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1,209
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|
51701
|
Discharge summary
|
report
|
Admission Date: [**2107-9-6**] Discharge Date: [**2107-9-19**]
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old white male
who was initially evaluated by the trauma service on the [**8-25**] after a fall on the commode. At that time, he was
noted to have multiple rib fractures and a small splenic lac.
He had stable hematocrits in the hospital and was discharged
to rehab on [**8-29**]. He was readmitted on [**9-6**],
brought in via the [**Last Name (un) 4068**] ER, for lethargy and hypotension
into the 80s/50s. The outside hospital hematocrit was listed
at 15 prior to the 3 units transfused. He was found to have
a posttransfusion hematocrit of 26, which was down from his
previous of 35. He was scanned and then transferred here
after being given 3 units of PRBCs and being intubated.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Parkinson's disease.
3. Lower leg elephantiasis.
4. COPD.
PAST SURGICAL HISTORY: Left total knee replacement.
HOME MEDICATIONS:
1. Serevent.
2. Advair.
3. Levoxyl.
4. Vicodin.
ALLERGIES: NKDA.
SOCIAL HISTORY: No use of tobacco or alcohol. Nursing home
report indicates alert and oriented at baseline.
INITIAL PHYSICAL EXAM: Vital signs - temperature 94.3, blood
pressure initially 121/30, remeasured at 145/57, heart rate
80, sat 100. The gentleman was intubated and sedated. He
had a regular rate and clear lungs bilaterally. He had a
distended and tense abdomen. He had bilateral right greater
than left lower extremity edema. This was consistent with
his previous history of especially right-sided elephantiasis.
The CT from outside hospital indicated a large amount of
intraperitoneal fluid. He had a trauma line placed in his
left groin in the trauma bay, and he was taken urgently to
the OR for suspected delayed onset of splenic bleed.
HOSPITAL COURSE: The gentleman was taken to the operating
room on the [**9-7**] and had an exploratory laparotomy,
during which was noted a large splenic bleed. He had a
splenectomy at that time. He had no other internal injuries
noted. The patient was sent to the Trauma SICU after the
operation. He had a left subclavian and Swan-Ganz catheter
placed secondary to decreasing urine output and rising
creatinine preoperatively. Opening pressures were within
normal limits with a wedge of 17-23, CVP 10-16, CCO [**4-30**] with
a CI greater than 3, SVO2 77-83%. His initial postoperative
crit was 26.1, and he was transfused with an additional 2
units of PRBCs with repeat hematocrit of 34. He required
calcium repletion, but his other lytes were within normal
limits.
The patient was initially hypothermic on presentation and was
warmed gradually with a bear-hugger. The patient was
extubated by evening on [**9-7**]. The Swan-Ganz catheter
was removed by [**9-8**], secondary to hemodynamic
stabilization. He remained afebrile on cefazolin and
Levaquin. His NG tube was DC'd on [**9-9**], and he was
taking small amounts of clear liquids without nausea or
vomiting in the unit. He was transferred over to the floor
on [**9-10**].
On the floor, Mr. [**Known lastname **] was noted to have a moderate
amount of abdominal distention with tympany. He had no
abdominal pain and no nausea. His incision from the surgery
remained intact with midline staples. There was also some
serous drainage noted from the site of the left groin Cordis
that had been pulled, but this resolved over the next several
days. He resolved chest PT q 4 h, as well as physical
therapy to attempt to improve the deconditioning that had
occurred while he was in the hospital. In addition, his
abdominal exam was closely followed while he was on the
floor.
The patient continued to tolerate POs well; however, he
remained distended. He reported that he was passing flatus,
but had had no bowel movement in many days. Dulcolax PR
seemed to have no effect. A KUB was checked on [**9-12**]
which just showed nonspecific bowel gas pattern with no
evidence of obstruction or perforation. His amylase was 51,
indicating no sign of pancreatic injury or inflammation. TSH
was checked to see if inadequate treatment of his
hypothyroidism might be contributing to his ileus, and it
turned out to be 13. So, his dose of levothyroxine was upped
from 50 mcg po to 75 IV with a plan to recheck a T4 in a
couple of days. He had a small bowel movement on that day,
the [**9-12**], but still remained quite distended. His
abdominal exam was closely followed.
His distention did not resolve by the following day, so a PO
and IV contrast abdominal CT was obtained in order to
determine if there was sign of obstruction or abscess. The
CT from the 21 showed no focally drainable collections, no
findings to suggest bowel obstruction, a small amount of
abdominopelvic ascites consistent with ex-lap, and mild
distention of the gallbladder without any discrete fluid
around it, and with some calculi. Since there was no
indication or obstruction or abscess, and the patient was
still tolerating POs, it was assumed that this distention and
lack of bowel movements was probably due to ileus. We
continued a bowel regimen with PO Dulcolax, as well as tid
ambulation to encourage return of bowel function. A free T4
was checked on the 23 which showed 0.9 at the lower end of
normal, so his levothyroxine was increased to 100 qd. He was
placed on [**Hospital1 **] lactulose which caused him to have several
large quantity bowel movements, and so the lactulose was
discontinued.
The patient required occasional albuterol nebs in order to
treat some mild expiratory wheezes. The patient also
required a few doses of lasix 20 mg IV for fluid overload.
Lower extremity and scrotal edema improved with lasix. His K
was repleted along with diuresis. The patient was noted to
be very weak and continued to require PT and assist with
ambulation. Prior to discharge to rehabilitation, he was
given the pneumococcal, meningococcal and H. flu vaccines.
LABS ON ADMISSION: CBC showed a white count of 17,
hematocrit 26, platelet count 185. Coags were PT 12.5, PTT
27.9, INR 1.0. Chem-7 - sodium 136, potassium 4.2, chloride
105, CO2 22, BUN 55, creatinine 2.2, and glucose 126. His UA
was positive which was why he was placed on Levaquin for 3
days for the urinary tract infection
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation unit.
DIAGNOSIS: Status post fall with delayed bleed from splenic
laceration, status post exploratory laparotomy with
splenectomy.
DISCHARGE MEDICATIONS:
1. Levothyroxine sodium 100 mcg po qd.
2. Bisacodyl 10 mg po qd prn.
3. Nystatin ointment applied up to qid prn.
4. Famotidine 20 mg po qd.
5. PRN Tylenol
6. Metoprolol 12.5 po bid.
7. Docusate 100 mg po bid.
8. Albuterol nebulizers q 6 h prn.
9. Heparin 5,000 U subcu q 12 h.
FOLLOW-UP in 2 weeks with Trauma Clinic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**MD Number(1) 107103**]
MEDQUIST36
D: [**2107-9-19**] 09:27
T: [**2107-9-19**] 09:33
JOB#: [**Job Number 107104**]
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74,289
| 149,502
|
39152
|
Discharge summary
|
report
|
Admission Date: [**2121-7-17**] Discharge Date: [**2121-7-20**]
Date of Birth: [**2072-3-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mr. [**Known lastname **] is a 49 year old man with
a past medical history signifcant for alcoholism, depression,
and a question of kidney and liver disease who was transferred
from an outside hospital where he had presented with
lightheadedness after a fall. He describes that 3 days ago he
experienced left sided rib pain following syncope and a fall
down stairs. This left sided flank pain prompted him to go to
the ER, where he was found to be in renal failure with a Cre 9
and low K and Mg, and a Na of 130. His electrolytes were
repleted and he was transferred to [**Hospital1 18**]. He reportedly has been
making normal urine volumes.
On arrival to the [**Hospital1 18**] ED, he complained of rib pain but per
report was a poor historian. A head CT scan failed to reveal
acute pathology and a CT abdomen revealed fat stranding around
the pancreas and no hydronephrosis. In addition, he was found to
have a 9th and 10th posterolateral left rib fractures. In the
ED, he was be hypotensive to SBPs in the 80s which persisted
despite 4L of fluid boluses. A left subclavian cental catheter
was placed to insure IV access. He required levophed for at
0.03mcg/kg/min to maintain an SBP in the 100s. He was then
transfered to the MICU.
On arrival to the MICU, he was found to be luicd and able to
give an account of his medical history and recent event. He was
still complaining of left sided rib pain but was otherwise
asymptomatic.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies 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
Depression
Tobacco Use
"?Kidney problems"
"?Liver problems"
Social History:
Lives alone in apt. Drinks alcohol daily 4-5 drinks for ~20 yrs.
Smokes 1 ppd. Denies any other illicits. Recently unemployed in
[**Month (only) **] as an automechanic. Completed HS and college. has always
worked as automechanic. married with 2 kids, separated 7 yrs
ago, still sees them however. is close to his sister and [**Name2 (NI) **]
(sister lives down the street from him). Wishes to pursue AA.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T:97.3 BP:106/71 P:84 R:13 O2:95% on RA
General: Alert, oriented, no acute distress answering question
appropriately
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: left sided flank tenderness, abodmen is soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2121-7-17**] 11:53PM LACTATE-1.1
[**2121-7-17**] 11:50PM GLUCOSE-98 UREA N-50* CREAT-6.3*# SODIUM-135
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-20* ANION GAP-16
[**2121-7-17**] 11:50PM cTropnT-<0.01
[**2121-7-17**] 11:50PM WBC-8.5 RBC-2.31* HGB-8.2* HCT-23.5* MCV-102*
MCH-35.5* MCHC-34.8 RDW-17.7*
[**2121-7-17**] 11:50PM PLT COUNT-224
[**2121-7-17**] 11:50PM PT-13.2 PTT-33.6 INR(PT)-1.1
[**2121-7-17**] 10:37PM URINE BLOOD-TR NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2121-7-17**] 10:37PM URINE RBC-0-2 WBC-[**2-28**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2121-7-17**] 07:34PM PT-12.8 PTT-23.2 INR(PT)-1.1
[**2121-7-17**] 06:41PM LACTATE-2.2* K+-4.2
[**2121-7-17**] 06:15PM ALT(SGPT)-22 AST(SGOT)-51* ALK PHOS-124 TOT
BILI-0.5
[**2121-7-17**] 06:15PM LIPASE-93*
CT Abd [**2121-7-17**]
1. minimally displaced posterolateral left 10th rib fracture.
evaluation
limited given lack of IV contrast, but no evidence of splenic
injury or
hematoma.
2. apparent mild fat stranding around the pancreas,
predominantly around the
head and near the duodenum. differential includes pancreatitis
or possible
contusion from fall. please correlate clinically and with labs.
3. Diffuse fatty infiltration of the liver.
4. Hyperdense 1.1 cm nodule at the upper pole of the right
kidney. Could
further assess with renal ultrasound on a nonemergent basis.
EKG: Diffiuse T wave inversion in II, III, aVF, and V4-6
Brief Hospital Course:
[**Known firstname 86739**] [**Known lastname **] is a 49 year old man who presented with left
sided flank pain after a syncopal event and fall. He was found
to have severe dehydration and acute renal failure. He
presented in [**2121-2-24**] for a similar presentation of severe
dehydration and acute renal failure.
.
Acute on chronic renal failure: Upon [**First Name9 (NamePattern2) 86740**] [**Known firstname 86739**] was found
to have profound dehydration, acute pre-renal failure, and
electrolyte abnormalities in the setting of chronic alcoholism
and poor PO intake. He received 4 liters of fluid in the ED,
followed by 7 units of fluid in the MICU and initially requried
levophed to maintain his pressures. His urine output was
carefully monitored in the unit and upon tranfer to the floor.
On the floor he was given 2L LR over the course of 2 days in
addition to PO rehydration. His creatinine improved
dramatically from 7.5 to 1.7 upon discharge. He tolerated PO
fluid and food intake well. U/A was negative. His calcium,
potassium and magnesium was repleted as needed daily.
.
Hypotension/Syncope: The patient had an episode of syncope
likely secondary to orthostasis and hypotension secondary to
dehydration. Upon arrival to the ED, his hypotension was
initially refractory to fluids and required norepinephrine. CK
and troponins were negative, echocardiogram did not find a
cause, no infectious focus was found. The ICU team was able to
wean the patient off of the norepinephrine drip shortly after
transfer from the ED. He was transferred to the floor and his
blood pressure remained within normal limits and orthostatics
were negative.
.
Anemia: The patient was found to have macrocytic anemia most
likely secondary to direct bone marrow effects due to chronic
alcoholism. B12 and folate were normal. He was supplemented
with folic acid, thiamine and multivitamins daily. He received
1 unit of PRBC and HCT remained stable thereafter. Guaiac
negative and no hematemesis to suggest UGIB. No evidence of
cirrhosis or cirrhosis, therefore no concern for variceal
bleeding. It is recommended the patient follow up with his
primary care physician regarding his anemia and continued
counseling regarding cessation of alcohol. He should continue
to take folate, thiamine and multivitamins daily.
.
EtOH abuse: The patient's last drink was [**2121-7-15**], states
approximately 4-5 drinks daily. He has a history of delerium
tremens, although only required diazepam x1. He was seen by
social work for options for addiction treatment and plans on
attempting to quit drinking. The importance of quitting
drinking and maintaining adequate/regular daily food and fluid
intake was extensively stressed. The patient's AST was elevated
at 49, indicative of possible alcoholic hepatitis that should be
repeated and monitored as an outpatient.
.
Rib fracture: The patient has non-displaced L posterolateral 9th
and 10th rib fractures secondary to his fall down stairs after
his syncopal event. He achieved adequate pain control using a
lidocaine patch at the site and acetaminophen.
.
Kidney nodules: CT abdomen showed 'Two exophytic nodules at the
upper pole of the right kidney for which further evaluation is
recommended. Ultrasound or MRI on a non-emergent basis is
recommended for further characterization.' Patient instructed
to talk to Dr. [**Last Name (STitle) 12982**] about this and he can make arrangements
for these tests.
.
Depression: The patient has not been taking his citalopram
prior to discharge. We recommend he follow up with his primary
care physician and possibly establish care with psychiatry to
restart this medication with close follow up.
.
The patient was full code for this admission.
*******PATIENT ELOPED BEFORE BEING SEEN BY THE ATTENDING
PHYSICIAN ON THE DAY OF DISCHARGE AND LEFT WITHOUT DISCHARGE
PAPERWORK *********
Medications on Admission:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Medications:
1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for rib pain : Please alternate patch 12 hours on and 12
hours off.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Marked hypovolemia/dehydration
Acute renal failure
Hypotension requiring pressure support in MICU
Mechanical fall with 9th and 10th posterolateral left rib
fractures
Alcoholism, continuous
Alcohol withdrawl- resolved
Depression
Anemia - macrocytic, normal B12 and folate
Syncope attributed to orthostasis
Kidney nodules
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 after falling down and
injuring your ribs. You were found to have SEVERE KIDNEY
FAILURE. It seems this is related to becoming extremely
dehydrated in the setting of drinking too much alcohol and not
drinking enough non-alcoholic liquids. You also appear to have
some malnutrition, possibly from not eating a healthy diet and
drinking too much. While in the hospital we gave you many
liters of fluid to rehydrate you and your kidney function has
improved. We recommend you maintain regular food and fluid
intake to prevent this from happening again.
.
We strongly recommend you stop drinking. Please seek support
and counseling in order to quit successfully through social work
and support groups such as alcoholics anonymous. Please do not
hesitate to contact social work here at the hospital should you
need help.
.
We made the following changes to your medications:
- Start omeprazole 40mg daily
- Start thiamine 100mg daily
- Start Multivitamin 1 tab daily
- Start folic acid 1mg daily
- Start Tylenol 650mg up to three times daily as needed for pain
.
Please follow up with your primary care doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 11370**]g citalopram for your depression.
.
Please take care. We wish you a speedy recovery.
Followup Instructions:
Please call Dr.[**Name (NI) 66002**] office on Monday morning to make a
follow up appointment within the next two weeks to recheck your
kidney function tests and follow up your anemia hospital
admission.
.
Please tell him that your CT scan of your abdomen showed 'Two
exophytic nodules at the upper pole of the right kidney for
which further evaluation is recommended. Ultrasound or MRI on a
non-emergent basis is recommended for further characterization.'
You should speak to Dr. [**Last Name (STitle) 12982**] about this and he can make
arrangements for these tests.
.
Please follow up with social work as needed for support and
counseling regarding quitting alcohol.
Completed by:[**2121-7-21**]
|
[
"285.8",
"403.90",
"303.91",
"276.9",
"593.9",
"584.9",
"E880.9",
"305.1",
"291.81",
"276.51",
"807.02",
"311",
"585.9",
"458.9",
"276.2",
"458.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10123, 10129
|
4833, 8715
|
279, 285
|
10512, 10512
|
3343, 4810
|
11978, 12680
|
2664, 2682
|
9392, 10100
|
10150, 10150
|
8741, 9369
|
10663, 11543
|
2712, 3324
|
11572, 11955
|
1797, 2138
|
231, 241
|
341, 1778
|
10169, 10491
|
10527, 10639
|
2160, 2226
|
2242, 2648
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,318
| 177,554
|
37556
|
Discharge summary
|
report
|
Admission Date: [**2167-12-22**] Discharge Date: [**2167-12-28**]
Date of Birth: [**2085-11-27**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Ruptured AAA
Major Surgical or Invasive Procedure:
[**2167-12-22**] Open repair of ruptured abdominal aortic aneurysm with
Dacron 16-mm tube graft.
History of Present Illness:
82 F with known AAA presented to [**Hospital6 5016**] with acute
onset of R. sided flank and back pain that started at 7 AM
today. Non-contrast CT scan showed a contained leak and she was
transferred to [**Hospital1 18**] for further care.
Past Medical History:
COPD on 3L home O2, CHF, asthma, known AAA
PSH: L. CEA
Social History:
2 children, 6 grandchildren
Family History:
N/C
Physical Exam:
PE: T: 99.5 BP: 142/73 HR: 68 Sats: 98% #LN
A&O x 3, very pleasant female in NAD
EOMI, anicteric sclera
Neck supple, no masses
RRR, no MRG, +S1, S2
CTAB
Abdomen soft, NT, ND. Midline incision clean, dry and intact
Bilateral femoral pulses 2+, pedal pulses dopperable
Feet warm bilaterally
No LE edema
Pertinent Results:
[**2167-12-27**] 04:00AM BLOOD WBC-10.3 RBC-3.41* Hgb-9.9* Hct-28.3*
MCV-83 MCH-29.0 MCHC-34.9 RDW-15.9* Plt Ct-134*
[**2167-12-26**] 04:51AM BLOOD WBC-12.6* RBC-3.59* Hgb-10.1* Hct-29.7*
MCV-83 MCH-28.2 MCHC-34.1 RDW-16.2* Plt Ct-92*
[**2167-12-27**] 04:00AM BLOOD Plt Ct-134*
[**2167-12-26**] 04:51AM BLOOD Plt Ct-92*
[**2167-12-27**] 04:00AM BLOOD Glucose-95 UreaN-22* Creat-1.0 Na-138
K-4.7 Cl-97 HCO3-36* AnGap-10
[**2167-12-26**] 09:36PM BLOOD K-3.7
[**2167-12-25**] 06:55PM BLOOD CK(CPK)-474*
[**2167-12-25**] 06:55PM BLOOD CK-MB-9 cTropnT-0.12*
[**2167-12-25**] 11:02AM BLOOD CK-MB-12* MB Indx-2.1 cTropnT-0.13*
[**2167-12-27**] 04:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
[**2167-12-26**] 09:36PM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
[**2167-12-23**] 06:22PM BLOOD Type-ART pO2-94 pCO2-43 pH-7.39
calTCO2-27 Base XS-0
[**2167-12-24**] 12:06AM BLOOD Glucose-113* K-4.2
[**2167-12-24**] 12:06AM BLOOD O2 Sat-94
[**2167-12-24**] 03:41AM BLOOD freeCa-1.09*
[**2167-12-25**] 11:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2167-12-25**] 11:00AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
[**2167-12-25**] 11:00AM URINE RBC-[**11-27**]* WBC-0 Bacteri-FEW Yeast-MOD
Epi-0
[**2167-12-25**] 11:00AM URINE CastHy-0-2
[**2167-12-23**] 01:03AM URINE Hours-RANDOM UreaN-258 Creat-43 Na-126
[**2167-12-25**] 4:12 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2167-12-25**]**
GRAM STAIN (Final [**2167-12-25**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2167-12-25**]):
TEST CANCELLED, PATIENT CREDITED
Brief Hospital Course:
[**2167-12-22**]
Patient was meflighted to [**Hospital1 18**] from [**Hospital3 **] with ruptured
AAA and flank pain. This was confirmed with CT. She was
emergently taken to the operating room with Dr. [**Last Name (STitle) **].
Tolerated the operation well. She was transferred to the ICU
post-operatively on neo and propofol. Hypothermic- on bear
hugger. Fluid resusitation with 4L bolus and continuous
infusion. Dopperable pedal pulses.
[**2167-12-23**]
Stable overnight. Vent weaned off and extubated. A-line in
place. Heparin SQ. Nitro infusing. IVF heplocked. Continue to
diuresis. BP stable.
[**2167-12-24**]
Transfer to VICU. Stable. OOB with PT. 3LNC Sat 98%.
[**2167-12-25**]
Tolerating clear diet. Continue diuresos. Pain control. Blood
cultures drawn and sent for elevated WBC. afebrile.
[**2167-12-26**]
Episode of Afib which converted with beta blockade. Recieved
1unit of PRBC for HCT of 26.4 due to blood loss during surgery.
CXR negative for pneumonia. Regular diet. All oral medications
started.
[**2167-12-27**]
Tolerating regular diet. Brief episodes of AF- converted to
sinus with increased BB.
[**2167-12-28**]
DC home with PT.
Medications on Admission:
combivent, pulmicort, cozaar, zyrtec, isosorbide,
prednisone, ASA (doses unknown)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for mild pain.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] ().
4. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Home Oxygen
Per home regimen of 3LNC continuous
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Ruputured AAA (pre-op diagnosis)
COPD on 3L home O2
asthma
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:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-15**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-10**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2168-1-13**] 3:00
Completed by:[**2167-12-28**]
|
[
"V46.2",
"285.1",
"276.52",
"428.0",
"493.20",
"427.31",
"441.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
5879, 5954
|
3030, 4187
|
311, 410
|
6057, 6057
|
1166, 3007
|
8950, 9134
|
821, 826
|
4319, 5856
|
5975, 6036
|
4213, 4296
|
6234, 8497
|
8523, 8927
|
841, 1147
|
259, 273
|
438, 680
|
6071, 6210
|
702, 759
|
775, 805
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
735
| 144,277
|
7943
|
Discharge summary
|
report
|
Admission Date: [**2127-3-13**] Discharge Date: [**2127-3-19**]
Date of Birth: [**2068-3-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left lower extremity weakness
Major Surgical or Invasive Procedure:
[**3-13**] T11-L1 decompressive laminectomy, tumor resection, T9-L2
instrumented fusion with neuromonitoring
History of Present Illness:
This is a 58-year-old female who is known to Dr. [**Last Name (STitle) **]. She was
diagnosed previously with a long history of renal cell carcinoma
and has recently presented with progressive metastases to her
lumbar spine. She has a large
lesion in the post. elements overlying T12-L1 with infiltration
of both lamina, the facet joint as well as the epidural space.
There was noted to be sig. spinal cord compression. The patient
is symptomatic.
It is felt that she is not a candidate for radiation therefore
[**Known firstname **] wished to undergo surgical decompression of the
lesion.
Past Medical History:
Renal Cell Carcinoma
Adrenal recurrence
Rt. nephrectomy [**2120**]
Adrenalectomy [**2122**]
Left knee surgery [**2121**]
T&A
Polypectomies
Social History:
non-smoker/non-drinker
Family History:
unknown
Physical Exam:
On Discharge:
Neurologically intact with the exception of Left lower extremity
weakness([**4-27**]) in the quadracep. Sensorium is reported to be
intact. Surgical incision is slightly erythemic, but intact.
There is a small blister noted adjacent to the right of midline
incision.
Pertinent Results:
[**2127-3-17**] WBC-9.1 RBC-2.87* Hgb-8.0* Hct-24.9* MCV-87 MCH-28.0
MCHC-32.3 RDW-15.3 Plt Ct-332
[**2127-3-17**] Plt Ct-332
[**2127-3-16**] Glucose-112* UreaN-8 Creat-0.6 Na-136 K-4.3 Cl-103
HCO3-30 AnGap-7*
[**3-14**] CT-T-spine: Post-operative thoracolumbar spine, with
posterior fusion from T10-L3 with pedicle screws in T10, T11,
T12, L2, and L3.
Satisfactory position of pedicle screws. Laminectomy from
T11-L1 with resection of metastases. Sacral soft tissue mass
causing bone destruction, and measuring almost 5 cm.
MRI T Spine: final report pending at discharge.
Intraoperative Pathology: final report pending at discharge
Brief Hospital Course:
To O.R. [**2127-3-13**] as planned. Immediately following
surgergy on post op day one and two the pt recieved a total of 4
units of packed red blood cells for symptomatic low urine
output, hypotension and decreasing Hematocrit. The pt tolerated
the transfusions well, with no signs of volume overload or
cardiac dysfunction. Subsequent hematocrits have been stable,
and symptoms of hypovolemia resolved. This is likely attributed
to intraoperative volume losses.
Lower extremity motor strength is noted to be improving
daily and the patient reports her preoperative pain is also
improved. PT has been consulted to work with the pt daily and
evaluate for any post discharge needs. She was found to be an
appropriate rehab candidate, and was discharged to an
appropriate facility on [**3-19**] with appropriate follow up
instructions.
Medications on Admission:
AMLODIPINE, HCTZ, Levothyroxine, Lorazepam, Nystatin,Omprazole,
Oxycodone, Valsartan, Zometa
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Center
Discharge Diagnosis:
Thoracic tumor
Discharge Condition:
Stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
*You will need to have your staples and stitch removed in [**8-1**]
days from your date of surgery. This may be done at the rehab
facility.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 4 weeks.
??????You will not need x-rays prior to your appointment, as this was
done during your acute hospialization.
Completed by:[**2127-3-19**]
|
[
"276.52",
"E878.8",
"V45.73",
"285.1",
"V12.51",
"198.5",
"V10.52",
"336.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4",
"81.63",
"03.09",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
3221, 3280
|
2239, 3078
|
299, 410
|
3339, 3348
|
1573, 2211
|
4834, 5245
|
1248, 1257
|
3301, 3318
|
3104, 3198
|
3372, 4811
|
1272, 1272
|
1286, 1554
|
230, 261
|
438, 1029
|
1051, 1191
|
1207, 1232
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50,826
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47028
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Discharge summary
|
report
|
Admission Date: [**2153-4-4**] Discharge Date: [**2153-4-18**]
Date of Birth: [**2082-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Abd Pain
Major Surgical or Invasive Procedure:
Temporary hemodialysis catheter placement (now removed)
Hemodialysis
History of Present Illness:
69 yo F with A Fib, hypertension and DM with renal failure s/p
renal transplant presenting with abdominal pain. Day prior to
admission she had acute onset of abdominal pain while in bed.
Pain persisted overnight and worsened the next day so came to
the ED. Denies fever, chills, NS, dysuria, c/p, palpitations,
back pain or other focal complaints.
.
In the ED, intial VS were T98.5, BP 164/78, HR 63, RR 18,
O298%RA, Pain [**8-6**], exam notable for absence of CVA TTP. Labs
notable for absence of WBC's, or LE by UA, INR 6.2 and Cr 3.1
(recent baseline). CT scan of abdomen showed stranding around
the R-kidney. Patient was given morphine 4mg IV x1, and
ciprofloxacin 400mg IV x1 for a possible UTI/pyelonephritis.
.
On arrival to the floor, patient was comfortable. She reported
[**8-6**] pain only with movement, but was otherwise comfortable.
.
ROS: + increased abdominal distension, otherwise no change to
bowel habits.
.
ROS: ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
During her hospital course her abdominal pain was felt to be
radicular pain due to lumbar spinal stenosis. In addition, on
[**4-7**] she also developed new bilateral lower extremity weakness
concerning for cauda equina compression given evidence of this
on MRI. Neurology was consulted to evaluate.
.
She also developed altered mental status starting sunday [**4-8**].
Possible causes considered include infection, seizure,
intracranial hemorrahge. She was started on ceftriaxone to treat
for UTI although culture not positive. She had a head CT and
head MRI both of which were unrevealing. Of note her MS did
improved after starting ceftriaxone.
.
She also developed progressive hyponatremia and hyperkalemia as
well as worsening renal failure. K was 6.5 on the day of
transfer to the ICU and she was given kayexalate, 10 units
regular insulin and 1 amp d50.
.
On the day of transfer to the MICU ([**4-9**]) she had a tunnelled
line placed in IR due to lack of access as well as possible need
for dialysis given worsening renal function.
Past Medical History:
1. ESRD due to diabetic nephropathy and hypertension s/p renal
transplant [**2147**]. CKD since that time with Cr 1.7 at baseline
post-transplant but now with baseline Cr closer to 3.0
2. Hypertension for 40+ years
3. Type DM II for 30+ years
4. Atrial Fibrillation on coumadin
5. CHF
6. COPD
7. Gout
8. Secondary hyperparathyroidism
9. Chronic Edema
10. Anemia [**1-29**] CKD
Social History:
Does not smoke, drink alcohol or use drugs. Lives with son, has
[**Name (NI) 269**] for coumadin dosing/labs.
Family History:
One sister with CAD and diabetes. Another sister with heart
disease NOS. One sister died of ovarian cancer at age of 77. No
other history of heart disease, cancer or diabetes. Both parents
deceased of unknown cause.
Physical Exam:
On Admission:
VS: T99.9, BP 142/66, HR 61, RR 20, O2 91%RA
GEN: elderly woman in NAD, awake, alert
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesions
NECK: Supple, difficult to appreciate JVD [**1-29**] habitus
CV: Reg rate, normal S1, S2. +systolic murmur
CHEST: coarse rales bilaterally - no wheezes, no ronchi
ABD: obese, prominent panus, +BS, no appreciable
hepatosplenomegaly, abdominal pain does not localize well but
greatest in lower quadrants, no rebound no guarding
EXT: chronic skin changes [**1-29**] burns and skin grafts, no skin
breakdown, 1+ LE Edema, clubbing or cyanosis
Back: no CVA tenderness
.
Pertinent Results:
[**2153-4-4**] 12:15PM WBC-6.9# RBC-4.23 HGB-12.4 HCT-39.2 MCV-93
MCH-29.4 MCHC-31.6 RDW-18.1*
[**2153-4-4**] 12:15PM NEUTS-83.3* LYMPHS-11.3* MONOS-4.9 EOS-0.3
BASOS-0.2
[**2153-4-4**] 12:15PM PLT COUNT-241
.
[**2153-4-4**] 12:15PM ALT(SGPT)-11 AST(SGOT)-17 ALK PHOS-70 TOT
BILI-0.7
[**2153-4-4**] 12:15PM GLUCOSE-125* UREA N-65* CREAT-3.1* SODIUM-139
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
.
[**2153-4-4**] 05:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2153-4-4**] 05:45PM URINE RBC-[**11-16**]* WBC-0-2 BACTERIA-MANY
YEAST-NONE EPI-[**3-1**]
[**2153-4-4**] 05:45PM URINE GRANULAR-0-2 HYALINE-[**6-6**]*
.
BUN/Cr trend:
[**2153-4-4**] 12:15PM BLOOD UreaN-65* Creat-3.1*
[**2153-4-5**] 06:15AM BLOOD UreaN-65* Creat-3.2*
[**2153-4-6**] 07:05AM BLOOD UreaN-73* Creat-3.8*
[**2153-4-7**] 06:15AM BLOOD UreaN-77* Creat-4.2*
[**2153-4-8**] 07:00AM BLOOD UreaN-85* Creat-5.2*
[**2153-4-9**] 05:30AM BLOOD UreaN-92* Creat-5.7*
[**2153-4-9**] 05:21PM BLOOD UreaN-100* Creat-5.9*
[**2153-4-9**] 11:53PM BLOOD UreaN-97* Creat-5.8*
[**2153-4-9**] 11:53PM BLOOD UreaN-97* Creat-5.8*
[**2153-4-10**] 03:32AM BLOOD UreaN-100* Creat-6.0*
[**2153-4-10**] 04:34PM BLOOD UreaN-77* Creat-4.5*#
[**2153-4-11**] 03:09AM BLOOD UreaN-83* Creat-5.0*
[**2153-4-11**] 03:20PM BLOOD UreaN-60* Creat-3.8*#
[**2153-4-12**] 08:45AM BLOOD UreaN-71* Creat-4.0*
.
[**2153-4-12**] CXR
New opacity in the left lower lobe in the retrocardiac area
suggests
aspiration given the clinical concern. Small-to-moderate
bilateral pleural
effusions are unchanged. Marked cardiomegaly is stable. Left
supraclavicular
catheter is in place. There is no pneumothorax.
.
[**2153-4-10**] ECHO
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 0-10mmHg.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild global
left ventricular hypokinesis (LVEF = 40 %) with more significant
hypokinesis of the septum The right ventricular cavity is mildly
dilated with borderline normal free wall function. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The ascending aorta is moderately
dilated. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (area 1.0-cm2). Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**12-29**]+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate to
severe [3+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. There
is moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2152-10-20**], left ventricular systolic function is now impaired.
The severity of tricuspid regurgitation has increased. The
severity of aortic regurgitation has increased. The other
findings are similar.
.
[**4-10**] EEG:
IMPRESSION: This is an abnormal routine EEG due to a slow and
disorganized background indicative of a mild encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. There are no epileptiform features noted.
.
[**4-9**] CXR: CVL tip at right atrium, no evidence of pneumothorax
or apical hematoma, cardiomegaly still present, interval
development of RLL opacity most likely aspiration or
aspiration/pleural effusion, mild volume overload in perihilar
areas.
.
[**2153-4-8**] MRI Head:
No evidence of acute ischemia. Extensive periventricular white
matter disease, consistent with small vessel ischemic change
with more defined lacunar-type infarcts also noted. Slight
interval increase in fluid within the left sphenoid sinus,
should be correlated for any signs of acute sinusitis
clinically.
.
[**2153-4-7**] MRI CTL spine:
Degenerative disc disease with evidence of spinal stenosis and
spinal cord compression in the cervical spine. Spinal stenosis
and cauda equina compression in the lumbar spine.
Hyperintensity of lumbar intervertebral discs most marked at
L2-3 and L4-5. Although these likely reflect degenerative disc
disease, the possibility of infection cannot be excluded.
A preliminary report was issued that read "spinal stenosis at C4
through C7 with severe disc protrusion and ligamentum flavum
calcification effacing thecal sac, worst at C6-7. No cord signal
change. No priors to establish time intensity relationship.
Thoracic cord no compression.
.
[**2153-4-7**] CT Head:
Corona radiata hypodensities bilaterally are age-indeterminate
in the absence of prior scans. If clinical suspicion for
acute/subacute stroke, consider MR for further characterization.
The white matter changes appear well defined, markedly
hypodense, and likely chronic. I agree that MR may be helpful if
there is continued concern of possible acute infarction.
.
[**2153-4-5**] Renal Transplant:
1. Interval increase in resistive indices, worrisome for
rejection.
2. Interval slight decrease in the pelvocaliectasis.
.
[**2153-4-4**] CT Abdomen/Pelvis:
1. Effacement of the fat around the transplant kidney for which
the
differential includes pyelonephritis and renal vein thrombosis.
Right
[**First Name9 (NamePattern2) **] [**Last Name (un) 103**] wall small seroma/ hematoma.
2. Increased right pleural effusion.
3. Prominent cisterna chyli.
4. Atherosclerotic vascular changes.
5. Persistent right renal cyst.
6. Stable appearance to left lower lobe pulmonary nodule.
.
MICRO
Urine cx negative x 4
Blood cx (including 1 mycolytic) negative x 6 (2 pending, no
growth to date)
CMV VL undetectable
MRSA screen negative x 2
C.Diff pending
LABS ON DISCHARGE
[**2153-4-17**] 05:17AM BLOOD Glucose-96 UreaN-76* Creat-2.1* Na-130*
K-3.8 Cl-91* HCO3-31 AnGap-12
.
Asymptomatic pyuria (urine cultures all negative)
[**2153-4-14**] 12:10PM URINE RBC-59* WBC-261* Bacteri-NONE Yeast-NONE
Epi-1 RenalEp-3
[**2153-4-7**] 02:41PM URINE RBC-21-50* WBC-[**11-16**]* Bacteri-MOD
Yeast-NONE Epi-[**6-6**] TransE-[**3-1**]
[**2153-4-4**] 05:45PM URINE RBC-[**11-16**]* WBC-0-2 Bacteri-MANY
Yeast-NONE Epi-[**3-1**]
Brief Hospital Course:
70 yo F with PMH AFib, hypertension, DM with ESRD s/p renal
transplant admitted with abdominal/back pain [**1-29**] spinal stenosis
with course c/b UTI, acute on chronic renal failure, altered
mental status and hyponatremia.
.
#. Acute on chronic kidney disease s/p transplant: Concerning
for transplant rejection with worsening hyperkalemia and volume
overload. Other consideration is NSAID induced given that pt was
taking NSAIDS for acute gout flare prior to admission. Other
possibilities are prerenal failure due to adrenal insfficiency
vs poor cardiac output vs volume depletion. FENA is consistent
with prerenal etiology. No evidence of post renal obstruction.
CMV not detected. Patient was intiated on dialysis and had
third round on [**2153-4-12**] and electrolytes improved. Cr continued
to trend down by day of discharge. Pt was tapered off high dose
steroids, and was continued on Prednisone 5mg PO daily.
Calcitriol and calcium carbonate were continued. Sodium
bicarbonate was discontinued. Prograf was adjusted and continued
at lower dose of 3mg PO q12 at discharge. Pt did not require any
additional sessions of hemodialysis, and temporary HD line was
removed on day of discharge by IR.
.
# Acute mental status change: This was thought to be secondary
to hyponatremia and uremia in setting of worsening acute on
chronic renal failure. MRI Head was negative for acute etiology.
Confusion resolved after several sessions of hemodialysis and
resolution of hyponatremia and uremia. Pt was AOx3 on day of
discharge, and back to baseline per family.
.
#. Depressed EF - Can't exclude CHF as cause of renal failure,
however stroke volume 5.5L per minute. Unlikley that there has
been an acute demise in her cardiac function, by exam not
hypoperfusing, bounding pulses, limited treamtnet options.
Cards was consulted, and did not think her cardiac function was
the cause for her worsening renal failure. By day of discharge,
pt's Metoprolol was titrated up to 25mg PO tid, Lasix 60mg PO
bid. Lisinopril and Isodil continued to be held while renal
function recovered. Lisinopril should be resumed in the near
future.
.
#. Hyponatremia: Thought hypovolemic hyponatremia by the floor
team, with urine lytes consistent with prerenal syndrome.
Sodium worsened to 122 from 139 on admission. Due to altered
mental status she was transferred to the ICU for hypertonic
saline. Patient was given stress dose steroids, TSH was normal,
ECHO with depressed EF to 40%. Resolved with dialysis and MS
improved. Was likely secondary to acute on chronic renal
failure and fluid overload. Pt was placed on a fluid restriction
of 1200ml. Na was stable at 129-130 at discharge.
.
# Back/Abdominal Pain: On admission, was initially thought to be
secondary to pyelonephritis given dirty u/a and localized to
lower abdomen, but given negative urine cultures and imaging,
now thought to be most likely related to lumbar spinal stenosis
and radiculopathy seen on CT abdomen/pelvis. Pt experienced
mental status change and developing weakness toward beginning of
admission, and Neurology and Neurosurgery were consulted. MRI
head was negative for acute etiology. Pt was given a dose of
Decadron 10mg per Neuro. Neurosurgery recommended conservative
management during acute mental status change and uremia.
Following management of electrolyte abnormalities in the MICU,
pt was transferred back to the floor with improvement in pain,
but persistent weakness in hand grip and lower extremities.
Neurosurgery re-evaluated pt, and felt that though symptoms
persisted, pt did show improvement, and thus would be able to
consider elective surgery in outpt setting. Pt will be following
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Neurosurgery to discuss possible
surgical management of the cervical/lumbar stenosis as
outpatient.
.
# Hand and lower extremity weakness: see above.
.
#Paroxysmal atrial fibrillation - currently in normal sinus
rhythm. Pt was continued on Amiodarone. Coumadin was temporarily
held on admission while supratherapeutic, then again when
temporary HD line was placed. Pt is now back on Coumadin, with
loading dose of 10mg PO daily to be given on day of discharge at
rehab, followed by 5mg PO qday with goal INR [**1-30**]. Pt is on
heparin SC, which should be discontinued when INR becomes
therapeutic.
.
#Diabetes - Pt experienced hypoglycemia with bs in the 60s
following her MICU stay, likely secondary to decreased PO
intake. Home NPH dosing was decreased from NPH 22units qam,
3units qpm to 13units qam and none in pm. Humalog insulin
sliding scale was also continued.
.
# HTN - Pt's Lisinopril and Lasix were initially held on
admission given acute on chronic renal failure. Then in the
MICU, above meds as well as Hydralazine were held given
hypotension. As blood pressure is now back to baseline, pt will
be discharged on Metoprolol and Lasix, with Hydralazine PRN, and
Lisinopril held as renal failure continues to resolve.
Lisinopril will need to be resumed in near future. Isodil should
also be considered.
.
# FEN- renal diet with sugar-free shake supplements, fluid
restrict 1200ml
.
# PPX- heparin sq while coumadin is becoming therapeutic, PPI
.
# CODE- Full
Medications on Admission:
AMIODARONE 200 qd
CALCITRIOL - 0.25 mcg 5 days a week
COLCHICINE - 0.6 mg Tablet qod
DARBEPOETIN ALFA IN POLYSORBAT [100 mcg/0.5 mL Syringe - inject
1 s/c once a week
FOLIC ACID - 1 mg Tablet qd
FUROSEMIDE 40 mg Tablet - 1.5 Tablet(s) by mouth twice a day
HYDRALAZINE - 10 mg Tablet tid
LISINOPRIL - 40 mg Tabletqd
METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet qd
MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet [**Hospital1 **]
PREDNISONE - 5 mg Tablet qd
PROTONIX - 40MG Tablet, qd
TACROLIMUS [PROGRAF] 4 mg q12
WARFARIN [COUMADIN] - 2.5 mg Tablet - [**2-28**] Tablet(s) by mouth at
bedtime or as directed by coumadin clinic
CALCIUM CARBONATE - 500 mg Tablet,qid prn
CALCIUM CARBONATE-VIT D3-MIN [CALTRATE PLUS] qd
FERROUS SULFATE qd
INSULIN NPH HUMAN RECOMB [HUMULIN N] - (Prescribed by Other
Provider) - 100 unit/mL Suspension - 22 units in the am, sliding
scale in PM
INSULIN REGULAR HUMAN [HUMULIN R] - (Prescribed by Other
Provider) - 100 unit/mL Solution - sliding scale 4 times daily
.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Simethicone 80 mg Tablet, Chewable Sig: [**12-29**] Tablet, Chewables
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for
constipation.
13. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units SC Injection TID (3 times a day).
18. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
19. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever .
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for yeast infection.
21. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Start [**2153-4-19**].
22. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM for 1 days: Administer [**2153-4-18**].
23. Insulin Glargine 100 unit/mL Solution Sig: Thirteen (13)
units Subcutaneous at bedtime.
24. HydrALAzine 10 mg IV Q6H:PRN
for SBP >170
25. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
26. Darbepoetin Alfa In Polysorbat 100 mcg/0.5 mL Pen Injector
Sig: One (1) injection Subcutaneous once a week.
27. Insulin Lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous QACHS: Please use as directed by sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Acute on chronic renal failure
Hyponatremia
Uremia
Cervical and lumbar spinal stenosis
Insulin dependent diabetes mellitus
Hypertension
.
Secondary:
Paroxysmal atrial fibrillation
Discharge Condition:
Good, afebrile, hemodynamically stable, AOx3, urinating
(incontinent)
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1200ml
.
You were admitted for evaluation of abdominal/back pain. You
were found to have spinal stenosis, which is likely contributing
to your pain as well as your hand and leg weakness. You will be
following up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Neurosurgery, as outpatient to
discuss surgical options.
.
Your hospital stay was also complicated by acute mental status
change, caused by your worsening kidney function. This as well
as your kidney function improved with temporary hemodialysis. As
your kidney function has continued to improve and you are
urinating on your own, you will not need additional dialysis.
You were resumed on your home Lasix.
.
Your blood sugars have been low during your stay, likely caused
by decreased eating. Your insulin was adjusted.
.
Your coumadin dose was adjusted, as you were supratherapeutic
when you were first arrived. Now you are subtherapeutic, so your
dose will need to be adjusted for INR [**1-30**].
The following changes were made to your medications:
STOP Colchicine
STOP Hydralazine
STOP Lisinopril
STOP CellCept
CHANGE Metoprolol to 25mg PO twice daily
CHANGE Coumadin to 10mg PO x 1 TODAY ([**2153-4-18**]), then decrease to
5mg PO DAILY
.
If you experience any fever, chills, nausea, vomiting, worsening
abdominal pain, new weakness/numbness, decreased urine output,
confusion, or have any other concerns, please notify the MD.
Followup Instructions:
Please have your CBC, Complete metabolic panel, and Coags
checked on FRIDAY [**2153-4-20**] with results faxed to the Renal
Transplant Center.
FAX: [**Telephone/Fax (1) 21335**]
.
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Neurosurgery,on [**2153-4-26**] at
1:30pm to discuss elective surgical options for your
cervical/lumbar stenosis. W/LMOB-3B [**Hospital1 18**] ([**Telephone/Fax (1) 88**]
.
Please follow-up with Kidney [**Hospital 1326**] Clinic. You will be
contact[**Name (NI) **] by the Clinic within the next week for an appointment.
.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] within 2 weeks.
[**Telephone/Fax (1) 250**].
.
You also have the following appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2153-4-25**] 8:00
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2153-5-16**] 9:00
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2153-5-16**] 9:30
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2153-4-18**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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|
10606, 15823
|
324, 395
|
19755, 19827
|
4099, 8972
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21415, 22805
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423, 2649
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2671, 3050
|
3067, 3178
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,595
| 107,278
|
18001
|
Discharge summary
|
report
|
Admission Date: [**2190-5-27**] Discharge Date: [**2190-6-4**]
Date of Birth: [**2139-2-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 51-year-old gentleman
with a past medical history of a type-A dissection which was
emergently repaired on [**2190-4-17**]. He had an uneventful
postprocedure course, and was following up with his primary
surgeon, when his blood pressures noted to be 240 systolic
and 130 diastolic. He was completely asymptomatic.
Specifically, he denied any chest pain, back, neck, abdominal
or headache pain. He also denied any change in his vision
and other neurological symptoms. He denied excessive use of
caffeine, alcohol, or tobacco use. He also denied missing
any doses of his hypertensive medications. The surgeon
referred the patient to the Emergency Room where he was
started on a nitroprusside drip for improvement of his
systolic blood pressure.
His blood pressure was lowered over the next couple of hours
to approximately 150 systolic, and then he was transferred to
the CCU for further observation.
PAST MEDICAL HISTORY:
1. Type A-aortic dissection, status post repair along with
aortic valve repair.
2. Hypertension.
3. Psoriasis.
ALLERGIES: The patient has no known allergies.
MEDICATIONS UPON ADMISSION:
1. Aspirin 325 q day.
2. Labetalol 400 mg po tid.
FAMILY HISTORY: Mother with emphysema. Father with
congestive heart failure. His brother and sister are healthy
without any medical complications.
SOCIAL HISTORY: The patient admits to drinking approximately
two beers every other day. He also smokes an occasional
cigarette approximately one cigarette every week. He is
currently employed as a fireman. He denies any IV drug use.
PHYSICAL EXAM UPON ADMISSION: The patient is afebrile with a
blood pressure of 151/81, his heart rate was 100 beats per
minute, his O2 saturations were 98% on room air. His weight
was 88 kg. In general, this is a well-developed and
well-nourished middle-age gentleman who appears his stated
age. He was in no apparent distress. He was alert and
oriented to person, place, and situation. His pupils are
equal, round, and reactive to light. Extraocular movements
are intact. His mucous membranes were dry and his oropharynx
was clear. His neck was supple without bruit or
lymphadenopathy. He had normal carotid upstroke without
jugular venous distention. His heart was tachycardic with a
2/6 systolic murmur heard best at the left upper sternal
border. The murmur failed to radiate and there was no
obvious heave. His lungs were clear to auscultation
bilaterally. There was no wheezing or crackles. His abdomen
was soft, nontender, nondistended without organomegaly. His
extremities were without clubbing, cyanosis, or edema. He
did have bounding pulses bilaterally in both the upper and
lower extremities. Skin: He had multiple nodular plaques
consistent with psoriasis along his knees, hands, back, and
trunk. Neurologically: Cranial nerves II through XII are
grossly intact. He had no motor or sensory deficits. His
memory was intact.
LABORATORIES UPON ADMISSION: White blood cell count of 5.3,
hematocrit of 36.2, platelet count of 310. His Chem-10
showed a sodium of 139, potassium 4.2, chloride of 105,
bicarb of 24. His BUN was 11 and creatinine 0.8 with a
glucose of 93.
Electrocardiogram showed patient had a sinus tachycardia with
a rate of approximately 105 beats per minute. He had a
normal axis. There were normal intervals. There were no
acute ST-T wave changes. He did have what appeared to be
left ventricular hypertrophy.
An echocardiogram revealed patient had his left atrium was
moderately dilated. His left ventricle showed moderate
symmetrical hypertrophy with an ejection fraction estimated
to be about 75%. He was without any aortic regurgitation.
He showed mild thickening of the mild valve chordae with the
tips of the papillary muscles calcified. The left ventricle
inflow pattern suggested impaired relaxation. He showed a
small pericardial effusion that was loculated. His aortic
root was moderately dilated.
A MRA of his abdomen and chest revealed an aortic dissection
throughout the aorta. The distal extent went to the distal
most aorta to the bifurcation. The dissection did not appear
to extend into the iliac arteries. The celiac and the SMA
were supplied by both true and false lumen. Of note, the
left renal artery appeared to be supplied by the false lumen
while the right renal artery was supplied by the true lumen.
It is also noted that the patient appeared to have
intermittent periods where the left renal artery was
obstructed by the flap.
HOSPITAL COURSE: This 51-year-old gentleman with a type A
aortic dissection status post repair along with an aortic
valve repair one month prior to admission. Was admitted with
asymptomatic hypertension. His hospital course is as
follows: 1. Hypertension: In the Emergency Room, the
patient was initially started on a nitroprusside drip. Once
transferred to the CCU, the oral labetalol dose was increased
and the nitroprusside was gradually weaned off.
Unfortunately, after maxing out the labetalol dose, the
patient's blood pressure remained elevated in the 160-180
range, and he was started up on an ACE inhibitor. The ACE
inhibitor dosage was also maxed out, and he was started on
both Norvasc and hydrochlorothiazide. The patient then
started to have intermittent periods of hypotension which
were resolved by placing him in the Trendelenburg position
and IV fluid bolus.
Gradually, he was weaned down to labetalol 800 tid and
Captopril 75 mg tid with good blood pressure control. During
his initial workup for secondary causes of hypertension, it
was found that the patient had hypothyroidism with a TSH of
approximately 15. He was started on Synthroid.
Additionally, a renal ultrasound was ordered, which showed a
question of possible left renal artery stenosis. A followup
MRA revealed the results which are listed above. He was seen
then by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] Interventional Cardiologist.
On the fifth day of his hospital admission, Dr. [**First Name (STitle) **]
successfully placed a left renal artery stent. He was then
transferred back to the CCU, and he was started on a
labetalol drip along with po labetalol. His blood pressure
remained elevated after maxing out the labetalol, and he was
started on a low dose ACE inhibitor. His blood pressure was
controlled with labetalol 800 mg tid and lisinopril 15 mg at
bedtime.
During his stay, the patient experienced no chest pain, no
back pain, no headache, and his renal function remained
stable.
2. Endocrine: The patient was found to be hypothyroid, and
he was started on low dose of Synthroid. He will be
following up with his primary care physician for further
management of his thyroid condition.
3. Psoriasis: Patient has a long history of psoriatic
lesions for which he was started on a high potent steroid
cream with positive results. He was to followup with a
dermatologist for further management options.
MEDICATIONS UPON DISCHARGE:
1. Lisinopril 15 mg q hs.
2. Labetalol 800 mg tid.
3. Plavix 75 mg q day.
4. Aspirin 325 mg q day.
5. Levothyroxine 25 mcg q day.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS:
1. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week.
2. Patient should follow up with Dr. [**First Name (STitle) **] on [**6-16**] at
10:30.
3. Patient was to followup with Dr. [**Last Name (Prefixes) **] on [**6-24**] at
12:00.
4. The patient was to contact his primary care physician to
followup in six weeks for further evaluation of his thyroid.
5. The patient should return to the Emergency Room if he
develops any acute throbbing headaches, any back pain, any
chest pain, any extreme shortness of breath. He was also
told not to operate any heavy machinery to include driving
any motor vehicles for at least two weeks while his
medications are being adjusted. If the patient were to
become hypotensive, he was told that he should lay down.
DISCHARGE CONDITION: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 6284**]
MEDQUIST36
D: [**2190-6-4**] 12:31
T: [**2190-6-8**] 09:55
JOB#: [**Job Number **]
|
[
"441.03",
"V43.3",
"405.91",
"440.1",
"244.9",
"696.1",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
8155, 8421
|
1355, 1489
|
4670, 7143
|
7159, 8133
|
159, 1076
|
3117, 4652
|
1098, 1273
|
1506, 1743
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,969
| 144,920
|
54248
|
Discharge summary
|
report
|
Admission Date: [**2128-2-27**] Discharge Date: [**2128-3-2**]
Date of Birth: [**2048-1-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
[**2128-2-27**] R-IJ placement in ED
History of Present Illness:
80 y.o woman with history of recurrent lung pneumonia and
empyema, Hep C cirrhosis and c-diff colitis who presents to the
hospital with a 3 day history of diarrhea, malaise, poor PO
intake and fevers. The patient had recently finished a course
of ceftriaxone and ciprofloxacin for treatment of her recurrent
empyema, and had been taking PO vancomycin for prophylaxis which
she had finished only recently on [**2128-2-20**].
.
The patient reports that over the past several days she has been
feeling increasingly tired, and had noticed some increased
diarrhea as well which she initially self treated with immodium
with good effect. However, on tuesday she noticed that her
stool was becoming more watery with her having to empty her
colostomy twice a day rather than once a day. On the day of
admission (friday), she felt nauseous and also felt that she had
a fever. Her son, who had come up to see her from [**Hospital1 1562**]
found her to be lethargic with a poor appetite, and as such was
concerned and brought her to the ED.
.
In the ED, initial vs were 102.3, hr 101 bp 91/49. The patient
however subsequently triggered for a blood pressure of 70/50,
for which she was given 2L of normal saline with only slight
improvement to 85/60. She was also started on IV flagyl for
empiric treatment of clostridium difficile colitis. A central
line was placed, and a 3rd litre of NS was started.
.
Once in the ICU, she reported feeling much better and complained
of being hungry. She stated that her blood pressures have
tended to run low in the 80s-90s. She denied any current fevers
or chills, no nausea, abdominal pain, chest pain, shortness of
breath, black stools or bloody stools.
.
Review of systems:
(+) Per HPI
(-) as above
Past Medical History:
1) Empyema from ID note, admitted "[**4-7**] with a large
right-sided empyema requiring chest tube and pigtail catheter
drainage. She received antibiotics with vancomycin and
ceftriaxone. Bacteria grew a pansensitive E. coli and a
penicillin sensitive enterococcus. She stopped her antibiotics
on [**5-14**]."
2) HCV Cirrhosis obtained via blood transfusion during colon
surgery in [**2097**]'s, h/o nodule with work-up underway by Dr. [**Last Name (STitle) 497**]
3) HTN
4) remote history of rectal cancer s/p colectomy and ostomy in
[**2103**]
5) h/o lacunar infarcts
6) Anxiety/Depression
7) GERD
8) h/o Multiple parastomal hernias with revisions and
repositions from RLQ to LLQ to LUQ [**6-/2122**]
9) s/p CCY in [**2127-1-3**]
Social History:
Lives alone in [**Location 1268**] with a nurse [**First Name (Titles) **] [**Last Name (Titles) 2176**] her daily.
Independent in ADLs, and most IADLs. She is a lifelong
non-smoker. No alcohol consumption since at least [**Month (only) 404**] and
was never a heavy drinker. Worked in a bank for years, retired.
Divorced.
Family History:
Mother with uterine cancer. Sister with [**Name2 (NI) 64650**]. Sister with
lung cancer.
Physical Exam:
Admission Exam:
VS: T 98.8, BP 99/55, HR 86, RR 25, SpO2 99% on 2L
Gen: NAD. Alert and oriented x3. Mood and affect appropriate.
Pleasant and cooperative. Resting in bed eating dinner.
HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: RRR. Normal S1, S2. Systolic murmur [**2-8**] at LLSB.
Chest: Respiration unlabored. Decreased breath sounds and
crackles at right base. No wheezes or rhonchi.
Abd: BS present. Soft, NT, ND. Ostomy in LUQ with soft stool and
gas in bag. No surrounding erythema. Large hernia at ostomy
site.
Ext: WWP. No LE edema. Digital cap refill <2 sec. Distal pulses
radial 2+, DP 2+, PT 2+.
Neuro: Moving all four limbs.
Discharge Exam:
T98.7 Tm 98.7 BP 98/52 (98-108) P87 RR18 Sa02 95RA
GENERAL: well appearing NAD
HEENT: MMM, OP clear
PULM: crackles at the bases bilaterally, otherwise clear and
unlabored
CARDS: RRR, normal S1 S2 3/6 SEM at the RUSB
ABD: soft, nontender, nondistended. LUQ ostomy with soft stool
in bag, no surrounding erythema, +hernia at site
EXT: WWP, 2+DP PT pulses.
Pertinent Results:
ADMISSION LABS:
[**2128-2-27**] 07:58PM GLUCOSE-100 UREA N-22* CREAT-0.8 SODIUM-134
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-20* ANION GAP-12
[**2128-2-27**] 07:58PM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-74 TOT
BILI-1.1
[**2128-2-27**] 07:58PM LIPASE-13
[**2128-2-27**] 08:22PM LACTATE-1.9
[**2128-2-27**] 07:58PM ALBUMIN-2.3*
[**2128-2-27**] 09:20PM WBC-8.4 RBC-2.97* HGB-9.9* HCT-29.6* MCV-100*
MCH-33.4* MCHC-33.5 RDW-14.7
[**2128-2-27**] 09:20PM PLT COUNT-66*
[**2128-2-27**] 09:20PM NEUTS-88.4* LYMPHS-5.4* MONOS-4.9 EOS-1.0
BASOS-0.3
[**2128-2-27**] 09:48PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2128-2-27**] 09:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-6.0 LEUK-NEG
DISCHARGE LABS:
[**2128-3-1**] 06:05AM BLOOD WBC-3.5* RBC-2.92* Hgb-9.6* Hct-29.3*
MCV-101* MCH-32.9* MCHC-32.7 RDW-14.4 Plt Ct-64*
[**2128-2-29**] 07:00AM BLOOD Neuts-72.3* Lymphs-15.3* Monos-5.9
Eos-6.1* Baso-0.5
[**2128-3-1**] 06:05AM BLOOD Glucose-96 UreaN-14 Creat-0.6 Na-137
K-4.1 Cl-112* HCO3-22 AnGap-7*
[**2128-3-1**] 06:05AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.6
MICRO:
[**2128-2-27**] Blood Cultures x2 - NEGATIVE
[**2128-2-28**] STOOL:
FECAL CULTURE (Final [**2128-3-1**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2128-3-1**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2128-2-29**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 111146**] [**Last Name (NamePattern1) **] @ 0323 ON [**2128-2-29**]
CC7A [**Numeric Identifier 100088**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
STUDIES:
EKG [**2128-2-27**]: Sinus rhythm with an aberrantly conducted atrial
premature beat with borderline P-R interval prolongation.
Diffuse non-specific ST segment flattening throughout. There is
anterior R wave regression, raising the possibility of prior
anterior wall myocardial infarction. Compared to the previous
tracing of [**2127-12-30**] limb lead voltage is lower. T waves are
actually slightly higher in lead aVL. Other abnormalities are
largely unchanged.
CXR [**2128-2-27**]:
FINDINGS: The pigtail catheter has been removed. There is
prominence of the interstitial markings and engorgement of the
pulmonary vasculature compatible with interstitial pulmonary
edema. There are no pleural effusions. There is no evidence of
pneumothorax. The cardiomediastinal and hilar contours are
normal. There are no focal consolidations concerning for
pneumonia. Clips overlie the right upper quadrant.
IMPRESSION: Mild interstitial pulmonary edema.
Brief Hospital Course:
The patient is an 80 y.o woman with recent history of pneumonia
complicated by E. coli empyema and clostridium difficile
infection who presents to the hospital with hypotension, fever
and diarrhea, found to have recurrent C. difficile infection.
1. HYPOTENSION: She presented with hypotension to the 70s that
was slow to respond to fluids. She was admitted to the MICU for
management, and was further resuscitated with 3 liters NS with
stabilization of her BP. She did not need pressor support.
She was started on empiric treatment for C. diff colitis with PO
vancomycin 125 mg q6hr and IV flagyl. Given her recent
complicated pneumonia and empyema, she was also covered for HCAP
with vancomycin and cefepime. She was called out to the floor in
stable condition. She maintained her oxygen saturations on
room air. HCAP coverage was discontinued once her C dif titer
returned positive. Her blood pressures ranged in the 90s for the
remainder of the hospitalization.
2. C DIFFICILE INFECTION: Her diarrhea was secondary to C. dif
infection, related to recent antibiosis. She was treated
empirically with PO vancomycin and IV flagyl. Her diarrhea
subsided over the following 4-5 days. Because she received
broad spectrum antibiotics, ID recommended a long vancomycin
taper over 6 weeks. She was tolerating a regular diet without
abdominal pain or diarrhea at the time of discharge.
3. HEPATITIS C CIRRHOSIS: Her spironolactone was initially held
given her hypotension, but was restarted prior to discharge as
her pressures became stable.
4. VAGINAL CANDIDIASIS: she received fluconazole in the MICU
with resolution of symptoms
PENDING TESTS AT DISCHARGE: none
TRANSITIONAL CARE ISSUES:
- Has ID followup in place for management of her empyema/c. dif
infection
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs po every 4 to 6 hrs as needed for wheezing
CEFTRIAXONE - (Not Taking as Prescribed: states was d/c'd in
rehab 2/1or [**2-4**]) - 2 gram Recon Soln - 2 gms every
twenty-four(24) hours Please continue for at least 4-6 weeks.
Further recommendation will be given from infectious disease
doctor at the follow-up appointment.
CIPROFLOXACIN - (Prescribed by Other Provider) - 500 mg Tablet
- one Tablet(s) by mouth twice a day till [**2128-2-13**]
FOLIC ACID - 1 mg Tablet - one Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth once a day
SPIRONOLACTONE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - [**1-6**]
Tablet(s) by mouth every six (6) hours as needed for pain
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - [**1-6**]
Tablet(s) by mouth at bedtime as needed for insomnia
VANCOMYCIN [VANCOCIN] - (Prescribed by Other Provider) - 125 mg
Capsule - one Capsule(s) by mouth twice a day till [**2128-2-20**]
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 650 mg Tablet
- Tablet(s) by mouth every six (6) hours as needed for fever or
pain
CALCIUM CARBONATE - (Prescribed by Other Provider) (Not Taking
as Prescribed: pt has not been taking) - 500 mg (1,250 mg)
Tablet - Tablet(s) by mouth three times a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Tablet, Chewable - one
Tablet(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - 250 mcg Tablet - one Tablet(s)
by mouth once a day
DOCUSATE SODIUM - (OTC) - 100 mg Capsule - one Capsule(s) by
mouth twice a day as needed for constipation
MICONAZOLE NITRATE [ZEASORB AF] - (Prescribed by Other
Provider) - 2 % Powder - apply to affected areas in skinfolds
twice a day as needed for rash
Discharge Medications:
1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO see below
for 6 weeks: 1 tab q6hr for 1 wk. 1tab q12hr for 1wk. 1tab qd
for 1wk. 1tab QOD for 1wk. 1tab q3days for 2weeks. .
Disp:*57 Capsule(s)* Refills:*0*
2. spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
7. tramadol 50 mg Tablet Sig: 0.25 Tablet PO every six (6) hours
as needed for pain: may take additional 12.5mg qhs.
8. trazodone 50 mg Tablet Sig: 0.25 Tablet PO at bedtime as
needed for insomnia.
9. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day.
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
11. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO once a day.
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. miconazole nitrate 2 % Powder Sig: One (1) application
Topical twice a day as needed for rash.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Clostridium dificile infection
2. Hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 69742**],
You came to the hospital with fevers, low blood pressure, and
diarrhea. An infection called Clostridium difficile colitis
caused these symptoms, and was caused by antibiotic treatment of
your lung infection. You were treated with several oral and IV
antibiotics, and will continue to take oral vancomycin over the
next 6 weeks according to a specific schedule that is attached.
It is highly likely that this infection will recur if this
regimen is not completed. If you require antibiotics for other
problems in the future, please mention your multiple C.
difficile infections to the prescribing providers.
The following changes have been made to your medications:
1. START VANCOMYCIN 125mg tablets as follows over the next 6
weeks:
- one tablet every six hours for one week
- one tablet every twelve hours for one week
- one tablet every day for one week
- one tablet every other day for one week
- one tablet every three days for two weeks
Please continue all other meds as previously prescribed.
It was a pleasure taking care of you, Ms. [**Known lastname 69742**]
Followup Instructions:
You have the following appointments available:
Department: [**Hospital3 249**]
When: THURSDAY [**2128-3-4**] at 12:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2128-4-9**] at 11:30 AM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: TUESDAY [**2128-6-8**] at 2:20 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
|
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"286.9",
"571.5",
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"008.45",
"263.9",
"284.1",
"569.69",
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"530.81",
"300.4",
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icd9cm
|
[
[
[]
]
] |
[
"38.97"
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icd9pcs
|
[
[
[]
]
] |
12195, 12252
|
7075, 8730
|
278, 316
|
12355, 12355
|
4413, 4413
|
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|
3197, 3287
|
10850, 12172
|
12273, 12334
|
8877, 10827
|
12506, 13619
|
5199, 7052
|
3302, 4023
|
4039, 4394
|
8744, 8749
|
2057, 2084
|
229, 240
|
8775, 8851
|
344, 2038
|
4429, 5183
|
12370, 12482
|
2106, 2841
|
2857, 3181
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,013
| 119,077
|
46291+58892
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-12-17**] Discharge Date: [**2124-1-3**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
male with coronary artery disease, status post left anterior
descending stent in [**2119**], peripheral vascular disease, status
post aortobifemoral bypass and status post femoral-femoral
bypass in [**2123-11-5**] who post procedure had loose
bloody diarrhea. A sigmoidoscopy was performed in [**2123-11-5**] which was consistent with ischemic colitis. Patient
was discharged to a rehabilitation facility and returned on
[**2123-12-17**] with persistent diarrhea, with creatinine
elevation to 1.2 (baseline creatinine 0.7), and dehydration.
Patient initially was admitted to the Surgical Service and
was treated for his diarrhea, which was presumed to be
ischemic colitis with loperamide, and the patient was also
placed on prophylactic antibiotics with levofloxacin and
Flagyl. The patient was given intravenous fluids for his
dehydration and presumed prerenal condition. However, the
patient became fluid overloaded on [**2123-12-20**] and was
noted to have rales on exam. The patient was then diuresed
with Lasix and hydrochlorothiazide but continued to remain in
congestive heart failure. Of note, the patient also has a
history of atrial fibrillation and received Coumadin during
his hospital stay with an elevated INR at 5.0. The patient
was intermittently reversed with Vitamin K and the warfarin
was discontinued transiently in order to allow his INR to
drift back to therapeutic state.
The patient's diarrhea has improved with loperamide, and
clostridium difficile toxin is negative. The patient was
transferred to the Medical Service on [**2123-12-27**] for
further management of his congestive heart failure.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post left anterior
descending stent in [**2119**].
2. Hypertension.
3. Left renal artery stenosis, 100% stenosis.
4. Nephrolithiasis.
5. Hyperlipidemia.
6. Status post aortobifemoral bypass in [**2123-11-5**].
7. Status post femoral-femoral bypass in [**2123-11-5**]
for thrombosis of the right femoral artery.
8. Ischemic colitis.
9. Congestive heart failure, diastolic dysfunction.
MEDICATIONS UPON TRANSFER:
1. Digoxin 0.125 mg po q.d.
2. Calcium carbonate 500 mg po b.i.d.
3. Lopressor 50 mg po b.i.d.
4. Aspirin 81 mg po q.d.
5. Captopril 6.25 mg po t.i.d.
6. Imdur 30 mg po q.d.
7. Protonix 40 mg po q.d.
8. Levofloxacin 500 mg po q.d.
9. Flagyl 500 mg po t.i.d.
10. Albuterol, Atrovent nebulizers prn.
11. Imodium 2 mg po t.i.d. prn diarrhea.
12. Multivitamin 1 tablet po q.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: In general, the patient looks younger
than his stated age in no acute distress. Temperature 98.5.
Blood pressure 134/64. Heart rate 90. Respiratory rate 18.
Oxygen saturation 93% on two liters. I's and O's 1308 in,
845 out. Head, eyes, ears, nose and throat: Pupils equal,
round and reactive to light. Oropharynx clear. Mucous
membranes slightly dry. Neck: No jugular venous distention.
Lungs: Bibasilar crackles. Cardiovascular: Regular rate
and rhythm, normal S1, S2, 2/6 systolic ejection murmur at
the right upper sternal border. Abdomen: Soft, nontender,
nondistended with positive bowel sounds. Extremities:
Bilateral 2+ pitting edema to the shins. Extremities in
>.....<boots.
LABORATORIES: PT 16.5, INR 1.8, sodium 134, potassium 4.4,
chloride 96, bicarbonate 32, BUN 18, creatinine 0.7, glucose
218. Calcium 7.3, magnesium 1.6, phosphorus 2.8.
HOSPITAL COURSE:
1. Cardiovascular: Congestive heart failure: The patient
was thought to be in mild failure secondary to diastolic
dysfunction. Patient had an echocardiogram performed
recently at Newborn [**Hospital **] Hospital which revealed an
ejection fraction of approximately 50-55% with no significant
wall motion abnormality. A chest x-ray was obtained which
showed congestive heart failure with bilateral pleural
effusions and atelectasis. A repeat chest x-ray obtained
upon further diuresis revealed a right upper lobe airspace
opacity which was thought to be either secondary to
asymmetric pulmonary edema or questionable pneumonia,
however, the patient did not have any signs or symptoms of
pneumonia to suggest that the patient had an infection.
Patient was diuresed with Lasix 20 mg b.i.d. and responded
well. Patient also was continued on an ACE inhibitor during
his hospital stay, as well as Lopressor. In terms of the
patient's coronary artery disease, the patient was continued
on his cardiac regimen of aspirin, Lopressor, ACE inhibitor,
and Imdur. The patient also has a history of atrial
fibrillation and was continued on his digoxin. Warfarin was
again re-administered and INR levels were followed closely
since the Levaquin elevated the INR level. Patient required
2 mg of warfarin on Monday, Friday and Saturday. This
regimen will be continued upon discharge from the hospital.
2. Gastrointestinal: Patient with ischemic colitis causing
diarrhea which was improved on a regimen of Imodium q. 2
hours prn diarrhea, as well as started on levofloxacin and
Flagyl for prophylaxis per the Surgical Team. The patient's
diarrhea stabilized to approximately two to four bowel
movements a day. These movements are grossly nonbloody and
the patient denies any abdominal pain or discomfort. The
patient should continue the levofloxacin and the Flagyl
antibiotic prophylaxis until he follows up with Surgery as an
outpatient.
3. Pulmonary: The patient's oxygenation status remained
stable on 3.5 liters with an oxygen saturation of
approximately 92-95%. It is thought that the patient's
oxygen requirement is likely secondary to a combination of
congestive heart failure, as well as atelectasis. As noted
above, a chest x-ray was obtained which revealed an opacity
in the right upper lobe which was either secondary to
asymmetric pulmonary edema or anomic infiltrate. However,
since the patient did not clinically seem to have any signs
of pneumonia, no antibiotics were started. In addition, the
patient remained afebrile and had no sputum production or
cough. The patient was encouraged to do incentive spirometer
and continued diuresis should help with his oxygenation.
4. Renal: The patient's renal function remained stable with
initiation of diuresis.
5. Endocrine: The patient was noted to have elevated blood
sugars during his hospital stay ranging from 150 to 250. The
patient was started on q.i.d. fingersticks and a regular
insulin sliding scale. It is possible that the patient
likely has new onset of diabetes mellitus. This should be
followed up as an outpatient.
6. Psychiatry: The patient's family requested that the
patient have a Psychiatry Consult given his lack of
motivation and depressed mood. Psychiatry was consulted and
felt that the patient had an adjustment disorder and
instituted a behavior plan which consisted of the patient's
sitting up in bed for breakfast and lunch, patient lying in
bed between breakfast and lunch and from lunch to 3 p.m. The
patient also should participate in Physical Therapy at a
predetermined appointment to be set by the physical
therapist. In addition, psychiatry recommended for his
depressed mood, that patient be started on Remeron 7.5 mg po
q.h.s., as well as Ritalin 5 mg po b.i.d. to help stimulate
his energy. The patient seemed to be tolerating both of
these medications well.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Congestive heart failure, diastolic dysfunction.
2. Coronary artery disease.
3. Atrial fibrillation.
4. Ischemic colitis.
5. Renal artery stenosis.
6. New onset diabetes mellitus.
7. Depressed mood, adjustment disorder.
8. Peripheral vascular disease.
9. Hypertension.
10. Hyperlipidemia.
DISCHARGE MEDICATIONS:
1. Digoxin 0.125 mg po q.d.
2. Protonix 40 mg po q.d.
3. Levofloxacin 500 mg po q.d.
4. Flagyl 500 mg po t.i.d.
5. Multivitamin 1 tablet po q.d.
6. Aspirin 81 mg po q.d.
7. Lasix 20 mg po b.i.d.
8. Regular insulin sliding scale.
9. Lopressor 50 mg po b.i.d.
10. Captopril 6.25 mg po t.i.d.
11. Imdur 30 mg po q.d.
12. Loperamide 4 mg po q. 2 hours for loose stools.
13. Calcium carbonate 500 mg po t.i.d.
14. Ritalin 5 mg po b.i.d. at 8 a.m. and 12 p.m.
15. Coumadin 2 mg q. Monday, Friday, Saturday.
16. Remeron 7.5 mg po q.h.s.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2124-1-1**] 15:11
T: [**2123-12-31**] 15:51
JOB#: [**Job Number 98442**]
Name: [**Known lastname 8870**], [**Known firstname 448**] Unit No: [**Numeric Identifier 15703**]
Admission Date: [**2123-12-17**] Discharge Date: [**2124-1-10**]
Date of Birth: [**2043-2-14**] Sex: M
Service: Medicine
HOSPITAL COURSE:
1. Cardiovascular: The patient became persistently
hypotensive with systolic blood pressure in the 70s-80s,
which initially was not responsive to intravenous fluids.
The patient was noted on electrocardiogram to have new
lateral T-wave inversions thought to be secondary to demand
ischemia. Cardiac enzymes were cycled and the patient ruled
out for a myocardial infarction.
The patient was transferred to the Medical Intensive Care
Unit on [**2124-1-4**] for further monitoring. It was
thought that the patient's hypertension was secondary to
overdiuresis with Lasix and aggressive beta blockade. The
patient's captopril and Imdur were discontinued. Patient was
fluid resuscitated with 3 liters of normal saline and
transfused 1 unit of packed red blood cells with
normalization of the systolic blood pressure to 100-120s.
On [**2124-1-6**], the patient was transferred out of the
Intensive Care Unit. Low dosed Lopressor, 12.5 mg po bid,
was restarted as well as Lasix 20 mg po q day for gentle
diuresis. In addition, the patient was continued on Coumadin
2 mg po q Tuesday and Friday (twice a week) to maintain an
INR between [**2-7**] for atrial fibrillation.
2. Psychiatry: The patient became lethargic on Remeron and
delirious on Ritalin, experiencing auditory hallucinations.
As a result, both of these medications were discontinued.
DISCHARGE MEDICATIONS:
1. Digoxin 0.125 mg po q day.
2. Protonix 40 mg po q day.
3. Flagyl 500 mg po tid.
4. Multivitamin one capsule po q day.
5. Enteric coated aspirin 81 mg po q day.
6. Regular insulin-sliding scale.
7. Loperamide 4 mg po q2h prn loose stools with a maximum
dose of 60 mg/day.
8. Levofloxacin 500 mg po q day.
9. Lopressor 12.5 mg po bid.
10. Lasix 20 mg po q day.
11. Coumadin 2 mg q Tuesday and Friday with a goal INR of
[**2-7**].
The patient's discharge date has been changed from [**2124-1-3**] to [**2124-1-10**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 285**]
Dictated By:[**Last Name (NamePattern1) 1667**]
MEDQUIST36
D: [**2124-1-9**] 13:43
T: [**2124-1-11**] 04:14
JOB#: [**Job Number 15704**]
|
[
"427.31",
"V45.82",
"440.1",
"428.0",
"272.4",
"557.9",
"401.9",
"276.5",
"309.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7501, 7549
|
7570, 7872
|
10331, 11087
|
8956, 10308
|
2705, 3579
|
123, 1783
|
1805, 2682
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,641
| 170,626
|
20383+57154
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-11-3**] Discharge Date: [**2182-11-19**]
Date of Birth: [**2106-6-3**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Quinidine/Quinine & Derivatives
Attending:[**First Name3 (LF) 1190**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Pacemaker placement
AV ablation
History of Present Illness:
CC: Shortness of breath
HPI: 75 year old male with history of COPD, CHF, PAF, CRI
presenting with dyspnea and hypoxia. Pt is a nursing home
resident on home O2 and started coughing 1-2 days ago. No
associated fever or pain. The nursing home noted him to have O2
sats in the 80's earlier today which was unresponsive to nebs
and non-rebreather. In the ED, RR noted to be in 30's-40's,
given albuterol, solumedrol and lasix 20 iv x 1 to which he
responded well. CXR with pulm effusion, likely volume overload.
ROS: Pt denies fever, chest pain, abd pain, nausea, vomiting,
leg pain. Patient states breathing is currently back to
baseline (after treatment in ED).
Past Medical History:
1. Chronic obstructive pulmonary disease.
2. Congestive heart failure.
3. Paroxysmal atrial fibrillation
4. Tachy brady syndrome
5. Arthritis.
6. Tibial fracture status post replacement.
7. Baseline asymptomatic bradycardia of unknown etiology.
8. Right carotid artery stenosis
9. TIA/CVA L sided weakness that resolved<24hr. [**2181-4-9**]
10. Chronic renal insufficiency
.
Meds:
risperdal 0.25 prn
coumadin (on hold, was 2mg po qday)
protonix 40
lisinopril 2.5
Dilt SR 180 qday
Celebrex
ASA 325
Vit E 400
Albuterol/Atrovent
Mag oxide 400
Ca + Vit D
Actonel 35 qweek
aricept 5 qday
Namenda 10 qday
Social History:
Pt lives at [**Location (un) **] nusing facility, pt used to smoke 2
packs/day since age 12 and quit few years ago, denies currently
EtOH use but hx of EtOH abuse, denies drug use.
Family History:
NC
Physical Exam:
97.0 HR 102 bp 127/71 RR 28 99%
Gen: Awake and alert, pleasant, tachypneic, but not in distress
HEENT: PERRL, OP clear, MMM
Neck: JVP to angle of jaw, supple
CV: S1, S2, RRR
Pulm: Bibasilar crackles, limited air flow b/l
Abd: Normoactive BS, soft, ND/NT, no rebound or guarding
Ext: cool, chronic-appearing ecchymotic discoloration of distal
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l, 1+DP b/l, no edema b/l
.
EKG: HR 114, sinus tachycardia, Left axis, wavy baselin, ?TWIs
in V4-5.
Pertinent Results:
Lab on Admission
[**2182-11-3**] 04:00PM WBC-11.3* RBC-4.58*# HGB-13.8*# HCT-42.2#
MCV-92 MCH-30.2 MCHC-32.8 RDW-13.5
[**2182-11-3**] 04:00PM NEUTS-78.0* LYMPHS-14.0* MONOS-5.0 EOS-2.0
BASOS-1.0
[**2182-11-3**] 04:00PM GLUCOSE-117* UREA N-33* CREAT-1.9* SODIUM-145
POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-27 ANION GAP-16
[**2182-11-3**] 05:17PM LACTATE-1.1
.
[**2182-11-3**] 05:17PM TYPE-ART TEMP-36.1 RATES-/26 O2-21 PO2-90
PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0 INTUBATED-NOT INTUBA
.
[**2182-11-3**] 04:00PM CK(CPK)-41 CK-MB-NotDone cTropnT-0.05*
*
Labs on Discharge
[**2182-11-18**] 08:10AM BLOOD Glucose-88 UreaN-52* Creat-1.6* Na-143
K-4.8 Cl-107 HCO3-26 AnGap-15
[**2182-11-19**] 09:05AM BLOOD WBC-16.7* RBC-4.03* Hgb-12.0* Hct-36.9*
MCV-92 MCH-29.8 MCHC-32.5 RDW-14.6 Plt Ct-187
*
PERSANTINE MIBI
IMPRESSION: 1. Normal myocardial perfusion study. 2. Severe
global hypokinesis with EF of 25%.
*
EXERCISE RESULTS
IMPRESSION: No anginal type symptoms or interpretable EKG
changes with
high grade AEA. Nuclear report sent separately.
SIGNED: [**Last Name (LF) **],[**First Name3 (LF) **]
Brief Hospital Course:
75 year old male with history of COPD, CHF, PAF, CRI presenting
with dyspnea and hypoxia likely combination COPD exacerbation
and CHF exacerbation.
.
1. SOB: Likely combination CHF and COPD. For COPD, the
patient received Albuterol and Atrovent Nebs q6hrs, and prn
Albuterol Nebs. The patient was also started on Prednisone and
Azithromycin. As the patient's respiratory status improved rhe
steroids were tapered. For his CHF the patient was diuresed with
Lasix. Electrolytes were monitored and repleted as needed.
.
The patient's course was complicated on [**2182-11-3**] when nursing
observed that the patient was having more labored breathing
despite multiple nebulizer treatment. A CXR showed increasing
small bilateral pleural effusions and collapse of the left lower
lobe. With more diuresis and aggressive chest PT, the patient's
respiratory status stabalized.
.
2. PAF/Arrhythmias: The patient's Coumadin was held throughout
most of his hospital course because of supratherapeutic INRs.
The patient was restarted on Coumadin after the cardiac
interventions.
.
3. AF/RVR: The patient hospital course was also complicated by
periods of tacchycardia to the 140s and bradycardia to the 40s.
Despite attempts to control the patient's heart rate with
Diltiazem and Lopressor, his heart was often 100's - 120's. On
[**11-7**] the patient's heart rate fell to the 20s, SBP in the 60s.
The patient was aymptomatic. Atropine and NS bolus was given
with no improvement in heart rate or blood pressure. The
patient was transferred to the CCU. In the CCU the patient's
blood pressure recovered to the 110s/60s with HR 50s-60s and
continued to be asymptomatic. The patient was medically managed
with Diltiazem and transferred to the floor. Despite this
conservative manangement the decision was made for the patient
to have a pace maker placed and an AV ablation. Following these
interventions, the patient's heart rate was maintained at 80.
.
3. Ischemia: On admission the patient had some ischemic changes
on his EKG. A stress test was done which showed no anginal type
symptoms or interpretable EKG changes with high grade AEA. In
the setting of having ischemia the decision was made to
discharge the patient on Toprol XL 50.
.
4. Dementia: The patient was continued on Namenda and Aricept
without any complications.
Medications on Admission:
risperdal 0.25 prn
coumadin (on hold)
protonix 40
lisinopril 2.5
Dilt SR 80
Celebrex
ASA 325
Vit E 400
Albuterol/Atrovent
Mag oxide 400
Ca + Vit D
Actonel 35/100
aricept
Namenda
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qday ().
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for Wheezing.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
11. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
15. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO QOD ().
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
18. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day: Please
hold for SBP<100, HR<60.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
19. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 16166**] Facility - [**Location (un) 538**]
Discharge Diagnosis:
COPD, CHF, CAD, Tacchybrady syndrome s/p pacemaker and AV
ablation
Discharge Condition:
Good
Discharge Instructions:
You are to seek medical services immediately if you should
experience chest pain, shortness of breath or any other
worrisome symptom.
Followup Instructions:
You are to followup with your PCP, [**Name10 (NameIs) **] [**Last Name (STitle) **], within 1-2 weeks
of discharge.
Completed by:[**2182-11-19**] Name: [**Known lastname 10196**],[**Known firstname 10197**] Unit No: [**Numeric Identifier 10198**]
Admission Date: [**2182-11-3**] Discharge Date: [**2182-11-19**]
Date of Birth: [**2106-6-3**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Quinidine/Quinine & Derivatives
Attending:[**First Name3 (LF) 107**]
Addendum:
The patient had been on steroids for his COPD exacerbation. At
the time of discharge the patient had been weaned off of
steroids. However the patient had an elevated WBC which had
been trending downward at the time of discharge. UA's were
negative and the patient was afebrile throughout his course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 10217**] Facility - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 108**] MD [**MD Number(1) 109**]
Completed by:[**2182-11-19**]
|
[
"331.0",
"428.0",
"585.9",
"427.81",
"427.31",
"491.21",
"403.91",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.83",
"37.72",
"37.34",
"38.93",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
9077, 9316
|
3570, 5906
|
325, 359
|
8034, 8040
|
2436, 3547
|
8222, 9054
|
1893, 1897
|
6134, 7818
|
7945, 8013
|
5932, 6111
|
8064, 8199
|
1912, 2417
|
266, 287
|
387, 1055
|
1077, 1678
|
1694, 1877
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 196,290
|
43274
|
Discharge summary
|
report
|
Admission Date: [**2182-12-29**] Discharge Date: [**2183-1-11**]
Date of Birth: [**2148-4-23**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 34-year-old male with
history of type 1 diabetes complicated by autonomic neuropathy
,
gastroparesis, and chronic renal insufficiency with coronary
artery disease and malignant hypertension that has led to
multiple admissions to [**Hospital1 69**] fo
r
nausea, vomiting, abdominal pain, and hypertensive urgency, wh
o
was last discharged from the hospital three days prior, and wh
o
presents again with abdominal pain for two hours duration with
associated nausea and vomiting for the past hour up to five
episodes. There was no blood in the vomitus. His blood press
[**Last Name (un) **]
was 240/130 by EMS.
In the Emergency Department, he received labetalol,
hydralazine, Morphine, and Ativan to control his symptoms.
He denies fevers, chills, diarrhea, chest pain, changes in
vision, dizziness. Further review of systems was
noncontributory. Patient states that this is his usual
presentation of his symptoms associated with high blood
pressure.
PAST MEDICAL HISTORY:
1. Type 1 diabetes diagnosed 13 years ago and complicated by
autonomic neuropathy, gastroparesis.
2. Malignant hypertension with poor control of his blood
pressure which is quite labile and has led to multiple
admissions to [**Hospital1 69**] for
abdominal pain, nausea, and vomiting. An extensive workup to
date has revealed no cause.
3. Coronary artery disease.
4. Chronic renal insufficiency with a baseline creatinine of
1.7-1.9.
5. History of [**Doctor First Name **]-[**Doctor Last Name **] tears.
6. Depression.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Nifedipine CR 60 mg p.o. q.d.
3. Clonidine patch.
4. Famotidine 20 mg p.o. b.i.d.
5. Erythromycin 250 mg p.o. q.i.d.
6. Metoclopramide 10 mg p.o. q.i.d.
7. Lopressor 150 mg p.o. b.i.d.
8. Lisinopril 10 mg p.o. q.d.
9. Glargine 5 units subQ q.h.s.
10. Ativan 2 mg p.o. q.6h.
11. Morphine 50 mg p.o. q.6h. prn.
SOCIAL HISTORY: Lives in [**Location 686**]. Denies alcohol,
tobacco, or intravenous drug use.
FAMILY HISTORY: His father has diabetes.
PHYSICAL EXAMINATION: Well-nourished African American male
in no acute distress. Vital signs: Temperature 99.4, blood
pressure 130/80, heart rate 84, respiratory rate 22, and
pulse oximetry 96% on room air. HEENT: Extraocular muscles
are intact. Pupils are equal, round, and reactive to light.
Anicteric sclerae. Oropharynx is clear, dry mucosal
membranes. Neck: No lymphadenopathy, no JVD, supple. Heart
regular, rate, and rhythm, normal S1, S2, no murmurs, rubs,
or gallops. Lungs are clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended, no masses.
Extremities: No clubbing, cyanosis, or edema. Neurologic:
cranial nerves II through XII are grossly intact.
LABORATORY DATA ON ADMISSION: White count 9.3.
Differential: 84.2% neutrophils, 10.2% lymphocytes, 3.9%
monocytes. Hematocrit 33.9, platelet count 236.
Electrolytes: Sodium 137, potassium 4.4, chloride 103,
bicarbonate 27, BUN 33, creatinine 1.6, glucose 274.
HOSPITAL COURSE:
1. Cardiovascular: Patient presented with prior poor control
of his hypertension. He was restarted on all of his regular
antihypertensive medications including Lopressor, nifedipine,
lisinopril, and clonidine, and for poor control of his blood
pressure, hydralazine and labetalol prn were added.
As further history was gathered during his hospital stay
indicated that the patient's symptoms may have been preceded
by micturition. The possibility of an intracystic
pheochromocytoma was considered despite the fact that the
patient has had negative urine metanephrines in the past. To
evaluate this possibility further, a MIBG scan was scheduled
for the following week. In preparation for this MIBG scan,
the patient was weaned off his alpha and calcium-channel
blockers as this was necessary for an accurate [**Location (un) 1131**].
During this time, his blood pressure remained quite labile.
The first labetalol and hydralazine were used for control,
but after further episodes of poorly controlled hypertension,
nitroglycerin IV drip was used as needed. Patient was
transferred to the [**Hospital Ward Name 517**] in preparation for this MIBG
scan. As his blood pressure continued to be quite labile, it
was clear that closer monitoring and better control of his
blood pressure was indicated, therefore the patient was
transferred to the MICU on [**1-7**], where a Nipride
drip was started. Patient was weaned off all of his
calcium-channel blockers, alpha blockers, and beta blockers
in preparation for the MIBG scan, which occurred on [**1-8**] and [**1-10**].
Patient was transferred back to Medicine floor on [**1-10**] and on [**1-11**], his blood pressure was well
controlled on his regular oral antihypertensive regimen. The
results of the MIBG scan were pending at the time of
discharge.
2. Endocrine: Patient has a history of type 1 diabetes. He
was continued on his regular glargine dose with regular
insulin-sliding scale to cover for elevated blood sugars,
fingersticks continued q.i.d.
3. Gastroparesis: When the patient was taking p.o. diet, he
was continued on his regular regimen per treatment of his
gastroparesis including erythromycin, Reglan, and famotidine,
antiemetics including Zofran were also used to control
intermittent nausea.
4. Fluids, electrolytes, and nutrition: Patient was advanced
slowly to his regular diet on admission after having a
history of nausea and vomiting. As his symptoms were thought
to sometimes follow eating he was made NPO to evaluate this
possible connection. During this time the patient received
PPN and then TPN and then nutrition consultation on [**1-3**]. He resumed his regular diabetic diet. IV fluids were
often administered during his hospital stay to address
increase in creatinine.
5. Renal: Patient has a baseline creatinine of 1.7 to 1.9.
During his hospital stay, his creatinine rose up to 2.6. IV
fluids were administered to address this renal failure.
Prerenal etiology was initially suspected but was not
supported by FENa calculation as creatinine elevation was
thought to be due to hypertensive and diabetic nephropathy.
At the time of discharge, his creatinine had trended towards
baseline.
6. Intravenous access: Patient had a Port-A-Cath and a right
IJ line placed during his hospital stay.
DISCHARGE CONDITION: Hemodynamically stable, afebrile with
blood pressure well controlled on p.o. medications. Patient
is asymptomatic.
DISCHARGE STATUS: Patient is being discharged to home. He
will be visiting his father, who is hospitalized at a local
hospital.
DISCHARGE DIAGNOSES:
1. Malignant hypertension.
2. Gastroparesis.
3. Type 1 diabetes.
4. Renal failure.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Azithromycin 250 mg p.o. q.i.d.
3. Lisinopril 10 mg p.o. q.d.
4. Metoclopramide 10 mg p.o. q.i.d.
5. Hydralazine 25 mg p.o. q.4h.
6. Metoprolol tartrate 100 mg 1.5 tablets p.o. b.i.d.
7. Clonidine 0.1 mg/24 hour patch one patch q.d.
8. Nifedipine 60 mg one tablet p.o. q.d.
9. Famotidine 20 mg p.o. q.d.
10. Lorazepam 1 mg 1-2 tablets p.o. q.6h. prn nausea.
11. Morphine sulfate 15 mg one tablet p.o. q.6h. prn pain.
12. Glargine 8 units subcutaneous q.d.
13. Humulin insulin-sliding scale as previously prescribed.
DISCHARGE INSTRUCTIONS: Please take all medications as
prescribed. Please continue to check your blood pressure at
least two times per day. If systolic blood pressures greater
than 150, please contact your primary care physician. [**Name10 (NameIs) **]
systolic blood pressures greater than 170, please report to
the Emergency Department for blood pressure control. Please
return to the Emergency Department if you have nausea,
vomiting, abdominal pain, headache, or other worrisome
symptoms.
RECOMMENDED FOLLOWUP: Please contact your primary care
physician for an appointment on [**1-13**] or [**1-14**]
to monitor your blood pressure and manage your medications.
Please keep the following appointment with Dr. [**First Name (STitle) **] in the
[**Hospital Ward Name 23**] Center Neurology [**2183-1-30**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 10451**]
Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36
D: [**2183-1-28**] 10:28
T: [**2183-1-31**] 08:48
JOB#: [**Job Number 93219**]
|
[
"414.01",
"593.9",
"337.1",
"584.9",
"536.3",
"250.61",
"401.0",
"530.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6505, 6753
|
2181, 2207
|
6774, 6858
|
6881, 7428
|
3186, 6483
|
7453, 8515
|
2230, 2920
|
167, 1132
|
2935, 3169
|
1154, 2066
|
2083, 2164
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,120
| 124,225
|
54135
|
Discharge summary
|
report
|
Admission Date: [**2161-11-27**] Discharge Date: [**2161-12-2**]
Date of Birth: [**2087-11-24**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Slurred Speech, Code stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 6164**] is a 74 yo man with little past medical history who
presents following sudden onset of slurred speech. His wife
states they were at dinner this evening around 8pm when she
noticed his speech became slurred and his left mouth drooping.
EMS was called and he was immediately brought to [**Hospital1 18**] where a
code stroke was called. Vitals on arrival where BP 237/117 with
a heart rate of 107.
Initally, the patient was able to state his name and age, the
month. He was following commands. NIH stroke scale was 7 for
facial paralysis (2), left arm weakness (4), left leg weakness
(1). He reported a [**5-9**] headache in his right head. He stated
his vision was blurry. He denies chest pain or shortness of
breath. Per his wife, he had been felling well but had what he
thought was a sinus infection this week. No other symptoms of
illnesses.
While conducting this inital exam, the patient's mental status
rapidly declined. His head deviated to the right and he denied
being able to feel his left side. He then became somnolent but
arousable to sternal rub. NSurg was called and the decision was
made to intubate.
Past Medical History:
per wife mild hypertension, untreated.
Per OMR, significant hypertension, untreated
No surgeries
Social History:
Married. Works as a farmer. Denies Smoking, + moderate alcohol
(daily), no drugs.
Family History:
Parents with hypertension
Physical Exam:
BP 237/117, HR 107 99% RA
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, normal s1/s2. No murmurs,
rubs,
or gallops appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: no rashes noted.
Neurologic (initial):
-Mental Status: Alert, oriented x 3. Language is fluent with
intact repetition and comprehension. diminished prosody. Pt.
was
able to name both high and low frequency objects. Able to read
without difficulty. Speech was dysarthric. There was no
evidence
of neglect.
-Cranial Nerves (initial):
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. Visual fields full on bedside to
finger counting in all quadrants.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: left lower facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor (INITIAL): Full in right arm, leg. No visible movement of
left arm. Full right leg. Left leg 5 seconds antigravity with
drift.
-Sensory (Initial): No deficits to pinprick or light touch
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 0 0 0 2 1
R 1 1 1 2 1
-Coordination: deferred
-Gait: deferred
Pertinent Results:
[**2161-11-27**] 08:49PM BLOOD WBC-6.8 RBC-5.18 Hgb-15.8 Hct-45.0 MCV-87
MCH-30.6 MCHC-35.2* RDW-13.6 Plt Ct-209
[**2161-11-28**] 02:53AM BLOOD WBC-8.3 RBC-4.42* Hgb-13.4* Hct-38.6*
MCV-87 MCH-30.3 MCHC-34.6 RDW-13.6 Plt Ct-182
[**2161-11-29**] 02:32AM BLOOD WBC-8.6 RBC-4.23* Hgb-12.9* Hct-37.3*
MCV-88 MCH-30.6 MCHC-34.6 RDW-13.8 Plt Ct-166
[**2161-11-30**] 03:20AM BLOOD WBC-10.2 RBC-4.00* Hgb-12.3* Hct-36.4*
MCV-91 MCH-30.8 MCHC-33.8 RDW-13.7 Plt Ct-173
[**2161-12-1**] 01:00AM BLOOD WBC-9.4 RBC-3.97* Hgb-12.6* Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.3* RDW-13.8 Plt Ct-155
[**2161-12-2**] 02:58AM BLOOD WBC-10.4 RBC-4.15* Hgb-12.7* Hct-37.1*
MCV-89 MCH-30.6 MCHC-34.2 RDW-13.5 Plt Ct-160
[**2161-11-27**] 08:49PM BLOOD PT-11.6 PTT-24.3 INR(PT)-1.0
[**2161-11-28**] 02:53AM BLOOD PT-12.9 PTT-25.2 INR(PT)-1.1
[**2161-11-29**] 02:32AM BLOOD PT-13.3 PTT-26.4 INR(PT)-1.1
[**2161-11-30**] 03:20AM BLOOD PT-12.8 PTT-23.2 INR(PT)-1.1
[**2161-12-1**] 01:00AM BLOOD PT-12.7 PTT-23.8 INR(PT)-1.1
[**2161-12-2**] 02:58AM BLOOD PT-12.8 PTT-22.3 INR(PT)-1.1
[**2161-11-27**] 08:49PM BLOOD Fibrino-302
[**2161-11-28**] 02:53AM BLOOD Glucose-108* UreaN-19 Creat-0.8 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2161-11-28**] 08:28AM BLOOD Glucose-116* Na-145 K-4.0 Cl-114* HCO3-24
AnGap-11
[**2161-11-28**] 01:46PM BLOOD Glucose-116* Na-149* K-4.1 Cl-116*
HCO3-24 AnGap-13
[**2161-11-28**] 08:15PM BLOOD Glucose-138* Na-150* K-3.9 Cl-118*
HCO3-24 AnGap-12
[**2161-11-29**] 02:32AM BLOOD Glucose-136* UreaN-25* Creat-1.0 Na-150*
K-3.8 Cl-117* HCO3-24 AnGap-13
[**2161-11-29**] 08:15AM BLOOD Glucose-128* UreaN-28* Creat-0.9 Na-150*
K-3.7 Cl-117* HCO3-27 AnGap-10
[**2161-11-29**] 02:33PM BLOOD Glucose-175* Na-148* K-3.4 Cl-118*
HCO3-24 AnGap-9
[**2161-11-29**] 09:20PM BLOOD Glucose-162* UreaN-29* Creat-0.8 Na-148*
K-3.8 Cl-120* HCO3-24 AnGap-8
[**2161-11-30**] 03:20AM BLOOD Glucose-163* UreaN-33* Creat-0.8 Na-150*
K-3.8 Cl-118* HCO3-26 AnGap-10
[**2161-12-1**] 01:00AM BLOOD Glucose-158* UreaN-40* Creat-0.8 Na-152*
K-3.6 Cl-121* HCO3-23 AnGap-12
[**2161-12-1**] 05:13AM BLOOD Na-156* K-4.0 Cl-124*
[**2161-12-1**] 12:39PM BLOOD Na-156* K-3.8 Cl-123*
[**2161-12-1**] 06:33PM BLOOD Na-153* K-3.6 Cl-121*
[**2161-12-2**] 02:58AM BLOOD Glucose-175* UreaN-46* Creat-0.7 Na-155*
K-3.2* Cl-119* HCO3-28 AnGap-11
[**2161-11-28**] 02:53AM BLOOD ALT-86* AST-86* LD(LDH)-205 CK(CPK)-153
AlkPhos-39* TotBili-0.8
[**2161-11-27**] 08:49PM BLOOD Lipase-29
[**2161-11-28**] 02:53AM BLOOD CK-MB-4 cTropnT-LESS THAN
[**2161-11-27**] 08:49PM BLOOD cTropnT-<0.01
[**2161-11-28**] 02:53AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.2 Cholest-155
[**2161-11-29**] 02:32AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.3
[**2161-11-29**] 09:20PM BLOOD Calcium-8.2* Phos-1.4*# Mg-2.4
[**2161-11-30**] 03:20AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.4
[**2161-12-1**] 01:00AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.3
[**2161-12-2**] 02:58AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.4
[**2161-11-28**] 02:53AM BLOOD Triglyc-125 HDL-59 CHOL/HD-2.6 LDLcalc-71
[**2161-11-28**] 02:53AM BLOOD Osmolal-302
[**2161-11-28**] 08:28AM BLOOD Osmolal-306
[**2161-11-28**] 01:46PM BLOOD Osmolal-310
[**2161-11-28**] 08:15PM BLOOD Osmolal-316*
[**2161-11-29**] 02:32AM BLOOD Osmolal-317*
[**2161-11-29**] 08:15AM BLOOD Osmolal-314*
[**2161-11-29**] 02:33PM BLOOD Osmolal-320*
[**2161-11-29**] 09:20PM BLOOD Osmolal-320*
[**2161-11-30**] 03:20AM BLOOD Osmolal-323*
[**2161-12-1**] 01:00AM BLOOD Osmolal-328*
[**2161-12-1**] 05:13AM BLOOD Osmolal-330*
[**2161-12-1**] 12:39PM BLOOD Osmolal-334*
[**2161-12-1**] 06:33PM BLOOD Osmolal-331*
[**2161-12-2**] 02:58AM BLOOD Osmolal-333*
[**2161-11-28**] 08:35AM BLOOD Type-ART pO2-117* pCO2-47* pH-7.37
calTCO2-28 Base XS-1
[**2161-11-28**] 09:38AM BLOOD Type-ART pO2-127* pCO2-32* pH-7.49*
calTCO2-25 Base XS-2 Intubat-INTUBATED
[**2161-11-28**] 02:14PM BLOOD Type-ART pO2-141* pCO2-37 pH-7.43
calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2161-11-29**] 02:44AM BLOOD Type-ART pO2-121* pCO2-39 pH-7.43
calTCO2-27 Base XS-2
[**2161-11-30**] 03:24AM BLOOD Type-ART pO2-153* pCO2-26* pH-7.47*
calTCO2-19* Base XS--2
[**2161-12-1**] 03:22AM BLOOD Type-ART pH-7.48*
[**2161-11-27**] 08:48PM BLOOD Glucose-90 Lactate-1.3 Na-143 K-3.7
Cl-96* calHCO3-29
[**2161-11-28**] 08:35AM BLOOD Lactate-1.7
[**2161-11-28**] 09:38AM BLOOD Lactate-2.3*
[**2161-11-28**] 02:14PM BLOOD Lactate-2.1*
[**2161-12-1**] 03:22AM BLOOD freeCa-1.01*
CT SCAN #1: Study Date of [**2161-11-27**] 8:52 PM
1. Right thalamic intraparenchymal hemorrhage with extension
into
the right cerebral peduncle. Minimal to no mass effect. There is
no midline shift. There are no other areas of hemorrhage.
2. Chronic microvascular disease, but no evidence for acute
infarct. The study and the report were reviewed by the staff
radiologist.
CT SCAN #2 Study Date of [**2161-11-27**] 10:16 PM
Short-interval expansion of right thalamic hemorrhage extending
via the right cerebral peduncle further into the midbrain, now
causing significant mass effect and 5-mm leftward shift. No
current evidence of transtentorial or tonsillar herniation. New
extension of blood products into the lateral, third, and fourth
ventricles, with mild increased temporal [**Doctor Last Name 534**] trapping.
CXR:
1. Low-lying endotracheal tube, terminating approximately 1.8 cm
from the carina.
2. Nasogastric tube in standard position.
3. Patchy opacity within the right lung base, which is
concerning
for
aspiration or infection.
NCHCT [**2161-12-1**]:
FINDINGS: Large hematoma in the right thalamus and putamen
extending down to
the pons, lateral, third and fourth ventricles are similar in
size and
appearance from prior study ([**2161-11-29**]). Mildly decrease of
leftward shift of
normally midline structures from 6 mm on [**2161-11-29**], now measuring
4 mm (2:15).
The suprasellar and quadrigeminal cisterns remain patent. Mild
swelling with
mass effect in the right ambient cistern is similar from prior
study
([**2161-11-29**]). Stable trace blood layering along the left frontal
cortical sulci
(2:26), similar in appearance from [**2161-11-29**]. No new focus of
hemorrhage is
noted.
A left frontal approach ventriculostomy catheter terminates in
the third
ventricle, unchanged in position from prior study. Interval
resolution of
bifrontal pneumocephalus.
The paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Large hematoma involving the right thalamus, basal ganglia
and extending
into the lateral ventricles bilaterally into the midbrain and
pons down to the
level of the fourth ventricle, is unchanged in size from prior
study.
2. Slightly decreased leftward shift of normally midline
structures.
3. Stable appearance of small subarachnoid hemorrhage overlying
the left
frontal lobe.
Brief Hospital Course:
As detailed above, Mr. [**Known lastname 6164**] presented with a hemorrhagic
stroke (IPH/IVH) and initial NIHSS of 7, but then became
unresponsive and repeat CT imaging revealed exapansion of his
hemorrhage. He was intubated and admitted to the ICU, where he
required osmotic therapy (hypertonic saline) for elevated
increased intracranial pressure. His exam/level of consciousness
never improved significantly, and remained in a coma, in the ICU
with mechanical ventilation for several days. After several
discussions with the primary Neruology team, the ICU team, his
wife/HCP, and including his outpatient PCP, [**Name10 (NameIs) **] was determined
that he would not want further escalation of his care with
invasive life-sustaining treatments, based on his previously
stated values and preferences and his grim prognosis. No
neurosurgical procedures were conducted. He died on [**2161-12-2**].
Medications on Admission:
EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector -
as
directed as needed
HYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet(s) by mouth once
a day
PREDNISONE - 20 mg Tablet - 3 Tablet(s) by mouth per day x
2days,
2 per day x 2days, 1 per day x 2days
Discharge Medications:
died
Discharge Disposition:
Expired
Discharge Diagnosis:
died
Discharge Condition:
dead
Discharge Instructions:
died
Followup Instructions:
died
Completed by:[**2162-3-30**]
|
[
"348.5",
"431",
"784.51",
"344.42",
"293.0",
"V49.86",
"401.9",
"V12.72",
"600.00",
"728.87"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"02.39",
"96.6",
"38.93"
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icd9pcs
|
[
[
[]
]
] |
11456, 11465
|
10218, 11118
|
343, 349
|
11513, 11519
|
3493, 10195
|
11572, 11607
|
1775, 1802
|
11427, 11433
|
11486, 11492
|
11144, 11404
|
11543, 11549
|
1817, 2365
|
276, 305
|
377, 1538
|
2380, 3474
|
1560, 1658
|
1674, 1759
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,338
| 172,326
|
9333
|
Discharge summary
|
report
|
Admission Date: [**2155-3-15**] Discharge Date: [**2155-4-14**]
Date of Birth: [**2097-9-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
right internal jugular venous line placement
tracheostomy
DCCV
History of Present Illness:
57 yo male with CAD s/p CABG who was found unresponsive at home
and quickly intubated in the ED. He had hematemesis and was
found to have an HCT of 16, an INR of 3.3 (on coumadin) and ARF.
He was given 7 units of PRBCs, 4 bags of FFP, 2 of Factor IX
complex, and 4 liters of saline in the ED. He was also started
on dopamine for pressure/HR support. He had an EGD in the ED
that showed gastritis and several gastric ulcers with clots but
no active bleeding. His pan-CT scan show no head bleed or
edema, bibasilar pneumonia, and stranding around the pancreas
(blood vs edema from pancreatitis). According to friends and
his children, he had been having a lot of pain and had been
taking Advil regularly for the past 2 weeks.
Past Medical History:
CABG
CHF with BiV pacer and ICD placement
L hip arthritis
DM
Hyperlipidimia
Social History:
Denies tobacco. occ ETOH. No illcit substances.
Family History:
NC
Physical Exam:
Vitals: T= 99.4, HR = 87, BP = 124/64, RR =18, SaO2 = 100% on
NRB.
General: Intubated
HEENT: Normocephalic and atraumatic head, anicteric sclera,
supple neck, pupils 3 -> 2 B
Neck: no nuchal rigidity
Chest: Chest rose and fell with equal size, shape and symmetry,
lungs were clear to auscultation bilaterally.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs
or gallops. Faint heart sounds
Abd: Normoactive BS, NT and ND. No masses or organomegaly. Obese
Ext: [**12-1**]+ B pitting LE edema, chronic venos stasis changes.
Neuro:PERRL
Pertinent Results:
Admission labs:
[**2155-3-15**] 09:00PM BLOOD WBC-22.4* RBC-2.29* Hgb-4.7* Hct-16.0*
MCV-70* MCH-20.7* MCHC-29.6* RDW-18.7* Plt Ct-405
[**2155-3-16**] 12:52AM BLOOD Neuts-84.8* Bands-0 Lymphs-13.4*
Monos-1.2* Eos-0.5 Baso-0.2
[**2155-3-15**] 09:00PM BLOOD PT-22.8* PTT-27.8 INR(PT)-3.3
[**2155-3-15**] 09:00PM BLOOD Glucose-159* UreaN-62* Creat-5.3* Na-135
K-5.2* Cl-98 HCO3-14* AnGap-28*
[**2155-3-15**] 09:00PM BLOOD ALT-81* AST-95* LD(LDH)-274* CK(CPK)-226*
AlkPhos-79 Amylase-87 TotBili-0.3
[**2155-3-15**] 09:00PM BLOOD Albumin-3.7 Calcium-8.6 Phos-7.9* Mg-2.3
[**2155-3-19**] 04:00AM BLOOD T4-3.6* Free T4-0.7*
[**2155-4-4**] 05:14AM BLOOD T4-5.3 T3-60* Free T4-0.8*
[**2155-3-16**] 04:38AM BLOOD Cortsol-17.8
[**2155-3-15**] 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-3-15**] 09:23PM BLOOD Type-ART pO2-34* pCO2-49* pH-7.20*
calHCO3-20* Base XS--8
[**2155-3-15**] 08:59PM BLOOD Glucose-145* Lactate-6.3* Na-136 K-5.3
Cl-100 calHCO3-18*
.
DISCHARGE LABS:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2155-4-14**] 03:45AM 13.0* 3.69* 9.8* 30.2* 82 26.5* 32.3
21.3* 487*
BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct
[**2155-4-14**] 03:45AM 487*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2155-4-14**] 03:45AM 181* 20 0.9 136 4.1 94* 28 18
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2155-4-14**] 03:45AM 1.9
.
MICRO:
H.pylori negative
AEROBIC BOTTLE (Final [**2155-3-20**]):
REPORTED BY PHONE TO [**Name8 (MD) 31918**],RN CC7C [**Numeric Identifier 19457**] 11:44PM [**2155-3-18**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
ANAEROBIC BOTTLE (Final [**2155-3-23**]): NO GROWTH.
[**2155-3-17**] 12:29 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2155-3-21**]**
GRAM STAIN (Final [**2155-3-17**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2155-3-21**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
WORK UP PER DR.[**Last Name (STitle) **] PAGER ([**Numeric Identifier 31919**]) [**2155-3-19**].
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.
YEAST. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2155-4-2**] 2:01 pm BLOOD CULTURE
**FINAL REPORT [**2155-4-9**]**
AEROBIC BOTTLE (Final [**2155-4-6**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1052**] [**Last Name (NamePattern1) **] [**2155-4-4**] AT 12:40PM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
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.
Please contact the Microbiology Laboratory ([**5-/2456**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2155-4-9**]): NO GROWTH.
[**2155-4-7**] 6:28 pm PLEURAL FLUID
GRAM STAIN (Final [**2155-4-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2155-4-10**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
PLEURAL
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso
[**2155-4-7**] 06:28PM 90* 7450* 39* 29* 6* 1* 25*
PLEURAL CHEMISTRY TotProt Glucose LD(LDH)
[**2155-4-7**] 06:28PM 3.5 159 163
.
REPORTS:
CT SCAN:
IMPRESSION:
1) Peripancreatic stranding consistent with acute pancreatitis.
Gallstones are present within the gallbladder.
2) Bilateral lower lobe consolidations and mild intralobular
septal thickening. The findings could represent atelectasis, but
given the distribution and history, aspiration is likely.
2) Calcified left ventricular apical aneurysm.
HEAD CT:
NONCONTRAST HEAD CT: Study is limited somewhat by patient
motion. Allowing for limitations, there is no evidence of intra
or extraaxial hemorrhage, hydrocephalus or shift of normally
midline structures. Questionable subtle areas of decreased
attenuation are seen in the right frontal region. Motion limits
evaluation, and a small contusion in this area cannot be
excluded. Note is made of bilateral asymmetrical rounded
low-attenuation areas in the basal ganglia, which could
represent areas of lacunar infarction. No basilar skull
fractures are seen. The patient is intubated and there are fluid
levels in the sphenoid and maxillary sinuses, with opacification
of many of the ethmoid air cells and fluid in the frontal
sinuses as well. This is a nonspecific finding in the setting of
intubation. The mastoid air cells are aerated.
IMPRESSION: No evidence of intracranial hemorrhage or skull
fracture. Nonspecific air fluid levels and sinuses in the
setting of intubation
.
ECHO: EF= 25%
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity is severely dilated. There is severe global left
ventricular
hypokinesis with some preservation of basal wall motion. Overall
left
ventricular systolic function is severely depressed.
3. The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
4. The aortic valve leaflets are mildly thickened.
5. The mitral valve leaflets are mildly thickened. There is
moderate
thickening of the mitral valve chordae. Trivial mitral
regurgitation is seen
Brief Hospital Course:
# Resp failure: [**1-1**] hypovolemic shock and MRSA PNA - The patient
was initially intubated for airway protection due to hypovolemic
shock. Initially the patient was very difficult to oxygenated
and ventilate. His sputum then grew out MRSA and his CXR was
consistent with vent-associated PNA. He was initially started on
Vancomycin and then was switched to linezolid for better lung
penetration after he was not improving on vancomycin. He was
briefly extubated on Saturday [**3-30**] and then was re intubated the
next day due to fatigue. Therefore, he received a tracheostomy
on [**4-3**], failed a SBT on [**4-3**] [**1-1**] dyspnea, and is undergoing a
slow wean. On discharge he was tolerating 12 hours off the vent
per day and can be encouraged to go longer. He should be
thoroughly rested on the vent at night on the settings of PS 15
and PEEP 5.
.
# Hypovolemic shock secondary to acute blood loss anemia - The
patient had been taking Motrin and was supertheraputic on
coumadin that he was taking for atrial fibrillation. He
underwent an EGD in the ED which showed gastritis. He was placed
on pressors and aggressively fluid resuscitated for several days
then eventually wean off. Following correction of his
coagulopathy and volume resuscitation, he was stable for the
rest of his stay. He is not discharged on Coumadin since he is
no longer in atrial fibrillation.
.
# Persistent fevers: The patient had a constant fever for 1 week
then defervesce. Multiple causes have been pursued and have not
reveled a source. His loculated pleural effusions were tapped,
head CT showed sinusitis for which he was treated with
ceftazidime for 7, he has no DVT. He briefly had a cellulitis,
but this resolved and he still was having fevers. He has a h/o
c.diff, but has been continued on the Flagyl for ppx. It is
thought then that his fevers may be from Linezolid. A 21 day
course was finished on [**4-14**]. He should undergo further workup
for his fevers, including TEE and hep serologies and more blood
cultures if he continues to be febrile 1 week after the
Linezolid is done.
.
# ARF - Initially he presented with ARF thought to be due to
NSAIDs vs ATN from hypotension. This completely resolved.
.
# Pancreatitis - Initially had mildly elevated amylase and
lipase. Completely resolved.
.
# Glucose resistance - The patient required an insulin SS during
his stay here and may need an oral diabetic [**Doctor Last Name 360**] as an
outpatient.
.
# CAD - s/p CABG. No active issues this hospital stay. His ASA
was restarted, however his BP would not tolerate starting the
Aldactone, ACEi, or Toprol. These should be added back as he
tolerates.
.
# CHF: The patient has congestive heart failure (EF 25%). He was
aggressively fluid resuscitated for most of his stay here due to
hypovolemia and renal failure. For the past few days, the team
is attempting diuresis of [**Telephone/Fax (1) 24628**] cc/day with Lasix 80 IV
BID. His diuresis should continue with Lasix as the medical team
feels necessary.
.
# Atrial Fibrillation: The patient was seen to have
irregularities with his pacemaker and an ICD shock therefore EP
was consulted. The ICD shock was inappropriate as it was given
in the setting of afib with RVR. Therefore he was loaded on
amiodarone and underwent DCCV and his mode was switched to DDDR
at 80 bpm. He should Continue amiodarone at 400 qday for a total
of 6 weeks then decrease down to 200 qday on [**First Name8 (NamePattern2) 1017**] [**5-17**]. He
should also have his LFTs and TFTs monitored on a regular basis.
He does not need anticoagulation at this time. He should f/u
with cardiologist and has an appointment on [**6-24**]. I have fax
the pacer changes to his cardiologist at [**Hospital3 **].
.
# Foot ulcers; The patient developed necrotic pressure ulcers on
the toes and soles of his feet. He was follow by podiatry who
drained these.
.
# Nutrition: The patient has been receiving tube feeds since he
could only eat when off the vent. Now that he can stay off the
vent for long periods of time, he should maintain a PO diet with
nutritional supplements and have a nutrition consult once at
[**Hospital1 **].
.
# Depression: The patient's Celexa was held while on Linelozid
[**1-1**]/ drug reactions. He will restart that in rehab. Since he
has been off for some time, he will be restarted on 20 mg qday
(took 60 mg qday at home). This can be increased over the next 2
weeks back to his home dose.
Medications on Admission:
Percocet prn
Ativan 1 TID
Imdur 30
Toprol? 50
Lasix 80 TID
Fosinopril 20
Lipitor 10
Aldactone 50
Quinidine 324 TID
Klonapin 0.5 TID
Celexa 60
Coumadin 5?
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
12. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 4 weeks: Then decrease to 200mg PO qday.
13. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Continue while the patient is
immobile.
14. Clobetasol Propionate 0.05 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day): apply to face and other affected aras .
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
16. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for hip pain.
17. Insulin Regular Human 100 unit/mL Solution Sig: As per
sliding scale Injection ASDIR (AS DIRECTED).
18. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 7 days.
19. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
20. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day: Hold
for NPO status.
21. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
22. Ensure Liquid Sig: One (1) PO three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
hypovolemic shock from gastric bleed
respiratory failure
MRSA pneumonia
pressure ulcers
recurrent fevers
depression
CAD
HTN
acute renal failure
atrial fibrillation with rapid ventricular rate
right hip arthritis
cellulitis
blood loss anemia
congestive heart failure
hypertension
Discharge Condition:
Stable. occasionally having fevers which are thought to be due
to his antibiotics. On the trach mask for about 12 hours a day
and the ventilator at night.
Discharge Instructions:
Call your PCP if you experience chest pain, bleeding, dark
stools, or increased cough.
Maintain a low sodium diet.
Followup Instructions:
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital 15629**] - Phone:
[**Telephone/Fax (1) 31920**]
Fax: [**Telephone/Fax (1) 31921**] You have an appointment [**6-24**] 1:00 and 1:30
appointment
PCP: [**Name10 (NameIs) **] [**Name11 (NameIs) 31922**] - Phone: [**Telephone/Fax (1) 31923**] Fax: [**Telephone/Fax (1) 31924**]
|
[
"511.9",
"V09.0",
"707.07",
"286.9",
"709.8",
"785.59",
"285.1",
"V53.32",
"518.84",
"427.31",
"531.00",
"E935.6",
"577.0",
"507.0",
"482.41",
"428.0",
"995.92",
"038.9",
"584.5",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"33.24",
"31.1",
"00.14",
"34.91",
"38.93",
"96.34",
"99.06",
"99.62",
"00.17",
"99.07",
"45.13",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15950, 16021
|
9104, 13536
|
291, 356
|
16344, 16500
|
1948, 1948
|
16664, 17039
|
1295, 1299
|
13740, 15927
|
16042, 16323
|
13562, 13717
|
16524, 16641
|
2957, 6822
|
1314, 1929
|
233, 253
|
384, 1115
|
7473, 9081
|
1965, 2941
|
6858, 7443
|
1137, 1214
|
1230, 1279
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,027
| 198,127
|
49944
|
Discharge summary
|
report
|
Admission Date: [**2126-11-12**] Discharge Date: [**2126-11-18**]
Date of Birth: [**2079-4-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Erythromycin Base / Cephalosporins /
Biaxin / Latex Gloves / Morphine / Levofloxacin
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Patient is a 47 yo woman who was just discharged yesterday for
influenza-like illness v. pneumonia, treated with doxycycline
due to multiple drug allergies who presents for hypoxia at her
PCP's office. Pt reports that she woke up on Tuesday with cold
chills, body aches, malaise, and fatigue. She had uncontrolled
coughing with phlegm with associated chest pain and shortness of
breath. She also reports urinary incontinence with coughing, no
dysuria, no
urinary frequency. She was admitted and treated with
doxycycline. She had refused the influenza swab. At home, pt
reports that her SOB was improved but she was still has
coughing, associated chest pain, and continued wheezing. She
continued to have fevers, chills. However, at her PCP's office,
she was febrile, tachycardic to 122, tachypneic, and satting 86%
after 2 nebulizer treatments. She also had basilar rales on
exam. No sick contacts. [**Name (NI) **] recent travels.
In the ED, initial VS were: 98.5. Labs were notable for WBC
11.5. U/A was notabled for lg blood. CXR showed persistent
bibasilar linear opacities, likely reflecting atelectasis. The
patient received doxycycline. ED spoke with ID, who rec. cont.
doxy for now; if no improvement, consider desensitization.
Vitals prior to transfer to the floor were: 101.4, 115,
170/100, 25, 97% on 3L.
Review of Systems:
(+) Per HPI plus night sweats, headaches
(-) Denies sinus tenderness, rhinorrhea or congestion. Denies
nausea, vomiting, diarrhea, constipation, or abdominal pain. No
dysuria, urinary frequency. Denies rashes. No numbness/tingling
or muscle weakness in extremities. All other review of systems
negative.
Past Medical History:
- HTN
- Hypercholesterolemia
- Environmental allergies
Social History:
Patient works for the [**Company 2318**]. She is married with 5 grown
children. She denies h/o tobacco, ETOH, and IVDU.
Family History:
Mother with h/o multiple heart attacks, now s/p CABG, starting
at 62 yo.
Physical Exam:
Vitals: 99.2, 178/121, 114, 28, 98 on 3L
Gen: NAD, AOX3
HEENT: MMM, sclera anicteric, not injected
Neck: no LAD, no JVD
Cardiovascular: tachycardic, regular rhythm, normal s1, s2, no
murmurs appreciated
Respiratory: CTAB, no crackles, occ. wheeze
Abd: normoactive bowel sounds, soft, non-tender, non distended
Extremities: No edema, 2+ DP pulses
NEURO: face symmetric, no tongue deviation
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Pertinent Results:
CXR:
IMPRESSION:
Persistent bibasilar linear opacities, likely reflecting
atelectasis.
However, a more focal opacification within the retrocardiac
region may be
suggestive of an infectious process or possibly aspiration.
CTA CHEST
Final Report
HISTORY: 47-year-old woman with dyspnea, fever and tachycardia,
not
responding to antibiotics.
COMPARISON: Chest CTA [**2125-6-3**]. Chest radiograph [**11-12**], [**2126**].
TECHNIQUE: Pre- and post-contrast axial images were obtained
through the
chest, using a PE protocol. Multiplanar reformatted images were
generated.
CT CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arterial
tree is
adequately opacified, and there is no pulmonary embolus. The
aorta is normal in size, without acute abnormalities. Great
vessels are unremarkable. The heart size is enlarged. There is
no pericardial effusion. There is no hilar, mediastinal, or
axillary lymphadenopathy by size criteria, although several
small lymph nodes are present in the mediastinum measuring up to
5 mm.
Lungs demonstrate large, wedge-shaped peripherally based,
relatively
homogeneous airspace consolidation at both lung bases. These
contain
prominent air bronchograms, and consolidation extends to the
hila.
Consolidation sometimes spares the most peripheral parts of the
lungs.
Following contrast administration, these regions are relatively
well
enhancing. There is intervening normal parenchyma between the
regions of
consolidation. Overall, this pattern is more consistent with
cryptogenic
organizing pneumonia rather than infection.
No nodules or masses are identified, although evaluation is
limited given
respiratory motion artifact. There is no pleural effusion.
FINDINGS: The tracheobronchial tree is patent to subsegmental
levels.
While this exam is not optimized for assessment of the abdomen,
no acute
abnormalities are noted in the upper abdomen.
OSSEOUS STRUCTURES: No worrisome bony lesions are identified.
IMPRESSION:
1. No pulmonary embolus or acute aortic abnormality.
2. Multiple wedge-shaped consolidations at both lung bases, in a
configuration most suggestive of cryptogenic organizing
pneumonia rather than infectious pneumonia.
[**2126-11-18**] 07:45AM BLOOD WBC-12.3* RBC-4.22 Hgb-11.1* Hct-33.6*
MCV-80* MCH-26.2* MCHC-33.0 RDW-13.8 Plt Ct-655*
[**2126-11-12**] 04:10PM BLOOD WBC-11.5* RBC-4.42 Hgb-11.8* Hct-36.1
MCV-82 MCH-26.7* MCHC-32.7 RDW-13.6 Plt Ct-502*#
[**2126-11-15**] 01:20PM BLOOD Neuts-89.9* Lymphs-7.3* Monos-1.8*
Eos-0.8 Baso-0.2
[**2126-11-12**] 04:10PM BLOOD Neuts-80.4* Lymphs-13.9* Monos-4.4
Eos-0.9 Baso-0.3
[**2126-11-15**] 01:20PM BLOOD PT-14.1* PTT-27.0 INR(PT)-1.2*
[**2126-11-18**] 07:45AM BLOOD UreaN-13 Creat-0.8 Na-136 K-5.1 Cl-96
HCO3-31 AnGap-14
[**2126-11-12**] 04:10PM BLOOD UreaN-12 Creat-0.8 Na-141 K-4.1 Cl-96
HCO3-28 AnGap-21*
[**2126-11-15**] 01:20PM BLOOD ALT-23 AST-23 AlkPhos-86 TotBili-0.6
[**2126-11-15**] 01:20PM BLOOD Calcium-10.0 Phos-3.2 Mg-2.4
[**2126-11-12**] 04:10PM BLOOD Hapto-823*
[**2126-11-12**] 08:05PM BLOOD Lactate-1.0
Brief Hospital Course:
47 yo woman with PMHx sig. for HTN who represents with fever and
hypoxia 1 day after discharge for pneumonia on doxycycline.
Pneumonia: CT scan confirmed bibasilar pneumonia, concerning for
aspiration. ID and allergy consulted. Given her multiple
severe antibiotic allergies, she was taken to the ICU for
meropenem desensitization. She did well on meropenem with
steady improvement in her hypoxia and fevers. A midline was
placed [**11-16**]. Doxycycline discontinued [**2126-11-17**] per ID. She
will complete a 14 day course of meropenem. Dr [**Last Name (STitle) 724**] will see
her in [**Hospital **] clinic in followup. Given question of cryptogenic
organizing PNA and interstitial abnormalities seen on CT, she
would also benefit from pulmonary followup. EpiPen provided at
discharge.
Hypertension: Continued home medications.
Tachycardia: the patient had intermittant sinus tachycardia
throughout her admission. CTA was negative for PE. She reports
that she has tachycardia at baseline, suspect aggravated by
infection.
OSA / ? aspiration: there is concern that the patient is having
nocturnal aspiration with her OSA. Speech and swallow eval
normal. Refused CPAP in house.
Urticaria: The patient developed hives 4 hours after her third
dose of meropenem. She was seen by allergy, who felt this was
likely due to chronic uritcaria and not a drug reaction. She
was given one dose of solumedrol and benadryl. She was started
on daily high dose fexofenadine.
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Hydralazine 50 mg PO BID
3. Hydrochlorothiazide 50 mg PO DAILY
4. Labetalol 400 mg PO BID
5. Doxycycline Hyclate 100 mg PO Q12H.
6. Acetaminophen 1000 mg PO Q6H as needed for pain, fever.
Discharge Medications:
1. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular once a day as needed for anaphylaxis.
Disp:*2 pens* Refills:*2*
2. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. meropenem 1 gram Recon Soln Sig: One (1) gram Recon Soln
Intravenous Q8H (every 8 hours) for 10 days.
Disp:*30 doses* Refills:*0*
4. 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.
5. diphenhydramine HCl 25 mg Capsule Sig: [**2-9**] Capsules PO Q6H
(every 6 hours) as needed for fever, rash, hives, itch, nausea .
6. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
8. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Pneumonia, bacterial
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with pneumonia that did not respond to prior
treatment with doxycycline. Due to your severe drug allergies,
you were desensitized to the antibiotic Meropenem in the ICU.
Your symptoms, including fever and cough improved on Meropenem.
A PICC line was placed so that you can complete a course of this
antibiotic at home. If you develop any symptoms of an allergic
reaction such as throat swelling use the Epipen and go to the ED
immediately.
