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28,245
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49110
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Discharge summary
|
report
|
Admission Date: [**2104-6-11**] Discharge Date: [**2104-6-26**]
Date of Birth: [**2021-7-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Intubation [**2104-6-11**]. Extubation [**6-20**].
PICC placed in IR [**6-19**].
EGD [**2104-6-13**]
History of Present Illness:
HPI: 82 year old male MMP including HTN, past strokes, dementia,
dysphagia and diffuse pain syndrome who presents with
respiratory distress in the setting of vomiting. Per nursing
report at [**Hospital 100**] Rehab at 5:30pm the patient had a small amount
of coffee ground emesis, and oxygenation saturation dropped to
87%. He was placed on oxygen and his saturations did not
respond. Other vitals at that time BP 160/100, P 92, RR: 30,
Temp: 98.6. EMS was called. EMS found the patient tachypneic in
the 40s and intubated his for respiratory distress with nasal
tube. The patient was transported to [**Hospital1 18**] where he was found to
have BP 105/66, RR: 20, P: 86, Temp (rectal) 99.0, O2 sat 100%
FiO2 60%, PEEP 5, CMV, with versed bolus for sedation. Patient
NG tube revealed hemocult positive material. CXR showed
bilateral lower lobe infiltrates consistent with aspiration.
Patient was given 40 mg protonix IV and a versed bolus. The
patient was noted to have a hematocrit of 48.8. He was
transfered to the MICU for further monitoring and care.
.
Per [**Hospital **] rehab, at baseline the patient is alert and
conversive but not ambulatory. He is incontinent of bowel and
bladder and dependent in all of his adls. Per his wife he ate a
very large lunch and soon afterwards began to spit up small
amounts of material into a tissue.
.
Past Medical History:
PMH (per [**Hospital 100**] Rehab):
Dysphagia
Urge Incontinence
Right thalamic bleed
Right eye blind, s/p stroke
B/L cataracts
Depression
Hypertension
Dementia, vascular
Gait d/o
BPH
Osteoarthritis
h/o GI bleed from NSAID
COPD
Sigmoid Diverticulitis
Hiatal Hernia
Stable pulmonary nodule
CKD (Cr 1-1.2)
Diffuse Pain Syndrome
s/p AAA repair
.
Social History:
PSocH: married to wife, [**Name (NI) **]. Lived for past 3 years at [**Hospital 100**]
Rehab. Prior tobacco. No current alcohol, tobacco. No illicits.
.
Family History:
NC
Physical Exam:
Physical Exam:
temp 99.8, HR 90, BP 132/103, RR: 25, spO2 AC 13/5, FiO2 50% TV
500 97%
gen: agitated
heent: perrl, ntg suctioning vomit
cv: rrr no m/r/g
pulm: rales at bilateral bases otherwiase CTA
abd: soft, mild grimace to epigastric palpation, mild
distension, normoactive bowel sounds
ext: no c/c/e
neuro: follows commands to open eyes and squeeze hands, unable
to follow commands regarding moving legs. Withdraws to pain.
.
Pertinent Results:
[**2104-6-12**] ECG: Sinus tachycardia at 100, nl axis, nl intervals.
non specific scooped ST/T waves changes in V2, V3.
Repeat ECG: sinus, HR 84, nl axis, nl intervals, good rwave
progression, resolution of non-specific ST/T wave changes
.
Labs:
149 | [**Age over 90 **] |19 / 158 AGap=14
--------------\
4.0 | 37 | 1.0
Ca: 9.8 Mg: 2.2 P: 3.3
ALT: 18 AP: 92 Tbili: 0.5 Alb: 3.9
[**Doctor First Name **]: 147 Lip: 61 AST: 17
PT: 13.9 PTT: 28.4 INR: 1.2
91
7.9 \15.7/ 150
/46.8\
N:90.6 L:5.8 M:3.6 E:0 Bas:0
Initial Labs from ED:
Na:146
K:3.8
Cl:94
TCO2:39
BUN: 19
Cr 1.0
Glu:164
.
Lactate:2.2
[**Doctor First Name **]: 141
PT: 14.4 PTT: 30.4 INR: 1.3
Fibrinogen: 468
89
8.5 \16.5/ 184
/48.8\
UA: SpecGr 1.015, Leuk Neg, Nitr Neg, Prot 30, Glu Neg, Ket Neg
RBC 0, WBC <1, Bact Rare, Yeast None, Epi <1
.
Studies
[**2104-6-12**] CXR: b/l lower lobe dense consolidation suggestive of
aspiration
.
CXR [**6-23**] In comparison with the study of [**6-22**], the degree of
pulmonary
vascular congestion radiographically has somewhat decreased.
Areas of
increased opacification are again seen bilaterally that could
reflect pleural effusion. The cardiomediastinal silhouette is in
the midline, so that there is no evidence of substantial volume
loss in the left hemithorax.
Brief Hospital Course:
Pt is an 82 year old male w/ CAD, HTN, vascular disease, chronic
dysphagia 2' hiatal hernia, and dementia who presents from rehab
after an episode of vomiting and aspiration.
.
# Respiratory Failure: Was intubated [**6-11**] w/ hypoxic respiratory
distress and pleural effusions. Pt was diagnosed with an
aspiration PNA w/ Klebsiella growing in sputum cx's on [**6-12**],
that were pan-sensitive and treated w/ ceftriaxone (10 day
course completed [**6-26**]). His aspiration is likely [**1-5**] his large,
chronic hiatal hernia. He was previously covered emperically for
vanc/zosyn/cipro until his speciations returned. He also had
bilateral dense infilatrates on chest x-ray c/w aspiration PNA
and pleural effusions, which did not need to be tapped. He also
has episodes of apnea attributed to dementia vs sedating meds
(morphine, fentanyl, ativan). He was extubated on 7.18, and his
ABG remained appropriate. Pt was continued on NC on the floor
and at discharge has O2 Sat 96% on 2L NC. His sputum returned +
for MRSA colonization on 7.21, and he was placed on precautions.
He was OOB and given chest PT. He was diuresed w/ Lasix as
needed but on discharge is off lasix.
.
# Hiatal Hernia: No actively bleeding vessels were seen on upper
endoscopy, so there was less concern for [**Doctor First Name **]-[**Doctor Last Name **] tears 2'
to vomiting. PO access was difficult to obtain on this patient,
as he failed his first S&S test, and was not a candidate for
open J-tube or endoscopic Dobhoff placement by GI due to his
MMPs and hiatal hernias, respectively. He was started on TPN for
~3 days ending [**6-24**]. He passed S&S test on 7.21, and his PO meds
were restarted and his diet was advanced as tolerated. See
discharge instructions for precautions for feeding.
.
# Hypernatremia: Patient was hypernatremic w/ Na up to 148 and a
FWD 2.2. Likely multifactorial etiologies (diuresis induced, 2'
to TPN, and decreased PO free water intake, hypercalcemic, =>
blocking ADH at the level of the collecting tubules, leading to
a DI-like diuresis). He was treated w/ D5W maintenance, and Na
was checked daily. He was encouraged to take water PO and
transition off of TPN. His TPN levels of Na and Calcium
gluconate were also reduced. At time of discharge, pt is off TPN
and lasix, taking PO and has a Na of 144 which has been normal
for 4 days.
.
# Hypercalcemia: Calcium was elevated to 10.5, free calc to
1.44. Likely related to immobilization vs. possible low
phosphate 2' to refeeding syndrome. Ionized calcium 1.44,
decreased to 1.39 ([**6-23**]) w/ PO4 repletion. Pt not symptomatic
(has dementia and poor stooling at baseline), no
bisphosphonates. PTH and AP WNL, unlikely malignancy or primary
hyperthyroidism. Can also occur w/ hypothyroidsm. Ca at
discharge is 10.8. Consider checking TSH as outpt. Pt will need
Ca levels followed up at [**Hospital1 1501**] and also should consider IVF there
for treatment of hypercalcemia.
.
# Elevated INR: Had an INR up to 2.4 this admission, likely 2'
to vitamin K deficiency, not on coumadin. He was given vit K IV
x1, and his INR resolved to 1.2 where it remained until
discharge.
.
# Dementia: Donepezil was held until patient passed S&S, then
he was restarted on home dose of donepezil PO.
.
# Hypotension: No acute bleeds noted on endoscopy, hct stable
between 32-35. He was initially re-started on Metoprolol IV, and
the rest of his antihypertensives were held (lisinopril). He had
an episode of low BPs to 80s o/n on 7.21, and his
antihypertensives were held thereafter. At discharge, pt off
lasix, lisinopril and metoprolol with BP 154/90.
.
# Dysphagia: passed S&S. Discharged on pureed food and nectar
thick liquids.
.
# Pain: Has chronic back pain. Was given morphine PRN for back
pain but this was d/c'd with concerns for possibility of
altering mental status. Discharged on PRN tylenol.
.
# + blood cx's: Patient had Blood cx's from [**6-12**] positive for
GPCs/GNRs (Corynebacterium/Propionibacterium). Patient did not
exhibit a septic picture (low grade temps o/n, BPs stable, no
pressors) and his most recent lines were placed on [**6-12**].
Surveillance cx's were NGTD. Deemed a contaminent, not treated.
.
# FEN: Initially NPO, then transitioned to TPN. Passed S&S on
7.21 => advanced diet as tolerated. Electrolytes were repleted
as neccessary.
Watched phosphate closely for refeeding syndrome.
.
# Access: PIV at discharge
.
# Code: Confirmed FULL while in Hospital. However, after
discussions with pt's dtr and wife on [**6-25**] with Dr. [**Last Name (STitle) **],
family decided to make pt DNR, [**Name (NI) 835**], DNH at [**Hospital1 100**] Home. The
family would also like a palliative care consult there. The pt
is discharged to [**Hospital1 1501**] where he is DNR, DNI, DNH.
Medications on Admission:
MEDICATIONS (per [**Hospital 100**] Rehab):
Furosemide 40mg daily
Lisinopril 40 mg daily
Metoprolol XL 200mg daily
Tylenol 650 mg [**Hospital1 **]
Docusate 250mg QAM
Donepezil 10mg daily
Mirtazapine 15mg qhs
Glucosamine 500 mg daily
Loratadine 10 mg daily
MVI daily
Ocuvite daily
Metamucil teaspoonful qhs
Senna 2 tabs bedtime
Sodium Fluoride 10ml swish and swallow daily
Sorbitol 15mg daily
Prune Juice 4 ounces daily
C.I.B. Plus 240ml daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO twice a day.
2. Docusate Sodium 250 mg Capsule Sig: One (1) Capsule PO qam.
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Glucosamine 500 mg Tablet Sig: One (1) Tablet PO once a day.
5. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Ocuvite 100-15-2-100 mg-unit-mg-mg Capsule Sig: One (1)
Capsule PO once a day.
8. Psyllium 3.4 g/5.8 g Powder Sig: One (1) tsp PO once a day:
mix in 8oz liquid.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed: hold for loose stools.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as
needed.
12. Maalox Plus Extra Strength 400-400-40 mg/5 mL Suspension
Sig: Thirty (30) ml PO Q4 hrs as needed for indigestion.
13. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ml PO every four
(4) hours as needed for cough.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary diagnosis:
Aspiration pneumonia with respiratory failure
Secondary diagnoses:
Dementia
hiatal hernia
hypernatremia
COPD
HTN
CKD
Discharge Condition:
Fair. O2 sat 96% on 2L NC
Discharge Instructions:
You were admitted with shortness of breath after you vomitted.
This required you to be intubated and you had a stay in our ICU.
At the time of discharge, you are doing well on oxygen by nasal
cannula. While you were here, you were also treated for
pneumonia. You finished a course of antibiotics while here.
You are being transferred back to [**Hospital1 100**] home off antibiotics
and on all your previous medications except those that might
sedate you.
Please call your doctor or return to the ED if you have
increasing shortness of breath, difficulty breathing, vomitting,
fever, chills, diarrhea, or any other concerning symptoms.
Followup Instructions:
Please follow up with your doctor [**First Name (Titles) **] [**Last Name (Titles) 100**] Home within one
week.
Completed by:[**2104-6-26**]
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|
2182, 2336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,708
| 197,576
|
30034
|
Discharge summary
|
report
|
Admission Date: [**2192-3-17**] Discharge Date: [**2192-4-5**]
Date of Birth: [**2136-10-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
blown pupil
Major Surgical or Invasive Procedure:
Right craniectomy and evacuation SDH
History of Present Illness:
HPI:56M reportedly fell last night in yard after EToH, crawled
into house and spent part night on floor. This morning not
arousable. Went to [**Hospital1 498**], found to have large R SDH with shift
and herniation. Right pupil fixed and dilated. On coumadin for
St. Jude's valve. intubated, given FFP and vitamin K and
medflighted here. ? of tremor vs seizure activity enroute -
stopped with ativan.
Past Medical History:
PMHx:[**Hospital3 **] valve
All:unknown
Social History:
Social Hx:unknown
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, intubated, in hard collar
HEENT: Pupils: R 6mm fixed and dilated, L 3.5mm nonreactive
Neck: Hard collar
Extrem: Warm and well-perfused.
Neuro:intubated, tremors
no movement UEs, triple flexion bilat [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 71649**] upgoing bilaterally
Pertinent Results:
CT:
large right SDH approx 8-9mm along convexity with shift and
herniation
[**2192-3-17**] 04:00PM WBC-16.0* RBC-4.06* HGB-12.2* HCT-35.9*
MCV-88 MCH-30.0 MCHC-34.0 RDW-16.1*
[**2192-3-17**] 04:00PM PLT COUNT-172
[**2192-3-17**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2192-3-17**] 04:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2192-3-17**] 04:00PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2192-3-17**] 04:59PM PT-14.4* PTT-21.6* INR(PT)-1.3*
[**2192-3-17**] 04:00PM UREA N-12 CREAT-0.8
[**2192-3-17**] 04:59PM FIBRINOGE-286
Brief Hospital Course:
Pt was evaluated in the ED and brought emergently to the OR
where under general anesthesia a right craniectomy with
evacuation of subdural hematoma was performed. Pt tolerated
this procedure and was transferred to the TICU for close
monitoring. Post op CT scan showed improvement. He began
leaking CSF from his head, the head was oversewn and was
reddened he was started on triple antibiotics. After a 10 day
course of antibiotics they were stopped with the exception of a
vancomycin for staph in his urine culture which grew out staph
on [**4-2**] we were planning a full days of Vanco for that
infection. He did have staph also grow out of his sputum.
He had a lumbar drain placed for approximately 5 days which
stopped further drainage from his head wound. His sutures were
removed and the redness in the wound decreased on daily basis he
has slight erythema but it is greatly improved.
There were focal seizures during early hospitalisation. The
patient was treated with dilantin and transitioned to
levetiracetam he has no further seizures.
Peg and trach were placed on [**2192-3-25**]. Discharge from the PEG
site has been noted but no erthyema was noted, our surgical team
was consulted and they felt it was normal drainage and they
would only become concerned if it developed erythema.
The patient was covered with heparin for drain removal and
coumadin restarted for anticoagulation in view of [**Hospital3 **]
valve. His goal INR is 2.5 he is being bridged from Heparin to
Coumadin. On [**4-5**] his last INR was 1.2 He had a PICC line
placed for Heparin and IV Vancomycin on [**4-4**].
He was transferred to the floor on [**2192-4-2**]. The patient was
reviewed by PT and OT. He has been interactive with staff
following intermittent commands, spontaneously moving right side
very briskly/sponteously. He does move the left side with some
weakness 3-4 in both arm and leg. He appears more
responsive/engaging with family
On discharge he was started on a bladder clamping/training
program.
The patient had a craniectomy and must wear helmut whenever out
of bed.
Medications on Admission:
Medications prior to admission:coumadin, asa,
[**Last Name (LF) 17339**],[**First Name3 (LF) 130**],zantac
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: [**11-29**] PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: [**11-29**] 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.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-8 Puffs
Inhalation Q4H (every 4 hours) as needed for when on vent.
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
9. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED).
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Right SDH
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
- Watch for drainage out of head wound
- Slight drainage noted from g-tube our surgery service feels it
is normal drainage and would not be worried unless it becomes
cellulitic looking
*****Must wear helmut at all times when out of
bed***************
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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 4 weeks with head CT call
[**Telephone/Fax (1) 3231**] for an appointment
Completed by:[**2192-4-5**]
|
[
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"780.39",
"251.8",
"E888.9",
"482.41",
"041.5",
"997.09",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"43.11",
"38.93",
"96.72",
"31.1",
"86.59",
"96.6",
"01.31",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5677, 5747
|
1968, 4059
|
331, 369
|
5801, 5825
|
1281, 1945
|
7463, 7614
|
917, 934
|
4216, 5654
|
5768, 5780
|
4085, 4085
|
5849, 7440
|
964, 1262
|
4116, 4193
|
280, 293
|
397, 800
|
822, 865
|
881, 901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,841
| 178,533
|
50896
|
Discharge summary
|
report
|
Admission Date: [**2200-9-24**] Discharge Date: [**2200-9-30**]
Date of Birth: [**2119-7-19**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Mechanical fall presenting with headache, confusion and
progressively worsening conscious level
Major Surgical or Invasive Procedure:
Endotracheal Intubation [**2200-9-24**]
History of Present Illness:
This is an 81 year old woman with complicated PMH who presented
following a
mechanical fall at her home sustaining a head injury. She was
then seen in [**Location (un) 620**] where a head CT showed a small right
frontal ICH with minimal edema and
no shift. She also has a comminuted right clavicular fracture.
On initial assessment by ED resident finishing at roughly 11:20
she was noted to have a non-focal exam but wsa confused A+Ox3
but was hypertesnsive with SBP 179. INR was noted to be 3.4.
By the time of my review perhaps 10 minutes after this she was
not verbalising at all, would intermittently obey commands and
would intermittently nod or shake head in response to
questioning and intermittently open eyes. She seemed to have
good limb power and there was pupillary asymmetry R>L. Given her
acute mental status changes, she was intubated in the ED and
warfarin was
reversed with PT concentrate and FFP and repeat CT scan showed
considerable worsening in her ICH with midline shift and almost
complete obliteration of the right lateral ventricle.
She was admitted to the ICU
Past Medical History:
PAST MEDICAL HISTORY:
1. Atrial fibrillation (diagnosed in [**2179**], changed from
dabigatran to warfarin)
2. Aortic stenosis (s/p bioprosthetic AVR and resection of LAA,
[**2200-5-28**])
3. Tachy-brady syndrome (s/p ablation of atrial tachycardia and
single-chamber pacemaker implant ([**Company 1543**] Sigma) in [**2-/2191**])
4. Hypertension
5. Hyperlipidemia
6. Hypothyroidism
7. Vascular disease including right carotid stenosis and left
subclavian stenosis
8. Right cerebellar embolic stroke in [**7-/2190**] (no residual
deficits)
9. Diverticulitis
10. Colon Cancer s/p partial colectomy (roughly 15 yrs ago)
11. Multiple small bowel obstructions
.
PAST SURGICAL HISTORY:
1. s/p Aortic valve replacement (aortic valve bioprosthesis),
removal of left atrial appendage
2. s/p Right shoulder arthroscopic subacromial decompression,
debridement ([**2199-2-20**])
3. s/p Laparoscopic cholecystectomy ([**2192-9-14**])
4. s/p Right shoulder subacromial decompression ([**2189-1-14**])
5. s/p Ex-lap, LOA, reanastomosis of proximal sigmoid colostomy
to the rectum ([**2184-1-6**])
6. Fistulotomy and anal sphincteroplasty ([**2182-2-18**])
Social History:
Lives alone in senior housing, remains active. Denies tobacco or
alcohol use; no recreational substance use. Using a walker.
Family History:
Father died of cancer at 60; Mother died at 83 with diabetes and
gangrene. Sisters and brother with emphysema brother died of
renal failure
Physical Exam:
Upon Admission:
O: T: 98.1 BP: 179/86 HR: 68 R 18 O2Sats 100% RA
Gen: Not opening eyes generally. Resisting eye opening. No
verbalising and not making noises. At times appropriately
nodding/shaking head to questioning.
HEENT: Pupils: R 4->3 mm L 3->2.5mm
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: AF on monitor irreg irreg. Normal S1/S2 with soft SM in
aortic area.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Drowsy, not opening eyes (but resisting eye
openning), no verbalising but shaking/nodding head in response
to
commands. Orientation: Unable to assess
Recall: Unable to assess
Language: No noises or verbalising
Cranial Nerves:
I: Not tested
II: Anisocoria R larger than L. R 4->3 mm L 3->2.5mm. Both
reactive to light but somewhat sluggish.
Unable to assess fields.
III, IV, VI: Roving eye movements when forecfully open eyes
aganst resistance with gaze deviation to left.
V, VII: Face symmetric.
VIII: Unabel to assess as not responding to commands
IX, X: Not lifting palate or vocalising but present gag.
[**Doctor First Name 81**]: Unable to assess
XII: Tongue midline but will not protrude to command.
Limb exam:
Forcefully resisting throughout but ? normal tone.
Motor:
Forcefully resisting and not obeying commands but seems
symmetric
with good power ? slightly reduced on left but questionable.
Sensation: Localisies to noxious in all 4 limbs.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 3
Technically difficult as forecfully resisting but 4 beats of
clonus on left.
Plantar reflexes extensor bilaterally
Cerebellar: Unable to assess. Roving eye movements and no clear
nystagmus.
At Discharge:
Deceased
Time of death 0900 [**2200-9-30**]
Pertinent Results:
Laboratory investigations:
Admission labs:
[**2200-9-24**] 11:25AM BLOOD WBC-8.3 RBC-4.01* Hgb-10.7* Hct-34.0*
MCV-85 MCH-26.6* MCHC-31.5 RDW-15.0 Plt Ct-296
[**2200-9-24**] 11:25AM BLOOD Neuts-81.5* Lymphs-14.5* Monos-2.8
Eos-0.8 Baso-0.4
[**2200-9-24**] 11:25AM BLOOD PT-34.0* PTT-32.7 INR(PT)-3.4*
[**2200-9-24**] 11:25AM BLOOD Glucose-115* UreaN-20 Creat-0.7 Na-138
K-3.6 Cl-104 HCO3-21* AnGap-17
[**2200-9-25**] 01:15AM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.8 Mg-2.0
[**2200-9-25**] 01:15AM BLOOD ALT-18 AST-32 AlkPhos-75 TotBili-0.9
.
INR trend:
[**2200-9-24**] 11:25AM BLOOD PT-34.0* PTT-32.7 INR(PT)-3.4*
[**2200-9-25**] 01:15AM BLOOD PT-13.6* PTT-28.9 INR(PT)-1.2*
[**2200-9-26**] 01:38AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1
[**2200-9-27**] 02:04AM BLOOD PT-12.8 PTT-25.6 INR(PT)-1.1
[**2200-9-28**] 01:52AM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2*
.
Final labs:
[**2200-9-28**] 01:52AM BLOOD WBC-4.9 RBC-3.59* Hgb-9.6* Hct-30.2*
MCV-84 MCH-26.7* MCHC-31.7 RDW-15.3 Plt Ct-225
[**2200-9-28**] 01:52AM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2*
[**2200-9-28**] 01:52AM BLOOD Glucose-146* UreaN-19 Creat-0.5 Na-136
K-4.7 Cl-103 HCO3-27 AnGap-11
[**2200-9-28**] 01:52AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.0
[**2200-9-26**] 01:38AM BLOOD Phenyto-16.0
.
.
Urine:
[**2200-9-24**] 12:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2200-9-24**] 12:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
[**2200-9-24**] 12:45PM URINE RBC-1 WBC-34* Bacteri-NONE Yeast-NONE
Epi-1
[**2200-9-24**] 12:45PM URINE Mucous-RARE
.
.
Microbiology:
[**2200-9-24**] 12:45 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2200-9-25**]**
URINE CULTURE (Final [**2200-9-25**]): NO GROWTH.
.
[**2200-9-24**] 3:45 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2200-9-27**]**
MRSA SCREEN (Final [**2200-9-27**]): No MRSA isolated.
.
.
Radiology:
CHEST (PORTABLE AP) Study Date of [**2200-9-24**] 11:59 AM
IMPRESSION: No acute intrathoracic process. NG and endotrachial
tubes are
adequately positioned.
.
CT HEAD W/O CONTRAST Study Date of [**2200-9-24**] 12:02 PM
FINDINGS: There has been substantial interval increase in the
previously seen right frontal lobe intraparenchymal hemorrhage
which now extends across midline to the left frontal lobe, with
surrounding edema, and with increased mass effect causing a 6 mm
right-to-left shift of normally midline structures and
subfalcine herniation. No uncal herniation is seen. There is
complete effacement of the right ventricular system and
extensive effacement of sulci due to mass effect with likely
also underlying edema. There is a small hyperdensity in the
posterior [**Doctor Last Name 534**] of the left lateral ventricle which may represent
new intraventricular hemorrhage. No hydrocephlus is seen. No
acute fracture is seen.
IMPRESSION:
1) Substantially increased right frontal intraparenchymal
hemorrhage which now extends into the left frontal lobe and with
increased surrounding edema and mass effect, as above. 6 mm
leftward midline shift. No definite uncal herniation.
2) Small hyperdensity in left posteral [**Doctor Last Name 534**] raises concern for
intraventricular hemorrhage.
.
CT C-SPINE W/O CONTRAST Study Date of [**2200-9-24**] 12:07 PM
IMPRESSION: Suboptimal exam secondary to motion. Given this, no
acute
fracture seen. Minimal anterolisthesis of C2 over C3 of
indeterminate age.
Possible right supraclavicular intramuscular/soft tissue
hematoma.
.
CT HEAD W/O CONTRAST Study Date of [**2200-9-25**] 5:56 AM
FINDINGS:
There is the large right frontal lobe intraparenchymal
hemorrhage with
subfalcine herniation crossing midline to the left frontal lobe.
The
subfalcine herniation and midline shift to the left may have
decreased
slightly from the prior exam. The intraventricular hemorrhage
layering in the
occipital horns has increased. Unchanged mild right cerebral
edema. There is
no descending transtentorial herniation.
IMPRESSION:
1. Possible slight interval decrease of the subfalcine
herniation.
2. Interval increase of the intraventricular hemorrhage layering
in the
occipital horns. No hydrocephalus.
.
CHEST (PORTABLE AP) Study Date of [**2200-9-26**] 5:01 AM
IMPRESSION: AP chest compared to [**9-24**]:
Bilateral pleural effusions, large on the left, moderate on the
right have not improved. Previous mild pulmonary edema has
cleared. There is no pulmonary or mediastinal vascular
congestion and heart size is top normal. ET tube is in standard
placement, nasogastric tube passes below the diaphragm and out
of view, and transvenous right atrial and right ventricular
pacer leads follow their expected courses.
Brief Hospital Course:
81F with a past medical history significant for recent aortic
valve surgery in [**Month (only) **] with a complicated post operative course,
AF for which dabigatran was changed to warfarin, AICD for
tachy-brady syndrome, PVD and carotid stenosis, previous bowel
cancer and partial colectomy, HTN, HLD presented to the ED as a
transfer from [**Hospital1 **] [**Location (un) 620**] following a mechanical fall at home
while mobilising to the bathroom. On assessment at [**Hospital1 **] [**Location (un) 620**],
she was found to be confused and had a non-focal examination. CT
head there revealed a small right frontal ICH and right
clavicular fracture. She was transferred to [**Hospital1 18**] and shortly
after admission her conscious level acutely deteriorated such
that she was not able to speak and did not follow commands. She
was intubated for airway protection in the ED and repeat CT head
showed substantially increased right frontal ICH which had
extended into the left frontal lobe and with increased
surrounding edema and mass effect with 6 mm leftward midline
shift. Her INR was 3.4 and this was reversed and the patient was
admitted to the ICU under the care of Dr. [**First Name (STitle) **]. She was seen
by the ACS service. Ortho was consulted to evaluate her clavicle
fracture. Surgical decompression was discussed with the family.
Her exam continued to remain poor and repeat CT showed
subfalcine herniation. After discussions with family on poor
prognosis for recovery, she was made comfort measures only on
[**2200-9-28**]. Palliative care were consulted and per their notes, the
patient had repeatedly told her family that she would never want
prolonged end of life care and a combined medical and family
decision was to remove ventilator assistance and make the
patient comfort measures only as above. She was pronounced dead
at 0900 on [**2200-9-30**]. Given that her initial injury was a
result of trauma, the medical examiner was contact[**Name (NI) **] and
accepted the case to view and will complete the death
certificate. Of note the patient has an AICD.
Medications on Admission:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 50 mcg 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 once a day.
4. metoprolol succinate 150mg daily but state 100mg daily on
cardilogy letter.
5. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
Change dose as directed by coumadin clinic on Friday when you
show up.
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 20 mg p.r.n. lower extremity edema
Discharge Medications:
Patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Traumatic large right frontal lobe intraparenchymal hemorrhage
with subfalcine herniation crossing midline to the left frontal
lobe
Supratherapeutic INR
Traumatic right clavicle fracture
Bilateral pleural effusion
Discharge Condition:
Patient deceased [**2200-9-30**]
Discharge Instructions:
Patient presented on [**2200-9-24**] with traumatic right sided
intracranial hemorrhage in addition to a right clavicular
fracture following a fall at home. Patient was on warfarin and
admission INR was 3.4. Patient was initially confused with a
non-focal examination however shortly after transfer from [**Hospital1 **]
[**Location (un) 620**] to [**Hospital1 18**], the patient rapidly deteriorated and was
intubated in the ED. Repeat head CT showed significant
progression of her hemorrhage with evidence of subfalcine
herniation. Warfarin was reversed in the ED and patient was
transferred to the ICU. Patient made poor neurological progress
in the ICU and given comorbidities and extent of ICH, the
decision was to make the patient CMO and the patient was
extubated and died with relatives present at 0900 on [**2200-9-30**].
Followup Instructions:
Patient deceased
|
[
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"244.9",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
12251, 12260
|
9539, 11624
|
402, 444
|
12518, 12553
|
4780, 4808
|
13432, 13452
|
2886, 3027
|
12210, 12228
|
12281, 12497
|
11650, 12187
|
12577, 13409
|
2265, 2728
|
3042, 3044
|
4716, 4761
|
267, 364
|
472, 1561
|
3714, 4702
|
4824, 9516
|
3058, 3472
|
3487, 3698
|
1605, 2242
|
2744, 2870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,782
| 159,285
|
28009
|
Discharge summary
|
report
|
Admission Date: [**2119-5-19**] Discharge Date: [**2119-5-22**]
Date of Birth: [**2083-1-2**] Sex: F
Service: MEDICINE
Allergies:
Methotrexate
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain and dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 68192**] is a 36F with h/o autoimmune scleritis who presents
with 3 week h/o SOB and chest tightness. Ms. [**Known lastname 68192**] states that
over the past three weeks she has been experiencing progressive
SOB. She saw a NP shortly after the onset of her symptoms, who
suspected reactive airway disease, and prescribed an albuterol
inhaler and prednisone taper (60mg x 2 days, followed by
decrease of 10mg every 2 days). She states that her symptoms
improved significantly on steroids, but after the taper had
completed, began to recur. Three days PTA she developed a
nonproductive cough. The night prior to admission, Ms. [**Known lastname 68192**]
experienced worsening SOB and chest tightness. She found it
difficult to lie flat in bed, and was more comfortable sitting
up. She became nauseated and vomited NBNB emesis x 2. She went
to the ED in [**Hospital1 392**], where she was found to be tachycardic to
120s and hypotensive to 90s. Her ECG demonstrated STE in [**Last Name (LF) 1105**], [**First Name3 (LF) **]
depression in AVL, TWI in [**First Name3 (LF) 1105**] and lateral leads, and q in [**First Name3 (LF) 1105**].
Initial CEs were CK 42, tropI<0.15. A CTA was done to r/o PE and
aortic dissection, which was reportedly negative, but which
demonstrated a moderate sized pericardial effusion. She was
given 2L NS, and sent to [**Hospital1 **] ED. In the ED, she was confirmed to
be hypotensive to 90s and tachycardic to 120s. Pulsus paradoxus
10mmHg. She received an additional 2L NS, and had a stat bedside
TTE done, which demonstrated small pericardial effusion (0.6cm
anterior, 1cm posterior), with significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling. There may have
been possible mild right ventricular diastolic indentation but
views suboptimal. She was admitted for close observation in CCU.
Immediate drainage was not thought to be indicated due to small
size of effusion. Currently, she complains of pleuritic chest
pain that was not improved by ketorolac, as well as shortness of
breath.
.
ROS: Notable for fatigue and exercise intolerance since [**1-9**].
6-pound weight gain in past year. Fever in the past 24-hours.
She also has had a chronic erythematous rash on her back for
years which waxes and wanes -- she has been told by
dermatologists that it is foliculitis. She also has occasional
rash on her nose and face that was diagnosed as rosacea. She
does have an apparent diagnosis of autoimmune scleritis,
diagnosed 6 years ago at [**Hospital 13128**]. She was treated with
MTX for 9 months, at which time she experienced apparent
MTX-associated lung toxicity, and MTX was d/c'ed. Ms. [**Known lastname 68192**] [**Last Name (Titles) 13230**]s any recent chest trauma or surgery, with no history of
XRT or malignancy. She denies any recent cold intolerance,
menstrual irregularities, changes to skin or hair, constipation
or diarrhea, arthralgias or joint effusions. Her BUN/Cr on
admission were normal at 11/0.7.
Past Medical History:
Autoimmune scleritis, as above
Social History:
Nonsmoker, occ EtOH, no h/o IVDU. Works as a nurse primarily in
nursing homes. She and her husband have a 3 year-old daughter
Family History:
Thyroid disease on her mother's side
Physical Exam:
T: BP: 95/63 HR: 114 RR: 31 SaO2: 99% 3L NC Pulsus 10mmHg
Gen: Caucasian female lying in bed, mild respiratory distress,
speaking in short sentences
HEENT: PERRL, OP pink and moist, no conjunctival injection,
sclerae anicteric
CV: Tachycardic, regular rhythm, nl S1 and S2, no m/r/g. JVP
elevated to angle of jaw.
Chest: Mild bibasilar crackles, no wheeze
Abd: Soft, NT/ND, +BS
Extr: cool, no LE edema
neuro: A&O x 3. [**12-5**]+ DTRs throughout, no obvious delayed
relaxation.
Skin: faint erythematous rash of forehead and nose,
non-blanching. Non-blanching petechial rash of shoulders and
back.
.
Pertinent Results:
ECG: Sinus tachycardia. Diffuse non-specific ST-T wave
abnormalities. There is slight ST segment elevations in leads
II, [**Month/Day (2) 1105**] and aVF. Active inferior ischemic process cannot be
excluded. Followup and clinical correlation are suggested. No
previous tracing available for comparison
.
[**5-19**] TTE:
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with
trivial mitral regurgitation. There is a small pericardial
effusion. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling. There may be mild right
ventricular diastolic indentation but views suboptimal.
.
[**5-20**] TTE:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
2. There is a small pericardial effusion. There are probably no
echocardiographic signs of tamponade.
3. Compared with the prior study (images reviewed) of [**2119-5-19**],
there is
probably no significant change.
.
[**5-22**] TTE:
Overall left ventricular systolic function is normal (LVEF>55%).
The remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is a trvial/small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2119-5-20**], no
change.
.
[**2119-5-19**] WBC-17.5* Hct-32.0* MCV-85 Plt Ct-305
Neuts-91.2* Bands-0 Lymphs-6.2* Monos-2.5 Eos-0 Baso-0.1
[**2119-5-22**] WBC-6.2 Hct-27.6* MCV-85 Plt Ct-317
.
[**2119-5-21**] PT-12.5 PTT-27.0 INR(PT)-1.1
[**2119-5-19**] ESR-77* CRP 148.5
[**2119-5-20**] [**Doctor First Name **]-NEGATIVE RheuFac-18* TSH-0.90
.
[**2119-5-19**] Glucose-149* UreaN-11 Creat-0.7 Na-138 K-4.2 Cl-104
HCO3-22
Calcium-8.3* Phos-4.8* Mg-2.1
[**2119-5-22**] Glucose-99 UreaN-12 Creat-0.8 Na-141 K-4.0 Cl-103
HCO3-29
.
[**2119-5-19**] ALT-95* AST-78* LD(LDH)-552* AlkPhos-172* Amylase-19
TotBili-1.1 Lipase 20
[**2119-5-21**] ALT-47* AST-19 AlkPhos-157*
[**2119-5-19**] CK(CPK)-45, 36. TropT <0.01, <0.01
.
Iron-14 calTIBC-259* Hapto-293* Ferritn-366* TRF-199
.
[**2119-5-19**] 01:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-NEGATIVE
[**2119-5-19**] 01:00PM BLOOD HCV Ab-NEGATIVE
[**Location (un) **] PCR pending at time of discharge
Brief Hospital Course:
1) Pericarditis/Pericardial Effusion: Intitial bedside TTE in ED
suggesting some evidence of minimal RV compromise; however,
effusion was only 0.6cm anterior and 1.0cm posterior, so thought
that risks of pericardiocentesis outweighed likely benefit. She
remained tachycardic to 130s and hypotensive to 90s/50s, and was
monitored very closely in CCU, given IVF overnight. The morning
after admission, pulsus noted to be 15cm, from 10cm the evening
before. Repeat TTE was done, which did not suggest worsening of
pericardial effusion. Images from OSH chest CTA reviewed, and
were negative for aortic dissection or pulmonary embolus. Her
symptoms were managed with indomethacin and colchicine, with IV
morphine for breakthrough symptoms and ativan for anxiety, which
worked effectively. Her regimen was tapered down to ibuprofen by
the time of discharge. Consideration was given to a
rheumatological cause of her effusion, ie [**1-5**] serositis from SLE
or RA. RF was mildly elevated at 18, and [**Doctor First Name **] was negative.
Rheumatology was consulted, who did not believe that her
effusion was rheumatologic in nature, as pt did not have any
other symptomatology consistent with SLE, RA or AS. They
recommended a L-S spine xray as an outpatient, given known HLA
B27 state. TSH was found to be normal, at 0.90. [**Location (un) **] PCR
was also sent, which was pending at time of discharge. She also
had a PPD placed prior to d/c to r/o TB as etiology of
pericardial effusion, as pt is a nurse who works in nursing
home. She was to have her sister or PCP read the PPD on [**5-23**].
.
2) Elevated LFTs: Ms. [**Known lastname 68192**] had mild transaminitis and
elevated alk phos and LDH at time of admission. EBV and
Hepatitis serologies were sent, which were negative. Her LFTs
all decreased steadily throughout her stay. The etiology of the
elevation is unclear, but could reflect possible congestion from
mild volume overloaded state resulting from aggressive volume
resuscitation on first presentation.
Medications on Admission:
Recent prednisone taper
Recent administration of albuterol inhaler, which she has not
used.
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day for 4 weeks: Please take with food. .
Disp:*84 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 2 weeks: do not drive or
operate heavy machinery while taking this medication. .
Disp:*20 Tablet(s)* Refills:*0*
3. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: [**12-5**]
Tablet, Delayed Release (E.C.)s PO once a day as needed for
stomach pain for 4 weeks.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pericarditispericardial effusion
Discharge Condition:
stable
Discharge Instructions:
If you develop worsening chest pain, shortness of breath, or
palpitations, please call your PCP or return to the ED.
Please take the ibuprofren as needed for the next few weeks as
the pericarditis is healing. Please take this with food and if
you develop stomach discomfort, you can fill the prescription
for Prilosec OTC.
Followup Instructions:
Please call your PCP and arrange [**Name Initial (PRE) **] follow up appointment in the
next few weeks. The rheumatology doctors also suggested that you
get plain films of your lumbar and sacral spine at some point in
the future to rule out ankylosing spondylitis (an autoimmune
condition).
Also, please have your PPD read by your sister or another health
care professional on [**5-23**].
|
[
"379.09",
"276.6",
"276.51",
"423.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9789, 9795
|
7042, 9057
|
294, 300
|
9871, 9879
|
4260, 7019
|
10250, 10641
|
3587, 3625
|
9200, 9766
|
9816, 9850
|
9083, 9177
|
9903, 10227
|
3640, 4241
|
232, 256
|
328, 3374
|
3396, 3428
|
3444, 3571
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,206
| 157,070
|
34285
|
Discharge summary
|
report
|
Admission Date: [**2107-8-1**] Discharge Date: [**2107-8-4**]
Date of Birth: [**2036-4-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Intermittant left face and hand numbness; transfer from OSH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History and physical is as per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11180**]
71 y/o male with hyperlipidemia who noted earlier on the day of
admission sudden onset left jaw numbness which lasted several
seconds and resolved spontaneously. He then noted left hand
numbness and tingling that also resolved by itself within a
minute. The entire episode lasted just a few minutes. He denied
any visual changes, dysarthria, confusion, chest pain, heart
palpitations, lightheadedness or nausea/vomiting. His wife, who
was with the pt when pt had these symptoms, did not notice
anything different about the patient. He went to outside
hospital where head CT showed small right posterior frontal
convexity subarachnoid hemorrhage. This is stable on repeat head
CT at [**Hospital1 18**] where patient was transferred for higher level of
care.
.
In the ED, vitals were: T: 98.3 BP: 215/90 HR: 79 R: 12 O2Sats:
99%. Was given Labetalol 10 mg IV x1 which decreased BP to
150s/90s at the time of transfer to floor. Was also given 1 L of
D5NS. Was seen by neurosurg who recommended discontinuation of
ASA for the near future and management of HTN. As hemorrhage is
stable, they did not recommend any further follow up CTs or
surgical interventions at this time.
Past Medical History:
polio
hydrocele s/p repair in [**2095**]
hyperlipidemia
? HTN (pt states he's had high BP readings in the past, but was
never prescribed medications)
Social History:
The patient lives with his wife, has 5 adult children.
Previously employed at paper mill and as janitor.
Tobacco: None
ETOH: 3-4 bottles beer daily, denies withdrawal, blackouts
Illicts: None
Family History:
NC
Physical Exam:
On admission to the [**Hospital Unit Name 153**] the physical exam was as follows:
Vitals: T: 96.1 BP:121/77 HR:62 RR: 16 O2Sat:98% RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MM somewhat dry, OP Clear
NECK: supple, no JVD, no LAD
Heart: 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
intact. Moves all 4 extremities. Strength 5/5 in upper and lower
extremities. Patellar, biceps DTR +1. Sensation intact
throughout. SKIN: No jaundice, cyanosis, or gross dermatitis. No
ecchymoses.
Pertinent Results:
Labs on admission [**2107-8-1**]:
Significant only for Cr of 1.1 (unknown baseline), and U/A with
50 ketones.
.
CT Head without contrast [**2107-8-1**]:
FINDINGS: There is a small area of subarachnoid hemorrhage over
the right
frontal cerebral convexity, near the vertex. There is a low
attenuation focus in the right frontoparietal cortex likely
representing a small area of old infarction. Similarly, there
are periventricular deep white matter changes consistent with
small vessel ischemic disease. There is no midline shift or mass
effect. There is a small calcified lesion in the left CP angle
(7 x 5 mm), likely represent a small meningioma. There is no
fracture and the visualized paranasal sinuses are clear.
CONCLUSION:
1. Small area of subarachnoid hemorrhage overlying the right
frontal cerebral convexity without mass effect.
2. Chronic small vessel ischemic changes.
3. Small calcified mass in the left CP angle likely representing
a small
meningioma.
[**2107-8-1**] 07:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2107-8-1**] 06:00PM GLUCOSE-92 UREA N-18 CREAT-1.1 SODIUM-141
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2107-8-1**] 06:00PM estGFR-Using this
[**2107-8-1**] 06:00PM WBC-5.3 RBC-4.77 HGB-14.3 HCT-41.9 MCV-88
MCH-30.1 MCHC-34.2 RDW-13.4
[**2107-8-1**] 06:00PM NEUTS-71.8* LYMPHS-20.1 MONOS-5.0 EOS-2.5
BASOS-0.6
[**2107-8-1**] 06:00PM PLT COUNT-198
[**2107-8-1**] 06:00PM PT-12.2 PTT-24.3 INR(PT)-1.0
Brief Hospital Course:
Assessment/Plan: Patient is a 71 year old male with history of
dyslipidemia, likely uncontrolled HTN presents with transient
neuro deficit and evidence of small right frontal SAH
.
#. SAH: Etiology unclear. The pt had no history of trauma.
Repeat CT at [**Hospital1 18**] stable from previous. Pt initally monitored
in [**Hospital Unit Name 153**]. Patient seen by Neurosurgery who felt no intervention
was necessary. Neurology was consulted. Pt was started on
nimodipine in ICU by ICU team for cerebral artery spasm but
neurology did not feel this was necessary and he was tapered
off. MRI/MRA head was obtained that showed right frontal
convexity area of slow diffusion indicating a small cortical
infarct with blood products either within the infarct or in the
adjacent sulcus. No mass effect seen. MRA of the head was
normal. There was no evidence of aneurysm. the patient did not
want to stay as an inpatient to receive a workup for possible
CVA but agreed to do it as an outpatient. He will get an MRA
neck and a 2D echo. His cholesterol and HbA1C levels were
within normal limits. The patient will follow up with neurology
as an outpatient. The patient was instructed to not take an ASA
for 2 weeks.
.
# HTN - Pt intially on Captopril and Nimodipine in ICU.
Nimodipine was weaned off. Captopril was transitioned to
Lisinopril. A follow up appointment was arrranged with the pts
PCP to check his BP.
.
# Hyperlipidemia - Continue statin
.
# FEN - Cardiac/heart healthy diet
.
# PPx: Pneumoboots
.
# Code: full, confirmed on admission
Medications on Admission:
simvastatin 40 mg once daily
ASA 81mg qd
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: one half Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for a small brain bleed that did not need
surgery. You will need to have an echocardiogram and MRA of
your neck. This is scheduled below.
You should not take aspirin for a total of 2 weeks after your
first symtoms. It is safe to resume this medication [**2107-8-15**].
It is important that you follow up with Dr. [**Last Name (STitle) 1617**] as scheduled
to follow up on your blood pressure and labwork as you will be
starting a new medication.
Followup Instructions:
Please keep these appointments. If the times are not good for
you, call and reschedule.
You have an appointment scheduled with Drs. [**Last Name (STitle) **] and
[**Name5 (PTitle) 18530**] from Neurology [**2107-9-7**] at 4pm.
Phone:[**Telephone/Fax (1) 44**].
Appointment with Dr. [**Last Name (STitle) 1617**] 2:30pm [**2107-8-18**] for BP follow up on
blood pressure. Please discuss with him if you need to keep the
[**8-30**] follow up with Dr. [**Last Name (STitle) 39151**].
You have a follow up appointment schdeuled [**2107-8-30**] at 10:45 am
with Dr. [**Last Name (STitle) 39151**] to follow up on your hospitalization and review
test results.
You have an echocardiogram scheduled Friday [**2107-8-12**] at 9:45 am
at Dr. [**Last Name (STitle) 39151**] office in [**Hospital1 189**].
You have an MRA of your neck scheduled at [**Hospital3 25357**] [**2107-8-11**] at 5:30pm. You should arrive at 5pm Please
call [**Telephone/Fax (1) 78916**] to answer some clinical questions.
Completed by:[**2107-8-5**]
|
[
"V12.02",
"782.0",
"272.4",
"401.9",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6272, 6278
|
4405, 5962
|
372, 379
|
6346, 6356
|
2857, 4382
|
6874, 7900
|
2086, 2090
|
6054, 6249
|
6299, 6325
|
5988, 6031
|
6380, 6851
|
2105, 2838
|
273, 334
|
407, 1687
|
1709, 1861
|
1877, 2070
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,559
| 188,900
|
34463
|
Discharge summary
|
report
|
Admission Date: [**2198-6-29**] Discharge Date: [**2198-7-9**]
Date of Birth: [**2150-6-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Clindamycin / Amiodarone
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Failure to wean off ventilator
Major Surgical or Invasive Procedure:
[**6-30**] bronchoscopy
[**7-2**] trach, Dobbhoff placement. Trach placed under direct vision
using rigid bronch.
History of Present Illness:
48 year M with subglottic stenosis and RF. In [**5-14**], the pt
was hospitalized due to a HR of 300. During attempted
cardioversion, pt coded and was intubated. Pt coded several
more times during the week. His HR then decreased to the 30s
and an AICD was placed. Pt bit through his tube and was
reintubated. He then failed an extubation trial. [**5-27**], he
was extubated, but within an hour when into Vtach and was
reintubated. He underwent a partially successful ablative
procedure and was discharge to rehab and home. During his
hospitalizaton, his re-intubations had become progressively more
difficult.
At his return home, pt began complaining of an odd feeling in
his throat. Laryngoscopy was normal. A bronchoscopy showed
subglottic stenosis and steroids were started. Pt progressively
worsened and presented to the ED again on [**6-25**]. A bronchoscopy
at Bay State showed his opening to be 3MM. The pt's airway was
dilated to allow passage of 6Fr tube, and pt was transferred to
[**Hospital1 18**]. Pt arrived intubated.
Past Medical History:
Possible tracheoesophageal fistula
Ablation procedure
Lap banding (100 lb weight loss in past few months)
VSD repair
HTN
Underactive thyroid
Diabetes type II
CHF/CAD
Social History:
Pt is not currently smoking. He is married and lives with his
family.
Family History:
Mother COPD
Father died of stroke at 60, PVD
Physical Exam:
On admission
Temp (F): 99.6
Heart Rate: 73
Blood Pressure: 110/69
Resp Rate: 18
O2 Sat(%): 100
Room Air/O2: vent
Ht (in): 6'3"
Wt (lb):290
Awake, able to nod appropriately to yes or no questions.
CVS: Pansystolic blowing murmur, heard best at left sternal
border
Pulm: intubated, clear to ausculation bilaterally
Abd: soft, non-tender, non-distended
Extremities: no cyanosis, no edema, no clubbing
Lymph nodes: no palpable cervical, supraclavicular, axillary,
or inguinal lymph nodes
Pertinent Results:
[**2198-7-4**] 06:45AM
WBC-11.3 RBC-4.01 Hgb-11.9 Hct-36.0 MCV-90 MCH-29.7 MCHC-33.1
RDW-15.7 Plt Ct-165
[**2198-7-2**] 02:14AM
PT-16.8 PTT-29.7 INR(PT)-1.5
[**2198-7-4**] 06:45AM
Glucose-152 UreaN-16 Creat-0.7 Na-141 K-3.5 Cl-104 HCO3-27
AnGap-14
Calcium-9.1 Phos-4.3 Mg-2.0
[**2198-6-29**] 09:05PM
pH-7.53 pO2-163 pCO2-37 calTCO2-32 Base XS-8 Lactate-1.6 K-3.9
Brief Hospital Course:
The patient arrived intubated on [**2198-6-29**]. Focoal subglottic
tracheal narrowing and cardiomegaly accompanied by main and L
pulmonary artery enlargement was visualized on the original CT
airway on [**2198-6-29**]. On [**2198-7-1**], the pt underwent a rigid
bronchoscopy, airway dilation and tracheostomy placement. The
patient tolerated the procedure well and was transferred back to
the ICU for continued monitoring. On [**2198-7-2**], the pt returned to
the OR for an open tracheostomy and dopenhoff placement. During
the bronchoscopy, tracheal stenosis was visualized just distal
to the cords. The pt remained in the ICU recovering until he
was transferred to the floor on [**2198-7-3**]. Speech and swallow
evaluated the pt and did not find him eligible at that time for
a PMV. A TEE performed on pt showed an intact membranous VSD
repair with no residual flow. Finally, ENT evaluated pt and
recommended a thin-slice airway CT. The airway CT was performed
on [**2198-7-6**] and showed the distal tip of the tracheostomy tube to
be extraluminal. On [**2198-7-7**], a rigid bronchoscopy/flexible
bronchoscopy w/ tracheal revision/tracheostomy exchange was
performed. Pt continued to recover. On [**2198-7-8**], the
tracheostomy balloon was deflated. On [**2198-7-9**], EP visited the
pt and interrogated his pacemaker/AICD. After undergoing speech
and respiratory therapy that same day, the pt was discharged.
Medications on Admission:
Toprol XL 25 mg daily
Lisinopril 2.5 mg daily
Mexiletine 150 mg [**Hospital1 **]
Levothyroxine 0.1 mg daily
Protonix 40 mg daily
Colace 100 mg daily
Albuterol inhaler 2 puffs q 3 hours PRN
Benadryl 50 mg q 6 hours prn
Coumadin
CPAP at home
Discharge Medications:
1. Tracheostomy Suction Device
One tracheostomy suction device
Size 10 French catheter for suction
2. Home Oxygen
Please provide humidified home oxygen for tracheostomy care
3. Hydrocortisone 0.5 % Ointment [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*2 tube* Refills:*0*
4. Atenolol 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Lidocaine-Prilocaine 2.5-2.5 % Cream [**Last Name (STitle) **]: One (1) Appl
Topical TID (3 times a day) as needed for pain at tracheostomy
site.
Disp:*1 tube* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for 2 weeks.
Disp:*600 ML(s)* Refills:*0*
8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Five (5) ml PO BID (2
times a day) as needed for constipation for 2 weeks.
Disp:*150 ml* Refills:*0*
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Three (3) ml Inhalation Q6H (every 6 hours) as
needed.
Disp:*50 nebs* Refills:*0*
10. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*50 nebs* Refills:*0*
11. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
12. Cephalexin 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA & Hospice Services
Discharge Diagnosis:
Subglottic and proximal tracheal stenosis
Discharge Condition:
Fair
Discharge Instructions:
Please call the office of Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 170**] if you
experience fever greater than 101.5, chills, shortness of
breath, chest pain, cough productive of sputum or blood,
swelling or redness around your incision, purulent drainage from
your wound or anything that should concern you.
Take medication as prescribed
Do not drive or operate heavy machinery while on pain
medication. You may take stool softeners for constipation.
Followup Instructions:
Please call the office of Dr. [**First Name (STitle) **] (Thoracic Surgery) at
[**Telephone/Fax (1) 170**] to make an appointment in 3 weeks.
Please call the office of Dr. [**Last Name (STitle) **] (Interventional Pulmonary)
at [**Telephone/Fax (1) 3020**] to make a follow up appointment in 3 weeks.
Please call the office of Dr. [**First Name (STitle) **] (Ear, Nose and Throat) at
[**Telephone/Fax (1) 2349**] to make a follow up appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2198-7-10**]
|
[
"745.4",
"427.31",
"401.9",
"250.00",
"E878.8",
"V45.86",
"V45.02",
"518.83",
"V15.1",
"413.9",
"V15.82",
"414.8",
"244.9",
"519.02",
"414.01",
"278.01",
"519.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"31.99",
"45.13",
"31.1",
"33.23",
"96.72",
"33.21",
"97.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6257, 6327
|
2803, 4238
|
320, 436
|
6412, 6419
|
2412, 2780
|
6936, 7527
|
1808, 1855
|
4529, 6234
|
6348, 6391
|
4264, 4506
|
6443, 6913
|
1870, 2393
|
250, 282
|
464, 1514
|
1536, 1704
|
1720, 1792
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,218
| 139,221
|
5644
|
Discharge summary
|
report
|
Admission Date: [**2199-1-27**] Discharge Date: [**2199-2-11**]
Date of Birth: [**2128-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Abacavir
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2199-2-5**] - Redo Sternotomy, AVR (21 CE magna tisuue),CABGx3
[**2199-1-29**] - Cardiac Catheterization
History of Present Illness:
70M with CAD s/p CABGx2v [**9-17**], PCI with [**Month/Year (2) **] to distal LCx [**9-23**],
PAF, RHD s/p bioprosthetic AVR and MVR, HIV admitted with chest
pain and palpitations.
The patient was in his usual state of health until the day of
presentation when he developed a rapid pulse/palpitations. The
onset was sudden and was soon followed by a sharp pain in his
left chest which radiated down his left inner arm. He states
that it is similar to his prior anginal experiences, although
more intense and more significant CP component. He endorses left
upper back pain, diaphoresis, palpitations and rapid pulse. He
denies lightheadedness or nausea. He took 2 SL NTG without
relief. He called EMS.
.
EMS arrived and gave an additional 3 NTG sprays without relief
and aspirin.
.
In the ED, the vitals were 99.2, ?84, 133/93, 100RA. The patient
went into atrial fibrillation with RVR. He had metoprolol 5mg IV
x3 and 50mg PO metoprolol. The chest pain resolved with
conversion to NSR. Laboratory data was significant for first set
of CE were negative. EKG with atrial tachycardia with
ventricular rates of 120s. The patient had lateral ST depression
in V5-V6, I, II.ST depressions persisted after rhythm converted
to NSR. CXR 1V reportedly unremarkable. Given persistent left
back pain despite improved chest pain, CTA chest performed; on
preliminary read, no evidence of dissection. Received total
morphine 8mg IV, 1 additional SLNTG; also, at recommendation of
cardiology fellows, was started on heparin gtt. On transfer to
the medicine service, 70, 120/63, 17, 99%2L NC.
.
Of note, seen in his cardiologist's office on [**2199-1-24**] for
exertional angina (with walking). Given lack of relief with
Imdur, patient was started on Nitro-patch 0.4 mg per hour for 12
hours every day. In addition, Lipitor was restarted at 20 mg
every other day.
.
REVIEW OF SYSTEMS:
(+) Per HPI. Reports 10lb weight loss over 6 months,
intentional. Reports chronic sinus congestion. Reports
constipation. Reports recent dysuria and urinary hesitancy.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea. Denies cough, shortness of breath.
Denies nausea, vomiting, diarrhea, or abdominal pain.
Past Medical History:
CAD s/p CABG x2V ([**9-17**]); s/p Endeavor [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22594**] circumflex
([**9-23**])
Paroxysmal atrial fibrillation
HIV
Rheumatic heart disease s/p bioprosthetic aortic and mitral
valves ([**2192**])
s/p sinus surgery
Social History:
Formerly worked for NEBH in supply department. Denies tobacco or
illicit drug use, now or in the past. Reports social alcohol
use. Lives alone.
Family History:
No known family history of CAD.
Physical Exam:
98.2 117/61 58 20 97RA
GENERAL: Comfortable, NAD
HEENT: NCAT; sclera anicteric; EOMI
NECK: Supple; without distended neck veins
CARDIAC: RRR; nl S1/S2; holosystolic murmur at LLSB and LUSB and
apex
LUNGS: bibasilar crackles, otherwise CTAB
ABDOMEN: Normoactive bowel sounds; soft, NTND
EXTREMITIES: No lower extremity edema.
NEURO: CNI-XII intact; upper and lower extremity strength 5/5
and equal bilaterally; gait not assessed
PULSES: 2+ DP, Femoral. No femoral bruit.
Pertinent Results:
[**2199-2-10**] 08:05AM BLOOD WBC-8.8 RBC-3.92* Hgb-11.4* Hct-35.6*
MCV-91 MCH-29.0 MCHC-31.9 RDW-15.8* Plt Ct-291
[**2199-2-11**] 07:20AM BLOOD Hct-34.1*
[**2199-2-10**] 08:05AM BLOOD Glucose-146* UreaN-11 Creat-0.9 Na-136
K-4.5 Cl-101 HCO3-24 AnGap-16
[**2199-2-11**] 07:20AM BLOOD UreaN-10 Creat-0.9 K-4.1
[**2199-2-11**] 07:20AM BLOOD Mg-2.3
[**2199-1-30**] Carotid ultrasound
Minimal bilateral ICA calcific plaque, no appreciable associated
stenosis (graded as less than 40% bilaterally).
[**2199-1-29**] - Cardiac Catheterization
1. Selective coronary angiography of this right dominant system
demonstrated native three vessel coronary artery disease. The
LMCA had
an ostial 30% , proximal 30% and diffuse disease throughout with
heavy
calcification leading to 80% stenosis before a complex
bifurcation with
D1 adn D1. There was moderate stenosis of the origin of S1. D1
was
heavily calcified with a proximal 75% stenosis which was similar
to the
previous cath. The was mild diffuse disease in the mid to
distal LAD.
The LCX had diffuse disease in the AV groove CX with patent [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 22595**]. The previously large and grafted OM remains occluded
with
scant filling via left-left collaterals. The RCA was difficult
to
engage with a JR4, AR1, AR2 as all these catheters selectively
intubated
the RV/conus branch and the brachiocephalic artery. Ultimately
a 5
French AL1 deep-seated the artery with a 20-30 mm Hg gradient
down the
vessel indicating a moderate RCA stenosis likely of 50% in size
which
was however not visualized. The RPDA was diffusely diseased
with a
stenosis at the origin of 60% and a mid stump of the prior SVG.
There
were patent lateral branches arising off the RPDA with faint
collaterals
to the LAD.
2. Resting hemodynamics revealed an elevated right and left
ventricular
enddiastolic pressure of 16 and 21 mm Hg, respectively. The
mean PA
pressure was 36 mmHg (phasic 60/23 mm Hg; pulmonary vascular
resistance
157 dynes/sec/cm-5). The PCW was 22 mm Hg. The cardiac index
was
preserved at 3.1 L/min/m2. The mean systemic arterial blood
pressure
was 75 mmHg (phasic 111/51 mm Hg).
3. There was a mean aortic valve gradient of 33 mm Hg
calculating to an
aortic valve area of 1.3 cm2 using an assumed oxygen consumption
of 125
mL/min/m2 to calculate cardiac output according to the Fick
principle.
[**2199-1-28**] ECHO
The left atrium is markedly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. The prosthetic
aortic valve leaflets appear normal, but the transaortic
gradient is higher than expected for this type of prosthesis. No
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The mitral prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2195-8-7**],
the estimated pulmonary artery systolic pressure is higher. The
aortic and mitral valve gradients are similar.
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
There is symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with focalities in the
anteroseptal wall.. Overall left ventricular systolic function
is mildly depressed (LVEF=45 % to 50%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
prosthetic aortic valve leaflets are thickened. The transaortic
gradient is higher than expected for this type of prosthesis.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
valvular mitral stenosis (area 1.5-2.0cm2). Trivial mitral
regurgitation is seen. There is calcification in the papillary
muscles.
There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on MR.
[**Known lastname 22591**] before surgery start.
POST-BYPASS:
Normal RV systolic function.
Overall LVEF 50%.
There is a mild hypokinesis in the mid to apical anteroseptal
walls similar to prebypass.
Trace MR.
The new aortic bioprosthesis is well seated and functioning well
with residual peak 35 and mean 17mm of Hg.
Intact thoracic aorta.
Brief Hospital Course:
Mr. [**Known lastname 22591**] was admitted to the [**Hospital1 18**] on [**2199-1-27**] for further
management of his chest pain. He ruled in for a non-ST-elevation
myocardial infarction and was continued on his plavix. Heparin
was started as well for anticoagulation and he remained pain
free. A cardiac catheterization revealed severe native and graft
disease from his previous surgery. (Please see cardiac
catheterization report) An echocardiogram was performed which
showed a normal ejection fraction however increased gradients
were noted across the bioprosthetic aortic valve. Given the
severity of his disease, the cardiac surgical service was
consulted for surgical evaluation. Mr. [**Known lastname 22591**] was worked-up
in the usual preoperative manner including a carotid duplex
ultrasound which did not show any hemodynamically significant
disease. Vein mapping was performed and adequate greater
saphenous venin was noted in his left lower extremity. On
[**2199-2-5**], Mr. [**Known lastname 22591**] was taken to the operating room where he
underwent a redo-sternotomy with coronary artery bypass grafting
to three vessels. (Please see operative note for details).
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. He was taken back to the operating
room on the eve of POD#0 for evaluation of post operative
bleeding. See operative note for details. Over the next 24
hours, he awoke neurologically intact and was extubated. His
post operative course was complicated by atrial fibrillation and
he underwent successful cardioversion on [**2199-2-8**]. He has
remained in sinus rhythm on oral amiodarone and lopressor. Chest
tubes and tempoary pacing wires were removed per protocol. He
was evaluated and treated by physical therapy for strength and
conditioning and was claered for discharge to home on POD# 6.
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Sotalol 120mg [**Hospital1 **]
Omega-3 fatty acids 2g [**Hospital1 **]
Nitro-patch 0.4mg per hour for 12 hours every day
Lipitor 20mg every other day
Atazanavir 300mg PO QHS
RiTONAvir 100mg PO QHS
ATRIPLA 600-200-300mg PO QHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
5. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Serial PT/INR
dx: s/p DCCV
goal INR 2-2.5 (x 1 month)
results to Dr. [**Last Name (STitle) 4020**] fax: [**Telephone/Fax (1) 1419**]
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 1
months: dose will change daily for goal INR 2-2.5. Dr.
[**Last Name (STitle) 4020**] to manage.
Disp:*60 Tablet(s)* Refills:*0*
9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: .5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week,
then 200mg/day until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a
day.
15. Atazanavir 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Redo Sternotomy, AVR (21 CE magna tisuue),CABGx3 [**2199-2-5**]
CAD -s/p CABG x2 [**9-17**] (as above)
-s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] LCX [**9-23**]
-Redo CABG [**2199-2-5**]
PAF -since surgery [**9-17**], with recurrence- DCCV [**10-18**] now in SR on
Sotolol
HIV-[**2182**] ( CD4 nadir 159 in [**2184**])
RHD (s/p bioprosthetic MVR/AVR - [**2192**])
s/p sinus surgery-chronic sinus congestion
dyslipidemia
basal cell carcinoma s/p multiple resections
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
1)Please shower daily including washing incisions gently with
mild soap, no baths or swimming, and look at your incisions
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
4)No driving for approximately one month until follow up with
surgeon
5)No lifting more than 10 pounds for 10 weeks
6)Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**2199-3-18**] 1:00. ([**Telephone/Fax (1) 4044**]
INR to be drawn [**2-12**] with results to: Dr. [**Last Name (STitle) 4020**] fax
[**Telephone/Fax (1) 1419**]
(confirmed with [**Doctor First Name **])
Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2199-2-25**] 3:00
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2199-3-7**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**]
Date/Time:[**2199-3-21**] 3:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2199-2-11**]
|
[
"998.11",
"285.9",
"427.31",
"V45.82",
"V10.83",
"414.02",
"518.82",
"272.4",
"E878.1",
"E934.8",
"426.13",
"398.90",
"996.02",
"E878.2",
"414.01",
"416.8",
"V08",
"410.71",
"788.20",
"458.29",
"790.92",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"88.56",
"99.62",
"37.23",
"36.15",
"34.03",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
12795, 12853
|
8771, 10636
|
286, 396
|
13422, 13518
|
3642, 8748
|
14071, 14910
|
3103, 3136
|
10951, 12772
|
12874, 13401
|
10662, 10928
|
13542, 14048
|
3151, 3623
|
2292, 2638
|
236, 248
|
424, 2273
|
2660, 2926
|
2942, 3087
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,624
| 143,973
|
54789
|
Discharge summary
|
report
|
Admission Date: [**2127-8-12**] Discharge Date: [**2127-8-19**]
Date of Birth: [**2045-1-2**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache and left sided weakness
Major Surgical or Invasive Procedure:
[**2127-8-13**] R frontoparietal craniotomy for evacuation of SDH
History of Present Illness:
This is an 82 year old man who is Albanian speaking, with one
week history of frontal headaches. His wife noted some
difficulty in dressing and generalized weakness. Family also
noted some slurred speech and comprehension that gradually
progressed over a 3 day period. He presented to [**Hospital3 **] for
evaluation and was found to have bilateral frontal acute on
chronic subdural collections with mild subfalcine herniation and
3mm midline shift.
Past Medical History:
HTN, HC
Social History:
He is a retired carpenter. He used to smoke. Lives at home with
wife. Albanian speaking
Family History:
NC
Physical Exam:
On Admission:
98.6 87 107/87 16 98% 2L Nasal Cannula
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm, reactive EOMs. Slight L sided tongue
deviation
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-22**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue slight L sided deviation
Motor: Normal bulk bilaterally. No abnormal movements,
tremors. Strength 3-4/5 of left and [**4-26**] on right upper
extremity.
Full power [**4-26**] throughout in lower extremity. Slight pronator
drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon discharge:
Awake, alert, PERRL, face symm, tongue midline, MAE full,
oriented x 3. Non-English speaking but family translates and
feels comprehension and speech intact.
Pertinent Results:
CT head [**2127-8-11**]:
1. No interval change. Large right frontal and small left
frontal subdural hematomas, acute-on-chronic, with right
subfalcine herniation and leftward shift of midline structures.
This was discussed with Dr. [**First Name (STitle) **] at 12:20 a.m. on [**2127-8-12**]
in person by Dr. [**Last Name (STitle) **].
2. Nonspecific focal hypodensity in the right corona radiata,
suggestive of an infarct of uncertain chronicity.
CT head [**2127-8-12**]
1. No interval change. Large right frontal and small left
frontal subdural hematomas, acute on chronic, with right
subfalcine herniation and leftward shift of midline structures.
2. Nonspecific focal hypodensity in the right corona radiata,
suggestive of an infarct of uncertain chronicity, unchanged in
the short interim.
CXR [**2127-8-12**]
Improvement in bilateral basilar lung opacities since prior
imaging. Otherwise, unchanged chest radiograph.
EKG [**2127-8-13**]
Sinus bradycardia. Poor R wave progression, likely a normal
variant. Cannot exclude prior anteroseptal myocardial
infarction. Compared to the previous tracing of [**2127-8-11**] no
diagnostic interim change.
CT head [**2127-8-13**]
1. Interval right craniotomy with evacuation of right subdural
hematoma and placement of drain along the right frontal
convexity.
2. Stable appearance of left subdural hematoma.
CXR [**2127-8-15**]:
FINDINGS: As compared to the previous radiograph, the lung
volumes continue to be low. There are areas of atelectasis in
the left perihilar and right basal lung. In addition, the
vascular diameters have slightly increased, potentially
reflecting mild fluid overload. No pleural effusions are seen.
No evidence of pneumonia.
CT head [**2127-8-18**]:
1. Interval subdural hematoma, presumably after removal of the
right frontal drain.
2. Stable appearance of left subdural hematoma.
Brief Hospital Course:
Mr. [**Known lastname 111986**] was admitted to the SICU at [**Hospital1 18**] on [**2127-8-12**]. CT
head was repeated and was table. Due to his weakness, he was
made NPO for the OR. On [**8-13**] he was taken tot he OR with Dr.
[**First Name (STitle) **] for right sided craniotomy for subdural hematoma
evacuation. He tolerated the procedure well and was placed in
the ICU for further monitoring with a subdural drain in place.
On [**8-14**] he was stable in the ICU and his sibdural drain was
removed. he had increased secretions and was wheezing so he
recieved Lasix and nebs with good effect. On [**8-15**] his BUN was
noted [**Last Name (un) **] slightly elevated and fluids were increased. Transfer
orderes were written for him to go to the floor. His exam was
significant for mild LUE weakness but otherwise intact. A chest
xray showed mild volume overload and IVF were discontinued. He
continued on neb treatments for wheezing. His subdural drain was
discontinued. On [**8-16**], he remained stable on the floor. On [**8-17**],
his respiratory status improved and was only requiring neb
treatments prn. On [**8-18**], patient worked with PT and a repeat
head CT was performed to follow-up. The CT was stable but did
show some acute blood but overall improved. On [**8-19**], he was
discharged to rehab.
Medications on Admission:
1. Simvastatin 20 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough/wheeze
3. Hydrochlorothiazide 25 mg PO DAILY
Home med
4. Lisinopril 20 mg PO DAILY
Hold for SBP < 110
Home med
5. Simvastatin 20 mg PO DAILY
Home med
6. Docusate Sodium 100 mg PO BID
7. LeVETiracetam 500 mg PO BID
8. Senna 2 TAB PO BID
9. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY
11. Artificial Tears 1-2 DROP BOTH EYES PRN eye irritation
12. Heparin 5000 UNIT SC TID
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN cough/wheeze
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) **]
Discharge Diagnosis:
Subdural Hematoma with midline shift
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:
Craniotomy for Hemorrhage
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound was closed with staples. You may wash your hair
only after staples 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 were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this when cleared by your neurosurgeon.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in 10 days(from your date of
surgery) for removal of your staples. This appointment can be
made with the Nurse Practitioner. Please make this appointment
by calling [**Telephone/Fax (1) 4296**]. You may also have them removed at your
rehab facility.
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in _4__weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2127-8-19**]
|
[
"432.1",
"728.87",
"784.0",
"348.4",
"401.9",
"276.69",
"272.0",
"518.0",
"799.02",
"784.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
6600, 6678
|
4531, 5846
|
338, 406
|
6759, 6759
|
2633, 4508
|
8734, 9285
|
1040, 1044
|
5994, 6577
|
6699, 6738
|
5872, 5971
|
6942, 8711
|
1059, 1059
|
266, 300
|
2455, 2614
|
434, 886
|
1620, 2439
|
1073, 1327
|
6774, 6918
|
908, 918
|
934, 1024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,209
| 114,078
|
29496
|
Discharge summary
|
report
|
Admission Date: [**2150-1-15**] Discharge Date: [**2150-1-28**]
Date of Birth: [**2074-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Ciprofloxacin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Postural Lightheadedness, dizziness
Major Surgical or Invasive Procedure:
[**2150-1-15**] cardiac catherization
[**2150-1-16**] Redo-Sternotomy, Aortic Valve Replacment with 19mm CE
pericardial tissue valve
[**2150-1-18**] Reexploration right hemothorax
History of Present Illness:
75 y/o female with known coronary artery disease s/p coronary
artery bypass graft x 4 now with severe aortic stenosis.
Referred for cardiac cath which revealed patent bypass grafts
but confirmed aortic stenosis. Now referred for surgical
intervention.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
[**2141**], Hyperlipidemia, Hypertension, Chronic Myelocytic Leukemia,
Gastroesophageal Reflux Disease, Stress Incontinence, Internal
Hemorrhoids, Recurrent UTIs, Hepatitis [**2123**], s/p Appendectomy,
s/p Bladder suspension, s/p Bilat. Cataract surgery
Social History:
Lives alone, widow, 6 children
Switch board operator, Tob: Quit in [**2140**]
Family History:
Mother died at 60 from CAD
Physical Exam:
VS: 51 12 202/59 5'2" 155#
Gen: NAD, lying flat after cath
Skin: Unremarkable with well-healed MSI, L radial harvest and L
Open SVG harvest sites
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR 4/6 murmur which radiates to carotids
Abd: Soft, NT/ND, +BS, -edema, -varicosities
Neuro: MAE, A&O x 3, Non-focal
Discharge
Vitals 99.3, 72 SR, 117/75, 20, RA sat 98% wt 66.9kg
General No acute distress
Neuro a/o x3 non focal
Pulm CTA bilat post/ant
Cardiac RRR no murmur/rub/gallop
Sternal inc healing no erythema, no drainage steris removed [**1-28**]
Left groin healing no drainage no erythema sm amt edema
Ext warm pulses palpable trace edema
Abd soft, NT, ND +BS, BM [**1-27**]
Pertinent Results:
[**2150-1-26**] 06:50AM BLOOD WBC-100.2* RBC-3.52* Hgb-10.5* Hct-31.2*
MCV-89 MCH-29.8 MCHC-33.6 RDW-15.3 Plt Ct-809*
[**2150-1-15**] 09:00AM BLOOD WBC-42.2* RBC-3.45* Hgb-10.1* Hct-29.1*
MCV-84 MCH-29.3 MCHC-34.7 RDW-17.3* Plt Ct-355
[**2150-1-24**] 06:07AM BLOOD Neuts-47* Bands-10* Lymphs-6* Monos-9
Eos-6* Baso-1 Atyps-1* Metas-8* Myelos-9* Promyel-3* NRBC-3*
[**2150-1-26**] 06:50AM BLOOD Plt Ct-809*
[**2150-1-15**] 09:00AM BLOOD Plt Ct-355
[**2150-1-15**] 09:00AM BLOOD PT-13.4* PTT-36.3* INR(PT)-1.2*
[**2150-1-26**] 06:50AM BLOOD Glucose-79 UreaN-16 Creat-1.0 Na-134
K-4.6 Cl-97 HCO3-24 AnGap-18
[**2150-1-15**] 09:00AM BLOOD Glucose-116* UreaN-15 Creat-0.7 Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
[**2150-1-19**] 02:02AM BLOOD ALT-37 AST-58* LD(LDH)-488* AlkPhos-48
Amylase-38 TotBili-1.2
[**2150-1-26**] 06:50AM BLOOD Calcium-8.6 Phos-3.8 Mg-3.1*
[**2150-1-15**] 09:00AM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
All microbiology no growth to date blood cultures not final
Procedure date Tissue received Report Date Diagnosed
by
[**2150-1-16**] [**2150-1-16**] [**2150-1-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma„
DIAGNOSIS
Aortic valve leaflets:
Extensive calcifications and focal chronic inflammation.
[**2150-1-27**]
Compared to [**2150-1-24**], the overall appearance of the lungs and
pleural spaces is unchanged. The pleural fluid anteriorly in the
right chest and the lateral pleural fluid/thickening raises the
question of loculation to a small degree, though there appears
to be persistent subpulmonic effusion making up the majority of
the right effusion. Resolving hemothorax is a consideration.
Atelectasis at the right lung base and mid lung persists. There
is a trace left pleural effusion and minimal left lung
subsegmental atelectasis. Heart size and mediastinal contour are
unchanged. Sternal wires are intact. 2.3 cm oval radiopaque
lesion overlying the right inferior aspect of the liver is
uncertain in location but also appeared to be present on the
[**2150-1-24**] chest film and could represent a gallstone, though this
is uncertain.
IMPRESSION:
1. Unchanged appearance of the lungs and pleural spaces with
complicated right pleural fluid, which could represent resolving
hemothorax. Nondependent portions of the collection raise
question of small loculations, unchanged.
2. Oval radiopacity over the right upper quadrant, unchanged
from [**2150-1-24**]. This is uncertain whether it is within the patient
and would likely represent a gallstone, or external to the
patient.
[**2150-1-16**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.6 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: 0.29 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aorta - Arch: 2.7 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: *2.7 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 1.9 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. Mild spontaneous echo contrast
in the body
of the LA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum.
No ASD or PFO by 2D, color Doppler or saline contrast with
maneuvers.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall
hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch.
Mildly dilated descending aorta. There are complex (>4mm)
atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS:
1. The left atrium is mildly dilated. Mild spontaneous echo
contrast is seen
in the body of the left atrium. No atrial septal defect or
patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%).
3. The right ventricular cavity is moderately dilated. Right
ventricular
systolic function is mildly hypokinetic.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta
is mildly dilated. There are complex (>4mm) atheroma in the
descending
thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
POST-BYPASS: Pt is being paced and is on an infusion of
phenylephriine
1. A bioprosthesis is well seated in the aortic position. No Ai
is seen.
Leaflets appear to open well. The mean gradient across the valve
is 20 mm of
Hg.
2. Biventricular function is preserved
3. Aorta is intact
4. MR appears slightly worse, no [**Male First Name (un) **] is seen.
5. Other findings are unchanged
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2150-1-20**] 12:11.
Brief Hospital Course:
As mentioned in the HPI Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a cardiac cath
which revealed severe AS, native CAD with clean bypass grafts.
All preoperative surgical work-up was performed and on [**2150-1-16**]
she was brought to the operating room where she [**Date Range 1834**] a
redo-sternotomy and aortic valve replacement. Please see
operative report for surgical details. Following surgery she was
transferred to the CSRU for invasive monitoring in stable
condition. She was weaned from sedation, awoke and was extubated
on postoperative day 1 and she continued to progress. On
postoperative day 2 she had right hemothorax and returned to the
operating room for reexploration. Later on post-op day two he
was weaned from sedation, awoke neurologically intact and was
extubated. Beta blockers and diuretics were initiated and she
was gently diuresed towards her pre-op weight. Chest tubes were
removed post-op day three/four and aggressive pulmonary toilet
was continued. Chest x-ray revealed small right apical PTX which
slowly decreased in size throughout hospital course. Once
extubated she appeared to have some delirium which slowly
improved over time with medication. On post-op day six she was
transferred to the telemetry floor. Her WBC remained elevated
throughout hospital course (secondary to CML) but multiple blood
and urine cultures were performed to r/o infection. She remained
stable over next several days and then had an episode of atrial
fibrillation on post-op day seven which was successfully
converted to SR with Lopressor. Physical therapy followed
patient during entire post-op course for strength and mobility.
Ms. [**Known lastname **] appeared stable but required additional PT and was
discharged to rehab on post-op day [**12-7**] with the appropriate
medication and follow-up appointments. Plan for follow up with
hematology/oncology on friday for initiation of treatment for
CML.
Medications on Admission:
Lipitor 10mg qd, Atenolol 50mg qd, Avapro 150mg qd, Imdur 30mg
qd, Aspirin 81mg qd, Nitrofurantoin 100mg [**Hospital1 **]
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: Two (2)
Capsule PO twice a day.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Aortic Stenosis s/p Redo-Sternotomy, Aortic Valve Replacment
PMH: Coronary Artery Disease s/p Coronary Artery Bypass Graft
[**2141**], Hyperlipidemia, Hypertension, Chronic Myelocytic Leukemia,
Gastroesophageal Reflux Disease, Stress Incontinence, Internal
Hemorrhoids, Recurrent UTIs, Hepatitis [**2123**], s/p Appendectomy,
s/p Bladder suspension, s/p Bilat. Cataract surgery
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appt
Dr. [**Last Name (STitle) **] 1 week after discharged from rehab ([**Telephone/Fax (1) 70780**])
please call for appt
Dr. [**Last Name (STitle) 10740**] 1 week after discharged from rehab ([**Telephone/Fax (1) 40144**])
please call for appt
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD (Heme/Onc) Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2150-1-30**] 9:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2150-1-28**]
|
[
"272.4",
"E878.2",
"998.11",
"530.81",
"427.31",
"V45.81",
"205.10",
"414.01",
"401.9",
"424.1"
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icd9cm
|
[
[
[]
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[
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"88.53",
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icd9pcs
|
[
[
[]
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11234, 11317
|
8213, 10152
|
352, 534
|
11738, 11744
|
2039, 8190
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1265, 1293
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10324, 11211
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11338, 11717
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10178, 10301
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11768, 12186
|
1308, 2020
|
277, 314
|
562, 815
|
837, 1154
|
1170, 1249
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,772
| 143,538
|
33896
|
Discharge summary
|
report
|
Admission Date: [**2198-1-5**] Discharge Date: [**2198-1-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Intubation
PICC line placement
History of Present Illness:
Mr [**Known lastname 21883**] is an 84-year-old man with a history of CABGx4 in [**2185**]
(LIMA-LAD, SVG-OM, SVG-Diag, SVG-RCA), chronic systolic CHF (EF
35% with ICD placed in [**2194**]), severe AS (area 0.6 cm2, gradient
33 mmHg, s/p valvuloplasty in [**5-/2197**]), who was transferred from
OSH for acute heart failure exacerbation in the setting of
severe AS. The patient presented to [**Location (un) 11248**] Hospital in New
[**Location (un) **] on [**2198-1-1**] with acute abdomen. Abd CT revealed
dilated small bowel with wall thickening. Seen by surgery, with
a working diagnosis of perforated diverticulum even though no
definite diverticulum was seen on imaging. Pt was treated with
IVF and pip-tazo. He then developed congestive heart failure
with troponin rising to 17.0. Echo at OSH showed EF of 25% with
critical AS with valve area 0.6 cm2 and moderate AI. He was
treated with BiPAP. The discharge summary mentioned usage of
"dopamine" at one point but patient was not on pressor on
transfer. Given that his prior valvuloplasty was done at [**Hospital1 18**],
he was transferred here for further management.
Past Medical History:
1. CARDIAC RISK FACTORS:: Diabetes (-), Dyslipidemia (+),
Hypertension (-), Remote smoking (+)
2. CARDIAC HISTORY:
-CABG: [**5-/2185**] with LIMA to LAD, SVG sequential to Ramus and OM,
SVG
to diag, SVG to RCA
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: ICD placed in [**2194**] for primary prevention, LVEF
-Severe AS: area 0.6 cm2, gradient 33 mg Hg, s/p valvuloplasty
in [**5-/2197**] at [**Hospital1 18**]
-LV dysfunction, EF 35% on prior echocardiograms
3. OTHER PAST MEDICAL HISTORY:
Appendectomy
Cholecystectomy
Remote non-alcoholic pancreatitis
Social History:
-Tobacco history: remote; Quit smoking:
-ETOH: none
-Illicit drugs: none
Widowed and lives alone. Works part time as a driver for a
Chevrolet dealer.
Family History:
No family history of early MI. Father died suddenly of a brain
aneurysm in his 50s. Mother died at age [**Age over 90 **] from Alzheimer??????s
disease.
Physical Exam:
GENERAL: Elderly man intubated, not responsive
HEENT: NCAT. Sclera anicteric. Pupils 3mm -> 1 mm bilaterally.
ET tube in place
NECK: Supple with JVP of 9 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Soft [**2-9**] late-systolic murmur.
LUNGS: Decreased BS at bases, from anterior.
ABDOMEN: Soft, BS present, no mass, no abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
LABS ON ADMISSION ([**2198-1-5**]):
.
HEMATOLOGY:
[**2198-1-5**] 02:06PM BLOOD WBC-15.4*# RBC-3.52* Hgb-11.4* Hct-32.7*
MCV-93 MCH-32.3* MCHC-34.7 RDW-13.5 Plt Ct-228
[**2198-1-5**] 02:06PM BLOOD Neuts-79* Bands-1 Lymphs-12* Monos-3
Eos-4 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2198-1-5**] 02:06PM BLOOD PT-14.3* PTT-24.6 INR(PT)-1.2*
.
CHEMISTRY
[**2198-1-5**] 02:06PM BLOOD Glucose-105 UreaN-83* Creat-2.1*# Na-149*
K-3.9 Cl-113* HCO3-28 AnGap-12
[**2198-1-5**] 02:06PM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.5 Mg-3.2*
Iron-17* Cholest-101
[**2198-1-5**] 02:06PM BLOOD ALT-76* AST-67* LD(LDH)-402* CK(CPK)-80
AlkPhos-123* TotBili-4.4*
.
CARDIAC ENZYMES:
[**2198-1-5**] 02:06PM BLOOD CK(CPK)-80 CK-MB-NotDone cTropnT-3.45*
proBNP-2729*
[**2198-1-5**] 09:24PM BLOOD CK(CPK)-134 CK-MB-3 cTropnT-2.88*
[**2198-1-6**] 05:30AM BLOOD CK(CPK)-121 CK-MB-3 cTropnT-2.93*
.
[**2198-1-5**] 02:06PM BLOOD calTIBC-172* VitB12-1167* Folate->20
Ferritn-841* TRF-132*
[**2198-1-5**] 02:06PM BLOOD Triglyc-228* HDL-10 CHOL/HD-10.1
LDLcalc-45
.
URINE:
[**2198-1-5**] 02:12PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-2* pH-5.5 Leuks-NEG
[**2198-1-5**] 02:12PM URINE RBC-801* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
.
.
MICROBIOLOGY:
Bl cx - negative
C diff - negative
sputum cx - negative
.
.
Other labs-
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2198-1-15**] 08:06AM 8.8 3.62* 11.9* 33.4* 92 33.0* 35.7*
13.0 391
[**2198-1-10**] 05:33AM 16.5* 3.60* 11.7* 33.2* 92 32.6* 35.4*
12.8 346
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2198-1-15**] 08:06AM 79 33* 1.2 136 4.0 104 22 14
ALT AST LD AlkPhos TotBili
[**2198-1-11**] 03:49AM 54* 52* 132* 2.5*
[**2198-1-10**] 05:33AM 52* 51* 288* 144* 4.1*
.
CARDIOLOGY:
TTE (1/3/9)
The left atrium is markedly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is moderately depressed (LVEF= 35-40 %) with
hypokinesis of the basal to mid inferior and inferolateral walls
and hypokinesis of the mid to distal septum. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (area <0.8cm2).
Mild (1+) 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: Suboptimal image quality. Regional left ventricular
systolic dysfunction consistent with multivessel coronary
disease. Elevated left ventricular filling pressure. Severe
aortic stenosis. Mild mitral regurgitation.
.
.
RADIOLOGY:
.
RUQ U/S ([**2198-1-6**]):
IMPRESSION:
1. Status post cholecystectomy.
2. No biliary ductal dilatation.
.
.
CT A/P ([**2198-1-10**]):
IMPRESSION:
1. Small contained fluid collection measuring 2.8 cm within the
mid abdomen abutting an adjacent loop of small bowel. No
surrounding stranding is identified to suggest an acute
inflammatory process. This had not changed since the prior CTs
from Lakes Regional General. Differential includes fluid filled
diverticulum, duplication cyst, though infectious etiology
cannot be ruled out based on imaging. The location within the
mesentery does not appear amenable to percutaneous image-guided
biopsy.
2. Severe aortic valve calcifications with dilated left
ventricular chamber size.
3. Mildly enlarged subcarinal lymph node.
4. Sigmoid colon diverticulosis.
5. Extensive calcified atherosclerotic plaque within the
abdominal aorta,
iliac branches and common femoral arteries.
6. Small amount of air within the bladder. Please correlate with
Foley
catheter placement.
7. Extensive degenerative changes within the lower lumbar spine
in which
further evaluation with MRI may be obtained as indicated.
Brief Hospital Course:
Mr [**Known lastname 21883**] is an 84yo M w CAD (s/p CABGx4), chronic sys CHF (s/p
ICD, EF 35% in [**1-/2198**]), severe AS (area 0.6 cm2, gradient 33
mmHg, s/p valvuloplasty in [**5-/2197**]), who originally p/w to OSH w
acute abdomen was found to have a possible small bowel
perforation, and was transferred to [**Hospital1 18**] for acute CHF
exacerbation [**2-5**] severe AS in the setting of small bowel
perforation, s/p intubation for respiratory failure.
.
# RESPIRATORY FAILURE: Likely [**2-5**] from pulmonary edema from
acute systolic CHF exacerbation. Pt was intubated and on
mechanical ventilation for hypoxemia. Condition improved w
diuresis/antibiotics and pt was successfully weaned from the
ventilator and extubated without problems. On discharge pt is
oxygenating in the mid-to upper 90s on RA.
.
# PUMP: acute on chronic systolic CHF exacerbation with
pulmonary edema [**2-5**] AS, leading to respiratory failure requiring
intubation. TTE at OSH showed LVEF = 25%, repeat TTE with
improvement to LVEF of 35-40% at [**Hospital1 18**]. On transfer to [**Hospital1 18**],
gentle diuresis was started with net 24-hr UOP goal of -500cc
given preload-dependent state [**2-5**] AS. Pt responded to Lasix 20mg
IV doses well. On discharge, pt on metoprolol and 20mg PO lasix.
Regarding ACEi/[**Last Name (un) **], patient has not tolerated it in the past [**2-5**]
AS per outpatient cardiologist. Wgt on discharge is 75.5kg.
.
# VALVES: critical AS - TTE showed LVEF 35-40%, Aortic area of
0.7cm2 ([**2198-1-6**]), preload dependent. S/p valvuloplasty in
5/[**2197**]. No valvuloplasty during this admission given clinical
stability. Might need valvuloplasty if indication for abdominal
surgery / diagnostic laparoscopy. Discharged on metoprolol 25mg
[**Hospital1 **].
.
# RHYTHM: normal sinus rhythm, on metoprolol.
.
# CORONARIES: Known CAD s/p CABGx4. Currently no acute ischemia,
Trp leak likely [**2-5**] to subendocardial ischemia in the setting of
CHF exacerbation, severe AS, and concurrent renal failure. CK
remained flat. Pt discharged on aspirin, metoprolol. Pravastatin
held due to transaminitis. No ACEi/[**Last Name (un) **] due to aortic stenosis.
Statin to be restarted once LFTs improve.
.
# SMALL BOWEL PERFORATION/ABSCESS: Pt presented to OSH w
abdominal pain. CT showed small amount of free air that was
attributed to diverticular perforation. Repeat CT at [**Hospital1 18**]
showed possible abscess near small bowel. Pt also w fever and
leukocytosis, but hemodynamically stable. Started on Zosyn at
OSH for broad coverage, continued at [**Hospital1 18**]. Surgery was
consulted, a diagnostic laparoscopy was considered, however, pt
improved clinically (nontender abdominal exam, downtrending WBC
count, afebrile). All cultures negative. Thus, invasive
intervention was deferred, especially given the severe aortic
stenosis. Pt on TPN breifly, transitioned to cleasr and
advancing to regular cardiac diet at transfer. Decreased
appetite, but increasing PO's slowly. On discharge, pt is
afebrile with resolved leukocytosis. Followup recommended with
surgery, Dr [**Last Name (STitle) 468**] on [**2198-2-5**], so evavalut abdomen. Will need
f/u CT abd. Zosyn will be continued until next surgery followup.
Weekly CBC/Chemistry should be checked.
.
# ACUTE RENAL FAILURE: Creatinine of 2.1 on transfer (baseline
~1.0), likely renal hypoperfusion secondary to poor forward
flow. FeUN = 23 < 50% (suggestive of prerenal etiology).
Resolved with improved perfusion.
.
# TRANSAMINITIS/HYPERBILIRUBINEMIA: Transaminitis likely due to
hypoperfusion in setting of CHF and severe AS. Unremarkable RUQ
U/S (no signs of CBD dilation, s/p cholecystectomy).
Hyperbilirubinemia of unclear etiology. Improving LFTs on
discharge. Pravastatin held, may be restarted after LFTs
resolve.
.
# ANEMIA: Hct 32 now, 39 in [**Month (only) 116**]. Combined iron-deficiency and
anemia of chronic disease. Stable in low 30-s.
.
# MENTAL STATUS/PSYCH: Pt w some confusion s/p extubation,
improved on discharge. Flat affect, depressed mood likely from
chronic medical conditions. Social work consulted for coping,
encouragement and emotional support provided.
.
# Hiccups: resolved with baclofen, stopped [**2-5**] mild confusion.
.
Will be tranfered to OSH for on going PT, cardiopulmonary
monitoring, IV abx, and furhter treatment by PCP.
Medications on Admission:
HOME MEDS:
ASA 325
lopressor 25
pravastatin
nitro PRN
zyrtec
MVI
niacin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Piperacillin-Tazobactam Na 4.5 g IV Q8H
day 1 = [**1-1**] (OSH)
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 71793**] [**Hospital 12018**] Hospital
Discharge Diagnosis:
acute on chronic systolic congestive heart failure exacerbation
acute respiratory failure secondary to cardiogenic pulmonary
edema
small bowel perforation complicated by abscess
.
severe aortic stenosis
coronary artery disease
acute renal failure
Discharge Condition:
afebrile, hemodynamically stable, oxygenating on room air;
confused in AMs, but mental status improves during the day
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you developed respiratory
failure due to fluid in your lungs from heart failure. This
likely happened in the setting of aortic stenosis and newly
found possible bowel perforation. We treated you with mechanical
ventilation, diuresis and antibiotics.
For your abdomen, you do not need surgery at this time. You have
a small pocket of infection in your abdomen, for which you are
on antibiotics. You will need to see sugery in 3 weeks for a
follow up evaluation and CT scan to see if you still need
antibiotics. In the meantime, you will need lab work at least
once a week. You have an appt with surgery at [**Hospital1 18**], but you can
reschedule to see someone at [**Location (un) 71793**] if needed. A copy of your
recent CT scan will be sent to the [**Hospital 71793**] hospital.
.
You should continue your medications as prescribed.
.
You will be transfered to the [**Hospital 71793**] [**Hospital 12018**] Hospital for
further care under your regular cardiologist- Dr. [**Last Name (STitle) 11250**].
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
Followup Instructions:
-Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 468**], surgery, office number [**Telephone/Fax (1) 476**], [**Hospital Ward Name 23**]
bldg [**Location (un) 470**], appointment [**2198-2-5**] at 10:45AM, please call to
cancel if you instead see a surgeon at [**Hospital 71793**] hospital.
-Needs repeat CT scan to evaluate change in abdominal abscess in
3 weeks, or sooner if change of symptoms. Evaluate for duration
of zosyn treatment.
PCP: [**Name10 (NameIs) **],[**Last Name (un) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 11254**]- will be following
at [**Hospital 71793**] hospital. Will follow CBC and lytes.
Completed by:[**2198-1-15**]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,229
| 165,594
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13068
|
Discharge summary
|
report
|
Admission Date: [**2191-8-12**] Discharge Date: [**2191-9-14**]
Date of Birth: [**2118-2-22**] Sex: M
Service: MEDICINE
Allergies:
Hydromorphone / Metoclopramide
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress, hypotension
Major Surgical or Invasive Procedure:
Endotracheal Intubation and Extubation
Tracheostomy tube placement and mechanical ventilation
Placement of temporary femoral HD catheter that was replaced
with Left PICC and Right tunnelled IJ HD line
PEG tube placement
History of Present Illness:
Mr. [**Known lastname 39953**] is a 73 yoM on HD-anuric, h/o AFib not currently on
coumadin (though is on at home), who is being transferred from
the neurology service for respiratory distress and hypoxia. He
was admitted on [**2191-8-12**] after a fall resulting in acute on
chronic SDH on the left; his course is complicated by seizure
and he has been started on fosphenytoin & phenytoin.
This evening he was noted to be in acute respiratory distress
with desats to the low to mid 90's on 3LNC (reportedly desatting
to the mid 70's on room air; has had a variable O2 requirement
since being admitted). His blood pressure dropped to the 70's
systolic and was responsive to the 80's and then 100's after a
250 cc NS bolus. he was febrile to 101.9. The neurology and
medicine MERIT teams were concerned for an aspiration event vs.
volume overload vs. PE. CXR is c/w volume overload; however it
is grossly unchanged from earlier films. His normal schedule is
M-W-F though he did not get dialyzed on Friday [**8-19**] because he
was having focal motor seizures. He was last dialyzed Saturday
[**2191-8-20**] for a shorter cycle b/c of low blood flow from the HD
catheter(per renal note). His mental status has been poor since
being in the hospital.
Of note, on arrival to MICU pt was being treated with vanco/gent
for a possible line infection given recent fevers. Nothing has
grown out of numerous blood cultures since [**2191-8-12**] yet he
continues to spike. he was briefly in MICU green on [**8-17**] - [**8-18**]
for fevers and hypotension to the 70's.
Since arriving to the MICU satting in the upper 90's on NRB,
code status was confirmed with his wife on the phone and he was
intubated with vecuronium and etomidate. He is currently on AC
500x14 with PEEP 5 at 50% FiO2. Peri-intubation, MAP's dropped
to the 50's and he was started on low dose levophed through his
right PICC.
Past Medical History:
Atrial fibrillation on coumadin
CHF-- no EF in our system
CAD s/p CABG
DM
ESRD on HD
Glaucoma
Cataracts
Asthma
? gout (per med list)
Social History:
wife is HCP; no illicits including no tobacco
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM UPON TRANSFER TO MICU:
====================================
Vitals T 99.9 BP 122/31 HR 79 RR 19 02sat 94%3L NC
GENERAL: NAD, resp non-labored
HEENT: Surgical pupils bilat NGT in place
NECK: supple no JVD, LAD
CARDIAC: reg rate nl S1S2 no m/r/g
LUNGS: coarse bibasilar breath sounds scattered bilat rhonchi on
anterior auscultation
ABDOMEN: soft obese NTND normoactive BS
EXT: warm, dry diminished distal pulses no c/c/e; R brachial
PICC and L HD cath sites c/d/i no erythema, tenderness
NEURO: Somnolent but arousable with eye-opening to verbal
stimuli; nonverbal; wiggles L toes to command; R upper and lower
extremity hemiparesis; toes mute
CHANGED PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals: HR 70, BP 119/37, O2 98% on T-piece
Gen: Miminally responsive, opens eyes but does not track or
follow commands.
Lungs: Coarse BS
CHEST: Right tunnelled line in place
ABD: Soft, NT, PEG in place
EXT: Trace edema
NEURO: Unchanged, opens eyes, pupils surgical but reactive, left
hand tremor/contraction
Pertinent Results:
[**2191-8-16**] RUE U/S
1. No deep vein thrombosis seen in the left arm. No subcutaneous
fluid collection identified.
2. Occluded left arm fistula graft.
3. Small amount of non-occlusive thrombus material seen adherent
to the intravenous line which is identified within the right
subclavian veins.
.
[**2191-8-15**] portable CXR
In comparison with earlier study of this date, there has been
placement of a nasogastric tube that appears to extend to the
upper portion of the stomach. However, the image is extremely
light in the upper abdomen. To better evaluate the tip of the
tube, a repeat study could be obtained showing the lower chest
and upper abdomen and using abdominal technique.
.
EKG [**8-17**] @ 1249 SR @ 80 bpm NA/NI QIII,F TWI I,aVL no ST
elev/depr not significantly changed from [**2191-8-12**].
.
[**2191-8-12**] CT Head:
1. Acute on chronic left subdural hematoma. It is measuring up
to 11 mm in
greatest dimension. A component of extra-axial hemorrhage
towards the vertex appears contiguous with the subdural
collection and is less likely epidural.
2. Left hemisphere sulcal effacement and unchanged 3-mm
rightward shift of
midline structures.
3. Small right frontoparietal acute subdural hematoma.
4. Partial opacification of right mastoid air cells. No fracture
is
identified.
[**2191-8-12**] MRI Head:
1. Left-sided subdural hematoma with fluid-fluid level,
unchanged in size or mass effect. No new hemorrhage or shift of
normally midline structures. Thin subdural hematoma layering
over the right frontal convexity is also unchanged.
2. No evidence of acute infarction.
3. No significant stenosis, occlusion, or aneurysm, although
evaluation of
intracranial vessels is somewhat limited due to patient motion.
4. Left sphenoid sinus opacification.
.
[**9-1**] MRV:
1. Narrowing of the right subclavian as well as right
brachiocephalic veins.
2. Narrowing of the left subclavian as well as left internal
jugular vein.
3. Widely patent SVC and the right-sided internal jugular line
ends in the
distal SVC. Linear filling defect in the left internal jugular
vein is
suggestive of a fibrin sheath from prior catheterization.
4. Enlarged mediastinal lymph nodes, some of which are unchanged
from prior CT and of uncertain significance. Assessment by chest
CT could be obtained as per clinical need.
.
[**9-6**] CT torso:
1. Endplate erosive changes involving L2 through L4. While these
have a
typical location for Schmorl's nodes, the increased hazy border
is concerning for underlying infectious etiology. MRI of the
lumbar spine is recommended for further evaluation.
2. Prominent mediastinal lymph nodes as described above. These
are
nonspecific. The largest lymph node measures 1.6 x 2.1 cm in the
prevascular space.
3. Mild fluid overload.
4. Multiple renal hypodensities, likely cysts.
5. Extensive vascular calcifications.
6. Anterior abdominal wall hernia containing loops of small
bowel without
evidence of obstruction.
.
[**9-6**] MRI L spine:
1. No evidence of osteomyelitis or discitis.
2. Multiple Schmorl's nodes.
3. Multilevel degenerative changes.
.
[**9-6**] ECHO:
Mild symmetric left ventricular hypertrophy with preserved
global biventricular systolic function. Mild mitral
regurgitation. Mildly dilated ascending aorta. These findings
are c/w hypertensive heart.
.
[**9-12**] EEG:
This is an abnormal routine EEG secondary to a background
that is slow and low voltage consisting of mixed delta and theta
activity, consistent with a mild to moderate diffuse
encephalopathy.
There were no focal, lateralized, or epileptiform features
noted.
.
[**9-13**] CXR:
In comparison with the study of [**9-12**], there are slightly
improved
lung volumes. The nasogastric tube has been removed and the
tracheostomy tube remains in place. There is little change in
the cardiomediastinal silhouette. The opacification at the left
base may be slightly improving. Mild prominence of the
interstitial markings is consistent with elevated pulmonary
venous pressure.
.
LABS on DISCHARGE:
CBC: 10.9/24.9/373
CHEM: 141/4.6/99/25/50/9
Brief Hospital Course:
73 y.o. M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin
admitted with acute on chronic L SDH complicated by right-sided
weakness and epileptiform behavior, requiring ICU level care for
sustained respiratory failure and sepsis.
# Sepsis: Pt was transferred from Neurology service after
episode of hypotension. He became normotensive after
discontinuation of HD and after 1 L fluid resuscitation. Lactate
WNL. PICC line was removed, and he was started on vancomycin
and gentamicin for presumed line sepsis. PICC tip cultures
showed no growth. Pt was normotensive on transfer to Neurology
Service. Pt continued to have fevers through gentamycin and
vancomycin. He was transferred back for respiratory distress,
and periintubation he developed MAPs in the 50s and was started
on levophed to maintain pressures. He continued to remain
hypotensive for days afterwards. Pt received CVVH for continued
dialysis until BP could tolerate HD. Throughout the remainder
of his hospitalization, he continued to have brief periods of
hypotension between longer periods of hypertension and is stable
without IV pressors.
# Encephalopathy/Seizures: This was felt to be due to acute on
chronic sub-dural hematoma and recurrent seizures. Neurology
and Epilepsy Teams assisted in management of the patient.
Repeated non contrast CT performed. Per Neurology, MRI/MRA not
needed. Pt's fos-phenytoin was continued and titrated per
Neurology. After his final transfer to the MICU on [**8-21**] he was
not noted to have any further seizures. He was continued on
fosphenytoin until due to concern of line clotting he was
transitioned to Keppra.
# Respiratory distress - Pt was noted to be hyopoxic distress
which resulted in transferr to the MICU. He was intubated. He
was treated for pneumonia and dialized for significant volume
overload and eventualy weaned from the ventilator. Shortly
after extubation he was again in respiratory distress, most
likely due to inability to clear secretionss. He was
reintubated and eventually received a tracheostomy for chronic
ventilation as he continued to have poor control of his
secretions.
# Fevers/pneumonia/line infections: Pt continued to have fevers
throughout his hospitalization. Which continued after an
extended treatment of MRSA pneumonia with Staph aureus. He
continued to have colonization in the setting of tracheostomy
with MRSA and GNR, determined not to be infection given lack of
fevers and white count. He developed a second line infection
with pulstular draininage around the site of insertion. He was
covered broadly with antibiotics to cover gram positive
organisms and gram negative rods given his brief periods of
hypotension. Line was necessary for access to continue
administration of pressors. MRV was done to assess vessels given
history of stenosis. MRV showed diffuse stenosis in his central
vessels, in all but the RIJ, the place of his infected line. A
femoral was inserted with plans to place a long term tunnel
line, most likely in the RIJ.
# ESRD: Renal team following. He was briefly on CVVH during a
period of hypotension requiring pressors. When blood pressure
improved he was continued on hemodialysis .
# Diabetes Mellitus: Continued on basal and SSI.
Medications on Admission:
Medications on transfer:
Gentamicin 90 mg IV QHD-- since [**8-17**]
Vancomycin 500 mg IV QHD-- since [**8-17**]
Fosphenytoin 100 mg PE IV BID
Fosphenytoin 200 mg PE IV QHS (Q8 hours)
Phenytoin 1000 mg IV x 1 given this afternoon
.
Acetaminophen 650 mg PO Q6H:PRN
SSI + Lantus 20 Qam, 10 QHS
Citalopram 40 mg QD
Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
Simvastatin 40 mg PO DAILY
Allopurinol 100 mg PO BID
Calcium Acetate [**2182**] mg PO TID W/MEALS
Fish Oil (Omega 3) 1000 mg PO BID
FoLIC Acid 1 mg PO DAILY
Fluticasone Propionate NASAL 1 SPRY NU DAILY
Cyanocobalamin 50 mcg PO DAILY
Lorazepam 1-2 mg IV Q4H:PRN seizure > 5 minutes
Gabapentin 100 mg PO BID
Neomycin/Polymyxin/Dexameth Ophth Susp. 1 DROP LEFT EYE Q6H
Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE [**Hospital1 **]
Atropine Sulfate Ophth 1% 1 DROP LEFT EYE [**Hospital1 **]
Timolol Maleate 0.25% 1 DROP RIGHT EYE [**Hospital1 **]
Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop(s)to R eye
Ophthalmic HS (at bedtime).
2. Timolol Maleate 0.25 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Atropine 1 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
4. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Neomycin-Polymyxin-Dexameth 3.5-10,000-0.1 mg-unit/g-%
Ointment [**Hospital1 **]: One (1) Appl Ophthalmic Q6H (every 6 hours).
6. Cyanocobalamin 100 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Lorazepam 2 mg/mL Syringe [**Hospital1 **]: One (1) Injection Q4H (every
4 hours) as needed for seizure: Hold for sedation or rr <12.
Only give for seizures.
10. Allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Four (4) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
12. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: One (1)
Subcutaneous once a day: Please give 50U Glargine at breakfast,
please also give q6hrs Regular ISS starting at 8U at 81 mg/dL,
and increase 2U every 40mg/dL .
13. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
14. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Lidocaine HCl 2 % Gel [**Hospital1 **]: One (1) Appl Urethral ASDIR (AS
DIRECTED) as needed for sacral ulcer.
16. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY ON
HD DAYS ONLY ().
17. LeVETiracetam 500 mg IV QAM
18. LeVETiracetam 250 mg IV QPM
19. Midodrine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QMOWEFR (Monday
-Wednesday-Friday) as needed for prior to HD on HD days.
20. Fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
21. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection PRN (as needed) as needed for line flush.
22. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
23. Oxymetazoline 0.05 % Aerosol, Spray [**Last Name (STitle) **]: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) for 3 days.
24. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution [**Hospital1 **]: Two (2) PO Q24H (every 24 hours).
25. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q6H (every 6 hours).
26. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: [**11-19**] PO Q6H (every 6
hours) as needed for fevers or pain.
27. Acidophilus-B.bifidum-B.longum 150 mg Tablet, Chewable [**Month/Day (2) **]:
One (1) Tablet, Chewable PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnoses/active issues this admission:
1. Acute on chronic left subdural hematoma
2. Hypoxia necessitating mechanical ventilation, s/p trach
placement
3. Hypotension requiring vasopressors
4. Seizures, now controlled with Keppra
5. Fevers, of unknown etiology, presumed to be due to medicines
6. ESRD, HD dependent
7. Likely sinus infection seen on CT sinuses, receiving ABx and
nasal spray course
Secondary Diagnoses:
Atrial fibrillation on coumadin
h/o CHF-- no EF in our system
CAD s/p CABG
DM
Glaucoma
Cataracts
Asthma
? gout (per med list)
Discharge Condition:
By the time of discharge, the pt was off vasopressors, was in
the process of being successfully weaned from mechanical
ventilation, was beginning to become more alert but still not
following commands, vital signs were stable, was not having any
active seizures, and was medically clear for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you had a fall and were found
to have a bleed in your head that was acute on top of a chronic,
previous subdural hematoma. You then developed respiratory
distress, your blood pressure dropped, and had some seizures,
and were transferred to the MICU where you were intubated, given
anti-seizure medicines, and finally needed a tracheostomy tube
and feeding tube inserted into your stomach.
While you were admitted, we continued your home hemodialysis. We
made the following changes to your home medication regimen:
STOPPED: Home Gabapentin, Fish oil, Calcium acetate,
Simvastatin, Citalopram.
CHANGED: Home Lantus 20/10 qam/pm with SSI, to Lantus 50U
qbreakfast with SSI as below on med reconciliation list.
STARTED: Docusate/Senna, Lidocaine gel to sacral wound, Keppra
as below (500/250 qam/pm with an extra 500mg each HD day),
Oxymetolazone and Augmentin [**2191-9-14**] = day [**12-28**]) for presumed
sinus infections seen on CT scan, and Lansoprazole.
You should take your medicines exactly as they are prescribed
after discharge.
Please return to the hospital if you experience fevers, chills,
or night sweats, difficutly breathing or if your respiratory
status worses, chest pain, abdominal pain, or any pain anywhere,
any seizure activity, decline in your mental status, or any
other concerns.
Followup Instructions:
You are being discharged to a rehab facility where they will
need to monitor your labs frequently.
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39752**]
Mian by calling [**Telephone/Fax (1) 39662**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"365.9",
"585.6",
"345.80",
"V45.11",
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"995.92",
"518.81",
"996.62",
"428.0",
"V58.61",
"482.42",
"V45.81",
"427.31",
"785.52",
"493.90",
"799.02",
"V58.67",
"250.00",
"428.32",
"461.8",
"403.91",
"038.9",
"852.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"38.93",
"96.04",
"96.72",
"31.1",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
15332, 15414
|
7876, 11123
|
332, 554
|
16013, 16316
|
3800, 4630
|
17715, 18115
|
2716, 2734
|
12181, 15309
|
15435, 15843
|
11149, 11149
|
16340, 17692
|
2749, 3415
|
15864, 15992
|
3443, 3781
|
259, 294
|
7807, 7853
|
582, 2481
|
4639, 7788
|
11174, 12158
|
2503, 2637
|
2653, 2700
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,846
| 154,152
|
41664
|
Discharge summary
|
report
|
Admission Date: [**2200-9-3**] Discharge Date: [**2200-9-12**]
Date of Birth: [**2137-11-19**] Sex: F
Service: SURGERY
Allergies:
Lotrel / Benicar
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Failing right BKA
Major Surgical or Invasive Procedure:
Right Above-Knee amputation on [**2200-9-9**]
History of Present Illness:
Ms. [**Known lastname 1391**] is a 62 year old female who presented to vascular
clinic from her rehabilitation facility on [**9-3**] with nonhealing
right BKA wound, flexion contracture, and inadequate pain
control.
Past Medical History:
PVD, CAD, HTN, HL, CRI s/p nephrectomy for renal cancer, anemia,
osteoporosis, folate deficiency
Social History:
[**1-12**] ppd until approximately 2 years ago
[**2-13**] drinks on weekends
Family History:
Father: diabetes, stroke and MI
Physical Exam:
PE on admission:
Gen: Alert, correctly answers orientation questions, but poor
short term memory, holding right BKA to her chest.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses.
Extremities: No femoral bruit/thrill, No LLE Edema, abnormal:
Right BKA wound.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. Other: Right BKA.
LLE Femoral: P. DP: D. PT: D.
DESCRIPTION OF WOUND: Right medial leg wound, with distal
opening, fibrinous exudate, mild surrounding erythema. Right
BKA
stump with black eschar at surgical incision site, surrounding
erythema, medial open aspect with fibrinous exudate.
PE on discharge:
Gen: AAOx4, pleasant and conversant, in no acute distress
CVS: RRR, normal S1 and S2, no M/R/G
Pulm: Clear bilaterally, no W/R/R
Abd: Soft, nontender, nondistended, +BS
Ext: R AKA wound clean, dry, intact with staples. No erythema,
no induration, no bleeding, no discharge, no purulence.
Neuro: CN II-XII grossly intact
Pulses: Femoral pulses palp b/l; L DP/PT dopplerable (R AKA)
Brief Hospital Course:
Ms. [**Known lastname 1391**] was admitted on [**2200-9-3**] from rehab after she
presented to the vascular clinic with a failing right BKA -
flexion contracted, poorly healing, with surrounding cellulitis,
and poor pain control. She was directly admitted to the
Vascular surgery floor for further evaluation and treatment.
She was started on IV vancomycin, ciprofloxacin, and
metronidazole for broad spectrum coverage for her BKA wound.
Physical therapy was consulted, and a soft knee immobilizer was
provided. Unfortunately, Ms. [**Known lastname 1391**] was unable to tolerate
the immobilizer and continued to hold her right BKA in a flexed
position near her chest, despite adequate pain control.
She was seen daily by physical therapy, and stretching and range
of motion exercises were performed, including reduction of the
knee flexion contracture to 26 degrees from horizontal. The
knee immobilizer was applied in this position, but Ms. [**Known lastname 1391**]
was again unable to wear it, and she removed it soon after the
team had left her room. Several types of knee braces were
tried, and she was equally unable to tolerate each. Despite
daily physical therapy, and several conversations about the
importance of having full knee range of motion, Ms. [**Known lastname 1391**] was
unable to make any progress in the treatment of her right knee
contracture. She was continued on IV antibiotics with daily
wound care for the poorly healing surgical wound, as well as the
medial open wound with minimal improvement. Chronic pain
consultation was obtained for assistance in the treatment of her
stump and phantom limb pain, and her regimen was adjusted
accordingly.
Twice during her pre-operative course, Ms. [**Known lastname 1391**] attempted a
voiding trial, as she had been transferred from her rehab with a
Foley catheter. On both occasions, Ms. [**Known lastname 1391**] was unable to
void independently, with bladder residual volumes over 500cc.
As the operative plan was formed, her Foley was reinserted and
remained in place until she had been stabilized post-op.
On [**9-8**], after lengthy discussion between Dr. [**Known lastname 1391**] and the
vascular surgery team, the patient, and her family, consensus
was reached to proceed with above knee amputation. Ms. [**Known lastname 1391**]
was appropriately prepared, and informed consent was obtained.
On [**9-9**], she underwent right above-knee amputation of her
failing BKA stump. The procedure was uncomplicated, but Ms.
[**Known lastname 1391**] became hypotensive with systolic blood pressure in the
60's post-operatively, requiring IV neosynephrine. She remained
otherwise stable, appropriate and conversant, with good pain
control, and good urine output. She was transfused with 2 units
of pRBCs for a post-operative hematocrit of 23.4 (from 32.3
pre-operatively), and given a 500cc fluid bolus. Her pain was
controlled with a dilauded PCA. She was weaned from Neo prior
to midnight and her blood pressure remained stable afterwards.
On POD#1, her diet was advanced, and she remained on bedrest.
Her pain was well controlled and her hematocrit remained stable.
POD#2, she was allowed OOB to chair x2 and was seen by physical
therapy for range of motion exercises of the right hip, which
she tolerated well. Her pain medication were switched to PO
dilauded and her previous PO oxycontin. She continued to
tolerate a regular diet. Her antibiotics were discontinued.
On [**9-12**], she was found to be tolerating her physical therapy,
with adequate pain control on PO medication, and was deemed
stable for discharge to [**Hospital3 **]. She will
continue on PO oxycontin and PO dilaudid for pain, and will not
require antibiotics or coumadin. She will need outpatient
urology follow up for evaluation of a possible neurogenic
bladder, which has been communicated to [**Hospital1 **] in person and
in discharge instructions. Ms. [**Known lastname 1391**] understood and agreed
with the plan.
Medications on Admission:
amlodipine
furosemide
hydralazine
lisinopril
lorazepam
metoprolol succinate
oxycodone
phenytoin sodium extended
warfarin
acetaminophen
aspirin
calcium carbonate-vitamin D3
docusate sodium
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. phenytoin sodium extended 100 mg Capsule Sig: Three (3)
Capsule PO QHS (once a day (at bedtime)).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): Hold for SBP<110.
11. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*30 Tablet Extended Release 12 hr(s)* Refills:*0*
12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain for 5 days.
Disp:*24 Tablet(s)* Refills:*0*
13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Failed Right Below-Knee Amputation
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:
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
.
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Please call [**Telephone/Fax (1) 1393**] to schedule a follow up appointment
with Dr. [**Known lastname 1391**] in clinic in 3 weeks for staple removal and
wound check.
Follow up with a urologist at [**Hospital1 **] as an outpatient.
|
[
"718.46",
"338.29",
"733.00",
"443.9",
"414.01",
"707.21",
"V45.73",
"788.29",
"997.62",
"272.4",
"V15.82",
"353.6",
"403.90",
"V10.52",
"E878.5",
"997.69",
"707.03",
"281.2",
"682.6",
"458.29",
"596.54",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.17"
] |
icd9pcs
|
[
[
[]
]
] |
7474, 7548
|
2002, 5996
|
294, 342
|
7627, 7627
|
12587, 12825
|
820, 854
|
6235, 7451
|
7569, 7606
|
6022, 6212
|
7803, 9413
|
869, 872
|
1597, 1979
|
237, 256
|
9425, 11887
|
11910, 12564
|
370, 588
|
886, 1583
|
7642, 7779
|
610, 709
|
725, 804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,232
| 108,412
|
4766
|
Discharge summary
|
report
|
Admission Date: [**2149-11-29**] Discharge Date: [**2149-12-4**]
Date of Birth: [**2072-3-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**Last Name (un) 11974**]
Chief Complaint:
Palpitations and NSVT
Major Surgical or Invasive Procedure:
EP Study
History of Present Illness:
The patient is a 77-year-old female with a past history of HTN,
HL, CAD s/p MI x 3 and CABG x 2, ischemic cardiomyopathy (EF 30
%), h/o NSVT s/p ICD (replaced 2 years ago), presenting from
[**Hospital3 **] with NSVT.
.
Of note, patient was admitted to [**Hospital1 18**] in [**Month (only) 956**] after ICD
firing in the setting of VT from a coughing attack. She had
been started on amiodarone on discharge, however, this was
discontinued
in [**Month (only) 547**] secondary to tingling/twitching in her ears and a
swollen throat. She was last seen in the device clinic in [**Month (only) 205**],
with no notable events on review.
.
She presented to [**Hospital3 **] with the initial complaint of
an episode of palpitations that she says began on Wednesday
night. She has been feeling this palpitations for a long time
(many months) but they had always gone away after a few minutes.
This episode, however, lasted for at least an hour and this is
what brought her to the OSH. She denies overt shortness of
breath, abd pain, or nausea. She denies any chest pain but does
endorse some dizziness.
.
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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, syncope or presyncope.
Past Medical History:
Hypertension
Hyperlipidemia
CAD s/p 3 MIs
Cardiomyopathy, EF 25%
NSVT with easily inducible sustained VT on EP study in [**3-/2136**]
-CABG: x2 [**2126**], [**2132**], both done at NEDH
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: [**Company 1543**] Micro [**Female First Name (un) 19992**] 2 ICD placed on [**2136-3-29**].
Exchanged for [**Company 1543**] ICD, EnTrust D154VRC ?in [**2143**] (last
interrogation per [**Hospital1 18**] webOMR notes [**2145-9-7**]).
3. OTHER PAST MEDICAL HISTORY:
Depression s/p ECT
S/p cholecystectomy
S/p hysterectomy
S/p thyroid surgery for a benign mass
S/p cataract surgery
Social History:
Married. Lives at home with her husband and her brother.
-Tobacco history: remote smoking history from age 20 to 30
-ETOH: occasional social drinking
-Illicit drugs: none
Family History:
Mother died of MI at age 38, brother at age 37. Other brother MI
at age 60.
Father lived to age [**Age over 90 **] and was healthy. No family history of
arrhythmia, cardiomyopathies.
Physical Exam:
ADMISSION PHYSICAL EXAM
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD appreciated.
CARDIAC: Rate very irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities but central scar noted,
well-healed, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM
Vitals - Tm/Tc: afeb/97.3 HR: 57-66 BP: 95/50 (90-114/50-67)
RR: 16 02 sat: 98% RA
In/Out:
Last 24H: 1740/2050
Last 8H: 0/675
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Very
pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple with no JVD appreciated.
CARDIAC: Regular rate and rhythm, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities but central scar noted,
well-healed, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+
Left: Carotid 2+ Radial 2+ DP 2+
Pertinent Results:
ADMISSION LABS
[**2149-11-30**] 08:45AM BLOOD WBC-4.9 RBC-4.89 Hgb-15.1 Hct-44.4 MCV-91
MCH-30.9 MCHC-34.0 RDW-13.4 Plt Ct-208
[**2149-11-30**] 08:45AM BLOOD PT-13.5* PTT-30.4 INR(PT)-1.2*
[**2149-11-30**] 08:45AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-141
K-3.9 Cl-104 HCO3-28 AnGap-13
[**2149-11-30**] 08:45AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
.
DISCHARGE LABS
[**2149-12-4**] 07:10AM BLOOD WBC-4.4 RBC-3.76* Hgb-11.9* Hct-35.4*
MCV-94 MCH-31.6 MCHC-33.5 RDW-13.4 Plt Ct-184
[**2149-12-3**] 07:55AM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.1
[**2149-12-4**] 07:10AM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-140
K-3.8 Cl-101 HCO3-30 AnGap-13
[**2149-12-4**] 07:10AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
.
IMAGING
[**2149-12-1**] [**Month/Day/Year **]: The left atrium is elongated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. There is severe regional left
ventricular systolic dysfunction with thinning/akinesis of the
inferolateral wall, mild dyskinesis of the inferior wall and
apex. The remaining segments are mildly hypokinetic. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %). 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) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. The mitral valve
leaflets are elongated. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. IMPRESSION: Mild symmetric
left ventricular hypertrophy with normal cavity size with
extensive regional systolic dysfunction c/w multivessel CAD or
other diffuse process. Compared with the prior study (images
reviewed) of [**2149-3-27**], the findings are similar.
.
[**2149-12-4**] Stress Test: INTERPRETATION: This 77 yo woman s/p MI
x3, CABG in [**2126**] and [**2132**], nonsustained MMVT and s/p ICD was
referred to the lab for arrhythmia evaluation. The patient
completed 9 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol representing an
average exercise tolerance for her age; ~ 4.8 METS. The exercise
test was stopped at the patient's demand secondary to fatigue.
No chest, back, neck or arm discomforts were reported by the
patient during the procedure. The subtle ST segment changes
noted anteriorly are uninterpretable for ischemia in the
presence of the RBBB. No significant ST segment changes were
noted inferiorly or in the lateral precordial leads. The rhythm
was sinus with rare isolated APBs. In additional, rare isolated
VPBs and one ventricular couplet was noted during the procedure.
In the presence of beta blocker therapy, the heart rate response
to exercise was limited. A flat blood pressure response was
noted with exercise; resting standing 94/46 mmHg, peak exercise
104/46
mmHg. Max RPP 8112, % MAX HRT RATE ACHIEVED: 55
IMPRESSION: Average exercise tolerance, however decreased in
exercise
time/exercise tolerance from previous ETT in [**2149-3-18**]. No
anginal
symptoms or objective ECG evidence of myocardial ischemia. No
exercise-induced VT. Blunted heart rate and blood pressure
response to
exercise.
Brief Hospital Course:
77-year-old female with a past history of HTN, HL, CAD s/p MI x
2 and CABG x 2, ischemic cardiomyopathy (EF 25 %), h/o NSVT s/p
ICD (replaced 2 years ago), presenting from [**Hospital3 **] with
NSVT.
.
.
ACTIVE ISSUES:
#. NSVT: Likely etiology is scarring from previous MIs v.
cardiomyopathy. Pt has defibrillator in place that was
investigated upon admission. Pt was on amiodarone in the past,
which worked well for her initially but then discontinued its
use in [**Month (only) 547**] due to adverse side effects. Only symptom has been
palpitations. Before her EP study, pt's symptoms and ectopy were
managed adequately with a lidocaine drip. Incidence of NSVT
decreased, but the patient continued to have some PVCs and
couplets. An EP study was performed, which showed dense scar
along the inferior wall from mid-wall to apex extending to the
infero-lateral wall and distal septum. The base of the heart was
normal. PES with up to triple extra-stimuli induced only
pleomorphic VT that --> to VFL --> external shocks. The pt had
multiple VT morphologies induced with cath manipulation and
burst pacing. The clinical VT was not induced and ablation was
therefore not performed. Pt was continued on metoprolol, and
then started on quinidine and mexilitine after the EP study,
with good control of pt's symptoms and no more ectopy on
telemetry.
.
.
CHRONIC ISSUES:
# CAD: Pt's history of CAD includes 3 MIs and CABG x2 in [**2126**]
and [**2132**]. She is on nitroglycerin at home for chest pain, but
did not need it during the hospitalization. She was continued on
her home lipitor and ezetimibe.
.
# HTN: Documented history of this problem, for which she had
been treated with hydralazine, isosorbide, and lopressor prior
to admission. However, she was slightly hypotensive in-house,
and so her home hydralazine and isosorbide were held, but she
was continued on her home lopressor. Before discharge, she was
transitioned to long-acting lopressor that she will take twice
daily. Pt has adverse reaction to Ace Inhibitors, more
specifically lisinopril as she develops severe mouth sores (so
bad she stopped taking all of her medicines). There was some
thought about starting her on Diovan, but due to her adverse
reaction to ace inhibitors (and their relationship to ARBs), she
was simply continued on lopressor and her isosorbide and
hydralazine were held.
.
# Chronic systolic heart failure: Documented history of this
problem. [**Name (NI) **] during this admission showed an EF of 25%. On
hydralazine and isosorbide at home but was held in-house.
.
# HLD: Documented history of this problem. Pt was continued on
home lipitor and ezetimibe.
.
# Anxiety: Documented history of this problem. Pt was continued
on home oxazepam.
.
TRANSITIONAL ISSUES
# Pt's isosorbide and hydralazine were held during the
hospitalization due to low blood pressures. Recommend
re-checking blood pressures at home and in her PCP's office to
determine the need to re-start these medications.
Medications on Admission:
ATORVASTATIN [LIPITOR] 20 mg Tablet, 1 Tablet PO BID
EZETIMIBE [ZETIA] 10 mg Tablet, 1 Tablet PO daily
HYDRALAZINE HCL 10MG Tablet, 1 Tablet PO TID
ISOSORBIDE DINITRATE 20 mg Tablet, 1 Tablet PO TID
LOPRESSOR 50mg Tablet, 1 Tablet PO TID
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - as directed once a
day
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - as directed once a day
OXAZEPAM 30mg Tablet, 1 Tablet PO TID
Discharge Medications:
1. quinidine gluconate 324 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release(s)* Refills:*2*
2. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxazepam 30 mg Capsule Sig: One (1) Capsule PO three times a
day.
6. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO BID (2 times a day).
Disp:*180 Tablet Extended Release 24 hr(s)* Refills:*2*
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Discharge Disposition:
Home
Discharge Diagnosis:
ventricular tachycardia
Chronic systolic congestive heart failure
coronary artery disease
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**].
You were admitted with palpitations caused by ventricular
tachycardia and needed to get intravenous medicine to control
the arrhythmias. An ablation was attempted by Dr. [**Last Name (STitle) **] but he
was not able to complete this procedure because the heart rhythm
that caused the palpitations was not able to be induced during
the procedure. Therefore, you have been started on 2 new
medicines to control the arrythmias, mexilitine and quinidine.
So far, these medicines seem to be working well for you. Please
check your blood pressure at home to make sure you are
tolerating the medicines.
.
We made the following changes to your medicines:
1. START taking mexilitine and quinidine gluconate to control
your ventricular tachycardia
2. CHANGE the metoprolol to succinate, a long acting version and
take only twice daily
3. STOP taking isosorbide mononitrate (Imdur) and hydralazine
for now, talk to Dr. [**Last Name (STitle) **] about restarting these medicines at
your next appt.
4. Eat a banana and drink [**Location (un) 2452**] juice every day with breakfast
to keep your potassium level high.
5. START taking magnesium tablets twice daily to increase your
magnesium levels
Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2150-1-5**] at 11:00 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
.
Name: BRIGHT,MARK T.
Specialty: FMILY MEDICINE
Location: [**Hospital **] HEALTH CENTER
Address: 200 [**Last Name (un) 12504**] DR, [**Location (un) **],[**Numeric Identifier 18464**]
Phone: [**Telephone/Fax (1) 18462**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above**
Department: CARDIAC SERVICES
When: FRIDAY [**2150-1-2**] at 1:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**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) 11975**]
|
[
"300.00",
"414.8",
"428.22",
"272.4",
"428.0",
"V45.02",
"311",
"427.1",
"V45.81",
"412",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.28",
"99.62",
"37.27",
"89.49",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
12348, 12354
|
7941, 8145
|
297, 307
|
12499, 12499
|
4625, 7918
|
13913, 14958
|
2799, 2983
|
11374, 12325
|
12375, 12478
|
10944, 11351
|
12650, 13890
|
2998, 4606
|
236, 259
|
8160, 9290
|
335, 1950
|
12514, 12626
|
2477, 2593
|
9306, 10918
|
1972, 2446
|
2609, 2783
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,019
| 104,634
|
39012
|
Discharge summary
|
report
|
Admission Date: [**2139-5-13**] Discharge Date: [**2139-5-19**]
Date of Birth: [**2099-9-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Amlodipine overdose
Major Surgical or Invasive Procedure:
Central line placement in Right Internal jugular vein
History of Present Illness:
This is a 39 year old with history of depression, COPD,
non-Hodgkin's lymphoma (in remission) transferred from [**Hospital **]
Hospital for evaluation of amlodipine ingestion in suicide
attempt. This AM, Mr. [**Known lastname **] [**Last Name (Titles) 7345**] ~700 mg amlodipine (70 tabs
of 10 mg Norvasc) at approximately 11 AM. He has had increasing
hopelessness over the last month and recently ordered amlodipine
over the internet. This AM, he [**Last Name (Titles) 7345**] the above pills and
felt lightheaded, fatigued and nauseated. He told his mother
about [**Name2 (NI) **] ingestion and she brought him to [**Hospital6 16464**]. At [**Hospital3 1280**], he reportedly had 2 episodes of syncope
and was initially noted to BP 90/47 with HR 120s with FSG 128.
His BP subsequently dropped to 70s and was given 2 L NS. He
also received 60 u insulin, 5 amps calcium, activated charcoal,
and started on levophed. Femoral line was attempted and
unfortunately was noted to be arterial and thus removed.
.
At [**Hospital1 18**] ER, BP 89-95/40-45 HR 90s-100s RR 18. He was seen by
toxicology with plans for Q30 min FSG and Q2H calcium checks.
He was continued on levophed peripherally and was transferred to
the MICU.
.
On arrival to the MICU, he reports feeling tired and wanting to
sleep. He notes that he no longer wants to harm himself and
noted that he is "too tired to even think about that."
Past Medical History:
COPD
Depression
Non-Hodgkin's Lymphoma
s/p facial skin graft for burns
Social History:
Denies smoking, ETOH
Family History:
Non-contributory
Physical Exam:
BP 93/64 HR 120s 97% RA T 97
Gen: Well-appearing male in NAD
HEENT: PERRLA, EOMI
CV: RRR S1 s2, no m/r/g
Resp: CTA anteriorloy
Abd: Soft, NT/ND +BS
Neuro: CN II-XII grossly in tact
Pertinent Results:
[**2139-5-14**] 04:24AM BLOOD WBC-8.7 RBC-4.78 Hgb-15.2 Hct-42.9 MCV-89
MCH-33.6* MCHC-37.9* RDW-13.8 Plt Ct-283
[**2139-5-13**] 04:20PM BLOOD WBC-11.5* RBC-4.56* Hgb-14.8 Hct-41.8
MCV-92 MCH-32.5* MCHC-35.5* RDW-13.8 Plt Ct-249
[**2139-5-13**] 04:20PM BLOOD Neuts-85.3* Lymphs-8.7* Monos-5.3 Eos-0.4
Baso-0.4
[**2139-5-13**] 04:20PM BLOOD Glucose-64* UreaN-12 Creat-1.1 Na-143
K-3.2* Cl-111* HCO3-21* AnGap-14
[**2139-5-13**] 09:05PM BLOOD Glucose-191* UreaN-13 Creat-1.1 Na-138
K-3.9 Cl-108 HCO3-20* AnGap-14
[**2139-5-14**] 04:24AM BLOOD Glucose-129* UreaN-10 Creat-1.0 Na-139
K-3.8 Cl-107 HCO3-22 AnGap-14
[**2139-5-14**] 12:24PM BLOOD TSH-0.79
[**2139-5-13**] 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2139-5-16**]
2:01 PM
IMPRESSION:
1. No central or segmental pulmonary embolism.
2. Moderate bibasal effusions and atelectasis at the lung bases.
3. Indeterminate 11-mm left lobe of thyroid nodule which can be
further
evaluated with a nonemergent ultrasound of the thyroid.
Brief Hospital Course:
This is a 39 yo with depression, COPD, Non-Hodgkin's lymphoma
admitted with CCB ingestion in suicide attempt and resultant
hypotension requiring pressors.
.
# CCB Ingestion: Patient [**Date Range 7345**] 700 mg of amlodipine, a
dihydropyridine, which predominantly causes vasodilitation and
can also cause resultant tachycardia. Elevated FSG is
frequently a sign of severe toxicity. Toxicology was called on
pt's arrival and serum calcium and fingersticks were closely
monitored in the ICU overnight. Pt was given a total of 2gm
calcium gluconate here. Fingersticks remained in the normal
range. A CVL was placed and levophed continued overnight and
weaned on the morning of [**2139-5-14**]. The pt remained stable on the
floor on [**2139-5-14**], and was medically cleared for discharge to
psychiatric facility on [**2139-5-14**]. Psychiatry and social work were
consulted and the pt was placed on a 1:1 sitter.
