significant
central canal stenosis. The thyroid appears normal. Lung apices
demonstrate mild apical scarring.
IMPRESSION: No acute fracture or malalignment of the cervical
spine.
N.B. This patient has had a total of 22 Head CTs and 15 C-spine
CTs since
[**2181-6-19**].
Brief Hospital Course:
49 yo M with long h/o chronic EtOH use and mulitple ED visits
for EtOH intoxication, discharged from ED this morning of
admission for EtOH intoxication who then seized shortly after
discharge. Seizure witnessed by bystander. Admitted to MICU for
needing frequent CIWA checking, then transferred to floor prior
to eloping.
# Seizure: Very likely [**1-6**] EtOH withdrawal. Could also be [**1-6**]
epiliptic sz - per prior records, has epilepsy, followed at [**Hospital1 2177**],
has been on Zonegran in the past (discharged on it [**2-10**]) but per
patient hasn't taken it in 1 month. Lytes were normal. Head CT
negative. Was seen by neruology who did not feel pt should start
an antiepileptic due to his chronic non-compliance and thought
that the sx was withdrawal induced. He was continued on CIWA
scale and had no further seizure activity, and did not require
any benzos prior to leaving the hospital (eloping).
# EtOH Abuse: Currently using etoh, no EtOH level done in ED on
[**8-14**]. Social work consult placed for addiction hx, but did not
see pt prior to his leaving the hospital. B12 was normal. Pt was
given thiamine, folate, and MV. LFTs showed mild elevation of
AST/ALT.
# Skin rash: Appears chronic, unclear what the cause is. Pt was
started on antifungal cream. HIV and Hep C test were checked,
and were negative.
# HTN: Unknown meds as out patient. BP's ranging 130-160's in
ED. Was restarted on Norvasc.
# Pancytopenia: Slightly lower than baseline, has had in past,
has been attributed to EtOH in past. MCV 95. However, concern
for other possible etiology. HIV and HepC checked and tests
negative. Multivitamin was started in-house.
Medications on Admission:
Zonegran - not taking
hx of Norvasc- was not taking
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Seizure
Alcohol withdrawal
Discharge Condition:
Good, vital signs stable
Discharge Instructions:
You were admitted to the ICU for a seizure that was likely
related to withdrawal from alcohol. You were given valium as
needed with improvement. You showed no furthr signs of
withdrawal while in the hospital.
YOu should return to the emergency room if you develop any
concerning symptoms such as chest pain, shortness of breath,
fever, tremulousness, dizziness.
Followup Instructions:
Pt left hospital without signing out AMA (eloped).
|
[
"530.85",
"V60.0",
"530.81",
"345.90",
"305.1",
"V15.81",
"291.0",
"303.01",
"782.1",
"284.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7047, 7053
|
5000, 6658
|
326, 332
|
7133, 7160
|
2924, 3771
|
7572, 7625
|
1905, 2154
|
6760, 7024
|
7074, 7112
|
6684, 6737
|
7184, 7549
|
2169, 2905
|
274, 288
|
1153, 1515
|
360, 930
|
3780, 4977
|
939, 1135
|
1537, 1668
|
1684, 1889
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,531
| 129,417
|
24166
|
Discharge summary
|
report
|
Admission Date: [**2193-7-12**] Discharge Date: [**2193-7-23**]
Date of Birth: [**2128-7-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
C/O increasing SOB -returns for bronchoscopic evaluation
Major Surgical or Invasive Procedure:
flexible and rigid bronchoscopy for debridement of granulation
tissue above and below T-Tube with interum trach then
replacement of T-Tube.
History of Present Illness:
65yo Portuguese speaking woman with h/o CAD s/p CABG with
chronic trach c/b tracheal stenosis s/p tracheal resconstruction
[**6-/2192**], transferred now from [**Hospital6 302**] with pneumonia.
She underwent 3v CABG in 10/[**2190**]. Hospital course was
complicated by recurrent pneumonias and 5week intubation. She
eventually underwent tracheostomy, which has been in place since
late [**2190**]. In [**6-/2192**] she underwent tracheal revision at [**Hospital1 18**].
She has been evaluated by interventional pulmonary multiple
times by bronchoscopy for subglottic stenosis and T-tube mucus
plugging, last on [**2193-5-10**].
.
She presented to [**Hospital6 302**] ED [**2193-7-11**] with a few days
of productive cough and nausea, and was diagnosed with
right-sided pneumonia. Initial vitals T 98.9 HR 78 BP 125/32 RR
22 100%6L/min. She was treated with levofloxacin and vancomycin.
She was evaluated by cardiology, who felt she was in slight
congestive heart failure, and ENT, who performed fiberoptic
laryngoscopy and tracheoscopy. Laryngoscopy reveals complete
subglottic obstruction, ?laryngeal web or subglottic mass.
Tracheoscopy revealed collapsing distal trachea with inspiration
and granulation around the tracheostomy tube.
On presentation now she c/o pain along her right lateral chest
wall. She denies shortness of breath. She complains of some
nausea, but denies abdominal pain.
Past Medical History:
tracheal stenosis
prolonged intubation (5-6 weeks) after
CABG X 3 performed at OSH in 12/[**2190**].
Balloon dilitation of the proximal trachea with excision of
granulation tissue on anterior tracheal wall,
IDDM, CAD, MI, PNA [**2189**]
Social History:
son and daughter live in [**Name (NI) 5503**] area. Very supportive
family
Family History:
non-contributory
Physical Exam:
GEN: comfortable, no accessory muscle use, coughing, NAD
HEENT: PERRL, anicteric, MMM, OP clear
Neck: trach, stridor, supple, no LAD, JVP nondistended
CV: tachy, regular, no mrg
Resp: diffuse inspiratory and expiratory wheeze, milding
decreased BS at right base
Abd: +BS, soft, NT, ND, no masses
Ext: no edema, 2+ DPs
Neuro: alert, answers yes/no questions appropriately, MAEW
Pertinent Results:
[**2193-7-22**]
EXAMINATION: AP chest.
A single AP view of the chest is obtained on [**2193-7-22**] at 1145
hours. It is very limited technically. It does, however, appears
to show cardiomegaly. Tracheostomy is in place. Right-sided PICC
line has its tip projected over the expected location of the
proximal SVC. There is increased density in both lower lung
zones, particularly on the right side, likely representing
airspace disease.
IMPRESSION:
Very limited image technically showing likely airspace disease
both lower lungs, more marked on the right side.
Bedside swallow eval:
SUMMARY / IMPRESSION:
Functional oral and pharyngeal swallowing ability with no signs
of aspiration at the bedside. "Silent" aspiration, or
aspiration
without coughing can not be ruled out on the basis of a bedside
swallowing evaluation alone. However, she seems safe to eat
regular consistency solids and to drink thin liquids. Nursing
reports that she can swallow pills whole w/water without
difficulty.
RECOMMENDATIONS:
1. Diet of regular consistency solids and thin liquids
2. Pills whole with water
3. We would be happy to perform a videoswallow if there are
further concerns about aspiration while eating or drinking
Brief Hospital Course:
Pt admitted to MICU for resp monitoring and frequent sxn'ing.
Sputum cultures obtained and started on levo, vanco while
awating culture results- history of MRSA PNA. Pt was transferred
from MICU to general floor on HD#3. Flex bronch was performed
on HD#4 which showed granulation tissue above and below the
T-Tube; T-Tube itself patent and supra and subglottic edema
noted. Moderate secretions cleared. Started on mucinex to break
up secretions, decadron and [**Hospital1 **] protonix as well as ongoing
genttle Iv hydration. picc Line was placed for IVAB.
HD#6 Pt scheduled for rigid bronch in the OR for laser
debridement of granulation tissue with ENT. D/t edema after
clearing of granultion tissue, T-tube was unable to be
re-inserted and temp trach was placed through stoma.
Swallow eval was done d/t daughter's report of pt coughing w/
po's as outpt. Bedside swallow eval was done w/o evidence of
aspiration. Tolerated reg diet.
HD#10 T-Tube was replaced in the OR w/o incident. Persistant
edema was noted which does not appear to be improving on oral
steriods therefore, they are being rapidly tapered. Edema will
improve gradually.
During this hospital course pt's glucose was difficult to
control on standing insulin and sliding scale dosing. [**Last Name (un) **]
team was consulted re: glucose management w/ some improvement
-further improvement will be noted when steriod taper completed.
She will remain on IVAB Vancomycin for 2 week total course.
She will have follow up w/ interventional pulmonology for a
bronchoscopy in 4 weeks.
Medications on Admission:
Amio 200', Pulmicort 0.5", Colace 100', Lasix 80", Glipizide
5", Insulin 75/25 20units [**Hospital1 **], SSI, Combivent neb Q2hr, Levoflox
500 Q48, synthroid 125mcg', Lisinopril 20', Metoprolol 50",
Nystatin TP"', Pioglitazone 15', Ranitidine 150', Sertraline
100', Vanc 1000'
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
11. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
16. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 days: [**7-22**] and [**7-23**].
17. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 2 days: [**7-24**] and [**7-25**].
18. Dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 days: 8/25/and [**7-27**] then d/c.
19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous Q 24H (Every 24 Hours) for 7 days: until
[**2193-8-1**].
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
Coronary artery disease s/p 3v CABG [**9-4**], Congestive heart
failute EF 30%, Hypertension, Hyperlipidemia, Diabetes Mellitus
II, Tracheomalacia s/p tracheoplasty & t-tube, Depression,
Hypothyroidism
Discharge Condition:
good
Discharge Instructions:
CAll [**Name6 (MD) **] [**Name8 (MD) **], MD/ Interventional Pulmonary [**Telephone/Fax (1) 3020**] or
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**] for any issues regarding your T-Tube.
Followup Instructions:
Please make follow-up appointment w/ Urology Dept- [**Hospital1 18**] Urology
Dept phone #-[**Telephone/Fax (1) 61400**].
Call Dr.[**Name (NI) 14680**] office [**Telephone/Fax (1) 3020**] to be seen for a flexible
bronchoscopy in 3 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2193-7-23**]
|
[
"272.4",
"584.9",
"V45.81",
"244.9",
"401.9",
"V58.67",
"428.0",
"412",
"493.22",
"482.41",
"250.00",
"519.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"97.23",
"31.5",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
7757, 7828
|
3990, 5539
|
376, 518
|
8074, 8081
|
2746, 3967
|
8330, 8691
|
2315, 2333
|
5867, 7734
|
7849, 8053
|
5566, 5844
|
8105, 8307
|
2348, 2727
|
280, 338
|
546, 1946
|
1968, 2206
|
2222, 2299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,427
| 101,329
|
2903
|
Discharge summary
|
report
|
Admission Date: [**2173-10-21**] Discharge Date: [**2173-10-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 86 year old female with a history of
hypertension, hypercholesterolemia, and dementia who presents
from [**Hospital3 **] with complaints of chest pain. The patient
is a poor historian, providing varied details since
presentation. [**Name (NI) **] unclear why she had come to the hospital.
Endoreses having experineced chest pain, which she describes as
daily, occuring with exercise. Says she infrequently gets with
rest. Denies any SOB, DOE, or palpitations. She has no history
of prior heart attack or being told she has a bad heart. No
headaches, blurred vision, or focal motor,sensory abnormalities.
In the ED, initial plan was to observe patient overnight with a
ROMI, and a ETT in the morning. During her ED stay, patinet had
an 16 beat run of NSVT, during which she was asymptomatic. Over
the course of the day, patient's BP had been drifing upward,
with systolic blood pressure rising from 155 to 264, and
developed respiratory distress. Her O2 sats dropped to low 90s.
She was initially given 5 mg of metoprolol x 2 without
significant effect. She was begun on a nitro gtt, with reduction
to SBP to 165. Additonally, she was begun on CPAP 10/5 and given
20mg IV lasix, to which she put out 500cc. She was successfully
ween to 5L O2 NC and sent to the CCU for further care. The
patient remained chest pain free throughout.
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope. Has markedly swollon legs with venous
stasis changes, which the patinet reports to be chronic for
months to years.
Per contact with pt's Alzheimer's facility, pt does not usually
complain of chest pain. They report that prior to presenting to
the [**Name (NI) **], pt had had a visitor after which she developed some
agitation. There is no record of chest pain, rather emotional
distress.
Past Medical History:
Hypertension
Hyperlipidemia
Dementia
Social History:
Patient is resident at springhouse [**Hospital3 **]. She has a
durable limited power of attorney to Robiee [**Doctor Last Name **]. Never
married, no children. Worked as a secretary.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: T=98.5 BP= 163/ 46 HR= 64 RR= 30 O2 sat= 100% on 5LNC
GENERAL: Frail elderly female in NAD. Oriented x2. Mood, affect
appropriate. Hard of hearing.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MM. No
xanthalesma.
NECK: Supple with JVP flat.
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. Patient
tachypic, no accessory muscle use. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ LE pre-tibial edema, with b/l erythema and skin
breakdown.
SKIN: LE stasis dermatitis with ulceration
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2173-10-22**] 04:16AM BLOOD WBC-7.8 RBC-4.11* Hgb-12.2 Hct-35.5*
MCV-86 MCH-29.7 MCHC-34.4 RDW-15.0 Plt Ct-131*
[**2173-10-21**] 04:20PM BLOOD PT-13.9* PTT-25.0 INR(PT)-1.2*
[**2173-10-22**] 04:16AM BLOOD Glucose-118* UreaN-12 Creat-0.8 Na-145
K-4.3 Cl-106 HCO3-32 AnGap-11
[**2173-10-22**] 04:16AM BLOOD CK(CPK)-41
[**2173-10-22**] 04:16AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2173-10-22**] 04:16AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.1 Cholest-PND
[**2173-10-22**] 04:16AM BLOOD Triglyc-PND HDL-PND
PA/LAT [**10-21**]:
1. Minimal bibasilar atelectasis.
2. Calcified structure in the left upper quadrant of uncertain
etiology.
ECHO [**10-22**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with normal free
wall contractility. 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 leaflets are mildly thickened. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Patient is an 86 year old female with a history of HTN,
dyslipidemia, and dementia who presented with complaints of
atypical chest pain, admitted with hypertensive emergency with
flash pulmonary edema.
# CORONARIES: The patient has no known history of significant
coronary disease. EKG only with mild ST changes in setting of
marked hypertension, and symptoms of pain atypcial for ACS
event. Had mild troponin elevation on second set of cardiac
markers, and flat CKs, thought to be most likely demand ischemia
in setting of marked systolic hypertension. No mediastinal
enlargement to suggest aortic dissection. Patient is a poor
historian, describing daily exertional chest pain with exercise,
but has varied answering to questions. On confirmation with pt's
[**Hospital3 **] facility, she had not previously ever complained
of chest pain. Pt was medically managed with aspirin, statin.
Prior to discharge she was restarted on her outpt atenolol and
added lisinopril 5mg for additional BP control.
# PUMP: The patient has no known history of heart dysfunction,
but did develop flash pulmonary edema in the setting of
hypertensive emergency. Pt responded very well to lasix both
symptomatically and on oxygen requirement. Pt did not require
any additonal doses of lasix since arriving to the CCU.
Echocardiogram showed moderate LVH, EF 75%, [**11-25**] TR, no wall
motion abnormalities and increased PCW.
# RHYTHM: No current or history of arrythmias
# HYPERTENSIVE URGENCY: Pt with no history of significant
systolic blood pressure elevation and only on atenolol 25mg
daily preivously. In the emergency room, pt's SBP rose to 260
complicated by flash pulmonary edema. Pt received IV beta
blockade and a nitroglycerin drip, which was able to be weaned
off within several hours. Etiology of hypertension was thought
to be mostly agitation and pt's BPs were well controlled with
home dose of atenolol and the addition of lisinopril 5mg daily.
Pt will need monitoring of electrolytes several days post
discharge to evaluate effects of new medicaiton.
# ACUTE PULMONARY EDEMA: Pt developed acute pulmonary edema in
the setting of hypertensive emergency. Improvement with blood
pressure control, diuresis, and CPAP, with thereafter good
saturations and comfort on minimal O2. Pt did not require any
additonal diuresis after arriving to the CCu.
# DEMENTIA: Pt was continued on Zyprexa.
Pt's code status was DNR/DNI throughout the hospitalization.
Medications on Admission:
Atenolol
Lipitor
ASA
Exelon
Zyprexa
MVI
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Rivastigmine 4.6 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Discharge Disposition:
Extended Care
Facility:
Springhouse
Discharge Diagnosis:
Hypertensive Urgency
Discharge Condition:
Stable, SBP 120s-140s.
Discharge Instructions:
You were admitted for very high blood pressure, thought to be
secondary to emotional distress. You blood pressure was well
controlled while you were here with the addition of Lisinopril
5mg daily. We also made sure that you did not have a heart
attack.
The following changes were made to your medications:
**ADD lisinopril 5mg by mouth daily
Please call your doctor or return to the hospital if you
experience any chest pain, shortness of breath, visual changes,
nausea, vomiting, lightheadedness or any other concerning
symptoms.
Followup Instructions:
Please see your primary care doctor in the next 1-2 weeks.
Completed by:[**2173-10-22**]
|
[
"401.0",
"518.4",
"707.19",
"459.81",
"272.0",
"707.22",
"294.8",
"276.0",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8417, 8455
|
5447, 7900
|
275, 281
|
8520, 8545
|
3899, 5424
|
9127, 9218
|
2888, 2948
|
7991, 8394
|
8476, 8499
|
7926, 7968
|
8569, 9104
|
2963, 3880
|
225, 237
|
309, 2555
|
2577, 2615
|
2631, 2872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,497
| 166,377
|
28094
|
Discharge summary
|
report
|
Admission Date: [**2129-10-12**] Discharge Date: [**2129-12-7**]
Date of Birth: [**2081-5-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
OSH transfer for pulmonary eval
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Central Venous Line
History of Present Illness:
48 year-old woman with history of chronic interstitial lung
disease/pulmonary fibrosis, paroxysmal atrial fibrillation on
[**6-12**] liters oxygen at home who presented to [**Hospital 67742**] Medical
Center (NH) on [**2129-10-8**] with c/o SOB. She was found to have O2
saturations in the mid-80's (baseline is low 90's) and was
tachypneic. Her saturations improved on Bi-PAP of 16 and 7 with
100% FiO2. While still in the ER, she went into atrial flutter
which resolved with Metoprolol 5 mg x 3. The patient was moved
to the [**Location (un) 67742**] MICU. On [**10-9**] she was emergently intubated. She
had a R IJ central line and a left radial a-line placed. The OSH
records are spare, but it appears that the pt was on abx,
possibly bactrim, zithromax, and/or zosyn, and solumedrol though
more information is unavailable. The pt was transferred to [**Hospital1 18**]
for further pulmonary w/u.
.
Upon arrival to the MICU the pt was already intubated but was
breathing uncomfortably and was in A fib with rapid RVR. The pt
was given lopressor 5 mg IV X3 with no effect on her heart rate.
The pt was placed on a dilt gtt for planned improved rate
control.
Past Medical History:
Chronic interstitial lung disease/pulmonary fibrosis
Paroxysmal atrial fibrillation (on coumadin) and ablation (/06)
Atherosclerotic cardiovascular disease
HTN
Hyperlipidemia
Obesity
Uncontrolled blood sugars (prednisone-induced)
Social History:
She has a history of tobacco abuse but currently does not smoke.
No EtOH or drug abuse
Family History:
Significant for mother dying of heart disease at age 47 after MI
at age 43.
Physical Exam:
T: 98.7 BP: 126/70 P: 122 RR: 22 sat: 97% vent
AC 550X15 FiO2 100%
General: intubated, sedated
HEENT: mm dry
Resp: coarse ronchi and crackles throughout
Card: atrial fibrillation with rate
Abd: obese, + BS, NT/ND, soft
Ext: trace edema b/l
Neuro: moving all four extremities
Pertinent Results:
Admission Labs:
==============
[**2129-10-12**] 11:33PM PT-14.7* PTT-27.3 INR(PT)-1.3*
[**2129-10-12**] 11:33PM WBC-16.9* RBC-3.54* HGB-11.5* HCT-34.5*
MCV-97
[**2129-10-12**] 11:33PM NEUTS-87.7* LYMPHS-8.6* MONOS-3.5 EOS-0.1
BASOS-0.1
[**2129-10-12**] 11:33PM ALBUMIN-3.7 CALCIUM-8.7 PHOSPHATE-5.4*
MAGNESIUM-2.9*
[**2129-10-12**] 11:33PM CK-MB-NotDone cTropnT-<0.01
[**2129-10-12**] 11:33PM ALT(SGPT)-206* AST(SGOT)-246* LD(LDH)-1269*
CK(CPK)-50 ALK PHOS-199* AMYLASE-52 TOT BILI-1.5
[**2129-10-12**] 11:33PM GLUCOSE-226* UREA N-26* CREAT-0.9 SODIUM-141
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-31 ANION GAP-15
.
RADIOLOGY:
==========
CTA [**2129-10-15**]
IMPRESSION:
1. Ill-defined ground-glass opacities in a peripheral and
basilar distribution. Findings are compatible with patient's
provided history of interstitial lung disease.
2. Linear calcification at the left lung base with anterior rib
fractures visualized along the seventh and eight ribs; likely
post-traumatic
.
CT ABD/PELV:
===========
IMPRESSION:
1. Significantly limited study due to attenuation by the
patient's large body habitus.
2. No significant change in diffuse ground-glass opacity of the
visualized lungs. This could represent chronic interstitial lung
disease; however, underlying infection cannot be excluded.
3. Prominence of the extrahepatic biliary duct at 12 mm. No
intrahepatic biliary ductal dilatation. Possible tiny gallstones
but there is no evidence of acute cholecystitis.
4. No intra-abdominal fluid collection or abscess identified
.
ECHO [**2129-10-13**]:
===========
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is difficult to assess but may be normal
(LVEF>55%).
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
.
[**12-2**] blood cultures: [**2-9**] coag negative staph
[**11-27**] blood cultures negative
[**12-2**] Urine CX: [**2129-11-27**] 8:26 am URINE
**FINAL REPORT [**2129-11-30**]**
URINE CULTURE (Final [**2129-11-30**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
Sputum culture [**11-26**]:
SPARSE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
.
[**Date range (1) 51721**] and 1022-10/25- Stool cx negative for c diff x 3
(twice)
[**11-10**], [**11-26**] sputum + for Klebsiella multidrug resistant
[**11-23**]: CTA IMPRESSION:
1. Very limited study secondary to ventilation state of patient
and arm positioning. No evidence of pulmonary embolism in the
main pulmonary artery, right pulmonary artery and left pulmonary
artery. Distal vessels not fully assessed secondary to technical
difficulties.
2. Slight improvement of the left apex and anterior aspect of
the right and left lower lobes in terms of ground-glass
opacities. Worsening/progression of opacities at the bases. This
could represent intraparenchymal hemorrhage.
3. Extensive mediastinal/hilar lymphadenopathy essentially
unchanged in appearance compared to the previous study.
.
[**12-3**] KUB :One portable supine view of the abdomen. Comparison
with [**2129-11-30**]. A Dobbhoff feeding tube is in place. This
terminates in the region of the distal end of the gastric antrum
or duodenal bulb. The bowel gas pattern is not remarkable.
IMPRESSION: Feeding tube in place.
Brief Hospital Course:
48 year-old woman with history of chronic interstitial lung
disease/pulmonary fibrosis, paroxysmal atrial fibrillation on
[**6-12**] liters oxygen at home who presented to [**Hospital 67742**] Medical
Center (NH) on [**2129-10-8**] with [**Hospital **] transfered to [**Hospital1 18**] for further
pulmonary w/u. Brief Hospital Course outlined below:
.
1. Respiratory distress: Known history of chronic interstitial
lung dz (NSIP) now presenting with worsening SOB in the setting
of atrial fibrillation. Intubated at OSH after failed attempts
at non-invasive positive pressure ventilation. Also with a
suspected component of PNA given chest film, wbc, fevers at OSH.
Treated empirically intially with vanco/zosyn/levo/bactrim and
started on Methylprednisolone stress dose steroids. Here,
bronch/bal revealed diffuse bleeding in airways without
localized source. No endobronchial lesion was identified. BAL
was negative for micro-organism. Negative for PCP, [**Name10 (NameIs) 8856**]
bactrim discontinued (remained on prophylactic bactrim dose).
Heparin (on for afib) was discontinued given hemoptysis. CXR
demonstrated evidence of pulmonary edema, therfore diuresed with
IV lasix. ECHO showed preserved EF. Steroids weaned slowly.
ANCA, Anti-GBM negative. [**Doctor First Name **] positive, but low titer 1:40. Chest
CT performed to better evaluate lung disease. No evidence of
focal infiltrate. Demonstrated ground-glass opacities in a
basilar and peripheral predominance c/w her history of
interstitial disease. Zosyn discontinued, and completed 14 day
course of empiric vanco/levo. Slowly weaned from vent. Extubated
on [**2129-10-21**]. [**2129-10-23**] initiated NIPPV for persistent desaturations
and increased work of breathing. Failed NIPPV and was
re-extubated [**2129-10-23**]. Unclear reason for recurrent
hypoxia/desaturation, however suspected secondary to body
habitus, with de-recruitment in supine position. After
re-intubation, continued diuresis to maintain euvolemia.
Physical therapy intitiated and placed out of bed to chair.
Noticeable improvement in need for o2 support in sitting
position, with offloading of abdominal pressure. Weaned pressure
support and re-attempted extubation on [**2129-10-30**] after improved
physical conditioning. However, relapse with reintubation on
[**11-4**] and tracheostomy on [**11-5**]. Pt developed ESBL Klebsiella
pneumonia and was treated with an 8 day course of Meropenem.
Several pressure support trials were attempted, but pt fatigued
towards the evenings. She finally tolerated PS persistantly
since [**2129-11-17**] and remained stable on PSV 5/13 and 50% FiO2.
Further attempt to wean PEEP or FiO2 were made but were
unsuccessful.
Again on [**11-27**] patient was found to be febrile with increasing
WBC and hypotension. Patient was briefly on pressors. Pan
cultures showed again Klebsiella in urine and sputum and in the
setting of leukocytosis and difficulty weaning from ventilator,
the patient was started again on broad spectrum abx and narrowed
to meropenem when sensitivities were isolated. After both
antibiotics and aggressive diuresis (as well as continued stress
dose steroids with taper) patient improved clinically and was
able to wean from the ventilator. She currently tolerates trach
mask well without significant dyspnea or hypoxia. She has been
afebrile and normotensive for >1 week and will finish her course
of meropenem on [**12-10**].
Patient currently with Passy-Muir valve inplace with additional
capping when not eating. Patient should have passy muir in
place for all meals
.
2. A fib with RVR: Per her OSH notes the pt was in and out of A
fib with ventricular rates of 120s-150s. Dilt gtt unsuccessful.
Loaded with amiodarone with conversion to NSR and subsequently
weaned down to daily maintenance dose amiodarone.
Anti-coagulation held initially given hemoptysis/hematuria,
however resumed once bleeding subsided. Dilt gtt could be
discontinued and pt only occassionally went into Afib overnight
but responded to IV Lopressor each time. Towards the end of her
hospital stay, she remained in NSR with occasional PVCs but
without anymore episodes of Afib. A heparin gtt was started
several times throughout her hospital stay but had to be held
because of a dropping Hct, hematuria or subcutaneous hematoma.
Shortly prior discharge she was placed again on a heparin gtt
and remained without any signs or symptoms of bleeding. Her Hct
remained stable.
Given that the patient had persistent bleeding on heparin, the
patient was placed on aspirin and heparin sc for prophylaxis
with the plan of treating with aspirin as an outpatient.
.
3. UTI: pt grew out Klebsiella per OSH as well as at [**Hospital1 18**]. Pt
completed 8d course of meropenem as part of her Klebsiella PNA
which also covered her UTI, but again showed positive u/a and
resistant growth of the urine cultures. Therefore, the patient
was again treated with meropenem
.
4. Hematuria: UTI v traumatic foley injury. Resolved off heparin
gtt.
.
5. CAD: cont asa/statin.
.
6. tramsaminitis: shock liver vs. undocumented prior liver
disease. LFTs returned soon towards baseline.
.
7. Hypothyroidism: cont synthroid.
.
8. DM: Patient had difficult to control FS for much of the
hospitalization. With the increasing infections as well as
stress dose steroids, the patient required increasing amounts of
insulin with poor control. Therefore the patient was placed on
a insulin gtt to evaluate insulin requirement. From this, the
patient was put on [**Hospital1 **] NPH to adequately cover FS. Patient with
improved FS control on day of discharge with 80 U NPH [**Hospital1 **] and
RISS
.
9. Ppx: pneumoboots, ppi, on and off heparin gtt depending on
dropping Hct or hematuria. Patient tolerating heparin SC well
.
10. FEN: Dobhoff in place. TFs. Electrolytes repleted as needed.
Patient with no signs of aspiration per swallow study (bedside)
but must have p-m valve in place for meals. Advancing diet,
should continue to monitor for signs of aspiration.
.
11. Access: R PICC
12. Code: FULL
.
13. Hypotension: Adrenal insufficiency in setting of acute
illness. Improved with stress dosed steroids. Prednisone
should be taperred to off over a 2 week course while closely
monitroing for signs of adrenal insufficiency.
Medications on Admission:
Home Medications (per OSH):
Diltiazem 125 mg sustained release PO q12 hours
Cozaar 50 mg PO daily
Lasix 40 mg PO daily
Coumadin 5 mg PO daily
Prednisone 30 mg PO daily
Toprol XL 25 mg sustained release daily
Nitroglycerin sublingually PRN
Lipitor 10 mg PO daily
Aspirin 325 mg PO daily
Albuterol nebulizers PRN
Lexapro 20 mg PO daily
Synthroid 75 mcg PO daily
Vitamin D 4000 units one capsule daily
Calcium 500 mg PO daily
Omeprazole 20 mg delayed release PO daily
Chlor-Con 20 mEq sustained release PO daily
Actonel 35 mgt PO daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
3. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
5. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
6. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 6-8 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritus.
9. Diltiazem HCl 90 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day): Hold if low blood pressure (<100).
10. Digoxin 250 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
11. Escitalopram 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
12. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
13. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
15. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
16. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
17. Captopril 12.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day).
18. Zolpidem 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO HS (at bedtime).
19. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: Ten (10) ML PO BID
(2 times a day) as needed for constipation.
20. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
21. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
22. Prednisone 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily): please start to taper to off over 2 weeks while closely
monitoring for adrenal insufficiency.
23. Insulin
Regular insulin sliding scale as attached
24. 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.
25. FOSAMAX 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day:
Patient must sit upright (90 degrees) for 3 hours after taking
medication.
26. Meropenem 1 g Recon Soln [**Hospital1 **]: One (1) Intravenous every
eight (8) hours for 4 days.
27. Zoledronic Acid 4 mg/5 mL Solution [**Hospital1 **]: One (1) injection
Intravenous Q MONTH ().
28. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) u
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Interstitial lung disease
Pneumonia, ventilator
Urinary tract infection
bacteremia
atrial fib
shock
Obesity
Hypothyroidism
adrenal insufficiency
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for worsening of your lung disease and had
several infections while you were in the hospital. You have
been treated with multiple antibiotics and were intubated.
After this you required a tracheostomy tube and will require one
for several more days.
.
Please take all medications as prescribed.
.
Please call your doctor or go to the ER if you have:
- Fever or chills
- Chest pain
- Shortness of breath
- Vomiting
- Diarrhea
- Weakness or passing out
- Any other concerning symptom
Followup Instructions:
[**Last Name (LF) 68319**],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 68320**], please follow up with Dr.
[**Last Name (STitle) **] in 1 week.
You should begin following up with a pulmonolgist at [**Hospital1 18**],
please call ([**Telephone/Fax (1) 513**] and make an appointment to be seen in
[**2-7**] months
|
[
"327.23",
"482.0",
"790.4",
"786.3",
"707.05",
"599.0",
"428.20",
"255.4",
"599.7",
"515",
"278.01",
"V09.91",
"518.84",
"E932.0",
"427.31",
"244.9",
"251.8",
"412",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"33.24",
"96.6",
"89.64",
"96.72",
"31.1",
"88.72",
"99.04",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
17952, 18034
|
7909, 14193
|
346, 391
|
18223, 18232
|
2347, 2347
|
18781, 19102
|
1959, 2036
|
14776, 17929
|
18055, 18202
|
14219, 14753
|
18256, 18758
|
2051, 2328
|
275, 308
|
419, 1584
|
2363, 7886
|
1606, 1838
|
1854, 1943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,610
| 106,194
|
52559
|
Discharge summary
|
report
|
Admission Date: [**2165-5-22**] Discharge Date: [**2165-6-3**]
Service: [**Doctor Last Name **]
CHIEF COMPLAINT: Hypotension, status post fall.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
gentleman with a past medical history significant for
coronary artery disease (status post coronary artery bypass
graft, aortic valve replacement) and prostate cancer (status
post transurethral resection of prostate) who presented to
the Emergency Department status post a fall with generalized
weakness, tachypnea, and fever.
The patient was reportedly in his usual state of health until
approximately one week prior to admission when he reports
progressive lethargy and fatigue with three to four days of
dyspnea on exertion. He also reports a several week history
of low back pain for which he was recently started on
Neurontin.
The patient was seen by his primary care physician one day
prior to admission and was found to have a white blood cell
count of 22 and a left shift with normal chemistries, liver
function tests, and hematocrit. The patient was planned for
an outpatient chest x-ray and blood cultures on the day of
admission when he reportedly fell secondary to lower
extremity weakness without loss of consciousness or head
trauma.