We have started fexofenadine; please take this medication every
day. Your other medications are unchanged.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] and Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at [**Hospital1 **] within 2
weeks. Call the office Tuesday morning to schedule this
appointment. [**Last Name (LF) 5533**],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 3581**]. It is very
important that you have an appointment with Dr. [**Last Name (STitle) 724**] within 2
weeks, if you are unable to make this appointment please call
the hospitalist [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD ([**Telephone/Fax (1) 70484**]) for help making
this appointment.
|
[
"507.0",
"272.0",
"401.1",
"327.23",
"V07.1",
"V15.09",
"708.8",
"599.71",
"482.9",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8676, 8728
|
5954, 7440
|
379, 401
|
8793, 8793
|
2912, 5931
|
9538, 10141
|
2318, 2392
|
7710, 8653
|
8749, 8772
|
7466, 7687
|
8944, 9515
|
2407, 2893
|
1779, 2084
|
332, 341
|
429, 1760
|
8808, 8920
|
2106, 2162
|
2178, 2302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,215
| 146,873
|
31296
|
Discharge summary
|
report
|
Admission Date: [**2183-7-30**] Discharge Date: [**2183-8-8**]
Date of Birth: [**2122-10-18**] Sex: M
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents / Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
dyspnea, 3vd
Major Surgical or Invasive Procedure:
PCI with stenting of LAD
History of Present Illness:
60 yo M with h/o ESRD, IDDM, CAD, CHF (EF 15-20%), CVA ([**6-16**]),
ANS dysfxn admitted to OSH with syncope [**Date range (1) 73815**]. 1st episodes
of syncope occurred a week prior after an extra HD session with
6L fluid removed, although pt denies preceding symptoms. He had
several more episodes of syncope and traumatic falls resulting
in hitting his head on the driveway, and losing consciousness
for a few minutes. According to wife, associated with upper
extremity shaking and eyes rolling up in the head, lasting a few
minutes. No urine or stool incontinence, no post-ictal states.
Pt denies associated CP, SOB.
CT of head on admission showed no acute event, + for marked
microvascular disease. He was noted to have elevated troponins,
flat and thought to be [**3-14**] renal failure, CK's flat. As part of
syncope w/u he underwent cardiac cath which revealed 3VD. During
the procedure, pt developed R extremity weakness and dysarthria,
MRI demonstrated multiple small cerebral and cerebeallar emboli
without hemorrhage. He was started on heparin. The patient
continued to experience several episodes of unresponsiveness
with temporary worsening of his R sided weakness. At least one
was during dialysis, ? related to relatively low BP. Repeat MRI
performed on [**7-17**], heparin stopped, and placed on ASA 650mg
daily. MRI repeated [**7-22**] with progression of infarct in L
frontal lobe. Unable to find cause of his multiple emboli,
work-up for vasculitis and hypercoagulable states recommended as
outpatient.
Pt discharged to rehab for 5 days, doing well with ambulation,
no episodes of syncope.
Pt went home in the afternoon of [**7-29**] feeling fatigued, mildly
disoriented. That night pt with PND while sleeping with one
pillow on flat bed (had been in semi-upright bed in hospital).
Dyspnea did not resolve and he presented to OSH (Lakes Regional)
on [**7-30**] with increased SOB. Afebrile, BP 162/82, HR 104, RR 22,
O2 94% on RA, 100% on 3L NC. Pt started on nitro paste,
transferred here for further care of CAD.
Past Medical History:
CAD s/p PCI in '[**96**] at [**Hospital 1514**] Hosp
EF 25%
DM II x 17 yrs hx neuropathy, nephropathy
ESRD on HD x2 yrs MWF, [**Location (un) 11252**] (Dr. [**Last Name (STitle) 33564**] [**Telephone/Fax (1) 73816**])
hx pancreatic rupture 17 yrs ago, s/p pancreatic debridement,
mesh placement with poor wound healing, resultant DM
L fem-popliteal bypass graft
s/p R CEA ([**Hospital 73817**] Hosp in [**Location (un) 31628**], NH) approx 10 yrs ago
- hx small CVA at time of CEA with R Bell's palsy, resolved
GERD
Glaucoma
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Cardiac History:
CABG: n/a
Percutaneous coronary intervention: PCI x1 '[**80**], unknown details
Pacemaker/ICD: n/a
Social History:
45 pack-year smoking hx, stopped over 20 yrs ago. Occ alcohol.
Lives at home with his wife. Worked for dairy company then
manager at [**Company **].
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father died from lung CA in his 60's (smoker),
mother from [**Name2 (NI) 499**] cancer in late 50s.
Physical Exam:
per Dr. [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 6812**]
VS: T 95.0 BP 150/72 HR 88 RR 12 O2 100% on 3L NC
Gen: elderly white male in NAD, oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. + b/l xanthalesma.
Neck: Supple with JVP to jaw.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. + S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
bibasilar carckles, no wheezes, good air entry. Pt breething
comfortably, speaks in full sentences, no accessory muscle use.
Abd: + old scar across upper abdomen with several poorly healed
scars, escar presents, no erythema or purulent discharge. Soft,
NTND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. + RUE AVF with good bruit
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: EOMI, visual fields full. + R facial droop, decreased R
sided facial sensation, tongue deviates to the R. Motor [**6-14**]
upper and lower extremities b/l.
.
Pulses:
Right: Carotid R with old scar 2+, Femoral 1+ Popliteal 1+ DP
dopplerable PT dopplerable
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP dopplerable PT
dopplerable
Pertinent Results:
EKG demonstrated sinus rhythm at 79, nl axis, borderline PR, +
IVCD, + LVH, T wave inversions I, aVL. ST depression
anterolaterally in I, aVL, V4-V6 unchanged from [**2183-6-10**].
.
TEE [**2183-7-17**]: mild LV dilation with evidence of inferior,
inferolateral and anterolateral apical infarction, EF 25%, mild
MR.
.
CARDIAC CATH [**7-17**] demonstrated:
LMCA - large, slightly ectacic, non-obstructive
LAD - very large, wraps around apex. 30-40% proximal with 95%
complex lesions at the take off of a large diagonal. 30-40%
plaquing distally. D1 is large, bifurcates with a tight 90%
proximal lesion.
LCx - a large vessel totalle occluded after OM1.
RCA - dominant, tortuous with 95% mid vessel lesion.
.
PET scan: reported viability of lateral wall.
.
LABORATORY DATA
Oupt labs [**7-30**]:
WBC 10.6, HCT 32.6, Plt 253
Na 142, K 4.4, Cl 92, Co2 34, BUN 37, Cr 7.9
Gluc 226, Ca 8.4
CK 145, Trop I 2.19 -> 2.43
LDH 268, HDL 25.
ABG: 7.47/47/82
BNP > 5000
.
Admission labs:
142 90 41
--------------< 188
5.2 38 9.8
CK: 120 MB: 6 Trop-T: 2.02
Ca: 8.2 Mg: 2.2 P: 5.6
ALT: 18 AP: 172 Tbili: 0.4 Alb:
AST: 29 LDH: 487 Dbili: TProt:
.
15.5 >---< 295
26
.
PT: 12.0 PTT: 22.2 INR: 1.0
.
[**7-31**]: Carotids: 1. 60%-69% stenosis of the right internal
carotid artery.
2. Less than 40% stenosis of the left internal carotid artery.
.
[**7-31**]: CXR no evidence of failure
.
[**7-31**]: ECHO: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is moderate to severe regional
left ventricular systolic dysfunction with
inferior/inferolateral akinesis, and distal septal/apical
hypokinesis, consistent with multivessel coronary artery
disease. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade I (mild)
LV diastolic dysfunction. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with moderate to severe
regional systolic dysfunction, c/w multivessel CAD. Mild mitral
regurgitation.
[**8-2**] MRI/A:
FINDINGS: BRAIN MRI: IMPRESSION: Foci of hyperintense signal
within left centrum semiovale and in the anterior portion of the
right centrum semiovale on diffusion images with corresponding
T2 and FLAIR abnormalities. In absence of ADC map, it could not
be confirmed whether these are due to acute infarcts or due to
T2 shine through. Repeat diffusion study with ADC map would help
for further assessment if clinically indicated. No mass effect
or hydrocephalus seen.
MRA OF THE NECK: IMPRESSION: Right internal carotid artery
demonstrates signal loss and narrowing of the flow signal
suggestive of high-grade stenosis. However, the examination is
somewhat limited by motion. Gadolinium-enhanced MRA or CTA would
help for further assessment of the stenosis if clinically
indicated.
MRA OF THE HEAD:IMPRESSION: Normal MRA of the head.
[**8-6**] PCI: COMMENTS:
1. Access was obtained via the RRA.
2. The lesion in the mid LAD was predilated with a 1.5mm and 2.0
mm
balloons, stented with two 3.0 mm stents and post dilated with a
3.5 mm
balloon with lesion reduction to 0%. The final angiogram showed
TIMI III
flow with no residual stenosis, no dissection, no perforation
and no
embolisation. The patient left the lab in a stable condition.
3. the RCA lesion was crossed easily with a ChoICE PT XS wire
This
procedure was postponed.
FINAL DIAGNOSIS:
1. Successful stenting of the LAD (Drug eluting)
2. PCI of the RCA was deferred.
Brief Hospital Course:
Pt is a 60 yo M with h/o ESRD, IDDM, CAD, CHF (EF 15-20%), CVA
(1 mo ago during cath), and autonomic dysfunction who is
transferred here after returning with increasing shortness of
breath and recently diagnosed 3VD. Hospital course by problem:
Dyspnea: Patient appeared comfortable on admission to the CCU.
He was mildly overloaded on exam and improved with HD the
following morning.
CAD: pt evaluated with cardiac cath recently although no clear
evidence of ischemia at that time. He was found to have 3VD,
although multiple comorbidities make him a high risk candidate
for CABG. We obtained baseline CE and an echo which showed
function impaired by 3VD. EKG was unchanged from prior with
anterolateral persistent ST depressions and T wave inversions.
We considered CABG evaluation and angioplasty. After neurology
evaluated patient's MRI/A and taking into consideration
patient's comorbidities and witnessed recurrence of CVA symptoms
with decreased blood pressure, patient was determined by CT
Surgery to be high risk for open heart surgery and the decision
was made to undergo PCI. A TEE was obtained to determine
location/severity of aortic atheroma so as to guide PCI
approach. Pt was transfused 1 unit of packed red blood cells for
a HCT of 29.5 before the procedure. [**8-6**] cath revealed a mid LAD
lesion of 80% and a 70% instent restenosis distal to this
lesion. The lesion in the mid LAD was stented with two 3.0 mm
drug-eluting stents with lesion reduction to 0%. The final
angiogram showed TIMI III flow with no residual stenosis, no
dissection, no perforation and no embolization. PCI of the RCA
was postponed. The patient tolerated the procedure well and was
continued on aspirin, plavix, stain, and ACEI for the remainder
of the hospitalization.
CVA: outpatient MRI showed evidence of multiple emoblic strokes.
Improving R sided paresis and R facial palsy during admission.
ASA was continued at outpatient dose of 650mg daily, but later
decreased to 325mg later in his course. We obtained echo and
carotid ultrasounds as above. No clear source of emboli was
found.
Syncope/cards rhythm: although it was originally felt to be
related to orthostasis, given his low EF an electrophysiology
consult was obtained. EP said placement of an AICD not
indicated at this point. Lasix 40mg po bid was started with
hopes that during HD a lower volume could be drawn off in the
ultrafiltrate, as hypotension was associated with HD.
ESRD: L AVF in place for access. Continued phos lo, epogen with
dialysis. Continued HD (rec'd [**8-2**], [**8-4**], [**8-6**], [**8-8**]).
HTN: continued lisinopril, coreg with holding parameters.
Gabapentin for neuropathy was d/c'd due to concern for
hypotension.
DM: continued [**Hospital1 **] NPH with sliding scale humalog. lisinopril was
decreased to 2.5mg and coreg was held initially per hypotension,
but coreg was gradually increased to 6.5mg [**Hospital1 **] to control BP.
The patient was maintained on a cardiac, diabetic diet, PPI, and
SC heparin. TEDs ordered to maintain venous return.
Code status discussed at admission - patient wishes to be full
code.
Medications on Admission:
CURRENT MEDICATIONS:
ASA 650 mg daily
Coreg 6.25 mg [**Hospital1 **]
Lisinopril 5 mg daily
Crestor 10mg daily
Prozac 20mg daily
Insulin NPH 16 U qAM, NPH 8 U qPM
Pantoprazole 40 mg daily
Phos Lo 667mg tid with meals
Timolol eye drops one drop each eye once daily
Epogen with dialysis 2x/wk
gabapentin 300mg daily
lasix 80mg po bid (makes approx [**2-11**] cup urine daily)
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Primary: syncope, CAD/ CHF
Secondary: HTN, hyperlipidemia, ESRD on dialysis, CVA, diabetes,
glaucoma
Discharge Condition:
good; hemodynamically stable, afebrile, VSS, ambulating well
Discharge Instructions:
You were admitted for evaluation of passing out. Work up
revealed that this was related to coronary artery disease. You
were taken for cardiac catheterization with revealed blockages
in your major arteries. For this reason, 2 drug eluting stents
were placed in your artery.
You were started on a new medication, Plavix, which will help to
thin your blood to prevent clots around these stents. IT IS VERY
IMPORTANT to take this medication daily until your outpatient
cardiologist discontinues it.
Your lisinopril was decreased to 2.5mg daily and your lasix was
decreased to 40mg twice daily because of your low blood
pressure. Please continue taking this dose until your outpatient
cardiologist increases it.
Please take your previous medications as prescribed.
Please call your doctor or return to the hospital if you
experience any further chest pain, shortness of breath,
palpitations, or excessive bleeding.
Followup Instructions:
Please follow-up with local cardiologist in [**2-11**] weeks.
Please have a repeat echocardiogram in [**3-15**] months. If EF< 30%
consider AICD evaluation.
If recurrent angina occurs, consider elective PCI of RCA.
|
[
"250.00",
"414.01",
"403.91",
"410.71",
"585.6",
"428.0",
"996.72",
"428.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"00.40",
"00.46",
"88.72",
"37.22",
"36.07",
"88.56",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
12350, 12458
|
8803, 9021
|
335, 362
|
12603, 12666
|
4819, 5776
|
13627, 13845
|
3338, 3520
|
12479, 12582
|
11952, 11952
|
8697, 8780
|
12690, 13604
|
3535, 4800
|
283, 297
|
9051, 11926
|
11973, 12327
|
390, 2427
|
8144, 8680
|
5792, 8128
|
2449, 3156
|
3172, 3322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,874
| 110,684
|
1653
|
Discharge summary
|
report
|
Admission Date: [**2109-10-10**] Discharge Date: [**2109-10-19**]
Date of Birth: [**2059-8-19**] Sex: M
Service: ACOVE
CHIEF COMPLAINT: This is a 50 year old male who was a direct
admission for hemoptysis, blood tinged sputum and increasing
shortness of breath.
PAST MEDICAL HISTORY:
2. HIV, last CD4 count [**2109-9-25**], was 151 with a viral load
of 423.
3. History of anus squamous cell carcinoma, status post
chemotherapy and radiation therapy.
4. Chronic obstructive pulmonary disease.
5. Mitral valve replacement in [**2102**], with a porcine valve.
Echocardiogram in [**2-6**], showed some mitral regurgitation,
6. Peripheral neuropathy.
7. Mediastinal seminoma in [**2095**], that was treated with
radiation and chemotherapy.
8. Testicular hypofunction.
9. Hypothyroidism.
10. Depression.
11. Atrial flutter.
HISTORY OF PRESENT ILLNESS: The patient had increased
shortness of breath over more than the week. He was seen in
Dr.[**Name (NI) 7750**] office on [**2109-9-26**], for hemoptysis that was
half blood and half sputum. Initially, the chest x-ray may
have shown left pneumonia for which he was treated with ten
days of Levofloxacin 250 mg per day. The patient says that
during the course of antibiotics he had decreased hemoptysis.
CT on [**2109-10-8**], showed no evidence of pulmonary embolus but
did show increased pulmonary nodules with a ground glass
appearance. The patient denied any chest pain but did feel
that he had increased pulsations in the neck over the last
few days.
REVIEW OF SYSTEMS: He has positive constipation since
radiation therapy for his anal cancer. He also complains of
pain in his legs and scrotal area from lymphedema post
radiation therapy for his cancer that has lasted over the
last two months. He has not obtained good pain control. He
denies any fever, chills, sweats, diarrhea or dysuria.
MEDICATIONS ON ADMISSION:
1. Stavudine 30 mg twice a day.
2. Lamivudine 150 mg twice a day.
3. Abacavir 300 mg twice a day.
4. Advair 250 mcg twice a day.
5. Aquaphor/Hydrocortisone 2.5% cream once daily.
6. Cyanocobalamin 1000 mcg/ml q.month.
7. Dapsone 100 mg once daily.
8. Delatestryl 200 mg/ml, administered as 1 cc q2weeks.
9. Digoxin 0.125 mg once daily.
10. Furosemide 40 mg once daily.
11. Lac-Hydrin 12% skin cream twice a day.,
12. Levofloxacin 250 mg p.o. once daily.
13. Ativan 2 mg q.h.s. p.r.n.
14. Marinol 2.5 mg twice a day.
15. Mepron 750 mg/5 cc given as 5 cc twice a day.
16 Mycelex 10 mg four times a day p.r.n. for thrush.
17. Potassium 40 meq once daily.
18. Proventil 90 mcg two tablets q4hours p.r.n.
19. Selenium Sulfide 2.5% once daily times seven days.
20. Triamcinolone Acetamide once daily.
21. Ultrase MT 18-59-18-59 one tablet three times a day.
22. Unithroid 100 mcg once daily.
23. Wellbutrin SR 100 mg once daily.
24. Dilaudid 2 mg q4hours p.r.n.
25. Duragesic 25 mcg per hour q72hours.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: Alcohol occasionally and now less than one
pack per day of cigarettes. He smokes marijuana every day.
FAMILY HISTORY: Mother died of an inner ear cancer. Father
had diabetes mellitus, coronary artery disease and brother
has alcohol abuse.
PHYSICAL EXAMINATION: On examination, the patient was
afebrile at 98.4, blood pressure 106/72, respiratory rate 28,
pulse 120. Initially on presentation, he was only saturating
at 83% in room air. After giving him three liters nasal
cannula, he saturated to 92%. Head, eyes, ears, nose and
throat examination - He had moist mucous membranes. Jugular
venous pressure to the angle of the jaw. His skin had woody
lymphedema, left leg greater than the right with positive
scrotal edema. He has no Kaposi lesions. Respiratory- He
had good air entry bilaterally but he had bilateral fine
crackles at the bases and some bronchial breath sounds at the
right upper lobe. Cardiovascular examination - harsh III/VI
systolic ejection murmur at the base and left sternal border.
The abdomen has positive bowel sounds, nontender,
nondistended, no organomegaly. His extremities showed
nonpitting edema.
LABORATORY DATA: White blood cell count 8,7, platelet count
157,000. Electrolytes were essentially unremarkable.
Neutrophils 75%.
CT of the chest on [**2109-10-8**], showed multiple pulmonary
nodules, associated ground glass opacities, new lung nodules
at the bases compared to [**2109-7-30**], minor scarring at the
right apex. No evidence of pulmonary embolus.
HOSPITAL COURSE: The patient was put on respiratory
precautions for his increasing shortness of breath with
hemoptysis. He was ruled out for tuberculosis and multiple
induced sputum and bronchoalveolar lavage from his
bronchoscopy sent for cytology and bacterial and fungal viral
infection. Essentially, his bronchoalveolar lavage had
negative cytology for malignant cells. His cryptococcal
antigen was negative. Three sets of acid fast bacilli and
cultures were negative. Coccidiodes was still pending to
date. His still antigen is negative. His sputum culture
only grew sparse growth of yeast. Fungal cultures were
negative. Legionella was negative. PCP was tested for and
was negative. Nocardia negative. Urine culture times two
negative. Blood cultures and fungal cultures no growth to
date.
The patient obtained a transthoracic echocardiogram which
showed an ejection fraction of 50% and akinesis of the apex
and paradoxical motion of the interventricular septum. He
had some right ventricular hypertrophy with mild to moderate
aortic regurgitation, moderate to severe tricuspid
regurgitation and at least some mild pulmonary hypertension.
Because all his laboratories were essentially negative for an
infectious disease workup, the patient was scheduled for a
VATS procedure and a Transesophageal Echocardiogram while
under general anesthesia. The patient went for the VATS
procedure on [**2109-10-16**], and failed extubation with pCO2 in the
90s. The patient was reintubated and transferred from te
Post Anesthesia Care Unit to the SICU on Neo-Synephrine and
pressure support of [**11-9**]. The Neo-Synephrine was
discontinued after twelve hours and the patient was
successfully extubated. His last arterial blood gas on
[**2109-10-18**], was pH 7.35/57/85. The patient's VATS had
demonstrated metastatic squamous cell carcinoma. The
Transesophageal Echocardiogram demonstrated an ejection
fraction of greater than 55%, left atrial dilatation, 2+
aortic regurgitation, no mitral regurgitation, 2+ tricuspid
regurgitation and no pericardial effusion, and a prosthetic
mitral valve.
Dr. [**Last Name (STitle) 2148**] spoke with the patient about his diagnosis of
metastatic squamous cell carcinoma to the lung. It was
agreed with the patient that he would be discharged with
Hospice care and no further intervention was to be pursued.
The patient was discontinued on all his antiretroviral
treatments and was only continued on pain control management
anxiety control medications and his antidepressant medication
as well as supplemental oxygen.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: The patient is DNR/DNI.
MEDICATIONS ON DISCHARGE:
1. Fentanyl patch 50 mcg/hour q72hours.
2. Marinol 2 to 5 mg p.o. twice a day.
3. Ativan 1 to 2 mg p.o. q4-8hours p.r.n.
4. Wellbutrin SR 100 mg p.o. once daily.
5. Proventil 90 mcg two puffs q4hours p.r.n. for cough.
6. Home supplemental oxygen to titrate to comfort.
7. Dilaudid 2 to 4 mg p.o. q2-4hours p.r.n.
8. Neurontin 300 mg p.o. three times a day.
The patient is to be admitted to Hospice/Palliative Care at
[**Hospital 2188**].
DISCHARGE DIAGNOSES:
1. Metastatic squamous cell carcinoma to the lung.
2. AIDS.
3. Hepatitis C.
4. Chronic obstructive pulmonary disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. [**MD Number(1) 9562**]
Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36
D: [**2109-10-19**] 10:27
T: [**2109-10-19**] 13:17
JOB#: [**Job Number 9563**]
|
[
"V10.06",
"486",
"428.0",
"458.2",
"V42.2",
"042",
"197.0",
"070.51",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.04",
"96.71",
"33.28",
"96.56"
] |
icd9pcs
|
[
[
[]
]
] |
3123, 3246
|
7664, 8053
|
7195, 7643
|
1924, 2985
|
4533, 7093
|
3270, 4515
|
1572, 1898
|
157, 284
|
894, 1552
|
306, 865
|
3002, 3106
|
7118, 7169
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,849
| 193,176
|
47041
|
Discharge summary
|
report
|
Admission Date: [**2167-12-28**] Discharge Date: [**2168-1-4**]
Date of Birth: [**2108-11-23**] Sex: M
Service: [**Company 191**]
Please see the previous dictation for the initial part of the
[**Hospital 228**] hospital course.
A renal ultrasound was obtained as per Infectious Disease
recommendation. It showed no evidence of hydronephrosis in
either kidney. There was a 3 mm stone within the interpolar
region of the left kidney without evidence of obstruction.
It was decided that the patient could follow-up with
Neurology as an outpatient for further evaluation of this
kidney stone. Based on these findings, the Infectious
Disease Consult stated that the patient would only require a
two week course of intravenous vancomycin, as well as
intravenous Ceftazidine. They stated that he could be
switched to levofloxacin po instead of ceftazidine
intravenously upon discharge.
Upon discussion with the attending, Dr. [**Last Name (STitle) **], he decided
to discharge the patient on Ciprofloxacin instead of
levofloxacin. The patient remained afebrile and
hemodynamically stable throughout the remainder of his
hospitalization. The patient will be discharged to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. He is scheduled with outpatient follow-up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 99750**] in the Multiple Sclerosis [**Hospital 878**]
Clinic. As per Neurology's recommendations, the patient was
tapered off Dilantin. He was continued on his Tegretol dose.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 15384**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2168-1-4**] 04:17
T: [**2168-1-4**] 16:21
JOB#: [**Job Number 99751**]
|
[
"785.52",
"340",
"584.9",
"707.15",
"518.81",
"599.0",
"707.0",
"038.9",
"788.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.71",
"96.04",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,245
| 113,042
|
40984
|
Discharge summary
|
report
|
Admission Date: [**2128-4-30**] Discharge Date: [**2128-5-9**]
Date of Birth: [**2081-9-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
dyspnea, calf pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 yo M with morbid obesity and hypertension presented to an OSH
with 5 day history of dyspnea on exertion and left calf
cramping. Patient reports he first noticed difficulty breathing
while mowing his lawn 5 days prior to admission and developed
progressive DOE with dyspnea at rest the past 1-2 days. His left
leg felt crampy 2 days ago but he did not notice increase in
edema or redness. He denies chest pain but says his chest feels
like he "just ran a marathon". No orthopnea, palpitations,
cough, fever/chills/night sweats. He has baseline edema of his
lower extremities, which he treats with elevation and
compression stockings. He has not had recent travel or
immobilization, no recent illnesses, no personal or family
history of blood clots or PE. He initially presented to [**Hospital1 **]
[**Location (un) 620**] with vitals of: 97.9, HR 118, BP 169/105, RR 22, O2 86%
on RA which improved to 95% on 2L NC. ECG there showed sinus
tach at 104 with no ST-T changes. His CXR there was a poor study
but did not indicate acute cardiopulmonary process. D-dimer was
measured and elevated to 8.93 (upper normal 0.48) and troponin
elevated to 0.065. Patient was transferred to [**Hospital1 18**] for further
management.
.
In the emergency department initial vitals were: T 97, HR 100,
BP 147/92, RR 18, O2Sat 98% 4L NC. He was empirically started on
heparin drip with 1000 unit bolus and set at a rate of [**2116**]
units per hour.
Reason for transfer to the MICU is concern for impending
clinical instability given hypoxemia. V/Q scan and CTA could not
be performed given body habitus.
.
At the MICU, patient was slightly agitated and in mild
respiratory distress. He was holding up his NRB mask and laying
flat in bed, speaking in full sentences, but tachypneic and
mildly diaphoretic. His vitals were BP 139/89, HR 116, O2 95% on
NRB. He reported mild SOB, no chest pain with inspiration, no
calf pain.
Past Medical History:
Hypertension
Obesity
Cellulitis in R leg
L ankle infection
Social History:
Lives alone, works as a mechanic and software programmer. Fairly
active at baseline. Never smoked, intermittent EtOH use ([**6-2**]
beers some days, sometimes a week without drinking), last drink
Wednesday (3-4 beers). No drug use. Mother passed away 5 weeks
ago from pancreatic cancer.
Family History:
No family history of blood clots or PEs. Mother had
pancreatic/liver cancer. Father died in [**2116**]. 3 siblings mostly
healthy, sister with MS.
Physical Exam:
ADMISSION EXAM:
GEN: obese man laying in bed in mild respiratory distress,
diaphoretic, speaking in full sentences, AOx3
HEENT: EOMI, PERRLA
NECK: obese, JVP could not be assessed, no cervical LAD
PULM: CTA anteriorly, no rales or wheezes
CARD: distant heart sounds, tachycardic, nl S1/S2, no m/r/g
ABD: obese, soft, NT, BS+
EXT: 2+ pitting edema b/l to knee, chronic venous stasis
changes, no open breaks in skin, faint distal pulses b/l
NEURO: AOx3, declined remainder of exam
PSYCH: anxious and slightly agitated
DISCHARGE EXAM:
Vitals: 96.9 136/63 55 20 96%RA
General: very obese gentleman in NAD
Lungs: Distant breath sounds but no wheezes, rales, ronchi
CV: PMI nondisplaced (difficult to palpate), no RV heave,
Regular rate, normal S1 + S2, no murmur
Ext: warm, 2+ DP and radial pulses, no clubbing, (+) stasis
dermatitis (brawny skin) from mid-shin downwards bilaterally;
RLE with small 1cm nonhealed ulcer with no pus or erythema;
palpable/tender area of induration posterior to left calf
Pertinent Results:
ADMISSION LABS
[**2128-4-30**] 10:30PM BLOOD WBC-10.8 RBC-5.32 Hgb-15.7 Hct-44.9
MCV-84 MCH-29.4 MCHC-34.9 RDW-13.3 Plt Ct-359
[**2128-4-30**] 10:30PM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-139
K-3.7 Cl-100 HCO3-26 AnGap-17
[**2128-5-1**] 03:51AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
[**2128-4-30**] 10:30PM BLOOD cTropnT-0.10*
[**2128-5-1**] 03:51AM BLOOD CK-MB-9 cTropnT-0.15*
[**2128-4-30**] 10:30PM BLOOD D-Dimer-7574*
[**2128-5-1**] 02:25AM BLOOD Type-ART Temp-36.1 pO2-85 pCO2-37
pH-7.46* calTCO2-27 Base XS-2 Intubat-NOT INTUBA
DISCHARGE LABS:
[**2128-5-6**] 07:55AM BLOOD WBC-9.5 RBC-5.41 Hgb-15.4 Hct-45.9 MCV-85
MCH-28.5 MCHC-33.6 RDW-13.3 Plt Ct-320
[**2128-5-9**] 07:30AM BLOOD PT-20.6* PTT-150* INR(PT)-1.9*
[**2128-5-6**] 07:55AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.2
CXR [**2128-5-1**]
Limited study due to technique. Cardiomegaly without signs for
acute cardiopulmonary process.
EKG [**2128-4-30**]
Artifact is present. Sinus rhythm. Normal tracing. No previous
tracing available for comparison.
EKG [**2128-5-3**]
Atrial fibrillation with rapid ventricular response. Diffuse
ST-T wave abnormalities are non-specific but clinical
correlation is suggested. Since the previous tracing of [**2128-5-1**]
atrial fibrillation has replaced sinus tachycardia and further
ST-T wave changes are present.
EKG [**2128-5-4**]
Sinus rhythm. Diffuse ST-T wave changes are non-specific but
clinical correlation is suggested. Since the previous tracing of
[**2128-5-3**] sinus rhythm has replaced atrial fibrillation.
Lower Extremity Ultrasound [**2128-4-30**]:
IMPRESSION: Nonocclusive thrombus in the left popliteal vein. No
definite
thrombus in the right lower extremity.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Mr. [**Known lastname 10132**] is a 46y/o gentleman who presented with SOB, hypoxia,
and LLE DVT - though CTA was not feasible, the clinical picture
was consistent with pulmonary embolus. He was started on a
Heparin drip until he was therapeutic on Warfarin. He became
stable from a respiratory standpoint and he was discharged home.
.
ACTIVE ISSUES
.
1. Hypoxia, SOB: Pulmonary Embolus.
Initial increased A-a gradient, O2 requirement, DVT, right heart
strain on EKG all consistent with PE. Though unable to get CTA
due to body habitus, clinical suspicion was very high. Not a
Lovenox candidate due to body weight; he was started on Heparin
gtt and bridged to Warfarin. He was weaned to to room air, and
had no O2 requirement even with ambulation. He will likley
require a 6 month course of treatment. He will follow up with
his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] after discharge (he was given a lab slip for
INR check), and will be followed at [**Hospital1 **] [**Location (un) 620**] [**Hospital 3052**].
.
2. LLE DVT: popliteal DVT.
Detected by tender palpable cord and confirmed by LENI. He was
anticoagulated as described above.
.
3. Paroxysmal Afib in the setting of PE: reslved.
He had a few episodes of Afib/RVR with rate up to 140 which
responded well to IV Diltiazem; the A fib resolved on [**2128-5-3**] (it
had been <48 hours) and he remained in NSR for the remainder of
his stay. Episodes were possibly due to PE; unknown if this has
been a problem in the past. He was started on Metoprolol 25mg
PO BID and will continue this after discharge.
.
4. Hypertension: SBP up to 200's as an outpatient; up to 160
here.
He had not taken Lisinopril for almost a year despite
encouragement from his PCP. [**Name10 (NameIs) **] was restarted on Lisinopril 10mg
daily, which was uptitrated to 20mg daily. He will follow up
with his PCP.
.
5. Class III obesity: a risk factor for not only PE, but also
CAD.
He was continued on ASA (81mg in the setting of
anticoagulation). He will have outpatient PCP f/u for healthcare
maintenance and would benefit from a sleep study.
.
TRANSITIONAL ISSUES
.
Code Status: Full Code
Emergency Contact: [**Name (NI) **] [**Name (NI) 44979**] (friend) [**Telephone/Fax (1) 89415**]
Labs/studies pending at discharge: none
Medications on Admission:
ASA 325mg daily
Lisinopril 12.5mg 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. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. warfarin 5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Outpatient Lab Work
INR Check on [**5-12**] and [**5-15**]
.
Please fax results to Dr [**First Name8 (NamePattern2) 30642**] [**Name (STitle) **] at [**Telephone/Fax (1) 36518**].
Discharge Disposition:
Home
Discharge Diagnosis:
DVT with possible PE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 10132**],
You were admitted with calf pain and shortness of breath and
were found to have a blood clot in one of your leg veins. It is
also possible that you have a clot in your lungs, so we are
treating this with a blood thinner called coumadin (warfarin)
which you will need to take for 6 months.
.
We have made the following changes to your medications:
- STARTED coumadin (warfarin)15 mg daily
- STARTED metoprolol 25mg twice daily
- INCREASED lisinopril to 20mg daily
Followup Instructions:
PRIMARY CARE
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M
Location: INTERNISTS ASSOCIATED
Address: [**Street Address(2) 21374**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 6163**]
Date: Tuesday, [**2128-5-11**] at 11AM
.
[**Hospital3 **]
At your follow-up appointment, you will be set up at an
[**Hospital3 **] to monitor your INR and Warfarin dose.
|
[
"285.9",
"415.19",
"278.01",
"459.81",
"518.81",
"288.60",
"427.31",
"453.41",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8548, 8554
|
5518, 7813
|
290, 297
|
8619, 8619
|
3819, 4352
|
9289, 9687
|
2636, 2785
|
7923, 8525
|
8575, 8598
|
7859, 7900
|
8770, 9120
|
4368, 5495
|
2800, 3317
|
3333, 3800
|
7827, 7833
|
9149, 9266
|
232, 252
|
325, 2234
|
8634, 8746
|
2256, 2316
|
2332, 2620
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,072
| 131,177
|
40716
|
Discharge summary
|
report
|
Admission Date: [**2192-7-30**] Discharge Date: [**2192-8-3**]
Date of Birth: [**2130-6-29**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left sided weakness, aphasia
Major Surgical or Invasive Procedure:
tPA
History of Present Illness:
62 yo F with hx HTN and HLD was at work this afternoon and
reported to not be speaking much around 2 PM onward. At 4 PM
she developed global aphasia and right hemiplegia and EMS was
called. No further information was available at time code stroke
was called.
Past Medical History:
- HTN
- HLD
- CAD s/p CABG/AVR [**12-13**]
- Dilated Cardiomyopathy
- Systolic CHF with EF 20%
Social History:
Pt reports that she used to live alone but since her recent
cardiac surgery her daughter has moved in with her. Resides in
[**Location (un) 686**]. Has a history of EtOH abuse and cocaine use. Has
been decreasing her alcohol consumption since her daugther moved
in.
Family History:
No early CAD or SCD per patient.
Physical Exam:
INITAL ADMISSION EXAM:
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 2
3. Visual fields: 2
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 4
7. Limb Ataxia: n/a
8. Sensory: 1
9. Language: 3
10. Dysarthria: n/a
11. Extinction and Neglect: 1
VS; BP 151/108 P 110 RR 20
Gen; awake, NAD
HEENT; NC/AT
CV; tachycardic, regular rate
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro; Awake with eyes open but does not follow any commands and
does not verbalize. Fixed left gaze deviation, unable to
overcome. Does not blink to threat on the right. Right facial
droop. Moves LUE and LLE spontaneously. 0/5 strength in RUE
and
RLE. Grimaces to noxious stimuli in RUE but no movement.
Upgoing toe on right, mute on left.
Pertinent Results:
TOX SCREENS
[**2192-7-30**] 10:00PM
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS
amphetmn-NEG mthdone-NEG
[**2192-7-30**] 04:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-7-31**] 05:38AM BLOOD ALT-30 AST-33 CK(CPK)-71 AlkPhos-96
TotBili-1.2
[**2192-7-31**] 05:38AM BLOOD %HbA1c-5.1 eAG-100
[**2192-7-31**] 05:38AM BLOOD Triglyc-65 HDL-52 CHOL/HD-2.5 LDLcalc-67
[**2192-8-3**] 06:15AM BLOOD PT-16.8* INR(PT)-1.5*
[**2192-7-30**]
CT PERFUSION: There is a matched perfusion abnormality with
reduced flow and increased mean transit time involving the left
inferior division MCA territory consistent with established
infarction.
IMPRESSION:
Area of increased mean transit time with reduced flow in the
left inferior
division of MCA with a vessel cutoff suggesting a reversible
infarct. No
evidence of intracranial hemorrhage.
MR HEAD W/O CONTRAST Study Date of [**2192-7-31**] 10:59 AM
1. Moderately large evolving acute infarct in the left posterior
MCA
territory, and additional small evolving acute infarcts in the
left ACA
territory and medial left temporal lobe. Embolic etiology should
be
considered.
ECHO
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 15-20%) with septal akinesis/dyskinesis, apical akinesis
and mid inferior/inferolateral akinesis and hypokinesis
elsewhere. The basal to mid anterolateral segments contract
best. [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.] No
left ventricular thrombus was identified. The right ventricular
cavity is mildly dilated with normal free wall contractility.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. A mitral valve
annuloplasty ring is present. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is at least moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. There is
atherosclerotic plaque in the aortic arch (in limited
Brief Hospital Course:
NEURO: R MCA STROKE
62 yo F with hx HTN and HLD was at work when she developed
global aphasia and right
hemiplegia. Her NIHSS was 22 and exam was notable for global
aphasia, fixed left gaze deviation, and right hemiplegia. There
were no early infarct signs on CT
head, CTA showed L M2 cutoff, and CT perfusion imaging showed
smaller infarct than what would expect given deficits. After
discussion with stroke fellow and attending, IV TPA was
administered at 0.9 mg/kg with 10% bolus over one minute at
17:43 followed by remainder as drip for one hour.
At 19:05, she was awake, alert but unable to vocalize. She
followed some simple one step command but inconsistently.
Conjugate eye deviation to left but can look over to the right
on volition. Decreased blink to visual threat on right. R-facial
droop. Dense right sided HP with hemisensory loss.
The patient was admitted to the Neuro ICU for post-tPA
monitoring. BP was allowed to autoregulate with goal SBP 120-185
(home antihypertensives were held).
The following morning, the neuro exam was significantly
improved. She was alert and oriented x 3, with intact naming,
repetition and comprehension. She had extreme difficulty
controlling her R arm and leg, and it seemed to be moving on its
own (severe flinging movements, such that the R wrist was
restrained). We wondering if this was an alien limb syndrome,
however her sensation was significantly impaired, in particular
her position sense, so this could also explain her difficulty.
The following day, the flinging and uncontrolled movements had
stopped. She was able to reach and grab objects with the R hand,
though it remained clumsy due to poor sensory input.
MRI showed moderately large evolving acute infarct in the left
posterior MCA
territory, and additional small evolving acute infarcts in the
left ACA
territory and medial left temporal lobe.
The etiology is most likely cardioembolic, given her history of
dilated cardiomyopathy. She was started on coumadin without a
bridge. Her fasting lipid panel was: CHOL 132, HDL 52, LDL 67,
TG 65.
LANGUAGE:
Pt was seen by the speech team. Summary and recommendations are
as follows:
Ms. [**Known firstname **] [**Known lastname **] presents with at least mild auditory
comprehension, moderate verbal expression deficits, and moderate
[**Location (un) 1131**] comprehension deficits on today's brief, informal
aphasia evaluation. Speech and voice appear WNL and pragmatics,
insight, problem solving, and attention were functional for
structured tasks. She is meeting acute needs in this setting
with verbal communication, though relies on her listener for
some inference to her specific thoughts. She will benefit from
further dx/tx of aphasia in a rehab setting upon d/c. Specific
goals should
include improved auditory comprehension of complex information,
reduced frequency of paraphasias and word finding, and
functional [**Location (un) 1131**] tasks to promote indepedence in the
community. Prognosis for improvement in communication is good
given her age, previous level of functioning, family supports,
and motivation. Her current personal goal is to determine
whether or not she'll be able to return to work at the Gap, as
she's concerned her physical and communication deficits will
make this too
challenging.
CARDS:
Her cardiac history was discussed with her outpatient
cardiologist, Dr. [**Last Name (STitle) 89031**] at [**Hospital 1263**] Hospital. She had MVR in
[**2191-10-5**] and has dilated CM (non-ischemic) with EF 25%. Repeat
TTE during this hospitalizaton showed EF 15-20%. She had no
evidence of failure. Blood pressures were low on minimal
medications (100-125) and so she was kept on only 25mg TID
Metoprolol and 5mg of lisinopril. She was started on coumadin
and baby aspirin. She has an appointment with her cardiologist
scheduled for [**Year (4 digits) 89031**].
ID: UTI
Patient had foul smelling urine and UA was grossly positive. She
was treated with Bactrim for 3 days.
SUBSTANCE ABUSE:
Urine tox was positive for cocaine. This may have been a factor
in causing her stroke. It may contribute to her cardiomyopathy.
The patient also has a history of EtOH abuse, though current
quantity is unclear. She did not exhibit any signs or symptoms
of EtOH withdrawal. Social work as consulted and the patient was
given resources for support.
Medications on Admission:
Metoprolol XR 100mg daily
Lisinopril 20mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right MCA stroke s/p tPA
Hypertension
Hypertension
CAD s/p CABG/AVR [**12-13**]
Dilated Cardiomyopathy
Systolic CHF with EF 20%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
NEURO: clumsy right hand/difficulty with motor planning, minimal
weakness of the right side. Right parietal drift. Language is
fluent but has frequent paraphasic errors.
Discharge Instructions:
You were admitted to evaluation of a stroke. It was felt that
your stroke was related to your poor heart function. Because of
this, you were started on a blood thinning medication, Coumadin.
You will need to work closely with your doctors to monitor this
medication and the correct dose, as too much or too little may
place you at risk for stroke or bleeding.
You were found to have cocaine in your system, which may have
contributed to your stroke. You need to STOP cocaine.
Followup Instructions:
Cardiology/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45513**]
[**9-7**] at 1:30
[**Apartment Address(1) **], Seton Building
[**Location (un) 81104**]
[**Location (un) 86**], [**Numeric Identifier 17591**]
Phone: ([**Telephone/Fax (1) 89032**]
(in replacement of previously scheduled [**10-1**]
appointment).
Department: NEUROLOGY
When: FRIDAY [**2192-9-21**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2192-8-3**]
|
[
"428.20",
"V45.81",
"401.9",
"414.00",
"428.0",
"342.90",
"434.91",
"599.0",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
9353, 9423
|
4494, 8838
|
341, 346
|
9595, 9595
|
1955, 4471
|
10453, 11161
|
1055, 1090
|
8936, 9330
|
9444, 9574
|
8864, 8913
|
9949, 10430
|
1105, 1936
|
273, 303
|
374, 636
|
9610, 9925
|
658, 754
|
770, 1039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,440
| 134,553
|
43894
|
Discharge summary
|
report
|
Admission Date: [**2172-11-14**] Discharge Date: [**2172-11-14**]
Date of Birth: [**2099-5-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Gentamicin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 73 year old woman with a history of Left MCA infarct
with hemorrhagic conversion in [**2169**]. She went to rehab and
recovered to the extent that she lives with son and has moderate
dysphasia. This evening she developed garbled speech, gait
instability and ultimately unresponsiveness. She was taken
to OSH and found to have an INR of 7 and a large right IPH. She
was transferred to [**Hospital1 18**] for further evaluation. Of note, her
son
was repeatedly taking her [**Name (NI) **] at home and she was not
hypertensive.
Past Medical History:
1. MCA embolic stroke c/b hemorrhagic transformation on coumadin
[**1-13**]. (residual aphasia & R sided weakness)
2. Hypertension
3. Tachy-brady syndrome s/p pacemaker
4. Paroxysmal atrial fibrillation
5. DM2
6. Diastolic HF ([**2169**])
7. Enterrococcal bacteremia treated with Amp/Gent, suspected
source suspected RLE cellulitis
8. Breast cancer s/p axillary dissection and chemo/radiation
9. Depression
10. Endometriosis
11. Shoulder pain
12. Incontinence
13. Severe COPD
14. Recurrent UTIs
Social History:
[**Year (4 digits) 595**]-speaking, lives with son [**Name (NI) **] who smokes. Pt has 45 yr
smoking hx x1/2 PPD. No EtOH or illicits per her son.
Family History:
Father died of stroke at 74.
Physical Exam:
100% int 14 P 79 126/64
The patient is intubated. She has corneal relfexes. She has no
gag but a weak cough. Pupils are 4 and MR. She does not open her
eyes to noxious stimuli. She exhibited slight WD of UE to
noxious
stimuli and triple flexion response in the LE's.
Pertinent Results:
[**2172-11-14**] 03:39AM BLOOD WBC-8.6 RBC-2.95* Hgb-7.8* Hct-24.7*
MCV-84 MCH-26.4* MCHC-31.5 RDW-16.2* Plt Ct-208
[**2172-11-14**] 03:39AM BLOOD Plt Ct-208
[**2172-11-14**] 03:39AM BLOOD Glucose-186* UreaN-45* Creat-1.2* Na-145
K-3.7 Cl-103 HCO3-26 AnGap-20
[**2172-11-14**] 03:39AM BLOOD Calcium-9.2 Phos-2.0* Mg-2.0
[**2172-11-14**] 04:16PM BLOOD Type-ART pO2-149* pCO2-83* pH-7.27*
calTCO2-40* Base XS-8
[**2172-11-14**] 09:17AM BLOOD Glucose-205* Lactate-1.5 Na-147 K-4.0
Brief Hospital Course:
Ms. [**Known lastname 94236**] [**Last Name (Titles) 18095**] massive intracerebral bleed on [**2172-11-14**].
Her INR was found to be 7 at the outside hospital. She was
transferred here for neurosurgical evaluation. Given the size of
her bleed in poor exam minimally reactive pupils and slight
withdrawl in uppers and triple flexion response in the LE's, no
intervention was offered and discussed at length with her son.
[**Name (NI) **] anticoagulation was reversed and she was admitted to an ICU
and made DNR/DNI. Her son appreciated that she could not recover
and she was made CMO and with removal of the tube she passed
away.
Medications on Admission:
atorvastatin 80 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
2. cephalexin 250 mg Capsule [**Name (NI) **]: One (1) Capsule PO once a day.
3. gabapentin 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO twice a
day.
4. metoprolol tartrate 50 mg Tablet [**Name (NI) **]: Two (2) Tablet PO twice
a day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. venlafaxine 37.5 mg Tablet [**Name (NI) **]: One (1) Tablet PO twice a
day.
7. cyanocobalamin (vitamin B-12) 100 mcg Tablet [**Name (NI) **]: One (1)
Tablet PO once a day.
8. docusate sodium 100 mg Capsule [**Name (NI) **]: Three (3) Capsule PO once
a day.
9. magnesium oxide 400 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a
day.
10. senna 8.6 mg Capsule [**Name (NI) **]: Two (2) Capsule PO twice a day.
11. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet [**Name (NI) **]: One
(1) Tablet PO once a day.
12. Co Q-10 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO twice a day.
13. insulin glargine 100 unit/mL Solution [**Name (NI) **]: Six (6) units
Subcutaneous once a day: inject 6 units SC daily as directed
.
14. insulin aspart 100 unit/mL Solution [**Name (NI) **]: INSULIN ASPART
[NOVOLOG] - 100 unit/mL Solution - inject sc according to
sliding scale based on fingerstick glucose up to tid; maximum 30
units daily Subcutaneous three times a day.
15. warfarin 4 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day:
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerbral Hemorrhage
Intraventricular Hemorrhage
MCA embolic stroke c/b hemorrhagic transformation on coumadin
[**1-13**]. (residual aphasia & R sided weakness)
Hypertension Tachy-brady syndrome s/p pacemaker
Paroxysmal atrial fibrillation
DM2
Diastolic HF ([**2169**])
Enterrococcal bacteremia treated with Amp/Gent, suspected
source suspected RLE cellulitis
Breast cancer s/p axillary dissection and chemo/radiation
Depression
Endometriosis
Shoulder pain
Incontinence
Severe COPD
Recurrent UTIs
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2173-2-3**]
|
[
"428.32",
"496",
"348.4",
"430",
"V49.86",
"438.11",
"599.0",
"041.6",
"790.92",
"728.87",
"V10.3",
"250.00",
"432.1",
"787.20",
"331.4",
"431",
"V58.61",
"427.31",
"438.89",
"311",
"V45.01",
"428.0",
"438.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4605, 4614
|
2401, 3034
|
294, 300
|
5160, 5169
|
1899, 2378
|
5222, 5256
|
1565, 1595
|
4576, 4582
|
4635, 5139
|
3060, 4553
|
5193, 5199
|
1610, 1880
|
238, 256
|
328, 865
|
887, 1384
|
1400, 1549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,468
| 171,147
|
37026
|
Discharge summary
|
report
|
Admission Date: [**2153-6-1**] Discharge Date: [**2153-6-8**]
Date of Birth: [**2127-9-27**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, pancreatitis
Major Surgical or Invasive Procedure:
None at [**Hospital1 18**]
.
Laparoscopic cholecytectomy at [**Hospital 8641**] Hospital, NH [**2153-5-23**]
ERCP with stone extraction at [**Hospital 8641**] Hospital, NH [**2153-5-24**]
History of Present Illness:
Patient is a 25year old female, 6 weeks s/p c-section for her
first child, who was transferred from the [**Hospital 8641**] Hospital ICU
tonight to Dr.[**Name (NI) 2829**] care for pancreatitis. She originally
underwent a laparoscopic cholecystectomy with IOC on [**2153-5-23**] for
a pre-operative diagnosis of "biliary colic & passed common bile
duct (CBD) stone". Grossly, she appeared to have chronic
cholecystitis. The cholangiogram demonstrated an obstructing
CBD stone, which did not pass with glucagon. A drain was left
in the gallbladder fossa. She then underwent an ERCP on [**2153-5-24**]
with sphincterotomy and stone extraction.
Prior to surgery she had multiple visits to her healthcare
providors for abdominal pain during the last 6 weeks of her
pregnancy. She reports she was told she had gas and
constipation. On [**2153-5-10**] she had a 12-hour attack of pain and
was noted to have abnormal LFT's (AST 387, ALT 246, AP 322, TB
1.5, Lip 351). RUQ U/S at that point demonstrated
cholelithiasis without evidence of cholecystitis; CBD measured
3.00 mm. She was given the name of surgeon and told to
follow-up. She saw him on [**2153-5-16**], who suspected she had passed
a stone, and scheduled her for an elective cholecytecomy on
[**2153-5-23**]. Her LFTs somewhat improved without intervention (AST
115, ALT 90, AP 208, TB 0.4), but she continued to have
intermitted RUQ/epigastric sharp, crampy abdominal pain
with radiation to the right shoulder.
Her transfer paperwork does not include a discharge summary or
MD notes aside from initial GI & OB consult notes. The following
timeline was pieced together from her nursing notes and the
patient:
Initially after her ERCP her abdominal pain was much improved.
However, on POD 2/PPD 1 she again developed significant pain
with tachycardia to 120's. She was started on a fentanyl PCA.
Transferred to the ICU for "SIRS". [**2153-5-26**] POD 3/PPD 2 she became
febrile to 103 with continued tacycardia. A CVL was placed and
TPN started. NGT placed for increased abdominal distension.
Bolused for CVP; JP removed approximately this day. [**2153-5-28**] POD
5/PPD 4 diuresed for CVP 20 and pitting edema. Continued to be
tachy to 120's, with sustained 130-140's. NGT continued with
output of approximately 500cc/12 hrs. Fleets enema given
resulting in small liquid stools. [**2153-5-29**] POD 6/PPD 5 continued
abdominal pain, febrile to 102.5, then 103. Vancomycin was
started. Remained tachy to 140's. Urine output 200cc's/hr.
[**2153-5-30**] POD 7/PPD 6 continued fever to 103, resistant to tylenol
and cooling blankes. CVL d/c'd. [**2153-5-31**] POD 8/PPD 7 NGT clamped,
minimal residuals. PICC placed. [**2153-6-1**] POD 9/PPD 8 NGT removed,
repeat CT scan, was then transferred to [**Hospital1 18**].
At this point she feels "crummy". RML/RLL abdominal pain worse
with movement, reasonably controlled with dilaudid 4mg IV q3. No
nausea or vomiting since NGT removed earlier today. No headache
or dizziness. Feels weak with "heavy legs". Has been walking
around the ICU daily "to keep her strength up". Has been NPO on
TPN. Breathing is much better than it was 3-4 days ago.
Past Medical History:
1. anxiety
2. goiter
3. c-section [**2153-4-25**], first child
4. s/p LEEP [**2149**] for CIN 3
5. Gallstone pacreatitis s/p lap CCY & IOC [**2153-5-23**] ([**Hospital 8641**]
Hospital, NH)
6. s/p ERCP with stone extraction [**2153-5-24**] ([**Location (un) 8641**] Hosapital, NH)
7. Sulfa Allergy
Social History:
Married. Healthy baby boy being cared for by her in-laws. Nurse
at [**Hospital 8641**] Hospital. No tobacco. Minimal alcohol.
Family History:
Ovarian cancer, polycystic kidney in maternal grandmother. [**Name (NI) **]
[**Name2 (NI) 499**] cancer, IBD, liver disease.
Physical Exam:
On Admission:
.
VS: 103.8 133ST 138/83 21 100% 2L
GENERAL: Diaphoretic, ill appearing. AOx3. Pleasant. Not
distressed. No jaundice or icterus.
LUNGS: CTA B/L
HEART: Tachycardia
ABDOMEN: Trochar sites C/D/I without erythema or induration with
steri-strips. Old RLQ drain exit site closed without drainage.
Slightly distended, soft. TTP RML/RLL. No tap/shake tenderness.
No guarding. Trace rebound.
EXTREM: Trace LE edema. (R) AC PICC site C/D/I. (L)IJ former CVL
site C/D/I.
Pertinent Results:
[**2153-6-8**] 06:45 Labwork:
Report Comment: Source: Line-PICC
COMPLETE BLOOD COUNT
White Blood Cells 17.8* K/uL (4.0 - 11.0), Red Blood Cells 3.18*
m/uL (4.2 - 5.4), Hemoglobin 8.1* g/dL (12.0 - 16.0), Hematocrit
25.1* % (36 - 48), MCV 79* fL (82 - 98), MCH 25.4* pg (27 - 32),
MCHC 32.1 % (31 - 35)
RDW 15.6* % (10.5 - 15.5)
DIFFERENTIAL
Neutrophils 83* % (50 - 70) TOXIC GRANULATION, Bands 0 %(0 - 5),
Lymphocytes 9* % (18 - 42), Monocytes 3 % (2 - 11), Eosinophils
4 % (0 - 4), Basophils 0 % (0 - 2), Atypical Lymphocytes 0 %,
Metamyelocytes 0 %, Myelocytes 1* % (0)
RED CELL MORPHOLOGY
Hypochromia NORMAL, Anisocytosis 1+, Poikilocytosis NORMAL,
Macrocytes NORMAL, Microcytes 1+,Polychromasia NORMAL, Platelet
Count 1017* K/uL (150 - 440).
138/101/15
----------< 88, AGap=17
4.7/25/0.6
Ca: 8.8 Mg: 2.0 P: 3.9
[**Doctor First Name **]: 233 Lip: 458
.
MICROBIOLOGY:
[**2153-6-2**] MRSA Screen: Negative.
[**2153-6-2**] Blood Cultures x2: No growth.
[**2153-6-2**] Urine Cx: No growth.
[**2153-6-3**] Stool for C. diff: negative.
[**2153-6-4**]: Blood Cx: Pending.
[**2153-6-6**] Blood Cx: Pending.
[**2153-6-6**] Urine Cx: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
[**2153-6-6**] Blood Cx: Pending.
[**2153-6-8**] Urine Cx: Pending.
[**2153-6-8**] Blood Cx x2: Pending.
.
[**2153-6-1**] CXR:
The right PICC line tip is at the cavoatrial junction.
Cardiomediastinal
silhouette is unremarkable. Bibasal opacities may represent
areas of atelectasis in conjunction with small bilateral
pleural effusions, although infectious process cannot be
excluded. Followup on the subsequent radiographs is recommended
for documentation of resolution or at least absence of
progression.
.
[**2153-6-2**] EKG:
Sinus tachycardia. Otherwise, within normal limits. No previous
tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
105 126 88 334/412 13 53 28
.
[**2153-6-2**] Outside Read of Abdominal CT with IV/PO Contrast:
1. Extensive multiloculated slightly complex intraperitoneal and
retroperitoneal fluid collection extending from the
posteroinferior aspect of the pancreas and third/fourth portion
of the duodenum. The degree of
complexity of the collections as well as multiple loculations
would make any percutaneous drainage attempt difficult.
2. No pancreatic necrosis. Branches of the SMA and SMV passing
through the
dominant fluid collection appear attenuated and may be at risk
for future
thrombosis or hemorrhage.
3. Reactive thickening of the adjacent loops of small and large
bowel, most marked involving the ascending [**Month/Day/Year 499**].
4. Simple bilateral mild-to-moderate pleural effusions.
5. Small enhancing fluid collection tracking within the mid
right lateral
abdominal wall, just adjacent to the tip of the liver, likely
corresponding to patient's prior port track.
5. Atypical configuration of the right kidney likely
representing a form of congenital malrotation. The kidney itself
appears to enhance normally.
.
[**2153-6-4**] CXR: Small bilateral pleural effusions.
.
[**2153-6-7**] CTA ABD W&W/O C & RECON:
Interval decrease in size of extensive multiloculated pancreatic
pseudocyst, although with increase in wall enhancement. The
collection now measures roughly 11.3 x 3.8 x 10 cm, previously
approximately 13.8 x 5.6 x 10 cm. No pancreatic necrosis. No
evidence of vascular complications, including no pseudocyst,
thrombus or evidence of hemorrhage. However, persistent
encasement and attenuation of ileocolic vessels, particularly
venous tributaries to the SMV, although without bowel wall
thickening or secondary signs of ischemia at this time. Interval
decrease in size of bilateral pleural effusions, now minimal.
Improvement in reactive bowel wall thickening of nearby loops of
bowel, but increase in mesenteric lymphadenopathy.
Brief Hospital Course:
The patient was transferred from the ICU at [**Hospital 8641**] Hospital, NH
to the SICU here for further evaluation and treament of the
aforementioned problems. She arrived NPO on TPN for nutrition
and hydration, received IV Dialudid for pain relief, and had a
foley catheter, A-line, and PICC in place, with the placement of
the latter confirmed by CXR. An abdominal CT performed at the
outside hospital, which was re-evaluated by [**Hospital1 18**] Radiology,
demonstrated a large complex, multiloculated fluid collection
adjacent to pancreas and into the paracolic gutter, likely
representing a pancreatic pseudocyst. IV Meropenem and
Vancomycin were continued. She was hemodynamically stable.
Neuro: Initially, pain was controlled on PRN IV Dialudid, which
was converted to Dilaudid PCA. On [**2153-6-6**], the PCA was
discontinued, and changed to Percocet PO PRN as well as the
addition of Toradol IV for back pain with good effect. Last day
of Toradol [**2153-6-8**].
CV: Arrived in sinus tachycardia due to dehydration, anemia and
fevers, which imporved with aggressive hydration and fever
reduction. Anemia remained stable. Platelet count slowly trended
upward, most likely due to inflammation. Otherwise, remained
stable from a cardiovascular standpoint.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
FEN/GU: Admitted NPO on TPN from outside hospital. IV fluid and
boluses given with good response and resolution of oliguria. She
was started on clear liquids on HD 2, which she tolerated, and
progressively advanced to a low residue, low fat diet by HD 5
with initial poor intake due to nausea. Improved dietary
tolerability by discharge day, but still with inadequate Po
intake. TPN was continued at time of transfer with
recommendation to discontinue when tolerating diet with adequate
nutritional intake. Electrolytes were routinely followed, and
repleted when necessary. Nutrition consulted during stay;
provided dietary teaching regarding low residue, low fat diet.
GI: Multilobular pancreatic pseudocyst on Abdominal CT. LFTs,
lipase and amylase followed closely, improving over time; diet
advanced as results trended downward. Managed conservatively.
Underwent CTA Pancreas on [**2153-6-7**], which revealed interval
decrease in size of extensive multiloculated pancreatic
pseudocyst with maturation.
ID: C-section and laparoscopic incisions remained c/d/i during
hospitalization. Continued experiencing episodic fevers 100.1 -
103.5 PO until HD 6. Pan-cultures from outside hospital as well
as those performed at [**Hospital1 18**] were unremarkable. Cdiff x1
negative. As fevers felt to be due to inflammation, IV
Vancomycin and Meropenem were discontinued on [**2153-6-3**];
antibiotic therapy never restarted. [**2153-6-8**] WBC 17.8 (up from
13.9). Blood cultures, U/A and UCx sent [**2153-6-8**].
Endocrine: The patient's blood sugar was monitored throughout
her stay while on TPN; sliding scale insulin dosing was adjusted
accordingly.
Hematology: The patient's complete blood count was examined
routinely; anemia remained stable. No transfusions were
required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
Psychosocial: Patient's newborn son being cared for by male
partner's parents and himself. Son in for frequent visits while
patient on floor. During stay, the patient was very emotional,
had coping issues due to homesickness and separation from
newborn son as well as question of possible post-partum
depression. Social Work consulted. Emotional support given.
Outpatient re-evaluation recommended.
At the time of discharge and transfer back to [**Hospital 8641**] Hospital in
[**Location (un) 3844**], the patient was doing well, afebrile with stable
vital signs. The patient was tolerating a low residue regular
diet while being continued on TPN, ambulating, voiding without
assistance, and pain was well controlled. The patient was
transferred back to [**Hospital 8641**] Hospital to complete her recovery, so
that she could be near her family, especially her newborn son.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
[**Last Name (un) 1724**]: vicodin prn (s/p c-section)
.
MEDS ON TRANSFER:
1. Zosyn 3.375 IV q6hrs ([**Date range (1) 83481**])
2. protonic 40mg IV BID
3. lorazepam 0.5-1mg q8hrs prn
4. LR @ 125
5. Dilaudid 1-4mg IV q2hrs
6. tylenol 650mg q4hrs prn
7. ambien 5-10mg qhs prn
8. fluconazole 150mg q4days (started [**2153-5-29**]) for vulvar edema &
possible early yeast infection, to continued while on abx
9. lopressor 5mg IV q4hrs prn HR > 140
10. vancomycin 1000mg q12hrs (started [**2153-6-1**])
11. Meropenem 1gm IV q8hr (started [**2153-6-1**])
12. TPN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-26**]
hours as needed for fever or pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for fever or pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Prenatal Vitamin with Minerals 28-0.8 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
Disp:*120 Cap(s)* Refills:*0*
8. Ondansetron 4-8 mg IV Q8H:PRN nausea
9. Famotidine 20 mg IV Q12H
10. Insulin Regular Human 100 unit/mL Solution Sig: 2-8 units
Injection As directed per Regular Insulin Sliding Scale.
11. PICC Care:
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
12. PIV Care:
Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8641**] Healthcare, NH
Discharge Diagnosis:
Primary:
1. Gallstone pancreatitis
2. Pancreatic pseudocyst
Secondary:
1. Post-partum
Discharge Condition:
Good.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain 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 [**4-29**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Please call ([**Telephone/Fax (1) 83482**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in 2 weeks.
Please call ([**Telephone/Fax (1) 2828**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] (Surgery) in [**2-21**] weeks.
Completed by:[**2153-6-8**]
|
[
"674.84",
"577.0",
"574.41",
"648.24",
"577.2",
"285.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
15183, 15244
|
8684, 13090
|
317, 507
|
15375, 15383
|
4818, 8661
|
18060, 18366
|
4182, 4308
|
13698, 15160
|
15265, 15354
|
13116, 13173
|
15407, 16862
|
16878, 18037
|
4323, 4323
|
249, 279
|
535, 3699
|
4337, 4799
|
3721, 4021
|
4037, 4166
|
13191, 13675
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,112
| 126,059
|
26499
|
Discharge summary
|
report
|
Admission Date: [**2128-1-15**] Discharge Date: [**2128-2-4**]
Date of Birth: [**2057-12-12**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
necrotic pancreatitis
Major Surgical or Invasive Procedure:
dobhoff feeding tube placement
History of Present Illness:
Ms [**Known lastname **] is a 70 y.o. woman with a history of COPD, EtOH
abuse, pancreas divisum & pancreatitis, and hemochromatosis who
presented to [**Hospital3 **] on [**2128-1-13**] with abdominal pain,
nausea, vomiting, WBC 19, and amylase of 3815. She was
diagnosed
with acute alcoholic pancreatitis. She was made NPO and started
on IVF. On presentation, she was "very uncomfortable", but
alert,
oriented and able to relay a coherent history.During HD#1, her
BP dropped to the 80s systolic and a dopamine drip was started.
She was also started on Zosyn. She started to become more
lethargic and less communicative during the first 24 hours of
her
hospitalization (which her family attributed to pain meds).
Then,
on [**1-14**] she had an ABG with pH 7.20, pCO2 60. Pt was then sedated
and intubated for acidosis/respiratory failure. Abdominal CT
showed pancreatic necrosis and she was transferred to [**Hospital1 18**] on
[**1-15**] for further management.
Past Medical History:
PMH:
1. pancreatitis with pancreas divisum
2. EtOH abuse
3. GERD
4. Htn
5. Hemachromatosis
6. COPD
Social History:
SH: [**3-13**] drinks EtOH/day. 30 pack-year tobacco history but has
since quit. Married with children. At baseline, she is an
active and highly functioning woman. She works and is completely
independent.
Family History:
FH: Maternal aunt with stroke. Family denies other history of
seizure, stroke, neurologic disorders.
Physical Exam:
Gen: NAD
Card: RRR
Pulm: clear to ascultation
Abd:soft, bowel sounds present, no tenderness
ext:no edema noted, pedal and radial pulses present
Pertinent Results:
[**2128-1-15**] 05:41PM BLOOD WBC-12.0* RBC-3.07* Hgb-9.0* Hct-27.0*
MCV-88 MCH-29.3 MCHC-33.4 RDW-14.0 Plt Ct-196
[**2128-1-20**] 03:28AM BLOOD WBC-16.0* RBC-2.57* Hgb-7.5* Hct-22.6*
MCV-88 MCH-29.3 MCHC-33.4 RDW-14.2 Plt Ct-376
[**2128-1-26**] 04:21AM BLOOD WBC-25.3* RBC-4.09* Hgb-12.2 Hct-35.4*
MCV-87 MCH-29.8 MCHC-34.4 RDW-14.4 Plt Ct-827*
[**2128-1-30**] 04:20AM BLOOD WBC-15.6* RBC-3.57* Hgb-10.2* Hct-30.4*
MCV-85 MCH-28.6 MCHC-33.6 RDW-14.6 Plt Ct-747*
[**2128-1-15**] 05:41PM BLOOD PT-13.0 PTT-28.0 INR(PT)-1.1
[**2128-1-28**] 01:54AM BLOOD PT-12.6 PTT-26.6 INR(PT)-1.1
[**2128-1-30**] 04:20AM BLOOD Plt Ct-747*
[**2128-1-15**] 05:41PM BLOOD Glucose-97 UreaN-11 Creat-0.6 Na-145
K-4.1 Cl-120* HCO3-18* AnGap-11
[**2128-1-22**] 02:55AM BLOOD Glucose-135* UreaN-9 Creat-0.5 Na-141
K-4.4 Cl-108 HCO3-25 AnGap-12
[**2128-2-2**] 04:13AM BLOOD Glucose-101 UreaN-17 Creat-0.4 Na-140
K-4.3 Cl-105 HCO3-26 AnGap-13
[**2128-1-15**] 05:41PM BLOOD ALT-12 AST-45* LD(LDH)-471* AlkPhos-39
Amylase-492* TotBili-0.5
[**2128-1-20**] 03:28AM BLOOD ALT-15 AST-24 LD(LDH)-488* AlkPhos-116
Amylase-55 TotBili-0.5
[**2128-1-25**] 02:45AM BLOOD ALT-26 AST-23 LD(LDH)-611* AlkPhos-157*
TotBili-0.3
[**2128-1-28**] 01:54AM BLOOD ALT-13 AST-14 LD(LDH)-410* AlkPhos-84
Amylase-88 TotBili-0.2
[**2128-1-15**] 05:41PM BLOOD Lipase-653*
[**2128-1-28**] 01:54AM BLOOD Lipase-52
[**2128-1-15**] 05:41PM BLOOD Albumin-2.6* Calcium-6.5* Phos-0.9*
Mg-1.5*
[**2128-2-2**] 04:13AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0
[**2128-1-20**] 04:21PM BLOOD calTIBC-186* Ferritn-360* TRF-143*
[**2128-1-27**] 02:14AM BLOOD Triglyc-117
[**2128-1-28**] 01:54AM BLOOD Vanco-15.4*
[**2128-1-15**] 05:51PM BLOOD Type-ART pO2-107* pCO2-38 pH-7.32*
calHCO3-20* Base XS--5
[**2128-1-16**] 09:53AM BLOOD Type-ART pO2-107* pCO2-35 pH-7.40
calHCO3-22 Base XS--1
[**2128-1-20**] 04:05PM BLOOD Type-ART pO2-110* pCO2-70* pH-7.32*
calHCO3-38* Base XS-7 Intubat-INTUBATED
[**2128-1-22**] 01:13PM BLOOD Type-ART Temp-39.4 Rates-/21 PEEP-8
FiO2-40 pO2-150* pCO2-40 pH-7.38 calHCO3-25 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2128-1-24**] 06:15PM BLOOD Type-ART pO2-113* pCO2-55* pH-7.35
calHCO3-32* Base XS-3
[**2128-1-27**] 06:38AM BLOOD Type-ART pO2-81* pCO2-56* pH-7.39
calHCO3-35* Base XS-6 Intubat-NOT INTUBA
[**2128-1-15**] 05:48PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2128-1-15**] 05:48PM URINE RBC-[**6-19**]* WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2128-1-15**] 05:48PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019
GRAM STAIN (Final [**2128-1-16**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2128-1-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ESCHERICHIA COLI. SPARSE GROWTH.
CT HEAD W/O CONTRAST
Reason: please eval for bleed, infarct
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with pancreatitis, now change in mental status
off sedation
REASON FOR THIS EXAMINATION:
please eval for bleed, infarct
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pancreatitis, no change in mental status off
sedation, please evaluate for bleed or infarct.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no evidence for acute intracranial
hemorrhage. Multiple subcortical and periventricular
hypodensities in the white matter of both cerebral hemispheres
are noted, likely a remnant of chronic small- vessel infarction.
The [**Doctor Last Name 352**]- white matter junction is distinct. The ventricles,
sulci, and cisterns are normalm without effacement. There is no
evidence for hydrocephalus. There is no mass effect or shift of
normally midline structures. The paranasal sinuses are clear.
Osseous structures are unremarkable. The cavernous carotid
arteries are calcified, atherosclerotic in origin.
IMPRESSION: No evidence for acute intracranial hemorrhage.
Previous small vessel infarcts. MR is more sensitive for the
evaluation of acute brain ischemia.
CT ABDOMEN W/CONTRAST [**2128-1-23**] 2:56 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: Pt with recent pancreatitis, recurrent fevers,
unidentified
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with chronic pancr, recent episode req intub,
slow to wean from vent, recurrent fevers, elev WBC
REASON FOR THIS EXAMINATION:
Pt with recent pancreatitis, recurrent fevers, unidentified
source, pls re-eval
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Chronic and acute pancreatitis, recurrent fevers.
Intubated.
No CTs for comparison.
TECHNIQUE: Axial images through the chest, abdomen and pelvis
with oral and IV contrast.
CT OF THE CHEST WITH CONTRAST: There are moderate bilateral
pleural effusions with bibasilar atelectasis. The endotracheal
tube is above the carina. There are no pathologically enlarged
axillary, hilar, or mediastinal lymph nodes. There are no
pulmonary consolidations or nodules. The airways are patent to
the level of the subsegmental bronchi bilaterally. The heart and
pericardium, and great vessels are normal.
CT OF THE ABDOMEN WITH CONTRAST: The liver, spleen, adrenal
glands, gallbladder, right kidney, and both ureters are normal.
A feeding tube is seen terminating in the duodenum. There is
free fluid tracking down both paracolic gutters, right greater
than left. There is nonenhancement of the majority of the
pancreatic body, with only limited enhancement seen within the
head and tail. There is fluid within the peripancreatic space,
as well as within the lesser sac and anterior perirenal space.
There is atherosclerotic calcification of the descending aorta,
and the branch points of the celiac axis, superior mesenteric
artery, renal artery, and inferior mesenteric artery. There are
no pathologically enlarged mesenteric or retroperitoneal lymph
nodes. Within the left kidney is an area of nonenhancement.
There are also two cysts within the left kidney. There is no
hydronephrosis.
CT OF THE PELVIS WITH CONTRAST: There is free fluid within the
pelvis. The uterus, rectum, sigmoid colon, and adnexa are
unremarkable. A Foley catheter is in the bladder. There are no
pathologically enlarged inguinal or pelvic lymph nodes.
BONE WINDOWS: Hardware within the left femur. No suspicious
lesions.
IMPRESSION:
1. Findings consistent with necrotizing pancreatitis with
peripancreatic stranding and effusions extending in the lesser
sac and anterior paparenal space. Moderate bilateral pleural
effusions, and ascites.
2. Focal area of nonenhancement within the left kidney, an
infarct and acute pyelonephritis on the differential diagnosis.
These findings were discussed with Dr. [**First Name (STitle) **] at 3:30 p.m. on
[**2128-1-23**].
Brief Hospital Course:
Here, she was weaned off pressors. She was found to have E. coli
in sputum cx and was treated initially with ampicillin, then
switched to vanc, levo, & flagyl which was completed by the time
of discharge. Attempts to wean from ventilator were intially
unsuccessful largely because of agitation, hypertension,
tachycardia, and tachypneiawhen propofol and fentanyl are
weaned.
Neurology was consulted who thought her exam to be consistent
with ETOH withdrawl. Recs of benzodiazepines standing and prn
per CIWA scale were followed.
Tube feeds were started on HD 6 via a Dobhoff tube. CT scan on
HD9 demonstrated bilateral pleural effusions and an abdomen c/w
necrotizig pancreatitis. Eventually, she was able to be
successfully extubated on HD10. Her sedation was minimized and
she tolerated weaning to oxygen via nasal cannula. She
eventually regained full orientation and was out of bed with
assistance.
She did develop abdominal distension and vomiting on HD13. An
NGT was placed with >1L of output per day. A KUB was consistent
with an ileus, TF were held and TPN was started. Foley was out
on HD17. Her NGT was self-d/c'ed and the patient did not have
any nausea/vomiting. Her diet was slowly advanced - clears
started on HD18, low fat diet on HD19, TPN halved. Patient was
discharged on HD21 in good condtion to [**Hospital3 **] for
further physical therapy and acute recovery.
Medications on Admission:
1. Ipratropium Bromide MDI 2 PUFF IH Q4H
2. AcetaZOLAMIDE 250 mg IV Q6H
3. Levofloxacin 500 mg PO Q24H
4. Acetaminophen 325-650 mg PO Q4-6H:PRN
5. Lorazepam 0.5-2 mg IV Q4H:PRN
6. Albuterol 2 PUFF IH Q4H
7. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN Mag<1.9
8. Ampicillin 2 gm IV Q6H
9. Metronidazole 500 mg PO TID
10. Calcium Gluconate 2 gm / 100 ml D5W IV PRN iCa++<1.12
11. Metoprolol 5 mg IV Q6H
12. Clonidine TTS 1 Patch 1 PTCH TD QFRI
13. Neutra-Phos 2 PKT PO ONCE
14. DopAmine 0-5 mcg/kg/min IV DRIP TITRATE TO MAP of 65
15. Pantoprazole 40 mg IV Q12H
16. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
17. Potassium Phosphate 15 mmol / 250 ml NS IV ONCE
18. Folic Acid 1 mg IV DAILY
19. Potassium Chloride 40 mEq / 100 ml SW IV PRN K<3.8
20. Heparin 5000 UNIT SC BID
21. Propofol 5-50 mcg/kg/min IV DRIP TITRATE TO sedation
22. Insulin SC
23. Thiamine HCl 100 mg IV DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
necrotizing pancreatitis
Discharge Condition:
improved, stable
Discharge Instructions:
Please come to the emergency room if you have persistent
abdominal pain, nausea/vomiting, shortness of breath, inability
to eat or drink, dizziness/weakness or diarrhea.
Please don't drive while taking pain medications.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**3-13**] weeks. Call
[**Telephone/Fax (1) 1231**] for an appointment.
Completed by:[**2128-2-4**]
|
[
"482.82",
"789.5",
"303.90",
"560.1",
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"275.0",
"577.8",
"530.81",
"291.81",
"577.1",
"790.7",
"401.9",
"518.81",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"99.15",
"96.72",
"38.91",
"99.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
11200, 11270
|
8883, 10269
|
335, 368
|
11339, 11358
|
2008, 4984
|
11626, 11783
|
1724, 1827
|
6352, 6467
|
11291, 11318
|
10295, 11177
|
11382, 11603
|
1842, 1989
|
274, 297
|
6496, 8860
|
396, 1361
|
1383, 1484
|
1500, 1708
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,756
| 172,034
|
40439
|
Discharge summary
|
report
|
Admission Date: [**2135-6-19**] Discharge Date: [**2135-6-20**]
Date of Birth: [**2110-8-18**] Sex: F
Service: MEDICINE
Allergies:
Diphenhydramine / pseudoephedrine / Latex / Dexamethasone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Airway edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 24 year old female with PMH of metastatic breast
cancer to lungs, liver, and bone complicated by multiple
vertebral fractures, currently on palliative chemotherapy and
XRT for about 1 month, who presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital
for further evaluation of 1 week of persistent nausea and
vomiting and was transferred to [**Hospital1 18**] for concern of airway
edema seen on imaging. She originally presented to the OSH with
1 week of N/V with her last chemotherapy being administered on
[**6-10**]. Her potassium was 3.1 which was repleted and she was
given zofran, dilaudid, IVFs, and was sent home. Later that
same day she represented to the OSH with inability to swallow
her saliva. At that point, her temperature was 100.3 and a CT
scan of her neck was performed. She was noted to have abnormal
thickening and edema of the aryepiglottic folds, right greater
than left, as well as nonspecific circumferential edema at the
pharyngeoesophageal junction on a CT scan of her neck at the
OSH. No abscess was noted on imaging. She was given
solumedrol, dilaudid, ativan, Tylenol, and clindamycin at the
OSH prior to being transferred to the ED here at [**Hospital1 18**] for
further evaluation.
.
In the ED, initial VS were: T=96.2, HR=80, BP=90/60, RR=22, and
POx=96% RA. She was not noted to be in any respiratory distress
and did not have any stridor. ENT was called to evaluate her
airway at which point it was noted that the patient has had a
several day history of progressive globus, dysphagia, and
odynophagia. She also reported airway discomfort at night.
During her initial wave of palliative radiation to
cervical/thoracic spine, she also developed similar symptoms
which resolved on steroid therapy that was subsequently stopped
about 3 weeks ago. She did report developing some rashes which
she attributed to the steroid administration. She was given
ceftriaxone and it was recommended that she receive IV Decadron
10mg every 8 hours for 24 hours and be admitted to the MICU for
airway observation. A 22g and 18g peripheral IV were placed.
Prior to transfer to the ICU her vitals were T=97, HR=63,
BP=93/68, RR=14, and POx=97% RA.
.
On the floor, her initial vitals were T97 BP114/87 RR12 P92
sat97RA. She is comfortable. She has no audible stridor. She
denies difficulty breathing, coughing, shortness of breath. She
otherwise notes diffuse abdominal soreness, but no N/V. She
mentions a recent episode of oral thrush several weeks ago.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Metastatic breast cancer to lungs, liver, and bone complicated
by multiple vertebral fractures, currently on palliative
chemotherapy and XRT for about 1 month
Social History:
Lives at home with mother in [**Name (NI) **]
Family History:
Mother with SLE, raynauds. Mother's side with "autoimmune
diseases." No cancer history
Physical Exam:
Vitals: T97 BP114/87 RR12 P92 sat97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. No pharyngeal
edema or massesnoted.
Neck: supple, JVP not elevated, no LAD. No stridor.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, sore to palpation diffusely, 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
Physical exam on the day of discharge:
VS: 97.2, BP 97/65, HR 72, RR 12, 96% RA
General: oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. No pharyngeal
edema or massesnoted.
Neck: supple, JVP not elevated, no LAD. No stridor.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, sore to palpation diffusely, 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:
1. Labs:
[**2135-6-19**] 02:50AM BLOOD WBC-0.9* RBC-3.16* Hgb-9.5* Hct-27.7*
MCV-88 MCH-30.0 MCHC-34.2 RDW-14.1 Plt Ct-403
[**2135-6-19**] 02:50AM BLOOD Neuts-27* Bands-5 Lymphs-36 Monos-30*
Eos-0 Baso-1 Atyps-1* Metas-0 Myelos-0 NRBC-4*
[**2135-6-19**] 02:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2135-6-19**] 02:50AM BLOOD PT-15.7* PTT-29.3 INR(PT)-1.4*
[**2135-6-19**] 02:50AM BLOOD Glucose-115* UreaN-3* Creat-0.3* Na-138
K-3.8 Cl-106 HCO3-22 AnGap-14
.
2. Imaging/diagnostics: none
.
3. Microbiology:
- Blood culture ([**2135-6-19**]): pending
- Urine culture ([**2135-6-19**]): negative
Brief Hospital Course:
Ms. [**Known lastname **] is a 24yoF with metastatic breast cancer currently
on chemo/XRT who was transferred to [**Hospital1 18**] out of concern for
laryngoedema, and who was found to have supraglottic edema
likely related to her therapy.
# SUPRAGLOTTIC EDEMA: Her globus, odynophagia, and dysphagia
are driven by the edema noted on her laryngeal examination. She
has no clinical signs of airway compromise- she is not in
respiroatroy distress, she is not stridorous, and her
saturations are excellent on room air. She is speaking normally
and is managing her own secretions. The inflammatory effects of
radiation therapy compounded by chemo-induced emesis and recent
thrush are probably causing this edema. She received Decadron
10 mg IV q8h x3 per ENT recommendation as well as cool
humidified air. The plan is for her to receive Augmentin for 9
more days. She was instructed to have a follow up with her
primary care physician [**Name Initial (PRE) 176**] 1 week of her discharge
# POSITIVE UA: She has leuks few bacteria on UA. She is
asymptomatic but mentions a recent fever. Due to her poor immune
status from chemo, she received a dose of ceftriaxone in the ED.
# METASTATIC BREAST CANCER. Poor prognosis with widely
metastatic disease, undergoing palliative chemo/rads. She had
Dilaudid for pain control. Methadone was held temporarily while
in the hospital given low RR.
# ANXIETY: She continued Ativan 0.25mg QID
# Goals of care. Patient was transitioned to hospice care upon
discharge home.
Medications on Admission:
-Methadone 5mg [**Hospital1 **]
-Dilaudid 2-4mg [**Hospital1 **]
-Ativan 0.25mg QID
-Vitamin D 500units daily
-Calcium 600mg daily
-restoril 15mg QHS
-nystatin
-zofran 4mg q6hr
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
2. Ativan 0.5 mg Tablet Sig: [**1-16**] Tablet PO four times a day as
needed for nausea.
3. methadone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
4. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
once a day.
5. Restoril 15 mg Capsule Sig: One (1) Capsule PO at bedtime.
6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every six (6) hours as needed for nausea.
7. Vitamin D Oral
8. nystatin Oral
9. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution Sig:
Ten (10) mL PO three times a day for 9 days.
Disp:*270 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
hospice of [**Location (un) 1121**] and greater [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Metastatic breast cancer
Laryngitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **], you were admitted to the [**Hospital1 827**] because you had difficulty swallowing and were
concerned that your throat was closing. We asked the ear, nose,
and throat doctors to examine [**Name5 (PTitle) **] and thought it was most likely
an infection of the larynx. We gave you antibiotics to treat it.
.
Medications:
ADDED: Augmentin for nine days for your throat infection
CHANGED: none
REMOVED: none
Followup Instructions:
Please make an appointment and follow-up with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**] within one week after discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2135-6-20**]
|
[
"174.8",
"198.5",
"300.00",
"197.0",
"478.6",
"112.0",
"E879.2",
"733.13",
"197.7",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8058, 8157
|
5609, 7131
|
338, 344
|
8256, 8256
|
4874, 5586
|
8863, 9191
|
3565, 3653
|
7359, 8035
|
8178, 8178
|
7157, 7336
|
8407, 8840
|
3668, 4855
|
286, 300
|
2921, 3301
|
372, 2903
|
8197, 8235
|
8271, 8383
|
3323, 3485
|
3501, 3549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,145
| 169,807
|
15861
|
Discharge summary
|
report
|
Admission Date: [**2114-12-26**] Discharge Date: [**2114-12-29**]
Date of Birth: [**2065-7-27**] Sex: F
Service: MEDICINE
Allergies:
Librium / Erythromycin Base / Vasotec
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
CHIEF COMPLAINT: transfer from [**Hospital1 1562**] for liver failure
REASON FOR MICU ADMISSION: hypotension
Major Surgical or Invasive Procedure:
CVL
Intubation
History of Present Illness:
49 yoF w/ a h/o ETOH and hep C cirrhosis presents from [**Hospital 1562**]
hospital after presenting with worsening jaundice and fatigue.
She was noted there to be hypotensive to the low 80s systolic,
noted to have an elevated bili and INR- she was given 4 Liters
IVF and transferred to the [**Hospital1 18**] ER.
.
In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat:
99%. In the ER she rec'd morphine 2mg IV x 4 doses for pain and
ceftriaxone 1g IV x 1. A right femoral line was placed. On
levophed on 0.15. She was given 4 L IVF in [**Hospital 1562**] hospital, 3
L in the ER at [**Hospital1 18**].
.
Prior to transport from the ER she was afebrile, HR 93 BP
108/71 O2 sat: 94% on 5L O2 NC.
.
Currently the patient complains of generalized abdominal pain,
moreso of the lower abdomen. No SOB, no Chest pain. She denies
any other symptoms. She has given conflicting reports regarding
ETOH intake, ranging from 6 beers 4 days prior to 1 pint of
vodka the night prior to her abdominal pain beginning.
Past Medical History:
1. Hepatitis C.
2. Alcoholic hepatitis.
3. History of alcohol abuse with withdraw seizures and DTs in
the past.
4. History of hypertension.
5. History of chronic pancreatitis.
6. Status post cesarean section and ectopic pregnancies in the
past.
7. History of traumatic wrist laceration in the past status
post
surgical repair with blood transfusions in [**2084**].
8. S/P ccy, s/p oophorectomy
9. DM II
Social History:
6 tabs of tylenol 3 days ago, 1 pint of hard liquor on [**Holiday **]
however the patient's history is relatively unreliable given
encephalopathy. She lives w/ friends, smokes [**Name2 (NI) **] and is a
current abuser of ETOH (daily)- unable to quantify. H/o opiate
abuse but no opiates x 1 year.
Physical Exam:
GENERAL: NAD, AOx2
HEENT: MM slightly dry, JVP 9cm
CARDIAC: RRR, SEM at the USB
LUNG: ronchi of R lower and middle lung fields
ABDOMEN: soft, obese, NT, ND, no masses, ascites
EXT: WWP, no c/c/e
NEURO: asterixis, mild confusion and somnolence
DERM: jaundice, icterus
Pertinent Results:
[**2114-12-26**] 10:08PM HCT-26.5*
[**2114-12-26**] 05:32PM LACTATE-2.6*
[**2114-12-26**] 05:20PM ALT(SGPT)-34 AST(SGOT)-79* LD(LDH)-231 ALK
PHOS-83 AMYLASE-14 TOT BILI-24.7*
[**2114-12-26**] 05:20PM UREA N-6 CREAT-1.0 SODIUM-134 POTASSIUM-4.0
CHLORIDE-100 TOTAL CO2-21* ANION GAP-17
[**2114-12-26**] 05:20PM LIPASE-26 GGT-75*
[**2114-12-26**] 05:20PM ALBUMIN-2.9*
[**2114-12-26**] 05:20PM IgG-[**2069**]*
[**2114-12-26**] 05:20PM HCT-27.8*
[**2114-12-26**] 06:01AM AFP-1.7
[**2114-12-29**] 03:57AM BLOOD WBC-19.2* RBC-2.14* Hgb-8.5* Hct-26.1*
MCV-122* MCH-39.6* MCHC-32.4 RDW-20.2* Plt Ct-147*
[**2114-12-29**] 03:57AM BLOOD PT-33.9* PTT-66.9* INR(PT)-3.4*
[**2114-12-28**] 07:38AM BLOOD Fibrino-127*
[**2114-12-27**] 08:50AM BLOOD FDP-10-40*
[**2114-12-27**] 08:50AM BLOOD Fibrino-125*
[**2114-12-29**] 04:10PM BLOOD Glucose-179* UreaN-9 Creat-1.7* Na-135
K-4.6 Cl-95* HCO3-8* AnGap-37*
[**2114-12-29**] 03:57AM BLOOD ALT-22 AST-78* LD(LDH)-395* CK(CPK)-13*
AlkPhos-55 TotBili-30.9*
[**2114-12-29**] 03:57AM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.4 Mg-2.2
[**2114-12-29**] 04:16PM BLOOD Type-ART pO2-77* pCO2-30* pH-6.96*
calTCO2-7* Base XS--25
[**2114-12-29**] 04:16PM BLOOD Lactate-16.4*
CT ABDOMEN [**2114-12-27**]
1. No evidence of portal vein thrombosis.
2. Cirrhotic liver with stigmata of liver disease. New segmental
regions of
hypodensity in segment II of the liver which may represent
perfusion
abnormality, focal hepatitis or dilated intrahepatic ducts, but
underlying
mass lesion is not excluded. Further assessment could be
performed by MRI once
the patient is able to cooperate with breathhold instructions.
3. Moderate ascites and anasarca.
4. Bibasilar atelectasis, underlying infection is not excluded.
CT CHEST [**2114-12-26**]
1. No evidence of lobar/bacterial pneumonia. Findings most
consistent with
volume overload, probably with superimposed areas of linear and
dependent
atelectasis. A concurrent atypical pneumonia is difficult to
exclude.
2. Slight increase in ascites, which is now hyperdense, most
consistent with
hemorrhage. Findings are very concerning for new intraperitoneal
hemorrhage,
particularly if there has been a recent procedure such as
paracentesis.
3. Unchanged markedly hypodense liver, consistent with fatty
liver,
presumably related to reported clinical history of liver
failure.
CXR [**2114-12-29**]:
FINDINGS: Comparison is made to the previous study from [**12-28**], [**2114**].
The tip of the endotracheal tube is 8 cm above the carina, could
be advanced 1
to 2 cm for optimal placement. The ETT tube has been pulled back
since the
previous study. The nasogastric tube and side port are well
below the
gastroesophageal junction. There has been mild improvement of
the airspace
opacities since the previous study. However, they remain
diffuse. There is a
right-sided PICC line with the distal lead tip at the distal
SVC.
Brief Hospital Course:
49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from
[**Hospital 1562**] hospital with acute hepatic failure.
She was admitted with acute alcoholic hepatitis and hypotension
and had gradually worsening liver function with a rising
bilirubin. She was also initially in renal failure but
responded to albumin. Two days prior to expiring, she developed
acutely worsening hypoxia with bilateral infiltrates and ARDS
requiring intubation. She required high levels of peep and an
esophogeal balloon was placed. She was also profoundly
hypotensive, requiring four pressors. She had a rising lactate
on broad spectrum antibiotics, and developed a profound lactic
acidosis with a lactate peaking at 16. Her family was contact[**Name (NI) **]
and her sons were able to see her before she expired at 5:30
p.m. on [**2113-12-29**]. They requested an autopsy.
Medications on Admission:
Metformin 1000mg daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2114-12-30**]
|
[
"276.1",
"799.02",
"571.0",
"571.2",
"401.9",
"305.1",
"790.92",
"458.9",
"250.00",
"570",
"305.50",
"577.1",
"070.70",
"518.0",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"54.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6427, 6436
|
5459, 6326
|
409, 425
|
6487, 6496
|
2535, 5436
|
6552, 6591
|
6399, 6404
|
6457, 6466
|
6352, 6376
|
6520, 6529
|
2242, 2516
|
278, 371
|
453, 1476
|
1498, 1911
|
1927, 2227
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,583
| 138,864
|
53034
|
Discharge summary
|
report
|
Admission Date: [**2161-4-29**] Discharge Date: [**2161-5-16**]
Date of Birth: [**2075-7-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
arterial line placement
central line placement
intubation
History of Present Illness:
85 M with history of HTN, hypercholesterolemia, PVD, lung ca s/p
right pneumonectomy presenting with increasing SOB x several
days and dry cough with fever at home. Denies CP/palpitations.
No n/v/d.
.
On arrival to ED, initial vitals 97.2 100 106/52 20 86% and
triggered for an O2 sat of 86%. Patient was placed on a NRB
with O2 sats up to 100%, but RR continued to rise to 30-40.
Initial CXR showed noew opacity in left base compatible with
PNA. Started on ceftriaxone and levofloxacin for presumed PNA.
Patient was subsequently intubated for increasing respiratory
distress and elevated lactate. Other notable labs were trop of
0.16, BNP of [**Numeric Identifier 10489**], Cr of 1.7 up from baseline of 0.8, WBC of
18.6 with left shift. EKG ST at 112 with new RBBB. Cardiology
consulted given trop elevation and felt likely secondary to
demand ischemia and hypoperfusion, recommended treatment with
asa, but no further intervention. After intubation, SBPs
dropped to 60s, started on peripheral levophed and left IJ CVL
was placed in ED. On transfer to MICU, patient's most recent
vitals were BP 96/48, 99, 99% on FiO2 60%, PEEP 8 on levophed
0.15. Given 3L NS down in ED.
.
On arrival to the MICU, patient is intubated and sedated. Vital
signs are BP 99/58, P 117, RR 17, O2 sat 97% intubated. No
further history is able to be obtained.
Past Medical History:
HTN, BPH s/p TURP, pleural pulmonary TB, lung ca s/p right
pneuomnectomy, PVD, prostate ca s/p XRT
Social History:
Divorced. Employed as custodian. Former heavy smoker, quit in
[**2128**]'s ?90's. Lives alone. Has a daughter who is in good
health.
Family History:
non contributory
Physical Exam:
admission exam
Vitals: BP 99/58, P 117, RR 17, O2 sat 97% intubated
General: Intubated, sedated, in NAD
HEENT: PERRL, ETT in place, NGT in place
Neck: supple, JVP not elevated, no LAD
CV: sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Lungs:Crackles at left base on anterior exam, absent
breathsounds on right
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place draining concentrated urine
Ext: cool extremities bilaterally with 2+ radial and DP pulses
bilaterally, no appreciable edema, right foot with small 1cm
circumference nonhealing ulcer on dorsum, no surrounding
erythema, no significant drainage
Neuro: intubated and sedated
Pertinent Results:
Admission Labs:
[**2161-4-29**] 10:45PM BLOOD WBC-18.6*# RBC-4.92 Hgb-14.4 Hct-43.9
MCV-89 MCH-29.3 MCHC-32.9 RDW-14.9 Plt Ct-112*
[**2161-4-29**] 10:45PM BLOOD Neuts-87* Bands-9* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2161-4-29**] 10:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2161-4-30**] 12:00AM BLOOD PT-19.3* PTT-33.0 INR(PT)-1.8*
[**2161-4-29**] 10:45PM BLOOD Glucose-185* UreaN-43* Creat-1.7* Na-127*
K-5.8* Cl-85* HCO3-18* AnGap-30*
[**2161-4-29**] 10:45PM BLOOD CK-MB-12* MB Indx-1.2 proBNP-[**Numeric Identifier **]*
[**2161-4-29**] 10:45PM BLOOD cTropnT-0.16*
[**2161-4-30**] 03:43AM BLOOD CK-MB-13* MB Indx-1.8 cTropnT-0.22*
[**2161-4-30**] 02:44PM BLOOD CK-MB-15* MB Indx-2.8 cTropnT-0.36*
[**2161-4-30**] 10:05PM BLOOD CK-MB-12* cTropnT-0.31*
[**2161-4-30**] 03:43AM BLOOD Calcium-7.5* Phos-4.1 Mg-1.9
[**2161-4-30**] 03:43AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2161-4-30**] 01:30PM BLOOD HIV Ab-NEGATIVE
[**2161-4-30**] 03:43AM BLOOD HCV Ab-NEGATIVE
[**2161-4-29**] 10:50PM BLOOD Lactate-10.6*
[**2161-4-30**] 04:04AM BLOOD O2 Sat-68
[**2161-4-30**] 03:58AM BLOOD freeCa-1.08*
.
urine
[**2161-4-30**] 01:20AM URINE Color-[**Location (un) **] Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2161-4-30**] 01:20AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-NEG
[**2161-4-30**] 01:20AM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-1
[**2161-4-30**] 01:20AM URINE CastGr-16* CastHy-8*
[**2161-4-30**] 01:20AM URINE Mucous-RARE
[**2161-5-2**] 10:12AM URINE Hours-RANDOM UreaN-428 Na-LESS THAN K-45
Cl-16
[**2161-5-2**] 10:12AM URINE Osmolal-375
.
MICROBIOLOGY:
.
[**2161-4-29**] 11:00 pm BLOOD CULTURE # 2.
**FINAL REPORT [**2161-5-6**]**
Blood Culture, Routine (Final [**2161-5-6**]): NO GROWTH.
[**2161-4-30**] 1:20 am URINE
**FINAL REPORT [**2161-5-1**]**
URINE CULTURE (Final [**2161-5-1**]): NO GROWTH.
[**2161-4-30**] 1:47 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2161-4-30**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2161-5-2**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2161-5-7**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2161-4-30**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2161-5-1**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2161-5-1**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2161-4-30**] 1:47 pm Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture (Final [**2161-5-4**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2161-5-1**]):
Less than 60 columnar epithelial cells; Specimen
inadequate for
detecting respiratory viral infection by DFA testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) 14775**] [**2161-5-1**]
10:30AM.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2161-5-4**]):
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
[**2161-5-7**] 5:07 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2161-5-9**]**
GRAM STAIN (Final [**2161-5-7**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2161-5-9**]):
Commensal Respiratory Flora Absent.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
ECG's:
Cardiovascular Report ECG Study Date of [**2161-4-29**] 10:50:22 PM
Sinus tachycardia. Right bundle-branch block. Non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of [**2145-7-19**] right bundle-branch block and sinus tachycardia are
now present.
TRACING #1
Cardiovascular Report ECG Study Date of [**2161-4-30**] 8:53:20 AM
Sinus rhythm with atrial premature depolarizations. Compared to
the previous tracing the heart rate is reduced. Otherwise, no
significant change.
TRACING #2
Cardiovascular Report ECG Study Date of [**2161-4-30**] 10:53:32 PM
Atrial fibrillation with a rapid ventricular response. Right
bundle-branch
block. Diffuse ST-T wave changes. Compared to the previous
tracing of [**2161-4-30**] the rhythm is atrial fibrillation with a
rapid ventricular response. Other findings are similar.
TRACING #1
Cardiovascular Report ECG Study Date of [**2161-5-1**] 2:01:58 AM
Sinus rhythm with atrial premature beat. Right bundle-branch
block.
Non-specific lateral T wave changes. Compared to the previous
tracing sinus rhythm is now present.
TRACING #2
Cardiovascular Report ECG Study Date of [**2161-5-3**] 6:15:10 AM
Atrial fibrillation with rapid ventricular response. Right
bundle-branch
block. Diffuse non-specific ST-T wave changes. Q-T interval is
prolonged.
Compared to the previous tracing of [**2161-5-1**] the rhythm is now
atrial
fibrillation and the ventricular response is rapid.
Cardiovascular Report ECG Study Date of [**2161-5-4**] 10:43:48 AM
Sinus rhythm with atrial premature depolarizations. Right
bundle-branch block. Non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2161-5-3**] the
cardiac rhythm is now sinus mechanism.
IMAGING:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-4-29**]
10:36 PM
IMPRESSION: Left basal pneumonia. Followup radiograph four
weeks after
treatment is recommended.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-4-29**]
11:15 PM
IMPRESSION: Satisfactory position of endotracheal tube with
findings of left basal pneumonia.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 109305**]Portable
TTE (Complete) Done [**2161-4-30**] at 10:04:10 AM FINAL
There is mild symmetric left ventricular hypertrophy. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The overall left ventricular ejection
fraction is severely depressed (LVEF = 25 %) secondary to
ventricular interaction with a pressure and volume overloaded
right ventricle. The right ventricular cavity is dilated with
severe global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The ascending aorta is mildly dilated.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen (may be
significantly underestimated due to the technically suboptimal
nature of this study). Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-4-30**]
12:44 AM
The ET tube tip is 7 cm above the carina. The NG tube tip is in
the stomach. Left internal jugular line tip is most likely in
the left brachiocephalic vein.
There is additional interval progression of left middle lower
lung
consolidation. No pneumothorax is seen. Small amount of
pleural effusion
cannot be excluded.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-4-30**] 1:09
AM
Portable AP radiograph of the chest was reviewed in comparison
to prior study obtained several minutes earlier. Currently, the
left internal jugular has been advanced with its tip most likely
at the superior SVC. The rest of the findings did not change in
the short interim.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2161-5-1**] 2:51 AM
IMPRESSION:
1. Multifocal left pneumonia and parapneumonic effusion.
2. Stable right pneumonectomy changes.
3. No evidence of pulmonary embolism. Probable pulmonary
hypertension.
4. Left adrenal adenoma.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-5-3**] 4:32
AM
IMPRESSION: AP chest compared to [**4-29**] through 17:
Large pneumonia in the left lung has increased in extent since
[**4-30**],
accompanied by increasing pleural effusion, of indeterminate
volume. The
patient has had right pneumonectomy. ET tube is in standard
position. Left jugular line ends in the upper SVC. No left
pneumothorax.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2161-5-5**] 2:56 PM
IMPRESSION: Right-sided PICC line in the right atrium, should
be withdrawn 4 cm for more optimal positioning in the low SVC.
Increasing left basilar pneumonia.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-5-6**] 2:21
AM
Multifocal pneumonia in the left lung is unchanged. The left
apex is still clear. Patient is status post right pneumonectomy
with white out of the right hemithorax. The cardiomediastinal
silhouette cannot be evaluated, is obscured by pleural and
parenchymal abnormalities. ET tube is in standard position. NG
tube tip is in the stomach. Right PICC tip is probably in the
mid SVC.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-5-6**] 4:43
PM
FINDINGS: As compared to the previous radiograph, the previous
feeding tube has been removed and replaced by a Dobbhoff
catheter. The catheter is in the mid esophagus. It should be
advanced by at least 20 cm to ensure position within the
stomach. The patient has also received a tracheostomy tube and
the endotracheal tube has been removed. Normal position of this
device.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-5-7**] 8:46
PM
FINDINGS: As compared to the previous radiograph, there is
unchanged
appearance of the left lung, with a known extensive left
pneumonia. The
monitoring and support devices are constant. Also constant is
the appearance of the post-pneumonectomy chest on the right.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-5-9**] 1:11
PM
FINDINGS: Comparison is made to previous study from [**2161-5-7**].
There is a tracheostomy tube, which is unchanged in position and
appropriately sited. There is again seen complete whiteout of
the right lung. There is a Dobbhoff tube whose tip is in the
fundus of the stomach. There is an airspace opacity in the left
mid and lower lung fields consistent with known pneumonia. This
is slightly more dense than on the prior study. There are no
pneumothoraces.
CXR [**2161-5-13**] 7:15 AM
IMPRESSION: Worsening extensive left lung consolidation.
Minimal aerated
left upper lobe.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Patient is an 85yo male with HTN, hypercholesterolemia, PVD, and
lung ca s/p pneumonectomy who presented with respiratory failure
and shock, and found to have pneumonia. He initially presented
with increasing SOB x 1 week with associated dry cough and
fever. He was quite ill from the time of presentation with
respiratory distress, for which he required intubation, as well
as hypotension requiring vasopressors. CXR was consistent with
PNA. Initial BAL showed gram positive cocci and he completed a
course of antibiotics for CAP. He improved and was successfully
weaned off all pressors, however, after initial improvement,
patient had recurrent fevers, leukocytosis, and worsening CXR.
Bronchoscopy was concerning for necrotizing PNA. Patient was
started on treatment for VAP with cipro, vanc, cefepime however
sputum culture showed STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA
and antibiotics were tailored to sensitivities. The patient's
respiratory status remained tenous from the start, he underwent
tracheostomy placement on [**2161-5-6**]. He continued on CMV with
increased minute ventilation. He had intermittent difficulty
tolerating ventilation with intermittent agitation requiring
increasing sedation. He later developed increasing bloody
secretions worsened by anticoagulation for Afib. His warfarin
was stopped and he was given 2mg of vitamin K. FiO2 and PEEP
requirements subsequently increased with some transient
improvement with suctioning. Overall, patient's respiratory
status continued to deteriorate, requiring FIO2 100%, appearing
increasingly uncomfortable despite increases in sedating
medications. The patient's clinical status was discussed with
his HCP who ultimately chose to gradually withdraw aggressive
medical care over several days. On [**2161-5-15**], per family/HCP
request, the ventilator was withdrawn. Patient was kept
comfortable with IV pain medications, and he expired at 10:20
pm. The family refused autopsy.
.
THE PATIENT'S COURSE WAS COMPLICATED BY THE FOLLOWING:
# Acute respiratory failure
See above.
.
# Septic shock
Hypotensive on admission requiring vasopressors, improved with
volume and treatment of underlying infection. Ultimately weaned
off pressors, though transiently required them for trach
procedure [**5-6**]. As patient was transitioned to comfort care did
not further address hypotension.
# Acute kidney injury
Patient developed ATN, likely from poor perfusion while
initially septic. From initial presentation and volume boluses,
patient remained volume up for length of stay and required lasix
diuresis. His creatinine intially normalized, however, renal
dysfuction gradually insued with associated electrolyte
abnormalities. As patient was transtioned to comfort measures,
laboratory studies were no longer monitored.
# Afib with RVR
Patient with intermittent Afib. He received amiodarone 1mg/min
x 6 hours then 0.5 mg/min for 18 hours however amio d/c??????d on
[**5-2**] as patient was in sinus rhythm and LFTs were rising. He
remained in SR thereafter. Metoprolol was held metoprolol in
setting of hypotension, and warfarin was ultimately discontinued
in the setting of airway bleeding.
# Anemia and thrombocytopenia:
Related to hemodilution in the setting of large amount of IV
fluids, marrow suppression in setting of acute infection, and
gradual blood loss from pulmonary process.
# Foot ulcer
His wound was evaluated by vascular surgery who felt it was
stable and not the cause of his sepsis.
Medications on Admission:
asa 81
HCTZ 25
pravastatin 40
percocet 1 tab qHS
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Discharge Condition:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"428.20",
"287.5",
"253.6",
"584.9",
"V15.82",
"E879.8",
"785.52",
"V45.76",
"V12.01",
"440.23",
"276.7",
"428.0",
"427.31",
"285.9",
"416.8",
"486",
"038.9",
"707.15",
"V58.67",
"250.00",
"276.0",
"518.84",
"272.4",
"V10.11",
"401.9",
"V10.46",
"997.31",
"995.92",
"V49.86",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.24",
"96.72",
"96.04",
"31.1",
"33.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18701, 18710
|
15063, 18573
|
312, 371
|
18773, 18875
|
2793, 2793
|
2043, 2061
|
18673, 18678
|
18731, 18752
|
18599, 18650
|
2076, 2774
|
6013, 15040
|
5854, 5977
|
265, 274
|
399, 1750
|
2809, 5821
|
1772, 1873
|
1889, 2027
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,885
| 133,139
|
52743
|
Discharge summary
|
report
|
Admission Date: [**2142-9-10**] Discharge Date: [**2142-9-16**]
Date of Birth: [**2069-1-24**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Ampicillin
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
LLQ abdominal pain
Major Surgical or Invasive Procedure:
Central Line Placement, Intubation/Extubation
History of Present Illness:
73 y/o F with h/o CAD s/p CABGx2, h/o CHF, PPM, PaHTN, CKD.
She has had several days of generally feeling unwell with
increased cough productive of clear sputum. Today, she was
watching football and preparing for bed early when she had
sudden left sided LLQ/flank/back pain that led to nausea and
almost immediate non-bloody vomiting. The pain persisted and was
a severe achiness, and she presented to [**Hospital3 24768**].
There, she had a U/A with trace blood and 3-5rbcs, and
non-contrast abdominal CT which was negative for
nephro/ureterolithiasis or free air. She was transferred to
[**Hospital1 18**] for further management.
In the ED, vital signs were initially: 97.6 50irreg 123/86 18 97
While being worked up, she also developed chest pain that she
stated was her anginal equivalent that has been occuring on a
near daily basis, confirmed with discussion with her PCP. [**Name10 (NameIs) 3754**]
were no significant ECG changes reported with the chest pain
that was recalcitrant to SL NTG but responded with IV morphine.
The ED staff recommended abdominal CT scanning with PO and IV
contrast for further workup. They began premedicating with
prednisone 40mg, ranitidine 150mg and diphenhydrame 50mg which
she started at 2:30am. She also started receiving normal saline
at 75cc/hr.
On the floor after receiving IV morphine in the ED, she is
currently entirely free of chest and abdominal pain.
Past Medical History:
- CAD s/p CABG x2, h/o MI
[**2105**] SVG-LAD, SVG-PDA
redo [**2123**] LIMA-ramus, SVG-RCA
Multiple PCIs, last one [**11-28**] with patent SVG-LAD and LIMA-RI,
last
stent [**2136**] prox L cx. Last cath [**1-1**] no intervenable lesions.
- Systolic heart failure with EF 50% in [**2138**]
- Pulmonary artery hypertension (mild) with 3+TR
- S/p Pacemaker for Mobitz II/SSS--initially implanted [**2123**] on
the right with a generator change in [**2127**] and in [**2135**]
- Chronic afib, not anticoagulated due to a history of bleeding
and spontaneously elevated INRs; at times a flutter with RBBB
- DM type II
- Chronic renal failure
- H/o MRSA infection on doxycycline
- Anemia, per pt has seen hematologist as outpatient in
[**Location (un) 1459**], RI and has had 2 bone marrow bxs done with no clear
etiology; currently on Procrit. Has had h/o guiac positive stool
but no frank GIB with last C-scope [**2137-2-27**] with sigmoid
diverticulosis and grade I internal hemorrhoids; EGD [**2137-2-25**] with
erosions in pylorus and antrum
- H/o vagina bleeding - negative bx, maintained on Aygestrin
- H/o gout
- S/p appendectomy
- S/p cholecystectomy
- S/p ventral hernia repair
- LGIB [**3-31**].
Social History:
Widowed, lives alone, has 5 children and grandchildren who often
visit nightly. No tobacco use, quit 40 years ago. Previously
smoked [**11-24**] ppd x 12 yrs. Denies EtOH or IVDA.
Family History:
Father died of lung CA at 71; mother died of MI at 67; sister
with CABG in 60s, brother who died of MI at age 64; son deceased
at age 19 from MVA (drunk driver struck him).
Physical Exam:
VS: 95.9 123/56 52 18 100% RA
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT: TR, dynamic JVP. neck supple, No lymphadenopathy in
cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs with b/l crackles, left sided egophany present
CARDIAC: Regular rhythm; II/VI SM radiating to carotids. IV/VI
SM at left sternal border, III/VI SM radiating to axilla.
ABDOMEN: Non-distended, and soft without tenderness. No
organomegaly.
EXTREMITIES:RLE>LLE in size, but no redness/warmth.
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact with
exception of left eye which is unreactive. BUE [**3-27**], and BLE [**3-27**]
both proximally and distally. No pronator drift.
Pertinent Results:
CBC:
[**2142-9-9**] 11:55PM BLOOD WBC-9.6 RBC-4.20 Hgb-12.3 Hct-37.3 MCV-89
MCH-29.2 MCHC-32.9 RDW-19.4* Plt Ct-200
[**2142-9-9**] 11:55PM BLOOD Neuts-67.9 Lymphs-24.0 Monos-4.5 Eos-2.7
Baso-0.9
[**2142-9-10**] 09:00AM BLOOD WBC-7.2 RBC-3.88* Hgb-10.8* Hct-35.2*
MCV-91 MCH-27.9 MCHC-30.7* RDW-18.6* Plt Ct-170
[**2142-9-10**] 09:00AM BLOOD Neuts-86.8* Lymphs-9.9* Monos-2.8 Eos-0.3
Baso-0.3
[**2142-9-11**] 07:10AM BLOOD WBC-11.3*# RBC-3.98* Hgb-11.4* Hct-35.3*
MCV-89 MCH-28.5 MCHC-32.1 RDW-19.4* Plt Ct-187
[**2142-9-12**] 07:15AM BLOOD WBC-8.8 RBC-3.74* Hgb-10.5* Hct-33.3*
MCV-89 MCH-28.1 MCHC-31.6 RDW-19.5* Plt Ct-160
[**2142-9-13**] 07:10AM BLOOD WBC-6.4 RBC-3.38* Hgb-9.7* Hct-30.2*
MCV-89 MCH-28.7 MCHC-32.1 RDW-19.5* Plt Ct-146*
[**2142-9-13**] 05:00PM BLOOD Hct-31.5*
[**2142-9-14**] 03:01AM BLOOD WBC-10.4# RBC-3.46* Hgb-9.7* Hct-33.4*
MCV-97# MCH-27.9 MCHC-28.9* RDW-18.2* Plt Ct-168
[**2142-9-14**] 03:01AM BLOOD Neuts-62.4 Lymphs-32.0 Monos-3.4 Eos-1.8
Baso-0.5
[**2142-9-14**] 10:38AM BLOOD WBC-21.6*# RBC-3.24* Hgb-9.1* Hct-29.6*
MCV-91 MCH-28.0 MCHC-30.7* RDW-18.7* Plt Ct-191
[**2142-9-14**] 10:38AM BLOOD Neuts-90.6* Lymphs-4.2* Monos-5.0 Eos-0.1
Baso-0.1
[**2142-9-14**] 05:17PM BLOOD WBC-18.1* RBC-3.24* Hgb-9.3* Hct-29.1*
MCV-90 MCH-28.8 MCHC-32.1 RDW-19.6* Plt Ct-166
[**2142-9-14**] 05:17PM BLOOD Neuts-87.8* Lymphs-6.3* Monos-5.5 Eos-0.2
Baso-0.2
[**2142-9-15**] 05:53AM BLOOD WBC-13.4* RBC-3.26* Hgb-9.3* Hct-29.4*
MCV-90 MCH-28.6 MCHC-31.7 RDW-19.6* Plt Ct-151
[**2142-9-16**] 04:04AM BLOOD WBC-19.7* RBC-2.69* Hgb-7.6* Hct-24.0*
MCV-89 MCH-28.2 MCHC-31.6 RDW-18.7* Plt Ct-208
[**2142-9-16**] 04:04AM BLOOD Neuts-85.0* Lymphs-8.5* Monos-6.3 Eos-0.1
Baso-0.1
Coags:
[**2142-9-9**] 11:55PM BLOOD PT-13.4 PTT-18.9* INR(PT)-1.1
[**2142-9-10**] 09:00AM BLOOD PT-14.8* PTT-21.8* INR(PT)-1.3*
[**2142-9-14**] 03:01AM BLOOD PT-14.0* PTT-30.2 INR(PT)-1.2*
[**2142-9-14**] 10:38AM BLOOD PT-14.4* PTT-27.5 INR(PT)-1.3*
[**2142-9-14**] 05:17PM BLOOD PT-13.8* PTT-26.8 INR(PT)-1.2*
[**2142-9-15**] 05:53AM BLOOD PT-13.6* PTT-29.9 INR(PT)-1.2*
[**2142-9-16**] 04:04AM BLOOD PT-15.1* PTT-26.5 INR(PT)-1.3*
Renal & Glucose:
[**2142-9-9**] 11:55PM BLOOD Glucose-194* UreaN-28* Creat-1.6* Na-142
K-4.0 Cl-105 HCO3-24 AnGap-17
[**2142-9-10**] 09:00AM BLOOD Glucose-247* UreaN-30* Creat-1.9* Na-139
K-5.2* Cl-105 HCO3-26 AnGap-13
[**2142-9-10**] 12:50PM BLOOD K-5.6*
[**2142-9-10**] 09:20PM BLOOD K-4.7
[**2142-9-11**] 07:10AM BLOOD Glucose-117* UreaN-37* Creat-2.4* Na-143
K-4.5 Cl-103 HCO3-29 AnGap-16
[**2142-9-12**] 07:15AM BLOOD Glucose-76 UreaN-39* Creat-2.3* Na-143
K-3.7 Cl-105 HCO3-29 AnGap-13
[**2142-9-13**] 07:10AM BLOOD Glucose-73 UreaN-41* Creat-2.1* Na-142
K-4.6 Cl-105 HCO3-31 AnGap-11
[**2142-9-14**] 03:01AM BLOOD Glucose-276* UreaN-38* Creat-2.3* Na-145
K-3.4 Cl-105 HCO3-24 AnGap-19
[**2142-9-14**] 10:38AM BLOOD Glucose-100 UreaN-42* Creat-2.0* Na-146*
K-4.4 Cl-108 HCO3-33* AnGap-9
[**2142-9-14**] 05:17PM BLOOD Glucose-139* UreaN-43* Creat-1.7* Na-145
K-4.6 Cl-107 HCO3-31 AnGap-12
[**2142-9-15**] 02:24AM BLOOD Glucose-317* UreaN-41* Creat-1.6* Na-140
K-4.4 Cl-102 HCO3-31 AnGap-11
[**2142-9-15**] 05:53AM BLOOD Glucose-324* UreaN-43* Creat-1.6* Na-145
K-4.5 Cl-105 HCO3-32 AnGap-13
[**2142-9-15**] 02:30PM BLOOD Glucose-162* UreaN-48* Creat-2.0* Na-144
K-4.5 Cl-105 HCO3-31 AnGap-13
[**2142-9-16**] 04:04AM BLOOD Glucose-151* UreaN-54* Creat-2.6* Na-142
K-5.0 Cl-105 HCO3-23 AnGap-19
Enzymes & Bilirubin:
[**2142-9-9**] 11:55PM BLOOD ALT-26 AST-38 CK(CPK)-42 AlkPhos-91
TotBili-1.1
[**2142-9-10**] 09:00AM BLOOD ALT-21 AST-36 LD(LDH)-208 CK(CPK)-35
AlkPhos-75 TotBili-1.0
Cardiac enzymes:
[**2142-9-9**] 11:55PM BLOOD CK-MB-NotDone
[**2142-9-9**] 11:55PM BLOOD cTropnT-0.01
[**2142-9-10**] 09:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2142-9-11**] 07:10AM BLOOD CK(CPK)-47
[**2142-9-11**] 07:10AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2142-9-12**] 07:15AM BLOOD CK(CPK)-56
[**2142-9-12**] 07:15AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2142-9-12**] 03:30PM BLOOD CK(CPK)-73
[**2142-9-12**] 03:30PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2142-9-14**] 03:01AM BLOOD CK(CPK)-87
[**2142-9-14**] 03:01AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2142-9-14**] 10:38AM BLOOD CK(CPK)-1309*
[**2142-9-14**] 10:38AM BLOOD CK-MB-111* MB Indx-8.5* cTropnT-2.88*
[**2142-9-14**] 05:17PM BLOOD CK(CPK)-1465*
[**2142-9-14**] 05:17PM BLOOD CK-MB-144* MB Indx-9.8* cTropnT-3.80*
Lipase:
[**2142-9-9**] 11:55PM BLOOD Lipase-28
Chemistry:
[**2142-9-10**] 09:00AM BLOOD Albumin-3.4 Calcium-8.5 Phos-3.5 Mg-1.7
[**2142-9-11**] 07:10AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.5*
[**2142-9-12**] 07:15AM BLOOD Calcium-7.5* Phos-4.0 Mg-2.3
[**2142-9-13**] 07:10AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.5
[**2142-9-14**] 03:01AM BLOOD Calcium-7.3* Phos-5.7*# Mg-3.5*
[**2142-9-14**] 10:38AM BLOOD Calcium-6.7* Phos-3.6# Mg-2.7*
[**2142-9-14**] 05:17PM BLOOD Calcium-6.7* Phos-3.6 Mg-2.6
[**2142-9-15**] 02:24AM BLOOD Calcium-6.4* Phos-3.2 Mg-2.3
[**2142-9-15**] 05:53AM BLOOD Calcium-7.3* Phos-3.9 Mg-2.4
[**2142-9-15**] 02:30PM BLOOD Calcium-7.0* Phos-4.6* Mg-2.4
[**2142-9-16**] 04:04AM BLOOD Calcium-7.0* Phos-5.6* Mg-2.3
Digoxin:
[**2142-9-9**] 11:55PM BLOOD Digoxin-1.3
Blood gases:
[**2142-9-14**] 02:23AM BLOOD Type-ART pO2-27* pCO2-69* pH-7.18*
calTCO2-27 Base XS--4
[**2142-9-14**] 03:05AM BLOOD Type-ART Temp-37.2 Rates-28/ PEEP-10
FiO2-100 pO2-22* pCO2-69* pH-7.17* calTCO2-26 Base XS--6
AADO2-639 REQ O2-100 -ASSIST/CON Intubat-INTUBATED
[**2142-9-14**] 03:53AM BLOOD Type-ART Temp-36.7 pO2-402* pCO2-47*
pH-7.35 calTCO2-27 Base XS-0 Intubat-INTUBATED
[**2142-9-14**] 06:48AM BLOOD Type-CENTRAL VE Temp-35
[**2142-9-14**] 05:37PM BLOOD Type-MIX pH-7.35
[**2142-9-15**] 01:42AM BLOOD Type-ART pO2-185* pCO2-46* pH-7.41
calTCO2-30 Base XS-4
[**2142-9-15**] 04:52PM BLOOD Type-ART Rates-/14 Tidal V-500 PEEP-5
FiO2-40 pO2-115* pCO2-44 pH-7.41 calTCO2-29 Base XS-3
Intubat-INTUBATED
Lactate:
[**2142-9-10**] 12:18AM BLOOD Lactate-2.2*
[**2142-9-10**] 12:18PM BLOOD Lactate-1.8
[**2142-9-10**] 12:58PM BLOOD Lactate-2.1*
[**2142-9-10**] 09:54PM BLOOD Lactate-2.2*
[**2142-9-11**] 07:44AM BLOOD Lactate-2.2*
[**2142-9-12**] 04:41PM BLOOD Lactate-2.9*
[**2142-9-14**] 03:53AM BLOOD Lactate-8.1*
[**2142-9-15**] 06:00AM BLOOD Lactate-2.3*
Hb fractions:
[**2142-9-14**] 03:05AM BLOOD O2 Sat-17
[**2142-9-14**] 06:48AM BLOOD O2 Sat-79
Free Calcium:
[**2142-9-14**] 03:05AM BLOOD freeCa-1.02*
[**2142-9-14**] 05:37PM BLOOD freeCa-0.89*
[**2142-9-15**] 01:42AM BLOOD freeCa-0.94*
Urine:
[**2142-9-11**] 10:13AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.049*
[**2142-9-11**] 10:13AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.0 Leuks-TR
[**2142-9-11**] 10:13AM URINE RBC-5* WBC-5 Bacteri-NONE Yeast-NONE
Epi-3 TransE-<1
[**2142-9-11**] 10:13AM URINE CastHy-1*
[**2142-9-11**] 10:13AM URINE Mucous-RARE
Micro: Blood culture [**9-9**]: No growth x 2
Blood culture [**9-14**]: Pending x2
CXR [**9-10**]: Patchy left retrocardiac lower lobe opacities, could
reflect an early consolidation.
CT Abd/Pelvis [**9-10**]: 1. Small wedge-shaped left kidney defects
represent infarcts of indeterminate age.
2. Indeterminate 1.2 cm nodular left adrenal lesion
statistically most likely represents an adenoma but multiphase
imaging can be obtained for further evaluation.
3. There are extensive atherosclerotic calcifications along
the SMA and
celiac axis, without secondary signs to suggest acute bowel
ischemia
KUB [**9-12**]: No evidence of bowel obstruction or free air
TTE [**9-14**]: The left atrium is elongated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is unusually small.
Overall left ventricular systolic function is normal (LVEF 60%).
The right ventricular free wall is hypertrophied. The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
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 to moderate
([**11-24**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a fat pad. There are no echocardiographic signs of
tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2141-3-17**], right ventriclular enlargement and contractile
dysfunction, and pulmonary hypertension, are now frankly severe.
CXR [**9-14**]: The ET tube tip is 4.5 cm above the carina. The right
internal jugular line tip is at the level of mid SVC. There is
no evidence of pneumothorax after insertion of the right
internal jugular line. The NG tube tip is in the stomach. The
right pacemaker leads terminate in right atrium and right
ventricle.
The patient is after median sternotomy and CABG with unchanged
appearance of the surgical wires and coronary stent that are
most likely located within the bypass graft rather than within
the native coronary arteries. There is still present mild
pulmonary edema with bibasal opacities that may represent
atelectasis versus partially resolved pulmonary edema and should
be closely followed.
Head CT [**9-14**]: No acute intracranial process
Chest CTA [**9-14**]: 1. No pulmonary embolus, aortic dissection or
aneurysm.
2. Enlarged right ventricular cavity relative to the left as
well as enlarged right atrium, consistent with the provided
history of right heart strain.
3. Diffuse ground-glass opacities as well as intralobular septal
thickening and subcutaneous edema, together are suggestive of
mild volume overload.
4. Redemonstration of pulmonary fibrotic changes, minimally
changed since
[**2140**].
CXR [**9-15**]: The ET tube tip is 3.3 cm above the carina. The NG
tube tip is in the stomach. The post-sternotomy wires are
intact. Cardiomediastinal silhouette is stable. There is
interval improvement of pulmonary edema which is currently still
present, minimal. The right internal jugular line tip is at the
level of mid SVC.
EEG [**9-15**]: Pending at time of expiration
CXR [**9-16**]: In comparison with the study of [**9-15**], there is
little overall change. Monitoring and support devices remain in
place. Cardiomediastinal silhouette is stable with mild
persistent elevation of pulmonary venous pressure.
Brief Hospital Course:
# Abdominal pain: The patient's initial chief complaint was
sudden abdominal pain, nausea, and vomiting at rest. CT showed
several wedge-shaped renal hypodensities, possibly consistent
with renal infarcts. Her abdominal pain was minimal on arrival,
and did not recur on the floor.
# Chest pain: While on the floor, the patient had recurrent
episodes of angina, which were initially relieved with 2-3
sublingual morphine tabs, 1-2 mg morphine, and oxygen. She
reported having these epiodes on an almost daily basis at home,
such that she had grown accustomed to sleeping on the sofa on
the [**Location (un) 448**] of her house, so that she did not have to walk
up stairs. Attempts to walk up stairs were consistently
interrupted by angina, so that she would have to take nitro
half-way up. She had been having these episodes for at least
several months. She also reported making frequent trips to her
local Emergency Department, where she would take aspirin and
nitroglycerin before returning home. The patient was written for
beta blockers and isosorbide but her dosing was limited because
of her borderline hypotension. Multiple conversations were held
between the patient and house staff, in which she re-iterated
her preference for full code status. Cardiology was consulted,
who recommended optimizing medical management, discontinuing
digoxin, and transfusing red blood cells, to increase the
patient's blood pressure and avoid ischemia from anemia. On the
early morning of [**9-14**], the patient had another episode of chest
pain, followed by an arrest. ACLS was initiated, and the patient
was found to be in PEA. She was shocked twice, which returned a
perfusing rhythm. She was transferred to the MICU. ****
# Atrial fibrillation: The patient had a pacemaker placed in
[**2123**], with her most recent generator change in [**2135**]. She had
been on warfarin anticoagulation in the past, but this had been
discontinued several years ago, when the patient experienced
episodes of rectal and vaginal bleeding. She also developed a
large hematoma in her left forearm, at the site of attempted IV
access by the EMT's that brought her to the hospital. Serial
EKG's taken on the floor showed an intermittently paced rhythm.
****
# Community acquired pneumonia: The patient had been diagnosed
with an infiltrate on chest x-ray prior to admission, and had
been started on levofloxacin as an outpatient. Admission chest
x-ray also showed an early infiltrate. She had generally
excellent oxygen saturation with intermittent oxygen
supplementation by nasal cannula. ****
# Acute on chronic kidney disease: Baseline creatinine 1.3, was
elevated to 1.9 on admission. Increased further after initial
abdominal/pelvis CT, in spite of pre-hydration and
pre-treatment. Acute injury thought to be secondary to potential
renal infarction, as read on CT. ****
# Pulmonary hypertension: The patient was initially started on
sildenafil, but this was discontinued when it was revealed that
she had not been on this medication since the Spring, when it
was assessed that she was not benefitting from it.
# Diabetes: Last HbA1c on record was 10.5% in [**2141-12-24**]. Her home
oral hypoglycemics including metformin were held, and she was
placed on an insulin sliding scale. ****
MICU COURSE:
Pt transfered to the MICU s/p cardiac arrest and resuscitation.
She was placed on the hypothermic protocol. Concern for PE as
etiology for arrest, however CTA negative for PE. EP consulted
who felt pacer was functioning appropriately. Pt had several
episodes of A fib with RVR that responded to diltiazem. Her UOP
started to drop and pressor support was increased. After
several family meetings she was initially made DNR, however
blood pressure continued to drop and family did not wish to
pursue aggresive care. She was made CMO and was extubated and
made comfortable. She expired shortly thereafter.
Medications on Admission:
Atorvastatin 40mg po daily
clopidogrel 75mg po daily
sildenafil 20mg po bid
spiriva 1 inh daily
asa 325mg po daily
mvi
omega 3 fatty acids
doxycycline 100mg po q12h
diltiazem sr 120mg po daily
diazepam 5mg po qhs
lasix 80mg po daily
omeprazole 20mg po bid
digoxin 125mcg po daily (sun tues thurs sat)
primidone 125mg po daily
glipizide sr 10mg po daily
aygestin 5mg po BID
albuterol
metformin 500mg po daily
metoprolol succinate 200mg po daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2142-9-19**]
|
[
"486",
"416.8",
"428.0",
"V66.7",
"427.31",
"427.1",
"250.00",
"785.51",
"428.22",
"V45.01",
"427.5",
"V02.54",
"593.81",
"412",
"V45.81",
"584.9",
"V45.82",
"518.81",
"414.01",
"562.10",
"585.3",
"413.9",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"96.04",
"38.93",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
19305, 19314
|
14886, 18782
|
299, 346
|
19365, 19532
|
4169, 7779
|
3226, 3401
|
19276, 19282
|
19335, 19344
|
18808, 19253
|
3416, 4150
|
7796, 14863
|
241, 261
|
374, 1782
|
1804, 3012
|
3028, 3210
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,592
| 136,506
|
42343
|
Discharge summary
|
report
|
Admission Date: [**2187-10-11**] Discharge Date: [**2187-10-20**]
Date of Birth: [**2119-5-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2187-10-16**] - Coronary artery bypass grafting x4: Left internal
mammary artery graft to left anterior descending, reverse
saphenous vein of the marginal branch, diagonal branch and
left-sided PDA.
