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27,002
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5699
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Discharge summary
|
report
|
Admission Date: [**2115-11-28**] Discharge Date: [**2115-12-11**]
Date of Birth: [**2052-7-8**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Optiray 350
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Right hemicolectomy
Resection of appendiceal mucoceole
History of Present Illness:
63M c MMP presented to [**Hospital1 18**] ED from home with increasing
abdominal pain and tenderness to touch. Pt stated that pain was
initially [**1-26**] and increased to [**5-26**], was found on presentation
to have rebound tenderness and guarding. Pt describes decreased
appetite and progressive, mild weight loss for past 2-3 months.
No other positives on ROS.
Past Medical History:
Depression 20 years
Erectile dysfunction
Angina
Hyperlipidemia
IDDM
CAD (CABG 3vd), 6 stents; last Cath [**9-22**]
Ulcerative colitis
HTN
Social History:
Married. Patient is a former optometrist who has been under a
great deal of stress, related to his health inhibiting his
ability to work. 5 year smoking history in 20s. No history of
etoh abuse. No IV or recreational drug use.
Family History:
Mother with CAD, CABG in her 60's. (+) Strong family history of
premature coronary artery disease, DM, HTN, Hyperlipidemia
Physical Exam:
General Appearance: Depressed affect, otherwise WN/WD male in
NAD
Vital signs AVSS, afebrile
HEENT: PERRLA, EOMI, no LAD
CVS: RRR, no m/r/g
PULM: CTAB, no r/r/c
ABD: NT/ND, (+) BS, Soft, midline incision is well healed, C/D/I
EXT: Warm and well perfused, trace edema to bilateral LE
Pertinent Results:
[**2115-12-9**] CXR: IMPRESSION: 1. Interval improvement in
interstitial pulmonary edema. 2. Unchanged appearance of mild
cardiomegaly and small bilateral pleural effusion, right greater
than left.
.
[**2115-11-28**] CT TORSO: IMPRESSION: Thin-walled, dilated (up to 6
cm) appendix consistent with a mucocele of the appendix.
Surrounding fat stranding indicates acute inflammation or
infection of the mucocele. Also, air and oral contrast within
the appendiceal mucocele indicates communication with the cecum,
likely the source and reason for the acute infection and
inflammation of the mucocele.
.
[**2115-11-28**] 11:05PM CK(CPK)-52
[**2115-11-28**] 11:05PM CK-MB-NotDone cTropnT-<0.01
[**2115-11-28**] 06:15PM GLUCOSE-244* UREA N-30* CREAT-1.5*
SODIUM-131* POTASSIUM-4.9 CHLORIDE-92* TOTAL CO2-27 ANION GAP-17
[**2115-11-28**] 06:15PM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2115-11-28**] 06:15PM PT-14.5* PTT-33.0 INR(PT)-1.3*
[**2115-11-28**] 02:20PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2115-11-28**] 02:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2115-11-28**] 02:20PM URINE RBC-[**2-18**]* WBC-[**5-26**]* BACTERIA-MOD
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2115-11-28**] 02:20PM URINE GRANULAR-0-2 HYALINE-0-2
[**2115-11-28**] 02:20PM URINE AMORPH-FEW URIC ACID-RARE
[**2115-11-28**] 01:30PM LACTATE-2.3*
[**2115-11-28**] 01:23PM estGFR-Using this
[**2115-11-28**] 01:23PM ALT(SGPT)-33 AST(SGOT)-21 LD(LDH)-201
CK(CPK)-52 ALK PHOS-60 AMYLASE-33 TOT BILI-1.0
[**2115-11-28**] 01:23PM LIPASE-19
[**2115-11-28**] 01:23PM cTropnT-<0.01
[**2115-11-28**] 01:23PM CK-MB-NotDone
[**2115-11-28**] 01:23PM WBC-15.7*# RBC-4.64 HGB-12.3* HCT-37.4*
MCV-81* MCH-26.4* MCHC-32.8 RDW-16.8*
[**2115-11-28**] 01:23PM NEUTS-82.4* LYMPHS-10.2* MONOS-6.7 EOS-0.3
BASOS-0.4
[**2115-11-28**] 01:23PM PLT COUNT-268
Brief Hospital Course:
Pt presented to the ED on [**2115-11-28**] with multi-day history of
increasing abdominal pain. Pt found to have CT demonstrating
thin-walled, dilated (up to 6 cm) appendix consistent with a
mucocele of the appendix or any cystic neoplasm. The patient has
severe coronary artery disease. At the time of his presentation
he was believed to be having active chest pain. Over the course
of the five days he has ruled out for myocardial infarction and
was treated with cipro/flagyl/vanc. His right lower quadrant
symptoms diminished somewhat but he still was distended and had
right lower quadrant peritoneal findings, including rebound
tenderness and guarding. His cardiac risk was recognized but
the risk of sepsis and bowel obstruction as well as the
possibility of underlying carcinoma warranted surgical
intervention.
Pt's cardaic treatment was optimized during his stay in the
TSICU. Cardiology recommended beta blocking the patient to goal
heart rate of less than 70. We discontinued diltiazem. We did
not agree to increase lipitor to 80 owing to the hypo-immune
effects of low cholesterol. We continued asa and plavix, and
diuresed the patient with a goal output of 500cc-1 liter per
day. The pt was stable on this regimen in the pre-operative
period.
After preparation, Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a right colectomy with
resection of his right lower quadrant mass on [**2115-12-3**] without
complications. He tolerated this procedure well. He was
transferred to the TSICU directly from the OR, and was extubated
on the evening following surgery without complication. On the
following morning he was transferred to the [**Hospital Ward Name 121**] 9 for recovery.
Cardiology participated in his post-operative care. They
recommended the continuation of his pre-operative medications
with the addition of isosorbide mononitrate and that he have
definitive follow up in one week post-discharge.
Post-operatively, Mr. [**Known lastname **] rapidly regained bowel function and
was given a diet on POD 2. He advanced to a regular diet by the
following day with passing of flatus and stool. At the time of
discharge he was afebrile, tolerating a regular diet, ambulating
without assistance and with clearance from physical therapy, and
with good pain control on PO medication. Pt's wound site was
clean, dry, and intact, without any signs of infection.
Medications on Admission:
ASA 325', lisinopril 40', lipitor 80', mesalamine 1200'',
lexapro 20', zetia 10', plavix 75', lasix 40'', norvasc 5',
metoprolol 50'', spironolactone 25', protonix 40', NPH, NTG PRN,
nitro patch
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H () as needed for pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain
for 1 months.
Disp:*60 Tablet, Sublingual(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Abdominal pain
Hypertension
Congestive heart failure
Discharge Condition:
Stable, to rehab
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], [**Hospital1 18**] Trauma Surgery, in 2 weeks.
Please call ([**Telephone/Fax (1) 22750**] to schedule and appointment.
.
Follow up with Dr. [**Last Name (STitle) **], [**Hospital1 18**] Cardiology, in ONE WEEK. Please
call ([**Telephone/Fax (1) 10085**] to schedule an appointment at your
convenience.
|
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54,353
| 157,091
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24360
|
Discharge summary
|
report
|
Admission Date: [**2135-1-24**] Discharge Date: [**2135-1-27**]
Date of Birth: [**2101-10-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Diabetic ketoacidosis
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
33-year-old female with history of type I DM, mitochondrial
myopathy, and blindness who presents to her PCP's office with
one week of dry, nonproductive cough, nausea, and vomiting. She
has had abdominal pain and poor PO intake. She was lightheaded
when she was standing and orthostatic in her PCP's office today.
She describes a mid-abdominal pain, nausea, and vomiting twice.
She denies dysuria. She has had UTIs before, but this is not
what they've felt like. She has not had fevers or chills. She
does feel slightly short of breath and is coughing. No chest
pain. No headaches, neck stiffness. No diarrhea, but she feels
slightly constipated and bloated. At home, her sugars have been
as high as the 350s, which is unusual for her.
.
In the ED, initial vitals were T 97.9, P 121, BP 133/94, R 20
and 97% on room air. She was noted to have an initial glucose of
294 and an anion gap of 24. She was started on an insulin drip,
potassium and magnesium replacement. She got a total of 3L NS.
She was given levofloxacin for potential pneumonia. She also
received zofran and morphine for her abdominal pain. She had a
repeat chem 7 which showed that her AG gap had closed.
.
On arrival to the floor, she is comfortable in bed. She says her
legs are sore. She has chronic leg pain due to her myopathy, but
they have been worse lately. She says her abdominal pain went
away.
.
Past Medical History:
Type I Insulin Dependent DM
Mitochondrial myopathy
Hypertriglyceridemia
Blindness
Palmoplantar keratoderma
.
Social History:
Lives alone at home; twin sister lives in same building. No
services per PCP [**Name Initial (PRE) 12883**]. She has no history of alcohol, illicits
or tobacco.
Family History:
Family history of type II DM; twin sister with mitochondrial
myopathy.
Physical Exam:
Admission physical:
Vitals: T 99.3, P 123, BP 143/83, R 18, 99% on RA
Gen - well appearing, NAD
HEENT - ATNC, PERRLA, dry mucous membranes, nystagmus
CV - RRR, no m,r,g
Lungs - CTA B, no wheezes, rhonchi or rales
Abd - soft, mildly tender around umbilicus, no rebound or
guarding, no distended, normoactive BS
Ext - warm, well perfused, no edema, mildly tender to palpation
Discharge physical:
VS: T 98.5 BP 91-108/54-70 HR 62-79 RR 18 98-100% RA
Gen: Well appearing, NAD
HEENT: Normocephalic, anicteric, oropharynx without erythema
Neck: No masses or lymphadenopathy
CV: S1, S2, no murmurs appreciated, Radial and pedal pulses 2+
bilaterally
Pulm: CTA bilaterally
Abd: Soft, NT, ND, BS+
Extremities: Warm and well perfused, no C/C/E
Neuro: AAOx3, CN III-XII grossly intact, strength 5/5 in LE
bilaterally
Psych: Pleasant, cooperative
Pertinent Results:
Admission labs:
[**2135-1-24**] 04:15PM BLOOD WBC-6.8# RBC-4.79 Hgb-13.3 Hct-39.1
MCV-82 MCH-27.7 MCHC-34.0 RDW-15.1 Plt Ct-368
[**2135-1-24**] 07:06PM BLOOD WBC-5.9 RBC-4.24 Hgb-11.4* Hct-34.1*
MCV-80* MCH-26.9* MCHC-33.4 RDW-15.3 Plt Ct-306
[**2135-1-24**] 11:12PM BLOOD PT-14.5* PTT-25.3 INR(PT)-1.3*
[**2135-1-24**] 04:15PM BLOOD Glucose-294* UreaN-9 Creat-0.7 Na-133
K-3.7 Cl-93* HCO3-16* AnGap-28*
[**2135-1-24**] 07:06PM BLOOD Glucose-139* UreaN-8 Creat-0.5 Na-138
K-3.3 Cl-102 HCO3-20* AnGap-19
[**2135-1-24**] 11:12PM BLOOD ALT-27 AST-58* LD(LDH)-288* CK(CPK)-539*
AlkPhos-70 TotBili-0.3
[**2135-1-24**] 07:06PM BLOOD Calcium-8.3* Phos-1.3*# Mg-2.5
[**2135-1-24**] 06:08PM BLOOD pO2-115* pCO2-32* pH-7.42 calTCO2-21 Base
XS--2
[**2135-1-24**] 06:08PM BLOOD Glucose-268* Lactate-5.1*
[**2135-1-24**] 07:19PM BLOOD Lactate-4.4*
[**2135-1-25**] 04:20AM BLOOD Lactate-4.5*
[**2135-1-25**] 07:47AM BLOOD Lactate-5.1*
[**2135-1-26**] 04:11AM BLOOD Lactate-2.5*
.
Discharge labs:
[**2135-1-27**] 07:00AM BLOOD WBC-4.4 RBC-4.05* Hgb-11.5* Hct-33.4*
MCV-82 MCH-28.3 MCHC-34.4 RDW-16.5* Plt Ct-370
[**2135-1-27**] 07:00AM BLOOD Glucose-154* UreaN-7 Creat-0.6 Na-139
K-4.1 Cl-101 HCO3-24 AnGap-18
.
IMAGING:
[**1-24**] CXR:
IMPRESSION: No acute cardiopulmonary process.
[**2135-1-25**] EKG:
Sinus rhythm. Delayed precordial R wave transition. Compared to
the previous tracing of [**2132-1-9**] the rate has slowed. Otherwise,
no diagnostic interim change.
Brief Hospital Course:
ASSESSMENT AND PLAN:
33-year-old female with history of type I DM, mitochondrial
myopathy, and blindness who presented with cough, nausea and
vomiting.
.
# Diabetic ketoacidosis: The patient originally went to the
Intensive Care Unit for an insulin drip and electrolyte
management. Within one day, her glucose was regularly below 200.
On the medicine floor, her glucose was relatively well
controlled with [**Name (NI) 8472**] and a Humalog insulin sliding scale.
[**Last Name (un) **] diabetes was consulted and adjusted her glargine upward
to 18 units by discharge. Before discharge, the patient was
provided with Humalog pen to demonstrate before nurse that she
was capable of handling appropriate use of pen for sliding scale
at home. The patient has close follow-up at [**Last Name (un) **] following
discharge.
.
# Urine colonization: The patient originally presented with a
urinalysis suggestive of infectio and mild abdominal tenderness.
She was started on levofloxacin therapy. The original urine
culture was > 100,000 organisms, but either alpha strep or
Lactobacillus. Second urine culture had the same results.
Because these were not pathogens, the levofloxacin was
discontinued.
.
# Cough: No consolidation was seen on X-ray. Patient mentioned
occasional productive cough. Given lack of fever and X-ray
findings, no specific antibiotic therapy was given. The
patient's cough may have been post-infectious or from viral URI.
She was afebrile for the duration of her stay of on the medicine
floor.
.
# Mitochondrial myopathy: The patieBnt reported having slightly
more pain in upper legs than usual, likely in the setting of
acute viral illness. Continued home carisoprodol and Lyrica.
The patient received occasional doses of Percocet, which
alleviated her upper leg pain.
.
# Hypertriglyceridemia: Continued home Lovaza therapy.
.
Medications on Admission:
HOME MEDICATIONS
ATENOLOL - 50 mg Tablet - One Half Tablet(s) by mouth daily
CARISOPRODOL - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 61694**] -
350 mg Tablet - [**11-28**] Tablet(s) by mouth at bedtime
CLOBETASOL - 0.05 % Cream - Apply over affected area at bedtime
GLUCOMETER TEST STRIPS - - ASDIR four times a day
INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - sliding scale
INSULIN GLARGINE [[**Month/Day (2) **] SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 16 at bedtime
ISOTRETINOIN [CLARAVIS] - 40 mg Capsule - 1 Capsule(s) by mouth
once a day [**Numeric Identifier 61695**] Ipledge #
ISOTRETINOIN [CLARAVIS] - 10 mg Capsule - 1 Capsule(s) by mouth
once a day [**Numeric Identifier 61695**] Ipledge # (pt. will be on 50 mg total of
Claravis)
METFORMIN [GLUCOPHAGE] - (Prescribed by Other Provider:
[**Name Initial (NameIs) **]) - 500 mg Tablet - 1 Tablet(s) by mouth 1 qAM, 2 at
night
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - 1 gram Capsule - 4
Capsule(s) by mouth qday
PREGABALIN [LYRICA] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13551**] -
200 mg Capsule - 1 Capsule(s) by mouth twice a day
UREA [CARMOL 40] - 40 % Cream - apply to hands and feet daily
ZOLPIDEM [AMBIEN] - (Prescribed by Other Provider: [**Name10 (NameIs) **] MD [**First Name (Titles) **] [**Hospital1 61696**] - Dr. [**Last Name (STitle) 61694**] - 10 mg Tablet - Tablet(s) by mouth
.
Medications - OTC
ALCOHOL SWABS - Pads, Medicated - ASDIR qday
ASPIRIN [ADULT LOW DOSE ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth once a day
INSULIN NEEDLES (DISPOSABLE) [PEN NEEDLE] - 31 gauge X [**4-11**]"
Needle - USE AS DIRECTED
LANCETS [BD ULTRA FINE LANCETS] - Misc - ASDIR at bedtime [**Month (only) 116**]
need to check up to 4 times per day
MAGNESIUM OXIDE - 400 mg Tablet - 2 Tablet(s) by mouth twice a
day
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO qHS () as
needed for leg pain.
3. pregabalin 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. omega-3 fatty acids Capsule Sig: Four (4) Capsule PO
daily ().
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. insulin glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous once a day.
7. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
8. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(secondary to blindness)
Discharge Instructions:
Ms. [**Known lastname 29571**],
It was a pleasure participating in your care at [**Hospital1 771**].
.
You were admitted to [**Hospital1 69**]
because your blood sugar was high. You went briefly to the
Intensive Care Unit in order to receive insulin in an IV and
hydration. Within one day, your blood sugar had stabilized and
you were able to be transferred to a regular medical floor of
the hospital. You were able to eat without any problems, and you
were able to give yourself insulin appropriately. The
specialists at [**Last Name (un) **] talked to you about increasing your [**Last Name (un) 8472**]
dose to 18 units. You have a follow-up appointment with them
that you are encouraged to keep to prevent you from needing to
come to the hospital again.
.
We also checked an X-ray to make sure your cough was not
pneumonia. You had no evidence of pneumonia. We further checked
your urine because you had abdominal pain when you first came
in. You did not have a urinary tract infection. We think your
cough and occasional feeling of nausea may be caused by a virus,
for which we have no medications. However, if you begin to feel
feverish, continue to have nausea, or feel worse overall, please
see your Primary Care Physician.
The following changes were made to your medications:
STOP taking metformin.
.
START taking 18 units of glargine insulin ([**Last Name (un) 8472**]) once a day.
.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2135-2-3**] at 11:40 AM
With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
When: Friday, [**2-4**], 9AM
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"277.87",
"250.13",
"369.4",
"276.51",
"599.0",
"359.89",
"272.1",
"079.99",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8979, 8985
|
4505, 6350
|
341, 347
|
9051, 9051
|
3024, 3024
|
10662, 11455
|
2078, 2150
|
8339, 8956
|
9006, 9030
|
6376, 8316
|
9241, 10639
|
4006, 4482
|
2165, 3005
|
265, 303
|
375, 1750
|
3040, 3990
|
9066, 9217
|
1772, 1883
|
1899, 2062
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,040
| 125,913
|
10206
|
Discharge summary
|
report
|
Admission Date: [**2146-7-10**] Discharge Date: [**2146-8-7**]
Date of Birth: [**2082-10-25**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
Spanish speaking male with a long and complicated medical
history, significant for diabetes mellitus, end-stage renal
disease on hemodialysis, hypertension, coronary artery
disease, and history of multiple lung infections, now
presenting with a left line site pain. Review of systems is
positive for nausea and vomiting, pain is also significant
along the spine in the back and along the legs, positive
history for malaise, increased shortness of breath, and a
non-productive cough. The patient denies any abdominal pain,
dysuria, or diarrhea.
His previous medical history is very involved. The patient
was last admitted in [**11-15**] for a superior vena cava syndrome,
occluded superior vena cava secondary to stenosis, and
possible deep vein thrombosis. The left internal jugular was
removed at that time. The patient was treated with Coumadin
and received hemodialysis through a femoral line at that
time. In [**Month (only) **], the arteriovenous fistula was unrepairable
and was removed in [**2146-6-14**]. A magnetic resonance
arteriography showed an occluded right system. The patient
was receiving dialysis through a left subclavian line which
now appears to be infected.
REVIEW OF SYSTEMS: Positive for chills.
PAST MEDICAL HISTORY:
1. End-stage renal disease, the patient receives
hemodialysis on Monday, Wednesday, and Friday at [**Hospital1 3494**]
where he is also followed by his primary care physician.
2. History of multiple line infections. Methicillin
resistant Staphylococcus aureus, vancomycin-resistant
enterococcus, and Klebsiella recently in [**8-16**],
vancomycin-resistant enterococcus in [**7-15**].
3. Diabetes mellitus.
4. Coronary artery disease, status post percutaneous
transluminal coronary angioplasty stent in left circ, status
post myocardial infarction.
5. Osteo-spine with previous line infection.
6. Chronic obstructive pulmonary disease.
7. Congestive heart failure.
8. Right internal jugular thrombosis and right subclavian
thrombosis as well as thrombosis of the superior vena cava
leading to a superior vena cava stenosis-like syndrome.
9. Peripheral vascular disease.
10. Hypertension.
11. Arteriovenous fistula thrombosis.
12. Atrial fibrillation paroxysmal, an echo in [**11-15**] showed a
normal ejection fraction.
HOME MEDICATIONS:
1. Amlodipine 10.
2. Aspirin.
3. Protonix.
4. Coumadin.
5. Nephrocaps.
6. Lactulose.
7. Morphine.
8. Atenolol.
9. Norvasc.
10. Zyprexa.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Does not use alcohol or smoke cigarettes.
Has been living with one woman for the majority of his life.
They are not married. At this time, she is his caretaker.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 101.2; heart
rate 75; blood pressure 150/68; respiratory rate 18; oxygen
saturation rate 95% on room air. General: patient is lying
in bed, breathing comfortably. Head, eyes, ears, nose and
throat: pupils are equal, round, and reactive to light and
accommodation, anicteric sclera. Neck: supple, no
lymphadenopathy. Chest: decreased breath sounds to the
bases with rails on deep inspiration. Cardiovascular: large
systolic murmur, no rubs, gallops, murmurs, consistent with
previously documented murmur. Abdomen: soft, non-tender,
non-distended, bowel sounds are present. Extremities: trace
edema, warm, weak pulses in lower extremities bilaterally,
dorsalis pedis pulses. Neurological: alert and oriented
times three, no focal deficits to gross confrontation.
LABS: White count normal 15.1; blood cultures pending.
HOSPITAL COURSE: The patient had a very long and complicated
hospital course.
1. Infectious Disease. The patient had a line infection and
was initially placed on vancomycin and gentamycin. The
gentamycin was continued for five days. His doses were
checked with the levels in hemodialysis and dosed
accordingly. The patient's blood cultures grew out a skin
sensitizing antibody. The patient was changed to oxacillin
which was started on [**7-13**]. Due to the back pain and the
patient's history of osteo to the spine with prior line
infections, there was concern over a receding of these bones.
It was decided that the patient would need a long course of
intravenous antibiotic therapy secondary to possible osteo as
well as ceding of multiple known blood clots. Due to his
heart murmur, there was also a question of endocarditis which
was evaluated. On the 20th, the patient's blood
sedimentation rate was 449, his white count 16.8. The
patient's back pain was evaluated with a magnetic resonance
scan of the cervical spine initially which showed an early
inflammatory process, though this was greatly resolved from
the last study. This was thought to be resolving from his
prior episode of osteomyelitis and not representing a new
condition. The patient also had a magnetic resonance scan of
the lumbar spine much later in his hospital course that
showed no osteo, no discitis which was relevant for possible
abscesses or hematomas in the psoas muscle which will be
discussed in a later section. The patient had a
transthoracic echocardiography initially to evaluate valvular
changes. The transthoracic echocardiography showed the left
atrium mildly dilated, a left to right shunt across the
internal atrial septum, consistent with a secundum-type
atrial septal defect, mild symmetric left ventricular
hypertrophy, and ejection fraction greater than 55. There
was, compared to the prior study, new aortic regurgitation
and the severity of mitral regurgitation was slightly
increased as this was suspicious for endocarditis. A
transesophageal echocardiography was ordered. The patient
initially refused the first attempt on [**7-18**]. The patient did
undergo a transesophageal echocardiography on [**2146-7-21**]. No
spontaneous echocontrast or thrombus was seen. No
vegetations were noted. The left ventricular ejection
fraction was consistent with greater than 55%. There were
abnormally thickened aortic valve leaflets with a non-mobile
focal echogenic structure, probable calcifications of the
non-coronary cusp, trace aortic insufficiency, and no aortic
abscess.
2. Abnormally thickened mitral valve encarditis with trace
mitral regurgitation. Moderate mitral annular calcification,
no vegetations. Abnormally thickened tricuspid valve, no
vegetations were seen. The possibility of endocarditis could
not be excluded. The patient was treated with intravenous
oxacillin beginning on [**7-13**] which was changed to intravenous
Cephazolin on [**7-27**] as this is dosed during dialysis and did
not require peripheral intravenous access and could be dosed
as an outpatient during dialysis sessions. The patient
continued to spike from [**7-10**] to [**7-19**]. The patient then
remained afebrile and stable throughout the rest of his
hospital admission.
3. Access. The patient had his initial infected line
changed over a wire on [**7-12**] as his INR was 2.1 and
Interventional Radiology felt uncomfortable removing the line
with this level of coagulation. Anticoagulation was held.
The patient was given Vitamin K as well as fresh frozen
plasma. The line was removed [**7-13**] and his hematocrit
stabilized. A PIC was added on [**7-20**] for intravenous
antibiotics as the patient had pulled out most of his
remaining peripheral access. On day 14 of intravenous
antibiotics, a permanent central dialysis catheter was placed
and his stem dialysis line which had been placed on [**7-12**] was
removed on [**7-28**]. A vascular mapping study was done on the
13th and Transplant will follow-up with these results to
evaluate for further fistula work-up. The patient
accidentally broke off one line of his PIC on [**8-1**] and then
this line was self discontinued on [**8-3**]. The patient went
home with stable and working dialysis access.
4. Hematology. The patient initially presented on Coumadin
for his paroxysmal atrial fibrillation. This was changed to
heparin to allow adjustments in his lines. In Interventional
Radiology, the patient had his line changed over a wire on
[**7-12**]. He was noted to have a large bleed at that time. This
will be discussed under the cardiovascular section. On [**7-20**]
the patient complained of some pain in his left thigh. There
was palpable pain over the lower abdomen and thigh area. The
patient had been on heparin sliding scale and had one dose
that was over 150 PTT. This was adjusted accordingly. This
pain began after this high supertherapeutic level. An
ultrasound was performed on the left thigh which showed no
fluid collection, no abscess. On the day of [**7-20**], the
patient's hematocrit was noted to drop from 31.5 to 25.6. He
developed an anion gap of 18. His CK increased to 263 while
his CKMB remained normal. The patient was afebrile. There
was no obvious source of bleed. The patient had one unit of
blood transfused. He had DIC labs performed which were
negative. The patient was taken for a CT of the pelvis with
no doubt a huge retroperitoneal bleed on the left which was 8
x 10 cm. The heparin was discontinued at that time and
Vascular Surgery was consulted. The patient was transferred
to the Intensive Care Unit from [**7-21**] to [**7-24**] where he received
8 units of packed red blood cells and 1 unit of fresh frozen
plasma. All anticoagulation was held. The patient received
dialysis while in the Intensive Care Unit, but clotted his
femoral dialysis access. This was changed over a wire while
the patient was in the Intensive Care Unit. His hematocrit
remained stable and he was transferred back to the floor on
the 10th. The patient's prior records of Hematology consults
were reviewed in regards to his superior vena cava syndrome
on [**2145-11-29**] which was noted for a questionable decrease in
protein S. His superior vena cava was secondary to stenosis
and thrombosis. At that time, he was started on three months
of anticoagulation. The patient was evaluated by Hematology
for further coagulation difficulties. The patient developed
anemia and was started on Epogen and hemodialysis. The
patient was transfused to keep the hematocrit above 30
throughout admission. On [**7-28**], the patient's PTT was noted
to once again be 150. This was unusual as he was not on
anticoagulation except heparin during his hemodialysis
sessions. Renal, Vascular, and Transplant team discussed the
issue of long-term coagulation with the Medical team. It was
felt that, in light of the patient's need for adequate
dialysis access and his history of clotting his lines and
fistulas, that his risk of re-bleed was well worth his risk
for clotting off all access that was necessary to provide
life saving and sustaining dialysis. The patient was started
on a light heparin sliding scale with the goal PTT of 50 to
80 and then change to Coumadin. His PTT was difficult to
control and once again at one point was 132. His INR
increased to 4.6 and all Coumadin and heparin were held. The
patient's INR continued to increase off Coumadin and off
sliding scale heparin. The patient was only receiving
heparin in dialysis. The patient had a large hematology
workup at that time to evaluate his difficult to control
coagulations. It was thought that his elevated INR was
secondary to an elevated PTT which was the result of heparin
dosed only during dialysis. All anticoagulation was held.
The patient was monitored until his INR was within a
therapeutic range. At 1.4, the patient was started back on
his home dose of Coumadin at that time and discharged home
for close follow-up for monitoring of his INR and coagulation
levels during dialysis.
5. Renal. The patient has end-stage renal disease on
hemodialysis. The patient received dialysis throughout his
hospital course. His volume status was adjusted multiple
times in dialysis. He was evaluated for peritoneal dialysis
as he has a history of infections and problems thrombosing
his dialysis lines. It was felt that he was not a candidate
for peritoneal dialysis at this time. The patient developed
increased itch, secondary to uremia, and increased phos
absorption after his large retroperitoneal bleed, secondary
to reabsorption of this bleed. He was started on three days
of Amphojel and improved with the help of the hemodialysis
team. The patient was also started on [**Doctor First Name **] as Benadryl
caused a change in mental status. This was followed by
hemodialysis and electrolytes were adjusted accordingly.
6. Cardiovascular. The patient had a history of paroxysmal
atrial fibrillation and was in and out of atrial fibrillation
throughout his hospital course. The patient had the infected
line changed over a wire on [**7-12**]. That evening, a large
amount of blood was noted on his bedsheets, presumably from
the site of line change. His hematocrit dropped from 31 to
25 over the course of [**7-13**]. He complained of crushing chest
pain and his troponin was 0.1, MB was 2, and CK 126. His
electrocardiogram showed ST depressions in V4 through V5.
The patient complained of his sharp back pain. There was a
question for aortic dissection. His pain resolved with
Nitroglycerin and 2 units of blood, as well as Nitroglycerin
paste. It was felt that this was likely demand ischemia.
The patient was taken to CT which showed no dissection, but
bilateral pulmonary effusions as well as a consolidation
consistent with infection versus septic emboli. The patient
was evaluated with a transthoracic echocardiography which has
been described previously. In the CT, the patient desatted
to an 02 sat in the 50s but was quickly revived and satted at
100% on 2 liters of oxygen. The patient's electrocardiogram
slowly resolved over time. The patient did not complain of
any further chest pain until the morning of [**8-1**]. The
patient was refused at dialysis because of this chest pain.
He responded to Nitroglycerin. Similar electrocardiogram
changes were noted with ST depressions in V5. The patient
was found on [**8-2**] to be 3 kilos down at hemodialysis. It was
thought this second episode of chest pain was also likely to
be secondary to demand ischemia. The patient improved with
fluids. The patient had frequent electrocardiogram checks
and these changes fully resolved over time. The patient was
on adequate cardiac therapy with beta-blockers, ace
inhibitors, aspirin, and anticoagulation. He did develop
some hypotension on Lopressor, but responded to a bolus
during this period of volume depletion. Volume depletion was
likely secondary to 3 days of nausea and vomiting.
7. Gastrointestinal. The patient experienced a 3 to 4 day
period of nausea and vomiting that preceded his 3 kilo volume
loss prior to the incidents described on [**8-1**]. This nausea
and vomiting was self limited. The patient responded to
boluses as well as increased by mouth intake.
8. Pulmonary. Initial CT showed questionable consolidation
at the right lung base. A repeat CT showed a 13 mm nodule at
the right lung base which was assessed by Pulmonary consult.
They felt this was likely a resulting septic emboli and
recommended a follow-up CT as an outpatient. A percussion
and postural drainage was also placed which was read as
negative.
9. Mental status changes. The patient had noticeable mental
status changes starting [**7-12**] and persisting through the
beginning of [**Month (only) 216**]. Over the weekend of [**7-17**], the patient
required Zyprexa, Risperdal, and restraints. Apparently, the
patient had tried to bite a staff member and pulled out most
of his peripheral lines. It was thought the patient was
sundowning as well as having a negative response to Benadryl.
As patient's temperature resolved, the medical condition
stabilized and his mental status changes resolved.
DISCHARGE DIAGNOSIS:
1. Methicillin-susceptible Staphylococcus aureus line
infection with possible septic emboli to the lung.
2. Possible endocarditis.
3. Status post large retroperitoneal bleed
4. End-stage renal disease on hemodialysis.
5. Diabetes mellitus type II.
6. Coronary artery disease with demand ischemia.
7. Allergy.
8. Possible coagulopathy.
9. Possible acquired factor 8 deficiency.
RECOMMENDED FOLLOW-UP:
1. The patient will proceed to dialysis three times a week.
2. The patient will have his INR, PT, and PTT checked Monday
at dialysis or by his home [**Hospital6 407**]
nursing.
3. He will contact Dr. [**Last Name (STitle) 34032**] with his coagulations.
4. Dr. [**Last Name (STitle) 34032**] will contact patient to adjust his Warfarin
dose.
5. The patient will follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the
transplant center.
6. The patient will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2146-8-9**]
for adjustment of his Warfarin.
7. The patient will follow-up with Dr. [**First Name (STitle) **] in the next few
weeks, his primary care physician.
DISCHARGE CONDITION: Fair, tolerating by mouth, minimal
walking, no nausea, vomiting, or diarrhea. His INR is down
to 1.2 on the day of discharge.
DISCHARGE MEDICATIONS:
1. Docusate sodium.
2. Senna.
3. Folic Acid, Vitamin B.
4. Pantoprazole 40.
5. Nitroglycerin sublingual as needed.
6. Metoprolol 100 three times a day.
7. Insulin regular sliding scale. The patient reports he
uses a regular sliding scale at home and is familiar with its
use.
8. Enalapril 10.
9. Amlodipine 10 once daily.
10. Fexofenadine 60 once daily as needed for itch.
11. Sarna lotion.
12. Aspirin 325 once daily.
13. Warfarin 7.5 once daily or as instructed by physician.
14. Epogen alpha with hemodialysis.
15. Cephazolin at hemodialysis.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 34033**]
MEDQUIST36
D: [**2146-8-17**] 12:20
T: [**2146-8-17**] 18:47
JOB#: [**Job Number 34034**]
|
[
"496",
"286.3",
"996.62",
"038.11",
"459.0",
"427.31",
"428.0",
"285.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
17202, 17330
|
17353, 18193
|
16025, 17180
|
3778, 16004
|
2513, 2697
|
1421, 1443
|
181, 1401
|
2913, 3760
|
1465, 2495
|
2714, 2898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,433
| 177,030
|
53289
|
Discharge summary
|
report
|
Admission Date: [**2179-11-26**] Discharge Date: [**2179-12-1**]
Date of Birth: [**2109-2-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Ampicillin / Gentamicin
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Transfer from TICU s/p craniotomy for SDH, also with suspected
aortic abcess
Major Surgical or Invasive Procedure:
Status-post right craniotomy for evacuation of subdural hematoma
History of Present Illness:
70M with PMH of Hep C, HTN, HL, aortic and tricuspid valve
endocarditis s/p AVR and TVR on [**2178-12-17**] with a week of
progressive weakness, fatigue and headache. Recently admitted
[**9-24**] with persistent endocarditis, he has not felt well since
that admission. TTE on [**11-26**] showed recurrent aortic root
abscess. He had an MRI performed on the morning of [**11-27**] that
showed a R sided acute on subacute SDH. He had a head CT/CTA
which showed no vascular malformation and he was brought to the
OR for emergent craniotomy and evacuation. He had 2 packs of
platelets intra-operatively as he was on daily ASA. Initial plan
was for TEE, however AMS and weakness likely [**1-18**] SDH and Dx of
aortic root abscess confirmed by TTE.
====
70M with PMH of Hep C, HTN, HL, aortic and tricuspid valve
endocarditis s/p AVR and TVR on [**2178-12-17**] with a week of
progressive weakness, fatigue and headache. Recently admitted
[**9-24**] with persistent endocarditis. Saw Dr[**Doctor Last Name **] today who
wrote: "Today in clinic, [**Known firstname 5279**] feels "terrible" - no energy,
dizzy, headache, felt very cold yesterday (despite temp in his
apartment being 79). He has not felt well since admission in
[**Month (only) 359**]. Given these symptoms and his history of recurrent
endocarditis, will check blood cultures, CBC, chem 7 and get him
into hospital. Probable TEE in am."
.
The patient denies fevers, chills or nightsweats and no CP. He
also denies paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope. he does endorse
worsening headache x 4 days. Of note, he underwent
EGD/Colonoscopy done for reflux and screening, respectively on
[**11-22**]. Findings were only significant for diverticulosis of the
sigmoid colon. He felt worse after this and the next day the
headache began.
.
Of note, his Abiotrophia endocarditis occurred about a year ago
and then again in [**Month (only) 359**], and he does have a porcine valve at
this time. He was about to complete a six-week course of
ampicillin and gentamicin in [**Month (only) **] when he noted diffuse
pruritus. He saw ID, who advised him to stop the Amp/Gent and
wrote: "So, therefore, we will try to do vancomycin for three
days. We will start at a gram every 24 hours given his renal
insufficiency, and this is a dose that he had used in the past.
After stopping the vancomycin, we will switch him to
moxifloxacin 400 mg daily for suppression, and we will need to
determine the duration of this at a later date." Echo done
(prelim) showed: Aortic root abscess with moderate aortic
regurgitation, bioprosthetic aortic valve replacement with
likely vegetation although not well seen and higher than
expected transvalvular gradient. Tricuspid valve replacement
well seated with normal gradients. Low-normal left ventricular
ejection fraction (EF 50-55%). WBC 7.6, afebrile in clinic
today.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
Aortic and tricuspid valve endocarditis s/p AVR and TVR in
[**12-25**] and recent admission [**9-24**] with abiotrophia/granulicatella
endocarditis and aortic abcess
- Psoriatic arthritis
- Hyperlipidemia
- Hypertension
- Hepatitis C
- diverticular disease
- degenerative joint disease
- MRSA
PAST SURGICAL HISTORY
- Aortic valve replacement with a 23mm St. [**Hospital 1525**] Medical Epic
tissue valve and a tricuspid valve replacement with a 33-mm
tissue valve in [**12-25**] by Dr. [**Last Name (STitle) **]
- s/p wisdom tooth extraction, root canal [**9-24**]
- osteomyelitis rifht foot after surgery
- s/p Right hip arthroplasty
- s/p hemorrhoidectomy
CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, Age
CARDIAC HISTORY:
-Endocarditis per above
Social History:
He is not married.
He has no children and lives alone.
No history of tobacco or alcohol.
Denies IVDA.
Family History:
No family history of CAD, MI, cancer. Per patient no family
medical problems.
Physical Exam:
VS: T 98 BP 132/89 HR 86 RR 17 O2 99/RA
GENERAL: Well appearing gentelman, conversant, laying in bed and
in no acute distress.
HEENT: Surgical scar with staples along the right occiput.
Sclera anicteric. No conjuntival hemmorhage. PERRL, EOMI. OP
clear, no exudates/pus
NECK: Supple, JVP ~9 cm.
CARDIAC: Regular rate, normal S1 S2. A 2/6 Systolic murmur is
appreciated along the right/left substernal boarder. No rubs or
gallops.
LUNGS: Clear to auscultation bilaterallery, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: Trace edema bilaterally. No osler nodes, [**Last Name (un) **]
lesions, or splinter hemorrhages. Palpable DP/PT pulses
bilaterally
SKIN: Pedal scaliness and hyperpigmentation with some evidence
of joint swelling.
NEURO: Alert and oriented x 3, CN 2-12 intact, 5/5 strength
throughout, sensation to light touch intact throughout, no
pronator drift, down going toes, normal finger to nose, normal
rapid alternating movements.
Pertinent Results:
EKG: sinus at 63, mildly irregular but no apparant PACs or PVCs,
no ST elevations. ST depression III, QtC 413. Unchanged from
[**10-15**]
2D-ECHOCARDIOGRAM: [**11-26**]
- Left atrium mildly dilated, mild LVH with normal cavity size
and global systolic function (LVEF>55%). Ascending aorta is
moderately dilated. Aortic arch is mildly dilated.
- A bioprosthetic aortic valve with mild (1+) paravalvular
aortic valve leak is present, through a relatively echolucent
area at the aortic annulus, adjacent to the right sinus of
Valsalva. The bioprosthesis itself is seated normally, without
evidence of dehiscence.
- A bioprosthetic tricuspid valve well seated, with normal
leaflet motion and transvalvular gradients. The severity of
tricuspid regurgitation seen is normal for this prosthesis.
- Estimated pulm artery systolic pressure is normal; borderline
pulmonary artery systolic hypertension.
MRI Head: [**11-27**]
Right sided subacute subdural hematoma which extends from
frontal
to occipital region is new since previous CT of [**2179-10-16**]. The
SDH is 15-mm in width with a midline shift.
CTA Head: [**11-27**]
- Right-sided subdural hematoma with mass effect and midline
shift.
- Except for vascular displacement due to mass effect from the
hematoma, no abnormalities are seen on CT angiography of the
head. No abnormal vascular structures or aneurysm identified.
CT Head: [**11-27**]
- Interval right craniotomy with expected post-surgical change
with
decreased mass effect. No evidence of new acute intracranial
hemorrhage or major vascular territory infarction.
LABORATORY DATA ON ADMISSION:
136 | 100 | 20
----------------< 112
4.2 | 24 | 1.4
Ca: 8.7 Mg: 2.2 P: 2.8
Phenytoin: 6.3
\ 90 /
8.0 --- 10.7
/30.9\
INR: 1.2
SELECT LABS ON DISCHARGE:
[**2179-11-30**] 07:15AM BLOOD WBC-6.1 RBC-3.72* Hgb-11.5* Hct-32.9*
MCV-89 MCH-31.1 MCHC-35.1* RDW-13.5 Plt Ct-206
[**2179-11-30**] 07:15AM BLOOD Plt Ct-206
[**2179-11-30**] 07:15AM BLOOD Glucose-90 UreaN-19 Creat-1.5* Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
[**2179-11-30**] 07:15AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.3 Mg-2.0
[**2179-11-30**] 07:15AM BLOOD Phenyto-8.6*
Brief Hospital Course:
70 year old gentleman with AVR/TVR [**2178-12-17**] [**1-18**] to
endocarditis, as well as HCV, HTN, and HL, admitted with concern
for persistant aortic abcess and subsequently found to have a
sub-dural hematoma of unclear etiology.
# Subdural Hematoma s/p Craniotomy and Evacuation: Discovered on
admission. Craniotomy and evacuation completed without
significant complications. Post-operative head CT showed
improvement in midline shift. Prophylactically treated with
dilantin and blood pressures kept < 140. Aspirin held. Patient
discharged with plans for removal of stiches in 2 weeks,
follow/up appointment in 4 weeks, and repeat non-contrast head
CT.
# Endocarditis: recurrent, with concern for persistent aortic
abcess on TTE. Follow up TEE unable to be completed during this
admission. Blood cultures all with no growth during this
admission. Afebrile. No new murmurs on exam. Patient continued
on moxifloxacin for suppression therapy.
# Arrythmia: History of Wenckebach and atrial fibrillation on
most recent hospitalization however in normal sinus rhythm
across this admission. Aspirin being held as above.
# HTN: Normotensive across hospitalization. Given SDH goal is
SBP < 140.
# Acute on Chronic Renal Insufficiency: Admitted with creatinine
at 1.8 vs baseline of 1.5, most likely pre-renal in setting of
lasix use. Home lasix held. Creatinine resolved and was 1.5 at
the time of discharge.
# Anemia: Stable, at baseline, HCT 32.9.
# Anxiety: Continued on home lorazepam and ativan.
# Psoriasis: Continued on home Calcipotriene and Clobetasol
creams.
# OSA: Continued on CPAP.
Medications on Admission:
Tylenol PRN pain
Fluticasone 50 mcg/Actuation Spray, daily
Clobetasol 0.05 % Cream [**Hospital1 **] for psoriasis
Calcipotriene 0.005 % Cream TID for psoriasis.
Docusate Sodium 100 mg [**Hospital1 **] PRN
Chlorhexidine Gluconate 0.12 % Mouthwash 15 ML [**Hospital1 **]
Lorazepam 0.5 mg QHS
Alprazolam 0.25mg [**Hospital1 **] PRN
Aspirin 325 mg daily
Moxifloxacin 400mg daily
Lasix 40mg [**Hospital1 **]
MVI
Discharge Medications:
1. Outpatient Lab Work
please check phenytoin level on Monday [**12-6**]. Please send
results to Dr.[**Name (NI) 12757**] office, phone: ([**Telephone/Fax (1) 26566**] fax: ([**Telephone/Fax (1) 109665**].
2. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO Daily () as
needed for Endocarditis: do not stop unless told to by your
infectious disease physician.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day): please have your phenytoin level checked
as directed.
[**Name Initial (NameIs) **]:*120 Capsule(s)* Refills:*2*
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) Mucous
membrane twice a day: resume your home regimen prior to
hospitalization.
9. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 10 days: Please
use only as needed for pain. Please do not drive or operate
machinery while taking this medication.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis:
- Subdural hematoma
Secondary diagnosis:
- Endocarditis
- Psoriatic arthritis
- Hypertension
- Hyperlipidemia
- Hepatitis C
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted from Dr.[**Doctor Last Name 35583**] office for evaluation
after reporting feeling unwell. Plans were made to undergo a
trans-esophageal echocardiogram (TEE), however a MRI obtained to
evaluate your headache demonstrated a type of bleeding around
the brain, called a subdural hematoma. You underwent surgical
evacuation of the bleeding and did well post-operatively.
The following medication changes were made:
- STOPPED aspirin due to the subdural bleed. Please discuss with
your neurosurgeon and cardiologist before re-starting this
- STARTED phenytoin 200 mg twice a day to prevent seizures. You
will need to have a level checked (through blood work) on
Monday, [**12-6**].
- STARTED oxycodone/acetaminophen 1-2 tablets every four hours
as needed for pain related to your surgery. Please note that
this contains acetaminophen (Tylenol).
- STOPPED lasix (taken for excess fluid)
Weigh yourself every morning, call Dr.[**Name (NI) 35583**] office to
discuss re-starting lasix (furosemide) if weight goes up more
than 3 lbs.
You were followed by the infectious disease team and should
continue the Moxifloxacin daily for your history of
endocarditis.
Please also follow up with your dentist for further management.
Followup Instructions:
Please follow up with Dr.[**Name (NI) 12757**] office around [**12-6**]
for staple removal. Please call his office to arranage for a
follow up appointment in the next few weeks--his office knows
you will be calling to arrange an appointment as his schedule is
being worked out. The number is ([**Telephone/Fax (1) 26566**]. You will need a
repeat head CAT scan at that time as well.
You will need to have blood work done to check the level of
phenytoin [**2179-12-6**], with the results faxed to Dr.[**Name (NI) 12757**]
office at fax ([**Telephone/Fax (1) 109666**].
Please follow up with your cardiologist, Dr.[**Doctor Last Name 3733**], at an
appointment made for you on [**12-21**] at 4:00 PM. If you need
to re-schedule, please call his office at ([**Telephone/Fax (1) 2037**].
Please follow up with Dr. [**Last Name (STitle) 13895**] (your infectious disease
provider) at an appointment made for you on Tuesday [**12-28**]
at 9:00 AM. If you need to re-schedule, please call ([**Telephone/Fax (1) 10**].
You also have an appointment with your renal (kidney) physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**], on Feburary 2nd, [**2179**]. The number for the
clinic is [**Telephone/Fax (1) 721**].
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
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[
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366, 433
|
12063, 12063
|
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4694, 4798
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,311
| 126,026
|
28264
|
Discharge summary
|
report
|
Admission Date: [**2186-8-15**] Discharge Date: [**2186-8-21**]
Date of Birth: [**2120-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
Mr. [**Known lastname 68645**] is a 66 yo M w/PMHx of Stage III metastatic NSCLC
([**7-/2184**]), sleep apnea, diabetes with nephropathy who was
transferred from an OSH for mental status changes and possible
PNA. He was found to have acute renal insufficiency with rise in
creatinine to 4.0 from baseline 1.5 ([**8-4**]).
Pt recently began chemotherapy under an experimental protocol.
After his first treatment, he was hospitalized for hypoxia [**12-22**]
malignant pleural effusion (per wife's report). After holding
Lovenox for thoracentesis on [**7-31**], he was noted to have swelling
of his LUE, so lovenox was restarted. He was also started on
Levofloxacin during this admission. He did have some confusion
and new changes in motor function during that stay, but CT head
was negative.
He was discharged to rehab 10 days prior to current admission.
At rehab facility he continued to have improved function. He
underwent the 2nd course of the experimental chemotherapy which
lasted 48h and completed on [**8-11**]. On [**8-12**], he received oxycontin
for pain (prior to this he had been receiving oxycodone). His
wife noted, that lethargy began on Saturday and acutely
progressed after receiving the 1st of 10 sessions of XRT on
Monday. The wife states that his last dose of oxycontin was the
day prior to admission jerking movements and staring episodes
are new. He developed a fever to 101 on day of admission. He was
also noted to be hypotensive to the systolics 90s-100s with HR
120s during his OSH ED stay. CXR at an OSH revealed multilobar
infiltrates. He was started on Ceftriaxone and Flagyl, then
transferred to [**Hospital1 18**].
In the [**Hospital1 18**] ED, the patient received one dose of Vancomycin and
NS. MS improved and pt transfered to floor. While getting CXR pt
noted to be more somnolent and briefly unresponsive to sternal
rub. ABG at this time was 7.26/69/76 on 4L NC. Found to be
hyperkalemic, NGT placement attempted to administer Kayexalate
but this was unsuccessful. Pt then responsive but continued to
be somnolent. BP stable in 100's and HR 102. O2sat stable at 96%
on 4L NC.
Given hypercarbia and possible need for BIPAP, he was admitted
to the MICU. He required BIPAP at night initially, but was soon
changed to NC. A pleural effusion was tapped on [**8-17**] and was
negative for malignant cells. His mental status, ARF and
hyperkalemia improved and he was called out to the floor, still
on 4liters NC.
Past Medical History:
1. Metastatic NSCLC - diagnosed in [**7-24**]
- on experimental chemo with last treatment on [**8-11**]
- XRT [**11-29**] on [**8-13**]
2. CAD s/p MI [**2174**], PCI with BMS
3. Diabetes melitus
4. Hyperlipidemia
5. PUD with UGIB on Lovenox
6. SVC clot - now on Lovenox
7. DVT left arm
8. Sleep Apnea
9. Peripheral neuropathy s/p taxane
10. History of flash pulmonary edema
Social History:
Denies alcohol or IVDU
Positive tobacco use
Family History:
NC~
Physical Exam:
VS: 96.9 BP 96/60 HR 102 RR 18 O2sat 96% 4L
Gen: Mildly Ill appearing, enlarged neck, arousable, responding
to all questions.
HEENT: Thick neck, w/ edema and induration on L > R. MM dry.
Hemorrhagic crusting of hard palate.
Hrt: RR. Tachycardic. No murmurs or rubs.
Lungs: Dullness to percussion over right lung, with minimal
breath sounds. Expiratory wheezing at left base. Distant breath
sounds.
Abd: NABS. S/obese. No organomegaly.
Ext: WWP. Trace pretibial edema. 2+radial pulses, 1+ DP pulses.
Left upper extremity markedly swollen. Lower ext without edema.
Mult areas of excoriation on lower ext and uppe of ext.
Neuro: Alert and oriented to self, time and "hospital". Able to
recall meds and recent medical course. Asterixis.
Pertinent Results:
LAB DATA:
CHEMISTRIES:
[**2186-8-15**] 04:30AM GLUCOSE-117* UREA N-36* CREAT-4.0*
SODIUM-132* POTASSIUM-5.8* CHLORIDE-96 TOTAL CO2-26 ANION GAP-16
[**2186-8-15**] 01:30PM PHOSPHATE-5.7* MAGNESIUM-2.0
[**2186-8-15**] 05:34PM freeCa-1.15
CBC:
[**2186-8-15**] 04:30AM WBC-10.7 RBC-3.27* HGB-9.2* HCT-27.3* MCV-83
MCH-28.2 MCHC-33.8 RDW-17.0*
[**2186-8-15**] 04:30AM NEUTS-84.7* LYMPHS-12.0* MONOS-1.4* EOS-1.8
BASOS-0.2
[**2186-8-15**] 04:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MICROCYT-1+
[**2186-8-15**] 04:30AM PLT COUNT-450*
COAGS:
[**2186-8-15**] 05:00AM PT-12.5 PTT-37.6* INR(PT)-1.1
UA:
[**2186-8-15**] 10:41AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2186-8-15**] 10:41AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2186-8-15**] 10:41AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2186-8-15**] 10:41AM URINE AMORPH-FEW
MISC:
[**2186-8-15**] 04:42AM LACTATE-1.4
[**2186-8-15**] 08:36PM ALBUMIN-2.9*
ABG:
[**2186-8-15**] 05:34PM TYPE-ART PO2-76* PCO2-69* PH-7.26* TOTAL
CO2-32* BASE XS-1
CXR ([**2186-8-15**]):
1. Dense opacity identified in the right upper lung field likely
corresponding to patient's known lung cancer.
2. Diffuse airspace opacity within the right lung fields
represents atelectasis versus pneumonia. Please correlate
clinically as there are no prior radiographs available for
comparison.
3. Normal position of right PICC line.
CXR ([**2186-8-18**]):
1. Interval removal of fluid with slight improved aeration of
the right lung with persistent large opacity in the right mid
lung zone, which consists of tumor and atelectasis.
2. Persistent asymmetric pulmonary edema. See report of recent
CT for more details.
CT head ([**2186-8-15**]):
1. No evidence of acute intracranial process. Please note that
metastatic disease cannot be excluded by this non-contrast
study.
2. Stranding in the fat overlying the right upper neck, near the
skull base. Correlation with physical examination is
recommended.
Note added at attending review: I think the soft tissue
stranding is on the left.
CT head ([**2186-8-20**]):
No evidence of acute intracranial hemorrhage or significant
change from the prior study.
Chest US ([**2186-8-16**]):
Moderate-sized right pleural effusion, the upper extent of which
cannot be visualized given lack of proper positioning. This
effusion appears amenable to ultrasound-guided thoracentesis and
can be performed with personnel from the referring team to
assist in positioning and monitoring patient.
Renal US ([**2186-8-16**]):
No evidence of obstruction.
CT Chest ([**2186-8-17**]):
1. Large right hilar mass with bronchial obstruction, extensive
mediastinal lymphadenopathy and axillary lymphadenopathy and
multiple left lung and possible thoracic vertebral metastases.
2. Bilateral pleural and small pericardial effusion. Possible
right pleural tumore implant.
3. Pericardial effusion.
Brief Hospital Course:
A/P: 66 yo M w/PMHx sx metastatic lung cancer s/p chemotherapy,
recent hospital stay for pneumonia presents from rehab with
altered mental status and acute renal failure with rise in
creatinine from 1.0 to 4.0.
1. Pneumonia:
PNA on CXR, presumed post-obstructive. Started vanco/zosyn and
transitioned to augmentin on [**8-18**]. Patient afebrile since. New
leukocytosis to 12 on [**8-20**], but was been asymptomatic. Was on
bipap on admission but transitioned and on discharge was on room
air with a low to mid 90s saturation. Ambulatory saturation in
the low 90s off O2.
Plan on discharge was for continuation of Augmentin (Day 1 =
[**8-15**]) for 14 total days. He was to be discharged with immediate
follow-up (same day) at [**Company 2860**].
2. ARF:
Etiology of renal failure was likely multifactorial including IV
contrast from recent admission, continuation of nephrotoxic
medications including LMWH, losartan, and furosemide, as well as
recent antibiotics, including ceftriaxone and vancomycin. Renal
was consulted and suspected ATN given casts in urine and period
of hypotension. Renal US did not show obstruction. Held [**Last Name (un) **] on
admission but restarted the morning of discharge (at half dose).
SCr returned to baseline and was 0.9 on discharge; the patient
was making good urine.
3. Hyperkalemia:
Was likely secondary to renal failure. Peaked at 6.4 on [**8-16**]
and was within normal limits upon discharge. The patient never
required dialysis.
4. MS changes-
This may have been secondary to oxycontin vs hypercarbia vs
uremia. His mental status remained poor over the first few days
in the ICU, but improved over his hospital stay. He was alert
and oriented to person, place (although he often thought he was
at B&W hospital) and time. Narcotics were held with use of
ultram for pain control - this worked well.
5. NSCLC:
Primary oncologist is Dr. [**Last Name (STitle) **] [**Name (STitle) 23**] at [**Company 2860**] ([**Telephone/Fax (1) 68646**].
Was getting radiation for postobstructive pneumonia. Had
recently received experimental chemotherapy.
Plan on discharge was for same-day followup at [**Company 2860**] for XRT with
scheduling of appointment with Dr. [**Last Name (STitle) 23**] at that time
6. SVC clot:
Initially treated with heparing drip - transitioned back to
lovenox 80 sc bid on [**8-20**].
7. DM
Initially, oral meds were held and a sliding scale was used. On
the morning of discharge, both oral hyperglycemics were
restarted as the patient was taking good PO.
8. History of UGIB:
Per report for OSH the patient had UGIB while on lovenox. The
patient's hematocrit was stable while in house - he was
initially on heparin and later back on lovenox.
9. Unequal pupils:
Not on exam of [**8-20**]; not noted on prior exams. Previous head CT
did not show any obvious cause for this and repeat head CT was
unchanged.
Communication: [**Name (NI) 335**] [**Name (NI) 68645**] (wife) [**Telephone/Fax (3) 68647**]
Code Status: DNR/DNI.
Medications on Admission:
MEDICATION (home):
albuterol INH 2 puff, Q6H
atenolol 100mg daily
atorvostatin 80mg daily
enoxaparin 80mg SC Q12H
esomeprazole 40mg [**Hospital1 **]
furosemide 40mg daily
neurontin 600mg TID
levofloxacin 500mg daily
lorazepam 0.5mg QHS
losartan 100mg [**Hospital1 **]
metformin 850mg [**Hospital1 **]
MVI
ondansetron 8mg [**Hospital1 **] PRN
oxazepam 10mg QHS
oxycodone 5mg Q4H PRN
paroxetine 20mg daily
pioglitazone 45mg daily
.
MEDICATIONS (at OSH):
Paroxetine 20mg daily
Senna 2 tabs [**Hospital1 **]
MVI
Atorvstatin 80mg qd
Colace [**Hospital1 **]
Lovenox 80mg SC bid
Esemeprazole 40mg [**Hospital1 **]
Neurontin 600mg tid
Ativan 0.5mg [**Hospital1 **]
Lasix 40mg qd
Losartan 100mg [**Hospital1 **]
Metformin 850mg [**Hospital1 **]
Serax 10 mg po qhs
Oxycodone prn
Actose 22.5mg po bid
Carafate 1gm QID
Reglan 10mg qachs
Tylenol prn
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: [**11-21**] Inhalation every
six (6) hours.
2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
5. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation, sleep.
7. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed for nausea.
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
14. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
15. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H PRN () as
needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
16. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
17. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO at bedtime.
18. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
greater [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
PNA
ARF
hyperkalemia
mental status change
pleural effusion
NSLCA
DM
history of UGIB
Discharge Condition:
Good; improved
Discharge Instructions:
You were admitted with a diangosis of pneumonia, acute renal
failure and mental status change.
If will be very important that you not take narcotic medications
at this time (examples include oxycontin, oxycodone, percocet).
You are being given a prescription for ultram which has worked
well for your pain while here.
Of note, your dose of losartan is currently half the dose that
were taking before coming into the hospital. You may need to go
back on the higher dose in a few days - please be sure to have
your blood pressure checked and this followed up by your PCP.
Also, we are holding your lasix on discharge. You have not been
getting it daily while here. Again, please be sure to address
this with your PCP at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment.
Additionally, you are being treated for a pneumonia and will be
given a total of 14 days of antibiotics. Be sure to complete
this course.
You are being discharged with plans for XRT today.
Followup Instructions:
You will be following up at [**Company 2860**] today for XRT. They will make
an appointment for you with Dr. [**Last Name (STitle) 23**] at that time.
Additionally, you should be sure to make an appointment to see
your PCP [**Last Name (NamePattern4) **] [**11-21**] weeks.
|
[
"428.0",
"V15.3",
"162.9",
"276.7",
"459.2",
"197.2",
"584.5",
"486",
"293.0",
"518.84",
"250.40",
"583.81",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
12523, 12630
|
7083, 10089
|
325, 341
|
12758, 12775
|
4066, 7060
|
13818, 14097
|
3292, 3297
|
10977, 12500
|
12651, 12737
|
10115, 10954
|
12799, 13795
|
3312, 4047
|
276, 287
|
369, 2817
|
2839, 3215
|
3231, 3276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,906
| 102,586
|
51598
|
Discharge summary
|
report
|
Admission Date: [**2180-10-7**] Discharge Date: [**2180-10-11**]
Date of Birth: [**2133-1-12**] Sex: F
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9871**]
Chief Complaint:
Severe back pain
Major Surgical or Invasive Procedure:
Removal of portacath
Femoral line
Pressor support
History of Present Illness:
47F with breast cancer metastatic to bone, breast, and lung,
status post multiple rounds of chemotherapy complicated by
herceptin-induced cardiomyopathy with Serratia
hypotension/sepsis. Patient presented to the Emergency
department with severe back pain unlike previous back pain due
to metastatic lesions, refractory to Vicodin. As patient was
being worked up in ED for spinal cord compression, patient
became extremely hypotensive to systolic blood pressures to
70s-80s. Patient was administered 4 liters of IV fluid bolus and
was transferred to the [**Hospital Unit Name 153**] where she was maintained on Levophed
and Vasopressin with SBP in 100s (MAPs 58-83). Patient was felt
to be in bacterial sepsis and empirically started on vancomycin
and ceftriaxone which was later changed to ceftazidime and
ciprofloxacin when blood cultures were positive for gram
negative rods X [**3-1**].