The patient was found by his son-in-law on the floor with an
increased respiratory rate and labored breathing; awake,
alert, and without complaints. The patient denied chest
pain, headache, melena, bright red blood per rectum, as well
as dysuria. However, the patient did report a 1-day history
of fevers with nausea, vomiting, and increased urinary
urgency with poor oral intake.
Of note, one week prior to admission, the patient was able to
walk two miles per day.
In the Emergency Department, the patient was found febrile to
101.5, with a systolic blood pressure of 68/30 (from an
initial blood pressure of 108/38), heart rate was 70s to 80s,
with an oxygen saturation of 100% on room air. The patient
was awake and mentating adequately at the time. The patient
was started on dopamine, intravenous fluids, and broad
spectrum antibiotics (ceftriaxone, Flagyl, and levofloxacin)
and transferred to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction in [**2149**] with subsequent coronary artery bypass
graft.
2. Status post porcine aortic valve replacement.
3. History of peptic ulcer disease; status post Billroth II.
4. Status post prior cerebellar stroke.
5. History of prostate cancer; status post transurethral
resection of prostate.
6. History of carotid stenosis; bilateral.
7. Peripheral neuropathy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. once per day.
2. Zocor 40 mg p.o. once per day.
3. Norvasc 5 mg p.o. once per day.
4. Neurontin 300 mg p.o. twice per day.
5. Atenolol 25 mg p.o. once per day.
6. Prevacid 15 mg p.o. once per day.
SOCIAL HISTORY: The patient is widowed and lives alone with
a supportive family. The patient denies tobacco, alcohol, as
well as illicit drug use.
FAMILY HISTORY: Family history was noncontributory.
REVIEW OF SYSTEMS: The patient denies melena, focal
weakness, paroxysmal nocturnal dyspnea, lower extremity
edema, orthopnea, and hematuria.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 101.5, blood pressure
was 98/60, heart rate was 97, respiratory rate was 24, and
oxygen saturation was 96% on 4 liters nasal cannula. In
general, the patient was a thin elderly male who appeared
tachypneic and in mild distress. Head, eyes, ears, nose, and
throat examination revealed normocephalic and atraumatic.
Pupils were equally round and reactive to light and
accommodation. Sclerae were anicteric. Mucous membranes
were dry. Edentulous. The oropharynx was clear. Neck
examination revealed supple with no lymphadenopathy or
jugular venous distention. Pulmonary examination revealed
bibasilar crackles; right greater than left. No egophony or
wheezing appreciated. Cardiovascular examination revealed a
regular rate and rhythm with a 3/6 systolic murmur at the
left lower sternal border radiating to the axilla with
well-healed midline sternal scar. Abdominal examination
revealed abdomen was soft with normal active bowel sounds.
No hepatosplenomegaly. No masses appreciated. Extremities
were warm and well perfused with 2+ dorsalis pedis and
posterior tibialis pulses. No edema. Neurologic examination
revealed awake and oriented times three. Diffusely weak, but
no focal weakness appreciated. Strength was 4+/5 throughout.
Sensation was intact with slightly decreased sensation in the
lower extremities bilaterally with 1+ symmetric reflexes.
Gait examination was deferred.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed complete blood count with a white blood
cell count of 37.6 (44% polys, 43% bands, 5% lymphocytes, and
5% monocytes), hematocrit was 32, mean cell volume was 87,
and platelets were 214. Chemistry-7 revealed sodium was 136,
potassium was 4.1, chloride was 105, bicarbonate was 16,
blood urea nitrogen was 46, creatinine was 2.4, and blood
glucose was 191. Prothrombin time was 16, INR was 1.7, and
partial thromboplastin time was 44.1. Total bilirubin was
0.3, ALT was 19, AST was 45, and alkaline phosphatase was 72.
Creatine kinase was 1261 with a negative MB and negative
troponin I. LDH was 280. Urine electrolytes with a urine
sodium of less than 10. Microbiology of data obtained from
admission with blood cultures times two on [**5-22**] and [**5-23**]
were without growth for the duration of the hospitalization.
Urine culture from [**5-22**] also without growth during the
hospitalization.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray on admission with
a new right lower lobe consolidation with air bronchograms.
No significant effusions were noted.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for management of hypotension with
presumed right lower lobe community-acquired pneumonia.
The patient was aggressively volume resuscitated with 6
liters of intravenous fluids for hypotension secondary to
presumed dehydration with possible sepsis. With intravenous
hydration, the patient's blood pressure normalized and the
patient was quickly weaned off dopamine.
The patient was noted to have elevated creatine kinase levels
(peak of 1893) with a negative MB index and was ruled out for
a myocardial infarction with three sets of cardiac enzymes.
On hospital day two, after intravenous hydration, the
patient's chest x-ray demonstrated a right lower lobe
infiltrate, and the patient was continued on broad empiric
antibiotics for presumed community-acquired pneumonia. The
patient continued with a 4-liter oxygen requirement on
transfer to the medicine floor.
On transfer to the medicine floor, the patient remained
afebrile on broad empiric antibiotics with no growth on
sputum, urine, as well as blood cultures. The patient
continued with a large oxygen requirement with continued
right lower lobe infiltrate.
Two days out of the Medical Intensive Care Unit, the patient
developed new onset atrial fibrillation with a rapid
ventricular rate to the 120s. The patient remained
normotensive; however, developed congestive heart failure in
the setting of rapid atrial fibrillation and required Lasix
diuresis. The patient was started on heparin as well as a
beta blocker which was titrated for rate control.
The Cardiology Service was consulted with recommendations for
a transesophageal echocardiogram and direct current
cardioversion given poorly tolerated atrial fibrillation.
The patient underwent a transesophageal echocardiogram
without evidence of intracardiac thrombus and subsequent
direct current cardioversion. The patient converted to a
sinus rhythm with one shock at 200 joules. However, shortly
thereafter, the patient was again found in atrial
fibrillation with a rapid ventricular rate.
The Electrophysiology Service was consulted who recommended
amiodarone loading and titration of Lopressor for improved
rate control. Despite efforts to adequately rate control the
patient with medications, the patient's rate remained
persistently elevated with continued dyspnea and oxygen
requirement.
A repeat chest x-ray demonstrated evidence of worsening
pneumonia with a question of the development of acute
respiratory distress syndrome.
On [**6-1**], after much discussion with the patient and the
patient's family, the patient was made comfort measures only.
The patient was started on morphine intravenously as needed
and eventually a morphine drip titrated for patient comfort.
The patient died peacefully on [**2165-6-3**].
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2165-6-11**] 15:04
T: [**2165-6-13**] 19:50
JOB#: [**Job Number **]
|
[
"276.5",
"486",
"V45.81",
"V42.2",
"427.31",
"V10.46",
"414.00",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
3132, 3169
|
2739, 2965
|
5973, 9082
|
3189, 5955
|
124, 156
|
185, 2224
|
2246, 2713
|
2982, 3115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,942
| 117,612
|
18952+57006
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-5-18**] Discharge Date: [**2169-5-31**]
Date of Birth: [**2085-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2169-5-18**] Left Ventricular Lead Placement via Left Thoracotomy
History of Present Illness:
This is an 83yo male with chronic systolic congestive heart
failure, chronic slow atrial fibrillation and a left bundle
branch block who recently underwent an upgrade to his St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) **] ICD in [**2169-4-11**]. Unfortunately Dr. [**First Name (STitle) **] was unable to
place the LV lead at that time. He was therefore referred for
surgical placement of epicardial LV leads. Currently his
symptoms include dyspnea on exertion. He denies orthopnea, PND,
LE edema, lightheadedness, chest pain.
Past Medical History:
- Chronic Systolic CHF
- Coronary Artery Disease s/p STEMI in [**2165**]. Underwent Taxus
stent to LAD at [**Hospital6 33**].
- Atrial Fibrillation
- History of NSVT
- Hypertension
- Dyslipidemia
- Chronic Renal Insufficiency, baseline Cr 1.4 to 1.7
- Osteoarthritis
- Spinal Stenosis, Chronic Low Back Pain
- Retinopathy
- BPH
- Complete occlusion of the left mid subclavian vein with
reconstituion medially via collateral vessels.
- History of Colon Cancer
- History of Basal Cell Carcinoma
- Psoriasis
- Iron Deficiency Anemia
- History of H. pylori [**2165**]
- Gout
- History of GI Bleed while on Lovenox [**2165**]
s/p St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) **] ICD [**2169-4-14**]
s/p Single chamber AICD [**2166-9-12**]
s/p Mohs surgery (Multiple) for basal cell
s/p Total Colectomy
s/p TURP
Social History:
Lives with: Alone in [**Location (un) 38**]
Occupation: Retired
Tobacco: quit 15 years ago after 50 pack year history
ETOH: [**3-17**] high balls weekly
Family History:
Son with coronary artery disease
Physical Exam:
PREOP EXAM:
Pulse: 50 AF Resp: 18 O2 sat: 98%
B/P Right: 121/65 Left: 120/65
Height: 67" Weight: 173lb
General: WDWN elderly male in NAD
Skin: Warm, Dry and intact. Multiple nevi and keratosis
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: Irregular rate and rhythm
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: Mild
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**2169-5-20**] Transthoracic Echo:
The right atrium is markedly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 25 %) with global hypokinesis and regional
septal and apical akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. 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
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2169-5-20**] Renal Ultrasound:
1. Normal kidneys, without hydronephrosis, nephrolithiasis, or
mass lesion. 2. Large ascites.
[**2169-5-23**] Abdominal Ultrasound:
1. Contracted gallbladder with gallstone identified within it.
2. Moderate amount of intra-abdominal ascites.
3. Bidirectional flow with reflux noted in the hepatic veins
with associated pulsatile flow in the portal vein - findings are
consistent with sequelae of right heart failure.
[**2169-5-31**] 04:35AM BLOOD WBC-5.5 RBC-2.60* Hgb-9.2* Hct-27.7*
MCV-107* MCH-35.2* MCHC-33.0 RDW-17.7* Plt Ct-145*
[**2169-5-30**] 04:30AM BLOOD WBC-5.6 RBC-2.56* Hgb-9.1* Hct-27.7*
MCV-108* MCH-35.4* MCHC-32.8 RDW-17.8* Plt Ct-128*
[**2169-5-31**] 04:35AM BLOOD PT-17.1* INR(PT)-1.5*
[**2169-5-30**] 04:30AM BLOOD PT-18.0* INR(PT)-1.6*
[**2169-5-31**] 04:35AM BLOOD Glucose-97 UreaN-40* Creat-2.6* Na-138
K-4.1 Cl-99 HCO3-31 AnGap-12
[**2169-5-30**] 04:30AM BLOOD Glucose-106* UreaN-25* Creat-1.9* Na-140
K-4.4 Cl-100 HCO3-29 AnGap-15
[**2169-5-29**] 04:05AM BLOOD Glucose-103* UreaN-41* Creat-2.4* Na-138
K-4.2 Cl-102 HCO3-24 AnGap-16
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent epicardial lead placement
via left mini-thoracotomy by Dr. [**Last Name (STitle) 914**]. For surgical details,
please see operative note. Following the operation, he was
brought to the CVICU in stable condition. Within 24 hours, he
awoke neurologically intact and was extubated without incident.
Device check on postoperative day one showed a normal
functioning biventricular ICD. He otherwise maintained stable
hemodynamics and transferred to the SDU on postoperative day
one. On postoperative day two, he became oliguric and
hypotensive with little response to fluid resuscitation.
Creatinine was rising, and patient became hyperkalemic. Renal
ultrasound showed normal appearing kidneys while echocardiogram
revealed no evidence of tamponade. Renal ultrasound was however
notable for large amount of ascites. He returned to the CVICU
for invasive monitoring. He was started on inotropes and CVVH
was initiated. Given findings of ascites, Warfarin was held for
the possibility of paracentesis. Renal service was consulted and
continued to manage CVVH. It appeared much of his acute on
chronic renal failure was attributed to contrast nephropathy
dating back to [**2169-4-11**] during failed attempt for percutaneous
left ventricular lead placement. Over several days, urine output
improved as did his creatinine. He gradually weaned from
inotropic support. He was transitioned from CVVH to intermittent
hemodialysis via tunnelled right internal jugular catheter. He
did have a 80 mg IV Lasix trial and made minimal urine in
response. His foley was removed and he is to be straight cathed
Q 24 hrs - last hemodialysis run was [**5-31**]. He is on a Mon Wed
Friday schedule for HD. He continued to make good progress and
was cleared for discharge to [**Hospital1 **] at [**Doctor Last Name 1263**] in
[**Location (un) 686**] on POD # 13 in stable condition Target INR 2.0- 2.5
for chronic A Fib. All follow up appointments were advised.
Medications on Admission:
-ALLOPURINOL - 100 mg Tablet - 1.5 Tablet(s) by mouth every
morning
-CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth every
morning
-CHOLESTEROL STUDY DRUG THROUGH [**Hospital1 112**] - 3 pills every evening
-COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth as needed
-FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth every
morning, one tablet at 6pm
-METOPROLOL SUCCINATE - 50 mg tablets - 2 Tablet(s) by mouth
every morning
-WARFARIN - 2 mg Tablet - 0.5 (One half) Tablet(s) by mouth
M/W/F, one tablet all other days
-VITAMIN D3 - 1,000 unit Capsule - 1 Capsule(s) by mouth once a
day
-FERROUS SULFATE - 325 mg Tablet - 1 Tablet(s) by mouth three
times a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb IH Inhalation Q6H (every 6 hours)
as needed for wheezes.
8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dose
2.5 mg Coumadin dose 4/20 (INR 1.5).
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Failed Left Ventricular Lead Placement
Chronic Systolic Congestive Heart Failure
Coronary Artery Disease, Prior PCI/Stenting
Chronic Atrial Fibrillation
Acute on Chronic Renal Insufficiency/ HD
Ascites
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Thoracotomy - healing well, no erythema or drainage
2+ lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving while taking narcotics
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] Tuesday [**6-20**] @ 1:45 pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] @ [**Location (un) 38**] office [**6-21**] @ 2:20
pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] in [**5-16**] weeks
[**Telephone/Fax (1) 3530**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0 to 3.0
First draw day [**6-1**]
*****please arrange for coumadin/INR f/u prior to discharge from
rehab***
Completed by:[**2169-5-31**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 9648**]
Admission Date: [**2169-5-18**] Discharge Date: [**2169-5-31**]
Date of Birth: [**2085-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 1543**]
Addendum:
Patient is not to take study drugs. Discussed with Primary
Principle Investigator and patient is disqualified from study
due to renal failure. Started on Simvastatin 20 mg daily.
Discharge Disposition:
Extended Care
Facility:
tba
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2169-5-31**]
|
[
"585.3",
"426.3",
"584.5",
"428.22",
"427.31",
"V45.82",
"397.0",
"414.01",
"V45.02",
"412",
"789.59",
"272.4",
"276.7",
"414.8",
"403.90",
"V10.05",
"785.51",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"89.64",
"37.74",
"38.93",
"39.95",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
11519, 11708
|
4999, 6990
|
296, 367
|
9306, 9492
|
2777, 4976
|
10168, 11496
|
1990, 2025
|
7711, 9007
|
9081, 9285
|
7016, 7688
|
9516, 10145
|
2040, 2758
|
237, 258
|
395, 949
|
971, 1803
|
1819, 1974
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,322
| 128,741
|
20616
|
Discharge summary
|
report
|
Admission Date: [**2172-12-15**] Discharge Date: [**2172-12-19**]
Date of Birth: [**2101-9-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived / Nut Flavor / Monosodium Glutamate / Hayfever
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2172-12-15**] - Coronary artery bypass grafting x4, left internal
mammary artery graft, left anterior descending, reverse
saphenous vein graft to the marginal branch, diagonal branch,
posterior descending artery.
History of Present Illness:
Stupendous 71 year old gentleman with known ischemic heart
disease who has had recent intermittent throat and jaw
discomfort consistent with his anginial symptoms. An exercise
tolerance test was performed which revealed inferoposterior and
lateral wall ischemia. A cardiac catheterization was performed
which showed severe three vessel disease. Given the severity of
his disease, he has been referred for surgical
revascularization.
Past Medical History:
Past Medical History:
CAD
Metabolic syndrome
Dyslipidemia
HTN
Obesity
Sleep apnea
Hayfever
Asthma as child
Past Surgical History:
Deviated septum repair
T+A at age 6
Basal cell carcinoma s/p resection on face
Prostate biopsy
Social History:
Occupation: Singer in choir
Last Dental Exam: Every three months
Lives with: Wife in [**First Name4 (NamePattern1) 745**]
[**Last Name (NamePattern1) **]: Caucasian
Tobacco: Never
ETOH: 1 glass of wine/day
Family History:
Father with CABGx4 in early 70's. Mother with MI, Brother with
MI.
Physical Exam:
Pulse: 82 SR Resp: 20 O2 sat: 98% RA
B/P Right: 158/91 Left: 160/82
Height: 68" Weight: 236lbs
General: WDWN in NAD
Skin: Dry [X] intact [X] Well healed left upper lip/nare
incision
HEENT: PERRLA, EOMI, Sclera anicteric, OP benign
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: LLE - Distal calf varicosity vs. lipoma. GSV
otherwise appears suitable.
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**2172-12-15**] ECHO
Pre-bypass:
The left atrium and right atrium are normal in cavity size. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. There is
mild (non-obstructive) focal hypertrophy of the basal septum.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF=50 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
Post-bypass:
The patient is not receiving inotropic support post-CPB.
Biventricular systolic function is preserved. All findings are
consistent with the pre-bypass findings. The aorta is intact
post-decannulation. All findings communicated to the surgeon.
[**2172-12-18**] 07:20AM BLOOD WBC-9.7 RBC-3.41* Hgb-10.4* Hct-30.8*
MCV-90 MCH-30.4 MCHC-33.6 RDW-12.4 Plt Ct-158
[**2172-12-15**] 03:03PM BLOOD PT-13.0 PTT-32.7 INR(PT)-1.1
[**2172-12-18**] 07:20AM BLOOD Glucose-125* UreaN-20 Creat-0.6 Na-135
K-4.1 Cl-99 HCO3-29 AnGap-11
[**2172-12-17**] 05:10AM BLOOD Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2172-12-15**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next 24 hours, Mr. [**Known lastname **] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Chest tubes and pacing
wires were removed per cardiac surgery protocol. He did have a
temperature to 101.9 with an elevated white blood cell count.
His central line was pulled and the patient remained afebrile
for the remainder of his hospital course with a normalized white
blood cell count. He was transferred to the step down unit in
stable condition. He continue to work with physical therapy for
increased strength and endurance. It was felt that he was stable
to be discharged home on post operative day # 4 with VNA
services.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth once a day
TRIAMTERENE-HYDROCHLOROTHIAZID - (Prescribed by Other Provider)
- 50 mg-25 mg Capsule - 1 Capsule(s) by mouth once a day
Medications - OTC
ASCORBIC ACID - (Prescribed by Other Provider) - 1,000 mg
Tablet
- 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
B COMPLEX VITAMINS - (Prescribed by Other Provider) - Capsule
- 1 Capsule(s) by mouth once a day
COENZYME Q10 - (Prescribed by Other Provider) - 200 mg Capsule
-
1 Capsule(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a
day
FLAXSEED OIL - (Prescribed by Other Provider) - 1,000 mg
Capsule
- 1 Capsule(s) by mouth once a day
MULTIVITS WITH MIN-FA-LYCOPENE [ONE-A-DAY MEN'S] - (Prescribed
by Other Provider) - 0.4 mg-600 mcg Tablet - 1 Tablet(s) by
mouth
once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth twice a day
VITAMIN E - (Prescribed by Other Provider) - 400 unit Capsule -
1 Capsule(s) by mouth once a day
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*1*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
Metabolic syndrome
Dyslipidemia
HTN
Obesity
Sleep apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**1-21**] at 1:15 PM
Primary Care Dr. [**Last Name (STitle) **] in [**12-12**] weeks
Cardiologist Dr. [**Last Name (STitle) 14522**] in [**12-12**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2172-12-19**]
|
[
"272.4",
"277.7",
"401.9",
"327.23",
"600.00",
"780.62",
"411.1",
"278.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7450, 7508
|
3871, 4884
|
344, 562
|
7612, 7708
|
2390, 3848
|
8248, 8664
|
1514, 1583
|
6484, 7427
|
7529, 7591
|
4910, 6461
|
7732, 8225
|
1177, 1274
|
1598, 2371
|
294, 306
|
590, 1025
|
1069, 1154
|
1290, 1498
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,677
| 168,601
|
16803
|
Discharge summary
|
report
|
Admission Date: [**2151-11-21**] Discharge Date: [**2151-11-26**]
Date of Birth: [**2073-8-14**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Sepsis and vt
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
Pt is a 78y/o AM w/ a PMH significant for CAD s/p LAD stent x2,
HTN, Afib, and CRI who presented with hypotension, a RBBB, and
PNA. He was in his USOH until [**11-19**] when he noted fevers and
dizziness. He went to a OSH and was found to have PNA. He
experienced 2 runs of VT, was started on lidocaine and
transferred to [**Hospital1 18**] for further management.
.
At [**Hospital1 18**], he was found to be hypotensive to the 70s with a
lactate of 4.5. He was started on sepsis protocol and sent to
the MICU for pressor support. In the MICU, he was hypotensive
requiring levophed, hypoxic requiring BiPAP, and w/
leukocytosis. He was changed from ceftriaxone/azithromycin to
zosyn/vancomycin and then his vanco was stopped after outside
BCx grew klebsiella. He was continued on IVF and endocrine was
consulted for hypothyroidism. As he was treated w/ abx he was
able to be weaned from both the lidocaine and levophed and
actually required BP control w/ metoprolol prior to call-out.
At the time of x-fer he has no complaints. He denies SOB, CP,
abdominal pain, N/V, HA, or other complaints. He has been
afebrile since 6pm on [**11-22**] and his bcx/ucx have been negative to
date here at [**Hospital1 18**].
Past Medical History:
Coronary artery disease s/p LAD stent [**10-21**]
Hypertension
Dyslipidemia
Atrial Fibrillation
Mild pulmonary artery hypertension
Mild AR
Chronic renal failure (baseline Cr 1.5)
Social History:
Immigrated from [**Location (un) 6847**] 3yrs ago
Lives with his wife
Previous tobacco use: 56yrs x2ppd, quit 3yrs ago
Family History:
unknown
Physical Exam:
99.9, 132/56, 82, 25, 99% 2L
Gen: Obese Asian man lying in bed in NAD
HEENT: EOMI, PERRLA, MMM, O/P clear
Neck: -LAD
CV: RRR, S1/S2 wnl, 2/6 SEM @ USB
Lungs: Inspiratory crackles at the L base, diffuse inspiratory
wheezes
Abd: Distended, S/NT, +BS, -HSM appreciated
Ext: -C/C/E
Neuro: CN 2-12 grossly intact, strength 5/5 bilaterally
Skin: -rashes
Pertinent Results:
Cath [**4-24**]:
1. Single-vessel coronary artery disease.
2. In-stent restenosis of the proximal LAD stent.
3. Moderate systolic hypertension.
4. Successful drug-eluting stenting of proximal LAD.
.
CXR [**2151-11-22**]: There is a left-sided IJ central venous catheter
with the distal tip in the brachiocephalic vein. The cardiac
size is unchanged. The lateral radiograph is suboptimal. There
is a pleural effusion, likely on the left side given the
retrocardiac opacity. Underlying infiltrate in the left base
would be difficult to exclude. Degenerative changes are seen at
the dorsal spine.
Interstitial markings are mildly prominent without overt
pulmonary edema.
.
ECHO [**2151-11-23**]:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF=55%). Apical
hypokinesis is present.
3. The ascending aorta is mildly dilated.
4. The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis. Mild (1+) aortic regurgitation is
seen.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
5. Compared with the findings of the prior study (images
reviewed) of [**2148-10-30**], the apical hypokinesis may be new, since
the apex was not well seen on the previous study.
[**2151-11-21**] 01:00AM BLOOD WBC-19.5*# RBC-3.70* Hgb-11.6* Hct-32.6*
MCV-88 MCH-31.3 MCHC-35.6* RDW-13.6 Plt Ct-172
[**2151-11-26**] 05:35AM BLOOD WBC-10.7 RBC-3.23* Hgb-10.6* Hct-29.3*
MCV-91 MCH-32.7* MCHC-36.1* RDW-13.8 Plt Ct-249
[**2151-11-21**] 01:00AM BLOOD PT-13.6* PTT-28.3 INR(PT)-1.2
[**2151-11-25**] 05:45AM BLOOD PT-12.5 PTT-29.4 INR(PT)-1.0
[**2151-11-21**] 01:00AM BLOOD Glucose-186* UreaN-47* Creat-3.0*# Na-140
K-3.5 Cl-106 HCO3-21* AnGap-17
[**2151-11-26**] 05:35AM BLOOD Glucose-99 UreaN-26* Creat-1.6* Na-141
K-3.9 Cl-109* HCO3-24 AnGap-12
[**2151-11-21**] 03:00AM BLOOD ALT-48* AST-24 AlkPhos-35* Amylase-62
TotBili-0.7
[**2151-11-24**] 06:25AM BLOOD ALT-32 AST-16 LD(LDH)-164 AlkPhos-43
TotBili-0.6
[**2151-11-21**] 01:00AM BLOOD CK-MB-4 cTropnT-0.21*
[**2151-11-21**] 11:00AM BLOOD CK-MB-6 cTropnT-0.09*
[**2151-11-21**] 04:58PM BLOOD CK-MB-5 cTropnT-0.06*
[**2151-11-21**] 03:00AM BLOOD Calcium-6.5* Phos-2.2* Mg-1.3*
[**2151-11-26**] 05:35AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.8 Cholest-PND
[**2151-11-21**] 03:00AM BLOOD CRP-99.9*
[**2151-11-21**] 01:11AM BLOOD Lactate-4.7*
[**2151-11-22**] 04:13AM BLOOD Lactate-1.1
[**2151-11-21**] 05:54AM BLOOD TSH-0.052*
[**2151-11-21**] 01:00PM BLOOD T3-55*
[**2151-11-21**] 05:54AM BLOOD Free T4-2.0*
[**2151-11-24**] 06:25AM BLOOD calTIBC-187* VitB12-246 Folate-5.6
Hapto-270* Ferritn-349 TRF-144*
Brief Hospital Course:
A/P: 78y/o man w/ a PMH significant for CAD, HTN, afib, and CRI
who presented w/ VT and presumed sepsis. He initially required
pressor support but has improved from a hemodynamic perspective
and was called out to the floor
.
1. Sepsis: The pt originally presented w/ hypotension, PNA on
CXR, a lactate of nearly 5 and + OSH klebsiella BCx. He required
pressor support and was treated, in turn, with
ceftriaxone/azithromycin, vanco/zosyn, and finally zosyn alone
as his OSH cultures grew pan-sensitive klebsiella in [**2-22**] bottles
(SENSITIVE: amikacin, amp/sulbactam, cefaxolin, ceftaz,
ceftriaxone, cefuroxime, cipro, gent, imi, levo, pip/tazo, tobra
RESISTANT: Ampicillin). He required IVF to maintain his
pressure along w/ levophed when first admitted to the unit but
was weaned off these prior to call out to the floor. Once he
came to the floor, he spiked temperatures to 101 on 2
consecutive days but these abated once his central line was d/c.
His antibiotics were switched to levaquin and he will complete
a 14d course at home. The blood and urine cultures drawn here
at [**Hospital1 18**] have yet to grow any bacteria and the patient is no
longer requiring supplemental oxygen or IVF.
.
2. Rhythm: Pt had two episodes of VT at OSH and requiring
lidocaine gtt. This therapy was continued in the MICU but was
weaned prior to call out to the floor. He developed a rate
dependent RBBB during his MICU course but this corrected with
better rate control. The patient has chronic afib as an
outpatient and had this on admission but was converted to NSR
with amiodarone. He has never been anticoagulated for his afib
and his PCP was [**Name (NI) 653**] about this and agreed to f/u with him
as an outpatient.
.
3. CAD: The pt was r/o for MI this admission. He was continued
on his bblocker, aspirin, and statin. He was restarted on his
ace-i after he recovered his renal function and was normotensive
(130/60 on the day of d/c) only on captopril 6.25 tid. He was
sent out on lisinopril 5mg qd (was on 40 on admission) and will
require BP titration as an outpatient if he again becomes
hypertensive.
.
5. Acute on Chronic RF: His baseline Cr appears to be 1.6-1.9
over the past few years but was elevated to 3.0 on admission.
This was attributed to a prerenal etiology [**12-23**] his septic
picture and his renal function recovered with fluid rehydration.
.
6. Endo: The patient had a significantly decreased TSH on MICU
admission along with an elevated free t4 and a low t3.
Endocrine was consulted and felt that there was no need to treat
him actuely for this problem but [**Name2 (NI) 33857**] outpatient
follow-up of his TFTs.
Medications on Admission:
lisinopril 40 mg qd
atenolol 25 mg qd
hydrochlorothiazide 25 mg qd,
amiodarone 200 mg qd
Lipitor 10 mg qd
Plavix 75 mg qd
aspirin 1 qd
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 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 once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Prinicpal:
1. Klebsiella Pneumonia.
2. Klebsiella Bacteremia and Septic Shock.
3. Non-Sustained Ventricular Tachycardia.
4. Acute Renal Failure.
5. Anemia of Inflammation.
Secondary:
1. Single Vessel Coronary Artery Disease.
2. S/P Bare Metal LAD stent c/b ISR - s/p PCI and DES.
3. Hypertension.
4. Chronic Kidney Disease Stage III.
5. Atrial Fibrillation.
Discharge Condition:
Good
Discharge Instructions:
Please take your medications as directed
Please keep your follow up appointments
Please call your PCP or return to the ER for:
1. fever to 101
2. chest pain
3. shortness of breath
4. other concerning symptoms
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2152-1-19**] 9:00
Please see your primary care physician ([**First Name8 (NamePattern2) 17362**] [**Doctor Last Name **]) on [**2151-12-2**]
at 9am
Completed by:[**2151-11-27**]
|
[
"038.49",
"482.0",
"785.52",
"403.91",
"396.3",
"427.1",
"426.4",
"585.3",
"427.31",
"414.01",
"995.92",
"272.4",
"584.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8632, 8707
|
5075, 7725
|
281, 305
|
9110, 9117
|
2303, 5052
|
9374, 9718
|
1911, 1920
|
7911, 8609
|
8728, 9089
|
7751, 7888
|
9141, 9351
|
1935, 2284
|
228, 243
|
334, 1555
|
1577, 1757
|
1773, 1895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,431
| 178,819
|
51389
|
Discharge summary
|
report
|
Admission Date: [**2143-4-27**] Discharge Date: [**2143-5-5**]
Date of Birth: [**2083-6-22**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Prograf / Phenergan / Haldol
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Chest tube placement
Thoracentesis
History of Present Illness:
The patient is a 59 M with h/o ESRD s/p failed renal transplant,
HTN, DM, PVD, chronic diarrhea; now presents w/ nausea,
vomiting, and abdominal pain x 3 days. Sent from nursing home.
He missed dialysis yesterday because he felt too sick to go. He
reports the sudden onset of abdominal pain, cramping, not
related to food. He describes it as diffuse. Improving since
early today. + diarrhea. No fevers or chills. + fatigue over
last few days. Denies chest pain, + shortness of breath, no
urinary symtoms, + weight loss - "alot", unable to say over how
long.
.
In the ED, initial vital signs were 94.8, 87, 132/93, 16,
100%RA. A CT abdomen showed a dilated common bile duct with mild
intrahepatic ductal dilatation and markedly dilated pancreatic
duct. The ERCP fellow was called from the ED and did not want to
do an urgent intervention. Surgery was called and recommended
ERCP to evaluate for pancreatitis/pancreatic mass. CXR showed an
entrapped lung. He received a dose of levo/flagyl in the ED.
.
He then had an MRCP which demosntrated a dilated main pancreatic
duct with multiple large cystic areas that appear to be in
communication with the main pancreatic duct, most prominent at
the tail of the pancreas. His CBD was 6 mm. His overall picture
was thought to be consistent with chronic pancreatitis. After
dialysis on [**4-29**] he was found to hypothermic to 93.1 with a BP of
96/70 depressed from baseline of SBP 110-120. He was also found
to have bandemia of 15%. This am he was hypothermia and
hypotension persisted despite 500 cc bolus and ceftriaxone and
vancomycin. A detailed discussion about code status was held
with his wife the evening prior to his tranfer and he remained
full code. He was transferred to [**Hospital Unit Name 153**] for further treatment.
.
In ICU, found to have multiloculated pleural effusion w/
purulent aspiration under ultrasound guidance by IP. Continued
on broad antibiotics, and chest tube placed for drainage.
However, given progressive decline with multiple co-morbidities,
code discussion was undertaken with family and the decision was
made to make patient CMO. Transferred out to medical floor on
morning of [**5-4**].
Past Medical History:
**ESRD s/p transplant (left kidney from brother) at [**Name (NI) 112**] [**1-/2134**], w/
h/o of complications from rejection, now stable with prednisone
tapered to 10 mg/d. On cellcept and neoral. s/p av fistula [**2131**],
s/p jump graft revision [**12/2133**] of AV fistula which had clotted.
s/p excision of pseudoaneurysm [**7-/2134**] of rt brachiocephalic
fistula. Followed by Dr. [**Last Name (STitle) **].