.
# Hypotension: Secondary to amlodipine ingestion and resultant
vasodilation and reflex tachycardia. Per pt, did not ingest any
other agents. Tox screen negative. No reason to suspect
infection, as remains afebrile. Urine cultures and blood
cultures were sent to rule out any infectious causes of
hypotension. Urine cultures were negative. Blood cultures from
[**2139-5-14**] show no growth to date on discharge, but are not yet
finalized.
.
# Tachycardia - patient was found to consistently tachycardic to
100-110s, likely compensation for vascualr vasodilation from
overdose of amlodipine. Patient was hydrated with IVF with some
improvement, now in the 90s. Amlodipine has a half life of
30-50hrs, will require more time before medication fully clears
his system. CTA of the chest did not show pulmonary embolism.
.
# COPD: Lungs clear. The pt's outpatient regimen of spiriva was
continued.
.
# Depression: Pt's outpatient psychiatric regimen was held as
patient's regimen was to be readdressed once in an inpatient
psychiatric facility.
.
# F/E/N:
Regular diet, replete electrolytes as above
.
# PPX:
heparin sq
.
# Full code
FOLLOW UP:
# Thyroid nodule: Please follow up " Indeterminate 11-mm left
lobe of thyroid nodule" seen on CTA of chest.
Medications on Admission:
Spirva
Prozac
Resperidone
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
consipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
Suicide Attempt
Amlodipine overdose
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after attempting suicide by taking an overdose
of amlodipine pills. You were treated in the ICU and then you
were medically cleared for discharge to a psychiatric facility.
Psychiatry saw you while you were inpatient.
You had a CT scan of the chest during this admission to rule out
a pulmonary embolism. The CT was negative. It did show a
Indeterminate 11-mm left lobe of thyroid nodule that should be
followed up with your primary care doctor.
Your home medications have been stopped, except for the Spiriva.
You will start a new psychiatric medication regimen at the
psychiatric facility you are going to.
Followup Instructions:
With: NP[**Last Name (un) **] [**Doctor Last Name 86517**]
Location: [**Street Address(2) 86518**], [**Location (un) 70989**] [**Numeric Identifier 86519**]
Phone: [**Telephone/Fax (1) 86520**]
Appointment: [**2139-6-9**] 9:00am
|
[
"311",
"309.81",
"496",
"458.9",
"241.0",
"972.6",
"785.0",
"202.80",
"E950.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6008, 6087
|
3320, 5375
|
335, 391
|
6178, 6178
|
2217, 3297
|
6983, 7215
|
1979, 1997
|
5572, 5985
|
6108, 6157
|
5521, 5548
|
6329, 6960
|
2012, 2198
|
5386, 5495
|
276, 297
|
419, 1829
|
6193, 6305
|
1851, 1924
|
1940, 1963
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,426
| 171,736
|
35890
|
Discharge summary
|
report
|
Admission Date: [**2144-10-9**] Discharge Date: [**2144-10-19**]
Date of Birth: [**2066-8-10**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7303**]
Chief Complaint:
Left femur fracture with total hip
Major Surgical or Invasive Procedure:
[**2144-10-9**]: Removal of left femur IM nail with revision left
total hip
History of Present Illness:
Mr. [**Known lastname 48587**] is a 78 year old man who was involved in an MVC
[**12/2143**] in which he suffered mutliple injuries including a left
femur fracture. Unfortunately he had a left total hip
arthroplasty with multiple revisions. He underwent fixation of
his femur and now presents for elective removal of hardware and
revision total hip arthroplasty.
Past Medical History:
-hypertension
-diabetes, type II, diet controlled
-coronary atery disease, MI in [**2135**], right coronary artery stent
placed in [**2135**]
-dysplipidemia
-deep vein thrombosis in [**1-1**], has IVC filter
-benign prostatic hypertrophy
-osteoarthitis
-L5 disc disease
-hip repairs bilterally
-Hernia
-Rotator cuff repair
-Car accident [**1-3**] with multiple injuries including multiple
lower extremity and pelvic fractures [**2144-1-3**] resulting in
external fixation of right leg and hardware placement in both
legs, also had liver laceration requiring multiple surgeries.
Trach and PEG placement before transfer to hospital
-C. Diff colitis from last hospitaliztion
-MRSA in Sputum per nursing home
Social History:
Denies smoking, drinks occassionally.
Married, has a son.
Wife is healthcare proxy.
Family History:
Non-contributary
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender
Extremities: LLE Incisions well healed, severe pain with ROM,
motor and sensory function normal except for R foot drop with
decreased sensation.
Pertinent Results:
[**2144-10-9**] 07:55PM GLUCOSE-139* LACTATE-1.7 NA+-139 K+-4.3
CL--108
[**2144-10-9**] 07:55PM HGB-12.6* calcHCT-38
[**2144-10-9**] 07:55PM freeCa-1.08*
[**2144-10-9**] 07:41PM PT-14.2* PTT-25.1 INR(PT)-1.2*
[**2144-10-9**] 07:41PM FIBRINOGE-309#
[**2144-10-9**] 04:08PM TYPE-ART RATES-8/ TIDAL VOL-780 O2 FLOW-1.5
PO2-168* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2144-10-9**] 04:08PM GLUCOSE-95 LACTATE-1.2 NA+-141 K+-3.7 CL--108
[**2144-10-9**] 04:08PM HGB-12.0* calcHCT-36
[**2144-10-9**] 04:08PM freeCa-1.14
[**2144-10-19**] 06:15AM BLOOD Hct-32.6*
[**2144-10-19**] 06:15AM BLOOD PT-28.0* INR(PT)-2.7*
[**2144-10-17**] 06:45AM BLOOD Glucose-101 UreaN-21* Creat-1.0 Na-142
K-4.2 Cl-108 HCO3-27 AnGap-11
[**2144-10-17**] 06:45AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.4
[**2144-10-10**] Hip Xray 1 view
New left THR in satisfactory position
Brief Hospital Course:
Mr. [**Known lastname 48587**] presented to the [**Hospital1 18**] on [**2144-10-9**] for an elective
left total hip revision. Prior to surgery he was prepped and
consented. He was taken to the operating room and underwent
removal of hardware with revision of his left total hip
arthroplasty. He had an intraop urology consult for foley
placement. His surgery took 10hrs and received 3 units of
packed red blood cells and 1 unit of plasma for acute blood loss
anemia. He was transferred to the surgical ICU for close
hemodynamic monitoring post operatively. On [**2144-10-10**] he was
extubated adn transferred to the floor for further care. On
[**2144-10-11**] he was again transfused with 3 units of packed red
blood cells due to actue blood loss anemia. On [**2144-10-13**] he was
fitted with a abduction brace. On [**2144-10-14**] his foley was taken
out but the patient had difficulty voiding and had bladder scans
with 500-900cc urine retained. He thus had another foley placed
without difficulty, flomax was started and the foley came out on
[**2144-10-18**] and he voided without difficulty subsequently. The
patient had some post-operative diarrhea that was short lived
and had negative C Diff cultures. On [**10-16**] the patient had
another low hct at 25.9 and required 2 units of pRBCs, after
which his hct responded appropriately. He also required a blood
transfusion on [**10-17**] but had a stable hct on [**10-18**] and [**10-19**],
both of which were above 30. Hematology was consulted for help
with managing his coumadin and determining length of treatment
for a hx of DVT. He was started on weight based lovenox until
theraputic on coumadidn (INR [**1-28**]). His lovenox was d/c'd after
INR was at goal and he was stable on 5mg of coumadin per day.
He should be maintained on coumadin (managed by PCP) for 6
months. On [**10-19**], a rehab bed was available and he was
discharged in stable condition. He will follow up with Dr.
[**Last Name (STitle) 5322**] and with urology.
Medications on Admission:
Coumadin, ASA, Lopressor, SSI, Seroquel
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed for agitation.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
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
[**Hospital1 **] prn as needed for constipation.
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Insulin Regular Human 100 unit/mL Solution Sig: 2-12 units
units Injection ASDIR (AS DIRECTED): per sliding scale protocol.
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR goal [**1-28**]. hold coumadin if supratherapeutic.
14. Outpatient Lab Work
Patient needs daily INR checks until stabilized on coumadin
regimen
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left femur revision/ revision total hip arthoplasty
Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be 50% WB on your left leg
Continue your medication as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Physical Therapy:
Activity: As tolerated
Left upper extremity: 50% WB
Abduction brace at all times
No active abduction of left hip.
Treatments Frequency:
Dry dressing daily or as needed for drainage or comfort
Keep incision clean and dry
Staples to be removed at follow up appointment with Dr. [**Last Name (STitle) 5322**]
Needs urology follow up (patient has phimosis and had difficult
foley placement with urinary retention after foley removed)
Monitor daily INR
Followup Instructions:
Please follow up as below:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2144-10-22**] 10:40
Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2144-10-22**] 11:00
Please call urology as soon as possible for a follow up visit in
1 week. The clinic phone number is [**Telephone/Fax (1) 3752**]. They are
aware that you need a follow up appointment and will work on
scheduling it.
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**]
|
[
"285.1",
"788.20",
"996.41",
"V43.64",
"E878.1",
"E819.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.65",
"00.70"
] |
icd9pcs
|
[
[
[]
]
] |
6336, 6433
|
2875, 4887
|
312, 391
|
6553, 6562
|
1955, 2852
|
7333, 7973
|
1633, 1651
|
4977, 6313
|
6454, 6532
|
4913, 4954
|
6586, 6833
|
1666, 1936
|
6851, 6971
|
6993, 7310
|
238, 274
|
419, 785
|
807, 1515
|
1531, 1617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,687
| 190,877
|
13127
|
Discharge summary
|
report
|
Admission Date: [**2110-2-3**] Discharge Date: [**2110-2-4**]
Date of Birth: [**2058-10-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 7518**] is a 51 year old man with a lifelong history of
IDDM who presented with hyperglycemia and nausea after his puppy
bit through the tubing of his insulin pump and he is now
transferred to the [**Hospital Unit Name 153**] for insulin drip. The patient reports he
was playing with his puppy last night and when he awoke this
morning he did not feel himself. He felt progressively worse
with increasing nausea throughout the morning and vomited 4
times. He subsequently checked his blood glucose level and found
it was 400 mg/dL. He attempted to bolus himself using his
insulin pump with no effect. After a second bolus attempt he
realized the tubing from his pump was broken. He called 911. On
EMS arrival he reported only nausea and hyperglycemia and denied
any other complaints.
.
In the ED, initial vs were: T 96 P 97 BP 155/90 R 16 O2 sat 100.
Labs were initially hemolyzed and repeat set was notable for
potassium 5.5. EKG showed sinus tach without peaked T-waves.
Patient was given 2 L NS, zofran, 8 U regular insulin and 8 U/hr
insulin gtt.
On the floor, the patient appeared generally well. He denied any
further nausea. A repeat FSG was 146.
.
Review of systems:
(+) Per HPI. Also endorses 1 week history of a cold now
resolving but with occasional non-productive cough.
(-) 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 diarrhea, constipation or changes in bowel habits. Denies
dysuria or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
IDDM (last HbA1C 6.1) occasional hypoglycemia to 20's w/o
symptoms
hyperlipidemia - controlled on medication
hypothyroid
depression
Social History:
Lives on [**Hospital3 **] with wife and their six children. Also has
3 dogs (beagles). Works [**Street Address(1) 4736**] as VP in real estate
finance. Exercises regularly.
- Tobacco: None
- Alcohol: Occasional
- Illicits: None
Family History:
Maternal grandmother and great ??????grandmother with Type I IDDM,
father with MI at 72, sister with lung CA at 39.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic
crescendo-decrescendo flow murmur at L upper sternal border. No
rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2110-2-3**] 01:00PM BLOOD WBC-13.0* RBC-5.09 Hgb-15.6 Hct-47.3
MCV-93 MCH-30.8 MCHC-33.1 RDW-12.6 Plt Ct-242
[**2110-2-3**] 01:00PM BLOOD Neuts-88.0* Lymphs-8.6* Monos-2.6 Eos-0.5
Baso-0.2
[**2110-2-3**] 01:00PM BLOOD Glucose-552* UreaN-31* Creat-1.7* Na-129*
K-5.7* Cl-89* HCO3-18* AnGap-28*
[**2110-2-3**] 01:00PM BLOOD Calcium-9.9 Phos-2.9 Mg-1.8
[**2110-2-3**] 01:11PM BLOOD Glucose-499* Lactate-2.4* Na-132* K-6.7*
Cl-95* calHCO3-18*
Discharge Labs:
[**2110-2-4**] 04:06AM BLOOD WBC-10.3 RBC-4.43* Hgb-13.4* Hct-38.8*
MCV-88 MCH-30.3 MCHC-34.6 RDW-12.5 Plt Ct-226
[**2110-2-4**] 04:06AM BLOOD Neuts-63.6 Lymphs-27.0 Monos-6.5 Eos-2.6
Baso-0.3
[**2110-2-4**] 04:06AM BLOOD Glucose-140* UreaN-26* Creat-1.5* Na-140
K-4.4 Cl-110* HCO3-22 AnGap-12
Studies:
ECG Study Date of [**2110-2-3**] 1:45:16 PM
Sinus tachycardia. ST-T wave abnormalities. No previous tracing
available for
comparison.
ECG Study Date of [**2110-2-4**] 7:54:46 AM
Sinus rhythm. Since the previous tracing the rate is slower.
ST-T waves are
improved.
CHEST (PORTABLE AP) Study Date of [**2110-2-4**] 5:50 AM
IMPRESSION: No acute cardiopulmonary abnormality. No pneumonia.
Brief Hospital Course:
Mr. [**Known lastname 7518**] is a 51 year old man with lifelong history of IDDM
who presented with hyperglycemia and nausea after his puppy bit
through the tubing of his insulin pump and he is now transferred
to the [**Hospital Unit Name 153**] for insulin drip.
#Diabetic Ketoacidosis: Due to sudden loss of insulin pump
function from his puppy chewing through the tubing. Patient has
had a cold in recent week but no other signs or symptoms of
infection. No recent medication changes or illicit drug use. Low
suspicion of any cardiac ischemia though he did have mild ST
depression in the lateral leads. Initial anion gap of 22 on
admission. He was placed on an insulin drip until his gap closed
supported with D5W infusion and was restarted on his insulin
pump requirements 2 hours prior to stopping his insulin drip.
His tubing was replaced and function was restored.
Per hospital policy, nutrition and [**Last Name (un) **] consults were ordered
per hospital protocol, however the patient declined both. He has
been diabetic for 41 years and by lab data, he is well
controlled. He felt as though he knows his diet very well, and
is able to control it on his own. He also felt that he knew the
reason for failure of his pump and felt the [**Last Name (un) **] consult was
unnecessary.
Cardiac issues: EKG showed ST changes on admission that
resolved. His enzymes were negative. However, given his risk
factors and having been diabetic for 41 years, as well as having
some renal insufficiency suggesting vascular disease, a stress
test may be indicated as an outpatient.
Follow-up:
- Out patient evaluation for possible stress test
# Renal insufficiency - Likely a component of pre-renal and
chronic kidney disease given his slight improvement with
hydration. Other possibilities include increased muscle mass and
diet supplementation in this gentleman who has a high muscle
mass. He had a creatinine of 1.7 on admission with mild
improvement to 1.5 after hydration. He will need follow-up as an
outpatient to clinically follow his kidney function.
# Hyponatremia - When corrected for hyperglycemia, expected
value ~140, suggesting minimal effect of diuresis, and primarily
driven by osmotic fluid shift. Normalized on discharge
# Hyperkalemia - Likely total body normal to low potassium with
extracellular shift related to low insulin, acidosis, and
osmotic shift on admission. His K was repleted below 4.5 and he
was monitored on telemetry.
# Hypothyroid, Hyperlipidemia, Depression - Chronic. Continue
home medications.
# Transition issues: He was discharged with instructions to
follow-up with his primary care physician [**Name Initial (PRE) 176**] 1-2 weeks for
further evaluation of his EKG changes and elevated creatinine.
Medications on Admission:
Insulin pump
Levoxil 25 mg PO daily
Simvastatin 20 mg PO daily
Zoloft 25 mg PO daily
Folic acid 1 mg PO daily
Multivitamin 1 tab PO daily
Discharge Medications:
1. insulin aspart 100 unit/mL Solution Sig: One (1)
Subcutaneous as directed: Please continue this medication as
previously prescribed. Any questions please contact Dr. [**Last Name (STitle) 40075**]
immediately.
2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Zoloft 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Diabetic ketoacidosis
Secondary Diagnosis:
Acute on chronic renal insufficiency
Hypothyroidism
Depression
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for diabetic ketoacidosis. This is likely
because your pump malfunctioned. You were treated in the ICU
with insulin and intravenous fluids and improved. Your blood
sugars were under good control back on your insulin pump and you
were discharged home.
Please note that your kidney function is slightly elevated. You
should discuss this with your primary care physician as this may
be a complication of your diabetes and may require treatment. If
not followed carefully it can lead to kidney failure.
Please follow up with your primary care physician ([**First Name4 (NamePattern1) 333**]
[**Last Name (NamePattern1) 40075**] [**Telephone/Fax (1) 40076**]) in the next 1-2 weeks. You should discuss
your kidney function to him at this time.
Also, you had a slight abdnormality on your EKG which normalized
when checked again. This should be discussed with your primary
care doctor, and you should discuss whether or not a cardiac
stress test is indicated.
No changes were made to your medications. Please continue to
take them as previously prescribed.
Followup Instructions:
Please follow up with your primary care physician in the next
1-2 weeks. His name is [**Name (NI) 333**] [**Name (NI) 40075**] and his number to set
the appointment up is [**Telephone/Fax (1) 40076**].
Completed by:[**2110-2-5**]
|
[
"585.9",
"V58.67",
"288.60",
"244.9",
"311",
"272.4",
"996.57",
"276.7",
"276.1",
"250.13",
"V45.85",
"584.9",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7814, 7820
|
4321, 7064
|
292, 299
|
8005, 8005
|
3129, 3129
|
9253, 9485
|
2442, 2560
|
7252, 7791
|
7841, 7841
|
7090, 7229
|
8156, 9230
|
3604, 4298
|
2575, 3110
|
1525, 2023
|
231, 254
|
327, 1506
|
7904, 7984
|
3145, 3588
|
7860, 7883
|
8020, 8132
|
2045, 2179
|
2195, 2425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,452
| 180,912
|
9553
|
Discharge summary
|
report
|
Admission Date: [**2125-10-18**] Discharge Date: [**2125-10-26**]
Date of Birth: [**2053-7-4**] Sex: M
Service: Vascular
CHIEF COMPLAINT: Asymptomatic abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with
extensive coronary artery disease, status post coronary
artery bypass graft and left carotid endarterectomy. Status
post carotid endarterectomy, an echocardiogram was done, and
an incidental abdominal aortic aneurysm was noted. The
aneurysm was 5.6 cm. The patient returns now for elective
surgery.
PAST MEDICAL HISTORY:
1. Coronary artery disease; history of angina, but no angina
since surgery. His echocardiogram showed left ventricular
ejection fraction of 58% with moderately severe mitral
regurgitation.
2. Osteoarthritis (of back and shoulders).
3. Hyperlipidemia.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft in [**2123-2-3**];
complicated by a methicillin-resistant Staphylococcus aureus
infection requiring intravenous vancomycin times seven weeks.
2. Left carotid endarterectomy in [**2123-12-6**].
3. Esophageal dilatation in [**2112**] and again in [**2118**].
MEDICATIONS ON ADMISSION:
1. Pravachol 40 mg p.o. q.d.
2. Atenolol 100 mg p.o. q.d.
3. Prilosec 20 mg p.o. q.d.
4. Motrin 800 mg p.o. t.i.d.
5. Nitroglycerin 0.4 (which he has not used since his
coronary artery bypass graft).
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were
stable. Blood pressure was 114/73. On general appearance,
the patient was a well-nourished, alert, white male in no
acute distress. Head, eyes, ears, nose, and throat
examination was unremarkable. There was no jugular venous
distention. The chest was clear to auscultation bilaterally.
Heart had a regular rate and rhythm. No murmurs, rubs, or
gallops. Abdominal examination was without mass or
tenderness. Extremities were without edema. Pulmonary
examination was intact.
RADIOLOGY/IMAGING: Preoperative studies included an
echocardiogram which was done on [**2125-9-7**] which
demonstrated inferobasal hypokinesis with left ventricular
dilatation and an ejection fraction of 50%. There was
moderately severe mitral regurgitation, left atrial
enlargement, aortosclerosis without stenosis, abdominal
aortic aneurysm of 4.9 cm.
A chest x-ray was without acute cardiopulmonary process.
PERTINENT LABORATORY DATA ON PRESENTATION: Complete blood
count revealed white blood cell count was 8.3, hematocrit was
42.2, platelets were 294,000. PT and PTT were normal.
Urinalysis was unremarkable. Blood urea nitrogen was 13,
creatinine was 1.1, potassium was 4.6.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area. He underwent abdominal aortic
aneurysm repair. He tolerated the procedure well. He
required transfusion of 1000 cc of cellsaver
intraoperatively. He was transferred to the Postanesthesia
Care Unit in stable condition.
Immediately postoperatively, his temperature maximum was
39.1, systolic blood pressure was 108/53. His pulmonary
artery pressure was 23/11 with a pulmonary capillary wedge
pressure of 5. He required Neo-Synephrine 0.25 mcg/kg per
minute. His urine output was adequate. His abdomen was
soft. The wounds were clean, dry, and intact. The patient
remained intubated and in the Postanesthesia Care Unit
overnight. An epidural was in place for analgesic control.
We felt the temperature might be drug related.
On postoperative day one, his fever defervesced. His
incisions were unremarkable. He had palpable dorsalis pedis
and posterior tibialis pulses bilaterally. The epidural was
discontinued. The patient was extubated and transferred to
the Vascular Intensive Care Unit for continued monitoring and
care.
On postoperative day three, he remained afebrile. His
abdomen was felt moderately distended and tympanitic. His
pulses were intact. His white blood cell count was 11.7.
His hematocrit was 37. Vancomycin peak was 34. He was
continued on vancomycin. His blood urea nitrogen remained
stable. His pain was controlled with a Dilaudid
patient-controlled analgesia. He was begun on clears, and
Dulcolax suppository was given. Nasogastric tube was
removed.
On postoperative day four, the patient continued to progress.
He was delined and transferred to the regular nursing floor.
A KUB was obtained because of persistent abdominal distention
which showed a postoperative ileus, no bowel obstruction, and
a dilated stomach. His diet was reversed to clears. Reglan
was considered intravenously. Physical therapy was requested
to see the patient and began ambulation. Case Management saw
the patient with regard to discharge planning.
By postoperative day seven, he continued to do well. He had
bowel sounds. The wounds were clean, dry, and intact. His
pulses were palpable. His diet was advanced.
DISCHARGE DISPOSITION: He was discharged on postoperative
day eight in stable condition to follow up with Dr. [**Last Name (STitle) 1391**]
in two weeks' time for skin clip removal.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Percocet one to two tablets p.o. q.4-6h. as needed (for
pain).
2. Colace 100 mg p.o. b.i.d.
3. Enteric-coated aspirin 325 mg p.o. q.d.
4. Pravastatin 40 mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Atenolol 100 mg p.o. q.d.
DISCHARGE DIAGNOSES: Abdominal aortic aneurysm repair.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2125-10-25**] 15:48
T: [**2125-10-25**] 15:52
JOB#: [**Job Number 16888**]
|
[
"424.0",
"272.4",
"560.1",
"401.9",
"441.4",
"E878.2",
"997.4",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
4922, 5082
|
5403, 5716
|
5109, 5381
|
1185, 2673
|
2692, 4898
|
866, 1159
|
160, 201
|
230, 565
|
587, 843
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,089
| 120,485
|
50270
|
Discharge summary
|
report
|
Admission Date: [**2110-12-31**] Discharge Date: [**2111-1-13**]
Date of Birth: [**2030-6-1**] Sex: F
Service: MEDICINE
Allergies:
Verapamil / Levaquin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hypoxic respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 80 yo F with dementia, mental retardation, diastolic
CHF, restrictive lung disease, recurrent pnas, h/o intubation,
anemia, who presents with hypoxic respiratory distress. Pt was
found to be in acute respiratory distress at her [**Hospital3 **]
facility with O2 sats in the 40s. Apparently the pt had been
noted to have severe lethary and wheezing at her [**Hospital 4382**]. She was placed on 100%NRB at her facility and was then
brought to ED.
.
In [**Name (NI) **], pt was found to be satting at 46%on RA and 91-100%NRB,
T98.5, HR 90, BP 165/76, RR22. She appeared to be in
respiratory distress with dusky cyanotic hands. Pt was
confused, disoriented, agitated and was placed in restraints.
She was given A/A nebs, solumedrol, levofloxacin 500 mg IV x1,
Vancomycin 1gm IV x1. Initial ABG revealed: 7.34/72/96 on 100%
NRB. She had a WBC of 14 with 92%PMN. CXR revealed RLL
atelectasis vs infiltrate.
Past Medical History:
-dementia
-mild mental retardation
-Diastolic CHF
-HTN
-SVT
-Restrictive lung dz
-Mult PNAs
-GERD
-diverticulosis
-DJD lower spine
-Osteoporosis
-Arthritis, left hand contracture
-Urinary/fecal incontinence
-Mult UTIs--indwelling foley
-CRI, bl Cr 0.8-1.1
-Anemia, bl HCT 28
-Depression
-hard of hearing, deafness in left ear
-headaches
-Hip surgery
-breast surgery involving with removal of calcium deposits
.
Cardiology Report ECHO Study Date of [**2110-8-19**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. 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.
Compared with the prior study (tape reviewed) of [**2109-3-22**], the
findings are similar.
.
Spirometry [**2108-12-31**]:
FVC 49% pred, 0.61; FEVQ 82% pred, 0.61; FEV1/FVC 169%pred
Social History:
Lives at [**Hospital2 **] [**Hospital3 **] [**Telephone/Fax (1) 70302**]. Health care
proxy [**Name (NI) **] [**Name (NI) **] (w)[**Telephone/Fax (1) 104838**], cell [**Telephone/Fax (1) 104839**].
Wheelchair bound due to arthritis. The patient was never a
smoker, does not drink alcohol. The patient obtains no exercise.
Family History:
Father--died of PE
Brother--died of lung CA
Physical Exam:
Vitals: T 98.4 BP 165/65 HR 86 RR 25 Sat 83-86% 4LNC
Gen: pleasant elderly woman, in mild resp distress with
accessory muscle use, able to speak in partial sentences, often
smiling
HEENT: EOMI, PERRL, OP clear with poor dentition
Neck: no LAD, JVP elevated to jaw on R but difficult to assess
due to accessory muscle use
CVS: RRR, nl s1 s2, 2/6 systolic murmur at RUSB
Chest: lungs CTA anteriorly
Abd: soft, NT/ND, NABS
Ext: no tenderness, no LE edema
Neuro: MAFE
Pertinent Results:
[**2110-12-31**] 09:11PM TYPE-ART PO2-62* PCO2-62* PH-7.33* TOTAL
CO2-34* BASE XS-3 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2110-12-31**] 09:11PM LACTATE-3.1*
[**2110-12-31**] 09:11PM O2 SAT-90
[**2110-12-31**] 09:11PM freeCa-1.13
[**2110-12-31**] 09:07PM GLUCOSE-151* UREA N-31* CREAT-1.5* SODIUM-144
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-31 ANION GAP-19
[**2110-12-31**] 09:07PM ALT(SGPT)-21 AST(SGOT)-21 LD(LDH)-226
CK(CPK)-192* ALK PHOS-85 AMYLASE-84 TOT BILI-0.3
[**2110-12-31**] 09:07PM LIPASE-73*
[**2110-12-31**] 09:07PM proBNP-5793*
[**2110-12-31**] 09:07PM CK-MB-3 cTropnT-<0.01
[**2110-12-31**] 09:07PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-4.5
MAGNESIUM-1.7
[**2110-12-31**] 09:07PM OSMOLAL-304
[**2110-12-31**] 09:07PM WBC-12.9* RBC-4.00* HGB-11.4* HCT-35.8*
MCV-90 MCH-28.4 MCHC-31.7 RDW-15.4
[**2110-12-31**] 09:07PM NEUTS-97.8* BANDS-0 LYMPHS-1.5* MONOS-0.4*
EOS-0.1 BASOS-0.2
[**2110-12-31**] 09:07PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2110-12-31**] 09:07PM PLT SMR-NORMAL PLT COUNT-263
[**2110-12-31**] 09:07PM PT-13.0 PTT-22.2 INR(PT)-1.1
[**2110-12-31**] 05:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2110-12-31**] 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-12-31**] 03:14PM TYPE-[**Last Name (un) **] PO2-35* PCO2-76* PH-7.32* TOTAL
CO2-41* BASE XS-8
[**2110-12-31**] 01:30PM CK(CPK)-179*
[**2110-12-31**] 01:30PM cTropnT-<0.01
[**2110-12-31**] 01:30PM CK-MB-3
[**2110-12-31**] 01:30PM WBC-14.0*# RBC-4.39# HGB-12.6 HCT-38.9 MCV-89
MCH-28.8 MCHC-32.5 RDW-15.6*
[**2110-12-31**] 01:30PM NEUTS-92.0* LYMPHS-4.3* MONOS-3.1 EOS-0.1
BASOS-0.5
[**2110-12-31**] 01:30PM HYPOCHROM-1+
[**2110-12-31**] 01:30PM PLT COUNT-272
[**2110-12-31**] 01:30PM PT-12.4 PTT-23.1 INR(PT)-1.1
[**2110-12-31**] 01:30PM D-DIMER-566*
[**2110-12-31**] 12:55PM TYPE-ART TEMP-36.7 O2-100 PO2-96 PCO2-72*
PH-7.34* TOTAL CO2-41* BASE XS-9 AADO2-558 REQ O2-91
INTUBATED-NOT INTUBA COMMENTS-NRB
.
CXR [**12-31**]:
IMPRESSION: Left basilar atelectasis vs. pneumonia.There is a
right diaphragmatic hernia which extends across the midline to
the
left, unchanged from [**2110-8-20**]. There is linear
atelectasis at the right base.
.
EKG: NSR, nl axis, biphasic T in precordial leads, Q in lead
III, atrial enlargement?
Brief Hospital Course:
On admission to the ICU, the pt was satting in the 80s on both
RA and 4LNC. Her ABG revealed: 7.33/62/62/34 with A-a gradient
of 95. Pt was started on a 500 cc bolus of NS and then D51/2 at
70 cc/hr. Pts sats dropped back down to 79% on 4LNC. She was
given combivent neb and suctioned, bringing her O2 sat back up
to 96% on 50%FIO2. Repeat ABG: 7.31/65/74 with A-a of 135.
Fluids were stopped and stat CXR revealed likely volume
overload. BNP came back 5793 and pt was given Lasix 20 mg IVx1,
[**12-1**] inch nitropaste, hydral 10 mg po. Her abx were changed from
ceftriaxone/azithro to zosyn given possibility of nosocomial
infxn. Vancomycin was continued to cover for aspiration PNA.
On the morning after admission, it was decided to again stop
diuresis and start gentle hydration. It was felt the pt was
initially dry on admission, leading to her hypernatremia, ARF.
She likely became volume overloaded in the setting of the NS
bolus of 500 cc over 1 hr. Following that fluid bolus, her Na
did improve to 144. She was restarted on NS at 100 cc/hr for 1
L. The hydralazine was discontinued and the diltiazem was
continued to maximize filling time. She was then discharged to
the floor and was intermittantly hypoxic on RA with sats between
88 - 95%. Therefore she needs rehab for pulmonary toilet.
.
# Hypoxic Resp Distress/Hypercarbic Respiratory
Distress/Respiratory acidosis: Ddx on admission--noscomial PNA,
aspiration pna, CHF, PE, ?contribution from chronic lung dx.
Leading dx is probably combination of aspiration and CHF. Pt
admitted with radiologic signs of a PNA. She was treated with
Levofloxacin, Vanc, and Solumedrol in the ED. D dimer elevated
to 556, however pt with stable hemodynamics and no other
evidence of PE. Pts volume status is unclear by PE, however BNP
elevation to 5793 assists in dx of CHF. A-a gradient of 95, up
to 135 after volume overload. Ruled out for an MI. We continued
empiric treatment for nosocomial and asp PNA with Zosyn; add
Vanc 1gm IV q48 hr given likely asp PNA. Diltiazem was continued
for rate control to improve diastolic dysfunction. She was
given A/A nebs prn. On the night of admission the pt satted
upper 80s-90s on 50%VM.
The pt developed hypercarbic resp distress and was intubated the
am of [**1-2**]. Pt developed hypercarbia on [**1-2**] with delta MS and
with ABG of 7.13/105/81 on 50% face tent. Pt was intubated in
the morniing and placed on AC. It was unclear if the hypercarbia
was due to MS changes or an aspiration or volume overload event.
She was extubated [**1-5**] and reintubated the same day for hypoxic
resp distress (sat 80% NRB) unresponsive to nitropaste and
Lasix. Again, the etiology of the hypoxia was unclear, but was
felt to be due to laryngeal edema given she had no leak on trach
collar. The pt was started on prednisone 40 mg po qd on [**1-5**].
She successfully was weaned to PS on [**1-6**] with spontaneous
breathing trials on [**1-6**] and [**1-7**] lasting 3 hrs at a time. She
finished her 10 day course of Zosyn and vanc. She needs rehab
for pulmonary toilet, as the last time she had an aspiration
event, she required weeks to be weaned from O2.
.
#Delta MS: The pt was noted to have an altered MS the am of [**1-2**]
when she was having the episode of hypercarbic respiratory
distress. It is unclear if the pts delta MS caused her
hypercarbic respiratory distress or vice versa. Pt was noted
the am [**1-2**] to have intermittent myoclonic activity, however able
to follow commands making seizure unlikely. Neuro felt pt has
polymyoclonus which is stimulus dependent. There was concern
for meningitis given ?nuchal rigidity by neuro consult exam,
however there is no evidence of this today. Head CT is negative
for acute process.
.
#ARF: Pts BL Cr is 0.8-1.1. Cr up to 1.6 on admission. Suspect
prerenal etiology given elevated BUN/Cr ratio and Na 147. As per
below under "pump", the pt was initially rapidly hydrated with
500 ccNS resulted in flash pulmonary edema. She was restarted
on gentle hydration the am after admission. The pts Creatinine
was noted to rise to 1.6 on [**1-1**] and her UO dropped over the
night into [**1-2**]. She was intially given several NS boluses and
then was given Lasix 20 mg IVx1. Her UO then improved. It was
felt the pt had a delicate fluid balance given her diastolic
dysfunction and will likely need intermittent hydration with
lasix to optimize forward flow. The pts Cr improved to 1.4 with
lasix and hydration, however it never returned to her original
baseline. The pt likely has a new baseline Cr level of 1.3-1.5.
.
#Elevated Na: Na 147 on admission. Pt appeared volume depleted.
Pt desatted after intial fluid bolus but Na did improve to 144.
The morning after admission the pt was started on slow rate of
NS given episode of hypoxia s/p NS bolus. Dilt was continued to
maximize rate control and CO. The pts Na ultimately normalized
after free water boluses.
.
#Elevated lactate: Lactate 3.2 on night of admission up from 1.2
in ED. Likely due to hypoperfusion in the setting of CHF.
Following fluid resusciation the pts lactate levels normalized.
.
#CV:
A Pump: Pt has h/o diastolic dysfunction,nl EF. Initial CXR did
not show clear signs of volume overload, but second CXR was c/w
volume overload. The pt likely flashed from rapid fluid
infusion. However, it was felt the pt was dry given her
clinical exam, ARF, and hypernatremia. The goal was to ideally
decrease HR for increased filling time and give gentle hydration
to increase CO. The pts diltiazem SR was changed to a QID
regimen. She was intially given 500cc NS on the night of
admission, however backflashed her fluids. She was given hydral
10 mg po x1, nitropaste, Lasix 20 mg IVx 1 and then 40 mg IVx1
over the night of admission. On the morning after admission it
was decided to restart gentle fluids to improve her CO. The pt
was given several fluid boluses on [**1-1**] and then 20 mg IV lasix
later that night due to decreased UO. Dilt gtt was started on
[**1-2**] to optimize filling time. It was felt the pt had a delicate
fluid balance given her diastolic dysfunction and would likely
need intermittent hydration with lasix to optimize forward flow.
TTE on [**1-2**] revealed nl systolic function with EF 55%, increased
E:A ratio indicative of diastolic dysfunction, and no LVH. The
pts dilt gtt was turned off the following day and was was
restarted on dilt 45 mg po TID. Her fluid balance was mostly
determined by her UO; she received intermittent fluids and
Lasix.
# Atrial fultter: while on the floor, the patient developed
atrial flutter with variable rate of conduction. Her BP was
stable the entire time and she was given IV dilt, which
converted her. Her dilt xr was increased to 180. She needs the
lowest heart rate she can tolerated given her distolic
dysfunction.
.
# Aspiration: The patient has a known aspiration risk. She has
had multiple admission for this inthe past, and the initial
insult to prompt this admission was an aspiration event. The
team as recommended that she be NPO and communicated this to the
neice, however, since eating is her main enjoyment, her neice
would like her to continue eating. She remains full code. This
needs to be addresed by her PCP with the [**Name9 (PRE) 21457**] again, since she
will likley continue to have recurrent aspiration pneumonias if
she continues to eat.
Medications on Admission:
--Tylenol prn
--SQ Heparin
--Protonix 40'
--Dilt HCL 120 SR qd
--ASA 81
--Atorvastatin 10'
--Cholecalciferol 400 '
--Lexapro 10 qd
--Tums 500 qd
--MV
--Atrovent neb q6hr
--Lasix 20 mg po qd
--Trazadone 25 mg qhs prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
once a day.
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Atrovent 0.02 % Solution Sig: One (1) Inhalation every six
(6) hours: atrovent neb q6 please.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
aspiration PNA
mental retardation
diastolic dysfunction and heart failure
Discharge Condition:
good, 95% on RA. feeding self with help.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
Return to the ED if you have O2 sat < 90% or HR > 120
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on Wednesday [**1-26**] at
8:30AM
|
[
"530.81",
"276.0",
"401.9",
"276.2",
"428.0",
"294.8",
"733.00",
"428.33",
"507.0",
"427.32",
"518.84",
"585.9",
"317",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14711, 14788
|
5917, 13297
|
309, 315
|
14906, 14948
|
3441, 5894
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15172, 15267
|
2894, 2940
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13323, 13541
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14972, 15149
|
2955, 3422
|
241, 271
|
343, 1265
|
1287, 2534
|
2550, 2878
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,622
| 175,017
|
22201
|
Discharge summary
|
report
|
Admission Date: [**2162-8-8**] Discharge Date: [**2162-8-13**]
Service: NEUROSURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Burr hole evacuation of left SDH
History of Present Illness:
HPI: The pt is a 84 year-old man w/ Hx of CAD, s/p AAA
repair,vascular dementia, CVA [**2150**], CRI and multiple other
medical problems presented to [**Name (NI) **] from [**Hospital 15303**] Rehab for
evaluation of confusion, R sided weakness and up to two falls in
the last 48 hours, but over 4 falls in the last few days. Per
son, he has been more confused over the past day, and his speech
has changed with word finding difficulties. He has been
reportedly coherent and able to make his own decisions up to
couple days ago. He has had acute changes in mental status
where he has began to forget to do ADLs (eg. forgot to feed
himself). He was also noted dragging "his right leg and R hand
with decreased strength."
Patient is very off baseline per HCP. [**Name (NI) **] son, he has had an hx
of prior ? "brain aneurysms" ~ 10yrs ago tx in TX, detailed
history is unknown.
On neuro ROS, reports a headache that is strong, but unchanged
from earlier today. He denies loss of vision, blurred vision,
diplopia, but ROS appears to be irreproducible.
Per [**Hospital1 100**] home records he has had progressive vascular
dementia,however his son states that he is [**Name (NI) 57933**] and alert, able
to perform basic ADLs independently (w/ exception of bathroom
use) a vast majority of the time. There are multiple
inconsistencies in hx obtained from son, HCP and records from
[**Hospital1 100**] Home.
Past Medical History:
-CAD
-AAA s/p repair
-HTN
-CVA in [**2150**]
-vascular dementia
-syncope
-hypercholesterolemia
-chronic renal insufficiency
-urinary retention, acontractile bladder without obstruction
-BPH
-constipation
-chronic pain, narcotic dependence
-depression
-severe anxiety
-GERD with barretts esophagus
-COPD
-Asthma
-Chronic low back pain
-UTI oxacillin resistant coag + staph
Social History:
World War II veteran. Lives with his wife, [**Name (NI) 24990**]. Past
smoking history is 30 pack-years. No alcohol or drugs.
Family History:
Denies history of seizures or syncopal events.
Physical Exam:
Physical Exam:
Vitals: T: 98.9F P: 67 R: 16 BP:139/79 SaO2:100% RA
General: Awake, cooperative, difficult to maintain attn.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, slightly distended.
Extremities: No edema, warm b/l.
Neurologic:
-Mental Status: Alert, oriented to self only. Attention
impaired. Intact repetition, able to read and speak without
difficulty, but with 3-5 second latency in his responses. Able
to follow central and appendicular commands. No evidence of
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
unable to perform due to miosis.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes to the right.
-Motor: Poor bulk, normal tone, but atrophy noted at temporal m.
and intrinsic hand and foot m.
R pronator drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Strength is full in UEs with exception of R deltoid 4, biceps
4+,
triceps 4, WE 4+. LE 4+ IP and 4+ hamstrings.
-Sensory:
Light touch - impaired on RUE and RLE.
Pinprick - not done
Cold sensation - not done
Vibratory sense - not done
Proprioception -not done
Extinction to DSS on the right.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 1
R 3 3 3 1 1
Plantar response was flexor L, mute on R.
-Coordination: No intention tremor.
-Gait: deferred.
on discharge: oriented x 2 with slight prompting, CN II-XII
intact, no facial , no drift, motor full, follows commands,
speech clear. Incision clean and dry. Staples in place.
Pertinent Results:
[**Known lastname 57934**],[**Known firstname **] [**Medical Record Number 57935**] M 84 [**2077-9-8**]
Cardiology Report ECG Study Date of [**2162-8-8**] 3:06:38 PM
Sinus rhythm. Possible left atrial abnormality. Septal Q waves
are
non-diagnostic. There is likely left ventricular hypertrophy
with early
repolarization. Compared to the previous tracing of [**2161-11-24**]
there is no
significant change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 174 98 [**Telephone/Fax (2) 57936**] 48
[**Known lastname 57934**],[**Known firstname **] [**Medical Record Number 57935**] M 84 [**2077-9-8**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2162-8-8**]
3:52 PM
[**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7408**] EU [**2162-8-8**] 3:52 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 57937**]
Reason: AMS, SLIGHT RIGHT SIDED WEAKNESS, EVALUATE FOR BLEED
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with AMS and slight right side weakness
REASON FOR THIS EXAMINATION:
please eval for evidence of bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SBNa SUN [**2162-8-8**] 5:50 PM
large left sided likely acute on chronic subdural hematoma. 7 mm
rightward
shift
Final Report
CT HEAD WITHOUT CONTRAST.
COMPARISON: [**2161-11-3**].
HISTORY: Altered mental status, evaluate for bleed.
TECHNIQUE: MDCT axially acquired images of the brain were
obtained. No IV
contrast was administered. Coronal and sagittal reformats were
not performed.
FINDINGS: There is a large left-sided subdural hematoma with
areas of
hyperdensity and hypodensities suggestive of acute on subacute
bleed. This
hematoma measures approximately 3.4 cm in maximal width. There
is rightward shift of normally midline structures by
approximately 7 mm (2, 18). There is adjacent mass effect with
effacement of the left frontal and posterior horns of the
ipsilateral lateral ventricle. There is no intraventricular
hemorrhage or evidence of trapped ventricle identified. The
basilar cisterns are patent. Slight widening of the ipsilateral
prepontine cistern is noted and could represent mild uncal
herniation.
The patient is status post remote right frontal craniotomy.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. The sulci
are prominent consistent with age-related atrophy. The
visualized paranasal sinuses are clear. There is no evidence of
acute fracture.
IMPRESSION: Large acute-on-subacute left subdural hematoma with
shift of
normally midline structures toward the right by approximately 7
mm and slight left uncal herniation.
[**Known lastname 57934**],[**Known firstname **] [**Medical Record Number 57935**] M 84 [**2077-9-8**]
Radiology Report CHEST (SINGLE VIEW) Study Date of [**2162-8-8**] 5:16
PM
[**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7408**] EU [**2162-8-8**] 5:16 PM
CHEST (SINGLE VIEW) Clip # [**Clip Number (Radiology) 57938**]
Reason: please eval for acute cardio-pulm process
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with altered mental status
REASON FOR THIS EXAMINATION:
please eval for acute cardio-pulm process
Final Report
CHEST SINGLE VIEW
COMPARISON: [**2161-11-25**].
HISTORY: Altered mental status.
FINDINGS: The cardiac silhouette is unchanged. The aorta is
unfolded and
ectatic with calcifications, similar in appearance when compared
to prior
exam. Calcified nodule within the left mid lung zone is again
identified and unchanged. Clips within the right upper quadrant
are noted. There is no focal consolidation, effusion, or
pneumothorax. Left basilar atelectasis is noted. Calcification
of the mitral valve is also identified.
IMPRESSION:
1. Left basilar atelectasis.
2. Ectatic and unfolded aorta with calcifications, unchanged.
Mitral valve
calcifications.
[**Known lastname 57934**],[**Known firstname **] [**Medical Record Number 57935**] M 84 [**2077-9-8**]
Radiology Report SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT
Study Date of [**2162-8-8**] 9:38 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG SICU-A [**2162-8-8**] 9:38 PM
SHOULDER (AP, NEUTRAL & AXILLA Clip # [**Clip Number (Radiology) 57939**]
Reason: Please assess for fx, other anl
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with MMP, now w/ R shoulder pain
REASON FOR THIS EXAMINATION:
Please assess for fx, other anl
Final Report
RIGHT SHOULDER [**2162-8-8**]
CLINICAL INFORMATION: Right shoulder pain.
FINDINGS: The humeral head is high riding consistent with
longstanding
rotator cuff tear. The humeral head articulates with the
acromion. There are degenerative changes at the glenohumeral
joint, moderate in degree. No
fracture or other deformity noted.
[**Known lastname 57934**],[**Known firstname **] [**Medical Record Number 57935**] M 84 [**2077-9-8**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2162-8-12**]
11:16 AM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2162-8-12**] 11:16 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 57940**]
Reason: 84 year old man s/p L sdh drainage, evaluate for change
prio
[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p L sdh drainage, evaluate for change prior
to discharge.
REASON FOR THIS EXAMINATION:
84 year old man s/p L sdh drainage, evaluate for change prior
to discharge.
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: [**First Name9 (NamePattern2) 57941**] [**Doctor First Name **] [**2162-8-12**] 4:46 PM
PFI: Left drainage catheter has been removed. No evidence of new
hemorrhage
or infarct. Improvement in pneumocephalus.
Final Report
INDICATION: 84-year-old male status post left subdural
hemorrhage drainage.
Interval followup.
TECHNIQUE: Multidetector axial CT scan of the head was obtained
without the administration of contrast.
COMPARISON: CT head dated [**2162-8-9**] and CT head dated
[**2162-8-8**].
FINDINGS
There has been interval removal of the left-sided drainage
catheter. There
has been improvement of the pneumocephalus from the prior
examination. There is now a fluid collection within the space.
There remains a small amount of hyperdensity layering
posteriorly consistent with a small amount of residual blood.
There are two burr holes in the left and surgical staples in
place. There is no evidence of new hemorrhage or infarction. The
ventricles are dilated and stable from prior examination. There
is persistent effacement of the sulci, unchanged from prior as
well as similar level of midline shift from prior. The paranasal
sinuses and mastoid air cells are unremarkable. The patient is
status post remote right-sided frontal craniotomy.
IMPRESSION:
1. Interval removal of left-sided catheter drainage with
improvement in
pneumocephalus. Recommend continued followup to ensure complete
resolution of pneumocephalus.
2. No evidence of new hemorrhage.
Brief Hospital Course:
Pt was tranferred in from rehab for evaluation of confusion. CT
of the brain revealed left sided chronic sdh with 7 mm of
midline shift. Being that the pt was on plavix he was given
platelets. He was loaded with dilantin for sz prophylaxis.
He was brought to the OR the following am for burr hole
evacuation of same. A catheter was left in the subdural space x
1.5 days to allow for brain expansion. It was then removed.
Follow up CT scans were stable.
PT and OT evals deemed the pt an appropriated candidate for
rehabilitation services.
Pt to restart his home dose plavix on [**2162-8-23**].
Medications on Admission:
Medications:
- Fentanyl patch 100 mcg every 72 hrs.
- Oxycodone 5mg Q4H prn
- Klonopin 1mg QHS
- [**Doctor Last Name **] hydroxide QHS 30ml
- vitamijn d 1000U
- Plavix 75 mg daily
- Loperamide, MOM, artificial tears prn
- Flomax 0.4mg daily
- Metoprolol tartrate 12.5mg [**Hospital1 **]
- Iron sulfate 325mg
- b12 injection 1mg monthly
- Wellbutrin SR 150mg [**Hospital1 **]
- Nasal [**Last Name (LF) **], [**First Name3 (LF) 282**] prn
- Nexium 40mg daily
- Sumatriptan 50mg daily
- APAP, simethicone, Maalox prn
Discharge Medications:
1. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ASDIR (AS DIRECTED).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-1**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-1**]
Tablets PO Q6H (every 6 hours) as needed for headache.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. LeVETiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
left SDH
Discharge Condition:
neurologically stable
Discharge Instructions:
General InstructionsYOUR STAPLES SHOULD BE REMOVED ON [**2162-8-19**]
?????? Have a frien/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.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You WILL need a CT scan of the brain with / without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2162-8-13**]
|
[
"600.01",
"852.21",
"E888.9",
"564.00",
"290.40",
"493.20",
"530.85",
"788.20",
"V15.88",
"784.3",
"728.87",
"437.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.28"
] |
icd9pcs
|
[
[
[]
]
] |
14195, 14280
|
11299, 11900
|
228, 263
|
14333, 14357
|
4232, 5225
|
15885, 16247
|
2264, 2312
|
12464, 14172
|
9541, 9617
|
14301, 14312
|
11926, 12441
|
14381, 15862
|
2965, 4034
|
2343, 2697
|
4049, 4213
|
179, 190
|
9649, 11276
|
291, 1705
|
2712, 2948
|
1727, 2101
|
2117, 2248
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,667
| 158,621
|
42651
|
Discharge summary
|
report
|
Admission Date: [**2166-2-27**] Discharge Date: [**2166-3-5**]
Date of Birth: [**2111-9-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2166-2-27**] Aortic valve replacement, [**Street Address(2) 17167**]. [**Hospital 923**] Medical
mechanical Regent valve
History of Present Illness:
54 year old female with 20 year history of a "heart murmur" who
has been complaining of progressive shortness of breath and
fatigue. Recent echocardiogram in [**2165-12-10**] revealed critical
aortic stenosis. Of note, she has no prior echocardiogram and
never been told she has aortic valve disease. She presents today
for surgical evaluation. Prior to surgical consultation, she
underwent cardiac catheterization which showed normal coronary
arteries. She also admits to exertional chest tightness and
"heart burn" symptoms. She denies orthopnea, PND, palpitations
and pedal edema.
Past Medical History:
Aortic Stenosis, history of syncope 15 years ago
Anxiety
s/p C-section
Social History:
Race: Caucasian
Last Dental Exam: extraction 3-4 months ago
Lives with: Parents
Occupation: Unemployed
Cigarettes: Denies
ETOH: 1-2 beers per night
Illicit drug use: Denies
Family History:
Denies premature coronary artery disease. Both parents still
alive. Mother underwent CABG in her early 70's.
Physical Exam:
Pulse: 84 Resp: 16 O2 sat: 100% room air
B/P Right: 123/83 Left: 119/79
Height: 59" Weight: 102 lbs
General: WDWN female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [ Murmur [x] grade 4/6 SEM radiating
to
carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: None
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: decreased
Carotid Bruit: transmitted murmurs
Pertinent Results:
TTE [**2166-2-27**]
PREBYPASS: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. And there is effacement of
the sinotubular junction. No thoracic aortic dissection is seen.
The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. Normal coronary sinus. No clot in LAA.
The PV is not well seen.
POSTBYASS: Normally functioning mechanical AV. Normal LV
function. No dissection seen after Ao Cannula removed. Otherwise
unchanged.
[**2166-2-27**] 10:39AM BLOOD WBC-13.5*# RBC-2.61*# Hgb-8.0*#
Hct-22.2*# MCV-85 MCH-30.6 MCHC-36.0* RDW-13.2 Plt Ct-128*#
[**2166-3-4**] 05:30AM BLOOD WBC-12.3* RBC-3.40* Hgb-10.4* Hct-29.8*
MCV-88 MCH-30.6 MCHC-34.9 RDW-13.5 Plt Ct-428#
[**2166-2-27**] 10:39AM BLOOD PT-16.7* PTT-34.1 INR(PT)-1.6*
[**2166-3-1**] 04:06AM BLOOD PT-19.6* PTT-29.2 INR(PT)-1.9*
[**2166-3-1**] 08:10AM BLOOD PT-24.2* INR(PT)-2.3*
[**2166-3-2**] 01:34PM BLOOD PT-26.8* INR(PT)-2.6*
[**2166-3-4**] 05:30AM BLOOD PT-17.2* PTT-41.8* INR(PT)-1.6*
[**2166-3-5**] 04:45AM BLOOD PT-23.7* PTT-108.7* INR(PT)-2.3*
[**2166-2-27**] 11:53AM BLOOD UreaN-9 Creat-0.5 Na-141 K-3.7 Cl-112*
HCO3-21* AnGap-12
[**2166-3-5**] 04:45AM BLOOD UreaN-10 Creat-0.6 Na-130* K-4.1 Cl-87*
[**2166-3-3**] 04:50AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.1
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**2-27**] she was brought directly to
the operating room where she underwent an aortic valve
replacement. Please see operative note for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours she was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one she was started on beta-blockers and diuretics
and gently diuresed towards her pre-op weight. Later on this day
she was transferred to the telemetry floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. Coumadin was initiated for mechanical aortic valve.
This was titrated for goal INR. She worked with physical therapy
for strength and mobility. On post-op day three INR jumped to
3.7 and Coumadin was held. Subsequent day the INR was 1.6.
Coumadin was again given along with Heparin drip. She was ready
for discharge home and just waiting for INR to be at therapeutic
level. On post-op day six she was finally discharged home with
VNA services and the appropriate medications and follow-up
appointments. Her PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**], [**First Name3 (LF) **] follow her
Coumadin and INR.
Medications on Admission:
Centrum silver daily, Calcium Carbonate 500mg daily, Tylenol prn
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. 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day: Please
take for mechanical aortic valve. Goal INR 2.5-3.5. Dose will
change according to INR and instructions regarding dose will be
given be PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33474**].
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
INR daily d/t sensitivity to Coumadin. Once stable, INR draw can
be according to PCP.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Critical symptomatic aortic stenosis
History of syncope 15 years ago
Anxiety
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Trace edema bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**4-2**] at 1:30pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] on [**3-25**] at 1:30pm
Wound check at [**Hospital Unit Name **] [**Hospital Unit Name **] on [**3-11**] at 11:00am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 33474**] in [**5-15**] weeks [**Telephone/Fax (1) 65542**]
**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 Aortic Valve Replacement
Goal INR 2.5-3.5
First draw [**2166-3-5**]
Results to phone Dr [**Last Name (STitle) 33474**]
Completed by:[**2166-3-5**]
|
[
"300.00",
"424.1",
"V58.61",
"276.1",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
6786, 6835
|
3889, 5267
|
329, 454
|
6956, 7151
|
2210, 3866
|
8074, 8890
|
1367, 1477
|
5382, 6763
|
6856, 6935
|
5293, 5359
|
7175, 8051
|
1492, 2191
|
270, 291
|
482, 1067
|
1089, 1161
|
1177, 1351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,589
| 148,031
|
49520
|
Discharge summary
|
report
|
Admission Date: [**2108-6-22**] Discharge Date: [**2108-6-25**]
Date of Birth: [**2029-12-26**] Sex: F
Service: MEDICINE
Allergies:
Nitrofurantoin / Cipro Cystitis
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Pacemaker insertion
History of Present Illness:
Mrs. [**Known lastname **] is a 78 yo F who presents with dizziness in the
setting of poor PO intake for several weeks. Per her daughter,
patient's PO intake has been decreased since hospitalization for
a perforated ulcer in [**Month (only) **] (has lost over 25 lbs in that
time period). Over the past several days, patient has been dizzy
and weak at home, and eating and drinking even less than
baseline. On the day prior to admission, felt nauseous after
eating a hamburger for lunch and vomited x1; resolved and was
able to tolerated seafood chowder for dinner. The morning of
admission, patient felt increasingly weak and dizzy,
particularly with movement, sitting or standing, and called EMS.
FS was 200 and EMS found her to be in a junctional bradycardia
and she was brought to the [**Hospital1 18**] for further evaluation.
.
In the ED, initial vitals were T97.4 HR42 BP155/47 RR18 O2
sat100% 4L NC. In the emergency room, EKG showed a junctional
bradyarrhythmia with a rate of 41 and increased RBBB from prior.
She was given 0.5 mg atropine for bradycardia with no
significant effect (HR 36-38). Initial labs were remarkable for
a creatinine of 3.7 (baseline 1.5-1.6), BUN 87, K 6.2, and
digoxin level of 2.0. CXR showed mild fluid overload. She was
seen by cardiology and toxicology and received aspirin 324,
digibind 6 vials, 10 units insulin, 1 amp D50, Na bicarb 150 mEq
in 1L D5W, and kayexelate 15 g. She received 5 mg of vitamin K
PO for her INR of 3.2 and was admitted to the CCU for further
management and monitoring. Prior to transfer VS were HR 37, BP
129/40, RR 12, O2 sat 100% on 3L.
.
In the CCU, patient denies any h/o syncopal events, chest pain,
SOB, fevers, chills, cough, or diarrhea. She does report
increasing LE edema and one episode of possible visual
hallucination (saw a person whom she spoke to who did not reply,
and subsequently disappeared). Reports compliance w/ all of her
medications.
.
On review of systems, she denies any prior history of stroke,
TIA, though her family feels her speech may be slightly more
slurred than usual. She denies h/o deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, or syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: NONE
-PERCUTANEOUS CORONARY INTERVENTIONS: NONE
-PACING/ICD: NONE
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation on coumadin
- Perforated ulcer s/p surgical repair in [**12-13**]
- History of breast cancer --> on Arimidex
- Bullous pemphigoid
- Dominant left pole thyroid nodule
- Chronic renal failure- baseline 1.5-1.6
- History of renal stones
- anemia
- asthma
- DJD
- Right eye infection
- Depression
Social History:
Lives with son and daughter in law in [**Name (NI) 2268**]. Previously
lived independently.
-Tobacco history: Life long non-smoker.
-ETOH: Rare socially.
-Illicit drugs: No history of illicit drug use.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry mucus membranes.
NECK: Supple with JVP at the clavicle at 30 degrees.
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, midly distended; non tender; active BS;
well-healed midline surgical incision; No HSM or tenderness.
EXTREMITIES: 2+ pedal edema, 1+ LE half way up the leg; No c/c.
SKIN: Several annular hyperpigmented macules on her back and
abdomen.
PULSES: DP 2+ PT 2+ b/l
Neuro: A&Ox3, CNII-XII tested and grossly intact; 5/5 strength
in upper extremities b/l; RLE movement impaired [**3-7**] knee pain,
5-/5 strength in LLE; FNF intact; no pronator drift
Discharge:
Vitals:99(99)-168/76-66-20-95%RA.
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CARDIAC: S1, S2. No m/r/g.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, midly distended; non tender; active BS;
well-healed midline surgical incision; No HSM or tenderness.
EXTREMITIES: 1+ pedal edema, R>L.
SKIN: Several annular hyperpigmented macules on her back and
abdomen.
Dressing over pacemaker site intact and dry.
PULSES: DP 2+ PT 2+ b/l
Neuro: A&Ox3, CNII-XII tested and grossly intact; 5/5 strength
in upper extremities b/l; RLE movement impaired [**3-7**] knee pain.
Pertinent Results:
ADMISSION LABS:
[**2108-6-22**] 09:00AM GLUCOSE-181* UREA N-87* CREAT-3.7*#
SODIUM-132* POTASSIUM-6.2* CHLORIDE-97 TOTAL CO2-22 ANION GAP-19
[**2108-6-22**] 09:00AM CALCIUM-9.8 PHOSPHATE-5.6*# MAGNESIUM-2.9*
[**2108-6-22**] 09:00AM WBC-11.4* RBC-3.88* HGB-9.9* HCT-30.5*
MCV-79* MCH-25.6* MCHC-32.6 RDW-15.4
[**2108-6-22**] 09:00AM NEUTS-79.9* LYMPHS-9.8* MONOS-3.5 EOS-6.3*
BASOS-0.4
[**2108-6-22**] 09:00AM PLT COUNT-296
[**2108-6-22**] 09:00AM PT-32.8* PTT-30.1 INR(PT)-3.2*
[**2108-6-22**] 09:00AM proBNP-[**2122**]*
STUDIES:
EKG: (8:57 AM) Junctional bradycardia at 41 bpm w/ slightly
increased RBBB from baseline. LAD suggestive of LAFB.
.
EKG: (13:25) Junctional bradycardia at 43 bpm w/ RBBB closer to
baseline, stable LAD.
.
CXR: [**6-22**]
1. Confluent lower lobe ill defined opacities likely represent
pulmonary edema however infectous process cannot be ruled out.
Recommend repeat radiograph after diuresis to assess for
resolution of opacities 2. Mild congestive heart failure with
bilateral left greater than right small pleural effusions.
.
CXR [**6-23**]
REASON FOR EXAMINATION: Followup of the patient after pacemaker
placement
through the left cephalic vein.
The left-sided pacemaker leads terminate in the expected
location of right
atrium and right ventricle. There is no evidence of
pneumothorax. The
patient is in mild interstitial pulmonary edema associated with
bilateral
pleural effusions, but grossly appears to be unchanged since the
prior study.
Brief Hospital Course:
78 yo F w/ h/o AF, DM, and HTN presenting with dizziness and
weakness in the setting of new junctional bradycardia.
.
# Junctional bradycardia: New from baseline and concerning for
digitalis toxicity in setting of clinical picture of nausea,
vomiting, and hallucination, as well as dig level of 2.0,
hyperkalemia and hyponatremia. Bradycardia, junctional rhythms,
atrial tachyarrhythmias with nodal blockade are some of the most
common manifestations of digitalis toxicity. EKG does not show
some of the classic changes associated with digitalis - the
"effect" including scooped ST segments and T wave changes,
however these tend to be associated more with chronic use than
acute toxicity. Digitalis toxicity could be secondary to new
renal failure. However, received digibin without significant
change in EKG, which would be expected. This raises concern for
underlying conduction disease/sinus node dysfunction therefore
decision made to undergo pacemaker placement ([**Company 1543**] dual-ch
ppm via L cephalic) on [**6-22**]. Her INR was reversed for the
procedure with 5 mg PO vitamin K and 2 units FFP. Pacer
interrogating on [**6-23**] and demonstrated appropriate function. Low
dose metoprolol restarted on [**6-23**]. Keflex was started [**6-23**] with
plan for 2 day treatment course to prevent pacemarker site
infection. Regarding anticoagulation, [**6-23**] INR 1.9 and patient
restarted on coumadin without bridge. Digoxin now listed as an
outpatient allergy. Pressor dressing removed on [**6-23**]; plain
dressing will remain in place until [**6-26**]
ON DISCHARGE:
-- Follow-up in Device Clinic in 1 week.
-- Holding dilt, started amlodipine 5mg, but may benefit from
ACEi as outpatient once the acute kidney injury resolves.
# Acute on chronic kidney injury/Acute renal failure: Patient w/
baseline creatinine between 1.4 and 1.5, here w/ elevation to
3.7. Likely occurred in setting of poor PO intake, vomiting, and
continued compliance with lasix. However, intrinsic renal
process (ATN) or post-renal process are still in differential.
Admission UA with 8WBC. Patient without complaint of dysuria.
Repeat UA/culture sent on [**6-23**] to rule out UTI. Patient peceived
1L D5W w/ bicarb in ED, 500 cc bolus with improvement in
creatinine. Transferred to medicine for further work-up of [**Last Name (un) **];
urine lytes ordered prior to transfer. At time of transfer
patient tolerating PO without nausea, vomiting with adequate
UOP. Decision made to hold home diuretic regimen as patient
thought to be intrasvascularly dry.
ON DISCHARGE:
- will start lasix 20mg daily, with the idea of uptitrating this
based on her weight as well as creatinine in the future. We
suspect her needed dose may have changed with improved forward
flow following pacer insertion.
# Possible Diastolic Dysfunction vs Symptomatic bradycardia:
Last echo in our system shows preserved EF >55%, but patient
with signs of volume overload on exam with significant lower
extremity edema. Could also have been related to poor forward
flow in the setting of bradycardia. Held home lasix in setting
of renal failure. CXR on [**6-23**] with interval increase in vascular
congestion. She was able to breathe on room air prior to
discharge without desaturation. Lasix will be restarted as
outpatient at 20mg per day and uptitrated as needed in the
future.
# Atrial fibrillation. Regarding anticoagulation, on coumadin at
home INR reversed prior to pacemaker placement with vitamin K
5mg. INR on [**6-23**] 1.9 and coumadin restarted; per EP no need for
heparin bridge for goal INR: [**3-8**]. We continued her on coumadin,
stopped digitalis, stopped diltiazem. She is currently on 25mg
of [**Hospital1 **] Lopressor, this can be uptitrated in the future if
needed. Her heart rate was well controlled in 70s after device
implantation.
# Hyperkalemia- Patient hyperkalemic on presentation- likely
secondary to acute on chronic renal insufficiency +/- digoxin
toxicity. Received insulin, D5W w/ bicarb, kayexelate. s/p
digibind, patient at risk for becoming hypokalemic. Serial lytes
monitored with hyperkalemia resolving by HD2.
# DM- Is on humalog 75/25 30 units [**Hospital1 **] w/ a sliding scale at
home. Last A1c 8.6 in [**2108-2-4**]. FSBS 186 in ED. Patient
continued on home insulin with QID FS. Her morning and evening
insulin were decreased to 15 [**Hospital1 **] based on glucose readings
during the last 2 hospital days. This may need to be uptitrated
as her PO intake increases.
# Microcytic Anemia. On admission HCT at baseline ~30. On HD2
HCT 26. Likely dilution as all counts down in setting of IV
hydration.
# Depression. Continued on home citalopram
# Asthma. Patient without wheeze. Albuterol PRN
TRANSITIONAL ISSUES:
#Blood Pressure - patient may benefit from starting an ACEi as
outpatient, after kidney function is allowed to normalize for
several days.
#Afib --- Follow-up in Device Clinic in 1 week.
-- Holding dilt, started amlodipine 5mg, but may benefit from
ACEi as outpatient once ARF resolves.
#CRF:ON DISCHARGE:
- will start lasix 20mg daily, with the idea of uptitrating this
based on her weight as well as creatinine in the future.
#DM - may need insulin adjusted as outpatient.
Medications on Admission:
digoxin 125 mcg a day
diltiazem CD 180 mg a day
metoprolol tartrate 50 mg [**Hospital1 **]
azathioprine 50 mg PO daily
acetaminophen with codeine 300-30 mg p.r.n.
albuterol inhaler p.r.n.
Arimidex 1 mg daily
citalopram 20 mg once daily
clobetasol ointment p.r.n.
hydroxyzine 25 mg PO q6hr PRN itching
furosemide 40 mg daily (written for [**Hospital1 **], but she takes once a
day)
Humalog 75/25 30 units b.i.d., Humalog sliding scale
omeprazole 20 mg daily
Coumadin 7.5 mg MWF, 5 mg T,Th, [**Last Name (LF) **], [**First Name3 (LF) **]
calcium with vitamin D b.i.d.
dorzolamide - timolol one drop right eye b.i.d.
prednisolone 1% one drop every hour in the right eye
Travatan 0.04% one drop at bedtime in the right eye
Alphagan 0.1% one drop in the right eye once daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO
twice a day as needed for pain.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for sob,
wheezing.
5. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
10. travoprost 0.004 % Drops Sig: One (1) Ophthalmic QHS (once
a day (at bedtime)).
11. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
12. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
13. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
14. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,TH,SA).
15. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS
(MO,WE,FR).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. hydroxyzine pamoate 25 mg Capsule Sig: One (1) Capsule PO
every six (6) hours as needed for itching.
18. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig:
Fifteen (15) units Subcutaneous twice a day: in AM and in PM
per sliding scale.
19. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous QACHS: per sliding scale.
20. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
21. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
22. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
1) Symptomatic Bradycardia
2) Urinary Tract Infection, fever
3) Hypertension
4) Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to our hospital with weakness and dizziness.
We have done multiple tests, and have determined that your heart
rate was low. You have received a pacemaker to help you with
this condition.
The following changes were made to your medications:
STOP - Digoxin
STOP - Diltiazem
CHANGE Metoprolol to 25mg twice a day
CHANGE Humalog 75/25 to 15 units twice a day, to control your
blood sugars. This may need to be increased.
CHANGE Lasix (furosemide) to 20mg daily - this medication may
need to be increased at discretion of your primary care provider
and based on your weight and kidney function.
START Cefpodoxime - take 1 pill twice a day for a total of 7
days.
START Amlodipine 5mg Daily for your blood pressure.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 250**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: CARDIAC SERVICES
When: FRIDAY [**2108-6-29**] at 9:30 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
Department: CARDIAC SERVICES
When: WEDNESDAY [**2108-8-1**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], 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
Completed by:[**2108-6-26**]
|
[
"493.90",
"V58.61",
"276.7",
"311",
"427.81",
"715.90",
"V10.3",
"584.9",
"403.90",
"426.53",
"250.00",
"428.32",
"272.4",
"427.31",
"599.0",
"428.0",
"V58.67",
"280.9",
"276.1",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
14957, 15092
|
6891, 8458
|
303, 325
|
15233, 15233
|
5376, 5376
|
16196, 17151
|
3647, 3762
|
12916, 14934
|
15113, 15212
|
12122, 12893
|
15409, 16173
|
3777, 3777
|
2990, 3063
|
11926, 12096
|
11620, 11912
|
254, 265
|
353, 2882
|
5393, 6868
|
3791, 5357
|
15248, 15385
|
3094, 3410
|
2904, 2970
|
3427, 3631
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,964
| 129,685
|
10411
|
Discharge summary
|
report
|
Admission Date: [**2118-11-9**] Discharge Date: [**2118-11-20**]
Date of Birth: [**2044-6-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Carcinoma of the right upper lobe.
Major Surgical or Invasive Procedure:
PROCEDURE PERFORMED:
1. Right thoracotomy with sleeve upper lobectomy.
3. Flexible bronchoscopy with clearance of secretions.
History of Present Illness:
Mr. [**Known lastname **] was a 74-year-old gentleman with biopsy-proven
squamous carcinoma of the left upper lobe. He had a negative
metastatic survey and underwent mediastinoscopy with no
pathologic findings one day prior to this admission. We
recommended sleeve upper lobectomy as he had adequate, but not
exceptional lung function. He agreed to proceed.
Past Medical History:
Significant for radiation for squamous carcinoma of the soft
palate. This was approximately 10 years ago, treated with
radiation therapy at [**Hospital 1474**] Hospital with no evidence of
recurrence to date. He also has a history of a lacunar infarct
and COPD.
Brief Hospital Course:
Patient underwent the sleeve resection on [**2118-11-9**]. He was on
pressors briefly in the operating room but otherwise tolerated
the procedure well. Cardiac enzymes were flat post-op and the
patient's EKG was without ischemic changes. He received one unit
of blood on POD1 for Hct of 26 to which he responded well. Later
that same day the patient developed rapid atrial fibrillation
and the senior house officer was called to the floor. Patient
was hemodynamically stable and converted back to NSR with 5mg IV
lopressor. He was also given magnesium and calcium gluconate
acutely and labs were sent. ABG was 7.27/46/151/22/-5. Patient
was confused at the time and his urine output remained
borderline throughout the night. The patient was not
anticoagulated given his recent surgery and presence of
epidural. Patient remained confused over the next several days,
and geriatrics medicine consult was obtained to help manage his
delerium and comorbid medical conditions. He had a hard time
clearing his secretions and flexible bronchoscopy was needed
several times over the following week as well as gentle
diuresis. On POD3 the patient was transferred to the SICU for
careful managment given his compromised respiratory status and
concern for need for possible intubation. He remained stable in
the ICU and after a repeat bronchoscopy was deemed stable enough
for transfer back to the floor the next day. Patient had brief
episodes of atrial fibrillation both while in the unit and once
transfered back to the floor which resolved with titration of
the beta blocker. The epidural and both chest tubes were removed
on POD4. Bedside swallow demonstrated the patient was at
significant risk for anpiration and tube feeds were started on
[**11-14**] with nutrution recommendations. As the patient's mental
status started to clear he was seen by physical therapy and
geriatrics medicine continued to follow, however he continued to
have difficulty clearing secretions and on [**11-16**] he was again
bronch'd after a chest x-ray demonstrated worsened atelectasis.
Intermittent diuresis combined with bronchoscopy as described
resulted in significant improvement in his pulmonary status.
Over the next several days his mental status cleared
significantly and he was increasingly mobile, ambulating with
assistance from PT. Rehabilitation screening had just begun when
patient's status took an unexpected downturn on the evening of
[**11-20**], unfortunately ending in death within an hour of the
initiation of events. The intern was called to bedside shortly
before midnight when the patient abruptly became severely
bradycardic upon returning to bed after a bowel movement. The
nurse called a code immediately and upon arrival to bedside the
patient was in PEA. The senior medical resident ran the code,
and the senior surgery resident arrived within 5 minutes after
being called into the hospital from home. Patient received
atropine, epinephrine and bicarbonate x4 with no response. ACLS
protocol continued to be followed as the patient's rhythm
deteriorated to ventricular fibrillation. After greater than
thirty minutes of attempted resuscitation the patient was
pronounced at approximately 1am. The senior surgery resident
discussed the case with Dr. [**Last Name (STitle) 952**], who notified the family
immediately. Autopsy was declined.
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Discharge Condition:
Deceased
Completed by:[**2118-12-12**]
|
[
"293.0",
"294.8",
"V10.02",
"162.8",
"427.31",
"496",
"V15.3",
"197.2",
"427.5",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"33.24",
"99.04",
"99.62",
"33.48",
"03.90",
"96.6",
"40.3",
"99.60",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
4545, 4554
|
1179, 4522
|
357, 484
|
4612, 4652
|
4575, 4591
|
282, 319
|
512, 871
|
893, 1156
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,241
| 150,240
|
24247
|
Discharge summary
|
report
|
Admission Date: [**2174-5-12**] Discharge Date: [**2174-5-19**]
Date of Birth: [**2139-9-13**] Sex: M
Service: SURGERY
Allergies:
Betadine
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Sudden onset mid back pain radiating to groins, left >right
Major Surgical or Invasive Procedure:
none
History of Present Illness:
34 year old morbidly obese man with a history of HTN, chronic
renal insufficiency presented to the ED after developing sudden
onset mid back pain radiating to groins, left >right. Patient
states that he was drinking a bottle of water at the time. He
denies dizziness or headache. Denies shortness of breath, chest
pain, nausea or emesis.
On presentation to the ED patient was found to have systolic
blood pressure in 215-230 range in acute on chronic renal
failure.
Past Medical History:
- Hypertension with hypertensive urgency x 1 in past
- Chronic renal insufficiency with baseline Cr 1.5
- Acute disseminated encephalomyelitis - per [**Hospital1 18**] records,
diagnosed at [**Hospital1 2025**], p/w photophobia and was sore from his L-ear to
his scapula; s/p craniotomy with biopsy and 5 week hospital
stay, recovered completely, no neurological symptoms since
- Bacteremia - [**Hospital3 **] [**9-4**], per patient from
eczema skin wound. Hospitalization [**2172-7-7**] for Group G
streptococcal bactermia.
- Eczema
- Childhood asthma--has not been on inhalers in years
- Allergic rhinitis
- Rotator cuff injury
.
ALLERGIES: Betadine--rash
Social History:
Social history is significant for the presence of current
tobacco use: 1-2PPD x 10 years. Patient denies alcohol abuse,
though he indiciates there have been times when he had to cut
back on his drinking. He works as a bartender. +tattooes done by
a friend, reports they are done under sanitary conditions.
Denies ever abusing IV drugs or cocaine. Lives with roommates.
Family History:
There is a family history of premature coronary artery disease:
mother [**Name (NI) 61530**] with CAD in her 40s. Father and sisters healthy.
Mother has DM that resolved after gastric bypass. Denies other
family h/o DM, HTN, or CAD.
Physical Exam:
Physical Exam: 98.4 VS BP: 149/74 84 20 99%RA wt. 145 kg
Gen: Obese African American male, appears somewhat uncomfortable
with movement. Appropriate.
HEENT: Dry mucus membranes. Sclera anicteric.
Neck: Supple. Normal ROM. Symmetric pulses without carotid
bruits.
CV: Regular rate and rhythm. Distant heart sounds. No murmur
appreciated.
Chest: Distant but clear.
Abd: Obese, soft, NTND, No HSM or tenderness.
Ext: 1+ edema bilaterally. Multiple areas of hypopigmentation.
Feet warm and well perfused. good capillary refill.
Pulses:
Car Fem DP PT
[**Name (NI) 167**]: 2+ 1+ 2+ Dop
Left: 2+ 1+ 2+ Palp
Pertinent Results:
[**2174-5-17**] 06:40AM BLOOD WBC-10.3 RBC-3.39* Hgb-10.8* Hct-31.7*
MCV-94 MCH-31.7 MCHC-34.0 RDW-13.4 Plt Ct-198
[**2174-5-16**] 04:36AM BLOOD WBC-11.7* RBC-3.50* Hgb-10.8* Hct-32.2*
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.8 Plt Ct-159
[**2174-5-15**] 01:08AM BLOOD WBC-11.0 RBC-3.72* Hgb-11.4* Hct-34.1*
MCV-92 MCH-30.5 MCHC-33.3 RDW-13.8 Plt Ct-149*
[**2174-5-14**] 05:52AM BLOOD WBC-12.1* RBC-3.51* Hgb-11.2* Hct-32.4*
MCV-92 MCH-31.8 MCHC-34.5 RDW-13.7 Plt Ct-149*
[**2174-5-13**] 12:34AM BLOOD WBC-10.4 RBC-3.65* Hgb-11.6* Hct-33.8*
MCV-93 MCH-31.9 MCHC-34.4 RDW-13.9 Plt Ct-136*
[**2174-5-12**] 08:34PM BLOOD Hct-35.7*
[**2174-5-12**] 05:05PM BLOOD Hct-37.5*
[**2174-5-12**] 08:43AM BLOOD WBC-14.0* RBC-4.00* Hgb-12.6* Hct-36.5*
MCV-91 MCH-31.6 MCHC-34.6 RDW-13.9 Plt Ct-144*
[**2174-5-12**] 12:30AM BLOOD WBC-15.9*# RBC-4.56* Hgb-14.2 Hct-41.2
MCV-90 MCH-31.1 MCHC-34.4 RDW-14.5 Plt Ct-176
[**2174-5-17**] 06:40AM BLOOD Plt Ct-198
[**2174-5-16**] 04:36AM BLOOD Plt Ct-159
[**2174-5-15**] 01:08AM BLOOD Plt Ct-149*
[**2174-5-14**] 05:52AM BLOOD Plt Ct-149*
[**2174-5-13**] 12:34AM BLOOD Plt Ct-136*
[**2174-5-13**] 12:34AM BLOOD PT-13.1 PTT-36.9* INR(PT)-1.1
[**2174-5-12**] 08:43AM BLOOD Plt Ct-144*
[**2174-5-12**] 08:43AM BLOOD PT-13.3 PTT-36.1* INR(PT)-1.1
[**2174-5-12**] 12:30AM BLOOD Plt Ct-176
[**2174-5-13**] 12:34AM BLOOD Fibrino-321#
[**2174-5-18**] 06:20AM BLOOD Glucose-88 UreaN-34* Creat-3.0* Na-141
K-4.0 Cl-106 HCO3-27 AnGap-12
[**2174-5-17**] 06:40AM BLOOD Glucose-83 UreaN-31* Creat-2.8* Na-144
K-3.9 Cl-106 HCO3-26 AnGap-16
[**2174-5-16**] 04:36AM BLOOD Glucose-115* UreaN-31* Creat-3.0* Na-140
K-4.7 Cl-105 HCO3-26 AnGap-14
[**2174-5-15**] 01:08AM BLOOD Glucose-104 UreaN-36* Creat-3.5* Na-142
K-3.7 Cl-106 HCO3-26 AnGap-14
[**2174-5-14**] 05:52AM BLOOD Glucose-108* UreaN-34* Creat-3.6* Na-139
K-3.3 Cl-102 HCO3-25 AnGap-15
[**2174-5-13**] 12:34AM BLOOD Glucose-116* UreaN-29* Creat-2.8* Na-138
K-3.6 Cl-104 HCO3-23 AnGap-15
[**2174-5-12**] 08:34PM BLOOD UreaN-29* Creat-2.9*
[**2174-5-12**] 08:43AM BLOOD Glucose-98 UreaN-29* Creat-2.7* Na-138
K-3.1* Cl-102 HCO3-25 AnGap-14
[**2174-5-12**] 12:30AM BLOOD Glucose-96 UreaN-32* Creat-2.9* Na-139
K-3.6 Cl-101 HCO3-23 AnGap-19
[**2174-5-16**] 04:36AM BLOOD ALT-15 AST-32 LD(LDH)-467* AlkPhos-52
Amylase-80 TotBili-0.7
[**2174-5-14**] 05:52AM BLOOD LD(LDH)-234 TotBili-0.7
[**2174-5-13**] 12:34AM BLOOD ALT-11 AST-17 CK(CPK)-320* AlkPhos-56
Amylase-71 TotBili-0.6
[**2174-5-12**] 04:55PM BLOOD CK(CPK)-487*
[**2174-5-14**] 05:52AM BLOOD Hapto-122
[**2174-5-12**] 08:43AM BLOOD TSH-3.0
[**2174-5-16**] 04:36AM BLOOD HCG-LESS THAN
[**2174-5-16**] 04:36AM BLOOD AFP-1.8
[**2174-5-12**] 12:30AM BLOOD HoldBLu-HOLD
[**2174-5-13**] 12:48AM BLOOD Lactate-1.0
[**2174-5-12**] 06:54PM BLOOD Lactate-0.9
[**2174-5-15**] Final Report SCROTAL ULTRASOUND.
FINDINGS: The right testicle measures 3.4 x 2.6 x 3.8 cm. The
left testicle measures 3.0 x 2.1 x 3.9 cm. There is normal
arterial and venous flow seen within both testes. There is a
small right-sided hydrocele. Within the left testicle, there are
multiple punctate microcalcifications identified. A hypoechoic
lesion measuring 2 x 2 mm is identified and does not contain
microcalcifications. Within the head of the left epididymis,
there is a 3 x 5 mm hypoechoic lesion consistent with a simple
cyst. An additional cyst is seen within the left epididymis
tail. The right epididymis is unremarkable.
IMPRESSION:
1. No evidence of abnormal vascular flow.
2. Small right-sided hydrocele.
3. Left testicular microcalcifications.
4. 2 x 2 mm hypoechoic lesion within the left testicle. Follow
up in 3 months is reccomended.
These findings were communicated directly to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24425**] at the
time of review. The study and the report were reviewed by the
staff radiologist.
[**2172-7-9**] CT abdomen and pelvis .
FINDINGS: The left kidney measures 10.4 cm. The right kidney
measures 10.9
cm. There is no mass, hydronephrosis, or stones.
There is wall-to-wall color flow of the right and left main
renal arteries. The resistive indices of the right main renal
artery ranges from 0.77 to 0.86, with resistive indices in the
lower and upper poles of 0.76. The resistive indices in the left
main renal artery is 0.79. Resistive indices in the upper left
and lower poles of the left kidney are 0.79 and 0.62
respectively.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Appropriate flow within the main renal arteries with
symmetric resistive
indices bilaterally.
The study and the report were reviewed by the staff radiologist.
CTA CHEST, ABDOMEN, AND PELVIS ON [**2174-5-12**]
FINDINGS: There is an intimal flap seen within the aortic arch
originating at the level of the right common carotid artery and
crossing the ostia of the left common carotid and left
subclavian arteries extending through the
thoracic aorta through the abdomen beyond the bifurcation into
the external iliac vessels. Thrombus is seen within both
external iliac vessels, extending minimally into the left common
femoral artery. The true lumen supplies both hypogastric
arteries as well as the left renal artery and a portion of the
celiac trunk and SMA. Both true and false lumens are well
opacified proximally, and the right renal artery is well
opacified. The phase of contrast administration is very early,
and there is poor enhancement of both kidneys, but no
differential enhancement is evident.
Bibasilar consolidation is seen, possibly due to aspiration. An
endotracheal tube terminates proximal to the carina. An
orogastric tube extends to the gastric antrum. Spleen is
homogeneous in attenuation, as is the pancreas. The adrenal
glands are normal in morphology. Liver reveals no abnormalities
on early arterial phase imaging. There is no ascites. No bowel
wall thickening.
IMPRESSION:
1. Type A aortic dissection originating at the level of the
right common
carotid and extending to the bilateral external iliac arteries,
with thrombus seen within these vessels. There is likely
hypoperfusion of the right kidney which is supplied by the false
lumen; however, early arterial phase imaging precludes
evaluation of the renal parenchyma.
2. Bibasilar pulmonary consolidations.
Radiology Report MR THORACIC SPINE W/O CONTRAST Study Date of
[**2174-5-12**] 11:21 AM
Final Report
MRI OF THE THORACIC AND LUMBAR SPINE WITHOUT GADOLINIUM.
Gadolinium could not be administered due to low EGFR.
HISTORY: Back pain.
Comparison is made with prior C-spine study from [**2172-7-11**].
[**2174-5-12**] SCHED CHEST (PA & LAT)
Final Report
FINDINGS: PA and lateral chest radiographs are reviewed without
comparison. Cardiac silhouette is unchanged. Thoracic aorta is
mildly tortuous, but also unchanged. Pulmonary vascularity is
normal. Lungs are clear. There is no pleural effusion or
pneumothorax. Note is made of bilateral gynecomastia.
IMPRESSION: No acute intrathoracic process. Unchanged
cardiomediastinal contours.
Cardiology Report ECG Study Date of [**2174-5-12**] 3:59:18 AM
Sinus rhythm. Left atrial abnormality. Non-specific T wave
inversions in
leads I, aVL and V4-V6. Minimal ST segment depression in lead
V6. ST-T wave
abnormalities are non-specific but might be related to left
ventricular
hypertrophy. Compared to the previous tracing of [**2173-8-14**] upward
bowing of
ST segment elevations in lead V2-V4 is no longer present.
Portable TEE (Complete) Done [**2174-5-12**]
Conclusions
No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level, which is
likely within normal limits for the patient's size. A mobile
density is seen in the distal aortic arch consistent with an
intimal flap/aortic dissection; there is no dissection or
significant enlargement of the ascending aorta. The right and
left coronary artery origins are visualized in their customary
positions with normal appearance of the ostia. A linear density
is seen in the descending aorta consistent with an intimal
flap/aortic dissection. There is flow in the false lumen. The
dissection flap likely extends into the distal abdominal aorta,
which cannot be visualized with TEE. 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
pericardial effusion.
IMPRESSION: [**Location (un) 11916**] type B (Debakey type III) aortic dissection
originating at the level of the distal aortic arch with
propagation into the descending thoracic aorta. No evidence of
ascending aortic enlargement or aortic rupture. No aortic
regurgitation or pericardial effusion. Normal biventricular
function. No significant valvular disease.
T-SPINE; L-SPINE (AP & LAT) Clip # [**Clip Number (Radiology) 61531**]
FINDINGS: Two views of the thoracic spine and two views of the
lumbar spine
are reviewed without comparison. There is no fracture. Vertebral
body and
intervertebral disc space heights are normal. Mild degenerative
changes are
seen in the lower lumbar spine, with degenerative loss of disc
space height at
L4-5, and moderate anterior osteophyte formation. Small anterior
osteophytes
are seen at multiple levels in the thoracic spine. Visualized
bowel gas
pattern is normal.
IMPRESSION: No fracture.
Brief Hospital Course:
34M h/o severe hypertension and hypertension nephropathy,
presenting to the ED on [**2174-5-12**] after experiencing an acute
onset of mid-thoracic back pain while drinking a bottle of
water. The pain radiated down into his groin bilaterally, L>R,
with subjective left leg numbness in his left heel, which
resolved. He denied HA, dizziness, or visual changes. He denied
CP, SOB, N/V. In the ED his initial VS were: T: 98.3F, BP:
182/87, HR: 87, RR: 16, SaO2: 98% RA. He admits that he ran out
of BP meds 3 weeks ago. HIs exam was notable for slight TTP at
T8-9, normal neuro exam, normal testicular exam with no hernia.
ECG demonstrated NSR at 87 bpm, notched p-waves (old), LVH
(old), biphasic T-waves in lateral leads (new). His BP rose to a
peak of 226/143 with HR 95, which was managed initially with
labetalol 20mg IV boluses. Back pain was difficult to control
with 2 tabs percocet, 4mg IV morphine x 3 and 1mg IV dilaudid.
He had wbc 15.9, 87% PMN. He was in acute on chronic renal
failure with BUN/Cr of 32/2.9 from baseline creatinine 1.5. He
received 3L NS. CK was in 700s with negative -MB fraction.
Urinalysis was negative for infection, though with spot protein
of 100, which is more than baseline. CXR was clear, with no
evidence of mediastinal widening. Plain films of L- and T-spine
unremarkable. Decision made to avoid CTA to r/o aortic
dissection due to compromised renal function. MRI was attempted,
but patient could not tolerate due to anxiety and discomfort.
Patient was admitted to MICU servcie for hypertension management
and for TEE. BP control switched to esmolol, BP was 153/89 at
time of transfer. Cards fellow aware. TEE showed Debakey type 2
Aortic dissection, involving aortic arch and extending all the
way down to bifurcation. No Ascending aortic involvement. Normal
LVF, no valvular problems, no pericardial effusion. Vascular
service was consulted- patient transferred to Vascular
Surgery/Dr.[**Last Name (STitle) **] service and CT Surgery/Dr. [**Last Name (STitle) 914**] consulted.
In the MICU BP control was difficult to attain, patient was
intubated and sedated for better BP control and possible
emmergent surgery. BP was aggressively controlled with titrating
Nitro and Esmolol drips with target BP 100-120. Surgery
discussion was deffered.
HD2 [**5-13**] still with elevated BP remains on Esmolol and Nitro
drips. CPAP on the vent. Pulses present throughout. Given
Morphine for pain control. Restarted home antihypertensives.
Started Clonidine patch, in an attempt to wean off IV
antihypertensives. Creatinine 2.8->2.9. Pain med switched to
Percocet and Valium.
HD3 [**5-14**] Remains intubated, sedated. BP in good control with
current meds.CTA showed-Type A aortic dissection originating at
the level of the right common
carotid and extending to the bilateral external iliac arteries,
with thrombus
seen within these vessels. There is likely hypoperfusion of the
right kidney
which is supplied by the false lumen; however, early arterial
phase imaging
precludes evaluation of the renal parenchyma. Serial HCT
followed. Creatinine 2.9. Renal consulted for persistently
rising creatinine-likely contrast nephropathy.
HD4 [**5-15**] PO Labetolol increased, able to wean off Nitro drip.
Weaned from vent and extubated. Transfer to VICU deferred
secondary to C/o testicular/groin pains- US abdomen/testicles-
showed 2 x 2 mm hypoechoic lesion within the left testicle.
Follow up in 3 months is reccomended.
HD5 [**5-16**] BP well controlled on Labetolol, Clinidine but still
requiring Hydralazine IV prn. Afebrile. Urology consulted for
testicular mass- recommeded to obtain tumor/CA markers aFP,
bHCG, LDH and LFTs- recommends repeat US in 6 wks. FU with Dr.
[**Last Name (STitle) 3748**]. Transferred to VICU.
HD6 [**5-17**] Good BP control. Creatinine peaked at 3.6->2.8. Renal
following. Dispo to home plan. Social work consult for
insurance/med procurement issues. Medical consult for long term
BP management-recs to wean down Labetolol to 800 mg from 1000
mg.
HD7 [**5-18**] Dispo plan for home tomorrow. Appointment arranged with
new PCP (Dr. [**Last Name (STitle) **] at the [**Company 191**] on [**2174-6-7**] for BP management.
HD8 [**5-19**] Renal and Dr. [**Last Name (STitle) **] in to see patient and make new
medication recs. Lasix and Lisinopril restarted. Labetolol
decreased to [**Hospital1 **]. Norvasc continued. Hydralazine and Isorsorbide
discontinued. Clonidine changed to po for Freecare coverage.
Patch d'ced and Clonidine to be started on Saturday. All
medications and plans fully discussed with patient. Patient will
have blood pressure monitored at [**Hospital 577**] Clinic and Cr checked
there tomorrow. Cr results will be sent to Dr. [**Last Name (STitle) 7473**].
Medications on Admission:
labetalol 600 mg [**Hospital1 **]
lisinopril 40 mg QD
lasix 80 mg [**Hospital1 **]
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
refill from [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**].
Disp:*60 Tablet(s)* Refills:*1*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): refill from [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**].
Disp:*30 Tablet(s)* Refills:*1*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed: refill from [**Name6 (MD) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 250**].
Disp:*60 Capsule(s)* Refills:*0*
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): refill from primary [**Name6 (MD) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 250**] .
Disp:*60 Tablet(s)* Refills:*1*
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day): refill from [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**].
Disp:*240 Tablet(s)* Refills:*1*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
refill from [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**].
Disp:*60 Tablet(s)* Refills:*1*
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. CloniDINE 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Start Saturday [**2174-5-21**].
Disp:*90 Tablet(s)* Refills:*1*
10. Outpatient Lab Work
Please draw Cr on [**2174-5-20**].
Fax results to Dr. [**Last Name (STitle) 7473**] (nephrologist)
fax:([**Telephone/Fax (1) 8387**] phone([**Telephone/Fax (1) 773**]
Discharge Disposition:
Home
Discharge Diagnosis:
Type B aortic dissection
PMHX: HTN, CRI, Acute disseminated encephalyomyelitis, s/p
craniotomy w/bx, Bacteremia - per patient from eczema skin
wound, Hospitalized [**2172-7-7**] for Group G strep bactermia; h/o
anemia and G6PD deficiency, LVH
Discharge Condition:
Stable
Discharge Instructions:
- You were admitted at the [**Hospital1 69**]
for
Type B Aortic dissection.
- It is important that you keep your systolic blood pressure
blelow
140.
- Take all your medications as prescribed.
- Go to the emergency room if you experience the same type of
pain
that you had before.
- Refrain from engaging in heavy lifting or strenous activities
otherwise you should be able to do most activities of daily
living.
- Eat a healthy well balanced diet.
- Follow-up with Dr. [**Last Name (STitle) **] as scheduled.
Followup Instructions:
You will need to have your blood pressure and Cr checked [**Last Name (STitle) 2974**]
[**5-20**] at 10am and your Blood pressure checked again on Monday
[**5-23**] at [**Hospital 577**] Health Center at [**Street Address(2) 59699**], [**Location (un) 577**]
[**Telephone/Fax (1) 17826**] (fax [**Telephone/Fax (1) 33775**]). You should continue with weekly
blood pressure checks until you visit with Dr. [**Last Name (STitle) **].
PRIMARY CARE FOLLOW UP
group [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2174-6-7**] 1:30
[**Location (un) 830**] ([**Hospital Ward Name 516**]/[**Hospital Ward Name 23**]). It is very important
for you to keep this appointment as you will have close follow
up of your medications and blood pressure.
VASCULAR FOLLOW UP
You will have a follow up in 1 month with Vascular Surgery Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone on [**2174-6-15**] at 1130am [**Doctor First Name 61532**] 5B ([**Hospital Unit Name **]). You will also have a CT scan of your
torso just prior to your appointment. CAT SCAN
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2174-6-15**] 10:15. Radiology [**Location (un) **], [**Hospital Ward Name **].
Renal FOLLOW UP
Dr. [**Last Name (STitle) 4883**], [**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 60**]. His secretary will call
you to fit you in for an appointment in the next week weeks.
Please call his office if you do not here from them. You will
need your Creatinine/kidney test closely followed.
UROLOGY FOLLOW UP
Urology Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **]
Phone: [**Telephone/Fax (1) 3752**] Date/Time:[**2174-6-9**] 11:00
Completed by:[**2174-5-19**]
|
[
"403.90",
"585.9",
"603.9",
"608.89",
"305.1",
"584.9",
"278.01",
"441.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
19022, 19028
|
12443, 17190
|
328, 335
|
19316, 19325
|
2849, 12420
|
19896, 21646
|
1917, 2151
|
17324, 18999
|
19049, 19295
|
17216, 17301
|
19349, 19873
|
2181, 2830
|
229, 290
|
363, 832
|
854, 1513
|
1529, 1901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,950
| 157,847
|
27595
|
Discharge summary
|
report
|
Admission Date: [**2105-5-25**] Discharge Date: [**2105-6-13**]
Date of Birth: [**2047-7-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
57M s/p CABG with severe SOB.
Major Surgical or Invasive Procedure:
[**2105-5-25**] Pericardial tamponade drainage and sternal wound
dehiscence, rewiring [**2105-5-25**]
[**2105-5-29**] Sternal wound debridement
[**2105-5-31**] Extensive sternal debridement, Right pectoralis muscle
local advancement flap, Left pectoralis muscle local advancement
flap, Omental flap closure of sternum
History of Present Illness:
This 57M is s/p CABGx3(LIMA->LAD, SVG->PDA, Ramus) on [**2105-5-9**].
He was discharged to home 6 days post op and and began
experiencing DOE a week later. He presented to the MWMC ER on
[**5-24**] and was evaluated by cardiology. He had a chest CT which
showed bil. pleural effusions and a pericardial effusion. He
had an echo which revealed cardiac tamponade and he was
emergently transferred to [**Hospital1 18**] for further treatment.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
[**2105-5-9**], Diabetes Mellitus, Hypertension, Hypercholesterolemia,
Obesity, Sleep Apnea-on CPAP, Diverticulosis, h/o Deep Vein
Thrombosis, s/p RLE varicose vein stripping, s/p Left Knee
surgery, s/p Salivary Stone removal, s/p cataract [**Doctor First Name **].
Social History:
Lives with wife. Currently unemployed. Quit smoking 25yrs ago.
Drinks 3 alcoholic beverages/day.
Family History:
Mother died of CAD in 80's
Physical Exam:
Gen: [**Male First Name (un) 4746**], SOB
T: 98 BP: 120/70 P: 100 RR: 20 O2 sat: 98% on 4 liters NC
HEENT: NC/AT, PERLA, EOMI, oropharynx benigm
Neck: supple, FROM, no lymphadenopathy or thyromegaly, ?JVD,
hard to discern b/c obesity, carotids 2+= bil. without bruits.
Lungs: Decreased BS at bases, mild rales bilat.
CV: RRR without R/G/M, nl. S1, S2
Abd: soft, obese, nontender, without massses or
hepatosplenomegaly
Ext: 3+ bil. LE edema, pulses 2+= bilat. throughout.
Neuro: nonfocal
Pertinent Results:
[**2105-6-13**] 04:15AM BLOOD WBC-7.2 RBC-3.03* Hgb-9.1* Hct-27.1*
MCV-89 MCH-30.0 MCHC-33.6 RDW-16.8* Plt Ct-308
[**2105-6-9**] 03:05AM BLOOD PT-15.9* PTT-26.1 INR(PT)-1.4*
[**2105-6-13**] 04:15AM BLOOD Glucose-101 UreaN-16 Creat-1.2 Na-136
K-4.1 Cl-103 HCO3-25 AnGap-12
[**2105-6-8**] 04:16AM BLOOD ALT-37 AST-54* LD(LDH)-228 AlkPhos-126*
Amylase-164* TotBili-2.3*
[**2105-5-29**] 3:05 pm SWAB STERNAL WOUND.
**FINAL REPORT [**2105-6-2**]**
GRAM STAIN (Final [**2105-5-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2105-6-2**]):
ALL ORGANISMS WORKED UP PER I.D..
SERRATIA MARCESCENS. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance 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.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S <=0.5 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S <=0.12 S
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC CULTURE (Final [**2105-6-2**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was admitted on [**2105-5-25**] and was immediately sent to
the cath lab to attempt to drain the pericardial effusion. He
was in cardiogenic shock and was taken to the OR and had a redo
sternotomy, drainage of pericardial effusion, and sternal
rewiring. The effusion was loculated and very posterior. The
sternum was fractured and required extensive rewiring. He was
transferred to the CSRU in stable condition on Propofol. POD#1
he was extubated and a PICC was placed. He required aggressive
respiratory therapy and on POD#3, his chest tubes were d/c'd and
he was transferred to the floor. He had SOB, fever, and
sternal drainage on POD#4, and was transferred back to the CSRU.
His sternal wound was opened and he was evaluated by plastic
surgery.
[**5-29**] he had open debridement of the wound in the OR and cultures
from that grew out Serratia Marcessans which is sensitive to
Vanco. He remained in the CSRU paralyzed and intubated and on
[**5-30**] Dr. [**First Name (STitle) **] performed an closure of the sternal wound with
omental and pectoralis flaps. He was unable to wean from the
vent for 7 days b/c secretions and agitation. He then required
aggressive respiratory therapy and eventually transferred to the
floor on pod# 9 and continued to progress. He had intermittent
confusion which eventually cleared. ID followed him throughout
this period and recommended 6 weeks of Vancomycin and
Levofloxacin. He still has 3 JP drains and stay sutures which
will be evaluated in at a plastic surgery appointment in 1 week.
He was transferred to rehab in stable condition on POD#14.
Medications on Admission:
Lopressor 12.5 mg PO BID
ASA 81 mg PO daily
FeSO4 325 mg PO daily
Lovenox 40 SC daily
Gemfibrizol 600 mg PO BID
Metformin 500 mg PO BID
Zetia 10 mg PO daily
Zocor 40 mg PO daily
Lasix 40 IV daily
Protonix 40 mg PO daily
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. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 weeks.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours).
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
20. Vancomycin 1,000 mg Recon Soln Sig: One (1) 1250mg
Intravenous every twelve (12) hours for 6 weeks.
21. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed. Tablet(s)
22. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO once
a day.
23. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
24. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
25. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
26. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Sternal Wound Dehiscence with Pericardial Effusion and Tamponade
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 on
[**2105-5-11**], Diabetes Mellitus, Hypertension, Hypercholesterolemia,
Obesity, Sleep Apnea-on CPAP, Diverticulosis, h/o Deep Vein
Thrombosis, s/p RLE varicose vein stripping, s/p Left Knee
surgery, s/p Salivary Stone removal, s/p cataract [**Doctor First Name **].
Discharge Condition:
stable
Discharge Instructions:
Please resume instructions from previous hospital discharge
which include: Not to drive for 1 month. Not to lift more than
10 pounds for at least 10 weeks.
[**Month (only) 116**] shower, but do not take a bath.
Please make all follow-up appointments.
Please call office with any concerns or questions regarding
chest wound.
Must take antibiotics for 6 weeks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD Phone:[**Telephone/Fax (1) 6331**]
Date/Time:[**2105-6-19**] 11:45
Dr. [**Last Name (Prefixes) **] in [**2-7**] weeks
Cardiology (Dr. [**Last Name (STitle) 3659**] in [**1-9**] weeks
PCP (Dr. [**Last Name (STitle) 9183**] in 2 weeks
Completed by:[**2105-6-13**]
|
[
"730.08",
"041.85",
"401.9",
"998.59",
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"278.00",
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"511.9",
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"V12.51",
"780.57",
"998.31",
"041.4",
"250.00",
"790.7",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90",
"86.74",
"96.72",
"37.12",
"88.72",
"77.61"
] |
icd9pcs
|
[
[
[]
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9340, 9414
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350, 669
|
9853, 9861
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2173, 5104
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281, 312
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1163, 1491
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1507, 1605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,159
| 139,227
|
27938
|
Discharge summary
|
report
|
Admission Date: [**2176-11-19**] Discharge Date: [**2176-12-4**]
Date of Birth: [**2116-11-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Intubation and extubation
EGD
History of Present Illness:
60M history of alcohol abuse, Childs B cirrhosis, varices on EGD
in [**2174**] on nadolol, found today by his family in bed, with large
amount of grossly bloody vomit in the trashcan, on the sheet,
and on the floor. The patient complains of nausea and many
episodes of bloody emesis, he denies abdominal pain diarrhea,
bright red blood per rectum, or melena. He is in distress from
his nausea, and has difficulty providing a history although he
is alert and oriented x 3.
.
In the ED, initial VS were: 100 136 129/57 14 100%. Hct 33 down
from 40 in [**Month (only) 216**]. Received 4 L IV fluids. Crossmatch x2, no
blood given. Valium given concern for withdrawal. Continued to
vomit and patient intubated for airway protection, although no
documented loss of gag. Patient had possible posturing during
intubation. OG tube placed, with return of 75 mL maroon-colored
bloody fluid. Protonix bolus and drip, octreotide bolus and
drip, ceftriaxone. Propofol drip for sedation.
.
On transfer, most recent vitals were 118 113/67 100% on vent
500/16/60/5.
.
On arrival to the MICU, patient was intubated and sedated. He
was not responsive to commands. He had minimal blood from OG
tube. Initial VS 110, 84/57, 97%.
Past Medical History:
Hypertension
Anemia
Ventral Hernia s/p repair
ETOH cirrhosis
([**2175-3-29**] labs: ALT 14 AST 49 Bili 1.3 albumin 3.4)
PVD treated by Dr. [**Last Name (STitle) **]
PSA
Social History:
Lives alone.
- Tobacco: heavy smoker
- Alcohol: 12 beers at least daily
- Illicits: daughters report pot daily, cocaine in past
Family History:
non contributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.1, 110, 84/57, 96% AC 500/16/5/50%
General: Sedated, intubated, unresponsive to commands
SKIN: spider angiomas, palmar erythema
HEENT: Sclera anicteric, pupils 4mm, minimally reactive to light
Neck: supple, JVP not elevated, no LAD
CV: regular, tachycardic, no murmurs
Lungs: upper airway rhonchi, no wheezes, rales
Abdomen: soft, bowel sounds hypoactive, no HSM appreciated, no
caput
Ext: warm, well perfused, 2+ pulses, clubbing of fingers, no
edema
Neuro: minimal pupil reflex, corneal reflex not tested, some
increased tonicity of extremeties
.
Discharge Physical Exam:
General: awake, alert and oriented x3, NAD
HEENT: sclerae anicteric, PERRLA, EOMI, MMM, OP clear
CV: RRR, nl S1 S2, no MRG
Resp: slight rales right base, otherwise CTAB, no wheezes or
rhonchi
Abd: soft, non-tender, distended
Ext: warm, well-perfused, 2+ edema to thighs, no cyanosis or
clubbing. + compression stockings (part of the day)
Neuro: CN II-XII normal, gait normal
Skin: spider angiomata on chest and forehead, palmar erythema
Pertinent Results:
Admission Labs:
[**2176-11-19**] 08:33PM BLOOD WBC-8.9# RBC-3.23* Hgb-11.0*# Hct-32.9*
MCV-102* MCH-34.1* MCHC-33.5 RDW-15.0 Plt Ct-91*
[**2176-11-19**] 08:33PM BLOOD Neuts-72.0* Lymphs-21.5 Monos-5.9 Eos-0.2
Baso-0.4
[**2176-11-19**] 08:33PM BLOOD PT-20.1* PTT-44.6* INR(PT)-1.9*
[**2176-11-19**] 08:33PM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-140
K-4.1 Cl-98 HCO3-22 AnGap-24*
[**2176-11-19**] 08:33PM BLOOD ALT-22 AST-72* AlkPhos-155* TotBili-4.6*
[**2176-11-19**] 08:33PM BLOOD Lipase-27
[**2176-11-20**] 03:44AM BLOOD CK-MB-7 cTropnT-0.12*
[**2176-11-19**] 08:33PM BLOOD Albumin-2.9* Calcium-8.6 Phos-2.8 Mg-1.4*
[**2176-11-19**] 08:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**Hospital3 **]:
[**2176-11-20**] 03:44AM BLOOD CK-MB-7 cTropnT-0.12*
[**2176-11-20**] 01:29PM BLOOD CK-MB-6 cTropnT-0.17*
[**2176-11-21**] 02:26AM BLOOD CK-MB-5 cTropnT-0.13*
[**2176-11-22**] 03:05AM BLOOD CK-MB-3
[**2176-11-28**] 07:15AM BLOOD HIV Ab-NEGATIVE
[**2176-11-24**] 05:33PM BLOOD Lactate-2.4*
[**2176-11-25**] 07:59AM BLOOD Lactate-2.2*
[**2176-11-27**] 04:10PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2176-11-27**] 04:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-NEG
[**2176-11-27**] 04:10PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1
[**2176-11-29**] 04:40PM ASCITES WBC-200* RBC-710* Polys-53* Lymphs-9*
Monos-20* Mesothe-7* Macroph-11*
[**2176-11-29**] 04:40PM ASCITES TotPro-0.6 Glucose-128 LD(LDH)-71
.
Discharge Labs:
[**2176-12-4**] 06:20AM BLOOD WBC-3.9* RBC-3.11* Hgb-10.3* Hct-31.3*
MCV-101* MCH-33.0* MCHC-32.8 RDW-17.2* Plt Ct-103*
[**2176-12-4**] 06:20AM BLOOD PT-20.5* INR(PT)-1.9*
[**2176-12-4**] 06:20AM BLOOD Glucose-97 UreaN-3* Creat-0.8 Na-134
K-3.6 Cl-99 HCO3-26 AnGap-13
[**2176-12-4**] 06:20AM BLOOD ALT-23 AST-54* AlkPhos-112 TotBili-4.0*
[**2176-12-4**] 06:20AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.6
.
Microbiology:
[**2176-11-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST -
NEGATIVE
[**2176-11-29**] 4:40 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2176-11-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2176-12-2**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2176-11-29**] BLOOD CULTURE - PENDING
[**2176-11-28**] BLOOD CULTURE - NO GROWTH
[**2176-11-28**] BLOOD CULTURE - NO GROWTH
[**2176-11-27**] URINE Legionella Urinary Antigen - NEGATIVE
[**2176-11-27**] BLOOD CULTURE - NO GROWTH
[**2176-11-27**] BLOOD CULTURE - NO GROWTH
[**2176-11-27**] URINE CULTURE - NO GROWTH
[**2176-11-26**] BLOOD CULTURE - NO GROWTH
[**2176-11-25**] BLOOD CULTURE - NO GROWTH
[**2176-11-25**] BLOOD CULTURE - NO GROWTH
[**2176-11-24**] BLOOD CULTURE - NO GROWTH
[**2176-11-24**] BLOOD CULTURE - NO GROWTH
[**2176-11-24**] URINE CULTURE - NO GROWTH
[**2176-11-23**] BLOOD CULTURE - NO GROWTH
[**2176-11-23**] BLOOD CULTURE - NO GROWTH
[**2176-11-23**] URINE CULTURE - NO GROWTH
[**2176-11-19**] MRSA SCREEN - NEGATIVE
[**2176-11-19**] URINE CULTURE - NO GROWTH
.
Imaging:
EGD ([**11-19**]):
Varices at the lower third of the esophagus
Nodularity, congestion, erythema and mosaic appearance in the
stomach body and fundus compatible with severe portal
hypertensive gastropathy
Otherwise normal EGD to second part of the duodenum
.
Liver ultrasound ([**11-20**]):
1. No biliary dilatation seen.
2. Nodular heterogeneous liver consistent with the patient's
known cirrhosis.
3. Splenomegaly and mild ascites.
4. Patent hepatic vasculature with a patent umbilical vein and
midline
varices.
.
CT Torso ([**11-24**]):
IMPRESSION:
1. Multifocal ground-glass opacities in the left upper lobe
consistent with infection.
2. Bilateral small pleural effusions with secondary atelectasis.
The right atelectasis has a small component that is
hypoattenuating in comparison to the other components and might
represent pneumonia.
3. Known cirrhosis with portosystemic collaterals and large
ascites. The right portal branches are diminutive most probably
related to the large recanalized paraumbilical vein. Note is
made of a varix of this recanalized vein.
4. No signs of bowel obstruction.
5. Acute left tenth rib fracture.
6. Ascites.
4. Patent hepatic vasculature with a patent umbilical vein and
midline varices.
.
Abdominal ultrasound ([**11-28**]):
Scans of the upper and lower abdomen demonstrates a large volume
of ascites, predominantly on the right side. An appropriate spot
was marked in the right flank for subsequent paracentesis by the
clinical team.
.
CXR ([**11-19**]):
SEMI-UPRIGHT AP VIEW OF THE CHEST: Endotracheal tube tip is at
the level of the thoracic inlet, terminating approximately 8.3
cm from the carina. The nasogastric tube tip is within the
stomach. The heart size is normal. The mediastinal and hilar
contours are unremarkable. There are low lung volumes with
crowding of the bronchovascular markings. Streaky opacities in
the lung bases likely reflect atelectasis. No pleural effusion
or pneumothorax is identified. There are no acute osseous
abnormalities.
IMPRESSION: Endotracheal and nasogastric tubes are in standard
positions. Low lung volumes with mild bibasilar atelectasis.
.
CXR ([**11-20**]):
FINDINGS: As compared to the previous radiograph, the patient
has received a new nasogastric tube. The tip of the tube
projects over the middle parts of the stomach, at the lower
aspect of the image. No evidence of complications, notably no
pneumothorax. Otherwise, the radiograph is unchanged.
.
CXR ([**11-21**]):
FINDINGS: As compared to the previous radiograph, the course of
the nasogastric tube is unchanged. The endotracheal tube is not
visualized and might have been removed in the interval. The lung
volumes have increased, potentially reflecting improved
ventilation. Better seen than on the previous radiograph is a
right medial basal opacity with several air bronchograms. This
opacity might represent atelectasis, but the possibility of
early pneumonia cannot be excluded. Close radiographic followup
is recommended.
.
CXR ([**11-23**]):
The NG tube tip is in the very proximal stomach and should be
advanced. Heart size is enlarged, stable. Mediastinum is stable.
There is interval progression of bilateral pleural effusions,
small-to-moderate and bibasilar consolidations, highly
concerning for infectious process. There is no
pneumothorax.
.
CXR ([**11-28**]):
IMPRESSION: Persistent moderate cardiac enlargement with
bilateral pleural effusions and plate atelectasis on the bases,
suspicious new acute pneumonic infection in left upper lobe
area. No pneumothorax.
.
KUB ([**11-22**]):
IMPRESSION: Nonspecific bowel gas pattern without evidence of
ileus or obstruction.
.
KUB ([**11-23**]):
There is evidence of mild dilatation of the large bowel with the
proximal portion of the transverse colon measuring up to 7 cm.
Mild dilatation of small bowel is demonstrated but overall the
findings are nonspecific with no definitive evidence of ileus or
obstruction. Degenerative changes are noted within the spine.
The decubitus view reveals no evidence of free air.
.
KUB ([**11-24**]):
As compared to [**2176-11-23**], there is slight additional
increase in the diameter of the proximal portion of the
transverse colon, up to 8 cm as compared to 7 cm on the prior
examination. The rest of the bowel demonstrate no evidence of
progression of dilatation. No appreciable free air is
demonstrated on the decubitus view. Overall, no evidence of
obstruction or
progression of the ileus is seen.
Brief Hospital Course:
60 yo M with PMH of alcohol abuse, Class B Childs Cirrhosis,
known esophageal varices on Nadolol who presented with
hematemesis, intubated in ED for airway protection due to
significant vomiting, s/p EGD without intervention, with a
hospital course complicated by abdominal distention and HCAP.
# GIB: Initially, it was thought to be possible variceal bleed
given known cirrhosis and varices on past EGD. EGD, however, did
not show bleeding varices (ie red [**Last Name (un) 23199**] sign), [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], or
ulcer. There were stigmata of recent bleeding and possible GAVE.
The patient was transfused 4 units for a Hct that fell from 33
to 26. He was initially treated with octreotide and protonix
drips. He had an OG tube that had scant coffee-grounds on
suction, but no further overt bleeding. The patient was switched
to protonix IV. He was given SC Vitamin K for INR 1.9 and
hepatic dysfunction. His plavix and aspirin were held. Pt's hct
was stable in the low 30's since transfer from the unit to the
medicine floor on [**11-24**]. He continued to have melanotic stool
without drop in Hct for several days, which then resolved prior
to discharge.
.
# Ileus: Patient with 2 days of abdominal distension, KUB down
in ICU showed distended loops of bowel raising concern for
obstruction vs. ileus. Therefore patient was made NPO and had a
NGT placed. Patient did not have a BM for the first 24 hours on
the medical floor again raising concern for obstruction or
ileus, although KUB was not consistent with either. The patient
did have a small BM on the night of [**11-23**] after biscodyl
suppository x 2 and a fleet's eneema with a scant amount of
bright red blood. Stool output increased starting [**11-25**] with
resolution of abdominal pain and distention. Patient required
electrolyte repletion during recovery from ileus, likely due to
high stool output.
.
# HCAP: Patient spiked a fever to 101.8 on the night of [**11-23**] and
had a CXR that showed new bibasilar consolidations concerning
for infection. Patient was also noted to have a non-productive
cough. Therefore, his antibiotic coverage was expanded from
cipro to Vanco and Zosyn. Blood, urine and sputum cultures were
obtained that showed no clear infectious [**Doctor Last Name 360**]. Legionella
negative, MRSA swab negative [**11-19**], no sputum sample received. CT
chest revealed multifocal pneumonia. Tobramycin was added on
[**11-24**]. Cultures continued to show no clear infectious [**Doctor Last Name 360**].
After a week of this therapy, the patient's fever resolved.
During this time tobramycin was switched to Levaquin. Two days
later, IV antibiotics were discontinued and he remained on oral
Levaquin for a planned 14 day course. He remained afebrile for
over 72 hours prior to discharge.
.
# Intubation for Airway Protection: The patient was intubated in
the ED for airway protection. He was succussfully extubated on
Hospital Day 2.
.
# Cirrhosis: EtOH cirrhosis decompensated w/ varices, ascites,
encephalopathy, thrombocytopenia. Paracentesis performed [**11-29**]
with good success, negative for SBP. Lactulose and rifaximin
held for ileus, restarted with return of stool output.
.
# EtOH Dependence: Pt's last drink was the day before
admission. He was kept on a CIWA scale in the unit, but did not
require any BZD's on the medicine floor and the CIWA scale was
d/c'd on [**11-23**]. He was treated with a banana bag, thiamine,
folate, MVI
.
# CODE: Full
# Communication: [**Name (NI) **] (HCP/daughter) [**Telephone/Fax (1) 68048**]
.
Transitional Issues:
- Blood culture pending final result
- Patient required repletion of electrolytes due to high stool
output. He was discharged on his home dose of potassium
repletion, which may need to be adjusted as his intake and
output normalize.
- The patient's nadolol was held for relative hypotension. This
may be restarted by outpatient providers if his BP rises.
Medications on Admission:
clopidogrel 75mg daily
vitamin D 50,000 unit Capsule by mouth weekly
folic acid 1mg tablet daily
lactulose 15ml by mouth twice daily
nadolol 20 mg a day
potassium 10mEq [**Hospital1 **]
ursodiol 500 twice daily
aspirin 81mg daily
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days: last dose 1/20.
Disp:*3 Tablet(s)* Refills:*0*
2. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day): Please titrate to [**12-20**] BMs/day.
5. ursodiol 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please draw chem 10 on [**12-6**] and fax to pt's pcp, [**Name10 (NameIs) **] [**Last Name (STitle) **], at
[**Telephone/Fax (1) 68049**] and Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 4400**]
9. 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*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
portal gastropathy
multifocal pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You came to the hospital with bloody vomiting.
You were found to have a large gastrointestinal bleed. Your
bleeding stopped, but you were found to have developed a
pneumonia. You had fevers and difficulty breathing. This was
treated with several antibiotics, after which your fever and
breathing both improved.
We made the following changes to your medications:
START Levofloxacin for 3 days
STOP aspirin and plavix given your recent bleeding. You have an
appointment scheduled with Dr [**Last Name (STitle) **] at which point you should
readress the need for these medications.
START thiamine and multivitamin
START pantoprazole
START lasix
START spironolactone
STOP nadolol, you can discuss restarting this with Dr [**Last Name (STitle) **]
.
Please have your lab work drawn on [**12-6**] and sent to your primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) 7941**] of your electrolytes.
It is vital that you abstain from alcohol. Any amount of
alcohol can lead to complications of your liver disease.
Followup Instructions:
Name: [**Last Name (Titles) **],[**Last Name (Titles) **]
Address: [**Street Address(2) 68050**], [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 68047**]
When: [**Last Name (LF) 766**], [**2174-12-10**]:00 AM
Department: LIVER CENTER
When: [**Month Day **] [**2176-12-20**] at 12:00 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]/CARDIOLOGY
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
*It is recommended that you see a cardiologist within 2 weeks.
Dr. [**Last Name (STitle) **] [**Name (STitle) **] will contact you with further instruction.
|
[
"571.2",
"572.2",
"560.1",
"285.1",
"486",
"401.9",
"537.89",
"456.21",
"305.1",
"511.9",
"995.93",
"287.5",
"291.81",
"572.3",
"443.9",
"276.8",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.13",
"34.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16433, 16439
|
10798, 14397
|
319, 350
|
16522, 16522
|
3054, 3054
|
17787, 18885
|
1943, 1961
|
15057, 16410
|
16460, 16501
|
14802, 15034
|
16672, 17071
|
4600, 5483
|
2001, 2562
|
14418, 14776
|
17100, 17764
|
267, 281
|
378, 1589
|
3070, 4584
|
5519, 10775
|
16537, 16648
|
1611, 1782
|
1798, 1927
|
2587, 3035
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,377
| 165,832
|
53745
|
Discharge summary
|
report
|
Admission Date: [**2172-8-11**] Discharge Date: [**2172-9-1**]
Service: SURGERY
Allergies:
Ace Inhibitors
Attending:[**Doctor First Name 5188**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
sp Exploratory Laparotomy, small bowel resection x 80cm for
ischemic enteritis [**8-14**]
sp Exploratory Laparotomy, closure of abdominal wall [**8-15**]
sp tracheostomy
sp retention suture placement for facial defect [**8-26**]
History of Present Illness:
83 year old male who presented to the [**Hospital1 18**] w/ ECG changes and
hypotension and was admitted to rule out MI.
Past Medical History:
CAD sp IMI [**2163**]
sp cardiac cath [**4-21**]: EF 35%, 2VD
Atrial fibrillation
CHF
h/o complete heart block s/p pace maker placement [**2163**]
COPD
OA
h/o AAA 4.5 cm
diverticulosis
h/o GI bleed [**2170**]
sp Right colectomy
[**Last Name (un) 1724**]: ASA 325qd, amio200qd, lasix 20qd, toprol xl 50qd, lipitor
20qd, percocet prn, protonix 40qd, tums+vitD, feso4 [All: ACE-I]
Social History:
Retired bricklayer, construction. Quit smoking 45 years ago, no
alcohol, no drug use.
Family History:
Non-contributory
Physical Exam:
Admission PE:
PE: T HR 77 BP 90/44 RR 24 90%3Lnc
GEN: alert, conversive, in pain, thin
HEENT: PERRL, anicteric, OP clear, MM dry
Neck: supple, JVP nondistended
CV: irreg irreg, no mrg
Resp: trace crackles R>L
Abd: decreased BS, firm, ttp BLQ with guarding.
erythematous crusting rash over RUQ and flank
Ext: no edema, 1+ DPs bilaterally
Neuro: A&Ox3, CN II-XII intact, MAEW
Pertinent Results:
[**2172-8-10**] 06:30PM BLOOD WBC-8.1# RBC-3.42* Hgb-11.1* Hct-32.7*
MCV-96 MCH-32.6* MCHC-34.0 RDW-13.9 Plt Ct-249
[**2172-8-14**] 07:29AM BLOOD WBC-4.0 RBC-3.40* Hgb-10.8* Hct-31.2*
MCV-92 MCH-31.8 MCHC-34.6 RDW-17.6* Plt Ct-180
[**2172-8-14**] 06:37PM BLOOD WBC-6.2 RBC-2.95* Hgb-9.4* Hct-26.4*
MCV-90 MCH-31.7 MCHC-35.4* RDW-18.4* Plt Ct-138*
[**2172-8-16**] 02:22AM BLOOD WBC-9.4 RBC-2.51* Hgb-7.7* Hct-23.1*
MCV-92 MCH-30.8 MCHC-33.6 RDW-18.2* Plt Ct-105*
[**2172-8-17**] 02:22AM BLOOD WBC-14.9* RBC-3.32* Hgb-10.4* Hct-30.7*
MCV-92 MCH-31.2 MCHC-33.7 RDW-17.4* Plt Ct-104*
[**2172-8-19**] 03:20PM BLOOD Hct-22.4*
[**2172-8-22**] 01:54AM BLOOD WBC-12.4* RBC-2.36* Hgb-7.4* Hct-21.7*
MCV-92 MCH-31.4 MCHC-34.2 RDW-16.3* Plt Ct-132*
[**2172-8-23**] 07:21PM BLOOD Hct-27.1*
[**2172-8-27**] 02:48PM BLOOD Hct-21.0*
[**2172-8-28**] 02:01AM BLOOD WBC-7.7 RBC-2.80* Hgb-8.7* Hct-25.3*
MCV-91 MCH-31.1 MCHC-34.3 RDW-16.0* Plt Ct-207
[**2172-8-30**] 03:22AM BLOOD WBC-22.0*# RBC-3.38* Hgb-10.4* Hct-31.5*
MCV-93 MCH-30.7 MCHC-33.0 RDW-16.0* Plt Ct-255
[**2172-9-1**] 04:45AM BLOOD WBC-14.4* RBC-2.52* Hgb-7.7* Hct-24.1*
MCV-96 MCH-30.6 MCHC-32.0 RDW-16.3* Plt Ct-145*
[**2172-8-30**] 02:58PM BLOOD PT-14.8* PTT-69.5* INR(PT)-1.3*
[**2172-8-25**] 07:38PM BLOOD PT-14.0* PTT-32.0 INR(PT)-1.2*
[**2172-8-10**] 06:30PM BLOOD Glucose-109* UreaN-56* Creat-2.6* Na-135
K-5.5* Cl-95* HCO3-28 AnGap-18
[**2172-8-13**] 06:25AM BLOOD Glucose-70 UreaN-45* Creat-1.9* Na-140
K-5.0 Cl-103 HCO3-30 AnGap-12
[**2172-8-14**] 12:55AM BLOOD Glucose-126* UreaN-50* Creat-2.4* Na-140
K-4.2 Cl-105 HCO3-23 AnGap-16
[**2172-8-16**] 06:48PM BLOOD Glucose-106* UreaN-46* Creat-1.9* Na-135
K-4.4 Cl-107 HCO3-20* AnGap-12
[**2172-8-24**] 02:40AM BLOOD Glucose-99 UreaN-82* Creat-1.3* Na-141
K-4.2 Cl-112* HCO3-22 AnGap-11
[**2172-8-27**] 03:08AM BLOOD Glucose-123* UreaN-94* Creat-1.6* Na-140
K-4.2 Cl-106 HCO3-23 AnGap-15
[**2172-8-29**] 01:39AM BLOOD Glucose-135* UreaN-89* Creat-1.8* Na-138
K-4.7 Cl-106 HCO3-20* AnGap-17
[**2172-8-30**] 02:58PM BLOOD Glucose-154* UreaN-89* Creat-2.5* Na-132*
K-5.2* Cl-102 HCO3-17* AnGap-18
[**2172-9-1**] 04:45AM BLOOD Glucose-172* UreaN-93* Creat-3.0* Na-131*
K-5.4* Cl-102 HCO3-23 AnGap-11
[**2172-8-10**] 06:30PM BLOOD ALT-18 AST-27 CK(CPK)-38 AlkPhos-166*
Amylase-57 TotBili-0.6
[**2172-8-24**] 05:15PM BLOOD ALT-7 AST-13 AlkPhos-63 Amylase-72
TotBili-0.5
[**2172-8-10**] 06:30PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2172-8-11**] 12:37AM BLOOD cTropnT-0.01
[**2172-8-21**] 03:13AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-8-10**] 06:30PM BLOOD Calcium-9.0 Phos-3.8 Mg-3.2*
[**2172-9-1**] 04:45AM BLOOD Calcium-7.1* Phos-7.3* Mg-2.3
[**2172-8-11**] 12:37AM BLOOD calTIBC-153* Ferritn-727* TRF-118*
[**2172-8-24**] 02:40AM BLOOD calTIBC-57* TRF-44*
[**2172-8-31**] 03:05AM BLOOD calTIBC-46* Ferritn-GREATER TH TRF-35*
[**2172-8-31**] 02:12PM BLOOD Cortsol-29.3*
[**2172-8-31**] 03:28PM BLOOD Cortsol-35.0*
[**2172-8-14**] 05:44AM BLOOD Type-ART pO2-148* pCO2-41 pH-7.25*
calTCO2-19* Base XS--8
[**2172-8-14**] 03:58PM BLOOD Type-ART pO2-126* pCO2-39 pH-7.33*
calTCO2-21 Base XS--4
[**2172-8-17**] 11:07AM BLOOD Type-ART pO2-107* pCO2-39 pH-7.32*
calTCO2-21 Base XS--5
[**2172-8-30**] 03:21PM BLOOD Type-ART pO2-105 pCO2-42 pH-7.26*
calTCO2-20* Base XS--7
[**2172-8-31**] 02:22PM BLOOD Type-ART pO2-92 pCO2-45 pH-7.22*
calTCO2-19* Base XS--9
[**2172-9-1**] 05:09AM BLOOD Type-ART pO2-88 pCO2-47* pH-7.16*
calTCO2-18* Base XS--11
[**2172-9-1**] 08:00AM BLOOD Type-ART pO2-92 pCO2-44 pH-7.20*
calTCO2-18* Base XS--10
[**2172-8-10**] 06:35PM BLOOD Lactate-1.7
[**2172-8-14**] 06:29AM BLOOD Glucose-99 Lactate-6.0* Na-132* K-3.7
Cl-112
[**2172-8-15**] 02:22AM BLOOD Lactate-1.5
[**2172-8-20**] 05:01PM BLOOD Glucose-121* Lactate-0.8
[**2172-8-29**] 07:27AM BLOOD Lactate-2.3*
[**2172-8-30**] 09:31AM BLOOD Glucose-154* Lactate-2.4*
[**2172-9-1**] 10:23AM BLOOD Lactate-1.6
[**2172-8-18**] 09:18AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**8-14**] CT Abd: Marked portal venous gas and pneumatosis within the
proximal small bowel and stomach consistent with ischemic bowel.
Given extensive vascular calcifications as well as history of
atrial fibrillation a likely etiology includes thromboembolic
disease.
[**8-15**] CXR: increased pneumothorax and increased subcutaneous air
[**8-16**] CXR: interval placement of a second left chest tube with
re-expansion of the left lung
[**8-28**] duplex B LE: thrombus identified in the great saphenous
vein continuing into the junction with the common femoral vein
and extending down to the mid portion of the right superficial
femoral vein
[**8-31**] CXR: Moderate-to-large right pleural effusion has
increased. Very small residual of left pneumothorax is seen at
the base of the left hemithorax with increasing
small-to-moderate left pleural effusion. Subcutaneous emphysema
in left chest wall has decreased since [**8-29**]. Mid level and
apical left pleural tubes are unchanged in their respective
positions. Progressive consolidation at the base of the left
lung could be atelectasis alone though pneumonia cannot be
excluded. Cardiac silhouette is substantially obscured by
adjacent pleura and parenchymal abnormality , but does not
appear appreciably changed. Increasing consolidation in the
right upper lung concerning for progressive pneumonia. Circular
lucency at the upper margin of this region is a subsumed bulla,
not a cavity.
Tracheostomy tube, right internal jugular line, right atrial and
right ventricular pacer leads are in standard placements.
Esophageal feeding and drainage tubes pass into the stomach and
out of view.
Brief Hospital Course:
83 year old male who presented to the [**Hospital1 18**] w/ ECG changes and
hypotension and was admitted to rule out MI. During his
hospital course, he had hematemesis and increasing abdominal
pain. A CT abdomen was obtained which showed small bowel
pneumotosis. The pt was brought to the operating room for
exploratory laparotomy and an 8o cm segment of small bowel was
found to be ischemic. The abdomen was left open and the pt was
brought back to the operating room the following day for a
"second look" procedure. Intraoperatively, the bowel appeared
viable with the exception of 1 cm of ischemia which was oversewn
with 3-0 silk. Post-operatively, the pt developed respiratory
distress in the ICU and was found to have decreased breath
sounds on the Left side. An emergent chest tube was placed X 2
with good result. The pneumothorax was thought to be a result
of his COPD/positive pressure ventilation.
Hospital Course was remarkable for the following events:
Failure to wean ventilator sp tracheostomy
DVT: B duplex of lower extremities were obtained as a part of a
fever work up which revealed RLE DVT. A heparin ggt was started
for a goal PTT of 60-80
Malnutrition-Albumin 1.5/TRF 144:
The pt was initially sustained on TPN and TF were started one
week post operatively via a Dobhoff feeding tube placed in the
jejunum. The TPN was weaned off as the pt was tolerating tube
feeds. When the pt became septic and hypotensive two weeks post
op, his tube feeds were held as he required multiple
vasopressors to sustain a MAP > 60. At this time, TPN was
restarted.
Secondary to the pt's severe malnutrition and catabolic state,
the pt exhibited impaired wound healing which led to fascial
dehiscence mid wound for approximately 2 cm. Ethicon wound
bridges were palced at the bedside on [**8-26**] to prevent
eviseration.
Sepsis/Hypotension:
The pt spiked a temperature to 101.5 and became massively
hypotensive requiring multiple vasopressors to sustain a mean
arterial pressure of 60.
Broad spectrum antibiotics were started. CXR revealed a R
pneumonia which did not improve despite antibiotics. Sputum
cultures grew pan sensitive Klebsiella.
Acute renal failure/anuria:
The pt's BUN and Creatine increased to 93/3.0 respectively.
Worsening renal failure led to volume overload, electrolyte
abnormalities and metabolic acidosis.
Due to the patient's comorbidies and worsening clinical
condition, a family meeting with the ICU Attending, social
worker and the patient's family was held on [**9-1**] and the a
decision to provide "comfort measures only" was made. The pt
expired shortly after.