Patient denies previous history of sepsis, has never been on
TPN, has no history of urinary tract infections, and has had
this porta cath since [**2179-4-27**]. In addition, patient complains
of history of loss of right hand dexterity over the last year,
with tingling in the fingertips of both hands, which she feels
started when she began taking Decadron. Otherwise, she denies
any asymmetric weakness or paresthesias.
Past Medical History:
1) Pulmonary embolism [**2180-6-27**], anticoagulated on Coumadin
(target INR [**2-29**])
2) Breast Cancer
3) Hypertension
4) Depression
5) S/P tonsilectomy
6) Cardiomyopathy due to Herceptin toxicity - Ejection fraction
<20%
Social History:
Patient lives at home with husband and three children, aged 22,
19, and 16.
- Denies tobacco use
- Drinks alcohol only occasionally
Family History:
Uncle: Liver cancer
Aunt: [**Name (NI) **] Tumor
Uncle: Congestive [**Name (NI) 3495**] Failure/Coronary artery disease
Father: alive and well
Mother: multiple cerebrovascular accidents
Physical Exam:
VS. T99F P85 BP110/52 (MAP71) RR20 95%
General: Pleasant, mildly obese woman in no acute distress
HEENT: NCAT. PERRL, EOMI, OMM, no lesions, no thrush.
Neck: supple, no cervical lymphadenopathy, no JVD.
CV: normal S1, S2, regular rate and rhythm, no murmurs, rubs, or
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
Abdomen: Bowel sounds present, nontender, nondistended, no
rebound or guarding.
Extremities: no pitting edema
Neuro: Alert and oriented X 3
- CNII-XII intact
- Strength 5/5 all extremities except right
- Reflexes 1+ throughout, symmetric, Negative for clonus.
- Sensation light touch intact throughout.
Pertinent Results:
[**2180-10-7**] 11:00PM GLUCOSE-195* UREA N-11 CREAT-0.3* SODIUM-134
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-20* ANION GAP-13
[**2180-10-7**] 11:00PM CALCIUM-8.1* PHOSPHATE-1.9* MAGNESIUM-2.5
IRON-69
[**2180-10-7**] 11:00PM calTIBC-225* FERRITIN-1437* TRF-173*
[**2180-10-7**] 11:00PM HCT-27.7*
[**2180-10-7**] 11:00PM PT-15.1* PTT-33.2 INR(PT)-1.4
[**2180-10-7**] 11:08AM PO2-98 PCO2-32* PH-7.43 TOTAL CO2-22 BASE
XS--1
[**2180-10-7**] 11:08AM K+-3.5
[**2180-10-7**] 11:08AM freeCa-1.05*
[**2180-10-7**] 11:00AM GLUCOSE-102 UREA N-15 CREAT-0.5 SODIUM-135
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-21* ANION GAP-14
[**2180-10-7**] 11:00AM ALT(SGPT)-39 AST(SGOT)-29 ALK PHOS-40
AMYLASE-48 TOT BILI-1.1
[**2180-10-7**] 11:00AM LIPASE-29
[**2180-10-7**] 11:00AM ALBUMIN-3.1* CALCIUM-7.0* PHOSPHATE-2.8#
MAGNESIUM-1.2*
[**2180-10-7**] 09:43AM LACTATE-2.4*
[**2180-10-7**] 05:13AM LACTATE-3.3*
[**2180-10-7**] 04:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2180-10-7**] 04:50AM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2180-10-7**] 02:20AM GLUCOSE-92 UREA N-20 CREAT-0.5 SODIUM-138
POTASSIUM-3.0* CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2180-10-7**] 02:20AM WBC-3.1*# RBC-3.41* HGB-10.6* HCT-30.5*
MCV-90 MCH-31.3 MCHC-34.9 RDW-16.7*
[**2180-10-7**] 02:20AM NEUTS-61 BANDS-16* LYMPHS-19 MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2180-10-7**] 02:20AM HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
[**2180-10-7**] 02:20AM PLT COUNT-81*
[**2180-10-7**] 02:20AM PT-24.3* PTT-150* INR(PT)-3.7
------------------
[**2180-10-7**] 4:35 am BLOOD CULTURE
**FINAL REPORT [**2180-10-9**]**
AEROBIC BOTTLE (Final [**2180-10-9**]):
REPORTED BY PHONE TO [**Last Name (LF) **] , [**First Name3 (LF) **] AT 10PM [**2180-10-7**].
SERRATIA MARCESCENS. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy..
Therefore, isolates that are initially susceptible may
become
resistant within three to four days after initiation of
therapy.
For serious infections, repeat culture and sensitivity
testing may
therefore be warranted if third generation
cephalosporins were
used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC BOTTLE (Final [**2180-10-9**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], @ 10PM [**2180-10-7**].
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2180-10-7**] 4:50 am URINE
**FINAL REPORT [**2180-10-8**]**
URINE CULTURE (Final [**2180-10-8**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Radiology Reports:
MRI Spine:
1. Findings indicative of metastatic focus in L2 vertebra
described by the recent bone scan of [**2180-8-2**].
2. Heterogeneous marrow signal in L1 vertebra indicative of
previous history of metastasis to this area.
3. No acute compression fracture or area of new pathologic
fracture.
4. No evidence of high grade thecal sac compression, or
compression of the distal spinal cord.
---
Chest X-Ray:
FINDINGS: Lung volumes are low. The heart size and pulmonary
vasculature are within normal limits. A Port-A-Cath device has
its tip in the central most SVC. There are no pleural effusions.
The previously identified right lower lobe mass lesion is again
identified and unchanged. There is overall no significant change
from the previous exam. The lungs are clear without evidence of
consolidation.
IMPRESSION: No radiographic evidence for pneumonia.
Brief Hospital Course:
47F with metastatic breast cancer and herceptin-induced
cardiomyopathy, now with Serratia hypotension/sepsis.
1) Sepsis: Patient had porta-cath removed by general surgery on
hospital day 2, and was weaned off pressors by hospital day 3.
Wound culture and gram stain yielded no organisms. Tip culture
was not performed. By hospital day 4, blood cultures speciated
Serratia with a high possibility of developing resistance to
third generation cephalosporins, and so antibiotics were changed
to ciprofloxacin and cefepime, and vancomycin was discontinued.
Patient continued to be hemodynamically stable without pressor
support, was afebrile, in no acute pain and was felt to be
stable for the floor on hospital day 4.
Infectious disease was briefly consulted with regard to the
organism and treatment course. Consultants advised that single
therapy with a third generation cephalosporin should be avoided
given the theoretical possibility of inducible beta-lactamase.
Therefore, it was recommended that patient be initiated on a
course of oral levofloxacin to continue treatment as outpatient.
Patient continued to be hemodynamically stable and afebrile and
was discharged home with a course of oral levofloxacin and to
return to clinic a week following discharge.
2) Anticoagulation: Patient had had a history of pulmonary
embolism in [**2180-6-27**] for which she is chronically
anticoagulated. However, patient's coumadin was held in order
to allow removal of the portacath. Following stabilization in
the [**Hospital Unit Name 153**] on day 3, coumadin therapy was reinitiated.
Consideration was given to decreasing patient's dose of coumadin
given her antibiotic therapy, however, at the time of discharge,
patient's INR was 1.6, and it was felt that patient would likely
reach therapeutic range during the week before returning to
clinic. Patient was instructed to follow up with oncology for
continued monitoring of anticoagulation.
3) Breast Cancer: Given patient's acute clinical instability,
chemotherapy (scheduled weekly carboplatin) was deferred.
Patient was to return to clinic for evaluation for chemotherapy
a week following discharge.
At the time of discharge, patient was in excellent clinical
condition with only complaints of mild back pain (which she
attributed to the hospital bed). She was instructed to continue
taking levofloxacin for 10 days following discharge, to continue
taking all of her outpatient medications except for
antihypertensives, and to follow up with her oncologist a week
following discharge.
Medications on Admission:
1) Vicodin
2) Protonix
3) Lisinopril
4) Effexor
5) Warfarin,
6) Toprol
7) Lasix
8) Ativan
9) Decadron
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
2. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Effexor 75 mg Tablet Sig: 1.5 Tablets PO once a day.
5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Dexamethasone 6 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day: For constipation while taking vicodin.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bacterial sepsis
Breast Cancer
Discharge Condition:
Good
Discharge Instructions:
1) Continue taking the following medications:
- Levofloxacin (antibiotic) 500mg by mouth daily for 10 days.
- Coumadin 5mg by mouth once daily
- Effexor 112.5mg by mouth once daily
- Decadron 6mg once daily
- Protonix 40mg once daily
- Lorazepam 0.5-1mg as needed for agitation or sleep
- Vicodin 1-2 tablets every 4-6hours for pain
- Docusate 100mg twice a day (stool softener)
Do not take Toprol or Lisinopril until you see Dr. [**Last Name (STitle) 2036**]
2) Call your doctor or come to the emergency room if you start
having severe pain, fever, chills, shortness of breath, or chest
pain.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-10-18**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3260**], [**MD Number(3) 3670**]: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-10-19**] 9:00
Provider: [**Name Initial (NameIs) 4426**] 19 Date/Time:[**2180-10-18**] 9:00
|
[
"198.3",
"198.5",
"285.9",
"197.0",
"428.0",
"996.62",
"038.40",
"276.1",
"174.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
10809, 10815
|
7368, 9918
|
329, 381
|
10890, 10896
|
3016, 7345
|
11547, 12030
|
2141, 2329
|
10071, 10786
|
10836, 10869
|
9944, 10048
|
10920, 11524
|
2344, 2997
|
273, 291
|
409, 1724
|
1746, 1974
|
1990, 2125
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,203
| 103,884
|
40865
|
Discharge summary
|
report
|
Admission Date: [**2166-7-13**] Discharge Date: [**2166-7-18**]
Date of Birth: [**2092-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Neck swelling
Major Surgical or Invasive Procedure:
[**2166-7-14**]: Removal of packing. Mediastinoscopy. Flexible
bronchoscopy and bronchoalveolar lavage (BAL).
[**2166-7-13**]: Redo mediastinoscopy. Packing of wound.
History of Present Illness:
73 y/o M with COPD found to have new RUL mass who is s/p
mediastinoscopy on [**2166-7-9**] presents with acute onset neck
swelling. The neck swelling began this morning and he is
complaining of dysphagia and difficulty breathing. He did not
some chest discomfort and took his home SL nitro with no change.
He has extensive cardiac history and is on Coumadin for AFib.
The coumadin was held 1 week prior to the medistinoscopy and he
was to be discharged home on coumadin with lovenox bridge.
According to the patient he did not take his home coumadin and
has been on the Lovenox only. He denies any fevers/chills, N/V,
abd pain, hematochezia/melena.
Past Medical History:
Bilateral pulmonary nodules
Hypothyroidism
DM II
Hypertension
Hyperlipidemia
CAD s/p DEstents in [**2159**] to LAD, RCA, PLV,
Atrial fibrillation on warfarin
Gastritis
COPD
Anemia
Hyponatremia
Cerebral aneurysm
CKD
PVD
Social History:
Married lives with family. Tobacco: 40 pack-year. Quit 40 years
ago. ETOH none
Occupation: bartender
Family History:
non-contributory
Physical Exam:
VS: T: 96.0 HR: 82-86 SR BP: 150-160/70-80 Sats: 96% RA
General: 74 year-old male sitting in chair in no distress
HEENT: normocephalic, mucus membranes moist
NEck: mild anterior neck swelling, incision site w/steri-strips
no erythema mild dark heme drainage
Card: RRR
Resp: decreased breath sounds on left otherwise clear
GI: benign
Extr: warm no edema
Neuro: awake, alert oriented
Pertinent Results:
[**2166-7-18**] WBC-16.9* RBC-3.98* Hgb-12.6* Hct-36.9* MCV-93 MCH-31.8
MCHC-34.3 RDW-15.2 Plt Ct-260
[**2166-7-17**] WBC-17.3* RBC-4.25* Hgb-13.0* Hct-38.4* MCV-91 MCH-30.6
MCHC-33.9 RDW-15.7* Plt Ct-223
[**2166-7-13**] WBC-11.2* RBC-2.75* Hgb-8.2* Hct-25.1* MCV-92 MCH-30.0
MCHC-32.8 RDW-16.6* Plt Ct-271
[**2166-7-18**] Glucose-182* UreaN-26* Creat-0.8 Na-133 K-4.0 Cl-94*
HCO3-24
[**2166-7-17**] Glucose-250* UreaN-27* Creat-0.8 Na-129* K-4.1 Cl-94*
HCO3-26
[**2166-7-13**] Glucose-322* UreaN-20 Creat-1.0 Na-121* K-4.6 Cl-87*
HCO3-22
[**2166-7-17**] Albumin-3.4* Calcium-8.7 Phos-1.7* Mg-2.2
CXR:
[**2166-7-16**]: The lungs show an unchanged right apical pneumothorax
with confluent lower lobe opacities, and mild edema unchanged. A
right lung mass is unchanged as well. A moderate left effusion
is unchanged as well. An NG tube terminating in the stomach is
unchanged.
[**2166-7-13**]: Lungs are low in volume. The cardiac silhouette is
mildly enlarged. The mediastinal silhouette is mildly prominent,
which may be post-procedural, or partially due to low lung
volumes. Bilateral lower lobe opacities are new. The hilar
contours are unremarkable. Previously noted pulmonary vascular
engorgement has resolved. Known nodular opacities in the right
upper lobe and lingular are stable. There are small bilateral
effusions. No pneumomediastinum or pneumothorax identified.
MICRO: all cultures were negative.
Brief Hospital Course:
Mr. [**Known lastname 89251**] was admitted [**2166-7-13**] for neck swelling secondary to
bleed after restarting Lovenox following cervical
mediastinoscopy on [**2166-7-9**]. He was taken to the operating room
for Redo mediastinoscopy with Packing of wound. No source of
bleeding was found. He was transfer to the TSICU intubated,
hypovolemic SBP 70's, Transfused 2 Unit of PRBC, CXR with Right
pleural effusion, CT placed with 600 mL serosanguinous drainage.
On [**2166-7-14**] he was taken back to the OR for Mediastinoscopy
Flexible bronchoscopy and bronchoalveolar lavage (BAL) and
packing removal.
Transferred back to TICU intubated and successfully extubated.
His oxygenation improved, titrated off oxygen with saturations
96% on room air.
Heme: Transfused 3 units of PRBC in OR & ED and 2 units while in
the SICU for HCT 25. Serial HCTs where followed and he remained
stable in the high 30.s
Hypertension: hypertensive SBP 180-200 requiring Labatelol drip
until taking PO's. His SBP improved 150's baseline 140's. His
home medications were restarted Lisinopril, felodipine.
Atrial Fibrillation: rate controlled with metropolol.
Anticoagulation: Warfarin was held. Aspirin restarted. Spoke
with his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 487**] whom agreed with Warfarin 3 mg with No
lovenox bridge.
Nutrition: Seen by speech and swallow for laryngeal edema on
[**7-15**]. He remained NPO for signs & symptoms of aspiration. An
NGT was placed and Tube feeds were started.
Speech continued to follow him. [**2166-7-16**] his laryngeal edema
improved the NGT was removed, a puree nectar thick liquid was
started. Video-swallow on [**2166-7-17**] showed improved pharyngeal
edema. He was transition to a soft mechanical diet with thin
liquids and aspiration precautions.
Endocrine: insulin sliding scale to maintain BS < 150. His home
dose Prandin was restarted when taking PO. Levothyroxine
restarted to once taking PO.
Hypervolemia: IV Lasix was given to Goal negative > 1. Liter
with good results. His home PO dose was restarted.
Electrolytes were replete as needed.
Pleural: small left pleural effusion. Ultrasound by
interventional pulmonology of left pleural effusion showed
approximately 300 mL. No thoracentesis was performed.
Disposition: He continue to make steady progress. Was seen by
physical therapy who recommended home with PT. He was
discharged on [**2166-7-18**].
Medications on Admission:
Tiotropium Bromide 18 mcg', Esomeprazole 40 mg', Albuterol
2puffs q4-6H, Furosemide 40 mg daily, Simvastatin 80 qhs,
Ferrous sulfat 325 mg daily, Coumadin, Cholecalciferol, Vitamin
D, Lisinopril 40 mg daily, Prandin 0.5 prior to meals, atenolol
100 mg daily, levotyroxine 75 mcg daily, felodipine 5 mg daily,
NTG, MVI
Discharge Medications:
1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. felodipine 5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3
times a day (before meals)).
10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO every four (4) hours.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Cervical mediastinoscopy [**2166-7-9**] complicated by bleed s/p Redo
mediastinoscopy, Packing of wound [**2166-7-13**]
Bilateral pulmonary nodules
Hypothyroidism
DM II
Hypertension
Hyperlipidemia
CAD s/p DEstents in [**2159**] to LAD, RCA, PLV,
Atrial fibrillation on warfarin
Gastritis
COPD
Anemia
Hyponatremia
Cerebral aneurysm
CKD
PVD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Difficulty breathing, swallowing or new hoarsness
-Increased bleeding for neck incision
Neck incision
-Cover with a clean dry dressing as needed. It will ooze for a
few days. Please call if there is a large amount of discharge
from the site.
-Steri-strips remove in 10 days or sooner should they start to
come off
Pain:
-Acetaminophen 650 mg every 6 hours as needed for pain
-Oxycodone 5 mg every 4-6 hours as needed for pain
-Take stool softners with narcotics
Activity
-Shower daily. Wash incisions with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-Do Not apply any lotions or creams to incisions
Warfarin
-Restart you standing dose on Sunday night. Take 3 mg Sunday and
Monday evening.
-Follow-up with your PCP on Tuesday for further warfarin
instructions.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2166-7-29**] 11:30 on
the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Follow-up with Dr.[**First Name (STitle) 487**] [**Telephone/Fax (1) 68410**] for warfarin managenment
on Tuesday.
Completed by:[**2166-7-18**]
|
[
"998.12",
"244.9",
"V15.82",
"V58.61",
"414.01",
"518.89",
"E878.8",
"585.9",
"496",
"427.31",
"V85.1",
"V45.82",
"458.9",
"250.00",
"437.5",
"511.9",
"272.4",
"276.1",
"403.90",
"478.25"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09",
"33.24",
"34.22",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7323, 7380
|
3424, 5853
|
324, 494
|
7763, 7763
|
1987, 3401
|
8864, 9284
|
1550, 1568
|
6221, 7300
|
7401, 7742
|
5879, 6198
|
7914, 8841
|
1583, 1968
|
271, 286
|
522, 1173
|
7778, 7890
|
1195, 1415
|
1431, 1534
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,203
| 181,603
|
53562
|
Discharge summary
|
report
|
Admission Date: [**2189-7-2**] Discharge Date: [**2189-7-7**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2189-7-3**]
Aortic valve replacement 21-mm St. [**Hospital 923**]
Medical Biocor Epic tissue valve.
History of Present Illness:
87 year old female known to our service (see H&P from [**2189-5-6**])
who is following up for further discussion regarding surgery for
her aortic stenosis. She has newly diagnosed atrial fibrillation
on Coumadin and now complains of fatigue with mild exertion.
Echo
in [**2189-4-19**] showed critical aortic stenosis with a valve area
of 0.4 cm2.
Past Medical History:
Aortic Stenosis
PMH:
Atrial fibrillation (diagnosised 2 weeks ago)
Left eye prosthesis s/p MVC [**2129**]
Osteoarthritis
UTI
Past Surgical History:
S/P left shoulder and arm plates from MVC
s/p Exploratory laparotomy, lysis of adhesions, repair of
incarcerated right obturator hernia with mesh, suture repair
left
obturator hernia
Cataract surgery right eye
Social History:
Lives with:Lives alone. Nephew lives one block away
Contact:[**Name (NI) **] [**Name (NI) **] (nephew) Phone# [**Telephone/Fax (1) 110086**]
Occupation:Retired. Volunteers at [**Hospital3 **] 2 days per
week
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-24**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother died of
MI at age 69
Physical Exam:
Pulse:75 Resp:18 O2 sat:98/RA
B/P Right:160/88 Left:168/83
Height:5'2.5" Weight:109 lbs
General:
Skin: intact [x]
HEENT: L eye EOMI [x]; R eye prosthetic. Decreasing hearing
bilaterally
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [+] grade 3 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Varicosities: +
Neuro: Grossly intact [x]
Pulses:
Femoral Right: p Left: p
DP Right: p Left: p
Radial Right: p Left:p
Carotid Bruit Right: - Left: -
Pertinent Results:
TEE [**2189-7-3**]
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**1-19**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-19**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened.
POSTBYPASS
Biventricular systolic function remains normal. There is a well
seated, well functioning bioprosthesis in the aortic position.
There is mild perivalvular AI. The MR is now trace. The TR is
now mild. The remaining study is unchanged from prebypass.
.
[**2189-7-7**] 04:17AM BLOOD WBC-8.0 RBC-3.47* Hgb-11.3* Hct-33.9*
MCV-98 MCH-32.5* MCHC-33.2 RDW-13.5 Plt Ct-104*
[**2189-7-6**] 04:44AM BLOOD WBC-10.7 RBC-3.61* Hgb-11.8* Hct-35.3*
MCV-98 MCH-32.5* MCHC-33.3 RDW-13.4 Plt Ct-106*
[**2189-7-7**] 04:17AM BLOOD UreaN-24* Creat-0.6 Na-134 K-4.4 Cl-100
[**2189-7-6**] 04:44AM BLOOD Glucose-85 UreaN-24* Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-30 AnGap-10
Brief Hospital Course:
The patient was brought to the Operating Room on [**2189-7-3**] where
the patient underwent Aortic Valve Replacement with Dr. [**Last Name (STitle) **].
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.
UTI was treated with Klebsiella. She had brief post-operative
confusion which resolved quickly. She remained in
rate-controlled AFib and coumadin was resumed. 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 **** the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged [**Hospital 1316**] Rehab in good condition
with appropriate follow up instructions.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Atenolol 25 mg PO DAILY
2. Digoxin 0.25 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Warfarin 2 mg PO DAILY16
3. Acetaminophen 650 mg PO Q4H:PRN analgesic
4. Amlodipine 5 mg PO DAILY
Hold for SBP<95
5. Aspirin EC 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Tartrate 37.5 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
8. Oxycodone-Acetaminophen (5mg-325mg) [**1-19**] TAB PO Q4H:PRN pain
RX *Endocet 5 mg-325 mg q4-6h Disp #*40 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis
PMH:
Atrial fibrillation (diagnosised 2 weeks ago)
Left eye prosthesis s/p MVC [**2129**]
Osteoarthritis
UTI
Past Surgical History:
S/P left shoulder and arm plates from MVC
s/p Exploratory laparotomy, lysis of adhesions, repair of
incarcerated right obturator hernia with mesh, suture repair
left
obturator hernia
Cataract surgery right eye
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2189-8-12**] 1:30
Please call to schedule the following:
Cardiology/Primary Care Dr. [**Last Name (STitle) **],[**Doctor Last Name **] [**Telephone/Fax (1) 31188**] in [**4-23**]
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
Coumadin for AFib
Goal INR [**2-20**]
First draw [**2189-7-8**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
Completed by:[**2189-7-7**]
|
[
"599.0",
"715.90",
"427.31",
"V58.61",
"780.09",
"041.3",
"511.9",
"424.1",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5732, 5762
|
3698, 4962
|
263, 368
|
6164, 6334
|
2226, 3675
|
7206, 7869
|
1522, 1587
|
5247, 5709
|
5783, 5908
|
4988, 5224
|
6358, 7183
|
5931, 6143
|
1602, 2207
|
216, 225
|
396, 745
|
767, 892
|
1143, 1506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,749
| 104,545
|
44564
|
Discharge summary
|
report
|
Admission Date: [**2112-2-4**] Discharge Date: [**2112-2-10**]
Date of Birth: [**2033-2-26**] Sex: F
Service: CV MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female, with a past medical history significant for
metastatic breast carcinoma with stable metastases to the
lung, as demonstrated on a CT scan in [**11/2111**], who presents
with a 1-month history of progressive dyspnea on exertion.
She also states that she has shortness of breath at rest, and
reports mild chest pressure with exertion and at rest. She
also reports bilateral lower extremity edema increasing over
the last 1 month. For work-up of this, her primary care
provider had the patient undergo a cardiac stress test on
[**2112-2-2**] which was negative for reversible perfusion
defects. However, the patient did experience atrial
fibrillation at that time. She also did have an
echocardiogram done on [**2112-2-4**], which showed a
moderate pericardial effusion which had increased slightly
since her previous echo. The patient denied any symptoms
suggestive of lightheadedness or syncope. She denies fevers
and cough.
PAST MEDICAL HISTORY:
1. New atrial fibrillation.
2. Pericardial effusion status post echo [**2112-2-4**],
which showed moderate pericardial effusion, no tamponade
physiology, ejection fraction of 60%, mild MR, moderate TR.
3. History of metastatic breast cancer, status post CT in
[**2111-11-23**] which showed stable lung metastases, and at
that time stable pericardial effusion.
4. Status post Persantine-MIBI [**2112-2-2**], which
showed no reversible perfusion defects.
5. Chronic renal insufficiency, status post nephrectomy.
6. Hypertension.
7. Hypothyroidism.
8. Hypercholesterolemia.
9. Gout.
10.Glaucoma.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Levoxyl.
2. Allopurinol.
3. Amaryl.
4. Arimidex.
5. Avandia.
6. Colace.
7. Iron.
8. Folate.
9. Protonix.
10.Lipitor.
11.Vitamin B12.
12.Norvasc.
SOCIAL HISTORY: The patient denies tobacco or alcohol. She
lives with her husband in [**Name (NI) 86**]. She does have a daughter
in [**Name (NI) 86**] who is involved in her care. The patient does have
stressors at home, including her husband who has bipolar
disease longstanding.
VITALS ON ADMISSION: Temperature 97.6, blood pressure
127/56, pulse 70, respiratory rate 22, satting 100% on 2
liters.
HEENT: Her extraocular movements were intact. Her
oropharynx was clear.
NECK: She had JVD to the midneck.
CHEST: She had bilateral crackles, left greater than right.
CARDIAC EXAM: She was irregularly irregular with a II/VI
harsh systolic murmur at the left lower sternal border.
ABDOMEN: Benign.
EXTREMITIES: 2+ edema. Of note, she had no pulses paradoxus
on exam.
LABORATORIES ON ADMISSION: White count 4.4, hematocrit 33.7,
platelets 198. Her chem-7 was normal. She had a UA which
was negative. Chest x-ray showed right heart border was
obscured with possible infiltrate. EKG was irregular with
poor R wave progression, which was new.
HOSPITAL COURSE: The patient was admitted for pericardial
drain procedure. She went to the cardiac catheterization
laboratory where under fluoro guidance she had a
pericardiocentesis and drain placement, and 450 cc of
straw-colored fluid was removed. Micro on pericardial fluid
was negative. However, cytology was still pending.
The patient did have follow-up echocardiogram. Her systolic
function was normal with an LV-EF of 55%. Ventricular wall
thickness and cavity size were also normal. She still had
moderate TR. She also had mild to moderate pulmonary artery
systolic hypertension, and she showed only a small
pericardial effusion. No tamponade. This echo was performed
after her pericardial drain was pulled.
A total of approximately 460 cc of pericardial fluid was
collected in the drain post her pericardiocentesis for a
total of approximately 900 cc of straw-colored fluid removed.
Her drain was pulled 24 hours after placement.
The patient was sent to the CCU for observation post
pericardial drain placement. There, she did have atrial
fibrillation. Coumadin therapy was not started secondary to
her known metastatic disease. The patient also had a
temperature to 101. This was most likely attributable to her
right infiltrate which was seen on her admission chest x-ray,
and she was started on Levofloxacin for presumed pneumonia.
She will complete a 7-day course of Levofloxacin. The
patient did not spike any further fevers after that initial
temperature of 101.
The patient also had increasing oxygen requirement during the
end of her hospital stay. It was believed this was secondary
to pneumonia, but more importantly signs of congestive heart
failure. She had serial x-rays which showed worsening
pulmonary congestion. She was treated with IV lasix 20 mg po
bid with good urine output. On the day of discharge, her
oxygen saturation improved. Initially, the patient was
satting 92% on 5 liters. On discharge, she was satting 95%
on 2 liters. The CCU team also felt that her hypoxia could
be attributable to either obstructive sleep apnea, or hypoxia
secondary to obesity, considering that a number of her oxygen
desaturations occurred at night. The patient will continue
lasix therapy for heart failure. She did have improved exam
and oxygen saturation on the day of discharge. She will be
continued on lasix 40 [**Hospital1 **] at [**Hospital **] Rehabilitation.
In terms of her breast cancer, the patient was seen by Dr.
[**Last Name (STitle) **], her primary oncologist. No therapy was initiated
for this during her hospital stay. She was continued on her
Arimidex which she was on as an outpatient, and she will
follow-up with Dr. [**Last Name (STitle) **] on [**2-16**].
The patient was continued on her Vitamin B12 for her anemia,
and for her atrial fibrillation no Coumadin was started,
again because of her known metastatic disease. However, she
was started on Lopressor 37.5 mg po bid.
The patient was also depressed during the course of her
hospital stay. Social work was involved. The patient did
not want to see psychiatry. She was on an SSRI previously as
an outpatient; however, she self-discontinued this and was
not interested in pharmacologic therapy. Social work
provided services, and also helped her in terms of estate
planning for the future.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: [**Hospital **] Rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Pericardial effusion, status post pericardiocentesis and
drain placement.
2. Atrial fibrillation.
3. Congestive heart failure.
4. Pneumonia.
5. Metastatic breast cancer.
DISCHARGE MEDICATIONS:
1. Allopurinol 100 mg po qd.
2. Arimidex 1 mg po qd as treatment for breast cancer.
3. Colace 100 mg po bid.
4. Ferrous sulfate 325 mg po bid.
5. Levothyroxine 50 mcg po qd.
6. Folic acid 1 mg po qd.
7. Atorvastatin 10 mg po qd.
8. Protonix 40 mg po qd.
9. Vitamin B12 1,000 mcg po qd.
10.Amlodipine 5 mg po qd.
11.Lopressor 37.5 mg po bid.
12.Miconazole powder tid prn.
13.Lasix 40 mg po bid.
14.Senna 1 tablet po bid.
15.Levofloxacin 250 mg po q 24 h, continue through [**2112-2-13**], then stop for a full 7-day course.
16.Amaryl 1 mg po qd.
17.Avandia 4 mg po qd.
FOLLOW-UP:
1. The patient will follow-up with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] on
[**2-16**] at 2:30.
2. She will also see Dr. [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) **] on [**2-16**] at
3:30.
3. The patient will also receive an echocardiogram in 1
month's time to reevaluate for pericardial effusion.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-661
Dictated By:[**Last Name (NamePattern1) 11207**]
MEDQUIST36
D: [**2112-2-10**] 10:58
T: [**2112-2-10**] 11:09
JOB#: [**Job Number 95445**]
cc:[**Last Name (NamePattern4) 95446**]
|
[
"197.0",
"272.0",
"198.89",
"486",
"427.31",
"428.0",
"274.9",
"244.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6465, 6639
|
6662, 7872
|
1819, 1968
|
3045, 6351
|
172, 1139
|
2777, 3027
|
1161, 1793
|
1985, 2262
|
6376, 6444
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,681
| 134,696
|
17125
|
Discharge summary
|
report
|
Admission Date: [**2166-5-19**] Discharge Date: [**2166-5-23**]
Date of Birth: [**2117-1-14**] Sex: M
Service: GENERAL MEDICINE
CHIEF COMPLAINT: Melena.
HISTORY OF PRESENT ILLNESS: This is a 49 year old man with a
history of hepatitis C and alcohol induced cirrhosis with
prior hospitalizations for bloody stools, who now presents
with melena. The patient was admitted to [**Hospital3 27946**]
on [**2165-7-29**], with melanotic stools. He had an endoscopy
performed at that time and found to have an erosive gastritis
and duodenitis. He was started on a proton pump inhibitor
and sent home. Since that time, the patient was readmitted
on [**2166-5-19**], with similar complaints of melanotic stools. An
esophagogastroduodenoscopy was performed at that time and
gastric varices were noted. After a biopsy was attempted,
the patient began to bleed and was transfused at [**Hospital3 31084**] a total of two units packed red blood cells and two
units of fresh frozen plasma and was transferred to [**Hospital1 1444**] for evaluation for a TIPS
procedure. Upon transfer to [**Hospital1 188**], the patient was admitted to the MICU and had remained
hemodynamically stable. The patient was transfusion
independent with a stable hematocrit range of 31.0 to 33.0.
Right upper quadrant ultrasound was performed on [**2166-5-20**],
confirming cirrhosis, moderate perihepatic ascites,
gallbladder sludge without ductal dilatation, normal flow
through the hepatic and portal vessels. The patient was
stable during the time on MICU and was transferred to the
floor on [**2166-5-21**].
The patient's history briefly is significant for a diagnosis
o hepatitis C in [**2159**], workup at [**Hospital3 27946**] Hospital.
The patient was treated with one month course of PEG
Interferon and Ribavirin in [**2165-11-27**], for only a month
period of time. The patient had to discontinue this
treatment regimen after developing adverse drug reaction.
Additionally, the patient has had a prior outside hospital
admission for hematemesis and melanotic stools as noted
above. The patient currently denies any acute complaints.
No mental status changes, no shortness of breath. The
patient has not had a bowel movement since admission and has
remained guaiac negative. The patient also denies chest
pain, nausea, vomiting, diarrhea, fever, cough, chills,
abdominal pain, dizziness.
PAST MEDICAL HISTORY:
1. Hepatitis C, type 1-A diagnosed in [**2159**], status post PEG
Interferon treatment with Ribavirin [**2165-11-27**], for only
one month.
2. Erosive gastritis, duodenitis diagnosed on
esophagogastroduodenoscopy in [**2165-7-28**], at [**Hospital3 31084**] Hospital.
3. Diabetes mellitus, type 2, currently not on regimen at
home.
4. Lumbar disc herniation.
5. History of hematemesis, melanotic stools in [**2165-7-28**].
MEDICATIONS ON ADMISSION:
1. Regular insulin sliding scale 4 units NPH in a.m.
2. Octreotide 50 mcg per hour intravenously.
3. Spironolactone 100 mg p.o. once daily.
4. Pantoprazole 40 mg p.o. q12hours.
5. Nadolol 20 mg p.o. once daily.
6. Levaquin 500 mg p.o. once daily for a seven day course.
SOCIAL HISTORY: Significant for tobacco times twenty years
and alcohol abuse. The patient reports last drink nine
months ago. Additionally, the patient has a history of
Cocaine and marijuana abuse. The patient is HIV negative.
FAMILY HISTORY: Significant for mother with diabetes
mellitus, type 2, who is alive. Father is deceased at 68
years with alcoholic cirrhosis.
PHYSICAL EXAMINATION: Temperature maximum is 98.8,
temperature current is 98.0, heart rate 67, blood pressure
127/57, respiratory rate 18, oxygen saturation 96 to 98%.
Input and output history, 891 input, 3060 output with a
negative balance of 2168cc. Generally, the patient is alert
and oriented times three. He is pleasant and talkative in no
acute distress. Head, eyes, ears, nose and throat
examination is normocephalic and atraumatic. Mild scleral
icterus. Oropharynx is clear. Moist mucous membranes, no
oral thrush. Cardiovascular examination - regular rate and
rhythm, no murmurs, rubs or gallops, normal S1 and S2.
Pulmonary examination is clear to auscultation bilaterally.
Abdominal examination is soft, mildly distended, ascites is
appreciated, active bowel sounds. Liver was percussed at 3.0
centimeters below the costophrenic border. He is nontender
and no caput medusa. Extremity examination - no palmar
erythema. No asterixis. No cyanosis, clubbing or edema. Two
to three spider angiomas present anteriorly on the patient's
chest.
On [**2166-5-20**], ultrasound - nodular shrunken liver, moderate
perihepatic ascites, gallbladder sludge, no ductal
dilatation, 15.8 centimeter enlarged spleen with normal flow
throughout the portal vessels.
LABORATORY DATA: The patient had a white blood cell count of
5.8, hematocrit 33.4 which was stable from previous
hematocrit. Platelet count 80,000. Chemistry profile showed
a sodium of 137, potassium 3.7, chloride 105, bicarbonate 25,
blood urea nitrogen 9, creatinine 0.6, glucose 157. Calcium
7.8, magnesium 1.5, phosphorus 3.7. Liver function test
panel which was done at outside hospital on [**2166-5-18**], showed
AST 127, ALT 130, alkaline phosphatase 176, total protein
5.8, total bilirubin 1.4. Prothrombin time 15.1, INR 1.5,
partial thromboplastin time 32.9.
HOSPITAL COURSE:
1. Upper gastrointestinal bleed - gastric varix - The
patient did not require any further transfusions. His
hematocrit remained stable in the 33.0 range. The patient
additionally was guaiac negative throughout his hospital
course. He did not have any hematemesis or abdominal
discomfort. Right upper quadrant ultrasound was unremarkable
for any acute process and confirmed his known liver
cirrhosis. The patient was initially treated with a five day
course of Octreotide 50 mcg per hour intravenously.
Additionally, the patient was started on Nadolol 20 mg p.o.
Once daily for varix prophylaxis. Additionally, the patient
was treated with Protonix for gastritis, peptic ulcer disease
prophylaxis. Also, the patient was treated with Aldactone in
the setting of ascites to reduce fluid overload.
2. Hepatitis C alcohol induced cirrhosis - The patient was
instructed to follow-up with operating table Liver Clinic for
potential low dose PEG Interferon treatment. Currently, the
patient is not being treated for hepatitis C. The patient
additionally received a four out of seven day course of
Levofloxacin for spontaneous bacteria peritonitis 500 mg p.o.
once daily.
3. Diabetes mellitus type 2 - During the [**Hospital 228**] hospital
course, regular insulin sliding scale was used. His blood
sugar ranged in the low to mid 100 range. Additionally, the
patient was treated with 4 units NPH every morning with
regular insulin sliding scale to cover throughout the day.
The patient was cited American Diabetic Association diet and
a low sodium diet as well.
CONDITION ON DISCHARGE: The patient is stable and discharged
to home.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed due to bleeding gastric
varix.
2. Hepatitis C alcohol induced cirrhosis.
3. Diabetes mellitus type 2.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. once daily.
2. Levofloxacin 500 mg p.o. once daily for four more days.
3. Aldactone 100 mg p.o. once daily. for four more days.
4. Nadolol 20 mg p.o. once daily.
FOLLOW-UP INSTRUCTIONS: The patient is to follow-up in the
Liver Clinic with Dr. [**Last Name (STitle) **] [**2166-6-12**], to evaluate potential
hepatitis C treatment with PEG Interferon. Additionally, the
patient was instructed to follow-up with newly appointed
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Hospital1 346**] by [**2166-6-5**], to evaluate further
insulin versus oral hypoglycemic [**Doctor Last Name 360**] for diabetes mellitus
control.
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], M.D. [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 1600**]
MEDQUIST36
D: [**2166-5-24**] 14:41
T: [**2166-5-30**] 10:41
JOB#: [**Job Number 48095**]
|
[
"070.51",
"287.5",
"305.50",
"250.00",
"303.93",
"530.81",
"572.3",
"571.2",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3397, 3525
|
7051, 7189
|
7215, 7405
|
2871, 3148
|
5389, 6958
|
3548, 5372
|
164, 173
|
202, 2394
|
7430, 8210
|
2416, 2845
|
3165, 3380
|
6983, 7030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,759
| 112,935
|
4017
|
Discharge summary
|
report
|
Admission Date: [**2129-4-26**] Discharge Date: [**2129-5-6**]
Date of Birth: [**2044-3-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
PICC placement X2 (second placement was IR-guided)
History of Present Illness:
85 yo M with vascular dementia, HTN, NIDDM, found to be
lethargic by family today. Labs at nursing home showed
hypernatremia, hyperglycemia. At the nursing home, the patient
was given insulin SC 6 units x 3, with no improvement in
hyperglycemia.
.
In the ED, initial vital signs were T 98.3 BP 104/62 HR 96 RR 40
Sat 100%/10L NRB. EKG showed new ST depressions inferolaterally
< 1 mm. CXR, head CT negative. He was given 2L of NS and 10
units of regular insulin. Vitals on transfer, T 99.5 HR 87 BP
129/55 RR 18 Sat 97%/RA.
.
Review of systems is unobtainable.
Past Medical History:
DM2
hypertension
hypercholesterolemia
vascular dementia with prominent frontal lobe findings and
behavioral problems and wandering
hepatitis B
deafness
asbestosis
glaucoma
cataract
essential tremor
psoriasis
Social History:
Lives at nursing home. Prior to his recent hospitalizations, he
was living with his wife and participating in daycare. More
recently, he has been at [**Hospital 37**] Nursing Home. As noted in
prior admits, he has had a notable decline in his level of
functioning over the past few months.
Tob: quit one year ago
EtOH: none recently
IVDA: family denies
Family History:
non-contributory
Physical Exam:
Vital signs: T 95.6 BP 148/85 HR 90 RR 18 Sat 93%/RA
Derm: Decreased skin turgor
General: Not speaking. Moving around in bed.
HEENT: Anicteric. Dry mucous membranes.
Neck: JVP 4 cm above RA.
Resp: CTAB.
CV: RRR. Normal s1, s2. No M/G/R.
Abd: +BS. Soft. NT/ND.
Ext: Warm extremities. Radial pulses 2+. No edema.
Neuro: Not speaking. Moving around in bed. Moving all
extremities. PERRL. Left eye deviated laterally.
Pertinent Results:
Admission labs:
[**2129-4-26**] 04:00AM BLOOD WBC-10.4# RBC-3.74*# Hgb-11.4*#
Hct-37.1*# MCV-99* MCH-30.5 MCHC-30.7* RDW-15.1 Plt Ct-236
[**2129-4-26**] 04:00AM BLOOD Neuts-82.5* Lymphs-12.7* Monos-2.5
Eos-0.6 Baso-1.6
[**2129-4-26**] 04:00AM BLOOD PT-17.2* PTT-24.8 INR(PT)-1.5*
[**2129-4-26**] 04:00AM BLOOD Glucose-653* UreaN-77* Creat-2.2*#
Na-177* K-3.9 Cl-130* HCO3-37* AnGap-14
[**2129-4-26**] 04:00AM BLOOD cTropnT-0.03*
[**2129-4-26**] 04:00AM BLOOD Calcium-10.3 Phos-3.2 Mg-3.4*
[**2129-4-26**] 04:14AM BLOOD Glucose-551* Lactate-2.3* Na-177* K-3.9
Cl-122* calHCO3-38*
[**2129-4-26**] 04:14AM BLOOD freeCa-1.35*
.
CT head w/o contrast [**2129-4-26**]:
1. No evidence of an acute intracranial process.
2. Small chronic infarct in the right caudate head, new since
[**2123**].
.
CXR (portable AP) [**2129-4-26**]: Mild pulmonary vascular congestion,
unchanged. No acute intrathoracic process.
.
.
MICRO:
[**2129-4-26**] 8:00 am URINE
**FINAL REPORT [**2129-4-28**]**
URINE CULTURE (Final [**2129-4-28**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
.
MRSA Screen Positive
.
DISCHARGE LABS:
Brief Hospital Course:
85 yo M with DM2, HTN, vascular dementia, presents with lethargy
in the setting of severe dehydration, hyperglycemia, and
hypernatremia, consistent with hyperosmolar hyperglycemic state.
.
# Hyperosmolar hyperglycemic state/DM2: The patient presented
with marked hyperglycemia and was started on an insulin drip.
With improvement in his hyperglycemia, he was transitioned to
subcutaneous insulin. Metformin was held. He was started on
lantus while needing D5W. When his D5W was stopped after his
sodium was corrected, his insulin was adjusted and his sugars
were mildly well-controlled. Insulin sliding scale was
eventually stopped and patient was restarted on metformin. He
was switched to metformin 500mg twice a day.
.
# Hypernatremia: The patient presented with profound
hypernatremia, with sodium 177-180. His free water deficit was
greater than 10 L. During a period of several days, his free
water deficit was gradually repleted with good effect. Last
serum sodium checked prior to discharge was 140. As patient's
labs were stable, they were not checked daily.
.
# Acute renal failure: The patient presented with creatinine
2.2, significantly elevated from his baseline of 0.9. This was
felt to be pre-renal in setting of severe dehydration. However,
given the patient's history of urinary retention, obstruction
may have also contributed, a Foley catheter was placed. The
patient was treated with IV fluids and Foley placement and his
creatinine slowly improved. At the time of discharge his
creatinine was 1.2. His mixed picture has resolved and he will
need to follow up with Urology.
.
# Urinary tract infection: U/A was positive. The patient was
started on empiric ceftriaxone and Vancomycin given gram
positive cultures in the past. Cultures grew out coagulase
positive staph aureus. Blood cultures were negative. He was
continued on vancomycin until he was able to tolerate oral
medications and then switched to bactrim for a total of 14 days.
Last dose is on [**2129-5-9**].
.
# Constipation: Patient appeared to be having some abdominal
discomfort and hard bowel movements. He was started on a more
aggressive bowel regimen and received a tap water enema the day
prior to admission. He should receive all constipation
medications until he is having soft, regular bowel movements. If
he does not have a bowel movement after 2 days, he should
receive a tap water enema.
.
# EKG changes: The patient had some lateral ST depression, which
were reviewed with cardiology and felt to be most consistent
with left ventricular hypertrophy with strain.
.
# Goals of care: Patient will be transitioned to hospice care
when he returns to [**Hospital3 2558**].
.
# CODE STATUS: DNR/DNI
Medications on Admission:
terazosin 10 mg QHS
latanoprost 0.005% 1 drop each eye QHS
finasteride 5 mg PO daily
mirtazepine 15 mg PO QHS
lactulose 30 cc TID PRN constipation
senna 8.6 mg PO BID PRN constipation
polyethylene glycol 17 grams daily PRN constipation
lactulose 15 cc PO daily
colace 100 mg PO daily
senna 1 tab PO QHS
trazodone 25 mg Q6H PRN agitation
ciprofloxacin 250 mg PO BID x 7 days
lactobacillus 1 cap [**Hospital1 **] x 7 days
trazodone 50 mg PO QHS
metformin ER 1000 mg QPM
simvastatin 20 mg QHS
colace 100 mg [**Hospital1 **] PRN constipation
Tylenol 650 mg PO Q6H PRN pain
vitamin D 50,000 units Qweekly x 8 weeks
Discharge Medications:
1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-5**]
Drops Ophthalmic PRN (as needed) as needed for red, dry eyes.
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days: last dose [**2129-5-9**].
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
three times a day as needed for constipation.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. lactobacillus acidoph & bulgar 1 million cell Tablet Sig:
One (1) Tablet PO twice a day.
13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
16. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
# Hypernatremia
# Hyperglycemia
# Acute Renal Failure
# Vascular Dementia
.
Secondary Diagnosis:
# Type II diabetes mellitus
# Hypertension
# Hypercholesterolemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were
admitted for high sugar levels and high sodium levels. You were
initially admitted to the intensive care unit (ICU) and then
transferred to the regular medical floor for further management.
Your sugars were better controlled and your sodium came down by
giving you back enough water. You mental status improved and
you were more cooperative and ready for discharge to your
nursing home.
.
We made the following changes to your medications:
- STARTED artificial tear drops as needed
- STOPPED terazosin (as recommended by your urologist at your
last visit)
.
You will need someone to sit and feed you until you have
completed meals. You should also always have access to water
(cup with straw in front of you). You were not getting enough
nutrition or water at your nursing home, which is why you ended
up in the hospital. It is imperative that the nursing staff
address this.
Please take your other medications as prescribed and keep your
follow up appointments.
Followup Instructions:
Name: [**Last Name (LF) 770**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Last Name (LF) **], [**First Name3 (LF) **] 440, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 5727**]
We are working on a follow up appointment in Urology within 1
week. The office will contact you at home with an appointment.
If you have not heard within 2 business days or have any
questions please call the office.
Completed by:[**2129-5-6**]
|
[
"599.0",
"V49.86",
"564.00",
"584.9",
"V58.67",
"041.12",
"286.7",
"290.40",
"276.0",
"290.41",
"401.1",
"707.03",
"788.29",
"333.1",
"250.22",
"437.0",
"285.9",
"707.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8681, 8751
|
3835, 6528
|
311, 363
|
8976, 8976
|
2037, 2037
|
10251, 10798
|
1570, 1588
|
7188, 8658
|
8772, 8867
|
6554, 7165
|
9159, 9674
|
3812, 3812
|
1603, 2018
|
9703, 10228
|
263, 273
|
391, 953
|
8888, 8955
|
2053, 3794
|
8991, 9135
|
975, 1184
|
1200, 1554
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,164
| 106,513
|
51206
|
Discharge summary
|
report
|
Admission Date: [**2187-10-7**] Discharge Date: [**2187-10-12**]
Date of Birth: [**2136-3-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
right arm pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 54 year old male with history of epilepsy that was
found at the bottom of a flight of 15 stairs presumably after
falling. He was transported to [**Hospital1 18**] ED where he complained of
right arm pain and was combative. He was intubated in the
emergency department for airway protection secondary to his
combativeness. The patient was found to have a difficult airway
and anesthesia was paged. In the ED, a 7cm L frontal laceration
was closed using staples. At the time of this exam, the patient
was intubated and thrashing and medical history as well as a
review of systems was not obtained. The patient has been
transferred to the TSICU and the following injuries have been
identified since admission to the hospital left zigomatic
fracture,left sphenoid sinus fracture,left lateral orbital
non-displaced fracture, Sternal fracture,L3, T15, T12, C6
compressions,Small anterior mediastinal hematoma, bilateral
posterior lung consolidation ,right distal radial fracture.
Neurosurgery has been asked to consult regarding the patients
Head CT from [**2187-10-7**] which is consistent with a left frontal
punctate hemorrhage.
Past Medical History:
PMH
1. Grand mal seizures
2. TBI secondary to motorcycle accident
3. Sleep apnea
4. psychosis secondary to seizure disorder
PSH
1. S/P Appendectomy
2. S/P temporal lobectomy [**2168**] for intractable seizures
3. IVC Filter placement
Social History:
Lives alone in an [**Hospital3 **] complex
ETOH none
Tobacco none
Family History:
non contributory
Physical Exam:
O: T:100.9 BP: 105/ 61 HR:94 R:20 O2Sats:100% CMV
ventilator
mode
Gen: intubated, exam performed off propofol, pt agitated,
thrashing in bed
HEENT: large left laceration approximated with staples Pupils:
3.5-3 EOMs:UTA
Neck: hard cervical collar in place
Extrem: Warm and well-perfused. Right upper extremity in cast-
distal radial fracture
Neuro:
Mental status: intubated,Awake and alert, follows some simple
commands, thrashing in bed
Orientation,Recall,Language: unable to assess
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3.5 to 3
mm bilaterally. Visual fields-UTA.
III, IV, VI: Extraocular movements-UTA
V, VII: Facial strength grossly symmetric.
VIII: Hearing -UTA.
IX, X: Palatal -UTA.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius-UTA.
XII: Tongue midline -UTA.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-10**] in LUE, Bilateral lower
extremities. Right upper extremity:fingers move to command, ROM
limited due to radial fracture and cast. Pronator drift-UTA
Sensation: UTA
Toes downgoing bilaterally
Coordination:UTA
Pertinent Results:
[**2187-10-7**] 09:26PM PLT COUNT-195
[**2187-10-7**] 09:26PM WBC-12.8* RBC-4.55* HGB-14.2 HCT-42.1 MCV-93
MCH-31.1 MCHC-33.6 RDW-14.4
[**2187-10-7**] 09:26PM PT-12.5 PTT-19.8* INR(PT)-1.0
[**2187-10-7**] 09:26PM GLUCOSE-137* LACTATE-2.8* NA+-139 K+-3.9
CL--98* TCO2-30
[**2187-10-7**] Head CT : 1. Punctate focus of hyperdensity in the left
frontal lobe, could be artifact; however, cannot exclude
hemorrhagic focus, and short-term followup CT recommended.
2. Fracture at the left zygomatic arch, of indeterminate age.
Fracture to the left sphenoid sinus. Non-displaced fracture of
the posterior lateral wall of the left orbit. Fracture through
the left sphenoid laterally that is an inferior continuation of
a frontal bone fracture.
3. Left frontal soft tissue hematoma.
[**2187-10-7**] CT C spine :
No acute fracture seen. Multilevel degenerative changes in the
cervical spine.
[**2187-10-7**] CT Torso : 1. Bilateral posterior lung consolidation,
could be aspiration or partial collapse.
2. Small anterior mediastinal hematoma with adjacent
nondisplaced sternal
fracture.
3. Attenuated splenic vein, age indeterminate, but with
collaters seen. IVC filter in place with more distal IVC
markedly attenuated, likely from chronic occlusion. Numerous
collateral vessels seen.
4. Hypodense left renal lesion, measuring Hounsfield units
greater than that typical for a simple cyst. Recommend further
evaluation with ultrsaound in a nonurgent setting.
5. Hyperenhancing focus in segment IVB of the liver, followup
with multiphase CT or MRI in a nonurgent setting.
6. Superior compression of T6, T8, and L3, as well as anterior
wedging of T12 vertebral bodies, of indeterminate age; correlate
with point tenderness.
7. Right shoulder degenerative change with possible joint loose
body.
Findings can be further evaluated starting with MRI if not
already evaluted previously.
8. Linear high density in sacral canal, could be calcification,
or vessels.
[**2187-10-7**] right wrist : Comminuted fracture of the distal radius
with mild displacement. Mildly displaced fracture of the ulnar
styloid. Prominent soft tissue swelling.
[**2187-10-8**] MRI spine : 1. Multiples vertebral body compression
deformities in the thoracic and lumbar spine which appear
chronic. There is no evidence of underlying bone marrow lesions,
suggesting that the fractures may be osteoporotic, unusual for
the patient's age.
2. The most significant, moderate T12 compression fracture is
associated with mild retropulsion and a mild kyphotic angulation
at T11-12, without mass effect on the spinal cord.
3. Multilevel cervical spondylosis with approximately moderate
spinal canal stenosis and moderate neural foraminal narrowing,
somewhat suboptimally evaluated due to artifacts. While the
spinal cord is deformed from C4-5 through C6-7, no definite cord
signal abnormalities are seen.
4. Multilevel lumbar spondylosis. Severe right neural
foraminal narrowing at L4-5 and L5-S1, with compression of the
exiting L4 and L5 nerve roots. Abutment and possible compression
of the traversing right L5 nerve root in the subarticular recess
at L4-5.
[**2187-10-8**] Head CT :
1. The previously identified left frontal punctate
hyperdensity is not
identified on this study. No new intracranial hemorrhage.
2. Prominence of the CSF spaces overlying the hemispheres, right
greater than left, may reflect chronic subdural collections,
more conspicuous on the right in comparison to one day prior,
which may reflect differences in positioning.
Test Name Value Units Reference Range
[**2187-10-12**] 07:05AM
NEUROPSYCHIATRIC
Phenobarbital 16.5 ug/mL 10.0 - 40.0
PERFORMED AT WEST STAT LAB
Phenytoin 8.0* ug/mL 10.0 - 20.0
PERFORMED AT WEST STAT LAB
Valproic Acid 39* ug/mL 50 - 100
PERFORMED AT WEST STAT LAB
Brief Hospital Course:
Mr. [**Known lastname 19961**] was evaluated in the Emergency Room by the Trauma
team and then admitted to the Trauma ICU for further management.
He was intubated in the ER for airway protection though alert
and oriented prior to this. Following an uneventful twenty four
hour period in the ICU he was easily extubated and although had
a very flat affect he was neurologically intact. His
Neurologist from [**Hospital6 1708**] was contact[**Name (NI) **] and
he was placed on all of his pre admission anti seizure
medications.
He was seen by the Ortho-spine service due to multiple
compression fractures noted on CT to determine if they were old
or new. After reviewing the MRI with Radiology it was
determined that all the fractures were old. he had no back pain
to palpation and his activity was changed to out of bed as
tolerated.
The Neurosurgery service was following his clinical exam and
head CT's. As there was no change in his exam and his Head CT
was unchanged after 24 hours they recommended a follow up head
CT in 4 weeks and a follow up appointment at that time.
The Opthomology Service examined Mr. [**Known lastname 19961**] and the globes were
intact but the would like to fully examine him as an out patient
so that his eyes can be dilated.
The Plastic surgery service will follow his facial fractures on
an out patient basis and his scalp staples can be removed on
[**2187-10-16**].
On [**2187-10-9**] he was transferred to the Trauma floor where he
continued to make good progress. His right distal radius
fracture was splinted and xray confirmed good alignment. He had
some swelling of his fingers but good CMS and his right arm was
elevated to reduce the edema. The Physical Therapy service
worked with Mr. [**Known lastname 19961**] to increase his mobility and improve
balance and gait training. He was able to walk with a rolling
walker with platform and hopefully after a short term rehab stay
he will be able to return home independently.
From a neurologic standpoint he remained seizure free however
his dilantin level was 8 on [**2187-10-12**] which reflected a dose of
200 mg PO TID. His routine dose was increased to 300 mg PO TID
and a dilantin level should be checked [**2187-10-14**]. His VA level
was also a bit low but the dose was not changed and levels
should be monitored.
He was discharged to rehab on [**2187-10-12**].
Medications on Admission:
1. Dilantin 200 mg PO TID
2. Depakote [**Telephone/Fax (1) 72240**]
3. Phenobarb 60 mg PO BID
4. Risperidol unknown dose
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO TID (3 times a day).
3. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary diagnosis
S/P Fall, found at the bottom of 14 stairs
1. left zygomatic fracture
2. left sphenoid sinus fracture
3. left lateral orbit non displaced fracture
4. sternal fracture
5. L3,T5,T12,C6 compression fractures
6. small anterior mediastinal hematoma
7. bilateral posterior lung consolidation
8. right distal radius fracture
Secondary diagnosis
1. Grand mal seizures
2. TBI secondary to motorcycle accident
3. Sleep apnea
4. psychosis secondary to seizure disorder
5. S/P Appendectomy
6. S/P temporal lobectomy [**2168**] for intractable seizures
7. IVC Filter placement
Discharge Condition:
Stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics. Call
[**Telephone/Fax (1) 1228**] for an appointment.
Call the Plastic Surgery clinic at [**Telephone/Fax (1) 5343**] for a follow up
appointment in 1 week ([**2187-10-19**])
Call [**Hospital **] Clinic at [**Telephone/Fax (1) 253**] for a follow up
appointment in 2 weeks
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 4 weeks. You will need a Head CT prior to that
appointment and the secretary will scedule this for you.
Call your Neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 112**] for a follow up
appointment in 2 weeks
Completed by:[**2187-10-12**]
|
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icd9cm
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[
[
[]
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,332
| 164,728
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1023
|
Discharge summary
|
report
|
Admission Date: [**2154-11-6**] Discharge Date: [**2154-12-4**]
Date of Birth: [**2100-3-11**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
adnexal mass
Major Surgical or Invasive Procedure:
total abdominal hysterectomy
bilateral salpingoopherectomy
omentectomy
cystoscopy
panniculectomy
History of Present Illness:
This is a 54-year-old gravida 0 woman who presented recently to
our emergency room with complaints of worsening right lower
quadrant pain. On detailed questioning, she reports that this
pain has been gradually getting worse over time, perhaps for
over a year now. She reports that while getting up out of bed
recently she felt a sharp stabbing pain in the right lower
quadrant that essentially left her immobilized. She was unable
to sit up. In the emergency room, a full evaluation was
performed. This included a CT scan, which revealed a complex
solid, cystic adnexal mass measuring 21.8 x 17 x 21.7 cm. This
mass appears to emanate from the right adnexal region. However,
a pedunculated fibroid or even leiomyosarcoma could not be
excluded as a potential etiology. A CA-125 level of 44 was
obtained and a CEA level of 2.1 was noted. [**Known firstname 6744**] has a number
of medical problems, but she reports she is overall fairly
stable at this point. [**Known firstname 6744**] denies manifestations of advanced
ovarian cancer. She denies any shortness of breath, difficulty
with gastrointestinal functioning, abdominal bloating. She has
no family history for ovarian cancer and no history of adnexal
masses. She denies recent fever, and there is no indication
that this growth is of the appendix or intestinal in origin.
Past Medical History:
Diabetes Mellitus, Type II
Hypertension
Asthma
OSA
Obesity
Migraine headaches
Lower extremity cellulitis
GERD
Arthritis
Social History:
She denies tobacco, drug, or alcohol use. She works at
[**Hospital3 1810**].
Family History:
Mother with h/o of DM. Father with h/o HTN and CAD, died at age
53. She also has a niece with MS. She reports her mother
developed lung cancer and had extensive cancer and progression
of the disease as reason for her death. She recently died only
within the past year ago. She has no other family history of
cancer and has no family history of thromboembolic disorder.
Physical Exam:
At the time of preoperative visit:
She appears in no apparent distress. She is morbidly obese.
HEENT: Normocephalic, atraumatic. Oral mucosa without evidence
of thrush or mucositis. Eyes, sclerae are anicteric.
Neck: Supple, there is no mass.
Lymph node survey, negative cervical, supraclavicular, axillary,
or inguinal adenopathy.
Chest: Lungs clear.