[**12/2139**]-follwed by [**Location (un) **] diaylsis-dr [**First Name8 (NamePattern2) **] [**Name (STitle) **]-
cell-[**Telephone/Fax (1) 106545**],office-[**Telephone/Fax (1) 34044**], dialysis
unit-[**Telephone/Fax (1) 55520**] 3 x per week
**Type I DM X 28 yrs. DM secondary to pancreatitis (h/o etoh
abuse).
Has been on insulin 23 yrs.
*HTN
*Neuropathy
*Back pain
*Anemia
*Pancreatitis
*Penile prosthesis
*PVD - s/p left 5th toe and right all 5 toes amputation
-hx DVT with PE
*Sleep disorder
*Pain medicine contract
*vocal cord polyps - h/o squamous cell in situ
*Dysphagia
*GERD
*idiopathic meningoencephalitis
*R shoulder arthroplasty [**8-27**] and I&D in [**12-28**]
*s/p L femoral neck fx [**9-28**]
*Right tib-fib fx nonunion s/p external fixation
*chronic diarrhea
*dementia
Social History:
Patient lives in Nursing Home. He has a wife named [**Name (NI) **]. [**Name2 (NI) **]
was a heavy drinker but quit several years ago. [**10-12**] pack year
smoker. Reportedly has been victim of domestic violence at hands
of his teenage daughter.
Family History:
Noncontributory.
Physical Exam:
VS: 96.6 118-126/73-83 79 24 97%3L
GEN: very thin/emaciated, older than stated age
HEENT: PERRL, EOMI, sclera anicteric, very dry mucous membranes
CV: RRR, no Murmurs
PULM: Pt unable to sit up or turn, but very scant BS on left,
coarse BS on right ant and lat
ABD: soft, + BS, nildly tender throughout
EXT: amputation of toes on left foot, no edema in lower
extremities
NEURO: alert & oriented x 3
Pertinent Results:
[**2143-4-30**] 07:50AM BLOOD Cortsol-29.5*
[**2143-4-28**] 10:43AM BLOOD PTH-154*
[**2143-4-28**] 05:53AM BLOOD calTIBC-39* VitB12-GREATER TH
Folate-GREATER TH Ferritn-410* TRF-30*
[**2143-5-3**] 04:30AM BLOOD Calcium-7.5* Phos-3.4 Mg-2.2
[**2143-4-27**] 12:38PM BLOOD cTropnT-0.08*
[**2143-4-30**] 07:50AM BLOOD proBNP-9843*
[**2143-4-27**] 12:38PM BLOOD Lipase-6
[**2143-4-28**] 05:53AM BLOOD Lipase-5
[**2143-4-29**] 04:57AM BLOOD Lipase-5
[**2143-4-27**] 12:38PM BLOOD ALT-17 AST-29 CK(CPK)-8* AlkPhos-188*
Amylase-9 TotBili-0.8
[**2143-4-28**] 05:53AM BLOOD ALT-12 AST-9 LD(LDH)-114 AlkPhos-135*
Amylase-6 TotBili-0.7
[**2143-4-30**] 07:50AM BLOOD LD(LDH)-74*
[**2143-4-27**] 12:38PM BLOOD Glucose-104 UreaN-32* Creat-3.5* Na-143
K-4.7 Cl-102 HCO3-31 AnGap-15
[**2143-4-29**] 04:57AM BLOOD Glucose-85 UreaN-63* Creat-4.3* Na-139
K-6.2* Cl-102 HCO3-25 AnGap-18
[**2143-5-2**] 06:16AM BLOOD Glucose-107* UreaN-28* Creat-1.9*#
Na-147* K-3.5 Cl-106 HCO3-33* AnGap-12
[**2143-5-3**] 04:30AM BLOOD Glucose-56* UreaN-40* Creat-2.3* Na-149*
K-3.3 Cl-106 HCO3-32 AnGap-14
[**2143-4-28**] 01:50AM BLOOD D-Dimer-891*
[**2143-4-29**] 02:36PM BLOOD Thrombn-21.3*
[**2143-4-27**] 12:38PM BLOOD PT-40.3* PTT-49.4* INR(PT)-4.5*
[**2143-4-27**] 12:38PM BLOOD Neuts-25* Bands-9* Lymphs-28 Monos-19*
Eos-0 Baso-0 Atyps-1* Metas-18* Myelos-0
[**2143-4-29**] 07:49PM BLOOD Neuts-82.6* Bands-0 Lymphs-10.4*
Monos-6.7 Eos-0.1 Baso-0.2
[**2143-4-27**] 12:38PM BLOOD WBC-3.1* RBC-3.85* Hgb-12.0* Hct-38.9*#
MCV-101*# MCH-31.1 MCHC-30.8* RDW-18.8* Plt Ct-73*
[**2143-5-3**] 04:30AM BLOOD WBC-8.9 RBC-1.97* Hgb-6.2* Hct-19.5*
MCV-99* MCH-31.5 MCHC-31.7 RDW-19.2* Plt Ct-32*#
[**2143-5-1**] 05:43PM PLEURAL WBC-3850* RBC-300* Polys-91* Bands-7*
Lymphs-0 Monos-1* Metas-1*
[**2143-5-1**] 05:43PM PLEURAL TotProt-3.7 Glucose-0 LD(LDH)-4380.
.
FLUID CULTURE (Final [**2143-5-4**]):
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
CT ABDOMEN WITH IV CONTRAST WITHOUT ORAL CONTRAST: There are
bilateral pleural effusions, left large in size, right moderate
in size. The large left pleural effusion has a dense rim. The
liver, gallbladder, spleen are within normal limits. There is a
mild amount of intrahepatic ductal dilatation and moderate
extrahepatic ductal dilatation with the common bile duct
measuring 9 mm in diameter. The pancreatic duct is markedly
dilated measuring 8 mm in diameter through its entire course.
There are coarsened calcifications through out the pancrease
with no large masses or intraductal stones identified. There are
marked vascular calcifications throughout the entire abdominal
vasculature. The kidneys are atrophic and there is a simple
renal cyst within the mid pole of the left kidney. There are
multiple additional hypodense foci within both kidneys that are
too small to characterize. The small and large bowel are within
normal limits. There are no large free-fluid pockets within the
abdomen. There is no free air. There is no retroperitoneal or
mesenteric lymphadenopathy.
.
CT PELVIS WITH IV CONTRAST: The left pelvic kidney appears
normal in morphology. However, there is no evidence of perfusion
within the left pelvic transplant kidney. This is consistent
with the provided history of chronic failure. The rectum and
sigmoid colon are unremarkable. The urinary bladder is not well
visualized. A penile implant is present.
.
IMPRESSION:
1. Dilated common bile duct with mild intrahepatic ductal
dilatation and markedly dilated pancreatic duct throughout a
calcified pancreas. These findings are more consistent with
chronic pancreatitis. There is no evidence of an obstructing
lesion.
2. Moderate-to-large bilateral pleural effusions as described
above. The left pleural effusion contains a dense rim that may
represent findings that are related to a prior pleurodesis, but
contrast enhancement of the pleura in the setting of infection
cannot be excluded.
.
MRI ABDOMEN WITHOUT GADOLINIUM: Images are limited due to
inability of the patient to cooperate with breath-hold
instructions. No IV contrast was administered. There is mild
prominence of the extra-hepatic bile ducts with maximal
dimension of the common bile duct of 7 mm. There is no
intrahepatic biliary ductal dilatation. Gallbladder and cystic
duct are unremarkable. The main pancreatic duct is dilated with
multiple large multiloculated cystic areas that appear to be
emanating from the pancreatic ducts. There is smooth distal
tapering of both the common bile duct and the main pancreatic
duct at the ampulla. Within the limits of this study, no
pancreatic head mass is identified. No focal liver lesions are
seen. The spleen and bone marrow demonstrate low signal
intensity on T2-weighted images consistent with
reticuloendothelial pattern of iron uptake. There are bilateral
well- circumscribed renal cysts, the largest at the interpolar
region of the left kidney measuring 6 mm. There are large
bilateral pleural effusions, subcutaneous edema, and small
perihepatic ascites.
.
IMPRESSION:
1. Limited study with no definite pancreatic head mass seen.
2. Dilated main pancreatic duct with multiple large cystic areas
that appear to be in communication with the main pancreatic
duct, most prominent at the tail of the pancreas, also seen on
previous imaging studies. Given the patient's clinical history
and diffuse parenchymal calcifications seen on previous CT
scans, findings are most consistent with changes related to
chronic pancreatitis. A main duct IPMT is felt to be less likely
given the other imaging and clinical findings.
3. Reticuloendothelial pattern of iron deposition.
4. Large bilateral pleural effusions, subcutaneous edema, and
small perihepatic ascites.
.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: Evaluation of the
right pulmonary artery and proximal segmental branches
demonstrates no filling defects consistent with pulmonary
embolism. There is no pulmonary embolism identified within the
left-sided branches of the pulmonary arteries. There is a large,
left-sided pleural effusion with attenuation characteristics
consistent of more complex fluid (Hounsfield unit equals 30).
Thus, an underlying component of loculation is likely. There is
associated compression of the entire left lung. There is a
moderate right pleural effusion that appears to be more simple
by attenuation characteristics. The visualized portion of the
anterior right lung appears grossly unremarkable. There is shift
of the mediastinum to the right secondary to the large left
pleural effusion. There is a small pericardial effusion as well.
There is no aortic dissection and the heart and great vessels
are otherwise grossly unremarkable. Limited views of the upper
abdomen are unremarkable.
.
IMPRESSION:
1. No evidence of left-sided pulmonary embolism.
2. No pulmonary embolism of the right pulmonary artery and
proximal segmental branches. A more thorough evaluation cannot
be performed secondary to respiratory motion within the
remaining aerated portion of the right lung.
3. Large left pleural complex effusion with associated
compressive atelectasis of the left lung. If indicated,
ultrasound characterization or guidance for thoracentesis may be
pursued for better evaluation of the pleural collections given
previous thoracentesis complication.
4. Multiple foci of air within the esophagus could be aspiration
risk.
5. Small pericardial effusion.
.
Brief Hospital Course:
See HPI. Pt expired was called out to the floor Comfort
Measures only and expired at 8:30 am on [**2143-5-5**].
Medications on Admission:
(Confirmed with [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] NH)
dilt SR 120 Qday
Vit C 500 mg QDay
Vit B complex
Synthroid 100 mcg
Chloestyromine
Pangestyme EC 1 cap TID
Tums 500 TID
Folic acid 1 mg QD
Lomotil 0.25 mg QID
Celexa 20 mg QDay
Oxycodone 10 mg QHS, 30 mg Q6AM
Catapress 0.2 mg Wed
Norvasc 5 mg Qday
ferrous sulfate daily
insulin sliding
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
ESRD s/p transplant
TypeI DM X 28 yrs.
Pancreatitis
Empyema with Sepsis
Pancytopenia
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"510.9",
"518.0",
"577.1",
"577.9",
"V58.67",
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"038.9",
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"357.2",
"443.9",
"991.6",
"996.81",
"571.2",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.91",
"34.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13113, 13122
|
12542, 12656
|
314, 351
|
13251, 13261
|
4523, 12519
|
13313, 13320
|
4063, 4081
|
13084, 13090
|
13143, 13230
|
12682, 13061
|
13285, 13290
|
4096, 4504
|
259, 276
|
379, 2552
|
2574, 3781
|
3797, 4047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,829
| 132,665
|
8206
|
Discharge summary
|
report
|
Admission Date: [**2124-8-25**] Discharge Date: [**2124-9-7**]
Date of Birth: [**2057-10-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**8-29**] Coronary Artery Bypass Graft x 3 (LIMA->LAD, SVG->OM, PDA)
History of Present Illness:
66 y/o male with recurrent chest pain. Went to OSH last week w/
chest pain/NSTEMI and was discharged with a scheduled ETT.
However pt had 8/10 chest pain with SOB on [**8-24**]. Chest pain
relieved w/ NTG, ASA, APAP< and tramadol, but pt then
experienced recurrent pain 30 minutes later and went to ED.
Past Medical History:
Coronary Artery Disease s/p NSTEMI
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Dilated Cardiomyopathy
Peripheral Vascular Disease s/p Right Fem-[**Doctor Last Name **] Bypass
Left foot ulcer (healed)
Chronic Renal Insufficiency
s/p Left Lung Resection d/t Tuberculosis
s/p Right Breast Tumor removal (benign)
Social History:
-Tobacco, +ETOH (2 gin/d), -IVDA
Lives with wife
Family History:
Non-contributory
Physical Exam:
General: NAD, lying flat after cath
Skin: Well-healed L Thoracotomy scar, well-healed right scar,
-rashes/ulcers
HEENT/NEck: NC/AT, Supple, -JVD, -Dentures
Cardiac: Distant S1S2 -c/r/m/g
Lungs: CTAB -w/r/r
Abd: Soft NT/ND, obese -r/r/g
Ext: RLE knee to ankle well healed scar, warm, -varicosities
Pertinent Results:
Cardiac Cath [**8-25**]: 1. Significant coronary artery disease in
LMCA, LAD, and RCA. 2. Depressed left ventricular systolic
function (LVEF = 35%) 3. Mild left ventricular diastolic
dysfunction, mild pulmonary
Echo (TTE) [**8-28**]: 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 moderately depressed with akinesis of the distal LV
and apex. The mid anterior and antero-septum appear hypokinetic.
The basal LV moves best. No masses or thrombi are seen in the
left ventricle. 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. There is no aortic valve stenosis. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is no pericardial effusion.
[**2124-8-25**] 12:20AM BLOOD WBC-7.3 RBC-3.71* Hgb-12.2* Hct-33.6*
MCV-91 MCH-32.9* MCHC-36.3* RDW-12.3 Plt Ct-298
[**2124-8-29**] 11:46AM BLOOD WBC-9.0 RBC-2.60*# Hgb-8.4*# Hct-24.0*#
MCV-92 MCH-32.1* MCHC-34.9 RDW-12.9 Plt Ct-175
[**2124-8-30**] 02:59AM BLOOD WBC-13.3* RBC-3.58*# Hgb-11.3*# Hct-32.4*
MCV-91 MCH-31.7 MCHC-35.0 RDW-14.8 Plt Ct-186
[**2124-8-30**] 02:59AM BLOOD PT-14.1* PTT-35.8* INR(PT)-1.3
[**2124-8-25**] 12:20AM BLOOD Glucose-319* UreaN-51* Creat-1.9* Na-136
K-4.8 Cl-101 HCO3-25 AnGap-15
[**2124-9-7**] 06:55AM BLOOD Glucose-90 UreaN-30* Creat-1.4* Na-138
K-4.4 Cl-98 HCO3-30 AnGap-14
Brief Hospital Course:
Patient admitted to [**Hospital1 18**] and underwent a cardiac cath which
revealed LMCA and 2 vessel disease. Cardiac surgery was then
consulted for surgical intervention. Prior to surgery pt first
needed vein mapping and carotid u/s secondary to pvd hx. As well
as an Echo. Pt. also had renal consult for CRI and [**Last Name (un) **]
consult for better DM management. On [**8-29**], pt was brought to the
operating room where he underwent a coronary artery bypass graft
x 3. Pt. tolerated the procedure well with no complications.
Please see op note for surgical details. Pt. was transferred to
CSRU in stable condition being titrated on Epinephrine,
Neosynephrine, and Propofol.
Pt did well in the immediate postop period, anesthesia was
reversed he was weaned from the ventilator and extubated. During
the evening of the operative day the pt was weaned from his Epi
drip, but continued to require Neosynepherine for BP control. On
POD#1 the pt was weaned from Neo drip. On POD#2 his chest tubes
were removed, he was begun on Beta blockade and transferred to
the floor for continued post-op care. By POD#3 the pt had
^BUN/Cr, his diuretics were discontinued, and other meds were
renal dosed. Over the next two days his BUN/Cr returned to
baseline, he diuretics were resumed and gradually increased. It
took several days to see a positive effect from the diuretic
therapy and ultimately Zaroxylin was also added.
During this period the pt had an otherwise uneventful hospital
course. His activity level was advanced with the assisstance of
the PT and nursing staff.
On POD#9 it was decided that the pt was stable and ready for d/c
to rehabilitation for continued postop care and cardiac
rehabilitation.
At time of d/c pt PE is as follows:
Neuro A&O x3, MAE, follows commands, nonfocal exam.
Pulm BS clear although somewhat diminished at bases
CV RRR, S1-S2 no Murmur. Sternum stable, incision C&D
Abdm soft,NT/ND/NABS
Ext warm, well perfused, 1+edema bilat. Left vein harvest site
with staples- minimal erythema at staples
Medications on Admission:
1. Zetia 10mg qd
2. Pravachol 80mg qd
3. Lasix 30mg [**Hospital1 **]
4. NPH 30/36 w/ HSS 5050>4 and +2 Q50
5. Neurontin 300mg [**Hospital1 **]
6. Diovan HCT 60/12.5
7. Plavix 75mg qd
8. [**Doctor First Name **] D 120-60
9. Aspirin 81mgg qd
10. Atenolol 50mg qd
11. Folic acid
12. Tramadol 50mg q6 prn
13. Tylenol 325 tid prn
14. Centrum
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Woodbriar - [**Location (un) 4444**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, wash incision with mild soap and water and pat dry.
No baths, lotions, creams or powders.
Call with temperature more than 101.4, redness or drainage from
incisions, or weight gain more than 2 pounds in one day or five
in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 29173**] 2 weeks
Cardiologist 2 weeks
Completed by:[**2124-9-7**]
|
[
"443.9",
"411.1",
"745.5",
"272.0",
"278.00",
"428.0",
"410.72",
"593.9",
"250.01",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.15",
"39.61",
"88.53",
"88.56",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
6727, 6790
|
3144, 5184
|
332, 403
|
6946, 6952
|
1507, 3121
|
7334, 7465
|
1157, 1175
|
5571, 6704
|
6811, 6925
|
5210, 5548
|
6976, 7311
|
1190, 1488
|
282, 294
|
431, 735
|
757, 1075
|
1091, 1141
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,389
| 184,470
|
44635
|
Discharge summary
|
report
|
Admission Date: [**2112-4-5**] Discharge Date: [**2112-4-9**]
Date of Birth: [**2036-1-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zithromax / Lisinopril / Simvastatin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath/Chest tightness
Major Surgical or Invasive Procedure:
[**2112-4-5**] Redo sternotomy/ Aortic valve replacement(27-mm St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 4041**])
History of Present Illness:
This 76 year old male underwent coronary artery bypass grafting
in [**2090**]. He called his cardiologist few days ago and stated that
he was having increased shortness of breath. A TTE revealed
severe aortic stenosis and he was referred for cardiac
catheterization to evaluate aortic stenosis and for current
coronary status. His catheterization confirmed severe aortic
stenosis and 70% lesion of his LAD.
Past Medical History:
aortic stenosis
coronary artery disease
s/p coronary artery bpass grafts
s/p redo sternotomy, aortic valve replacement/coronary bypass
hypertension
Dyslipidemia
Infarct-related cardiomyopathy
Moderate aortic stenosis
Heart block with dual chamber PPM [**5-/2107**] gen change [**10/2110**]
Atrial fibrillation
Polio
Pilonidal cyst
Kidney Stones
Arthritis
s/p Total left knee replacement
Surgery for foot drop [**2056**]
s/p tonsillectomy
S/p inguinal Hernia repair
Social History:
Lineage from [**Country 2559**]. He is a retired funeral
director, former cigarette smoker, does not drink alcohol.
Family History:
Positive for heart disease. Everything else is
negative.
Physical Exam:
Pulse: Resp:18 O2 sat: 98% RA
B/P Right: 109/79 Left: 101/69
Height:5ft 11" Weight:222lbs
Five Meter Walk Test #1_______ #2 _________ #3_________
General:examination done while on bedrest
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [] __trace -+1
edema___
Varicosities: None [x]
Neuro: Grossly intact [x]Right lower leg weakness
Pulses:
Femoral Right:trace Left:trace
DP Right: trace Left:trace
PT [**Name (NI) 167**]: trace Left:trace
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2112-4-5**] ECHO
PRE-BYPASS:
Mild spontaneous echo contrast is seen in the body of the left
atrium. Mild spontaneous echo contrast is present in the left
atrial appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with focalities in the mid and
apical lateral wall.. Overall left ventricular systolic function
is mildly depressed (LVEF=45 %).
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. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
An eccentric, posteriorly directed jet of Moderate (2+) 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.
LVEF 45%. No new regional wall motion abnormalities.
The aortic bioprosthesis is stable and functioning well with a
residual mean gradient of 2 mm of Hg
Mild MR. [**Name13 (STitle) **] other valvular findings.
Intact thoracic aorta..
[**2112-4-7**] 05:39AM BLOOD WBC-10.5 RBC-3.77* Hgb-11.2* Hct-35.6*
MCV-94 MCH-29.8 MCHC-31.6 RDW-13.9 Plt Ct-102*
[**2112-4-5**] 07:15AM BLOOD WBC-5.5 RBC-5.19 Hgb-15.1 Hct-48.7 MCV-94
MCH-29.2 MCHC-31.1 RDW-13.7 Plt Ct-200
[**2112-4-7**] 05:39AM BLOOD PT-13.3* PTT-28.5 INR(PT)-1.2*
[**2112-4-5**] 12:54PM BLOOD PT-13.6* PTT-33.6 INR(PT)-1.3*
[**2112-4-5**] 11:40AM BLOOD PT-16.7* PTT-33.6 INR(PT)-1.6*
[**2112-4-7**] 05:39AM BLOOD Glucose-126* UreaN-25* Creat-1.1 Na-138
K-4.5 Cl-106 HCO3-26 AnGap-11
[**2112-4-5**] 12:54PM BLOOD UreaN-24* Creat-0.8 Na-141 K-4.1 Cl-112*
HCO3-23 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2112-4-5**] for surgical
management of his aortic valve disease. He was taken to the
Operating Room where he underwent redo sternotomy with
replacement of his aortic valve with a 27-mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**]
tissue valve. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. On postoperative day one, he awoke neurologically
intact and was extubated.
That day he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The Physical Therapy service was consulted for
assistance with his postoperative strength and mobility.
Beta blockade was begun. Chest tubes and pacing wires were
removed per protocols and
he progressed. He was cleared for home discharge. Coumadin for
his chronic atrial fibrillation was resumed and will continue to
be managed by Dr. [**First Name (STitle) **] as preoperatively. All follow up
appointments were arranged, wounds were clean and healing well
at discharge.
Medications on Admission:
allopurinol 300', lipitor 20', aricept 5/hs, lasix 80', toprol
50', ntg-prn, flomax 0.4', valsartan 40', coumadin 7.5 3x/wk, 5
4x/wk, aspirin 81', vit d3 1000u', claritin 10', centrum silver
qd, vitamin E 800u'
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
8. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: 5mg (two tablets 4/7&8, then as directed by Dr. [**First Name (STitle) **] after
INR check [**4-11**].
Disp:*100 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
INR on [**2112-4-11**] and prn
Please call results to Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 24398**] or FAX
[**Telephone/Fax (1) 95532**]
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. potassium chloride 10 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
aortic stenosis
s/p redo sternotomy, aortic valve replacement
s/p coronary artery bypass grafts
Hypertension
Dyslipidemia
s/p dual chamber PPM [**5-/2107**]
s/p generator change [**10/2110**]
chronicAtrial fibrillation
h/o Polio
Pilonidal cyst
Kidney Stones
Arthritis
Total left knee replacement
s/p Surgery for foot drop [**2056**]
s/p Tonsillectomy
S/p inguinal Hernia repair
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema tarce
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2112-5-5**] at 1:30pm
Cardiologist:Dr. [**First Name (STitle) 437**] on [**2112-4-13**] at 11:20am on [**Hospital Ward Name 23**] 7
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 24398**]) in [**4-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw [**2112-4-11**]
call results to Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PHONE:[**Telephone/Fax (1) 24398**]/FAX:
[**Telephone/Fax (1) 95532**]
Completed by:[**2112-4-9**]
|
[
"V58.61",
"274.9",
"V17.3",
"V45.01",
"428.32",
"424.1",
"736.79",
"V45.81",
"V43.65",
"138",
"428.0",
"272.4",
"401.9",
"V17.41",
"427.31",
"746.4",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7443, 7518
|
4513, 5653
|
337, 480
|
7941, 8111
|
2449, 4490
|
8999, 9941
|
1557, 1617
|
5914, 7420
|
7539, 7920
|
5679, 5891
|
8135, 8976
|
1632, 2430
|
262, 299
|
508, 917
|
939, 1406
|
1422, 1541
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,938
| 190,764
|
15942
|
Discharge summary
|
report
|
Admission Date: [**2160-1-30**] Discharge Date: [**2160-2-12**]
Date of Birth: [**2100-4-18**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Briefly, this is a 59-year-old
male status post coronary artery bypass graft times five on
[**2160-1-3**] and had been discharged home on [**1-15**]
with minimal sternal drainage and was scheduled to follow up
in two weeks for a sternal wound check.
The patient presented for a wound check and was subsequently
admitted for a sternal wound infection. The patient reports
living in a small poorly heated trailer in which he had
refrained from bathing due to the cold conditions. The
patient reports a low-grade temperature while at home; now
resolved. However, he had noted increased foul-smelling
drainage since discharge from the hospital. The patient had
been feeling a mild muscular chest pain. No nausea,
vomiting, or diaphoresis.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. Coronary artery disease; status post coronary artery
bypass graft times five in [**2159-12-12**] with automatic
internal cardioverter-defibrillator implantation.
2. Hypertension.
3. Status post myocardial infarction.
4. Hypercholesterolemia.
5. Status post motor vehicle accident with a syncopal event.
6. Agoraphobia.
7. Anxiety.
8. Depression.
9. Blindness of the right eye.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Colace 100 mg p.o. b.i.d.
2. Percocet as needed.
3. Amitriptyline 25 mg p.o. q.d.
4. Perphenazine 4 mg p.o. q.d.
5. Metoprolol 50 mg p.o. b.i.d.
6. Atorvastatin 10 mg p.o. q.d.
7. Amiodarone 200 mg p.o. t.i.d. (times three month) and
then 200 mg p.o. q.d.
8. Aspirin 325 mg p.o. q.d.
9. Lisinopril 5 mg p.o. q.d.
10. Isosorbide dinitrate 40 mg p.o. t.i.d. (times six
weeks).
PHYSICAL EXAMINATION ON PRESENTATION: On examination, the
patient was afebrile with stable vital signs. In sinus
rhythm. The chest was clear to auscultation bilaterally. No
wheezes or rhonchi. The sternum was stable. The superior
sternal aspect was mildly erythematous and an opened area at
the inferior two inches with purulent drainage.
HOSPITAL COURSE: The patient was admitted and placed on
antibiotics. The wound was cultured. Electrophysiology
consulted and recommended aggressive antibiotic treatment for
his sternal site to avoid implantable
cardioverter-defibrillator infection. The patient continued
to do well and underwent a sternal debridement on hospital
day four.
The Plastic Surgery Service was then consulted, and they
intervened and performed a bilateral percutaneous endoscopic
gastrostomy tube advancement without any complications.
The patient was placed on the usual sternal precautions and
continued to do well throughout his stay with an
uncomplicated hospital course.
The patient was awaiting rehabilitation placement and agreed
to be discharged to such until [**2-11**], at which point he
said he would prefer to be discharged to his home (which was
a trailer). Social Work, Case Management, Psychiatry
Service, Cardiology Service, and the Cardiothoracic Surgery
Service all advised against this and felt that he would be
better served being discharged to a rehabilitation facility
at least for a period of time to insure proper resolution of
this episode. The patient adamantly refused and was deemed
to be competent, and was therefore, the patient was
discharged to his home on [**2160-2-12**].
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient had followup
scheduled with Dr. [**Last Name (STitle) 1537**] in four weeks and with the patient's
cardiologist (Dr. [**Last Name (STitle) 284**].
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Status post sternal debridement.
2. Bilateral percutaneous endoscopic gastrostomy tube
advancement.
MEDICATIONS ON DISCHARGE: (The patient was to be discharged
on)
1. .................... hydrobromide 10 mg p.o. q.d.
2. Ascorbic acid 500 mg p.o. b.i.d.
3. Zinc sulfate 220 mg p.o. q.d.
4. Isosorbide mononitrate extended-release 60 mg p.o. q.d.
5. Colace 100 mg p.o. q.d.
6. Percocet one to two tablets p.o. q.4-6h. as needed (for
pain).
7. Aspirin 325 mg p.o. q.d.
8. Lisinopril 5 mg p.o. q.d.
9. Amiodarone 200 mg p.o. q.d.
10. Atorvastatin 10 mg p.o. q.d.
11. Metoprolol 50 mg p.o. b.i.d.
12. Perphenazine 4 mg p.o. q.d.
13. Amitriptyline 25 mg p.o. q.h.s.
14. Levofloxacin 500 mg p.o. q.d. (times a 7-day course).
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2160-2-12**] 14:54
T: [**2160-2-12**] 14:56
JOB#: [**Job Number 45698**]
cc:[**Last Name (STitle) **]
|
[
"998.59",
"V45.81",
"401.9",
"E878.2",
"V45.02",
"041.85",
"272.0",
"296.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"86.22",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
3847, 3953
|
3980, 4893
|
1448, 2228
|
2247, 3523
|
3557, 3727
|
3742, 3826
|
180, 922
|
945, 1421
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,709
| 141,174
|
43003
|
Discharge summary
|
report
|
Admission Date: [**2179-10-22**] Discharge Date: [**2179-11-2**]
Date of Birth: [**2118-2-26**] Sex: M
Service: PLASTIC
Allergies:
Macrolide Antibiotics / Ambien
Attending:[**First Name3 (LF) 10416**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
s/p wide debridement of sacral decubitous in OR
History of Present Illness:
# Sacral decubitus ulcer
- initially treated with vancomycin, meropenem and daptomycin
- then grew VRE -> ID consulted -> tigecycline for 6 weeks
- underwent loop ostomy on [**2179-9-29**] to remove fecal contamination
- last debrided on [**2179-10-2**]
- last cx [**2179-10-2**] w/ MDR Pseudomonas, [**Last Name (un) 36**] to zosyn
# Epidural abscess [**7-15**] due to MSSA
- s/p laminectomy C7-T10 w/ washout
- T10 paraplegic since
# IDDM
# MI s/p CABG x4 ~[**2174**]
# Chronic back pain
# Peripheral neuropathy
# Gout
# OSA
Past Medical History:
Epidural abscess [**7-15**] due to MSSA s/p laminectomy
Diabetes
MI s/p CABG 5 years PTA
Chronic back pain
neuropathy- unable to feel the bottom of his feet
gout
obstructive sleep apnea
Social History:
No EtoH since CABG, heavy smoker 50 years x 2ppd, lives with
girlfriend. [**Name (NI) **] used intranasal cocaine, no IVDA
Family History:
non contributory
Physical Exam:
VS - Tc 96.8, BP 83/63, HR 72, RR 18, sats 100% on AC 700z18,
FiO2 100%, PEEP 5 -> 10
UOP 200cc
Gen: Pale, morbidly obese male, sedated and intubated. Not
following commands, not responding to painful stimuli.
HEENT: Sclera anicteric. Pupils 2mm bilaterally, minimally and
sluggishly reactive. OP not assessed due to intubation. JVD not
able to be assessed due to body habitus. Face appears symmetric.
CV: Difficult to hear heart sounds, but seems regular, normal
S1. S2. No m/r/g.
Lungs: CTA anteriorly. No crackles/wheezes/rhonchi.
Abd: Obese, soft, NTND. Hypoactive BS. Ostomy in RLQ. Cellulitic
changes on flanks bilaterally.
Ext: Gross pitting edema to thighs bilaterally. Has necrotic
heel ulcers bilaterally (dry) and necrotic ulcer on base of R
great toe (dry). Chronic venous stasis color changes to both
calves. Has large sacral decub, but not able to be visualized
currently.
Neuro: Not responsive to sternal rub. Not responsive to painful
stimuli on either hand. Toes not responsinding to Babinski
bilaterally. Not able to illicit patellar or ankle reflexes
bilaterally. Grimaced w/ insertion of NGT.
Pertinent Results:
MICRO:
none
.
IMAGING:
EKG [**10-22**] - RBBB, rate of 93
.
CXR [**10-22**] - (my read) clear lung field, enlarged heart, can not
follow NGT into stomach, ETT in place
Brief Hospital Course:
A/P: 61yo M w/ an extensive PMH notable for morbid obesity,
paraplegia due to an extensive epidural abscess, CAD, here for
hypotension in setting of wound debridement for sacral decubitus
ulcer.
.
# HYPOTENSION: Patient still hypotensive and on levophed despite
nearly 20 L of fluids. Continued to be tachycardic with an
elevated lactate and leukocytosis. Concern now for septic shock
given the lack of improvement with large volumes of fluids.
Unable to obtain SC vs. IJ central line to measure CVP but
clinically he still appears to have a need for further fluid
rescucitation. Infectious source is likely his sacral decub ->
may have become transiently bacteremic intraop. Also has PICC
line in place, so will consider line infection. Will send urine
for UA and cx, blood cx and stool cx (given marked leukocytosis
and long term use of abx, should r/o Cdiff).
- fluid boluses and levophed for MAP > 60, SBP > 90
- blood to maintain hct > 30
- serial lactates
- check UA, urine cx, blood cx, stool cx for Cdiff
- cont zosyn, linezolid, flagyl for empiric antibiotic coverage
- hold on [**Last Name (un) 104**] stim for now given that we would not give
steroids given poor wound healing
- no evidence of cardiac ischemia, EKG unchanged from prior,
cardiac enzymes negative x 2 sets
.
# LEUKOCYTOSIS: Unclear etiology, but raises concern for
infectious source.