History of Present Illness:
68 year old female with history of coronary artery disease s/p
stent and diabetes that presented for routine physical and was
sent for stress test, she denies any symptoms except SOB with
walking up stairs. She denies any chest
pain or discomfort but per outside records there was chest
pressure. She then was referred for cardiac catheterization
that revealed significant disease with decreased systolic
function and is now transferred for surgical evaluation.
Past Medical History:
Psoriasis
Pneumonia
Diabetes Mellitus type 2
Coronary artery disease
Myocardial infarction [**2164**] s/p stent
Hypertension
Depression
Chronic bone on bone pain - Right ankle after fracture
Anxiety
Past Surgical History
s/p repair of Rt Ankle fx with pins
s/p appendectomy
s/p Ovarian cyst removal
Social History:
Last Dental Exam: 6 months ago
Lives with: Alone (separated from spouse)
Contact: [**Name (NI) **] [**Last Name (NamePattern1) **] Phone # [**Telephone/Fax (1) 91723**] cell [**Telephone/Fax (1) 91724**]
Occupation: Intake coordinator
Cigarettes: Smoked yes [x] last cigarette 25 years ago
Hx: 20 pyh
ETOH: < 1 drink/week [] [**1-22**] drinks/week [x] >8 drinks/week []
Illicit drug use none
Family History:
Father deceased 39 MI and pneumonia
Mother deceased 62 MI
Sister deceased 75 [**Name2 (NI) 91725**]
Son [**Name (NI) 3495**] failure
Physical Exam:
Pulse: 43 Resp: 18 O2 sat: 98 % RA
B/P Right: 150/64 Left: 150/68
General: no acute distress sitting in chair but emotional at
times tearing
Skin: Dry [x] multiple areas of red scaly areas scalp, left
flank
buttock, left elbow, ecchymosis under bilateral eyes s/p door
hitting her in face
HEENT: Left pupil 3mm right 2mm reactive to light bilateral EOMI
[x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade [**12-21**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
deformity right ankle d/e fx Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2187-10-16**] ECHO
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with focalities in the
anterior and infeior septal regions. Overall left ventricular
systolic function is moderately depressed (LVEF= 30-35 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. 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. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS:
Preserved RV systolic function.
LVEF 35%.
The previous wall motion abnormalities still persist.
Intact thoraicc aorta.
No new valvular findings.
[**2187-10-19**] 05:34AM BLOOD WBC-10.4 RBC-3.05* Hgb-9.1* Hct-28.2*
MCV-92 MCH-29.9 MCHC-32.4 RDW-13.5 Plt Ct-154
[**2187-10-18**] 05:44AM BLOOD WBC-10.0 RBC-3.02* Hgb-9.4* Hct-27.7*
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.8 Plt Ct-111*
[**2187-10-17**] 03:11AM BLOOD WBC-10.2 RBC-3.55* Hgb-11.0* Hct-33.0*
MCV-93 MCH-31.1 MCHC-33.4 RDW-13.9 Plt Ct-113*
[**2187-10-19**] 05:34AM BLOOD UreaN-25* Creat-0.8 Na-138 K-4.8 Cl-98
[**2187-10-18**] 05:44AM BLOOD Glucose-127* UreaN-16 Creat-0.7 Na-135
K-4.3 Cl-100 HCO3-30 AnGap-9
[**2187-10-17**] 03:11AM BLOOD Glucose-105* UreaN-18 Creat-0.7 Na-141
K-4.4 Cl-109* HCO3-28 AnGap-8
[**2187-10-16**] 10:07PM BLOOD Na-138 K-4.5 Cl-107
Brief Hospital Course:
Mrs. [**Known lastname 91726**] was admitted to the [**Hospital1 18**] on [**2187-10-11**] for surgical
management of her coronary artery disease. She was worked-up in
the usual preoperative manner and found to be suitable for
surgery. On [**2187-10-16**], Mrs. [**Known lastname 91726**] was taken to the operating
room where she underwent coronary artery bypass grafting with
left internal mammary artery graft to left anterior descending,
reverse saphenous vein of the marginal branch, diagonal branch
and left-sided PDA. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. Within 24 hours, she awoke neurologically intact and
was extubated. On postoperative day one, she was transferred to
the step down unit for further recovery. She was gently diuresed
towards her preoperative weight. Diuresis was increased for
moderate left effusion. The physical therapy service was
consulted for assistance with her postoperative strength and
recovery. Beta blocker was increased and Lisinopril was started
for better blood pressure control, however the Lisinopril was
stopped and Lopressor was decreased due to
hypotension/bradycardia on POD3. Chest tubes and pacing wires
were removed per cardiac surgery protocol. On POD #4 she was
ambulating in the halls with assistance, tolerating a full po
diet and her incision was healing well. It was felt that she was
safe for discharge to Penacook Place rehab at this time. All
appropriate appointments were arranged.
Medications on Admission:
Zocor 20 mg daily
Aspirin 325 mg daily
Glyburide 2 mg daily
Atenolol 50 mg daily
Diazepam 20 mg [**Hospital1 **] as needed
Etodolac 300 mg as needed
Lisinopril 40 mg daily
Discharge Medications:
1. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): to buttock, left flank and left elbow .
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO TID (3 times a day).
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
ADD when & if BP tolerates
Home dose was 40mg.
Discharge Disposition:
Extended Care
Facility:
Penacook Place - [**Location (un) **]
Discharge Diagnosis:
Psoriasis
Pneumonia
Diabetes Mellitus type 2
Coronary artery disease
Myocardial infarction [**2164**] s/p stent
Hypertension
Depression
Chronic bone on bone pain - Rt ankle after fx
Anxiety
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol/Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on Wed [**11-7**] at 1:30 PM in
the [**Hospital **] medical office building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) **] on [**10-25**] at 10:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 50167**] in [**3-20**] weeks [**Telephone/Fax (1) 72680**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2187-10-20**]
|
[
"V15.82",
"V15.51",
"250.80",
"427.89",
"458.29",
"311",
"412",
"V45.82",
"V17.3",
"401.9",
"511.9",
"696.1",
"338.29",
"285.1",
"287.5",
"411.1",
"414.01",
"276.69",
"300.00",
"719.47"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7661, 7725
|
4656, 6177
|
323, 527
|
7959, 8182
|
2875, 4633
|
9155, 9818
|
1773, 1908
|
6400, 7638
|
7746, 7938
|
6203, 6377
|
8206, 9132
|
1923, 2856
|
273, 285
|
555, 1020
|
1042, 1343
|
1359, 1757
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,686
| 188,689
|
41445
|
Discharge summary
|
report
|
Admission Date: [**2111-4-1**] Discharge Date: [**2111-4-10**]
Date of Birth: [**2070-8-26**] Sex: M
Service: PLASTIC
Allergies:
Codeine / Vicodin
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Right arm pain
Major Surgical or Invasive Procedure:
[**2111-4-1**] INCISION & DRAINAGE, IRRIGATION & DEBRIDEMENT, VAC
DRESSING PLACEMENT, RIGHT UPPER EXTREMITY [**Location (un) **]
[**2111-4-4**] Right arm washout and I&D, VAC dressing
History of Present Illness:
40 yo M with h/o drug use who presents with
7 days of progressive arm pain and drainage. He originally
injected himself IM in the right arm with percocet. 5 days ago
he became febrile to 102 and began noticing purulent discharge
from the drainage site. He self-lanced this wound with a
straight razor 3 days prior to presentation. He awoke this
morning with severely increased arm pain, swelling, and new
redness and is here seeking care.
He reports emesis today, denies CP/SOB/N/D.
ED Course: Patient febrile, in significant pain. CBC with
elevated WBC. BC PND. CT Scan (wet read) with evidence of
necrotizing fascitis throughout right forearm up to humeral
epiphysis, hyperdensity in medial aspect of upper arm consistent
with needle end.
Past Medical History:
IVDU
Social History:
Previous drug user (cocaine, injected), denies
drug use in past 3 years. Previous EtOH. Disabled, married.
Family History:
Noncontributory
Physical Exam:
NAD, A/Ox3
CTAB
RRR
soft
WWP, RUE - vac in place, distal pulses intact, no
erythema/drainage
Pertinent Results:
IMAGING DATA:
CT [**2111-4-1**]
FINDINGS: Diffuse edema within the soft tissues of the forearm
and upper arm with a soft tissue defect noted along the radial
aspect of the mid forearm. There is tracking soft tissue gas
along the deep fascial intramuscular planes as well as edema
which extends from the distal radius proximally to the level of
the mid humerus. Findings are compatible with necrotizing
fasciitis. A linear metallic foreign body measuring
approximately 11 mm in length is embedded within the biceps
muscle and is seen on series 7, image 95 and 96. It is likely
that this foreign body is not related to the acute process. The
[**Last Name (un) 90160**] bones appear unremarkable with normal bony mineralization
and no cortical destruction, or erosive changes to suggest
osteomyelitis. Given that IV contrast was not administered, the
evaluation for fluid collections is limited.
.
IMPRESSION: Extensive subcutaneous and deep fascial edema with
gas tracking along the deep fascial planes compatible with
necrotizing fasciitis. The extent of involvement is detailed
above, though extends from the level of the distal humerus
through the level of the distal radius. Small retained foreign
body embedded within the biceps muscle as detailed. No evidence
of osteomyelitis.
Brief Hospital Course:
The patient was admitted to the Acute Care Surgical Service on
[**2111-4-1**] for evaluation and treatment of necrotizing fasciitis.
Admission RUE CT revealed subcutaneous and deep fascial edema
with gas tracking along the deep fascial planes compatible with
necrotizing fasciitis extending from the level of the distal
humerus through the level of the distal radius with fevers to
105 and leukocytosis to 17,000. The patient underwent open
debridement and VAC dressing placement, which went well without
complication (reader referred to the Operative Note for
details). The patient was hemodynamically stable. Following a
second debridement procedure, the patient returned to the
operating room for split thickness skin graft placement with VAC
dressing by the Plastics and Reconstructive Surgery Service,
monitored and subsequently discharged.
.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient was started
empirically on Vancoymcin, Zosyn, and Clindamycin. Wound care -
Pt required two debridement procedures and vac dressing
placement. Surgical sites were routinely monitored for signs of
infection.
.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerance. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with VNA services
for dressing changes. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Neurontin, Trileptil, Trazodone
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 2 weeks: do not drive, operate machinery, or take tylenol
while on this medication.
Disp:*75 Tablet(s)* Refills:*0*
2. clindamycin HCl 300 mg Capsule Sig: 1.5 Capsules PO every 6
hours daily for 2 weeks followed by twice daily for 2 weeks for
1 months: 475mg PO q6 for 2 weeks followed by 500mg PO BID for 2
weeks.
Disp:*120 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing soft tissue infection right forearm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hopsital with a sever skin infection in
your right arm. The infection required several operations and
use of special dressing devices. You were seen and evlauted by
Infectious Disease and were given intravenous antibiotics.
You should AVOID injections of any substances into your
bloodstream and skin.
If you have been prescribed narcotics for pain control these
medications should be taken only as directed by mouth. DO NOT
take illicit drugs, drink alcohol, drive or operate heavy
machninery while on these types of medications.
Followup Instructions:
Follow up with Plastic Surgery Clinic in 1 week. Call
[**Telephone/Fax (1) 5343**] for an appointment.
Completed by:[**2111-4-14**]
|
[
"304.20",
"070.54",
"345.90",
"276.1",
"728.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"82.09",
"83.39"
] |
icd9pcs
|
[
[
[]
]
] |
5626, 5632
|
2881, 5101
|
291, 477
|
5724, 5724
|
1574, 2858
|
6458, 6591
|
1429, 1446
|
5184, 5603
|
5653, 5703
|
5127, 5161
|
5875, 6435
|
1461, 1555
|
237, 253
|
505, 1258
|
5739, 5851
|
1280, 1286
|
1302, 1413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,470
| 116,222
|
37450+58149
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-1-6**] Discharge Date: [**2177-1-11**]
Date of Birth: [**2123-12-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2177-1-6**] Coronary Artery Bypass Graft x 3 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
obtuse marginal, saphenous vein graft to posterior descending
artery)
History of Present Illness:
52 year old man with increasing chest pain, nausea, vomiting
over the past 6 weeks. A subsequent catheterization revealed
multi-vessel coronary artery disease. Transferred for surgical
evaluation
Past Medical History:
s/p Myocaridial Infarction in '[**75**]
Hypertension
Hyperlipidemia
Tobacco use
chronic hip and shoulder pain
s/p right ankle injury
s/p right leg injury requiring plating and screws
s/p discectomy
Social History:
Occupation: construction supervisor
Tobacco: Quit [**2176-12-12**]
ETOH:3-6 packs of beer per week quit [**2176-12-12**]
Family History:
father with CAD age 70
Physical Exam:
Height: 5'8" Weight: 205lbs
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] 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[x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Brief Hospital Course:
Admitted same day surgery and underwent coronary artery bypass
graft surgery. See operative report for further details. He
received cefazolin for perioperative antibiotics and
Ciprofloxacin for cystoscopy in operating room due to false
passage with foley placement by urology. Post operatively he
was transferred to the intensive care unit for management. In
first twenty four hours he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
He was transferred to the floor on post operative day one.
Physical therapy worked with him on strength and mobility.
Chest tubes and pacing wires were discontinued without
complication. Foley was discontinued and the patient voided
successfully. Ace inhibitor was not started because blood
pressure would not tolerate it. He was discharged home in good
condition on POD 5. He will follow up with his personal
urologist, Dr. [**Last Name (STitle) 20222**], on discharge.
Medications on Admission:
Aspirin, plavix, zocor, lopressor
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*qs * Refills:*0*
9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Acute on chronic systolic heart failure
False channel s/p cystoscopy for catheter placement
Past medical history:
s/p Myocaridial Infarction in '[**75**]
Hypertension
Hyperlipidemia
Tobacco use
chronic hip and shoulder pain
s/p right ankle injury
s/p right leg injury requiring plating and screws
s/p discectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with dilaudid 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:
[**Hospital1 **] heart center [**Telephone/Fax (2) 6256**]
Dr [**Last Name (STitle) **] [**Name (STitle) **] [**2177-1-30**] at 9am
Heart center [**Hospital1 **] [**Location (un) **] [**Telephone/Fax (1) 6256**]
Dr [**Last Name (STitle) 20222**] Tuesday [**2177-1-28**] at 1130am
Please call to schedule appointments
Primary Care Dr.[**First Name (STitle) **] in [**11-30**] weeks [**Telephone/Fax (1) 84156**]
Completed by:[**2177-1-11**] Name: [**Known lastname 13379**],[**Known firstname **] J Unit No: [**Numeric Identifier 13380**]
Admission Date: [**2177-1-6**] Discharge Date: [**2177-1-11**]
Date of Birth: [**2123-12-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Potassium supplement was deleted from Mr. [**Known lastname 13381**] discharge
medication list, as his Potassium was typically >4.3
post-operatively.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*qs * Refills:*0*
9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 6688**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2177-1-11**]
|
[
"599.4",
"413.9",
"724.8",
"719.41",
"272.4",
"338.29",
"412",
"401.9",
"428.23",
"414.01",
"V15.82",
"428.0",
"719.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"57.32",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7381, 7577
|
1754, 2715
|
332, 534
|
4605, 4701
|
5241, 6229
|
1135, 1159
|
6252, 7358
|
4209, 4362
|
2741, 2776
|
4725, 5218
|
1174, 1731
|
282, 294
|
562, 759
|
4384, 4584
|
997, 1119
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,626
| 182,907
|
47058
|
Discharge summary
|
report
|
Admission Date: [**2191-2-25**] Discharge Date: [**2191-3-30**]
Date of Birth: [**2128-1-14**] Sex: F
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: Patient is a 63-year-old female
with a history of metastatic carcinoid tumor to the liver
status post radiofrequency ablation in [**2190-12-19**], who
presented to the hospital complaining of three to five week
history of productive cough and dehydration. Patient's
carcinoid tumor was first diagnosed seven years ago during a
small bowel resection for a small bowel obstruction. Patient
has failed treatment with thalidomide and Temodar, and she
underwent radiofrequency ablation in [**2188-9-18**] and as
recently as [**2190-12-19**]. She has had persisting
diarrhea, which is being treated with Sandostatin and
cutaneous flushing.
Approximately 3-5 weeks prior to admission, patient started
developing a productive cough, and initially presented to
[**Hospital 1474**] Hospital. She had an extensive workup at the
[**Hospital 1474**] Hospital including CT scan, HIDA scan, bronchoscopy.
Sputum culture at [**Hospital 1474**] Hospital showed a MRSA.
Bronchoscopy demonstrated no tracheal lesions. She is
started on Vancomycin and was improving in her symptoms. The
CT scan at [**Hospital 1474**] Hospital showed an area of necrosis in
the right lower lobe of the lung and HIDA scan was performed
to assess for a possible biliary bronchial fistula. Patient
was transferred to [**Hospital1 **] [**First Name (Titles) **] [**2191-2-25**],
for further treatment.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Carcinoid syndrome.
MEDICATIONS AT HOME:
1. Advair one puff b.i.d.
2. Combivent MDI.
3. Vancomycin 1 gram q.12.
4. Norvasc 10 mg p.o. q.d.
5. Prednisone 20 mg p.o. q.d.
6. Patient had been taking Sandostatin for diarrhea.
ALLERGIES: Patient reports no known drug allergies.
SOCIAL HISTORY: Patient denies using alcohol. She reports 5-
10 pack year history of smoking.
LABORATORY STUDIES ON ADMISSION: White count of 6.0,
hematocrit of 30.1, platelets of 176. Chemistries: Sodium
142, potassium 3.3, chloride 101, CO2 35, BUN 13, creatinine
0.5, and glucose of 119. Calcium 9.0, magnesium 2.2,
phosphate 3.3. PT 13.3, PTT 24.4, and INR of 1.2.
HOSPITAL COURSE: Upon her transfer to the [**Hospital1 **], the report on the HIDA scan appeared to suggest
biliary bronchial fistula. Thoracic Surgery consult was
obtained and patient was evaluated by Dr. [**Last Name (STitle) 952**]. Initially
on admission, patient was doing well, therefore, the control
of the fistula was the primary concern, and the patient
underwent an ERCP on [**2191-2-28**], with Dr. [**Last Name (STitle) **]. At
the ERCP, there was a suggestion of extravasation of contrast
in the biliary tree to the surface of the dome of the liver.
There was no visualized bronchial fistula seen on the exam.
However, patient was having bilious sputum during the
procedure.
Patient developed respiratory difficulty and was transferred
to the Surgical Intensive Care Unit on [**2191-3-2**], where
she was started on broad-spectrum antibiotics. Patient
underwent a CT-guided drainage of the right pleural effusion
on [**2191-3-3**], with return of approximately 200 cc of
bilious fluid in chest tube one and 100 cc in chest tube two.
Patient subjectively reported feeling better, and patient was
supported in our care. Patient continued on broad-spectrum
antibiotic coverage with Zosyn and fluconazole, and
Infectious Disease consult was obtained and was recommended
that patient be started on meropenem instead of Zosyn.
Patient continued on meropenem and fluconazole for positive
pleural fluid Gram stain and sparse C. albicans. Patient
also developed a urinary tract infection with Enterococcus
and was being treated appropriately.
Patient underwent a flexible bronchoscopy on [**2191-3-15**],
which showed a persistent small fistula in the right lower
lobe bronchus with bile spilling into the airway. After
extensive discussion and evaluation, patient elected to
undergo surgical repair and went to the OR on [**2191-3-18**]
for right thoracotomy and diaphragmatic repair and lung
debridement. Please see the operative report for further
details.
Postoperatively, patient received an epidural for pain
control and was started on Vancomycin in addition to
meropenem for broad-spectrum antimicrobial coverage until the
operative cultures came back. The intraoperative culture
came back with C. albicans and Vancomycin-resistant
Enterococcus, and patient was started on linezolid. Patient
was improving in her condition slowly. She had persistent
leak in her chest tube, which required a prolonged treatment,
and on discharge patient has one chest tube which is
connected to a Heimlich valve.
Patient is supported by total parenteral nutrition in
addition to her p.o. intake to supplement her nutritional
status, and is discharged with TPN being cycled at nighttime.
Patient was also evaluated by Physical Therapy for
deconditioning and is found to be in need of rehab, and the
patient is discharged on [**2191-3-30**], in stable condition.
DISCHARGE STATUS: Discharged to rehab hospital.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Metastatic carcinoid disease status post radiofrequency
ablation with right lower lobe methicillin-resistant
Staphylococcus aureus pneumonia complicated by biliary
bronchial fistula.
2. Status post right thoracotomy and diaphragmatic repair,
and lung debridement with confirmation of vancomycin-
resistant Enterococcus.
3. Right lower lobe pneumonia/necrosis with persisting air
leak.
4. Hypertension.
DISCHARGE MEDICATIONS:
1. Tylenol 325-650 mg p.o. q.4-6h. prn pain.
2. Pepcid 20 mg p.o. b.i.d.
3. Linezolid 600 mg p.o. q12.
4. Levaquin 500 mg p.o. q.24.
5. Dilaudid 2 mg q.3-4h. prn pain.
6. Heparin 5000 units subQ q.8h.
7. Pyridoxine 50 mg p.o. q.d.
8. Insulin-sliding scale as per sliding scale.
9. Lomotil 2.5/0.025 mg p.o. q.6h. Prn.
10. Megace 40 mg p.o. q.i.d.
11. Patient is also prescribed TPN to be cycled
overnight to supplement her p.o. intake.
FOLLOW UP: Patient is to followup with Dr. [**Last Name (STitle) 952**] at his
office within one week and is to call the office for
appointment time. Patient is to followup with Dr. [**Last Name (STitle) **] in 1-
2 weeks and is to call the Transplant Center for follow-up
appointment. Patient has a follow-up appointment with Dr.
[**First Name (STitle) **] with Infectious Disease on [**2191-5-9**] at 10:30 a.m.,
telephone number [**Telephone/Fax (1) 457**]. Patient needs chemistry
laboratories drawn every other day for adjustment of TPN and
then every week as she is stable on TPN, and needs CBCs drawn
every week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 12164**]
MEDQUIST36
D: [**2191-3-30**] 12:39:01
T: [**2191-3-30**] 13:28:48
Job#: [**Job Number 99763**]
|
[
"197.7",
"513.0",
"510.0",
"599.0",
"996.59",
"996.74",
"482.41",
"E879.8",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.81",
"33.93",
"97.49",
"51.85",
"99.04",
"33.24",
"34.51",
"34.73",
"99.15",
"99.10",
"38.93",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
5198, 5205
|
5226, 5650
|
5673, 6123
|
2272, 5176
|
1640, 1876
|
6135, 7026
|
186, 1556
|
2007, 2254
|
1578, 1619
|
1893, 1992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,666
| 191,068
|
39762
|
Discharge summary
|
report
|
Admission Date: [**2179-12-17**] Discharge Date: [**2179-12-30**]
Date of Birth: [**2125-12-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Endocarditis
Major Surgical or Invasive Procedure:
1. Percutaneous Drain placement for treatment of Acute
Cholecystitis on [**2179-12-25**]
2. PICC line placement on [**2179-12-30**]
History of Present Illness:
54 y/o M with history of hypertension, NIDDM, Hepatitis C, IVDU
with recent diagnosis of Endocarditis (s.epidermitis, treated
with valve replacement and vancomycin for 6 weeks), Who was
admitted on [**12-15**] to [**Hospital3 **] with fevers, confusion, nausea and
vomiting. Was found to have Lactic Acid of 9, 30% bands and
acute renal failure. He was admitted to their ICU and was
started on triple antibiotic therapy ( Vanc, ertapenem and
daptomycin), ECHO was done, showed no valve dysfunction or
vegetation. His blood cultures came bac [**4-4**] with Staph Aureus (
no sensitivities were availabe), ertapenem was stopped, and
continued on dapto high dose. His platelets dramatically
decreased, which was felt secondary to his sepsis. On transfer
his platelets were 42K. His family wanted him transferred to
[**Hospital1 18**]. By [**12-17**] he developed confusion, word finding difficulty.
MRI was performed demonstrating 3 areas of possible emboli in
his brain. At this time he was transferred to [**Hospital1 18**].
.
Labs at transfer were significant for WBC of 9,5, 28 bands, Hgb
10.6, Hct of 30, platelets 42. Na 132, K 2.8, Cloride of 106,
Co2 0f 19, BUN 30, Creatinine 1, gluc 106, Ca 7.7, Phosphate
1.9, Mag 2.2, trop 2.5.
. On physical exam there Tmax 98.9, HR 100-110, RR 30s, BP
118/78, O2sat 98 on 3L. Clear lungs, systolic ejection murmur,
good bowel sounds, warm extremities, some petechial-type rash
covering parts of hands and chest.
.
.
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:
- Hepatitis C
- Left facial periorbital cellulitis [**4-/2179**], treated with
Vancomycin
DM, HTN, knee and shoulder surgeries
Social History:
Lives in [**Location 701**] with girlfriend, was working at the VA.
Smoker. Last alcohol and IVDU reported in [**2175**].
Tobacco history: +
- ETOH: +, sober for 4 years
- Illicit drugs: + IVDU, heroin and cocaine, sober for 4 years
- Former firefighter, now works as an aide in [**Hospital **] Nursing Home
Family History:
Three children in good health. One brother died of an OD. Mother
died of diabetes at 79, Fatehr is 82 years old with HLD, and
HTN.
Physical Exam:
GENERAL: Pleasant male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Sclera anicteric. Conjunctiva were pink, left eye notable
for conunctival petechiae, no pallor or cyanosis of the oral
mucosa.
NECK: Supple with JVP of 6 cm. Multiple small punctate scabs on
neck and face.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, III/VI diastolic murmur heard at apex and LUSB, no
rubs/gallops
LUNGS: Diffuse bibasilar crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. + BS
EXTREMITIES: No swelling or edema.
SKIN: [**Last Name (un) 1003**] lesions noted on palms b/l, splinter hemorrhage on
left 5th digit, palmar erythemia, spider angiomas on neck and
left shoulder girdle
PULSES:Right: Carotid 2+ DP 2+ PT 2+,Left: Carotid 2+ DP 2+ PT
2+
On Discharge:
Pertinent Results:
[**2179-12-17**] 06:08PM O2 SAT-98
[**2179-12-17**] 06:08PM LACTATE-1.4 K+-3.9
[**2179-12-17**] 06:48PM PT-15.1* PTT-33.6 INR(PT)-1.3*
[**2179-12-17**] 06:08PM TYPE-ART TEMP-37.5 PO2-118* PCO2-22* PH-7.49*
TOTAL CO2-17* BASE XS--3
[**2179-12-17**] 06:48PM PT-15.1* PTT-33.6 INR(PT)-1.3*
[**2179-12-17**] 06:48PM PLT COUNT-48*#
[**2179-12-17**] 06:48PM NEUTS-81.8* BANDS-0 LYMPHS-13.5* MONOS-3.1
EOS-1.4 BASOS-0.3
[**2179-12-17**] 06:48PM WBC-8.1 RBC-3.96*# HGB-11.2*# HCT-32.0*
MCV-81*# MCH-28.4# MCHC-35.1* RDW-16.1*
[**2179-12-17**] 06:48PM CALCIUM-8.2* PHOSPHATE-2.0* MAGNESIUM-2.0
[**2179-12-17**] 06:48PM ALT(SGPT)-51* AST(SGOT)-57* ALK PHOS-45 TOT
BILI-0.9
[**2179-12-17**] 06:48PM estGFR-Using this
[**2179-12-17**] 06:48PM GLUCOSE-117* UREA N-26* CREAT-1.0 SODIUM-131*
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-18* ANION GAP-11
.
Microbiology:
[**2179-12-17**] 6:48 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Final [**2179-12-23**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
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.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
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------------ <=0.5 S
.
[**12-22**] Blood Culture, Routine (Final [**2179-12-26**]):
STAPH AUREUS COAG +.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=2 S
LEVOFLOXACIN---------- =>16 R
OXACILLIN------------- 4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
HIV VL: pending
Imaging:
.
RUQ U/S ([**2179-12-24**]):
IMPRESSION: Stone lodged in the gallbladder neck with
gallbladder distention
and positive son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. These findings are
consistent with
early acute cholecystitis. Correlate with clinical presentation.
.
HIDA scan ([**2179-12-25**]):
Serial images over the abdomen show uptake of tracer into the
hepatic parenchyma. Tracer activity is noted in the duodenum at
3 minutes, and in the distal small bowel at 9 minutes. There is
complete failure of
gallbladder visualization, even after administration of 2 mg of
IV morphine, repeat HIDA injection, and delayed imaging up to 30
minutes.
CT torso ([**2179-12-27**]):
IMPRESSION:
1. Extensive lymphadenopathy involving chest, abdomen and
pelvis, as
described above. Marked splenomegaly. The above findings are
most concerning for lymphoma. A left paraaortic node measuring
1.8 x 2.6 cm is most amenable to biopsy (2:74).
2. A cholecystostomy drain is in satisfactory position. A
gallstone within
the gallbladder neck is present.
3. Bibasilar atelectatic changes. Left lower lobe opacity, which
most likely represents atelectasis, however infectious process
may be considered in the right clinical setting.
.
ECHO [**2179-12-20**]: 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. Right atrial
appendage ejection velocity is good (>20 cm/s). No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). The descending thoracic aorta is mildly dilated.
There is simple atheroma in the descending thoracic aorta to 40
cm. The bioprosthetic aortic valve prosthesis is well-seated
with normal leaflet motion. No masses or vegetations are seen on
the aortic valve. There is paravalular thickening (seen-post
prosthetic valve surgery) without paravalvular leak or abscess.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened without mass or vegetation seen. Mild [1+]
mitral regurgitation is seen. .There is no pericardial effusion.
IMPRESSION: Well-seated aortic valve bioprosthesis without
discrete vegetation/abscess or valvular regurgitation.. Mildly
thickened mitral valve with mild mitral regurgitation but
without vegetation seen.
.
.
.
ECHO [**2179-12-29**]
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. The interatrial septum is
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. There are simple atheroma in the descending thoracic
aorta. A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic valve leaflets appear normal 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. There is mild aortic paravalvular thickening,
which is consistent with post-operative changes. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
.
IMPRESSION: No echocardiographic evidence of vegetation or
abscess. Normally seated bioprosthetic aortic valve with mild
paravalvular thickening, consistent with post-operative changes.
Mildly thickened mitral valve with mild mitral regurgitation.
.
Compared with the prior study (images reviewed) of [**2179-12-20**],
the findings are similar.
.
Brief Hospital Course:
Hospital Course:
54 year old gentleman with history of hypertension, NIDDM,
Hepatitis C, IVDU with recent diagnosis of Endocarditis
(s.epidermitis, treated with valve replacement and vancomycin
for 6 weeks), who was admitted on [**2179-12-15**] to [**Hospital3 **] with
fevers, confusion, nausea and vomiting. Found to have MRSA
bacteremia (4/4 bottles). Was started on triple therapy, then
narrowed to daptomycin only. Found also to have possible brain
septic emboli on OSH MRI and developed acute cholecystitis
during admission, confirmed with HIDA scan.
.
# Endocarditis: Patient was discharged home on [**10-1**] after
Dr.[**Last Name (STitle) 914**] performed AVR on [**9-23**] with VNA and IV Vancomycin x 6
weeks through PICC. Subsequently found to have MRSA bacteremia
at OSH and was started on daptomycin and admitted to IV drug use
at home. Aortic insufficiency was not seen at ECHO at OSH. MRI
however demonstrated evidence of septic emboli to brain. After
extensive discussion with ID he was started on Vancomycin and
Gentamicin. Rifampin was added initially however then
discontinued given concern for rifampin resisitance and then
again restarted restarted prior to discharge. On [**2179-12-22**],
blood cultures were positive for MRSA after several days of
negative culutres. TEE was performed on [**12-20**] and [**12-29**] and
showed no vegetations or evidence of abscesses, despite some PR
prolongation (200-210 msec at baseline, up to 260 msec during
admission. CT torso did not reveal any abscesses to explain the
recurrence of the positive culture despite antibiotic coverage,
but did reveal extensive chest, abdominal, and pelvic
lymphadenopathy along with splenomegaly, thought to be reactive
vs. lymphoma (LDH normal). On discharge patient had negative
cultures x 5 days. He will require a total of 6 weeks of
vancomycin and rifampin. Gentamycin discontinued on discharge.
- Continue Vancomycin and Rifampin until [**2180-2-4**]
.
# Acute cholecystitis: During admission, on [**2179-12-24**], patient
developed RUQ tenderness with elevated bili and alk phos. RUQ
u/s and HIDA scan demonstrated acute cholecystitis. General
surgery was consulted and recommended percutaneous
cholecystostomy. On [**2179-12-26**], interventional radiology placed
cholecystostomy drain. This drain should remain in place for at
least a few weeks and he will be followed by surgery upon
discharge.
- Follow up cholecystostomy
- Continue ciprofloxacin until [**2179-12-31**]
.
# Hyponatremia: Patient developed progressively worsening
hyponatremia that did not improve with multiple liters of fluid
resuscitation. With elevated urine osmolality, we believe that
SIADH was causing his hyponatremia. He was started on a fluid
restriction and IVF were held. He should be maintained on a
fluid restriction on discharge, especially free water. Sodium
on dicharge was 129 and improving.
- Fluid and free water restriction and follow - up electrolytes
.
# Acute Kidney Injury: The patient developed acute injury while
an inpatient. Urine electrolytes demonstrated he was likely
dry, likely in the setting of decreased oral intake in the
setting of acute infection and being NPO. He was given IV
fluids initially but was then fluid restricted due to
hyponatremia so difficult to correct. Creatinine on admission
was 1.0 and was 1.9 at the time of discharge. H
-Follow up renal function.
.
#. CT findings: Extensive chest, abdominal, and pelvic
lymphadenopathy along with splenomegaly, thought to be reactive
vs. lymphoma.
- CT should be repeated as an outpatient once illness is
resolved for further evaluation.
.
# Thrombocytopenia / anemia - Platelets on admission were
42,000, with possible DIC picture likely [**2-2**] to sepsis. Hct of
32.0. HIV serology negative, HIV viral load is pending upon
discharge. His platelets were monitored daily and improved.
Hematocrit remained stable throughout at baseline.
- His HIV viral load should be followed-up as an outpatient.
.
# Narcotic/benzo withdrawal - Patient was initially tachycardic
and diaphoretic on admission, denies recent drug use, but then
admitted recent valium and percocets. He was initially on a CIWA
scale with valium coverage. To treat his pain associated with
the cholecystostomy procedure, he was given Percocet and Valium,
but these were tapered upon discharge.
.
# CHF - Patient has a history of diastolic heart failure. Last
echo showed overall left ventricular systolic function at low
normal levels (LVEF 50-55%). He was continued on lisinopril 5 mg
and metoprolol succinate 50 mg [**Hospital1 **]. We held his aspirin given
thrombocytopenia on admission as well as possible brain emboli
secondary to endocarditis.
.
# Diarrhea - Initial diarrhea concerning for C. diff, given
antibiotic use and recent hospitalization. Empirically given
Flagyl, though C. diff toxin negative x 2. Even though the
diarrhea seemed to slow after fluid resuscitation, due to high
suspicion, C. diff PCR was sent and is still pending on
discharge.
- Discontinue Flagyl when until Clostridium difficile PCR
returns
.
# Hepatitis C - He was diagnosed with Hepatitis C in [**2174**]. He
was told he had low viral loads andtreatable genotype. Never
underwent treatment or liver biopsy. Last viral load [**9-16**] -
28,900 IU/mL. 2 cords of grade I varices on last EGD in
[**Month (only) **].
- He will eventually need liver biopsy to stage fibrosis and to
confirm that it is Hep C related. This should be done once
patient is discharged.
.
# Type 2 Diabetes Mellitus - Last A1c 5.01 in [**2179-9-1**]. We
held his metformin while inpatient and covered with insulin
sliding scale. He will be restarted upon discharge. A diabetic
low salt diet was continued while in house.
Medications on Admission:
Medications on Transfer:
- Was initially on Ertapenem, but came in on Dapto 460mg Q24Hrs
- Had 1 dose of Vancomycin
*
1. Tylenol PRN
2. Daptomycin 600 IV Q24hrs
3. Nexium 40 IV daily
4. Novolog sliding scale
5. Ativan 1mg IV q4hrs prn
6. Nitrostat 0.5 SL
7. Zinc Oxide topical
.
.
Discharge Medications (from [**10-1**]):
1. ALBUTEROL 90 mcg HFA 2 puffs inh prn
2. LISINOPRIL - 5 mg Daily
3. METOPROLOL SUCCINATE SR -50 mg [**Hospital1 **]
4. RANITIDINE HCL 150 mg Daily
5. VANCOMYCIN 1gm q 12 hrs -completed
6. ASPIRIN 81 mg
7. DOCUSATE 100 mg Capsule [**Hospital1 **]
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for pain.
2. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8
Hours) as needed for endocarditis: start date: [**2179-12-29**]
stop date: [**2180-2-4**]
.
6. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 1 days: start date: [**2179-12-25**]
stop date: until Clostridium difficile PCR returns
.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): start date: [**2179-12-25**]
stop date: [**2179-12-31**]
.
9. 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.
10. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous
q48hours: start date: [**2179-12-24**]
stop date: [**2180-2-4**]
.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-2**] Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Bacterial Endocarditis of Bioprosthetic Valve
Acute Renal Failure
Acute Diastolic Congestive Heart Failure
Hypertension
Acute Cholecystitis
Intravenous Drug use history
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a reoccurance of the infection in your blood with a
staph bacteria. You will need a total of 6 weeks of intravenous
antibiotics to treat this infection. It is extremely important
that you refrain from any IV drug use after you leave to prevent
another infection that will be more complicated or impossible to
treat. Because of the infection, you had a small stroke in your
brain. You also had many skin changes that have since resolved.
During the treatment of your infection, we found a stone lodged
in the neck of the gallbladder that was causing inflammation and
an infection. You were treated with a 7 day course of
antibiotics for this and a percutaneous drain was placed to
drain any bile. You will need to have your gallbladder out in
the future after the infection is totally cleared. The drain
will stay in place until that time or until the stone passes.
.
We made the following changes in your medicines:
1. Decrease Metoprolol to 50 mg daily
2. Stop Albuterol and Lisinopril
3. Change Ranitidine to omeprazole to treat your heartburn
4. Discontinue Aspirin and colace
5. Restart Vancomycin to treat the blood infection
6. Start Rifampin to treat the blood infection
7. Start Percocet as needed every 8 hours for pain around the
percutaneous drain
8. Start valium as needed for anxiety
9. Start Flagyl and Cipro to treat the gallbladder infection for
one more day
Followup Instructions:
[**Last Name (LF) 816**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 87573**] Surgery
Building: [**Last Name (NamePattern1) 439**], [**Location (un) **]
Primary Cities: [**Location (un) 86**]
Primary Phone:([**Telephone/Fax (1) 87407**]
Appt: [**1-6**] at 9am
Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP-Cardiology
When: THURSDAY [**2180-1-20**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**]
Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: INFECTIOUS DISEASE
When: THURSDAY [**2180-1-6**] at 2:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2180-3-3**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Test for consideration post-discharge: Vancomycin
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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] |
icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,581
| 114,787
|
39397
|
Discharge summary
|
report
|
Admission Date: [**2138-8-15**] Discharge Date: [**2138-8-20**]
Date of Birth: [**2062-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mild fatigue, mild DOE
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times 5;
left internal mammary artery graft to left anterior descending,
reverse saphenous vein grafts to the ramus intermedius, marginal
branch, right coronary artery and diagonal branch.
History of Present Illness:
75 yo M with PMH significant for hypertension, hyperlipidemia,
and diabetes with recent abnormal stress echo. He endorses only
mild fatigue and dyspnea on
exertion and denies chest discomfort or other anginal symptoms.
He presented for cardiac catheterization and was found to have
3VD and [**1-22**]+MR. We are asked to consult for surgical
revascularization and possible mitral valve repair or
replacement
Past Medical History:
Hypertension, Hyperlipidemia, Type I Diabetes on insulin pump,
Ulcerative Colitis, Prior remote GI Bleed, none in 10 yrs, GERD,
h/o broken right ankle, s/p total right hip arthroplasty
[**11/2137**], s/p tonsillectomy
Social History:
Family History:no CAD
Race:Caucasian
Last Dental Exam:[**2138-5-20**]
Lives with:wife at [**Name (NI) **] Retirement Community. Wife has
significant memory issues.
Occupation:
Tobacco:quit [**2091**]
ETOH:prior heavy drinking, quit last year
Family History:
Has 2 sons. Former marathon runner
Father had a stroke at around 70 years of age.
Physical Exam:
Pulse:76 Resp:18 O2 sat:98% RA
B/P Right:157/76 Left:156/71
Height:5'8" Weight:155 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 II/VI SEM
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 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right/Left: Transmitted murmur
Pertinent Results:
Preop
[**2138-8-15**] 07:43AM HGB-12.4* calcHCT-37
[**2138-8-15**] 07:43AM GLUCOSE-206* LACTATE-1.0 NA+-134* K+-4.2
CL--99*
[**2138-8-15**] 11:25AM WBC-6.2 RBC-2.94*# HGB-9.8*# HCT-27.3*#
MCV-93 MCH-33.2* MCHC-35.8* RDW-14.0
[**2138-8-15**] 11:25AM PT-15.3* PTT-35.9* INR(PT)-1.3*
[**2138-8-15**] 11:25AM FIBRINOGE-193
[**2138-8-15**] 12:31PM UREA N-14 CREAT-0.6 SODIUM-139 POTASSIUM-3.7
CHLORIDE-108 TOTAL CO2-24 ANION GAP-11
Discharge
[**2138-8-15**] 11:25AM BLOOD WBC-6.2 RBC-2.94*# Hgb-9.8*# Hct-27.3*#
MCV-93 MCH-33.2* MCHC-35.8* RDW-14.0 Plt Ct-124*
[**2138-8-15**] 11:25AM BLOOD PT-15.3* PTT-35.9* INR(PT)-1.3*
[**2138-8-15**] 12:31PM BLOOD UreaN-14 Creat-0.6 Na-139 K-3.7 Cl-108
HCO3-24 AnGap-11
[**2138-8-17**] 02:36AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.2 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection
velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
to moderate ([**12-21**]+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Mild PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PREBYPASS
The left atrium is mildly dilated. No spontaneous echo contrast
is seen in the body of the left atrium or left atrial appendage.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size is normal with normal free wall
contractility.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. The mitral
annulus is dilated (4.4 cm in the long axis and 3.3 cm in the
short axis) but the leaflets coapt well. Mild to moderate ([**12-21**]+)
mitral regurgitation is seen. Mitral regurgitation is not
worsened by fluid administration or afterload augmentation.
There is no pericardial effusion.
POSTBYPASS
The patient is AV paced and is not on any inotropes.
Left ventricular systolic function remains normal (LVEF>55%).
Mild aortic regurgitation persists.
Mitral regurgitation is slightly improved and is now mild. The
leaflets continue to coapt well.
The thoracic aorta is intact.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
Radiology Report CHEST (PORTABLE AP) Study Date of [**2138-8-17**]
11:23 AM
Final Report
HISTORY: Chest tube removal, to assess for pneumothorax.
FINDINGS: In comparison with study of [**8-15**], all of the
monitoring and support devices have been removed. Specifically,
there is no evidence of
pneumothorax. Bibasilar atelectatic changes persist.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. See operative report
for further details. In summary he had:
Coronary artery bypass grafting times 5, with left internal
mammary artery graft to left anterior descending, reverse
saphenous vein grafts to the ramus intermedius, marginal branch,
right coronary artery and diagonal branch. His bypass time was
92 minutes with a crossclamp time of 79 minutes. He tolerated
the operation well and was transferred post-operatively to the
intensive care unit for recovery and further management.
Received cefazolin for perioperative antibiotics.
In first twenty four hours he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
On post operative day one he remained in the intensive care unit
for blood glucose management and due to bradycardia requiring
pacing so he was not started on beta blockers. All tubes line
and drains were removed per cardiac surgery protocol. He
remained in the intensive care unit waiting for an available
floor bed. He was transferred to the stepdown floor on post
operative day three. The remainder of his hospital course was
uneveventful. Physical therapy worked with him on strength and
mobility. He continued to progress and was ready for discharge
home with services on post operative day 5. He is to follow up
with Dr [**Last Name (STitle) **] in clinic in 3 weeks.
Medications on Admission:
Atenolol 25mg po daily
Folic Acid 1mg po daily
Levothyroxine 100mcg po daily
Niacin 1000mg po qHS
Simvastatin 40mg po daily
Sulfasalazine 1000mg po BID
Valsartan 160mg po daily
ASA 81mg po BID
Calcium carbonate 500mg po PRN
Centrum Silver
Amoxicillin 2g po 1 hour before dental procedures
Discharge Medications:
1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Subcutaneous Insulin Pump Miscellaneous
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO HS (at bedtime).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
9. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for (R)forearm phlebitis for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]Hospice
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass grafting
times
5; left internal mammary artery graft to left anterior
descending, reverse saphenous vein grafts to the ramus
intermedius, marginal branch, right coronary artery and diagonal
branch.
PMHx: Hypertension, Hyperlipidemia, Type I Diabetes on insulin
pump,
Ulcerative Colitis, Prior remote GIB, none in 10 yrs, GERD, h/o
broken right ankle, s/p total right hip arthroplasty [**11/2137**],
s/p tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions: Sternal - healing well, no erythema or drainage
Leg bilateral EVH sites- healing well, no erythema or drainage.
Edema: 1+ pedal edema bilat
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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2138-9-11**] 1:15
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9751**] is away on vacation. Dr [**Last Name (STitle) **]
office will schedule f/u appointment and call you next week to
let you know when it is.
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 56850**] in [**3-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2138-8-20**]
|
[
"272.4",
"V58.66",
"V53.91",
"451.82",
"458.29",
"411.1",
"556.9",
"250.01",
"401.9",
"530.81",
"V43.64",
"999.2",
"E879.8",
"414.01",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10444, 10498
|
6917, 8365
|
344, 567
|
11011, 11261
|
2292, 6894
|
12185, 12935
|
1524, 1608
|
8706, 10421
|
10519, 10990
|
8391, 8683
|
11285, 12162
|
1623, 2273
|
282, 306
|
595, 1005
|
1027, 1248
|
1264, 1264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,449
| 177,929
|
54652
|
Discharge summary
|
report
|
Admission Date: [**2109-7-29**] Discharge Date: [**2109-8-2**]
Date of Birth: [**2040-3-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / ketia
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2109-7-29**] Coronary artery bypass graft x3: Left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to ramus and posterior descending arteries
History of Present Illness:
69 year old man with hypercholesterolemia, family history of
coronary artery disease, onset of chest heavinesss about three
months ago occurring during gym workouts would last a few
minutes then resume his workout. Denies any episodes at rest. He
was sent to the [**Hospital1 **] emergency room and then was tranferred to
[**Hospital1 18**] for Cardiac Cath in early [**Month (only) 216**]. Cath showed severe
coronary artery disease and was referred for surgery.
Past Medical History:
Hyperlipidemia
Hypothyroidism
Seasonal Allergies
Anxiety
s/p Bilateral ingunial hernia rpr. [**2078**]
Social History:
He lives alone and is retired. He never smoked and drinks less
than one alcoholic beverage per week. He denies illicit drug
use.
Family History:
His mother has angina symptoms, and passed away at age 78 after
cardiac surgery. His father died at age 64 year.
Physical Exam:
Pulse:71 Resp:20 O2 sat:99% RA
B/P Right: Left:143/76
Height: 5'9 Weight:95kg
General:NAD,AAOx3, no focal deficits
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen:Soft[x]non-distended[x]non-tender[x] bowelsounds+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:cath site Left:+2
Carotid Bruit: None
Pertinent Results:
[**2109-7-29**] Echo: PRE-BYPASS: There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Estimated 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 ascending
aorta. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. Mild (1+) aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2109-7-29**]
at 0930. Post Bypass: There is preserved left ventricular
function that is unchanged from prebyass. There is no obvious
evidence of aortic dissection. Valvular function is unchanged
from prebypass with continued mild aortic regurgitation.
.
[**2109-7-29**] 11:49AM BLOOD WBC-22.4*# RBC-3.91* Hgb-12.1* Hct-34.8*
MCV-89 MCH-31.0 MCHC-34.9 RDW-13.1 Plt Ct-210
[**2109-8-2**] 06:20AM BLOOD WBC-10.8 RBC-3.60* Hgb-11.1* Hct-33.0*
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.4 Plt Ct-276
[**2109-7-29**] 11:49AM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.3*
[**2109-7-29**] 11:49AM BLOOD UreaN-12 Creat-0.8 Na-140 K-4.2 Cl-112*
HCO3-22 AnGap-10
[**2109-8-2**] 06:20AM BLOOD Glucose-103* UreaN-21* Creat-1.0 Na-135
K-4.4 Cl-100 HCO3-31 AnGap-8
[**2109-7-30**] 02:59AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1
[**2109-8-1**] 03:57AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8
Brief Hospital Course:
The patient was brought to the Operating Room on [**7-29**] where the
patient underwent Coronary artery bypass graft x3: Left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to ramus and posterior descending
arteries. Endoscopic harvesting of the long saphenous vein.
Please see operative note for surgical details. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with VNA services in
good condition with appropriate follow up instructions.
Medications on Admission:
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Aspirin 325 mg PO DAILY
3. WelChol *NF* (colesevelam) 625 mg Oral daily
4. Multivitamins 1 TAB PO DAILY
5. Co Q-10 *NF* (coenzyme Q10;<br>coenzyme Q10-vitamin E) 100 mg
Oral daily
6. garlic *NF* 500 mg Oral daily
7. saw [**Location (un) 6485**] *NF* 450 Oral daily
8. flaxseed oil *NF* 1200 Oral daily
9. Magnesium Oxide 250 mg PO DAILY
10. krill oil *NF* [**Medical Record Number 111783**]-50 mg Oral daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
2. Levothyroxine Sodium 125 mcg PO DAILY
3. WelChol *NF* (colesevelam) 625 mg ORAL DAILY
4. Furosemide 20 mg PO BID Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
5. Metoprolol Tartrate 37.5 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 [**12-3**] tablet(s) by mouth three
times a day Disp #*150 Tablet Refills:*1
6. Oxycodone-Acetaminophen (5mg-325mg) [**12-3**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-3**] tablet(s) by mouth
every four (4) hours Disp #*65 Tablet Refills:*0
7. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
RX *potassium chloride 20 mEq 1 mEq by mouth twice a day Disp
#*14 Tablet Refills:*0
8. Ranitidine 150 mg PO BID Duration: 2 Weeks
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*28 Capsule Refills:*0
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*28 Capsule Refills:*0
9. saw [**Location (un) 6485**] *NF* 450 Oral daily
10. Multivitamins 1 TAB PO DAILY
11. Magnesium Oxide 250 mg PO DAILY
12. krill oil *NF* [**Medical Record Number 111783**]-50 mg Oral daily
13. garlic *NF* 500 mg Oral daily
14. flaxseed oil *NF* 1200 Oral daily
15. Co Q-10 *NF* (coenzyme Q10;<br>coenzyme Q10-vitamin E) 100
mg Oral daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Hyperlipidemia
Hypothyroidism
Seasonal Allergies
Anxiety
s/p Bilateral ingunial hernia repair. [**2078**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office on [**2109-8-8**] at 10:15 in
the [**Hospital **] medical office building, [**Hospital Unit Name **]
Surgeon Dr. [**First Name (STitle) **] on [**2109-8-27**] at 2:30 [**Telephone/Fax (1) 170**] at 10:15 in
the [**Hospital **] medical office building, [**Hospital Unit Name **]
Cardiologist: Please obtain referral to cardiologist from PCP
Please call to schedule the following:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2109-8-2**]
|
[
"244.9",
"413.9",
"300.00",
"V17.3",
"458.29",
"272.0",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6893, 6950
|
3611, 4901
|
290, 473
|
7183, 7352
|
2044, 3588
|
8140, 8996
|
1254, 1368
|
5405, 6870
|
6971, 7032
|
4927, 5382
|
7376, 8117
|
1383, 2025
|
240, 252
|
501, 966
|
7054, 7162
|
1108, 1238
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,267
| 115,686
|
795
|
Discharge summary
|
report
|
Admission Date: [**2158-9-11**] Discharge Date: [**2158-9-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Failure to thrive, acute renal failure, mental status change,
tremor
Major Surgical or Invasive Procedure:
G-tube placement
History of Present Illness:
86 yo F with dementia, HTN, CKD with recent discharges from
[**Hospital1 18**] for FTT, ARF and UTI admitted today from rehab due to poor
PO intake and concern of new body tremors/neck spasm; found to
have acute on chronic renal failure. The pt has had two recent
admissions for similar complaints. Today, the pt was referred to
her PCP's office and was found to have cogwheel rigidity and
neck spasm. Additionally, HCT was found to be slightly below
baseline and LFTs were abnormal by report, although not yet
available here. Unfortuantely, at the time of the interview the
pt was minimally oriented and thus could not provide much
history.
Past Medical History:
Auditory Hallucinations- not a seizure Disorder
Dementia
Hypertension
Depression
h/o falls
Chronic Renal Insufficiency (Cr 2.2-2.9)
Osteoporosis
Renal Medullary Necrosis
Organic Brain Syndrome
Recent L rib fx
Social History:
Retired garment industry worker. Unmarried. No Tob, EtOH or drug
history. Recently moved to a nursing home.
Family History:
Negative for seizures or stroke, otherwise NC.
Physical Exam:
VS: T 96, BP 136/52, HR 71, RR 20, 97%RA
Gen: Elderly female, lying in bed, awake and responsive but
otherwise disoriented.
HEENT: EOMI, anicteric slera, MM dry, OP clear
Neck: supple, no LAD
CV: RRR, soft heart sounds, soft 3/6 SEM at RUSB
Pulm: CTAB with decent effort, no wheeze or crackles aprpeciated
Abd: thin, soft, + BS
Ext: warm, 2+ DP pulses, no pitting edema, no calf tenderness
Neuro: Awake and alert, not oriented. Intermittently able to
follow
one step commands. CNII-XII intact, motor and gross sensation
intact throughout.
Pertinent Results:
[**2158-9-11**]
WBC-9.6 Hgb-8.2* Hct-26.2* MCV-84 RDW-15.8* Plt Ct-245
Neuts-78.2* Lymphs-16.9* Monos-3.9 Eos-0.8 Baso-0.2
PT-12.4 PTT-18.3* INR(PT)-1.0
Glucose-74 UreaN-54* Creat-3.4* Na-141 K-5.9* Cl-109* HCO3-21*
AnGap-17
ALT-346* AST-59* LD(LDH)-280* AlkPhos-174* TotBili-0.3
Albumin-3.5
.
CXR [**2158-9-11**]: Stable atelectasis in the left lower lobe with no
evidence of
focal consolidations.
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM
# Failure to Thrive: Thought to be [**3-11**] dementia and poor PO
intake; has had multiple similar admissions in the past for the
same reason. After discussion with [**Hospital 228**] health care proxy,
IR was consulted and agreed to place a G-tube because of her
persistent FTT related to poor PO intake even in the setting of
monitoring at rehab. This was placed on [**2158-9-13**].
.
Following the procedure, the patient developed chest/abdominal
pain and leakage was noted around the G-tube. Pt was started on
Zosyn and Flagyl overnight given the possibility of a
perforation. Overnight the patient was noted to be hypotensive
with SBP's in the 90's, which was well below her baseline BP as
well as low urine output. Later the patient was also noted to
have a moderate amount of hematemesis. Surgery was consulted and
CT abdomen was suspicious for for extravasation of contrast.
Given clinical changes, she required transfer to ICU for further
management. After discussion with family regarding grave
prognosis, decision was made to provide aggressive comfort
measures. Pain medications were administered and she passed
away at 11:03 pm on [**2158-9-15**]. Autopsy will be pursued given
clinical circumstances.
.
Medications on Admission:
Lisinopril 20 mg daily
Atenolol 25 mg daily
HCTZ 25 mg daily
Norvac 5 mg daily
ASA 81 mg daily
Aricept 10 mg daily
Lipitor 10 mg daily
Risperdal 0.25 mg [**Hospital1 **]
Fosamax 70 mg weekly
Mirtazapine 15 mg QHS
Senna
Colace
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
Possible gastric perforation
Failure to thrive
Acute on chronic renal failure
Mental status change
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"733.00",
"311",
"585.9",
"536.49",
"567.9",
"294.8",
"276.2",
"785.52",
"285.21",
"578.0",
"568.89",
"995.92",
"E878.3",
"584.9",
"038.9",
"276.7",
"403.90",
"781.0",
"783.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
4009, 4018
|
2452, 3705
|
330, 348
|
4174, 4183
|
2018, 2429
|
4234, 4239
|
1394, 1442
|
3982, 3986
|
4039, 4153
|
3731, 3959
|
4207, 4211
|
1457, 1999
|
222, 292
|
376, 1019
|
1041, 1252
|
1268, 1378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,604
| 142,011
|
45750
|
Discharge summary
|
report
|
Admission Date: [**2169-2-12**] Discharge Date: [**2169-2-24**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain, constipation, chills
Major Surgical or Invasive Procedure:
[**2169-2-14**] Exploratory laparotomy, subtotal colectomy, [**Doctor Last Name 3379**]
pouch and ileostomy
History of Present Illness:
Ms. [**Known lastname **] 89y/o lady with HTN, dCHF, and multiple admissions for
diverticulitis (most recently in [**2168-11-24**]) who presented to
the ED with abdominal pain and chills.
.
Patient states that for 1-2 weeks, she has had LLQ and lower
abdominal pain. Has been increasingly constipated for ~1 week.
She has had chills but no documented fever. Spitting up brownish
phlegm, but no cough or other URI symptoms. Poor PO intake at
home, mild nausea. Had a loose bowel movement on the day of
presentation but no blood. She and her family felt this was
similar to prior episodes of diverticulitis so she came to the
ED.
.
In the [**Hospital1 18**] ED, initial VS: pain [**5-4**], T 100.0, HR 86, BP
137/91, RR 16. Labs notable for WBC 9.8 (75% PMNs), Cr 1.3
(baseline is 1), K 2.9, Ca [**66**].7. She received 40mEq of
potassium. CXR with no signs of PNA but did show air/fluid
levels in the gut. CT abdomen/pelvis showed sigmoid
diverticulitis with dilated fluid filled colon increased in
caliber since prior exam, suggestive of evolving colonic
obstruction. ACS was consulted and felt there was no surgical
intervention needed at this time; obstruction felt to be likely
due to stool, recommended manual disimpaction and they will
follow along. She received Morphine for pain control, Zofran for
nausea, and Ciprofloxacin/ Metronidazole. Received 1L NS in the
ED. She is admitted to Medicine for management for
diverticulitis with colonic obstruction. VS prior to transfer
were T98.3, HR 69, RR 16, BP 158/97, POx 95%RA.
.
Upon arrival to the Medicine floor, she feels fins but still has
crampy abdominal pain, now mostly in her lower abdomen. Nothing
else is bothering her except that she is tired from being in the
ED. She is not passing any gas and feels very constipated. Last
BM was a loose stool on the day of presentation prior to coming
in to the ED.
.
REVIEW OF SYSTEMS:
Denies fever, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
Hypercholesterolemia
diastolic CHF
Obesity
GERD
Diveriticulosis
Anxiety
Alcohol abuse
Fe deficiency anemia
Degenerative joint disease of the glenohumeral joint with
rotator cuff tear
Spinal stenosis L4-L5 and L3-L4, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
treated with steroid injections
s/p bilateral knee replacement
Diverticulitis
Social History:
Patient lives alone in apartment in [**Location (un) 669**]. Her son [**Location (un) **]
lives upstairs. She has two sons and one is a pharmacist at
[**Hospital1 18**] ([**Location (un) **]). Pt has VNA services and home health aide M-F. No
tobacco, no etoh. Has history of social drinking.
Family History:
No known family history of heart problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.2F, BP 158/78, HR 70, R 16, O2-sat 96% RA
GENERAL - Pleasant well-nourished elderly lady in no acute
distress; sleepy but easily arousable and interactive; oriented
to year, month, hospital name
HEENT - EOMI, sclerae anicteric, dry MM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - distant heart sounds but S1+S2, no murmur audible, no
extra heart sounds heard
LUNGS - clear to auscultation throughout, with crackles at the
bases
ABDOMEN - (+)bowel sounds; mildly distended; soft; tender to
deep palpation of lower abdomen and LLQ; no rebound or guarding
DRE - External hemorrhoids, firm mass deep within vault. Guiac
negative
EXTREMITIES - warm, no edema, 2+ Dp pulses bilaterally
SKIN - no rashes or lesions
NEURO - sensation grossly intact throughout, gait deferred
Pertinent Results:
PERTINENT LABS:
[**2169-2-12**] 06:15AM BLOOD WBC-11.7* RBC-4.19* Hgb-13.3 Hct-38.1
MCV-91 MCH-31.8 MCHC-34.9 RDW-14.0 Plt Ct-247
[**2169-2-11**] 07:50PM BLOOD Neuts-75.0* Lymphs-20.5 Monos-2.8 Eos-0.8
Baso-0.8
[**2169-2-14**] 12:45PM BLOOD PT-12.7* PTT-27.3 INR(PT)-1.2*
[**2169-2-11**] 07:50PM BLOOD Glucose-105* UreaN-15 Creat-1.3* Na-131*
K-2.9* Cl-91* HCO3-27 AnGap-16
[**2169-2-11**] 07:50PM BLOOD ALT-14 AST-29 AlkPhos-78 TotBili-0.6
[**2169-2-11**] 07:50PM BLOOD Albumin-3.7 Calcium-10.7* Phos-3.8 Mg-1.6
[**2169-2-11**] 07:50PM BLOOD Lactate-2.0 K-3.5
.
CXR:
FINDINGS: The heart size is at the upper limits of normal,
similar to prior exam. The mediastinal and hilar contours are
within normal limits. The lungs show no lobar consolidation.
Again a hiatal hernia is present. There is no pleural effusion
or pneumothorax. There is no subdiaphragmatic free air.
Air-fluid levels noted below the diaphragm may indicate
obstruction or delayed gastrointestinal transit.
IMPRESSION: No evidence of pneumonia; question of intestinal
obstruction or slowed intestinal transit. CT pending.
CT PELVIS W/CONTRAST Study Date of [**2169-2-11**] 10:52 PM
IMPRESSION:
1. Findings suggestive of evolving colonic obstruction with low
transition
point in the distal sigmoid colon in the region of known
diverticulitis, with apparent inflammatory tethering. Underlying
mass must be excluded once inflammation resolves. No free air.
2. Trace perihepatic ascites.
3. Gallbladder sludge or stone.
4. Hiatal hernia.
5. Right renal cyst.
ABDOMEN (SUPINE & ERECT) Study Date of [**2169-2-13**] 12:06 PM
IMPRESSION:
1. Markedly dilated ascending and transverse colon measuring up
to 8 cm in
diameter with accompanied air-fluid levels on the lateral
decubitus study. These findings are consistent with a colonic
obstruction. No free air. Careful imaging followup is advised
and clinical assessment is also suggested.
Brief Hospital Course:
Ms. [**Known lastname **] 89y/o lady with HTN, dCHF, and multiple admissions for
diverticulitis (most recently in [**2168-11-24**]) who presents
with sigmoid diverticulitis and possible evolving colonic
obstruction.
.
#. Evolving colonic obstruction:exam becoming concerning for
evolving colonic obstruction. Surgery on board and following
closely. Per surgery request colonic gastrograph is being
performed today and possible operation later in day.WBC
increased to 10.9 from 7.
- NPO for now
- IVF PRN if not tolerating adequate PO intake
- antibiotics:cipro/flagyl day 1 was [**2-12**]
- pain control w/ acetaminophen, oxycodone, tramadol
- appreciate Surgery recs
- serial abdom exams w/ possible surgery later in the day
.
# [**Name (NI) 97480**] pt most likely also has a recurrent infection
in the area of evolving colonic obstruction. She has been
afebrile, but increasing WBC. Unclear whether infection vs
obstruction acutely causing increase.
- cont cipro/flagyl D1 [**2-12**]
- monitor for signs of fever
- serial abdom exams
.
#. Hypertension: stable
- holding HCTZ for hypokalemia
- holding Enalapril for [**Last Name (un) **]
- continue Metoprolol
.
#. Chronic Diastolic heart failure: stable.
She is not clinically volume overloaded.
- continue BB
- holding ACE-i for resolving [**Last Name (un) **] and possible surgery
- continue to hold Lasix, not volume overloaded pt not taking in
much po
- monitor daily weights, I/O monitoring
.
#. Hyperlipidemia: stable.
- continue statin
.
#. Anxiety: stable.
- continue Bupropion XL, Mirtazapine
#. [**Last Name (un) **]: likely prerenal.
Cr was 1.3 on admission (baseline is 1.0). She reports poor PO
intake at home and thisa appears most likely prerenal. Also,
unclear if she has been using NSAIDs (Salsalate) which is on
prior med list.
- IVF as above
- trend Cr, renally dose meds, avoid nephrotoxins
- consider spinning urine, although improved creatinine with
hydration
.
#. Hypokalemia: likely multifactorial.
She reports "spitting up" which could represent emesis and GI
losses, though this seems to be phlegm rather than vomit.
Otherwise, her hypokalemia can also be explained by diuretic use
(she has continued HCTZ but has been holding Lasix since she was
feeling ill.)
- hold HCTZ
- hold Lasix
- continue potassium supplementation PRN
** Surgical course **
Following admission and IV hydration, the patient had
progressive abdominal pain with no passage of flatus or stool.
On the morning of HD#2 a gastrograffin enema demonstrated
inability of rectal contrast to pass beyond the distal sigmoid
colon, consistent with a complete colonic obstruction. Following
a discussion with the patient and her son, she was consented for
surgery and proceeded to the OR. Intraoperative findings were
notable for a distended, fluid-filled colon with friable tissue,
particularly in the region of the cecum. She underwent a
Subtotal colectomy with [**Doctor Last Name 3379**] pouch and ileostomy.
The pathological specimen consisted of perforated diverticulitis
with abscess and fistulous connections to small bowel. There was
no carcinoma seen and the sampled lymph nodes were normal.
Her postoperative course was complicated by multiple organ
dysfunction: cardiovascular requiring prolonged vasopressor
support; respiratory requiring prolonged ventilatory support;
renal requiring CVVH; and GI requiring TPN. Her course is
summarized by system:
NEURO: She maintained on Fentanyl and Versed drips for the first
several days postop and was then transitioned to boluses of
these medications for pain control and sedation. When her
sedation was lightened she was able to respond to commands and
move all four extremities.
CARDIOVASCULAR: Her early postop course was marked by a large
fluid requirement due to: under-resuscitation preop, massive
fluid sequestration in the bowel, a long operative procedure
with an open abdomen, and postop SIRS/sepsis. In the first days
post op transthoracic echocardiography at the bedside
demonstrated adequate filling of the heart and her blood
pressures were therefore managed with pressors. She was started
on pressors intraoperatively and postop continued on Neo and
Levophed for several days. The Neo was able to be weaned off but
her cardiac course was further complicated by atrial
fibrillation that required an Amiodarone drip. This lowered her
blood pressure and Vasopressin was added to the Levophed to
maintain perfusion.
She was unable to wean off pressors during her entire
postoperative course.
PULMONARY: She has remained in respiratory failure requiring
ventilatory support on CMV since her surgery and her ventilatory
support was unable to be decreased. Her course has also been
complicated by pleural effusions.
GI: The patient's ileostomy has not functioned since the
surgery, and she has been managed wtih NGT drainage. Her ostomy
failed to produce gas or stool On POD#7 given her failure to
progress a CT abd was obtained that demonstrated: volume
overload w/ excess intraperitoneal fluid without abscess;
attenuated mesenteric blood flow c/w low flow state; a long
segment of jejunum w/ wall thickening that may represent
infection or ischemia.
RENAL: The early postoperative course was marked by rising
Creatinine (max 2.0 from baseline of 1) and low urine output.
After extensive discussions with the son, the decision was made
to pursue CVVH for removal of excess fluid. A dialysis catheter
was placed in the IJ. This was initially found to have
excessively high flows and due to concern over possible
stenosis, a temporary femoral line was placed until the IJ could
be repositioned by IR. She has tolerated CVVH without
difficulty. By POD#9 she had begun to make small amounts of
urine on her own.
F/E/N: She was started on TPN for nutritional support while
waiting for return of function of her GI tract.
Heme: Her platelets dropped in the early days after surgery.
This raised concern for Heparin Induced Thrombocytopenia.
Heparin was stopped, lines were changed to non-heparin coated
lines. DVT/PE prophylaxis was begun with Lovenox. Heparin
antibody test was negative.
By POD#10 it was apparent that the patient was not improving.
She remained in multisystem organ failure as outlined above.
During the entire postoperative course the family was involved
with the patient's care and SICU team was instrumental in
discussing with the family the patient's prognosis. By POD#10
the fact that the patient had not progressed, was still on
pressors, on high ventilator support and dialysis led to a
further conversation with the family. The conclusion of this was
that the patient was placed on Comfort Measures Only. Shortly
thereafter she died.
Medications on Admission:
Aspirin 81mg PO daily
Metoprolol succinate ER 200 mg daily
Enalapril 20 mg daily
Hydrochlorothiazide 25 mg daily
Simvastatin 20 mg QHS
Bupropion XL 150 mg QAM
Mirtazapine 15 mg QHS
Salsalate 500 mg [**Hospital1 **] PRN
Tramadol 50 mg Q6H PRN
Famotidine 40 mg [**Hospital1 **] PRN
Nystatin 100,000 unit/g Topical Powder [**Hospital1 **] under breasts PRN
Docusate Sodium 100 mg [**Hospital1 **]
Benefiber 1 Packet [**Hospital1 **]
Miralax daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Diverticulitis, bowel obstruction, multisystem organ failure
Discharge Condition:
patient made CMO, expired
Discharge Instructions:
n/a patient made CMO, expired
Followup Instructions:
n/a patient made CMO, expired
Completed by:[**2169-2-25**]
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18,123
| 184,509
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3584
|
Discharge summary
|
report
|
Admission Date: [**2200-2-1**] Discharge Date: [**2200-3-6**]
Date of Birth: [**2125-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Not feeling well
Major Surgical or Invasive Procedure:
PICC line placement under fluoroscopy ([**2200-2-4**])- this was later
d/c'd since it clotted and was not working and no further IV abx
were needed.
PEG and trach placement ([**2200-3-3**])
PICC line placement under fluoroscopy ([**2200-3-5**])
History of Present Illness:
74 F with DM2 neuropathy, chronic LE edema, recurrent LE
cellulitis, MRSA history, CRI, AFIB not on coumadin, here
because she has not been feeling well for several days. No
N/V/D, no fever. EKG shows no changes. Dig level was checked in
ED, although patient is apparently not on digoxin (digoxin <
0.2). CXR shows small R sided infiltrate and effusion. Received
Levo 500 x1. T100.3, received tylenol 500 x1. Patient was
breathing easily and was 95% RA.
Past Medical History:
-Chronic atrial fibrillation, never on anticoagulation per
patient's wishes
-Type 2 Diabetes complicated by peripheral neuropathy
-Hypertension
-Hyperlipidemia
-PVD s/p bilateral fem [**Doctor Last Name **] bypasses
-Colon cancer [**2187**] s/p colectomy, treatment with 5-FU, in
remission since.
-Bilateral cataracts
-Obstructive sleep apnea
-Urge incontinence
Social History:
Patient is retired and formerly worked at [**Location (un) 8599**]Hospital
in computers. She lives alone in senior housing in [**Location (un) 686**].
She has several close friends that help her with her shopping
and getting to appointments. She has a remote smoking and
alcohol history (puffed an occasional cigarette in social
gatherings 50 years ago) denies any illict drug use.
Family History:
NC
Physical Exam:
VS: 97.8 / 118/56 / 98 / 20 / 94% 2L
Gen: Awake and alert, NAD, pleasant female
HEENT: MM dry
Heart: irreg, irreg, no s3/s4, no m,r,g
Lungs: CTAB, poor air movement but no crackles
Abdomen: obese, soft, NT/ND, +BS
Extremities: Bilateral edema, chronic venous stasis changes with
overlying erythema & warmth, 2+ DP bilaterally
Pertinent Results:
CXR PA/lat ([**2200-1-31**]): Patchy opacity in the right middle lobe
likely representing pneumonia. Right-sided pleural effusion.
Mild CHF.
.
CXR (lateral decubitus) ([**2200-2-1**]): Only minimal layering of right
effusion.
.
[**2200-1-31**] 08:30PM WBC-9.5 RBC-3.60* HGB-9.9* HCT-28.9* MCV-80*
MCH-27.5 MCHC-34.3 RDW-14.4
[**2200-1-31**] 08:30PM NEUTS-89.8* LYMPHS-4.4* MONOS-5.0 EOS-0.7
BASOS-0.2
[**2200-1-31**] 08:30PM UREA N-61* CREAT-1.6* SODIUM-134
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-26 ANION GAP-17
[**2200-2-1**] 09:30AM calTIBC-263 FERRITIN-151* TRF-202
[**2200-2-2**] 10:55AM BLOOD ERYTHROPOIETIN-58.0
[**2200-2-1**] 09:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.6 Iron-15*
Brief Hospital Course:
# Respiratory distress: Ms. [**Known lastname 16352**] was admitted to the
floor for treatment of her pneumonia/hypoxia. She was intially
treated with levofloxacin, and then ceftriaxone/azithromycin for
presumed community-acquired bacterial pneumonia. On this
regimen, however, her hypoxia worsened (in spite of some
diuresis) and she developed a leukocytosis and some delirium.
Considering her recent discharge from rehab, it was thought that
her pneumonia may have been nosocomial so her antibiotics were
changed to vanco/Zosyn. She had a PICC line placed for
outpatient IV antibiotics. With this regimen, her leukocytosis
and delirium improved, and her oxygen requirement initially
improved but then worsened and she was transferred to the unit
and intubated. She completed the course of vanco/zosyn but
continued to have heavy secretions which grew out MRSA. Another
7 day course of vanc/zosyn was started on [**2-17**] and the zosyn was
completed, but the vanc was changed to linezolid since MRSA
repeatedly grew out of sputum and BAL cultures. A 10 day course
of linezolid was completed on [**3-2**]. She was diuresed aggressively
with the thought that pulm edema could have been restricting her
respiratory status. However, she was extubated twice and both
times had to be reintubated. The reasons for this were thought
to be secondary to copious upper airway secretions (which her
family members remark have been present in the past) in
combination with altered mental status requiring sedatives. Both
times the patient initially looked well after extubation, but
she remained confused and had a difficult time coughing up her
copious upper airway secretions. She also had severe OSA. She
would become agitated and try to get out of bed, but even mildly
sedating meds such as zyprexa would make her somnolent and then
her upper airway would become obstructed. Bipap seemed to help
temporarily, but when she would wake up she would become
agitated and would not tolerate the mask. After the 3rd
intubation it was felt she will require a long wean off the vent
hopefully after her mental status improves so that she may
cooperate. A trach and PEG were placed. She will require further
aggressive attempts to get her off of ventilatory support.
Incidentally, she was noted to have persistent elevation of her
right hemidiaphragm and at some point in the future she should
have inspiratory/expiratory CXRs to evaluate for diaphragmatic
paralysis (which may be contributing to her repeated
pneumonias).
.
# Urinary tract infection/fevers: the patient had her foley
changed and Ua sent on [**3-5**] which had many WBC's. She then
started spiking fevers and was started on ciprofloxacin on [**3-6**]
with plan for 7 day treatment. Urine culture is still pending at
the time of discharge and should be followed up on to ensure
that ciproflox is an adequate antibiotic for treatment.
.
# C.diff: Three days into this antibiotic course, she developed
diarrhea and stool studies returned positive for C. Difficile
toxin A. She was started on metronidazole and was continued on
this until she finished her vanco/Zosyn/Linezolid course. Her
diarrhea cleared and WBC went down.
.
# Anemia: She was noted to be markedly anemic upon admission.
Her iron studies were consistent with iron deficiency anemia, so
her PO iron polysaccharide dose was increased. Her
erythropoeitin level was elevated, implying that she simply does
not have the iron stores for adequate erythropoeisis. Given her
history of colon cancer, her PCP may decide to repeat a
colonoscopy (though this was negative in 6/[**2198**]). Hct was
relatively stable for most of the admission.
.
# ARF on CRI/Volume status: Several days into her
hospitalization, her creatinine was noted to increase up from a
baseline of 1.6 to a peak of 2.1. It was presumed that she may
have been prerenal from overdiuresis. She experienced some
improvement with gentle hydration, but the slow recovery of her
renal function implied that she may have also had a component of
ATN in the setting of her septicemia. She did not require HD and
Cr improved with time back to baseline. She required some doses
of lasix to aggressively diurese and seemed to respond best to
500mg IV diuril followed by 100mg of lasix. Lower doses or using
lasix alone often did not seem to instigate an increase in urine
output. On [**3-3**] she was given a dose of diuril and lasix and
diuresed about 3L over the next 2 days. However, late on [**3-5**] her
UOP dropped and since has remained at approx 15cc/hour. Ua
showed a UTI and she was started on ciprofloxacin. FeUrea was
calculated at 8% (indicating possible prerenal physiology) but
the pt did not respond to a 1L fluid bolus (no increased urine
output). A CXR later showed increasing pulm edema and pleural
effusions. At the time of discharge ([**3-6**]) the plan was to treat
the pt's UTI with Cipro but avoid giving further IVF given the
pulmonary edema, however, if she continues to spike fevers she
may require further IVF. It is hoped that once the patient is
able to get out of bed more she will be able to mobilize fluids
and diurese on her own.
.
# altered mental status: Her family noted that when she returned
home from her last stay at rehab, she was "as sharp as a tack".
On this admission the patient was first noted to have confusion
relatively soon after her admission and this was initially
attributed to infection. However, she was subsequently intubated
and then had to be kept on potentially sedating/mind-altering
medications in order to keep her comfortable. When she was
extubated these meds were removed but she only remained
extubated for 2.5 days at the most, and her mental status did
not clear during this time, however, it was felt that it might
take her longer than this to clear the medications. No other
toxic/metabolic causes of her altered mental status were
discovered, and it is hoped that now with the trach and PEG, she
will be able to be off all potentially mind-altering medications
and will have a chance to fully clear her mental status.
However, with the development of the urinary tract infection on
[**3-5**] and fevers, this may also contribute. Hopefully, with
continued treatment of the UTI her mental status will improve.
.
# DM: She was initially put on her home insulin regimen of 15
units of 70/30 insulin [**Hospital1 **]. With this, however, she had several
hypoglycemic episodes, so her dose was titrated down and has
been stable with 8 qam and 6 qpm along with the sliding scale
insulin.
.
# AFib: at times her HR was very hard to control, particularly
when she was unable to take po meds. She was initially on
diltiazem only, but metoprolol was added for better rate
control, especially given that it was unclear if her tachycardia
in the setting of her 1st extubation may have led to further
pulmonary edema and reintubation. She was well rate controlled
with the combination of metoprolol and diltiazem. Per records,
she has never been anticoagulated for her AFib at her request
per agreements/discussions with her PCP.
.
# Upper extremity swelling: Left slightly greater than Right.
Ultrasound on [**2-11**] was negative for DVT. Repeat ultrasound LUE
[**2-17**] also negative. Upper extremity edema has been constant and
consistently greater than LE edema and this was felt [**1-3**] to the
fact that she had undergone PVD surgery on her legs in the past
which may have changed the lymph drainage systems.
.
# HTN: at times the pt had difficult to control BP but then
especially when she was sedated her BP would often drop. She was
titrated up on diltiazem and metoprolol as above and then given
hydralazine as well to control BP. She was restarted on an ACEi
after her ARF improved but this was d/c'd again when Urine
output decreased as we did not want to cloud the picture of
potential renal failure. Lisinopril can be restarted once urine
output and Cr are stable.
.
# FEN: a PEG was placed on [**3-3**] given that she had been trach'd
and continued to have altered mental status. Tube feeds of
Nutren Pulmonary Full strength Goal rate: 40 ml/hr, Residual
Check: q4h. Hold feeding for residual >= : 150 ml. Flush w/ 50
ml water q4h.
.
# Pain: after trach and PEG the pt seemed to c/o discomfort at
the trach site which was initially managed with a fentanyl gtt
which was then changed to oxycodone. On [**3-6**] pain seemed to be
improved and oxycodone was d/c'd, with hopes that being off of
potentially mind-altering meds would help her MS clear.
Medications on Admission:
-Aspirin 81mg daily
-Amlodipine 10mg daily
-Docusate Sodium 100mg [**Hospital1 **]
-Diltiazem HCl 240 mg SR daily
-Furosemide 40mg [**Hospital1 **]
-Lisinopril 40mg daily
-Polysaccharide Iron Complex 150mg daily
-MVI daily
-Senna 8.6 mg [**Hospital1 **]
-Ditropan XL 15mg daily
-Clonidine 0.2 mg/24 hr Patch QMon
-Insulin 70/30 15 units [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
3. Polysaccharide Iron Complex 150 mg Capsule [**Hospital1 **]: One (1)
Capsule PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for diarrhea.
6. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5,000 units
Injection TID (3 times a day).
7. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical PRN
(as needed).
8. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
10. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Ten (10) ML PO Q6H (every
6 hours).
11. Diltiazem HCl 90 mg Tablet [**Hospital1 **]: One (1) Tablet PO four times
a day: hold for sBP<110, HR<65.
12. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day): hold for sBP<110, HR<65. .
13. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
[**Hospital1 **]: Eight (8) units Subcutaneous qam.
14. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
[**Hospital1 **]: Six (6) units Subcutaneous qpm.
15. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Hospital1 **]: see
attached sliding scale. units Subcutaneous qid.
16. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. Ciprofloxacin 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
19. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6
hours).
20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnoses: nosocomial bacterial pneumonia with
septicemia, C. Difficile colitis, urinary tract infection.
.
Secondary diagnoses: chronic kidney disease, atrial
fibrillation, iron deficiency anemia, type 2 diabetes mellitus
with complication
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with pneumonia which required
high-powered IV antibiotics and you completed these courses.
You also developed an infectious diarrhea which was treated with
antibiotics.
.
Please take all medications as prescribed. Please attend all
followup appointments. If you experience chest pain, shortness
of breath, high fevers, loss of consciousness, or other
concerning symptoms, then you need to seek medical attention.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] (PCP) in the next few weeks. Please call
[**Telephone/Fax (1) 250**] to schedule an appointment.
|
[
"401.9",
"357.2",
"008.45",
"241.1",
"518.81",
"996.64",
"250.60",
"293.0",
"482.41",
"V09.0",
"E879.9",
"729.81",
"788.31",
"272.4",
"428.30",
"327.23",
"038.9",
"V58.67",
"280.9",
"584.5",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"00.14",
"34.91",
"38.93",
"33.22",
"96.72",
"31.1",
"33.24",
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
14202, 14274
|
2941, 8089
|
330, 576
|
14566, 14574
|
2227, 2918
|
15072, 15212
|
1861, 1865
|
11843, 14179
|
14295, 14411
|
11465, 11820
|
14598, 15049
|
1880, 2208
|
14432, 14545
|
274, 292
|
604, 1059
|
8104, 11439
|
1081, 1444
|
1460, 1845
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,290
| 174,142
|
10307
|
Discharge summary
|
report
|
Admission Date: [**2110-1-21**] Discharge Date: [**2110-1-28**]
Service: SURGERY
Allergies:
Penicillins / Spironolactone
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Gangrene of the right foot
Major Surgical or Invasive Procedure:
[**2110-1-21**] Right popliteal to dorsalis pedis artery bypass
with non reversed right lesser saphenous vein and angioscopy.
History of Present Illness:
This 84-year-old gentleman has gangrene involving the lateral
aspect of his right foot. He had an arteriogram which showed
occlusion of his anterior tib and
posterior tibial arteries over a long distance. His peroneal
artery was opened but was diseased distally and he reconstituted
a small caliber dorsalis pedis artery. Vein mapping showed a
saphenous vein patent from the groin to the
calf. He had the distal vein harvested for CABG before.
Past Medical History:
1. Insulin dependent-diabetes mellitus.
2. Coronary artery disease, three vessel with an ejection
fraction of 20-25%; s/p CABG [**2103**] LIMA-LAD, SVG-OM and SVG-RCA
3. Prostate cancer status post radical prostatectomy [**2096**], no
chemotherapy and no XRT
4. Paget's disease
5. Ulcerative colitis
6. Peripheral vascular disease s/p LLE bypass, left popliteal to
DP; [**3-12**] mild proximal [**Month/Year (2) **] stenosis
7. Status post left first toe amputation in [**4-4**]
8. Right inguinal hernia repair [**2099-9-3**]
9. Status post left carpal tunnel release in [**2088**]
10. Right carpal tunnel release in [**2100**]
11. Status post appendectomy in [**2053**]
12. CVA to the thalamus 6-8 years ago with no deficit.
13. Cardiomyopathy
14. s/p left 1st toe amputation [**1-6**] osteomyelitis
15. Left shoulder fracture status post fall [**2105**]
16. Mild mitral regurgitation, Echo [**2106**]
17 Mild pulmonary hypertension, Echo [**2106**]
18. Appendectomy [**2054-11-3**]
19. LE ulcerations, followed by [**Doctor Last Name **]
20. s/p ICD placement in [**2103**], revision [**2105**] - unclear reason
besides was delaying CABG for 2-3 weeks to get affairs in order
Social History:
Widowed [**2105**], retired engineer, does not use alcohol. He quit
smoking in [**2059**] after 15 years of smoking three packs per day
while in the Navy, inaddition to cigars and pipes. There is no
history of alcohol abuse but drinks several times each week.
Family History:
Family history notable for brother being a 'blue baby' who died
at 26, brother died [**1-6**] MI at 47. Mothers and sisters with DM.
Physical Exam:
VS: 98.0 P: 70 BP: 97/62 RR: 20 Spo2: 99% RA
Gen: NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL
CV: RRR, normal S1, S2. No m/r/g. No S3 or S4.
Resp: unlabored, no accessory muscle use. mild bibasiler rales
Abd: Thin, soft, NT, ND. No HSM or tenderness.
Extremities/Skin: bilateral 2 pitting edema with distal
erythema; Right leg with 1cm dorsal ulcer about 2-3 mm deep,
Left foot with lateral eschar ~5cm wide, appears necrotic, also
with dorsal 1cm ulcer. Incisions: RLE open to air with
steristrips. Minimal drainage. Incision from knee to ankle.
Stage II pressue ulcer to coccyx
Pertinent Results:
[**2110-1-25**] 06:30AM BLOOD WBC-7.7 RBC-3.26* Hgb-10.6* Hct-31.6*
MCV-97 MCH-32.7* MCHC-33.7 RDW-17.0* Plt Ct-201
[**2110-1-24**] 04:07AM BLOOD Hct-29.0* Plt Ct-166
[**2110-1-23**] 04:11AM BLOOD Hct-29.8* Plt Ct-179
[**2110-1-22**] 04:50AM BLOOD WBC-11.1*# Hgb-11.2* Hct-33.6* Plt Ct-232
[**2110-1-21**] 06:15PM BLOOD Hgb-11.1* Hct-32.9* Plt Ct-222
[**2110-1-25**] 06:30AM BLOOD Plt Ct-201
[**2110-1-25**] 06:30AM BLOOD PT-15.2* PTT-33.9 INR(PT)-1.3*
[**2110-1-24**] 04:07AM BLOOD Plt Ct-166
[**2110-1-23**] 04:11AM BLOOD Plt Ct-179
[**2110-1-21**] 06:15PM BLOOD PT-14.5* PTT-91.7* INR(PT)-1.3*
[**2110-1-25**] 06:30AM BLOOD Glucose-74 UreaN-27* Creat-1.2 Na-140
K-4.6 Cl-98 HCO3-39* AnGap-8
[**2110-1-21**] 06:15PM BLOOD Glucose-132* UreaN-22* Creat-1.1 Na-144
K-3.3 Cl-103 HCO3-37* AnGap-7*
[**2110-1-21**] 06:15PM BLOOD ALT-30 AST-32 AlkPhos-140*
[**2110-1-21**] 06:15PM BLOOD CK-MB-4 cTropnT-0.04*
[**2110-1-22**] 04:57AM BLOOD Type-ART Temp-37.7 FiO2-35 O2 Flow-2
pO2-103 pCO2-58* pH-7.42 calTCO2-39* Base XS-10 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2110-1-25**] 06:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2
[**2110-1-21**] 04:39PM BLOOD Glucose-160* Lactate-1.9 K-3.2*
Portable TEE (Complete) Done [**2110-1-21**] at 3:32:45 PM FINAL
Conclusions:
The left atrium is markedly dilated. Moderate to severe
spontaneous echo contrast is seen in the body of the left
atrium. The right atrium is markedly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 0-10mmHg. Overall left ventricular systolic
function is severely depressed (LVEF= XX %). The estimated
cardiac index is borderline low (2.0-2.5L/min/m2). The
calculated myocardial performance index was0.9 (MPI A = 602 ms;
MPI B = 330 ms). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Transmitral
Doppler and tissue velocity imaging are consistent with Grade
III/IV (severe) LV diastolic dysfunction. with severe global
free wall hypokinesis. The descending thoracic aorta is mildly
dilated. There are three aortic valve leaflets. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.
Brief Hospital Course:
[**2110-1-21**] Admitted direct via holding room for a scheduled LE
bypass, taken to OR and underwent Right popliteal to dorsalis
pedis artery bypass with non reversed right lesser saphenous
vein and angioscopy. Patient invasive lines (foley, a-line,
PA-line, and central line)were placed. Patient tolerated
procedure, recovered in the PACU and then transferred to [**Hospital Ward Name 121**]
5/VICU/telemetry for further observation. Overnight patient had
probelms w/ tachycardia-managed w/ IV Metoprolol. Pain managed
w/ IV Hydromorphone.
[**2110-1-22**] No acute events. On LE BP pathway. Remains on bed rest.
Clears and PO meds re-started. Given Albumin and NS for volume.
Electrolytes repleted. Remains VICU.
2/19-20/09 No acute events. Continues LEBP pathway. Diet
advanced. Art line and foley d/c'd, central line switched to
PIV. Physical therapy evaluation, touch down WB on R, FWD on L.
Remains VICU. Pain mananged. Foley replace, unable to void.
2/21-22/09 No acute events. Continues LEBP pathway. had some
problems w/ [**Name2 (NI) 34279**]-given on Bisacodyl and given fleet
enema. Became floor status. Pain management still an issue.
Having breakthrough pain requiring IV pain medications.
[**2110-1-27**] No acute events. Urine output scant, and unable to take
in large po fluids, given IV fluid bolus. Out of bed w/ assist.
Pain meds converted to PO.
[**2110-1-28**]
Stable overnight. Transferred to Rehab with indwelling foley.
Medications on Admission:
SQ Heparin
Amiodarone 200 mg qd
Levothyroxine 112 mcg. qd
[**Month/Day/Year **] 81 mg po qd
Folic Acid 1 1 mg po qd
ISS
NPH 20 U QAM
Eplerenone 25 mg qd
Cipro 250 mg [**Hospital1 **]
Brimonidine 1gtt [**Hospital1 **]
Lasix 80 IV BID
Hydralazine 10 mg po tid
Isosorbide dinitrate 10 mg tid
eucerin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic TWICE
DAILY ().
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
[**3-10**] H () as needed for pain.
14. Humalog Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime Q6H
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
Insulin Dose
0-60 mg/dL [**12-6**] amp D50 [**12-6**] amp D50 [**12-6**] amp D50 [**12-6**] amp D50 [**12-6**]
amp D50
61-150 mg/dL 0 Units 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 2
Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 4
Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 6
Units
> 300 mg/dL 8 Units 8 Units 8 Units 8 Units 8 Units
15. NPH Insulin
24 units with breakfast
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
PVD w/ Gangrene of the right foot.
history of CAD s/p CABG [**2103**] (LIMA-LAD, SVG-RCA, SVG-OM)
history of CVA no deficits
history of insulin dependent diabetes
history of CHF (EF 20%)
history of prostate CA s/p prostatectomy,
history of VT arrest s/p ICD placement with 4 firings last year
history of hypothyroidism
Post-op constipation-treated
Post-op hypovelemia- fluid resuscitated
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-7**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2110-2-10**] 1:20
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3070**]
Date/Time:[**2110-4-1**] 11:15
Completed by:[**2110-1-28**]
|
[
"416.8",
"V45.02",
"731.0",
"707.03",
"440.24",
"V45.81",
"428.0",
"564.09",
"V10.46",
"276.52",
"707.22",
"458.29",
"V49.71",
"250.00",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
9016, 9158
|
5426, 6877
|
262, 390
|
9590, 9599
|
3162, 5403
|
12442, 12779
|
2360, 2494
|
7224, 8993
|
9179, 9569
|
6903, 7201
|
9623, 12009
|
12035, 12419
|
2509, 3143
|
196, 224
|
418, 863
|
885, 2066
|
2082, 2344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,714
| 150,541
|
36723
|
Discharge summary
|
report
|
Admission Date: [**2182-7-16**] Discharge Date: [**2182-7-25**]
Date of Birth: [**2110-5-17**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Terbutaline / Talwin Nx / Percocet / Inhalants /
Cefepime
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Non-ST elevation Myocardial Infarct
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Endotracheal Intubation
Femoral Central Line
Arterial Line
History of Present Illness:
72 yo female with h/o DM, HTN, HLD, longstanding sarcoid on home
O2, newly diagnosed paroxysmal Afib ([**7-4**]) s/p DDD pacemaker
placement secondary to CHB on [**2182-5-25**], who presented to the ED
[**7-15**] with AF and flash. She developed flash pulmonary edema ->
intubated; on neo gtt. Troponin: 0.01, 0.27 CK: 22, BNP 6848.
She also went into atrial fibrillation with RVR at the time
though the time course is not documented. Her cardiac enzymes
were elevated at [**Hospital3 1280**] and EKG was concerning for anterior
ischemia she was transferred to [**Hospital1 18**] for NSTEMI. She stayed in
the MICU in OSH overnight and was transferred here for further
management.
Upon arrival here, the patient went to cardiac cath. She was
found to have a Mid LAD lesion distal to D2. Received a bare
metal stent to the mid-LAD. Patient has an allergy to ASA (SOB),
so is set to receive 75 mg plavix [**Hospital1 **]. In the cath lab she was
in and out of AF.
Patient was started on heparin and integrillin gtt in cath lab.
Was found to have an INR of 2.6. Her heparin gtt was stopped,
but integrillin continued.
Upon arrival to the CCU, patient was in Afib with RVR; HR into
the 130s. She was found to be hypotensive and shocked once, she
did not return to sinus rhythm. Given amiodorone 150 mg IV x 1,
and started on a dilt gtt. She continued to have low BP, so
phenylephrine was started at 1 mcg/min.
.
Unable to assess ROS b/c of intubation.
Past Medical History:
1. DDD Pacemaker, placed [**2182-5-27**] secondary to 3rd degree HB
2. Diabetes Mellitus
3. 40 year history of Sarcoidosis with multiple organ
involvement on chronic prednisone therapy
4. COPD secondary to sarcoidosis on home oxygen 3LNC
5. Dyslipidemia
6. Hypertension
7. H/o Hypercalcemia secondary to sarcoid
8. Hypothyroidism
9. Depression
10. Diabetic Nephropathy
11. Superficial Phlebitis
12. GERD
13. Cholecystectomy
[**86**]. Lysis of adhesions of the pancreas
15. Traumatic Brain Injury as child with no residual deficit
16. Hysterectomy
17. H/o kidney stones s/p lithotripsy
Social History:
Lives at home with husband
-[**Name (NI) 1139**] history: Never
-ETOH: Denies
-Illicit drugs: Unable to obtain
Family History:
Non-contributory
Physical Exam:
T=98.4 BP=74/43 HR=124 RR=25 O2 sat= 100% on AC
GENERAL: Intubated, sedated
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with slightly increased JVP.
CARDIAC: IIRR, tachycardic, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Course
breath sounds bilaterally in anterior lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Left femoral line in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: DP 1+ PT 2+, Left: DP 1+ PT 2+
Pertinent Results:
Admission Labs:
[**2182-7-16**] HCT-35.1*
[**2182-7-16**] PLT COUNT-288
[**2182-7-16**] POTASSIUM-3.6
[**2182-7-16**] CK(CPK)-83
[**2182-7-16**] CK-MB-NotDone
[**2182-7-16**] TYPE-ART O2-100 PO2-344* PCO2-52* PH-7.39 TOTAL CO2-33*
BASE XS-5 AADO2-328 REQ O2-59 -ASSIST/CON INTUBATED-INTUBATED
[**2182-7-16**] GLUCOSE-148* LACTATE-1.8
[**2182-7-16**] GLUCOSE-159* UREA N-21* CREAT-1.1 SODIUM-144
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-33* ANION GAP-15
[**2182-7-16**] cTropnT-0.12* proBNP-[**Numeric Identifier 68079**]*
[**2182-7-16**] ALBUMIN-3.4
[**2182-7-16**] %HbA1c-5.8
[**2182-7-16**] WBC-24.2* RBC-4.15* HGB-11.8* HCT-36.4 MCV-88 MCH-28.4
MCHC-32.4 RDW-14.7
Discharge Labs:
WBC 11.2 Hb 8.3 Hct 26.4 Plt 231
Na 145 K 3.9 Cl 106 HCO3 32 BUN 40 Crt 0.8 Glucose 170
Ca 7.8 Mg 2.1 Phos 2.1
INR 2.1 PTT 38.8
Reports:
Cardiac Cath ([**2182-7-16**]): 1. Selective coronary angiography of
this right dominant system demonstrated two vessel disease. The
LMCA had no angiographically appaernt disease. The LAD was a
small caliber vessel with a long, sub-total occlusion extending
fromthe mid-LAD until D2. The first diagonal branch was of
moderate size with a 90% ostial stenosis. The LCx was a
moderate sized vessel with a small OM1, moderate sized OM2 and a
large OM3. The OM2 had a 90% ostial stenosis and a focal 90%
proximal stenosis. The RCA is a large dominant vessel with mild
luminal
irregularities proximally and in the mid portion.
2. Resting hemodynamics revealed elevated right and left hear
filling
pressures with secondary pulmonary hypertension. The RVEDP was
17mmHg
and the mean PCWP was 21mmHg. The cardiac index was at the
lower limit
of normal at 2.17 l/min/m2.
3. Left ventriculography was deferred.
4. Successful PTCA and stenting of the mid LAD with a 2.0 x 23
Mini
Vision bare metal stent. Final angiography revealed no residual
stenosis, no angiographically apparent dissection, and TIMI 3
flow. (see
PTCA comments for details)
.
Echo ([**2182-7-17**]): The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded (LV apex not
clearly seen). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with focal hypokinesis of
the apical free wall. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The tricuspid valve leaflets are
mildly thickened. There is severe pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
CXR ([**2182-7-17**]): Central adenopathy is very severe involving both
hila, right greater than left in the paratracheal and
prevascular mediastinum. Hilar adenopathy is inseparable from
the perihilar consolidation or even large perihilar nodules, and
there is extensive peribronchial infiltration in both lower
lungs, particularly the left, obscuring left heart border. How
much of this is chronic and how much is new would depend upon
comparison to prior chest imaging currently unavailable. Without
comparison studies, I cannot say whether there is acute
pneumonia or mild interstitial edema and whether the central
adenopathy, though it contains some calcifications indicative of
chronicity, is entirely stable.
ET tube is in standard placement. Nasogastric tube passes
below the diaphragm and out of view. Transvenous right atrial
and right ventricular pacer leads are noted. No pneumothorax.
Pleural effusion, if any, is small, on the left.
.
CT Chest ([**2182-7-19**]): 1. Findings compatible with advanced
sarcoidosis. Enlarged pulmonary artery likely reflects an
element of pulmonary hypertension. Tiny left pleural effusion.
No CT evidence of definite active infection.
2. Partially seen solid right upper pole lesion. This may
represent a
hyperdense renal cyst. However, targeted ultrasound of the upper
pole of the right kidney is recommended for further
characterization.
3. Delayed renal excretion.
.
Upper Extremity DVT Study ([**2182-7-21**]): No evidence of left upper
extremity DVT.
Brief Hospital Course:
72 yo female with h/o DM, HLD, HTN, Afib with RVR, s/p pacemaker
and sarcoid who presented with acute heart failure after an
NSTEMI leading to flash pulmonary edema.
.
# NSTEMI: Patient presented with atrial fibrillation with RVR
and hypotension and was immediately sent for cardiac
catheterization. She was found to have 2 vessel disease and
received a bare metal stent to the mid-LAD artery. She is on
Plavix 75mg daily, Simvastatin 80mg daily, and aspirin 325mg
daily. During this admission, she was desensitized to aspirin
without complication. Her dose of Toprol XL was increased to
300mg daily for rate control after MI and atrial fibrillation.
She is also on lisinopril 5mg daily for blood pressure control.
# Respiratory Failure: Patient presented intubated from an
outside hospital secondary to flash pulmonary edema. A chest CT
w/o contrast showed severe sarcoidosis, which appeared to have
progressed from prior scans done as an outpatient. She was also
diagnosed with ventilator associated pneumonia, and had acute on
chronic heart failure. Her lung function improved with diuresis
and she was extubated [**2182-7-20**]. She was placed on BIPAP and
experienced significant respiratory distress after extubation.
At this point, it was decided that she would be DNR/DNI and she
was started on a morphine drip. Her respiratory status
significantly improved and she was eventually weaned down back
to her baseline oxygen requirement of 3 liters oxygen by nasal
cannula. Despite an oxygen requirement at baseline, patient
continued to have moments of increased work of breathing and
tachypnea. These episodes were relieved with lasix and morphine.
She and her family decided that she would be comfort measures
only care, and she was started on morphine contin 30 mg [**Hospital1 **] with
morphine solution 5-10mg q 2 hours for breakthrough pain. She
was also given xopenex and ipratroprium nebulizers as needed.
# RHYTHM: Upon admission to the CCU, the patient was in atrial
fibrillation with a rapid rate into the 130-140s. She acutely
became hypotensive and was shocked at 200 Joules one time. She
did not return to sinus rhythm and was given 150 mg IV
Amiodarone and eventually started on a diltizem drip. Her blood
pressures were stabilized with a phenylephrine drip which was
subsequently weaned. Her rhythm was difficult to control
throughout her admission and she was ultimately placed on
amiodorone 400 mg [**Hospital1 **], diltiazem SR 240 mg daily, and Toprol XL
300mg daily. She converted to a paced sinus rhythm on [**2182-7-21**]
and remained out of atrial fibrillation through the time of
discharge. Her amiodarone should be decreased to 200mg daily on
[**2182-7-29**]. These medications should be continued at
discharge, as she is much more comfortable when her heart rhytm
is not atrial fibrillation.
# Fever/Leukocytosis: The patient had episodes of high-grade
fevers and leukocytosis during her admission. She was treated
for possible ventilator-associated pneumonia with Vancomycin and
Cefepime. She continued to have fevers and due to concern for C
Diff, she was started on Flagyl. Her fevers did not resolve
with aggressive antibiotics, tylenol, and ice packs, and the
patient's family decided that she would be comfort measures
only. Antibiotics were then stopped and her fevers resolved.
Therefore, it was felt her fevers were possibly a reaction to
either vancomycin or cefepime. Flagyl was continued to possible
C Diff after her neurologic and respiratory status improved.
She had a femoral central line which was placed in sterile
conditions and this was removed before discharge.
# Left arm swelling: Patient had significant left upper
extremity swelling. There was concern for a DVT in this arm but
an ultrasound showed no thrombus. The amount of swelling was
stable at discharge.
# Hypertension ?????? Her blood pressure was labile while she was
intubated and during her respiratory distress. As she improved,
her blood pressure was managed with metoprolol and lisinopril,
as above.
# Diabetes type 2: During the course of the patient's active
infection, the patient was placed on stress dose of steroids.
She was also on continuous tube feeds. The combination of these
factors caused her to have high blood sugars that were not
controlled on a sliding scale insulin regimen. She was briefly
on an insulin drip that controlled her blood sugar effectively.
Once she was stabilized and extubated, her tube feeds were d/c'd
and she began a taper of her steroid dose to her home dosage of
7.5 mg daily. Her insulin gtt was d/c'd and she was transitioned
from a sliding scale to her home medication of metformin.
fingersticks should be checked teice daily before breakfast and
dinner. If Fs are > 200 and PO's imporve, would consider
restarting glipizide at 10 mg twice daily.
# PUMP: Patient had a TTE which showed preserved EF of >55% per
TTE. She occasionally had signs of fluid overload clinically,
and was diuresed appropriately. At discharge, she had no
clinical signs of heart failure. If SOB worsens, would consider
Furosemide 20mg daily as this may help with breathing.
# Anemia: Patient remained anemic throughout her
hospitalization. Her stool was guaiac positive. It was felt her
anemia may be contributing to her shortness of breath and
therefore one unit of blood was given during the admission for a
hematocrit of 22. The transfusion did not appear to improve her
shortness of breath.
# Sarcoidosis: Patient has end-stage sarcoidosis with skin and
liver involvment. Before admission, she was on home O2 at 3L
and this was also her oxygen requirement at discharge.
Pulmonary was consulted during the admission as there was some
concern in starting amiodarone in this patient due to pulmonary
complications. Amiodarone was started, as it rarely causes
acute pulmonary side effects.
# Dyslipidemia: Lipid panel shows TC 157, TG: 156 HDL 30 LDLc
96. As patient is comfort measures only at discharge, will not
be aggressive with her lipid reduction.
# Hypothyroidism: Continued synthroid at 25 mcg daily during
admission.
# Depression: Continued paroxetine 10 mg daily.
# GERD: Treated with famotidine 20mg daily.
# Goals of Care: Patient was intubated on this admission. Upon
extubation, there was a family meeting and it was decided to
make the patient DNR/DNI. After her improvement, the goals of
care were discussed with the patient and her family. She
continues DNR/DNI status, and preferred to have comfort measures
only. Palliative care was consulted who recommended liquid
morphine and long acting morphine for respiratory comfort and
pain control.
**At discharge, the patient wishes to be DNR/DNI. She also
wishes to be DO NOT REHOSPITALIZE**
Medications on Admission:
Zetia 10 mg Tablet one Tablet(s) by mouth daily
Glipizide 10 mg Tablet one Tablet(s) by mouth twice a day
Levothyroxine 25 mcg Tablet one Tablet(s) by mouth daily
Metformin 500 mg Tablet one Tablet(s) by mouth in am, 2 tablets
in pm
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) one Tablet(s)
by mouth daily
Paroxetine HCl 10 mg Tablet one Tablet(s) by mouth daily
Prednisone 2.5 mg Tablet two Tablet(s) by mouth in am , one
tablet at night nr Propoxyphene N-Acetaminophen 100 mg-650 mg
Tablet 1 Tablet(s) by mouth prn as needed for pain
Sotalol 120 mg Tablet one Tablet(s) by mouth twice a day
Warfarin 1 mg Tablet 6.5 Tablet(s) by mouth daily
Saccharomyces boulardii [Florastor] 250 mg Capsule one
Capsule(s) by mouth twice a day for one week, ? first dose
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H: PRN as needed for shortness of breath or wheezing.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 3 days.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start 200mg Daily. [**2182-7-29**].
12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days: Last Dose 7/31.
13. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)): Start [**2182-7-27**].
14. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)): Start [**7-27**].
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
17. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
18. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
19. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
20. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4H () as needed for wheezing.
21. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
22. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO every 2 hours
as needed for dyspnea.
23. MS Contin 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] home
Discharge Diagnosis:
Non-ST elevation myocardial infarct
Acute On Chronic diastolic congestive Heart Failure EF 55%
Atrial Fibrillation with rapid ventricular response
Sarcoid fibrosis with pulmonary hypertension, on chronic O2
Discharge Condition:
Stable. Afebrile. Comfortable on 3L Nasal Canula.
Discharge Instructions:
You presented to the outside hospital with increased fluid in
your lungs and a rapid heart rate called atrial fibrillation. At
that time you required substantial help breathing so a breathing
tube was placed in your throat and a machine helped you breath.
At the hospital you were found to have an elevation in cardiac
enzymes(a marker that can indicate heart attack). At that time
you were transferred to [**Hospital1 69**] for
cardiac catheterization. At [**Hospital1 18**] you had a stent placed in one
of the arteries of your heart and because you have an allergy to
aspirin were desensitized in the CCU. You initially had trouble
breathing on your own secondary to a ventilator associated
pneumonia. Finally we were able to remove the breathing tube and
you were stable on 3L oxygen through nasal canula. Throughout
this time we also provided medications to help control your
atrial fibrillation. After extubation you expressed your wishes
to be DNR/DNI and to not be Rehospitalized.
The following changes were made to your medical regimen.
1. You were started on morphine pills and liquid for your
breathing
2. You were started on Amiodarone to keep your heart rate low
3. You were started on Diltiazem and Metoprolol to keep your
heart rate low.
4. We stopped your Gipizide
5. You are on a prednisone taper
6. We stopped your sotolol, warfarin, Darvocet, zetia, and
pantoprazole
7. You were started on Lisinopril to prevent fluid in your lungs
and help your heart beat better
8. You were started on Prochlorperazine for nausea to use if
needed
9. You are on nebulizer treatment and oxygen for your lungs.
10. You are on Clopodigrel (Plavix)to keep the stent open
11. You were started on Famotidine to treat your heartburn
instead of the Pantoprazole.
Follow up based on your wishes. At anytime it is your decision
to change your DNR/DNI/DO NOT REHOSPITALIZE status.
Followup Instructions:
Follow up with your primary care physician, [**Name10 (NameIs) 2085**], and
pulmonologist as you feel necessary. At this time we do not feel
any follow up is required given your desires for care.
|
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22,622
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28449
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Discharge summary
|
report
|
Admission Date: [**2133-9-29**] Discharge Date: [**2133-10-16**]
Date of Birth: [**2075-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from Lakes [**Hospital 12018**] Hospital for EP evaluation
Major Surgical or Invasive Procedure:
EP study with VT ablation
EP study with aflutter ablation
Cardiac catheterization
Thoracotomy and placement of epicardial lead
BIV pacer upgrade surgically
History of Present Illness:
Mr. [**Known lastname **] is a 58 year old w/hx of MI at age 40 with subsequent
cabg 8 yrs ago, DM II on Prandin, CM with an EF of 20%, and
atrial ICD. Sunday AM, the patient experienced DOE,
uncomfortable sensation in his chest and fatigue. He presented
to his local fire station where rural residents can get VS
checks. They found his HR to be 173 and took him to [**Location (un) 59322**] hospital where has was found to be in a wide complex
tachycardia @173. They attempte rx w/adenosine x 2 with no
effect, followed by Lopressor and Cardizem, resulting in
hypotension. He was shocked with 100 J to sinus rhythm, where
he has remained w/significant ventricular ectopy. He was loaded
onIV amiodarone followed by Amiodarone 400mg TID.
.
Per OSH, BSP runs low 70-90??????s typically and is completely
asympomatic and has been getting his cardiac meds with those
pressures. Echo done yesterday revealed ef of 15-20%, dilated LV
w/multiple focal WMAs. BGs @ OSH of 178, 293, 292. ABG of
7.4/34/62 on RA. He received mucomyst 1200 [**Hospital1 **] @ OSH. His I/O
from OSH of 1840/1350 on day one and 1600/[**2076**] day two. He had
elevated tropnonins (.15, .44, .43), nl TSH.
.
He is transferred to [**Hospital1 18**] to Dr. [**Last Name (STitle) **] for possible cardiac
catheterization, possible ugrade to [**Hospital1 **]-V pacer, possible
transplant evaluation.
Past Medical History:
CAD w/MI @ 40yo; s/p CABG 8ya
DMII
CM; EF 15%
ICD w/single atrial lead, set to fire @HR180. Had multiple
chamber ICD, but leads removed for incorrect function.
?OSA- per pt report, negative sleep study at [**Hospital **] hosp.
Social History:
One whiskey every two weeks. Nonsmoker. Never IVDA. Lives
alone.
Family History:
FH: Father died of MI @ 69. No DM in family.
Physical Exam:
98.2 104/63 69 20 99%2L FS178
Not in distress
MMM and clear, neck supple, no LAD
HR not entirely regular; no murmurs; JVD not visible
Subtle exp wheezes
Obese, lg ventral hernia (chronic per pt), nt, +BS
WWP X 4 w/bil pitting edema
Nonfocal neuro
RLE calf lesion w/irregular borders, variation in color; per
patient, unchanged since childhood
Pertinent Results:
Labs from OSH:
Wbc 15.3 upon arrival, today is 15.1, hct 43, plt 176, bands 77%
NA 131, k 4.6 upon arrival. Today is 133, k 4.0
Bun 27/2.1 on arrival. Today is 24/1.2 creat.
Glucose on arrival was 421, today has been running 170??????s-
prandin held this am d/t pt is NPO d/t unsure of plan.
Alk phos 49, mg 2.3
Amylase and lipase normal
TROP peak of 0.44 on Sunday.
***Cath:
Brief Hospital Course:
58M w/CAD, DMII, CM, ICD taken to Lakes [**Hospital 12018**] Hospital for
ventricular tachycardia where he underwent [**Hospital 69001**] transferred to
[**Hospital1 18**] for further evaluation.
.
#Electrophysiology -- He remained out of VT from the time of
DCCV at Lakes [**Hospital 12018**] Hospital, though with significant
ventricular ectopy. He was seen by the EP service who took him
to the lab for a VT-ablation, for which amiodarone was stopped.
The ablation of his RBBB superior axis VT, felt to be scar
mediated was sucessful, and the patient tolerated the procedure
well. However, after his cardiac catheterization performed the
following day, looking for an additonal ischemic etiology for
his VT (as below), he developed atrial flutter, and so the EP
service brought him back to the lab for an a-flutter ablation.
During the ablation he developed an atrial tachycardia that
conveted into atrial fibrillation that could not be
pace-terminated, so he was cardioverted with 200 joules into a
sinus rhythm. Dofetilide was loaded post-procedurally to
prevent recurrence of atrial fibrillation. Following this he
had an echo that confirmed [**Last Name (LF) 69002**], [**First Name3 (LF) **] it was felt he would
benefit from an upgrade to a biventricular ICD; to best
accomplish this, he was taken to the OR on [**2133-10-9**] for the
placement of an epicardial lead placement. The procedure went
well and after one night's observation in the CSRU, he returned
to the cardiology service. As his insurance would not cover the
medication, dofetilide was stopped. For the remainder of the
admission he remained in a paced rhythm, with occasional sinus
rhythm. Warfarin was initiated for his atrial fibrillation with
an initial heparin bridge.
.
#Coronary artery disease -- With multiple risk factors and prior
interventions, he was taken the cath lab for evaluation of his
coronaries. He was found to have mild left main disease, a 70%
proximal LAD lesion filled distally by LIMA, 80% OM1 lesion,
totally occluded OM2, proximally occluded RCA with the PDA
filled by a jump graft from the LIMA. RA pressure was 21, PCWP
33, cardiac index 1.4. The cath team sucesfully ballooned the
OM1 lesion. He remained chest pain free for the entire
admission. He was continued on aspirin, carvedilol, and
pravastatin.
.
#Heart failure -- His cardiac function was quite depressed, as
the above echo and cath lab hemodynamics reveal. For much of
the admission he appears volume overloaded with notable
peripheral edema. He did not, however, have significant
pulmonary symptoms. He was gradually diuresed with IV
furosemide with a good effect and was discharge on a standing
dose of this medication. He had no major electorlyte problems
on this medication. The biventricular ICD also was
re-established for help with maintaining ventricular synchrony.
In additon, he was discharged on carvedilol and told to both
weigh himself daily and adhere to a two gram sodium diet, about
which he was given considerable, detailed teaching.
.
#Type two diabetes -- His blood sugar was somewhat difficult to
control early in the hosptial course. He was admitted on only
repaglinide,a nd his blood glucose was quite elevated on this
medication. Whilst in the CSRU he was maintained on an insulin
drip. On the floor, an insulin sliding scale was continued, yet
the patient was fairly adamant that he did not want to take
insulin as an outpatient. As such, he was put on increasing
doses of oral hypoglycemics; by the time of discharge, his blood
sugars were well controlled on a regimen of repaglinide,
glyburide, and metformin.
Medications on Admission:
Home Meds:
Coreg 12.5 [**Hospital1 **]
Lisinopril 2.5 QD
Lasix 40mg QD
Sprironolactone 25 QD
Prandin .5mg [**Hospital1 **]
Pravachol 20mg QD
.
Transfer meds:
Amio 400 PO tid (loading)
Prandin .5mg [**Hospital1 **]
Lasix 50mg QD
Spironolactone 25mg QD
Coreg 12.5mg [**Hospital1 **]
Prinivil 2.5mg QD
Pravachol 20mg QD
Percocet 1-2 tabs PO Q6H PRN
Tylenol 650 Q4h PRN
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prandin 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
13. Glyburide 5 mg Tablet Sig: 2 in the morning, 1 at night
Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QHS (once a day (at bedtime)).
Disp:*10 Tablet Sustained Release(s)* Refills:*0*
16. Lancets Misc Sig: One (1) lancet Miscell. twice a day.
Disp:*qs lancets* Refills:*2*
17. glucose test strips Sig: One (1) strip twice a day.
Disp:*qs strips* Refills:*2*
18. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
19. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community Health and Hospice of NH
Discharge Diagnosis:
Ventricular tachycardia
Atrial flutter
Atrial fibrillation
Coronary artery disease s/p PTCA to OM1
Decompensated congestive heart failure, biventricular
Type two diabetes, uncontrolled
Discharge Condition:
Good, with normal, paced rhythm, no symptoms
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a fast heart rate and rhythm
(ventricular tachycardia), underwent procedures to prevent this
rhythm from happening (ablation of ventricular tachycarida and
atrial flutter) and had a new pacer lead placed (epicardial
lead), and were started on a blood thinner to prevent blood
clots.
.
Please take all medications as instructed. If you experience
chest pain, chest pressure, shortness of breath, palpiations, or
other sx of concern to you, please call your doctor or report to
the ED immediately.
Followup Instructions:
You have an appointment to have your blood thinner level checked
with Dr.[**Name (NI) 69003**] nurse [**First Name (Titles) **] [**Last Name (Titles) 3816**] [**2133-10-20**]; you can go in
at your convenience. Dr.[**Name (NI) 69003**] office will call you to
make an appointment in the next week; call at [**Telephone/Fax (1) 11254**] if
you have not heard from them or for questions.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2133-10-19**]
10:30
This is in the [**Hospital Ward Name 23**] Building, on [**Initials (NamePattern4) 1388**] [**Last Name (NamePattern4) **], on the
seventh floor.
.
Please call Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9671**] at the [**Last Name (un) **] Diabetes
Center at ([**Telephone/Fax (1) 69004**] for a followup appointment.
|
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"428.0",
"250.00",
"996.01",
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icd9cm
|
[
[
[]
]
] |
[
"04.81",
"37.26",
"34.99",
"33.43",
"37.23",
"88.56",
"37.27",
"34.04",
"37.76",
"88.57",
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] |
icd9pcs
|
[
[
[]
]
] |
9110, 9175
|
3129, 6756
|
382, 539
|
9403, 9450
|
2728, 3106
|
10040, 10916
|
2299, 2346
|
7173, 9087
|
9196, 9382
|
6782, 7150
|
9474, 10017
|
2361, 2709
|
275, 344
|
567, 1945
|
1967, 2197
|
2213, 2283
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,300
| 189,469
|
29073
|
Discharge summary
|
report
|
Admission Date: [**2134-11-23**] Discharge Date: [**2134-12-4**]
Date of Birth: [**2054-2-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
CC:[**CC Contact Info 70015**]
Major Surgical or Invasive Procedure:
tracheal stent(removed)
tracheostomy
History of Present Illness:
80yom with recent mitral valve repair and one vessel cabg
[**2134-8-18**], course complicated by polymicrobial empyema (e. coli,
enterococcus, actinomyces), cardiogenci shock, respiratory
failure, with prolonged vent weant and renal failure and was
subsequently transferred to [**Hospital 70016**] rehab hospital. Was
initially taken to [**Hospital 1727**] Medical Center on [**2134-11-20**] after being
found down, intubated enroute. Initially hypotensive in the ED,
afebrile, thought sepsis of unclear source started on dopamine
and vasopressin also given linezolid and zosyn. [**Last Name (un) **] stim with
inadequte response and he was given fludricort/hydrocort.
Patient also with positive troponin thought to be NSTEMI in
setting of demand ischemia.
.
Following day patient noted to be doing better and was extubated
and later reintubated after CT report with tracheal stenosis.
Patient also taekn off linezolid after no source identified.
TEE done at OSH negative for vegetation, EF 20% per report.
Patient is now being transferred for w/u tracheal stenosis.
.
On transfer, Pt denies any complaints.
Past Medical History:
s/p CABG X 1 vessel and mitral valve repair s/p annuloplasty.
course complicated by empyema, cardiogenic shock and renal
insufficiency, difficult to wean and had trach/peg [**8-25**].
Anemia
Post operative Atrial fibrillation
h/o GI bleed
hperlipidemia
GERD
Social History:
retired stock broker, widowed, smoking history unknon, etoh
unknown.
Family History:
n/c
Physical Exam:
T 97.9 BP 112/69 HR 86 RR 14 O2sat 100%
Vent settings: AC 600X 12, P5, Fio2 40%.
.
General: Elderly male lying in bed.
HEENT: PERRL, no scleral icterus noted, MMM
Neck: supple
Pulmonary: Lungs CTAB
Cardiac: RRR, nl. S1S2, +Systolic mumor at apex
Abdomen: soft, NT/ND, PEG and ostomy site clean
Extremities: No C/C/E bilaterally
Skin: stage III decub
Neurologic: able to follow commands. Moves all extremities.
Pertinent Results:
EKG: NSR at 88, nl axis, nl intevals. q waves in III, F, V1, V2
no baseline for comparision.
[**2134-11-23**] 03:31AM PT-18.5* PTT-56.2* INR(PT)-1.7*
[**2134-11-23**] 03:31AM PLT COUNT-167
[**2134-11-23**] 03:31AM WBC-10.0 RBC-3.92* HGB-10.8* HCT-35.0* MCV-89
MCH-27.5 MCHC-30.9* RDW-18.7*
[**2134-11-23**] 03:31AM ALBUMIN-3.2* CALCIUM-9.4 PHOSPHATE-2.2*
MAGNESIUM-2.5
[**2134-11-23**] 03:31AM CK-MB-NotDone cTropnT-0.11*
[**2134-11-23**] 03:31AM ALT(SGPT)-73* AST(SGOT)-63* LD(LDH)-203
CK(CPK)-11* ALK PHOS-95 TOT BILI-1.0
[**2134-11-23**] 03:31AM GLUCOSE-128* UREA N-39* CREAT-1.2 SODIUM-147*
POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-25 ANION GAP-13
.
[**11-26**]- ECHO - The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is top normal/borderline dilated. There is mild to moderate
regional left ventricular systolic dysfunction with inferior
akinesis and hypokinesis of the infero-septum and
infero-lateral walls. No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size is normal. There is
mild global right ventricular free wall hypokinesis. There is
abnormal septal motion/position. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
to moderate ([**12-21**]+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. A mitral valve
annuloplasty ring is present. The transmitral gradient is normal
for this ring. Mild to moderate ([**12-21**]+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
CT NECK W/CONTRAST (EG:PAROTIDS) [**2134-12-1**] 4:20 PM
FINDINGS:
Patient is intubated with the endotracheal tube through the
oropharynx. The bulb of the endotracheal tube is inflated. Due
to the presence of the endotracheal tube and inflated bulb, it
is impossible to evaluate for subglottic stenosis or or larynx.
There is a band-like structure noted along the posterior aspect
of the distal trachea beyond the tip of the endotracheal tube
(series 401B, image 30), which could be due to a web. In
addition, there are secretions, partly aerosolized within the
oropharynx and the trachea. The end of the endotracheal tube is
approximately 4.6 cm above the tip of the carina.
Evidence of bilateral lung disease, incompletely evaluated on
the present CT scan.
Evidence of degenerative changes involving the cervical and
thoracic vertebral bodies in the form of osteophytes and facet
joint degeneration.
Status post CABG.Degenerative changes are also noted in
bilateral sternoclavicular joints and distal ends of the
clavicles.
IMPRESSION:
1. As the patient is intubated with inflated bulb of the ETT, it
is impossible to assess for subglottic or laryngeal stenosis.
Recommend direct visualization for assessment.
2. Bilateral lung disease, incompletely evaluated and
characterized on the present study. To consider CT of the chest
for better evaluation.
3. Degenerative changes noted involving the cervical and
thoracic spine, bilateral sternoclavicular joints.
(The case was discussed with the chest radiology team by Dr.
[**Last Name (STitle) **], regarding the possibility of better assessment on CT chest
per tracheal stenosis protocol. However, the chest radiology
team prefers direct visualization of the larynx to 3D CT,
considering the fact that the patient is intubated with inflated
bulb of the ETT).
.
Brief Hospital Course:
80 with history of recent CABG, MV repair admitted to outside
hospital for hypotension after being found down, concerning for
sepsis. Patient was transferred to us for tracheal stenosis
management.
.
# Respiratory failure/tracheal stenosis
Patient was intubated on arrival. However, he extubated himself
while in the ICU. He developed acute hypoxic respiratory failure
and was promptly re-intubated. He was evaluated by
interventional pulmonary and had tracheal stent placed on
[**2134-11-29**]. The stent however migrated on [**2134-11-30**] and was then
removed. He was then evaluated by ENT who recommended
tracheostomy, which he received on [**2134-12-3**]. Direcet
laryngoscopy reveals soft anterior stenosis area 2cm below vocal
cords, taking up to approximately 70% of lumen. #6 Portex trach
was placed/ He is scheduled to have follow up with ENT in [**1-23**]
weekd for future CO2 ablation. At that time, interventional
pulmonary would assist with placement of [**Location (un) **] T tube.
.
# Sepsis
Patient had been normotensive since transfer to [**Hospital1 18**]. No clear
source of infection per workup at outside hospital. All
antibiotic was discontinued. He remained afebrile, normal WBC
and normal blood pressure. All culture data remained negative as
well.
.
# Post trach fever - Post trach patient had a low grade fever of
100.1, o2 sat was 93-95% on 30% fiO2. CXR with mild pulm edema.
Sputum culture and urine cultures were sent. He was given 1
dose of 10mg IV lasix and started on Zosyn again for presumed
VAP (he received one dose prior to transfer). Please call Micro
at [**Hospital1 18**] [**Telephone/Fax (1) 4645**] to follw up the culture data.
.
# Cardiac
Patient had episodes of chest pain while in the ICU. EKG did not
show any changes from baseline. Cardiac enzymes were cycled and
remained negative. Echocardiogramwas performed, revealing EF
35-40%. Cardiology consult was obtained prior to general
anesthesia for rigid bronchoscopy and he was cleared for the
procedure. He was continued on aspirin and metoprolol.
- Strict I/Os.
.
# A. fib
Patient was rate controlled on metoprolol. He was also continued
on heparin drip. Coumadin should be restarted.
# Prophylaxis
Patient remained on famotidine and heparin drip throughout ICU
stay
# nutrition
He remained on tube feeds while intubated
#Access:peripheral IVs
#Code Status: Full
Medications on Admission:
famotidine 20 mg iv each day
fludricortisone tablet 0.1mg, [**12-21**] tab daily
hydrocortisone 50 mg q6 hours
ipratropium inhaler 2 puffs q6h
megesterol suspension 40 mg/ml 400 mg [**Hospital1 **]
metoprolol 5 mg iv qhours
zosyn 2.25 grams every 6 hours
zoloft 75mg each day
heparin gtt
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lidocaine HCl 1 % Solution Sig: Five (5) ML Injection Q1-2H
() as needed for cough.
7. Penicillin V Potassium 250 mg Tablet Sig: Four (4) Tablet PO
Q6H (every 6 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Lorazepam 1-2 mg IV Q4H:PRN
11. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4-6H
(every 4 to 6 hours) as needed.
12. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: as directed as directed Intravenous ASDIR (AS DIRECTED):
currently at 1100u/h. Please adjust according to your hospital
protocol for heparin drip.
13. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1727**] Medical Center
Discharge Diagnosis:
1. tracheal stenosis
2. hypotension from ?sepsis
3. atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
You have been discharged to [**Hospital 1727**] Medical Center ICU. Your care
will be dictated by the doctors at that hospital. Please direct
your questions and concerns to them. If you have any questions
or concerns about your course here please call us at [**Hospital1 18**].
Followup Instructions:
1. Please follow up with ENT in 2 weeks for follow up
procedures.
PLease call ([**Telephone/Fax (1) 6213**] for [**Hospital1 18**] ENT department if you run
into any problems.
Completed by:[**2134-12-4**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
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icd9pcs
|
[
[
[]
]
] |
9878, 9939
|
6069, 8442
|
345, 384
|
10055, 10064
|
2360, 6046
|
10390, 10598
|
1909, 1914
|
8780, 9855
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9960, 10034
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8468, 8757
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10088, 10367
|
1929, 2341
|
276, 307
|
412, 1525
|
1547, 1806
|
1822, 1892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,087
| 148,454
|
14590
|
Discharge summary
|
report
|
Admission Date: [**2105-2-9**] Discharge Date: [**2105-2-14**]
Date of Birth: [**2020-12-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Dyspnea
Major Surgical or Invasive Procedure:
[**2-9**] Aortic stenosis s/p Redo-sterntomy, Aortic valve
replacement
History of Present Illness:
83 year old gentleman with history of coronary artery disease
status post CABG in [**2076**] followed by two drug eluting stents to
the left anterior descending artery in [**2096**] who has known aortic
stenosis followed by serial echocardiograms. Over one month ago
he was admitted for further work-up for chest pain. Workup
revealed native three vessel coronary artery disease with
essentially patent vein grafts however his aortic stenosis was
found to be significantly worse by catheterization. An
echocardiogram showed moderate aortic stenosis, severe mitral
regurgitation and moderate tricuspid regurgitation. He continues
to be symptomatic with occasional chest tightness, dyspnea on
exertion and worsening fatigue. Given the severity of his
disease and new onset of symptoms, he was seen and accepted by
Dr [**Last Name (STitle) **] for surgical revascularization and valve replacement.
However PT was noted to have slow GI bleeding and he underwent
extensive work-up to evaluate source prior to surgery.
Colonoscopy and two endoscopies were negative for any
significant findings. His coumadim and aspirin have been on hold
for over a month. He was cleared for surgery and is being
admitted today to the cardiac surgery service for his surgery
tomorrow.
Past Medical History:
- PTCA with DES to LAD x2 in [**2096**]
- Atrial fibrillation
- Hypertension
- Hyperlipidemia
- BPH
- PUD nonbleeding
- Ventricular ectopy
- Cataracts
- Gastric lymphoma
- B-12 deficiency
- Squamous cell cancer left ear
- H/O GI Bleed [**3-8**] (Transfused 2 units)
- H/O Peptic ulcer
Past Surgical History:
- Coronary artery bypass graft x 2: [**2076**], SVG-LAD, SVG to RCA
- gastric lymphoma s/p partial gastrectomy with occ dumping
syndrome
- s/p left parathyroidectomy [**11-28**]
- s/p partial gastrectomy [**6-28**]
Social History:
Race: Caucasian
Last Dental Exam: [**2104-5-28**]
Lives with: Wife in [**Name2 (NI) **]
Occupation: Shellfish farmer. Active with boating and fishing.