Heart: Regular rate and rhythm.
Back: No spinal or CVA tenderness.
Abdomen: Soft. Pannus is quite pendulous, and around the
umbilicus and inferiorly, there is a woody edema identified.
There is no palpable mass; however, given her morbid obesity, it
is extremely difficult to feel anything beyond the pannus.
Extremities: There is no calf tenderness to palpation.
Pelvic reveals normal external genitalia. Inner labia minora
are normal. The urethral meatus is normal. Speculum was
placed, normal cervix is seen. Pap smear is obtained. Bimanual
exam is limited due to her obesity. I am unable to appreciate
the adnexal mass, although I know there is a fullness on the
right side. I do not appreciate any nodularity in the posterior
cul-de-sac. I do not appreciate a mass on the left side. There
is no parametrial nodularity.
Upon arrival to the [**Hospital Unit Name 153**]:
Vitals: T:96.4 P:79 BP:139/67 SaO2: 95% on FI02 50%
General: intubated sedated
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: diffuse coarse, low pitched expiratory wheezing and
rhonchi L/R, bilateral breath sounds
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, ND, hypoactive bowel sounds, no masses or
organomegaly noted, large lower abdominal incision with 2 JP
drains
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.
Pertinent Results:
[**2154-11-6**] 11:23PM URINE COLOR-DKBROWN APPEAR-Cloudy SP
[**Last Name (un) 155**]-1.024
[**2154-11-6**] 11:23PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-NEG
[**2154-11-6**] 08:41PM GLUCOSE-174* UREA N-15 CREAT-1.2* SODIUM-137
POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-28 ANION GAP-14
[**2154-11-9**] 06:42AM BLOOD Glucose-105 UreaN-20 Creat-2.1*# Na-141
K-4.4 Cl-108 HCO3-23 AnGap-14
[**2154-11-11**] 06:01AM BLOOD Glucose-88 UreaN-32* Creat-5.5*# Na-138
K-4.7 Cl-105 HCO3-21* AnGap-17
[**2154-11-13**] 03:35AM BLOOD Glucose-39* UreaN-35* Creat-7.2* Na-139
K-4.3 Cl-103 HCO3-26 AnGap-14
[**2154-11-15**] 10:51PM BLOOD Glucose-160* UreaN-50* Creat-7.8* Na-140
K-4.4 Cl-99 HCO3-26 AnGap-19
[**2154-11-16**] 08:25AM BLOOD Glucose-152* UreaN-52* Creat-8.2* Na-137
K-4.2 Cl-99 HCO3-25 AnGap-17
[**2154-11-18**] 05:12AM BLOOD Glucose-87 UreaN-64* Creat-9.6*# Na-137
K-4.4 Cl-97 HCO3-25 AnGap-19
[**2154-11-19**] 04:45AM BLOOD Glucose-95 UreaN-44* Creat-6.9*# Na-138
K-4.3 Cl-100 HCO3-26 AnGap-16
[**2154-11-24**] 06:15AM BLOOD Glucose-54* UreaN-42* Creat-7.7*# Na-134
K-4.0 Cl-95* HCO3-28 AnGap-15
[**2154-11-25**] 06:21AM BLOOD Glucose-67* UreaN-45* Creat-8.4* Na-136
K-4.5 Cl-97 HCO3-27 AnGap-17
[**2154-11-26**] 06:38AM BLOOD Glucose-62* UreaN-24* Creat-5.5*# Na-139
K-4.1 Cl-97 HCO3-32 AnGap-14
[**2154-11-27**] 04:05AM BLOOD Glucose-173* Creat-6.1* Na-134 K-4.2
Cl-95* HCO3-30 AnGap-13
[**2154-11-28**] 06:22AM BLOOD Glucose-136* UreaN-21* Creat-4.9*# Na-140
K-4.0 Cl-97 HCO3-33* AnGap-14
[**2154-11-29**] 05:01AM BLOOD Glucose-141* UreaN-23* Creat-5.4* Na-140
K-3.9 Cl-98 HCO3-33* AnGap-13
[**2154-11-10**]:
IMPRESSION
1. No evidence of intraperitoneal or retroperitoneal hematoma.
2. Dilated loops of small bowel proximally, may relate to
post-surgical
ileus. However, an early small-bowel obstruction cannot be
excluded.
3. Small amount of nonspecific fluid and stranding seen within
mid abdomen
and pelvis, likely post-surgical.
[**2154-11-12**]: CXR
1. Nasogastric tube tip not well seen, may be only as far as the
distal
esophagus. Repositioning is recommended.
2. Dilated loops of small bowel, likely secondary to
postoperative ileus.
3. Mild pulmonary vascular congestion. Cardiomegaly
[**2154-11-16**]: Lower extremity veins, Left
No color flow or compressibility of the left popliteal vein
concerning for possible DVT. Minimal Doppler waveforms obtained
in the left
popliteal vein may represent sluggish or slow flow.
[**2154-12-1**]: CXR
Left PICC tip is difficult to evaluate. It can be seen only to
the mid SVC.
There is moderate cardiomegaly. The central pulmonary arteries
are enlarged.
There is no CHF, pneumonia, pneumothorax or pleural effusion.
Right jugular
vein catheter tip is in the lower SVC.
[**2154-11-26**] Upper extremity veins
No evidence of DVT
[**2154-11-7**] 03:16PM BLOOD WBC-2.5*# RBC-5.89*# Hgb-15.0# Hct-49.4*#
MCV-84 MCH-25.5* MCHC-30.3* RDW-14.9 Plt Ct-146*#
[**2154-11-7**] 04:43PM BLOOD WBC-5.6# RBC-3.46*# Hgb-8.9*# Hct-29.0*#
MCV-84 MCH-25.6* MCHC-30.6* RDW-14.9 Plt Ct-314#
[**2154-11-7**] 11:01PM BLOOD WBC-6.4 RBC-3.53* Hgb-9.1* Hct-29.2*
MCV-83 MCH-25.9* MCHC-31.3 RDW-14.3 Plt Ct-294
[**2154-11-10**] 01:20PM BLOOD WBC-9.0 RBC-3.51* Hgb-9.4* Hct-30.6*
MCV-87 MCH-26.7* MCHC-30.6* RDW-14.7 Plt Ct-339
[**2154-11-14**] 04:48AM BLOOD WBC-15.7* RBC-3.53* Hgb-9.3* Hct-29.2*
MCV-83 MCH-26.4* MCHC-31.9 RDW-15.2 Plt Ct-397
[**2154-11-19**] 04:45AM BLOOD WBC-7.1 RBC-3.23* Hgb-8.4* Hct-26.6*
MCV-82 MCH-25.9* MCHC-31.4 RDW-15.0 Plt Ct-228
[**2154-11-21**] 04:49AM BLOOD WBC-6.5 RBC-3.26* Hgb-8.4* Hct-26.4*
MCV-81* MCH-25.7* MCHC-31.7 RDW-15.1 Plt Ct-226
[**2154-11-27**] 04:05AM BLOOD WBC-6.6 RBC-2.90* Hgb-7.3* Hct-23.3*
MCV-81* MCH-25.3* MCHC-31.4 RDW-16.7* Plt Ct-320
[**2154-11-28**] 06:22AM BLOOD WBC-7.1 RBC-3.12* Hgb-7.9* Hct-25.5*
MCV-82 MCH-25.3* MCHC-31.0 RDW-17.1* Plt Ct-286
[**2154-11-29**] 05:01AM BLOOD WBC-7.9 RBC-2.92* Hgb-7.6* Hct-23.6*
MCV-81* MCH-25.9* MCHC-32.0 RDW-17.3* Plt Ct-279
[**2154-11-20**] 05:07AM BLOOD ALT-39 AST-64*
[**2154-11-24**] 06:15AM BLOOD TSH-7.4*
[**2154-11-26**] 06:38AM BLOOD Cortsol-13.1
[**2154-11-10**] 06:15AM BLOOD Cortsol-28.1*
[**2154-11-26**] 02:49PM BLOOD BETA-HYDROXYBUTYRATE-PND
[**2154-11-26**] 06:38AM BLOOD INSULIN-PND
[**2154-11-26**] 06:38AM BLOOD C-PEPTIDE-PND
[**2154-11-26**] 03:14PM BLOOD SULFONYLUREAS-PND
Brief Hospital Course:
The patient underwent total abdominal hysterectomy, bilateral
salpingoopherectomy, omentectomy, cystoscopy, and
panniculectomy. She tolerated surgery well with 400 cc blood
loss, but had reduced urine output requiring 4l NS. She was
briefly hypotensive and hypertensive in the OR, requiring
transient phenylephrine. She arrived in the [**Hospital Unit Name 153**] ventilated,
still paralyzed with epidural anesthesia.
Pt remained in the [**Hospital Unit Name 153**] from POD#0-7 and was called out to the
gyn oncology service on POD#7.
Summary of hospital course by problem listed below.
1. Hypoxemia: Per anesthesia, pre-op eval revealed baseline
saturations of 89%. While in the [**Hospital Unit Name 153**], the patient was found to
be hypoxic given PaO2 of only 77 while on 50% FiO2- A-a gradient
220. This raised the question of acute hypoxemia vs. long
standing (e.g. secondary to moderate pulm HTN/OSA). Her CXR
demonstrated decreased lung volumes on left side in particular
with low ET tube as well as poor visualization of left
hemidaphragm indicating that hypoxia could be due to decreased
ventilation of the left lung or hidden PNA. She was extubated
on POD#1. Respiratory acidosis on ABG led to initiation of
Bipap as needed. After developing a fever overnight on POD#[**1-4**],
a consultation with the infectious disease team was obtained
given concern for aspiration pneumonia. Vancomycin and zosyn
were initiated on POD#2, and ciprofloxacin was added on POD#3
for treatment of ventilator-associated pneumonia. She was
continued on these antiobiotics until POD#11. She remained well
oxygenated on 4L NC which was very slowly weaned off on POD#13.
She wsa discharged on room air.
2. Hypotension
Given hypotension intraoperatively and the evening of POD#0, the
decision was made to hold home antihypertensive medications.
The patient received IV boluses as needed to keep MAP>65. The
patient was hemodynamically stable and never required pressors
while in the ICU. At the time of callout, the pt. was no longer
hypotensive. Home antihypertensive medications were re-started
POD#12 starting with metoprolol. Nifedipine was added on POD#21
when blood pressures continued to be elevated on one [**Doctor Last Name 360**]. She
was discharged on Metoprolol 50 mg XL daily and Nifedipine 90 mg
XL daily. BP typically averaged 140s/80s.
3. Pain control
Pain was controlled with epidural, managed by the acute pain
service until discontinuation on POD#2. Morphine PCA was
instituted but later discontinued given low renal clearance.
Low dose IV Dilaudid PRN was used for pain control for the
remainder of ICU stay. Adequate pain control was achieved. Pt
was kept on IV dilaudid for pain control until she was
adequately tolerating POs on POD#13 and was switched to PO
dilaudid and tylenol. She was using Tylenol at time of
discharge.
4. Renal failure - The patient had significantly decreased UOP
during her stay in ICU that was not responsive to IVF.
Creatinine bump was noted on POD#3. Renal service was consulted
and concluded that ARF was due to ATN precipitated by transient
hypotension peri-operatively. The patient had HD catheter
placed in the left IJ and HD was initiated on POD #6. The
patient underwent hemodialysis every other day until her
hemodialysis was discontinued on [**11-29**]. Her creatinine at
highest level was 9.6. At time of discharge the creatinine was
3.2. The patient's hemodialysis port is still in place and to
be removed by interventional radiology likely on [**12-5**] or [**12-6**]
when patient has INR < 2.0
5. Ileus / Nutrition - The patient was diagnosed with likely
functional ileus postoperatively. NG tube was placed and the
patient was maintained NPO. Given long term NPO, TPN was
initiated on POD#6. She was advanced to regular diet and TPN was
discontinued on [**2154-11-21**]. She was discharged on regular diet.
6. Elevated TSH - On POD#18 ([**11-24**]) the patient was found to
have TSH elevated to 7.6 and her cortisol was elevated to 28.
OMR shows that her TSH was WNL at 2.7 in [**2149**]. This represents
subclinical hypothyroidism that may be due to her multiple acute
illness, including recent pneumonia, influenza A infection, and
renal failure requiring dialysis. Her TSH should be rechecked
5-6 weeks after her hospital discharge.
7. Diabetes - Patient was on an insulin sliding scale with
relatively adequate glycemic control until POD#17. Glyburide was
restarted for better control. On POD#23-26 she became
hypoglycemic. Her diet was changed from diabetic to regular and
she was started on D5 1/2NS IVF. Blood sugars continued to range
between 47-80s and responded only minimally to oral glucose
tablets, D50 boluses and glucose gel. An endocrine consult was
obtained and they diagnosed iatrogenic hypoglycemia due to
glyburide in the setting of renal failure. She was treated with
a one time dose of 50mcg octreotide with good response. With
improvements in her renal function, glyburide was again
restarted at 5 mg. Her fingersticks were in suboptimal control
in mid 100s at time of discharge.
.
8. DVT - A DVT of the left lower extremity was diagnosed after
swelling was noted on the patient's left leg. A heparin drip was
started and bridged to coumadin. Lovenox was not used due to
patient's BMI and renal failure. The patient was on Coumadin 5
mg daily until [**12-2**] 1600 which was her last dose. The patient
is currently off coumadin at time of discharge to reverse the
patient's INR briefly for removal of tunnelled hemodialysis port
catheter likely [**12-5**] or [**12-6**].
9. Infectious disease: Patient complained of flu-like symptoms
after discharge from the ICU associated with fevers. She was
started A flu swab was obtained and she was diagnosed with
influenza A, likely H1N1. Tamiflu was started and renally dosed
at 30mg on every other hemodialysis day. She was kept on droplet
precautions until 10 days following her last fever. Dose was
completed after a total of 10 days. All contact precautions were
discontinued prior to discharge.
.
10. Prophylaxis - Pt was kept on Subcutaneous heparin TID for
DVT prophylaxis as well as pneumoboots. She was given a proton
pump inhibitor. She was kept on kefzol per plastics
recommendations for prophylaxis until her JP drains were
removed. The kefzol was discontinued when she was started on
the vancomycin, zosyn, and cipro for her pneumonia. When these
antibiotics were discontinued after resolution of the pneumonia,
Kefzol was again restarted and discontinued on [**2154-11-30**] when the
JP drain was discontinued by plastic surgery.
.
11. Anemia: The patient received 2 units of packed RBC following
surgery. Postoperatively, she had anemia with hematocrits stable
at 22-24%. The anemia was thought to be due to anemia of chronic
disease. The patient was started on iron TID with colace even
though iron studies did not reflect iron deficiency anemia.
Medications on Admission:
albuterol prn
fluticasone 50mcg 2 sprays [**Hospital1 **]
fluticasone-salmeterol 250/50 IH [**Hospital1 **]
glyburide 5mg PO daily
HCTZ 25mg PO daily
metformin 1000mg PO BID
toprol xl 100mg daily
nifedipine xl 60mg PO daily
omeprazole 20mg PO daily
docusate
senna
oxycodone 5mg q6hrs PO daily
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) ML Inhalation [**Hospital1 **] (2 times a day).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Benign abdominopelvic mass
Acute renal failure
DVT
Pneumonia
H1N1 Infuenza
Discharge Condition:
stable, renal failure improving
Discharge Instructions:
- Please call your doctor if you experience fever > 100.4,
chills, nausea and vomiting, worsening or severe abdominal pain,
heavy vaginal bleeding, chest pain, trouble breathing, or if you
have any other questions or concerns.
- Please call if you have
redness and warmth around the incision, if your incision is
draining pus-like or foul smelling discharge, or if your
incision reopens.
- No driving while taking narcotic pain medication as it can
make you drowsy.
- No heavy lifting or strenuous exercise for 6 weeks to allow
your incision to heal adequately.
- Nothing per vagina (no tampons, intercourse, douching for 6
weeks.
- Please keep your follow-up appointments as outlined below.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**], PA, from Interventional Radiology will arrange
removal of hemodialysis tunnelled- port catheter when INR is <
2.0. This will likely occur on [**12-5**] or [**12-6**] this week. Patient
will need to be transported to the Interventional Radiology
suite on [**12-5**] or [**12-6**] when INR in goal range
.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] PA-C
[**Hospital1 69**]
Interventional Radiology/Clinical Center [**Apartment Address(1) 6746**]
Phone: [**Telephone/Fax (1) 6747**]
Fax: [**Telephone/Fax (1) 6748**]
Beeper:9-1162
.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**]
Gynecolgy Oncology
Date and time [**2154-12-12**] at 2:40pm
Location: Gyn Specialities, [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 6749**], [**Location (un) 830**], [**Location (un) 86**]
Phone:[**Telephone/Fax (1) 5777**]
.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: [**Hospital3 **] Post [**Hospital **] Clinic
Date and time: Tuesday, [**12-9**] at 11:30am
Location: [**Hospital3 **], [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 6750**], [**Location (un) 830**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 250**]
This appointment is for follow up to your hospitalization. You
will then be connected to your Primary Care provider after this
visit.
.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time:[**2154-12-17**] 11:00 Plastic Surgery
[**Hospital Ward Name **] [**Hospital1 69**]
[**Location (un) **] [**Last Name (un) 6752**] Building
for prolene-suture removal
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
|
[
"799.02",
"518.0",
"346.90",
"488.1",
"250.00",
"V64.2",
"215.6",
"401.9",
"E878.8",
"458.29",
"622.10",
"560.1",
"416.8",
"530.81",
"997.4",
"453.40",
"493.90",
"614.6",
"997.31",
"997.5",
"E849.8",
"278.1",
"220",
"278.01",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"68.49",
"65.61",
"54.91",
"54.25",
"86.83",
"38.95",
"39.95",
"57.32",
"03.90",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
16825, 16891
|
8581, 15500
|
301, 399
|
17010, 17044
|
4176, 8558
|
17786, 19657
|
2023, 2398
|
15844, 16802
|
16912, 16989
|
15526, 15821
|
17068, 17763
|
2413, 4157
|
249, 263
|
427, 1769
|
1791, 1912
|
1928, 2007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,126
| 196,314
|
53336
|
Discharge summary
|
report
|
Admission Date: [**2132-10-28**] Discharge Date: [**2132-11-6**]
Date of Birth: [**2066-2-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Cardiomyopathy and heart failure
Major Surgical or Invasive Procedure:
[**2132-10-28**]-Pacer/defibrillator generator change, attempted lead
placement
[**2132-10-29**] - Mini Left Thoracotomy with LV epicardial lead
placement.
History of Present Illness:
This 66 year old black male with significant non-ischemic
cardiomyopathy who underwent ICD implant in [**2128**]. He has NYHA
Class II congestive heart failure
with an EF of 30%. The patient was hospitalized in [**2132-9-11**]
for a CHF
exacerbation treated with intravenous diuretics. The patient
reports a moderate limitation with physical activity and a low
energy level. The patient reports shortness of breath with mild
exertion relieved with rest. The patient denies
lightheadedness, palpitations, pre syncope, syncope or chest
pain. The patient denies rest symptoms. recent interrogation of
his device revealed that he had episodes of non sustained VT, no
episodes of sustained VT and no therapies were delivered. The
optiVol index was noted to be high implying ongoing heart
failure. It was decided to proceed with upgrading his current
device to a BIV/ICD.
Past Medical History:
Non ischemic cardionyopathy
s/p gastric bypass
hypertension
gout
obstructive sleep apnea
Social History:
Married and retired police officer. He denies tobacco or illicit
drug use. Upon questioning, the patient has an extensive h/o
alcohol use. He admits to being a heavy social drinker.
Family History:
Grandmother with CAD but no premature CAD in family. Mother with
cancer, sister with DM.
Physical Exam:
Admission:
Pulse: 67 Resp:20 O2 sat: not recorded -on room air
B/P 138/87
Height: 5 feet 8 inches
Wt: 240 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none Right: 2+ Left:2+
Pertinent Results:
[**2132-11-2**] 05:23AM BLOOD WBC-6.2 RBC-3.66* Hgb-11.1* Hct-32.0*
MCV-88 MCH-30.5 MCHC-34.8 RDW-13.5 Plt Ct-171
[**2132-11-1**] 02:58AM BLOOD WBC-7.9 RBC-3.56* Hgb-10.3* Hct-32.3*
MCV-91 MCH-28.8 MCHC-31.8 RDW-14.0 Plt Ct-118*
[**2132-11-3**] 06:03AM BLOOD UreaN-24* Creat-1.6* Na-140 K-4.2
[**2132-11-2**] 05:23AM BLOOD Glucose-136* UreaN-21* Creat-1.5* Na-141
K-3.8 Cl-103 HCO3-29 AnGap-13
[**2132-11-1**] 02:58AM BLOOD Glucose-127* UreaN-25* Creat-1.6* Na-143
K-4.2 Cl-109* HCO3-27 AnGap-11
[**2132-10-31**] 12:51AM BLOOD Glucose-109* UreaN-30* Creat-2.3* Na-142
K-4.8 Cl-111* HCO3-22 AnGap-14
[**2132-10-30**] 03:13PM BLOOD Glucose-108* UreaN-29* Creat-2.7* Na-140
K-5.0 Cl-108 HCO3-24 AnGap-13
[**2132-10-30**] 02:37AM BLOOD UreaN-25* Creat-2.2* Na-141 K-4.3 Cl-107
HCO3-23 AnGap-15
[**2132-11-3**] 06:03AM BLOOD ALT-26 AST-31 LD(LDH)-262* AlkPhos-93
Amylase-143* TotBili-1.2
[**2132-11-1**] 02:58AM BLOOD Lipase-28
[**2132-11-3**] 06:03AM BLOOD Albumin-3.4
[**2132-10-29**] 07:15AM BLOOD %HbA1c-6.8*
[**2132-10-31**] 09:28AM BLOOD Type-ART Temp-38.0 pO2-112* pCO2-54*
pH-7.24* calTCO2-24 Base XS--4
ECHO
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 109737**]TTE
(Complete) Done [**2132-10-30**] at 12:12:19 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**Known firstname 275**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] Cardiac Electrophysiology
[**Street Address(2) 8667**], [**Hospital Ward Name **] 4
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2066-2-16**]
Age (years): 66 M Hgt (in): 68
BP (mm Hg): 108/57 Wgt (lb): 240
HR (bpm): 101 BSA (m2): 2.21 m2
Indication: Coronary artery disease. Left ventricular function.
Right ventricular function. Shortness of breath.
ICD-9 Codes: 786.05, 423.3, 424.0
Test Information
Date/Time: [**2132-10-30**] at 12:12 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 8154**] Bzymek, RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W000-0:00 Machine: Other
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm
Left Ventricle - Stroke Volume: 44 ml/beat
Left Ventricle - Cardiac Output: 4.44 L/min
Left Ventricle - Cardiac Index: 2.01 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.18 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 4 < 15
Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg
Aortic Valve - LVOT VTI: 14
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *2.8 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - E Wave deceleration time: 201 ms 140-250 ms
Tricuspid Valve - Peak Velocity: 0.0 m/sec
TR Gradient (+ RA = PASP): *30 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: *2.4 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2131-5-18**].
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA.
LEFT VENTRICLE: Normal LV wall thickness. Dilated LV cavity.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Cannot assess
regional RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views. Suboptimal image quality - body habitus. The rhythm
appears to be A-V paced.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is dilated. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. LV systolic function appears depressed
(?30%) but images are suboptimal for assessment of wall motion.
The right ventricular cavity is mildly dilated with grossly
preserved contractility but views are suboptimal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2131-5-18**],
left ventricular systolic function appears more vigorous in the
setting of tachycardia.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2132-10-30**] 14:57
Brief Hospital Course:
Mr. [**Known lastname 37160**] was admitted to the [**Hospital1 18**] on [**2132-10-28**] for placement
of an epicardial lead. He was worked-up in the usual
preoperative manner and was ready for surgery. On [**2132-10-28**] the
generator was upgraded but attempts at transvenous lead
placement were unsuccessful by the electrophysiology service.
On [**10-29**] he was taken to the Operating Room where he underwent a
left minithoracotomy with placement of epicardial ventricular
leads. (Please see operative note for details.) Postoperatively
he went to the post anesthesia care unit. He developed
epigastric pain and a surgery consult was obtained. No acute
surgical issues were found beyond colonic ileus and he was
transferred to the cardiac surgery intensive care unit for
monitoring. His creatinine rose to 2.2.
Antigas medications and promotility agents were given, narcotics
were stopped and he improved. Attempts at gastric and rectal
tube placement were unsuccessful (there was no stomach
distention). His CT was removed, he was mobilized and over two
days the ileus resolved, flatus passed and his diet was advanced
from clears to regular heart healthy.
As he was hydrated, urine output picked up and his creatinine
normalized to his baseline of 1.7. He was placed back on his
preoperative medications and transferred to the floor.
By post-operative day 6 he was ready for discharge to home. He
was tolerating a regular diet, ambulating and moving his bowels.
Wounds were clean and healing well. Arrangements were made for
follow up and instructions discussed with him.
Medications on Admission:
calcium carbonate 500mg daily
tamsulosin 0.4mg po daily
spironalactone 25mg daily
crestor 40mg daily
prilosec 20mg daily
lasix 20mg daily
finasteride 5mg daily
allopurinol 100mg daily
asa 81 mg daily
coreg 6.25 mg TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Attempted placement pacemaker leads [**2132-10-28**]
Left thoracotomy and placement of ventricular leads for
biventricular pacemeker/defifrillator [**2132-10-29**]
Non ischemic cardiomyopathy
s/p [**Company 1543**] Virtuoso Dual chamber ICD
hypertension
Sleep apnea
Chronic renal insufficiency
s/p Gastric bypass surgery
Gout
Discharge Condition:
good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision until it has healed.
Please shower daily. No bathing or swimming for 1 month.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month or while taking narcotics for pain.
Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 1 month (surgeon) ([**Telephone/Fax (1) 170**]).
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-15**] weeks.([**Telephone/Fax (1) 7728**])
Dr. [**Last Name (STitle) **] in [**1-15**] weeks
Completed by:[**2132-11-6**]
|
[
"585.9",
"428.22",
"278.00",
"560.1",
"274.9",
"327.23",
"425.4",
"428.0",
"403.90",
"V45.02",
"427.89",
"426.3",
"584.9",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.97",
"37.79",
"00.54"
] |
icd9pcs
|
[
[
[]
]
] |
11378, 11433
|
8149, 9741
|
354, 512
|
11803, 11810
|
2492, 6876
|
12370, 12657
|
1741, 1831
|
10010, 11355
|
11454, 11782
|
9767, 9987
|
11834, 12346
|
6925, 8126
|
1846, 2473
|
282, 316
|
540, 1413
|
1435, 1525
|
1541, 1725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,248
| 189,591
|
11685
|
Discharge summary
|
report
|
Admission Date: [**2160-2-18**] Discharge Date: [**2160-2-25**]
Date of Birth: [**2096-4-18**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
transfer from OSH after he presented there s/p fall, altered
mental status, hypoglycemia
Major Surgical or Invasive Procedure:
Endotracheal tube placement, extubation
History of Present Illness:
Mr. [**Known lastname **] [**Known lastname 4597**] is a 63 yo male with hx of obesity, DM, CAD s/p
stent on [**1-17**] who presented to [**Hospital6 33**] today by
his wife who found him on the floor. She had seen him around
945 am normal, left for an appointment, and when she returned
she was on the floor, but awake. She called EMS. EMS found the
patient dysarthric with difficulty moving. FS was 70 and on
recheck 240.
At the [**Hospital3 **] ED he was aphasic. He became cyanotic with
decreased respirations and was intubated. Prior to intubation
it was reported that he had no focal neuro deficits, although he
was only partially following commands. There was also concern
for a right-sided facial droop. A code stroke was called and he
underwent a head CT which was negative for bleed. Neuro
evaluated him and he was admitted to their ICU. Of note, the
EKG in the ED showed new atrial fibrillation. There was also
verbal report that he had persistent hypoglycemia and was
treated with D50 and placed on a D10 gtt. He also underwent a
head CTA which was negative and right humerus X-ray which showed
an unchanged communited and impacted fracture.
On arrival to the MICU he is normotensive, sedated, and
intubated.
Unable to obtain ROS as patient is intubated and sedated
Past Medical History:
# Type 2 diabetes mellitus diagnosed 30 years ago.
# Hypertension
# CAD - abnl stress test s/p cath [**2160-1-18**] showing single
vessel disease in the LAD with 90% stenosis s/p bare metal stent
# Dyslipidemia
# Morbid obesity with patient planning to undergo laparoscopic
banding surgery which was placed on hold after stent placement
in [**Month (only) **].
# Chronic lower extremity venous insufficiency.
# History of foot ulcers.
# Cataracts.
# Traumatic detached retina.
# Humeral fracture on [**2160-2-1**]
Social History:
(per OMR/OSH records)
He lives with his wife. [**Name (NI) **] history of tobacco, alcohol, or drug
use.
Family History:
(per OMR/OSH records)
Significant for diabetes
Physical Exam:
GEN: Middle-aged male laying in bed intubated and sedated.
HEENT: Left pupil slightly smaller then the right pupil, both
small and slightly reactive to light.
RESP: Ventilated. CTAB anteriourly.
CV: distant heart sounds, RRR, no MRG.
ABD: +BS, sof, obese, NTND
EXT: no c/c/e; right upper arm with large bruies present.
Patient grimaces to any touching of his right arm.
SKIN: no rashes/no jaundice/no splinters
NEURO: sedated and intubated, withdraws to pain. Moves all
extremities spontaneously. Does not open eyes to command or
follow any commands.
Pertinent Results:
Admission labs:
OSH: [**2160-2-18**]
Na 137 K 3.7 Cl 103 Bicarb 24 BUN 44 Cr 1.5 Glu 56
Ca 9.2 TP 6.4 Alb 3.7
AST 20 ALT 17 Alk Phos 102 Tbili 0.2
Trop-T 0.02 CK 4
.
WBC 8.0 Hct 39.1 Plt 204
81% N 10.4 % L 6.8% M
.
INR 1.1 PTT 32.8
.
Admission labs here:
[**2160-2-18**] 10:28PM GLUCOSE-94 UREA N-39* CREAT-1.1 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
[**2160-2-18**] 10:28PM ALT(SGPT)-18 AST(SGOT)-25 LD(LDH)-359* ALK
PHOS-93 TOT BILI-1.1
[**2160-2-18**] 10:28PM ALBUMIN-3.4* CALCIUM-8.8 PHOSPHATE-3.9
MAGNESIUM-2.2
[**2160-2-18**] 10:28PM TSH-0.72
[**2160-2-18**] 10:28PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-2-18**] 10:28PM WBC-9.6 RBC-3.99* HGB-12.3*# HCT-34.3* MCV-86
MCH-30.9 MCHC-35.9* RDW-13.2
[**2160-2-18**] 10:28PM NEUTS-82.6* LYMPHS-10.8* MONOS-5.6 EOS-0.7
BASOS-0.3
[**2160-2-18**] 10:28PM PLT COUNT-217
[**2160-2-18**] 10:28PM PT-13.3 PTT-25.2 INR(PT)-1.1
[**2160-2-18**] 10:28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2160-2-18**] 10:28PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2160-2-18**] 11:04PM LACTATE-0.8
[**2160-2-18**] 11:04PM TYPE-ART TEMP-35.0 PO2-163* PCO2-43* PH-7.39
TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2160-2-24**] 12:25 4.8 3.69* 11.3* 32.1* 87 30.7 35.4* 13.7 175
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2160-2-25**] 05:52 [**Telephone/Fax (2) 37001**] 4.0 104 28 11
Calcium Phos Mg
[**2160-2-25**] 05:52 8.1* 3.4 2.1
Vanco
[**2160-2-20**] 06:21 16.8
.
Micro:
[**2160-2-19**] URINE CULTURE-NEG
[**2160-2-19**] BLOOD CULTURE-NEG
[**2160-2-18**] SPUTUM GRAM STAIN-4+ GNR(S). 4+ GPC IN PAIRS,
CHAINS, AND CLUSTERS; RESPIRATORY CULTURE- HEAVY GROWTH
Commensal Respiratory Flora.
_________________________________________________________
ACINETOBACTER SP.
| STAPH AUREUS COAG +
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- <=0.5 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- <=1 S 0.25 S
OXACILLIN------------- 0.5 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
[**2160-2-18**] URINE CULTURE-NEG
[**2160-2-18**] BLOOD CULTURE-NEG
[**2160-2-18**] MRSA SCREEN-NEG
.
EKG: sinus rhythm with no STE or STD
.
Imaging:
OSH imaging:
CTA head [**2160-2-18**]:
No major vessel stenosis or occlusion evident.
.
non-con head CT [**2160-2-18**]:
No large territtorial infarct of hemorrhage identified.
humerus X-ray [**2160-2-18**]:
Comminuted and impacted fracture of the proximal right humerus.
.
CXR [**2160-2-18**]: left-sided PICC line with tip projected over the
distal SVC. Shallow inspiration. Likely mild vascular
congestion.
.
CT C-spine ([**2-19**]):
IMPRESSION:
1. No fracture or subluxation.
2. Left paracentral disc herniation at C5/6 deforms the spinal
cord and
causes moderate spinal canal narrowing. If there is a clinical
suspicion for a cord contusion or chronic myelopathy, MRI would
be helpful for further evaluation.
3. The endotracheal tube terminates. Recommend advancement.
.
CTA chest ([**2-19**]):
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Central venous catheter terminating in the proximal azygos
vein.
3. Diffuse bilateral ground-glass opacities likely representing
pulmonary
edema.
4. Bibasilar consolidation, somewhat heterogeneous within the
left lower lobe likely representing a combination of atelectasis
and pneumonia.
Brief Hospital Course:
**OUTSTANDING ISSUE: Incidental finding on CT spine, C5-C6 disc
herniation
.
63 yo male with hx of obesity, DM, CAD s/p stent on [**1-17**]
transferred from an OSH after being found down, altered, and
possibly cyanotic in the setting of hypoglycemia.
.
# Fall/altered mental status/?stroke: Unclear etiology of his
fall, may be secondary to hypoglycemia. Had head CT, C-spine,
and CTA which was negative for acute process or PE. Nonfocal
neuro exam here. Cortisol normal. CE trend negative. Still
unclear what caused his fall. Mental status is currently at
baseline. Neuro exam non-focal, RUE exam limited by pain.
.
# Hypoxic respiratory failure/PNA: Most likely due to an acute
aspiration event during period of altered mental status, but PNA
could also have been the driving event causing his hypoglycemia
and acute mental status changes. CTA demonstrating diffuse
bilateral ground glass opacities and bibasilar consolidation
concerning for PNA and ruled out PE. Given recent hospital
exposure and concern for aspiration he was initially started on
vanc/zosyn. This was broadened the morning after admission with
cefepime (instead of zosyn) and levofloxacin. Sputum culture
gram stain showed 4+ gram positive cocci and 4+ GNR, culture
grew acinetobacter and staph aureus. He was successfully
extubated [**2-19**]. Pt w/O2 sat in mid 90%s on RA, completed 7 day
course of IV vancomycin, cefepime and levofloxacin.
.
# Hypoglycemia/Diabetes: Patient is on large does of NPH and
regular insulin as well as oral agents as an outpatient. He
took all of his medications the morning of admission then was
found down (presumably he didn't eat). He doesn't remember
events of that morning. Possibly he took extra insulin by
accident. His hypoglycemia is likely due to the large doses of
insulin he took without adequate food intake. On arrival was
still hypoglycemic off D10, so IVF with D5 were continued. They
have been weaned off and he is normoglycemic. Diet was advanced
on [**2-20**]. Patient was seen and followed by [**Last Name (un) **] during
admission; pt discharged on home oral agents and decreased
insulin regimen (NPH 20 units QAM/QHS and humalog sliding
scale). Follow-up appointment w/[**Last Name (un) **] scheduled for patient
prior to discharge.
.
# Acute diastolic congestive heart failure: likely [**3-12**] to large
amt of IVF given in ICU; was positive ~6L upon transfer to
floor. Pt w/increased LE edema, c/o increased abdominal
distention. Pt was diuresed w/IV lasix 20mg with improved LE
edema and pt perception of abdominal distention.
.
# Hypertension/Transient hypotension: Initially his carvedilol
was held on admission. He was slightly hypotensive while
intubated and given many IVF boluses and was transiently on
levophed the morning of [**2-19**]. His hypotension improved after
extubation. It was thought that the propofolol was contributing
to his low BPs initially. He was restarted on his home dose of
carvediolol on [**2-20**]. Pt remained normotensive after transfer to
floor from ICU on home regimen.
.
# Atrial fibrillation: The patient was reported to have new
atrial fibrillation at the OSH ED (no EKG was sent). Not
currently in a.fib on EKG here. Is already on ASA for CAD.
Will need to discuss with PCP/outpatient cardiologist if ASA
should be increased to 325 mg daily. He was continued on ASA 81
mg daily here.
.
# Right humerus fracture: Per OSH was being conservatively
managed. Repeat X-ray at the OSH was unchanged from imaging
during the initial diagnosis. His pain was controlled with
standing tylenol and fentanyl gtt initially. He was
transitioned to oxycodone once extubated.
.
# Hx of CAD s/p recent stent: EKG without ischemic changes.
Cardiac enzymes were initally negative at the OSH and trended
here and were normal. The 30 day course of plavix after
placement of his bare metal stent has been completed so plavix
was stopped. He was continued on ASA and his carvedilolol was
restarted on [**2-20**] once no longer hypotensive.
.
Code: Full code
Medications on Admission:
Medications on transfer:
ASA 81 mg po daily
D10W 75 cc/hr
D5NS 100 cc/hr
Lovenox 40 mg SQ qhs
Pantoprazole 40 mg IV daily
Propofol gtt
.
Medications at home:
ASA 81 mg po daily
Carvediolol 12.5 mg po daily
NPH 50 units qam
NPH 80 units qhs
Regular insulin 10 units qam
Regular insulin 30 units qpm
Metformin 1500 mg po daily
Pioglitazone 45 mg po daily
Simvastatin 20 mg po qhs
Diovan/Hctz
Plavix
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. metformin 500 mg Tablet Sig: Three (3) Tablet PO once a day.
3. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Diovan HCT 160-25 mg Tablet Sig: One (1) Tablet PO once a
day.
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
7. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO q 2 weeks.
8. NPH insulin human recomb 100 unit/mL Suspension Sig: 20 units
Subcutaneous QAM and QHS.
Disp:*qs 1 month* Refills:*2*
9. Humalog 100 unit/mL Solution Sig: please follow sliding scale
Subcutaneous four times a day: Please follow sliding scale with
meals and at bedtime.
Disp:*qs 1 month* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypoxic respiratory failure requiring intubation
Type II diabetes
Hypoglycemia
Aspiration pneumonia
.
Secondary:
Coronary artery disease
Acute diastolic congestive heart failure
Morbid obesity
Right humorus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **] [**Known lastname 4597**],
You were admitted for low blood sugar, confusion and low oxygen
levels in your blood. You needed a breathing tube to help with
your oxygen levels for a short period of time. Your insulin
dosage was changed and doctors [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **] saw you during your
admission. You were also received 7 days of IV antibiotics due
to concern for a lung infection.
.
Please make the following changes to your medications:
-STOP regular insulin
-STOP Plavix - you completed the prescribed 1 month course
during your hospital stay
.
-REDUCE NPH to 20 units every morning and 20 units at bedtime
for your diabetes
-START Humalog sliding scale with meals and bedtime for your
diabetes
-CONTINUE Actos and Metformin for your diabetes
.
Please continue all other medications as prescribed.
.
Please be sure to follow-up with your primary care physician and
[**Name9 (PRE) **] physician as scheduled below.
Followup Instructions:
Name: [**Last Name (LF) 7280**], [**Name8 (MD) **] NP
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Tuesday [**2-26**] at 2:30PM
Department: [**Hospital3 249**]
When: FRIDAY [**2160-2-29**] at 9:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], 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: PODIATRY
When: FRIDAY [**2160-3-14**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: PAT PREADMISSION TESTING
When: MONDAY [**2160-3-17**] at 10:30 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
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2,265
| 134,020
|
21158
|
Discharge summary
|
report
|
Admission Date: [**2126-1-21**] Discharge Date: [**2126-4-26**]
Date of Birth: [**2049-8-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Mental status changes and increased oral secretion
Major Surgical or Invasive Procedure:
Liver biopsy
History of Present Illness:
76 year-old male with hx of traumatic brain injury with
bilateral SDH and R MCA stroke in [**10-4**] after being on
coumadin, hx of multi-resistant Klebsiella pneumonia, MRSA
bacteremia/pneumonia, VRE bactremia, s/p tracheostomy and PEG
[**10-29**] who was transferred from [**Hospital3 **] with fever of
101.6, mental status changes, and increasing oral secretions.
At baseline, the patient responds to verbal stimuli, able to
follow some commands, and occasionally speaks through PMV.
However, his mental status does wax and wane. His daughter
reports that over the past 10-12 hr prior to admission, his
mental status has been poor, minimally responsive, not
responding to sternal rub, and only rarely opens his eyes. She
also states that the respiratory therapy at Rehab noted
increasing secretions and thickening of secretions over the last
2-3 days. She states that her father's O2 sats were dropping
into 60's for [**2-28**] minute intervals today as well. From the
rehab notes, new sputum culture growing pan-resistant Klebsiella
that is sensitive to meropenem and ertrapenem. Urine cx growing
same species ([**1-19**]). Patient was started on Ertrapenem and
doxycycline. Patient was sent to [**Hospital1 18**] ED for further
management.
Past Medical History:
Past Medical History:
-- living independently with his wife prior to below
-- ([**9-29**]) fall on coumadin --> bilateral SDH/SAH and R MCA
stroke
-- s/p tracheostomy and PEG ([**10-29**])
-- MRSA bacteremia and MRSA PNA ([**10-29**])
-- high grade VRE facecium bacteremia ([**10-29**])
-- Multi-Drug resistant Klebs pneum (PNA and UTI) ([**11-29**]) and
recently at [**Hospital1 **] ([**2126-1-19**])
-- asp PNA ([**11-29**])
-- presumed UGIB ([**11-29**])
Prior to TBI:
-- CAD s/p MI [**9-/2124**]
-- PVD
-- HTN
-- occluded right carotid
-- myelodysplasia-s/p tx with procrit and transfusion
-- SCC head and neck s/p XRT
-- h/o CVA
-- h/o squamous cell carcinoma s/p radiation with PET/CT showing
complete remission
-- IVC filter placed [**2125-11-5**]
full time, completely independent, able to carry on conversation
Social History:
Previous tobacco use. Prior to traumatic injury, was working
full time, completely independent, able to carry on
conversation.
Family History:
Non-contributory
Physical Exam:
VS 99.8 90-130/40-60 80-100 16-20 92%
Gen: NAD, responsive to painful stimuli and minimally to verbal
Skin: stage II sacral decubs on L buttocks/ L heel/ L knee, not
infected appearing with dressing in place
Lines: right picc, left peripheral line, no erythema or
discharge
HEENT: MM dry, PERLLA, EOMI, no JVD, no carotid bruits, no
lymphadenopathy, trach in place
Lungs: coarse/rhoncherous breath sounds bilaterally with no
wheeze
CV: rr, s1 and s2, +[**3-3**] holosystolic at apex-> axilla
Abd: +b/s, soft, nd, nt, PEG intact-no tenderness, erythema
Ext: no LE extremity edema, trace bilateral UE edema, non-tender
[**1-27**]+ pulses throughout
NEURO: No response to verbal stimuli, localizes to pain,
bilateral decroticate posturing (L>R), tongue deviates to the
right, + grasp reflex, +Doll's eyes. Pupils 3->2mm bilaterally.
Pertinent Results:
Studies:
CT head: Left parietal and frontal subdural hematomas are again
identified. Several small areas of increased attenuation seen
within the left parietal subdural hematoma which were not
present on the most recent prior study. These are suspicious for
rebleeding within the subdural hematoma. The size of the
parietal subdural hematoma is essentially unchanged measuring
approximately 11 mm in greatest dimension. The tiny left frontal
subdural hematoma is stable in appearance. Encephalomalacic
changes throughout the brain are stable. The ventricles,
cisterns, and sulci are stable with no evidence of
hydrocephalus.
The osseous structures demonstrate bifrontal and parietal prior
craniotomies. Opacification is seen within the frontal, ethmoid,
sphenoid, and bilateral mastoid air cells. There is
near-complete opacification of the right maxillary sinus. These
findings are stable compared to the prior study.
Brief Hospital Course:
Hospital Course: Initially he finished 2 weeks course of
Meropenem/Ampicillin for VRE and bacteremia and ESBL Klebsiella
PNA. Pt also noted to have ulcers of L knee, heel, decubitous.
MS did not improve after treating infection. Pt with episode of
questionable seizure on [**1-21**]. EEG done on [**1-21**] with abnormal
focal sezire from L parasagittal area. Dilantin was then
started for seizure ppx. His hospital course was complicated by
multiple trips to the ICU for likely sepsis from either
aspiration pneumonia and cellulitis/osteo. On [**2-18**], he was
febrile, hypoxic to 89% RA, hypotensive to 70/30. He was fluid
resuscitated, Vanc/meropenem were re-started, and transferred
back to the floor on [**2-19**]. Pt was stable until he became febrile
on [**3-11**] and meropenem re-started. Pt had a witnessed aspiration
on [**3-12**]. On [**3-13**], Vanc re-started for persistent fever. Stool
was + for C.diff and Flagyl was started. Pt also noted to have
transaminitis, ultrasound showing hypoechoic lesions, and
following abdominal CT showed multiple liver lesions. The
lesion was biopsied and the pathology was consistent with
adenocarcinoma. The primary was thought likely colon ca given
his hx of colon ca, and hx of GIB. On [**3-20**], pt became febrile,
BP 70-80/40's, HR in 120, got 4L IVF and 2 units of PRBC. The
following day, he got abd CT which showed small pericapsular
hematoma but not big enough to account for the hypotension.
Given his new cancer diagnosed, his wife decided to make him
DNR/DNI. He was treated with 2 week course of Vanc/meropenem
and remained clinically stable. He was off the antibiotics for
several days. He was clinically stable until [**4-5**] when he had
another episode of fever and hypotension, so Vanc/meropenem were
re-started and IVF given to maintain his BP. He again remained
afebrile and hemodynamically stable until [**4-23**]. At that time he
spiked fever, blood, urine sent for culture and chest x-ray
obtained. Chest x-ray with no change/evidence of infiltrate.
Urine came back with Gram negative rods. Patient started on
vanc/meropenem initially which was switched to meropenem once
urinary source revealed. Patient needs imipenem or meropenam
given history of pseudomonas. Speciation pending at time of
discharge. Needs meropenam for additional 10 days. Patient has
had chronic foley requirement. He had few episodes of urethal
bleed when attempted to remove the foley in early [**Month (only) 958**]. At
that time a 3-way foley was inserted for irrigation. Plan is to
keep foley in place given significant clots/bleeding and
difficulty in re-placing a new catheter and to minimize
patient's suffering.
1. Hypotension/fever. He was transferred to the unit on [**2-17**]
with hypotension, trop leak, and new Klebsiella pna. Again
trasferred to Unit [**2-18**] for hypotension which responded to
fluids and transfusion. Finished course of meropenem for ESBL
Klebsiella on [**2126-3-2**]. It was thought to be secondary to
hypovolemia, however also considered cardiogenic shock, sepsis,
and adrenal insufficiency. [**Last Name (un) **] stim test negative. BP
responded to NS boluses and 2 Units of PRBC's. Hypotension
resolved but did require periodic NS boluses over [**Date range (1) 15001**]
weekend again. BP since stabilized. Knee ulcer (as below) c/w
polymicrobial contamination without radiographic signs of
osteomyelitis. Recurrent aspiration pneumonia or pneumonitis
also is a risk fact for recurrent infection. Per ENT, new trach
will not necessarily limit further aspiration because always
will have some cuff leak. Main indications for trach would be
the need for PS or need for pulmonary toilet, the latter of
which is the case here. On [**3-20**] became hypotensive to 40/P and
was febrile with temp of 103, so cx'd again x 2 with mycolytics
and given 4 L NS and total of 2 u. PRBC overnight. BP and Hct
responded well and pt has been stable since. Abdominal CT
performed for ? perf (s/p liver bx and possible primary colon ca
as risk factors) some mild peri-hepatic hematoma with small
amount of blood tracking down to pelvis but insufficient to
explain the degree of hypotension. Upright CXR showed no free
air below diaphragm. Troponin was down from baseline. No
indication to pursue rule-out. Patient finished a 14 day course
of meropenem and Vancomycin. As noted above, clinically stable
until [**4-5**] and then re-spiked/hypotension, got anotehr 2 week
course of vanc/meropenem. Off antibitoics again for a few days
and then re-spiked [**4-23**]--no singificant hypotension. As above,
GNR in urine, needs 10 more days of meropenem. Flagyl for two
weeks beyond meropenem course for history of c. diff.
2. Ulcers: A) Left heel--no osteo on plain film, podiatry could
not probe to bone, cont W-->D dressings. B) knee--seen by
plastics, chemical debridement and wet-to-dry dressings with
duoderm dressing changed daily; daily wet-to-dry dressings, no
pressure on knee. Debridement to knee with probing to patella by
plastics but no osteo by plain films of knee. On [**3-8**], patella
began appearing brownish in inferior section. Surrounding skin
with erythema, which has decreased over time. Wife of pt refuses
MRI b/c believes would put the patient through excessive
discomfort. D/w plastics, who agreed on starting vanco for
cellulitis. Has since completed that course. Over the past few
weeks, no significant change and not thought to be infectious
source. Dressing changes continued as noted.
3. Nausea/emesis: C.diff positive. Started metronidazole 500 mg
tid on [**2126-3-13**] for total 14-day course; but has been repeatedly
on and off antibiotics so will need to extend for 14 days after
other abx finished.
4. Liver mets: Patient was found to have transaminitis and RUQ
u/s showed liver mass c/w abscess. CT +/- showed multiple
enhancing hypodense masses c/w metastatic disease or abscesses.
Pt received diagnostic liver biopsy on [**3-18**] consistent with
adenocarcinoma. Considering colon ca as a possible primary.
However, given his overall poor prognosis, decision was made to
not pursue any diagnostic/therapeutic intervention.
5. Hypothyroidism. Cont levothyroxine, TSH initially 26 likely
secondary to inadeq absorption of synthroid w/ sucralfate.
Sucralfate discontinued and Prevacid was started instead. We
have titrated up levothyroxine from 88 to 200. TSH will need to
be checked every 4 weeks and have the synthroid dose changed
accordingly.
6. MS: Mental status changes from bilateral SDH and R MCA
stroke. EEG showing abnormal epileptiform waves, likely from
the SDH and R MCA stroke. Dilantin was started for seizure
prophylaxis. MS did not return to previous baseline after
treatment of multiple infections and resolution of subclinical
seizures. CT Head unchanged x2 (repeat done on [**1-28**] given
question of pt indicating HA.) Repeat EEG showed no evidence of
seizure while on dilantin. Dilantin level
initially therapeutic until increase in tube feedings. Dilantin
level was checked multiple times and corrections were made to
keep corrected dilantin level <20. Will need to continue to have
dilantin levels checked. At this time patient awakens to voice
or direct stimulation. He occasionally will say one word, but
words are random and not logically connected to conversation.
Although patient responds to voice, unclear that patient is
responding appropriately to any other stimuli or if limited
responses are merely random. Patient has been at this baseline
for at least a month.
7. Seizure/dilantin: Adjusted dose [**2126-2-28**] (after corrected
dilantin level of 6.1) to dilantin 150mg [**Hospital1 **] and qhs. Repeat
dilantin, albumin labs on [**2126-3-2**] showed corrected dilantin ~7
and so dosing changed on [**2126-3-3**] to 200 [**Hospital1 **] and 150 qhs.
Rechecked dilantin, free dilantin on [**2126-3-12**], showing corrected
dilantin level >20. Hodling dosing and will re-check level on
[**2126-3-16**]. Once corrected dilantin level <20, restarted dosing at
200 mg qAM, 150 mg qPM, and 150 mg qhs. Levels checked ~[**3-21**] and
dilantin level was high once corrected for albumin but this
level was in the context of tube feedings being held, so will
re-check. Tube feedings tend to decrease the absorption.
Throughout [**Month (only) 958**] continued to re-check dilantin and adjust as
needed. Re-check of dilantin and albumin scheduled for [**2126-4-29**].
8. MDS. Transfusion dependent. Transfuse for HCT <25, Plts <50.
Has not needed transfusion over last 2 weeks of admission.
9.Zoster. Patient presented with zoster lesions which eventually
healed. Acyclovir was d/c'ed on [**2126-2-5**].
10.Trach care: aggressive suctioning and chest PT, maintain sats
>93%.
11. Patient with extreme contractures of extremities. Felt
likely due to cerebral insults. No intervention at this time.
.
.
12. Px: PPI, (unable to tolerate pneumoboots secondary to skin
breakdown), has IVC filter, continue zinc and vit c, collagenase
for ulcers.
- has received pneumococcal, influenza vaccine.
.
13. Code. DNR/DNI/no pressors. Please note, care has been
modified to accomodate wishes of wife and to limit's patient's
pain and suffering. For example, maintenance of foley catheter
is needed for history of urethral clots/bleeding but optimally
it would be changed with current UTI. To minimize patient's
suffering, however, will maintain this foley and treat through
the infection.
Similar rationale behind keeping mid-line at this time, not more
aggressively working up adenocarcinoma etc.
.
14. Access. Mid-line placed in Mid-[**Month (only) 956**]. Given that other
sources of infection identified and to limit pain/procedures in
this patient with grave prognosis, have maintained line. Seen by
IV team who feels line can be maintained until it malfunctions.
It is currently functioning well.
Medications on Admission:
ASA 325 mg po qd
Protonix 40 mg po qd
Synthroid 75 mcg po qd
Lopressor 12.5 mg po tid
Doxycycline 100 mg po bid
Ertapenem 1 gm IV QD
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 100mg PO BID
(2 times a day).
2. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day) as needed.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
5. Ascorbic Acid 100 mg/mL Drops Sig: One (1) PO DAILY (Daily).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) 500 mg
solution Intravenous every six (6) hours for 10 days.
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
12. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO TID (3
times a day).
13. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Methylphenidate HCl 5 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) 325 mg PO
Q4-6H (every 4 to 6 hours) as needed.
16. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) Injection
QMOWEFR (Monday -Wednesday-Friday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] @ [**Hospital1 336**]
Discharge Diagnosis:
Enterococcal Bacteremia, Klebsiella Urinary Tract Infection and
Pneumonia, cellulitis, hypothyroidism, seizure disorder,
subdural hematoma, urethral bleeding, coronary artery disease,
metastatic adenocarcinoma
Discharge Condition:
Stable
Discharge Instructions:
All medications as prescribed.
Contact MD if you have any fevers, chills, new trouble
breathing, drop in blood pressure, worsening cough.
Follow up with your primary care doctor, Dr. [**Last Name (STitle) 6160**].
Care as per rehabilitation facility.
Followup Instructions:
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6160**]
at [**0-0-**].
|
[
"507.0",
"238.7",
"996.62",
"V44.0",
"599.7",
"V10.82",
"438.0",
"008.45",
"682.6",
"707.09",
"518.84",
"707.03",
"053.9",
"790.7",
"244.9",
"345.3",
"482.0",
"V10.00",
"707.07",
"197.7",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.48",
"50.11",
"99.04",
"38.93",
"96.6",
"96.72",
"99.05",
"86.22",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
16050, 16115
|
4500, 4500
|
365, 379
|
16369, 16377
|
3555, 3564
|
16676, 16807
|
2667, 2685
|
14565, 16027
|
16136, 16348
|
14407, 14542
|
4517, 14381
|
16401, 16653
|
2700, 3536
|
275, 327
|
407, 1660
|
3573, 4477
|
1704, 2506
|
2522, 2651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,723
| 160,890
|
28440
|
Discharge summary
|
report
|
Admission Date: [**2180-7-24**] Discharge Date: [**2180-8-4**]
Date of Birth: [**2145-7-4**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Zosyn
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypoxia, new diagnosis of congestive heart failure
Major Surgical or Invasive Procedure:
D&E
History of Present Illness:
35F w/PMH SLE (followed at [**Hospital1 112**]) presenting initially to labor
and delivery 21 weeks pregnant with shortness of breath and mild
lower back pain. She had recently been discharged after a
hospitalization for a lupus flare and was undergoing a steroid
taper due to increased edema and hypertension. She reports that
she had noted a 15 pound weight gain over one week and
difficulty lying flat, but denied ankle edema. She also endorsed
2d of dyspnea on exertion and 1d of lower back cramping. She
denied chest pain, fevers, chills, or known sick contacts.
At L&D triage, she was noted to be tachycardic to the 120-130
range, with oxygen saturation of 97% on room air. A chest x-ray
was completed that demonstrated bilateral pleural effusions,
cephalization of vessels, and enlarged heart, consistent with
CHF. Evaluation of the fetus demonstrated intra-uterine fetal
demise. Cardiology completed an urgent echocardiogram which
demonstrated a depressed ejection fraction of 30%.
Past Medical History:
- SLE: diagnosed in [**2168**], manifested by kidney disease
(membranous nephropathy by report of biopsy), facial rash,
Sjogren's syndrome, Raynaud's phenomenon, and pleuritis
- Gastritis
- Restrictive lung disease: followed by Dr. [**Last Name (STitle) **], noted to
be moderate to severe on PFTs completed 5/[**2179**].
- History of pancytopenia associated with varicella zoster
infection
- History of persistent thrombocytopenia
- Baseline proteinuria (Cr 0.8-0.9 pre-pregnancy)
Social History:
Patient is a computer programer in [**Location (un) 745**] and married. She was
accompanied at presentation by her husband [**Name (NI) **] and sister. She
denies tobacco or EtOH. This was her first pregnancy.
Family History:
adopted
Physical Exam:
Afebrile, Heart rate 96, Blood pressure 132/107, Oxygen
saturation 99% on 2 L nasal cannula, Respiratory rate 18
General: Fatigued, slightly withdrawn but appropriate for
situation, tearful at times. Pleasant.
HEENT: NC/AT. No scleral icterus or conjunctival pallor. MMM.
JVP elevated at 10 cm.
Lungs: Bilateral rales at bases up 1/3 of lung field, no wheezes
or rhonchi.
Cardiac: Borderline tachycardic, no rubs or gallops
Abdomen: Soft, gravid uterus, normo-active bowel sounds,
non-tender
Extr: No significant edema, radial/DP/PT 2+ bilaterally,
slightly cool feet but normal capillary refill
Neuro: A&Ox3, CN's symmetric
Skin: No lesions appreciated
Psych: Sad, tearful
Pertinent Results:
[**2180-7-24**]
ESR 35 / Fibrinogen 382 / CRP 10.5
INR .9 / PTT 22.5
WBC 16.2 / hct 30.3 / Plt
C3 53 / C4 10
TSH .38
Na 136 / K 4.5 / Cl 105 / CO2 17 / BUN 50 / Cr 1.1 / BG 111
Ca 8.9 / Mg 1.3 / Uric Acid 9.1
ALT 30 / AST 26 / LDH 287 / Alk PHos 111 / TB .3
[**2180-8-4**]
WBC-10.6 RBC-2.54* Hgb-8.5* Hct-25.7* MCV-101* Plt Ct-163
Glucose-94 UreaN-37* Creat-1.1 Na-135 K-4.6 Cl-104 HCO3-20*
Mg-1.8
IMAGING:
CXR ([**7-24**]): FINDINGS: The heart is mildly increased in size.
There are bilateral pleural effusions. There is hazy bilateral
vasculature with pulmonary vascular redistribution.
IMPRESSION: CHF.
TTE ([**7-24**]): Moderate global hypokinesis. Moderate mitral
regurgitation.
CT C spine [**2180-7-27**] Unremarkable study of the cervical spine.
Brief Hospital Course:
35 year old female with history of SLE and restrictive lung
disease presenting with new-onset systolic CHF and intra-uterine
fetal demise.
1. Shortness of breath:
Patient was found to have a new diagnosis of systolic heart
failure with EF 30% and BNP=55,060. Differential diagnosis
includes lupus myocarditis, peripartum cardiomyopathy, or acute
decrease in ejection fraction in the setting of critical
illness. Pt was seen in consultation by cardiology and was
started on a beta blocker, which was titrated up to Toprol 50mg
PO qAM, and she is being sent home on Lasix 40mg PO Daily. ACE-I
was not added given borderline-low blood pressures. Her
discharge weight is 156.8 pounds. She will follow-up in the
Heart Failure Clinic.
2. Fetal demise:
Patient underwent D&E under general anesthesia without
complication. Social support was provided by social work.
3. SLE:
Patient is followed by rheumatoloy at [**Hospital1 112**], and was seen by the
inpatient rheumatology consult team. She was started on stress
dose steroids in preparation for her D+E, and these were
decreased to Prednisone 60mg PO daily on discharge with plans
for outpatient follow-up to determine an appropriate taper.
Imuran was stopped on [**2180-8-1**], and Cellcept was started on
[**2180-8-2**]. She has a follow-up appointment at [**Hospital1 112**] on [**2180-8-10**] at
9:00 a.m.
4. Thrombocytopenia:
Likely [**12-20**] SLE. Platelet count was stable during this hospital
stay.
5. Anemia: Likely [**12-20**] anemia of chronic disease secondary to
SLE, blood loss during D&E, and a physiologic anemia of
pregnancy. Her Hct has remained stable at 26.