- f/u UA, urine cx, blood cx, stool cx for Cdiff
- continue antibiotics
.
# RESPIRATORY FAILURE: Had issues with hypoventilation
intraoperatively. Seems to have improved with changes in his
vent settings. CXR with worsening pulmonary edema likely
secondary to IVF fluid resuscitation. Most recent ABG with
metabolic acidosis, normal PaCO2. Appears to be working against
the vent so will work with ventilator to optimize ventilation
today. Appears to be oxygenating well.
.
# SACRAL DECUBITUS: Debrided in OR. No cultures taken. Last
culture on [**10-2**] showed Pseudomonas (MDR) but [**Last Name (un) 36**] to zosyn. Also
w/ proteus (no [**Last Name (un) 36**]). Cx from [**8-27**] was polymicrobial (included
bacteroides). Not planning on closing the wound or using vac
dressing. Likely the infectious source driving the septic shock.
- f/u plastic surgery recs
- dressing changes as able
- transfuse to keep Hct >30
- cont abx
- cont zinc, ascorbic acid
.
# ANION GAP METABOLIC ACIDOSIS: Likely due to his lactic
acidosis. Cr is 1.1, from baseline of 0.7-0.8 with decrease
urine output. Likely prerenal azotemia vs. component of ATN.
- continue IVF resuscitation as noted above. If component of
ATN may not be able to assess volume status via urine output so
will bolus for blood pressure.
- recheck lactate regularly -> goal MAP >60, SBP >90
- may need urine electrolytes to further evaluate
.
# CAD: Has a h/o CAD and is s/p CABG: EKG with right heart
strain but no change from prior. Two sets of negative cardiac
enzymes.
- currently holding PO lopressor given pressor dependence
- restart ASA
- monitor on telemetry
.
# Increased size of left pupil: Both pupils reactive but left
greater than right. Unclear if this is old or new. [**Month (only) 116**] need
to consider decreasing sedation and checking more formal
neurologic exam. Unable to obtain brain imaging secondary to
body habitus.
.
# DIABETES MELLITUS: On HISS with FS QID.
.
# HYPOALBUMINEMIA: Albumin of 1.4, likely due to poor
nutritional state.
- nutrition consult for low albumin
- hold on RUQ U/S for now
.
# FEN: OGT in place. Nutrition consult to start tube feeds. IVF
as above. Check lytes daily, will replete prn.
.
# ACCESS: R groin CVL, L PICC, L A-line
.
Overall, patient's clinical status continued to deteriorate in
spite of aggressive fluid recussitation, broad spectrum
antibiotics, pressors, and respiratory support. This was likely
due to sepsis from his chronic wound. Pt expired as a result of
cardiopulmonary arrest on [**2179-11-2**] and his family was made aware.
Medications on Admission:
MEDS: (at rehab)
ascorbic acid 500mg PO BID
enoxaparin 40mg SC Q12
fentanyl 75mcg/hr Q3d TD
ferrous sulfate 325mg PO BID
folic acid PO QD
ISS - regular
linezolid 600mg PO BID - started [**2179-10-14**], expires [**2179-11-13**]
lopressor 12.5mg PO BID
nystatin 5mL PO TID
zosyn 4.5gm IV Q6 - started [**2179-10-14**], expires [**2179-11-13**]
ranitidine 150mg PO BID
simvastatin 40mg PO QHS
zinc sulfate 220mg PO QD
acetaminophen 650mg PO Q6 hrs prn
alum hydroxide 30mL PO Q4 hrs prn
alb neb Q6 prn
ipratroprium neb Q6 prn
dilaudid 2mg PO Q6 hrs prn
percocet 2 tab PO Q6 prn
trazadone 25mg PO QHS prn
miconazole TP prn
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"518.5",
"V09.80",
"278.01",
"038.49",
"780.57",
"286.9",
"584.5",
"V44.3",
"707.03",
"V02.59",
"355.8",
"250.00",
"995.92",
"785.59",
"344.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"38.95",
"99.15",
"00.14",
"86.22",
"99.04",
"96.6",
"96.04",
"39.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7266, 7275
|
2638, 6569
|
304, 353
|
7321, 7325
|
2445, 2615
|
7376, 7381
|
1277, 1295
|
7239, 7243
|
7296, 7300
|
6595, 7216
|
7349, 7353
|
1310, 2426
|
253, 266
|
381, 910
|
932, 1120
|
1136, 1261
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,651
| 155,209
|
26340
|
Discharge summary
|
report
|
Admission Date: [**2181-12-13**] Discharge Date: [**2182-1-31**]
Date of Birth: [**2134-1-26**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
1) Bilateral IR guided nephrostomy tube placement
2) exploratory laparotomy, resection of pelvic masses, bilateral
salpingoophorectomy
History of Present Illness:
47yo F with abdominal pain for ten months worsening over the
last week. Pt saw a new PCP today who noted large abdominal mass
on exam and sent her to [**Hospital1 **]. US at OSH
demonstrated a 20cm mass in abdomen as well as lab abnormalities
including hyperkalemia (K 6.1) with ECG findings, renal failure
(creatinine of 11.5), hyponatremia (Na 121), leukocytosis (WBC
of 20.1) and anemia (Hct of 17 s/p one unit of PRBCs) leading to
x-fer to [**Hospital1 18**]. The pt also received fentanyl 50mcg IV x1, and
ativan 0.5mg IV x1 prior to transfer.
The pt reports increasing abdominal pain which is described
as intermittent sharp pain worse in the LLQ. The pt also admits
to 55lb weight loss during this span, constipation, n/v and
decreased PO intake.
In the ED, the pt underwent a CT scan which confirmed the
finding of a 20 cm mass. She received 2mg ativan and 2mg
dilaudid after which, she became somewhat lethargic requiring
0.4mg naloxone x2. She was given insulin/D50, calcium
gluconate, and kayoxalate for her hyperkalemia and sodium bicarb
for her acidosis.
Gyn was consulted in the ED regarding the large ovarian mass and
recommended formal consult in the AM, CA-125, CEA, ureteral
stents and further characterization of mass for planned excision
at some point in the future.
Renal was consulted in the ED and recommended correction of
underlying acidosis with barcarbonate infusion and continuation
of treatment of hyperkalemia with kayexolate, lasix, calcium
gluconate and insulin/D50.
Urology was consulted in the ED and recommended bilateral
ureteral stents.
Past Medical History:
None
Social History:
Tob: 1ppd x 20 years
EtOH: occasional
Illicit drugs: denies
Family History:
no family hx of CA.
Physical Exam:
VS: 84, 111/65, 15, 100%
Gen: thin almost cachectic tired appearing female asleep in NAD.
easily awoken with physical stimuli.
HEENT: temporal wasting, EOMI, anicteric, mm dry
Chest: CTA bilaterally
CV: rrr, s1, s2, no m/r/g
Abd: large palpable hard mass in LLQ, which is dull to
percussion, slightly tender to palpation.
Back: no CVA tenderness, no spinal or paraspinal tenderness
Ext: wwp, no c/c/e
Pertinent Results:
Pelvic CT [**2181-12-12**]:
"1. Large complex multilocular cystic masses, originating within
the pelvis. The appearance is concerning for bilateral ovarian
cystadenocarcinomas. There is associated multicystic extension
into [**Location (un) 6813**] pouch with invasion into the liver and right
kidney.
2. Bilateral marked hydroureter and hydronephrosis from
narrowing of the distal ureters bilaterally."
Brief Hospital Course:
Pre-op Course:
The pt was admitted to Medicine for pre-op stabilization. Her
hospital course is summarized briefly below by issue:
1. ARF:
As ARF was thought to be [**1-17**] bilateral obstuctive
hydronephrosis, bilateral nephrostomy tubes were placed by IR.
Renal was consulted, and the pt initially required IV bicarb and
bicitra, in addition to aggressive NS hydration, for tx of a
metabolic acidosis and hyperkalemia. Hyperkalemia resolved
after administration of kayexelate, insulin, glucose, and D50 in
the ED, and acidosis resolved within the first few days of
hospitalization. However Cr initially did not improve, so a
Permacath was placed in anticipation for HD. However, cr began
to improve on HD #6 and HD was ultimately not required. Pt made
good urine from L kidney after nephrostomy placement, however R
kidney put out only ~ 50 cc/day of thick fluid, which grew E
coli. Nephrostogram confirmed good R nephrostomy placement, and
it was felt that R kidney was probably more permanantly damaged
from pyelonephritis as well as a more complete obstruction. A
Renal perfusion scan showed almost no flow on R, decreased flow
L. Her new baseline Cr ranges from 3.5 - 3.9.
2. Pyleonephritis with bacteremia:
Pt grew pan-sensitive E coli from R nephrostomy tube and blood
cultures, and was treated with a 2 week course of Levofloxacin.
3. Breast mass:
Gyn/Onc service followed throughout pre-op evaluation. CEA 2.8
(WNL), CA-125 73 (high). A pre-op CXR showed no evidence of
mass or PNA. Mammogram was deferred as pt was felt to be too
unstable for transport to the [**Hospital Ward Name **], however the Breast
surgery service was consulted, and felt the mass was more c/w
with a fibroadenoma on history and bedside US. A MRI of the
head was negative for metastasis. Pain from the mass was
treated with PO Oxycodone with good effect.
4. Small bowel obstruction:
The pt developed nausea and vomiting and increasing abdominal
distention on [**12-21**], and a portable KUB showed evidence of partial
SBO. Pt was managed conservatively with an NGT to suction, was
kept NPO, and a PICC was placed and TPN administered to maintain
nutrition pre-op.
5. Anemia:
Iron studies were checked, and this was felt to be [**1-17**]: #1
anemia of chronic disease, [**1-17**] low epogen from kidney invasion +
#2 bleeding into the tumor. The pt initially required multiple
transfusions to increase her hct to > 30, which was Gyn/Onc's
goal given anticipated blood loss in the OR. Her hct was fairly
stable after initial transfusions, though she did require 2 more
units of PRBCs over the next week as her hct slowly drifted
down, most likely [**1-17**] #2 above. Stool was guiac negative.
6. Hyponatremia:
This was felt to be [**1-17**] ARF + dehydration, and resolved with NS
resuscitation.
The pt was then transferred to the gynecologic oncology service
on [**12-28**] for an exploratory laparotomy, resection of pelvic mass,
bilateral salpingo-oophorectomy and lysis of adhesions. Please
see the dictated operative note for details regarding the
procedure. The pt's postoperative course significant for the
following issues:
1. CV:
The pt required aggressive fluid resuscitation
intraoperatively. Upon transfer to the ICU, her BP remained
stable off of pressors. She remained stable after transfer to
the floor, with HR and BP well within the normal range. The pt
remained hemodynamically stable for the remainder of her
hospital stay.
2. Pulmonary:
The pt was transferred to the PACU and then to the ICU intubated
and sedated. She was extubated on POD#1 and was gradually
weaned off of oxygen, requiring no supplemental O2 by POD#3.
Her O2 saturation remained stable on room air for the remainder
of her hospital stay.
3. Heme:
The pt received a total of 7u pRBCs, 4u FFP, and 1 6-pack of
platelets intraoperatively. A developing coagulopathy was noted
intraoperatively, although she was not clinically
anticoagulated. Her Hct and INR were followed serially
postoperatively, and she received an additional 3u pRBCs and 2u
FFP in the ICU to maintain a Hct of 25 and a normal INR. Her
Hct remained stable at ~30 until POD#7 when it slowly drifted
down over several days to a nadir of 26; she was transfused an
additional 2u pRBCs to achieve a Hct of 30 in order to optimize
her response to chemotherapy. The pt's hematocrit remained
stable around 28-30 for the remainder of her hospital stay.
4. Renal:
The pt's Cr was 3.3 on the day of her surgery, and remained in
the 3.3-3.9 range for the remainder of her hospital stay. Her
output from her Foley was minimal, and it was D/C'd on POD#8.
Her R nephrostomy tube continued to have a low output; her L
nephrostomy tube was very productive, accounting for virtually
her entire urine output. She diuresed during her postoperative
hospital stay. Electrolytes were repleted with her TPN.
5. ID:
The pt was started on empiric coverage w/ Levaquin and Flagyl
after her surgery. A Gram stain of the fluid drained from her
tumors grew sparse pan-sensitive E. coli. She never had a fever
postoperatively. The antibiotics were D/C'd on POD#5, after
completion of a total 14 day course for her pyelonephritis.
6. FEN/GI:
The pt had a small bowel obstruction caused by an adhesion
tethering her terminal ileum; this was released during surgery.
Her NG tube was left in place postoperatively, and its output
decreased to ~250cc in a day. The NG was clamped on POD#3, and
D/C'd on POD#4. The pt advanced her diet slowly without
difficulty, and she tolerated a regular diet on POD#10. Her TPN
had been D/C'd intraoperatively. It was restarted on POD#2, and
continued until POD#13 when her PO intake was deemed adequate by
nutrition services. The pt tolerated adequate po intake for the
remainder of her hospital course.
7. Prophylaxis:
The pt wore SCDs in bed until she was able to ambulate. She had
heparin and Pepcid in her TPN. When the TPN was D/C'd, SC
heparin and PO PPI were initiated.
8. Ovarian cancer: Given the pt's diagnosis of unstaged clear
cell carcinoma of the ovary, chemotherapy was initiated during
the [**Hospital **] hospital stay. On [**2182-1-8**], the pt underwent her first
round of chemotherapy w/ carboplatin alone given concern for the
increased toxicitiy of combined carboplatin w/ taxol. The pt's
CA125 level was checked on [**2182-1-25**] prior to her second round of
chemotherapy and was found to be eleveated at 103 (increased
from 72 on [**2182-12-13**]). The pt underwent her second chemotherapy
cycle on [**2182-1-30**] and was treated w/ both carboplatin and taxol
given the pt's improvement in overall functional status. She
will follow-up with Dr. [**Last Name (STitle) 2244**] in 3 weeks for her 3rd cycle.
9. Psych:
Psych was consulted postoperatively given concern for the pt's
episodic anxiety as well as depressive symptoms. Psych felt
that the pt's symptoms most closely resembled an adjustment
disorder w/ depressive and anxious components, and recommended
starting the pt on celexa as well as clonopin 1mg tid. The pt
was started on celexa w/o difficulty but was noted to be very
somulent w/ the clonopin to the point where she slept all day
and was not able to get out of bed. The clonopin was decreased
to 1 mg [**Hospital1 **] but the pt still remained somulent the majority of
the time. Thus, the clonopin was discontinued; the pt continued
to do well w/o any noted anxiety episodes.
On POD# 34 and HD#50 , the pt was deemed stable for discharge to
home w/ VNA. She will follow-up with Dr. [**Last Name (STitle) 2244**] in 3 weeks for
her 3rd chemotherapy cycle, as well as for a nephrostomy tube
change on [**2-25**].
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Disp:*1000 ML(s)* Refills:*1*
3. Sorbitol 70 % Solution Sig: One (1) Miscell. [**Hospital1 **] (2 times a
day).
Disp:*60 * Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*120 Tablet(s)* Refills:*2*
5. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): Please apply both 100 mcg
patch with 25 mcg patch for total dose of 125 mcg every 72
hours.
Disp:*30 Patch 72HR(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 tube* Refills:*1*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/ MEALS ().
Disp:*180 Tablet, Chewable(s)* Refills:*2*
9. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Transdermal every
seventy-two (72) hours.
Disp:*30 patches* Refills:*2*
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-23**]
hours as needed for break through pain: This medication is for
break-through pain only; if you need to take it once a day or
more frequently, please contact your doctor so that other pain
medications may be increased.
Disp:*60 Tablet(s)* Refills:*2*
12. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours for 3 days: Please take this medication for 3 days after
chemotherapy for treatment of nausea.
Disp:*30 Tablet(s)* Refills:*1*
13. Saline Flush 0.9 % Syringe Sig: Two (2) syringes Injection
once a day: For saline flush of bilateral nephrostomy tubes.
Disp:*100 syringe* Refills:*2*
14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety.
Disp:*90 Tablet(s)* Refills:*1*
15. Neulasta 6 mg/0.6mL Syringe Sig: One (1) Subcutaneous 1x
for 1 days: to be given on [**2-1**].
Disp:*1 1 syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
vna east
Discharge Diagnosis:
Clear cell ovarian carcinoma
Discharge Condition:
stable
Discharge Instructions:
- Please call your physician if you experience fever > 100.5,
chills, vomiting so that you cannot keep hydrated, worsening or
severe abdominal pain. Please call if your incision becomes
red, warm, has drainage, or if your incision reopens. Please
call with any other questions or concerns.
- Please take your medications as prescribed.
- Please keep your follow-up appointments as outlined below.
Followup Instructions:
The following appointments have been set up for you:
1) [**Last Name (LF) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 5777**] Call to schedule appointment after
you finish your chemotherapy tx
2) Interventional Radiology for nephrostomy tube change; [**Hospital Ward Name **]. Please report to the Day Care Center at 7:00 am on
[**2182-2-25**] (Monday). You cannot eat or drink anything after
midnight prior to this appointment, which is to change your
nephrostomy tubes.
3) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2182-1-31**] 9:30 (you will get your nulasta shot in the
clinic prior to leaving)
4) Dr. [**Last Name (STitle) 2244**], [**2182-2-25**] (Monday) at 10:00 am for 3rd round of
chemotherapy.
5) Dr. [**Last Name (STitle) **] from nephrology on [**2182-3-5**] at 2:30 pm on [**Location (un) **] of [**Hospital Ward Name 23**] Building (ask Dr. [**Last Name (STitle) 2244**] whether you need to
see nephology; if not, it is okay to cancel this appointment)
|
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"197.6",
"280.0",
"041.4",
"593.4",
"276.7",
"196.2",
"584.5",
"620.8",
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icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.08",
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"99.25",
"54.59",
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"38.93",
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"55.93",
"99.07",
"87.75",
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] |
icd9pcs
|
[
[
[]
]
] |
13150, 13189
|
3111, 10784
|
344, 481
|
13262, 13271
|
2682, 3088
|
13719, 14789
|
2222, 2244
|
10839, 13127
|
13210, 13241
|
10810, 10816
|
13295, 13696
|
2259, 2663
|
290, 306
|
509, 2099
|
2121, 2128
|
2144, 2206
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,806
| 137,134
|
6241+55742
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-1-26**] Discharge Date: [**2175-2-17**]
Date of Birth: [**2119-7-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Right-sided weakness and sensory loss.
Major Surgical or Invasive Procedure:
[**2175-1-26**] open brain biopsy
[**2175-1-31**] Thoracentesis
[**2175-2-4**] Lumbar puncture
[**2175-2-4**] Thoracentesis
[**2175-2-7**] Attempted lumbar puncture
[**2175-2-7**] Lumbar puncture under flouroscopic guidance
[**2175-2-8**] Paracentesis
[**2175-2-8**] PICC placement
[**2175-2-9**] PICC placement
History of Present Illness:
55yoF w h/o non-resectable Pancreatic CA who presented in [**Month (only) **]
[**2173**] with Right sided weakness and sensory loss, found on
imaging to have Left posterior cerebral hyperdensity. Biopsy
negative for tumor. She has had seizures, GI bleed and DVT in
the interval, on Keppra but not anticoagulated. A recent MRI [**Month (only) **]
[**2174**] now showing interval progression of lesion. Dexamethasone
started 4mg QD with mild improvement in patient symptoms of RUE
weakness and gait instability. Continues to wear AFO RLE for
weakness/foot drop. Also now c/o blurry vision L>R. Presents
today for consideration repeat biopsy of growing lesion,as
recommended by the BTC. Denies recent fevers, cough. Endorses
Rt hand tremor.
Past Medical History:
1. Pancreatic Adenocarcinoma
2. Postoperative sepsis after Whipple's
3. Bipolar disorder, psychiatric hospitalizations
4. Asthma
5. Hypertension, currently off medications
6. Chronic resting tremor since [**2168**]
7. Cholecystectomy
Social History:
Worked as a clerk for an engineering firm; has been unemployed
since [**2164**]. She currently lives in a nursing facility. She has
friends and family (cousins) nearby for support. She used to
drink 4 alcoholic drinks/ night but quit in [**2164**]. no hx illicit
drug use. Reportedly able to ambulate independently at baseline
but requires assistance with ADLs.
Family History:
Grandmother with stroke at age 57
Mother with rheumatic heart disease, CAD, Colon cancer (in
20s-resected)
Father with AML
Uncle on mother's side with stomach cancer
Physical Exam:
On admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: equal, round, reactive, EOMs intact b/l
Neck: Supple.
Lungs: unlabored respirations, no audible wheeze
Cardiac: RRR.
Abd: Soft, NT
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech slow with good comprehension and repetition.
No dysarthria or paraphasic errors.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 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 finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
+ tremor Rt hand. Strength 4/5 R tricep, TA/GS, otherwise
intact.
No pronator drift.
.
AFO in place Rt foot.
.
Sensation: Intact to light touch bilaterally.
.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
Pertinent Results:
ADMISSION LABS:
[**2175-1-27**] 03:59AM BLOOD WBC-6.9 RBC-4.39 Hgb-10.6* Hct-34.1*
MCV-78* MCH-24.2* MCHC-31.1 RDW-17.5* Plt Ct-109*
[**2175-1-31**] 10:34AM BLOOD Neuts-90.6* Lymphs-6.1* Monos-3.1 Eos-0.1
Baso-0.1
[**2175-1-31**] 10:34AM BLOOD PT-16.5* PTT-29.9 INR(PT)-1.6*
[**2175-1-27**] 03:59AM BLOOD Glucose-180* UreaN-14 Creat-0.6 Na-143
K-3.9 Cl-109* HCO3-29 AnGap-9
[**2175-1-31**] 10:34AM BLOOD LD(LDH)-346*
[**2175-2-1**] 04:19AM BLOOD ALT-24 AST-22 LD(LDH)-238 AlkPhos-100
Amylase-13 TotBili-0.7
[**2175-2-1**] 04:19AM BLOOD Lipase-10
[**2175-1-30**] 04:54AM BLOOD proBNP-361*
[**2175-1-31**] 10:34AM BLOOD proBNP-232*
[**2175-1-27**] 03:59AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1
.
[**2175-1-31**] EEG: IMPRESSION: This is an abnormal video EEG
monitoring session because of diffuse mild background slowing
indicative of a mild diffuse encephalopathy of non-specific
etiology. There are occasional broad- based left central
epileptiform discharges indicative of a potential epileptogenic
focus in this region. Compared to the prior day's recording,
there is improvement with faster frequencies appearing in the
background and less frequent epileptiform discharges.
.
[**2175-2-3**] CXR: IMPRESSION: AP chest compared to [**1-31**] through
[**2-1**]: Moderate-to-large right pleural effusion has
increased, producing mild leftward mediastinal shift. Right lung
base is atelectatic, as expected.Right upper lung and left lung
are clear. Right infusion port ends in the mid-to-low SVC. No
pneumothorax.
.
[**2175-2-3**] CT HEAD: IMPRESSION: Stable postoperative changes without
acute intracranial abnormality.
.
[**2175-2-4**] CXR: IMPRESSION: Increased right effusion.
.
[**2175-2-6**] Ultrasound BLE: DVT of right popliteal vein.
.
[**2175-2-6**] EEG PRELIM: IMPRESSION: This portable routine EEG was
abnormal due to the presence of a slow, disorganized background
and bursts of generalized slowing. These findings are suggestive
of a diffuse encephalopathy, indicating widespread cerebral
dysfunction, of nonspecific etiology. No epileptiform features
were seen.
.
[**2175-2-6**] MRI/MRA Brain: IMPRESSION:
1. Postsurgical changes status post left parietal craniotomy
with resection of left frontal lesion. Residual enhancement is
difficult to evaluate in this limited exam. There is a 3.5 mm
focus of slow diffusion in the inferior aspect of the surgical
bed likely representing postoperative cytotoxic edema.
2. Very limited study. The internal carotid arteries, basilar
and vertebral arteries are grossly unremarkable. The anterior,
middle and posterior cerebral arteries are not well seen.
.
[**2175-2-8**] U/S ABD: Technically successful diagnostic and
therapeutic paracentesis. Samples were sent to the laboratory.
.
[**2175-2-8**] pCXR FINDINGS: As compared to the previous radiograph,
the patient has received a new left PICC line. Tip of the line
projects over the cavoatrial junction. No evidence of
complications, notably no pneumothorax. The right Port-A-Cath is
in unchanged position. Unchanged right pleural effusion.
.
[**2175-2-9**] EEG: PRELIM: This is an abnormal ICU continuous video EEG
due to the slow and disorganized background of [**5-7**] Hz indicative
of a diffuse moderate encephalopathy. There are infrequent
generalized and bilateral frontal sharp wave epileptiform
discharges indicative of frontal and generalized cortical
irritability and increased propensity to seizures. However, no
clear electrographic seizures are recorded in this study.
Compared to the previous day's recording, there is a slight
decrease in the frequency of epileptiform discharges
particularly during the night.
.
[**2175-2-10**] CT HEAD: IMPRESSION: Study limited due to significant
motion related artifacts despite repetition.
1. Stable post-operative changes in the left frontoparietal
region with small amount of blood products and edema in the left
frontal lobe.
2. No new intra- or extra-axial hemorrhage. No new mass effect
or evidence of herniation. Correlate clinically to decide on the
need for further workup.
.
DISCHARGE LABS:
[**2175-2-17**] 05:40AM BLOOD WBC-7.0 RBC-3.78* Hgb-9.6* Hct-30.9*
MCV-82 MCH-25.5* MCHC-31.2 RDW-21.4* Plt Ct-73*#
[**2175-2-5**] 09:56AM BLOOD Neuts-92.3* Lymphs-4.0* Monos-3.5 Eos-0.1
Baso-0.2
[**2175-2-12**] 05:30AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**]
[**2175-2-17**] 05:40AM BLOOD PT-19.5* PTT-107.2* INR(PT)-1.8*
[**2175-2-10**] 01:05PM BLOOD FDP-10-40*
[**2175-2-17**] 05:40AM BLOOD Fibrino-71*
[**2175-2-1**] 04:19AM BLOOD Ret Aut-0.8*
[**2175-2-17**] 05:40AM BLOOD Glucose-150* UreaN-28* Creat-0.4 Na-141
K-4.3 Cl-113* HCO3-23 AnGap-9
[**2175-2-14**] 06:00AM BLOOD LD(LDH)-373*
[**2175-2-16**] 04:30AM BLOOD ALT-26 AST-38 AlkPhos-144* TotBili-0.8
[**2175-2-11**] 06:00AM BLOOD Albumin-2.5* Calcium-7.8* Phos-2.5*
Mg-2.0
[**2175-2-17**] 05:40AM BLOOD Calcium-7.1* Phos-3.0 Mg-2.1
[**2175-2-1**] 04:19AM BLOOD calTIBC-293 Hapto-45 Ferritn-38 TRF-225
[**2175-2-11**] 06:00AM BLOOD Triglyc-67
[**2175-2-13**] 05:33AM BLOOD Ammonia-38
[**2175-2-5**] 04:53AM BLOOD Osmolal-328*
[**2175-2-8**] 01:06PM BLOOD Prolact-11
[**2175-2-8**] 05:47AM BLOOD TSH-0.057*
[**2175-2-9**] 06:55AM BLOOD PTH-47
[**2175-2-8**] 01:06PM BLOOD T4-3.9* calcTBG-0.91 TUptake-1.10
T4Index-4.3*
[**2175-2-9**] 06:55AM BLOOD 25VitD-31
[**2175-2-10**] 06:15AM BLOOD Valproa-83
[**2175-2-5**] 09:56AM BLOOD Lithium-0.2*
[**2175-2-6**] 06:14PM BLOOD Lactate-1.9
[**2175-2-1**] 04:19AM BLOOD CA [**81**]-9 -2618
[**2175-2-8**] 01:06PM BLOOD NEURONAL NUCLEAR ([**Doctor Last Name **]) ANTIBODIES Negative
Brief Hospital Course:
55yo woman with advanced pancreatic cancer admitted for brain
biopsy of growing lesion and noted to have right-sided weakness
with ongoing seizures. During the foley catheter placement in
the OR, she was noted to have a vaginal abrasion. GYN consult
was called intraoperatively and the patient was evaluated. They
recommended sitx baths for comfort and Social Work consult to
screen for sexual abuse, which was done. She remained stable
post-operatively, the biopsy done without complication. CT head
revealed no hemorrhage and biopsy was consistent with metastatic
pancreatic adenocarcinoma. On [**2175-1-27**], she was neurologically
stable and was cleared for transfer to the stepdown. On
[**2175-1-28**], she appeared more withdrawn and restless. She was also
not moving the right UE as well. A head CT was performed which
was stable. An EEG which showed generalized slowing, but no
seizure activity. Her levetiracetam was increased plus an
additional bolus. On [**2175-1-30**], EEG revealed persistent
eliptiform waves. Oxygen saturation was 88-91%, so she was
started on face tent O2. CXR revealed white out of the right
lung, so she was started on levofloxacin. BNP was slightly
elevated at 361. On [**2175-1-31**], her mental status had improved
greatly; she was interactive with examiners. Interventional
pulmonary was consulted and thoracocentesis yielded 1600cc of
milky white fluid, consistent with chylothorax, cytology
negative. There was a question of an 8mm right apical
pneumothorax post-procedure. She maintained O2 sats of 92-96%
on 2-4L via nasal cannula. Cytology from the pleural fluid were
negative for malignancy.
.
She was transferred to the Oncology Hospitalist service on
[**2175-2-1**]. Radiation Oncology was consulted and she started
palliative whole brain XRT [**2175-2-1**], to receive 5 fractions until
[**2175-2-8**]. Due to continued R sided weakness a Head CT was ordered
which was negative. The patient remained with flat affect and
waxing and [**Doctor Last Name 688**] communication, intermittantly following
commands. This was thought to be due to recurrent seizures.
Valproate was added to levetiracetam and titrated up. She
developed a fever to 100.5F on [**2175-2-2**] and was cultured, CXR
showed re-accumulating effusion, but she remained well
oxygenated. During the evening of [**2175-2-3**], Ms. [**Known lastname 24298**] became
acutely more encephalopathic and unresponsive. By the morning
of [**2175-2-4**], she was obtunded and was unable to open her eyes. CT
head and MRI/MRA brain non-diagnostic. EEG [**2175-2-6**] showed
diffuse slowing, but no seizure. LP [**2175-2-4**] and [**2175-2-7**] under
fluoroscopic guidance did not confirm infection. After blood,
urine and CSF cultures were sent, she was started empirically on
ceftazadime and vancomycin. Vancomycin was changed to
daptomycin for a positive urine culture growing vancomycin
resistant enterococcus ([**Month/Day/Year **]). Foley catheter was changed.
Pleural effusion reaccumulated; repeated thoracentesis [**2175-2-4**].
Paracentesis performed [**2175-2-8**] also negative for infection. EEG
on [**2175-2-9**] also showed diffuse slowing consistent with
encephalopathy without seizures. Hypernatermia resolved with IV
fluids, then recurred. Hypercalcemia resolved with IV fluids,
calcitonin, and pamidronate. On [**2175-2-5**], her RLE was noted to be
swollen and ultrasound revealed a new popliteal DVT despite
prophylactic SC heparin. Despite her high risk for bleeding due
to recent brain biopsy and recent admission to [**Hospital1 112**] for GI
bleeding while receiving warfarin, she was anticoagulated with
heparin gtt after discussion with the Neurosurgery service, her
primary medical physician, [**Name10 (NameIs) 24301**], and health-care
proxy [**Name (NI) **] [**Name (NI) **]. Persistent DIC. Minimal improvement in
encephalopathy. Family decided on hospice. TPN, fluids,
anticoagulation, and IV meds stopped. Transferred to
[**Hospital1 1501**]/hospice.
.
# Encephalopathy: Unclear etiology. Started a couple days after
brain biopsy. XRT stopped after day #2 of 5. Head CT stable,
MRI/MRA brain negative. EEG [**2175-2-6**] showed diffuse slowing, but
no seizure. However EEG [**2175-2-9**] showed a propensity for seizure.
Levetiracetam changedd to valproate. Lithium stopped. No
improvement with correction of hypernatremia or hypercalcemia.
[**Month/Day/Year **] UTI possible cause. No other infections found. Euthyroid
sick unlikely cause. Normal B12 and folate. Normal ammonia
level. Negative anti-[**Doctor Last Name **] Ab. Completed course ceftazadime
(allergic to penicillin) and daptomycin (for [**Doctor Last Name **] UTI) [**2175-2-15**].
She marginally improved and family decided for hospice. Stopped
valproate and dexamethasone given goals of care.
- Follow-up cultures.
- NPO while obtunded.
- F/U EEG final reads.
.
# Fever and [**Month/Day/Year **]/staph UTI: Fever resolved. Started ceftazadime
and vancomycin [**2175-2-4**] after LP. LP repeated [**2175-2-7**]. Diagnostic
pleurocentesis [**2175-2-4**] negative for infection. Vancomycin
changed to daptomycin [**2175-2-6**] for [**Month/Day/Year **] UTI. Diagnostic
paracentesis [**2175-2-8**] negative. Stopped ceftazadime (penicillin
allergy) and daptomycin [**2175-2-15**].
- F/U cultures.
.
# Hypernatremia: Likely due to hypovolemia, hyperglycemia, and
resulting diuresis. Improved with IV fluids and glucose
control. Nephrology consulted. Urine osm consistent with
hypovolemia. Improved again with increased volume of TPN and
1/2NS fluids. Family decided against a feeding tube.
.