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: [**12-29**] drink/week [X] [**2-3**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
Father with fatal MI at 62, grandfather with MI in 60s. No
family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; Mother had CAD and died in her early 70's.
Physical Exam:
Pulse: 72 AF Resp: 16 O2 sat: 98%
B/P Right: 151/60 Left: 144/55
Height: 69" Weight: 147
General: WDWN in NAD
Skin: Warm, Dry and intact. Sternotomy well healed. Well healed
upper abdominal incision.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign, Teeth in
fair repair
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: Irregular, High pitched IV/VI systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Trace LE Edema
Varicosities: Left GSV appears suitable on standing. There are
some anterior varicosities noted. Right is sugically absent with
a well healed saphenectomy incision
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:2 Left:1
Radial Right:2 Left:2
Carotid Bruit Transmitted bilat but ? bruit in left neck
Discharge Exam:
VS: T: 99.0 72-84 Afib BP: 110-135/60-70 Sats: 94% RA
General: 84 year-old male in no apparent distress
Card: irregular, normal S1,S2
Resp: decreased breath sounds bilateral late fine crackles at
left base
GI: benign
Extr: warm 1+ edema bilateral
Wound: sternal incision clean, dry intact, no erythema,
discharge or sternal click.
Neuro: non-focal
Pertinent Results:
[**2105-2-10**] Echo: PREBYPASS: Preserved LV systolic function with
LVEF> 55% but in the setting of moderate MR. The left atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. 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. No
thoracic aortic dissection is seen. The aortic valve leaflets
are severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). The mitral valve leaflets are
moderately thickened. Moderate (2+) mitral regurgitation is seen
with vena contracta of around 0.5cm and jet area of 8cm2.. There
is no pericardial effusion. Intact IAS. No clot seen in LAA,
dilated coronary sinus but no persistent left SVC (normal entry
of contrast throught the left arm IV.
POSTBYPASS: MR is now trace. Normally functioning bioprosthetic
AV with no significant regurg or stenosis. Normal function. No
dissection seen after aortic cannula removed.
.
CXR: [**2105-2-14**]: 1. Status post median sternotomy with stable
postoperative cardiac mediastinal contours. There is persistent
but slightly less free
intraperitoneal air underneath the right hemidiaphragm. There is
persistent bibasilar air space opacities which likely reflects
patchy atelectasis in the setting of small bilateral pleural
effusions. No pulmonary edema. No evidence of pneumothorax.
[**2105-2-12**] WBC-10.6 RBC-3.46*# Hgb-10.3*# Hct-30.3 Plt Ct-121*
[**2105-2-10**] WBC-7.4 RBC-3.45* Hgb-9.7* Hct-30.5* Plt Ct-218
[**2105-2-14**] PT-17.9* INR(PT)-1.7*
[**2105-2-13**] PT-18.5* INR(PT)-1.7*
[**2105-2-12**] PT-25.6* INR(PT)-2.5*
[**2105-2-11**] PT-12.7* INR(PT)-1.2*
[**2105-2-14**] UreaN-31* Creat-1.1 Na-135 K-3.8 Cl-97
[**2105-2-9**] Glucose-134* UreaN-21* Creat-1.2 Na-137 K-3.9 Cl-105
HCO3-25
[**2105-2-14**] Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 43029**] was admitted a day before surgery due to being on
Coumadin for atrial fibrillation. He was placed on Heparin and
underwent surgical work-up on [**2-9**]. The following day he was
brought to the operating room where he underwent a
redo-sternotomy, aortic valve replacement. Please see operative
note for surgical details. Following surgery he was transferred
to the CVICU for invasive monitoring in stable condition. Within
24 hours he was weaned from sedation, awoke neurologically
intact and extubated. On post-op day one he was started on
beta-blockers and diuretics and diuresed towards his pre-op
weight. Later this day he was transferred to the step-down floor
for further care. Chest tubes and epicardial pacing wires were
removed per protocol. He worked with physical therapy for
assistance with strength and mobility. Coumadin was restarted
for his chronic atrial fibrillation and will be followed by his
cardiologist after discharge. He made good progress and was
discharged to home with VNA services on post-op day 4 with the
appropriate medications and follow-up appointments.
Medications on Admission:
Amoxicillin dental prophylaxis
Vitamin B 12 1000mcg injected monthly
Omeprazole 20mg daily
Maalox
Flomax 0.4mg daily
**Coumadin*** 4mg alt with 6mg on hold
Red yeast rice 600mg Twice daily
Welchol 1250mg twice daily
Folic acid 1mg daily
Metoprolol 12.5mg twice daily
Aspirin 81mg daily on hold
lasix 20mg [**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. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain, fever.
6. colesevelam 625 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
13. Outpatient Lab Work
Hematocrit and Hgb. Results to be sent to Dr. [**Last Name (STitle) 2912**]
[**Telephone/Fax (1) 8543**]
Discharge Disposition:
Home with Service
Facility:
tba
Discharge Diagnosis:
- Aortic stenosis s/p Redo-sterntomy, Aortic valve replacement
Past history:
- PTCA with DES to LAD x2 in [**2096**]
- Atrial fibrillation
- Hypertension
- Hyperlipidemia
- BPH
- PUD nonbleeding
- Ventricular ectopy
- Cataracts
- Gastric lymphoma
- B-12 deficiency
- Squamous cell cancer left ear
- H/O GI Bleed [**3-8**] (Transfused 2 units)
- H/O Peptic ulcer
Past Surgical History:
- Coronary artery bypass graft x 2: [**2076**], SVG-LAD, SVG to RCA
- gastric lymphoma s/p partial gastrectomy with occ dumping
syndrome
- s/p left parathyroidectomy [**11-28**]
- s/p partial gastrectomy [**6-28**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+ bilateral
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
Wound check: [**Hospital Unit Name **] [**Last Name (NamePattern1) **], [**Hospital Unit Name **] on [**2105-2-24**]
at 10:15AM
Surgeon: Dr. [**Last Name (STitle) **] on [**2105-3-11**] at 1:45PM in the [**Hospital Unit Name **]
[**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2912**] [**Telephone/Fax (1) 8543**] follow-up as
directed
**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: Chronic Atrial
fibrillation
Goal INR 2-2.5
First draw Monday [**2-16**]
Results to phone to Dr. [**Last Name (STitle) 2912**] at [**Telephone/Fax (1) 8543**]
Completed by:[**2105-2-14**]
|
[
"427.31",
"V58.61",
"424.1",
"V10.83",
"V10.04",
"600.00",
"V12.71",
"414.01",
"401.9",
"V45.81",
"V10.79",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8850, 8884
|
5995, 7115
|
317, 389
|
9527, 9767
|
4091, 5972
|
10690, 11598
|
2581, 2757
|
7487, 8827
|
8905, 9267
|
7141, 7464
|
9791, 10667
|
9290, 9506
|
2772, 3705
|
3721, 4072
|
259, 279
|
417, 1680
|
1702, 1987
|
2242, 2565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,043
| 160,253
|
14222
|
Discharge summary
|
report
|
Admission Date: [**2175-2-15**] Discharge Date: [**2175-2-21**]
Service: UROLOGY
Allergies:
Amoxicillin / Penicillins / Coumadin
Attending:[**First Name3 (LF) 824**]
Chief Complaint:
weakness and malaise
Major Surgical or Invasive Procedure:
Repair bladder perforation.
History of Present Illness:
86 y/o M w/ with hx of DMII, chronic UTI, PVD, hyperthyroidsm on
methimazole, resident of Tower [**Doctor Last Name **] skilled nursing facility,
who presents with one day of generalized weakness and malaise.
Feeling ok yesterday, however woke this am with generalized
weakness, and not able to stand. Had to lower himself to the
floor, but did not fall or lose conciousness. Denies associated
HA, dizziness, CP, sob, n/v/d, abd pain. No focal weakness,
visual change, or change in mental status. Has chronic dysuria
and urgency, but no new changes in urinary symptoms. + feeling
cold, chills.
.
In ER, triage vitals include temp 99.6, O2 sat 88% RA. wbc 11.0,
CXR negative, U/A positive, EKG without ischemic changes. Rec'd
levofloxacin. admit to medicine
.
ROS: as per hpi, otherwise negative
Past Medical History:
1. DMII- on insulin
2. severe chronic axonal neuropathy, radiculopathy and
plexopathy (due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop
for many years. L3 compression fracture.
3. prostate CA s/p XRT dx'd [**2156**]
4. cataract s/p bilateral laser surgery, also with "macular
edema" s/p dexamethasone injxn.
5. Hard of hearing
6. history of utis, including MRSA + UTI (last two urine samples
negative for MRSA).
7. atrial fibrillation- not on coumadin due to h/o bleed
8. hyperthryoidsm- worsened on amiodarone tx, now on
methimazole, followed by endocrinology
9. h/o CVA [**2172**]
10. chronic urinary incontinence, s/p TURP [**10-7**]
* Unable to tolerate foley catheters->causes bleeding [**3-4**] hx of
radiation cystitis.
Social History:
Smoked 2ppd x 25 years, quit [**2137**]. Comes in from tower [**Doctor Last Name **]
skilled nursing facility. Baseline able to walk short distances
with walker and assist, otherwise uses wheelchair.
Family History:
No illnesses, strokes, DM or early heart attacks run in the
family.
Physical Exam:
T 100.3, 125/84, HR 98, RR 20, 96% RA
Gen: sleeping but easily arousable, no acute distress, hard of
hearing
HEENT: EOMI, dry mm, anicteric
Neck: supple, no jvd
Lungs: clear b/l. no r/r/w
Heart: Irregularly irregular, systolic murmur heard throughout
precordium.
Abd: Soft, NT, ND + BS, no suprapubic tenderness
Ext: No edema, rashes noted, trace pedal edema b/l
Skin: normal
Neuro: A&O x 3. motor strength 5/5 UE's, [**6-5**] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/dist. did
not assess gait. sensation normal to light touch b/l.
affect: normal
Pertinent Results:
Admission Labs:
------------
[**2175-2-15**] 07:30PM WBC-11.0 RBC-4.18* HGB-12.5* HCT-35.9* MCV-86
MCH-30.0 MCHC-34.9 RDW-13.6
[**2175-2-15**] 07:30PM NEUTS-83.1* LYMPHS-10.1* MONOS-6.4 EOS-0.2
BASOS-0.2
[**2175-2-15**] 07:30PM PT-13.9* PTT-29.3 INR(PT)-1.2*
[**2175-2-15**] 07:30PM CALCIUM-8.9 PHOSPHATE-2.6* MAGNESIUM-2.1
[**2175-2-15**] 07:30PM GLUCOSE-90 UREA N-23* CREAT-1.0 SODIUM-135
POTASSIUM-6.2* CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2175-2-15**] 09:25PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-LG
[**2175-2-15**] 07:42PM LACTATE-1.5 K+-4.2
CXR [**2175-2-15**]-
PA AND LATERAL CHEST: Stable mild cardiomegaly. The thoracic
aorta is
tortuous without focal dilatation. Lungs are mildly
hyperinflated with stable chronic linear opacity at the left
base likely scarring versus atelectasis. There is no pleural
effusion or pneumothorax. Pulmonary vasculature is normal.
Surgical clip projects over the right upper abdomen.
IMPRESSION: Stable changes with hyperinflation and mild left
basilar
atelectasis versus scarring. No radiographic evidence of
pneumonia or CHF.
EKG [**2175-2-15**]- reviewed by me, demonstrates afib, vent rate in
100s. normal axis. no acute ST changes. compared to EKG dated
[**2173-10-11**]. in NSR at that time.
Brief Hospital Course:
A/P: 86 y/o M w/ with hx of DMII, chronic UTI, PVD,
hyperthyroidsm on methimazole, resident of Tower [**Doctor Last Name **] skilled
nursing facility, who presents with one day of generalized
weakness and malaise
# Bladder perforation/peritonitis - On hospital day 3, the pt
began to complain of [**11-10**] LLQ pain that was not relieved with
IV morphine. On examination, the pt was found to have a rigid
abdomen with peritoneal signs. Surgery was consulted and a stat
CT abd/pelvis with contrast was significant for bladder
perforation. A CT cystogram confirmed these findings and the
patient was taken emergently to the OR by urology for exlap with
closure of the bladder over a portion of the peritoneum with a
placement of a JP drain. He became transiently hypotensive
during the case and required the initiation of neosynephrine gtt
to maintain SBPs > 100. He was then transported to the ICU where
propofol and neo gtts were turned off and the pt was extubated
successfully without event. He was monitored in the ICU setting
for > 24 hrs to ensure hemodynamic stability and to monitor
output from his JP drain and foley. He was then transferred to
urology for further management.
# UTI - [**Month (only) 116**] have contributed to pt's underlying malaise/lethary
on admission. He was switched from levaquin to ciprofloxacin on
admission to the floor. Unfortunately, a urine culture was not
sent but blood cultures came back positive for GNR resistant to
fluoroquinolones. Post-surgery, the patient was placed on
vancomycin and meropenem. Subsequently, the pt did not have any
fevers and WBC trended down.
# malaise/lethargy - [**Month (only) 116**] have been secondary to underlying
infection with UTI. Hypothyroidism [**3-4**] oversuppression with
methimazole was considered and a TSH was checked that was wnl.
EKG was without ischemic changes. CXR was negative for
pneumonia. The pt was not hypoglycemic during hospital course.
# DMII controlled with complications - Continued NPH and covered
with insulin sliding scale.
# Hyperthyroidsm - Worsened on amiodorone tx (now off), on
methimazole, followed by endocrine as outpatient. Most recent
TFTs [**1-7**]- normal TSH 2.5, fT4 1.2, TT3 105. Repeat TSH while
in house was wnl.
# A-fib - Continued on bisoprolol. Not anti-coagulated as outpt.
# PVD - Continued pentoxyfiline.
# Spinal stenosis/chronic neuropathy- assistance with
ambulation, PT consult
Medications on Admission:
bisoprolol 2.5mg daily
tylenol prn
pentoxyfiline 400mg [**Hospital1 **]
novolin 38 units qam
simvastatin 10mg daily
multivitamin daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Bladder perforation
Discharge Condition:
Stable.
Discharge Instructions:
-You may shower 2 days after surgery, but do not tub bathe,
swim, soak, or scrub incision for 2 weeks. Bandage strips will
fall off over time. No heavy lifting for 4 weeks.
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
-Follow up with Dr. [**Last Name (STitle) 770**] in 1 week for wound check, call to
make appointment
-Please do not drive or consume alcohol while taking pain
medications.
-Please resume home medication but avoid aspirin and advil for
one week.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 770**] for f/u appt.
Please f/u PCP immediately upon [**Name Initial (PRE) **]/c.
|
[
"V12.54",
"355.8",
"242.90",
"V10.46",
"038.49",
"599.0",
"443.9",
"909.2",
"427.31",
"596.6",
"567.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.89"
] |
icd9pcs
|
[
[
[]
]
] |
6753, 6829
|
4147, 6568
|
263, 293
|
6893, 6903
|
2796, 2796
|
7531, 7654
|
2127, 2197
|
6850, 6872
|
6594, 6730
|
6927, 7508
|
2212, 2777
|
203, 225
|
321, 1117
|
2812, 4124
|
1139, 1893
|
1909, 2111
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,681
| 152,381
|
11824
|
Discharge summary
|
report
|
Admission Date: [**2134-12-16**] Discharge Date: [**2134-12-19**]
Service:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 805**] is an 89 year-old
woman who is admitted to the Medical Intensive Care Unit for
further management of unresponsiveness and hypotension. She
is a resident of [**Hospital3 537**] with multiple medical problems
including severe sacral decubitus ulcer, paroxysmal atrial
fibrillation and dementia who has been progressively
declining over the last several weeks. She has been recently
started on broad spectrum antibiotics and has become
progressively less responsive. On the afternoon of admission
she was found unresponsive to painful stimuli. Her
temperature at that time was 96.9, heart rate 109, her blood
pressure was 90/50 and her respiratory rate was 32 and her
oxygen saturation was 80% on 4 liters. The patient was
brought to the [**Hospital3 **] Emergency Room by ambulance.
In the Emergency Room the patient was intubated secondary to
hypertension and unresponsiveness. Her blood pressure
initially was 80/50, and subsequently dropped to 60 systolic.
A right femoral line was inserted. The patient's
electrocardiogram revealed rapid atrial fibrillation. The
patient was started on Dopamine. Her heart rate increased to
140 and Dopamine was subsequently discontinued and the
patient was continued with aggressive hydration. After
receiving 2 liters of normal saline the patient's systolic
blood pressure increased to 100 systolic, but subsequently
dropped to 60 and the Dopamine was restarted. The patient
underwent a head CT, which revealed no change. A chest x-ray
revealed a likely right middle lobe pneumonia. The patient
received one dose of Levofloxacin. She was transferred to
the Medical Intensive Care Unit for further care.
There, Dopamine was discontinued and she underwent a
synchronized cardioversion with 100, 200 and 360 jewels
without success. Her blood pressure remained in the 90 to
100 range systolic.
PAST MEDICAL HISTORY: 1. Dementia. 2. Paroxysmal atrial
fibrillation. 3. Congestive heart failure. 4. Coronary
artery disease. 5. Left above the knee amputation. 6.
Positive PPD. 7. Fibroids. 8. Breast mass. 9. Lung
nodule. 10. Sacral decubitus ulcer.
ALLERGIES: No known drug allergies.
MEDICATIONS: 1. Levaquin 500 mg q day. 2. Piperacillin 4
grams q 8 hours. 3. Gentamycin 70 mg q 8 hours. 4.
Atrovent. 5. Ceftriaxone 1 gram q 12 hours. 6. Depakote
325 mg t.i.d. 7. Enalapril 10 mg q day. 8. Diltiazem 90
mg q.i.d. 9. Lactulose 30 mg b.i.d. 10. Tamoxifen 10 mg
b.i.d. 11. Norvasc 10 mg q.d. 12. Remeron 50 mg q.d. 13.
Flagyl.
SOCIAL HISTORY: The patient lives at [**Hospital3 537**]. Her
primary care physician [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital6 **].
PHYSICAL EXAMINATION: In general, the patient is a frail
elderly African American woman who is intubated and sedated
and minimally responsive to verbal or painful stimuli. Her
temperature was 98.8 rectally. Her blood pressure was 90/60
on 10 mcg of Dopamine. Her heart rate was 130 to 140 and her
assist control ventilation was 500 cc by 14 breaths per
minute with an FIO2 of 100%. Her head, eyes, ears, nose and
throat was remarkable for anicteric sclera and constricted
pupils and dry mucous membranes. She had no jugulovenous
distention. She had diffuse rhonchi. Her heart was tachy
and irregular. Her abdomen was mildly distended and
nontender. Her extremities revealed a left above the knee
amputation and her right lower extremity was warm with trace
edema and 1+ pedal pulses. Her neurologic examination, she
was not responsive to verbal or painful stimuli.
LABORATORY DATA: White blood cell count 34.4, hematocrit
38.9. Sodium 138, potassium 3.2, chloride 102, bicarb 22,
BUN 10, creatinine .6, glucose 143. ALT 4, alkaline
phosphatase 105, amylase 127, lipase 10, total bilirubin 0.4,
CK 16, calcium 8.3, magnesium 1.8, phosphorous 3.5, INR 1.3,
PT 13.7, PTT 35.0. Electrocardiogram showed atrial
fibrillation with normal axis rate of 150. Chest x-ray
showed opacified right heart consistent with right middle
lobe pneumonia.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit where she was treated for overwhelming
sepsis presumed to be due to a right middle lobe pneumonia
and contamination from a large sacral decubitus ulcer and
osteomyelitis, which had previously been deemed inoperable.
She ultimately succumbed to sepsis.
1. Hypotension: The patient required multiple pressors.
She was initially placed on neosinephrine, which was
eventually switched over the Levophed drip. Ultimately the
patient's blood pressure decreased to systolic pressures in
the 60s despite maximal management with pressers and fluids.
The patient ultimately expired secondary to sepsis.
2. Sacral ulcer: The ulcer had previously been deemed
nonsurgically treatable. It was treated with intravenous
antibiotics including Levofloxacin and Ceftazidime for
pseudomonal coverage.
3. Respiratory: The patient was mechanically ventilated on
assist control ventilation.
4. Renal: The patient's urine output decreased secondary to
renal hyperperfusion consistent with shock.
5. Code status: Attempts were made repeatedly to discuss
the patient's grave prognosis with the family. On [**12-18**]
an attempt was made to contact the family who did not meet
with the Medical Intensive Care Unit attending. It was felt
that CPR would not be indicated in this patient by the
attending physician and [**Name Initial (PRE) **] record of this was made in the
chart. On the evening of the patient's demise, the family
was contact[**Name (NI) **] and agreed to make the patient's comfort a
priority and the patient was placed on a morphine drip. She
expired at 5:45 a.m. after her heart was found to be in
asystole.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2134-12-19**] 19:45
T: [**2134-12-24**] 12:57
JOB#: [**Job Number 37344**]
|
[
"785.59",
"427.31",
"518.81",
"276.2",
"707.0",
"112.1",
"038.9",
"584.9",
"482.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.62",
"96.71",
"96.6",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4209, 6169
|
2861, 4191
|
113, 1987
|
2010, 2663
|
2680, 2838
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,650
| 166,267
|
21771
|
Discharge summary
|
report
|
Admission Date: [**2133-4-22**] Discharge Date: [**2133-4-24**]
Date of Birth: [**2110-10-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
22 yo type 1 diabetic man with 1 day of nausea/vomiting. He had
been in his usual state of health on Tuesday, but awoke feeling
nauseated on Wednesday morning. He had very poor appetite and
was unable to keep any food or liquid down, with several
episodes of nonbloody, nonbilious vomiting following eating
Wednesday afternoon. When the N/V did not remit, he came to the
ED.
.
He does not have any known sick contacts, although he lives in a
college dorm. He denies chills, fevers, headaches, cough,
diarrhea, abdominal pain, dysuria, or myalgias. He has not had
any chest pain or dyspnea.
.
In the ED T98.0 HR122 BP120/70 RR20 Sat 100% on RA. He was given
ceftriaxone 1gm iv for empiric coverage because of leukocytosis
and started on insulin gtt. Received approximately 2L NS in the
ED.
Past Medical History:
DM type I for 10 years, uses insulin pump, last visit at [**Last Name (un) **]
[**11-14**], now following in [**State 760**].
- wisdom tooth extraction 2 weeks pta
Social History:
Occupation: student at BU, also works for [**Company 57194**]
Drugs: none
Tobacco: none
Alcohol: none
Other
Family History:
Mother HTN, maternal grandparent with T2DM. No family hx other
endocrine disorders, cancer, or early CAD
Physical Exam:
Tmax: 36.7 ??????C (98.1 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 117 (117 - 117) bpm
BP: 127/54(71) {127/54(71) - 127/54(71)} mmHg
RR: 10 (10 - 10) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, acne in various stages of healing on back
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, time, and place,
Movement: Purposeful, Tone: Not assessed
Pertinent Results:
PORTABLE AP CHEST RADIOGRAPH: The heart size is normal.
Mediastinal and hilar contours are unremarkable. The lungs are
clear. There is no pleural effusion. There is no pneumothorax.
Osseous structures are unremarkable.
IMPRESSION: Normal chest radiograph
Admit Labs:
-----------
[**2133-4-22**] 11:40PM BLOOD Glucose-489* UreaN-30* Creat-1.2 Na-138
K-6.2* Cl-105 HCO3-6* AnGap-33*
[**2133-4-23**] 11:05AM BLOOD Glucose-256* UreaN-15 Creat-0.9 Na-138
K-3.9 Cl-115* HCO3-17* AnGap-10
[**2133-4-23**] 11:05AM BLOOD ALT-21 AST-12 LD(LDH)-106 AlkPhos-66
TotBili-1.0 DirBili-0.3 IndBili-0.7
[**2133-4-23**] 11:05AM BLOOD Albumin-3.7 Calcium-8.0* Phos-1.5*#
Mg-1.8
[**2133-4-23**] 11:28AM BLOOD Type-[**Last Name (un) **] Temp-37.1 pO2-93 pCO2-35
pH-7.32* calTCO2-19* Base XS--7 Intubat-NOT INTUBA
[**2133-4-23**] 06:47AM BLOOD Glucose-248* Lactate-1.4 Na-137 K-4.2
Cl-112 calHCO3-14*
.
Other Labs/Studies:
-------------------
[**2133-4-24**] 08:05AM BLOOD WBC-7.0# RBC-3.98*# Hgb-12.0*# Hct-34.0*#
MCV-86 MCH-30.2 MCHC-35.4* RDW-12.9 Plt Ct-242
[**2133-4-24**] 08:05AM BLOOD Glucose-187* UreaN-9 Creat-0.8 Na-139
K-4.0 Cl-108 HCO3-19* AnGap-16
[**2133-4-23**] 11:05AM BLOOD Glucose-256* UreaN-15 Creat-0.9 Na-138
K-3.9 Cl-115* HCO3-17* AnGap-10
[**2133-4-23**] 11:05AM BLOOD ALT-21 AST-12 LD(LDH)-106 AlkPhos-66
TotBili-1.0 DirBili-0.3 IndBili-0.7
[**2133-4-22**] 11:40PM BLOOD Amylase-24 DirBili-0.4*
[**2133-4-22**] 09:25PM BLOOD ALT-35 AST-17 AlkPhos-118* TotBili-2.3*
[**2133-4-24**] 08:05AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.6
[**2133-4-23**] 11:05AM BLOOD Albumin-3.7 Calcium-8.0* Phos-1.5*#
Mg-1.8
[**2133-4-22**] 09:25PM BLOOD %HbA1c-12.7*
[**2133-4-23**] 11:28AM BLOOD Type-[**Last Name (un) **] Temp-37.1 pO2-93 pCO2-35
pH-7.32* calTCO2-19* Base XS--7 Intubat-NOT INTUBA
[**2133-4-22**] 10:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.021
[**2133-4-22**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-250 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
UCx ([**4-23**]) - negative
Blood Cx ([**4-22**]) - NGTD x 2
Brief Hospital Course:
22 yo M with DMI dx at age 10, presents in DKA, possible [**1-10**]
viral gastroenteritis.
.
# Type I Diabetes Mellitus, Uncontrolled with DKA
# Nausea/Vomiting/Leukocytosis with question of viral process
Given 1 day h/o vomiting (without diarrhea, and poor diabetes
control at baseline - HbA1c >12 on this admit) with BS in 200??????s
per pt report, likely baseline dehydration may have contributed
to rapid development of DKA. Patient placed on insulin gtt and
managed with IVF, K+ replacement, frequent VBG, electrolyte
checks. AG closed with treatment. Patient was seen by [**Last Name (un) **] and
recommended starting glargine 20 units qhs and humalog sliding
scale. Fingersticks relatively stable on this regimen, therefore
patient was transferred to the medicine floor on [**4-23**] evening.
The following day, the patient was well and did not have any
complaints. Was tolerating a regular diet. He did have one
fingerstick (prior to lunch) recorded at 423. He was given 14
units of Humalog. Fingerstick was checked 3 hours later and was
in the 200s. He was covered with the regular sliding scale
coverage. He is to resume using his insulin pump upon going
home. He was given a prescription for Lantus and Humalog to be
used in case his pump is not functioning. He was set up with a
[**Last Name (un) **] appointment three days after discharge for follow up. He
is planning on moving out of state, therefore will need to
establish care with new provider. [**Name10 (NameIs) **] this was explained to
patient who expressed understanding.
.
# Elevated Bilirubin
The patient initially had an elevated bilirubin. However this
resolved prior to discharge and he did not have any abdominal
tenderness. This may have been elevated due to his viral
syndrome.
Medications on Admission:
insulin pump, basal rate of 1unit/hr, with boluses at meals
based on carbohydrates and FSBS
Discharge Medications:
1. Lantus 100 unit/mL Solution Sig: as directed Subcutaneous at
bedtime: To be used if insulin pump not functioning. Please
take 20 units daily in the evening.
Disp:*1 vial* Refills:*0*
2. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
qAC and qHS: To be used if insulin pump not functioning. Take
pre-meal and pre-dinner per sliding scale (for correction) plus
pre-meal amount per calculated carbs.
Disp:*1 vial* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Type I Diabetes Mellitus with ketoacidosis
Leukocytosis
Elevated bilirubin
Nausea/Vomiting
Discharge Condition:
Afebrile, vital signs stable
Discharge Instructions:
Please take all medications as prescribed. You can resume using
your insulin pump when you get home. It is very important that
you calculate your carbohydrates and adjust your dose
accordingly. If your pump is not working, you can use the
lantus (long-acting insulin) and humalog (short-acting insulin)
instead. You are being given prescriptions for vials of these
medications.
.
It is very important that you keep yourself well hydrated with
water.
.
Once you move, you will need to establish a primary care doctor
and an endocrinologist to manage your diabetes.
.
Please call your doctor or return to the emergency room if you
should develop increased nausea/vomiting, elevated or decreased
blood sugars, confusion, blurry vision, or any other concerning
symptom.
Followup Instructions:
[**Hospital **] [**Hospital 982**] Clinic: Dr. [**Last Name (STitle) 57195**] [**Name (STitle) 28007**]. Monday [**4-27**],
9AM. ([**Telephone/Fax (1) 17484**]
|
[
"V45.85",
"787.01",
"288.60",
"250.13",
"277.4",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7163, 7169
|
4777, 6553
|
319, 325
|
7303, 7333
|
2701, 4754
|
8151, 8315
|
1482, 1588
|
6696, 7140
|
7190, 7282
|
6579, 6673
|
7357, 8128
|
1603, 2682
|
276, 281
|
353, 1146
|
1169, 1336
|
1352, 1466
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,858
| 139,272
|
32044
|
Discharge summary
|
report
|
Admission Date: [**2117-3-31**] Discharge Date: [**2117-4-4**]
Date of Birth: [**2051-3-8**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Ace Inhibitors / Penicillins / Benzodiazepines
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 66 y.o woman with history of EtOh cirrhosis, liver
cancer, known portal hypertensive gastropathy who presents today
after being found down at 6am at her residency at [**Location (un) 582**]
[**Location (un) 620**]; apparently she had fallen from bed to the floor. She
was initially sent to [**Hospital 882**] hospital, where per report she
had a head CT, c-spine, pelvic and chest x-rays, all of which
were negative at which point she was transferred to [**Hospital1 18**] for
futher care after being given a dose of lactulose and
levofloxacin for a possible urinary tract infection.
.
On arrival to the emergency room, she was noted to be still
quite altered. Her stools were noted to be grossly melanotic,
and the liver service was consulted who recommended starting
protonix and octreotide drips. NG lavage was unsuccessful. On
transfer to the ICU, the patient was noted to be hemodynamically
stable and vitals were HR 74, BP 141/54, RR 18, Sat 100%RA.
On arrival in the ICU, the patient was alert and oriented x 0.
She responded to yes/no questions and obeyed some basic
commands, but was otherwise unable to provide much to the
history. She denied dizziness, lightheadedness, shortness of
breath, chest pain or abdominal pain.
.
Review of systems:
(+) Per HPI, otherwise unable to obtain.
Past Medical History:
1. Cirrhosis c/b encephalopathy
2. Hepatocellular CA s/p resection
3. Diabetes
4. Hypertension
5. Congestive heart failure, EF 55% TTE [**2108**]
6. Coronary artery disease
7. Chronic kidney disease stage III baseline creatinine 1.4
8. s/p ORIF L hip
9. History of gluteal muscle bleed secondary to coagulopathy
10.Gastropathy
Social History:
The patient does not smoke. She did drink alcohol but has not
since developing liver disease. According to prior discharge
summaries she has not had any illicit drug use. She is a
resident of [**Location 582**] [**Location (un) 620**].
Family History:
Non-contributory.
Physical Exam:
On Admission:
General: Alert, oriented x 0, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
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 tenderness in RLQ, non-distended, bowel
sounds present, no rebound tenderness or guarding, palpable
nodular liver edge. No caput medusa. No ascites noted.
GU: foley in place.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No spider angiomas noted.
Neuro: Patient moving all 4 extremities, positive for asterixis
-----------------
Discharge Exam
Oriented to person, place, year, month, but not day. Not able
to say months of year backards.
No asterixis.
No abdominal tenderness.
Pertinent Results:
ADMISSON LABS:
[**2117-3-31**] 10:20PM WBC-4.6 RBC-2.75* HGB-8.8* HCT-26.5* MCV-97
MCH-32.2* MCHC-33.3 RDW-19.9*
[**2117-3-31**] 10:20PM NEUTS-82.1* LYMPHS-12.8* MONOS-4.2 EOS-0.5
BASOS-0.4
[**2117-3-31**] 10:20PM PLT COUNT-119*#
[**2117-3-31**] 10:20PM PT-14.2* PTT-27.8 INR(PT)-1.2*
[**2117-3-31**] 10:20PM GLUCOSE-134* UREA N-36* CREAT-1.5* SODIUM-143
POTASSIUM-3.6 CHLORIDE-116* TOTAL CO2-18* ANION GAP-13
[**2117-3-31**] 10:20PM ALT(SGPT)-35 AST(SGOT)-55* ALK PHOS-132* TOT
BILI-1.5
[**2117-3-31**] 10:20PM CALCIUM-8.7 PHOSPHATE-4.3 MAGNESIUM-2.1
[**2117-3-31**] 10:20PM LIPASE-17
[**2117-3-31**] 10:20PM AMMONIA-30
[**2117-3-31**] 10:27PM LACTATE-1.8
MICRO:
[**2117-3-31**] Blood Culture- Pending
[**2117-4-1**] Urine Culture- No Growth
STUDIES:
[**2117-4-1**] CXR:As compared to the previous radiograph, the patient
has received a nasogastric tube. The tube shows a normal course.
The tip of the tube is securely located stomach, the side port
is at the gastroesophageal junction. Normal lung volumes. No
recent pneumonia, no pulmonary edema. No pleural effusions.
Borderline size of the cardiac silhouette with slightly enlarged
left ventricle, calcified wall of the aortic arch.
[**4-1**] LEFT HAND XR:There is a fracture involving the base of the
proximal phalanx to the small finger. There is a slight
irregularity at the bases of the third and fourth proximal
phalanges suspicious for small nondisplaced fractures. There is
soft tissue swelling involving the third, fourth, and fifth
digits. Degenerative changes of the first CMC joint is noted.
There is generalized demineralization.
[**2117-4-1**] RUQ U/S W/ DOPPLERS: Status post right hepatectomy. The
residual left lobe demonstrates nodular appearance and lobulated
contour consistent with cirrhosis. There is a hypoechoic lesion
in the periphery of segment III measuring 1.9 x 1.5 cm. This
lesion demonstrates mild vascularity in its periphery and is
worrisome for HCC. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. There is no evidence of
ascites. The spleen is enlarged measuring 15.7 cm. The pancreas
is within normal limits. The main portal vein is widely patent
with hepatopetal flow. Left hepatic vein and IVC are patent
throughout. Main hepatic artery and left hepatic arteries are
patent. There is a large recanalized paraumbilical vein.
IMPRESSION:
1. 1.9 x 1.5 cm hypoechoic lesion in segment III of the liver
worrisome for HCC.
2. Cirrhotic liver.
3. Status post right hepatectomy.
4. Large recanalized paraumbilical vein.
5. Splenomegaly.
.
DISCHARGE LABS
[**2117-4-4**] 08:50AM BLOOD WBC-3.0* RBC-3.26* Hgb-10.9* Hct-30.9*
MCV-95 MCH-33.4* MCHC-35.3* RDW-17.7* Plt Ct-88*
[**2117-4-4**] 08:50AM BLOOD PT-15.4* PTT-36.6* INR(PT)-1.4*
[**2117-4-4**] 08:50AM BLOOD Glucose-215* UreaN-19 Creat-1.2* Na-133
K-3.9 Cl-110* HCO3-14* AnGap-13
[**2117-4-4**] 08:50AM BLOOD ALT-28 AST-35 LD(LDH)-296* AlkPhos-115*
TotBili-1.1
[**2117-4-4**] 08:50AM BLOOD Albumin-2.3* Calcium-7.5* Phos-2.7 Mg-1.7
Brief Hospital Course:
66 y.o woman with history of EtOH cirrhosis and portal
gastropathy who presented with hepatic encepholapthy and an
upper GI bleed likely second to known Gastric Antral Vascular
Ectasia.
.
#Hepatic Encephalopathy - The patient was admitted with hepatic
encepholpathy. Precipitating factors included urinary tract
infection, upper GI bleed, and constipation. A RUQ U/S with
Dopplers did not provide any etiology for her hepatic
encephalopathy. Her lactulose was uptitrated until she was
having [**5-18**] bowel movements per day and she was changed to
rifaximin 550 mg [**Hospital1 **]. Her confusion cleared and prior to
discharge she was completely oriented, though still having
difficulty with attention (unable to say months of the year
backwards). She is discharged on lactulose which should be
titrated to 3 bowel movements per day and 550 mg of rifaximin
[**Hospital1 **]. She should follow-up with hepatology at [**Hospital1 2025**] in [**8-22**] days.
.
#Upper Gastrointestinal bleeding / Gastric Antral Vascular
Ectasia - The patient presented with melanotic stools and a
hematcrit that decreased to 23. She is at baseline transfusion
dependent and has a known history of GAVE, but no varices. She
was initially placed on an octreotide drip with IV pantoprazole
[**Hospital1 **]. She was transfused a total of 3 units. Prior to discharge
her hematocrit was stable at 30.9. She should follow-up with
her gastro-enterologist within the week for an EGD and we would
strongly recommend Argon laser therapy for GAVE.
.
#EtOH Cirrhosis - Currently, she is Child's-[**Doctor Last Name 14477**] class high
B/low C. She is in the process of initiating process to be
listed for tranpslantation at [**Hospital1 2025**]. She was maintained on
propanolol. Her spironolactone and lasix were held in the
setting of hypovolemia secondary to a bleed. She is discharged
on decreased dose of lasix (40 mg daily) and her outpatient dose
of spironolactone (50 mg daily).
.
#1.9 x 1.5 cm hypoechoic lesion in segment III of the liver
worrisome for
HCC: RUQ/US showed a lesion in the liver concerning for
recurrence of previous HCC. She will need close follow-up from
hepatology at [**Hospital1 2025**] including MRI for further assessment.
.
#Urinary tract infection - The patient was initially found at
[**Hospital 882**] Hospital to have a UTI with positive UA. She received
levofloxacin at [**Hospital 882**] Hospital, then ciprofloxacin here. She
Will continue ciprofloxacin for 2 more days to treat a 7 day
course of complicated UTI.
.
#Left Finger Fractures - The patient had a fall prior to
admission during which she injured her left hand. A CT of the
head from [**Hospital 882**] hospital was negative for intracranial
process. The x-ray of the left hand here showed fractures of
the proximal 3rd, 4th, and 5th phalanges. The patient was seen
by PT here and placed in a splint. She should follow-up in the
hand clinic.
.
#Diabetes Mellitus - The patient is discharged on her home
insulin regimen of 35 units of NPH [**Hospital1 **] with an insulin sliding
scale.
.
#Psych medications - The patient is discharged on her home doses
of Effexor and Abilify.
.
#Code Status: Full Code
.
#Pending Labs: Blood culture pending from [**3-31**].
.
#Transition Care: It is imperative that the patient have close
follow-up including hepatology follow-up with her providers at
[**Hospital1 2025**] within 7-10 days for her decompensated cirrhosis and newly
found lesion concerning for HCC. Gastroenterology follow-up
with EGD and possibly Argon laser therapy in the next 7-10 days.
Hand clinic follow-up within 1-2 weeks.
Medications on Admission:
Fe sulphate 325 daily
folic acid 1mg daily
multivitamin 1 tab daily
lasix 60mg daily
rifaxamin 200mg tid
lactulose 30cc qid
NPH insluin 35 units [**Hospital1 **]
ISS
abilify 5mg daily
omeprazole 40mg [**Hospital1 **]
propranolol 40mg [**Hospital1 **]
spironolactone 50mg dialy
thiamine 100mg daily
effexor 37.5mg [**Hospital1 **]
vit d2 50,000U qweek
klonopin 0.5mg qhs
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): please titrate to 3 bowel movements per day.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
6. propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO QHS.
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous twice a day.
14. insulin lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous four times a day: resume outpatient sliding scale.
15. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
16. multivitamin Tablet Sig: One (1) Tablet PO once a day.
17. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis: Hepatic Encepholpathy, Upper GI bleed
secondary to gastric antral vascular ectasia, Fractures of left
3rd, 4th, and 5th phalanges
Secondary Diagnosis: Alcoholic Cirrhosis, Portal Gastropathy,
Diabetes Mellitus, Hypertension, Depression.
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 were admitted to the hospital for confusion from liver
disease. You were diagnosed with a urinary tract infection.
You also had some bleeding from your stomach that required blood
transfusions. finally you broke fingers on your left hand
requiring a splint. You should follow-up your liver problems
with the liver doctors at [**Hospital3 2576**] [**Hospital3 **] within the next
10-14 days if possible. You should follow-up with your
gastroenterologist at [**Hospital 882**] Hospital for an endoscopy for
treatment of your stomach bleeding. Finally you should
follow-up with a hand specialist in the next 1-2 weeks for your
fractures.
.
Please Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
.
The following changes were made to your medications:
Your Rifaxamin dose was CHANGED to 550 mg [**Hospital1 **].
Your lasix dose was DECREASED to 40 mg daily.
You were STARTED on ciproloxacin which you should continue for
two more days.
Followup Instructions:
Please call your liver specialist at the [**Hospital **] [**Hospital 75045**] Hospital
to make a follow-up appointment for 7-10 days.
.
Please call your gastroenterologist at [**Hospital 882**] hospital to make
an appointment for esophagogastroduodenoscopy (EGD) for [**8-22**]
days.
.
Please call the Hand Clinic at [**Hospital1 **] at
[**Telephone/Fax (1) 274**] to make an appointment for the next 1-2 weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
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[
[
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11685, 11762
|
6216, 9847
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,255
| 135,071
|
7246
|
Discharge summary
|
report
|
Admission Date: [**2202-1-5**] Discharge Date: [**2202-1-9**]
Date of Birth: [**2136-11-27**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
gentleman with a history of kidney and pancreatic transplant
secondary to insulin-dependent diabetes mellitus, a cardiac
history including a myocardial infarction in [**2190**],
percutaneous transluminal coronary angioplasty and stent to
the right coronary artery in [**2195**], and coronary artery bypass
graft in [**2200-11-4**] who presents with several days of
nausea, diarrhea, and weakness.
By report, the patient had hyperkalemia two weeks ago which
was treated with Kayexalate, and the patient was discharged
from [**Hospital3 3583**]. The patient's diarrhea persisted and
stopped two days prior to admission to the [**Hospital1 346**] after Imodium. The patient reports
hydrating very well over the past few days but not as well
prior to this. The patient fell down the stairs two days
ago, unwitnessed, but presumed mechanical fall. No loss of
consciousness. He states that he just simply tripped and has
been able to ambulate since the fall.
Today, the patient was complaining of left rib pain as well
as acting "slow" and lethargic (per wife). The patient was
initially taken to [**Hospital3 3583**] where he had a white blood
cell count of 33 with a bandemia of 27% and a sodium of 111.
The patient was given normal saline and levofloxacin. A
chest x-ray and chest computed tomography were done (and read
as bilateral lower lobe infiltrates and no abdominal pain
processes), and the patient was transferred here to the [**Hospital1 1444**] Medical Intensive Care Unit
for further care.
The patient was quite sleepy but arousable upon admission and
lucid on examination. He complained of left rib pain and
back pain, status post fall. The patient denied abdominal
pain, nausea, or vomiting. His diarrhea stopped two days
ago. He denied headache, fevers, chills, or dysuria;
however, he does report fatigue and weakness.
PAST MEDICAL HISTORY:
1. Type 1 diabetes mellitus.
2. Status post kidney and pancreatic transplant in [**2190**]
(with a baseline creatinine of 1.1 to 1.7).
3. Retinopathy.
4. Coronary artery disease.
(a) Status post myocardial infarction in [**2190**] and
percutaneous transluminal coronary angioplasty.
(b) Status post right coronary artery stent in [**2195**].
(c) [**2200-11-4**] catheterization showed 3-vessel disease,
90% left anterior descending artery, left circumflex 90%,
right coronary artery 80%.
(d) [**2200-11-4**] coronary artery bypass graft (CABG) with
left internal mammary artery to the left anterior descending
artery, saphenous vein graft to obtuse marginal, and
saphenous vein graft to posterior descending artery.
5. Obstructive sleep apnea.
6. Foot ulcerations.
MEDICATIONS ON ADMISSION:
1. Cyclosporine 125 mg by mouth twice per day.
2. Imuran 25 mg by mouth once per day.
3. Prednisone 5 mg by mouth once per day.
4. Aspirin 325 mg by mouth once per day.
5. Zantac 150 mg by mouth twice per day.
6. Bactrim double strength by mouth on Monday, Wednesday,
and Friday.
7. Lopressor 50 mg by mouth in the morning and 25 mg by
mouth in the evening.
8. Colace.
9. Multivitamin.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: The patient is married. Lives on [**Hospital3 **].
Two daughters are local. The family is very involved in the
patient's care. He denies tobacco, or alcohol use, or
illicit drug use.
PHYSICAL EXAMINATION ON PRESENTATION: General physical
examination revealed the patient appeared exhausted. He was
sleeping but arousable. The patient's temperature was 97.5
degrees Fahrenheit, his heart rate was 80, his blood pressure
was 140/74, his respiratory rate was 16, and his oxygen
saturation was 97% on 2 liters. Head, eyes, ears, nose, and
throat examination revealed the sclerae were injected and
bilateral lashes were crusted. The mucous membranes were
dry. The neck was supple. No jugular venous distention.
The lungs were clear to auscultation anteriorly. Bases with
coarse breath sounds. No crackles. Cardiovascular
examination revealed a regular rate and rhythm. Tachycardic
to the 80s. Normal first heart sounds and second heart
sounds. A 2/6 systolic ejection murmur at the left upper
sternal border. The abdomen was soft with well-healed
surgical scars. There were normal active bowel sounds. Left
lower quadrant renal graft was mildly tender. Right lower
quadrant pancreatic graft was nontender. Back examination
revealed no ecchymoses. Extremity examination revealed 1+
nonpitting edema in the lower extremities bilaterally. The
dorsalis pedis pulses were absent. The legs were hairless.
The skin was warm and dry. No rashes. Neurologic
examination revealed the patient moved all extremities. He
was following commands. The face was symmetric. Lucid in
brief conversation. The patient was alert and oriented
times three. The patient was lethargic.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
upon admission revealed the patient's white blood cell count
was 27.9, his hematocrit was 35.2, and his platelets were
249. Differential revealed 68 polys, 28 bands, 1 lymphocyte,
and 3 monocytes. Chemistry revealed the patient's sodium was
111, potassium was 4.7, chloride was 84, bicarbonate was 17,
blood urea nitrogen was 41, creatinine was 1.9, and blood
glucose was 102. Serum osmolalities were 251, creatinine
clearance was 40.8, and fractional excretion of sodium was
0.17%. Urinalysis was negative. Urine sodium was less than
10, urine chloride was less than 10, urine creatinine was 99,
urine osmolalities were 330. Lactate was 1.04. Blood
cultures were pending.
PERTINENT RADIOLOGY/IMAGING: A KUB revealed nonspecific
bowel gas pattern. No free air or obstruction.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HYPONATREMIA ISSUES: The patient had a 2-week history of
diarrhea and was started on aggressive hydration prior to
admission. The patient was thought to be hypovolemic with
hyponatremia. The patient was given aggressive normal saline
boluses to replete his volume status. The patient's sodium
slowly improved during this admission and reached a maximum of
122. The patient also transiently received 3% normal saline
on hospital day 3 with some response in his sodium. The patient
was maintained on D-5-W with 3 ampules of bicarbonate at a
continuous infusion during this admission.
Syndrome of inappropriate secretion of antidiuretic hormone
could not be evaluated due to the patient's hypovolemic
status.
2. DIARRHEA ISSUES: The patient's stool was sent for
culture and Clostridium difficile toxin. The patient's stool
was positive for the Clostridium difficile antigen.
Upon admission, it was thought that the patient likely had
Clostridium difficile and by mouth Flagyl treatment was
started empirically.
An initial computerized axial tomography was performed upon
admission on [**1-6**] which showed diffuse colonic wall
thickening. There was fat stranding throughout the abdomen.
There was no free air or pneumatosis. These findings were
thought to be consistent with Clostridium difficile colitis.
The patient's diarrhea worsened initially upon admission but
did improve during his hospital course. On the day of the
patient's passing, by mouth vancomycin was also initiated for
fear that the patient's infection was not being treated due
to his decline in status (see below). The patient's
leukocytosis and bandemia persisted during his admission;
however, stress-dose steroids were initiated which did cloud
these laboratory results. Stress-dose steroids were started
in an effort to help resolve the diffuse colonic
inflammation. These were stopped on [**1-9**] because the
patient's clinical status was worsening.
The patient had a repeat computerized axial tomography on
[**1-9**] which showed likely diffuse thickening of the wall
of the entire colon; consistent with the patient's known
diagnosis Clostridium difficile colitis. The patient's
imaging could not exclude pneumatosis coli. There was no
evidence of free air in the abdomen or pelvis.
The Transplant Surgery team was consulted upon this report
and followed the patient clinically. Their feeling was that
this was consistent with Clostridium difficile colitis, and
they wished to follow the patient clinically. Surgery was
not indicated at this time.
3. OTHER INFECTIOUS ISSUES: The patient was continued on
broad-spectrum antibiotics during his admission for fear that
the Clostridium difficile colitis was not the only infectious
source for the patient's clinical status. The patient was
continued on levofloxacin, metronidazole (as per above), and
vancomycin, as well as his prophylactic Bactrim dose.
On [**1-8**], the patient became hypotensive and required
pressors. He was initiated on dopamine and was attempted to
be transitioned onto Levophed. At the time of the patient's
passing, he was requiring both pressors. His last dose of
dopamine was at 4 mcg and Levophed was at 0.17. The patient
was afebrile during his admission.
4. CORONARY ARTERY DISEASE ISSUES: The patient was
maintained on aspirin and a beta blocker until his
hypotension developed, and his beta blocker was held. The
patient had a troponin leak which began on [**1-9**] to
0.69. Just before the patient's passing, his troponin level
was 1.64; which was strongly positive for an acute myocardial
infarction. The patient's creatine kinase was also elevated.
These initial elevations were thought to be due to a diffuse
end-organ process that was not specific to a myocardial
infarction or acute coronary process; however, it was thought
that the patient's cause of death was likely a cardiac arrest
due to overwhelming lactic acidosis (please see below).
5. PULMONARY ISSUES: The patient has obstructive sleep
apnea and used continuous positive airway pressure during his
admission. The patient had persistent bilateral lower lobe
atelectasis versus infiltrate versus effusions. His oxygen
requirement increased on the day of his passing to 6 liters
via nasal cannula, and his breathing became more
uncomfortable.
Blood gases were checked during this admission. On [**1-9**] at 2 o'clock, the patient's blood gas was a pH of 7.27, a
PCO2 of 23, and a PO2 of 76. The patient was closely
monitored, and a blood gas was checked again just as the
patient passed which showed a pH of 7.53, a PCO2 of 61, and a
PO2 of 123. This was after several ampules of bicarbonate.
It was thought that the patient was severely acidotic at the
time of his passing due to a lactic acidosis. His lactate
continued to rise, and just before passing his lactate was
8.8. His lactate earlier in the day was 4.9.
6. LACTIC ACIDOSIS ISSUES: The patient's lactate continued
to rise on the day of his passing. This was thought to be
due to a likely mesenteric infarction or severe ischemia.
This was likely due to the overwhelming inflammation and
infectious burden of his Clostridium difficile colitis (as
explained above). The patient never had any abdominal pain.
Upon passing, the patient's passed a large bloody stool.
This was consistent with the thought that mesenteric
infarction and ischemia were likely largely responsible for
the patient's death. The patient's bicarbonate was 11 just
before the time of his death.
7. ACUTE RENAL FAILURE ISSUES: The patient's kidney
function was at just above baseline upon admission. Urine
electrolytes and immunosuppressive medication levels were
continuously checked. He was followed by the Renal Service.
On [**1-8**], the patient's creatinine took a large hit and
continued to rise persistently with decreasing urine output.
On the day of the patient's passing, the patient's urine
output was essentially zero.
It was thought that this renal failure was most likely
prerenal azotemia, and hydration was continued.
8. ACCESS ISSUES: The patient had a right internal jugular
triple lumen placed upon admission. On [**1-9**], this was
changed over a wire to a cordis so a Swan-Ganz catheter could
be floated. This was done on the afternoon of the patient's
passing. This procedure was done when the patient's clinical
status was poor, and a better assessment of his volume status
was needed. Initial numbers showed normal filling pressures
throughout the heart with a cardiac output of 2.2 and a
systemic vascular resistance of [**2198**]. These numbers were
thought to be consistent with hypovolemia with vasa-
constriction. The patient's passing occurred soon after
these initial numbers were received.
9. CODE EVENT ISSUES: The patient's clinical status slowly
worsened throughout the day on [**1-9**]. The patient was
found in cardiac arrest and respiratory arrest at approximately 9
p.m. on [**1-9**] by his nurse. A code blue was called, and the
patient was coded for approximately 30 minutes. The patient did
not respond to resuscitation or intubation, and he passed away at
approximately 9:30 p.m.
The family was immediately notified along with the attending
on call in the Medical Intensive Care Unit. The patient's
family declined an autopsy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 9244**]
MEDQUIST36
D: [**2202-1-11**] 00:02
T: [**2202-1-11**] 07:16
JOB#: [**Job Number 26811**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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2861, 3282
|
5888, 13473
|
161, 2037
|
2059, 2835
|
3299, 5854
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,104
| 155,662
|
48619
|
Discharge summary
|
report
|
Admission Date: [**2153-2-1**] Discharge Date: [**2153-2-22**]
Date of Birth: [**2091-6-10**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman
who initially presented in [**2152-11-23**] with back, and
abdominal pain, and fevers.
He was discharged subsequent to that and was treated on an
outpatient basis with ciprofloxacin for question prostatitis.
He continued to have pain and eventually had a computed
tomography scan of the abdomen which showed a 7-cm left
pericolic abscess and thickening of the splenic flexure.
He was admitted to the hospital upon discovering this in
[**2152-12-24**] and placed on broad spectrum antibiotics
with ampicillin, levofloxacin, and Flagyl. He underwent
computed tomography-guided drainage of the abscess collection
that grew out enterococcus in two strains; of which one was
vancomycin resistant.
One month following (on [**2153-2-1**]), he again noticed
abdominal pain with chills and cramping with emesis. He had
a follow-up computed tomography which demonstrated another
abscess adjacent to the previously drained collection was
noted on repeat computed tomography done at this time. He
was admitted to the hospital and placed on broad spectrum
antibiotics consisting of levofloxacin and Flagyl and
scheduled for percutaneous drainage of the second collection.
Of note, the patient had grown vancomycin-resistant
enterococcus from the prior collection that was drained in
[**Month (only) 404**].
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Status post angioplasty times two.
3. Coronary artery disease.
4. Hypercholesterolemia.
5. Hypertension.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION:
1. Glucophage 1000 mg twice per day.
2. Glipizide 10 mg twice per day.
3. Actos 40 mg by mouth once per day.
4. Lipitor 40 mg by mouth once per day.
5. Spironolactone 50 mg by mouth once per day.
6. Diltiazem 180 mg by mouth once per day.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination revealed the patient had a temperature of 99.1,
his heart rate was 108, his blood pressure was 176/79, and
his respiratory rate was 18. He was alert and oriented times
three and in no apparent distress, comfortable. The lungs
were clear to auscultation bilaterally. The abdomen was
obese, soft, nontender, and nondistended. His extremities
were warm. He had a drain in place in his left upper
quadrant with dark serous fluid. Rectal examination had
normal tone. No stool in the vault, normal prostate, and
guaiac-negative.
PERTINENT LABORATORY VALUES ON PRESENTATION: Initial
laboratories significant for a white blood cell count of
16.1. The rest of his laboratories were within normal
limits. He was also pan-cultured at the time.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
abdomen showed an increase in the left upper quadrant fluid
collection with a significant amount of air and fluid;
consistent with an abscess with the percutaneous catheter
inferior and posterior, and no communication with between the
abscess collection and the percutaneous drain.
BRIEF SUMMARY OF HOSPITAL COURSE: Based on the patient's
clinical presentation, he was admitted to the hospital and
started on intravenous levofloxacin and Flagyl. He was made
nothing by mouth and placed on intravenous hydration and
pan-cultured.
He was taken the following day for a computed
tomography-guided drainage of the left upper quadrant
collection. He continued to spike fevers, and the decision
was made to take him to the operating room for definitive
resection and drainage of the abscess. He was taken to the
operating room on [**2153-2-6**] where he underwent a en bloc
excision of the abdominal tumor with a transverse colectomy,
partial gastrectomy, splenectomy, and distal pancreatectomy.
Intraoperatively, they found a large intra-abdominal tumor
involving the above-mentioned strictures in transverse colon
and splenic flexure as well as the transverse mesocolon. An
intraoperative gastroscopy was done which showed
no mucosal lesion, but the lesion was found to be
clearly adherent to the stomach. The liver was free of
disease.
The patient tolerated the procedure well and was transferred
to the Recovery Room intubated and sedated. The remainder of
the hospital course will be outlined by system.
1. NEUROLOGIC ISSUES: He had an epidural catheter placed
intraoperatively, and this was run with good pain control.
He was also maintained on low-dose propofol for additional
sedation.
However, on postoperative day two, he spiked a fever to
101.2, and his epidural catheter was removed by the Acute
Pain Service. He was changed to intermittent boluses of
Dilaudid for pain which he tolerated well. His propofol was
discontinued, and he was maintained on Dilaudid only. After
extubation, he had minimal pain receiving only intermittent
doses of Dilaudid; however, he did have some episodes of
confusion and persistent pulling out of his nasogastric tube.
He cleared somewhat and was transferred to the floor.
However, on postoperative day 12, he had an episode of acute
confusion and was given Narcan, and all of his narcotics were
discontinued. At this time, he was felt to have a PCO2 of 80
which decreased to 66 after treatment.
He was transferred back to the Intensive Care Unit at this
time for further monitoring and continued to sundown, but he
was easily reoriented. The following day, he was found out
of bed on the floor trying to go to bathroom. He had a
completely nonfocal examination. At the time of discharge,
he had cleared and was oriented times three with all sedative
medications discontinued.
2. CARDIOVASCULAR ISSUES: The patient reported a history of
bronchospasm with beta blockers, and thus was maintained on a
diltiazem drip for heart rate control. After his tube feeds
were being tolerated, he was changed to intermittent oral
diltiazem with good heart rate control in the 70s and 80s.
He remained hemodynamically stable throughout his
hospitalization.
3. RESPIRATORY ISSUES: Postoperatively, her remained
intubated. Just out of the operating room had an increasing
oxygen requirement because of decreased oxygen saturations
and an increased positive end-expiratory pressure
requirement.
A chest x-ray was consistent with mild congestive heart
failure. He was stabilized, and his ventilator was slowly
weaned on pressure support. However, he initially did not
tolerate a pressure support wean after adequate diuresis;
however, he was able to tolerate very minimal settings.
He subsequently developed a left lower lobe opacity, and a
sputum culture grew out multiresistant Klebsiella, for which
he was changed to meropenem. He was eventually able to be
extubated on postoperative day nine. However, he continued
to have a significant oxygen requirement and continued to
have low-grade temperatures. He received aggressive
pulmonary toilet with chest physical therapy and was weaned
down to room air at the time of discharge. He did have one
episode of hypoxia, as previously mentioned, when he was on
the floor associated with his acute confusion with a
saturation of 73% on room air. He was placed on a
nonrebreather with improved oxygenation. After transfer to
the Intensive Care Unit, he was able to be weaned off his
oxygen. However, on chest x-ray he continued to have a left
lower lobe opacity/consolidation consistent with a ventilator
associated pneumonia.
3. GASTROINTESTINAL ISSUES: He underwent the
above-mentioned procedure including a splenectomy, partial
gastrectomy, distal pancreatectomy, and transverse colectomy.
At the time of this dictation, the final pathology results
were still pending.
He was started on tube feeds on postoperative day four.
These were advanced to goal, and he tolerated them well
without difficulty throughout his hospitalization. His
nasogastric tube was self-discontinued on [**2-15**] and was
replaced without incident, and his tube feeds were resumed.
He again self-discontinued his nasogastric tube, and it was
changed over to a Dobbhoff tube. However, this was post
extubation. After he stabilized from a respiratory
standpoint, this was removed, and he was started on an oral
diet.
Because of a persistently elevated white blood cell count, he
underwent an abdominal computed tomography on [**2-17**] which
showed some consolidation of the left lung base and a small
amount of ascites around the liver, but no evidence of an
abscess or drainable collection.
Because he continued to have a persistent white count, his
[**Location (un) 1661**]-[**Location (un) 1662**] fluid was sent for culture, and this
subsequently grew out vancomycin-resistant enterococcus, and
his antibiotic regimen was changed. His [**Location (un) 1661**]-[**Location (un) 1662**]
amylase was 151,230. Based on this elevated amylase, the
decision was made to leave the [**Location (un) 1661**]-[**Location (un) 1662**] drain in place.
Of note, the patient had two [**Location (un) 1661**]-[**Location (un) 1662**] drains placed
postoperatively; however, during an episode of acute
confusion one was inadvertently removed and the second one
was damage. However, it continued to function and he will be
discharged to rehabilitation with this [**Location (un) 1661**]-[**Location (un) 1662**] drain in
place.
4. GENITOURINARY ISSUES: The patient received several fluid
boluses during the early postoperative hours for a low urine
output. This stabilized, and he was deemed ready for
diuresis on postoperative day four. He initially had a poor
response, but by postoperative day five started to make
significant urine and was changed to a Lasix drip. However,
he was found to respond better to bolused doses of Lasix and
was changed back. He was successfully diuresed down to close
to his estimated preoperative weight. His Foley was
discontinued on postoperative day sixteen.
5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: As stated above,
the patient received multiple fluid boluses for low urine
output during postoperative days one through two. However,
he was subsequently changed to maintenance fluids, but these
were discontinued when his tube feeds were advanced to goal.
He tolerated goal tube feeds throughout most of his hospital
course and has now been changed to an American Diabetes
Association diet.
He received the typical electrolyte repletions during his
hospital stay. However, of note, he developed a significant
metabolic alkalosis around postoperative days nine to ten
which was thought to have precipitated his bicarbonate
retention. He was placed Diamox for this with improvement in
his serum bicarbonate from 40 to the low 30s. At the time of
discharge, he continued to have a stable bicarbonate and
electrolytes.
6. ENDOCRINE ISSUES: The patient was initially placed on an
insulin drip due to a high serum glucose. He was changed
over to NPH when his tube feeds were at a steady state with
an accompanying sliding-scale; however, he needed
intermittent periods with an insulin drip due to difficult
glycemic control.
His oral hypoglycemics were restarted on [**2-21**]; however,
he continued to have elevated glucose levels. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consultation is currently pending with an Addendum to follow
with their recommendations.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was obtained with recommendations to
continue the patient on his oral hypoglycemic medications
with close monitoring of his blood sugars and consideration
to add a basal insulin such as Lantus should there be
problems with glycemic control and continue to hold the
Actos.
7. HEMATOLOGIC ISSUES: He was transfused 2 units of blood
preoperatively, and postoperatively remained stable with the
exception of transfusion of 2 units for a hematocrit of 26
and 27 from presumed blood loss anemia. His hematocrit
stabilized, and he needed no further transfusions throughout
his hospitalization.
For deep venous thrombosis prophylaxis, he was placed on
three times per day subcutaneous heparin at a dose of 5000
units. However, due to his obesity and immobility, he was
considered at high risk and changed to Lovenox 30 twice per
day on postoperative day eight. Of note, in concordance with
his elevated white blood cell count to the 20s, his platelet
count continued to rise with a peak at 988. He was started
on aspirin on [**2-19**], and his platelet count is currently
trending down.
8. INFECTIOUS DISEASE ISSUES: As stated above, the patient
presented with fevers and had fevers preoperatively as well.
The initial abscess, as stated above, had grown two species
of enterococcus of which one was vancomycin resistant. His
intraoperative cultures grew enterococcus, and his culture
from his second preoperative percutaneous drain grew
gram-negative rods of two morphologies; Proteus and
Enterococcus that was vancomycin sensitive. Based on these
presumptive cultures, he was placed on levofloxacin and
Flagyl postoperatively until the final intraoperative
cultures came back. These grew alpha strep, two species of
gram-negative rods, and again probable enterococcus. Because
of his persistent fevers and elevated white blood cell count,
vancomycin was started on [**2153-2-8**] to provide
additional coverage for Enterococcus. He continued to have
low-grade fevers and an elevated white blood cell count. He
was pan-cultured on multiple occasions. His sputum culture
from [**2-8**] grew Klebsiella pneumoniae that was highly
resistant and essentially only sensitive to meropenem to
cover him for a ventilator associated pneumonia.
He was noted to have some drainage from the right lateral
portion of his incision which was initially serosanguineous
only with turning; however, it progressed to a thick purulent
appearing material and on postoperative day eight the wound
was opened at the bedside. The fascia was intact, and a
moderate amount of serosanguineous and fatty fluid was
drained, but no large collection of pus was encountered. He
was maintained on wet-to-dry dressing changes; however, the
swab from that incision grew Klebsiella that was gain highly
resistant and enterococcus that was resistant to
levofloxacin, and penicillin, and ampicillin and sensitive to
vancomycin. His levofloxacin was discontinued when the
meropenem was started. Additionally, the fluid from his
[**Location (un) 1661**]-[**Location (un) 1662**] drain was sent for culture. However, one of
these grew out vancomycin-resistant enterococcus. At the
time the sensitivity came back, he was than changed to
linezolid on [**2153-2-19**]. His white blood cell count
subsequently decreased from the 20s, he had been 20.9, to 12,
down to 10.3, and he defervesced.
Of note, because of his splenectomy he received his post
splenectomy vaccines on [**2152-2-21**]; consisting of
meningococcus, pneumovax, and haemophilus influenza type B.
Of note, he is to stay on antibiotics for a total of two
weeks from [**2153-2-19**] to consist of linezolid 600 mg
intravenously twice per day and meropenem 1 gram
intravenously q.8h.; again for a total of 14 days from [**2153-2-19**].
9. TUBES/LINES/DRAINS: He currently has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**]
drain in his left upper quadrant that will remain in place
and a left subclavian triple lumen catheter. The left
subclavian triple lumen should remain in to facilitate the
administration of his intravenous antibiotics and should be
removed after 14 days after his antibiotic course is
completed.
DISCHARGE DIAGNOSES:
1. Large abdominal tumor; status post en bloc resection.
2. Status post transverse colectomy.
3. Status post partial gastrectomy.
4. Status post splenectomy.
5. Status post distal pancreatectomy.
6. Ventilator associated pneumonia.
7. Diabetes mellitus.
8. Hypertension.
9. Blood loss anemia; resolved.
10. Intra-abdominal abscess; status post percutaneous
drainage.
MEDICATIONS ON DISCHARGE:
1. Glucophage 1 gram by mouth twice per day.
2. Glipizide 10 mg by mouth twice per day.
3. Aspirin 325 mg by mouth once per day.
4. Diltiazem 180 mg by mouth once per day.
5. Lovenox 30 mg subcutaneously q.12h.
6. Regular insulin sliding-scale.
7. Linezolid 600 mg intravenously q.12h. (to end after
completed doses on [**2153-3-5**]).
8. Meropenem 1 gram intravenously q.8h. (to end after
completed doses on [**2153-3-5**]).
9. Miconazole powder as needed.
10. Albuterol nebulizer q.6h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]
(telephone number [**Telephone/Fax (1) 2981**]) in two weeks from discharge.
2. The patient was to follow up with his primary care doctor
(Dr. [**First Name (STitle) 1313**] two weeks from discharge (telephone number
[**Telephone/Fax (1) 7318**]).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2153-2-22**] 10:47
T: [**2153-2-22**] 11:09
JOB#: [**Job Number 102279**]
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icd9pcs
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31,858
| 188,159
|
31688
|
Discharge summary
|
report
|
Admission Date: [**2185-10-16**] Discharge Date: [**2185-10-26**]
Date of Birth: [**2118-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
colonoscopy
endoscopy
placement of PICC line
placement of a-line
hemodialysis
History of Present Illness:
67M Vietnamese-speaking PMH ESRD on HD, history of GIB/PUD, AF
(not on coumadin per records), transferred from OSH with GIB.
The patient presented with painless BRBPR and was admitted to
the OSH ICU [**2185-10-12**] for hemodynamic instability and continued
BRBPR. EGD [**2185-10-12**] negative for acute bleeding although showed
reflux esphagitis and hiatal hernia. Bleeding scan [**2185-10-13**]
showed GIB likely located to small bowel. The patient continued
to have multiple bloody BM and went for angiography on [**2185-10-14**]
to locate the source of the bleed but coded in the angiography
suite for PEA and respiratory failure. The patient was
intubated. The patient was initially treated with vasopressin
but this was discontinued prior to transfer for bradycardia. The
patient became bradycardic with SBP 40s [**2185-10-15**] while on
vasopressin and received atropine. In total, the patient was
transfused 19 units PRBC, 8 untis FFP, 3 units platelets and 2
doses DDAVP over the course of stay at OSH. There was initial
concern for DIC given low fibrinogen and platelets; hematology
was consulted and believed the coagulopathy was due to dilution
from the massive blood transfusion.
.
On transfer, the patient's hematocrit had been stable mid-30s
for last 18 hours. The patient was intubated and sedated and
unable to provide further history.
Past Medical History:
1. Stage 5 CKD due to polycystic kidney disease on HD M,W,F;
nephrologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
2. PUD/history of GIB
3. Atrial fibrillation, not on coumadin
4. Chronic anemia
5. Hypertension
6. Hyperlipidemia
7. History of ventricular tachycardia and bradycardia
8. History of C. difficile colitis
9. Status post cholecystectomy
[**88**]. Question gout; patient on colchicine as outpatient
Social History:
Patient is from [**Country 3992**]. Significant for past smoking history.
Family History:
unknown
Physical Exam:
Vital signs: T 97.6 HR 75 BP 178/92 RR 24 O2sat 98% on AC
AC: Tv500 RR 16 FiO2 0.5 PEEP 5
General: Elderly male, intubated
HEENT: Sclera anicteric, PERRL
Heart: RRR, no MRG
Lungs: Coarse BS anteriorally
Abdomen: NABS, soft, NTND, liver 1 cm below costal margin
Extremities: No CCE
Skin: Cool, no rashes
Neurologic: Sedated, responds to painful stimuli, + corneal
reflex, + gag reflex
Pertinent Results:
Labwork on arrival to [**Hospital1 18**]:
[**2185-10-16**]
WBC-18.1* HGB-13.1* HCT-37.1* MCV-88 RDW-16.3* PLT COUNT-134*
NEUTS-91.4* LYMPHS-3.3* MONOS-2.6 EOS-2.5 BASOS-0.2
PT-11.2 PTT-28.2 INR(PT)-0.9 FIBRINOGE-361
GLUCOSE-72 UREA N-40* CREAT-5.6* SODIUM-142 POTASSIUM-4.0
CHLORIDE-102
TOTAL CO2-27 ANION GAP-17
CALCIUM-7.2* PHOSPHATE-7.0* MAGNESIUM-1.9
ALT(SGPT)-15 AST(SGOT)-33 LD(LDH)-324* ALK PHOS-67 TOT
BILI-0.6
ABG: PO2-78* PCO2-47* PH-7.41 TOTAL CO2-31* BASE XS-3 INTUBATED
.
CXR ([**10-16**]): ET tube in standard placement. Nasogastric tube ends
in the stomach. Dual- channel left supraclavicular central
venous line ends in the SVC. Heart moderately enlarged. Right
pleural effusion small. Left basal atelectasis mild. Upper lungs
clear. No pneumothorax.
.
blood cultures negative
.
[**2185-10-25**]. Echo.
Conclusions:
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF 70%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. Right
ventricular systolic function is borderline normal. The aortic
root is mildly dilated at the sinus level. The ascending aorta
is mildly dilated. There are complex (mobile) atheroma in the
aortic arch. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There
is no pericardial effusion.
Brief Hospital Course:
GI bleed. Patient was transferred to [**Hospital1 18**] after significant GI
bleed, although his hematocrit remained stable while at [**Hospital1 18**]..
EGD and colonoscopy failed to finda source of bleed.
Diverticulid in sigmoid colon were seen, but were not thought to
be the cause of bleed. The bleed is likely localized to small
bowel per bleeding scan; differential for this patient includes
small bowel lymphoma or other neoplasm, AVM. He was given an
[**Hospital1 648**] for a capsule study has an outpatient.
.
Respiratory failure s/p PEA arrest. Patient was intubated at
OSH from respiratory failure likey due fluid overload on CXR.
BAL did not reveal a pneumonia so antibiotics were stopped on
[**2185-10-21**]. He was- Pt extubated on [**2185-10-20**] without complication.
.
ESRD on HD: Patient received dialysis on M,W,F while
hospitalized and was followed by renal.
.
Hypertension. His blood pressure remained high during
hospitalization likely due to fluid overload. His home blood
pressure meds were continued and metoprolol was added with
better BP control. He received frequent HD and was treated IV
hydralazine PRN.
.
Neurologic Status. There was concern for anoxic brain injury
following PEA arrest at outside hospital. However, head CT was
negative and neuro exam did not reveal any abnormalities.
.
FULL CODE
Medications on Admission:
Amlodipine 10 mg QD
Nephrocaps one capsule daily
Doxazosin 2 mg [**Hospital1 **]
Colchicine 0.6 mg QD
Renagel 800 mg TID
Fosrenol 1gm TID
Cardura 2 mg [**Hospital1 **]
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Nulytely 420 g Recon Soln Sig: One (1) 4 L bottle PO Once for
1 days: Please drink one 4 Liter of Nulytely on [**11-10**], one
day prior to capsule study.
Disp:*1 4 Liter bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. GI Bleed NOS.
2. Acute Blood Loss Anemia.
3. Hypovolemic PEA Arrest.
4. Mitral Regurgitation and Annular Calcification
Secondary:
1. CKD Stage V on HD.
2. Polycystic Kidney Disease.
3. Hypertension.
4. Hyperlipidemia.
5. Atrial Fibrillation.
6. Peptic Ulcer Disease.
7. Secondary Hyperparathyroidism.
Discharge Condition:
fair
Discharge Instructions:
You were admitted for gastrointestinal bleeding. You were given
numerous blood transfusions and got a colonoscopy and endocscopy
which failed to find a source of bleed. You had difficulty
breathing because you were given so much fluid and blood and you
suffered a cardiac arrest, so you were put on a mechanical
ventillator.
.
You were started on a new medication to lower your blood
pressure called Metoprolol which you will take twice day.
Continue to take Amlodipine and Doxazosin for high blood
presusure.
You were also started on other medications to correct your
electrolytes: Sevelamer, Cinacalcet, and Calcium Acetate.
Please continue to take these medications at home. You can stop
taking Fosrenal (lanthanum).
.
If you have any gastrointestinal bleeding, shortness of breath,
chest pain, or any other alarming symptoms, please call your
doctor or come to the emergency department.
Followup Instructions:
You will need to have a capsule study on Friday [**11-11**] at
7:45 AM with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD ([**Telephone/Fax (1) 1983**]). You will need
to take the NuLyteley the day before the capsule study, on
[**11-10**]. On [**11-10**], you can not eat any solid foods and
instead can only dreak clear liquids. After midnight on [**11-11**], you cannot eat or drink anything until after the doctors
[**Name5 (PTitle) 648**]. Attached are detailed instructions and directions
to the [**Name5 (PTitle) 648**].
.
Please call your primary care physician to set up an [**Name5 (PTitle) 648**]
in 1 to 2 weeks.
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.95",
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icd9pcs
|
[
[
[]
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7525, 7583
|
4916, 6260
|
330, 409
|
7941, 7948
|
2795, 4893
|
8891, 9551
|
2366, 2375
|
6479, 7502
|
7604, 7920
|
6286, 6456
|
7972, 8868
|
2390, 2776
|
276, 292
|
437, 1793
|
1815, 2259
|
2275, 2350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,894
| 122,090
|
26220
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 64973**]
Admission Date: [**2118-2-25**]
Discharge Date: [**2118-3-15**]
Date of Birth: [**2047-12-14**]
Sex: F
Service: VSU
HISTORY OF PRESENT ILLNESS: Briefly, this is a 70-year-old
female, with a known abdominal aortic aneurysm, transferred
from an outside hospital with severe abdominal tenderness and
hypotension. A CT scan at the outside hospital showed no
extravasation; however, she was hypotensive on evaluation
with severe abdominal pain.
PAST MEDICAL HISTORY: Significant for cryptogenic cirrhosis,
mitral valve regurg, lap-chole, total abdominal hysterectomy,
status post appendectomy, and status post ventral hernia
repair.
MEDICATIONS: Included propranolol, spironolactone, Lasix and
Levoxyl.
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAM: She was afebrile. VITAL SIGNS: Her heart rate
was 65, blood pressure in the 60s, and she was 100% on 2
liters. She had significant abdominal tenderness with
guarding.
Her white count was normal, INR was 1.3, and her PT was 30.
Her BUN and creatinine were 27. and 1.5.
HOSPITAL COURSE: Patient was taken to the operating room
emergently for a question of a ruptured abdominal aortic
aneurysm. Intraoperatively, it was found that she had a large
aneurysm. There was also extensive bleeding from her
cirrhosis and; therefore, she was left packed and open.
Please see the operative report for further details.
Postoperatively, she was transferred to the surgical
intensive care unit, and she was aggressively resuscitated.
After this was done, over the next couple of days she
stabilized, bladder pressures were followed, and she was
treated for ARDS with an esophageal balloon, and ventilatory
management, and an echo was done which showed normal EF.
The patient was then returned to the operating room for
abdominal washout. Transplant surgery was consulted who
assisted in the operative intervention. At this time, it was
decided that the patient would return to the operating room.
During the second washout, a Vicryl mesh was placed, and a
VAC dressing was continued. Her LFTs were followed, and her
platelet count was also followed, and her platelet count
began to slowly fall. Because of this, a HIT panel was sent,
and this was positive. Her heparin was stopped, her lines
were changed, and she was followed from this standpoint.
Postoperatively, from the second washout she was continued on
ventilatory management, and she was kept on Levophed for
blood pressure control. She continued to require significant
fluid resuscitation, as she was losing over 3-4 liters of
ascites fluid from her open abdomen. VAC dressings were
changed at the bedside multiple times, and there was slow
granulation tissue. She was started on TPN for nutritional
support during this time.
After multiple attempts at weaning the ventilator were
attempted, it was decided that the patient would proceed to a
tracheostomy, as she was not weaning adequately. Because of
this, a tracheostomy was performed, and she did well from
that standpoint. She slowly began to improve. However, LFTs
continued to rise, and her VAC drain output continued to stay
high at over 5 liters. She was continued to be replaced with
albumin, as well as with IV fluid. During this time, she
began spiking fevers. Pancultures were done, and she was
found to have Pseudomonas in her lungs and; therefore, she
was changed from Zosyn to meropenem. She became afebrile at
that point, and she continued to do well from a pulmonary
standpoint. However, she continued to require high
ventilatory support with high PEEP and high pressure support,
and she was intermittently switched back and forth between
assist control and CPAP.
From a graft standpoint, she had palpable pulses and good
distal perfusion throughout. She was attempted on multiple
occasions to be given anticoagulation using argatroban and
lepirudin. However, her creatinine clearance and primary
liver function abnormalities did not allow for adequate
anticoagulation. She had multiple episodes of bleeding, both
from her NG tube, as well as from her Foley which required
significant blood product resuscitation. As her bilirubin and
LFTs began to rise, and her VAC output continued to rise, a
hepatology consult was performed, and a liver ultrasound was
also done. The liver ultrasound found that she had thrombosed
her portal vein, and because of her dropping hematocrit, the
hepatology service proceeded with an endoscopy. Multiple
esophageal varices were identified, and while no active
bleeding was present, these were significant, and felt that
they would likely cause bleeding in the future. Therefore,
they were banded.
Again, she began having high fevers, and she had ventilator
acquired pneumonia with the Pseudomonas, and this had now
become resistant to meropenem. Therefore, she was changed to
ciprofloxacin. At the same time, she had blood cultures which
had gram-positive cocci. She was started empirically on
vancomycin. During one of these episodes of hypotension, she
had some [**Known lastname **] changes which were concerning for myocardial
ischemia. An EKG was done, and cardiology was consulted. They
felt that ultimately this was due to demand ischemia from her
overwhelming sepsis. They had no further suggestions other
than supportive care as tolerable.
Multiple family meetings were done, as the patient continued
to not improve. The family was present throughout multiple of
these decisions, and it was decided ultimately that she would
be made DNR pending any further results or deterioration.
After proceeding with the ultrasound and finding the
thrombosis of her portal vein, a repeat family meeting was
held, and it was decided that the patient would be made
comfort measures only. She was made comfort measures on
[**2118-3-15**] and passed away shortly thereafter.
Patient's family was present throughout the entire time, and
after the meeting was there at the time when the patient
passed away. Patient died at 1:15 p.m. on [**2118-3-15**].
The patient's family declined a postmortem evaluation at this
time.
DISCHARGE DIAGNOSES:
1. Liver failure,
2. Thrombosed portal vein.
3. Esophageal varices.
4. Abdominal aortic aneurysm status post abdominal aneurysm
repair.
5. Status post abdominal washouts.
6. Status post Vicryl mesh closure of the abdomen and VAC
placement.
7. Status post tracheostomy for respiratory failure.
8. Ventilator acquired pneumonia.
The patient passed away on [**2118-3-15**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2118-3-15**] 14:16:49
T: [**2118-3-15**] 14:55:46
Job#: [**Job Number 64974**]
|
[
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"995.91",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
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"42.33",
"96.72",
"38.91",
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icd9pcs
|
[
[
[]
]
] |
6100, 6752
|
1100, 6079
|
812, 1082
|
191, 488
|
511, 796
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,102
| 176,122
|
35448
|
Discharge summary
|
report
|
Admission Date: [**2168-3-23**] Discharge Date: [**2168-3-27**]
Date of Birth: [**2089-7-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
NSTEMI and Left hip fracture
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Treatment left intertrochanteric hip fracture with
intramedullary nail.
History of Present Illness:
Mrs. [**Known lastname 80797**] is a 78 y o f with no known past medical history who
presented to an OSH on [**3-18**] after fall/hip fracture, and was
also diagnosed with an NSTEMI. She was transferred to [**Hospital1 18**] for
cath, was initially admitted to [**Hospital Ward Name 121**] 3, but had atrial
fibrillation with rapid ventricular rate and delerium which
resulted in transfer to the CCU.
The patient initially presented to [**Hospital3 **] on [**2168-3-18**]
after a mechanical fall which resulted in a left-sided hip
fracture. The patient was sitting at a bench and tried sliding
off to get up, but the bench was shorter then anticipated, and
she fell to the floor. The husband says she had not complainted
of any chest pain, LH, shortness of breath prior to the fall. no
bowel or bladder incontinence.
On admission to OSH, patient had troponin I of 0.21 initially
thought secondary to sinus tachycardia (HR 100s). Subsequent
troponins continued to rise with peak at 1.99 at which point she
was started on asa, plavix, beta blocker, statin, and lovenox.
Cardiology was consulted and patient was transferred to the OSH
ICU. serial cardiac enzymes trended down (last 1.53). Her EKG
did not show any ST elevation but did have T wave inversions
inferolaterally that deepened throughout her admission. She was
diagnosed with a non-st elevation MI and was transferred to
[**Hospital1 18**] for cardiac catherization.
At the OSH ICU, she developed atrial fibrillation with RVR and
was treated with IV lopressor persistent RVR. She had a CXR that
showed mild diffuse interstitial edema suggestive of congestive
heart failure with a normal sized heart. A TTE showed LV
dilation, apical, septal, inferior and anterior akinesis, mild
MR, and PA pressure of 38mmHg with LVEF 20%. She received some
fluids and had a 5 point Hct drop (32->27) that was thought to
be dilutional. She was treated with one unit of pRBCs. Because
NSTEMI and afib, hip surgery was deferred for now.
The patient was transferred here for cardiac catherization
around noon today. Per report the patient recieved dilauded,
morphine and ativan the night before transfer and had been
delerious since. When she got the the floor, she was delerious,
in a fib with rvr with rates >150. She had a 5second pauses x2
and was transferred to the CCU for further management of her
cardiac issues.
On arrival to the CCU, she was a&o x2-3, complaining only of
pain in her hip, [**8-8**]. She denied chest pain, shortness of
breath, lightheadedness or any other symptoms. Her family were
at the bedside and report that her mental status was improved
since this morning, but far from baseline.
Past Medical History:
None known
Social History:
Patient is retired. She lives with her husband in [**Location (un) 686**],
MA. Until recently had been the primary care taker of her [**Age over 90 **] yo
mother who now resides in a nursing home. She smokes [**1-1**] ppd.
Drinks < 1 drink per month. Denies the use of any illicit drugs
or medications.
Family History:
Noncontributory
Physical Exam:
VS: 102 rectal, hr 112, bp 145/64, RR 27, 97% 3L
GENERAL: NAD, foggy, but no longer fankly delerious. Oriented x3
with some prompting. answere questions appropriately.
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: tachycardic, irregular. no murmurs, rubs.
LUNGS: mild bibasilar crackles, otherwise clear
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+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs
[**2168-3-23**] 06:04PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2168-3-23**] 06:04PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2168-3-23**] 06:04PM URINE RBC-[**6-8**]* WBC-[**3-3**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2168-3-23**] 06:04PM URINE GRANULAR-0-2 HYALINE-0-2 WBCCAST-<1
[**2168-3-23**] 06:04PM URINE MUCOUS-MOD
[**2168-3-23**] 02:45PM TYPE-ART PO2-75* PCO2-34* PH-7.51* TOTAL
CO2-28 BASE XS-3 INTUBATED-NOT INTUBA
[**2168-3-23**] 02:45PM LACTATE-1.4 K+-3.7
[**2168-3-23**] 02:45PM O2 SAT-95
[**2168-3-23**] 12:50PM GLUCOSE-106* UREA N-21* CREAT-0.6 SODIUM-140
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
[**2168-3-23**] 12:50PM estGFR-Using this
[**2168-3-23**] 12:50PM ALT(SGPT)-14 AST(SGOT)-22 CK(CPK)-261* ALK
PHOS-90 TOT BILI-0.6
[**2168-3-23**] 12:50PM CK-MB-5 cTropnT-0.27*
[**2168-3-23**] 12:50PM CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.0
CHOLEST-133
[**2168-3-23**] 12:50PM TRIGLYCER-114 HDL CHOL-48 CHOL/HDL-2.8
LDL(CALC)-62
[**2168-3-23**] 12:50PM WBC-11.6* RBC-3.96* HGB-10.5* HCT-32.0*
MCV-81* MCH-26.6* MCHC-32.9 RDW-13.8
[**2168-3-23**] 12:50PM PLT COUNT-175
[**2168-3-23**] 12:50PM PT-14.7* INR(PT)-1.3*
Interval/Discharge Labs
[**2168-3-24**] 06:02PM BLOOD Hct-27.5*
[**2168-3-25**] 10:47AM BLOOD WBC-12.6*# RBC-3.74* Hgb-10.4* Hct-31.0*
MCV-83 MCH-27.8 MCHC-33.5 RDW-13.8 Plt Ct-200
[**2168-3-27**] 07:00AM BLOOD WBC-10.9 RBC-4.04* Hgb-11.4* Hct-33.0*
MCV-82 MCH-28.2 MCHC-34.5 RDW-14.1 Plt Ct-234
[**2168-3-27**] 07:00AM BLOOD PT-24.2* PTT-34.4 INR(PT)-2.4*
[**2168-3-27**] 07:00AM BLOOD Glucose-92 UreaN-27* Creat-0.4 Na-142
K-3.8 Cl-107 HCO3-24 AnGap-15
[**2168-3-23**] 12:50PM BLOOD ALT-14 AST-22 CK(CPK)-261* AlkPhos-90
TotBili-0.6
[**2168-3-24**] 03:28AM BLOOD ALT-16 AST-28 LD(LDH)-302* AlkPhos-74
TotBili-0.6
[**2168-3-24**] 03:28AM BLOOD Albumin-3.1* Calcium-8.2* Phos-2.9 Mg-2.6
[**2168-3-23**] 12:50PM BLOOD Triglyc-114 HDL-48 CHOL/HD-2.8 LDLcalc-62
[**2168-3-24**] 03:28AM BLOOD TSH-<0.02*
[**2168-3-24**] 03:28AM BLOOD Free T4-2.5*
[**2168-3-25**] 04:24AM BLOOD Anti-Tg-PND Thyrogl-PND antiTPO-PND
[**2168-3-25**] 04:24AM BLOOD THYROID STIMULATING IMMUNOGLOBULIN
(TSI)-PND
Micro:
Urine cx: negative
Blood cx: pending x2
C diff: pending x1
[**3-23**] Head CT
No acute intracranial hemorrhage. MR [**Name13 (STitle) 430**] is more sensitive for
subtle lesions or small acut einfarcts. Study limited due to
motion.
[**3-24**] Cardiac Cath
Selective coronary angiography of this right dominant system
revealed
no obstructive coronary artery disease. The LMCA had no
significant
disease. The LAD had no significant disease, with the distal LAD
barely
reaching the apex. The LCX consisted of a branching intermediate
vessel
without an AV groove CX, and had no significant disease. The RCA
was a
large dominant vessel, with a proximal 20-30% hazy stenosis and
a 40-50%
stenosis in the mid portion.
[**3-24**] Echo: The left atrium is normal in size. The right atrial
pressure is indeterminate. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
anterior and septal apical hypokinesis (LVEF 40-45%). No masses
or thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
L hip Xrays: reads pending
Brief Hospital Course:
1. NSTEMI: Patient ruled in for NSTEMI with elevated troponin
1.99 at OSH and .27 here with diffuse t wave inversions on ECG
and EF 20% on OSH echo. She was given aspirin 325, plavix 75,
metoprolol IV as needed for HR as below and started on heparin
IV for ACS and monitored on telemetry. Repeat Echo showed mild
left regional systolic dysfunction with distal anterior, septal
and apical hypokinesis c/w CAD as well as mild mitral
regurgitation. EF 40%. Cardiac cath showed no focal occlusions
and there was no intervention performed. Etiology of ECG changes
and elevated biomarkers thought to be NSTEMI with either
autolysis of clot or ischemia related to spasm, or Takotsubo's
related to stress associated with fall and hip fx. She was
continued on ASA 81, beta blocker, statin, and started on low
dose ACE upon discharge. Plavix was not continued due to no
stenting.
2. Atrial Fibrillation: In am of admission had RVR as fast as
160s. On the floor she was given 5mg iv lopressor and had 5 sec
conversion pause. She had 2 more episodes in CCU but no further
episodes after PO beta blocker was uptitrated and she
subsequently remained in sinus rhythm. Amiodarone was started
for rhythm control but discontinued when TSH found to be
abnormal. Anticoagulation was started with coumadin, and INR was
up to 2.4 after one dose at 2mg, so this was held for one day
and decreased to 1mg daily. She will need close INR monitoring
as outpatient.
3. Left hip fracture: Patient had pinning of left hip yesterday,
tolerated well. Treating pain with acetaminophen, and occasional
tramadol. Regarding DVT prophylaxis, patient has a therapeutic
INR on warfarin. Will follow up in 2 weeks with orthopedics.
4. Hyperthyroidism: By labs prior to starting amiodarone.
Further testing for thyroid antibodies is pending. Patient to
follow up with endocrine as an outpatient.
5. Systolic CHF: Acuity is unclear. [**Name2 (NI) **] of 20% is low for a first
NSTEMI. Repeat echo shows improvement of EF to 40-45%, which may
represent Takutsubo??????s, stress related cardiomyopathy. Patient
did not appear hypervolemic and was not started on diuretics.
6. Delirium: Patient was A+O x3 prior to getting
dilaudid/morphine/ativan the night prior to transfer to [**Hospital1 18**].
After these medications, she became delirious, with
disorientation and agitation. Her head CT weas negative and her
mental status returned to baseline by later the following day.
Narcotics were avoided.
7. Diarrhea: Patient had 7 brown watery stools during her final
two days in the hospital. This was guaiac negative x1, the
patient had no fevers or leykocytosis, and no abdominal pain. A
C diff toxin was sent and is pending at discharge. Please call
the [**Hospital1 18**] lab at [**Telephone/Fax (1) 66600**] to follow up this result.
8. Code: Was changed during admission, with final decision to be
DNR, although okay to intubate.
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
2. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain: Try tylenol first.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold
for SBP < 100.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Please hold for SBP < 100 and/or HR < 60.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehabilitation
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. NSTEMI
2. Left Hip Fracture
3. Atrial Fibrillation
4. Hyperthyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for treatment of your hip and
your heart. For your heart, you likely had a small heart attack.
You had a cardiac catheterization performed and there was no
significant heart disease found. You were started on several new
medications listed below. For treatment of your broken hip, you
had surgery with placement of a nail to stabilize the fracture.
We started the following medications:
- Aspirin, lisinopril, metoprolol, and atorvastatin for your
heart and blood pressure.
- Warfarin to thin the blood due to atrial fibrillation, an
abnormal heart rhythm you had while in the hospital.
Please go to all follow up appointments, including regular blood
testing of your INR, which helps calculate the proper dose of
your warfarin.
Please seek immediate medical attention if you develop worsened
hip pain, chest pain, shortness of breath, back pain,
light-headedness, dizziness, passing out, fevers, shaking
chills, or night sweats.
Followup Instructions:
You will follow up with a new primary care physician, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. We will try to schedule an appointment; please call
[**Telephone/Fax (1) 250**] next week to verify an appointment.
Your new cardiologists will be Drs. [**Last Name (STitle) 171**] and [**Name5 (PTitle) **]. Again, we
will try to schedule you an appointment. Please call their
office next week at [**Telephone/Fax (1) **] to verify.
Please follow-up with Dr. [**Last Name (STitle) **] with orthopedic surgery in 2
weeks. Please call the office to schedule an appt. Phone:
[**Telephone/Fax (1) 1228**] His address is: [**Location (un) **], [**Hospital Ward Name 23**] 2
Clinical Center, park in the garage under the building.
Endocrinology: Dr. [**Last Name (STitle) **] [**5-13**] at 3:00pm.
Phone: ([**Telephone/Fax (1) 9072**] [**Location (un) 436**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Hospital Ward Name 516**], [**Hospital1 69**]
Completed by:[**2168-3-27**]
|
[
"E884.5",
"428.20",
"787.91",
"428.0",
"410.71",
"285.9",
"820.21",
"427.31",
"425.4",
"780.60",
"780.09",
"242.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.55",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
11508, 11567
|
7915, 10816
|
343, 441
|
11703, 11712
|
4225, 7892
|
12727, 13751
|
3499, 3516
|
10871, 11485
|
11588, 11588
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10842, 10848
|
11736, 12704
|
3531, 4206
|
275, 305
|
469, 3128
|
11607, 11682
|
3150, 3162
|
3178, 3482
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,187
| 194,093
|
5904
|
Discharge summary
|
report
|
Admission Date: [**2127-12-12**] Discharge Date: [**2127-12-16**]
Date of Birth: [**2076-10-23**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Motrin
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Seizures, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51yo M with h/o ETOH dependence who drinks 12 pack of beer and 1
pint of vodka daily and h/o chornic pancreatitis, h/o HCV s/p
IFN presents with seizures and abdominal pain. Pt was at
Bourwood and was noted to have seizure activities and was sent
to [**Hospital1 18**]. Pt does not recall any details but only remembers
being confused. Denies any chest pain/sob/LH/palpitations prior
to passing out.
.
On [**2127-12-12**], Pt presented to [**Hospital1 336**] for abdominal pain and was
discharged around 1pm on [**12-12**] after receiving ativan. While in
the ED at [**Name (NI) 336**], pt was noted to be on floor by tech, had fallen
foward, did not strike head, no LOC. Pt was mumbling, eyes open,
somewhat slurred speech, shaking extremities. Pt was complaining
of vision trouble. Pt was noted to have UE shaking and not
answering questions but then after shaking stopped, pt became
near instantly conversational. CT head was obtained and was
negative. Psych was consulted and was sent to [**Hospital1 **]. There,
pt had an episode as above. No previous seizures h/o or DT per
pt. Denies auditory/visual hallucination.
.
Pt reports his abdominal pain feels like previous "pancreatitis"
pain. Last ETOH on [**12-11**] with 12 beer and "some whiskey." +
anorexia and nausea but no vomiting. No fevers, chills, or bowel
habit changes.
.
In the [**Name (NI) **], pt received morphine, valium, and zofran.
.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, chest pain or
tightness, palpitations. Denies vomiting, diarrhea, or
constipation. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
ETOH use
HTN
COPD
Depression, treated with ECT never had suicide attempt in the
past.
Pancreatitis
Anxiety
Autoimmune demyelinating neuropathy- tx with IVig
Hepatitis C tx with IFN
Lumbar disc surgery
Social History:
Pt lives alone. Worked in electronics and as a musician. Last
worked 4 months ago in computers. Has one son who is 27 yrs old.
Divorced on SSDI. Smokes 1 ppd x 30 years, Drinks 12 pack and 1
pint of vodka a day. Longest sobriety ~2wks in detox in [**2099**].
Has been to AA in the past.
Family History:
Brother with anxiety, mother with depression.
Physical Exam:
VS: 98.2, 92, 130/84, 18, 96% on RA, abdominal pain [**8-17**]
Gen: NAD, appears comfortable
HEENT: NCAT, EOMI, PERRL. Anicteric, no conjunctival pallor. OP
clear, MMM.
Neck: No JVD, no LAD
Cor: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: soft +BS, NT/ND, No HSM
Extrem: no c/c/e
Skin: no rashes
Neuro: CN II-XII in tact bilaterally. Strength is [**5-12**] in upper
and lower extremities. Diminished sensation of L face to light
touch (old per pt) and decreased sensation of upper extremities
from fingers to elbow bilaterally (not new) + tremor. A&Ox3.
Pertinent Results:
[**2127-12-12**] 08:55PM BLOOD WBC-4.9 RBC-4.23* Hgb-12.3* Hct-35.5*
MCV-84 MCH-29.1 MCHC-34.6 RDW-14.5 Plt Ct-287
[**2127-12-12**] 08:55PM BLOOD Neuts-65 Bands-0 Lymphs-31 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2127-12-13**] 06:50AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0
[**2127-12-14**] 05:00AM BLOOD ESR-23*
[**2127-12-13**] 06:50AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-141
K-3.6 Cl-105 HCO3-28 AnGap-12
[**2127-12-12**] 08:55PM BLOOD ALT-26 AST-70* AlkPhos-58 TotBili-0.4
[**2127-12-13**] 06:50AM BLOOD ALT-18 AST-38
[**2127-12-12**] 08:55PM BLOOD TotProt-7.1 Albumin-4.2 Globuln-2.9
Calcium-9.1 Phos-2.1* Mg-2.2
[**2127-12-13**] 10:20AM BLOOD Iron-221*
[**2127-12-12**] 08:55PM BLOOD Lipase-46
[**2127-12-16**] 07:10AM BLOOD Lipase-31
[**2127-12-13**] 10:20AM BLOOD calTIBC-339 VitB12-275 Folate->20
Ferritn-57 TRF-261
[**2127-12-14**] 05:00AM BLOOD %HbA1c-5.5
[**2127-12-13**] 10:20AM BLOOD Prolact-21* TSH-2.2
[**2127-12-14**] 05:00AM BLOOD CRP-1.7
[**2127-12-14**] 05:00AM BLOOD PEP-POLYCLONAL IgG-1010 IgA-426* IgM-178
[**2127-12-12**] 09:03PM BLOOD Glucose-128* Na-136 K-7.7* Cl-100
calHCO3-27
[**2127-12-12**] 08:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-12-14**] 08:33AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2127-12-14**] 08:33AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
.
Micro: None new.
.
Imaging:
CT head non-contrast ([**2127-12-12**]): No acute intracranial process.
Sinus disease as described above.
.
EEG with video monitoring ([**2128-12-14**]): Final report pending.
Interpretation by neuro was that episodes of shaking show no
correlated signs of seizure acitivty on EEG.
Brief Hospital Course:
The patient was admitted with concern for alcohol withdrawal and
seizure activity. Admission labs were notable for low grade
anemia to Hct 34 otherwise normal electrolytes, LFT's and
pancreatic enzymes. Non-contrast head CT was negative for
bleeding. The patient was placed on a CIWA scale with valium.
The patient had clinical signs of good control of withdrawal
symptoms including normal heartrate and blood pressure and only
minimal tremulousness throughout his hospitalization.
The patient had numerous episodes of unresponsiveness
characterized by rigid, low frequency shaking of the upper and
lower extremities. These episodes were witnessed by both the
primary medical team and the neurology consult service.
Initially there was concern for EtOH withdrawal seizures.
Ultimately these were deemed to be pseudoseizures. This was
confirmed by EEG with video monitoring which revealed no seizure
activity at the time of the events, reviewed by the neurology
consult team. Initially the patient was treated with IV ativan
during these episodes with rapid resolution of his symptoms.
Later in his hospitalization he received IV saline with similar
rapid resolution of symptoms. These episodes last for up to 15
minutes without intervention before spontaneously remitting.
When these episodes end there is rapid return of interactive,
appropriately oriented mentation within seconds to minutes.
Sometimes the patient appears confused within the first minute
after an episode. He has no incontinence or tongue biting.
The patient was confirmed to have polysubstance abuse on urine
tox screen including cocaine positive status. This test was also
positive for benzo's and opiates after the patient received
benzo's as part of CIWA scale and morphine as part treatment for
abdominal pain.
The patient complained of severe abdominal pain. Initially there
was concern for pancreatitis in the setting of EtOH use however
the patient had normal pancreatic enzymes and abdominal exam was
entirely benign. He initially received narcotic pain medications
however he does not require ongoing narcotics.
Anemia. Presumed secondary to chronic alcohol use. Iron studies,
B12 and folate were within normal limits. The patient can have
further work-up as an outpatient.
As work-up for lower extremity neuropathy noted on neurology
consultation, the patient had HgbA1c at goal, normal TSH. SPEP
was notable for a polyclonal hypergammaglobulinemia and UPEP was
normal. CRP was normal and ESR was mildly elevated at 23. This
can be further evaluated as an outpatient.
For his history of hypertension, the patient was continued on
home clonidine.
Depression. The patient was continued on his outpatient
antidepressant regimen. He requested to be DNR/DNI. This should
be further addressed during psychiatric care after discharge.
The patient was medically cleared for discharge on [**2127-12-16**].
Medications on Admission:
Klonipin 1mg [**Hospital1 **]/prn
Clonidine 0.1mg [**Hospital1 **]
Prilosec 20mg qday
Neurontin 900mg QID per pt
[**Name (NI) 23314**] 60mg qday but not taking
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QID (4
times a day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q3H PRN (): For
CIWA>10.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Alcohol withdrawal
Polysubstance abuse
Pseudoseizures
Depression
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with alcohol withdrawal. Please continue to
receive valium as needed for withdrawal symptoms. You will
continue to receive psychiatry care regarding alcohol and
cocaine use.
There was concern for seizures but these are pseudoseizures
likely due to psychiatric disease. You will continue to receive
psychiatry care after discharge.
You complained of abdominal pain during your hospitalization.
There were no signs of pancreatitis on lab work.
You will contine to receive care at an inpatient psychiatry
facility.
Take all medications as prescribed.
Call your doctor or return to the hospital for any new or
worsening nausea, vomiting, loss of consciousness or any other
concerning symptoms.
Followup Instructions:
You will contine to receive care at an inpatient psychiatry
facility.
After discharge from this facility, you should schedule new
primary care. If you would like to be seen at [**Hospital1 771**], call [**Telephone/Fax (1) **].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
|
[
"305.60",
"070.54",
"577.1",
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"496",
"291.81",
"303.91",
"577.0",
"401.9",
"305.50",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8891, 8906
|
5053, 7940
|
305, 312
|
9029, 9038
|
3274, 5030
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2644, 2691
|
8150, 8868
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7966, 8127
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2706, 3255
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241, 267
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340, 2100
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2122, 2324
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2340, 2628
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,065
| 137,855
|
39857+58331
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-12-5**] Discharge Date: [**2125-1-11**]
Date of Birth: [**2085-1-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Cardiogenic shock
Major Surgical or Invasive Procedure:
Intraortic ballon pump placement and removal
Tandem Heart placement and removal
Arterial-line placement and removal
Central-line placement and removal
Hemicraniectomy
Intubation and extubation
Tracheotomy
PEG tube placement
PICC line placement
History of Present Illness:
39 yo male with history of IDDM, HTN, [**Hospital 85819**] transferred from [**Hospital 64110**] for cardiogenic shock. Per the patient's family,
he was experiencing "flulike" symptoms for the past 5 days
including nausea, weakness, and low grade fevers. He reported
orthopnea and nausea with lying flat to his fiance. Today, he
felt worsening dyspnea and chest pain, so called EMS. The
patient was found by EMS to be ashen, diaphoretic, dyspneic and
near syncopal.
.
Initial vitals at OSH: Afebrile, HR 74, RR 24, BP 117/77 92% on
100 BiPAP. EKG revealed lateral ST depressions (I, aVL, V5-V6)
and ST elevation in III, q waves in III but not III or AvF.
Stat echo with EF of 30% distal septal, apical and
anterior/lateral wall akinesis with evidence of LV thrombus,
mild MR, mild TR. His labs were significant for ABG of
7.36/31/46/17.5 (on BiPAP), WBC 18.3, Hct 34.5, Lactic acid 3.8,
Crn 3.8, Trop I 3.85. CXR revealed bilateral nonspecific
airspace disease with likely consolidation of the left middle
lobe. He was given lasix 40mg IV, levophed drip, zosyn 3.375mg,
vancomycin 1gm, ASA 325mg, and heparin drip. PICC was placed.
Cardiology was [**Name (NI) 653**], and he was planned to be admitted to
the CCU. However, as he decompensated on BiPAP PaO2 in 40s, he
was intubated with PEEP 10 and 100% with a PAO2 in the 70-80's.
He was sedated with versed and fentanyl on transfer via
[**Location (un) **].
.
On arrival to the cath lab, the patient was significantly
hypoxic to the low 80s. FiO2 maintained at 100% and increased
PEEP to 14, however ABG revealed persistent hypoxia with PO2 of
63-66. An IABP was placed with marginal improvement in
hemodynamics and oxygenation. Left heart cath revealed LMCA no
CAD, LAD diffuse disease with prox ulcerated 90% and distal 70%,
LCx prox 80%, occluded OM1, OM2 60% prox, TO prox RCA with
collaterals from the left. He received three BMS, one to LAD,
one to LCx and one to OM1. He received a total of 200mg IV
lasix with appropriate urine output, 600mg PO plavix, 10units of
regular insulin. As the patient's oxygen saturation did not
improve with IABP and intervention, TandemHeart was placed. His
oxygenation and PCWP (39-22) improved dramatically after this
intervention. He was maintained on levophed and dobutamine.
Levophed was discontinued prior to transfer.
.
ROS could not be obtained as patient is intubated. As per OSH
records: positive for nausea, vomiting, weakness, decreasing
appetite, some chest pressure.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY: none
.
Social History:
-Tobacco history: quit 10 years ago
-ETOH: 7 beers/drinks per day
-Illicit drugs: current marijuana use, cocaine quit 5 years ago
Family History:
Mother has diabetes. Father is deceased, had diabetes, renal
failure and CAD.
Physical Exam:
Physical exam on admission
GENERAL: intubated, sedated, paralyzed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: unable to assess
CARDIAC: distant heart sounds, [**1-28**] holosystolic murmur
LUNGS: bilateral crackles, coarse breath sounds bl.
ABDOMEN: distended, obese, soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits. sheaths, PICC and a
line in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1 PT 1
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1 PT 1
.
Physical exam on discharge:
VS: T: 99 HR:100 BP:109/67 O2: 95
GENERAL: trached, responsive to verbal stimuli and blinking eyes
to command and raising arm/wiggling fingers/toes to command
HEENT: Pupils sluggish to light, EOMI. Tracks midline. right
sided craniotomy incision C/D/I with notablly soft to palpation
on right side of scalp
CARDIAC: Tachycardic,, nl s1/s2, difficult to appreciate any
murmurs. Cannot assess for JVP
LUNGS: Coarse b/s bilaterally
ABDOMEN: distended, obese, soft, distended, Pt wiggles fingers
when asked if he has abdominal tenderness to palpation. PEG site
mid left abdomen dressing c/d/I, cholecystostomy site RUQ also
c/d/I draining dark green bile
EXT: 1+ distal pulses, [**12-24**]+ edema to the shin BL
SKIN: Rash on chest and right groin. Ecchymoses in epigastric
region. Left hip blister with skin breakdown. No drainage
currently. Also with sacral decub ulcer stage 2
Neuro: moves right arm spontaneously, wiggles fingers,, blinks
to command
Pertinent Results:
Labs on admission:
[**2124-12-5**] 07:50PM PLT COUNT-393
[**2124-12-5**] 07:50PM NEUTS-88.8* LYMPHS-6.5* MONOS-4.1 EOS-0.4
BASOS-0.3
[**2124-12-5**] 07:50PM WBC-17.8* RBC-3.66* HGB-10.6* HCT-31.6*
MCV-87 MCH-29.1 MCHC-33.6 RDW-13.2
[**2124-12-5**] 07:50PM %HbA1c-8.5* eAG-197*
[**2124-12-5**] 07:50PM VIT B12-557
[**2124-12-5**] 07:50PM ALBUMIN-2.9* CALCIUM-7.9*
[**2124-12-5**] 07:50PM CK-MB-10 MB INDX-7.2* cTropnT-1.23*
[**2124-12-5**] 07:50PM ALT(SGPT)-92* AST(SGOT)-175* CK(CPK)-139 ALK
PHOS-62 AMYLASE-23 TOT BILI-0.5 DIR BILI-0.3 INDIR BIL-0.2
[**2124-12-5**] 07:50PM estGFR-Using this
[**2124-12-5**] 07:50PM GLUCOSE-330* UREA N-78* CREAT-4.1*
SODIUM-132* POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-17* ANION
GAP-23*
[**2124-12-5**] 07:57PM freeCa-1.06*
[**2124-12-5**] 07:57PM HGB-10.8* calcHCT-32 O2 SAT-84
[**2124-12-5**] 07:57PM GLUCOSE-320* LACTATE-1.3 K+-4.2 CL--98*
[**2124-12-5**] 07:57PM TYPE-ART TIDAL VOL-450 PO2-63* PCO2-47*
PH-7.24* TOTAL CO2-21 BASE XS--7 -ASSIST/CON INTUBATED-INTUBATED
[**2124-12-5**] 09:04PM HGB-10.8* calcHCT-32 O2 SAT-86
[**2124-12-5**] 09:04PM TYPE-ART TIDAL VOL-400 PEEP-10 O2-100 PO2-66*
PCO2-42 PH-7.27* TOTAL CO2-20* BASE XS--7 AADO2-605 REQ O2-99
-ASSIST/CON INTUBATED-INTUBATED
[**2124-12-5**] 10:01PM O2 SAT-94
[**2124-12-5**] 10:01PM TYPE-ART TIDAL VOL-450 PEEP-20 O2-90 PO2-94
PCO2-42 PH-7.28* TOTAL CO2-21 BASE XS--6 AADO2-506 REQ O2-85
-ASSIST/CON INTUBATED-INTUBATED
.
Labs on discharge:
[**2125-1-11**] 06:06AM BLOOD WBC-10.5 RBC-2.91* Hgb-8.4* Hct-26.3*
MCV-90 MCH-28.8 MCHC-31.9 RDW-15.9* Plt Ct-352
[**2125-1-11**] 06:06AM BLOOD PT-22.6* PTT-49.2* INR(PT)-2.1*
[**2124-12-14**] 10:50PM BLOOD Fibrino-669*
[**2124-12-27**] 03:28AM BLOOD Ret Aut-2.7
[**2125-1-7**] 02:10AM BLOOD Heparin-0.62
[**2125-1-11**] 06:06AM BLOOD Glucose-159* UreaN-62* Creat-1.2 Na-138
K-4.0 Cl-100 HCO3-28 AnGap-14
[**2125-1-8**] 03:15AM BLOOD ALT-39 AST-28 LD(LDH)-448* AlkPhos-179*
TotBili-0.4
[**2124-12-22**] 03:35AM BLOOD CK-MB-7 cTropnT-4.20*
[**2124-12-21**] 03:53AM BLOOD CK-MB-21* MB Indx-2.6 cTropnT-5.35*
proBNP-[**Numeric Identifier **]*
[**2124-12-20**] 08:30AM BLOOD CK-MB-28* MB Indx-4.6 cTropnT-4.00*
proBNP-[**Numeric Identifier **]*
[**2124-12-6**] 05:15AM BLOOD CK-MB-17* MB Indx-7.2* cTropnT-2.24*
[**2125-1-11**] 06:06AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.3
[**2124-12-27**] 03:28AM BLOOD Hapto-513*
[**2124-12-5**] 07:50PM BLOOD %HbA1c-8.5* eAG-197*
[**2124-12-6**] 01:15AM BLOOD Triglyc-197* HDL-19 CHOL/HD-5.9
LDLcalc-54
[**2125-1-11**] 06:06AM BLOOD Vanco-18.4
.
ECHO [**2124-12-6**]:Overall left ventricular systolic function is
severely depressed (LVEF= 15-20 %). A left ventricular
mass/thrombus cannot be excluded. Right ventricular chamber size
and free wall motion are normal. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Compared with the prior study
(images reviewed) of [**2124-12-6**], spontaneous echo contrast is
seen in the left ventricle. The degrees of mitral and tricupsid
regurgitation and pulmonary hypertension have increased. The
other findings are similar.
CT HEAD [**12-10**]: IMPRESSION:
1. Large right middle cerebral artery territory infarction
involving both
divisions, with diffuse right cerebral hemispheric swelling and
mass effect on the right frontal [**Doctor Last Name 534**], with a 3-mm leftward
shift of midline structures. No hemorrhage detected. 3. Pan
sinus opacification, likely relates to the endotracheal
intubation.
CT HEAD [**12-11**]: 1. Stable-appearing large right MCA infarct with
no evidence of hemorrhagic conversion. 2. Stable leftward shift
of normally midline structures.
CT HEAD [**12-14**]:
1. New right uncal herniation, increased leftward shift of
normally midline structures with increased trapping of the left
lateral ventricle, increased effacement of the right lateral
ventricle and basal cisterns.
2. Right MCA territory infarct with few punctate foci of
[**Month/Year (2) 13215**], which could represent petechial changes versus
relative [**Name (NI) 13215**] of preserved cortex within the area of
hypodense infarct.
CT HEAD [**1-1**]:
IMPRESSION:
1. Evolving right MCA infarction with hemorrhagic
transformation.
2. Unchanged small focus of hemorrhage and extracranial soft
tissues
overlying the craniectomy site.
3. Slight decrease in previously noted degree of midline shift.
4. Increased opacification of ethmoid air cells, sphenoid sinus,
and frontal
sinus compared to prior.
CT TORSO [**12-14**]:
IMPRESSIONS:
1. Bilateral predominantly lower lobe consolidations probably
represent
combination of atelectasis, aspiration, and/or infection. 2.
Small bilateral pleural effusions. 3. Subtle wedge-shaped
hypodense regions in the spleen suggest splenic infarct. 4.
Atherosclerotic calcifications, notable for the patient's age.
LAD and LCX coronary artery stents in place.
CT TORSO [**1-1**]:
IMPRESSION:
1. Interval progression of extensive pulmonary consolidation,
compatible
with pneumonia. Moderate bilateral pleural effusions have
minimally increased since the earlier study of [**2124-12-14**].
2. No organized intra-abdominal fluid collections to suggest
abscess. Small amount of ascites. 3. Stable appearance of the
splenic infarct.
CT ABD/PELVIS [**1-5**]:
IMPRESSION:
1. No perihepatic fluid or evidence of perihepatic hemorrhage.
2. Small amount of simple intra-abdominal ascites layering
within the pelvis. 3. Bilateral moderate right greater than left
pleural effusions. Stable bilateral lower lobe consolidation. 4.
Stable splenic infarction.
GALLBLADDER U/S [**1-7**]:
Uncomplicated percutaneous cholecystostomy tube placement.
Catheter should
remain in place for minimum of three to four weeks to allow
tract maturation prior to removal.
.
ECHOCARDIOGRAM [**12-26**]:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. A large thrombus is seen in the left ventricle (~1.5
x 1.7 cm). Left ventricular systolic function is severely
depressed with inferior hypokinesis/akinesis and mid to distal
septal akinesis and apical akinesis/dyskinesis. Right
ventricular chamber size is normal with depressed free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared to the prior report (study unavailable for review) of
[**2124-12-20**], left ventricular systolic function is now more
depressed.
.
CORONARY CATHETERIZATION [**12-5**]:
COMMENTS:
1. Successful PCI to LAD and Cx lesions with BMS for patient in
cardiogenic shock.
2. Successful placement of Tandem Heart left ventricular support
device.
3. Aspirin indefinitely.
4. Plavix 75mg daily for 1 month.
5. Wean vasopressors as tolerated.
6. Goal ACT greater than 200. Check ACT per tandem heart
protocol.
7. Follow urine output and oxygenation.
8. Venous catheter is positioned at 53.6cm
9. Selective coronary angiography of this right dominant system
demonstrated three vessel coronary artery disease. The LMCA had
no
angiographically-apparent CAD. The LAD had diffuse disease,
with a
proximal ulcerated 90% lesion and and a distal 70% stenosis.
The LCx
had a proximal 80% lesion with diffuse disease distally. The
OM1 was
occluded and an OM2 had a 60% proximal stenosis. The RCA was
totally
occluded proximally.
10. Resting hemodynamics revealed severe right ventricular
filling
pressure, with an RVEDP of 32 mmHg. This is likely secondary to
left
heart failure, with a mean PCWP of 39 mmHg. Left heart
catheterization
was avoided due to LV thrombus in [**Hospital 8050**] hospital echo. While
cardiac
index was 2.2 L/min/m2 on 3 pressors, the patient was markedly
hypoxic
and had a low SVO2 saturation. After intervention and insertion
of
Tandem Heart support, pressors were weened and oxygentation
improved.
PCWP reduced to 22 mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery with PCI to LAD, LCx, and OM2.
2. Cardiogenic shock with severely elevated left and right
sided
filling pressures.
3. Severe hypoxemia.
4. Successful insertion of a Tandem Heart support device.
.
MICROBIOLOGY:
- BRONCHOALVEOLAR LAVAGE ([**2125-1-2**]):
GRAM STAIN (Final [**2125-1-2**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2125-1-8**]):
Commensal Respiratory Flora Absent.
YEAST. ~6OOO/ML.
FUNGAL CULTURE (Preliminary):
YEAST.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2125-1-3**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED
.
- Urine culture ([**2125-1-6**]): No growth
.
- Blood culures: multiple, all negative.
-C diff from [**12-21**], [**12-27**], [**12-28**], [**1-1**] all negative
.
PENDING LABS ON DISCHARGE (to be followed-up by nursing facility
- Blood culture ([**2125-1-6**]): pending
Brief Hospital Course:
39 yo male with history of IDDM, HTN, HLD, admitted with
cardiogenic shock in setting of NSTEMI with hospital course
complicated by stroke with hemmorhagic conversion and residual
left sided paralysis, left ventricular thrombus, [**Last Name (un) **],
cholecysitis
He was initially transferred from [**Hospital6 17183**] for NSTEMI
and cardiogenic shock on [**12-5**]. He initially underwent cardiac
cath where he was found to have severe diffuse 3VD and had BMS
to LAD and Cx lesions. This was complicated by worsening
cardiogenic shock requiring intra-aortic balloon pump and after,
when no improvement was seen in cardiac function, a Tandem Heart
LVAD was placed. He was paralyzed while on the Tandem Heart and
when taken off paralysis, it was noted he left sided weakness.
CT head [**12-10**] showed a large R MCA infarct w/ 3mm midline shift.
TTE done at that time showed large LV thrombus and an EF of 35%.
Neurology was consulted and it was decided to continue
anticoagulation. Serial head CTs the next 2 days showed that the
infarct was stable and no evidence of hemorrhagic conversion but
on [**12-14**] CT head showed worsening midline shift and uncal
herniation. He then underwent R hemicraniectomy for urgent
decompression [**12-14**]. He remains on heparin ggt given high risk
for thromboembolism. His course was also complicated by NSTEMI
(up-trending CE's on [**12-19**]), respiratory failure, acute renal
failure, and persistent fevers.
Mr [**Known lastname 87697**] was intubated for approximately 3 weeks due to volume
overload and ventilator acquired pneumonias before undergoing
tracheostomy and PEG placement for persistent ventilator
dependence. During his hospitalization underwent a complete 14
day course of Vancomycin and Meropenem for fevers without
identified source. However, upon completion of the course he
continued to spike daily fevers. CT Torso reveled persistent
VAP afte which BAL was performed, but cultures all showed no
growth. He was restarted on Vanco and Meropenem for treatment
of VAP as seen on CT scan. At the time of his discharge he was
weaned from a vent requiring only a trach mask. He continues to
have some difficulty with secretions.
His fever workup also included a HIDA scan which confirmed
acalculus cholecystitis for which percutaneous cholecystostomy
was placed ([**2125-1-5**]) which should remain in place for four
weeks. Follow up with interventional radiology has already been
arranged. Post drain placement, pt was noted to have a small
drop in Hct to nadir of 24. Ct of the abdomen showed no
evidence of bleed. His Hct has since remained stable at 26 at
the time of discharge. All cultures to date have been negative.
Vancomycin and Meropenem are to continue through [**2125-1-15**] to
complete a 10 day course. Vanco goal trough is 15-20. He has a
PICC line placed in the left arm which can be removed after
antibiotic treatment and IV diuresis is complete.
Patient continues to suffer from severe cardiomyopathy with EF
of 15%. During his hospitalization he developed acute renal
failure due to poor cardiac output in the setting of cardiogenic
shock, then volume overload. His creatinine improved with
diuresis and he did not require any renal replacement therapy.
At time of discharge creatinine was approximately 1.0. He is
being discharged on 80mg IV lasix twice daily, which may require
titration based on his overall volume status and converted to
oral. Renal function and electrolytes should be monitored
regularly. Systolic blood pressures have been 100-130 on his
current regimen of antihypertensive therapy metoprolol 50mg q6h,
lisinopril 10 mg daily and should be titrated to maintain tight
BP control.
At present Mr [**Known lastname 87697**] will require continued antiplatelet therapy
and anticoagulation (INR goal [**1-25**])given his severe CAD and LV
thrombus. His neurological prognosis suggests good recovery of
his right side with aggressive rehabilitation. It is unlikely
he will regain function of his left side. Higher cortical
prognosis is unclear at this point. He is now awake and
responding to commands and able to move his right side, but
remains hemiparetic on the left. He is still unable to verbally
communicate. He has occasional episodes of anxiety/agitation
for which psychiatry has recommended Haldol 5 mg QID, Quetiapine
Fumarate 50 mg qhs, and Lorazepam 1-2 mg PO/NG Q4H:PRN. When
agitated he often moves his right arm up and down occassionally
banging the side rail and pulling at tubes and lines. He is to
follow up with neurology and neurosurgery as outpatient. He is
to continue Keppra for several months, extact time course to be
determined by neurology, for seizure prophylaxis. His QTc was
able and on discharge EKG was 458 ms.
Mr [**Known lastname 87697**] developed several skin injuries due to limitations of
positioning for most of his hospitalization (due to craniotomy).
He has a healing blister on his left hip. He also has a stage
II sacral decubitus ulcer. He will require frequent turning as
well as Vitamin A and Zinc. He is unable to close his left eye
which is prone to corneal abrasion. He requires a protective
topical barrier applied to the eyes as noted in the medication
list. He should not sleep with his head down on the right side
to prevent brain injury. Pt is able to get out of bed and work
with physical therapy, however will require a helmet at all
times when out of bed.
Pt's diabetes has been managed aggressively, he is currently on
Glargine 30U qAM and 25q PM with a conservative Regular insulin
sliding scale. His tube feeding has consisted of boost glucose
control which he has tolerated well.
# Code status: Pt is DNR. He is currently trached.
Medications on Admission:
1. Amytriptyline 75mg Daily
2. Aspirin 81 daily
3. Atenolol 50 daily
4. Citalopram 60 daily
5. Clonidine 0.1mg [**Hospital1 **]
6. esomeprazole 40 daily
7. fenofibrate 145 qhs
8. HCTZ 25mg daily
9. Insulin detemir (levemir) 60 intis 9am, 65 9pm
10. Lispro 18 before bkfst and lunch, 22 dinner
11. Nifedipine 60mg [**Hospital1 **]
12. rosurvastatin 10 daily
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
3. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H
(every 6 hours) as needed for temp>101.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. levetiracetam 100 mg/mL Solution [**Hospital1 **]: One (1) PO BID (2
times a day).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
SOB/wheeze.
9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/wheeze.
10. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Last Name (STitle) **]: One
(1) Appl Ophthalmic QID (4 times a day).
11. hydralazine 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H PRN ()
as needed for SBP>140.
12. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet, Chewable
PO DAILY (Daily).
14. atorvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
15. citalopram 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
16. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily) for 10 days.
17. vitamin A 10,000 unit Capsule [**Last Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily).
18. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Thirty (30) units
Subcutaneous qam.
19. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Twenty Five (25) units
Subcutaneous qpm.
20. ascorbic acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
21. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours).
22. warfarin 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4
PM.
23. quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime) as needed for AGITATION.
24. lisinopril 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
25. lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
26. haloperidol 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times
a day) as needed for agitation.
27. meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q6H (every 6 hours): to be completed on [**1-15**].
28. furosemide 10 mg/mL Solution [**Month/Year (2) **]: Eighty (80) mg Injection
[**Hospital1 **] (2 times a day).
29. insulin regular human 100 unit/mL Solution Injection
30. vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) g
Intravenous once a day for 1 days: dose based by level. To be
completed [**1-15**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Non-ST elevation myocardial infarction
Cardiogenic shock
Congestive heart failure
Respiratory failure
Pneumonia
Acalculous cholecystitis
Right MCA infact with hemorrhagic conversion
Acute renal failure
Normocytic Anemia
Insulin-dependent diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound but ok to sit in chair with assist
Discharge Instructions:
Mr. [**Known lastname 87697**], you were admitted to the [**Hospital1 827**] because you had a heart attack. Your heart was
not pumping well and we had to put you on devices to assist your
heart. There was a clot in your heart which went to your brain,
leading to a stroke. You developed bleeding and swelling in your
brain and had part of your skull removed to decompress you
brain. You developed an infection of your gallbladder and we
treated you with antibiotics and placed a drain to remove bile.
You developed swelling all over your body, but we were able to
remove the excess fluid with medications. You were on a
breathing machine for a long time, but eventually you were able
to breath through a hole in your trachea that was placed. You
are fed through a tube that goes to your stomach. We also
treated you for a pneumonia with antibiotics. Because you had a
heart attack and also had a clot in your heart, you will need to
remain on a blood thinner called Coumadin for the rest of your
life. You will be going to a long-term acute care facility after
discharge.
.
You will follow-up appointments with Neurology, Cardiology,
Interventional Radiology, and Neurosurgery after discharge, as
listed below.
.
We made the following changes to you medications:
STOPPED:
-Amitriptyline 75 mg daily
-Atenolol 50 mg daily
-Clonidine 0.1 mg twice a day
-Esomeprazole 40 mg daily
-Fenofibrate 145 mg at night
-Hydrochlorothiazide 25 mg daily
-Nifedipine 60 mg twice a day
-Rosurvastatin 10 mg daily
.
STARTED:
-Albuterol Inhaler and [**Doctor First Name **] as needed
-Artificial tear ointment 1 application to left eye four times a
day
-Ascorbic acid 500 mg twice a day
-Atorvastatin 80 mg daily
-Bisacodyl 10mg daily
-Clopidogrel 75 mg per day
-Docusate liquid 100mg twice a day
-Furosemide 80 mg IV twice a day
-Haloperidol 5 mg by mouth four times a day
-hydralazine 20 mg by mouth every 6 hours as needed for sBP >140
-ipratropium bromide MDI as needed
-Lansoprazole 30 mg daily
-Levetiracetam oral 1000 mg po twice a day (to be continued for
until [**2125-4-22**])
-Lisinopril 10 mg daily
-lorazepam 1-2 mg po every 4 hours as needed for anxiety
-meropenem 500 mg IV every 6 hours (to continue until [**2125-1-15**])
-vancomycin 1000 mg IV every 24 hours (to continue until
[**2125-1-15**])
-metoprolol tartrate 50 mg every 6 hrs
-metolazone 5 mg daily
-oxycodone 5 mg every 6 hours as needed for pain
-quetiapine 50 mg by mouth as night
-warfarin 10 mg daily at 4 PM
-zinc sulfate 220 mg daily
.
CHANGED:
-Aspirin 81 mg to 162 mg daily
-Citalopram 60 mg to 20 mg daily
-Insulin Glargine 30 units in morning and 25 units at night
(changed from Insulin detemir 60 units in morning and 65 units
at night)
-Regular Insulin sliding scale (chnaged from Lispro 18 for
breakfast and lunch, 22 at dinner)
-
-
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2125-2-5**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: TUESDAY [**2125-2-6**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2125-2-6**] at 1 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**2125-3-20**] 01:00p [**Last Name (LF) **],[**First Name3 (LF) **]
[**Hospital6 29**], [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
Name: [**Known lastname 9146**],[**Known firstname **] Unit No: [**Numeric Identifier 13917**]
Admission Date: [**2124-12-5**] Discharge Date: [**2125-1-11**]
Date of Birth: [**2085-1-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13918**]
Addendum:
Medication listed in the d/c summary has two notable changes:
1) Vancomycin is to be given 1gm q48 hours, next dose to be
administered [**1-13**].
2) Metoprolol dose was reduced to 25mg q6h. Please hold for SBP
< 100, HR < 55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] [**Hospital **] Hospital - [**Location (un) 2653**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 13919**]
Completed by:[**2125-1-11**]
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3258, 3267
|
3127, 3200
|
3283, 3417
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,572
| 184,613
|
25670
|
Discharge summary
|
report
|
Admission Date: [**2102-8-5**] Discharge Date: [**2102-8-23**]
Date of Birth: [**2037-9-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 33596**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
1. Thoracocentesis
2. Bronchoscopy
3. PICC placement R Arm
4. pessary fitting
History of Present Illness:
65 year old woman who came to the ED in [**Location (un) 620**] with dyspnea,
dysuria and bony pain. She was essentially healthy until 2 weeks
ago when she developed symptoms of urinary burning and also
developed problems with fatigue. However, she was able to
function normally and then a few days ago developed significant
[**Last Name **] problem and had been using some Advil and bone compresses.