6. Acute Renal Failure:
Pt's creatinine peaked at 1.2, from a baseline of 0.9, likely
due to poor forward flow in the setting of CHF, although
worsening lupus nephritis could not be ruled out. Her creatinine
was stable at 1.0-1.1 for several days prior to discharge.
Follow-up with nephrology was scheduled for [**8-22**], which
was the earliest available appointment.
7. Diarrhea:
Patient experienced several episodes of loose stools during this
hospitalization. C.Diff was sent and negative. Patient feels
this is due to her Metoprolol, but understands the importance of
this medication.
Medications on Admission:
AZATHIOPRINE - 50 mg Tablet - 0.5 Tablet(s) by mouth daily
CYANOCOBALAMIN - 1,000 mcg/mL Solution - 1000 mcg IM each week
for 4 weeks, then every 4 weeks
FOLIC ACID - 1 mg Tablet once a day
HYDROXYCHLOROQUINE [PLAQUENIL] 200 mg Tablet once a day
LABETOLOL 300 TID
METHYLPREDNISOLONE [MEDROL] - currently on 28 mg [**Hospital1 **].
NIFEDIPINE - 30 mg Tablet Sustained Release daily
PANTOPRAZOLE [PROTONIX] - 40 mg daily
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] one daily
VITAMIN D 400 UNIT/DAY
Discharge Medications:
1. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*1 month's supply* Refills:*0*
9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Acute Systolic Congestive Heart Failure
2. Intrauterine Fetal Demise
3. Acute Renal Failure
4. Systemic Lupus Erythematosus
5. Tachycardia
6. Thrombocytopenia
Discharge Condition:
Stable. Patient is ambulating and tolerating oral intake.
Discharge Instructions:
You were admitted to the hospital for treatment of your
shortness of breath. You were found to have a new diagnosis of
congestive heart failure, lupus flare, and kidney failure. For
your congestive heart failure, you were started on Metoprolol
and Lasix. For your lupus flare, you were started on Prednisone
and Cellcept.
Please seek immediate medical attention if you develop fevers,
shaking chills, night sweats, headaches, shortness of breath,
worsening or changing chest pain.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 68982**] [**2180-8-10**] 9:00 a.m.
DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] [**2180-8-14**] 11:00 (Cardiology)
Dr. [**Last Name (STitle) 3638**] [**Telephone/Fax (1) 22**] [**2180-8-16**] 4:30
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 721**] [**2180-8-22**] 4:00
|
[
"582.81",
"648.93",
"428.0",
"710.2",
"443.0",
"648.23",
"632",
"710.0",
"285.9",
"276.2",
"428.21",
"287.5",
"787.91",
"648.63",
"518.89",
"646.23",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"69.02"
] |
icd9pcs
|
[
[
[]
]
] |
7894, 7953
|
3605, 5830
|
327, 332
|
8178, 8238
|
2823, 3582
|
8768, 9144
|
2104, 2113
|
6381, 7871
|
7974, 7974
|
5856, 6358
|
8262, 8745
|
2128, 2804
|
237, 289
|
360, 1354
|
7993, 8157
|
1376, 1860
|
1876, 2088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,511
| 102,068
|
28272
|
Discharge summary
|
report
|
Admission Date: [**2193-5-22**] Discharge Date: [**2193-5-28**]
Date of Birth: [**2149-9-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Platinum Complexes / Aspirin / Shellfish
Derived
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Fever, chills, nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 43-year-old woman with a pmhx. of recurrent ovarian
carcinoma (s/p TAH-BSO, IV and intraperitoneal chemotherapy,
radiation, and microperforation of simoid colon requiring
sigmoid resection with end-colostomy) who presents from home
with fevers, chills, and nausea of one day.
Patient recently began ixabepilone chemotherapy on [**2193-5-2**] and since that time reports increased vaginal discharge,
which she describes as "yellow and brown debris." States that
she has been using about 2 pads per day, soaking through each,
and that discharge is "liquidy" in character. This is an
entirely new symptom for her. Also about one week ago patient
noticed that her stoma "looked different." It seemed retracted
into her abdominal wall, and there was increased "light pink
bubbles" at the opening. She went to see her ostomy nurse on
day prior to admission who told her to come into the hospital if
she developed fevers, chills, or increased abdominal pain. Ms.
[**Known lastname 45419**] woke up with these symptoms on day of admission and
came to the ED.
At [**Hospital1 18**] ED, patient had a CT which showed a small rectal stump
leak, locule of air near staple line of [**Doctor Last Name **] pouch, and a
colovaginal fistula, which had likely been developing over the
course of weeks (and was not likely the cause of her current
symptoms). Surgery was consulted and they felt that given the
contained leak and proximity of likely residual tumor, there
were no good (or safe) surgical options. It was recommended
that patient be treated with antibiotic coverage and remain NPO
for the time being.
In the ED initial vitals were: 100 136 134/77 20 100. Patient
was given vancomycin 1g, cefepime and metronidazole 500mg. Mag
was noted to be 1.2 and patient given 2g. Na was 128 (131 on
repeat) and k was 5.6 (4.2 on repeat). WBC 23. Also given 6L
of fluid. Patient remained tachy into the 130, SBP 97-120. A
U/A revealed trace modertate blood, trace leuks and glucosuria.
Zofran and tylenol were given symptomatically. On transfer, BP
was 125/80, HR 120, and she was satting 99%RA.
ROS: Chills, nausea, vomiting, abdominal pain in LLQ. Negative
for headache, trouble swallowing, shortness of breath, chest
pain, palpitations, dysuria, or any other concerning signs or
symptoms.
Past Medical History:
Past Oncologic history:
[**Known firstname **] is 43 yo woman with advanced ovarian ca. She is s/p
debulking surgery and hysterectomy and bilateral
salpingo-oopherectomy. She received iv and intraperitoneal
chemotherapy as part of her adjuvant chemotherapy ending in
[**2193**]7. She was enrolled in study getting oral [**Doctor Last Name 360**] AZD2171
until [**12-11**]. She resumed tx with single [**Doctor Last Name 360**] [**Doctor Last Name **] as of
[**2191-5-12**]; but had reaction with dose 6/08. Started doxil [**2191-7-21**].
Had evidence of disease progression so tx changed to Alimta on
[**2191-11-17**] till [**2-12**]. Tx changed to Weekly taxol with Avastin on
[**2192-3-8**]. Due to neuropathy from taxol; tx changed to weekly
taxotere on [**2192-6-28**]. She had sigmoid colon perforation and had
colon ressection and colonostomy on [**2192-7-6**]. She has been slow to
heal and resummed chemo with gemzar on [**2192-10-11**]. Tx changed to
Topotecan on
[**2192-12-14**].
.
Past Medical History:
Diabetes
Hypothyroidism
HTN (improved- no meds since [**Month (only) **])
Clear cell ovarian Cancer
s/p TAH-BSO, appendectomy, omentectomy [**2189**]
s/p sigmoid resection [**7-12**]
Social History:
Patient lives alone and is in the middle of a divorce. Her
father is her HCP. Does not smoke or drink. Continues to work
in fundraising at WGBH (send the flyers, doesn't do the radio
commercials).
Family History:
Mother with NHL, tongue CA, died of "strep throat." Father has
a pacemaker.
Physical Exam:
VS: Temp: 101.7, BP: 98/53, HR: 108, SPO2: 97% RA
GENERAL: Thin, chronically ill appearing woman, no acute
distress, lying in bed
CHEST: Clear to auscultation bilaterally
CARDIAC: RRR, II/VI systolic murmur throughout precordium
ABDOMEN: +BS, ostomy bag in place with gas, tenderness in LLQ
near ostomy site
EXTREMITIES: No edema bilaterally
SKIN: Warm, diaphoretic
NEURO: Alert and oriented to person, place, time, and event
Pertinent Results:
[**2193-5-22**] 09:00AM BLOOD WBC-23.2*# RBC-3.71* Hgb-10.5* Hct-31.1*
MCV-84 MCH-28.3 MCHC-33.8 RDW-15.7* Plt Ct-573*
[**2193-5-27**] 07:30AM BLOOD WBC-15.6* RBC-2.75* Hgb-7.3* Hct-23.4*
MCV-85 MCH-26.5* MCHC-31.3 RDW-15.6* Plt Ct-500*
[**2193-5-22**] 09:00AM BLOOD Glucose-412* UreaN-12 Creat-0.9 Na-128*
K-5.6* Cl-86* HCO3-26 AnGap-22*
[**2193-5-26**] 07:20AM BLOOD Glucose-96 UreaN-8 Creat-0.6 Na-135 K-4.3
Cl-102 HCO3-25 AnGap-12
[**2193-5-22**] 09:00AM BLOOD ALT-11 AST-32 AlkPhos-140* TotBili-0.4
[**2193-5-26**] 07:20AM BLOOD Phos-2.5* Mg-1.7
[**2193-5-22**] 02:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.024
[**2193-5-22**] 02:15PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2193-5-22**] 03:05PM URINE UCG-NEG
Micro:
[**2193-5-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-22**] Blood Culture, Routine-
{STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP}; Anaerobic Bottle Gram
Stain-
[**2193-5-22**] Blood Culture, Routine-{STREPTOCOCCUS ANGINOSUS
(MILLERI) GROUP}; Anaerobic Bottle Gram Stain
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- 1 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Radiology:
[**5-22**] CT ABDOMEN W/O CONTRAST IMPRESSION: (pt reports hx of
allergy to contrast)
1. Interval increase of left pelvic mass with close association
with the
bowel.
2. Enterovaginal fistula.
3. Locules of gas near the staple line of the Hartmann's pouch;
it is unclear if it is intra- or extra-luminal, infectious
process at this site not excluded. No evidence of parastomal
collection.
4. Gallbladder sludge without evidence of acute cholecystitis.
5. Bilateral hydronephrosis, stable from previous study.
6. Hepatic hypodensity, concerning for metastasis.
[**5-26**] KUB FINDINGS: Gas and stool are seen throughout the colon
to the region of the splenic flexure. Gas is seen in some mildly
dilated loops of small bowel measuring up to 4 cm, without
air-fluid level. This likely represents an ileus.
UNILAT LOWER EXT VEINS LEFT IMPRESSION: No evidence of DVT.
Brief Hospital Course:
43 yo femaled with advanced ovarian cancer, was admitted with
complaints of fever, chills, and was found to have SIRS/septic
shock, and was initially managed in the ICU. She was started on
empiric coverage with broad spectrum antibiotics. She was found
to be bacteremic with strep anginosus, which is likely d/t
intrabdominal fisulization/abscesses. A CT of her abdomen and
pelvis (without contrast due to allergy) showed significantly
worsening ovarian cancer, colovaginal fistulization, and
possible microperforation vs infection at her [**Doctor Last Name 3379**] pouch.
She clinically stabilized, however further discussion with her
oncologist and surgeon revealed that there are no further
therapeutic options to offer, and she is not a candidate for
surgery. Her primary oncologist is Dr. [**Last Name (STitle) **]. She
was transitioned to DNR/DNI, and she elected to go home with
hospice care.
Her blood cultures later revealed strep anginosus (milleri), and
her antibiotics were changed to oral flagyl and levofloxacin, as
she prefered an oral regimen for palliation. At the time of
discharge, she was still having low-grade temps, but seh was not
symptomatic from them. She will complete a 2 week course of
antibiotics on [**2193-6-5**].
.
* Colovaginal fistula - She has a known colovaginal fistula,
however there are no surgical options per GynOnc discussion. It
does appear that her vaginal discharge may be improving slightly
with antibiotic treatment.
.
* LLE Edema - She was noted to have some left sided edema
(LLE/LUE). THere was intially concern for possible DVT, however
LENI;s were negative. The edema is most likely related to =
tumor blocking lymphatic drainage. Elevation and LLE compression
hose were recommended for comfort.
.
* Ovarian cancer - Per primary oncologist, pt has no further
chemotherapy options. Transitioned to DNR/DNI and palliative
care consulted and assisted throughout the hospitalization.
-- Patient is being discharged to home with hospice
.
* DM -
Pt had several episodes of hypoglycemia on lantus due to
decreasing oral intake. Her lantus dose was serially
downtitrated. Tight glucose control not necessary at this time,
but would like to avoid extreme highs that may produce symptoms.
- Pt discharged on reduced lantus dose without sliding scale.
.
* Hypothyroidism - continue synthroid
.
* Hyperlipdemia - Hold statin and Tricor
.
* Ostomy Retraction - Ostomy is retracted as per ostomy nurse
and surgery consult. Now with resuming stool output. KUB showed
some stool c/w constipation. She was treated with Miralax with
some improvement in her stool output. She was recommened to
continue to take stool softeners and Miralax and to stay well
hydrated to prevent constipation in the future. She may also
use milk of magnesia as well as needed.
.
PPX: Pt is at high risk for DVT given ovarian cancer. Pt will be
discharged on daily dosing of lovenox to prevent DVT for
palliative benefit
[**Date Range **]: home today with hospice. She is DNR/DNI. Her oncologist,
Dr. [**Last Name (STitle) **] will be the contact person for the Hospice
agency.
Medications on Admission:
Tricor 145 QD
Crestor 40 QD
Lantus 80units QHS and Humalog sliding scale
Levothyroxine 100mcg QD
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Last Name (STitle) **]:*60 Capsule(s)* Refills:*2*
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) inj Subcutaneous
once a day.
[**Last Name (STitle) **]:*30 inj* Refills:*0*
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
[**Last Name (STitle) **]:*30 packet* Refills:*0*
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
[**Last Name (STitle) **]:*8 Tablet(s)* Refills:*0*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 8 days.
[**Last Name (STitle) **]:*24 Tablet(s)* Refills:*0*
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
[**Last Name (STitle) **]:*60 Tablet(s)* Refills:*0*
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four
times a day as needed for pain.
11. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous once a day: please continue to follow your
blood sugars. Decrease your dose if you have low sugars, and
call your PCP.
[**Name Initial (NameIs) **]:*1 vial* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
# Recurrent ovarian cancer
# Bacteremia; Strep Anginosus
# Colovaginal fistula
# Diabetes, Type 2 on insulin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers, chills, and nausea, and you were
found to have bacteria in your blood, which is being treated
with antibiotics. After discussion with GYN-Oncology and
surgery, there are no further treatment options for your ovarian
cancer. You will be followed at home by Hospice, who will make
sure that any symptoms remain well managed.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-5-30**] at 2:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-5-30**] at 3:00 PM
With: [**Name6 (MD) 5338**] [**Name8 (MD) 5339**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-6-6**] at 2:00 PM
With: [**Name6 (MD) 5338**] [**Name8 (MD) 5339**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"782.3",
"183.0",
"356.9",
"276.7",
"250.80",
"569.5",
"E933.1",
"276.1",
"244.9",
"V58.67",
"599.72",
"E878.8",
"564.00",
"995.92",
"E932.3",
"197.6",
"401.9",
"V87.41",
"996.69",
"038.0",
"619.1",
"785.52",
"V44.3",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11926, 11975
|
7110, 10218
|
354, 361
|
12128, 12128
|
4697, 7087
|
12658, 13525
|
4150, 4228
|
10365, 11903
|
11996, 12107
|
10244, 10342
|
12279, 12635
|
4243, 4678
|
293, 316
|
389, 2695
|
12143, 12255
|
3732, 3916
|
3933, 4134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,943
| 160,905
|
47746
|
Discharge summary
|
report
|
Admission Date: [**2177-4-1**] Discharge Date: [**2177-4-2**]
Date of Birth: [**2113-8-18**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
titration of BiPAP
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63-year-old woman with ALS who is being admitted for titration
of BiPAP. An attempt was made last several nights ago at
initiating BiPAP 10/5 cm H2O through a respiratory therapist
from [**Hospital 6549**] Medical. However, the patient apparently
became bradycardic and tachypneic with a drop in oxygen
saturations. Two attempts were made at using BiPAP but met with
the same complication. She needed a sleep study for titration,
but was unable to be booked at [**Hospital1 18**] which could not accomodate
her needs (wheelchair, hospital bed, likely MD/hospital
support). She was rescheduled for astudy in the [**Location (un) 76489**]
campus this [**Month (only) **], but has had problems with long apneas and
bradycardia at the nursing home. Therefore, the decision was
made to admit her for an inpatient titration of BiPAP.
Past Medical History:
1. ALS - diagnosed [**9-4**] in the context of 6 months of
progressive
generalized muscle weakness. She has had progressive weakness,
now including severe dysarthria, and dysphagia. Now tih chronic
respiratory failure with an FVC < 50%
2. Chronic edema felt to be due to inactivity, ? diastoic
dysfunction
3. Osteoarthritis
4. Osteopenia
5. H/o Hashimoto's Thyroiditis
6. Hypertension
7. Chronic sciatica
Social History:
The pt has been divorced for 15 years. Retired RN. Lives in
downstairs apartment from daughter/granddaughter. Quit tobacco
30 years ago. No alcohol, drug use.
Family History:
Multiple family members with thyroid disease. Brother with DM.
Mother with [**Name (NI) 2481**] disease.
Physical Exam:
VITALS: T 97.0, HR 76, BP 154/85, RR 24, O2 sat 99%RA
GEN: Alert, oriented, NAD.
HEENT: Supple neck.
CV: RRR, no murmurs.
LUNGS: CTAB, decreased BS at bases.
BACK: no CVAT.
ABD: Soft, NT, ND.
EXT: 1+ bilateral dependent LE edema.
NEURO: CN II-XII intact. PERRL. EOMI. 1-2/5 strength in the
right leg, [**12-5**] in the left leg. 1-2/5 strength in the arms. She
has difficulty with annunciation likely due to bulbar
dysfunction.
Pertinent Results:
[**2177-4-1**] 05:41PM BLOOD Type-ART Temp-36.1 Rates-/24 pO2-79*
pCO2-41 pH-7.43 calHCO3-28 Base XS-2 Intubat-INTUBATED
Vent-SPONTANEOU
[**2177-4-1**] 11:58PM BLOOD Type-ART pO2-84* pCO2-49* pH-7.41
calHCO3-32* Base XS-4
[**2177-4-2**] 01:33AM BLOOD Type-ART Temp-36.4 pO2-74* pCO2-49*
pH-7.38 calHCO3-30 Base XS-2 Intubat-NOT INTUBA
[**2177-4-1**] 05:41PM BLOOD Glucose-92
[**2177-4-1**] 05:41PM BLOOD O2 Sat-96
Brief Hospital Course:
63-year-old woman with ALS who was admitted for titration of
BiPAP.
.
1. Chronic respiratory failure with restrictive physiology due
to ALS - Checked a baseline ABG and initiated a BiPAP trial on
admission. Place A-line and started BiPAP at 5/5 with the goal
to increase IPAP as much as she tolerates. She remained stable
and comfortable on [**7-5**] and was discharged on these settings.
Goal should be to provide as much assistance as possible during
inspirations. She was followed by Dr. [**Last Name (STitle) **], sleep fellow,
during her admission. Final recommendations were to use BiPAP
[**7-5**] during the night and prn day for respiratory distress on a
nasal mask.
.
2. FEN - regular diet. Aspiration precautions.
.
3. PPX - Heparin SC, Protonix.
Medications on Admission:
1. Colace
2. Flonase
3. Ambien
4. Multivitamin
5. Celexa 20 mg daily
6. Synthroid 50 mcg daily
7. Vitamin c
8. Senna
9. Rilutek 50 mg [**Hospital1 **]
10. Motrin 400 mg Q4 prn
11. Ditropan 5 mg TID prn
12. Lasix 20 mg daily
13. Sudafed Q12 hours prn
14. Albuterol
15. Benadryl 25 mg PO QHS PRN
16. Co-Enzyme Q10
17. [**Doctor First Name **]
18. Mucinex
19. Tyleonol PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for increased secretions.
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
14. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) as needed for urinary incontinence.
15. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, increased secretions.
18. nasal face mask
Please use for Bi-PAP when pt does not tolerate full face mask.
Setting should be at I 8 PEEP E
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
ALS - BiPAP titrated
Discharge Condition:
Unchanged - weak but stable.
Discharge Instructions:
You were admitted to the hospital for titration of your BiPAP
machine. This was done. You should use this as instructed (at
night or during the day if you have difficulty breathing
Followup Instructions:
Dr. [**Last Name (STitle) **] as instructed
Dr. [**Last Name (STitle) **]
Appointment on [**4-10**] in [**Location (un) 620**] for PSG
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2177-5-14**] 1:30
Completed by:[**2177-4-2**]
|
[
"733.90",
"335.20",
"245.2",
"724.3",
"401.9",
"518.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
5659, 5700
|
2790, 3553
|
295, 302
|
5765, 5796
|
2352, 2767
|
6027, 6330
|
1781, 1888
|
3974, 5636
|
5721, 5744
|
3579, 3951
|
5820, 6004
|
1903, 2333
|
237, 257
|
330, 1159
|
1181, 1588
|
1604, 1765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,906
| 191,184
|
24082
|
Discharge summary
|
report
|
Admission Date: [**2157-3-12**] Discharge Date: [**2157-3-14**]
Date of Birth: [**2115-7-10**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
SEPTIC SHOCK, anuric RF, cirrhosis, respiratory failure
Major Surgical or Invasive Procedure:
Intubation
HD
History of Present Illness:
41 yo W w/ hx alcoholic cirrhosis admitted on [**2157-3-5**] @ [**Hospital **] w/ jaundice, R back pain and pain/edema of RLE.
She reported she had taken no more than 2 extra strength Tylenol
per day for 3 days prior to admission to [**Hospital3 **]. She also
took ASA and motrin prn for pain relief.
.
On admission she was noted to have BP 84/44. She was admitted to
the ICU w/ concern for septic shock. She received fliuds,
levophed and neosynephrine for hypotension. She also received
vanco/zosyn for cellulitis (LENIs and Xrays were negative for
DVT, or osteo) and levofloxacin was added with improvement in
her RLE cellulitis. A CT of the abdomen was negative for
abscess.
.
Her creat was 1.3 on admission and peaked at 1.7, then came down
to 0.9 on HD # 3 @ [**Hospital3 **] w/ improvement of her BP. She was
weaned off her pressors, changed to oxacillin, and transferred
to the floor.
.
Over the next few days of her hospitalization, her UOP decreased
and her creatinine rose (from 0.3 baseline to 4.0) and she had
waxing and [**Doctor Last Name 688**] MS status. Her UOP had been ~ 70cc/24h the day
of transfer and her renal failure did not improve w/ albumin and
fluid. She had a UCx that grew out > 100K E.Coli and a vaginal
Cx w/ staph aureus, she was switched back to zosyn.
.
On [**2157-3-12**] she had an episode of epistaxis and was thought to
have aspirated blood. She was intubated for airway protection,
received 4U FFP and was transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
She was admitted to the [**Hospital1 18**] SICU/Transplant team. She was
found to be hypothermic w/out active bleeding and her BP via
a-line on admission was 124/98. She was continued to vanco/zosyn
and a swan was placed. She was transfused w/ PRBC's, plts and
FFP.
.
Over the next 24 h she became progressively hypotensive and was
started on neo, levo and vasopressing gtt. Per renal, her
vasopressing was increased to 0.08U/hr and she had a R fem line
placed for CVVHD.
Past Medical History:
PMHX:
alcoholic cirrhosis - followed at [**Hospital6 **], in [**8-28**]
s/p w/u negative for other etiologies w/ radiographic diagnosis
(by MRI/U/S) w/ portal HTN and splenomegaly w/ recanulization of
umbilical vein; no hx GIB, encephalopathy or SBP, anemia,
C-section x 2
Social History:
EtOH abuse w/ alcoholic cirrhosis, does not qualify for
transplant [**1-26**] recent EtOH use; per chart 6drinks/day, last
drink reportedly 3 wks PTA; tobacco 1/2ppd; worked as school bus
driver, lived w/ husband;
Family History:
DMII; father w/ prostate & esophageal ca, MI @ age 40, and
alcoholism;
Physical Exam:
PE:
T min 94.0 ax, 95.0 PR Tc 97.0 82 (70-80) 86/45 MAP 61 (54-63)
AC 350 35 -> 3
.
PA 91/44 PAP mean 37 CVP 28 PCWP none obtained CO therm
10.8L/min CI 4.66 SVR 219
SVO2 71%
.
Gen: cauc W w/ anasarca, swollen conjunctiva w/ eyes kept open
by them, intubated, sedated; not responsive to commands
HEENT: edematous conjunctiva, jaundiced
Heart: RRR, S1, S2, no m/r/g
Lungs: upper resp sounds transmitted, no wheezing
ABd: obese, ND/no masses appreciated
Ext: 4+ b/l edema; RLE erythematous, warm cellulitis; R groin
skin break down w/ yeast inf
Derm: mult petechiae, telangiectasias on upper chest
Pertinent Results:
wbc 17 89% PMNs/ 4% bands; hct 27 (up from 25) plt 130 (up from
83 s/p 1 bag plts);
INR 1.6 PTT 42 fibrinogen 183
U/A dirty;
.
creat 3.8 (down from 4.1 on adm here, 1.3 on adm to [**Hospital3 **])
bicarb 16 AG 15 lact 3.6
T.bili 16 ALT/AST 18/55 alk phos 73 [**Doctor First Name **]/lip wnl
LDH 312 alb 2.7 phos 5.1 calc 7.8
hepatitis serologies pending
vanco level pending (prev 15.7)
serum tox negative
.
ABG 7.19/37/71
.
@ [**Hospital3 **]
wbc 11.2 hct 25.4 @ baseline plt 88 (@ baseline) Na 129
creat 1.3 NH3 51 INR 2.5 salicylate level < 2.0 acetaminophen
level 2 [ref 0-10] no EtOH detected;
prev studies antismooth muscle ab negative, liver kidney
microsome ab negative, HBV and HCV serologies negative
.
hct 27-31 w/ MCV 108-112 plt 29-50 ([**2071-3-8**])
ASO titer 235 [**2157-3-5**]
.
Renal U/S - R 13.3cm L 14.5cm no hydro, lg ascites
b/l LENI - no DVT
.
Micro data from [**Hospital3 **]:
[**2157-3-11**] UCx yeast
[**2157-3-6**] UCx Hafnia Alvei, Diptheroids, Coag Negative Staph
[**2157-3-5**] UCx E.Coli
[**2157-3-5**] Vaginal Cx - staph aureus, nl flora, yeast
.
[**2157-3-5**] BCx x 2 No Growth; [**2157-3-11**] BCx x 2 NGTD
.
RAD:
US: Prelim: no portal clots
CXR:
[**2157-3-12**] ETT in R mainstem bronchus; b/l alveolar opacities
[**2157-3-13**] ETT 1cm from [**Female First Name (un) 5309**], + swan; o/w unchanged
.
TTE [**2157-3-8**] @ [**Hospital3 **] - EF 65% no vegetation, mild MR, mild
LAdil;
.
EKG: NSR @ 85bpm, no change c/w baseline
Brief Hospital Course:
41 yo W w/ hx alcoholic cirrhosis transferred from OSH w/ RLE
cellulitis, ARF, septic shock, and respiratory failure.
Admitted [**2157-3-12**] - Died [**2157-3-14**] @ 15:00PM.
.
# Septic shock - likely [**1-26**] RLE cellulitis, although aspiration
pna and urosepsis are also possibilities. Swan numbers are c/w
distributive shock. SBP is also a possibility given her
cirrhosis, although she has been on ABx recently. She is on 3
pressors, and although she is not very acidemic, her acidosis is
likely contributing as well as her hypoalbuminemia and
cirrhosis.
- placed on levo, neo and vasopressin
- pancultured BCx, UCx, sputum Cx -- placed on
levofloxacin/zosyn & vanco to double cover pseudomonas, cover
MRSA, SBP and anaerobes for asp pna
- CVVHD to correct acidosis
.
# Cirrhosis - [**1-26**] EtOH, end stage. Followed by hepatology.
.
# Renal Failure - Followed by renal - likely [**1-26**] ATN w/ sepsis
and distributive shock, although HRS is also possible. Her
acidosis is [**1-26**] her anuric ARF. On CVVHD.
.
# Respiratory Failure - asp pna and pulmonary edema, ventilated
by ARDSnet protocol w/ low TV (8cc/kg/min)
.
# Acidosis - [**1-26**] ARF, hyperventilating for compensation. On
CVVHD.
.
# Epistaxis - s/p eval and packing by ENT [**2157-3-12**]
.
# Thrombocytopenia - [**1-26**] sequestration
.
On [**2157-3-14**] her husband changed her code status from DNR to CMO.
Her pressors and ventillator were stopped and the patient
expired at 15:00PM.
Medications on Admission:
Phenylephrine HCl 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP above
60 [**3-12**] @ 2258
Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation [**3-12**] @
2258
Piperacillin-Tazobactam Na 4.5 gm IV Q8H *Awaiting ID Approval*
[**3-12**] @ 2258
Vancomycin HCl 1000 mg IV PRN level <15 [**3-13**] @ 0200
Calcium Gluconate 2 gm / 100 ml D5W IV ONCE Duration: 1 Doses
[**3-13**] @ 0203
Furosemide 80 mg IV ONCE Duration: 1 Doses 03/20 @ 0203
Furosemide 40 mg IV ONCE Duration: 1 Doses 03/20 @ 0450
Calcium Gluconate 3 gm / 250 ml NS IV ONCE Hypocalcemia and
Hypotension. Duration: 1 Doses 03/20 @ 0745
Phytonadione 10 mg SC DAILY INR > 1.5 with bleeding. Duration: 3
Days [**3-13**] @ 0749
Calcium Gluconate 2 gm / 100 ml NS IV ONCE Duration: 1 Doses
[**3-13**] @ 1024
Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP > 60
[**3-13**] @ 1039
Furosemide 1-5 mg/hr IV DRIP INFUSION [**3-13**] @ 1125
Pantoprazole 40 mg IV Q24H [**3-13**] @ 1125
Vasopressin 0.08 UNIT/MIN IV DRIP TITRATE TO Continuous at 0.04
Units/min. [**3-13**] @ 1159
IV 1000 ml 1/2NS
Continuous at 80 ml/hr [**3-13**] @ 0113
.
drips:
propofol gtt
vasopressin @ 0.8 U/min
levophed gtt
neosynephrine gtt
lasix gtt
80cc/hr IV 1/2NS
.
Abx: vanco, zosyn
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory arrest
Sepsis
AFR
Liver failure
Discharge Condition:
Dead
Discharge Instructions:
.
Followup Instructions:
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
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50,359
| 123,826
|
22611
|
Discharge summary
|
report
|
Admission Date: [**2197-5-14**] Discharge Date: [**2197-5-21**]
Date of Birth: [**2111-2-5**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Lethargy, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 year old male with h/o cryptogenic cirrhosis, CHF, Afib, DM,
critical AS, IgA nephropathy and leukocytoclastic vasculitis who
presents with altered mental status, fatigue, lethargy and
jaundice.
At baseline he is independent with a walker and was active
yesterday. By the evening, he had decreased responsiveness and
was not answering questions during the night. He has improving
petechiae all over his body from a recent vasculitis. Denies
fevers, cough.
Brought to [**Hospital3 **] where initial vitals were 95.0
87/44. Ammonia 101. CT head unremarkable. Given vanco, zosyn,
lactulose, 3L NS, and started on a dopamine gtt. Treated with
warmed IVF and a bear hugger. Was with daughter and son-in-law.
[**Name (NI) **] was then transferred to the [**Hospital1 18**] ED.
In our ED, initial vitals were 97.4 122 109/66 20 97% 2L NC.
Triggered on arrival for hypotension with BP's 80/60. Exam
notable for toxic appearing male with petechial rash c/w known
leukocytoclastic vasculitis. FAST u/s was negative. A right IJ
was placed. He was changed to a levophed gtt. Given 500cc in
our ED. Does have mildly positive UA. Considered LP but didn't
due to lack of leukocytosis or fever. Considered hepatic
encephalopathy vs sepsis as etiology of his hypotension. ECG
with mild ST depressions in V1-V2. Most recent vitals 97.6 88
110/47 19 100%4L. Lactate wnl.
Pt was recently hospitalized [**Date range (1) 58629**] for "acute liver
decompensation." Recent illness in [**State **] and newly dx'd liver
disease with jaundice, ascites, and portal thrombosis. Was
cardiac catheterized [**4-17**] in consideration of AS causing
anasarca results showed: severe aortic stenosis (gradient of
53mmHg, valve area of 0.85cm2), mildly elevated filling
pressures, mild pulmonary hypertension but insufficient to
explain the degree of portal hypertension seen on exam. He was
started on lasix, spironolactone and rifaximin. He followed with
Dr. [**Last Name (STitle) 23804**] at [**Hospital1 **] [**Location (un) 620**]. First hepatology clinic visit [**5-2**]
(limited note) started lactulose, creat 1.7, bili 2.8, BP
100/60, slow afib. New PCP [**Name Initial (PRE) **] ([**Doctor Last Name **]) on Friday creat 2.3,
ammonia 90, wbc wnl, bili 1.3, INR 1.3. Family was unable to
afford rifaximin as outpt. New medications include vitamin E and
milk thistle per daughter. [**Name (NI) **] other new meds including pain
killers. Pt has been stooling regularly ([**2-5**] BMs daily).
On the floor, pt is drowsy and unable to answer questions very
well. He knows he is in a hospital but not oriented to date and
cannot provide medical history. Family is at bedside and report
recent hx of fatigue and lethargy since yesterday AM. He was
engaged and able to go out to dinner last night but noted to be
very sleepy around 9pm and was poorly responsive and confused
around 0100. They called an ambulance which took them to [**Hospital 10287**]. He had no complaints during the day aside from some
mild nausea and vomiting (vomited "1 tsp of peanuts" after
dinner) and has some baseline dysphagia with coughing that was
worse than usual yesterday. Family denies increasing abd girth,
abd pain, chest pain, SOB, or constipation. Code status
confirmed full code by daughter/HCP.
Past Medical History:
Hearing loss - wears a hearing aide
Congestive heart failure (last TTE [**2197-4-6**]: Mild symmetric left
ventricular hypertrophy with normal global and regional
biventricular systolic function. Critical calcific aortic
stenosis. Mild mitral regurgitation.)
Atrial fibrillation
Arthralgias
Diabetes mellitus
Hypothyroidism
Critical aortic stenosis (valve area <0.8cm2)
Tonsillectomy
Polypectomy
Chronic L knee pain
Social History:
Italian is first language. Lives with wife in [**Name (NI) 745**]. Distant
history of smoking (3 pack years), quit >40yrs ago. Rare EtOH.
No Illicits.
Family History:
DM. No liver disease.
Physical Exam:
Vitals: T: 97.5 BP:105/52 P: 86 R: 18 O2: 100/2L
General: drowsy and lethargic, elderly male, lying in bed, NAD,
arousable
HEENT: Sclera slightly discolored (brown) but anicteric, oral
mucosa pink/dry, oropharynx clear, tongue midline
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar rales, poor respiratory effort
CV: irregularly irregular rhythm, normal rate, normal S1 + S2,
III/VI crescendo-decrescendo murmur radiating to carotids and at
apex, no rubs or gallops
Abdomen: soft, non-tender, mildly distended, positive fluid
wave, bowel sounds present, no rebound tenderness or guarding,
liver border palpated 4 fingerbreadths below costal margin,
spleen not palpated
GU: +foley, blood at urethral meatus, no scrotal edema
Ext: warm, well perfused, petechial rash diffusely distributed
over torso + extremities, 2+ pulses, no clubbing, cyanosis, 3+
edema to mid-calves, mild non-pitting edema of b/l UE,
+asterixis elicited
Pertinent Results:
Admission labs:
[**2197-5-14**] 12:25PM WBC-9.2 RBC-3.10* HGB-11.2* HCT-32.5*
MCV-105* MCH-36.1* MCHC-34.4 RDW-14.2
[**2197-5-14**] 12:25PM NEUTS-81.8* LYMPHS-12.9* MONOS-4.2 EOS-0.4
BASOS-0.7
[**2197-5-14**] 12:25PM PLT COUNT-216
[**2197-5-14**] 12:25PM GLUCOSE-134* UREA N-47* CREAT-1.7* SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
[**2197-5-14**] 12:25PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-3.2
MAGNESIUM-2.1
[**2197-5-14**] 12:25PM ALT(SGPT)-27 AST(SGOT)-50* ALK PHOS-164* TOT
BILI-1.9* DIR BILI-1.1* INDIR BIL-0.8
[**2197-5-14**] 12:25PM LIPASE-50
[**2197-5-14**] 12:25PM cTropnT-0.03*
[**2197-5-15**] 04:08AM BLOOD TSH-5.2*
[**2197-5-15**] 03:10PM BLOOD Free T4-1.3
[**2197-5-15**] 04:08AM BLOOD Cortsol-11.4
[**2197-5-14**] 02:00PM BLOOD Ammonia-LESS THAN 6
Discharge labs:
[**2197-5-20**] 05:55AM BLOOD WBC-6.6 RBC-2.74* Hgb-9.3* Hct-28.6*
MCV-104* MCH-34.1* MCHC-32.7 RDW-14.8 Plt Ct-120*
[**2197-5-20**] 05:55AM BLOOD Glucose-134* UreaN-43* Creat-1.6* Na-135
K-4.7 Cl-101 HCO3-25 AnGap-14
[**2197-5-20**] 05:55AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
[**2197-5-19**] 06:46AM BLOOD ALT-20 AST-31 AlkPhos-138* TotBili-1.6*
Microbiology:
[**2197-5-14**] Urine, Blood cultures negative.
Radiology:
CHEST PORT. LINE PLACEMENT Study Date of [**2197-5-14**]
IMPRESSION:
1. Right internal jugular line in upper to mid SVC.
2. Low lung volumes limit evaluation for pneumonia or small
nodules. If
desired, repeat study can be performed.
3. Acute fractures of right lateral 6th-8th ribs.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2197-5-14**]
IMPRESSION:
1. Partially distended gallbladder, with moderate wall
thickening (possibly
reactive). HIDA scan could be considered to evaluate for early
acute or
chronic cholecystitis.
2. Cirrhosis, without detectable portal venous flow.
GALLBLADDER SCAN Study Date of [**2197-5-15**]
IMPRESSION:
Gallbladder filling and excretion is visualized with no evidence
of acute
cholecystitis.
TIB/FIB (AP & LAT) LEFT Study Date of [**2197-5-16**]
FINDINGS: No definite evidence of bony abnormality or gas in
soft tissues. If there is serious clinical concern for
osteomyelitis, MRI would be the next imaging procedure.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2197-5-18**]
IMPRESSION:
1. No evidence of DVT.
2. Abnormal right groin Doppler could be caused by a small
arteriovenous
fistula. Suggest pelvic CTA to look for possible fistulous
communication in this region.
Brief Hospital Course:
Patient is an 86 yo man with PMHx sig. for cryptogenic
cirrhosis, leukocytoclastic vasculitis, and critical AS with a
recent prolonged hospitalization who was admitted from [**Location **]
[**University/College **] with lethargy, acute mental status changes, and
jaundice. At the time of admission he was septic and required
vasopressor therapy in the ICU. He was also noted to have
hepatic encephalopathy and this imrpoved with lactulose therapy.
Please [**Last Name 788**] problem list below for details on hospital course.
# Septic shock: His hypotension on admission was concerning for
evolving sepsis picture given hypothermia, hypotension, and
tachycardia. He was started on levophed in the ED (transitioned
from dopamine started at OSH) and it was continued in the MICU.
He received 75g of albumin for fluid resuscitation given concern
for third spacing. Levophed was weaned within 48 hours without
difficulty. TSH 5.2, t4 1.3, cortisol 11.4. Pt also did not have
any record of steroid use for his recent leukocytoclastic
vasculitis. His blood pressure stabilized and has been
attributed to a likely underlying infection/septic shock, though
source was not clear. Both urine and blood cultures were
negative. HIDA scan was negative for acute cholecystitis.
Patient did not have appreciable ascites on RUQ or bedside
son[**Name (NI) **] to perform a paracentesis. He was started on
vancomycin, zosyn empirically and changed to ciprofloxacin,
flagyl when cultures returned negative. He is to complete a 14
day course. He did have some difficulty tolerating the full
doses of his diuretics and these were titrated up slowly.
# Hepatic encephalopathy: Mental status changes were attributed
to septic shock and hepatic encephalopathy given history of
cryptogenic cirrhosis and asterixis present on exam. Lactulose
and rifaximin was started and with stooling he had appreciable
MS improvements. His mental status returned to baseline by
discharge; asterixis had resolved.
# Cryptogenic cirrhosis: The patient has a history of cirrhosis
diagnosed in [**2192**]. Complete w/u of his liver disease during
recent admission was negative including viral hepatitis (except
for HAV IgG antibodies), hemochromatosis, autoimmune. MRI was
negative for PV thrombosis. Bedside u/s not impressive for good
ascites pocket. RUQ obtained and showed cirrhosis w/o
perihepatic ascites or pv thrombosis. Home dose lasix and
spironolactone was restarted at a lower dose given his low blood
pressure.
Per ICU team, pt's family exhibited some confusion regarding
medications necessary for their father's cirrhosis management.
They had been holding his diuretic and did not fill
prescriptions for lactulose or rifaximin; the latter [**3-8**] cost.
They requested assistance with regard to medication access.
Social work was consulted. The importance of taking lactulose
regularly was emphasized.
# IgA nephropathy: He continued to put out adequate urine via
foley catheter, and his creatinine remained stable.
# Critical aortic stenosis: Recent cardiac catheterization was
notable for mildly elevated heart pressures and aortic valve
measured to be 0.8 cm2. PA pressure was 32/16 and PCWP 20 mmHg.
Betablocker was held on admission for hypotension and restarted
at a lower dose given low blood pressures.
# Atrial fibrillation: Patient was rate controlled on the
smaller metoprolol dose. Coumadin was discontinued on prior
admission after family meeting with continuation of low dose asa
for stroke prevention. He was continued on a low dose aspirin
but betablocker was held on admission. The issue of
anticoagulation was not addressed during his stay.
# Leg ulcers: He has 3 ulcers on his RLE, attributed to
vascular insufficiency. Wound RN consult recommended local care.
Tibia film was negative for overt signs of osteomyelitis.
# Diabetes mellitus type 2, controlled, with complications: FSBG
were followed and he was treated with insulin while
hospitalized, discharged on his home glyburide regimen.
# Guaiac positive stool: He had no frank BRBPR or melena. His
HCT remained stable in house. Consider colonoscopy as
warranted.
# CODE STATUS: This was discussed in detail with daughter
including the limited likelihood that Mr. [**Known lastname 58630**] would
survive a code. However, the family/patient feel strongly that
he should be Full Code.
*******Transitions of care*******
- Patient is on lower doses of lasix, spironolactone, and
metoprolol, limited by blood pressure. This should be increased
as necessary/tolerated.
- Patient is noted to have brown, guaiac positive stool. HCT
during his hospitalization remained stable at 28-31.
Medications on Admission:
1. levothyroxine 100 mcg Tablet QD
2. petrolatum ointment
3. rifaximin 550 mg Tablet [**Hospital1 **] (not taking)
4. aspirin 81 mg Tablet, Chewable QD
5. furosemide 80 mg Tablet [**Hospital1 **]
6. spironolactone 75 mg daily
7. Outpatient Physical Therapy Patient will need wheelchair with
elevated leg rest.
8. metoprolol succinate 50 mg QD
9. glyburide 5 mg Tablet QD
[lactulose per outpt hepatologist but not listed w family]
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO once a day.
Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2*
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*qs x 1 month ML(s)* Refills:*0*
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
10. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 2 weeks.
Disp:*qs x 2 weeks * Refills:*0*
11. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sepsis shock
Hepatic encephalopathy
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Dr. [**Known lastname 58630**],
You were admitted to the hospital with confusion and low blood
pressure. You improved with treatment for your liver disease
(lactulose) and with antibiotics for your infection. It is very
important that you continue to take your lactulose daily and
only hold it if you have had more than 3 bowel movements that
day.
CHANGES IN MEDICATIONS:
- Your lasix dose was decreased to 40 mg twice a day.
- Your spirinolactone dose was decreased to 50 mg once a day.
- Your metoprolol XL dose was decreased to 12.5 mg once a day.
- Please continue to take the antibiotics ciprofloxacin and
flagyl until [**2197-5-28**].
Followup Instructions:
Name: [**Name (NI) **] [**Name8 (MD) **],MD
Specialty: Gastroenterology
Address: [**Apartment Address(1) 58580**], [**Location (un) **],[**Numeric Identifier 18724**]
Phone: [**Telephone/Fax (1) 3259**]
Appointment: [**5-24**] at 3:15pm
Name:[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER
Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 3858**]
When: Thursday, [**5-25**] at 2:45pm
Please evaluate if need cardiology follow up before next
scheduled appt in [**Month (only) 205**].
|
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"599.70",
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"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
14136, 14194
|
7770, 12426
|
339, 345
|
14274, 14396
|
5267, 5267
|
15131, 15855
|
4273, 4296
|
12907, 14113
|
14215, 14253
|
12452, 12884
|
14457, 15108
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6084, 7747
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4311, 5248
|
282, 301
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373, 3649
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5283, 6068
|
14411, 14433
|
3671, 4088
|
4104, 4257
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,470
| 131,939
|
2549+55386
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-10-5**] Discharge Date: [**2153-10-7**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
with an extensive past medical history including cirrhosis,
ascites, portal hypertension, hypertension with renal artery
stenosis, chronic stable angina, history of acute renal
failure, pelvic fracture in [**2153-3-24**], diverticulosis/
diverticulitis, diarrhea, gout, hypothyroidism, who presents
with failure to thrive. The patient reports a four day
history of decreased p.o. intake, nausea, and generalized
weakness and fatigue. The patient also reports an extensive
history of diarrhea that has now been active over the last
four to five days with three to four bowel movements per day
described as watery, nonbloody consistent with multiple past
episodes. The patient denies fevers, chills or sweats or any
recent infections or illnesses. She describes her baseline
as dyspnea on exertion and shortness of breath with her
normal daily activities. She denies chest pain. She does
report diffuse abdominal pain with diarrhea, however, none at
rest. She describes her legs as weak and her activities as
diminished over the last few days. The patient also reports
extensive weight loss, approximately 25 to 30 lbs within the
last year. Part of this weight loss has been attributed to
affective diuresis for prominent ascites per her primary care
physician. [**Name10 (NameIs) **] patient also denies any recent antibiotic use
or change in her medical regimen.
The patient lives with at home her daughter and will be
discharged to an extended care facility with a bed already
reserved.
ALLERGIES: Augmentin with rash, question of sulfur
allergies.
PAST MEDICAL HISTORY: Ascites, cirrhosis, portal
hypertension, history of acute renal failure, diverticulosis,
diverticulitis, hypertension, coronary artery disease, stable
angina, chronic dyspnea, hypertriglyceridemia, gout,
hypothyroidism, chronic bronchitis, chronic weight loss,
chronic diarrhea, recent pelvic fracture in [**2153-3-24**], and
pancreatic insufficiency.
PAST SURGICAL HISTORY: Hysterectomy, cholecystectomy,
appendectomy.
MEDICATIONS ON ADMISSION: Aldactone 25 p.o. q.d., Colchicine
0.6 mg b.i.d., Vicodin 5/500 1 to 2 tablets prn pain, Flonase
50 one to two q.d., Lasix 20 mg p.o. q.d., Colace 100 mg p.o.
b.i.d., Trazodone 50 mg p.o. q.h.s., Protonix 40 mg p.o.
q.d., Nadolol 40 mg p.o. q.d., Diltiazem 300 mg p.o. q.d.,
K-Dur 20 mEq p.o. q.d., Pancreas 1 to 2 tablets t.i.d. with
meals, Kaopectate 600 for loose stools, Senokot for
constipation, Clonidine 0.2 mg tablets, one-half tablet p.o.
b.i.d., sublingual Nitroglycerin, Timolol eye drops, Dilantin
eye drops, Synthroid 25 mcg p.o. q.d., Demeclocycline 150 mg
p.o. b.i.d.
PHYSICAL EXAMINATION: On admission vital signs revealed
99.1, 162 to 198/71 to 90, 68 to 80, 16, 100% on room air.
General, this is an age appropriate pleasant female in no
apparent distress, alert and oriented times three. Head,
eyes, ears, nose and throat, normocephalic, pupils equal and
reactive to light and accommodation. Extraocular muscles
intact. Anicteric. Oral mucosa was moist. There was no
pharyngeal exudate or erythema. However, lips were dry and
cracked. Chest was clear to auscultation bilaterally.
Cardiovascular, regular rate and rhythm, normal S1 and S2, no
murmurs, rubs or gallops auscultated. 2+ carotids, no
bruits. Abdominal examination, bowel sounds normoactive,
distended, mild left lower quadrant tenderness, no rebound
and no guarding. Extremities, no clubbing or cyanosis, 2+
pitting edema bilaterally.
LABORATORY DATA: Admission laboratory data revealed there
was no complete blood count drawn in the Emergency
Department. Chem-7 was 126, 4.8, 92, 22, 12, 0.9 and 71,
calcium 9.3, phosphorus 3.2, magnesium 1.4, PT/INR, PTT
14.8/1.4, and 29.2. CPK MB within normal limits, troponin
0.03. Urinalysis was reported negative. Cultures were sent.
Fecal cultures sent for bacteria Escherichia coli. In the
Emergency Department there was an abdominal computerized
tomography scan which showed diffuse ascites, cirrhotic
nodular liver, diffuse diverticular disease.
Chest x-ray was not done. Electrocardiogram was not done.
Other pertinent studies in her past medical history revealed
she had an esophagogastroduodenoscopy done in [**2153-4-24**]
showing portal gastropathy, grade 1 varices. She had a
colonoscopy done in [**2153-4-24**] which showed diverticulosis,
hemorrhoids Grade 2. She had an echocardiogram done on [**2153-5-18**] showing left ventricular ejection fraction of 65%,
normal wall motion and no gross abnormalities, 1 to 2+ mitral
regurgitation and 2+ tricuspid regurgitation.
IMPRESSION:
1. Cirrhosis
2. Ascites
3. Portal hypertension
4. Sigmoid diverticulosis
5. Chronic fractures of the right superior and inferior
pubic rami.
HOSPITAL COURSE: This is a very pleasant elderly female with
the last name of [**Name (NI) 12926**] who presents with a past medical
history significant for cirrhosis, ascites, portal
hypertension, esophageal varices, hypertension, coronary
artery disease, history of chronic renal failure, gout,
recent pelvic fractures and pancreatic insufficiency who
presents essentially with failure to thrive times four to
five days with reported generalized weakness, decreased
appetite, weight loss and diarrhea.
1. Failure to thrive - The patient has been living with her
daughter since [**2153-3-24**] following pelvic fracture. The
daughter reports recent decline in function, decreased
appetite, weakness, fatigue, weight loss and recurrent
diarrhea which is an ongoing problem for this patient. The
patient has had a loss of appetite with decreased p.o. intake
and will be sent to a nursing care facility on discharge for
closer monitoring. Treatment for failure to thrive consisted
of adequate hydration, encouraging p.o. intake, complete
blood count which ruled out anemia, stool guaiacs which were
subsequently negative.
2. Diarrhea - The patient had a history of diarrhea,
longstanding, intermittent now, over the last four to five
days up to three to four times a day. Stool cultures were
sent. Clostridium difficile toxins were sent, initially read
as negative. Given the patient's age and chronicity of
diarrhea and extensive work at muscle form, she does not have
any associated respectives for Clostridium difficile colitis,
however, it was determined that an empiric treatment with
Flagyl for ten days may be beneficial in this patient with
little with regards to side effects. Consequently the
patient was started on 500 mg b.i.d., Flagyl in the setting
of liver disease. She was treated with dehydration, all
stats were negative. Kaopectate was continued and
electrolytes were repeated as necessary.
3. Hyponatremia - The patient has a sodium of 126 on
admission which was down to 128 on [**2153-9-24**], tracking
back upwards on discharge. She does have a reported history
of sodium of 138 on [**5-13**]. Her decreased sodium was
probably secondary to her ascites with a component of
syndrome of inappropriate antidiuretic hormone. She was
started on a fluid-restricted diet. The Demeclocycline was
continued at 150 b.i.d. Urine electrolytes were not assessed
given the fact that she was on Lasix and Aldactone.
4. Hypertension - The patient came in with elevated blood
pressures of 160 to 190, however, with the initiation of her
medications in-hospital her blood pressures normalized. She
was continued on her home regimen of Diltiazem, Clonidine and
appropriate diuretic.
5. Diverticulosis - The patient had a history of and has
evidence of diverticuli on computerized axial tomography
scan. She had a temperature reported as high as 99.8 in the
hospital. She had some mild left lower quadrant tenderness
to palpation, subsequently she was started on Ciprofloxacin
500 mg p.o. q.d.
6. Rule out myocardial infarction - Given the patient's new
lethargy and history of coronary artery disease, she was
initiated for rule out myocardial infarction in the Emergency
Department. The patient subsequently ruled out with negative
enzymes, negative electrocardiogram.
7. Ascites cirrhosis - The patient has obvious evidence of
ascites. She was continued on her home Aldactone 25 q.d.,
Lasix q.d. for edema. She was maintained on fluid
restriction, liver function tests were assessed with
laboratory data.
8. Pancreatic insufficiency - The patient takes Pancreas
which was continued. She had a mildly elevated lipase,
slightly greater than 100. No further workup was performed
at this time.
9. Electrolyte abnormalities - The patient's electrolytes
were repleted as necessary in the hospital course.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Failure to thrive
2. Rule out myocardial infarction
3. Diarrhea
4. Pain, abdominal left lower quadrant
5. Ascites
6. Diverticulosis/diverticulitis
7. Hyponatremia
DISCHARGE MEDICATIONS:
1. Levothyroxine 25 mcg p.o. q.d.
2. Diltiazem 300 mg p.o. q.d.
3. Nadolol 40 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
5. Lasix 20 mg p.o. q.d.
6. Spironolactone 25 mg p.o. q.d.
7. Timolol eyedrops, one drop b.i.d.
8. Clonidine 0.1 mg tablet p.o. b.i.d.
9. Colchicine 0.6 mg tablet p.o. b.i.d.
10. Vicodin 5/500 one to two tablets p.o. q. 4-6 hours prn
for pain
11. Colace 100 mg tablet b.i.d.
12. Trazodone 50 p.o. q.h.s.
13. Pancreas, amylase/lipase Proteus 2 tablets p.o. t.i.d.
with meals
14. Kaopectate
15. Senna
16. Dilantin/Lantanoprost one drop q.h.s.
17. Flagyl 500 mg tablet p.o. b.i.d. for seven days
18. Ciprofloxacin 500 mg tablet p.o. q.d. for seven days
19. Nitroglycerin 0.3 mg sublingual tablets prn for chest
pain as needed
RECOMMENDED FOLLOW UP PLAN: The patient is follow up with
primary care physician, [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3306**], [**Location (un) **]
Internal Medicine on [**2153-10-16**] at 2:30 PM. The
patient will be discharged to a nursing home facility, name
to be stated later.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], M.D. [**MD Number(1) 1208**]
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2153-10-7**] 11:48
T: [**2153-10-7**] 12:52
JOB#: [**Job Number 12927**]
Name: [**Known lastname 1910**], [**Known firstname 1911**] Unit No: [**Numeric Identifier 1912**]
Admission Date: [**2153-10-5**] Discharge Date: [**2153-10-18**]
Date of Birth: [**2060-6-28**] Sex: F
Service: .
ADDENDUM: This is an addendum to the Hospital Course.
This is a [**Age over 90 **] year old female with an extensive past medical
history as noted above, who was initially admitted on
[**10-5**], with failure to thrive, dehydration and
weakness for four days prior to admission. The patient also
had had abdominal pain with eating, diarrhea for four to five
days, with three to four bowel movements a day described as
watery and nonbloody consistent with multiple past episodes.
The patient was admitted to Medicine during her hospital
course.
The Gastrointestinal Service was consulted and an MRA was
performed which showed severe stenosis of the celiac access
and superior mesenteric artery, consistent with mesenteric
ischemia as well as bilateral renal artery stenosis.
Vascular and Cardiothoracic Surgery were involved and the
patient was referred to peripheral catheterization which was
performed on [**10-11**].
During the procedure, the celiac artery and SMA- were
centered, however, she also had a right heart catheterization
performed to assess the patient's filling pressures. During
the procedure, there was difficulty in advancing the catheter
into the pulmonary artery. This caused transient complete
heart block, so the patient had a temporary pacing wire
inserted with recovery to normal sinus rhythm with a new left
bundle branch block.
Post procedure, the patient was noted to be tachypneic,
hypoxic, and hypotensive. She went into PEA arrest secondary
to the pericardial effusion which was tamponading her heart.
She was started on Neo-Synephrine and Dopamine at the
bedside. A pericardiocentesis was performed with the
evacuation of 220 cc of bloody fluid.
The patient then had a repeat right heart catheterization.
The patient was then admitted to the Coronary Care Unit.
During her Coronary Care Unit admission, her anti-coagulation
for her atrial fibrillation was discontinued secondary to her
bleeding risk. On the 18th, she was noted to have decreased
mental status and being completely unresponsive to voice and
the Neurology Service was consulted.
They felt that the mental status change were secondary to
possible anoxic brain injury versus metabolic derangement.
By the 20th, the patient's mental status returned to baseline
and the Neurology Service had signed off. Of note, the
patient had been hemodynamically stable but intermittently
had episodes of atrial fibrillation. No rate control was
initiated secondary to the history of complete heart block
and given the patient's surgical risk, it was unclear whether
or not she would be a good candidate for pacemaker placement.
After the five days in the Coronary Care Unit, the patient
was sent to the medical floor where she was stable. She
received Physical Therapy. Nutrition was consulted. On the
25th, the patient's strength was improving and she was
clinically stable, so she was discharged to her
rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Primary failure to thrive.
2. Coronary artery disease status post myocardial infarction
ten years ago; rule out myocardial infarction.
3. Diarrhea.
4. Left lower quadrant abdominal pain.
5. Ascites.
6. Diverticulosis.
7. Hyponatremia.
8. Portal hypertension.
9. History of acute renal failure.
10. Pancreatic insufficiency.
11. Status post complete heart block with temporary pacer
placement.
12. Grade I varices.
13. Mesenteric ischemia status post stenting of celiac and
SMA-arteries.
14. Cardiac tamponade status post pericardial effusion
drainage.
15. Mental status changes, now at baseline.
DISCHARGE INSTRUCTIONS:
1. The patient should follow-up with her primary care
physician, [**First Name8 (NamePattern2) 1913**] [**Last Name (NamePattern1) 1914**], on a week after discharge and is
to call for the appointment.
2. She was discharged to an extended care facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Levothyroxine 25 micrograms p.o. q. day.
2. Pantoprazole 40 mg p.o. q. day.
3. Furosemide 20 mg p.o. q. day.
4. Spironolactone 25 mg p.o. q. day.
5. Timolol Maleate eyedrops, one drop to each eye twice a
day.
6. Colchicine 0.6 mg tablets, she is to take one tablet p.o.
Twice a day and hold for diarrhea.
7. Percocet, one to two tablets p.o. q. four to six hours
p.r.n. pain.
8. Lantoprasol eye drops, one drop to each eye q. h.s.
9. Aspirin 325 mg p.o. q. day.
10. Propranolol 10 mg p.o. twice a day.
She is to continue to have a cardiac heart healthy diet with
1500 ml fluid restriction.
She should continue to get Physical Therapy and Occupational
Therapy at the nursing home.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**]
Dictated By:[**Name8 (MD) 1915**]
MEDQUIST36
D: [**2153-11-2**] 16:53
T: [**2153-11-2**] 23:02
JOB#: [**Job Number 1916**]
|
[
"427.31",
"413.9",
"998.11",
"276.5",
"557.1",
"571.5",
"491.9",
"427.5",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"39.50",
"37.21",
"37.0",
"88.48",
"89.64",
"39.90",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
13597, 14206
|
14545, 15527
|
2237, 2821
|
4941, 8767
|
14230, 14487
|
2164, 2210
|
2844, 4923
|
155, 1764
|
1787, 2140
|
14513, 14522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,768
| 147,912
|
4908
|
Discharge summary
|
report
|
Admission Date: [**2141-6-24**] Discharge Date: [**2141-6-27**]
Date of Birth: [**2073-9-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: (Per medical Intensive Care Unit
resident admission note) The patient is a 67 year old male
with metastatic adenocarcinoma of the rectum, coronary artery
disease and type 2 diabetes mellitus brought by emergency
medical services to [**Hospital6 256**] from
[**Hospital3 2558**] and intubated in the field for presumed
aspiration event. Last admission to [**Hospital6 649**] was [**3-28**] to [**4-20**] for nausea, vomiting
and abdominal pain. He underwent exploratory laparotomy with
lysis of adhesions and repair of parasternal hernia,
complicated by perioperative aspiration event requiring
intubation, prolonged delirium and paroxysmal atrial
fibrillation, discharged to [**Hospital3 2558**] where he had been
slowly declining, lethargic, bed-bound, minimally verbal,
Percocet, nausea and vomiting, suctioned to tube feeds,
exclusively last week on Levofloxacin and Flagyl since
approximately [**6-19**] for a presumed aspiration event. This
morning around 5 AM he started coughing and vomiting, a
moderate amount of tube feeds, became tachypneic. He
desaturated to 92% on room air which increased to 82% on 10
liters. He continued to vomit times two. His temperature
101.2. He was hemodynamically stable and emergency medical
services was called. The vital signs were 160 to 180/80 to
90 and heartrate 150 to 170s. Suctioned "pus" from airway.
he then went from 79% on 5 liters to 88% on 15 liters and he
was intubated in the field. He was brought to the Emergency
Department where he was placed on low ventilations. On
examination he had coarse bilateral breathsounds responsive
to tactile stimuli. White blood count was around 32,000, INR
1.7. Chest x-ray showed patchy and nodular bilateral
opacities. Computerized tomography scan of the head showed
mass in the left parietal lobe with hemorrhagic rim,
vasogenic edema and shift of the midline to the right. He
was given Ceptaz, Clindamycin, Ativan, Lopressor and
Decadron.