# Ascites: 2L paracentesis [**2175-2-8**] negative for SBP. No elevated
triglycerides, cytology negative. F/U cultures.
.
# Seizures: EEG [**2175-2-6**] diffusely slowed, but no seizure
activity. EEG [**2175-2-9**] also slowed, but seizure propensity
present. Second loading dose of valproate [**2175-2-3**]. Valproate
level was supratherapeutic [**2175-2-6**], decreased dose frm 750mg [**Hospital1 **]
--> 500mg [**Hospital1 **], but level [**2175-2-8**] is subtherapeutic --> increased
back to 750 [**Hospital1 **]. Neuro-oncology consulted. Levetiracetam
stopped as possible cause of encephalopathy. Stopped valproate
given goals of care.
- Seizure precautions.
.
# Hypercalcemia: Initially improved with IV fluids and
calcitonin but recurred until treated with pamidronate 90mg
after correction of hypovolemia. Etiology included combination
of lithium, hypovolemia, and malignancy.
.
# Hyperglycemia/diabetes: Due to dexamethasone and Whipple.
Endocrinology consulted. Discontinued insulin glargine given
goals of care. Continued insulin sliding scale.
.
# Euthyroid sick syndrome: Consulted Endocrinology. No repeat
thyroid labs given goals of care.
.
# Recurrent pleural effusion: Repeat thoracentesis [**2175-2-4**]
consistent with chylothorax. Cytology and cultures negative.
.
# Metastatic pancreatic cancer with brain metastasis: CA [**81**]-9
2618 on [**2175-2-1**]. Started pallitaive WBRT (received 2 of 5
fractions) but has been held since [**2175-2-6**] given mental status
changes. Health-care proxy does not want any further
tests/treatment due to failure to improve, poor quality of life,
poor prognosis, and suffering. [**Hospital1 1501**]/hospice care arranged.
Stopped dexamethasone given goals of care.
.
# Anemia: Microcytosis, hypochromia, ferritin 38, retic 0.8, Fe
sat 13%, haptoglobin 45, consistent with iron-deficiency anemia.
Also DIC with occasional schistocytes, hypofibrinogenemia, and
coagulopathy.
.
# Coagulopathy: Likely due to DIC. Persistant despite vitamin
K. Fibrinogen low, stable. FFP following LP [**2175-2-4**].
.
# Thrombocytopenia: Stable since admission, range 84-128.
Likely due to DIC and splenomegaly/infection. Schistocytes
reported on smear.
.
# RLE DVT: She is at high risk for bleeding given her recent
brain bx and GI bleed (EGD & colonoscopy negative at [**Hospital1 112**]).
MRI/MRA negative, so began heparin ggt. Stopped
anti-coagulation given goals of care.
.
# Abuse investigation: First-degree 1cm superficial perineal
laceration at posterior forchette in the midline discovered
during foley placement in OR for brain biopsy. [**Last Name (un) **] baths,
analgesics, peribottle for comfort. Screened for domestic and
sexual violence underway (patient was sedated when examined).
Social work coordinated appropriate investigation.
.
# Thrush: D/C fluconazole given goals of care.
.
# Bipolar disorder: Stopped valproate (surrogate for lithium)
given goals of care. Use haloperidol for agitation prn.
Psychiatry consulted.
.
# Constipation: Bisacodyl suppository titrated to daily stool.
.
# FEN: TPN. NPO while unresponsive. Restarted IV normal saline
due to returning hypernatremia. Repleted hypokalemia.
.
# GI PPx: PPI IV. Bowel regimen.
.
# DVT PPx: Stopped heparin drip for DVT given goals of care.
.
# ACCESS: PICC placed [**2175-2-9**], peripheral and port.
.
# Precautions: Seizure, contact ([**Name (NI) **]).
.
# CODE: DNR/DNI (confirmed with health-care proxy),
transitioning to hospice at [**Hospital1 1501**].
Medications on Admission:
1. ALBUTEROL 90 mcg 2 puffss po every 6 hours prn
2. BUPROPION 300 mg by mouth once a day
3. CITALOPRAM 20 mg by mouth once a day
4. LEVETIRACETAM 1,000 mg by mouth twice a day
5. LIDOCAINE-PRILOCAINE 2.5 %-2.5 % weekly apply prior to access
6. LIPASE-PROTEASE-AMYLASE 24,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit
PO TID with meals
7. LITHIUM CARBONATE 600 mg by mouth twice a day
8. OMEPRAZOLE 40 mg by mouth twice a day
9. RISPERIDONE 1-2 mg by mouth twice a day 2mg in AM, 1mg in PM
10. CHOLECALCIFEROL 1,000 unit by mouth once a day
11. DOCUSATE 100 mg by mouth twice a day
12. FERROUS 325 mg (65 mg iron) by mouth once a day
13. MULTIVITAMIN 2 Tablets by mouth once a day
14. SENNOSIDES 17.2 daily except day of and day after chemo
15. VITAMIN A 25,000 unit by mouth once a day
16. DEXAMETHASONE 4mg QAM
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nEB Inhalation Q4H PRN shortness of
breath or wheezing.
2. bisacodyl 10 mg Sig: One Suppository Rectal DAILY PRN
constipation.
3. acetaminophen 1,000 mg/100 mL (10 mg/mL) Sig: 1000 MG IV Q6H
PRN pain.
4. insulin regular human 100 unit/mL Solution Sig: SC QID: Per
sliding scale.
5. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.5-1.0 mg PO
q4HR PRN Seizure, nausea, anxiety.
6. morphine 10 mg/5 mL Solution Sig: [**5-11**] mL PO q4HR PRN Pain or
dyspnea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 24302**] Healthcare
Discharge Diagnosis:
Metastatic pancreatic adenocarcinoma (pancreatic cancer)
Brain fetastasis (cancer spread to the brain)
Pleural effusion (fluid in your lung)
Ascites (fluid in your abdomen)
Seizures
Urinary tract infection (bladder infection)
Encephalopathy (loss of conciousness, altered mental status)
DVT of right lower extremity (blood clot)
Hypernatremia (high sodium)
Diabetes (high sugar)
Hypercalcemia (high calcium)
Thrush (yeast infection of the mouth)
Bipolar disorder
Anemia (low red blood cells)
Thrombocytopenia (low platelets)
Disseminated intravascular coagulation (abnormal blood clotting)
Discharge Condition:
Mental Status: Unresponsive.
Level of Consciousness: Obtunded
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for a brain biopsy which showed you have
metastatic pancreatic cancer to the brain. You were started on
whole brain radiation therapy but were unable to continue due to
a change in mentation (encephalopathy). You became very drowsy
and could no longer answer questions or follow commands. You
also were found to have seizures, so valproate (Depakote) was
given to control this. Levetiracetam (Keppra) was subsequently
stopped. No cause of the altered mental state was found despite
extensive tests including CT, MRI, and spinal taps (lumbar
puncture) and covering with antibiotics. High calcium was
treated with medications (calcitonin and pamidronate), high
blood sugars treated with insulin, and high sodium treated with
IV fluids. You had fevers that were from a urinary tract
infection that was treated with IV antibiotics. You had fluid
removed from your right lung and your abdomen that did not show
infection. You developed a blood clot in your right leg that
has been treated with IV heparin, a blood thinner, but this was
stopped early when you left the hospital considering no
improvement in your overall condition. Blood clotting labs have
been abnormal and platelets low, but these did not require
treatment. You have also been anemic (low red blood cell
count). Your bipolar disorder is being treated with valproate
(Depakote) instead of lithium. You also were given an
anti-fungal medication fluconazole for thrush, a fungal
infection in the mouth. Given your poor quality of life, mental
status change, and lack of improvement, your health-care proxy
[**Name (NI) **] made the decision with advice from your doctors and family
to keep you comfortable and to stop having tests and any
treatment not focused on comfort.
.
MEDICATION CHANGES:
1. Stop levetiracetam (Keppra).
2. Stop lithium.
3. Stop bupropion (Wellbutrin), citalopram, and risperidone.
4. Stop pancreatic enzymes.
5. Stop omeprazole.
6. Stop iron and vitamins.
7. Stop dexamethasone.
8. Lorazepam as needed for seizures, nausea, or anxiety.
9. Acetaminophen (Tylenol) for pain.
10. Morphine for pain or shortness of breath.
Followup Instructions:
PLEASE CALL DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3150**] FOR ANY QUESTIONS OR CONCERNS.
Name: [**Known lastname 4146**],[**Known firstname **] Unit No: [**Numeric Identifier 4147**]
Admission Date: [**2175-1-26**] Discharge Date: [**2175-2-17**]
Date of Birth: [**2119-7-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 4148**]
Addendum:
Expected to expire within 6mo.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4149**] Healthcare
[**Name6 (MD) **] [**Last Name (NamePattern4) 4150**] MD [**MD Number(2) 4151**]
Completed by:[**2175-2-17**]
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23333, 23529
|
9201, 18378
|
339, 652
|
20513, 20513
|
3501, 3501
|
22786, 23310
|
2073, 2240
|
19260, 19799
|
19901, 20492
|
18404, 19237
|
20627, 22394
|
7554, 9178
|
2255, 2255
|
22414, 22763
|
261, 301
|
680, 1420
|
2730, 3482
|
7154, 7538
|
3517, 5026
|
2269, 2494
|
20528, 20603
|
1442, 1677
|
1693, 2057
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,160
| 115,120
|
41646+58463
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-9-8**] Discharge Date: [**2167-9-16**]
Date of Birth: [**2108-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
known Mitral Regurg-eval for Mitral Valve
repair/Replacement
Major Surgical or Invasive Procedure:
[**2167-9-8**]
Radical mitral valve repair with posterior leaflet P1/P2)
triangular resection with ring annuloplasty using
[**Last Name (un) 3843**]-[**Doctor Last Name **] Physio II 30-mm ring.
Resection of left atrial appendage.
History of Present Illness:
59 year old male with a long standing history of asymptomatic
severe mitral regurgitation secondary to posterior flail
leaflet.
A recent echocardiogram demonstrates interval progression of
mildly enlarged left ventricle, moderate left atrial enlargement
with preserved systolic function, EF 65%. The patient denies
shortness of breath or chest discomfort. He states he will
occasionally take a 45 minute walk without any shortness of
breath or difficulty. He presents today for elective cardiac
cath. Cardiac surgery consulted for evaluation of Mitral Valve
repair vs.Replacement.
Past Medical History:
Severe Mitral Regurgitation,Esophageal
Reflux,Trigger Finger
Social History:
Last Dental Exam:[**2167-5-3**]-Dr.[**Last Name (STitle) 90537**] at [**Last Name (NamePattern4) 75882**] Community Health
Lives with:Lives with wife and daughter
Contact: Phone #
Occupation:Works fulltime as a signs fabricator/installer
Cigarettes: Smoked no [] yes [x] -occasional cigar
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-9**] drinks/week [x] >8 drinks/week []
Illicit drug use-denies
Family History:
Uncle died of an MI, grandfather had DM
Physical Exam:
Pulse:61 Resp:20 O2 sat: 98%
B/P 106/94
Height: 5 ft 9inches
Weight: 200lbs
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]intermittent (R)exp wz
Heart: RRR [x] Irregular [] Murmur [] grade _IV/VI SEM_____
Abdomen: Soft [x] non-distended [x] nonx-tender [x] bowel
sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema []none
appreciated at this time _____ Varicosities: (R)LE
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none appreciated, pulse Right:2+ Left:2+
Pertinent Results:
[**2167-9-11**] 05:49AM BLOOD WBC-11.8* RBC-3.44* Hgb-11.1* Hct-30.0*
MCV-87 MCH-32.3* MCHC-37.0* RDW-12.5 Plt Ct-151
[**2167-9-8**] 01:08PM BLOOD WBC-17.1*# RBC-4.51* Hgb-13.9* Hct-39.0*
MCV-87 MCH-30.8 MCHC-35.6* RDW-12.9 Plt Ct-190
[**2167-9-8**] 01:08PM BLOOD PT-14.3* PTT-44.6* INR(PT)-1.2*
[**2167-9-11**] 05:49AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-138 K-3.9
Cl-102 HCO3-28 AnGap-12
[**2167-9-8**] 01:08PM BLOOD UreaN-10 Creat-0.8 Na-142 K-4.1 Cl-112*
HCO3-25 AnGap-9
[**2167-9-15**] 06:30AM BLOOD WBC-8.5 RBC-3.50* Hgb-11.0* Hct-29.7*
MCV-85 MCH-31.4 MCHC-37.1* RDW-12.9 Plt Ct-349
[**2167-9-14**] 06:00AM BLOOD WBC-7.4 RBC-3.55* Hgb-11.1* Hct-30.3*
MCV-85 MCH-31.3 MCHC-36.6* RDW-12.9 Plt Ct-271
[**2167-9-15**] 06:30AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-139
K-4.3 Cl-104 HCO3-26 AnGap-13
[**2167-9-14**] 06:00AM BLOOD Na-144 K-4.5 Cl-107
[**2167-9-13**] 08:57AM BLOOD UreaN-13 Creat-0.7 Na-141 K-4.3 Cl-103
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: *7.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Normal regional LV systolic function. [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global
RV free wall hypokinesis.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Eccentric MR jet. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
REGIONAL LEFT VENTRICULAR WALL MOTION:
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. Regional left ventricular wall
motion is normal. [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque.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 moderately thickened. An
eccentric, anteriorly directed jet of Severe (4+) mitral
regurgitation is seen.
POSTBYPASS
LV function now appears borderline normal (LVEF ~ 50%). The LV
is now moderately dilated. The RV appears less dilated and its
function is improved compared to prebypass. There is a ring
prosthesis in the mitral position. The MR is now trace. The
remaining study is unchanged from prebypass
Brief Hospital Course:
59 year old whose preoperative transesophageal echo showed
severe mitral regurgitation, and his preoperative cardiac cath
showed normal coronaries. The patient was felt to be a good
candidate for mitral valve repair. The patient was admitted to
the hospital and brought to the operating room on [**2167-9-8**] where
the patient underwent a radical mitral valve repair with
posterior leaflet (P1/P2) triangular resection with ring
annuloplasty using [**Last Name (un) 3843**]-[**Doctor Last Name **] Physio II 30-mm ring and
resection of left atrial appendage. 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, alert
and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. 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. Chest tubes and pacing wires were discontinued without
complication. POD #2 the patient spiked a temperature to 102 and
was pan cultured. Central line was removed and tip culture came
back negative. He did have some nausea and liver function tests
and abdominal ultrasound were both negative for a source of
fevers. He was started on Kefzol and continued with fevers over
the next several days. He had multiple blood cultures drawn -
all of which are no growth to date. He was switched to
Vancomycin and infectious disease service was consulted. They
recommended switching to Keflex for a 10 day course. On POD 8 he
had been afebrile x greater than 24 hrs and sternum was without
erythema or draiange. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 8 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions.
Medications on Admission:
OMEPRAZOLE -20 mg Capsule Q AM
Zantac 75mg QPM
Medications - OTC
HORSE CHESTNUT Dosage uncertain
BilBERRY- Dosage uncertain
MULTIVITAMIN -Dosage uncertain
SAW [**Location (un) **] - Dosage uncertain
VITAMIN E -Dosage uncertain
ZINC - Dosage uncertain
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:*1*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q3hours as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. 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:*1*
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
10. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-4**] Sprays Nasal
QID (4 times a day).
11. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Severe mitral regurgitation.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] on [**10-20**] at 1:15pm
Cardiologist: Dr. [**First Name (STitle) 1975**] [**Name (STitle) 66687**] on [**9-24**] at 1:00pm
Wound check in cardiac surgery office [**Telephone/Fax (1) 170**]
[**Hospital **] medical building on Thrus [**9-24**] at 10:15 am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 29117**] in [**4-7**] weeks [**Telephone/Fax (1) 70698**]
**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:[**2167-9-16**] Name: [**Known lastname 14297**],[**Known firstname 14298**] Unit No: [**Numeric Identifier 14299**]
Admission Date: [**2167-9-8**] Discharge Date: [**2167-9-16**]
Date of Birth: [**2108-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1543**]
Addendum:
[**2167-9-16**] 06:30
COMPLETE BLOOD COUNT
White Blood Cells 9.5 4.0 - 11.0 K/uL
Red Blood Cells 3.67* 4.6 - 6.2 m/uL
Hemoglobin 11.2* 14.0 - 18.0 g/dL
Hematocrit 31.1* 40 - 52 %
MCV 85 82 - 98 fL
MCH 30.5 27 - 32 pg
RDW 12.9 10.5 - 15.5 %
Platelet Count 381 150 - 440 K/uL
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 413**] VNA
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2167-9-16**]
|
[
"424.0",
"305.1",
"781.0",
"428.0",
"428.20",
"V12.72",
"727.04",
"V17.49",
"727.03",
"998.59",
"V14.2",
"429.3",
"429.5",
"V18.0",
"458.29",
"401.9",
"272.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"37.36",
"39.61",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
11970, 12183
|
5783, 7893
|
357, 590
|
9594, 9763
|
2568, 4603
|
10604, 11947
|
1744, 1786
|
8197, 9447
|
9542, 9573
|
7919, 8174
|
9787, 10581
|
4642, 5760
|
1801, 2549
|
256, 319
|
618, 1202
|
1224, 1287
|
1303, 1728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,510
| 171,334
|
12899
|
Discharge summary
|
report
|
Admission Date: [**2177-3-26**] Discharge Date: [**2177-4-2**]
Service: MEDICINE
Allergies:
Penicillins / Latex / Lisinopril / Cephalosporins / Aspirin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shorthess of Breath
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
Mr. [**Known lastname 39657**] is an 89 year old man with a history of COPD,
hypertension, hyperlipidemia, and type II diabetes. He has had a
one month history of progressive shortness of breath. This has
been accompanied by a productive cough and a 10 lb weight loss
over the past month. He had been started on an inhaler one month
ago which he attributed to the shortness of breath. He presented
to his PCP yesterday who noted that the patient was satting 90%
on room air. A chest xray was performed which showed a large
left-sided pleural effusion. He is a former smoker for 55 years
([**2-15**] PPD). He quit in [**2149**]. He was sent to the ED for further
workup and evaluation.
.
In the ED, the patient's VS were T 97.4, P 86, R 20, BP 127/49,
O2 100% on 2L. A CXR showed a moderate left-sided pleural
effusion. CT showed a loculated left effusion with left lower
lung mass concerning for lung neoplasm. He was given Levaquin
for possible underlying PNA.
.
ROS:
Denies any fevers, chills, chest pain, lightheadedness, melena,
hematochezia, abdominal pain, headaches.
Past Medical History:
Hypertension
Hyperlipidemia
DM2 (last HgA1c 7.6%)
COPD
BPH
Oncomycosis
Bilateral total knee replacements
Social History:
The patient lives in an apartment near his daughter. [**Name (NI) **] smoked 1
ppd and quit in [**2149**]. Still working 2 jobs.
Family History:
Mother had diabetes. No history of CAD or cancer.
Physical Exam:
VITALS - T: 99.5, HR: 84, BP: 160/70; RR: 22; 02sat: 81RA,
93on4L
.
GENERAL: NAD, patient sitting in bed, patient conversant;
patient is breathing without distress on 4L NC
HEENT: no scleral icterus; pupils equal, round, and reactive to
light; mucous membrances moist; neck supple with no
lymphadenopathy appreciated; oropharynx clear
CARDIAC: RRR; normal S1 + S2; no rubs, murmurs, or gallops
LUNGS: hyporesonant in L lower lung field; no rales, rhonchi, or
wheezes
ABDOMEN: soft, non-tender, non-distended, no masses or
organomegaly
EXTREMITIES: no clubbing or edema; warm and well perfused; no
calf tenderness
SKIN: no rashes/lesions
NEURO: A&Ox3; CN II-XII grossly intact; sensation normal
throughout; 5/5 strength throughout
PSYCH: appropriate affect
Pertinent Results:
[**2177-3-26**] 10:55AM BLOOD WBC-8.1 RBC-3.75* Hgb-10.5* Hct-34.0*
MCV-91 MCH-28.1 MCHC-31.0 RDW-12.5 Plt Ct-461*
[**2177-3-27**] 06:30AM BLOOD WBC-8.9 RBC-3.40* Hgb-9.5* Hct-30.5*
MCV-90 MCH-27.8 MCHC-31.0 RDW-12.3 Plt Ct-433
[**2177-3-28**] 06:28AM BLOOD WBC-8.6 RBC-3.45* Hgb-9.6* Hct-30.6*
MCV-89 MCH-27.7 MCHC-31.2 RDW-12.1 Plt Ct-425
[**2177-3-26**] 10:55AM BLOOD PT-13.6* PTT-31.7 INR(PT)-1.2*
[**2177-3-26**] 01:10PM BLOOD Glucose-57* UreaN-26* Creat-1.0 Na-143
K-4.8 Cl-109* HCO3-23 AnGap-16
[**2177-3-27**] 06:30AM BLOOD Glucose-31* UreaN-20 Creat-0.9 Na-141
K-4.5 Cl-105 HCO3-28 AnGap-13
[**2177-3-28**] 06:28AM BLOOD Glucose-108* UreaN-22* Creat-1.0 Na-138
K-4.4 Cl-100 HCO3-30 AnGap-12
[**2177-3-26**] 10:55AM BLOOD cTropnT-0.01
[**2177-3-26**] 01:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2177-3-28**] 06:28AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2177-3-27**] 06:30AM BLOOD TotProt-6.1* Calcium-9.3 Phos-3.4 Mg-2.2
[**2177-3-27**] 05:24PM BLOOD Type-ART pO2-149* pCO2-49* pH-7.40
calTCO2-31* Base XS-4
[**2177-3-27**] 05:24PM BLOOD Lactate-0.7
[**2177-3-28**] 08:33AM BLOOD Lactate-0.8
[**2177-3-31**] 06:50AM BLOOD WBC-7.6 RBC-3.37* Hgb-9.4* Hct-30.1*
MCV-90 MCH-27.9 MCHC-31.2 RDW-12.8 Plt Ct-390
[**2177-3-31**] 06:50AM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-137
K-4.5 Cl-102 HCO3-25 AnGap-15
[**2177-3-29**] 04:22AM BLOOD calTIBC-118* Ferritn-989* TRF-91*
[**2177-3-31**] 06:50AM BLOOD VitB12-395 Folate-8.8 Hapto-436*
.
Microbiology
[**2177-3-27**] 1:27 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2177-3-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2177-3-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2177-4-2**]): NO GROWTH.
ACID FAST SMEAR (Final [**2177-3-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
.
**FINAL REPORT [**2177-3-31**]**
URINE CULTURE (Final [**2177-3-31**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
AZTREONAM SUSCEPTIBILITY REQUESTED PER DR [**Last Name (STitle) **]
([**Numeric Identifier 39658**]).
AZTREONAM = SENSITIVE, sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging
[**2177-3-26**] CXR
IMPRESSION:
1. Moderate-to-large left pleural effusion with overlying
atelectasis. Left
hilar/infrahilar opacity could reflect combination of effusion,
atelectasis
and consolidation, however an underlying mass is not excluded
and is of
concern. Recommend follow up to resolution. Chest CT with
intravenous contrast
would better evaluate for underlying mass.
2. COPD.
[**2177-3-26**] CT Chest
1. Findings are very concerning for a left lower lung mass with
lymphangitic spread and associated loculated left lower
effusion.
2. Diffuse mediastinal, hilar and axillary adenopathy is
concerning for
metastasis.
3. There is severe diffuse centrilobular emphysema.
4. Findings likely represent pulmonary arterial hypertension.
5. Diffuse severe coronary artery atherosclerotic
calcifications.
5. Scattered subcentimeter opacities in the left upper lung and
right lung apex may represent neoplastic, infectious or
inflammatory etiology.
[**2177-3-28**] Chest xray
Small left pleural effusion is re-accumulating. Consolidative
abnormality at the left lung base, unchanged. Left upper lobe
mass is difficult to see. Right lung grossly clear. Heart size
is normal. There is no pneumothorax or pulmonary edema.
.
Cytology
[**2177-3-27**] Pleural Fluid pending
Brief Hospital Course:
Mr. [**Known lastname 39657**] is an 89 year old man with a 55 year smoking
history. He presented with new onset shortness of breath,
pleural effusion, and a mass concerning for lung cancer.
Hospital course by problem is below.
.
HYPOXIA / PULMONARY EFFUSION: A CT scan in the emergency
department revealed a loculated left pleural effusion and a mass
concerning for malignancy. He was treated with levofloxacin for
possible pneumonia. He had a thoracentesis the day after
admission which removed 1.8 L. After the procedure he developed
re-expansion pulmonary edema. He was briefly placed on a
non-rebreather. Later that evening his temperatures were
elevated to a Tmax of 100. The following morning he had
increasing oxygen requirements and was again placed on a non
rebreather. He was transferred to the MICU for further
management. His antibiotic coverage was expanded to vancomycin.
He continued to have difficulties with hypoxia. After
discussion, he stated he did not want to be intubated. He was
kept on a non-rebreather. He was seen by palliative care in the
ICU and decided to pursue hospice care. As his breathing status
improved, he was transferred back to the floor on [**3-29**]. His
oxygen was gradually weaned from 5 L to 2 L. He was discharged
on home oxygen. He was discharged with a total duration of 10
days of levofloxacin.
.
# LUNG MASS: The mass is suspicious for malignancy with
lymphangitic spread. This is likely responsible for his
exudative pleural effusion. Cytology of pleural fluid was still
pending at time of discharge. Mr. [**Known lastname 39657**] was aware of the
likely malignancy. He declined additional diagnostics or
treatment. Palliative care met with him and his family. He
expressed a desire to go home and receive VNA and hospice care.
.
# UTI: Mr. [**Known lastname 39657**] had >100,000 E. coli on urine culture. He
was asymptomatic. Aztreonam was started in the ICU. This was
switched to Bactrim on [**3-31**] when sensitivities returned. He was
discharged home with Bactrim through [**4-3**] for 7-day total course
of antibiotics for UTI.
.
# ANEMIA: His hematocrit was stable throughout the
hospitalization. He had findings consistent with anemia of
chronic inflammation. There was no evidence of blood loss.
Normal B12 and folate. He will follow up with PCP as an
outpatient.
.
# Diabetes Mellitus type II: Mr. [**Known lastname 39657**] was initially kept
on his home blood glucose regimen. However, the morning after
admission he had an episode of hypoglycemia. His insulin regimen
was drastically reduced to 7 units in the morning and 5 units in
the evening of NPH. His blood glucose was well controlled. He
was to check his blood glucose frequently and follow up with his
PCP.
.
# Hypertension: Mr. [**Known lastname 39657**] was prescribed irbesartan for
hypertension. However, he reported never taking the medication.
He was not treated with anti-hypertensives while hospitalized.
His blood pressure was in the 110's-120's.
.
# CODE: On admission Mr. [**Known lastname 39657**] stated that he was a full
code. When he was transferred to the ICU, code status was
readdressed with Mr. [**Name14 (STitle) 39659**] and his daughter. [**Name (NI) **] decided that
he wanted his code status changed to DNR/DNI.
.
# DISPO: Mr. [**Known lastname 39657**] was discharged home with VNA
services/hospice, oral antibiotics, and home O2.
.
Medications on Admission:
Ipratropium -does not take
Humulin N 25/15
Avapro 150 mg daily (irbesartan) - does not take
Discharge Medications:
1. Respiratory
Please provide continuous home oxygen at 3 L/min by nasal
cannula.
2. Humulin N 100 unit/mL Suspension Sig: Seven (7) units
Subcutaneous every morning.
3. Humulin N 100 unit/mL Suspension Sig: Five (5) units
Subcutaneous at bedtime.
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: Please take until [**4-6**].
Disp:*4 Tablet(s)* Refills:*0*
5. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days: Please take until [**4-3**]. Take one tablet tonight.
Then take one tomorrow morning and one tomorrow night.
Disp:*3 Tablet(s)* Refills:*0*
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*1*
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Pleural Effusion
Lung Mass
Community Acquired Pneumonia
Urinary Tract Infection
Secondary Diagnosis:
Diabetes
COPD
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Thank you for allowing is to take part in your care. You were
admitted to the hospital because of worsening shortness of
breath. While you were in the hospital a procedure called a
thoracentesis was performed. This procedure removed fluid from
around your lungs. After the procedure you were having
difficulty breathing. You went to the intensive care unit
briefly.
As discussed in the hospital please do not drive FOR 6 WEEKS.
After this time, please discuss this with your physician.
We made several changes to your medications.
We decreased your insulin because you were having hypoglycemia.
You are currently taking 7 units in the morning and 5 units in
the evening. Please check your blood sugars frequently. Please
discuss with your doctor how to adjust your insulin if you are
having high blood sugars (greater than 200).
We added levofloxacin for pneumonia. Please take this until
[**4-6**].
We added Bactrim for your urinary tract infection. Please
continue this until [**4-3**].
We also are giving you an albuterol inhaler. Please use this
with your ipratropium inhaler if you are having shortness of
breath.
You are also going home on oxygen therapy. Please use this to
help with your shortness of breath.
Followup Instructions:
Please follow up with your primary care physician. [**Name10 (NameIs) **] have
scheduled the following appointment for you:
MD: [**First Name8 (NamePattern2) **] [**Last Name (un) **]
Specialty: Internal Medicine/ PCP
[**Name Initial (PRE) 2897**]/ Time: Friday, [**2177-4-4**]:30am
Location: [**Location (un) 2129**], [**Location (un) 2274**] [**Location (un) **]
Phone number: [**Telephone/Fax (1) 2261**]
|
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icd9cm
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[
[
[]
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[
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|
[
[
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1549, 1679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,686
| 130,450
|
43205
|
Discharge summary
|
report
|
Admission Date: [**2156-1-8**] Discharge Date: [**2156-1-16**]
Date of Birth: [**2090-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
dehydration and ? pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 65 year old man with atrial fibrillation and
hypothyroidism, who was diagnosed with squamous cell CA of the
tongue in [**2153**], s/p chemo and radiation. Recently, he has biopsy
proven mets in the sternum and T3-T7. He presented to clinic on
[**2156-1-8**] for evaluation and he was found to be hypoxic and
dehydrated. He notes that approximately 3 weeks ago he presented
to his doctor [**First Name (Titles) 151**] [**Last Name (Titles) 7186**] of breath and was diagnosed with
pneumonia and given a Z-pack. He improved after that but then
again felt worse and was given another Z-pack. In the last week
he has felt progressively short of breath and has been staying
on the couch. He denies fever, but says he has sweats on most
days. Also denies cough, occasional chest pain, some swelling in
his ankles, no blurry vision, confusion. Also, he over the past
6 months he has had progressive poor appetite he has lost some
weight. Otherwise, he complains of xerostomia and difficulty in
swallowing.
Past Medical History:
- Squamous cell CA of the tongue: dx [**3-16**]; stage 3-4; started
cisplatin and radiation therapy on [**2154-5-27**]
- CAD: s/p CABG 2 vessels in [**2143**] and [**2146**]; NSTEMI in [**3-15**] s/p
cardiac catheterization.
- CHF: echo [**11-14**] w/ moderate regional left LV systolic
dysfunction with near akinesis of the basal inferior and
inferolateral walls, LVEF 35%, 1+ MR.
- Atrial fibrillation: s/p DCCV in [**11-13**] w/ subsequent reversion
to AF.
- ICD: placed [**12-17**]
- Hypertension
- Hyperlipidemia
- Depression
Social History:
He is a retired salesman who lives with his long-term partner
named [**Name (NI) **] for 30 years. He has no children. He smoked greater
than 30 years but quit recently. No alcohol or IV drug use.
Family History:
Mother with h/o CAD.
Physical Exam:
T: 97.6 BP: 129/78 RR: 24 HR: 76 02:96% on 2L
Gen: Cachectic male, NAD
HEENT: anicteric, EOMI, PERRL, dry mucosa with breakdown of the
mucosa.
Neck: left sided fullness, palpaple fibrosis.
CV: RRR
Pulm: Diffuse expiratory wheezing, bilateral crackles at the
bases.
Abd: soft, non tender, BS +.
Ext: 1+ non-pitting edema.
Neuro: Alert and oriented x3, CN 2-12 intact, strength 5/5
bilateral and symmetric lower and upper extremities.
Pertinent Results:
On Admission:
[**2156-1-8**] 03:35PM BLOOD WBC-18.5*# RBC-4.90 Hgb-11.5* Hct-35.9*
MCV-73* MCH-23.4* MCHC-32.0 RDW-15.3 Plt Ct-501*
[**2156-1-8**] 03:35PM BLOOD PT-22.1* PTT-28.6 INR(PT)-2.1*
[**2156-1-8**] 03:35PM BLOOD Glucose-82 UreaN-15 Creat-0.5 Na-138
K-4.4 Cl-99 HCO3-31 AnGap-12
[**2156-1-8**] 03:35PM BLOOD proBNP-3557*
[**2156-1-8**] 03:35PM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.6 Mg-2.2
On Day of Demise:
[**2156-1-16**] 04:05AM BLOOD WBC-14.8* RBC-3.75* Hgb-9.0* Hct-28.9*
MCV-77* MCH-24.0* MCHC-31.1 RDW-15.5 Plt Ct-405
[**2156-1-16**] 04:05AM BLOOD PT-42.3* PTT-30.2 INR(PT)-4.6*
[**2156-1-16**] 04:05AM BLOOD Glucose-108* UreaN-11 Creat-0.4* Na-145
K-3.5 Cl-105 HCO3-37* AnGap-7*
[**2156-1-16**] 04:05AM BLOOD ALT-15 AST-24 LD(LDH)-319* AlkPhos-155*
TotBili-0.CT
Imaging:
----------
CT Chest [**2156-1-9**]:
IMPRESSION:
1. Multifocal bilateral air space opacities most consistent with
acute
infection.