The problem continued with significant fatigue over the past 24
hours and she came to the emergency room. She was also feeling
mild degree of dyspnea, which was relieved with a nonrebreathing
mask.
Her exam was notable for tachycardia and peripheral cyanosis.
She was also found to have severe uterine prolapse. She denied
any symptoms of chest pain, back pain or abdominal pain. She was
started on Levofloxacin, Gentamicin and Flagyl. Her respiratory
status worsened over few hours and she was intubated (AC, RR26,
FiO2 39, PEEP 5, TV450). Her blood gas showed a ph 7.31, pCO2
32, pO2 221, HCO3 15.6. Her CXR was suggestive for ARDS. She
also developped acute renal failure with a Creatinine of 4.0.
Her systolic blood pressure was found to be in the fifties. She
was given 7 liters of fluid and was started on Levophed and
Vasopressin. She was admitted to the MICU with the diagnosis of
urospesis. An A-line and a RJ-central line was placed. The was
Pt was found to have an elevated troponin 141 > 200 and CK 1300
> 1700 without apparent EKG-changes. She was started on Aspirin,
Heparin gtt and Plavix. Her blood gas at that time showed a pH
of 7.3, pCO2 17, PO2 119, HCO3 8.4. She was given 2amp of
bicarbonate and received more Bicarbonate ? on the transfer to
[**Hospital1 18**]. Her second showed worsened pulmoary edema. The urine
culture grew out E.coli and Proteus mirabilis. Her blood culture
was positive for gram-negative rods,presumptive E.coli,
pan-sensitive. The pt was started on Rocephin 2mg [**Hospital1 **] and all
other Abx were discontinued. An US of the abdomen showed:
multiple non-obstructive calculi in the left kidney and bladder,
small echogenic left kidney and cholelithiasis. The pt also
experienced one episode of Vtach 5 beats, but was asymptomatic.
The VS at that time were T 100.2, HR 80s, CVP 11. She was given
2 L of fluids in the ICU.
The decision was made to tranfer her to the [**Hospital1 18**]. She received
11 L up to now.
Past Medical History:
Essentially quite unremarkable. She has had a history of
hemorrhoids.
She has not seen a physician in almost 10 years.
Social History:
works for [**Company 38877**], is a nonsmoker,lives with her
husband. two children
Family History:
Her son does have a history of asthma.
Physical Exam:
Gen: NAD, intubated, unresponsive
HEENT: ET in place, pupils pinpoint with brisk reaction to
light, no JVD visible, periorbital edema
Lungs: mild LLL crackles
Heart: S1 normal, S2 gallop best heard over ICR 2 L, RR,
relative bradycardia
Abd: soft, nt, mildly distended, hyporeactive bowel sounds
Ext: mild distal cyanosis of fingertips and foot soles, toes,
sacral edema
Neuro, unresponsive, Reflexes 1+, neg Babinsky
Pertinent Results:
[**2102-8-5**] 11:58AM TYPE-ART TEMP-38.1 TIDAL VOL-726 PEEP-5 O2-55
PO2-153* PCO2-29* PH-7.21* TOTAL CO2-12* BASE XS--15
INTUBATED-INTUBATED VENT-CONTROLLED
[**2102-8-5**] 11:59AM FIBRINOGE-508*
[**2102-8-5**] 11:59AM PT-15.6* PTT-71.1* INR(PT)-1.6
[**2102-8-5**] 11:59AM PLT SMR-VERY LOW PLT COUNT-51*
[**2102-8-5**] 11:59AM WBC-23.8* RBC-2.84* HGB-9.0* HCT-27.4* MCV-96
MCH-31.6 MCHC-32.8 RDW-15.0
[**2102-8-5**] 11:59AM HAPTOGLOB-231*
[**2102-8-5**] 11:59AM CALCIUM-6.5* PHOSPHATE-4.6* MAGNESIUM-1.7
[**2102-8-5**] 11:59AM CK-MB-88* MB INDX-6.2* cTropnT-6.92*
[**2102-8-5**] 11:59AM ALT(SGPT)-124* AST(SGOT)-166* CK(CPK)-1418*
ALK PHOS-218* TOT BILI-0.2
[**2102-8-5**] 11:59AM GLUCOSE-78 UREA N-55* CREAT-2.9* SODIUM-152*
POTASSIUM-3.3 CHLORIDE-120* TOTAL CO2-11* ANION GAP-24*
[**2102-8-5**] 01:30PM FDP-80-160*
[**2102-8-5**] 02:02PM LACTATE-1.8
..
[**2102-8-5**] 07:53PM TYPE-ART TEMP-36.5 RATES-32/ TIDAL VOL-469
PEEP-5 O2-45 PO2-148* PCO2-21* PH-7.28* TOTAL CO2-10* BASE
XS--14 INTUBATED-INTUBATED VENT-CONTROLLED
[**2102-8-5**] 05:24PM WBC-27.1* RBC-3.77*# HGB-11.7*# HCT-34.7*#
MCV-92 MCH-31.1 MCHC-33.9 RDW-15.8*
[**2102-8-5**] 11:04PM GLUCOSE-167* UREA N-48* CREAT-2.6*
SODIUM-146* POTASSIUM-3.9 CHLORIDE-117* TOTAL CO2-10* ANION
GAP-23*
[**2102-8-5**] 11:26PM LACTATE-4.2*
Abd u/s:
Conclusion> multiple non-obstructive calculi in the left kidney
and bladder, small echogenic left kidney and cholelithiasis.
..
CXR [**8-4**]: Cardiac silhouette is enlarged. There is pulmonary
edema. No definite pleural effusion identified.
..
Micro
Urine [**8-4**]: E coli >100,000, proteus <10,000
Bld [**8-4**]: 2 type of gm neg; first if pan-sensitive E coli
..
CT [**8-6**]:
1. Moderate sized bilateral pleural effusions with reactive
atelectasis.
2. Left non-obstructing renal stones. Atrophic and cortical
scarring seen
within the left kidney. No evidence of hydronephrosis or
hypoattenuating
areas to indicate an abscess on this limited study in the
kidneys bilaterally.
3. Anasarca, periportal edema and gallbladder wall edema
consistent with
fluid third spacing. Gallstones.
4. Bladder calculi. The bladder appears slightly distended
with a small
amount of intravesicular air, likely iatrogenic from Foley
placement.
..
Echo [**8-7**]: Mild biventricular hypokinesis c/w cardiomyopathy:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
mild global left ventricular hypokinesis. There is mild global
right ventricular free wall hypokinesis. 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 mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
..
CT Abdomen [**8-10**]:
1. Right pyelonephritis. At least two renal infarcts which
could be related
to pyelonephritis although embolic sources should be
investigated.
2. Atrophic left kidney with a large calculus in a renal calix.
Mildly
dilated left ureter without evidence of an obstructing stone.
3. Gallstones.
4. Bilateral pleural effusions.
..
Echo [**8-11**]
1. The left atrium is mildly dilated. No atrial septal defect or
patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
3. Mild (1+) aortic regurgitation is seen.
4. No echocardiographic evidence of endocarditis seen.
..
Cytology ([**2102-8-17**])
DIAGNOSIS: Pleural fluid:ATYPICAL.
One cluster of atypical mesothelial cells, probably
reactive, in a background of mesothelial cells.
..
Bedside Swallow Evaluation ([**2102-8-15**])
SUMMARY / IMPRESSION:
There were no signs of aspriation on her bedside swallowing
evaluation today. She appears safe to take a full PO diet as
tolerated as long as she is seated fully upright in bed.
..
([**2102-8-17**])
CXR: (multiple CXRs previous - to follow effusions, lines)
Portable AP view of the chest dated [**2102-8-18**] at 19:14 is compared
with the same examination from 2 hours earlier. The right
internal jugular centralvenous catheter has been removed. There
has been interval withdrawal of the right PICC line, which now
terminates in the mid superior vena cava. The heart, hilar, and
mediastinal contours are unchanged. The bilateral pleural
effusions are unchanged. Again, there is no pneumothorax. The
surrounding osseous and soft tissue structures are unchanged.
IMPRESSION: Status post removal of right internal jugular
catheter with
partial withdrawal of the right PICC line, which now terminates
in the mid
superior vena cava.
..
[**2102-8-17**]
Pleural Tap: 8 WBC (5% polys, 72% lymphs), 181 RBC, 11 atypical
cells (mesos)
WBC RBC HGB HCT MCVMCH RDW
[**2102-8-23**] 14.3* 3.45* 10.6*31.1* 90 30.6 34.0 16.5*
[**2102-8-22**] 8:06P 28.9*
[**2102-8-22**] 3:52A 13.7* 2.60* 7.9* 24.3* 94 30.5 32.6 17.2*
[**2102-8-21**] 6:35A 15.4* 2.81* 8.5* 26.2* 93 30.3 32.5 17.0*
[**2102-8-20**] 6:30A 16.6* 2.93* 8.8* 27.3* 93 30.1 32.4 16.1*
[**2102-8-19**] 4:31A 18.8* 2.98* 9.1* 27.7* 93 30.5 32.8 15.5
[**2102-8-18**] 4:56A 17.9* 3.44* 10.3*31.9* 93 30.1 32.4 15.2
Diff from [**8-18**]: N: 94 L:4 M:2
[**2102-8-17**] 4:22A 13.1* 3.20* 9.7* 30.1* 94 30.2 32.1 15.3
[**2102-8-16**] 4:02A 19.4* 3.18* 9.7* 30.1* 95 30.5 32.1 15.8*
[**2102-8-15**] 4:00A 15.1* 3.06* 9.2* 27.6* 90 30.2 33.5 15.5
[**2102-8-14**] 3:56A 20.2* 2.94* 8.9* 27.0* 92 30.3 33.0 15.6*
[**2102-8-13**] 3:54A 23.5* 3.16* 9.6* 29.5* 94 30.2 32.4 15.6*
[**2102-8-12**] 5:06A 21.2* 2.83* 8.5* 26.7* 94 30.0 31.9 16.1*
[**2102-8-11**] 4:54A 23.6* 2.97* 9.0* 28.0* 95 30.3 32.1 16.3*
[**2102-8-10**] 3:46A 26.4* 3.15* 9.5* 29.3* 93 30.1 32.3 16.5*
[**2102-8-9**] 2:15P 29.1* 3.20* 9.7* 29.4* 92 30.3 33.0 16.3*
[**2102-8-9**] 1:32A 26.7* 3.14* 9.5* 28.5* 91 30.4 33.4 16.4*
[**2102-8-8**] 3:55A 26.6* 3.36* 10.3* 30.6* 91 30.8 33.8 16.9*
[**2102-8-7**] 3:54A 24.3* 3.33* 10.2* 29.9* 90 30.6 34.1 16.7*
[**2102-8-6**] 9:44P 24.7* 3.31* 10.3* 29.2* 89 31.2 35.3* 16.6*
..
Platelets: [**Date range (1) 60233**]: Range: 30s-40s
[**8-10**]: 88
[**8-11**]: 133
[**8-12**]: 174
[**8-13**]: 236
[**Date range (1) 64022**]: 400s-600
..
Coags: [**Date range (1) 64023**]: INR: 1.0-1.2 PTT: 24.1-29
..
REtic count: [**8-22**]: 2.3
..
[**2102-8-22**] 8:06P
Glu BUN Cr Na K Cl HCO3 AnGap
[**2102-8-22**] 102 15 0.6 142 3.0* 105 28 12
[**2102-8-21**] 82 17 0.6 145 3.8 110* 26 13
[**2102-8-20**] 93 20 0.6 143 3.0* 108 25 13
[**2102-8-19**] 94 25* 0.6 141 4.1 109* 25 11
[**2102-8-18**] 127*24* 0.6 140 3.9 105 24 15
[**2102-8-18**] 158* 22* 0.6 141 3.9 105 28 12
[**2102-8-17**] 137* 23* 0.6 146* 4.3 102 35*
[**2102-8-16**] 142* 22* 0.7 145 4.6 105 30
[**2102-8-15**] 123* 17 0.7 146* 4.9 107 28
[**2102-8-14**] 119* 12 0.7 147* 4.3 107 28 16
[**2102-8-14**] 97 11 0.7 146* 3.7 105 31
[**2102-8-13**] 141* 9 0.7 147* 4.1 106 32
[**2102-8-13**] 118* 12 0.7 146* 3.8 108 30
[**2102-8-12**] 4:08P 112* 14 0.7 146* 3.8 108 29
[**2102-8-12**] 5:06A 110* 16 0.7 143 4.0
[**2102-8-11**] 4:54A (42) 93 20 0.8 146* 3.8
[**Date range (1) 64024**]: Creat: 2.5 -> trended down to 1.0
Na: 143-147
K: 3.3-4.2
BUN: 24-46
..
Ca/Mg/Ph:
Ca: 8.9-9.2
Mg: 1.6-2.0
Phos: 2.0-3.5
..
LFTs
[**2102-8-18**] ALT: 50* AST: 32 LDH: 276* AlkPhos: 476* Amyl:202*
TBili:0.5
[**2102-8-14**] 69* 62* 32 563* 236*
0.4
[**2102-8-9**] 123* 101* 1033*
0.5
..
Lipase:
[**8-10**]: 280
[**8-13**]: 259
[**8-14**]: 229
[**8-18**]: 192
..
CK/Troponins:
[**2102-8-14**] 3:56A (64)
[**8-14**] 2 0.41*
[**8-8**] 5 4.40*
[**8-7**] 9
[**8-6**] 12* 2.99*
[**8-6**] 32* 4.6
[**8-5**] 44 2.94*
[**8-5**] 76 5.11
[**8-5**] 88 6.92
Brief Hospital Course:
A/P: 64 yo woman here with urosepsis, metabolic acidosis,
NSTEMI, DIC and ARF secondary to ATN.
..
1.Urosepsis/ secondary VAP: Urosepsis: secondary to e.coli
infection which had been pansensitive at OSH. Further cultures
obtained at [**Hospital1 18**] have been negative to date. No hydronephrosis
or pyonephrosis seen on U/S or CT. CT corroborated u/s findings
w/ stones in left kidney and bladder. CT [**8-6**] w/ no evidence of
paranephric abscess. Following the lack of improvement with
appropriate Abx therapy further imaging was obtained. US [**8-9**]
now evidence of cholecystitis or paranephric abcess. New CT done
on [**8-10**] did not show any signs of pyelonephrosis,
hydronephrosis, abcess or pancreatitis. Left kidney showed signs
of pyelonephritis with no focal collection but two wedge shaped
areas of hyposperfusion most likely in the setting of
pyelonephritis. TEE [**8-11**] did not show any signs of endocarditis
but an improvement of cardiac function with an ejection fraction
of now >55%. Gyn consult for evaluation of uterus prolaps with
purulent secretions > stage three, no source of infection.
Central line and arterial line were changed on the [**8-12**]. A
-- following culture data: BAL Cx grew out yeast
-- leukocytosis persistent > other source of infection >
broadened coverage to Zosyn and Flagyl > further broadened for
gram+ coverage on [**8-9**] with Vancomycin as necrotic fingers
might be a source of infection, catheter tip cultures were
negative
--As the pt still had a high WBC count and new low grade fever
with deteriorating respiratory status a VAP with a bacteria
resistant to Zosyn and Vanco was suspected. Sputum cx were taken
and Meropenem was started [**8-14**]. Complete Vancomycin and
Meropenem course [**8-24**].
--[**8-16**] bronchoscopy showed tracheobronchitis with copious
secretions, tx with Meropenem as above
--[**8-19**] Patient with continued improvement in respiratory status,
now with decreased cough and secretions and tolerating NC O2
well
--[**Date range (1) 64025**]: Patient has been afebrile. Meropenem and Vancomycin
to be stopped after doses on [**2102-8-24**]. WBC ct still slightly
elevated.
.
2. Respiratory failure: hypercarbic resp failure in setting of
metabolic alkalosis. Following significant improvement of the
pt's respiratory status a SBT was tried on the [**8-12**] and the pt
was extubated subsequently. Pt developed significant wheezes and
tachypnea since extubation which are most likely due to
tracheobronchitis and copious secretions. on albuterol and
ipratropium Nebs and iv steroids for component of airway
hyperreagibility. Patient able to cough up secretions on her
own. Pt able to tolerate 4L of NC. Pt subjectively improved
after R sided thoracentesis.
> BAL lavage sent for cx - cx negative, Gram stain negative, no
WBC or RBC
> f/u results of [**8-17**] thoracentesis R effusion: interpretation
might be limited as specimen formed clots before analysis but
fluid analysis suggestive of transudative effusion. Preliminary
cultures show no growth.
> L thoracentesis attempted on [**8-18**] but unable to obtain enough
fluid for analysis
> taper down steroids
> [**Date range (1) 64025**]: Patient has not experienced respiratory distress;
also, she has been saturating well on room air and maintained on
nebulizers.
.
3. On admission Renal failure: from ATN in the setting of
sepsis, no hydronephrosis, muddy brown casts on urine sediment:
4.6->3.3->2.9->2.5-->2.0-->1.7-->1.3-->1.0. NOw resolved. Cr on
discharge was 0.6 ([**2102-8-23**]).
.
4. on admission DIC: FDP increased + elevated coags +
schistocytes-> + DIC, on admission from sepsis. Resolved with
improved INR and coags but remained thrombocytopenic with
unclear source for significant part of admission. HIT
antibodies were negative so presumed [**1-25**] to DIC. Eventually
increased to normal limits on own. Discharge Plt count was 455.
.
5. On admission: NSTEMI: ST changes on tele. CK 1400, MB=88,
trop T 6.92. ECGs w variable 1mm ST elevation II, V5-V6. Patient
pain free before intubated for hypoxia. Cardiac enzymes
gradually normalized. Cardiology consulted on admission and felt
that patient not candidate for catheterization because of how
acutely ill she was. They felt that most likely NSTEMI [**1-25**]
demand and recommended only ASA. Patient needs to follow up
with cardiology as outpatient for potential stress test +/or
catheterization. TEE [**8-11**] did not show any signs of
endocarditis but an improvement of her cardiac function with an
ejection fraction of now >55%. Initial TTE ([**8-7**]) had shown EF
30-35% possibly [**1-25**] to cardiomyopathy of sepsis. Initial TTE
had shown significant hypokinesis but this was not see on the
follow up TTE.
.
6. Elevated transaminases and alk phos, cont to follow. Increase
in AP initially thought to be due to ceftriaxone > stopped. Alk
Phos now trending down. So far unclear. Possible medication
effects in addition to initial damage due to hypoperfusion.
- Continue to monitor and would follow as outpatient
..
7. INcreased Lipase/Amylase: considered pancreatitis or
medication side effects. Flagyl can lead to an increase.
Pancreatitis unlikely as CT negative. Stopped Flagyl and
monitored trend. Stable in 200 range.
- continue to monitor as outpatient
- if not resolving consider pancreatic imaging in the future
..
8. Oral rash: Herpes infection> improving
- as per ID recs on Acyclovir-> course completed on [**8-21**]
.
9. Metabolic alkalosis likely contraction alkalosis +
respiratory acidosis due to CO2 retention most likely due to
secretions
- continue to monitor
- acetazolamide was given 3x for metabolic alkalosis, most
recently [**8-18**] AM> improvement in alkalosis
.
10. Cyanotic/Nectrotic fingertips and toes: Vascular surgery was
consulted; no indications for intervention currently as there
were no signs of infected necrosis. Plastics saw patient on
[**8-18**] and will follow 1 week after discharge.
.
11. Access-PICC ([**8-18**])
.
12. Contact-husband and daughter
.
13. Code: FULL
.
Discharged: To [**Hospital3 **]. Patient stable over past 3 days.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO qd () for 3
doses.
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 4
doses.
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 4
doses.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous every
eight (8) hours for 1 days: Last day of Meropenem is [**2102-8-24**].
9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 1 days: Last day of
Vancomycin is [**2102-8-24**].
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 3 days.
11. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): until ambulating
regularly.
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
14. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day for 14 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Urosepsis
2. NSTEMI
3. uterine prolapse
4. Dry gangrene
5. Herpes labialis
6. Anemia
Discharge Condition:
stable on room air, working with physical therapy,
hemodynamically stable
Discharge Instructions:
Please monitor for temperature > 101, weeping from fingers or
toes, shortness of breath, chest pain, or other concerning
symptoms.
Followup Instructions:
1. Follow up with Plastic Surgery. An Appointment has been made
for next week. THey will call to confirm.
2. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Obstetrics and Gynecology
for a pessary check on [**2102-10-2**] at 3 PM. Location:
[**Hospital Ward Name 23**] [**Location (un) **]. Phone: [**Telephone/Fax (1) 12136**]
3. Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **], who will be your new
primary care doctor. You will need this doctor to arrange your
stress test for you to evaluate for evidence of heart disease,
your colonoscopy to work-up your anemia (low blood count), and
to follow-up your cholesterol panel.
Completed by:[**2102-8-23**]
|
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
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"96.72",
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icd9pcs
|
[
[
[]
]
] |
19488, 19558
|
11910, 15813
|
321, 401
|
19690, 19766
|
3550, 11887
|
19945, 20669
|
3057, 3097
|
18072, 19465
|
19579, 19669
|
18043, 18049
|
19790, 19922
|
3112, 3531
|
276, 283
|
429, 2799
|
15827, 18017
|
2821, 2941
|
2957, 3041
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,624
| 178,751
|
8258
|
Discharge summary
|
report
|
Admission Date: [**2162-5-6**] Discharge Date: [**2162-5-10**]
Date of Birth: [**2112-8-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
coronary artery bypass grafts
x5(LIMA-LAD,SVG-diag,SVG-OM1-OM2,SVG-pda) [**2162-5-6**]
History of Present Illness:
This 49 year old white male presented to his primary care doctor
with progressive fatigue and dyspnea. Work up demonstrated
coronary artery disease and catheterization previously revealed
triple vessel disease. he is admitted now for elective
revascularization.
Past Medical History:
End stage renal disease on hemodialysis
hypertension
hyperlipidemia
s/p left arm ACV fistula
insulin dependent diabetes mellitus
Hepatitis C
Social History:
Married, lives with spouse and 3 children. Works in building
maintenance at a hotel. Denies tobbaco, etoh. No hx of IVDU.
No tattoos.
Family History:
Father with type I DM
Physical Exam:
Admission:
Pulse:80 Resp:16 O2 sat:98%RA
B/P Right:183/86 Left: Left wrist AVF
Height:5'6" Weight:140lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur ESM II/VI LUSB, HSM III/VI
RUSB
Abdomen: Soft, non-distended, non-tender [x]
Extremities: Warm, well-perfused [x] Edema mild pedal
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: nd
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2162-5-10**] 05:30AM BLOOD WBC-6.2 RBC-2.54* Hgb-8.4* Hct-24.0*
MCV-94 MCH-33.0* MCHC-35.0 RDW-16.9* Plt Ct-163
[**2162-5-9**] 04:00AM BLOOD WBC-8.3 RBC-3.01* Hgb-9.3* Hct-28.3*
MCV-94 MCH-30.9 MCHC-32.9 RDW-16.6* Plt Ct-148*
[**2162-5-6**] 11:28AM BLOOD WBC-5.1 RBC-2.26*# Hgb-6.8*# Hct-21.1*#
MCV-93 MCH-30.1 MCHC-32.3 RDW-16.4* Plt Ct-101*
[**2162-5-10**] 05:30AM BLOOD Glucose-118* UreaN-72* Creat-7.4*# Na-135
K-4.6 Cl-95* HCO3-28 AnGap-17
[**2162-5-6**] 12:36PM BLOOD UreaN-22* Creat-4.0* Cl-110* HCO3-24
[**2162-5-7**] 03:25AM BLOOD Glucose-108* UreaN-29* Creat-5.0* Na-138
K-4.9 Cl-107 HCO3-23 AnGap-13
Brief Hospital Course:
Following admission he went to the Operating Room where
revascularization was performed. See operative note for
details. He weaned from bypass on Propofol,Insulin and
neoSynephrine infusions. He remained stable and weaned from the
ventilator and pressors with out incident. He was dialyzed on
POD 1 and remained stable.
He required reinsertion of the Foley on POD 3 for urinary
retention(800cc) and was sent to rehab with the ctaheter to
remain until he is a bit more mobile. Wounds are clean and
healing well at discharge.
Physical Therapy saw the patient for mobility and strength,
however, he required a stay at rehabilitation prior to return
home. He was transfered to [**Location (un) 511**] Siai-[**Location (un) 86**] on [**5-10**].
Medications and restrictions are as outlined elsewhere.
Medications on Admission:
Doxazosin 2mg po BID
Lisinopril 40mg po daily
Hydralazine 50mg po TID
Metoprolol 50 mgpo [**Hospital1 **]
Amlodipine 5 mg po BID
Simvastatin 20mg po daily
ASA 81mg po daily
Humalog SS with meals and at bedtime
Lantus 100units/ml 10units [**Hospital1 **]
Peginterferon weekly
Nephrocaps
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Peginterferon Alfa-2a 180 mcg/mL Solution Sig: One (1) ml
Subcutaneous 1X/WEEK ([**Doctor First Name **]).
13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous twice a day.
16. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**]- [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafts
end stage renal disease on hemodialysis
Insulin dependent diabetes mellitus
hypertension
Hepatitis C
Right carpal tunnel syndrome
s/p left arm AV fistula
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema absent
Discharge Instructions:
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.
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**]).
**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:
Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**Last Name (LF) 766**], [**6-7**] at 1:30.
Please schedule appointments with:
primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 21566**])
Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Renal as scheduled for dialysis (Dr. [**Last Name (STitle) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2162-5-10**]
|
[
"250.01",
"403.91",
"070.70",
"585.6",
"414.01",
"285.21",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.14",
"38.93",
"36.15",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
4954, 5022
|
2384, 3186
|
343, 432
|
5278, 5511
|
1746, 2361
|
6266, 6792
|
1060, 1083
|
3524, 4931
|
5043, 5257
|
3212, 3501
|
5535, 6243
|
1098, 1727
|
280, 305
|
460, 725
|
747, 889
|
905, 1044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,058
| 129,301
|
49907
|
Discharge summary
|
report
|
Admission Date: [**2180-3-5**] Discharge Date: [**2180-3-12**]
Date of Birth: [**2128-8-14**] Sex: F
Service: MEDICINE
Allergies:
Zoloft / Tetracyclines / Prozac / Paxil
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Claudication
Major Surgical or Invasive Procedure:
Catheterization
R IJ central venous line placement
History of Present Illness:
51 year-old female with PMH of CAD s/p CABGx4, HTN,
hyperlipidemia, s/p MVR and AVR, and severe PVD who presents
from home the day of admission for heparinization prior to a
planned intervention for worsening claudication. Ms. [**Known lastname 104253**]
has had severe claudication in the past and underwent a R SFA
atherectomy and angioplasty in [**5-/2179**] and stenting of the L SFA
total occlusion in 07/[**2178**]. She then underwent a CABG x4 and MVR
and AVR in 10/[**2178**]. Over the early winter months, she remained
asymptomatic from claudication, likely secondary to decreased
exertion. Approximately 1-2 months ago, she started to notice R
leg pain in the back of her calf with walking. It then
progressed to be rest pain. Then her L leg began to ache. It
progressed to the point where both posterior calves ache when
walking the length of a hallway. She is forced to stop and rest
for a few minutes before being able to continue walking. She
also has pains in the back of her calves at rest, like her legs
are falling asleep, at night. Despite the fact that her R leg
started first and that her R leg appears worse by recent ABIs,
her L leg is more painful to her and feels "tired" all the time.
She denies having any swelling in her feet (above her baseline -
her LLE has been slightly swollen ever since her CABG) or a cold
foot. Her feet remain warm and well perfused. There had been a
planned intervention at the end of [**1-/2180**] which she was
admitted for. However, her mother passed away and she was unable
to undergo the intervention. She was admitted for heparinization
in anticipation of an intervention planned for Wednesday. She
last took Coumadin on Friday night (2 days PTA) and her INR
today at home was 2.0.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains (other than chronic
hip/back pain), cough, hemoptysis, black stools or red stools.
She denies recent fevers, chills or rigors. She does endorse
exertional calf pain, L>R. All of the other review of systems
were negative.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Peripheral vascular disease status post bilateral lower
extremity SFA revascularization by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], most
recently in [**2179-6-19**].
- [**2179-4-12**] ABIs: Right: 0.55, decreasing to 0.15 with exercise.
Left: 0.41, decreasing to 0.21 with exercise. Impression: Left
iliofemoral arterial disease, right SFA disease, possible left
SFA disease, bilateral infrapopliteal arterial disease.
- [**2179-5-20**] right SFA atherectomy and angioplasty (Dr. [**First Name (STitle) **]
- [**2180-2-3**]-ABIs as below
2. Cardiomyopathy: [**2178-2-27**] admission to [**Hospital1 18**] [**Location (un) 620**] with
CHF, cardiomyopathy, EF = 25%. etiology unclear; repeat echo
[**2178-3-31**] EF = 55%.
4. History of coronary artery disease status post CABG x3 and
AVR/MVR in [**2179-9-19**], under the care of Dr. [**Last Name (STitle) **].
5. Asymptomatic bilateral carotid artery disease status post
[**Doctor First Name 3098**] stent, under the care of Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] prior to
cardiac surgery in [**2179-9-19**].
6. Congenital hip dysplasia status post left total-hip
replacement
7. Chronic back pain
8. Hyperlipidemia
9. Status post appendectomy
10. Status post cholecystectomy
Social History:
The patient is married and has a 26 year-old daughter. She lives
in [**Hospital1 189**]. She used to work as a nursing assistant in ALF but
had to retire due to back/hip pain. Has recently been working in
retail but that is on hold until she completes cardiac rehab.
Smoked 1 ppd x 36 years, quit at age 50. Occasional EtOH.
Family History:
Mother: CAD, hypercholesterolemia, MI in 50s, breast cancer.
Fater: DM2, CVA. Siblings: Healthy.
Physical Exam:
VS - T 98.3, BP 171/65, HR 55, RR 16, sats 97% on RA
Gen: Thin middle aged 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, no JVD. + carotid bruit on R.
CV: RR, mechanical S1 and 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 palpated.
No abdominial bruits appreciated. + BS throughout.
Ext: No c/c. L LE is slightly more swollen than R -> per pt, is
her baseline since CABG.
Skin: Diffuse erythematous rash over extremities/shoulders
bilaterally -> per pt, is sun/tanning damage.
.
Pulses (on palpation):
Right: Carotid 2+ Femoral, Popliteal, DP absent; ? PT 1+
Left: Carotid 2+ Femoral, Popliteal, DP, PT absent
Pertinent Results:
Labwork on admission:
WBC-8.1 Hct-39.0 MCV-92 Plt Ct-232
PT-19.8* PTT-31.8 INR(PT)-1.9*
Glucose-108* UreaN-9 Creat-0.6 Na-140 K-4.7 Cl-105 HCO3-21*
AnGap-19
Calcium-9.5 Phos-3.5 Mg-2.2
.
Labwork on discharge:
[**2180-3-12**] 05:10AM BLOOD WBC-8.7# RBC-2.65* Hgb-8.1* Hct-24.2*
MCV-91 MCH-30.4 MCHC-33.3 RDW-15.9* Plt Ct-183
[**2180-3-12**] 05:10AM BLOOD PT-32.1* PTT-31.0 INR(PT)-3.4*
[**2180-3-12**] 05:10AM BLOOD Glucose-92 UreaN-10 Creat-0.5 Na-133
K-3.7 Cl-99 HCO3-28 AnGap-10
[**2180-3-7**] 03:32AM BLOOD ALT-17 AST-19 LD(LDH)-280* AlkPhos-140*
TotBili-1.4
[**2180-3-12**] 05:10AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.9
[**2180-3-6**] 04:15AM BLOOD Triglyc-67 HDL-59 CHOL/HD-4.2
LDLcalc-174*
.
ECG Study Date of [**2180-3-5**] 6:29:32 PM
Sinus bradycardia
Right bundle branch block
Prolonged Q-Tc interval
ST-T wave changes may be in part primary
These findings are nonspecific but clinical correlation is
suggested
Since previous tracing of [**2179-9-26**], ST-T wave abnormalities
decreased
.
[**3-6**] CT abdomen/pelvis:
IMPRESSION:
1. Moderate-sized extraperitoneal hematoma in pelvis, extending
mostly into the space of Retzius with small retroperitoneal
extension anterior to right psoas muscle. This is contiguous
with stranding in the right groin.
2. Small pleural effusion which demonstrates high Hounsfield
units greater than expected of simple pleural fluid. Hemothorax
cannot be excluded.
3. Tiny amount of blood anterior to liver.
4. Likely hematoma about newly placed right superficial femoral
artery stent. This study was performed without IV contrast. If
there is concern for pseudoaneurysm or extravasation about the
stent, femoral vascular ultrasound is recommended.
.
[**3-6**] Difficult Crossmatch
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname 104253**] has a
new diagnosis of allo-antibodies to the E and K antigens. The E
and K antigens are members of the Rhesus and [**Doctor Last Name **] antigen blood
groups, respectively. Both of these antibodies are capable of
mediating hemolytic transfusion reactions. In the future, blood
transfusions for this patient should be restricted to ABO and
crossmatch compatible red cells that are negative for both E and
K antigens. Approximately 63% of ABO compatible blood will be
negative for both of these antigens. A wallet card and letter
stating the above will be sent to the patient.
.
[**3-6**] Peripheral atheterization
FINAL DIAGNOSIS:
1. Right lower extremity PVD as evidenced by moderate diffuse
disease of
the CFA and total occlusion of the SFA with distal flow
preservation via
the PFA.
2. Left lower extremity PVD as evidenced by origin stenosis
involving
the SFA and PFA.
3. Successful Silverhawk atherectomy of the left SFA/PFA origin.
4. Successful "rescue" PTA of the PFA origin.
.
[**3-7**] LE U/S
IMPRESSION:
1. No evidence of DVT.
2. 7-cm predominantly hypoechoic collection around left SFA
stent, which may represent hematoma or seroma; however clinical
correlation is required. .
.
[**3-9**] CT abdomen/pelvis
IMPRESSION:
1. Large extraperitoneal hematoma in the pelvis which compared
to prior CT from [**2180-3-6**], appears slightly increased in
size.
2. Small bilateral pleural effusions with adjacent compressive
atelectasis.
.
[**3-10**] CXR
Right jugular line tip projects over the lower SVC. No
pneumothorax. Small right pleural effusion unchanged. Heart size
moderately enlarged but stable. Lungs grossly clear.
.
ECG Study Date of [**2180-3-10**] 7:45:52 AM
Sinus rhythm. Left atrial abnormality. Right bundle-branch
block. Q waves in lead III unsupported by Q waves in leads II or
aVF. Compared to the previous tracing of [**2180-3-9**] ST segment
depressions are no longer present in leads V4-V6.
Brief Hospital Course:
51 year-old female with history of CAD s/p CABG, MVR and AVR,
and severe PVD who presented for heparinization prior to
intervention for worsening claudication. The patient received
intervention to left SFA and PFA; the procedure was complicated
by retroperitoneal bleed.
.
1. Peripheral vascular disease. The patient has severe bilateral
lower extremity PVD per ABI in 02/[**2179**]. The patient underwent
peripheral catheterization with intervention to left SFA and PFA
with report as above. The patient's INR was 2.0 prior to
procedure and the patient was given FFP. The plan was for
subsequent right-sided intervention during this admission but
the procedure was complicated by retroperitoneal bleed as below.
The patient was continued on aspirin. The patient was started on
plavix and pravastatin. The patient will follow-up with Dr.
[**First Name (STitle) **].
.
2. Retroperitoneal bleed. The patient complained of increased
back pain above baseline after the procedure. The patient's
hematocrit was noted to have dropped from 35 to 28 and CT
abdomen showed extraperitoneal/retroperitoneal hemorrhage. The
patient was transfused a total of three units packed red blood
cells. Repeat CT abdomen showed a small increase in the size of
the hemorrhage but was otherwise stable. The patient was
followed by Vascular Surgery but did not require intervention.
Anticoagulation was resumed for AVR/MVR after the patient's
hematocrit was stable x 24 hours. The patient's hematocrit was
stable in the mid-20s on discharge.
.
3. Cardiovascular:
a. Coronary artery disease: The patient has known CAD and is s/p
CABG x4 in 10/[**2178**]. There was no evidence of active ischemia
during hospitalization. The patient was discharged on aspirin,
statin, beta-blocker, and [**Year (4 digits) **]-inhibitor. The patient was placed
on plavix for her peripheral stents.
.
b. Rhythm: The patient remained on normal sinus rhythm. The
patient was continued on a beta-blocker.
.
c. Pump: Last ejection fraction pre-CABG was >55%. The patient
likely has an element of diastolic heart failure. The patient
had one episode of flash pulmonary edema in the setting of
receiving IVF for hydration in the context of continued
nausea/vomiting. She responded to furosemide 10 mg IV x1 and put
out > 500 cc urine to this with resolution of symptoms. The
patient was continued on beta-blocker and [**Year (4 digits) **]-inhibitor.
.
4. Status post AVR and MVR: The patient is on coumadin as an
outpatient and was admitted for heparinization prior to her
schedule procedure. The patient was off of all anticoagulation
briefly in the setting of the retroperitoneal bleed but was
re-started on heparin and coumadin once her hematocrit was
stable and discharged with a therapeutic INR.
.
5. Hyperlipidemia. Zocor was discontinued [**1-/2180**] due to LFT
abnormalities. The patient's LFTs were stable and she was
started on pravastatin during this admission.
The patient's liver function tests should be rechecked as an
outpatient.
.
6. Hypertension. The patient's blood pressure was quite labile
from systolics 90 to 200 when nauseated and vomiting. The
patient's anti-hypertensive regimen was titrated during
admission and the patient was discharged on her home regimen.
.
7. Back pain. The patient was continued on oxycontin 80 mg TID
initially, then reduced to 40 mg [**Hospital1 **] for concern for sedation.
The patient needed very little as needed pain medication on the
reduced dose.
.
8. Nausea/vomiting. The patient had severe nausea/vomiting for
six days after catheterization and has a history of
nausea/vomiting after catheterization or surgery. She responded
to compazine, ativan, anzemet as needed and was tolerating a
regular diet prior to discharge.
.
9. Urinary tract infection. The patient had a positive
urinalysis and urine culture was positive for E. coli,
pan-sensitive. Per the patient's husband, the patient has had
urinary tract infections in the past with Foley catheterization.
The patient was give Bactrim to complete a seven-day course.
Medications on Admission:
lisinopril 20mg PO QD
protonix 20mg PO QD
metoprolol 100mg PO BID
aspirin 81mg PO QD
coumadin 3-5mg as directed
oxycontin 80mg PO TID
oxycodone 5mg PO prn for breakthrough pain
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Primary:
1. Peripheral Vascular Disease
2. Retroperitoneal Bleed
3. Hypertension
4. Anticoagulated for AVR/MVR
5. Constipation
6. Urinary tract infection
.
Secondary:
1. Coronary artery disease status post CABG in [**9-23**]
2. Congenital hip dysplasia status post left total hip
replacement
3. Chronic back pain
4. Status post appendectomy
5. Status post cholecystectomy
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted for a catheterization for your peripheral
vascular disease. You had a retroperitoneal bleed after your
catheterization but your hematocrit has been stable for several
days.
.
Several of your medications were changed during your hospital
course.
- You were started on Plavix. It is very important that you take
this medication every day to prevent clots in the stent. It is
very important that you also continue your aspirin.
- You should take only 2 mg of coumadin daily and continue to
check your INR at home.
- You were started on pravastatin to lower your cholesterol.
- You were started on bactrim (an antibiotic) for a urinary
tract infection. Continue taking this medication for five more
days.
- Your oxycontin was decreased to 40 mg twice daily.
- Please take colace, senna, and bisacodyl as needed for
constipation.
.
Please seek medical attention immediately if you develop chest
pain, shortness of breath, fever > 101 or other concerning
symptoms.
.
Please schedule your follow-up appointments as below.
Followup Instructions:
Please call ([**Telephone/Fax (1) 7236**] to make a follow-up appointment with
Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] within the next week.
.
Please call ([**Telephone/Fax (1) 3346**] to make a follow-up appointment with
your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within the next two
weeks.
|
[
"444.22",
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"00.41",
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"39.50",
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"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
13502, 13567
|
9243, 13275
|
312, 365
|
13983, 14021
|
5505, 5513
|
15103, 15517
|
4415, 4513
|
13588, 13962
|
13301, 13479
|
7931, 9220
|
14045, 15080
|
4528, 5486
|
5714, 7914
|
260, 274
|
393, 2703
|
5527, 5700
|
2725, 4057
|
4073, 4399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,799
| 176,753
|
52785+59465
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-8-29**] Discharge Date: [**2181-9-9**]
Date of Birth: [**2112-4-2**] Sex: F
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
female with known coronary artery disease (status post
myocardial infarction in [**2174**]; status post coronary artery
bypass graft times three with a left internal mammary artery
to the left anterior descending artery, saphenous vein graft
to obtuse marginal, and saphenous vein graft to right
coronary artery in [**2174**]) who predominantly to the [**Hospital 620**]
campus complaining of chest pain for three hours with the
onset in the evening of [**8-28**] while at rest. This chest
pain was associated with nausea and shortness of breath.
The patient reported that earlier that day she was a
restrained driver in an automobile accident in which her car
was hit on the passenger side in the front. There was no
airbag deployment, but after the accident the patient vomited
once and developed chest discomfort with radiation to the
right breast and arm. At that time, the patient reported
that her chest pain was [**10-26**] in severity.
On arrival to the [**Hospital 620**] campus, the patient's
electrocardiogram showed 2-mm ST elevations in leads II, III,
and aVF with 2-mm ST depressions in V5 and V6. Leads aVR,
aVL, and V1 to V3 had inverted T waves.
The patient was given aspirin and morphine and was started on
heparin and Integrilin drips and was transferred to [**Hospital1 1444**] for emergent cardiac
catheterization.
During the cardiac catheterization, the patient had
occasional episodes of hypotension and was started on
atropine and dopamine. The patient was found to have
bleeding from her groin after multiple access attempts. Her
hematocrit was revealed to be 28 and a Swan-Ganz catheter
showed low right atrial and pulmonary capillary wedge
pressures.
The patient was transferred to the Coronary Care Unit without
having any interventional performed. The patient was
transfused 2 units of packed red blood cells and given
intravenous fluids.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
(a) Status post myocardial infarction in [**2174**].
(b) Status post coronary artery bypass graft surgery in [**2174**]
with a left internal mammary artery to the left anterior
descending artery, saphenous vein graft to obtuse marginal,
and saphenous vein graft to right coronary artery.
2. Hypertension.
3. Osteoporosis.
4. Hypercholesterolemia.
5. Gastroesophageal reflux disease.
6. External hemorrhoids.
7. Negative colonoscopy in [**2177-11-17**].
8. Anxiety.
9. Status post a ruptured appendix with partial cecectomy
30 years ago.
10. Status post hiatal hernia repair in [**2177-10-17**].
11. Status post back surgery for scoliosis in [**2175-10-18**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg by mouth once per day.
2. Atenolol 50 mg by mouth once per day.
3. Pravastatin 20 mg by mouth once per day.
4. Prilosec 20 mg by mouth every day.
SOCIAL HISTORY: The patient is divorced. The patient does
not smoke and does not drink.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 95.3 degrees
Fahrenheit, her heart rate was 71, her blood pressure was
127/61, her respiratory rate was 18, and her oxygen
saturation was 97% on room air. In general, a thin woman in
no acute distress. The patient was confused. Head, eyes,
ears, nose, and throat examination revealed pupils were
equal, round, and reactive to light. Sclerae were anicteric.
The oropharynx was clear. The neck was supple. No masses.
A right internal jugular triple lumen line was present. No
jugular venous distention. The lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. A grade [**1-22**] to 2/6
systolic ejection murmur at the left lower sternal border.
The abdomen was soft and mildly tender in the lower
quadrants. No distention. Positive bowel sounds. There was
a large epigastric ventral hernia. Groin revealed minimal
oozing of blood in the left and right groin sites. Distal
pedal pulses were intact. Neurologic examination revealed
the patient followed commands. Extraocular muscles were
intact. The level of consciousness initially varied.
Cranial nerves II through XII were grossly intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data
on admission revealed her white blood cell count was 10.6,
her hematocrit was 36.7, and her platelets were 326. Mean
cell volume was 92. Her sodium was 134, potassium was 4,
chloride was 93, bicarbonate was 27.7, blood urea nitrogen
was 22, creatinine was 1.1, and blood glucose was 119. Her
calcium was 9.1. Her magnesium was 1.9. Her albumin was
3.8. Her ALT was 58. Her AST was 25. Troponin was 0.3.
Creatine phosphokinase was 48. Her INR was 1.2.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
normal sinus rhythm at a rate of 60. Normal axis. ST
elevations of 2 mm in leads II, III, and aVF and V5 and V6.
ST depressions in V1 to V3. Lead aVL with T wave flattening
and inversion.
A chest x-ray revealed no pneumonia or congestive heart
failure with mild cardiomegaly.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. MYOCARDIAL INFARCTION ISSUES: The patient's creatine
kinase peaked on [**8-29**] at 1641. The patient's initial
cardiac catheterization was unsuccessful for any intervention
and was complicated by a retroperitoneal bleed. The
procedure was terminated at that time as the patient's
hemodynamic instability and retroperitoneal bleed presented
prevented further attempts at stent placement.
After the patient's hematocrit stabilized, she was
transferred out of the Coronary Care Unit to the Cardiology
floor where she had occasional episodes of jaw pain and chest
pain which were relieved with sublingual nitroglycerin.
The patient underwent a Persantine MIBI on [**9-7**]; during
which the patient had [**5-26**] chest pressure and chest pain with
the infusion, but no electrocardiogram changes. The MIBI
portion revealed moderate partially reversible defects
involving the mid and lateral wall which extended to the apex
and a hypokinetic lateral wall, with an ejection fraction of
62%.
The following day, the patient developed an additional
episode of chest pain while at rest. The patient was started
on a heparin drip and given sublingual nitroglycerin. The
pain resolved. The patient was to undergo a repeat cardiac
catheterization on [**9-10**] with a planned intervention at
that time.
2. RETROPERITONEAL BLEED ISSUES: After the multiple access
attempts during the patient's initial cardiac catheterization
the patient's hematocrit dropped, and she became hypotensive.
The patient underwent an urgent abdominal and pelvic
computerized axial tomography which revealed a large
left-sided retroperitoneal hematoma in the pelvis,
diverticulosis without evidence of diverticulitis, and no
evidence of bowel obstruction. A ventral hernia containing
nonobstructive loops of transverse colon.
The patient was transfused with two units of packed red blood
cells, and her hematocrit was followed serially. After
several days, her hematocrit was found to be stable in the
low 30s.
In addition, a repeat abdominal computed tomography on [**9-4**] revealed a greatly decreased left pelvic wall hematoma.
At this point, the patient's retroperitoneal bleed was felt
to have resolved, and the patient's hematocrit was felt to be
stable.
The decision was made to proceed with cardiac catheterization
on [**2181-9-10**].
3. HYPOTENSION ISSUES: The patient had several episodes of
hypotension while on the Cardiology floor. The patient's ACE
inhibitor was discontinued as was her daily nitrate in order
to maintain her systolic blood pressure around 100. The
patient was given several boluses of intravenous fluids as
needed and was continued on her daily Lopressor for rate
control and for cardiac benefits.
4. URINARY TRACT INFECTION ISSUES: On [**9-4**], the
patient was found to have developed a low-grade fever
overnight and was complaining of dysuria that a.m. and mild
suprapubic abdominal pain. The patient's urine culture
revealed greater than 100,000 colonies of Escherichia coli
which was pan-sensitive. The patient was started on 500 mg
by mouth of Levaquin daily.
5. HYPERCHOLESTEROLEMIA ISSUES: The patient was continued
on her daily Lipitor.
6. ANXIETY ISSUES: The patient was continued on her daily
Paxil and trazodone at night. In addition, she was covered
with Ativan as needed. The patient was found to have
significant anxiety with an additional component borderline
personality trait. She often had irrational fears regarding
her medical care and her treatment by the staff and would
frequently complain about hospital amenities, and hospital
food, as well as nursing and physician [**Name Initial (PRE) **].
The patient was continuously given reassurance by both
nursing and physician staff, and the patient responded well
to this increased attention and increased communication.
NOTE: The remainder of the [**Hospital 228**] hospital course will be
dictated by the covering intern taking over on [**Last Name (LF) 766**], [**2181-9-10**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2181-9-9**] 10:38
T: [**2181-9-12**] 10:15
JOB#: [**Job Number 108859**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 17831**]
Admission Date: [**2181-8-29**] Discharge Date: [**2181-9-18**]
Date of Birth: [**2113-4-2**] Sex: F
Service:
ADDENDUM:
Briefly, the patient is a 69 year old woman with CAD status
post MI and CABG who presented on [**2181-8-28**] with chest pain
post MVA. Ruled in for an NST EMI. Cardiac cath on [**8-28**]
complicated by hemodynamic unstable retroperitoneal bleed
which was stabilized by transfusions. Transferred out of CCU
on [**2181-9-1**]. Managed medically, but on [**9-8**] noted to have
chest pain with lateral ST elevations, anterior STD and on
recatheterization on [**9-10**] noted to have previously occluded
DOM with TIMI-3 flow, 60 percent LAD lesion with native three
vessel disease. Left circumflex had diffuse 80 percent
proximal disease. OM filled via SVG to OM2 graft to RCA.
Mild diffuse disease SVG to RCA, SVG to OM2 with tubular
proximal 40 percent lesion, LIMA to LAD known atretic. LAD
was intervened with Cypher stent, but jailed to D1 with
plaque shift leading to severe chest pain, EKG changes,
hypotension to SBP in the 40s. The patient subsequently
intubated with pressors and IABP placed. Balloon pump
removed [**9-11**]. Noted fever to 101.4. Successfully extubated
on [**9-12**]. Transferred to floor on [**9-12**].
1. CAD. Continued aspirin, Plavix, statin. Changed
captopril to lisinopril and continued beta blocker.
2. Ventilator associated pneumonia. The patient was
afebrile. Sputum cultures were pending. She was continued
on vancomycin.
3. Retroperitoneal bleed. The patient was hemodynamically
stable with stable hematocrit on the floor.
4. The patient was discharged to rehab after P.T. eval.
5. The patient also had right lower extremity DVT, right
popliteal clot with some flow of right superior femoral clot
and common femoral clot with no flow on lower extremity
Doppler. She was treated with IV heparin and warfarin.
Aspirin and Plavix were continued. Her INR quickly went up
to 5.0. Warfarin was held. Goal INR was 2 to 3.
DISCHARGE STATUS: Discharge date [**2181-9-5**]. Discharged to
extended care facility rehab.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Methicillin resistant Staphylococcus aureus ventilator
associated pneumonia.
2. Deep vein thrombosis.
3. Non-ST elevation myocardial infarction.
4. Retroperitoneal bleed.
5. Hypotension.
6. Coronary artery disease.
7. Urinary tract infection.
8. Methicillin resistant Staphylococcus aureus pneumonia.
9. Hypercholesterolemia.
10. Hypertension.
11. Anxiety.
12. Upper respiratory infection.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gm IV q.12 for two weeks for MRSA ventilator
associated pneumonia.
2. Plavix 75 mg p.o. q.d.
3. Paxil 10 mg p.o. q.d.
4. Atorvastatin 25 mg p.o. q.d.
5. Aspirin 325 mg p.o. q.d.
6. Lisinopril 2.5 mg p.o. q.d.
7. Polyvinyl alcohol drops ophthalmic one to two drops
p.r.n. as needed.
8. Beclomethasone nasal spray 42 mcg one spray b.i.d.
9. Lorazepam 0.5 mg p.o. q.six hours p.r.n. anxiety.
10. Ambien 5 to 10 mg p.o. q.h.s.
11. Atenolol 50 mg p.o. q.d.
12. Trazodone 50 mg p.o. q.h.s.
13. Multivitamin one capsule p.o. q.d.
14. Warfarin 1 mg p.o. q.d., goal INR is 2 to 3. INR on
discharge is 5. Warfarin was held. However, INR to be
rechecked two days after discharge and adjust as directed.
FOLLOWUP: Follow up with PCP in one to two weeks, for
cardiology with Dr. [**Last Name (STitle) 690**] in one to two weeks and Dr. [**Last Name (STitle) **].
Dictated By:[**Name8 (MD) 2295**]
MEDQUIST36
D: [**2182-1-8**] 12:40
T: [**2182-1-13**] 20:45
JOB#: [**Job Number 17832**]
|
[
"410.31",
"453.8",
"458.9",
"998.12",
"401.9",
"427.5",
"599.0",
"E878.8",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"37.22",
"37.61",
"99.20",
"36.01",
"88.52",
"36.07",
"88.56",
"37.23",
"96.04",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
11842, 12245
|
12268, 13284
|
2867, 3036
|
5305, 11787
|
161, 2071
|
2094, 2841
|
3053, 5271
|
11812, 11821
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,068
| 159,717
|
20027
|
Discharge summary
|
report
|
Admission Date: [**2105-11-9**] Discharge Date: [**2105-11-12**]
Service: Medical Intensive Care Unit
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female with poorly differentiated adenocarcinoma of the
stomach (on chronic prednisone for rheumatoid arthritis) who
presented with one episode of hematemesis and coffee-grounds.
The patient reports feeling well up until this episode when
she felt "clots" in her mouth. The patient does report black
stool with constipation as well, but she is on iron therapy.
She denies any change in bowel habits.
At the rehabilitation facility, the patient's initial vital
signs were stable but subsequent hypotension developed to a
blood pressure of 80/56 with a heart rate of 132.
In the Emergency Department, a nasogastric lavage revealed
frank blood changing to a fruit-punch color with no clearing
of bleeding after two liters of fluid. The patient received
one unit of packed red blood cells for a hematocrit of 23.9.
The patient was admitted to the Intensive Care Unit for
further evaluation.
PAST MEDICAL HISTORY:
1. Gastric adenocarcinoma (poorly differentiated); diagnosed
in [**2105-7-17**].
(a) The patient received no chemotherapy, radiation therapy,
or surgical intervention.
(b) Liver metastases were present on a positron emission
tomography scan done at [**Hospital6 1129**].
2. Rheumatoid arthritis (on chronic prednisone).
3. Aortic stenosis (with a valve area of 0.9 cm2 and an
ejection fraction of 65% on an echocardiogram done at
[**Hospital6 1129**]).
4. Status post laparoscopic cholecystectomy secondary to
cholecystitis.
5. Depression.
6. Chronic lower extremity ulcerations.
7. Endoscopic retrograde cholangiopancreatography in [**2099**]
for pancreatitis.
8. Status post colonoscopy in [**2105-7-17**] (done at
[**Hospital6 1129**]) which showed diffuse
"small/mild diverticula."
MEDICATIONS ON ADMISSION:
1. Prednisone 10 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Calcium carbonate and vitamin D.
4. Celexa 20 mg by mouth once per day.
5. Pantoprazole 40 mg by mouth once per day.
6. Colace 100 mg by mouth twice per day.
7. Vitamin B12.
8. Iron sulfate 325-mg tablets one tablet by mouth twice
per day.
9. Celebrex 200 mg by mouth twice per day.
10. Glucosamine one tablet by mouth twice per day.
11. Vicodin with dressing changes.
12. Trazodone 25 mg by mouth at hour of sleep.
13. Remeron 15 mg by mouth at hour of sleep.
14. Duragesic patch 25-mg patch transdermally q.72h.
ALLERGIES:
1. BENZODIAZEPINES (unknown reaction).
2. PENICILLIN (unknown reaction).
3. The patient's records also indicate OPIOIDS allergies;
however, she is on opioid therapy without issues.
SOCIAL HISTORY: The patient is living in On [**Hospital **]
Rehabilitation Center in [**Location (un) **], [**State 350**]. She has
been there for seven weeks for physical therapy and treatment
of her lower extremity ulcerations. She reports tobacco for
"many years," but she quit greater than twelve years ago.
The patient denies alcohol or drug use. Her husband passed
away in [**2105-7-17**]. She has family nearby; her children
and grandchildren. Her son and contact throughout this
admission was [**Name (NI) **] [**Known lastname **] (telephone number [**Telephone/Fax (1) 53937**]; cell
phone number [**Telephone/Fax (1) 53938**]).
CODE STATUS: The patient is do not resuscitate/do not
intubate but wishes for aggressive treatment.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
upon admission revealed the patient's temperature was 99
degrees Fahrenheit, her blood pressure was 115/58, her heart
rate was 107, her respiratory rate was 18, and her oxygen
saturation was 95% on room air. In general, the patient was
a comfortable elderly woman in no acute distress. Head,
eyes, ears, nose, and throat examination revealed nasogastric
tube was in place. The mucous membranes were dry. The
conjunctivae were pale. The neck was supple. Jugular venous
pulsation was flat. No bruits or radiation of murmurs.
Pulmonary examination revealed the lungs were clear to
auscultation bilaterally. No wheezes or crackles.
Cardiovascular examination revealed a 3/6 systolic murmur
heard everywhere. The patient was tachycardic but regular.
The abdominal examination was benign. No hepatosplenomegaly.
No masses. There were normal active bowel sounds. Extremity
examination revealed ulnar deviation of the bilateral digits.
There was joint swelling. Mildly tenderness to palpation.
The patient had chronic superficial lower extremity
ulcerations which did not appear erythematous or purulent.
The patient did have tenderness around the ulcerations.
Rectal examination revealed the patient was guaiac-positive
with brown/hard stool. Neurologic examination revealed the
patient was intact. Alert and oriented times three.
Strength was [**3-21**] throughout. No focal deficits. Skin
examination revealed no rashes. There were bilateral lower
extremity ulcerations.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
upon admission revealed the patient's white blood cell count
was 7.3, her hematocrit was 23.9, her mean cell volume was
76, RDW was 17.5, and her platelets were 433. The patient's
coagulations were normal. Chemistries were significant for a
blood urea nitrogen of 38 and a creatinine of 0.9; otherwise,
chemistry was normal.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
sinus tachycardia at a rate of 104.
A computerized axial tomography of the chest done in [**2105-7-17**] (per [**Hospital6 1129**] report) revealed
a dilated pulmonary artery and small bilateral pleural
effusions, with no metastases.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. UPPER GASTROINTESTINAL BLEED ISSUES: The patient was
seen by Gastroenterology in the Emergency Department and
underwent an upper endoscopy upon arrival to the Intensive
Care Unit.
The esophagogastroduodenoscopy report commented on blood in
the fundus and in the bulb, deformity of the pylorus, and a
small hiatal hernia. A follow-up esophagogastroduodenoscopy
was planned for the following morning due to the inability to
move the large blood clot in the stomach.
The patient was transfused two units of packed red blood
cells on the evening on admission and received one more unit
on the following day; for a total of three units during this
hospital admission. Her hematocrit remained stable for
several days at 30.
The repeat upper endoscopy showed a mass in the fundus and
antrum with no obvious bleeding site. There was blood in the
fundus and old adherent blood found throughout the stomach.
The hematemesis was thought likely due to an ulcerating mass.
The patient's Celebrex, aspirin, and iron were held during
this admission. The patient was started on high-dose
intravenous pantoprazole and was changed to a by mouth
regimen of pantoprazole 40 mg by mouth twice per day upon
discharge.
The patient was kept nothing by mouth with sips during the
first two days of her admission and was advanced to a clear
liquid diet on day three with good tolerance.
2. GASTRIC ADENOCARCINOMA ISSUES: The patient has known
metastases in her liver. She did not wish for chemotherapy
or surgical intervention.
The poor prognosis was discussed with the patient's family in
a family meeting, and it was thought that aggressive
treatment for her blood loss would be pursued for now. The
patient was aware of hospice services and will consider them
in the near future. The patient also did not wish to discuss
her prognosis and diagnosis; however, she was fully aware of
her illness.
3. RHEUMATOID ARTHRITIS ISSUES: The patient was continued
on her chronic prednisone dose at 10 mg by mouth once per day
even though this may add to her risk of bleeding. It was
thought that an adrenal insufficiency state would be more
harmful.
4. PAIN MANAGEMENT ISSUES: The patient was maintained on
her Fentanyl patch in addition to Tylenol and Vicodin. All
nonsteroidal antiinflammatory medications were held do to
worry of worsening gastrointestinal bleeding.
5. AORTIC STENOSIS ISSUES: The patient's aortic stenosis
was stable with a valve area of 0.9 cm2. She had no evidence
of congestive heart failure during this admission.
6. DEPRESSION ISSUES: The patient was continued on her home
dosing of citalopram and mirtazapine.
7. NUTRITIONAL ISSUES: The patient was encouraged to drink
clears; however, she had a small appetite. It was thought
that nutrition might become an issue in the near future for
this patient; however, she wished to eat without any
supplementation.
8. DISPOSITION ISSUES: A family meeting was held with the
patient's son on [**11-12**] to discuss long-term plans and
goals for this patient. It was decided that the patient
would continue to be do not resuscitate/do not intubate.
However, the patient wished to pursue aggressive treatment of
further bleeding episodes for now. The patient's family was
made aware of hospice and would be interested in this in the
near future (as explained above).
The patient was to be discharged to her rehabilitation
facility on [**Location (un) **] when a bed becomes available; likely on
[**11-12**] or [**11-13**].
A Physical Therapy Service consultation was obtained prior to
discharge in addition to a Palliative Care Service
consultation.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to On [**Hospital **]
Rehabilitation/Nursing facility.
MEDICATIONS ON DISCHARGE:
1. Prednisone 10 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Calcium carbonate and vitamin D.
4. Celexa 20 mg by mouth once per day.
5. Pantoprazole 40 mg by mouth twice per day.
6. Colace 100 mg by mouth twice per day.
7. Vitamin B12 by mouth every day.
8. Iron sulfate 325-mg tablets one tablet by mouth twice
per day.
9. Glucosamine one tablet by mouth twice per day.
10. Vicodin with dressing changes.
11. Trazodone 25 mg by mouth at hour of sleep.
12. Remeron 15 mg by mouth at hour of sleep.
13. Duragesic patch 25-mg patch transdermally q.72h.
Please note that the patient's Celebrex and aspirin should be
held indefinitely; however, the patient should continue her
daily prednisone dosing. The patient was also on a higher
dose of pantoprazole than previous to admission.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Gastric adenocarcinoma.
3. Aortic stenosis.
4. Rheumatoid arthritis.
5. Depression.
6. Chronic lower extremity ulcerations.
7. Diverticulosis.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up as indicated at
the rehabilitation facility.
2. The patient was also instructed to follow up with her
primary care physician as needed (Dr. [**First Name4 (NamePattern1) 30512**] [**Last Name (NamePattern1) 53939**]).
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**], M.D. [**MD Number(1) 1178**]
Dictated By:[**Last Name (NamePattern1) 9244**]
MEDQUIST36
D: [**2105-11-12**] 10:50
T: [**2105-11-12**] 11:06
JOB#: [**Job Number 53940**]
|
[
"197.7",
"714.0",
"424.1",
"578.0",
"707.12",
"285.1",
"V58.65",
"151.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10422, 10609
|
9572, 10401
|
1910, 2729
|
10642, 11175
|
5758, 9398
|
9413, 9545
|
141, 1064
|
1086, 1883
|
2746, 5724
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,919
| 168,667
|
680
|
Discharge summary
|
report
|
Admission Date: [**2173-12-8**] Discharge Date: [**2173-12-22**]
Date of Birth: [**2103-2-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2173-12-17**] - Pericardectomy
[**2173-12-14**] - Cardiac Catheterization
[**2173-12-10**] - Pericardial Window
[**2173-12-9**] - Cardiac Catheterization
History of Present Illness:
The patient is a 70 year old woman with history of PAF,
hypertension who presents with shortness of breath. The patient
has had some sob and cough since [**2173-11-15**], when she was admitted
to St E with chest pain (sharp, substernal, pleuritic,
non-positional), shortness of breath and fatigue found to be in
new afib and started on coumadin. At that time an ETT was
negative and she completed a r/o MI. She was hypoxic at that
time requiring 4-6L of nasal cannula. On [**2173-11-18**] she had a CTA
chest that showed small bilateral pleural effusions and
bilateral lower lobe atelectasis w/o evidence for PE. On [**2173-11-19**]
she had a tte ef>70% and trivial pericardial effusion. She
subsequently saw her cardiologist (at [**Hospital3 5097**]) who stopped
coumadin as has converted to sinus. She saw her PCP [**Last Name (NamePattern4) **] [**12-3**]
cough, sob, abd pain CT abd -> bilat effusions, small pericard
effusion and started on levoflox. She represented to her PCP
with worsening shortness of breath and fatigue and was referred
to the ED. She is very mildly short of breath and her cough is
dry. She only gets mild chest pain with coughing.
.
ED COURSE: Initial vital signs were 100.4 75 88/54 24 96%4L. She
transiently dipped her blood pressure to 80s which responded
slowly but well to 2L IVF. She also received 1 dose of empiric
decadron for adrenal insufficiency. She had a CTA that was
negative for PE but showed pericardial and pleural effusions as
well as mediastinal fat stranding. A formal TTE was done as well
which showed no tamponade physiology. CT surgery was consulted
with regard to the fat stranding and recommended getting
cultures of the effusions if possible. She received ceftriaxone
and azithromycin.
.
ROS: weight stable, prior abdominal bloating is gone. no rash.
no joint pain, no muscle pain. her last colonoscopy was 1year
ago and was normal. never been on steroids. no tanning of skin.
chronically constipated but had black stools 3 days ago. had
been drinking very little for the past week.
Past Medical History:
paroxysmal atrial fibrillation
dementia
hypertension
osteopenia
hypercholesterolemia
Social History:
Born in [**Country 532**], worked as xray tech, married and lives with
husband. One daughter lives out of state. no cig/drug/etoh.
never worked on farm nor in factory. no pets.
Family History:
Mother died of heart disease
Physical Exam:
T: 98.3 BP: 118/70 P:74 RR: 24 O2 sats: 93%6L, 91% on RA
pulsus [**10-29**]
Gen: NAD
HEENT:NCAT, PERRLA, EOMI
Neck: No masses, supple. no bruits, JVP ~12-13 cm
CV: Distant heart sounds, RRR no MRG, nl S1, S2
Resp: Dullness at base bilaterally, decreased breath sounds
bilaterally [**11-17**] way up
Abd: NABS, soft, NTND, no guarding/rigidity/rebound
Back: no CVA tenderness
Rectal: no tenderness, no masses Guaiac: negative brown stool
Ext: no CCE, 2+/4 symmetric pedal pulses
Neuro: a,ox3
CN: II-XII intact
Sensation: light touch intact to face/hands/feet
Strength: [**3-21**] in upper and lower extr
Skin: no rashes
Joints: no knee, wrist or hand swelling or tenderness
Pertinent Results:
EKG: sinus @70. nl axis and intervals. no ST-T changes. compared
to
CXR:
1. Moderate bilateral pleural effusions, left greater than
right.
2. Mild enlarged cardiac silouhette, with a slight globular
appearance.
CTA chest:
1. Moderate sized pericardial effusion with stranding in the
mediastinal and epicardial fat concerning for mediastinitis.
Given this finding, clinical correlation for infected
pericarditis is recommended. Given the early phase of imaging,
enhancement of the pericardium will not be detectable on this
study.
2. Large bilateral pleural effusions, left greater than right,
with
associated compressive atelectasis.
3. No evidence of pulmonary embolism.
4. Right thyroid nodules and calcifications. Clinically
correlate.
TTE: [**2173-12-8**] - Normal left atrium size. No ASD. Right atrial
pressure is 10-15mmHg. LV wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%) RV
chamber size and free wall motion are normal. There is abnormal
septal motion/position. Mildly dilated ascending aorta. Mildly
dilated aortic arch. The aortic valve leaflets (3) are mildly
thickened but no aortic stenosis. No AR. The mitral valve
leaflets are mildly thickened. No MVP. Physiologic MR. Moderate
[2+] TR. The estimated pulmonary artery systolic pressure is
normal. Small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade. Pericardial
constriction cannot be excluded.
TTE [**2173-12-9**] - Overall LV systolic function is normal (LVEF>55%).
RV chamber size and free wall motion are normal. There is
abnormal septal motion. Small, echodense pericardial effusion.
The pericardium appears thickened. The echo findings are
suggestive but not diagnostic of effusive-constrictive process.
There are no echocardiographic signs of tamponade.
IMPRESSION: Small echodense pericardial effusion without echo
signs of tamponade. Probable effusive-constrictive physiology.
If clinically indicated, a cardiac MR ([**Telephone/Fax (1) 5098**]) or right
heart catheterization is recommended to investigate for
constrictive physiology.
TTE [**2173-12-10**] - Pre-pericardial window:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Overall left ventricular systolic function is normal
(LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. Simple atheroma in the aortic arch and the descending
thoracic aorta.
5. Aortic valve leaflets are mildly thickened. No AR
6. The mitral valve leaflets are mildly thickened. No MR
7. The tricuspid valve leaflets are mildly thickened.
8. Small pericardial effusion measuring 1-1.2cm located
primarily along the inferior and inferior-lateral aspects of the
heart. The pericardium appears thickened. No echocardiographic
signs of tamponade.
9. There are bilateral pleural effusions, right greater than
left.
.
TTE Post-pericardial window:
1. Biventricular function is preserved.
2. The size of the pericardial effusion has decreased to 0.5 cm
along the inferior-lateral position.
3. Bilateral pleural effusions are no longer evident post-chest
tube placement.
[**2173-12-8**] WBC-19.8*# RBC-3.77* Hgb-11.6* Hct-33.2* MCV-88
MCH-30.8 MCHC-35.0 RDW-12.7 Plt Ct-401 Neuts-84* Bands-3
Lymphs-4* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-12-10**] WBC-12.5* RBC-3.98* Hgb-12.0 Hct-36.0 MCV-91 MCH-30.3
MCHC-33.4 RDW-12.4 Plt Ct-451*
[**2173-12-11**] WBC-10.5 RBC-3.91* Hgb-12.4 Hct-35.3* MCV-91 MCH-31.8
MCHC-35.1* RDW-13.0 Plt Ct-419
[**2173-12-12**] WBC-10.3 RBC-3.69* Hgb-10.9* Hct-32.8* MCV-89 MCH-29.6
MCHC-33.3 RDW-12.8 Plt Ct-334
[**2173-12-9**] PT-16.5* PTT-28.8 INR(PT)-1.5*
[**2173-12-10**] PT-15.3* PTT-44.9* INR(PT)-1.3*
[**2173-12-12**] PT-14.1* PTT-25.7 INR(PT)-1.2*
[**2173-12-8**] Glucose-117* UreaN-33* Creat-1.7* Na-133 K-4.9 Cl-96
HCO3-22
Calcium-8.6 Phos-3.3 Mg-2.2
[**2173-12-10**] Glucose-95 UreaN-23* Creat-1.1 Na-142 K-4.3 Cl-103
HCO3-27
[**2173-12-11**] Glucose-107* UreaN-16 Creat-0.9 Na-137 K-3.8 Cl-102
HCO3-23
[**2173-12-12**] Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.7 Cl-103
HCO3-27
[**2173-12-9**] 06:55AM BLOOD ALT-25 AST-17 LD(LDH)-252* AlkPhos-145*
TotBili-0.2
[**2173-12-10**] 10:05AM BLOOD LD(LDH)-229
[**2173-12-9**] 04:45PM BLOOD %HbA1c-6.1*
[**2173-12-11**] 08:10AM BLOOD TSH-2.4
[**2173-12-9**] 06:55AM BLOOD RheuFac-17* [**Doctor First Name **]-NEGATIVE
[**2173-12-9**] 06:55AM BLOOD [**Location (un) 5099**] VIRUS B ANTIBODIES-PND
[**2173-12-9**] 06:55AM BLOOD ADENOVIRUS ANTIBODY-PND
[**2173-12-12**] 07:40AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-PND
[**2173-12-8**] 03:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2173-12-8**] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2173-12-10**] 06:12PM PLEURAL TotProt-3.4 Glucose-114 LD(LDH)-1432
[**2173-12-10**] 06:13PM PLEURAL WBC-750* RBC-[**Numeric Identifier 5100**]* Polys-15*
Lymphs-65* Monos-0 Eos-1* Meso-8* Macro-11*
[**2173-12-10**] 1:31 pm PLEURAL FLUID
GRAM STAIN (Final [**2173-12-10**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Pending):
ACID FAST SMEAR (Final [**2173-12-11**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Pending):
[**2173-12-17**] 2:30 pm TISSUE PERICARDIUM.
GRAM STAIN (Final [**2173-12-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2173-12-20**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2173-12-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2173-12-19**]): NEGATIVE for Pneumocystis jirvovecii
(carinii).
CMV IgG ANTIBODY (Final [**2173-12-14**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
51 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
[**2173-12-14**] Cardiac Catheterization
1. One vessel branch coronary artery disease with diffuse
atherosclerosis.
2. Mild left and moderate right ventricular diastolic heart
failure.
3. Mild pulmonary arterial hypertension.
4. Hemodynamic findings consistent with pericardial
constriction.
Brief Hospital Course:
Mrs. [**Known firstname **] [**Known lastname 5101**] was admitted to the [**Hospital1 18**] on [**2173-12-8**] for further
management of her shortness of breath. An echocardiogram was
suggestive of a small pericardial effusion and pericardial
constriction could not be ruled out. A CTA was performed which
revealed a moderate sized pericardial effusion with stranding in
the mediastinal and epicardial fat concerning for mediastinitis.
Given this finding, clinical correlation for infected
pericarditis was recommended. The cardiology service was
consulted who recommended a pericardial window. The cardiac
surgery service was consulted and on [**2173-12-10**] Mrs. [**Known lastname 5101**] was taken
to the operating room where she underwent a pericardial window
with Dr. [**First Name (STitle) **]. Please see separate dictated operative note for
details. Pathology revealed organizing fibrinous pericarditis
with adjacent adipose tissue has a prominent perivascular
lymphocytic inflammation that is focally transmural (lymphocytic
vasculitis). The latter findings raise the possibility of the
spectrum of collagen vascular diseases. Viral and bacterial
cultures were negative except for an indeterminate past
cytomegalovirus. Postoperatively she developed rapid atrial
fibrillation for which digoxin and beta blocker were given. As
she remained in rapid atrial fibrillation, amiodarone was
started. Mrs. [**Known lastname 5101**] continued to have symptoms of constrictive
pathology and an echocardiogram was performed which confirmed
continued constriction. She was taken back to the
catheterization lab where she was found to have single branch
vessel coronary artery disease and hemodynamics strongly
suggestive of constrictive physiology. Given these findings it
was elected to return to the operating room. On [**2173-12-17**], Mrs. [**Known lastname 5101**]
was taken to the operating room where she underwent a sternotomy
with pericardiectomy. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. She later awoke neurologically intact and was
extubated. Diuresis was initiated. On [**2173-12-19**], Mrs. [**Known lastname 5101**] was
transferred to the cardiac surgical step down unit for
monitoring. Amiodarone was continued for atrial fibrillation.
Dr. [**Last Name (STitle) 171**] followed Mrs. [**Known lastname 5101**] and recommended [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts
monitor on discharge. Physical therapy worked with her daily to
increase her strength and mobility. Subcutaneous heparin was
started as she was not as ambulatory as expected. Coumadin was
started for atrial fibrillation. Mrs. [**Known lastname 5101**] continued to make
steady progress and was discharged to rehabilitation on [**2173-12-22**].
She will follow-up with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) 171**] and her primary
care physician as an outpatient. Dr. [**Last Name (STitle) 5102**] will manage her
coumadin dosing once she is discharged from rehabilitation for a
goal INR of 2.0-2.5 for atrial fibrillation.
Medications on Admission:
Levofloxacin started [**2173-12-3**]
atenolol 50 mg daily
aspirin 325 mg daily
hydrochlorothiazide 25 mg daily
simvastatin 20 mg daily
Actonel 35 mg weekly
colace
prilosec 20 mg daily
celebrex 200 mg
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 weeks: Then starting [**2173-12-29**] switch to 200mg daily until
otherwise instructed.
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Coumadin 1 mg Tablet Sig: Dose for goal INR of 2.0-2.5 for AF
Tablets PO once a day: Goal INR is 2.0-2.5 for AF. Tablet(s)
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
weeks.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Units Injection TID (3 times a day): Continue until INR
therapeutic.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Primary:
Pericardial effusion s/p pericardial window and pericardiectomy
Secondary:
Pleural effusion
Atrial fibrillation
Hypertension
Hypoxia
Acute renal failure
Discharge Condition:
Stable
Discharge Instructions:
1) Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or 5 pounds in one week.
Please contact surgeon with any wound issues. ([**Telephone/Fax (1) 1504**]
2) Shower daily. No baths, lotions, creams or powders to
incisions until they have fully healed.
3) No lifting more than 10 pounds for 10 weeks.
4) No driving for 1 month or until follow up with surgeon.
5) Take amiodarone 400mg daily for 1 week and then ([**2173-12-29**])
decrease to 200mg daily therafter.
6) [**Doctor Last Name **] of hearts monitor on discharge with daily transmissions
to Dr.[**Name (NI) 5103**] office.
7) Coumadin follow-up upon discharge from rehab as per
preasdmission with Dr. [**Last Name (STitle) 5102**] ([**Telephone/Fax (1) 5104**]. Goal INR is 2.0
for AF.
8) Continue sub Q heparin until INR therapeutic or patient is
ambulating more.
9) Call with any questions or concerns
Followup Instructions:
Please schedule an appointment with your primary care doctor Dr.
[**Last Name (STitle) 5102**] at [**Telephone/Fax (1) 5105**] in the next 1 to 2 weeks.
You should also schedule an appointment with cardiologist, Dr.
[**Last Name (STitle) 171**] ([**Telephone/Fax (1) 1987**] in the next 2 weeks.
Follow up with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1504**] in 4 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2173-12-22**]
|
[
"428.30",
"511.9",
"423.2",
"427.32",
"799.02",
"401.9",
"584.9",
"255.41",
"427.31",
"428.0",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"37.23",
"37.31",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
14979, 15056
|
10244, 13372
|
341, 500
|
15262, 15271
|
3626, 8837
|
16228, 16735
|
2887, 2917
|
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|
15077, 15241
|
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|
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|
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|
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|
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|
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|
528, 2568
|
9346, 9456
|
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|
2693, 2871
|
8869, 9009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,415
| 139,671
|
53003
|
Discharge summary
|
report
|
Admission Date: [**2127-11-18**] Discharge Date: [**2127-11-24**]
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone / Keflex
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is [**Age over 90 **] yo f with HTN, DM II, OA, and h/o Klebsiella UTI
(multi-drug resistant), who reportedly had episode of
hematemesis this AM. Pt lives at [**Hospital1 **], and vomited 80cc of
bright red blood this AM, and was also found to be tachycardic
and diaphoretic. She had SOB and abdominal pain as well. Per
pt's son, she was "sharp as a tack" 2 days ago for a birthday
party (her birthday is today), and now has worsened mental
status. No hx of diarrhea, hematochezia, hematuria, or dysuria.
Per pt's son, pt may have had course of [**Name (NI) **] for UTI several
months ago.
.
In the [**Name (NI) **], pt had Temp 101.6, BP 200/108, HR in the 140's, was
diaphoretic, and c/o abdominal pain. NG lavage was attempted x
2, but was unsuccessful due to pt's inability to cooperate. The
pt also refused central line placement. Pt was found to have a
dirty UA, and a CT abd showed pan-colitis. She was given 2L NS,
Levoflox 500mg IV, Vanc 1g IV, Morphine 2mg x 2, Protonix 40mg
IV, Metoprolol 5mg IV x 1, Anzemet 12.5mg x 1, and Tylenol 650mg
PR.
.
Past Medical History:
- DM type II - ? steroid induced (per notes) -> no meds
- Hypertension
- Osteoarthritis
- Rheumatoid arthritis on prednisone
- CRI - baseline creatinine is 0.9 to 1.3.
- Neurogenic bladder
- Dementia
- s/p total right hip replacement in [**2116**]
- PMR with chronic pain on prednisone, Fentanyl
- Depression
- h/o Klebsiella UTI (multi-drug resistant)/urosepsis
- h/o hyperkalemia
- Stage II sacral decub on R buttock
Social History:
Has lived at [**Hospital **] nursing home x several years. Is bedbound and
needs assistance w/ ADLs like eating/dressing/toileting because
of her contractures and pain. She is DNR/DNI.
Family History:
NC
Physical Exam:
Vitals: T 96.3 BP 168/109 HR 118 RR 31 O2 98% RA
Gen: elderly female, moaning occasionally
HEENT: PERRL
Neck: Supple. JVD flat
Cardio: tachycardic, no m/r/g appreciated
Resp: crackles [**3-8**] way up on R, crackles [**1-6**] way up on L
Abd: soft, nd, diffusely tender, +BS, no rebound/guarding
Ext: LE contractures. No c/c/e
Neuro: A&Ox1 (knows only name)
Rectal (per ED): brown stool, guaiac negative
Pertinent Results:
CT abd: Pancolitis. The appearance is nonspecific and could be
secondary to infection, an inflammatory process, or ischemia.
Severe atherosclerotic disease; however, the mesenteric vessels
appear patent. Gallbladder fundal adenomyosis. Low attenuation
splenic foci, which are incompletely characterized on this exam.
.
CXR: Cardiomegaly with a tortuous aorta is again seen and
unchanged. Pulmonary vascularity is unremarkable. No
infiltrate or consolidation is identified within the lung. No
pleural effusion is seen. No intraperitoneal free air is
identified. Gas-distended fundus of the stomach is noted.
.
EKG: sinus tach @ 126, LAD, nl intervals, <1mm STD in V5-V6
Brief Hospital Course:
A/P: [**Age over 90 **] yo f with HTN, DM II, OA, h/o UTI's, who now presents
with hematemesis, UTI, and pan-colitis.
.
#) Hematemesis: Upon admission, the patient was reported to have
approximately 50cc of hematemsis. She was admitted to [**Hospital Unit Name 153**] in
hemodynamically stable condition. Her Hct upon admission was
50.0, thought to represent hemoconcentration [**2-6**] severe
dehydration in the setting of pan-colitis. This returned to her
baseline around 28-30 after IVF hydration and then remained
stable. GI was made aware of pt, however plan for EGD was
deferred as pt/family wish to avoid aggressive invasive
measures. The patient had no further episodes of hematemesis
and her Hct remained stable. ASA, NSAIDS were avoided and she
was put on Protonix.
.
#) Pan-colitis: An abdominal CT scan with contrast upon
admission showed a pan-colitis. The differential included
infectious (? C dif), inflammatory, or ischemic causes. An
infectious etiology was thought to be most likely given fever,
elevated WBC count, and was guaiac negative. Ischemia was
thought to be less likely given pan colitis distribution. Stool
cultures were sent and were negative (C dif x 3 was negative as
well as Campylobacter, O&P and stool culture. She was treated
with flagyl, and meropenem for 6 days. Pain control acheived
with fentanyl patch + prn morphine. After three negative C difs
and clinical improvement in her abdominal exam, her antibiotics
were discontinued.
.
#) Respiratory distress/Hypoxia: While in the ICU, the patient
was noted to have one episode of mild respiratory distress with
pulmonary edema after getting IVF hydration. She was
approximately +7 Liters at the time after aggressive IVF
hydration for pan-colitis. Her respiratory distress was [**2-6**]
volume overload and mild CHF from diastolic dysfunction. She
was gently diuresed with excellent response to Lasix 10mg IV and
got daily Lasix. She will be discharged on daily PO Lasix which
will need to be titrated based on daily weights, monitoring Cr
and UOP (this was discussed with patient's PCP [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) **]
before discharge).
.
#) Acute Renal Failure: Upon admission, the patient's Cr was 1.0
(near her baseline 0.9-1.3). Her Cr climbed to as high as 1.4
after gentle diuresis for volume overload with Lasix. Her
creatinine trended down and was 1.2 upon discharge. Her volume
status and creatinine will need to be monitored as an outpatient
as she will be going home on daily Lasix 10mg daily (this may
need to be titrated, possibly qday or QOD).
.
#) UTI: The patient has a long history of multiple Klebsiella
UTIs that are multi-drug resistant (ESBL, extended spectrum
beta-lactamase producing). Her urine culture upon admission
showed Klebsiella (again ESBL but sensitive to Meropenem, pt
cannot take cephaloporins or PCN, Klebsiella was resistant to
Cipro, Bactrim, Nitrofurantoin and Levofloxacin). She completed
a 6 day course of Meropenem.
.
#) Tachycardia: The patient was admitted with tachycardia to the
120s thought to be [**2-6**] intravascular volume
depletion/dehydration as well as from diffuse abdominal pain.
After volume resuscitation upon admission and resolution of
pain, the patient's HR improved. She appears to run between
90s-105 at baseline.
.
#) Hypertension: Pt has a h/o of HTN, which was treated with
metoprolol and initially with prn hydral and nitropaste. Her
blood pressure improved during her hospital stay and she
required only Metoprolol to control her BP during the remainder
of her hospital stay.
.
#) Fever: Thought to be secondary to UTI and colitis. She
completed 6 days of Meropenem for resistent Klebsiella UTI and
Flagyl for colitis of unclear etiology (C dif x 3 negative).
Her fevers trended down during this admission and she was
afebrile before discharge.
.
#) Mental status change: Thought to be likely secondary to
infection and hypovolemia superimposed on mild dementia. On HD
#2, her MS improved significantly after IVFs. She was restarted
on Remeron and Neurontin after her mental status returned to
baseline.
.
#) Arthritis: Stable. She was continued on her outpatient
low-dose prednisone, and fentanyl patch.
.
#) DM II: Her diabetes was reportedly diet controlled (thought
possibly to be [**2-6**] steroids). Finger sticks were elevated on
admission likely due to infection. She was maintained on an
insulin sliding scale and required minimal coverage.
.
#) FEN: Patient was maintained on a regular diet with thickened
liquids.
.
#) Comm: son [**Name (NI) 109259**] [**Name (NI) 12246**], HCP (cell: [**Telephone/Fax (1) 109181**], office:
[**Telephone/Fax (1) 109260**], home: [**Telephone/Fax (1) 109261**], admin assistant Ms. [**Last Name (Titles) 8260**]
[**Telephone/Fax (1) 109262**]), grandson [**Name (NI) **] ([**Telephone/Fax (1) 109263**])
.
#) Code: DNR/DNI (discussed with son, [**Name (NI) 109259**] [**Name (NI) 12246**]); Son
requesting no aggressive procedures preferring instead for
medical management
.
Medications on Admission:
MEDS (per last d/c summary):
Atenolol 25 mg qd
Prednisone 5 mg qd
Mirtazapine 15 mg qhs
Bisacodyl 10 mg qd prn
Acetaminophen 325 mg q4-6h prn
Gabapentin 300 mg qhs
Fentanyl 150 mcg/hr Patch 72HR
Aspirin 325 mg qd
Pantoprazole 40 mg qd
MVI
Polysaccharide Iron Complex 150 mg qd
Lidocaine HCl 2 % 1ml tid prn mouth discomfort
Nystatin 100,000 unit/mL Suspension qid prn
Ipratropium Bromide 0.02 % Solution q6h prn
Hep SC tid
Colace [**Hospital1 **] prn
[**Hospital1 **] [**Hospital1 **] prn
Insulin sliding scale
Oxycodone 5 mg q4-6h prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
GI bleed
Pan-colitis
UTI
.
Secondary:
DM Type II
HTN
Osteoarthritis
Rheumatoid arthritis
CRI (baseline Cr 0.9-1.3)
Neurogenic bladder
Dementia
s/p total right hip replacement [**2116**]
PMR with chronic pain on fentanyl, prednisone
Depression
H/O Klebsiella UTI (multi-drug resistant)
Stage II sacral decub on R buttock
.
Discharge Condition:
.
Stable: Taking good PO intake, abdominal pain resolved, no
further episodes of hematemesis
.
Discharge Instructions:
.
1- Please take all medications as prescribed. You were started
on a new medication, Lasix (Furosemide), which will help to
prevent congestive heart failure and fluid buildup in your
lungs. This was discussed with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) **]. The patient should be followed with daily
weights, O2 sat, and electrolytes should be monitored including
Creatinine and Potassium to titrate Lasix dosing.
.
2- Your aspirin and subQ heparin were stopped because you had a
GI bleed. Please start pneumoboots for DVT prophylaxis as an
outpatient.
.
3- Please call your doctor if you experience worsening shortness
of breath, fevers, abdominal pain or worsening diarrhea.
.
Followup Instructions:
.
Please followup with your physicians at [**Hospital1 599**] and with your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2127-11-24**]
|
[
"276.51",
"585.9",
"599.0",
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"714.0",
"403.90",
"428.0",
"725",
"294.8",
"E932.0",
"556.6",
"707.03",
"428.31",
"V58.65",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8808, 8880
|
3173, 8222
|
263, 269
|
9255, 9352
|
2472, 3150
|
10172, 10502
|
2027, 2031
|
8901, 9234
|
8248, 8785
|
9376, 10149
|
2046, 2453
|
212, 225
|
297, 1366
|
1388, 1808
|
1824, 2011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
406
| 174,925
|
45912
|
Discharge summary
|
report
|
Admission Date: [**2126-10-24**] [**Month/Day/Year **] Date: [**2126-10-29**]
Date of Birth: [**2058-1-29**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Vancomycin / Codeine
Attending:[**First Name3 (LF) 9157**]
Chief Complaint:
Fevers.
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
69 yo F with a hx/o cervical cancer s/p radiation with several
radiation-induced sequelae (short gut syndrome requiring
long-term TPN via indwelling central line, resultant central
line infections, and recurrent UTIs in setting of radiation
cystitis & self-catheterization) presents to ED via EMS for
fevers accompanying her most recent TPN infusion. Pt also
reports urinary frequency.
According to the patient, she awoke at 2 AM with shakes & a
fever to 104. She was too tired to go to the ED, but took
tylenol. She continued to intermittently wake up with
fevers/chills through the morning. She relates her symptoms to
starting her TPN cycle just before these episodes. She mentions
several days of urinary urgency, frequency, & cloudy urine. She
has had at least 10 admissions for UTI/urosepsis with cultures
revealing frequent enterococcus & recently a resistant E coli
UTI last winter.
The patient's central line was changed about 4 days ago prior to
admission for frequent leaks. The patient recounts numerous
line infections. She does daily alcohol dwells to prevent
infection.
Upon arrival to the ED, her initial vitals were T103.4, HR 101,
BP 117/100, RR 18, Sat 100RA. She was given 2LNS immediatley.
Urinalysis revealed significant leukouria, and she had a WBC
elevation to 21.0 with 95%PMN. Creatinine was 1.5 from 1.0,
though lactate normal at 1.9. Per ED staff, the central line
site was mildly erythematous but did not appear infected. CXR
unremarkable. She received vancomycin. Her BP was reportedly low
in the 88-90 range following administration of dilaudid for
pain. Prior to transfer to MICU, VS were P 82 BP 88/41 Sat 99RA
RR 14.
Upon arrival to the MICU, her initial VS were: T 102.9 P 101 BP
147/53 P 75 RR 20 Sat 98% RA. She complained of feeling poorly
and endorsed recent generalized aches, malaise, headaches,
fatigue, weakness for the past few days. There is no abdominal
pain or change in ostomy output. She feels dehydrated but has
been trying to keep up with fluid intake. No N/V. No NSAIDs. No
chest pain or shortness of breath.
She has chronic pain from her back, neck, and "entire left
side." On chronic opioids including methadone 5mg & oxycodone
5mg QID. Current pain [**7-28**] when [**6-28**] is at baseline.
Past Medical History:
1. Cervical CA s/p TAH BSO ([**2096**]), XRT with recurrence in [**2097**]
2. Radiation cystitis & urinary Retention
----> Performs straight catheterization ~8x per day
4. R ureteral stricture
----> c/b recurrent infections
----> s/p right nephrectomy ([**2123**])
5. Recurrent UTIs:
----> Klebsiella (amp resistant)
----> Enterococcus (Levo resistant)
6. Radiation enteritis s/p colostomy ([**2109**]) with resultant short
gut syndrome
----> TPN x 15 years via indwelling central line (Hickman)
----> Multiple prior PICC line / Hickman infections
7. Osteoporosis
8. Hypothyroidism
9. Migraine HA
10. Depression
11. Fibromyalgia
12. Chronic abdominal pain syndrome
13. DVT / thrombophlebitis from indwelling central access
14. Lumbar radiculopathy
15. SBO followed by surgery
[**31**]. STEMI [**2-20**] Takotsubo CMP (clean coronaries on cath [**4-27**])
17. Hyponatremia: previously attributed to HCTZ use
19. Suspected [**Month/Year (2) **] [**3-/2126**]
Social History:
- Lives with her husband in an [**Hospital3 4634**] [**Last Name (un) **].
- Tobacco: 80-pack-year smoking history but quit 18 years ago.
- EtOH: Denies
- Illicit drug use: Denies
- Ambulates with a walker but frequently falls
- Independent in ADLS.
Family History:
- Father: EtOH abuse, CAD
- Brother: RCC, CAD
- 3 children, all healthy.
Physical Exam:
ADMISSION EXAM:
Vitals: T103.4 HR 101, BP 117/100, RR 18, Sat 100RA.
General: fatigue, weak appearing, speaking softly, shaking
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: ostomy bag with liquid stool. soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: right subclavian CVL site is clean, nonerythematous, no
exudates.
[**Last Name (un) 894**] EXAM:
Afebrile.
GEN: Thin woman asleep, rouses easily to voice. NAD.
HEENT: NCAT, MMM
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB no c/w/[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]: +NABS in 4Q. Soft, mild TTP in epigastrium with voluntary
guarding. No involuntary guarding or rebound.
EXT: WWP, no c/c/e.
NEURO: Responds appropriately to questions. MAEE.
Pertinent Results:
ADMISSION LABS:
--------------
[**2126-10-24**] 11:09PM TYPE-MIX
[**2126-10-24**] 11:09PM O2 SAT-69
[**2126-10-24**] 09:52PM SODIUM-123* POTASSIUM-4.3 CHLORIDE-96
[**2126-10-24**] 04:40PM URINE HOURS-RANDOM UREA N-329 CREAT-46
SODIUM-20 POTASSIUM-36 CHLORIDE-40
[**2126-10-24**] 04:40PM URINE OSMOLAL-251
[**2126-10-24**] 04:40PM URINE UHOLD-HOLD
[**2126-10-24**] 04:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2126-10-24**] 04:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2126-10-24**] 04:40PM URINE RBC-1 WBC-86* BACTERIA-NONE YEAST-NONE
EPI-0
[**2126-10-24**] 04:40PM URINE WBCCLUMP-FEW
[**2126-10-24**] 04:26PM LACTATE-1.9
[**2126-10-24**] 04:12PM GLUCOSE-93 UREA N-19 CREAT-1.5* SODIUM-123*
POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-19* ANION GAP-18
[**2126-10-24**] 04:12PM WBC-21.0*# RBC-3.42* HGB-9.6* HCT-28.6*
MCV-84 MCH-28.1 MCHC-33.7 RDW-13.4
[**2126-10-24**] 04:12PM NEUTS-94.8* LYMPHS-3.6* MONOS-1.4* EOS-0
BASOS-0.1
[**2126-10-24**] 04:12PM PLT COUNT-270
[**2126-10-24**] 04:12PM PT-12.6 PTT-28.9 INR(PT)-1.1
10/06/1 URINE CULTURE (Final [**2126-10-25**]):
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 ORGANISMS/ML..
CXR [**2126-10-24**]: Note is made of a dialysis catheter, with the tip
terminating at the upper cavoatrial junction. Cardiac,
mediastinal and hilar contours are normal. There is a calcified
right breast implant. The lungs are clear. There is no pleural
effusion or pneumothorax. A chronic L1 compression fracture is
unchanged.
RENAL ULTRASOUND [**2126-10-25**]:
Normal-appearing left kidney. Collapsed bladder is not well
visualized.
[**Month/Day/Year 894**] LABS:
--------------
[**2126-10-28**] 05:43AM BLOOD WBC-4.0 RBC-2.84* Hgb-8.0* Hct-23.6*
MCV-83 MCH-28.1 MCHC-34.0 RDW-13.6 Plt Ct-247
[**2126-10-29**] 05:59AM BLOOD Glucose-101* UreaN-7 Creat-1.2* Na-135
K-3.9 Cl-101 HCO3-22 AnGap-16
[**2126-10-29**] 05:59AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Patient is a 68-yo F w recurrent TPN-line infections, recurrent
UTIs due to self-catheterization for radiation cystitis presents
with sepsis.
ACTIVE DIAGNOSES:
# Septic Shock: Patient was initially hemodynamically stable on
admission with fevers to 102-103, leukocytosis, & tachycardia.
Her lactate & CV sat were within normal limits. Her systolic
blood pressure fell to the 70s systolic but remained fluid
responsive; received an additional 5 L normal saline in the MICU
in addition to 2L given in the ED. Pressors were not required
and her BP stabilized by her second hospital day. Suspected
sources included UTI versus line infection. She began IV
vancomycin & meropenem based on a history of resistant
enterococcus & E coli UTI, as well as serratia line infections.
Blood cultures pulled off the line failed to grow bacteria, and
the access site was nonerythematous without pain or [**Month/Day/Year **].
Here line was therefor not changed or removed. Urine culture
eventually showed Group B Strep; meropenem was discontinued. On
the floor the patient's vital signs were stable. Her blood
cultures continued to be negative. As such, her urine was
thought to be the most likely source of sepsis.
# Urinary Track Infection: The patient's urine culture revealed
10-100K Group B Strep. She was continued on vancomycin with a
plan to [**Month/Day/Year **] her with vancomycin 1g Q24H infusions for a
total of two weeks. She will have her vancomycin trough as well
as basic labwork checked twice before her course of antibiotics
is completed. Although group B strep is sensitive to
penicillin, the patient refused medications that required dosing
any more frequently than twice a day.
# Acute Kidney Injury: The patient's creatinine on admission
was elevated to 1.5 from baseline of [**1-19**].2. Given her
hypotension, this was likely due to prerenal [**Last Name (un) **]. Her
creatinine slowly improved with fluid resuscitations; it was 1.2
for several days prior to [**Last Name (un) **].
#. Hyponatremia: Her initial Na low at 123. No mental status
changes apparent on exam. Her sodium improved with fluid
resuscitation suggesting a component of hypovolemia. On
[**Last Name (un) **] her sodium was 122.
CHRONIC DIAGNOSES:
# Hypertension: The patient was noted to have blood pressures as
high as 190s on her last day of admission. She may need to have
her blood pressure medications readjusted as an outpatient.
# Chronic Pain: The patient endorses chronic musculoskeletal &
abdominal pain. On the floor, she was restarted on her home
regimen of methadone 5 mg QID & oxycodone.
# Short Gut Syndrome: The patient will resume TPN on [**Last Name (un) **].
# Hypothyroidism: Levothyroxine was continued.
# Depression: Fluoxetine was continued.
# Fibromyalgia: Pain control as above.
# Radiation Cystitis: Initially a Foley placed. This was
discontinued on the floor; the patient self-catheterizes.
#. Anemia: The patient's HCT was stable in the high twenties
through admission, which is her baseline level.
TRANSITIONAL ISSUES:
# Infusion Set-Up: The patient was reinitiated on her TPN as an
outpatient. Vancomycin infusions were set-up with her infusion
company (course to complete on [**2126-11-7**]). She will need
outpatient labwork for as long as she is on vancomycin.
# Outpatient Labwork: The patient was provided with
prescriptions for a vanco trough & basic metabolic chemistries
on [**11-1**] & [**11-5**] to monitor for possible side effects of her
antibiotics. The patient was instructed to ensure that the
labwork is faxed to her PCP's office.
# Follow-Up: The patient will follow-up with her primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **].
Medications on Admission:
ALPRAZOLAM - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia
BETAMETHASONE DIPROPIONATE - 0.05 % Lotion - apply to rash twice
a day
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg
Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for
headaches
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1000
mcg/ml IM once a month
DARIFENACIN [ENABLEX] - 15 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth daily Mon thru Fri, skip Sat and Sun
ESTRADIOL [VIVELLE-DOT] - 0.0375 mg/24 hour Patch Semiweekly -
apply one patch twice weekly
ETHANOL 70% - - 2 mL ethanol lock, 2 hour dwell time, each
lumen, repeated every 24 hr
FEXOFENADINE [[**Doctor First Name **]] - 60 mg Tablet - 1 Tablet(s) by mouth
once a day
FLUOXETINE [PROZAC] - 20 mg Capsule - 1 Capsule(s) by mouth
three times a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth four times a
day
HYOSCYAMINE SULFATE - (Prescribed by Other Provider) - 0.125 mg
Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed
for bladder spasm
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth once a day
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - one patch once a day
LISINOPRIL - 10 mg Tablet - 3 Tablet(s) by mouth once a day
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day as
needed.
MECLIZINE - 25 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for dizziness
METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth four times a day
for pain
METRONIDAZOLE - 0.75 % Gel - apply to rash twice a day
ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth every eight
(8) hours as needed for nausea
OXYCODONE - 5 mg Tablet - one Tablet(s) by mouth every six (6)
hours as needed for pain
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
PILOCARPINE HCL [SALAGEN] - 5 mg Tablet - one Tablet(s) by mouth
four times a day
SUMATRIPTAN SUCCINATE - 50 mg Tablet - 1 Tablet(s) by mouth at
onset of headache. [**Month (only) 116**] take additional 1 tablet in 2 hours as
needed.
[**Month (only) **] Medications:
1. vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
every twenty-four(24) hours for 9 days: Please run slowly over 2
hours. To end on [**2126-11-7**].
[**Date Range **]:*9 g* Refills:*0*
2. Outpatient Lab Work
Vanco trough before dose on [**2126-11-1**] and [**2126-11-5**]. Fax results
to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] at [**Telephone/Fax (1) 4004**].
3. Outpatient Lab Work
Please draw basic metabolic panel on [**2126-11-1**] and [**2126-11-5**]. Fax
results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] at [**Telephone/Fax (1) 4004**].
4. Heparin LockFlush(Porcine)(PF) 10 unit/mL Syringe Sig: Five
(5) mL Intravenous as dir: Flush with heparin 5 mL 10 units/mL
after each dose of antibiotic or TPN. SASH.
[**Telephone/Fax (1) **]:*QS 30 day supply* Refills:*0*
5. Saline Flush 0.9 % Syringe Sig: Five (5) mL Injection As
directed: Flush with 5 mL normal saline before & after each
medication & TPN. SASH.
[**Telephone/Fax (1) **]:*QS 30 day supply* Refills:*3*
6. Central Line Dressing
Change dressing & tubing weekly.
7. Ethanol 70%
To be instilled into each central catheter lumen for local dwell
for 2 hours daily at completion of TPN or if no TPN, instilled
into each central catheter lumen for local dwell for 2 hours
daily.
[**Telephone/Fax (1) **]: QS
Refill: 0
8. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. betamethasone dipropionate 0.05 % Lotion Sig: One (1)
application Topical twice a day: To rash.
10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
11. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
12. darifenacin 15 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
13. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO As directed: [**Telephone/Fax (1) 766**]-Friday (skip Sat & Sun).
14. Vivelle-Dot 0.0375 mg/24 hr Patch Semiweekly Sig: One (1)
patch Transdermal Twice weekly.
15. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO three times
a day.
17. gabapentin 300 mg Capsule Sig: One (1) Capsule PO four times
a day.
18. hyoscyamine sulfate 0.125 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for bladder spasm.
19. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
21. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
22. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
23. meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for dizziness.
24. methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
25. metronidazole 0.75 % Gel Sig: One (1) application Topical
twice a day: to rash.
26. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
27. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
28. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
29. pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
30. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
once a day as needed for headache: Take at onset of headache.
[**Month (only) 116**] take additional 1 tablet in 2 hours as needed.
[**Month (only) **] Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
[**Last Name (NamePattern1) **] Diagnosis:
PRIMARY DIAGNOSIS:
- Sepsis
SECONDARY DIAGNOSIS:
- Urinary tract infection
- Indwelling TPN line
[**Last Name (NamePattern1) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Last Name (NamePattern1) **] Instructions:
Ms. [**Known lastname 13275**], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to the hospital with a serious
infection leading to a condition called "sepsis". Your blood
pressure was low so you went to the ICU. Your blood cultures
were negative and we did not feel that your TPN catheter was
infected. We did find, however, that you may have a urinary
tract infection that could have been the cause of your symptoms.
You were started on antibiotics to treat your infection. These
antibiotics will need to be continued with your home infusion
company for 9 days after your [**Hospital1 **].
MEDICATIONS CHANGED:
- Medications ADDED:
----> Please START taking vancomycin 1g IV every day (Start date
[**2126-10-24**], end date [**2126-11-7**])
- Medications STOPPED: None.
- Medications CHANGED: None.
You will have labwork drawn periodically to monitor your kidney
function, which will be followed up by your primary care doctor.
Followup Instructions:
The following appointments have been scheduled for you:
PCP:
[**Name Initial (NameIs) **]: [**Hospital3 249**]
When: [**Hospital3 **] [**2126-11-4**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*Dr. [**First Name (STitle) 1022**] will be following up on the labs that will be drawn
periodically (first draw on [**2126-11-1**]).
Department: RHEUMATOLOGY
When: WEDNESDAY [**2127-2-5**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GASTROENTEROLOGY
When: THURSDAY [**2127-3-20**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"V45.73",
"584.9",
"244.9",
"412",
"785.52",
"599.0",
"401.9",
"595.82",
"909.2",
"038.9",
"338.29",
"729.1",
"E879.2",
"579.3",
"733.00",
"V44.3",
"276.1",
"311",
"V10.41",
"276.2",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7024, 7203
|
320, 329
|
4990, 4990
|
18139, 19319
|
3880, 3954
|
10806, 16785
|
3969, 4971
|
10123, 10780
|
273, 282
|
357, 2614
|
16835, 16928
|
5006, 7001
|
16804, 16814
|
16943, 18116
|
7221, 10102
|
2636, 3596
|
3612, 3864
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,196
| 138,757
|
24080
|
Discharge summary
|
report
|
Admission Date: [**2199-3-2**] Discharge Date: [**2199-3-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation;
Esophagoduodenogastroscopy.
History of Present Illness:
The patient was and 84 year old male with a history of HTN and
DMII who was in his usual state of health until threee days
prior to admission when he developed a mild, nonproductive
cough, rhinorrhea, diarrhea and a fever to 100F. On the night of
admission, he awoke with sudden onset of shortness of breath. He
called EMS who documented an oxygen saturation of 95% on 100%
NRB. On arrival to the ED, th OS was in the 80's on room air:
hypertension, tachypnea and tachycardia were noted. On review of
systems, he denied chest pain, joint/muscle aches, abdominal
pain, nausea, vomiting, prior PND (before the episode as above),
swelling or orthopna. There was no recent plane rides or orther
prolonged stationary period, trauma, or history of surgery.
ED course: OS 80s RA. He was hypertensive, tachypnic and
tachycardic (SVT). CXR showing upper/midzone multilobar PNA.
Ceftriaxone and Azithromycin were started.
Past Medical History:
HTN, DMII, Glaucoma.
Social History:
The patient lives with his wife and has a son. [**Name (NI) **] is active with
daily exercises. He quit tobacco 30 years prior.
Family History:
NC.
Physical Exam:
temp 100.6, BP 157/79, HR 107-102, RR 26-28, O2 89% on 2L -->
97% on 100% NRB
Gen: resting comfortably in minimal resp distress
HEENT: nonicteric sclera, MM slightly dry
Neck: +JVD to 7cm
Chest: crackles at bases bilaterally
CV: tachy, reg rhythm, no murmurs
Abd: +BS, soft, NTND
Ext: no edema
Neuro: grossly intact
Pertinent Results:
[**2199-3-2**] 03:00AM WBC-12.4* RBC-4.31* HGB-11.8* HCT-34.0*
MCV-79* MCH-27.4 MCHC-34.7 RDW-14.2
[**2199-3-2**] 03:00AM NEUTS-86.9* BANDS-0 LYMPHS-9.4* MONOS-2.0
EOS-1.6 BASOS-0.2
[**2199-3-2**] 03:00AM PLT COUNT-317
.
[**2199-3-2**] 03:00AM GLUCOSE-174* UREA N-15 CREAT-1.0 SODIUM-136
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-19* ANION GAP-19
[**2199-3-2**] 03:22AM LACTATE-4.5*
[**2199-3-2**] 03:00AM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.5*
.
[**2199-3-2**] 03:00AM CK-MB-NotDone cTropnT-<0.01 proBNP-1100*
[**2199-3-2**] 11:20AM CK(CPK)-55
[**2199-3-2**] 11:20AM CK-MB-NotDone cTropnT-0.03*
[**2199-3-2**] 03:30PM CK(CPK)-53
[**2199-3-2**] 03:30PM CK-MB-NotDone cTropnT-0.03*
.
[**2199-3-2**] 06:47AM LACTATE-1.0
.
[**2199-3-2**] 06:47AM TYPE-ART PO2-76* PCO2-33* PH-7.43 TOTAL
CO2-23 BASE XS-0
.
Brief Hospital Course:
The patient was admitted with increasing respiratory distress
and was intubated. He then completed a seven day course of ABX
for CAP. A definite pathogen was not identified, but atypical
(possibly malignant vs premalignant) cells were seen in BAL
along with chest imaging revealing upper lung-zone infiltrates.
He improved from a respiratory standpoint and was weaned from
MV. He suffered several episdoes of new-onset AF/RVR in the
setting of his acute illness - a BB was added and titrated. Of
note, the patient had SBPs to the 200s upon extubation, but
otherwise tolerated it well. His BB and ACe-i were increased
accordingly. The patient's post-ICU course was complicated by
resolving confusion as well as an incidental upper GI bleed
(proven to be from PUD).
1. Resp Distress: The patient had an ICU MV/intubation course as
above. On admission, he leukocytosis, increased lactate, and
fever with multifocal PNA vs ARDS on CXR. His Chest CT showed
dense apical infiltrates of unclear etiology, but he did well on
CAP Rx (Ceftriaxone and Azithromycin). There was likely
underlying lung disease of unclear etiology contributing to his
clinical picture. His BAL was without organisms , but showed
atypical cells (see below). Amongst and after MV, he was
continued on Ipratropium Bromide Neb 1 NEB IH Q6H:PRN and O2: by
the middle of his course (soon after transfer to the floor) he
was stable on room air and seemed comfortable. He was scheduled
for Pulmonary follow-up.
2. UGIB: Late in his course, the patient had asymptomatic
melena. He was consistently hemodynamically stable and c
omfortable. He had a positive NG lavage (red-brown, coffee
grounds) and a subsequent EGD showing a duodenal
clotted/bleeding ulcer and received cautery and local
epineprhine INJ. He received one unit of PRBC and was
hematocrit-stable thereafter. He was followed by the GI service
and was commenced on PPI [**Hospital1 **]. H. pylori antibodies were pending
on discharge.
3. Atypical Lung Cells: Upon BAL, abnormal cells were visualized
which were deemed likely mucinous metaplasia, but the low
possibility of mucinous adenocarcinoma existed. Pulmonary
follow-up and repeat imaging was arranged.
4. PAF: He had new onset PAF/RVR over this hospital course,
which was possibly related to the acute stress of infectiona and
resp distress. This initially manifested in the MICU, but he
then had brief bursts (3-5 seconds) of SVT vs PAF and sinus
tachycardia on the floor. He was continued BB, while monitoring
his PR prolongation. Anticoagulation was not started given the
fact this was a new-onset AF in the setting of acute illness and
his new UGIB. A possible Holter as outpatient after acute
stressors resolved was deferred to his PCP.
5. HTN: He was titrated on the following regimen for relatively
difficult to manage HTN: Lisinopril 40 mg PO DAILY, Metoprolol
37.5 mg PO TID, HCTZ 50 mg PO DAILY, and Amlodopine 5 mg PO
DAILY.
6. DMII: He was on FS QID with Insulin SC. He was controlled
with Metformin at home.
7. Enlarged Thyroid: An incidental heterogeneous thyroid with
coarse calcifications and associated adenopathy was seen on CT,
concerning for malignancy. His TFTs were normal. An U/S showed
a large dominant nodule within the right lobe of the thyroid
gland (5.4 cm) and a heterogeneous appearance of the left lobe
of the gland. He was slotted to have outpatient endocrine
follow-up and a biopsy for a malignancy evaluation.
Medications on Admission:
metformin
lisinopril
nifedipine
MVI
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
3. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
4. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 600 mg
Miscell. [**Hospital1 **] (2 times a day) for 4 doses: Mucomyst 600 mg by
mouth in the morning and the evening of [**4-22**] and then again
immediately after the CAT Scan - on [**2199-4-23**], please take
Mucomyst 600 mg by mouth at 1PM and then again in the evening. .
[**Year (4 digits) **]:*2400 bottle* Refills:*0*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO twice a day.
[**Year (4 digits) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO once a
day: Please confirm this dosing with your primary doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
1) Apical Multi-Lobar Pneumonia.
2) Duodenal Peptic Ulcerative Disease and Hemorrhage.
Secondary Diagnosis:
3) Hypertension.
4) Diabetes Mellitus Type II.
Discharge Condition:
Good/Stable.
Discharge Instructions:
1) If you have any dark or black stools, diarrhea, nausea,
vomiting, abdominal pain, light-headedness,dizziness, you may be
bleeding in your stomach; please contact your doctor or return
to the emergency room immediately.
2) If your breathing becomes difficult, or you become short of
breath, have fevers, chills, sweats or any other concerning
symptoms please contact your doctor or return to the emergency
room.
3) Please take your new medications as instructed.
4) You have a CAT Scan of your chest scheduled for [**2199-4-22**]. Please take Mucomyst 600 mg by mouth in the morning and
the evening of [**4-22**] and then again immediately after the CAT
Scan - on [**2199-4-23**], please take Mucomyst 600 mg by mouth
at 1PM and then again in the evening. Please do not eat any
solid foods for three hours before the CAT Scan.
Followup Instructions:
1) Please see your primary doctor (Dr. [**First Name (STitle) **] [**Last Name (un) 61237**]in
[**Location 16080**]) in [**2-16**] days. You must have your blood level
(hematocrit) checked at that time. If it is low, Dr. [**First Name (STitle) **] will
refer you to a stomach doctor (gastroenterologist) or to the
emergency room. Dr. [**First Name (STitle) **] will also check your blood glucose
levels and your blood pressure. Your medicines will be adjusted
accordingly. Please confirm your Metformin dose with your
primary doctor.
2) Please see Dr. [**First Name (STitle) 2643**] and Dr. [**First Name (STitle) 437**], your new stomach doctors
(gastroenterologists) for the following appointment:
Provider [**Name9 (PRE) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST OFFICE (SB) Where: LM [**Hospital Unit Name **] GASTROENTEROLOGY Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2199-3-29**]
2:00
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12427**], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2199-4-16**] 1:40
3) Please see your new lung doctor (pulmonologist) for the
following appointment:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2199-4-22**] at 12:45PM in the [**Location (un) **] of
the [**Hospital Ward Name 23**] Building at the Pulmonary Clinic. Prior to this
appointment, please obtain a CAT Scan of your hcest (see below
for instructions).
4) Please also obtain a CAT Scan of your chest on the same day
you see your new lung doctor. Please take Mucomyst as instructed
(which protects your kidneys) prior to the CAT Scan:
Provider CAT SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-4-22**] 11:45
5) Please call for an appointment with your new thyroid doctor
(endocrinologist) at the Thyroid [**Hospital **] Clinic. Please contact
them for an appointment at ([**Telephone/Fax (1) 61238**]. You should make an
appointment to be seen in the next month.
You will undergo a Fine Needle Aspiration (FNA) of your thyroid
to evaluate a nodule:
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"790.7",
"518.89",
"532.00",
"041.86",
"041.19",
"250.00",
"211.1",
"535.50",
"428.0",
"427.31",
"799.0",
"365.9",
"486",
"535.40",
"241.0",
"285.1",
"518.81",
"285.29",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"45.16",
"38.91",
"96.72",
"96.04",
"33.24",
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
7535, 7610
|
2694, 6127
|
268, 337
|
7829, 7843
|
1843, 2671
|
8723, 11041
|
1486, 1491
|
6213, 7512
|
7631, 7631
|
6153, 6190
|
7867, 8700
|
1506, 1824
|
221, 230
|
365, 1280
|
7759, 7808
|
7650, 7738
|
1302, 1324
|
1340, 1470
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,306
| 183,571
|
52486
|
Discharge summary
|
report
|
Admission Date: [**2137-10-16**] Discharge Date: [**2137-10-24**]
Date of Birth: [**2059-8-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 78 year old patient
who reports having heaviness and shortness of breath with
exertion and recently had a positive stress test and was
referred to [**Hospital6 256**] for cardiac
catheterization.
PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease;
2. Chronic back pain due to degenerative joint disease; 3.
Anxiety.
ALLERGIES: Ex-Lax which causes hives.
PREOPERATIVE MEDICATIONS:
1. Toprol XL 50 mg p.o. q.d.
2. Diovan 160 mg p.o. q.d.
3. Remeron 50 mg p.o. q.h.s.
4. Evista 60 mg p.o. q.d.
5. Prilosec 20 mg p.o. q.d.
6. Multivitamin q.d.
7. Calcium q.d.
8. Plavix 75 mg p.o. q.d.
9. Xanax .125 mg prn
HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital6 1760**] on [**10-16**] for cardiac
catheterization. Cardiac catheterization showed a left
ventricular ejection fraction of 72%, 70% left main coronary
artery ostial stenosis, twin left anterior descending system
with large single first diagonal branch with diffuse proximal
calcification, 90% stenosis of the left anterior descending
proximally to the takeoff of the first diagonal branch which
has an 80% ulcerated stenosis at its ostium, 40% mid left
circumflex and 95% right coronary artery stenosis. The
patient was referred to Dr. [**Last Name (Prefixes) **] for coronary artery
bypass surgery. The patient was taken to the Operating Room
on [**10-17**] for a coronary artery bypass graft times four,
left internal mammary artery to left anterior descending,
saphenous vein graft to right coronary artery, saphenous vein
graft to obtuse marginal, saphenous vein graft to diagonal.
The patient was transferred to the Intensive Care Unit in
stable condition on Propofol and Neo-Synephrine infusion.
The patient was weaned the next day from mechanical
ventilation early on the first postoperative evening. On
postoperative day #1 the patient continued to require
low-dose Neo-Synephrine infusion to maintain adequate
systolic blood pressure. The patient required aggressive
pulmonary toilet maintaining oxygenation. On postoperative
day #2 the Neo-Synephrine was weaned off. The patient was
started on low dose beta blocker and Lasix. The patient's
pulmonary artery catheter was removed. On postoperative day
#2 the patient was seen by physical therapy and over
subsequent evaluations it was determined that the patient
would benefit from a stay at [**Hospital 5735**] rehabilitation. On
postoperative day #3, the patient's chest tubes were removed.
The patient's hematocrit was noted to be 23.2 which was felt
to be dilutional and the patient was transfused 1 unit of
packed red blood cells with post transfusion hematocrit of
27. On postoperative day #4, the patient was transferred
from the Intensive Care Unit to the regular part of the
hospital where the patient continued to work with physical
therapy and they again recommended, due to the patient's
physical therapy level as well as the patient's social
situation at home, the patient would be best served by
[**Hospital 5735**] rehabilitation. On postoperative day #5 the
patient was noted to have periods of sinus tachycardia with
rates into the 130s. This was thought to be due to a
significant amount of anxiety about whether or not the
patient would have to go home. The patient was reassured.
The patient requested to be restarted on Xanax as well as the
patient's Lopressor was increased with good control of her
heartrate and by postoperative day #6 the patient was cleared
for discharge to home.
CONDITION ON DISCHARGE: Temperature maximum 99.4, pulse 100,
sinus rhythm, blood pressure 136/72, respiratory rate 14,
room air oxygen saturation 94%. The patient's weight on
postoperative day #6 is 65.8 kg. Preoperatively the
patient's weight was 63 kg. Neurologically the patient was
awake, alert and oriented times three, very anxious. Heart
regular rate and rhythm without rub or murmur. Breathsounds
clear bilaterally. Abdomen was soft, nontender, positive
bowel sounds, tolerating a regular diet. His lower
extremities show 1 to 2+ pitting edema, left greater than
right, extremities are warm and well perfused. External
incision is clean and dry. Steri-Strips were intact.
Strength is stable.
LABORATORY DATA: White blood cell count 9.3, hematocrit
30.2, platelet count 332, sodium 142, potassium 4.2, chloride
107, bicarbonate 27, BUN 18, creatinine 0.7.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease
2. Status post coronary artery bypass graft
3. Anxiety
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day
2. Tylenol 650 mg p.o. q. 4 hours prn
3. Protonix 40 mg p.o. q. day
4. Xanax 0.125 mg p.o. q. 6 hours prn
5. Lopressor 25 mg p.o. t.i.d.
6. Colace 100 mg p.o. b.i.d.
7. Remeron 50 mg p.o. q.h.s. prn
CONDITION ON DISCHARGE: The patient is to be discharged to
rehabilitation in stable condition.
FO[**Last Name (STitle) 996**]P: The patient should follow up with her
cardiologist, Dr. [**Last Name (STitle) 1295**] in one to two weeks. The patient
should follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
in one to two weeks. The patient should follow up with Dr.
[**Last Name (Prefixes) **] in one month.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2137-10-24**] 18:18
T: [**2137-10-24**] 19:43
JOB#: [**Job Number 108405**]
|
[
"285.9",
"721.90",
"413.9",
"530.81",
"401.9",
"300.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"39.61",
"36.13",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4661, 4898
|
4552, 4638
|
564, 3655
|
161, 368
|
391, 538
|
4923, 5628
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,494
| 164,195
|
8197+55921
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-3-15**] Discharge Date: [**2141-4-6**]
Date of Birth: [**2085-6-2**] Sex: M
Service: TRANS [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 55 -year-old gentleman
with end stage renal disease secondary to diabetes mellitus,
who presented eight months status post cadaveric renal
transplant. He was noted to have a rising creatinine on
routine follow up. He was otherwise asymptomatic. His
cadaveric renal transplant was from a 64 -year-old donor with
occult ischemia times fifteen hours in [**2140-6-23**]. His
best creatinine postoperatively was 2.1. His course has been
complicated by a urinary tract infection in [**2140-10-23**]
with a subsequent increase in creatinine. A renal biopsy at
this time showed signs of rejection and he received a three
day pulse of steroids and subsequently did well.
PAST MEDICAL HISTORY: Diabetes mellitus, chronic renal
failure with end stage renal disease prior to transplant,
peripheral vascular disease, hypertension.
PAST SURGICAL HISTORY: Status post bilateral below the knee
amputation, status post left open reduction, internal
fixation of hip, status post arthroscopic lysis of peritoneal
adhesions, status post left cataract extraction, status post
multiple A-V fistulas, status post peritoneal dialysis
catheter.
ADMITTING MEDICATIONS: Prograf 3.0 mg po bid, prednisone 10
mg po q day, Rapamune 3.0 mg po q day, Zantac 150 mg [**Hospital1 **],
Bactrim single strength one q day, Metoprolol 50 mg [**Hospital1 **],
aspirin 81 mg po q day, NPH insulin 38 units in the AM and 8
units in the PM.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission, afebrile. In general, a
well appearing gentleman in no acute distress. Chest is
clear to auscultation bilaterally. Cardiac: normal sinus
rhythm. Abdomen: soft, nontender, nondistended, graph
nontender. Extremities: status post bilateral below the knee
amputation.
HOSPITAL COURSE:
1. Immunosuppression: The patient underwent biopsy which
revealed acute cellular rejection. Because of this his
immunosuppressive regimen was altered. He received an
increased dose of prednisone and Rapamune. In addition, he
received one pulse of Thymoglobulin. During the actual
infusion, the patient was hemodynamically stable. Several
hours following the infusion, however, the patient became
hypotensive and tachycardic. Because of this he was
transferred to the Intensive Care Unit for invasive
monitoring.
Infectious Disease work up for this was negative, as outlined
further below. Because of this, it was felt that the patient
had a strong reaction to the Thymoglobulin specifically, and
he received no further treatment with this medicine. The
patient underwent a second biopsy before making any further
changes in his immunosuppressive regimen. This biopsy
revealed microangiopathy and decreased evidence of rejection.
Because of this, his Prograf was discontinued and he was
started on azathioprine. His most recent creatinine is 3.6
which has trended downward significantly from a peak of
almost 5.0.
2. Respiratory: The patient did very well from a
respiratory standpoint with no issues. During the
hypotensive episode noted above, his respirations remained
stable. After transfer to the unit, because of the need for
invasive monitoring, he was intubated. He was extubated
with ease with good gases after one attempt. Following this
he had coarse breath sounds which resolved with ambulation
and incentive spirometry. He did not develop any pneumonia.
3. Cardiovascular: The patient had persistent hypertension
throughout his stay and for this multiple regimens were
instituted. The regimen that finally decreased his blood
pressure from the 190-200 systolic over 90-110 diastolic
range was a combination of Lopressor 150 mg po bid and
Norvasc 10 mg a day. This regimen resulted in some
bradycardia into the 50's which the patient tolerated very
well.
4. Gastrointestinal: The patient had intermittent diarrhea
during his stay. This was worked up for Clostridium
difficile and he was negative. Following this, he was
treated symptomatically with Lomotil or Imodium with
improvement. In addition, he was treated with Creon prior to
his meals with some improvement.
5. Genitourinary: The patient was seen by Urology for
urinary retention. For this a Foley was left in place.
Eventually, however, this was removed and the patient voided.
By urologist's recommendations, he was also started on
Urecholine.
6. Heme: The patient's hematocrit slowly trended downward
to 21 while he was on his immunosuppressive regimen. No
bleeding source was identified. He was transfused two units
of packed red blood cells and his hematocrit has remained
stable between 26 and 29 since then. In addition, the
patient received Epogen.
7. Fluids, electrolytes, and nutrition: The patient had
intermittent electrolyte abnormalities that were corrected.
Except for during bouts of diarrhea, the patient had good po
intake without nausea or vomiting.
8. Endocrine: The patient's blood sugars were initially
well controlled. Following his transfer back to the unit,
however, his blood sugars rose into the 400's. Because of
this he was started on an insulin drip. After approximately
twelve hours on the insulin drip, ketones were no longer
present in his urine and his blood sugars came down into the
100's. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained, who managed his
regimen with NPH insulin and Humalog sliding scale. He had
one episode of low blood sugars in the middle of the night
which resolved with po intake.
9. Musculoskeletal: The patient received a Physical
Therapy consult, as he had become somewhat deconditioned
during his two days in the unit and given his bilateral
below the knee amputations, it was felt that it would be
beneficial for him to have assistance with improving his
abilities and strength. The patient did very well with
physical therapy. He was discharged to home physical
therapy by the inpatient service.
DISCHARGE MEDICATIONS: Prednisone 20 mg po q day, Rapamune
5.0 mg po q day, azathioprine 100 mg po q day, Lopressor 150
mg po bid, Norvasc 10 mg po q day, Zantac 150 mg po q day,
Creon four tablets before meals, Imodium prn, Urecholine 5.0
mg po tid, Lasix 40 mg po prn, but not to be used q day as
this has resulted in increased creatinine, Epogen 4,000 units
subcutaneous Monday, Wednesday, Friday, calcium carbonate
1,250 mg po tid, Bactrim single strength po q day, Nystatin
5.0 cc po tid, ganciclovir 500 mg po q day.
NPH insulin: while the patient takes good po's, he does well
with 30 units in the morning and 8 units in the PM. While
taking poor po's the patient does well with 22 units in the
morning and 6 units in the PM. It is anticipated that his
po's will improve by the time of his discharge and he will
leave on a regimen of NPH 30 and 8. His insulin sliding
scale as defined by the [**Hospital **] Clinic is as follows: Humalog
sliding scale before breakfast 0 to 200 - no intervention,
201 to 250 - 5 units, 251 to 300 - 7 units, 301 to 350 - 9
units, and 351 to 400 - 11 units. Humalog sliding scale
before lunch and dinner is less than 200 - 0 units, 201 to
250 - 8 units, 251 to 300 - 10 units, 301 to 350 - 12 units,
351 to 400 - 14 units. Humalog at bedtime is 2 units of
Humalog insulin if blood sugar is greater than 350.
DISCHARGE INSTRUCTIONS: The patient should have a low
sodium, renal diet. In addition, he should follow up with
his surgeon, Dr. [**Last Name (STitle) 15473**], as well as with his primary care
physician and his nephrologist. The patient should do
fingersticks qid and also follow a diabetic diet.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], M.D. [**MD Number(1) 15476**]
Dictated By:[**Name8 (MD) 27611**]
MEDQUIST36
D: [**2141-4-5**] 11:06
T: [**2141-4-5**] 11:03
JOB#: [**Job Number 29133**]
Name: [**Known lastname 5094**], [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 5095**]
Admission Date: [**2141-3-15**] Discharge Date: [**2141-4-7**]
Date of Birth: [**2085-6-2**] Sex: M
Service:
ADDENDUM: Over the last two days of his admission, the
patient's white count went down to 3.5 and then 3.1. Because
of this, his azathioprine should be held and he should follow
up for a lab test on the Monday after admission for a white
count check, to see if his azathioprine should be restarted.
In addition, the patient's creatinine continued to improve,
to 2.9 on the day of his discharge.
[**First Name11 (Name Pattern1) 394**] [**Last Name (NamePattern4) 5096**], M.D. [**MD Number(1) 5097**]
Dictated By:[**Name8 (MD) 4769**]
MEDQUIST36
D: [**2141-4-7**] 09:33
T: [**2141-4-10**] 09:01
JOB#: [**Job Number 5098**]
|
[
"455.2",
"788.20",
"038.9",
"276.5",
"996.81",
"599.0",
"V49.75",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.23",
"45.23",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6124, 7455
|
1973, 6100
|
7480, 9005
|
1050, 1649
|
1672, 1956
|
189, 868
|
891, 1026
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,407
| 108,201
|
11313
|
Discharge summary
|
report
|
Admission Date: [**2159-3-12**] Discharge Date: [**2159-3-17**]
Date of Birth: [**2115-1-5**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 44-year-old-female
with end-stage liver disease and transjugular intrahepatic
portosystemic shunt who presents with two to three days of
dyspnea on minimal exertion. She has also noticed increasing
abdominal girth, increasing pain, bilateral leg pain (left
greater than right), and worsening problems keeping her
balance. She fell once in her living room yesterday. She
denied head trauma or other significant trauma. No chest
pain. No urinary symptoms. She has a chronic cough. She
denies recent medication indiscretion of illicit drugs. She
has never had similar symptoms before except the dyspnea
which she had last when she had a pleural effusion.
PAST MEDICAL HISTORY:
1. End-stage liver disease secondary to alcohol abuse and
herpes C virus.
2. Status post transjugular intrahepatic portosystemic
shunt.
3. Type 2 diabetes mellitus; poor compliance with
maintaining good glycemic control and frequent episodes of
hyperglycemia.
4. Asthma.
5. Hypertension.
6. Pancytopenia.
7. Status post total abdominal hysterectomy.
8. Tuberculosis that was treated.
9. History of pancreatitis.
10. History of suicide attempts; her psychiatrist is
Dr. [**First Name (STitle) **] at [**Location (un) 669**] Comprehensive.
ALLERGIES: TYLENOL and ASPIRIN.