PAST MEDICAL HISTORY: 1. Rectal cancer diagnosed in [**2136**],
T3N2, status post AP resection, diverting colostomy, status
post chemotherapy, 5-FU and Leucovorin, status post radiation
[**2140-1-12**], normal colonoscopy [**2140-3-11**], right ileac
mass, metastatic to retroperitoneum, right ileac, lungs
followed by Dr. [**Last Name (STitle) 1940**]. 2. Diabetes mellitus Type 2. 3.
Coronary artery disease status post coronary artery bypass
graft in [**2135-12-12**], echocardiogram [**2139-12-12**] with
ejection fraction of greater than 65%, anteroseptal aneurysm.
4. Cardiovascular disease, preoperative coronary artery
bypass graft ultrasound showed an left internal coronary
artery occlusion and an right internal coronary artery mild
occlusion. 5. High cholesterol. 6. Deep vein thrombosis
in [**2140-6-11**]. 7. Right hydronephrosis, obstruction of
right distal ureter by metastases status post stent. 8.
Atrial fibrillation [**2141-4-11**].
SOCIAL HISTORY: [**Hospital3 2558**] for two and a half months.
His wife, [**Name (NI) **], is [**Name (NI) **]. He sons are [**Name (NI) 12412**] and
[**Name (NI) **] who speak English. He quit tobacco five years ago, 40
years times one pack per day, no alcohol.
PHYSICAL EXAMINATION: Physical examination on admission
revealed intubated, middle-aged male responsive to tactile
stimuli. Temperature 100.2 axillary, heartrate 116, blood
pressure 115/76, 36 IMV pressure support 8, positive
end-expiratory pressure 5, 500/10 actual 28 to 35, FIO2 50%,
7.35 pH, pCO2 48, pO2 264. On IMV, pressure support 5, FIO2
100 500 by 10. Skin, warm and dry, anicteric, diaphoretic.
Head, eyes, ears, nose and throat, normocephalic, atraumatic,
blood on lower lip. Pupils are round 2 mm bilaterally,
sluggish, positive cataracts. Tube at 22 cm. Neck supple.
No lymphadenopathy. Coarse bilateral breathsounds worse at
bases, distant. Heart, tachycardiac, no murmurs appreciated.
Abdominal, positive bowel sounds, colostomy in left lower
quadrant, positive percutaneous endoscopic gastrostomy tube
on the left. No edema. No calf tenderness. Responds to
tactile stimuli, blinks. Reflexes, left upper extremity 0/4,
right upper extremity 0/4, right lower extremity 0.4, left
lower extremity 0/4, tone left upper extremity greater than
right upper extremity.
LABORATORY DATA: On admission white blood count 31.9,
hematocrit 37.0, platelets 520. PT 16, PTT 27.5, sodium 136,
potassium 5.2, chloride 95, carbon dioxide 23, BUN 26,
creatinine 0.9, glucose 248, ALT 41, AST 11. Alkaline
phosphatase 101, amylase 83.
HOSPITAL COURSE: The patient was admitted to the Medicine
Intensive Care Unit. He was admitted by Neurosurgery.
Multiple family meetings occurred and resulted in family
deciding to withdraw care, extubate the patient and make him
comfort-measures-only. The patient called out to the floor
on [**2141-6-26**]. He will be discharged to home with hospice
care.
DISCHARGE STATUS: Discharge to [**Hospital3 2558**] with hospice
care.
CONDITION ON DISCHARGE: Poor.
DISCHARGE DIAGNOSIS:
1. Acute respiratory failure
2. Aspiration pneumonia
3. Coma, not diabetic or hepatic
4. Hypoxemia
5. Anemia, not otherwise specified
6. Coagulation defect, not other specified
7. Terminal comfort care
8. Metastatic rectal carcinoma
MEDICATIONS ON DISCHARGE: Tylenol 650 p.r. q. 6 hours;
Scopolamine patch q. 72 hours; Fentanyl patch 200 mcg q. 48
hours; Fentanyl Citrate 50 mcg intravenously q. 1 hours as
needed for moderate pain; Fentanyl Citrate 100 mcg
intravenously q. 1 hours as needed for severe pain; Fentanyl
25 mcg intravenously q. 1 hours as needed for mild pain;
Morphine Sulfate 5 mg sublingual q. 1 hours as needed for
moderate pain, 3 mg sublingual q. 1 hours as needed for
moderate pain, 1 mg sublingual q. 1 hours as needed for mild
pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10388**], M.D.
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2141-6-27**] 08:10
T: [**2141-6-27**] 08:13
JOB#: [**Job Number 20449**]
|
[
"197.0",
"518.81",
"198.3",
"250.00",
"427.31",
"507.0",
"197.6",
"780.01",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5181, 5423
|
5450, 6203
|
4710, 5128
|
3367, 4692
|
160, 2109
|
2132, 3076
|
3093, 3344
|
5153, 5160
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,644
| 198,654
|
14166+14167
|
Discharge summary
|
report+report
|
Admission Date: [**2112-6-1**] Discharge Date: [**2112-6-4**]
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
woman with a history of paroxysmal atrial fibrillation,
tachy-brady syndrome, as well as placement of a dual chamber
pacemaker [**2112-5-19**] at [**Hospital3 3583**]. After her pacemaker was
placed, she reports two weeks of palpitations, fatigue,
increasing shortness of breath, episodes of lightheadedness.
She had no chest pain or loss of consciousness. With her
increasing shortness of breath, she was seen by her
cardiologist who advised her to be admitted to [**Hospital3 6265**] for evaluation of her pacemaker. There, she had a
chest x-ray and echocardiogram which showed both her
pacemaker leads had changed position since [**5-19**]. She also was
noted to have a circumferential pericardial effusion with
right atrial collapse. It was thought that she might have
had displaced pacemaker leads with perforation leading to her
pericardial effusion. She was transferred to [**Hospital3 **] for
further management. Her repeat echocardiogram at [**Hospital3 6265**] showed no change in the amount of effusion
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation.
2. Chronic renal insufficiency.
3. Status post pacemaker placement.
MEDICATIONS ON ADMISSION: Amiodarone, 200 mg PO q day;
Cozaar, 50 mg PO q day; aspirin, 81 mg PO q day, Protonix, 40
mg PO q day; diltiazem, 30 mg PO t.i.d..
ALLERGIES: Benadryl, codeine, sulfa, aspirin.
SOCIAL HISTORY: She quit smoking 15 years ago. Social
alcohol. Lives alone. High functioning. Works as a museum
curator.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: A young appearing 81-year-old woman.
Afebrile, with blood pressure 160/80, pulse 80, respirations
20, saturation 92% on room air. HEENT exam: Normocephalic,
atraumatic. Oropharynx clear. Cardiovascular exam: She is
irregularly irregular. JVP of about 10 cm and a pulsus
paradoxus also present. Pulmonary: Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended, with
positive bowel sounds. Extremities: She had trace edema.
LABORATORY DATA: Significant only for an hematocrit of 31.
Chest x-ray showed an enlarged cardiac silhouette.
She had an echocardiogram on admission which showed no
significant change in her pericardial effusion.
HOSPITAL COURSE: She had a pericardial lead revision. Her
pericardial effusion remained stable. She was briefly
transferred to the CCU for closer observation after the
procedure, and she continued to do well. Had another repeat
echocardiogram prior to discharge which showed smaller size
of her pericardial effusion. She was discharged to home in
good condition.
DISCHARGE MEDICATIONS:
1. Amiodarone, 200 mg PO q day.
2. Cozaar, 50 mg PO q day.
3. Aspirin, 81 mg PO q day.
4. Diltiazem, 30 mg PO t.i.d..
5. Protonix, 40 mg PO q day.
6. Sublingual nitroglycerin p.r.n..
7. Keflex, 500 mg q.i.d. times seven days.
DISCHARGE DIAGNOSES:
1. Status post pacemaker revision.
2. Pericardial effusion.
3. Paroxysmal atrial fibrillation.
4. Chronic renal insufficiency.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1201**], M.D. [**MD Number(1) 1202**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2112-10-7**] 14:43
T: [**2112-10-7**] 14:59
JOB#: [**Job Number **]
Admission Date: [**2112-6-1**] Discharge Date: [**2112-6-4**]
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
woman with a history of paroxysmal atrial fibrillation,
tachy-brady syndrome, as well as placement of a dual chamber
pacemaker [**2112-5-19**] at [**Hospital3 3583**]. After her pacemaker was
placed, she reports two weeks of palpitations, fatigue,
increasing shortness of breath, episodes of lightheadedness.
She had no chest pain or loss of consciousness.
With her increasing shortness of breath, she was seen by her
cardiologist who advised her to be admitted to [**Hospital3 6265**] for evaluation of her pacemaker. There she had a
chest x-ray and echocardiogram which showed both her
pacemaker leads had changed position since [**5-19**]. She also
was noted to have a circumferential pericardial effusion with
some right atrial collapse. It was thought that she might
have had displaced pacemaker leads with perforation leading
to her pericardial effusion. She was transferred to [**Hospital3 **] for further management. Her repeat echocardiogram at
[**Hospital3 3583**] showed no change in the amount of effusion.
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation.
2. Chronic renal insufficiency.
3. Status post pacemaker placement.
MEDICATIONS ON ADMISSION: Amiodarone, 200 mg PO q day;
Cozaar 50 mg PO q day; aspirin 81 mg PO q day, Protonix 40 mg
PO q day; diltiazem 30 mg PO t.i.d..
ALLERGIES: Benadryl, codeine, sulfa, aspirin.
SOCIAL HISTORY: She quit smoking 15 years ago. Social
alcohol. Lives alone. High functioning. Works as a museum
curator.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: A young appearing 81-year-old woman.
Afebrile, with blood pressure 160/80, pulse 80, respirations
20, saturation 93% on room air. HEENT exam: Normocephalic,
atraumatic. Oropharynx clear. Cardiovascular exam: She is
irregularly irregular. JVP of about 10 cm and a pulsus
paradoxus also present. Pulmonary: Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended, with
positive bowel sounds. Extremities: She had trace edema.
LABORATORY DATA: Significant only for an hematocrit of 31.
Chest x-ray showed an enlarged cardiac silhouette.
She had an echocardiogram on admission which showed no
significant change in her pericardial effusion.
HOSPITAL COURSE: She had a pericardial lead revision. Her
pericardial effusion remained stable. She was briefly
transferred to the CCU for closer observation after the
procedure and she continued to do well. She had another
repeat echocardiogram prior to discharge which showed smaller
size of her pericardial effusion. She was discharged to home
in good condition.
DISCHARGE MEDICATIONS:
1. Amiodarone, 200 mg PO q day.
2. Cozaar, 50 mg PO q day.
3. Aspirin, 81 mg PO q day.
4. Diltiazem, 30 mg PO t.i.d..
5. Protonix, 40 mg PO q day.
6. Sublingual nitroglycerin p.r.n.
7. Keflex, 500 mg q.i.d. times seven days.
DISCHARGE DIAGNOSES:
1. Status post pacemaker revision.
2. Pericardial effusion.
3. Paroxysmal atrial fibrillation.
4. Chronic renal insufficiency.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1201**], M.D. [**MD Number(1) 1202**]
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2112-10-7**] 14:43
T: [**2112-10-7**] 14:59
JOB#: [**Job Number **]
|
[
"593.9",
"427.81",
"423.0",
"E870.0",
"285.9",
"427.31",
"996.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0",
"38.91",
"37.75",
"37.76"
] |
icd9pcs
|
[
[
[]
]
] |
5100, 5115
|
6462, 6868
|
6201, 6441
|
4779, 4956
|
5824, 6178
|
5138, 5805
|
3563, 4620
|
4642, 4752
|
4973, 5083
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,067
| 140,990
|
41294
|
Discharge summary
|
report
|
Admission Date: [**2130-3-16**] Discharge Date: [**2130-4-26**]
Date of Birth: [**2087-11-11**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
1. Placement of pheresis catheter
2. Endotrachial intubation
3. Placement of subclavian catheter
4. Placement of PICC line
5. Placement of nasogastric tube
History of Present Illness:
42 year-old woman with history of recurrent pancreatitis,
polysubstance abuse (including alcohol and IV heroin) and
hypertriglyceridemia who presented to OSH on [**2130-3-15**] with severe
abdominal pain. She was transferred for management of
multi-organ failure in the setting of severe pancreatitis. On
note says the patient has been having abdominal pain for a few
days. Her husband reported that she called him home from work
yesterday. He found her crying on floor with abdominal pain.
He thinks she may have had some nausea and vomiting and
potentially diarrhea because she was going to the bathroom
frequently. He called EMS and she was sent to hospital. He
reports that he did not think she had been drinking recently;
however, he has found several empty pints of vodka and thinks
she may have been drinking [**1-29**] pints of vodka a day. He notes
that she has been using too much percocet recently and does not
think that she has been taking any of her prescription
medications as the pill bottles are all full. He does not think
she has been particularly depressed lately and denies that she
may have been suicidal or trying to overdose of pills or
alcohol.
At the OSH, she was initially afebrile, tachy to 114,
hypertensive to SBP 150s, RR 24 and satting 98% ra. Her labs
were notable for a hyponatremia to 127, nl BUN/Cr, WBC 7.3 and
Hct was 41 on admission. Initial lipase was 395, but increased
to 400 the following day. [**Last Name (un) **] criteria on admission was 0.
Overnight, she required high doses do dilaudid for pain control.
She developed hypoxia, worsening respiratory distress and was
intubated at 6am on [**3-16**]. She became hypotensive and developed
anuric [**Last Name (un) **] despite 5-6L of NS. This mornign her Hct is up to 51
this am on OSH labs. She has had no UOP in transit. She has
been febrile to 102, despite tylenol and ibuprofen. She is on
0.3 of levofed to keep MAP>60. She has a metabolic acidosis
with pH down to 7.09.
Review of Systems:
Positive for abdominal pain, denies other pain, full ROS limited
by intubation.
Past Medical History:
- Recurrent pancreatitis - from hypertriglyceridemia and alcohol
ingestion in the past since [**31**]/[**2128**]. Last admission was [**8-/2129**]
- Hypertension
- Hypertriglyceridemia
- Hyperlipidemia
- History of Cesarean section
- Obesity
- Polysubstance abuse
Social History:
Married with 2 children (3 yo and 5yo). Prior history of IVDU:
heroin use in the past. Husband does not think she has been
using drugs recently, but could not be sure. Current tob use:
1-1.5 PPD. Current alcohol: use 2 pints of vodka daily for last
several years. There is concern for domestic violence in her
household.
Family History:
Noncontributory
Physical Exam:
VS: Febrile
GEN: intubated, alert, nods yes/no to questions.
HEENT: PERRL, EOMI, anicteric, no supraclavicular or cervical
lymphadenopathy, JVP flat
RESP: CTA in all lung fields, no w/r/r. ventilated breath sounds
CV: tachy, but regular rate, S1 and S2 wnl, no m/r/g
ABD: absent bowel sounds, mildly distended, soft, voluntary
guarding, diffusely, very tender to perussion. obese.
EXT: cold extremities, pulse are dopplerable at PT/DP and radial
SKIN: no rashes/no jaundice/no splinters
GU: foley in place, patient is menstruating.
NEURO: alert oriented to person, follows commands. Moves all 4
extremities on command.
Pertinent Results:
Admission Labs: [**2130-3-16**]
WBC-9.1 RBC-4.34 Hgb-14.4 Hct-47.3 MCV-109* MCH-32.8* MCHC-30.4*
RDW-16.6* Plt Ct-219
Glucose-99 UreaN-26* Creat-3.1* Na-138 K-5.8* Cl-120* HCO3-12*
AnGap-12
ALT-25 AST-131* LD(LDH)-970* AlkPhos-43 TotBili-0.4
Lipase-2808*
Albumin-2.2* Calcium-3.4* Phos-3.1 Mg-1.4*
Triglyc-3317*
Lactate-2.7*
[**2130-4-26**] 06:15AM BLOOD WBC-7.4 RBC-2.95* Hgb-9.0* Hct-25.0*
MCV-85 MCH-30.6 MCHC-36.1* RDW-17.6* Plt Ct-84*
[**2130-4-23**] 06:00AM BLOOD PT-13.3 PTT-27.6 INR(PT)-1.1
[**2130-4-18**] 07:29AM BLOOD Fibrino-502*
[**2130-4-26**] 06:15AM BLOOD Glucose-133* UreaN-18 Creat-0.6 Na-133
K-3.7 Cl-102 HCO3-25 AnGap-10
[**2130-4-26**] 06:15AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.4
Mg-1.5*
[**2130-4-26**] 06:15AM BLOOD Triglyc-262*
CT ABDOMEN/PELVIS ([**2130-3-15**]): Extensive inflammatory change
around the pancreas with peripancreatic effusion. No fluid
collections. Pancreas enhances normally. No e/o necrosis. no
pseudocyst or abscess. GB somewhat distended. Fatty liver. No
thickened loops of bowel. Also noted, low density mass in left
ovary c/w ovarian cyst.
MRCP ([**2130-3-25**]):
1. There is severe pancreatitis with areas of reduced
enhancement in the head and neck which may represent early
necrosis/ischemia.
2. High signal intensity peripancreatic fluid is present, either
hemorrhagic fluid or fat necrosis. If there is concern about
active bleeding, a CTA could be performed to further evaluate.
3. Aberrant right hepatic duct arises from the mid CBD.
ECHO ([**2130-4-4**]):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Regional left ventricular wall motion
is normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is no ventricular septal defect. 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 masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality.
Physiologic mitral regurgitation is seen (within normal limits).
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal regional and global biventricular systolic function.
CT ABDOMEN/PELVIS ([**2130-4-14**]):
1. Limited study due to the lack of intravenous contrast.
Extensive
peripancreatic fat stranding and retroperitoneal and
intraperitoneal fluid
collections, stable since the prior study, and are consistent
with acute
pancreatitis.
2. No evidence of retroperitoneal bleed.
3. Mild splenomegaly.
4. Stable bilateral simple pleural effusions with basal
atelectasis.
Brief Hospital Course:
SEVERE ACUTE PANCREATITIS WITH FORMING PSEUDOCYST AND ASSOCIATED
PANCREATIC NECROSIS: the patient was initially septic with ARDS,
she was in distributive shock and intubated for hypoxemic
respiratory failure. She required massive fluid resuscitation
with 19 liters of IVF and vasopressor agents. She was treated
also with bowel rest and meropenem for antibiotics. She had
ongoing fevers for several weeks that had eventually resolved.
Her diet was advanced to clear liquids, she refused nasojejunal
feeding and therefore was initiated on TPN and discharged on
this. She will follow up with general surgery in 3 weeks with a
repeat CT scan of her abdomen with contrast, if her pseudocyst
is fully formed Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] may perform surgery for
symptomatic treatment of a large pseudocyst. Her pancreatitis
was likely related to ETOH use and possible contribution from
hypertriglyceridemia.
COAG NEGATIVE STAPH PICC LINE INFECTION: she was treated with a
13 day course of vancomycin (planned 14 day course limited by
thrombocytopenia). PICC was removed and replaced.
THROMBOCYTOPENIA: hematology consulted ([**Name8 (MD) 22656**] MD) and the
patient had a + antiplatelet antibody. Vancomycin was the likely
culprit and was discontinued, her plts continued to drop despite
discontinuation of this so gemfibrozil was discontinued. Her
platelet nadir was 9, she did require a platelet transfusion
when it reached this level. She had no clinical evidence of
bleeding. She required a 5 day course of IVIG which did help her
platelets recover. Her last dose of IVIG was on Saturday [**4-22**]
and her platelets remained stable at 84 at the time of discharge
on [**4-26**]. Given the likely need for her gemfibrozil in the
future and given the liklihood that this was vancomycin induced;
when her platelets normalize gemfibrozil should be reintroduced
and plts should be monitored closely to see if she again
develops thrombocytopenia. She will f/u with Dr. [**Last Name (STitle) 22656**] the
week after discharge.
ANXIETY, DEPRESSION: she was treated with an increased dose of
sertraline, psychiatry consulted, clonazepam stopped given
history of abuse of benzodiazepines.
CHRONIC NARCOTIC USE AS WELL AS HISTORY OF NARCOTIC ABUSE: the
patient most recently was using heroin via inhalation. She also
is on chronic narcotics for pain related to chronic pancreatitis
or other etiology. On this admission she had a clear organic
reason for pain with the severe necrotizing pancreatitis, she
was treated with high doses of IV narcotics, she was weaned down
to 7.5mg po oxycodone q4hrs. Upon discusssion with her primary
care physician we felt the safest would be to limit her
narcotics but not to discontinue them altogether. Following her
surgery we may be able to completely wean her off however she
still has a tender abdomen related to her large forming
pseudocyst. She was discharged on a 28 day supply of percocet
(3 per day, to be filled only at [**Location (un) 11269**] Osco pharmacy). This
was discussed with her PCP and she has a narcotic contract with
her PCP.
Acute kidney injury: Resolved with rehydration, peak Cr 3.8.
Medications on Admission:
Medications at home: (husband confirms med list but doubts she
was actually taking any of these regularly)
Folic acid 1mg PO daily
TriCor 48 mg PO daily
Lopid 600mg PO BID
Lisinopril 5mg PO Daily
Simvastatin 20 mg PO QHS
Percocet 1 tab QID PRN
Discharge Medications:
1. sertraline 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO three times a day as needed for pain: to be filled only at
Osco in [**Location (un) 11269**].
Disp:*84 Tablet(s)* Refills:*0*
6. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day): swish and spit.
Disp:*500 ML(s)* Refills:*1*
7. Outpatient Lab Work
Weekly labs to be faxed to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] MD
[**Telephone/Fax (1) 18738**] (phone is [**Telephone/Fax (1) 11476**])
Chem 10 (Na, K, Cl, bicarb, BUN, Cr, glucose, Ca, Mg, Phos),
Triglycerides, LFTs (AST, ALT, Alk phos, Total bilirubin)
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Home Care Program
Discharge Diagnosis:
1. Pancreatitis, severe with necrosis
2. Peripancreatic fluid collection / pseudocyst
3. Bacteremia / septicemia (coagulase negative staph)
4. Benzodiazepine withdrawal / dependence
5. Hypertriglyceridemia
6. Anasarca
7. Anemia
8. Collapsed lung / hypoxia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with severe pancreatitis and required a long
stay in the medical ICU. It is extremely important that you stop
using drugs and alcohol.
Please take your medications as prescribed and make your follow
up appointments.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2130-5-3**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: FRIDAY [**2130-5-12**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
**Please arrive for this appointment at 9AM. You must also fast
3 hours before this test**
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2130-5-12**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN ([**Last Name (LF) **],[**First Name3 (LF) **]
H. [**Telephone/Fax (1) 33146**]) IN 4 WEEKS.
|
[
"790.7",
"303.91",
"276.2",
"E930.8",
"276.0",
"785.59",
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"041.10",
"263.0",
"518.5",
"292.84",
"278.00",
"287.49",
"272.1",
"518.0",
"577.1",
"584.5",
"577.0",
"560.1",
"401.9",
"285.9",
"305.50",
"577.2",
"275.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.71",
"39.95",
"38.97",
"96.72",
"96.6",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
11535, 11604
|
7028, 10226
|
291, 449
|
11904, 11904
|
3879, 3879
|
12314, 13493
|
3207, 3224
|
10520, 11512
|
11625, 11883
|
10252, 10252
|
12055, 12291
|
10273, 10497
|
3239, 3860
|
2484, 2565
|
239, 253
|
477, 2465
|
3895, 7005
|
11919, 12031
|
2587, 2852
|
2868, 3191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,324
| 153,161
|
49678+49679
|
Discharge summary
|
report+report
|
Admission Date: [**2135-9-5**] Discharge Date: [**2135-10-6**]
Date of Birth: [**2075-6-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
[**First Name3 (LF) **] leak s/p liver resection
Major Surgical or Invasive Procedure:
[**2135-9-5**] ex lap, debridement of liver, omental flap
History of Present Illness:
Per Dr.[**Name (NI) 1369**] note: "The patient is a 60-year-
old male who underwent a segment IVB resection
cholecystectomy on [**2135-7-8**] for intrahepatic
cholangiocarcinoma/hepatocellular carcinoma and stage III
fibrosis secondary to alcohol. Postoperatively, he has
developed persistent ascites leak of nearly 2 liters per day,
as well as a small [**Year (4 digits) **] leak. He has undergone ERCP and
endoscopic stenting. This has persisted and has required the
administration of outpatient IV fluid. There has been no
diminution in the tempo of the leak and he is therefore
brought to the operating room for exploration, oversewing of
the presumed [**Year (4 digits) **] leak and identification of the source of
ascites. It should be noted that he did have venous studies
that demonstrated no evidence of portal hypertension."
Past Medical History:
heavy EtOH
HTN
cholangiocarcinoma & hepatocellullar carcinoma, s/p segment IVb
resection, cholecystectomy, intraoperative ultrasound ([**2135-7-8**])
[**Month/Day/Year **] leak from cut surface s/p drainage and ERCP with stent
([**2135-7-21**])
esophageal candidiasis
Social History:
Has a college education. Employed as a travel [**Doctor Last Name 360**]. Married
and
has two adult children.
Family History:
Father died of prostate cancer. Mother alive with CHF.
Physical Exam:
72 inches, 71.8 kg
97.1 -82-116/66, 18 99% RA
A&O, anicteric sclerae
Neck-free range of motion
Cor S1S2 normal
Lungs-clear
Ext-no edema
Pertinent Results:
[**2135-9-5**] 08:56AM HGB-11.4* calcHCT-34
[**2135-9-5**] 08:56AM GLUCOSE-129* LACTATE-0.9 NA+-137 K+-3.3*
CL--107
[**2135-9-5**] 11:30AM HCT-32.0*
[**2135-9-5**] 08:00PM GLUCOSE-202* UREA N-8 CREAT-0.7 SODIUM-135
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15
[**2135-10-6**] 04:50AM BLOOD WBC-10.2 RBC-3.98* Hgb-11.0* Hct-32.8*
MCV-82 MCH-27.7 MCHC-33.6 RDW-16.2* Plt Ct-592*
[**2135-9-28**] 05:00AM BLOOD Neuts-62.9 Lymphs-18.9 Monos-6.7
Eos-10.8* Baso-0.7
[**2135-9-20**] 06:27PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-1+ Polychr-1+ Schisto-OCCASIONAL
[**2135-10-6**] 04:50AM BLOOD Plt Ct-592*
[**2135-10-6**] 04:50AM BLOOD Glucose-108* UreaN-14 Creat-1.1 Na-135
K-3.4 Cl-93* HCO3-31 AnGap-14
[**2135-10-5**] 05:55AM BLOOD estGFR-Using this
[**2135-10-6**] 04:50AM BLOOD ALT-14 AST-25 AlkPhos-318* TotBili-0.3
[**2135-10-6**] 04:50AM BLOOD Albumin-3.8 Calcium-10.0 Phos-4.0 Mg-1.7
[**2135-9-14**] 06:00AM BLOOD VitB12-527 Folate-9.9
[**2135-9-28**] 05:00AM BLOOD Vanco-22.8*
[**2135-9-21**] 03:05PM BLOOD Type-ART pO2-100 pCO2-36 pH-7.43
calTCO2-25 Base XS-0
[**2135-9-21**] 03:05PM BLOOD Lactate-0.6 K-3.6
[**2135-9-20**] 02:57PM BLOOD Hgb-10.4* calcHCT-31
[**2135-9-21**] 03:05PM BLOOD freeCa-1.17
Brief Hospital Course:
On [**9-6**], he underwent exploratory laparotomy, debridement of
liver, omental flap. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please
see operative report for details. There was a large amount of
fibrinous debris in the base of the segment IVB resection with
omentum adherent to the area. There was a large amount of
fibrinopurulent debris along the lateral aspect of the resection
margin. Two 19 [**Doctor Last Name 406**] drains were placed,
1 laterally and 1 in the resection bed. The omentum was replaced
into the resection bed.
Postop, he was in a lot of pain with pain score of [**9-9**].
Dilaudid dosing was adjusted and toradol iv was initiated for
three days. Pain lessened. Urine output was adequate. He
developed a temperature of 102 on pod 0. Perioperative Unasyn
was switched to Vanco and Zosyn. The picc line was removed with
the tip sent for culture. Blood, urine and [**Date Range **] were sent for
culture as well and are negative to date. Diet was advanced on
pod 1. The JPs were non-bilious with outputs averaging 20 and
30cc. The incision was clean, dry and intact.
Patient was passing flatus POD 2 and BM by POD 3. Drain output
was consistently greater in the medial drain over the lateral
drain, and the lateral drain was removed and a stitich placed on
POD 3. The medial drain put out 1-2 L of fluid each day
thereafter. This fluid was replaced at a rate of [**2-1**] cc per cc
to keep [atient near euvolemic. A Portal vein study on POD 6
Normal hepatic and portal venous pressure. The pressure
measurements were compared with the exam performed on [**8-15**],
without any changes. Due to the high outpur of [**Last Name (LF) **], [**First Name3 (LF) **] IR
drainage was attempted and new PTC placed, as well as pigtail
drianage catheter on [**9-20**] without incident. However patient was
kept intubated post procedure and therefore was taken to the
SICU. After extubation the following day, he was given two
units of PRBC's for drop in HCT to 24, with subsequent rise to
30.5. He was returned to the floor on [**9-21**], and diet was
advanced slowly until regular. Patient required intermittent
dose of lasix for fluid balance. A repeat cholangiogram and
drain study was performed on [**9-26**] with successful exchange of a
previously placed biliary catheter for a new 10-French modified
multipurpose drainage catheter. The second previously placed
biliary catheter was removed. Pt tolerated procedure well. He
awas advanced slowly on his diet. Patient did well but
continued to drian large volumes of fluid and liver US was
performed [**9-29**] which showed fluid collection, stable, in
surgical bed. No attempt was made for further intervention.
Patient had a CT scan on [**10-6**] prior to discharge which was
significant for 1) Fluid collection at the hepatic resection
site again noted with slight increase in the overall amount of
fluid as detailed above and 2) Small right pleural effusion
again seen, slightly increased in size since the prior
examination. Patient was cleared for discharge with strict
instructions and follow up appointments. Pt was given clear
instruction on drian teaching prior to discharge.
PAIN:
Pain was an issue through out patients stay. Initially this was
controlled with dilaudid IV. As patient tolerated PO he was
changed to oral pain medication, and by the last week of stay he
was transferred slowly to methadone. He was discharged on 20 of
methadone [**Hospital1 **] and oral dilaudid 2mg every 3 hours as needed.
CONSULTS:
Interventional Radiology was consulted numerous times [**First Name9 (NamePattern2) 63960**]
[**Last Name (un) **] stay as detailed above.
Psychiatry saw patient POD 5 for anxiety and frustration. He
was begun on haldol PRN and followed for the remainder of his
hospital course. He was discharged on Remeron.
Rheumatology was patient POD 11 for gout exacerbation, with
recommendations for prednisone taper, increase in colchicine,
which were followed. Pt was scheduled for follow up as
outpatient with [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD.
Medications on Admission:
cipro 500', [**Last Name (un) **] 300", protonix 40", sucralfate 1"", aldactone
25'
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. 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*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): for pain.
Disp:*56 Tablet(s)* Refills:*0*
6. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed.
Disp:*105 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
[**Last Name (un) **] leak s/p liver resection
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office if you develop fevers, chills,
nausea, vomiting, increased abdominal pain, redness/drainage
from incision or drain sites.
[**Month (only) 116**] shower, no heavy lifting, no driving while taking pain
medication
Followup Instructions:
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2135-10-20**] 8:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2135-10-20**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-10-12**] 3:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Admission Date: [**2135-10-8**] Discharge Date: [**2135-12-2**]
Date of Birth: [**2075-6-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Large volume drain output s/p liver resection with biliary leak
Major Surgical or Invasive Procedure:
[**2135-10-10**]: Tube cholangiogram
[**2135-10-11**]: Left PICC line placement
[**2135-10-18**]: Tube Cholangiogram
History of Present Illness:
60yo M with [**Month/Day/Year **] and ascites leak s/p segment IVB resection
([**7-8**]), s/p ex lap with debridement of liver, omental flap ([**9-5**]),
s/p pull-back cholangiogram, crossed R hepatic duct disruption
([**9-20**]), s/p PTC exchange with no side holes ([**9-26**]) who now
presents with large volumes of greater than 2 liters daily from
the drains
Past Medical History:
heavy EtOH
HTN
cholangiocarcinoma & hepatocellullar carcinoma, s/p segment IVb
resection, cholecystectomy, intraoperative ultrasound ([**2135-7-8**])
[**Month/Day/Year **] leak from cut surface s/p drainage and ERCP with stent
([**2135-7-21**])
esophageal candidiasis
Social History:
Has a college education. Employed as a travel [**Doctor Last Name 360**]. Married
and
has two adult children.
Family History:
Father died of prostate cancer. Mother alive with CHF.
Physical Exam:
VS: 99.1, 74, 107/74, 20, 98% RA
Gen: NAd
Neuro: A+Ox3
Pulm: CTA bilaterally
Card: RRR
Abd: Soft, non-tender, non-distended, PTC and JP drains in place
with bilious appearing drainage
Extr: warm, well perfused
Pertinent Results:
On Admission: [**2135-10-8**]
WBC-7.4 RBC-3.93* Hgb-10.7* Hct-31.8* MCV-81* MCH-27.3 MCHC-33.7
RDW-15.8* Plt Ct-431
PT-12.7 PTT-31.4 INR(PT)-1.1
Glucose-106* UreaN-22* Creat-1.8* Na-135 K-3.8 Cl-91* HCO3-31
AnGap-17
ALT-10 AST-18 AlkPhos-253* TotBili-0.3
Calcium-10.2 Phos-5.0* Mg-1.9
Brief Hospital Course:
Patient readmitted with persistent large drain output from both
the JP and PTC drains. On admission he was volume resuscitated.
The PTC drain output was replaced with normal saline cc/cc. The
JP was replaced with 1/2 cc/cc with Normal saline. On [**10-10**], a
tube cholangiogram showed the right biliary internal/external
drainage in place. Leakage of the contrast material from the
right hepatic duct was somewhat less prominent than on the
previous studies. The PTC continued to drain ~ 400cc and the JP
~200-300cc. Post cholangiogram, the JP drainage increased to
850cc bilious drainage and the PTC increased to as high as 4
liters clear bilious fluid per day. Levaquin was continued.
On [**10-11**], a left picc line was placed for IV fluid. A CXR
confirmed a left-sided PICC line. On [**10-16**] an U/S was done of
the left arm to evaluate increased tenderness and firmness of UE
near the PICC line. This was negative for DVT.
He remained on po dilaudid 6mg prn and methadone. Methadone was
increased to 30mg [**Hospital1 **].
Kcals were recorded. He was taking in ~2400-1700 kcals. A
nutrition assessment was obtained.
Rheumatology saw him for increased left foot pain and mild
swelling. There was slight erythema at the 1st toe. He had
previously been treated for gout with colchicine. Uric acid was
6. In addition to colchicine, ibuprofen 800mg tid was added. He
also tried a 3 day course of prednisone 40 mg. This was not
continued due to plans for surgery for repair of [**Hospital1 **] leak. He
complained of increased swelling at the left ankle and some
slight swelling in the hamstring area of the left leg. On [**11-8**]
LENI's were done bilaterally ruling out DVT.
Gradually the drain outputs trended down with the PTC decreasing
to 2 liters/d and the JP to 10-20cc.
A repeat tube cholangiogram was done on [**10-18**] showing persistent
leakage of contrast through the mid portion of the right biliary
duct accessed and the catheter was repositioned in place. The
leak appeared smaller. On [**10-27**] an U/S was done to reassess for
intra-abdominal fluid collection. This showed unchanged fluid
collections at the hepatic resection site. No new collections
were seen. On [**11-1**] an attempt was made to provide sclerotherapy
to the area of the [**Month/Day (2) **] leak. Exam showed persistent leak with a
connection between the right hepatic duct and intra-abdominal
fluid collection. Sclerotherapy of the abdominal cavity with 200
mg of Doxycycline injected via the in situ JP drain was
performed. In addition, he underewnt placement and upsizing of
the previous biliary drain with a new 12 French
internal-external modified biliary catheter. He was receiving
Unasyn at this time which was continued. The leak persisted
following this intervention and the patient was then scheduled
for a Right hepatic resection.
Patient underwent surgery on [**2135-11-10**] with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. It
was decided at the time of operation to not proceed with the
lobectomy due to findings of a leak in the middle of the base of
the cavity. The transhepatic catheter was visualized. The leak
opening was ~ 2-3 mm. At that time a Roux-en-Y
hepaticojejunostomy using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 1968**] technique was
performed. A pigtail catheter was placed into the Roux-en-Y.
Traction placed on the transhepatic catheter and this traction
was used to pull the Roux-en-Y loop up over the leaking area in
the base of the resection cavity. This was then placed on
significant tension and sutured to the skin using interrupted
3-0 nylon sutures. The Roux-en-Y appeared to be snug up against
the area of the leak. Two [**Doctor Last Name 406**] drains were also placed at the
time of surgery. Please see the operative note for further
details. Post op the drain remianed with bilious fluid. Alk phos
trended down from 700 to the 258. On [**11-12**] [**Month/Year (2) **] was noted in the
JP. On [**11-17**] a tube cholangiogram was done revealing a patent
biliary catheter with pigtail loop formed in the jejunum loop
and a small leak noted at the jejunal catheter biliary
anastomosis laterally. An ERCP was performed on [**11-21**]. This
noted extravasation of contrast into the right main hepatic
duct. A Biliary stent was placed into the left hepatic duct to
bypass the [**Month/Year (2) **] leak. Post procedure amylase and lipase were
normal. The amount of bilious drainage via the JP decreased.
Vancomycin was added for erythema along the incision. The
incision required opening at two spots near the right of center
and the lateral side. 2x2 dressings were done [**Hospital1 **]. A culture of
the wound revealed 3+PMNs and sparse growth of enterococcus
resistent to ampi/pcn and sensitive to vanco. Vanco was changed
to zosyn. Zosyn was eventually changed to cipro was continued
[**Hospital1 **]. The erythema resolved.
Pain was initially managed with an epidural. He experienced
bilateral shoulder and upper back pain. Methadone and iv pain
medication was used. The epidural was eventually removed and
IV/po dilaudid were resumed with improved pain relief. Diet was
advanced and tolerated. Seroquel was added by Psychiatry to help
with problems falling asleep. This was stopped after a brief
period and remeron was resumed at 60mg.
He was ambulatory, vital signs were stable. The PTC was capped 1
day after the ERCP. The JP output averaged ~ 1300cc. IV fluid
replacements were not resumed. Oral fluid intake was encouraged,
but he was not to force/increase fluids to replace JP outputs.
A KUB was done on [**11-25**] to evaluate the biliary stent placement
given that the JP drainage had increased. This appeared as
though the stent had migrated out of the left intrahepatic
biliary duct into the common [**Month/Year (2) **] duct. Therefore, an ERCP was
done on [**11-28**]. This showed evidence of a previous
sphincterotomy noted in the major papilla. A plastic stent was
noted in the major papilla. The stent was removed. Cannulation
of the biliary duct was successful and deep with a balloon
catheter using a free-hand technique. Extravasation of contrast
consistent with post operative [**Month/Year (2) **] leak was noted at the right
main hepatic duct. The CBD was non dilated with no filling
defects. The left intrahepatic ducts were normal.
A 10 cm by 10 Fr double pig tail biliary stent was placed
successfully in the left main hepatic duct.
A 14 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed
successfully in the left main hepatic duct.
A 16 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed
successfully in the right main hepatic duct.
Two 10 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stents were placed
successfully in the middle third of the common [**Doctor Last Name **] duct.
Amylase and lipase were normal post ERCP and his diet was
advanced. This was tolerated. Post procedure day 1, the JP
drainage decreased, but this increased to 1500cc on post
procedure day 2. A KUB was done to assess for stent migration.
He was discharged with vital signs stable. He was ambulatory.
VNA services were arranged for dressing changes.
On [**12-1**] a HIDA scan was done to evaluated direction of biliary
leak. Biliary leak, confirmed tracer activity within surgical
drain within 10 minutes
of scan initiation. Unable to distinguish persistent tracer
acivity around
segement IV as within the Roux loop or adjacent to anastomosis.
Tracer activity within the duodenum suggests patent CBD,
although the CBD was not visualized on current study.
He was discharged home. He was independent in self emptying the
JP. Follow up appointment was scheduled for the following week
with Dr. [**Last Name (STitle) **].
Medications on Admission:
cipro 500', [**Last Name (un) **] 300", protonix 40", sucralfate 1"", aldactone
25', Colchicine 0.6'''
Discharge Medications:
1. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO q 3 hours as
needed for pain.
Disp:*42 Tablet(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*42 Tablet(s)* Refills:*0*
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal q
day as needed as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
6. Methadone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day) as needed for pain for 10 days.
Disp:*60 Tablet(s)* Refills:*0*
7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*180 Tablet(s)* Refills:*0*
8. Mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*0*
11. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary leak s/p segment IV resection
depression
malnutrition
Discharge Condition:
good
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] Dr [**Last Name (STitle) **] if you experience fever > 101,
chills, nausea, vomiting, worsening of pain, large changes in
the color, consistency or foul smell to the drainage.
Measure and record Drainage from each tube daily. Bring record
of drainage with you to Dr [**Last Name (STitle) 4727**] clinic visit.
You will be replacing the PTC drain output at cc per cc.
Followup Instructions:
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], psychiatrisit, on [**12-15**]
at 9am in the [**Hospital Unit Name **], [**Apartment Address(1) **], on the [**Hospital Ward Name 516**] of
[**Hospital1 **]. Call [**Telephone/Fax (1) 1387**] with questions or if
you need directions.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-12-7**] at 3:40pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2135-12-2**]
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32,253
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31419
|
Discharge summary
|
report
|
Admission Date: [**2137-7-7**] Discharge Date: [**2137-8-1**]
Date of Birth: [**2058-9-1**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Decreased responsiveness, L thalamic/BG bleed
Major Surgical or Invasive Procedure:
PEG placement
Tracheostomy
History of Present Illness:
78 year old RH male with a history of COPD, asthma, CHF, and
Afib who this morning at 7am, got up to go use the bedside
urinal while his wife and downstairs and she heard a grunting
sound. She went upstairs and found him on the ground. When she
told him she was going to call 911, he was mumbling "no, no" and
pointing to the bed. Since she couldn't get him into bed, she
went to get her two sons at home. The sons got to the bedroom
and noticed that he wasn't moving his right side and had a right
facial droop.
.
He was taken to [**Hospital **] Hospital where on CT scan he was found
to have a 3 cm left basal ganglia bleed with intraventricular
hemorrhage. His INR was found to be 2.4 and he was given 2
units of FFP and Vitamin K 10mg. He was combative and not
responding to questions, so he was intubated and transferred to
[**Hospital1 18**]. At arrival here, repeat head CT showed a 4.5 cm basal
ganglia bleed with intraventricular hemorrhage and small amount
of midline shift. His INR is 1.8.
Past Medical History:
Chronic asthma
CHF
Afib on Coumadin (INR 2 weeks ago was 2.4)
bilateral cataracts
COPD
"nervousness."
PCP is [**Name9 (PRE) **] [**Name9 (PRE) 73983**]
Social History:
Used to work in a leather factory, smoked 3ppd x 45 years but
quit 12 years ago, no alcohol or other drug use.
Family History:
Mom fractured her leg, was hospitalized and passed away at the
hospital. Dad had a stroke at 85 and passed away a few years
later.
Physical Exam:
Vitals: T AF BP 129/74 HR 71 RR 14 100%,
intubated
General: Intubated and sedated, central obesity
CV: Irregularly irregular, no murmurs
Pulm: Fine crackles bilaterally
Abdomen: Obese, NABS
Extremities: Pitting edema to knees
.
Neuro: Does not follows opens, opens eyes intermittently,
surgical pupils bilaterally, corneals intact bilaterally,
suppreses OCR, no blink with visual threat, facial movements
assymetric with right lid lag and blunted right NLF, gag intact,
cough intact. Good strength with left arm and leg (at least
[**4-18**]), right arm flaccid, right lower leg with some purposeful
withdrawal to pain. Reflexes - none eliced at patella and
achilles, none at right arm, 1+ biceps and brachiradialis of
left arm. Right toe equivocal, left downgoing.
Pertinent Results:
Admission Labs:
[**2137-7-7**] 11:35AM URINE RBC-[**6-23**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2137-7-7**] 11:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2137-7-7**] 11:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2137-7-7**] 11:35AM PT-19.3* PTT-27.8 INR(PT)-1.8*
[**2137-7-7**] 11:35AM PLT COUNT-160
[**2137-7-7**] 11:35AM NEUTS-85.8* LYMPHS-10.3* MONOS-3.6 EOS-0.2
BASOS-0.2
[**2137-7-7**] 11:35AM WBC-7.3 RBC-4.25* HGB-14.9 HCT-42.0 MCV-99*
MCH-35.0* MCHC-35.4* RDW-14.2
[**2137-7-7**] 11:35AM CALCIUM-9.0 PHOSPHATE-2.3* MAGNESIUM-2.4
[**2137-7-7**] 11:35AM CK-MB-6 cTropnT-0.02* CK(CPK)-142
[**2137-7-7**] 11:35AM GLUCOSE-143* UREA N-13 CREAT-1.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-30 ANION GAP-12
Head CT [**7-7**]:
CT HEAD WITHOUT CONTRAST: There is a large hyperdense focus
within the left thalamus consistent with acute hemorrhage with
associated edema. This focus measures approximately 4.4 x 3.5
cm. In addition, there is hyperdense material within the
occipital horns of the lateral ventricles, left greater than
right consistent with hemorrhage.
Bilateral maxillary sinus mucosal thickening. Fluid within the
ethmoid cells. Mucosal thickening of the sphenoid sinuses.
IMPRESSION:
1. 4.4 x 3.5 cm left thalamic hemorrhage.
2. Intraventricular hemorrhage occupying the occipital horns of
the lateral ventricles, left greater than right.
Repeat Head CT [**7-8**]:
FINDINGS: There is redemonstration of the large hemorrhage
situated within the left lentiform nucleus, left internal
capsule and thalamus with
intraventricular hemorrhage, largely within the left lateral
ventricle but
also layering in the right occipital [**Doctor Last Name 534**]. There is a moderate
amount of
edema surrounding the hemorrhage within the basal ganglia
region. Overall, there has been negligible interval change in
the appearance of the scan compared to the study obtained
approximately 13 hours prior to the present study.
CONCLUSION: Stable, abnormal study as noted above.
CT C spine [**7-7**]:
1) No evidence of acute cervical spine fracture.
2) Findings consistent with DISH (diffuse idiopathic skeletal
hyperostosis).
3) Two well-corticated fragments posterior to the spinous
processes of C6 and C7 likely relate to old trauma or additional
enthesopathy.
4) Hemorrhage within the occipital horns of the lateral
ventricles better demonstrated on the prior head CT.
EEG [**7-16**]: Abnormal portable EEG due to the persistently slow
background. This indicates a widespread encephalopathy.
Medications,
metabolic disturbances, and infection are among the most common
causes.
Hypoxia and low flow states are also possible explanations.
There were
no areas of prominent focal slowing, but encephalopathies may
mask focal
findings. There were no epileptiform features.
NCHCT [**7-16**]: There is persistence of a large hemorrhage situated
within the left lentiform nucleus, left internal capsule, and
thalamus with intraventricular spread layering in the occipital
horns bilaterally. Overall there is likely more edema compared
to [**7-8**] and approximately 7-mm of rightward subfalcine
herniation slightly also larger compared to prior. No new
intracranial hemorrhage is identified and no new abnormal
extra-axial fluid collection is seen.
Surrounding osseous structures are unremarkable. Mild ethmoid
and maxillary sinus mucosal thickening with more extensive
sphenoid sinus thickening is noted. There is persistent near
complete opacification of the mastoid air cells bilaterally. The
findings are likely inflammatory in origin.
IMPRESSION: Persistent left basal ganglia/thalamic hemorrhage
with slightly increased edema and rightward subfalcine
herniation.
RUQ U/S [**7-20**]:
1. Limited right upper quadrant ultrasound demonstrates no
evidence of acute cholecystitis. There is a moderate amount of
sludge within the gallbladder.
2. Large cystic structure within the right kidney incompletely
evaluated on this examination.
ECHO [**7-22**]: Preserved global biventricular systolic function. No
definite
cardiac source of embolism, valvular pathology, or pathologic
flow
identified.
CXR [**7-23**]: Stable chest findings in patient with tracheostomy and
status post ganglion hemorrhage.
CT Sinus [**7-23**]: Compared with the prior CT scan of [**7-16**],
there is now only moderate left and minimal right-sided sphenoid
air cell mucosal thickening. There is very minimal mucosal
thickening along the medial wall of the left maxillary sinus.
The ethmoid and frontal sinuses are normally pneumatized.
However, there remains essentially total loss of aeration of the
left mastoid sinus complex, including the left mastoid antrum,
aditus ad antrum, and left epitympanic recess. The right mastoid
sinus complex is incompletely encompassed on the available axial
scans. There appears to be slightly less opacification at this
time in this locale. The right epitympanic recess as well as
aditus ad antrum and right mastoid antrum appeared to be
normally aerated. Please note that the reconstructed images do
not encompass the mastoid sinuses, as the requested examination
was a CT scan of the paranasal sinuses.
CONCLUSION: Somewhat less extensive paranasal sinus mucosal
thickening. Please see above report with regard to the mastoid
sinuses.
COMMENT: Of course, this study does not constitute an optimal
protocol for brain imaging, but there does appear to be
reimaging of the large left basal ganglia region hemorrhage,
which has likely undergone some reduction in density due to the
evolution of the blood products over time.
Brief Hospital Course:
Mr. [**Known lastname 40503**] is a 78 year old man who presented with a left
thalamic and basal ganglia hemorrhage. His hospital course by
problem is as follows:
1. Neuro: ICH. The mechanism was thought to be supratherapeutic
INR. Pt. was admitted to the Neuro ICU. Head CT was repeated on
[**7-8**] and the hemorrhage was stable. INR was monitored Q6H for
the first 48 hours, and pt. received several more units of FFP
to keep INR < 1.4, along with 2 more doses of Vitamin K. His
sedation was weaned off on HOD #4. His blood pressure was
controlled with goal MAP < 130, with PO Metoprolol and IV
Metoprolol and Hydralazine PRN. His improvement was slow but
steady. A repeat HCT was done on [**7-30**] which showed improvement.
On exam he had persistent aphasia, inattentivenss and did not
follow commands. He was able to move both leads and the L arm
spontaneously but had persistent R arm weakness.
2. ID: Pt. developed a fever on HOD #2. Sputum culture grew GNR
and GPC in P&C, and pt. was started on Cipro, Vanc, and Zosyn
for broad coverage for ventilator associated pneumonia. This
was tailored to Zosyn as the cultures grew beta-lactamase
producing H. flu. He completed a 9-day course of Zosyn; however,
he continued to have fevers. ID was consulted, who felt that his
persistent fevers were initially due to a drug fever due to
Zosyn. He had mild fevers for two days after the Zosyn was
stopped, but none after that. He had no further localizing
symptoms or culture results. He then developed another fever on
[**7-27**] and was recultured. Zosyn and vanc were restarted and his
cultures grew staph and GNR from the trach. He was treated for
tracheitis and will complete a 7 day course of antibiotics on
[**8-2**].
3. CV: Atrial fibrillation. This is long-standing for the pt. He
was rate controlled with PO metoprolol. He was maintained with
MAP < 130. Initially, his INR was reversed and all
anti-coagulation was held. After 10 days, ASA 81 was started.
Then after 16 days, and after discussing carefully with his
family the risks and benefits, warfarin was restarted on his
family's request. His INR on discharge was 1.4 and will require
continued monitoring every 2-3 days until he has a stable goal
INR of [**2-16**].
4. Pulmonary: VAP. He was treated for VAP as above. He
initially had difficulty weaning from vent given fluid overload
from FFP and from PNA, and was thus given a tracheostomy on [**7-14**].
He was eventually extubated and was doing well on a 40% trach
mask.
5. GI: An NG Tube was initially placed, and he was started on
tube feeds. He received a PEG on [**7-14**], and tube feeds continued.
He was maintained on an H2 blocker.
6. Endo: He was covered with a RISS.
7. CODE: Full
8. Dispo: To rehab.
Medications on Admission:
Protonix, Singulair, Albuterol, Atrovent, Lasix, Diltiazem CD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Fever > 100.4.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection [**Hospital1 **] (2 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed.
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
14. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
17. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 1 days.
18. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Stroke
Hypertension
Dyslipidemia
Diabetes
Atrail Fibrillation
Pneumonia
Chronic Obstructive Pulmonary Disease
Heart Failure
Trachitis
Discharge Condition:
Stable: on discharge he remained aphasic, not following comands
but moving his L arm and leg spontaneously
Discharge Instructions:
1. PLEASE CHECK INR EVERY 2-3 DAYS UNTIL STABLE AT GOAL [**2-16**]
2. PLEASE STOP VANCO AND ZOSYN ON [**8-2**] (7 day course)
3. Please take all medications as prescribed
4. Please keep all appointments as scheduled
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2137-10-8**] 3:30
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"721.8",
"428.0",
"496",
"E930.0",
"V58.61",
"401.9",
"286.9",
"431",
"493.90",
"780.6",
"427.31",
"518.81",
"482.2",
"464.10",
"041.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"31.1",
"38.93",
"96.6",
"96.72",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
12890, 12969
|
8405, 11148
|
358, 386
|
13146, 13254
|
2700, 2700
|
13519, 13769
|
1740, 1874
|
11260, 12867
|
12990, 13125
|
11174, 11237
|
13278, 13496
|
1889, 2681
|
273, 320
|
414, 1421
|
2716, 8382
|
1443, 1596
|
1612, 1724
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,384
| 127,610
|
34580
|
Discharge summary
|
report
|
Admission Date: [**2130-8-1**] Discharge Date: [**2130-8-7**]
Date of Birth: [**2076-6-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2130-8-1**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to Ramus, SVG to lPDA)
History of Present Illness:
Mr. [**Known lastname 4887**] is a 54 yo male with known CAD who presented to OSH ED
with chest pain. Pain initially relieved with NTG but then
returned. He was brought to for a cardiac cath which revealed
left main and three vessel disease. He was then transferred to
[**Hospital1 18**] for surgical intervention.
Past Medical History:
Coronary Atery Disease s/p Stents x 2 [**2126**], Hypertension,
Hypercholesterolemia, Gastroesophageal reflux disease,
Migraines, Cervical disc disease
Social History:
Denies tobacoo use. Admits to 7 ETOH drinks/wk.
Family History:
+Mother and Father died from CAD
Physical Exam:
VS: 80 18 112/71 8736kg
Gen: WDWN male in NAD, lying in bed
Skin: Unremarkable
HEENT: PERRL, EOMI, Anicteric
Neck: Supple, FROM, -carotid bruits
Chest: CTAB
Heart: RRR
Abd: Soft, NT/NT +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**8-2**] Echo: Pre Bypass: The left atrium is mildly dilated and
elongated. No spontaneous echo contrast is seen in the left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. No mitral regurgitation is seen. Post
Bypass: Patient is Apaced on no drips. Perserved biventricuar
function. LVEF 55%. Aortic contours intact. MR is trace, TR is
unchanged. Remaining exam is unchanged. All findings discussed
with surgeons at the time of the exam.
[**2130-8-7**] 09:10AM BLOOD Hct-27.9*
[**2130-8-5**] 07:30AM BLOOD WBC-7.8 RBC-2.66* Hgb-8.1* Hct-23.7*
MCV-89 MCH-30.6 MCHC-34.2 RDW-12.6 Plt Ct-249
[**2130-8-2**] 03:30PM BLOOD PT-13.5* PTT-27.6 INR(PT)-1.2*
[**2130-8-5**] 07:30AM BLOOD Glucose-107* UreaN-17 Creat-0.9 Na-136
K-4.3 Cl-98 HCO3-28 AnGap-14
[**2130-8-1**] 11:00PM BLOOD ALT-26 AST-20 LD(LDH)-143 CK(CPK)-107
AlkPhos-59 TotBili-0.3
[**2130-8-3**] 03:07AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9
[**Known lastname **],[**Known firstname **] E [**Medical Record Number 79382**] M 54 [**2076-6-17**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2130-8-4**] 9:59
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2130-8-4**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79383**]
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
54 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval for pneumothorax s/p chest tube removal
Provisional Findings Impression: LCpc FRI [**2130-8-4**] 12:49 PM
Since yesterday, left chest tube and mediastinal drain were
removed. There is
no pneumothorax. Bibasilar atelectasis decreased. There is no
volume overload.
Final Report
CHEST PORTABLE AP:
REASON FOR EXAM: 54 y/o man s/p CABG. R/O pneumothorax s/p chest
tube removal.
Since yesterday, left chest tube and mediastinal drain were
removed. There is
no pneumothorax. Bibasilar atelectasis decreased. There is no
volume overload.
Mild right minor fissural thickening is probably due to fluid.
No other
change.
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) 3891**]
Approved: FRI [**2130-8-4**] 2:30 PM
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 4887**] was transferred from OSH due
to his coronary artery disease. He was appropriately worked up
prior to surgery and was brought to the operating room on [**8-2**]
where he received a coronary artery bypass graft x 4. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Later that day he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he
appeared to be doing well and was transferred to the telemetry
floor for further care. His chest tubes and epicardial pacing
wires were removed per protocol. The remainder of his post-op
course was uneventful and he worked with physical therapy for
strength and mobility. On post-op day 5 he was discharged home
with VNA services.
Medications on Admission:
Aspirin 325mg qd, Zetia 10mg qd, Lisinopril 10mg qd, Toprol XL
50mg qd, Prilosec 20mg qd, Zocor 80 mg qd, NTG, Percocet prn,
Plavix 300mg on [**8-1**]
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. 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. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): total
dose 75mg a day .
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Atery Disease s/p Coronary Artery Bypass Graft x 4
PMH: s/p Stents x 2 [**2126**], Hypertension, Hypercholesterolemia,
Gastroesophageal reflux disease, Migraines, Cervical disc
disease
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 8579**] in [**1-22**] weeks
Dr. [**Last Name (STitle) 7962**] in [**12-21**] weeks
Wound check [**Hospital Ward Name **] 6 - please schedule with RN
Completed by:[**2130-8-7**]
|
[
"413.9",
"530.81",
"722.91",
"414.01",
"346.90",
"V45.82",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"39.64",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6427, 6476
|
4097, 4952
|
330, 433
|
6713, 6719
|
1373, 3072
|
7230, 7476
|
1036, 1070
|
5153, 6404
|
3112, 3137
|
6497, 6692
|
4978, 5130
|
6743, 7207
|
1085, 1354
|
280, 292
|
3169, 4074
|
461, 777
|
799, 955
|
971, 1020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,195
| 164,990
|
1123
|
Discharge summary
|
report
|
Admission Date: [**2136-4-18**] Discharge Date: [**2136-4-23**]
Date of Birth: [**2067-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 4679**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2136-4-18**]
1. Left thoracotomy and left upper lobectomy with
bronchoplasty.
2. Buttressing of bronchial closure with intercostal
muscle.
3. Therapeutic bronchoscopy.
History of Present Illness:
Mr. [**Known lastname 7228**] is a 68 year old male with history of
stage III colon ca s/p LAR and adjuvant chemotherapy in [**2128**].
Patient was found to have metastatic disease to LUL associated
with LUL collapse. It's unclear if the consolidation of his LUL
is all tumor burden or combination of tumor with persistent
collapsed lung. The patient was last seen [**2136-3-1**] for eval of
his
LUL tumor, went for a bone marrow biopsy/heme-onc eval and
returns today to finalize plans for a LUL sleeve lobectomy. His
heme eval indicates lymphoplasmocytic lymphoma and there is no
contraindication for him to proceed with the planned surgery.
Currently, he denies SOB, has minimal DOE, no cough,hemoptysis,
chest or abd pain, no new bone pain or HA. Weight is stable. He
presents now for surgical resection.
Past Medical History:
--rectosigmoid cancer (T3 N2)-s/p LAR and adjuvant chemo in [**2128**]
now with recurrent metastatic lesion to LUL of lung
--obstructive uropathy s/p suprapubic catheter
--chronic anemia
--diverticulitis
--left inguinal hernia repair-[**2116**]
Social History:
Lives alone, works part-time as an attorney. No tobacco, etoh
or illicits.
Family History:
Sister deceased age 70 from breast cancer. No known fhx of
colon cancer.
Physical Exam:
Temp 98 HR 90 BP 135/70 RR 18 O2 sat 98% RA
Gen: cachexic male, pale, NAD
Neck: no [**Doctor First Name **]
Chest: clear A+P, scoliosis
Cor: RRR no murmurs
Abd: soft, nontender, suprapubic tube in, no masses
Ext: no edema
Pertinent Results:
[**2136-4-18**] 03:20PM WBC-11.9* RBC-3.62* HGB-9.1* HCT-29.4*
MCV-81* MCH-25.0* MCHC-30.9* RDW-18.6*
[**2136-4-18**] 03:20PM PLT COUNT-406
[**2136-4-18**] 03:20PM GLUCOSE-110* UREA N-21* CREAT-0.7 SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2136-4-18**] 03:20PM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-1.7
[**2136-4-21**] CXR :
1) Small left apical pneumothorax, slightly larger than one day
earlier.