2. New moderate left pleural effusion.
3. Increase in size of several mediastinal lymph nodes may
rleate to
infection, though attention is recommended on follow-up.
Attention should also be again paid to the unchnanged right
lower lobe nodule.
4. Progression of thoracic spine osseous metastases.
CT Head [**2156-1-15**]:
IMPRESSION: No evidence of hemorrhage, mass effect, midline
shift or other
acute abnormalities. No evidence of enhancing brain lesions. No
significant
change on the pre-contrast images compared to [**2154-8-5**].
CXR [**2156-1-16**]:
Since yesterday, all tubes and catheters are in unchanged
position.
Right upper lobe opacity persists, likely due to aspiration.
Left lower lobe opacity increased, could be due to worsening
atelectasis or superimposed aspiration. Left pleural effusion
also increased. There is no other overallchange.
Micro and Path:
------------------
Legionella Urinary antigen [**2156-1-11**]: Negative
BAL [**2156-1-12**]:
GRAM STAIN (Final [**2156-1-12**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2156-1-14**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2156-1-19**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2156-1-13**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2156-1-13**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2156-1-25**]): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Final [**2156-2-1**]): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2156-1-13**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Pleural fluid ([**2156-1-13**]):
GRAM STAIN (Final [**2156-1-13**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Brief Hospital Course:
65 year old male with squamous cell CA of tongue, with recurrent
disease and evidence of metastases and recent spread to spine
who presented with worsnening dyspnea on exertion and weight
loss.
The patient's chief reason for presenting to the ICU was
multifactorial hypoxia due to his COPD, CHF, pleural effusion
and probable aspiration pneumonia/pneumonitis. On presentation
he was started on levofloxacin for aspiration pneumonia.
Nevertheless he continued to have worsening of his dyspnea and
sputum production and during the day of [**2156-1-11**] he was noted to
be increasingly hypoxic and his oxygen saturations were dropping
to the 80's on 6L NC. He was switched to 100% NRB and
maintained sats in the 90's on that but appeared to be tiring
and was transferred to the ICU on [**2156-1-11**]. At that point a blood
gas revealed profound respiratory acidosis and he was then
intubated for ventilatory failure. The patient has treated with
vancomycin, cefepime, metronidazole for aspiration/HAP and was
gently diuresed. No microbiologic diagnosis of the patient's
pneumonia was ever made and despite BAL no organisms were ever
isolated. On [**2156-1-13**] a thoracentesis was performed to evaluate
for complicated effusion and this showed sterile inflammatory
fluid consistent with parapneumonic effusion. The patient did
improve somewhat allowing some weaning of ventilatory settings
and acutally self extubated on [**2156-1-14**]. Unfortunately, after
extubation mental status remained poor and the patient became
progressively more hypercarbic requiring reintubation on [**2156-1-15**].
On the morning of [**2156-1-16**] NIF was checked and was less than 30
suggesting generalized muscle weakness and high likelihood of
ventilatory failure if extubated. With this information, and
given the patient had been reluctant to undergo chemotherapy in
the first place and had expressed a desire to not be permanently
sustained on artificial means, his husband and family decided to
terminally extubate the patient and make him comfortable. He
was extubated on the evening of [**2156-1-16**] and gradually became more
hypoxic before expiring of respiratory failure. His husband
declined autopsy.
Medications on Admission:
# Maalox/Diphenhydramine/Lidocaine 15-30 mL PO 15 MINUTES BEFORE
MEALS AS NEEDED FOR MOUTH PAIN
# Metoprolol Succinate XL 200 mg PO DAILY Please hold for SBP
<100 or HR <60 Order date: [**1-8**] @ 1421
# Albuterol 0.083% inhaled Q4H:PRN [**Month/Year (2) 7186**] of breath
# Omeprazole 20 mg PO DAILY
# Amiodarone 200 mg PO DAILY
# OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN
# Digoxin 0.25 mg PO DAILY
# Furosemide 20 mg PO BID
# Simvastatin 40 mg PO DAILY
# Heparin 5000 UNIT SC TID
# Venlafaxine 200 mg PO QAM
# Venlafaxine 100 mg PO QPM
# Isosorbide Dinitrate 10 mg PO TID
# Warfarin 7.5 mg PO DAYS (MO,TH) Warfarin 5 mg PO DAYS
([**Doctor First Name **],TU,WE,FR,SA)
# Levothyroxine Sodium 50 mcg Order date: [**1-8**] @ 1602
# Lisinopril 20 mg PO
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Squamous Cell cancer of the head and neck with T-spine
involvement
Acute Systolic heart failure
Deconditioning
Dehydration
Aspiration pneumonia
Hypertension
CAD s/p CABGx2
Atrial Fibrillation
Discharge Condition:
Patient expired
|
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[
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342, 349
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1430, 1967
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1983, 2182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,887
| 138,596
|
11864+11884+11865+56294+56295
|
Discharge summary
|
report+report+report+addendum+addendum
|
Admission Date: [**2104-12-6**] Discharge Date:
Service: Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
male with a history of tobacco abuse, who was admitted to an
outside hospital on [**2103-12-30**] with workup showing a
right upper lobe lung mass. The patient underwent resection
of the lung mass in [**2104-10-23**]. Postoperatively, the
patient had abdominal pain and underwent an exploratory
laparotomy on [**2104-11-3**]. Postoperatively, the
patient developed ischemic colitis and underwent a colectomy
and jejunal colic anastomosis.
The patient was re-explored on [**2104-11-20**], which
showed an infarcted distal colon, which was resected. The
patient underwent jejunal sigmoid anastomosis.
Postoperatively from that, the patient developed an
enterocutaneous fistula and abdominal wound dehiscence. The
patient was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] to Dr.[**Name (NI) 1745**] service on [**2104-12-6**].
PAST MEDICAL HISTORY: Glaucoma.
PAST SURGICAL HISTORY: Hernia repair.
MEDICATIONS ON ADMISSION: Regular insulin sliding scale,
Timoptic 0.5% eye drops o.s.b.i.d., Xalatan 0.005%
o.u.q.h.s., Flagyl 500 mg i.v.q.8h. and Levaquin 250 mg
i.v.q.24h.
HOSPITAL COURSE: The patient was initially admitted to the
Surgical Intensive Care Unit but his condition was judged to
be stable and he was transferred to the floor. While on the
floor, the ostomy team was consulted and they were able to
put an ostomy bag around the wound. A sump drain was placed
into wound and put to low wall suction with a gauze wrapped
around it as so to create and suction in order to keep the
wound clean. The nursing staff was doing dressing changes
every four hours.
The patient's condition improved and he was started on total
parenteral nutrition on hospital day number two. The patient
has been stable with the enterocutaneous fistula output
continuously decreasing. The patient was also placed on
somatostatin 100 mcg subcutaneously three times a day.
During his hospital course, the patient appeared to be
depressed and a psychiatry consult was obtained. The patient
was placed on Ritalin and Remeron per psychiatry
recommendation.
On hospital day number eight, a PICC line was placed and the
patient has been on total parenteral nutrition and will
probably require long term total parenteral nutrition. On
hospital day number 17, the patient was started on some sips
for comfort, and Ritalin and Remeron for oral medications.
Other than that, the patient was kept on nothing by mouth and
on total parenteral nutrition.
The patient is pending discharge currently.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2104-12-23**] 12:03
T: [**2104-12-23**] 14:18
JOB#: [**Job Number 37431**]
Admission Date: [**2104-12-6**] Discharge Date: PENDING
Service: GOLD-GENSX
THIS IS AN ADDENDUM TO THE PREVIOUS DICTATION.
Since the last dictation, the [**Hospital 228**] hospital course has
not been significantly changed. The patient was started on
Somatostatin secondary to some leakage from the
enterocutaneous fistula. The patient was started
Somatostatin on [**1-15**] and has been taken off
Somatostatin [**1-20**]. Since then, he has not had any
enterocutaneous output. He continues to require TPN q. day.
His medications as of now include:
DISCHARGE MEDICATIONS:
1. Nystatin 5 cc p.o. swish and swallow.
2. Butanol 0.5%, one drop left eye twice a day.
3. Xalatan 0.005%, one drop bilateral eyes q. h.s.
4. Remeron 30 mg p.o. q. h.s.
5. Ritalin 5 mg p.o. q. a.m.
6. Serax 15 mg p.o. q. h.s. p.r.n.
He requires wound care, dressing changes four times a day and
enterocutaneous output monitoring, Physical Therapy, daily
TPN, volume [**2102**], amino acids 75, dextrose 325 and fats 50.
He requires heparin 6000 in the TPN, Zantac 150 in the TPN,
insulin of 45 units in the TPN including a Regular insulin
sliding scale of 131 to 160, 3 units, 161 to 200, 4 units;
201 to 250, 7 units; 251 to 300, 9 units; and over 300 they
were instructed to call the house officer. If the patient
cannot have heparin or Zantac in TPN he would require heparin
5000 subcutaneously twice a day; Zantac 150 mg p.o. twice a
day. The patient is on sips.
The rest of the dictation will be completed by the intern
starting in [**2104-1-24**]. The patient is still pending
rehabilitation placement.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2105-1-22**] 16:32
T: [**2105-1-22**] 16:45
JOB#: [**Job Number 37471**]
Admission Date: [**2104-12-6**] Discharge Date: [**2105-3-26**]
Service: GOLD-GENSX
STAT ADDENDUM:
Mr. [**Known lastname 37432**] was seen by the urology service on [**2105-3-25**] due to problems with urinary retention after his
prolonged hospitalization. It was thought that his prolonged
and complicated postoperative course may contribute to this
with a possible component of benign prostatic hypertrophy.
Recommendations were made to continue with Flomax 0.4 mg po
qd and that the patient keep his Foley catheter in for one
week at which time another voiding trial is to be attempted
when his rehabilitation situation has improved. Additional
follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] of urology at ([**Telephone/Fax (1) 37433**] if
the patient is still unable to void.
DISCHARGE DIAGNOSES:
1. Status post revision jejunal sigmoid anastomosis
2. Status post enterocutaneous fistula
3. Urinary retention
DISCHARGE MEDICATIONS: As listed in primary summary dated
[**2105-3-25**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2105-3-26**] 08:38
T: [**2105-3-26**] 09:08
JOB#: [**Job Number 37434**]
Name: [**Known lastname 6716**], [**Known firstname 133**] Unit No: [**Numeric Identifier 6717**]
Admission Date: Discharge Date: [**2105-1-8**]
Date of Birth: [**2026-7-24**] Sex: M
Service:
ADDENDUM: In addition to TPN qd, the patient was started on
tube feeds on hospital day 20, [**2104-12-25**], which the
patient tolerated well. However, there was noticed to be
resumed enterocutaneous fistula output and thus the tube
feeds were DC'd. The G-tube was removed. The patient's
enterocutaneous output remained the same for several days.
However, the patient was given somatostatin for two days
which decreased the output and subsequently somatostatin was
stopped. The patient is currently stable with no
enterocutaneous fistula output in need of physical therapy,
occupational therapy and TPN daily.
SYSTEMS: The patient is being followed by psychiatry for
depression, being treated with Remeron 15 mg po q hs and
Ritalin 2.5 mg po q am at 8:00 in the morning.
CARDIOPULMONARY: The patient is stable.
GI: The patient has a dehiscent wound from previous
abdominal surgery. The tissue is clean, healing well with
granulation tissues. There has been no enterocutaneous
fistula output which usually consists of a thick green
foul-smelling substance. The wound requires dressing
changes, wet-to-dry, qid. With increase in enterocutaneous
output, the wound requires dressing changes q 4 h. The
patient is currently NPO, only on sips of clears, having poor
PO intake. Also, the patient is restricted in terms of PO
intake to relieve the stress on the enterocutaneous fistula.
The patient is producing adequate urine output. He is
incontinent with a condom catheter.
ENDOCRINE: The patient is on regular insulin, sliding scale.
He has a history of glaucoma being treated with Xalatan
0.005% and Betimol 0.5%.
FEN: The patient is currently on TPN 2,000 cc, aminoacids
100 gm/D, dextrose 325 gm qd, fat 50 gm qd and tube feeds.
The patient is using heparin 6,000, ranitidine 150, insulin
55 and zinc 10. Electrolytes have been stable, dependent on
q 3 days lab values. If patient is not going to receive
heparin or ranitidine or insulin in TPN, please put patient
on those medications.
DISPOSITION: The patient is discharged on [**2105-1-8**]
in stable condition.
FOLLOW-UP PLAN: To have TPN for 2-3 weeks, then potential
feeding trial. If eating and no fistula output, surgery will
be performed to close the abdomen one month from now at the
earliest by Dr. [**Last Name (STitle) 1180**]. The patient is stable and ready for
discharge to rehab.
[**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**], M.D. [**MD Number(1) 3712**]
Dictated By:[**Name8 (MD) 3713**]
MEDQUIST36
D: [**2105-1-6**] 23:36
T: [**2105-1-12**] 13:33
JOB#: [**Job Number 6718**]
Name: [**Known lastname 6716**], [**Known firstname 133**] Unit No: [**Numeric Identifier 6717**]
Admission Date: [**2104-12-6**] Discharge Date: [**2105-3-25**]
Date of Birth: [**2026-7-24**] Sex: M
Service: GOLD-GENSX
ADDENDUM TO A PREVIOUS DISCHARGE SUMMARY DICTATED
[**2105-1-22**].
HISTORY OF THE PRESENT ILLNESS: Please see prior discharge
summary.
HOSPITAL COURSE: (continued) Since the previous dictation,
the patient has undergone several events, which will be
listed below. In the end of [**Month (only) **], the patient's
enterocutaneous fistula had closed and he had been taken off
his Somatostatin. He had an upper GI series with small bowel
followthrough done [**1-19**], which showed a prolonged
transit time of about seven hours with some dilated small
bowel loops, but no definite evidence of a fistula at that
time. The TPN was also discontinued and after 72 hours,
approximately around the [**12-23**], he was started on
diet. Over the next few weeks, Mr. [**Known lastname **] then developed
intermittent abdominal distention and cramping alternating
with diarrhea. He had occasional bouts of emesis with this.
He additionally, over the time course, developed acute renal
failure with rising creatinine to 2.9. GI consultation was
obtained. The TPN was restarted and he underwent colonoscopy
and esophagogastroduodenoscopy, both of which showed
nonspecific friability and ulcerations with erythematous
areas. These were biopsied with a nonspecific pattern and
viral cultures were sent, which were negative.
He also underwent a barium enema, which showed a pattern in
the distal sigmoid colon and distal small bowel consistent
with a functional ileus, but no evidence of obstruction. Due
to the patient's inability to tolerate p.o., a GI
consultation was obtained with recommendations made for MRI
and MRA to rule out venous thrombosis. This was performed
[**2-12**], which again showed mild-to-moderate dilated
bowel proximal and distal to the anastomosis consistent with
an ileus. There was no venous thrombosis demonstrated on
this study. There was, however, seen an abnormal area of
soft tissue enhancement, which could possibly represent some
localized ischemia. The patient remained stable, however, on
[**2-15**], it was found on physical examination that his
midline abdominal wound had again dehisced with exposed bowel
and a serosal tear representing a new small-bowel fistula.
At this point it was decided that he had failed nonoperative
management. He was taken to the operating room [**2105-2-18**], at which time he underwent an exploratory
laparotomy with takedown of enterocutaneous fistula, lysis of
adhesions, revision of the enterosigmoid colostomy, small
bowel resection, and a component separation ventral
herniorrhaphy under general endotracheal anesthesia. The
operative time was approximately 10 hours, during which the
patient received ten liters of fluid, three units of packed
cells. He had good urine output throughout the case,
however, towards the end he became mildly acidotic. He was
then transferred to the Surgical Intensive Care Unit,
intubated, and sedated. The ICU course was complicated by
hypotension requiring pressors, high blood sugars requiring
an insulin drip.
On postoperative day #4, the patient spiked. The
perioperative antibiotics had been discontinued the day
before and he was restarted on Ceftriaxone at that time.
Chest x-ray was consistent with likely left lower lobe
pneumonia.
The patient continued to require pressors and developed
sepsis.
On postoperative day #5, he was pancultured. The CVL was
changed over wires. Antibiotics were changed from
Ceftriaxone to Cipro. Blood cultures grew out coagulase
negative staph. Sputum grew out yeast and gram-negative
rods. Repeat sputum cultures grew out Klebsiella oxytoca,
which was pansensitive. He was then placed on IV Cipro.
On postoperative day #6, he was noted to have necrosis along
the incision line and wound breakdown. The staples were
removed and the wound debrided. He was started on wet-to-dry
dressing changes. He continued to spike and he was changed
back to Ceftriaxone. He continued to be intubated, sedated,
on pressors, TPN and Somatostatin. Pressors were weaned on
postoperative day #8 and on postoperative day #9, he was
extubated without problems. [**Name (NI) **] remained in the ICU, however,
for further management secondary to altered mental status,
which slowly improved. The white blood cell count was also
still elevated. He continued to have copious secretions. He
had a repeat abdominal CT scan [**3-4**], to evaluate for
intra-abdominal abscess. There were a few small fluid
collections visualized, however, no definite abscesses were
identified. He was eventually transferred to the regular
floor on postoperative day #14, off antibiotics.
Of note, the patient experienced an episode of paraphimosis,
which was reduced by the Department of Urology.
He was started on clears on postoperative day #17.
On postoperative day #19, the patient complained of dull,
left-sided chest pain at rest. EKG showed some T-wave
flattening in V4 through V6. The pain was relieved with
nitroglycerin. The patient was given an aspirin, additional
Lopressor, and started on oxygen. Cardiac enzymes were
cycled, which were negative. Cardiology consultation was
called and it was recommended that noninvasive testing could
be done at a later date. The patient had no further episodes
of chest pain throughout his hospitalization. It was further
noted on the patient's labs that his creatinine began rising
reaching a peak of 2.7. Renal consultation was called on
[**2105-3-13**]. It was felt that this was due to acute renal
failure. He underwent renal ultrasonography on the [**2105-3-14**], which showed normal kidneys, no evidence of
hydronephrosis, stones, or masses.
Over the course of the next few weeks, the patient's diet was
advanced as tolerated. However, he continued to complain of
intermittent abdominal distention and fullness, limiting his
p.o. intake. This symptomatology would be relieved by bowel
movements. He was then allowed to take POs ad lib. He was
continued on the TPN for further nutritional support.
HOSPITAL COURSE: (review by systems)
NEUROLOGICAL: The patient initially suffered from depression
during his early hospitalization based on psychiatry
recommendations from consultation obtained [**2104-12-12**].
He was placed on Ritalin. Based on the further
recommendations from the Department of Psychiatry, he was
maintained on Remeron and Ritalin to help manage his
depression and attentiveness. He had periods of confusion
postoperatively after extubation in the ICU, which
spontaneously resolved. The patient is now alert, oriented
times four. He does, however, continue to have periods of
dysphoria. He is not requiring any pain medication at this
time.
CARDIOVASCULAR: The patient was initially stable from a
cardiovascular standpoint. However, due to likely sepsis,
postoperatively, he had significant pressor requirements,
which were eventually weaned. He also had one episode of
left dull chest pain for which he was ruled out for
myocardial infarction by enzymes. He continues on Lopressor,
currently at 50 mg p.o.b.i.d., and he is hemodynamically
stable at this time.
RESPIRATORY: The patient, postoperatively, had a prolonged
nine-day intubation, complicated by the patient being
subsequently improved. He has been able to maintain room-air
saturations in the high 90s.
GASTROINTESTINAL: As per above, after a prolonged course of
the NPO with intermittent abdominal pain, distention, the
patient is able to tolerate some PO intake, which is limited
by a feeling of early satiety and intermittent distention,
relieved by bowel movements. He underwent upper series with
small bowel followthrough [**2105-3-17**], which again showed
a delayed transit time, but no mechanical obstruction. He
continues on a diet, ad lib with TPN for full nutritional
support. The patient was noted to have copious diarrhea,
question of bacterial overgrowth was raised. He was,
thereby, started on Doxycycline 100 mg p.o.b.i.d.
GENITOURINARY: Mr. [**Known lastname **] suffered from acute renal
failure. Renal consultation was obtained and thought was
that this may be ATN secondary to a hypotensive episode. The
creatinine had stabilized at 2.0. He did, however, have an
Enterococcus UTI for which he was treated with Ampicillin.
He has also had difficulty with urinary retention requiring
multiple Foley catheter insertions. Urology consultation is
pending at this time. He was started on Flomax on which he
continues at this time.
HEMATOLOGY: Over the course of his ICU stay, he required
several transfusions postoperatively. The hematocrit
stabilized at 29. In addition, because of the preoperative
question of mesenteric ischemia, he underwent a
hypocoagulable workup, which was negative.
ENDOCRINE: The patient initially required an insulin drip
immediately postoperative for management of high blood
glucose while on TPN. He has been stabilized on a regimen of
70 units of insulin in his TPN with fingersticks in the low
to mid 100s.
INFECTIOUS DISEASE: Initially, Mr. [**Known lastname **] was afebrile,
however, he developed pneumonia postoperatively, growing
Klebsiella oxytoca and gram-positive bacteria, further
identified as coagulase-positive staph. He was treated with
a full course of antibiotics for this, including Ceftriaxone
and Ciprofloxacin.
He completed a ten-day course of Ceftriaxone. However, he
continued to have an elevated white blood cell and low-grade
temperatures. Stool was sent for C. difficile, which was
negative. Urine culture, from [**3-8**], grew Enterococcus
and yeast, for which she was treated with a full course of
Ampicillin.
He defervesced and the white count decreased to 10 and then
8.6.
WOUND: After the patient's initial fistula closed with
development of the new fistula, as stated above,
postoperatively the incision underwent extensive flap
necrosis and breakdown. However, the fascia remained intact.
The abdominal wall was debrided and he was placed on t.i.d.
Wet-to-dry dressing changes. The wound progressively began
to granulate in and currently has beefy red, healthy
granulation tissue with a few areas of fibrinoid. The wound
is clean and there is no exudate or drain.
CONDITION ON DISCHARGE: Mr. [**Last Name (Titles) 6719**], after undergoing an
extensive hospitalization, is stable and in good condition
for discharge to a rehabilitation facility to further
convalesce. He is hemodynamically stable. He is taking POs
ad lib. He is stable on TPN. He is afebrile with a normal
white blood cell count. The hematocrit is stable, as well.
He is able to ambulate with the assistance of a walker and
one person.
DISCHARGE STATUS: Mr. [**Known lastname **] has been accepted at the
rehabilitation hospital of [**State 6720**]to which he is
anticipated to be discharged [**2105-3-26**].
DISCHARGE INSTRUCTIONS: Mr. [**Known lastname **] is to continue on
TPN. He is currently stable with a volume of 1600 cc per
day; 75 gram per day of amino acids; 320 grams per day of
dextrose and 50 grams per day of fat with an additional 600
units of heparin; 70 units of insulin and 15 mg of zinc.
Electrolytes have remained stable and can be modified as
needed.
He is on t.i.d. dressing changes to the anterior abdominal
wound with moist saline gauze and DuoDerm hydrophilic gel.
He is to receive physical therapy for ambulation.
The patient currently has an indwelling Foley catheter.
Further instructions regarding removal are to follow.
The patient is to followup with Dr. [**Last Name (STitle) 1180**] in the clinic in two
weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o.b.i.d.
2. Protonix 40 mg p.o.q.d.
3. Vitamin C 500 mg p.o.q.d.
4. Ativan 0.5 mg p.o.q.h.s.p.r.n.
5. Xalatan drops 0.05% OU q.h.s.
6. Betimol drop 0.5% OS b.i.d.
7. Ritalin 5 mg p.o.b.i.d.; second dose not after 3 p.m.
8. Reglan 5 mg p.o.q.i.d.
9. Flomax 0.4 mg p.o.q.d.
10. Epogen 3000 units subcutaneously three times a week.
11. Remeron 30 mg p.o.q.h.s.
12. Doxycycline 100 mg p.o.b.i.d.
13. Carnation Instant Breakfast one p.o.t.i.d.
14. Regular insulin sliding scale.
15. TPN as outlined above.
DISCHARGE DIAGNOSIS:
1. Status post revision of jejunosigmoid anastomosis.
2. Status post closure enterocutaneous fistula.
3. Cataracts.
4. Glaucoma.
[**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**], M.D. [**MD Number(1) 3712**]
Dictated By:[**Last Name (NamePattern1) 5986**]
MEDQUIST36
D: [**2105-3-25**] 15:16
T: [**2105-3-25**] 15:25
JOB#: [**Job Number 6721**]
|
[
"997.3",
"998.3",
"998.6",
"998.59",
"553.20",
"997.4",
"162.3",
"997.5",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.93",
"96.72",
"45.62",
"46.74",
"54.59",
"53.59",
"96.6",
"45.22",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5717, 5833
|
20888, 21420
|
21441, 21856
|
1158, 1308
|
15348, 19501
|
20147, 20865
|
1115, 1131
|
105, 1057
|
1080, 1091
|
19526, 20122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,507
| 194,158
|
26754
|
Discharge summary
|
report
|
Admission Date: [**2118-2-8**] Discharge Date: [**2118-2-15**]
Date of Birth: [**2050-7-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
ERCP with [**Hospital1 **]-CAP electrocautery ([**2118-2-10**])
AV fistulagram ([**2118-2-11**])
History of Present Illness:
Mr. [**Known lastname 1022**] is a 67 year-old man presenting with melena. Recently
admitted in [**Hospital1 **] under Dr.[**Last Name (STitle) **] on [**2-2**] with RUQ pain and mildly
deranged LFTs. CT-showed thick walled GB with CBD upper normal
6.6mm. No pancreatitis.
Re-presented to [**Hospital1 **] with abdominal pain and nausea with
deranged LFTs. Transferred here for ERCP on [**2118-2-7**] and then
transferred back to [**Hospital1 **]. Today he was noted to have 2
episodes of dark melanotic stools the second one was just after
dialysis about 1400. He did not have any hematemesis. They
planned on giving him 1 unit PRBCs prior to transfer. He did not
have any hemodynamic instability and his Hct went from 34 on
[**2-1**] to 32.4 on [**3-3**] to 31.4 today at 13:35. He denies any
recent NSAID use, he has never had a significant GIB before but
has had some small amounts of BRBPR w/ constipation. He had
several episodes of dry heaves yesterday without hematemesis.
ERCP [**Numeric Identifier **] pager. Ref:Dr.[**Last Name (STitle) 27673**] ([**Telephone/Fax (1) **]- page operator).
On the floor, He denies any pain or current complaints.
Review of systems:
Negative other than above
Past Medical History:
1. Diabetes type II
2. Hypertension
3. ESRD on dialysis via AV-fistula
4. CAD per d/c summary (endorses history of pacer but denies
heart attack, stents or cardiac cath)
5. Pacemaker placed for bradyarrhythmia
6. Ankle fracture from slip on ice several weeks ago
Social History:
Originally from [**Country 10181**], lives with his wife. Retired from
[**Location (un) **] in [**2104**] as assembly worker. Has 2 sons and one
daughter. His daughter's phone number (Yokang [**Telephone/Fax (1) 65905**]).
Previously was heavy drinker/smoker 2ppd but quit 10 years ago.
Family History:
Non-contributory
Physical Exam:
Vitals: T:97.7 BP: 121/54 P:67 R: 16 O2: 100% on 2L NC
General: Alert, oriented, no acute distress, speaks minimal
english.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased in the bases with scant crackles in bases
CV: Regular rate and rhythm, normal S1 + S2, holosystolic
murmur.
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, Fistula w/ palpable thrill in LUE. No palmar erythema.
Cast on LLE
Rectal: Small amount soft brown stool
Skin: One small spider angioma on his L chest
Pertinent Results:
Admission Labs: [**2118-2-8**]
WBC-8.7 RBC-2.95* Hgb-9.8* Hct-28.9* MCV-98 MCH-33.2* MCHC-33.9
RDW-13.2 Plt Ct-168
PT-12.8 PTT-25.4 INR(PT)-1.1
Glucose-123* UreaN-43* Creat-8.6*# Na-139 K-4.3 Cl-97 HCO3-30
AnGap-16
ALT-104* AST-68* LD(LDH)-292* AlkPhos-163* TotBili-1.1
Albumin-3.7 Calcium-8.3* Phos-4.5 Mg-2.3
Nadir HCT ([**2118-2-10**]): 21
ERCP ([**2118-2-10**]): Evidence of a previous sphincterotomy was noted
in the major papilla. Erythema was noted at the apex of the
sphincterotomy.
A small amount of oozing blood was noted on the upper aspect of
the sphincterotomy, at approximately 2 oclock. [**Hospital1 **]-CAP
electrocautery was applied for hemostasis successfully.
Brief Hospital Course:
1. Upper GI bleeding with acute blood loss anemia. Transferred
from OSH after 2 episodes of melena status post sphincterotomy
at [**Hospital1 18**] on [**2-7**]. After initially stable HCT, dropped to 21 on
[**2118-2-10**] prompting repeat ERCP. This showed a small amount of
oozing blood on the upper aspect of the sphincterotomy site;
[**Hospital1 **]-CAP electrocautery was applied for hemostasis successfully.
.
In total, 4 units of pRBC were transfused.
.
Post-procedure he had severe abdominal pain with concern for
performation. Plain radiographs were read as possibly having a
very small amount of free air. CT abdomen was reassuring as no
air was seen.
- contin Amoxicillin-Clavulanic Acid 500 mg PO/NG Q12H for 7 day
course given concern for possible microperforation. D1=[**2-13**].
.
2. ESRD. Noted to have inadequate dialysis during initial
sessions. Underwent AV fistulagram with 2 areas peripheral
venous stenoses which were angioplastied. Pt's fistula function
improved on HD.
- due for HD [**2118-2-16**] (Wed)
.
3. Hypertension. Antihypertensive medications held initially
given his acute bleeding.
- continue Amlodipine 10 mg PO/NG DAILY
Currently holding clonidine 0.2 mg [**Hospital1 **], diovan 80 mg [**Hospital1 **],
atenolol 50 mg [**Hospital1 **], lisinopril 40 mg daily, lasix 80 [**Hospital1 **]
In discussion with Nephrology, expect pt's BP control will
improve as he contin to receive more effective HD, thus will not
resume additional BP Rx for now.
.
.
DISP: discharged to Rehab
Medications on Admission:
Home medications
phos lo 667mg three tabs TID,
clonidine 0.2 mg [**Hospital1 **],
lisinopril 40 mg daily,
lasix 80 [**Hospital1 **],
atenolol 50 mg [**Hospital1 **],
diovan 80 mg [**Hospital1 **],
norvasc 10 mg daily,
humalog 30 mg qam, 15 mg qpm.
OSH medications
Catapres 0.1mg [**Hospital1 **]
Renagel 800mg TID
Norvasc 10mg daily
Phoslo 667 TID
Zestril 40mg daily
diovan 80mg [**Hospital1 **]
Protonix 40mg IV daily
Ambien 5mg QHS
Zofran 4mg Q6 PRN N/V
Tylenol 650mg Q4
Labetalol 10-20mg Q4 IV PRN
Compazine 5-10mg IV Q6 PRN N/V
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day for 7 days.
2. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous QACHS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] Twin Oaks care and Rehab
Discharge Diagnosis:
1. GI bleeding, post sphincterotomy
2. Acute blood loss anemia
3. Post-procedure pancreatitis
4. Hypertension
5. Choledocholithiasis
6. ESRD on dialysis
7. Diabetes, type II
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 with bleeding after your recent ERCP. In order
to treat this you required another ERCP in which they were able
to find the area that was bleeding and your bleeding was
stopped. You also had a procedure on your fistula, and your
dialysis worked better.
Followup Instructions:
Department: TRANSPLANT CENTER
When: WEDNESDAY [**2118-3-2**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"V54.89",
"585.6",
"V45.11",
"276.7",
"414.01",
"997.4",
"996.73",
"428.0",
"285.1",
"V45.01",
"E878.8",
"998.11",
"250.40",
"577.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"39.95",
"51.10",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
6317, 6389
|
3693, 5205
|
309, 408
|
6607, 6607
|
2986, 2986
|
7084, 7397
|
2249, 2267
|
5789, 6294
|
6410, 6586
|
5231, 5766
|
6790, 7061
|
2282, 2967
|
1615, 1642
|
263, 271
|
436, 1596
|
3002, 3670
|
6622, 6766
|
1664, 1928
|
1944, 2233
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,506
| 196,510
|
14162
|
Discharge summary
|
report
|
Admission Date: [**2109-11-27**] Discharge Date: [**2109-12-4**]
Date of Birth: [**2051-6-29**] Sex: M
Service:
MOST RESPONSIBLE DIAGNOSIS: Left hemothorax (delayed
hemothorax after recent coronary artery bypass grafting
surgery).
OTHER DIAGNOSES:
1. Recent coronary artery bypass grafting with use of the
left internal mammary artery.
2. Recent treatment for atrial fibrillation.
3. Recent anticoagulation for atrial fibrillation.
PROCEDURES:
1. [**2109-11-28**] - bedside insertion of chest tube.
2. [**2109-11-28**] - Dr. [**Last Name (STitle) 954**] - left thoracoscopy for
hemothorax.
HISTORY: This man recently underwent coronary artery bypass
graft surgery by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. He had done well and went
home. However, he returned on the evening of [**11-27**]
complaining of shortness of breath and left pleuritic pain.