Medications on Admission:
ASA 325qd, amio200qd, lasix 20qd, toprol xl 50qd, lipitor 20qd,
percocet prn, protonix 40qd, tums+vitD, feso4 [All: ACE-I]
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
ischemic bowel
pneumonia
atrial fibrillation
acute renal failure
wound dehiscence
CAD sp IMI [**2163**]/ sp cardiac cath [**4-21**]-EF 35%, 2VD
Complete heart block s/p pace maker placement
COPD
OA
AAA 4.5 cm
diverticulosis
PSH: R colectomy
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2172-9-16**]
|
[
"412",
"V10.51",
"998.32",
"458.9",
"427.31",
"584.9",
"557.0",
"518.81",
"486",
"414.01",
"276.51",
"053.79",
"427.81",
"V45.01",
"496",
"512.1",
"428.0",
"285.29",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"31.1",
"99.15",
"46.79",
"34.04",
"38.93",
"93.90",
"33.23",
"45.91",
"96.6",
"86.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10000, 10009
|
7180, 9800
|
236, 466
|
10294, 10298
|
1568, 7157
|
10349, 10489
|
1140, 1158
|
9973, 9977
|
10030, 10273
|
9826, 9950
|
10322, 10326
|
1173, 1549
|
182, 198
|
494, 616
|
638, 1019
|
1035, 1124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,266
| 148,266
|
48225
|
Discharge summary
|
report
|
Admission Date: [**2139-4-27**] Discharge Date: [**2139-5-7**]
Date of Birth: [**2071-1-25**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
1. T4 bilateral laminotomy, medial facetectomy.
2. T5 bilateral laminectomy for removal of extradural
lesion.
3. T6, T7, T8 bilateral laminectomy, medial facetectomy,
foraminotomy for extradural mass.
4. Biopsy of bone and soft tissue, deep, sent to Pathology.
History of Present Illness:
68 yo M w/ HTN, DM, CAD s/p CABG, and recently dx metastatic
poorly differentiated adenocarcinoma, unknown primary possibly
lung, w/ mets to spine, s/p cycle 6 of carboplatinum, taxol
(last [**3-13**]) presented cord compression at T6 on MRI spine s/p
T5-8 laminectomy, transferred to MICU for hypotension and fever.
.
Pt presented [**4-27**] after MRI as outpt "high-grade spinal canal
narrowing at T6, and moderate spinal canal narrowing at T8,"
that was concerning for cord compression. He was admitted to
OMED service, where ortho and rad onc were consulted. He had
MRI c-spine that showed mets involving c4-t2. He was taken to
the OR for laminectomy of T5-8, medial facetectomy, foraminotomy
for extradural mass on [**4-29**]. On POD #2, pt triggered for
hypotension w/ BP 90/60. He also spiked a temperature to 100.7.
He received total 2.5L IVFs, and was started on vanc and
ceftaz. His BP did not improve and remained 80s-90s/40s, w/ HR
in 100s-110s. He got a CTA that did not show evidence of PE.
His urine output was recorded as 1125. His vac drained 15cc and
was d/c'd today.
.
Currently, pt denies lightheadedness, sob, cp, n/v, abdominal
pain, dysuria, cough. He has not had a bowel movement for days,
but is passing gas. He does endorse some back pain.
.
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:
HTN
DM
Hypercholesterolemia
ASVD
proteinuria
CABG
Wife [**Name (NI) 12808**] [**Name (NI) **] is HCP
open angle glaucoma
Laminectomy on [**2139-4-29**]
Social History:
Pt married.
- Tobacco: former smoker
- Alcohol: infrequent
- Illicits: denies
Family History:
Father passed away of MI at 60
Physical Exam:
VS: 100.7, 92/52, 112, 22, 91% ra
Gen: Mild respiratory distress
HEENT: EOMI, PERRL, MMM, OP clear
Neck: no JVD, no LAD
CV: regular rate and rhythm, no murmurs
Resp: CTAB, no wheezes or crackles
GI: soft NTND no HSM, +BS
Ext: no c/c/e, +pneumoboots
Neuro: CNII- CNXII intact, strength and sensation intact
throughout
Psych: A&OX3, appropriate
BLE: 5/5 strength L2-S1
Pertinent Results:
[**2139-4-27**] 04:30PM NEUTS-82.3* LYMPHS-9.9* MONOS-7.6 EOS-0.1
BASOS-0.1
[**2139-4-27**] 04:30PM NEUTS-82.3* LYMPHS-9.9* MONOS-7.6 EOS-0.1
BASOS-0.1
[**2139-4-27**] 04:30PM WBC-7.5 RBC-3.38* HGB-9.8* HCT-30.1* MCV-89
MCH-28.9 MCHC-32.5 RDW-15.0
.
[**2139-5-7**]
WBC-10.5 RBC-2.95* Hgb-8.7* Hct-26.1* MCV-88 MCH-29.4 MCHC-33.3
RDW-14.7 Plt Ct-277
Glucose-160* UreaN-58* Creat-1.6* Na-142 K-4.7 Cl-112* HCO3-20*
AnGap-15
ALT-35 AST-92* LD(LDH)-890* CK(CPK)-252 AlkPhos-362* TotBili-0.6
Albumin-2.3* Calcium-7.4* Phos-5.0* Mg-2.2
.
[**5-7**] SINGLE FRONTAL VIEW OF THE CHEST: The endotracheal tube ends
at the level of thoracic inlet, approximately 7.5 cm above the
carina. The entire course of the trachea is not well seen. There
is a linear lucency along the right aspect of the superior
mediastinum which may represent an angulated deviated trachea
versus air within the mediastinum. Other linear lucencies within
the mediastinum are consistent with pneumomediastinum. Extensive
reticular nodular opacities are again seen bilaterally,
consistent with known metastatic disease. Cardiomediastinal
contours are unchanged. Gaseous dilation of bowel loops are
noted.
IMPRESSION: Findings concerning for pneumomediastinum.
Endotracheal tube
ends at the level of thoracic inlet. Recommend further
evaluation with chest CT.
.
[**5-7**] PORTABLE AP CHEST RADIOGRAPH:
There is almost complete white out of the left lung, new
compared to prior examination. The acute change is concerning
for lobar collapse and a large pleural effusion, possible
hemothorax. Multiple reticular nodular opacities throughout the
remainder of the aerated lung is unchanged. The tip of the
endotracheal tube is at the level of the thoracic inlet,
unchanged from prior. No other significant change from prior.
IMPRESSION:
1. New severe white out of the left lung, probably collapse and
large pleural effusion, possible hemothorax.
2. Endotracheal tube at thoracic inlet, unchanged.
3. Stable reticular nodular opacities in the right lung.
Brief Hospital Course:
The patient was initially admitted to the Oncology service and
evaluated by the Ortho spine team. He was transferred to the
[**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for
the above procedure without complication. For details please
refer to the dictated operative note. TEDs / pneumoboots were
used for postoperative DVT prophylaxis. Intravenous antibiotics
were continued for 24hrs postoperatively per standard protocol.
The patient's pain was controlled with IV pain medications
followed by oral analgesics once tolerating POs. The patient's
diet was advanced as tolerated. The foley was removed on POD2.
Physical therapy was consulted for mobilization.
.
On POD2 the patient was noted to have hypotension to SBPs 90's
associated with tachycardia to 110's and hypoxia 90's on RA and
a low grade fever. At CT chest was negative for PE. He was
transferred to the ICU for closer monitoring given his
metastatic CA history and started on empiric IV antibiotics. He
was stable in the ICU and improved with IVF and transferred out
to the floor.
.
On the floor, the pt was persistently febrile, although his
fever curve was trending downwards by abx day 6. The plan was to
continue an 8 day empiric course of vanc/ceftazidime, although
Cx were all negative and even CT torso failed to reveal a
source. Pain control became an issue, particularly left shoulder
pain. Pt is known to have metastatic disease. He required enough
short-acting pain morphine to warrant starting MS Contin, which
was uptitrated. However, pt became more somnolent, but still
complained of pain when he was awoke. He had episodes of
hypotension to the 80s requiring boluses. He ultimately was
given Narcan for his somnolence. He woke immediately, but began
to complain of chest tightness. He was suctioned deeply for
suspected mucous plug, but was intermittently desaturating, even
on 6L NC. He was transferred to the MICU, where he was intubated
immediately as was unresponsive and unable to protect his
airway.
.
=====================
[**Hospital Unit Name 13533**] [**Date range (1) 26511**]
=====================
.
# Acute Hypoxic Respiratory Failure: Initial ABG revealed
significant hypercapnia in setting of narcotics and altered
mental status, so hypoxic respiratory failure was initially
attributed to hypoventilation. As stated above, he was
immediately intubated upon arrival to the [**Hospital Unit Name 153**] and continued on
broad antibiotics. He remained on mechanical ventilation. It was
then noticed that his endotracheal tube appeared high. On
bronchoscopy a new necrotic obstructing mass was noticed in his
airway causing tracheal deviation. It was unlikely to be
procedure-related trauma, given appearance of the obstruction.
Most likely the patient experienced an acute bleed of a necrotic
tumor, which compressed his airway and led to inability to
provide adequate mechanical ventilation. This ultimately led to
his expiration.
.
# Hypotension: On the evening of arrival to the [**Hospital Unit Name 153**] the patient
began to experience labile blood pressures, dropping to the 80s
systolic while sleeping and climbing to the 140s systolic when
awakened. He was given two 1L NS fluid boluses without change in
his hemodynamics. Transient hypotension was initially attributed
to the use of Propofol for sedation (subsequently changed to
Fentanyl/Midazolam) and perhaps large amounts of pain medication
that were slow to clear secondary to impaired liver and renal
function. He was started on peripheral dopamine for pressure
support.
.
# Acute Kidney Injury: Thought likely secondary to Contrast
Nephropathy based on timing and urine electrolytes. He continued
to have adequate urine output and his Creatinine trended down.
.
# Metastatic Adenocarcinoma: Suspected lung primary and known
bony and liver mets. The patient had undergone 6 cycles of
taxol/carboplatin. He also underwent a T5-8 laminectomy for
suspected cord compression secondary to a spinal met on [**4-29**]. He
suffered tremendous pain from his extensive disease, which was
controlled with Fentanyl boluses in the [**Hospital Unit Name 153**].
.
# Coronary Artery Disease: EKGs obtained were consistent with
prior and showed no evidence of acute ischemia. He was ruled out
for myocardial infarction with two negative sets of cardiac
biomarkers.
.
# Diabetes Mellitus: On oral anti-hyperglycemics at home, which
were held. Fingersticks were checked q6h and insulin provided as
needed.
.
# Anemia: Likely secondary to chronic inflammation from
underlying malignancy. Hct remained stable.
Medications on Admission:
Betimol 0.5 % Eye Drops one drop in each eye daily
Xalatan 0.005 % Eye Drops one drop in each eye at bedtime
Lipitor 80 mg Tab one Tablet(s) by mouth in the evening
Fish Oil 1,000 mg Cap ? frequency
Aspirin 325 mg Tab one Tablet(s) by mouth daily.
Metformin 1,000 mg Tab one Tablet(s) by mouth daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
-Expired
-Metastatic Adenocarcinoma
-Respiratory Failure
-Hypotension
Discharge Condition:
expired
Discharge Instructions:
not applicable; patient expired
Followup Instructions:
not applicable; patient expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"V45.81",
"197.7",
"E947.8",
"E938.3",
"E849.7",
"V66.7",
"276.69",
"564.00",
"414.00",
"336.3",
"584.9",
"780.97",
"401.9",
"724.01",
"V58.69",
"276.51",
"458.29",
"162.9",
"780.60",
"365.10",
"272.4",
"V15.82",
"198.5",
"486",
"285.22",
"250.00",
"518.81",
"338.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"96.71",
"83.21",
"96.04",
"77.49"
] |
icd9pcs
|
[
[
[]
]
] |
10068, 10077
|
5101, 9679
|
289, 560
|
10190, 10199
|
3062, 5078
|
10279, 10449
|
2627, 2659
|
10029, 10045
|
10098, 10169
|
9705, 10006
|
10223, 10256
|
2674, 3043
|
1886, 2336
|
238, 251
|
588, 1867
|
2358, 2512
|
2528, 2611
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,986
| 121,551
|
54307
|
Discharge summary
|
report
|
Admission Date: [**2194-10-30**] Discharge Date: [**2194-11-24**]
Date of Birth: [**2129-5-5**] Sex: M
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
CT guided Drainage left upper quadrant catheter placement into a
large abdominal and pelvic pancreatic fluid collection, with
drainage of 2250 cc.
.
8 French catheter into a perisplenic fluid collection and
exchange of a second catheter into the left paracolic fluid
collection, with no significant residual fluid identified on
post-procedure images
.
PICC
.
Successful repositioning of peripancreatic catheter to a
position more closely approximating the pancreatic tail
History of Present Illness:
This is a 65 year old male transferred from [**Hospital3 **]. He
underwent a left laparoscopic nephrectomy on [**10-21**] for renal
cell carcinoma. His post-op course was complicated by acute
tubular necrosis, gastritis/bleeding peptic ulcer, LLL
pneumonia, and pancreatitis. The patient received 2 units of
PRBCs on POD 8 for low HCT. Abd CT on POD 9 revealed
peripancreatic fluid collection concerning for possible
disruption of the pancreatic duct.
On transfer, he complained of [**10-8**] sharp abdominal pain in
bilat. lower quadrant of abdomen.
Past Medical History:
recently diagnosed L RCC, depression, HTN, herniated disc,
spinal stenosis, chronic back pain, nephrolithiasis, R knee DJD
PSH: L nephrectomy & adrenalectomy ([**10-21**]), 2 R knee surgeries,
L knee surgery
Social History:
Divorced
Lives with daughter in [**Name (NI) **]
Smokes 1-1.5 ppd x 50 years
No EtOH
No DOA
Family History:
NC
Physical Exam:
97.8, 81, 136/70, 20, 94% RA
Gen: Anxious, NAD, uncomfortable secondary to abdominal pain.
CV: RRR, no M/R/G
Chest: decreased breath sounds bilat.
Abd: soft, distended, tender on palpation to bilat. lower
quadrants and left flank. 6 cm midline abd incision intact with
steri strips. 3 intact lap site incisions on let abd covered
with steri strips, +typany, no rebound, no guarding.
Ext: warm, 1+ EDEMA, stage 1 sore on coccyx
Pertinent Results:
[**2194-10-30**] 10:22PM BLOOD WBC-21.0* RBC-4.38* Hgb-10.7* Hct-32.6*
MCV-74* MCH-24.4* MCHC-32.8 RDW-15.9* Plt Ct-387
[**2194-11-3**] 05:04AM BLOOD WBC-14.6* RBC-3.94* Hgb-9.6* Hct-29.0*
MCV-74* MCH-24.3* MCHC-33.0 RDW-16.5* Plt Ct-341
[**2194-11-6**] 05:42AM BLOOD WBC-8.3 RBC-4.10* Hgb-10.1* Hct-30.2*
MCV-74* MCH-24.7* MCHC-33.5 RDW-16.5* Plt Ct-373
[**2194-11-7**] 04:12AM BLOOD Glucose-143* UreaN-21* Creat-1.2 Na-134
K-4.5 Cl-98 HCO3-32 AnGap-9
[**2194-11-4**] 11:05AM BLOOD ALT-25 AST-37 AlkPhos-191* Amylase-170*
TotBili-1.6*
[**2194-11-6**] 05:42AM BLOOD ALT-16 AST-16 AlkPhos-151* Amylase-171*
TotBili-0.6
[**2194-10-30**] 10:22PM BLOOD Lipase-220*
[**2194-11-4**] 11:05AM BLOOD Lipase-288*
[**2194-11-6**] 05:42AM BLOOD Lipase-184*
.
CT GUIDANCE DRAINAGE [**2194-10-31**] 1:43 PM
IMPRESSION:
1. Patient is status post left upper quadrant catheter placement
into a large abdominal and pelvic pancreatic fluid collection,
with drainage of 2250 cc.
.
CT PELVIS W/CONTRAST [**2194-11-2**] 8:07 AM
IMPRESSION:
1. Interval increase in volume of fluid, which extends from the
pancreatic tail into the left renal fossa and along the left
pericolic gutter.
2. Inflammatory changes around the pancreatic tail causes
thrombosis of the splenic vein in this region. Splenic artery
appears patent.
3. Findings compatible with pancreatitis. Poor enhancement of
the pancreatic tail could reflect parenchymal necrosis.
4. No change in bilateral pleural effusions, left greater than
right.
5. 2 mm right middle lobe pulmonary nodule redemonstrated for
which no additional followup is needed in a patient without
history of malignancy or risk factors for lung cancer.
.
ERCP [**2194-11-3**]
Cannulation: Cannulation of the pancreatic duct was performed
with a sphincterotome using a free-hand technique.
Pancreas: The pancreatic duct appeared normal in the area of the
head and body. A post surgical leak was noted in the area of the
tail.
Procedures: A 8 mc by 7 Fr Zimmon single pigtail pancreatic
stent was placed successfully to resolve the leak.
Impression: 1. Normal major papilla
2. Cannulation of the pancreatic duct was performed with a
sphincterotome using a free-hand technique.
3. The pancreatic duct appeared normal in the area of the head
and body. A post surgical leak was noted in the area of the
tail.
4. A 8 mc by 7 Fr Zimmon single pigtail pancreatic stent was
placed successfully to resolve the leak.
Recommendations: 1. Return to Surgery service/ Dr [**Last Name (STitle) 468**]
2. NPO till recovery then start clears and advance as tolerated
3. ERCP in 3 weeks to remove the PD stent.
.
CT CHANGE PERCUTANEOUS TUBE [**2194-11-6**] 10:10 AM
IMPRESSION:
1. Patient status post placement of a new 8 French catheter into
a perisplenic fluid collection and exchange of a second catheter
into the left paracolic fluid collection, with no significant
residual fluid identified on post-procedure images.
2. Unchanged bilateral pleural effusions with adjacent
atelectasis.
3. Multiple non-obstructing right renal calculi measuring up to
9 mm.
.
CT ABDOMEN W/CONTRAST [**2194-11-11**] 9:43 AM
IMPRESSION:
1. Two drainage catheters in the left mid abdomen as described.
The paraspinal catheter is draining the pancreatic tail
collection, which has decreased in size since its placement on
[**11-6**]. The left flank catheter is situated within a nearly
completely obliterated fluid collection. No new drainable fluid
collections identified.
2. Otherwise, unchanged internal pancreatic drain, and distended
gallbladder with a focal area of hyperattenuation.
3. Improved pleural effusions, right more so than left.
.
CT PERITINEAL DRAIN EXCLUDING APPENDICEAL [**2194-11-16**] 6:20 PM
IMPRESSION: Successful CT-guided placement of an 8 French
catheter into a recurrent perisplenic fluid collection.
Approximately 100 cc were aspirated and a sample was submitted
for chemistry and microbiology analysis.
.
CT FISTULOGRAM S&I [**2194-11-21**] 4:34 PM
IMPRESSION: Successful repositioning of peripancreatic catheter
to a position more closely approximating the pancreatic tail.
Brief Hospital Course:
This is a 65 year old male with pancreatitis and peripancreatic
fluid collection on CT, s/p left nephrectomy for [**Hospital 111254**]
transferred from [**Hospital3 **].
Peripancratic fluid collection: A CT showed a large fluid
collection and on [**10-31**] had CT guided drainage placement into a
large abdominal and pelvic pancreatic fluid collection, with
drainage of 2250 cc.
His drain was accidently self D/C'd and he required a new drain
on [**11-2**]. Thereafter, a 10 French pigtail catheter was inserted
directly into the collection utilizing a trocar technique.
Approximately 350 cc of opaque beige colored fluid was aspirated
and sent for Gram stain and culture.
He went for ERCP on [**11-3**] and the pancreatic duct appeared normal
in the area of the head and body. A post surgical leak was noted
in the area of the tail.
Procedures: A 8 mc by 7 Fr Zimmon single pigtail pancreatic
stent was placed successfully to resolve the leak.
Then on [**2194-11-6**] he had placement of a new 8 French catheter
into a perisplenic fluid collection and exchange of a second
catheter into the left paracolic fluid collection, with no
significant residual fluid identified on post-procedure images.
The drains continued to put out thick brown/maroon fluid. The
output decreased with time.
A CT was obtained on [**11-11**]. Two drainage catheters in the left
mid abdomen as described. The paraspinal catheter is draining
the pancreatic tail collection, which has decreased in size
since its placement on [**11-6**]. The left flank catheter is
situated within a nearly completely obliterated fluid
collection. No new drainable fluid collections identified.
Otherwise, unchanged internal pancreatic drain, and distended
gallbladder with a focal area of hyperattenuation. Improved
pleural effusions, right more so than left.
FEN: HE was NPO with IVFs. A PICC line was placed and TPN was
initiated. He continued on TPN.
After the CT on [**11-11**], we advanced his diet and monitored his
drain output. He was tolerating a diet, not complaining of
increasing abdominal pain.
We monitored his drain output and then the more superior drain
was removed on [**11-14**]. On [**11-16**], he became hypotensive and septic
due to an increase in the fluid collection and went for
CT-guided placement of an 8 French catheter into a recurrent
perisplenic fluid collection. Approximately 100 cc were
aspirated and a sample was submitted for chemistry and
microbiology analysis. On [**11-21**] he went for successful
repositioning of peripancreatic catheter to a position more
closely approximating the pancreatic tail.
Cultures grew [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
He was treated with Imipenem and Fluconazole IV. He will go
home with Levofloxacin for 1 week.
He will return to clinic in 2 weeks for a CT scan.
Medications on Admission:
trazodone, celebrex, lorazepam
Discharge Medications:
1. PT Device
Bilateral neoprene knee sleeve.
Osteoarthritis
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 1 months.
Disp:*30 Patch 24 hr(s)* Refills:*0*
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for inability to sleep.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed. Tablet(s)
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Home Health & Hospice Services, Inc.
Discharge Diagnosis:
Pancreatitis
Peripancreatic fluid collection
Malnutrition
Sepsis
Hypotension
Discharge Condition:
Good
Tolerating a diet
Pain well controlled
Drains in place
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please take any new meds as ordered.
* Continue to amubulate several times per day.
* Continue to eat several, small meals through-out the day.
* You are going home with your drains in place. Continue with
drain care, including flushing drains 3-4x/day.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **], ERCP, for stent removal.
Call ([**Telephone/Fax (1) 10532**] to schedule this appointment.
Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. Call [**Telephone/Fax (1) 2835**]
with questions or concerns.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2194-12-8**]. Arrive
at 9:30am. [**Hospital Unit Name **] [**Location (un) 470**].
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2194-12-8**]
11:15
Completed by:[**2194-11-24**]
|
[
"263.9",
"V10.52",
"038.9",
"995.91",
"997.4",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"52.93",
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10393, 10479
|
6272, 9248
|
282, 756
|
10600, 10662
|
2160, 6249
|
11880, 12515
|
1694, 1698
|
9329, 10370
|
10500, 10579
|
9274, 9306
|
10686, 11857
|
1713, 2141
|
228, 244
|
784, 1336
|
1358, 1569
|
1585, 1678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,510
| 105,429
|
39070
|
Discharge summary
|
report
|
Admission Date: [**2139-3-20**] Discharge Date: [**2139-3-28**]
Date of Birth: [**2060-1-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
decreased exercise tolerance
Major Surgical or Invasive Procedure:
[**2139-3-20**] s/p Aortic valve replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra
Porcine)
History of Present Illness:
79 year old female with known aortic stenosis followed by serial
echocardiograms who presented to clinic in [**2139-1-12**] for
evaluation for aortic valve replacement given recent
echocardiographic evidence of severe
aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] 0.76. She has a long standing
history of heart murmur. She has noted mild decrease in exercise
tolerance over the last several years. She denies exertional
shortness of breath, chest pain and syncope. She presents this
morning for aortic valve replacement.
Past Medical History:
Hypercholesterolemia
Aortic Stenosis
Hypercoagulable state (Heterozygous for Factor V leiden)
Uterine Prolapse, pessary ring in place
Microscopic Hematuria - currently undergoing evaluation
History of Small Bowel Obstruction
Anxiety/Depression
History of Rosacea
s/p SBO requiring surgery [**5-18**]
s/p C-section x 1
Social History:
Lives with: Husband
Occupation: Retired
Tobacco: small amount of smoking greater than 25 years ago
ETOH: occasional, no history of excessive intake
Family History:
Siblings with valve replacements and bypass surgery in their
60-70's. Daughter with history of DVT.
Physical Exam:
Pulse: 83 Resp: 20 O2 sat: 100%
B/P Right: 103/61 Left: 106/59
General: Elderly female in NAD, appears younger than stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x], no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 systolic ejection
murmur
radiating to carotids and precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace/Varicosities: GSV suitable, no varicosities
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: transmitted murmurs
Pertinent Results:
[**2139-3-24**] 06:15AM BLOOD WBC-10.7 RBC-3.73* Hgb-11.0* Hct-33.1*
MCV-89 MCH-29.6 MCHC-33.3 RDW-16.2* Plt Ct-130*
[**2139-3-25**] 06:45AM BLOOD PT-15.1* INR(PT)-1.3*
[**2139-3-20**] 11:48AM BLOOD PT-14.2* PTT-40.1* INR(PT)-1.2*
[**2139-3-25**] 06:45AM BLOOD UreaN-20 Creat-0.5 K-3.6
[**2139-3-24**] 06:15AM BLOOD Glucose-104* UreaN-24* Creat-0.5 Na-141
K-3.9 Cl-102 HCO3-33* AnGap-10
[**2139-3-26**] 09:40AM BLOOD PT-31.1* INR(PT)-3.1*
[**2139-3-25**] 06:45AM BLOOD PT-15.1* INR(PT)-1.3*
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. 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
aorta is mildly dilated. There are simple 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). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
mild valvular mitral stenosis (area 1.5-2.0cm2). Mild to
moderate ([**12-13**]+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2139-3-20**] at 830am.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. Leaflets seem to move well
and the valve appears well seated. No aortic insufficiency seen.
The images post bypass are not of great quality due to extreme
rotation of the heart to the left. Mean gradient across the
valve is 10 mm Hg. Mild mitral regurgitation persists. Aorta is
intact post decannulation.
Brief Hospital Course:
Admitted same day surgery and underwent aortic valve
replacement. See operative report for further details. She
received cefazolin for perioperative antibiotics. Post
operatively she was transferred to the intensive care unit for
management. In the first twenty four hours she was weaned from
sedation and awoke neurologically intact. She remained
intubated due to respiratory acidosis and on post operative day
one was extubated. She continued to progress and was ready for
transfer on post operative day two to the floor. Physical
therapy worked with her on strength and mobility. She developed
atrial fibrillation which was treated with betablockers and
amiodarone. She was started on coumadin for anticoagulation due
to atrial fibrillation as well as amiodarone. She had
fluctuating INRs but settled on a dose of 1 mg coumadin.
She was deemed ready for discharge to [**Location (un) **] Health Rehab by
Dr. [**Last Name (STitle) **] on post operative day eight.
Medications on Admission:
Citalopram 20mg po daily
Simvastatin 40mg po daily
ASA 81mg po daily
MVI 1 tab po daily
Caltrate Plus 1 tab po daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Caltrate Plus 600-400 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
Coumadin follow-up through [**Hospital 2274**] [**Hospital3 **] once
discharged from rehab with results to [**Telephone/Fax (1) 55854**] (conf. w
[**Doctor First Name **]), Dr. [**Last Name (STitle) 86612**] to follow, first INR draw [**2139-3-29**] in rehab
with rehab to dose until discharge and follow closely secondary
to fluctuating INRs,
dx: atrial fibrillation, INR goal [**1-14**]
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily until further instructed.
Disp:*120 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
11. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days: for urinary tract
infection.
Disp:*4 Tablet(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: titrate as needed for diuresis of [**12-12**].5L negative daily
toward pre-operative wt of 59 kgs.
Disp:*14 Tablet(s)* Refills:*2*
13. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
doses: first INR draw [**2139-3-29**] in rehab with rehab to dose until
discharge and follow closely secondary to fluctuating INRs, dx:
atrial fibrillation, INR goal [**1-14**].
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] healthcare rehab
Discharge Diagnosis:
Aortic Stenosiss/p AVR
Hypercholesterolemia
Hypercoagulable state (Heterozygous for Factor V leiden)
Uterine Prolapse, pessary ring in place
Microscopic Hematuria - currently undergoing evaluation
History of Small Bowel Obstruction
Anxiety/Depression
Rosacea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol 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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2139-4-23**] 1:00
Please call to schedule appointments
Primary Care Dr [**First Name4 (NamePattern1) 17728**] [**Last Name (NamePattern1) **] in [**12-13**] weeks [**Telephone/Fax (1) 17465**]
Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19**] in [**12-13**] weeks
Coumadin follow-up through [**Hospital 2274**] [**Hospital3 **], first
INR draw [**2139-3-27**], results to [**Telephone/Fax (1) 55854**] (conf. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]), Dr.
[**Last Name (STitle) 86612**] to follow
Completed by:[**2139-3-28**]
|
[
"427.31",
"289.81",
"599.0",
"997.1",
"276.6",
"272.0",
"618.1",
"599.72",
"276.2",
"424.1",
"300.4",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7656, 7715
|
4363, 5341
|
350, 488
|
8018, 8113
|
2467, 4340
|
8737, 9414
|
1596, 1698
|
5509, 7633
|
7736, 7997
|
5367, 5486
|
8137, 8714
|
1713, 2448
|
282, 312
|
516, 1072
|
1094, 1414
|
1430, 1580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,530
| 199,136
|
5474+5475+5476
|
Discharge summary
|
report+report+report
|
Admission Date: [**2163-3-7**] Discharge Date: [**2163-3-11**]
Date of Birth: [**2087-12-30**] Sex: M
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 75 year-old
male with coronary artery disease status post myocardial
infarction in [**2155**] and transition cel carcinoma of the left
ureter status post left ureterectomy and colon cancer,
prostate cancer and chronic obstructive pulmonary disease.
The patient was found to have a right renal mass.
PAST MEDICAL HISTORY: Significant for right colectomy, left
distal ureterectomy, hypertension, diabetes, peripheral
vascular disease, colon cancer, resected rectal CA and right
carotid bruits and myocardial infarction. The patient's
preop ejection fraction was 55%.
ALLERGIES: Intravenous contrast anaphylactic allergic
reaction.
MEDICATIONS: Insulin, atenolol, Lipitor, Lasix, Trazodone,
Klonopin and Humulin.
HOSPITAL COURSE: The patient was taken by Dr. [**Last Name (STitle) **] to the
Operating Room on [**2163-3-7**] and underwent a right
nephrectoureterectomy and postoperatively the patient did
well. The patient was extubated in the Operating Room and
transferred to the Intensive Care Unit due to his severe
comorbidities. The patient was transferred to the floor on
postoperative day number two in stable condition. However,
the patient got acutely agitated on the night of
postoperative day two and required several doses of Haldol.
An electrocardiogram at the time showed no change from
preoperative electrocardiogram. The patient was not acutely
hypoxic at the time. The electrolytes at that time were
normal. The patient's condition improved with several doses
of Haldol and on postoperative day number three the patient
complained of some shortness of breath. His cardiac enzymes
were cycled and they were all negative. All four sets of
troponin was less then .14 and CK was mildly elevated 430.
Cardioloyg Service saw the patient and recommended some
diuresis and some alteration in his medications.
The patient got a VQ scan, which was low probability for PE.
On postoperative day number four and on the same day the
patient's JP drain and nasogastric tube was discontinued.
Epidural was discontinued and the right central line was also
discontinued. On postoperative day three the patient began
to pass some gas and was started on a regular diet and on
postoperative day number four the patient was tolerating a
regular diet and has been passing gas from below. The
patient is deemed ready for discharge.
Physical examination prior to discharge, the patient was
afebrile with stable vital signs. Chest was clear. Abdomen
was soft, nontender, nondistended. Heart was regular rate
and rhythm. the patient had been tolerating a regular diet
and had been passing flatus. The patient has been ambulating
DISCHARGE MEDICATIONS: Humulin 20 units subQ q.a.m. and 42
units subQ q.p.m., Tylenol 25 mg po b.i.d., Lipitor 20 mg po
q.d., Lasix 40 mg po t.i.d. and Lopressor 50 mg po b.i.d.,
Hydralazine 10 mg po t.i.d., Tylenol #3 one to two tabs po q
4 to 6 hours prn, aspirin 325 mg po q.d., Colace 100 mg po
b.i.d.
The patient is instructed to follow up with Dr. [**Last Name (STitle) **] in one
to two weeks and the patient is to be discharged with VNA for
Foley care, wound checks and vital signs monitoring. The
patient will be discharged with Foley catheter. Prior to
discharge the urine was light red from the Foley output.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Location (un) 22140**]
MEDQUIST36
D: [**2163-3-11**] 09:00
T: [**2163-3-11**] 09:15
JOB#: [**Job Number 22141**]
Admission Date: [**2163-3-7**] Discharge Date: [**2163-3-13**]
Date of Birth: [**2087-12-30**] Sex: M
Service: Urology
SURGERY DURING ADMISSION:
Right nephroureterectomy [**2163-3-7**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
CONDITION ON DISCHARGE: Stable.
ADDENDUM:
Mr. [**Known lastname 18036**] was prepared for rehabilitation having been off
any sitters since [**2163-3-11**]. He is currently tolerating a
regular diabetic diet. He has restarted all of his
preoperative medications. His incision is clean, dry and
intact. His staples are open to air. His Foley catheter is
draining well with clearing urine. He will be discharged to
rehabilitation to follow up with Dr. [**Last Name (STitle) **] [**2163-3-16**] when
staples will be removed and the Foley catheter will be
removed. His medications upon discharge are Tylenol 650 mg
p.o. q 4 hours p.r.n. pain, Lopressor 50 mg p.o. b.i.d.,
hydralazine 10 mg p.o. t.i.d., Lasix 120 mg p.o. q. A.M.,
Colace 100 mg p.o. b.i.d., aspirin 325 mg p.o. q.d., Lipitor
20 mg p.o. q.d., Protonix 40 mg p.o. q.d., Clonidine 0.3 mg
p.o. b.i.d., Trazodone 25 mg p.o. q.d., NPH 20 units
subcutaneous q A.M., 42 units subcutaneous q. P.M. and Cipro
250 mg p.o. b.i.d. to start on [**2163-3-15**] times five days (to
start the day before follow up with Dr. [**Last Name (STitle) **]). He is being
discharged to rehabilitation to continue with postoperative
recovery and physical therapy. His discharge diet is
diabetic, cardiac diet. He will follow up with Dr. [**Last Name (STitle) **]
[**2163-3-16**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Last Name (NamePattern1) 22142**]
MEDQUIST36
D: [**2163-3-13**] 09:24
T: [**2163-3-13**] 09:39
JOB#: [**Job Number 22143**]
Admission Date: [**2163-3-7**] Discharge Date: [**2163-3-14**]
Date of Birth: [**2087-12-30**] Sex: M
Service: UROLOGY
ADDENDUM
DISPOSITION: The patient was discharged on [**2163-3-14**],
in stable condition to [**Hospital **] Rehabilitation Facility.
DISCHARGE MEDICATIONS: His medications have been changed
slightly to decrease his Clonidine dose to 0.1 mg p.o. b.i.d.
His Hydralazine was discontinued. He will start on Cipro 250
mg p.o. b.i.d. on Tuesday, [**2163-3-15**], one day prior to
his follow-up visit with Dr. [**Last Name (STitle) **] ([**2163-3-16**]) for
staple removal and Foley catheter removal. His Insulin at
this point is one-half his usual dose. On discharge he has
received 10 U subcutaneous NPH in the morning and 21 U
subcutaneous NPH in the evening. This is half of his usual
dose. When his diet has returned to his preoperative
baseline, his NPH can be increased back accordingly.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Last Name (NamePattern1) 22144**]
MEDQUIST36
D: [**2163-3-14**] 15:23
T: [**2163-3-14**] 15:26
JOB#: [**Job Number 22145**]
|
[
"414.01",
"293.0",
"189.2",
"V10.46",
"V10.06",
"189.1",
"428.0",
"496",
"568.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
5944, 6582
|
922, 2830
|
169, 486
|
509, 904
|
6607, 6901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,577
| 187,215
|
5705
|
Discharge summary
|
report
|
Admission Date: [**2189-1-12**] Discharge Date: [**2189-1-20**]
Date of Birth: [**2142-12-16**] Sex: M
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
spontaneous renal hemorrhage
Major Surgical or Invasive Procedure:
Angiography
History of Present Illness:
46M transferred from [**Hospital3 7571**]Hospital with hypotension to
mid-80s, INR of 4.2 and intra-parenchymal L kidney hemorrhage
detected by CT scan. Vit K and FFP were given. Upon arrival
here patient has had a HR of 50 and SBP between 90 and 100 that
has remained constant. A CT scan obtained here showed a
16x9x11cm L kidney hematoma with active extravasation. Pt's INR
had corrected to 2.5 but the hct has fallen from 30.8 to 26.5.
Preparations are being made for embolization by interventional
radiology.
Past Medical History:
1. Heart disease:
- s/p Anterior MI ([**2178**]) with tPA and rescue PCI of LAD
--> P104 biliary stent placed in ostial LAD
--> 4.0x22mm in proximal LAD
--> 4.0x15mm in mid LAD
- s/p MI ([**9-24**])
- ICD placed in [**10-25**] with Pacemaker/ICD generator change on
[**2186-9-5**]
- PCI ([**2185-1-6**])
--> LMCA: free of disease
--> LAD: patent previously placed stents with 20% ISR in the
proximal segment
--> LCX: free of flow limitations
- s/p Cardiac arrest ([**8-28**])
- EF 20% and LV thrombus
2. Hypertension
3. Hyperlipidemia: [**9-24**]: TC 177; LDL 103; HDL 54
4. End-stage renal disease:
- s/p basilic vein brachial artery AV fistula
5. h/o line sepsis
Social History:
Remote tobacco (10pk/yr; quit 9yr ago). EtOH abuse prior to
[**2178**] but none since. No IVDU but remote cocaine use per OMR.
Lives with his parents and is unemployed. Has one daughter.
Family History:
There is no family history of premature coronary artery disease
(although fater did have CAD) or sudden death.
Physical Exam:
Exam on Admission:
VS: T 97 HR 50 paced 100/50 18 99% on 2L
GEN: NAD, A&Ox4
HEENT: PERRLA, EOMI, anicteric, no LAD
CV: RRR, no m/r/g, pacemaker palpable, no overlying
erythema or tenderness
PULM: CTAB,
ABD: firm, ttp L flank and CVA
EXT: warm, +2 distal pulses, fistula in L arm + thrill
Exam on Discharge:
VS: T 98.9 HR 62 BP 110/70 RR 20 Sats 97% RA Wt 73.5kg
GEN: WDWN M in NAD
CV: PERRLA, EOMI, anicteric
RESP: CTA bilateral
ABD: NDNT
EXT: + thrill in LUE, no C/C/E
Pertinent Results:
[**2189-1-12**] 11:31PM WBC-5.4 RBC-3.01* HGB-10.4* HCT-28.7* MCV-95
MCH-34.5* MCHC-36.2* RDW-20.2*
[**2189-1-12**] 11:31PM PLT COUNT-68*
[**2189-1-12**] 08:43PM PT-19.5* PTT-31.8 INR(PT)-1.8*
[**2189-1-12**] 07:48PM WBC-5.2 RBC-2.97* HGB-10.1* HCT-27.8* MCV-94#
MCH-33.9* MCHC-36.2* RDW-19.9*
[**2189-1-12**] 07:48PM PLT SMR-VERY LOW PLT COUNT-78*
[**2189-1-12**] 03:31PM HCT-27.4*
[**2189-1-12**] 03:31PM PT-24.0* INR(PT)-2.3*
[**2189-1-12**] 10:42AM HCT-23.9*
[**2189-1-12**] 10:42AM PT-23.0* PTT-34.7 INR(PT)-2.2*
[**2189-1-12**] 03:50AM GLUCOSE-177* UREA N-58* CREAT-10.5*#
SODIUM-139 POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-25 ANION GAP-21*
[**2189-1-12**] 03:50AM ALT(SGPT)-24 AST(SGOT)-58* ALK PHOS-105 TOT
BILI-0.7
[**2189-1-12**] 03:50AM LIPASE-71*
[**2189-1-12**] 03:50AM CALCIUM-8.9 PHOSPHATE-5.5*# MAGNESIUM-2.4
[**2189-1-12**] 03:50AM PT-25.2* PTT-33.6 INR(PT)-2.5*
Brief Hospital Course:
Briefly, this is a 46 year-old man who was transferred here from
[**Hospital3 7571**]Hospital for a renal parenchymal hemorrhage. At
[**Hospital3 22765**], he had hypotension to mid-80s, INR of
4.2 and intra-parenchymal L kidney hemorrhage detected by CT
scan. Vit K and FFP were given. Upon arrival here patient has
had a HR of 50 and SBP between 90 and 100 that has remained
constant. A CT scan obtained here showed a 16x9x11cm L kidney
hematoma with active extravasation. The patient's INR was
corrected to 2.5 but his hct dropped from 30.8 to 26.5. Mr.
[**Known lastname **] was admitted directly to the Intesive Care Unit on HD
1. He was transferred to the floor on HD 3. Mr. [**Known lastname **] was
discharged home on HD 9.
Neuro: On admission the patient was awake and alert. He did not
require any sedation while in the ICU. The patient was started
on Dilaudid on admission. He was started on a Dilaudid PCA while
in the ICU. His PCA was discontinued on HD 3 and he was started
on percocet.
HEENT: The patient was anicteric on admission. He had no issues
with this system during this hospitalization.
CV: On admission, the patient was started on his home
medications of amiodarone, digoxin, simvastatin and toprol. His
aspirin and coumadin were held for his elevated INR and his
hematoma around his left kidney.
RESP: Mr. [**Known lastname **] had some mild crackles at his lung bases on
HD 2.
GI: The patient had a bowel movement on HD 6. Mr. [**Known lastname **]
complained of some nausea on HD 7. He had no other problems with
his gastrointestinal system during this hospitalization.
GU: The patient was dialyzed on HD 1 with 4.7L removed. The
patient had a foley catheter placed on HD 1 which was removed on
HD 2 when it was determined that the patient was oliguric at
baseline. The patient was again dialyzed on HD 3 with 4L
removed. Mr. [**Known lastname **] was dialyzed again on HD 4 with 3.4L
removed. He was dialyzed again on HD 7 with 4L removed.
FEN: The patient was started on a clear liquid diet on HD 2. He
was advanced to a regular diet on HD 3. He was discharged home
after tolerating a regular diet.
HEME: Left renal artery embolization was attempted on HD 1, but
there were no evidence of active bleeding from the left renal
artery, or from two left lumbar arteries in the area of the
hemorrhage. Mr. [**Known lastname **] had a femoral line placed in his right
groin that same day for central venous access. The patient was
given 2 units of FFP and 5 units of packed red blood cells prior
to and during hemodialysis on HD 1. He had hematocrits checked
every 6 hours starting on HD 1. His right groin sheath was
removed on HD 2. He was transfused 3 units of packed red blood
cells on HD 2. On HD 3, his hematocrits were checked every
twelve hours to monitor hemostasis. On HD 4, his hematocrit was
checked every day. Mr. [**Known lastname **] was started on Coumadin 5mg on
HD 4. The patient also received Epogen 5000 units IV on HD 4. On
HD 8, Mr. [**Known lastname 22766**] INR was elevated to 4.9. He was given 2
units of fresh frozen plasma and his INR corrected to 3.1. He
was discharged home on Coumadin 2mg qday and the plan to have
close followup of his INR.
ID: The patient had no problems with this system during this
hospitalization.
ENDO: The patient had no problems with this system during his
hospitalization.
Medications on Admission:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed.
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a week.
12. Zemplar 2 mcg Capsule Sig: One (1) Capsule PO once a day.
13. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Start
on [**2189-1-21**].
Disp:*60 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please draw PT/INR on Wednesday [**1-21**] and Friday [**1-23**] and fax
results to Dr [**First Name (STitle) **] and also to the transplant clinic at [**Hospital1 18**] at
[**Telephone/Fax (1) 697**].
dx: spontaneous renal hemorrhage, supertherapeuric INR
Discharge Disposition:
Home
Discharge Diagnosis:
spontaneous renal hemorrhage
Discharge Condition:
Good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] if you
experience fever > 101, chills, nausea, vomiting, diarrhea,
inability to take or keep down medications or increasing
abdominal pain.
Have PT/INR drawn Wednesday and Friday at dialysis. Results
should be sent to Dr [**First Name (STitle) **] as well as being faxed to [**Hospital 1326**]
clinic at [**Telephone/Fax (1) 697**].
Do not drive if taking narcotic pain medications
Start Coumadin on Wednesday [**1-21**] at 2 (two) mg.
Followup Instructions:
Follow up with your PCP this week.
Call [**Hospital 1326**] clinic to schedule an appointment.
Follow up with your transplant coordinators at [**Hospital1 2025**].
|
[
"V45.02",
"276.6",
"V15.82",
"E934.2",
"585.6",
"427.31",
"458.9",
"414.01",
"403.91",
"V17.3",
"459.0",
"V45.82",
"412",
"305.03",
"414.8",
"272.4",
"305.63"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.45",
"88.42",
"99.04",
"39.95",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
8915, 8921
|
3317, 6687
|
296, 310
|
8994, 9001
|
2388, 3294
|
9551, 9718
|
1769, 1882
|
7796, 8892
|
8942, 8973
|
6713, 7773
|
9025, 9528
|
1897, 1902
|
228, 258
|
338, 856
|
2205, 2369
|
1916, 2186
|
878, 1545
|
1561, 1753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,917
| 189,546
|
3370
|
Discharge summary
|
report
|
Admission Date: [**2125-9-26**] Discharge Date: [**2125-9-27**]
Date of Birth: [**2046-3-14**] Sex: F
Service: MEDICINE
Allergies:
Senna / Iodine / Optiray 350
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 year old female with recent flash pulmonary edema [**1-16**] HTN
urgency, with hx of DM2, HTN, AS s/p AVR with bioprothetic AS,
and pacemaker placed for complete heart block, who presetend to
the ED for acute dyspnea and elevated blood pressure.
Per the patient, she was at day care and had not taken her
medications at their scheduled time the day prior to admission.
She took her scheduled doses two hours apart that day. On the
following morning the visiting nurse came to her house and found
her blood pressure in her L arm to be 220/165. Per the patient,
her breathing had become more heavy, but she did not feel like
she could get enough air. She had felt fatigued for the last
week, and had slept more, but denied any other new symptoms.
She reports some left shoulder and jaw pain, but this has been
present and unchanged for the last week. She denies any chest
pain, discomfort, N/V, diaphoresis, palpitations,
lightheadedness, dizziness, or cough, claudication. She has PND
at night, but no orthopnea. She was able to lay supine the
night prior to her presentation. She has been hospitalized for
CHF exacerbations twice this year (including this admission).
At baseline, she has been able to walk 500 meters without any
sypmptoms (self reported).
.
Of note, during her last admission for hypoglycemia, she had
flash pulmonary edema and respiratory distress after her L arm
blood pressure was found to be elevated to 218/118.
.
ROS: (+) urinary frequency, loose stools. DVT ten years prior,
(-) for fevers, chills, night sweats, melena, BRBPR (recent),
.
In the ED, initial vitals were afebrile, 148/84, 90s, RR 40s,
97% NRB. She was given 100IV lasix and put out 500cc, given ASA
325, SL nitro, nitro gtt, put on BiPAP with symptomatic
improvement. Current vitals 153/48 V-paced 60s, RR19 100%
BiPAP. No ABG done.
.
Upon arrival to the floor, she was chest pain free without any
acute respiratory distress. VS: 97.5 60 152/42 10 96 on 4L.
She was started on her home medications.
.
Past Medical History:
1. CARDIAC RISK FACTORS: (+ 6.1 [**6-23**])Diabetes, (+) Dyslipidemia,
(+) Hypertension
2. CARDIAC HISTORY:
-CABG: CABG (SVG to PDA with AVR [**2118**])
-PERCUTANEOUS CORONARY INTERVENTIONS: Cypher stent to LAD [**7-19**]
-PACING/ICD: Complete Heart Block s/p [**Company 1543**] Sigma
dual-chamber pacemaker with DDDR pacemaker placement [**2120**]
(placed for syncopal episode)
3. OTHER PAST MEDICAL HISTORY:
4. Calcific Aorta,
5. Diabetes mellitus type 2 on insulin and oral agents.
6. Hypertension.
7. Hypercholesterolemia.
8. Schwanomma T11 to T12 s/p resection ([**2-16**]).
9. PVD with bilateral sublavian stenosis (R - 80%, L -40%)
10. Depression
11. Left atrial thrombus noted on TEE at SEMC [**12-23**] now on
coumadin
10. Flash pulmonary edema on last admission after BP 218/118
11. Rectal Bleeding
Social History:
Lives with Husband. Adult [**Name2 (NI) **] Care.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Brother MI [**79**]
Father/Mother HTN
Physical Exam:
VS: T= 97.5 BP= 152/42 HR= 60 RR= 10 O2 sat= 96 4L
GENERAL: Obese, pale female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP undecernable [**1-16**] body habitus.
CARDIAC: No carotid bruit. Normal S1, S2, no S3 or S4. Blowing
systolic II/VI murmur ar RUSB radiating to carotids. IV/VI
blowing systolic mumur radiating to axilla and back. No
ventricular heave or thrill.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. No femoral bruits. 2+ edema at shins,
calvs.
SKIN: Stasis dermatitis, but ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP non-palp PT non-palp
Left: Carotid 2+ Femoral 2+ DP non-palp PT non-palp
Pertinent Results:
Admission labs:
[**2125-9-26**] 07:35PM GLUCOSE-100 UREA N-17 CREAT-1.0 SODIUM-143
POTASSIUM-3.0* CHLORIDE-104 TOTAL CO2-32 ANION GAP-10
[**2125-9-26**] 07:35PM CK(CPK)-58
[**2125-9-26**] 07:35PM CK-MB-3 cTropnT-0.03*
[**2125-9-26**] 07:35PM CALCIUM-8.3* PHOSPHATE-4.0# MAGNESIUM-1.9
[**2125-9-26**] 10:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2125-9-26**] 10:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2125-9-26**] 10:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2125-9-26**] 10:00AM URINE HYALINE-0-2
[**2125-9-26**] 09:45AM cTropnT-0.01
[**2125-9-26**] 09:45AM LACTATE-1.7
[**2125-9-26**] 09:45AM PT-22.7* PTT-25.0 INR(PT)-2.1*
[**2125-9-26**] 09:28AM GLUCOSE-273* UREA N-18 CREAT-1.0 SODIUM-143
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-29 ANION GAP-14
[**2125-9-26**] 09:28AM estGFR-Using this
[**2125-9-26**] 09:28AM proBNP-2207*
[**2125-9-26**] 09:28AM CALCIUM-8.4 PHOSPHATE-5.7*# MAGNESIUM-2.2
[**2125-9-26**] 09:28AM WBC-7.0 RBC-4.19* HGB-11.4* HCT-35.1* MCV-84
MCH-27.1 MCHC-32.4 RDW-15.2
[**2125-9-26**] 09:28AM NEUTS-81.6* LYMPHS-13.0* MONOS-2.9 EOS-2.1
BASOS-0.4
[**2125-9-26**] 09:28AM PLT COUNT-176
TTE [**9-27**]:
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%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The prosthetic aortic valve
leaflets are thickened. The transaortic gradient is higher than
expected for this type of prosthesis. There is severe
bioprosthetic aortic valve stenosis. Mild to moderate ([**12-16**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
severe mitral annular calcification. An eccentric, anteriorly
directed jet of moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing from both the mitral and aortic annuli,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images
unavailable for review) of [**2124-1-24**], the mitral
regurgitation is probably worse (and almost certainly
underestimated in both studies), and the pulmonary hypertension
is also worse.
Brief Hospital Course:
79 y/o female with significant risk factors for CAD, s/p CABG,
AVR, s/p atrial thrombus on anticoagulation, PM for complete
heart block who presented with acute dsypnea, and hypertension
urgency.
# Dyspnea: Presumed diagnosis was flash pulmonary edema in the
setting of chronic hypertension, restenosed bio-prosthetic
valve, and non-adherence to medication regimen. Dyspnea
symptomatically improved with diuresis, afterload reduction, and
rate control with diltiazem. Cardiac enzymes were flat.
Respiratory status returned to baseline. Echo prior to
discharge showed severe bioprosthetic aortic valve stenosis and
worse mitral regurgitation compared to previous studies. The
patient was discharged home in stable condition with addition of
long-acting diltiazem, increase in BB was, and ACEi was
downtitrated. She was extensively counseled in the presence of
the husband and with a [**Name (NI) 595**] interpreter about the importance
of strict compliance with medication regimen (has VNA most days
of the week) and sodium restriction. It is unclear if she is a
candidate for re-do AVR as in OMR, it is stated in some places
that she was deemed a non-candidate (too high risk with
extensively calcified aorta) and in other places recorded that
she had not wished to consider surgery. Given repeated
hospitalizations, she was interested in discussing the
risks/benefits of surgery with Dr. [**Last Name (STitle) 914**]. Therefore, she was
scheduled for appropriate follow-up, including with
cardiothoracic surgery.
.
# CAD/CHF: Medical management for these chronic problems were as
above. There were no findings to suggest ischemia as an etiology
to her decompensation.
Medications on Admission:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO QAM.
5. Lantus 100 unit/mL Solution Sig: Twenty Three (23)
Subcutaneous once a day.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO QAM.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
19. Omega-3 Fatty Acids Oral
20. Acetaminophen Oral
Discharge Medications:
1. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
2. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
3. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day:
qAM.
5. Lantus 100 unit/mL Cartridge Sig: Twenty Three (23) Units
Subcutaneous once a day.
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. valsartan 40 mg Tablet Sig: Three (3) Tablet PO once a day:
Take this medication in the morning.
Disp:*90 Tablet(s)* Refills:*2*
8. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. furosemide 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
16. furosemide 80 mg Tablet Sig: 1.5 Tablets PO once a day: qAM.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
drops Ophthalmic once a day as needed for dry eye.
19. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
20. DILT-XR 180 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Pulmonary edema due to poorly controlled high blood pressure.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 15615**],
It was a pleasure taking care of you on this admission. You
came to the hospital because your blood pressure was high; it's
possible that this is because you weren't taking your
medications correctly. We took off some extra fluid and started
additional blood pressure medications. You were feeling much
better upon discharge home.
It is very important that you take all of your medications
regularly. Please follow the instructions of your outside
providers and your visiting nurse. If you are having trouble
taking your medications, please let your primary care doctor
know.
Please keep all of your appointments.
Return to the hospital if you develop any of the Danger Signs
detailed below.
No changes were made to your medications other than the
following:
# STOPPED Carvedilol 25 mg ONCE daily
# STARTED Carvedilol 25 mg TWICE daily
# STOPPED Valsartan 120 mg TWICE daily
# STARTED Valsartan 120 mg ONCE daily
# STARTED Diltiazem 180 mg XL (long-acting) ONCE daily
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2125-10-12**] 3:20
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 15631**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2125-10-2**]
9:00
Provider: [**Name10 (NameIs) 18**] SLEEP CLINIC. Date/Time: [**2125-10-18**], 11:00.
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2125-10-2**] 2:30
Please make an appointment with your primary care physician in
the next 1 week.
|
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69,776
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14587
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Discharge summary
|
report
|
Admission Date: [**2129-11-23**] Discharge Date: [**2129-11-24**]
Date of Birth: [**2057-10-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tegretol / Spironolactone
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
hip reduction
History of Present Illness:
This is a 72 year-old male with PMH of diastolic heart failure
with an EF=65%, AS s/p mechanical AVR, AF on coumadin, CAD s/p
CABG, pulmonary hypertension, 3rd degree heart block s/p PPM,
and severe COPD who was discharged to LTAC yesterday after a
month-long hospitalization for MRSA bacteremia secondary to a
PICC line complicated by left prostethic hip seeding requiring
OR washout and prolonged intubation after the procedure who now
presents with worsening left hip pain and evidence of
dislocation on an X-ray taken at his LTAC. The patient was
delirious at time of discharge and unable to effectively
communicate that he was having pain in his left hip. According
to the patient's son, his mental status quickly cleared at the
LTAC and he was able to report severe pain in his left hip. This
provoked the LTAC to obtain X-rays of the hip which showed
dislocation necessitating transfer back to [**Hospital1 18**] for ortho
evaluation. He remains on vanco for MRSA bacteremia to complete
a 6 week course per ID recommendations and still has his midline
in place.
.
In the emergency department initial vital signs were 99.2, 83,
108/56, 16, 99% 2L NC. He was later noted to have a fever of
102, but his son says that he did not feel as though the patient
had a fever because he did not feel warm and his temperature
resolved quickly to 99, although he was given 1gm of Tylenol. He
received 500cc of IVFs for SBP in the 90s and his SBP climbed to
110s. He also received Zosyn 4.5gms as a CXR in the ED could not
r/o PNA and his vanco level was checked at 16.7. An EKG showed
atrial fibrillation and no changes from his prior. Orthopedics
was consulted and his hip was reduced under conscious sedation
with propofol. Repeat films after the hip manipulation showed
successful relocation of the hip. He was admitted for documented
fever on vanco in the setting of low SBP to the 90s.
.
On arrival in the ICU the patient was alert, pleasant, and
conversational. The son notes that the patient's mental status
improved dramatically after his hip was put back into place by
ortho and postulates that his delirium was likely related to
pain. Otherwise, the patient has no complaints and did not feel
febrile in the ED. He feels as though he is improved from the
time he was discharged.
Past Medical History:
-CAD s/p 2V CABG
-HTN
-HLD
-Severe diastolic CHF (EF >60% [**2129-2-7**])
-Pulmonary Hypertension
-A fib on coumadin
-Hx of 3rd degree block s/p PPM, currently V-paced
-Hx of AS s/p AVR with [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] Mechanical Valve ([**2116**])
-COPD
-Hx of CVA c/b seizure DO, on lamictal
-Diet-controlled DM
-Chronic Kidney Injury
-Chronic lethargy and confusion with concern for Dementia
-Focal disection of abd aorta - noted CT abdomen [**2126-10-16**]-
unchanged from [**2124**]
-BPH (no difficulty voiding)
-s/p L ORIF and THR [**9-/2128**]
Social History:
He currently lives with wife and son in a two story home. He is
a retired newpaper journalist; He moved to the U.S.A. in [**2098**],
but returned to [**Country 11150**] to work. He returned here permanently in
[**2120**]. He does not currently smoke, but quit 10 years ago with an
80 pack year history.
Family History:
There is a family history of CAD. All sisters and brothers are
deceased.
Physical Exam:
VS: T=97, HR=87, BP=126/56, RR=21, POx=100% on NC
GEN: comfortable, pleasant
HEENT: dry MM, EOMI, PERRL
NECK: supple
PULM: CTAB with crackles noted at the bases
CARD: Irregularly irregular
ABD: soft, NT/ND, BS+
EXT: no clubbing or edema
SKIN: Multiple ecchymoses and wounds unchanged from previous
admission
NEURO: A+Ox1-2, diminished range of motion of left shoulder and
elbow, left hip range of motion not assessed given recent ortho
manipulation to reset hip in socket
Pertinent Results:
Admission labs:
[**2129-11-22**] 02:40AM WBC-12.7* RBC-2.72* HGB-7.9* HCT-24.5* MCV-90
MCH-29.0 MCHC-32.2 RDW-20.1*
[**2129-11-22**] 02:40AM GLUCOSE-60* UREA N-83* CREAT-2.9* SODIUM-138
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-31 ANION GAP-11
[**2129-11-22**] 02:40AM CALCIUM-8.2* PHOSPHATE-4.3 MAGNESIUM-2.1
Brief Hospital Course:
Please see previous discharge summary for full details of recent
course. This brief admission is summarized below.
ASSESSMENT AND PLAN:
This is a 72 year-old male with PMH of diastolic heart failure
with an EF=65%, AS s/p mechanical AVR, AF on coumadin, CAD s/p
CABG, pulmonary hypertension, 3rd degree heart block s/p PPM,
and severe COPD who was discharged to LTAC yesterday after a
month-long hospitalization for MRSA bacteremia secondary to a
PICC line complicated by left prostethic hip seeding requiring
OR washout and prolonged intubation after the procedure who now
presents with worsening left hip pain and evidence of
dislocation on an X-ray taken at his LTAC. The dislocated hip
was reduced under conscious sedation in the ED.
#. Fever: The patient was asymptomatic and it is unclear if
this was a real fever. All of his labs, his urinalysis, and his
chest xray appeared improved from prior. His blood pressure was
also >90 systolic, an improvement from his recent baseline.
There was no evidence of new infection. Vancomycin was
continued for the recent MRSA bacteremia. This was redosed for
his improved renal function..
.
#. Left prosthetic hip dislocation. The patient was having
significant pain that was relieved by manipulation of his hip
joint back into proper alignment. Ortho recommended continuing
the abduction pillow between his legs until his follow up
appointment on [**12-6**]. He may weight bear as tolerated by taking
the pillow off temporarily and using posterior hip precautions.
.
#. Aortic stenosis s/p AVR: INR was subtherapeutic at 1.5 on
admission. Heparin gtt was continued with a goal PTT of 40-60.
His INR goal remains on the lower side with a goal INR of
1.8-2.2 given his propensity for bleeding. Heparin drip was
continued and coumadin increased to 2 mg daily.
#. Acute kidney injury. Previous baseline creatinine was 1.5 to
2.0. His creatinine peaked at 3.9 his last admission secondary
to ATN. His creatinine was improved to 2.6 this admission.
.
#. COPD: Continue home Flovent, albuterol, ipratropium, and
tiotropium.
.
#. FEN: Regular diet
.
#. CODE STATUS: DNR (no chest compressions), but OK to intubate
.
#. EMERGENCY CONTACT: [**First Name4 (NamePattern1) 20765**] [**Name (NI) 43025**] [**Name (NI) **] (son/HCP) at
[**Telephone/Fax (1) 43026**]
.
#. DISPOSITION: ICU for now
.
Medications on Admission:
vancomycin 500 mg QOD, goal 15-20 (cont through ID appnt [**11-29**])
sildenafil 20 mg tab 2 PO TID
aspirin 81 mg tab daily
furosemide 80 mg IV BID
warfarin 1 mg tab PO Q4PM
heparin drip: 800U/hr adjust PTT 50-70
bisacodyl 5 mg tab 2 tabs prn
docusate sodium 100 mg 1 [**Hospital1 **]
folic acid 1 mg tab PO daily
latanoprost 0.005 % gtt QHS
lamotrigine 150 mg PO BID
dorzolamide 2 % gtt [**Hospital1 **]
acetaminophen 325 mg 1 Q6H prn
senna 8.6 mg tab [**Hospital1 **] prn
polyethylene glycol 3350 17 gram/dose prn
albuterol sulfate 2.5 mg /3 mL (0.083 %) neb Q6H prn
famotidine 20 mg tab PO Q24H
quetiapine 50 mg tab QHS prn insomnia, agitation
humalog insulin sliding scale
Flovent HFA 220 mcg/Actuation Aerosol 1 [**Hospital1 **]
Vitamin D-3 400 unit Tablet 2 PO daily
tiotropium bromide 18 mcg inh daily
multivitamin 1 PO daily
ipratropium bromide 17 mcg/Actuation HFA 1 inh QID prn
Calcium 500 mg (1,250 mg) 1 PO BID
simvastatin 20 mg 1 tab PO daily
Discharge Medications:
1. sildenafil 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
8. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation. g
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
13. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia, agitation.
15. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
18. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
20. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
21. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
22. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: goal INR 1.8-2.2 Please stop heparin drip when at goal.
23. Furosemide 80 mg IV BID
24. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Eight Hundred (800) units Intravenous ASDIR (AS
DIRECTED): 800 units / hour currently, titrate to PTT goal
50-70. Stop when INR >1.8.
25. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q48H (every 48 hours): please adjust as needed for
goal trough level 15-20. This will continue at least until he
follows up with infectious disease clinic on [**11-29**].
.
26. lab work
Please do CBC with differential and basic metabolic panel and
fax to [**Telephone/Fax (1) 1419**] on [**11-27**], two days prior to his infectious
disease appointment.
27. insulin
Please resume insulin humalog sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
primary: dislocated hip
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because of a dislocated hip. This was
fixed. Your warfarin was increased because of a low INR and
your vancomycin was increased because of improved kidney
function. Otherwise, none of your medications was changed.
Followup Instructions:
1) cardiology - Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2129-11-28**] 2:30
2) infectious disease - Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB)
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-11-29**] 3:30
3) orthopedics - [**2129-12-6**] 12:40 xray on [**Hospital Ward Name 23**] [**Location (un) **], 1:00
appointment with provider [**Name9 (PRE) **] in ortho clinic, [**Hospital Ward Name 23**]
[**Location (un) **]
Completed by:[**2129-11-24**]
|
[
"790.7",
"272.4",
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"250.00",
"293.0",
"996.42",
"041.12",
"V43.3",
"428.32",
"496",
"427.31",
"428.0",
"V45.01",
"E928.9",
"V43.64",
"600.00",
"585.9",
"416.8",
"438.89",
"799.4",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.75"
] |
icd9pcs
|
[
[
[]
]
] |
10686, 10757
|
4506, 6851
|
310, 325
|
10826, 10826
|
4170, 4170
|
11267, 11876
|
3588, 3662
|
7859, 10663
|
10778, 10805
|
6877, 7836
|
11001, 11244
|
3677, 4151
|
262, 272
|
353, 2638
|
4187, 4483
|
10841, 10977
|
2660, 3251
|
3267, 3572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,917
| 162,938
|
10940
|
Discharge summary
|
report
|
Admission Date: [**2184-8-30**] Discharge Date: [**2184-9-2**]
Date of Birth: [**2136-3-17**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 48 year old male
transferred from [**Hospital3 4298**] with inferior myocardial
infarction on Integrelin for evaluation and possible
catheterization. History is limited by the fact that the
patient is heavily sedated and somnolent.
The patient presented to [**Hospital6 8283**] with
complaints of chest pain and weakness. Electrocardiogram was
with 2.[**Street Address(2) 2811**] elevations in leads III and aVF.
Cardiac enzymes were elevated and, at that time, his vital
signs were pulse 140, blood pressure 160/100, respiratory
rate 20 and 99% oxygen saturation in room air. He was
started on Lovenox, Nitroglycerin drip, Lopressor 5 mg
started on Integrelin, however, inadvertently put on
supratherapeutic dose. He was chest pain free subsequently
and transferred to [**Hospital1 69**].
Upon arrival at 2:30 a.m., the patient had vital signs of
heart rate 118, blood pressure 154/100. He had received 1 mg
of Ativan and 50 mg of Fentanyl in route. Additional
Lopressor 5 mg intravenous times four with little change in
his blood pressure. On examination, the patient was
currently chest pain free although he was unable to answer
questions well due to his somnolent nature, but he was easily
arousible.
PAST MEDICAL HISTORY:
1. Lung cancer diagnosed [**4-4**], oncologist, Dr. [**Last Name (STitle) 35530**],
at Cape Code Hospital. Status post recent chemotherapy four
days prior to admission and recently completed a course of
radiation therapy.
2. Renal agenesis of one kidney.
3. Status post back surgery.
4. Gastroesophageal reflux disease.
5. Motorcycle accident in [**2170**].
6. History of sinus tachycardia of unknown etiology.
MEDICATIONS ON ADMISSION:
1. Prilosec.
2. Tylenol.
3. Flexeril.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has heavy tobacco use and
currently drinks six to twelve beers per week. He lives with
his wife and is currently employed.
PHYSICAL EXAMINATION: In general, the patient is resting in
bed, lethargic but easily arousible. Vital signs revealed
heart rate 112, blood pressure 160/76, 100% in room air.
Head, eyes, ears, nose and throat - The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. Mucous membranes are dry. The lungs
are clear to auscultation bilaterally. Bronchial breath
sounds noted in the right lung. Chest examination revealed a
well healed scar on the left side. Cardiovascular -
tachycardic at approximately 120 beats per minute with normal
S1 and S2, no S3 or S4, no murmurs noted. Carotids showed
normal volume and upstroke. The abdomen was soft, nontender,
nondistended with normoactive bowel sounds. Guaiac
examination revealed soft brown stool that occult blood
positive. Extremity examination revealed no cyanosis,
clubbing or edema, dorsalis pedis and posterior tibialis
pulses 2+ bilaterally and symmetric.
LABORATORY DATA: At [**Hospital1 69**],
white blood count 6.2, hematocrit 27.4, platelets 151,000.
Coagulation studies were normal. Sodium was 139, potassium
4.3, chloride 107, bicarbonate 20, blood urea nitrogen 15,
creatinine 0.6, glucose 110. CK 356, troponin 21.4.
Toxicology screen was negative for any substances including
ethanol.
Head CT was negative for intracranial bleed. Chest x-ray at
the outside hospital revealed a right upper lobe opacity and
no effusions.
Electrocardiogram at [**Hospital1 69**]
revealed sinus tachycardia 121 beats per minute, axis 39,
intervals 0.132, 0.96, 0.401, no ST elevations or
depressions, no T wave inversions.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] Coronary Care Unit for evaluation
and treatment of an acute inferior myocardial infarction. He
was admitted to the Coronary Care Unit for further
observation overnight.
The morning after arrival he was taken to the cardiac
catheterization laboratory which revealed a left ventricular
ejection fraction of 45%, left dominant system with a normal
left main artery, minimal disease in the left anterior
descending, 80% stenosis in the mid left circumflex artery,
total occlusion of small right coronary artery branch that
was percutaneous transluminal coronary angioplastied. The
patient subsequently became bradycardic and hypotension which
required Atropine and temporary wire and resolved well.
Prior to the cardiac catheterization, the patient's
hematocrit fell to 26.7. He was transfused two units of
packed red blood cells with subsequent rebound of his
hematocrit to 31.7. After cardiac catheterization, the
patient was brought back to the Coronary Care Unit and
followed postoperatively. He was started on Lopressor and
Captopril which were rapidly titrated. The patient remained
tachycardic after his myocardial infarction with heart rates
approximately 120.
On hospital day three, the patient was tachycardic to
approximately 130 to 140s and was noted to be diaphoretic.
He denied any chest pain or shortness of breath at that time.
Electrocardiogram was taken without changes except for
persistent sinus tachycardia. However, he responded to
intravenous Lopressor. It was felt his symptoms of
persistent sinus tachycardia was either one of alcohol
withdrawal or signs of heart failure following a myocardial
infarction. However, in speaking with the patient and his
wife, it has been noted in the past that he has been
tachycardic in doctors' offices with unknown etiology.
By hospital day four, the patient was chest pain free, was
without chest pain, shortness of breath, nausea or vomiting.
He continued to be slightly tachycardic but experienced no
palpitations and vital signs were completely stable. At the
time of hospital discharge, he was ambulating well without
difficulty and was ready to be discharged to home with
follow-up with his outpatient physician.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home in good
condition after an acute inferior myocardial infarction.
FOLLOW-UP: He is asked to follow-up with his outpatient
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within one week.
DISCHARGE DIAGNOSIS: Acute inferior myocardial infarction.
DISCHARGE MEDICATIONS:
1. Mavik 2 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Atenolol 100 mg p.o. q.d.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 14434**]
MEDQUIST36
D: [**2184-9-2**] 14:17
T: [**2184-9-6**] 09:04
JOB#: [**Job Number 35531**]
cc:[**Telephone/Fax (1) 35532**]
|
[
"410.41",
"427.89",
"753.0",
"162.8",
"401.9",
"285.9",
"796.3",
"305.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"37.78",
"88.53",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
6362, 6799
|
6300, 6339
|
1851, 1931
|
3735, 5978
|
2108, 3717
|
159, 1384
|
1406, 1825
|
1948, 2085
|
6003, 6278
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,825
| 167,523
|
36876
|
Discharge summary
|
report
|
Admission Date: [**2121-1-18**] Discharge Date: [**2121-1-26**]
Date of Birth: [**2059-9-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Left IJ Central line placement
Dialysis Line replacement
History of Present Illness:
61yo man with a recently diagnosed metastatic renal cell CA to
brain s/p cyberknife, lung, and [**First Name3 (LF) 500**] admitted for hypotension.
At rehab today the patient became agitated and was waxing and
[**Doctor Last Name 688**] with his mental status. At times he would be oriented X2
and other times will mumble. Per nephew he did not notice the
patient having or complaining of any chills, cough,diarrhea,
chest pain, dyspnea, abdominal pain. Dialysis at the rehab was
stopped prematurely for what is thought to be agitation however
it remains unclear.
He was recently discharged from [**Hospital1 18**] for acute on chronic
renal failure and hyperkalemia found on pre-op labs prior to
debulking nephrectomy. This recent admission
([**0-0-**]) was complicated by hypotension and rapid
afib. He was given 6L IV fluids, pip/tazo, and vancomycin for
possible sepsis with CT chest which suggested a LLL infiltrate
with effusion. Afib converted to NSR with metoprolol IV pushes
and amiodarone loading. Because of hypoxemia, there was
suspicion for PE and Echo did not show right heart strain, LE's
doppler U/S and V/Q scan were negative for clots, so
anticoagulation was stopped. Furosemide given for pulmonary
edema and hypoxemia, but his ARF worsened and Nephrology was
consulted, and dialysis started [**2121-1-3**]. Drowsiness and
confusion waxing and [**Doctor Last Name 688**] during his admission and was
attributed to toxic encephalopathy and in the differenitial was
sedative medication vs. anoxic brain injury.EEG revealed mild
to moderate encephalopathy of toxic, metabolic, or anoxic
etiology. Fell and broke left humerus [**2121-1-7**] (pathologic),
then received XRT to left humerus. Generalized weakness/fatigue
slowly improving on discharge [**2120-1-17**].
In the ED, initial VS were: 99 88 113/68 16 93% 3L . Febrile up
to 103.4L NS infused. Patient noted to have new neutropenia and
given Vancomycin and Zosyn. For pain he was given Morphine,
Ketorolac , and Tylenol.Levophed drip was started. Recieved a CT
abdomen out of concern for a recto-vesicular fistula which was
equivocal.
On arrival to the MICU, He says "it hurts all over" and does not
elaborate further. His vitals were 100/80, P-85, 96% 6Liters NC
Past Medical History:
Oncology history:
-metastatic renal cell carcinoma, unknown subtype, with
metastatic disease in the right frontal lobe, pulmonary nodules
and marked adenopathy.
- s/p CyberKnife to CNS.
- Scheduled [**2121-1-7**] to have lapascopic nephrectomy and IVC
thrombectomy for tumor thrombus in the IVC.
.
Other PMH:
- Chronic renal insufficiency, recent creatinine 1.7
- Enlarged prostate, found a few days ago, found at time
varicocele being worked up by urology
- Peripheral neuropathy, prior to diagnosis of diabetes, likely
about 15 years ago
- Diabetes II, 8 years ago
- GERD
- Cataract surgery to right eye, pseudophakia
- varicocele
- hypertension
- hypercholesterolemia
Social History:
Smoking: Stopped [**2080**], one pack per day prior for about five
years.
Alcohol: No - prior "more than just social use", but not for 25
years.
Drugs: No.
Living Situation: Lives with mother, he helps care for her -
difficulty walking, CAD, OA, legally blind, PPM - he is primary
care provider. [**Name10 (NameIs) 382**] not determined yet.
Education and Language: English, graduate, works as attorney
-insurance defence law.
Functional Baseline: Independent.
Other: No military service, no toxic exposures, in [**Country 6171**] for
four days, eight years ago
Family History:
Mother - childhood disorder affected one eye, AION the other,
CAD, OA, irregular heart beat/block.
Father - died in 40s from MVA.
Siblings - one sister died of breast cancer, another sister
well.
[**Name2 (NI) 83278**] - MGM CAD, MGF stroke.
PGP's - PGM CAD, PGF CAD.
An aunt (father's sister) with breast cancer.
Physical Exam:
Admission Physical Examination:
Vitals: 100/80, P-85, 96% 6Liters NC , afebrile
General: Alert, oriented X2 , no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
Tongue has some scabbed 5mmX5mm scabs, hyperpigmented,
nontender, non draining.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: no wheezes,insp. rales LLL, ronchi , decreased breath
sounds toward bases b/l
Abdomen: soft, non-tender, distended, bowel sounds present, no
organomegaly
GU: foley , dark maroon urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact . Pupils sym. 4mm reactive to
light b/l.
Discharge Physical Examination:
Vital signs: -
CV: no heart sounds
Resp: no breath sounds
Neuro: no corneal reflex
Pertinent Results:
Admission Labs
[**2121-1-18**] 08:10AM TYPE-[**Last Name (un) **] TEMP-36.8 O2 FLOW-6 PO2-47* PCO2-51*
PH-7.29* TOTAL CO2-26 BASE XS--2 INTUBATED-NOT INTUBA
COMMENTS-CENTRAL VE
[**2121-1-18**] 06:11AM GLUCOSE-104* UREA N-37* CREAT-5.2* SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-19
[**2121-1-18**] 06:11AM ALT(SGPT)-23 AST(SGOT)-36 LD(LDH)-571*
CK(CPK)-43* ALK PHOS-71 TOT BILI-0.5
[**2121-1-18**] 06:11AM CK-MB-2 cTropnT-0.08*
[**2121-1-18**] 06:11AM ALBUMIN-2.0* CALCIUM-7.0* PHOSPHATE-4.8*
MAGNESIUM-1.9
[**2121-1-18**] 06:11AM WBC-0.5*# RBC-3.37* HGB-9.4* HCT-28.6* MCV-85
MCH-28.1 MCHC-33.0 RDW-16.6*
[**2121-1-18**] 06:11AM NEUTS-48* BANDS-0 LYMPHS-43* MONOS-3 EOS-0
BASOS-6* ATYPS-0 METAS-0 MYELOS-0
[**2121-1-18**] 06:11AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2121-1-18**] 06:11AM PT-18.2* PTT-32.8 INR(PT)-1.7*
[**2121-1-18**] 06:11AM PT-18.2* PTT-32.8 INR(PT)-1.7*
[**2121-1-18**] 06:11AM GRAN CT-240*
[**2121-1-18**] 05:26AM TYPE-MIX PO2-62* PCO2-46* PH-7.33* TOTAL
CO2-25 BASE XS--1 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2121-1-18**] 05:26AM LACTATE-1.8
[**2121-1-18**] 05:26AM O2 SAT-87
[**2121-1-18**] 03:07AM COMMENTS-GREEN TOP
[**2121-1-18**] 03:07AM LACTATE-3.0* K+-4.8
[**2121-1-18**] 12:50AM URINE COLOR-RED APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2121-1-18**] 12:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
[**2121-1-18**] 12:50AM URINE RBC->182* WBC-3 BACTERIA-MOD YEAST-NONE
EPI-0
[**2121-1-18**] 12:50AM URINE AMORPH-OCC
[**2121-1-18**] 12:50AM URINE MUCOUS-RARE
[**2121-1-18**] 12:42AM COMMENTS-GREEN TOP
[**2121-1-18**] 12:42AM LACTATE-2.7*
[**2121-1-18**] 12:31AM GLUCOSE-128* UREA N-37* CREAT-5.5* SODIUM-135
POTASSIUM-6.9* CHLORIDE-94* TOTAL CO2-23 ANION GAP-25*
[**2121-1-18**] 12:31AM PT-16.9* PTT-25.5 INR(PT)-1.6*
[**2121-1-18**] 12:31AM PLT SMR-NORMAL PLT COUNT-298
[**2121-1-18**] 12:31AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2121-1-18**] 12:31AM NEUTS-28* BANDS-1 LYMPHS-56* MONOS-15* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2121-1-18**] 12:31AM WBC-1.2*# RBC-3.71* HGB-10.4* HCT-31.1*
MCV-84 MCH-27.9 MCHC-33.3 RDW-16.1*
[**2121-1-18**] 12:31AM ALBUMIN-2.6* CALCIUM-8.4 PHOSPHATE-5.0*
MAGNESIUM-2.2
Brief Hospital Course:
MICU Course
61yo man with a recently diagnosed metastatic renal cell CA to
brain s/p cyberknife, lung, and [**Year/Month/Day 500**] admitted for hypotension
and neutropenia. Patient was admitted to the ICU on pressors and
IV abx but given pt's deteriorating clinical status refractory
to maximum medical therapy, family made patient CMO. The
[**Hospital 228**] hospital course was complicated by [**Last Name (un) **], afib,
dementia, neutropenia and fevers. Patient was transferred to the
medicine floor where he was followed by inpatient hospice and
declared to have passed away at 1500 on [**2121-1-26**] in the presence
of the family.
Medications on Admission:
1. levetiracetam 500 mg PO BIDExtra 250mg to be given after
dialysis.
2. levetiracetam 250 mg PO ASDIR (AS DIRECTED): This is an
additional dose to be given after each dialysis session.
3. pantoprazole 40 mg PO Q24H.
4. simvastatin 10 mg PO DAILY.
5. B complex-vitamin C-folic acid 1 mg 1 TAB PO DAILY:
Nephrocap.
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-13**] Sprays Nasal
QID PRN dry nose.
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID.
8. oral wound care products Gel in Packet Sig: 15 ML Mucous
membrane TID.
9. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane QID PRN Pain.
10. oxycodone 5-10mg PO Q3H PRN Pain.
11. docusate sodium 100 mg PO BID.
12. senna 8.6 mg PO BID PRN Constipation.
13. aspirin 81 mg PO DAILY.
14. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS.
15. sunitinib 50 mg PO DAILY: 4 weeks on, 2 weeks off.
16. metoprolol tartrate 12.5 mg PO BID: Hold for SBP <100.
17. amiodarone 200 mg Tablet Sig: 400mg PO BID x2 weeks, then
400mg PO daily.
Check EKG weekly x2 weeks.
18. mirtazapine 7.5 mg PO HS.
19. heparin (porcine) 5,000 unit/mL Solution Sig: 1mL SC TID.
Discharge Medications:
-
Discharge Disposition:
Expired
Discharge Diagnosis:
- Respiratory Failure
- Metastatic Renal Cancer
- Acute Renal Failure
Discharge Condition:
Expired.
Discharge Instructions:
.
Followup Instructions:
.
|
[
"284.12",
"356.9",
"530.81",
"V66.7",
"198.5",
"038.9",
"427.31",
"V45.11",
"250.00",
"189.0",
"E879.1",
"E849.7",
"528.09",
"999.32",
"584.9",
"518.81",
"585.6",
"349.82",
"E930.9",
"196.2",
"785.52",
"403.91",
"486",
"285.21",
"198.3",
"V49.86",
"V54.11",
"272.0",
"995.92",
"197.0",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"97.49",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9527, 9536
|
7664, 8304
|
315, 373
|
9650, 9661
|
5241, 7641
|
9711, 9716
|
3944, 4259
|
9501, 9504
|
9557, 9629
|
8330, 9478
|
9685, 9688
|
4274, 4284
|
5137, 5222
|
265, 277
|
401, 2654
|
2676, 3348
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3364, 3928
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29,947
| 122,474
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32293
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Discharge summary
|
report
|
Admission Date: [**2151-12-22**] Discharge Date: [**2152-1-12**]
Date of Birth: [**2069-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
"I've been swimming to the left"
Major Surgical or Invasive Procedure:
Left sided Burr Holes
Left sided craniotomy
tracheostomy [**1-2**] by trauma surgery
PEG tube placement [**1-2**] by trauma surgery
History of Present Illness:
82yo white,right handed male with significant cardiac hx of 6
vessel CABG, symptomatic Atrial Fibrillation, pacemaker
currently on coumadin/ASA reports that for past 2weeks feels he
is drifting to the left when he swims, gait instability with
leaning to the left, and R.sided h/a with increased extension to
R.temporal region. Pt swims every day and notes he recently
feels as though he is having difficulty with the strokes and
swimming straight in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Pt also reported he was showering
yesterday and suddenly felt off balance, falling to the left out
of the tub from a standing position to the ground landing on his
back. Denies striking his head, denies LOC. States the headaches
have been intermittent with some relief from Tylenol, but the
h/a extends further each day x1week. Pt denies any recent
illness, no hx of falls, no N/V, no change of vision, taste or
smell, denies sensory loss or subjective weakness. [**12-22**] pt
sought care from his cardiologist for the above mentioned
symptoms, labwork and head CT were ordered. Head CT showed lg
subacute R.frontal SDH. INR 2.9-pt given 1unit FFP, 5mg IV [**Name (NI) 75481**]
pt then transferred to [**Hospital1 18**].
Past Medical History:
'[**30**] 6 vessel bypass
'[**39**] symptomatic Atrial Fibrillation,
'[**42**] pacemaker
'[**50**] bilateral hernia repair
chronic constipation
Social History:
Lives with his wife, denies smoking, ETOH, illegal drugs.
Family History:
Son: gout
Physical Exam:
98.2 BP: 193/96 HR: 80 R: 18 O2Sats: 100%2L
Gen: WD/WN,youthful well appearing,comfortable, NAD.
HEENT: Normocephalic Pupils: PERRLA [**3-19**] EOMs intact with FFOV
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-20**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally minimal
conjugated lateral 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 [**5-22**] throughout. No pronator drift
Sensation: Intact to light touch, propioception.
Reflexes: B T Br Pa Ac
Right 2------------>
Left 2------------>
Toes mute.
Coordination: normal on finger-nose-finger, diminshed rapid
alternating movements
Exam On Discharge:
Pertinent Results:
LABS:
MICRO:
No growth to date in blood, urine, stool or sputum cx
.
PERTINENT LABS:
Peak troponin: 5.51
Peak CK: 2691
.
Hct ranged from 28-31.
WBC as high as 18, but on day of discharge was #####
.
On discharge:
Na 138
K 4.0
HCO3 104
CL 28
BUN/cre: 18/1.0
ALT 109 (peak 126)
AST 98 (peak 186)
.
STUDIES:
.
[**2151-12-22**] CT HEAD WITHOUT CONTRAST:
There is large right subdural hematoma, measuring up to 2.7 cm
in maximum thickness. Intermediate density of the hematoma is
likely compatible with subacute chronicity. There is adjacent
sulcal effacement. There is leftward subfalcine herniation with
15-mm shift of the midline structures. There is no acute
intracranial hemorrhage or major vascular territorial
infarction. There is an 8-mm hypodensity in the right basal
ganglia, likely representing lacunar infarction, of uncertain
chronicity.
There is air-fluid level in the left maxillary sinus. There is
fluid in the right middle ear cavity, and clinical correlation
is advised. Surrounding soft tissues and osseous structures are
unremarkable.
.
IMPRESSION:
1. Large right subdural hematoma with associated ipsilateral
sulcal effacement with left-[**Hospital1 **] subfalcine herniation.
Intermediate density of the hematoma likely compatible with
subacute chronicity. No prior studies available for comparison
to assess interval change.
2. Fluid in the left maxillary sinus and right middle ear.
.
[**2151-12-26**] CT HEAD WITHOUT CONTRAST:
Patient is status post recent trans burr hole evacuation of a
right convexity subdural collection. A moderate amount of mixed
density extraaxial collection remains overlying the right
cerebral
hemisphere, unchanged from prior exam. The degree of leftward
shift of
normally midline structures (12 mm) and effacement of the
subjacent sulci is essentially unchanged. Basal cisterns remain
open. No new hemorrhage is identified. Note is made of
equivocal loss of [**Doctor Last Name 352**]-white differentiation along the right
frontoparietal cortex, which may be related to post-surgical
swelling. An air-fluid level is identified within the left
maxillary sinus. The remainder of the visualized paranasal
sinuses and mastoid air cells remain normally aerated.
Cavernous carotid are heavily calcified.
.
IMPRESSION: Stable appearance of mixed density extraaxial
collection along the right cerebral convexity status post burr
hole evacuation. Note is made of subtle equivocal loss of
[**Doctor Last Name 352**]-white matter differentiation along the right frontoparietal
cortex, which may be related to post surgical swelling. If there
is concern of infarction an MR examination or a CTP may be
helpful.
.
[**2151-12-27**] HEAD CT WITHOUT CONTRAST:
FINDINGS: There is now a drain in the right subdural
collection. The tip
of the catheter appears to extend beyond the subdural space into
the brain with a small amount of surrounding edema. The size of
the hematoma has decreased compared to the prior study. The
degree of leftward shift and subfalcine herniation remains
essentially stable. There is no new hemorrhage, and no change in
degree of sulcal effacement. Subtle area of hypodensity in the
right frontal lobe may relate to post- surgical edema.
.
IMPRESSION: Interval decrease in size of mixed density along
the right
cerebral convexity status post evacuation and drain placement.
The drain
appears to extend beyond the subdural space into the brain.
Essentially
unchanged the rest of the examination.
.
[**2151-12-30**] Non-contrast head CT.
FINDINGS: There is interval decrease in the degree of
pneumocephalus compared to previous exam. Drainage catheter has
been removed in the interim. The overall thickness of the
extraaxial collection has decreased compared to previous exam
with less underlying sulcal effacement and slightly less
midline shift (displacement of the septum pellucidum to the left
of 6 mm, previously approximately 9 mm). Dural thickening is
present in the right frontal region. No new foci of hemorrhage
are seen. There is no new ventricular dilatation. Fluid is seen
in the left maxillary sinus and in the left middle ear. There
is mucosal thickening of the ethmoid sinuses.
.
IMPRESSION: Interval removal of drainage catheter with decrease
in extra
axial fluid/hematoma size and mass effect.
.
.
[**2152-1-10**] ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with focal hypokinesis of the basal half of
the inferolateral wall. The remaining segments contract normally
(LVEF = 50-55 %). The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. 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. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD. Moderate mitral regurgitation. Mild pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of [**2151-12-28**],
left ventricular systolic function has improved and the severity
of mitral and tricuspid regurgitation and the estimated
pulmonary artery systolic pressure all are reduced.
.
[**2152-1-11**] CXR: FINDINGS: PA and lateral views of the chest
demonstrate some interval clearing of the right upper lobe
infiltrate; the infiltrate is still present but is less opaque.
There are small bilateral pleural effusions that are similar in
size compared to prior. The pacemaker and tracheostomy are
unchanged.
Brief Hospital Course:
TRAUMA ICU COURSE:
Mr [**Known lastname **] was admitted to the ICU for close neurological
observation. On admission to the ICU his INR was reversed with
Profiline, FFP and platelets due to his Aspirin use. He was
taken to the OR and underwent a burr hole evacuation on [**12-23**].
Post operative CT showed. Post operative CT showed slightly
increase size of shift. On [**12-25**] he suffered an MI and had and
developed left sided weakness a stat head ct showed stable
appearance. On [**12-26**] his CT showed new hemorrhage after a
bedside aspiration. The patient underwent a formal craniotomy.
On [**12-27**] the patient suffered another MI requiring pressors and
antiarrhythmics. He remained intubated for 8 days, although he
continued to progress neurologically. He continued to be
intubated for so long because the patient expressed wishes not
to be reintubated if he was ever extubated and failed the trial.
Mr. [**Known lastname **] agreed to a tracheostomy and a PEG placement, which
he received on [**1-2**]. A chest xray on [**1-2**] showed bilateral
patchy infiltrates and a left pleural effusion. He was started
on trach mask trials starting on [**1-3**]. Early on the morning of
[**1-4**], Mr. [**Known lastname **] decided that he wanted to be DNR/DNI status.
He stated that regardless of his good neurosurgical prognosis
that he did not wish to prolong his life any further and that he
felt that he lived a full life already for the past 82 years. A
social work consultation was requested later that day.
.
CCU COURSE:
82 M readmitted to CCU after SDH detailed above for mangement of
ongoing NSTEMI first noted on [**12-25**]. Active CCU issues include:
.
# Cardiac: On the morning of [**2151-12-25**], he told his son that he
felt like he'd been "sitting up too long", developed [**5-27**] chest
pain, squeezing, radiating to his upper arms bilaterally,
diaphoretic and nauseated at the time. He denies any LH,
dizziness, vision changes, palpitations, SOB, cough, or vomiting
associated with his pain. He was given sublingual ntg as well
as a nitropatch with minimal improvement in his symptoms (his
pain went from a [**5-27**] to a [**3-27**]) but mild hypotension which
resolved after nitropatch stopped. He was also given 2mg
morphine IV and 2.5mg of lopressor IV. His EKG revealed deep T
wave inversions in V1-6, with ST depressions in V3-5, as well as
<1mm ST depressions in I. Given his hypotension, his EKG
changes, and the inability to use anticoagulation because of his
recent SDH, he was transferred to the CCU for further medical
management of a possible NSTEMI.
.
In the CCU, 3rd SL ntg completely resolved of his symptoms. He
did, however, complain of continued "nausea" in his chest,
unrelieved by zofran or nitroglycerin. Adequate HR and BP
response was able to be achieved by IV boluses and PO doses of
metoprolol. Repeat EKG when CP free continued to show the EKG
changes mentioned above. From the cardiac stand point, post-op
his CI was initially low, dobutamine was started on [**2151-12-30**] and
was weaned off on [**1-3**] at 5 pm maintaining adequate CI. His
metoprolol was also been weaned down from 75 TID to 25 TID.
.
Given the inability to anticoagulate pt [**2-19**] SDH, pt was not a
candidate for catheterization/heparin and was therefore managed
conservatively. His ASA was initially held, then restarted
[**2151-12-26**]. CK peaked at 2691, pt was treated with low dose
metoprolol [**2-19**] hypotension which gradually resolved, as well as
atorvastatin and lisinopril. His atorvastatin dose was reduced
to 40 mg daily, as his liver function studies were elevated,
presumedly from hepatic congestion secondary to heart failure.
His EF per [**Month/Day (2) **] on [**12-28**] was 45% with with mild regional LV
systolic dysfunction with inferior and lateral hypokinesis.
Prior [**Month/Year (2) **] from [**1-23**] from OSH records showing EF of 60%, mild to
moderate concentric LVH. He was aggressively diuresed (1-2L/day
x 3d) over the course of his CCU course with gradually improving
O2 sats. On [**1-6**], he was breathing comfortably on 50%
tracheostomy mask, and decision was made to downsize his cuff,
which was done [**1-6**], and removed on [**1-10**].
.
Regarding cardiac rhythm, pt has a pacemaker for apparent h/o
tachy/brady, and has a h/o paroxysmal afib, with RVR. He was
treated with an amiodarone load, and given total load of 8g
during his SICU course. His daily dose was decreased to 200mg po
qdaily upon transfer to the CCU. He is on metoprol, as above.
.
Pt is not currently a candidate for anticoagulation [**2-19**] subdural
hematoma, and should not be anticoagulated until he has
followed-up in the neurosurgical clinic and been cleared from
their standpoint. This will occur on [**2152-2-16**].
.
Regarding valves, by [**Name (NI) **] pt has no AS, 3+ TR, 3+ MR. In [**1-23**],
ECHO at OSH showing 1+ MR, trace TR. Plan is for an outpt f/u
[**Date Range **] once volume status has improved to assess final degree of
regurgitation.
.
Pt will need to follow-up with cardiology within 4-6 weeks of
his discharge. At that time he should have a follow-up
echocardiogram.
.
# Subdural hematoma: Pt is s/p evacuation of subdural hematoma
on [**2151-12-23**] and re-evacuation overnight on [**12-26**]. Postoperatively
doing well. Neurosurgery signed off pt's care at time of CCU
transfer [**1-4**]. Per their reccomendations, pt should continue
200mg po bid of dilantin until he has f/u w/ neurosurgery as
outpatient in 4 weeks w/ head CT done at that time. Pt will need
to call to arrange this f/u appointment. He was cleared to
resume aspirin, but should not initiate any other
anticoagulation until he has been seen by neurosurgery. He
should have a weekly dilantin level checked while in rehab and
adjusted for his albumin level. His goal dilantin level is
[**11-6**].
.
# Trasaminase elevation - pt with transient rise in LFTs, likely
felt [**2-19**] passive congestion from CHF in setting of NSTEMI, this
resolved without intervention. Urine legionella was negative,
and medication side effect secondary to statin or amiodarone was
felt unlikely. On [**1-10**] LFTs were down to AST=98, ALT=109.
.
# Respiratory: Patient was initially intubated in SICU and
subsequently s/p tracheostomy. His respiratory status was
complicated by pneumonia as well as pulmonary edema. Pneumonia
course and treatment as below. He was diuresed with lasix with
resolution of pulmonary edema. His respiratory gradually
improved, and he will continue lasix 60mg po daily as an
outpatient. His trach cannula size was decreased from 8 french
to 6 french and capped. Patient tolerated this very well, was
sating well on room air for several days, and on [**2152-1-11**],
tracheostomy was removed by surgery.
.
# ID: During his hospital course, he had intermittent and
recurrent fevers and leukocytosis. He was started on abx on
[**12-26**] (including Vanc, levo, flagyl), which were broadened to
Vanc/Cefepime when he again developed leukocytosis on [**1-4**]. His
blood, urine, stool cultures remained negative; however, on CXR,
he developed a PNA in the RUL. A midline line was placed for
abx, and his coverage was narrowed to Cefepime only for
pneumonia. Cefepime was chosen given patient's PCN allergy and
per ID, this was least likely to interact. By discharge, he had
been afebrile for greater than 3 days and leukocytosis had
resolved.
.
# Gout: Following aggressive diuresis, pt developed painful
swelling and erythema of all of his PIP joints in both hands as
well as all joints in toes. He had a minor history of gout prior
to this, but had never experienced anything so severe.
Rheumatology was consulted and felt that despite its atypical
appearance, this was consistent with gout. Uric acid 5.1. He
received colchicine and indomethacin with improvement of
symptoms. He was discharged with plan to take colchicine for 2
weeks or shorter if symptoms resolve quicker. His colchicine
dose was decreased to 0.6mg qdaily on [**1-11**] because of diarrhea
felt [**2-19**] colchicine and improvement of his symptoms. If
symptoms persist, he should follow-up with rheumatology either
as referred by PCP or at [**Hospital1 18**] with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 12434**]
(information for appt given to pt.)
.
# Hypernatremia: Patient developed mild hypernatremia likely
secondary to decreased free water before he was tolerating POs.
This normalized after patient started eating POs.
.
# FEN: A PEG was placed by trauma surgery on [**1-2**], and pt was
initated on tube feeds. Upon transfer to the CCU, pt was seen
by Speech and swallow who recommended thin liquids, ground
solids. Patient ate soft solids once his wife brought in his
dentures. Supplement such as Ensure were added as albumin was
quite low. On [**1-10**] per nutrition recs, pt was felt to be eating
well, and may have his tube feeds discontinued completely once
he consume > half of his tray. calorie counts were performed.
Per the trauma surgery service, the PEG should not be removed at
this time as no track formed yet and risk of stomach falling
away from bowel wall if removed too early. He should follow-up
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the trauma surgery clinic 4 weeks after
discharge for outpatient removal of PEG tube. He will need to
call to arrange for this follow-up appointment.
.
# PPX: pt treated with pneumoboots, PPI, and prn bowel regimen.
.
# ACCESS: a midline catheter was placed on [**1-9**] for the purpose
of antibiotic administration.
.
# CODE: pt initially expressed desire to be DNR/DNI while on the
surgical service during his acute decompensation. This was
re-addressed with pt upon transfer to the CCU, and on [**1-5**], he
changed his code status to FULL CODE.
#######################################
APPOINTMENTS FOR FOLLOW-UP AFTER D/C FROM HOSPITAL:
1. Pt needs follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] 4-6 weeks
following d/c from hospital
2. Pt needs f/u with neurosurgery with repeat head CT on
[**2152-2-16**], as detailed above.
3. Pt needs f/u with urology regarding hematuria in 4 weeks
after d/c from hospital.
4. Pt may follow-up with rheumatology if his gout symptoms do
not resolve after discharge
5. Pt will need to see Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of truma surgery to have
PEG tube removed 4 weeks after discharge from hospital.
Medications on Admission:
Prevacid 30mg QD
Coumadin 5mg M,W,Fri,Sat,Sun
Coumadin 2.5mg Tu, Thurs
Lipitor 20mg QPM
Atenolol 25mg QAM
Lisinopril 10mg QAM
ASA 81mg QAM
VitC/B6 QAM
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): Can stop if pt ambulating at
leats 3 times per day.
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
18. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: Day 1= [**2152-1-9**]
Can also stop once resolution of symptoms.
19. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
20. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 2 days: last day [**2152-1-14**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary:
Right frontal subdural hematoma
non-st-elevation myocardial infarction
Discharge Condition:
Neurologically stable, breathing well on room air, pain free
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? 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, drainage
?????? Fever greater than or equal to 101?????? F
ADDITIONAL DISCHARGE INSTRUCTIONS:
You had a heart attack after your craniotomy called a
Non-ST-segment elevation myocardial infarction. You were
medically treated for this, and certain medications have been
added an adjusted to your medication list. It is very important
that you take all medications as prescribed.
You also developed a pneumonia and received antibitoics for
this.
Please call 911 or go to the emergency room if you have any
chest pain, chest tightness/pressure, difficulty breathing,
severe back pain, abdominal pain, bloody stools, fever greater
than 101, weight gain greater than 3 pounds in one day or any
other concerning symptoms.
Followup Instructions:
1. An appointment has been made for you on [**2152-2-16**] @245 PM for a
repeat CT scan of your head to monitor your craniotomy and
subdural hematoma. The scan is at [**Hospital1 7768**], [**Location (un) **].
You have an appointment with Dr. [**Last Name (STitle) 739**] afterwards at
3:30PM @ [**Hospital Unit Name 18400**], [**Location (un) 86**], MA. You will need
to discuss whether it is safe for you to begin anticoagulant
medications at this appointment. If you have questions, or need
to reschedule, you can reach Dr.[**Name (NI) 4674**] office at
[**Telephone/Fax (1) 1669**].
.
2. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**4-23**] weeks after
you have seen [**Doctor Last Name 739**] in clinic. Her office should be
contacting you to make an appointment, but if you don't hear
from them in one week after discharge from hospital, please call
to schedule an appointment to see her. Her office number is
([**Telephone/Fax (1) 29517**].
.
3. Please follow-up with urology regarding the blood seen in
your urine. You can either have your primary care doctor refer
you so a urologist or you can call ([**Telephone/Fax (1) 772**] to see any
urologist at [**Hospital1 18**].
.
4. Please follow-up with rheumatology if you continue to have
gout or joint pains. You can follow-up in the [**Hospital 18**] [**Hospital 2225**]
clinic [**Telephone/Fax (1) 2226**] to see Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 12434**].
.
5. Please follow-up with the trauma surgery clinic with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in 4 weeks after discharge from the hospital to have your
gastric feeding tube removed. Please call ([**Telephone/Fax (1) 22750**] to
schedule this appointment.
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[
[
[]
]
] |
21910, 21982
|
9238, 19718
|
306, 440
|
22106, 22169
|
3414, 3483
|
24212, 25998
|
1965, 1976
|
19920, 21887
|
22003, 22085
|
19744, 19897
|
23566, 24189
|
1991, 2267
|
3627, 9215
|
234, 268
|
468, 1706
|
2560, 3374
|
3395, 3395
|
2282, 2544
|
3499, 3613
|
1728, 1873
|
1889, 1949
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,915
| 157,451
|
30137
|
Discharge summary
|
report
|
Admission Date: [**2176-3-29**] Discharge Date: [**2176-4-12**]
Date of Birth: [**2148-10-31**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Necrotizing fasciitis
Major Surgical or Invasive Procedure:
1. Debridement and irrigation of right lower portion of leg
(circumferential). Application of wound VAC dressing.
2. Skin graft
History of Present Illness:
Mr. [**Known lastname 71818**] is a 27-year-old gentleman who 12
days ago incurred an injury to the right lower leg while
moving a refrigerator. He subsequently developed swelling,
induration and erythema. Over the course of this last 2-3
days the pain and swelling had increased. Over the course of
this day, the erythema had spread dramatically. On
examination the patient had boggy edema circumferentially.
There were numerous bullae with tense clear fluid. The patient
was unable to dorsiflex his foot and he was in a tremendous
amount of pain.8 days after inciting event was taken to OR for
nec fascitis.
Past Medical History:
alcoholism by report
Social History:
Significant etoh use.
Pertinent Results:
[**2176-3-29**] 03:51PM COMMENTS-GREEN TOP
[**2176-3-29**] 03:51PM LACTATE-1.4
[**2176-3-29**] 03:35PM GLUCOSE-103 UREA N-10 CREAT-0.9 SODIUM-130*
POTASSIUM-3.0* CHLORIDE-87* TOTAL CO2-29 ANION GAP-17
[**2176-3-29**] 03:35PM estGFR-Using this
[**2176-3-29**] 03:35PM WBC-23.0* RBC-5.20 HGB-15.2 HCT-42.5 MCV-82
MCH-29.1 MCHC-35.7* RDW-13.7
[**2176-3-29**] 03:35PM NEUTS-93.2* BANDS-0 LYMPHS-3.8* MONOS-2.6
EOS-0.4 BASOS-0.1
[**2176-3-29**] 03:35PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2176-3-29**] 03:35PM PLT SMR-NORMAL PLT COUNT-208
Brief Hospital Course:
The patient was admitted [**3-29**] and was debrided in the OR the
same day by General Surgery. The patient was placed on IV
antibiotics. Plastic Surgery was consulted for skin grafting.
The patient was taken again to the OR by General Surgery [**4-1**]
for debridement and a vac dressing was placed. On [**4-4**], the
Plastic Surgery team took the patient to the OR for skin graft.
He had a VAC dressing in place for 5 days. Upon removal of the
VAC dressing, the graft was noted to have excellent take.
The patient's hosptal course has been complicated by the
following:
1. Increased creatinine. Baseline 0.6. Up to 1.5. On
discharge, creatinine was 1.1
2. Low hematocrit noted on [**4-6**] - 18.8. The patient was
transfused 2 units PRBCs.
3. Personality changes. Pscyhiatric consult was obtained. The
patient was started on remeron qhs instead of ambien and the
following labs were sent per their recommendations: vitamin B12,
folate, RPR, TSH.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO three
times a day for 2 weeks.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing faciitis of the right lower leg
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* Temperature greater than 101.5 F
* Sloughing of the skin grafted to your lower leg
* Pain not controlled by your pain medications
* Increasing redness, pain, or drainage from your right lower
leg
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] in clinic next week. Please call ([**Telephone/Fax (1) 71819**] to schedule your appointment.
|
[
"041.01",
"728.86",
"E916"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"86.69",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
3152, 3158
|
1859, 2821
|
337, 473
|
3246, 3255
|
1215, 1836
|
3573, 3717
|
2876, 3129
|
3179, 3225
|
2847, 2853
|
3279, 3550
|
276, 299
|
501, 1113
|
1135, 1157
|
1173, 1196
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,955
| 100,320
|
51333
|
Discharge summary
|
report
|
Admission Date: [**2201-4-30**] Discharge Date: [**2201-5-8**]
Date of Birth: [**2115-1-13**] Sex: M
Service: SURGERY
Allergies:
Indomethacin
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
[**2201-4-30**]
1. Exploratory laparotomy, resection of gastrojejunostomy
and Billroth II anastomosis, with Roux-en-Y
reconstruction.
2. Partial transverse colectomy with primary anastomosis.
3. Feeding jejunostomy.
History of Present Illness:
86M with h/o gastric cancer s/p partial gastrectomy and Billroth
II reconstruction [**2178**], jejunostomy tube placement in 2/[**2199**]. He
also has a medical history significant for NSTEMI in [**2181**] and
[**2199**] now s/p CABG as well as critical aortic stenosis s/p
valvuloplasty (peak AV gradient of 10 mm Hg, and valve area of
1.1). He has been experiencing GI bleeds at the site of his
gastrojejunal anastamosis, requiring multiple hospitalizations.
EGD cauterization and EGD clipping were performed at the site of
bleeding were performed, but were unable to control the GI
bleeding. Prior EGDs concerning for gastro-jejunal anastamotic
polyps and bleeding ulcers with high-grade dysplasia. These were
concerning for recurrence of gastric carcinoma, and he is now
s/p redo of the gastrojejunostomy with roux en y reconstruction,
and resection of recurrent carcinoma, with clear margins on
frozen section. On entry into the abdomen, a perforation of the
transverse colon with contained abscess was discovered, and
partial transverse colectomy with primary anastamosis was
performed. Feeding jejunosotmy tube was placed.
Past Medical History:
Gastric Cancer s/p partial gastrectomy and BII [**2178**], h/o GIBs at
the site of his anastamosis, recent EGDs with clipping and
cauterization, severe AS s/p emergent valvuloplasty [**2201-1-8**] c/b
ARDS requiring prolonged intubation leading to dysphagia,
Cholangitis s/p sphincterotomy and stent [**2189**], Coronary artery
disease, prior NSTEMI [**2181**] and [**2199**] ([**Month (only) **]), s/p CABG,
Cerebrovascular Disease, prior stroke [**2195**], Carotid Disease,
Hypertension, Dyslipidemia, BPH, Gout, Chronic Anemia
Social History:
Romanian-Russian. He is married lives with wife who is 84 yo. He
has 2 [**Year (4 digits) **], [**Name (NI) 24006**] (HCP) that helps with care and [**Name (NI) **] . Had
recent VNA which he has been refusing help and tube feeds. Has
40+ pack-year hx, quit [**2179**]. Since [**2201-1-23**] D/C (for severe ARDS
requiring emergent valvuloplasty of AS) has been at [**Hospital1 1501**] and
walking independently with walker and close supervision and most
recent went back home post discharge.
Family History:
Father died of MI and age 78
Mother died of liver cancer at age 81
Physical Exam:
Vitals: Pain 4 T 97.9 HR 80 BP 155/53 RR 16 SpO2 100%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, minimal TTP in lower quadrants, no
rebound or guarding, normoactive bowel sounds, no palpable
masses
DRE: pt refused.
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2201-4-30**] 09:50PM WBC-4.4 RBC-2.94* HGB-9.9* HCT-29.3* MCV-100*
MCH-33.6* MCHC-33.7 RDW-16.0*
[**2201-4-30**] 09:50PM PLT COUNT-133*
[**2201-4-30**] 09:50PM PT-13.9* PTT-28.0 INR(PT)-1.2*
[**2201-4-30**] 09:50PM GLUCOSE-131* UREA N-23* CREAT-0.9 SODIUM-144
POTASSIUM-4.4 CHLORIDE-117* TOTAL CO2-22 ANION GAP-9
[**2201-4-30**] 09:50PM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-1.6
[**2201-5-4**] UGI :
No evidence of leak at the gastrojejunostomy site.
[**2201-5-5**] Video swallow :
Aspiration of thin liquids with residue in the valecula and
piriform sinuses.
[**2201-5-6**] CT Abd/pelvis :
1. Fat- and fluid-containing right inguinal hernia without bowel
content.
2. Status post recent abdominal surgery with postoperative
pneumoperitoneum and fluid within the abdomen.
3. Increased bilateral moderate pleural effusions, left greater
than right.
4. Status post gastrectomy and gastrojejunostomy with revision
as well as
partial transverse colectomy. Anastomoses appear within normal
limits.
5. Previously noted upper pole left renal cyst with increased
density on
contrast-enhanced exam now demonstrates lower density
non-contrast study.
Further evaluation could be obtained with ultrasound.
6. Interval resolution of anterior abdominal wall hematoma.
Brief Hospital Course:
Mr. [**Known lastname 2262**] was taken to the OR on [**4-30**] for exploratory
laparotomy, resection of gastrojejunostomy and Billroth II
anastomosis, with Roux-en-Y reconstruction, partial transverse
colectomy with primary anastomosis, feeding jejunostomy for
recurrent GIB and history of gastric CA. Postoperatively, the
patient was taken to the SICU for recovery. He was extubated and
did well over the course of POD 0. His hematocrits were stable
in the 26-27 range. His TF were started via the J tube. His NGT
was to suction. On POD 1, he remained hemodynamically stable and
tolerated his tube feeds however his hematocrits started to
slowly decrease. He was transferred to the floor on POD 2 and
given his persistent anemia with a hct of 21, he was transfused
two units of PRBC.
Following transfer to the Surgical floor his hematocrit remained
stable in the 30-32 range. He began tube feeds via his J tube
and tolerated them well. The speech and swallow service
evaluated him on multiple occasions but he had frank aspiration
on video swallow and therefore was given sips of nectar thick
liquids for comfort. He will need this followed up.
He required mineral oil via his J tube to start his bowel
function and it was effective. As he is prone to constipation
his narcotic pain medication was stopped and he was given
scheduled Tylenol for pain. He will continue Senna and Colace as
well.
His Surgical wound was healing well and some of his staples were
removed prior to discharge. The remaining staples will be
removed at his first post op appointment. He had an abdominal CT
on [**2201-5-6**] as he has had a right inguinal hernia nut had a bit
more pain on palpation. The CT was done and confirmed that the
hernia sac was fat and fluid filled as opposed to bowel and his
pain gradually resolved.
The Physical Therapy service evaluated him and recommended a
stay in a short term rehab prior to returning home to increase
his mobility and endurance after this hospitalization.
Medications on Admission:
atorvastatin 40 mg daily, metoprolol tartrate 25 mg
[**Hospital1 **], lansoprazole 30 mg daily, mirtazapine 15 mg Tablet [**Hospital1 **]: 0.5
Tablet PO HS (at bedtime), docusate sodium 100 mg [**Hospital1 **], senna
[**Hospital1 **],
acetaminophen 650 prn
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
Injection TID (3 times a day).
2. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2
times a day): Hold for SBP < 110, HR < 65.
3. haloperidol 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. mirtazapine 30 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime).
6. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Colace 60 mg/15 mL Syrup [**Hospital1 **]: Twenty Five (25) ml PO twice a
day.
8. atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
9. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Ten (10) ml PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
1. Recurrent gastric cancer.
2. Colonic perforation and abscess
3. Acute blood loss 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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-21**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**]
Date/Time:[**2201-5-12**] 11:30
Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2201-5-14**] 1:30
Completed by:[**2201-5-8**]
|
[
"550.90",
"285.1",
"412",
"401.9",
"569.83",
"V49.86",
"V12.54",
"272.4",
"V12.72",
"600.00",
"578.1",
"568.0",
"V15.82",
"569.5",
"151.8",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"45.74",
"54.59",
"96.6",
"43.7"
] |
icd9pcs
|
[
[
[]
]
] |
7705, 7795
|
4513, 6509
|
280, 506
|
7930, 7930
|
3218, 4490
|
9907, 10202
|
2745, 2814
|
6818, 7682
|
7816, 7909
|
6535, 6795
|
8113, 9571
|
9587, 9884
|
2829, 3199
|
232, 242
|
534, 1665
|
7945, 8089
|
1687, 2219
|
2235, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,445
| 196,379
|
45253
|
Discharge summary
|
report
|
Admission Date: [**2143-3-17**] Discharge Date: [**2143-3-19**]
Service: MEDICINE
Allergies:
Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 F with PMH of HTN, dCHF, functional MS who presented to the
ED with respirtory distress and HTN. Of note, she recently
presented with similar symptoms of hypertensive urgency c/b
pulmonary edema requiring a brief intubation from
[**Date range (3) 96701**]. Her home nifedipine was discontinued and she
was started on a BP regimen of carvedilol/ lasix/ lisinopril.
.
Since her discharge from the hospital, the patient reports that
she had been feeling well and was able to do her ADLs without
dyspnea. However, per VNA vital sign monitoring, her BP was
"poorly controlled" and on Wednesday, her PCP increased her
lisinopril to 20mg daily and lasix to 40mg daily. Although she
thinks that her weight had been stable, does admit to increased
lower extremity edema and orthopnea requiring her to sleep in an
upright recliner (also helps back pain). Overall, she has been
compliant with her low salt diet but yesterday went to a
barmitzvah where she had lox, potatoe latkas, i.e. high sodium
content.
.
This morning, patient was cleaning up a spill when she became
acutely short of breath and diaphoretic. Denied any chest pain,
palpitations, dizziness, headache or other complaints. +
Productive cough since onset of symptoms. No fevers, chills, or
other systemic symptoms.
.
VS on arrival to ER were 97.4 94 220/120 38 99% 10L NRB. Quickly
desated to 70s with RR in 40s. Pt was placed on BiPAP. EKG with
no acute changes with an old LBB and CXR with pulm edema. Pt was
given SLN 0.4mg x 1 and started on a nitro gtt, lasix 100mg x 1,
Morphine 4mg x 1, Levoflox IV, ordered for Cefepime x 1, and
Vancomycin x 1. Foley was placed and so far 250ml of UO. Vital
signs at transfer were improved to HR 96 BP 153/84 RR 28 O2 99%
on CPAP [**9-21**] 50% fio2, and 0.5 mcg/ml/hr nitro gtt.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
per OMR review
1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])
PAST SURGICAL HISTORY - per OMR
- s/p bilateral TKA
- L hip replacement, pins in right hip, most recent surgery [**1-17**]
yr ago
- S/p TAH in [**2098**]
Social History:
She lives alone in [**Location (un) 96700**] and is very active at
baseline. Ambulates independently. Spends Mon/Fri at the
cultural center, Tues playing trumpet in a band, and Weds/Thurs
running erands. Has 3 cars at home and drives. Retired
teacher. Never married and without children. Smoked 2ppd x
10-15 years until [**2094**], glass of wine <1x/week. No other drug
use.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None
Family History:
Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **].
Father died at 49 from coronary thrombosis.
Sister with [**Name2 (NI) 499**] cancer.
Another sister with pancreatic cancer.
Niece and nephew (in same family) both with [**Name (NI) 4278**].
She is last surviving relative.
Physical Exam:
On admission:
VS: T=Afebrile.BP=146/73 HR=80 RR=20 O2 sat= 99% (BIPAP 10/8)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. systolic murmur [**2-17**]. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis, mild kyphosis. Resp
were unlabored, no accessory muscle use. Crackles to mid field
posteriorly on right and at base on left, no wheezes or rhonchi.
ABDOMEN: Soft, ND. No HSM but slight tenderness to palpation in
upper right quadrant. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees
bilaterally. No femoral bruits.
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+
On discharge:
VS: T=Afebrile.BP=146/73 HR=80 RR=20 O2 sat= 99% (BIPAP 10/8)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5-7cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. systolic murmur [**2-17**]. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis, mild kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases
bilaterally. No wheezes, or rhonchi.
ABDOMEN: Soft, ND. No HSM but slight tenderness to palpation in
upper right quadrant. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: Warm, well perfused, 1+ pitting edema to mid shin
bilaterally. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
[**2143-3-17**] 08:48AM PO2-392* PCO2-49* PH-7.35 TOTAL CO2-28 BASE
XS-0
[**2143-3-17**] 08:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2143-3-17**] 08:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2143-3-17**] 08:35AM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2143-3-17**] 08:35AM URINE MUCOUS-RARE
[**2143-3-17**] 08:29AM COMMENTS-GREEN TOP
[**2143-3-17**] 08:29AM LACTATE-2.8*
[**2143-3-17**] 08:24AM GLUCOSE-254* UREA N-21* CREAT-1.2* SODIUM-140
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
[**2143-3-17**] 08:24AM ALT(SGPT)-46* AST(SGOT)-33 CK(CPK)-183 ALK
PHOS-91 TOT BILI-0.2
[**2143-3-17**] 08:24AM cTropnT-0.02*
[**2143-3-17**] 08:24AM CK-MB-6 proBNP-2307*
[**2143-3-17**] 08:24AM CALCIUM-9.1 PHOSPHATE-5.3*# MAGNESIUM-2.5
[**2143-3-17**] 08:24AM WBC-7.8 RBC-5.10 HGB-13.7 HCT-44.6 MCV-88
MCH-26.9* MCHC-30.7* RDW-15.8*
[**2143-3-17**] 08:24AM NEUTS-67.7 LYMPHS-25.6 MONOS-4.8 EOS-1.0
BASOS-0.9
[**2143-3-17**] 08:24AM PLT COUNT-721*#
[**2143-3-17**] 08:24AM PT-11.8 PTT-22.6 INR(PT)-1.0
[**2143-3-17**] 08:24AM PT-11.8 PTT-22.6 INR(PT)-1.0
[**2143-3-17**] 08:24AM PT-11.8 PTT-22.6 INR(PT)-1.0
[**2143-3-17**] 08:24AM PT-11.8 PTT-22.6 INR(PT)-1.0
ON Discharge:
[**2143-3-19**] 05:48AM BLOOD WBC-4.9 RBC-3.72* Hgb-10.0* Hct-31.6*
MCV-85 MCH-27.0 MCHC-31.8 RDW-15.4 Plt Ct-446*
[**2143-3-19**] 05:48AM BLOOD Glucose-91 UreaN-26* Creat-1.1 Na-139
K-4.3 Cl-100 HCO3-33* AnGap-10
[**2143-3-19**] 05:48AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2
CXR [**2143-3-17**]:
IMPRESSION: Diffuse bilateral opacities as described above. The
patient has demonstrated a propensity for developing confluent
opacities in a very similar distribution reference to series of
chest x-rays on [**3-6**] and 24th of this year. These
opacities have relative similar distribution; however, the last
x-ray of [**3-7**] demonstrated a relative improvement.
Therefore, this is most likely representing the patient's unique
distribution of pulmonary edema in the setting of decompensated
heart failure. However, the appearance, in and of itself, is
nonspecific and multifocal pneumonia or massive aspiration
remain diagnostic considerations. In the clinical context, CHF
is favored.
##########################################################
Microbiology:
[**2143-3-17**]: URINE CULTURE (Final [**2143-3-18**]): NO GROWTH.
[**2143-3-17**]: Blood Culture: PENDING
Brief Hospital Course:
86 yo f with hx of HTN, mitral stenosis and diastolic
dysfunction presenting with repeat HTN urgency and likely flash
pulm edema in setting of dietary discretion
.
# Pulm Edema: likely a combination of volume overload from
dietary indiscretion and hypertensive urgency leading to
pulmonary edema. This is supported by crackles to mid field on
exam, increased peripheral pitting edema, increased JVD,
increased BNP. BIPAP was started, as well as a nitro gtt. She
was given lasix with a goal diuresis of -2L. Her carvedilol was
restarted at 12.5mg [**Hospital1 **]. She achieved her goal diuresis on the
first night and was weaned to RA. Her SBP remained 120-140. She
received another dose of lasix 20mg PO on the evening prior to
discharge (given euvolemia on morning exam). On the night prior
to discharge, her carvedilol was increased to 25mg [**Hospital1 **]. She
underwent physical therapy and had a nutrition consult explain
the require diet. Her lisinopril was not restarted given that
her SBP was 120 on day of discharge. She was instructed to limit
her sodium intake and to weight herself every day, her Wt on the
day of discharge was 58.9 Kg
# HTN: presented with hypertensive urgency that likely reflected
her high sympathetic tone in setting of dyspnea and which
contributed to her acute pulmonary edema. A nitro gtt was
started and her home carvedilol was continued. Her BP quickly
normalized, she remained SBP 120-150s in the 24 hrs prior to
discharge.
.
# CAD: no Chest pain currently, CE flat, no symptoms of ACS on
this admission
# Abdominal pain: intermittent, chronic and mild and disappeared
quickly after admissioin. Her LFTs were nl range,
.
# Breast CA: patient on oupatient regimen of Fluoxymesterone
which she brought. We continued home fluoxymesterone
.
# RHYTHM: pt in sinus tach likely [**1-16**] reflexive tachycardia.
Quickly reverted to sinus in setting of diuresis and decreased
afterload. She had no significant arrythmias on tele.
.
TRANSITIONAL ISSUES:
Blood Cultures need to be followed up on
Medications on Admission:
- Aspirin 81 mg DAILY
- Omeprazole 20 mg Capsule qday
- Fluoxymesterone 10 mg PO BID
- Carvedilol 6.25 mg Tablet PO BID
- Lisinopril 10 mg Tablet PO HS
- Furosemide 20 mg Tablet PO once a day.
- Scopolamine base 1.5 mg Patch Q 72 hours
- Roxicet 5-325 mg Tablet PO four times a prn pain
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. fluoxymesterone 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours.
7. Roxicet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic diastolic CHF exacerbation
.
Secondary Diagnosis:
-Hypertension
-functional mitral stenosis
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 are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were
admitted because your blood pressure was very high, you had too
much fluid on your body and som eof it went into your lungs and
you were having difficulty breathing. You were given
medications to help remove the fluid from your body as well as
lower your blood pressure. You quickly had lots of fluid
removed and were feeling better and walking around. You were
seen by a dietician who made recommendations regarding your
diet. It is important to AVOID salt as well as limiting how
much fluid you drink.
.
The followin medications were CHANGED:
Carvedilol 6.25mg by mouth twice a day --> 25mg by mouth twice a
day
.
The following medication was STOPPED:
lisinopril 10mg by mouth at bedtime
.
Please take your other medications as prescribed
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
please follow up with your the following physicians:
Department: [**State **]When: WEDNESDAY [**2143-3-27**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: CARDIAC SERVICES
When: WEDNESDAY [**2143-4-24**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], 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
|
[
"428.33",
"486",
"428.0",
"401.9",
"V10.05",
"198.5",
"197.0",
"394.0",
"174.8",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12159, 12217
|
9151, 11121
|
306, 312
|
12389, 12389
|
6616, 6621
|
13531, 14222
|
4238, 4534
|
11521, 12136
|
12238, 12238
|
11210, 11498
|
12572, 13508
|
4549, 4549
|
2789, 2862
|
7958, 9128
|
11142, 11184
|
263, 268
|
340, 2664
|
12324, 12368
|
12257, 12303
|
6636, 7944
|
12404, 12548
|
2893, 3735
|
2686, 2769
|
3751, 4222
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,090
| 145,253
|
39800
|
Discharge summary
|
report
|
Admission Date: [**2132-7-30**] Discharge Date: [**2132-8-2**]
Date of Birth: [**2088-6-2**] Sex: M
Service: NEUROSURGERY
Allergies:
Shellfish / seasonal
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
None
Major Surgical or Invasive Procedure:
left frontal craniotomy for tumor resection
History of Present Illness:
This is a 44 y/o man who had a bone scan for some knee pathology
where increased uptake was noted in the brain;further work up
revealed a left frontal parasagital meningeoma that showed some
growth over time.
Past Medical History:
Anxiety
Social History:
nc
Family History:
nc
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: no adventicious sounds
Cardiac: RRR.
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 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: 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 [**5-10**] throughout. No pronator drift
Sensation: Intact to light touch, propioception
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
PHYSICAL EXAM UPON DISCHARGE:
non focal
dissolvable sutures
Pertinent Results:
[**2132-7-30**] MRI:
1.Unchanged extra-axial enhancing dural-based mass lesion,
consistent with left parafalcine meningioma. No new lesions are
identified.
2. Interval improvement in the pattern of mucosal thickening on
the left
maxillary sinus, with no evidence of air-fluid level.
[**7-30**] NCHCT: IMPRESSION: Status post resection of left frontal
meningioma with expected post-procedure findings.
[**2132-7-31**] MRI: Status post resection of left frontal meningioma
with
postoperative changes. Small amount of air, meningeal
enhancement and blood products. No residual nodular enhancement
is seen. No mass effect or hydrocephalus.
Brief Hospital Course:
The patient was admitted to the Neurological Surgery Service for
resection of a left frontal meningioma. The patient was taken to
the OR and underwent an uncomplicated left frontal craniotomy w/
intraoperative image guidance, microscopic dissection and
duraplasty. The patient tolerated the procedure without
complications and was transferred to the ICU in stable condition
for frequent neuro monitoring. Please see operative report for
details. Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with diet and pain control. The patient was transferred
to the floor as less frequent monitoring was needed.
The patient received peri-operative antibiotics as well as
Keppra for seizure prophylaxis. The incision was clean, dry,
and intact without evidence of erythema or drainage; and the
extremities were NVI throughout. The patient was discharged in
stable condition with written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient will be continued on chemical seizure prophylaxis
for post-operatively. All questions were answered prior to
discharge and the patient expressed readiness for discharge.
Medications on Admission:
none
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 500 mg PO BID
RX *Keppra 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Senna 1 TAB PO BID
5. Acetaminophen-Caff-Butalbital [**1-7**] TAB PO Q4H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [**1-7**]
tablet(s) by mouth q4hr Disp #*60 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
status post meningioma exicison
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Craniotomy for Subdural/Epidural Hematoma
Dr. [**Last Name (STitle) 14354**] [**Name (STitle) **]
?????? 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 have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. 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.
?????? **You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2132-8-18**]
at 1PM. 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:[**2132-8-2**]
|
[
"300.00",
"493.90",
"225.2",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
4427, 4433
|
2553, 3844
|
288, 334
|
4509, 4509
|
1883, 2530
|
6330, 6804
|
639, 643
|
3899, 4404
|
4454, 4488
|
3870, 3876
|
4660, 6307
|
658, 840
|
244, 250
|
1833, 1864
|
362, 572
|
1092, 1803
|
4524, 4636
|
594, 603
|
619, 623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,695
| 111,574
|
42426
|
Discharge summary
|
report
|
Admission Date: [**2117-3-18**] Discharge Date: [**2117-3-26**]
Date of Birth: [**2035-1-22**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Left Auricular Mass
Major Surgical or Invasive Procedure:
[**2117-3-18**]: Left total auriculectomy. Left lateral temporal bone
resection. Left modified radical neck dissection. Left
parotidectomy. Left thyroid lobectomy. Left temporalis flap.
Temporoparietal fascial graft to middle ear. Placement of
split-thickness skin graft. (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**], Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1837**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
History of Present Illness:
82-year-old male with history of squamous cell carcinoma of his
left ear. He had previously undergone resection and skin graft
reconstruction which was complicated by poor wound healing and
MRSA infection. Due to persistence in poor wound healing he
underwent a second surgical procedure at which time it was found
that there was cartilage involvement. He was sent to [**Hospital 18**]
[**Hospital **] clinic for further evaluation and consideration
of resection. At the time of presentation the patient had
continued left ear pain.
After a review of the imaging the the extent of the malignancy
considered the patient was offered surgical excision and
reconstruction. The patient elected to proceed with this
procedure.
Past Medical History:
Hypertension.
Coronary artery disease status post MI.
Gastroesophageal reflux and history of peptic ulcers.
CLL.
Depression.
Arthritis.
Carbon monoxide poisoning.
Social History:
He smoked 15-20 years, but is not currently. He
does not drink alcohol. He is retired and used to be a
taxidermist. He is widowed.
Family History:
Cancer, diabetes, heart disease, and respiratory
disease.
Physical Exam:
General Appearance: He is a stable appearing male in some
degree
of pain from his ear, in no acute distress.
Airway: There are no signs of obstruction.
Facial Region: I found no evidence of any swelling, tenderness,
mass, or adenopathy. In particular, the parotids were free of
any masses or adenopathy. Postauricular region was free of any
adenopathy or masses.
Ears: The left auricle is densely involved with a granulomatous
mass which appears to extend up to but not through the skin of
the posterior surface of the auricle. The tumor does extend
down
towards the external auditory canal and blocks it to the point
where I cannot see the most distal portion of the tumor. It
fills the conchal bowl. There was no obvious extension off of
the auricle.
Neck: There was no palpable mass or adenopathy.
Transoral Exam: I found no evidence of any chronic inflammatory
or neoplastic changes affecting the oral cavity or the
oropharynx.
Pertinent Results:
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Otolaryngology service
on [**2117-3-18**] to undergo Left total auriculectomy, Left lateral
temporal bone resection, Left modified radical neck dissection,
Left parotidectomy, Left thyroid lobectomy, Left temporalis
flap, Temporoparietal fascial graft to middle ear, and placement
of split-thickness skin graft with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**], Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1837**], and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please see the separate
operative notes for full details of the operation. The patient
was transferred to the SICU post-operatively for further
management and remained intubated due to his post-operative
volume status. He remained stable overnight and was extubated
without event on POD1. He was noted to have some increased
swelling around the temporalis flap and oozing along his
incision line and remained in the SICU for an additional night.
He was transferred to the floor on [**2117-3-20**]. His pain was
controlled on an oral regimen. Due to some evidence of dysphagia
post-operatively, the patient underwent a bedside fiberoptic
examination which demonstrated left hypopharyngeal ecchymosis
without significant edema. The patient was evaluated by Speech
and swallow and underwent video swallow which did not show
evidence of aspiration. His diet was slowly advanced to soft
diet with thin liquids. He had three drains placed
intraoperatively by both the Otolaryngology and Plastic Surgery
service. These were sequentially removed once meeting removal
criteria. The patient's wound was managed with gentle cleaning
and covered with xeroform changed twice daily. The patient had
difficulty with insomnia during his hospital course which slowly
resolved. Due to an episode of urinary retention post-op the
patient required replacement of a foley catheter which was
removed without event and no further voiding difficulty. On
[**2117-3-26**] the patient's pain was well controlled, he was
ambulating with assistance and wounds remained stable. He was
felt to be stable for discharge to home with VNA.
Medications on Admission:
Tamsulosin 0.4 mg p.o. at bedtime, omeprazole 40 mg
p.o. once daily, finasteride 5 mg p.o. daily, bupropion 150 mg
p.o. daily and bisoprolol/HCTZ 5/6.25 mg daily.
Discharge Medications:
1. bisoprolol-hydrochlorothiazide 5-6.25 mg Tablet Sig: One (1)
Tablet PO once a day.
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain.
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*300 mL* Refills:*2*
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye care.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] home health of [**Location (un) 5450**] and southern NH
Discharge Diagnosis:
Left Auricle Squamous Cell Carcinoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Please keep wounds clean and dry. Ok to gently clean incisions
with saline. Please Do not clean around the skin graft. Place
xeroform dressing to incision and skin graft at all times and
change twice daily.
No lifting >10 lbs x2 weeks
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 19848**] CUTANEOUS ONCOLOGY
Phone:[**Telephone/Fax (1) 19462**] Date/Time:[**2117-3-31**] 11:00
.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time: Friday [**2117-4-2**] 2:15
Dr.[**Name (NI) 27488**] office is located on the [**Hospital Ward Name **], [**Hospital Unit Name **],
[**Location (un) 442**], [**Hospital Unit Name 6333**].
|
[
"401.9",
"246.9",
"788.20",
"780.52",
"E878.8",
"780.09",
"V12.71",
"787.22",
"V10.61",
"173.22",
"412",
"530.81",
"997.5",
"414.01",
"311",
"V15.82",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"18.39",
"40.41",
"06.2",
"20.61",
"01.6",
"18.79",
"31.42",
"26.30"
] |
icd9pcs
|
[
[
[]
]
] |
6337, 6442
|
2960, 5173
|
294, 790
|
6523, 6523
|
2937, 2937
|
6942, 7418
|
1896, 1956
|
5387, 6314
|
6463, 6502
|
5199, 5364
|
6683, 6919
|
1971, 2916
|
235, 256
|
818, 1541
|
6538, 6659
|
1563, 1728
|
1744, 1880
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,578
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50056
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Discharge summary
|
report
|
Admission Date: [**2185-4-5**] Discharge Date: [**2185-4-12**]
Service: MEDICINE
Allergies:
Percocet / Simvastatin
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Left leg pain and syncope
Major Surgical or Invasive Procedure:
Small Bowel Enteroscopy
Right Internal Jugular Vein Catheterization
Left Knee Arthrocentesis
History of Present Illness:
Briefly this is an 88 year old male with hypertension, atrial
fibrillation s/p pacemaker placement, GI bleeding, prostate
cancer MGUS and chronic renal insufficiency who presented from
home with left knee pain and syncope. The patient reports that
he was in his usual state of health prior to admission. On the
day of presentation he woke up with significant pain in his
right knee with swelling. It made it difficult for him to
ambulate. Later in the morning the patient was sitting on the
comode when he began to "act funny" and subsequently "blacked
out." He does not rememeber this event well but says that his
daughters were present. He does not report any head trauma. He
does note that the week prior to this event he was experiencing
black stools. He also experienced non-bloody emesis x 1 on the
day of presentation. He had had multiple admissions in the past
for dizziness and melena. He was brought to the emergency room
for further evaluation.
In the ED, his VS were 96.7, 59, 111/33, 19, 98%RA. He was
guaiac negative on exam. An old facial droop on the right was
noted. EKG showed v-paced rhythm. Trop was 0.14 around his
baseline with CRI. NH4 was 99 around his baseline. No asterixis.
He was given 1L NS, ASA 325mgX1 and admitted for further workup.
On admission the floor the patient was noted to be hypotensive
with systolic blood pressures in the 60s with altered mental
status. He was not noted to have any melena or hematochezia.