MEDICATIONS ON ADMISSION: Lithium 300 mg p.o. b.i.d.,
thiamine 100 mg p.o. q.d., trazodone 100 mg p.o. q.h.s.
p.r.n., Humalog sliding-scale, albuterol meter-dosed inhaler
p.r.n., [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 mEq p.o. q.d., atenolol 25 mg p.o. q.d.,
lactulose 30 cc p.o. t.i.d., Celexa 10 mg p.o. q.d.,
Lasix 40 mg p.o. b.i.d., Seroquel 25 mg p.o. t.i.d. p.r.n.
(but she has not been taking this), iron gluconate 320 mg
p.o. q.d., insulin 75/25 65 units subcutaneous q.a.m. and
30 units subcutaneous q.p.m. (at dinner time),
Flovent 110 mcg inhaler 4 puffs inhaled b.i.d.,
Protonix 40 mg p.o. q.d., spironolactone 100 mg p.o. q.d.,
Tessalon Perles 100 mg p.o. q.i.d. p.r.n.
SOCIAL HISTORY: She was born in [**Country **] [**Country **] and emigrated to
the United States at the age of eight. She has been married
twice. Her first husband died. [**Name2 (NI) **] second husband she
divorced. She has three children ages 26, 23, and 21; all
are in legal trouble. She has been sober for six months.
She has a history of cocaine and alcohol abuse. She lives
with her son and her son's wife who are both helping care for
her. She has a history of several suicide attempts; most
recently last month.
FAMILY HISTORY: Alcoholism, bipolar disorder, and diabetes
run in her family.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 98.6, blood pressure of 124/82, pulse of 88,
respiratory rate of 22, oxygen saturation of 98% on 2 liters.
In general, she was alert, in no acute distress, lying in
bed. Head, eyes, ears, nose, and throat revealed peripheral.
Extraocular movements were intact. Sclerae were anicteric.
The oropharynx was clear. Mucous membranes were moist. The
neck was supple. Shotty cervical lymphadenopathy. Pulmonary
revealed decreased breath sounds on the right hemithorax and
decreased fremitus on the right hemithorax. The left
hemithorax was essentially clear to auscultation.
Cardiovascular revealed normal first heart sound and second
heart sound. A regular rate and rhythm. A 2/6 systolic
murmur heard at the left sternal border. The abdomen was
distended, diffusely tender, with positive bowel sounds. No
rebound or guarding. The rectal examination was occult-blood
negative in the Emergency Room. The skin was with no rash.
Extremities revealed left lower extremity and right lower
extremity were diffusely tenderness to palpation, left
greater than right. Neurologically, she was alert and
oriented times three. Cranial nerves II through XII were
intact. Deep tendon reflexes were 2+ at the knees and
ankles, biceps, and brachioradialis. There was no
asterixis, and she was not confused.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed Chem-7 with a sodium of 136, potassium
of 4.2, chloride of 104, bicarbonate of 24, blood urea
nitrogen of 6, creatinine of 0.6, blood glucose of 228. The
ALT was 40, AST was 89, alkaline phosphatase was 142, total
bilirubin was 2.6. PT was 15.2, PTT was 33.4, INR was 1.6.
Amylase of 53 and lipase of 144. Complete blood count
revealed a white blood cell count of 3.3 (which is her
baseline), hematocrit of 37.8, platelets of 41 (which is her
baseline). The differential revealed 49% neutrophils,
40% lymphocytes, 6% monocytes, 3% eosinophils).
RADIOLOGY/IMAGING: A chest x-ray showed increased size of
the right-sided effusion. There were loculated components of
the effusion in the upper lung. There was complete right
lung collapse.
Abdominal ultrasound revealed flow in the left portal vein
was reversed from what it should be, status post transjugular
intrahepatic portosystemic shunt. There was increased stent
stenosis compared to prior Doppler performed in [**2159-1-9**].
Electrocardiogram showed nonspecific inferior ST-T changes.
There was no change from [**2158-1-9**]; otherwise, she was
in normal sinus rhythm.
IMPRESSION: This is a 44-year-old-female with end-stage
liver disease and transjugular intrahepatic portosystemic
shunt who presented with increasing dyspnea on exertion,
abdominal pain, and increased abdominal girth.
The patient had transjugular intrahepatic portosystemic shunt
stenosis seen on ultrasound. This caused ascites and
tracking of the ascites fluid into the pleural space, and her
enlarging effusion was responsible for her pulmonary
symptoms.
HOSPITAL COURSE: The Pleural Service was initially
consulted to address the issue of her pleural effusion. The
Pleural Service felt that a thoracentesis would not be
indicated initially until the shunt stenosis was fixed
because the effusion would otherwise accumulate very rapidly
after a tap.
Therefore, the Liver Service was consulted who agreed that
she needed a transjugular intrahepatic portosystemic shunt
revision. The Interventional Radiology Service was
consulted, and after receiving a transfusion of one bag of
platelets, the patient was taken to Interventional Radiology
where she underwent transjugular intrahepatic portosystemic
shunt extension.
Unfortunately, after the transjugular intrahepatic
portosystemic shunt revision, the patient could not be
extubated due to her pleural effusion so she was briefly
admitted the Medical Intensive Care Unit. There, she
underwent thoracentesis with greater than 2 liters of fluid
taken off.
Following this procedure, she was extubated without
complications, and she was transferred back to the General
Medicine Service.
A post procedure ultrasound showed functioning transjugular
intrahepatic portosystemic shunt, and the patient had
complete resolution of her dyspnea and abdominal pain. Her
abdominal girth was decreasing for the last two days of
admission. She had some right upper quadrant pain status
post procedure that was almost certainly due to the stent,
and this pain responded well to Ultram.
We continued her outpatient cardiac regimen as well as her
outpatient diabetes regimen. We also continued lithium,
trazodone q.h.s. p.r.n., and Celexa. She did not request
Seroquel, so this was not given. Her inhalers were also
continued.
DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**].
CONDITION AT DISCHARGE: Condition on discharge was good.
MEDICATIONS ON DISCHARGE:
1. Albuterol meter-dosed inhaler 2 puffs q.i.d. p.r.n. for
wheezes.
2. Atenolol 25 mg p.o. q.d.
3. Iron gluconate 320 mg p.o. q.d.
4. Flovent 110-mcg inhaler 4 puffs inhaled b.i.d.
5. Lithium 300 mg p.o. b.i.d.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 mEq p.o. q.d.
7. Lactulose 30 cc p.o. t.i.d.
8. Protonix 40 mg p.o. q.d.
9. Spironolactone 100 mg p.o. b.i.d.
10. Tessalon Perles 100 mg p.o. q.i.d. p.r.n. for cough.
11. Thiamine 100 mg p.o. q.d.
12. Trazodone 100 mg p.o. q.h.s. p.r.n. for insomnia.
13. Celexa 10 mg p.o. q.d.
14. Seroquel 25 mg p.o. t.i.d. p.r.n. for anxiety.
15. Furosemide 40 mg p.o. b.i.d.
16. NPH insulin/Humalog 75/25 65 units subcutaneous q.a.m.
and 30 units subcutaneous q.p.m.
DISCHARGE FOLLOWUP: Follow-up appointments were scheduled
with her primary care physician (Dr. [**Last Name (STitle) 36295**] at the [**Hospital6 6613**] for [**3-30**] and with her hepatologist
(Dr. [**Last Name (STitle) **] on [**3-20**].
DISCHARGE DIAGNOSES:
1. Transjugular intrahepatic portosystemic shunt stenosis.
2. Pleural effusion.
3. Ascites.
4. Type 2 diabetes mellitus.
5. Asthma.
6. Hypertension.
7. Depression.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2159-6-13**] 16:52
T: [**2159-6-14**] 11:45
JOB#: [**Job Number 12623**]
|
[
"789.5",
"518.5",
"070.54",
"996.1",
"511.8",
"572.3",
"571.2",
"284.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.50",
"39.90",
"96.71",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
2718, 5840
|
8753, 9176
|
7719, 8488
|
1477, 2172
|
5859, 7643
|
7658, 7692
|
8510, 8732
|
165, 836
|
859, 1450
|
2189, 2701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,092
| 198,934
|
44483
|
Discharge summary
|
report
|
Admission Date: [**2156-9-4**] Discharge Date: [**2156-9-21**]
Date of Birth: [**2090-12-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
nonhealing ulceration on right heel
Major Surgical or Invasive Procedure:
right heel incision and drainage [**2156-9-5**]
Dx Aortogram & R LE angiogram [**2156-9-9**]
right below knee amputation [**2156-9-16**]
History of Present Illness:
Patient with known perpheral arterial diseas and venous stasis
skin changes with a nonhealing rt. heel ulceration since
Feburary [**2155**].Patient has been followed by a podiatrist in New
[**Location (un) **]. VNA services have been following patient for wound
care. Recently started on home Ceftriaxone. Was evaluated by VNA
after recieving a call that he had been experiencing increasing
right foot pain. Patient denies any constutional symptoms.
patient evaluated in the ER and now admitted for further care.
Past Medical History:
historyof DM2 w neuropathy
historyof coronary artery disease s/p MI
history of chroinc systolic CHF with excerbation--treated
history of atrial fibrillation,anticoagulated
history of polyarthritis rheumatica,predisone dependant
Social History:
Pt and wife live at home in [**Name (NI) 8117**], [**Name (NI) **]. Pt retired in [**11-28**]
from
his work as a manager in auto sales. He states he hopes to
return to his previous work part-time in the future. He has a
close family.
ETOH:denies
Tobacco: former use
Family History:
N/C
Physical Exam:
Vital signs: 97.0-64-16 B/P 96/p
Gen: drowsy, AAOx3, no acute distress
Pulm: basalar crackles
Heart: irregular,irregular
ABD:bengin
EXT: bilateral edema 3+R>L,pitting with hyperpigment changes to
lower extermities. Right lower extermity blaanching erythema.
right punched out heel ulceration.with underminding if
surrounding tissue. no frank purulence but some seropurulent
drainage on dressing
Pulses: palpable femoral 1+ bilateral,DP triphasic dopperable
signals bilaterally PT dopperable triphasic signal left, rt. Pt
absent.
Neuro: nonfocal
Pertinent Results:
[**2156-9-4**] 05:03PM BLOOD WBC-14.7* RBC-3.66* Hgb-10.6* Hct-33.1*
MCV-91 MCH-29.0 MCHC-32.1 RDW-15.8* Plt Ct-411
[**2156-9-12**] 01:50AM BLOOD WBC-17.2* RBC-3.48* Hgb-9.9* Hct-32.0*
MCV-92 MCH-28.5 MCHC-31.0 RDW-15.8* Plt Ct-355
[**2156-9-16**] 02:42PM BLOOD WBC-10.3 RBC-3.52* Hgb-9.9* Hct-32.2*
MCV-92 MCH-28.2 MCHC-30.8* RDW-16.1* Plt Ct-380
[**2156-9-17**] 04:49AM BLOOD WBC-14.3* RBC-3.62* Hgb-10.4* Hct-32.9*
MCV-91 MCH-28.7 MCHC-31.6 RDW-16.6* Plt Ct-390
[**2156-9-21**] 04:38AM BLOOD WBC-8.9 RBC-3.32* Hgb-9.6* Hct-30.1*
MCV-91 MCH-29.1 MCHC-32.0 RDW-17.0* Plt Ct-398
[**2156-9-4**] 05:03PM BLOOD PT-19.9* PTT-64.7* INR(PT)-1.9*
[**2156-9-9**] 01:45PM BLOOD PTT-62.4*
[**2156-9-14**] 06:44AM BLOOD PT-16.3* PTT-66.6* INR(PT)-1.5*
[**2156-9-17**] 04:49AM BLOOD PT-26.2* PTT-49.7* INR(PT)-2.6*
[**2156-9-18**] 07:56AM BLOOD PT-16.0* PTT-54.8* INR(PT)-1.4*
[**2156-9-21**] 04:38AM BLOOD PT-19.9* PTT-61.4* INR(PT)-1.9*
[**2156-9-4**] 05:03PM BLOOD Glucose-93 UreaN-45* Creat-1.4* Na-126*
K-4.7 Cl-87* HCO3-30 AnGap-14
[**2156-9-5**] 09:04AM BLOOD Glucose-90 UreaN-42* Creat-1.4* Na-126*
K-5.2* Cl-93* HCO3-23 AnGap-15
[**2156-9-11**] 06:30AM BLOOD Glucose-49* UreaN-21* Creat-1.0 Na-135
K-4.2 Cl-99 HCO3-31 AnGap-9
[**2156-9-14**] 06:44AM BLOOD Glucose-55* UreaN-15 Creat-0.9 Na-137
K-4.5 Cl-98 HCO3-35* AnGap-9
[**2156-9-20**] 03:24AM BLOOD Glucose-119* UreaN-11 Creat-0.7 Na-135
K-4.0 Cl-101 HCO3-28 AnGap-10
[**2156-9-21**] 04:38AM BLOOD Glucose-137* UreaN-13 Creat-0.8 Na-134
K-4.1 Cl-99 HCO3-29 AnGap-10
[**2156-9-5**] 05:06AM BLOOD CK(CPK)-165
[**2156-9-17**] 04:49AM BLOOD ALT-16 AST-47* CK(CPK)-341* AlkPhos-304*
TotBili-0.6
[**2156-9-4**] 05:03PM BLOOD proBNP-[**Numeric Identifier 95326**]*
[**2156-9-5**] 05:06AM BLOOD CK-MB-4 cTropnT-0.12*
[**2156-9-5**] 03:53PM BLOOD CK-MB-3 cTropnT-0.13*
[**2156-9-8**] 07:59PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2156-9-13**] 10:14AM BLOOD proBNP-[**Numeric Identifier 95327**]*
[**2156-9-17**] 04:49AM BLOOD CK-MB-4 cTropnT-0.03*
[**2156-9-5**] 03:53PM BLOOD TSH-2.0
[**2156-9-5**] 03:53PM BLOOD T4-6.5 T3-56*
[**2156-9-4**] 05:03PM BLOOD CRP-256.7*
[**2156-9-6**] 07:51PM BLOOD Vanco-22.0*
[**2156-9-7**] 07:33AM BLOOD Vanco-15.5
[**2156-9-11**] 05:52PM BLOOD Vanco-26.5*
[**2156-9-12**] 09:35AM BLOOD Vanco-14.2
[**2156-9-17**] 08:53PM BLOOD Vanco-7.7*
[**2156-9-11**] 06:30AM BLOOD Digoxin-0.6*
[**2156-9-15**] 04:04AM BLOOD Digoxin-1.2
[**2156-9-17**] 04:49AM BLOOD Digoxin-1.1
[**2156-9-5**] 01:59PM BLOOD Type-ART pO2-77* pCO2-37 pH-7.43
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2156-9-5**] 10:29PM BLOOD pO2-72* pCO2-25* pH-7.58* calTCO2-24 Base
XS-2
[**2156-9-7**] 02:22AM BLOOD pH-7.48* Comment-GREEN TOP
[**2156-9-17**] 12:50AM BLOOD Type-MIX pO2-35* pCO2-38 pH-7.43
calTCO2-26 Base XS-0
[**2156-9-5**] 01:59PM BLOOD Lactate-1.3
[**2156-9-7**] 02:22AM BLOOD Glucose-254* K-4.4
[**2156-9-5**] 01:21AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2156-9-5**] 01:21AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
[**2156-9-5**] 01:21AM URINE RBC-[**6-1**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2156-9-5**] 01:21AM URINE CastHy-[**11-11**]*
[**2156-9-16**] 09:57PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2156-9-16**] 09:57PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2156-9-16**] 09:57PM URINE RBC-[**6-1**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-<1
[**2156-9-5**] 01:21AM URINE Hours-RANDOM UreaN-435 Creat-135 Na-LESS
THAN Uric Ac-21.7
[**2156-9-5**] 8:05 am TISSUE RIGHT HEEL TISSUE.
**FINAL REPORT [**2156-9-9**]**
GRAM STAIN (Final [**2156-9-5**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1125 ON [**2156-9-5**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
TISSUE (Final [**2156-9-9**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 95328**]
([**2156-9-5**]).
ANAEROBIC CULTURE (Final [**2156-9-9**]): NO ANAEROBES ISOLATED.
SWAB RIGHT HEEL WOUND.
**FINAL REPORT [**2156-9-8**]**
WOUND CULTURE (Final [**2156-9-8**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
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.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 95329**]
([**2156-9-5**]).
SENSITIVITIES:
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2156-9-11**] 9:12 am SWAB Source: instep right foot.
**FINAL REPORT [**2156-9-17**]**
GRAM STAIN (Final [**2156-9-11**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Final [**2156-9-13**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 95329**]
([**2156-9-5**]).
ANAEROBIC CULTURE (Final [**2156-9-17**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE
POSITIVE.
[**2156-9-6**] 5:48 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2156-9-7**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2156-9-7**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13214**] @ 0528 ON [**2156-9-7**]-CC7C
[**Numeric Identifier 40857**].
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).
[**2156-9-14**] 12:40 am STOOL CONSISTENCY: FORMED
**FINAL REPORT [**2156-9-14**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2156-9-14**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 64342**] [**Last Name (NamePattern1) 31774**] @ 5:12A [**2156-9-14**].
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).
[**2156-9-19**] 6:48 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2156-9-19**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2156-9-19**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
9/1308 ECG: Atrial fibrillation with rapid ventricular response.
Right bundle-branch block. Prior anteroseptal myocardial
infarction. No previous tracing available for comparison.
[**8-30**] ECHO: The left atrium is elongated. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated with
moderate to severe regional hypokinesis with severe hypokinesis
of the distal 2/3rds of the left ventricle (LVEF = 25 %). The
basal segments contract best. The estimated cardiac index is
normal (>=2.5L/min/m2). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
moderate to severe aortic valve stenosis (area 0.8cm2). Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen. An
eccentric jet of mild to moderate [[**12-24**]+] is seen directed the
interatrial septum. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. IMPRESSION: Left ventricular cavity enlargement with
extensive regional systolic dysfunction c/w multivessel CAD or
other diffuse process. Moderate to severe aortic valve stenosis.
Moderate pulmonary artery systolic hypertension. Mild aortic
regurgitation.
[**2156-9-8**] CXR: The cardiomegaly is severe, unchanged since prior
study. There is overall improvement in pulmonary edema with
still present residual opacities in the lower lobes that might
represent residual of edema although atelectasis cannot be
excluded. There is no appreciable pleural effusion although note
is made that the left costophrenic angle was excluded from the
field of view. The left PICC line catheter tip is in proximal
SVC.
[**2156-9-14**] RX STRESS TEST: INTERPRETATION: 65 yo man (h/o CAD,
CHF and atrial fibrillation) was referred for evaluation prior
to vascular surgery. The patient was administered 0.142
mg/kg/min of persantine over 4 minutes. No chest, back, neck or
arm discomforts were reported by the patient during the
procedure. In the presence of baseline abnls and digoxin
therapy, no
additional ST-T segment changes were noted from baseline. The
rhythm was atrial fibrillation with occasional isolated VPDs
noted
during the procedure. By doppler, the patient was hypertensive
at
baseline with an appropriate blood pressure response to the
persantine
infusion. Three min post-myoview, the patient received 125 mg
aminophylline IV. IMPRESSION: No anginal symptoms or significant
ECG changes from baseline. Nuclear report sent separately.
NUCLEAR: INTERPRETATION: The image quality is adequate but
limited by motion. Left ventricular cavity size is dilated at
stress and rest.
Rest and stress perfusion images reveal fixed moderate/severe
inferior and
apical defects but otherwise uniform tracer uptake throughout
the left
ventricular myocardium. Gated images could not be obtained due
to atrial fibrillation. IMPRESSION: Fixed moderate to severe
defect involving inferior wall and apex. Dilated LV at rest and
stress.
[**9-16**] CXR: FINDINGS: There has been interval increase in
pulmonary vascular congestion. Bibasilar atelectasis is
unchanged. There is a very small right-sided pleural effusion.
Mild cardiomegaly is unchanged. Mediastinal contours are
obscured by the overlying metalic body. A left PICC is seen
projecting in good position, though its tip is obscured by the
foreign body. There is a new right internal jugular Swan-Ganz
catheter with tip ending in the main pulmonary artery.
IMPRESSION: 1. Interval worsening in pulmonary vascular
congestion. 2. New right IJ Swan-Ganz catheter ending in the
region of the main pulmonary artery.
[**2156-9-17**] ECG: Atrial fibrillation, mean ventricular rate 94.
Right bundle-branch block. Compared to the previous tracing of
[**2156-9-13**] no major change.
[**2156-9-18**] CXR: FINDINGS: As compared to the previous radiograph,
the Swan-Ganz catheter has been removed; however, the
introduction sheath is still in place. There is a PICC line
inserted over the left upper extremity, the tip of the PICC line
projects over the mid SVC. As compared to the previous
radiograph, there is slightly improved ventilation
of the retrocardiac lung areas. Otherwise, the lungs are
unremarkable and
show no evidence of newly occurred focal parenchymal opacity
potentially
suggestive of pneumonia. Moderate cardiomegaly without signs of
overhydration. No pleural effusions, no pneumothorax.
Brief Hospital Course:
[**9-4**] Admitted
[**Date range (1) 95330**] Right heel debridment.Transfered to CVICU for rapid
AF RVR and hypotension requiring Dilt gtt. and nep gtt.
Cardology consulted.cardiac enzymes cycled.dig added to regment
for rythmn control.cardiac enzymes CK 15-14, troponins 0.03-.04
[**2156-9-6**]: ECHO obtained, results attached
[**2156-9-7**]: Pt tested C. Diff positive
[**2156-9-9**]: Dx angio performed showing limited options for
revascularization. Given pt's poor cardiac status, the pt was
given the option of R BKA vs bypass with the understanding that
BKA presented his best chances for early healing and ambulation
and also provided less overall risk given his poor health. Pt
and family decided to pursue R BKA and he was medically managed
to optimize pre-op cardiovascular status.
[**2156-9-12**]: R foot debridement at bedside. Dilt drip weaned
[**2156-9-14**]: Pre-op persantine stress test was performed and the
decision was made with recommendation from Cardiology to
postpone R BKA two days to achieve a further 2L diuresis.
[**2156-9-16**]: Pt was taken to the OR after it was determined he was
in adequate condition from a cardiovascular standpoint.
Swan-Ganz catheter & Brachial arterial line were placed by
anesthesia and Femoral/Sciatic nerve block was administered. R
BKA was performed without complication. Pt tolerated the
procedure well and was transfered to the VICU postoperatively in
stable condition.
[**2156-9-17**]: Pt tolerated a regular Diabetic/Cardiac diet, pain
was well controlled.
[**2156-9-18**]: Swan-Ganz catheter was removed
[**2156-9-19**]: Pt fell on amputation site while getting OOB to Chair
with PT. Stump was evaluated serially and felt to be intact.
[**2156-9-21**]: Pt is discharged to rehab in stable condition with a
foley catheter in place.
Medications on Admission:
Coumadin 7.5mg PO 6/7 days, plavix 75mg PO daily, asa 81mg PO
daily, citalopram 20mg PO daily, crestor 2.5mg PO daily,
prednisone 6mg PO daily, coreg 6.25mg PO daily, lasix 80mg PO
BID, lisinopril 1.25mg PO daily, lantus 35/35, humalog hs ss,
spironolactone 12.5 QOD, bisocodyl 10mg daily, prn colace,
oxycodone/apap 10/650 prn, Vit D 400 daily, Vit B12 Daily,
calcium 1200 daily, ceftriax 1g daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
3. Rosuvastatin 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Prednisone 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
9. Carvedilol 6.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please check pt's INR [**2156-9-22**]. He was admitted on 7.5 mg
PO 6 out of 7 days. However, he has become therapeutic quickly
on 5 mg PO daily. Adjust dose as necessary tp keep INR 2.0-3.0.
He may need to revise his dosing schedule after his course of
Flagyl has ended.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-24**] Sprays Nasal
PRN (as needed).
13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
This is a new medication started during this admission. Last Dig
level [**9-17**] was 1.1.
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
15. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER
DAY (Every Other Day).
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Insulin Regimen
Insulin SC: Sliding Scale & Fixed Dose
Fingerstick QACHS
Breakfast: Glargine 25 Units
Insulin SC Sliding Scale:
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60mg/dL [**12-24**] amp D50 [**12-24**] amp D50 [**12-24**] amp D50 [**12-24**] amp D50
61-140mg/dL 0Units 0Units 0Units 0Units
141-160mg/dL 4Units 5Units 4Units 0Units
161-180mg/dL 6Units 6Units 6Units 0Units
181-200mg/dL 8Units 7Units 8Units 0Units
201-220mg/dL 10Units 9Units 10Units 2Units
221-240mg/dL 12Units 11Units 12Units 4Units
241-260mg/dL 14Units 13Units 14Units 6Units
261-280mg/dL 16Units 15Units 16Units 8Units
> 280mg/dL Notify MD Notify MD Notify MD Notify MD
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days: Continue through [**10-2**], which
completes fourteen days after neg C Diff toxin test.
21. Lisinopril 2.5 mg Tablet Sig: [**12-24**] Tablet PO once a day:
Please start med Friday [**2156-9-24**].
22. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day:
Please weigh pt daily. When he gains 2lbs or more in one day
please start Lasix at 40mg PO BID. He was admitted on 80 mg
Lasix [**Hospital1 **] but we have found he responds very well to smaller
doses.
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital 11042**] Hospital Rehabilitation Unit
Discharge Diagnosis:
non healing rt. heel ulceration
history of perpheral vascular disease s/p angiogram with
stenting ? vessels
history of CHF,with excerbation,compensated
history of coronary artery disease,s/p MI
history of atrial fibrillation,anticoagulated
history of polymyalgia rheumatica, steroid dependant
Discharge Condition:
Stable
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
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 resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Please get weights daily. When he gains 2lbs or more in one day
please start Lasix at 40mg PO BID. He was admitted on 80 mg
Lasix [**Hospital1 **] but we have found he responds very well to smaller
doses.
Please check pt's INR [**2156-9-22**]. He was admitted on 7.5 mg PO 6
out of 7 days. However, he has become therapeutic quickly on 5
mg PO daily. Adjust dose as necessary tp keep INR 2.0-3.0. He
may need to revise his dosing schedule after his course of
Flagyl has ended.
It was necessary to start Digoxin on this admission, please
continue.
Followup Instructions:
Please call [**Telephone/Fax (1) 1393**] to make a follow-up appointment with
Dr. [**Last Name (STitle) 1391**] in 2 weeks.
**Please follow up with your Cardiologist in 3 weeks.**
Completed by:[**2156-9-21**]
|
[
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"V58.67",
"682.7",
"707.14",
"458.29",
"428.23",
"427.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
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"88.42",
"88.48",
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] |
icd9pcs
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[
[
[]
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20885, 20965
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21302, 21311
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2167, 15151
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,682
| 196,055
|
47973
|
Discharge summary
|
report
|
Admission Date: [**2151-10-4**] Discharge Date: [**2151-10-15**]
Date of Birth: [**2106-4-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
TIPS
History of Present Illness:
45f with alcoholic cirrhosis and known varices presented to [**Hospital 6451**] hospital on [**9-23**] with hematemesis and maroon stools.
An initial EGD showed no bleeding. On the second day of
admission she spiked a temp to 102 and was eventually treated
with Unasyn for a GPC UTI. On [**9-26**] she re-bled and became
hypotensive transiently (briefly on phenylephrine gtt), and was
transfused; a tagged rbc scan was negative. On [**10-3**] she had
large volume hematemesis, with a hct dropping from high 20's to
19 and had a repeat EGD that showed fundic varices that had clot
but no active bleed. Octreotide drip was begun, and she was
then transferred ([**10-4**]) to [**Hospital1 18**] for TIPS that was performed
[**10-5**] without incident. She has since been stable from a
hemodynamic and hematalogic standpoint. At the time of
interview, she denied any f/c, lh, chest pain, dyspnea, cough,
sputum, hemoptysis, abd pain, n/v/d, further hematemesis. She
had one episode of diarrhea on [**10-5**], and the c. diff was
negative.
Past Medical History:
-Alcoholic cirrhosis with varices
-Ongoing alcholol abuse
-Ulcerative esophagitis
-Hypothyroidism
.
PSH:
-Cervical cone bx
Social History:
She's married, has no children, 3 cats She works at the post
office. No tobacco, (+) EtOH (?[**12-28**] liter wine qday).
Family History:
There's a heavy etoh abuse hx in the family
Physical Exam:
PE: t 100.7/100.5, bp 108/49, hr 76, rr 18, spo2 96% 3L
gen- pleasant f, looks age, function's fair, non-tox, nad
heent- mild icterus, op clear with mmm
neck- no jvd
cv- rrr, s1s2, no m/r/g
pul- moves air well, no w/r/r
abd- soft, nt, min distension, nabs, no hsm
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- a&ox3, no focal cn/motor deficits, minimal asterixis
Pertinent Results:
[**2151-10-4**] 11:47PM OSMOLAL-284
[**2151-10-4**] 11:21PM GLUCOSE-127* UREA N-21* CREAT-0.6 SODIUM-127*
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-16* ANION GAP-11
[**2151-10-4**] 11:21PM ALT(SGPT)-24 AST(SGOT)-97* ALK PHOS-98
AMYLASE-77 TOT BILI-5.5*
[**2151-10-4**] 11:21PM LIPASE-93*
[**2151-10-4**] 11:21PM ALBUMIN-1.9* CALCIUM-7.3* PHOSPHATE-3.9
MAGNESIUM-2.0
[**2151-10-4**] 11:21PM WBC-24.2* RBC-2.52* HGB-8.3* HCT-23.3* MCV-93
MCH-32.9* MCHC-35.6* RDW-22.9*
[**2151-10-4**] 11:21PM NEUTS-86.0* LYMPHS-8.1* MONOS-4.7 EOS-0.8
BASOS-0.4
[**2151-10-4**] 11:21PM ANISOCYT-3+ POIKILOCY-1+ MACROCYT-2+
MICROCYT-1+
[**2151-10-4**] 11:21PM PLT COUNT-334
[**2151-10-4**] 11:21PM PT-19.0* PTT-40.2* INR(PT)-1.8*
ABDOMEN U.S. (COMPLETE STUDY) PORT [**2151-10-5**] 8:48 AM
[**Hospital 93**] MEDICAL CONDITION:
45 year old woman with etoh cirrhosis, portal hypertension,
upper GI Bleed at OSH, transferred for possible TIPS
REASON FOR THIS EXAMINATION:
evaluate for ascites amenable to tap and please evaluate liver
flow with dopplers prior to TIPS
FINDINGS: Liver appears very heterogeneous, with coarsened
echotexture and nodular appearance consistent with cirrhosis.
Study is limited in evaluation for parenchymal liver lesions by
abdominal gas and patient respiratory movement. Portal vein is
identified with bidirectional low velocity flow, although
predominantly hepatopetal. A moderate amount of perihepatic
ascites is seen, with more ascites in the lower abdomen and
pelvis. No stones identified within the gallbladder. The
gallbladder wall does appear edematous, consistent with
patient's liver disease. Common duct is not dilated. The right
kidney measures 10.0 cm. The left kidney measures 11.9 cm. No
definite evidence of stones or hydronephrosis, although
evaluation of the parenchyma again limited by overlying gas. The
spleen appears unremarkable. Pancreas and aorta are not clearly
visualized on this study.
IMPRESSION:
Very coarsened, nodular appearing liver with heterogeneous
echotexture consistent with cirrhosis. Bidirectional flow,
although predominantly hepatopetal, within the portal vein.
Moderate amount of perihepatic ascites.
CXR clear X 2 during admission
Brief Hospital Course:
45 W with etoh cirrhosis transferred with UGIB from fundic
varices, now controlled s/p tips with subsequent stable vitals
and hct.
.
#GIB -- Pt had stable hct s/p tips. She hadknown varices, and
the the decreased portal pressures will hopefully prevent
further bleeds. no bleeds during this hospitalization. Hct
stable.
- continue [**Hospital1 **] PPI, nadolol
.
#Cirrhosis -- likely [**1-28**] ETOH cirrhosis. Pt had AFP 3.6 and
hepatitis panels negative. Rising bili and elevated enzymes may
represent Acute ETOH hepatitis vs. hepatic ischemia [**1-28**] TIPS.
Discriminant function >33, but as pt. had recent GI bleed, held
off on steroids and bili started to improve. Started on
diuretics during her stay and diuresed well prior to discharge
- SW consulted for continued ETOH use
- On lactulose, ppi, and nadolol.
- now on 40/100 of lasix/aldactone. will go home on this dose
.
#Etoh abuse -- long h/o ETOH abuse with previous h/o withdrawal
sx. During her admission she did not show any e/o withdrawal.
- Con't mvi, thiamine, folate.
- SW arranged with pt. services for ETOH cessation which pt.
states she will access.
.
#Fever/leukocytosis -- Pt had fever on transfer and was started
on ceftriaxone empirically for possible SBP/UTI given ascites
and inability to successfully get bedside tap. Blood Cultures
now negative. More likely [**1-28**] acute alcoholic hepatitis. Pt.
became afebrile, but WBC remained elevated, c/w ETOH hepatitis.
LFTs continue to trend down. C. Diff studies negative.
Ceftriaxone d/c'd upon discharge.
.
Hyponatremic on admit, improved on diuretics, likely [**1-28**]
hypervolemic hyponatremia [**1-28**] liver dz.
.
#Diarrhea -- diarrhea resolved (other than loose stool from
lactulose), likely [**1-28**] lactulose. C. Diff negative
.
#Anemia -- Modestly macrocytic with fairly wide rdw, making
multiple etiologies potentially culprit. likely [**1-28**] liver dz.
B12, folate wnl. Fe studies c/w ACD.
.
Medications on Admission:
-Alprazolam 0.5mg po prn
-Propranolol 20 mg po bid
-Nexium 40 mg po qday
Discharge Medications:
1. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal QID (4
times a day).
Disp:*1 qs* Refills:*2*
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every
8 hours) as needed.
Disp:*1 qs* Refills:*2*
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Alcoholic Hepatitis
___________________
Depression
hypothyroidism
Discharge Condition:
good, ambulating with walker, satiing 100%Ra, tolerating POs
Discharge Instructions:
please seek medical attention should you develop a fever,
increased abdominal distension, abdominal pain, yellowing of
your skin, bleeding from your rectum, hematemesis, or confusion.
Also return should you develop nausea, vomiting, dizziness,
chest pain or shortness of breath.
Please stop drinking any alcohol at this time, as it will
adversely affect your health. Adhere to a low salt diet
(<2g/day), and take all medications exactly as prescribed.
Follow up at the appts. as below
Followup Instructions:
You have the following appointments which you should attend:
Provider: [**Name10 (NameIs) 10079**] [**Name11 (NameIs) 10080**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2151-10-21**] 3:00 in [**Hospital Ward Name **] bldg. [**Location (un) **], south suite
.
Please report to appointment 1 hour before appointment in order
to have your labs drawn.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2151-10-29**] 9:00 in the [**Hospital Unit Name **] [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
|
[
"578.1",
"572.3",
"280.0",
"244.9",
"303.91",
"571.2",
"311",
"276.1",
"787.91",
"456.8",
"571.1",
"276.52",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.91",
"39.1",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7601, 7672
|
4436, 6380
|
328, 335
|
7783, 7846
|
2208, 2996
|
8383, 9112
|
1710, 1755
|
6504, 7578
|
3033, 3146
|
7693, 7762
|
6406, 6481
|
7870, 8360
|
1770, 2189
|
277, 290
|
3175, 4413
|
363, 1407
|
1429, 1553
|
1569, 1694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,128
| 157,773
|
51170
|
Discharge summary
|
report
|
Admission Date: [**2114-5-17**] Discharge Date: [**2114-5-28**]
Date of Birth: [**2038-10-2**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement
History of Present Illness:
HPI: 75yo F with h/o DM, 70packyr history of smoking, COPD on
home O2, presented to an OSH with symptoms of malaise, dyspnea
and CP (substernal pressure radiating to both shoulders,
+diaphoresis, B arm radiation). Pt ignored symptoms x few days
and presented to OSH with an acute coronary syndrome by enzymes
and ECG. She was started on heparin gtt, Lovenox, nitro gtt,
Lopressor for ACS. CP increased, ECG showed worsening lateral
ST depression and STE in V1 and aVR. CK neg., Trop I 2.2.
She was transferred to [**Hospital1 18**] for urgent catheterization.
During cath was found to have 3VD. Cardiac Surgery team was
involved and decided against CABG due to poor renal status and
O2 dependent COPD. Pt underwent high risk intervention:
rotational atherectomy of LMCA and LCx (80% distal LMCA into LCx
origin), s/p kissing Cypher stents to LMCA into LAD and LCx. No
intra aortic balloon pump placed due to occluded right common
iliac artery.
Past Medical History:
DM
COPD (2L NC at home)
s/p Appendectomy
Social History:
SocHx: lives alone in mobile home, grandson [**Name (NI) 653**].
Estranged from majority of her family. 70pk/yr h/o smoking, no
EtOH or drug use. FULL CODE (discussed)
Family History:
Sister with lung cancer at age 60
Sister with uterine cancer at age 57
Physical Exam:
T afebrile HR 107 RR 20 BP 118/56 O2 sat 88-92% 4L NC
general: ill-appearing woman lying in bed
HEENT: PERRL
Neck: JVD to 10cm, no carotid bruits
CV: RRR, nl S1/S2, no murmur
Lungs: Bronchial breath sounds R>L, scattered wheezes
Abd: soft, NT, ND, +BS
L groin: venous sheath in place, mild oozing partially
saturating
the dressing, soft, no bruit
Ext: no edema, warm, DP pulses difficult to palpate but
dopplerable b/l
Pertinent Results:
EKG: ([**5-15**])-sinus tach @ 110; ST depression V4-V6; 0.5mm STE V1,
aVR
([**5-16**])-sinus tach @ 121; deep ST dep. V4-6, STE V1,aVL
([**5-17**])-postcath: decreased lateral ST dep and STE V1R and
aVR
Cardiac cath:
RIGHT ATRIUM {a/v/m} 14/12/11
RIGHT VENTRICLE {s/ed} 50/21
PULMONARY ARTERY {s/d/m} 50/28/33
PULMONARY WEDGE {a/v/m} 31/34/30
LEFT VENTRICLE {s/ed} 143/34
AORTA {s/d/m} 134/63/99
**CARDIAC OUTPUT
HEART RATE {beats/min} 90
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 62
CARD. OP/IND FICK {l/mn/m2} 3.2/2.0
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 2200
PULMONARY VASC. RESISTANCE 75
LMCA-distal calcific 80% into LCx and LAD
LAD-60% proximal stenosis
LCx-80% origin, 50% mid vessel
RCA-to prox w/ L to R collaterals
Successful rotational atherectomy, PTCA and stenting of the
LMCA/LCX/LAD bifurcation with two 2.5 mm Cypher drug-eluting
stents.
Final angiography showed no residual stenosis, no dissection and
normal
flow.
CT w/o contrast [**2114-5-24**]:
FINAL REPORT
"1) 12-mm lobulated nodule within the right lower lobe. The
features are
concerning for possible neoplasm. This could be further
evaluated with chest
CT, or alternatively, with follow-up chest CT in six weeks
following treatment
of the patient's acute symptoms.
2) Severe emphysema.
3) Ground-glass and confluent nodular opacities with
bronchiectasis within
the right lung, findings that are suggestive of right-sided
pneumonia vs
aspiration, although tuberculosis must be excluded. 4) Hiatal
hernia.
5) Cholelithiasis.
6) Hypodense lesions within the right and left kidneys, too
small to
accurately characterize on the right and consistent with cysts
on the left.
7) Compression fracture of an upper lumbar vertebra."
CT with contrast [**2114-5-26**]:
1. No pulmonary artery aneurysm or embolism identified.
2. Mild increased interstitial and aveolar opacity in the
posterior right
lower lobe, consistent with probable right lung aspiration
and/or pneumonia as
previously suggested.
[**2114-5-17**] 09:58PM GLUCOSE-96 UREA N-31* CREAT-0.8 SODIUM-136
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
[**2114-5-17**] 09:58PM CK(CPK)-103
[**2114-5-17**] 09:58PM CK-MB-7 cTropnT-0.34*
[**2114-5-17**] 09:58PM ALBUMIN-3.2* CALCIUM-7.8* PHOSPHATE-3.2
MAGNESIUM-1.8
[**2114-5-17**] 09:58PM WBC-21.3* RBC-3.71* HGB-10.7* HCT-32.2*
MCV-87 MCH-28.7 MCHC-33.1 RDW-13.0
[**2114-5-17**] 09:58PM NEUTS-90.4* LYMPHS-4.2* MONOS-5.3 EOS-0
BASOS-0.1
[**2114-5-17**] 09:58PM PLT COUNT-267
[**2114-5-17**] 09:58PM PT-13.4* PTT-25.7 INR(PT)-1.2
SPUTUM LAB # [**Numeric Identifier 106208**] LOGIN: [**2114-5-25**] 8:56P LOC: INPATIENT
SITE: EXPECTORATED
TIME TAKEN: 6:42 PM Source: Expectorated.
GRAM STAIN (Final [**2114-5-25**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2114-5-27**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD #1. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
BRONCHOALVEOLAR LAVAGE LAB # [**Numeric Identifier 106209**] LOGIN: [**2114-5-24**] 4:42P
LOC: INPATIENT
TIME TAKEN: 1:30 PM
GRAM STAIN (Final [**2114-5-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2114-5-26**]):
>100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
ACID FAST SMEAR (Final [**2114-5-25**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Brief Hospital Course:
1)CAD: s/p revascularization of LMCA/LAD/LCx. Pt tolerated this
high risk PCI well. Has chronically occluded RCA filling via L
to R collaterals. Not felt to be a surgical candidate due to
comorbid conditions. Started on ASA, BB, high dose Lipitor,
Plavix. Started on Integrilin but was d/c'd early due to a
stable femoral hematoma. Post-cath, she experienced
intermittent CP with hypoxia, and had associated ST depressions
in V4-V6. The episode was thought to be more likely secondary
to demand ischemia from respiratory decompensation rather than
stent thrombosis as patient did not have ST elevations. Enzymes
trended to peak: CK-MB 7.8, TropT 0.68. On Lipitor 80. Also
started on ACE-i on 3rd day of hospital stay.
2)Pump: Markedly elevated L and R sided filling pressures,
depressed CO on cath. Echo showed EF of 30-40% with inf/post
hypokinesis, 1+MR, and moderate pulm HTN. Gently diuresed, with
improvement of pulmonary edema on CXR. Hemodynamically stable.
Continuing very gentle diuresis.
3)Hypoxia: Out of proportion to degree of pulm edema, likely
pneumonia and COPD exacerbation. Intubated on night of
admission after desatting to 80% on NRB, w/ ABG of 7.4/48/48 and
exam showing poor air movement. CXR showed b/l basilar and RML
infiltrates and pleural effusions. She was started on
antibiotics for pneumonia. She was also given nebs, MDIs, and
stress dose steroids for COPD exacerbation. Subsequent CXRs
showed improvement of pulmonary edema/pneumonia. Pt
self-extubated on night of [**5-19**] and had an ABG of 7.42/55/98.
She was monitored on 70% FM and maintained good O2 sats. Put on
10L FM with 4L NC, often removed FM and still maintained good O2
sats. Plan to taper steroids, continue nebs and MDIs, wean O2
as tolerated. Discharged on 3L N.C. and 5mg prednisone. (See
"pneumonia" below).
4)Pneumonia: Bilateral basilar and RML infiltrates and pleural
effusions on CXR. She was started on Zosyn and Azithro for CAP
in a COPD patient on chronic steroids. WBC was elevated with
left shift, but also on steroids. Afebrile, WBC trending down.
F/u CXR showed resolving pneumonia. Antibiotic coverage
spectrum narrowed to CTX and Azithro, then switched to po
levoflox to complete 10 day course.
Post-extubation, the patient had intermittent small volume
hemoptysis (small blood on tissue without large clots) thought
to be due to pharyngeal trauma from intubation. A Chest CT was
performed on [**2114-5-24**] demonstrating:
"1) 12-mm lobulated nodule within the right lower lobe. The
features are
concerning for possible neoplasm. This could be further
evaluated with chest
CT, or alternatively, with follow-up chest CT in six weeks
following treatment
of the patient's acute symptoms.
2) Severe emphysema.
3) Ground-glass and confluent nodular opacities with
bronchiectasis within
the right lung, findings that are suggestive of right-sided
pneumonia vs
aspiration, although tuberculosis must be excluded. 4) Hiatal
hernia.
5) Cholelithiasis.
6) Hypodense lesions within the right and left kidneys, too
small to
accurately characterize on the right and consistent with cysts
on the left.
7) Compression fracture of an upper lumbar vertebra."
The pulmonary service was consulted. They were initially
concerned that the Chest CT might demonstrate a pulmonary artery
aneurysm, so a CT with contrast was performed on [**2114-5-26**]. This
did not demonstrate PA aneurysm.
Although clincial suspicion for TB was extremely low, the
patient was placed on TB precautions and was ruled out for TB by
bronchoscopy with negative BAL and 3 AFB- sputums. The final
expectorated sputum sample demonstrated small growth of
pseudomonas. The infectious disease service was consulted for
recommendations regarding the optimal treatment. They felt that
"the most definitive bacteriologic assessment of the etiology of
pneumonia is the BAL which demonstrated >10,000 CFU of
Oropharyngeal flora." Thus the pseudomonas was not felt to be
the clinically significant organism. Given patient's clinical
improvement, they recommended a 14 day course of levofloxacin
and flagyl. ***They also recommended a f/u Chest CT and f/u
White Blood Cell Count by her primary doctor as an
outpatient***.
5) Diabetes: Most likely due, in some part, to steroid use.
Well controlled on sliding scale. Did not require more than 4
units per day. Should transition to glipizide (per home
regimen) at rehab.
6)EN: Gentle diuresis. Increased BUN/Cr ratio, but maintaining
normal creatinine. Repleting electrolytes as needed. Heart
healthy diet.
7)Code status: Full code. Discussed with patient.
8)Communication: Pt has restraining order against all family
members except grandson, [**Name (NI) **]. The discharge instructions were
discussed with the patient's primary care physician.
9)Proph: H2 blocker (given steroid use), Ca, pneumaboots.
9)Dispo: [**Hospital3 1107**] Rehab [**Telephone/Fax (1) 19791**]
Medications on Admission:
Serevent, Flovent, Prednisone 5, Nifedibine XL 50qd, Zantac,
Nortriptyline, triazolam gas
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 months.
3. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed.
4. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO QID (4 times a day) as needed.
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) teaspoon PO
BID (2 times a day).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q4H (every 4 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for PRN cough.
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**3-27**]
MLs PO Q6H (every 6 hours) as needed for cough.
11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): SLIDING SCALE.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Ventilator Associated Pneumonia
Coronary Artery Disease with Non-ST Elevation Myocardial
Infarction
Congestive Heart Failure
COPD
DM
Discharge Condition:
stable at 96% on 3L N.C.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 liter
Notify doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] of fevers, cough, nausea, chest
discomfort, abdominal discomfort, arm numbness/pain,
palpitations or any other symptoms of concern. Smoking is the
worst thing you can do for your health.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) 62516**] (primary doctor)
[**Telephone/Fax (1) 106210**] within 1 week. ***You need to have a follow-up CT
Scan of the Chest in 1 month*** You need to have a follow-up
White Blood Cell count. We also recommend a pneumovax
immunization at your primary doctor's office.
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 6937**] within 2
weeks of leaving the hospital.
Completed by:[**2114-5-28**]
|
[
"416.0",
"424.0",
"414.01",
"518.81",
"V15.82",
"496",
"250.00",
"998.12",
"410.71",
"585",
"428.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"88.56",
"36.05",
"33.24",
"37.23",
"96.71",
"99.20",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13146, 13243
|
6365, 11318
|
287, 333
|
13420, 13446
|
2138, 6342
|
13882, 14438
|
1581, 1653
|
11458, 13123
|
13264, 13399
|
11344, 11435
|
13470, 13859
|
1668, 2119
|
237, 249
|
361, 1313
|
1335, 1377
|
1393, 1565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,923
| 168,899
|
48080
|
Discharge summary
|
report
|
Admission Date: [**2142-4-16**] Discharge Date: [**2142-4-21**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 83 yo woman with only known vascular RF HTN "well
controlled since starting cozaar" who presents with acute onset
L
weakness/ataxia starting at 8:30AM. She had been in USOH with
no
recent illnesses, and ate breakfast this AM as usual. She was
working out, lifting weights at 8:30 when she noticed that she
had trouble getting the weight above her head with the left
hand.
The hand and arm also felt numb. She called her daughter at
several minutes after 8:30, who traveled to her house to find
that she was walking with a relative's walker, as she was having
trouble with the left leg as well - the left arm still felt weak
and clumsy. EMS was called and code stroke was activated;
patient arrived at 9:45AM at same time as stroke team, awaiting
patient. No slurred speech, language difficulties, changes in
facial appearance, visual c/o or other sx at that time, no HA
(though she periodically gets posterior HA's, last one was last
thursday). She did seem nervous to daughter. [**Name (NI) 13866**] at scene was
97. VS upon arrival included BR 180/100 and HR 80s (sounded
regular), awaiting EKG. NIHSS score was 3 for L arm and leg
ataxia and subtle L leg drift. Furthermore, she was unable to
walk when tested. A head CT was performed stat and showed no
early signs of stroke. CTA showed no vascular occlusion (recons
pending), and CT perfusion was preliminarily normal as well.
She
began to have semi-rhythmic shaking of the left leg and periodic
tremulousness of the left arm with preserved consciousness - it
was unclear whether this could be related to subcortical
vascular
lesion affecting basal ganglia versus seizure activity - due to
the severity of deficits (couldn't walk) she was taken
emergently
to MRI (10:45AM on the table). DWI sequences performed first
revealed two punctate lesions suggestive of embolic infarcts -
post frontal and parietal on R. There was a white matter lesion
on DWI that appeared confluent and was suspected to represent
edema related to strokes, thus TPA given for weight of 140lbs
(estimated based on appearance and information from daughter):
total dose of 57.2 mg=mL, with initial bolus 5.7 mg administered
by nursing at 11:14, infusion 51.5 mg at 11:26. Pt to be
transferred to ICU for further care. Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]
present throughout.
Past Medical History:
PMH:
HTN
Hyperparathyroidism
Recent "varicose vein injections"
No known heart or kidney problems, no coumadin hx
Social History:
Social History:
Lives with sister, runs/walks [**2-17**] miles per day and does yoga,
eats healthy diet, does not smoke or drink etoh
Family History:
Family History:
Sister with heart problems, no strokes in family
Physical Exam:
Normal neurologic exam, except for mild dysmetria of the left
arm and end-gaze nystagmus (the latter likely due to dilantin)
Brief Hospital Course:
The patient was admitted to the neurological ICU after being
given tPA. It is uncertain, however, whether she had an
infarction. While in the scanner on admission, she had a
left-sided seizure, where her leg convulsed. She was started on
dilantin and keppra, with the plan to increase keppra gradually
and taper off of dilantin.
On admission, CT, CTA and CTP showed:
1. No perfusion abnormality. Please note that the area of
concern on subsequent MR brain is not fully covered by the
limited perfusion images.
2. No evidence of significant stenosis within the circle of
[**Last Name (LF) 431**], [**First Name3 (LF) 16423**] tributaries, or head and neck vessels.
3. Three-mm saccular, narrow necked aneurysm at the origin of
the anterior temporal branch of the right middle cerebral
artery.
4. Minimal hyperdensity within the right parietal subcortical
white matter. This is a nonspecific finding, but may be
associated with mild calcifications. Along with the imaging
findings of the MR brain, these could represent fine
calcifications associated with a low-grade glioma.
5. 18 x 12 mm left parieto-occipital meningioma.
6. Bilateral thyroid nodules.
She sustained no complications of tPA and was transferred to the
neurology floor service for further treatment and evaluation.
MRI on admission showed "1. Small areas of slow diffusion within
the right frontal and parietal cortex involves both [**Doctor Last Name 352**] and
white matter regions. The extent and involvement of the white
matter is less consistent with infarction, and is more
consistent with an infiltrating lesion -a low-grade glioma most
likely. Although only partially imaged on the associated
perfusion CT, this is corroborated by the normal perfusion in
this region.
Further evaluation with MR perfusion and spectroscopy is
recommended once patient's condition stabilizes. Depending on
the results of these, nad the patients renal function, contrast
enhanced MR may be indicated.
2. Left parietooccipetal meningioma. Correlation with old
studies recommended
Further studies, including MRS [**Last Name (STitle) **] recommended, as well as
sequences not obtained on the original MRI, due to time
constraints related to tPA use. Repeat MRI showed "The
enhancement pattern and the ASL perfusion findings are
suggestive of an infiltrative brain neoplasm as compared to an
infarct". MRS [**Last Name (STitle) 654**] "spectroscopic findings are suggestive of a
neoplastic lesion"
CT torso to rule out malignancy showed
"1. Abnormally heterogeneous appearance of the _____ thyroid
lobe. This could be further evaluated with a thyroid ultrasound.
2. A 12-mm lesion in the left kidney, may represent a solid
lesion versus a hyperdense cyst. Further evaluation with
ultrasound or MR is recommended. Solitary pulmonary nodule in
the right middle lobe.
3. Bilateral adrenal adenomas.
4. Prominent right axillary lymph nodes."
The patient will be seen as an outpatient by neuro-oncology and
stroke. Of note, she clearly expressed the desire not to have
medical information withheld from her, no matter what the
diagnosis; this stood in contrast to her daughters' wishes, but
the patient was deemed to have decisional capacity. The patient
did, however, say that she would like her family to be present
at any discussions about her diagnosis. This wish was
assiduously adhered to by the housestaff, nursing and her
attendings.
In terms of her hypertension, cozaar was held and the patient
restarted on her thiazide. Blood pressure was well controlled.
We will reserve restarting cozaar until as an outpatient, as her
creatinine caused her GFR to hover just above 30, the limit for
MRI studies.
Medications on Admission:
ASA 325mg
Cozaar 100mg qd
HCTZ 25 mg qd
Discharge Medications:
1. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Discontinue after evening dose on [**4-21**].
2. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Start in am on [**4-22**].
3. Dilantin 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take from [**Date range (1) 52620**].
4. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day: Take on [**4-22**] only.
5. Dilantin 100 mg Capsule Sig: One (1) Capsule PO once a day
for 1 days: Take on [**4-25**] then discontinue.
6. Dilantin 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take at 8am and 4pm daily until [**4-21**], then discontinue.
7. Dilantin 100 mg Capsule Sig: 1.5 Capsules PO at bedtime:
Until after [**4-21**] dose.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. 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*
11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure, likely secondary to brain tumour
Discharge Condition:
Normal neurologic exam, apart from end-gaze nystagmus and
left-sided dysmetria
Discharge Instructions:
You were admitted to the neurology service after having a
seizure. You should continue to take your medications as
prescribed and you cannot drive until you are seizure-free for
six months. Avoid bathing, swimming or climbing or any
activities where you would be at risk should you lose
consciousness.
You will be readmitted next week, likely Tuesday, for a brain
biopsy tentatively scheduled for Wednesday [**4-25**]. The admission
office will contact you regarding the admission time.
Followup Instructions:
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2142-5-7**] 3:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2142-4-23**]
|
[
"227.0",
"241.0",
"342.90",
"780.39",
"252.00",
"437.3",
"401.9",
"785.6",
"593.9",
"237.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8170, 8176
|
3151, 6812
|
231, 237
|
8262, 8343
|
8880, 9143
|
2936, 2987
|
6903, 8147
|
8197, 8241
|
6838, 6880
|
8367, 8857
|
3002, 3128
|
180, 193
|
265, 2615
|
2637, 2752
|
2784, 2904
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,761
| 118,970
|
41876
|
Discharge summary
|
report
|
Admission Date: [**2177-10-23**] Discharge Date: [**2177-10-28**]
Date of Birth: [**2100-11-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion/ increased fatigue
Major Surgical or Invasive Procedure:
s/p Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] porcine valve)/Left
Atrial appendage ligation-[**2177-10-24**]
History of Present Illness:
This is a 76yo male with known aortic stenosis. Over the last
six
months, he has noted worsening dyspnea on exertion and in [**Month (only) 205**]
admits to an episode of exertional chest pain. Most recent
echocardiogram revealed severe aortic stenosis. In preperation
for aortic valve replacement, cardiac catheterization was
performed which showed normal coronary arteries.He was also
diagnosed with atrial fibrillation and has been on Warfarin for
approximately 3 years. He presents today for preoperative
admission for AVR/?MVR/?MAZE with Dr.[**Last Name (STitle) **].
Past Medical History:
Aortic Stenosis
Mitral Regurgitation
chronic diastolic Heart Failure
Hypertension
Hyperlipidemia
Back pain with R foot neuropathy
Diastolic dysfunction
COPD
Atrial Fibrillation
Sleep Apnea, on DJ CPAP
RLL PNA /COPD exacerbation [**4-28**]
bladder polyps
renal calculi
Kleinfelter's syndrome
Past Surgical History:
Right foot surgery
Back surgery
Cholecystectomy
B ing. herniorrhaphies
Vocal cord dilatation
Social History:
Lives with: Wife
Contact: Phone #
Occupation: Retired factory worker
Cigarettes: Smoked no [] yes [X] last cigar 30 yrs ago Hx:[**4-22**]
cigars per day
Other Tobacco use:
ETOH: < 1 drink/week [x] [**2-24**] drinks/week [] >8 drinks/week []
Illicit drug use-none
Family History:
noncontributory
Physical Exam:
Physical Exam
Pulse:73 Resp:16 O2 sat: 98%
B/P Right: 138/83 Left: 134/79
Height:5'7" Weight:178
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera, OP unremarkable
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs: Exp Wzs/coarse BS bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade [**3-23**] radiates
throughout precordium to carotids___
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM, healed RUQ scar
Extremities: Warm [x], well-perfused [x] Edema [B]trace
__none___
Varicosities: None [x]
Neuro: Grossly intact [x]nonfocal exam, MAE [**5-22**] strengths
Pulses:
Femoral Right: Left:
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: Left:
Carotid Bruit murmur radiates to B carotids
Pertinent Results:
[**2177-10-24**] 12:43PM BLOOD WBC-10.7 RBC-3.62*# Hgb-11.3* Hct-33.8*#
MCV-93 MCH-31.1 MCHC-33.3 RDW-14.4 Plt Ct-141*
[**2177-10-23**] 02:45PM BLOOD WBC-5.7 RBC-4.27* Hgb-13.5* Hct-39.2*
MCV-92 MCH-31.7 MCHC-34.5 RDW-14.4 Plt Ct-179
[**2177-10-24**] 12:43PM BLOOD PT-13.5* PTT-29.7 INR(PT)-1.2*
[**2177-10-24**] 12:43PM BLOOD UreaN-22* Creat-1.1 Na-141 K-4.4 Cl-110*
HCO3-23 AnGap-12
[**2177-10-28**] 06:00AM BLOOD WBC-7.8 RBC-2.90* Hgb-9.3* Hct-26.5*
MCV-91 MCH-32.0 MCHC-35.1* RDW-13.9 Plt Ct-120*
[**2177-10-27**] 03:30AM BLOOD WBC-8.8 RBC-2.97* Hgb-9.4* Hct-28.1*
MCV-95 MCH-31.6 MCHC-33.3 RDW-14.0 Plt Ct-109*
[**2177-10-28**] 06:00AM BLOOD Glucose-103* UreaN-25* Creat-0.9 Na-139
K-4.1 Cl-102 HCO3-30 AnGap-11
[**2177-10-27**] 03:30AM BLOOD Glucose-113* UreaN-29* Creat-1.2 Na-141
K-4.7 Cl-104 HCO3-32 AnGap-10
[**2177-10-26**] 07:00AM BLOOD Glucose-104* UreaN-20 Creat-1.1 Na-141
K-3.9 Cl-100 HCO3-37* AnGap-8
[**2177-10-28**] 06:00AM BLOOD PT-13.2 INR(PT)-1.1
[**2177-10-27**] 03:30AM BLOOD PT-13.7* INR(PT)-1.2*
[**2177-10-26**] 07:00AM BLOOD PT-13.1 INR(PT)-1.1
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Indication: Aortic valve disease. Chest pain. Left ventricular
function. Preoperative assessment. Prosthetic valve function.
Atrial ectopy. Dilated cardiomyopathy.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2177-10-24**] at 09:17 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.1 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *57 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 31 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild spontaneous echo contrast in the LAA.
Depressed LAA emptying velocity (<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Mild to moderate ([**1-19**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
PREBYPASS
Mild spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild to
moderate ([**1-19**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen.
POSTBYPASS
Biventricular systolic function is preserved. There is a well
seated, well functioning bioprosthesis in the aortic position.
No AI is visualized. The MR now appears trace. The remaining
study is otherwise unchanged from the prebypass period.
Brief Hospital Course:
On [**2177-10-23**] Mr.[**Known lastname **] was admitted to [**Hospital Ward Name 121**] 6 for IV
Heparin,preoperative workup including pulmonary function
testing, labs, CXR, MSSA swab.Pulmonary consulted regarding PFT
results, as pt is seen by a pulmonologist as an out pt.
On [**2177-10-24**] Mr.[**Known lastname **] was taken to the operating room and
underwent Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] porcine
valve)/Left Atrial appendage ligation with Dr.[**Last Name (STitle) **]. Please
see operative report for further details. Cardiopulmonary bypass
time= 92 minutes. Cross Clamp time= 73 minutes. He tolerated the
procedure well and was transferred to the CVICU intubated and
sedated. He awoke neurologically intact and weaned to extubate
without incident. He weaned off pressor support and
Beta-blocker/Statin/Aspirin and diuresis were initiated.
He was transferred to [**Hospital Ward Name 121**] 6 and continued to progress well. He
was in chronic atrial fibrillation preop and postoperatively he
was in rate controlled atrial fibrillation. He was restarted on
Coumadin with a goal INR 2.0-2.5. He is to resume home dosing
of Coumadin and have INR checked and called into Dr [**Last Name (STitle) **]. He
was ambulating without difficulties, tolerating a full po diet
and his wounds were healing well at the time of discharge. He
was discharged home in stable condition with all follow up
appointments advised.
Medications on Admission:
***WARFARIN 5 mg Tablet - 1 Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] 40 mgTablet - 1 Tablet(s) by mouth once
a
day
CARISOPRODOL 350 mg Tablet 1 Tablet(s) by mouth twice a day
CELECOXIB [CELEBREX] 200 mgCapsule - 1 Capsule(s) by mouth once
a
day
CLONAZEPAM 0.5 mg Tablet - 1Tablet(s) by mouth three times a
day
LIDOCAINE [LIDODERM] 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply once a day
METOPROLOL TARTRATE 50 mg Tablet - 0.5 (One half) mg by mouth
twice a day
TESTOSTERONE [ANDROGEL] 1.25 gram per Actuation (1 %) Gel in
Metered-dose Pump - 3 pumps once a day
CALCIUM CARBONATE - (Prescribed by Other Provider) - 500 mg
calcium (1,250 mg) Tablet - 1 Tablet(s) by mouth once a day
CHONDROITIN SULFATE A [CHONDROITIN SULFATE] Dosage uncertain
GLUCOSAMINE SULFATE 750 mg Tablet - 2 Tablet(s) by mouth twice
a
day
MULTIVITAMIN Tablet - 1 Tablet(s) by mouth once a day
VIT C-VIT E-LUTEIN-MIN-OM-3 [OCUVITE] - 150 mg-30 unit-[**Unit Number **] mg-150
mg Capsule - 1 Capsule(s) by mouth once a day
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
daily months: take as directed for goal INR 2.0-2.5 for atrial
fibrillation.
Disp:*100 Tablet(s)* Refills:*0*
9. celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily ().
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Discharge Worksheet-Discharge Diagnosis-Last Updated by:
[**Last Name (LF) **],[**First Name3 (LF) 1238**], PA on [**2177-10-24**] @ 1549
s/p AVR/LAA ligation
Secondary:
Aortic Stenosis
Mitral Regurgitation
chronic diastolic Heart Failure
Hypertension
Hyperlipidemia
Back pain with R foot neuropathy
Diastolic dysfunction
COPD
Atrial Fibrillation
Sleep Apnea, on DJ CPAP
RLL PNA /COPD exacerbation [**4-28**]
bladder polyps
renal calculi
Kleinfelter's syndrome
Past Surgical History:
Right foot surgery
Back surgery
Cholecystectomy
B ing. herniorrhaphies
Vocal cord palsy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
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 Wed [**12-3**] at 1:00 PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] on [**11-21**] at 12:00pm
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**Known firstname **] M. [**Telephone/Fax (1) 64296**] on [**11-4**] at
11:30 AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Filbrillation
Goal INR 2.0-2.5
First draw [**2177-10-29**]
Results to phone Dr [**Last Name (STitle) **] in [**Hospital1 1474**] [**Telephone/Fax (1) 64296**]
FAX: [**Telephone/Fax (1) 12835**]
Completed by:[**2177-10-28**]
|
[
"272.4",
"496",
"V15.82",
"758.7",
"428.32",
"327.23",
"V70.7",
"V58.61",
"401.9",
"724.2",
"427.31",
"355.8",
"518.89",
"428.0",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"37.36"
] |
icd9pcs
|
[
[
[]
]
] |
10846, 10901
|
6847, 8307
|
316, 451
|
11517, 11745
|
2696, 5760
|
12692, 13563
|
1804, 1821
|
9379, 10823
|
10922, 11384
|
8333, 9356
|
11769, 12669
|
11407, 11496
|
5800, 6824
|
1836, 2677
|
237, 278
|
479, 1054
|
1076, 1367
|
1501, 1788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,060
| 190,154
|
32454
|
Discharge summary
|
report
|
Admission Date: [**2127-11-19**] Discharge Date: [**2127-12-23**]
Date of Birth: [**2053-4-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Compazine
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Giant paraesophageal hernia.
Major Surgical or Invasive Procedure:
[**Last Name (un) **]-Nissen Gastroplasty
History of Present Illness:
The patient is a 74-year-old woman with significant shortness of
breath and dysphagia who on CT scan was noted to have a giant
paraesophageal hernia with the entire stomach, as well as the
entire transverse colon herniated above the diaphragm. She was
brought to the OR today for repair.
Past Medical History:
HTN, Smoking, Hypercholesterolemia, Asthma/COPD, D&C, history of
anemia.
Social History:
Former smoker, lives alone
Family History:
non-contributory
Physical Exam:
General: 74 year-old female in no apparent distress
HEENT: normocephalic., mucus membranes moist
Neck: supple, no lymphadenopathy
Card: regular, rate & rhythm, normal S1,S2, no murmur/gallop or
rub
Resp: decreased breath sounds otherwise clear bilaterally
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm 3+ edema
Incision: abdomen clean, dry, intact with steri-strips
Neuro: non-focal
Pertinent Results:
CHEST (PA & LAT) [**2127-12-21**]
CHEST (PA & LAT)
FINDINGS: There is moderate bilateral pleural effusions, right
greater than left, that are similar in size compared to the
study from five days ago. The feeding tube tip is in the
stomach. Residual contrast is seen in the colon. There is volume
loss in both lower lungs and an underlying infectious infiltrate
cannot be totally excluded. There is right subclavian line tip
in the SVC/RA junction.
VIDEO OROPHARYNGEAL SWALLOW [**2127-12-19**]
VIDEO FLUOROSCOPIC OROPHARYNGEAL SWALLOWING EVALUATION: An oral
and pharyngeal swallowing evaluation was performed in
conjunction with the speech and pathology department. Under
continuous video fluoroscopy, barium of various consistencies
was administered orally to the patient.
ORAL PHASE: There is moderate-to-severe impairment of bolus
formation. Mild impairment in terms of bolus control was also
noted. There is mild-to- moderate impairment of AP tongue
movement.
PHARYNGEAL PHASE: Palatal elevation, laryngeal elevation,
laryngeal valve closure, and epiglottic deflection were within
normal limits. No significant residue was noted in the
valleculae or piriform sinuses. A 13-mm barium tablet
administered to the patient was noted to be retained within the
valleculae but cleared with liquids. The tablet was noted to
clear into the stomach subsequently.
ASPIRATION/PENETRATION: A small amount of penetration was noted
with mixed- consistency barium. There was no aspiration.
IMPRESSION: Mild-to-moderate oral-pharyngeal dysphagia. For
further details, please refer to the speech and pathology report
from the same day.
Date: [**2127-12-19**]
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION
PHARYNGEAL PHASE:
Swallow initiation was timely. Palatal elevation, laryngeal
elevation, laryngeal valve closure and epiglottic deflection
were
all wfl. Pharyngeal transit was timely with adequate pharyngeal
constriction. No residue was seen in the valleculae or pyriform
sinuses, but the pill became stuck in the valleculae and only
cleared with bites of puree. Pharyngoesophageal sphincter
opening
appeared wfl at the height of the swallow.
ESOPHAGEAL SCREEN:
A pan down of the esophagus was completed after the barium
tablet, but noted the pill was slow moving (in part likely [**12-20**]
NG
tube). Per the radiologist, it did clear past the Nissen.
ASPIRATION/PENETRATION:
The pt had one episode of penetration with the mixed
consistency,
but cleared it at the height of the swallow. No aspiration was
seen.
[**2127-11-19**] WBC-10.7# RBC-3.10*# Hgb-9.9*# Hct-28.3*Plt Ct-198
[**2127-12-21**] WBC-11.5* RBC-3.33* Hgb-10.7* Hct-32.1 Plt Ct-604
[**2127-11-19**] Glucose-101 UreaN-11 Creat-0.7 Na-140 K-4.3 Cl-113*
HCO3-20
[**2127-12-23**] Glucose-121* UreaN-25* Creat-1.0 Na-137 K-4.5 Cl-101
HCO3-29
Brief Hospital Course:
pt admitted for repair of diaphragmatic hernia. Case was
initiated laproscopically then converted to laparotomy d/t
hypercarbia. [**Name (NI) **] pt developed PTX and bilat chest tubes
were inserted and maintained on sxn. Pt remained intubated and
admitted to the ICU on low dose neo and fluid resuscitated for
low u/o.
POD#1 right chest tube w/ no air leak and left to sxn w/ air
leak.
POD#2 vent weaned and pt extubated. Tube feed started.
right chest tube d/c'd.
[**12-9**] CT torso: Decrease in oral contrast extravasation adjacent
to lower R paraesophageal region, small amount continues to
extravasate. Mild increase in moderate B/L pleural effusions.
Left sided dependent atelectasis/consolidation. Multiple sub 5
mm pulmonary nodules of the lung apices are unchanged. New
short-term development of the remainder of nodules suggest their
inflammatory origin.
EVENTS:
[**11-19**] OR for paraesophageal hernia ([**Last Name (un) **]-Nissen) repair
[**11-20**]: extubated [**11-22**]: readmit to ICU afib RVR [**11-27**]: extubated
[**11-28**]: back in aflutter, converted w/ PO dilt, lopressor
/17/08 CT GUIDED DRAINAGE ESOPHAGEAL LEAK
INDICATION: [**Last Name (un) **]-Nissen postop day 14 with contained
esophageal leak;
[**12-8**]: back to ICU s/p desat, stat intub on floor.
[**12-8**]: [**Last Name (un) **]: little secretions,tracheo bronchomalacia
[**12-9**]: EGD Negative
[**12-10**]: transfused 2 units PRBCs; bronch by IP: only LLL
secretions, failed PS trial on vent, back on AC, lasix for
diuresis
[**12-13**]: zosyn/vanc/fluc stopped. Chest tube d/c'ed. Bronch showed
some tracheomalacia and secretions
[**12-14**]: extubated, TF's restarted , lasix prn, OOB to chair
[**12-15**]: Dobhoff pulled, OOB/chair
[**12-16**]: Dobhoff replaced. ICU o/n per team because fragile.
[**12-17**]: Barium Swallow revealed no aspiration
[**12-19**]: Seen by Speech for bedside swallow who recommended
video-swallow which revealed no aspiration and DOSS of 4. They
recommended PO diet with thin liquids which she tolerated.
[**12-22**]: Her diet was advanced to soft mechanical. Her lower
extremities were edematous and a bilateral lower extremity
ultrasound was negative for DVT.
[**12-23**]: She continued to make steady progress and was discharged
to rehab and will follow-up with Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
Verapamil 120, Pravastatin 20, ASA 81, nexium, albuterol INH
Discharge Medications:
1. Nexium 20 mg Capsule, Delayed Release(E.C.) [**First Name (STitle) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Senna 8.6 mg Tablet [**First Name (STitle) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. heparin [**Last Name (STitle) **]: 5000 (5000) Units Subcutaneous three times a
day.
6. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 5
days.
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q6H (every 6 hours) as needed for
wheeze/sob.
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for prn wheeze/sob.
10. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Five (5) ML PO BID (2
times a day).
11. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: One (1) PO twice a
day: Swish & spit.
12. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) ML PO Q6H
(every 6 hours) as needed.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Potassium Chloride 10 mEq Capsule, Sustained Release [**Last Name (STitle) **]:
One (1) Capsule, Sustained Release PO once a day for 5 days.
14. Pravastatin 20 mg PO once daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12564**] Health Network
Discharge Diagnosis:
HTN, smoking, hypercholesterolemia, asthma/COPD, D&C, history of
anemia.
repair of diaphgramatic hernia w/Colles gastroplasty on [**2127-11-19**]
Discharge Condition:
deconditioned.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if you develop difficulty
swallowing, nausea, vomiting, chest pain, shortness of breath,
fever, chills or any issues that concern you.
Monitor CBC, lytes, BUN & Cre. Replete lytes as needed
Lasix 40 mg once daily for lower extremity edema
Followup Instructions:
You have a follow up appointment with DR. [**First Name (STitle) **] on [**1-6**] at
10:30am on the [**Hospital Ward Name **] [**Hospital Ward Name 23**] clinical center [**Location (un) **].
Plaese arrive 45 minutes prior to your appointment and present
to [**Location (un) **] rdaiology for a Chest XRAY.
Completed by:[**2127-12-23**]
|
[
"427.31",
"511.9",
"997.1",
"997.5",
"401.9",
"518.5",
"493.20",
"427.32",
"272.0",
"V64.41",
"553.3",
"512.1",
"584.9",
"998.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"54.91",
"38.91",
"33.24",
"99.15",
"96.6",
"96.04",
"33.23",
"96.72",
"38.93",
"44.66"
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icd9pcs
|
[
[
[]
]
] |
8346, 8409
|
4128, 6469
|
308, 352
|
8599, 8616
|
1294, 4105
|
8967, 9306
|
828, 846
|
6581, 8323
|
8430, 8578
|
6495, 6558
|
8640, 8944
|
861, 1275
|
239, 270
|
380, 670
|
692, 768
|
784, 812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,052
| 105,218
|
33948
|
Discharge summary
|
report
|
Admission Date: [**2125-5-21**] Discharge Date: [**2125-5-31**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Thalamic bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 year old with h/o CAD, HL, HTN, AF s/op Coumadin, BG bleed
[**4-20**] (gait unsteadiness, confusion, vertigo, found moderate L
BG ICH with IV extension, also had microbleeds on GRE* so
Coumadin stopped indefinitely), was discharged with many
medications (including amiodrarone, atenolol and aspirin),
failed
follow-up. He was discharged home with services but after a few
days went to inpatient rehab for several weeks. He now takes no
medications other than stool softeners.
7 months ago his daughter came to collect her parents with the
bad snowstorms in NH as they had no power. They were taken to
LA,
[**State 4565**] for 7 months but he kept saying he wanted to go back
to NH. Apparantly all meds and all medical care was put on hold.
2 weeks ago they finally moved back to their house in NH. Of
note, his wife says that other than his bleed and his colon
surgery, he has no past medical history whatsoever.
At baseline, he walks with a cane, has a walker but doesn't use
it. His R leg was the weaker leg since the bleed. Some modest
daily exercise on a local trail in [**Last Name (un) **]. He was able to his
bills
and was reportedly still very sharp. His speech was mildly
slurred.
This past week he asked weird questions ("it's Tuesday right" x2
when it was Wednesday), and he has been complaining of dizziness
for several months, on standing. This AM he stayed in bed, and
his wife found him struggling to get upright. Later he rolled
out
of bed on the floor. The neighbors were alarmed, 911 was called.
In HFH CT scan reveiled L thalamic/GP bleed.
ROS AS above. Constipation. Dizziness with standing.
Past Medical History:
-axillar abscess, s/p I & D
-PAF
-CAD, s/p CABG [**2116**] with peri-operative DVT
-chronic RLE edema
-SNHL secondary to bomber in WWII
-HCV
-HTN
-HLD
-hemicolectomy for perforated diverticulitis '[**10**].
-R knee arthroscopy
Social History:
As above. Has son in FL and daughter in CA. Wife is close to
86 and is here with him. Smoked from '[**55**]-'[**60**], none since. No
alcohol. Live in NH, they have known their neighbors for many
years.
Physical Exam:
Cardiac S1S2 remote heart tones but with low-pitched
pansystolic murmer. Pulm clear. Abdomen supple. Extremities
warm.
NE Alert, drifts off when left alone. Just mildly inattentive
but
sufficiently cooperative. Oriented. Naming intact (limited
testing). Comprehension intact for neurological exam
instructions. Mild perseveration.
Severely dysarthric speech, short sentences, fluent.
PERRL, EOMI, dense R visual neglect, registers finger movements
in R visual field though. R facial droop. Tongue straight.
Formal strength testing complicated but appears 4+ on R. L full.
R sided dense hemineglect, but no extinction to DSS. Sensation
intact to touch, and joint position sense intact (L more
reliable).
Reflexes 1+ symm, R patellar 2+, L 1+, toe up on R (old?).
Gait deferred.
Pertinent Results:
Echo: Severe AS, trace AR, LVH, EF >75%, mild LAE.
CT w/o contrast:
1. Large hemorrhage in the left basal ganglia extending in the
left thalamus
and lateral ventricles bilaterally. Mild shift of normally
midline
structures.
2. Mild mucosal thickening in the ethmoid air cells, and left
maxillary
sinus.
[**2125-5-21**] 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2125-5-21**] 11:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2125-5-21**] 11:00AM PT-14.2* PTT-30.3 INR(PT)-1.2*
[**2125-5-21**] 11:00AM PLT COUNT-102*
[**2125-5-21**] 11:00AM NEUTS-51.3 LYMPHS-43.4* MONOS-4.3 EOS-0.4
BASOS-0.5
[**2125-5-21**] 11:00AM WBC-4.0 RBC-4.64 HGB-14.2 HCT-42.1 MCV-91
MCH-30.7 MCHC-33.8 RDW-14.2
[**2125-5-21**] 11:00AM URINE GR HOLD-HOLD
[**2125-5-21**] 11:00AM URINE HOURS-RANDOM
[**2125-5-21**] 11:00AM CK-MB-NotDone cTropnT-<0.01
[**2125-5-21**] 11:00AM CK(CPK)-71
[**2125-5-21**] 11:00AM estGFR-Using this
[**2125-5-21**] 11:00AM GLUCOSE-125* UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2125-5-21**] 06:40PM PLT COUNT-96*
Brief Hospital Course:
Patient admitted to neurology ICU service for monitoring of left
basal ganglia hemorrhage with intraventricular extension due to
hypertension and medication noncompliance.
Neuro: He required restraints for agitation and got 5mg zyprexa
the 1st night. On hospital day 2 he was more somnolent,
speeking less, and no longer oriented to self. Repeat head CT
was unchanged and somnolence was attributed to medication
effect.
CV: Repeat echo was requested given h/o critical aortic stenosis
per the wife and the medication noncompliance to evaluate for
heart failure or other changes. SBP was kept below 160. He had
some tachypnea as high as 32 reported but CXR was negative for
pulmonary edema. He had no other signs such as WBC elevation or
fever to indicate occult pneumonia. Metoprolol low dose of
12.5mg [**Hospital1 **] was started pngt.
Resp: Stable
FEN/GI: Pt was too somnolent and dysarthric for swallow eval.
NGT was placed.
There were no active heme, endocrine, renal, or infectious
issues.
Neurology Floor Course: The patient was transferred to th
eneurology floors on 06/ 11/ 09. He required feeds through the
NGT till 06 17 09. Then the decision for PEG was made and the pt
finally received G tube on 06 17 09.
Medications on Admission:
Ocuvite, Amiodarone, Atenolol, Simvastatin, Terazosin, ASA.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]- [**Location (un) 8957**]
Discharge Diagnosis:
Basal ganglia bleed (LEFT)
CAD
HLD
HTN
AF
Discharge Condition:
His examination at discharge is remarkable for his left gaze
preference, crossing the midline. He has right hemiparesis and
facial weakness.
Discharge Instructions:
You have had a brain bleed. The reason for the bleed seems to be
uncontrolled hypertension.
In addition, you have required tube feeds given your inability
to swallow. Finally, you received a G-tube that will ensure you
meet your nutritional goals.
You have had a brain bleed. The reason for the bleed seems to be
uncontrolled hypertension.
In addition, you have required tube feeds given your inability
to swallow. Finally, you received a G-tube that will ensure you
meet your nutritional goals.
Followup Instructions:
You will follow up with Dr. [**Last Name (STitle) **] in the stroke clinic on
[**2125-7-17**] 3:30 pm. Phone:[**Telephone/Fax (1) 2574**]
|
[
"427.31",
"781.94",
"424.1",
"V45.81",
"272.4",
"389.10",
"401.9",
"414.00",
"342.91",
"431",
"V15.81",
"V58.61",
"277.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
5778, 5847
|
4437, 5667
|
287, 293
|
5933, 6077
|
3227, 4414
|
6623, 6764
|
5868, 5912
|
5693, 5755
|
6101, 6600
|
2428, 3208
|
232, 249
|
321, 1941
|
1963, 2192
|
2208, 2413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,267
| 132,067
|
48380
|
Discharge summary
|
report
|
Admission Date: [**2192-8-15**] Discharge Date: [**2192-8-25**]
Date of Birth: [**2138-3-6**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypotension and altered mental status
Major Surgical or Invasive Procedure:
ICU admission for observation
Hemodialysis
History of Present Illness:
Ms. [**Known lastname 37559**] is a 54 yo female with ESRD on HD, PVD s/p L BKA,
h/o L stump osteomyelitis s/p Vanco/[**Last Name (un) **] for 6 weeks completed
in [**5-6**], DM, OSA, admitted with hypotension of 64/42 at
dialysis. She was given 1L NS at dialysis and her BP improved to
140/doppler.
.
In the ED, her initial vitals were 149/72, RR 18, HR 59, 94% on
2LNC. She was hypotensive to 90/D in the [**Last Name (LF) **], [**First Name3 (LF) **] she was given
another L of IVF. CXR showed possible PNA, so she was given
vancomycin and levaquin. She was also noted to be somnolent and
patient was found to have two fentanyl patches on her body, one
of which was removed. A head CT was performed which was
unchanged. Given her history of OSA, an ABG was performed with
showed a pCO2 of 49.
.
She remained hypotensive with SBP in the 70s, and she was
transferred to the MICU.
.
She reports fatigue over the past three days and increased
sleepiness. She is tearful intermittently though denies home
stressors or depressed mood. She denies cough, shortness of
breath, chest pain, fevers, chills, dysuria, skin rash, or any
other symptoms.
Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]
- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.
- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma
Social History:
Admitted from rehab. Has two sisters, one daughter. [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.
Physical Exam:
VS: T 97.5, HR 61, BP 114/34, 96% on 3LNC, RR 8
Gen: alert and oriented x 2 (did not know date), conversant
HEENT: PERRL, EOMI, o/p clear
CV: RRR, systolic murmur at LUSB
Pulm: Clear anteriorly, though poor inspiratory effort,
unlabored, decreased respiratory rate
Abd: obese, soft, NT, ND
Ext: peripheral edema present, left AKA
Neuro: alert and oriented x 2, moving all extremities, CNs [**1-10**]
intact
Pertinent Results:
Admission Labs:
.
142 | 105 | 43 /
--------------- 114
5.5 | 24 | 7.6 \
.
Ca 9.6
Mg 2.5
P 5.7
.
.. \ 10.4 /
7.8 ------ 109
.. / 33.7 \
.
ABG 7.31/51/75/27
.
Lactate 1.1
.
[**2192-8-17**]
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.7 3.24* 10.0* 30.8* 95 30.7 32.3 18.1* 107
.
Glu BUN Creat Na K Cl HCO3 AnGap
197* 26* 5.6* 141 4.0 102 28 15
.
[**2192-8-20**]
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
7.0 3.54* 10.8* 33.7* 95 30.6 32.0 17.2* 133
.
Glu BUN Creat Na K Cl HCO3 AnGap
159* 28* 6.0* 136 4.4 99 25 16
.
[**2192-8-22**]
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
7.0 3.54* 10.9* 33.1* 94 30.7 32.8 17.8* 157
.
Glu BUN Creat Na K Cl HCO3 AnGap
231* 29* 6.6*# 134 4.5 101 22 16
.
.
Imaging:
[**2192-8-15**]. CT Head. No acute process seen.
.
[**2192-8-15**]. CXR. Wet read: linear opacity right mid lung
concerning for evolving pneumonia, ddx includes atelectasis.
FINAL FINDINGS: Central venous catheter is stable. The study is
extremely limited by patient body
habitus. The right-sided layering pleural effusion is no longer
present.
Linear opacity of the right mid lung may represent evolving
pneumonia or
atelectasis.
.
[**2192-8-16**] CXR: Linear opacity in the right middle lung is most
likely atelectasis and is unchanged. Allowing the difference in
position of the patient, there is now more clearly visualized
moderate right pleural effusion. There is mild fluid overload.
Main central pulmonary arteries are prominent unchanged from
prior CT from [**2192-6-7**]. Cardiomegaly is mild. Right
subclavian catheter remains in place with tip in the SVC.
[**2192-8-19**] Plain film ABD: Vasculopathy. Paucity of bowel gas is
non-specific. No dilalated loops of small bowel or air fluid
levels to suggest obstruction.
Brief Hospital Course:
1. Hypotension. Patient noted to be hypotensive at dialysis
with ongoing blood pressure readings with systolics of 90s
though patient is entirely asymptomatic. As outpatient, patient
is noted to have SBPs of 130s and 140s. Most likely dehydration
versus med effect secondary to over-sedation with narcotics.
Patient received 2L IVF and is on HD. Accurate blood pressures
are difficult to attain given patients obesity. No evidence to
suggest sepsis in spite of concern for pneumonia in ED; patient
denies symptoms of pneumonia, is afebrile and does not have an
elevated WBC. Also with normal lactate. Antiobiotics were
stopped on admission to the floor. No evidence of blood loss or
EKG changes. Her antihypertensives and narcotics were held
initailly, and patient's BP remained stable in the ICU, on the
floor and during HD. Home meds were restarted slowly, with no
further drops in BP.
.
2. Altered mental status. Patient reportedly somnolent in the
ED, though on admission, per daughter, patient is at her
baseline, though has slept more frequently during the day than
normal. [**Month (only) 116**] be secondary to OSA (and lack of consistent BIPAP
use), depression (patient tearful on exam), or overmedication
with opioids. Head CT in ED unchanged. Patient noted to have
PCO2 of 51 on admission, which is increased from the past.
Patient back at basline by transfer from ICU and rest of
hospital stay. Patient restarted on home psych meds.
.
3. Diabetes. Continued standing humalog and HISS. Serum
glucose remained in the 100s to 200s throughout the
hospitalization.
.
4. OSA. Patient noted to have elevated CO2 on admission. This
may have contributed to patient's somnolence in ED. Patient
reports she ws not using bipap every night. Continued on BIPAP
at night without difficulty, although the patient will take off
the BiPAP after only a few hours use per night due to
discomfort.
.
5. Hyperkalemia. No evidence of EKG changes on admission.
Given kayexelate x 1. Received HD x2 with resolution of
hyperkalemia. No further episodes during hospital stay.
.
6. CAD. Unclear why patient is on plavix; patient does not
report history of stent placement. Continued aspirin, statin,
plavix during hospital stay.
.
7. ESRD on HD. Continued phos binders, nephrocaps, and dialysis
MWF. Received dialysis on [**8-20**], [**8-20**] and [**8-22**]. Spoke with
transplant surgery team, and it was decided to evaluate the
patient as an outpatient for an AV graft.
.
8. Nausea/vomiting. The patient developed nausea and vomiting
on [**2192-8-19**]. After one day of ice chips and around the clock
anti-emetics, the N/V subsided. The patient was taking po
without problems the rest of the hospital stay.
.
9. Dispo. Patient was ready to go back to Rehab on Friday
([**8-17**]), but needed to be rescreened by the Rehab facility.
Stayed through the weekend, as this did not take place until
Monday [**8-20**]. She was rejected by her previous Rehab, and got a
bed at a new Rehab. Unfortunately, the patient's HD slot was
lost, and she was re-placed, which took an additional week in
the hospital to coordinate.
Medications on Admission:
Lactulose 30 mg prn
Seroquel 25 mg q 12 hour
Sensipar 60 mg daily
Renagel 2400 TIDWF
Zemplar 4 mcg MWF IV
Nitropaste prn
Novolog sliding scale
HSQ
Senokot 1 [**Hospital1 **]
Reglan 5 mg TID
Nexium 20 mg daily
Colace 100 mg daily
Zocor 10 mg daily
Lopressor 12.5 q 12 hours
Lovenox 40 mg daily
Aranesp 100 Mo
Remeron 15 mg qhs
Duralgesic 75 mcq q3day
Aspirin 81 daily
Nephrocaps 1 daily
Ambien 5 mg
Ultram 50 [**Hospital1 **]
Perocet 2 tabs 1 6 hours neuronitn 300 prn
Novolog sliding scale
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*60 Tablet(s)* Refills:*2*
13. Paricalcitol 5 mcg/mL Solution Sig: One (1) Intravenous
3X/WEEK (MO,WE,FR).
14. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) as needed for nausea.
18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for stump pain.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 1495**] [**Hospital 11042**] Nursing Care Center
Discharge Diagnosis:
Primary diagnoses:
Altered mental status, likely secondary to narcotic overdose
Hypotension, likely secondary to dehydration and narcotic
overdose
Secondary diagnoses:
ESRD with HD
HTN
DM
OSA
Discharge Condition:
Good, tolerating diabetic/renal diet, using BiPAP, VSS, good
mentation
Discharge Instructions:
You were admitted to the hospital for your low blood pressure at
dialysis and also a low level of consciousness. We found two
pain patches on your back and arm, which is most likely why you
were so sleepy and why your blood pressure was low. In the
future, you should only use one pain patch at a time, if you
even need them at all. We have started Tylenol for your pain.
You do not need to be on antibiotics.
You may resume your medications that you were on before you came
to the hospital. Your blood pressure medication (Lopressor
12.5mg [**Hospital1 **]) was restarted.
You will also need to make an appointment for evaluation to get
an arteriovenous fistula in order to have better dialysis
access.
Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 101900**] the Emergency Department right away
if any of the following problems develop:
* You have recurrent loss of consciousness in the next 6 months.
* You are not getting better in 24 hours, or you are getting
worse in any way.
* You experience new chest pain, pressure, squeezing,
tightness, a rapid heartbeat or palpitations.
* You have shaking chills, or a fever greater than 102 degrees
(F).
* You have new or worsening difficulty breathing.
* You develop abdominal (belly) pain, vomiting, black or bloody
stool.
* You develop severe headache, dizziness, confusion or change in
behavior.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please make an appointment with your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] by calling
[**Telephone/Fax (1) 250**]. You should follow up within 1-2 weeks to assess
your recovery.
You will also need to call [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**], who is the Surgery
Transplant Coordinator at ([**Telephone/Fax (1) 20193**]. She will help you set
up a time to be evaluated for an ateriovenous fistula for better
hemodialysis access.
Completed by:[**2192-8-25**]
|
[
"518.81",
"403.91",
"585.6",
"496",
"E852.9",
"327.23",
"V49.76",
"967.9",
"276.7",
"707.05",
"250.00",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10345, 10450
|
4977, 8102
|
308, 352
|
10687, 10760
|
3152, 3152
|
12256, 12767
|
2543, 2710
|
8643, 10322
|
10471, 10619
|
8128, 8620
|
10784, 12233
|
2725, 3133
|
10640, 10666
|
231, 270
|
380, 1530
|
3168, 4954
|
1552, 2373
|
2389, 2527
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,544
| 190,121
|
3120
|
Discharge summary
|
report
|
Admission Date: [**2107-8-12**] Discharge Date: [**2107-9-1**]
Date of Birth: [**2030-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**8-24**] Video-assisted thoracic surgery, right pleural biopsy and
flexible bronchoscopy with bronchoalveolar lavage.
.
[**8-27**] Right VATS hemothorax evacuation.
History of Present Illness:
Ms. [**Known lastname 4249**] is a 77-year-old female with known atrial
fibrillation, CHF, depressed EF to 35% who presented with
shortness of breath worsening over two weeks. She came in to [**Hospital1 **]
for a planned PMIBI today. She became very SOB during the test
and O2 sats went to 85% on RA. Her sats came up w/ O2. She was
sent to the ER. She stated that she has had increasing DOE for
the past 3 weeks (since last hospitalization). She denied
PND,orthopnea, fever, or chills. She complained productive cough
that has been getting better over the past couple of weeks (she
was treated w/ Z-pack and ceftriaxone for a presumed PNA during
last admission for similar symptoms from [**Date range (1) 14790**].) No LE
swelling. She does not know what her baseline dry weight is.
.
In the ED, initial vitals: 98.2, 76, 113/81, 28, 95% on 4L. She
was given lasix 40 mg X 1. She was admitted for CHF
exacerbation. On arrival to the floor, she was no longer feeling
SOB.
.
ROS:
(+) as per hpi; may have lost some weight recently but unsure
how much
(-) 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:
- hypertension
- Systolic heart failure (EF 30%)
- atrial fibrillation (recently started on amiodarone as
out-patient)
- DJD
- TAH
- Normocytic anemia
Social History:
She lives in [**Location 669**] with her son. Denies current tobacco,
alcohol, or IVDA. Is able to ambulate and take care of herself
at home.
Family History:
No family members with hx of TB
Physical Exam:
VS: tm 99.0, hr 97 afib, bp 140/77, rr 20, sat 98 RA
GEN: NAD, Awake A&O x3, pleasant
HEENT: NC/AT, EOMI, MMM
Cards: nl S1 & S2. No m/r/g
Resp: decrease R sided breath sounds, scattered crackles
diffusely
2 Chest tubes in place on right side.
Abdomen: + bs, soft, nt/nd
Extremities: trace lower ext edema b/l, DP 2+ b/l
Neuro: A&O x3
Pertinent Results:
Admission Labs:
[**2107-8-12**] 11:50PM CK(CPK)-67
[**2107-8-12**] 11:50PM CK-MB-NotDone cTropnT-0.01
[**2107-8-12**] 04:30PM GLUCOSE-112* UREA N-24* CREAT-1.0 SODIUM-142
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-32 ANION GAP-16
[**2107-8-12**] 04:30PM estGFR-Using this
[**2107-8-12**] 04:30PM CK(CPK)-73
[**2107-8-12**] 04:30PM CK-MB-NotDone cTropnT-<0.01 proBNP-2151*
[**2107-8-12**] 04:30PM WBC-5.3 RBC-3.82* HGB-12.0 HCT-34.4* MCV-90
MCH-31.5 MCHC-35.0 RDW-15.7*
[**2107-8-12**] 04:30PM NEUTS-79.6* LYMPHS-13.9* MONOS-4.9 EOS-1.6
BASOS-0
[**2107-8-12**] 04:30PM PLT COUNT-151
[**2107-8-12**] 04:30PM PT-15.3* PTT-29.7 INR(PT)-1.4*
[**2107-8-11**] 03:50PM PT-14.4* INR(PT)-1.3*
.
[**8-12**] PMIBI:
INTERPRETATION:
Left ventricular cavity size is moderately enlarged.
Rest and stress perfusion images reveal a moderate fixed
inferolateral wall perfusion defect and a moderate fixed apical
wall perfusion defect.
Gated images reveal global hypokinesis.
The calculated left ventricular ejection fraction is 36%.
Compared with the study of [**2104-2-20**], there are no changes in
the perfusion defects seen. However, cavity size is enlarged
with reduced function compared to prior study.
IMPRESSION: 1. Moderate fixed inferolateral wall and a moderate
fixed apical wall perfusion defect. No significant change from
prior study. 2. There has been an increase in dilatation of left
ventricle with global hypokinesis and reduced function. (EF=
36%).
.
[**8-12**] Stress 61% of HR:
INTERPRETATION: This 77 yo woman with CHF and Afib was referred
for
evaluation of CAD and shortness of breath. Patient presented
with
difficulty breathing that has been bothering her for about a
week. Lungs were clear to auscultation pre-procedure. The
patient was infused with 0.142mg/kg/min of Persantine over 4
minutes. No neck, back, arm or chest discomfort was reported
during the procedure. No significant ST segment changes were
noted in the presence of baseline ST-T wave abnormalities. The
rhythm was atrial fibrillation with occasional isolated
multifocal VPDs and one V.couplet in recovery. Hemodynamic
response to infusion was appropriate. 2 minutes post-MIBI
injection, the patient was given 125mg of IV aminophylline.
Patient's SaO2 post-procedure was 85%. Following administration
of 4L of O2 NC, SaO2 improved to 97%.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
.
[**2107-8-14**] CT Chest:
CT CHEST WITHOUT IV CONTRAST: There has been interval increase
in size of the right-sided pleural effusion which now is
moderate to large in size. There is also new extension of
effusion along the right horizontal fissure. There is new mild
pericardial effusion. The left lung is unremarkable with no
evidence of effusion. There is a small stable ground glass
nodular density within the right middle lobe measuring 7 mm.
There is no hilar lymphadenopathy. Within the mediastinum, there
is an enlarged lymph node measuring 13 mm along the pretracheal
nodal chain seen best on series 2, image 17. There is no hilar
lymphadenopathy. The heart is markedly enlarged as demonstrated
previously. The main pulmonary arteries are enlarged. There is
a 2.6-cm right mid-pole simple renal cyst and a 3.9-cm left
mid-pole simple renal cyst.
IMPRESSION:
1. Increase in size of right pleural effusion, now moderate to
large.
2. New mild pericardial effusion.
3. No evidence of pneumonia.
4. Stable cardiomegaly.
5. Bilateral simple renal cysts.
6. Single nonspecific enlarged 13 mm mediastinal lymph node.
.
[**2107-8-22**] CT CHEST WITH AND WITHOUT IV CONTRAST: There has been
interval decrease in the right effusion, which is small to
moderate in size. The anteromedial and posteromedial components
are loculated and there layering high attenuation material in
the posteromedial component. There are no enhancing pleural
nodules or masses. There is impaction of a right upper lobe
segmental bronchus, and there is layering fluid in the right and
left main bronchi. There is peribronchiolar nodular density in
the right upper lobe, not visualized on the previous study.
There is a 6 mm subpleural right upper lobe nodular density (5,
18), not definitely visualized on the previous study. Band- like
linear density in the right middle and right lower lobe is
compatible with atelectasis. There is a borderline enlarged
right pretracheal lymph node, now measuring 10 mm in short axis.
There are no enlarged hilar or axillary lymph nodes. The
thoracic aortic caliber is normal, with mild calcification.
There is global cardiomegaly, to the greatest degree involving
the left atrium. There is no pericardial effusion. ABDOMEN:
There are two left renal cortical hypodensities and one right
renal cortical hypodensity, measuring up to 4.3 cm in the left
upper renal cortex. one of which is too small to characterize in
the left interpolar region and the others of which are
compatible with cysts. Gallstones are noted. OSSEOUS
STRUCTURES: There are no findings suspicious for malignancy.
There is mild dextroconvex thoracic scoliosis with moderate
endplate osteophytes.
IMPRESSION: 1. Small-to-moderate, partially loculated right
pleural effusion with a small amount of layering hemorrhage
posteromedially in lower right chest. 2. Right upper lobe
peribronchiolar nodules, compatible with aspiration or
infection. Minimal layering fluid in the bronchi may suggest
aspiration over infection. 3. Right upper lobe nodule is likely
inflammatory in nature. However, a followup CT is recommended in
[**1-25**] months to assess for resolution and to exclude a small focus
of bronchoalveolar cell carcinoma.
.
[**8-12**] CXR:
FINDINGS: Portable upright chest radiograph is obtained. Low
lung volumes limit evaluation. There is persistent right-sided
pleural effusion, with probable atelectasis of portions of both
the right middle and lower lobes. Left basilar opacity likely
represents subsegmental atelectasis. No definite pleural
effusion is seen on the left. Prominence of pulmonary
vasculature is noted, slightly asymmetrically increased on the
right, which may in part be due to patient rotation. Findings
likely indicate underlying congestion. The heart size is
difficult to assess but appears mildly enlarged. Tortuosity of
the thoracic aorta is noted. There is no pneumothorax.
IMPRESSION:
Cardiomegaly, with pulmonary vascular congestion. Stable right
pleural effusion, likely with atelectasis of right middle and
lower lobe segments. Left basilar atelectasis.
.
CXR [**2107-8-27**]:
Single AP view of the chest is obtained on [**2107-8-27**] at 14:05 and
is compared with the prior radiograph performed at 10:15 the
same day. There appears to be a small collection of air
adjacent to the site of the pleural tubes and the chest on the
right side. No apical pneumothorax is visualized. Loculated
fluid on the right side appears unchanged. Appearances of the
left chest are unchanged.
IMPRESSION:
Small focal collection of air near the site of the insertion of
the pleural tubes.
.
PATHOLOGY
[**2107-8-18**]
Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells and abundant inflammatory cells.
.
[**2107-8-24**]
Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Highly cellular
sample with morphologically reactive lymphoid infiltrate and
blood. Few, if any mesothelial cells are seen.
.
[**2107-8-24**]
Pleural biospy:
GROSS: A frozen section diagnosis by Dr. [**Last Name (STitle) **]. Fu reads
"Granulomatous inflammation, non-necrotizing on cut sections; no
malignancy identified; final diagnosis pending permanent
section."
DIAGNOSIS:
I. Pleural biopsy:
- Numerous non-caseating granulomas with rare foci of
caseation.
II. Parietal pleural biopsy:
- Numerous non-caseating granulomas with rare foci of
caseation.
- Special stains performed on block B. No micro-organisms are
seen on AFB stain. Fungal stains, particularly PAS-D reveal
rare fungal forms.
.
Brief Hospital Course:
Ms. [**Known lastname 4249**] is a 77 year old woman with cardiomyopathy and
systolic dysfunction (EF 36%), chronic atrial fibrillation on
coumadin, hypertension, and hyperlipidemia who was admitted on
[**2107-8-12**] with dyspnea likely secondary to a right pleural
effusion of unknown etiology. Status post VATs for a pleural
biopsy, her hospital course was complicated by a right
hemothorax which was drained in the OR and with subsequent chest
tubes.
.
#. R pleural effusion (unknown etiology): Sarcoid or fungal
infection was most likely underlying cause of the pleural
effusion and associated granulomatous inflammation seen on VATS.
Briefly, the R pleural effusion was present on admission and
did not change in size. Given that it was unilateral, it was
decided she should undergo thoracentesis. This was delayed a
few days given her INR took some time to normalize after
coumadin was discontinued. Thoracentesis on [**8-17**] revealed a
serosanguinous effusion that was exudative in nature and had a
lymphocytic predominance. There were no mesothelial cells. The
nature of the effusion raised the differential of pleural TB,
rheumatologic disease, lymphoma, and sarcoid. RF and [**Doctor First Name **] were
negative. PPD was negative as was AFB smear/culture of pleural
fluid. Serum LDH was nl and there was no evidence of
lymphadenopathy on imaging. In the meantime, the pt reported
feeling significantly better since undergoing thoracentesis.
Within a few days, however, it seemed the effusion was returning
to a small to moderate degree. By [**2103-8-22**] it had taken a
loculated appearance with some hemorrhagic layering. Given the
exudative effusion and the lack of diagnosis, it was recommended
the patient undergo VATS for evacuation of the effusion and
pleural biopsy. She underwent VATS on [**2107-8-24**], this revealed
granulomatous inflammation. Infectious disease was consulted
and recommended the patient be ruled out for TB and be placed in
respiratory precautions although, at the time her presentation
and imaging was not consistent with TB. She was subsequently
ruled out for TB with 3 negative sputums, and pathological
evaluation of the pleural tissue revealed mostly noncaseating
granulomas. Assays (including serologies) for Histoplasmosis,
Blastomycosis, Paracoccidioides, Coccidioides, and Aspergillus
were sent, and the patient was scheduled for outpatient followup
with the infectious disease consultant who saw her during this
hospitalization. Sarcoid was also possible despite the ACE
value which was within normal limits. The patient was advised
to followup with her PCP for further workup of sarcoid.
.
# Hemothorax: On [**2107-8-26**], her blood pressure dropped to SBP
60-70 and her hematocrit dropped from 28 to 22. This was in the
setting of a supratherapeutic INR. She was urgently taken to
the OR where she had 750 mL of blood evacuated and two chest
tubes placed. She went to the MICU overnight for observation.
She received two units of PRBC and remained hemodynamically
stable. She was then transferred back to the floor. Chest tube
drainage at the bedside was minimal, and the patient's
hematocrit remained stable. Coumadin was held until discharge
and then restarted with close outpatient followup of INR.
.
# Chronic systolic CHF: The patient has a known depressed EF of
36%. The dyspnea on presentation was originally thought to be
due to a CHF exacerbation; however, further evaluation suggested
the R pleural effusion was the most likely cause of the SOB.
For most of the [**Hospital 228**] hospital stay she appeared euvolemic:
no JVD or peripheral edema. Mild crackles on lung exam
resolved. She was maintained on her home dosage of furosemide
40 mg daily and fluid and sodium restricted. An ACE-i
(Lisinopril 5 mg daily) was initially held given the patient's
recent mild renal failure but it was restarted and prescribed at
discharge.
.
# Afib: Coumadin was held in the setting of the hemothorax.
Amiodarone was stopped on admission for work up of pleural
effusion; it was not restarted pending further outpatient workup
of pleural effusion. The patient's atrial fibrillation was
adequately rate controlled in house on metoprolol tartrate; upon
discharge, she was given metoprolol succinate 200 mg daily,
which is beneficial in the setting of a depressed EF. Coumadin
2 mg qHS was restarted upon discharge.
.
# Renal insufficiency: She transiently had mildly elevated
creatinine in setting of low hematocrit (possible hypoperfusion)
but her creatinine normalized to 0.8-0.9 upon discharge. As
mentioned above, the ACE-inhibitor was held until the renal
insufficiency resolved.
.
# Hyperlipidemia: Continued Pravastatin 20 mg daily.
.
# Prophylaxis: DVT prophylaxis was provided with pneumoboots.
The patient was maintained on a bowel regimen.
.
# FEN: She was given a low-sodium, cardiac diet. She adhered to
1.5 L fluid restriction.
.
# Access: PIVs
.
# Code Status: presumed Full
.
# Dispo: Home with services and scheduled followup appointment
with ID, cardiology, and PCP.
Medications on Admission:
aspirin 81 mg daily
lisinopril 20 mg daily
Coumadin 2 mg nightly
Norvasc 5 mg daily
pravastatin 20 mg daily
metoprolol 37.5 mg twice daily
Lasix 40 mg daily
amiodarone 200 mg daily
.
Allergies: NKDA
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
Pleural effusion
Hemothorax
.
Secondary
Atrial fibrillation
Hypertension
Hyperlipidemia
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted to hospital with shortness of breath. A fluid
collection was noted on your lungs. A procedure called VATS,
video assisted thoracic surgery, was performed. You then
developed a collection of blood on your lungs called a
hemothorax. The blood on your lungs was drained in the
operating room with chest tubes and you subsequently improved.
You were noted to have granulomas on a biopsy of your pleural
tissue. The cause of this lung disease is unclear and may be a
fungal infection, sarcoidosis, or another cause. It is
important for you to followup with the following appointments
scheduled for you (listed below) to complete the workup of your
lung disease.
.
For congestive heart failure managment, it is very important
that you follow the instructions given:
- weigh yourself daily and call your doctor if your weight
increases by > 3 pounds
- follow a low-salt diet
- restrict your fluid intake to 1.5 liters per day
.
Please note the following medication changes:
1. Norvasc and amiodarone were discontinued. Please stop
taking these medications.
2. The dosage of lisinopril was decreased to 5 mg daily.
3. The metoprolol you were taking at home was discontinued. It
was replaced by a new medication, Toprol XL (metoprolol XL), 200
mg daily. It is a longer acting medication and will improve
your heart function.
.
Otherwise, resume your home medications.
.
Please keep all followup appointments.
.
Please seek medical attention immediately if you develop fever,
chills, increased shortness of breath, chest pain, have a cough
productive of blood, become increasingly fatigued, or notice any
bleeding from the sites where your chest tubes were removed.
Please also contact a physician or go to the [**Name (NI) **] for any other
concerning symptoms.
Followup Instructions:
1. You have been scheduled for a followup appointment with your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on Friday, [**9-2**], at
10:45 AM. His office telephone is [**Telephone/Fax (1) 3581**].
.
2. Please follow-up with your cardiologist, [**Name6 (MD) 1918**] [**Name8 (MD) **],
MD, at the following scheduled appointment: Date/Time:[**2107-9-8**]
11:20 AM. His office is located in the [**Hospital Ward Name 23**] Clinical Center
at [**Hospital1 18**], and his office may be reached at [**Telephone/Fax (1) 902**].
.
3. You have been scheduled for a followup appointment with
infectious disease specialist, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD, on
Date/Time:[**2107-9-12**] 9:00 AM. His clinic is located in Suite G of
the [**Hospital Unit Name **] basement located at [**Hospital1 18**] [**Hospital Ward Name 517**] across
from the Emergency Deparment. The clinic address is [**Last Name (NamePattern1) 8028**], and his clinic phone number is [**Telephone/Fax (1) 457**].
|
[
"584.9",
"427.31",
"401.9",
"428.22",
"998.11",
"272.4",
"511.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.06",
"34.91",
"34.20"
] |
icd9pcs
|
[
[
[]
]
] |
16542, 16599
|
10609, 15685
|
322, 491
|
16739, 16777
|
2657, 2657
|
18608, 19675
|
2254, 2287
|
15934, 16519
|
16620, 16718
|
15711, 15911
|
16801, 17772
|
2302, 2638
|
17792, 18585
|
275, 284
|
519, 1905
|
2673, 10586
|
1927, 2079
|
2095, 2238
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,965
| 124,460
|
6183
|
Discharge summary
|
report
|
Admission Date: [**2141-11-27**] Discharge Date: [**2141-12-1**]
Date of Birth: [**2059-11-21**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Asacol
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
ICD firing
Major Surgical or Invasive Procedure:
Electrophysiology Study with Ablation of 1 of 2 Foci
History of Present Illness:
82 y/o male with CAD s/p CABG, hypertension, CHF EF 35%, atrial
fibrillation, and sustained VT with ICD and subsequent catheter
ablation treatment who presents following an episode of ICD
firing earlier today at home. The patient was at home the day of
presentation watching television when he suddenly became
lightheaded and diaphoretic and his ICD fired. He states that he
had similar symptoms when his ICD fired in the past. His last
episode of ICD firing was in early [**10-11**] and was admitted to the
hospital.
.
In the ED, initial vitals were T: 95.1 HR: 120 BP: 121/79 RR: 16
O2Sat: 97% on 4LNC. EP was called and he was found to be in slow
VT. He received an amiodarone bolus and was started on a gtt.
Plans were made for cardioversion and he received etomidate.
However, the slow VT was able to be broken via antitachycardia
pacing. He was also loaded with Plavix, given 80 mg of
atrovastatin PO x 1, and a heparin gtt was started with concern
for possible ACS.
Past Medical History:
1. Coronary artery disease, status post IMI and coronary artery
bypass graft in [**2121**].
2. Status post V-fib arrest and ICD placement in [**2131**].
3. History of ulcerative colitis diagnosed in [**2128**], last scoped
in [**2136-2-4**].
4. Recurrent DVT bilaterally from the year [**2133**]. On coumadin
5. Hypertension.
6. Hypercholesterolemia.
7. History of TB, status post thoracotomy in [**2088**] with wedge
resection.
8. Status post right inguinal hernia repair.
9. Postphlebitic syndrome.
10. s/p flutter ablation x2
[**44**]. CHF: EF = 30% 11/04
12. Supraventricular tachycardia.
13. Ventricular tachycardia.
14. CRI [**2-4**] to CHF.
15. s/p fall and right hip hemiarthroplasty, [**1-10**].
Social History:
The patient is married with two children, lives with his wife at
home. He smoked many years ago, but stopped when he was
diagnosed with TB. He drinks an occassional glass of wine.
Family History:
Father had a "leaky valve." The patient's mother had
hypertension.
Physical Exam:
On presentation
VS - T 97.6 HR 60 V-paced BP 140/53 RR 17 98%RA
Gen: WD/WN elderly male in NAD. Oriented x 3. Mood, affect
appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple without JVD or lymphadenopathy.
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 wheezes or
rhonchi.
Abd: Soft, NT/ND. No HSM or tenderness. Normoactive BS.
Ext: No c/c/e.
Rectal: Guaiac negative in the ED.
On discharge:
Gen: NAD, A+O x 3
HEENT: Moist mucosal membranes, no JVD
CV: RRR, no murmurs
PULM: CTA B, resps unlabored
ABD: Soft, NT, ND, +BS, no HSM or masses.
EXT: No edema, large area of ecchymosis over right groin with
firm nontender hematoma over lower abdomen and in iliac groove.
Warm, well perfused distally.
Pertinent Results:
[**2141-12-1**] 05:40AM BLOOD WBC-5.9 RBC-3.25* Hgb-9.4* Hct-27.0*
MCV-83 MCH-28.9 MCHC-34.7 RDW-15.4 Plt Ct-178
[**2141-11-27**] 04:45PM BLOOD Neuts-57.1 Lymphs-35.1 Monos-4.3 Eos-3.0
Baso-0.5
[**2141-12-1**] 05:40AM BLOOD PT-16.1* PTT-25.7 INR(PT)-1.4*
[**2141-12-1**] 05:40AM BLOOD Glucose-83 UreaN-24* Creat-1.0 Na-139
K-3.7 Cl-103 HCO3-30 AnGap-10
[**2141-11-28**] 04:20AM BLOOD CK(CPK)-125
[**2141-11-28**] 04:20AM BLOOD CK-MB-3 cTropnT-0.01
[**2141-12-1**] 05:40AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
CXR [**11-27**]: Stable cardiomegaly with no acute pulmonary process.
ECHO [**11-28**]: The left atrium is dilated. The left ventricular
cavity size is normal. There is mild to moderate regional left
ventricular systolic dysfunction (35-40%) with inferior
akinesis/dyskinesis and inferolateral akinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-4**]+) mitral regurgitation is seen.
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect). The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2140-9-27**],
findings are similar. Left ventricular systolic function appears
similar.
US [**11-28**]:
Findings are compatible with the arteriovenous fistula at the
puncture site.
US [**11-30**]:
1. No AV fistula or psueudoaneurysm.
2. Small right groin hematoma.
US [**12-1**]:
Previously demonstrated AV fistula appears to have resolved.
There is now no evidence of fistula or pseudoaneurysm
Brief Hospital Course:
The patient is an 82 year old male with CAD s/p CABG and
multiple MIs, HTN, CHF EF 35%, afib, and sustained VT with ICD
and subsequent catheter ablation treatment who presents with an
episode of ICD firing, found to be in slow VT.
# CAD - The patient has a history of CAD with multiple MIs, but
had no signs of active ACS while hospitalized (cardiac enzymes
negative x 3, EKGs without changes). Pt was maintained on his
[**Hospital 3782**] medical regimen, with switch of hydralazine to ace
inhibitor. Pt maintained his baseline normal renal function
after initiating ACE inhibitor and was monitored carefully given
his prior history of ARF on ACEi.
# [**Name (NI) **] - Pt remained euvolemic, with a known baseline LVEF of
35%.
# Rhythm - Pt presented after ICD firing and was found to be in
slow VT in the ED. He was able to be paced out of VT, received a
bolus of amiodarone, was started on a gtt, and eventually
transitioned to an oral amiodarone regimen. Pt underwent
ablation, with success in 1 of 2 foci. Pt's pacer setting was
changed to Anti-Tachycardia Pacing at 122bpm, and his
beta-blocker was titrated up. Pt was monitored on telemetry with
no additional arrhythmias.
# Groin bleed - Pt's ablation was complicated by a bleed after
removal of the venous and arterial sheaths. Pt developed a new
bruit which was evaluated by a femoral ultrasound. This showed
an AV fistula, in the setting of INR 2 and PTT 78. Vascular
surgery was consulted and did not feel surgical intervention was
necessary unless pt developed uncontrollable bleeding,
hypoperfusion to the extremity or high output heart failure. Pt
did not develop any of these complications, maintained a stable
Hct for several days and on reevaluation by ultrasound had
resolution of the AV fistula.
# Hypertension - Continue home meds. No active issues.
# History of Atrial fibrillation - Pt remained in sinus rhythm
thoughout admission. His coumadin was held given the ablation,
and not restarted in the setting of groin bleed/ AV fistula.
Upon resolution of these issues, pt was restarted on
anticoagulation with Lovenox bridge to be administered by VNA,
and INR follow up.
# h/o DVT - Pt was prophylaxed with pneumoboots while
anticoagulation was held.
Medications on Admission:
Amiodarone 200 mg PO daily
Toprol XL 75 mg PO daily
Spironolactone 25 mg PO daily
Hydrochlorothiazide 25 mg PO daily
Digoxin 0.0625 mg PO QOD
Sertraline 25 mg PO daily
Warfarin 2 mg QSU,MO,WE,FR
Warfarin 1 mg QTU,TH,SA
Docusate Sodium 100 mg PO daily
Fish Oil 1 gram daily
Atorvastatin 40 mg PO daily
Imdur ER 90 mg PO daily
Hydralazine 50 mg PO TID
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
3. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Aldactazide 25-25 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO every
Tues/Thurs/Sat.
13. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes x3.
14. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
Disp:*8 syringes* Refills:*2*
15. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO every
Sun/Mon/Wed/Fri.
16. Outpatient Lab Work
Please check your INR on Monday [**12-4**] and call results to [**Hospital 191**]
[**Hospital3 **] at [**Telephone/Fax (1) 15347**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Ventricular Tachycardia with Internal Cardiac Defibrillator
firing
Paroxsymal Atrial fibrillation on Warfarin
Chronic Systolic congestive Heart Failure: EF 35%
Coronary Artery Disease
Hypertension
Deep Vein Thrombosis
Discharge Condition:
Stable
Hct 27
K 3.7 (repleted)
BUN 24
Creat 1.0
WBC 5.9
Discharge Instructions:
You had ventricular tachycardia, a dangerous heart rhythm that
was converted into a normal rhythm by your ICD at home. We
adjusted some settings on your pacemaker/ICD and performed an
ablation procedure in one out of two areas in your heart that
were causing the ventricular tachycardia. After the ablation
procedure, you developed an aneurysm and some bruising in your
right groin area. On the day you were discharged, the aneurysm
seems to be resolving and it is OK to resume your warfarin. You
will be taking Lovenox at home until your warfarin is
therapeutic.
New medicines:
1. Lovenox: a subcutaneous injection that acts as a blood
thinner. You will take this shot twice daily until your INR is
greater than 2.0.
2. Lisinopril: this is in place of your Hydralazine to keep your
blood pressure controlled and help your heart [**Name (NI) 4581**] better
3. Toprol: this was increased to 75 mg (3 tablets) every day
4. Stop taking Hydralazine
5. Continue your warfarin schedule as before.
.
Please check your INR on Monday [**12-4**] using the
prescription attached.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: about 8 cups per day
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2141-12-13**] 1:50
Electrophysiology:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2141-12-18**]
2:30
.
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-12-18**] 3:00
.
Vascular Surgery:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 2395**] [**Hospital **] Medical Office
Building, [**Hospital Unit Name 24120**]. Please call the
office on Monday afternoon. You need a follow-up visit with Dr.
[**Last Name (STitle) **] in 2 weeks from discharge and an ultrasound of your right
groin area on the same day.
Completed by:[**2141-12-1**]
|
[
"428.22",
"V12.51",
"556.9",
"V58.61",
"V43.64",
"585.9",
"E878.8",
"427.1",
"997.2",
"428.0",
"998.11",
"272.0",
"442.3",
"403.90",
"V45.02",
"427.31",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.27",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
9362, 9433
|
5219, 7452
|
290, 345
|
9695, 9753
|
3389, 5196
|
11043, 11891
|
2294, 2363
|
7853, 9339
|
9454, 9674
|
7478, 7830
|
9777, 11020
|
2378, 3049
|
3064, 3370
|
240, 252
|
373, 1349
|
1371, 2077
|
2093, 2278
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,782
| 190,648
|
34419
|
Discharge summary
|
report
|
Admission Date: [**2101-10-26**] Discharge Date: [**2101-11-2**]
Date of Birth: [**2018-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zetia
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue/Edema/DOE
Major Surgical or Invasive Procedure:
[**2101-10-27**] - CABGx5 (Left internal mammary artery->Left anterior
descending aretry, Saphenous vein graft(SVG)->Diagonal artery,
SVG->First obtuse marginal artery, SVG->Second obtuse marginal
artery, SVG->Right coronary artery)
History of Present Illness:
This is a 83 year old gentleman with known CAD and
cardiomyopathy with class II CHF. Prior RCA stenting in [**2084**] and
he had a negative EP study in [**2098**] for NSVT. Mr. [**Known lastname 79128**] had a
recent episode of CHF in [**9-16**]. A cardiac catheterization was
performed which revealed severe three vessel disease and he was
referred for surgical revascularization.
Past Medical History:
Cardiomyopathy, NSVT, RCA stent [**2084**], hypertension, type 2
diabetes mellitus, hyperlipidemia, systolic chronic congestive
heart failure, prior myocardial infarction, renal calculi,
benign prostatic hypertrophy,B-12 deficiency with anemia
PSH: Left carpal tunnel releases, left total hip replacement,
right inguinal herniorrhaphy, and TURP
Social History:
Retired. Lives alone as he is widowed. He has three daughters.
[**Name (NI) 4084**] smoked and does not drink alcohol.
Family History:
Father with MI at age 52.
Physical Exam:
Admission
60 irregular 132/78 69" 160lbs
GEN: NAD, elderly
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP benign
NECK: Supple, no JVD, no carotid bruits
LUNGS: CTA
HEART: Occassionaly irregular. No murmur, Nl S1-S2
ABDOMEN: Soft, NT/ND/NABS
EXT: Warm, well perfused, mild LE edema, mild toe rubor
NEURO: Nonfocal
Discharge
VS T 98.2 BP102/68 HR60SR RR18 O2sat 95%-RA
Gen NAD
Neuro A&Ox3, non focal exam
Pulm CTA-Bilat. somewhat diminished in bases
CV RRR, sternum stable. Incision CDI
Abdm soft, NT,ND/+BS
Ext warm, 3+ pedal edema bilat
Pertinent Results:
[**2101-10-26**] 05:21PM UREA N-17 CREAT-0.9 CHLORIDE-112* TOTAL
CO2-22
[**2101-10-26**] 05:21PM WBC-13.6* RBC-3.49*# HGB-11.0*# HCT-31.4*#
MCV-90 MCH-31.4 MCHC-35.0 RDW-13.8
[**2101-10-26**] 05:21PM PLT COUNT-143*
[**2101-10-26**] 05:21PM PT-15.4* PTT-37.3* INR(PT)-1.4*
[**2101-10-26**] 04:23PM GLUCOSE-164* LACTATE-3.1* NA+-135 K+-4.1
CL--109
[**2101-11-1**] 05:48AM BLOOD WBC-8.2 RBC-3.41* Hgb-10.6* Hct-31.1*
MCV-91 MCH-31.2 MCHC-34.2 RDW-14.7 Plt Ct-158
[**2101-11-1**] 05:48AM BLOOD Plt Ct-158
[**2101-10-30**] 10:09AM BLOOD PT-14.4* PTT-32.1 INR(PT)-1.3*
[**2101-11-2**] 05:18AM BLOOD Glucose-94 UreaN-28* Creat-1.3* Na-134
K-4.7 Cl-101 HCO3-24 AnGap-14
[**2101-10-26**] ECHO
PREBYPASS
1. The left atrium is moderately dilated. Moderate to severe
spontaneous echo contrast is present in the left atrial
appendage. No atrial septal defect or PFO is seen by 2D or color
Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 15 %). with moderate global hypokinesis.
3. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-9**]+) mitral regurgitation is seen.
5. There is no pericardial effusion.
6. Dr [**Last Name (STitle) **] was notified in person of the results on
[**2101-10-26**]
POSTBYPASS
1. Patient is on epinephrine, milrinone, and phenylephrine
infusions
2. Left ventricular function is marginally improved with an EF
20-25%. Global hypokinesis.
3. Mitral regurgitation remains mild to moderate.
4. Smooth ascending aortic contours after decannulation.
Descending aorta similar size to prebyass.
5. All findings communicated to Dr. [**Last Name (STitle) **] at the time of
CBP ending
[**Known lastname **],[**Known firstname 79129**] [**Medical Record Number 79130**] M 83 [**2018-8-24**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2101-10-28**] 2:10
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2101-10-28**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79131**]
Reason: s/p ct removal ? PTX
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with s/p cabg
Provisional Findings Impression: LCpc FRI [**2101-10-28**] 4:03 PM
Since [**2101-10-26**], the patient was extubated, the
nasogastric tube,
mediastinal drains, and left chest tube were removed. There is
no
pneumothorax. Small right pleural effusion slightly increased.
Left pleural
effusion is still tiny. Left retrocardiac atelectasis increased.
No volume
overload.
Final Report
CHEST, PORTABLE AP
REASON FOR EXAM: 83-year-old man, status post CABG, status post
chest tube
removal. Rule out pneumothorax.
Since [**2101-10-26**], the patient was extubated, nasogastric
tube,
mediastinal drains, and left chest tube were removed. There is
no
pneumothorax.
Small right pleural effusion slightly increased. Left pleural
effusion is
still tiny. Left retrocardiac atelectasis increased. There is no
volume
overload.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: FRI [**2101-10-28**] 4:41 PM
Brief Hospital Course:
Mr. [**Known lastname 79128**] was admitted to the [**Hospital1 18**] on [**2101-10-26**] 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. Please see operative note for details.
Postoperatively he was taken to the cardiac surgical intensive
care unit on epinephrine, milrinone, and propofol drips. On
postoperative day one, Mr. [**Known lastname 79128**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. he was transfused and amiodarone was started
for runs of V Tach. Over the next several days his iv drips were
weaned off and on POD #5 he was transferred to the floor.
He did well, remained hemodynamically stable, his activity level
was advanced and on POD7 he was discharged home with visiting
nurses.
Medications on Admission:
Enalapril 2.5 qam, 1.25 qpm, Toprol XL 12.5', ECASA 325',
Glyburide 2.5 qam, 1.25 qpm, Vitamin B12 inj qmon, Lasix 40'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO with
breakfast.
Disp:*30 Tablet(s)* Refills:*2*
4. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO after dinner.
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x1 week then 400mg QD x1 week then 200mg QD.
Disp:*60 Tablet(s)* Refills:*1*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
9. Enalapril Maleate 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease
s/p CABGx5
non sustained ventricular tacchycardia
RCA stents [**2084**]
Cardiomyopathy
diabetes mellitus
Hyperlipidemia
hypertension
h/o Myocardial infarction
benign prostatic hypertrophy
Anemia
Nephrolithiasis
B-12 deficiency
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.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**First Name (STitle) **] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) 5263**] in [**3-13**] weeks.
Please call all providers for appointments.
Completed by:[**2101-11-2**]
|
[
"414.01",
"425.4",
"427.1",
"V43.64",
"412",
"458.29",
"401.9",
"600.00",
"250.00",
"428.0",
"428.23",
"281.1",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.15",
"36.14",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7962, 8021
|
5600, 6450
|
291, 526
|
8316, 8323
|
2062, 4410
|
9065, 9412
|
1459, 1486
|
6619, 7939
|
4448, 5577
|
8042, 8295
|
6476, 6596
|
8347, 9042
|
1501, 2042
|
234, 253
|
554, 938
|
960, 1307
|
1323, 1443
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,996
| 199,702
|
17059+56821+56822
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2165-6-12**] Discharge Date: [**2165-6-27**]
Date of Birth: [**2130-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Shellfish / Nafcillin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fatigue/Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2165-6-12**] - 1. Redo, redo sternotomy. 2. Third time aortic valve
replacement with a 19-mm onyx mechanical valve, serial number
[**Serial Number 47966**].
3. Replacement of ascending aorta and hemi arch with a 26-mm
Dacron graft using deep hypothermic circulatory arrest.
[**2165-6-13**] - Sternal washout and closure with removal of packs.
History of Present Illness:
This 34 year old Hispanic male hemodialysis (on transplant
list) with a history of MSSA aortic valve endocarditis in [**2161**]
is s/p
bioprosthetic aortic valve replacement on [**2161-9-18**] complicated by
a perivalvular abscess requiring homograft valve and aortic root
replacement with reimplantation of coronary arteries on [**2161-9-29**].
He subsequently was treated with a 6 week course of nafcillin
and maintained on dicloxacillin through [**11-24**]. In [**8-25**] he was
treated for what was believed to be recurrent MSSA endocarditis
with 6 weeks of Rifampin and cefazolin and has been on Keflex
indefinitely for suppressive therapy. He was re-admitted
[**2-28**]/-[**3-8**] with fevers
and enterococcal bactermia and was diagnosed with presumed
E.faecalis prosthetic valve endocarditis. TEE at that time
showed
moderate to severe mitral regurgitation (3+), but did not reveal
an abscess and he was hemodynamically stable. The source of his
bacteremia was never found and he was sensitized and started on
ampicillin. He has completed the six week course of Ampicillin
as of [**4-10**] and has been transitioned to levofloxacin for
suppression. He was seen by Infectious Disease in [**2165-3-18**]
after completing his intravenous antibiotics. Given the degree
of valve dysfunction,
surgery was recommended.
Past Medical History:
end stage renal disease
s/p left arm arteriovenous fistula
s/p percutaneous angioplasty [**2164-10-21**] and [**2165-2-1**] of fistula
h/o Aortic valve endocarditis with MSSA
s/p bioprosthetic aortic valve replacement [**2161-9-18**]
h/o peri-valvular abscess
s/p redo sternotomy, redo aortic valve replacement with
homograft valve and aortic root replacement and reimplantation
of coronary arteries ([**2161-9-29**])
recurrent MSSA bacteremia with presumed recurrent endocarditis
in [**8-25**]
H/O systolic and diastolic dysfunction, EF >55% 8/08
Bilateral subclavian vein, left internal jugular and left
brachiocephalic thromboses
s/p brachiocephalic vein stent.
Hypertension
Hyperlipidemia
Chronic fatigue syndrome
h/o Pyloric stenosis
Social History:
Originally from [**Male First Name (un) 1056**]. Has 3 sons. Drinks 2-3
drinks/month, continues to smoke 1ppd x10 years, no illicits.
Works part-time as a teacher.