Please see comment. Left hemithorax volume loss, unchanged.
2) Osteotomy vs fracture left 6th rib posteriorly.
3) Small amount of subcutaneous emphysema anterior to the
anterior edge of the
hemidiaphragm, newly visible.
Brief Hospital Course:
Mr. [**Known lastname 7228**] was admitted to the hospital and taken to the Operating
Room where he underwent a left thoracotomy with left upper
lobectomy. Please see formal Op note for details. He tolerated
the procedure well and returned to the PACU in stable condition.
He maintained stable hemodynamics and his pain was well
controlled with an epidural catheter.
Following transfer to the Surgical floor he continued to make
good progress. His chest tubes were draining minimally, without
air leak and were removed on post op day # 2. His epidural
catheter was also removed and his pain was controlled with
standing Tylenol and occasional Oxycodone. He was up and
walking initially with Physical Therapy and eventually he was
ambulating independently. He remained free of any pulmonary
complications post op.
His narcotic pain meds were minimized as he developed
constipation post op, requiring Dulcolax and magnesium citrate
which were effective. He was tolerating a regular diet without
difficulty and MiraLax was added to his regime. After an
uncomplicated recovery he was discharged to home on [**2136-4-23**] and
will follow up in 2 weeks in the Thoracic Clinic.
Medications on Admission:
Senna prn, Colace prn, Vit D 50K qweek.
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
5. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
6. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2)
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic colon cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 1000 mg every 6 hours for pain but if you need
something stronger take Oxycodone.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2136-5-10**] at 9:00 AM
With: [**Known firstname **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2136-5-15**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2136-4-23**]
|
[
"200.10",
"197.0",
"600.01",
"564.00",
"788.20",
"V10.05",
"285.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"03.90",
"32.49"
] |
icd9pcs
|
[
[
[]
]
] |
4645, 4651
|
2731, 3913
|
312, 493
|
4720, 4720
|
2050, 2708
|
6368, 7178
|
1710, 1785
|
4004, 4622
|
4672, 4699
|
3939, 3981
|
4871, 6345
|
1800, 2031
|
269, 274
|
521, 1332
|
4735, 4847
|
1354, 1600
|
1616, 1694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,404
| 154,992
|
7503
|
Discharge summary
|
report
|
Admission Date: [**2127-3-22**] Discharge Date: [**2127-3-25**]
Date of Birth: Sex: M
Service: Cardiac Surgery
BRIEF HISTORY: This is a 58-year-old male with a history of
coronary artery disease, hypertension, hypercholesterolemia,
non-insulin dependent-diabetes mellitus, and obesity, who
presented with chest pain associated with episodes of renal
colic. During workup, he was found to have severe left main
disease following catheterization. An intra-aortic balloon
pump was placed, although the patient was on the Medicine
Cardiology service, and he was taken to the operating room on
the morning of [**2127-3-25**].
This is a 58-year-old man with unstable angina, who underwent
coronary artery bypass grafting on the morning of [**2127-3-26**]. Please refer to the operative report in detail in
regards to this procedure.
The operation went very well. Approximately 10 minutes after
arrival to the Intensive Care Unit, the patient had a sudden
cardiac arrest and underwent
closed followed by open cardiac massage, and was taken
emergently back to the operating room. Please refer to the
second operative report for the details of this procedure.
Briefly, the patient was placed on cardiopulmonary bypass, and
was further resusciated. He was briefly separated from CPB,
but could not be maintained off bypass despite high doses of
inotropic agents and IABP. Because he was severely hypoxic, he
was not a candidate for a ventricular assist device.
The patient was unable to be successfully revived and was
pronounced dead in the operating room at 2:50 p.m. on
[**2127-3-25**]. The patient's family was notified, and an autopsy
is pending.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 12027**]
MEDQUIST36
D: [**2127-3-28**] 21:10
T: [**2127-3-29**] 10:27
JOB#: [**Job Number 27451**]
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10,881
| 177,423
|
23878
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 60907**]
Admission Date: [**2150-4-6**]
Discharge Date: [**2150-4-22**]
Date of Birth: [**2109-6-6**]
Sex: M
Service: TRA
ADMITTING DIAGNOSIS: Multiple trauma.
Mr. [**Known lastname 1557**] was a 40-year-old male who was brought into the
emergency room on the day of admission after a motorcycle
crash. He had been helmeted and crashes his motorcycle on the
highway. Subsequently, he stood up and was struck by an
oncoming car. This car did not stop at the scene, but
pedestrians phoned EMS. He was med flighted to the [**Hospital1 18**] and
en route became hypotensive and was intubated. Also en route,
he had angiocath decompression of his left chest, and he was
felt to have a pneumothorax.
On arrival to the trauma bay, his hemodynamics were unstable,
and he was tachycardic and hypotensive. He had bilateral
chest tubes placed. He had an obvious right femur deformity
and pelvic instability on exam. He had gross hematuria upon
placement of the Foley. He had his pelvis wrapped in a sheet
for stability, and with ongoing hemodynamic instability and
the requirement of blood transfusions and crystalloid, he had
a diagnostic peritoneal lavage done. This revealed no gross
blood, and white count and red count later came back at 156
and 62,500 respectively.
His chest x-ray revealed a right scapular fracture, left
clavicular fracture, multiple bilateral rib fractures, and
subcutaneous air. Pelvic fracture revealed an open-book
pelvis with a wide diastasis. Significant labs were that of a
hematocrit of 26.4, a lactate of 6.9, and a creatinine of
1.7.
After initial resuscitation and after interpretation of the
diagnostic peritoneal lavage as being negative, he was taken
to the angio suite, where he had bilateral internal pudendal
arteries and bilateral anterior gluteal arteries embolized
for active bleeding. He also had an aortogram of the arch to
rule out any aortic injury. He was brought to the ICU, where
he continued to be hemodynamically unstable requiring nearly
30 units of pack cells in total, and 22 units of plasma, and
22 units of platelets. His lactate remained elevated and his
blood pressure was still not stable. His abdomen had become
distended, and the following morning, he was taken for CT
scan. On CT scan, he had a gross amount of fluid in the
abdomen consistent with blood and was felt to be
extravasating from his spleen.
He was taken immediately to the operating room where
exploratory laparotomy was performed and a splenectomy done.
Also in the operating room, there was an external fixator
placed by orthopedics on his pelvis as well as his femur. He
stabilized to some degree after that, and was brought back to
the intensive care unit. His significant events from that
point included an inferior vena cava filter that was placed
on hospital day 3 for prophylaxis against the complications
of DVT. He had returned to the operating room on hospital day
#5 for internal fixation of his femur and pelvis. On hospital
day #6, he returned to the operating room for closure of his
abdomen.
Initially, his abdomen had been left open and secured with a
[**Location (un) 5701**] bag as he was too distended to be closed. From a
neurological standpoint, he was showing some evidence of
movement and had a CAT scan of his head that showed no
damage. His kidneys were starting to show evidence of
failure, and he had rhabdomyolysis with elevated CKs, which
was being treated with alkalinization of his urine.
On approximately hospital day #10, after attempts at
ventilator weaning had failed, decision was made to place a
percutaneous tracheostomy tube. After discussions with the
family and consent was obtained, this was attempted at the
bedside. This was complicated by mild hypoxia in conjunction
with hyperkalemia that led to a cardiac arrest. CPR was
initiated immediately, and he regained a rhythm and a blood
pressure. Subsequent to that event, his neurologic status
deteriorated, and he slowly showed worsening of brainstem
function. He was kept ventilated with a tracheostomy for the
days to follow.
His gastrointestinal system was intact for feeding purposes,
but he did have an elevated bilirubin in the mid portion of
his hospital course as high as 28. This was presumed to be
from his massive blood transfusion requirement. His bilirubin
came down, but later in his course after the cardiac arrest,
he started to have an elevation of his transaminases. On
consulting with cardiology and hepatology, it was felt that
this was secondary to right heart failure that had come about
after his cardiac arrest. They had no specific prescription
for this.
From an infectious disease standpoint, he had multiple
cultures taken for intermittent fevers throughout his
admission. He had blood cultures that grew out both coag-
negative Staph and later vancomycin-resistant Enterococcus.
This is treated initially with vancomycin until the
enterococcal species came back, and he was eventually changed
to linezolid. All lines were changed appropriately, and at
the time of discharge, those results are still pending.
On the weekend prior to his eventual expiration, he underwent
a MRI of his head and spine as his neurological condition was
not improving and there was some note of decreased rectal
tone to go alone with the spiking fevers that he was having.
There was some concern that he had hypoxic brain injury as
well as a small concern that he could have a spinal cord
abscess causing neurological dysfunction and fever. While in
the MRI scanner, despite frequent suctioning, he had mild
episodes of hypoxia and again in the setting of some mild
hyperkalemia, experienced a second cardiac arrest. Of note,
he had been undergoing daily hemodialysis around this time to
combat this hyperkalemia. This arrest lasted approximately 3
minutes, and he was stabilized and again brought to the
intensive care unit.
He subsequently had worsening of his neurologic status and
neurology became involved. Because of the arrest, the MRI of
the head was never completed. On neurological exam, he
eventually lost nearly all brainstem reflexes including cold
calorics, corneals, and pupillary reflexes. He had an EEG
done, which showed severe diffuse encephalopathy, but did not
necessarily fulfill the criteria for lack of cerebral
activity.
On the morning of his eventual demise, he underwent an apnea
test, which he passed. He, after approximately 1.5 minutes
off the ventilator, did start to have spontaneous
respirations. Therefore, the criteria for brain death was not
met. Subsequent to this, a family meeting took place after
consulting with nephrology between the family, the ICU team,
and the trauma team. After long discussion as to his current
condition and grave prognosis, the family decided to pursue
comfort measures only and withdrew ventilator support. He
expired shortly thereafter. The medical examiner was
contact[**Name (NI) **] and accepted the case for postmortem examination.
DATE OF EXPIRATION: [**2150-4-22**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern1) 60908**]
MEDQUIST36
D: [**2150-4-22**] 16:43:22
T: [**2150-4-23**] 08:32:59
Job#: [**Job Number 60909**]
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icd9pcs
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[
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181, 7285
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,854
| 136,158
|
32054
|
Discharge summary
|
report
|
Admission Date: [**2185-8-14**] Discharge Date: [**2185-8-22**]
Date of Birth: [**2115-11-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD with variceal banding
History of Present Illness:
69 year old male with esophageal varices s/p banding presenting
to OSH from home after 3 episodes hemetemesis and epistaxis.
Taken to OSH ED, pressures 40/20 started on dopamine and NS
boluses. HCT 25, INR 1.6 Given 2 units blood and 2 units FFP,
triple lumen femoral line placed. [**Location (un) 7622**] to [**Hospital1 18**], Dopamine
stopped en route. HCT at [**Hospital1 18**] 23, started on octreotide gtt.
Patient arrived without complaints [**Name8 (MD) **] RN and ED staff, but had
500 cc darkly blood emesis in the ED and was intubated. RT
suctioned signficant amount of dark bloody fluid from mouth.
Liver team contact[**Name (NI) **] and coming in to see patient. No further
blood products administered, patient transferred to MICU for
endoscopy.
.
Transferred from MICU after GIB
.
HPI upon reaching floor: The [**Hospital **] medical history and hospital
course were reviewed. Briefly, this is a 69M with esophageal
varices s/p banding presenting to OSH from home after 3 episodes
hemetemesis and epistaxis begining on the morning of [**2185-8-14**]. He
was severely hypotensive, put on pressors, and given blood and
FFP before being medflighted to [**Hospital1 18**]. Here, he was intubated
for airway protection during EGD [**8-14**], which showed a variceal
bleed and was rebanded. He was extubated successfully [**8-16**]. He
has received blood transfusions to Hct goal of 28. S/p TIPS he
received IV PPI and octreotide drip. His Hct has remained stable
and the patient has not had recent episodes of lightheadedness
or shortness of breath. He states his chronic angina is a sharp
pain in the right chest as well as in the inner left arms
slightly above the elbow. He occasionally takes nitro for this
when it gets bad, ~once a week on average, and this helps. He
states he has not had a stress test for eight years.
.
On the floor he complains of mild SOB for one day, continued
melena yesterday. He denies CP, dizziness, HA, palpitations,
shoulder or jaw pain, hematochezia.
Past Medical History:
PMH:
-Cirrhosis-unclear etiology, no history of etoh or hepatitis.
-portal hypertension
-esophageal varices: s/p UGIB X 2. Banding twice (8 bands then
18 bands placed). Last EGD [**2185-7-26**] with extensive varices
beginning inside cricopharyngeus and extending all the way to
the GE junction. No normal mucosa and some scarred areas with
new varices on top. In the stomach there were large varices in
the cardia. Mucosa of body and stomach with portal hypertensive
gastropathy worst from last endoscopy. No banding done at this
time.
-Diabetes mellitus
-Hypertension
-Rheumatic fever x 2 and a "rheumatic heart"
-CAD s/p MI--s/p 3v CABG at [**Hospital1 2025**] (confusion per wife re: 3v vs
1v). Patient with chronic stable angina since procedure.
-Kidney stones s/p penile urethra surgery to remove the stone
-Migraine headaches
-Asbestosis
.
Social History:
married, no children, no tob, etoh, drugs. retired pipe fitter
and was involved with asbestos removal. He lives in [**Location 730**], MA
with his wife.
Family History:
mother died of MI at age 70, father died of MI at age 70. Sister
died of TB.
Physical Exam:
MICU admission:
PE:
vitals:
general: intuabted, sedated, dry blood over nose and mouth
heent: PERRL, anicteric
neck: JVD not assessed
car: RRR no murmur
resp: coarse BS bilaterally-ant/lat
abd: s/nt/nd/nabs
ext: no edema
Skin: no jaundice
Pertinent Results:
Admission Labs:
[**2185-8-14**] 02:20AM PT-18.5* PTT-38.0* INR(PT)-1.7*
[**2185-8-14**] 02:20AM WBC-8.4 RBC-2.38* HGB-7.6* HCT-23.0* MCV-97
MCH-31.9 MCHC-33.0 RDW-16.0*
[**2185-8-14**] 02:20AM NEUTS-84.1* BANDS-0 LYMPHS-11.9* MONOS-3.6
EOS-0.3 BASOS-0
[**2185-8-14**] 02:20AM PLT SMR-LOW PLT COUNT-85*
[**2185-8-14**] 02:20AM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-1.9
[**2185-8-14**] 02:20AM GLUCOSE-226* UREA N-30* CREAT-1.1 SODIUM-140
POTASSIUM-5.3* CHLORIDE-110* TOTAL CO2-19* ANION GAP-16
[**2185-8-14**] 05:00AM FIBRINOGE-135*
[**2185-8-14**] 05:00AM ALBUMIN-2.4* CALCIUM-7.1* PHOSPHATE-2.9
MAGNESIUM-1.9
[**2185-8-14**] 05:00AM ALT(SGPT)-69* AST(SGOT)-115* LD(LDH)-247 ALK
PHOS-49 AMYLASE-98 TOT BILI-2.4*
[**2185-8-14**] 05:00AM LIPASE-27
[**2185-8-14**] 05:25AM TYPE-[**Last Name (un) **] PH-7.32*
[**2185-8-14**] 05:25AM LACTATE-3.6*
[**2185-8-14**] 05:25AM freeCa-0.95*
[**2185-8-14**] 08:30AM CK(CPK)-144
[**2185-8-14**] 08:30AM CK-MB-10 MB INDX-6.9* cTropnT-0.07*
[**2185-8-14**] 04:07PM CK(CPK)-198*
[**2185-8-14**] 04:07PM CK-MB-15* MB INDX-7.6* cTropnT-0.12*
[**2185-8-14**] 08:30AM UREA N-33* CREAT-1.1 SODIUM-139 POTASSIUM-5.0
CHLORIDE-110* TOTAL CO2-21* ANION GAP-13
[**2185-8-14**] 04:23PM GLUCOSE-128* LACTATE-2.1*
[**2185-8-14**] 04:23PM TYPE-ART TEMP-35.8 TIDAL VOL-450 PEEP-5 O2-50
PO2-193* PCO2-31* PH-7.46* TOTAL CO2-23 BASE XS-0
INTUBATED-INTUBATED
[**2185-8-14**] 08:09PM HCT-26.1*
.
Discharge Labs:
[**2185-8-22**] 12:40PM BLOOD WBC-5.0 RBC-3.25* Hgb-10.2* Hct-29.9*
MCV-92 MCH-31.4 MCHC-34.2 RDW-17.8* Plt Ct-55*
[**2185-8-22**] 12:40PM BLOOD Glucose-83 UreaN-24* Creat-1.2 Na-137
K-4.2 Cl-107 HCO3-25 AnGap-9
[**2185-8-22**] 05:10AM BLOOD ALT-62* AST-56* AlkPhos-64 TotBili-1.7*
[**2185-8-22**] 12:40PM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
.
Other labs:
[**2185-8-20**] 07:15AM BLOOD CK-MB-3 cTropnT-0.40*
[**2185-8-19**] 04:55AM BLOOD Triglyc-55 HDL-37 CHOL/HD-3.8 LDLcalc-92
LDLmeas-87
[**2185-8-15**] 02:23PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2185-8-15**] 02:23PM BLOOD Smooth-POSITIVE
[**2185-8-15**] 02:23PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2185-8-15**] 02:23PM BLOOD IgG-1720* IgA-702* IgM-74
SLA AUTOANTIBODY 3.7 0.0-20.0 U
[**2185-8-22**] 11:23AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
[**2185-8-22**] 11:23AM URINE Hours-RANDOM Creat-184 Na-41
HCV VIRAL LOAD (Final [**2185-8-17**]): HCV-RNA NOT DETECTED.
Blood Cultures [**2185-8-14**]: negative x 2
.
Imaging:
CHEST (PORTABLE AP) [**2185-8-14**] 3:17 AM
AP SUPINE CHEST: There is an endotracheal tube, which terminates
4.2 cm above the carina. The thoracic aorta is tortuous. Lung
volumes are low. There are extensive bilateral pleural plaques,
many of which are calcified; there is asymmetric pleural
thickening along the lateral left hemithorax. There is a patchy
opacity in the retrocardiac left lower lobe, primarily, as well
as more hazy opacity in the left mid lung.
There is no definite evidence of pneumothorax. The patient is
status post median sternotomy. Overall, the lungs have an
inhomogeneous appearance with many small patchy areas of opacity
bilaterally.
IMPRESSION:
1. Standard placement of endotracheal tube.
2. Extensive asbestos related pleural plaques. Asymmetric
pleural thickening and/or loculated fluid on the left --
although nonspecific, this raises concern for mesothelioma. A CT
of the chest is recommended to further assess these findings.
3. Patchy opacities throughout both lungs, but particularly in
the left lower lobe retrocardiac area and may be due to
infection, aspiration, and/or atelectasis
.
ECG: NSR at 71 bpm, normal axis, long QTc, TWF in aVL
.
TTE [**2185-8-16**]: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 60-70%) Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened 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. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
.
Chest CT [**2185-8-17**]:
1. Asbestos related pleural calcifications with a loculated
effusion noted at the left base. While no masses are identified,
further evaluation of the pleural fluid with direct sampling to
exclude mesothelioma may be helpful as clinically indicated.
15mm paraesophageal lymph node as described.
2. Extensive coronary artery atherosclerotic calcifications
status post CABG.
3. Cirrhotic liver with ascites.
.
CHEST (PA & LAT) [**2185-8-22**] 11:39 AM
TWO VIEWS OF THE CHEST: Bilateral pleural thickening and
calcification is not significantly changed since prior
radiographs. However, a prominent left pleural effusion with
asymmetric left pleural thickening suggests the possibility of
mesothelioma. The presence of minimal interstitial changes at
the bases of the lungs is also consistent with previous
asbestosis exposure. No significant change is identified since
the prior study, given difference in technique.
IMPRESSION: Pleural thickening/calcification and interstitial
changes are consistent with asbestos exposure and possible
asbestosis.
Moderate left pleural effusion/thickening with volume loss is
concerning for mesothelioma. Consider thoracentesis or PET-CT
for further assessment.
.
Transthoracic ECHO [**2185-8-22**]:
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve 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. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2185-8-16**],
the current study is superior in technical quality. The findings
are likely similar.
CLINICAL IMPLICATIONS:
Based on [**2184**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
A/P: 69 year old male with cirrhosis and esophageal varices
presenting with variceal bleed requiring endoscopic banding, and
asbestos-related lung injury.
.
# UGIB: variceal bleed, emergent endoscopy with banding in the
ICU. pt resuscitated with blood products (given at [**Hospital1 18**]: 4
prbcs, 2 plt, 1 FFP) to hct goal 28. given IV PPI and octreotide
drip for 48 hrs as well as 5 days of IV ceftriaxone. He was
stabilized and sent to the floor, though he continued to have
melena. He was started on nadalol 20 [**Hospital1 **] after 48 hrs for
secondary prevention. He did not require emergent TIPS, but was
scheduled for rebanding on [**8-27**].
.
# Resp F: pt was intubated for airway protection and procedure:
EGD. Extubated successfully [**8-16**]
.
#. Cirrhosis: with GIB and recent concern re: confusion per
wife. Ultrasound of liver: cirrhosis, patent veins. He was
continued on lactulose post procedure for expected hepatic
encephalopathy. Tolerated well. INR at baseline, tbili and LFTs
were at baseline or below.
.
# Hypotension: related to UGIB. Supported with fluid and blood
products as above, currently resolved.
.
#. CAD and rheumatic heart disease: pt w/ hx of MI and CABG. ASA
and heparin were held due to GIB. He was given nitro prn for
chronic stable angina. Troponins trended up most likely due to
demand ischemia given hypotension. Echocardiogram showed
preserved LV function and minimal valvular dysfunction and mild
pulmonary artery systolic hypertension. He was rate controlled
with Beta blocker. Cardiology was consulted for transplant
workup.
.
#. Asbestos Lung Injury - Chest xray and CT Chest showed lung
changes related to asbestos exposure. CXRs concerning for
mesothelioma, though CT less concerning as it showed no masses,
though the 15mm paraesophageal lymphnode and loculated pleural
effusion concerning. Final CXR read returned after patient
discharge and patient cancelled GI follow-up. Findings of the
radiology were communicated with the patient and the patient's
PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) **], MA and copies of the
radiology was sent to both the patient and Dr. [**Last Name (STitle) **]. A copy
of this discharge summary is also being sent to Dr. [**Last Name (STitle) **].
Per radiology, the patient may benefit from PET-CT or
thoracentesis. If PET-CT is done, pleuroscopy with biopsy may
be indicated. Per Dr. [**Last Name (STitle) **], Mr. [**Known lastname 75058**] is receiving close
follow up in his home town. He may benefit from follow up with
pulmonology.
.
#. DM: DM: RISS with fingersticks. Glipizide was held.
.
#. Code: Full (confirmed with wife). Wife states that patient
would never want to be a vegetable, but would want resuscitation
for reversible causes.
.
#. Communication: wife [**Name (NI) **] [**Name (NI) 75058**] [**Telephone/Fax (1) 75059**]. She will be
unable to physically get to the hospital to visit her husband
secondary to health, distance and car problems. Would like to be
called with updates.
Medications on Admission:
All: PCN
.
Medications:
nitro prn
Prilosec
Colace
Glipizide
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. 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*
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
TID (3 times a day) as needed.
Disp:*1 1* Refills:*0*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*3000 cc* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
upper GI bleed, s/p esophageal varices banding
.
Secondary:
Cirrhosis
protal HTN
esophageal varices
DM
HTN
Hx of rheumatic fever
CAD s/p MI and CABG in [**2160**]
Hx of kidney stones
Migraine headaches
Asbestosis
Discharge Condition:
Good. Hematocrit stable. No hematemasis. Taking PO.
Discharge Instructions:
You were seen at [**Hospital1 18**] for an upper GI bleed. You received an
upper endoscopy during which your bleeding esophageal varices
were banded. You were stabilized on the floor. You also
experienced injury to your heart while you were bleeding. You
will need to follow up with cardiology.
.
You should return to the ED or call your primary care provider
if you experience blood in your vomit, black tarry stools,
abdominal pain, worsening swelling in your belly, confusion,
fever greater than 101.4 degrees F, or any other symptoms that
concern you.
Followup Instructions:
You will need a repeat endoscopy. That will be scheduled with
Dr. [**Last Name (STitle) **] for Friday [**2185-8-26**]. You will also need follow up in
the liver clinic with Dr. [**Last Name (STitle) **]. That is being arranged and
you will be notified of the time and date of that appointment.
Please call [**Telephone/Fax (1) 2422**] this Thursday if you have not heard
from anyone regarding the need for repeat EGD this Friday.
.
Please follow up with Dr. [**Last Name (STitle) 73**] of cardiology on Tuesday
[**9-13**] at 11:20 AM at [**Hospital 23**] Clinic [**Location (un) 436**]
([**Telephone/Fax (1) 902**]). It is very important that you come to this
appointment. Please call if you need to cancel or reschedule
this appointment.
.
You should also follow up with your primary care physician in
the next 2-3 weeks.
|
[
"285.9",
"456.20",
"571.5",
"398.90",
"511.9",
"507.0",
"501",
"584.9",
"537.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"38.91",
"96.04",
"42.33",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
14566, 14572
|
10529, 13615
|
285, 313
|
14838, 14892
|
3752, 3752
|
15500, 16330
|
3399, 3477
|
13725, 14543
|
14593, 14817
|
13641, 13702
|
14916, 15477
|
5220, 5563
|
3492, 3733
|
10270, 10506
|
234, 247
|
341, 2341
|
3768, 5204
|
2363, 3213
|
3229, 3383
|
5575, 10247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,790
| 157,100
|
54680+59623
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-7-12**] Discharge Date: [**2113-7-18**]
Date of Birth: [**2034-2-3**] Sex: M
Service: MEDICINE
Allergies:
Novocain / ciprofloxacin
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Loose dark stools.
Major Surgical or Invasive Procedure:
[**2113-7-12**]: Upper endoscopy.
[**2113-7-13**]: Intubation for repeat upper endoscopy.
[**2113-7-13**]: Upper endoscopy with esophageal varices sclerotherapy.
History of Present Illness:
79 year old male with adenocarcinoma of colon s/p 11 cycles 5-FU
(last dose [**2113-7-8**]) who presented to OSH after experiencing 6
episodes 'dark chocolate pudding' stools last night. Developed
lightheadedness/generalized weakness this AM and went to
[**Hospital 1562**] Hospital where his hematocrit was 19.0. Tachy to 100s,
systolics of low 100s. Recevied 3U pRBCs prior to transfer to
[**Hospital1 18**] ED. Apparently underwent CT angio of abdomen at OSH which
showed no source of bleed. Patient denies history of GI bleed,
not on coumadin, denies other medical problems besides
adenocarcinoma.
His adenocarcinoma was diagnosed in [**Month (only) 956**] after his PCP
referred him for a CT scan. He has been following with his
Oncologist for Q2weekly chemotherapy, has tolerated chemo
generally well. Says it makes him fatigued/decreased appetite.
He has needed Qmonday and friday 1.5 L fluid infusions at his
oncologists office re: poor PO intake.
In the ED, initial VS were: 103 102/83 18 99% 2L
As per ED, rectal exam was positive for melena. NG tube returned
bright maroon contents which became pink after he got fluids. He
was type and screened, bolused PPI, and transferred to ICU. On
arrival to the MICU, patient's VS. HR 95 BP 114/67 SpO2 98% on
RA.
Past Medical History:
Colon ca: Dx [**1-/2113**], metastatic to liver, s/p 11 cycles 5-FU
q2wks, most recently given [**2113-7-8**].
Cataracts ([**2111**]).
Laparotomy for ileus (>10 years ago).
Social History:
He denies tobacco, denies EtOH, denies other drug use. Lives
with wife and step daughter. Retired [**Company 16410**] civilian
engineer.
Family History:
Mother had diabetes, father was healthy.
Physical Exam:
ADMISSION EXAM:
Vitals: 95 BP 114/67 SpO2 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur
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:
[**2113-7-12**] 05:20PM PT-14.9* PTT-27.7 INR(PT)-1.4*
[**2113-7-12**] 05:20PM PLT COUNT-107*
[**2113-7-12**] 05:20PM NEUTS-94.4* LYMPHS-4.0* MONOS-1.5* EOS-0
BASOS-0.1
[**2113-7-12**] 05:20PM WBC-22.7* RBC-2.88* HGB-9.1* HCT-27.3* MCV-95
MCH-31.7 MCHC-33.4 RDW-17.9*
[**2113-7-12**] 05:20PM ALBUMIN-2.8*
[**2113-7-12**] 05:20PM ALT(SGPT)-21 AST(SGOT)-74* ALK PHOS-290* TOT
BILI-0.8
[**2113-7-12**] 05:20PM estGFR-Using this
[**2113-7-12**] 05:20PM GLUCOSE-134* UREA N-46* CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-18* ANION GAP-12
[**2113-7-12**] 05:35PM LACTATE-2.2*
[**2113-7-12**] 10:43PM PLT COUNT-109*
[**2113-7-12**] 10:43PM WBC-20.1* RBC-2.49* HGB-8.0* HCT-23.2* MCV-93
MCH-32.0 MCHC-34.3 RDW-18.1*
[**2113-7-12**] 10:43PM CALCIUM-7.8* PHOSPHATE-2.9 MAGNESIUM-1.9
[**2113-7-12**] 10:43PM GLUCOSE-126* UREA N-43* CREAT-0.6 SODIUM-142
POTASSIUM-3.5 CHLORIDE-115* TOTAL CO2-19* ANION GAP-12
[**2113-7-12**] 11:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2113-7-12**] 11:17PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028
.
GI Endoscopy reports:
[**7-12**]:
Impression: moderate esophagitis
Grade II Varices at the lower third of the esophagus
Blood in the stomach body
Medium hiatal hernia
Normal mucosa in the duodenum
Mucosa suggestive of Barrett's esophagus
Otherwise normal EGD to third part of the duodenum
Recommendations: No clear source of upper GI bleed found.
Differentials include: distal esophagitis, esophageal varices or
Dieulafoy's lesion (since they can bleed intermittently) or
small bowel metastasis distal to third portion of duodenum.
Continue iv PPI drip tonight and change to po Prilosec 20 mg [**Hospital1 **]
tomorrow AM.
Start Octreotide drip and continue for 72 hours given grade II
esophageal varices and uncertainty if they are the cause of
bleeding.
Prophylaxis with Ceftriaxone 1 gm daily for 7 days.
Serial Hct.
Transfuse to keep hct around 25. Recommend against a higher hct
goal since that would worsen GI bleeding if indeed it is
variceal bleed.
Liquid diet tonight. Advance as tolerated tomorrow AM.
No need for NG tube.
Since, no clear source of bleeding found, it is possible that
the bleeding is secondary to small bowel metastasis. Recommend
MR enterography to evaluate for the same.
If re-bleeds, would consider repeat EGD and possible capsule
endoscopy.
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.
.
[**2113-7-13**] EGD:
Impression: Varices at the lower third of the esophagus
Esophageal stricture
Otherwise normal EGD to third part of the duodenum
Recommendations: -If rebleeds, will need to alert the liver
service for glue injection of varices
-Given no evidence of cirrhosis, change from ceftriaxone to
ciprofloxacin for a total course of 5 days for prophylaxis
-Will need repeat EGD with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks
-Nonurgent video swallow to evaluate the esophageal ring in
order to guide if further EGDs with banding device can be
attempted
-OK to stop PPI, but continue octreotide drip for now
-Two peripheral IV's at all times, serial Hcts with goal Hct 25
(avoid overtransfusion in setting of portal hypertension)
.
[**2113-7-12**] CT ABD: IMPRESSION: Limited assessment demonstrating
cecal mass, no active site of arterial extravasation,
cholelithiasis, splenic enlargement, and multiple liver
metastases. Splenic enlargement is worrisome for sequelae of
portal hypertension or an infiltrative process otherwise than
metastatic colon carcinoma. If there is concern for ongoing
bleeding, repeat exam could be performed.
.
[**2113-7-13**] ABD U/S: IMPRESSION:
1. Patent portal and hepatic veins with directionally
appropriate flow.
2. Heterogeneous hepatic echotexture compatible with metastatic
disease.
.
[**2113-7-13**] CXR: FINDINGS: No previous images. Cardiac silhouette
is within normal limits and there is no pulmonary vascular
congestion or pleural effusion. No discrete pneumonia. Central
catheter tip is somewhat difficult to see, though probably is in
the mid-to-lower SVC.
.
[**2113-7-17**] VIDEO SWALLOW: IMPRESSION: No evidence of aspiration,
penetration, or obstruction.
.
[**2113-7-17**] ECHO: IMPRESSION: No valvular vegetations seen. If
clinically indicated, a TEE would better exclude small
vegetations.
.
DISCHARGE LABS:
[**2113-7-18**] 06:00AM BLOOD WBC-9.9 RBC-3.19* Hgb-9.6* Hct-28.8*
MCV-90 MCH-30.1 MCHC-33.3 RDW-20.7* Plt Ct-147*
[**2113-7-15**] 04:52PM BLOOD Neuts-90.6* Lymphs-5.4* Monos-3.4 Eos-0.6
Baso-0.1
[**2113-7-17**] 06:00AM BLOOD PT-15.5* PTT-30.3 INR(PT)-1.5*
[**2113-7-13**] 01:27PM BLOOD Fibrino-308
[**2113-7-18**] 06:00AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-133
K-3.8 Cl-104 HCO3-22 AnGap-11
[**2113-7-15**] 06:00AM BLOOD Albumin-2.4* Calcium-7.3* Phos-3.1 Mg-1.8
[**2113-7-15**] 06:00AM BLOOD ALT-16 AST-66* AlkPhos-176* TotBili-1.4
[**2113-7-16**] 05:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2113-7-16**] 05:20AM BLOOD HCV Ab-NEGATIVE
[**2113-7-13**] 10:08PM BLOOD Lactate-1.2
Brief Hospital Course:
79yo man with metastatic colon CA to liver admitted for upper GI
bleed, transferred from [**Hospital 1562**] Hospital. Presented with
melena, lightheaded, HCT 19. CTA negative. Transfused 3U RBCs
and transferred to [**Hospital1 18**].
.
# Upper GI bleed: In the ICU, EGD [**2113-7-12**] showed moderate
esophagitis, grade II distal esophageal varices, and blood in
the stomach, but no active source of bleeding. He was treated
with PPI IV, octreotide gtt, and ceftriaxone prophylaxis.
Transfused 2U RBC, 2U FFP, and 1U PLTs [**2113-7-13**]. EGD was repeated
with intubation for airway protection [**2113-7-13**]. This showed
evidence of recent bleeding from esophageal varices. Band
ligation was attempted but unsuccessful, so sclerotherapy was
performed on all three varices. There was also an esophageal
stricture. RUQ US only showed metastatic disease. Ceftriaxone
was changed to ciprofloxacin PPx for a 5-day course. PPI was
switched to PO and octreotide gtt continued x72hrs. Video
swallow to evaluate high-up (by upper sphincter) esophageal ring
was negative. Tolerated regular diet without additional
bleeding. Followed CBC [**Hospital1 **] while having melena. Transfused for
HCT <25, avoiding over-transfusion in setting of portal HTN.
Cipro changed back to ceftriaxone due to a rash and for
treatment of Strep viridans bacteremia.
- Plan for repeat EGD with Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**1-7**] weeks.
.
# Drug rash: Resolved after cipro changed to ceftriaxone.
.
# Diarrhea: Due to upper GI bleed. C. diff PCR negative.
Improved.
.
# Coagulopathy: Likely due to liver dysfunction from metastatic
disease. Normal fibrinogen. Mild. No change after vitamin K
5mg x1. Some improvement with FFP [**2113-7-13**].
.
# Bacteremia: Blood culture [**2113-7-12**] grew Strep viridans. Started
on vancomycin, changed to ceftriaxone for better Strep viridans
coverage per ID. TTE negative for vegetations. TEE
contraindicated due to recent bleeding esophageal varices.
Continue and plan for IV ceftriaxone as outpatient 2wks per ID
consult.
- Sensitivity to ceftriaxone still PENDING.
- F/U cultures and sensitivities.
.
# Anemia/thrombocytopenia: Baseline anemia and thrombocytopenia
are likely due to chemotherapy. Anemia worse with acute GI
bleed; stabilized. Followed CBC [**Hospital1 **] while still having melena.
.
# Leukocytosis: Due to infection +/- G-CSF. On antibiotics for
bacteremia.
.
# Abnormal LFTs: Due to liver mets. HepBsAg/Ab and hepC Ab
negative.
.
# Pain: None.
.
# FEN: Advance diet to regular. Repleted hypokalemia.
.
# DVT prophylaxis: Pneumoboots. Avoided heparin with GI bleed.
.
# GI prophylaxis: PPI. No bowel regimen with diarrhea.
.
# Lines: Peripheral IV.
.
# Precautions: None (C. diff negative).
.
# CODE: FULL.
Medications on Admission:
-Neupogen - every Monday post chemo-cycle (last given yesterday)
-Megesterol
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth DAILY Disp #*30
Tablet Refills:*3
2. Senna 1 TAB PO BID:PRN Constipation
3. CeftriaXONE 1 gm IV Q24H
Day #1 is [**2113-7-15**].
RX *ceftriaxone 1 gram 1g Daily Disp #*7 Gram Refills:*0
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
1. Upper gastrointestinal bleed.
2. Esophageal varices.
3. Metastatic colon cancer.
4. Strep viridans bacteremia (bacteria in the blood).
5. Drug rash, resolved when ciprofloxacin (antibiotic) was
stopped.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for upper gastrointestinal
bleeding, transferred from an outside hospital. You initially
went to the Intensive Care Unit (ICU) and underwent upper
endoscopy (EGD) [**2113-7-12**]. This showed esophageal varices (swollen
blood vessels), the likely source of bleeding. You were
transfused blood, plasma, and platelets and started on IV
medication to stop the bleeding (pantoprazole and octreotide).
The endoscopy (EGD) was repeated the following day [**2113-7-13**] while
you were intubated (on a breathing machine) to protect your
airway from bleeding. Banding of the esophageal varices was
attempted, but unsuccessful. Then the varices were sclerosed
(burned) to prevent future bleeding. This seems to have worked
as your blood counts remained stable. A blood culture from the
day you were admitted grew a bacteria called Streptococcus
viridans. IV antibiotics were given and you will need to finish
a course of this at home. Infectious Disease specialists saw
you to help guide treatment of this infection. Echocardiogram
showed no bacterial growth on the heart. YOU WILL NEED A REPEAT
UPPER ENDOSCOPY (EGD) ON [**8-22**] AND REPEAT BLOOD CULTURES
IN TWO WEEKS THROUGH YOUR PRIMARY CARE PHYSICIAN.
.
MEDICATION CHANGES:
1. Ceftriaxone once daily.
2. Pantoprazole once daily.
Followup Instructions:
PLEASE CALL YOUR PRIMARY CARE PHYSICIAN [**Last Name (NamePattern4) **]. [**First Name (STitle) 275**] [**Doctor Last Name **] AT
[**Telephone/Fax (1) 43120**] FOR AN APPOINTMENT IN TWO WEEKS AND REPEAT BLOOD
CULTURES.
.
PLEASE FAST (NO EATING OR DRINKING) FROM MIDNIGHT THE NIGHT
BEFORE THE PROCEDURE.
Department: ENDO SUITES
When: TUESDAY [**2113-8-22**] at 8:00 AM
.
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2113-8-22**] at 8:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 111818**],MD
Specialty: Hematology/Oncology
When: Tuesday [**7-25**] at 4:20pm
Address: 26 [**Location (un) **] DR [**Last Name (STitle) **] A, [**Hospital1 **],[**Numeric Identifier 111819**]
Phone: [**Telephone/Fax (1) 66058**]
Name: [**Known lastname 12459**],[**Known firstname **] A Unit No: [**Numeric Identifier 18364**]
Admission Date: [**2113-7-12**] Discharge Date: [**2113-7-18**]
Date of Birth: [**2034-2-3**] Sex: M
Service: MEDICINE
Allergies:
Novocain / ciprofloxacin
Attending:[**First Name3 (LF) 4148**]
Addendum:
The esophageal varices are due to portal hypertension and the
portal hypertension was likely due to liver metastases.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 709**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 4150**] MD [**MD Number(2) 4151**]
Completed by:[**2113-9-15**]
|
[
"456.20",
"287.49",
"553.3",
"197.7",
"530.3",
"285.1",
"153.9",
"790.7",
"693.0",
"285.3",
"E931.9",
"396.3",
"041.09",
"787.91",
"572.3",
"E933.1",
"530.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"42.33",
"96.71",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
14665, 14868
|
8086, 10889
|
303, 466
|
11607, 11607
|
2866, 2866
|
13102, 14642
|
2130, 2172
|
11016, 11274
|
11379, 11586
|
10915, 10993
|
11757, 13003
|
7376, 8063
|
2187, 2847
|
13023, 13079
|
245, 265
|
494, 1762
|
2882, 7360
|
11622, 11733
|
1784, 1958
|
1974, 2114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,069
| 140,746
|
12965+56421
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-1-8**] Discharge Date: [**2154-1-19**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Bilateral foot ulcers
Major Surgical or Invasive Procedure:
right below knee amputation [**2154-1-11**]
left5 SFA to PT bypassgraft with issvg, left SFA endartectomy,
angioscopy [**2154-1-14**]
angio with bilateral lower extremity runoff [**2154-1-9**]
PICC line rt. [**2154-1-17**]
History of Present Illness:
86y/o male with histroy of PVD s/p rt. fem-DP bypass graft with
composite SVG
for rt. foot ulcer [**10-6**]
Returned for right calf wound infection s/p primary closure d/c
[**11-5**]
returns now with persistant right foot wound and new left #2
toe tip wound which probes to bone.Denies any constutional
symptoms.Now admitted for evaluatiion and treatment.
Past Medical History:
seizure disorder, last seizure [**2141**]
hypertension
asthma
sleep apnea, uses CPAP
avascular necrosis of left hip
history of peptic ulcer disease
macular degeneration
colonic polyps
internal hemmroids
anxiety disorder
s/p left hip arthroplasty [**2128**]
s/ppartial gastrectomy [**2134**]
s/p left hip revision [**9-/2144**]
s//p umbilical hernia repair
BPH
Social History:
retired single. Lives in a trailer home. Has not been home since
[**10-6**]
habits former [**Month/Year (2) 1818**] d/c x 19 yrs
ETOH; d/c'd x 19 years
Family History:
unknown
Physical Exam:
Vital signs: 97.5-56-20 138/68
HEENT:rt. carotid bruit. carotid pulses palpable 1+ no JVD
Lungs: L > chest A/P diameter with expiratory wheezes
LT.>Rt.Ronchros rt. air way sounds
Heart: distant ? irregular. no mumur or gallop
ABD: protrubrent, soft, nontender active bowel sounds. no
abdominal bruits.
PV: right foot: lateral foot wouond 2x3cm with clean base with
tendon exposed . no excudates. Left #2 toe tip wound probes
tobone. no erythema,excudate, excudaates
pulses: right femoral 2+ palpable,absent popliteal pulses
bilaterally,rt. DP absent. Rt. Pt dopperable. Left pedal pulses
dopperable. graft pulse palpable.
Neuro: orient x3. grossly intact
Pertinent Results:
[**2154-1-8**] 11:51PM WBC-5.1 RBC-2.69* HGB-7.8* HCT-24.6* MCV-92
MCH-29.2 MCHC-31.9 RDW-15.8*
[**2154-1-8**] 11:51PM PLT COUNT-231
[**2154-1-8**] 11:51PM PT-13.3 PTT-28.6 INR(PT)-1.1
[**2154-1-8**] 11:51PM GLUCOSE-212* UREA N-34* CREAT-1.5* SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2154-1-8**] 11:51PM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-2.2
Brief Hospital Course:
[**2154-1-8**] admitted to vascular service. Wound cultures obtained.
Started on Vanco,levo, and flagyl. Placed on bedrest. wound care
began.
[**2154-1-9**] u/s of carotids rt. ICA 40-50%, left ICA 60-69%. Graft
duplex : occluded graft. Rt. sfa and tibial disease with severe
forefoot decreased flow.Angiogram: severe bilateral femoral
-tibial disease.
[**2154-1-11**] Rt. BKA
[**2154-1-14**] POD# 5/DOS left sfa-pt bpg with issvg and lefeet SFA
endarectomy, angioscopy. Patient tolerated the procedure and
tranasfered to PACU extubated.Urinary output borderline. Fluid
bolus prn.Transfused for HCT. 28.2
[**2154-1-15**] POD# [**7-3**] no overnight events.afebrile. dieta advanced.
IV fluids heplocked.
[**2154-1-17**] POD# [**8-3**] afebril wounds clean dry and intact. graft
pulse palpabale with palpable pedal pulses. PT evaluated
patient. recommend rehabilitation. PICCline placed for continued
antibiotics for two weeks.Social service consult for emotional
support.[**2154-1-18**] POD# [**9-4**] Patient is doing well and ready for
rehab. He is full weight bearing.
Medications on Admission:
detrol 2mgm [**Hospital1 **]
amidarone 200mgm qd
cozaar 50mgm qd
lasix 40mgm qd
glipazide 10mgm qd
lipitor 10mgm qd
protonix 40mgm qd
KCl 50meq qd
avandia 8mgm qd
colace 100mgm [**Hospital1 **]
lopressor 75mgm [**Hospital1 **]
atrovent MDI puff 2 qid
Emycin 500mgm [**Hospital1 **] x 10 days ([**Date range (1) 17553**])
percocet tab q4h prn
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 weeks.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
13. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gm
Intravenous twice a day for 2 weeks.
17. 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
18. Insulin Reg (Human) Buffered 100 unit/mL Solution Sig: as
directed Injection four times a day: AC:
glucoses <150/no insulin
glucoses 151-200/2u
glucoses 201-250/4u
glucoses 251-300/6u
glucoses 301-350/8u
glucoses 351-400/10u
glucoses > 400 / 12u.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Health of [**Hospital3 **] - [**Location (un) 32944**]
Discharge Diagnosis:
bilateral foot infection
history of seizure disorder
hypertension
asthma/COPD
left hip avascular necrosis s/p hip arthroplasty [**2128**],revision
[**2144**]
history peptic ulcer disease, asymptomatic
diabetes type 2 with nocturnal hypoglycemia
coronary artery diseased
gout
history of PVD s/p rt, fem-dp with composite vein [**10-6**]
Discharge Condition:
stable
Discharge Instructions:
moniter CBC, Bun, Cr weekly while on Vancomycin
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) 1391**]. call for appoointment [**Telephone/Fax (1) 1393**]
Completed by:[**2154-1-18**] Name: [**Known lastname 7186**],[**Known firstname 7187**] Unit No: [**Numeric Identifier 7188**]
Admission Date: [**2154-1-8**] Discharge Date: [**2154-1-19**]
Date of Birth: [**2067-6-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**1-18**] Podiatry performed an osteotomy on Left second toe. There
were no complications. Patient still ready for rehab.
swab from [**1-17**] still reporting: gram + cocci to ID or
sensitivities
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 6463**] Health of [**Hospital3 7189**] - [**Location (un) 7190**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2154-1-19**]
|
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"730.17",
"V12.71",
"427.32",
"731.8",
"440.31",
"780.39",
"493.20",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"84.15",
"99.04",
"38.93",
"38.18",
"86.28",
"88.48",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
7195, 7457
|
2569, 3644
|
282, 507
|
6357, 6365
|
2165, 2546
|
6461, 7172
|
1464, 1473
|
4036, 5855
|
5997, 6336
|
3670, 4013
|
6389, 6438
|
1488, 2146
|
221, 244
|
535, 895
|
917, 1279
|
1295, 1448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,873
| 129,429
|
8807+55976
|
Discharge summary
|
report+addendum
|
Admission Date: [**2114-11-18**] Discharge Date: [**2114-12-6**]
Date of Birth: [**2073-4-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
weight gain, DOE
Major Surgical or Invasive Procedure:
Redo sternotomy/MVR923mm St. [**Male First Name (un) 923**] mechanical)/TV repair(28mm
annuloplasty band) [**2114-11-26**]
History of Present Illness:
Patient is a 41yo woman with h/o DM type [**First Name8 (NamePattern2) 30749**] [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] in
[**2112**] (congenital bicuspid valve) who presents for right heart
catheterization in anticipation of MVR.
.
Ms. [**Known lastname 23609**] was admitted 1 month ago to [**Hospital1 18**] with acute diastolic
heart failure. TTE done during that admission demonstrated
moderate to severe mitral and tricuspid regurgitation; increased
from 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **] from [**2113-9-22**]. Although echocardiogram
showed evidence of possible former rheumatic heart disease, the
underlying cause of her valvular dysfunction is unclear. [**Name2 (NI) **]
was diuresed with lasix with improvement in her fluid status and
dyspnea. She now presents for MVR.
.
Patient reports that she has been "exhausted all the time" since
her discharge. She is dyspneic with minimal exertion, such as
walking down the [**Doctor Last Name **]. +Orthopnea, uses 3 pillows at night.
Denies PND or ankle edema. +8 pound weight loss in last month,
which she attributes to poor appetite. She does admit to
depression, and states she is not sleeping well, though she is
optimistic about improving after surgery.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative except as noted in HPI.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
Type 1 DM--A1C 7.5% in [**2114-9-22**]; c/b peripheral neuropathy and
retinopathy; on insulin pump
[**Year (4 digits) 1291**] [**2112-3-22**]: St. [**Male First Name (un) 923**] 19 mm valve. Prior to this found
to have bicuspid valve, [**Location (un) 109**] 0.6 with mean gradient 40.
Anemia with baseline Hct 28-31
Mitral regurg (3+ on TTE [**2114-11-5**]) and 3+ TR
Mitral stenosis (mild with rheumatic valvular deformities on
[**Month/Day/Year 113**] [**2113-9-22**])
Depression
Anxiety
Dyslipidemia
Hypertension
Celiac disease
.
ALLERGIES: NKDA
.
OUTPATIENT CARDIOLOGIST: Dr. [**Last Name (STitle) **]
PCP: [**Name10 (NameIs) **] [**Name11 (NameIs) 30747**] in [**Location (un) 932**]
Endocrinologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**], [**Last Name (un) **]
Psych: Dr. [**Last Name (STitle) 16471**] ([**Last Name (un) **])
Social History:
Social history is significant for the presence of current
tobacco use; quit 1.5 years ago but still sometimes sneaks a
cigarette. Smoked x 10 years previously. There is history of
alcohol abuse, but she has been sober x5 years. Also with h/o
percocet abuse, sober x5 years. She does not feel that narcotic
pain control while in the hospital will trigger a relapse. She
is a nurse, though is not currently working. She has a 10 year
old daughter ([**Name (NI) **]) and a life partner named [**Name (NI) **]; [**Name2 (NI) **] live
nearby.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her mother has a h/o cervical Ca, father died
of prostate cancer.
Physical Exam:
VS - 98.9 138/80 68 16 98% RA.
Gen: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.
Slightly short of breath with conversation.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
MMM, old cavities with fillings.
Neck: Supple with JVP of 5 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2 with loud click. IV/VI systolic murmur
throughout precordium. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + Crackles at bases; no
wheezes or rhonchi.
Abd: Scar from prior c-section. +BS. Soft, NTND. No HSM or
tenderness. Abd aorta not enlarged by palpation. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: + Hypopigmented macules on chest, arms, legs, and trunk,
most prominent on chest and arms. Occasional scabs are early
stage of same process per patient. No stasis dermatitis, ulcers,
scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
CARDIAC CATH performed on [**2112-3-11**] demonstrated:
1. Coronary arteries are normal.
2. Severe aortic stenosis.
3. Normal ventricular function, LVEF 66%
[**2114-12-6**] 02:56AM BLOOD WBC-5.6# RBC-3.35* Hgb-8.8* Hct-27.4*
MCV-82 MCH-26.2* MCHC-32.1 RDW-17.8* Plt Ct-336
[**2114-12-6**] 02:56AM BLOOD PT-33.3* PTT-103.1* INR(PT)-3.5*
[**2114-12-5**] 11:42AM BLOOD PT-23.0* PTT-51.7* INR(PT)-2.2*
[**2114-12-4**] 05:45AM BLOOD PT-14.9* PTT-67.2* INR(PT)-1.3*
[**2114-12-3**] 03:55PM BLOOD PT-13.7* PTT-93.1* INR(PT)-1.2*
[**2114-12-6**] 02:56AM BLOOD Plt Ct-336
[**2114-12-6**] 02:56AM BLOOD Glucose-56* UreaN-8 Creat-0.8 Na-132*
K-4.1 Cl-94* HCO3-31 AnGap-11
CHEST (PA & LAT) [**2114-12-5**] 8:42 AM
CHEST (PA & LAT)
Reason: assess for effusions/infiltrates
[**Hospital 93**] MEDICAL CONDITION:
41 year old woman s/p MVR
REASON FOR THIS EXAMINATION:
assess for effusions/infiltrates
HISTORY: Status post MVR.
FINDINGS: In comparison with the study of [**11-27**], the Swan-Ganz
catheter has been removed. No definite pneumothorax is
appreciated on the left. There is some residual atelectatic
change at the left base.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] M [**Hospital1 18**] [**Numeric Identifier 30750**] (Complete)
Done [**2114-11-26**] at 1:53:55 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2073-4-19**]
Age (years): 41 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for MVR/TVR
ICD-9 Codes: 440.0, 424.1, 394.2, 424.2
Test Information
Date/Time: [**2114-11-26**] at 13:53 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2007AW4-: Machine: 4
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 2.4 cm <= 3.4 cm
Aorta - Arch: 2.0 cm <= 3.0 cm
Aorta - Descending Thoracic: 1.5 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *20 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 13 mm Hg
Aortic Valve - Valve Area: *1.1 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 2.3 m/sec
Mitral Valve - Mean Gradient: 9 mm Hg
Mitral Valve - MVA (P [**1-23**] T): 1.1 cm2
Findings
LEFT ATRIUM: Dilated LA. No spontaneous [**Month/Day (2) 113**] contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Suboptimal technical quality, a focal LV wall motion
abnormality cannot be fully excluded. Mild-moderate global left
ventricular hypokinesis. Mildly depressed LVEF. [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Dilated RV cavity. Moderate global RV free wall
hypokinesis. Abnormal septal motion/position.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Normal
aortic arch diameter. Simple atheroma in aortic arch. Simple
atheroma in descending aorta.
AORTIC VALVE: Bileaflet aortic valve prosthesis ([**Last Name (Prefixes) 1291**]). Increased
[**Last Name (Prefixes) 1291**] gradient. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
mitral annular calcification. Moderate thickening of mitral
valve chordae. Moderate valvular MS (MVA 1.0-1.5cm2) Moderate to
severe (3+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate to severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE CPB The left atrium is dilated. No spontaneous [**Last Name (Prefixes) 113**] 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. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is mild to moderate
global left ventricular hypokinesis (LVEF = 40 %). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] The right
ventricular cavity is dilated. There is moderate to severe
global right ventricular free wall hypokinesis. There is
abnormal septal motion/position consistent with prior cardiac
surgery. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. A bileaflet
aortic valve prosthesis is present. The transaortic gradient is
higher than expected for this type of prosthesis. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. The posterior mitral leafllet is, essentially,
immobilized. There is moderate thickening of the mitral valve
chordae. There is moderate valvular mitral stenosis (area 1.1
cm2). Moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen.
POST CPB The patient is receiving milrinone and epinephrine by
infusion. Exam limited by poor [**Last Name (Prefixes) 113**] windows. Right ventricular
free wall function is much improved, now low normal to normal.
Left ventricular function, which can only be assessed from the
transgastric windows, appears normal with an ejection fraction
of about 60%. A bileaflet prosthesis is located in the mitral
position. It appears well seated. Both leaflets can be seen
moving. There is normal mild valvular regurgitation. A
perivalvular component can not be completely ruled out. The
maximum gradient across the valve is about 18 mm Hg with a mean
pressure of 7 mm Hg in the setting of a cardiac output of 6 l/m.
A tricuspid valve annuloplasty ring is seen in situ. It also
appears well seated. There is at least mild, eccentric tricuspid
regurgitation. Can not rule out a perivalvular component. The
mean gradient across the tricuspid valve is 5 mm Hg. The
thoracic aorta is intact.
Brief Hospital Course:
Patient is a 41yo woman with IDDM and [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] from [**2112**]
admitted for cardiac cath in anticipation of MVR. She was
started on a heparin gtt. She was seen by nephrology for
hyponatremia, and was fluid restricted and her doses of
trileptal and celexa were reduced. Cardiac cath on [**11-20**] showed
no CAD, elevated right and left filling pressures and severe
pulmonary hypertension.
She was taken to the operating room on [**2114-11-26**] where she
underwent a redo-sternotomy, MVR(mechanical) and TV repair. She
was transferred to the ICU in critical but stable condition on
levophed, epinephrine, and milrinone. She awoke and was
extubated on POD #1. She was weaned from her vasoactive drips by
POD #2. She was found to be in complete heart block and was seen
by EP. She was transfused 1 unit for hct 27 and SBP 80s. She was
started on heparin for her mechanical valves. She was followed
by [**Last Name (un) **]. She was transferred to the floor on POD #5. Her
rhythm recovered, she was started on coumadin and her epicardial
pacing wires were dc'd.
By post-operative day 10 her INR was therapeutic, but it rose
quickly from the previous day and it was recommended that she
stay overnight to ensure that her INR does not rise even
further. She expressed the desire to return home regardless.
The risks of doing so were stressed to her, yet she continued to
express the desire to leave against medical advice. Her INR was
scheduled to be checked by visiting nursing on the day after her
discharge.
Medications on Admission:
Insulin pump
Valsartan 120 mg PO daily
Buspirone 20 mg PO tid
Trazodone 300 mg qhs
Atenolol 25 mg PO daily
Celexa 80 mg PO daily
Wellbutrin SR 200 mg PO bid
Atorvastatin 80 mg PO daily
Oxcarbazepine 900 mg PO qhs
Coumadin 7-8mg QHS
Furosemide 20 mg PO daily
--not taking her iron or ASA
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
7. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(s)* Refills:*0*
10. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*0*
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: check INR [**12-7**] with results to [**Hospital1 18**] coumadin
clinic/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**].
Disp:*60 Tablet(s)* Refills:*0*
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
MR, TR now s/p MVR/TVRepair
HTN, ^chol, DM I, neuropathy, anxiety, eye sx, shoulder sx, c
sec, s/p [**Company 1291**](19mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **]) [**3-26**] c/b sternal dehiscence,
retinopathy, anemia, depression, restless leg syndrome
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.
Coumadin-check INR [**12-6**] with results to [**Hospital1 18**] coumadin
clinic/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] RN, [**Telephone/Fax (1) 30751**]. Further checks and dosing
[**Name8 (MD) **] RN [**Doctor Last Name 9449**]. Goal INR 3-3.5 for mechanical [**Doctor Last Name 1291**]/MVR. Spoke to
Ms. [**Last Name (Titles) 9449**] [**12-6**] to confirm follow up.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 30747**] 2 weeks
Coumadin follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] [**2114**]
Already Scheduled appointments:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2114-12-31**] 1:40
Completed by:[**2114-12-6**] Name: [**Known lastname 5367**],[**Known firstname **] M Unit No: [**Numeric Identifier 5368**]
Admission Date: [**2114-11-18**] Discharge Date: [**2114-12-6**]
Date of Birth: [**2073-4-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Discharge diagnoseds updated.
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
MR, TR now s/p MVR/TVRepair
chronic systolic heart failure
chronic diastolic dysfunction
HTN, ^chol, DM I, neuropathy, anxiety, eye sx, shoulder sx, c
sec, s/p AVR(19mm St. [**First Name4 (NamePattern1) 744**] [**Last Name (NamePattern1) 5369**]) [**3-26**] c/b sternal dehiscence,
retinopathy, anemia, depression, restless leg syndrome
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2114-12-18**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
[]
]
] |
17789, 17834
|
12261, 13870
|
339, 464
|
16241, 16249
|
5072, 5838
|
16949, 17766
|
3750, 3898
|
14207, 15842
|
5875, 5901
|
17855, 18318
|
13896, 14184
|
16273, 16926
|
3913, 5053
|
283, 301
|
5930, 12238
|
492, 2287
|
2309, 3179
|
3195, 3734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,363
| 164,591
|
32705
|
Discharge summary
|
report
|
Admission Date: [**2189-1-4**] Discharge Date: [**2189-1-5**]
Date of Birth: [**2136-4-25**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubated prior to arrival
History of Present Illness:
52 year old male with PMH methamphatime/[**First Name3 (LF) **] abuse, HCV, HIV is
transferred from [**Hospital3 6592**] after being found down in an
"wreck" of a motel room. He is admitted to the MICU intubated
with altered mental status.
Accorting to the report he was somnolent when EMS arrived and
was given narcan, he sat straight up, began spitting blood
(undocumented quantity, and there was documentation that) EMS
noted multiple bottles of human growth hormone blood tinged
water in the toilet bowl. He was brought to [**Hospital 8125**] Hospital ED
where he was intubated for airway protection. Initial labs at
[**Doctor First Name 8125**] were remarkable for Trop T <0.01, Lactate 1.2, urine was
positive for Amphetamines and Benzodiazepines, negative for
barbituates, cocaine, methadone, opiates, PCP. [**Name Initial (NameIs) **] <10, APAP
<2, Salicylate <2. He was agitated and given atican 8mg,
morphine 4mg IV, vanco 1g, zosyn 3.75.