His hematocrit on presentation was 32 but the following morning
it had decreased to 22. He received a liter of IVF, one unit of
O negative blood while awaiting type and cross with subsequent
improvement in his blood pressure and mental status. He was
subsequently transferred to the MICU.
In the MICU, hypotension was felt to have been most likely from
GIB. Also found to have hemarthrosis of the left knee which was
not felt to be contributing significantly to his decreased
hematocrit. He had no signs of infection, no EKG changes, TnT
stable with ARF, improving. Got vitamin K and FFP on admit to
ICU. Small bowel enteroscopy showed no active bleeding or AVMs,
only small erosion in antrum. He received a total of 8 units
PRBCs in the MICU with stabilization of his hematocrit in the
range of 28 to 30. Of note he also developed laboratory
abnormalities consistent with low grade DIC with
thrombocytopenia, decreased fibrinogen at 64 and elevated fibrin
degredation products of 160-320. He received one dose of
cryoprecipitate with improvement. He was transferred to the
floor in stable condition.
Of note- MICU team spoke with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**] whom discussed his
prior 6 GIB with similar presentations with a dramatic HCT drop
in absence of melena/hematochezia, no other sx other than HCT
drop. Melena or guaiac + stools appear ~2 days later. He is
unaware that family declines endoscopies. He also noted that pt
has known severe DJD/arthritis of knees and stated that if knee
effusion was asymmetric then most certainly sustained trauma to
knee although has close to 24hour supervision. Pt has underlying
dementia w/waxing & [**Doctor Last Name 688**] change in AMS. Pt never received
anticoagulation for AF due to severe GIB risk. He is not on
ASA/NSAIDs for same reason.
On re-transfer to the floor, the patient was hemodynamically
stable. He currently denies specific complaints including
fevers, chills, lightheadedness, dizzines, chest pain, shortness
of breath, nausea, vomiting, abdominal pain, dysuria, hematuria,
leg pain or swelling. No bowel movements over a 24 hour period.
All other review of systems negative in detail.
Past Medical History:
1. Prostate cancer dx'd [**2179**]- maintained on lupron (no
surgery/xrt).
2. Hypertension
3. Aortic insufficiency (2+).
3. Paroxysmal atrial fibrillation (not on anticoagulation)
4. Sick sinus syndrome s/p PPM for symptomatic bradycardia, [**5-18**]
5. Iron deficiency anemia/ anemia of chronic disease
6. Chronic Renal Failure
7. Pulmonary Hypertension (TTE [**10-17**] PASP 38mmhg)
8. Secondary hyperparathyroidism (low 25-hydroxyvitamin D, s/p
tx)
9. MGUS, IgG monoclonal gammopathy
10. s/p GSW with retained pleural fragment
11. s/p pacemaker placement.
12. Severe bilateral DJD of the knees
13. Gout
14. Refractory UGIB from jejunal AVMs, diagnosed in [**7-/2180**], and
duodenal ulcers, diagnosed in [**4-/2183**]
15. Encephalopathy and hyperammonemia without evidence of
hepatic
dysfunction.
Social History:
Pt lives with his wife, his daughter [**Name (NI) 2048**] is the HCP. Remote
smoking history, no ETOH, and no illicit drug use
Family History:
There is no history of premature CAD, HTN. One daughter who died
with ESRD.
Physical Exam:
Vitals: T: 97.3 BP: 164/63 HR: 80 RR: 20 O2: 96% on RA
GENERAL - NAD, pleasant, lying in bed, no acute distress
HEENT - PERRL, sclerae anicteric; partial ptosis R (old)
NECK - supple. no JVD, right IJ in place
RESP - clear to auscultation bilaterally, no wheezes, rales,
ronchi
CARDIAC - paced rhythm. Normal S1/S2; [**2-16**] Diastolic murmur at
LUSB
EXT - 2+ ankle edema bilaterally; Left knee effusion without
tenderness, mildly decreased range of motion
NEURO - Alert and oriented x 3, able to move all extremities.
Pertinent Results:
Chemistries:
[**2185-4-5**] 07:30AM GLUCOSE-133* UREA N-34* CREAT-2.4* SODIUM-143
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-19* ANION GAP-16
[**2185-4-5**] 07:30AM ALT(SGPT)-7 AST(SGOT)-20 LD(LDH)-253*
CK(CPK)-84 ALK PHOS-60 TOT BILI-0.8
[**2185-4-5**] 07:30AM ALBUMIN-2.5* CALCIUM-8.9 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2185-4-5**] 07:30AM VIT B12-1313* FOLATE-9.1
[**2185-4-5**] 07:30AM TSH-2.6
[**2185-4-5**] 12:30AM AMMONIA-99*
[**2185-4-5**] 10:29PM LD(LDH)-260* TOT BILI-0.9 DIR BILI-0.3 INDIR
BIL-0.6
[**2185-4-5**] 03:48PM HAPTOGLOB-96
[**2185-4-5**] 03:48PM FDP-160-320*
[**2185-4-5**] 03:48PM FIBRINOGE-64*
[**2185-4-11**] 06:34AM BLOOD Glucose-97 UreaN-45* Creat-2.7* Na-143
K-3.5 Cl-112* HCO3-21* AnGap-14
[**2185-4-9**] 05:48AM BLOOD Fibrino-222
[**2185-4-7**] 03:41AM BLOOD PSA-1.2
[**2185-4-7**] 03:41AM BLOOD PEP-TRACE ABNO
Hematology:
[**2185-4-5**] 12:30AM WBC-6.6 RBC-3.20* HGB-10.6* HCT-32.0*
MCV-100* MCH-33.0* MCHC-33.0 RDW-15.7*
[**2185-4-5**] 12:30AM NEUTS-73.2* LYMPHS-20.3 MONOS-4.9 EOS-1.5
BASOS-0.1
[**2185-4-5**] 12:30AM PLT COUNT-86*#
[**2185-4-5**] 07:30AM WBC-5.9 RBC-2.23*# HGB-7.1*# HCT-22.1*#
MCV-99* MCH-31.9 MCHC-32.2 RDW-15.6*
[**2185-4-5**] 07:30AM PLT COUNT-91*
[**2185-4-5**] 07:30AM PT-19.6* PTT-55.5* INR(PT)-1.8*
[**2185-4-11**] 06:34AM BLOOD WBC-8.5 RBC-3.40* Hgb-10.4* Hct-31.0*
MCV-91 MCH-30.5 MCHC-33.5 RDW-17.9* Plt Ct-154
Cardiac Enzymes:
[**2185-4-5**] 12:30AM BLOOD CK(CPK)-40 cTropnT-0.14*
[**2185-4-5**] 07:30AM BLOOD CK(CPK)-84 CK-MB-NotDone cTropnT-0.12*
[**2185-4-5**] 03:48PM BLOOD CK(CPK)-53 CK-MB-NotDone cTropnT-0.12*
Urinalysis:
[**2185-4-9**] 12:54AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2185-4-9**] 12:54AM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2185-4-9**] 12:54AM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-1
[**2185-4-7**] 03:41AM URINE Hours-RANDOM Creat-173 Na-22 TotProt-61
Prot/Cr-0.4*
[**2185-4-7**] 03:41AM URINE U-PEP-AWAITING F IFE-PND Osmolal-333
EKG: Regular ventricular paced rhythm. Underlying atrial rhythm
is probably atrial fibrillation. Since the previous tracing of
[**2184-12-30**] no significant change.
Imaging:
HIP UNILAT MIN 2 VIEWS LEFT PORT [**2185-4-5**] 2:19 PM
No comparisons. No acute fracture or dislocation is seen. No
lucent or sclerotic lesion is noted. Atherosclerotic vascular
calcification is seen. Soft tissues are otherwise unremarkable.
Severe degenerative changes of the left knee are noted, and
there is a large knee joint effusion. These are unchanged
compared to the previous examination.
FEMUR (AP & LAT) LEFT PORT; HIP UNILAT MIN 2 VIEWS LEFT PO
No comparisons. No acute fracture or dislocation is seen. No
lucent or sclerotic lesion is noted. Atherosclerotic vascular
calcification is seen. Soft tissues are otherwise unremarkable.
Severe degenerative changes of the left knee are noted, and
there is a large knee joint effusion. These are unchanged
compared to the previous examination.
CHEST (PORTABLE AP) [**2185-4-5**] 9:59 AM
In comparison with the study of [**2184-12-30**], there is no
significant change. Again there is persistent extension of
intra-abdominal bowel loops into the right hemithorax with known
bullet fragment. Pacemaker device is again seen and there is
stable appearance of the heart and lungs.
KNEE (2 VIEWS) LEFT [**2185-4-5**] 12:48 AM
There is severe tricompartmental joint disease with osteophyte
formation and loss of the normal joint space in addition to
regions of subchondral sclerosis. The severe underlying
degenerative changes limits the ability for subtle fractures;
however, no obvious displaced fractures are identified. There is
a slight irregularity in the region of the tibial tubercle and
at the insertion of the quadriceps tendon. Marked vascular
calcification is noted, and there is a moderate-to-large a
suprapatellar joint effusion.
ECHOCARDIOGRAM [**2185-4-6**]:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild global left ventricular hypokinesis
(LVEF = 45 %). There is no ventricular septal defect. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. 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.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2184-6-21**],
the overall LVEF is slightly lower.
Microbiology:
[**2185-4-5**] 7:30 am SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Final [**2185-4-6**]): NONREACTIVE.
JOINT FLUID LEFT KNEE.
GRAM STAIN (Final [**2185-4-6**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2185-4-9**]): NO GROWTH.
[**2185-4-7**] 4:55 pm STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2185-4-8**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2185-4-9**] 12:54 am URINE
URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000
ORGANISMS/ML.
Brief Hospital Course:
88 year old male with hypertension, atrial fibrillation s/p
pacemaker placement, GI bleeding, prostate cancer MGUS and
chronic renal insufficiency who presented from home with left
knee pain and syncope.
Syncopal episode: The patient has a history of multiple
syncopal episodes. The differential diagnosis considered
included vasovagal, cardiac, hypovolemic and neurologic causes
of syncope. The event happened while the patient was sitting on
the comode which argues for a vasovagal etiology. Hypovolemia
also likely contributed as on presentation the patient had
evidence of gastrointestinal bleeding. On presentation he had
evidence of confusion which improved dramatically once he was
resuscitated with blood products for his bleeding. At the time
of discharge he denied lightheadedness or dizziness. He was
monitored on telemetry throughout his stay with evidence of
atrial fibrillation which was well rate controlled. He is
scheduled for pacemaker interrogation in one week. No further
workup was pursued.
Gastrointestinal Bleeding: The patient has a history of 6 prior
episodes of gastrointestinal bleeding from small bowel AVMs.
His most recent bleeding episode occurred three months ago. The
patient reports developing black stools three days prior to
presentation. His hematocrit was within his baseline on
presentation but dropped 10 points within the first 24 hours of
this admission with associated hypotension to the 60s systolic
and altered mental status. He received 7 units of packed RBCs
in total from his bleeding. He was transferred to the MICU
where he underwent small bowel enteroscopy which demonstrated
AVMs but no active bleeding. At the time of discharge his
hematocrit had been stable for over 48 hours. His blood
pressures were stable. He was tolerating a regular diet.
Further workup with a double balloon enteroscopy was considered
but deferred at this time.
Left Knee Effusion: On presentation the patient was complaining
of left knee pain with associated knee swelling. Xray from the
emergency room showed a large effusion with evidence of
osteoarthritis. He underwent arthrocentesis which showed
evidence of hemearthrosis. He subsequently underwent hip and
femur films which were negative for fracture. He was seen by
the orthopedic surgery service who recommended conservative
management with tylenol for pain. He did not receive NSAIDs
given his history of gastronitestinal bleeding. It was not
thought that the bleeding in his knee was sufficient to account
for his decreased hematocrit and hypotension.
Thrombocytopenia: On presentation his platelet count was 86
from a baseline of 150 to 200. The etiology of this finding on
presentation is unclear but there was concern for low grade DIC.
He had a low fibrinogen at 64 and fibrin degredation products
of 160-320. The hematology service was consulted who
recommended following the patient clinically. He received one
dose of cryoprecipitate. His platelet count slowly improved to
154 on the day of discharge. He will follow up with his primary
hematologist Dr. [**Last Name (STitle) **].
Urinary Tract Infection: Urine culture on [**2185-4-9**] grew > 100,000
e. coli. He was started on ciprofloxacin with plans to complete
a 7 day course. On discharge he was on day [**3-18**].
Atrial Fibrillation/Sick Sinus Syndrome: The patient has
evidence of an irregular, wide complex rhythm and is status
post-pacemaker placement. He has known atrial fibrillation and
sick sinus syndrome and is followed here by electrophysiology.
At the time of discharge he was taking his home dose of
metoprolol. He will follow up in device clinic in one week for
pacemaker interrogation.
Anemia: The patient's baseline hematocrit ranges from 28 to 32.
During this admission he had a normal B12 and hematocrit. He
also has known MGUS with concern for decreased marrow
production. He also likely has chronic gastrointestinal
bleeding from AVMs. As above, he required 7 units of PRBCs
during this admission for gastrointestinal bleeding. On
discharge his hematocrit was 31.0. Further workup for his
gastrointestinal bleeding would be limited to a double balloon
enteroscopy vs. allowing for periodic transfusions. At this
time, further endoscopy was deferred. He will follow up in
hematology clinic.
Stage 4 Chronic Kidney Disease: the patient's baseline
creatinine ranges between [**2-13**]. In the setting of
gastrointestinal bleeding his creatinine increased to 3.6. After
resuscitation his creatinine quickly improved to baseline and
was 2.7 on the day of discharge. His medications were renally
dosed. He was continued on his home dose of calcitriol. He
will follow up with his nephrologist Dr. [**Last Name (STitle) 4090**].
Dementia: No active inpatient issues. He was continued on his
home donepazil and quetiapine.
Hypertension: As above, the patient presented with syncope,
likely in the setting of gastrointestinal bleeding. On hospital
day two his blood pressures dropped into the 60s systolic. His
antihypertensive medications were held in this setting. At the
time of discharge he was tolerating his home antihypertensive
regimen which includes metoprolol and amlodipine.
Hyperlipidemia - The patient has an allergy to simvastatin
reported in the online medical record. On admission he was
taking atorvastatin. This medication was continued as he
appears to be tolerting it well.
Prophylaxis: He received subcutaneous heparin for DVT
prophylaxis, and IV protonix given his gastrointestinal
bleeding. He also received an aggressive bowel regimen.
Code: Full Code
Communication: Daughters [**Name (NI) 2155**] [**Telephone/Fax (1) 104517**]; [**Name2 (NI) 2048**]
[**Telephone/Fax (1) 104518**]
Disposition: To rehab
Medications on Admission:
1. Quetiapine 25 mg 0.5 Tablet PO QD ().
2. Donepezil 5 mg PO HS (at bedtime).
3. Atorvastatin 10 mg PO DAILY (Daily).
4. Calcitriol 0.5 mcg PO DAILY (Daily).
5. Lactulose (30) ML PO TID (3 times a day).
6. Fluticasone 50 mcg Nasal DAILY (Daily).
7. Darbepoetin Alfa qoweek ().
8. Pantoprazole 40 mg PO Q24H (every 24 hours).
9. Amlodipine 5 mg PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg PO TID (3 times a day).
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Aranesp SureClick -Polysorbate 60 mcg/0.3 mL Pen Injector
Sig: One (1) Subcutaneous every other week .
7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary:
Gastrointestinal Bleeding
Left Knee Effusion
Atrial Fibrillation
Sick sinus syndrome
Chronic Anemia
Acute on chronic renal failure
Secondary:
Aortic Insufficiency
MGUS
Encephalopathy
Discharge Condition:
Stable. Oriented to person, hospital and [**2185**]. Ambulating with
significant assistance. Breathing comfortably on room air.
Discharge Instructions:
You were seen and evaluated for your knee pain and your
lightheadedness. You were found to have swelling of your knee
and when a sample of this fluid was taken you were found to have
blood. It was thought that this was secondary to
osteoarthritis. You also had a low blood count and underwent
upper endoscopy. You required 7 units of blood to control this
gastrointestinal bleeding.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take ciprofloxacin 750 mg daily for 7 more days
2. Please take tylenol 325-650 mg every six hours as needed for
pain
Please keep all your follow up appointments.
Please seek immediate medical attention if you experience any
lightheadedness, dizziness, chest pain, shortness of breath,
worsening abdominal pain, black or red stools, falls at home or
any other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2185-4-19**] 9:40
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2185-4-21**] 8:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2185-4-21**]
9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone [**Telephone/Fax (1) 250**] Date/Time:
[**2185-6-2**] 09:00a
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] Date/Time: [**2185-4-28**] 04:00p
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
18291, 18346
|
11046, 16811
|
256, 351
|
18583, 18716
|
5664, 7062
|
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5030, 5108
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5123, 5645
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7079, 10951
|
191, 218
|
10980, 11023
|
379, 4043
|
4065, 4868
|
4884, 5014
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
268
| 110,404
|
1592
|
Discharge summary
|
report
|
Admission Date: [**2198-2-11**] Discharge Date: [**2198-2-18**]
Date of Birth: [**2132-2-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 65 year old female
with a past medical history notable for diabetes mellitus,
hypertension, coronary artery disease status post myocardial
infarction and coronary artery bypass graft, right lower
lobectomy, asthma and congestive heart failure, who presents
complaining of cough times one week, malaise and fatigue.
The patient had a low grade temperature of 99.6 F., at home.
The patient denied any lower extremity edema or weight gain.
The patient's peak flows at home were in the 150 range.
The patient was recently admitted to the hospital [**1-28**]
until [**2-5**] for similar complaints of shortness of
breath and cough. At that time, she was treated with
steroids, Azithromycin and nebulizers for a presumed
bronchitis exacerbation.
In the Emergency Room, the patient was treated with a
Combivent nebulizer, Solu-Medrol intravenously, Levaquin and
Lasix.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Neuropathy.
3. Hypertension.
4. Coronary artery disease status post inferior myocardial
infarction in [**2182**]; status post coronary artery bypass graft
in [**2190**]; most recent catheterization in [**2196-8-1**] with an
ejection fraction of 40%; left internal mammary artery with
40% disease and right coronary artery with 90% disease.
5. Status post right lower lobectomy for question of
tuberculosis disease at age 16.
6. Asthma.
7. Congestive heart failure.
8. Fibromyalgia.
9. Osteoarthritis.
10. Low back pain secondary to spinal stenosis.
ALLERGIES: Penicillin and tetracycline.
MEDICATIONS AT TIME OF ADMISSION:
1. Aspirin 325 mg a day.
2. Prednisone taper.
3. Protonix 40 mg a day.
4. Trandolapril 2 mg a day.
5. NPH 34 units in the morning and 26 units at night.
6. Subcutaneous insulin.
7. Albuterol inhaler.
8. Fluticasone inhaler.
9. Valium p.r.n.
10. Sotalol 80 mg twice a day.
11. Nystatin swish and swallow.
SOCIAL HISTORY: The patient lives at home independently.
She has around 12 siblings. She has a 30 pack history of
tobacco but quit in [**2182**]. She does not use any alcohol.
PHYSICAL EXAMINATION: Temperature 99.5 F.; pulse 96; blood
pressure 110/60; respiratory rate 24; pulse oximetry 95% on
two liters. In general, a sad tearful female with a flat
affect. HEENT: Pupils are equal, round and reactive to
light. Mucous membranes were moist. Neck is supple without
any jugular venous distention. Chest: Crackles at the lung
bases about [**2-3**] of the way up. Cardiovascular: Regular
rate, no murmurs. Abdomen is soft. Extremities are warm
without edema with good pulses. Neurological is alert and
oriented times three.
LABORATORY: Data at the time of admission is white blood
cell count of 10.3 with 70% neutrophils, hematocrit of 39.7,
platelets of 226. Sodium 134, potassium 4.4 hemolyzed,
chloride 95, bicarbonate 29, BUN 24, creatinine 1.4 with
baseline of 1.0, and glucose of 120.
Chest x-ray shows blunting of the left costophrenic angle,
right middle and lower lobe pneumonia.
EKG with normal sinus rhythm at a rate of 95, old Q waves in
the inferior leads with no acute ST changes.
HOSPITAL COURSE:
1. Hypoxic hypercarbic respiratory failure: The patient was
initially admitted to the Medical Floor for treatment of her
multi-lobar pneumonia. She initially maintained an oxygen
saturation of greater than 95% on three liters of nasal
cannula, however, developed hypoxia to 80% with saturation of
90% on non-rebreather, in the setting of a narrow complex
tachycardia while she was on the floor. However, the patient
remained hypoxic at about 96% on a nonrebreather; therefore
she was transferred to the Fenard Intensive Care Unit.
In the Intensive Care Unit her arterial blood gas revealed a
pH of 7.16, a pCO2 of 74 and pO2 of 94 with abnormal mental
status. The patient's culture data revealed a Methicillin
resistant Staphylococcus aureus pneumonia and the patient's
antibiotic regimen was changed to Vancomycin. There was also
a question of aspiration.
The patient was initially tried on a trial of Bi-PAP,
however, she did not tolerate this very well and her mental
status decreased to the point of requiring intubation.
Initially there was significant confusion regarding her code
status, as on a previous admission it was documented that she
wanted to be resuscitated but did not want to be intubated.
So, after discussion with various of her attendings and given
her clinical status, the decision was made to intubate the
patient as she was in acute respiratory distress.
The patient continued to require high ventilatory support and
had adult respiratory distress syndrome physiology.
2. Tachycardia: The patient, just prior to her transfer to
the Intensive Care Unit, had a tachycardia that was presumed
to be either an atrial tachycardia versus an NRT. She
decreased her rate from the mid 200s to 100 after receiving
diltiazem 20 mg intravenously and was followed closely in the
Intensive Care Unit. She had multiple episodes of
tachycardia and the Electrophysiology Service was consulted
as well as the Electrophysiology physician, [**Name10 (NameIs) **],
occasionally her rhythm would break with Idenosine and
occasionally with Diltiazem and eventually she was on a
diltiazem drip. There was a question of amiodarone loading
as well.
Of note, her Sotalol, which she had been maintained on as an
outpatient, had been discontinued during her hospital course
as she had started to develop renal failure.
3. Hypotension: The patient remained hypotensive after she
was intubated and was not fluid responsive. Her MAPs were
around 50. She was started on norepinephrine and vasopressin
and the etiology was thought to be sepsis although it then
also became cardiogenic later in her hospital course.
4. Acid Base: The patient had a mixed respiratory and
metabolic acidosis. She was given intravenous fluids and her
respiratory status was maintained with a ventilator, although
it was very difficult to correct her acid base status given
her overwhelming sepsis as well as her worsening renal
failure.
5. Acute Renal Failure: The patient had worsening renal
failure likely secondary to acute tubular necrosis with
anuria. CVH was debated upon, however, ultimately a change
in the patient's code status did not require use of this node
of volume removal.
DISPOSITION: After extensive discussion with the family,
initially the patient was clearly full code as she was
intubated, ventilated and on pressors, however, after two to
three family meetings and multi-system organ failure
including cardiovascular, pulmonary, renal with overwhelming
sepsis, Methicillin resistant Staphylococcus aureus pneumonia
and progressive overall worsening, it was decided that goal
for care would change from "Do Not Resuscitate" "Do Not
Intubate" followed by COMFORT MEASURES ONLY status. The
patient had multiple family members who came to see her prior
to her demise.
The patient expired at 03:55 a.m. on [**2198-2-18**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2198-4-5**] 13:13
T: [**2198-4-6**] 22:25
JOB#: [**Job Number 9246**]
|
[
"427.5",
"428.0",
"584.5",
"482.41",
"038.9",
"493.22",
"276.1",
"427.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.71",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3271, 7357
|
2241, 3254
|
157, 1033
|
1055, 2036
|
2054, 2217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,544
| 107,251
|
45535
|
Discharge summary
|
report
|
Admission Date: [**2116-12-24**] Discharge Date: [**2116-12-28**]
Date of Birth: [**2050-11-14**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Morphine / Penicillins / Darvon / Macrobid
Attending:[**Doctor First Name 1402**]
Chief Complaint:
presyncopal episodes
Major Surgical or Invasive Procedure:
EP ablation
History of Present Illness:
66yof w/ pmh CAD s/p CABG '[**85**], AAA repair, DM, PVD s/p bilat
AKA, hypoithyroid, hyperlipidemia, CHF, dizziness, chroinic
wounds (healed pressure ulcer on back, red cuts under breasts,
old healing abd wound), presents to OSH [**12-20**] w/ presyncopal
episodes and hypotension that had been on and off for three
days. She was managed on the floor but tx to CCU [**12-21**] for per
report sustained VT w/ BP 50/. She was intubated and shocked
x5. She was started on Procainamide gtt at 3mg/min, Neo gtt and
propofol gtt. Per report, while pt intubated and sedated, her
she had no VT. Her last shock was [**12-21**].She was weaned from
sedation and extubated [**12-22**] and her VT re-occurred. Since then,
she has been in NS/SB 48-52 and has recurrent VT (5-10 beat
runs) w/ BP 80-90/.
She reported presyncopal attacks for 3 days prior to [**Last Name (un) **]
presentation to the OSH. During these episodes, she felt dizzy
and had reduction in her vision. No associated chest pain, [**Doctor Last Name **]
or palpitations. No history of diarrhoea, vomiting or reduced
intake. There had been no recent change in her home medications.
In addition, she reprots that her caregiver noticed dark stool
on day 2 of symptoms, unclear whether melanotic. Denies any
BRBPR, no nausea/vomiting/abdominal pain.
Transferred to [**Hospital1 18**] for possible EP ablation of the focus of
her presumed Vtach. On arrival at [**Hospital1 18**] CCU, ECG in sinus
revealed RBBB, LAFB, left atrial abnormality. ECG from OSH([**Hospital1 34**])
showed NSVT negative in II, III, F, positive in 1, L, transition
at V3/V4 in setting of SVT possible AT at 260.
Past Medical History:
- CAD s/p MI [**2085**], s/p CABGx3
- h/o AAA repair in [**2104**] at [**Hospital1 112**]
- HTN
- Hyperlipidemia
- Hypothyroidism
- CHF (EF 30-35%)
- PVD s/p B AKA [**12-31**] infection of total knee prostheses, with
left side revision [**2112**] and known DVT (on coumadin).
- ventral hernia (incisional)
- s/p cholecystectomy ([**2084**])
- depression
- precautions (MRSA - [**12-6**], VRE - leg [**1-6**], ESBL - urine klebs
[**10-6**])
Social History:
She lives at with a personal care attendant, is able to
dress/feed herself, but needs a [**Doctor Last Name 2598**] lift to move around. 1.5
ppd tobacco. Denies etoh, ivdu. Sister [**Name (NI) **] (HCP) lives in
[**Name (NI) 8447**] ([**Telephone/Fax (1) 97139**].
Family History:
Father: hx HTN, angina
Physical Exam:
ON ADMISSION:
Tcurrent: 36.3 ??????C (97.3 ??????F)
HR: 100 (72 - 100) bpm
BP: 91/61(66) {87/43(55) - 96/69(73)} mmHg
RR: 14 (14 - 24) insp/min
SpO2: 91%
Heart rhythm: SR (Sinus Rhythm)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular cardiac impulse, normal S1, S2. No
murmurs or added heart sounds. No thrills, lifts.
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 abdominial bruits.
EXTREMITIES: Bilateral AKA. No femoral bruits. Mild edema on the
lower limb stumps bilaterally.
SKIN: Healing scars on her back, active lesions beneath her
breasts.
PULSES:
Right: Carotid 2+ Femoral 2+
Left: Carotid 2+ Femoral 2+
Pertinent Results:
CXR [**2116-12-25**]
Sinus rhythm with ventricular premature beats. Right
bundle-branch block. Left anterior fascicular block.
Anterolateral lead ST-T wave abnormalities are primary and are
non-specific. Since the previous tracing of [**2114-4-1**] ventricular
ectopy is present. Otherwise, there is no significant change.
.
- CXR at OSH showed no evidence of pulmonary congestion.
.
- ECG: ECG in sinus revealed RBBB, LAFB, left atrial
abnormality. ECG from OSH([**Hospital1 34**]) showed NSVT negative in II, III,
F, positive in 1, L, transition at V3/V4 in setting of SVT
possible AT at 260.
.
- ECHO: [**2116-12-21**] at [**Hospital6 33**]. Full report in chart.
Of note, EF 10-15%. Severe diffuse hypokinesis. Akinesis and
aneursymal deformity of apical walls. Mild mitral
regurgitation, trace tricuspid regurgitation, PASP estimated at
13mmHg + RA pressure.
.
CT ABD/PELVIS [**2116-12-26**]
1. Diffuse thinning of anterior abdominal musculature with
diffuse bulge of abdomen. Fat containing umbilical hernia.
Multiple gas-filled loops of bowel including the transverse
colon, finding which can be seen in bedbound patients. No bowel
obstruction.
2. Diffusely abnormal abdominal aorta with long-segment fusiform
aneurysm (5 cm), as previously described. Size is similar to
that seen on [**2114-4-1**], however now with increased mural thrombus,
effectively resulting in decreased size of true lumen. Also now
occluded right common iliac artery, with reconstitution of flow
seen at right common femoral artery.
3. Cardiomegaly with left ventricular enlargement and left
ventricular
aneurysm.
4. Possible 3-mm right lower lobe nodule, incompletely imaged.
[**First Name8 (NamePattern2) **]
[**Last Name (un) 8773**] criteria, if the patient is at high risk for
intrathoracic
malignancy, follow-up CT would be recommended in 1 year.
Otherwise, no
further imaging would be recommended.
5. Multiple renal hypodensities, too small to characterize.
.
TTE [**2116-12-25**]
Poor image quality. The left atrium is mildly dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis of the distal 2/3rds of the ventricle. A left
ventricular mass/thrombus cannot be excluded (not seen but poor
visualization of the apex cannot exclude). There is no
ventricular septal defect. The diameters of aorta at the sinus,
ascending and arch levels are normal. The mitral valve leaflets
are mildly thickened. Mild to moderate ([**11-30**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion. EF 20-25%.
Compared with the prior study (images reviewed) of [**2114-4-4**], no
clear change (given LV dysfunciton persists, Takotsubo CM is no
longer on the differential). If indicated, a repeat study with
echo contrast OR a cardiac MRI may better assess LV/RV function
and exclude apical thrombus.
Brief Hospital Course:
66F with CAD s/p CABG [**2085**], HL, PAD s/p B/L AKA in [**2112**] & AAA
endovascular repair [**2104**], hypothyroid, 1 PPD [**Last Name (LF) 1818**], [**First Name3 (LF) **] 30-35%
per [**Hospital1 34**] echo [**2114**], obesity, decub ulcer, ventral hernia with
ulceration p/w VT storm to [**Hospital1 34**] now transferred to [**Hospital1 18**] for
possible VT ablation by Dr. [**Last Name (STitle) 13177**].
.
#Arrhythmia: SVT with RBBB with intervals of VTach (runs of
between 3 and 18 each time). At least two ectobic sites, one in
the atria causing the SVT and one causing the VT. Probable
causes previous MI, hyper/hypotension, elytes. Pt denies any
CP/SOB/orthopnea. TSH was normal at 1.8. ECG from [**Hospital1 34**] showed
NSVT negative in II, III, F, positive in 1, L, transition at
V3/V4 in setting of SVT possible AT at 260.
ECG on arrival to [**Hospital1 18**] in sinus showed RBBB, LAFB, left atrial
abnormality
Pt was started on procainamide gtt at 3, VT initially reduced
but then flared up and gtt was increased to 4, and then DCd
prior to ablation. CCU attending ?????? 60 minutes critical care. Pt
continued to have runs of VT and was taken for ablation. EP lab
transseptal approach to ablate focus in LV, however found
several other foci of VT as well as AT. Given multiple foci not
all of which successfully ablated, decision to treat with
antiarrythmics. Pt also had a competing atrial tachycardia.
Given procainamide 950mg IV bolus which converted to sinus
(although sinus rhythm difficult to tell from VT - mainly by
rate - VT rate was 130, sinus in 90s) and then transitioned to
amiodarone with procainamide DCd. Pt was monitored but continued
having occasional runs of VT, and plan was to place permanent
pacer. Progressive second degree heart block throughout day
after the procedure with HR transiently dropping to 30s although
BP stable. Resited RIJ to left cordis/ trauma line and placed
temp transvenous pacer. However, she developed septic picture
and permanent hardware was not able to be placed in that setting
(see sepsis, below). Patient had sedation weaned and did not
regain consciousness. In the setting of increasing leukocytosis,
worsening renal failure, anasarca, and acute wound dehiscence at
her groin puncture sites extending deep into the groin tissue,
patient was transitioned to comfort measures only per the wishes
of her family on the morning of [**2116-12-28**]. At 1827 on [**12-28**],
patient expired peacefully of cardiac arrest, with family at
bedside.
.
# Hypotension: Patient's SBP during course of illness ranged
from low of 50s to 90. In the unit the MAPS have been btw 55-70
with SBP of 77-94 and DBP of 48-60. Probable causes are
cardiogenic(previous MI with non-contractile myocardium, SVT/VT,
valvular dxs), hypovolemia, anemia, sepsis, hypothyroidism,
non-compliance to medication). Pt was started on levophed but in
setting of VT/arrythmia with increased ectopy this was changed
to neosynephrine.
.
# CHF: Ptn with previous hx of CAD/MI and CABG.On Ace inh and BB
at home. Probable causes for decompensation include arrythmias,
hypovolemia, anemia. Repeat echo shows decline in EF: [**Month (only) **]/12 -
10-15%, from 30-35% in [**2114**]. Diuresis was attempted with lasix
but was minimally successful. Diuretics then held in setting of
hypotension. ACEI and Bblocker also held in setting of
hypotension.
.
# [**Last Name (un) **]: Creatinine 0.8 on [**2116-12-21**], went up to 1.8 on [**2116-12-27**].
Renal assisted in examination of urine sediment and no casts
were seen. Cytology consistent with pre-renal picture (shrunken
RBCs) but no signs of ATN. FeNa was 0.13%.
.
# Sepsis - WBC to 23 on [**2116-12-27**]. Pt still with phenylephrine
pressor requirement, fevers, and intermittently tachycardic. UA
was dirty and there was evidence of skin breakdown around the
areas where pt had vascular access. PT also had history of MRSA
colonization, and was started empirically on vanc/cefepime. -
central line in RIJ was changed over a wire. New line was placed
in LIJ and catheter tip of RIJ was sent for culture. Urine
culture showed no growth. Blood cultures pending at time of
expiration.
.
# Anemia: Normocytic normochromic anemia. Probably 2/2 blood
loss (dark stool reported), hemolysis or anemia of chronic
illness. Hct down at 31 from 38 five days earlier.
.
# Supratherapeutic INR - pt had INR of 2.5 on presentation (on
warfarin for h/o DVT) which peaked at 4.5 on [**2116-12-26**] even though
coumadin was held after INR was supratherapeutic at 3.5.
.
# Sacral, chest, abdominal, groin wounds: Chronic wounds. Groin
wounds developed secondary to femoral catheterization. Pain
controlled with methadone.
Medications on Admission:
- Levothyroxine 50mcg/d
- Plavix 75mg/d
- Lisinopril 5mg/d
- Imdur 30mg [**Hospital1 **]
- Pravachol 20mg/d
- Coumadin
- Methadone 20mg/d
- Ativan PRN
- Hydroxyzine PRN
Discharge Medications:
expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"584.9",
"V58.61",
"V02.54",
"E934.2",
"998.30",
"427.0",
"311",
"V66.7",
"879.3",
"280.0",
"790.92",
"458.9",
"426.13",
"426.52",
"875.1",
"V12.51",
"428.0",
"440.20",
"427.1",
"244.9",
"401.9",
"V45.81",
"414.00",
"995.92",
"272.4",
"428.22",
"V49.76",
"V49.86",
"305.1",
"E879.8",
"038.9",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"38.97",
"37.78",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
11879, 11888
|
6930, 11618
|
338, 351
|
11940, 11950
|
3838, 6907
|
12006, 12017
|
2793, 2817
|
11846, 11856
|
11909, 11919
|
11644, 11823
|
11974, 11983
|
2832, 2832
|
278, 300
|
379, 2030
|
2846, 3819
|
2052, 2494
|
2510, 2777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,167
| 185,509
|
12788
|
Discharge summary
|
report
|
Admission Date: [**2138-5-17**] Discharge Date: [**2138-6-1**]
Date of Birth: [**2062-7-15**] Sex: F
Service: Acove
HISTORY OF PRESENT ILLNESS: This is a 75-year-old female
with a history of metastatic breast cancer who was originally
admitted to [**Hospital3 3834**] [**Hospital3 **] on [**5-3**] with
complaints of diarrhea and fevers. Of note, she had recently
completed (in [**2138-3-24**]) a course of Xeloda for right
axillary breast cancer recurrence. At the outside hospital
she was initially treated with IV fluids. On [**5-10**] CT scan
was done which showed dilated large and small bowel with
thickened colon wall. She was started on a course of Cipro
and Flagyl on [**5-12**]. She was also started at this time on a
course of Vancomycin for empiric coverage of a right middle
lobe pneumonia that was seen on that CT scan. On [**5-14**] the
patient started to spike temperatures and had increased
somnolence as well as increased diarrhea. On [**5-17**] the
patient was desaturating to 60-70% and was subsequently
intubated. She then became hypotensive requiring pressors.
Culture data from the outside hospital was notable for MRSA
in stool and sputum. The patient was transferred to the [**Hospital1 1444**] MICU on [**2138-5-17**].
HOSPITAL COURSE:
1. Infectious Disease: On admission the patient appeared
septic. She was placed on Vancomycin, Levofloxacin and
Flagyl to cover GI, lung, and line as possible sources.
Neo-Synephrine was weaned off within 24 hours with aggressive
volume resuscitation. Follow-up abdominal CT on [**5-18**] was
consistent with enterocolitis and also showed a right lower
lobe pneumonia. The patient completed a 14 day course of
Vancomycin on [**5-26**] for presumed MRSA pneumonia. The
Levofloxacin and Flagyl were discontinued on [**5-21**] as the
patient's diarrhea was much improved. On [**5-30**] a repeat CT
showed right lower lobe consolidation and the patient had an
increasing white blood cell count. Vancomycin was restarted
at this time for a recurrent MRSA pneumonia.
2. Cardiovascular: The patient was noted to have many PVCs
and some short runs of MSVT on telemetry in the MICU.
Lopressor was initiated and titrated up during the MICU
course with improvement in these findings.
3. Pulmonary: The patient was intubated on [**5-17**] for
hypoxemic respiratory failure. She underwent a very slow
wean from the ventilator and was eventually extubated on [**5-26**].
Post extubation she had some episodes of desaturation to the
80's which responded easily to suctioning. She was therefore
monitored in the ICU for two days following these episodes
with no further episodes of hypoxia.
4. GI: The patient's enterocolitis was presumed to be
secondary to Xeloda toxicity (the patient was on a quite high
dose). This diarrheal illness resolved in [**4-28**] days.
Following extubation, the patient was noted to have a weak
cough and gag reflex and was therefore high aspiration risk.
She was on TPN throughout the admission.
5. Renal: The patient's creatinine was 1.8 at admission and
had been as high as 2.4 at the outside hospital. The
patient's baseline is unclear but the creatinine improved
during the hospital course to 1.1.
6. Heme: The patient had an elevated INR on admission which
corrected with Vitamin K. During the admission the patient's
hematocrit drifted down to 23 and she was transfused one unit
of packed red blood cells on [**5-26**].
On [**5-31**] the patient was transferred to the regular floor from
the MICU. At the time of transfer she denied any pain,
shortness of breath or discomfort. However, at approximately
11:45 the patient was found in her room with no pulse and no
respirations. The code team was called and CPR and ACLS
protocols were followed. The code lasted approximately 25
minutes but the efforts were unsuccessful. The patient was
pronounced dead at 12:15 a.m. on [**2138-6-1**]. The
appropriate family members were [**Name (NI) 653**] and the family has
agreed to an autopsy.
CONDITION ON DISCHARGE: Deceased.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 15468**]
MEDQUIST36
D: [**2138-6-1**] 12:14
T: [**2138-6-3**] 19:08
JOB#: [**Job Number 39427**]
|
[
"427.1",
"E933.1",
"198.89",
"427.5",
"V10.3",
"518.81",
"558.9",
"038.11",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"99.15",
"38.93",
"96.04",
"96.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1290, 4031
|
162, 1273
|
4056, 4332
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,658
| 116,147
|
48020
|
Discharge summary
|
report
|
Admission Date: [**2188-5-10**] Discharge Date: [**2188-5-17**]
Date of Birth: [**2129-6-19**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Ibuprofen / Aspirin
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Pericardial effusion/tamponade
Major Surgical or Invasive Procedure:
Insertion of Pericardial drain
Cardiac Catheterization showing lesion in left circumflex artery
History of Present Illness:
The patient is a 58 year old male with a history of "benign"
colonic neoplasm, h/o positive PPD, bronchitis, HTN and
hyperlipidemia who was transferred from [**Hospital 1263**] hospital s/p
tamponade with large pericardial effusion s/p pericardial drain.
Prior to admission, the patient had visited the ER with flu-like
symptoms and placed on Zpack and advair. He also initially
reported noticing a swollen right ankle that was later described
by [**Name8 (MD) **] MD [**First Name (Titles) 3**] [**Last Name (Titles) **] +1 pedal edema. He denies any arthralgias
or rashes. He denies any contact with TB, recent travel or sick
contacts. [**Name (NI) **] admits to having night sweats, chills and a cough
with rusty sputum for the past few weeks with increased
shortness of breath and orthopnea, no chest pain. He denies any
recent weight loss and denies ever having a colonic neoplasm,
benign or malignant, with a recent colonoscopy at [**Hospital 1263**]
hospital 1 month ago. He does admit to having smoked 1 ppd for
5-7 years but quit 20 years ago. He also admits to having been
exposed to asbestos as a former shipyard worker for 10 years 20
years ago.
His first troponin was 0.02 and then 2.8 at [**Doctor Last Name 1263**]. Echo was
positive for tamponade with a negative CT for dissection. On
[**2187-5-9**], underwent pericardiocentesis with 1800 cc fluid
obtained with negative cytology with cell block pending. Opening
wedge was 28 and final wedge 12.
Pericardial fluid:
protein 7.7
LDH 339
WBC 7
Hct 21%
Amylase 63
AFB pending, fungal pending, culture pending, GS pending
EKG [**2188-5-8**]:
Electrical alternans, normal axis. low voltage.
Past Medical History:
Bronchitis
HTN
s/p MVA
Hyperlipidemia
h/o pleural effusion
h/o "benign" colonic neoplasm? -documented by MDs at [**Doctor Last Name 1263**]
where colonoscopy was performed but denied by patient
hemorrhoids
diverticulosis
h/o positive PPD - born in the US, likely exposed as child in
[**State 3908**]
Social History:
The patient works for [**Company 2318**]. He is married. He is a former smoker
having smoked 1 ppd for 5-7 years in the past. He admits to
occasional EtOH. He also admits reluctantly to a history of
cocaine use but will not elaborate. He admits to having tested
for HIV in the past. He was formerly exposed to asbestos as a
former shipyard worker from [**2153**]-[**2163**].
Family History:
Mother - deceased from bone cancer, ?CHF
Father - Alcoholic, deceased at young age from alcoholism
Physical Exam:
P=112 BP=130/94 RR=28 95%
Gen- Mildly anxious, appears upset, AOX3
HEENT - PERLA, EOMI, positive nontender submandibular [**Doctor First Name **] with
palpable, nontender thyroid, no supraclavicular,
anterior/posterior cervical [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3495**] - Regular rate and rhythm, no murmurs/rubs or gallops
Lungs - Clear to auscultation bilaterally
Abdomen - Pericardial drain in place with clean, intact site
with no pus, Soft, no hepatosplenomegaly, active bowel sounds,
nontender/nondistended
Ext - No C/C/E
Pertinent Results:
Echo [**2188-5-11**]:
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Conclusions:
1. LV function is moderately depressed with an estimated
ejection fraction of
35-40%. There is akinesis of the mid to distal septum. Due to
poor apical
windows, other focal wall motion abnormalities cannot be
excluded.
2. There are no hemodynamically signficant valve abnormalites.
3. There is a small pericardial effusion with some pericardial
thickening.
There is no RV or RA collapse. There is no echo evidence of
cardiac tamponade.
4. The RV appears at least mildly dilated with at least mildly
depressed
systolic function.
CHEST (PORTABLE AP) [**2188-5-10**] 7:02 PM
IMPRESSION: [**Month/Day/Year **] small pleural effusion. Enlarged cardiac
silhouette consistent with the patient's history of pericardial
effusion.
Brief Hospital Course:
The patient is a 58 year old African-American male with a
history of positive PPD, ?colonic neoplasm who presented to
[**Hospital 1263**] hospital with large pericardial effusion s/p
pericardiocentesis on [**2188-5-8**] with pericardial drain transferred
to [**Hospital1 18**] for medical management.
1. Pericardial effusion: He had a pericardial drain in place on
transfer. This was pulled out 1 day after admission when output
had decreased to a minimal amount of serosanguinous fluid. All
cultures of fluid from [**Doctor Last Name **] hospital were negative (AFB,
fungal, aerobic), and cell block/cytology was also negative. He
had multiple repeat echos while in-house to assess for
reaccumulation or change. There was no reaccumulation, and
effusion was trivial at time of discharge. Given that he had a
positive PPD (placed while in-house), sputum was sent x 3 for
AFB smear and was negative. Although the cause of his effusion
was still unclear at time of discharge, it was likely a viral
myocarditis/pericarditis (given malignancy and TB virtually
excluded). Given his positive PPD, the decision was made to
treat with Isoniazid (and vitamin B6) prophylactically). He
will have his LFt's checked monthly through his PCP while on
this therapy. He was also instructed no to drink alcohol while
on this medication.
2. CAD: He was noted to have a depressed EF (to 30-35%) on TTE.
He underwent a ETT-MIBI that showed EF=35% with global HK, no
fixed/reversible defects. The decision was made to take him for
cardiac catheterization (?3vd or other balanced lesions
contributing to global HK). Catheterization showed 70% lesion
of left circumflex. No stent was inserted, for patient had a
?[**Doctor Last Name **] allergy. He was desensitized for [**Doctor Last Name **] prior to discharge
and will return for stenting of left circumflex. He was started
on a beta blocker, ACEI, [**Last Name (LF) 4532**], [**First Name3 (LF) **], lipitor prior to
discharge. Of note, TTE on the day prior to discharge showed an
improved EF of 40%. He never had any anginal symptoms while
in-house.
3. Hypertension: He was on HCTZ on admission. This was stopped,
and he was maintained on ACEI/BB and discharged on these
medications. His bp remained under good control throughout
hospitalization.
4. Tachycardic: He was tachycardic to 100-110's. This
persisted even after removal of the pericardial drain. He was
started on a beta blocker with some improvement in the
tachycardia
6. Dispo: He was discharged after [**First Name3 (LF) **] desensitization and will
return for cardiac catheterization 2-3 days after discharge. He
was instructed about the importance of taking his [**First Name3 (LF) **] and [**First Name3 (LF) 4532**]
daily to avoid in stent thrombosis (and to avoid resensitization
to [**First Name3 (LF) **]).
Medications on Admission:
Meds on Admission:
MVI
HCTZ
ALL:
[**First Name3 (LF) **]-hives/rash
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Please check AST, ALT, alkaline phosphatase, total bilirubin
once a month and fax results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 51132**], fax ([**Telephone/Fax (1) 101287**]
7. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO once a day for
9 months.
Disp:*30 Tablet(s)* Refills:*8*
8. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day
for 9 months.
Disp:*30 Tablet(s)* Refills:*8*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Pericardial tamponade/effusion
2. Congestive Heart Failure, EF=30%
Secondary Diagnoses:
1. Hypretension
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications as described in this
discharge paperwork. We made the following changes to your
medication regimen.
- We added Toprol XL 100 mg daily, to help with your
heartrate and blood pressure
- We added Lisinopril, a medication to help with your blood
pressure. Please take 10 mg daily
- We stopped your hydrochlorothiazide.
- We added Isoniazid, a medication to be taken for your
possible exposure to tuberculosis. You should take this
medication for 9 months. Do not drink alcohol while on this
medication, for this could cause serious liver damage. In
addition, you should have your liver function tested monthly
while on this medication. You should also take Vitamin B6 daily
while on this medication
- Please take Lipitor, a medication to help lower your
cholesterol, 20 mg daily
- Please take Aspirin 325 mg daily. Also take [**Telephone/Fax (1) **] 75 mg
daily. It is extremely important that you take these
medications every day. If you miss a dose, you risk clotting
off the stents in your heart which could cause death. In
addition, missing aspirin doses may result in becoming allergic
to this medication again.
2. Please follow up with your PCP and cardiology as described
below.
3. Please call your PCP if you are experiencing chest pain,
shortness of breath, fever, chills, lightheadedness, dizziness,
or with any other concerns.
Followup Instructions:
1. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 51132**] ([**Telephone/Fax (1) 89769**])
within 1-2 weeks of discharge. He should check your liver
function tests at this time while you are on Isoniazid and
Lipitor. You will need to get your liver function tested
monthly (results faxed to ([**Telephone/Fax (1) 101288**].
2. Please plan on coming in for your cardiac catheterization on
Monday, [**2188-5-19**], to [**Hospital Ward Name **] 4. Do not eat breakfast on this
morning. Cardiology (Dr. [**Last Name (STitle) 5021**] will call you to schedule
this and confirm date and time.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"V14.6",
"428.0",
"795.5",
"272.4",
"414.01",
"420.91",
"401.9",
"429.9",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
8363, 8369
|
4380, 7220
|
325, 423
|
8541, 8547
|
3538, 4357
|
10005, 10769
|
2839, 2939
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7339, 8340
|
8390, 8390
|
7246, 7251
|
8571, 9982
|
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|
8502, 8520
|
255, 287
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451, 2108
|
8409, 8481
|
7265, 7316
|
2130, 2431
|
2447, 2823
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,677
| 134,916
|
46541
|
Discharge summary
|
report
|
Admission Date: [**2134-7-3**] Discharge Date: [**2134-7-17**]
Date of Birth: [**2076-11-14**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Joint aspiration (Left Knee)
Right Subclavian CVL placement
Flexible Sigmoidoscopy with biopsy
Left knee irrigation and debridment with polyliner exchange
(left knee)
History of Present Illness:
This is a 57 year old female with history of bipolar disorder
and psychosis who had a TKR on [**2134-6-15**] and had been in rehab
until she developed fevers to 104 and swelling in the left lower
extremity yesterday. She was started on cephalexin and
ciprofloxacin but continued to be febrile up to 104 today so she
was brought to the ED.
In the ED intial VS T 99.9, P 108, BP 106/57, RR 22, O2 96% on
4L. Exam notable for a very swollen left lower extremity that
was quite warm with some erythema. Maximum heart rate was in the
130s. She received 3 liters IV fluid with improvement of her
tachycardia to the 90's. She also received vancomycin and
piperacillin-tazobactam for empiric coverage of infection.
Ortho was initially concerned about septic arthritis and tapped
the joint, but thought fluid was very clear and unlikely to be
infected and therefore triaged patient to MICU. VS prior to tx
BP 93/41,P 100, RR 25, O2 99% on 2L, CT w/o air. LENI negative.
.
Review of systems:
(+) Per HPI
(-) 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:
Bipolar disease with psychosis and an episode of NMS in [**2116**]
Non-healing cellulitis in [**2129**]
R TKR [**2132-8-18**]
Spinal stenosis
cholecysectomy
OA
Delirium
Left Knee TKR [**5-/2134**]
Social History:
The patient denies tobacco or alcohol use. The patient has been
at [**Hospital3 **] post-surgery but normally she lives alone and
has two children. The patient's sister assists her during
exacerbations of her bipolar disorder. Sister is HCP.
Family History:
NC
Physical Exam:
Physical Exam on Presentation:
General: Tired and somnolent, 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
Left lower Ext: warm, swollen over right, no erythema, incision
intact, adeqaute ROM
Physical Exam at Discharge:
Vitals:Tmax: 99.6, Tcurrent: 98.4, BP:112/65, HR:78, RR:18
General: A+Ox3, energetic and NAD
Abdomen: soft, nontender, stable gaseous distension, bowel
sounds present, no rigidity or guarding
Extremities: 1+ pitting edema in LLE, incision clean, dry, and
intact, mild erythema around incision
Pertinent Results:
Admission Labs:
=================
[**2134-7-3**] 06:43PM TYPE-[**Last Name (un) **] TEMP-38.9 PO2-86 PCO2-50* PH-7.29*
TOTAL CO2-25 BASE XS--2 INTUBATED-INTUBATED COMMENTS-GREEN TOP
[**2134-7-3**] 06:43PM LACTATE-1.5 NA+-139
[**2134-7-3**] 06:43PM freeCa-0.96*
[**2134-7-3**] 06:30PM GLUCOSE-100 UREA N-13 CREAT-1.2* SODIUM-137
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11
[**2134-7-3**] 06:30PM CK(CPK)-60
[**2134-7-3**] 06:30PM CK-MB-2 cTropnT-0.02*
[**2134-7-3**] 06:30PM ALBUMIN-2.8* CALCIUM-7.2* PHOSPHATE-3.5
MAGNESIUM-1.6
[**2134-7-3**] 06:30PM WBC-10.4 RBC-2.64* HGB-7.2* HCT-23.2* MCV-88
MCH-27.4 MCHC-31.2 RDW-14.1
[**2134-7-3**] 06:30PM NEUTS-41* BANDS-43* LYMPHS-4* MONOS-9 EOS-1
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2134-7-3**] 06:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL
[**2134-7-3**] 06:30PM PLT COUNT-590*
[**2134-7-3**] 06:30PM PT-15.2* PTT-29.0 INR(PT)-1.3*
[**2134-7-3**] 06:30PM FIBRINOGE-530*
[**2134-7-3**] 03:45PM JOINT FLUID WBC-425* HCT-3.5* POLYS-67*
LYMPHS-15 MONOS-0 MACROPHAG-18
[**2134-7-3**] 03:45PM JOINT FLUID NUMBER-NONE
[**2134-7-3**] 10:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2134-7-3**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
[**2134-7-3**] 10:50AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2134-7-3**] 10:50AM URINE MUCOUS-RARE
[**2134-7-3**] 10:32AM COMMENTS-GREEN TOP
[**2134-7-3**] 10:32AM GLUCOSE-95 LACTATE-1.9 K+-3.7
[**2134-7-3**] 10:10AM GLUCOSE-94 UREA N-11 CREAT-1.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-17
[**2134-7-3**] 10:10AM CRP-176.3*
[**2134-7-3**] 10:10AM WBC-14.0*# RBC-3.03* HGB-8.3* HCT-26.6*
MCV-88 MCH-27.3 MCHC-31.1 RDW-13.9
[**2134-7-3**] 10:10AM NEUTS-89.1* LYMPHS-4.3* MONOS-5.4 EOS-0.9
BASOS-0.4
[**2134-7-3**] 10:10AM PLT COUNT-757*
[**2134-7-3**] 10:10AM PT-13.8* PTT-26.8 INR(PT)-1.2*
[**2134-7-3**] 10:10AM SED RATE-86*
DISCHARGE LABS
================
[**2134-7-17**] 05:27AM BLOOD WBC-10.5 RBC-1.89*# Hgb-5.1*# Hct-16.2*#
MCV-86 MCH-27.0 MCHC-31.5 RDW-16.4* Plt Ct-794*
[**2134-7-17**] 07:36AM BLOOD Hct-22.3*#
[**2134-7-17**] 05:27AM BLOOD PT-14.9* PTT-37.6* INR(PT)-1.3*
[**2134-7-7**] 06:10AM BLOOD Ret Aut-0.8*
[**2134-7-17**] 05:27AM BLOOD Glucose-103* UreaN-6 Creat-0.9 Na-144
K-3.8 Cl-109* HCO3-28 AnGap-11
[**2134-7-6**] 05:22AM BLOOD LD(LDH)-107 TotBili-0.1 DirBili-0.1
IndBili-0.0
[**2134-7-17**] 05:27AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
[**2134-7-6**] 05:22AM BLOOD calTIBC-144 Hapto-323* Ferritn-1224*
TRF-111*
[**2134-7-3**] 10:10AM BLOOD CRP-176.3*
[**2134-7-17**] 05:27AM BLOOD Vanco-19.5
[**2134-7-14**] 04:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2134-7-14**] 04:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2134-7-8**] 06:24AM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2134-7-8**] 05:21PM JOINT FLUID WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier **]* Polys-94*
Lymphs-0 Monos-0 Macro-6
[**2134-7-3**] 03:45PM JOINT FLUID WBC-425* HCT,Fl-3.5* Polys-67*
Lymphs-15 Monos-0 Macro-18
[**2134-7-9**] 12:10PM OTHER BODY FLUID WBC-3250* RBC-[**Numeric Identifier 14123**]* Polys-90*
Lymphs-6* Monos-0 Macro-4*
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:15PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND
[**2134-7-9**] 12:10PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND
[**2134-7-9**] 12:10PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND
MICROBIOLOGY DATA:
===================
Blood cultures 6/18, [**7-4**], [**7-5**], [**7-8**], [**7-14**] FINAL NEGATIVE
Blood culture [**7-15**] PENDING
Urine culture [**7-3**], [**7-4**] NO GROWTH
Urine cultures 6/23 Culture workup discontinued. Further
incubation showed contamination with mixed skin/genital flora.
Clinical significance of isolate(s)uncertain. Interpret with
caution. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.
Stool culture [**7-4**] FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2134-7-4**] 6:31 pm STOOL CONSISTENCY: WATERY
OVA + PARASITES (Final [**2134-7-5**]):
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.
FECAL CULTURE (Final [**2134-7-6**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2134-7-6**]): NO CAMPYLOBACTER
FOUND.
[**7-14**] Stool culture C. Diff NEGATIVE
[**7-15**] Stool culture C. Diff NEGATIVE
[**2134-7-9**] 12:10 pm TISSUE Site: KNEE
SYNOVIAL TISSUE LEFT KNEE #1.
MEMBRANE FROM FEMORAL NOTCH, LEFT KNEE.
SYNOVIAL TISSUE #2 LEFT KNEE
MEDIAL POCKET HEMATOMA--LFT--KNEE. = All of these had PMNs,
[**1-18**]+, but NO MICROORGANISMS SEEN. TISSUE (Final [**2134-7-12**]): NO
GROWTH. ANAEROBIC CULTURE (Final [**2134-7-15**]): NO GROWTH.
[**7-3**] MRSA Screen NEGATIVe
[**2134-7-3**] 3:45 pm JOINT FLUID
GRAM STAIN (Final [**2134-7-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-7-6**]): NO GROWTH.
[**2134-7-8**] 5:21 pm JOINT FLUID Source: Knee.
GRAM STAIN (Final [**2134-7-8**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-7-11**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-7-9**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2134-7-9**] 12:10 pm FLUID,OTHER Site: KNEE
LEFT KNEE SYNOVIAL FLUID.
GRAM STAIN (Final [**2134-7-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-7-12**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-7-15**]): NO GROWTH.
[**2134-7-9**] 12:10 pm FLUID WOUND Site: KNEE
SYNOVIAL FLUID DRAINED FROM LFT. KNEE.
GRAM STAIN (Final [**2134-7-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-7-12**]): NO GROWTH.
IMAGING:
==========
[**2134-7-3**]
PORTABLE AP CHEST RADIOGRAPH: Mild left base
atelectasis/scarring again seen.
There is no focal consolidation or pneumothorax. There is no
vascular
congestion or pleural effusions. Cardiomediastinal and hilar
contours are
within normal limits.
IMPRESSION: No acute cardiopulmonary process.
[**2134-7-4**]
PORTABLE CHEST XRAY
Right subclavian central line tip at SVC/RA junction. No
pneumothorax
detected.
There are low inspiratory volumes. Allowing for this, I doubt
the presence of
significant CHF. Bibasilar atelectasis noted. No effusion.
Compared with [**2134-7-3**], at 22:37 p.m., the right central line
appears to have
been retracted. On the current examination, comparative density
between the
right and left chest is similar, suggesting that the appearance
on the most
recent previous film was an artifact related to overlying soft
tissues.
[**2134-7-3**]
LENIS
IMPRESSION:
1. No DVT in the left leg. Marked left lower extremity edema
without fluid
collections.
[**2134-7-4**]
LOWER EXTREMITY CT
CT LEFT LOWER EXTREMITY. MDCT imaging was performed from the mid
femur to the
ankle without IV contrast. Sagittal and coronal reformats were
performed.
COMPARISON: Left leg venous ultrasound [**2134-7-3**].
FINDINGS: The patient has undergone total left knee
arthroplasty, and the
hardware appears intact. There are no fractures. Degenerative
changes are
present at the ankle, and mid foot.
[**2134-7-4**]
ABDOMINAL XRAY
No SBO, inadequate evaluation of free air due to portable
technique. Sigmoid
dilated to 10.5cm is air filled, recommend continued evaluation
and followup
abdominal film if indicated.
- PORTABLE ABDOMEN Study Date of [**2134-7-6**] 9:01 AM
IMPRESSION: Similar moderate colonic distention. No definite
evidence of pneumoperitoneum, within the limits of supine
radiograph.
- KNEE (2 VIEWS) LEFT Study Date of [**2134-7-9**] 2:26 PM
IMPRESSION: Post-surgical changes of the left knee. Status post
I and D. Intact hardware.
- PORTABLE ABDOMEN Study Date of [**2134-7-12**] 9:38 AM
FINDINGS: Again seen is gaseous distention of the colon,
measuring up to 9.5
cm in diameter. There are no definite loops of air filled
distended small
bowel. No large quantity of free air is identified on the supine
radiographs.
IMPRESSION: Persistent gaseous distention of the colon,
consistent with
ileus.
- PORTABLE ABDOMEN Study Date of [**2134-7-15**] 3:19 PM
IMPRESSION: No significant change in the degree of colonic
distention, most
consistent with ileus.
- PORTABLE ABDOMEN Study Date of [**2134-7-17**]
Read PENDING
PATHOLOGY
=========
Pathology Report Tissue: GI BX'S (2 JARS) Study Date of [**2134-7-16**]
Report not finalized.
Assigned Pathologist [**Last Name (LF) **],[**First Name3 (LF) **] M.
Logged in only.
PATHOLOGY # [**-1/2754**]
GI BX'S (2 JARS)
Brief Hospital Course:
57 year-old female with a past medical history of bipolar,
dementia, recent left TNK on [**6-15**] presenting with sepsis with
probable source from C.Difficile infection.
# Sepsis with probable source of C.Diff infection: Originally
thought to be from possible septic joint/cellulitis, and
empirically started on vancomycin/cefepime. Patient was initally
septic, and was transferred to the ICU from the ED. No evidence
of septic joint on aspiration. Incision site appeared CDI on
exam. Joint fluid not consistent with septic joint while on
antibiotics. C.Diff positive on assay. Discontinued IV
vancomycin/cefepime and placed on PO vancomycin with IV Flagyl.
Clinical picture is much improved with hemodynamic stability
by HD#2. Patient was transferred to the floor where treatment
for C. diff continued. While on the floor, patient's knee became
more painful with surrounding erythema and swelling. A repeat
tap was done which showed elevated WBC copunt and >90% PMN. She
was taken back to the OR for debridement of the knee with
replacement of lining on [**2134-7-9**]. Patient tolerated the
procedure well, but upon returning to the floor had an increase
in the volume of her diarrhea. She was continued on PO
Vancomycin and IV Flagyl for treatment of C. diff and multiple
KUB's demonstrated colonic gaseous distension. She never vomited
and continued to have copious diarrhea at this time. Patient
tolerated a full diet, and stool volume decreased and became
less loose over time, though gaseous distension remained. She
was without abdominal pain. The distension was deemed to be
chronic ileus and she was discharged with instructions to follow
up in two months for repeat KUB.
# Sigmoid dilation on KUB: No evidence of obstruction, however
11 cm dilated sigmoid on KUB. Concern for possible toxic
megacolon. Continued NPO status and got surgical evaluation for
aid in management. With improving clinical picture, toxic
megacolon was deemed unlikely. Rectal tube placed with improved
symptomatology. Repeat KUB post rectal tube showed stable
dilation and absence of abdominal complaints in patient. She
tolerated food, and had stool output that progressed from
copious and watery to smaller quantities and semi-formed. She
remained afebrile and asymptomatic and the distension was felt
to be a chronic ileus. GI performed a flexible sigmoidoscopy
which per report did not show any pseudomembranes; biopsies were
taken and are pending at the time of discharge.
#Fluid Balance: LOS fluid balance +11 Liters during treatment
for sepsis and electrolyte abnormalities. However, patient had
large volume watery stool output and was NPO for procedures on
several days, decreasing her fluid balance. Clinically, patient
was euvolemic on discharge.
#Status Post TKR and subsequent washout with lining replacement:
Patient's original septic picture was felt to be from C.diff but
she subsequently developed septic arthritis in the left knee
given marked pain, erythema, and swelling in the affected knee.
She went back to the OR for debridement and replacement of the
prosthetic lining. Cultures of the joint fluid and blood were
negative, and samples of the joint tissue were sent for PCR.
Without organism identified, patient was started on IV
Vancomycin to cover the most likely offending organisms, and has
been stable and improving on that therapy to discharge.
Chronic Diagnoses:
# Bipolar affective disorder: Continued depakote, risperidone,
and lorazepam
# Anemia: Patient's Hct dropped in hospital in the setting of
multiple procedures, blood draws, and acute illness, but was
stable on discharge. Iron studies showed pattern consistent with
anemia of chronic disease. She was discharged with iron
supplementation.
Transitional Issues:
Patient will be discharged to rehab for extended recovery with
PT. From there she will be evaluated for home services.
Orthopedic followup: Patient will be seen for a wound check with
her orthopedist on [**2134-7-23**]. Stitched should remain in until
this time.
Patient should stay on Lovenox 40units SC daily for 3 weeks, and
then discuss with her orthopedist taking aspirin for an
additional 3 weeks.
Infectious disease followup:
Patient will continue IV Vancomycin therapy for a total of 6
weeks post-surgery and send weekly BUN, CR, CBC with Diff
vancomycin trough level and LFT's to the [**Hospital **] clinic.
Patient will continue IV Flagyl for C.diff for 2 weeks
post-discharge, and continue oral vancomycin until tapered down
by her infectious disease doctor.
The results of the PCR test of joint tissue will be available in
a few weeks and should be followed up by the infectious disease
doctors.
PCP [**Name Initial (PRE) 4939**]:
Patient will see her PCP within one week of discharge and
arrange for a repeat KUB in two months to evaluate her chronic
ileus. The results of patient's flexible sigmoidoscopy with
biopsies should be available for PCP's review as well.
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*100 Tablet(s)* Refills:*0*
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. risperidone 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
Disp:*28 syringe* Refills:*0*
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg/0.4mL
Subcutaneous once a day: One injection to abdomen daily.
Disp:*21 40mg/0.4mL* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
5. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 35 days.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 2
weeks.
13. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
14. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
15. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
18. risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six
(6) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: septic arthritis of left knee, C. diff colitis, Chronic
Ileus
Secondary: Anemia, Bipolar Disorder, 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:
Dear Ms. [**Known lastname **],
You were admitted to the hospital because you had fever and low
blood pressure at your rehab. You were found to have an
infection called C. diff colitis in your colon. You were
stabilized in the ICU with antibiotics were and transferred to
the medical floor. On the medical floor, your knee became red
and inflamed with a new infection and the orthopedic surgeons
performed a surgery to clean out the infection from your knee on
[**2134-7-9**]. When you returned from surgery, you continued to have
diarrhea as you were still recovering from C. diff colitis.
Because you had so much abdominal distension at this time, and
because your diarrhea lasted so long, the gastroenterologists
performed a flexible sigmoidoscopy procedure to look inside your
colon and take samples to be sure there wasn't a persistant
infection or other visible cause for your diarrhea in addition
to the infection. Shortly afterwards, your diarrhea greatly
improved, your knee appeared to be healing well, and it was felt
that your were ready to transfer to a rehabilitation facility
for the remainder of your recovery. Your belly remains distended
with gas, but because you are eating and stooling without issue,
this can be followed up as an outpatient.
Please make the following changes to your home medications:
1. START taking Lovenox 40 units by subcutaneous injection daily
for three weeks following discharge. When that is complete after
three weeks, DISCUSS taking aspirin for an additional 3 weeks
with your PCP and orthopedic surgeon, as this may interact with
your Divalproex.
2. START wearing TEDS stockings for a total of six weeks
3. START taking Vancomycin 1,000mg twice daily intravenously
until [**9-20**].
4. START taking metronidazole 500mg every eight hours
intravenously for two weeks
5. START taking Vancomycin 250mg by mouth every six hours until
you are instructed to stop by your infectious disease doctor.
Please send the following lab results weekly starting [**2134-7-20**] to
the Infectious Disease Clinic at [**Telephone/Fax (1) 1419**]:
CBC with diff, BUN, creatinine, liver function tests, and
vancomycin trough levels (one hour before you receive your dose)
The Orthopedic Surgeons have the following discharge
instructions for you as well, some of which overlap with your
medical team's 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. 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.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in two (2) 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 (3)
weeks to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg TWICE daily
for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
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 two (2)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise
or heavy lifting until follow up appointment.
Followup Instructions:
Call Dr[**Name (NI) **] office at [**Telephone/Fax (1) 1228**] to be seen on [**7-23**]
for a wound check for your leg.
Please call to confirm your appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**]
in the Infectious Disease Clinic at [**Hospital1 827**]. It is scheduled for:
DATE: [**2134-7-29**]
TIME: 9AM
Please contact your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**] at [**Telephone/Fax (1) 823**], to
schedule a follow-up appointment within a week of discharge. You
will need a follow-up abdominal x-ray in two months to verify
that your belly distension is chronic when you are eating and
stooling normally.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
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80,287
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42069
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Discharge summary
|
report
|
Admission Date: [**2173-9-15**] Discharge Date: [**2173-10-6**]
Date of Birth: [**2132-11-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Compazine / Benadryl
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Transfer from OSH for increasing apneic spells secondary to
tracheobronchomalacia
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
40 yo F with h/o obesity, obstructive v central sleep apnea, and
tracheomalacia requiring tracheostomy. She was admitted to
[**Hospital 1727**] Medical on [**9-1**] with LE cellulitis and treated with IV
vancomycin and cefepime for 5 days and switched to PO Keflex. On
[**9-3**], her trach was changed out but she became apneic,
unresponsive, and hypoxic, with desaturation to the 30s. She was
given narcan without significant changes. A head CT was normal.
She was bagmask ventilated with improvement of her saturations
to 100%. She was placed on a vent transiently, but subsequently
weaned back to trach collar. On [**9-7**], the patient underwent a
bronchoscopy that showed severe tracheobroncheomalacia with
80-90% collapse. The patient is transfered here for
Interventional Pulmonary evaluation and possible treatment for
her TBM.
.
Of note, at night, her trach is capped, and she wears oronasal
adaptive servo ventilation with O2 bled in. She has significant
baseline dyspnea with exertion and central apneic spells. She is
reported to be comfortable at rest without dyspnea or hypoxia,
or hemodynamic instability. On the floor, the patient is stable
and comfortable. She notes that her lower extremity cellulitis
has much improved. Her breathing is stable and she is not
hypoxic, nor dyspnic while speaking. She states that her apneic
episodes are initiated by coughing spasms.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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:
- Morbid Obesity
- Obstructive Sleep Apnea
- Trachealmalacia s/p tracheostomy
- Iron Deficiency Anemia
- Asthma
- Insulin Dependent Diabetes Mellitus
- Hypothyroidism
- Depression
- Multiple Sclerosis
- Anxiety/Depression
- Chronic Venous Stasis
- GERD
- DVT/PE
- Hypothyroidism
Social History:
She lived at Brentwood Skilled Nursing Facility. No tobacco,
alcohol, drugs.
Family History:
DM, Hypothyroidism
Physical Exam:
ADMISSION EXAM
VS: 97.4, 118/70, 85, 18, 95% trach mask
GA: AOx3, NAD, obese
HEENT: PERRLA. MMM.
Cards: distant heart sounds, RRR S1/S2 heard. no
murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, obese NT, +BS. no g/rt.
Extremities: slight edema, dried, cracked skin of anterior shin
of site of treated cellulitis. No fluctuance, overlying
erythema, or drainage
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Gait not tested
DISCHARGE EXAM
VS: 97.7, 120/70, 72, 18, 97% on 40% tach mask
Gen: NAD
Heart: RRR, no MRG
Lungs: CTAB, slight decreased breath sounds at bases
Abd: soft, NT, obese, +BS
Ext: resolving cellulitis, some chronic stasis dermatitis
changes
Pertinent Results:
ADMISSION LABS
[**2173-9-16**] 06:25AM BLOOD WBC-7.6 RBC-4.05* Hgb-10.5* Hct-33.0*
MCV-81* MCH-25.8* MCHC-31.7 RDW-17.5* Plt Ct-359
[**2173-9-16**] 06:25AM BLOOD PT-11.8 PTT-25.5 INR(PT)-1.0
[**2173-9-16**] 06:25AM BLOOD Glucose-134* UreaN-21* Creat-0.6 Na-139
K-4.2 Cl-98 HCO3-30 AnGap-15
[**2173-9-16**] 06:25AM BLOOD Calcium-10.1 Phos-3.8 Mg-1.5*
.
DISCHARGE LABS
[**2173-10-6**] 05:19AM BLOOD WBC-6.9 RBC-3.29* Hgb-8.3* Hct-26.0*
MCV-79* MCH-25.3* MCHC-32.0 RDW-16.8* Plt Ct-386
[**2173-10-6**] 05:19AM BLOOD Glucose-134* UreaN-39* Creat-1.7* Na-142
K-3.9 Cl-102 HCO3-32 AnGap-12
[**2173-10-6**] 05:19AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.0
.
PERTINENT LABS
[**2173-9-21**] 02:28AM BLOOD Neuts-78* Bands-4 Lymphs-13* Monos-3
Eos-0 Baso-1 Atyps-1* Metas-0 Myelos-0
[**2173-9-21**] 02:28AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL Bite-OCCASIONAL
[**2173-9-27**] 06:11AM BLOOD Ret Aut-1.1*
[**2173-9-27**] 06:11AM BLOOD calTIBC-283 Hapto-315* Ferritn-105
TRF-218
[**2173-9-30**] 08:08AM BLOOD Type-ART Temp-36.7 FiO2-40 pO2-35*
pCO2-71* pH-7.28* calTCO2-35* Base XS-3 Intubat-NOT INTUBA
[**2173-9-29**] 08:39AM BLOOD Type-ART Temp-36.7 pO2-136* pCO2-59*
pH-7.34* calTCO2-33* Base XS-4 Intubat-NOT INTUBA
[**2173-9-21**] 02:43AM BLOOD Type-[**Last Name (un) **] pO2-77* pCO2-54* pH-7.34*
calTCO2-30 Base XS-1 Comment-GREEN TOP
[**2173-9-19**] 11:04PM BLOOD Type-ART pO2-96 pCO2-57* pH-7.34*
calTCO2-32* Base XS-2
[**2173-9-18**] 02:26AM BLOOD Type-ART pO2-65* pCO2-57* pH-7.36
calTCO2-34* Base XS-4 Intubat-INTUBATED
[**2173-9-29**] 05:14AM BLOOD LEAD (BLOOD)-Test - negative
.
MICROBIOLOGY
[**2173-9-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT - negative
[**2173-9-21**] URINE URINE CULTURE-FINAL INPATIENT - no
growth
[**2173-9-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STAPH AUREUS COAG +} INPATIENT (MRSA positive)
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2173-9-18**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2173-9-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT - negative
[**2173-9-17**] URINE URINE CULTURE-FINAL - negative
.
PERTINENT STUDIES
[**9-17**] CT trachea: IMPRESSION:
1. There is no CT evidence to suggest tracheobronchomalacia.
2. Small hiatal hernia.
.
[**9-17**] PFTs:
SPIROMETRY 8:56 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 0.88 3.67 24
FEV1 0.72 2.85 25
MMF 0.77 3.25 24
FEV1/FVC 81 78 105
DLCO 8:56 AM
Actual Pred %Pred
DSB 7.34 21.50 34
VA(sb) 1.27 5.41 23
HB 10.50
DSB(HB) 8.17 21.50 38
DL/VA 6.45 3.97 162
.
[**9-20**] EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of mild diffuse background slowing and slow alpha rhythm. These
findings are indicative of mild diffuse cerebral dysfunction
which is
etiologically non-specific. None of the patient's typical
episodes of
confusion were recorded during the study. No epileptiform
discharges or
electrographic seizures are present.
.
[**9-22**] 24 hour EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of mild diffuse background slowing. These findings are
indicative of
mild diffuse cerebral dysfunction, which is etiologically
non-specific.
There was one pushbutton event for unclear reasons, and the EEG
around
this time shows no change from baseline. There were no
epileptiform
discharges or electrographic seizures. Compared to the prior
day's
recording, there is no significant change.
.
[**9-22**] Renal US
FINDINGS: The right kidney measures 14.4 cm and the left kidney
measures 13.7 cm. There is no hydronephrosis. No cyst or stone
or solid mass is seen in either kidney. No perinephric fluid
collection is identified. The bladder is collapsed on a Foley
catheter.
IMPRESSION: No hydronephrosis. Unremarkable renal ultrasound.
.
[**9-23**] MRI brain
FINDINGS:
There are scattered areas of periventricular and subcortical
white matter
signal abnormality identified, which are nonspecific, though
likely related to the patient's known history of multiple
sclerosis. There is no associated T1 signal abnormality.
Otherwise, the brain parenchyma is normal in signal intensity.
There is no
signal abnormality identified within the brainstem. There is no
evidence of hemorrhage. There is no parenchymal edema, mass
lesion, or mass effect. There is no focus of abnormal
susceptibility to suggest the presence of blood products, and
there is no area of slow diffusion to suggest acute or subacute
infarct.
Ventricles and sulci are normal in size and configuration. There
is no shift of midline structures or effacement of the basal
cisterns.
The globes, orbits, and extracranial soft tissues are normal.
Paranasal
sinuses and mastoids are well aerated.
IMPRESSION:
1. White matter T2/FLAIR signal abnormalities, in the
subcortical and
periventricular white matter, which are by imaging nonspecific,
given the
clinical history of multiple sclerosis, likely reflect MS
plaques.
2. No acute intracranial process identified, including no
hemorrhage, edema, mass effect, or infarct. No explanation for
"unresponsiveness".
.
[**9-20**] Bronchoscopy: The flexible bronchoscope was advanced
through the mouth. The vocal cords appeared mildly erythematous.
The proximal tracheal mucosa was edematous and mildly
erythematous. The tracheostomy tube was approximately 3cm from
the vocal cords. The #6 Portex cuffed tracheostomy tube was
partially retracted to allow for passage of the scope to distal
airways. Minimal granulation tissue was noted at the edge of the
stoma. A prominent posterior membrane was present in the
trachea. Left and right lungs to the segmental level were patent
without lesions.
.
other findings: Dynamic maneuvers were performed with the
following findings: trachea proximal to stoma - unable to assess
malacia due to edema; trachea distal to stoma - no collapse; LMS
- no collapse; RMS - severe 100% collapse; [**Hospital1 **] - mild collapse.
The scope was then removed and the procedure completed.
Brief Hospital Course:
This is a 40 yo F with PMH significant for central apnea/obesity
hypoventilation syndrome, MS, tracheomalacia, respiratory
distress s/p tracheostomy, DM2, hypothyroid, and
depression/anxiety who was transfered to [**Hospital1 18**] for further
evaluation of her tracheomalacia and recurrent episodes of LOC.
ACTIVE ISSUE
# Unresponsiveness: During this hospitalization, the pt had
multiple episodes of LOC witnessed by hospital staff, lasting
from 1 min to 15 mins. Her unresponsive episodes were always
self-limited with stable VS during the interim. It is not
exactly clear the underlying etiology of her recurrent
unresponsiveness. The current working diagnosis is between
unusually high sleeping drive vs pseudoseizure. During the
first episode, a code blue was called and she was transferred to
the MICU. It was notable that pt maintained normal HR, BP, and
O2 sats throughout these episodes. There had been several
episodes that pt was reported to have bilateral LE tremor.
Neurology was consulted. CT head showed no evidence of acute
bleed. 24 hour EEG monitoring was performed, which did not show
evidence of epileptic wave form during those unresponsive
episodes. There was also no evidence of narcolepsy or cataplexy
given the lack of transition between awake wave to REM sleep
wave. Inpatient sleep study was performed with patient using
trach mask at 40% FiO2 showed moderate sleep apnea, central >
obstructive process. Of note, pt remained stable vital signs
with good oxygen saturation throughout the night. Pt is
recommended to sleep with trach mask at 40% FiO2 per our sleep
team after conducting and reviewing the sleep studies. We
started her on Provigil in the AM, which could be uptitrated as
tolerated. So far patient did very well since the initiation of
this medication, and has not had any unresponsive episodes.
# Tracheomalacia: Pt was transferred to [**Hospital1 18**] for concerns of
tracheomalacia identified on bronchoscopy at OSH. The patient
was seen by our interventional pulmonologists for workup of her
frequent apneic spells associated with coughing spasms. The
patient had PFT testing, a CT trachea/bronchial protocol, and a
bronchoscopy. The bronchoscopy showed 100% collapse of the RMS
of the right lobe. The other segments of the lungs did not
collapse. The study also showed erythema and edema of the
subglottis suggestive of laryngeal reflux. There is no evidence
of air way collapse on CT trachea/bronchial protocol. Because of
these findings, the pulmonologists did not feel that stenting of
the RMS would provide improvement of her apnea. Pt is a poor
surgical candidate given her medical comordities, which makes
stenting not desirable as it is often a temporary intervention.
Currently we recommend optimzing her management of GERD and
asthma, which are the likely underlying cause for her cough.
# Leukocytosis: The patient developed a low grade fever and
leukocytosis (WBC 22.9) on HD#2. Blood, urine, and sputum cx
were sent and she was started on vanc/zosyn. Sputum cx grew
MRSA, and zosyn was discontinued. Her leukocytosis quickly
resolved, by #HD4 was wnl, suggesting it may have been
post-procedural. However given the e/o MRSA in her sputum she
completed 5 day course of IV vancomycin.
# Acute renal faliure: On HD#4 pt had acute rise in creatinine
from 0.8 to 1.5. Her creatinine continued to rise to 3.0 and
then stabilized. Fractional excretion of Na was <1%, however
her creatinine did not improve with IV fluids. Labs showed no
peripheral or urine eos to suggest AIN, and renal U/S ruled out
obstruction. Renal service was consulted and observed muddy
brown casts in urine, suggesting ATN. Pt is maintaining good
urine output, however, her creatinine has not returned to her
baseline at the time of discharge. She should continue
supportive care (avoid diuretics or nephrotoxic agents, trend
creatinine) and follow up with her PCP to ensure resolution of
her creatinine.
# Conjunctival hemorrhage: Pt was noted to have bilateral
conjunctiva hemorrhage and periocular lesion during this
admission. Pt was seen by opthalmology. The nature of the
lesion was thought to be traumatic. Upon discharge, clearance
of her hemorrhage has been noticed.
# Meralgia Paresthetica: Pt c/o numbness and burning sharp pain
on lateral aspects of right thigh. The presentation was
consistent with meralgia parathetica, especially given her body
habitus and long time on the bed. We discontinued morphine and
started her on gabepentin 300 [**Hospital1 **]. Please uptitrate as needed.
# Anemia: Microcytic anemia with Hct in mid 20s. Per pt, pt had
long history of iron deficiency anemia. Per patient, she could
not absorb po iron. In the past, she had received iv iron via
portcath, which was placed 3 years ago. Her last treatment
according to her was 6 months ago. Workup is notable for mild
iron deficiency with normal ferritin. There is no clinical
evidence of bleeding. Her lead level was also normal.
CHRONIC ISSUES:
# Multiple sclerosis: Pt has a documented history of MS. She
underwent a non-contrast MRI which showed white matter T2/FLAIR
abnormalities in the periventricular white matter which likely
reflect old MS plaques. Pt had a baclofen pump, which runs at
1148.4mcg/day. The pump has been followed by Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1356**]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 91297**]).
# Retinitis Pigmentosa: Pt has documented history of retinitis
pigmentosa. She was evaluated by ophthalmology during this
admission. Her central vision was 20/30 bilaterally. However,
her peripheral vision was signficantly compromised bilaterally.
# DM2: The patient has documented history of type 2 DM. She was
treated with home dose glargine and sliding scale short acting
insulin.
# Hypothyroidism: we continued levothyroxin 200 mg daily.
#. LE cellulitis: Resolved. LE with stasis dermatitis changes
but no concern for reinfection.
#. Depression: The patient was continued on her Paxil and
Abilify. We discontinued clonazepem given the risk of
respiratory depression.
TRANSITIONAL ISSUES
# CODE STATUS: FULL
# ACCESS: peripheral IV, portcath
# MEDICATION CHANGES:
- STARTED Modafinil 100 mg qAM
- STARTED Gabapentin 300 mg q12h
- STARTED ferrous sulfate 300 mg qd
- STARTED Pantoprazole 40 mg [**Hospital1 **]
- STOPPED Omeprazole
# FOLLOW UP ISSUES:
- Pt is recommended to sleep with trach mask at 40% FiO2, NOT
BiPAP via nasal pillow. She should continue to be followed by
her outpatient sleep doctor.
- Please follow her Cr as it has been down trending after her
ATN. In the mean time, please avoid nephrotoxic medication and
renally dose all medication.
- Pt need follow up with ophthalmology for retinitis
pigmentosa. It was found stable during this admission.
- Pt need neurology follow up with multiple sclerosis. It was
found stable during this admission.
- [**Month (only) 116**] uptitrate her gabapentin for meralgia paresthetica as
needed
- Please follow on iron deficiency anemia. Pt had iv iron
supplement in the past.
- [**Month (only) 116**] uptitrate her Provigil as tolerated.
- Please avoid sedating medication, such as opiates and Benzo.
Medications on Admission:
Advair 250/50 1 puff q 12
Montelukast 10mg PO daily
Albuterol/Ipratropium nebs prn
Vancomycin 1750mg IV q12
Cefepime 2g IV q12
Heparin 7500u sc TID
Simvastatin 40mg PO daily
Senna 1 tab PO qhs
TUMS 2 tabs daily
Insulin Lispro TID with meals (no dosing)
Insulin glargine 20 units sc BID
Aripiprazole 5mg PO daily
Clonazepam 0.5mg PO qhs
Paroxetine 60mg PO daily
Vitamin D 800 untis PO daily
Levothyroxine 200mcg PO daily
Calcium/Vitamin D 125 U 2 tab tid PO
Discharge Disposition:
Extended Care
Facility:
[**Hospital 32458**] Rehab
Discharge Diagnosis:
Primary Diagnosis:
- Tracheobronchomalacia
- Laryngeal Reflux
Secondary Diagnosis:
- central sleep apnea
- obstructive sleep apnea
- multiple sclerosis
- retinitis pigmentosa
- meralgia paresthetica
- microcytic anemia
- GERD
- asthma
- diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
You were admitted to the hospital because you had increased
episodes where you became unresponsive during the day and
sometimes stopped breathing associated with coughing spasms. Our
pulmonary colleagues performed a bronchoscopy that showed some
collapse of a small part of the lung, but nothing that requires
stenting or surgical repair. They recommended optimizing
treatment for your acid reflux and asthma. You were also found
to have multiple episodes of unresponsiveness. We don't have a
good explanation for these episodes, but we don't think they are
seizures, or complications from your multiple sclerosis. You
also underwent sleep study, and our sleep specialist felt that
sleep with trach mask is the best option at this time, and there
is no need to use BiPAP. We felt that right now are you stable
and can go to an extended care facility for continued care.
.
Please note that the following medication has been changed:
- Please START to take Modafinil 100 mg tablet by mouth in AM
daily
- Please START to take Gabapentin 300 mg capsule by mouth every
12 hours
- Please START to take ferrous sulfate 300 mg tablet by mouth
daily
- Please START to take Pantoprazole 40 mg tablets by mouth twice
a day
- Please START to apply miconazole powder to groin area twice a
day
- Please START to apply Camphor-menthol lotion to dry skin as
needed daily
- Please STOP clonazepam as it may cause problems with your
somnolence
- There is otherwise no change to your previous medication list.
.
It has been a pleasure taking care of you here at [**Hospital1 18**]. We
wish you a speedy recovery.
.
NOTE: PLEASE MAKE SURE THAT YOUR FOLEY IS REMOVED UPON ARRIVAL
OF THE EXTENDED CARE FACILITY
Followup Instructions:
Please make sure that you have follow up appointments with your
previous neurologist, ophthalmologist, and sleep specialist
after returning to [**State 1727**].
|
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16,752
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43558+58632
|
Discharge summary
|
report+addendum
|
Admission Date: [**2110-8-29**] Discharge Date: [**2110-9-4**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization-[**2110-8-29**]
History of Present Illness:
[**Age over 90 **] yo male with h/oCAD s/p anterior MI in [**2-15**] with a stent to
the LAD. This was complicated by dissection of LM, which was
then stented (jailing the LCx). Had a relook [**Date Range **] in [**5-17**] with
patent LM, LAD stentsbut extensive 3vd. He presented today with
acute SOB and subsequently found to be in CHF. He also had ST
depressions in V3-V5 and a TroponinT of .54. He received
heparin, integrillin and IV lasix in the ED and taken to [**Date Range **]
lab.
[**Date Range **] showed patent LM, LAD stents, but occluded LCx. Procedure
was complicated by inability to pass a wire into the LCx(the
stent in the LM was protruding into the aorta). Therefore, he
was not revascularized. Also had elevated PCWP=30 and a mixed
venous O2 of 46%. He was started on dobutamine and this
increased to 62%. Currently, he is feeling much better. Now
without CP, SOB, as compared to the morning, when he had PND,
SOB, and his anginal symptoms.
Past Medical History:
1.CAD s/p anterior wall MI in [**2-15**]
2.CRI with baseline Cr of 1.7-1.9
3.PMR-on prednisone chronically
4.Hypothyroidism
5.Hypercholesterolemia
6.HTN
Social History:
Married and lives with his wife.
[**Name (NI) **] 1 son
50 pack year smoking history, but quit 30 years ago.
Family History:
Non-contributory
Physical Exam:
Vitals: HR=106, BP=96/44, RR=24-28, O2 sat=100% on NRB
Gen: Mild respiratory distress, lying supine
HEENT: MMM, NCAT, No LAD
Resp: No accessory muscle use, Crackles laterally bilat.
CV:RRR, no MRG, nL S1, S2, no S3,S4
Abd:+BS, NT/ND, Soft. Abdominal Hernia present on Right.
Ext: No femoral bruits, distal pulses dopplerable bilat., 2+
pitting edema to knees bilat.
Neuro:A&O
Skin: Cool, pink
Pertinent Results:
[**2110-8-29**] 12:30PM BLOOD WBC-14.9* RBC-2.97* Hgb-9.3* Hct-28.0*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.6 Plt Ct-480*
[**2110-8-29**] 10:23PM BLOOD WBC-10.8 RBC-2.58* Hgb-7.8* Hct-24.3*
MCV-94 MCH-30.1 MCHC-32.0 RDW-13.6 Plt Ct-372
[**2110-8-31**] 05:58AM BLOOD WBC-15.1*# RBC-3.40* Hgb-10.4*# Hct-30.2*
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.8* Plt Ct-294
[**2110-9-1**] 05:41AM BLOOD WBC-12.4* RBC-3.47* Hgb-10.6* Hct-31.5*
MCV-91 MCH-30.6 MCHC-33.7 RDW-15.2 Plt Ct-297
[**2110-9-3**] 05:15AM BLOOD WBC-13.0* RBC-3.52* Hgb-10.6* Hct-32.0*
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.6 Plt Ct-242
[**2110-8-29**] 10:23PM BLOOD Neuts-81.5* Lymphs-11.8* Monos-5.1
Eos-1.4 Baso-0.2
[**2110-9-3**] 05:15AM BLOOD Plt Ct-242
[**2110-8-29**] 12:30PM BLOOD PT-12.8 PTT-22.0 INR(PT)-1.1
[**2110-9-2**] 05:23AM BLOOD PT-12.9 PTT-45.3* INR(PT)-1.1
[**2110-8-29**] 12:30PM BLOOD Glucose-108* UreaN-44* Creat-2.1* Na-137
K-4.3 Cl-103 HCO3-19* AnGap-19
[**2110-8-31**] 05:58AM BLOOD Glucose-104 UreaN-34* Creat-1.8* Na-141
K-4.0 Cl-104 HCO3-23 AnGap-18
[**2110-9-1**] 05:41AM BLOOD Glucose-94 UreaN-35* Creat-1.6* Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
[**2110-9-3**] 05:15AM BLOOD Glucose-96 UreaN-37* Creat-1.5* Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
[**2110-8-31**] 01:50PM BLOOD LD(LDH)-337* TotBili-0.7
[**2110-8-29**] 12:30PM BLOOD CK(CPK)-90
[**2110-8-29**] 10:23PM BLOOD CK(CPK)-135
[**2110-8-30**] 05:00AM BLOOD CK(CPK)-136
[**2110-8-30**] 12:21PM BLOOD CK(CPK)-130
[**2110-8-29**] 12:30PM BLOOD cTropnT-0.54*
[**2110-8-29**] 10:23PM BLOOD CK-MB-15* MB Indx-11.1* cTropnT-0.73*
[**2110-8-30**] 05:00AM BLOOD CK-MB-14* MB Indx-10.3*
[**2110-8-30**] 05:00AM BLOOD cTropnT-0.80*
[**2110-8-30**] 12:21PM BLOOD CK-MB-12* MB Indx-9.2*
[**2110-8-30**] 05:00AM BLOOD Calcium-7.8* Phos-4.3# Mg-1.7
[**2110-9-3**] 05:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.6
[**2110-8-31**] 01:50PM BLOOD calTIBC-209* Ferritn-458* TRF-161*
[**2110-9-1**] 05:41AM BLOOD TSH-1.1
[**2110-8-30**] 05:00AM BLOOD Cortsol-92.8*
[**2110-8-29**] 04:05PM BLOOD Type-ART pO2-61* pCO2-28* pH-7.46*
calHCO3-21 Base XS--1 Intubat-NOT INTUBA
[**2110-8-30**] 01:40AM BLOOD Type-ART O2 Flow-4 pO2-77* pCO2-33*
pH-7.47* calHCO3-25 Base XS-0 Intubat-NOT INTUBA
[**2110-8-30**] 01:42AM BLOOD Type-ART pO2-130* pCO2-34* pH-7.47*
calHCO3-25 Base XS-2
[**2110-9-1**] 05:58AM BLOOD Type-ART pO2-90 pCO2-39 pH-7.47*
calHCO3-29 Base XS-4
[**2110-8-29**] 04:05PM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-91
[**2110-9-1**] 05:58AM BLOOD O2 Sat-97
[**2110-8-29**] 11:09PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-<1.005
[**2110-8-29**] 11:09PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-TR
[**2110-8-29**] 11:09PM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
URINE CULTURE (Final [**2110-8-31**]): NO GROWTH.
Blood and Catheter tip Cx NTD.
[**Month/Day/Year **]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed severe coronary artery disease. The LMCA was extremely
difficult to engage. It was eventually best engaged with a JL5
cattheter. The LMCA had only mild disease. The LAD had diffuse
disease.
The previously placed LAD stent was patent. The LCx was totally
occluded. The RCA was not engaged.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with a depressed cardiac index.
3. Failed PCI of the LCX.
FINAL DIAGNOSIS:
1. NSTEMI.
2. Severe coronary artery disease.
3. Elevated filling pressures and depressed cardiac output.
4. Failed PCI of the LCX.
Abd CT:
IMPRESSION:
1. No evidence of retroperitoneal hematoma or intraperitoneal
hematoma.
2. Infrarenal abdominal aortic aneurysm measuring 4.2 cm in
greatest dimension.
3. Bowel containing right inguinal hernia without evidence of
bowel obstruction.
4. Bilateral pleural effusions with atelectasis.
Echo: EF=35%
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity
size are normal. There is moderate regional left ventricular
systolic
dysfunction with focal hypokinesis of the basal half of the
inferior and
inferolateral walls and distal lateral and apical walls. The
remaining
segments contract well (suboptimal views). Right ventricular
chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (tape unavailable
for review)
of [**2-15**], the inferior and inferolateral dysfunction is new c/w
interim
ischemia/infarction. The severity of mitral regurgitation has
slightly
increased.
Brief Hospital Course:
This [**Age over 90 **] yo male with a CAD history came from the [**Age over 90 **] lab on
dobutamine due to CHF in the setting of his acute MI. He was
not able to be revascularized.
1.CAD: He was put on ASA, Plavix, and a statin, but not heparin,
as his vessel is totally occluded. A B-blocker and ACE-I were
initially held due to hypotension. His enzymes were followed
until they began to trend down. NTG was used as needed for
chest pain. His BP began to improve, and his dobutamine was
weaned off. An ACE-I was gradually added as his BP would
tolerate, and then a B-blocker was added as he recovered
further. On D/C, he was on stable doses of both with good
tolerance of his BP and heart rate. He remained CP free
throughout the hospitalization. He had daily ECGs which showed
no new ischemia. He was sent home with NTG to use for anginal
pain.
2.Pump: He was initially in CHF with high filling pressures and
MR [**First Name (Titles) **] [**Last Name (Titles) **]. Likely result of acute MI. He was initially on
dobutamine post-[**Last Name (Titles) **]. This was weaned, but his BP was kept at
levels high enough to ensure renal perfusion and adequate CO.
He was also given Lasix as needed for gentle diuresis as his BP
would tolerate. This improved his pulmonary symptoms. In
addition, an ACE-I was added as soon as he could tolerate it for
afterload reduction. This was not done immediately, as he
remained on the hypotensive side early in his admission. He was
requiring O2 due to maintain adequate oxygenation. By D/C, he
was maintaining adequate O2 saturations on room air. He had an
echo which showed an EF of 35% His LE edema, pulmonary edema,
and JVD all gradually resolved as he recovered in the hospital.
He had an arterial line placed to help monitor his blood
pressure, as his peripheral BP was not always a true
measurement. He was sent home with a prescription for Lasix 20
mg with instructions to weigh himself daily and take 1 tablet if
his weight increases 2 lbs or more in one day.
3.Rhythm: He remained in NSR, but did have a good number of
PACs. These were all asymptomatic and not treated.
4.Pulmonary: As above, he initially required O2 due to pulm
edema from CHF. As he was diuresed with doses of lasix, and his
heart recovered some function, all symptoms improved. He was
free of oxygen by discharge.
5.CRI:Post-[**Last Name (Titles) **], he was intravascularly dry and had received a
dye load. His Cr increased to 2.1 from his baseline of 1.6-1.7.
It quickly returned to his baseline the next day, and remained
there until D/C.
6.PMR: He is on chronic prednisone at home. Adrenal
insufficiency was considered due to hypotension, as were stress
dose steroids. It was decided that he was adequately covered
with his home doses, and these were continued. No issues.
7.Hypothyroidism: Continued levothyroxine at home doses withiut
issue. TSH was nL on this admission.
8.He was stabilized and transferred to the floor after several
days in the ICU. He did well there, eating and drinking well.
He was seen by PT and they recommended he have home PT on D/C.
He was sent home to his wife and son for further recovery. He
was not interested in rehab at this time. We did set up a VNA
and home PT for him.
Medications on Admission:
Lipitor 10 qd
ASA 81 qd
Plavix 75 qd
Lisinopril 10 qd
Lasix 40 qd
Toprol XL 150 qd
Prednisone 10 qd
Levoxyl 75 mcg qd
Norvasc 10 qd
Omeprazole 20 qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
8. Metoprolol Succinate 50 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:*0*
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take 1 tab every 5 minutes for chest pain. Maximum 3 tabs in 15
minutes. If pain not resolved, go to the ED.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO as directed:
Please weigh yourself daily. If weight increases by 2 lbs or
more from one day to the next, then take 1 tab of Lasix that
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Posterior ST elevation MI
Chronic renal insufficiency
Polymyalgia rheumatica
Hypothyroidism
Discharge Condition:
Pt was stable. Ambulating with assistance off of oxygen.No
chest pain or SOB with exertion.
Discharge Instructions:
Please call your doctor or return to the hospital if you have
new chest pain or shortness of breath at home.
STOP your Norvasc and Lasix.
Your dose of Lipitor was increased from 10 mg/day to 40 mg/day.
Your dose of Toprol XL was decreased from 150 mg/day to 50
mg/day.
Weigh yourself every day. If your weight increases by 2 lbs or
more from one day to the next day, then take 20 mg of Lasix that
day.
Followup Instructions:
Please call Dr [**Last Name (STitle) **] to arrange a cardiology follow-up
appointment in 3 weeks to 1 month.
Please call your PCP to arrange [**Name Initial (PRE) **] follow-up in 1 week.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4023**] Date/Time:[**2111-2-19**] 3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Name: [**Known lastname 14791**],[**Known firstname 14792**] Unit No: [**Numeric Identifier 14793**]
Admission Date: [**2110-8-29**] Discharge Date: [**2110-9-4**]
Date of Birth: [**2018-8-2**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2110-8-29**]
Brief Hospital Course:
Note for PCP: [**Name10 (NameIs) **] [**Known lastname **]' echocardiogram demonstrated valvular
disease significant enough to be classified as moderate risk for
endocarditis. He will need to have antibiotic prophylaxis for
any dental work.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
Discharge Diagnosis:
Posterior ST elevation MI
Chronic renal insufficiency
Polymyalgia rheumatica
Hypothyroidism
Discharge Condition:
Pt was stable. Ambulating with assistance off of oxygen.No
chest pain or SOB with exertion.
Discharge Instructions:
Please call your doctor or return to the hospital if you have
new chest pain or shortness of breath at home.
STOP your Norvasc and Lasix.
Your dose of Lipitor was increased from 10 mg/day to 40 mg/day.
Your dose of Toprol XL was decreased from 150 mg/day to 50
mg/day.
Weigh yourself every day. If your weight increases by 2 lbs or
more from one day to the next day, then take 20 mg of Lasix that
day.
Followup Instructions:
Please call Dr [**Last Name (STitle) 690**] to arrange a cardiology follow-up
appointment in 3 weeks to 1 month.
Please call your PCP to arrange [**Name Initial (PRE) **] follow-up in 1 week.
Provider: [**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) 2448**] [**Name8 (MD) **], M.D. Where: [**Hospital6 189**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 14794**] Date/Time:[**2111-2-19**] 3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**]
Completed by:[**2110-9-4**]
|
[
"593.9",
"424.0",
"785.51",
"244.9",
"428.0",
"285.9",
"414.01",
"410.61",
"725"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.20",
"38.91",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
13718, 13772
|
13452, 13695
|
13387, 13429
|
13908, 14002
|
2082, 5463
|
14455, 15025
|
1636, 1654
|
10336, 11640
|
13793, 13887
|
10163, 10313
|
5480, 6850
|
14026, 14432
|
1669, 2063
|
13328, 13349
|
345, 1317
|
1339, 1494
|
1510, 1620
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,990
| 177,134
|
39045+58255
|
Discharge summary
|
report+addendum
|
Admission Date: [**2114-3-19**] Discharge Date: [**2114-3-27**]
Date of Birth: [**2050-6-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
urgent coronary artery bypass graftsx 3(LIMA-LAD,SVG-OM,SVG-RCA)
[**2114-3-20**]
Left heart catheterization, coronary angiogram [**2114-3-20**]
History of Present Illness:
This 63 year old [**Known lastname **] male was seen at [**Hospital3 **] for
chest pain. He ruled out for infarction, however, a stress test
was positive for ischemia with preserved left ventricular
function. He continued to have episodic pain and was transferred
on IV Nitroglycerin and Heparin pain free for catheterization.
Past Medical History:
asthma
hypertension
gastroesophageal reflux
hyperlipidemia
Social History:
retired engineer, lives alone.
quit smoking 20 years ago,drinks [**1-13**] glasses of wine daily.
Family History:
non contributory
Physical Exam:
Admission:
Pulse:71 Resp: 18 O2 sat: 99 RA
B/P Right: 129/83 Left: 117/81
Height: 70in Weight:192 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: dressing in place 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
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. The
descending thoracic 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. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known lastname 1007**], J before
surgical incisioin.
Post Bypass:
Preserved biventricular systolic function.
LVEF 55%.
All other findings similar to prebypass.
Intact thoracic aorta
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2114-3-20**] 16:08
?????? [**2107**] CareGroup IS. All rights reserved.
[**2114-3-22**] 05:55AM BLOOD WBC-10.2 RBC-3.73* Hgb-11.1* Hct-31.9*
MCV-85 MCH-29.8 MCHC-34.9 RDW-14.0 Plt Ct-106*
[**2114-3-21**] 03:29AM BLOOD WBC-10.8 RBC-3.67* Hgb-11.3* Hct-31.3*
MCV-85 MCH-30.7 MCHC-36.1* RDW-14.2 Plt Ct-87*
[**2114-3-22**] 05:55AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-139
K-4.2 Cl-104 HCO3-29 AnGap-10
[**2114-3-23**] 09:05AM BLOOD UreaN-15 Creat-1.1 K-4.1
Brief Hospital Course:
Catheterization revealed a 95% left main lesion and 50% RCA
stenosis. Surgical intervention was requested and he was taken
to the Operating Room that day for bypass surgery. See operative
note for details.
He weaned from bypass on a Propofol infusion in stable condtion.
He remained stable, awoke intact, was weaned from the
ventilator and extubated. Beta blockade was resumed as well as
diuresis begun.
He transferred to the floor on POD #1 where Physical Therapy saw
him for mobility and strengthening. CTs and temporary pacemaker
wires wre removed according to protocol. Beta blocker was
initiated and the patient was diuresed toward his preoperative
weight. He was cleared for discharge to rehab on POD # 3.
Medications on Admission:
Ranitidine 150mg po bid
Fluticasone-salmeterol diskus IH [**Hospital1 **]
Imdur 30mg daily
Lopressor 12.5mg [**Hospital1 **]
simvastatin 20mg qd
ASA 325mg qd
IV heparin
IV NTG
Plavix - last dose: [**3-20**] 600mg
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 DAILY
(Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x3
hypertension
hyperlipidemia
asthma
gastroesophageal reflux
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Vicodin 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. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 170**]) on [**4-25**] at 1pm
Primary Care: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] ([**Telephone/Fax (1) 81482**]in [**1-13**] weeks
Cardiologist: Dr.[**Last Name (STitle) 86567**] in [**1-13**] weeks
Completed by:[**2114-3-23**] Name: [**Known lastname **],[**Known firstname **] D Unit No: [**Numeric Identifier 13696**]
Admission Date: [**2114-3-19**] Discharge Date: [**2114-3-27**]
Date of Birth: [**2050-6-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 135**]
Addendum:
Mr. [**Known lastname 85**] developed a fevr to 101.3 prior to planned discharge
on [**3-23**]. Blood cultures, urine and throat cultures were sent
and yielded nothing. He had viral illness like symptoms which
resolved over 48 hours, he remained afebrile. He was discharged
in good condition fro reahbilitation prior to return to
independent living.
Chief Complaint:
see summary
Major Surgical or Invasive Procedure:
urgent coronary artery bypass grafts x
3(LIMA-LAD,SVG-OM,SVG-RCA) [**2114-3-20**]
Left heart catheterization, coronary angiogram [**2114-3-20**]
History of Present Illness:
see summary
Past Medical History:
asthma
hypertension
gastroesophageal reflux
hyperlipidemia
Social History:
retired engineer, lives alone.
quit smoking 20 years ago,drinks [**1-13**] glasses of wine daily.
Family History:
non contributory
Physical Exam:
see summary
Pertinent Results:
[**2114-3-26**] 06:30AM BLOOD WBC-8.1 RBC-2.99* Hgb-9.4* Hct-25.9*
MCV-87 MCH-31.6 MCHC-36.5* RDW-13.6 Plt Ct-219
[**2114-3-26**] 06:30AM BLOOD Glucose-119* UreaN-20 Creat-1.0 Na-136
K-3.9 Cl-101 HCO3-26 AnGap-13
Brief Hospital Course:
see summary and addendum
Medications on Admission:
see summary
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 DAILY
(Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
12. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 2314**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hypertension
hyperlipidemia
asthma
gastroesophageal reflux
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Vicodin 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) 1477**]
Followup Instructions:
Please call to schedule appointments
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1477**]) on [**4-25**] at 1pm
Primary Care: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 13697**]in [**1-13**] weeks
Cardiologist: Dr.[**Last Name (STitle) 13698**] in [**1-13**] weeks
[**Hospital Ward Name **] 6 [**Hospital 13699**] clinic in 2 weeks ([**Telephone/Fax (1) 2440**])- your nurse [**First Name (Titles) **] [**Last Name (Titles) 13700**]e an appointmnet
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2114-3-27**]
|
[
"780.62",
"530.81",
"401.9",
"493.90",
"272.4",
"414.01",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"36.12",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
10070, 10150
|
8703, 8729
|
7999, 8146
|
10311, 10407
|
8466, 8680
|
10949, 11661
|
8401, 8419
|
8791, 10047
|
10171, 10290
|
8755, 8768
|
10431, 10926
|
8434, 8447
|
7948, 7961
|
8174, 8187
|
8209, 8269
|
8285, 8385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,588
| 165,603
|
30598
|
Discharge summary
|
report
|
Admission Date: [**2119-3-26**] Discharge Date: [**2119-4-7**]
Date of Birth: [**2041-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22990**]
Chief Complaint:
xfer from [**Location (un) **], ? new afib
Major Surgical or Invasive Procedure:
DC cardioversion
Dobbhoff feeding tube placement
History of Present Illness:
78yo M, dizziness with PMH of IDDM, afib not on coumadin (GIB,
frequent falls), bradycardia s/p pacer, diastolic CHF with EF
55%, chronic microvascular infarcts who presented to an OSH
after falling at home. He reports to me that his legs felt weak
and then he lost consciousness. He denied lightheadedness, chesp
pain, palpitations, loss of bowel/bladder, though per OSH notes,
he reportedly had dizziness and one second of chest pain before
falling. He endorses orthopnea, chronic SOB, denies PND. Per
OSH, he was down for roughly one hour. In the OSH, he had a
negative head CT, EKGs showed anterolateral ST-TW changes, and
he had a CPK of over 1200 with MB 18.4 and TropI of 0.8. An ECHO
showed EF 40-45%. He was started on heparin at some point during
his stay. On [**3-25**], complained of L shoulder pain without N/V,
F/C, SOB, chest discomfort. PE showed large bruise on left
lateral chest wall. Heparin was discontinued. CT scan showed
chest hematoma and lymphnodes suspicious for malignancy. On
[**3-25**], his HCT was 31.7, down from 44 on admission. He was noted
to have an decrease in EF compared to previous ECHOs, so he was
transferred to [**Hospital1 18**] for possible cath. On the floor he denies
chest pain, lightheadedness, but endorses shortness of breath.
.
Has chest wall hematoma.
Past Medical History:
IDDM
afib, not on coumadin (GIB and frequent falls)
h/o brady, now s/p pacer
diastolic CHF with EF of 55% in [**5-/2118**]
CRI: stage iv, baseline Cr of 2.6-3.0
h/o PPM
bilateral peripheral neuropathy
L sided Bell's palsy
h/o osteo of great Left toe
bilateral cataract surgery
h/o falls (last one beginning of [**2119-3-11**])
Neuro issues, being worked up for possible parkinson's disease
GIB in the setting of diverticulitis
psoriasis
chronic microvascular infarcts (per prior records)
Social History:
Social history is significant for the absence of current tobacco
use. There is he drinks 1-2 drinks of ETOH per day. lives alone
in apt in [**Location (un) **].
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: 98.6; BP 135/89; HR 77; RR 18; 100% on 2L
gen: well appearing, nad, pleasant
heent: ncat, mmm, eomi, anicteric sclera
neck: supple, no elevated jvd
chest: poor air movement, bibasilar crackles 1/3 up lung fields,
no wheezes. Large left sided echymosis.
cv: heart irregularly irregular, nl s1/s2, no m/r/g
abd: s/nd/nabs, mild ttp diffusely, no rebound
extr: no c/c/e, 1+ distal pulses
neuro: oriented to person and place, not to time. left sided
facial droop, upper extremity strenth 3+/5 on right, [**3-15**] on
left, LE [**4-15**] left weaker than right. Sensation to light touch
intact throughout. Poor neuro exam d/t cooperation.
Pertinent Results:
[**2119-3-26**] 11:50PM BLOOD WBC-8.9 RBC-3.16*# Hgb-10.2*# Hct-28.8*#
MCV-91 MCH-32.1* MCHC-35.2* RDW-13.6 Plt Ct-157
[**2119-3-30**] 01:58PM BLOOD WBC-11.2* RBC-3.20* Hgb-10.6* Hct-29.7*
MCV-93 MCH-33.0* MCHC-35.6* RDW-14.0 Plt Ct-228
[**2119-3-31**] 07:45PM BLOOD WBC-7.8 RBC-2.70* Hgb-8.6* Hct-25.4*
MCV-94 MCH-32.0 MCHC-34.1 RDW-14.7 Plt Ct-187
[**2119-3-26**] 11:50PM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.2*
[**2119-3-31**] 07:45PM BLOOD PT-27.2* PTT-37.2* INR(PT)-2.7*
[**2119-3-26**] 11:50PM BLOOD Glucose-101 UreaN-42* Creat-2.6* Na-139
K-4.0 Cl-107 HCO3-20* AnGap-16
[**2119-3-31**] 07:45PM BLOOD Glucose-130* UreaN-57* Creat-3.2* Na-136
K-4.1 Cl-106 HCO3-20* AnGap-14
[**2119-3-30**] 01:58PM BLOOD ALT-26 AST-23 LD(LDH)-250 AlkPhos-81
TotBili-2.0*
[**2119-3-26**] 11:50PM BLOOD CK(CPK)-403*
[**2119-3-26**] 11:50PM BLOOD CK-MB-6 cTropnT-0.15*
[**2119-3-27**] 07:25AM BLOOD CK(CPK)-364*
[**2119-3-27**] 07:25AM BLOOD CK-MB-7 cTropnT-0.21*
[**2119-3-29**] 01:00AM BLOOD CK(CPK)-156
[**2119-3-29**] 01:00AM BLOOD CK-MB-6 cTropnT-0.12*
[**2119-3-30**] 08:00AM BLOOD CK(CPK)-176*
[**2119-3-30**] 08:00AM BLOOD CK-MB-8 cTropnT-0.17*
[**2119-3-31**] 07:45PM BLOOD CK(CPK)-224*
[**2119-3-31**] 07:45PM BLOOD CK-MB-7 cTropnT-0.40*
[**2119-3-31**] 07:45PM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
[**2119-3-29**] 07:15AM BLOOD VitB12-1178* Folate-11.3
[**2119-3-29**] 02:01PM BLOOD %HbA1c-5.8
[**2119-3-29**] 07:15AM BLOOD Triglyc-83 HDL-32 CHOL/HD-2.6 LDLcalc-35
[**2119-3-29**] 07:15AM BLOOD TSH-0.90
[**2119-4-1**] 01:19AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.0 Leuks-TR
[**2119-4-1**] 01:19AM URINE RBC-21-50* WBC-[**3-15**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2119-4-4**] COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2119-4-4**] 05:30AM 9.8 3.06* 9.8* 28.6* 93 32.0 34.3
19.2* 200
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2119-4-4**] 05:30AM 132* 88* 3.9* 140 4.8 110* 16* 19
.
UCx negative [**2119-3-29**]
.
CT HEAD W/O CONTRAST [**2119-3-27**] 5:37 PM
FINDINGS: Several axial slices are degraded by motion artifact,
some of which were subsequently repeated. A metallic density is
noted adjacent to the left orbit creating streak artifact
limiting evaluation in this region. There is no evidence of
acute hemorrhage or mass effect. There is no hydrocephalus. The
major intracranial cisterns are preserved.
There is near complete opacification of the right maxillary
sinus with a focus of high-attenuation material within, possibly
representing calcification or fungal chronic infection. This
region opacification appears to distort the superomedial
maxillary sinus wall with extension into the adjacent ethmoid
sinuses. A small amount of opacification is detected in the left
maxillary sinus. The right mastoid air cells are completely
opacified while the left are clear. There is complete
opacification of the right frontal sinus.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Opacification of multiple right-sided sinuses. Given the
unilateral aspect of this process, this may represent a
congenital process. Recommend correlation with clinical history
and outside hospital radiographs if available. A CT or MRI of
the paranasal sinuses with contrast may be obtained for further
evaluation if indicated.
.
Portable TTE (Complete) Done [**2119-3-27**] at 8:31:04 AM FINAL
Findings
This study was compared to the prior study of [**2118-9-21**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%).
Transmitral Doppler and TVI c/w Grade III/IV (severe) LV
diastolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Moderately dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate
([**1-11**]+) MR. LV inflow pattern c/w restrictive filling
abnormality, with elevated LA pressure.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Suboptimal image quality - poor subcostal views.
Suboptimal image quality -poor suprasternal views. The rhythm
appears to be atrial fibrillation.
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade III/IV (severe) LV diastolic dysfunction.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is moderately 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 structurally normal. Mild to moderate ([**1-11**]+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
TEE (Complete) Done [**2119-3-29**] at 11:56:11 AM FINAL
Findings
LEFT ATRIUM: Dilated LA. No thrombus/mass in the body of the LA.
Mild spontaneous echo contrast in the LAA. Depressed LAA
emptying velocity (<0.2m/s) No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in
the body of the RA or RAA. No mass or thrombus in the RA or RAA.
Normal interatrial septum. No ASD by 2D or color Doppler.
AORTA: Complex (>4mm) atheroma in the aortic arch. Complex
(>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Mild to
moderate ([**1-11**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
Information section). The posterior pharynx was anesthetized
with 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given
as an antisialogogue prior to TEE probe insertion. No TEE
related complications.
Conclusions
The left atrium is dilated. No thrombus/mass 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 spontaneous echo contrast is seen in the
body of the right atrium or right atrial appendage. No mass or
thrombus is seen in the right atrium or right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. There
are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**1-11**]+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No left atrial appendage thrombus. Dilated left
atrium and left atrial appendage with significant spontaneous
echo contrast and reduced ejection velocity of the left atrial
appendage. Mild to moderate mitral and mild tricuspid
regurgitation.
.
CHEST (PORTABLE AP) [**2119-3-30**] 2:52 PM
CHEST AP: There is stable moderate cardiomegaly and pulmonary
vascular congestion. The degree of interstitial edema is not
significantly changed. No pleural effusion is definitely
identified. Single lead pacemaker or ICD device is in unchanged
position.
IMPRESSION: Unchanged mild pulmonary edema.
.
CT HEAD W/O CONTRAST [**2119-3-30**] 10:40 AM
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect or acute territorial infarction. There is no evidence of
hydrocephalus. The major intracranial cisterns are preserved.
Again there is almost complete opacification of the right
maxillary sinus with a focus of high attenuation material
within, likely consistent with a calcification or chronic fungal
colonization with extension into the adjacent ethmoidal air
cells. Unchanged opacity of the left maxillary sinus. Again the
right mastoid air cells are completely opacified and the left
remain clear. Unchanged opacity of the right frontal sinus.
Metallic density is again noted on the left orbit producing
significant streak artifact.
IMPRESSION:
No significant change in comparison with the prior study, there
is no evidence of intracranial acute hemorrhage.
Persistent opacity of multiple right-sided paranasal sinuses. A
dedicated CT of the paranasal sinuses is recommended, if
clinically warranted, MRI could be obtained if the metallic
material noted on the left orbit is MRI compatible.
.
CHEST (PORTABLE AP) [**2119-3-30**] 3:18 AM
FRONTAL CHEST RADIOGRAPH: A single lead right-sided pacemaker is
seen in unchanged position. There is mild cardiomegaly.
Interstitial markings have mildly increased. There is no focal
consolidation, pneumothorax, or pleural effusion.
IMPRESSION: Subtle increase in interstitial markings indicating
mild
.
CT HEAD W/O CONTRAST [**2119-3-31**] 5:51 PM
FINDINGS: There is no intra- or extra-axial hemorrhage, shift of
the normally midline structures, mass effect or hydrocephalus.
Periventricular and subcortical white matter hypodensity
reflects changes of chronic microvascular ischemia. Prominence
of the ventricles and sulci is consistent with age- related
atrophy. Metallic density is again noted adjacent to the left
orbit creating streak artifact, limiting evaluation of this
region. Basal cisterns are not effaced. As before, there is
almost complete opacification of the right maxillary sinus with
focal increased attenuation representing inspissated secretions
versus fungal colonization. This process extends into the
adjacent ethmoid air cells. There is unchanged opacity of the
left maxillary sinus and right mastoid air cells. The right
frontal sinus is nearly completely opacified. No fractures are
seen.
IMPRESSION: No significant change in comparison to the prior
study. No evidence of acute intracranial hemorrhage. As before,
dedicated CT of the paranasal sinuses is recommended given
persistent opacity at multiple right- sided nasal sinuses.
.
CHEST (PORTABLE AP) [**2119-3-31**] 7:26 PM
COMPARISON: [**2119-3-30**].
As compared to the previous examination, there is no major
change. Moderate cardiomegaly with moderate signs of
overhydration. No pleural effusions, no masses.
.
ECG Study Date of [**2119-3-26**] 8:19:56 PM
Artifact is present. Atrial fibrillation with a controlled
ventricular
response. Ventricular ectopy. Diffuse non-specific ST-T wave
changes.
Compared to the previous tracing atrial fibrillation is new.
.
ECG Study Date of [**2119-3-29**] 10:25:00 AM
Atrial fibrillation with controlled ventricular response.
Compared to the
previous tracing of [**2119-3-26**] the ST segment depression previously
recorded
is more prominent with T wave inversions in leads I, aVL and
V3-V6 and
ST segment depression in lead II. These findings are consistent
with
acute anterolateral and apical ischemic process. There is left
ventricular
hypertrophy. Followup and clinical correlation are suggested.
.
ECG Study Date of [**2119-3-29**] 1:41:32 PM
Marked sinus bradycardia with occasional A-V conduction and
idioventricular rhythm is new as compared with prior tracing of
[**2119-3-29**]. Followup and clinical correlation are suggested.
.
ECG Study Date of [**2119-3-29**] 1:57:38 PM
Wandering atrial pacemaker and occasional ventricular ectopy.
Compared to the previous tracing of [**2119-3-29**] wandering atrial
pacemaker has appeared.
.
ECG Study Date of [**2119-3-29**] 4:09:12 PM
Sinus rhythm and frequent atrial ectopy and occasional
ventricular ectopy.
Diffuse non-specific ST-T wave changes. Compared to the previous
tracing
of [**2119-3-29**] the rate has increased. The lateral ST segment
changes persist.
Clinical correlation is suggested.
.
ECG Study Date of [**2119-3-30**] 3:09:54 AM
Atrial fibrillation with controlled ventricular response.
Compared to the
previous tracing of [**2119-3-29**] atrial fibrillation with controlled
ventricular response has appeared. The lateral ST-T wave changes
consistent with ischemia have increased. Clinical correlation is
suggested.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2119-4-4**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
.
Urine Culture: Pending
.
CXR: RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2119-4-4**] 8:17 AM
CHEST (PORTABLE AP)
Reason: Please evaluate for acute pathology such as aspiration
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with vascular dementia, atrial fibrillation, DM,
tachy-brady syndrome, now with cough.
REASON FOR THIS EXAMINATION:
Please evaluate for acute pathology such as aspiration
HISTORY: Diabetes with cough.
FINDINGS: In comparison with study of [**3-31**], respiratory motion
somewhat degrades the image. Enlargement of the cardiac
silhouette persists. The hemidiaphragms are not sharply seen,
though this could merely reflect the respiration of the patient
rather than a true finding. Prominence of central vessels
persists and a pacemaker device remains in place.
No gross evidence of pneumonia on this limited study. A lateral
view would be most helpful if clinically possible.
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2119-4-3**] 2:41 PM
CT HEAD W/O CONTRAST
Reason: Please evaluate for acute pathology
Field of view: 25
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with vascular dementia, A. Fib, DM, tachy-brady
syndrome s/p PPM w/ altered mental status
REASON FOR THIS EXAMINATION:
Please evaluate for acute pathology
CONTRAINDICATIONS for IV CONTRAST: Kidney function
ROUTINE UNENHANCED HEAD CT
HISTORY: Vascular dementia, diabetes, altered mental status.
Comparison is made with [**2119-3-31**].
FINDINGS:
The study is motion degraded. Within limits of the examination,
no acute infarction or hemorrhage is seen. There are extensive
small vessel ischemic sequelae in the subcortical and
periventricular white matter. Bilateral basal ganglion lacunes
are seen.
Ventricles are unchanged.
IMPRESSION:
Study limited by motion, no definite acute abnormality is seen.
MRI would be more sensitive for detection of acute ischemia.
.
Brief Hospital Course:
A/P: 78M IDDM, tachy brady syndrome, s/p PPM placement and s/p
recent lacunar infarct, s/p cardioversion for a fib became
bradycardic / hypotensive- tx to CCU, now hemodynamically stable
and called out to floor w/ active issues as R trunk superficial
hematoma and anemia related to this as well as acute on chronic
renal failure.
.
#Rhythm: He was in atrial fibrillation upon admission. Given
his reduced functional capacity, it was though he might benefit
from cardioversion and short term anticoagulation, especially if
he is in a controlled setting like rehab or skilled nursing
facility to decrease risk of fall. Heparin was started, as was
amiodarone. He underwent cardioversion, which was complicated
by bradycardia and hypotension, with pacemaker firing at 40bpm.
He spent three days in the PACU, the duration extended because
of medication-related mental status changes. He stabilized and
returned to the floor. He also did not remain in NSR, but
reverted to afib, at which time anticoagulation and amiodarone
was stopped. The decision to stop anticoagulation was made with
discussions with his family. His pacemaker was adjusted to fire
at 50 bpm given his hypotension during the episode. His aspirin
was increased to 325mg qday. His rate control continued with
carvedilol.
.
#CAD: He was transferred from the OSH for cardiac
catheterization given his elevated enzymes and decrease in EF on
ECHO. He did not undergo cath at [**Hospital1 18**] because it was felt that
medical management would be more appropriate in a patient with
this many comorbidities. He was given aspirin as above as well
as lipitor.
.
#Pump: (LVEF>55%) w/ LV diastolic dysfunction. He had a chest
xray consistent with pulmonary edema in the PACU and he diuresed
impressively with IV lasix. He was continued on carvedilol,
though his ace-inhibitor was held because of his worsening renal
failure.
.
# Anemia- likely secondary to superficial hematoma and in the
setting of cardioversion in the PACU. HCT improved with
transfusion of one unit of pRBCs back to his baseline during the
stay of 30 or greater.
.
#neuro: He had focal weakness upon admission, old facial droop,
and poor mental status. Per neurology, his symptoms/signs are
likely due at least in part to lacunar infarct, pure motor of
internal capsule. CT negative for bleed x 4 here. No MRI given
pacer. His mental status continued to wax and wane, and he was
though possibly to be encephalopathic from meds plus acute
illness. He likely has a degree of dementia, and his symptoms
can partly be attributed to delirium in the setting of changing
environments, acute illness, and medications. Patient's course
complicated by acute on chronic renal failure [**2-11**] to poor PO
intake, and urinary tract infection.
.
#Acute on chronic renal insufficiency: His creatinine initially
improved upon admission, but worsened after his PACU stay,
possibly related to his episode of hypotension or related to the
IV lasix he received. His lasix was then held, as was his
ace-inhibitor.
.
#DM: NPH [**Hospital1 **] and ISS
.
#FEN: diabetic/heart healthy diet,
.
#PPx: INR supertherapeutic - sc heparin when it drops below 2,
bowel regimen
.
#Access: PIV
.
While in the ICU patient had multiorgan failure. Family
meetings were held and the patient was made CMO and died
comfortably on [**2119-4-7**].
Medications on Admission:
Home Meds:
NPH 10 units [**Hospital1 **]
lovastatin 20 qd
calcitriol 0.25 mg q MWF
Lasix 20mg qd
coreg 12.5 po bid
lisinopril 5mg qd
vit d.
asa 325
plavix 75
colace
senna
.
OSH Meds upon transfer:
mucomyst 600mg [**Hospital1 **]
aspirin 325
calcium carbonate 500 tid with meals
calcitriol 0.25 q M/W/F
carvedilol 12.5 [**Hospital1 **]
plavix 75 qday
colace
ferrous sulfate 325 tid
lasix 20 po qday
lisinopril 5 qday
multivitamins
simvastatin 40 vitamin D 400IU daily
NPH 10 [**Hospital1 **]
ssi novolog
nitropaste 2 inch q 4 hrs
tylenol
guaifenesin/dextromethorphan
morphine sulfate 1-2 mg IV q 4 hr prn pain
Discharge Medications:
None, patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Primary:
atrial fibrillation s/p failed cardioversion
lacunar infarcts
Acute on Chronic Renal Failure
.
Secondary:
IDDM
h/o brady, now s/p pacer
diastolic CHF with EF of 55% in [**5-/2118**]
CRI: stage iv, baseline Cr of 2.6-3.0
h/o PPM
bilateral peripheral neuropathy
L sided Bell's palsy
h/o osteo of great Left toe
bilateral cataract surgery
h/o falls (last one beginning of [**2119-3-11**])
Neuro issues, being worked up for possible parkinson's disease
GIB in the setting of diverticulitis
psoriasis
chronic microvascular infarcts (per prior records)
Discharge Condition:
Expired.
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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42,196
| 153,929
|
43398
|
Discharge summary
|
report
|
Admission Date: [**2170-4-24**] Discharge Date: [**2170-5-24**]
Date of Birth: [**2098-2-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Zestril
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Fever, AMS, rectal bleeding
Major Surgical or Invasive Procedure:
1. Paracentesis, x2
2. Intubation, extubation
3. Lumbar puncture
History of Present Illness:
Pt is a 72 yo female with h/o HTN, HL, DM, herpes zoster,
anemia, hyperparathyroidism, and renal cell carcinoma s/p
bilateral nephrectomy resulting in ESRD on HD. She also has h/o
A fib and AS with porcine AVR done in [**2170-3-19**] which was
uncomplicated and she was discharged to rehab. At rehab she
contracted c diff and was readmitted for abd pain, distension,
and severe c diff colitis. During this admission in [**Month (only) 958**] she
ultimately required a subtotal colectomy and diverting ileostomy
and [**Doctor Last Name **] pouch. At the time of this admission she had been
on peritoneal dialysis and was switched and she was started on
HD.
.
Since this admission her mental status has never been the same.
Prior to her subtotal colectomy in [**Month (only) 958**] she was alert and
oriented x3 and doing her ADLs. Since her surgery she has been
more confused and alert and oriented x1 or 2 on some days and
not talking on other days.
.
On [**2170-4-24**] she returned with fever up to 101.3 and rectal
bleeding from [**Doctor Last Name **] pouch. In the ED she had CT abd done
which only showed contrast thickening in rectum. Her CXR was
notable for atelectasis. Her CT head was negative. Cardiac
surgery and Transplant surgery are following as pt is on renal
TP list.
.
Differential of her fevers at admission included c diff of
rectal stump (on vanco enemas and IV flagyl), SBP (had prev h/o)
given pt had ascities (paracentesis negative for SBP),
endocarditis (TTE showed no vegetation), and PNA. She has been
convered with meropenem and daptomycin since admission given h/o
SBP and TP said ok to stop daptomycin today and to continue
meropenem for possible PNA. She has also been on acyclovir for
possible herpetic stomatitis. She has had a respiratory
alkalosis with occasional RR in the 20s to 30s. She is on 2 L
and was never hypoxic.
.
Her [**Doctor Last Name 3379**] pouch has stopped bleeding and INR 1.4 down from
2.1 on admission. HCT have been stable at 24-26.
.
Neuro was consulted for her AMS. At rehab she had been noted to
have UE jerking. An EEG was done there which was non diagnostic
but keppra was started at rehab in case she was having
subclinical seizures. Neuro recommended to get EEG and to
consider LP. TSH was elevated. RPR and B12 were both normal.
.
In the TSICU, she was sleepy but arousable.
.
Review of systems: Unable to obtain ROS secondary to mental
status.
Past Medical History:
Toxic colitis with full-thickness
colonic ischemia on the sigmoid colon
s/p exploratory laparotomy with subtotal colectomy and ileostomy
[**2170-4-5**]
PMH:
- Aortic valve stenosis
- Hypertension
- Dyslipidemia
- Diabetes Mellitus Type II
- History of renal cell carcinoma status post nephrectomy
resulting in ESRD, requires peritoneal dialysis since [**2164**]
- History of peritonitis over five years ago
- History of herpes Zoster several years ago
- History of C. difficile colitis
- Anemia
- Arthritis, History of Gout
- Hyperparathyroidism
Social History:
lived alone before operation, residing at rehab prior to
admission; no ETOH, distant smoking history
Family History:
non contributory
Physical Exam:
ADMISSION:
Vitals: T:98.4 BP:105/51 P:86 RR:24 O2: 100% 2L
General: sleepy but arousable elderly Caucasian woman, unable to
answer questions
HEENT: NCAT, OP clear, dry MM
Cardiac: RRR load S2, healed sternotomy scar
Pulmonary: CTAB anteriorly
Abdomen: +BS, soft, non tender, large mid abdomen surgical wound
healing by secondary intention with pink granulation tissue. no
exudate, no odor. Unable to view rectum in pt's current
condition.
Extremities: 2+ pitting edema in hands bilaterally and 2+
pitting edema in lower legs
Neurologic: Opens eyes. Does not follow any commands other than
wiggling toes on command. PERRL. Generally moving eyes but
unable to test CN II, IV, VI. Tongue in midline but pt did not
stick out completely. No facial droop. UE tone increased and
mildly rigid in UE. Pt able to squeeze both hand with much
prompting. Does not move arms spontaneously. Resists mildly in
UE when moving her.
.
DISCHARGE:
VS - 98.7 98.7 126/66 107-126/51-70 84 70-86 16 96% RA BG 98
24H not recorded/-- +250 ostomy
GENERAL - lying down in bed, appropriate, less agitated this
morning, NAD
HEENT - NC/AT, sclerae anicteric, dry MM
NECK - supple, JVP mildly elevated, difficult to assess
LUNGS - clear bilaterally though decreased BS at left>right
base, no crackles, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, SEM heard throughout precordium, nl S1-S2
CHEST: HD catheter in place, clean, no erythema, non-tender
ABDOMEN - +BS, ostomy in place with brown-green stool, soft, no
rebound/guarding
EXTREMITIES - warm, dry, trace DP pulses, no [**Location (un) **]; R PICC in
place, no erythema
SKIN: ~3cm sacral decubitus ulcer with clean base, granulation
tissue, no drainage
NEURO - awake, A&Ox2, states "I'm at the hospital," though
unable to name which one, states that she does not know the
year. CNs II-XII grossly intact, moving extremities
Pertinent Results:
ADMISSION LABS:
[**2170-4-24**]: WBC 9.7 Hct 26.5 plt 257
WBC range: 2.9-15.8
Hct range: 20.3-29.7
.
[**2170-4-24**]:
Na 145 K 4.5 Cl 109 CO2 28 BUN 29 Cr 3.7
.
DISCHARGE LABS:
[**2170-5-24**]: 12.6 Hct 25.7 Plt 320
Na 135 K 4.0 Cl 99 CO2 25 BUN 12 Cr 2.2
.
Iron studies [**2170-5-20**]:
Iron Binding Capacity, Total 75* 260 - 470 ug/dL
Ferritin 2290* 13 - 150 ng/mL
Transferrin 58* 200 - 360 mg/dL
.