Family History:
mother - breast ca at 45, survivor, aunt - died of MI at 50, no
other family hx of renal disease, no DM or other CA in the
family
Physical Exam:
admission:
Pulse: 76sr Resp: 18 O2 sat: 100%
B/P 108/68
Height: 68in Weight: 68.2kg
General: Well appearing in NAD
Skin: Dry, warm and intact. Well healed sternotomy. Left
fistula.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x], Murmur V/VI HSM @base radiating to
neck & IV/VI diastolic at RUSB
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [X]
Extremities: Warm [x] well-perfused[x] Trace Edema
Varicosities: None
Neuro: Grossly intact
Pulses:
Femoral Right:1+ Left:1+ No incision noted
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:1+ (prior [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36066**] AVF)
Carotid Bruit: can not assess due to radiation of murmur
Pertinent Results:
[**2165-6-12**] ECHO
PRE BYPASS The left atrium is moderately dilated. The left
atrium is elongated. No spontaneous echo contrast is seen in the
body of the left atrium. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is
intermittently seen. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is mild to moderate global left ventricular hypokinesis (LVEF =
40 %). The right ventricle displays focal hypokinesis of the
apical free wall. The rest of the right ventricular segments
display mild to moderate hypokinesis. There are simple atheroma
in the descending thoracic aorta. The number of aortic valve
leaflets cannot be determined. The aortic valve is not well
seen. There is a small vegetation on the aortic valve. There is
mild aortic valve stenosis (valve area 1.2 cm2). Severe (4+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is receiving epinephrine and nor
epinephrine by infusion. Biventricular systolic function is
improved. Left ventricular ejection fraction is in the 50 to 55%
range. There is a bileaflet prosthesis in the aortic position.
It appears well seated. Both leaflets can be seen opening and
closing. There is mild valvular aortic regurgitation which
appears to represent the normal "washing" jets associated with
this valve. No perivalvular regurgitation is appreciated but a
small jet can not be completely ruled out. The maximum gradient
across the valve was measured at 71 mmHg with a mean gradient of
53 mmHg at a cardiac output of about 7.5 liters/minute. The
effective orifice area is about 1.25 cm2. The gradients are
higher and the effective area lower than would be expected for
this valve but a definitive cause can not be ascertained. The
mitral regurgitation is now trace. The thoracic aorta appears
intact. All of these findings were discussed with Dr. [**Last Name (STitle) 914**] in
the operating room at the time of the study.
[**2165-6-26**] 04:40AM BLOOD WBC-8.6 RBC-3.43* Hgb-10.1* Hct-33.0*
MCV-96 MCH-29.4 MCHC-30.6* RDW-20.2* Plt Ct-116*
[**2165-6-12**] 06:11PM BLOOD WBC-5.7 RBC-2.56* Hgb-8.0* Hct-24.5*
MCV-96 MCH-31.4 MCHC-32.9 RDW-18.4* Plt Ct-91*
[**2165-6-26**] 04:40AM BLOOD PT-18.4* PTT-29.0 INR(PT)-1.7*
[**2165-6-12**] 06:11PM BLOOD PT-16.1* PTT-44.2* INR(PT)-1.4*
[**2165-6-26**] 04:40AM BLOOD Glucose-88 UreaN-58* Creat-PND Na-137
K-4.1 Cl-97 HCO3-26 AnGap-18
[**2165-6-12**] 07:56PM BLOOD UreaN-66* Creat-8.8*# Cl-111* HCO3-27
[**2165-6-26**] 04:40AM BLOOD ALT-39 AST-549* LD(LDH)-650* AlkPhos-152*
Amylase-215* TotBili-1.0
[**2165-6-16**] 01:18AM BLOOD AST-56* LD(LDH)-330* AlkPhos-95
Amylase-966* TotBili-0.3
[**2165-6-26**] 04:40AM BLOOD Lipase-118*
[**2165-6-16**] 01:18AM BLOOD Lipase-14
[**2165-6-26**] 04:40AM BLOOD Phos-5.0*# Mg-3.0*
[**2165-6-27**] 07:15AM BLOOD WBC-8.5 RBC-3.48* Hgb-10.5* Hct-33.3*
MCV-96 MCH-30.1 MCHC-31.5 RDW-20.9* Plt Ct-125*
[**2165-6-27**] 07:15AM BLOOD PT-16.7* INR(PT)-1.5*
[**2165-6-27**] 07:15AM BLOOD Glucose-97 UreaN-84* Creat-9.5*# Na-130*
K-4.5 Cl-91* HCO3-24 AnGap-20
[**2165-6-27**] 07:15AM BLOOD ALT-37 AST-426* LD(LDH)-529* AlkPhos-154*
Amylase-253* TotBili-0.8
Brief Hospital Course:
Mr. [**Known lastname 11041**] was admitted to [**Hospital1 18**] on [**2165-6-12**] for surgical
management of his aortic valve disease. He was taken directly to
the Operating Room where he underwent a redo, redo sternotomy
with replacement of his aortic valve using a 19mm Onyx
mechanical valve and replacement of his ascending aorta and
hemiarch. He required multiple blood products and alarge amount
of fluid. Given this, his chest was packed and left open over
night. His coagulopathy was corrected and on [**2165-6-13**], he
returned to the Operating Room where he underwent sternal
washout with chest closure. He was again taken to the Intensive
Care Unit for monitoring.Please refer to Dr[**Last Name (STitle) 5305**] operative
note for further details.
He remained intubated and sedated on pressors overnight.
Hemodialysis was performed the next morning. Extubation was
attempted later, however, he failed this due to an altered
mental status. The Infectious Disease service was consulted for
assistance given his history of endocarditis. Vancomycin and
Ancef were recommended to be continued until tissue cultures
returned. Coumadin was started for anticoagulation for his
mechanical valve. The renal service continued to follow him
closely and hemodialysis was continued.
On [**2165-6-18**], Mr. [**Known lastname 11041**] was successfully extubated and he had no
further confusion. As there was no growth from his
intraoperative tissue samples, antibiotics were discontinued.
Dental prophylaxis is recommended for life. As he was noted to
be thrombocytopenic, a Heparin induced thrombocytopenia assay
was sent which was negative. He went into a rapid atrial
fibrillation/flutter and was cardioverted on[**2165-6-24**] successfully
into sinus rhythm.
He was unable to be on Amiodarone or statins due to elevated
liver function tests so Lopressor was titrated up for better
rate control and he was continued on Coumadin. He did have an
INR peak at 10.8 and Coumadin was held for several days and
restarted at a lower dose. Hepatology was consulted for
elevated liver function tests and amylase/lipase which were
trending down at the time of discharge and he remained
asymptomatic for abdominal pain. He did require an aggressive
bowel regimen due to severe constipation and was treated with
Lactulose and Miralax.
On POD# 15 after hemodialysis, he was cleared by Dr.[**Last Name (STitle) 914**] for
discharge to home with VNA. All follow up appointments were
advised. First INR draw by VNA arranged for [**2165-6-28**].
Anticoagulation will be followed by the [**Hospital6 **]
coumadin clinic.
Medications on Admission:
ANTI-OXIDANT - (Prescribed by Other Provider) - Dosage
uncertain
ATORVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet -
1
Tablet(s) by mouth daily
B COMPLEX-VITAMIN C-FOLIC ACID [RENAL CAPS] - (Prescribed by
Other Provider) - 1 mg Capsule - 1 Capsule by mouth daily
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - [**1-19**] Tablet(s)
by
mouth q 4-6 hours for L arm pain
LABETALOL - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 200 mg Tablet - 1 Tablet by mouth twice a day on
Monday, Wednesday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**]; none on Tuesday, Thursday or
Saturday
LANTHANUM [FOSRENOL] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 500 mg Tablet, Chewable - [**1-19**]
Tablet(s)
by mouth TID prn
LEVOFLOXACIN [LEVAQUIN] - 250 mg Tablet - 1 Tablet(s) by mouth
every other day Take two tablets on day one, then take one
tablet
every other day
LISINOPRIL - (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet by mouth daily on Monday, Wednesday, [**Month/Day (2) 2974**], and [**Month/Day (2) 1017**]
LISINOPRIL - 10 mg Tablet - 1 Tablet by mouth daily on Tuesday,
Thursday, Saturday
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**1-19**] Tablet(s) by
mouth q4-6h as needed for pain
SEVELAMER HCL [RENAGEL] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 800 mg Tablet - 3 Tablet(s) by mouth
three times a day
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
Dosage uncertain
ASPIRIN - (OTC; Dose adjustment - no new Rx) - 325 mg Tablet -
1
Tablet(s) by mouth daily
B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (OTC) - Tablet - 1
Tablet(s) by mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day Take Colace while taking narcotic pain medications to
prevent
constipation
OMEGA-3-DHA-EPA-FISH OIL [FISH OIL HIGH POTENCY] - (Prescribed
by Other Provider) - 200 mg-300 mg Capsule - 2 Capsule(s) by
mouth once a day
VITAMIN E - (Prescribed by Other Provider) - Dosage uncertain
ZINC - (OTC) - Dosage uncertain
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for blood pressure.
Disp:*30 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for renal failure.
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for renal failure.
Disp:*30 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for gi prophylaxis.
Disp:*30 Tablet, Delayed Release (E.C.)(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. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS) as needed for renal failure.
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic insufficiency
Aortic valve stenosis
end satge renal failure
s/p left arteriuovenous fistula creation
s/p percutaneous fistula angioplasty [**2164-10-21**] and [**2165-2-1**]
Aortic valve endocarditis with MSSA
s/p bioprosthetic aortic valve replacement [**9-23**]
s/p redo sternotomy, homograft redo aortic valve and aortic root
replacement with reimplantation of coronary arteries
([**2161-9-29**])
MSSA bacteremia with recurrent endocarditis in [**8-25**] - On
cephalexin 500 [**Hospital1 **] since for suppressive therapy
endocarditis [**1-27**] following angioplasty of stenotic
areteriovenous fistula
congestive heart failure secondary to valve pathology
H/O systolic and diastolic dysfunction, EF >55% 8/08
Bilateral subclavian vein, left IJ and left brachiocephalic
thromboses
s/p brachiocephalic vein stent.
Hypertension
chronic Low back pain
Hyperlipidemia
Chronic fatigue syndrome
h/o Pyloric stenosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Morphine IR
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on Wednesday, [**2165-7-16**] at 1:15PM
([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-19**] weeks ([**Telephone/Fax (1) 250**])
Cardiologist: Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**1-19**] weeks
Other Scheduled Appointments:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2165-6-21**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2165-7-3**] 10:30
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication=Mechanical valve
Goal INR 2.5-3.0
First draw [**2165-6-28**]
Results to [**Company 191**] Anticoagulation Management Services
phone [**Telephone/Fax (1) 2173**] fax
Completed by:[**2165-6-27**] Name: [**Known lastname 4428**],[**Known firstname **] A Unit No: [**Numeric Identifier 8864**]
Admission Date: [**2165-6-12**] Discharge Date: [**2165-6-27**]
Date of Birth: [**2130-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Shellfish / Nafcillin
Attending:[**First Name3 (LF) 1543**]
Addendum:
Medication Addendun;
Pt was discharged on Nephrocaps. Therefore Folic Acid
prescription was voided.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2165-6-27**] Name: [**Known lastname 4428**],[**Known firstname **] A Unit No: [**Numeric Identifier 8864**]
Admission Date: [**2165-6-12**] Discharge Date: [**2165-6-27**]
Date of Birth: [**2130-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Shellfish / Nafcillin
Attending:[**First Name3 (LF) 1543**]
Addendum:
Medication addendum-
Just prior to discharge, Pt placed back on home dose of
Lisinopril 20 mg daily to optimize BP control
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2165-6-27**]
|
[
"997.1",
"427.31",
"305.1",
"790.4",
"272.4",
"518.81",
"424.1",
"427.32",
"V49.83",
"585.6",
"E878.1",
"428.0",
"348.30",
"276.7",
"564.09",
"287.5",
"428.42",
"285.21",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"96.6",
"35.22",
"96.71",
"38.93",
"99.62",
"38.45",
"39.95",
"96.04",
"96.59"
] |
icd9pcs
|
[
[
[]
]
] |
17919, 18136
|
7535, 10149
|
328, 677
|
14509, 14736
|
4046, 7512
|
15508, 17159
|
2989, 3121
|
12271, 13463
|
13565, 14488
|
10175, 12248
|
14760, 15485
|
3136, 4027
|
261, 290
|
705, 2026
|
2048, 2791
|
2807, 2973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,252
| 181,362
|
28109
|
Discharge summary
|
report
|
Admission Date: [**2194-8-5**] Discharge Date: [**2194-8-19**]
Date of Birth: [**2125-9-26**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Ciprofloxacin / Percocet / Augmentin
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
EGD
History of Present Illness:
65 year old female past medical history significant for
Prader-Willi Syndrome, HTN, hyperlipidemia, developmental delay,
2 previous MI's, s/p cath in 96, 98, unknown results. Pt reports
onset of chest pain, substernal [**5-26**] non radiating, no
associated N/V/diaphoresis x 1 hour at rest in day program. Pt
to [**Location (un) 620**] [**Hospital1 69**], chest pain free
on arrival. EKG NSR@61, ST elevation V3, repeat NSR. CK-MB 34.9,
CPK 261, trop T 0.081. BP 140/76, HR 60. 1 liter NS given. Pt
given heparin bolus 3800 units, heparin GGT at 1000 units,
plavix loaded 600 mg, sent to [**Hospital1 18**]
.
Of note, pt previously admitted for chest pain NSTEMI to [**Location (un) 620**]
[**Date range (3) 68347**] for similar complaint NSTEMI, CK 266, MB 22.4,
trop 0.07. ECHO at that time with normal EF, nml wall motion, 1+
MR. She also reports fall this Sunday with abrasion, associated
with loss of balance, as per group home, PCP [**Name Initial (PRE) 12309**].
Past Medical History:
Prader-Willi syndrome
2 previous NTEMI's
Hypertension
ileostomy 96
schizo-affective disorder
SIADH - last admission
Social History:
Lives in a group home. Parents deceased x 20 + years. Healthcare
proxy is [**Name (NI) 1439**] [**Name (NI) 1968**], [**Telephone/Fax (1) 68348**]. Unable to assess hx
further.
Family History:
Unknown
Physical Exam:
ADMISSION EXAM
Vitals- 97.8, 158/75, 64, 18, 98%, 0/10 pain
General- short, smiling female in no acute distress, with
bandage on head.
HEENT- abrasion forehead left, blood on gauze. No other
abrasions or lacerations. PERRL. No JVP appreciated.
CV- RRR, no M/R/G
lungs- CTAB, no wheezes noted.
Abdomen- surgical scar vertical, non tender, slight distenstion.
+ BS
groin- 2 + fem pulses
Extr- no edema, cyanosis, clubbing, foot deformity bilaterally,
2+DP
Small hands.
Pertinent Results:
[**2194-8-5**] 09:50PM CK-MB-20* MB INDX-9.7* cTropnT-0.09*
[**2194-8-5**] 09:50PM CK(CPK)-207*
[**2194-8-5**] 10:22PM PTT-150*
[**2194-8-6**] - C.CATH
1. Selective coronary angiography revealed a right dominant
system with
LMCA, LAD and LMCX that were free of angiographically apparent
disease
and an RCA that had a 20% proximal lesion but was otherwise free
of
disease.
2. Left ventriculography showed normal function.
3. Limited hemodynamic assessment showed low normal systemic
aortic
pressures.
Findings
1. Coronary arteries are normal.
2. Normal ventricular function.
.
[**2194-8-7**] - ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is unusually small. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 70%). No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
[**2194-8-8**] - CHEST (PA & LAT)
1. Right retrocardiac opacity which likely represents pneumonia.
2. Leftward deviation of the trachea. This may be due to a
multinodular goiter. CT chest examination can be performed if
clinically indicated.
.
[**2194-8-8**] - EGD
Small hiatal hernia
Esophageal erosion
Angioectasias in the fundus, stomach body and antrum
Angioectasias in the duodenal bulb, first part of the duodenum
and second part of the duodenum
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
1) Chest pain
Ms. [**Known lastname 68349**] chest pain was initally considered to be unstable
angina in the setting of moderately elevated enzymes and two
previous MI's in the past. Other things in the differential
diagnosis included GERD, costochondral pain, coronary vasospasm,
myocarditis and pleuritic pain. There were no acute EKG changes.
Troponin was borderline at 0.08 and MB mildly positive. The
patient underwent cardiac catheterization which demonstrated 20%
proximal RCA stenosis, but was otherwise clean and no
intervention was deemed necessary. Her symptoms may have been
related to coronary vasospasm, however her upper GI pathology
noted on EGD (see below), was also likely contributed. Given
non-flow limiting coronary artery disease and upper GI bleed,
she was maintained off ASA and Plavis.
2) Upper GI bleed:
Ms. [**Known lastname **] developed hematemesis/coffee-ground emesis
following Plavix load and heparin drip. Heparin, plavix and
aspirin were held and she was started on IV PPI. EGD showed
diffuse angioectasias throughout stomach and down to duodenal
bulb, along with esophageal erosions. She was transferred to
MICU for further managment and developed melana. She was
transfused a total of 4U PRBCs, 2FFP and 1 bag platelets. Hct
stabilized and she was transferred to the floor. Her GI bleeding
was most likely precipitated by heparin/plavix. Given diffuse
nature of AVMs, no endoscopic intervention was possible. The
surgical service was consulted, however they did not recommend
surgery (which would need to be extensive), given stabilization
of the patient's hematocrit. She has scheduled follow-up with
Gasteroenterology at [**Hospital1 18**] and they will decide whether or not
to perform a follow-up EGD. She should have a colonoscopy as an
outpatient.
3) Aspiration Pneumonia/Pneumonitis
The patient developed crackles after the episode of hematemesis.
This finding raised concern for pneumonia versus an aspiration
pneumonitis. CXR demonstrated retrocardiac opacity, but the
patient remained afebrile, without a leukocytosis or symptoms.
Thus, antibiotic coverage was not initiated. Lungs were clear at
discharge and the patient was stable on room air. She underwent
a bedside speech and swallow evaluation, along with a video
swallow study. This revealed mild oropharyngeal dysphagia with
aspiration of clear liquids. She should adhere to a soft
solids/thickened liquid diet to avoid future aspiration. She
will need outpatient follow-up for tracheal deviation
demonstrated on CXR. There was some concern for thyroid
pathophysiology. TSH was slightly elevated. Levothyroxine was
increased to 100 micrograms per day. She will need repeat
thyroid studies 6 weeks following discharge.
4) SIADH
She was continued on salt tablets for known hyponatremia likely
secondary to anti-psychotic induced SIADH. She was continued on
her home doses of anti-psychotics for her schizo-affective
disorder.
Given the patient's need for physical therapy and ambulation
with a walker, she was discharged to a rehabilitation facility.
Medications on Admission:
Plavix 75 mg
Metoprolol 50 daily
Zestril 5 mg
lipitor 20 mg
ASA 325 mg
Protonix 40 qd
salt tablets [**Hospital1 **]
Depakote 750 [**Hospital1 **]
Ditropan XL 15 hs
Risperdal 4 [**Hospital1 **]
Pamelor 50 HS
Synthroid 75 mcg
Tylenol
Glucosamine
Multivitamins
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day): please
take 750 mg twice a day just as you previously had. .
7. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
9. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Nasal once a day.
13. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*5*
14. Risperidone 1 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
15. Sucralfate 100 mg/mL Suspension Sig: Ten (10) mL PO qid.
Disp:*1 month* Refills:*5*
16. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Lifecare of [**Location (un) **]
Discharge Diagnosis:
Primary:
chest pain - cath with clean coronaries- no intervention
performed.
Secondary:
Upper GI bleed
SIADH
Hypertension, Schizoaffective disorder
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
You were admitted with chest pain and had elevated enzymes. You
had a cardiac catheterization which showed clean coronaries, and
no intervention was thus needed. You had an upper GI bleed which
has resolved.
-Please do not take aspirin or plavix given GI bleed.
- Addition of Norvasc 5 mg.
-Please take your salt tablets as you previously had, and go to
get your sodium level checked tomorrow with Dr. [**Last Name (STitle) 17567**].
-Please keep all appointments
-Please return to the hospital if you are experiencing chest
pain, shortness of breath, fainting or any other symptoms
concerning to you.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 17567**] in 2 weeks. You can make an
appointment by calling [**Telephone/Fax (1) 17568**]. He should check your
hematocrit.
- given your levothyroxine dose was increased, you should have
repeat thyroid function tests checked in 6 weeks.
- you should have an outpatient colonoscopy
.
Please follow-up with Dr. [**Last Name (STitle) **] (Cardiology) on [**8-20**] at
2:30pm. [**Telephone/Fax (1) 4105**].
.
Please follow-up with Dr. [**Last Name (STitle) **] (Gasteroenterology) on Monday,
[**9-8**] at 3pm. [**Hospital Ward Name 23**] Bldg. [**Location (un) 436**]. Phone:
[**Telephone/Fax (1) 1954**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
|
[
"244.9",
"285.1",
"786.59",
"E939.3",
"295.70",
"507.0",
"272.4",
"253.6",
"759.81",
"537.83",
"401.9",
"530.89",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"88.53",
"99.04",
"37.22",
"88.55",
"99.07",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8944, 9003
|
4124, 7184
|
322, 352
|
9210, 9219
|
2215, 4101
|
9869, 10643
|
1704, 1713
|
7493, 8921
|
9024, 9189
|
7210, 7470
|
9243, 9846
|
1728, 2196
|
271, 284
|
380, 1352
|
1374, 1492
|
1508, 1688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,075
| 177,414
|
7223
|
Discharge summary
|
report
|
Admission Date: [**2104-1-17**] Discharge Date: [**2104-1-20**]
Date of Birth: [**2044-6-27**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 59 year old man
with a history of stage IV adenocarcinoma of the lung, who
originally presented with a neck mass in [**2102-8-8**] and was
found to have stage IV lung cancer with metastases to his
left neck and subcarinal lymph nodes, status post a right
upper lobe wedge resection in [**2102-10-8**]. He completed a
course of carboplatin and Taxol as well as radiation therapy.
A follow-up CT scan in [**2103-6-8**] and [**2103-9-8**] showed
interval worsening of the pulmonary nodules as well as
retroperitoneal lymph nodes. He was started on taxotere
therapy in [**2103-8-8**]. In [**2103-10-8**], an isolated brain
metastases was discovered, status post suboccipital
craniotomy with resection of tumor and stereotactic
radiosurgery in [**2103-11-8**].
The patient presented to [**Hospital3 417**] Hospital the Saturday
prior to admission with atypical right sided chest pain.
There, a CT angiogram showed small filling defects of
tertiary branches of his pulmonary vasculature and a
pericardial effusion. He was started on heparin, with a drop
in his platelet count from 244,000 to 130,000 in three days.
He was believed to have HIT and was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for Hirudin therapy.
In the Emergency Room, the patient was comfortable, with a
heart rate in the 120s and a blood pressure 110 to 120/70.
His oxygen saturation was 98% on two liters. A repeat CT
angiogram showed tiny nonocclusive filling defects in the
lower lobes bilaterally, consistent with emboli, and a large
pericardial effusion with a pulsus of 30. An emergent
echocardiogram was performed that was consistent with
tamponade. The patient was taken to the catheterization
laboratory for pericardiocentesis under fluoroscopy.
PAST MEDICAL HISTORY: 1. Stage IV adenocarcinoma with clear
cell features of lung, as described above. 2. Hypertension.
MEDICATIONS ON ADMISSION: Accupril 10 mg p.o.q.d.,
Prednisone 10 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient smoked one pack per day for
forty years and occasionally uses alcohol. He has no history
of drug abuse. He is married and lives with his wife.
PHYSICAL EXAMINATION: On physical examination, the patient
was a pleasant male in no acute distress who was afebrile
with a heart rate of 115, respiratory rate 20s, blood
pressure 90s/60s with an oxygen saturation of 98% on two
liters. Head, eyes, ears, nose and throat: Unremarkable.
Neck: No jugular venous distention. Lungs: Clear to
auscultation bilaterally. Cardiovascular: Tachycardiac with
no murmurs but a rub in systolic and diastole loudest at the
apex. Abdomen: Benign. Extremities: Without edema, groin
sites looked good.
LABORATORY DATA: White blood cell count was 11.6, hematocrit
29.7, platelet count 237,000 and normal differential.
Coagulation studies showed a prothrombin time of 14.6, INR
1.5 and partial thromboplastin time 34.1. Chem-7 showed a
sodium of 135, chloride 101, bicarbonate 20, BUN 22 and
creatinine 1.4. Electrocardiogram revealed sinus tachycardia
with biphasic P waves but normal voltage criteria after
catheterization.
HOSPITAL COURSE: Mr. [**Known lastname 26762**] was admitted to the Coronary Care
Unit after a pericardial drain was placed in the
catheterization laboratory. He was observed to have a large
amount of serosanguinous drainage that tapered off over two
days. The drain was successfully removed after a repeat
echocardiogram showed minimal reaccumulation and he had
drained less than 25 cc over 24 hours.
A repeat echocardiogram performed 24 hours after the drain
was pulled showed no further reaccumulation of fluid. The
drainage fluid was positive for malignant cells and so was
likely secondary to lung metastases.
As anticoagulation for his pulmonary embolism was
contraindicated secondary to his bleeding pericardial
metastases, an inferior vena cava filter was placed to lower
the risk of future pulmonary embolism.
The patient's oncologists, Dr. [**Last Name (STitle) 26763**] and Dr. [**Last Name (STitle) **], had a
discussion with him regarding his life expectancy, which is
about one month secondary to his underlying disease. The
patient understood this and wished to remain a full code.
After the repeat echocardiogram after drain removal was
negative, the patient was discharged home to follow up with
an echocardiogram in three days to evaluate for recurrence of
the fluid.
CONDITION AT DISCHARGE: Improved.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Tamponade secondary to pericardial metastases.
2. Pulmonary embolism, status post inferior vena cava filter
placement.
3. Stage IV metastatic adenocarcinoma of the lung.
4. Hypertension.
DISCHARGE MEDICATIONS:
Prednisone 10 mg p.o.q.d.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2104-1-24**] 18:48
T: [**2104-1-27**] 17:16
JOB#: [**Job Number 26764**]
|
[
"162.8",
"401.9",
"197.2",
"415.19",
"420.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"37.0",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
4792, 4991
|
5014, 5319
|
2156, 2262
|
3428, 4716
|
2460, 3410
|
4731, 4771
|
161, 2004
|
2027, 2129
|
2279, 2437
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,349
| 161,837
|
30134
|
Discharge summary
|
report
|
Admission Date: [**2147-4-13**] Discharge Date: [**2147-5-4**]
Date of Birth: [**2074-5-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Abdominal pain, shortness of breath.
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
PICC line placement (x2) and removal (x1)
History of Present Illness:
72 year-old female with past medical history of idiopathic
pancreatitis, asthma, T2DM, hyperlipidemia, HTN, recently
discharged from [**Hospital1 18**] on [**4-7**] after being tx'd from OSH for
further evaluation of pancreatitis. Per her last discharge
summary, she had a CT scan at the OSH on [**2-19**] which demonstrated
new pancreatitis. On [**3-12**] a CT of thorax demonstrated multiple
low density lesions in the pancreas suggestive of pancreatic
pseudocysts, and a f/u CT on [**3-15**] revealed phlegmon like changes,
particular to the head of the pancreas. The final CT on [**3-22**] at
the OSH showed worsening cystic changes. There was no elevated
in amylase and lipase and her biliary ducts were normal. CA [**58**]-9
was normal from her last admission. There was concern for
autoimmune pancreatitis given her history of asthma and a IgG4
level is pending. CFRT mutation was negative.
.
She was transferred from rehab the day of admission with
abdominal pain. The patient describes her pain as a pressure
throughout the abdomen, [**9-20**], non-radiating. The pain is
similar to her prior episode of pancreatitis. The pain occurred
acutely and awoke the patient from sleep. The pain is now 0/10
after receiving morphine in the ED. The patient states she has
baseline abdominal pain, [**2-18**], relived by percocet. She denies
nausea, vomiting, diarrhea, melena, BRBPR. Her last bowel
movement was the day prior to admission. She complains of
subjective fevers. She last ate the evening prior to admission.
Of note, the patient was to have an appointment with Dr. [**Last Name (STitle) **]
the day after admission. The patient also complained of SOB and
wheezing relieved by combivent nebs.
.
In the ED, VS 100.6 119 134/69 25 93%RA. In the ED she received
levofloxacin 750 mg x 1, flagyl 500 mg x 1, 2 L NS, morphine 4
mg x 1, tylenol 650 mg x 1, combivent nebs x 3.
.
ROS: As above. Denies CP, cough, dysuria. Review of systems
otherwise negative in detail.
Past Medical History:
Idiopathic Pancreatitis - Pseudocyst
Asthma
DM II
Hyperlipidemia
HTN
MRSA colonization of sputum
Social History:
Discharged to rehab facility from last admission. Lives with
husband. Nonsmoker, nondrinker, no h/o IVDU.
Family History:
No family history of cancer or autoimmune disease. Father died
at age 80 from CAD. Mother died of emphysema.
Physical Exam:
VS 97.6 98 108/47 21 96% 4LNC
Gen: NAD, breathing full sentences
HEENT: Sclera anicteric, PERRL, OP clear without lesions, MM dry
Neck: No JVD
Heart: RRR, no MRG
Lungs: CTAB, expiratory wheezing thoughout, mildly prolonged
expiratory phase, good respiratory effort
Abd: Hyperactive bowel sounds, tympanitic, mild distention, some
tenderness throughout, no rebound/guarding; bruising at presumed
sites of heparin administration but no Grey-[**Doctor Last Name **]/Cullen signs
Ext: No CCE
Skin: Warm, no rashes, scattered echymoses
Pertinent Results:
Labwork on admission:
[**2147-4-13**] 10:35AM WBC-16.6* RBC-3.76* HGB-11.4* HCT-35.4*
MCV-94 MCH-30.3 MCHC-32.1 RDW-14.9
[**2147-4-13**] 10:35AM PLT SMR-NORMAL PLT COUNT-393
[**2147-4-13**] 10:35AM NEUTS-52 BANDS-43* LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2147-4-13**] 10:35AM PT-12.1 PTT-25.8 INR(PT)-1.0
[**2147-4-13**] 10:35AM GLUCOSE-71 UREA N-16 CREAT-0.6 SODIUM-143
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-38* ANION GAP-12
[**2147-4-13**] 10:35AM ALT(SGPT)-18 AST(SGOT)-20 CK(CPK)-18* ALK
PHOS-102 AMYLASE-44 TOT BILI-0.2
[**2147-4-13**] 10:35AM LIPASE-17
[**2147-4-13**] 10:35AM CK-MB-NotDone
[**2147-4-13**] 10:35AM cTropnT-0.02*
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2147-4-13**]
IMPRESSION:
1. Distended gallbladder that contains sludge. No evidence of
cholecystitis is noted including no gallbladder wall edema, wall
thickening, pericholecystic fluid.
2. Complex cystic structure is seen medial to the gallbladder
arising from the pancreatic bed. This corresponds to the
pseudo-cysts that were seen on pancreatic bed. However the
suspecious focus of air mentioned on CT was not seen on the this
cystic structure.
.
CT ABDOMEN W/CONTRAST [**2147-4-13**]
IMPRESSION:
1. The pancreas has been replaced by innumerable pseudocysts
that extend beyond the pancreatic bed as above. The foci of air
in some of these pseudocysts and within the remnant uncinate
process, along witht he peripancreatic stranding, suggest acute
on chronic pancreatitis. Air also may be introduced by
instrumentation (ERCP), but unlikely in this case. Correlate
with history of such procedure. The presence of innumerable
cysts may also be due to underlyng IPMN, and workup to exclude
it may be pursued once acute presentation resolves.
2. Findings at the lung bases appear new compared to CT from
[**2147-3-31**] and are suggestive of either multilobar pneumonia versus
aspiration. Close clinical correlation is recommended.
.
CHEST (PORTABLE AP) [**2147-4-13**]
IMPRESSION: Stable left pleural effusion with left basilar
atelectasis. No definite focal consolidation or superimposed
edema. Limited examination due to positioning. If clinically
feasible, consider PA and lateral views in the radiology suite
for better evaluation.
.
[**2147-4-21**]: Colonoscopy:
Impression: Diverticulosis of the sigmoid colon
There was liquid stool throughout the colon. There was no fresh
or old blood seen in the colon.
Otherwise normal colonoscopy to cecum
Recommendations: Repeat screening colonoscopy as an outpatient
to look for small polyps that may have been missed.
.
[**2147-5-1**] right upper extremity ultrasound:
REPORT: There is normal compressibility, augmentation, and
respiratory variation within the deep veins of the right upper
extremity. It should be noted that the patient's PICC line is
within the cephalic vein and there is definitely thrombus
surrounding the cephalic vein, but this does not appear to
extend proximally into the axillary subclavian region. It does
not appear to be entirely occlusive.
CONCLUSION:
PIC in right cephalic vein with surrounding clot, which does not
appear to extend proximally into the axillary or subclavian
regions. Small amount of flow is identified surrounding PICC.
.
[**2147-5-2**] CT Pancreas:
CT ABDOMEN: Few images through the lung bases demonstrate
bibasilar atelectasis and small bilateral pleural effusions,
relatively unchanged from [**2147-4-26**].
There has been near total replacement of the pancreas by
multiple cystic collections. These extend inferiorly along the
mesentry, as well as via the foramen of [**Location (un) 45041**] into the
retroperitoneum on the right. Some of these cystic collections
have foci of air, and some have areas of mixed attenuation (4,
25), which could represent hemorrhage and/or infection. However,
the amount of air in this collection is unchanged from the prior
study.
There is no ascites. Spleen, liver, gallbladder are normal in
appearance. The parenchyma of both kidneys enhances
symmetrically. Small stone is seen in the right kidney,
unchanged.
CT PELVIS: Foley catheter is present in the bladder. A small
amount of free fluid is seen within the pelvis. There is
diverticulosis of the sigmoid colon without diverticulitis.
Degree of anasarca is unchanged, and there is increased
subcutaneous edema in the left flank.
BONE WINDOWS: No suspicious lytic or blastic lesions.
IMPRESSION: Multiple cystic lesions in the pancreas are
relatively unchanged in size. Some of these have foci of air.
This finding too is unchanged from the prior study. There is no
free air in the abdomen.
.
[**2147-5-3**] Right upper extremity ultrasound:
FINDINGS: Since prior exam, there has been interval removal of
the
right-sided PICC line. The previously described right cephalic
vein clot is not visualized on the current study. Evaluation of
the flow is difficult due to the size of the vessel; however,
color flow is identified.
IMPRESSION: Since prior exam, the previously described cephalic
vein clot has resolved. Interval removal of right upper
extremity PICC line.
Brief Hospital Course:
72 year-old female with pmhx of idiopathic pancreatitis, asthma,
T2DM, hyperlipidemia, HTN acute on chronic pancreatitis who
presents from floor with GI bleed.
.
# GI Bleed - Patient with 10 point Hct drop and GI bleed seen on
tag red cell scan. Angio was not able to find source of bleed.
GI will plan to scope patient. The patient did not have any
evidence of pancreatic cyst bleed based on several repeat CT
scans, and had a negative EGD, colonoscopy showed diverticulosis
but no activ bleeding, but it was thought that it was likely a
diverticular bleed. During her hospital course she received 4
units of blood and responeded appropriately with stable HCTs.
.
# Pancreatitis - Acute on chronic with pancreatic
abscess/necrosis/pseudocysts with air on imaging. Etiology
believed idiopathic; autoimmune panel pending from last
admission. No evidence of gallstones of RUQ US this admission.
Amylase/lipase not elevated consistent with history of chronic
pancreatitis. Surgery and GI teams involved (Dr. [**Last Name (STitle) **] and
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] respectively), no plans for surgery (likely
not surgical candidate with limited pulmonary statis), but would
consider possible EUS guided biopsy vs. Fna to eval. cysts if
imaging shows some improvement to be addressed at follow-up
appointment.
- Imipenem-cilistatin and Fluconazole for necrosing pancreatitis
to continue indefinitely (course to be determined by Dr.
[**Last Name (STitle) **].
.
# Hospital Acquired pneumonia: Patient with respiratory distress
(hypoxia) and CT chest showed likely bibasilar PNA. Treated with
vancomycin for 14 days and Imipenum ongoing. Improvement of
respiratory status.
.
# MRSA Bacteremia - Most likely from pulmonary source from HAP.
Treated with 14 day course of vancomycin. TTE without
vegetations. Surveillance cultures negative.
.
# Asthma - Patient with severe wheezing on exam improved with
steroids and aggressive nebs for asthma. She was treated with
solumedrol then transitioned to prednisone for long taper of
steroids. We increased here advair dose to 500/50. She was
treated with standing xopenex (instead of albuterol because of
tachycardia) and ipratropium nebs with albuterol prn. She was
weaned to supplemental O2 of 2-3L with sats 93-98%. ABG with
likely respiratory acidosis as compensation for metabolic
alkalosis.
.
# C. diff - Patient tested + for c.diff toxin. She will need to
continue IV flagyl for 7-14 days after completion of imipenum.
.
# Tachycardia - Appears sinus vs MAT. Patient had tachycardia
in the 100s which improvd to 90's on 25mg TID of betablocker.
Monitor closely for bronchospasm in setting of steroid taper.
Could consider change to diltiazem.
.
# Metabolic Alkalosis - Urine cl of 110, thus likely secondary
to steroids. [**Month (only) 116**] have component of respiratory acidosis from
pulm disease although pulm is more likely compensatory.
.
# DM - Patient had DM type 2 on admission. Concern about
progression of pancreatitis with possible insufficient insulin
production. Would treat like DM1 in terms of needing some basal
insulin if NPO. Treated with insulin gtt while on high dose
steroids and transitioned to glargine and humalog ISS. Patient
had decreasing insulin needs with steroid taper. She was
discharged on a significantly lower dose of glargine than she
had been on 22 to 12U to avoid hypoglycemia. Patient did have
several early morning low sugars (50-60s) which easily responded
to PO intake. Dosing was changed from noon to in the morning,
which appeared to help.
.
# Hyperlipidemia - Hold PO lipitor in setting of likely steroid
induced myopathy.
.
# HTN - Normotensive. Tolerated Beta blocker.
.
# Depression/Anxiety - Patient with situational depression and
passive suicidal ideation. Psychiatry was consulted. She was
started on Remeron QHS to help with depression, sleep and
appetite with good effect. She was tappered off of ativan and
started on standing 12.5 mg TID of seroquel (25mg TID made her
very sleepy). Her preferences are no morphine (causes
hallucinations) and no sedating medications during the day.
Palliative care and social work were involved.
.
# Malnutrition - Likely secondary to prolonged hospitalization
and frequent periods of NPO as well as concurrent infection
(pneumonia, bacteremia, c.diff, pancreatitis).
She was started on pancreatic enzymes to help with digestion and
absorption. She was taking good POs with supplements TID at
discharge.
.
# Right venous thrombosis - secondary to PICC line. We removed
the right PICC line and placed a smaller single lumen PICC in
the left arm. Based on the risk benefit of systemic
anticoagulation and repeat GIB the decision was made to hold on
anticoagulation. Repeat ultrasound showed resolution.
.
# Pressure ulcer - admitted with pressure ulcer. Wound care was
consulted with recs included.
.
# CODE - DNR/DNI, confirmed with patient and HCP (husband); they
have written goals of care. Signed form to go with patient.
Medications on Admission:
Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID
Ipratropium Bromide q6hrs
Insulin Regular SS
Zolpidem 5 mg qhs PRN
Atorvastatin 40 mg QD
Ascorbic Acid 500mg [**Hospital1 **]
Zinc Sulfate 220 QD
Heparin Lock Flush 1mg QD
Protonix 40 mg QD
Vitamin D 800 unit QD
DILT-XR 120 mg QD
Oxycodone-Acetaminophen 5-325 mg Q4 PRN
Heparin (Porcine) 5,000 unit/mL TID
Montelukast 10 mg QD
Levalbuterol HCl 0.63 mg/3 mL Q6hrs
Insulin Glargine 8 units QHS
Prednisone taper 35 mg QD
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QIDACHS (4 times a day (before meals and at
bedtime)).
2. Imipenem-Cilastatin 500 mg IV Q6H
Day 1=[**4-13**]
3. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
4. Pangestyme-EC 20,000-4,500- 25,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY
WITH MEALS).
5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
6. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Fluconazole 200 mg Tablet Sig: 0.5 Tablet PO Q24H (every 24
hours).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please continue while not
ambulating frequently.
15. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1)
Inhalation Q4H (every 4 hours).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
17. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed for wheezing.
18. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
19. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous three times a day: to complete [**6-24**] day
course after other antibiotics have finished. .
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP < 100, HR < 60. .
21. Prednisone 10 mg Tablet Sig: According to taper schedule
Tablet PO once a day: Please give 7 days of 40mg, 7 days of
30mg, 7 days of 20mg and then 10mg ongoing until seen by doctor.
.
22. Insulin Glargine 100 unit/mL Solution Sig: 12U Subcutaneous
QAM: Please adjust with Po intake and steroid taper. .
23. Insulin Lispro (Human) 100 unit/mL Solution Sig: Sliding
scale Subcutaneous QIDACHS: Please see attached HISS. .
24. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 68876**] Nursing and Rehab
Discharge Diagnosis:
Necrotic Pancreatitis
Asthma
MRSA bacteremia
Gastrointestinal Bleed (lower, likely diverticular)
Metabolic alkalosis
Diabetes
Malnutrition
C. Diff
right arm venous thrombosis
pressure ulcer
Hypertension
Tachycardia
Depression
Anxiety
Discharge Condition:
Fair - CT scan still showing extensive pancreatitis, possibly
slightly better, tolerating PO diet and supplements without
problems.
Discharge Instructions:
You were admitted with severe pancreatitis of unclear etiology.
You were treated with IV antibiotics and require ongoing IV
antibiotics until instructed by Dr. [**Last Name (STitle) **].
.
Please take all of your medications as prescribed.
.
Please return to the hospital with any worsening abdominal pain,
fever, chills, difficulty breathing, inability to tolerate food
or any other problems.
.
Please ensure that you follow up as listed below.
Followup Instructions:
You have the following appointments scheduled:
1. You must have a repeat CAT scan done of your pancreas. It is
very important that you have this done prior to seeing Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
The following appointments has been scheduled for you:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2147-5-26**] 1:00
Please arrive to the [**Hospital Ward Name 23**] Building [**Location (un) **] at noon for your
1pm scan
.
You will then need to go to your appointment with Dr. [**Last Name (STitle) **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2147-5-26**] 2:00.
.
2. You should also be seen by the Pulmonary Doctor. The
following appointment has been scheduled:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2147-6-5**] 3:20
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2147-6-5**] 3:40
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2147-6-5**] 3:40
|
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"785.0",
"996.74",
"577.1",
"041.11",
"263.9",
"E849.7",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"38.93",
"88.47",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
16532, 16598
|
8455, 13487
|
350, 410
|
16876, 17010
|
3351, 3359
|
17504, 18767
|
2673, 2783
|
14056, 16509
|
16619, 16855
|
13513, 14033
|
17034, 17481
|
2798, 3332
|
274, 312
|
438, 2413
|
3373, 8432
|
2435, 2534
|
2550, 2657
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,347
| 136,024
|
38971
|
Discharge summary
|
report
|
Admission Date: [**2173-2-19**] Discharge Date: [**2173-3-2**]
Service: MEDICINE
Allergies:
Strawberry
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
EGD (multiple)
Colonoscopy
Blood transfusion
Tagged red blood cell scan
History of Present Illness:
86 yo f with hx of hypertension, gastric ca s/p bilroth II in
06, now transfered from OSH due to GI bleed. Pt was admitted
about a week ago to [**Hospital **] Hospital due to BRBPR. She underwent
4 EGDs with clippping of the gastroduodenal artery x 1. On her
last EGD she had a non-bleeding vessel in a ulcer at an
anastomosis site. She had a CT scan that did not show metastatic
disease. She was discharged home yesterday then reportedly had
some rectal bleeding yesterday and today and returned to
[**Location 26380**]. She had a hct today at the OSH of 33 and was given 1
liter NS. She was then transfered to [**Hospital1 18**].
.
In the ED, initial VS were: 98.4 86 144/69 16 98. Pt was not
able to quantify the bleeding or describe it. On exam the pt has
melena in the vault. Later she had a BM (1 tsp of mahogony
stool). GI was consulted. PIV 18g x 2 were placed. Before the pt
was transfered to the floor she had rigors and a temp of 102.
Then pt had brownish red emesis that was positive for blood,
~150ml. NGT was placed and pt was lavaged with 1000ml. At first
the output was frothy and [**Last Name (un) 17993**] brown, later became green.
Blood cx were drawn. Pt was given Pantoprazole 40 mg,
Acetaminophen 650mg PR, Lidocaine Jelly 2% 5mL, Ondansetron
2mg/mL-2mL, MetRONIDAZOLE (FLagyl) 500mg. Also given 2 liters
NS. KUB showed no free air. GI requested MICU admission for
scope. VS on transfer were HR 86 115/68 18 98%RA with NGT and
repeat hct was 35.
.
On the floor, pt is a poor historian, but is feeling well. She
c/o a gagging sensation from her NGT. No pain, SOB, or other
complaints.
Past Medical History:
-gastric ca hx with bilroth II in 06
-recent GI bleed
-HTN
-dementia (pt reports problems with memory since her 70s)
-umbilical hernia repair
Social History:
Pt lives with 3 of her sons in [**Name (NI) **]. She has 11 children and
is a widow. She enjoys singing love songs to her husbands
portrait. She does not use any walking assistance devices and
denies falls. Able to walk and do ADL's such as
laundry/cleaning. Son [**Name (NI) **] is HCP. Multiple children very
involved in her care.
- Tobacco: none
- Alcohol: none
- Illicits: none
Daughter [**Name (NI) **] plans to take her to appointments.
Family History:
Unable to elicit, secondary to dementia.
Physical Exam:
Vitals: T: 100.6 BP: 141/52 P: 84 R: 17 O2: 95%RA
General: Alert, oriented to hospital, city and time, no acute
distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present with cloudy urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NERUO: unable to state the months of the year backwards and
dificulty spelling writing
*******
Notable components of exam on discharge:
abdomen soft non-tender non-distended
ambulating without difficulty
conversational
Pertinent Results:
Admission chemistry:
141 108 19 106 AGap=13
3.7 24 1.3
.
Admission LFT's:
ALT: 16 AP: 59 Tbili: 0.5
AST: 20 Lip: 37
.
Admission CBC:
91
8.5 > 9.9 < 185
29.4
N:73.2 L:22.6 M:2.3 E:1.4 Bas:0.5
.
Admission Coags:
PT: 12.5 PTT: 26.3 INR: 1.1
.
Urine culture [**2-19**]:
URINE CULTURE (Final [**2173-2-23**]):
BETA STREPTOCOCCUS GROUP B. >100,000 ORGANISMS/ML..
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
2/5 blood cultures - no growth final.
.
[**2-24**]:
Tagged RBC scan:
1. No definite evidence of active GI bleed at this time. In case
of
continued clinical concern a repeat study in about 48 hours can
be obtained. 2. Intense uptake in the left upper quadrant is
likely due to stomach uptake of free pertechnetate.
Visualization of the thyroid gland compatible with free
pertechnetate contaminating the tracer. 3. Left thyroid nodule.
Thyroid ultrasound is suggested for further evaluation.
.
[**2-22**] EGD:
Large amount of clot found in the stomach and at the anastomotic
site of the efferent limb. The overlying clot was washed away
with water flushes. There was an area of mucosa noted in this
area with an ulceration with an area of adherent clot. This clot
was not able to be washed away with flushes. Question the
possibility of an underlying bleeding vessel. A clip was noted
from a prior upper endoscopy. Four additional clips were placed
with success. No active bleeding was noted.
Blood in the stomach
Otherwise normal EGD to stomach
Recommendations: Follow hematocrit closely. Continue PPI [**Hospital1 **].
.
[**2-22**] colonoscopy;
Blood in the colon
Otherwise normal colonoscopy to transverse colon
Recommendations: Continue to monitor hct. If continues to bleed,
will need to consider repeat colonoscopy vs. bleeding scan.
.
[**2-24**] EGD:
Previous partial gastrectomy and gastrojejunal anastomosis
Ulcer on the jejunal wall 1 cm beyond the gastrojejunal
anastomosis, with clips attached, no active bleeding
Otherwise normal EGD to 20 cm beyond the gastrojejunal
anastomosis
Recommendations: Continue inhospital monitoring
.
[**2-26**] EGD:
Prior cratered ulcer was seen at the anastomotic site. Three
visible vessels were seen within the cratered ulcer. One clip
was placed on the larger visible vessel (near the junction of
the afferent and efferent limb). Once the clip was placed, this
area began to ooze. An additional clip was placed and then BICAP
thermal therapy was applied with successful hemostasis.
One superficial ulceration without evidence of bleeding noted on
stomach wall.
Previous of the stomach
Otherwise normal EGD to gastrojejunal anastomosis.
Recommendations: Follow Hct. PPI [**Hospital1 **]. Carafate slurry. NPO.
.
[**2-26**] H.Pylori serology:
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2173-3-1**]):
POSITIVE BY EIA.
(Reference Range-Negative).
.
Discharge labs:
WBC 6.2
Hb 11.3
Hct 34.1
Plt 194
Cr 0.9
Brief Hospital Course:
86 y/o F with hx of gastric cancer s/p surgical resection
(Bilroth II) in [**2169**] p/w recent recurrent upper GI bleed now
transfered from OSH for recurrent bleeding, admitted to ICU
after having hematemesis and a fever, then transferred to the
floor.
.
# Upper GI bleed: Pt has a hx of a gastric cancer s/p resection
and now has had recurrent bleeds over last week at her
anastomsis site and is s/p a clipping of a gastroduodenal
branch. She was initially admitted to the MICU where she
received one unit pRBC, however as NG lavage was negative and
she remained hemodynamically stable she was quickly transferred
to the general medical floor. GI, surgery and IR were consulted.
followed the patient while in-house and given negative repeat
nasogastric lavage, patient was transferred to the floor. Prior
to EGD/Colonoscopy, patient was continued on Sucralfate,
protonix [**Hospital1 **] IV with every 6-8 hour hematocrits. Patient had
EGD/colonoscopy on [**2-22**]. On [**2-24**] patient felt lightheaded and saw
double vision, in the setting of hemodynamic stability, and Hct
had dropped [**3-18**] points. 2 units blood transfused, and hct bumped
appropriately. The next morning, repeat EGD performed that
showed evidence of old bleed, but no active bleed. That same
day, tagged RBC scan performed to attempt to localize source of
bleeding, but did not show any definite GI bleed. Patient next
had a repeat EGD on [**2-26**] in which further clipping was done (see
results section).
After that final procedure, patient's Hct was serially checked
and remained stable. Her diet was advanced and well tolerated.
PPI changed to PO. Sucralfate continued. Patient was ambulating
and was notably pain-free throughout her entire time on the
hospital floor. Serology was positive for H.pylori and the
patient was started on quadruple therapy for 2 week course.
Believe the anastamosis site s/p gastric cancer resection was
vulnerable to ulceration/bleed, and in the setting of H.pylori
infection resulted in further ulceration and hence the bleed.
Follow up with GI was arranged prior to discharge.
.
# Fever: UA was positive therefore she was treated with
Ciprofloxacin. Urine culture did then grow two species
infection. Treated for e.coli and beta strep in her urine
(asymptomatic), with an antibiotic course. Afebrile afterwards,
without leukocytosis, without dysuria.
.
# Renal failure: Creatinine on admission to OSH was 1.6 --> 1.3
on admission to [**Hospital1 18**] but responded to 4 liters total of normal
saline and one unit pRBC to 1.2. Continued hydration, in setting
of NPO and bleed, again brought Cr down lower. On discharge, Cr
was stable and patient was without dysuria and was hydrating on
her own through PO.
.
# HTN: Blood pressures were mildly elevated in the setting of
holding her home amlodipine and lisinopril given the recent GI
bleed. These were continued to be held in the setting of bleed.
Beta-blocker started to help reduce patient's pre-op risk, in
case had to urgently go to surgery. Once GI bleed issue resolved
and Hct's were stable, stopped beta-blocker and restarted
patient's home anti-hypertensive regimen.
.
# Memory impariment / Presumed dementia: Patient is a very poor
historian and has little short term memmory. Unclear if she
officially has a dx of dementia, but appears to on exam. Patient
was monitored closely for delirium, re-oriented frequently and
tubes/drains were minimized when possible. Without issues during
this hospitalization. Requires outpatient follow up.
.
# Communication: Son [**Name (NI) **] is HCP; he was updated throughout the
[**Hospital 228**] hospital course.
.
# Code: Full, confirmed.
Medications on Admission:
(per D/C summary)
-omeprazole 20mg [**Hospital1 **]
-amlodipine 5mg PO qday
-lisinopril 10mg PO qday
-MV
-fish oil
.
Allergies: Strawberries cause hives
Discharge Medications:
1. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*1*
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
3. 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*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: Two (2)
Tablet PO QID (4 times a day) for 2 weeks.
Disp:*112 Tablet(s)* Refills:*0*
7. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
8. Tetracycline 250 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 2 weeks.
Disp:*112 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed.
Hypertension.
Urinary tract infection.
Dementia.
Helicobacter pylori infection.
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hosptial with blood in your stool. Your
blood levels were monitored and you were rehydrated. You
continued to have blood in your stool, the gastrointestinal team
and the surgical team were consulted regarding your care. With
multiple imaging studies by the gastrointestinal team to looks
at your esophagus, stomach, and intestines, they saw evidence of
bleeding at the stomach, near the site of your prior surgery
where there was bleeding & an ulcer. You were transfused blood
and IV fluids, and you had clips placed at the bleeding site.
After the clips were appropriately placed, your blood counts
were closely monitored and they remained stable for multiple
days. We believe the bleeding had to do with a bacteria in your
stomach as well as it being a complication at your prior
surgical site where there was a bleeding ulcer. Your diet was
advanced to regular and you were tolerating that well; you were
also feeling well and walking well. You had stopped bleeding,
and on discharge your blood levels were stable.
.
You had a fever that resolved. You were found to have a urinary
tract infection, and were treated with a course of antibiotics.
.
You spent a night in the ICU and then were on the regular
hospital floor.
.
Changes to your medications include:
- START Metonidazole four times a day for 2 weeks
- START Bismuth four times a day for 2 weeks
- START Tetracycline four times a day for 2 weeks
- START Pantoprazole twice a day
- START Sucralfate four times a day
- START Senna daily, as needed for constipation
- CONTINUE your other home medications
.
Please see your primary care physician this [**Name9 (PRE) 2974**] and have her
check your blood level to make sure that it is stable. On
discharge from the hospital today ([**3-2**]), your Hematocrit
level was 34.1).
.
Please call your doctor or return to the hospial if you develop
vomiting with blood, bloody stool, lightheadedness, shortness of
breath, chest pain, or other symptoms that concern you or your
family.
Followup Instructions:
Please see your primary care physician:
[**Last Name (NamePattern4) **]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine/ PCP
[**Name Initial (PRE) 2897**]/ Time: Friday, [**2175-3-5**]:40pm
Location: [**Last Name (un) **], [**Hospital1 **] MA
Phone number: [**Telephone/Fax (1) 10508**]
Please have your blood count checked at this appointment to make
sure that it is stable.
.
Please see the following specialist for your stomach bleed:
Dr. [**First Name (STitle) **] [**Name (STitle) **], MD
[**Hospital Unit Name 1825**] - [**Hospital3 **], [**Location (un) **].
Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2173-3-17**] at 4:00pm
Completed by:[**2173-3-12**]
|
[
"041.86",
"276.51",
"584.9",
"041.4",
"534.40",
"599.0",
"401.9",
"V10.04",
"285.1",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
11796, 11802
|
6992, 10654
|
230, 304
|
11936, 11936
|
3447, 6912
|
14118, 14833
|
2582, 2624
|
10857, 11773
|
11823, 11915
|
10680, 10834
|
12083, 14095
|
6928, 6969
|
2639, 3325
|
178, 192
|
332, 1940
|
3344, 3428
|
11950, 12059
|
1962, 2106
|
2122, 2566
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,798
| 187,802
|
33806
|
Discharge summary
|
report
|
Admission Date: [**2108-3-1**] Discharge Date: [**2108-3-13**]
Date of Birth: [**2051-10-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**Known firstname 922**]
Chief Complaint:
SS chest pain radiating to jaw and back
Major Surgical or Invasive Procedure:
[**3-5**] Bentall with [**Street Address(2) 11599**]. [**Male First Name (un) 923**] Mechanical Valved Graft
Composite
History of Present Illness:
56 yo M presented to OSH with 1 week h/o CP radiating to jaw and
back. R/o for MI, found to have 5.9 cm ascending [**Male First Name (un) 5236**] without
dissection.
Past Medical History:
GERD
syncope
cervical arthritis
? of sleep apnea
T&A
s/p deviated septum repair
eye surgery as child
Social History:
quality control supervisor
denies tobacco
denies etoh
Family History:
brother and father with MI
Physical Exam:
HR 78 RR 18 BP 142/74
Well appearing M in NAD
Right eye with strabismus
Difficulty extending neck
Lungs CTAB
RRR 1-2/6 diastolic murmur
Abdomen benign
Extrem warm, no edema, 2+ pulses t/o
Pertinent Results:
[**2108-3-10**] 10:00AM BLOOD WBC-7.8 RBC-4.04* Hgb-13.0* Hct-36.4*
MCV-90 MCH-32.3* MCHC-35.8* RDW-12.8 Plt Ct-278
[**2108-3-13**] 07:15AM BLOOD PT-20.4* PTT-90.7* INR(PT)-1.9*
[**2108-3-12**] 05:05AM BLOOD PT-18.8* PTT-60.5* INR(PT)-1.7*
[**2108-3-11**] 05:40AM BLOOD PT-17.0* PTT-62.5* INR(PT)-1.5*
[**2108-3-10**] 10:00AM BLOOD PT-15.1* PTT-33.7 INR(PT)-1.3*
[**2108-3-11**] 05:40AM BLOOD Glucose-118* UreaN-20 Creat-1.0 Na-139
K-3.4 Cl-111* HCO3-19* AnGap-12
CHEST (PORTABLE AP) [**2108-3-8**] 10:28 AM
CHEST (PORTABLE AP)
Reason: r/o pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
56 year old man s/p Bental.
REASON FOR THIS EXAMINATION:
r/o pleural effusions
PORTABLE CHEST, [**2108-3-8**]
COMPARISON: [**2108-3-6**].
INDICATION: Assess for pleural effusions.
Small pleural effusions have developed with adjacent worsening
basilar atelectasis. Cardiomediastinal contours are widened
without change compared to prior post-operative radiographs.
There is no evidence of pulmonary edema or pneumothorax.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 78159**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 78160**] (Complete)
Done [**2108-3-5**] at 3:08:18 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**Known firstname 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2051-10-29**]
Age (years): 56 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Bentall
ICD-9 Codes: 786.51, 440.0, 441.2, 424.1
Test Information
Date/Time: [**2108-3-5**] at 15:08 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Pager number 30532**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
[**Pager number **] - Ascending: *5.2 cm <= 3.4 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Pager number **]: Markedly dilated ascending [**Pager number 5236**]. Simple atheroma in
[**Pager number **] [**Pager number 5236**].
AORTIC VALVE: Bicuspid aortic valve. Severe (4+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Right ventricular chamber size and free wall motion
are normal.
The ascending [**Pager number 5236**] is markedly dilated There are simple
atheroma in the [**Pager number **] thoracic [**Pager number 5236**]. The proximal
[**Pager number **] [**Pager number 5236**] measures 2.9 cm. More distally it is 2.4 cm.
The aortic valve is bicuspid. Severe (4+) aortic regurgitation
is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
There is no pericardial effusion.
Post-Bypass: Patient is AV-Paced, on no pressors or inotropes. A
prosthetic [**Pager number 5236**] valve and ascending [**Pager number 5236**] are in place. No
leak, no AI. Trivial MR. [**First Name (Titles) 42464**] [**Last Name (Titles) 5236**] intact. Mild
biventricular systolic dysfxn remains.
Brief Hospital Course:
He was admitted to cardiac surgery ICU for blood pressure
control. He underwent cardiac cath on [**3-2**] which showed a distal
40% LMCA and 40% mid LAD. Echo showed 4+ AI. He was cleared by
dental. He was taken to the operating room on 2.11 where he
underwent a Bentall with a mechanical valve. He was transferred
to the ICU in stable condition. He was extubated on POD #1. He
was started on coumadin for his mechanical valve. He continued
to have a high oxygen requirement, and was diuresed. He was
transferred to the floor on POD #4. He required a heparin gtt
while his INR was subtherapeutic. His INR was 1.9 and he was
ready for discharge home on POD #8. Spoke with [**Doctor First Name **] at Dr.
[**Last Name (STitle) 78161**] office who has agreed to manage coumadin.
Medications on Admission:
nexium
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. Coumadin 5 mg Tablet Sig: Two (2) Tablet PO once a day for 1
days: 2 tablets (10 mg) tonight [**3-13**], then 1.5 tablets (7.5 mg)
[**3-14**]. Check INR [**3-15**].
Disp:*60 Tablet(s)* Refills:*1*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Partners [**Name (NI) **] [**Name2 (NI) **]
Discharge Diagnosis:
s/p Bentall
GERD
syncope
cervical arthritis
sleep apnea
T&A
deviated septum repair
eye surgery as child
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week,
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 39008**] 2 weeks
Cardiologist 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Completed by:[**2108-3-13**]
|
[
"518.0",
"414.01",
"530.81",
"721.0",
"746.4",
"441.2",
"997.3",
"424.1",
"511.9",
"V16.1",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.64",
"39.63",
"89.68",
"37.22",
"39.61",
"88.56",
"89.64",
"34.04",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
7499, 7573
|
5290, 6067
|
313, 434
|
7721, 7729
|
1092, 1655
|
8043, 8179
|
840, 868
|
6124, 7476
|
1692, 1720
|
7594, 7700
|
6093, 6101
|
7753, 8020
|
883, 1073
|
234, 275
|
1749, 5267
|
462, 629
|
651, 753
|
769, 824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,788
| 106,135
|
3604
|
Discharge summary
|
report
|
Admission Date: [**2175-9-24**] Discharge Date: [**2175-10-19**]
Date of Birth: [**2124-12-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / [**Hospital1 **] Tylenol Plus / Sunflower Oil /
Clindamycin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
nausea / vomiting
Major Surgical or Invasive Procedure:
transjugular liver biopsy
History of Present Illness:
50M with tea colored urine, nausea, mild epigastric pain, and
vomiting x1 on [**9-24**] to the ER, then admitted to the floor. Pt
transfered to MICU on Day 2. Pt has a hx HBV cirrhosis s/p OLT
in [**2156**] ([**Hospital1 1774**]), ESRD ?s/p IgG nephtropathy vs. tacro tox
resulting in kidney transplant [**2166**] ([**Hospital1 18**]). Pt currently
denies fevers and chills or frank [**Hospital1 **] in the urine or stool,
but endoeses dysuria and describes epigastric pain as "buring",
constant, non-radiating. In the ED received Unasyn for concern
of cholangitis, RUQ u/s showed patent portal vasculature, no
ascites, normal echotecture of liver, and no intra- or
extra-hepatic biliary dilitation. However, LFT markedly
elevated above baseline. Pt admited to floor and underwent an
ERCP today under GA (fenatyl, midaz, propofol, and paralytics),
distal part of bile duct is "completely excluded" from proximal
biliary tree, pt has a hepato-jujenostomy, normal pancreatogram,
and they performed a sphincterotomy. Pt was hypotensive in PACU
and during the procedure. Pt received 1400cc in the PACU
without response (SBP in 80's baseline 115). On the floor the
pt continued to be lethargic, at times confused, and c/o
lightheadedness. On the floor the SBP remained in the 80's
despite 1L NS bolus, and was associated with poor urine output,
persistently poor mental status, and an ABG was 7.32/37/98 with
lactate 1.7, with WBC 19.7 up from 5.5 in AM, Cr up to 2.3 from
1.6, LFT still elevated, bili up to 6.5, while pt afebrile, not
complaining of pain, no nausea or vomiting. Pt received
cefazolin during procedure and was received cipro/flagyl on
floor for ?cholangitis, and was started on vancomycin [**9-25**] to
expand coverage. ERCP fellow recomends IR guided perc
transhepatic drainage. Transplant surgery was consulted for
their input whether the pt needs an operation.
Past Medical History:
* LBP -- [**2173-12-28**] MRI with heterogeneously enhancing L5 lesions
* L brachiocephalic AV fistula aneurysm c/b hematoma now s/p
repair
* Liver Cirrhosis ? [**2-1**] Hepatitis B
* End Stage Liver disease s/p orthotic liver transplant ([**3-/2157**])
* ESRD s/p LRRT [**2-1**] cyclosporine-tacro toxicity ( [**6-2**]) @ [**Hospital1 1774**]
* Renal osteodystrophy with osteoporosis
* s/p multiple hernia repairs
* s/p splenectomy
* HTN
* Hyperlipemia
* GERD
* Depression
* Hematuria
* Colonic polyps
* OSA on CPAP
Social History:
Drugs: denies
Tobacco: denies
Alcohol: denies
Other: Lives alone. Single. No children.
Family History:
Two brothers with IgA nephropathy; one brother with cirrhosis;
both deceased
Physical Exam:
Admission PE:
VS: 97.4, 137/93, 68, 20, 99RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: olt scars well healed, tender to palpation in the
epigastrium, non-tender in the right upper quadrant, Soft/ND, no
masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions. No spider angiomata.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-4**] throughout, sensation grossly intact throughout, no
asterixis.
Discharge PE:
VS: Tc 97.6 Tm 98.2 145/78 (131-156/74-86) 73 (73-104) 22 97 on
3L
8h: 1100 out/120+100 IV in
24h: 2175 out/420+600 IV in
Gen: jaundiced, ill-appearing, weak, lethargic, falling in and
out of sleep during interview
HEENT: dry mucous membranes, icteric sclerae
CV: RRR, S1, S2 no murmurs/rubs/gallops appreciated
lungs: limited lung exam, worsening crackles b/l, [**3-3**] the way
up lung fields, decreased breath sounds at the bases, resps
unlabored
abdomen: horizontal abdominal scar, increasing distension and
tympany today; with R sided abdominal tenderness, no
rebound/guarding
ext: warm, well perfused, 2+ DP pulses, trace LE edema
Neuro: AAO x3, but very lethargic
Pertinent Results:
Admission labs:
.
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] WBC-10.6 RBC-4.49* Hgb-14.4 Hct-43.7
MCV-97 MCH-32.1* MCHC-32.9 RDW-14.0 Plt Ct-243
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] WBC-5.1# RBC-3.14*# Hgb-10.3*# Hct-36.3*
MCV-116*# MCH-32.8* MCHC-28.4*# RDW-15.3 Plt Ct-131*
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] WBC-20.8*# RBC-4.24*# Hgb-13.8*# Hct-40.9
MCV-97# MCH-32.5* MCHC-33.7# RDW-14.9 Plt Ct-194
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] WBC-19.7* RBC-3.83* Hgb-12.8* Hct-37.4*
MCV-98 MCH-33.4* MCHC-34.2 RDW-14.4 Plt Ct-208
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] PT-32.0* PTT-35.0 INR(PT)-3.2*
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] PT-33.8* PTT-40.3* INR(PT)-3.4*
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] PT-33.5* PTT-37.7* INR(PT)-3.3*
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] Glucose-101* UreaN-18 Creat-1.6* Na-140
K-3.9 Cl-108 HCO3-24 AnGap-12
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] Glucose-679* UreaN-16 Creat-1.3* Na-132*
K-3.8 Cl-104 HCO3-18* AnGap-14
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] Glucose-116* UreaN-20 Creat-1.6* Na-138
K-4.6 Cl-109* HCO3-20* AnGap-14
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] Glucose-196* UreaN-27* Creat-2.3* Na-134
K-5.1 Cl-108 HCO3-21* AnGap-10
[**2175-9-26**] 02:33AM [**Month/Day/Year 3143**] Glucose-99 UreaN-30* Creat-2.5* Na-137
K-4.5 Cl-108 HCO3-22 AnGap-12
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] ALT-302* AST-245* LD(LDH)-275*
AlkPhos-276* Amylase-118* TotBili-3.8* DirBili-2.7* IndBili-1.1
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] ALT-233* AST-189* LD(LDH)-258*
AlkPhos-214* Amylase-82 TotBili-3.8*
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] ALT-261* AST-204* LD(LDH)-316*
AlkPhos-253* Amylase-83 TotBili-5.2* DirBili-4.0* IndBili-1.2
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] ALT-217* AST-163* AlkPhos-199*
TotBili-6.5*
[**2175-9-26**] 02:33AM [**Month/Day/Year 3143**] ALT-170* AST-118* LD(LDH)-220
AlkPhos-164* TotBili-6.8*
[**2175-9-27**] 03:30AM [**Month/Day/Year 3143**] ALT-151* AST-86* AlkPhos-128 TotBili-7.3*
DirBili-1.6* IndBili-5.7
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] Albumin-3.0* Calcium-7.8* Phos-2.0*
Mg-1.6
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] Albumin-3.3* Calcium-9.2 Phos-2.2* Mg-1.7
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] Albumin-3.0*
[**2175-9-26**] 02:33AM [**Month/Day/Year 3143**] Calcium-8.3* Phos-2.7 Mg-1.5*
.
LFT trends:
.
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] ALT-302* AST-245* LD(LDH)-275*
AlkPhos-276* Amylase-118* TotBili-3.8* DirBili-2.7* IndBili-1.1
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] ALT-233* AST-189* LD(LDH)-258*
AlkPhos-214* Amylase-82 TotBili-3.8*
[**2175-9-30**] 06:58AM [**Month/Day/Year 3143**] ALT-112* AST-118* AlkPhos-163*
TotBili-7.0*
[**2175-10-1**] 04:01AM [**Month/Day/Year 3143**] ALT-105* AST-127* AlkPhos-172*
TotBili-7.6*
[**2175-10-1**] 06:00PM [**Month/Day/Year 3143**] ALT-100* AST-123* LD(LDH)-281*
AlkPhos-182* TotBili-8.3*
[**2175-10-2**] 03:21AM [**Month/Day/Year 3143**] ALT-97* AST-125* AlkPhos-197*
TotBili-9.3*
[**2175-10-3**] 06:15AM [**Month/Day/Year 3143**] ALT-90* AST-138* AlkPhos-244*
TotBili-11.7*
[**2175-10-8**] 03:44AM [**Month/Day/Year 3143**] ALT-45* AST-78* AlkPhos-171*
TotBili-14.4*
[**2175-10-9**] 04:50AM [**Month/Day/Year 3143**] ALT-39 AST-65* LD(LDH)-255* AlkPhos-152*
Amylase-34 TotBili-17.5*
[**2175-10-10**] 02:41AM [**Month/Day/Year 3143**] ALT-36 AST-64* LD(LDH)-240 AlkPhos-139*
TotBili-18.5* DirBili-14.6* IndBili-3.9
[**2175-10-11**] 04:52AM [**Month/Day/Year 3143**] ALT-44* AST-71* AlkPhos-132*
TotBili-19.5*
[**2175-10-12**] 06:33AM [**Month/Day/Year 3143**] ALT-54* AST-90* AlkPhos-129 TotBili-23.4*
[**2175-10-13**] 05:47AM [**Month/Day/Year 3143**] ALT-70* AST-104* AlkPhos-147*
TotBili-24.5*
[**2175-10-14**] 06:30AM [**Month/Day/Year 3143**] ALT-79* AST-105* AlkPhos-141*
TotBili-23.7*
[**2175-10-15**] 05:15AM [**Month/Day/Year 3143**] ALT-110* AST-129* AlkPhos-157*
TotBili-24.4*
[**2175-10-16**] 06:50AM [**Month/Day/Year 3143**] ALT-123* AST-138* AlkPhos-146*
TotBili-25.3*
[**2175-10-17**] 05:35AM [**Month/Day/Year 3143**] ALT-152* AST-153* AlkPhos-152*
TotBili-31.1*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] ALT-172* AST-151* AlkPhos-164*
TotBili-32.2*
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] ALT-174* AST-132* AlkPhos-171*
TotBili-34.6*
.
Discharge Labs:
.
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] WBC-20.3* RBC-2.68* Hgb-8.9* Hct-27.3*
MCV-102* MCH-33.1* MCHC-32.4 RDW-20.5* Plt Ct-210
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] PT-17.9* INR(PT)-1.6*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] Glucose-191* UreaN-98* Creat-2.7* Na-139
K-4.8 Cl-110* HCO3-16* AnGap-18
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] Glucose-168* UreaN-114* Creat-3.3* Na-138
K-5.0 Cl-108 HCO3-14* AnGap-21*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] ALT-172* AST-151* AlkPhos-164*
TotBili-32.2*
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] ALT-174* AST-132* AlkPhos-171*
TotBili-34.6*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] Albumin-3.5 Calcium-9.9 Phos-5.1* Mg-2.7*
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] Albumin-3.3* Calcium-9.8 Phos-6.4*
Mg-2.8*
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] HBsAg-NEGATIVE
[**2175-9-27**] 03:10PM [**Month/Day/Year 3143**] IgM HAV-NEGATIVE
[**2175-9-29**] 04:23AM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HBc-NEGATIVE
[**2175-10-3**] 10:28AM [**Month/Day/Year 3143**] Smooth-POSITIVE A
[**2175-10-16**] 07:16PM [**Month/Day/Year 3143**] AMA-NEGATIVE Smooth-POSITIVE *
[**2175-10-3**] 10:28AM [**Month/Day/Year 3143**] [**Doctor First Name **]-NEGATIVE
[**2175-10-5**] 01:59PM [**Month/Day/Year 3143**] CEA-2.9 PSA-0.3
[**2175-10-6**] 05:27AM [**Month/Day/Year 3143**] CRP-29.0*
[**2175-10-16**] 07:16PM [**Month/Day/Year 3143**] [**Doctor First Name **]-NEGATIVE
[**2175-10-3**] 06:15AM [**Month/Day/Year 3143**] IgG-1082
[**2175-10-16**] 07:16PM [**Month/Day/Year 3143**] IgG-887 IgM-26*
.
RUQ u/s [**2175-9-24**]
IMPRESSION: Normal transplant liver ultrasound. Major
intrahepatic vessels
patent with appropriate flow. No ascites.
.
CT abdomen [**2175-10-11**]
Coiling of pigtail catheter in between the liver capsule and the
internal
thoracic wall might be causing irritation and abdominal pain.
Pulling of the catheter back is recommended.
2. A right-sided pleural effusion is mildly increased in size
with respect to [**2175-10-6**]. Bilateral bibasilar
moderate-to-severe atelectasis is
stable.
3. Diffuse pancreatic calcifications are unchanged with respect
to prior CT.
4. Ascites has decreased in size with respect to prior CT.
5. Stable moderate cardiomegaly.
.
[**2175-10-11**]
IMPRESSION: Successful removal of a biliary catheter. No
immediate
complication.
.
[**2175-9-27**]: transcutaneous liver biopsy
A. Liver, allograft, transjugular needle core biopsy:
1. Moderate portal mononuclear inflammation with foci of
lymphocytic bile duct damage and focally prominent plasma cells.
2. Bile ductular proliferation with associated neutrophils and
moderate hepatocellular and canalicular cholestasis.
3. No definite endothelialitis is seen.
4. Trichrome stain shows increased portal fibrosis with some
periportal extension (Stage 2 fibrosis, in this limited sample;
definitive staging deferred given the limitations of transvenous
sampling).
5. Iron stain shows no stainable iron.
6. Reticulin stain is pending evaluation and will be reported in
an addendum.
B. Liver, allograft, transjugular needle core biopsy:
Minute fragments of liver parenchyma measuring up to 0.3 cm in
greatest dimension demonstrating:
1. Bile ductular proliferation with associated neutrophils and
moderate hepatocellular and canalicular cholestasis.
2. No definite endothelialitis.
3. Mildly increased portal fibrosis with some periportal
extension seen on Trichrome stain.
4. Fragments of venous wall with subendothelial
lymphoplasmacytic inflammation.
5. No stainable iron on iron stain.
Note: The above biopsies show two distinct histologic patterns
of injury; one with bile ductular proliferation with intraductal
neutrophils and cholestasis which suggests ascending cholangitis
or sepsis, and the other with portal, predominantly lymphocytic
inflammation with occasional foci of prominent plasma cells,
lymphocytic bile duct injury, and lobular apoptotic hepatocytes.
The latter findings in a patient nearly 20 years following liver
transplantation suggest a possible immune-mediated hepatitis, or
alternatively, a component of treated acute cellular rejection.
Given the lymphocyte-predominant pattern of portal inflammation
and the setting of immunosuppression, workup by the
Hematopathology consult team to rule out a post-transplant
lymphoproliferative disorder is warranted and will be reported
in an addendum. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was notified of the findings by
telephone by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7017**] on [**2175-9-28**].
ADDENDUM #1:
Reticulin stain shows normal plate thickness and distribution in
the limited trans-venous sample.
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/rna
Date: [**2175-9-30**]
Hematopathology Addendum: T-cell dominant mixed lymphoid
infiltrate, favor reactive, see note.
Note: Sections of the specimen reveal mixed periportal
inflammation composed of lymphocytes, neutrophils and rare
plasma cells. By immunohistochemistry the cells express CD3,
CD5 and CD20 confirming that there is a mixed population of
B-cells and T-cells. CD138 highlights occasional plasma cells;
however kappa and lambda stain cannot be interpreted due to high
background staining. MIB-1 stains occasional hepatocytes and
lymphocytes. LMP stain is negative.
[**2175-10-10**]
DIAGNOSIS:
Liver, allograft, needle core biopsy:
1. Moderate portal and mild lobular mixed inflammation
including prominent neutrophils with associated bile duct
proliferation and focally prominent plasma cells.
2. Severe hepatocellular and canalicular cholestasis.
3. Focal lymphocytic cholangitis and bile duct damage seen.
4. No steatosis is seen.
5. Focal areas of centrivenular mononuclear cell infiltrate
with prominent plasma cells.
6. Trichrome stain shows increased portal/periportal fibrosis
with focal septal formation (Stage 2 fibrosis).
7. Iron stain shows no increase in stainable iron.
Note: The presence of plasma cells, particularly in the area of
centrivenular region and focal lymphocytic cholangitis is
consistent with an immune-mediated process. The differential
diagnosis includes acute cellular rejection vs. post-transplant
chronic immune mediated hepatitis. However, the prominent
neutrophilic infiltrate is unusual and a concurrent biliary
obstruction and sepsis cannot be entirely excluded. Compared to
the prior biopsy, there is an increase in the degree of
inflammation, particularly the neutrophilic and plasma cell
components. Evaluation is limited by technical artifact due to
processing. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] was notified of the preliminary
findings on [**2175-10-11**] by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**].
ADDENDUM:
An immunohistochemical stain for C4d is negative. Satisfactory
controls were obtained.
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/tkb
Date: [**2175-10-16**]
Clinical: 50 year old with history of liver transplant in [**2156**],
now with worsening liver function tests of unclear etiology.
Gross: The specimen is received in one formalin filled
container, labeled with the patient's name "[**Known lastname 16229**], [**Known firstname **]"
and the medical record number. It consists of a tan yellow to
focally green liver core biopsy measuring 1.7 cm in length x
(0.1) cm in diameter, entirely submitted in cassette A.
.
EGD: [**2175-10-1**]
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum:
Other slow bleeding at the ampulla was seen.
Impression: Slow bleeding at the ampulla was seen.
Otherwise normal EGD to second part of the duodenum
.
EGD: [**2175-10-1**]
Limited exam showed grade [**2-2**] varices at the lower esophagus.
There was no evidence of active bleeding.
Limited exam showed mild portal hypertensive gastropathy. There
was no evidence of active bleeding.
There were both fresh bleeding and a large clot at the ampulla.
At both upper corners of the major papilla, it was injected with
1:10,000 epinephrine with a total of 6 cc. The clot was
partially dislodged with the injection needle and bipolar probe
and the sphincterotomy site was exposed. The apex of the
sphincterotomy site was cauterized with the bipolar probe with
good hemostasis. There was no bleeding at the end of procedure.
Otherwise normal EGD to third part of the duodenum.
Recommendations: Avoid anticoagulation for at least the next
48-72 hrs, and longer if possible.
If any abdominal pain, recurrent bleeding, fever, or any other
concerning symptom please call oncall ERCP fellow or Dr. [**First Name (STitle) 908**].
Serial H/H.
.
EGD: [**2175-10-8**]
Varices at the lower third of the esophagus
Mosaic appearance in the stomach compatible with portal
hypertensive gastropathy
Ulcer with adherent clot in the area of the papilla - no active
bleeding was noted. Ulcer is at the base of the sphincterotomy.
(injection)
Otherwise normal EGD to third part of the duodenum
Recommendations: Given absence of active bleeding or visible
vessel, h/o recent cautery to papilla, and presence of severe
portal HTN, decision was made not to further cautherize the
papilla. There is a high likelyhood that this lesion with heal.
High dose PPI. Keep INR < 1.5.
Return patient to hospital [**Hospital1 **].
Brief Hospital Course:
Mr. [**Known lastname 16229**] is a 50M w history of Hep B cirrhosis s/p liver
transplant [**2156**], IgA nephropathy s/p renal transplant in [**2166**]
who initially presented with epigastric pain, abnormal LFTs, AP,
INR, and TBili, initially s/p ERCP for a working diagnosis of
cholangitis with septic shock, was started on broad spectrum
antibiotics and later had PTC placed with no subsequent change
in LFTs. Course further complicated by increasing LFTs s/p 3
liver biopsies, melena s/p 3 EGDs, renal failure, and
respiratory distress, and course of high dose steroids for
autoimmune hepatitis versus rejection.
.
# Acute liver failure: The patient initially presented with
possible cholangitis, despite no evidence of bile duct dilation
on imaging; received 1 dose Unasyn in ED, but has allergy so
that was stopped and patient was covered with Cipro/Flagyl. The
patient went for ERCP and during which bile duct was NOT
cannulated given patient hepatojejunostomy s/p liver transplant.
After procedure, pt was hypotension, bolused, and antibiotics
broadened and sent to unit out of concern for sepsis. In spite
of treatment for presumed cholangitis, the patient's LFTs did
not improve. The patient's LFTs worsened throughout his course
and in total he underwent three biopsies. The initial biopsies
showed evidence of bile duct proliferation which could be c/w
obstruction, as well as a second immune mediated process.
Because of the possible concern for obstruction, the patient was
kept on antibiotics and a PTC was placed. However, in spite of
biliary decompression, the patient's LFTs continued to trend up.
.
In order to rule out a secondary process like PTLD (as there was
some lymphocytic proliferation on initial biopsies, as well) the
patient underwent PET scan, which was negative. During this
time, the patient's LFTs were continuing to increase. Repeat
biopsies showed similar bile duct proliferation, but the second
biopsy also showed more evidence of an autoimmune process,
either an autoimmune hepatitis versus a rejection picture.
Because of this, the patient was started on 125 mg methylpred
pulse steroids. 500 mg methylpred was not used because of the
suspicion of underlying infection; the patient was also
continued on broad spectrum antibiotics during the pulse steroid
treatment. In spite of the pulse dose steroids, the patient's
LFTs continued to rise. An extensive work up was pursued for
viral etiologies of her liver failure and he was found to be
[**Doctor First Name **], anti-mitochondial negative, Hep B core ab postive with Hep
B viral load <40, anti-smooth muscle titer 1:20, normal IgG,
negative EBV, CMV, negative Hep D ab and PCR, negative HSV,
Varicella, LCMV negative, among others.
.
After receiving the pulse dose of steroids, the patient
underwent a third liver biopsy which showed some decrease in
inflammation, with evidence of possible chronic rejection;
however, no definite diagnosis could be made based on biopsy, as
pathology not completely consistent with rejection. At this
point the patient's LFTs were continuing to trend up, with
Tbilis in the 30s. The option of retranplanting the patient
came up, but before a full pretransplant evaluation began, the
patient declined the option. The next possible option for him
was ATG. However, given the patient's worsening condition,
volume overload, and worsening creat, as well as his desire to
just go home, it was decided to not go ahead and give the
patient ATG. Instead, he was discharged to home with hospice.
.
# s/p renal and liver transplant: The patient was kept on his
home immunosuppressive agents (tacrolimus and MMF), with his
tacrolimus dose adjusted according to AM tacro levels. While in
the MICU for the first time, his tacr level was found to be ~
19, and his tacro was held for a few days and then restarted at
a lower dose. The patient's tacrolimus levels were adjusted to
0.5 mg [**Hospital1 **] and towards the end of his hospitalization, his MMF
was increased to 1000 mg [**Hospital1 **]. It is unclear whether the patient
worsening LFTs were due to rejection, as his biopsy results were
never clearly indicative of rejection. Moreover, his acute
renal failure may also have been related to rejection, but a
biopsy was never done (see below).
# melena: After getting the first ERCP, the patient reported
having some melena. He was scoped on [**2175-10-1**] and found to have
oozing from ampulla, s/p epinephrine injection and coag of site.
The patient continued to have melena after this procedure and
also had a crit drop, which prompted rescoping him on [**2175-10-8**].
On this endoscopy, found portal hypertensive gastropathy and
ulcer with adherent clot in the area of the papilla and was
given 2 injections of epinephrine. Because no definite source
of bleeding was found, the patient underwent colonoscopy, which
was negative for any sources of bleeding, and a capsule
endoscopy.
.
# hypoxia: During this hospitalization, the patient developed
an oxygen requirement. Initially, it was thought to be [**2-1**]
fluid overload, as during his first MICU stay, he was very net
fluid positive. He was also found to be very crackly on lung
exam, and had improved breathing with Lasix. CRXs at this time
also showed evidence of pulmonary edema. Lasix was also used
cautiously, as he was also in acute renal failure and his creat
was trending up during the hospitalization. However, as the
hospitalization progressed and the patient't liver failure
worsened, his respiratory status also worsened. By the time of
discharge, he was on 4-6L NC, and it is likely that
hepato-pulmonary syndrome was also a component to this new O2
requirement. The patient also had a TTE with bubble study done
that showed evidence of a small PFO vs. pulmonary AV fistula.
The patient's oxygen requirement did not improve and he was
discharged to home hospice with home O2 for comfort.
.
# [**Last Name (un) **] in setting of Renal Transplant: Initially, the patient'
creat was 1.6 (baseline around 1.3-1.5), then began to trend up.
Was initally thought to be [**2-1**] prerenal azotemia, and creat
improved with fluids. Of note, the patient also had a
tacrolimus level that peaked ~19, and tacrolimus toxicity was
also on the differential. The option of renal biopsy was also
considered, but since his creat responded to fluids initially,
it was never pursued. The patient's creat began to trend up
again, and given the possibility of cirrhosis based on imaging,
the possibility of HRS was considered. The results of the third
liver biopsy showed that the patient did not have cirrhosis and
the possibilty of rejection of his kidney was raised, as HRS was
less likely at this time. However, given patient's
decompensation at this point and his desire to go home, kidney
biopsy was not pursued. During the hospitalization, medications
were renally dosed and nephrotoxic drugs avoided.
.
# ileus: The patient developed an ileus during the
hospitalization, unclear etiology. His lytes were repleted
aggressively, and the pt was on bowel rest when severe. KUBs
showed dilated loops of bowel without any evidence of free air.
Initially, the ileus resolved, and diet was advanced as
tolerated. However, it recurred again and the patient was kept
NPO again. An NGT was attempted, but the patient could not
tolerate it.
.
# Hepatitis B: The patient was not on any antiviral therapy as
an outpatient. His Hep B viral load was less than 40, and he was
initially started on 100 mg daily, which was then switched to 50
mg daily given his worsening renal function.
.
#. History of SMV Thrombosis: The patient was diagnosed with SMV
thrombosis a few months ago and was on coumadin at home. Early
on in the hospitalization he was on a heparin drip. However,
when he started having melena, all anticoagulation was held.
.
# goals of care: The patient was initially full code on
admission, however towards the end of the hospitalization, we
had a goals of care conversation with the patient and his
family, as his liver enzymes continued to increase in spite of
our treatment efforts. During these conversations, the patient
made it clear he was not willing to undergo another liver
transplant and he decided he wanted to be DNR/DNI. The patient
also declined the option for AGT and decided that he wants to go
home. The patient was set up for home hospice.
.
# L arm swelling: The patient has some L arm swelling early on
during the admission. A ultrasound was done showing a clot in a
superficial vein. Warm compresses were used and Tylenol (less
than 2 grams daily) was used for pain. pain
.
#HTN: The patient's home antihypertensive medications, including
amlodipine, metoprolol, and lisinopril were held.
.
#Hyperlipemia: Given the patient's liver injury, his home
simvastatin was held.
.
#GERD: The patient's omeprazole was also held as it can cause
cholestasis.
.
#Depression: The patient's cymbalta was also held as it can
cause cholestasis.
.
#OSA on CPAP: The patient was kept on CPAP at night.
.
Transitional Issues:
.
# home with hospice: The patient will be discharged to home
with hospice.
Medications on Admission:
oxycodone sr 20mg [**Hospital1 **]
compazine 5mg qam prn
risedronatre 35mg weekly
simvastatin 20mg daily
tacrolimus 2mg [**Hospital1 **]
tmp-smx ss mwf
asa 325mg daily
coumadin 5mg daily
amlodipine 10mg daily
duloxetine 60mg daily
lisinopril 5mg daily
lorazepam .5mg tid
metoprolol tartrate 150mg daily--this is per the patient; last
d/c summary says metop succ 100mg daily
mycophenolate mofetil 500mg [**Hospital1 **]
omeprazole 20mg [**Hospital1 **]
oxycodone 5mg qid prn
Discharge Medications:
1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2-20 mg PO q1 hour as needed for pain, SOB, anxiety: please take
sublingually (under tongue).
Disp:*30 mL* Refills:*0*
2. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
4. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itchiness.
Disp:*30 Tablet(s)* Refills:*0*
5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itchness.
Disp:*1 bottle* Refills:*0*
6. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itchiness.
Disp:*30 Capsule(s)* Refills:*0*
7. oxygen, 2-6 L NC as needed for comfort
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
primary diagnosis:
liver failure, possibly acute on chronic rejection
status post liver transplant for Hepatitis B cirrhosis
status post kidney transplant for IgA nephropathy
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Clear and coherent.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 16229**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted because you were having abdominal
pain and your urine was rust colored. We initially treated your
infection with antibiotics, but there was no improvement in your
condition and your condition and liver enzymes continued to
worsen. We also placed a drain into your bile ducts so that we
could decompress them and drain all of the infected fluid, but
that also did not improve your liver enzymes.
.
You underwent three liver biopsies in total, and there is still
no clear explanation for why your liver is failing right now.
The biopsies showed that you some evidence of obstruction, as
well as an immune mediated process that could be rejection. We
started you on steroids, but there was no improvement on the
steroids either.
.
In addition to the worsening liver enzymes you also had a
problem with [**Name2 (NI) **] in your stools. We think that this started
after you had an endoscopy to look at your bile ducts. Because
of this bleeding, you had mutiple endoscopies that were looking
for a bleeding source, including a colonoscopy and a capsule
endoscopy (where you swallowed a camera pill).
.
Your kidney function also suffered while you were here. We
think that it was initially related to not having enough fluid
going to your kidneys. Your kidneys initially responded to
fluids, but then continued to worsen.
.
Your breathing was also affected while you were in the hospital.
We initially thought this was due to getting too much fluid to
help perfuse your kidneys better. You responded to medications
that helped take some of this extra fluid off, but this
medication also affected your kidney function. As your liver
failure progressed, we think that your worsening respiratory
status was due to the liver failure itself.
.
We are discharging you home with hospice care.
.
We made the following changes to your medications:
STOP all of your home medications
START medications for your comfort only, including morphine,
ativan, sarna lotion, benadryl, atarax, oxygen, and oxycodone as
needed
Followup Instructions:
CMO
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2175-10-19**]
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30,449
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10082+56102
|
Discharge summary
|
report+addendum
|
Admission Date: [**2104-12-14**] Discharge Date: [**2104-12-22**]
Service: CARDIOTHORACIC
Allergies:
Methotrexate / Sulfa (Sulfonamides) / Quinine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
presyncope & DOE
Major Surgical or Invasive Procedure:
cardiac catheterization
AVR(#21CE Magna pericardial)PFO closure [**12-19**]
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
Ms. [**Known lastname 33681**] is an 87 yo female with severe AS, HTN, PVD, s/p
CVAx2 who presents for pre-operative catheterization and aortic
valve replacement. Ms. [**Known lastname 33681**] reports that she has had
shortness of breath for more than six months and has had
increasing pre-syncope over the past few months. She reports
intermittent leg swelling, but none at present. She reports
orthopnea, but no PND. She is unable to walk more than one
block due to both claudication and shortness of breath.
.
At present she denies shortess of breath, chest pain, fevers,
chills, nausea, vomiting, diarrhea.
.
Past Medical History:
PAST MEDICAL HISTORY:
severe Aortic Stenosis with AI
Hypertenion
Peripheral [**Known lastname 1106**] disease with severe claudication
Transient ischemic attack
B/l Carotid stenosis
CRI (Cr 1.5-1.9)
Rheumatoid arthritis
COPD
Osteoporosis
s/p CVA x 2 (occipital, cerebellar)
Social History:
Social history is significant for the absence of current tobacco
use, though patient has a 25 PY smoking history and quit 10
years ago. There is no history of alcohol abuse but has one
drink per day. There is no family history of premature coronary
artery disease or sudden death.
Family History:
Family history is significant for son with diabetes and sister
with stroke.
Physical Exam:
PHYSICAL EXAMINATION:
VS - T 98.4, BP 150/50, HR 68, RR 18, 02 Sat 98% on RA
Gen: WDWN middle aged 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: no JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2/6 Systolic ejection murmur. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, wheezes or
rhonchi. Crackles at bases bilaterally.
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+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Brief Hospital Course:
Ms. [**Known lastname 33681**] was admitted for preoperative cardiac cath which
she underwent on [**12-15**]. She was maintained on IV heparin after
cath due to her history of CVA and coumadin use. She was seen by
renal. She was cleared for surgery by dental. She had a UTI for
which she was treated with cipro and her surgery was postponed.
She was taken to the operating room on [**12-19**] where she underwent
an AVR (tissue) and PFO closure. She was transferred to the ICU
in critical but stable condition. She was treated with
prophylactic vancomycin perioperatively because she was in house
preoperatively. She was given stress dose steroids. She remained
intubated overnight. Initially, She had complete heart block and
was paced, however her rhythm recovered to NSR. She was
extubated on POD #1. She was transferred to the floor on POD #2.
She did well postoperatively and was ready for discharge to
rehab on POD #3. She was restarted on coumadin. She is being
treated for a UTI, her foley could be discontinued on [**12-23**].
Medications on Admission:
CURRENT MEDICATIONS:
Actonel 35 mg PO once a week
Prednisone 5 mg Tablet dialy
Toprol XL 50 mg daily
Pantoprazole 40 mg PO Q12H
Atorvastatin 10 mg PO DAILY
Warfarin 2 mg Tablet QHS (Last dose Friday)
Aspirin 325 mg Tablet PO once a day
Citracal 2 tabs [**Hospital1 **]
Centrum silver daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Tablet, Delayed Release (E.C.)(s)
6. PredniSONE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Check INR [**12-24**].
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
sev AS w/AI, PFO now s/p AVR/PFO closure
HTN,PVD w/claudication,TIA,B/L Carotid Stenosis, COPD,
Osteoporosis,CVAx2(occipital/cerebellar),CRI(1.5-1.9)
Discharge Condition:
GOod.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Already scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2105-2-25**] 3:40
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2105-4-13**] 2:45
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2105-4-21**]
3:00
Completed by:[**2104-12-22**] Name: [**Known lastname 5887**],[**Known firstname 1911**] D. Unit No: [**Numeric Identifier 5888**]
Admission Date: [**2104-12-14**] Discharge Date: [**2104-12-22**]
Date of Birth: [**2017-7-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Methotrexate / Sulfa (Sulfonamides) / Quinine
Attending:[**First Name3 (LF) 1543**]
Addendum:
Seen by PCP at discharge and medications altered.
Pertinent Results:
[**2104-12-22**] 06:35AM BLOOD WBC-12.7* RBC-3.46* Hgb-10.3* Hct-30.5*
MCV-88 MCH-29.7 MCHC-33.6 RDW-14.5 Plt Ct-140*
[**2104-12-20**] 04:16AM BLOOD WBC-14.6* RBC-3.71* Hgb-11.1* Hct-32.7*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.6 Plt Ct-142*
[**2104-12-22**] 06:35AM BLOOD Plt Ct-140*
[**2104-12-19**] 12:18PM BLOOD PT-15.6* PTT-42.0* INR(PT)-1.4*
[**2104-12-22**] 06:35AM BLOOD Glucose-89 UreaN-36* Creat-1.1 Na-144
K-3.6 Cl-108 HCO3-29 AnGap-11
HEST (PORTABLE AP) [**2104-12-20**] 9:47 AM
CHEST (PORTABLE AP)
Reason: eval for pneumothorax
[**Hospital 5**] MEDICAL CONDITION:
87 year old woman with recent surgery s/p chest tube removal
REASON FOR THIS EXAMINATION:
eval for pneumothorax
CHEST X-RAY
CLINICAL INDICATION: 87-year-old woman with recent surgery,
status post chest tube removal, assess for pneumothorax.
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2104-12-19**]. The patient is
status post median sternotomy and aortic valve replacement.
There is a Swan-Ganz catheter in place in a satisfactory
position. The lungs are grossly unchanged since the prior
examination. There is a left basilar hazy opacity, likely
reflects an underlying small effusion and atelectasis. No
pneumothorax is seen. The cardiomediastinal silhouette is within
normal limits.
[**Hospital1 8**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 5887**], [**Known firstname 1911**] [**Hospital1 8**] [**Numeric Identifier 5889**] (Congenital)
Done [**2104-12-19**] at 1:43:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 33**]
[**Hospital Unit Name 5890**]
[**Location (un) 42**], [**Numeric Identifier 5891**] Status: Inpatient DOB: [**2017-7-27**]
Age (years): 87 F Hgt (in): 60
BP (mm Hg): / Wgt (lb): 90
HR (bpm): BSA (m2): 1.33 m2
Indication: Intraoperative TEE for AVR/ASD closure/[**Last Name (un) 5892**]
ICD-9 Codes: 745.5, 435.9, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2104-12-19**] at 13:43 Interpret MD: [**Name6 (MD) 5893**]
[**Name8 (MD) 5894**], MD
Test Type: TEE (Congenital) Son[**Name (NI) 5895**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5896**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine: 1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 60 ms
Mitral Valve - MVA (P [**2-5**] T): 3.7 cm2
Findings
LEFT ATRIUM: Dilated LA. Mild spontaneous echo contrast in the
LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the
LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Left-to-right
shunt across the interatrial septum at rest. Small secundum ASD.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Complex (>4mm) atheroma in the ascending aorta. Normal aortic
arch diameter. Complex (>4mm) atheroma in the aortic arch.
Normal descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Moderate-severe AS
(area 0.8-1.0cm2). Moderate to severe (3+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Moderate thickening of
mitral valve chordae. Calcified tips of papillary muscles. No
MS. [**First Name (Titles) **] [**Last Name (Titles) 5897**] MS (MVA 1.5-2.0cm2). Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
1. The left atrium is dilated. A left-to-right shunt across the
interatrial septum is seen at rest. A secundum type ASD is seen.
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. Right ventricular chamber size and free wall motion are
normal. There is calcification of the subvalvular apparatus.
4. There are complex (>4mm) atheroma in the ascending aorta.
There are complex (>4mm) atheroma in the aortic arch. 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 moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Moderate to
severe (3+) aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen. There is moderate thickening of
the mitral valve chordae and calcified papillary muscle tips
7. The tricuspid valve leaflets are mildly thickened.
8. There is no pericardial effusion.
POST-BYPASS:
Pt removed from cardiopulmonary bypass AV paced and on
phenylephrine infusion.
1. An aortic valve bioprosthesis is noted in the aortic valve
position. It is well seated; there is good excursion of the
leaflets; there is no paravalvular leak or aortic regurgitation.
Mean gradient across the valve is 5mmHg.
2. The secundum atrial septal defect has been repaired but a
much smaller leak seen across the interatrial septum and surgeon
notified of the same with posititve bubble from right to left.
3. Biventricular function is maintained.
4. Aortic contours are intact post-decannulation.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Tablet, Delayed Release (E.C.)(s)
6. PredniSONE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily):
Check INR [**12-24**]. Was on 2 mg daily preoperatively.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
12. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please monitor BP and d/c diovan if necessary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
Discharge Diagnosis:
sev AS w/AI, PFO now s/p AVR/PFO closure
HTN,PVD w/claudication,TIA,B/L Carotid Stenosis, COPD,
Osteoporosis,CVAx2(occipital/cerebellar),CRI(1.5-1.9)
Discharge Condition:
GOod.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 86**] 2 weeks
Already scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**], M.D. Phone:[**Telephone/Fax (1) 5898**]
Date/Time:[**2105-2-25**] 3:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5899**], MD Phone:[**Telephone/Fax (1) 5900**]
Date/Time:[**2105-4-13**] 2:45
Provider: [**Name10 (NameIs) 282**] LAB Phone:[**Telephone/Fax (1) 283**] Date/Time:[**2105-4-21**]
3:00
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2104-12-22**]
|
[
"585.4",
"443.9",
"276.6",
"433.10",
"414.01",
"403.90",
"733.00",
"782.0",
"745.5",
"424.1",
"496",
"433.30",
"599.0",
"714.0",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"88.53",
"35.21",
"35.71",
"88.72",
"37.22",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
14329, 14395
|
2651, 3689
|
277, 355
|
14589, 14597
|
6727, 7267
|
14896, 15616
|
1655, 1732
|
13175, 14306
|
14416, 14568
|
3715, 3715
|
14621, 14873
|
1748, 1748
|
1770, 2628
|
221, 239
|
7393, 13152
|
7303, 7364
|
3736, 4006
|
383, 1043
|
1087, 1341
|
1357, 1639
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,962
| 172,844
|
48021+59052
|
Discharge summary
|
report+addendum
|
Admission Date: [**2108-7-17**] Discharge Date: [**2108-8-5**]
Service:
This is an 80 year-old female with multiple complex medical
problems who presented with metastatic gastric cancer, status
post Ziloda and Aronest due the Friday following admission on
[**2108-7-17**]. She presents for admission on the 12th with
complaints of increased heart rate, feeling hot and cold,
though unsure if she is febrile over the past three days, as
well as the feeling of head fullness and weakness. She has a
one year history of atrial fibrillation, but cannot
cardiovert secondary to no anticoagulation. Also planned for
the Thursday following admission is a ureteral right stent
for hydronephrosis. She had a left stent placed one
months prior to this admission due to external compression
for lymphadenopathy and radiation in the past. In
preparation for this procedure she was off her normal 81 mg
of aspirin per day. She also has a history of hard to treat
urinary tract infections. In the emergency department the
patient was hypotensive. She was asymptomatic but they
titrated down her metoprolol. She got 10 mg of diltiazem and
she got fluids in the Emergency Room. She had a temperature
to 103 following cultures.
PAST MEDICAL HISTORY: 1) Metastatic cancer from
gastroesophageal junction diagnosed [**7-/2107**], locally advanced,
status post three months of Ziloda, biweekly Aronest
injections, weekly Taxol cycle 3. 2) External compression of
ureters bilaterally, status post lateral stent with right
hydronephrosis awaiting stent. 3) Remote history of
aneurysm/intracranial bleed. Has been on phenobarb for
atrial fibrillation times one year refractory to
cardioversion and cannot anticoagulate. She has a remote
history of gastrointestinal bleeding, gastroesophageal reflux
disease, hypothyroidism, coronary artery disease, status post
old inferior posterior myocardial infarction with inducible
ischemia, history of orthostatic hypotension.
ALLERGIES: Questionable allergy to aspirin. History of
allergies to penicillin, sulfa drugs and Dilantin.
MEDICATIONS: Phenobarbital 30 mg q.h.s., Fentanyl 25 mcg q
72 hours, aspirin 81 mg, Lipitor 40 mg q.d., metoprolol 12.5
b.i.d., multivitamin, Milontin 50 mcg q.d., Prozac.
PHYSICAL EXAMINATION: Temperature was 99.4, with maximum
temperature of 103, blood pressure 112/69, heart rate 118 to
140, 97 percent on room air. General: elderly, in no
apparent distress. Head, eyes, ears, nose and throat:
pupils equal, round, reactive to light, extraocular movements
intact. Mucous membranes dry. No jugular venous distention.
Neck supple. Chest: Port-A-Cath on right. crackles in left
base. Clear to auscultation otherwise. Cardiovascular:
irregular rate, S1, S2. No rubs. Patient is tachycardic.
Abdomen soft, active bowel sounds, nontender, nondistended.
No suprapubic tenderness, no rebound or guarding. 2+ pulses
bilaterally dorsalis pedis. No edema. Poor skin turgor with
tenting.
LABORATORY: Urinalysis was cloudy with moderate leukocytes,
large blood, positive nitrate and 30 protein, greater than 50
WBCs, many bacteria, rare yeast, epis 2. Sodium 130,
potassium 4.6, chloride 96, bicarb 27, BUN 25, creatinine
1.2, glucose 96, calcium 8.3, magnesium 2, phos 3, white
count 6.3,, hematocrit of 30.7, platelets of 319, INR of 1.3.
Chest x-ray is stable, cardiomegaly, no congestive heart
failure, no infiltrate. CTA without pulmonary embolus.
Urine cultures and blood cultures are pending.
HOSPITAL COURSE: Patient was determined to be in atrial
fibrillation with rapid ventricular rate, unable to be
anticoagulated due to history of aneurysm. Patient was then
initiated on diltiazem for rate control. During this time
patient went for her right ureteral stent placement by
interventional radiology, at which point the first two
attempts failed. Following the attempt there was a large
hematoma. Patient had a hematocrit drop from 30 to 25, at
which point she was transferred to the medical Intensive Care
Unit for monitoring. Patient remained stable both
hemodynamically and hematocrit-wise, and then was transferred
to the oncology service for further management. While on the
floor patient was again in atrial fibrillation, though she
was continued on her diltiazem, and then Digoxin was added at
the request of her primary cardiologist, Dr. [**Last Name (STitle) **]. Following
that patient's rate was maintained between the 80s and 100.
At that point she was taken off telemetry since she was
asymptomatic, though persisted in irregular rhythm. Once
transferred to the Oncology Service, patient went for a third
attempt at a right percutaneous nephrostomy placement. This
was done successfully, but the day following the procedure
the patient was noted to be hypotensive in the 70s though
mentating. Blood was also noted in the nephrostomy tube.
Based on the hypotension and the concern for retroperitoneal
bleed, patient was transferred to the Funard Intensive Care
Unit for further monitoring. While in the Intensive Care
Unit,, patient was transferred two units of blood and 10
liters of colloid. Once she remained hemodynamically stable
with her blood pressures ranging in the high 80s to low 90s
patient received a CT of the abdomen to evaluate the level of
retroperitoneal bleed. There was no evidence of bleed,
except for a clot in the renal pelvis on the right.
Interventional Radiology and urology determined that it would
not be wise to go in for another procedure but to just
monitor the patient. Patient continued to have occasional
hematocrit drops though nothing acute. She was transfused to
maintain a hematocrit of greater than 30 due to her history
of coronary artery disease and an inferior myocardial
infarction. To further evaluate the stent, the patient
underwent a nephrostogram, which showed patency of the stent,
though continued clot which they felt was dissolving and the
cause of the dark blood in the nephrostomy tube. Since
patient continued to have blood in the tube, on [**8-2**]
interventional radiology performed an angiogram to evaluate
for active bleeding. There was no evidence of active
bleeding, but a thin walled arteriovenous malformation was
noted, though to prevent further rupture, it was determined
that Interventional radiology would embolize it. This was
performed without complication. Patient's hematocrit was
monitored following this procedure, she was again transfused
to keep her hematocrit greater than 30. Once her hematocrit
was determined to be stable the patient was deemed safe to
discharge from the Interventional Radiology standpoint. They
requested that she follow up approximately one week post
discharge for a repeat nephrogram and an intended
internalization of the nephrostomy. Of note, while the
patient was here, initial urinalysis was positive for E. Coli
which she was treated for a full course of ciprofloxacin for
ten days. This finished, and she had a fever again. She was
recultured and again started on Cipro briefly for a total of
14 days. Follow up urinalysis showed no bacteria but did have
10,000 to 100,000 yeast, though she was treated with
Diflucan. Patient's acute renal failure remained relatively
stable in the low 2s throughout the course of her stay, this
was followed closely in the setting of both her urinary tract
infections with multiple manipulations but interventional
radiology. Patient remained anemic during this stay but goal
hematocrit remained greater than 30 in the setting of her
coronary artery disease. The persistent drop was thought to
be due to the hematoma around the nephrostomy as well as the
clot in the renal pelvis. There was no evidence of active
bleeding that was persisting. With the hematocrit stable
patient was deemed safe to discharge. From her oncology
standpoint chemotherapy was not initiated during this stay
while acute issues were flaring. Her hypothyroidism was not
an active issue and she was maintained on her Synthroid.
Patient continued to be noted to be orthostatic while she was
here, but since she had a history it was determined that her
baseline blood pressure was in the low 90s, and she would
occasionally drop to the 80s, but she continued to mentate
and felt fine. No further fluid was given to her due to her
extensive edema.
Coronary artery disease: She was continued on her Lipitor,
but her aspirin was held due to the bleeding and the multiple
interventions. We will continue to hold the aspirin at her
discharge due to the planned nephrogram and potential
internalization of the nephrostomy. Her electrolytes
remained stable, and she was continued on a cardiac diet
except for the times that she was n.p.o. for procedures.
DISCHARGE DIAGNOSES:
Atrial fibrillation.
Hydronephrosis of right, status post multiple percutaneous
nephrostomy attempts.
Renal pelvic hematoma.
Renal arteriovenous malformations, status post embolization.
Hypothyroidism.
Coronary artery disease, status post myocardial infarction.
Orthostatic hypotension.
DISCHARGE MEDICATIONS: Furosemide 40 mg p.o. q.d.,
fluconizole 200 mg p.o. q 48 hours, lactulose 30 ml p.o.
t.i.d., p.r.n., senna 2 tablets p.o. b.i.d., Digoxin .125 mg
p.o. q.o.d., diltiazem 60 mg p.o. q.i.d., Fentanyl patch 25
mcg an hour q 72 hours, ciprofloxacin 250 mg p.o. q 18 hours,
erythropoietin 40,000 units subcutaneus one time a week on
Tuesday, Docusate 200 mg p.o. b.i.d., Percocet 1 tablet p.o.
q 4 to 6 hours p.r.n., Tylenol 325 to 650 mg p.o. q 4 to 6
hours p.r.n., ferrous sulfate 325 mg p.o. q.d., pentropozole
40 mg p.o. q 24, torvostatin 40 mg p.o. q.d., levothyroxine
50 mcg p.o. q.d., phenobarbital 30 mg p.o. q.h.s.,
multivitamins 1 capsule q.d.
DISCHARGE CONDITION: Stable.
DEPOSITION: Discharged to nursing home.
FOLLOW UP: With interventional radiology [**8-8**] for
nephrostogram with Dr. [**Last Name (STitle) 101289**] of oncology. Patient is full
code.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13111**]
Dictated By:[**Name8 (MD) 8876**]
MEDQUIST36
D: [**2108-8-3**] 18:22
T: [**2108-8-3**] 20:14
JOB#: [**Job Number 101290**]
Name: [**Known lastname 16269**], [**Known firstname 3551**] Unit No: [**Numeric Identifier 16270**]
Admission Date: [**2108-7-17**] Discharge Date: [**2108-8-5**]
Date of Birth: [**2028-3-30**] Sex: F
Service:
ADDENDUM:
The patient was transfused two units of blood on [**2108-8-4**].
Her repeat hematocrit was 31.9 posttransfusion. The
hematocrit remained stable on the morning of [**2108-8-5**], so the
patient was discharged to rehabilitation on [**2108-8-5**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**]
Dictated By:[**Name8 (MD) 1915**]
MEDQUIST36
D: [**2108-8-5**] 11:57
T: [**2108-8-5**] 13:09
JOB#: [**Job Number 16271**]
|
[
"276.1",
"276.5",
"998.12",
"151.0",
"285.1",
"427.31",
"997.5",
"197.6",
"590.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.45",
"55.93",
"99.29",
"87.75",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
9716, 9767
|
8733, 9021
|
9045, 9694
|
3511, 8712
|
9779, 10913
|
2277, 3493
|
1256, 2254
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,764
| 110,589
|
345
|
Discharge summary
|
report
|
Admission Date: [**2166-8-25**] Discharge Date: [**2166-8-27**]
Service: [**Hospital Unit Name 196**]
Allergies:
Prednisone
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
amaurosis fugax and syncope
Major Surgical or Invasive Procedure:
L Internal carotid artery stent placement.
History of Present Illness:
82 yo Male with symptomatic [**Doctor First Name 3098**] stenosis admitted to CCU after
carotid stent placement. Pt has severe vascular disease - 90%
[**Doctor First Name 3098**] stenosis, 30-60% [**Country **] stenosis, CAD - NQWMI in [**2-11**] (found
2VD - 70% ostial RCA, TO LCx distally with collateral flow). Pt
also has PVD and ?RAS. Sig risk factors include DM,
hyperlipidemia, heavy tobacco use. Pt tolerated procedure well.
Of note he did have low BP on arrival before procedure started
(had taken captopril at home). He was asymptomatic with sBP in
the 70's. Was brought to the CCU on neosynephrine.
Pt is relatively poor historian - unable to explain why he
had procedure. Per notes, pt began to become symptomatic with L
sided amaurosis fugax x 2 episode (pt describes vision going
dark all around a pinpoint of light in the center of his vision)
and syncopal episode ~1month prior where he was sitting in a
chair and lost consciousness although he maintained his seated
position but had urinary incontinence.
Past Medical History:
1. Severe chronic obstructive pulmonary disease on 1.5-3L home
O2.
2. CAD - s/p NQWMI in [**2-11**] as above.
3. Diabetes mellitus - controlled by diet and glyburide.
4. Common Bile duct stones - had cholangitis ~1month ago with
placement of percutaneous drain. CCK planned for [**9-9**].
5. S/p benign lung nodule removal [**2149**].
6. s/p appy.
Social History:
Pt lives with wife. Smoked 4 ppd x 40 years, quit 9 months ago.
Used to drink 6 beers/night but has not had much EtOH in the
last 2 months. Denies other drug use.
Family History:
Mother died of cancer (unknown type) in her 80's.
Father died in 80's of unknown disease.
No known h/o CAD, CVA's, PVD.
Physical Exam:
aF, HR 71, BP 150/70 RR 11, O2sat 100% on 3L NC.
Gen: in NAD
HEENT: PERRLA, EOMI, no sceral icterus
Neck: supple, no lymphadenopathy.
CV: decreased heart sounds. +S1, S2. No m/r/g appreciated.
Pulses 1+ R carotid. L carotid pulse not palpable. B DP/PT not
dopplerable.
Lungs: (ant auscultation) CTA bilaterally. No wheezes or
crackles
Abd: S/NT/distended. +BS. No HSM. Percutaneous biliary drain in
place with tan/brown drainage.
Ext: no c/c/ trace edema B LE. Cold feet. Eczema on R hand.
Neuro: A&Ox3. CN II-XII in tact. Strength 5/5 throughout.
Sensation in tact to light touch.
Pertinent Results:
[**Doctor First Name 3098**] stent report:
1. Access was retrograde via the right CFA.
2. Thoracic aorta: Type I arch without flow-limiting disease.
3. Renal arteries: bilateral disease, mild on the RRA. The
LRA had a
focal 80% lesion.
4. Subclavian arteries: The RSCA had a focal 60% lesion after
the
origin of the vertebral. The LSCA had mild disease.
5. Carotid/vertebral arteries: The right vertebral is patent
without
lesions. There was mild disease at the origin of the left
vertebral.
The cerebellar arteries are normal. The basilar system filled
the left
MCA from a patent PCOM. The RCCA was normal. The [**Country **] had a
60% lesion
and filled the ipsilateral ACA, MCA and contralateral ACA via
the ACOM.
The LCCA was normal. There was a focal 90% lesion at the
bifurcation.
The [**Doctor First Name 3098**] filled the ipsilateral MCA.
6. Successful stenting of the [**Doctor First Name 3098**] was performed with a 7.0 x
40 mm
Precise stent.
7. Right femoral angiography demonstrated severe diffuse
disease in the
RCFA with almost complete obstruction of distal filling from the
6F
sheath.
FINAL DIAGNOSIS:
1. Severe [**Doctor First Name 3098**] stenosis.
2. Stenting of the [**Doctor First Name 3098**].
3. Severe left RAS.
4. Severe right CFA disease.
Brief Hospital Course:
82 yo man with severe vascular disease with symptomatic [**Doctor First Name 3098**]
disease, 90% stenosis on U/S with amaurosis fugax and possible
syncopal episode now s/p carotid stent with good restoration of
flow.
1. CV:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] s/p stent: Keep pt on ASA, plavix, atorvastatin. sBP was
kept between 140-160 initially to keep flow brisk in setting of
new stents and then overnight as Neo was weaned BP started to
fall. Neo was increased for a few hours, but then BP remained
stable and Neo was titrated off. Etiology for hypotension was
felt to most likely be increased vagal tone after [**Doctor First Name 3098**] surgery.
Pt will continue to refrain from taking BP meds for the next few
days and follow up for a BP check on [**8-29**].
B. CAD: Continue ASA, plavix, simvastatin. Restart BP meds (BB
and ACE) as outpt after BP check.
2. Pulm: COPD - continue inhalers and nebs prn. Nasal Cannula O2
to keep sats ~92%.
3. Renal: RAS seen on cath. Dr. [**First Name (STitle) **] likely to place stents in
future. Cr remained stable after surgery.
4. ID: stable.
5. GI: percutaneous biliary drain in place. Scheduled for
surgery [**9-9**] in [**Hospital1 1474**].
6. GU: pt voided easily with good UOP. Restart Proscar on
discharge.
7. Heme: post-procedure hct stable. No s/sx hematomas. No
bruits.
8. Endo: NIDDM. Continue RISS and restart glyburide as outpt.
Diabetic diet.
9. Neuro/Psych: reports no recent EtoH. Pt showed no s/sx of
withdrawal.
10. Ppx: DVT ppx - encouraged ambulation. PT/OT helped. Eating.
11. Comm: with pt and family.
12. Code: Full
13. Dispo: To home with good follow up on [**8-29**] with Dr. [**Last Name (STitle) **]
and with Dr. [**First Name (STitle) **] on [**2166-10-14**].
Medications on Admission:
Lasix 20 mg daily
Imdur 30 mg daily
Proscar 5 mg daily
Glyburide 2.5 mg daily
Captopril 25 mg twice daily
ASA 325 mg daily
Simvastatin 10 mg daily
Amitriptyline 10 mg dialy
Serevent discus 50 mcg twice daily
Flovent 220 mcg 2 puffs twice daily
Albuterol/Atrovent inhalers prn
Albuterol/Atrovent Nebulizer prn 2-4 times daily
Plavix 75 mg dialy
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) for 30 days.
3. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol Sulfate 0.083 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Amitriptyline HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Severe vascular disease
2. Severe chronic obstructive pulmonary disease on 1.5-3L home
O2.
3. CAD
4. Diabetes mellitus - controlled by diet and glyburide.
5. Common Bile duct stones - had cholangitis ~1month ago with
placement of percutaneous drain. CCK planned for [**9-9**].
Discharge Condition:
stable
Discharge Instructions:
Please do NOT take your BP medications (Furosemide, Isosorbide,
and captopril) until you see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday, [**8-29**]. If you develop changes in vision, new numbness, or loss of
consciousness, call Dr. [**First Name (STitle) **] right away.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday [**8-29**] to
have your blood pressure checked. Dr. [**Last Name (STitle) **] can restart your BP
medications at this time if it is appropriate. Call [**Telephone/Fax (1) 3183**]
to verify your appointment.
Also, please follow up for VASCULAR STUDY Where: CC CLINICAL
CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2166-10-14**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2166-10-14**] 2:00
|
[
"440.1",
"433.10",
"414.01",
"401.9",
"458.29",
"V46.2",
"250.00",
"362.34",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
7275, 7281
|
3987, 5758
|
266, 310
|
7605, 7613
|
2677, 3798
|
7969, 8623
|
1938, 2059
|
6153, 7252
|
7302, 7584
|
5784, 6130
|
3815, 3964
|
7637, 7946
|
2074, 2658
|
199, 228
|
338, 1368
|
1390, 1742
|
1758, 1922
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,799
| 155,805
|
24515
|
Discharge summary
|
report
|
Admission Date: [**2169-1-24**] Discharge Date: [**2169-1-28**]
Date of Birth: [**2110-11-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Phenergan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2169-1-24**] Coronary Artery Bypass Graft x 2 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
obtuse marginal)
History of Present Illness:
58 year old female with known coronary artery disease who
continues to have symptoms. She was again referred for a cardiac
cath which showed 50% left main disease.
Past Medical History:
Coronary Artery Disease status post percutaneous coronary
intervention with stents, Hypertension, Hyperlipidemia, Diabetes
Mellitus, Hypothyroidism, Obstructive sleep apnea,
Gastroesophageal reflux disease, Carotid disease, Fibromyalgia,
status post Appendectomy, status post Hysterectmy, status post
lumbar discectomy, status post c-section
Social History:
The patient lives with her husband, she works as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**]
teacher. There is no history of tobacco use, occasional EtOH,
no illicit drug use.
Family History:
Her father passed away from MI at 59yo. Father with CAD and
Type 2 DM, Mother s/p CVA at 84yrs with pacemaker, Sister with
Type 2 DM.
Physical Exam:
Vitals: 75 16 180/61
General: No acute distress, well nourished
Skin: Unremarkable with healed mid-line abdominal incision
Neck: Supple, full range of motion
Chest: Clear lungs bilaterally
Heart: Regular rate and rhythm, no murmur
Abdomen: Soft, non-tender, non-distended, +bowel sounds
Extremities: Warm, well-perfused, -edema
Neuro: Grossly intact, alert and oriented x 3
Pertinent Results:
[**2169-1-27**] 09:38AM BLOOD WBC-8.1 RBC-2.87* Hgb-8.8* Hct-24.3*
MCV-85 MCH-30.7 MCHC-36.2* RDW-13.4 Plt Ct-209
[**2169-1-27**] 09:38AM BLOOD Glucose-225* UreaN-15 Creat-1.0 Na-136
K-3.6 Cl-96 HCO3-34* AnGap-10
[**2169-1-27**] 09:38AM BLOOD Mg-1.8
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit and was brought to the
operating room on [**1-24**] where she underwent a coronary artery
bypass graft x 2. Please see operative report 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.
Her chest tubes were removed on post-op day two and she was
transferred on this day to the telemetry floor for further care.
[**Last Name (un) **] was consulted for management with her diabetes and
insulin pump. Epicardial pacing wires were removed on post-op
day three. The physical therapy service was consulted for
assistance with post-operative strength and mobility. By the
time of discharge on POD 4 the patient was ambulating freely,
the wound was healing and pain was controlled with oral
analgesics.
Medications on Admission:
Plavix 75mg daily, Prevacid 30mg daily, Tricor 145mg daily,
Levothyroxine 50mgcg daily, Toprol XL 50mg daily, Amlodipine 5mg
daily, Aspirin 325mg daily, Crestor 20mg daily, Ursodiol 300mg
daily, Calcium tabs daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Clopidogrel 75 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*0*
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
8. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-18**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed.
Disp:*qs * Refills:*0*
10. Prevacid 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:*0*
11. Lorazepam 0.5 mg Tablet Sig: .5 Tablet PO Q8H (every 8
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
1 weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Doctor Last Name **] [**Location 269**]
Discharge Diagnosis:
Coronary Artery Disease status post Coronary Artery Bypass Graft
x 2
Secondary: Hypertension, Hyperlipidemia, Diabetes Mellitus,
status post percutaneous coronary intervention with stents,
Hypothyroidism, Obstructive sleep apnea, Gastroesophageal reflux
disease, Carotid disease, Fibromyalgia, status post
Appendectomy, status post Hysterectmy, status post lumbar
discectomy, status post c-section
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 11250**] in [**12-20**] weeks
Dr. [**Last Name (STitle) 61962**] in [**11-18**] weeks
Completed by:[**2169-1-28**]
|
[
"362.01",
"V58.67",
"327.23",
"V45.85",
"724.2",
"244.9",
"V45.82",
"250.50",
"414.01",
"530.81",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5095, 5168
|
2072, 2975
|
312, 462
|
5609, 5615
|
1798, 2049
|
6019, 6202
|
1253, 1389
|
3239, 5072
|
5189, 5588
|
3001, 3216
|
5639, 5996
|
1404, 1779
|
262, 274
|
490, 655
|
677, 1020
|
1036, 1237
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,794
| 136,926
|
42187
|
Discharge summary
|
report
|
Admission Date: [**2177-8-12**] Discharge Date: [**2177-8-20**]
Date of Birth: [**2101-6-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Hypoxia, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76yoF with a history of stage IV renal clear cell carcinoma
metastatic to the bone and lung s/p radical nephrectomy and
experimental treatment with tivozanib, HTN, HLD, and CAD s/p PCI
who is presenting with 2 days of fever and dyspnea. She reports
that on saturday she began feeling febrile and noticed that she
was becoming fatigued while performing her ADLs. On sunday and
monday she became increasingly short of breath and fatigued and
began having chills with her fever. She reports a temp of 102 on
Monday night that prompted her to contact her PCP who advised
her to go to the emergency room.
.
Patient has metastatic renal cell carcinoma and is currently
receiving therapy on a clinical trial with a novel antibody
against PD-L1. The study drug has been associated with
autoimmune sideeffects including pneumonitis, but clinical
picture in the ED was more concerning for an infectious process.
She was started on Levaquin.
.
On [**8-15**], Pt was ready to be discharged but then developed acute
hypoxia (transisent to 80s) and tachycardia to 150. Her BP
dropped to 80s/50s (baseline 100-120/70s), with transiet O2 sat
to 80s, which resolved. At that time, she was responsive to
command and denies CP, SOB, n/v/d, diaphoresis. On arrival to
the MICU, patient's VS. TEMP 98.6, HR 110, BP 84/61, RR 24, 92%
on 2L. By the time she arrived in the MICU, she has converted
back into a regular tachycardia; the only intervention she
received was vagal maneuvers. Cardiology was consulted and
recommended starting low dose metoprolol 12.5 mg TID daily
instead of her ACEi. She was given 1L IVF and had LE dopplers
which were negative. At 6:30am [**8-16**], she had HR to 120's, SBP
90's, was asymptomatic, given 500 cc NS bolus with pressure
responsive to the 100s but developed crackles bilaterally. Her
SBP improved to 100's. Her Metoprolol 12.5mg TID was changed
back to [**Hospital1 **] for low BP 88/50s later that afternoon. She
received Lasix 20mg IV. On [**8-17**], she completed her course of
Levofloxacin (repeat CXR showed no clear evidence of PNA) and
was called-out to the floor. On transfer, she states that she
feels relatively well and that her breathing is stable.
Past Medical History:
Metastatic renal cell carcinoma
Hypertension
Dyslipidemia
CAD s/p PCI
Osteopenia
Internal hemorrhoids
- last colonoscopy [**2176-10-4**] for +FOBT with benign polyps only
Last normal mammogram [**2176-8-22**]
s/p BL knee replacement [**12/2175**] and [**1-/2176**]
Social History:
She has two sons, one in [**Name (NI) 86**] and the other in [**Male First Name (un) 1056**].
Her son who lives in [**Name (NI) 86**] is [**First Name8 (NamePattern2) 71**] [**Name (NI) **] [**Last Name (NamePattern1) **]. [**First Name5 (NamePattern1) 36211**]
[**Last Name (NamePattern1) 91489**] is her neice who is an OB/Gyn and lives in CT; she is
very involved with Ms. [**Known lastname 91490**] care with Ms. [**Known lastname 91490**]
consent. Never smoker. No sig EtOH history. She lived in the
U.S. for twenty years after marrying here. She used to work as a
teacher's aid.
Family History:
An uncle had cancer, likely colon cancer. + hx of CAD. Brother
has prostate cancer. Mother and Father died in their 80s; mother
had alzheimer's and died of MI, father died of unknown causes
Physical Exam:
General: Dark skin, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
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.
Pertinent Results:
Admission Labs:
[**2177-8-12**] 11:40AM BLOOD WBC-3.9* RBC-5.16 Hgb-16.0 Hct-48.4*
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.7 Plt Ct-191
[**2177-8-12**] 11:40AM BLOOD Neuts-56.1 Lymphs-30.8 Monos-10.9 Eos-1.2
Baso-1.0
[**2177-8-12**] 11:40AM BLOOD PT-11.1 PTT-26.6 INR(PT)-1.0
[**2177-8-12**] 11:40AM BLOOD Glucose-96 UreaN-23* Creat-1.4* Na-135
K-4.6 Cl-102 HCO3-22 AnGap-16
[**2177-8-12**] 11:40AM BLOOD proBNP-157
[**2177-8-13**] 06:15AM BLOOD Calcium-10.2 Phos-3.3 Mg-2.1
[**2177-8-12**] 12:04PM BLOOD Lactate-1.5
Discharge labs:
[**2177-8-20**] 06:35AM BLOOD WBC-4.4 RBC-4.86 Hgb-14.4 Hct-44.6 MCV-92
MCH-29.6 MCHC-32.2 RDW-14.1 Plt Ct-240
[**2177-8-20**] 06:35AM BLOOD Glucose-100 UreaN-20 Creat-1.2* Na-138
K-4.6 Cl-108 HCO3-24 AnGap-11
[**2177-8-20**] 06:35AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.0
[**8-12**] EKG: Sinus rhythm. Normal ECG. Compared to the previous
tracing of [**2177-7-31**] there is no significant change.
[**8-12**] CXR: IMPRESSION: Significant burden of metastatic disease
with innumerable bilateral pulmonary nodules. Although no
definite superimposed consolidation is identified, small area of
infection would be difficult to exclude given burden of disease.
[**8-15**] ECHO: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion. IMPRESSION: Normal global and regional
biventricular systolic function.
[**8-15**] EKG: Supraventricular tachycardia at 145 beats per minute,
likely an A-V nodal re-entrant tachycardia with pseudo S waves
in leads II, III and aVF. Compared to the previous tracing of
[**2177-8-12**] the A-V nodal re-entrant tachycardia rhythm is new.
[**8-15**] CXR: CONCLUSION: 1. There is no pulmonary edema or new
lung consolidation. 2. Diffuse pulmonary metastases, perhaps
mildly decreased, with some lesions that appear cavitary.
[**8-15**] LENI: Conclusion: No evidence of DVT in right or left
lower extremity.
[**8-16**] CXR: IMPRESSION: 1. Possible developing pneumonia within
the left lower lobe. Consider standard PA and lateral chest
radiographs for more complete evaluation when the patient's
condition permits. 2. Widespread pulmonary nodules and
lymphadenopathy consistent with
metastatic disease.
3. Small bilateral pleural effusions.
Brief Hospital Course:
76 F with metastatic RCC, admitted initially for fever and pna,
was treated for CAP, and transferred to [**Hospital Unit Name 153**] for acute
tachycardia and hypotension.