On arrival to the [**Hospital1 18**] ED Vitals were p:77 bp:115/96 rr14 no
temperature recorded. By report, he appeared comfortable on the
vent moving all extremities. PEERLA, 4-5mm small amout of dry
crusted blood on mouth. NG lavage was performed with 750 of NS
down the OG tube, which returned "coffee grounds" per ED
resident. Given Ceftriaxone 1G IV and started on propofol, PPI
bolus and drip. ABG CMV 500x14 5X100% 7.38/39/362/24 Vitals on
transfer p72 120/79 (120-132/70-85) SaO2100% CMV Fio2100% 500x14
+5
On arrival to the MICU, he was intubated and sedated and unable
to contribute to the medical history. Called HCP [**Name (NI) **] [**Name (NI) **]
said he spoke with [**Known firstname **] yesterday told him he was going to
[**Location (un) **] to see a friend and do [**Name (NI) **] and "[**First Name4 (NamePattern1) 76204**] [**Last Name (NamePattern1) **]". States
patient was recently in [**Hospital **] hospital after overdose of [**Hospital **]
and crystal [**Hospital **]. States that patient has been using human
growth hormone by prescription.
Past Medical History:
HIV diagnosed in [**2163**] -CD4 count 525. Never had an opportunistic
infection.
Hepatitis C diagnosed in [**2176**]. Liver biopsy a few months prior
that showed no inflammation or fibrosis.
Severe depression
CAD s/p catheterization
HTN
C4-C5 laminectomy
Carpal tunnel surgery
PTSD
Social History:
Estranged from Sister and [**Name (NI) 18806**]. Partner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is HCP
- [**Name (NI) 1139**]: Cigarettes 1ppd >10 years
- Alcohol: no
- Illicits: [**Name (NI) **], Methamphetamine,
Family History:
Father Alcoholism
Mother dementia
HCP is unaware of any diseases
Physical Exam:
Admission:
Vitals: T:96.4 BP:119/77 P:71 R:20 O2: 100% Volume Control
550x20 Peep:5 Fio2:100%
General: Sedated, intubated opens eyes to command, moving all
extremities
HEENT: PERRL, Clotted blood on lips and teeth. small laceration
on forehead.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation in anterior lung fields, no
wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Rectal: GUIAC negative yellow stool
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Eyes open to command, moving all extremities, following
simple commands. hand grip full, babinski downgoing.
Discharge
General: Alert and oriented x3, in NAD
HEENT: PERRL, CNIII-XII intact. MMM.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation in bilateral lung fields, no
wheezes, rales, or ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Eyes open to command, moving all extremities. hand grip
full, babinski downgoing. Strength 5/5 in UE/LE bilaterally.
Normal finger-to-nose bilaterally
Pertinent Results:
[**2189-1-4**] 03:10PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-POS mthdone-NEG
[**2189-1-4**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-1-4**] 03:10PM GLUCOSE-83 UREA N-23* CREAT-1.1 SODIUM-142
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-20* ANION GAP-20
[**2189-1-4**] 04:32PM WBC-4.9 LYMPH-35 ABS LYMPH-1715 CD3-70 ABS
CD3-1200 CD4-34 ABS CD4-577 CD8-33 ABS CD8-561 CD4/CD8-1.0
[**2189-1-4**] 10:50PM GLUCOSE-107* UREA N-16 CREAT-1.0 SODIUM-140
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2189-1-4**] 07:46PM LACTATE-0.8
[**2189-1-4**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2189-1-4**] 04:45PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
Brief Hospital Course:
52 year old male with PMH methamphatime/[**Month/Day/Year **] abuse, HCV, HIV, HTN
is admitted with altered mental status in the setting of
possible [**Month/Day/Year **] overdose and intubated for airway protection.
# Altered mental status:
The patient's altered mental status was most likely due to abuse
of [**Month/Day/Year **], complicated by coingestion of MDMA and possibly
clonazepam. The patient has an established history of [**Month/Day/Year **] abuse,
and per report of his partner, had stated his intention to use
both [**Month/Day/Year **] and MDMA before he was found unresponsive. [**Month/Day/Year **] abuse is
also consistent with reports that he was initially agitated when
taken to the [**Hospital3 6592**] ED when prior to being intubated, as
the [**Hospital3 **] toxidrome often features agitation followed by coma.
Infection and intracranial pathology were ruled unlikely as he
was afebrile, and had a negative UA, CXR, and non-contrast CT
Head @ [**Hospital3 6592**].
.
The patient remained intubated until his second hospital day due
to prolonged unresponsiveness, which cleared by mid-morning on
[**1-5**]. Although [**Month/Year (2) **] is rapidly metabolized, prolonged periods of
unresponsiveness can be a complication of coingestion (with
agents such as BZDs), which is a strong possibility in his case.
After extubation, the patient rapidly became entirely alert and
appropriately oriented. He remained so after several hours of
observation.
.
# Airway protection:
The patient had initially been intubated @ the [**Hospital3 6592**] ED
due to concern over the safety of his airway, as he was agitated
and had reportedly had some hematemesis in the field. On arrival
to the [**Hospital1 18**] ED, the patient had evidence of dried blood at his
mouth, and an NG lavage returned some coffee-ground appearing
material, which cleared. Given that the patient had no evidence
of active bleed, and a Rockall score of 0, it was judged that he
was unlikely to have a significant source of bleeding beyond
possible [**Doctor First Name 329**]-[**Doctor Last Name **] tears. Notably, nausea and vomiting are
known side effects of [**Doctor Last Name **]. The patient's extubation was
uneventful, and he had no further nausea or vomiting afterward.
.
# Overdose: by report patient had planned to take [**Doctor Last Name **] and
methamphetamine before being found down. In addition to airway
support, the patient was monitored for signs of benzodiazepine
withdrawal, which he did not manifest. Social work was
consulted after the patient was extubated to assess his
resources and support for treating his addiction. He expressed
no suicidal or homicidal ideation, and by all accounts his drug
overdose (though not his drug use) was unintentional.
.
# Crush myopathy:
The patient was found down and had a mildly elevated creatine
kinase, suggestive of a very mild crush myopathy (although
elevated CK levels and rhabdomyolysis have been noted in case
series of rhabdomyolysis). The patient's CK elevation was mild
and he received 150 mEq of Sodium Bicarbonate with IV fluid
resuscitation in the ED. His subsequent CK measurements
decreased, and he had no complaints of muscle pain at the time
of discharge.
.
# HIV:
Per the medical record, the patient has no history of
opportunistic infections. CD4 count was 577 on testing. A viral
load was also sent with HCP consent. The patient's outpatient
HIV medications were continued during his hospitalization.
.
# Depression:
The patient's home anti-depressive regimen was continued during
the hospitalization.
Medications on Admission:
Reyataz 300mg daily
Truvada 1 tab daily
Norvir 100mg daily
Depacote 1000mg [**Hospital1 **]
Welbutrin 200mg daily
Celexa 20mg Daily
Acyclovir 400mg [**Hospital1 **]
Clonazepam 1mg daily
Zolpidem daily PRN
Tramadol dose unknown
diphenoylate/atropine
Ibuprofen
Discharge Medications:
Reyataz 300mg daily
Truvada 1 tab daily
Norvir 100mg daily
Depacote 1000mg [**Hospital1 **]
Welbutrin 200mg daily
Celexa 20mg Daily
Acyclovir 400mg [**Hospital1 **]
Clonazepam 1mg daily
Zolpidem daily PRN
Tramadol dose unknown
diphenoylate/atropine
Ibuprofen
Discharge Disposition:
Home
Discharge Diagnosis:
Altered Mental Status
Gamma Hydroxybutyrate / Methamphetamine intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized because you were found unresponsive due to
drug abuse. You were unable to protect your airway and were
temporarily intubated for your safety. You were hospitalized in
the intensive care unit until you were able to breath on your
own and were more oriented. It is important to note that drugs
such as Gamma Hydroxybutyrate ([**Hospital1 **]) and Methamphetamine (MDMA)
can kill you.
Overdose. An overdose occurs when you take more [**Hospital1 **] than your
body can handle. This can happen the first time using [**Hospital1 **] or
even if you do not use [**Hospital1 **] often. You can overdose even when
using a small amount of [**Hospital1 **]. Overdose may include any of the
signs and symptoms of [**Hospital1 **] intoxication. You may lose
consciousness, have a seizure (convulsion), your heart may stop
beating, and you may die.
Dependence. You may be dependent on these drugs when you need to
use more over time to get the same effects. Dependence also
occurs when you need to use [**Hospital1 **] more often. You may change the
way you use these drugs , such as from snorting to injecting, to
get a stronger form of the drug. Your body may get used to the
amount of [**Hospital1 **] you use. If this occurs you may need more [**Hospital1 **] to
get the same effects. This is called tolerance. You may spend
all of your time getting and using the drug. You may be unable
to stop using it, even though it causes physical or mental
health problems. Dependence may also cause problems with your
relationships with people. When you try to stop using [**Hospital1 **], you
may have withdrawal symptoms and strong cravings for the drug.
Death. You may die from use of these drugs because your heart is
unable to pump correctly. These drugs can lead to death from a
heart attack, kidney failure, seizure, or stroke. Blood vessels
in the body or brain can burst, causing bleeding and death. If
you inhale (breathe in) [**Hospital1 **], your airways can swell up and
narrow, making it hard to breathe. This may also cause you to
stop breathing. You may be more likely to kill yourself because
of depression (deep sadness) and anxiety. [**Hospital1 **] use can also make
you want to hurt or kill other people.
We strongly encourage you to seek help for dealing with your
addiction and use of these substances. Help is available, both
through your primary care doctor, as well as through resources
that our social worker discussed with you.
NO changes were made to your medications on this admission.
Seek care immediately or call 911 if:
You have withdrawal symptoms and want to start using drugs
again.
You have chest pain. Your heart rate or breathing may be rapid.
You are so nervous that you cannot cope.
You have a seizure or lose consciousness.
You feel sick or throw up, or have headaches or trouble
breathing. You may also have chest pain and feel dizzy.
Followup Instructions:
Please follow up with your primary care doctor at the soonest
possible opportunity.
Completed by:[**2189-1-5**]
|
[
"305.70",
"968.4",
"V08",
"E855.1",
"359.89",
"305.80",
"518.81",
"414.01",
"E854.2",
"070.70",
"969.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9416, 9422
|
5244, 5472
|
292, 320
|
9541, 9541
|
4405, 5221
|
12612, 12726
|
2953, 3020
|
9132, 9393
|
9443, 9520
|
8848, 9109
|
9692, 12589
|
3035, 4386
|
231, 254
|
348, 2371
|
9556, 9668
|
2393, 2678
|
2694, 2937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,476
| 162,370
|
53234
|
Discharge summary
|
report
|
Admission Date: [**2139-4-1**] [**Month/Day/Year **] Date: [**2139-4-7**]
Date of Birth: [**2057-5-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim / Nsaids
Attending:[**Doctor First Name 2080**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
81F with h/o severe bronchiectasis, followed in pulmonary clinic
by Dr. [**Last Name (STitle) **], admitted with dyspnea.
.
Pt notes increasing dyspnea over past week, along with chronic
cough, no frank change in sputum production, but increased
cough. She uses 2-3L home O2, but has been using up to 4L
recently. She was seen by chest PT, which has been her daily
routine, and today was noted to be markedly tachypneic and more
hypoxic (90%4L, usually mid 90s%4L by report). She declined
referall to the ED, and was therefore direct admitted to the
medicine floor.
.
Upon arrival to the medical floor, VS notable for fever 100.8,
RR 45-50 (my count). she is tachypneic, speaking in [**12-20**] word
sentences, and admits to dyspnea, worse than baseline. Lung
exam is roncherous, with green/yellow sputum. She denies chest
pain, orthopnea, lower extremity edema, but beleives her weight
has been increasing over the past few days. She has been taking
her lasix daily, but does not know her dry weight. CXR showed
no focal infiltrate, but was reveiewed with her pulmonary
fellow, and felt c/w bronchiectasis. No significant pulmonary
edema. ECG is paced, with negative sgarbossa criteria (h/o afib
s/p av ablation, s/p PM). JVP was elevated 10-12cm at 90
degrees.
.
She was treated with albuterol nebulizers x 2, atrovent x1,
without improvement. ABG was obtained 7.45/44/55 on 4-5L O2.
Given toxic appearance, she was given iv cefepime, and ordered
for vanco/levo after disscussion with pulmonary fellow, though
sputum cultures in past have always shown psuedomonas always
sensitive to levaquin. She also received 20mg iv lasix, and
foley was ordered placed. Code status was reviewed with the
patient, and her son, and she confirmed DNR/DNI status, but
would consider BiPaP. MICU consult was obtained, and although
she had improved slightly (now speaking in [**2-19**] word sentences),
given her tenuous pulmonary status, tachypnea, she was brought
to the MICU.
Past Medical History:
#CAD - Cath ([**3-/2134**]) - LMCA and LCx, no disease; LAD: proximal
and mid vessel 30% stenoses; RCA - mild luminal irregularities
Pacemaker/ICD ([**Company 1543**] Sigma SDR303 B pacemaker), in [**1-/2132**]
#Atrial fibrillation, status post AVJ ablation and DDD pacer
#Congestive heart failure (EF 30% in [**2135**])
#MV repair and TVR ([**4-/2132**])
#Bronchiectasis with presumed pseudomonal colonization ([**Month (only) 404**]
[**2135**] and treated with ceftazidime and azithromycin): Previously
suffered exacerbations in [**Month (only) **] and [**2135-8-19**] that were
treated with meropenem/ciprofloxacin and ceftazidime as
outpatient
#Depression
#Hyperparathyroidism
#Pan-sensitive E.coli UTI on hospital admission last month
#DJD; recently tapered off morphine
Social History:
Lives in [**Location (un) 55**]. She worked as a lecturer on Egyptology
at the MFA in [**Location (un) 86**]. Husband is deceased. She lives with her
son and has an aid most days of the week. Has three sons, [**Name (NI) **],
[**Doctor First Name **] and [**Doctor Last Name **]. Quit smoking 30 years ago, had a 5 pack year
history. Previously, she drank one drink/day but no ETOH now
for many years.
Family History:
Her father and mother are both deceased. Her father had HTN. Her
mother had [**Name (NI) 19917**] disease and died as an elderly woman. There
is a negative family history of colon cancer, breast cancer,
diabetes, and premature coronary artery disease. She has three
natural children who are alive and well and one brother who is
alive and well.
She also has a 17 year old granddaughter recently diagnosed with
melanoma
Physical Exam:
VS: 100.8 117/66 78 40 (45-50 my count) 91%4L (up from
86%4L on arrival)
GEN: tachypneic, sitting up, speaking in [**12-20**] word sentences,
pursed lip breathing, uncomfortable. cachectic.
HEENT: JVP 10-12cm.
CV: distant, regular.
PUL: diffuse, bilteral, roncherous breath sounds.
ABD: soft, NTND, +BS.
EXT: no edema.
SKIN: no rash.
PSYCH: pleasant.
Pertinent Results:
LABS:
[**2139-4-1**] 06:10PM BLOOD WBC-13.8* RBC-4.81 Hgb-13.9 Hct-42.5
MCV-88 MCH-28.9 MCHC-32.7 RDW-13.3 Plt Ct-230
[**2139-4-1**] 06:10PM BLOOD PT-18.5* PTT-28.2 INR(PT)-1.7*
[**2139-4-1**] 06:10PM BLOOD Glucose-128* UreaN-27* Creat-0.7 Na-136
K-4.4 Cl-97 HCO3-32 AnGap-11
[**2139-4-1**] 06:55PM BLOOD Type-ART pO2-55* pCO2-44 pH-7.45
calTCO2-32* Base XS-5
[**2139-4-1**] 06:55PM BLOOD O2 Sat-89
.
.
STUDIES:
[**2139-4-1**] CXR:
CHEST, PA AND LATERAL: The lungs are again hyperexpanded, with
diffuse
bronchiectasis. Globally increased reticulonodular markings
likely represent acute exacerbation of disease, with mucoid
impaction of small airways. Right atrial and ventricular
pacemaker courses in expected position. The cardiomediastinal
silhouette and hilar contours are normal, with changes of CABG
and tricuspid annuloplasty. There are no pleural effusions or
pneumothorax.
IMPRESSION: Acute on chronic bronchitis.
.
.
[**2139-4-1**] ECG: my [**Location (un) 1131**], v-paced, underlying afib, LAD, negative
sgarbosa criteria, with new loss of RBBB pattern since [**12-28**]
office ECGs. formal report:
.
Cardiology Report ECG Study Date of [**2139-4-1**] 7:29:54 PM
Atrial fibrillation with ventricular pacing. Since the previous
tracing
of [**2138-10-2**] no significant change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
.
CXR:
FINDINGS: Radiodense guidewire of right PICC terminates just
below the
expected cavoatrial junction. Widespread areas of bronchiectasis
and
bronchiolitis are again demonstrated as well as developing areas
of
superimposed consolidation, particularly in the right upper and
both lower
lobes. This could reflect an acute bacterial pneumonia
superimposed upon the
patient's reported history of chronic MAC infection.
Asymmetrical hilar
enlargement, right greater than left, is in keeping with known
lymphadenopathy
detected on prior chest CTA which also demonstrated evidence of
mediastinal
lymphadenopathy.
.
Sputum:
[**2139-4-1**] 3:30 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2139-4-3**]**
GRAM STAIN (Final [**2139-4-1**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2139-4-3**]):
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
.
[**Month/Day/Year **] Labs:
[**2139-4-5**] 04:20AM BLOOD WBC-10.6 RBC-4.35 Hgb-12.7 Hct-39.0
MCV-90 MCH-29.2 MCHC-32.6 RDW-13.3 Plt Ct-211
[**2139-4-6**] 02:39AM BLOOD PT-30.6* PTT-30.1 INR(PT)-3.0*
[**2139-4-5**] 04:20AM BLOOD Glucose-88 UreaN-16 Creat-0.6 Na-139
K-3.8 Cl-99 HCO3-34* AnGap-10
Brief Hospital Course:
81F with h/o systolic CHF, severe bronchiectasis, on 2L O2 at
baseline, admitted from chest PT with tachypnea, hypoxia, and
fever.
.
# dyspnea / tachypnea / hypoxemia / bronchiectasis flare -
initial concerning was for infection given fever, roncherous
breath sounds, and underlying severe pulmonary disease. ddx
also included systolic congestive heart failure, given initially
elevated JVP, and patient's report of increased weight over past
few days (last recorded weight 98 lb in [**12-28**] cardiology note, pt
reports baseline weight 90s, currently 105.7lbs on admission),
and less likely PE given above exam.
.
upon arrival to the medical floor, pt was febrile to 101,
tahypneic to 40s-50s, speaking in 1 word sentences, using
accessory muscles, and in distress. ABG notable for hypoxemia
in setting of 4-5L O2 (PO2 55), but more cocerning for PCO2 44
in setting of RR=40-50. she was not a significant chronic
retainer based on prior ABGs. CXR consistent with
bronchiectasis, but without frank significant infiltrate.
.
she was started on albuterol, atrovent nebs, lasix 20mg iv x1
given, cefepime/vanco/levaquin given underlying pulmonary
disease, and frequent health care encounters, though reveiw of
prior sputum cultures revealed bacteria largely levaquin
sensitive. repeat sputum culture ordered. she improved only
modestly, thus ICU evaluation obtained. she confirmed DNR/DNI
status, with her son present. given tenuous respiratory status,
ongoing RR 30s, sats 86% on 6L, fever 101, she was transferred
to ICU for closer monitoring, where she slowly improved
overnight without additional intervention, and was returned to
the medical floor on [**4-2**] PM, with RR 30s, sats 90% on 3L (close
to baseline), and speaking more comfortably.
.
on [**2139-4-3**], vancomycin was discontinued based on sputum with
GNRs only. After discussion with her pulmonologist, plan was
made for [**Date Range **] home on a course of cefepime/levaquin x14
days through [**2139-4-15**]. PICC line was placed. she was continued
on aggressive chest PT, albuterol, atrovent nebs, spiriva. the
severity of her underlying lung disease was discussed with
patient, son, and confirmed with her pulmonologist.
.
ultimately, she was discharged with plan for 14 days of
levofloxacin/cefepime, and close follow-u with her PCP and
pulmonologist.
.
# CAD, native - reported allergy to aspirin. not on BB [**1-20**]
pulmonary disease. initial ECG noted ?loss of RBBB morpholgy in
precordium, however formal [**Location (un) 1131**] felt unchanged from [**9-26**].
she denied chest pain. ACS was felt unlikely given above.
.
# acute on chronic systolic congestive heart failure - as above,
pt initially given 20mg iv lasix x1 given concern for
contribution from mild pulmonary edema, though not marked on
CXR, and now LE edema. she was then resumed on her home regimen
of lasix, spirinolactone.
.
# atrial fibrillation - s/p AVN ablation, PM placement. pt
continued on coumadin. she is not on a BB as above.
- Given her antibiotics and increasing INR, her coumadin was
decreased to 1mg daily until her antibiotics were finished, with
instructions to resume her normal dose thereafter. Her
[**Month/Year (2) **] INR was 3. We recommended repeat INR in 2 days.
.
# axiety/depression - continued on home regimen of citalopram,
ativan.
.
# CODE - DNR/DNI confirmed with patient, and son, [**Name (NI) **] at
bedside.
# COMM - [**Name (NI) **] (son) [**Telephone/Fax (1) 109500**].
.
To do:
1. complete 14 day course antibiotics (cefepime/levofloxacin)
2. chest PT, nebs, pulmonology follow up
3. coumadin dose decreased to 1mg daily until finishes
antibiotics. Frequent INR checks should be performed. Most
recent INR [**2139-4-6**] was 3
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs by mouth every four (4) to six (6) hours as needed
for cough/wheezing
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth q
week
CITALOPRAM [CELEXA] - 20 mg Tablet - 2 Tablet(s) by mouth once a
day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inhaled twice a day rinse after use
FUROSEMIDE [LASIX] - 20 mg Tablet - 0.5 (One half) Tablet(s) by
mouth once a day and increase as directed by Dr [**Last Name (STitle) **]
LISINOPRIL - 5 mg Tablet - [**12-20**] Tablet(s) by mouth once a day
LORAZEPAM - 0.5 mg Tablet - [**12-20**] Tablet(s) by mouth qhs as
needed
for sleep
POTASSIUM CHLORIDE [KLOR-CON 10] - (Not Taking as Prescribed:
not taking) - 10 mEq Tablet Sustained Release - 1 Tablet(s) by
mouth qd as directed by Dr [**Last Name (STitle) **]
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
SPIRONOLACTONE - 25 mg Tablet - [**12-20**] Tablet(s) by mouth once a
day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
WARFARIN [COUMADIN] - 1 mg Tablet - Take up to 3 tablets by
mouth
once a day or as directed by [**Company 191**] Anti-Coag
Medications - OTC
CALCIUM CITRATE-VITAMIN D3 - (OTC) - 315 mg-200 unit Tablet - 3
Tablet(s) by mouth once a day
GUAIFENESIN [MUCINEX] - (OTC) - 600 mg Tablet Sustained Release
- 2 Tablet(s) by mouth twice a day prn
MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Tablet -
1 Tablet(s) by mouth once a day
[**Company **] Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 9 days: through [**2139-4-15**].
Disp:*9 Tablet(s)* Refills:*0*
6. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: until antibiotics completed, then resume normal dose.
13. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 9 days: through [**2139-4-15**].
Disp:*9 Recon Soln(s)* Refills:*0*
14. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
15. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
16. Outpatient [**Name (NI) **] Work
PT/INR check: send to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Fax: [**Telephone/Fax (1) 3382**]
[**Telephone/Fax (1) **] Disposition:
Home With Service
Facility:
Critical Care Systems
[**Telephone/Fax (1) **] Diagnosis:
primary:
bronchiectasis flare with community acquired pneumonia
atrial fibrillation
[**Telephone/Fax (1) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Telephone/Fax (1) **] Instructions:
you were admitted to the hospital with worsening shortness of
breath, likely due to bronchitis/infection in the setting of
your chronic bronchiectasis.
.
you were treated with iv antibiotics, and lasix, with some
improvement, but were [**Hospital **] transferred to the ICU for closer
monitoring. upon return to the medical floor, your symptoms
slowly imroved with antibiotics.
.
you received daily aggressive chest physical therapy.
.
you were ultimately discharged to home with instructions to
complete a regimen of Levofloxacin and Cefepime for 14 days,
through [**2139-4-15**], in addition to your usual medications.
.
the following changes were made to your medication regimen:
1. you were started on antibiotics Levofloxacin and Cefepime, to
complete a 14 day course.
2. Please DECREASE your Coumadin to 1mg daily until you finish
your antibiotics, then resume to normal dose. Please have your
INR checked in [**1-21**] days.
.
INR at [**Date Range **]: 3
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
you will need to follow-up with CHEST PT as per your usual
routine.
Department: REHABILITATION SERVICES
When: TUESDAY [**2139-4-7**] at 2:50 PM
With: [**Name (NI) **] DING, PT, DPT [**Telephone/Fax (1) 2484**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
you will need to follow-up closely with your primary care
physician, [**Name10 (NameIs) **] appointment has already existed for you:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2139-4-8**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], 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: REHABILITATION SERVICES
When: WEDNESDAY [**2139-4-8**] at 3:00 PM
With: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS [**Telephone/Fax (1) 2484**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"494.1",
"715.90",
"428.0",
"V58.61",
"427.31",
"V45.81",
"300.4",
"V43.3",
"414.01",
"799.02",
"252.01",
"486",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7215, 10949
|
306, 322
|
4382, 7192
|
15713, 16844
|
3566, 3990
|
10975, 14436
|
4005, 4363
|
259, 268
|
350, 2329
|
14451, 15690
|
2351, 3129
|
3145, 3550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,077
| 166,684
|
52345
|
Discharge summary
|
report
|
Admission Date: [**2174-5-30**] Discharge Date: [**2174-6-10**]
Date of Birth: [**2096-12-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
Cardiac catheterization
Electrophysiologic study
ICD implant placement
History of Present Illness:
77 y/o man with a history of diabetes, coronary disease s/p CABG
[**2162**] and several subsequent PCI, chronic renal failure, copd,
and atrial fibrillation on coumadin presents as a transfer from
[**Hospital **] hospital with chest pain.
He was admitted last week to [**Hospital **] hospital with chest pain
and ruled out for acute MI. He refused catheritization at that
time and was discharged. He was re-admitted sunday [**5-28**] with
recurrent chest pressure, diaphoresis, which began while at
dinner saturday night. He was found with a HR in the field of
160, BP 90s systolic. In the emergency department an EKG showed
an SVT, interpreted as atrial flutter. He had a blood pressure
in the 70s and attempts at chemical cardioversion with lopressor
IV and adenosine were unsuccesful. He then received amiodarone
and versed and became unresponsive with a BP in the 40s. He was
DC cardioverted with apparent return of atrial fibrillation the
60s and SBP 130. (pre and post-cardioversion telemetric strips
are not available).
.
He was admitted to [**Hospital **] hospital. His hospital course was
complicated by recurrent chest pain and a troponin elevation
wtihout CK elevation. It was presumed secondary to cardioversion
as EKGs were without ischemic changes. At some point he
converted to normal sinus rhythym with a markedly prolonged PR
interval. His metoprolol dose was increased to 100mg twice
daily, but this was decreased subsequently as he developed 2:1
wenkebach. He was evaluated by cardiology and was transfered to
[**Hospital1 18**] for consideration of cardiac cath and/or flutter ablation.
His coumadin was held, INR was 1.8 on transfer.
Past Medical History:
# Coroary Artery Disease: CABG [**2152**]. PCI in [**4-/2170**], [**5-/2170**], and
10/[**2170**].
-PCI [**4-/2170**]: Atritic LIMA, occluded SVG to OM1/OM2, patent
SVG-Diag, unsucessful attempt at PCI of OM1 for placement of DES
to graft. Lcx dissection
-PCI [**5-/2170**]: succesful PCI of SVG to OM
-PCI [**9-/2171**]: patnet SVG-D2, patent SVG OM1-OM2, no intervention
# Diabetes Mellitus
# Atrial Fibrillation, on coumadin
# Stroke with residual left hand dysfunction
# Hyperlipidemia
# Diverticulitis with partial bowel resection, colostomy s/p
reversal
# Chronic Renal Failure, b/l 1.5-2
# COPD
# Hypertension
# Tobacco Use, active
# Gout
# GERD
Social History:
Lives in [**Location **] by himself. divorced, currently in a
relationship. Had 5 children, 1 passed away in [**2164**]. Former part
time police officer and welder, retired. Quit smoking most
recently 2 weeks ago, no etoh use.
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
98.3 160/63 62 18 97%RA
GEN: elderly male, not in any acute distress, obese
HEENT: moist mucus membranes
CV: RRR s1, s2, no M/G/R
RESP: course bs bialterally, low-pitched expiratory wheezes, no
crackles
ABD: soft, obese, several lumps palpated (?sub-cu scar tissue)
midline scar noted and laparoscope scars noted left and right of
midline.
EXT: no edema
Pertinent Results:
[**2174-5-31**] 06:25AM BLOOD WBC-11.8* RBC-3.99* Hgb-11.9*# Hct-35.7*
MCV-89 MCH-29.7 MCHC-33.2 RDW-17.8* Plt Ct-221
[**2174-6-10**] 09:00AM BLOOD WBC-10.5 RBC-3.52* Hgb-10.5* Hct-32.7*
MCV-93 MCH-29.8 MCHC-32.1 RDW-17.5* Plt Ct-173
[**2174-5-31**] 06:25AM BLOOD Neuts-69.4 Lymphs-21.7 Monos-6.1 Eos-2.2
Baso-0.5
[**2174-6-10**] 09:00AM BLOOD PT-13.1 PTT-30.8 INR(PT)-1.1
[**2174-6-10**] 09:00AM BLOOD Glucose-192* UreaN-40* Creat-1.9* Na-139
K-4.6 Cl-108 HCO3-24 AnGap-12
[**2174-5-31**] 06:25AM BLOOD Glucose-120* UreaN-43* Creat-1.7* Na-143
K-4.7 Cl-109* HCO3-22 AnGap-17
[**2174-6-1**] 06:55AM BLOOD cTropnT-0.28*
[**2174-5-31**] 06:25AM BLOOD TSH-2.7
[**2174-5-31**] 06:25AM BLOOD CK(CPK)-41
Brief Hospital Course:
1. Ventricular tachycardia
Patient presented for cardiac cath, and after admission
presented with a new wide-complex tachycardia, which was
interpretted as non-sustained VT with rate 150. He underwent
cardiac catherization on [**6-1**] in order to identify any ischemic
cause of arrhythmia or conduction delays. Cath showed patent
grafts and ostial stenosis of both right and left main
coronaries, not ammenable to intervention. Patient likely
perfuses via retrograde filling of LAD from diagonal stent and
collaterals. Patient then had EP study on [**6-6**]. However, the
clinical NSVT could not be induced. Two other VT patterns were
induced, and patient became unstable with these. In order to
prevent these unstable VTs, and also to allow adequate drug
therapy without inducing bradycardia, a dual chamber [**Company 1543**]
ICD was therefore placed on [**6-7**]. The ICD was set to pace VT at
a rate of 180. The evening after ICD placement, patient
developed sustained VT with hypotension (SBP 80) and slowed
mentation. He spontaneously converted to NSR, but VT recurred
within minutes. EP was called and ICD was adjusted to threshold
HR 160. Patient was transferred to CCU overnight on [**6-7**] and
received bolus of amiodarone and continued on metoprolol.
Patient then remained in NSR with occasional non-sustained VT
without symptoms terminated with anti-tachycardia pacing by the
ICD. Last run was 11:30 pm on [**6-7**]. He remained hemodynamically
stable. Per EP rec's, patient was started on mexelitine on [**6-8**],
but it was held on [**6-9**] after CNS changes including mental
inattention and sluggishness. His mental faculties returned to
baseline after Mexilitine was held and he had no further
episodes of arrythmia. Based on discussion with the cardiology
attending the plan is to continue on Metoprolol and not start an
anti-arrhythmic and allow the ICD to pace Mr. [**Known lastname 4027**] out of his
Ventricular Tachycardia. If he requires frequent defibrillations
however anti-arrhythmic therapy would have to be reconsidered.
- Mr. [**Known lastname 4027**] will need to follow up with his device clinic
appointment
- The Electrophysiology clinic was notifed of pt's discharge and
contact rehab centre for an appointment with Dr. [**Last Name (STitle) **] at
[**Hospital1 18**], if you have not heard from them by Wednesday please call
his office [**Telephone/Fax (1) 62**]
2. Coronary disease
Cath demonstrated patent grafts from prior CABG, with no
significant change since prior PCI on [**9-13**]. Patient was
continued on home metoprolol and Imdur. He was restarted on ASA,
Statin and Lisinopril.
3. Atrial fibrillation
Patient has chronic a fib, with complications including previous
stroke. He is chronically anticoagulated and rate controlled.
Coumadin was held and heparin drip started due to procedures and
tenous course. Following his ICD placement, he was restarted
directly on to Coumadin without Heparin bridge. Rate control
with metoprolol was continued.
- Please continue to check PT/INR every Monday and Friday and
titrate his Warfarin dose for a goal INR of 2.0-3.0.
4. Acute on chronic renal failure:
Patient has baseline creatinine 1.8-2.0, was 1.6-2.0 during
hospitalization. Urine output remained stable. Prior to
discharge pt's Lisinopril was restarted but his Furosemide
dosing was held.
5. Pain control
Patient complained of pain over the ICD site and shoulder pain
following EP study and ICD placement. Pain is likely due to the
ICD and not cardiac event, pain was controlled on Tylenol with
Codeine and lidocaine patch.
6. DM
Patient's home glucotrol and Zestril was held, and patient was
controlled on insulin sliding scale. Fingersticks were well
controlled.
7. Hypertension
Patient was continued on home Metoprolol and Imdur. His home
Lisinopril was briefly held due to an elevated Creatinine but
restarted prior to discharge. His blood pressure improved
significantly during his hospitalization.
8. COPD
Patient was started on Albuterol, Atrovent and Advair for
wheezing. His wheezing improved markedly with this regimen. He
was encouraged to quit smoking. Outpatient PFT's are
recommended.
9. Gout
Patient had no evidence of acute flare, he was continued on
renally dosed allopurinol.
10. GERD
Home PPI was held on admission to the CCU to avoid increasing
pneumonia risk, but was restarted after episodes of severe
reflux with drinking.
Medications on Admission:
Allopurinol 300mg po qday
Imdur 120mg po Qday
Coumadin 5mg po Qday
Novolog prior to meals
zocor 80mg po qday
atroven nebs ih q4-6h prn
albuterol nebs ih q4-6h prn
metoprolol tartrate 50mg po BID
prilosec 20mg po BID
furosemide 40mg po qday
tramadol prn
aricept 10mg po qhs
glucotrol XL 5mg po qday
zestril 10mg po qday
NTG sL prn
aspirin 81mg po qday
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-10**] Inhalation Q6H (every 6 hours) as needed
for dyspnea.
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Daily at 4pm.
12. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Glucotrol XL 5 mg Tablet Extended Rel 24 hr (2) Sig: One (1)
Tablet Extended Rel 24 hr (2) PO once a day.
15. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times a day.
16. Acetaminophen-Codeine 300-15 mg Tablet Sig: One (1) Tablet
PO q8H:PRN as needed for pain for 7 days.
17. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
18. Stockings
Please wear compression stockings for you lower extremity edema
19. Outpatient Lab Work
Pleae have your blood drawn every Monday and Friday to check
your PT, INR. Your Coumadin medication will be titrated by the
rehab doctors based on this lab
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Primary: Ventricular tachycardia, Hypertension, COPD, A.
Fibrillation, Diabetes Mellitus, Coronary Disease
Secondary: Hyperlipidemia, h.o. Stroke, GERD
Discharge Condition:
Improved, Stable.
Discharge Instructions:
You were admitted to the hospital after an episode of chest pain
that was found to be an abnormal heart rhythm. You were first
taken to [**Hospital **] Hospital, where the abnormal heart rhythm was
converted to a normal rhythm using an electrical impulse to your
heart. You continued to have chest pain, however, so you were
taken to the [**Hospital3 **] [**Hospital 1225**] Medical Center. While you
were here, you continued to have episodes of this unstable heart
rhythm. As a result, the Cardiology team placed a pacemaker and
defibrillator device into your left chest to prevent further
arrythmias from occurring.
If you experience another episode of chest pain, sweating,
dizziness, lightheadedness, nausea, vomiting, or feel like you
might pass out, please call your primary care doctor or go to
the nearest emergency room.
Medications:
1. While you were in the hospital, your Allopurinol dose was
decreased from 300mg once daily to 100mg once daily due to your
chronic kidney disease. Please continue to take this medication
as directed.
2. Several of your blood pressure medications were changed based
on your improved hypertension. Your Imdur dose was decreased
from 120mg once daily to 90mg once daily. Please take this
decreased dose was directed. In addition, your Lasix dose was
stopped. Please do not continue taking this medication until you
see your primary care physician.
3. You had some wheezing in the hospital that did not resolve
with your home dose of Albuterol and Atrovent. As a result,
another medication was added, called Advair. Please continue to
take this medication as directed.
Followup Instructions:
Please follow-up in the Cardiology DEVICE CLINIC on [**2174-6-15**] at 10:00AM. Phone:[**Telephone/Fax (1) 62**].
Please follow-up with your cardiologist: Dr. [**First Name (STitle) **] Gaca at
[**Hospital **] Hospital in the next two weeks. You can make an
appointment by calling [**Telephone/Fax (1) 44655**].
Please also follow-up with your primary care provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 31446**] [**Name (STitle) 8521**] at [**Hospital **] Hospital within the next month. You may
schedule an appointment at [**Telephone/Fax (1) 54268**].
You will be contact[**Name (NI) **] by the cardiology office at the [**Hospital 61**] Deaconness for follow-up with Dr. [**Last Name (STitle) **]. If you do
not hear from them by Wednesday [**6-15**], please call
[**Telephone/Fax (1) 62**] to schedule an appointment.
Please check your INR level every Monday & Friday for a goal of
[**1-11**].
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
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|
[
[
[]
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icd9pcs
|
[
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|
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277, 298
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,913
| 126,690
|
49817
|
Discharge summary
|
report
|
Admission Date: [**2137-5-17**] Discharge Date: [**2137-5-30**]
Date of Birth: [**2071-3-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
tracheal bronchial malacia
Major Surgical or Invasive Procedure:
tracheal resection
flexible bronchoscopy
History of Present Illness:
Ms. [**Known lastname 104111**] is a 66-year-old
woman who had pneumonia in [**2137-2-1**], which required
prolonged intubation and subsequent reintubation for failure
to wean. Subsequently at rehab she developed stridor, cough
and worsening dyspnea on exertion. She was found to have a
full tracheal stenosis measuring 3-4 cm. This was noted to be
approximately 1.8 cm from the cricoid and was 7.5 cm away
from the carina. She did have some distal malacia most
notably in the bronchi.
Past Medical History:
Cardiomyopathy (EF=25% on [**2137-4-9**]), HTN, hyperlipidemia, cervical
cancer s/p TAH, R oophorectomy ??????60s, cholecystectomy, colonic
tubular adenoma s/p polypectomy, obesity, anemia
Social History:
Former ICU nurse, ex-smoker 30 pack year history, stopped 20
years ago
Family History:
non-contributory
Physical Exam:
general: Obese female in NAD.
HEENT: neck w/ incisional erythema and swelling below surgical
incision.
Chest: coarse at the bases otherwise clear
COR: RRR S1, S2
abd: obese, soft, round, NT, ND,+BS
extrem: no C/C/E. right PICC line in place.
neuro: intact
Pertinent Results:
CXR [**5-25**]
Mild cardiomegaly is unchanged. There is enlargement of the main
pulmonary arteries suggesting pulmonary hypertension. Multiple
small subsegmental atelectasis and linear atelectasis are in the
right upper and lower lobes and in the posterior segment left
lower lobe. This is unchanged from prior study. If any there is
a small right pleural effusion. Left subcutaneous emphysema in
the neck is better seen in prior CT neck from [**5-23**].
barium swallow [**5-23**]
There is marked subcutaneous emphysema seen in the left side of
the neck and supraclavicular soft tissues on the scout image.
Water-soluble contrast (Conray) followed by thin barium was
administered (with multiple views obtained. Barium passes freely
through the esophagus, with no evidence of a leak. There is no
significant retention in the valleculae or piriform sinuses. No
structural abnormalities are noted in the region of the pharynx
and upper esophagus. There are normal primary peristaltic
contractions.
IMPRESSION: No evidence of esophageal perforation as discussed
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] on the day of the study.
Ct scan neck [**2137-5-23**]
IMPRESSION:
1. Marked improvement in subcutaneous emphysema along the left
neck. Interval development of soft tissue density along the
anterior midline soft tissues of the lower neck, which may
represent dense secretions versus inflammatory changes. No
simple fluid collection or region of abnormal enhancement is
seen to suggest abscess formation. Interval partial resolution
of increased attenuation along the paratracheal fat in the
superior mediastinum.
2. Multiple small mediastinal lymph nodes, right upper lobe
pulmonary nodule, and reticular/peribronchial opacities in the
right upper lobe, unchanged.
Please see the detailed report on CT Trachea done on [**2137-5-2**]
regarding recommendations for the lung nodules.
3. Tiny 5mm hypodense nodule in the left lobe of thyroid, not
adequately assessed. US of thyroid can be considered.
Brief Hospital Course:
pt was admitted and taken to the OR for tracheal rescetion on
[**2136-5-16**]. OR course uneventful. Pt admitted to the SICU Briefly
on neo for hypotension and for close pulmonary monitoring and
aggressive pulmonary tiolet. Guardian stitch in place. Pain
controlled w/ PCA.
POD#3 Transfused PRBC for Post op anemia and hypotension. Neo
was weaned off. Pt was transferred from the ICU to the floor and
the JP drain was d/c'd. Echo was done and revealed EF 25% d/t
cardiomyopthy- acute on chronic heart failure.
POD# 4 incisional erythema was noted, low grade temp and WBC
increased to 14- IV vanco was started.
POD#5 wound remained erythematous and mild crepitus was noted.
Abx coverage was broadened to include cipro and flagyl.
POD#6 increased crepitus noted and neck CT and barium swallow
done to eval for fluid collection in the neck and possible
esophageal leak. Both studies were negative.
POD#8 bronch was done w/o obvious disruption of anastomosis.
Cough supression regimen was maximized - guardian stitch broke
and was not replaced. WBC slowly decreasing. Broad spectrum abx
continued.
POD#9 wound erythema improved. Oxygen sats 75% on roomair sats
93% on 2 liters w/ amb.
POD#10 neck wound opened - minimal amt of serosang drainage.
POD#11 d/c'd w/ [**Hospital1 **] dressing changes and IV vanco, po cipro and
flagyl. Will have outpt pulmonary rehab.
Medications on Admission:
digoxin 250', carvedilol 12.5", zestril 15', ASA 81', nitro
SL prn, atrovent MDI, humibid 30/600"
celexa 20', protonix 40', Tums 1000", colace, vitD3 400', zantac
150", KCL 20', lipitor 20', senna
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 5 days.
Disp:*10 doses* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1*
12. Picc line care
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.
13. picc line care
Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*65 Tablet(s)* Refills:*0*
15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed.
16. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
18. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
19. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
20. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-2**] Inhalation
every 4-6 hours.
21. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
22. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day.
23. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a
day.
24. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Group A strep PNA [**2-8**] requiring 5 wk intubation, resulting in
post intubation tracheal stenosis, Cardiomyopathy (EF=25% on
[**2137-4-9**]) HTN, hyperlipidemia, cervical cancer, s/p TAH, R
oophorectomy, cholecystectomy, colonic tubular adenoma s/p
polypectomy, obesity, anemia
MRSA
tracheal resection and reconstruction c/b wound infection.
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop
productive cough, neck swelling or pain, fever, chills or have
any other symptoms that concern you.
wear your oxygen at all times.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on the
[**Hospital Ward Name **] [**Hospital Ward Name 23**] clinical center on [**2137-6-6**] at 4pm. Please
arrive 45 minutes prior to your appointment and report to the
clincal center [**Location (un) 470**] radiology for a chest XRAY
Completed by:[**2137-6-4**]
|
[
"599.0",
"278.00",
"V10.41",
"519.19",
"425.4",
"272.4",
"401.9",
"285.9",
"428.0",
"998.31",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.79",
"31.5",
"38.93",
"99.04",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
7482, 7540
|
3570, 4932
|
327, 369
|
7931, 7938
|
1513, 3547
|
8196, 8532
|
1203, 1221
|
5181, 7459
|
7562, 7910
|
4958, 5158
|
7962, 8173
|
1236, 1494
|
261, 289
|
397, 885
|
907, 1098
|
1114, 1187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,927
| 122,522
|
21171
|
Discharge summary
|
report
|
Admission Date: [**2188-4-21**] Discharge Date: [**2188-5-7**]
Date of Birth: [**2128-3-3**] Sex: F
Service: MED
HISTORY: The patient was a 60-year-old female who was
transferred to [**Hospital1 69**] from an
outside hospital for management of cryptogenic cirrhosis.
The patient has a history of cryptogenic cirrhosis,
hypertension, diabetes mellitus with increasing abdominal
girth and pain for a few days prior to her presentation to
the outside hospital. At the outside hospital, the patient
had profound hematemesis. She was transferred to the ICU for
intubation and underwent emergent EGD. EGD disclosed three
esophageal varices which were banded. The patient received a
total of 8 units of packed red blood cells and 16 units of
FFP in the ICU at [**Hospital1 2177**]. She was also started on an octreotide
drip for 5 days. The patient was also given levofloxacin
empirically for SBP. Apparently, the patient was thought to
be grossly fluid overloaded and diuresis was initiated with
Lasix and spironolactone. The patient's renal function began
to worsen and she was transferred to [**Hospital1 18**] for further workup
and possible liver transplant.
PAST MEDICAL HISTORY: Cryptogenic cirrhosis x 17 years.
Previous workup unknown.
Hypertension.
Diabetes mellitus type 2.
ALLERGIES: No known drug allergies.
TRANSFER MEDICATIONS:
1. Protonix 40 mg b.i.d.
2. Vitamin K p.o. q. Friday.
3. Levofloxacin 500 mg p.o. q.d.
4. Vancomycin 1 g b.i.d.
5. Propranolol 10 mg t.i.d.
6. Aldactone 100 mg q.d.
7. Lasix 120 mg IV b.i.d.
8. Albuterol nebulizers p.r.n.
9. Atrovent nebulizers p.r.n.
10. Lactulose 30 mg t.i.d.
11. Calcium carbonate.
12. Colace.
13. Senna.
14. Nystatin.
15. Sliding scale insulin.
SOCIAL HISTORY: The patient was born in El [**Country 19118**], moved
to the United States 17 years ago. Remote history of alcohol
use decades ago. Denies use of tobacco.
FAMILY HISTORY: Negative for cirrhosis.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.3 degrees,
blood pressure 100/60, heart rate 54, respiratory rate 18, O2
saturation 96 percent on 2 L. General: Patient lying in
bed, appears cachectic, speaks Spanish only. HEENT: Scleral
icterus. Pupils equally round and reactive to light. Neck:
Supple, no JVD. Heart: Regular rate and rhythm. No
murmurs, rubs or gallops. Lungs: Crackles at bases
bilaterally. Abdomen: Obese, shifting dullness, mild
tenderness to palpation. Extremities: Trace pedal edema.
Neurologic: The patient noted to be grossly intact.
LABORATORY DATA ON TRANSFER: White count 20.5, hematocrit
36.6, and platelets 53. Chemistries: Sodium is 143,
potassium 3, chloride 99, bicarbonate 36, BUN 67, creatinine
1.7, with a glucose of 204. ALT was 72, AST 103, alkaline
phosphatase 112, total bilirubin 20.5, direct bilirubin 11.6.
RADIOLOGY DATA: From [**Hospital1 2177**] on [**2188-4-8**], ultrasound of the
abdomen disclosed ascites, large spleen, no cholecystitis.
CT of the abdomen on [**2188-4-8**] at outside hospital disclosed
cholelithiasis, numerous varices, pleural hypertension,
splenomegaly, no pancreatic abnormalities.
ASSESSMENT: A 60-year-old female with cryptogenic cirrhosis
and recent GI bleed secondary to esophageal varices,
transferred to [**Hospital1 18**] for management of ascites, acute renal
failure, and possible liver transplantation.
HOSPITAL COURSE: The [**Hospital 228**] hospital course will be
reviewed by problems.
Cirrhosis: As noted above, the patient has a history of
cryptogenic cirrhosis. The patient was followed closely by
the Liver Service during her hospitalization and numerous
studies were sent off for workup of the etiology of
cirrhosis. The patient was maintained on SBP prophylaxis
with levofloxacin during her hospital stay. She was also
maintained on lactulose. The patient was noted to have
increasing ascites during her hospitalization. Initially her
diuretics were held given worsening renal failure.
Paracentesis was attempted on [**2188-4-25**] with only 1 L of fluid
removed. Paracentesis was subsequently attempted when
patient was transferred to the ICU. The patient was also
followed by the Liver Transplant Service since she was
initially considered a candidate for liver transplant. As
will be discussed below, the patient eventually developed
infections, which precluded her from being a transplant
candidate.
GI bleed: As noted above, at outside hospital, the patient
was noted to have upper GI bleed secondary to esophageal
varices. During her hospitalization at [**Hospital1 18**], she was
maintained on propranolol. She underwent repeat EGD on
[**2188-4-23**]. She was found to have grade 3 esophageal varices,
3 bands were placed. The patient was also noted to have
portal gastropathy. The patient continued to have guaiac-
positive stools during her hospitalization. She had no
further episodes of hematemesis.
Acute renal failure: On transfer to [**Hospital1 18**], the patient was
noted to be in acute renal failure, thought to be secondary
to prerenal azotemia since she was over-diuresed at the
outside hospital. The patient's renal function continued to
worsen and eventually patient's urine output dropped off.
Renal consult was obtained on [**2188-4-29**]. The Renal Service
felt that the patient's renal failure may be secondary to
numerous insults to include GI bleeding, infection, and
possibly hepatorenal syndrome. Diuretics were held given
concern for prerenal azotemia. The patient was given a trial
of octreotide and mitogen without much improvement in her
renal function. Ultimately, the patient required placement
of a hemodialysis line on [**2188-5-1**] and hemodialysis was
initiated on [**2188-5-2**].
Coagulopathy: During the patient's hospitalization, she was
noted to have prolonged PT, PTT, and thrombocytopenia.
Hematology consult was obtained for workup of her
coagulopathy. The patient was thought to have DIC secondary
to chronic liver disease. She required administration of FFP
prior to procedures during her hospitalization.
Infectious disease: As noted above, the patient required
levofloxacin for SBP prophylaxis. She was noted to have
leukocytosis during much of her hospitalization. Numerous
glycosurias were obtained. On [**2188-5-1**], the patient was
found to grow [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 29361**] from a catheter tip. In
addition, she grew E. coli from her blood. Blood culture on
[**2188-5-2**] grew yeast. Infectious Disease Service was involved
in the patient's care. The patient was maintained on the
appropriate antibiotics during her hospitalization to include
Zosyn, AmBisome, and vancomycin. On [**2188-5-5**], the patient
was noted to have pseudohyphae and hyphae in her sputum.
Respiratory culture later grew mold. Chest x-ray on [**2188-5-6**]
showed worsening consolidation in the right lung and it was
felt that the patient had a fungal pneumonia. Given the
patient's disseminated fungal disease, it was determined that
she was no longer a candidate for liver transplantation.
Respiratory failure: During the patient's hospitalization,
she was noted to be dyspneic on several occasions.
Initially, she was thought to have pneumonia and was treated
appropriately. The patient was transferred to the MICU on
[**2188-4-29**] for management of her hypoxia and acute renal
failure. She became progressively more hypoxemic and
required intubation on [**2188-5-5**]. As noted above, the patient
had a worsening consolidation in her right lung. The patient
underwent bronchoscopy in an attempt to discern which
organisms were causing the patient's pneumonia. Respiratory
culture ultimately grew mold and it was thought that the
patient had disseminated fungemia.
Given the patient's deterioration over the course of this
hospitalization and her disseminated fungal infections, both
the Liver Service and the Liver Transplant Service determined
that the patient was no longer a candidate for a liver
transplant. This was conveyed to the patient's family during
a meeting on [**2188-5-6**]. Over the course of the night on
[**2188-5-6**], the patient declined further. She expired on the
night of [**2188-5-7**]. Family were present at her bedside.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 6327**]
Dictated By:[**Doctor Last Name 22663**]
MEDQUIST36
D: [**2188-5-29**] 11:07:39
T: [**2188-5-29**] 21:49:11
Job#: [**Job Number 56125**]
|
[
"112.5",
"287.4",
"456.20",
"584.9",
"038.40",
"286.9",
"572.4",
"789.5",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"42.33",
"99.07",
"33.24",
"96.04",
"38.95",
"96.71",
"39.95",
"96.6",
"89.64",
"38.91",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
1964, 2010
|
3421, 8540
|
1373, 1772
|
2025, 3403
|
1211, 1351
|
1789, 1947
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,021
| 156,698
|
7951
|
Discharge summary
|
report
|
Admission Date: [**2200-3-7**] Discharge Date: [**2200-3-15**]
Date of Birth: [**2139-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin / adhesive tape / Chlorpromazine
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2200-3-7**]
[**2200-3-11**] CABG x3 (LIMA to LAD, SVG to OM, SVG to DIAG)
History of Present Illness:
The patient is a 60 year old male with CAD s/p MI with DES to
LAD in [**2196**] c/b ISRS in [**2196**] (re-stent) and [**4-/2199**] (BMS x3) and
DES to proximal LAD in [**9-/2199**], rapid atrial tachycardia s/p
AVNRT ablation, DM2, ESRD on HD (last done yesterday), and PVD
s/p partial left foot amputation. He reports that he developed
a productive cough on [**2200-3-3**]. He did not have any fevers or
chills. Later that night, he developed substernal chest pain
and pressure like "an elbow pressing in the chest" up to [**6-17**] in
intensity. He denied any associated dyspnea, nausea, vomiting,
or diaphoresis. The pain resolved with SLNG, but recurred the
next morning shortly before his PCA arrived. He has had anginal
chest pain in the past with a similar quality, but not as
severe. He continued to have chest pain, and was brought to the
[**Hospital3 417**] ED.
.
He was admitted to [**Hospital3 417**] on [**2200-3-4**], where he was found
to have hyperkalemia and Troponin elevation with peak 43.71.
His CXR reportedly showed "mild congestion." He was started on
a Heparin drip. His pain resolved and he had no further
complaints of chest pain, but did have dyspnea getting up to the
commode. He was transferred here today for cardiac
catheterization. Vital signs prior to transfer were T 98.9, HR
68 (SR with LBBB), BP 117/62, RR 22, and SpO2 98% on RA. At the
OSH, he was also noted to be intermittently incontinent of
stool.
.
Cardiac catheterization today was attempted with a right radial
approach, but was unsuccessful, and was converted to a right
femoral approach. The cath showed 3VD and no intervention was
performed. He is now being evaluated for possible CABG. On
arrival to the floor, he was CP free and reported no pain or
tenderness at the cath site. He continued to have a somewhat
productive cough.
.
Cardiac review of systems is notable for absence of current
chest pain, paroxysmal nocturnal dyspnea, orthopnea, significant
ankle edema, palpitations, syncope, or presyncope. He does
report DOE, and is able to walk less than 150 ft and climb less
than one flight of stairs before becoming SOB at baseline.
.
On further review of systems, he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He has had a clot
removed from his dialysis fistula in the past. He denies recent
fevers, chills or rigors. All of the other review of systems
were negative.
Past Medical History:
Coronary Artery Disease s/p cabg x3
Myocardial Infarction
Paroxysmal Atrial Fibrillation
End Stage Renal Disease on Hemodialysis
Peripheral Vascular Disease
Diabetes Mellitus Type 2
Hypertension
Hyperlipidemia
PTSD/Personality disorder/Depression
Social History:
Lives with: lives alone with a dog in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 28523**]
- has a personal care attendant
- his cousin, [**Name (NI) **] [**Name (NI) 28524**], is the HCP
Occupation: retired aircraft mechanic and veteran
Lives: alone / uses guide dog
Race: Caucasian
Tobacco: never
ETOH: none-30yrs
Family History:
# Father -- deceased from a stroke with HTN, DM, CAD s/p CABG
# Mother -- deceased from COPD
# Paternal Grandfather -- MI at age 65-70, died after MI at age
85
# Maternal Grandfather -- died after MI at age 67
# Brother -- HTN and DM2
# Brother(another) -- estranged
# Sister -- mental retardation
No family history of early MI, arrhythmia, cardiomyopathy,
diabetes, hypertension, or hyperlipidemia.
Physical Exam:
Physical Exam On Admission:
VS: T 97.3, BP 132/68, HR 65, RR 18, SpO2 100% on RA
Gen: Middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva without pallor
or injection. MMM, OP benign.
Neck: Supple, full ROM. Unable to assess JVP. No cervical
lymphadenopathy.
CV: Somewhat distant heart sounds. RRR with normal S1, S2. No
M/R/G. No S3 or S4.
Chest: Respiration unlabored. Few bibasilar crackles on limited
exam. No wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, obese, NT, ND.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. No femoral
bruits. Distal pulses intact 2+ radial, DP, and PT. Left partial
foot amputation.
Neuro: CN II-XII grossly intact. Moving all four limbs.
Pertinent Results:
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. 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
are normal. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF=25-30 %). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque . There are three aortic
valve leaflets. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
Mild to moderate ([**2-9**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
POST CPB:
1. Improved [**Hospital1 **]-ventricular systolic function ( EF = 30-35%)
2. Mitral regurgitation is moderate now
3. Unchanged tricuspid regurgitation
4. Intact aorta
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
[**2200-3-14**] 06:18AM BLOOD WBC-11.1* RBC-2.58* Hgb-8.6* Hct-25.0*
MCV-97 MCH-33.3* MCHC-34.3 RDW-15.1 Plt Ct-199
[**2200-3-13**] 09:40PM BLOOD WBC-12.1* RBC-2.71* Hgb-9.0* Hct-26.2*
MCV-97 MCH-33.0* MCHC-34.1 RDW-15.0 Plt Ct-185
[**2200-3-13**] 01:50AM BLOOD PT-14.1* PTT-27.7 INR(PT)-1.2*
[**2200-3-14**] 06:18AM BLOOD Glucose-199* UreaN-44* Creat-7.1* Na-133
K-4.2 Cl-92* HCO3-29 AnGap-16
[**2200-3-13**] 09:40PM BLOOD Glucose-277* UreaN-36* Creat-6.3*#
Na-132* K-4.6 Cl-91* HCO3-28 AnGap-18
[**2200-3-13**] 01:50AM BLOOD Glucose-193* UreaN-23* Creat-4.7*# Na-135
K-4.2 Cl-94* HCO3-29 AnGap-16
[**2200-3-14**] 06:18AM BLOOD Calcium-9.7 Phos-4.5 Mg-3.1*
[**2200-3-13**] 09:40PM BLOOD Mg-3.0*
[**2200-3-13**] 01:50AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.5
Brief Hospital Course:
The patient is a 60 year old male with CAD s/p MI with DES to
LAD in [**2196**] c/b ISRS in [**2196**] (re-stent) and [**4-/2199**] (BMS x3) and
DES to proximal LAD in [**9-/2199**], rapid atrial tachycardia s/p
AVNRT ablation, DM2, ESRD on HD, and PVD s/p left foot
amputation who was admitted to OSH on [**2200-3-4**] with chest pain
with positive cardiac biomarkers and was transferred to [**Hospital1 18**]
for management of NSTEMI. He underwent cardiac catheterization,
which showed three vessel disease. He subsequently underwent
CABG....
.
# NSTEMI with coronary artery disease: The patient presented to
[**Hospital3 417**] hospital on [**2200-3-4**] in setting of chest pain
with troponin I elevation to 43.71 and CK-MB 30.8. He has a
significant history of CAD s/p multiple PCI with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28525**]
and ISRS. Cardiac cath showed on [**2200-3-7**] three vessel disease
and severe diastolic dysfunction. No intervention was
performed, and he was evaluated for CABG by Cardiac Surgery.
CABG was subsequently performed... He was continued on his home
cardiac regimen of Aspirin, Atorvastatin, Metoprolol, and Imdur.
His Clopidogrel was held prior to surgery.
.
# Pump: He was found to have severe diastolic dysfunction on
cardiac cath with ECHO performed on [**2200-3-8**] showing LVEF 40 %
with mild global left ventricular hypokinesis. He does not have
any clinical symptoms of heart failure.
.
# Rhythm: He has a history of AVNRT s/p ablation in 3/[**2199**]. He
also has a history of PAF, and reports episodes every few months
for the last several years. His CHADS2 score is 2 for
hypertension and diabetes. He is currently on Aspirin 325 mg PO
daily and Clopidogrel 75 mg PO daily. He was continued on
Aspirin and Metoprolol. His Clopidogrel was held prior to
surgery.
.
# Cough: He reports developing a productive cough since [**2200-3-3**]
around the same time as his chest pain. He was afebrile and his
WBC count was not elevated.
.
# Hypertension: Continued Metoprolol and Amlodipine.
.