MICRO:
[**Month/Day/Year 3143**] CX [**4-25**], [**4-26**], [**4-29**], [**5-1**], [**5-4**], [**5-6**], [**5-7**], [**5-8**], [**5-9**],
[**5-14**], [**5-15**]: NEGATIVE
[**Month/Year (2) 3143**] CX [**5-19**]: PENDING
.
C DIFF [**4-26**], [**4-27**], [**5-8**], [**5-14**], [**5-19**]: NEGATIVE
.
C. Diff PCR sent [**2170-5-23**]: PENDING at time of discharge
.
RPR NEGATIVE
.
[**2170-4-25**] 11:06 am FLUID,OTHER PERICARDIAL FLUID..
**FINAL REPORT [**2170-5-1**]**
GRAM STAIN (Final [**2170-4-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2170-4-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2170-5-1**]): NO GROWTH.
.
[**2170-5-10**] 5:33 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2170-5-10**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white [**Month/Day/Year **] cell count..
FLUID CULTURE (Final [**2170-5-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2170-5-16**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2170-5-11**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2170-5-12**] 11:42 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2170-5-16**]**
GRAM STAIN (Final [**2170-5-12**]):
[**11-13**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2170-5-16**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
VANCOMYCIN SUSCEPTIBILITY TESTING CONFIRMED BY
SENSITITRE.
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
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 2 S
.
CYTOLOGY:
PERITONEAL FLUID [**5-10**]: NEGATIVE FOR MALIGNANT CELLS
CSF FLUID [**5-1**]: NEGATIVE FOR MALIGNANT CELLS
.
Cardiology:
ECHO [**2170-4-25**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Left ventricular systolic
function is hyperdynamic (EF>75%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. The mitral
valve leaflets are mildly thickened. No masses or vegetations
are seen on the mitral valve, but cannot be fully excluded due
to suboptimal image quality. There is severe mitral annular
calcification. There is moderate functional mitral stenosis
(mean gradient 8 mmHg) due to mitral annular calcification. Mild
(1+) mitral regurgitation is seen. No masses or vegetations are
seen on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. There is an anterior space which most
likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2170-3-7**], a
bioprosthetic valve has replaced the stenotic native aortic
valve. There is no echocardiographic evidence of endocarditis.
If clinically indicated, a TEE may better assess the prosthetic
aortic valve.
.
TTE [**5-10**]:
Conclusions
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size and free wall motion are normal.
A bioprosthetic aortic valve prosthesis is present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
mild functional mitral stenosis (mean gradient 6 mmHg) due to
mitral annular calcification. Trivial mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2170-4-25**], the findings are similar.
.
TEE [**5-10**]:
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis leaflets
appear to move normally. No masses or vegetations are seen on
the aortic valve. No aortic valve abscess is seen. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-21**]+) mitral regurgitation is seen.
Tricuspid valve is normal. No tricuspid regurgitation. Pulmonic
valve is normal. No pulmonic regurgitation. There is no
pericardial effusion.
IMPRESSION: No valvular vegetations demonstrated. Well-seated
bioprosthetic aortic valve with normal function. Mild to
moderate mitral regurgitation. Preserved left ventricular
systolic function.
.
Radiology:
CXR:
SUPINE UPRIGHT CHEST X-RAY, [**2170-4-24**] AT 1206 HOURS.
HISTORY: Altered mental with indwelling right PICC line. Assess
for location of line.
COMPARISON: [**2170-4-16**].
IMPRESSION: The PICC line has migrated with the distal tip at
the junction of the subclavian and axillary arteries. Lung
volumes are markedly diminished with resultant bronchovascular
crowding. It is difficult to entirely exclude a mild element of
volume overload. Additionally, hazy opacity at the left lung
base and to a lesser severity on the right likely reflect
atelectasis, although concurrent infectious infiltrate cannot be
entirely excluded on the Basis of this examination alone.
CT Head ([**2170-4-24**])
INDICATION: 72-year-old woman with altered mental status.
Question bleed or ischemia.
COMPARISON: None available.
TECHNIQUE: MDCT images were acquired through the head without
contrast.
Multiplanar reformations were obtained and reviewed.
FINDINGS:
No acute hemorrhage, large vascular territory infarct, shift of
midline
structure or mass effect is present. Prominence of the
ventricles and sulci are compatible with mild age appropriate
atrophy. The visible paranasal sinuses show mild mucosal
thickening within the left sphenoid sinus. Both mastoid air
cells are opacified, without evidence of osseous destruction.
IMPRESSION:
No acute intracranial process. Bilateral mastoid air cell
opacification
suggestive of ongoing inflammation.
.
MRI HEAD [**2170-5-2**]:
IMPRESSION:
1. Generalized cerebral volume loss.
2. Mild small vessel ischemic change.
3. No evidence of an acute infarction or mass.
4. Bilateral fluid-filled petromastoid air cells without
evidence of a
nasopharyngeal mass.
5. Contrast was not administered due to poor renal function and
EGFR less
than 20.
.
CT TORSO [**2170-5-10**]:
IMPRESSION:
1. No focal fluid collections identified.
2. Right adrenal mass is unchanged and not completely
characterized on this study, but its heterogeneity is concerning
for metastasis. Further evaluation with an MRI is suggested.
3. Moderate ascites increased since the prior examination with
layering
material within the ascitic fluid concerning for hemorrhagic
ascites. Adherent hyperdense material along the left abdominal
wall (2, 74) is noted; please correlate with history of recent
paracentesis.
4. Bilateral pleural effusions, left greater than right with
adjacent
atelectasis versus infection.
5. Ground glass opacity in bilateral upper lobes, left greater
than right,
may represent aspiration versus pneumonia.
6. Increased anasarca.
7. Right PICC tip likely within left brachiocephalic vein in the
midline.
.
CXR [**2170-5-20**]:
FINDINGS: In comparison with study of [**5-18**], there is little
overall change. Monitoring and support devices remain in place.
Continued enlargement of the cardiac silhouette with
mild-to-moderate pulmonary vascular congestion. Increasing
opacification at the left base is consistent with worsening
atelectasis and effusion. In the appropriate clinical setting,
supervening pneumonia would have to be considered.
.
CXR [**2170-5-23**]:
IMPRESSION:
1. Unchanged left basilar opacification is some combination of
atelectasis and pleural effusion.
2. Resolved mild pulmonary edema.
3. Improved right basilar opacities.
4. Low lung volumes.
Brief Hospital Course:
HOSPITAL COURSE:
Pt is a 72F recent s/p valvuloplasty (AVR on [**3-19**]), ESRD on PD
post-op course complicated by readmission for C.Diff colitis
with toxic megacolon requiring exploratory laparotomy and
subtotal collectomy with ileostomy intubated for 6 days and
converted to HD from PD, discharged on [**4-18**] with 2 week course
of Flagyl to rehab, who re-presented with reported fever to
101.3, altered mental status and bloody discharge from her
[**Doctor Last Name **] pouch. Pt had prolonged hospitalization. Fevers with
unclear source with negative [**Name (NI) **] cultures, C. diff, and stool
cultures. Pt had paracentesis on [**4-25**] with negative gram stain.
Initially treated with broad spectrum antitbiotics. TTE
demonstrated no vegetations. Pt's course also complicated by
Delirium. Pt was evaluated by Neurology and LP was done, and
negative for meningitis. Thought to be toxic metabolic
encephalopathy. MRI was negative for mass or acute ischemia
(however, non-contrast given ESRD). Pt had anemia during her
hospitalization, thought to be from slow GI bleed vs. slow bleed
from initial peritoneal dialysis. She was transfused (total of 8
units PRBC's, last [**2170-5-16**]) during this admission and started on
Epo with HD. Pt also with anemia of chronic disease with high
ferritin.
Course also complicated by acute respiratory failure, attributed
to volume overload and possible central tachypnea. She required
stay in MICU and intubation. She developed a MRSA
ventilator-associated pneumonia and was treated with Vancomycin.
She was continued on dialysis during this hospitalization. Her
respiratory status improved and she had O2 sats high 90s to 100%
on RA on day of discharge.
She was discharged to acute [**Month/Day/Year **] for continued
management of her multiple medical problems.
.
# Altered mental status:
Before operation a few months ago, she was AAOx3 and verbal. She
has had cognitive decline since operation but overall is
significantly worse from her true baseline. Neurology was
consulted with impression of non-focal exam consistent with
toxic metabolic encephalopathy with contributors including renal
failure, colitis, and sedatin medication. She was also noted to
have tremors at rehab with concern for seizures. EEG showed no
seizure activity. Neuro-imaging included normal head CT. LP
showed elevated protein with no cells - differential included
resolved bacterial meningitis, seizure, isolated CNS vasculitis.
Neurology felt this continued to be c/w toxic metabolic. In
the ICU, famotidine was discontinued due to 1% incidence of coma
as side effect. She continued dialysis. Acyclovir continued
until CSF HSV negative. MRI showed generalized cerebral volume
loss, mild small vessel ischemic change, no evidence of an acute
infarction or mass, bilateral fluid-filled petromastoid air
cells without evidence of a nasopharyngeal mass. Phenytoin level
was found to be high and this was held. Continuous EEG tracing
continued to show signs of encephalopathy and [**Female First Name (un) **], but no
seizure activity so all anti-epileptics were held. During her
ICU course, she continued to have delirium, which was attributed
to multiple etiologies including ESRD, intermittent fevers,
hypoxic respiratory failure requiring intubation. On the medical
floors, her mental status improved. She was oriented to place
and person but not date on discharge. She was answering
questions appropriately. She was quite tearful as her mental
status improved and would benefit from social work, and
continued reassessment of goals of care with her family while at
[**Female First Name (un) **].
.
# Hypoxic respiratory failure: Pt had tachypnea throughout the
admission, which was initially attributed to possible central
tachypnea. However, on the evening of [**5-9**], pt became
increasingly tachypneic with severely elevated A-a gradient on
top of chronic respiratory alkalosis. Pt was admitted to the
MICU for closer monitoring, respiratory distress progressed
requiring intubation. Etiology unclear, but ddx include [**Name (NI) **]
given [**Name (NI) **] transfusion in the afternoon, flash pulmonary edema,
or PE. [**Name (NI) **] thought to be unlikely; [**Name (NI) **] transfusion workup
was sent. PE thought to be less likely given on SC heparin,
though given prolonged immobility and recent surgery, definitely
with several risk factors for PE, though she was not tachycardic
and denied chest pain. Worsening infection such as HCAP
considered, but no clear evidence of PNA intially and without
cough or clear infiltrate on CXR. Thought that pulmonary edema
contributing. Pt was monitored closely in the MICU, and abx were
discontinued given no clear source. Renal continued to follow
and pt had CRRT in evening of [**5-10**], which she tolerated well.
Pt found to be growing GPC's from Sputum, and was started on
Vanc/Cefepime for VAP. Sputum Cx grew out MRSA, and she was
continued on Vancomycin. SBT was attempted, and pt was extubated
on with plans to not reintubate. She tolerated extubation well
and was continued to improve her respiratory status such that
she was only on nasal cannula. She was transferred to the
medicine floors and we were able to wean her oxygen down to 2L.
She had O2 sats in high 90s to 100% on RA on the day of
discharge.
.
# Fever: Patient transferred from NSG home with reported fevers
that were felt presumably to be due to C. Diff (which she had in
the previous hospitization). On On admission to the trauma SICU
and continued on flagyl (since [**4-5**]), started on vancomycin
enema, acyclovir (for report of herpes sore on lip), meropenem,
and daptomycin. [**Month/Year (2) **] cultures were negative, Stool ostomy -
negative for campylobacter, shigella, salmonella , Stool rectum
- negative for c.diff and Peritoneal fluid - no pmns, no
micro-orgs, no growth. TTE showed no vegetation. CT abdomen
showed mild wall thickening of the Hartmann's pouch such that
colitis could not be completely ruled out. She spiked fever
again on [**4-26**] with negative cultures again. Daptomycin was
stopped on [**4-27**] and meropenem stopped on [**4-29**]. Vanco was stopped
on [**5-2**]. As above, meningitis was considered, but ruled-out with
negative LP. Patient had a low grade fever on [**5-2**] and was
pan-cultured which didn't show any infection. The patient
remained afebrile until [**5-6**] when she had low grade fever and
this continued on the evening of [**5-7**]. She had an episode of
hypotension and leukopenia so infection was suspected and she
was started on Vanco/Cefepime/Flagyl to cover HAP and C. Diff.
This was discontinued during her MICU stay as no clear source.
As above, sputum culture showed GPC's. [**Date Range **] cultures and C.
Diff were negative. As above, she was treated for MRSA VAP, and
she defervesced. She remained afebrile on the medicine floors.
Though she remained afebrile, C. diff PCR was sent given mild
leukocytosis (as discussed below), and pending at the time of
discharge. She remained afebrile for >7 days prior to discharge.
.
# Leukocytosis: Pt had a mild leukocytosis on the medicine
floors, WBC ranging from [**1-1**]. Pt remained afebrile with repeat
CXR without clear infiltrate, and no cough. Differential showed
no bands, with mild neutrophilic predominance. Repeat CXR again
showed no infiltrate. [**Month/Year (2) **] cultures from [**5-19**] continued to be
pending at the time of discharge. Given history of C. diff,
despite multiple negative C. diff Ag's during this
hospitalization, C. diff PCR was sent and pending at the time of
discharge. Her WBC count was 12.6 at the time of discharge,
trended down, and as above, she remained afebrile without
localizing symptoms.
.
# Ascites: Pt had paracentesis initially on presentation given
fevers, without growth from cultures. Pt had large volume
ascites on CT later in hospitalization and given continued
fevers, and had therapeutic and diagnostic tap in the MICU.
Approximately 4L serosanguinous fluid tapped, with SAAG<1.1.
Cytology & cultures sent, which showed no growth and no evidence
of malignancy. Her abdominal distention improved with dialysis.
.
# Hypotension: Intermitently hypotensive in the ICU with SBP's
in 80's. She was pan-cultured and this was negative and given
patient didn't have fever this was felt unlikely to be due
sepsis. Her mental status was so poor that it was not possible
to detect a change. Did not bolus IVF given total body volume.
Started midodrine for [**Month/Year (2) **] pressure with improvement. On
transfer to the floor the patient's [**Month/Year (2) **] pressure was initially
>100 so midodrine was held. On the night of [**5-7**] her SBP was
again found to be 80 and she had a low grade fever. She
received a 500cc bolus and SBP improved. Random cortisol was
added on that showed 28.9. Pt likely had developing sepsis given
VAP while in the ICU. She required pressor support with
Levophed. During her MICU stay, she was started on Midrodrine,
and was able to be weaned off Levophed. On the medicine floors,
her BP improved, and she was discharged on Midrodrine. All
anti-hypertensives on admission were held.
.
# Tachypnea/Alkalosis: Throughout her admission the patient has
been intermittently tachypneic to 40s and her ABG continued to
show respiratory alkalosis. Etiology was unclear but was
presumed to be central tachypnea or autonomic dysregulation
(though no other signs of ICP). LENIs were negative for clot.
It was clear these ongoing symptoms were not from a PE as her
respiratory status was stable for >2 weeks, so CTA was not
pursued. Again, as above, pt was intubated, extubated, and
respiratory status improved.
.
# Anemia: Admission Hct 26. On admission Patient having was
small amount of [**Date Range **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] pouch and mucus. She was on
coumadin for atrial fibrillation and her INR was 4 on arrival to
the hospital. She was transferred to the ICU for further
management. Coumadin was held in the ICU. The surgical team was
concerned for colitis and ordered a CT scan, which revealed no
bowel perforation, or dilation. Stool cultures and C. diff were
negative. She had no signs of brisk bleeding but her HCT dropped
<22 on 3 occasions. Each time she responded to PRBCs given in
dialysis. Hemolysis labs were normal. It was felt that the
ongoing anemia was multifactorial given her poor nutritional
status, ESRD, chronic disease, phlebotomy, and guaiac positive
ostomy output. She was transfused a total of 8 units of PRBC's
during this admission, with last transfusion [**5-16**], in the MICU,
prior to transfer to the medicine floors.
On the medicine floors, pt's Hct was stable, and was 25.7 on the
day of discharge. Again, she had no signs of active bleeding.
She was started on Lansoprazole given guaiac positive output. As
above, C. diff PCR was sent and pending at the time of
discharge.
Pt was planned to continue with Epo with HD.
.
#. Recent AVR for aortic stenosis:
Transplant surgery discussed with cardiac surgery who indicated
anticoagulation could be held given patient has porcine valve.
Warfarin was held during admission and discontinued on
discharge.
.
#. ESRD on HD: History of renal cell carcinoma s/p bilateral
nephrectomy resulting in ESRD, requiring peritoneal dialysis
since [**2164**]. Pt continued on dialysis during this admission. She
required CRRT during her MICU course. On the medicine floors she
had HD, which she tolerated well.
She will continue HD on discharge. Continue on Nephrocaps,
Cinacalcet, and EPO & Zemplar with HD. Last received HD [**2170-5-23**],
plan for MWF schedule at [**Month/Day/Year **].
.
# Atrial fibrillation with RVR, paroxysmal: On [**2170-5-1**]
post-op, the patient went into afib with RVR while she was not
taking PO meds (metoprolol and amiodarone) due to poor mental
status and inability to place NG tube due to concern for
seizures. Patient was given metoprolol and diltiazem but became
hypotensive and was transferred back to the MICU and loaded with
Amiodarone. She was transitioned to PO amiodarone and patient
was sinus soon afterwards. In the MICU, her amiodarone was
discontinued as afib was paroxysmal s/p procedure. She remained
in sinus rhythm with no need for rate-control or
anti-coagulation.
.
# Nutrition: Pt required tube feeds while intubated during her
MICU stay. Her albumin was low at 2.8. She had a speech &
swallow evaluation on [**5-22**], and was advanced to a dysphagia diet.
Plan for repeat S&S evaluation on [**5-24**]; however, given time
constraints, this was not able to be done prior to discharge to
the LTAC.
Pt should have re-evaluation with speech & swallow today or
tomorrow to advance diet as able. Pt had a diet of Regular;
Cardiac/Heart healthy , Diabetic/Consistent Carbohydrate
Consistency: Ground (dysphagia); Thin liquids please have 1:1
supervision with all meals, maintain aspiration precautions at
time of discharge/
.
# Sacral decubitus ulcer, pressure heel ulcers: Wound followed
the patient and helped with skin care. On discharge, the sacral
ulcer had a clean base with pink granulation tissue without
evidence of infection.
Pt should have wound care continued at [**Month/Day (1) **] - current
recs:
Recommendations:
Continue pressure relief measures per pressure ulcer
guidelines.
Sacrum: cleanse with wound cleanser, pat dry
Apply DuoDerm Gel to the wound bed
Cover with Mepilex Sacral Border dressing
Change dressing every 3 days or prn.
.
# Ostomy: followed by wound during her hospitalization.
Recommend continuing recs at LTAC:
TREATMENTS/EQUIPMENT/INTERVENTION:
Cleanse stoma/peristomal skin with warm water.
Filled in wound at junction separation with Stomahesive powder.
Dab no-sting barrier wipe peristomal skin.
Apply [**Last Name (un) **] seal around stoma to cover and protect junctional
wound.
Apply [**First Name9 (NamePattern2) 93403**] [**Doctor Last Name **] [**Doctor Last Name **] pouch Dist # [**Numeric Identifier 24338**] [**Doctor First Name **] # [**Numeric Identifier 20839**] cut
to template size
.
#. Dyslipidemia: Continued home atorvastatin while patient
taking PO meds but otherwise held.
.
#. DM II: Glucose well controlled on insulin.
.
# Right adrenal mass: Noted as stable on CT abdomen. This should
be followed-up as outpatient.
.
TRANSITIONAL CARE:
1. CODE: DNR/DNI, CONFIRMED WITH SON, [**Name (NI) **] [**Name (NI) 3271**]
2. CONTACT: [**First Name4 (NamePattern1) **] [**Known lastname 3271**] [**Telephone/Fax (1) 93404**] (cell)
2. FOLLOW-UP:
- RENAL/HD at [**Telephone/Fax (1) **]
- DOCTORS AT REHAB
3. MEDICAL MANAGEMENT:
- SEVERAL CHANGES TO MEDICATIONS MADE as noted in paperwork
- Speech & Swallow re-evaluation [**5-24**] or [**5-25**] to advance diet as
able
- Continue discussion of goals of care with patient and family.
Pt quite tearful on medicine floors, and pt may not want to be
readmitted if issues arise. Should address with family if
develops illness whether or not she and they would want ICU
level care.
4. OUTSTANDING STUDIES/LABS:
- [**Month/Day (4) 3143**] CULTURES 4/30
- C. diff PCR
- Pt should have follow-up for continued right adrenal mass
5. RISKS TO RE-HOSPITALIZATION:
- Pt with continued Delirium
- Multiple medical problems with previous readmissions
Medications on Admission:
1. Acetaminophen 325 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO Q6H prn
2. Allopurinol 100 mg Tablet [**Month/Day (4) **]: 1.5 Tablets PO EVERY OTHER DAY
3. Atorvastatin 10 mg Tablet QD.
4. Albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (4) **]:
6-10 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing
5. Amiodarone 200 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO once a day:
400mg daily x 1 week, then 200mg daily until further instructed.
6. Metoprolol tartrate 25 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO TID.
7. Ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Month/Day (4) **]: [**6-29**]
Puffs Inhalation Q6H (every 6 hours) prn
8. Albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) Inhalation Q4H (every 4 hours).
9. Cepacol Sore Throat + Coating 15-5 mg Lozenge [**Month/Year (2) **]: One (1)
10. Lidocaine HCl 2 % Solution [**Month/Year (2) **]: One (1) ML Mucous membrane
TID (3 times a day) as needed for mouth sores.
11. Acyclovir 400 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H
12. Tramadol 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H pain
13. Metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback [**Month/Year (2) **]:
One (1) Intravenous Q8H (every 8 hours) for 11 days: through
[**2170-4-28**].
14. Nystatin 100,000 unit/mL Suspension [**Month/Day/Year **]: Five (5) ML PO QID
(4 times a day).
15. Ondansetron 2 mg IV Q8H:PRN nausea
16. Heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Month/Day/Year **]: One (1) Intravenous ASDIR (AS DIRECTED): 700
units/hr for goal PTT 50-70
17. Warfarin 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO WD goal INR
2-2.5
18 Insulin lispro 100 unit/mL Solution [**Month/Day/Year **]. ISS
Discharge Medications:
1. atorvastatin 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
2. allopurinol 100 mg Tablet [**Month/Day/Year **]: 1.5 Tablets PO once a day.
3. acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO every six (6)
hours as needed for pain.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) treatment Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
5. ipratropium bromide 0.02 % Solution [**Month/Day/Year **]: One (1) treament
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
6. Lidocaine Viscous 2 % Solution [**Month/Day/Year **]: One (1) solution Mucous
membrane three times a day as needed for mouth sores.
7. tramadol 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every six (6)
hours as needed for pain.
8. midodrine 5 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO TID (3 times a
day).
9. cinacalcet 30 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO DAILY (Daily).
10. B complex-vitamin C-folic acid 1 mg Capsule [**Month/Day/Year **]: One (1) Cap
PO DAILY (Daily).
11. miconazole nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical QID
(4 times a day) as needed for rash.
12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
14. ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
15. gabapentin 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at
bedtime).
16. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
17. hydromorphone (PF) 1 mg/mL Syringe [**Last Name (STitle) **]: 0.25 mg Injection
Q4H (every 4 hours) as needed for pain.
18. oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain .
19. insulin regular human 100 unit/mL Solution [**Last Name (STitle) **]: As directed
units Injection QACHS: For BG <150, no insulin, 151-200 2 units,
201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10.
20. heparin, porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary Diagnoses:
1. Fever
2. Delirium
3. Ventilator associated pneumonia
4. ESRD on HD
5. Anemia
6. Hypotension
Secondary:
1. Aortic stenosis s/p AVR
2. Renal cell carcinoma s/p nephrectomy
3. C. difficile colitis c/b by toxic Megacolon s/p ex lap with
subtotal colectomy and diverting ileostomy [**2170-4-5**]
4. Gout
5. Hyperparathyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 3271**],
It was a pleasure taking care of you during this admission. You
had a very prolonged course. You were re-admitted to the
hospital from [**Known lastname **] with continued fevers. You were
treated with broad-spectrum antibiotics. You were also more
confused during this hospitalization. You were evaluated by
neurology and had an MRI of the brain with no new abnormalities.
You had sampling of your spinal fluid, which revealed no
infection. During your stay, your breathing became fast, and you
required intubation. You were taken care of in the ICU, and
required close monitoring. You were found to have a pneumonia
for which you were treated with antibiotics. During your stay
your [**Known lastname **] pressure was intermittently low, requiring medication
for [**Known lastname **] pressure support. Your [**Known lastname **] pressure then improved.
You also had dialysis during this admission which you will
continue.
The following medications were changed during this admission:
- STOP Amiodarone
- STOP Metoprolol tartrate
- STOP Acyclovir
- STOP Metronidazole
- STOP Nystatin
- STOP Warfarin
- START Midrodrine 15mg by mouth three times daily
- START Nephrocaps 1 tablet by mouth daily
- START Cinacalcet 15mg by mouth daily
- START Miconazole powder as needed for rash
- START Aspirin 81mg by mouth daily
- START Lansoprazole 30mg by mouth daily
- START Gabapentin 100mg by mouth at night for neuropathic pain
(burning sensation).
**Your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 9004**] to increase or decrease this dose based
on your dialysis sessions. This medication may make you tired or
sleepy.
- START Hydromorphone 0.25mg intravenously every 4hrs as needed
for pain
- START Oxycodone 2.5-5mg every 4hrs as needed for pain.
**Both the Hydromorphone and Oxycodone medication may also make
you very tired or sleepy.
- START Heparin 5000units subcutaneously three times daily while
you are at rehab (this is to help prevent clots)
- START Epoeitin with dialysis
- START Zemplar with dialysis
- CHANGE the dose of Ondansetron 2mg intraveneously to 4mg every
8 hours as needed for nausea
Please continue the other medications were on prior to this
admission.
Followup Instructions:
Please follow-up with the doctors [**First Name (Titles) **] [**Last Name (Titles) **].
Completed by:[**2170-5-24**]
|
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"518.81",
"V45.11",
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] |
icd9cm
|
[
[
[]
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] |
[
"99.15",
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"39.95",
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"88.72",
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|
310, 377
|
35513, 35513
|
5453, 5453
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3523, 3542
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32624, 35057
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35144, 35492
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30803, 32601
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15522, 17330
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35693, 37913
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5630, 7066
|
3557, 5434
|
7253, 15482
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7099, 7217
|
2766, 2817
|
243, 272
|
405, 2747
|
5469, 5614
|
35528, 35669
|
2840, 3389
|
3405, 3507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,662
| 163,361
|
34721
|
Discharge summary
|
report
|
Admission Date: [**2120-1-3**] Discharge Date: [**2120-4-5**]
Date of Birth: [**2095-8-16**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Ampicillin
Attending:[**First Name3 (LF) 9415**]
Chief Complaint:
Stomach hurts
Major Surgical or Invasive Procedure:
Central line placements
CVVH
History of Present Illness:
The patient is a 24 y/o female complainging of 2 days abdominal
pain that is diffuse but greater in the right upper quadrant.
The pain radiates to the right shoulder and the lower back. She
has had nausea and non-bloody / non-bilious vomiting. Her last
bowel movement was 2 days ago and was normal and nonbloody. She
continues to pass flatus. The patient has had no fevers. The
patient was initially seen at an outside facility and noted to
have acute hepatic failure by labs. On arrival to [**Hospital1 18**] the
patient was mildly hypotesive and anuric. After 8 liters of
fluid her hypotension improved but her anuria did not. On
questioning, the patient reports 3 to 4 drinks per night 4 days
per week. She has been taking 3 tylenol twice daily for a tooth
ache. The last time she took any tylenol was two days ago. The
patient denies overdosing on tylenol. She denies any current or
recent suicidal ideation.
Past Medical History:
Lymes disease, D&E
Social History:
[**3-13**] alcoholic drinks 4 days per week
smokes 1 pack cigs per day
no drugs
lives with boyfriend
Family History:
Non contributory
Physical Exam:
Alert and oriented X 3; No acute distress
Severe conjuctival injection/hemorrhage
Extremely poor dentition
Heart regular rate and rhythm
Chest clear to auscultation bilaterally with no crackles,
wheezes, or rhonchi
Abdomen soft, non-distended, globally tender with guarding
greateds in RUQ
No hernias
Trace lower extremity edema
Pertinent Results:
IMAGING:
[**4-4**] CXR 2 View: FINDINGS: Comparison is made with prior
radiograph from [**2120-3-20**]. The tracheostomy tube has been
removed. The lungs are clear without pneumonia or CHF. There is
no pneumothorax or pleural effusion. The cardiomediastinal
silhouette is normal. The bones are unremarkable.
IMPRESSION: No acute intrathoracic process.
[**4-2**] RUQ U/S:
IMPRESSION:
1. Small gallstones and sludge are seen in the gallbladder. No
evidence of cholecystitis.
2. The liver is diffusely hyperechoic. These findings may
represent fatty
infiltration, however, more significant forms of liver disease
such as hepatic fibrosis and cirrhosis cannot be entirely
excluded.
[**3-23**] KUB:There is no free air below the diaphragms. There is no
evidence of bowel dilatation worrisome for a small or large
bowel obstruction. The percutaneous gastrostomy is unremarkable.
[**3-18**] CT Sinus/Maxillary: Persistent polypoid mucosal thickening
with rim calcification in the sphenoid sinuses, which may be
related to inspissated secretions or fungal colonization.
Resolution of circuferential mucosal thickening in the remainder
of the sphenoid sinuses. Unchanged mild mucosal thickening in
the maxillary sinuses.
[**3-8**] TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen, but study quality is
insufficient to exclude a small vegetation. Moderate tricuspid
regurgitation.
=========================
MICROBIOLOGY:
[**4-2**] HCV Viral Load: 1,870,000 IU/mL
[**3-27**]: Urine Cx Negative
[**3-19**]: BAL:
GRAM STAIN (Final [**2120-3-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2120-3-22**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. 10,000-100,000 ORGANISMS/ML..
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2120-3-20**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2120-4-2**]):
YEAST.
ACID FAST SMEAR (Final [**2120-3-20**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Final [**2120-5-20**]): NO MYCOBACTERIA
ISOLATED.
[**3-19**]: Bld Culture x 2 Negative
[**3-6**]: Bld Culture: Blood Culture, Routine (Final [**2120-3-12**]):
ENTEROCOCCUS FAECIUM.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 79583**]
[**2120-3-4**].
[**3-4**]: Bld Culture:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin Sensitivity testing performed by Etest.
Daptomycin = SENSITIVE ( 0.25 MCG/ML ).
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 0.5 S
VANCOMYCIN------------ <=1 S
[**2-22**]: Bld Culture
KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 2 S
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
LABS:
[**2120-4-5**] 07:40AM BLOOD WBC-7.0 RBC-2.84* Hgb-8.8* Hct-25.7*
MCV-90 MCH-31.0 MCHC-34.4 RDW-16.9* Plt Ct-202
[**2120-4-4**] 07:30AM BLOOD WBC-6.4 RBC-2.81* Hgb-8.9* Hct-25.3*
MCV-90 MCH-31.6 MCHC-35.1* RDW-16.9* Plt Ct-220
[**2120-4-3**] 06:20AM BLOOD WBC-7.5 RBC-2.80* Hgb-8.4* Hct-25.4*
MCV-91 MCH-30.1 MCHC-33.1 RDW-16.9* Plt Ct-251
[**2120-4-2**] 06:50AM BLOOD WBC-6.3 RBC-2.91* Hgb-8.8* Hct-26.3*
MCV-90 MCH-30.3 MCHC-33.6 RDW-17.0* Plt Ct-270
[**2120-4-1**] 06:20AM BLOOD WBC-6.2 RBC-2.85* Hgb-8.9* Hct-25.5*
MCV-90 MCH-31.4 MCHC-35.1* RDW-17.3* Plt Ct-289
[**2120-1-30**] 06:24PM BLOOD WBC-19.5* RBC-2.37* Hgb-8.1* Hct-23.9*
MCV-101* MCH-34.1* MCHC-33.8 RDW-19.5* Plt Ct-201
[**2120-1-30**] 01:43AM BLOOD WBC-23.7* RBC-2.26* Hgb-7.8* Hct-23.2*
MCV-102* MCH-34.3* MCHC-33.5 RDW-19.9* Plt Ct-236
[**2120-1-29**] 02:14AM BLOOD WBC-21.9* RBC-2.25* Hgb-7.9* Hct-22.6*
MCV-100* MCH-34.8* MCHC-34.7 RDW-20.2* Plt Ct-189
[**2120-1-28**] 02:14AM BLOOD WBC-25.4* RBC-2.42* Hgb-8.1* Hct-24.1*
MCV-100* MCH-33.5* MCHC-33.6 RDW-19.8* Plt Ct-184
[**2120-1-27**] 04:06AM BLOOD WBC-24.7* RBC-2.46* Hgb-8.5* Hct-24.2*
MCV-98 MCH-34.4* MCHC-35.0 RDW-19.4* Plt Ct-146*
[**2120-1-23**] 12:51AM BLOOD WBC-31.8* RBC-2.95* Hgb-10.1* Hct-28.8*
MCV-98 MCH-34.1* MCHC-35.0 RDW-19.6* Plt Ct-218
[**2120-1-22**] 02:24AM BLOOD WBC-24.2* RBC-2.90* Hgb-9.8* Hct-27.4*
MCV-95 MCH-33.7* MCHC-35.6* RDW-19.4* Plt Ct-214
[**2120-1-21**] 05:50PM BLOOD WBC-24.8* RBC-2.85* Hgb-9.9* Hct-26.9*
MCV-94 MCH-34.9* MCHC-36.9* RDW-19.1* Plt Ct-216
[**2120-1-17**] 03:14AM BLOOD WBC-19.4* RBC-2.39* Hgb-8.4* Hct-24.2*
MCV-101* MCH-35.2* MCHC-34.8 RDW-21.2* Plt Ct-139*
[**2120-1-16**] 04:04AM BLOOD WBC-18.8* RBC-2.50* Hgb-8.5* Hct-25.2*
MCV-101* MCH-34.1* MCHC-33.8 RDW-21.6* Plt Ct-123*
[**2120-1-11**] 02:23AM BLOOD WBC-34.9* RBC-2.96* Hgb-10.0* Hct-27.7*
MCV-94 MCH-33.8* MCHC-36.1* RDW-23.8* Plt Ct-57*
[**2120-1-10**] 12:47PM BLOOD WBC-38.9* RBC-2.97* Hgb-10.0* Hct-28.3*
MCV-95# MCH-33.8* MCHC-35.4* RDW-23.4* Plt Ct-80*#
[**2120-1-9**] 03:19PM BLOOD WBC-56.5* Hct-22.6* Plt Ct-48*
[**2120-1-9**] 02:22AM BLOOD WBC-40.5* RBC-2.11* Hgb-8.2* Hct-24.1*
MCV-114* MCH-38.8* MCHC-34.0 RDW-16.6* Plt Ct-48*
[**2120-1-8**] 06:31PM BLOOD WBC-30.2* Plt Ct-42*
[**2120-1-3**] 06:02PM BLOOD WBC-12.9* RBC-2.81* Hgb-11.0* Hct-31.2*
MCV-111* MCH-39.1* MCHC-35.3* RDW-14.4 Plt Ct-210
[**2120-1-3**] 02:10PM BLOOD WBC-15.5* RBC-2.78* Hgb-10.5* Hct-29.8*
MCV-107* MCH-37.8* MCHC-35.2* RDW-15.0 Plt Ct-245
[**2120-3-23**] 09:15AM BLOOD PT-14.9* INR(PT)-1.3*
[**2120-1-5**] 02:29PM BLOOD PT-21.1* PTT-44.2* INR(PT)-2.0*
[**2120-1-5**] 03:17AM BLOOD PT-23.1* PTT-44.8* INR(PT)-2.2*
[**2120-1-4**] 02:47PM BLOOD PT-26.2* PTT-43.1* INR(PT)-2.6*
[**2120-1-3**] 06:02PM BLOOD PT-27.0* PTT-47.7* INR(PT)-2.7*
[**2120-1-3**] 02:10PM BLOOD PT-38.0* PTT-58.5* INR(PT)-4.1*
[**2120-2-7**] 05:42PM BLOOD Fibrino-327#
[**2120-2-7**] 05:16PM BLOOD FDP-160-320*
[**2120-1-20**] 02:27AM BLOOD Fibrino-639*#
[**2120-1-13**] 01:43AM BLOOD Fibrino-462*#
[**2120-1-10**] 02:00AM BLOOD Fibrino-280#
[**2120-2-16**] 03:15AM BLOOD Fibrino-318
[**2120-4-5**] 07:40AM BLOOD Glucose-102 UreaN-5* Creat-1.0 Na-137
K-4.3 Cl-103 HCO3-25 AnGap-13
[**2120-4-4**] 07:30AM BLOOD Glucose-97 UreaN-4* Creat-1.0 Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
[**2120-4-3**] 06:20AM BLOOD Glucose-89 UreaN-6 Creat-1.0 Na-140 K-4.4
Cl-106 HCO3-24 AnGap-14
[**2120-4-2**] 06:50AM BLOOD Glucose-91 UreaN-10 Creat-1.2* Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
[**2120-1-3**] 11:00PM BLOOD Glucose-113* UreaN-25* Creat-3.8* Na-129*
K-6.0* Cl-99 HCO3-17* AnGap-19
[**2120-1-3**] 06:02PM BLOOD Glucose-81 UreaN-24* Creat-3.4* Na-131*
K-5.6* Cl-103 HCO3-15* AnGap-19
[**2120-1-3**] 02:10PM BLOOD Glucose-57* UreaN-24* Creat-3.6* Na-130*
K-5.2* Cl-101 HCO3-17* AnGap-17
[**2120-4-5**] 07:40AM BLOOD ALT-149* AST-120* AlkPhos-193*
[**2120-4-4**] 07:30AM BLOOD ALT-135* AST-98* AlkPhos-182*
[**2120-4-3**] 06:20AM BLOOD ALT-138* AST-119* AlkPhos-179*
TotBili-0.6
[**2120-4-2**] 06:50AM BLOOD ALT-129* AST-116* AlkPhos-187*
TotBili-0.7
[**2120-4-1**] 06:20AM BLOOD ALT-113* AST-107* AlkPhos-189*
[**2120-3-31**] 03:25PM BLOOD ALT-99* AST-91* AlkPhos-195*
[**2120-3-30**] 08:45AM BLOOD ALT-79* AST-76* AlkPhos-179*
[**2120-3-29**] 03:00PM BLOOD ALT-74* AST-86* AlkPhos-185*
[**2120-3-27**] 06:10AM BLOOD ALT-60* AST-64* AlkPhos-188*
[**2120-3-26**] 04:25PM BLOOD ALT-54* AST-53* AlkPhos-185*
[**2120-3-24**] 09:45AM BLOOD ALT-46* AST-46* AlkPhos-176* TotBili-0.6
[**2120-3-23**] 09:15AM BLOOD ALT-45* AST-51* AlkPhos-170* TotBili-0.6
[**2120-3-20**] 03:51AM BLOOD ALT-20 AST-35 CK(CPK)-30 AlkPhos-155*
TotBili-0.7
[**2120-1-4**] 07:53PM BLOOD ALT-709* AST-[**2078**]* AlkPhos-142*
Amylase-188* TotBili-10.8*
[**2120-1-4**] 02:47PM BLOOD ALT-738* AST-2329* LD(LDH)-821*
AlkPhos-120* Amylase-202* TotBili-9.7* DirBili-7.3* IndBili-2.4
[**2120-1-4**] 03:01AM BLOOD ALT-873* AST-4376* LD(LDH)-2790*
AlkPhos-98 Amylase-300* TotBili-7.8* DirBili-6.0* IndBili-1.8
[**2120-1-3**] 11:00PM BLOOD ALT-1043* AST-5935* LD(LDH)-4250*
AlkPhos-101 Amylase-380* TotBili-7.1* DirBili-4.8* IndBili-2.3
[**2120-1-3**] 06:02PM BLOOD ALT-1135* AST-8252* LD(LDH)-5493*
AlkPhos-109 Amylase-375* TotBili-6.0* DirBili-4.4* IndBili-1.6
[**2120-1-3**] 02:10PM BLOOD ALT-1282* AST-8748* CK(CPK)-1501*
AlkPhos-104 TotBili-5.4*
[**2120-3-23**] 09:15AM BLOOD Lipase-47
[**2120-3-15**] 07:56PM BLOOD Lipase-38
[**2120-1-4**] 02:47PM BLOOD Lipase-858*
[**2120-1-4**] 03:01AM BLOOD Lipase-1518*
[**2120-1-3**] 11:00PM BLOOD Lipase-2449*
[**2120-1-3**] 06:02PM BLOOD Lipase-2596*
[**2120-1-3**] 02:10PM BLOOD Lipase-3423*
[**2120-4-5**] 07:40AM BLOOD Calcium-10.4* Phos-4.0 Mg-1.7
[**2120-4-4**] 07:30AM BLOOD Calcium-10.5* Phos-3.1 Mg-1.4*
[**2120-4-3**] 06:20AM BLOOD Calcium-9.9 Phos-3.3 Mg-1.5*
[**2120-4-2**] 06:50AM BLOOD Calcium-10.6* Phos-4.3 Mg-1.7
[**2120-4-1**] 06:20AM BLOOD Albumin-3.8 Calcium-10.9* Phos-5.0*
Mg-1.7
[**2120-3-31**] 03:25PM BLOOD Calcium-10.7* Phos-5.5* Mg-1.8
[**2120-2-20**] 04:15AM BLOOD calTIBC-212* Ferritn-899* TRF-163*
[**2120-1-24**] 11:22AM BLOOD Triglyc-165*
[**2120-4-2**] 06:50AM BLOOD Free T4-1.3
[**2120-4-1**] 09:55AM BLOOD PTH-<6*
[**2120-1-3**] 06:02PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2120-3-5**] 03:42AM BLOOD PEP-NO SPECIFI IgG-1649* IgA-272 IgM-234*
IFE-NO MONOCLO
[**2120-1-3**] 06:02PM BLOOD HIV Ab-NEGATIVE
[**2120-1-3**] 02:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-52.0*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2120-4-2**] 06:50AM BLOOD PARATHYROID HORMONE RELATED PROTEIN-Test
[**2120-4-2**] 06:50AM BLOOD VITAMIN D 25 HYDROXY-Test
[**2120-4-2**] 06:50AM BLOOD VITAMIN D [**2-4**] DIHYDROXY-Test Name
[**2120-3-11**] 01:57PM BLOOD VITAMIN B1-Test
[**2120-2-9**] 04:12PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2120-1-30**] 04:21PM BLOOD B-GLUCAN-Test
[**2120-1-7**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2120-1-3**] 06:02PM BLOOD COPPER (SERUM)-Test
[**2120-1-3**] 06:02PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2120-1-3**] 06:02PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-zeTest
[**2120-1-3**] 06:02PM BLOOD CERULOPLASMIN-Test
[**2120-1-3**] 06:02PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-Test Name
Brief Hospital Course:
The patient was initially admitted to the transplant surgical
service with pancreatitits, acute liver failure, and acute renal
failure. All of unclear origin. Hepatology, renal, and
infectious disease consults were obtained. Over the first 48
hrs of admission the patient developed encephalopathy and
respiratory failure due to congestive heart failure and was
therefore intubated. Serial head CT's were performed ruling out
hemorrhage and swelling negating the need for cranial bolt
placement. Serial abdominal CT's were performed showing
non-necrotizing pancreatititis. Liver ultrasound showed patent
hepatic vasculature. The patient was begun on CVVH for anuric
acute renal failure with respiratory failure due to congestive
heart failure. The patient was pan cultured on admission. Blood
and urine were negative. She underwent bronchoscopy producing
black sputum which grew yeast. The patient had postitive
hepatitis C serologies. The patient had labs showing EBV and
CMV exposure but no current infection. She was HIV negative.
Stool cultures were negative. The patient was seen by OMFS and
underwent facial CT showing no sinusitis and no tooth abscesses.
Despite the patient's liver failure, she was not listed for
transplantation as she retained synthetic function. It was
believed that the patient's liver failure was secondary to a
septic response rather than Hep C, tylenol, or alcohol. Without
a clear etiology however, it was presumed to be due to her
pancreatitis. Her renal function gradually improved and her
CVVH or HD sessions were discontinued.
The patient was treated with broad spectrum antibiotics
including vancomycin, meropenem, flagyl, fluconazole, and
caspofungin at various times. A repeat abdominal CT showed
diffuse colonic inflammation presumed to be infectious. She was
treated with po vancomycin and iv flagyl for presumed C. diff,
although no C. diff samples returned positive. The patient also
had a drop in platelets, so a HIT panel was sent which returned
negative.
Over the weekend of [**3-12**], she continued to make incremental
progress with battling ARDS. Her TPN was discontinued as she
was tolerating goal tube feeds. She required pressor support
with norepinephrine. Over the dates of [**3-14**], she continued to
improve neurologically and her midazolam drip was weaned off.
She tolerated CPAP/PSV well on [**2-15**].
Patient spiked fever and became septic again on [**2120-2-19**]. She was
found to have Klebsiella Oxytoca growing out of her blood on
[**2120-2-20**] and [**2120-2-22**]. Etiology of the blood culture was not
identified. Patient was trasnfered to Medicine Intensive Care
Unit for futher care of her ventilator dependence and altered
mental status. She underwent diagnostic left thoracentesis and
lumbar puncture (altered mental status) both of which were
negative for infection. Infectious Disease specialists were
following her. All of her lines including HD line were pulled.
She was treated with 14 day course of meropenem (completed on
[**3-9**]) given the Klebsiella was resistant to multiple organsisms
as above. She grew Enterococcus Faecium on [**2120-3-4**] and [**2120-3-6**].
Another A-line was removed. Her transthoracic and
transesophageal echocardiograms did not show any vegetations.
She underwent another abdominal/pelvis CT which did not show any
new changes. Patient was initially treated with ampicillin
which was broadened to Vancomycin and Meropenem given concern
for VAP. Patient compeleted 6 week course of fluconazole on
[**2120-3-9**] for multiple fungal infections including sputum,
urine, skin and maxillary sinus tissue. Patient was also found
to have a right sphenoid lesion and ENT was reconsulted. They
felt that the lesion is improving and recommended followup in
two weeks.
Neurology and psychiatry were following the patient for altered
mental status. No clear etiologies were found after extensive
workup including EEG, MRI and Lumbar puncture. She had
nonspecific finding of ventriculitis on MRI however this would
not explain her presentation per Neurology service. A lumbar
puncture was unrevealing. Patient was weaned off of standing
methadone and lorazepam. She was started on standing Haldol
with as needed Haldol to treat her agitation.
Endocrinology was consulted due to mild hypercalcemia and
abnormal thyroid funciton. She was diagnosed with sick
euthyroid syndrome and does not need thryoid supplementation.
Patient received hydration and hypercalcemia resolved. She also
had episodes of hypernatremia which resolved with free water
repletion.
Patient underwent therpeutic thoracentesis by interventional
pulmonologist with pigtail placement on [**2120-3-6**] in order to
facilitiate weaning off of the vent. This was complicated by
small pneumothorax. Pig tail was eventually removed on [**2120-3-12**].
Patient also received diuretics including PRN furosemide IV and
transient furosemide drip for removal of excess fluids.
Furosemide drip was discontinued as she experienced contraction
alkalosis. Patient transiently tolerated trach mask for
approximately 18 hours however had to be placed back on pressure
support due to rapid shallow breathing and stressed appearance.
The patient developed fevers in the first week of [**Month (only) 958**] and
despite a through investigation, no infectious cause was
identified; the fevers resolved with the termination of
Ampicillin treatment for Enterococcal bacteremia.
The patient had renal failure, requiring HD, which eventually
resolved. She weaned off the ventilator to trach mask and was
fitted for a P-M valve. She worked with physical therapy and was
transferred to the floor afebrile to await placement at rehab.
Following transition to the floor:
##. RUQ tenderness: Pt was noted to have RUQ tenderness on deep
palpation as well as an increased Alk Phos. An U/S was obtained
which was equivocal for cholecystitis. Surgery were consulted an
recommended a HIDA scan, unfortunately pt did not tolerate the
scan. Given lack of leukocytosis and fevers pt was monitored
with serial abdominal exams which showed improvement and
eventual resolution of her abdominal pain. Given her hepatic
shock on admission her RUQ likely was resolving inflammation of
her liver.
##. Sinus Tachycardia: Ms. [**Known lastname 10132**] was also noted to be
intermittently in the low 100s likely due to decompensation from
her prolonged hospital course. Following increased activity with
PT pt's sinus tachycardia became less frequent.
##. Tracheostomy: Following transition to the floor pt was
successfully transitioned to a PMV and then decanulation with
Interventional Pulmonary team. Prior to discharge the site of
her tracheostomy was noted to be healing well with no signs of
infection. Pt was discharged on a regimen of Albuterol inhalers.
##. Anxiety: During entire hospital course pt was noted to be
agitated at times, understandable given the severity of her
condition as well as prolonged hospital course. Psychiatry were
consulted and followed patient whilst on the floor. Pt was
discharged on Clonidine per psych recs as well as close psych
follow-up.
##. Tremors: During her course on the floor Ms. [**Known lastname 10132**] was noted
to have tremors likely from myopathy given her prolonged ICU
course. PT and OT was consulted and followed pt during her
hospitalization course. Pt was recommended to have home PT and
OT, unfortunately due to her insurance satus she was unable to
qualify for prolonged PT and OT. Pt was advised to obtain a
prescription for Physical and Occupational therapy from her
primary care provider.
##. Insomnia: Pt was noted to have difficulty with sleeping
during hospital course and was discharged on a PRN regimen of
Trazadone 50mg-100mg at bedtime.
##. Shock Liver: Upon review of her admission data pt's shock
liver presentation was noted to be multifactoral. She was
followed in house by the Liver team who, in discussion, believed
her presentation to be due to her necrotizing pancreatitis in
addition to her excessive EtoH intake and Tylenol toxicity.
During her hospitalization course pt's transaminases were
trended and noted to be improving along with her synthetic
function. Pt was discharged with follow up with a Hepatologist
(Dr. [**Last Name (STitle) 10285**]. Pt was advised to stop her Alcohol intake and be
cautious with Acetaminophen use (limiting to <2grams per 24 hour
period).
##. Hepatitis C: Pt noted to be positive for Hepatitis C, upon
discussion with the pt she likely acquired it several years ago
when she was using IV drug use. Discussed with pt and her
boyfriend that there is a risk the her Hepatitis C may be
sexually transmitted. As mentioned above she was also advised to
follow up with the Hepatologist.
##. Hypercalcemia: Pt was also noted to be mildly hypercalcemic,
asymptomatic prior to discharge likely due to the length of her
immobilization. Pt was worked up for her hypercalcemia with a
PTHrp, Vit D 1-25OH, Vit D 25OH, which were pending at time of
discharge, results will be followed up by pt's PCP.
Medications on Admission:
None
Discharge Medications:
1. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for with Haldol: Please give with Haldol.
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
9. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every 6
hours) as needed for pain.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
11. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for severe agitation.
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
13. Acetaminophen 160 mg/5 mL Solution Sig: Three [**Age over 90 **]y
Five (325) mg PO Q6H (every 6 hours) as needed for fever or
pain.
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute liver failure, Acute Kidney Injury, Acute
respiratory failure, Necrotizing Pancreatitis, Colitis,
Encephalopathy, [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **] Maxillary infection, Klebsiella
Oxytoca bacteremia, Hepatitis C, Anemia.
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were transferred to this hospital with multiorgan failure.
Whilst in the hospital you were very sick and in the ICU where
you needed you have a breathing machine. You had a difficulty
time coming of the ventilator so you had a tracheostomy
performed and a feeding tube to help with your nutrition. You
finished a course of antibiotics and antifungal treatment for a
jaw and blood infection. You had teeth removed. You were then
monitored on the floor where your breathing improved and we were
able to remove your tracheostomy as well as your feeding tube.
The physical therapists saw you in the hospital and noted that
you were strong enough to go home with physical therapy. You do
need occupational therapy to help regain your function. Please
do all the occupational therapy exercises provided to you while
you were in the hospital.
We have started you on 3 new medications.
1. Please take Albuterol Inhaler, please take 1-2 puffs every 4
hours as needed for wheezing.
2. Please take Clonidine 0.1mg twice a day for your anxiety.
3. You take can an additional 0.1mg Clonidine once a day as
needed for your anxiety top of your twice a day dose.
4. Please take Trazadone 50mg-100mg at bedtime only as needed
for insomnia. Do not take this medication if you do not need to.
This medication may cause drowsiness do not operate any heavy
machinery or operate a vehicle on this.
You should not drink any alcohol as it can further damage your
liver. Alcohol can also interact dangerously with your
medications.
We have set you up with a new doctor's appointment, it is
important that you attend this. We also set you up to see a
Liver specialist at [**Hospital1 **]. Your home services
can start as soon as you are able to pay for them or your
insurance will cover them.
Please let your new doctor know that you will need physical
therapy, occupational therapy, visiting nursing services at
home.
If you have any increased difficulty breathing, fevers, chills,
please return to the ED.
Followup Instructions:
You have a appointment with your new doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her
office is located at [**Street Address(2) 79584**], [**Location (un) **], [**Numeric Identifier 79585**]. The phone number is [**Telephone/Fax (1) 79586**]. Your appointment is
scheduled for [**2120-4-11**], it is very important that you keep this
appointment.
You also have an appointment with the Liver Specialist, Dr.
[**First Name (STitle) **] [**Name (STitle) 10285**]. His clinic is in the liver [**Name (STitle) **] on the [**Location (un) **]
of the [**Hospital Unit Name **] at [**First Name (Titles) **] [**Last Name (Titles) **].
Your appointment is on [**2120-4-18**] at 1000. His clinic phone number
is: [**Telephone/Fax (1) 2422**].
You will need to have your blood drawn on [**2120-4-18**] to check your
Calcium level as it has been high whilst you were in the
hospital. Please have the results faxed over to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
fax number [**Telephone/Fax (1) 79587**]. Dr. [**Last Name (STitle) **] can contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
at [**Hospital1 18**] regarding vitamin D testing pending at time of
discharge by emailing [**University/College 79588**].
You are strongly encouraged to follow-up with mental health. You
will be contact[**Name (NI) **] by Nurse [**First Name4 (NamePattern1) **] [**Name (NI) 32355**] with an appointment.
You can contact [**Name (NI) **] [**Name (NI) 32355**] at ([**Telephone/Fax (1) 62044**].
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67,230
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41382
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Discharge summary
|
report
|
Admission Date: [**2121-4-25**] Discharge Date: [**2121-4-28**]
Date of Birth: [**2045-10-8**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone / morphine / Codeine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
The patient is a 75 yo F with h/o CAD s/p CABG, COPD, GERD, IBS,
DM who is transferred from [**Hospital3 2737**] with endobronchial
mass and hemoptysis for possibility of lymph node biopsy by IP.
She initially presnted this past Juanuary with dyspnea. This did
not improve to two courses of antibiotics. A CXR ordered by her
PCP showed [**Name Initial (PRE) **] cavitary lesion confirmed on CT. She also developed
hemoptysis. She went for bronch today which showed: airway
erythema of the left main bronchus, evidence of tumor in the
left upper and left lower lobe bronchi. The tumor was friable
and bled readily. Brushings and endobronchial biopsies were
obtained. Hemostasis was achieved with epi. She was maintianted
intubated on the vent and transferred here for further
evaluation and possible transbronchial lymph node biopsy.
.
She reports having subjective fever and cough at home with
pleuritic chest pain. She denies weight loss. She has a history
of smoking but quit 30 years ago. She had a negative ppd 5 years
ago. She does travel out of the coutry to the carribean yearly,
stays in hotels.
ROS: c/o pain at back of throat
Past Medical History:
CAD, s/p CABG
DM
COPD
GERD
IBS
Hypothyroid
HLD
Social History:
quit smoking 30 yrs ago
Family History:
NC
Physical Exam:
VS: Tc 96.7, Tm 101.8, BP 95-125/63, HR 82, RR 22, O2sat 98% RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: Crackles diffusely, left > right, no wheeze
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin:
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
Pertinent Results:
1. Labs on admission:
[**2121-4-25**] 10:45PM BLOOD WBC-9.1 RBC-2.97* Hgb-8.5* Hct-25.3*
MCV-85 MCH-28.5 MCHC-33.6 RDW-14.6 Plt Ct-206
[**2121-4-26**] 06:18PM BLOOD Hct-24.0*
[**2121-4-27**] 03:09AM BLOOD WBC-8.2 RBC-3.46* Hgb-10.2* Hct-30.0*
MCV-87 MCH-29.6 MCHC-34.1 RDW-14.7 Plt Ct-163
[**2121-4-25**] 10:45PM BLOOD Neuts-86.6* Lymphs-9.0* Monos-3.0 Eos-1.1
Baso-0.3
[**2121-4-25**] 10:45PM BLOOD PT-12.2 PTT-25.3 INR(PT)-1.0
[**2121-4-25**] 10:45PM BLOOD Glucose-155* UreaN-12 Creat-0.9 Na-130*
K-3.5 Cl-98 HCO3-22 AnGap-14
[**2121-4-25**] 10:45PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8
.
2. Labs on discharge:
[**2121-4-28**] 07:25AM BLOOD WBC-8.9 RBC-3.92* Hgb-11.4* Hct-33.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-14.8 Plt Ct-215
[**2121-4-28**] 07:25AM BLOOD Glucose-145* UreaN-7 Creat-0.7 Na-135
K-4.0 Cl-98 HCO3-26 AnGap-15
[**2121-4-26**] 06:18PM BLOOD CK(CPK)-53
[**2121-4-26**] 06:18PM BLOOD CK-MB-2 cTropnT-<0.01
[**2121-4-28**] 07:25AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.6
.
Urine Studies:
[**2121-4-26**] 05:12PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2121-4-26**] 05:12PM URINE Blood-MOD Nitrite-POS Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2121-4-26**] 05:12PM URINE RBC->182* WBC-87* Bacteri-FEW Yeast-NONE
Epi-<1
.
Urine culture ([**2121-4-26**]): Gram negative rods
.
3. Imaging/diagnostics:
- CXR ([**2121-4-25**]): The heart size is enlarged. The patient is after
median sternotomy, most likely due to CABG. In the left lung,
there is a cavitary lesion approximately 5.5 cm in diameter.
There is significant central lucency and relatively thin walls
up to 9 mm in diameter, representing aknown neoplasm as per
outside CT report (discusssed with Dr [**Last Name (STitle) 63576**]) . The cavity
appears at the level of the left hilus. It is unclear if
connected or not connected to the left hilus. There is faint
opacity in the right lower lung that might represent developing
infectious process. There is no evidence of pulmonary edema.
.
- CXR ([**2121-4-27**]): Bibasilar opacities consistent with a
combination of atelectasis and pleural effusion left greater
than right have worsened. Cardiomegaly is stable. Patient has
been extubated. Cavitary lesion in the left lung with
significant central lucency and thin walls representing neoplasm
as per outside CT report is unchanged. The mass measures up to
5.4 cm and the peripheral rim is also unchanged at 9 mm.
Mediastinal wires are aligned. There is mild vascular
congestion.
.
- Bronchoscopy ([**2121-4-26**]):
Left main carina very abnormal friable mucosa, elecrocautary
used to acheive hemostasis and EBUS used to FNA station 7 4R and
left hilar mass, as well as BAL of LUL sent for micro. Otherwise
normal to tracheobronchial tree.
.
Pending results on discharge (to be followed by inpatient
provider and outpatient pulmonologist)
- Sputum culture ([**2121-4-26**])
- Bronchoalveolar lavage ([**2121-4-26**])
- Blood culture ([**2121-4-26**])
- Endobronchial mass biopsy ([**2032-4-25**])
Brief Hospital Course:
75 yo F with endobronchial mass and hemoptysis, intubated for
airway protection and transferred for further evaluation,
possible LN biopsy.
# Hemoptysis/Endobronchial Mass - Hemoptysi most likely
secondary to endobronchial mass in proximate left upper and left
lower lobe bronchi. She arrived intubated for airway protection
given friability of masses on bronch at OSH. On hospital day 2,
she underwent bronchoscopy that showed left main carina very
abnormal friable mucosa, elecrocautary used to acheive
hemostasis and EBUS used to FNA station 7 4R and left hilar
mass, as well as BAL of LUL sent for micro, otherwise normal to
tracheobronchial tree. She was extubated and admitted to the
MICU for observation. She had no further hemoptysis, dyspnea or
hypoxia. Possible diagnosis of cancer was discussed with
patient. She will follow-up in thoracic oncology clinic, to be
arranged by interventional pulmonologyt fellow.
.
# Hypotension - Patient was noted to be hypotensive with SBP
80's on night after bronchoscopy. She recieved IVF as well as 2
units PRBCs for drop in HCT (appropriate increase in HCT on
check after transfusion). Blood pressure improved/ Initial
concern for possible sepsis given UA that showed evidence of UTI
and she was started on antibiotics. Additionally started
vancomycin due to bronch the day prior. She remained
hemodynamically stable, HCT stable. Vancomycin was stopped prior
to discharge.
.
# Hyponatremia: Na 130 on admission. Etiology likely hypovolemic
hyponatremia, resolved with IVF and was 135 on discharge.
.
# Urinary Tract Infection - UA positive for UTI, initially
started on Cefepime for concern of sepsis. Due to fact that
hyoptension normalized with minimal intervention and patient
clinically looked well, tapered antibiotic to PO Cipro.
.
#. CAD, s/p CABG [**2099**] - Held aspirin, metoprolol, statin,
valsartan, imdur, and lasix given hemoptysis on admission.
Restarted on metoprolol prior to discharge.
.
# GERD: placed on PPI while NPO.
.
# Hypothyroid - continued levothyroxine
.
# Diabetes - While inpatient, held oral hypoglycemics, placed
on humalog insulin sliding scale.
.
# COPD - Continued ipratropium MDI.
.
Pending results on discharge (to be followed by inpatient
provider and outpatient pulmonologist)
- Sputum culture ([**2121-4-26**])
- Bronchoalveolar lavage ([**2121-4-26**])
- Blood culture ([**2121-4-26**])
- Endobronchial mass biopsy ([**2032-4-25**])
Medications on Admission:
ASA 81
calcium carbonate 500 daily
cholecalciferol [**2110**] unit daily
diflunisal 500mg
Esomeprazole 40 daily
Furosemide 40mg daily
Ginkgo Biloba
Imdure 60 mg daily
levothyroxine 25 mcg
metoprolol tartrate 25 mg daily
mvi
pioglitozone/metformin (15/850) 1 tab daily
simvastatin 80 qhs
tiotroprium bromide 18mcg daily
valsartan 160mg daily
Discharge Medications:
1. simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
3. pioglitazone-metformin 15-850 mg Tablet Sig: One (1) Tablet
PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ginkgo biloba Tablet, Soluble Sig: One (1) Tablet,
Soluble PO once a day.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: From [**2121-4-27**] - [**2121-4-29**] for a 3 day
course. .
Disp:*4 Tablet(s)* Refills:*0*
11. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
12. cholecalciferol (vitamin D3) 2,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Endobronchial mass
Hemoptysis
Hyponatremia
Urinary tract infection
.
SECONDAR DIAGNOSIS:
Coronary artery disease
Hypothyroidism
Diabetes
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Last Name (Titles) 90080**], you were transferred to the [**Hospital1 827**] because you were found to have a mass in your
bronchi and had blood in your sputum. The interventional
pulmonologists did a bronchoscopy and cauterized the bleeding
vessels and also obtained a biopsy of the mass. You tolerated
the procedure. You developed a urinary tract infection and we
gave you medication to treat that which you will finish at home.
You have transiently low blood pressure which resolved. We are
holding many of your blood pressure medications as a result.
Please talk to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**] them.
.
You will be contact[**Name (NI) **] by the pulmonologists regarding follow-up
appointment with the thoracic oncology clinic.
.
Medications:
ADDED:
- ciprofloxacin 500 mg by mouth every 12 hours from [**2121-3-27**] -
[**2121-3-29**]
CHANGED: none
HELD (Please talk to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**]
this):
- Aspirin
- Diflunisal
- Imdur
- Valsartan
Followup Instructions:
Name: [**Last Name (LF) 90081**],[**First Name3 (LF) 90082**] E
Location: [**Hospital 22163**] MEDICAL P.C.
Address: [**Male First Name (un) 22164**], [**Location (un) **],[**Numeric Identifier 38978**]
Phone: [**Telephone/Fax (1) 22166**]
When: [**Last Name (LF) 766**], [**2121-5-12**]:30AM
.
*** You will be contact[**Name (NI) **] by the interventional pulmonology
clinic regarding follow-up with the thoracic oncology clinic. If
you do not hear from them, please call Ms. [**First Name4 (NamePattern1) 24039**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 7769**]. ***
Completed by:[**2121-4-28**]
|
[
"244.9",
"496",
"786.6",
"V45.81",
"250.00",
"786.30",
"458.9",
"276.1",
"530.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"33.24",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
9223, 9229
|
5303, 7743
|
303, 317
|
9434, 9434
|
2262, 2270
|
10676, 11292
|
1612, 1617
|
8136, 9200
|
9250, 9250
|
7769, 8113
|
9585, 10653
|
1632, 2243
|
252, 265
|
2873, 5280
|
345, 1483
|
9269, 9413
|
2284, 2854
|
9449, 9561
|
1505, 1554
|
1570, 1596
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,893
| 170,667
|
19143
|
Discharge summary
|
report
|
Admission Date: [**2106-10-1**] Discharge Date: [**2106-10-4**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is an 82-year-old male
with complaints of right upper vision changes for the last
3-4 months. Patient has a past medical history of aortic
valve replacement in [**2101-9-20**], biventricular
pacemaker and defibrillator placement in [**2105-3-20**], right
hemicolectomy in [**2101**], incisional herniorrhaphy in [**2101**],
chronic renal insufficiency, hypertension.
Patient had complaints of upper altitude, no visual loss
effecting the right eye, and paresthesias effecting his right
foot and right arm. Patient was evaluated by neurologist and
then referred to Dr. [**Last Name (STitle) 1132**] for a possible stent angioplasty.
On [**2106-10-1**], the patient underwent a right stent placement
with angioplasty of the right ICA. Patient had 90% stenosis
of the right ICA and carotid bifurcation.
PHYSICAL EXAMINATION: On physical exam, he is a frail
elderly man in no acute distress. Right pupil is larger than
the left, both react equally. EOMs are full without
nystagmus. Chest was clear to auscultation without rales,
rhonchi, or wheezing. Cardiac: Regular, rate, and rhythm,
pacemaker in the left upper chest. Abdomen is soft,
nontender, nondistended with multiple incisions that are
well-healed. Extremities: No clubbing, cyanosis, or edema.
He has got positive pedal pulses. His strength is 4-/5 in
the upper and lower extremities. He has a steady gait.
He underwent the stent angioplasty without complications.
Was transferred and monitored in the ICU. His vital signs
are stable. He is awake, alert, and oriented times three
with fluent speech. His cranial nerves were intact. He had
no drift. His strength is [**5-24**]. Sensation was intact to
light touch and proprioception. His groin sheath was removed
postprocedure day #1. He had no hematoma and positive pedal
pulses. He was transferred to the regular floor, and
evaluated by Physical Therapy and Occupational Therapy, found
to be safe for discharge to home. His vital signs remained
stable, and he was neurologically intact.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Aspirin 325 p.o. q.d.
3. Percocet 1-2 tablets p.o. q.4-6h. prn.
4. Famotidine 20 mg p.o. b.i.d.
5. Digoxin 0.125 mg p.o. q.o.d. Monday, Wednesday, Friday,
Saturday.
6. Amiodarone 200 mg p.o. q.o.d.
7. Lactulose 30 mg p.o. q.8h. prn.
8. Enalapril 5 mg p.o. q.d.
9. Lasix 60 mg p.o. q.d.
10. Aspirin 325 p.o. q.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**Last Name (STitle) 1132**] in
one month.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2106-10-4**] 08:53
T: [**2106-10-6**] 05:22
JOB#: [**Job Number 52241**]
|
[
"593.9",
"427.31",
"428.0",
"V45.02",
"433.10",
"401.9",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.90",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
2179, 2521
|
961, 2156
|
124, 938
|
2580, 2906
|
2546, 2555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,729
| 157,582
|
33275
|
Discharge summary
|
report
|
Admission Date: [**2115-5-22**] Discharge Date: [**2115-5-29**]
Service: MEDICINE
Allergies:
Haldol / Penicillins / Augmentin
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
Right internal jugular central venous line
PEG replacement
PICC line placement
History of Present Illness:
Mr. [**Known lastname 77261**] is an 87 yo male s/p CVA, nonverbal at baseline, who
presents from rehab with fevers and hyperglycemia. His daughter
provides the history. Mr. [**Known lastname 77261**] has had fevers for the past week.
He has also had cough and intermittently was noted by daughter
to have mild SOB. He was treated for PNA with levo/flagyl. He
continued to have fevers and had labwork sent. Per the daughter,
the pt's physician was concerned about the labs and recommended
evaluation in the ED. In the ED at [**Hospital1 18**], initial VS 97.1
112/73 70 2 97 RA. UA was positive for UTI with WBC 12.1.
Serum sodium was noted to be 155. He recieved 3L NS in the ED.
He was treated with vanc/cefepime. He was given 5 units reg
insulin for glucose 474.
Past Medical History:
s/p CVA left frontoparietal and temporooccipital [**2110**],
nonverbal, s/p PEG placement
Traumatic subdural hematoma x 2
HTN
Type II DM
Dementia
Atrial flutter: off warfarin due to traumatic subdural x 2
Social History:
Lives in [**Hospital **] Health center. Supportive daughters and wife.
[**Name (NI) 3003**] Chinese Restauranteur. No tobb or etoh
Family History:
No family history of pulmonary disease obtained
Physical Exam:
Admission Exam
VS: Temp: 97.1 BP: 83/58 HR: 82 RR: 22 O2sat: 99 RA
Gen: Resting in bed, non-verbal, NAD
HEENT: PERRL, EOMI. Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, old midline scar, g-tube in place
Extremities: no cyanosis, clubbing, edema.
Neurological: alert and oriented X 3,
Psychiatric: Appropriate.
Pertinent Results:
[**2115-5-22**] 01:05AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.025
[**2115-5-22**] 01:05AM URINE BLOOD-LG NITRITE-POS PROTEIN-TR
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2115-5-22**] 01:05AM URINE RBC-[**11-15**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2115-5-22**] 12:53AM COMMENTS-GREEN TOP
[**2115-5-22**] 12:53AM LACTATE-3.3*
[**2115-5-22**] 12:35AM GLUCOSE-474* UREA N-76* CREAT-1.5*
SODIUM-155* POTASSIUM-4.2 CHLORIDE-121* TOTAL CO2-21* ANION
GAP-17
[**2115-5-22**] 12:35AM estGFR-Using this
[**2115-5-22**] 12:35AM ALT(SGPT)-7 AST(SGOT)-14 ALK PHOS-62 TOT
BILI-0.4
[**2115-5-22**] 12:35AM LIPASE-57
[**2115-5-22**] 12:35AM CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-3.1*
[**2115-5-22**] 12:35AM WBC-12.1*# RBC-4.09*# HGB-13.0*# HCT-40.9#
MCV-100* MCH-31.8 MCHC-31.8 RDW-14.9
[**2115-5-22**] 12:35AM NEUTS-79.7* LYMPHS-14.5* MONOS-2.8 EOS-2.6
BASOS-0.4
[**2115-5-22**] 12:35AM PLT COUNT-145*
[**2115-5-22**] 12:35AM PT-13.4 PTT-23.7 INR(PT)-1.2*
.
CXR [**2115-5-22**]:
UPRIGHT RADIOGRAPHS OF THE CHEST: Mildl enlargement of the
cardiac silhouette
is chronic. The aorta is tortuous. Lungs are clear. Healed right
posterior rib
fractures include the right third, fourth, sixth, seventh,
eighth and ninth
ribs.
.
MICRO:
URINE CULTURE (Final [**2115-5-25**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- 4 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
OXACILLIN------------- =>4 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
VANCOMYCIN------------ <=1 S
.
FECAL CULTURE (Final [**2115-5-26**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2115-5-25**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2115-5-23**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2115-5-27**] 11:48 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2115-5-28**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2115-5-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative). .
.
AXR [**2115-5-25**]:
HISTORY: 87-year-old man with sepsis, recovering, but more
distended with
diarrhea, evaluate for colonic distention.
TECHNIQUE: A supine abdominal x-ray dated [**2115-5-25**] at 11:15
a.m. was
obtained. Comparison is made to a prior CT scan of the abdomen
and pelvis
dated [**2115-3-24**].
FINDINGS:
Scattered gas and stool is seen throughout the colon. No
evidence for small-
bowel obstruction. No obvious free air.
A G-tube projects over the left upper quadrant. Multilevel
degenerative
changes are seen in the lumbar spine.
IMPRESSION: Nonspecific bowel gas pattern.
The study and the report were reviewed by the staff radiologist.
IMPRESSION:
Multiple healed right rib fractures.
.
CT abdomen/pelvis with oral contrast [**2115-5-26**]:
CT ABDOMEN/PELVIS WITH CONTRAST: In the visualized lung bases,
there are new
small bilateral pleural effusions, left more than right. There
are associated
atelectasis in both bibasilar region, however, cannot rule out
superimposed
infectious process. The cardiac size is within normal limits. In
the abdomen,
the assessment of parenchymal organs are limited by the non-IV
contrast study.
The liver appears unchanged, without focal abnormality. The
gallbladder is
not well visualized. The pancreas slightly appeared to have
fatty replacement
but otherwise within normal limits. The spleen, adrenal glands,
and kidneys
are unchanged and within normal limits. In the left lower pole
of the kidney,
there is a calcific exophytic density, likely represents a
calcified renal
cyst, unchanged in appearance. Bilateral perinephric fat
stranding in the
anterior pararenal space, nonspecific, is unchanged.
The indwelling PEG tube is malpositioned, with the balloon
partially
intralumenal and partially in the subcutaneous track. There is
no evidence of
extraluminal oral contrast leak. The stomach, duodenum, loops of
small bowel
and colons are patent with oral contrast, without evidence of
bowel
obstruction.
There is interval minimally increase of the bilateral
pericolonic fat
stranding, left more than right, but no evidence of colonic wall
thickening to
suggest acute colitis. This fat stranding appears to be
extending from the
perinephri fat stranding. A small region of fat stranding is
also seen
subjacent to the aortic bifurcation, also non- specific. A small
amount of
stool is noted in the rectal vault, with unchanged appearance of
perirectal
fat stranding and minimally prominent rectal wall.
There is an indwelling Foley catheter, with a balloon inflated
inside the
prostate. Evaluation of the collapsed bladder is limited, but no
gross
abnormality is identified. There is no free fluid or air in the
intra-
abdominal cavity or the pelvis.
Several small, scattered lymph nodes are seen in the
messenteric,
retroperitoneal and inguinal regions, but no lymphadenopathy is
identified.
There is no fluid collection in either the abdomen or pelvis
suspicious for
abscess.
BONE WINDOW: There is an unchanged L2 compression fracture, but
no acute
fracture or dislocation. Significant vascular calcification is
seen along the
descending aorta and its major branches. No lytic or blastic
lesion
suspicious for metastasis is identified.
IMPRESSION:
1. No definite evidence of acute colitis. Nonspecific mild
pericolonic fat
stranding in the descending colon, without colonic wall
thickening.
2. No fluid collection suspicious for abscess.
3. The PEG balloon is malpositioned, partially dislodged in the
subcutaneous
track, but no evidence of oral contrast leak.
4. Foley balloon inflated inside the prostate.
5. Unchanged L2 compression fracture.
.
CXR [**2115-5-26**]:
IMPRESSION: AP chest compared to [**5-23**] and 31.
Pulmonary and mediastinal vascular congestion accompanied by
small increasing
right pleural effusion suggests that the basal predominant
opacification in
the lungs is due to pulmonary edema and not pneumonia. Mild
cardiomegaly
stable. Right jugular line ends in the SVC.
.
TTE [**2115-5-28**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No masses
or vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Suboptimal image quality. No obvious
echocardiographic evidence of valvular vegetations. Mild
symmetric left ventricular hypertrophy with preserved global
left ventricular systolic function. Dilated thoracic aorta.
Right ventricular dilation with borderline normal function. Mild
mitral and aortic regurgitation.
If clinically indicated, a transesophageal echocardiogram may
better assess for valvular vegetations.
Brief Hospital Course:
87 yo M with recent stroke admitted to the medical floor for
fever and hyperglycemia. Pt was hypotensive shortly after
admission to the floor, requiring an ICU admission for
hypotension, hypernatremia, and hyperglycemia.
.
ICU Course
The patient was transferred to the ICU after hypotension on the
floor. Central access was obtained and fluid rescusitation
commenced. The patient did not require pressor support or
intubation. He was found to have an E.Coli/Staph Aureus UTI
which was initially covered with Vanc/Zosyn/Cefepime and
transitioned to Bactrim prior to transfer back to the general
medical floor. After initial volume repletion, the patient was
transitioned to an insulin gtt and D5W to correct hyperglycemia
and hypernatremia. Over a 72 hour period his Na was reduced
from 160 to 146 and his insulin was transitioned to lantus with
sliding scale. Prior to callout, the patient developed a 4
second pause with intermittent sinus bradycardia on telemetry.
His donepezil was discontinued and his heart rate normalized to
the 60s.
.
The following is the remainder of his course by problem after
transfer back to the general medical floor:
.
# Hypotension/Fever: His hypotention initially resolved with IVF
in the ICU. His lisinopril, norvasc, baclofen, and flomax were
held. Once BP began to normalize, baclofen and flomax were
resumed. Pt was treated with Vanc/Zosyn/Cefepime initially in
the ICU,and then tailored to bactrim to treat his staph aureus/E
Coli UTI. On the evening of transfer back to the floor on
[**2115-5-26**], the patient again became febrile to 101.9 with SBP in
the 70s. His antibiotic coverage was extended to
Vanc/Cefepime/Flagyl for broad abdominal/pulmonary/urologic
coverage, and he was bolused 4 L NS. His baclofen and flomax
were again stopped. Continued to hold BP meds. Repeat CXR showed
a possible new LLL PNA, however subsequent CXR relayed that this
was more likely effusion/atelectasis in the LLL. Given his
abdominal distension and diarrhea, CT abdomen/pelvis was
performed. This showed no obstruction, colitis, or abscess. He
also had no noted sacral osteomyelitis or abscess. ESR was only
24. C diff was negative x 3 and stool cultures were negative.
Repeat UA still appeared dirty so urine culture was again sent
but was negative. Repeat blood cultures were negative. TTE on
[**5-28**] showed no vegetations and EF of 55%. He was continued on
Vanc/Cefepime/Flagyl to cover for potential aspiration PNA (as
pt was noted to be aspirating while here), and to cover his UTI.
He was afebrile for 48 hours at the time of discharge and will
complete 8 days of Vanc/Cefepime/Flagyl
.
# Bradycardia: The patient has developed pauses, sinus
bradycardia to the 50s, and bursts of tachycardia in the high
90s while in the ICU. This rhythm is preliminarily consistent
with sick sinus syndrome. The patient is not on any culprit
medicines (beta blockers, lithium, digoxin, cimetidine). Aricept
was stopped as this can cause bradycardia. Once transferred back
to the floor, the pt continued to have pauses up to 2 seconds
and HR in the 50s. He would also have bursts of HR up to 120s.
Discussion of pacemaker was not pursued at this time in the
setting of infection, but if pt has persistent pauses or
symptoms, then pacemaker discussion may need to occur in the
future.
.
# Hypovolemic Hypernatremia: Due to on-going insufficient free
water repletion. As per above, Na was as high as 160 on transfer
to the ICU. With IVF and free water flushes through his PEG, his
Na normalized prior to transfer back to the general medical
floor. Na was 139 at discharge.
.
# E. Coli & Staph Aureus UTI: Pts urine grew E Coli and Staph
aureus, both sensitive to bactrim. Given staph aureus in the
urine, blood cultures were checked but were negative. He was
admitted with a foley in place (had chronic foley since [**3-4**]),
which may be the culprit. Initially was treated with
Vanc/Cefepime/Zosyn, but tailored down to bactrim based on urine
sensitivities. As per above, once pt was hypotensive again, his
antibiotics were again changed back to Vanc/Cefepime/flagyl and
UA/urine culture were repeated. This second culture on
antibiotics came back negative. Would complete course of Vanc as
per above.
.
# Hyperglycemia/DMII: Pts lantus dose was increased as needed
for initial fingersticks in the 400s. He was also managed on
sliding scale insulin.
.
# ?Altered mental status: Pt was very lethargic on admission.
Likely lethargic due to infection/dehydration in setting of
underlying dementia. Discussed with family, and at baseline pt
will often open his eyes and acknowledge his family when they
come to visit, but at times he will sleep for 1-2 days straight.
Confirmed with family that his mental status while here was at
baseline. Noted to often resist us opening his eyes, nonverbal,
not interactive, often sleeping.
.
# Pulmonary edema: Pt had noted edema on CXR on [**2115-5-26**] after 4
L NS fluid resuscitation. No Lasix was given due to low BP
initially. Oxygen saturation remained mid 90s on room air. TTE
on [**2115-5-28**] showed normal EF at 55%. On day of discharge [**5-29**], pt
had increased wheezing and crackles in his lungs on exam (still
satting 98% RA), so given Lasix 10 mg IV x1. As BP tolerates, pt
may need some gentle diuresis after the aggressive fluid
resuscitation he received here.
.
# Acute renal failure: Admission Cr had been 1.5, up from
baseline of 0.9. Lisinopril was held and pt was given IVF. His
creatinine improved with IVF to 0.9 at discharge.
.
# History of traumatic subdural: Continued keppra for seizure
prophylaxis
.
# decubitis ulcer: Pt has a stage III ulcer on his upper R
trochanter and a stage II on his sacrum. Also has a R heel
ulcer. Seen by wound care. He will need frequent ulcer
monitoring, turning in bed, etc.
.
# PEG tube replacement: Pts PEG tube fell out on [**2115-5-26**] after
returning from CT scan. His tubefeeds were held and his PEG tube
was replaced by IR on [**2115-5-27**].
.
# Anasarca: Albumin low at 2.7. Nutrition recommended adding
benefiber to his tube feeds.
.
# Leukopenia: WBC was lower at 3.5 on both [**5-28**] and [**5-29**]. [**Month (only) 116**] be
dilutional or related to Vancomycin. Would repeat CBC on [**2115-6-1**]
to ensure WBC is stable.
.
# Atrial fibrillation: Currently not anticoagulated due to SDH,
supposedly from falls. He is on ASA 81 mg daily. Can consider
anticoagulation as outpatient given that his greatest risk of
fall is with the [**Doctor Last Name 2598**] lift, which is a modifiable risk factor.
No rate control given h/o bradycardia.
.
# Diarrhea/abdominal discomfort: Pt had diarrhea while here,
requiring rectal tube. C diff was negative x 2. Pt has been on
antibiotics, which may have been causing his current diarrhea.
Pt had some tenderness on exam with palpation. Given persistent
fevers/hypotension, CT abdomen/pelvis was performed on [**2115-5-26**].
This showed no obstruction, colitis, or abscess. He also had no
noted sacral osteomyelitis or abscess. CT abdomen did note foley
in prostatic urethra, so pts foley was advanced and his
abdominal pain resolved. Diarrhea also was slowing by time of
discharge so his rectal tube was removed.
.
# BPH: Flomax was stopped due to hypotension. If a voiding trial
is to be performed in the future, would resume flomax 1 week
prior.
.
# s/p CVA: Pt is on baclofen at baseline. It has been held due
to recent hypotensive episodes. Can consider restarting as BP
remains stable (had been on 2.5 mg three times a day).
.
# Goals of care: Discussed with pts wife, daughter [**Name (NI) **], and
daughter [**Name (NI) **]. Pts family wants pt to be full code at this
time, but would not want extended life support.
Medications on Admission:
Docusate Sodium 50 mg [**Hospital1 **]
Baclofen 2.5 mg TID
Tamsulosin 0.4 mg qhs
Amlodipine 5 mg daily
Trazodone 75 mg PO HS
Paroxetine HCl 30 mg daily
Ascorbic Acid 500 mg [**Hospital1 **]
Thiamine HCl 100 mg daily
Folate 1mg qd
Aspirin 81 mg daily
Lansoprazole 30 mg daily
Levetiracetam 500 mg/mL [**Hospital1 **]
Donepezil 5 mg qhs
Magnesium Hydroxide 400 mg/5 mL 30 ml po Q6H prn
Bisacodyl 10 mg daily prn
Lantus 14 QHS with HISS
Calcium Carbonate 1,250 mg/5 mL(500 mg) TID
Cholecalciferol (Vitamin D3) 400 unit daily
Acetaminophen 1000 mg Tablet TID prn pain
Lisinopril 2.5 mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**] [**Location (un) **]
Discharge Diagnosis:
Hypernatremia
Hypotension
Urinary tract infection
Acute renal failure
Discharge Condition:
stable.
Discharge Instructions:
You were admitted with confusion, high sodium, dehydration,
acute renal failure, and a urinary tract infection. Your blood
pressure dropped while you were here, requiring admission to the
ICU. Your blood pressure again dropped, and you were started on
broad spectrum antibiotics. Your blood pressures have improved,
and you have had no more fevers for over 48 hours.
.
The following medication changes have been made: Your lisinopril
and norvasc have been stopped due to low blood pressure. Your
baclofen and flomax have also been held due to low blood
pressure. Your aricept has been stopped in case this was causing
your low heart rate. Your lantus was increased to 29 units a
day. You will need to complete 4 more days of antibiotics.
.
Call your doctor or go to the ER for any worsening confusion,
recurrent fevers, abdominal pain, vomiting, persistent diarrhea,
or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 6924**] after discharge.
|
[
"E879.6",
"707.03",
"707.07",
"707.23",
"787.91",
"707.04",
"427.81",
"511.9",
"041.4",
"584.9",
"427.32",
"518.0",
"599.0",
"250.00",
"438.11",
"276.0",
"041.11",
"401.9",
"294.8",
"996.64",
"536.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.02",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19235, 19302
|
10882, 15276
|
244, 324
|
19416, 19426
|
2091, 10859
|
20376, 20452
|
1513, 1562
|
19323, 19395
|
18623, 19212
|
19450, 20353
|
1577, 2072
|
201, 206
|
352, 1121
|
15291, 18597
|
1143, 1349
|
1365, 1497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,213
| 154,718
|
10090
|
Discharge summary
|
report
|
Admission Date: [**2146-6-27**] Discharge Date: [**2146-7-3**]
Date of Birth: [**2075-8-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Doxycycline
Attending:[**Known firstname 922**]
Chief Complaint:
shoulder pain
Major Surgical or Invasive Procedure:
[**2146-6-27**] - Coronary artery bypass graft x 5, with left internal
mammary artery to left anterior descending coronary artery,
reversed single saphenous vein graft from the aorta to the
posterior descending coronary artery, reversed single saphenous
vein graft from the aorta to the first obtuse marginal coronary
artery, reversed single saphenous vein graft from the aorta to
the ramus coronary artery, as well as reversed single saphenous
vein graft from the aorta to the first diagonal coronary artery.
History of Present Illness:
This is a 70-year-old gentleman
who recently developed some shoulder pain which correlated
with exercise. He underwent a stress test which was positive
and this obviously led to a catheterization. The
catheterization revealed 3-vessel disease. Based on his
findings and his medical history of diabetes and hypertension
as well as hypercholesterolemia, it was recommended he
undergo coronary artery bypass graft. The patient understood
the risks and benefits of the procedure, including, but not
limited to bleeding, infection, myocardial infarction,
stroke, death, renal and pulmonary insufficiency, as well as
the possibility of a blood transfusion and future
revascularization procedures, and the patient then agreed to
proceed.
Past Medical History:
Diabetes, diet controlled
Dyslipidemia
Hypertension
Social History:
Social history is significant for the absence of current tobacco
use, quit 30yrs ago. There is no history of alcohol abuse; He
drinks [**2-9**] glasses of wine nightly. Retired from
medical/military electronics
Family History:
He has several siblings with CAD. He had a brother who underwent
CABG at 59 and died one year later. He has one other brother and
two sisters with CAD. There is no family history of premature
coronary artery disease or sudden death.
Physical Exam:
VS: T 98.4, BP 124/80, HR 80, RR 20, O2 sat 98% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6cm; no carotid bruits
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. 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:
Right: Carotid 2+ Femoral 2+ Popliteal did not check DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal did not check DP 2+ PT 2+
Pertinent Results:
[**2146-6-27**] ECHO
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. 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 descending
thoracic aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. An eccentric,
posteriorly directed jet of Mild (1+) mitral regurgitation is
seen.
POSTBYPASS
Biventricular systolic function is preserved. The study is
otherwise unchanged from prebypass.
[**2146-6-29**] CXR
The patient is after median sternotomy and CABG. There is no
change in the left retrocardiac opacity most likely consistent
with atelectasis. Small amount of pleural effusion cannot be
excluded but appears grossly unchanged compared to the prior
study. There is improvement in the aeration of the right lower
lung with a right small pleural effusion being unchanged. There
is no evidence of failure. There is no evidence of pneumothorax.
[**2146-7-3**] 07:05AM BLOOD
WBC-8.5 RBC-3.51* Hgb-10.1* Hct-31.0* MCV-88 MCH-28.8 MCHC-32.7
RDW-15.5 Plt Ct-313
[**2146-7-3**] 07:05AM BLOOD
PT-19.1* INR(PT)-1.8*
[**2146-7-2**] 07:15AM BLOOD
Glucose-99 UreaN-13 Creat-0.7 Na-140 K-4.0 Cl-106 HCO3-23
AnGap-15
[**2146-7-1**] 09:09PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2146-6-27**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to five vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. Within 24
hours, he had awoke neurologically intact and was extubated.
Beta blockade, aspirin and a statin were resumed. He was then
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. Pt did go into afib He was
given amio he did convert to NSR. He is on coumadin 3 mg [**Doctor Last Name **].
His INR on DC is 1.8.
As per Dr [**Last Name (STitle) 914**]. Pt will follow his INR with Dr [**Last Name (STitle) **]. VNA
is set up to have INR drawn at home. They will fax the INR to Dr
[**Last Name (STitle) **] office. If VNA cannot get INR drawn. Pt was given a
prescription to go to the lab and have his INR drawn. The lab
will fax the results to Dr [**Last Name (STitle) **] office. Dr [**Last Name (STitle) 914**] and the
patient know that this has not been set - up. I will email Dr
[**Last Name (STitle) **]. with the patients information. I will also attempt to
page her. INR is 1.8. Coumadin 3 mg is given q night. I have
talled extensively with the patien. he agrees to the
aforementioned format.
Medications on Admission:
HCTZ 25mg QD
Lisinopril 5mg QD
Aspirin 325mg QD
Lipitor 40mg QD
Toprol XL 50mg QD
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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
6. 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*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day, on [**7-7**] decrease to 400
mg daily, then decrease to 200mg [**7-14**] and follow up with Dr [**Last Name (STitle) **].
Disp:*80 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Packet(s)* Refills:*0*
12. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal is [**3-13**].
Disp:*30 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
Dr [**Last Name (STitle) **] Fax: ([**Telephone/Fax (1) 8137**]
INr draw fax the reslts to Dr [**Last Name (STitle) **] off / first draw [**7-5**]
then [**7-7**] then per PCP
14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABGx5
HTN
Hyperlipidemia
Diet controlled diabetes
Afib
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
8) Pt/INR for coumadin dosing Dr [**Last Name (STitle) **] will follow your INR.
your goal is [**3-13**]. VNA will fax the results to her office. If VNA
cannot draw INR you have to take the prescription to your local
lab and have them draw you INR. You should do this [**7-5**]. On DC
your INR is 1.8.
1) Overview of warfarin: action, daily dosing, mg strength,
using
pill-keeper and calendar, avoiding/management of missed doses.
2) PT/INR monitoring: given explanation of test results and goal
range. Stressed the importance of obtaining labwork when ordered
to avoid bleeding and clotting complications.
3) Medications: drug interactions reviewed, emphasizing the need
to notify ACMS of any changes in use of prescription or OTC
medications (including acetaminophen) and avoidance of
NSAIDS/ASA
containing drugs. Specifically requested patient to notify ACMS
of any addition of OTC/herbals/supplements/prescription drugs so
that potential warfarin interactions may be investigated.
4) Dietary considerations: reviewed vitamin K's intraction with
warfarin. Stressed the importance of consistency in weekly diet,
[**Location (un) 1131**] food labels for ingredients, serving sizes of vitamin K
[**Doctor First Name **] foods, avoidance of nutritional supplements and
multivitamins containing vitamin K.
5) Alcohol use: Explained interaction with warfarin, potential
increased bleeding risk associated with alcohol intake,
importance of communicating changes in alcohol intake pattern
with ACMS providers.
6) Bleeding: implications reviewed including signs and symptoms
of minor and major bleeding, when to call ACMS (Mon-Fri 9am-5pm)
and when to call [**Company 191**] providers on call (after hour and weekends)
and importance of seeking urgent care for medical emergencies.
7) Safety considerations: reviewed common home safety hazards,
reinforced importance of injury prevention with good lighting,
nonskid rugs, and consistent seatbelt use. Advised patient to
carry Anticoagulation ID card and /or Medic Alert ID.
8) Procedures: reviewed implications related to dental,
surgical,
and medical procedures. Emphasized the need to notify all
providers of warfarin therapy and ACMS of upcoming procedures
and
any dosage recommendations made by other providers.
9) For female patients: avoiding pregnancy. Reviewed potential
tetrogenic effects of warfarin on the fetus. Reviewed need to
use
effective and consistent birth control measures while taking
warfarin. Instructed to inform ACMS and PCP if planning [**Name Initial (PRE) **]
pregnancy. Also instructed patient to contact ACMS or PCP
immediately if pregnancy occurs.
Followup Instructions:
Please call to schedule appointments
Dr [**Last Name (STitle) 914**] 4 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) **] in on [**Telephone/Fax (1) 250**]. Call and make an appointment to
have your INR followed, as discussed. This should be on [**7-5**].
You can go to her office and have the INR checked or use the
prescription that I gave you to go to an outside lab. Then they
will fax the results to her office. I have set up VNA to draw
your INR anf fax the results to her office. Any three will
surfice. But you must call Dr [**Last Name (STitle) **] to have her follow your
INR. I have e-mailed her yout information.
As discussed with Dr [**Last Name (STitle) **] we have set you up to see Dr [**Last Name (STitle) **]
from cardiology
Scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 5647**], M.D. Date/Time:[**2146-9-1**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2146-7-14**] 9:00
Completed by:[**2146-7-3**]
|
[
"V15.82",
"272.4",
"451.84",
"780.6",
"999.2",
"E849.7",
"250.00",
"V17.3",
"E879.8",
"427.31",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"39.63",
"36.15",
"36.14",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8195, 8253
|
4615, 6127
|
299, 810
|
8361, 8368
|
3043, 4592
|
11772, 12808
|
1891, 2125
|
6259, 8172
|
8274, 8340
|
6153, 6236
|
8392, 11749
|
2140, 3024
|
246, 261
|
838, 1570
|
1592, 1646
|
1662, 1875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,058
| 189,308
|
29264
|
Discharge summary
|
report
|
Admission Date: [**2155-10-9**] Discharge Date: [**2155-10-24**]
Date of Birth: [**2102-6-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
diabetic ketoacidosis
Major Surgical or Invasive Procedure:
flexible sigmoidoscopy x 2
History of Present Illness:
Mr. [**Known lastname **] is a 53 year old man with h/o IDDM, EtOH abuse, HTN,
who was found to be altered with FS [**2143**], admitted to the ICU
with DKA.
The patient was found to be lethargic at home today by his son.
EMS was called. FS at that time was 1900. He was brought
initially to [**Hospital6 33**], found to have AG 27, K 3.0,
Glc [**2140**]. He was started on insulin gtt and K repletion, and
transferred to [**Hospital1 18**] due to lack of ICU beds at [**Hospital3 **].
They considered intubation at that point given AMS, but did not
intubate prior to transfer.
Of note, the patient was admitted to [**Hospital6 33**] in
[**8-17**] with DKA. Family notes that the patient ate an excessive
amount of sugary foods on purpose to induce diabetic coma as a
suicide attempt.
In the ED, initial VS: 97.2 70 125/75 20 97%. The patient was
altered, but o/w HD stable and protecting his airway. Labs
notable for HCT 31.7, Glc 1222, K 2.6, HCO3 13, Cr 2.0, ALT 69,
AP 270. Anion gap 24. UA with trace ketones and Glc 1000. CXR
unremarkable. Patient was continued on insulin gtt (currently @
11.5units/hr), repleted with K. Given 2L IVF (1.7L at OSH for
total 3.7L). Vitals prior to transfer: 122/87, 72, 18, 100% RA.
On the floor, the patient is awake, oriented only to self,
following some commands. C/o being cold. He states that he
vomited yesterday, been having diarrhea for 2 days. Denies
ingesting toxins or excess sugary foods.
Past Medical History:
- IDDM
- PVD: s/p L SFA prox occlusion and reconstitution of popliteal
artery in [**2154-11-6**], s/p L femoral popliteal in situ bypass in
[**2155-1-7**]
- hypothyroidism
- HTN
- NHL [**2135**]
- ETOH abuse
- psych disorder, h/o suicide attempt in the past
- h/o Ecoli urosepsis [**3-17**]
- h/o microcytic anemia
Social History:
Lives in a camper behind his sister-in-law's house. History of
past EtOH abuse. Pt endorses mild alcohol use, and current
tobacco use. Pt denies IVDU, or other illicit drugs.
Family History:
Patient denies family history of cardiac or hemachromatosis.
Physical Exam:
Admission Exam:
Vitals: T: 96.3 BP: 110/71 P: 65 R: 18 O2: 100%RA
General: Alert, orientedx1, mild distress - unable to fully
assess
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: irregularly irregular, S1 + S2, no murmurs, rubs, gallops
Abdomen: extremely tender throughout, ++guarding, hypoactive
bowel sounds
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aaox3, CNs [**1-18**] intact, strength and sensation grossly
nl.
Discharge Exam:
General: AOx3, very thin, slight man in NAD
HEENT: Sclera anicteric, MMM, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: regular, S1 + S2, no murmurs, rubs, gallops
Abdomen: tender abdomen throughout, no guarding or rebound; BS+,
no organomegaly
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: aaox3, CNs [**1-18**] intact, strength and sensation grossly
nl.
SKIN: multiple skin lesions, 1-3 cm round erythematous, crusted
lesions
Pertinent Results:
Admission Labs:
[**2155-10-8**] 11:25PM BLOOD WBC-8.3 RBC-3.25* Hgb-10.0* Hct-31.7*
MCV-98 MCH-30.8 MCHC-31.6 RDW-14.8 Plt Ct-259
[**2155-10-8**] 11:25PM BLOOD Neuts-89.1* Lymphs-8.5* Monos-1.7*
Eos-0.1 Baso-0.7
[**2155-10-8**] 11:25PM BLOOD PT-12.2 PTT-23.6 INR(PT)-1.0
[**2155-10-8**] 11:25PM BLOOD Glucose-1222* UreaN-32* Creat-2.0*#
Na-145 K-2.6* Cl-108 HCO3-13* AnGap-27*
[**2155-10-8**] 11:25PM BLOOD ALT-69* AST-23 AlkPhos-270* TotBili-0.3
[**2155-10-8**] 11:25PM BLOOD Lipase-43
[**2155-10-8**] 11:25PM BLOOD Albumin-3.7 Calcium-9.1 Phos-1.5* Mg-2.1
[**2155-10-9**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-10-9**] 01:02AM BLOOD Type-[**Last Name (un) **] pO2-85 pCO2-41 pH-7.18*
calTCO2-16* Base XS--12 Intubat-NOT INTUBA Comment-GREEN TOP
[**2155-10-8**] 11:36PM BLOOD Glucose-GREATER TH Lactate-3.9*
[**2155-10-8**] 11:36PM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-68 COHgb-2
MetHgb-0
URINE:
[**2155-10-9**] 01:15AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
[**2155-10-9**] 01:15AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2155-10-9**] 01:15AM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
NonsqEp-<1
[**2155-10-9**] 03:08AM URINE Hours-RANDOM UreaN-189 Creat-16 Na-65 K-8
Cl-65
[**2155-10-9**] 03:08AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
OTHER PERTINENT LABS:
[**2155-10-9**] 01:00AM BLOOD CK(CPK)-96
[**2155-10-9**] 08:00AM BLOOD CK(CPK)-144
[**2155-10-9**] 01:00AM BLOOD CK-MB-6 cTropnT-0.03*
[**2155-10-9**] 08:00AM BLOOD CK-MB-7 cTropnT-0.03*
[**2155-10-9**] 05:47PM BLOOD cTropnT-0.01
[**2155-10-9**] 01:00AM BLOOD VitB12-1185* Folate-14.6
[**2155-10-9**] 05:01AM BLOOD Cholest-147 Triglyc-56 HDL-70 CHOL/HD-2.1
LDLcalc-66
[**2155-10-9**] 02:59AM BLOOD TSH-55*
[**2155-10-9**] 03:20AM BLOOD Lactate-8.7*
[**2155-10-9**] 06:06PM BLOOD Lactate-2.1*
MICRO:
[**2155-10-9**], [**10-11**], [**10-12**] UCx: NEGATIVE
MRSA screen: negative
Urine cx: negative
STUDIES:
[**2155-10-8**] EKG: Baseline artifact. Underlying rhythm is difficult
to discern but most likely atrial fibrillation with moderate
ventricular response. ST-T wave changes that are non-specific.
[**2155-10-8**] CXR: No acute intrathoracic process.
[**2155-10-9**] KUB: No evidence of obstruction or ileus.
[**2155-10-9**] CTA abd/pelvis:
1. Hypoenhancement of portion of the splenic flexure as well as
the distal
descending/sigmoid colon with a focal area of sigmoid mural
edema which is
concerning for mild ischemia. No pneumatosis, adjacent colonic
stranding or perforation. This seems unlikely to be the cause of
the patient's lactic acidosis; however, it could be a
contributing factor. These findings are accompanied by occlusion
of the origin of the [**Female First Name (un) 899**] with collateral retrograde flow seen,
though the [**Female First Name (un) 899**] is irregular and with diminutive left colic and
sigmoid arterial branches. The large artery adjacent to the
hypoperfused splenic flexure suggests there is also small vessel
arterial disease.
2. Stenosis of the SFA origin with occlusion of the SFA at the
lower edge of the images. Collateral branch of the SFA is also
noted to be stenotic at its origin.
3. Right external iliac artery focal high-grade stenosis.
4. Status post femoral bypass on the left with occlusion of the
left SFA.
Left thigh AV fistula in the profunda territory is not
completely imaged with early filling of the left common femoral
vein.
5. Hyperdense liver suggest hemochromatosis. Hepatomegaly. No
nodularity.
Esophageal varices strongly suggest portal hypertension. Liver
biopsy should be considered.
6. Hypoenhancing pancreas with atrophic tail suggests chronic
pancreatic
disease, though no evidence or sequela of chronic or acute
pancreatitis are seen. In the setting of known diabetes,
consider chronic autoimmune
pathologies.
EGD ([**2155-10-15**]):
Esophagus: Normal esophagus.
Stomach:
Contents: Retained bilious secretions and digested food was seen
in the stomach. There was some fat droplets noted in the
retained contents.
Duodenum:
Mucosa: Abnormal vascularity and edema of the mucosa were noted
in the duodenal bulb. Cold forceps biopsies were performed for
histology at the duodenal bulb.
Impression: Retained fluids in stomach
Abnormal vascularity and edema in the duodenal bulb (biopsy)
(biopsy)
Otherwise normal EGD to third part of the duodenum
Sigmoidoscopy ([**2155-10-15**]):
Findings:
Mucosa: The entire colon was abnormal from the anus to 40cm of
colon. There was severe submucosal edema and/or infilatrate
suggestive of coblestoneing or submucosal hemorrhage. There was
friability noted of the entire colon and rectum. After the
rectum the mucosa was pale, friable, severely edematous with
some contact bleeding. In the colon itself, the mucosa was
edematous with a pale appearance reminiscent of cerebral gyri.
There was a question of pseudomembranes verus thick mucous
however it was able to be washed off to reveal the underlying
abnormal mucosa. No transition to normol colon was seen. Cold
forceps biopsies were performed for histology at the rectum and
colon.
Impression: Granularity, friability, erythema and congestion in
the rectum to 40cm (biopsy)
Severe submucosal edema/infiltration of the rectum and colon.
Sigmoidoscopy ([**2155-10-22**]):
Findings:
Other: The scope was advanced to 25 cm; stool prevented further
passage of the scope. The mucosa of the sigmoid was black with
areas of pale mucosa occasionally seen. Mucous and stool covered
the mucosa and was able to be partially washed off. No
transition to normal mucosa was seen. Cold forceps biopsies
were performed for histology at the sigmoid colon. The biopsies
were difficult to obtain given the tissue was thickend. No
bleeding was noted after biopsies were taken The mucosa of the
rectum was abnormal but not black. Erythema, congestion and some
pale dicoloration of the mucosa was seen. Cold forceps biopsies
were performed for histology at the rectum.
Impression: The scope was advanced to 25 cm. The mucosa of the
sigmoid was black with areas of pale mucosa occasionally seen.
Mucous and stool covered the mucosa and was able to be washed
off. No transition to normal mucosa was seen. (biopsy)
The mucosa of the rectum was abnormal but not black. Erythema,
congestion and some pale dicoloration of the mucosa was seen.
(biopsy)
Otherwise normal sigmoidoscopy to splenic flexure
PATH:
[**10-15**]:
DIAGNOSIS:
Intestinal mucosal biopsies, four:
A. Duodenal bulb:
Small intestinal mucosa, within normal limits.
B. Duodenum:
Small intestinal mucosa, within normal limits.
C. Rectum:
Diffuse ischemic colitis, additionally involving
superficially sampled submucosa, see note.
D. Colon:
Diffuse ischemic colitis with submucosal involvement and
focal pseudomembrane formation, see note.
Note: The differential diagnosis for the ischemic pattern of
injury includes primary vascular etiologies (favored in this
case, given documented imaging findings of mesenteric
occlusion), certain infections (such as C. difficile), and least
commonly, the use of certain drugs.
[**10-22**]:
DIAGNOSIS:
Colon, mucosal biopsies, two:
A. Sigmoid: Fragments of necrotic tissue with bacteria and
focal acute inflammation; no colonic tissue seen.
B. Rectum: Fragments of fibrinopurulent exudates and bacteria;
no colonic/rectal tissue seen.
STOOL:
[**2155-10-13**] 10:26AM STOOL NA-81 K-25 Osmolal-369
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
C difficile Toxin PCR Negative
Specimen Source: Stool
FECAL FAT, QUALITATIVE, RANDOM
Test Result Reference
Range/Units
FECAL FAT, QUALITATIVE Abnormal A Normal
Normal - Tiny fat globules, <1 micron in diameter
and too difficult to count, were observed
microscopically under high power.
Abnormal - Fat globules, 1 to 8 microns in
diameter, and <100 globules per high
power field were observed micro-
scopically.
Grossly Abnormal - Large fat globules, 9 to 75
microns in diameter, and so numerous
that there was very little fecal
background observed microscopically
under high power.
PANCREATIC ELASTASE 1, STOOL
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
---------------
Pancreatic Elastase in Stool
Patient Value: <50.0 ug E/g stool
Interpretation: Severe exocrine pancreatic insuffiency
* Please Note: This specimen was liquid/fibrous in
consistency. a formed stool should be tested for more accurate
results.
Reference Values For Pancreatic Elastase in Stool
200 to >500 ug Elastase/g stool = Normal
100 to 200 ug Elastase/g stool = Moderate to
slight
exocrine
pancreatic
insufficiency
<100 ug Elastase/g stool = Severe exocrine
pancreatic
insuffiency
[**2155-10-9**] 8:01 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2155-10-12**]**
FECAL CULTURE (Final [**2155-10-12**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2155-10-11**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2155-10-9**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2155-10-12**] 6:20 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2155-10-13**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2155-10-13**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2155-10-14**] 9:53 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2155-10-15**]**
OVA + PARASITES (Final [**2155-10-15**]) x 4:
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.
[**2155-10-14**] 9:37 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2155-10-17**]**
MICROSPORIDIA STAIN (Final [**2155-10-17**]): NO MICROSPORIDIUM
SEEN.
OVA + PARASITES (Final [**2155-10-15**]):
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.
Cryptosporidium/Giardia (DFA) (Final [**2155-10-15**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
[**2155-10-21**] 9:08 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2155-10-23**]**
MICROSPORIDIA STAIN (Final [**2155-10-23**]): NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final [**2155-10-22**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2155-10-22**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2155-10-23**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2155-10-22**]):
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.
FECAL CULTURE - R/O VIBRIO (Final [**2155-10-23**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2155-10-23**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2155-10-22**]):
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2155-10-22**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
PERTINENT INTERVAL LABS:
DISCHARGE LABS:
[**2155-10-23**] 06:10AM BLOOD WBC-7.3 RBC-3.15* Hgb-9.2* Hct-26.8*
MCV-85 MCH-29.1 MCHC-34.2 RDW-14.6 Plt Ct-798*
[**2155-10-23**] 06:10AM BLOOD Ret Aut-2.7
[**2155-10-24**] 08:00AM BLOOD Glucose-206* UreaN-6 Creat-1.0 Na-137
K-4.5 Cl-102 HCO3-30 AnGap-10
[**2155-10-24**] 08:00AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.7
[**2155-10-23**] 06:10AM BLOOD Hapto-237*
[**2155-10-9**] 05:47PM BLOOD cTropnT-0.01
[**2155-10-9**] 08:00AM BLOOD CK-MB-7 cTropnT-0.03*
[**2155-10-9**] 01:00AM BLOOD CK-MB-6 cTropnT-0.03*
[**2155-10-14**] 06:49AM BLOOD calTIBC-163* Ferritn-646* TRF-125*
[**2155-10-9**] 01:00AM BLOOD VitB12-1185* Folate-14.6
[**2155-10-16**] 06:05AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.6 Iron-10*
[**2155-10-14**] 06:49AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7 Iron-13*
[**2155-10-15**] 06:10AM BLOOD Albumin-3.0* Calcium-8.8 Phos-3.0 Mg-1.7
[**2155-10-11**] 12:00PM BLOOD %HbA1c-10.0* eAG-240*
[**2155-10-9**] 02:59AM BLOOD TSH-55*
[**2155-10-14**] 06:49AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE
[**2155-10-14**] 01:00PM BLOOD HIV Ab-NEGATIVE
[**2155-10-14**] 06:49AM BLOOD tTG-IgA-3
[**2155-10-14**] 06:49AM BLOOD HCV Ab-NEGATIVE
[**2155-10-18**] 06:48AM BLOOD Lactate-1.5
[**2155-10-13**] 05:38PM BLOOD Lactate-1.6
[**2155-10-12**] 07:35AM BLOOD Lactate-1.3
[**2155-10-11**] 05:33PM BLOOD Lactate-2.1*
[**2155-10-11**] 04:18AM BLOOD Lactate-2.8*
[**2155-10-9**] 06:06PM BLOOD Lactate-2.1*
[**2155-10-9**] 08:25AM BLOOD Lactate-3.1*
[**2155-10-9**] 05:29AM BLOOD Lactate-7.1*
[**2155-10-20**] 06:55
C-PEPTIDE
Test Result Reference
Range/Units
C-PEPTIDE <0.10 L 0.80-3.10
ng/mL
HEREDITARY HEMOCHROMATOSIS MUTATION ANALYSIS
Test Result Reference
Range/Units
Hereditary Hemochromatosis DNA Mutation Analysis
DNA Mutation Analysis See Below
RESULT: HETEROZYGOUS FOR THE H63D MUTATION
INTERPRETATION: DNA testing indicates that this
individual is positive for one copy of H63D mutation in
HFE gene. This individual is negative for the C282Y
mutation. This result reduces the likelihood of
hereditary hemochromatosis (HH) in this individual.
However, it does not rule out the presence of other
mutations within the HFE gene or a diagnosis of HH.
The risk of this individual carrying a HFE mutation
other than those tested in this assay depends greatly
on family and clinical history as well as ethnicity.
This assay does not test for other primary or secondary
iron overload disorders. Consider genetic counseling
and DNA testing for at-risk family members.
[**Initials (NamePattern5) **] [**Last Name (NamePattern5) 1662**], Ph.D., FACMG
Director, Molecular Genetics
Hereditary hemochromatosis (HH) is an autosomal
recessive disorder of iron metabolism that results in
iron overload and potential organ failure. It is one
of the most common genetic disorders in individuals of
European-Caucasian ancestry, with an estimated carrier
frequency of 10%. HH is caused by mutations in the HFE
gene. Most individuals with HH (60-90%) are homozygous
for the C282Y mutation. A smaller percentage of
affected individuals are either compound heterozygous
for the C282Y and H63D mutations (3%-8%), or homozygous
for the H63D mutation (approximately 1%).
This assay detects the two mutations in the HFE gene,
C282Y (NM_000410.2: c.845G>A) and H63D (NM_000410.2: c.
187C>G), that are commonly associated with HH. The
mutations are detected by multiplex-polymerase chain
reaction (PCR) amplification, followed by digestion of
the amplification products with the restriction enzymes
Rsal and NlaIII, for the detection of the C282Y and
H63D mutations respectively. Fluorescent-labeled
restriction fragments are detected by capillary
electrophoresis.
This assay does not detect other mutations in the HFE
gene that can cause HH. Since genetic variation and
other factors can affect the accuracy of direct
mutation testing, these results should be interpreted
in light of clinical and familial data.
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY
======================
Mr. [**Known lastname **] is a 53 year old man with h/o IDDM, h/o non-adherence
with medications, prior hospitalizations for DKA, EtOH abuse,
chronic diarrhea, who was admitted with DKA, abdominal pain.
======================
ACTIVE ISSUES
======================
#. DKA / Diabetes: Unclear trigger - most likely [**1-8**] to
medication non-adherence. Patient came in with anion gap of 24,
which closed with insulin gtt and IVF. Patient was initially
stabilized in the intensive care unit, requiring approximately
17L of IVF. Patient was restarted on SC insulin. There was no
evidence of infection, based upon imaging studies and laboratory
data. Electrolytes were repleted aggressively and monitored
closely. Once called out to the floor, the patient's blood
sugars were managed with the aid of [**Last Name (un) **] Diabetes Center
consultants. The patient was maintained on lantus and pre-meal
humalog, in addition to a HISS, for the majority of the
hospitalization. The patient was transitioned to a 75/25
humalog mix towards the end of the hospitalization, to simplify
his regimen and promote compliance. The patient tolerated a
diabetic diet with supplements. Blood sugars were variable, and
the patient is sensitive to insulin. The patient acts much like
a Type I diabetic, likely [**1-8**] endocrine pancreatic insufficiency
(c-peptide low). A social worker met with the patient on
multiple occasions to discuss medication compliance, and to help
the patient with access to resources. Physical therapy worked
with the patient throughout the stay.
#. Abdominal pain / Diarrhea: Patient with marked guarding on
initial abdominal exam, in the setting of high lactate and dark
red watery stool, so CTA abd/pelvis was done to rule out
mesenteric ischemia. CTA shows occluded [**Female First Name (un) 899**] - likely chronic per
vascular with good collateral flow. ASA increased from 81mg to
325mg PO daily, continued home statin. Pain may be related to
chronic diarrhea (~1 year). Unclear etiology of diarrhea - per
patient had colonoscopy in [**3-17**] that was negative for Crohn's
disease. Pt notes has been having diarrhea for approx one year,
is incontinent of stool, and soiled himself approx 5 times per
night while at home. Output was 1.5-4L per day while here. Stool
is worse at night, large volume. Infectious work-up entirely
negative, including HIV, hepatitis, stool cultures (including
bacterial, o/p, c. diff), TTG neg. Elastase was low, which may
demonstrate exocrine pancreatic dysfunction, yet creon tablets
were started and no improvement was noted. Pt had
EGD/sigmoidoscopy that demonstated significant abnormalities,
friability, rectal inflammation, severely edematous bowel.
Biopsy demonstrates evidence of ischemic bowel. A repeat
sigmoidoscopy approx one week later showed improvement of the
rectal region, but black, ischemic mucosa in the distal colon
with necrosis. Thus, much of the diarrhea was thought to be
secondary to chronic ischemic bowel, exacerbated by a second
"hit" of ischemia with hypovolemia secondary to DKA. The
patient was evaluated by surgery (colorectal and vascular), with
no indication for urgent surgery. Due to high risk of ongoing
diarrhea, and development of complications including stricture
or even perfortation, the patient was offered inpatient
colectomy. He declined, chosing to go home for the [**Holiday 1451**]
holiday and to follow up closely in colorectal surgery clinic.
Due to sub-optimal nutrition, the patient may require
supplemental nutrition (TPN) as a bridge prior to an elective
surgical intervention. It should be noted, however, that the
patient is at increased risk for perforation, considering
imaging results (flex sig) and any worrisome abdominal symptoms
should be taken very seriously.
.
#. Anemia: Widely variable Hct from 22-28 (b/l 25-27 per OSH
records) while patient has been admitted. The patient received a
transfusion of one unit pRBCs when Hct was 22, with an
appropriate rise in Hct to 29 afterwards). Anemia likely
secondary to poor production in the setting of systemic illness,
in addition to occult loss in profuse diarrhea (guaiac positive
stools), in addition to phlebotomy.
Iron: 10
calTIBC: 163
Ferritn: 646
TRF: 125
.
#. Renal failure: Cr improved, with renal failure resolved (Cr
2.0 on admission, 0.9 by discharge). Likely prerenal given DKA.
Cr was also 2 on admission to [**Hospital3 **] in [**8-17**]. Given
patients reasonable blood pressures, we continued to hold Lasix,
Lisinopril at discharge.
.
#?Hemochramotosis: CT scan demonstrating hypodense liver. Iron
studies Total iron/TIBC 76.7%, >50% can be suggestive of
hemochromatosis. HFE demonstrates HETEROZYGOUS FOR THE H63D
MUTATION. Likely not responsible for his constellation of
symptoms, given heterozygosity. Repeat iron studies
demonstrated markedly lower total body iron.
#. Afib: Afib on admission for several hours, with no documented
history in records. Rate was well controlled without
medications. Patient spontaneously converted to NSR several
hours after admission and has remained in NSR throughout
hospitalization. Poor candidate for anticoagulation despite
CHADS2 of 2, so continued asprin (decreased to ASA 81 in the
setting of blood loss with diarrhea).
#. L heel pressure sore: nursing managed with anti-pressure
booties. Patient also had multiple other sores on body, likely
related to poor nutrition and poor healing.
=======================
INACTIVE ISSUES
=======================
#. EtOH abuse: no e/o w/d. Never scored on CIWA, did not
require benzodiazepines. Social work consulted.
#. HTN: pt normotensive, 100-130s. Stopped lisinopril and lasix
#. Hypothyroidism: TSH 55, unclear if patient is adherent with
meds at home. Also difficult to interpret in the setting of
acute infection. Continued home Levothyroxine 200mcg PO daily.
Will need outpatient thyroid studies in [**3-12**] weeks.
=======================
TRANSITIONAL ISSUES
=======================
1. MEDICATION CHANGES
CONTINUE levothyroxine 100 mcg Tablet Sig: One (1) Tablet by
mouth once a day.
START Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: One
(1) dose Subcutaneous twice a day: Please take 9 units before
breakfast and 8 units before dinner. .
START Humalog 100 unit/mL Solution Sig: per sliding scale per
sliding scale Subcutaneous once a day: PLEASE REFER TO INSULIN
SLIDING SCALE.
CONTINUE simvastatin 40 mg Tablet Sig: One (1) Tablet by mouth
DAILY (Daily).
START loperamide 2 mg Capsule Sig: One (1) Capsule by mouth QID
(4 times a day) as needed for diarrhea.
START nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
CONTINUE aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable by mouth DAILY (Daily).
START mirtazapine 15 mg Tablet Sig: One (1) Tablet by mouth HS
(at bedtime).
CONTINUE multivitamin Tablet Sig: One (1) Tablet by mouth DAILY
(Daily).
PLEASE STOP THE FOLLOWING MEDICATIONS: (we have decreased the
number of pills taken daily in an effort to improve compliance)
Lantus 8units Subcutaneous every AM
Lasix 20mg by mouth daily
Omeprazole 20mg by mouth daily
Nystatin powder topical three times per day
Reglan 10mg by mouth twice per day
Thiamine 100mg by mouth daily
Folate 1mg by mouth daily
Lisinopril 5mg by mouth daily
2. Pt should have thyroid function tested as outpatient, as TSH
abnormal, but was in setting of systemic inflammation.
3. Follow-up appointments:
PCP [**Name Initial (PRE) **]: Monday, [**11-3**] @ 11am
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 70353**],MD
Location: [**Hospital **] MEDICAL ASSOCIATES-[**Location (un) **]
Address: [**State 70354**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 57304**]
**Please discuss following up with the [**Last Name (un) **] Diabetes Center.
They have a free care service you can apply to by calling them @
[**Telephone/Fax (1) 70355**], or maybe he can refer you to an Endocrinologist in
your area.
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2155-11-6**] at 9:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 11714**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Medications on Admission:
(per OSH ED records):
Lantus 8units SC qAM
Humalog sliding scale
Lasix 20mg PO daily
Omeprazole 20mg PO daily
KCl 10mEq PO daily
Nystatin powder TP TID
Reglan 10mg PO BID
Levothyroxine 200mcg PO daily
Thiamine 100mg PO daily
MVI 1tab PO daily
Folate 1mg PO daily
ASA 81mg PO daily
additional meds per [**8-17**] H&P:
Lisinopril 5mg PO daily
Simvastatin 40mg PO daily
Discharge Medications:
1. Outpatient Lab Work
TSH, please fax results to PCP [**Telephone/Fax (1) 70356**] [**Last Name (LF) 57303**],[**First Name3 (LF) **] A
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: One (1)
dose Subcutaneous twice a day: Please take 9 units before
breakfast and 8 units before dinner. .
Disp:*qs qs* Refills:*0*
4. Humalog 100 unit/mL Solution Sig: per sliding scale per
sliding scale Subcutaneous once a day: PLEASE REFER TO INSULIN
SLIDING SCALE. .
Disp:*qs qs* Refills:*0*
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*0*
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: diabetic ketoacidosis
secondary diagnosis: chronic diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you while you were at the [**Hospital1 1535**].
You were admitted to the hospital for a very high blood sugar
(an episode called diabetic ketoacidosis). You were initially
stabilized in the Intensive Care Unit, at which point your blood
sugars stabilized. We employed the help of the specialists from
[**Last Name (un) **] Diabetes Center in formulating the plan for your diabetic
regimen.
While in the hospital, you also had a large amount of diarrhea.
This is a chronic issue for you, but we worked up this problem
to undercover the reason. The specialists in gastroenterology
saw you during this hospitalization, as well as our surgical
colleagues. Your diarrhea while you were in the hospital is
most likely secondary to low blood flow in your colon. It is
likely that you may need a colon surgery in the future. We have
set up an appointment for you to be seen by a colon surgeon. It
is very important for you to keep this appointment, because you
are at risk for your colon perforating or having a hole in it
because of the damage that has been done to it already.
Your blood sugars vary very widely throughout the day. It is
important that you take frequent readings of your blood sugar by
fingerstick. We have come up with an insulin regimen that
should be amenable to you. Please communicate with your primary
care doctor regarding your blood sugars and if you are having
any problems.
While in the hospital, you were on a nicotine patch. You should
continue to abstain from smoking, and please discuss with your
primary care doctor regarding other options. You should
continue also to abstain from alcohol, as this can cause your
diabetic care to be worse, you to have higher blood sugars, in
addition to other health concerns.
MEDICATIONS
Outpatient Lab Work
You should have your TSH lab test as an outpatient, please fax
results to PCP [**Telephone/Fax (1) 70356**] [**Last Name (LF) 57303**],[**First Name3 (LF) **] A
CONTINUE levothyroxine 100 mcg Tablet Sig: One (1) Tablet by
mouth once a day.
START Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig:
One (1) dose Subcutaneous twice a day: Please take 9 units
before breakfast and 8 units before dinner. .
START Humalog 100 unit/mL Solution Sig: per sliding scale
per sliding scale Subcutaneous once a day: PLEASE REFER TO
INSULIN SLIDING SCALE.
CONTINUE simvastatin 40 mg Tablet Sig: One (1) Tablet by
mouth DAILY (Daily).
START loperamide 2 mg Capsule Sig: One (1) Capsule by mouth
QID (4 times a day) as needed for diarrhea.
START nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
CONTINUE aspirin 81 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable by mouth DAILY (Daily).
START mirtazapine 15 mg Tablet Sig: One (1) Tablet by mouth
HS (at bedtime).
CONTINUE multivitamin Tablet Sig: One (1) Tablet by mouth
DAILY (Daily).
PLEASE STOP THE FOLLOWING MEDICATIONS:
Lantus 8units Subcutaneous every AM
Lasix 20mg by mouth daily
Omeprazole 20mg by mouth daily
Nystatin powder topical three times per day
Reglan 10mg by mouth twice per day
Thiamine 100mg by mouth daily
Folate 1mg by mouth daily
Lisinopril 5mg by mouth daily
Followup Instructions:
PCP [**Name Initial (PRE) **]: Monday, [**11-3**] @ 11am
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 70353**],MD
Location: [**Hospital **] MEDICAL ASSOCIATES-[**Location (un) **]
Address: [**State 70354**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 57304**]
**Please discuss with your PCP following up with the [**Last Name (un) **]
Diabetes Center. They have a free care service you can apply to
by calling them @ [**Telephone/Fax (1) 70355**], or maybe he can refer you to an
Endocrinologist in your area.
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2155-11-6**] at 9:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 11714**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"262",
"V85.0",
"427.31",
"285.9",
"557.1",
"276.8",
"577.1",
"276.0",
"401.9",
"275.03",
"V58.67",
"305.00",
"250.13",
"584.9",
"787.91",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
29883, 29889
|
19967, 27430
|
327, 356
|
30012, 30012
|
3617, 3617
|
33445, 34329
|
2377, 2439
|
28735, 29860
|
29910, 29910
|
28344, 28712
|
30163, 33422
|
15903, 19944
|
2454, 3043
|
3059, 3598
|
27454, 28318
|
266, 289
|
384, 1828
|
29972, 29991
|
3633, 5040
|
29929, 29951
|
5062, 15887
|
30027, 30139
|
1850, 2167
|
2183, 2361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,792
| 132,278
|
43346
|
Discharge summary
|
report
|
Admission Date: [**2206-10-20**] Discharge Date: [**2206-10-20**]
Date of Birth: [**2147-6-23**] Sex: M
Service: MEDICINE
Allergies:
Lovenox / Keflex
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
59M history of nonischemic cardiomyopathy (EF 40%), ICD, recent
admission to CCU with ablation of V. tach, discharged 9 days ago
who complains of 15 pound weight gain, worsened dyspnea and
orthopnea since that time. No infectious symptoms. on torsemide
and spironolactone at home. He saw Dr. [**Last Name (STitle) **]/Dr. [**Last Name (STitle) **] in
the office on [**2206-10-17**] for evaluation, at which time they
increased his torsemide 30mg Qdaily to 50mg Qdaily (he was
discharged on a dose of torsemide 30mg QOD, but had been taking
it daily). This is in addition to his spironolactone. Per
patient, he felt worse over the weekend with fatigue, SOB,
orthopnea. Cr on office visit [**10-17**] was 1.8-->3.7 today.
.
In the ER, intial VS 96.4 73 95/70 12 94% RA. On exam, lungs
clear, edema up to the abdomen. chest x-ray consistent with some
failure but not significantly changed from prior. BNP improved
from prior (799 from [**2156**] a year ago). Blood pressure 70s
systolic, with its baseline is 80s, mentating well. Blood
pressure did transiently dip down to 69/50, after which he was
given 200cc IVF with response to 78/57. bedside u/s showing
large pericardial effusion. EKG paced at a rate of 72. Trop
0.05. Vital signs on transfer to the unit were HR 70 BP 78/57 RR
20 Pox 97% 2L (94 on RA).
.
In the ICU, c/o mid scapular
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-Recent infected right leg hematoma ([**Year (4 digits) 8974**], completed Bactrim
[**2205-7-5**])
-Nonischemic cardiomyopathy s/p BiV ICD implantation: EF 40%,
?viral
-Hypertension
-Systolic CHF: secondary to cardiomyopathy, EF 40%
-Heart block: etiology unclear, R sided PPM placed then replaced
with ICD (R)/BiV PPM (L) ([**12/2199**])
-Atrial fibrillation
-Tracheobronchomalacia (recently diagnosed on CT chest [**3-/2205**])
-Sarcoidosis involving lungs, lymph nodes, ?heart
-Pulmonary hypertension
-Subglottic stenosis
-Ventral hernia repair w/ prolonged respiratory failure,
hospitalization
-Obstructive sleep apnea (central and obstructive, untreated)
-Obesity
-Depression
-Panic attacks
-CKD, baseline Cr. ~1.5
-Neuropathy, following gastric stapling in [**2192**]
- Left ankle reconstruction, bilateral knee surgeries
Cardiac Risk Factors: -Diabetes, -Dyslipidemia, +Hypertension
.
Cardiac History:
Biventricular Pacemaker/ICD, in [**12/2199**]
Social History:
Former consultant, married with two children but wife recently
left him. Just went to daughter's college graduation. No current
tobacco or alcohol use
Family History:
Father had coronary artery disease and hypertension. Mother had
hypertension, diabetes, ear tumor. Brother had renal cell
carcinoma.
Physical Exam:
VS: T=97 BP=77/34 HR= 81 RR= 17 O2 sat= 95% pulsus of 10
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 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. distant heart sounds
LUNGS: No chest wall deformities, scoliosis or kyphosis. labored
breathing with crackles to the mid back bilaterally
ABDOMEN: Soft, very distented, no fluid wave.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2206-10-20**] 01:30AM PT-27.5* PTT-59.7* INR(PT)-2.6*
[**2206-10-20**] 01:30AM PLT COUNT-400#
[**2206-10-20**] 01:30AM NEUTS-86.2* LYMPHS-7.1* MONOS-5.8 EOS-0.7
BASOS-0.2
[**2206-10-20**] 01:30AM WBC-14.1*# RBC-4.03* HGB-11.6* HCT-36.1*
MCV-90 MCH-28.7 MCHC-32.1 RDW-15.5
[**2206-10-20**] 01:30AM cTropnT-0.05* proBNP-799*
[**2206-10-20**] 01:30AM GLUCOSE-132* UREA N-48* CREAT-3.4*#
SODIUM-133 POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-21* ANION
GAP-22*
[**2206-10-20**] 03:30AM DIGOXIN-0.2*
[**2206-10-20**] 03:30AM GLUCOSE-131* UREA N-53* CREAT-3.7*
SODIUM-132* POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-25 ANION GAP-15
[**2206-10-20**] 10:00AM PLT COUNT-74*#
[**2206-10-20**] 10:00AM WBC-3.9*# RBC-2.36*# HGB-7.0*# HCT-23.2*#
MCV-98# MCH-29.4 MCHC-30.0* RDW-16.3*
.
CXR
IMPRESSION:
1. Cardiomegaly, although pericardial effusion cannot be
excluded; consider echocardiogram - discussed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
9:21 am on [**2206-10-20**] over the phone.
2. Low lung volumes with bibasilar atelectasis.
.
ECHO
[**2206-10-20**]
Left ventricular wall thicknesses and cavity size are normal.
There is a moderate to large circumferential pericardial
effusion with right ventricular diastolic collapse, consistent
with impaired fillling/tamponade physiology.
IMPRESSION: Moderate to large circumferential pericardial
effusion with echo evidence of increased pericardial
pressure/tamponade physiology.
Compared with the prior study (images reviewed) of [**2206-10-11**], the
pericardial effusion and tamponade findings are new.
.
[**2206-10-20**] - echo
Initial images at 10:16am demonstrate right ventricular cavity
dilation with a small (>1cm) anterior pericardial effusion. The
effusion is much smaller than the echo earlier in the day and
the right ventricular cavity is much larger.
10:29am images demonstrate a similar small anterior pericardial
effusion.
10:44am images demonstrate akinesis of the heart without very
small anterior pericardial effusion. The right ventricular
remains dilated.
Brief Hospital Course:
59M history of nonischemic cardiomyopathy (EF 40%), ICD, recent
admission to CCU with ablation of V. tach, discharged 9 days ago
who complains of 15 pound weight gain, worsened dyspnea and
orthopnea since that time. In the [**Name (NI) **], pt was found to be
hypotensive and in right sided heart failure. A bedside echo at
6:00 am was performed that showed pericardial effusion, pt was
given IVF given preload dependent state. Cardiology was
consulted and repeat echo performed at 7:14, and pt was brought
to the cath lab for drainage of effusion. INR was elevated, so
ffp was ordered to reduce chance of bleeding during procedure.
.
In holding area, pt was in respiratory distress and hypotensive
to 80's systolic, with levophed infusion. Pt was urgently
prepped and drapped, could not lie flat b/c respiratory
distress. Pericardiocentesis was performed with subxyphoid
approach and 400cc bloody fluid was aspirated, blood pressure
improved to 120's systolic and levophed was reduced.
Echocardiographic confirmation of catheter position was diffult
to determine and pt grew hypotensive and apneic. CPR was
started and pt was rapidly intubated. Pericardial catheter was
removed post cutdown to xyphoid and needle accessed pericardial
space and an additional 120cc of fluid was removed. Echo
confirmed effusion had resolved, but at this point pt was in PEA
arrest. C-[**Doctor First Name **] was present and determined that ECMO futile. Pt
expired at 10:27AM. Medical Examinerwas notified to request
autopsy and case was declined by Dr.
[**First Name (STitle) **] at 11:15 AM. Family was notified of patient's passing by
Dr. [**Last Name (STitle) **].
Medications on Admission:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
10 digoxin 125 ugm daily
11. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
13. torsemide 20 mg Tablet Sig: 1.5 Tablets PO QOD ().
14. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
pericardial tamponade
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"427.5",
"428.0",
"427.41",
"135",
"425.4",
"416.0",
"423.9",
"785.51",
"427.31",
"327.23",
"517.8",
"428.20",
"V45.02",
"423.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.04",
"96.71",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
9243, 9252
|
6427, 8093
|
291, 312
|
9317, 9326
|
4342, 6404
|
9378, 9513
|
3377, 3511
|
9215, 9220
|
9273, 9296
|
8119, 9192
|
9350, 9355
|
3526, 4323
|
240, 253
|
340, 2215
|
2237, 3193
|
3209, 3361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,221
| 169,792
|
9746
|
Discharge summary
|
report
|
Admission Date: [**2130-9-2**] Discharge Date: [**2130-9-18**]
Date of Birth: [**2080-4-29**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
cardiac arrest, transferred from OSH for cooling
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy with removal of foreign body
Left subclavian line placement
Arterial line placement
History of Present Illness:
50yo M with history of possible diabetes and hepatitis C found
down by EMS in asystole with low BS. (Possibly surrounding drug
paraphenalia). FS glucose = 46 in the field. He was intubated
and given D50, epinephrine and atropine. He developed Vfib and
was defibrillated x 1 and resumed SR. He presented to OSH ED in
bradycardia and given more atropine. In the [**Name (NI) **] pt given
amiodarone drip 1mg/min, Dopamine drip, ASA, Versed for
sedation. Repeat FS=86 and given add'l D50. Lactate 6.3. Tox
negative. Head CT showed occipital hematoma, he was boarded and
collared. OGT placed. No foley cath placed given hypospadia. Pt
was transferred from OSH ([**Hospital3 **]) to [**Hospital1 18**] for cardiac
arrest hypothermia protocol. Vital on transfer: BP 120s, HR70,
O2sat99% on 100%FiO2. OSH labs: tot bili 0.7, Alkph=48, AST=53,
CK=560, MB=11.1, Trop=?, Valproic acid level=41, EtoH<10, neg
barbiturate, neg benzo, ne antidepressant,
.