He was found to have a large hemothorax. A chest tube was
placed. He had been on a variety of agents that may have
inhibited his ability to clot. He was formally
anticoagulated because of atrial fibrillation when he was
discharged home from hospital. In addition, he was also on
various antiplatelet agents, perhaps a combination of all
these agents predispose to a late postoperative bleed. It
seemed that the bleeding was related to the previous open
heart surgery.
HOSPITAL COURSE: He was resuscitated with intravenous fluids
and blood products. Fresh-frozen plasma was given to try to
normalize PT and PTT. A chest tube was inserted. Ongoing
bleeding was suspected. He was taken to the operating room
for thoracoscopy. Thoracoscopy revealed extensive clotting
within the chest. We completely evacuated the clot, but we
were careful to leave a tiny rim of clot on the left internal
mammary bed. I suspected that is where the bleeding was
coming from.
By the time we got him to the operating room, the active
bleeding seemed to have stopped and that is probably related
to all the coagulation factors that he had received.
Postoperatively, he was left on the vent for a day or so. As
he recovered, we removed the chest tubes. He was discharged
home about a week after surgery in fairly good condition.
Followup was arranged for Dr.[**Name (NI) 31850**] office and also with
Dr. [**Last Name (STitle) 1537**]. At the time of this dictation, he has been seen in
the office, and his chest x-rays returning to normal.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 954**], M.D. 2918
Dictated By:[**Last Name (NamePattern4) 42151**]
MEDQUIST36
D: [**2110-2-19**] 13:49
T: [**2110-2-20**] 07:01
JOB#: [**Job Number 42152**]
|
[
"998.11",
"V58.61",
"V45.81",
"272.0",
"427.31",
"401.9",
"511.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"34.04",
"34.4"
] |
icd9pcs
|
[
[
[]
]
] |
1400, 2701
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,785
| 115,099
|
32985
|
Discharge summary
|
report
|
Admission Date: [**2178-3-12**] Discharge Date: [**2178-3-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
diarrhea and ICD fire
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a [**Age over 90 **] yo M with a PMH of CAD s/p CABG, s/p ICD in
[**2173**], who p/w 1 week of diarrhea, fevers, and ICD firing x4
yesterday. The pt states that over the past week, he has had
many (<10) brown, watery stools, associated with lower abdominal
cramping prior to bowel movements. The abdominal cramping is
alleviated with bowel movements, and he is often incontinent of
stool at this time. He states that his wife has told him he has
had a temp over 100 F over the past week. He also notes that his
ICD fired 4 times yesterday as he was walking out of the
bathroom, which has never happened to him before. He has had
decreased po intake of foods and fluids over the past 3-4 days.
He denies any palpitations, LOC, chest pain, shortness of
breath, dysuria, nausea, vomiting, headaches, cough, leg
swelling, rashes, or chills.
.
Of note, the pt was hospitalized at [**Location (un) **] [**Location (un) 1459**] from
[**Date range (1) 75564**]/08 for probable urosepsis and positive blood cultures
for E Coli (grown in bottle from [**2-13**]). His E Coli was
pansensitive. He was treated with CTX while inpatient, and then
discharged to [**Hospital 76713**] rehab where he was treated with Avelox
for his positive blood culture. The pt was discharged from rehab
1 week ago, which is when he started to have diarrhea.
.
In the ED, the pts vitals were: Tm 100.4, HR 102-128, BP
86-107/32-56, R 20-26, Sat 96% 2L NC. He received 3 L NS, 2 L of
LR, flagyl 500 mg IV x2, Levofloxacin 500 mg IV x1, Vanc 1 gm IV
x1. Blood cultures and urine cultures were drawn. Because he was
hypotensive to the 80s and tachy to the 120s, a right subclavian
central line was placed. He was responsive to fluid boluses in
the ED. He was seen by EP and ICD interrogation revealed
underlying AF with RVR. Initially he had rapid AF, then regular
ventricular rate CL 290: shock with 29J into rapid AF, but still
in VF detection zone: 5 more shocks. Then another episode AD-->
rapid regular tachycardia CL 260 msec: teminated while charging
but therapy not aborted due to a few short coupled beats while
in AF. His VF detection range was changed to CL 320 msec.
.
He was given a total of 7.5L of fluid in his roughly 2 day stay
in the MICU and his blood pressure responded. He continued to
be tachycardic, though was documented to be in sinus tach by
EKG. His metoprolol was restarted on [**2178-3-15**].
.
Upon transfer, he denied CP, palpitations, SOB, lightheadedness.
Past Medical History:
CAD s/p CABG in [**2169**] for L main disease
ischemic cardiomyopathy with h/o CHF
TTE [**4-15**]: EF 15-20%, RV dilation,LV global hypokinesis
cardiac cath [**5-14**]: patent grafts to LAD, OM1, and OM2
s/p ICD in [**2173**] for compromised LV function and recurrent
syncope
BPH
h/o elevated PSA
h/o renal insufficiency--baseline Cr 1.2
DJD of neck and spine
NSTEMI in [**2169**]
HTN
hyperlipidemia
Gout
h/o DVT
Social History:
The pt denies any alcohol, tobacco, or illicit drug use. He
lives at home with his wife. [**Name (NI) **] recently was discharged from
rehab 1 week ago. He is a retired postal worker. He has no
children.
Family History:
non-contributory
Physical Exam:
VS: Temp: 98.0 Tm 98.8 BP: 119/55, 94-157/53-95 HR: 102, 102-138
O2sat 99, 92-100%3L NC
GEN: pleasant, comfortable, NAD
HEENT: NCAT, EOMI, MMM, +dentures
RESP: decreased breath sounds at BL bases, mild bibasilar
crackles bilaterally. o/w ctab.
CV: irreg irreg, S1 and S2 wnl, no m/r/g
ABD: mildly distended, mild tenderness to palpation in bilateral
lower quadrants, no rebound or guarding, NABS
EXT: 2+ LE bilaterally, no c/c
NEURO: AAOx3. CN 2-12 intact grossly. Moving all 4 extrem
equally.
Pertinent Results:
[**2178-3-20**] 06:00AM BLOOD WBC-12.0* RBC-3.88* Hgb-12.2* Hct-38.5*
MCV-99* MCH-31.5 MCHC-31.7 RDW-15.4 Plt Ct-371
[**2178-3-20**] 06:00AM BLOOD Glucose-147* UreaN-27* Creat-1.3* Na-140
K-3.9 Cl-112* HCO3-17* AnGap-15
[**2178-3-13**] 08:20AM BLOOD ALT-14 AST-15 CK(CPK)-47 AlkPhos-70
TotBili-1.1
[**2178-3-13**] 02:59PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2178-3-13**] 08:20AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2178-3-12**] 09:20PM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2178-3-13**] 08:20AM BLOOD TSH-3.1
[**2178-3-20**] 06:00AM BLOOD Digoxin-0.3*
[**2178-3-20**] 06:00AM BLOOD WBC-12.0* RBC-3.88* Hgb-12.2* Hct-38.5*
MCV-99* MCH-31.5 MCHC-31.7 RDW-15.4 Plt Ct-371
[**2178-3-20**] 06:00AM BLOOD Glucose-147* UreaN-27* Creat-1.3* Na-140
K-3.9 Cl-112* HCO3-17* AnGap-15
[**2178-3-20**] 06:00AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.1
[**2178-3-13**] 08:20AM BLOOD TSH-3.1
[**2178-3-13**] 08:20AM BLOOD Cortsol-49.7*
[**2178-3-16**] 12:12AM BLOOD Lactate-2.4*
[**2178-3-14**] 04:12AM BLOOD freeCa-1.15
.
MICRO:
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2178-3-15**]):
REPORTED BY PHONE TO [**Last Name (LF) 4174**],[**First Name3 (LF) 2671**] @ 07:36, [**2178-3-15**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**3-13**] Blood Cx x4 NGTD
[**3-13**] Urine Cx NGTD
.
IMAGING:
CXR [**3-13**]: No acute pulmonary process. Hypertensive
cardiomediastinal configuration. Small left pleural effusion.
Indwelling AICD.
.
TTE [**3-14**]: The left atrium is moderately dilated. There is severe
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. There is mild global left ventricular
hypokinesis (LVEF = 40-50 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The right ventricular free wall
is hypertrophied. Right ventricular chamber size is normal. with
depressed free wall contractility. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. A mitral valve
annuloplasty ring may be present. An eccentric, anteriorly
directed jet of Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. There is a trivial/physiologic
pericardial effusion.
.
CXR [**3-16**]: 1. Slight decrease in the left small pleural effusion.
2. Otherwise there is essentially no significant interval
change.
.
ECG Study Date of [**2178-3-16**] 12:05:52 AM
Probable sinus tachycardia with atrial premature complexes but
may be
multifocal atrial tachycardia
Consider left ventricular hypertrophy
Delayed R wave progression - is nonspecific but could be due in
part to left ventricular hypertrophy
Nonspecific ST-T abnormalities
Since previous tracing of [**2178-3-15**], probably no significant
change
Brief Hospital Course:
A/P: [**Age over 90 **] yo M with a PMH of CAD s/p CABG, h/o atrial
fibrillation, s/p ICD in [**2173**], who p/w 1 week of diarrhea,
fevers, ICD firing x4, found to be in afib with RVR and
hypotensive.
.
# Hypotension: Initially thought due to sepsis from GI source.
Covered with levo/flagyl/vanc/zosyn, last antibiotic d/c'd on
[**2178-3-14**], now just on flagyl for cdiff as below. Hypotension
responded to fluid. UCx negative. BCx pending x 4, and CXR shows
only a small L pleural effusion. No other clear focus of
infection is evident. Lactate improved. BCx were negative x 4,
UCx negative x 1. Home lisinopril and diuretics were held, and
should be restarted as blood pressure allows.
.
# arrhythmia: originally afib by device detection/firing, now
looks like MAT by EKG, likely related to volume depletion vs.
sepsis upon admission. He is not on anticoagulation. Will defer
to outpatient physician for decision about anticoagulation given
age and comorbidities. TSH wnl. EP consulted and recommended
digoxin 0.0625, which was increased to 0.125 daily based on dig
level. He will need a repeat dig level on [**2178-3-27**]. His
lisinopril was held as above, and continued to be held to allow
blood pressure room for beta blocker. Will defer to
rehab/primary care physician [**Last Name (NamePattern4) **]: restarting lisinopril,
titrating digoxin.
.
# Diarrhea: cdiff positive, other fecal studies pending. cont to
have diarrhea. WBC much improved. On flagyl day 7 of 14, cont
until [**2178-3-27**]. Started on loperamide and opium tincture prn
after WBC began to trend down.
.
# volume overload: bilateral basilar crackles, suggestion of
vascular congestion by CXR, and bilateral dependent edema. Also
has an oxygen requirement. He received prn lasix. His home
lasix and aldactone was held as above. Will defer to
rehab/primary care physician [**Last Name (NamePattern4) **]: restarting diuretics. Please
wean O2 as tolerated.
.
# Low UOP: likely from dehydration from diarrhea. Responded to
boluses. He should be encouraged to take PO fluids, IVF prn,
though gently given dependent edema.
.
# hypernatremia: Briefly had hypernatremia with Na 146. Likely
related to NS IVF. He was given D5W and LR. Hypernatremia
resolved.
.
# CAD: s/p CABG. No current issues. ICD shocks were due to rapid
afib. Pt has 0.[**Street Address(2) 1755**] depressions in precordial leads, no prior
EKG to compare to. Elevated troponin, but CKs flat x 3. [**Month (only) 116**] be
demand ischemia from RVR and also with renal failure. He was
continued on aspirin 325, simvastatin. Lisinopril as above.
.
# Acute Renal Failure: Bl Cr 1.2. Admission Cr is 1.8, likely
due to dehydration. Improved and stable at 1.3 to 1.4, near
baseline. Held scheduled lasix and aldactone as above
.
# HTN: restart lisinopril when pressures tolerate.
.
# BPH: terazosin held for BP, restarted upon discharge.
.
# F/E/N: IVF. Replete lytes PRN. reg diet. He may benefit from a
speech/swallow study, though had no witnessed aspiration here.
.
# PPx: no bowel regimen given pt's diarrhea, sq Heparin.
.
# Code Status: DNR/DNI
.
# Communication: wife, [**Name (NI) 730**] [**Name (NI) **], [**Telephone/Fax (1) 76714**]
.
# Follow-up: with Dr. [**Last Name (STitle) 76715**] and Dr. [**Last Name (STitle) 76716**] as above.
Medications on Admission:
ASA 325 mg daily
Lisinopril 10 mg daily
Allopurinol 100 mg dily
Terazosin 2 mg at night
Metoprolol 200 mg daily
Lasix 40 mg daily
Aldactone 25 mg daily
Tylenol 1 g q h8hr
ultram 50 mg q 6 hr prn
Simvastatin 20 mg daily
Discharge Medications:
1. Outpatient Lab Work
Digoxin level [**2178-3-27**].
Titrate digoxin accordingly.
Please fax to Dr. [**Last Name (STitle) 76715**]. Phone [**Telephone/Fax (1) 9219**], Fax
[**Telephone/Fax (1) 76717**].
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for arthritis pain.
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days: Continue through [**2178-3-27**].
11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
12. Opium Tincture 10 mg/mL Tincture Sig: Five (5) Drop PO Q6H
(every 6 hours) as needed for diarrhea.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY AT 6 AM ().
14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Terazosin 2 mg Capsule Sig: Two (2) Capsule PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center - [**Location (un) **]
Discharge Diagnosis:
Hypotension due to presumed sepsis; source never isolated
C.dif colitis
Atrial fibrillation with RVR
MAT
Inappropriate ICD firing s/p adjustment by the EP service
Acute on Chronic RF
.
CAD s/p CABG in [**2169**] for L main disease
ischemic cardiomyopathy with h/o CHF
TTE [**4-15**]: EF 15-20%, RV dilation,LV global hypokinesis
cardiac cath [**5-14**]: patent grafts to LAD, OM1, and OM2
s/p ICD in [**2173**] for compromised LV function and recurrent
syncope
BPH
h/o elevated PSA
h/o renal insufficiency--baseline Cr 1.2
DJD of neck and spine
NSTEMI in [**2169**]
HTN
hyperlipidemia
Gout
h/o DVT
Discharge Condition:
Stable for discharge to rehab
Discharge Instructions:
You were seen at [**Hospital1 18**] for diarrhea, rapid heart rate, and your
defibrillator firing. You were found to have a heart
arrhythmia. Your defibrillator was recalibrated. You have a
gastrointestinal infection for which you will need to continue
antibiotics as prescribed.
.
You should discuss with your primary care provider about
possibly started coumadin or another anticoagulation drug to
thin your blood given you have an arrhythmia.
.
Your diuretics were also held during your stay. Please discuss
with your primary care provider about restarting those.
.
You should return to the emergency department or call your
primary care provider if you experience chest pain, worsening
shortness of breath, wheezing, fevers/chills greater than 101.5
degrees F, your defibrillator firing, or any other symptoms that
concern you.
Followup Instructions:
SCHEDULED APPOINTMENTS:
Dr. [**Last Name (STitle) 76716**], Thursday [**2178-4-2**], 1:45pm. Phone:[**Telephone/Fax (1) 9219**]
.
Dr. [**Last Name (STitle) 76715**], Thursday [**2178-4-2**], 2:00pm. Phone:[**Telephone/Fax (1) 9219**]
.
Please call if you need to cancel.
|
[
"276.0",
"995.91",
"403.90",
"008.45",
"458.9",
"272.4",
"584.9",
"V45.02",
"427.31",
"414.01",
"600.00",
"038.9",
"276.51",
"274.9",
"511.9",
"V45.81",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12165, 12240
|
7132, 10438
|
284, 291
|
12882, 12914
|
4013, 7109
|
13798, 14074
|
3464, 3482
|
10708, 12142
|
12261, 12861
|
10464, 10685
|
12938, 13775
|
3498, 3994
|
223, 246
|
319, 2789
|
2812, 3227
|
3243, 3448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,487
| 141,451
|
30221
|
Discharge summary
|
report
|
Admission Date: [**2162-2-8**] Discharge Date: [**2162-3-6**]
Date of Birth: [**2124-6-6**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8257**]
Chief Complaint:
nasuea/vomiting/abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 37 yo 29 w pregnant female with pancreatitis. She has
been having trouble with nausea and vomiting throughout the
pregnancy however over this past weekend her symptoms worsened
significantly with increaseing nausea and vomiting. She has had
multiple sick contacts and attributed this to her worsening
symptoms. She had some LUQ abd pain with vomiting over the
weekend but otherwise no other abd symptoms. Monday [**2-8**] she
awoke and had a particularly severe episode of vomiting after
which she developled severe/burning epigastric pain radiating to
both sides and back. She has not had this pain before and so
presented to an OSH ED where she was found to have elevated
amylase and lipase and then transferred to [**Hospital1 18**].
Past Medical History:
PMH :
C-section x3
Social History:
Patient has 3 children, lives with father of first child,
although divorced
Physical Exam:
vss WNL
ABD Exam: soft
gravid, with epigastric tenderness.
Pertinent Results:
[**2162-2-8**] 08:52PM GLUCOSE-88 UREA N-5* CREAT-0.4 SODIUM-141
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-23 ANION GAP-15
[**2162-2-8**] 08:52PM estGFR-Using this
[**2162-2-8**] 08:52PM ALT(SGPT)-6 AST(SGOT)-13 AMYLASE-655* TOT
BILI-0.6
[**2162-2-8**] 08:52PM LIPASE-1282*
[**2162-2-8**] 08:52PM CALCIUM-8.4 PHOSPHATE-2.2* MAGNESIUM-1.5*
URIC ACID-3.3
[**2162-2-8**] 08:52PM WBC-11.0 RBC-3.50* HGB-9.7* HCT-28.9* MCV-83
MCH-27.8 MCHC-33.6 RDW-15.6*
[**2162-2-8**] 08:52PM PLT COUNT-389
[**2162-2-8**] 08:52PM PT-13.2* PTT-25.2 INR(PT)-1.1
[**2162-2-8**] 08:52PM FIBRINOGE-339
Brief Hospital Course:
Ms [**Name13 (STitle) 71994**] was initially managed in the ICU.
With regards to abdominal pain. She was diagnosed with
pancreatitis given elevated amylase and lipase. It was unclear
if the gallstone was related to the pancreatitis since bilirubin
and alk phos are normal and the Ultrasound showed no evidence of
bilary obstruction. General surgery was consulted to determine
need for imaging and likelihood if imaging demonstrated
findings, if would proceed with surgery. They did not believe
she needed emergent surgery. GI was also consulted and
recommended aggressive hydration, NPO for bowel rest, and TPN.
While on the antepartum floor, the patients pain was initially
controlled with a Fentanyl PCA. She was transitioned to a
dilaudid PCA with similar response. On [**2-10**] started Ativan to
aid, given concern anxiety.
She was transferred to the antepartum floor on [**2-27**].
Her abdominal pain slowly resolved and an attempt was made to
advance her diet. She did not tolerate this advancement,
therefore she was made NPO again. Per GI's recommendation she
had repeat ultrasound of right upper abdomen was performed on
[**2162-2-19**] that showed the existance of a gallstone but no evidence
of bilary obstruction and a normal appearing pancreas. After
several days of bowel rest, her diet was advanced again and
again she did not tolerate this advancement. She was made NPO
and GI was reconsulted. GI recommended prolonged bowel rest and
TPN was started. Again, her diet was again advanced very slowly
to full liquids. Chronic pain medicine was also consulted for
recommendations to pain management other than the Dilaudid PCA,
namely duragesic patch and PO dilaudid.
With regards to her pregnancy she had continues fetal monitoring
while in the ICU. She was made betamethasone compete on [**2-1**].
She had twice daily reassuring fetal heart tracings. On [**2-9**] she
had EFW 1390g 50%. She also had weekly reassuring biophyscial
profiles. On [**2-26**] she was transferred to Labor & Delivery for
prolonged monitoring because of variable decelerations.On L&D
she had reassuring prolonged monitoring and BPP [**6-23**]. She was
found to be contracting every 4 minutes but SVE was
closed/long/posterior. Her contractions resolved with IV
hydradation. Given reassuring fetal monitoring and resolution of
preterm contractions she was transferred back to the antepartum
floor.
With regards to her anemia, her hematocrit stablized and she
remained asymptomatic.
She did not receive any blood transfusions.
On [**3-6**], the patient was found to be stable for discharge.
She was tolerating a full liquid diet and per nutrition
recommendations, her TPN was discontinued. She was using a
150mcg/h duragesic patch and 4-8mg PO Dilaudid q4h with adequate
pain relief. Fetal testing was reassuring.
Medications on Admission:
none
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*20 Patch 72 hr(s)* Refills:*0*
2. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. natachews Sig: One (1) once a day.
Disp:*60 * Refills:*2*
4. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea: take as needed.
Disp:*40 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis and pain
pregnancy
Discharge Condition:
good
Discharge Instructions:
-drink and advance diet as tolerated
-pain meds as needed
-walk as able
-keep tract of fetal movements at least 10 in 2 hours and call
if not feeling this
Followup Instructions:
Dr. [**Last Name (STitle) **] this week, we will call you with an appt, if you have
any issues please call [**Telephone/Fax (1) 30286**] please
|
[
"338.4",
"646.83",
"574.20",
"659.63",
"648.23",
"654.23",
"285.9",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"75.34",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5315, 5321
|
1981, 4795
|
356, 362
|
5397, 5404
|
1367, 1958
|
5608, 5755
|
4850, 5292
|
5342, 5376
|
4821, 4827
|
5428, 5585
|
1288, 1348
|
286, 318
|
390, 1136
|
1158, 1180
|
1196, 1273
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,324
| 101,201
|
32958
|
Discharge summary
|
report
|
Admission Date: [**2151-11-17**] Discharge Date: [**2151-11-27**]
Date of Birth: [**2107-10-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fatigue, shortness of breath
Major Surgical or Invasive Procedure:
[**2151-11-17**] Cardiac Catheterization
[**2151-11-19**] Bentall Procedure utilizing a 23mm Homograft with Repair
of a Sinus Valsalva Fistula
[**2151-11-24**] Placement of Dual Chamber Permanent Pacemaker(Guidant
Insignia Ultra DR)
History of Present Illness:
Mr. [**Known lastname 76674**] is a 44 year old male who was diagnosed with rectal
abscess and alpha hemolytic Streptococcus aortic valve
endocarditis on [**2151-10-15**]. He completed a course of Flagyl and
Ceftriaxone. Serial echocardiograms showed severe AI with a L->R
shunt from the sinus of valsalva to right ventricle. At time of
admission, he reported worsening fatigue associated with
shortness of breath with minimal activity and frequent
palpitations. He was admitted for further evaluation and
treatment.
Past Medical History:
Aortic Valve Endocarditis(Alpha Hemolytic Streptococcus)
Aortic Insufficiency
Rectal Abscess
History of Pancreatic Pseudocyst - s/p Percutaneous Drainage
History of Gallstone Pancreatitis
History of Lap Chole
History of Duodenal Stricture - s/p Gastrojejunostomy
History of Renal Cell Carcinoma - s/p Cryoablation
Prior Toe Surgery
Social History:
Married works as a project manager and has been working from
home over the past few weeks. No children. He denies any alcohol
use or IVDU. He reports smoking 1/2ppd x 20 years, quit on
[**2151-10-15**].
Family History:
Denies any family history of premature CAD. States his father
had an MI in his 70s, still living. Possible CAD on his mother's
side of the family. No history of known sudden death.
Physical Exam:
Blood pressure was 113-133/31-41 mm Hg while seated. Pulse was
109 beats/min and regular, respiratory rate was 16 breaths/min.
Generally the patient was well developed, well nourished and
well
groomed. The patient was oriented to person, place and time. The
patient's mood and affect were not inappropriate.
There was pale conjunctiva without cyanosis of the oral mucosa.
The neck was supple with JVP of 8 cm. The carotid waveform was
normal. There was no thyromegaly. The were no chest wall
deformities, scoliosis or kyphosis. The respirations were not
labored and there were no use of accessory muscles. The lungs
has
bibasilar rales.
Palpation of the heart revealed a prominent PMI. There were no
thrills, lifts or palpable S3 or S4. He is tachycardic with a
[**1-20**] holosystolic murmur best appreciated at LUSB. The abdominal
aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-11-27**] 05:44AM 5.5 3.31* 9.3* 28.0* 85 27.9 33.0 15.9*
264
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-11-27**] 05:44AM 101 15 1.1 137 4.4 100 31 10
[**2151-11-17**] Cardiac Catheterization:
1. Coronary angiography in this right dominant system revealed
no angiographically apparent coronary artery disease in the
LMCA, LAD, LCx, and RCA (although coronaries could not be well
opacified due to severe aortic regurgitation).
2. Resting hemodynamics revealed markedly elevated left and
right sided filling pressures with mean PCW of 21 mmHg and RVEDP
of 25 mmHg. There was severe pulmonary arterial hypertension
with PASP of 66 mmHg. The cardiac index was preserved at 3.2
L/min/m2. There was normal systemic arterial pressure with SBP
of 114 mmHg and DBP of 56 mmHg. There was a left-to right shunt
with oxygen step-up at RV flow and a possible fistula from sinus
of Valsalva to RV demonstrated by selective injection and
supravalvular aortography.
[**2151-11-17**] TEE:
Right ventricular systolic function is normal. Overall left
ventricular function is normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 45 cm from the incisors. There are
three aortic valve leaflets. There is a moderate to large sized
vegetation on the aortic valve involving the right and
non-coronary cusps. The vegetation measures 0.4cm x 1.5cm. The
left coronary cusp is moderately thickened. There is no aortic
root abcess cavity seen. Severe (4+) aortic regurgitation is
seen with reversal of flow in the descending thoracic aorta.
There is prominent color flow in the area of the right coronary
cusp which may represent a sinus of valsalva fistula (aortic
root to RA/RVOT). The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
[**2151-11-18**] Abdominal CT Scan:
1. No retroperitoneal hematoma.
2. Right upper quadrant pericolonic and peripancreatic
induration at least some of which may be secondary to known
previous procedures. This may represent recurrent or acute
pancreatitis and as patient cannot receive contrast, MRI may
also be informative. Note also higher density contents of right
colon (question intraluminal blood) compared to the remainder
bowel. Is patient guaiac positive?
3. Persistent contrast opacification kidneys, now greater than
24 hours past contrast administration indicative of ATN. Note
additional density abnormality right lateral kidney. ?is this
site of patient's previous known RF ablation for renal cell
cancer?
4. Small amount of free intraperitoneal fluid and
small-to-moderate size right pleural effusion, neither of which
measure blood density.
5. Mildly enlarged spleen.
6. Diverticulosis.
[**2151-11-21**] Chest/Abdominal CT Scan:
1. Large areas of consolidation seen within the lungs
bilaterally, with air bronchograms, concerning for infection.
2. New diffuse patchy ground-glass airspace opacities seen
bilaterally, right greater than the left. 3. No evidence of
retroperitoneal hematoma. Small amount of nonspecific free fluid
in pelvis. Stranding in pelvic soft tissues possibly represent
small amount of interstitial hemorrhage.
4. Post-operative changes seen within the chest, with multiple
lines and tubes. Pneumomediastinum and small bilateral
pneumothoraces seen, consistent with post-operative changes.
[**2151-11-22**] TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve appears to be a homograft. The
aortic valve prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is moderate pulmonary artery
systolic hypertension.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2151-11-27**] 10:46 AM
CHEST (PA & LAT)
Reason: check atel
[**Hospital 93**] MEDICAL CONDITION:
44 year old man with
REASON FOR THIS EXAMINATION:
check atel
CLINICAL HISTORY: Pacer placed, check for pneumothorax, unable
to raise left arm.
CHEST: The position of the pacemaker is unchanged. No
pneumothorax is present. The left lung appears clear.
Patchy opacities are again noted within the right lung, not
significantly changed since the prior chest x-ray of [**11-25**]. These probably represent areas of pneumonia.
IMPRESSION: No significant change since [**11-25**].
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Brief Hospital Course:
Mr. [**Known lastname 76674**] was admitted and underwent cardiac catheterization
and transesophageal echocardiogram which confirmed aortic valve
endocarditis, severe aortic insufficiency and a sinus of
Valsalva fistula. Coronary angiography showed normal coronary
arteries. His creatinine on admission was noted to be 1.8. He
remained on intravenous Ceftriaxone per ID recommendations.
Based on the above, cardiac surgery was consulted and further
evaluation was performed. He was cleared for surgery by dental,
but will require extractions after he recovers from surgery. His
acute renal insufficiency was attributed to hypoperfusion given
his severe aortic insufficiency. He was also noted to be anemic
which required several blood transfusions. An abdominal CT scan
was performed which ruled out a retroperitoneal bleed. He
otherwise remained stable on medical therapy and was eventually
cleared for surgery.
On [**11-19**], Dr. [**First Name (STitle) **] performed a Bentall procedure with a
homograft along with repair of sinus of Valsalva fistula. Given
that his hospital stay was greater than 24 hours prior to
surgery, he was given Vancomycin for perioperative coverage. For
surgical details, please see seperate dictated operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. He remained anemic and continued to
require intermittent blood transfusions. There was no evidence
of active bleeding. Following extubation, he experienced poor
oxygenation along with some hemoptysis. Chest x-rays were
notable for extensive bilateral consolidations and bilateral
pleural effusions. Right sided chest tube was placed and
diagnostic/therapeutic bronchoscopy was performed. Blood tinged
secretions were noted in the lower lobes along with an occlued
right middle lobe by mucosal edema. Bronchoalveolar lavage was
performed and sent for culture. Antibiotic coverage was
temporarily broadend for nosocomial pneumonia. Cultures
eventually grew out MRSA and antibiotics were titrated
accordingly per ID recommendations. Over several days, his
oxygenation gradually improved. All chest tubes were eventually
removed without complication. Since the operation, he was noted
to have complete heart block and remained entirely pacer
dependent. The EP service was consulted and recommended
permananent pacemaker which was successfully placed on [**11-24**] without complication. He continued to make clinical
improvements and eventually transferred to the SDU for further
care and recovery. His renal function normalized, and he
continued to respond well to antibitioc therapy. Per ID
recommendation, he will need to remain on Levofloxacin until
[**2151-11-28**] and Vancomycin until [**2151-12-5**]. The remainder of his
postoperative course was uneventful and he was medically cleared
for discharge on postoperative day 8.
Medications on Admission:
Omeprazole 40 [**Hospital1 **], Atorvastatin 40 qd, Zyrtec 10 qd, Klor con 20
qd, Lasix 120 qam, Lorazepam 2 [**Hospital1 **], Ambien 12.5 qhs, Ceftriaxone
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
AV endocarditis(Strep viridans) and Aortic Insufficiency
Postoperative Complete Heart Block
Postoperative MRSA Pneumonia
Postoperative Pleural Effusions
Anemia
Acute Renal Insufficiency
Hypertension
Hyperlipidemia
Rectal Abscess
Discharge Condition:
Good.
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)Complete course on antbiotics as directed
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-19**] weeks(cardiologist) - call for appt
Dr. [**Last Name (STitle) 76675**] in [**12-19**] weeks(PCP) - call for appt
Dr. [**Last Name (STitle) **] in [**2-19**] weeks(cardiac surgeon)- call for appt
EP Device Clinic in 1 week - call for [**Telephone/Fax (1) 76676**]
Dr. [**First Name (STitle) 1075**] in Infectious Disease Clinic - call for appt. @
[**Telephone/Fax (1) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2151-11-27**]
|
[
"997.3",
"997.1",
"414.19",
"421.0",
"041.09",
"272.0",
"424.1",
"486",
"511.9",
"426.0",
"285.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"37.23",
"36.99",
"88.56",
"37.72",
"38.45",
"88.42",
"96.05",
"39.61",
"37.83",
"33.24",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
11032, 11084
|
7902, 10826
|
309, 544
|
11357, 11365
|
3105, 7246
|
11745, 12324
|
1682, 1865
|
7283, 7304
|
11105, 11336
|
10852, 11009
|
11389, 11722
|
1880, 3086
|
241, 271
|
7333, 7879
|
572, 1090
|
1112, 1445
|
1461, 1666
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,473
| 182,112
|
33755
|
Discharge summary
|
report
|
Admission Date: [**2101-1-27**] Discharge Date: [**2101-2-5**]
Date of Birth: [**2020-6-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
AVR (23 [**First Name8 (NamePattern2) **] [**Male First Name (un) **] porcine), CABG x2 (LIMA>LAD, SVG>RAMUS) [**1-27**]
History of Present Illness:
80 yo M with history significant for ischemic cardiomyopathy
with progressive dyspnea on exertion.Cath showed as with [**Location (un) 109**]
1.05 and 3VD. He was referred for surgery.
Past Medical History:
Ischemic cardiomyopathy, (EF 19%), COPD, AS, S/P gastric cancer,
renal insufficiency, Depression, Anemia, HTN, ED, BPH
Social History:
retired sheet metal worker
15 pack year history of tobacco, quit 25 years ago.
1 etoh per month
lives with spouse.
Family History:
NC
Physical Exam:
HR 69, RR 18 BP 112/76
NAD
Lungs CTAB anteriorly
Heart RRR 3/6 SEM->carotids
Abdomen Soft, NT/ND, well healed [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 924**] warm, no edema
Pertinent Results:
[**2101-2-5**] 07:55AM BLOOD
WBC-4.9 RBC-3.48* Hgb-10.2* Hct-30.0* MCV-86 MCH-29.4 MCHC-34.0
RDW-14.5 Plt Ct-190
[**2101-1-30**] 03:46AM BLOOD
PT-14.6* PTT-43.8* INR(PT)-1.3*
[**2101-2-4**] 06:00AM BLOOD
Plt Ct-173
[**2101-2-4**] 06:00AM BLOOD
Glucose-72 UreaN-25* Creat-1.1 Na-142 K-3.8 Cl-106 HCO3-28
AnGap-12
[**2101-2-2**] 7:16 AM
HISTORY: Status post CABG.