===== ACTIVE ISSUES =======
# Hypotension/Tachycardia: During admission, patient had two
episodes of acute onset narrow complex tachycardia and
hypotension, with EKG concerning for SVNRT or AVRT. Vagal
maneuvers ineffective. During initial episode, patient
spontaneously converted to sinus rhythm upon transfer to the
[**Hospital Unit Name 153**]. During the second episode, she converted to sinus rhythm
after receiving 6mg of adenosine. CTA negative for PE, LENIs
negative bilaterally, ECHO elatively normal (EF > 55%) without R
heart strain. Cardiology recommended metoprolol 12.5mg [**Hospital1 **] for
rate control. Her home lisinopril was held. She was later
switched to metoprolol 25mg extended release.
# Volume overload: most likely secondary to fluid boluses though
EF > 55% without diastolic dysfunction findings on echo.
Findings are suggestive of bilateral basal crackles along with
slightly elevated JVP. She was producing adequate urine, and was
allowed to autodiurese given her borderline BP.
# Dyspnea: Clinical picture suggestive of infectious etiology,
but imaging confounded by metastatic diseases in lungs. She was
treated with levofloxacin (day 1 [**8-14**]) for 5 days without
clinical improvement. Blood cultures showed no growth. PE workup
negative. Possibly due to tumor burden with component of volume
overload. Patient discharged with continued O2 requirement.
# UTI: asymptomatic, culture grew pansensitive E.coli. Was
covered with levofloxacin and repeat UA was negative.
=========== INACTIVE ISSUES =============
# Metastatic RCC: Patient diagnosed with RCC in [**7-/2176**], s/p
right nephrectomy in [**8-/2176**], with pulmonary, liver and bone
mets. On Tivozanib, experimental treatment. Progressive disease
on CT chest with contrast on [**2177-7-22**]. She was not actively
treated for her RCC during admission.
# HTN: She takes lisinopril at home, which was switched to
metoprolol for rate control given episodes of AVRT.
# HLD - well controlled on simvastatin.
========== TRANSITIONAL ISSUES ====================
- She should follow up with cardiology as an outpatient.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 5 mg PO DAILY
2. Sertraline 75 mg PO DAILY
3. Simvastatin 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Aspirin 81 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral daily
Discharge Medications:
1. oxygen
2-3L via nasal cannula with ambulation for desaturations of 80%,
pulse dose for portability
Ambulating on 3L she is [**Age over 90 **]% RA sat 92% Dx metastatic renal
cell carcinoma
2. Aspirin 81 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Sertraline 75 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP<95, HR<60
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
metastatic renal cell carcinoma
atrio-ventricular reentrant tachycardia
community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was such a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with shortness of breath and fever. We treated you with
antibiotics for a pneumonia, and you improved. You developed an
abnormally fast heart rhythm and low blood pressure, for which
you spent some time in the intensive care unit. You were seen
by the cardiology team, who recommended controlling your heart
rate with medication. This medication, metoprolol succinate,
can also cause low blood pressure, so it is very important that
you let your doctors know if [**Name5 (PTitle) **] have symptoms like dizziness
and lightheadedness.
You are being discharged with oxygen. We suspect that the
cancer in your lungs has made it difficult to maintain a normal
level of oxygen in your blood. You will have some nursing care
at home to help monitor your blood oxygen levels.
You missed a dose of your chemotherapy while you were here. Dr.
[**Last Name (STitle) **] is aware and you will be contact[**Name (NI) **] with a date and time for
the next round.
The following changes were made to your medications:
1. START METOPROLOL SUCCINATE 25mg daily
2. STOP LISINOPRIL because it causes further low blood pressure
3. STOP calcium supplements because your calcium level is
somewhat high, probably due to your cancer
Please continue all other previously prescribed medications.
I wish you the best of luck, Ms. [**Known lastname **].
Followup Instructions:
Please call to make an appointment with me, [**Doctor Last Name 122**] Tremaglio, at
our practice at [**Hospital1 18**], called [**Hospital3 **]. The phone
number is [**Telephone/Fax (1) 2010**].
Department: BMT/ONCOLOGY UNIT
When: WEDNESDAY [**2177-9-10**] at 8:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2177-8-24**]
|
[
"458.9",
"276.69",
"041.49",
"585.9",
"427.89",
"414.01",
"198.5",
"V46.2",
"197.0",
"518.4",
"V10.52",
"733.90",
"272.4",
"403.90",
"V43.65",
"486",
"276.1",
"V45.73",
"197.7",
"599.0",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10303, 10358
|
7050, 9341
|
325, 332
|
10503, 10503
|
4313, 4313
|
12131, 12743
|
3462, 3654
|
9776, 10280
|
10379, 10482
|
9367, 9753
|
10654, 12108
|
4840, 7027
|
3669, 4294
|
265, 287
|
360, 2554
|
4329, 4824
|
10518, 10630
|
2576, 2843
|
2859, 3446
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,763
| 105,221
|
10356
|
Discharge summary
|
report
|
Admission Date: [**2150-3-9**] Discharge Date: [**2150-3-16**]
Date of Birth: [**2108-4-25**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
CC: epigastric pain
Major Surgical or Invasive Procedure:
Cardiac catheterization w/ DES placed to proximal and mid RCA
Intubation and mechanical ventilation
R IJ placement and removal
History of Present Illness:
41yo F with Type I DM, HTN, hx renal transplant 4 years ago, and
recent admit for left heel cellulitis who presents after
developing CP that woke her from sleep at 3AM today. Has had
stuttering CP for 2 days but it has been constant since 3am.
Felt very weak and fatigued. Husband found her crawling up the
stairs of their home this AM, did not have the energy to change
her clothes. Took her to ER in pajamas. Has felt SOB and
fatigued for several weeks. Has had epigastric pain for the last
2 days which she thought was gas pain or her gastroparesis. Took
Tums w/ no relief. Developed back/shoulder pain o/n, again no
relief.
.
Came to ER in AM. Found to be hypotensive w/ SBP 87/46 (last BP
[**Last Name (un) **] was 146/79), HR 95, temp 96.3. Got EKG in ER which showed
ST elevations in II, III, avF and ST depressions in I, avL. Got
ASA, ativan, 1L NS, plavix 300x1, and heparin gtt. In cath lab,
found to have occluded RCA with difficult stent placement (no
reflow) that eventually required IC nipride injection to
establish flow.
.
During the procedure, pt's mived venous O2 sat dropped to 37%
and her CI fell to less than 2.0. She became agitated and had
mental status changes, making her unable to comply with keeping
her leg straight. She was intubated for SOB and agitation. After
intubation, MV02 improved to 58%. ABG 7.18/27/373 w/ bicarb 11,
BE -16. Sent to CCU for further monitoring.
Past Medical History:
PMH:
ESRD s/p LRRT 4 years ago
Type I DM since [**58**] yo, triopathy
HTN
CRI
PVD
Left LE ulcer/cellulitis with recent admit
Gastroparesis
Hyperlipidemia
.
[**Doctor First Name 147**] HX:
Laser treatment to eye
hx right breast lump s/p resection
LRRT in [**2146**]
Social History:
Lives w/ husband in [**Name (NI) 16848**], MA. + tobacco in past, no tob or
EtOH currently.
Family History:
+ CAD, hypercholesterolemia, HTN, cancer
Physical Exam:
VS: T 94.7, BP 106/63 (161/87), HR 94-104, RR 19-22, sats 100%
Vent: AC Tv 450 (actual 500), RR 10, Fi02 60%, PIP 16, Peak 14
HEENT: Sclera anicteric.
NECK: Neck supple, no appreciable JVD
LUNGS: CTA anteriorly and at bases, no crackles, wheezes,
rhonchi.
HEART: Tachycardic, regular. Normal S1, S2. No m/r/g.
ABD: Soft, NTND. + BS, no masses. Scar in LLQ from kidney
transplant.
EXT: No edema. 2+ PT, DP pulses bilaterally.
NEURO: Sedated, but moving all 4 ext spontaneously.
SKIN: No rashes.
Pertinent Results:
LABS on admission:
MICRO:
[**2150-3-9**]: blood cx negative
[**2150-3-9**]: urine cx negative
[**2150-3-10**]: blood cx (mycolytics/fungal isolators) negative
[**2150-3-10**]: blood cx negative x2
[**2150-3-10**]: urine cx negative
[**2150-3-11**]: C diff negative
[**2150-3-13**]: urine cx negative
[**2150-3-15**]: C diff pending
.
IMAGING:
[**2150-3-9**] CATH:
RA 19/21/17
RV 32/19
PA 32/21/26
WEDGE 25/28/22
AORTA 99/61/74
CO/CI 3.9/2.7 -> 2.27/1.54
SVR 1169
.
1. Selective coronary angiography revealed a right dominant
system with severe diffuse disease. The LAD was totally occluded
in the mid-vessel. There was a diffusely diseased bifurcating
large diagonal up to 70%. The LCX had a 70% lesion in the mid
vessel. There was a totally occluded OM. The RCA was 100%
occluded proximally, which was thought to be the culprit lesion.
2. Hemodynamics post intervention revealed elevated filling
pressures
(RVEDP 19 mm Hg, PCWP mean 22 mm Hg) with hemodynamics
consistent w/
RV infarction. Initially patient was somewhat hypotensive,
requiring
dopamine. Post intervention, patient's blood pressure improved
and
dopamine was discontinued. Post intervention CI was 2.01, with
arterial pH of 7.17. Repeat CI was 1.5 with a arterial pH of
7.23; at that time patient had SBP >120.
3. Patient became increasingly agitated post intervention with
mental
status changes and metabolic acidosis. She was unable to lay
flat with sheaths in her groin. She was intubated and sent to
the CCU.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated filling pressures consistent with RV infarction.
3. Low cardiac index and acidemia without hypotension.
.
[**2150-3-9**] ECHO: There is symmetric left ventricular hypertrophy.
There is severe regional left ventricular systolic dysfunction
(EF 25%) with akinesis of the inferior wall, infero-septum and
apex. The antero-septum is hypokinetic. The basal to mid
anterior and lateral walls move best. There is moderate
spontaneous echo contrast seen in the LV cavity but no masses or
thrombi are seen. There is severe global right ventricular free
wall hypokinesis. The pulmonary artery
systolic pressure could not be determined. There is a small to
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade. IMPRESSION: Severe,
regional LV systolic dysfunction c/w multivessel CAD. RV
systolic dysfunction.
.
[**2150-3-9**] CXR: Endotracheal tube tip in satisfactory position
.
[**2150-3-9**] CXR: There has been interval placement of a right
internal jugular vascular catheter, with the tip terminating in
the region of the junction of the superior vena cava and right
atrium. There is no evidence of pneumothorax, and there has
otherwise been no significant change since the recent study of
several hours earlier.
.
[**2150-3-9**] RENAL U/S: Unremarkable transplant kidney without
hydronephrosis.
.
[**2150-3-10**] CXR: AP single view of the chest obtained with patient
in semi-upright position is analyzed in direct comparison with a
similar previous study obtained on [**2150-3-9**]. The
patient remains intubated, the ETT in unchanged position. The
same holds for an internal jugular approach central venous line
terminating at the cavo-atrial junction and a Swan-Ganz catheter
approached from below terminating in the main pulmonary artery.
NG tube reaches stomach. Patient is less inflated during this
exposure in comparison with the previous study. There is no
evidence of new parenchymal densities or CHF but the pulmonary
vasculature is slightly more crowded. The lateral pleural
sinuses remain free.
Brief Hospital Course:
41yo F w/ DMI s/p LRRT [**2146**] and recent hospitalization for L
heel ulcer, presents w/ inferior STEMI with course complicated
by ARF.
.
# ISCHEMIA: Ms. [**Known lastname **] presented with an inferior STEMI. On
admission CK 361, MB 18, MBI 5.0, trop 2.66). She was taken
straight to the cath lab where she was found to have diffuse
disease, but total occlusion of her RCA which was felt to be the
culprit lesion. Two [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] were placed in the RCA, but they
were unable to establish good reflow post-stenting. IC nipride
was injected and good flow was eventually established. She was
also started on Reopro in the cath lab. PA sats were as low as
37% intra-procedure, but improved to 59% after intubation. ABGs
in cath lab showed an acidemia (pH 7.18) and her lactate was
9.1. IABP was not placed secondary to her severe PVD. In the
cath lab, she initially required a dopamine gtt to keep her BP
up, but by the end of the procedure, she had to be given nipride
to control her BP. Her CO and CI were low and overnight,
dobutamine was added for inotropy. With the addition of
dobutamine, her PA sats improved to 70%, her lactate came down
to 1.3, and her UOP improved to 40cc/hr. Her enzymes peaked at
CK of 1124, MB of 34, and troponin of 6.35. She had persistent
ST elevations on EKG after her intervention, and they remained
on EKG throughout the rest of her hospitalization. She remained
chest pain free after her extubation, although she had
intermittent episodes of epigastric discomfort that were not
associated with any EKG changes. These were felt to most likely
be related to her gastroparesis and GERD. She was continued on
aspirin and plavix after the placement of her stents. She was
continued on her outpatient dose of pravachol for secondary MI
prevention. She was started on coreg with good effect on her BP
and HR. Despite her depressed EF, an ACE inhibitor was not
started given her acute renal failure. It was felt that the
decision to start an ACE inhibitor could be delayed to the
outpatient setting. She will follow-up with Dr. [**Last Name (STitle) **] in [**1-19**]
weeks.
.
# PUMP: An ECHO was performed in the cath lab and showed an EF
of 20-25%, with apical and inferior akinesis and a small
pericardial effusion. A repeat TTE on the floor was unchanged,
with no increase in pericardial effusion and no evidence
tamponade physiology. She unfortunately did not show any
improvement in her EF, either. Her CO and CI were low on
transfer from the CCU, and dobutamine was started with
improvement in both. The dobutamine was able to be weaned off on
[**2150-3-10**]. She had minimal urine output for the first several days
of her hospitalization, which caused her to become volume
overloaded. She was not diuresed, however, due to her renal
failure and Renal never felt that HD was indicated. She
eventually began to autodiurese and mobilize her extra fluid on
her own. She was advised to follow a low [**Date Range **] diet in order to
prevent further fluid accumulation. For medical management of
her heart failure, she was started on coreg but ACE inhibitors
had to be held secondary to her renal failure. ECHO confirmed an
akinetic apex, but it was not felt to be acute thus there was no
need for anticoagulation currently. She will need a repeat echo
in 1 month's time, at which time, if she has not had improvement
in her EF, she will be considered for placement of an ICD.
.
# RHTYHM: She remained in NSR for most of her stay. She
displayed a prolonged PR interval during her first hospital day,
but her PR was back down to 0.186 by [**3-10**]. She was monitored on
telemetry while she was here and had frequent EKGs which showed
slowly resolving ST elevations in the inferior leads.
.
# ARF: Renal was consulted because of her history of a living
related donor renal transplant and her chronic
immunosuppression. It was felt that her ARF was multifactorial,
with components of ATN, prerenal azotemia, and contrast-induced
nephropathy. Her Cr peaked at 4.3 and then trended down. She
never became anuric, but her immunosuppression did have to be
held for several days based on elevated troughs and likely poor
clearance. Despite becoming fluid overloaded, she never
developed any respiratory symptoms and was able to remain on RA
without any changes in her oxygen saturation. Renal helped
manage her electrolytes, with the intermittent use of bicitra
and phoslo. She was restarted on her immunosuppression once her
CrCl began to improve. She will follow up with renal in [**1-19**]
weeks after discharge, but will have her immunosuppression
levels checked by her PCP in order to guage the changes in the
doses of her immunosuppression with the improvement of her
creatinine.
.
# METABOLIC ACIDOSIS: On admission, she had a pure anion gap
metabolic acidosis, likely related her elevated lactate from
hypoperfusion. The gap was slow to resolve, however, in spite of
improvement in her lactate. It was felt that early renal failure
was also a component as it required the addition of bicitra to
bring her gap back to normal.
.
# ANEMIA: She was anemic on admission. Anemia workup revealed a
mixed picture, likely ACD as well as iron deficiency. She was
started on iron supplementation as well as Epo injections
briefly. Her Hct improved and renal decided she no longer needed
the Epo injections, but did recommend that she continue on iron
supplements.
.
# DM TYPE I: Ms. [**Known lastname **] is a lifelong diabetic with poor glucose
control. Since [**2147**], her HgbA1c has not been <11.3. She was
originally started on an insulin gtt and [**Last Name (un) **] was consulted
for help in managing her insulin regimen. She was titrated off
the insulin gtt and started on Lantus QAM with a RISS. Her
fingersticks were under modest control on this regimen, and the
patient liked this regimen more than the regimen of NPH that she
had been taking at home.
.
# LEFT HEEL ULCER: Ms. [**Known lastname **] had recently been admitted for a
deep L heel ulcer. Podiatry was notified of her admission and
consulted on her while she was here. She was originally started
on vancomycin and zosyn because she was febrile on admission and
there was concern for sepsis, given her hypotension, low SVR,
and fevers. However, her heel ulcer seemed to be healing and she
became afebrile. Her hemodynamics began to improve and she
became afebrile, so vancomycin and zosyn were discontinued.
Podiatry felt that she needed continued abx as she was at high
risk for infection so she was started on PO dicloxacillin which
she seemed to tolerate well. Podiatry also recommended that she
be seen by vascular surgery as an inpatient, and they
recommended imaging (MRI/MRA) but the patient refused. She will
be set up to see vascular surgery as an outpatient once her ARF
resolves and she is more willing to take IV contrast again.
Podiatry also made recommendations as to optimal wound care for
her L heel ulcer. She will follow-up with Dr. [**Last Name (STitle) **] in [**7-27**]
after discharge.
.
#. FEN: She was given a cardiac, heart healthy, low [**Last Name (LF) **], [**First Name3 (LF) **]
diet. She received no IVF during her stay due to her volume
status. She did, however, receive two units of pRBCs because of
an acute drop in her hematocrit after her catheterization. Her
electrolytes were checked regularly and were repleted to keep
her K >4 and Mg >2.
.
#. ACCESS: Originally, she had a venous and arterial sheath left
in place post-catheterization. They were pulled and she was
given a R IJ and a R art line instead. Once she was called out
of the unit, both her central line and arterial line were pulled
and she was managed on the floor with just peripheral IV access.
.
#. PPX: Pneumoboots for DVT prophylaxis. She was given a PPI for
her GERD/GI issues. No bowel regimen was needed given her
diarrhea. Incentive spirometer.
.
#. CODE: FULL
.
#. DISPO: Home w/ services (home PT and VNA for wound care).
Follow-up appointments were scheduled with: cardiology, GI,
vascular surgery, renal, podiatry and [**Last Name (un) **].
Medications on Admission:
Tacrolimus 2mg PO BID
sirolimus 4mg PO QD
pravastatin 10mg PO QD
Bactrim 1 DS TIW
Percocet PRN
ranitidine 150mg [**Hospital1 **]
silvadene 1% cream topical [**Hospital1 **]
D/c [**2-9**] from podiatry on abx:
dicloxacillin 500mg PO QID x 2weeks
levofloxacin 500mg PO QD x 2weeks
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pravastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 3 weeks.
Disp:*84 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Inferior ST elevation MI
Systolic heart failure (EF 20-25%)
Acute renal failure
.
Secondary diagnosis:
L heel ulcer
Diabetes mellitus type I
Discharge Condition:
Good. Afebrile, BP stable, chest pain free.
Discharge Instructions:
1. Please call your PCP or go to the nearest ER if you develop
any of the following symptoms: chest pain, palpitations,
shortness of breath, difficulty breathing, epigastric pain or
burning, fevers, chills, leg swelling or numbness, increase in
weight, decreased urination, or any other worrisome symptoms.
2. Please take all your medications as prescribed, especially
your aspirin and plavix. These medications need to be taken
every day to help keep your stents open.
3. Please keep all your follow-up appointments.
Followup Instructions:
1. Please follow-up with your PCP [**Last Name (NamePattern4) **] 1 week. You will need to
have all of your electrolytes checked, including your BUN and
Cr. Please ask to have these faxed to your kidney doctors.
[**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 250**].
2. Please follow-up with Dr. [**Last Name (STitle) **] (cardiology) on [**2150-3-24**] at
11:30 in [**Hospital Ward Name 23**] 7. Phone # ([**Telephone/Fax (1) 5909**].
3. Please follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2625**]
(vascular surgery) on [**2150-4-8**] at 2:30 PM
4. Please follow-up with Dr. [**Last Name (STitle) **] (podiatry) in Provider:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2150-3-18**] 9:30
5. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] ([**Hospital **] clinic) on
[**2150-3-19**] at 8:30 AM on the [**Location (un) **] [**Telephone/Fax (1) 2378**].
6. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D./Dr. [**Last Name (STitle) 4920**]
(renal) on [**2150-3-27**] 9:50 AM at the [**Hospital Unit Name **] [**Location (un) 436**]
[**Telephone/Fax (1) 23134**].
7. Please follow-up with [**Name6 (MD) **] [**Last Name (NamePattern4) 25130**], M.D.
(gastroenterology) on [**2150-5-11**] at 11:00am. If you have any
questions or need to reschedule this appointment, please call
his office at [**Telephone/Fax (1) 1954**].
8. Please follow-up for a repeat echocardiogram of your heart on
[**2150-4-15**] 11:00 AM at the [**Hospital Ward Name 2104**] building [**Location (un) **] of [**Hospital1 1535**] [**Hospital Ward Name 516**]. The day after your
echocardiogram, please call Dr.[**Name (NI) 5907**] office and inquire
about a follow-up appointment to review the results.
Completed by:[**2150-3-17**]
|
[
"443.9",
"458.8",
"285.21",
"250.51",
"536.3",
"337.1",
"250.41",
"250.61",
"428.20",
"584.5",
"583.81",
"362.01",
"707.14",
"426.11",
"996.81",
"428.0",
"427.1",
"357.2",
"410.41",
"276.2",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.46",
"00.40",
"99.04",
"37.23",
"96.71",
"38.91",
"36.07",
"96.04",
"00.17",
"89.62",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
15614, 15689
|
6451, 14557
|
292, 421
|
15893, 15939
|
2835, 2840
|
16505, 18464
|
2264, 2306
|
14887, 15591
|
15710, 15710
|
14583, 14864
|
4335, 6428
|
15963, 16482
|
2321, 2816
|
233, 254
|
449, 1851
|
15832, 15872
|
15729, 15811
|
2855, 4318
|
1873, 2139
|
2155, 2248
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,805
| 170,331
|
24671
|
Discharge summary
|
report
|
Admission Date: [**2189-2-10**] Discharge Date: [**2189-2-24**]
Date of Birth: [**2116-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
difficulty swallowing
Major Surgical or Invasive Procedure:
Laparoscopic and thoracoscopic minimally invasive total
esophagogastrectomy.
2. Flexible esophagoscopy.
s/p miniesophagogastrectomy [**2-11**],
History of Present Illness:
72-year-old woman who developed a dysphagia and was found to
have a distal esophageal adenocarcinoma, stage T3N0. She
underwent induction chemoradiotherapy and underwent
restaging. On restaging, she had no evidence of progression
with an excellent response. She is, therefore, taken forward
for combined thoracoscopic and laparoscopic total
esophagogastrectomy to complete her trial at palliative
therapy. Therefore the following procedure was performed.
Past Medical History:
Esophogeal cancer T-3, N-0 s/p chemotherapy, radiation therapy,
hypertension, hypothyroid, retrosternal goiter removal;
Pulmonary embolus, Deep vein thrombus
supraventricular tachycardia, atrial fibrillation
Her medicines include Levoxyl, Zestoretic, and quinine
Social History:
Patient lives with her husband of 40 years.
patient is [**Name8 (MD) **] RN- past work in critical care, VNA, Case
management, and most recently as IV RN at local pharmacy as
pharmacy tech.
Very knowledgeable regarding disease, interventions, and care
necessary post-op.
Family History:
Significant for her father having lung cancer. She did consume
tobacco. Her mother had peptic ulcer disease. She has one sister
and three brothers, all of whom are healthy.
Physical Exam:
General- thin spry elederly female in NAD
HEENT-PERRLA, sclera anicteric
Lungs-CTAB
Cor-RRR, episodes of irreg by pt report
Abd-soft, nontender, non-distended. Jejunostomy tube in place
Ext-no edema.
Neuro- fully intact, appropriate
Pertinent Results:
[**2189-2-10**] 05:20PM PT-21.6* INR(PT)-2.1*
[**2189-2-10**] 05:20PM PLT COUNT-242
[**2189-2-10**] 05:20PM PLT COUNT-242
[**2189-2-10**] 05:20PM CALCIUM-9.4 PHOSPHATE-3.7 MAGNESIUM-1.9
[**2189-2-10**] 05:20PM GLUCOSE-101 UREA N-25* CREAT-1.0 SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2189-2-17**] 05:30AM 7.0 2.93* 9.6* 27.5* 94 32.7* 34.8 14.8
231
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2189-2-18**] 05:50AM 17.1*1 45.5* 1.6*
1 NOTE NEW NORMAL RANGE AS OF 12:00AM [**2189-1-21**].;ABNORMAL
PROTHROMBIN TIME (PT) INCREASED DUE TO;LABORATORY CHANGE TO A
MORE SENSITIVE PT [**Name (NI) 25013**].;INR VALUES REMAIN THE SAME. MONITOR
WARFARIN BASED ON INR ONLY!
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2189-2-14**] 02:34AM 434*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2189-2-16**] 02:34PM 109* 11 0.6 134 3.9 100 25 13
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2189-2-13**] 11:00AM 74
Source: Line-portacath
[**2189-2-13**] 01:28AM 117
OTHER ENZYMES & BILIRUBINS Lipase
[**2189-2-12**] 12:16AM 10
Brief Hospital Course:
Patient admitted [**2189-2-10**] with diarrhea and dehydration prior to
surgery, 3 days s/p jejunostomy tube manipulation at [**Hospital 1562**]
Hospital. KUB normal evening of admission. Patient maintained on
lovenox pre-op at home, [**Hospital **] held x7 days. IVF started, coag
labs obtained.
POD#0-2/15- Pre-op 2units FFP for INR=1.9. Patient tolerated
porcedure well, transferred to ICU extubated and in stable
condition w/ bilat chest tubes, JP drain at cervical
incision,lopressor IV q6h started, and pain control .
POD#1- Stable overnight w/ good pain control. maintenance IVF,
heparin gtt, CXR slightly wet, rapid Afib, amio started,
trophic TF started @10cc/hr
POD#[**2101-1-29**] hep gtt decreased PTT=94.8
POD#[**2102-2-26**] 10 Lasix IV, TF->[**2-28**] str, PTT=150->42, CXR-small R
pleural eff slightly improved, small L PTX, hep gtt 650->600
POD#[**2103-3-30**] UGi/SBFT passed, [**Month/Day/Year **] 5, CT x 2 dc'd, NGT dc'd
POD#[**2104-4-28**] clears started, [**Month/Day/Year **] 5@qhs.
POD#[**2105-5-29**] PTT=46, heparin gtt incr to 750u/hr, full liquids,
meds to PO tolerated well. Pain control w/ roxicet elixer. Dispo
planning initiated for tube feeding and supplies.
POD#[**2106-6-28**] TF cycled, INR 1.8, JP dc'd , 2.5 [**Month/Day/Year **]
POD#[**2107-7-30**] INR2.3, hep gtt d/c, [**Month/Day/Year **] 2mg; staples removed,
TF cycle @120cc/hrx16h tol well.j-tube replaced(accidently fell
out)j-tube placement confirmed by abd xry w/gastrographin, wt
55.6
[**2-21**] INR=2.6, [**Month/Year (2) **]=2, WBC=12
[**2-22**]: given 1 unit PRBC, wght 54.0 kg, TF- Peptomen VHP-90cc/hr
for 10 hours tolerated well.
[**2-23**] Lasix 10mg in am, 2 mg [**Month/Year (2) **] in a.m.; INR 2.2, [**Month/Year (2) **]
2 in pm; TF to be advanced to 110 cc/hr x8hr cycle mod. Dispo
planning in process.
[**2189-1-29**]- INR 2.1. Discharged to home in company of husband.
[**Name (NI) 62270**] instructions given and reviewed w/ patient from RN and
NP. Discharge services as described in d/c plan. D/C on
[**Name (NI) **] 2mg qd until INR draw [**2189-2-27**] @ PCP [**Name Initial (PRE) 3726**]
Medications on Admission:
levoxyl 50 mcg; [**Name Initial (PRE) **]-held pre-op; lovenox 50mgx1 dose 2/14,
zestoretic, quinine
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: 10-15 cc PO BID (2
times a day).
Disp:*250 cc* Refills:*2*
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed: please crush for j-tube.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q3-4H PRN ().
Disp:*250 ML(s)* Refills:*1*
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Heparin Flush Port (10units/ml) 5 ml IV DAILY:PRN
10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units
heparin) each lumen Daily and PRN. Inspect site every shift.
8. [**Name Initial (PRE) 197**] 1 mg Tablet Sig: One (1) Tablet PO once a day: take
as directed.
Disp:*30 Tablet(s)* Refills:*2*
9. [**Name Initial (PRE) 197**] 2 mg Tablet Sig: One (1) Tablet PO once a day: take
as directed.
Disp:*30 Tablet(s)* Refills:*2*
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily): monthly supply- suspension.
Disp:*qs mg* Refills:*2*
11. tube feeding
Peptomin THP-full strength;
Goal rate:90 ml/hr over 8 hours--4 cans/day
Flush w/ 30 ml water q8h
12. tube feeding supplies
combat pump
jejunostomy tube supplies:
IV pole
feeding bags
60 cc catheter tip syringes
other supplies
jejunostomy tube supplies
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days.
Disp:*120 Tablet(s)* Refills:*0*
14. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for aroung J tube site.
Disp:*1 1* Refills:*1*
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime for 1
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 635**] VNA
Discharge Diagnosis:
Esophogeal cancer T-3, N-0 s/p chemotherapy, radiation therapy,
hypertension, hypothyroid, retrosternal goiter removal;
Pulmonary embolus, Deep vein thrombus
supraventricular tachycardia, atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**]/ Thoracic Surgery ([**Telephone/Fax (1) 170**]office for:
fever, shortness of breath, chest pain, difficulty swallowing,
excessive nausea or vomitting, escessive drainage or foul odor
from incisions, j-tube site.
You may shower when you return home. no tub baths for 3-4 weeks.
Take new medications as directed- Amiodarone-give through J tube
** 400mg(2 pills)2x/day from [**2-21**] to [**2-27**], then 400mg(2 pills)
daily ongoing until Dr. [**Last Name (STitle) **] stops medication. Ask at
follow-up appointment.
[**Last Name (STitle) 197**]:2mg every day. Have INR level checked as below.
Follow with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) **]/INR monitoring,
[**Last Name (Titles) **] dosage as directed. Follow at lab for blood draws- have
blood drawn 2 days after discharge, then as directed by Dr.
[**Last Name (STitle) **].
Monitor your weight 3-4 times/week. Record and bring to
follow-up appointments.
Tube feedings/ support w/ [**Hospital3 **] Home Infusion- [**Telephone/Fax (1) 62271**];
fax [**Telephone/Fax (1) 62272**].
VNA- [**Hospital3 62273**] [**Telephone/Fax (1) 62274**]/fax[**Telephone/Fax (1) **].
Change J- tube dressing daily/as needed. Inspect for severe
Followup Instructions:
Call Dr.[**Name (NI) 1816**] office for an appointment in [**1-30**] weeks days-
[**Telephone/Fax (1) 170**]
Completed by:[**2189-2-24**]
|
[
"276.51",
"300.00",
"V44.4",
"401.9",
"V12.51",
"151.0",
"458.29",
"244.0",
"787.91",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.42",
"99.07",
"96.6",
"42.23",
"99.04",
"42.58"
] |
icd9pcs
|
[
[
[]
]
] |
7579, 7633
|
3312, 5426
|
351, 502
|
7885, 7892
|
2023, 3289
|
9233, 9373
|
1581, 1755
|
5577, 7556
|
7654, 7864
|
5452, 5554
|
7916, 9210
|
1770, 2004
|
290, 313
|
530, 989
|
1011, 1276
|
1292, 1565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,072
| 164,987
|
13178
|
Discharge summary
|
report
|
Admission Date: [**2134-3-26**] Discharge Date: [**2134-4-4**]
Date of Birth: [**2056-6-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Zetia
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2134-3-26**] Coronary artery bypass grafting x4 with a left internal
mammary artery to left anterior descending artery and reverse
saphenous vein grafts to the posterior descending artery, the
distal left circumflex artery and the first diagonal artery
History of Present Illness:
77 year old female transferred from [**Hospital6 5016**] with 3
vessel disease for potential CABG. Patient has a long-standing
history of CAD s/p angioplasty twice in the past, in [**2113**] and
[**2115**]. Her last cath was in [**2129**] showing total RCA occlusion, 65%
proximal LAD, 20% LM, EF 65%. She presented yesterday to HFH
with 1 hour of severe midsternal chest pain radiated to the
right jaw. EKG with poor RV progression and T inversion in V1,
troponins slightly elevated. Cardiac catheterization showed 85%
proximal LAD stenosis, 99% RCA lesion with left to right
collaterals and 75% stenosis of the circumflex with normal EF.
She was advised to have a CABG and she agreed to proceed, and
was transferred to [**Hospital1 18**].
Past Medical History:
Coronary artery disease
Mild Mitral Regurgitation
Peripheral Vascular Disease
Paroxysmal A.Fib
Anxiety
Pre-renal azotemia/renal insufficiency
Chronic Diarrhea
Non-insulin dependent diabetes mellitus
Hypertension
Hyperlipidemia
h/o right thyroid nodule (benign by biopsy)
Osteopenia
Lipoma
Pilonidal cyst
Cataracts
Aortobifem bypass [**2129**]
Bilateral cataract extractions
Excision of lipomas on back and right thigh
Social History:
Race: caucasian
Last Dental Exam: 7 months ago
Lives with: alone, widowed, has 2 children
Contact: daughter [**Name (NI) 803**] Phone # [**Telephone/Fax (1) 40187**]
Occupation: retired
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [] [**1-26**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
Mother died of complications from DM
Father died of TB, young
Brothers died under 60 from heart disease
Physical Exam:
Pulse: 58 Resp: 18 O2 sat:
B/P Right: 134/62
Weight: 164.68 lbs, 74.7 Kg
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Discharge Exam:
VS: T: 98.1 HR: 59 SR BP: 107/53 Sats: 93% RA WT: 76.9 kg
General: 77 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: clear breath sounds throughout
GI: benign
Extr: warm bilateral with trace edema
Incision: sternal clean dry intact no erythema or click. Left
lower extremity vasoview incisions clean dry intact no erythema
Neuro: awake, alert oriented. moves all extremities
Pertinent Results:
Chest CT [**2132-3-26**]: 1. Substantial enlargement of the right thyroid
lobe that potentially may contribute to the abnormality
demonstrated on the chest radiograph. The assessment of the
right thyroid lobe with ultrasound is suggested. 2. Mild
centrilobular emphysema. Pulmonary nodules as described that
should be reevaluated in three months for assessment of their
stability based on the size of the largest nodule. 3. Sparing of
the ascending aorta from calcifications. 4. Enlarged kidney
cyst. 5. Small hiatal hernia.
.
Echo [**2134-3-31**]: PRE-BYPASS: No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the aortic arch. There
are both simple and complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets are moderately
thickened. The left coronary cusp has poor leaflet excursion.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Trace aortic regurgitation is seen. Trivial mitral regurgitation
is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results in the operating room.
POST-BYPASS: Patient is AV paced and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Aorta is intact post decannulation. Rest of the examination is
unchanged.
.
CXR: [**2134-4-3**]: he small left apical pneumothorax is no longer
seen and has resolved. There is atelectasis at the left base.
There are small bilateral pleural effusions. There is
cardiomegaly and mediastinotomy wires identified. There are no
signs for overt pulmonary edema.
Lab:
[**2134-4-4**] WBC-9.6 RBC-3.83* Hgb-9.9* Hct-32.3* MCV-85 MCH-25.9*
MCHC-30.7* RDW-15.7* Plt Ct-216
[**2134-3-26**] WBC-7.5 RBC-4.53 Hgb-11.1* Hct-35.5* MCV-78* MCH-24.5*
MCHC-31.3 RDW-15.1 Plt Ct-208
[**2134-4-4**] Glucose-117* UreaN-29* Creat-1.1 Na-138 K-4.5 Cl-102
HCO3-28
[**2134-3-26**] Glucose-149* UreaN-26* Creat-1.0 Na-140 K-3.8 Cl-106
HCO3-23
[**2134-3-26**] ALT-10 AST-17 LD(LDH)-133 AlkPhos-49 TotBili-0.4
[**2134-3-26**] %HbA1c-6.2* eAG-131*
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 40188**] was transferred from
outside hospital after cath revealed severe coronary artery
disease. Upon admission she was surgical worked up and received
medical management. Following work-up she was brought to the
operating room on [**2134-3-31**] and underwent a coronary artery bypass
graft x 4. Please see operative note for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Later this day she was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one she was started on beta-blocker and diuretics
and gently diuresed back to her pre-op weight. Later this day
she was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. She remained in sinus rhythm 50-60's, blood pressure
100-118. She was restarted on her Metform 500 mg [**Hospital1 **] with blood
sugars 116-160's. Her Actos was held and should be restarted as
an outpatient. She noted to have mild confusions while on
narcotics. She was changed to tramadol with improvement in her
mental status and good pain control. She worked with physical
therapy for strength and mobility. She continued to make steady
progress and was discharged to [**Hospital3 **] in [**Hospital1 3597**] NH
[**Telephone/Fax (1) **]. She will follow-up as an outpatient.
Medications on Admission:
Actos 30mg daily, metformin 500mg [**Hospital1 **], metoprolol 50mg [**Hospital1 **], isdn
120mg am, 60mg pm, hyzaar 50/12.5 [**Hospital1 **], simvastatin 80mg hs,
vitamin D 400IU daily, asa 162mg daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever, pain.
6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
4 days.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO Q12H (every 12 hours) for 4 days.
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Regular Insulin Sliding Scale AC & HS
71-149 mg/dL 0 Units 0 Units 0 Units 0 Units
150-179 mg/dL 2 Units 2 Units 2 Units 2 Units
180-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-219 mg/dL 6 Units 6 Units 6 Units 6 Units
220-239 mg/dL 8 Units 8 Units 8 Units 8 Units
240-260 mg/dL 10 Units 10 Units 10 Units 10 Units
14. losartan-hydrochlorothiazide 50-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 4
Past medical history:
Mild Mitral Regurgitation
Peripheral Vascular Disease
Paroxysmal A.Fib
Anxiety
Pre-renal azotemia/renal insufficiency
Chronic Diarrhea
Non-insulin dependent diabetes mellitus
Hypertension
Hyperlipidemia
h/o right thyroid nodule (benign by biopsy)
Osteopenia
Lipoma
Pilonidal cyst
Cataracts
Aortobifem bypass [**2129**]
Bilateral cataract extractions
Excision of lipomas on back and right thigh
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema:trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]: [**2134-5-5**] 1:45
in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] [**2134-4-14**] at 11:45a ([**Last Name (un) 40189**], STE#404, [**Hospital1 **],MA)
Please call to schedule appointments with your Primary Care Dr.
[**Last Name (STitle) **] [**Name (STitle) **] in [**3-25**] weeks
Please follow up with Oral surgeon for outpatient tooth
extraction vs. restoration
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2134-4-4**]
|
[
"300.00",
"787.91",
"414.01",
"401.9",
"733.00",
"272.4",
"427.31",
"424.0",
"496",
"521.00",
"250.00",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9015, 9062
|
5735, 7151
|
291, 548
|
9582, 9799
|
3422, 5712
|
10722, 11566
|
2143, 2248
|
7404, 8992
|
9083, 9144
|
7177, 7381
|
9823, 10699
|
2263, 2898
|
2914, 3403
|
241, 253
|
576, 1318
|
9166, 9561
|
1775, 2127
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,045
| 135,619
|
10091
|
Discharge summary
|
report
|
Admission Date: [**2105-11-23**] Discharge Date: [**2105-11-24**]
Date of Birth: [**2060-6-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Dizziness and lightheadedness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 45yo F PMHx fibromyalgia, UC, COPD who presented to
OSH w suddent onset dizziness, found to have new onset [**Hospital **]
transferred to [**Hospital1 18**] for further management. Patient reports
that at 5pm on day prior to transfer, she was in front of her
house finishing some yard work when she had a single episodes of
dizziness that she described as "being at the top of a
rollercoaster", which lasted for several seconds with
spontaneous resolution; associated with subsequent palpitations,
and without any exacerbating/relieving factors that she could
identify. No associated chest pain, SOB, HA, syncope, visual
changes, neck pain, fevers/chills, vomiting/diarrhea, BRBPR,
dysuria. Patient reports she No recent change in medications.
Smokes 1pk/day, drinks 8 cups coffee/day.
.
On day of admission, patient awoke with indigestion and
palpitations. Patient went to previously scheduled OBGYN visit,
where she was noted to have a rapid heart rate, prompting a
referral to OSH ED. At OSH patient was noted to be in a wide
complex tachycardia. She received 6mg + 12 mg IV adenosine
without resolution of tachycardia. She received a bolus of
amiodarone, started on amio drip, and was transferred to [**Hospital1 18**]
for further evaluation and management. In the [**Hospital1 18**] ED, initial
vital signs were BP 113/76 HR 137 RR 16 O2Sat98%/2LNC. EKG
demonstrate regular monomorphic wide complex tacycardia c/w LV
septal VT. Physical exam was significant for comfortable
patient without any distress, otherwise unremarkable. CBC,
Chem7, cardiac enzymes were unremarkable. Patient was continued
on amiodarone drip at 1mg/min. Attempts at conversion were made
with IV adenosine 6mg, then 12mg, as well as verapamil 5mg
without resolution of VT. Patient was given ASA 325mg and
admitted to CCU for further management.
.
On arrival to the floor, patient is comfortable, reports
palpitations, denies CP/SOB. On review of systems, patient
reported 1 month of cough. Review of systems otherwise
negative.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Ulcerative Collitis
- Fibromyalgia
- s/p R ACL / Meniscal Repair ([**10/2105**])
- s/p IUD placement
Social History:
Lives [**Location 6409**] w Husband. [**Name (NI) 1403**] as Bus driver. Drinks 8
cups coffee / day. 30pk-yr history. Denies etoh, illicits.
Family History:
Unknown as she is adopted.
Physical Exam:
ADMISSION EXAM:
VS: 97.1 133 102/74 22 98%RA
GENERAL: Appropriate, comfortable, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVD 6cm w occasional [**Doctor Last Name **] A waves
CARDIAC: rapid irreg irregular, no m/r/g.
LUNGS: Resp unlabored, no accessory muscle use. CTA b/l
ABDOMEN: Soft, obese, nontender.
EXTREMITIES: shallow 1cm abrasion over L shin, draining clear
fluid; no cyanosis/edema
Right: DP 2+ PT 2+ Left: DP 2+ PT 2+
.
DISCHARGE EXAM:
GENERAL: Appropriate, comfortable, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVD 6cm
CARDIAC: RRR, no m/r/g.
LUNGS: Resp unlabored, no accessory muscle use. CTA b/l
ABDOMEN: Soft, obese, nontender.
EXTREMITIES: shallow 1cm abrasion over L shin, draining clear
fluid; no cyanosis/edema
Right: DP 2+ PT 2+ Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2105-11-23**] 03:00PM GLUCOSE-95 UREA N-13 CREAT-0.6 SODIUM-142
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
[**2105-11-23**] 03:00PM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-1.8
[**2105-11-23**] 03:00PM WBC-8.8 RBC-4.19* HGB-13.6 HCT-39.6 MCV-95
MCH-32.4* MCHC-34.3 RDW-14.0
[**2105-11-23**] 03:00PM NEUTS-71.2* LYMPHS-22.7 MONOS-4.1 EOS-1.7
BASOS-0.4
[**2105-11-23**] 03:00PM PLT COUNT-413
[**2105-11-23**] 03:00PM PT-12.7 PTT-25.6 INR(PT)-1.1
.
PERTINENT LABS:
[**2105-11-23**] 03:00PM cTropnT-<0.01
[**2105-11-23**] 10:15PM BLOOD CK-MB-2 cTropnT-<0.01
[**2105-11-23**] 10:15PM BLOOD %HbA1c-5.7 eAG-117
[**2105-11-23**] 10:15PM BLOOD Triglyc-146 HDL-48 CHOL/HD-3.2 LDLcalc-76
.
DISCHARGE LABS:
[**2105-11-24**] 06:24AM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-144
K-4.5 Cl-113* HCO3-24 AnGap-12
[**2105-11-24**] 06:24AM BLOOD Calcium-8.3* Mg-2.0
[**2105-11-24**] 08:23AM BLOOD WBC-7.1 RBC-3.59* Hgb-11.9* Hct-34.5*
MCV-96 MCH-33.3* MCHC-34.6 RDW-14.0 Plt Ct-309
.
CXR [**2105-11-23**]
FINDINGS: In comparison with the outside study of this date, the
cardiac
silhouette remains within normal limits and there is no evidence
of acute
focal pneumonia. The pulmonary vessels are not as sharply seen,
raising the possibility of mild elevation of pulmonary venous
pressure.
.
ECHO:[**2105-11-24**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Normal global and regional biventricular
systolic function.
Brief Hospital Course:
45yo F PMHx w/o known cardiac history presented with new onset
VT, otherwise hemodynamically stable, without clear underlying
etiology.
.
ACTIVE ISSUES:
# Idiopathic Left Ventricular Tachycardia (ILVT): Admitted with
sustained wide monomorphic tachycardia without hemodynamic
compromise. Her VT was felt to be ILVT because of the RBBB
morphology, relatively [**Name2 (NI) 15015**] QRS with needlepoint R in V1 and
lack of structural or ischemic heart disease. She was given
Adenosine and verapamil 5mg in the ED which failed to convert
her rhythm. She was then transferred to the CCU where she
received procainamide with prompt conversion to NSR. An Echo
done the day of discharge did not reveal structural
abnormalities. She was started on verapamil SR 240mg daily for
VT suppression and discharged with the plan to follow up with
Dr. [**Last Name (STitle) **] for an EP study and potential ablation.
.
# Anxiety: Patient was given Ativan to help with anxiety. The
patient was informed that this medication is highly addictive,
so if she continues to have anxiety after the VT ablation, she
should discuss anxiety with her PCP and consider [**Name Initial (PRE) **] long acting
anti-anxiety medication such as an SSRI to prevent anxiety
before it starts and avoid addictive benzodiazepines. She was
instructed that Ativan is a sedative and so she should NOT
drive, operate heavy machinery, or make important decisions
while on this medication.
.
CHRONIC ISSUES:
# Ulcerative Colitis: Diagnosed [**2099**], per patient well
controlled at this time. Continued balsalazide and recommended
outpatient follow up to try and control her UC while also try to
help with tobacco cessation.
.
# Fibromyalgia: On Savella as outpatient. This was briefly as it
may infrequently cause tachycardia. This medication was
restarted because it is highly unlikey to have cuased her VT.
.
# COPD: Had some mild SOB and wheezing while admitted which
improved without nebulizers/inhalers. She sporadically takes
Advair at home.
.
TRANSITIONAL ISSUES:
# Cardiac MRI: Mrs. [**Known lastname 33704**] would likely benefit from cardiac MR
which we would recommend on an outpatient basis to evaluate her
anatomy prior to possible VT ablation.
Medications on Admission:
- Balsalazide 4tabs qAM, 5tabs qPM
- Savella 1 taq [**Hospital1 **]
- Vicodin 1 tab TID prn pain
- Sporadic Advair
Discharge Medications:
1. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
2. balsalazide 750 mg Capsule Sig: Four (4) Capsule PO qAM ().
3. balsalazide 750 mg Capsule Sig: Five (5) Capsule PO qPM ().
4. Savella 100 mg Tablet Sig: One (1) Tablet PO bid ().
5. verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: Please stop this
medication two days prior to your EP procedure.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*0*
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety: Do NOT drive, operate heavy machinery, or
make important decisions while on this medication.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Ventricular Tachycardia
Secondary Diagnoses: COPD, Fibromyalgia, Ulcerative colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 33704**],
It was pleasure taking part in your medical care here at [**Hospital1 18**].
You were admitted to the hopsital because you had a fast heart
rhythm called ventricular tachycardia. You were given a medicine
that stopped this heart rhythm and returned your heart to a
normal rhythm. We started a new medicine called verapamil that
will help to prevent the fast heart rate. You should follow up
with your cardiologist for a procedure called an ablation to
help prevent the arrhythmia in the future.
.
You should NOT drive until your ablation procedure.
.
You were very anxious during your stay. You were given Ativan
to help with anxiety. This medication is highly addictive, so
if you continue to have anxiety after your EP procedure, you
should discuss anxiety with your PCP and consider [**Name Initial (PRE) **] long acting
antianxiety medication that can prevent anxiety before it
starts. This medication can also make you sleepy, so you should
NOT drive, operate heavy machinery, or make important decisions
while on this medication.
.
The following changes were made to your medication regimen:
-START Verapamil 240mg daily - Please take this every day
-Continue taking all other medications as directed
Followup Instructions:
Please follow up with your PCP within one week of discharge.
You will be contact[**Name (NI) **] by the electrophysiologist office to
schedule an ablation within the next 1-2 weeks.
|
[
"729.1",
"427.1",
"496",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8836, 8842
|
5715, 5853
|
305, 312
|
8988, 8988
|
3735, 3735
|
10411, 10596
|
2859, 2887
|
8098, 8813
|
8863, 8863
|
7959, 8075
|
9138, 10388
|
4468, 5692
|
2902, 3356
|
8927, 8967
|
2485, 2546
|
3372, 3716
|
7745, 7933
|
235, 267
|
5868, 7164
|
340, 2375
|
3751, 4217
|
8882, 8906
|
9003, 9114
|
4233, 4452
|
2577, 2681
|
7180, 7724
|
2397, 2465
|
2697, 2843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,989
| 149,481
|
31391
|
Discharge summary
|
report
|
Admission Date: [**2158-10-13**] Discharge Date: [**2158-10-21**]
Date of Birth: [**2081-12-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
This is a 76 year old feamle with PMH of COPD on home O2 of 3L
NC, HTN, CHF, IDDM, PVD with stents to bilateral legs, recently
diagnosed lung adenocarcinoma one year ago and recently found to
have mets to the liver presenting with progressive shortness of
breath requiring non-invasive ventilation at OSH and was
intubated to protect her airway and sent to [**Hospital1 18**] for possible
stenting of the right bronchus intermedius as a means to
potentially improve her baseline shortness of breath. She was
initially admitted to OSH on [**10-9**] with weakness, dyspnea, and
cough. She was started on levofloxacin and seen by pulmonary
for the suspicion that her symptoms are caused by an
obstructive process as a result of the mass.
Past Medical History:
history of diabetes
history of CVA (right hemiparesis with speech changes in [**2133**])
history of osteoarthritis,s/p Rt. hip repair
history of stage 3, chronic kidney disease cr. 2.5
history of asthma
history of colon cancer stage 1,s/p colon resection [**2150**]/p f/up
colonoscopy [**11-13**]- negative for reoccurance
history of pneumonia [**2150**]
history of hypertension
history of hyperlipdemia
history of gall stones s/p ccy
history of cataracts s/p Ou lens
history of neck lipoma s/p excision
Social History:
She is married and lives with her husband. She ambulates
independently. She is a former smoker who quit 15 years ago. She
previously smoked 1.5-2 PPD for 30 years. She denies ETOH use.
Family History:
non contributory
Physical Exam:
GEN: intubated, sedated, but able to respond to commands
HEENT: PERRL, anicteric, dry MM, op without lesions
RESP: Coarse breath sounds b/l with good air movement throughout
CV: RRR, no m/r/g
ABD: nd, +b/s, soft, nt
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Intubated, sedated, responds to yes/no questions with
nodding.
Pertinent Results:
Labs upon admission
[**2158-10-13**] 11:35PM BLOOD WBC-7.2 RBC-3.44* Hgb-8.9* Hct-27.5*
MCV-80* MCH-25.9* MCHC-32.4 RDW-16.7* Plt Ct-157
[**2158-10-18**] 03:13AM BLOOD Neuts-83* Bands-5 Lymphs-2* Monos-2 Eos-1
Baso-0 Atyps-0 Metas-4* Myelos-3*
[**2158-10-18**] 03:13AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2158-10-13**] 11:35PM BLOOD PT-16.7* PTT-23.9 INR(PT)-1.5*
[**2158-10-13**] 11:35PM BLOOD Glucose-195* UreaN-44* Creat-1.9* Na-143
K-5.3* Cl-112* HCO3-16* AnGap-20
[**2158-10-13**] 11:35PM BLOOD ALT-15 AST-12 LD(LDH)-195 AlkPhos-78
TotBili-0.3
[**2158-10-13**] 11:35PM BLOOD Albumin-2.6* Calcium-8.6 Phos-4.0 Mg-1.8
[**2158-10-18**] 03:19PM BLOOD calTIBC-116* VitB12-1665* Folate-10.9
Ferritn-1096* TRF-89*
[**2158-10-17**] 03:48AM BLOOD TSH-2.4
[**2158-10-18**] 03:13AM BLOOD Cortsol-29.8*
[**2158-10-18**] 05:29AM BLOOD Vanco-17.4
[**2158-10-15**] 04:46AM BLOOD Type-ART Rates-16/ PEEP-5 FiO2-50 pO2-72*
pCO2-57* pH-7.15* calTCO2-21 Base XS--9 -ASSIST/CON
Intubat-INTUBATED
[**2158-10-16**] 12:13PM BLOOD Lactate-0.9
[**2158-10-16**] 12:13PM BLOOD O2 Sat-97
[**2158-10-16**] 12:13PM BLOOD freeCa-1.13
Labs most recent to extubation:
[**2158-10-20**] 03:15AM BLOOD WBC-10.9 RBC-3.13* Hgb-8.0* Hct-25.0*
MCV-80* MCH-25.5* MCHC-31.8 RDW-18.4* Plt Ct-189
[**2158-10-18**] 03:13AM BLOOD PT-16.0* PTT-26.2 INR(PT)-1.4*
[**2158-10-20**] 03:15AM BLOOD Glucose-182* UreaN-76* Creat-1.5* Na-144
K-4.1 Cl-114* HCO3-20* AnGap-14
[**2158-10-20**] 03:15AM BLOOD Phos-2.0* Mg-2.1
[**2158-10-20**] 03:22AM BLOOD Type-ART Temp-36.1 pH-7.49*
[**2158-10-19**] 07:47PM BLOOD Type-ART Temp-37.2 Rates-20/0 Tidal V-500
PEEP-5 FiO2-50 pO2-63* pCO2-37 pH-7.37 calTCO2-22 Base XS--3
-ASSIST/CON Intubat-INTUBATED
Imaging:
CT head [**2158-10-19**]: No acute intracranial abnormality. No evidence
of intra or extra-axial lesion in this non-contrast study.
LENIs [**2158-10-18**]: No evidence of DVT in either lower extremity.
CXR [**2158-10-18**]: As compared to the previous radiograph, the most
lateral right aspect of the right hemithorax is missing. With
this limitation in mind, there is no relevant difference as
compared to the previous examination. The monitoring and support
devices are in unchanged position. No evidence of complication,
notably no pneumothorax. Unchanged moderate right hilar
enlargement, with relatively diffuse and many peripheral right
parenchymal opacities. The extent of the pre-existing right
pleural effusion cannot be determined given that it is not
visualized. No abnormality is seen in the left lung. Unchanged
size of the cardiac silhouette.
CT chest w/o contrast [**2158-10-15**]: 1. Large infiltrating right hilar
mass occluding the bronchus intermedius and portions of the
right middle lobe and right lower lobe proximal bronchi. There
is extensive mediastinal adenopathy including a large precarinal
node, which may be contiguous with the dominant hilar mass.
Several suspicious spiculated satellite nodules are also noted
within the right middle and right lower lobe with additional
suspicious left lower lobe nodule. Superimposed presumed
post-obstructive bronchiolitis is seen in the right upper, right
middle and right lower lobes. Known underlying centrilobular
emphysema.
2. Large hypoattenuating right hepatic lesion presumably site of
biopsy-
proven metastases. Several subcutaneous soft tissue nodules are
present which is an atypical location for lung metastases. A
concomitant second malignancy such as melanoma is not excluded.
Several of these lesions are not located at sites typically used
for subcutaneous injections.
3. Small right pleural effusion and trace perihepatic ascites.
4. Atherosclerotic disease including coronary artery
calcifications.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 73953**] was a 76 year old woman with PMH of COPD on home O2
of 3L NC, HTN, CHF, IDDM, PVD with stents to bilateral legs,
recently diagnosed lung adenocarcinoma with mets to the liver
who presented with progressive shortness of breath requiring
non-invasive ventilation at OSH and was intubated to protect her
airway and sent to [**Hospital1 18**] for possible stenting of the right
bronchus intermedius as a means to potentially improve her
baseline shortness of breath.
.
Respiratory failure: The patient had progressive shortness of
breath that required noninvasive ventilation at OSH. She was
electively intubated to protect her airway prior to transfer to
[**Hospital1 18**]. Her repiratory failure was in large part secondary to
collapsed airway secondary to obstruction by her NSCLC. LENIs
were negative. Nebulizers were continued. Theophylline was
held.
.
Lung cancer with airway obstruction: IP was consulted on
admission. Review of CT from 2 weeks prior demonstrated
near-complete collapse of bronchus intermedius. IP performed
bedside bronchoscopy via her ET tube and found now complete
collapse. Because of the anatomy of her occlusion, stenting was
not possible. She received the first of 2 palliative radiation
treatments without improvement in her respiratory status. Due
to progressive oxygen requirements and poor prognosis, decision
was made with her husband and children to change focus of care
to comfort. She was extubated the morning of [**2158-10-21**] in the
company of her extended family. She was given a morphine drip
and passed away at 11:10am. Family denied autopsy. Admitting
notified. [**Location (un) 511**] organ bank was notified prior to
extubation and, but unfortunately patient was not a candidate
due to her malignancy and active post-obstructive pneumonia.
Medications on Admission:
Medications at home:
-Torsemide 20mg daily
-calcium 500mg [**Hospital1 **]
-Zoloft 100mg daily
-iron sulfate 325mg [**Hospital1 **]
-Lipitor 40mg daily
-ranitidine 150mg daily
-clonidine 0.3mg daily
-ASA 81mg daily
-Onglyza 5mg daily
-Lantus 10units in AM
-Levothyroxine 100mcg daily
-Singulair 10mg
-[**Last Name (un) **]-24 300mg daily
-Symbicort 160mcg 2 puffs 2 times daily
-Albuterol
.
Meds on transfer:
-Zoloft 100mg daily
-Levoxyl 100mcg daily
-Onglyza 5mg daily
-Iron sulfate 325mg daily
-Albuterol inh PRN
-Lipitor 40mg daily
-Zantac 150mg daily
-Calcium 500mg [**Hospital1 **]
-MVI daily
-Clonidine 0.3mg daily
-Theophylline 300mg daily
-Lantus 10 units daily
-Singulair 10mg daily
-Oxazepam 10mg HS
-Ativan 0.5mg TID PRN
-ASA 81mg daily
-Levaquin 500mg IV daily
-Duonebs four times daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary collapse
Acute on chronic respiratory failure
Stage IV pulmonary non-small cell lung cancer with bronchial
obstruction
Post-obstructive pneumonia
Hypotension
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2158-10-21**]
|
[
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"493.20",
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"440.20",
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icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.72",
"92.29"
] |
icd9pcs
|
[
[
[]
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] |
8822, 8831
|
6087, 7940
|
345, 357
|
9048, 9057
|
2267, 6064
|
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286, 307
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385, 1124
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1146, 1653
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1669, 1855
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8375, 8767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,402
| 197,871
|
8087
|
Discharge summary
|
report
|
Admission Date: [**2129-8-12**] Discharge Date: [**2129-8-18**]
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
transferred for hypotension, CHF, and acute kidney injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 85yo male with a h/o CHF, CAD s/p CABGx2,
severe MR, HTN, hyperlipidemia, and CKD, who was tranfered to
[**Hospital1 18**] from [**Hospital6 17032**] in the setting of CHF
exacerbation and acute on chronic kidney disease for possible
hemodialysis. The patient was briefly admitted to NVMC from
[**Date range (1) 28875**] for chest pain, then readmitted after presenting
again on [**2129-8-6**]. At time of second admission, he c/o
intermittent sharp left arm pain, blurred vision in his right
eye, and a fall at his home. In ED he was found to be
hypotensive with SBP in the 70s. He was given 3 boluses of
250mL NS, without effect. He was started on dopamine in the ED,
but developed chest pain and the dopamine was stopped. He was
then admitted to the ICU for further management. He was noted to
have Cr of 3.24, elevated above his baseline (1.3-1.4 per
notes). Other notable labs included a troponin of 0.1 on
admission [**2129-8-6**], which peaked at 0.31 on [**2129-8-7**] and had
decreased to 0.27 on [**2129-8-8**].
During that admission he was seen by nephrology and cardiology,
and was initially felt to be volume depleted. His Lasix and
Cozaar were held, and he was gently hydrated with IVF, including
a bicarb drip. His Cr trended down to 2.16 on [**2129-8-8**], and his
BP was up to the 90s. However he then developed worsening CHF,
with CXR demonstrating worsening pulmonary vascular congestion
and an enlarging left-sided pleural effusion. An echo revealed
normal LVEF (58%), severe MR, and moderate pulmonary HTN
(pulmonary artery systolic pressure in mid-50s). Of note, the
patient had a cardiac cath done about one month prior, which
revealed severe diffuse left main disease with 75% ostial and
95% proximal LAD lesions, as well as diffuse disease and distal
occlusion of native RCA. Plan was for medical management.
.
On [**2129-8-10**] patient was noted to have decreasing urine output, as
well as rising Cr. He did not respond to a bolus of IV Lasix,
was started on a Lasix gtt at 10mg/hr, and his Lasix had to be
titrated up to 20mg/hr. His BUN/Cr continued to rise, his
sodium levels were decreasing, and he developed nausea and
vomiting suggestive of uremic symptoms. Given his worsening
renal function, he was transferred to [**Hospital1 18**] for possible
hemodialysis. Prior to transfer, he was started on a dobutamine
drip.
.
On arrival to the [**Hospital1 18**] ICU patient was placed on monitoring and
resumed on a dobutamine drip and furosemide drip. His dobutamine
drip was shortly stopped as his BPs were stable, and his Lasix
drip has been titrated down to 5mg/hr. He was initially
admitted to the MICU, then transferred to the CCU for management
of his CHF. Since admission to [**Hospital1 18**], he has been diuresing
well, with a net fluid balance of negative 2.26 liters. His BP
remains stable off pressors. He has still been hypoxic,
requiring a high-flow oxygen face mask with FiO2 of 100% to
maintain O2 sats in the mid-90s. Renal is following, and felt
the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] may be secondary to cardiorenal physiology.
.
On admission to the CCU, the patient c/o SOB and
lightheadedness, but denies any CP, abdominal pain, N/V/D,
constipation, arthralgias, or myalgias. No recent fever or
chills. All other review of systems negative, although the
patient does not provide much history on questioning. Prior to
his recent hospitalizations, he had been living alone. He
reports he was able to climb stairs, but would develop some
dyspnea on exertion. He denies orthopnea or PND. He does report
leg pain on walking, although he cannot fully describe the
quality of the pain. He has bilateral lower extremity edema at
baseline, per his previous reports. He denies any episodes of
syncope.
Past Medical History:
1. Congestive heart failure (LVEF 58% by recent echo)
2. CAD (recent cardiac cath demonstrated severe diffuse left
main disease with 75% ostial and 95% proximal LAD lesions,
native RCA diffusely diseased and occluded distally)
3. HTN
4. Hyperlipidemia
5. Pulmonary HTN
6. Severe mitral regurgitation
7. Diverticulitis
8. Gastric AV malformation
9. Chronic kidney disease
10. PVD with aortoiliac aneurysm
11. Second degree AV block
12. Tachybrady syndrome
13. Anemia
14. Ulcerative colitis
15. h/o GI bleed
16. Rheumatoid arthritis
17. Central retinal artery occlusion, right eye.
18. ? Remote COPD
CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, ? Controlled
DM2
.
CARDIAC HISTORY:
-CABG: s/p CABG [**2097**], repeat CABG [**2121**] with LIMA to LAD, reverse
SVG to posterolateral branch RCA, reverse SVG to OM branch of
circumflex
Social History:
Patient lives alone. His neighbor is his healthcare proxy. [**Name (NI) **]
has a remote smoking history, quit over 30 years ago. Reports
drinking occasionally, once per week. No illicit drug use.
Family History:
Non-contributory. No known family history of CAD, CHF, or kidney
disease.
Physical Exam:
VS: T=96.3 BP=99/68 HR=87 RR=17 O2 sat= 97% on high-flow oxygen
face mask (FiO2 100%)
GENERAL: Thin, cachectic appearing male in NAD. Frequently
falling asleep, but able to answer most questions appropriately.
Oriented to person, hospital setting, and year. Unable to state
name of hospital.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple, with JVD just under level of mandible.
CARDIAC: Irregularly irregular rhythm. Systolic ejection murmur
heard best at left lower sternal border. Holosystolic murmur
heard best at apex and radiating to axilla. PMI located in 5th
intercostal space, slightly left of midclavicular line.
LUNGS: Respirations unlabored, no accessory muscle use at time
of exam. Diminished sounds left lung about half-way up lung
fields. Diminished sounds right base. Crackles present
bilaterally.
ABDOMEN: Soft, NTND. No HSM. Bowel sounds present.
EXTREMITIES: 3+ edema of lower extremities bilaterally to level
of knee.
SKIN: No rashes noted.
PULSES:
Right: Radial 2+ Femoral 2+
Left: Radial 2+ Femoral 2+
Pertinent Results:
[**2129-8-12**] 08:32PM GLUCOSE-129* UREA N-73* CREAT-3.1*#
SODIUM-134 POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-23 ANION GAP-21*
[**2129-8-12**] 08:32PM CALCIUM-8.1* PHOSPHATE-5.8* MAGNESIUM-2.5
[**2129-8-12**] 08:32PM WBC-10.9 RBC-3.61* HGB-10.7* HCT-33.2* MCV-92
MCH-29.5 MCHC-32.1 RDW-18.0*
[**2129-8-12**] 08:32PM PLT COUNT-184
[**2129-8-12**] 08:32PM PT-14.8* PTT-30.9 INR(PT)-1.3*
[**2129-8-18**] 04:25AM BLOOD WBC-8.9 RBC-3.47* Hgb-10.3* Hct-31.8*
MCV-92 MCH-29.6 MCHC-32.3 RDW-17.7* Plt Ct-163
[**2129-8-18**] 04:25AM BLOOD Neuts-86.4* Lymphs-9.3* Monos-3.7 Eos-0.3
Baso-0.2
[**2129-8-18**] 04:25AM BLOOD PT-14.8* PTT-33.1 INR(PT)-1.3*
[**2129-8-18**] 04:25AM BLOOD Glucose-175* UreaN-89* Creat-2.3* Na-139
K-4.3 Cl-91* HCO3-34* AnGap-18
[**2129-8-18**] 04:25AM BLOOD ALT-22 AST-28 AlkPhos-75 TotBili-1.5
[**2129-8-18**] 04:25AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.8 Mg-2.2
[**2129-8-13**] 08:19PM BLOOD Cortsol-47.6*
ECHO [**8-13**]: The left atrium is elongated. The estimated right
atrial pressure is 0-10mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Diastolic function could
not be assessed. The right ventricular cavity is markedly
dilated with mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, anteriorly directed
jet of Moderate to severe (3+) mitral regurgitation is seen. Due
to the eccentric nature of the regurgitant jet, its severity may
be significantly underestimated (Coanda effect). The tricuspid
valve leaflets are mildly thickened. There is severe pulmonary
artery systolic hypertension.
IMPRESSION: Mild concentric left ventricular hypertrophy with
preserved function. Marked right ventricular dilation with mild
hypokinesis. Severe pulmonary hypertension. Moderate to severe
eccentric mitral regurgitation.
CXR [**2129-8-16**]: As compared to the previous radiograph, there is
unchanged moderate cardiomegaly and bilateral pleural effusion,
left more than right. Unchanged evidence of moderate pulmonary
edema. No interval appearance of focal parenchymal opacity
suggesting pneumonia. No pneumothorax.
RENAL U/S [**2129-8-13**]: Atrophic cortices with increased echogenicity
of both kidneys consistent with medical renal disease.
EKG [**2129-8-15**]: Atrial fibrillation with modest ventricular
response. Right ventricular conduction delay. Borderline low
limb voltage. Consider dilated ventricle given preserved
precordial limb lead voltages. Compared to the previous tracing
of [**2129-8-14**] both tracings may represent atrial fibrillation.
Recommend obtaining another tracing at double standardization to
detect possible low amplitude P waves which would indicate
possible regular atrial activity.
Brief Hospital Course:
85yo male with a h/o CHF, CAD s/p CABGx2, severe MR, HTN,
hyperlipidemia, and CKD, admitted from OSH with acute on chronic
kidney injury in setting of recent hypotension and worsening
pulmonary edema.
#CHF: The patient developed worsening pulmonary edema in the
setting of fluid resuscitation for hypotension at OSH. He
initially had a poor response to diuretics at OSH, and was
transferred to [**Hospital1 18**] for possible hemodialysis. However he was
diuresing well with good urine output on a Lasix gtt at 5mg/hr
upon admission to the CCU. His dobutamine drip was stopped, and
his blood pressure tolerated this diuresis off pressors. The
patient initially remained hypoxic, requiring a high-flow oxygen
face mask to maintain O2 sats in the mid-90s. However, his
oxygen was gradually weaned to delivery via nasal cannula. His
lung exam was remarkable for diminished breath sounds and
prominent crackles bilaterally, and CXR revealed bilateral
pleural effusions as well as pulmonary vascular congestion. A
repeat TTE [**2129-8-13**] revealed LVH with preserved LVEF but severe
MR, pulmonary HTN, and marked RV dilation with mild hypokinesis.
The patient was continued on Lasix gtt, then transitioned to
Lasix IV boluses with close monitoring of volume status,
hemodynamics, and electrolytes. He appeared euvolemic on the
day of discharge and was on a stable regimen of metalazone and
lasix. His daily weights will need to be followed closely, with
adjustments made to his lasix as needed.
# Acute on chronic kidney disease: Cr was elevated above
baseline on admission (1.3-1.4), and peaked at 3.2 on [**2129-8-13**].
Renal consulted, and felt patient likely had [**Last Name (un) **] secondary to
renal hypoperfusion in setting of poor forward flow. We also
considerd the possibility that patient developed ATN during
admission to OSH when he was hypotensive to the 70s. Continued
gentle diuresis, with goal to remove about 1 liter of fluid per
day. Over the course of admission, the patient's Cr trended
down and stabilized around 2.5-2.7. A renal ultrasound revealed
findings consistent with medical renal disease. Losartan was
stopped. His creatinine was stable at 2.3 on the day of
discharge. He will need follow-up with a nephrologist in two to
four weeks. We attempted to arrange follow-up at the [**Hospital1 18**] but
he preferred a nephrologist closer to his home.
# CAD: S/p CABG x2, with most recent surgery [**2121**]. Per outside
hospital reports, patient had recent cardiac cath that revealed
severe diffuse left main disease with 75% ostial and 95%
proximal LAD lesions, as well as diffuse disease and distal
occlusion of native RCA. TTE [**2129-8-13**] reveals preserved LVEF and
severe MR. [**Name13 (STitle) **] was continued on aspirin and metoprolol.
# Anemia: Previous work-ups have revealed anemia likely
secondary to iron deficiency, and patient has history of GI
bleeds. He was continued on his outpatient dose of ferrous
sulfate, and his HCT remained stable during admission.
# Central retinal artery occlusion right eye: Occured [**2129-8-9**]
during patient's admission to OSH. Seen by ophtho at OSH, who
felt occlusion likely secondary to cholesterol emboli, and that
no further treatment was indicated at this time. Carotid US did
not reveal significant stenosis. Patient should follow up with
ophtho as outpatient for further evaluation.
# Rheumatoid arthritis: Continued Prednisone 20mg PO daily
(patient's home dose).
# Ulcerative colitis: Continued Mesalamine.
PROPHYLAXIS: He received DVT prophylaxis with SC herapin. His
pain management was with Tylenol prn pain. His bowel regimen
was with Colace and Senna.
During his admission, nutrition, speech and swallow, PT, social
work, and case management were involved. Of note, he has no
living family and social work will need to be involved in his
continued management and social services after discharge from
rehab.
Medications on Admission:
HOME MEDICATIONS:
1. Aspirin 81mg PO daily
2. Lasix 20mg PO daily
3. Cozaar 25mg PO daily
4. Asacol 800mg 3 times per day
5. MVI 1 tab PO daily
6. Ferrous sulfate 325mg PO daily
7. Prednisone 20mg PO daily
8. Propranolol 2.5mg PO BID
9. Ibuprofen prn pain
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1)
Tablet PO DAILY (Daily).
3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u
Injection [**Hospital1 **] (2 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours) for 3 days: last day [**8-21**].
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO TID (3
times a day).
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Acute on chronic diastolic heart failure
Coronary artery disease
Urinary tract infection
Ulcerative colitis
Discharge Condition:
Alert and oriented to person and place.
Able to stand with assistance but unable to ambulate.
Discharge Instructions:
You were admitted for acute heart failure and shortness of
breath. We removed fluid from your body and your heart function
and breathing improved. It will be important for you to closely
watch your diet, avoid salty foods, and take your medications.
Your medication changes include:
Start Lasix 80 mg daily
Start Metolazone 2.5 mg daily
Start Metoprolol 6.25mg three times per day
Stop Propranolol
Stop Cozaar
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
It is important that you keep all of your doctor's appointments.
Followup Instructions:
Please schedule a follow-up appointment with your PCP and your
cardiologist within one week. You also need to follow-up with a
nephrologist and an opthalmologist within two weeks, and your
PCP will need to arrange this.
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,717
| 122,614
|
41688
|
Discharge summary
|
report
|
Admission Date: [**2105-9-2**] Discharge Date: [**2105-9-11**]
Date of Birth: [**2034-4-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Intermittent episodes of chest burning
Major Surgical or Invasive Procedure:
[**2105-9-3**] Coronary artery bypass grafting times 4 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein graft to the right coronary artery,
second obtuse marginal artery and diagonal artery
[**2105-9-2**] Cardiac catheterization
[**2105-9-5**] Cardiac catheterization
History of Present Illness:
71 year old with CAD status post MI treated with thrombolytics
at [**Hospital1 112**] in [**2091**]. Has not seen anyone for at least 5 years. In the
beginning of [**Month (only) 216**] he began to have intermittent episodes of
chest burning which woke him from sleep and occasionally on
exertion while mowing grass or walking his dog. An
echocardiogram on [**2105-8-17**] showed systolic function was normal
with a LVEF greater than 55%. Nuclear imaging on [**2105-8-19**]
demonstrated mildly reduced systolic function with a medium
sized inferolateral defect which is mostly reversible,
consistent with perhaps a small inferoapical infarction and a
larger area of adjacent inferolateral ischemia.
Past Medical History:
Coronary artery disease s/p MI and TPA at [**Hospital1 112**] in [**2-/2092**]
Essential hypertension
Hypercholesterolemia
Social History:
Lives with: wife.
Occupation: Retired teacher. Retired military.
Cigarettes: Smoked no [] yes [x] Quit cigars after MI
ETOH: [**2-2**] drinks/week [x] 1-1.5 Glasses wine daily
Illicit drug use: none
Exercise: Walks up to 2 miles daily
Family History:
Father CVA at 70 year old
Physical Exam:
T98 Pulse: 54 Resp: 18 O2 sat:
B/P Right: 119/89 Left: 122/92
Height: 6 feet 2 inches
Weight: 235 lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] MMM- oropharnyx-pink w/o lesions
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
Neuro: Grossly intact [x] nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: cath Left: 2+
Carotid Bruit no
Pertinent Results:
[**2105-9-2**] 03:00PM BLOOD WBC-5.8 RBC-4.42* Hgb-14.1 Hct-39.6*
MCV-90 MCH-32.0 MCHC-35.7* RDW-12.7 Plt Ct-143*
[**2105-9-2**] 03:00PM BLOOD PT-12.4 INR(PT)-1.0
[**2105-9-2**] 03:00PM BLOOD Plt Ct-143*
[**2105-9-2**] 03:00PM BLOOD Glucose-125* UreaN-19 Creat-0.7 Na-137
K-3.7 Cl-105 HCO3-27 AnGap-9
[**2105-9-2**] 03:00PM BLOOD ALT-19 AST-19 AlkPhos-38* TotBili-0.7
[**2105-9-2**] 03:00PM BLOOD ALT-19 AST-19 AlkPhos-38* TotBili-0.7
[**2105-9-2**] 03:00PM BLOOD %HbA1c-5.6 eAG-114
.
[**2105-9-5**] CArdiac Catheterization:
1. Native three vessel coronary artery disease.
2. Patent LIMA-LAD, SVG-OM, SVG-Diag and SVG-RCA.
.
[**2105-9-10**] Lower Extremity Ultrasound:
1. Deep vein thrombosis identified within the right calf within
the posterior tibial and within the peroneal veins. 2. Deep vein
thrombosis also identified within the left calf in the posterior
tibial veins.
.
[**2105-9-11**] 06:20AM BLOOD WBC-10.2 RBC-3.38* Hgb-10.7* Hct-31.1*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.1 Plt Ct-195#
[**2105-9-8**] 06:45AM BLOOD WBC-7.8 RBC-3.83* Hgb-12.3* Hct-34.5*
MCV-90 MCH-32.1* MCHC-35.7* RDW-13.6 Plt Ct-129*
[**2105-9-7**] 02:27AM BLOOD WBC-8.5 RBC-3.59* Hgb-12.0* Hct-32.7*
MCV-91 MCH-33.5* MCHC-36.8* RDW-12.8 Plt Ct-132*
[**2105-9-6**] 05:55AM BLOOD WBC-10.7 RBC-3.59* Hgb-12.0* Hct-32.7*
MCV-91 MCH-33.6* MCHC-36.8* RDW-12.8 Plt Ct-113*
[**2105-9-11**] 06:20AM BLOOD PT-20.8* INR(PT)-1.9*
[**2105-9-10**] 06:30AM BLOOD PT-18.8* INR(PT)-1.7*
[**2105-9-9**] 06:50AM BLOOD PT-17.5* INR(PT)-1.6*
[**2105-9-8**] 06:45AM BLOOD PT-14.4* INR(PT)-1.2*
[**2105-9-7**] 02:27AM BLOOD PT-11.9 INR(PT)-1.0
[**2105-9-11**] 06:20AM BLOOD Glucose-115* UreaN-21* Creat-0.8 Na-136
K-4.1 Cl-100 HCO3-28 AnGap-12
[**2105-9-9**] 06:50AM BLOOD Glucose-90 UreaN-27* Creat-0.7 Na-136
K-4.3 Cl-100 HCO3-29 AnGap-11
[**2105-9-8**] 06:45AM BLOOD Glucose-91 UreaN-26* Creat-0.8 Na-138
K-4.3 Cl-100 HCO3-29 AnGap-13
[**2105-9-7**] 02:27AM BLOOD Glucose-100 UreaN-29* Creat-0.9 Na-137
K-4.3 Cl-98 HCO3-28 AnGap-15
[**2105-9-6**] 05:55AM BLOOD Glucose-134* UreaN-27* Creat-0.9 Na-135
K-4.9 Cl-100 HCO3-28 AnGap-12
[**2105-9-5**] 09:31AM BLOOD UreaN-23* Creat-1.0 Na-135 K-3.8 Cl-100
HCO3-21* AnGap-18
[**2105-9-9**] 06:50AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1
Brief Hospital Course:
He presented for cardiac catheterization for evaluation of chest
discomfort that revealed severe coronary artery disease. He was
admitted following catheterization for medical management and
underwent pre-operative work-up. On [**9-3**] he was brought to the
operating room and underwent a coronary artery bypass graft x 4.
Please see operative note 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 started on beta-blockers and diuretics and gently diuresed
towards his pre-op weight. He did develop atrial fibrillation
post operatively which he was started on amiodarone. Later on
this day he was transferred to the step-down floor for further
recovery. On post operative day two he had a ventricular
fibrillation arrest that after further review was related to R
on T with pacer firing. He was resuscitated and brought to the
intensive care unit. He self extubated self on transport to
intensive care unit, and remained extubated. Electrophysiology
was consulted for evaluation. He underwent cardiac
catheterization that day to evaluate coronaries and grafts which
revealed all grafts patent. In further evaluation
electrophysiology interrogated epicardial wires that resulted in
second ventricular fibrillation. He was resuscitated and
epicardial wires were removed with no further ventricular
fibrillation. He did not require intubation and remained
neurologically intact. He remained in the intensive care unit
for monitoring and on [**9-7**] was transferred to the floor for the
remainder of his care. His betablockers were adjusted for heart
rate management and he continued on amiodarone for his atrial
fibrillation. He was subsequently diagnosed with bilateral deep
vein thromboses seconardy to complaints of bilateral calf pain.
Given that his INR was subtherapeutic, he was started on
Enoxaparin. Given atrial fibrillation and DVT, Warfarin was
dosed for a goal INR between 2.0 to 3.0. He was medically
cleared for discharge home with services on [**2105-9-11**]. At
discharge, he will remain on Enoxaparin until his INR reaches
2.0 or greater. Prior to discharge, arrangements were made with
Dr. [**Last Name (STitle) 90611**] and the [**Hospital 46**] [**Hospital 197**] Clinic to monitor INR as an
outpatient.
Medications on Admission:
ATENOLOL - 25 mg once a day
LISINOPRIL - 5 mg once a day
SIMVASTATIN - 20 mg at bedtime
ASPIRIN - 162 mg once a day
COENZYME Q10 - 200 mg once a day
MULTIVITAMIN daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400 mg twice a day until [**9-13**] then decrease
to 400 mg once a day until [**9-20**] then decrease to 200 mg daily
until follow up with cardiologist .
Disp:*70 Tablet(s)* Refills:*0*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day:
dose 10 mg due to amiodarone please discuss with cardiologist
dose adjustment when off amiodarone .
Disp:*30 Tablet(s)* Refills:*1*
7. Lopressor 100 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*1*
8. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication A fib and DVT
Goal INR 2.0 - 3.0
First draw [**2105-9-14**]
Please send results to Dr [**Last Name (STitle) 90611**] office # [**Telephone/Fax (1) 82558**] fax #
[**Telephone/Fax (1) 90612**] - please check INR monday, wednesday and friday for
two weeks then decrease frequency per Dr [**Last Name (STitle) 90611**] (please no
weekend INR checks)
9. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Titrate for goal INR between 2.0 - 3.0.
Disp:*60 Tablet(s)* Refills:*2*
10. enoxaparin 100 mg/mL Syringe Sig: One (1) mL Subcutaneous
Q12H (every 12 hours) for 3 days: Please discontinue when INR
reaches 2.0 or greater.
Disp:*3 day supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Postop Atrial Fibrillation
Postop Ventricular fibrillation arrest
Hypertension
Hypercholesterolemia
Postop Deep Vein Thrombosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol and ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
.
Labs: PT/INR for Coumadin ?????? indication A fib/DVT
Goal INR 2.0 - 3.0
First draw [**2105-9-14**]
Please send results to Dr [**Last Name (STitle) 90611**] office # [**Telephone/Fax (1) 82558**] fax #
[**Telephone/Fax (1) 90612**] - please check INR monday, wednesday and friday for
two weeks then decrease frequency per Dr [**Last Name (STitle) 90611**] (please no
weekend INR checks)
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**10-8**] at 1:00pm,
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] on [**9-28**] at 2:00pm
Wound check appointment at 9/20 at 10:30 am - at Cardiac surgery
office [**Hospital **] medical building [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) 60611**] in [**3-31**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A fib/DVT
Goal INR 2.0 - 3.0
First draw [**2105-9-14**]
Please send results to Dr [**Last Name (STitle) 90611**] office # [**Telephone/Fax (1) 82558**] fax #
[**Telephone/Fax (1) 90612**] - please check INR monday, wednesday and friday for
two weeks then decrease frequency per Dr [**Last Name (STitle) 90611**] (please no
weekend INR checks)
Completed by:[**2105-9-11**]
|
[
"412",
"V17.3",
"287.5",
"453.41",
"453.42",
"V15.82",
"427.41",
"414.2",
"427.5",
"401.9",
"285.9",
"V58.61",
"272.0",
"997.1",
"E878.2",
"411.1",
"997.2",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.57",
"88.56",
"39.61",
"36.13",
"99.60",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
9261, 9313
|
4810, 7225
|
348, 670
|
9546, 9775
|
2553, 4787
|
11004, 12081
|
1816, 1844
|
7445, 9238
|
9334, 9525
|
7251, 7422
|
9799, 10981
|
1859, 2534
|
270, 310
|
698, 1400
|
1422, 1546
|
1562, 1800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,060
| 190,142
|
32243
|
Discharge summary
|
report
|
Admission Date: [**2178-1-5**] Discharge Date: [**2178-1-11**]
Date of Birth: [**2128-2-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
s/p MV Repair (34mm annuloplasty band) [**2178-1-6**]
History of Present Illness:
49 yo male found to have a heart murmur a few months ago. Two
echos showed [**2-3**]+ MR with a ? of chordal tear. Relatively
asymptomatic ;now referred for surgery.
Past Medical History:
MR
[**First Name (Titles) **]
[**Last Name (Titles) 75388**] delayed
elev. lipids
double vision left eye
PSH: pectus repairs x2 ( age 5 and age 16)
repair bil. gynecomastia
tonsillectomy
Social History:
works in housekeeping/laundry
never used tobacco
no ETOH
lives with parents
Family History:
brother had [**Name (NI) 1291**] at 36
uncle died with CABG at 63;father with thoracic aneurysm
Physical Exam:
NAD;[**Name (NI) 75388**] disabled;anxious
5'9" 171#
hirsute;well healed chest scars
HR 80 right 123/71 left 123/77
99% RA sat
HEENT unremarkable
supple/full ROM
CTAB; pectus excavatum present
RRR 4/6 SEM best heard at LLSB
soft, NT, ND, +BS
extrems warm, well-perfused, no edema or varicosities noted
neuro grossly intact;[**Name (NI) 75388**] delayed
murmur transmitted to both carotids
Pertinent Results:
[**2178-1-10**] 07:35AM BLOOD WBC-11.2* RBC-2.91* Hgb-8.7* Hct-25.5*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.7 Plt Ct-155
[**2178-1-10**] 07:35AM BLOOD Plt Ct-155
[**2178-1-10**] 07:35AM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-140
K-3.5 Cl-103 HCO3-29 AnGap-12
[**2178-1-9**] 12:29PM BLOOD TotBili-0.7 DirBili-0.2 IndBili-0.5
[**2178-1-9**] 02:32AM BLOOD ALT-36 AST-48* AlkPhos-52 Amylase-33
TotBili-0.6
[**2178-1-10**] 07:35AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.2
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 75389**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75390**] (Complete)
Done [**2178-1-6**] at 1:42:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2128-2-27**]
Age (years): 49 M Hgt (in): 69
BP (mm Hg): 124/74 Wgt (lb): 175
HR (bpm): 84 BSA (m2): 1.95 m2
Indication: Intra-op TEE for MVR
ICD-9 Codes: 424.0, 786.05
Test Information
Date/Time: [**2178-1-6**] at 13:42 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW210-0:0 Machine: [**Numeric Identifier 3652**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: 0.29 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Arch: 2.1 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Findings
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Partial mitral leaflet flail. Torn mitral chordae.
No MS. Eccentric MR jet. Effective regurgitant orifice is
>=0.40cm2. MR vena contracta is >=0.7cm Severe (4+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is markedly dilated. No atrial septal defect
is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 5. There is
partial mitral leaflet flail of P2 scallop. Torn mitral chordae
are present. An eccentric, anterior directed jet of The
effective regurgitant orifice is >=0.40cm2 The mitral
regurgitation vena contracta is >=0.7cm. Severe (4+) mitral
regurgitation is seen.
6. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine. Pt was
in sinus/ junctional tachycardia
1. Biventricular function is preserved
2. A mitral annuloplasty ring is seen well seated. Trivial MR is
noted. Some [**Male First Name (un) **] is noted that significantly improved with Beta
Blockade and volume infusion. Due to poor echo windows an LVOT
gradient was not obtained.
3. Other findings are unchanged
4. Aorta is intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2178-1-12**] 09:49
Conclusions
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) There is no ventricular septal defect. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. A mitral
valve annuloplasty ring is present. The mitral annular ring
appears well seated and is not obstructing flow. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2178-1-6**], the mitral valve has been repaired; trace
mitral regurgitation is present.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2178-1-8**] 4:52 AM
CHEST (PORTABLE AP)
Reason: interval evaluation
[**Hospital 93**] MEDICAL CONDITION:
49 year old man s/p MVR
REASON FOR THIS EXAMINATION:
interval evaluation
INDICATION: 49-year-old man status post mitral valve replacement
interval evaluation.
COMPARISON: [**2178-1-7**] at 6:15 p.m., approximately 11
hours prior to the current study.
SINGLE VIEW, CHEST: Unchanged loculated pleural effusion in the
right minor fissure. Bibasilar atelectasis, unchanged. Small
amount of mediastinal air is unchanged. Mild interstitial edema
and vascular engorgement slightly more prominent compared to
prior study. Hilar contour is within normal limits.
Cardiomediastinal silhouette is unchanged. No pneumothorax.
IMPRESSION: Slight interval progression of vascular engorgement
with mild interstitial edema. Unchanged right loculated pleural
effusion and bibasilar atelectasis and mediastinal air.
DL
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2178-1-9**] 10:15 AM
?????? [**2172**] CareGroup IS.
Brief Hospital Course:
Admitted [**1-5**] after his surgery cancelled for an emergency case.
Underwent MVrepair via sternotomy on [**1-6**] after mini-right
thoracotomy approach was abandoned due to lung
adhesions.Transferred to the CVICU in stable condition on
titrated phenylephrine and propofol drips.Extubated early in the
AM POD #1. Chest tubes and pacing removed without incident and
transferred to the floor on POD #3. Beta blockade titrated and
gently diuresed toward his preoperative weight.Continued to make
good progress and cleared for discharge to home with services on
POD #5. Pt. is to make all follow up appts. as per discharge
instructions.
Medications on Admission:
lisinopril 20 mg/HCTZ 25 mg daily
paxil 40 mg daily
zocor 80 mg daily
ASA 81 mg 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. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
3. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
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:*2*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-8**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Paroxetine HCl 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
vna carenetwork
Discharge Diagnosis:
Mitral regurgitation s/p MV repair
[**Month/Day (3) 75388**] delayed
double-vision left eye
[**Month/Day (3) **]
elev.chol.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds.
Call our office for sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1159**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 11493**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. [**Telephone/Fax (1) 170**]
Completed by:[**2178-1-12**]
|
[
"424.0",
"783.40",
"272.0",
"401.9",
"V64.42",
"285.9",
"458.29",
"754.89",
"511.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"88.72",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
10733, 10779
|
8776, 9412
|
333, 389
|
10947, 10955
|
1432, 7522
|
11283, 11563
|
905, 1002
|
9548, 10710
|
7559, 7583
|
10800, 10926
|
9438, 9525
|
10979, 11260
|
1017, 1413
|
281, 295
|
7612, 8753
|
417, 584
|
606, 796
|
812, 889
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,614
| 109,642
|
22203
|
Discharge summary
|
report
|
Admission Date: [**2152-8-7**] Discharge Date: [**2152-8-9**]
Service: MED
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 57942**] is an 83 year old
lady with a history of thyroid cancer metastatic to lung with
status post thyroidectomy in [**2142**] and multiple episodes of
radioactive iodine treatment which she has subsequently
failed and has extensive localization in the neck. She is
also status post Guillain-[**Location (un) **] syndrome with diaphragmatic
paralysis which initially required tracheostomy in [**2142**]. She
required another tracheostomy in [**2145**] for recurrent
pneumonias which she has kept until this time. However, she
had progressive difficulty with trach changes and
bronchoscopy on the day of admission showed 100 percent
obstruction of the trachea above the tracheostomy tube by a
mass consistent with a tumor. The patient has not been able
to phonate since [**2151-9-22**] when her current
tracheostomy tube was placed. She additionally requires
ventilatory support at night and is on trach collar during
the day.
PAST MEDICAL HISTORY: Thyroid cancer, lung metastases, bone
metastases, history of cataracts, atrial fibrillation on
Coumadin, ulcerative colitis, history of bilateral DVTs
status post [**Location (un) 260**] filter placement in [**2142**], mitral
regurgitation, asthma, history of Guillain-[**Location (un) **] with right
hemidiaphragm paralysis, status post PEG which has been
removed, status post thyroidectomy in [**2143**], ? borderline
diabetes mellitus, hypertension, cataracts, ocular migraines.
MEDICATIONS AT HOME: Albuterol nebs q4h prn, Asacol 800 mg
po qd, Coumadin 2.5 mg po qd, Lovenox, Cartia-XT 240 qd,
Zantac 150 mg po qd, K-Dur 20 mEq po qd, Levoxyl 137 mcg po
qd, prednisone 5 mg po qd.
ALLERGIES: Penicillin, iodine and multiple medication
sensitivities.
INITIAL PHYSICAL EXAMINATION: The patient was afebrile.
Heart rate was in the 90's and atrial fibrillation. Blood
pressure was 136/66. Respiratory rate was 25. O2 sat was 99
percent on trach collar. Initial exam - alert, ill-appearing
female in no apparent distress. Lungs - adequate breath
sounds bilaterally. Heart - irregularly irregular. Abdomen
was soft with positive bowel sounds, nontender. Extremities
are warm with no edema. Neuro - grossly intact.
LABORATORY: White count was 5.2 with a hematocrit of 39.1,
potassium 4.1, BUN and creatinine 10 and 0.7. INR was 1.2.
EKG showed atrial fibrillation at 97 and chest x-ray shows
multiple pulmonary metastases.
BRIEF HOSPITAL COURSE: Mrs. [**Known lastname 57942**] was admitted to the
hospital to the Intensive Care Unit overnight because of her
requirement for ventilatory support. On hospital day #2, she
was taken to the Operating Room with Interventional
Pulmonology where she underwent flexible and rigid
bronchoscopy. They saw the upper trachea 100 percent
obstructed by tumor. This was excised and debrided and a No.
4 Shiley tracheostomy tube was placed. There were no
complications. The patient tolerated the procedure well. She
was transferred back to the Intensive Care Unit, ventilated
by her tracheostomy. On postoperative day #1, she was weaned
back to trach collar and deemed stable for discharge to home.
DISCHARGE DIAGNOSIS: Tracheal obstruction status post
excision, debridement and tracheostomy change.
DISCHARGE MEDICATIONS: Same as admission medications.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] in one
to two weeks.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**]
Dictated By:[**Last Name (NamePattern1) 13030**]
MEDQUIST36
D: [**2152-8-9**] 09:13:55
T: [**2152-8-9**] 09:55:59
Job#: [**Job Number 57943**]
|
[
"V13.8",
"493.90",
"V12.51",
"193",
"427.31",
"556.9",
"198.5",
"197.3",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"31.42",
"31.5",
"96.71",
"97.23"
] |
icd9pcs
|
[
[
[]
]
] |
2544, 3233
|
3360, 3392
|
3255, 3336
|
1596, 1858
|
3404, 3723
|
1881, 2520
|
116, 1068
|
1091, 1574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,623
| 130,650
|
21387
|
Discharge summary
|
report
|
Admission Date: [**2193-7-12**] Discharge Date: [**2193-7-15**]
Date of Birth: [**2135-12-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hypoglycemia, hypertenive emergency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 57 y/o female with h/o NIDDM, HTN, CRI, who p/w
hypertensive emergency and hypoglycemia from the ED. Patient
reports that for the last 2 days she was having a generalized
headache, blurry vision, and decreased urination. Beginning
Thursday, she noted that her BS were between 65-69, which is low
for her. She took glucose tablets and ate, bringing her sugars
up. Early Friday morning, she woke up at 2 am feeling clammy and
shaky. She checked her sugars which were around 55. She again
took glucose tablets and ate, bringing her sugars up to 100.
During the rest of the day, her sugars were normal around
150-160 until early evening when at an event in [**Location (un) 86**], she
again began to feel clammy and shaky. EMS was called and her FS
was 31. She was given 1 amp of D50 with good response of FS to
100's. She was also noted to be hypertensive to 220/110 in the
field and was subsequently brought into the ED.
.
In ED, VS were T 98.0, BP 230/110, HR 89, RR 23, SaO2 99%/RA.
She was started on Nipride gtt 0.5 mcg/kg/hr, increased to 1
mcg/kg/hr for goal SBP 190's. Given 1 L of NS as well and foley
was placed.
.
Currently, reports a mild h/a, but denies any other symptoms.
ROS negative for f/c/s, vision changes, URI sx, SOB, CP/palps,
n/v/abdominal pain, constipation, extremity swelling or
weakness. Does have chronic diarrhea at baseline. Of note, her
NPH dose was recently increased from [**6-21**] to [**7-23**] one week ago.
Past Medical History:
DM x 10 years--type 1.5
peripheral neuropathy
gastroparesis
retinopathy
hypertension
seizure disorder
chronic diarrhea
Social History:
lives with brother, no smoking, alcohol or drugs
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM -
VS: T 97.7, BP 148-161/61-67, HR 81, RR 16, SaO2 100%/RA
General: Pleasant, AAF in NAD, AO x 3.
HEENT: NC/AT, PERRL, EOMI. MMM, OP clear.
Neck: supple, no JVD or bruits.
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS
Ext: no c/c/e, pulses 2+ b/l
Neuro: AO x 3, CN II-XII intact, visual fields intact. Normal
motor strength and sensation throughout. Gait not tested.
.
Pertinent Results:
[**2193-7-12**] 07:41PM PLT COUNT-216
[**2193-7-12**] 07:41PM HYPOCHROM-1+ MICROCYT-1+
[**2193-7-12**] 07:41PM NEUTS-68.4 LYMPHS-25.4 MONOS-4.6 EOS-1.5
BASOS-0.1
[**2193-7-12**] 07:41PM WBC-4.8 RBC-4.15* HGB-10.9* HCT-33.0* MCV-80*
MCH-26.3* MCHC-33.1 RDW-14.6
[**2193-7-12**] 07:41PM GLUCOSE-171* UREA N-27* CREAT-1.4* SODIUM-142
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2193-7-12**] 08:14PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2193-7-12**] 08:14PM CK-MB-4 cTropnT-<0.01
[**2193-7-12**] 08:14PM LIPASE-15
[**2193-7-12**] 08:14PM ALT(SGPT)-14 AST(SGOT)-23 CK(CPK)-153*
AMYLASE-96 TOT BILI-0.3
[**2193-7-12**] 09:27PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2193-7-12**] 09:27PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
Brief MICU course: 57 y/o female with IDDM, CRI, HTN, MM, p/w
hypoglycemia and hypertensive emergency.
.
1. Hypertensive emergency
Considered emergency given end-organ symptoms of increased Cr,
h/a, blurry vision. Spike likely in setting of stress-response
to hypoglycemia and possibly [**1-17**] fact that today is her sister's
death anniversary. Weaned Nipride gtt with BPs 130's-150s off
nipride. Restarted low-dose BB and cozaar and CE's x 2
negative.
.
2. Hypoglycemia - now resolved. Pt with recent episodes of
hypoglycemia. Recently increased NPH to [**7-23**] from [**6-21**] last week.
?[**Last Name (un) 56493**] effect given hypoglycemia at 2 am. Continued with a
lower dose of NPH at 6 units qAM and 4 units qPM and coverage
with HISS. Held Actos while in MICU.
.
3. CRI - +proteinuria, baseline 1.0-1.2. Likely some component
of diabetic nephropathy, to see [**Last Name (un) **] nephrologist on Monday.
Acute on CRI likely [**1-17**] decreased perfusion from hypertensive
emergency. Encourage po, control BP as above. Cr trended down
from 1.4 -> 1.1 in MICU.
.
4. Anemia - chronic, with baseline 28-32, etiology unclear.
.
5. Elevated IgG - to be followed with heme/onc, appt in 2 weeks
for f/u
.
Brief floor course:
Pt was transferred to floor one day after admission, and her
blood pressure remained in SBP 120-130, with one o/n 160/100,
which resolved without any change in medication. Blood sugar
remained well controlled. Renal function was stable with a Cr of
1.2 at d/c. Hct 27.9 at discharge which is near her baseline of
28-32. At time of discharge, she was AFVSS. She was instructed
to f/u with [**Last Name (un) **] the day of discharge to get better control of
her sugars.
Medications on Admission:
1. NPH 8 units qAM, 8 units qHS
2. Cozaar 25 mg qd
3. Actos 45 mg qd
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. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive emergency and hypoglycemia
Discharge Condition:
Good
Discharge Instructions:
Please d/c home and return to hospital if having chest pain,
shortness of breath, blurry vision, new or worsening headache,
significantly decreased urine output, systolic blood
pressure>180 or diastolic BP>100
Followup Instructions:
Please f/u with Hem/Onc in one week for w/u of elevated IgG
F/u with [**Last Name (un) **] PCP today at 1pm
F/u with [**Last Name (un) **] nephrologist today at 2pm
Completed by:[**2193-7-15**]
|
[
"250.80",
"584.9",
"585.6",
"285.29",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5543, 5549
|
3398, 5102
|
350, 356
|
5633, 5640
|
2532, 3375
|
5898, 6094
|
2063, 2082
|
5222, 5520
|
5570, 5612
|
5128, 5199
|
5664, 5875
|
2097, 2513
|
275, 312
|
384, 1838
|
1860, 1980
|
1996, 2047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,021
| 175,440
|
45653
|
Discharge summary
|
report
|
Admission Date: [**2145-1-26**] Discharge Date: [**2145-2-3**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Low back and leg pain
Major Surgical or Invasive Procedure:
L1-L4 laminectomy and T12-L4 instrumented fusion
History of Present Illness:
Persistent pain after conservative management of L2 burst
fracture.
Past Medical History:
OSA on Bipap at night [**12-21**] at 2L
Idiopathic Cardiomyopathy (Last EF 55% ~6 months ago)
S/P ICD for recurrent VT in [**2125**]
BPH s/p TURP
AAA
Anxiety
HTN
Social History:
Former psychologist. Lives at home with wife. Smoked until age
40 but quit since (~20 pack-year). Average 2 drinks/night
usually wine or beer. No illicit drugs or substances. Patient
denies any traveling outside MA in the last 6 months.
Family History:
Patient denies any history of cancer, DM or CAD.
Physical Exam:
[**5-17**] /5 BLE, SILT
Refelxes 2+ BLE,
Bilteral upper extremities [**6-16**]
Upper lumbar spine tenderness.
Pertinent Results:
[**2145-1-26**] 09:00PM TYPE-ART PO2-91 PCO2-38 PH-7.41 TOTAL CO2-25
BASE XS-0
[**2145-1-26**] 03:35PM TYPE-ART PO2-152* PCO2-41 PH-7.38 TOTAL
CO2-25 BASE XS-0
[**2145-1-26**] 03:35PM freeCa-1.14
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#6. Physical
therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO Q 12H (Every
12 Hours).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Anxiety.
6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for Pain.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. Mexiletine 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
L2 burst fracture with lumbar canal stenosis
Discharge Condition:
Stable
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or while lying in bed.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
o We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Ambulation with assistance to make him independent ambulator.
Treatments Frequency:
Physical therapy to improve mobilization
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2145-2-15**] 10:00
Completed by:[**2145-2-2**]
|
[
"338.18",
"441.4",
"327.23",
"403.90",
"V45.02",
"428.0",
"V15.82",
"300.00",
"E885.9",
"338.29",
"274.9",
"362.51",
"805.4",
"433.00",
"V12.54",
"459.81",
"V43.65",
"287.5",
"425.4",
"724.02",
"428.32",
"433.20",
"585.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"77.79",
"38.93",
"81.08",
"81.05",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
3441, 3586
|
1312, 2183
|
287, 338
|
3675, 3684
|
1086, 1289
|
6174, 6412
|
891, 941
|
2206, 3418
|
3607, 3654
|
3708, 3786
|
956, 1067
|
6025, 6087
|
6109, 6151
|
5523, 6007
|
3820, 4030
|
226, 249
|
4518, 5511
|
366, 435
|
457, 620
|
636, 875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,071
| 121,831
|
25142
|
Discharge summary
|
report
|
Admission Date: [**2119-7-28**] Discharge Date: [**2119-8-9**]
Service: MEDICINE
Allergies:
Dicloxacillin / Cleocin Hcl / Penicillins / Tape / Levaquin
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
unsteady gait, recent fall
Major Surgical or Invasive Procedure:
bilateral subdural burr hole for hemorrhage evacuation
History of Present Illness:
This is an 83 y/o gentleman w/ history of a significant fall
with head trauma dating back to [**8-29**]. Since a few weeks after
this fall he states he has felt "wobbly." He states he doesn't
feel steady on his feet while he walks, not because of weakness
but because he feels his balance is "off."
About 9 days prior to this admission, he fell again. For the
past three days he has had a headache. A CT scan at the [**Location (un) 86**]
VA showed chronic bilateral large (1.6 cm at greatest thickness)
subdural hematomas, no midline shift.
He was originally admitted here to neurogsurgery service for
drainage of the subdurals. He was transferred to medicine
following bilateral burr holes. His hospital course has been
complicated by decompensated heart failure, delerium,
hypoxia/hypercarbia resp distress requiring a transient MICU
stay (not intubated).
History is obtained via pt's daughter as he is unable to give a
history. He has been noted be more confused and somnolent over
the past 1-2 days, and has had some loose stools. The pt says
"yes" when asked if he has a cough, but cannot give more details
& denies other complaints. Pt was recently treated for a UTI
with unknown antibiotic.
Past Medical History:
1) T8-9 three column fracture with pseudarthrosis secondary to
ankylosing spondylitis. He subseqsently underwent a T6-T12
fusion in [**11-30**].
2) AS
3) CHF
4) CAD
5) DM
6) CRI
7) Pulm HTN
8) ^chol
9) BPH
10) s/p TCC bladder surgery, requires leg bag
11) [**Last Name (un) 865**] esophagus, h/o duodenal ulcer
12) Asbestosis, restrictive lung disease
13) Follicular thyroid cancer
Social History:
lives alone, independent.
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
Vital signs: T 98.2 BP: 183/81 HR: 64 RR: 16 O2Sat.: 98 %
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Attention: Able to recite [**Doctor Last Name 1841**] forwards and backwards.
Registration intact.
Recall: [**1-26**] 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 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 finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-30**] throughout. No pronator drift.
Sensation: Intact to light touch, symmetric.
Reflexes: B T Br Pa Ac
Right 1+--------->
Left 1+--------->
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
Gait: deferred until AM
Pertinent Results:
Labs: at [**Hospital **] hosp: wbc 9.3, hct 33.3, plt 233;
Na 137 K 5.5 Cl 102 CO2 28 BUN 35 Cr 1.6 Ca 9.4
PTT 24.4 INR 1.1 on admission.
.
[**2119-7-28**] 01:30AM WBC-10.6 RBC-3.55* HGB-11.1* HCT-32.0* MCV-90
MCH-31.2 MCHC-34.6 RDW-13.2
[**2119-7-28**] 01:30AM NEUTS-72.5* LYMPHS-23.5 MONOS-2.8 EOS-0.8
BASOS-0.3
[**2119-7-28**] 01:30AM PLT COUNT-208
[**2119-7-28**] 01:30AM PT-13.5* PTT-23.6 INR(PT)-1.2
[**2119-7-28**] 01:30AM GLUCOSE-118* UREA N-32* CREAT-1.4* SODIUM-141
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-27 ANION GAP-14
[**2119-7-28**] 06:25AM K+-5.0
[**2119-7-28**] 05:44PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.5*
.
Imaging:
[**2119-8-5**] CTA of chest- No PE. Mildy enlarged pretracheal,
paratracheal, prevascular, precarinal, and subcarinal lymph
nodes are identified, the largest of these measuring 1.6 cm in
diameter. This finding may be reactive, but correlation with
patient's history of malignancy is recommended. Increased
diameter of the main pulmonary artery, suggesting underlying
pulmonary arterial hypertension. Mild-to-moderate congestive
heart failure pattern. Moderate-sized left pleural effusion with
associated atelectatic changes
[**2119-8-4**] CXR - Persistent right-sided pleural and parenchymal
opacities, which could potentially be due to chronic scarring,
although an acute process is not excluded without more remote
radiographs for comparison. No significant change since
earliest chest x-ray at this institution performed 5 days
earlier.
[**2119-8-3**] CXR - Interval increase in pulmonary interstitial edema
reflecting likely worsening CHF. Left lower lobe consolidation,
which could be atelectasis or developing pneumonia. No
pneumothorax.
[**2119-8-3**] CT Head - Slight increase in size of extraaxial fluid
collection since prior study. There has been some reduction in
the degree of pneumocephalus.
[**2119-8-1**] ECHO - Preserved global and regional biventricular
systolic function. Dilated ascending aorta. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
[**2119-7-30**] CXR - Probable right effusion which may be chronic. No
other evidence for failure.
[**2119-7-28**] CT Head - Large bilateral subdural hematomas, causing
significant local mass effect on the brain parenchyma. Old
studies are not available to assess for interval change, and
there does not appear to be an appreciable hyperdense component
to suggest an acute re-hemorrhage.
.
Cultures:
[**2119-7-31**] Urine - No growth
[**2119-8-3**] Urine - yeast
[**2119-7-31**] Blood - No growth
[**2119-8-3**] Blood - pending
[**2119-7-31**] Stool - negative for c.diff
[**2119-8-1**] Stool - negative for c.diff
[**2119-8-2**] Stool - negative for c.diff
Brief Hospital Course:
83 year old male admitted on [**2119-7-28**] for evacuation of chronic
subdural hematomas, transferred to the MICU on [**2119-8-3**] ago for
respiratory distress found to have pulmonary edema and
presumptively treating for aspiration PNA.
.
1. Subdural Hematomas: Pt was admitted to Neurosurgery on
[**2119-7-28**] for evacuation of bilateral subdural hematomas. He did
well on post-operative days 1 through 3, remaining awake, alert,
conversive and moving all extremeties. He was then transferred
to medicine with hypoxia. Repeat CT after hematoma evacuation
showed slight increase in size of extraaxial fluid collection
and some reduction in the degree of pneumocephalus. Pt's mental
status returned to his baseline and stayed stable neurologically
on medicine wards. Please, call Dr.[**Name (NI) 9034**] office [**Telephone/Fax (1) 1669**]
and set up a date for CT of head and follow up appointment with
Dr. [**Last Name (STitle) **] in [**3-1**] weeks.
.
2. Hypoxia: On POD#3, pt had an increasing oxygen requirement,
increasing from 2L to 4L to BiPAP. Pt's ABG initially
7.26/58/57, then 7.30/55/96 on 4L NC. Pt was then transferred
to the MICU for hypercarbia resp failure and hypoxia. He was
thought to have an aspiration pneumonia vs CHF. A CTA of chest
was negative for PE and showed on ground glass consistent with
CHF. CTA of chest also showed mildy enlarged pretracheal,
paratracheal, prevascular, precarinal, and subcarinal lymph
nodes are identified, the largest of these measuring 1.6 cm in
diameter. This finding may be reactive, but correlation with
patient's history of malignancy is recommended. He was started
on Levo/Flagyl but was switched to ceftriaxone/flagyl when the
coverage was deemed inadequate. His volume status was difficult
to determine and he was given gentle doses of Lasix. A swallow
study showed no evidence of aspiration on video swallow. His O2
was titrated down and he was called out to the floor. On day of
discharge, he was 92% on room air and 96-97% on 1L NC. Given
his multiple pulmonary problems, he will need aggressive
pulmonary rehab. Regarding mediastinal lymphadenopathy, please
compare it to his previous CT of chest and eval for any further
workup.
.
3. Diastolic Dysfxn: As above, pt was noted to be volume
overloaded on CTA that was contributing to his hypoxia. He was
gently diuresed as his creatinine would tolerate. He responded
well to 40 of po Lasix so he should restart his home dose of
20mg qd on the day following discharge. He was continued on 5mg
Lisinopril and his metoprolol was titrated up to keep his
SBP<130. The final dose was metoprolol 100mg [**Hospital1 **].
.
4. HTN: Metoprolol was titrated up to keep<130. Lisinopril was
continued.
.
5. Acute on chronic renal Failure: Pt's baseline creatinine is
1.5 and he was admitted with a cr of 1.7. Post-op, his
creatinine started to rise further and urine output dropped to
20cc/hr; it peaked on HD#4 at 2.4. It appeared to be related to
diuresis wit Lasix and decreased after Lasix was held. Pt
received mucomyst and Bicarb prior to CTA but creatinine rose ot
1.7 (from 1.5) after the study. On day of discharge, his
creatinine was returned to baseline at 1.5.
.
6. Leukocytosis: On post-operative day #4, the patient developed
a cough, spiked a fever to 102.5 F and his urine output dropped
to approximately 20 cc per hour. As above, he was thought to
have an aspiration PNA based on possible opacities on CXR and he
was started on levo/flagyl and then switched to
ceftriaxone/flagyl. Blood and urine cx were negative. He was
discharged on cefpodixime and flagyl for a total of a 14 day
course.
.
7. Somnolence: Pt was noted to be somnolent post-operatively
likely secondary to hypercarbia and infection. Worsening bleed
was ruled out by CT. On discharge, pt was AO x 3. Of note, he
is confused at baseline.
.
8. DM: Home NPH doses were halved after surgery when pt was NPO.
Glucose was elevated but controlled with humalog sliding scale.
He was discharged on his home dose of NPH 16in the am and 4 at
night.
.
8. BPH: continued finasteride and terazosin
.
9. PPX: PPI, SQ heparin
.
10. Code: DNR/DNI
Medications on Admission:
cyclobenzaprine 5 mg hs,
albuterol inh 2 puffs [**Hospital1 **], gabapentin 300 mg qday, insulin
(novolin) 16 u am, 4 u hs; lisinopril 5 qday, metoprolol 50
qday,
lovastatin 40 qday, prilosec 20 qday, lasix 20 qday, dulcolax
supp, finasteride 5 qday, sennosides 2 Tabs qday, terazosin 5 mg
qday, lidoderm patch, psyllium
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Terazosin 2 mg Capsule Sig: 2.5 Capsules PO HS (at bedtime).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
mL Injection three times a day.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
injection Subcutaneous twice a day: resume your home fixed dose
of 16 u. AM, 4 u. PM.
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): last day = [**2119-8-14**].
19. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours: last dose = [**2119-8-14**].
20. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
units Subcutaneous four times a day: per sliding scale.
21. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: start
on [**2119-8-9**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
bilateral subdural hematomas s/p evacuation
Aspiration pneumonia
Congestive heart failure-diastolic dysfunction
Acute on chronic renal failure. Acute renal insufficiency -
resolved.
Discharge Condition:
stable on 1L nasal cannula (92% on RA), BP well controlled,
baseline confused
Discharge Instructions:
1) Call Dr.[**Name (NI) 9034**] office or return to the ED if you have a
change in mental status, fevers or drainage from your incisions.
2) Take your antibiotics as prescribed for a total of 14 days.
3) Follow up with your primary care physician [**Name Initial (PRE) 176**] 1-2 weeks.
4) You may resume all your home medications as previously
prescribed except metoprolol (we increased the dose). It's okay
to take aspirin per neurosurgery. Restart your home dose of
Lasix (20mg a day) tomorrow.
5) Please call Dr.[**Name (NI) 9034**] office [**Telephone/Fax (1) 1669**] and set up a
date for CT of head and follow up appointment with Dr. [**Last Name (STitle) **] in
[**3-1**] weeks.
Followup Instructions:
Follow-up in 10 days with Dr. [**Last Name (STitle) **] then again in [**3-1**] weeks
with a head CT. Call [**Telephone/Fax (1) 1669**] for the appointments.
.
Follow-up in [**11-27**] weeks with your PCP.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"414.01",
"428.30",
"285.9",
"403.91",
"424.1",
"428.0",
"E888.9",
"507.0",
"584.9",
"276.5",
"600.00",
"518.81",
"276.2",
"799.0",
"852.29",
"501",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
12936, 12984
|
6439, 10593
|
293, 349
|
13211, 13291
|
3695, 6416
|
14027, 14328
|
2051, 2069
|
10966, 12913
|
13005, 13190
|
10619, 10943
|
13315, 14004
|
2099, 2469
|
227, 255
|
377, 1584
|
2861, 3676
|
2484, 2845
|
1606, 1991
|
2007, 2035
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,012
| 173,770
|
54362
|
Discharge summary
|
report
|
Admission Date: [**2196-1-1**] Discharge Date: [**2196-1-13**]
Date of Birth: [**2135-7-11**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Melena and hematemesis
Major Surgical or Invasive Procedure:
[**2196-1-3**]: Exploratory laparotomy and oversewing of bleeding
duodenal ulcer and pyloroplasty
History of Present Illness:
The patient is a 60 year-old man with HIV, HCV cirrhosis and HCC
s/p nodule resection and left lateral segmentectomy [**12-11**]. He
was doing well following discharge and actually had the best day
in a long time yesterday. This morning he awoke at about 6am
feeling unwell. He went to the bathroom where he had a normal
bowel movement followed by the sensation that someone had turned
on a
furnace in his body. Following this hot-flash he felt light
headed. He got up and went back to bed with the help of his
roommate. Soon thereafter he had the sensation that he had to
move his bowels and went to the bathroom where he passed a large
black and tarry stool with some red blood. He passed out on the
way back to bed and was found by his roommate.
Comes with BRBPR and syncope for evaluation in the ER he vomited
50 cc of red blood
Past Medical History:
HIV
HCV with cirrhosis
HCC
HTN
Diverticular disease with bloody diarrhea
Social History:
Lives with his partner, [**Name (NI) **] x 20+ years (HIV status unknown)
Food service prep manager
Quit smoking in [**8-/2194**]
(-) EtOH since [**2178**]
Denies any other drug use
No children
Cat (indoor)
Family History:
Uncle-colon CA
Both parents-died of old age, he does not know of any heart or
kidney disease
Physical Exam:
Vital Signs T 97, HR 117, BP 100/60, RR 28, 99% RA
HEENT pale
Heart RRR
Lungs Clear
ABD soft JP with serous fluid non distended
Ext no edema
Pertinent Results:
On Admission: [**2196-1-1**]
WBC-7.3 RBC-2.82* Hgb-9.1* Hct-28.3* MCV-100* MCH-32.3*
MCHC-32.2
RDW-17.1* Plt Ct-202
PT-19.2* PTT-30.3 INR(PT)-1.8*
Glucose-131* UreaN-23* Creat-0.9 Na-137 K-4.8 Cl-109* HCO3-19*
AnGap-14
ALT-42* AST-118* CK(CPK)-109 AlkPhos-123* Amylase-209*
TotBili-0.6
Lipase-137* Albumin-2.7* Calcium-7.8* Phos-2.2* Mg-1.8
[**2196-1-5**] 11:48PM BLOOD calTIBC-166* Ferritn-586* TRF-128*
On Discharge [**2196-1-13**]
WBC-3.6* RBC-3.63* Hgb-11.4* Hct-34.3* MCV-95 MCH-31.3 MCHC-33.1
RDW-16.2* Plt Ct-69*
PT-17.7* PTT-50.4* INR(PT)-1.6*
Glucose-85 UreaN-12 Creat-0.7 Na-139 K-3.9 Cl-109* HCO3-24
AnGap-10
ALT-37 AST-106* AlkPhos-103 Amylase-220* TotBili-1.1 Lipase-165*
Albumin-2.7* Calcium-7.9* Phos-2.8 Mg-1.9
Brief Hospital Course:
60 y/o male admitted through the ER with BRBPR and also
hematemesis. Hematocrit 28% (down from 37% 1 week prior) given
fluids, FFP and 2 units RBCs in ED prior to admission to the
SICU.
An EGD was performed on admission showing varices in the lower
third of the esophagus, an ulcer on the posterior duodenal bulb.
GI felt that the most likely source of bleeding was the bulbar
ulcer.
Patient was hypotensive to the 60's systolic and was having
fresh bleeding in the stool. He continued to receive pRBCs as
needed to maintain Hct to 30%. On [**1-3**] his Hct fell back to 23%
requiring the transfusion of another 5 units. He was taken
emergently to the OR with Dr [**First Name (STitle) **] [**Name (STitle) **] and upon opening the
abdomen, the pylorus was opened longitudinally onto the duodenum
whereupon the team encountered arterial pulsatile bleeding from
the base of a 1- cm ulcer in the posterior part of the 1st
portion of the duodenum. All 4 corners of the ulcer were over
sewn with big 2-0 silk sutures to control the bleeding. He was
transferred back to the SICU in stable condition.
He was transfused with 2 units RBC's on the 18th and was
extubated. He was started on TPN on that day which was continued
through [**1-11**].
He was transferred to the surgical floor on [**1-6**].
On [**1-8**] patient underwent Gastrografin study of GI tract which
demonstrates JP drain in the right upper quadrant and tip of NG
tube within the stomach. Gastrografin contrast was administered
via NG-tube, showing contrast passing promptly from the stomach
into the duodenum without evidence of leak. Note is made of
narrowing of the first portion of the duodenum, likely related
to postoperative edema. The NG tube was pulled following this
study and patient was advanced in the following days with good
PO intake.
HIV meds were started on [**1-11**] once diet well tolerated.
JP drain was removed on [**1-12**].
Plan is to discharge to home on [**1-13**]. PT recommended evaluation
at home. He was initially very weak and although has improved
over the hospitalization, he may require further PT assist at
home.
Medications on Admission:
HIV Regimen (on [**2195-10-15**]) together at night w/Efavirenz 600mg-1
tab; Emtricitabine/tenofovir 200/300 mg- 1 tab; Atenolol 50'
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
2. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO daily ().
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO q 6 hours PRN as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
HIV, HCV cirrhosis and HCC s/p nodule resection and left lateral
segmentectomy [**2195-12-11**] now s/p bleeding duodenal ulcer with
repair and pyroplasty
Discharge Condition:
Fair/stable
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever > 101,
chills, nausea, vomiting, diarrhea, dark/tarry stools or blood
noted in stool or vomiting of blood. Continue to eat as well as
possible and drink enough fluids to keep urine light yellow.
Monitor skin and eyes for yellowing.
Monitor incision for redness, drainage or bleeding
No heavy lifting
Do not drive if taking narcotic pain medications
You may shower, pat incision dry
Followup Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for appointment [**1-20**].
Follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] (Infectious disease) first week in
[**Month (only) 404**]. This can be done at same time as appointment with Dr
[**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2196-1-13**]
|
[
"456.21",
"571.5",
"155.0",
"562.12",
"532.40",
"070.70",
"458.9",
"042",
"530.10",
"303.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.15",
"96.07",
"99.04",
"96.71",
"45.13",
"44.42",
"44.29"
] |
icd9pcs
|
[
[
[]
]
] |
5253, 5304
|
2612, 4725
|
289, 389
|
5503, 5517
|
1861, 1861
|
6040, 6532
|
1590, 1684
|
4909, 5230
|
5325, 5482
|
4751, 4886
|
5541, 6017
|
1699, 1842
|
227, 251
|
417, 1252
|
1875, 2589
|
1274, 1349
|
1365, 1574
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,367
| 144,518
|
46416
|
Discharge summary
|
report
|
Admission Date: [**2123-5-18**] Discharge Date: [**2123-6-3**]
Date of Birth: [**2060-7-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2123-5-24**] Redo Sternotomy, Replacement of Ascending Aorta utilizing
a 30mm Gelweave Graft
History of Present Illness:
Mrs. [**Known lastname 23081**] is a 62 year old female with known ascending aortic
aneurysm. She was admitted for heparinization and additional
cardiac workup prior to surgical intervention.
Past Medical History:
- Rheumatic fever as child, now s/p AVR with [**Hospital3 9642**]
mechanical valve in 4/86
- Hypertension
- Palpitations(Afib/AVNRT/Aflutter)- followed by Dr. [**Last Name (STitle) **] -
s/p successful ablation on [**2123-3-18**]
- Depression
- Migraines
- Low Back Pain
- Anemia
- History of Subdural hemorrhage - [**2120**]
- History of renal stones
- Osteoarthritis
- Hysterectomy
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her brother had a CVA.
Physical Exam:
Admission
VS: T 98.1, BP 148/88, HR 85, RR 20, SAT 96% on room air
General: well developed female in no acute distress
[**Year (4 digits) 4459**]: oropharynx benign, sclera anicteric
Neck: supple, no JVD, no carotid bruits
Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: alert and oriented, nonfocal
Discharge
VS: T98.3 HR 73SR BP 101/56 RR 20 O2sat 96%RA
Gen: NAD
Neuro: A&Ox3, nonfocal exam
Pulm: CTA bilat
CV: RRR sharp click. Sternum stable, incision w/steris
Abdm: soft, NT/ND/+BS
Ext: warm, no edema
Pertinent Results:
[**2123-5-18**] 05:31PM BLOOD WBC-5.0 RBC-3.55* Hgb-11.2* Hct-32.6*
MCV-92 MCH-31.6 MCHC-34.4 RDW-13.0 Plt Ct-214
[**2123-5-18**] 05:31PM BLOOD PT-17.1* PTT-22.6 INR(PT)-1.6*
[**2123-5-18**] 05:31PM BLOOD Glucose-106* UreaN-14 Creat-0.7 Na-140
K-3.3 Cl-104 HCO3-30 AnGap-9
[**2123-5-18**] 05:31PM BLOOD ALT-17 AST-21 AlkPhos-73 Amylase-120*
TotBili-0.3
[**2123-5-18**] 05:31PM BLOOD %HbA1c-5.4
[**2123-6-3**] 06:30AM BLOOD WBC-8.8 RBC-2.80* Hgb-8.8* Hct-26.4*
MCV-94 MCH-31.3 MCHC-33.3 RDW-16.0* Plt Ct-404
[**2123-6-3**] 06:30AM BLOOD Plt Ct-404
[**2123-6-3**] 06:30AM BLOOD PT-31.9* PTT-31.8 INR(PT)-3.4*
[**2123-6-3**] 06:30AM BLOOD Glucose-107* UreaN-15 Creat-1.0 Na-139
K-3.8 Cl-102 HCO3-30 AnGap-11
[**2123-5-20**] Cardiac Cath:
1. Selective coronary angiography in this right dominant patient
revealed no angiographically apprarent CAD. The LMCA, LAD, RCA,
LCX and their branches were without flow limiting disease. 2.
Limited hemodynamics revealed a blood pressure of 167/78 with HR
70 in sinus. 3. The mechanical single disc valve appeared to be
functioning properly on fluoroscopy.
[**2123-5-24**] ECHO
Pre-CPB: There is a tilting-disc Aortic valve prosthesis in
place. There is no AI. There is marked dilation of the ascending
aorta, measuring 5.2 cm. There is mild dilation of the
descending aorta. The mitral valve is moderately thickened, with
mild MR. There is good biventricular systolic fxn.
Post-bypass: There is a tube graft on the ascending aorta.
Prosthetic valve fxn and biventricular systolic fxn appear
preserved. Other parameters as prebypass.
Brief Hospital Course:
Mrs. [**Known lastname 23081**] was admitted and started on intravenous Heparin for
her mechanical aortic valve. She underwent cardiac
catheterization which showed normal coronary arteries.
Additional workup showed a positive urinalysis for which she was
started emiprically on antibiotics. Urine culture eventually
grew out mixed flora, consistent with contamination and
antibiotics were discontinued. She was cleared by the dental
service after radiographic and clinical examination showed no
evidence of infection. Her preoperative course was otherwise
uneventful.
On [**5-24**], Dr. [**Last Name (STitle) 1290**] performed a redo sternotomy, and
replacement of her ascending aorta. For surgical details, please
see seperate dictated operative note. Following the operation,
she was brought to the CSRU for invasive monitoring. Within 24
hours, she was extubated without incident. She initially
experienced some difficulty with word finding but otherwise
remained neurologically intact. All narcotics and benzos were
discontinued. Initially hypertensive, she required Labetolol and
Hydralazine in addition to beta blockade for adequate blood
pressure control. Over severals days, her hemodynamics and
mental status improved and she transferred to the telemetry
floor on postoperative day three. Medical therapy was optimized
and she continued to make clinical improvements with diuresis.
She developed atrial fibrillation which was treated with an
increase in her cardizem and beta blockade. Coumadin was started
for anticoagulation. Ultimately, amiodarone was started with
conversion back into a normal sinus rhythm. Mrs. [**Known lastname 23081**] was
noted to be anemic and was transfused with 2 units of packed red
blood cells. A large right pleural effusion was noted on chest
x-ray and thoracentesis was performed which drained 700cc of
serosanguinous fluid. Mrs. [**Known lastname 23081**] continued to make steady
progress and was discharged to her home with visiting nurse on
[**2123-6-3**]. She will follow-up with Dr. [**Last Name (STitle) 1290**], her cardiologist
and her primary care physician as an outpatient. [**Hospital 197**] clinic
will manage her coumadin dosing for a goal INR of 2.0-2.5
Medications on Admission:
Coumadin - stopped [**5-15**]
[**Month/Year (2) **] - stopped [**5-15**]
Atenolol 50 [**Hospital1 **]
Xanax prn
Lasix 10 qd
Kcl 10 qd
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours): [**Hospital1 **] x10 days then
QD.
Disp:*40 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
400mg [**Hospital1 **] x7days then 400mg QD 7days then 200mg QD.
Disp:*56 Tablet(s)* Refills:*0*
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day: 40mg
[**Hospital1 **] x10 days then 40mg QD.
Disp:*60 Tablet(s)* Refills:*0*
12. Warfarin 2 mg Tablet Sig: Pt to take 4mg [**Date range (1) 30469**] then as
directed by the coumadin clinic Tablets PO once a day: Target
INR 2.5-3 for mechanical Aortic valve. INR to be followed by
[**Hospital 197**] Clinic.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Ascending Aortic Aneursym - s/p Asc Ao Replacement
Aortic Valve Replacement(mechanical)in [**2102**]
History of Afib/AVNRT/Aflutter - s/p successful ablation on
[**2123-3-18**]
Hypertension, Hyperlipidemia, History of Rheumatic Fever,
History of Cerebral Bleed - s/p Surgical Evaluation, Anemia,
Chronic Abdominal Pain, History of Renal Calculi, Migraine HA
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-22**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7626**] in [**2-20**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**2-20**] weeks.
Completed by:[**2123-6-3**]
|
[
"427.31",
"441.2",
"511.9",
"V43.3",
"401.9",
"272.0",
"285.9",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"88.56",
"39.61",
"38.93",
"99.04",
"34.91",
"38.45",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7644, 7699
|
3605, 5820
|
330, 428
|
8101, 8108
|
2006, 3582
|
8426, 8694
|
1199, 1304
|
6004, 7621
|
7720, 8080
|
5846, 5981
|
8132, 8403
|
1319, 1987
|
280, 292
|
456, 649
|
671, 1057
|
1073, 1183
|
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