Of note, pt was recently hospitalized at [**Hospital3 **] for
hypoglycemia with similar presentation FS=17. Family raised
question of possibly pt leaving AMA. On u-500 insulin. Pt found
down in field and admitted for management of glucose levels.
.
On admission to [**Hospital1 18**], he was placed on Arctic Sun Protocol with
rectal and esophageal temp probe. Started on Fentanyl gtt and
versed gtt, and vecuronium 10mg IV push. Temp 91.0 rectal after
cooling initiated in ED. R groin triple lumen line placed and pt
admitted to CCU for further management.
.
On the floor, pt continued on Arctic Sun protocol s/p arrest.
Arteria line was placed. Pt hemodynamically stable on telemetry
monitoring and continued intubation, sedation, paralytic. Family
informed of clinical status; sister [**Name (NI) 32879**] identified herself as
closest living relative.
Past Medical History:
1) Hypertension
2) Diabetes Mellitus (on U-500 insulin) - recent hospitalization
at [**Hospital3 **] for hypoglycemia
3) Diabetic retinopathy
4) Bipolar Disorder
5) Chronic Back Pain
6) Right eye blindness
7) Hyperkalemia from ACE-inhibitor
8) Depression
9) Bilateral cataracts
Social History:
SOCIAL HISTORY: unmarried, unemployed
-Tobacco history: unknwn
-ETOH:
-Illicit drugs:
Family History:
Unknown
Physical Exam:
PHYSICAL EXAMINATION on admission:
GENERAL: Intubated obese caucasian male, sedated wearing
C-collar
HEENT: small abrasion on R forehead; Anisocoria R>L pupil size
NECK: cervical collar in place
CARDIAC: very distant heart sound, No apparent m/r/g. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Ventilated. Anterior exam only - some crackles noted on R lung
exam.
ABDOMEN: Soft, obese. No HSM or tenderness. BS noted.
EXTREMITIES: +edema in all extremities, nonpitting
GU: very small penis with inferior pinpoint urethral meatus
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
.
Physical Exam on Day of Discharge:
Pertinent Results:
LABS:
XXXXXXXXX
.
Studies:
ECG Study Date of [**2130-9-2**]
Sinus rhythm with first degree atrio-ventricular conduction
delay.
Non-specific QRS widening. Tented T waves in the anterior
precordial leads. Consider hyperkalemia. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 [**Telephone/Fax (3) 32880**]/479 24 67 9
.
CHEST (PORTABLE AP) Study Date of [**2130-9-3**]
FINDINGS: In comparison with the study of [**9-2**], the tip of the
endotracheal tube is at the upper clavicular level,
approximately 6.8 cm above the carina. Nasogastric tube again
extends into the stomach. Mild enlargement of the cardiac
silhouette persists. There is again an area of hazy
opacification involving the upper portion of the left lung. This
raises the possibility of contusion or possible pneumonia.
Volume loss in the left upper lobe could also be considered.
Right lung is clear.
.
ABDOMEN (SUPINE ONLY) PORT Study Date of [**2130-9-3**]
FINDINGS: Single view fails to show the uppermost portion of the
abdomen and the course of the nasogastric tube. There is a
virtually gasless abdomen except for some gas within the colon.
Although there is no evidence of obstruction, if there is
serious clinical concern for dilated, fluid-filled loops of
bowel, CT would be necessary to definitely exclude an
obstruction.
.
ECG Study Date of [**2130-9-4**]
Sinus rhythm. Right axis deviation is non-specific but cannot
exclude left
posterior fascicular block or possible right ventricular
overload. Delayed
R wave progression with late precordial QRS transition.
Borderline prolonged QTc interval. Findings are non-specific.
Clinical correlation is suggested. Since the previous tracing
of [**2130-9-3**] further right axis deviation is present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 178 92 [**Telephone/Fax (2) 32881**]9 31
.
CHEST (PORTABLE AP) Study Date of [**2130-9-5**]
IMPRESSION:
1. Findings concerning for left upper lobe collapse and
central/mediastinal adenopathy. Recommend further evaluation
with CT to evaluate for underlying malignancy. This was
discussed with Dr.[**First Name4 (NamePattern1) 20069**] [**Last Name (NamePattern1) 32882**] and at the time of approval a
contrast enhanced CT had been requested.
2. Interval repositioning of Swan which is now terminating in
the proximal
right lobar or distal right main pulmonary artery.
3. Deep left subclavian catheter extending into the right
atrium, withdrawal by 5 cm to position at the cavoatrial
junction is recommended.
.
CT HEAD W/O CONTRAST Study Date of [**2130-9-7**]
FINDINGS: There is no evidence of hemorrhage, infarct, mass,
mass effect or edema. There is diffuse sinus disease with
mucosal thickening of the
bilateral maxillary, ethmoid and sphenoid sinuses as well as the
mastoid air cells. There is calcification seen in the petrous
portion of the right
internal carotid artery. There are no fractures seen.
IMPRESSION: Extensive sinus disease. Carotid artery
calcifications.
.
CT C-SPINE W/O CONTRAST Study Date of [**2130-9-7**]
FINDINGS: Visualization below C7 is limited by artifact from an
endotracheal balloon. No fracture of the cervical spine is seen.
There is mild degenerative disease with a bridging osteophyte
seen at C3-C4 level.
Calcifications of the left and right carotid arteries are seen.
There are no soft tissue abnormalities in the prevertebral and
paravertebral spaces.
Endotracheal tube and orogastric tube are seen within the
trachea and
esophagus respectively.
IMPRESSION: Exam limited below C7. No cervical spine fracture
seen.
Calcified internal carotid arteries.
.
CT CHEST W/CONTRAST Study Date of [**2130-9-7**]
FINDINGS:
Obstruction of the left main bronchus, approximately 4.2 cm from
the carina si by a lesion of low density, approximately 50
Hounsfield units tissue. The left upper lobe is completely
collapsed with a low-density material seen in the bronchi (the
appearance of "drowned lung"). The rest of the tracheal and
bronchial tree is patent throughout. There is left hilar
lymphadenopathy, 2:27, approximately 1.5 cm in diameter. The
aorta is unremarkable. Main pulmonary artery is dilated up to 4
cm, finding that might be consistent with pulmonary
hypertension. The mediastinum is shifted to the left due to the
left upper lobe collapse. The left lower lobe is expanded till
the apex with the superior segment of the left upper lobe being
located in the apex posterior to the collapsed left upper lobe,
Luftsichel sign. The heart size is minimally enlarged. There is
no pericardial effusion. The Swan-Ganz catheter tip is in right
lower lobe pulmonary artery and to secure its position in the
main pulmonary artery should be pulled back approximately 8 cm.
The imaged portion of the upper abdomen demonstrates moderate to
significant splenomegaly and otherwise is unremarkable within
the limitations of this study that was not designed for
evaluation of intra-abdominal pathology. The NG tube tip is in
the stomach. The ET tube tip is approximately 5 cm above the
carina.
The right upper lobe and the right middle lobe are grossly
unremarkable.
Right lower lobe posterior opacities most likely consistent with
aspiration combined with atelectasis. Infectious process,
although cannot be excluded, is less likely. Left lower lobe
area of atelectasis is noted posteriorly as well. There are no
bone lesions worrisome for infection or neoplasm.
IMPRESSION:
1. Complete collapse of left upper lobe as described in
detailed. Evaluation of the patient with bronchoscopy is highly
recommended for therapeutic and if necessary diagnostic purposes
since the obstruction might be either mucous plug or
endobronchial neoplasm (less likely but cannot be entirely
excluded).
2. Right lower lobe posterior opacity most likely a combination
of
atelectasis and aspiration.
3. Slightly too distal position of the tip of the Swan-Ganz
catheter in the right lower lobe pulmonary artery.
4. Mild cardiomegaly.
.
CHEST (PORTABLE AP) Study Date of [**2130-9-8**]
FINDINGS:
Left upper lung veil-like opacity is stable in appearance dating
back to
[**2130-9-2**] exam. This finding corresponds to left upper lobe
collapse as
demonstrated on CT chest of [**2130-9-7**]. Hilar,
mediastinal and cardiac silhouettes are stable. No pleural
effusions, pulmonary edema or
pneumothorax. ET tube is 6 cm from the carina. Swan-Ganz
catheter tip projects over proximal right pulmonary artery. NG
tube is within non-distended stomach, tip out of view.
IMPRESSION:
Persistent left upper lobe collapse.
.
CHEST (PORTABLE AP) Study Date of [**2130-9-9**]
FINDINGS: There is an OG tube with the tip in the proximal
stomach. The
proximal port is at the gastroesophageal junction. There is
patchy left lower lobe volume loss in the retrocardiac region.
There is a left subclavian line with tip in the SVC. The ET tube
is in similar location to prior. There is a small right
effusion.
Brief Hospital Course:
Pt is a 50yo Caucasian male with h/o DM, recent hospitalization
for hypoglycemia, HTN, bipolar do, found down in the field with
FS=46 and PEA arrest. He was given D50 and pt went into vfib
arrest. Pt defibrillated and no ST elevations on EKG noted. He
was intubated, and transferred to [**Hospital1 18**] from OSH for cooling s/p
cardiac arrest.
.
Cardiac arrest: Patient was found to be hypoglycemic at the time
w/FS of 46. Hypoglycemic and toxicology etiologies were
considered. [**Hospital1 32883**] tox screen was within normal limits. EKG at
OSH showed no ST segment elevations; cardiac enzymes were
initially elevated CE at OSH (likely secondary to arrest) and
trended downward. He was cooled per Arctic Sun cooling protocol
and antiarrhythmic therapy with Amiodarone was used. Dopamine
drip was used for BP support. ECHO was performed to eval for
structural abnormalities which showed small, thick-walled left
ventricle, LVEF 70-75%. Chest Xray suggested left upper lobe
collapse, however CT of chest was defered because pt was on
CVVH. Renal status improved and pt was able to come off CVVH for
CT of Head, C-spine and Chest. Head and spine CT showed no
fracture or acute intracranial process. However, Chest CT showed
an obstruction of the left main bronchus, approximately 4.2 cm
from the carina by a lesion of low density; the left upper lobe
was completely collapsed with a low-density material seen in the
bronchi (the appearance of "drowned lung"). Therapuetic and
diagnostic bronchoscopy was recommended and performed which
revealed that the patient had aspirate an insulin cap. Per
family, pt was in the habit of biting of the top of insulin pen
prior to injection. It was hypothesized that the patient inhaled
and choked on the insulin cap and in the process injected
himself with insulin becoming both hypoxic and hypoglycemic,
causing the PEA arrest.
.
Hypoglycemia: Most likely contributed to PEA arrest. Noted
recent difficulty managing blood glucose levels, with recent
admission to [**Hospital3 **] hospital for hypoglycemic episode. DM
managed on U-500 insulin and probable cause for hypoglycemia.
Blood glucose was closely monitored, hypoglycemia was corrected
during admission. [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendation pt was placed on
insulin drip for glucose management and then transitioned to
regular ISS. After extubation, the patient was seen by speech
and swallow and his diet was slowly advanced. Pt has outpt
endocrine/[**Last Name (un) **] follow-up for continued management of his DM2
after discharge.
.
Pneumonia: Upon admission, there was concern for pneumonia
(?aspiration) as he was found down in the field, chest xray
findings were initially suggestive of infiltrate, and he was
showing signs of SIRS. He was intially started on Vancomycin and
Levofloxacin, then transitioned to Vancomycin and Unasyn due to
concern for anaerobic bacteria. Blood cultures came back
negative. Patient continued to have fevers despite antibiotics,
however fevers stopped after the insulin cap was removed,
indicating he was likely having a localized inflammatory
response to the foreign body obstruction rather than VAP.
Antibiotics were stopped after cap was removed.
Respiratory failure: Pt was unable to protect airway in setting
of vfib arrest and collapse of LUL secondary to aspirated
insulin cap. We had trouble weaning him from the ventilator
secondary to agitation. However, on [**2130-9-10**] his sedation was
turned off and he was successfully extubated.
Renal failure: Unclear [**Name2 (NI) **] creatinine baseline. Acute injury
possible secondary to poor cardiac forward flow in setting of
cardiac arrest. His urine output was low, creatinine was
increasing, K+ was increasing and he did not have much response
to NS boluses. Therefore, CVVH was started and continued for
several days. Cr and BUN were trended, renal function improved
and pt was able to be taken off of CVVH. Pt autodiuresed
successfully.
.
GU: poor urine output and anatomy restricting use of
conventional foley cath. Likely hypospadias - require small
catheter sized for urethral meatus. GU consult for assistance
with foley cath placement. Urine output gradually improved after
CVVH was started.
.
s/p Fall: Pt found down in field, likely diagnosis hypoglycemia
and PEA arrest. Small abrasion on forehead likely [**2-7**] to fall
trauma. Anisocoria [**2-7**] blindness - unlikely to be an acute
process. CT head clear at OSH and repeat CT of head in house was
negative for acute intracranial process. CT of C-spine was
negative for fracture.
.
Bipolar disorder: home divalproex acid initially was held in
setting of hypothermia protocol. However, per neuro consult, it
was felt to be safe to restart as pt's clinical condition
improved. Patient had some sedation when restarting/up-titrating
depakote, he was seen by psychiatry to recommending switching to
long acting depakote at bedtime. An ammonia level was checked
out of concern for depakote side effect and was normal.
Psychiatry recommended small standing PO dose of haldol at night
for agitation as well. The patient improved on the new regimen
on long acting depakote and haldol and was much more alert
during the daytime and his agitation resolved. He will need a
valproic acid level on [**2130-9-19**], goal level is 50-80.
.
Anemia and thrombocytopenia: Patient may have had mild HITT
secondary to heparin as platelets normalized after heparin
stopped. Anemia etiology unknown, although may have been due to
critical illness
.
Neurologic status: The patient will need to follow up with Dr.
[**First Name (STitle) **] in the anoxic brain injury clinic as an outpatient.
He will be discharged to rehab to regain strength and undergo
intensive PT and [**Hospital **] rehab.
.
Pt was full code during this admission.
Medications on Admission:
Lisinopril 5mg daily
Metoprolol Tartrate 200mg qAM, 100mg qPM
HCTZ 25mg daily
Simvastatin 80mg daily
Aspirin 81mg daily
Divalproex ER 500mg daily
Prednisolone Ophth Eye Drops daily?
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
3. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
4. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime):
please give at 10 pm
check ECG for QTc prolongation.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO DAILY (Daily).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Haloperidol 5 mg Tablet Sig: 0.5-1 Tablet PO BID (2 times a
day) as needed for agitation.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for Pain.
11. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: [**1-7**]
Tablet, Chewables PO TID (3 times a day) as needed for
indigestion.
12. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
13. Insulin Glargine 100 unit/mL Solution Sig: Fifty Three (53)
units Subcutaneous once a day: give before breakfast.
14. Insulin Aspart 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day: with FS before meals and at
HS.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PEA Cardiac Arrest
Hypoglycemic episode
Acute Renal Failure
Respiratory Failure
Delerium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 32884**],
Thank you for allowing [**Hospital1 18**] cardiac care unit to participate in
your care. You were initially transferred here from [**Hospital 21242**]
[**Hospital 107**] Hospital after you experienced a low blood sugar
causing you to have a cardiac arrest. You were found down by
emergency medical services without a pulse and with blood sugar
of 46. At this time, they needed to shock your heart with a
defibrillator to regain your heart beat, put a tube down your
throat to help you breathe, and start medications to maintain
your blood pressure.
You were transferred to [**Hospital1 18**] for a special treatment called
Artic Sun Cooling Protocol, in which we cooled your body
temperature to help prevent damage to your brain and heart after
cardiac arrest. You also required dialysis for your kidneys, as
they experienced temporary dysfunction during hospitalization.
You experienced difficulty breathing during hospitalization. We
performed a procedure called bronchoscopy in which we put a
camera down into your lungs, and discovered you had aspirated
into your lungs the cap to your insulin vial when you had your
cardiac arrest. The cap was removed, and your breathing
improved, and we were able to wean you off mechanical
ventilation.
We required you to stay a few more days in the ICU in order to
manage your high blood pressure and blood sugars. You were then
transferred to the regular medical floor until you were ready to
be discharged.
The following changes were made to your home medications:
- Your metoprolol was replaced with labatolol for high blood
pressures
- Lisinopril was increased to 10 mg daily
- Your insulin was changed to 53 units of Glargine and a humalog
sliding scale.
- Aspirin was increased to 325 mg daily
- Divalproex was changed to a long acting dose at 10pm
- Oxycontin was decreased to 10 mg daily
- Amlodipine was added for blood pressure control
- Haldol was added to decrease your confusion at night
- Calcium carbonate and Pantopriazole were added to treat
heartburn type symptoms.
- colace was added to prevent constipation
- Tylenol was added to treat your back and chest pain.
- Hydrochlorothiazide was discontinued.
Please be sure to follow-up with your primary care [**Provider Number 32885**]
week after discharge.
We also recommend follow-up with an endocrinologist for
management of your high insulin requirements. Please check your
blood sugars when you wake up, before lunch, and before bedtime,
and keep a journal for your doctor so that s/he can adjust your
insulin adequately to prevent future hypoglycemic episodes.
Followup Instructions:
[**Last Name (un) **] ([**Telephone/Fax (1) 2384**]) [**Last Name (un) 3911**] [**Location (un) **]
[**10-4**] 8:30 register
8:30 eye images
9:00 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32886**] (endocrinologist)
10:00 [**First Name9 (NamePattern2) 32887**] [**Doctor Last Name 1726**] (diabetic educator)
*if your insurance requires a referral, please make the referral
out to Dr. [**Last Name (STitle) 32886**]*
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] - COGNITIVE NEUROLOGY UNIT
Address: [**Last Name (LF) **], [**First Name3 (LF) 860**] Building [**Location (un) 551**] [**Apartment Address(1) 32888**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1690**]
Appointment: Monday [**2130-10-9**] 10:30am
Completed by:[**2130-9-18**]
|
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"289.84",
"E912",
"427.5",
"348.1",
"357.2",
"250.60",
"250.50",
"V58.67",
"518.0",
"785.59",
"752.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"32.01",
"99.81",
"96.72",
"96.6",
"89.64",
"39.95",
"98.15",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
17912, 17982
|
10341, 16165
|
324, 434
|
18115, 18115
|
3414, 10318
|
20943, 21882
|
2684, 2693
|
16398, 17889
|
18003, 18094
|
16191, 16375
|
18300, 19834
|
2708, 2729
|
19852, 20920
|
236, 286
|
462, 2263
|
2743, 3395
|
18130, 18276
|
2285, 2564
|
2596, 2668
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,603
| 110,764
|
12026
|
Discharge summary
|
report
|
Admission Date: [**2143-8-27**] Discharge Date: [**2143-9-6**]
Date of Birth: [**2096-10-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
colonoscopy [**2143-8-28**]
thoracentesis [**2143-9-5**]
History of Present Illness:
46M s/p liver transplant [**2143-7-26**] presents to the ED from
[**Hospital **] Rehab after having [**5-16**] bloody bowel movements overnight
accompanied with hallucinations. He bright red blood per rectum
mixed with stool/on the toilet paper/in the toilet bowl
intermittently over the past week though it wasn't obvious or
severe until last night when he had [**5-16**] bloody bowel movements,
initially "almost entirely" clot with some solid material in it
and transitioning to mostly brown liquid stool with some blood
in
it. He reports that he has otherwise been having [**2-12**] normal,
formed bowel movements daily, no diarrhea or constipation.
He also reports hallucinations last night, confirmed by his RN
who accompanies him from [**Hospital1 **]. He reports that he felt as
though his cat was following him and that there was someone
speaking to him in a low voice. He readily acknowledges that he
was aware the entire time as he is now that these were, in fact,
hallucinations and not real. He denies hallucinations currently
but does feel slightly "foggy...like it's hard to pay
attention".
Of note, his post-operative course was significant for
persistent
hyperkalemia for which he was started on fludricortisone with
good results. This was discontinued in clinic followup.
ROS: As per HPI, otherwise denies fevers, chills, nausea,
vomiting.
Past Medical History:
- Alcohol cirrhosis c/b esophageal varices (grade III) with
bleed s/p banding in [**7-/2142**], ascites/SBP ([**5-/2142**]),
encephalopathy, rectal varices
- Alcoholic hepatitis [**2-/2141**]
- Recurrent hepatic hydrothorax
- Hemolytic anemia on prednisone
- Type 2 diabetes mellitus
- Hypertension
- Hyperlipidemia
- Strep viridans and MSSA bacteremia s/p Vancomycin X 2 weeks
[**5-/2142**]
- Alcohol abuse (last drink [**2142-3-13**])
- GERD
- Depression/anxiety
- OSA on CPAP
- h/o Atrial fibrillation s/p cardioversion not on
anticoagulation
Social History:
Currently lives at a rehab facility, where per documentation he
requires assistance with most ADLs (bathing, ambulating,
dressing) though he can eat independently. He has never smoked
and denies IVDU, but used cocaine, ecstasy and special K prior
to [**2122**]. He is close to a brother and sister both live in the
area. He is currently unemployed. He denies current tobacco or
alcohol use, states last EtOH was [**2142**].
Family History:
Patient states that father and mother likely both had EtOH
abuse. His father died of an infection, his mother passed away
of complications from CVA 2 years ago.
Physical Exam:
Vitals: 97.6 106 108/68 18 100 RA
NAD, AAOx3 and appropriate in conversation but admits difficulty
with concentration
mild tachycardia
RRR, unlabored respiration
abdomen soft, non-tender, non-distended, midline xiphoid portion
of [**Last Name (un) **]-[**Last Name (un) **] incision open and midly wet with
fibrinoupurulent fluid at base
DRE: liquid brown stool with small amount of gross blood, no
hemorrhoids immediately visible or palpable on exam
ext no edema
11.9 > 27.1 < 115
128 | 97 | 22
--------------< 110
5.6 | 22 | 0.9
ALT 21 AST 19 AP 70 Tb 0.9 Alb 3.4
INR 1.3
UA negative
Pertinent Results:
[**2143-8-27**] 01:00PM BLOOD WBC-11.9*# RBC-2.91* Hgb-9.2* Hct-27.1*
MCV-93# MCH-31.6 MCHC-33.9 RDW-17.1* Plt Ct-115*
[**2143-8-27**] 07:35PM BLOOD WBC-9.1 RBC-2.53* Hgb-8.1* Hct-24.2*
MCV-94 MCH-31.8 MCHC-33.7 RDW-17.0* Plt Ct-93*
[**2143-8-28**] 01:48PM BLOOD WBC-10.3 RBC-3.19* Hgb-10.0* Hct-29.3*
MCV-92 MCH-31.5 MCHC-34.3 RDW-17.2* Plt Ct-84*
[**2143-9-6**] 06:09AM BLOOD WBC-6.0 RBC-3.45* Hgb-10.8* Hct-32.1*
MCV-93 MCH-31.3 MCHC-33.6 RDW-17.0* Plt Ct-137*
[**2143-9-2**] 12:23AM BLOOD PT-13.0* PTT-32.9 INR(PT)-1.2*
[**2143-9-6**] 06:09AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-137
K-4.1 Cl-107 HCO3-23 AnGap-11
[**2143-8-27**] 01:00PM BLOOD ALT-21 AST-19 AlkPhos-70 TotBili-0.9
[**2143-9-6**] 06:09AM BLOOD ALT-16 AST-16 AlkPhos-61 TotBili-0.6
[**2143-9-6**] 06:09AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8
[**2143-9-1**] 09:00AM BLOOD TSH-2.2
[**2143-9-6**] 06:09AM BLOOD tacroFK-8.6
[**2143-9-5**] 5:31 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2143-9-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
46M s/p liver transplant [**2143-7-26**] presents to the ED from [**Hospital **]
Rehab with bloody stools and hallucinations. On admission, hct
was 27.1. He was transferred to the SICU where a colonoscopy was
performed. This demonstrated a small polyp in the distal colon
that was not removed. There was an irregular, bumpy, friable
mucosa in the rectum that was biopsied. Large non-bleeding
hemorrhoids were seen. Otherwise, normal colonoscopy to cecum.
He was transfused with 3 units of PRBC with hct increase to 29.
Hct remained stable. Rectal mucosal biopsies demonstrated
colonic mucosa with surface hyperplastic change; otherwise,
within normal limits. He was started on iron. EGD was not done
at that time, but will be arranged as an outpatient.
Liver duplex was unremarkable. LFTs were stable.
Immunosuppression continued with daily adjustment to Prograf
based on trough levels.
He developed SVT/afib which was treated with Lopressor and
diltiazem. He continued to have intermittent brief episodes of
tachycardia with rates up to 200. Lopressor and Diltiazem doses
were adjusted. He was ruled out for MI. Once stable, he was
transferred out of SICU. However, he went back to the SICU on
[**9-1**] for non-sustained Vtach which responded to diltiazem doses
and lopressor adjustment. Once stable again, he was transferred
back to Med-[**Doctor First Name **] unit again.
On [**9-4**], he complained of SOB. Breath sounds were diminished [**2-11**]
way up on right lung. CXR showed a small pleural effusion. This
was also noted on liver duplex. A repeat CXR was done on [**9-5**],
showing stable RLL and possibly RML collapse. IP was consulted
and a 1400ml thoracentesis was performed. Post thoracentesis CXR
revealed significantly improved right pleural effusion, to near
resolution and no pneumothorax. Pleural effusion was
unremarkable. Culture was negative. Follow up CXR on [**9-6**]
demonstrated small re accumulation of right pleural effusion.
His mental status was notable for confusion and a delirium.
Oxycodone, Wellbutrin,and Lidocaine patch were stopped.
Prednisone was decreased to 10mg daily. Mental status became
more alert/oriented and improved, however, he continues to be
slow to answer and disorganized in his thought process/answers.
Blood sugars were well controlled.
Abdominal incision wound VAC continued to be changed every 3
days. Output/drainage was minimal.
PT evaluated and recommended rehab. He feels weak during
ambulation and has decreased endurance. SBP runs on the low side
and fall precautions were implemented. SBP ranged between
99-114/73 with HR in 80s. O2 was mid 90s to 100 on room air.
[**Hospital **] Rehab was approved and he will transfer there today.
Medications on Admission:
bupropion 75', fluconazole 400', folic acid 1', lasix 20',
lantus 18', lispro SS, MMF 1000'', protonix 40', prednisone
17.5', bactrim SS', tacrolimus 3'', valcyte 900', venlafaxine XR
150', colace, vit D2, iron sulfate, thiamine
All: NKDA
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Bacitracin Ointment 1 Appl TP ASDIR
Daily to left 1st toe
3. Dextrose 50% 25 gm IV PRN hypoglycemia
4. Diltiazem Extended-Release 240 mg PO DAILY
Start once daily dosing with ER dosing on [**9-5**]
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluconazole 400 mg PO Q24H
7. FoLIC Acid 1 mg PO DAILY
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. NPH 18 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
10. Metoprolol Tartrate 25 mg PO TID
hold for HR <60
11. Mycophenolate Mofetil 1000 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. PredniSONE 10 mg PO DAILY
Decrease on [**9-4**]
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. ValGANCIclovir 900 mg PO DAILY
16. Venlafaxine XR 150 mg PO DAILY
17. Tacrolimus 3 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Melena
colon polyp
Afib
abdominal incision wound
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 will be transferring to [**Hospital **] Rehab in [**Location (un) 701**]
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following:
temperature of 101 or greater, chills, nausea, vomiting,
jaundice, confusion, dizziness, shortness of breath, abdominal
pain, incision wound has pus or foul odor, bloody bowel
movements or any concerns
-you will need to have blood work drawn twice weekly for lab
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-9-11**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-9-18**] 10:00
Completed by:[**2143-9-6**]
|
[
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"416.8",
"292.81",
"427.1",
"E939.0",
"427.31",
"511.9",
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"300.4",
"272.4",
"E935.2",
"455.6",
"E938.5",
"276.7",
"578.9",
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"327.23",
"283.9",
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"250.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"48.24",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
8756, 8827
|
4955, 7664
|
310, 369
|
8920, 8920
|
3591, 4793
|
9563, 9937
|
2793, 2956
|
7955, 8733
|
8848, 8899
|
7690, 7932
|
9103, 9540
|
2971, 3572
|
4910, 4932
|
264, 272
|
397, 1766
|
4877, 4877
|
8935, 9079
|
1788, 2335
|
2351, 2777
|
4825, 4840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,687
| 134,776
|
41318+58438
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-1-3**] Discharge Date: [**2119-1-11**]
Date of Birth: [**2052-1-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
adbominal pain
Major Surgical or Invasive Procedure:
[**2119-1-3**]
ERCP with sphincterotomy
[**2119-1-5**]
Laparoscopic converted to open cholecystectomy
History of Present Illness:
66yoF with medica history significant for hypertension comes
in from an OSH where she presetned early this mronig with < 24
hours of RUQ abdominal pain, intractable nausea and vomiting
(bilious) and fever to 101. Patient states pain came on
suddenly
at 2 pm, 4 hours after her last meal. Normal bowel movements
yesterday. No chest pain. No dyspnea. No headache. Denies
prior episodes of similar pain.
Past Medical History:
PMH: HTN
PSgH: open appendectomy (perforated) in [**2107**]
Social History:
+ETOH abuse
Family History:
NC
Physical Exam:
Temp:98.8 HR:88 BP:116/60 Resp:22 O(2)Sat:96
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, icteric sclera
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Right upper quadrant tenderness, no rebound, no
guarding
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Pertinent Results:
[**2119-1-3**] 11:45AM BLOOD WBC-19.0* RBC-3.84* Hgb-13.2 Hct-40.1
MCV-105* MCH-34.4* MCHC-32.9 RDW-14.1 Plt Ct-282
[**2119-1-3**] 11:45AM BLOOD Neuts-90* Bands-2 Lymphs-3* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2119-1-3**] 11:45AM BLOOD PT-13.1 PTT-24.7 INR(PT)-1.1
[**2119-1-3**] 11:45AM BLOOD Glucose-137* UreaN-18 Creat-0.9 Na-137
K-3.8 Cl-100 HCO3-23 AnGap-18
[**2119-1-3**] 11:45AM BLOOD ALT-190* AST-232* AlkPhos-509*
TotBili-10.2*
[**2119-1-4**] 05:50AM BLOOD ALT-151* AST-141* AlkPhos-376* Amylase-30
TotBili-10.1* DirBili-8.9* IndBili-1.2
[**2119-1-5**] 04:05AM BLOOD ALT-127* AST-105* AlkPhos-366* Amylase-46
TotBili-8.7* DirBili-7.5* IndBili-1.2
[**2119-1-6**] 06:00AM BLOOD ALT-92* AST-83* CK(CPK)-304* AlkPhos-280*
Amylase-58 TotBili-6.0*
[**2119-1-6**] 09:24AM BLOOD ALT-87* AST-75* LD(LDH)-153 CK(CPK)-268*
AlkPhos-299* TotBili-5.5* DirBili-4.5* IndBili-1.0
[**2119-1-3**] 11:45AM BLOOD Lipase-19
[**2119-1-6**] 06:00AM BLOOD cTropnT-0.09*
[**2119-1-3**] 11:45AM BLOOD Albumin-3.9
[**2119-1-5**] 02:32PM BLOOD Type-ART O2 Flow-100 pO2-82* pCO2-79*
pH-7.16* calTCO2-30 Base XS--2 Intubat-NOT INTUBA
Comment-NON-REBREA
[**2119-1-5**] 03:50PM BLOOD Type-ART pO2-160* pCO2-57* pH-7.26*
calTCO2-27 Base XS--2
[**2119-1-6**] 06:52AM BLOOD Type-ART O2 Flow-3 pO2-79* pCO2-44
pH-7.36 calTCO2-26 Base XS-0
[**2119-1-6**] 09:59AM BLOOD Type-ART pO2-47* pCO2-41 pH-7.40
calTCO2-26 Base XS-0
ERCP [**2119-1-3**]: Opacification of the common duct demonstrates
diffuse
severe dilatation to approximately 2 cm. Two large filling
defects are seen within the common duct. Balloon sweep was
performed with extraction of stones by report.
CTA [**2119-1-6**]:
1. No evidence of pulmonary embolism.
2. Right lower lobe consolidation concerning for infection.
3. Small bilateral pleural effusions and left basilar
atelectasis.
4. Mild interlobular septal thickening consistent with pulmonary
edema.
ECHO [**2119-1-6**]:
Mild right ventricular cavity enlargement with basal free wall
hypokinesis. Mild pulmonary artery systolic hypertension. Mild
mitral regurgitation with normal valve morphology.
Brief Hospital Course:
This is a 66 year old F transferred to [**Hospital1 18**] for ERCP to treat
choledocholithiasis. The patient underwent ERCP on [**1-3**] with
balloon extraction of 2 stones. She then underwent a
laparoscopic converted to open CCY on [**1-5**]. Postoperatively,
the patient had altered mental status and low O2 sats. She was
hypercarbic and hypoxic and was given neostigmine in the PACU
with some response. Following transfer to the Surgical floor she
eventually became disoriented with marginal O2 saturations
prompting transfer to the MICU.
Her chest Xray showed some right lower lobe consolidation and
her EKG showed a new RBBB with a troponin of 0.09. A CTA was
negative for PE and a cardiac echo showed mild RV enlargement
with basal free wall hypokinesis, mild PAS hypertension and mild
MR consistent with right heart strain from a pulmonary source.
As her CTA was negative she underwent vigorous pulmonary toilet
with chest PT and incentive spirometry although her mental
status compromised her ability to use the spirometer
effectively.
Following transfer to the Surgical floor she began to make slow
progress. All of her sedatives /narcotics were discontinued as
she was quite sensitive to them. She was treated with Tylenol
for pain. Her diet was gradually advanced to regular and
tolerated well. Her foley catheter has been discontinued and she
is due to void this afternoon. As her medications were limited,
her mental status improved.
She was evaluated by the Physical therapy service and was able
to walk independently though she was very deconditioned. Home
Physical Therapy was recommended to help her get back to her
baseline. Her incision was healing well and she was discharged
to home on [**2119-1-11**] and will follow up in the Acute Care Clinic
in [**1-19**] weeks.
Medications on Admission:
Atenolol 50mg PO daily
Triamterene/hctz 37.5/25mg PO daily
Prempro 0.625-2.5 mg qd
Zoloft 50 mg qd
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Acute cholecystitis and choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with abdominal pain from
stones in your common bile duct.
* An ERCP was done to remove the stones and following that your
gallbladder was removed.
* Your recovery was prolonged due to problems with delirium
which delayed further progress. For this reason you are being
discharged to rehab so that you can regain your strength and
mobility and improve your nutrition so that you return home at
your baseline.
* Do NOT drink alcohol
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-25**] lbs until you follow-up with your
surgeon.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at your first follow up
appointment.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-19**] weeks.
Completed by:[**2119-1-11**] Name: [**Known lastname 14243**],[**Known firstname **] Unit No: [**Numeric Identifier 14244**]
Admission Date: [**2119-1-3**] Discharge Date: [**2119-1-11**]
Date of Birth: [**2052-1-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11689**]
Addendum:
After a second evaluation by Physical Therapy, Mrs. [**Known lastname **] was
able to walk independently and safely therefore she will not
need VNA for home Physical Therapy. She will return to the [**Hospital **]
Clinic for staple removal in [**12-18**] weeks.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11690**] MD [**MD Number(2) 11691**]
Completed by:[**2119-1-11**]
|
[
"305.00",
"401.9",
"799.02",
"514",
"V64.41",
"574.31",
"291.81",
"426.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"38.93",
"51.22",
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
9397, 9562
|
3669, 5470
|
318, 423
|
6189, 6189
|
1539, 3646
|
8596, 9374
|
989, 993
|
5619, 6060
|
6123, 6168
|
5496, 5596
|
6340, 8192
|
8208, 8573
|
1008, 1520
|
263, 280
|
451, 860
|
6204, 6316
|
882, 944
|
960, 973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,031
| 194,039
|
51724
|
Discharge summary
|
report
|
Admission Date: [**2113-3-11**] Discharge Date: [**2113-3-13**]
Date of Birth: [**2059-8-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Vomiting, diarrhea and hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 y/o F with PMH of schizophrenia, pica, chronic abdominal
pain, HTN and DM who presents with 1 day of vomiting and
diarrhea found to be hypertensive to SBP 250's in setting of
missing her BP meds. Of note, she has had numerous recent
admission for the exact same issue.
.
She had been in her usual state of health until she awoke from
sleep with sharp epigastric abd pain, N/V the night prior to
presentation. Emesis was described as [**Doctor Last Name 352**], no blood or coffee
grounds. She had eaten 2 hotdogs and popcorn the night before.
The pain was similar to past events, constant, non-radiating,
and followed by diarrhea with 4-5 loose, watery, [**Doctor Last Name 352**] stools. No
melena, BRBPR. She denies eating any unusual substances such as
gloves (from her hx of pica).
.
In ED, VS 97.2, 230/135, 90, 20, 100%RA. She was given 1 inch
nitropaste, 20 labetalol IV X 2 with minimal improvement in BP.
Finally started on nitro gtt, zofran and gradual improvement of
SBP to 140-150's. The patient was admitted to the MICU for
further management of her asmptomatic hypertension.
Past Medical History:
schizophrenia
pica (eats seude daily from cut-up pieces of gloves)
chronic abominal pain
HTN
DM2
hyperlipidemia
s/p hysterectomy
Social History:
Lives alone, on disability.
Smoking: smokes 1PPD, 30 PY history
EtOH: none
Illicits: marijuana
Family History:
no family h/o cancer, IBS, similar abdominal pain, no h/o CAD.
daughter with DM.
Physical Exam:
Vitals: T 36.1 BP 168/94 HR 89 RR 18 O2sat 96%
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, mild epigastric tenderness, 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:
[**2113-3-11**] 04:00PM GLUCOSE-139* UREA N-6 CREAT-0.5 SODIUM-141
POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-23 ANION GAP-18
[**2113-3-11**] 04:00PM estGFR-Using this
[**2113-3-11**] 04:00PM CK(CPK)-43
[**2113-3-11**] 04:00PM cTropnT-<0.01
[**2113-3-11**] 04:00PM CK-MB-NotDone
[**2113-3-11**] 04:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2113-3-11**] 04:00PM URINE HOURS-RANDOM
[**2113-3-11**] 04:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2113-3-11**] 04:00PM WBC-7.0 RBC-5.15 HGB-14.8 HCT-44.8 MCV-87
MCH-28.7 MCHC-33.0 RDW-15.7*
[**2113-3-11**] 04:00PM NEUTS-85.7* LYMPHS-11.6* MONOS-1.7* EOS-0.9
BASOS-0.1
[**2113-3-11**] 04:00PM PLT COUNT-289
[**2113-3-11**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2113-3-11**] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2113-3-11**] 04:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
Images:
[**12-10**] CT A/P:CT ABDOMEN WITH IV CONTRAST: Aside from mild
dependent atelectasis and atelectasis along the lingula, the
lung bases appear clear. No pleural or pericardial effusion is
noted. The liver, gallbladder, spleen, pancreas, left adrenal
gland, right kidney and
both ureters appear normal. Incidental note is made of a couple
of small
splenules. A 6-mm hypodensity in the lower pole of the left
kidney is too
small to accurately characterize, but likely represents a cyst.
There is
suggestion of a small oval shaped nodule along the superior limb
of the right adrenal gland, which measures approximately 14 x 9
mm and is incompletely characterized on this single phase study
(2:16).
The stomach and small bowel appear normal. Scattered colonic
diverticula are noted, particularly along the splenic flexure
and descending colon, without inflammatory changes. Note is also
made of prominent fat density in the region of the ileocecal
valve, measuring approximately 2.3 cm. No free air or free fluid
is noted within the abdomen. There is diastasis of the rectus
abdominus in the periumbilical region, with small fat containing
umbilical hernia. Atherosclerotic calcifications are noted along
the aorta and iliac arteries, without aneurysmal dilatation. No
lymph node enlargement is noted meeting CT size criteria for
adenopathy.
CT PELVIS WITH IV CONTRAST: The mildly distended urinary bladder
appears
normal. The uterus is absent. The adnexa appear unremarkable. A
single
diverticulum is noted along the sigmoid colon without
inflammatory changes. Pelvic loops of small bowel and the
appendix appear normal. No pelvic free fluid or adenopathy is
noted.
OSSEOUS STRUCTURES: No region of bony destruction is seen
concerning for
malignancy.
IMPRESSIONS:
1. No evidence of hematoma seen within the abdomen or pelvis.
2. Scattered colonic diverticula noted, without evidence of
diverticulitis.
3. Prominent fat noted in the region of the terminal ileum.
4. Incompletely characterized small right adrenal nodule. [**Month/Year (2) 4338**]
may be
performed for further characterization if clinically warranted.
[**12-10**] EGD: Erythema in the antrum compatible with AVMs vs.
antral erosions. (biopsy); otherwise normal
.
[**12-10**] Colonoscopy:Internal hemorrhoids, Diverticulosis of the
sigmoid colon, Mass in the cecum (biopsy) -> found to be lipoma,
Polyp in the cecum (polypectomy), Polyps in the rectum
(polypectomy). Otherwise normal colonoscopy to cecum
.
[**11-9**] Gastric emptying study: nml
.
EKG: NSR, nl axis, nl intervals, TWI III (old), TWI V2-3 (new),
no ST changes compared to prior EKG in 1/[**2113**].
Culture Data --- U/A from [**3-11**] - contamination w genital flora
Brief Hospital Course:
53 y/o F with PMH of schizophrenia, pica in the setting of iron
deficiency anemia, chronic abdominal pain, HTN and DM who
presented with 24 hours of vomiting and diarrhea found to have
SBP 230s.
.
# Malignant hypertension: Hypertensive urgency, no signs of end
organ damage. Likely secondary to missing her AM BP meds and
also in setting of pain although pheochromocytoma remains a
possiblity especially in light of her CT findings in [**12-10**] with
a small adrenal mass. The patient was weaned off of nitro gtt
over several hours. Her home BP meds were slowly reintroduced
and the patient returned to normotension over the next 36 hours.
As the patient was interested in leaving the hospital and was
well-appearing and normotensive, she was scheduled for an
adrenal [**Date Range 4338**] as an outpatient. She was kept on her home regimen
of amlodipine 2.5, metoprolol 100mg [**Hospital1 **] and lisinopril 40mg at
the time of discharge since she has been stable on this regimen
for quite sometime. Consideration was given to removing
beta-blockade and introducing alpha-antagonists but, as overall
incidence of pheo is low, and the patient wanted to return home,
there was more concern for orthostatic hypotension and increased
BP due to alteration of regimen then for causing unopposed
catecholamine surge. The patient's PCP/office was contact[**Name (NI) **] in
an effort to ensure further work up to exclude pheo including
[**Name (NI) 4338**] and urine catecholamines after beta-bloackade is safely
removed and alternative blood pressure medications are
introduced. The patient was counselled on the signs and symptoms
of end-organ damage including headaches, vision changes, chest
pain, and confusion. She was encouraged to return to the
emergency room if any of these symptoms occur.
.
# Vomiting/diarrhea/abdominal pain: Chronic for many years,
unclear etiology and she has been seen by GI for this issue. GI
feels that this may be non-ulcer dyspepsia. Gastric emtying
study in [**11-9**] with normal emptying. RUQ U/S normal. No
leukocytosis or focal exam today. Other etiologies include
abdominal migraine, severe IBS, cyclical vomiting or stigmata of
hypertensive crisis either in the setting of or the absence of
catcholamine surge. The patient's symptoms resolved shortly
after presentation and she was continued on antiemetics and PPI.
.
# Diabetes mellitus type II: The patient was covered with
sliding scale insulin while in-house and was asked to restart
metformin upon discharge.
.
# Schizophrenia: Non-pharmacologic treatment, followed by
psychiatry as outpatient.
.
On [**2113-3-13**] the patient was asking to go home. As she was
well-appearing with normal vital signs, she was scheduled for
adrenal [**Date Range 4338**] and had previously scheduled GI follow up including
[**Date Range 4338**] enteroscopy. Her PCP's office was contact[**Name (NI) **] to ensure follow
up for rule out pheochromocytoma and a copy of this discharge
summary was faxed to [**Location (un) 686**] House Family Practice.
Medications on Admission:
lisinopril 20 daily
pantoprazole 40 daily
pravastatin 20 daily
metoprolol 100 [**Hospital1 **]
iron 325 daily
metformin 1000 [**Hospital1 **]
ASA 81 daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Phenergan 25 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
8. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a
day.
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Dyspepsia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the intensive care unit because your blood
pressure was extremely high and you required a nitroglycerin
drip for control. You were quickly weaned off the drip and
transferred to the regular floor with vast improvement in your
blood pressure. You were restarted on your regular blood
pressure meds prior to discharge.
Your blood pressure was likely very high because of your nausea
and vomiting with resulting inability to take your meds. You
should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4539**] as you have already arranged
in order to figure out why you keep having these episodes. You
should also follow up with Dr. [**Last Name (STitle) 107139**] in the next couple of
weeks.
Upon reviewing a CT scan of your stomach that was done in
[**2112-12-3**], there was a small lesion on one of your adrenal
glands. Most often this represents a small adenoma, or benign
finding but can sometimes represent abnormal tissue that causes
your blood pressure to surge very high at random intervals. You
will need to have an [**Year (4 digits) 4338**] of your adrenals to further
characterize this tissue. This has been scheduled for you.
You have been given an anti-nausea medication to take at the
start of any nausea you might have to try to prevent these
episodes in the future.
Followup Instructions:
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2113-3-24**] 3:00
The [**Month/Day/Year 4338**] is on the [**Hospital Ward Name 517**] Clinical Center Basement. You
should not eat or drink for 4 hours prior to the [**Hospital Ward Name 4338**].
Provider: [**Name10 (NameIs) 706**] [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 11065**] Date/Time:[**2113-4-13**]
9:30
Provider: [**Name10 (NameIs) 706**] [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 11065**] Date/Time:[**2113-4-13**]
10:30
As above, you should follow up with your primary care doctor
within the next couple of weeks.
|
[
"787.91",
"401.0",
"250.00",
"789.00",
"272.4",
"787.01",
"275.2",
"276.8",
"295.90",
"307.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10115, 10121
|
6124, 9151
|
307, 313
|
10196, 10203
|
2351, 6101
|
11589, 12230
|
1716, 1799
|
9356, 10092
|
10142, 10175
|
9177, 9333
|
10227, 11566
|
1814, 2332
|
232, 269
|
341, 1434
|
1456, 1587
|
1603, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,835
| 169,116
|
46090
|
Discharge summary
|
report
|
Admission Date: [**2133-2-14**] Discharge Date: [**2133-2-19**]
Date of Birth: [**2053-2-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Tetracycline Analogues
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79yo F tobacco smoker from home hospice for CMML, who presents
with worsening SOB. The pt was initially placed to home hospice
several years ago when she was diagnosed with CCML (a from of
MDS) and given a prognosis of 6 mo. However she has done well
for several years at home and has recently reversed her code
status from DNR/DNI/CMO to full code. She however remained in
home hospice as they were providing additional care at home. Her
symptoms initially began with n/v/d which began on Tues night.
The vomitus was initially food only but then began to have dry
heaves. The diarrhea was described as loose, large volume,
frequent, [**Location (un) 2452**] stools. During a 4-6 hour period that night she
had continuous bowel movements which were initially formed but
then became loose. The diarrhea has since resolved and the pt
reports development of constipation with last BM on Wed. There
was no blood, mucous or black stools. Over the last two days,
the pt reports difficulty breathing, fevers to 101 at home
associated with chills, cough with white/clear sputum, and
chest/abdominal pain under the right ribs. The pain in the rib
occurs constantly but is worsened with cough. The pt also admits
to runny nose, sore throat and sinus congestion since this AM.
The pt denies any head ache, neck stiffness or photophobia. The
pt was given levofloxacin and steroid taper (Prednisone 60mg ->
currently 40mg) by the hospice nurses without any improvement.
The pt denies sick contacts. [**Name (NI) **] travel. The pt reports receiving
pneumovax 6-8 years previously but did not get a flu shot this
year.
In the ED, the pt was found to be febrile to 100.4, with HR of
74, BP: 157/81, RR: 20, SaO2: 99% on Nebulizer. The pt was found
to have increased dyspnea and wheezing. The pt was given
solumedrol, as well as nebulizers and ceftriaxone 1g IV. The pt
initially improved with 1L NS and nebulizer treatments. However
she acutely desaturated to 85% on 4L NC. She was then started on
continuous nebs with some resolution of sx. The CXR demonstrated
a prominent aortic contour of unknown significance leading to a
CTA. In addition, the pt also complained of some abdominal pain
leading to an Abd CT as well.
In the [**Hospital Unit Name 153**], the pt reports feeling as if the fever just broke,
but reports continued cough with sputum which is improving. The
pt also reports the abd pain has since resolved. The pt reports
being very thirsty.
Past Medical History:
1. CMML (Chronic myelomonocytic leukemia). The pt was diagnosed
three years ago. Originally presented to OSH ED with diarrhea
and then found to have leukocytosis. BM biopsy subsequently
revealed the dx of CMML. The pt refused medications for sx
treatment of CMML except for laxative and antidiarrheals. The pt
is followed by [**First Name5 (NamePattern1) 3403**] [**Last Name (NamePattern1) 30396**] of [**Hospital3 **] whom she
sees every 6 months.
2. LBP s/p L3-5 laminectomy, L4-5 diskectomy, L5-S1 diskectomy
and L3-S1 fusion with iliac crest and pedicle screw c/b post op
thrombocytopenia thought to be due to DIC in [**2120**]
3. Retinal vein occlusion.
4. Anemia.
5. s/p CCY
Social History:
The pt lives at home with her daughter and is set up for home
hospice. The pt is currently working on a book entitled "Young
Pianist capture of inspiration". She reports she must get
through the book, she is [**3-21**] of the way to completion.
1. Tob: 0.5ppd to 1ppd x 64yrs.
2. EtOH: never
3. Illicit drugs: never
Family History:
1. Mother: deceased from kidney trouble
2. Father: deceased from kidney trouble
3. No sibling
4. Son x2: diabetes
5. Daughter: alive and well.
No family history of CA, CAD, CVA
Physical Exam:
VS in ED: T: 100.4, HR: 74 -> as high as 102, BP: 157/81 -> as
low as 115/33, RR: 20, SaO2: 99% on Neb
VS in [**Hospital Unit Name 153**]: HR: 89, BP: 131/33, RR: 19, SaO2: 98% on 5L.
GEN: elderly female in NAD conversing fluently in full
sentences.
HEENT: PERRL, EOMI, anicteric, mm dry, op clear
Neck: no JVD
Chest: expiratory wheezing throughout with prolonged expiratory
phase, no crackles
CV: RRR, S1, S2, no m/r/g
Back: cystic mobile slightly tender mass on back - right upper
scapula. Evidence of prior well healed surgical scar on lumbar
spine.
Abd: soft, non-distended, slightly tender to palpation over the
right middle quadrant, no rebound, guarding, ?[**Doctor Last Name 515**] sign.
well healed surgical scar over RUQ
Ext: wwp, no c/c/e.
Pertinent Results:
STUDIES:
ECG [**2133-2-14**]: sinus arrhythmia (variable PR interval), nml axis,
nml intervals, nml QRS, RSR' in V1, V2, no obvious Q waves or
acute ST or T wave changes although lateral leads have some
minor ST depression that are diff to appreciate.
.
CXR [**2133-2-14**]: Evaluation of the lung bases is limited by blur,
likely related to patient's motion. Heart size and pulmonary
vascularity is normal. The aorta is unfolded with a prominent
ascending aortic contour. There is no pulmonary consolidation,
pleural effusion, or pneumothorax. The visualized osseous
structures appear unremarkable.
IMPRESSION: Prominent ascending aortic contour of uncertain
clinical
significance.
.
CTA [**2133-2-14**]: (preliminary read) Multifocal opacities in both
lungs, most prominent in the lower lobes with tree-in-[**Male First Name (un) 239**]
opacities in the right upper lobe consistent with infectious or
inflammatory process.
NO evidence of PE or aortic dissection, although evaluation of
the
retroperitoneal is severely limited by streak artifact from
orthopedic
hardware.
.
[**2133-2-14**] 10:15AM BLOOD WBC-48.3* RBC-3.88* Hgb-12.3 Hct-34.3*
MCV-89 MCH-31.8 MCHC-35.9* RDW-15.0 Plt Ct-62*
[**2133-2-19**] 07:40AM BLOOD WBC-29.5* RBC-3.72* Hgb-11.4* Hct-32.5*
MCV-87 MCH-30.5 MCHC-34.9 RDW-14.4 Plt Ct-109*
[**2133-2-15**] 04:17AM BLOOD Neuts-59 Bands-1 Lymphs-1* Monos-28*
Eos-0 Baso-0 Atyps-3* Metas-3* Myelos-5*
[**2133-2-15**] 04:17AM BLOOD PT-14.0* PTT-29.0 INR(PT)-1.2*
[**2133-2-14**] 10:15AM BLOOD Glucose-144* UreaN-23* Creat-1.2* Na-140
K-3.1* Cl-98 HCO3-29 AnGap-16
[**2133-2-19**] 07:40AM BLOOD Glucose-90 UreaN-22* Creat-1.0 Na-139
K-3.5 Cl-96 HCO3-29 AnGap-18
[**2133-2-14**] 10:15AM BLOOD ALT-30 AST-39 LD(LDH)-350* CK(CPK)-211*
AlkPhos-64 Amylase-53 TotBili-0.3
[**2133-2-14**] 10:15AM BLOOD CK-MB-5
[**2133-2-14**] 10:15AM BLOOD cTropnT-<0.01
[**2133-2-15**] 04:17AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.4*
[**2133-2-19**] 07:40AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.2*
Brief Hospital Course:
A/P: 79yo F with CMML from home hospice who presents with
progressive sob, fevers and cough. She was initially cared for
in the [**Hospital Unit Name 153**] where she received vanco/levo for ? pneumonia and
nebulizer treatments for her long smoking history. She was
repleted w/ IVF and given stress dose steroids given her recent
course of steroids. She did well overnight in the [**Hospital Unit Name 153**] and
never required intubation. She was called out on the day after
admission where her course was significant for the following.
.
1. SOB: Her initial CT showed bilateral opacities suggestive of
pneumonia. Her vanco/levo were initially continued as were her
nebulizers. Because of her long smoking history, the patient
was given a rapid steroid taper and responded immediately to
this addition. Because of her quick response to steroids,
absence of fever, and negative cultures, it was felt that her
presentation was more consistent w/ a COPD flare than a
pneumonia. Her vancomycin was stopped but she was continued on
her levaquin and will complete a full course at home. She
continued to improve throughout her hospitalization and passed
her PT evaluation w/out excessive SOB.
.
2. CMML: The patient has been at home under hospice care prior
to temporarily reversing her code status to full for treatment
of her SOB. No interventions were targeted at her underlying
malignancy and the patient wished to resume her DNR/DNI status
on discharge and return home to her hospice services. Her
chronic pain [**2-19**] this malignancy was managed on her home regimen
of fentanyl patch w/ satisfactory relief.
.
3. Hyperglycemia: Given her steroid taper, the patient was
maintained on an ISS while an inpatient.
.
4. Renal failure: Her ARF on admission improved w/ hydration
while in the [**Hospital Unit Name 153**] and was not an issue on the floor.
.
5. Psych: Her home lexapro was continued
.
Medications on Admission:
1. Levofloxacin x 2d
2. Prednisone taper (currently on 40mg once daily)
3. Fentanyl patch 100mcg Q3 days
4. Morphine PRN (but only taking once every 6 months as
excessive morphine causes agitation/MS changes)
5. Folic acid
6. Vitamin C
7. Lexapro for depression
8. Colace
9. Anti-diarrheals PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO qd () for 2
doses.
Disp:*4 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 2
doses.
Disp:*2 Tablet(s)* Refills:*0*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
10. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) neb
Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*1 bottle* Refills:*0*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
4 days.
Disp:*4 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Discharge Disposition:
Home With Service
Facility:
Healthcare Dimensions
Discharge Diagnosis:
Primary: COPD flare
.
Secondary: CMML
Discharge Condition:
Stable
Discharge Instructions:
Please take your meds as directed
Please keep your f/u appointments
Followup Instructions:
Please make an appointment to see your PCP [**Name Initial (PRE) 176**] 2weeks
Completed by:[**2133-2-19**]
|
[
"738.4",
"205.10",
"482.41",
"305.1",
"V09.0",
"276.8",
"285.22",
"586",
"493.22",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10656, 10708
|
6833, 8744
|
323, 330
|
10790, 10799
|
4828, 6810
|
10916, 11026
|
3862, 4041
|
9090, 10633
|
10729, 10769
|
8770, 9067
|
10823, 10893
|
4056, 4809
|
280, 285
|
358, 2806
|
2828, 3512
|
3528, 3846
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,155
| 158,892
|
32224
|
Discharge summary
|
report
|
Admission Date: [**2187-1-5**] Discharge Date: [**2187-1-27**]
Date of Birth: [**2128-1-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Metastatic adenocarcinoma of colon to liver
Major Surgical or Invasive Procedure:
Extended left hepatic lobectomy, segment [**5-30**] mass resection,
segment 6, mass resection x2. Extensive lysis of adhesions. Tru
Cut bx of the right lobe of the liver.
Small bowel resection with primary anastomosis.
wound vac
Intubation
Swan-ganz catheter
History of Present Illness:
The patient is a 58-year-old female who underwent a right
hemicolectomy, ileal transverse colostomy and cholecystectomy on
[**2185-10-27**] for an invasive, moderately differentiated
adenocarcinoma of the cecum with invasion into the wall and into
the pericolonic adipose tissue. Incidentally, metastatic
tumor was present in 7 out of 10 regional lymph nodes. She was
evaluated in [**2185-9-22**], demonstrating 7 lesions in the
liver consistent with metastatic adenocarcinoma of the colon.
Five were confined to the left
lobe including the left lateral segment and medial segment.
However, she also had a lesion in the inferior aspect of segment
6 in the right lobe and a deep lesion at the junction of segment
6 and 7.
A CT done at [**Hospital1 18**] on [**2185-11-30**] demonstrated multiple rim
enhancing low attenuation lesions throughout the liver
consistent with a history of metastatic colon cancer. She also
had a large amount of low attenuation ascites in the abdomen and
stranding was thought to represent peritoneal involvement with
tumor. Over the past year she has been treated with chemotherapy
and has had follow-up CT scans that have shown resolution of the
peritoneal findings and ascites along with significant shrinkage
of the liver masses. Follow up CT scan showing resectability of
lesions. She is admitted on this admission for elective hepatic
resections.
Past Medical History:
Elevated cholesterol, colon cancer, R hemicolectomy,
ileotransverse colostomy, and cholecystectomy ([**2184**]), craniotomy
in [**2168**] for an aneurysm. Two C-sections
Social History:
Lives with spouse. Former [**Name2 (NI) 1818**]. Quit 1 yr ago.
Family History:
Non-contributory
Physical Exam:
Tmax 98 Temp 97.6 HR 81 BP ranges 90-140/57-66 RR 19 SaO2 98%
General: NADS, Alert and awake
Skin: Normal
HEENT: no scleral icterus
Oropharynx: multiple whittish plaques on tongue, buccal mucosa
and palate
Neck: No lymphadenopathy or thyromegaly
Carotids: 2+/4+ without bruits
Lungs: clear to auscultation and percussion
Cardio: S1,S2, no S3, S4, murmurs or rubs, RRR
Abdomen: normal bowel sounds, mildly distended, no
hepatosplenomegaly, masses or tenderness, incision are
well-healed, no ascites
Extremities: No peripheral edema
Neuro: grossly intact, no focal deficits.
Pertinent Results:
[**2187-1-5**] 05:29PM BLOOD WBC-16.1* RBC-2.76*# Hgb-8.6* Hct-24.3*
MCV-88# MCH-31.3# MCHC-35.4*# RDW-17.2* Plt Ct-91*
[**2187-1-6**] 02:11AM BLOOD WBC-25.2*# RBC-4.10*# Hgb-13.3#
Hct-35.1*# MCV-86 MCH-32.4* MCHC-37.8* RDW-16.6* Plt Ct-95*
[**2187-1-6**] 02:44PM BLOOD WBC-25.2* RBC-3.86* Hgb-12.2 Hct-33.3*
MCV-86 MCH-31.5 MCHC-36.5* RDW-17.1* Plt Ct-106*
[**2187-1-7**] 02:16AM BLOOD WBC-25.4* RBC-3.40* Hgb-10.6* Hct-30.0*
MCV-88 MCH-31.2 MCHC-35.3* RDW-17.4* Plt Ct-80*
[**2187-1-7**] 07:25PM BLOOD WBC-28.7* RBC-3.36* Hgb-10.6* Hct-29.4*
MCV-88 MCH-31.6 MCHC-36.2* RDW-17.2* Plt Ct-93*
[**2187-1-8**] 02:49AM BLOOD WBC-23.6* RBC-3.14* Hgb-9.6* Hct-27.9*
MCV-89 MCH-30.8 MCHC-34.6 RDW-17.2* Plt Ct-84*
[**2187-1-9**] 03:13AM BLOOD WBC-19.1* RBC-3.23* Hgb-9.8* Hct-28.7*
MCV-89 MCH-30.4 MCHC-34.3 RDW-17.4* Plt Ct-115*
[**2187-1-10**] 04:28AM BLOOD WBC-25.8* RBC-3.22* Hgb-9.8* Hct-29.1*
MCV-90 MCH-30.3 MCHC-33.6 RDW-16.9* Plt Ct-125*
[**2187-1-11**] 03:28AM BLOOD WBC-37.2* RBC-3.27* Hgb-10.1* Hct-29.1*
MCV-89 MCH-30.8 MCHC-34.6 RDW-17.1* Plt Ct-172
[**2187-1-11**] 08:09PM BLOOD WBC-24.2* RBC-3.52* Hgb-10.8* Hct-31.2*
MCV-89 MCH-30.6 MCHC-34.5 RDW-17.5* Plt Ct-233
[**2187-1-12**] 03:29AM BLOOD WBC-23.1* RBC-3.53* Hgb-10.4* Hct-30.9*
MCV-88 MCH-29.5 MCHC-33.7 RDW-17.3* Plt Ct-210
[**2187-1-12**] 03:04PM BLOOD WBC-22.8* RBC-3.20* Hgb-9.4* Hct-27.8*
MCV-87 MCH-29.4 MCHC-33.8 RDW-17.5* Plt Ct-216
[**2187-1-26**] 03:30PM BLOOD WBC-34.4* RBC-3.05* Hgb-9.3* Hct-26.3*
MCV-86 MCH-30.6 MCHC-35.4*# RDW-18.3* Plt Ct-106*
[**2187-1-5**] 08:59AM BLOOD PT-16.9* PTT-27.5 INR(PT)-1.5*
[**2187-1-5**] 01:15PM BLOOD PT-20.3* PTT-36.3* INR(PT)-1.9*
[**2187-1-5**] 01:15PM BLOOD Plt Ct-181
[**2187-1-5**] 03:12PM BLOOD PT-18.2* PTT-56.3* INR(PT)-1.7*
[**2187-1-5**] 03:40PM BLOOD Plt Smr-VERY LOW Plt Ct-73*#
[**2187-1-6**] 02:44PM BLOOD PT-24.5* PTT-52.5* INR(PT)-2.4*
[**2187-1-24**] 02:14AM BLOOD PT-24.1* PTT-55.8* INR(PT)-2.3*
[**2187-1-25**] 09:11PM BLOOD PT-28.1* PTT-66.9* INR(PT)-2.8*
[**2187-1-26**] 03:30PM BLOOD PT-28.6* PTT-69.9* INR(PT)-2.9*
[**2187-1-5**] 05:29PM BLOOD Glucose-127* UreaN-8 Creat-0.7 Na-148*
K-3.2* Cl-108 HCO3-24 AnGap-19
[**2187-1-6**] 02:11AM BLOOD Glucose-208* UreaN-10 Creat-0.8 Na-143
K-4.4 Cl-108 HCO3-26 AnGap-13
[**2187-1-21**] 02:37AM BLOOD Glucose-92 UreaN-40* Creat-1.1 Na-141
K-4.5 Cl-109* HCO3-24 AnGap-13
[**2187-1-24**] 02:14AM BLOOD Glucose-119* UreaN-67* Creat-1.8* Na-140
K-4.5 Cl-111* HCO3-22 AnGap-12
[**2187-1-24**] 03:08PM BLOOD Glucose-104 UreaN-73* Creat-2.0* Na-141
K-4.5 Cl-112* HCO3-20* AnGap-14
[**2187-1-25**] 12:28PM BLOOD Glucose-117* UreaN-83* Creat-0.8 Na-140
K-5.3* Cl-109* HCO3-19* AnGap-17
[**2187-1-25**] 09:11PM BLOOD Glucose-80 UreaN-87* Creat-1.6* Na-142
K-5.2* Cl-109* HCO3-19* AnGap-19
[**2187-1-26**] 03:30PM BLOOD Glucose-121* UreaN-94* Creat-2.4* Na-137
K-5.1 Cl-108 HCO3-16* AnGap-18
[**2187-1-5**] 05:29PM BLOOD ALT-137* AST-313* AlkPhos-65 TotBili-2.8*
[**2187-1-6**] 02:11AM BLOOD ALT-388* AST-561* LD(LDH)-536* AlkPhos-74
TotBili-6.7*
[**2187-1-7**] 07:25PM BLOOD ALT-412* AST-316* AlkPhos-103
TotBili-6.9*
[**2187-1-12**] 03:29AM BLOOD ALT-115* AST-73* CK(CPK)-67 AlkPhos-157*
TotBili-7.7*
[**2187-1-15**] 03:20AM BLOOD ALT-38 AST-50* LD(LDH)-446* AlkPhos-137*
TotBili-7.2*
[**2187-1-15**] 02:17PM BLOOD ALT-36 AST-46* AlkPhos-124* TotBili-8.7*
[**2187-1-17**] 02:05AM BLOOD ALT-28 AST-60* AlkPhos-107 TotBili-13.8*
[**2187-1-17**] 06:27PM BLOOD ALT-30 AST-67* AlkPhos-118* TotBili-14.2*
DirBili-9.4* IndBili-4.8
[**2187-1-21**] 02:37AM BLOOD ALT-45* AST-104* LD(LDH)-391*
AlkPhos-128* TotBili-14.8*
[**2187-1-23**] 02:03AM BLOOD ALT-50* AST-129* AlkPhos-135*
TotBili-18.8*
[**2187-1-24**] 02:14AM BLOOD ALT-63* AST-150* AlkPhos-131* TotBili-25*
[**2187-1-25**] 09:11PM BLOOD ALT-47* AST-114* AlkPhos-76 TotBili-30.0*
[**2187-1-26**] 04:29AM BLOOD ALT-44* AST-104* AlkPhos-81 TotBili-30.5*
[**2187-1-26**] 03:30PM BLOOD ALT-34 AST-85* CK(CPK)-44 AlkPhos-90
TotBili-33.9*
[**2187-1-5**] 05:29PM BLOOD Albumin-3.3* Calcium-14.2* Phos-3.2
Mg-2.6
[**2187-1-7**] 02:16AM BLOOD Albumin-2.8* Calcium-9.1 Phos-2.7 Mg-1.8
[**2187-1-14**] 02:22AM BLOOD Albumin-2.2* Calcium-8.3* Phos-2.6*
Mg-2.2
[**2187-1-22**] 02:34AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.5
[**2187-1-23**] 02:03AM BLOOD Albumin-2.0* Calcium-7.9* Phos-3.0 Mg-2.5
[**2187-1-24**] 02:14AM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.6 Mg-2.6
[**2187-1-25**] 02:10AM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.5 Mg-2.7*
[**2187-1-25**] 09:11PM BLOOD Albumin-4.1 Calcium-8.7 Phos-5.8* Mg-2.8*
[**2187-1-26**] 04:29AM BLOOD Albumin-3.8 Calcium-8.5 Phos-6.1* Mg-2.7*
[**2187-1-14**] 08:32AM BLOOD Vanco-17.8
[**2187-1-17**] 07:23PM BLOOD Vanco-18.8
[**2187-1-23**] 06:01AM BLOOD Vanco-40.5*
[**2187-1-24**] 06:56AM BLOOD Vanco-28.6*
[**2187-1-25**] 06:17AM BLOOD Vanco-21.8*
[**2187-1-26**] 04:29AM BLOOD Vanco-18.7
[**2187-1-26**] 03:47PM BLOOD Type-ART pO2-163* pCO2-30* pH-7.34*
calTCO2-17* Base XS--8
[**2187-1-26**] 09:58AM BLOOD Type-ART pO2-111* pCO2-29* pH-7.35
calTCO2-17* Base XS--7
[**2187-1-26**] 06:17AM BLOOD Type-ART pO2-115* pCO2-28* pH-7.35
calTCO2-16* Base XS--8
[**2187-1-5**] 10:04AM BLOOD Glucose-238* Lactate-1.4 Na-138 K-2.9*
Cl-109
[**2187-1-13**] 07:57PM BLOOD Glucose-185* Lactate-2.7* K-3.2*
[**2187-1-25**] 09:42PM BLOOD Lactate-2.7*
[**2187-1-26**] 03:47PM BLOOD Glucose-114* Lactate-3.6* K-5.2
Path:
Small bowel nodule (A):
1. Peritoneal fibrous adhesions, with focal fibrosis extending
into the muscularis propria.
2. No tumor.
II. Additional small bowel nodules (B):
1. Peritoneal fibrous and fibrinous adhesions.
2. No tumor.
III. Liver, needle biopsy (C):
1. Minimal inflammation and mild steatosis.
2. No tumor, necrosis or fibrosis.
IV. Liver, left lobe, resection (D-I):
1. Metastatic adenocarcinoma with necrosis, consistent with
colonic origin.
2. There is no tumor at the resection margin.
V. Liver, segment 4/segment 5, resection (J):
Metastatic adenocarcinoma with extensive necrosis, present at
tissue edge.
VI. Liver, segment 6 tumor, resection (K-M):
Metastatic adenocarcinoma with necrosis, not present at
resection margin.
VII. Liver, segment 6, resection (N-O):
Metastatic adenocarcinoma with necrosis; not present at
resection margin.
VIII. Liver, segment 6, re-resection (P-Q):
Small foci of metastatic adenocarcinoma, not present at
resection margin.
IX. Liver, segment [**5-30**], resection (R-S):
Metastatic adenocarcinoma with necrosis, not present at
resection margin.
X. Small bowel, resection (T-V):
1. Small intestine with focal acute peritonitis and
unremarkable mucosa.
2. Three lymph nodes: No tumor (0/3).
[**Doctor First Name 81**]. Bowel remnants (W):
1. Colon segment with peritoneal fibrous adhesions and focal
acute peritonitis.
2. Unremarkable mucosa.
3. No tumor.
XII. Omentum (X-Z):
1. Focal fibrosis.
2. No tumor.
Liver US: [**2187-1-6**]
IMPRESSIONS:
1. Patent hepatic vasculature with appropriate waveforms in all
remaining
vessels including portal venous, hepatic venous and arterial
systems.
2. 2.6 cm hyperechoic lesion located anteriorly and inferiorly
in the right lobe, most likely representing postsurgical change
Liver US: [**2187-1-9**]
IMPRESSION:
1. No biliary dilatation and no intrahepatic fluid collection
identified.
2. Scant trace of ascites in the perihepatic space.
3. Patent and appropriate hepatic vasculature.
4. Small right pleural effusion.
LENI [**2187-1-9**]
IMPRESSION:
1. No evidence of deep venous thrombosis in the right upper
extremity.
2. Subcutaneous fluid in the right upper extremity as detailed
above.
[**Last Name (un) 1372**]-intestinal tube [**2187-1-18**]
Positioned post-pyloric
CT abdomen [**1-20**]
IMPRESSION:
1. Interval development of more focal left upper lobe and
probable right
middle lobe pneumonia. Decrease in bilateral pleural effusions
as described
above.
2. No organized intra-abdominal fluid collections identified.
Can not
exclude component of carcinomatosis. Hyperdense collections
along multiple
surgical resection beds likely represent resolving postoperative
hematoma and
indwelling surgical glue and Surgicel.
3. No evidence of bowel obstruction. New left groin hematoma as
above.
4. Interval development of a small bowel containing ventral
hernia at the
midline without signs of strangulation. This is consistent with
underlying
dehiscence of the abdominal wall musculature/fascia of
approximately 6.5cm
Echo [**1-24**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global 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%). The estimated
cardiac index is high (>4.0L/min/m2). 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. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
CXR [**1-24**]
The position of the Dobbhoff tube, Port-A-Cath and the PICC line
as well as abdominal drains is unchanged. Cardiomediastinal
silhouette is unchanged. Widening of left upper mediastinum
again can be seen with no significant change since the prior
study and actually is due to a left upper lobe consolidation
adjacent to the mediastinum. There is no interval change in left
basal atelectasis and right basal plate-like areas of
atelectasis. No appreciable pneumothorax is seen.
Liver US [**1-25**]
No evidence of a portal vein thrombosis.
CXR [**1-26**]
Findings: There has been no interval change in the position of
Port Cath, PICC line, endotracheal tube, NG tube, the drainage
tube of the right upper quadrant. There has been interval
improvement in aeration of the left upper lobe. The left
retrocardiac consolidation is unchanged. There has been interval
clearing of the right upper lobe opacity. New middle lobe
density has developed. Small bilateral pleural effusions are
unchanged. No pneumothorax is detected.
[**2187-1-12**] 1:33 pm SWAB Source: Abd wound.
**FINAL REPORT [**2187-1-14**]**
GRAM STAIN (Final [**2187-1-12**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2187-1-14**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
[**2187-1-12**] 10:15 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2187-1-14**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2187-1-14**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75343**] @ 6:00A [**2187-1-14**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2187-1-13**] 10:16 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2187-1-21**]**
GRAM STAIN (Final [**2187-1-13**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2187-1-21**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
[**2187-1-15**] 7:18 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2187-1-17**]**
GRAM STAIN (Final [**2187-1-15**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2187-1-17**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
[**2187-1-22**] 5:52 pm URINE Source: Catheter.
**FINAL REPORT [**2187-1-23**]**
URINE CULTURE (Final [**2187-1-23**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2187-1-25**] 4:49 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2187-1-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2187-1-28**]): ~1000/ML
OROPHARYNGEAL FLORA.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
Patient was admitted to Dr.[**Name (NI) 1369**] general surgery service and
taken to the operating room on [**2187-1-5**] for a left hepatic
lobectomy, segment [**5-30**] mass resection, segment 6, mass resection
x2, extensive lysis of adhesions, biopsy of the right lobe of
the liver, and small bowel resection with primary anastomosis.
She received 6000ml of crystalloid, 10 units FFP, 10 units pRBC,
1 unit of platelets intraoperatively. She was kept intubated and
transferred to the intensive care unit in stable condition for
further monitoring. Patient did require pressors and fluid for
hypotension and oliguria overnight. Morphine provided for pain.
Unasyn for empiric prophlaxis. NG placed for gastric
decompression. Placed on insulin sliding scale for blood sugar
control.
On [**2187-1-5**] - [**2187-1-9**], she was weaned off pressor support.
Succesfully extubated; encouraged use of incentive spirometry.
Still required mulitple fluid supplementation for oliguria. LFT
and electrolytes were checked and monitored daily. Urine output
only marginal throughout. Abdominal ultrasound was normal.
Eventually, advanced to a clear diet with fluid for continued
oliguria. Ultrasound for right arm swelling and returned normal
without any clots.
She was transferred to the general surgical floor on [**2187-1-10**].
Pain controlled with IV morphine. Received fluid bolus x 2 for
marginal urine output. Urine electrolytes analysis indicate FeNA
< 1%. Developed sudden onset shortness of breath, SaO2 of 70%,
requiring oxygen, tachypnea with concurrent diaphoresis. This
seemed to occur as she was receiving one liter bolus for
oliguria. She was transferred to ICU, given lasix for diuresis.
CT angiogram negative for any PE. With prolonged NPO state, TPN
initiated and nutrition consulted. She was kept on face tent of
50%; however, saturations did not improve with increased work of
breathing. Pt was then intubated for resp distress. Started on
Vanco/Flagyl/Zosyn for empiric coverage given elevated wbc (29);
C.Diff sent with sudden development diarrhea; CT abd repeated;
A-line and CVL placed; and Vigileo started. ET found to be down
right mainstem bronchus and had to be repositioned. Placed on
maximum volume of pressor support for hypotension.
On [**2187-1-13**] she received lasix with FFP to help with diuresis and
improving respiratory status. 2u pRBC transfused to maintain
intravascular volume. She was pan-cultured for fever 101 as
well. Noticed erythema around incisional site, requiring
multiple dressing changes for leakage. Wound vac applied. C.diff
returned positive, kept on IV flagyl. Albumin infused
intermittently for intravascular repletion. Her pressors and
vent settings were slowly weaned. Bilateral lower extremity
ultrasound was negative for DVT, albumin started, vasopressin
started.
On [**2187-1-16**], she received another two units pRBC on [**2187-1-16**]. HIT
panel sent concerning for low platelets returned negative.
Patient was weaned off all pressors and weaned to CPAP with
pressure support. Plan to continue with diuresis. Dobhoff placed
to begin tubefeeds, picc line placed, zosyn was discontinued.
Her bilirubin continues to elevate daily at 13.8. With continued
high stool output, she was changed to a PO vancomycin. Patient
succesffully diuresed with decreased vent settings. On [**2187-1-19**],
patient was extubated.
A rash noted over patient's left flank. ID consulted for
concerns of resistant cellulitus. Dermatology also consulted for
opinion of possible drug reaction. Started on meropenem for
better G- coverage for presumed cellulitis in addition to
vancomycin. TPN discontinued after meeting TF goal. With high
drain output from abdomen, CT ordered, revealing wound
dehiscence and bilateral pneumonia. She remained briefly
hypotensive (SBP 80s), received albumin x 1 w/ good response,
UOP remained stable. Continues to have waxing and [**Doctor Last Name 688**] mental
status.
Dermatology agreed with diagnosis of cellulitus. Hct slowly
trending down, oliguria responsive to fluid boluses. She
received 1u PRBC. LFT continued to be elevated. Jaundice still
objectively evident - [**Male First Name (un) 1658**] colored stools, scleral icterus. She
continues to have oliguria with hypotension. Attempted to
continue intravascular protein repletion with albumin. Lasix
held. Pain medication held to improve mental status.
On [**2187-1-23**], patient repleted with IV hydration and albumin due to
excessive drainage from wound vac. She continues to have
oliguira. Vancomycin dosing held and adjusted based on trough
levels. Oxygenation worsening. CXR showing increased left lobe
consolidation. Aztreonam started for G- coverage, meropenem
stopped for questionable etiology of rash. TTE to assess cardiac
function, which showed normal EF with hyperdynamic state. She
required boluses/albumin for prerenal (FENA 0.2). Patient
desaturated overnight with bradycardia episodes to 30 and
hypotension, responded with atropine.
From [**2187-1-24**] - [**2187-1-26**], patient continued to have worsening renal
function with oliguria. Responding to intermittent fluid
boluses. Treated with hepatorenal protocol with albumin
infusion. Urine did not respond. Liver enzymes continue to be
elevated. With worsening respiratory status, increasing work of
breathing, requiring intubation to support airway. Patient
received bronchoscopy, which revealed no major mucus plugging.
Swan-ganz was attempted to assess and monitor patient's overall
state given state of multi-organ failure. However, with
thrombosed arteries to upper extremity, plan was aborted after
several failed attempts. TEE performed instead ruling out
hypovolemic or cardiogenic shock.
Given multi-organ failure (liver, renal, pulmonary distress) and
prognosis, family's decision was to discontinue all intervention
on [**2187-1-26**]. Social work involved throughout hospitalization to
help with coping. Patient started on a morphine drip for comfort
measures. Tube feeds, antibiotics and all other medications were
discontinued. She was kept intubated. DNR signed after
clarification with family and attendings. Patient expired on
[**2187-1-27**].
Medications on Admission:
citalopram 20mg PO daily
cyanocobalamin 1000mcg/ml sq monthly
warfarin 2.5mg PO daily
Iron
loperamide
MVI
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Hepatorenal syndrome -ARF (ATN) and liver failure
Respiratory distress
Rash of unclear etiology
[**Name (NI) 75344**] failure
metastatic carcinoma of colon to liver
Discharge Condition:
Expired [**2187-1-27**]
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
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icd9cm
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[
[
[]
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[
"96.04",
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[
[
[]
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21723, 21732
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21948, 21973
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2944, 15301
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22026, 22160
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2317, 2335
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21694, 21700
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21753, 21927
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21564, 21671
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21997, 22003
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2350, 2925
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15334, 15356
|
273, 318
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644, 2026
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2048, 2220
|
2236, 2301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,536
| 141,981
|
11216
|
Discharge summary
|
report
|
Admission Date: [**2125-4-22**] Discharge Date: [**2125-5-10**]
Date of Birth: [**2067-10-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Head CT
Brain MRI
Abdominal MRI
Renal MRI/MRA
EEG
pMIBI
Resection of abdominal mass
History of Present Illness:
57F with PMH significant for h/o T2DM, s/p renal
transplant [**2122**] on immunosuppressants (Tacrolimus, prednisone
and
azathioprine), who presents to the ED with occipital headache x
2 weeks. She also admitted intermittant blurry vision, which she
attributed to her DM. She had an episode of vomiting the morning
of admission, which prompted her husband to bring her to the [**Name (NI) **].
Initial BP was 250/80 in the ED -> was given 20mg labetolol
which dropped her BP to the 160's. Neurology was consulted, and
witnessed her eyes beating to the left rhythmically, with
eyelids fluttering with the beating nystagmus. She was noted to
be unresponsive to pain or voice during this event, which lasted
for approximately 3 minutes. She was given 2mg IV ativan and the
nystagmus quickly resolved, but her eyes remained fixed to the
left for about a minute, after which her eyes returned to
midline. Her BP during the event was over 200, but after the
ativan it dropped to 170's. FS 174 during the event. She was
noted to be somnolent
afterwards, but within the next 30 - 40 min or so she easily
awakened, would answer some questions and follow commands, but
was very inattentive. She was noted to have a left sided
pronator drift and an inability to raise left leg to gravity.
Non-contrast head CT done before her seizure demonstrated
possible low attenuation within the white matter of the left
occipital lobe and within the right occipital lobe to a lesser
extent. There were also foci of low attenuation within the
subcortical white matter within the right frontal hemisphere. A
second noncontrast head CT was done after the episode that
demonstrated no interval change. An EEG was also done in the ED
and showed showed slowing, no nonconvulsive status per neuro
read. LP demonstrated 1 wbc, prot 47, gluc 97, no oligoclonal
bands.
Mrs. [**Known lastname 36061**] and her husband deny any past h/o seizure, stroke or
infection of the brain. She has had decreased PO intake recently
and had an admission for diarhea and metabolic acidosis
recently. No
fevers, chills, or complaints other than headache per husband.
She takes care of all her medical problems herself and the
husband does not know all the details of her illnesses nor her
meds. She was last seen by Dr. [**Last Name (STitle) **] on [**4-3**], at which point
her BP was noted to be 180/90, with repeat 160/80. Several med
changes were instituted at that time: Cellcept 500mg [**Hospital1 **] was
switched to azathioprine 100mg qD, epogen decreased from 3 x per
week to 2 x per week due to painful injections, Crestor
restarted at 20mg qD, and
Lasix started at 40mg PO qD for elevated BP.
Mrs. [**Known lastname 36061**] was admitted to the Neuro ICU for hypertensive
emergency, and was monitored overnight, with no events. She was
transferred to the medicine service under Dr. [**Last Name (STitle) **] with
neurology consulting for further management.
Past Medical History:
DM, last a1c 7.7 in [**2123**]
ESRD (2o2 IDDM and HTN), s/p renal transplant [**2122**] on
immunosuppressants, episode of allograft nephropathy documented
by biopsy
HTN
b/l thoracotomy for spontaneous PTX, [**2110**]
Hyperlipidemia
Social History:
Pt was raised in the Phillipines, immigrated to the US in
[**2096**]. Married lives with husband. 2 kids. No tob/etoh/drugs.
Family History:
NC
Physical Exam:
T: 97.9F BP: 150/41 HR: 62 RR: 27 SaO2: 96% 4L NC
GEN: Lying in bed comfortably, NAD
HEENT: NC/AT, anicteric sclera, MMM, PERRL
NECK: supple, no meningismus, no LAD
CHEST: CTAB, no w/r/r, poor inspiratory effort
CV: RRR, nl S1 and S2, no m/r/g
ABD: soft, NT/ND, mildly tender over site of orthotopic kidney,
which pt states is chronically present, +BS throughout
EXTREM: no LE edema, thrill left forearm
NEURO:
A&Ox3, but answering questions slowly
CN intact
no pronator drift, strength 5-/5 bilaterally.
Pertinent Results:
[**2125-4-22**] 01:00PM PT-11.3 PTT-27.4 INR(PT)-1.0
[**2125-4-22**] 01:00PM PLT COUNT-151
[**2125-4-22**] 01:00PM HYPOCHROM-3+ MICROCYT-1+
[**2125-4-22**] 01:00PM NEUTS-82.1* LYMPHS-13.3* MONOS-3.0 EOS-1.3
BASOS-0.3
[**2125-4-22**] 01:00PM WBC-6.1 RBC-5.31 HGB-14.2 HCT-45.3 MCV-85
MCH-26.8* MCHC-31.4 RDW-15.2
[**2125-4-22**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-8.4
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2125-4-22**] 01:00PM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-4.4
MAGNESIUM-2.0
[**2125-4-22**] 01:00PM CK-MB-2
[**2125-4-22**] 01:00PM cTropnT-0.06*
[**2125-4-22**] 01:00PM LIPASE-41
[**2125-4-22**] 01:00PM ALT(SGPT)-22 AST(SGOT)-50* LD(LDH)-835*
CK(CPK)-125 ALK PHOS-109 AMYLASE-43 TOT BILI-0.4
[**2125-4-22**] 01:00PM GLUCOSE-147* UREA N-61* CREAT-3.3* SODIUM-142
POTASSIUM-7.0* CHLORIDE-109* TOTAL CO2-21* ANION GAP-19
[**2125-4-22**] 03:06PM COMMENTS-GREEN TOP
[**2125-4-22**] 09:28PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1*
POLYS-48 LYMPHS-21 MONOS-31
[**2125-4-22**] 09:28PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
[**2125-4-22**] 09:28PM CEREBROSPINAL FLUID (CSF) PROTEIN-47*
GLUCOSE-97
.
Bone Scan [**2125-5-7**]:
IMPRESSION: 1) No evidence of osseous metastatic disease. 2)
Vague left upper quadrant soft tissue uptake. 3) Uptake in both
native right and transplanted RLQ kidneys. Prior left
nephrectomy. 4) Diffuse increase in bilateral leg soft tissue
uptake, may reflect poor renal function or vascular disease.
.
Stress test:
Impression: No anginal symptoms or ischemic EKG changes. Nuclear
report sent seperately.
Mibi
IMPRESSION:
No myocardial perfusion defects identified. LVEF of 58%
.
Abd US:
IMPRESSION: Following extensive evaluation of the left upper
quadrant heterogeneous mass, it is felt that it likely
represents an exophytic hepatic lesion arising from segment II.
Accounting for this, the mass is suspicious for hepatocellular
carcinoma.
.
Liver pool blood study:
IMPRESSION:
Large splenic/perisplenic mass is not consistent with a
cavernous hemangioma or splenule.
.
MRA kidney:
IMPRESSION:
1. Tortuous transplant renal artery with multiple 90-degree
turns with folds giving apparent mild narrowing to the
transplant renal artery. Distal folding gives narrowing that
approaches but is less than 50%. Widely patent anastomosis.
2. Small renal transplant upper pole defect likely from prior
biopsy. No concerning lesion within the transplant kidney or
perirenal fluid collections.
3. Right native renal artery stenosis approaching 50%. Minimal
function remaining in native kidney. Left nephrectomy.
.
MR Abd:
IMPRESSION:
1. Left upper quadrant mass likely splenic in origin, not
completely characterized. While a splenic hemangioma is
statistically most likely, this is uncertain. Comparison with
remote prior films would be best, but if not available, a tagged
red cell nuclear medicine study or biopsy is recommended.
2. Multiple small pancreatic cystic lesions raise the question
of side branch IPMT.
3. Suspicion for proximal right renal artery stenosis in the
native kidney, incompletely evaluated on this study. Transplant
kidney not seen on this study.
4. Cholelithiasis.
.
Renal Transplant US:
IMPRESSION: Diastolic flow is only seen in one branch of the
lower pole of the kidney. Otherwise no diastolic flow is
identified in the upper or mid poles. These findings were
discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] at 5:10 p.m. on [**2125-4-29**].
.
Echo:
Conclusions:
1.The left atrium is moderately dilated. The left atrium is
elongated.
2. There is moderate symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The ascending aorta is mildly dilated.
5.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation
is seen. The left ventricular inflow pattern suggests impaired
relaxation.
7.There is moderate pulmonary artery systolic hypertension.
8. There is a small to moderate sized pericardial effusion.
There are no
echocardiographic signs of tamponade.
.
Brain MRI:
IMPRESSION: Findings on MRI of the brain is consistent with the
clinical history of hypertensive encephalopathy, with edema
visualized within the white matter of primarily the posterior
portions of the brain. There are no diffusion signal
abnormalities to indicate infarction.
MR angiography is within normal limits.
MR [**First Name (Titles) 36062**] [**Last Name (Titles) 4059**] patency of the major intracranial
veins.
.
CT head:
IMPRESSION: No intracranial hemorrhage. Foci of low attenuation
within the subcortical white matter as described above, could be
small vessel ischemic change. Clinical correlation is
recommended. If further evaluation is warranted, an MRI should
be performed
Brief Hospital Course:
1) Hypertensive emergency/Seizure:
Mrs. [**Known lastname 36061**] had brain MRI/A/V that was consistent with occipital
lobe leukoencephalopathy [**2-22**] hypertension. Her Prograf was also
d/c'ed for potential contribution to this condition. She had an
LP that was normal, with negative EBV, CMV, and HSV. EEG was
read as abnormal for slowed bilateral posterior background
rhythms, c/w encephalopathy. Her mental status and neurological
exam quickly returned to baseline, and her BP meds were titrated
for optimal BP control. Her ultimate regimen was amlodipine 10mg
PO qD, metoprolol 100mg PO bid, and doxazosin 1mg PO bid. Diovan
was also used, but d/c'ed as her renal function worsened. She
had no further seizures or hypertensive episodes. She also had a
renal MRI/A of her native and graft kidney to assess for RAS as
a secondary cause of her worsening HTN. Her graft RA had several
luminal-narrowing 90-degree turns, but was overall widely
patent. Her native kidney RA had evidence of atherosclerotic 50%
lesion.
.
2) Possible lymphangioleiomyomatosis:
After transfer to medical floor, it was observed that Mrs. [**Known lastname 36061**]
had a persistent O2 requirement. On specific questioning, Mrs.
[**Known lastname 36061**] stated that she had been told by an outside pulmonologist
that she had emphysema. She also had a h/o thoracotomy in her
early 40s where pleurodesis was performed for spontaneous PTX.
CXR demonstrated an interstitial process with some suggestion of
cystic disease. Pulmonary service was consulted, and a chest CT
was done, which demonstrated diffuse thin-walled parencymal
cysts which, in a female non-smoker, was thought to be most
consistent with pulmonary lymphangioleiomyomatosis, although
there were features that were not consistent. The case was
discussed at a pulmonary conference, and no other possible
diagnoses could be suggested. The CT also suggested an
enlargement of Mrs.[**Known lastname 36063**] pulmonary arteries. A TTE was done,
which confirmed moderate pulmonary artery hypertension. PFTs
were also done, demonstrating a mild obstructive pattern, which
was similar to OSH PFTs from [**2123**], and significantly worse than
OSH PFTs from [**2117**]. She was not bronchodilator-responsive.
Attempts were made to determine if slides were done of lung
parenchyma from her previous thoracotomy. She was d/c'ed on home
O2, and instructed to f/u in pulmonary clinic.
.
3) Abdominal mass:
On the abdominal cuts from Mrs.[**Known lastname 36063**] chest CT, a large, 8cm
heterogeneous mass was seen anterior and superior to the spleen.
A dedicated MRI was done of the lesion, which confirmed
thin-walled septa and hypoattenuating nodules within the mass,
which was thought to be associated with the spleen. This was
thought to be most c/w splenic hemangioma, though not classic. A
tagged rbc scan was done, which confirmed that the mass was not
a splenule or hemangioma. A f/u U/S done to verify splenic
origin of the mass rather found that it seemed to be contiguous
with segment II of her liver. It was thought that this mass was
likely HCC given the location as well as the mildly elevated
AFP. Transplant surgery decided to excise the tumor. A pMIBI was
done as part of a cardiac w/u, which demonstrated no evidence of
ischemia. The patient was discharged to home with a plan to
return for the operation.
.
4) Renal failure:
As mentioned, tacrolimus was held in the setting of
leukoencephalopathy. She was restarted on Cellcept 500mg PO bid
and prednisone 5mg PO qD. The CellCept was increased to tid
dosing when Ms. [**Known lastname 36061**] did not experience any recurrence of her
diarrhea. Throughout her stay, Mrs.[**Known lastname 36063**] renal function was
tenuous. Her creatinine increased, peaking at 4.5. There was a
suspicion that her hypertensive episode could have damaged her
graft kidney, or that she could have RAS which caused the
original hypertensive episode. An renal MRI/A of her graft and
native kidney demonstrated 50% RAS of her native RA, but no
significant occlusion of her graft RA other than that induced by
folding of the RA. She was intermittently on lasix for lung
crackles and increased LE edema. The assessment by the renal
team was that this was likely chronic allograft nephropathy.
.
5) T2DM:
Continued half of home dose of NPH, and covered with HISS. BS
were reasonably controlled, though not optimized, during her
stay.
.
6) Hyperlipidemia:
Continued rovustatin. Renally dosed to 5mg PO qD as renal
function deteriorated.
.
7) Prophylaxis - Maintained on subcutaneous hepatin,
pantoprazole, bowel regimen
.
8) Code: Full Code
.
9) Dispo: Pending resolution of acute medical issues
Medications on Admission:
prednisone 5 daily
prograf 2mg [**Hospital1 **] (last level was 5.2 [**3-26**])
sodium bicarb
lisinopril 20
iron
epogen
NPH
alendronate
bactrim 3x/week
metoprolol 100 [**Hospital1 **]
crestor 20
imuran 100 daily
lasix 40 daily
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*12 Tablet(s)* Refills:*2*
4. 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*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO BID (2 times a day).
Disp:*1800 ML(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Insulin
Insulin 70/30
Take 17units SC QAM; 13units SC QPM
Dispense: qs
Refills: 2
13. Oxygen
2L continuous O2 by nasal canula
for oxygen saturation <88% on room air
14. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive emergency
Seizures due to hypertensive emergency
Acute on chronic renal failure - graft nephropathy
Leukoencephalopathy
Liver lesion
Cystic lung disease
Type II diabetes mellitus
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a very elevated blood pressures and a
seizure. Please continue to take all medications as prescribed
and wear the oxygen. You will return to the hospital next
Friday for the biopsy as the surgeons have discussed with you.
.
If you develop worsening headache, blurry vision, decreasing
urination, fevers, abdominal pain, or any other concerning
symptom, please contact your primary care physician, [**Name10 (NameIs) **] kidney
doctor, and/or return to the emergency department.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-6-5**] 11:10
.
You should also make an appointment to see Dr. [**First Name (STitle) **] in the next
1-2 weeks. You can call [**Telephone/Fax (1) 36064**] for an appointment. He
should arrange for you to have a repeat head CT and EEG in 4
weeks.
.
Please return to the hospital next Thursday, [**2125-5-17**] for
your surgery on Friday [**2125-5-18**]. You will be admitted to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] service.
.
You should also plan to follow-up with a lung doctor. You can
call ([**Telephone/Fax (1) 513**] to schedule an appointment
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
[
"403.91",
"996.81",
"780.39",
"416.8",
"585.6",
"155.0",
"250.40",
"E878.0",
"323.9",
"582.9",
"235.7",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15797, 15803
|
9282, 13956
|
324, 409
|
16039, 16048
|
4324, 8990
|
16599, 17423
|
3776, 3780
|
14234, 15774
|
15824, 16018
|
13982, 14211
|
16072, 16576
|
3795, 4305
|
277, 286
|
437, 3361
|
8999, 9259
|
3383, 3617
|
3633, 3760
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,922
| 181,701
|
29203
|
Discharge summary
|
report
|
Admission Date: [**2115-12-5**] Discharge Date: [**2115-12-10**]
Date of Birth: [**2060-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
Virtual colonoscopy
History of Present Illness:
55yo M w/ h/o recurrent bladder ca s/p cystectomy w/ ileal
conduit p/w BRBPR to OSH. Hct dropped 34->22. EGD normal. Cscope
unable to complete due to blood but tics seen. Tagged RBC +
activity in RLQ. Transferred to [**Hospital1 18**] ICU where Hct has remained
stable. Seen by GI and plan is to continue holding
anticoagulation and repeat scope on Monday. Pt feeling well,
denies abd pain, N/V, LH, SOB, CP.
Past Medical History:
Metastatic bladder CA now in remission s/p chemo/xrt
s/p cystectomy and ileal loop urinary diversion and also radical
prstatectomy with bilateral pelvic lymph node dissection.
b/l DVTs, most recent seen in IVC to right femoral vein s/p IVC
filter [**2115-1-17**]
Nephrolithiasis.
Anemia - baseline mid 30s.
Social History:
From [**Country **] originally. denies smoking works at a deli in
beaconhill.
Family History:
denies fh of bleeding or clotting disorders.
Physical Exam:
per admitting resident:
T 97.4 BP 100/62 P 56 RR 16
Mid aged man in NAD
sclera anicteric, MMM
supple, no LAD
CTAB
RRR S1/S2 no M
soft, +BS, NT, Midline surgical scar, nephrostomy bag draining
yellowish urine in RLQ
no edema, no clubbing
Pertinent Results:
[**2115-12-5**] 10:27PM GLUCOSE-88 UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-25 ANION GAP-9
[**2115-12-5**] 10:27PM estGFR-Using this
[**2115-12-5**] 10:27PM CALCIUM-8.7 PHOSPHATE-2.4* MAGNESIUM-1.5*
[**2115-12-5**] 10:27PM WBC-8.4 RBC-2.98* HGB-9.3* HCT-26.3* MCV-88
MCH-31.1 MCHC-35.3* RDW-14.4
[**2115-12-5**] 10:27PM PLT COUNT-164
[**2115-12-5**] 10:27PM PT-11.4 PTT-27.5 INR(PT)-1.0
Brief Hospital Course:
55 year old man with history of metastatic bladder cancer and
recurrent DVTs on Lovenox admitted with lower GI bleeding.
Right lower quadrant source of bleed on red blood cell scan.
Attempts to visualize colon by conventional and CT virtual
colonoscopy failed because of sigmoid angulation and inadequate
preparation, respectively. On Ct scan, a right psoas mass, most
consistent with a hematoma, was seen. Since the hematocrit of
the patient was stable and outside records from [**2115-3-30**]
mentioned a mass in the right pelvis, the patient was
discharged. Lovenox was held until follow-up with primary care
doctor. Also, a repeat outpatient CT colonoscopy with better
preparation should be considered.
Medications on Admission:
Lovenox 0.6 mg/kg SC BID
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
2. Outpatient Lab Work
cbc, creatinine
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
GIB
.
Secondary diagnosis:
Metastatic, recurrent bladder cancer
h/o DVTs
Discharge Condition:
Good. Stable Hct of 31.
Discharge Instructions:
We recommend that you do NOT resume your lovenox until talking
to your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. You likely have a bleeding source in
your colon that we have been unable to visualize. The bleeding
has stopped and you have remained hemodynamically stable and
your hematocrit is stable, but you are at risk of bleeding from
this source again with anticoagulation. A CT scan of your
abdomen showed a right pelvic mass, most likely a hematoma,
which had been described previously in [**2115-3-30**].
.
Please continue to take your other medications as prescribed.
.
Please follow up with your PCP as scheduled. Please bring your
outpatient lab results to your PCP (Dr. [**Last Name (STitle) **]
.
Please see a doctor if you feel dizzy, or have blood in your
stool again.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2116-1-1**] at 8:00
AM. Her number is [**Telephone/Fax (1) 60859**].
.
Please go to Dr.[**Name (NI) 29042**] office later this week to have your
labs drawn and sent to Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2115-12-10**]
|
[
"285.1",
"728.89",
"V10.51",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
2983, 2989
|
2023, 2732
|
343, 376
|
3124, 3149
|
1573, 2000
|
4003, 4459
|
1255, 1301
|
2807, 2960
|
3010, 3010
|
2758, 2784
|
3173, 3980
|
1316, 1554
|
276, 305
|
404, 814
|
3056, 3103
|
3029, 3035
|
836, 1144
|
1160, 1239
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,835
| 104,250
|
23971
|
Discharge summary
|
report
|
Admission Date: [**2164-6-11**] Discharge Date: [**2164-6-15**]
Date of Birth: [**2127-3-10**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity, gallstones
Major Surgical or Invasive Procedure:
Laproscopic Roux-en-Y gastric bypass, laproscopic
Cholecystectomy
History of Present Illness:
The patient is a37-year-old woman who has been on multiple
supervised diets with a maximum weight loss of 80 pounds with
regain. She reports being heavy her entire life. She has been
evaluated by [**Hospital1 **] [**First Name (Titles) 1560**] [**Last Name (Titles) 28350**] Program
and deemed a good candidate for surgical weight loss.
Past Medical History:
hypertension
dysplipidemia
gallstones
laparoscopy for ovarian cysts
Social History:
Denies alcohol, tobacco, or drug use. She is married with one
daughter who is age 18.
Physical Exam:
BP 110/62, weight of 305 pounds
Gen: alert, awake, NAD
Neck: supple, no LAD
Pulm: CTAB
CV: RRR, no murmurs
ABd: soft, NT, no rebound/gaurding
Extr: warm, well-perfused
Pertinent Results:
[**2164-6-11**] 12:26PM BLOOD Hct-35.5*
[**2164-6-12**] 02:13AM BLOOD WBC-9.3 RBC-3.75* Hgb-11.2* Hct-32.9*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.4 Plt Ct-146*
[**2164-6-13**] 02:28AM BLOOD WBC-9.4 RBC-3.81* Hgb-11.2* Hct-33.6*
MCV-88 MCH-29.4 MCHC-33.3 RDW-13.7 Plt Ct-136*
[**2164-6-14**] 05:32AM BLOOD WBC-7.3 RBC-3.54* Hgb-10.7* Hct-30.9*
MCV-88 MCH-30.3 MCHC-34.6 RDW-13.5 Plt Ct-149*
[**2164-6-12**] 02:13AM BLOOD PT-12.8 PTT-23.3 INR(PT)-1.1
[**2164-6-12**] 02:13AM BLOOD Glucose-122* UreaN-5* Creat-0.5 Na-140
K-3.5 Cl-105 HCO3-26 AnGap-13
[**2164-6-13**] 02:28AM BLOOD Glucose-110* UreaN-8 Creat-0.5 Na-142
K-3.4 Cl-108 HCO3-27 AnGap-10
[**2164-6-14**] 05:32AM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-144
K-3.9 Cl-107 HCO3-28 AnGap-13
[**2164-6-12**] 02:13AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.5*
[**2164-6-13**] 02:28AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.9
[**2164-6-14**] 05:32AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
[**2164-6-12**] Upper GI Evaluation: patent anastamosis, no leak
Brief Hospital Course:
This is a 37year old female with morbid obesity and gallstones
who presented
for operative management. SHe underwent a laparoscopic roux-en-y
gastric bypass procedure with cholecystectomy on [**2164-6-11**]
(please see the operative note of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for full
details). Postoperatively she had some issues with pain control
and respiratory issues requiring an overnight stay in the
intensive care unit. She had an upper GI swallow evaluation on
post-op day 1 which revealed a patent anastamosis with no leak.
She was then started on a stage 1 diet. Her foley catheter was
removed and she was transitioned to roxicet off her PCA. She
ambulated on her own. On post-op day 2 she was started on a
stage 2 diet which was advanced to stage 3 which she tolerated
well. She was discharged to home on post-op day 4 in good
condition. All questions were answered to her satisfaction upon
discharge.
Discharge Medications:
1. Methadone 10 mg/5 mL Solution Sig: Eighty (80) ml PO once a
day for 2 days.
Disp:*160 ml* Refills:*0*
2. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO twice a
day.
Disp:*600 ml* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ml PO every 4-6 hours as needed for pain.
Disp:*200 ml* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Morbid obesity with comorbidities.
Discharge Condition:
stable
Discharge Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in two weeks. You may shower.
Please return to the hospital or call the office if you develop
fevers, red streaking around the wound, nausea, or vommitting.
Please follow the diet that you were taught by the
nutritionists. Please take an adult multi-vitamin a day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in two weeks. His office number
is [**Telephone/Fax (1) 61050**].
Completed by:[**2164-7-18**]
|
[
"278.01",
"574.10",
"724.2",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23",
"44.38"
] |
icd9pcs
|
[
[
[]
]
] |
3619, 3625
|
2184, 3147
|
340, 408
|
3704, 3713
|
1179, 2161
|
4080, 4230
|
3170, 3596
|
3646, 3683
|
3737, 4057
|
990, 1160
|
274, 302
|
436, 780
|
802, 871
|
887, 975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,733
| 149,734
|
30368
|
Discharge summary
|
report
|
Admission Date: [**2108-2-21**] Discharge Date: [**2108-2-25**]
Date of Birth: [**2033-10-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bee Pollens
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Decreased exercise tolerance with Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2108-2-21**] Coronary Artery Bypass Graft x 3 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to posterior descending artery)
History of Present Illness:
The patient is a 74 year old white male who recently has noticed
a decrease in exercise tolerance as well as dyspnea on exertion.
Stress test suggested ischemia. Cardiac catheterization and
coronary angiography revealed 2 vessel disease and the patient
was referred for surgical revascularization.
Past Medical History:
Coronary Artery Disease
Hyperlipidemia
Hypertension
Depression
Mild Benign prostatic hypertrophy
Rash treated with cyclosporine
Past surgical history: bilateral hernia repair, right knee
arthroscopy, bilateral cataract surgery
Social History:
Retired. Quit smoking 30 yrs ago after 30 pack year history.
Drinks one alcoholic beverage per day. Lives with wife.
Family History:
Non-contributory
Physical Exam:
Vitals: 50 163/81 72' 191lbs
General: No acute distress
Skin: Mild chronic rash
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally
Heart: Regular rate and rhythm with 2/6 systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused with large varicosities on left, mild
on right
Neuro: Grossly intact, non-focal
Pertinent Results:
[**2108-2-21**] 01:19PM BLOOD WBC-8.9# RBC-2.38*# Hgb-7.9*# Hct-21.9*#
MCV-92 MCH-33.3* MCHC-36.2* RDW-12.7 Plt Ct-130*
[**2108-2-24**] 06:00AM BLOOD WBC-7.1 RBC-2.37* Hgb-7.7* Hct-21.9*
MCV-92 MCH-32.3* MCHC-35.1* RDW-12.7 Plt Ct-140*
[**2108-2-21**] 01:19PM BLOOD PT-15.2* PTT-39.8* INR(PT)-1.3*
[**2108-2-21**] 02:33PM BLOOD PT-14.9* PTT-43.5* INR(PT)-1.3*
[**2108-2-21**] 02:33PM BLOOD UreaN-14 Creat-0.9 Cl-109* HCO3-23
[**2108-2-24**] 06:00AM BLOOD Glucose-122* UreaN-24* Creat-1.1 Na-133
K-4.3 Cl-97 HCO3-27 AnGap-13
[**2108-2-25**] 07:10AM BLOOD Hct-28.8*#
Brief Hospital Course:
Mr. [**Known lastname 72234**] was a same day admit after undergoing pre-operative
work-up prior to admission and was brought to the operating room
where he underwent a coronary artery bypass graft. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Later this day he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he was
transferred to the telemetry floor for further care. Chest tubes
were removed on post-op day two and epicardial pacing wires were
removed on post-op day three. Chest x-ray following chest tube
removal revealed small apical pneumothorax. This remained
stable. The patient received two units of packed red blood
cells for a hematocrit of 21%. This would rise to 28%.
Hospital course was uneventful and the patient was discharged
home with VNA services in good condition on POD 4.
Medications on Admission:
Atenolol 25mg daily, Terazosin 10mg daily, Paxil 10mg daily,
Zocor 10mg daily, Aspirin 81mg daily, Clonidine 0.3mg [**11-18**] tab
[**Hospital1 **], Triamterene/HCTZ 37.5/25mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Cyclosporine 100 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours).
Disp:*60 Capsule(s)* Refills:*2*
5. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Clonidine 0.3 mg Tablet Sig: [**11-18**] Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary Artery Disease
Hyperlipidemia
Hypertension
Depression
Mild Benign prostatic hypertrophy
Rash treated with cyclosporine
Past surgical history: bilateral hernia repair, right knee
arthroscopy, bilateral cataract surgery
Discharge Condition:
good
Discharge Instructions:
no driving for one month
no lifting greater than 10 pounds for 10 weeks
no lotions, creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage, weight
gain of 2 pounds in 2 days or 5 pounds in 1 week
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 2912**] in [**12-20**] weeks
Dr. [**First Name (STitle) **] in [**11-18**] weeks
Completed by:[**2108-2-25**]
|
[
"782.1",
"272.4",
"600.00",
"401.9",
"311",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4643, 4706
|
2303, 3241
|
367, 563
|
4976, 4982
|
1714, 2280
|
5293, 5471
|
1292, 1310
|
3473, 4620
|
4727, 4855
|
3267, 3450
|
5006, 5270
|
4878, 4955
|
1325, 1695
|
274, 329
|
591, 892
|
914, 1042
|
1158, 1276
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,521
| 174,496
|
48665
|
Discharge summary
|
report
|
Admission Date: [**2181-3-8**] Discharge Date: [**2181-3-13**]
Date of Birth: [**2118-2-26**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Demerol
Attending:[**First Name3 (LF) 18051**]
Chief Complaint:
post menopausal bleed
Major Surgical or Invasive Procedure:
supracervical hysterectomy, lysis of adhesions, pelvic washings
History of Present Illness:
63 G1P1 presenting with post menopausal bleed. Unable to obtain
endometrial biopsies due to cervical stenosis. Pt did not
tolerate TVUS. MRI showed thickened endometrium to 1cm. Denies
F/C/N/V. No dysuria/change in bowel habits. No other sxs
referrable to pelvis.
Past Medical History:
PMH: 1. Colon cancer: [**Location (un) **] B2 in [**2172**] status post resection
followed
by chemotherapy and radiation. She had a subsequent adenoma of
the right colon that was resected in [**2175**].
2. Two slipped discs in her neck.
3. Anal fissure.
4. Hypertension.
5. Type 1 diabetes x 52 years complicated by retinopathy and
neuropathy. microalbuminuria last creat 1.2
6. Pneumovax within the past 2 years.
7. Flu vaccine yearly.
8. h/o lung nodules.
9. EF 70% mild LVH, tr MT, tr TR, mild AI
10. h/o sz d/o
11. glaucoma
PSH: C/S, colectomy x2,
OB: C/S x1
Gyn: no abnl pap, no sti
Social History:
divorced, lives alone.
previously worked as a clinical laboratory scientist and was
exposed to benzine and "other chemicals", however denies any
occupational or known inhalation exposure. She smoked up to 2
packs a day for 15 years and quit in [**2154**]. She drinks only [**2-1**]
glasses of wine a week.
Family History:
Her father died at 63 from a cerebrovascular accident, her
mother is 96 alive and well. She has 2 sisters and 1 brother
who
are alive and well.
Physical Exam:
Initial exam notable for
nl vulva, atrophic vagina,
cervix not well visualized
limited but normal bimanual and rectovaginal exam
Pertinent Results:
[**2181-3-8**] 12:02PM BLOOD Hct-26.6*
[**2181-3-10**] 08:00AM BLOOD WBC-5.9 RBC-3.52* Hgb-11.5* Hct-32.9*
MCV-94 MCH-32.7* MCHC-35.0 RDW-13.4 Plt Ct-116*
[**2181-3-12**] 05:25AM BLOOD WBC-3.4* RBC-3.43* Hgb-11.0* Hct-31.6*
MCV-92 MCH-32.2* MCHC-34.8 RDW-13.5 Plt Ct-106*
[**2181-3-9**] 04:05AM BLOOD PT-12.4 PTT-21.1* INR(PT)-1.0
[**2181-3-8**] 12:02PM BLOOD Glucose-233* UreaN-21* Creat-1.6* Na-141
K-4.0 Cl-107 HCO3-24 AnGap-14
[**2181-3-10**] 08:00AM BLOOD Glucose-174* UreaN-26* Creat-2.6* Na-141
K-4.4 Cl-109* HCO3-19* AnGap-17
[**2181-3-10**] 08:00AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.9
[**2181-3-12**] 05:25AM BLOOD Glucose-113* UreaN-28* Creat-2.1* Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
[**2181-3-12**] 05:25AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.6
[**2181-3-13**] 05:40AM BLOOD UreaN-30* Creat-1.6*
Brief Hospital Course:
The patient was admitted to the ICU following her surgery on
[**2181-3-8**] for management of oliguric acute renal failure and blood
sugar control. She was transferred to gyn oncology on [**3-9**].
Her surgery was difficult due to the effects of prior radiation
therapy. See report for details.
Her post operative course is as follows
1) Acute renal failure/oliguria: the patient had minimal output
for several hours following the case. Her catheter was
functional and hematocrit was appropriate for intraoperative
losses. She was given fluid challenge as well as 2 units of
pRBC with no improvement in uop. Her creatine increased to 2.4
from preop of 1.0. Urology was consulted to eval for post renal
causes - A renal US showed no hydronephrosis, she had no CVA
tenderness, and a CT of her pelvis showed no evidence of
ureteral or bladder injury. Nephrology was also consulted to
evaluate for intrinsic renal dysfunction. Her urine sediment
was non-specific. Her oliguric renal failure was thought to be
secondary to intraoperative hemodynamic change in the setting of
existing diabetic nephropathy. It was recommended than an MRA
be obtained to assess for renal artery stenosis. The patient
was unable to get this scan due to clostrophobia and anxiety.
She will arrange for outpatient open MRA with her PCP. [**Name10 (NameIs) **]
urine output gradually improved and she had brisk diuresis on
post op day 2. Her creatinine was followed closely and is 1.6 at
time of this discharge summary.
2) Acute blood loss anemia: her HCT fell from a preop of 30 to
26.6 post op. Due to her age and medical history and oliguria
she was transfused 2 units of PRBC with appropriate rise in HCT.
Her HCT remained stable for the remainder of her
hospitalization.
3) Type 1 Diabetes: Her blood sugars were followed closely in
the perioperative period. She was continued on a regular
insulin sliding scale and NPH. These were adjusted as her diet
increased. She continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet and her blood sugars
remained in control.
4) Hypertension: Her blood pressures were moderately controlled
in the immediate post op period. Her ACE inhibitor was held in
the setting of acute renal failure. She was continued on
metoprolol which was increased to 100mg [**Hospital1 **]. Hydralazine was
added for improved control in place of enalapril. She was
restarted on her Enalapril on day of discharge
5) Dispo: she was followed by PT who felt she was stable for
discharge without services. Her PCP [**First Name4 (NamePattern1) 11894**] [**Last Name (NamePattern1) 12923**] was
contact[**Name (NI) **] and will see the patient in follow up for continued
management of her diabetes, hypertion, and renal function.
Medications on Admission:
Keppra 500 mg po bid
NPH 22 u q am
HISS
enalapril 20 mg po bid
metoprolol 50 mg po bid
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
Disp:*90 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
5. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Continue insulin, Kepra as usual
Discharge Disposition:
Home
Discharge Diagnosis:
uterine cancer
acute renal failure with oliguria
acute blood loss anemia
hypertension
diabetes
Discharge Condition:
good. stable
Discharge Instructions:
no heavy lifting, nothing in vagina, no exercise 6 weeks
no driving 2 weeks
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/GYN NON-PPS CC8 Where: [**Hospital 4054**] OBSTETRICS & GYNECOLOGY Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2181-4-9**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 96976**] Date/Time:[**2181-5-2**] 10:00
Dr. [**First Name4 (NamePattern1) 11894**] [**Last Name (NamePattern1) 102346**], [**Hospital1 2177**] - [**Telephone/Fax (1) 102347**] Call to schedule
appointment for this week to check blood pressure and kidney
function
Obtain MRA of renal arteries
|
[
"401.9",
"182.0",
"250.51",
"682.2",
"780.39",
"627.1",
"285.1",
"614.6",
"250.61",
"998.59",
"V10.05",
"276.5",
"362.01",
"E879.2",
"357.2",
"788.5",
"584.9",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.23",
"54.59",
"68.39"
] |
icd9pcs
|
[
[
[]
]
] |
6316, 6322
|
2775, 5542
|
303, 368
|
6461, 6475
|
1944, 2752
|
6599, 7319
|
1633, 1779
|
5679, 6293
|
6343, 6440
|
5568, 5656
|
6499, 6576
|
1794, 1925
|
242, 265
|
396, 666
|
688, 1292
|
1308, 1617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,086
| 168,211
|
16405+56760
|
Discharge summary
|
report+addendum
|
Admission Date: [**2199-1-27**] Discharge Date:
Service: MICU
This is a dictation summary from admission until [**2199-2-10**]. The rest will be completed by next intern.
CHIEF COMPLAINT: Respiratory distress.
admitted with decreased responsiveness and respiratory
distress. Patient's past history of present illness is not
well known except that the patient has been noted to have
increasing dyspnea over the past month or two, most notable
with exertion. An exact number cannot be known. The patient
gets short of breath after a block or so. The family of the
patient also said that the patient had been coughing for a
unresponsiveness and very short of breath. She was not noted
to have any fevers, chills, nausea, vomiting, abdominal pain,
diarrhea or constipation, rhinorrhea or sore throat prior to
admission.
EMS was called and the patient was brought to the Emergency
Department. In the Emergency Department, she had a chest
x-ray which demonstrated right middle lobe pneumonia.
Arterial blood gas revealed 7.11/93/300. Patient was placed
on BiPAP with minimal improvement in her gas. Patient was
then intubated. A thick sputum was also suctioned from her.
She also received Solu-Medrol and nebulizers in the Emergency
Department for a question of a chronic obstructive pulmonary
disease flare.
Patient's blood pressure was systolic 120s to 140s and
briefly dropped to 50/20. Patient was started on dopamine,
however, increased to 190s. Dopamine was changed to Neo with
improvement of the patient's rate and pressure. She received
Ceftriaxone and Flagyl and 1400 cc of intravenous fluid and
sent to the Medical Intensive Care Unit for further
evaluation.
PAST MEDICAL HISTORY:
1. Diabetes. No further information available.
2. Hypertension.
3. Arthritis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Hydrochlorothiazide 25 mg po q.d.
2. Lisinopril 40 mg po q.d.
3. Tolazamide 250 mg po q.d.
4. Naprosyn 500 mg po b.i.d.
SOCIAL HISTORY: The patient drinks approximately one drink
per day, usually to help her sleep. She denies any history
of tobacco or drug use per the family. The patient lives
with her daughter and her family is very involved in her
care, especially her granddaughter, [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 46664**]. Patient's primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 46665**].
PHYSICAL EXAMINATION: Temperature 101.8, 104. Blood
pressure 120/40. General: The patient is vented, sedated in
no acute distress. Head, eyes, ears, nose and throat:
Pinpoint pupils, but received morphine in the Emergency
Department. Normocephalic, atraumatic. No icterus. Small
hemorrhage in left conjunctivae. Neck supple. Heart:
Regular rate and rhythm, no murmurs, rubs or gallops. Lungs:
Coarse rhonchi bilaterally. Inspiratory and expiratory
wheeze with increased expiratory time. Abdomen: Soft,
nontender, nondistended with positive bowel sounds.
Extremities: Cool, no edema.
LABORATORIES: White blood cell count 22, hematocrit 47,
creatinine of 2.1. Toxicology screen negative.
Electrocardiogram: Sinus tachycardia at 132 with normal
axis, normal intervals, Qs in III and aVF. Chest x-ray with
right middle lobe pneumonia.
HOSPITAL COURSE:
1. Pulmonary: The patient was admitted with possible
aspiration pneumonia given the questionable history of
alcohol use, although, upon further questioning, his history
of alcohol was less substantial. Patient was started on
levofloxacin, Flagyl and vancomycin. She was also started on
Combivent nebulizers and Solu-Medrol for question of chronic
obstructive pulmonary disease exacerbation given the
patient's wheezing on physical examination. Patient remained
afebrile after a couple of days and the vancomycin was
discontinued. As there appeared to be no indication of
flora, the patient was be treated for 14 days with
levofloxacin and Flagyl for a probable aspiration pneumonia.
Because the patient was noted to be noted to have severe
wheezing and also had an effusion on chest x-ray, CT was
performed of the chest which showed no change in her
pneumonia. It did note small bilateral pleural effusions.
Patient was attempted several times to be weaned to pressure
support from AC ventilation, however, she did tolerate this
and she became very agitated and desynchronous with the
ventilator.
On hospital day six, the patient had a bronchoscopy to
further examine her wheezing as she had no history of chronic
obstructive pulmonary disease, smoking, and no clear reason
for her wheezing. Bronchoscopy demonstrated very severe
tracheomalacia with 80-90% distal tracheal collapse, also severe
malacia of her RMST/RBI with complete obstruction of the bassilar
segments of the right lower lobe, moderate collapse of her left
main stem bronchus. At this point, the patient's
steroids were discontinued and in house, the following day,
the patient was brought to the OR by Interventional Pulmonary for
stenting of her distal trachea and left mainstem were
performed. Patient's wheezing did not improve and she
remained difficult to wean. The plan was then to remove the
stents and to perform a tracheostomy, to wean her off her AC and
ventilatory support.
On hospital day ten, the patient's temperature spiked and
grew gram positive cocci in her sputum. The vancomycin was
restarted and awaiting final respiratory cultures.
2. Cardiovascular: The patient was initially brought to the
floor on Neo after her failure with dopamine. Patient's
blood pressure remained somewhat tenuous and the patient's
Neo was changed to a vasopressin with good improvement. She
remained on this for approximately two hospital day and then
was able to wean off her pressures altogether. She underwent
cardiac echocardiogram which demonstrated normal ejection
fraction, moderate to severe mitral regurgitation. Patient
remained off her blood pressure medications with minor
fluctuations in her blood pressure.
Patient became increasingly total volume overloaded during
her admission, up to 20 liters positive. However, her
intervascular space remained volume depleted. She was then
tried to be diuresed with Lasix, although, this tended to dry
her out. On hospital day 12, the patient received 20 of
Lasix intravenously and dropped her pressures to the 70s.
She was restarted on vasopressin which provided only some
improvement in her blood pressure.
On hospital day 14, the patient was started on dopamine with
the hope of improving her profusion to her kidneys in hope of
auto-diuresis.
3. Renal: Patient was admitted with acute renal failure
with a creatinine of 2.0. She was noted to have normal renal
function prior to admission. Patient was treated with
intravenous fluids in the Emergency Department. This slowly
resolved over several days until she came to a creatinine of
0.8 which was felt to be her baseline.
4. Infectious Disease: Patient was started on antibiotics
for her pneumonia as listed in the pulmonary section. On
hospital day 14, the patient remained to have low grade
temperature spikes. Patient will have CT of the sinuses to
rule out sinusitis. She will be changed from Levaquin to
vancomycin and ceftazidime for a presumed sinusitis until the
CT scan results have returned.
5. Nutrition: Patient was started on tube feeds upon
admission. Promote with fiber. Patient tolerated these well
through her nasogastric or OT tube. Due to patient's
inability to wean off the ventilator, the option of
percutaneous endoscopic gastrostomy was discussed with the
patient's family. The agreed that percutaneous endoscopic
gastrostomy was wanted should the patient still have some
chance of recovery. Gastrointestinal came to evaluate the
percutaneous endoscopic gastrostomy and once the patient is
off pressors, they will perform this procedure.
6. Fluid and electrolytes: The patient became increasingly
volume overloaded during the length of her stay up to 20
liters positive. The reasoning for her inability to secrete
this fluid is not clear. Should have normal renal function.
Patient does have a low abdomen which is likely contributing
to this problem. >.....<pressors with diuresis may be
wanted.
7. Prophylaxis: The patient will remain on H2 blocker due
to lack of intravenous PPI availability. Pneumoboots and
heparin subcutaneously.
8. Code status: Patient is full code. Should the patient's
prognosis worsen, this should be readjusted with the family.
9. Endocrine: Patient was maintained on an insulin drip,
taken off her oral hypoglycemic. Increase fingersticks as
well once the patient is off pressors and is doing better,
she will be returned to insulin or oral hypoglycemics.
DICTATION WILL BE CONTINUED BY INTERN TAKING OVER THIS
SERVICE.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**First Name3 (LF) 46666**]
MEDQUIST36
D: [**2199-2-10**] 01:23
T: [**2199-2-10**] 13:30
JOB#: [**Job Number 46667**]
Name: [**Known lastname **], [**Known firstname **] [**Known firstname 8588**] Unit No: [**Numeric Identifier 8589**]
Admission Date: [**2199-1-27**] Discharge Date: [**2199-2-14**]
Date of Birth: [**2114-11-5**] Sex: F
Service:
ADDENDUM: Covering time since dictation of [**2199-2-10**].
HOSPITAL COURSE: 1. Pulmonary - The patient was continued
on Vancomycin for the presumed gram positive cocci pneumonia.
She continued to necessitate mechanical ventilation up until
the time of this dictation. She has remained on assist
control for most of this time, with unsuccessful episodes on
pressor support. At the present time the plan is to continue
attempts to wean her onto pressor support. The patient
underwent a tracheostomy towards the end of her hospital
stay, a procedure which she tolerated without any
complications. Despite this, however, the patient still
could not be weaned off assist control at the time of this
dictation. The patient also underwent removal of her
tracheal stent at the same time she was given the
tracheostomy; this also occurred without any complication.
The current plan is to discharge the patient to a
rehabilitation facility on intravenous antibiotics which she
will get through a PICC line. The ultimate goal is for the
patient's respiratory status to be significantly improved and
for laboratory or radiographic evidence in the form of
cultures or chest x-rays to correlate with this improvement
prior to being taken off of her antibiotics.
2. Cardiovascular - The patient remained on Telemetry
throughout her hospital stay. She was successively weaned
off of the vasopressor and dopamine which she had been placed
on during her hospital stay. On [**2-14**], the patient once
again began having increased blood pressure, most likely
secondary to volume depletion. Her blood pressures responded
well to a fluid bolus of 500 cc. At the time of this
dictation the plan is for the patient to be discharged to a
rehabilitation facility without any cardiac medications.
3. Renal - The patient had no further increases in her
creatinine. She did, however, have periods of decreased
urine output which were resolved by fluid boluses. She also
responded well to being on pressors aimed at increasing her
urine output, and these were discontinued shortly after being
started once a good output was reached.
4. Infectious disease - The patient was continued on
antibiotics for her pneumonia. The patient underwent a
computerized tomography scan of the sinuses to rule out
sinusitis, and this computerized tomography scan revealed
marked left maxillary sinusitis for which she was started on
Ceftazidime, which she received in addition to her
Vancomycin. The plan is for the patient to continue on these
medications for at least a period of 10 to 14 days.
5. Nutrition - The patient had her nasogastric tube
discontinued as it was found to be coiled in her hypopharynx
on x-ray. The patient underwent placement of a percutaneous
endoscopic gastrostomy at the same time that she underwent
her tracheostomy installation. The patient tolerated
placement of the percutaneous endoscopic gastrostomy without
any problems. She also tolerated tube feeds without any
problems. The plan is to discharge the patient to the
rehabilitation facility with the percutaneous endoscopic
gastrostomy in place so she may continue to receive enteral
nutrition.
6. Fluids and electrolytes - The patient's urine output as
noted earlier was low at times during the end of her hospital
stay, and this responded well to fluid boluses. During her
hospital stay her electrolytes were repleted by intravenous.
The patient's net fluid balance is still approximately
positive 17 liters. However, she seems to be intravascularly
depleted. The plan is for the patient to continue to receive
tube feeds and for electrolytes to be checked occasionally.
7. Prophylaxis - The patient will be continued on an H2
blocker through her feeding tube. She will also be continued
on pneuma boots and heparin subcutaneously.
8. Endocrine - The patient was changed to a sliding scale
insulin regimen, which covered her adequately during her
hospital stay. The plan is for the patient to go to
rehabilitation on a regular insulin sliding scale.
CODE STATUS: The patient continues to be full code.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To a rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Tracheobronchomalacia, status post stenting with
subsequent stent removal and tracheostomy placement.
2. Status post hypercarbic respiratory failure.
3. Status post intubation, complicated by failure to wean.
4. Right middle lobe pneumonia.
5. Left maxillary sinusitis.
6. History of hypertension.
7. History of diabetes.
8. Status post acute renal failure episode, resolved.
DISCHARGE MEDICATIONS:
1. Bisacodyl 10 mg p.o. p.r. q.d. prn
2. Senna one tablet p.o. b.i.d. prn
3. Docusate sodium liquid 100 mg p.o. b.i.d.
4. Lansoprazole 30 mg nasogastric q.d. through percutaneous
endoscopic gastrostomy
5. Miconazole powder, 2% one application topically t.i.d.
prn
6. Regular insulin sliding scale
7. Albuterol 1 to 2 puffs inhaled q. 4 hours prn
bronchospasm
8. Albuterol nebulizers
9. Lorazepam 2 to 6 mg intravenously q. 2 hours prn
10. Desitin one application topically q.i.d. prn
11. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn pain or fever
12. Nystatin oral suspension 5 ml p.o. q.i.d. prn
13. Heparin 5000 units subcutaneous q. 8 hours
14. Ceftazidime 1 gm intravenously q. 12 hours, currently day
#5 of 10 to 14 days.
15. Vancomycin 1000 mg intravenously q. 24 hours, day #8 of
10 to 14 days. The too should be ended at the same time,
preferably on the last date of the Ceftazidime.
FOLLOW UP PLAN: The patient should be discharged to a
rehabilitation facility where she will receive medical care.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Last Name (NamePattern1) 2144**]
MEDQUIST36
D: [**2199-2-14**] 17:40
T: [**2199-2-14**] 18:32
JOB#: [**Job Number 8590**]
|
[
"584.9",
"276.6",
"518.84",
"250.00",
"707.0",
"519.1",
"507.0",
"458.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"93.90",
"31.99",
"96.6",
"33.22",
"96.72",
"38.91",
"33.23",
"38.93",
"96.04",
"96.05",
"31.1",
"33.91"
] |
icd9pcs
|
[
[
[]
]
] |
13956, 15218
|
13545, 13933
|
9433, 13442
|
2466, 3295
|
201, 1692
|
1714, 1976
|
1993, 2443
|
13467, 13524
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,532
| 123,114
|
45348
|
Discharge summary
|
report
|
Admission Date: [**2143-5-1**] Discharge Date: [**2143-5-3**]
Date of Birth: [**2073-3-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
BRBPR X2
Major Surgical or Invasive Procedure:
Colonoscopy with clipping at polypectomy site
History of Present Illness:
70 yom with HTn, DM and polypectomy 1 day PTA. Went home and
was ok for ~24 hours but had 2 episodes of BRBPR after that.
Initial Vitals 98.3 HR 101, BP 158/88 O298%RA. Patient deinied
any complaints at the time. No chest pain, sob,
lightheadedness. Initialy Hct 32 in the ER. Patient had 2 IVs
placed and GI was called. He had one [**Last Name (un) 30212**] BM in the ER and
dropped SBP to 79 briefly. Repeat hct was 27.9 and she was
given 2 units PRBC.
.
At time of transfer to the MICU, he denies any chest pain,
shortness of breath. denies lightheadedness, nausea, vomiting.
Denies recent fevers or chills.
Past Medical History:
HTN
DM
Hyperchol
Social History:
denies etoh, tobacco.
Family History:
Mother with [**Name2 (NI) 499**] ca in 70s lived until age [**Age over 90 **].
Physical Exam:
well appearing elderly male in nad
mmm, perrl
chest ctab
cvr - regular no r/m/g
abd - soft, nt
ext- no edema
Pertinent Results:
admission data
[**2143-5-1**] 12:50a
139 | 106 | 27 AGap= 08
--------------<295
3.9 | 25 | 1.4
estGFR: 50/61 (click for details)
PT: 12.6 PTT: 28.5 INR: 1.1
MCV 87
12.8 >---< 284
......32.8 D
..N:84.8 Band:0 L:12.7 M:2.0 E:0.3 Bas:0.3
Anisocy: OCCASIONAL Poiklo: OCCASIONAL
Plt-Est: Normal
.
.
ECG: NSR @85, nl axis, nl intervals. non specific st -t
changes and no prior for comparision.
.
[**2143-4-29**] -
A 3 cm flat polyp was noted in the cecum.
A second 1 cm flat polyp was also noted in the cecum.
A small sessile polyp 7mm size was seen adjacent to the large
polyp.
Successful submucosal injection with saline / methylene blue at
two flat polyps in the cecum.
Successful endomucosal resection was performed on two flat
polyps after submucosal injection.
Both the polyps were totally removed using a hot snare in the
cecum.
A single-piece polypectomy was performed using a cold snare in
the cecum.
The polyp was completely removed.
.
.
.
[**2143-5-1**]
Bright red blood encountered in the [**Month/Day/Year 499**]. The cecum was
reached.
The previous polypectomy sites were identified. Active arterial
bleeding was noted from the polypectomy site at the cecal pole.
Successful hemostasis was achieved by application of three
hemoclips. For safety reasons a resolution hemoclip was also
applied to the second polypectomy site
Brief Hospital Course:
70 yom with BRBPR after polypectomy 1 day ago.
.
# BRBPR - most likely LGIB from polypectomy site. Ddx includes
AVM vs very likely to be UGIB (no history of recent nsaid use).
Hct was monitored serially and received PRBC prn to maintain hct
>30. He underwent repeat endoscopic procedure with GI following
AM and was noted to have active arterial bleeding near
polypectomy site at the cecal pole. Successful hemostasis was
achieved by application of three hemoclips. Received one more
unit PRBC after the procedure and hct remained stable. He was
transferred to the medical floor for further monitoring and
discharged home once hct was stable.
.
# HTN - antihypertensives held initially given gib.
.
# [**Doctor First Name 48**]- no baseline creatinine, on admission. Maybe prerenal
from GIB. Meds were dosed renally and creat improved to 1.2
prior to d/c.
# DM - glucophage was held and covered with ISS in house.
# Hyperchol - cont statin.
Medications on Admission:
ASA 325 po daily (stopped 7 days ago)
Benacar
Glucophage 500 mg [**Hospital1 **]
Hydrochlorothiazide
Norvasc 10mg daily
Zocor 10 mg daily
Multivitamin
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): Resume usual home regimen.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
1. GI bleeding
2. Acute blood loss anemia
3. Polyp
4. Hypertension
5. Diabetes Mellitus
Discharge Condition:
Crit stable x 48 hours, no evidence of further bleeding.
Discharge Instructions:
Follow up as below.
Contact your doctor or go to the emergency room if you develop
further blood in your stool, develop abdominal pain, fevers or
any other new concerning symptoms.