FINDINGS: In comparison with the study of [**2-1**], there is little
overall change. Substantial opacification is again seen at the
right base, consistent with persistent pleural effusion and
probable underlying atelectasis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Left Ventricle - Stroke Volume: 33 ml/beat
Left Ventricle - Cardiac Output: 2.45 L/min
Left Ventricle - Cardiac Index: *1.54 >= 2.0 L/min/M2
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *25 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 13 mm Hg
Aortic Valve - LVOT VTI: 13
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - E Wave: 0.8 m/sec
TR Gradient (+ RA = PASP): *28 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2101-1-21**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA. The IVC was not visualized.
The RA pressure could not be estimated.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderate regional LV systolic dysfunction. No LV mass/thrombus.
No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with conduction
abnormality/ventricular pacing. Prominent moderator
band/trabeculations are noted in the RV apex.
AORTA: Mildly dilated aortic sinus. Normal ascending aorta
diameter. Normal descending aorta diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views. Suboptimal image quality - poor suprasternal views. The
rhythm appears to be atrial fibrillation. Left pleural effusion.
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis and thinning and anterolateral
hypokinesis. The remaining segments contract normally (LVEF =
30-35 %). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. No aortic regurgitation is
seen. The mitral valve leaflets and supporting structures are
mildly thickened. Mild [1+] mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal functioning bioprosthetic aortic valve.
Regional left ventricular systolic dysfunction consistent with
coronary artery disease. Moderate tricuspid regurgitation.
Pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2101-1-21**],
the aortic valve has been replaced with a normal functioning
bioprosthetic valve. The regional wall motion abnormalities and
overall left ventricular systolic function appear similar.
Brief Hospital Course:
He was taken to the operating room on [**1-27**] where he underwent an
AVR/CABG. He was transferred to the ICU in critical but stable
condition on epi, neo and propofol. He was extubated later that
same day. His epi and neo were weaned to off over the next
several days. He was transfused. He had atrial fibrillation for
which he was started on amiodarone. No coumadi required. He was
transferred to the floor on POD # 6. All DChest tubes / PW and
foley were removed. There was no sequele noted. PT saw pt,
recommended rehab. Pt stable for rehab.
Medications on Admission:
Atenolol 50', Lisinopril 5', Prevacid 30', Levitra 20', Effexor
XR 150', Effexor 75', (effexor xr and reg d/t meds supplied by
pcp),
Wellbutrin XL 300', Iron 325', Tylenol prn, Hytrin 5', Vitamin C
1000', Vitamin B-12 500', Cranberry fruit tabs 475', Omega-3
Fish Oil'
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days. Tablet(s)
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: prn for pain.
6. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 3 months.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): TAPER ASA FOLLOWS:
400 BIDD X 7 DAYS
THEN
200 [**Hospital1 **] X 7 DAYS
THEN
200 QD THERE AFTER.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
15. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
AS/CAD s/p AVR/CABG
Ischemic cardiomyopathy, (EF 19%), COPD, S/P gastric cancer,
renal insufficiency, Depression, Anemia, HTN, ED, BPH
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 28436**] 2 weeks
Dr. [**Last Name (STitle) 4469**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2101-2-5**]
|
[
"V10.04",
"424.1",
"998.0",
"707.03",
"585.9",
"600.00",
"E878.2",
"403.90",
"496",
"414.01",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"35.21",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8313, 8410
|
5716, 6264
|
323, 446
|
8589, 8599
|
1184, 5693
|
8898, 9051
|
950, 954
|
6584, 8290
|
8431, 8568
|
6290, 6561
|
8623, 8875
|
969, 1165
|
280, 285
|
474, 660
|
682, 802
|
818, 934
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,221
| 140,153
|
10800
|
Discharge summary
|
report
|
Admission Date: [**2125-11-13**] Discharge Date: [**2125-11-20**]
Date of Birth: [**2072-2-23**] Sex: M
Service: MEDICINE
Allergies:
Tetanus & Diphtheria Tox,Adult / Lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Acute Kidney Injury
Fatigue
Worsening Dyspnea
Major Surgical or Invasive Procedure:
[**2125-11-13**]: Right heart catheterization
History of Present Illness:
Mr. [**Known lastname 21006**] is a 53 yo Hispanic/Latino gentleman, with a PMH
significant for non-ischemic CMP (diagnosed [**11/2124**], [**2-28**] severe
flu-like syndrome) last EF 25% in [**12/2124**], HTN, HLD, t2DM, and
obesity. He presents to [**Hospital1 18**] CCU on [**2125-11-13**] as a direct
admission from outpatient cardiologist, who noted a Cr of 4.0,
up from 2.9 recently (baseline is ~2.5), and recommended a
right/left heart catheterization w/ possible milrinone drip.
.
On interview, pt endorses recent worsening of PND, fatigue, and
loss of sex drive x 1 week, as well as decreased PO intake x 2
weeks. In addition, he reports mild, non-productive cough.
Otherwise, he denies recent illnesses, fevers, chills or rigors.
.
On review of systems, he specifically 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 exertional
buttock or calf pain. He denies SOB, chest pain, palpitations,
increased weight, increased swelling in legs. He describes
urination as normal in amount, color, and smell recently, with
no associated dysuria or incontinence. All other review of
systems are negative.
.
Cardiac review of systems is notable for absence of chest pain,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
At baseline, he is a chef, is up and about in the kitchen, and
bikes up to 5 miles daily (CHF NYHA class 1 in [**2125-8-27**]).
.
Of note, he is on Torsemide 100mg at home, which was decreased
from 160mg daily recently (over the summer), [**2-28**] worsening
creatinine.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: non-ischemic, idiopathic cardiomyopathy, EF
25% in 12/[**2124**]. Associated CHF was NYHA class 1 in 8/[**2125**].
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- non-ischemic cardiomyopathy, NYHA class 1 in [**2125-8-27**]
- Obesity
- Diabetes type 2
- Hypertension
- Hyperlipidemia
- Chronic kidney disease
Social History:
Works as a chef. Functional at baseline, able to work.
Bicycling up to 5 miles a day prior to 2 weeks ago. His main
hobby is automechanics and building cars.
- Tobacco history: nonsmoker
- ETOH: moderate alcohol intake
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Father died at age of early 60s from alcohol-related health
problems and diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=98.2 BP= 159/76 HR=64 RR=18 O2 sat= 94% ra
GENERAL: NAD.Obese. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace bilateral edema at ankles. Extremities warm
and well perfused.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAMINATION:
VS: 125-140s/70s HR 60-70s
GENERAL: obese, NAD, sitting upright, A+Ox3
HEENT: JVP at 6 cm
CHEST: CTAB
CV: RRR, no murmurs
ABD: obese abdomen, normoactive BSt; soft, non-tender,
non-distended,
EXT: 1+ pedal edema, DP and PT pulses [**1-28**]+ bilaterally.
NEURO: non-focal
Pertinent Results:
Admission labs:
[**2125-11-12**] 12:30PM BLOOD WBC-9.0 RBC-4.17* Hgb-12.6* Hct-37.5*
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.6 Plt Ct-365
[**2125-11-12**] 12:30PM BLOOD PT-12.5 INR(PT)-1.1
[**2125-11-12**] 12:30PM BLOOD UreaN-50* Creat-4.0*# Na-147* K-5.3*
Cl-107 HCO3-28 AnGap-17
[**2125-11-12**] 12:30PM BLOOD Mg-2.3
.
Pertinent labs:
[**2125-11-13**] 03:54PM BLOOD WBC-8.2 RBC-3.98* Hgb-11.7* Hct-35.5*
MCV-89 MCH-29.3 MCHC-32.9 RDW-14.3 Plt Ct-337
[**2125-11-13**] 06:57PM BLOOD Neuts-71.0* Lymphs-19.7 Monos-5.3 Eos-3.5
Baso-0.5
[**2125-11-13**] 06:57PM BLOOD ALT-16 AST-17 CK(CPK)-209 AlkPhos-132*
TotBili-0.2
[**2125-11-13**] 06:57PM BLOOD CK-MB-5 cTropnT-0.06* proBNP-7903*
[**2125-11-13**] 06:57PM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.8 Mg-2.1
[**2125-11-13**] 06:57PM BLOOD %HbA1c-8.1* eAG-186*
[**2125-11-13**] 06:57PM BLOOD Osmolal-310
[**2125-11-13**] 03:54PM BLOOD Digoxin-0.9
[**2125-11-13**] 06:57PM BLOOD Digoxin-0.8*
[**2125-11-13**] 06:58PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2125-11-13**] 06:58PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
.
Discharge labs:
[**2125-11-20**] 06:40 7.9 3.42* 9.9* 29.8* 87 28.8 33.0 13.8 336
[**2125-11-20**] 06:40 125*1 77* 4.7* 141 4.4 106 26 13
[**2125-11-19**] 05:57 186*1 79* 4.9* 140 4.4 105 25 14
[**2125-11-18**] 05:58 148*1 76* 5.1* 138 4.2 102 25 15
CHEMISTRY Calcium Phos Mg
[**2125-11-20**] 06:40 8.7 5.6* 2.6
[**2125-11-19**] 05:57 8.7 5.2* 2.7*
[**2125-11-18**] 05:58 8.4 5.0* 2.6
.
Right heart catheterization [**2125-11-13**]:
HEMODYNAMICS
RIGHT ATRIUM {a/v/m} 18/16/14
RIGHT VENTRICLE {s/ed} 70/18
PULMONARY ARTERY {s/d/m} 70/34/49
PULMONARY WEDGE {a/v/m} 34/40/29
**CARDIAC OUTPUT
O2 CONS. IND {ml/min/m2} 124
A-V O2 DIFFERENCE {ml/ltr} 65
CARD. OP/IND FICK {l/mn/m2} 4.3/1.9
**RESISTANCES
PULMONARY VASC. RESISTANCE 372
**% SATURATION DATA (NL)
SVC LOW 55
PA MAIN 55
AO 92
1. Hemodynamic measurements demonstrate the presence of severe
pulmonary artery hypertension and elevate pulmonary vascular
resistance. There was elevation of the wedge pressure consistent
with left ventricular failure. Right heart filling pressures
were moderately elevated consistent wiht right ventricular
failure
FINAL DIAGNOSIS:
1. Severe systolic and diastolic ventricular dysfunction.
2. Severe primary pulmonary hypertension.
.
Renal U/S w/ doppler to eval RAS, [**2125-11-14**]:
- Normal appearance to bilateral kidneys without evidence for
renal artery stenosis, stones, masses or hydronephrosis.
- Normal diastolic flow bilaterally
- Normal bladder
.
TTE [**2125-11-14**]:
- LA ?????? dilated
- LV ?????? mild, symmetric hypertrophy; mildly dilated ventricular
cavity (smaller than prior study in [**12/2124**]); unable to exclude
focal wall motion abnormality; mildly depressed systolic
function (LVEF= 50-55 %), though improved from prior study
(LVEF= 25% to 30%)
- Septum - no ventricular septal defect
- RV - chamber size and free wall motion are normal
- Aortic Valve - aortic valve leaflets are mildly thickened; no
aortic valve stenosis
- Mitral Valve - mitral valve leaflets are mildly thickened; no
mitral valve prolapse; trivial mitral regurgitation
- Other: very small pericardial effusion.
.
[**2125-11-15**] CHEST (PORTABLE AP): Frontal view of the chest was
obtained. A Swan-Ganz catheter terminates over the right
ventricular outflow tract. Mild-to-moderate cardiomegaly is
unchanged. Mediastinal, hilar, and pulmonary vessels are mildly
congested with mild pulmonary edema, new since [**2125-1-24**]. Left lower lobe appears similar to [**2125-1-24**]
radiograph with retrocardiac opacity compatible with left lower
lobe pneumonia and probable left pleural effusion that is
moderate and unchanged. No pneumothorax. IMPRESSION: Left lower
lobe probable pneumonia with probable moderate-sized left
pleural effusion, similar to findings on [**2125-1-24**]
radiograph. New mild pulmonary vascular congestion with mild
pulmonary edema.
Brief Hospital Course:
Mr. [**Known lastname 21006**] is a 53yoM with h/o non-ischemic CMP (diagnosed
[**11/2124**], occurred after a severe flu-like syndrome), HTN, HLD,
T2DM, and obesity. He was admitted to [**Hospital1 18**] CCU on [**2125-11-13**] as
a direct admission from outpatient cardiology, with concern for
Acute Kidney Injury (Cr 4.0<-2.9) in the setting of recent
fatigue and worsening PND.
.
BY PROBLEM:
# Non-Ischemic Cardiomyopathy, secondary to Hypertension and
non-ischemic post-viral cardiomyopathy (11/[**2124**]).
- On presentation, pt was found to be hypertensive and
euvolemic, with no overt clinical signs of fluid overload.
However, based on recent change in functional status, to include
NYHA class 3 symptoms, he underwent right cardiac
catheterization for diagnostic hemodynamic assessment. This was
significant for: severe pulmonary artery hypertension [PULMONARY
ARTERY {s/d/m} 70/34/49] and elevated pulmonary vascular
resistance [PULMONARY VASC. RESISTANCE 372], as well as elevated
PCWP [PULMONARY WEDGE {a/v/m} 34/40/29] consistent with
left-ventricular failure. As this was worrisome for severe
systolic and diastolic heart failure, invasive monitoring via
Swann-Ganz catheter was initiated, along with aggressive
afterload reduction.
- In the setting of acute kidney injury (Cr rise of 2.9 to 4.0),
Milrinone infusion was considered but not initiated, given pt's
adequate urine output and generally euvolemic fluid status.
- While monitored, pulmonary artery pressures were noted to
improve significantly with improved blood pressure control,
achieved with nitroglycerin infusion, isosorbide mononitrate and
hydralazine, in addition to outpatient carvedilol. As this was
atypical for a purely primary pulmonary artery hypertension,
therapy for hypertension was optimized (excluding the use of
ACE/[**Last Name (un) **] agents [**2-28**] renal failure), and pt follow-up was arranged
with previous cardiologist for further management.
- At the time of discharge, blood pressure readings had improved
to <140/90s, and pt was educated as to changes in medication
regimen, lifestyle modifications and necessary follow-up. The
patient's digoxin and [**Last Name (un) **] were held at discharge pending
improvement of his renal function, and his carvedilol was
reduced to 12.5 mg. His torsemide was also reduced to 20 mg.
.
# Acute on Chronic Kidney Disease, likely secondary to chronic
hypertension and uncontrolled diabetes mellitus.
- As noted, pt was admitted with a Creatinine elevation to 4.0
from 2.9 (baseline is ~2.5). On admission, medication
reconciliation included temporary discontinuation of outpatient
Torsemide and Losartan.
- While elevated creatinine was initially attributed to
pre-renal etiology, given systolic dysfunction noted on cardiac
catheterization, further evaluation via urinalysis and urine
electrolytes revealed a FEUrea of 42% and Protein/Creatinine
ratio of 10.0, consistent with intrinsic renal dysfunction and
nephrotic range proteinuria.
- Though noted retrospectively to be related to uncontrolled
hypertension and diabetes, a multifactorial etiology, to include
alternate infectious or systemic disease states, was not able to
be excluded with inpatient workup. Consultation with Nephrology
service was in agreement to widen differential given acute
nature of this presentation, and thus a work-up to include
SPEP/UPEP, fat pad vs. renal biopsy, renal ultrasound and
HIV/viral infections was undertaken. Renal ultrasound was
insignificant and described no clear renal artery stenosis or
diastolic flow dysfunction. Fat-pad biopsy, to investigate
presence of amyloidosis, was deferred to outpatient follow-up
with nephrology. Per nephrology recommendations, pt had renal
biopsy, and his results are still pending. He will follow up
with renal as an outpatient.
- At time of discharge, creatinine was noted to be trending down
(4.7 at discharge) , with improved blood pressure control and
consistently adequate urine output. The patient's digoxin, [**Last Name (un) **],
glipizide and metformin were all held and the patient was
started on calcium acetate because of elevated phosphate levels.
- Outpatient follow-up, to reassess workup results and
alternate/additional etiologies for chronic renal dysfunction,
was arranged.
.
# Hypertension, likely multifactorial, to include essential
hypertension and probable obstructive sleep apnea.
- As documented, pt had a history of hypertension on
presentation, and was noted to be hypertensive to >180/100s on
exam. This was thought inconsistent with catheterization results
suggesting systolic dysfunction. In the setting of acute kidney
injury, valsartan and torsemide were discontinued, and afterload
reduction via nitroglycerin was initiated on admission.
- As pulmonary artery pressures were noted to improve with
afterload reduction, hydralazine and isosorbide mononitrate were
added to outpatient carvedilol, and patient tolerated these
additions, as well as conversion to PO therapy, very well.
- The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] was stopped because of his kidney function
and he was started on Imdur and hydralazine. His carvediolol
was also decreased.
- At time of discharge, pt was noted to be stable on new
medications, and outpatient follow-up with sleep pathology was
arranged for sleep study. Pt will likely require CPAP therapy at
home.
.
# Diabetes, uncontrolled, on metformin and glipizide. Last HbA1C
was 6.8% in [**2125-5-27**], and when remeasured was 8.1. He was
managed on an insulin sliding scale while in-house and his home
medications were held. The patient was discharged off his
metformin and glipizide and started on Lantus daily. He was
education about SC injections.
.
# Hyperlipidemia: Documented history of this problem, for which
the patient was continued on his home Crestor.
- Aspirin 81mg was initiated, as pt has multiple risk factors
for Coronary Artery Disease.
.
# Moderate Left Pleural Effusion, since [**12/2124**]
- Pt asymptomatic as to this problem, but this did not resolve
with improved pulmonary vascular congestion, clinically. Will
refer to PCP for outpatient workup, with questionable future
diagnostic thoracentesis if no improvement.
.
TRANSITIONAL ISSUES:
1.) Will request repeat labs 3 days after discharge, to assess
improving renal function.
2.) As above, pt will require close management as to multiple
new medications and further follow-up. As the patient's renal
function improves, consider restarting some of the medications
that were discontinued.
3.) Left pleural effusion was not investigated while inpatient,
given asymptomatic status and persistent nature. However,
further investigation is advised, to include repeat imaging and
diagnostic thoracentesis if no improvement.
4.) Patient was noted to be apneic while lying flat. Recommend
sleep study as an outpatient to evaluate for OSA.
5.) The patient has a anti-GBM antibody, ANCA serologies are
still pending. The patient will follow these up at his next
renal appointment.
Medications on Admission:
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth daily
GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day
Increase when directed.
[**Last Name (un) **] STOCKINGS - - [**Last Name (un) **] compression stockings 30 -40mmg hg
fitted
LOSARTAN - 100 mg Tablet - 1 Tablet(s) by mouth once a day
METFORMIN [GLUCOPHAGE] - 500 mg Tablet - 1 Tablet(s) by mouth am
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
TORSEMIDE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - (On Hold from [**2125-1-16**] to unknown for hold until
seen by opthalmologist ) - 81 mg Tablet, Delayed Release (E.C.)
-
1 Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - use
for testing sugar twice a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH TEST] - Strip - use for
testing blood sugar twice a day
Discharge Medications:
1. Outpatient Lab Work
Please check chem-7 and CBC on Thursday [**2125-11-22**] with results to
Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 11616**], Phone: [**Telephone/Fax (1) 7976**]
Fax: [**Telephone/Fax (1) 13238**]
2. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: [**1-28**] units
Subcutaneous at bedtime.
Disp:*1 box* Refills:*2*
3. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
7. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*240 Capsule(s)* Refills:*2*
8. Insulin Pen Needle 31 X [**1-30**] Needle Sig: [**1-28**] needle
Miscellaneous twice a day.
Disp:*150 needles* Refills:*2*
9. lancets Misc Sig: One (1) unit Miscellaneous twice a day.
Disp:*150 units* Refills:*2*
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
- Idiopathic/Non-Ischemic Cardiomyopathy, secondary to
Hypertension and Post-Viral Cardiomyopathy
- Acute Renal Insufficiency
- Hypertension, Uncontrolled
Discharge Condition:
Medically stable. Renal function improving. No respiratory
distress. Improved cardiac function by echocardiogram.
Discharge Instructions:
Dear Mr. [**Known lastname 21006**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because of fluid
overload and kidney failure and was diuresed with medicines to
remove the extra fluid. Your kidney function initially worsened
but is now improving over the last 2 days. It is unclear why
your kidney function worsened and a team of nephrologists have
been following you. A biopsy was done on [**11-19**] to determine the
cause of the kidney failure. You can discuss the results of the
biopsy with Dr. [**Last Name (STitle) 11616**] next week and with the nephrologist, Dr.
[**Last Name (STitle) 4883**] at the end of [**Month (only) **]. In the meantime, we have
discontinued your diabetes pills and have started you on Lantus
at bedtime. Please check your blood sugars before breakfast and
dinner and call Dr. [**Last Name (STitle) 11616**] if your blood sugars are lower than
75 or higher than 300. YOu will meet with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] NP from
[**Hospital **] clinic to discuss next steps in treating your diabetes.
We have also scheduled an appt with a pulmonologist for a sleep
study to check you for sleep apnea.
Your heart function is much better now than it was but we still
want you to watch for fluid retention. Weigh yourself every
morning, call Dr. [**First Name (STitle) 437**] if weight goes up more than 3 lbs in 1
day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. STOP taking digoxin, glipizide, metformin and losartan
2. START Imdur and hydralazine to take the place of the losartan
until your kidneys improve
3. Decrease carvedilol to 12.5mg ([**1-28**] tab) twice daily
4. START calcium acetate to lower your phosphorus levels
5. DECREASE Torsemide to 20 mg daily instead of 100 mg
6. START Lantus insulin at bedtime, please check your blood
sugars twice daily and record.
7. Continue aspirin 81 mg daily
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2125-11-27**] at 3:30 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2125-11-30**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: WEST [**Hospital 2002**] CLINIC: Nephrology
When: MONDAY [**2125-12-24**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: MEDICAL SPECIALTIES: Pulmonary and sleep medicine
When: FRIDAY [**2125-11-23**] at 2:00 PM
With: DR [**Last Name (STitle) 2004**] / DR [**First Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], NP
Specialty: Endocrinology
When: Wednesday [**11-21**] at 11:30a
Location: [**Last Name (un) **] Diabetes Center
Address: [**Last Name (un) 3911**], [**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2384**]
You will see a nurse practitioner for this visit as well as a
diabetes educator. It is very important that you keep this
appointment.
Completed by:[**2125-11-20**]
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,707
| 124,305
|
5338
|
Discharge summary
|
report
|
Admission Date: [**2151-11-14**] Discharge Date: [**2151-11-17**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Sulfonamides / Gadolinium-Containing
Agents / Demerol / Morphine
Attending:[**First Name3 (LF) 21731**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
History per the ER record as the patient presents intubated with
no known family contacts. Ms. [**Known lastname **] is a 59yo woman wiht h/o
Mast Cell Degranulation Syndrome who presented today with
wheezing and stridor at home. She had no known trigger. She also
had abdominal pain epigastrically radiating to her back, which
is typical of her typical MCAS flares. She called her
gastroenterologist and was told to take her epi pen and take an
ambulance to the ER.
.
At home the patient used her epi pen once and came to the ER. In
the ER she was noted to have wheezes bilaterally and stridor. In
the ER the patient received benadryl 50mg iv x 1, albuterol neb,
pepcid 20mg iv x 1, dilaudid 2mg iv x 2, epinephrine 0.3mg sQ x
1 ,anzemet 12.5mg iv x 1, magnesium 2gm iv x 1, and due to
tiring she was intubated with etomidate and succinylcholine
peri-intubation. Although the patient had stated that she was a
difficult intubation, she was easily intubated on first attempt
in the ER with a size 7.0 ETT.
.
Notably on her last admission the patient was intubated for a
flare of her MCAS and required 2-3 days of intubation as well as
a prolonged steroid taper. She was believed to have associated
pancreatitis at that time.
.
ROS: unable to perform given pt sedated and intubated
Past Medical History:
- Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **]
who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by
Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice.
- Depression/anxiety/bipolar d/o, hx of SI
- MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
- HTN
- erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]. also
had shortening of villi.
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- Anemia, iron studies c/w AOCD
- Hemorrhoids
- pt reports recent EGD demonstrated vegetable bezoar (?[**12-7**]).
- Status post hysterectomy and oophorectomy
- h/o MRSA infection (porthacath associated)
- portacath placed [**3-8**] - d/c'd [**2-4**] MRSA infection
- portacath placed [**2151-6-9**]
Social History:
recently divorced. son and daughter in AZ & OH. No tobacco or
EtOH.
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
Exam on admission to the MICU:
afebrile HR 76 BP 100/55, RR 15, O2 100% on AC 500x15 FiO2 100%
PEEP 5
Gen: sedated, intubated. arousable, follows commands
HEENT: PERRLA, NCAT, OG and ETT tubes in place
Neck: no JVD, no LAD
Cor: s1s2, rrr, no r/g/m
Pulm: CTAB
Abd: obese, nontender, decreased BS, no organomegaly
Ext: no c/c/e, w/w/p, 2+ pt bilaterally
Skin: no rashes noted, bruising bilateral wrists/hands
.
Exam on transfer to the floor:
afebrile HR 90 BP 130/70 RR 20, O2 98% RA
Gen: patient sitting in bed, watching television
HEENT: PERRLA, NCAT, MMM slightly dry, OP clear
Neck: no JVD, no LAD
Cor: nl rate, S1S2, no gmr
Pulm: faint inspiratory wheezes throughout lung fields
Abd: soft, nontender, decreased BS, no organomegaly
Ext: no c/c/e, w/w/p, 2+ pt, 2+ dp bilaterally
Skin: no rashes noted, bruising bilateral wrists/hands [**2-4**]
venipunctures
Access: R portacath
Pertinent Results:
Admission labs:
[**2151-11-14**] 10:00PM BLOOD WBC-5.6 RBC-4.13* Hgb-12.6 Hct-35.9*
MCV-87 MCH-30.5 MCHC-35.1* RDW-13.5 Plt Ct-210
[**2151-11-14**] 10:00PM BLOOD Neuts-58 Bands-0 Lymphs-22 Monos-9
Eos-10* Baso-0 Atyps-0 Metas-1* Myelos-0
[**2151-11-14**] 10:00PM BLOOD PT-11.5 PTT-26.0 INR(PT)-1.0
[**2151-11-14**] 10:00PM BLOOD Glucose-183* UreaN-12 Creat-0.9 Na-141
K-3.4 Cl-108 HCO3-24 AnGap-12
[**2151-11-14**] 10:00PM BLOOD ALT-17 AST-18 CK(CPK)-79 AlkPhos-79
Amylase-40 TotBili-0.1
[**2151-11-14**] 10:00PM BLOOD Lipase-27
[**2151-11-14**] 10:00PM BLOOD cTropnT-<0.01
[**2151-11-15**] 04:29AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.6 Iron-22*
[**2151-11-15**] 04:29AM BLOOD calTIBC-207* Ferritn-26 TRF-159*
.
CXR [**2151-11-14**]:
There is a right-sided Port-A-Cath device terminating near the
cavoatrial junction. A calcified left hilar lymph node is
noted. There is interval improvement in the previously
demonstrated patchy opacity in the left lower lobe with possible
minimal residual opacity. There is no evidence of pneumothorax.
The cardiac and mediastinal contours are stable.
.
CXR [**2151-11-15**]:
ET tube is identified with its tip approximately 4.8 cm from the
carina. Right-sided central venous catheter is unchanged in
position and
appropriate. NG tube is identified with its side port within
the stomach,
however, the tip is below the borders of this film.
Cardiomediastinal
silhouette is unchanged. Calcified left hilar lymph node is
again seen.
Lungs appear clear and no pleural effusion is identified. No
pneumothorax is seen.
Brief Hospital Course:
A/P: 59yo woman with h/o Mast Cell Activation Syndrome presents
with symtpomsm suggestive of her typical flares (wheeze,
stridor, abd pain) and was intubated secondary to tiring in the
ER despite good ABG.
.
1. Mast Cell Activating Syndrome: On presentation the patient
reported abdominal pain which was located in the epigastric/RUQ
region, which radiated to her back. The patient also had
associated wheezing and stridor. All of these symptoms are
typical of her mast cell flares. The ER followed the patient's
usual protocol for anaphylaxis, which she brought with her to
the hospital. This included IV dilaudid, epinephrine, IV
solumedrol and IV benadryl. She was intubated due to tiring,
which is her third intubation for anaphylaxis. The trigger of
her mast cell degranulation flair was unknown. Amylase and
lipase were sent given location of abdominal pain and were
normal. In the ICU the patient was continued on gastrocrom,
zantac, and PPI and she was started on benadryl IV q6h and
solumedrol 125mg IV q8h. Her fexofenadine and atarax were
initially held. Dr. [**Last Name (STitle) 79**] who follows her as an outpatient was
contact[**Name (NI) **] to provided treatment recommendations. The patient's
steroids were quickly tapered from 125mg q8h to 80mg q8h. The
patient was extubated sucessfully and was transferred to the
floor. She was restarted on her remaining home meds. Her pain
was controlled with a standing order of dilaudid 0.5-2mg q3H IV
(per Dr.[**Name (NI) 18707**] recommendation).
.
On the floor the patient remained stable, however she did have
two episodes of "degranulation" that presented with a series of
symptoms starting with worsening abdominal pain, diffuse
itching, followed by wheezing. A trigger was called on the
floor during the first episode. Her pain and breathing
difficulties resolved following her protocol with epinephrine
SC, benadryl IV, solumedrol IV and stacked albuterol nebs. The
patient's O2 sats remained stable throughout. Following two days
on the floor the patient was feeling much better. Her
medications were switched to PO with prednisone taper. The
patient's abdominal pain and wheezing significantly improved.
She will complete a 12 day steroid taper and was discharged home
on percocet for her pain. She will follow up with Dr. [**Last Name (STitle) 79**] and
with pain clinic to manage her chronic pain.
.
2. HTN: continued patient's cardizem CD with holding parameters.
.
3. Hyperglycemia: Given the high dose steroids the patient was
put on an insulin slide scale.
.
4. depression/anxiety/bipolar: continued outpatient cymbalta and
seroquel. Adderal was initially held given patient was sedated
on ventilator but this was restarted once extubated.
.
5. osteoarthritis: continued outpatient plaquenil
Medications on Admission:
gastrocrom 300mg qid
cardizem CD 120mg po qday
atarax 25mg po bid
zantac 300mg po daily
seroquel 200mg po qhs
cymbalta 60mg po qhs
plaquenil 200mg po bid
adderal 15mg po qday
fexofenadine 180mg po bid
omeprazole 20mg po bid
ambien 10mg po prn
zofran 8mg po prn
dilaudid 2mg po prn
percocet 5/325 po prn
klonopin 0/5mg po prn
fioricet prn
Discharge Medications:
1. Cromolyn 100 mg/5 mL Solution Sig: Three Hundred (300) mg PO
every six (6) hours.
2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: Three (3)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. Cardizem CD 120 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
4. Ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO q8h () as
needed for nausea.
5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO HS (at bedtime).
7. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Amphetamine-Dextroamphetamine 5 mg Capsule, Sust. Release
24HR Sig: Three (3) Capsule, Sust. Release 24HR PO daily ().
9. Ranitidine HCl 15 mg/mL Syrup Sig: Three Hundred (300) mg PO
once a day.
10. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 15 days.
Disp:*60 Tablet(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: per instructions Tablet PO once
a day for per instructions days: please take 6 pills (60mg) for
three days, then take 4 pills (40mg) for 3 days, then take 2
pills (20mg) for 3 days, then take 1 pill (10mg) for 3 days.
Disp:*40 Tablet(s)* Refills:*0*
14. Fioricet [**Medical Record Number 3668**] mg Tablet Sig: One (1) Tablet PO every
4-6 hours.
15. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
mast cell degranulation syndrome
respiratory distress
abdominal pain
.
Secondary:
Depression/anxiety
gastroesophageal reflux disease
hypertension
Discharge Condition:
Afebrile. Ambulating. Tolerating PO. Abdominal pain and
breathing improved.
Discharge Instructions:
Please contact your allergist or gastroenterologist if you have
worsening shortness of [**Medical Record Number 1440**], chest pain, or abdominal pain.
Please return to the ED if you experience signifcant worsening
pain or breathing.
.
Please continue to take your medications as prescribed.
.
You will need to complete a course of Prednisone for your recent
flare. Please continue to take this medication as prescribed.
Followup Instructions:
Please call your Gastroenterologist Dr. [**Last Name (STitle) 79**] at [**Telephone/Fax (1) 1954**] the
morning after discharge to schedule a follow up appointment.
.
You also have an appointment scheduled for [**2151-12-15**] at 1:20pm
with Dr. [**Last Name (STitle) 79**].
.
Please follow up in pain clinic for management of your chronic
pain.
|
[
"285.29",
"279.8",
"300.4",
"577.1",
"530.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10107, 10113
|
5293, 8073
|
357, 370
|
10312, 10390
|
3712, 3712
|
10861, 11210
|
2721, 2796
|
8462, 10084
|
10134, 10291
|
8099, 8439
|
10414, 10838
|
2811, 3693
|
314, 319
|
398, 1681
|
3728, 5270
|
1703, 2619
|
2635, 2705
|
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