As discussed, do not take aspirin, or other medications that can
cause bleeding such as NSAIDS (for example motrin, ibuprofen,
alleve). Before starting any new medication, check with a
doctor.
Otherwise, you can resume your usual medications. As discussed,
start the benicar tomorrow and then norvasc on Sunday.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) 1313**] within a week or two. Have your
blood count checked at that time.
You can also contact Dr. [**Last Name (STitle) **] if you have any recurrent
bleeding, abdominal pain or any other new concerning symptoms.
Completed by:[**2143-5-4**]
|
[
"285.1",
"593.9",
"272.0",
"998.11",
"276.52",
"250.00",
"E878.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4054, 4060
|
2701, 3650
|
322, 369
|
4191, 4249
|
1337, 2678
|
4795, 5082
|
1113, 1193
|
3851, 4031
|
4081, 4170
|
3676, 3828
|
4273, 4772
|
1208, 1318
|
274, 284
|
397, 1018
|
1040, 1058
|
1074, 1097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,843
| 177,125
|
41595
|
Discharge summary
|
report
|
Admission Date: [**2179-1-1**] Discharge Date: [**2179-1-12**]
Date of Birth: [**2114-5-15**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
unresponsive episode
Major Surgical or Invasive Procedure:
Bronchial Lavage
FNA of lung nodule
TEE
History of Present Illness:
[**Known firstname **] [**Known lastname 90431**] is a 64-year-old man with past medical
history notable for atrial fibrillation, prior occipital stroke,
and diabetes who presents after being found down outside of his
car. The patient himself has poor recollection of the events
surrounding his admission. He does remember driving He pulled
his car over and got out of his car, he was then found down
approximately 300 feet from his car down the road. He was noted
to be face down, confused and with a right frontal hematoma.
He does note problems with his memory over the last few weeks.
He sites
being unable to remember appointments and dates. His girlfriend
who was interviewed prior also noticed that the patient was
having difficulty with memory.
Past Medical History:
Atrial fibrillation
R occipital stroke
DM
Social History:
Patient smokes 2 cigars a week, 1 to 2 glasses of wine on
occasion. Retired computer programmer
Family History:
Maternal side: alzheimers disease
Physical Exam:
Admission Physical Examination:
Gen:patient sitting in bed, bandage above right eye, awake,
alert
HEENT: R sided hematoma over right eye,MMM,no nuchal rigidity
CV:NL S1/S2, RRR
Lungs:CTA B/L, no crackles,
Abd:soft , non tender, normal bowel sounds.
Ext:FROM, + 2 pulses through out
Skin:dark skin tag noted on upper left chest.
Neuro:
MS: oriented to name, [**1-1**] or 5th, [**2179**], [**Hospital 90432**]
Hospital, Unsure of which one, DOW backward completed in 25 s,
[**Doctor Last Name 1841**] Backwards([**Month (only) **],[**Month (only) 1096**]),
3 objects:(ball, [**Location (un) **], honesty), able to repeat the words,
remembers [**11-30**] with multiple choice at 3 minutes, 0/3 at five
minutes. Calculation intact. Repetition intact.
Names fingers, thumb, thumb nail, for feather says [**Location (un) **],
no paraphrasic errors, speech is fluent with normal prosody. He
has trouble with Luria motor sequencing bilaterally
CN:left upper temporal field cut on gross visual field
testing,EOMI,PERRLA(4mm to 2mm bilaterally), no facial
assymetry,
no ptosis, hearing intact, palate elevates symmetrically, tongue
is midline with FROM,
Motor:
No pronator Drift, no asterixis, No grasp.
Delt [**Hospital1 **] Tri FE WE WF IP Quad HS TA GC
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensory: decreased proprioception and vibration of toes
bilaterally,
Cb:No dysmetria or ataxia on finger to nose.
Gait: Unstaedy at times. Not ataxic or wide based.Negative
Romberg.
DTR: +2 at the biseps, triceps, brachioradialis, patella, +1 at
ankles, toes appear to be up going by TFL.
Pertinent Results:
[**2179-1-1**] 09:25PM WBC-5.7 RBC-4.53* HGB-14.3 HCT-40.2 MCV-89
MCH-31.6 MCHC-35.6* RDW-13.1
[**2179-1-1**] 09:25PM PLT COUNT-284
[**2179-1-1**] 09:25PM PT-24.6* PTT-23.6 INR(PT)-2.4*
[**2179-1-1**] 09:25PM FIBRINOGE-481*
[**2179-1-1**] 09:36PM GLUCOSE-336* LACTATE-2.8* NA+-137 K+-4.3
CL--96* TCO2-25
[**2179-1-1**] 09:25PM CALCIUM-9.9 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2179-1-1**] 09:25PM UREA N-15 CREAT-1.2
[**2179-1-1**] 09:25PM cTropnT-<0.01
[**2179-1-1**] 09:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Studies:
CT head ([**2179-1-1**]): Hypodensity in the right basal ganglia and
right frontal lobe of unclear etiology and could represent
subacute/acute infarction or possible underlying mass
CT torso: No acute traumatic findings, Multiple pulmonary
nodules measuring up to 1.2 cm (superior segment RLL), Remote
splenic infarct
CT C-spine: No acute fracture or malalignment
CTA: Unchanged edema within the right frontal white matter with
MR suspicious for resolving underlying hematoma. There is no
evidence of aneurysm, AVM, or other vascular cause; Probable 7mm
pseudoaneurysm arising from the distal right superficial
temporal artery with adjacent subcutaneous soft tissue injury;
Chronic right occipital infarct.
MR head ([**2179-1-2**]): Right basal ganglia signal abnormality with
blood products and irregular enhancement could be due to a
subacute infarct with enhancement or less likely due to an
enhancing primary neoplasm. Given the appearances are more
suggestive of a subacute infarct, a followup study should be
obtained; Moderate ventriculomegaly out of proportion for sulci
indicates normal pressure hydrocephalus in proper clinical
setting; Right frontal scalp hematoma with a small 1-cm area of
gadolinium enhancement could be due to active extravasation at
the time of imaging.
EEG: normal EEG in the waking and sleeping states. Note is made
of a poorly organized background rhythm which is a normal
variant. There were no epileptiform discharges or electrographic
seizures.
MR head (with ASL and MR Spec): process in the right basal
ganglia most likely represents a slightly atypical appearance of
evolving non- and hemorrhagic contusion related to the patient's
trauma (with overlying subgaleal hematoma); Subacute infarct
with subsequent hemorrhagic conversion (serendipitously
subjacent to the site of scalp trauma) seems less likely; No
increased perfusion or spectroscopic abnormality to specifically
suggest underlying neoplasm.
Bronchial Lavage: Negative for malignant cells
FNA (lung nodule): atypical
TTE: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. There are focal calcifications in the aortic
arch. The number of aortic valve leaflets cannot be determined.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
TEE: Small mobile echodensity on the aortic valve as described
above c/w Lambl's or vegetation. Mild aortic regurgitation.
Interatrial septal aneurysm with possible patent foramen ovale
Brief Hospital Course:
Mr. [**Known lastname 90431**] is a 64 year old with recurrent AFib (converted)
on coumadin and
diabetes found 300 feet from his car (driving alone), on
theground confused, with right frontal subgaleal hematoma
Basal Ganglia Lesion: Initial MR imaging showed right basal
ganglia signal abnormality with blood products. It was unclear
if this was due to atypical hematoma, underlying mass that bled,
underlying AVM that bled or stroke with hemorrhagic conversion.
A CTA was obtained to see if any vascular abnormalities could be
identified; no evidence of aneurysm, AVM, or other vascular
cause was identified. Given the possibility of an underlying
mass, CT torso was evaluated and a derm consult was obtained to
look for any possible primary tumors. No evidence of skin lesion
concerning for melanoma as per Derm, but there was pulmonary
nodules (largest of which is 1.2 cm) identified. At the request
of Neuro-oncology, MRI was repeated with ASL and Spectroscopy.
Based on these sequences, there was low suspicion of underlying
neoplasm and the final report noted that the process in the
right basal ganglia most likely represents a slightly atypical
appearance of evolving non- and hemorrhagic contusion. While
this is possible, it would not explain why he became
unresponsive, resulting in the trauma. Images reviewed with
stroke attending and there was concern that there might have
been an underlying AVM or cavernoma that resulted in the bleed,
which was subacute, and which resulted in a seizure. A subacute
bleed would also explain the findings noted by his girlfried
that he had been having increased confusion and falls in the 2
[**Last Name (un) 90433**] prior to admission. A routine EEG was obtained; this was
normal. However, given the concern for seizure activity
resulting in his unresponsive episode, he was started on Keppra;
his current dose is 1000 mg [**Hospital1 **]. The plan is for him to have a
repeat MRI 6 weeks from the initial MRI and than follow-up with
Dr. [**First Name (STitle) **]. If there is any evidence of unerlying mass on the
repeat MRI, he will follow-up with Dr. [**Last Name (STitle) 724**] in the
[**Hospital **] clinic.
Lambl's Excursions: Given his history of stroke and the
possibility that his right basal ganglia lesion was due to
hemorrhagic conversion of a stroke, an ECHO was performed to
evaluate for clot. The TTE showed an elongated left atrium but
was otherwise normal. A TEE was then performed, which showed
small mobile echodensity on the aortic valve as described above
c/w Lambl's or vegetation. No evidence of any infection and
blood cultures have been taken and have remained sterile, so
unlikely vegetation. A Lambl's excursion can produce clots,
resulting in strokes. Of note, he was also on Coumadin in the
past for a.fib, but this was held on admission due to his bleed.
Currently, it is beleived that the risk of restarting Coumadin
given the basal ganglia hemorrhagic contusion/hemorrhage
outweighs the benefit of starting it for stroke prevention.
However, given his history of a. fib, right basal gnaglia
stroke, and now the finding of the echodensity on aortic valve,
he will likely need to be restarted on Coumadin in future,
particularly after repeat MRI if blood products resolved and no
evidence of underlying mass. At this time, he was started on ASA
325 mg for stroke prevention and will be continued on this until
it is safe to restart him on Coumadin.
Pulm Nodule: On CT torso, pulmonary nodules were found, largest
one being 1.2 cm. He had a bronchial lavage and FNA of the
nodule. The bronchial lavage was negative for malignant cells.
The FNA was atypical but nondiagnostic. He will follow-up with
Dr. [**Last Name (STitle) **] and have a PET scan for evaluation of this nodule in 4
weeks.
Diabetes: He has history of diabetes and was on Humalog and
Lantus at home. During hospitalization, he remained on sliding
scale insulin. His FSGs on day of discharge were in upper 100s
and low 200s. He was NPO multiple days for studies/procedures so
Lantus and Humalog were not restarted, but when he returns to
his usual regimen in rehab/as outpatient, restarting his home
diabetic regimen should be considered.
UTI: He was found to have UTI and was started on a 10 day course
of Bactrim. He will complete this course at rehab.
Medications on Admission:
Humalog 20 Units
Lantus 40 Units
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
4. Insulin
Please follow sliding scale insulin as provided.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
R basal ganglia bleed -ruptured AVM vs. hematoma vs. hemorrhagic
conversion of stroke vs. underlying mass
Likely seizure
pulmonary nodule
Lambl's Excrecence
DM
old R occipital stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital after being found unresponsive by
your car. You were initially admitted to the trauma ICU, but
there was no evidence of any traumatic injuries found on
imaging, so you were transferred to the neurology service. MRI
of your head showed blood in the part of your brain called the
basal ganglia; it is unclear if this blood is from a traumatic
injury, from an underlying stroke or mass or from a rupted
arterial malformation. You underwent further brain imaging to
help clarify, and while definitive results are limited by the
blood that is present, it does not appear that there is an
underlying mass.
During the work-up for the brain imaging abnormality, you had
a CT scan of your torso, which showed some pulmonary nodules.
You underwent a procedure called bronchial lavage and fine
needle aspiration of the nodule to see if the nodule was
malignant. The FNA results were inconclusive, so the pulmonary
service would like to see in 4 weeks with a PET scan to
follow-up on this.
Given the bleeding found in your head, it is likely that you
had a seizure and this resulted in your unresponsive episode;
you were started on an antiseizure medication called Keppra.
Given your history of stroke and the possibility that this was
a stroke with hemorrhagic conversion, you had imaging of your
heart to see if there were any clots. The TTE showed enlargement
of the left atrium, so a more invasive procedure called
transesophageal echo was performed. This showed likely Lambel's
Excrecence on your aortic valve; this has a low likelihood of
sending clots, resulting in strokes. Given your bleed, we
believe the risks of anticoagulation with Coumadin outweigh the
benefits at this time, so we have started you on Aspirin 325 mg.
After your repeat MRI, we may consider starting Coumadin again
for stroke prevention.
With your likely seizure, as per Massachussets law, you are
not allowed to drive for 6 months.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **] (pulmonary), MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2179-2-23**] 8:30
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2179-2-23**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**] (neurology), MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2179-3-1**] 2:30
You will be contact[**Name (NI) **] regarding PET scan, which pulmonary is
requesting prior to follow-up with them.
An MRI has been ordered for you for [**2179-2-15**] (please do not get
earlier than this date as it needs to be 6 weeks from initial
MRI to make sure blood products have cleared). It is important
to get this MRI completed prior to seeing Dr. [**First Name (STitle) **].
Completed by:[**2179-1-12**]
|
[
"599.0",
"873.42",
"250.00",
"V58.61",
"518.89",
"780.62",
"V15.88",
"431",
"427.31",
"780.39",
"348.89",
"305.1",
"V58.67",
"348.5",
"424.1",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"88.72",
"33.27"
] |
icd9pcs
|
[
[
[]
]
] |
11272, 11417
|
6550, 10860
|
325, 367
|
11644, 11644
|
3045, 6527
|
13790, 14654
|
1350, 1385
|
10943, 11249
|
11438, 11623
|
10886, 10920
|
11831, 13767
|
1400, 1410
|
1433, 3026
|
265, 287
|
397, 1156
|
11659, 11805
|
1178, 1221
|
1237, 1334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,771
| 199,374
|
10429
|
Discharge summary
|
report
|
Admission Date: [**2183-8-14**] Discharge Date: [**2183-8-19**]
Date of Birth: [**2124-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Left arm pain with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to OM1 to
OM2, SVG to PDA)
History of Present Illness:
59 y/o male with atypical symptoms (left arm pain) and abnormal
stress test who was found to have three vessel disease by cath.
He was then referred for surgical intervention.
Past Medical History:
Hypertension, Hypercholesterolemia, Diabetes Mellitus, Chronic
Renal Insufficiency, Hepatitis B
Social History:
Waiter. Denies ETOH or tobacco use.
Family History:
Non-contributory
Physical Exam:
VS: 55 20 106/68 113/65 5'3" 153#
General: 59 y/o asian male in NAD
HEENT: NCAT, EOOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR 2/6SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -c/c/e, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
Echo [**8-14**]: Pre-CPB: Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic [**Month/Year (2) 5236**]. 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 pericardial effusion. Post CPB: Preserved biventricular
systolic fxn. No AI, trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Other parameters as
pre-bypass.
CXR [**8-16**]: The left chest tube, mediastinal drains, and Swan-Ganz
catheter have been removed. There is bilateral bibasilar volume
loss with probable small left effusion. An underlying infectious
infiltrate cannot be totally excluded. Otherwise, the lungs are
clear.
[**2183-8-14**] 02:37PM BLOOD WBC-9.5# RBC-3.26* Hgb-10.1*# Hct-28.2*
MCV-86 MCH-30.9 MCHC-35.8* RDW-13.7 Plt Ct-105*#
[**2183-8-17**] 05:40AM BLOOD WBC-7.3# RBC-2.62* Hgb-8.3* Hct-22.6*
MCV-87 MCH-31.8 MCHC-36.8* RDW-14.2 Plt Ct-150
[**2183-8-18**] 06:45AM BLOOD WBC-8.1 RBC-3.78*# Hgb-11.3*# Hct-31.7*#
MCV-84 MCH-29.8 MCHC-35.6* RDW-15.3 Plt Ct-223
[**2183-8-14**] 03:37PM BLOOD PT-12.5 PTT-28.4 INR(PT)-1.1
[**2183-8-14**] 03:37PM BLOOD UreaN-17 Creat-0.9 Cl-111* HCO3-22
[**2183-8-17**] 05:40AM BLOOD Glucose-142* UreaN-17 Creat-1.1 Na-137
K-3.9 Cl-100 HCO3-29 AnGap-12
[**2183-8-18**] 06:45AM BLOOD WBC-8.1 RBC-3.78*# Hgb-11.3*# Hct-31.7*#
MCV-84 MCH-29.8 MCHC-35.6* RDW-15.3 Plt Ct-223
[**2183-8-18**] 06:45AM BLOOD Plt Ct-223
Brief Hospital Course:
Mr. [**Known lastname 34500**] was a same day admit and on [**8-14**] he was brought
to the operating room where he underwent a coronary artery
bypass graft x 4. Please see operative report for surgical
details. He was then transferred to the CSRU for invasive
monitoring in stable condition. Later on op day he was weaned
from sedation, awoke neurologically [**Month/Year (2) 5235**] and was extubated. On
post-op day two his chest tubes were removed. He was weaned off
Neo-synephrine also on this day and started on beta blockers and
diuretics. He was gently diuresed towards his pre-op weight. He
was later transferred to the cardiac floor for ongoing care. His
epicardial pacing wires were removed on post-op day three and he
was transfused to units of pRBC's secondary to a low HCT (22.6).
HCT at time of discharge was 31.7. Physical therapy followed
patient during entire post-op course for strength and mobility.
He appeared to be doing well with stable labs and vital signs
and was discharged home with VNA services and the appropriate
follow-up appointments.
Medications on Admission:
Avapro 300mg qd, Pravachol 80mg qd, Epivir 100mg qd, Lopressor
50mg [**Hospital1 **], Nifedipine 30mg qd, HCTZ 25mg qd, Aspirin 81 mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
8. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Chronic Renal Insufficiency, h/o Hepatitis B, mild Carotid
Disease, Kidney stones
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions and gently pat dry. Do not take
bath.
Do not apply lotions, creams, ointments, or powders to
incisions.
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
If you develop a fever or notice chest drainage or redness
around incisions, please contact office.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) 23903**] in [**1-20**] weeks
Dr. [**Last Name (STitle) **] in [**2-21**] weeks
Completed by:[**2183-8-20**]
|
[
"414.01",
"585.9",
"401.9",
"272.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5232, 5238
|
2825, 3894
|
360, 440
|
5484, 5490
|
1153, 1641
|
5865, 6044
|
833, 851
|
4081, 5209
|
5259, 5463
|
3920, 4058
|
5514, 5842
|
866, 1134
|
281, 322
|
468, 645
|
667, 764
|
780, 817
|
1651, 2802
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,308
| 174,505
|
35531
|
Discharge summary
|
report
|
Admission Date: [**2124-6-8**] Discharge Date: [**2124-6-20**]
Date of Birth: [**2069-10-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Abdominal discomfort
Major Surgical or Invasive Procedure:
[**2124-6-12**] - Paracentesis
[**2124-6-20**]- Paracentesis
History of Present Illness:
This 55 Hispanic male arrived from [**Location 7196**] 2 months ago and is
s/p aortic valve replacement with a mechanical valve 10 years
ago. He has had increasing fatigue and shortness of breath over
the past year and has also developed
ascites and has had 2 paracenteses. He was admitted 1 month ago
with shortness of breath and had an outpatient echocardiogram 2
days ago which revealed a 6 centimeter ascending aortic
aneurysm. He had a subtheraputic INR at the time and his
cardiologist prescibed a Lovenox bridge. The patient could no
afford the prescription and presented to the emergency
department to receive the medication. He complained of
abdominal discomfort and had an abdominal CT which revealed an
aortic dissection. A chest CT was then performed and revealed a
Type A dissection.
Past Medical History:
-Aortic (mechanical) valve replacement 10 years ago
-Dilated cardiomyopathy LVEF 30%,
-Liver disease with unclear etiology.
-Right upper extremity aneurysm s/p surgical intervention 10
years ago
-? Resection clavicular mass? 2year ago
Social History:
Patient visting US from Guatamala. Arrived 3 weeks ago, seeing
medical care, plans to stay 6 months in the US. Patient quit
smoking 11 yrs ago, previously smoked 1 PPD for 10 years. Social
ETOH. Married, with five children.
Family History:
Father and Uncle with heart disease.
Physical Exam:
Physical Exam
Pulse: 72 Resp: 20 O2 sat: 98%
B/P Right: 94/59 Left: 88/69
Height: 59" Weight: 51.3 kg
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 [] non-distended [] non-tender [x] bowel sounds +
[x]sl. abdominal distention
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []+ Venous stasis changes
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right:no Left:no
Pertinent Results:
[**2124-6-18**] 07:40AM BLOOD WBC-5.1 RBC-3.86* Hgb-12.5* Hct-38.0*
MCV-98 MCH-32.5* MCHC-33.0 RDW-15.9* Plt Ct-139*
[**2124-6-20**] 05:50AM BLOOD PT-22.1* PTT-83.3* INR(PT)-2.1*
[**2124-6-20**] 12:25AM BLOOD PT-20.8* PTT-114.7* INR(PT)-2.0*
[**2124-6-19**] 09:10AM BLOOD PT-16.6* PTT-50.8* INR(PT)-1.5*
[**2124-6-18**] 07:40AM BLOOD Glucose-85 UreaN-20 Creat-0.9 Na-137
K-4.7 Cl-102 HCO3-25 AnGap-15
[**2124-6-8**] CTA
1. Type A dissection involving the right internal carotid artery
and left
subclavian artery extending to the iliac bifurcation.
2. Superimposed Type B dissection arising from the distal
arch/descending
aorta extending just below the takeoff of the SMA.
3. Ascending aortic aneurysmal dilatation measuring 6.6 x 7.8
cm. Left
subclavian artery aneurysm measuring 3.0 x 2.3 cm. Abdominal
aortic aneurysm measuring 3.9 x 4.9 cm.
4. Large right pleural effusion and cardiomegaly. No pericardial
effusion.
5. Moderate amount of ascites, partially imaged.
6. Heterogenous appearance of liver with reflux of contrast from
IVC/hepatic veins.
Note that the true lumen is compressed but patent and feeds the
celiac and
SMA, each false lumen gives rise to one renal artery. Overall no
findings of ischemia however.
[**2124-6-9**] CT Scan Cardiac
1. Possibly obstructive mixed plaque in the mid LCX at the
origin of the
single OM branch.
2. Non-obstructive calcified plaque involving the distal left
main.
3. Nonobstructive mixed plaque involving the LAD and RCA.
4. Known thoracic aortic aneurysm with a type A dissection
[**2124-6-12**] ECHO
The left atrium is dilated. No mass/thrombus is seen in the left
atrium or left atrial appendage. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is dilated. Overall left ventricular systolic
function is depressed (LVEF= 40 %). The right ventricular cavity
is dilated with depressed free wall contractility. The aortic
root is markedly dilated at the sinus level. The ascending aorta
is markedly dilated. The descending thoracic aorta is moderately
dilated. A mobile density is seen in the ascending aorta, aortic
arch, and descending aorta, consistent with an intimal
flap/aortic dissection. The aortic wall is thickened consistent
with an intramural hematoma. Ther is predominant thrombosis of
the false lumen distal to the left subclavian (up to 40 cm from
the incisoirs) with a small channel of antegrade flow. A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis leaflets appear to move normally. The transaortic
gradient is normal for this prosthesis. The mitral valve
leaflets are structurally normal. The mitral valve leaflets do
not fully coapt. An eccentric, posteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Markedly dilated ascending aorta with type A
dissection involving the ascending aorta, arch, and descending
aorta. Normal functioning mechanical aortic valve.
Moderate-severe mitral regurgitation. Biventricular dilatation
and hypokinesis.
[**2124-6-12**] Stress Test
No anginal symptoms or additional ST segment changes from
baseline. Nuclear report sent separately.
Gated Perfusion Study
1. Large, moderate to severe, fixed inferior wall defect as well
as a small,
moderate, fixed defect in the mid-lateral wall. A thallium study
could be
performed to evaluate for any viability in these regions, if
clinically
indicated.
2. Markedly dilated LV cavity with calculated EDV of 231 ml.
3. Reduced ejection fraction at 33%.
Brief Hospital Course:
Mr. [**Known lastname 68506**] was admitted to the [**Hospital1 18**] on [**2124-6-8**] for further
management of his abdominal pain. He underwent a CT scan which
showed a Type A dissection involving the right internal carotid
artery and left subclavian artery extending to the iliac
bifurcation, a superimposed Type B dissection arising from the
distal arch/descending aorta extending just below the takeoff of
the superior mesenteric artery, an ascending aortic aneurysmal
dilatation measuring 6.6 x 7.8 cm with the left subclavian
artery aneurysm measuring 3.0 x 2.3 cm, an Abdominal aortic
aneurysm
measuring 3.9 x 4.9 cm, a large right pleural effusion and
cardiomegaly, a moderate amount of ascites, partially imaged and
a heterogenous appearance of liver with reflux of contrast from
IVC/hepatic veins. The hepatology service was consulted given
his ascites. Paracentesis was performed with the fluid being
negative for malignant cells. The infectious disease service was
consulted for an infectiuos etiology of his liver disease. No
infectious process was identified during admission, however,
there are pending tests on discharge. ID will follow up on these
results. The patient's ascites reaccumulated and he did undergo
a second paracentesis on the day of discharge. A family meeting
was held to discuss the risks and benefits of surgery. The
patient and his family have decided to take some time to make a
decision regarding surgery. Coumadin was resumed for his
mechanical aortic valve. When INR was therapeutic, the patient
was discharged home with extensive follow up instructions.
Medications on Admission:
Carvedilol 6.25'', digoxin 250, lovenox 60'', lasix 40,
lisinopril 2.5, spironolactone 25, warfarin 5
Discharge Medications:
1. Outpatient Lab Work
Chem 7
results to Dr. [**Last Name (STitle) 171**], fax:[**Telephone/Fax (1) 19842**]
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
dose will change daily for goal INR [**3-14**], Dr. [**Last Name (STitle) 23903**] to manage.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
serial PT/INR
dx: mechanical aortic valve
goal INR [**3-14**]
results to Dr. [**Last Name (STitle) 23903**] [**Telephone/Fax (1) 17826**]
Discharge Disposition:
Home
Discharge Diagnosis:
s/p mechanical AVR [**25**] years ago.
Dilated cardiomyopathy with LVEF 30%
Liver disease
Repair of right upper extremity aneurysm
Discharge Condition:
good
Discharge Instructions:
1) You are taking coumadin for a mechanical aortic valve. Your
goal INR is 2.0-3.0. You will need daily PT/INR testing until
otherwise instructed by Dr.[**Name (NI) 65892**] office. Please take daily
coumadin only as instructed. Please note that your daily dose
may change based on your blodd work (PT/INR).
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 23903**] for coumadin management and in
2 weeks for routine follow-up appointment. [**Telephone/Fax (1) 17826**] Please
call for appointment.
Please follow-up with Dr. [**Last Name (STitle) 914**] in [**3-14**] weeks ([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) 171**] 1 week
Lab Draw in 1 week (lab slip included in prescriptions)
Completed by:[**2124-6-20**]
|
[
"443.29",
"573.0",
"V58.61",
"425.4",
"428.0",
"441.02",
"V15.82",
"327.27",
"428.43",
"789.59",
"427.89",
"443.21",
"424.0",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.72",
"88.42",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9133, 9139
|
6090, 7695
|
341, 404
|
9314, 9321
|
2500, 6067
|
9677, 10098
|
1753, 1791
|
7848, 9110
|
9160, 9293
|
7721, 7825
|
9345, 9654
|
1806, 2481
|
281, 303
|
432, 1235
|
1257, 1495
|
1511, 1737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,208
| 194,289
|
51865
|
Discharge summary
|
report
|
Admission Date: [**2132-8-14**] Discharge Date: [**2132-8-28**]
Date of Birth: [**2077-1-21**] Sex: F
Service: General Surgery
PRINCIPAL DIAGNOSIS:
Ventral hernia and abdominal abscess.
PHYSICAL EXAMINATION: HEENT - Mucous membranes moist, no
ulcers. Extraocular movements intact. Pupils are equal,
round, and reactive to light. No cervical lymphadenopathy.
Sclerae anicteric. Chest was clear to auscultation in the
superior and middle lobes. Decreased breath sounds in the
lower lobes. Cardiac - Regular rate and rhythm, no murmurs,
no bruits. Abdomen - Soft, very distended secondary to fluid
edema, positive fluid shift, positive bowel sounds, left
lower quadrant tenderness to palpation that has been constant
since postoperative period. No rebound tenderness.
Abdominal incision without cellulitis or purulence. No
hepatosplenomegaly noted.
Extremities - +2 to +3 bipedal edema. Strength, flexion and
extension [**4-20**] in the lower extremity and [**4-20**] in the upper
extremity, sensation grossly intact to light touch.
LABORATORY DATA: On [**2132-8-19**], white blood cells 6.9, red
blood cells 3.69, hemoglobin 9.7, hematocrit 29.9, and
platelets 187. Urinalysis performed on [**2132-8-14**] was
negative. Chemistry performed on [**2132-8-19**] revealed sodium
138, potassium 4.1, chloride 102, BUN 9, creatinine 0.7, and
glucose 192. Albumin level was not measured. Calcium 8.4,
magnesium 1.8. Vancomycin level on [**2132-8-18**], peak 24.6,
trough 10.2. Arterial blood gases drawn on [**2132-8-15**]
revealed pH 7.41, pCO2 42, pO2 94, total bicarbonate 28, base
axis 1. Culture of abdominal swab on [**2132-8-14**], Gram's
stain final, wound culture final, Staphylococcus aureus,
coagulase positive, Corynebacterium species diphtheroids.
IMAGING: CT scan of the abdomen and pelvis was performed on
[**2132-8-20**]. The impression was significant improvement in
previously seen ventral hernia. Ileostomy in the right lower
quadrant. No suspicious collections were seen.
HOSPITAL COURSE: [**Known firstname 501**] [**Known lastname 107403**] is a 55-year-old female
with past medical history remarkable for multiple ventral
hernia repairs and debridement, status post colectomy, due to
familial polyposis. She presented to our service on
[**2132-8-14**] for peristomal hernia repair, incision and
drainage of abdominal abscess collection, and abdominoplasty.
The patient underwent laparotomy, extensive lysis of
adhesions, excision of fistula, repair of peristomal hernia,
component separation, incision and drainage of abscess. No
operative complications were noted, and the patient was
transferred to the Surgical Intensive Care Unit for close
monitoring postoperatively.
Since wound abscess culture showed coagulase-positive
Staphylococcus aureus species, Vancomycin was initiated along
with levofloxacin for additional gram-negative coverage. The
patient was continuously monitored until [**2132-8-18**] in the
Surgical Intensive Care Unit and transferred to the floor
where diet was appropriately advanced with return of bowel
function evidenced by ostomy output and gaseous filling.
Hospital course was only remarkable for continued left lower
quadrant residual discomfort which was aggressively pursued
with CT scan due to high probability of a seroma formation.
The CT revealed no evidence of fluid collection. Since the
patient required one month of intravenous antibiotics and
assistance for mobility, the decision was made to discharge
the patient to a rehabilitation facility where she would be
able to obtain these services.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation facility with
intravenous Vancomycin therapy until [**2132-9-20**] and
levofloxacin therapy until [**2132-8-29**].
FOLLOW-UP: The patient has been scheduled for a follow-up
surgical clinic visit with Dr. [**First Name (STitle) **] on Friday, [**2132-8-29**]
at 10:30 a.m., and Dr. [**Last Name (STitle) **] on Friday, [**2132-8-29**] at
12:30 p.m.
DISCHARGE MEDICATIONS:
1. Albuterol nebulizer solution one vial p.r.n. q.6 hours
inhaled.
2. Albuterol ipratropium inhaler two puffs q.6 hours.
3. Diphenhydramine chloride 25 mg p.o. 30 minutes prior to
Vancomycin administration.
4. Fluoxetin 40 mg p.o. q.d.
5. Furosemide 40 mg p.o. q.d.
6. Insulin glargine 80 units p.o. q.h.s.
7. Levofloxacin 500 mg p.o. q.d. for seven days with final
dose on [**2132-8-29**].
8. Metoprolol 25 mg p.o. t.i.d.
9. Percocet one to two tablets q.4-6 hours p.r.n. pain.
10. Protonix 40 mg p.o. q.d.
11. Quinapril 10 mg p.o. q.d.
12. Vancomycin 1.25 mg q.12 hours intravenously for one month
with the last dose on [**2132-9-20**] with peak and trough to
be drawn after the third dose administration upon
arriving at the rehabilitation care facility.
DISCHARGE DIAGNOSIS:
Status post laparotomy, excision of fistula, extensive lysis
of adhesions, repair of peristomal hernia, component
separation, irrigation and debridement of abscess,
abdominoplasty.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 11079**]
MEDQUIST36
D: [**2132-8-21**] 11:31
T: [**2132-8-21**] 12:19
JOB#: [**Job Number 92847**]
|
[
"998.6",
"250.01",
"729.1",
"569.69",
"567.2",
"401.9",
"515",
"493.90",
"568.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.41",
"44.63",
"86.83",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
4052, 4844
|
4865, 5312
|
2050, 3617
|
231, 2032
|
3632, 4029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,732
| 126,770
|
22588+22589
|
Discharge summary
|
report+report
|
Admission Date: [**2119-8-1**] Discharge Date: [**2119-8-10**]
Date of Birth: [**2051-4-20**] Sex: M
Service: CSURG
Allergies:
Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
68 YO MALE WITH PMH OF HTN AND HYPERCHOLESTEROLEMIA. THAT
PRESENTED WITH HX OF DIZZINES. WAS FOUND TO HAVE CAROTID
DISEASE, BEING WORK UP FOR PREOP CEA HAD POSITIVE STRESS TEST
AND SUBSECUENT CATH SHOWINGH TRIPPLE VESSEL DISEASE. RIGTH 70%
LMCA 50% OTIAL RCA NORMAL EF.
Major Surgical or Invasive Procedure:
68 YO MALE SP CABG X2 LIMA TO LAD SVG TO OM
History of Present Illness:
68 YO MALE WITH PMH OF HTN AND HYPERCHOLESTEROLEMIA. THAT
PRESENTED WITH HX OF DIZZINES. WAS FOUND TO HAVE CAROTID
DISEASE, BEING WORK UP FOR PREOP CEA HAD POSITIVE STRESS TEST
AND SUBSECUENT CATH SHOWINGH TRIPPLE VESSEL DISEASE. RIGTH 70%
LMCA 50% OTIAL RCA NORMAL EF.
DENIES CHEST APIN AT ADMISSION, UNDERWENT CABG X3
Past Medical History:
HYPERTENSION, GERD, HYPERCHOLESTEROLEMIA, HIATAL HERNIA, ASTHMA,
OSTEOMILEITIS
Social History:
DENIES
Family History:
UNREMARKABLE
Physical Exam:
LUNGS CAT
HEART RRR NM NG
WOUND CLEAN
STERNUM SATBLE
CNS ORIENTED X3
EXT POS PULSES NO EDEMA
Pertinent Results:
PT UNDERWENT CABG X2 ON [**2119-8-1**] NO COMPLICATIONS.POD #2 WAS DC
FROM CSRU TO THE FLOOR. CHEST TUBES REMOVED WITH UOT
COMPLICATION.
Brief Hospital Course:
68 YO MALE WITH PMH OF HTN AND HYPERCHOLESTEROLEMIA. THAT
PRESENTED WITH HX OF DIZZINES. WAS FOUND TO HAVE CAROTID
DISEASE, BEING WORK UP FOR PREOP CEA HAD POSITIVE STRESS TEST
AND SUBSECUENT CATH SHOWINGH TRIPPLE VESSEL DISEASE. RIGTH 70%
LMCA 50% OTIAL RCA NORMAL EF.
UNDERWENT CAB X2 ON [**8-1**] UNCOMPLICATED POST OP COURSE. DC TO
FLOOR POST OP DAY 2, CHEST TUBES DC WITH OUT COMPLICATIONS. PT
WALKING [**Name (NI) 58575**] STAIRS, ON OPTIMAL STAE FOR DC
Medications on Admission:
ATENOLOL 20 QD ASA 81MG POQD
RANITIDINE 150 PO BID, LIPITOR 20MG PO QD
Discharge Medications:
1. Isosorbide Mononitrate 30 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*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. 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*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Metoclopramide 10 mg IV Q6H:PRN
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) **] VNA
Discharge Diagnosis:
68 YO MALE SP CABG X2 LIMA TO LAD SVG TO OM, HYPERTENSION,
HYPERCHOLESTEROLEMIA.CAD.
Discharge Condition:
GOOD SELF FEEDING SELF AMBUTATION
Discharge Instructions:
MEDIASTINAL WOUND CARE WITH BETADINE, CHEST WOUND PRECAUTIONS,
AMBULATE QID. CARDIAC DIET
Followup Instructions:
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 58576**] ([**Telephone/Fax (1) 1504**] 3 WKS FORM DC
Completed by:[**2119-8-5**] Admission Date: [**2119-8-1**] Discharge Date: [**2119-8-10**]
Date of Birth: [**2051-4-20**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 68-year-old patient
with a history of hypertension and hypercholesterolemia who
complained of dyspnea on exertion which has been increasing
over the past several months.
[**Last Name (STitle) 58577**]nted to an outside hospital for a syncopal episode
and was found upon workup to have coronary artery disease and
was ultimately referred for catheterization. This revealed a
right-dominant system with a 60 to 70 percent left main
coronary artery stenosis as well as a 40 to 50 percent ostial
right stenosis. He also had a normal left ventricular
ejection fraction with no regional wall motion abnormalities
and no mitral regurgitation. He was referred to Dr. [**Last Name (Prefixes) 411**] for coronary artery bypass grafting.
PAST MEDICAL HISTORY: Hypertension, gastroesophageal reflux
disease, hiatal hernia, asthma, injury to the right eye with
loss of vision, history of osteomyelitis as a young child,
hypercholesterolemia, vertigo, and arthritis.
PAST SURGICAL HISTORY: Status post laminectomy, status post
umbilical hernia repair, status post eyelid surgery, status
post sebaceous cyst removal, status post open
cholecystectomy, status post appendectomy, status post right
leg surgery as a child, and status post hemorrhoidectomy.
MEDICATIONS ON ADMISSION: Atenolol 20 mg p.o. q.d., aspirin
81 mg p.o. q.d., Zantac 150 mg p.o. q.d., Lipitor 20 mg p.o.
q.d., meclizine as needed (for vertigo).
ALLERGIES: The patient states an allergy to CODEINE which
causes nausea and itching.
SOCIAL HISTORY: The patient is married. He lives with his
wife. [**Name (NI) **] he is a retired photographer. He is a former
smoker. He has a 42-pack-year history of smoking; he quit
eight years ago. Alcohol intake is one to two drinks per
year. There is no recreational drug use.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
hospital on [**2119-8-1**] and was taken to the operating
room where he underwent coronary artery bypass grafting times
two with a LIMA to the LAD and a saphenous vein graft to the
OM by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **].
Postoperatively, he was transported from the Operating Room
to the Cardiac Surgery Recovery Unit in good condition on
nitroglycerin and propofol drips. On the night of surgery,
the patient was weaned from mechanical ventilation and
successfully extubated.
On postoperative day one, he was transferred from the Cardiac
Surgery Recovery Unit to the telemetry floor. He was
hemodynamically stable. He was begun on diuresis and beta
blockade. On postoperative day two, he had complaints of an
inability to sleep and nausea but had remained
hemodynamically stable; although his creatinine had risen
slightly from 1.1 to 1.3 on postoperative day two. His chest
tubes and epicardial wires were discontinued on postoperative
day two. He had begun ambulation and cardiac rehabilitation
at that time.
The patient remained on the telemetry floor with stable vital
signs and in a normal sinus rhythm. Over the next few days,
his oxygen was weaned off and on room air had an adequate
saturation of above 94 percent consistently. The only
remaining problem that persisted for Mr. [**Known lastname 6164**] was that of
lower extremity and scrotal edema which was quite pronounced
for a number of days. His diuresis was increased, but as it
was being increased his creatinine also rose slightly every
day. Ultimately, his Lasix was discontinued and he was
placed on intravenous nesiritide for approximately 48 hours.
He did have a good response to this with a drop in his weight
as well as a decrease in the peripheral edema and a decrease
in his serum creatinine level. It did peak at 1.5 and
ultimately has come down to 1.2.
Due to the ongoing edema, a Vascular Surgery consultation was
obtained. It was their recommendation to obtain an
ultrasound of the femoral veins to rule out a deep venous
thrombosis. The lower extremity noninvasive study was read
as partially occlusive thrombus in the right greater
saphenous vein; however, his right greater saphenous vein has
been entirely harvested as conduit for his coronary artery
bypass procedure up to the femoral region. Initially with
the [**Location (un) 1131**], the patient was placed on heparin but this was
discontinued the following morning when it was determined
that this vein had been removed.
Over the next 24 hours or so the patient continued to diurese
well. He stated he was much more comfortable with the
peripheral edema. ACE wraps were put on both of his legs,
and his scrotal edema had also significantly decreased. His
nesiritide was discontinued. The patient continued to
improve from a clinical standpoint and was discharged home on
[**2119-8-10**] in good condition on postoperative day nine.
Physical examination upon discharge revealed his temperature
was 98.4, his pulse was 90 (in a normal sinus rhythm), his
blood pressure was 110/56, and his oxygen saturation on room
air was 98 percent. The patient's weight was 86.7 kilograms
- which was down over the past few days but still up about 3
kilograms from his preoperative weight. The lungs were clear
to auscultation bilaterally. His heart was regular in rate
and rhythm. No murmurs noted. His sternum was stable. His
incisions were clean and dry with no erythema. His
peripheral edema had significantly decreased as had the
scrotal edema, and he was fully ambulatory independently.
MEDICATIONS ON DISCHARGE:
1. Imdur 30 mg p.o. q.d.
2. Colace 100 mg p.o. b.i.d.
3. Enteric coated aspirin 325 mg p.o. q.d.
4. Lipitor 20 mg p.o. q.d.
5. Plavix 75 mg p.o. q.d. (for three months).
6. Protonix 40 mg p.o. q.d.
7. Atenolol 100 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient was to follow up with his
primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57151**]) in one to two
weeks. He should follow up with his primary cardiologist
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32255**]) in one to two weeks, and he should
follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] from Cardiac Surgery in
three to four weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post coronary artery
bypass graft.
2. Hypertension.
3. Hypercholesterolemia.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2119-8-11**] 09:06:29
T: [**2119-8-11**] 09:45:20
Job#: [**Job Number 58578**]
|
[
"414.01",
"401.9",
"V15.82",
"530.81",
"782.3",
"424.0",
"433.10",
"608.86",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"00.13",
"99.04",
"89.62",
"36.11",
"89.64",
"89.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3475, 3531
|
1375, 1837
|
535, 580
|
3660, 3695
|
1214, 1352
|
3833, 4126
|
1072, 1086
|
10330, 10703
|
1958, 3452
|
3552, 3639
|
9616, 9845
|
5439, 5663
|
3719, 3810
|
5149, 5412
|
1101, 1195
|
5982, 9590
|
225, 497
|
9866, 10309
|
4155, 4897
|
4920, 5125
|
5680, 5953
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,048
| 189,055
|
22048
|
Discharge summary
|
report
|
Admission Date: [**2121-10-6**] Discharge Date: [**2121-10-23**]
Date of Birth: [**2096-4-20**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 1124**] is a
postoperative admission admitted directly to the Operating
Room. His preadmission testing chief complaint was chest
pain times one year ago following a session of weightlifting.
The patient was noted to have an incidental murmur by his
primary care provider who then did an echocardiogram which
showed the patient to have a bicuspid aortic valve and a
dilated ascending aorta. The patient was further worked up.
He denies any recent chest pain.
The patient had a cardiac catheterization done on [**2121-8-14**] that showed an ejection fraction of 51 percent. No
coronary artery disease. Bicuspid aortic valve, mild aortic
insufficiency, and a significantly dilated ascending aorta,
with no mitral regurgitation.
The patient had a cardiac flow map done on [**2121-8-6**] that
showed a severely dilated ascending aorta, 53 mm from the
valve annulus, 44 mm to the arch, normal ascending and
descending aorta, ejection fraction was 59 percent. The
aortic valve was bicuspid with a vertical commixture. He had
minimal biatrial enlargement, mild atrial regurgitation, and
mild mitral regurgitation.
PAST MEDICAL HISTORY:
1. Bicuspid aortic valve with dilated aorta.
2. Chronic sinusitis.
3. Tonsillectomy.
4. Septoplasty.
MEDICATIONS ON ADMISSION: Claritin 10 mg by mouth daily and
clonazepam 0.5 mg p.o. twice daily as needed.
ALLERGIES: The patient states no known drug allergies.
FAMILY HISTORY: His father is alive and well at the age of
54. He had a myocardial infarction at the age of 50. His
mother is alive and well at the age of 54. She has a
diagnosis of hypertension.
SOCIAL HISTORY: The patient lives with his parents in
[**Location (un) 11333**], [**State 350**]. He denied tobacco use. Alcohol with
about 20 drinks per week. No other marijuana, intravenous
drug use, or cocaine use.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
heart rate of 120 (sinus rhythm), his blood pressure was
126/94, his respiratory rate was 20, his height was 6 feet,
and his weight was 275 pounds. In general, a young white
male in no acute distress. Neurologically, alert and
oriented times three. Cranial nerves II through XII were
grossly intact. Motor strength was [**5-14**] in all extremities.
The skin was dry without lesions. Head, eyes, ears, nose,
and throat examination revealed extraocular muscles were
intact. The pupils were equal, round, and reactive to light.
No sinus tenderness. The sclerae were anicteric and not
injected. The mucous membranes were moist. The neck was
supple with no lymphadenopathy or thyromegaly. The chest was
clear to auscultation bilaterally. Heart revealed a regular
rate and rhythm with a 4/6 systolic ejection murmur at the
aortic area. The abdomen was soft, nontender, and
nondistended. There were normal active bowel sounds. The
extremities were warm and well perfused with no clubbing,
cyanosis, or edema. No varicosities. Good distal pulses
throughout.
RADIOLOGY: Electrocardiogram showed sinus tachycardia at 107
and nonspecific T wave changes in leads III and aVF.
SUMMARY OF HOSPITAL COURSE: As stated previously, the
patient was a direct admission to the Operating Room on
[**10-6**]. Please see the Operative Report for full
details. In summary, the patient had a Bentall procedure
with complete arch replacement and 34 St. [**Male First Name (un) 923**] mechanical
aortic valve and 30 Gelweave graft. His bypass time was 226
minutes, with a cross-clamp time of 204 minutes, and a
cardiac arrest time of 15 minutes.
The patient tolerated the operation and was transferred from
the Operating Room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient was in a sinus rhythm at
100 beats per minute with a mean arterial pressure of 58 and
a central venous pressure of 12. He was on propofol at 20
mcg/kilogram per minute. The patient did well in the
immediate postoperative period. His anesthesia was reversed.
He was weaned from the ventilator and successfully extubated.
The patient remained hemodynamically stable throughout the
day the surgery.
On postoperative day one, the patient complained of the acute
onset of right hand and foot numbness described as nonpainful
pins and needles. A Neurology consultation was called at
that time to assess for cerebral vascular involvement.
Additionally, the patient complained later during the day of
pain on passive flexion and extension of the legs, and
Vascular Surgery was called to assess the patient for
compartment syndrome.
Following assessment by the Vascular Surgery Department, the
patient was brought to the Operating Room where he had a
right leg fasciotomies performed for right lower extremity
compartment syndrome. Following the fasciotomies, the
patient had pulses bilaterally with good capillary refill.
The patient stated that the pins and needles feeling were
much less acute; however, he still did have a complaint of an
area in his lower foot that was numb.
On postoperative day two, the patient remained
hemodynamically stable with improved sensation in his lower
extremities and a minimal amount of residual numbness. At
that time, he was transferred to the floor for continued
postoperative care and cardiac rehabilitation.
Over the next several days, the patient did well. His
fasciotomy sites remained clean with only a minimal dusky
area over the lateral fasciotomy incision. He was maintained
on intravenous fluids with bicarbonate. Physical Therapy and
Occupational Therapy were consulted to assist with
ambulation. Additionally, the patient was begun on a heparin
infusion for protection of his mechanical aortic valve.
On [**10-13**], the patient was made nothing by mouth for
delayed closure of his fasciotomies. On [**10-14**], the
patient returned to the Operating Room for debridement of the
anterior compartment and closure of his fasciotomies by the
Vascular Service. It should be stated that throughout this
period, the patient remained tachycardic with a heart rate
between 100 and 120 (sinus rhythm) and hemodynamically stable
with a blood pressure generally in the 120/80 range.
Following closure of fasciotomies sites, the patient was
started on Coumadin for long-term management of his aortic
valve.
On [**10-17**], given the patient's persistent tachycardia an
echocardiogram was done to evaluate heart function. At that
time, a large pericardial effusion was found. By report, the
effusion appeared to be loculated with right diastolic
ventricular collapse; consistent with tamponade physiology.
The patient was then brought to the Catheterization
Laboratory for drainage of the pericardial effusion. Several
attempts were made to drain the pericardial effusion;
however, drainage was unable to be performed. Following
attempted pericardiocentesis, the patient was transferred to
the Cardiothoracic Intensive Care Unit for further
monitoring.
On [**10-18**], the patient was brought back to the Operating
Room for a pericardial window and drainage of the effusion
via a left anterior thoracotomy, following which the patient
was hemodynamically stable and recovered in the
Cardiothoracic Intensive Care Unit. He was ultimately
transferred back to [**Hospital Ward Name 121**] Two for continued postoperative care
and recovery. Please see the Operative Report for full
details. In summary, the operating team was able to mobilize
the loculated fluid collections that were bloody with no
murkiness and no odor. Cultures were sent for Gram stain.
Following the procedure, there was no evidence of compression
by echocardiogram, and the incision was closed. A chest tube
was left in the pleural space.
The patient spent the next several days increasing his
activity level with the assistance of the nursing staff and
Physical Therapy staff. On postoperative day three from his
thoracotomy, the chest tube was discontinued.
DISCHARGE DISPOSITION: On postoperative days 18, 17, and 5
it was decided that the patient was stable and ready to be
discharged to home.
PHYSICAL EXAMINATION ON DISCHARGE: At the time of this
dictation, the patient's physical examination is as follows.
Vital signs revealed his temperature was 98.5, his heart rate
was 86 (sinus rhythm), his blood pressure was 110/64, his
respiratory rate was 20, and his oxygen saturation was 94
percent on room air. Weight on discharge was 118.7.
Preoperative weight was 120. The patient was alert and
oriented times three. He was moving all extremities. He
followed commands. Respiratory examination revealed the
lungs were clear to auscultation bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. First heart
sounds and second heart sounds with sharp clicks. The
sternum was stable with a 2-cm open wound at the top of the
incision line. Clean margins on the 2-cm open area. The
abdomen was soft, nontender, and nondistended. There were
normal active bowel sounds. The extremities were warm and
well perfused with no edema. Right calf fasciotomy sites
with sutures clean and dry.
LABORATORY DATA ON DISCHARGE: Prothrombin time was 19 and
INR was 2.3.
CONDITION ON DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: He is to be discharged home with visiting
nurses.
DISCHARGE INSTRUCTIONS:
1. The patient is to have followup with Dr. [**First Name (STitle) 449**] E. However
regarding his Coumadin dosing. His first INR check will
be on the 14th with the results called to Dr. [**Last Name (STitle) **].
2. The patient is to have followup with Dr. [**Last Name (STitle) 2109**] in
two to three weeks.
3. The patient is to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
regarding fasciotomies and to have the sutures removed on
[**10-29**] at 10:00 a.m. in the [**Hospital **] Clinic.
4. The patient is to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in
four weeks.
DISCHARGE DIAGNOSES: Status post Bentall procedure with a 32
graft and a 31 St. [**Male First Name (un) 923**] aortic valve replacement complicated
by compartment syndrome and pericardial tamponade requiring a
window.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg by mouth twice daily.
2. Dilaudid 2 mg to 4 mg by mouth q.4h. as needed.
3. Metoprolol 100 mg by mouth three times daily.
4. Aspirin 81 mg by mouth daily.
5. Clonazepam 0.5 mg by mouth twice daily as needed.
6. Warfarin as directed to maintain a goal INR of 2.5 to 3.
The patient is to take 4 mg on the day of discharge and
then as directed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2121-10-24**] 18:52:57
T: [**2121-10-25**] 12:30:15
Job#: [**Job Number 10696**]
|
[
"427.89",
"441.2",
"729.9",
"746.4",
"423.8",
"998.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45",
"37.12",
"37.21",
"83.14",
"35.22",
"83.45",
"83.65"
] |
icd9pcs
|
[
[
[]
]
] |
8118, 8255
|
1633, 1817
|
10213, 10412
|
10438, 11139
|
1478, 1616
|
9496, 10191
|
3315, 8094
|
9285, 9327
|
166, 1326
|
1348, 1451
|
1834, 3286
|
9352, 9472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,151
| 156,287
|
2931
|
Discharge summary
|
report
|
Admission Date: [**2111-11-2**] Discharge Date: [**2111-11-7**]
Service: MICU
HISTORY OF THE PRESENT ILLNESS: This is an 83-year-old woman
with a history or restrictive lung disease, 02 dependent at
home who was transferred from an outside hospital on [**2112-10-31**] for treatment of a right hip intertrochanteric
fracture along with rhabdomyolysis. The patient was found in
her home on the bathroom floor after sustaining a mechanical
fall. It was believed that the patient was on the floor for
at least two days before a neighbor noticed that she was not
answering her phone, at which time EMS was alerted and they
went nextdoor.
At the outside hospital, x-ray showed the fracture and her
initial CK value was 2,866 with an index of 4, troponin of
1.15. Her BUN to creatinine ratio was 120:1.9. She was
initially admitted to a medicine team for fluid rehydration
and treatment of her azotemia prior to going for a right hip
replacement.
Shortly after being admitted to the Medicine Floor, her 02
saturation was approximately 68% on 3 liters of nasal cannula
and she showed increasingly labored breathing. Her
respiratory rate was between 28 and 32 breaths per minute.
Her heart rate was in the low 100s. Initial arterial blood
gas showed a pH of 7.19, PC02 of 81, P02 66. Her cardiac
enzymes showed a CK of 1,982 and a troponin greater than 50
with an MB of 81.
PAST MEDICAL HISTORY:
1. Restrictive lung disease, 02 dependent at home.
2. Osteoarthritis.
3. Left Bell's palsy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Detrol.
2. Vioxx.
SOCIAL HISTORY: The patient does not smoke. She does not
use any IV drug use, rare alcohol use. She is widowed with
two grown children.
LABORATORY DATA: Her initial laboratories showed a white
blood count of 9.0, hematocrit 42.2, platelet count 143,000.
Sodium 149, potassium 4.2, bicarbonate 23, chloride 112, BUN
111, with a creatinine of 1.5 and a glucose of 136. Her CKs
showed a peak CK of 1,982, peak troponin greater than 50 and
an MB of 81.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile, heart rate 81 breaths per minute, blood
pressure 101/49, respiratory rate 26 breaths per minute, 02
saturation of 87%. General: This is a frail appearing
female. She was alert and oriented times three. She was in
minor respiratory distress. The patient had JVD to the
mandible. She was without lymphadenopathy. Heart: Regular
rate and rhythm with a loud S1, S2, and an S3. Lungs: Clear
to auscultation bilaterally. No wheezing, rales, or rhonchi.
Abdomen: Midepigastric hernia, well-healed midabdominal
scar. Extremities: The patient had extreme pain in her
right hip and was unable to move it in any direction. She
had no edema, cyanosis, clubbing, but did, however, have some
chronic venostasis change in the lower extremities.
ASSESSMENT/PLAN: This is an 83-year-old female with a
history of restrictive lung disease. She was admitted to the
MICU for respiratory distress and further management of her
rhabdomyolysis.
1. ORTHOPEDICS: The patient was seen by the Orthopedic
Service. She had an open reduction and internal fixation of
her right hip.
2. PULMONARY: The patient was initially intubated due to
her respiratory distress. It was later found out that the
patient had a wish to be DNR/DNI. After stabilizing her, the
decision was made to extubate her. Following extubation,
after several discussions with the family, it was determined
that if the patient were to develop further respiratory
distress that she would not be reintubated and that she would
be made comfortable.
Unfortunately, shortly after being extubated on [**2111-11-6**], the patient appeared to develop some labored breathing
and was unable to maintain good oxygenation with a BIPAP
machine. She was then made comfortable and she unfortunately
passed away on [**2111-11-7**].
3. CARDIAC: The patient had some nonsustained venous
tachycardia. It was successfully treated with calcium
channel blockers and a beta blocker. She did have several
episodes of hypotension for which she required Neo.
4. RENAL: The patient had acute renal failure secondary to
rhabdomyolysis. She was aggressively treated with IV fluids
and gradually her creatinine and BUN decreased.
This covers the period of her admission from [**2111-11-2**]
until her untimely death on [**2111-11-7**].
DIAGNOSIS:
1. Right hip fracture.
2. Acute renal failure.
3. Respiratory distress.
4. Supraventricular tachycardia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 6284**]
MEDQUIST36
D: [**2112-2-24**] 04:28
T: [**2112-2-24**] 21:02
JOB#: [**Job Number 14108**]
|
[
"428.0",
"820.02",
"518.81",
"427.31",
"276.2",
"410.71",
"584.9",
"728.89",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"79.35",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1581, 1605
|
2097, 4801
|
1408, 1558
|
1622, 2082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,029
| 198,362
|
52700
|
Discharge summary
|
report
|
Admission Date: [**2104-1-14**] Discharge Date: [**2104-1-18**]
Date of Birth: [**2039-2-13**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
dizzy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 108723**] is a 64F with DM, CAD, cirrhosis, and Crohns
presented to [**Hospital 464**] clinic today c/o headache and feeling
"not right" like her sugar was low. She was unable to check a
fingerstick at the time. She felt a little better after eating a
candy bar (with fingerstick to 190's) but then feeling of
malaise recurred. In office BP 82/40 so she was sent to the ED
for further eval.
.
In ED, her vitals were 97.5 65 80/45 20 100% on RA. BP recorded
nadired at 71/33. She was given 2L of NS and started on
levophed. FAST scan was negative. Of note, she had a revision of
her right TKR on [**2103-11-22**].
.
On review of systems, she denies fevers, chills, sweats, chest
discomfort, palpitations, pleuritic chest discomfort,
hemoptysis, leg pain or swelling, nausea, vomiting, poor PO,
abdominal discomfort, diarrhea, dysuria, sore throat, myalgias,
bleeding, melena or hematochezia, changes to antihypertensives
or pain medications. She has had a very occasional
non-productive cough and occasional constipation. Today she has
had a few episodes of lightheadedness which resolved, no
orthostatic symptoms. She does feel thirsty. She has been able
to ambulate with a walker.
Past Medical History:
1. CAD s/p RCA w/BMS on [**2102-2-2**]
2. Diastolic CHF (Recent EF~55%)
3. Crohn's Disease: h/o pancolitis w/o small bowel involvement
4. Chronic Renal Failure (Cr~1.4 at baseline).
5. DM Type II
6. Hypertension
7. h/o idiopathic dilated CMP now resolved
8. Peptic ulcer disease.
9. Alcoholic cirrhosis.
10. GERD.
11. Rheumatoid arthritis.
12. Pulmonary embolus in [**2098**].
13. Total right knee replacement with subsequent chronic pain.
14. [**Doctor Last Name **] mal seizure in childhood.
15. Cervical disc disease.
16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X-
Ray with EMG consistent with mild radiculopathy.
17: Recent GIB in [**2-17**] of unclear etiology
Social History:
Patient lives with a disabled son in [**Name (NI) 669**]. She has one other
son who is currently incarcerated. She was married but divorced
a long time ago. quit smoking 10 years ago. Drank ~1 pint
alcohol/day x 10 years, quit 10 yrs ago. No illicit drugs.
Family History:
Mom died of [**Name (NI) 499**] cancer. Father with DM requiring bilateral
below the knee amputation. One sister has had cervical
cancer(cured) and rheumatoid arthritis. Most members of her
family have trouble with hypertension. No one else with IBD.
Grandmother with [**Name2 (NI) 499**] cancer.
Physical Exam:
Vitals 97.6 71 123/51 21 100% on 2L NC
General Pleasant overweight woman in no distress
HEENT Sclera white, conjunctiva pale. hoarse voice
Neck RIJ in place
Pulm Lungs with few rales right base persisting after cough, no
dullness to percussion or egophony
CV Regular S1 S2 no m/r/g
Abd Soft nontender +bowel sounds no HSM or mass guic negative
Extrem Hands and feet cool with palpable pulses, no edema. R
knee with increased warmth, wound with granulation tissue,
somewhat tender to touch, no erythema or obvious clinical
effusion. Minimal knee discomfort on knee flexion. LE ~symmetric
in size.
Neuro Alert and interactive
Pertinent Results:
[**2104-1-18**] 07:30AM BLOOD WBC-11.0 RBC-3.15* Hgb-9.1* Hct-27.2*
MCV-87 MCH-28.9 MCHC-33.4 RDW-14.6 Plt Ct-290
[**2104-1-17**] 08:50AM BLOOD WBC-12.6* RBC-3.38* Hgb-10.2* Hct-29.4*
MCV-87 MCH-30.2 MCHC-34.8 RDW-14.7 Plt Ct-296
[**2104-1-16**] 06:20AM BLOOD WBC-14.2* RBC-3.05* Hgb-9.0* Hct-26.8*
MCV-88 MCH-29.5 MCHC-33.6 RDW-14.5 Plt Ct-249
[**2104-1-15**] 05:08AM BLOOD WBC-11.6* RBC-3.23* Hgb-9.4* Hct-28.2*
MCV-87 MCH-29.1 MCHC-33.3 RDW-14.8 Plt Ct-278
[**2104-1-14**] 07:10PM BLOOD WBC-11.7* RBC-2.95* Hgb-8.6* Hct-26.2*
MCV-89 MCH-29.3 MCHC-33.1 RDW-14.9 Plt Ct-277
[**2104-1-14**] 05:01PM BLOOD WBC-13.4*# RBC-3.54* Hgb-10.3* Hct-31.1*
MCV-88# MCH-29.1 MCHC-33.1 RDW-14.8 Plt Ct-325
[**2104-1-14**] 02:50PM BLOOD WBC-12.4* RBC-3.82* Hgb-11.2* Hct-34.6*
MCV-90 MCH-29.2 MCHC-32.3 RDW-14.9 Plt Ct-353
[**2104-1-15**] 05:08AM BLOOD Neuts-80.3* Lymphs-14.1* Monos-3.2
Eos-2.1 Baso-0.3
[**2104-1-14**] 07:10PM BLOOD Neuts-73.2* Lymphs-20.1 Monos-3.6 Eos-2.8
Baso-0.3
[**2104-1-14**] 05:01PM BLOOD Neuts-71.8* Lymphs-20.9 Monos-4.5 Eos-2.3
Baso-0.5
[**2104-1-16**] 06:20AM BLOOD PT-14.1* PTT-29.4 INR(PT)-1.2*
[**2104-1-18**] 07:30AM BLOOD Glucose-60* UreaN-9 Creat-1.3* Na-137
K-4.0 Cl-104 HCO3-25 AnGap-12
[**2104-1-17**] 08:50AM BLOOD Glucose-72 UreaN-11 Creat-1.3* Na-139
K-4.0 Cl-105 HCO3-25 AnGap-13
[**2104-1-16**] 06:20AM BLOOD Glucose-73 UreaN-15 Creat-1.3* Na-141
K-3.9 Cl-111* HCO3-20* AnGap-14
[**2104-1-15**] 05:08AM BLOOD Glucose-81 UreaN-22* Creat-1.6* Na-138
K-4.0 Cl-112* HCO3-18* AnGap-12
[**2104-1-14**] 05:01PM BLOOD Glucose-122* UreaN-27* Creat-2.3* Na-134
K-4.1 Cl-102 HCO3-22 AnGap-14
[**2104-1-18**] 07:30AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.3*
[**2104-1-14**] 02:50PM BLOOD Calcium-8.3* Phos-5.7*# Mg-1.4*
Brief Hospital Course:
1. Hypotension: On admission, the idea that the patient had
evidence of sepsis given leukocytosis was considered. Possible
sources included septic knee (with resulting bacteremia); less
evidence for pulmonary, GI, or GU. Thought that hypovolemic,
cardiogenic, anaphylactic etiologies less likely. PE a
possibility given ortho procedure this fall and prior clot
history but seems less likely as not hypoxic. No evidence for
tamponade. The patient was volume resuscitated, given empiric
vancomycin and ceftriaxone to cover for possible septic joint,
however knee films and ortho eval of right knee suggestive that
knee not nidus of infection. Held home [**Last Name (un) **] and beta blocker.
Cardiac enzymes cycled.
2. Acute on chronic renal failure: Likely seccondary to
hypotension. Improved with fluids. Renally dosed meds and
avoid nephrotoxins, hold [**Last Name (un) **]
3. Anemia: Patient likely hemoconcentrated at admission. No
active bleeding. Iron, B12, folate levels within normal limits
[**9-16**]. Followed hct daily, type +screen. Patient did not
require a transfusion.
4. Chronic pain: Continued home pain medications with holding
parameters
5. h/o chronic pancreatitis: Continued pancreatic enzyme
replacement, pain meds as above
6. DM: Continued insulin, follow fingersticks goal <150
7. CAD: Continued ASA, statin. Held [**Last Name (un) **] in setting of renal
failure and BB in setting of hypotension.
8. Crohn's disease: Continued mesalamine
9. CHF, chronic, diastolic: Held [**Last Name (un) **] and BB as above. Appeared
euvolemic on exam.
10. h/o EtoH abuse: Patient denied any recent drinking.
Medications on Admission:
creon
ciprofloxacin 250mg po bid
cymbalta
neurontin
folate
hydroxyzine
insulin glargine
mesalamine
metoprolol
omeprazole
oxycodone and oxycontin
simvastatin
omeprazole
valsartan
asa 81mg po daily
vitamin D
ferrous sulfate
ambien prn
tylenol
Discharge Medications:
1. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times
a day.
5. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for itching.
8. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) Units
Subcutaneous qHS.
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
twice a day.
16. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
17. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Homecare
Discharge Diagnosis:
Primary:
Hypotension
Right ankle sprain s/p fall
Secondary:
s/p Right Total Knee Replacement
Discharge Condition:
Good
Discharge Instructions:
You were admitted with hypotension (low blood pressure) and were
treated with pressors and fluids with resolution of your
symptoms. You were also given a short course of antibiotics. You
were monitored after the discontinuation of your antibiotics and
have done well. It is very important that you follow up with
your primary care physician for further monitoring. You should
also return to the ED if you develop a fever, night sweats,
shortness of breath or any symptoms that concern you. You should
also monitor your knee for any evidence of increased redness,
swelling or increased drainage from your wound.
.
Because you had decreased blood pressure your valsartan to 40 mg
daily. Your metoprolol has been changed to metoprolol tartrate
50mg twice daily. (Please ensure that your are taking metoprolol
TARTRATE 50mg twice daily and not metoprolol SUCCINATE - you
have had multiple prescriptions in the past by both names) You
should discuss these changes with your regular doctor.
Please return to the ED or call your regular doctor if you
experience fever, chills, shortness of breath, abdominal pain,
knee pain that is worse, discharge or puss form your knee or any
other symptom that concerns you.
Followup Instructions:
Please maintain your scheduled follow up listed below:
Internal Medicine:
Provider: [**First Name11 (Name Pattern1) 2482**] [**Last Name (NamePattern4) 10466**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2104-1-23**] 8:20
Orthopedics:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2104-2-1**] 11:20
Gastroenterology:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2104-2-4**] 11:45
Infectious Disease:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-2-7**]
10:30
Completed by:[**2104-5-12**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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|
5239, 6885
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286, 292
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241, 248
|
320, 1526
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1548, 2231
|
2247, 2507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,243
| 107,769
|
26200
|
Discharge summary
|
report
|
Admission Date: [**2191-3-4**] Discharge Date: [**2191-3-4**]
Date of Birth: [**2153-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
ethanol intoxication, suicidal ideation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
38yoM h/o EtoH and heroin abuse, h/o SI attempt in [**2186**], BIBEMS
after verbal acclimation of pending suicide attempt, found to be
intoxicated with concern for withdrawal, admitted to [**Hospital Unit Name 153**] for
withdrawal monitoring.
Patient was brought to ED after he told his uncle that he was
going to jump off the BU bridge. Uncle found [**Name2 (NI) **] on patient.
In [**Hospital1 18**] ED, afebrile, hr 107 to 140, sbp 160/59, 97%ra, rr 17,
Patient walking and asking for ativan with ethanol level of 486.
Given 10mg po diazapem, then with increased tachycardia and htn,
so given 10mg iv, angry when denied ativan. Patient section 12
due to suicidal attempt; pt evasive/circumferential when asked
direct questions. Initially admitted to heroin abuse, then
denied. Admitted to [**Hospital Unit Name 153**] for monitoring given multiple triggers
on CIWA scale.
Past Medical History:
1. ADHD
2. learning disorder (dyslexia)
3. major depression
4. bipolar affective disorder
5. antisocial personality disorder
6. hx head trauma [**1-31**] a beating during court-mandated vocational
program in TX
7. ethanol abuse - szs [**1-31**] ethanol withdrawal/DTs, per pt
8. ?heroin use
.
Psych hx: Bridgwater x2, "21" psych hospitalizations in [**State 2690**],
>50 detoxes, last 2yrs ago. Suicide attempt [**2186**] - hanging.
Social History:
Etoh: + since [**94**], reportedly up to 2pints of vodka/d 2-3 days/wk
Tobacco: 3ppd, smoking since age 13
Illicit Drug Use: cocaine/heroin, both IV. Last used cocaine
[**3-2**], heroin [**2-28**]. Pt reports multiple detox programs. Marijuana
once weekly, methamphetamine once weekly.
Denied sexual activity. Lives in [**Location **], lost job as
cook/prep employee of 17 years. Stated he is a registered sex
offender from an incident several years ago when intoxicated.
Mother lives in [**State 2690**], father disabled.
Family History:
NC
Physical Exam:
T=98 BP=161/99 HR=101 RR=14 98%ra
PHYSICAL EXAM
GENERAL: cooperative, NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. R submandibular
lymph node palpated, non tender, no thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: decreased effort, CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM, [**Doctor Last Name 7282**] sign (-), 3
spiders angiomas on upper torso.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: upper ext scratches
NEURO: A&Ox3. Appropriate, odd affect. CN 2-12 grossly intact.
No asterixis.
Pertinent Results:
[**2191-3-4**] 02:45AM BLOOD WBC-6.9 RBC-4.84 Hgb-15.7 Hct-44.8 MCV-92
MCH-32.4* MCHC-35.1* RDW-13.8 Plt Ct-253
[**2191-3-4**] 02:45AM BLOOD Neuts-75.0* Lymphs-18.0 Monos-3.7 Eos-1.5
Baso-1.8
[**2191-3-4**] 02:45AM BLOOD Plt Ct-253
[**2191-3-4**] 02:45AM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-139
K-4.1 Cl-94* HCO3-20* AnGap-29*
[**2191-3-4**] 02:45AM BLOOD ALT-41* AST-107* LD(LDH)-297*
CK(CPK)-381* AlkPhos-70 TotBili-0.3
[**2191-3-4**] 02:45AM BLOOD Albumin-4.7
[**2191-3-4**] 02:45AM BLOOD Osmolal-415*
[**2191-3-4**] 02:45AM BLOOD TSH-PND
[**2191-3-4**] 02:45AM BLOOD ASA-NEG Ethanol-486* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-3-4**] 08:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2191-3-4**] 08:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2191-3-4**] 08:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
38 year old man with a history of alcohol and heroin abuse, h/o
SI attempt in [**2186**], brought in by EMS after calling uncle to
report his pending suicide attempt, found to be intoxicated with
concern for withdrawal, admitted to [**Hospital Unit Name 153**] for withdrawal
monitoring.
.
# Ethanol intoxication/cocaine use: The pt reported a
polysubstance abuse hx, significant ethanol hx, with report of
withdrawal/DTs in past. Cocaine screen (-), last reported use 2
days prior. Patient was monitored on an alcohol withdrawal
scale, was given po diazepam for tachycardia and hypertension,
but did not show other signs of withdrawal. Patient was given
thiamine, folate, multivitamins, and ivf. Labs showed a
transaminitis, likely [**1-31**] to ethanol use, but should be
rechecked in future. Patient was advised to quit drinking
ethanol.
.
# Suicide attempt: Likely triggered by recent firing from job at
a [**Location (un) 6002**] shop where the pt had been employed for 17 years. The
pt reported being followed by psych, and reported a history of
suicidal ideation in past. The pt was initially section 12,
cannot leave AMA, as per psych recs in ED. He was transferred
to [**Hospital Unit Name 153**] with sitter. The psychiatry team then determined that
the pt did not qualify for section 12, and the pt willingly
accepted admission to an inpatient psychiatric treatment
facility. TSH was normal on this admission.
.
# Anion-gap acidosis: On admission the pt's AG was 25, likely
secondary to ethanol. Osmolar gap suggested other unaccounted
anion, but on repeat electrolyte check the anion gap had
resolved.
.
Medications on Admission:
none
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q1H (every hour)
for 10 doses: Please give every hour for symptoms of withdrawal
(tachycardia, tremor) and hold for symptoms of sedation,
intoxication (slurred speech, ataxic gait).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. ethanol intoxication
Secondary:
Suicidal ideation, suicide attempt, alcohol withdrawal
Discharge Condition:
patient discharged to detox center, ambulating, tolerating PO
feeds
Discharge Instructions:
Mr [**Known lastname **]: You were admitted for alcohol intoxication, concern for
suicidal ideations, and you were evaluated by psychiatry. You
were given fluids and was medication for alcohol withdrawal.
You were discharged in stable condition.
.
Please seek medical attention if you develop chest pain,
shortness of breath, nausea, vomiting, or any other concern that
is out of the ordinary.
Followup Instructions:
Please arrange follow up for the pt with his primary care doctor
(Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 17826**]) when he leaves inpatient
psychiatric treatment.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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6007, 6022
|
4007, 5632
|
359, 366
|
6157, 6227
|
3025, 3984
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,512
| 155,861
|
20788
|
Discharge summary
|
report
|
Admission Date: [**2188-2-27**] Discharge Date: [**2188-3-6**]
Date of Birth: [**2141-12-4**] Sex: M
Service: MEDICINE
Allergies:
piperacillin-tazobactam-dextrs / Cipro
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
shortness of breath and purulent sputum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46M with Bronchectasis s/p lobectomy in [**2163**] presents to ED
with complaints of cough productive of green sputum, dspnea and
fever x 2 months. He initially notieced worsening of sx on [**2-16**]
with increased sputum production, and dyspnea worse when laying
flat due to sputum production. He was seen by his PCP [**2-18**] who
performed CXR showing pneumonia, he was treated with
moxifloxicin and prednisone taper. The symptoms did not improve
and he continued to spike fever to 101. He was seen in pulmonary
clinic today where vitals were t:101, 104/50 p117 anf 91% on RA
he was referred to the [**Hospital1 18**] ED.
.
In the ED he was noted to be hyponatremic to 122, and received
2L NS. WBC was 20.4 He received albuterol/ipratropium nebs. He
received a dose of methylprednisolone as well as
vanc/[**Last Name (un) 2830**]/azithro for CXR showing RLL PNA air fluid levels on
right and left. Peak flow was 100. He was noted to be
hypotensive to 90/60 prompting MICU admission
.
On arrival to the MICU, VS are 98.2 79 93/58 21 95% 2L.
He reports persistnet cough and sputum. He reports his sx are
overall improved from 10 days ago put persist
.
Review of systems:
(+) Per HPI
(-) Denies 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:
Bronchectasis
-erectile dysfunction
Small Bowel Obstruction
- burn to his right torso s/p release procedure at age 16
- s/p RM lobectomy [**2163**]
Social History:
Lifelong non-smoker who is originally from [**Country 10181**]. Currently
unemployed. Lives with his wife and two kids in [**Name (NI) 745**]. No EtOH,
IVDU or recreational drugs.
Family History:
five brothers and sisters, none with lung disease. Father had TB
and DM.
Physical Exam:
ON ADMISSION
Vitals: 98.2 79 93/58 21 95% 2L
General: Thin/cachectic, sitting up, tenting, moderate resp
distress. lots of secretions , right eye ptosis
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse rhonchi bilaterally. Bronchial breathing.
Inspiratory crackles more so on the left base
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
ON DISCHARGE
Vitals: 98.2 P84 BP108/66 RR 18 95% RA
General: Thin/cachectic, sitting up,right eye ptosis
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse rhonchi bilaterally. Bronchial breathing.
Inspiratory crackles bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2188-2-27**] 12:00PM BLOOD WBC-20.4* RBC-4.01* Hgb-11.1* Hct-34.6*
MCV-86 MCH-27.6 MCHC-32.0 RDW-13.6 Plt Ct-447*#
[**2188-2-27**] 12:00PM BLOOD Neuts-90.1* Lymphs-6.0* Monos-3.6 Eos-0.1
Baso-0.2
[**2188-2-27**] 12:00PM BLOOD PT-14.7* PTT-31.0 INR(PT)-1.4*
[**2188-2-27**] 12:00PM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-122*
K-5.0 Cl-86* HCO3-24 AnGap-17
[**2188-2-27**] 12:00PM BLOOD Calcium-7.7* Phos-3.7 Mg-1.8
[**2188-2-27**] 12:25PM BLOOD Lactate-1.6
CXR [**2188-2-27**]: IMPRESSION: Interval progression of airspace
disease, particularly at the left lung base concerning for
pneumonia. Superimposed air-fluid level in the left lung base
medially, potentially air within enlarged bronchus versus
cavitary pneumonia. Multiple air-fluid levels at the right lung
base suggestive of fluid within dilated bronchi as demonstrated
on previous exam. CT scan would offer additional detail.
CT CHEST [**2188-2-28**]
1. Multifocal pneumonia as seen on chest radiographs from [**2-27**].
2. Worsening cystic bronchiectasis in both lower lobes.
Air-fluid levels at
the right base are most likely secretions. No evidence of
abscess.
3. Pneumobilia. Question whether this patient has had a recent
biliary
intervention.
4. Tracheal diverticulosis, unchanged.
5. Stable mediastinal lymphadenopathy.
BRONCHOSCOPY [**2188-3-6**]
BAL samples obtained.
Extensive cystic disease
Foreign body noted and query of possible tracheo-oesophageal
fistula
Brief Hospital Course:
# Sepsis secondary to pneumonia with acute bronchiectasis:
Confirmed pneumonia noted on CT chest [**2188-2-28**]. CT chest also
showed progression of bronchiectasis with multiple fluid/air
levels. Patient was continued on broad antibiotics
Vancomycin/Meropenem/Azithromycin. Gram stain of sputum showing
4+ g- rods, 4+ g+ rods, G+ cocci in pairs and clusters,
eventually came back as contamination with oral flora. He was
started on aggressive broncho-pulmonary hygiene. Steroids were
held given no evidence of bronchospasm. A more adequate sputum
sample was required and a bronchoscopy was done on [**2188-3-6**].
However, sputum came back showing oral flora suggestive of his
airways being colonized. Bronchoscopy showed cystic disease as
well as a small foreign body which was unable to be retrieved
during procedure. This raised a concern for a new
tracheo-oesophageal fistula. Interventional pulmonary team will
work him up for this when he is back from his trip next week. He
was discharged on [**2188-3-7**] to complete home IV ertapenem (14 day
course of carbopenem). He had already a planned trip to go out
of town. It was explained to him that it was a better idea to
stay in [**Location (un) 86**] and have home IV nurses visit but he chose to
take IV antibiotics with him in his suitcase on his trip and
administer them himself abroad ([**Location (un) 19061**] and [**Location (un) 55444**]). IP will
follow up with him as an out-patient for further work-up
# Hyponatremia: Given rapid response to 2L IVF, patient was
thought to be volume deplete. His sodium remained corrected
throughout the remainder of his hospitalization.
# Hypotension: Concern for septic physiology given reported
normal baseline and significant penumonia. However, patient had
no evidence of lactic acidosis. BP did not respond to bolus.
After speakign to the patient and reviewing the medical record,
pt's BP tends to run in the 90s to low 100s.
# Coagulopathy: INR 1.4 which appears chronically elevated.
Could be nutritional vs component of liver dysfunction.
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-26**] Inhalation Q4H (every 4 hours).
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. sertraline 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
7. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once prior to
intercourse.
8. tadalafil 20 mg Tablet Sig: One (1) Tablet PO 45 minutes
prior to intercourse.
9. Moxifloxacin start on [**2-18**] up until day of admission
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-26**] Inhalation Q4H (every 4 hours).
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. sertraline 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
7. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once prior to
intercourse.
8. tadalafil 20 mg Tablet Sig: One (1) Tablet PO 45 minutes
prior to intercourse.
9. ertapenem 1 gram Recon Soln Sig: One (1) gram Injection once
a day for 12 days. Disp:*12 doses* Refills:*0*
10. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: fill and take with you and take in place of ertapenem if
anything goes wrong. Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
Bronchiectasis complicated by pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **]
You were admitted to the [**Hospital1 18**] on [**2188-2-27**] after your symptoms of
shortness of breath and coughing up sputum worsened even after
an oral course of levoquin and steroids from your PCP [**Last Name (NamePattern4) **]
[**2188-2-18**]. On admission you had a fever and chest X-ray and CT
imaging of your chest showed evidence of a pneumonia in you left
lung and some progression of your bronchiectasis.
You were treated with oxygen, albuterol nebulisers and
antibiotics (vancomycin, meropenem and azithromycin). This
course of antibiotics lasts ten days and needs to be
administered intravenously. Since you are improving, we can
send you home with a PICC line through which the antibiotics can
be administered by a visiting nurse. Your duration of
antibiotics will be *****.
Your bone mineral density score also showed osteoporosis and it
should be discussed wtih Dr. [**Last Name (STitle) **] or your Primary care
physician about starting you on bisphosphonate tablet.
At home you will continue:
Albuterol nebulisers - 2 vials every 6 hours if needed
Fluticasone 110mcg 2 puffs twice daily
Sertraline 25mg once daily
Sildenafil 100mg 1 hour prior to intercourse
tadalafil 20 mg 1 hour prior to intercourse
Mucinex 1200mg once daily
Calcium and Vitamin D over the counter supplements.
To your regimen we added:
ipratropium nebulisers 1 vial four times a day as and when
needed.
It was a pleasure looking after you at the [**Hospital1 18**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12293**], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2188-3-25**] 8:40
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2188-4-9**] 8:40 with Dr. [**Last Name (STitle) **]
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2188-4-9**] 9:00
Completed by:[**2188-3-12**]
|
[
"486",
"733.00",
"799.4",
"494.1",
"790.4",
"276.1",
"286.9",
"263.0",
"724.2",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9040, 9106
|
5127, 7195
|
337, 343
|
9190, 9190
|
3663, 5104
|
10864, 11341
|
2225, 2299
|
8015, 9017
|
9127, 9169
|
7221, 7992
|
9341, 10841
|
2314, 3644
|
1557, 1839
|
258, 299
|
371, 1538
|
9205, 9317
|
1861, 2011
|
2027, 2209
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,547
| 163,474
|
2889
|
Discharge summary
|
report
|
Admission Date: [**2116-9-30**] Discharge Date: [**2116-10-20**]
Date of Birth: [**2071-10-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
bacteremia
Major Surgical or Invasive Procedure:
Removal of HD line
History of Present Illness:
Mr. [**Known lastname 13974**] is a 44 year-old man with paraplegia s/p multiple
spinal and hip/groin infections, ESRD on HD, recent SBO
complicated by ischemic bowel s/p colectomy with primary
anastamosis [**2116-9-4**], who presents with hypotension, fevers,
and positive blood cultures from rehab. He had a R subclavian
tunneled line (placed [**2-/2116**]) through which he was receiving
dialysis MWF. He was in his usual state of health until, on [**8-28**]
at dialysis, he had a temperature fo 38. Blood cultures were
drawn. After dialysis he felt awful, consisting mostly of chills
and malaise without any change in his chronic nausea or
abdomianl pain. He did not have any pain around the line site.
Today, blood cultures grew staph aureas, sensitivities
unknown. He was given 1 g of vancomycin and transferred to
[**Hospital1 18**]. Of note, blood pressures on all prior notes at [**Hospital 3278**]
Medical Center where he lives have been 70-90 systolic.
.
In the ED, initial VS 101.4 108 90/47 20 100%. He was given
piperacillin-tazobactam. HD line was removed by IR. Surgery
was consulted and recommended CT abdomen which showed no
evidence of ischemic bowel but did demonstrate a thrombus in the
SVC. He was given a heparin bolus followed by drip. He was
also given a total 1.5 L of NS. VS prior to transfer: BP now
93/50 after 1.8 L total IVF. VS prior to transfer: 99.3, 101,
93/52, 97% RA
.
On acceptance to the ICU, the patient feels well but does
complain of his chronic low back pain, pain at the site of the L
EJ catheter, and chronic abdominal pain. He denies further
chills, nausea. He also denies chest pain, shortness of breath.
He does not make urine.
Past Medical History:
- Paraplegia ([**2101**], T11 level; fell out of window from 3rd story
at detox facilty -> spinal burst fractures)
- Renal amyloidosis by biopsy [**2-/2116**]; on HD since [**2-29**] via R
tunnelled subclavian line. S/p failed R arm fistula.
- Osteomyelitis of the left hip in [**2111**], s/p girdlestone
procedure to remove proximal femur
- left groin abscess [**2111**], s/p L orchiectomy and debridement,
had considered hemipelvectomy with colostomy
- DVT of the LE, [**2111**]
- [**Female First Name (un) **] parapsilosis bacteremia, [**2111**]
- bacteroides fragilis bacteremia, [**2111**]
- h/o polysubstance abuse
.
Past Surgical history
-multiple spinal surgeries initially for rodding/fusion of
T11/12-sacral spine [**2101**]
-multiple debridements of spine, hip, girdle stone [**2111**]
-multiple groin debridements [**2111**]
-L orchiectmy [**2111**]
-SBO complicated by ischemic bowel s/p colectomy with primary
anastamosis [**2116-9-4**]
Social History:
Had been living at home. Remote h/o drug and alcohol abuse.
Single. On disability. Musician.
Family History:
MI and HTN in father
Physical Exam:
VS: 99.8 106/62 96 97%RA
Constitutional: comfortable, pale, friendly, oriented x 3
HEENT: MMM, EOMI, anicteric sclera
Lungs: CTA-B, good aeration b/l
Cardiovascular: RRR, soft systolic ejection murmur
Abdominal: soft, mildly distending, nontender, large midline
scar +BS
Extr/Back: Sacral and bilateral gluteal ulcers that are deep but
do not probe to bone. No purulence or surrounding erythema. Left
groin ulcer probes to bone. There are also multiple ulcers on
legs -L dorsal foot, R leg, L heel, all of which appear clean,
dry, and without purulence; 3+ pitting edema bilaterally
Neuro: insensate below the level of the umbilicus, CN II-XII
intact
Pertinent Results:
On admission:
[**2116-9-29**] 10:50PM BLOOD WBC-7.2 RBC-2.53* Hgb-8.0* Hct-25.6*
MCV-101* MCH-31.5 MCHC-31.1 RDW-17.4* Plt Ct-250
[**2116-10-4**] 11:50PM BLOOD WBC-7.2 RBC-1.79* Hgb-5.6* Hct-17.6*
MCV-98 MCH-31.2 MCHC-31.7 RDW-17.9* Plt Ct-323
[**2116-10-5**] 12:54AM BLOOD WBC-7.4 RBC-1.79* Hgb-5.5* Hct-16.8*
MCV-96 MCH-30.6 MCHC-31.8 RDW-18.1* Plt Ct-332
[**2116-10-5**] 04:46AM BLOOD WBC-6.3 RBC-1.94* Hgb-6.1* Hct-18.5*
MCV-96 MCH-31.3 MCHC-32.7 RDW-18.2* Plt Ct-275
[**2116-10-5**] 05:13AM BLOOD WBC-6.3 RBC-1.98* Hgb-6.0* Hct-19.0*
MCV-96 MCH-30.4 MCHC-31.7 RDW-18.1* Plt Ct-260
[**2116-10-8**] 02:45AM BLOOD WBC-6.6 RBC-2.65* Hgb-8.2* Hct-24.3*
MCV-92 MCH-30.8 MCHC-33.5 RDW-18.6* Plt Ct-253
[**2116-10-9**] 07:14AM BLOOD WBC-9.6 RBC-3.09* Hgb-9.5* Hct-27.9*
MCV-90 MCH-30.9 MCHC-34.2 RDW-18.6* Plt Ct-326
[**2116-10-11**] 05:25AM BLOOD WBC-10.9 RBC-2.98* Hgb-9.3* Hct-27.7*
MCV-93 MCH-31.3 MCHC-33.7 RDW-20.9* Plt Ct-333
[**2116-10-12**] 04:05AM BLOOD WBC-11.6* RBC-2.57* Hgb-8.1* Hct-24.9*
MCV-97 MCH-31.6 MCHC-32.6 RDW-20.8* Plt Ct-292
[**2116-10-13**] 06:06AM BLOOD WBC-11.0 RBC-2.57* Hgb-8.2* Hct-24.4*
MCV-95 MCH-32.1* MCHC-33.7 RDW-20.6* Plt Ct-308
[**2116-10-14**] 06:03AM BLOOD WBC-7.4 RBC-2.38* Hgb-7.7* Hct-22.8*
MCV-96 MCH-32.4* MCHC-33.9 RDW-20.5* Plt Ct-260
[**2116-10-14**] 10:39AM BLOOD Hct-24.4*
[**2116-9-29**] 10:50PM BLOOD Neuts-87.3* Lymphs-9.2* Monos-1.8*
Eos-0.9 Baso-0.8
[**2116-9-29**] 10:50PM BLOOD PT-13.6* PTT-33.4 INR(PT)-1.2*
[**2116-9-29**] 10:50PM BLOOD Plt Ct-250
[**2116-9-30**] 09:21AM BLOOD PTT-55.6*
[**2116-10-14**] 01:42PM BLOOD PT-14.5* PTT-35.8* INR(PT)-1.3*
[**2116-10-14**] 06:03AM BLOOD Plt Ct-260
[**2116-10-14**] 06:03AM BLOOD PT-14.7* PTT-45.9* INR(PT)-1.3*
[**2116-10-5**] 05:13AM BLOOD Fibrino-288#
[**2116-10-5**] 05:13AM BLOOD Ret Aut-0.6*
[**2116-9-29**] 10:50PM BLOOD Glucose-87 UreaN-27* Creat-2.7* Na-131*
K-5.0 Cl-96 HCO3-25 AnGap-15
[**2116-9-30**] 09:21AM BLOOD Glucose-81 UreaN-34* Creat-2.7* Na-133
K-4.7 Cl-100 HCO3-26 AnGap-12
[**2116-10-1**] 01:24PM BLOOD Glucose-86 UreaN-42* Creat-3.7* Na-134
K-5.5* Cl-101 HCO3-24 AnGap-15
[**2116-10-6**] 03:49AM BLOOD Glucose-69* UreaN-59* Creat-3.1* Na-138
K-4.9 Cl-106 HCO3-23 AnGap-14
[**2116-10-7**] 03:14AM BLOOD Glucose-63* UreaN-33* Creat-2.2* Na-139
K-4.3 Cl-106 HCO3-25 AnGap-12
[**2116-10-8**] 02:45AM BLOOD Glucose-77 UreaN-21* Creat-1.9* Na-137
K-4.2 Cl-104 HCO3-28 AnGap-9
[**2116-10-12**] 04:05AM BLOOD Glucose-101* UreaN-18 Creat-2.0* Na-136
K-4.1 Cl-106 HCO3-26 AnGap-8
[**2116-10-13**] 06:06AM BLOOD Glucose-79 UreaN-32* Creat-2.7* Na-134
K-4.8 Cl-103 HCO3-26 AnGap-10
[**2116-10-14**] 06:03AM BLOOD Glucose-84 UreaN-26* Creat-2.0* Na-134
K-4.5 Cl-101 HCO3-28 AnGap-10
[**2116-10-5**] 05:13AM BLOOD LD(LDH)-150
[**2116-9-30**] 09:21AM BLOOD AlkPhos-192*
[**2116-9-29**] 10:50PM BLOOD ALT-20 AST-21 AlkPhos-249* TotBili-0.2
[**2116-9-29**] 10:50PM BLOOD Lipase-21
[**2116-9-29**] 10:50PM BLOOD cTropnT-0.09*
[**2116-9-29**] 10:50PM BLOOD Albumin-2.2* Calcium-6.9* Phos-2.9 Mg-1.6
[**2116-9-30**] 09:21AM BLOOD Calcium-6.5* Phos-3.0 Mg-1.5*
[**2116-10-1**] 01:24PM BLOOD Calcium-6.9* Phos-3.9 Mg-1.6
[**2116-10-2**] 07:20AM BLOOD Calcium-6.8* Phos-4.9* Mg-1.6
[**2116-10-10**] 06:06AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.9
[**2116-10-12**] 04:05AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.9
[**2116-10-13**] 06:06AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.0
[**2116-10-14**] 06:03AM BLOOD calTIBC-49* Ferritn-837* TRF-38*
[**2116-10-5**] 05:13AM BLOOD Hapto-154
[**2116-10-3**] 07:58AM BLOOD pH-7.35
[**2116-10-2**] 07:45AM BLOOD Type-ART pH-7.51*
[**2116-9-30**] 10:01AM BLOOD Type-[**Last Name (un) **] pH-7.40 Comment-GREEN TOP
[**2116-9-29**] 11:11PM BLOOD Lactate-2.7*
[**2116-10-3**] 07:58AM BLOOD freeCa-1.12
[**2116-10-2**] 07:45AM BLOOD freeCa-0.85*
[**2116-9-30**] 10:01AM BLOOD freeCa-0.92*
.
On Discharge: [**10-20**]
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.1 2.61* 8.4* 25.8* 99* 32.1* 32.4 19.3* 358
Glucose UreaN Creat Na K Cl HCO3 AnGap
87 28* 2.2* 138 4.4 102 30 10
Calcium Phos Mg
7.4 3.5 1.9
.
Hep panel: pending
.
MICRO:
[**2116-9-29**]
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- 1 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
Blood Culture, Routine (Final [**2116-10-6**]):
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
WOUND CULTURE (Final [**2116-10-3**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
OXACILLIN------------- 1 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
.
JOINT FLUID LEFT HIP ASPIRATE.
**FINAL REPORT [**2116-10-11**]**
GRAM STAIN (Final [**2116-10-7**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2116-10-11**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 1140A, [**2116-10-8**].
PSEUDOMONAS AERUGINOSA.
SPARSE GROWTH OF THREE COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
.
[**2116-10-11**] 10:00 am TISSUE LEFT DEEP HIP.
GRAM STAIN (Final [**2116-10-11**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2116-10-14**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 13975**] [**2116-10-12**] 13:05.
PSEUDOMONAS AERUGINOSA.
SPARSE GROWTH OF THREE COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 8 I
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
.
Portable TTE (Complete) Done [**2116-9-30**] at 12:05:19 PM
FINAL
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No masses or vegetations are seen on the aortic valve.
Mild (1+) aortic regurgitation is seen. The aortic regurgitation
jet is eccentric. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. No mass or vegetation
is seen on the mitral valve. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
No masses or vegetations are seen on the pulmonic valve, but
cannot be fully excluded due to suboptimal image quality. There
is a very small pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild aortic regurgitation.
No apparent echocardiographic evidence of endocarditis.
Preserved regional and global biventricular systolic function.
Moderate pulmonary hypertension.
If clinically indicated, a transesophageal echocardiogram may
better assess for valvular vegetations.
.
CT PELVIS W/CONTRAST Study Date of [**2116-9-30**] 12:59 AM
IMPRESSION:
1. Thrombus within the superior vena cava, with organization and
peripheral location suggestive of chronic timeframe.
2. Postoperative change and fluid within the abdomen that is
nonspecific with no dilated loops of small or large bowel.
Questionable sigmoid thickening versus underdistension, that is
unchanged since [**2116-9-4**]. No abnormal intra-abdominal fluid
collections. Subcutaneous emphysema likely related to
post-surgical change.
3. Extensive multiple bony deformities and fluid collection
between the left femoral neck and left acetabulum from known
chronic osteomyelitis. The fluid collection appears increased
since CT from [**2116-9-4**].
4. Splenomegaly.
5. Subcutaneous emphysema in the right anterior chest wall,
likely related to recent instrumentation.
.
EGD [**2116-10-6**]:
Impression: Erythema and congestion in the antrum compatible
with mild gastritis
Retained fluids in stomach
Bilious fluid was seen in the stomach and duodenum.
Otherwise normal EGD to third part of the duodenum
Recommendations: The findings do not account for the symptoms
Will discuss with team re: small intestinal evaluation for
source of bleeding (capsule vs tagged RBC scan vs CT
Angiography).
Brief Hospital Course:
A 44 year-old man with a history of paraplegia and ESRD with
tunnelled HD line presents with fevers and positive blood
cultures from HD.
.
# Staph aureas and proteus bacteremia: Patient with MRSA in his
blood at HD and at [**Hospital1 **]. Most likely secondary to HD line, but
patient also has multiple wounds, any of which could potentially
seed his blood. Currently none of the wounds have purulent
drainage or otherwise appear infected. Pt was never
hemodynamically unstable given his baseline BPs are high 70s to
90s. The patient's HD line was removed on arrival to [**Hospital1 **]. His
cultures at [**Hospital1 18**] show blood culture positive for Proteus on
[**9-29**], catheter tip culture positive for MRSA on [**9-30**], and wound
culture positive for MRSA on [**9-30**]. ID consulted. Patient was
treated with vancomycin and initially cefepime. Cefepime later
transitioned to ceftaz (dosing at HD) with a plan for a total of
6week. Once blood cultures cleared a permanent tunnel line later
placed. He was on flagyl earlier in the admission which was
discontinued on [**10-5**] as there was no clear indication. Plan to
follow up in [**Hospital 4898**] clinic.
.
#. Drainage of fluid collection around left acetabulum:
Infectious disease was consulted and felt that the pt's
collection in his left hip was increased from prior CT and
recommended sampling and drainage as this was also another
likely source of infection/bacteremia. Because the pt became
unstable, drainage and full washout was delayed initially but
aspiration culture showed pseudomonas. Pt was then placed on
cefepime (start date of [**10-8**]). After he was stablized (see GI
bleed section below) he went to OR w/ortho on [**10-11**] and is s/p
washout and drain placement [**10-11**]). Site healed well without
complication. Drain pulled on [**10-13**]. Per ortho will follow-up in
ortho clinic in 1 week for removal of left hip sutures: Monday
[**10-26**] at noon. At discharge site looked to be healing well with
minimal tenderness, no drainage.
.
# GI bleed: Hct fell acutely from 22.7 to 16 on night of
[**2117-10-7**]. There was report of melena. He was given 2 units
pRBC with appropriate bump in Hct. he was placed on a
pantoprazole gtt. His endoscopy showed gastritis but there was
concern for possible bleed at anastomosis site. He was
transfused additional units of RBCs on [**10-8**] to give HCT room in
case he bled on the hep gtt; pt received a total of 6 units. He
was changed to pantoprazole 40mg [**Hospital1 **] IV on [**10-8**]. The plan was
for capsule study should he rebleed. He stablized and did not
rebleed during the remainder of his stay. No further imaging
performed. Transitioned to PPI [**Hospital1 **]. He was able to be
transferred back the medicine floor on [**10-9**]. HCT were monitored
and remained stable. HCT at time of discharge: 25.8. Per GI,
will plan to discharge patient on [**Hospital1 **] PPI for next 3 weeks. Will
be seen by GI as outpatient.
.
# Anemia. Acute anemia in house secondary to GI bleed however
patient with baseline normocytic anemia. Receives EPO at HD.
Labs reveal inappropriate retic count. Iron studies reflective
of anemia of chronic disease. Hemolysis labs negative. HCT
monitored. Stable at time of discharge.
.
# SVC DVT: SVC clot was seen on a non-contrast CT on prelim
read. This was presumably caused by HD line which had come
infected and was removed. He was started on a heparin gtt. This
was stopped when there was concern for GI bleed, as above.
Survellance blood cultures were taken to determine when it as
safe for preminent line placement (temp line was placed for HD
in the meantime). A tunneled HD line was placed on [**10-8**].
Patient was started on coumadin on [**10-13**]. Heparin stopped on
[**10-17**] after patient had been therapeutic for 24hrs. Patient
started on coumadin 5mg daily. Coumadin held on [**12-1**] due
to supra-therapeutic INR. INR at time of discharge: 2.7.
Coumadin 5mg restarted on [**10-20**]. Plan for INR to be checked at
rehab. Plan to anti-coagulate for 3-6mths. At 3mth plan to
reassess need for ongoing anti-coagulation with PCP; risks vs
benefits as patient with h/o GI bleed.
.
# ESRD: Apparently secondary to amyloidosis, on HD since
[**09**]/[**2115**]. Renal placed a temporary IJ access for dialysis. A
tunneled line was placed on [**10-8**]. Sevelamer, calcium acetate,
and nephrocaps were continued. Line without tenderness, erythema
at time of discharge. Will follow-up with outpatient
nephrologist and continue HD as scheduled.
.
# Hypotension: Per notes at rehab and review of records from
recent admission here, baseline SBP has been running high 70s to
90s. Midodrine was continued in house.
.
# Paraplegia: complicated by multiple ulcers and severe
constipation. Continue aggressive outpatient bowel regimen.
Wound care was consulted and recommendations followed.
.
FEN: renal diet
Comm: mother [**Name (NI) 450**] [**Name (NI) 13976**] [**Telephone/Fax (1) 13977**], HCP
[**Name (NI) 7092**]: FULL CODE, confirmed with patient
.
Follow-up with ID and [**Name (NI) 5498**]. D/c'ed to rehabilitation
facility
Medications on Admission:
heparin 5000 units TID
bisacodyl 10 mg daily
PEG 17 g daily
docusate 100 mg [**Hospital1 **]
magnesium hydroxine 400 mg q12h
duloxetine 60 mg daily
senna 17.2 mg [**Hospital1 **]
nephrocaps 1 cap daily
gabapentin 600mg after HD
calcium acetate 667 mg tid with meals
albuterol nebulizers
clonazepam .5 mg tid
sevelamer 800 mg [**Hospital1 **]
lisinopril 20 mg daily
oxycodone 20 mg q4h prn
oxycontin 20 mg [**Hospital1 **]
acetaminophen [**Telephone/Fax (1) 1999**] mg q6h prn
famotidine 20 mg [**Hospital1 **]
geodon 40 mg qam, 60 mg pqm
midodrine 5 mg TID on non HD days; 10 mg TID on HD days
collagenase clostridium hist. 250 unit/g Ointment daily
Discharge Medications:
1. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO AFTER
DIALYSIS ().
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, cough, wheeze.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety/agitation.
6. ziprasidone HCl 20 mg Capsule Sig: Two (2) Capsule PO QAM
(once a day (in the morning)).
7. ziprasidone HCl 20 mg Capsule Sig: Three (3) Capsule PO QPM
(once a day (in the evening)).
8. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
13. oxycodone 5 mg Tablet Sig: Four (4) Tablet PO Q4H (every 4
hours) as needed for pain.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-23**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
17. collagenase clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily).
18. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
19. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol).
20. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
21. ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln
Injection QHD (each hemodialysis).
22. Outpatient Lab Work
Please obtain weekly CBC w/diff; Chem 7; LFTs; ESR, CRP,
Vancomycin trough, please fax to infectious disease clinic ([**Telephone/Fax (1) 10739**]
23. Outpatient Lab Work
Please obtain daily INR to monitor anticoagulation
24. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
25. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
26. senna 8.6 mg Capsule Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
27. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
28. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for
nausea/vomitting.
29. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Bacteremia likely related to either a line infection or due to
collection in the left hip
SVC clot
left hip infection + pseudomonas
Paraplegia
Multiple chronic non-healing ulcers
.
Secondary:
ESRD on hemodialysis
Pneumonia
Anemia
hypotension
GI bleed, unknown source
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital because of low blood pressure
and fevers at dialysis. You were found to have a possible
infection of your dialysis line and a clot in the blood vessel
that was likely infected. Your dialysis line was removed. You
were also found to have pneumonia, which was treated with
antibiotics.
.
For your clot, you received heparin to help prevent the clot
from increasing. However while in the hospital you also had
bleed in your gastrointestinal track which required blood
transfusion and readmission to the ICU. Although you had a EGD
to try to identify the source of the bleed, no definitive source
could be identified. Your blood counts were monitored closely
and they were found to be stable. Prior to discharge your
anticoagulation was transitioned from heparin to coumadin.
.
It was also felt that the collection in your left hip had
increased in size and might also be another source of infection.
Once you were stable and out of the ICU, you were taken to the
OR by [**Location (un) **] to have this washed out and a drain placed.
Cultures showed that this collection was growing Pseudomonas
which appeared to be sensitive to the antibiotics you were on.
.
Your condition improved and you were able to be discharged to a
rehabilitation facility to complete your recovery before
returning home.
.
After your blood cultures remained negative for a number of
days, it was determined safe to replace your dialysis line. You
will continue to received dialysis as scheduled as an
outpatient.
.
The following changes were made to your medications:
- Please continue to take IV Vancomycin and Ceftazidine for
treatment of the infection that was found in your blood and your
hip. You will continue treatment for a total of 6weeks and
follow-up with ID.
- Please START taking warfarin to continue the treatment of your
clot; you will continue anti-coagulation for 6mths time. You
will need to have your INR monitored at rehab and at home.
- Please START taking Ziprasidone Hydrochloride 40 mg PO/NG QAM
and Ziprasidone Hydrochloride 60 mg PO/NG QPM.
- Please CONTINUE using Advair, albuterol and ipratropium
nebulizers while you recover from your pneumonia; plan to [**Doctor Last Name **]
for at least 1month.
- Please CONTINUE using Nicotine Patch 14 mg patch DAILY; DO NOT
SMOKE!
- Please START Pantoprazole 40mg twice daily.
- Please STOP FAMOTIDE twice daily
- Please take MIDODRINE 10mg three times daily on HD days; take
5mg three times daily on non-HD days.
- Please STOP taking lisinopril 20 mg daily
- Please continue to take all of your other home medications as
prescribed
.
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) **], GI doctors, infectious disease doctors and [**Name5 (PTitle) **]
[**Name5 (PTitle) **] providers.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) **], GI, infectious disease doctors and [**Name5 (PTitle) **] [**Name5 (PTitle) **]
providers.
.
You will need to have your INR checked as well as labs to
monitor the treatment of your infection.
.
Department: [**Name5 (PTitle) **]
When: [**10-26**] at 12 noon
With: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2116-11-2**] at 10:30 AM
With: DR. [**Last Name (STitle) 13979**] MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2116-11-5**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Gastroenterology Follow-up.
[**11-19**] at 8:20
[**Hospital Unit Name 1825**] [**Hospital Ward Name 516**] [**Location (un) 453**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2116-10-20**]
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59,570
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20608
|
Discharge summary
|
report
|
Admission Date: [**2197-12-18**] Discharge Date: [**2197-12-22**]
Date of Birth: [**2113-2-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 55087**] is a 84F with PMH of CAD, hypertension, dCHF, asthma
on prednisone who was noted to be hypotensive with sbp80s in
cardiologist's office. Patient endorsed mild fatigue and
baseline exertional dyspnea, but was otherwise asymptomatic. She
uses her asthma medications on these days and feels better. She
otherwise denies chest pain, orthopnea, PND, leg edema,
lightheadedness, syncope and palpitations.
.
In the ED, initial VS were 96.7 64 110/79 16 100%. EKG was
unchanged from prior. Labs were significant for creatinine 1.5
(baseline 0.6), HCT 33 (baseline 30). UA was unremarkable. Blood
cultures and urine cultures were sent. Troponin was <0.01. On
CXR, there was concern for possible pna and she was started on
cefepime and azithromycin. while in the ED, her systolic BP
dropped to 62/34. She was given 4 L NS. VS on transfer to the
MICU were T 97.4, P: 63, BP: 91/42, RR: 16, O2Sat: 100, RA.
Past Medical History:
CAD: manifest as coronary calcification seen on a CT, no hx of
MIs
Hypertension
dCHF with exertional dyspnea
Atypical chest pain
Gastritis
Asthma
Osteoarthritis s/p left total knee replacement [**2195-9-1**],
right total knee replacement [**2196-10-31**]
Osteopenia
Obesity
Stress incontinence
Depression
Breast biopsies (benign)
Umbilical herniorrhaphy
Social History:
She is from [**Country 7192**], and lives with her daughter. Denies any
tobacco, alcohol, or drug use. Uses walker at home.
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission:
T98.6 HR 65-80's BP 79-107/40-75 O2 sat 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, obese, unable to assess JVP not elevated
CV: distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: 1+ ankle edmea, warm, well perfused, 2+ pulses, no
clubbing, cyanosis
Neuro: CNII-XII intact, alert, oriented
Physical Exam on Discharge:
Tc97.7 Tm 98.3 HR 64-71 BP 112-146/50-63 RR 18 O2 sat 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, obese, JVP not elevated
CV: distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: 1+ ankle edmea, warm, well perfused, 2+ pulses, no
clubbing, cyanosis
Neuro: CNII-XII intact, alert, oriented
Pertinent Results:
Labs on Admission:
[**2197-12-18**] 12:43PM BLOOD WBC-10.0 RBC-3.50* Hgb-10.9* Hct-33.2*
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.0 Plt Ct-172
[**2197-12-18**] 12:43PM BLOOD Neuts-72.5* Lymphs-20.6 Monos-3.6 Eos-2.9
Baso-0.4
[**2197-12-18**] 12:43PM BLOOD Glucose-98 UreaN-48* Creat-1.5* Na-136
K-5.1 Cl-101 HCO3-27 AnGap-13
[**2197-12-19**] 04:23AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
[**2197-12-18**] 03:47PM BLOOD Lactate-1.1
Cardiac Enzymes:
[**2197-12-19**] 04:23AM BLOOD CK(CPK)-52
[**2197-12-19**] 04:23AM BLOOD CK-MB-2 cTropnT-<0.01
[**2197-12-18**] 12:43PM BLOOD cTropnT-<0.01
AM Cortisol:
[**2197-12-20**] 07:05AM BLOOD Cortsol-3.8
[**2197-12-19**] 04:23AM BLOOD Cortsol-4.3
Micro:
Blood cultures 12/19: NGTD at the time of discharge
Imaging:
Portable CXR [**12-18**]: IMPRESSION: No acute cardiopulmonary
process.
Labs on Discharge:
[**2197-12-22**] 07:37AM BLOOD WBC-9.3 RBC-3.26* Hgb-10.1* Hct-30.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-13.4 Plt Ct-156
[**2197-12-22**] 07:37AM BLOOD Glucose-84 UreaN-14 Creat-0.8 Na-140
K-4.3 Cl-102 HCO3-32 AnGap-10
[**2197-12-22**] 07:37AM BLOOD Calcium-9.5 Phos-3.4 Mg-1.8
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Ms. [**Known lastname 55087**] is a 84F with PMH of CAD, hypertension, dCHF, asthma
on chronic prednisone, who was found to be hypotensive to 62/34
in the ED.
ACTIVE DIAGNOSES:
#Hypotension: Patient presented to her cardiologist for routine
follow-up and was found to have systolic BP in the 80s. She
felt mildly fatigued and had baseline dyspnea on exertion. She
denied chest pain, dizziness, confusion. Also denied cough,
fever, chills, dysuria, diarrhea, or other signs of infection.
CXR was clear and UA only had 2 WBCs. Differential for
hypotension included cardiogenic, septic, hypovolemic or
distributive from adrenal insufficiency (patient on chronic
steroids for asthma). She did not appear to be in heart
failure, thus leading to low suspicion of cardiogenic process.
EKG was unchanged and cardiac enzymes in ICU were trended and
remained negative. Patient also had no infectious symptoms to
suggest sepsis. An AM cortisol was checked and returned
appropriately low at 4.4 (her adrenals have been suppressed by
exogenous steroids). Acute kidney injury and mild
hemoconcentration suggests hypovolemia to be the etiology of her
hypotension, possibly in the setting of BP meds persisting
secondary to renal failure, and aggressive diuresis. After
receiving 3L NS in the ED, she became normotensive and remained
normotensive in the ICU. She received no more fluids while in
the ICU and metoprolol, enalapril, and lasix were held. She was
monitored on telemetry with no events. Endocrine consult does
not believe adrenal insufficiency led to hypotension. Per PCP,
[**Name10 (NameIs) **] was kept on prednisone 10mg daily because had asthma
attack when was tapered to 7.5mg. PT cleared patient to go home
with home PT (patient initially desatted to 87% on RA while
walking, but sounded wheezy and O2 sat came up quickly after
resting, but on repeat the next day, patient did not desat while
walking and maintained 97% on RA). After discussion with Dr
[**Last Name (STitle) **], patient will be put back on lasix 20mg daily and
enalapril 5mg daily. She should monitor her bp at home and will
f/u with him as outpatient.
#Acute kidney injury: On admission, creatinine was elevated to
1.5 from baseline 1.1, likely secondary to volume depletion from
diuretics. UA was negative for UTI. She received 3L NS in the ED
and repeat Cr in the morning was back to baseline 1.1.
Diuretics and ACEi were held in the setting of [**Last Name (un) **]. Creatinine
was trended with daily improvement. Lasix was restarted prior
to discharge, and patient was notified to restart enalapril at a
lower 5mg dose 5 days after discharge.
#Adrenal Insufficiency. This is secondary to chronic prednisone
therapy and AM cortisol is appropriately low. Patient was
informed she should have a medical alert bracelet notifying
people she has adrenal insufficiency from prednisone use (should
she ever become very ill, she may need extra prednisone). She
should get outpatient bone mineral density test, and should
change calcium carbonate to calcium citrate since she is also on
PPI and absorption may not be as good for carbonate in the
setting of low acidity.
#Asthma: Patient has had multiple asthma exacerbations and is
now on long-term oral prednisone 10 mg po daily. When she was
tapered to 7.5mg, she had an exacerbation requiring
hospitalization. She was continued on home prednisone as well
as ipratroprium and albuterol inhalers. No wheezing was noted
during hospitalization, and no sign of asthma exacerbation
during this hospitalizaiton.
#Diastolic CHF: Patient appeared euvolemic on exam after fluid
resuscitation in ED, and had no pulmonary crackles and normal
CXR on admission. Per outpatient cardiologist, prior to
discharge, she was restarted on lasix 20mg, enalapril at a lower
dose of 5mg. Metoprolol and spironolactone were discontinued.
# Constipation: Patient is chronically constipated and usually
has a bowel movement q3-5 days. She was provided with an
aggressive bowel regimen.
CHRONIC DIAGNOSES:
# Hyperlipidemia: She was continued on her home statin regimen.
TRANSITIONAL ISSUES:
Because patient has been on chronic prednisone, she should
receive an outpatient Bone Mineral Density test and start
bisphosphonates if necessary.
Patient should wear an alert bracelet that she is on chronic
prednisone and adrenal insufficient, such that if she ever
develops serious illness, people will know she will not be able
to mount a cortisol response.
Medications on Admission:
Albuterol nebs
ENALAPRIL MALEATE 20 mg po once a day
FUROSEMIDE [LASIX] 20 mg by mouth once a day
IPRATROPIUM
METOPROLOL SUCCINATE - 25 mg po once a day
PREDNISONE 10 mg po mouth daily
SIMVASTATIN 40 mg po daily
SPIRONOLACTONE 25 mg by mouth daily (daughter thinks this has
been stopped)
TRAMADOL
ASPIRIN 81 mg by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D]
DOCUSATE SODIUM
FERROUS SULFATE
OMEPRAZOLE 20 mg by mouth once a day
Singulair
Discharge Medications:
1. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. ipratropium bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for wheezing.
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig:
One (1) NEB Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
10. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Singulair 4 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO every six (6) hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Hypotension
Diastolic Heart Failure
Asthma
Adrenal Insufficiency secondary to chronic steroid use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 55087**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with low blood pressure,
which resolved after we gave you fluids by IV. We did not give
you any of the blood pressure medication you usually take. You
also had some mild renal injury, which also resolved by itself
with fluids as well. At the time of discharge, your blood
pressure was in the normal range and you were not taking any
medications for blood pressure.
Please note that the following changes have been made to your
medications:
- Please STOP taking Spironolactone
- Please STOP taking Metoprolol
- Please DECREASE your dose of Enalapril to 5mg
- Please START taking calcium citrate instead of calcium
carbonate, as you will absorb this medication better
**Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
Please follow-up with the following appointments:
Name: [**Last Name (LF) 14919**],[**First Name3 (LF) **] E.
Address: [**Apartment Address(1) 14920**], [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 14918**]
*Please walk into your doctors office for a follow up
appointment for your hospitalization. The office will be closed
for the holidays until [**2198-1-2**] but you can walk in anytime after
that from 8am-4pm. Any questions please call the office.
Department: CARDIAC SERVICES
When: MONDAY [**2198-1-22**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Previously scheduled appointments:
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2198-1-17**] at 9:00 AM
With: [**Last Name (un) 6410**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], AU.D. [**Telephone/Fax (1) 6411**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2198-2-21**] at 10:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2197-12-23**]
|
[
"458.29",
"V58.65",
"715.96",
"272.4",
"401.9",
"412",
"564.09",
"E944.4",
"493.90",
"276.52",
"255.41",
"584.9",
"V43.65",
"428.32",
"428.0",
"733.90",
"414.01",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10550, 10625
|
4201, 4397
|
317, 325
|
10767, 10767
|
3065, 3070
|
11859, 13308
|
1816, 1833
|
9219, 10527
|
10646, 10746
|
8738, 9196
|
10950, 11836
|
1848, 1862
|
2487, 3046
|
8349, 8712
|
3503, 3886
|
266, 279
|
3905, 4178
|
353, 1282
|
3084, 3486
|
10782, 10926
|
4415, 8328
|
1304, 1659
|
1675, 1800
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,124
| 148,823
|
21017
|
Discharge summary
|
report
|
Admission Date: [**2161-7-30**] Discharge Date: [**2161-8-17**]
Date of Birth: [**2103-11-16**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
sacral osteomyelitis and pelvic abscesses, MRSA
Major Surgical or Invasive Procedure:
anterior and posterior debridement of vertebral osteomyelitis
and multiple pelvic abscesses with diverting loop colostomy
History of Present Illness:
CC: abscess
HPI: 57 yo M with paraplegia, status post MRSA bacteremia (St.
[**Female First Name (un) **]. hosp) likely from R trochanteric decub, tx with
vanc/rifampin x 5 wks, then 84 days of linezolid.
Patient's problems began in early [**Month (only) 958**] of this year, when he
developed fevers to 104 and chills, and presented to [**Hospital 27034**] hospital. At that time, he was bacteremic with MRSA and
a source for the infection was sought after, with an extensive
negative work up. This included a Transesophageal
echocardiogram time two, CT of chest /abdomen and pelvis. He
does have a large right gluteal decubitus ulcer, which was
debrided [**2161-3-8**], and this may have been the presumed
source. He was treated with vancomycin, as well as rifampin.
He at some point returned to [**Location **] with similar problems, and
was transferred to [**Hospital3 **] on [**2161-5-16**] for further mgt of
his persistent fever and MRSA bacteremia. At [**Hospital3 5097**], he had a
CT scan demonstrating osteomyelitis with destruction of L5-S1.
He was to be continued on vancomycin for a full 12-week course -
however, on [**5-21**] the pt was found to have a pneumonia, so the
vancomycin was stopped and he was begun on a 12-week course of
linezolid instead. He was discharged from [**Hospital3 5097**], to a rehab
facility, on [**2161-6-11**].
On [**2161-7-23**], the pt presented to [**Hospital3 934**] hospital after
experiencing fever to 103. On admission, his decub ulcer was
noted to extend down to the bone. He got levofloxacin IV in the
emergency department. WBC-16.3, Urine culture with > 100
thousand gram negative rods, growing pan-resistant enterbacter
cloace and psuedomonas sensitive to gent only. Started on gent.
blood cultures from [**7-25**] and [**7-26**] with MRSA. CT LS spine/pelvis
showed marked destruction of osseous fragment involving part of
L5 and S1. MRI showed inflam phlegmon L5-S1, and L sacrospinous
ligament collection. Seen by N-[**Doctor First Name **], recommended extensive [**Doctor First Name **],
to be done here.
ROS: Patient denies recent wt gain/loss, headaches, visual
changes, shortness of breath, chest pain or tightness, cough,
nausea, vomiting.
Labs: CBC-WBC 15.6, Hct 26 (30 at OSH five days ago)
K 5.2, Cr 0.7, coags wnl
UA: +nitrites, mod leuk, 0-2 WBC, few bact
Past Medical History:
PMH:
0. MRSA bacteremia, started [**2161-4-12**], TEE neg., tx with 5 wks
vanc, 84 d. course of linezolid
1. paraplegia (T5) - [**3-9**] MVA 27 years ago
2. Diabetes-1,diagnosed 10 years ago, on insulin
3. Atrial flutter, new during admission in [**Month (only) 547**]. Was begun on
coumadin but no longer takes.
4. hypertension
5. CHF
6. GI bleed [**3-9**] esophageal ulcers
7. h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] esophagitis
8. h/o persistent lung collapse
9. h/o DVT
10. h/o pna in [**6-9**]
Social History:
Lives in [**Location 55842**] home
Nonsmoker, non drinker
Family History:
Non contributory
Physical Exam:
PE: T 100.3 BP: 100/60 P: 88 R: 20 94% on RA
Gen: alert and oriented male, pleasant, appears in no apparent
distress.
HEENT: pupils equal round and reactive to light, extraocular
movements intact, orophyarnx clear, moist mucous membranes. no
jugular venous distention.
Lungs: clear to auscultation bilaterally, no
wheezes/rhonchi/crackles
CV: heart sounds distant, regular rate and rhythm, no murmurs
rubs or gallops
Abd: soft, non tender and non distended, positive for bowel
sounds. no palpable hepatosplenomegaly.
Ext: no clubbing cyanosis or edema, 2+ distal pulses.
Skin: patients entire gluteal region is erythematous. on right
side, there is an approx 3 cm decub ulcer that extends down to
his pelvic bone. no frank pus around wound, but but when
dressing was removed it did have a greenish fluid on it.
Pertinent Results:
MRI Lumbar Spine [**2161-8-1**]:
IMPRESSION: Osteomyelitis of L5 and S1 level with large
interosseous abscess extending into the presacral region
anteriorly and posteriorly to the interspinous regions and soft
tissue. Enhancing inflammatory soft tissues are seen within the
spinal canal in the lumbar region. Findings were discussed with
the resident covering the patient at the time of interpretation
of this study on [**2161-8-2**] at 3:30 P.M.
[**2161-8-2**] MRI Right hip:
IMPRESSION: 1. Suboptimal study. Repeat study including pre and
post contrast images with non-breath hold technique is
recommended.
2. Extensive osseous destruction involving the bilateral sacral
ala and lower lumbar spine, with adjacent fluid collection
extending into the buttocks. Findings are consistent with
osteomyelitis.
3. Large ulceration of the superficial tissue underlying the
right ischial tuberosity, involving the hamstring insertion.
4. 5 cm long fistulous tract extending from the midline above
the buttocks to the rectum.
[**2161-8-6**] CT abdomen:
IMPRESSION:
1. Extensive inflammatory mass centered about the L5/S1
interspace with associated frank bony destruction. These
findings are compatible with the patient's known history of
chronic osteomyelitis. At this time, no drainable fluid
collection is identified.
2. Ulceration of the superficial soft tissues underlying the
right ischial tuberosity as above with associated inflammatory
changes and soft tissue thickening surrounding the right hip
joint but no abscess formation. This process appears separate
from the spinal process.
Cultures:
[**7-31**]: Enterobacter and pseudomonas
[**7-30**]: blood cultures negative to date
[**7-30**]: urine eterobacter cloacae time 2
Brief Hospital Course:
He was transferred from [**Hospital3 934**] hospital on [**7-30**].
He was on IV meropenem ([**7-31**]) and vancomycin ([**8-3**]) for his MRSA
infection. He was hydrated and given antibiotics and was
admitted for depbridement of his paraspinal, psoas, aravertebral
and presacral abscesses. He had a debridement of the ulcer with
diverting transverse loop colostomy on [**2161-8-7**]. He was
placed in the intensive care unit on a ventilator. His
antibiotics were continued. he He had twice daily dresing
changes from wet to dry. Plastic surgery and Neurosurgery
evaluated him daily and assisted in the dressing changes. He
was also followed by [**Last Name (un) **] while in the hospital, to help
maintain tight control of his blood sugars. He was extubated by
[**8-9**], and was transferred out to the floor on [**8-10**]. he
began a diet and tolerated regular food. The patient did
remarkably well after his surgery, was tolerating a regular
diet, his vital signs and lab values were normal and his white
blood cell count trended back to normal. He was stable to go to
rehab by [**8-13**], and needed rehab for help with dressing
changes. The infectious disease service suggested 3 weeks of
vancomycin for a total course of 6 weeks, and to stop the
merepenem on discharge. Plastic surgery decided that wet to dry
dressings were appropriate, and that a vac dressing would not be
placed at this time. He has plans to follow up with ID and with
plastic surgery for further management of his wounds. he was
discharged in stable condition to the rehab facility
Medications on Admission:
Meds: vanc 750 qd, hep sq 5000 [**Hospital1 **], protonix 40 qd, MVI 1 qd,
FESO4 325 qd, senna 2 tab qhs, insuline NPH 20/5, RISS, cardizem
CD 90 qd, isordil 10 tid, rythmol 100 q 8h, lopressor 50 tid,
hydral 10 q6, mylicon 80 q 6h, dulcolax supp 10 qd, baclofen 20
q6h, folate 1 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, KCl 40 qd, vit C 500 [**Hospital1 **], zinc
sulfate 220 qd
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q12H (every 12 hours).
Disp:*60 injections* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*120 Nebs* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*120 nebs* Refills:*2*
4. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
PRN (as needed) as needed for psoriasis.
Disp:*1 tube* Refills:*0*
5. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
Disp:*240 Tablet(s)* Refills:*2*
6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
8. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical QD (once a day).
Disp:*1 tube* Refills:*2*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO QD (once
a day).
Disp:*30 Capsule(s)* Refills:*2*
18. Diltiazem HCl 90 mg Capsule, Sust. Release 12HR Sig: One (1)
Capsule, Sust. Release 12HR PO QD (once a day).
Disp:*30 Capsule, Sust. Release 12HR(s)* Refills:*2*
19. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 3 weeks.
Disp:*42 Recon Soln(s)* Refills:*0*
20. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection
ASDIR (AS DIRECTED). Disp:*30 syringe* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Elihu White Nursing & Rehabilitation - [**Location (un) 38**]
Discharge Diagnosis:
1. Sacral osteomyelitis
2. Status post sacral debridement
3. Parapelegia
4. atrial flutter
5. Hypertension
6. Congestive heart failure
7. esophogeal ulcer
8. history of deep vein thrombosis
Discharge Condition:
stable
Discharge Instructions:
Please call with any spiking fevers, intractable nausea,
inability to tolerate food, new drainage from wounds
Followup Instructions:
Please follow up in 1 week with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Plastic
surgery.
Please follow up with Dr. [**Last Name (STitle) 55843**] in [**2-6**] weeks, call his
office for an appointment
The patient needs to set up an appointment with Dr. [**First Name (STitle) **] in [**Hospital **]
clinic in 4 weeks ([**Telephone/Fax (1) 457**]).
Patient needs to have a vancomycin peak level drawn [**2161-8-19**] and
a chemistry (sodium, potassium, glucose, BUN, creatinine,
Bicarbonate, Chloride). Please fax results to Dr.[**Name (NI) 55844**]
attention at [**Telephone/Fax (1) 1419**]
|
[
"250.81",
"428.0",
"731.8",
"427.32",
"567.2",
"324.1",
"686.9",
"707.0",
"730.18"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4",
"86.22",
"46.03"
] |
icd9pcs
|
[
[
[]
]
] |
10577, 10665
|
6087, 7664
|
339, 463
|
10903, 10911
|
4336, 6064
|
11069, 11703
|
3470, 3488
|
8108, 10554
|
10686, 10882
|
7690, 8085
|
10935, 11046
|
3503, 4317
|
252, 301
|
491, 2830
|
2852, 3379
|
3395, 3454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,950
| 154,983
|
48520
|
Discharge summary
|
report
|
Admission Date: [**2123-7-26**] Discharge Date: [**2123-8-16**]
Date of Birth: [**2083-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
Nausea / Vomiting
Major Surgical or Invasive Procedure:
-Placement of percutaneous G-J tube converted to gastrotomy tube
-Placement of Port-a-cath
-Placement of PICC line
History of Present Illness:
This is a 40 year old male with history of metastatic gastric
cancer status post subtotal gastrectomy with billroth II
anastamosis and omentectomy in [**2120**] with complicated
post-operative course mostly notable for mechanical
complications or operative and radiation management of his
primary maligancy who was found to have recurrence in peritoneal
nodules in [**5-/2123**] and presented with nausea / vomiting. Patient
had been last seen in surgical clinic for post-operative
follow-up on [**2123-7-14**] and was reportedly doing well and
tolerating diet without any issues.
At the time of presentation to the ED the patient reported two
weeks of nausea and vomiting. This was severe enough so that he
was not able to tolerate any PO intake without vomiting despite
vigorous encouragement from his partner. [**Name (NI) **] reported feeling
quite lethargic and uncomfortable. Per his wife the patient was
having regular bowel movements. No fevers, chills, night sweats
and other review of systems negative.
While in triage, pt was hypotensive with sbp 89/63. Received
1.5L
of IVF, several doses of morphine and anti-emetics. Found to
have
potassium of 6.6 and was treated with Kayexalate, insulin,
bicarbonate and dextrose. He also received vancomycin,
ciprofloxacin, and Flagyl. He was admitted to the surgical
intensive care unit for further management.
Past Medical History:
Past Oncologic/ Surgical History:
Gastric cancer, metastatic
-[**9-/2120**]: Subtotal gastrectomy with billroth II anastamsosis and
omentectomy as well as radical lymph node dissection, because of
positive omental margins patient received adjuvant
chemoradiation with radiotherapy and 5FU
-[**11/2122**]: Developed biliary stricture managed with
choleycystotomy tube
-[**2-/2123**]: Roux-en-Y hepaticojejunostomy to right posterior
hepatic and confluence of right anterior and left hepatic ducts
over two 5-french feeding tubes in [**2-/2123**] for refractory
post-radiation CBD stricture
-[**5-/2123**]: Patient presented with SBO and at exploratory
laparotomy found to have peritoneal carcinomatosis and
obstruction of Roux limb, had operative repair of colon
enterotomy and biopsy of peritoneal nodules showing recurrent
gastric cancer
Other Past Medical History:
-Carbapenemase resistant escherichia blood stream infection
-Chronic pain
Social History:
Lives in [**Location 669**] with his wife. [**Name (NI) **] a son from a prior marriage.
Unemployed chef. Tobacco: denies. EtOH: denies. Illicits:
denies
Family History:
Maternal grandmother with "stomach cancer"
Father with diabetes
Physical Exam:
Admission Exam:
Vitals: 99 109 103/38 17 100 2L NC
Gen: lethargic, somnolent, sleepy, feels thirsty
HEENT: sunken fontanelle, dry mucous membranes, anicteric
Lungs: CTA
Cardio: RRR
Abd: soft, incisions c/d/i, transhepatic tubes in place and to
gravity with dark bilious drainage (some drainage to skin),
tender to drain site, act BS
Rectal: refused
Ext: no edema, palpable distal pulses
Pertinent Results:
LABORATORY RESULTS:
Admission Labs:
WBC-12.3*# RBC-5.16# Hgb-13.5* Hct-38.1* MCV-74*# Plt- 687
--Neuts-87.2* Lymphs-10.2* Monos-2.3 Eos-0.1 Baso-0.1
PT-17.3* PTT-30.5 INR(PT)-1.6*
ALT-153* AST-80* LD(LDH)-170 AlkPhos-688* TotBili-2.5*
Lipase-104*
Glucose-138* UreaN-129* Creat-6.6*# Na-124* K-6.6* Cl-79*
HCO3-20*
Calcium-7.9* Phos-5.2* Mg-2.2
Albumin-4.8
Discharge Labs:
WBC-6.9 RBC-3.19* Hgb-8.7* Hct-27.7* MCV-87 RDW-16.2* Plt
Ct-448*
PT-12.6 PTT-29.9 INR(PT)-1.1
Glucose-107* UreaN-19 Creat-0.4* Na-135 K-3.8 Cl-102 HCO3-26
ALT-25 AST-22 AlkPhos-246* TotBili-3.2*
Calcium-6.8* Phos-3.5 Mg-1.8
MICROBIOLOGY:
Blood cultures *2 from [**2123-7-26**] and [**2123-8-3**]: No growth
RADIOLOGY RESULTS:
CT Abdomen and Pelvis W/ Contrast [**2123-7-26**]:
IMPRESSION:
Moderate gastric and esophageal fluid-filled distention .
Findings are
concerning for gastric outlet obstruction. There is no evidence
of small or
large bowel obstruction.
UGI series [**2123-7-28**]:
IMPRESSION: No significant passage of contrast into the
jejunostomy, with
concurrent gastroesophageal reflux.
Brief Hospital Course:
This is a complicated 40 year old man with metastatic gastric
cancer presenting with nausea/vomiting likely due to gastric
outlet obstruction from metastatic disease.
1) Nausea/ Vomiting/Gastric outlet obstruction: Upon
presentation the patient was initially admitted to the surgical
intensive care unit for management of his volume depletion and
presumed gastric outlet obstruction. He was fluid resuscitated
and called out to the floor where he continued to have
persistent refractory nausea. On [**2123-8-3**] a percutaneous G-J
tube was placed beyond the site of gastric outlet obstruction
but was not able to transverse a distal jejunal obstruction. He
was not able to tolerate feeds through this tube and due to pain
at the site and no clear utility it was exchanged on [**8-5**] for a
simple venting gastrotomy tube. Given multiple sites of bowel
wall involvement and peritoneal carcinomatosis intolerance of
PO's thought most likely to severe functional impairment as well
as likely multiple sites of mechanical obstruction. Therefore,
decision was made to medically manage nausea with ondansetron,
lorazepam, and prochlorperazine while patient remained on TPN
feeds and attempts were made to address his total body disease
burden. On the noted anti-emetics the patient did
intermittently complain of nausea but generally was without
emesis and managed to tolerate small amounts of liquids by
mouth.
2) Metastatic Gastric Cancer: The patient had peritoneal
carcinomatosis and a large burden of intra-abdominal disease
leading to significant symptom burden. In conversation with his
oncologist, after mechanical attempts to bypass obstructions
failed, the patient and his partner chose to pursue palliative
ECF regimen with goal of tumor bulk reduction and symptomatic
improvement (primarily a hope of being able to tolerate more of
a PO diet). To this end the patient was transferred from the
surgical to medical oncology service on [**2123-8-10**] and his
chemotherapy was initiated. He tolerated the initiation of
chemotherapy without initial ill effects and was discharged on
continuous infusion chemo to follow up with his primary
oncologist.
3) Nutrition: Patient was unable to tolerate any significant PO
nutrition so received TPN through PICC placed [**2123-7-29**] and then
portacath placed [**2123-8-3**]. An attempt at enteral feeds was
briefly made but was not tolerated. His TPN was adjusted with
the nutrition services recommendations and he evidenced no major
electrolyte abnormalities or worsening hepatitis.
4)Pain: The patient initially presented primarily with nausea
but then developed rather significant abdominal pain. Initial
attempts to control this led to significant oversedation but
eventually was able to tolerate fentanyl patch and oral
hydromorphone regimen with minimal pain unless abdomen was
pushed on or other provocative events occured. Patient would
often moan in pain and be very resistant to exam making full
evaluation difficult but no signs/ symptoms of acute
intra-abdominal process. The patient was discharged on oral
hydromorphone and a fentanyl patch as his standing pain regimen.
5) Depression/ Psychosocial: Throughout his hospitalization the
patient had a great deal of difficulty engaging in discussions
of his care and was often in significant emotional and or
physical distress, moaning in pain and/or refusing to respond to
providers or other questions. He did acknowledge great
difficulty coping with his recurrent cancer diagnosis and the
extremely burdensome symptoms that came with this. He expressed
a clear preference for his spouse to perform all line and
dressing cares, which was very understandably taxing on her and
social work and palliative care remained involved to help with
coping and support decision-making as best as they were able.
4) Goals of Care: Despite multiple well cited conversations
with the family where providers explained the patient had
incurable disease with goals aiming at comfort and palliation
the patient and particularly his wife expressed sentiments
relating to his cancer being "cured." These difficult decisions
will be continued in the outpatient environment.
5) Chronic biliary obstructions: The patient was continued on
his standing levofloxacin and ursodiol, there were never any
signs of current, active infection so antibiotics started in the
ED were stopped on [**7-27**].
The patient was discharged with [**Month/Year (2) 269**] with plans for home TPN and
infusional chemo through port and PICC lines in place.
Medications on Admission:
hydromorphone 4 mg every four
hours p.r.n. pain, prochlorperazine maleate 10 mg every eight
hours p.r.n., ursodiol 300 mg p.o. twice daily, Colace 100 mg
p.o. twice daily, iron sulfate 325 mg p.o. daily, and senna 8.6
mg p.o. twice daily.
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety, nausea.
Disp:*200 Tablet(s)* Refills:*0*
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
5. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
7. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*300 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
Please check weekly CBC with differential, ALT, AST, ALK Phos,
Total Bilirubin, Sodium, Potassium, Chloride, HCO3, BUN, Cr, and
glucose, Calcium, Magnesium, and Phosphate and fax results to
[**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], RN and [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**], MD at [**Telephone/Fax (1) 18738**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Healthcare
Discharge Diagnosis:
Metastatic gastric cancer with gastric outlet obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for an obstruction of your
stomach. The surgeons evaluated you and placed a tube to
decompress your stomach as well as starting you on TPN. You
then came to the oncology service to receive chemotherapy in
hopes of shrinking your tumor and allowing you to eat. You are
being discharged on one chemotherapy [**Doctor Last Name 360**] as well as TPN.
Your medications have been changed. Please take your
medications exactly as prescribed.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 8770**] Date/Time:[**2123-8-20**]
12:30
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-8-20**] 1:30
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2123-10-27**] 11:30
|
[
"584.9",
"238.71",
"276.1",
"V66.7",
"285.22",
"151.9",
"537.0",
"286.9",
"197.6",
"276.2",
"576.2",
"338.3",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"44.32",
"86.07",
"38.91",
"99.15",
"87.54",
"51.98",
"99.25",
"99.04",
"43.11",
"96.07",
"97.05"
] |
icd9pcs
|
[
[
[]
]
] |
10766, 10823
|
4595, 9145
|
333, 450
|
10925, 10925
|
3492, 3512
|
11575, 11969
|
3003, 3069
|
9434, 10743
|
10844, 10904
|
9171, 9411
|
11076, 11552
|
3866, 4572
|
3084, 3473
|
276, 295
|
478, 1849
|
3528, 3850
|
10940, 11052
|
2739, 2814
|
2830, 2987
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,481
| 136,601
|
2977
|
Discharge summary
|
report
|
Admission Date: [**2111-3-17**] Discharge Date: [**2111-4-4**]
Date of Birth: [**2031-10-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Fever, Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79F w/ DM type 2, arthritis recent admission to [**Hospital1 18**] in [**2111-1-31**]
-[**2111-2-18**] for subdural hematoma after a fall with hospital course
complicated by altered mental status requiring intubation, DKA,
PNA, UTI and s/p PEG.
She was dicharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] on [**2111-2-18**] and now:
presents after large emesis at 1AM there and subsequently
developed SOB and rhonchi. At that time, vitals were T 99.1, BP
133/72, HR 113, RR 24, 95% RA. At 5AM, she was noted to have
rhonchi and RR 32 with HR 135, so she was sent to [**Hospital1 **] with
concern for aspiration.
.
In ED, T 102, HR 125, BP 120/62, 96%RA, RR 24. EKG revealed
sinus tachycardia. She received 3L NS, was started on
Vanc/cefepime/clinda, and blood, urine cx sent.
.
Upon arrival to ICU, patient is non-responsive (baseline) no
further history was obtained.
.
Past Medical History:
- recent SDH followed by neurosurgery, new aphasic baseline
- 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:
T: 100.6 (rectal) BP: 112/35 HR: 120's RR: 24 O2Sats: 97%RA
Gen: opens eyes to gentle shaking and noise, but does not follow
commands
HEENT: Pupils: Left 1mm, surgical, Right 2-1mm
EOMs- unable to test
Lungs: coarse BS bilaterally
Cardiac: tachycardic, no murmurs
Abd: Soft, NT, BS+; peg tube insertion well healed, no erythema
Extrem: Warm and well-perfused, no skin breakdown, no erythmea
or swelling
Neuro: opens eyes to shaking and loud noise
Motor: Normal bulk and tone bilaterally.
Pertinent Results:
EKG: sinus tachy with PACs, nl axis
Labs: see below
.
At last admission: C. diff neg X 3, enterococcus (pan-sensitive)
UTI, blood cx NGTD
[**2111-3-17**] 07:20AM BLOOD WBC-17.1* RBC-3.14* Hgb-9.0* Hct-29.1*
MCV-93 MCH-28.7 MCHC-30.9* RDW-17.0* Plt Ct-1239*
[**2111-3-17**] 07:20AM BLOOD Neuts-85.0* Bands-0 Lymphs-8.1* Monos-2.3
Eos-4.3* Baso-0.2
[**2111-3-17**] 07:20AM BLOOD Glucose-125* UreaN-20 Creat-0.6 Na-135
K-5.2* Cl-100 HCO3-23 AnGap-17
[**2111-3-18**] 02:05AM BLOOD Glucose-83 UreaN-8 Creat-0.4 Na-132*
K-3.9 Cl-104 HCO3-20* AnGap-12
[**2111-3-18**] 02:05AM BLOOD ALT-15 AST-27 LD(LDH)-267* AlkPhos-124*
TotBili-0.2
[**2111-3-17**] 06:25PM BLOOD cTropnT-0.03*
[**2111-3-17**] 07:20AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2111-3-18**] 02:05AM BLOOD Albumin-2.3* Calcium-7.3* Phos-2.5*
Mg-1.4*
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2111-3-17**] 10:32 PM
CTA CHEST W&W/O C&RECONS, NON-
Reason: pls eval for PE
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
79 year old woman with recent SDH and decreased mobility at
rehab now with fever, tachypnea, tachycardia
REASON FOR THIS EXAMINATION:
pls eval for PE
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 79-year-old male with recent subdural hemorrhage and
decreased mobility, now presenting with fever, tachycardia, to
rule out pulmonary embolism.
TECHNIQUE: CT of the chest was performed without intravenous
contrast followed by CT of the chest post administration of
intravenous contrast, and reconstructions were performed in the
axial, sagittal and coronal planes.
COMPARISON: There is no relevant prior CT for comparison.
FINDINGS:
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There is no pulmonary embolism or aortic dissection. There are
small bibasal effusions with extensive consolidation in the left
lower lobe most likely infectious or may be related to
aspiration. There is biapical pleural thickening and scarring.
The visualized liver and spleen appear unremarkable.
There is a hiatus hernia containing food residue.
MUSCULOSKELETAL: There are extensive multilevel degenerative
changes present in the spine.
CONCLUSION:
1. No pulmonary embolism or aortic dissection.
2. Consolidation at the left lung base along with small bibasal
effusions likely infectious or may be related to aspiration.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2111-3-18**] 3:49 PM
CT HEAD W/O CONTRAST
Reason: pls eveal for worsening SDH or increased ICP
[**Hospital 93**] MEDICAL CONDITION:
79 year old woman with hx SDH, now declined mental status
REASON FOR THIS EXAMINATION:
pls eveal for worsening SDH or increased ICP
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Declining mental status.
TECHNIQUE: Non-contrast head CT.
COMPARISON: [**2111-3-10**].
FINDINGS: Redemonstrated is evolving hemorrhage within the right
frontal lobe, unchanged in size. The small mass effect along the
right frontal [**Doctor Last Name 534**] is also unchanged. There is a small resolving
subdural hemorrhage in the left parietal lobe that has slightly
decreased in size. No new hemorrhage is identified. The
appearance of the ventricular system is unchanged, remarkable
for involutional change. The [**Doctor Last Name 352**]-white matter differentiation
is preserved. Periventricular white matter hypodensities and the
osseous structures are unchanged, with redemonstration of a
displaced right occipital and temporal bone fractures with
opacification of the mastoid air cells.
IMPRESSION: Overall, no significant interval change without
acute hemorrhage.
Brief Hospital Course:
79 yo hx DM2 recently admitted for SDH and at rehab who now p/w
fevers, tachycardia, emesis and likely aspiration PNA vs
pneumonitis.
#ASPIRATION PNA: fever, leukocytosis & LLL consolidation on CT
most likely due to aspiration PNA vs pneumonitis. Pt was ruled
out for influenza A/B. She completed a course of Vancomycin and
cefepime for aspiration pneumonia. Respiratory status improved,
she was breathing comfortably on room air without fever for
several days prior to transfer back to nursing home. Follow up
CT chest showed resolving LLL pneumonia and atelectasis, no
evidence of PE.
#h/o ? C. Diff, -early in hospitalization she was continued on
treatment for for C. Diff as she was recently positive & being
treated with Flagyl at OSH. C.diff toxins were negative x 3
during this hospitalization and she was asymptomatic.
# Subdural hemorrhage: family was concerned that pt was having
MS changes on [**3-18**], non-con head CT was essentially unchanged.
MS seemed to improve over the course of the day. Pt is followed
by Dr. [**Last Name (STitle) **] for SDH as outpt. Neurology was consulted as was
Dr. [**Last Name (STitle) **], EEG was performed, MRI was orderd
Neuro consulted, and [**Doctor Last Name **] called. EEG done and MR ordered
Dr. [**Last Name (STitle) **] recommended large volume lumbar puncture to be done
to see if patient has communicating hydrocephalus and needs VP
shunt. This was done on [**3-21**] with removal of 32 cc of clear
CSF. No clinical change apparent in 24 hours after this
procedure. CSF cell counts were normal, no evidence of
infection, cultures were negative. She remained at her nonverbal
baseline throughout this hospitalization.
She had a noncontrast CT head on day of discharge in
anticipation of follow up with Neurosurgery.
She was continued on seizure prophylaxis, without evidence of
seizure activity
Amantadine was started per neurology recomendations to see if it
would help improve her mental status.
Her baseline since her subdural hematoma is non-verbal, not
following commands, sometimes opens eyes.
.
# Sinus Tachycardia: persistent chronic tachycardia without
apparent etiology, but multiple possibilities including fever,
hypovolemia, pe, or central process. Tachycardia persisted
after fever resolved, after volume resuscitation with ivfs ct
chest was negative for PE. TSH was within normal limits.
Ongoing tachycardia of 100's to 110's. Of note, had been on
beta blocker on admit--was discontinued here initially with
acute illness. Could consider re-starting at rehab if ongoing
tachycardia.
# Thrombocytosis: reactive, stable
.
# DM: controlled with glargine and HISS, with labile blood
sugars, particularly when tube feeds were held for procedures
etc.
Medications on Admission:
MEDS (from rehab):
tylenol
vitamin D 400 daily
calcium 500 daily
keppra 500 mg (5ml) oral solution QAM; 1000mg QPM
prevacid 30 daily
metoprolol 25 mg daily
SQ heaprin
milk of magnesia
loperamide
Ceftriaxone 2 gm IV (started [**3-4**])
fluconazole 400 mg then 200 mg daily (started [**3-4**])
levaquin 500 mg
flagyl 500 mg Q8H started [**2111-3-6**]
lantus 44 units + regular SS
Discharge Medications:
1. Levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: 1000 (1000) mg PO QAM
(once a day (in the morning)).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day/Year **]: One (1)
Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day/Year **]: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: Five Hundred (500) mg
PO QPM (once a day (in the evening)).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Amantadine 50 mg/5 mL Syrup [**Last Name (STitle) **]: One Hundred (100) mg PO
DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
9. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
10. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q12H (every 12
hours) as needed.
11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: 325-650 mg PO Q6H
(every 6 hours) as needed.
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) neb Inhalation Q6H (every 6 hours).
13. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Fifty (50) units
Subcutaneous qAM.
14. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
units Injection as directed: Please see attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1.Aspiration pneumonia
2.tachycardia
3.subdural hematoma / frontal contusion/intracerebral hemorrhage
4. DM II uncontrolled with complications
Discharge Condition:
afebrile, breathing comfortably, nonverbal, opens eyes
Discharge Instructions:
All medications as prescribed.
Follow up with outpatient provders as scheduled.
If patient has fevers, chills, new complaints, contact MD.
Patient's mental status on discharge is non-verbal, sometimes
opens eyes, not responsive to commands.
Followup Instructions:
Follow up with the neurosurgeon:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2111-4-14**] 11:00
Follow up with your primary care doctor within the next few
weeks.
Call to schedule follow up appointment.
|
[
"238.71",
"293.0",
"721.90",
"V44.1",
"507.0",
"599.0",
"008.45",
"362.01",
"427.89",
"250.62",
"518.0",
"V58.67",
"285.29",
"250.52",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.21",
"99.04",
"96.6",
"87.03",
"87.41",
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10571, 10644
|
5739, 8473
|
333, 339
|
10830, 10886
|
2116, 3108
|
11175, 11459
|
1573, 1591
|
8902, 10548
|
4652, 4710
|
10665, 10809
|
8499, 8879
|
10910, 11152
|
1606, 2097
|
275, 295
|
4739, 5716
|
367, 1273
|
1295, 1436
|
1452, 1557
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,573
| 180,525
|
33293
|
Discharge summary
|
report
|
Admission Date: [**2167-3-26**] Discharge Date: [**2167-3-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Hypoxia, confusion, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 77287**] is an 88yo male with PMH significant for colon
cancer with known metastases to the liver and lung who presents
with respiratory distress, hypotension, and confusion. Per
patient's daughter, the patient has not been himself over the
past few days. He has been frantic, nervous, and concerned that
he cannot breath. The patient confirms this on questioning and
has noted increasing SOB over the past few days. He is on 2L NC
at home. Earlier this evening, Mr. [**Known lastname 77287**] told his daughter
that he could not breath. "I am so nervous" he said. Half hour
later his daughter found him slouched in a chair, disoriented,
and somewhat unreponsive. He was also hyperventilating at the
time. There was no report of fevers, chills, chest pain,
abdominal pain, or any other symptoms. He does admit to a
chronic productive cough. Upon EMS arrival, his O2 sat was 75%
on 2L NC which increased to 91% after a neb treatment.
.
In the ED his initial vitals were T 94.9 BP 162/105 AR 94 RR 40
O2 sat 97% on NRB (15L). He was noted to be wheezy. He received
a Combivent neb, Levaquin 750mg IV, Ceftriaxone 1g IV,
Vancomycin 1g IV, Solumedrol 125mg IV, and ASA 325mg PO. His SBP
dropped to 79/46 and he was immediately infused with IVFs
through his port with an immediate bump in his BP to 103/56. His
O2 sat also improved to 98% on 4L.
.
On further questioning, the patient was recently completed his
last cycle of 5-FU on [**3-14**]. On a follow-up CT scan he was found
to have partial lung collapse. He was admitted to [**Hospital1 2025**] and
started on supplemental oxygen at this time. Per family, he is
not a candidate for further chemotherapy and plans were being
made for hospice care.
Past Medical History:
1)Metastatic colon ca: s/p resection in [**2164**] complicated by
leak; underwent ileostomy but hospital course complicated by
septic shock. He then underwent reverse ileostomy. He has known
metastases to liver and lung. Completed last cycle of
chemotherapy on [**2167-3-14**] with 5-FU.
2)CAD s/p stent in [**2161**] and [**2163**] at [**Hospital6 2561**]
3)Atrial fibrillation
4)Hx of pulmonary embolism/DVT in R leg in [**2164**] on Coumadin
5)Hx of respiratory failure s/p tracheostomy
6)Anxiety
Social History:
Lives with wife and daughter. [**Name (NI) 3003**] tobacco use, quit 15 years
ago. No current alcohol or IVDA.
Family History:
NC
Physical Exam:
vitals T 95.3 BP 138/82 AR 76 RR 23 O2 sat 99% on 4L NC
Gen: Pleasant male, sitting in bed
HEENT: Dry mucous membranes
Heart: Distant heart sounds, no audible m,r,g
Lungs: Diffuse rhonchi posteriorly with expiratory wheezes
Abdomen: Multiple surgical scars, soft, NT/ND, +BS
Extremities: No LE edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
Labs on admission:
[**2167-3-26**] 08:00PM BLOOD WBC-7.5 RBC-4.28* Hgb-13.6* Hct-42.6
MCV-100* MCH-31.7 MCHC-31.8 RDW-14.8 Plt Ct-283
[**2167-3-26**] 08:00PM BLOOD PT-20.1* PTT-34.2 INR(PT)-1.9*
[**2167-3-26**] 08:00PM BLOOD Glucose-228* UreaN-17 Creat-1.2 Na-141
K-4.6 Cl-102 HCO3-26 AnGap-18
[**2167-3-26**] 08:00PM BLOOD CK(CPK)-64
[**2167-3-26**] 08:00PM BLOOD cTropnT-0.13*
[**2167-3-26**] 08:00PM BLOOD Calcium-9.1 Phos-6.8* Mg-2.0
[**2167-3-26**] 08:00PM BLOOD Digoxin-0.3*
[**2167-3-26**] 08:10PM BLOOD Lactate-2.9*
.
Labs on discharge:
[**2167-3-27**] 05:14AM BLOOD WBC-4.8 RBC-3.51* Hgb-11.4* Hct-34.4*
MCV-98 MCH-32.4* MCHC-33.1 RDW-15.0 Plt Ct-193
[**2167-3-27**] 05:14AM BLOOD PT-21.5* PTT-33.0 INR(PT)-2.0*
[**2167-3-27**] 05:14AM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-143
K-4.3 Cl-106 HCO3-30 AnGap-11
[**2167-3-27**] 05:14AM BLOOD Calcium-8.1* Phos-2.9# Mg-1.8
.
Microbiology:
[**2167-3-26**] Blood cx - NGTD
[**2167-3-27**] Blood cx - NGTD
.
Imaging:
[**2167-3-26**] CXR:
IMPRESSION: Extensive patchy opacities without comparison study
available.
There is likely baseline pulmonary metastatic disease with
possible
superimposed infectious infiltrates. Atypical edema cannot be
excluded as
well. Small bilateral pleural effusions.
Brief Hospital Course:
Mr. [**Known lastname 77287**] is an 88 year old male with metastatic colon cancer
who presents with increasing respiratory distress, confusion,
and hypotension.
.
1) Respiratory distress: Patient was noted to be hypoxic at
home. On initial presentation, his oxygen saturation was 72% on
his home 2L of oxygen. He responded immediately to nebulizer
treatements, which made the most likely diagnosis of his
respiratory distress bronchospasm. He was maintained on
nebulizer treatments and prednisone to complete a 5 day burst.
He was however, also covered with levofloxacin and flagyl for
possible pneumonia given his CXR appearance that showed
metastatic disease with inability to rule out underlying
pneumonia.
He was discharged with nebulizer treatments at home, oxygen as
needed at home, prednisone to complete 5 day burst, and
levofloxacin/flagyl to complete 7 day course.
.
2) Hypotension: Patient was transiently hypotensive in ED with
BP improvement quickly with IVFs. Likely dehydrated based on
history obtained from daughter. [**Name (NI) **] has had poor PO intake over
the past week. No evidence of an infection. IVF was continued
during hospital course with improvement in blood pressure.
.
3) Mental status changes: Per daughter, patient was found to be
confused earlier this evening. Mental status returned to
baseline upon arrival to [**Hospital1 18**] after treatment of hypoxia with
nebulizer treatments. Patient does not remember course of
events. Mental status remained at baseline during hospital
course.
.
4) Metastatic colon cancer: Patient has metastases to liver and
lung. He is not a candidate for additional chemotherapy and was
scheduled to meet with hospice nurses on day after admission.
Hospice evaluated patient in the hospital and was set up to
discharge home on hospice.
.
5) Coronary Artery Disease: Patient with history of 2 stents at
outside hospital. No complaint of chest pain on this admission.
Troponin mildly elevated. EKG unremarkable. Patient was ruled
out for acute MI. No further active issues during hospital
course.
.
6) History of DVT/PE: Diagnosed in the setting of surgery. On
anti-coagulation as outpatient. Coumadin was continued with
goal INR 2 (lower end given history of lung metastases and
hemoptysis).
.
7) Atrial fibrillation: Patient currently in sinus rhythm.
Outpatient sotalol and digoxin were continued.
.
8) Anxiety: Per family, pt is extremely anxious at baseline
likely related to underlying cancer and prognosis. Remeron was
continued. Patient was given morphine as needed.
.
9) Code: DNR/DNI (confirmed with HCPs); daughter:
(H)[**Telephone/Fax (1) 77288**], (C)[**Telephone/Fax (1) 77289**]; son: (H)[**Telephone/Fax (1) 77290**],
(C)[**Telephone/Fax (1) 77291**].
.
10) Dispo: Patient discharged home with hospice.
Medications on Admission:
Digoxin 0.125mg PO daily
Sotalol 80mg PO TID
Fluoxetine 10mg PO daily
Prevacid 30mg PO daily
Coumadin 1mg PO daily
Remeron 7.5mg PO QHS
Iron PO BID
Multivitamin with minerals
Oxycodone 5mg PO Q6H PRN
Potassium 20mEQ PO daily
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
Disp:*30 nebulizer* Refills:*3*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q4 () as needed for shortness of breath or
wheezing.
Disp:*30 nebulizer treatment* Refills:*3*
3. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
12. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 5 days.
Disp:*4 Tablet(s)* Refills:*0*
13. Morphine Concentrate 20 mg/mL Solution Sig: [**6-23**] mL PO q
2hrs as needed for shortness of breath, anxiety, or pain.
Disp:*50 mL* Refills:*6*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice [**Location (un) 270**] East
Discharge Diagnosis:
Primary:
Bronchospasm
Possible pneumonia
Dehydration
.
Secondary:
Metastatic Colon Cancer to lung and brain
Atrial Fibrillation
History of DVT/PE
Discharge Condition:
Stable. Discharged with hospice care.
Discharge Instructions:
You were admitted to the hospital with respiratory distress and
confusion. You were treated with breathing treatments and
antibiotics with improvement of your symptoms. You were
discharged on hospice care to complete course of antibiotics.
.
Please take medications as directed.
.
Please follow up with appointments as directed.
.
Please call hospice nurses or your physician as needed.
Followup Instructions:
Follow up with physicians as needed
|
[
"519.11",
"V10.05",
"276.51",
"V58.61",
"427.31",
"197.0",
"293.0",
"485",
"198.3",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8878, 8964
|
4368, 7164
|
294, 301
|
9154, 9195
|
3090, 3095
|
9632, 9671
|
2720, 2725
|
7440, 8855
|
8985, 9133
|
7190, 7417
|
9219, 9609
|
2740, 3071
|
223, 256
|
3635, 4345
|
329, 2051
|
3109, 3616
|
2073, 2575
|
2591, 2704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,121
| 120,345
|
2702
|
Discharge summary
|
report
|
Admission Date: [**2141-10-18**] Discharge Date: [**2141-10-20**]
Date of Birth: [**2082-3-31**] Sex: F
Service: SURGERY
Allergies:
Bactrim / Captopril / A.C.E Inhibitors / Alphagan P
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Presents for elective BKA
Major Surgical or Invasive Procedure:
Left groin hematoma evacuation [**10-19**]
History of Present Illness:
Patient is 59F with L femoral-anterior tibial bypass graft done
on [**5-25**] which failed and was revised in [**9-25**]. The graft failed
and she continued to have symptoms of rest pain. She presented
on [**10-18**] for an elective BKA.
Past Medical History:
PMH:
Peripheral Vascular Disease
Type 1 DM
Peripheral Neuropathy
CAD
COPD
Asthma
hx pneumonia
hx PE
hypothyroidism
hyperlipdemia
CRI
Anxiety
Depression
Hiatal hernia with reflux
PSH:
rt. TMAx2
CABG's [**2131**]
breast reduction
IVC filter
rt. fem-[**Doctor Last Name **] bpg
left fem-at bpgw PTFE 6/06,[**9-25**], removal of fem at graftw VPAof
LCFA [**5-25**] rt.fem-[**Doctor Last Name **].
Social History:
non contributory
Family History:
non-contributory
Physical Exam:
On admission:
AVSS
NAD
RRR
CTA B/L
Ext: - 3 ulcers over L foot, unchanged from previous admission,
no signs of infection.
No palpable pulses in LLE
Palp graft in RLE
Pertinent Results:
On admission:
[**2141-10-18**] 07:20PM PT-16.0* PTT-33.0 INR(PT)-1.5*
[**2141-10-18**] 07:20PM PLT COUNT-332
[**2141-10-18**] 07:20PM WBC-10.1 RBC-2.88* HGB-8.4* HCT-23.7* MCV-82
MCH-29.1 MCHC-35.4* RDW-14.4
[**2141-10-18**] 07:20PM %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
[**2141-10-18**] 07:20PM CALCIUM-9.5 PHOSPHATE-3.2 MAGNESIUM-1.8
Brief Hospital Course:
Patient was admitted pre-operatively on the afternoon of [**10-18**]
for an elective BKA on [**10-19**]. On admission she was examined,
and outside of significant anxiety over the procedure, was found
to have the same exam as when she previously left the hospital.
She was made NPO after midnight for a BKA on [**10-19**] and recieved
vancomycin, levofloxacin, and flagyl the night of admission for
preoperative prophylaxis. On the evening of [**10-18**] she
complained of nausea. An EKG was done which was unchanged from
baseline.
At 0400 on [**10-19**] she was found on the floor next to her bed
by the nurses unresponsive. An immediate code blue was called
with response by medical and surgical house officers. She was
found to be pulseless and with occasional agonal respirations.
ACLS protocols were initiated and the patient was intubated
without difficulty. She recieved 2 rounds of chest
compressions, epinephrine, and atropine. A triple lumen
catheter was placed in the R groin after multiple attempts.
Pulses were regained and a rhythm was reestablished. She was
transferred to the SICU where she required multiple pressors for
hypotension. In the SICU a TTE was done which showed severely
depressed left ventricular function but no thrombus. Over the
course of the next day her CK's rose into the [**Numeric Identifier 961**] and her
Troponin was 4.7 at its peak.
The patient at that time was noted to be bleeding briskly
from her multiple groin sticks and developing a large hematoma.
Pressure was held and over the course of the day the hematoma
continued to enlarge requiring multiple transfusions of blood
products including pRBCs, platelets and FFP. She was taken to
the OR for hematoma evacuation. No active bleeding was seen but
the femoral vessels were not explored. For details please see
OP note. After no improvement in her clinical status the family
decided to make the patient CMO on the morning of [**10-20**]. All
pressors were stopped and she passed away shortly after at 11am.
Medications on Admission:
ASA 81', Atorvastatin 40', albuterol prn, Plavix 75', diazepam
5HS, Fluticasone 2puffs", lasix 80', dilaudid 2-4prn, NPH 22qAM,
15qPM, ISS >200, Ipratropium 2puffsQID, isosorbide dinitrate
20''', latanoprost drops, metoprolol 50", valsartan 80',
linezolid x 3 days
Discharge Disposition:
Expired
Discharge Diagnosis:
Myocardial Infarction
Coronary artery disease
Peripheral Vascular Disease
Type 1 Diabetes
Hypothyroidism
Discharge Condition:
Death
Discharge Instructions:
Patient passed away.
Followup Instructions:
Patient is deceased.
Completed by:[**2141-10-20**]
|
[
"V64.1",
"V58.67",
"585.9",
"403.90",
"996.74",
"440.24",
"998.12",
"493.20",
"E878.8",
"410.71",
"707.14",
"357.2",
"553.3",
"272.4",
"250.60",
"244.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"99.07",
"96.04",
"99.04",
"99.60",
"99.05",
"96.71",
"86.09",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4050, 4059
|
1706, 3735
|
339, 384
|
4208, 4216
|
1339, 1339
|
4285, 4338
|
1120, 1138
|
4080, 4187
|
3761, 4027
|
4240, 4262
|
1153, 1153
|
274, 301
|
412, 653
|
1354, 1683
|
675, 1070
|
1086, 1104
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,391
| 136,458
|
38892
|
Discharge summary
|
report
|
Admission Date: [**2180-3-25**] Discharge Date: [**2180-4-4**]
Date of Birth: [**2100-8-23**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
intracranial bleed found on CT, left sided numbness and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 13004**] is an 80 yo RH man with a PMH remarkable for HTN, DM,
CHF([**Known lastname **] failure), AF (INR 5.3) and gout p/w sudden onset of
left sided weakness and loss of sensation in his LEFT hemibody.
He started with these symptoms early in the morning on [**2-22**]. He
did not have a headache at the time. He did not have any visual
problems or difficulty swallowing or a facial droop per his
family. He reports not been able to move the left side of his
body as usually, however, it felt weak. He did not check his
BPs. He has been compliant with his medications. He cannot
determine when he developed numbness but it is
completely numb now. He had trouble moving his left arm
appropriately toward different targets. He did not bump into
objects. He felt unsteady when changing positions (standing up).
Things were spinning around him. It lasted for 1 minute and then
stopped. There was no tinnitus. No other symptoms associated. He
did
not have a slurred speech. He was able to understand and produce
normal sentences.
His family insisted that he went to the hospital 24h ago, but he
refused. Today, he finally went to OSH given his relatives'
insistence. He also started with a headache today. It is of
throbbing quality, left sided (temple), non-radiated. He has
never had this headache before. There has been no fall, or TBI.
No LOC.
Baseline: Lives with his son. [**Name (NI) 4461**]. [**Name2 (NI) 6934**] on his own (no cane).
Last week left home to drive to the grocery store. He purchased
the groceries and returned home without any navigation problems.
[**Name (NI) **] also visited a relative who had had a stroke and was on rehab
on his own without difficulties.
On general review of systems, the pt denies recent fever or
chills,sleep deprivation or any aggravating factor that may
precipitate the episodes. No night sweats or recent weight loss
or gain. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Went to OSH. BPs 190s and metoprol 5 mg iv *2. CT CNS: RIGHT BG
bleed. Sent to [**Hospital1 18**].
Received in the ED at [**Hospital1 18**]:
Labetalol 100 mg / 20 mL Vial 1 McCallum, [**Last Name (NamePattern4) 86305**]
Phytonadione 10mg/mL Amp 1 McCallum, [**Last Name (NamePattern4) 86305**]
Labetalol 600 mg in 5% Dextrose 1 from Pharmacy
Past Medical History:
HTN (+), CHF ([**Last Name (LF) **], [**First Name3 (LF) **] 40-45% and pulmonary HTN), AF (+), DM
(+), CKD, Gout (+)
Question of prostate Ca with mets to the bone.
Ascitis in abdominal US in 01/ [**2179**]
Social History:
Lives with his son. [**Name (NI) 4461**]. [**Name2 (NI) 6934**] on his own (no cane).
Last week left home to drive to the grocery store. He purchased
the groceries and returned home without any navigation problems.
[**Name (NI) **] also visited a relative who had had a stroke and was on rehab
on his own without difficulties.
Tobacco (-)
ETOH (-)
Drugs (-)
He worked as mechanic for airplanes.
Family History:
Hx of early strokes (-)
Seizures (-)
CNS tumors (-)
Demyelinating conditions (-)
Autoimmune conditions (-)
Procoagulant conditions (-)
CAD (-)
Physical Exam:
PE: performed in Vietnamese (although he speaks English)
Temp 98.6, 67 177/98 17RR 98
GSC: 15
General: alert, awake, normal affect
Orientation: oriented to person, place, date, situation.
.
DOW backwards +: in less than 20 seconds.
Follows simple axial and appendicular commands: closes and opens
his eyes, shows me the tongue. Gives me a thumb or a provides
and
releases a grip at command.
Follows three step commands: "take this piece of paper with your
right hand, fold it into two parts and return it to me with the
left hand".
Recalls major events: 9/ 11 [**Location (un) 7349**] attack (but he remembers a
terrorist attack with explosives in NY) and recent events such
as
the earthquake in [**Country 2045**].
Spatial memory: remembers where is the clock in the room.
Recalls who is the president
.
Speech/Language: in Vietnamese: fluent w/o paraphasic (phonemic
or semantic) errors; comprehension, repetition, naming (high and
low frequency objects): normal. Prosody: normal. Understands the
passive voice: "the kid killed the lion".
.
Praxis/ agnosia: Able to brush teeth. Able to recognize I am
brusing my teeth. Able to mimic me brushing my teeth.
.
No field cuts: to red pin in different quadrants.
There is no extinction to double visual stimuli.
Able to tell how many people there are in the room .
No prosopagnosia, no anosognosia, no asomatognosia. No
agraphestesia. Able to read and write.
Calculus: intact to number of quaters in $1.75
Abstract thinking:Common features: banana and school bus:
normal.
CN:
I: not tested
II,III: VFF to confrontation, PERRL 3mm to 2mm, fundus w/o
papilledema. No red desaturation. OD and OS 20/ 20. Pin hole
exam/ Madox-Rod exam: not required.
III,IV,VI: EOMI, no ptosis. No pathological nystagmus. Normal
pursuit. Optokinetoc nystagmus: intact
V: sensation intact V1-V3 to LT.
VII: Facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**3-29**] bilaterally
XII: tongue protrudes midline, no dysarthria
.
Rinne: R ear: AC>BC, LEFT ear AC> BC
[**Doctor Last Name 15716**]: central.
Motor:
Normal bulk.
Tone: normal.
No tremor, no asterixis or myoclonus. No pronator drift:
.
There is mild weakness on the LEFT, plus a component of mild
neglect that improves when looking at the limb:
Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 3+ 5 3 3+ 3+
Right 5 5 5 5 5
.
IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]: Pl.flex
Left 4 5 4 4 4 5
Right 5 5 5 5 5 5
.
Deep tendon Reflexes:
.
Bicip: Tric: Brachial: Patellar: Achilles Toes:
Right 2 2 2 1 0 DOWNGOING
Left 2 2 2 1 0 UPGOING
.
Sensation: No perception of PP, light touch, vibration, and
temperature in his left hemibody. No propioception in his left
hemibody.
.
Coordination: impaired on the left as a function of decreased
position sense and weakness in:
*Finger-nose-finger
*Rapid Arm Movements
*Fine finger tapping.
Labs: OSH
CBC: normal.
Chem: Creat 3.7, BUn 77.
CK and trop : pending
Ekg: Af 80 bpm, with hemodynamic ST depression in lateral leads.
CT CNS:
OSH: loading.
[**Hospital1 **]: my read: 22*17 mm maximum diameter RIGHT BG bleed with
minimial edema and mass effect. No evidence of hydrocephalus.
Pertinent Results:
[**2180-3-28**] 02:19AM BLOOD WBC-11.3* RBC-2.66* Hgb-8.7* Hct-25.5*
MCV-96 MCH-32.8* MCHC-34.2 RDW-16.3* Plt Ct-209
[**2180-3-27**] 02:37AM BLOOD WBC-11.8* RBC-2.78* Hgb-9.0* Hct-26.0*
MCV-94 MCH-32.2* MCHC-34.4 RDW-15.6* Plt Ct-215
[**2180-3-25**] 02:21PM BLOOD Neuts-67.2 Lymphs-19.4 Monos-7.3 Eos-5.6*
Baso-0.4
[**2180-3-28**] 02:19AM BLOOD Plt Ct-209
[**2180-3-27**] 02:37AM BLOOD Plt Ct-215
[**2180-3-28**] 02:19AM BLOOD Glucose-115* UreaN-49* Creat-3.6* Na-140
K-4.2 Cl-109* HCO3-19* AnGap-16
[**2180-3-27**] 02:37AM BLOOD Glucose-98 UreaN-54* Creat-3.4* Na-143
K-4.0 Cl-109* HCO3-22 AnGap-16
[**2180-3-26**] 02:00AM BLOOD ALT-13 AST-39 LD(LDH)-238 CK(CPK)-317
AlkPhos-79 TotBili-0.7
[**2180-3-26**] 02:00AM BLOOD CK-MB-4 cTropnT-0.11*
[**2180-3-25**] 02:21PM BLOOD cTropnT-0.12*
[**2180-3-28**] 02:19AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1
[**2180-3-26**] 02:00AM BLOOD Triglyc-258* HDL-24 CHOL/HD-7.4
LDLcalc-102
[**2180-3-26**] 02:00AM BLOOD TSH-1.5
Imaging:
Initial [**Hospital1 18**] Head CT:
Interval increase of right thalamic hemorrhage from 12 x 15 mm
to 20 x 25 mm over the last three hours from outside hospital
study. Thin rim of surrounding edema without significant mass
effect. No intraventricular or subarachnoid extension. No
hydrocephalus.
Repeat Head CT:
Unchanged likely hypertensive right thalamic hemorrhage without
intraventricular or subarachnoid extension.
Brief Hospital Course:
Mr. [**Known lastname 13004**] is an 80 yo RH man with a PMH remarkable for HTN, DM,
CHF([**Known lastname **] failure), AF (INR 5.3) and gout p/w sudden onset of
left sided weakness in his LEFT hemibody and loss of sensation
in his LEFT hemibody.
HOSPITAL COURSE:
The patient intially went to the [**Hospital6 2910**].
There a head CT was performed and he was found to have a right
thalamic hemorrage. He was also noted to have a supra
therapuetic INR of 5.3. He was given nitro paste for an elvated
blood pressure of 204/88. There is no record of him recieving
any FFP or vit K at the outside but after the transfer to [**Hospital1 18**]
his INR was noted to be 2.6. In the [**Hospital1 18**] emergency room he had
a repeat head CT which showed an increase in the size of the
bleed. In the emergency room he was given FFP, vitamin K and
profiline. He was than admitted to the ICU for
neuro-monitoring.
NEURO:
The patient's repeat head CT on [**2180-3-26**] did not show any
significant change from the admission CT. On [**3-26**] the patient
had a decrease in responsiveness, given the recent normal head
CT it was thought to be secondary to a dose of diluadid that the
patient recieved and as the day progressed he returned to his
baseline responsiveness. The patient continued to do well in
the ICU. His blood pressure was intially controlled on a
labetalol drip, which he was eventually weaned off of and placed
back on oral medications. His coumadin and anti-platelet agents
were held. Heparin for DVT prophylaxis was started. The
patient showed some strength in the left arm and leg, although
with significant neglect. The patient will move his left side
but only with a large amount of concomitant visual stimulation.
The patient was kept on frequent neuro checks. The patient
remained stable in the ICU and was transferred to the neurology
floor. He demonstrated ongoing improvement in his exam with
good volitional strength in the left upper extremity but poor
coordination. In his left lower extremity he continued to have
minimal volitional movement. After he had remained stable with
an improving neurological exam and no evidence of expansion of
his hemorrhage, he was started on baby aspirin 81 mg in place of
coumadin for stroke prophylaxis on [**4-3**]. He should be off of
coumadin indefinitely, and whether he may ultimately resume this
will be discussed in his follow-up appointment. He should
certainly continue on the aspirin 81 mg daily.
CV
The patient has a previous diagnosis of atrial fibrillation and
diastolic heart failure (EF=40-45%). The patient's coumadin was
held secondary to the bleed. He was hypertensive on arrival and
intially needed to be started on a labetalol gtt which was
weaned off on [**2180-3-28**] and he was transitioned to oral
medications. On [**4-3**] aspirin was resumed in place of coumadin
at a dose of 81 mg for some cardiac and stroke protection with a
relatively lower risk of hemorrhagic expansion than coumadin.
Potential for ever resuming coumadin will be discussed with his
neurologist at his follow-up appointment with Dr. [**First Name (STitle) **]. His
blood pressure was be observed rigorously to ensure that it is
no higher than 160 systolic with a goal of normotension.
Renal
The patient was noted on arrival to be in renal failure. Based
on prior notes the patient has had stage II-III renal failure
for at least the last year (with some elevatation as far back as
[**2173**]). Prior work-up had only revealed small kidneys without
specific pathology. His creatinine was followed serially with
improvement to 2.8-3 prior to discharge which is the higher
range of his previously noted baseline. Additionally, the
patient's colchicine was discontinued given the potential to
worsen renal function.
Pulmonary:
The patient was noted to have frequent wheezing, particularly
during sleep, throughout his hospitalization. He at times
seemed to respond to lasix, but at other times seemed to have a
good fluid balance and respond to albuterol. While he had no
known underlying pulmonary disease, concern was that there may
be both a cardiac and pulmonary component to his wheeze, thus we
recommended obtaining both echocardiogram and pulmonary function
tests as an outpatient to ascertain his baseline function in
these areas.
Medications on Admission:
Coumadin 2 mg qd
Carvelidol 25 [**Hospital1 **], hydralazine 50 [**Hospital1 **], Bumetanide 2 mg qd,
Imdur 30 mg qd, digoxine 0.125 mg qd
Colchicine 0.6 mg qd at 2:00 pm.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain .
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): sliding scale .
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
7. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
8. Amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every
8 Hours).
10. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation every 4-6 hours
as needed for wheezing.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): while minimally
ambulatory to reduce risk of DVT.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Basal ganglia hemorrhage.
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Neurological exam:
-Mental status: alert, oriented to month, year, hospital
-CN: Question intermittent right facial droop when tired, left
eyelid with mild ptosis, dyarthria
-Motor: Right side full; left side with mild weakness in the [**2-28**]
range but significant ataxia out of proportion to his weakness
-Senation: intact
-Coordination: markedly diminished in the left upper and lower
extremities
Discharge Instructions:
Mr. [**Known lastname 13004**] was admitted with left sided weakness, sensory
changes, and discoordination. He was found to have a basal
ganglia hemorrhage. In addition, he has a history of chronic
renal insufficiency and had a slight worsening in his renal
function upon presentation which seems to have improved just at
the high end of his baseline around 3.0 (baseline 1.5-3).
Mr. [**Known lastname 13004**] was noted to have frequent wheezing during
hospitalization, at times responding to lasix and at other times
responding to albuterol. It seems both an echocardiogram and
pulmonary function tests following hospitalization would be
reasonable to ensure that both the pulmonary and cardiac
components to his wheezing may be addressed.
Given that Mr. [**Known lastname 13004**] had a bleed in his brain, he should be off
of coumadin indefinitely. Instead, he should continue on the
baby aspirin (81 mg) at least until he is seen by Dr. [**First Name (STitle) **] in
follow-up to minimize his risk of stroke.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2180-5-9**] 8:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2180-4-4**]
|
[
"784.51",
"403.90",
"790.92",
"428.0",
"431",
"416.8",
"342.90",
"351.8",
"250.00",
"428.32",
"427.31",
"274.9",
"285.9",
"584.9",
"585.3",
"E934.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14585, 14655
|
8634, 8883
|
380, 386
|
14725, 14840
|
7221, 8215
|
16346, 16624
|
3581, 3725
|
13180, 14562
|
14676, 14704
|
12983, 13157
|
8900, 12957
|
15303, 16323
|
3740, 7202
|
14894, 14895
|
276, 342
|
414, 2922
|
8501, 8611
|
14910, 15279
|
2944, 3153
|
3169, 3565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,503
| 120,857
|
20039
|
Discharge summary
|
report
|
Admission Date: [**2201-8-30**] Discharge Date: [**2201-9-10**]
Date of Birth: [**2131-4-24**] Sex: M
Service: SURGERY
Allergies:
Iodine / Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD with duodenal stent
Exploratory laparotomy with G-J feeding tube placement
History of Present Illness:
69 year old Italian speaking gentleman diagnosed with
non-operable pancreatic CA in [**12-12**], s/p multiple CBD stent
placements, who is admitted with abdominal pain with N/V x2
days. Pt also c/o heartburn. Abdominal pain sharp with radiation
to back/right shoulder baldes and right flank. [**5-19**] severity
unable to control pain with pain pills. 10 lb wt loss this
month. FSBS increased recently. +CHest tightness- unclear if
different than heartburn, not exertional in nature associated
with abdominal pain.
Denies F/C, black/bloody stool, dysuria, hematuria.
Past Medical History:
1. Pancreatic CA, as above
2. PUD
3. Ventricular ectopy, possibly secondary to small MI at age 40
4. Osteoarthritis
5. Emphysmea
6. Anxiety
PSH:
- s/p laminectomy in 30s, for back pain following a car
accident.
- appendectomy in youth
- vein ligation for vericosities
Social History:
Italian-speaking. History of heavy smoking, currently several
cigarettes per day. [**1-11**] glasses wine per day, no hx heavy EtOH.
Lives with sister and her husband in [**Name (NI) 1475**]. Single,
without children. Retired shoe-factory worker.
Family History:
CAD in mother, father, and sister.
Cerebral aneurysms in sister.
Negative for pancreatic, colorectal, or any other CAD.
Physical Exam:
VS: Tmax 98.3 pulse 93, BP 110/72, RR 22, sats 95% on 3L.
GEN: The patient is a cachectic, NAD, speaking in full
sentences, frail appearing.
HEENT: Anicteric, MMM, OP clear, PERRL, EOMI Upper teeth, lower
molars missing.
NECK: supple, no LAD. No Virchow's node appreciated.
PULM: Reduced breath sounds bilaterally. Tympanitic. End
expiratory wheezes throughout.
CV: NSR, no MRG.
ABD: soft, NT/ND, no rebound or guarding. No masses appreciated.
No organomegally. No periumbilical nodes appreciated.
EXT: warm, 2+ pulses B at radius and DP. Varicosity noted on
anterior aspect of R crus.
NEURO: AAOx3,
Pertinent Results:
[**2201-8-30**] 07:57PM K+-4.2
[**2201-8-30**] 05:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.023
[**2201-8-30**] 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2201-8-30**] 02:16PM GLUCOSE-123* LACTATE-2.1*
[**2201-8-30**] 02:10PM GLUCOSE-119* UREA N-17 CREAT-0.8 SODIUM-135
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-24 ANION GAP-18
[**2201-8-30**] 02:10PM ALT(SGPT)-19 AST(SGOT)-31 ALK PHOS-125*
AMYLASE-39 TOT BILI-0.7
[**2201-8-30**] 02:10PM LIPASE-11
[**2201-8-30**] 02:10PM CALCIUM-10.1 PHOSPHATE-3.9 MAGNESIUM-2.1
[**2201-8-30**] 02:10PM WBC-8.8 RBC-5.05 HGB-14.2 HCT-41.8 MCV-83
MCH-28.2 MCHC-34.1 RDW-14.2
[**2201-8-30**] 02:10PM NEUTS-67.2 LYMPHS-25.5 MONOS-5.3 EOS-1.3
BASOS-0.7
[**2201-8-30**] 02:10PM PLT COUNT-253
[**2201-8-30**] 02:10PM PT-13.1 PTT-28.2 INR(PT)-1.1
[**2201-9-2**] 11:03PM BLOOD WBC-13.1*# RBC-4.42* Hgb-12.9* Hct-38.1*
MCV-86 MCH-29.2 MCHC-33.9 RDW-14.2 Plt Ct-191
[**2201-9-5**] 03:30AM BLOOD WBC-9.7 RBC-3.60* Hgb-10.1* Hct-30.5*
MCV-85 MCH-28.1 MCHC-33.2 RDW-14.1 Plt Ct-188
[**2201-9-8**] 06:58AM BLOOD WBC-8.1 RBC-3.92* Hgb-11.0* Hct-32.7*
MCV-84 MCH-28.1 MCHC-33.6 RDW-13.7 Plt Ct-262
[**2201-9-8**] 06:58AM BLOOD Plt Ct-262
[**2201-9-2**] 11:03PM BLOOD Glucose-143* UreaN-9 Creat-0.5 Na-137
K-3.9 Cl-105 HCO3-20* AnGap-16
[**2201-9-5**] 03:30AM BLOOD Glucose-82 UreaN-12 Creat-0.5 Na-134
K-3.7 Cl-101 HCO3-24 AnGap-13
[**2201-9-8**] 06:58AM BLOOD Glucose-123* UreaN-13 Creat-0.6 Na-134
K-4.5 Cl-100 HCO3-25 AnGap-14
[**2201-8-31**] 07:20AM BLOOD ALT-17 AST-20 LD(LDH)-150 CK(CPK)-35*
AlkPhos-113 Amylase-32 TotBili-0.7
[**2201-9-5**] 03:30AM BLOOD ALT-14 AST-15 LD(LDH)-124 AlkPhos-72
Amylase-15 TotBili-0.9
[**2201-9-4**] 02:49AM BLOOD Albumin-2.6* Calcium-7.7* Phos-2.2*
Mg-1.8
[**2201-9-8**] 06:58AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.7
[**2201-9-6**] 12:41PM BLOOD Type-ART pO2-62* pCO2-30* pH-7.50*
calHCO3-24 Base XS-0
Brief Hospital Course:
70 YO male with hx of pancreatic cancer since [**12-12**], s/p
multiple CBD stents, admitted to Geriatric Medicine with
abdominal pain and N/V. His abdominal pain was considered to
likely be multifactorial from pancreatic ca, ischemia/SMA and
partial gastric outlet obstruction by tumor. Repeat CT showed
enlarged mass encasing hepatic artery and SMA. Patient went for
EGD/duodenal stent placement on [**9-2**] complicated by
post-procedure SOB and abdominal pain concerning for
perforation. He then underwent exploratory laparotomy where no
perforation was identified and a feeding G-J tube and [**First Name9 (NamePattern2) 53961**] [**Doctor Last Name **]
drain were placed. Please see OP report for details.
Post-operatively the patient remained intubated for low O2
saturations and was admitted to the SICU. He was empiracally
treated with Levofloxacin/Flagyl and his pain was
well-controlled. Patient was extubated on the evening on POD 1
and did well. He was started on tube feeds. On POD 4 he was
transferred to the floor. His O2 sats were intermittantly low
in the 80s-90s on nasal cannula, consistent with his severe
COPD. He tolerated tube feeds at goal and was able to be
discharged to rehab on POD 6.
Medications on Admission:
Megestrol
Mirtazapine
RISS
protonix
pancreas
Cholecalciferol
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
2. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
per sliding scale units Subcutaneous four times a day.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Pancreatic CA s/p EGD/duodenal stent, ex lap with GJ feeding
tube
COPD
Anxiety
Discharge Condition:
stable, tolerating tube feeds, 02 sats adequate for COPD
Discharge Instructions:
Please call your physician if you are having
temperatures > 101.5, severe chest pain, shortness of breath,
abdominal pain, signs of incisional infection including redness,
increased pain, or drainage of pus.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**1-11**] weeks, call to schedule
an appointment [**Telephone/Fax (1) 476**]
|
[
"250.00",
"799.4",
"568.89",
"530.81",
"537.0",
"157.8",
"198.89",
"567.2",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"44.22",
"44.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6822, 6893
|
4330, 5555
|
322, 403
|
7016, 7075
|
2336, 4307
|
7332, 7471
|
1579, 1700
|
5666, 6799
|
6914, 6995
|
5581, 5643
|
7099, 7309
|
1715, 2317
|
268, 284
|
431, 1001
|
1023, 1293
|
1309, 1563
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,063
| 118,645
|
26413
|
Discharge summary
|
report
|
Admission Date: [**2143-7-8**] Discharge Date: [**2143-7-17**]
Date of Birth: [**2106-7-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Loose stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 65319**] is a 37M with a h/o IDDM, pancreatic insufficiency,
and EtOH dependence who was admitted to the MICU for DKA and
transferred to the medicine service for further management
following gap closure. He reports loose stools and bilateral LE
burning pain for many months, as well as non-bloody emesis and
decreased PO intake for several days PTA. He was admitted most
recently to [**Hospital1 18**] [**Date range (1) 65320**] for hyperglycemia (HA1c of 12.8),
EtOH intoxication, and weight loss. At that time, his insulin
regimen was changed to Lantus 25 units qam and Humalog SS [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recommendations. He indicates that he has not used
insulin regularly since discharge, given his homelessness and
limited access to supplies or food. Of note, it was his birthday
on the day PTA, and he drank 2 beers; he denies ingestion of any
other substances.
In the ED, VS were as follows: 97.1 92 92/60 20 94% FS>350.
Admission labs were notable for K of 3.7, glucose of 391, anion
gap of 23, and lactate of 6.5. UA with 1k glucose. Serum and
urine toxicity screens negative. Urine and blood cultures were
obtained. Patient received 40mg IV KCl, 5 units insulin IV and
insulin gtt @ 5 units/hr, as well as IVNS with KCl @ 200
cc/hour. Repeat lactate was 4.5 prior to admission to the MICU.
Past Medical History:
IDDM
Pancreatitis x 2 in [**12-21**] and [**8-22**]
HBV surface ag positivity
Abnormal hemoglobin electropheresis in [**2136**]
H. pylori on EGD biopsy
Malaria as a child
Social History:
He grew up in [**Country **] and has lived in the United States since
his mid-20s.
2+ packs of cigarettes per week. EtOH as noted above. Denies
illicit/IVDU.
.
Family History:
Not addressed on this admission.
Physical Exam:
Exam on admission
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL, dry MM, oropharynx clear
no exudates, lesions or thrush
Neck: supple, JVP not elevated, no LAD
CV: Tachycardiac, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
diminished sensation to level of bilateral ankles, gait
deferred, finger-to-nose intact
Exam at discharge
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL, dry MM, oropharynx clear
no exudates, lesions or thrush
Neck: supple, JVP not elevated, no LAD
CV: Tachycardiac, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
diminished sensation to level of bilateral ankles, gait
deferred, finger-to-nose intact
Pertinent Results:
Labs on admission
CBC: 6/34.9/324
Lytes: 141/3.7/94/24/10/0.4/351 AG 27 7.7/2.3/1.7
LFTs: 26/28/0.2/144
sTox: EtOH 183
VBG: pO2-99 pCO2-37 pH-7.41 calTCO2-24 Base XS-0
Labs at discharge
CBC: 7.1/38.4/351
Lytes: 131/4.4/95/26/13/0.4/196 AG 14 10/4.6/2
Additional [**Hospital3 **]
D-Dimer-177
TSH-1.2
BLOOD HIV Ab-NEGATIVE
EKG [**2143-6-30**]
Sinus rhythm. Left anterior fascicular block. Biatrial
abnormality. Compared to the previous tracing axis is slightly
more leftward. The other findings are similar.
EKG [**2143-7-8**]
Sinus rhythm. Left anterior fascicular block. Compared to the
previous tracing of [**2143-6-30**] decreased QRS voltage throughout,
particularly in the precordial leads and delayed R wave
progression. Clinical correlation is suggested.
EKG [**2143-7-12**]
Normal sinus rhythm. Left atrial abnormality. Complete right
bundle-branch block. Left anterior hemiblock. Compared to the
previous tracing of [**2143-7-8**] there is now an incomplete right
bundle-branch block.
TTE [**2143-7-15**]
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No valvular pathology or pathologic flow identified.
Brief Hospital Course:
Mr. [**Known lastname 65319**] is a 37M with a h/o IDDM, pancreatic insufficiency,
and EtOH dependence who was admitted to the MICU for management
of DKA and transferred to the medicine service for further
management following gap closure.
#IDDM: Patient with known h/o DM since [**2136**], including polyuria,
polydypsia, polyphagia, and weight loss in the setting of HA1c
of 12.8 on [**6-29**], found to have DKA with elevated lactate on
admission. He was admitted initially to the MICU, where he was
treated with an insulin gtt until his gap closed and
subsequently transitioned to SC insulin prior to transfer to the
floor. With daily uptitration of Lantus and Humalog SS under
[**Last Name (un) **] guidance, his glucose eventually remained 200s-300s
throughout the course of the day on 60 units Lantus qam, 30
units Lantus qpm, and a Humalog SS as follows:
Breakfast Lunch Dinner Bedtime
71-119 mg/dL 13u 13u 13u 0u
120-159 18 18 18 0
160-199 23 23 23 0
200-239 28 28 28 4
[**Telephone/Fax (2) 65321**] 33 6
280-319 38 38 38 8
[**Telephone/Fax (2) 65322**] 43 10
[**Telephone/Fax (2) 65323**] 48 12
Of note, his insulin regimen at discharge reflects ample PO
intake in-hospital, and his dosing may require adjustment once
his access to food becomes more limited, given his homelessness;
at least in the initial post-discharge period, he will be
staying at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House, where his access to food and
medication will be consistent.
# Anion gap acidosis: Most likely multifactorial including
lactic acidosis, alcoholic ketoacidosis, and DKA. Most prominent
contributor likely DKA precipitated by medication noncompliance
in the setting of EtOH abuse. Patient was without evidence of
infection (UA negative, CXR wnl, afebrile with WBC wnl), active
pancreatitis or other major illness that might have precipated
DKA. Lactic acidosis likely secondary to hypoperfusion in the
setting of loss (diarrhea, poor PO intake, polyuria). On
presentation to ED, patient with anion gap of 23 and lactate of
6.8; on arrival to MICU gap closed to 13 with lactate
downtrending to 4.5. K was aggressively repleted and hydrated
with D51/2NS with K. Thiamine was supplemented. Insulin gtt was
started initially and then transitioned to subcutaneous insulin.
#Tachycardia: Patient with known h/o sinus tachycardia on
previous admission [**6-29**], as well as in the ED on [**2-17**], with
persistent asymptomatic tachycardia to 100s at rest and
120s-140s on ambulation. Despite IVF to correct osmotic diuresis
[**1-17**] hyperglycemia, his tachycardia persisted. He remained
afebrile/HD stable without leukocytosis or other signs of
infection throughout admission, with negative D-dimer and normal
TSH. Multiple EKGs demonstrated sinus tachycardia with
incomplete RBB and L anterior hemiblock, but TTE was essentially
negative for underlying pathology. Ultimately, his postural
tachycardia was presumed [**1-17**] diabetic autonomic neuropathy,
though his elevated HR at rest could not be explained
completely. Beta blocker treatment was not not initiated on this
admission, but may need to be readdressed on PCP [**Name9 (PRE) 702**] if
tachycardia persists.
#Anemia: Patient with chronically low MCV p/w microcytic anemia
(Hct 34.9, MCV 80) in the setting of low Fe (31) with normal
ferritin and TIBC. Ferrous sulfate was initiated and increased
to 325mg [**Hospital1 **] by the time of discharge. Hct remained stable
(35-39) throughout admission.
#Peripheral Neuropathy: Patient with known bilateral LE burning
pain and paresthesias p/w persistent symptoms without focal
neurologic deficits, with the exception of decreased sensation.
Gabapentin 300mg tid was uptitrated to 600mg tid and
amitriptyline 100mg daily was continued; further uptitration may
be considered on PCP [**Last Name (NamePattern4) 702**].
#EtOH dependence: Patient with known EtOH dependence, but no h/o
withdrawl seizures or LOC; he claims not to drink more than 2
beers at a time. He did not score on CIWA throughout admission.
He will be discharged to [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House, where he may
continue to receive further counseling.
#Pancreatic insufficiency: Patient with known h/o pancreatic
insufficiency in the setting of poorly controlled diabetes p/w
chronically loose stools. LFTs were normal, and HIV and stool C.
difficile were negative on this admission. Creon was uptitrated
on this admission to 4 caps per meal, and his stool remains
formed.
#Transitional issues:
-IDDM: Follow-up arranged with Dr. [**Last Name (STitle) **] at [**Last Name (un) **] at 9am on
[**2143-7-25**].
-Tachycardia: [**Month (only) 116**] consider beta blocker on PCP [**Name9 (PRE) 702**] if
persistent.
-Anemia: Will need CBC and Fe studies on PCP [**Name9 (PRE) 702**] to avoid
Fe overload and exclude other causes of anemia.
-Peripheral neuropathy: [**Month (only) 116**] consider uptitration of gabapentin
on PCP [**Name9 (PRE) 702**] if symptoms persist.
-EtOh dependence, homelessness: Discharged to [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **]
House.
-Pancreatic insufficiency: [**Month (only) 116**] need uptitration of Creon on PCP
[**Name9 (PRE) 702**] if symptoms persist.
Medications on Admission:
1. Gabapentin 300 mg PO TID
2. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
3. Amitriptyline 100 mg PO HS
4. FoLIC Acid 1 mg PO DAILY
5. Thiamine 100 mg IV DAILY Duration: 1 Days
6. Creon 12 2 CAP PO QIDWMHS
7. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using UNK Insulin
Discharge Medications:
1. Amitriptyline 100 mg PO HS
2. Thiamine 100 mg IV DAILY Duration: 1 Days
3. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
4. Creon 12 4 CAP PO QIDWMHS
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 600 mg PO TID
7. Glargine 60 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Loperamide 2 mg PO QID:PRN diarrhea
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 11015**] House
Discharge Diagnosis:
Diabetic Ketoacidosis, Uncontrolled Insulin Dependent Diabetes,
Pancreatic Insufficiency, Diabetic Neuropathy, Iron Deficiency
Anemia, Tachycardia
Discharge Condition:
Improved, mental status at baseline, ambulatory
Discharge Instructions:
Mr. [**Known lastname 65319**], it was a pleasure to participate in your care at
[**Hospital1 18**]. You were admitted for diabetic ketoacidosis, a very
dangerous complication of uncontrolled diabetes. You were
treated with insulin in the intensive care unit and then on a
regular medical floor. You were seen by the [**Last Name (un) **] Diabetes
Center team, and you will have a follow up appointment with Dr.
[**Last Name (STitle) **] on [**2143-7-25**] at 9 am. You also were noted to have diarrhea in
the hospital, which is due to pancreatic insufficiency. You were
treated for this with Creon (enzyme replacement) and your
diarrhea improved. For the pain in your legs, your dosage of
gabapentin was gradually raised to 600mg three times daily. In
the hospital you also were noted to have a persistently fast
heart rate and abnormal electrical activity in your heart. You
underwent imaging of your heart, which showed an essenially
normal heart. The following changes were made to your
medications: Creon dose increased to 4 caps daily, gabapentin
dose increased to 600mg three times daily, insulin lantus
increased to 60 units in the morning and 30 units in the
evening, with an insulin sliding scale. For your iron deficiency
anemia, you were started on iron supplements. It is very
important that you continue to take your Lantus even if you are
not going to eat very much. Your insulin will still be good
even if it is not refrigerated. In addition to following up at
the [**Last Name (un) **] Diabetes Center, you should follow up with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 2177**].
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name3 (LF) 16433**] O. MD
Location: [**Last Name (un) **] DIABETES CENTER
When: Thursday [**7-25**] at 9 am
Address: ONE [**Last Name (un) **] CENTER, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R
When: Tuesday [**7-23**] at 3pm
Location: [**Hospital1 2177**]-FAMILY MEDICINE DEPT
Address: 1 [**Hospital6 **] PLAZA, [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 65318**]
|
[
"577.1",
"V60.0",
"280.9",
"337.1",
"V85.0",
"303.90",
"787.91",
"305.1",
"V58.67",
"785.0",
"250.12",
"V15.81",
"783.21",
"250.62"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11762, 11869
|
5587, 10307
|
314, 320
|
12060, 12110
|
3437, 5564
|
13789, 14329
|
2097, 2132
|
11387, 11739
|
11890, 12039
|
11077, 11364
|
12134, 13766
|
2147, 3418
|
10328, 11051
|
263, 276
|
348, 1707
|
1729, 1902
|
1918, 2081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,241
| 117,186
|
38706
|
Discharge summary
|
report
|
Admission Date: [**2171-6-21**] Discharge Date: [**2171-6-27**]
Date of Birth: [**2128-10-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Mediastinal germ cell tumor
Major Surgical or Invasive Procedure:
[**2171-6-21**]: Median sternotomy and right anterior thoracotomy
and radical resection of mediastinal tumor. Right middle lobe
wedge resection.
History of Present Illness:
The patient is a 42-year-old gentleman who was treated with
chemotherapy for a very large germ cell tumor which was causing
SVC syndrome. The tumor responded well with some size diminution
and resolution of an increased AFP, however, the mass was still
quite large,impinging on both the heart and lung. He was
admitted following Median sternotomy and right anterior
thoracotomy and radical resection of mediastinal tumor. Right
middle lobe wedge resection.
Past Medical History:
SVC syndrome
Pulmonary Embolism (on lovenox pre-op)
Anxiety
Social History:
The patient has a significant other of 6+ years.
He worked for [**Doctor Last Name 634**] Electronics at a desk job, with no
particular toxic exposures. He reports that he smoked minimally,
[**1-19**] cigarettes per week, but nothing in >7yrs. He reports [**3-21**]
drinks a week, and denies drug use. He lives in [**Location (un) 3844**].
Family History:
Reviewed and noncontributory for any
malignancies. Mother had two minor strokes
Physical Exam:
VS: T: 96.0 HR 100 ST BP 99/67 Sats 99% RA
General: anxious but in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: decreased breath sounds Right>left
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: sternal/clam-shell clean dry intact no erythema, no
discharge, no sternal click
Neuro: awake, alert, oriented.
Pertinent Results:
[**2171-6-27**] WBC-6.3# RBC-3.37* Hgb-10.0* Hct-30.2 Plt Ct-285
[**2171-6-24**] WBC-13.0* RBC-3.23* Hgb-9.4* Hct-28.7 Plt Ct-222
[**2171-6-21**] WBC-15.0*# RBC-4.08* Hgb-12.1* Hct-35.9 Plt Ct-240
[**2171-6-27**] Glucose-92 UreaN-13 Creat-0.9 Na-134 K-3.7 Cl-97
HCO3-27
[**2171-6-27**] Calcium-8.6 Phos-4.3# Mg-1.9
[**2171-6-24**] Glucose-95 UreaN-8 Creat-0.9 Na-135 K-3.9 Cl-99 HCO3-29
[**2171-6-21**] Glucose-150* UreaN-10 Creat-0.8 Na-140 K-3.7 Cl-108
HCO3-24
CXR:
[**2171-6-27**]: A small right hydropneumothorax is stable. Elevation
of the right hemidiaphragm is unchanged. Cardiomediastinal
contours are also unchanged with cardiac size normal. The
sternal wires are aligned. Right subcutaneous emphysema is
unchanged. The left lung is clear.
[**2171-6-26**]: Within the right lung there is still presence of
atelectasis as well as there is a loculated hydropneumothorax
involving both apex and costal pleura that appears to be
minimally increased since the prior study (after removal of the
chest tubes). Pleural loculations are also seen anteriorly as
better evaluated on the lateral view.
Brief Hospital Course:
Mr. [**Known lastname 46860**] was admitted on [**2171-6-21**] following successful Median
sternotomy and right anterior thoracotomy and radical resection
of mediastinal tumor. Right middle lobe wedge resection. He was
extubated in the operating room, monitored in the PACU prior
transfer to the floor.
Respiratory: with aggressive pulmonary toilet, incentive
spirometer, nebs, ambulation he titrated off oxygen with room
air oxygen saturations 94-96%.
Chest tubes (3) anterior, a posterior and a right-angled chest
tube in the right chest. They were to low-wall suction for 48
hrs, then to water-seal. The anterior apical had a persistent
air leak. Small-moderate serosanguinous drainage. The
posterior chest-tube was remove on [**2171-6-26**]. Once the
persistent air leak resolved the remainder 2 Chest-tube were
removed.
Chest films: serial chest films showed LLL collapse which
improved. Left lower lobe atelectasis, small bilateral pleural
effusions and bibasilar atelectasis. right small apical
pneumothorax. Right subcutaneous emphysema. Discharge film
showed small right hydropneumothorax is stable. Elevation of
the right hemidiaphragm is The sternal wires are aligned. Right
subcutaneous emphysema is unchanged. The left lung is clear.
Cardiac: hemodynamically stable in sinus rhythm 80-100. BP
90-110.
GI: bowel function returned. PPI continued
Nutrition: tolerated regular diet
Renal: Foley removed on [**2171-6-25**]. Renal function normal with
good urine output.
Electrolytes replete as needed
Neuro: awake, alert oriented but anxious requiring occasional
anxiolytics.
Heme: Intraoperative he was transfused for 2 units of PRBC. HCT
30-35 remained stable. On [**2171-6-26**] his home dose Lovenox 80mg
q12H was restarted to complete treatment of the previous PE in
[**1-27**] and SVC syndrome.
Pain: Bupivacaine Epidural with Dilaudid PCA managed by the
acute pain service. Remove [**2171-6-25**] converted to PO pain
medication with good control.
Disposition: He was seen by physical therapy who reviewed
sternal precautions with him. He ambulated independently and
was discharged to home with VNA on [**2171-6-27**].
He will follow-up with Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Lovenox 80mg q12, alprazolam 0.25 mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
3. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: take with food and water.
Disp:*90 Tablet(s)* Refills:*0*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*30 syringes* Refills:*2*
5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA & Hospice
Discharge Diagnosis:
Germ cell tumor of the mediastinum s/p neoadjuvant chemotherapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Sternal incision develops redness, drainage or feels unstable.
-Chest tube site. Remove dressing and cover site with a bandaid
until healed.
-You may shower. Wash incision with mild soap rinse pat dry.
-No swimming for 6 weeks
-No driving for 1 month. Lap seat belt only.
-No lifting greater than 10 pounds
-Take stool softners with narcotics.
-Walk 4-5 times a day for 10-15 minutes to goal of 30 minutes
daily
Followup Instructions:
Follow-up with Dr, [**Name (NI) **] [**0-0-**] Date/Time:[**2171-7-11**]
3:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Completed by:[**2171-6-27**]
|
[
"998.81",
"512.1",
"V58.61",
"164.8",
"V12.51",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.29",
"34.3"
] |
icd9pcs
|
[
[
[]
]
] |
6151, 6220
|
3065, 5299
|
305, 452
|
6328, 6328
|
1938, 3042
|
7096, 7389
|
1398, 1480
|
5390, 6128
|
6241, 6307
|
5325, 5367
|
6479, 7073
|
1495, 1919
|
238, 267
|
480, 940
|
6343, 6455
|
962, 1023
|
1039, 1382
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
768
| 170,167
|
6666
|
Discharge summary
|
report
|
Admission Date: [**2175-2-3**] Discharge Date: [**2175-2-13**]
Date of Birth: [**2109-4-15**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 65-year-old female
with coronary artery disease and atrial fibrillation
presented here with her second episode of significantly sharp
abdominal pain. She describes having a prior episode for
which she had necrotic bowel, which was operated upon. Her
pain began suddenly the day prior to admission prompting her
visit to the Emergency Department at [**Hospital3 417**] Hospital,
where she was noted to have a concerning physical exam as
well as increased digoxin levels and increased INR level.
She was reversed in terms of her anticoagulation and
scheduled for the operating room, and then was transferred to
the [**Hospital1 69**].
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.0, heart
rate 82, blood pressure 135/78, respiratory rate 26, and
saturation 97 percent on room air. Alert and oriented times
three. Appeared somewhat toxic and nasogastric tube in
place. Heart was regular rate and rhythm. Lungs were clear
to auscultation bilaterally. Abdomen was tense and tender
with rebound in the right lower and left lower quadrants,
also revealing a well-healed scar from prior surgery. Rectal
exam was positive for melena and guaiac positive. Distal
pulses were 2 plus. Extremities were warm and well perfused.
HOSPITAL COURSE: It was at this time the patient was
admitted for further evaluation and treatment at [**Hospital1 346**]. Patient was preoperatively
prepared. Laboratories were drawn. Hematocrit was 34.8.
White count was 9.8. Electrolytes were within normal limits.
Liver function tests were within normal limits. INR was 1.1.
EKG was done that revealed the heart to be in normal sinus
rhythm at a rate of 85 beats per minute. There was no
pneumothorax on chest x-ray. CAT scan showed dilated loops
and contrast was making it to the right colon.
Patient was placed nothing by mouth and continued on the
nasogastric tube. Vancomycin, levofloxacin, and Flagyl were
started. An A-line has been placed as well as internal
jugular venous central line. Thus the patient was brought to
the operating room for acute peritonitis, where extensive
lysis of adhesions took place. There was noted to be
volvulus and a loops of small bowel around an adhesion.
Patient tolerated the procedure well and blood loss was
estimated to be 100 mL. Patient was transferred to the
Trauma Intensive Care Unit after this operation. Patient was
also seen by the Vascular Service for consideration of
possible infarcted bowel. They agreed with the plan to
explore the abdomen.
In the operating room, there was noted to be no signs of any
ischemic bowel and just the adhesions since bowel volvulus
was described previously. The patient did have a troponin
level of 0.057. Patient was also seen by Cardiology at this
time due to ST depressions seen on EKG on the day of
admission. Digoxin was held as the level was 3.3, and was
noted to be well rate controlled in atrial fibrillation. It
was decided that it would be best to re-anticoagulate her
when safe from a surgical perspective and to followup with
the primary cardiologist. They also stated that this was
unlikely to be ischemic in origin.
On hospital day number three, postoperative day number two,
patient began to have increased pain issues. Patient was
given Fentanyl and Dilaudid, and received mild improvement.
Patient was febrile at this point to 100.3 and antibiotics
were continued. Pulses were followed.
Patient was extubated at this point. Toradol was also added
for further pain control. Antibiotics were stopped at this
time. There was no source of infection that can be noted.
The patient was then transferred to the floor. As we awaited
regaining bowel function, the patient was seen by Physical
Therapy, who initially thought the patient would need likely
stay in the rehabilitation facility and shortly thereafter
cleared her for discharge her to home, and on [**2175-2-13**], patient was stable. All vital signs were within normal
limits. Patient was tolerating a regular diet. Was out of
bed and increasing her activity participating in incentive
spirometry. Was urinating without difficulty and it was
determined that the patient could be discharged to home with
outpatient physical therapy and for her to resume her
previous medications as she had been taking them, and to also
resume her anticoagulation.
DISCHARGE DIAGNOSES: Small bowel obstruction with volvulus.
Peritonitis.
Coronary artery disease.
Atrial fibrillation.
Congestive heart failure.
Hypercholesterolemia.
Hypertension.
Chronic obstructive pulmonary disease.
Osteoporosis.
Chronic back pain.
RECOMMENDED FOLLOWUP: The patient is to followup with Dr.
[**Last Name (STitle) **] in [**2-12**] weeks, call to schedule an appointment.
DISCHARGE MEDICATIONS:
1. Morphine sulfate 30 mg sustained release by mouth every 12
hours.
2. Oxycodone 5 mg two tablets every four hours as needed for
breakthrough pain.
3. Docusate sodium 100 mg by mouth twice a day.
4. Ibuprofen 600 mg by mouth every eight hours.
5. Coumadin 1 mg by mouth every other day at night.
6. Warfarin 2 mg by mouth every other day at night.
7. Patient is to resume the remainder of her home
medications.
DISPOSITION: The patient is to be discharged to home with
home physical therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2175-2-13**] 11:54:07
T: [**2175-2-13**] 12:41:14
Job#: [**Job Number 25440**]
|
[
"794.31",
"560.2",
"567.2",
"403.91",
"414.00",
"V45.81",
"427.31",
"786.59",
"412",
"V58.61",
"496",
"272.4",
"578.1",
"560.81",
"796.0",
"E942.1",
"428.0",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"54.59",
"54.11",
"38.93",
"99.77"
] |
icd9pcs
|
[
[
[]
]
] |
4535, 4917
|
4940, 5719
|
1441, 4513
|
182, 849
|
864, 1423
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,561
| 123,611
|
20736
|
Discharge summary
|
report
|
Admission Date: [**2153-4-8**] Discharge Date: [**2153-4-15**]
Date of Birth: [**2087-6-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 66 year old, white
male patient with a history of coronary artery disease. He
is status post myocardial infarction in [**2150**] and also has a
past medical history of diabetes. He presented on the morning
of [**4-8**] to an outside hospital after having two to three
days of intermittent chest pain which did radiate to his left
arm and was relieved with sublingual nitroglycerin. In the
Emergency Department, at the outside hospital, he was placed
on intravenous nitroglycerin. He ruled in for myocardial
infarction with a troponin of 0.6 and a CPK of 107. He was
transferred to [**Hospital1 69**] on [**2153-4-8**] for cardiac catheterization. This revealed a left
ventricular ejection fraction of 30% and significant three
vessel coronary artery disease. He was referred for coronary
artery bypass graft.
PAST MEDICAL HISTORY:
1. Status post myocardial infarction in [**2150**].
2. Status post pilonidal cyst removal.
3. Status post tonsillectomy and adenoidectomy.
4. Status post bilateral cataract extraction in [**2153**].
5. Non insulin dependent, diet-controlled diabetes type II.
MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Sublingual nitroglycerin prn.
ALLERGIES: Percodan, causing nausea and vomiting.
SOCIAL HISTORY: The patient does have a 90 pack year smoking
history; however, he quit 19 years ago and remote heavy
alcohol history but none in many recent years. The patient
is married and lives with his wife and he is retired.
PHYSICAL EXAMINATION: On admission, physical examination was
unremarkable.
The patient's cardiac catheterization revealed significant
three vessel coronary artery disease with decreased left
ventricular ejection fraction of 30%. The patient was taken
to the operating room on [**2154-4-10**] where he underwent
coronary artery bypass graft times four with a left internal
mammary artery to the left anterior descending, saphenous
vein to obtuse marginal one, saphenous vein to diagonal and
saphenous vein to posterior descending artery.
Postoperatively, the patient was transported from the
operating room to the cardiac surgery recovery unit in good
condition on epinephrine, Neo-Synephrine and Propofol drips.
The patient was weaned from mechanical ventilation and
extubated on the night of surgery. On postoperative day
number one, he remained on low doses of epinephrine and
Neo-Synephrine drips for continued hypotension with an
adequate cardiac output. He was on a nasal cannula with good
oxygen saturation. Over the course of the next 24 hours, the
patient was weaned off of his epinephrine, remained on low
dose Neo-synephrine for some persistent hypotension. He also
had atrial fibrillation on the morning of postoperative day
number two which was treated with intravenous Amiodarone and
the patient has subsequently converted to normal sinus
rhythm.
On postoperative day number two, [**4-12**], the patient had
his mediastinal chest tubes removed. The left pleural tube
remained in place. Due to fairly high output, although it
was mostly serous in nature, he still had a significant
volume of drainage from that left pleural tube and it was
thought best to leave it in until the drainage had decreased.
The patient was subsequently transferred out of the cardiac
surgery recovery unit to the telemetry floor on postoperative
day number three. The patient began ambulation and continued
to progress adequately from a physical therapy standpoint.
Subsequent chest x-ray revealed a small left apical
pneumothorax with an intermittent air leak in the Pleura-Vac
from the left chest tube which had remained in. Therefore,
the chest tube was left in for a few more days. Ultimately,
the air leak resolved. The volume of pleural drainage
significantly decreased and the chest tube was removed on
[**4-15**], postoperative day number five. The patient has had
no subsequent atrial fibrillation. It was known upon removal
of the chest tube that he did have a small left apical
pneumothorax at that time and since the chest tube had been
removed approximately 24 hours after the chest tube was
discontinued, a subsequent chest x-ray revealed a very small
left apical pneumothorax, possibly a bit smaller in size than
previous. The patient has remained on room air with good
oxygen saturation and he is being discharged home today on
[**2153-4-15**], postoperative day number six, status post
coronary artery bypass graft. His condition upon discharge
today is as follows: He is afebrile. He is in normal sinus
rhythm with a rate of 76. His blood pressure is 130/70;
respiratory rate is 20 with a room air oxygen saturation of
97%. Neurologically, the patient is grossly intact. He has
no apparent neurologic deficit. On pulmonary examination, his
lungs were clear to auscultation bilaterally. His coronary
examination was regular rate and rhythm with no murmur noted.
His abdomen is slightly obese, positive bowel sounds. He is
nontender and nondistended. The patient states that he has
had a bowel movement today. He has trace bilateral pedal
edema. His sternal and right leg saphenectomy incisions are
clean and dry with no drainage, no erythema and the patient
is discharged to home today with [**Hospital6 **].
His most recent laboratory values are from yesterday, [**4-15**], which include a white blood cell count of 6.3, hematocrit
of 29.3 and platelet count of 288,000. Sodium of 135;
potassium of 4.1; chloride of 98; C02 30; BUN 16; creatinine
0.8; glucose 132.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. twice a day times one week.
2. Potassium chloride 20 meq p.o. twice a day times one
week.
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Enteric coated aspirin 325 mg p.o. q. day.
6. Plavix 75 mg p.o. q. day.
7. Amiodarone 400 mg p.o. twice a day times one week and
then decrease to 200 mg p.o. twice a day times one week and
then decrease to 200 mg p.o. q. day. This is to continue at
this dose until discontinued by the patient's primary
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**].
8. Lopressor 25 mg p.o. twice a day.
9. Dilaudid 2 mg p.o. q. four hours prn for pain.
10. Ambien 5 mg p.o. q h.s. prn sleep.
The patient is to follow-up with Dr. [**First Name (STitle) **], his primary care
physician, [**Name10 (NameIs) **] two to three weeks. The patient is to
follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**], his cardiologist, in
two to three weeks.
He is to follow-up with Dr. [**Last Name (STitle) **], cardiac surgeon in four
weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Postoperative atrial fibrillation.
3. Type II diabetes mellitus.
DISCHARGE CONDITION: Good.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2154-4-16**] 03:48
T: [**2154-4-16**] 17:19
JOB#: [**Job Number 55338**]
|
[
"427.31",
"411.1",
"E878.2",
"414.01",
"512.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.53",
"37.22",
"39.61",
"88.55",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6887, 7158
|
6765, 6865
|
5659, 6744
|
1659, 5636
|
158, 984
|
1006, 1403
|
1420, 1636
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,722
| 182,118
|
29270
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 70364**]
Admission Date: [**2124-12-11**]
Discharge Date: [**2125-2-5**]
Date of Birth: [**2124-12-11**]
Sex: F
Service: Neonatology
HISTORY: Baby girl [**Known lastname 70365**] was the 971-gram product of a 27
and [**12-31**]-week gestation born to a 38-year-old G2/P0 (now 1)
mother.
PRENATAL SCREENS: Blood type O-, antibody negative,
hepatitis surface antigen negative, rubella immune, RPR
nonreactive, GBS unknown.
COMPLICATIONS: Pregnancy uncomplicated until day of delivery
when mother awoke with contractions. Came to the [**Hospital1 346**] to find her cervix was 4 cm with a
bulging bag with spontaneous rupture of membranes of clear
fluid. Decelerations shortly thereafter. Infant was
delivered by cesarean section. The infant delivered in
breech presentation, was vigorous, responded nicely with bag
mask ventilation, and subsequently intubation with a 2.5 ET
tube. Apgars were 6 and 8 at one and five minutes.
PHYSICAL EXAMINATION ON ADMISSION: Anterior fontanelle soft,
flat. Eyes appear normal by external examination. Eyes,
ears, nose, mouth appear within normal limits. NECK: No
masses. No adenopathy. Clavicles normal to palpation.
CHEST: Breath sounds clear and equal bilaterally, slightly
diminished. CARDIOVASCULAR: Normal heart sounds. No
murmur. Perfusion good. ABDOMEN: No masses. No
hepatosplenomegaly. Umbilical vessels 3 times. GU: Appears
as normal premature female. Anus patent. BACK AND
EXTREMITIES: Skin with diffuse bruising of back, head,
extremities. NEURO: Active. Normal tone, strength for 27-
week.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: [**Known lastname **] was intubated in the delivery
room for management of respiratory distress syndrome.
She received a total of 1 dose of surfactant therapy. On
day of life #2, presented with pulmonary hemorrhage
prompting transition to high-frequency ventilation. She
later transitioned off, back to conventional ventilation.
On day of life #7, transitioned to CPAP. She was
intubated on day of life #11 for increasing spells. On
[**12-30**], the infant noted to have increasing needs for
suctioning and copious amounts of endotracheal
secretions. A tracheal aspirate was sent and was positive
for staph aureus. She was treated for 14 days with
oxacillin. Attempted extubation on day of life #29
([**2125-1-9**]). Extubation attempt failed due to
increased work of breathing and stridor. The infant was
given racemic epinephrine and steroids in the hope to
continue CPAP, but the infant continued to deteriorate -
prompting reintubation. At that time, ORL from
[**Hospital3 1810**] was consulted, and it was
recommended a rigid bronch once the infant reached 2
kilos. The infant was maintained on minimal support of
16/5 with a rate of 14 in room air. On [**2125-1-26**]
she self-extubated, but had to be immediately reintubated
due to stridor and increased work of breathing. On
[**2125-2-1**], she self-extubated and again failed to
stay extubated despite racemic epinephrine and steroids.
She received 3 doses of Decadron 0.5 mg IV q.12h., which
were discontinued on [**2125-1-2**], at 3:00 p.m. The
infant is currently on 16/5 with a rate of 14 in room
air. She is receiving caffeine citrate for management of
apnea and bradycardia of prematurity. She is receiving
11 mg PG q.24h. at noon. She is currently scheduled for
a rigid bronch on [**2125-2-6**], at 10:00 a.m.
2. CARDIOVASCULAR: [**Known lastname **] is status post indomethacin
therapy on [**12-13**] for presumed patent ductus
arteriosus following a pulmonary hemorrhage.
Echocardiogram on [**12-20**] revealed no patent ductus
arteriosus. The infant is currently stable with no
audible murmur. Heart rates range 140s to 180s with
blood pressures 83/43 with a mean of 56.
3. FLUIDS AND ELECTROLYTES: Her birth weight was 971 grams.
Her length was 34.5 cm. Her head circumference was 25.5
cm. Her discharge weight is 2105 grams, head
circumference 31cm, length 45cm. She was initially
started on 100 cc/kg/day of parenteral nutrition.
Enteral feedings were initiated on day of life #6. She
achieved full enteral feedings by day of life #15. Her
max enteral intake was 150 cc/kg/day of breast milk 30
calories with added Beneprotein. She is currently
receiving 130 cc/kg/day of breast milk 26 calories with
Beneprotein. She is being fluid restricted for her
respiratory status. Her most recent set of laboratory
results on [**2125-1-23**]: She had a sodium of 135,
potassium of 4.6, chloride of 101, total CO2 of 28,
calcium of 10.1, phos of 5.7, alkaline phosphatase of
268. On [**2125-1-29**], she had a complete blood count
of a white count of 11.7, hematocrit of 30.1, platelets
205, 36 polys, 1 band, 40 lymphs. On [**1-28**], her
gentamicin dose pre was less than 0.3, and her post was
5.9.
4. GI: Resolved hyperbilirubinemia on [**2124-12-26**]. Her
peak bilirubin was 5.6/0.3. She was treated with
phototherapy.
5. HEMATOLOGY: The patient's blood type is O positive. Her
last transfusion was on [**2125-1-23**]. She received
blood for hematocrit of 27.3. Her most recent hematocrit
is on [**2125-1-29**], of 30.1. She is currently
receiving ferrous sulfate supplementation.
6. INFECTIOUS DISEASE: A CBC and blood culture at birth
were benign. The infant received 48 hours of ampicillin
and gentamicin. On [**2124-12-30**], the infant presented
with increasing secretions. A trache aspirate was
obtained and later cultured staph aureus and klebsiella.
The infant was treated for a total of 14 days with
oxacillin dor the staph aureus. Oxacillin was
discontinued on [**1-13**]. On [**1-24**], the infant
presented with increasing secretions. A tracheal
aspirate was obtained at that time, which later cultured
foe Staph aureus and Klebsiella. The infant completed a 2
week course of oxacillin, last dose on [**2-5**]. For
Klebsiella coverage she is receiving gentamicin and
cefotaxime for a total of 14 days, which should be
discontinued on [**2125-2-8**].
7. NEURO: Head ultrasounds have been within normal limits x
3, with her most recent being on [**2125-1-12**].
8. SENSORY:
1. AUDIOLOGY: Hearing screen has not been performed,
but should be done prior to discharge to home.
2. OPHTHALMOLOGY: Most recently examined on [**2125-1-29**], revealing immature retinal vessels to zone 2
with recommended followup in 2 weeks.
9. PSYCHOSOCIAL: The parents are invested and involved and
up-to-date.
CONDITION ON DISCHARGE: Guarded.
DISCHARGE DISPOSITION: To [**Hospital3 1810**] for
bronchoscopy/ORL consultation - r/o upper airway obstruction.
PRIMARY PEDIATRICIAN: Not yet identified.
CARE AND RECOMMENDATIONS AT DISCHARGE:
1. Feeds at discharge: Continue 130 cc/kg/day of breast
milk 26 calories with Beneprotein.
2. Medications: Caffeine citrate of 11 mg p.o. daily,
gentamicin 5.5 mg IV q.24h., cefotaxime 90 mg IV q.8h.
and ferrous sulfate 0.3 mL (4 mg/kg/day) pg daily and
vitamin E 5 units pg daily.
3. Car seat position screening: Not applicable
4. State newborn screens have been sent per protocol and
have been within normal limits.
5. Immunizations received: The infant received hepatitis B
vaccine on [**2125-1-15**]. The infant also received
Synagis vaccine on [**2125-1-13**] (due to RSV case in
NICU).
DISCHARGE DIAGNOSES:
1. Premature infant born at 27 and [**12-31**]- week gestation
2. Respiratory distress syndrome
3. Rule out sepsis with antibiotics
4. Hyperbilirubinemia
5. Patent ductus arteriosus
6. Pulmonary hemorrhage,
7. Staphylococcus aureus pneumonia
8. Klebsiella pneumonia
9. Apnea and bradycardia of prematurity
10. Anemia of prematurity
11. Stridor, s/p several failed extubation, r/o upper airway
obstruction
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2125-2-4**] 03:48:38
T: [**2125-2-4**] 11:32:40
Job#: [**Job Number 70366**]
|
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icd9pcs
|
[
[
[]
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6906, 7041
|
7736, 8394
|
1647, 6847
|
7105, 7715
|
1007, 1619
|
7080, 7090
|
6872, 6882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,429
| 103,854
|
4985
|
Discharge summary
|
report
|
Admission Date: [**2147-12-18**] Discharge Date: [**2147-12-29**]
Date of Birth: [**2094-1-28**] Sex: F
Service: MEDICINE
Allergies:
Oxaliplatin / Iodine Containing Agents Classifier /
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
nausea and emesis
Major Surgical or Invasive Procedure:
Bilateral Nephrostomy Tube Placement [**2147-12-19**]
History of Present Illness:
53 yo f with hx of metastatic colon CA, Spanish speaking, who
presented with n/v/d and was sent to ER for evaluation from her
oncologist. She has not been eating or drinking for last 5 days
due to n/v after returning from a trip to [**Country 7192**]. She has
been having abdominal pain, but does not like to take her
narcotics.
.
On the floor (interview not with interpreter at this time, so
limited) pt complains of pain in her abdomen, worse with
sitting. Some right sided chest dicomfort. States she has had
swelling her LLE for about 1 month, but no pain in her leg. She
is not currently having nausea, but had some this AM. She
reports urinating today with no pain, but a small amount of
blood.
.
VS on arrival were 97.4 101 181/104 18. Pt was found to have ARF
with Cr from 0.8 to 6.7 and hyperkalemic to 7.2. She has a known
mass compressing left ureter and now with a new compression of
the right ureter on CT scan. Urology was consulted and
recommended IR to place a percut nephrostomy tube. Pt was tx
with D50 and insulin, and kayexalate 30. Hypoglycemia ensued
after tx and she was given a [**11-26**] amp D50 with improvment of BS
to 105. K down to 5.5. IVF x 2 liters were given. Pt also had a
neg head CT. Right sided CP, negative LENI, concern for PE, pt
not anticoagulated in ER. No CTA due to Cr. PNA present on CT.
She was given ceft and azithro. VS at trasfer HR-106, SBP-142
16, 100% RA, BS 105.
.
Past Medical History:
- adenocarcinoma of distal sigmoid colon [**1-1**], s/p sigmoid
colectomy by Dr. [**Last Name (STitle) 1120**] on [**2144-2-17**]. T3 lesion measuring 7 cm x
6 cm x 4 cm,
low-grade, [**2-4**] lymph nodes were involved with cancer
- completed adjuvant chemotherapy with FOLFOX in 10/[**2143**]. CEA
continued to slowly rise from 7 in [**12/2145**] to 9.5 in [**2-/2146**]
to 18 in 08/[**2145**]. CT imaging demonstrated new left
hydronephrosis with a 10.4 cm prevertebral mass at the point of
the ureteral obstruction. PET scan in [**7-/2146**] confirmed disease
recurrence near the sigmoid anastomosis causing the ureteral
obstruction. She additionally had evidence of metastatic
disease to the mesentery and mesenteric nodes. She underwent
percutaneous nephrostomy tube placement on [**2146-12-8**]. [**Known firstname **]
completed two cycles of FOLFIRI and on CT [**2147-4-14**]
she had disease progression involving the known omental
metastases and innumerable pulmonary metastasis.
- admission for PE [**2147-4-17**] for inpatient anticoagulation.
- [**2147-6-20**]: Discussion for participation to a clinical trial
with Cisplatin / V1 inhibitor
- [**2147-7-21**]: left sided nephrostomy tube replacement
- [**7-/2147**]: nephrostomy tube removal
- [**2147-8-23**]: Start on Capecitabine
- Left hydronephrosis with 2.4 cm prevertebral mass at the point
of apparent ureteral obstruction in pelvis. Failed ureter stent
.
Social History:
She is married. She has two children. She used to work as a
cleaning person. She does not presently smoke cigarettes but did
smoke about two cigarettes per day for 20 years and quit three
yrs ago just prior to her surgery. She does not drink alcohol
Family History:
There is no family history of breast, ovarian or colon cancer.
Her mother died at age 75 of hypertension and cardiovascular
disease. Her father died at age 82 of a hemorrhagic stroke.
She has two brothers and five sisters. Two of those had uterine
cancer at the age of 49 and 40.
Physical Exam:
ON ADMISSION
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM,
RESP: CTA b/l with good air movement throughout
CV: tachy, S1 and S2 wnl, no m/r/g
ABD: distend, firm, tender to palpation, +BS
BACK: mild CVA tenderness
EXT: no c/c, 1+ pitting edema in LLE
SKIN: no rashes/no jaundice
NEURO: Moving all extremites, able to ambulate to commode.
.
ON DISCHARGE
Vitals 98.7 140/86 105 16 98%RA
I/O: R nephrostomy 500o/n, 950cc day prior, bathroom unrecorded
GEN: NAD, AOx3
HEENT: MMM, OP clear
CV: tachy, RR, nl S1S2 no MRG
PULM: CTA b/l
ABS: BS+, mildly tender to palpation, multiple masses palpated
throughout abdomen
BACK: Nephrostomies are c/d/i
EXT: 2+ DP/PT/radial pulses, no c/c/e
Pertinent Results:
Blood Counts
[**2147-12-18**] 11:23AM BLOOD WBC-11.2* RBC-3.73* Hgb-9.5* Hct-29.4*
MCV-79* MCH-25.5* MCHC-32.4 RDW-17.1* Plt Ct-424
[**2147-12-20**] 04:08AM BLOOD WBC-20.0* RBC-3.13* Hgb-8.1* Hct-24.9*
MCV-80* MCH-25.8* MCHC-32.4 RDW-17.9* Plt Ct-380
[**2147-12-26**] 05:25AM BLOOD WBC-12.4* RBC-3.64* Hgb-9.5* Hct-29.5*
MCV-81* MCH-26.2* MCHC-32.3 RDW-16.6* Plt Ct-415
.
Coags
[**2147-12-24**] 06:30AM BLOOD PT-13.2 PTT-24.0 INR(PT)-1.1
.
Chemistry
[**2147-12-18**] 11:23AM BLOOD UreaN-63* Creat-6.8*# Na-133 K-7.2*
Cl-95* HCO3-26 AnGap-19
[**2147-12-22**] 05:23PM BLOOD Glucose-114* UreaN-20 Creat-2.3* Na-144
K-2.5* Cl-106 HCO3-27 AnGap-14
[**2147-12-25**] 02:30PM BLOOD Glucose-94 UreaN-17 Creat-1.1 Na-137
K-3.9 Cl-102 HCO3-26 AnGap-13
[**2147-12-26**] 05:25AM BLOOD Glucose-95 UreaN-19 Creat-1.3* Na-135
K-4.1 Cl-101 HCO3-25 AnGap-13
.
Imaging
[**2147-12-18**] CXR
1. New small right pleural effusion, with right lower lobe
atelectasis or
consolidation.
2. Diffuse pulmonary nodular metastases.
.
[**2147-12-19**] CT Abd
1. Right lower lobe pneumonia and trace effusion.
2. Apparent increase in size and number of metastatic pulmonary
nodules at
the lung bases.
3. New heterogeneously hypodense liver. This could represent
fatty
infiltration, but congestive edema and/or diffuse metastases are
not excluded.
4. New mild-to-moderate right hydronephrosis, with incompletely
visualized transition point in mid right ureter, suggestive of
obstruction by peritoneal metastasis.
5. Chronic left moderate-to-severe hydronephrosis and atrophy,
secondary to obstruction by left L5 paravertebral mass.
6. Multiple prominent fluid-filled small bowel loops, suggestive
of ileus or partial obstruction secondary to increasing
mesenteric adhesions.
7. Diffuse omental and peritoneal implants.
8. Cholelithiasis.
9. Fibroid uterus.
.
[**2147-12-22**] Nephrostomy Tubes Placement
Bilateral ureteric stenoses, more prominent on the left side.
Satisfactory placement of bilateral nephroureteric stents (8
French x 24 cm). Patient would require routine stent change in
three months.
Brief Hospital Course:
HOSPITAL COURSE
53yo female with w metastatic colon cancer admitted with acute
ureteral obstruction secondary to metastasis, now status-post
bilateral percutaneous nephrostomy tube placement, hospital
course complicated by pyelonephritis and community acquired
pneumonia, treated with antibiotics, made comfort measures only,
discharged to home with hospice care
.
ACTIVE
# Acute Kidney Injury: Patient was admitted with a creatinine of
7.2 secondary to obstructive uropathy from compression by
peritoneal metastases. Patient underwent placement of bilateral
percutaneous nephrostomy tubes by IR [**2147-12-19**], and
nephrouretheral stents on [**2147-12-22**], after which the patient's
Cr trended down to 1.3. The patient had good UOP from right
urostomy, but poor output from L nephrostomy tube (<100cc/day)
which was thought to be secondary to known chronic
hydronephrosis. Urine cultures from L nephrostomy tube grew
MSSA, prompting antibiotic treatment with 5d augmentin and 14d
doxycycline. After 1wk abx, repeat culture was negative and the
L tube was capped. The R tube was not capped, given continued
high output from the R nephrostomy tube, thought to be secondary
to known compression of the bladder by peritoneal metastases.
.
# Community Acquired Pneumonia: Admission CXR demonstrated RLL
consolidation, for which the patient received 5d augmentin, 14d
doxycycline. At discharge patient was given script for
remainder of doxy course.
.
# Metastatic Colon Cancer: Primary issue during hospitalization
became pain [**12-27**] multiple metastases. Given poor prognosis,
patient decided to be made comfort measures only. With
palliative input, pain regimen of dilaudid and fentanyl patch
was started. Patient was discharged home with hospice care.
.
TRANSITIONAL
1. Code status: Patient was DNR/DNI for the duration of this
admission, and was converted to comfort measures only several
days prior to discharge
2. Pending: No labs pending at time of discharge
3. Transition of Care: Patient was scheduled for follow-up with
Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] for [**1-22**]. Instructions for
nephrostomy tube maintenance were sent home with patient. IR
requested follow-up visit in 6-12weeks, decision regarding
scheduling necessity was deferred to outpatient oncologist.
Patient was discharged home with hospice care.
Medications on Admission:
-Docusate Sodium 100 mg PO BID
-Ondansetron 4 mg IV Q8H:PRN nausea
-Fentanyl Patch 25 mcg/hr TP Q72H
-Oxycodone SR (OxyconTIN) 30 mg PO Q12H
-Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
-Senna 1 TAB PO/NG [**Hospital1 **]:PRN constiapation
-HYDROmorphone (Dilaudid) 0.5 -1 mg IV Q2H:PRN pain
-Heparin 5000 UNIT SC TID
Discharge Medications:
1. Hospital Bed
Semi-electric hospital bed
Patient has a medical condition, which requires positioning of
the body, which is not feasible in an ordinary bed to alleviate
pain
Diagnosis: Peritoneal Carcinomatosis (ICD-9 158.8 Malignant
neoplasm of specified parts of peritoneum)
2. Bedside Comode
Patient is confined to a single room
Dx: ICD 9 code 158.8
3. Normal Saline Flush 0.9 % Syringe Sig: Two (2) flush
Injection once a day: for nephrostomy tube flushes.
Disp:*60 flushes* Refills:*3*
4. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
5. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
7. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 4 days.
Disp:*8 Capsule(s)* Refills:*0*
8. hydromorphone 4 mg Tablet Sig: 1.5 Tablets PO every 2 hours
as needed for pain.
Disp:*500 Tablet(s)* Refills:*0*
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
insomnia.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
13. Reglan 10 mg Tablet Sig: One (1) Tablet PO QID with meals
and before bed.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY
Metastatic Colon Cancer
SECONDARY
Acute Kidney Injury Secondary to Obstruction status-post
Bilateral Nephrostomy Tube Placement
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 **]:
.
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for treatment of kidney
failure. This was caused by tumors blocking your urine from
leaving your kidneys. You had nephrostomy tubes placed to drain
the urine, and then had stents placed to help prevent blockage
of your kidneys. You are now stable and being discharged home
to be with your family. You will have visiting nurses to help
care for you.
.
During this hospitalization, you decided to focus on treating
your pain, so WE STOPPED ALL PREVIOUS MEDICATIONS, and started
the following medications:
- Colace for constipation
- Senna for constipation
- Fentanyl for pain
- Dilaudid for pain
- Compazine for nausea
- Zofran for nausea
- Reglan for nausea
- Ativan for sleep
- Olanzapine for sleep
- Doxycycline (for 4 days) for infection
.
Please see below for your recommended follow-up appointments
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2148-1-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
[
"276.7",
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"197.0",
"590.80",
"593.4",
"591",
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] |
icd9cm
|
[
[
[]
]
] |
[
"55.03",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
11277, 11334
|
6718, 9078
|
357, 413
|
11515, 11515
|
4623, 6695
|
12638, 13066
|
3604, 3887
|
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11355, 11494
|
9104, 9429
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11698, 12615
|
3902, 4604
|
300, 319
|
441, 1862
|
11530, 11674
|
1884, 3317
|
3333, 3588
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,138
| 127,580
|
35060
|
Discharge summary
|
report
|
Admission Date: [**2168-10-4**] Discharge Date: [**2168-10-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
T8-T10 laminectomy and T5 to L1 posterior fusion
History of Present Illness:
Patient is an 86 yo female with a history of Parkinson's
disease, HTN, COPD, and previous stroke who was transferred from
[**Hospital3 **] on [**2168-10-4**] s/p fall and T9 fracture with cord
compression. Patient was going to the bathroom at home, where
she lives on the [**Location (un) 1773**] of her son's house, when she
reports slipping on urine in the bathroom. The patient
activated lifeline. She was taken to [**Hospital6 **], where
she was found to have decreased rectal tone, a T9 compression
fracture, and loss of sensation in both extremities. She was
emergently transferred to [**Hospital1 18**] and was evaluated for surgery.
The patient received 2 Units of PRBCs and was sent to surgery
for a posterior thoracic laminectomy of T8, T9, T10, and
posterior fusion of T5 to L1. She received another 3 Units of
PRBCs during this operation. The patient was transferred to the
T-SICU, where she remained intubated until [**2168-10-6**]. She was
extubated and presented with hypoactive delerium. The Geriatric
medicine team was consulted, and she was transferred to CC7 for
further treatment and evaluation. Patient's full history was
reviewed in OMR.
.
Past Medical History:
Parkinson's disease
Hypertension
Stroke
Hypothyroid
COPD (not on inhalers)
Osteporosis
Cervical fracture (C2) from fall
L groin burn
PAST SURGICAL HISTORY:
T5-L1 decompression and fusion
t11 vertebroplasty
B/L cataract surgery
Social History:
Patient denies EtOH use. She smoked in the past. She denies
IVDU. Patient lives alone on the [**Location (un) **] apartment and her
son lives downstairs. She has two aids during daytime and
daughter visits every day to assist with IADLs, but patient is
alone at night. She has been instructed to call her son
downstairs when she needs to use the bathroom at night, but does
not do so regularly, leading to multiple falls. She has a walker
and uses a mechanical wheelchair in the house, though not at
night. Widowed for ~50 yrs.
Family History:
Non-contributory
Physical Exam:
GEN: Elderly woman, well nourished, on her side, in NAD
HEENT: Dry mucous membranes. Oropharynx clear and without
exudates. Right eye s/p cataract surgery
NECK: No JVD, No LAD, supple
RESP: CTAB anteriorly
CARDIAC: RRR, no r/m/g, nl S1 and S2
ABD: +BS, non-tender, non-distended
EXT: 2+ DP pulses, no edema, no cyanosis
NEURO: AAO x3. CN II-XII intact. Strength 5/5 upper
extremities B, Decreased sensation in LE B. Toes upgoing
bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2168-10-4**] 03:41PM BLOOD WBC-14.5* RBC-2.71* Hgb-8.7* Hct-26.9*
MCV-99* MCH-32.1* MCHC-32.3 RDW-15.3 Plt Ct-430
[**2168-10-4**] 03:41PM BLOOD Neuts-86.1* Lymphs-10.9* Monos-2.8
Eos-0.1 Baso-0.1
[**2168-10-4**] 03:41PM BLOOD PT-12.3 PTT-22.8 INR(PT)-1.0
[**2168-10-4**] 03:41PM BLOOD Glucose-126* UreaN-11 Creat-0.3* Na-140
K-3.6 Cl-108 HCO3-22 AnGap-14
[**2168-10-4**] 03:41PM BLOOD CK(CPK)-53
[**2168-10-4**] 03:41PM BLOOD CK-MB-4
[**2168-10-4**] 03:41PM BLOOD cTropnT-<0.01
[**2168-10-5**] 03:54AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.1
[**2168-10-4**] 03:53PM BLOOD Lactate-1.2
.
.
PERTINENT LABS/STUDIES:
.
WBC: 14.5 -> 9.6 -> 20.1 -> 16.0 -> 14.5 -> 11.3
Hct: 26 -> 32.6 -> 41.3 -> 35.1 -> 33.2 -> 31.8
Blood Cx: No growth
.
CT Spine ([**2168-10-4**]): Compression deformity of T9 vertebral body
with retrolisthesis of T9 on T10, with marked canal narrowing.
Please review MR of earlier the same day to evaluate the spinal
cord. Extensive, old bilateral rib fractures. Bilateral pleural
effusions with associated atelectasis. Retained contrast in the
renal collecting systems, right greater than left, incompletely
evaluated. Large hiatal hernia.
CXR ([**10-5**]): Left lower lobe atelectasis with small pleural
effusion. Hiatal hernia.
.
CXR [**10-9**]:
Right picc has been placed. The tip terminates in the superior
vena cava,
partially obscured by overlying thoracic spinal fixation
hardware. Since the prior study, there has been interval near
resolution of the large left pleural effusion. There are
residual small bilateral pleural effusions with atelectasis at
both lung bases. There is at least one healed rib fracture on
the left.
.
DISCHARGE LABS:
[**2168-10-10**] 05:33AM BLOOD WBC-11.3* RBC-3.44* Hgb-10.8* Hct-31.8*
MCV-92 MCH-31.3 MCHC-33.9 RDW-16.0* Plt Ct-288
[**2168-10-10**] 05:33AM BLOOD Plt Ct-288
[**2168-10-10**] 05:33AM BLOOD Glucose-106* UreaN-9 Creat-0.3* Na-141
K-3.6 Cl-107 HCO3-24 AnGap-14
[**2168-10-10**] 05:33AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
Brief Hospital Course:
Patient is a 86 yo woman with h/o Parkinsons and HTN who
presented s/p fall with T9 compression fracture.
.
#. S/P Laminectomy and fusion: Patient had a fall at home and
suffered a compression fracture of T9. She had a laminectomy
and fusion of T8-T10 on [**10-5**]. She endured the surgery without
complication. She had two drains in place in the incision site,
which were both pulled during this hospital admission. The
patient attempted to wear a TLSO brace, but this was deemed too
uncomfortable for the patient at this time. Physical Therapy
worked with the patient during this admission, and they feel
that she could benefit from further training and assistance at a
rehabilitation facility. The patient has slight sensation in
her lower extremities, but she is not able to move her legs
voluntarily.
.
#. Shortness of Breath: Patient had an episode of shortness of
breath on [**10-8**]. She was found to have a white-out on CXR. She
was started on Vancomycin and Zosyn for possible
hospital-acquired pneumonia. She had a PICC placed on [**10-9**], and
the placement CXR showed resolution of the acute process. The
patient was discharged on Vancomycin and Zosyn in the setting of
possible pneumonia.
.
#. Delerium: Per the geriatrics team, the patient had an
episode of fluctuating cognition after her surgery. She was
thought to have hypoactive delerium secondary to advanced age,
recent surgery, narcotics, and admission to hospital. The
patient's famotidine prescription was changed to omeprazole and
she was placed on Miralax daily for adequate bowel control. The
patient did not have any more acute events of delirium during
this hospital stay.
.
#. Pneumonia: On [**10-8**] am she developed acute resp distress. CXR
showed opacification of the Left lung. O2 sats remained stable.
Thereafter she was started on vanco/zosyn for presumed hosp
acquired pna. F/u CXR showed resolution of this infiltrate but
given the acute nature of her resp issues, the antibiotics were
continued. PICC was placed. PLEASE PULL PICC ONCE IV ABX NO
LONGER NEEDED.
.
#. Pain: The patient is currently on Tylenol and Morphine for
pain. She states that her pain is well controlled on this
regimen. She needs bowel regimen for constipation in the
setting of narcotics.
.
#. Paroxysmal Atrial Fibrillation: The patient had an episode
of AFib with RVR on [**2168-10-6**]. The patient was asymptommatic.
She was given IV Metoprolol and Diltiazem, and she was then
placed back on her home dose of Diltiazem. The patient
converted back to NSR and has remained in this rhythm for the
remainder of her hospital course.
.
# Parkinson's Disease: The patient has a h/o parkinson's. She
was maintained on her home dose of carbidopa/levodopa on this
admission and did not have any acute events during this hospital
stay.
.
# CODE STATUS: DNR/DNI. Reconfirmed with patient and daughter.
Medications on Admission:
Sinemet 25/100 QID
Diltiazem SR 240
Levoxyl 50
Lasix 20
Timolol OD eye gtt [**Hospital1 **]
Alpahgan OD eye gtt [**Hospital1 **]
Fosamax 70 weekly
Simvastatin 20 mg daily
ASA 81 mg
.
MEDICATIONS ON TRANSFER:
Tylenol 325-650 PO q6h
Albuterol MDI
Brimonidine Tartrate gtt
Carbidopa-Levodopa 25-100 1 tab qid
Calcium Gluconate
Diltiazem 60 mg PO qid
Colace 100 mg [**Hospital1 **]
Famotidine 20 mg [**Hospital1 **]
Morphine prn
Simvastatin 20 mg daily
Timolol Maleate gtt
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
5. Calcium 600 + D 600-125 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
DAILY (Daily).
Disp:*30 packet* Refills:*2*
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 5 days.
15. Zosyn 4.5 gram Recon Soln Sig: One (1) bag Intravenous three
times a day for 5 days.
16. 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.
17. Morphine Sulfate 2-4 mg IV Q4H:PRN prn
hold for sedation
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
T9 compression fracture
Delerium - resolved
Atelectasis vs PNA - treated with IV abx.
constipation likely [**2-27**] narcotics for pain
Secondary:
Atrial Fibrillation
Discharge Condition:
Good. Patient's vital signs are stable. Resp status improved
Discharge Instructions:
You were admitted to the hospital because you fell at home. You
broke a vertebrae in your back, which then compressed your
spinal cord. You were transferred her to have surgery to
relieve this compression. While you were here, the surgeons
operated on your back. You were confused after the surgery, so
we monitored you closely for any complications over the next few
days.
Please take all medications as prescribed.
Please keep all previously scheduled appointments. Please
followup with Dr. [**Last Name (STitle) 1007**] in the Spine center in 3wks.
Please return to the ED or your healthcare provider immediately
if you experience shortness of breath, chest pain, confusion,
loss of consciousnes, fevers, chills, or any other concerning
symptoms.
Followup Instructions:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. Phone: [**Telephone/Fax (1) **]. Date/Time: [**11-8**]
at 8:30 am
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office to schedule an appointment
in [**3-29**] weeks. His number is ([**Telephone/Fax (1) 2007**]
Completed by:[**2168-10-10**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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] |
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|
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|
272, 323
|
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|
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2376, 2825
|
224, 234
|
351, 1525
|
2861, 4513
|
8000, 8263
|
1547, 1681
|
1793, 2326
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,769
| 173,954
|
10546
|
Discharge summary
|
report
|
Admission Date: [**2145-4-12**] Discharge Date: [**2145-4-24**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
NIPPV
cardiac catheterization s/p stents to L subclavian and iliac
History of Present Illness:
82 yo woman with extensive vascular history (below), breast
cancer in the past s/p L mastectomy in [**2128**], htn, high chol, and
possible diagnosis of colon cancer treated 2 yrs ago with chemo
which she self-d/c'ed, who had presented for elective
angiography for lower extremity ischemia, and had developed
nausea felt to be angina equivalent. After heparin gtt, she
went for cardiac cath on [**4-14**] PM and was found to have patent
grafts and 3vd, though low flow to LIMA and RLE vessels, thus
s/p stenting of right CIA and L subclavian. She developed left
sided weakness since then, unknown last well time. Heparin was
used prior to the cath, which was stopped at noon on [**4-15**]; she
did well during the procedure, although post-procedure there was
a groin hematoma and hematocrit drop requiring 2 units prbc's.
She moved well on exam last night. This morning, there was no
neuro exam performed, but she was apparently talking, with
no facial droop and normal language (?8 or 9AM). Cardiovascular
exam was considered to be stable. Just after 9AM she was seen
by the nurse, who found her to be unresponsive to voice; soon
afterwards, she had returned to [**Location 213**]. At 11AM she was seen by
the resident and appeared to have, once more normal language and
speech, but she was not moving the right side of her body.
Neuro
was contact[**Name (NI) **] at 11:15 and arrived at 11:30AM. Initial NIHSS
was unscorable because the patient was able to open eyes, but
did not speak at all, did not blink to threat on the left,
withdrew minimally to noxious stimuli (decreased on the left
upper extremity). DTRs were [**Name2 (NI) 19912**] at the knees and toes were
mute.
She was seen ten minutes later and language function was back to
normal with normal naming and speech, but a dense homonomous
hemianopsia, extinction to double simultaneous stimulation over
the left hemibody, weakness of the left arm, NIHSS of 5. On
further questioning later with family present, "peripheral
vision on the left" has been worse over the past month, though
she also has cararacts.
Past Medical History:
-HTN
-High chol
-PVD
-CAD s/p CABG x 4V [**2137**], no MI
-Breast cancer s/p L mastectomy [**2128**]
-Anemia
-TAH [**2109**]
-R->L fem-[**Doctor Last Name **] bypass
-Cataract surgery
-??Dx colon cancer 2 yrs ago s/p chemo, which pt d/c'ed because
of nausea
Social History:
She lives alone, is a nonsmoker, son lives nearby and is
involved with her care; daughter in [**Name2 (NI) **].
Family History:
Unknown.
Physical Exam:
Examination:
T 100.1 (had temp>101 earlier), bp 102/38, rr 18, 96%RA
General: white female, NAD
Heart: regular rate and rhythm with III/VI SEM RUSB, radiation
to
bilateral carotids vs bruits
Lungs: clear to auscultation anteriorly bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Mental Status: The patient was initially not speaking at all,
staring but not following commands; ten minutes later, she was
oriented to self, [**Hospital1 **], with intact language (no errors, normal
repetition) and normal speech. She was able to follow
multi-step
commands, and naming was intact. There was no apraxia or
agnosia.
Cranial Nerves: PERRLB 3->2, EOMI with no nystagums, +dense left
homonomous hemianopsia. Sensation on the face is intact to
light
touch but there is extinction on the left cheek to DSS. Facial
movements are normal and symmetrical. Hearing is intact to
finger
rub. The palate elevates in the midline. The tongue protrudes in
the midline and is of normal appearance.
Motor System: Bulk is normal; tone thought initially to be
increased x bilat arms when pt first seen but was likely flexor
tonic posturing during seizure; there is weakness in the left
arm
with 4/5 delt, and [**4-11**] triceps, [**5-12**] biceps, weak hand grasp,
left
sided pronator drift; there is also 4+/5 weakness of the
contralateral deltoid but elswhere in the right upper extremity
strength was normal. The patient can lift both legs off the bed
and hold them for over 5 seconds. There is no tremor.
Reflexes: The tendon reflexes are present, [**Month/Day (1) 19912**] in the knees
with bilaterally mute toes and normal.
Sensory: Sensation is present on the left side of the body, but
the patient has left hemibody extinction to DSS.
Coordination: There is some dysmetria of left finger to nose and
[**Doctor First Name **] in proportion to weakness.
Gait: Gait was not assessed.
Pertinent Results:
[**2145-4-12**] 07:30PM PT-11.7 PTT-21.6* INR(PT)-1.0
[**2145-4-12**] 07:30PM PLT COUNT-396
[**2145-4-12**] 07:30PM WBC-9.7 RBC-2.81* HGB-9.1* HCT-27.9* MCV-99*
MCH-32.5* MCHC-32.7 RDW-16.9*
[**2145-4-12**] 07:30PM CALCIUM-11.9* PHOSPHATE-3.1 MAGNESIUM-1.6
[**2145-4-12**] 07:30PM GLUCOSE-242* UREA N-36* CREAT-1.4* SODIUM-140
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2145-4-12**] 07:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2145-4-12**] 07:52PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2145-4-12**] 07:52PM URINE GR HOLD-HOLD
[**2145-4-12**] 07:52PM URINE HOURS-RANDOM
Pre-procedure CXR:
PA AND LATERAL CHEST FILMS: Lung volumes are at the upper limit
of normal. The heart size is normal. Mediastinal and hilar
contours are unremarkable. Patient is status post sternotomy.
Prominent costochondral calcifications. Lung fields demonstrates
a 7mm in the left lung fields, may be a calcified granuloma.
Right basilar nodular opacity is probably a nipple shadow. There
are no pleural effusions. There is biapical pleural
calcification.
IMPRESSION: Right upper and basilar nodules. Right basilar
nodule is probably a nipple shadow. Comparison with prior films
recommended. In the absence of prior films, chest CT recommended
for the right upper nodule.
[**4-12**]:
CAROTID SERIES COMPLETE.
REASON: Bruit.
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Moderate plaque is identified bilaterally. It is
somewhat calcified.
On the right, peak systolic velocities are 123, 94, 253 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3.
This is consistent with 40 to 59% stenosis.
On the left, peak systolic velocities are 152, 89, 166 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.7.
This is consistent with a 60 to 69% stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Moderate plaque with a left 60 to 69% and a right 40
to 59% carotid stenosis.
VENOUS DUPLEX, UPPER AND LOWER EXTREMITY.
REASON: Patient in need of bypass.
FINDINGS: Duplex evaluation was performed of both upper and
lower extremities. Left greater saphenous vein is patent with
diameters ranging from 0.17 to 0.45 cm. The saphenous vein below
the knee is somewhat diminutive.
Right cephalic vein is patent with diameters ranging from 0.24
to 0.30 cm. The right basilic vein is patent with diameters
ranging from 0.35 to 0.49 cm.
The left cephalic vein is not visualized. The left basilic vein
is patent with diameters ranging from 0.18 to 0.46 cm.
IMPRESSION: Patent left greater saphenous vein with somewhat
diminutive features below the knee. Patent bilateral basilic
veins and right cephalic veins with diameters as noted.
[**4-14**]: ABDOMINAL MRI/A
ABDOMINAL MRA: The aorta is normal in caliber. Diffuse
mild-to-moderate plaque is seen throughout the visualized
abdominal aorta including a more severe focal plaque
approximately 2 cm inferior to the renal arteries resulting in
narrowing of 50%. Celiac axis is normal. The origin of the SMA
is normal; however, multiple moderate focal stenoses are seen
within the visualized portion of the SMA. There is severe
stenosis at the origin of the left renal artery and
moderate-to-severe stenosis at the origin of the right renal
artery.
At the origin of the right common iliac artery, there is focal
high-grade stenosis and possible short segment occlusion. No
significant disease is seen within the remainder of the right
common iliac artery. Mild irregularity is seen within the right
external iliac artery.
There is complete occlusion of the left common iliac artery.
The right common femoral artery appears normal. There is a
patent femoral- femoral bypass graft. Retrograde flow is seen
within severely diseased external iliac and common femoral
arteries on the left.
RIGHT LOWER EXTREMITY MRA: Severe multifocal narrowing is seen
throughout the right SFA and popliteal arteries. Below the knee,
there is single vessel run off. The anterior tibial artery
demonstrates a few mild focal stenoses and terminates at the
level of the ankle. Minimal flow is seen within a severely
diseased dorsalis pedal artery. The DP artery is not directly
supplied by the AT artery. Minimal flow is seen within severely
diseased peroneal and posterior tibial arteries. Both vessels
occlude in the proximal to mid calf.
LEFT LOWER EXTREMITY: Severe multifocal disease is seen
throughout the left SFA and popliteal arteries. Blooming
artifact from a clip at the femoral- femoral bypass results in
non-visualization of the proximal SFA. Below the knee, there is
two-vessel run off. Mild-to-moderate multifocal disease is seen
within the tibioperoneal trunk which supplies patent posterior
tibial and peroneal arteries. The PT artery continues as a
plantar arch. The peroneal artery terminates in the distal calf.
A severely diseased anterior tibial artery occludes proximally.
IMPRESSION:
1. Diffuse atheromatous disease within the aorta.
2. Bilateral renal artery stenosis, left side greater than
right.
3. Focal high-grade stenosis (and possibly short segment
occlusion) at the origin of the right common iliac artery. Total
occlusion of the left common iliac artery.
4. Patent fem-fem graft
5. Severe multifocal disease within both thighs, as described
above.
6. Single vessel run off on the right with minimal flow in a
severely diseased dorsalis pedal artery.
6. Two-vessel run off on the left.
Evaluation of the reformatted images on a separate workstation
was valuable in delineating the anatomy.
CARDIAC CATH REPORT [**4-14**]:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system
with severe three vessel coronary artery disease. The LMCA, the
LCX, and
the RCA had proximal occlusions. The LAD had flow from the [**Female First Name (un) 899**].
The OM
system filled via collaterals from the LAD. The PDA and PLB had
no
angiographically apparent flow limiting lesions.
2. Selective graft venography revealed a patent SVG to RCA.
The SVG
to OM1 had an occlusion at the origin. The SVG to D1 to D2 had a
touchdown lesion in the D1.
3. Selective arterial conduit angiography revealed a patent
LIMA to
LAD.
4. Peripheral angiography showed an 80% origin stenosis of
the right
CIA and an occluded left CIA. The fem-fem graft was patent with
flow to
the left CFA. The right SFA had a 99% origin stenosis with slow
flow
with occlusion of the SFA at the adductor canal. The left
subclavian
artery had a 70% eccentric lesion with a pressure gradient of 10
mmHg
after the administration of NTG.
5. Resting hemodynamics demonstrated normal right, pulmonary,
and
left sided pressures with a 20 mmHg gradient across the aortic
valve and
a normal cardiac index (3.4 l/min/m2).
6. Left ventriculography showed no wall motion abnormalities
(EF 60
to 65%) with no mitral regurgitation.
6. Successful stenting of the right CIA with a 7.0 mm Genesis
stent.
7. Successful stenting of the left subclavian artery with a
6.0 mm
Genesis stent, post-dilated to 7.0 mm.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG to RCA, occluded SVG to OM, patent SVG to D1 to
D2.
3. Patent LIMA to LAD.
4. Moderate Aortic Stenosis.
2. Successful stenting of the right CIA.
3. Successful stenting of the left subclavian artery.
CT BRAIN [**4-15**]:
NON-CONTRAST HEAD CT SCAN: There are multiple large rounded
lesions within the brain which are hyperdense, consistent with
hemorrhagic metastases. At least six metastatic lesions are
visualized. There is a large hemorrhagic lesion involving the
right occipital lobe measuring 4.3 cm in diameter. A larger more
ill-defined lesion is noted within the right parietal lobe
superiorly. Other lesions are found within bilateral frontal
lobes. There is a moderate amount of edema surrounding the
hemorrhagic metastasis, demonstrated as hypodensity of the
surrounding white matter. There is no shift of the normally
midline structures at this time. The large right occipital
hemorrhagic metastasis results in mass effect on the occipital
[**Doctor Last Name 534**] of the right lateral ventricle. The third and fourth
ventricles are unremarkable. The visualized paranasal sinuses
and mastoid air cells are clear. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: Multiple hemorrhagic metastases within the brain.
MRI WITH CONTRAST [**4-17**]:
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with history of cancer with
cardiac catheterization and intracranial hemorrhage for further
evaluation to rule out metastatic disease.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were obtained before
gadolinium. T1 sagittal, axial and coronal images were obtained
following gadolinium. Correlation was made with the head CT of
the same date, [**2145-4-16**].
FINDINGS: There are multiple areas of signal abnormalities seen
within the both cerebral hemispheres. The largest lesion now
measuring 5 x 3 cm demonstrating acute blood products is seen in
the right occipital region with surrounding edema. There is
irregular rim enhancement seen following the administration of
gadolinium which extends to subependymal enhancement of the
occipital [**Doctor Last Name 534**] of the right lateral ventricle. The occipital
[**Doctor Last Name 534**] of the right lateral ventricle is compressed. Additionally,
several rounded areas of enhancement and signal changes are seen
in both cerebral hemispheres measuring 1-2 cm in size involving
the frontal and parietal lobes consistent with mild surrounding
edema. These findings are consistent with metastatic disease.
There is mild mass effect on the right lateral ventricle without
significant midline shift. The basal cisterns are patent. There
is mild brain atrophy identified.
IMPRESSION: Findings indicative of hemorrhagic metastatic
disease with the largest lesion in the right occipital lobe and
several other lesions measuring from 1-2 cm in both frontal and
parietal lobes. Mass effect is seen on the right lateral
ventricle without midline shift.
[**4-17**] CXR:
Single portable chest radiograph demonstrates interval
development of moderate, bilateral, pleural effusions when
compared to [**2145-4-17**]. Additionally, there is interval
development of prominence of the pulmonary vasculature,
representing worsening CHF. Trachea is in the midline. A right
subclavian central venous catheter remains unchanged in
position. Surgical clips project over the mediastinum. The
patient is again seen to be status post median sternotomy.
IMPRESSION:
Worsening CHF.
[**4-19**] CXR:
Findings; compared to [**2145-4-18**], there is a new Dobbhoff tube with
the tip projecting over the mid abdomen. Right subclavian CVL is
unchanged. Pulmonary edema has worsened. There is a new left
perihilar consolidation. There are small bilateral pleural
effusions. Left subclavian stent reidentified.
IMPRESSION:
1. Interval worsening of pulmonary edema with bilateral pleural
effusions.
2. New left perihilar consolidation.
Brief Hospital Course:
82 yo woman with cad, pvd, htn, high chol, breast ca in the
past, and questionable history of colon cancer 2 yrs ago, who
developed left sided weakness morning after cath, as well as L
extinction on DSS, L homonomous hemianopsia, and at least two
periods of unresponsiveness lasting at least several minutes in
duration suggestive of seizures, with CT scan showing multiple
areas of hemorrhage in both cerebral hemispheres, and large left
occipito-parietal hemorrhage suggestive of bleeding into mets
(vs amyloid, less likely). No hypertension to suggest that this
was HTN related. She was dilantin loaded and started on
standing dilantin. The head of the bed was kept above 30
degrees, and MRI was ordered.
The patient had initially been admitted to the vascular surgery
service with cardiology consulting for the catheterization. She
was transferred to the neuro ICU for additional care. Code
status was discussed with the patient and with her family, and
she expressed wishes that she did not want to be on a
ventillator to prolong her life. She was also informed of the
likelihood (based on head CT) that the brain lesions were
metastases and that her prognosis was poor. MRI of the brain
with gado confirmed that these lesions were likely mets.
CT of the torso for further metastatic workup was desired, but
the patient developed acute renal failure thought related to
contrast nephropathy. She was given IV fluid, which exacerbated
her already poor cardiac function, and she developed CHF. She
was maintained on BiPAP (NIPPV) in the ICU for several days; the
family again mentioned that she should under no circumnstances
be intubated. On [**4-19**], her creatinine had improved, and she was
weaned from BiPAP to facemask with 10L O2. She had also had an
elevated WBC count and some chest xray evidence of pneumonia at
this time. Because she had clinically improved, a feeding tube
(Dobhoff) was placed and she was transferred to the stepdown
unit for further management. At this point she was following
commands, answering simple questions (limited by her shortness
of breath), lifting the left arm against gravity with some
resistance as well, right arm remained full strength, and she
still had the left homonomous hemianopsia, although extraocular
muscles were intact in their movements.
Within hours of transfer to the floor, she developed respiratory
distress and as BiPAP could not be arranged on the floor at that
time, she was transferred back to the ICU (SICU now).
Clinically, her neuro exam remained stable and her kidney
function improved; she diuresed well. However, she was still
requiring facemask. Neuro-oncology was curbsided regarding
?palliative measures, and neuro-onc agreed that given her story
she was likely a poor candidate for chemo. The numerous brain
lesions could be treated with whole brain irradiation as one
palliative measure. Radiation oncology was consulted and agreed
that this was a possibility if the family desired it. On [**4-21**]
she dropped her sats again and developed further respiratory
distress while in the ICU. As her clinical status had not
adequately improved within days, and because the underlying
process was thought to be irreversible, another family
discussion was held and she was made CMO. She was given
morphine for air hunger and for comfort, and other medications
aimed at treating underlying processes were discontinued. She
expired on [**4-24**] at 5:45 am. Immediate cause of death was
respiratory failure. The family declined an autopsy.
Medications on Admission:
Hm meds include metoprolol, lisonpril, norvasc, asa 81, lipitor
80, HCTZ; Plavix added in house post stent. Last heparin gtt at
1200 on [**4-15**]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cerebral hemorrhages
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"486",
"428.0",
"E934.2",
"272.0",
"V66.7",
"411.1",
"198.3",
"424.1",
"V45.81",
"414.01",
"431",
"401.9",
"447.1",
"E879.0",
"518.82",
"584.9",
"250.00",
"440.22",
"998.12",
"E947.8",
"997.02",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.46",
"99.04",
"00.41",
"88.48",
"39.50",
"88.56",
"96.6",
"39.90",
"88.47",
"37.23",
"93.90",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
19779, 19788
|
16014, 19551
|
284, 352
|
19852, 19862
|
4841, 11969
|
19915, 20037
|
2892, 2902
|
19750, 19756
|
19809, 19831
|
19577, 19727
|
11986, 15991
|
19886, 19892
|
2917, 3223
|
224, 246
|
380, 2465
|
3574, 4822
|
3238, 3558
|
2487, 2747
|
2763, 2876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,862
| 182,246
|
50549
|
Discharge summary
|
report
|
Admission Date: [**2149-9-16**] Discharge Date: [**2149-9-17**]
Date of Birth: [**2096-5-13**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Asymptomatic Left carotid stenosis
Major Surgical or Invasive Procedure:
[**2149-9-17**]: left carotid endartertectomy
History of Present Illness:
This 52-year-old with a total carotid occlusion
on the right has had a progressing asymptomatic high-grade
stenosis of the left internal carotid artery now in the 70-
79% range. She was advised to have a carotid endarterectomy.
Past Medical History:
1. Hyperlipidemia
2. Hypertension
3. s/p Breast Reduction
4. s/p Tubal Ligation
Social History:
Divorced with 2 children; live in boyfriend
Quit smoking [**2149-5-6**]; Smoked 1ppd x 35 years,
denies ETOH
Family History:
Father with CAD s/p CABG. Hyperlipidemia in her sister and son.
Diabetes in her uncle who also had an MI and died at age 63. No
hx of strokes.
Physical Exam:
vss afebrile
gen: wdwn in nad
neck: supple, no edema, incision c/d/i with steri strips in
place
card: rrr
lungs: cta bilat
abd: soft no m/t/o
extremities: warm, well perfused; palpable fem/dp/pt bilat
neuro: alert and oriented x 3; cn ii - [**Doctor First Name **] grossly intact
Pertinent Results:
[**2149-9-17**] 04:09AM BLOOD WBC-12.6*# RBC-3.94* Hgb-11.3* Hct-33.3*
MCV-85 MCH-28.7 MCHC-34.0 RDW-14.3 Plt Ct-254
[**2149-9-17**] 04:09AM BLOOD Glucose-131* UreaN-21* Creat-0.9 Na-141
K-4.6 Cl-109* HCO3-25 AnGap-12
Brief Hospital Course:
Ms. [**Known lastname **] was admitted for an elective left carotid
endarterectomy on [**9-17**]. She was pre-op'ed , consented and taken
to the OR where she underwent a Left CEA without comcplication.
She was taken to the PACU for recovery where she remained
hemodynamically stable. She was then transfered to the VICU
overnight where blood pressures were controlled with
nitroglycerin gtt. She did have a mild headache while on nitro,
this resolved when nitro was discontinued. Ms. [**Known lastname **] was voiding
without difficulty, ambulating independently and tolerating a
regular diet on the morning of POD 1. Her labs were stable and
she was deemed stable for discharge home with family.
Medications on Admission:
Atenolol 25mh', Celexa 40mg', Plavix 75mg', Tricor, Advair 250
mcg-50 mcg", Levoxyl, Lisinopril 40mh', Metformin, Rosuvastatin
40mg'.
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Synthroid Oral
10. metformin Oral
11. please resume home doses of synthroid and metformin
** you should bring a list of all medications, including doses
to your next appointment so that we can appropriately update
your medications in our system **
12. NO WORK
for 2 weeks ([**Date range (1) 78946**]) due to surgery.
Discharge Disposition:
Home
Discharge Diagnosis:
left asymptomatic carotid stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving x 1 week, and no driving while taking until pain
medications. No work x 2 weeks
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment in 4 weeks
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
[**2149-10-20**] 01:45p [**Last Name (LF) 1111**],[**First Name3 (LF) 1112**] B.
LM [**Hospital Unit Name **], [**Location (un) **]
VASCULAR SURGERY (SB)
[**2149-10-20**] 01:00p VASCULAR [**Apartment Address(1) **] ([**Doctor First Name 6811**])
LM [**Hospital Unit Name **], [**Location (un) **]
VASCULAR LMOB (NHB)
Completed by:[**2149-9-17**]
|
[
"433.30",
"V45.81",
"433.10",
"414.00",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
3487, 3493
|
1606, 2305
|
350, 398
|
3572, 3572
|
1364, 1583
|
6555, 6917
|
903, 1048
|
2490, 3464
|
3514, 3551
|
2332, 2467
|
3723, 5961
|
5987, 6532
|
1063, 1345
|
275, 312
|
426, 657
|
3587, 3699
|
679, 760
|
776, 887
|
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