# Hyperlipidemia: Continued Atorvastatin 80 mg PO daily
.
# Diabetes: His HgbA1c was 7.3% on admission labs. He was
continued Insulin NPH 18 units SC BID and a Regular Insulin
sliding scale.
.
# ESRD on HD: He is on a Tue/[**Last Name (un) **]/Sat schedule with last session
yesterday prior to admission. He was kept on his regular
dialysis schedule and home regimen of Nephrocaps and Calcium
Acetate.
.
# OSA: He has shown signs of OSA duringhis stay with
desaturation and evidence of airway obstruction during sleep.
Recommend outpatient evaluation for OSA.
.
# Neuro/Psych: He is reportedly on Neurontin 200 mg PO TID on
Sun/Mon/Wed/Fri and 200 mg PO BID on Tue/[**Doctor First Name **]/Sat per his
records. This was decreased to Neurontin 300 mg PO QHD while
admitted.
Cardiac Surgery Course:
The patient was brought to the operating room on [**2200-3-11**] where
the patient underwent CABG x 3 with Dr. [**Last Name (STitle) **]. Please see
operative report for full details. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, 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. He
was dialyzed on [**3-13**] and [**3-14**] with plan for next dialysis on
[**2200-3-18**] at rehab. 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 **** the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to [**Hospital1 **] in [**Location (un) 701**]
in good condition with appropriate follow up instructions.
Medications on Admission:
Aspirin 325 mg PO daily
Clopidogrel 75 mg PO daily
Atorvastatin 80 mg PO QHS
Metoprolol tartrate 100 mg PO BID
Amlodipine 2.5 mg PO daily
Imdur 60 mg PO daily
Nitroglycerin 0.4 mg SL PRN chest pain
Nephrocaps 1 mg PO daily
Calcium Acetate 667 mg 2 Caps PO TID with meals
Insulin NPH 18 units SC BID
Regular Insulin Sliding Scale
Famotidine 20 mg PO every other day
Colace 100 mg PO BID PRN constipation
Neurontin 200 mg PO TID on Sunday, Monday, Wednesday, and Friday
Neurontin 200 mg PO BID on Tuesday, Thursday, and Saturday
Zolpidem 5 mg PO QHS PRN insomnia
Naproxen 220 mg PO Q12H
Multivitamin 1 tab PO daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Eighteen (18) units Subcutaneous twice a day.
6. insulin regular human 100 unit/mL Solution Sig: One (1)
injection Injection four times a day: According to sliding
scale.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q48H (every 48
hours).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily). Cap(s)
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for temp>38.
18. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
19. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day): Sun, Mon, Wed, Fri.
20. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day): Tues, Thurs, Sat.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease s/p cabg x3
Myocardial Infarction
Paroxysmal Atrial Fibrillation
End Stage Renal Disease on Hemodialysis
Peripheral Vascular Disease
Diabetes Mellitus Type 2
Hypertension
Hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/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**
Followup Instructions:
You should schedule followup appointments with your:
Surgeon: Dr. [**Last Name (STitle) **] in 3 weeks [**Telephone/Fax (1) 170**]
Cardiologist:Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**4-11**] weeks [**Telephone/Fax (1) 8725**]
PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] within 4-5 weeks of discharge. His office
can be reached at [**Telephone/Fax (1) 28526**].
**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:[**2200-3-15**]
|
[
"429.9",
"403.91",
"327.23",
"311",
"V49.73",
"414.01",
"V45.11",
"272.4",
"583.81",
"250.51",
"440.29",
"V02.54",
"585.6",
"250.61",
"536.3",
"362.01",
"424.0",
"369.4",
"357.2",
"250.41",
"416.8",
"301.9",
"410.71",
"V58.67",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"36.13",
"37.22",
"36.15",
"00.14",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13507, 13589
|
6852, 10972
|
319, 423
|
13843, 14060
|
4813, 5777
|
14900, 15529
|
3628, 4030
|
11637, 13484
|
13610, 13822
|
10998, 11614
|
14084, 14877
|
4045, 4059
|
269, 281
|
451, 2992
|
4073, 4794
|
3014, 3262
|
3278, 3612
|
5787, 6829
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,034
| 149,091
|
2459
|
Discharge summary
|
report
|
[** **] Date: [**2161-8-27**] Discharge Date: [**2161-8-29**]
Date of Birth: [**2121-12-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Fever, dysuria, L flank pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
39yo woman with recent travel to [**Country 3992**], [**Country 12602**], and
[**Country 12603**] presented on Wednesday night with headache, abdominal
pain, left flank pain, anorexia, N/V/Diarrhea, fever. She had a
temperature at home over last weekend. It was a/w headache then
on Monday, she developed abd pain/n/v/diarrhea. She had approx
4 BM per day x2 days and two bouts of emesis. She had decreased
PO intake. she also reports dysuria since Monday and one
episode of hematuria on wednesday. She described the pain as
[**6-6**] epigastric with left flank radiation. It was not relieved
by BM. It was dull and aching.
.
Given her poor health, came to ED. She was hemodynamically
stable with BP 100. She was noted to have a leukocytosis to 28
(90% Neutrophils). There she received Ctx, vanco, decadron and
copious IVF.
Past Medical History:
Hep B positive [**2155**]
sinusitis
gastric ulcer, dx in the [**2124**] rx with dicyclomine
EGD in [**8-1**]: neg
H Pylori neg in [**2152**]
UTI in [**3-2**], multiple in the past
no known pyelo
Social History:
She is married and has three children, and her husband lives in
[**Country 3992**]. She travels to SE [**Female First Name (un) 8489**] about once per year for 4 weeks.
She works at a bank, but does not interact with customers.
No tobacco, ET-oh or other drug use.
No use of supplements or herbal medicine.
She feels safe in all her relationships and is not the victim of
violence.
Family History:
Her mother has DM. She reports a distant relative having
"kidney disease", but was unable to specify further.
Physical Exam:
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) **]
VS: 98.1 HR 92 95/53 RR 22 96% RA
eomi perrla no icterus
RRR no MGR
CTAB
soft TTP LLQ
no edema
aaox4 FROM, gait and station not evaluated.
Pertinent Results:
Labs:
[**Last Name (Titles) **] CBC: WBC 28 with left shift, Hct 30.4 Plt 292
Discharge CBC: WBC 10.8, Hct 31.9 Plt 312
LFTs: ALT 21 AST 22 LDH 252 Alk Phos 116 Amylase 26 TBili 0.3 D
Bili 0.2 Haptoglob 351
blood and urine cx negative
U/A on [**Last Name (Titles) **] large blood, trace leuks, [**2-1**] WBC
.
Radiology:
CXR: NAD
CT Abdomen: IMPRESSION:
1. Severe left pyelonephritis.
2. Wall edema in the nondistended gallbladder.
3. Calcified mediastinal lymph nodes consistent with prior
granulomatous disease.
Brief Hospital Course:
IMP: 39yo woman transferred from ICU after presenting with
fevers, chills, nausea, abd pain, left flank pain, and dysuria.
HOSPITAL COURSE BY PROBLEM:
.
# Pyelonephritis: UA on DOA demonstrated only mild bacteria and
WBC's, but CT demonstrated severe L pyelonephritis. She was
admitted to the MICU for concerns about SIRS. Also given her
recent travel, we were concerned about malaria. Notably, her
smear was negative and the patient reports taking antimalarials
during her trip to SE [**Female First Name (un) 8489**]. She was put on vanc and
ceftriaxone, decadron and received ~ 4 L of IVF. She remained
hemodynamically stable and was switched to 500 mg of levo. She
was then transferred to the medical unit, where her condition
continued to improve to a final WBC count of 10.8, and she
remained afebrile with improved abdominal pain. We continued
her on levoflox 500mg qd for a 14d course with close followup
with her PCP.
.
# Anemia: Patient with stable hct but certainly down from
baseline last year of 38. Appeared to be anemia of chronic
inflammation. There was no evidence for hemolysis. This may
require further workup as an outpatient.
.
# Epigastric pain: Patient reports hx of PUD. She had a neg EGD
one year ago. However, we continued to treat her with
dicyclomine and checked an H. Pylori test. It was pending upon
discharge.
Medications on [**Female First Name (un) **]:
fluticasone spray
dicyclomine 10 mg QID
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
2. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
4. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for gas.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Pyelonephritis
2. Fever
3. Headache
4. Diarrhea
5. Abdominal pain
6. Hypotension
Secondary:
1. Anemia
2. Peptic ulcer disease
Discharge Condition:
Good. Patient is in only moderate discomfort and is able to eat,
walk and perform activities of daily living.
Discharge Instructions:
Please take all medications as prescribed. If you begin to
experience any symptoms such as: fever, painful urination, blood
in urine, dizziness, nausea, vomiting or weakness, call your PCP
or come to the emergency department. Please take your
antibiotics as directed. It is very important to complete the
course.
Followup Instructions:
Please contact your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**] [**Telephone/Fax (1) 2936**], to schedule a
follow-up appointment within one week.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"789.06",
"285.9",
"590.10",
"784.0",
"458.9",
"780.6",
"533.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4768, 4774
|
2847, 2970
|
359, 366
|
4956, 5068
|
2308, 2824
|
5432, 5737
|
1865, 1977
|
4312, 4745
|
4795, 4935
|
5092, 5409
|
1992, 2289
|
273, 321
|
2998, 4289
|
394, 1230
|
1252, 1448
|
1464, 1849
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,536
| 105,450
|
11489+56243
|
Discharge summary
|
report+addendum
|
Admission Date: [**2157-3-20**] Discharge Date: [**2157-3-31**]
Service: MEDICINE
Allergies:
Penicillins / Warfarin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 F presented to ED w/ complaints of bilateral lower extremity
pain and weakness over the lsat 9-10 days. She lives alone in
her own apartment and is now having trouble ambulating because
"my legs just won't work well, and I have pain from hips to my
feet". She was recently admitted and treated with Azith +
Cefpox for presumed URI. At that time, it was recommended by PT
consult that she go to rehab, but she refused. Her daughter
stayed with her at home until today when she went back to NY.
Patient then came here. She states she wanted to come into ED
on Friday, but daughter [**Name (NI) 36665**]'t let her.
.
ROS: No HA, falls, fever, SOB, CP, abd pain, cough, chills,
flank pain, numbness, change speech, diarrhea, vomiting,
dysuria, rash or syncope. Other 10 pt detail is negative
.
In the ED vital signs wer 98.6, 168/82, 85, 18, 99%RA. They
noted her abdomen to be tender. Urinalysis was concerning for
urinary tract infection so she was given Ciprofloxacin for
presumed UTI. (Prior UAs have shown WBCs, leuk est, without
doucmented UTI). She denies dysuria, fever, flank pain. Other
labs were normal. She received xrays of pelvis, hips, L-S spine
and these were reportedly normal (final read pending). A 5 x
2.5cm AAA was noted on CT aortogram, and felt to be unchanged
from prior evaluations (final read pending). She has stable
mild hip flexor weakness but no other neurologic symptoms.
.
She has no elected HCP in her chart. A daughter is listed as
her emergency contact.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Coronary Artery Disease s/p CABG in2006
4. Paroxysmal atrial fibrillation
5. Right common iliac stenosis with retrograde dissection
6. Abdominal aortic aneurysm (4.5 x 4.7 cm)
7. h/o hyperthyroidism
8. Cataracts
9. Vitamin B12 deficiency
10. history of Gallstone pancreatitis
11. Hearing Loss
12. s/p appendectomy
13. Uterine prolapse s/p pessary placement (none now)
14. s/p Spinal infarct 10 yrs ago. Patient now has partial
numbness in both leg, vagina and perineum.
15. Recent antibiotic treatment: Azithromycin/Cefpodoxime [**2-26**]
Social History:
Home: lives alone; widowed; has a daughter in [**Name (NI) 531**]
([**Female First Name (un) **])
and son [**Doctor First Name 4884**] in [**State 4565**]
EtOH: Denies
Drugs: Denies
Tobacco: 60-80 PPY history, quit > 10 years ago
Family History:
Father - died at age 77 with bleeding PUD
Mother - died in 90s with history of HTN
Sister - died at age 59 with colon cancer
Physical Exam:
VS: 98.2, 65, 173/81, 98% RA
GEN: Well in NAD
ENT:Anicteric, OP clear w/o lesions, no [**Doctor First Name **], nl thyroid, no
bruits
LUNGS: CTA bilat
COR: Regular w/ occasional premature beat, nl S1/S2, no audible
MRG
ABD: soft, non-tender, palpable pulsatile mass, no HSM, active
b.s.
EXT: no C/C, no edema
SKIN: no rash or lesions
NEURO: A&O x 3, moves all extremities, strength grossly intact
except 4+/5 left hip flexor vs R, all else is symmetric, no
sensory deficits, patient walks with me in the hallway taking my
arm. Initially states she can't get beyond the bed, but when
distracted seems to walk well and does so down the hallway with
me. Stands to side of bed and gets in bed on her own without
difficulty.
Pertinent Results:
[**2157-3-20**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2157-3-20**] 02:25PM URINE RBC-0-2 WBC-[**4-28**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2 RENAL EPI-0-2
[**2157-3-20**] 10:40AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-SM
[**2157-3-20**] 10:40AM URINE RBC-0 WBC-21-50* BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2157-3-20**] 10:38AM LACTATE-1.4
[**2157-3-20**] 10:30AM GLUCOSE-100 UREA N-15 CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
[**2157-3-20**] 10:30AM LIPASE-33
[**2157-3-20**] 10:30AM CALCIUM-8.6 PHOSPHATE-2.9
[**2157-3-20**] 10:30AM WBC-5.9 RBC-4.20 HGB-11.0* HCT-33.3* MCV-79*
MCH-26.2* MCHC-33.0 RDW-15.1
[**2157-3-20**] 10:30AM PLT COUNT-418
[**2157-3-20**]
Pelvic xray
Hip xray
L-S xray
CT aortogram
Brief Hospital Course:
87 yo female admitted with self-reported functional decline.
This coincides with her daughter having left to return to
out-of-state home after being with her for several weeks after
last admission. Patient has reportedly declined home VNA and
home PT, and she states they weren't giving me what I needed,
though is vague about the latter. Soon after admission she
developed AF with RVR.
.
Atrial fibrillation with rapid ventricular response: The
patient has a long h/o AF wiht RVR. An IV amio load was started
and soon afterward she cardioverted back to SR. Unfortunately
she refused to take the PO amio as she developed the same side
effects that she previously had on this drug. She was put back
on her Toprol XL and the dose was titrated to 100 mg [**Hospital1 **]. Her
resting HR's are in the 50-60's at this dose and she ambulates
without symptoms. If she failed this BB dose, may consider
dronedarone. At this higher dose of BB she does occasionally go
into AF, but the rates stay in the 100-120 range rather than
200+ as she had on admission. Should have a high threshold for
holding BB. Would avoid adding HCTZ as electrolyte abnormalities
propigate her AF.
Coronary Artery Disease: s/p CABG in [**2154**]. She has a known
reversible LAD defect on stress testing with ST changes with
rapid rates which have now resolved. We continued ASA 325.
Cellulitis: The patient got an infection at an IV site. This was
treated with ancef/keflex and it improved rapidly. She will
complete a 5 day course.
Anemia: Hematocrit at baseline. Continue B12 supplements
Deconditioning:The patient is quite deconditioned from her
multiple hospital stays and needs physical therapy. This was not
working well at home and we have arranged inpatient rehab for
her.
Dirty UA: Repeat UA's were not significant for infection. Would
not treat w/o symptoms.
Code: confirmed DNR/DNI
Communication: Patient . Patient requests that her family not be
contact[**Name (NI) **]. [**Telephone/Fax (1) 36659**] ([**Name2 (NI) **]TER)
Medications on Admission:
Regular Daily meds
1.Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2.Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3.Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
.
Non-regular meds
4.Pyridoxine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6.Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation for 3 doses.
Discharge Medications:
1. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis: 427.31 ATRIAL FIBRILLATION
Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN
Secondary Diagnosis: 414.05 CAD, BYPASS GRAFT
Secondary Diagnosis: 285.9 ANEMIA, UNSPECIFIED
Secondary Diagnosis: 682.3 CELLULITIS, ARM
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:
Patient being transferred to a facility.
Followup Instructions:
(if patient no longer in rehab)
Department: [**Hospital3 249**]
When: TUESDAY [**2157-4-12**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2157-4-19**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname 6526**],[**Known firstname 2281**] Unit No: [**Numeric Identifier 6527**]
Admission Date: [**2157-3-20**] Discharge Date: [**2157-3-31**]
Date of Birth: [**2069-4-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Warfarin
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Patient was not discharged but rather transferred to ICU on
[**3-30**].
Brief Hospital Course:
Ms. [**Known lastname **] was transferred to the ICU on [**3-30**]. She had
developed leukocytosis, abdominal pain, hypotension and lactic
acidosis. She also was also in atrial fibrillation with heart
rates to the 170s. She was converted into normal sinus rhythm
with amiodarone; however her hypotension and acidosis did not
improve. She had been on antibiotics and there was concern for c
difficile colitis. She was treated with PO vanc and IV flagyl
but did not improve. Her lactate peaked at 6.2 on [**3-31**] and her
blood pressure dropped to systolic of 60s. She was clear in her
wishes to be DNR/DNI. Her family was called and they felt that
initiation of blood pressure support would not be her wishes and
goals of care were transitioned to comfort measures. She was
started on morphine and non-essential medications were stopped.
She passed soon after. Her family declined autopsy but the cause
of the decline leading to her death was felt to have been most
likely bowel infarction in the setting of atrial fibrillation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2157-3-31**]
|
[
"276.1",
"783.7",
"401.9",
"038.9",
"V45.89",
"557.0",
"309.28",
"427.31",
"584.5",
"682.4",
"441.4",
"624.8",
"V16.0",
"268.9",
"294.9",
"999.39",
"389.9",
"285.9",
"682.3",
"995.92",
"414.01",
"623.8",
"E879.8",
"V15.81",
"276.2",
"272.4",
"785.52",
"008.45",
"782.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10368, 10611
|
9315, 10345
|
246, 252
|
7818, 7818
|
3528, 4433
|
8066, 9292
|
2645, 2771
|
7037, 7451
|
7565, 7565
|
6503, 7014
|
8001, 8043
|
2786, 3509
|
198, 208
|
280, 1780
|
7773, 7797
|
7584, 7611
|
7833, 7977
|
1802, 2380
|
2396, 2629
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,542
| 124,737
|
32936
|
Discharge summary
|
report
|
Admission Date: [**2189-11-30**] Discharge Date: [**2189-12-5**]
Date of Birth: [**2130-10-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
occasional SOB
Major Surgical or Invasive Procedure:
AVR(#23 MM Tissue valve)([**11-30**])
History of Present Illness:
60 yo M with history of heart murmur since his 20's, followed by
serial echo which most recently showed a trileaflet AV but
functionally bicuspid valve with fused leaflets and severe AI.
MRI also showed severe AS. Cath showed no CAD. He was referred
for AVR.
Past Medical History:
AI/AS, depression, ADHD, Aspergers syndrome, BPH, LBP
Social History:
lives alone
quit tobacco 15 years ago after 3 ppd
Sober for 23 years
Family History:
NS
Physical Exam:
NAD
Lungs CTAB
Heart RRR 3/6 SEM with radiation to carotids
Abdomen Soft/NT/ND
Neuro Grossly intact
Extrem warm, no edema
Pertinent Results:
[**2189-12-5**] 07:25AM BLOOD WBC-10.6 RBC-3.01* Hgb-9.0* Hct-26.4*
MCV-88 MCH-29.8 MCHC-33.9 RDW-13.8 Plt Ct-326
[**2189-12-5**] 07:25AM BLOOD Plt Ct-326
[**2189-12-1**] 03:05AM BLOOD PT-12.5 PTT-32.9 INR(PT)-1.1
[**2189-12-5**] 07:25AM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-140
K-4.2 Cl-105 HCO3-25 AnGap-14
CHEST (PA & LAT) [**2189-12-3**] 5:55 PM
CHEST (PA & LAT)
Reason: eval for effusions
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p AVR
REASON FOR THIS EXAMINATION:
eval for effusions
HISTORY: Status post AVR, to evaluate for effusions.
FINDINGS: In comparison with the study of [**12-1**], there is
increasing left pleural effusion. There is also increase in the
smaller right pleural effusion. Mild atelectatic changes are
seen at the bases in this patient who has undergone a previous
median sternotomy.
IMPRESSION: No evidence of acute pneumonia.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76632**], [**Known firstname 198**] [**Hospital1 18**] [**Numeric Identifier 76633**] (Complete)
Done [**2189-11-30**] at 9:36:48 AM 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: [**2130-10-31**]
Age (years): 59 M Hgt (in): 64
BP (mm Hg): 128/76 Wgt (lb): 145
HR (bpm): 58 BSA (m2): 1.71 m2
Indication: Intra-op TEE for AVR
ICD-9 Codes: 440.0, 424.1
Test Information
Date/Time: [**2189-11-30**] at 09:36 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW209-9:2 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.36 >= 0.29
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *3.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *48 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - LVOT pk vel: 0.67 m/sec
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. Normal
interatrial septum. No ASD by 2D or color Doppler.
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.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Severe (4+) AR. Eccentric AR jet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. The MR vena contracta is
<0.3cm. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. 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.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Severe (4+) aortic regurgitation
is seen. The aortic regurgitation jet is eccentric.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and was
in sinus rhythm.
1. A well-seated bioprosthetic valve is seen in the aortic
position with normal leaflet motion and gradients (mean gradient
= 10 mmHg). No aortic regurgitation is seen.
2. Biventricular functions is preserved
3. Aortic contours are intact post decannulation.
4. Other findings are unchanged
Brief Hospital Course:
He was taken to the operating room on 1.14 where he underwent an
AVR. He was transferred to the ICU in stable condition. He was
extubated on POD #1. He continued to require intermittent neo
which was weaned to off by POD #2 and he was transferred to the
floor. He did well postoperatively. He remained in the hospital
after having a fever on POD #4. He was afebrile x 24 hours and
was ready for discharge on POD #5. He complained of tooth pain
and was started on Penicillin and asked to follow upw ith his
local dentist.
Medications on Admission:
AI/AS, depression, ADHD, Aspergers syndrome, BPH, LBP
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 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. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Chlordiazepoxide HCl 25 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
10. Penicillin V Potassium 250 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
AI/AS now s/p AVR
depression, ADHD, Aspergers syndrome, BPH, LBP
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 50274**] 2 weeks
Dr. [**Last Name (STitle) 5874**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2189-12-5**]
|
[
"780.6",
"998.89",
"525.8",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
8419, 8481
|
6629, 7151
|
338, 378
|
8590, 8598
|
1008, 1409
|
846, 850
|
7255, 8396
|
1446, 1470
|
8502, 8569
|
7177, 7232
|
8622, 8874
|
8925, 9081
|
865, 989
|
284, 300
|
1499, 6606
|
406, 666
|
688, 743
|
759, 830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,571
| 169,682
|
19490
|
Discharge summary
|
report
|
Admission Date: [**2108-3-22**] Discharge Date: [**2108-3-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
The patient is an 84 year old female with a history of CAD s/p
CABG, Afib w/ PPM, recent ORIF c/b wound dehiscence, PMR (not on
steroids) who was admitted to the MICU for recurrent CDiff and
dehydration on [**2108-3-22**]. The patient's course has been fairly
complicated beginning with a fall in [**2107-11-28**] requiring R
hemiarthroplasty which was complicated by wound
dehiscence/hematoma formation requiring evacuation in [**1-4**] and
further complicated by acute renal failure which ultimately
resolved. Since then, the patient has had episodes of Cdiff at
rehab intermittently for 7 day bouts for the last three weeks.
Apparently, most recently, PCP has ordered PO vanco for
treatment of Cdiff confirmed by lab specimens.
.
On arrival in the ED her temp was noted to be 101.2 89 98/34 18
98%2LNC, subsequently to 88/22, given 6L NS w/ ~1L UOP, and
subsequent improvement of BP to 110s-120s on arrival to MICU for
?sepsis. In addition, she was given ASA 325, levofloxacin 500,
tylenol, flagyl 500 IV, and potassium repletion. Central line
placed in LIJ which showed CVP of 12, however, mixed venous O2
sat on arrival 96%.
.
On arrival to MICU, RR ~30, but the patient denied feeling short
of breath, O2 sat ~100% 3LNC.
Past Medical History:
# CAD 4vCABG 11/[**2098**]. No history of MI or angina. Done as pre-op
for cholecystectomy.
# S/p RV pacer [**2093**] and replaced [**2103**] for arrhythmia
# HTN
# Hypercholesteremia
# Ventral hernia - massive, present for 17 years without
complications, except has wound under this hernia (in the
intertriginous area)
# Afib on anti-coagulation
# Polymyalgia rheumatica - was on long-term prednisone, weaned
in [**2102**].
# Macular degeneration - legally blind
# History of hyponatremia (127-132) thought to be hypovolemic
# s/p cholecystectomy
# s/p 'tummy tuck' 30 years ago
# Chronic stasis ulcers LE- followed by Dr. [**Last Name (STitle) **]
# osteoarthritis
Social History:
Originally from South [**Country 480**]. Lives in [**Location **] [**Hospital3 **].
Reports being dependent on others with bathing, dressing. Has a
motorized wheelchair. She has 4 children. 6 [**Last Name (un) **] yr history, quit
smoking 15 years ago. Rare etoh. Plays bridge with friends
regularly.
Family History:
Mother with breast CA and colon CA, Father parkinsons
Physical Exam:
VS 97.2 P 76 BP 110/67 21 96% 3LNC
GENERAL: Tachypneic but otherwise in no distress, elderly female
appearing stated age, able to speak full sentences, pleasant,
AOX3
HEENT: PERRL, EOMI,
NECK: no JVD, supple, no LAD
CARDIOVASCULAR: S1, S2, irregularly irregular, II/VI systolic
LUNGS: Diffuses wheezes, no overt rales
ABDOMEN: Large ventral hernia, slightly tender to touch and
warm, but otherwise remainder of abdomen is nontender,
hyperactive bowel sounds.
EXTREMITIES: Warm, venous stasis ulcers bilaterally, +2 p edema
throughout
Pertinent Results:
[**2108-3-21**] 09:23PM URINE RBC-0 WBC-[**1-30**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2108-3-21**] 09:13PM LACTATE-1.5
[**2108-3-21**] 09:00PM GLUCOSE-95 UREA N-19 CREAT-0.8# SODIUM-136
POTASSIUM-2.8* CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
[**2108-3-21**] 09:00PM LD(LDH)-263*
[**2108-3-21**] 09:00PM ALT(SGPT)-9 AST(SGOT)-21 CK(CPK)-29 ALK
PHOS-99 AMYLASE-18 TOT BILI-0.5
[**2108-3-21**] 09:00PM LIPASE-10
[**2108-3-21**] 09:00PM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2108-3-21**] 09:00PM CORTISOL-33.0*
[**2108-3-21**] 09:00PM WBC-26.1*# RBC-3.16* HGB-9.1* HCT-28.1*
MCV-89 MCH-28.8 MCHC-32.4 RDW-17.1*
[**2108-3-21**] 09:00PM NEUTS-86* BANDS-5 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
CT ABD/PELVIS
1. Pancolitis most likely secondary to Clostridium difficile. No
evidence of pneumatosis or free or mesenteric venous air. Most
of the colon is located within the large ventral hernia.
.
DISCHARGE LABS:
[**2108-3-27**] 05:29AM BLOOD WBC-16.7* RBC-3.32* Hgb-9.3* Hct-29.4*
MCV-88 MCH-28.1 MCHC-31.8 RDW-17.4* Plt Ct-495*
[**2108-3-27**] 05:29AM BLOOD Neuts-75.2* Lymphs-11.4* Monos-10.5
Eos-2.9 Baso-0
[**2108-3-27**] 05:29AM BLOOD PT-36.6* PTT-37.6* INR(PT)-4.0*
[**2108-3-27**] 05:29AM BLOOD Glucose-80 UreaN-6 Creat-0.5 Na-135 K-3.4
Cl-102 HCO3-28 AnGap-8
[**2108-3-27**] 05:29AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.6
.
.
CHEST (PA & LAT) [**2108-3-23**] 8:56 AM
Moderate-to-severe cardiomegaly is longstanding. Small bilateral
pleural effusions are present, either persistent or recurrent
since [**2108-1-9**]. Lateral view only suggest new localized
edema or generalized peribronchial infiltration in one of the
lower lobes, probably the left. Edema is less likely given the
absence of pulmonary vascular plethora or any change in the
already dilated cardiomediastinal silhouette. Aspiration should
be considered. Tip of the left jugular line projects over the
SVC. Right atrial and ventricular pacemaker leads follow their
expected courses from the right pectoral pacemaker.
Brief Hospital Course:
The patient is an 84 year old female with a history of CAD s/p
CABG, 2+MR, Afib w/ PPM, s/p ORIF/hematoma evacuation, admitted
for CDiff colitis.
.
# C. Diff Colitis:
The patient was treated with IV flagyl and PO vanco with
improvement of symptoms clinically; she will continue the
antibiotics to complete a 14 day course. She was treated with
IVF and electrolyte repletion.
.
# Positive blood cultures:
The patient had [**12-1**] blood cultures positive for Coag Negative
Staph. She was treated with empiric IV Vancomycin from
[**Date range (1) 52920**]. All repeat blood cultures were negative, therefore,
the IV Vanco was discontinued on [**3-26**].
# Hypotension:
The patient was hypotensive on admission, most likely due to
dehydration rather than sepsis; her BP stabilized with IVF
resuscitation. Her verapamil was restarted on hospital day 2.
.
# Afib/anticoagulation:
The patients INR was elevated on admission, therefore her
Coumadin was held. Albumin level was very low (2.1) which is
contributing to the coagulopathy. The INR was 4 on day of
discharge from the hospital. She should be resumed on coumadin
3mg once INR is less than 3 and the INR should be monitored on a
weekly basis to ensure it remains therapeutic once re-starting
coumadin.
.
# Wheezing:
She was continued on nebulizers: albuterol and atrovent.
Respiratory function improved throughout her hospitalization.
She has a long smoking history, COPD likely played a role.
Also, may be secondary to volume overload, though no evidence of
overt CHF on exam. The patient was allowed to autodiurese given
recent hypotension. She was discharged on albuterol and atrovent
nebs.
.
# Code status: Presumed FULL.
.
# Communication: [**First Name8 (NamePattern2) 52921**] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (1) 52922**]
.
# DISPO:
Patient discharged to rehab. Patient not yet ambulating
independently so foley was kept in place. It should be removed
once she is out of bed ambulating or if she prefers to use bed
pan/urinal.
Medications on Admission:
Warfarin
HCTZ
Percocet
Indomethacin
Lipitor
Verapamil
PO Vancomycin
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 9 days.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for Pain.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever or pain.
9. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
10. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Clostridium Difficile Colitis
Coagulase negative staph bacteremia
Supratherapeutic INR
COPD
Atrial fibrillation
Hypertension
Discharge Condition:
Hemodynamically stable, diarrhea improved, tolerating PO's.
Discharge Instructions:
During this admission you have been treated for dehydration and
C. difficile colitis.
Please continue to take all medications as prescribed. Seek
immediate medical care if you develop fevers, worsening
diarrhea, abdominal pain, dizzyness, or any other concerning
symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2108-4-5**] 10:50
|
[
"725",
"272.0",
"715.98",
"V45.81",
"276.51",
"790.92",
"041.19",
"008.45",
"496",
"790.7",
"401.9",
"459.81",
"414.00",
"369.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8435, 8506
|
5248, 7270
|
270, 294
|
8675, 8737
|
3202, 4132
|
9060, 9215
|
2577, 2632
|
7389, 8412
|
8527, 8654
|
7296, 7366
|
8761, 9037
|
4148, 5225
|
2647, 3183
|
222, 232
|
322, 1552
|
1574, 2242
|
2258, 2561
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,974
| 152,673
|
8336
|
Discharge summary
|
report
|
Admission Date: [**2148-5-9**] Discharge Date: [**2148-5-18**]
Date of Birth: [**2085-10-3**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethoxazole/Trimethoprim / Valium / Erythromycin Base /
Neurontin / Estrogens / Quinine / Zoloft / Paxil / Barbiturates
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 62 yo female with PMH CAD, MVR (on coumadin),
AAA, COPD, anemia presents with GIB.
Pt was recently admitted to [**Hospital1 18**] last week for cardiac cath for
work up of recent DOE/SOB and increasing chest pain over the
past month. Cardiac cath revealed no changed - she had patent
RCA stents and LIMA to LAD. Pt was put on heparin bridge and
restarted on coumadin prior to discharge. Pt states that she saw
her PCP 3 days PTA (monday) to have her [**Hospital1 263**] checked, which was
3.2. On the day prior to admission, pt developed worsening
fatigue, weakness, and lightheadedness. She had a brief episode
of chest discomfort at rest, which she describes as a pressure
like feeling. That evening, pt had an episode of bloody
diarrhea, which she describes as black stool w/dark red blood
mixed in. Pt denies any prior hx of GIB. Pt denies hematemesis,
coffee ground emesis, nausea, vomiting, abdominal pain. Denies
recent NSAID use, other that daily baby [**Hospital1 **]; denies steroid use.
Pt had no further episodes of bloody stools that evening. She
presented to [**Hospital3 7571**]Hospital the following morning. She
states she was given Vitamin K there and was transferred to
[**Hospital1 18**].
In the [**Name (NI) **], pt was given 2U FFP, 2U PRBC. 3 large bore IVs were
placed. NG lavage was negative. Pt was seen by GI, who may
consider EGD in AM. EKG was noted to have ST depressions in the
lateral leads. She underwent colonoscopy - were able to reach
the ascending colon - no obvious source of bleed. Patient has
been transfused a total of 7 U PRBCs since admission on [**5-9**]. No
further bloody bowel movements or melena during admission.
Ontransfer from unit to floor, pt denied CP, SOB, states
weakness/fatigue is improved.
Past Medical History:
Mitral valve replacement(#25 Carbomedics valve) [**7-21**]
AAA (3.6 cm in [**8-22**] on MRI)
CAD s/p s/p ST elevation IMI [**6-21**], CABG in [**7-21**] LIMA to LAD,
reverse SVG from aorta to R PDA
Multiple caths as follows:
[**2-25**]: RCA engaged with difficulty heavily calcified with
diffuse plaquing prox-mid 60%, distal 40% in-stent restonosis,
distal 60% just before PDA, 70% prox PDA; LIMA to LAD patent;
SVG -RCA known occluded; no intervention [**9-23**]: patent LIMA,
native RCA with 40% proximal disease, 40-50% ISR in the mid
stent, RCA was very difficult to engage, but was finally done
with an AL1 catheter.
[**3-22**]: patent LIMA, SVG to RCA was occluded, 2 hepacoat stents
to her native mid + distal RCA.
[**6-21**]: 2.75 x 18 mm stent to her RCA.
[**2148-1-30**] ([**Location (un) **]) Stress test with reversible ant wall defect.
EF 75%
Past Medical History:
- porphyria cutanea tarta- presented with blisters on hands,
scleral icterus, red urine, diagnosed with + protoporphyrins in
urine, not active x 4 years, hx of phlebotomy for this, none in
several years
- COPD
- Nucleated L eye - [**2-22**] complications from trauma -> leading to
trigeminal neuralgia -> s/p surgery for pain control -> loss of
nerve function with damage to eye -> enucleation
- Anemia
- Trigeminal neuralgia
- CHF - calculated LVEF on P-MIBI [**3-8**] 83%, 50-55% on last TTE
in [**2-23**]
- Hyperlipidemia
- Kidney stones 8 months ago
- s/p L ankle repair
Social History:
Retired speech therapist, married, 30+ pack year tobacco
history, quit 3 years ago, no ETOH, no drug use.
Family History:
Mother is alive and well
Father has [**Name (NI) 29512**] disease
Physical Exam:
VS: t97.7, p67 (60-80), 116/37 (110-120/40-50s), rr12, 100%RA
Gen: pale, NAD
HEENT: pale conjunctiva, anicteric, L prosthetic eye, dry MM
CVS: soft HS, RRR, nl s1 s2, [**2-26**] holosystolic murmur at upper
sternal border, difficult to appreciate mechanical valve
Lungs: CTAB, no c/w/r
Abd: soft, NT, ND, +BS
Ext: no edema
Pertinent Results:
EKG: NSR@91, nl axis, 1st degree AV delay, new TWI and slight
downsloping STD in 1, L; new TWI and 1-2mm STD in V2-6
GI studies:
EGD ([**2145**]): Erythema, congestion and edematous folds in the
stomach body and fundus compatible with gastritis. Salmon
colored mucosa distributed in a segmental pattern, suggestive of
Barrett's Esophagus
Colonoscopy ([**2145**]): Normal
Brief Hospital Course:
The patient is a 62 yo female with PMH CAD, MVR (on Coumadin),
AAA, Anemia, porphyria cutanea tarda presents with GI bleed in
setting of supratherapeutic [**Year (4 digits) 263**].
.
GI bleed: The patient presented with a HCT of 16/[**Year (4 digits) 263**] 8.5 and
melena/dark red blood. The patient had a stable AAA and no
evidence of fistula on aortic u/s [**2148-5-3**]. DDx includes AVM,
ulcer, angioectasia, Dieulafoy's. An NG lavage was negative in
the ER. She received 2 units FFP, vitamin K, and 2 units PRBC
in the ED. We held her beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], and Coumadin. [**First Name3 (LF) 263**]
significantly decreased (to 2.5) after FFP and Vitamin K. She
was started on IV Protonix [**Hospital1 **] and GI was consulted. The
patient was admitted to the ICU and an EGD was performed. There
were healed erosions but no evidence of acting bleeding. She
was eventually transfused a total of 5 units of PRBC and her HCT
bumped to 38. HCT stabilized. She was scheduled for a
colonoscopy on [**2148-5-13**] which found erythema in the distal rectum
and anus most likely reflecting trauma from rectal tube. No
polyps, diverticula, or other findings to explain GI bleed. No
blood or clots seen in colon. The scope could not be passed
beyond ascending colon due to poor tolerance. Will need to aim
for tight [**Date Range 263**] control. If patient starts to bleed again while
on anticoagulation, will likely need capsule endoscopy. Patient
was discharged on Protonix.
.
CAD: Pt's recent chest pain is likely secondary to ischemia in
the setting of anemia, as seen on EKG (lateral depressions).
Enzymes were cycled and were negative. She was continued on her
statin. She had another episode of chest pain on the evening of
[**2148-5-11**] in which she was treated with SL nitro, Lasix, morphine,
and metoprolol. Her EKG was unchanged. A CXR showed pulmonary
edema. Her symptoms quickly improved. Cardiac enzymes were
again cycled and were negative. Continued on statin, Isordil,
beta [**Date Range 7005**], and aspirin.
.
s/p MVR: On Coumadin. Presented with supratherapeutic [**Date Range 263**] of
8.5. The patient was placed on a heparin drip after her [**Date Range 263**]
dropped below 2.5. [**Date Range 263**] 3.2 on discharge. Continue Coumadin
with plan to check [**Date Range 263**] on [**5-20**] as outpt.
.
History of CHF: Recent normal echo ([**4-25**]). On the patient second
night of admission she had an acute onset of chest tightness
with evidence of pulmonary edema on CXR. She was treated with
10mg Lasix IV with improvement of symptoms. She was restarted
on her home dose of Lasix 20mg QD.
.
CRI: Creatinine at baseline
.
Trigeminal Neuralgia: continued on Dilaudid and fentanyl patch.
.
Insomnia: continued amitriptyline qhs.
.
Hyperlipidemia: continued Lipitor.
Medications on Admission:
Allergies:
1. Sulfamethoxazole/Trimethoprim
2. Valium
3. Erythromycin Base
4. Neurontin
5. Estrogens
6. Quinine
7. Zoloft
8. Paxil
9. Barbiturates
Medications:
1. Aspirin 325 mg qd
2. Amitriptyline 50 mg qhs
3. Hydromorphone 4 mg q4h prn
4. Fentanyl 100 mcg/hr Patch q72HR
5. Atorvastatin 10 mg qd
6. Metoprolol Tartrate 25 mg [**Hospital1 **]
7. Cyanocobalamin 1000 mcg qd
8. Pantoprazole 40 mg qd
9. Isosorbide Dinitrate 40 mg SR [**Hospital1 **]
10. Furosemide 20 mg qd
11. Coumadin 3 mg (Tues/[**Last Name (un) **]/Sun) 2mg ([**Doctor First Name **],Mo,Wed,Fri,Sat)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. GI bleed in setting of supratherapeutic [**Doctor First Name 263**]
2. Coronary Artery Disease
3. Mitral Valve Replacement
Secondary Diagnoses:
1. Trigeminal Neuralgia
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications exactly as prescribed and
described in this discharge paperwork.
2. Please follow up with your PCP as described below.
3. Please call your PCP if you are experiencing chest pain,
shortness of breath, fever, chills, bleeding/blood in your
stools, or with any other concerning symptoms.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**] ([**Telephone/Fax (1) 29515**]) to schedule
follow up within 1 week of discharge. You should have your [**Telephone/Fax (1) 263**]
checked on [**2148-5-20**].
.
Continue to have your INRs checked as you have been doing, goal
[**Date Range 263**] 2.5-3.5
|
[
"280.0",
"277.1",
"401.9",
"496",
"276.2",
"V43.3",
"286.9",
"553.3",
"V45.81",
"578.1",
"428.0",
"414.01",
"E934.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8110, 8116
|
4644, 7488
|
390, 396
|
8354, 8361
|
4246, 4621
|
8735, 9078
|
3820, 3887
|
8137, 8285
|
7514, 8087
|
8385, 8712
|
3902, 4227
|
8306, 8333
|
344, 352
|
424, 2196
|
3103, 3680
|
3696, 3804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,326
| 174,151
|
4923
|
Discharge summary
|
report
|
Admission Date: [**2118-5-14**] Discharge Date: [**2118-5-25**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fevers, hypotension
Major Surgical or Invasive Procedure:
Femoral HD line removal
Temporary femoral HD line placement
Temporary femoral HD line removal
Femoral HD line placement
History of Present Illness:
59M with MMP including ESRD on HD, h/o recurrent line infection
with current femoral tunneled catheter in place, now admitted
with fevers from HD unit. Pt was feeling well until [**5-14**]
morning, when he developed rigors during dialysis-- he was found
to have a fever, and was subsequently given one dose of
vancomycin and gentamicin, and brought to the ED. Of note, pt's
usual HD schedule in MWF, but was changed to T/Th/Sat this week
due to death of his father last week.
.
In [**Name (NI) **], pt was febrile to 103.5, with HR 104, BP 120s/60s.
Bladder scan showed urine in bladder, but ISC unsuccessful. When
seen on the floor early this morning, pt was sleepy and only
awoke for few seconds, then fell asleep again. Unable to obtain
complete history from patient due to somnolence.
.
Of note, pt has had multiple admissions for MSSA line sepsis,
most recently in [**2117-12-24**], during which time a femoral
catheter was removed and replaced in the R groin. He completed a
course of cefazolin in [**Month (only) **], and was seen by ID at that time.
Past Medical History:
- MSSA HD line infection with septic lung emboli [**9-1**] with left
pleural effusion
- h/o Hepatitis B, treated
- Non-ischemic cardiomyopathy, last EF 40-45%
- MI [**2086**] per pt
- CVA [**2086**] per pt (?residual LE weakness)
- ESRD on hemodialysis [**1-25**] HTN. Currently dialyzed through R
femoral line. EDW 80 kg as of [**2118-1-3**].
- Multiple thrombectomies in LUE and R thigh AV fistula
- Graft excision for infected thigh graft [**2117-5-26**]
- Seizure disorder since mid [**2097**] after starting dialysis
- Hungry bone syndrome status post parathyroidectomy
- Pituitary mass
- Anemia of chronic disease
- s/p PEG tube placement [**2117-10-29**]
Social History:
Has 2 PhDs in History and likes to be called "Dr. [**Known lastname 2026**]" only.
Says he walks with a walker at baseline. Says he has no family
that he would like called in case of emergency. Father recently
passed away.
Tobacco - Denies
EtOH - Reports occasional use, but drinks vodka when he does
drink
Illicit drugs - Denies
Family History:
Father - DM
Mother - Deceased age 41 of renal failure
One son - healthy
Physical Exam:
Physical Exam:
General: African American Male lying flat in bed in NAD
HEENT: Sclera anicteric, dryMM, EOMI
Neck: supple, JVP not elevated
Lungs: CTAB
CV: RRR, [**1-29**] SM in axilla, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
back: No ulcers
Ext: AV fistulas both arms, no edema in lower extremities, 2+ DP
pulse bilaterally, fem HD line in place with clean dressing.
NEURO: A+OX3
.
Pertinent Results:
Labs on admission:
CBC
[**2118-5-14**] 05:35PM BLOOD WBC-7.6 RBC-4.87# Hgb-12.2*# Hct-40.3#
MCV-83 MCH-25.0* MCHC-30.2* RDW-17.5* Plt Ct-314
[**2118-5-14**] 05:35PM BLOOD Neuts-84.0* Lymphs-10.5* Monos-3.7
Eos-1.6 Baso-0.4
BMP
[**2118-5-14**] 05:35PM BLOOD Glucose-104* UreaN-41* Creat-6.8* Na-143
K-5.3* Cl-99 HCO3-28 AnGap-21*
LFTs
[**2118-5-14**] 05:35PM BLOOD ALT-39 AST-35 AlkPhos-125 TotBili-0.5
[**2118-5-14**] 05:35PM BLOOD Lipase-66*
Other chemistry
[**2118-5-15**] 05:57AM BLOOD Genta-2.4*
[**2118-5-16**] 03:56AM BLOOD Type-[**Last Name (un) **] pO2-150* pCO2-41 pH-7.38
calTCO2-25 Base XS-0
[**2118-5-14**] 05:35PM BLOOD Lactate-2.0
[**2118-5-16**] 03:56AM BLOOD Lactate-0.8
==================================================
Chest X ray [**2118-5-14**]:
The lungs are low in volume with minimal atelactasis in both
lung bases. The
cardiac silhouette is top normal. The mediastinal silhouette and
hilar
contours are normal. There are small bilateral pleural
effusions. There is a
healed rib fracture on the right.
IMPRESSION:
Small bilateral pleural effusions.
[**2118-5-16**] TTecho:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild to moderate regional left ventricular systolic dysfunction
with near akinesis of the inferior wall and inferior septum and
moderate hypokinesis of the remaining segments (LVEF = 30 %).
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2118-1-6**],
the findings are similar (LVEF was overestimated on the prior
study)
[**2118-5-19**] TEecho:
No atrial septal defect is seen by 2D or color Doppler. There is
moderate regional left ventricular systolic dysfunction (EF
30-35%) with inferoseptal wall akinesis and inferior wall
hypokinesis. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. There are filamentous strands on the aortic leaflets
consistent with Lambl's excresences (normal variant). Trace
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. No
vegetation/mass is seen on the pulmonic valve.
IMPRESSION: No evidence for valvular vegetation, abscess or
mass. Moderate left ventricular systolic dysfunction. Mild
mitral regurgitation
Radiology Report US EXTREMITY NONVASCULAR RIGHT Study Date of
[**2118-5-16**]
FINDINGS: Transverse and sagittal images of bilateral upper
extremities were obtained. Three nonfunctioning fistula grafts
are identified; one in the right upper arm, one in the left
upper arm, and one in the left forearm. No flow was identified
within these grafts on color Doppler imaging. There is no
subcutaneous fluid collection seen in either arm. No suspicious
soft tissue mass is identified.
IMPRESSION: No collection identified in either arm at the sites
of the old
fistula grafts.
=
=
=
=
=
=
=
=
=
=
=
================================================================
Labs at discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2118-5-25**] 06:05 4.9 3.74* 9.2* 31.5* 84 24.5* 29.1* 17.5*
483*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2118-5-25**] 06:05 711 35* 7.4* 138 4.8 97 27 19
Brief Hospital Course:
# MRSA Bacteremia: Blood cultures obtained on [**5-14**] grew MRSA.
The patient was continued on vancomycin by HD protocol. His HD
line was initially retained despite purulence coming from the
catheter site. However, on hospital day # 2 he developed
hypotension in the setting of receiving lisinopril. He was
transferred to the MICU for concern of sepsis. There his BP was
checked in his legs as he had a history of bilateral UE fistulas
and clots, it was much improved to 110-120s. He was however
tachycardic to 120s, and this improved with IVF. He was 4 liters
positive for his MICU stay. On [**5-16**], his femoral line was
removed by IR. ID was consulted and recommended vancomycin, no
gentamycin. A TTE was negative for vegetation, but the patient
was still febrile as high as 104. An U/S of his bilateral old
fistulae was done and showed no abscess or infected clot. A TEE
was later performed and also negative for vegetations. Renal
followed closely and the patient was given a 24 hr line holiday
before placing a temp line for hemodialysis. He was dialyzed
twice before the temp HD catheter was removed. Blood cultures
were still positive after the temp line was placed. He then had
another 72 hr line holiday. Survelence blood cultures remained
negative. His permanent HD line was placed on [**2118-5-24**]. He will
need to continue his course of vancomycin at HD until [**2118-6-15**]
for a total 4 week course. He will need to follow up in [**Hospital **]
clinic on [**2118-6-2**]. He will need weekly CBC and vanc troughs
drawn and sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD at [**Telephone/Fax (1) 1419**].
.
# ESRD: The patient presented from HD. He had hemodialysis
again on [**5-19**] and [**5-20**], then on [**2118-5-24**] after his new line was
placed. His Lanthanum and Sevelamer were continued. He should
continue to have vancomycin dosed with HD until he completes his
course on [**2118-6-15**].
.
# chronic systolic CHF: The patient showed no signs or symptoms
of volume overload. Hew as continued on ASA 81 mg daily and
digoxin 125 mcg Q every other day. His lisinopril was held
given concern for sepsis and hypotension. He should restart his
home dose lisinopril at discharge. He should continue his
schedule of HD.
.
# Social/father death: The patient's father passed away the week
prior to his presentation and the funeral was held in New
Jersey. The patient stated that he did not want to attend the
funeral. Social work was contact[**Name (NI) **].
.
# Hyperkalemia: The patient was noted to be hyperkalemic at
presentation. EKG was unconcerning. His potassium was
monitored. No Kayexalate was administered.
.
# History of seizures: The patient was continued on his home
dose trileptal and Levetericetam
.
# Hepatitis B: Stable. LFTs were not elevated
.
# History of GI bleed: The patient was continued on his home
dose omeprazole
Medications on Admission:
Acetaminophen 650mg q8hr PRN
Allopurinol 150mg QOD
ASA 81 mg daily
Cefazolin 3gm qFriday
Cefazolin 2gm qMon, qWed
Digoxin 0.125mg PO EVERY SUN, TUE, [**Doctor First Name **], SAT
Levetiracetam 500 mg po TID ON HD DAYS M, W, F
Levetiracetam 500 mg PO BID ON NONHD DAYS Tu, Th, Sat, Sun.
Folic Acid 1 mg po daily
Fentanyl 50 mcg/hr Patch 72 hr
Oxcarbazepine 300 mg po tid on non-HD days (Tu, Th, Sat, Sun).
Oxcarbazepine 300 mg po QID on HD days (M-W-F)
Gabapentin 300 mg PO BID
Sevelamer HCl 1600 mg po tid w/ meals
Omeprazole 40 mg po daily
Heparin 5,000u SC TID
Albuterol nebs PRN
Ipratropium nebs PRN
Discharge Medications:
1. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q HD ().
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
16. Bisacodyl 10 mg Suppository Sig: Ten (10) mg Rectal once a
day as needed for constipation.
17. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
18. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: Two [**Age over 90 10973**]y
Seven (237) mL PO twice a day.
19. Outpatient Lab Work
Please have a CBC/diff and vanc trough drawn once a week fpr the
next 3 weeks. Please fax these to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD at
[**Telephone/Fax (1) 1419**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Center
Discharge Diagnosis:
MRSA Bacteremia
Sepsis
Hypotension
ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a line infection. Your
blood was found to be growing a bacteria called methicillin
resistant Staph. Aureus. You were treated with antibiotics.
Your line was also removed and a new permanent line was placed.
.
Please continue to take vancomycin for a total of 4 weeks,
ending [**6-15**]. You will need to have your blood checked once a
week and send the results to the [**Hospital **] clinic at fax [**Telephone/Fax (1) 1419**].
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Please follow-up with your appointments as listed below.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: THURSDAY [**2118-6-2**] at 1:50 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
This is a follow up of your hospitalization. You will be
reconnected with your primary infectious disease physician after
this visit.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2118-6-17**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"996.62",
"412",
"995.91",
"285.21",
"787.91",
"276.7",
"275.5",
"253.8",
"V45.11",
"276.2",
"585.6",
"428.0",
"425.4",
"038.12",
"428.22",
"403.91",
"345.90",
"E879.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"86.07",
"38.95",
"97.49",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
12569, 12651
|
7116, 10040
|
333, 455
|
12741, 12741
|
3176, 3181
|
13537, 14328
|
2593, 2667
|
10693, 12546
|
12672, 12720
|
10066, 10670
|
12892, 13514
|
2697, 3157
|
274, 295
|
6848, 7093
|
483, 1543
|
3196, 6829
|
12756, 12868
|
1565, 2229
|
2245, 2577
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,565
| 156,579
|
51662
|
Discharge summary
|
report
|
Admission Date: [**2139-8-12**] Discharge Date: [**2139-8-24**]
Date of Birth: [**2091-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
48 yo with known CAD/AS/AI/MR, s/p RCA stent [**3-21**] w/worsening
SOB/DOE and fatigue
Major Surgical or Invasive Procedure:
AVR(21mm tissue)/MV rep.(21mm [**Doctor Last Name 405**] band)/CABGx1 [**2139-8-13**]
History of Present Illness:
Mrs. [**Known lastname 107044**] is a 48 yo w/known CAD/AS/AI/MR and s/p RCA stent
[**3-21**]. She has had recent increase in shortness of breath,
dyspnea on exertion and fatigue.
Past Medical History:
HTN
SVT
h/o hodgkins lymphoma-s/p XRT
MR/AS/AI/CAD
LBBB
asthmatic bronchitis
^chol, NIDDM
ovarian dysfunction
s/p RCA stent [**3-21**]
s/p splenectomy
s/p cholecystectomy
Social History:
she lives with her husband and works in software support
denies tobacco, drinks 2 glasses wine/day
Family History:
non contributary
Physical Exam:
discharge physical exam:
T:98.3 P79SR BP 118/61 RR:16 SpO2 96%on RA weight:84.2 kg
N:awake, alert, oriented x3, no focal deficits
CV:regular rate and rhythm without rub or murmur
Resp:breath sounds clear bilaterally
Abd:+bowel sounds, soft, non-tender, non-distended
Extremities:warm, well perfused, trace edema LLE>RLE
L vein harvest incisionx3 clean, dry and intact
sternal incision clean, dry, no erythema, no drainage, sternum
stable
Pertinent Results:
[**2139-8-22**] 05:58AM BLOOD Hct-28.5*
[**2139-8-20**] 06:25AM BLOOD WBC-10.1 RBC-2.91* Hgb-9.2* Hct-27.8*
MCV-96 MCH-31.7 MCHC-33.2 RDW-14.7 Plt Ct-236
[**2139-8-24**] 06:15AM BLOOD PT-18.8* PTT-31.8 INR(PT)-2.3
[**2139-8-23**] 10:15AM BLOOD Glucose-221* UreaN-15 Creat-0.9 Na-128*
K-4.8 Cl-93* HCO3-25 AnGap-15
Brief Hospital Course:
Mrs. [**Known lastname 107044**] was admitted to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2139-8-12**] and taken to the operating room with Dr.
[**Last Name (STitle) **] for CABG(SVG-LAD)/AVR(21mm CE pericardial tissue)/MV
repair. Please see operative note for full details. She was
transferred to the intensive care unit in stable condition. She
was kept intubated on the first post operative night, but was
easily weaned and extubated on POD#1 without difficulty. She
required low dose milrinone to support her cardiac output and
Natrecor to aid in diuresis thru POD#6. During this time she
had multiple episodes of atrial fibrillation and was started on
lo dose beta blocker and amiodarone. She transferred from the
ICU to the regular floor on POD#7. On the morning of POD#8, she
developed atrial fibrillation with rapid ventricular response,
was given Lopressor and amiodarone with little change. An
electrophysiology consult was obtained and she was electively
cardioverted to sinus rhythm on POD#9. After cardioversion, it
was recommended that she have amiodarone 200 mg tid for 3 weeks
and Coumadin for 3 months, as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor.
She was noted to have hyponatremia and was started on fluid
restriction and her sodium stabilized at 128. She was cleared
by physical therapy on POD#11 and discharged to home on POD#12.
Medications on Admission:
plavix 75 qd
HCTZ 12.5 qd
diovan 80 q M-W-F
diovan 160 q T-Th-Sat-Sun
toprol XL 50 qd
synthroid 150 qd
metformin 500 [**Hospital1 **]
aspirin 81 qd
advair 250/50 [**Hospital1 **]
singulair 10 qd
albuterol prn
vitamin E
flaxseed oil
centrum
calcium
iron
amoxicillin prophylaxsis
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
6. Metformin 500 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times
a day for 1 months.
Disp:*90 Tablet(s)* Refills:*0*
13. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: then take as directed by Dr. [**Last Name (STitle) 13175**] for INR goal of [**3-18**].5.
Disp:*30 Tablet(s)* Refills:*0*
15. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Aortic stenosis
Mitral regurgitation
Coronary artery disease
Atrial fibrillation
hyponatremia
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, 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) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 13175**] for 1-2 weeks
Completed by:[**2139-8-24**]
|
[
"427.31",
"428.0",
"250.00",
"276.1",
"493.92",
"424.0",
"244.9",
"424.1",
"997.1",
"V10.79",
"414.01",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"00.13",
"35.21",
"36.11",
"35.33",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5682, 5733
|
1863, 3356
|
409, 497
|
5871, 5878
|
1525, 1840
|
6221, 6468
|
1034, 1052
|
3684, 5659
|
5754, 5850
|
3382, 3661
|
5902, 6198
|
1067, 1067
|
282, 371
|
525, 707
|
729, 902
|
918, 1018
|
1092, 1506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,360
| 136,399
|
20845
|
Discharge summary
|
report
|
Admission Date: [**2188-6-30**] Discharge Date: [**2188-7-7**]
Date of Birth: [**2113-10-2**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old,
Caucasian male patient with a history of diabetes mellitus
and hypertension, who initially presented to an outside
hospital on [**2188-6-26**], with a several week history of
progressive dyspnea on exertion and fatigue with his usual
activities. The patient states that in addition to the
several week history of dyspnea on exertion and fatigue, over
one to two days prior to admission he has noted increased
orthopnea, edema and chest pressure. In the emergency
department at [**Hospital **] Hospital the patient was noted to have
hematocrit of 27 with chest x-ray showing failure. The
patient became progressively dyspneic with oxygen saturations
ranging 90 to 93 percent in room air. Due to impending
respiratory failure, the patient was placed on CPAP and given
Lasix with improvement in his symptoms. While hospitalized,
the patient received three units of packed red blood cells.
He was taken to the cardiac catheterization lab on [**6-30**],
but had an episode of "flash pulmonary edema" and was
transferred to [**Hospital1 18**] for further evaluation.
PAST MEDICAL HISTORY: Hypertension.
Diabetes mellitus type 2.
Gout.
Right hearing loss/vertigo.
Bilateral knee pain.
Status post cholecystectomy.
Status post cataract surgery.
Diabetic retinopathy.
MEDICATIONS:
1. Glyburide 2.5 mg p.o. q.day.
2. Atenolol 50 mg q.day.
3. Lisinopril 30 mg q.day.
4. Glucophage 850 mg b.i.d.
5. Amaryl 4 mg q.day.
6. Hydrochlorothiazide 25 mg q.day.
7. Aspirin 81 mg q.day.
8. Vitamin C 500 q.six hours.
9. Norvasc 10 mg q.day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a retired banker. He
currently lives with his wife. [**Name (NI) **] denies a history of
tobacco or alcohol use. The patient swims 30 laps in the
pool three to four times a week.
PHYSICAL EXAMINATION: Afebrile, blood pressure 110/45, heart
rate 76, respiratory rate 18, 93 percent on 4 liters. In
general, the patient was an elderly man in no acute distress,
pleasant and cooperative. HEENT pupils equal, round,
reactive to light. Extraocular movements intact. The
patient had dry mucous membranes and oropharynx was clear.
Neck no evidence of jugular venous distention or thyromegaly.
Lungs decreased breath sounds in bilateral bases with rales
in the right lower lobe. Heart regular rate and rhythm,
normal S1, S2, no murmurs, rubs or gallops appreciated.
Abdomen normoactive bowel sounds, mildly distended, soft,
nontender. Extremities no evidence of cyanosis, clubbing or
edema. The patient had 2 plus DP and PT pulses bilaterally.
LABORATORY DATA: White blood cells 7.1, hematocrit 31.4,
platelets 309. INR 1.0. Sodium 136, potassium 3.9, chloride
101, bicarb 27, BUN 31, creatinine 1.7, glucose 241. Mag
1.6. HDL 27, LDL 58. TSH 0.16. EKG normal sinus rhythm at
86 beats per minute, normal axis, left bundle branch block.
HOSPITAL COURSE: CHF. The patient was transferred from
[**Hospital **] Hospital, having had an echocardiogram there that
revealed an ejection fraction of 20 percent with moderate MR
[**First Name (Titles) **] [**Last Name (Titles) **] as well as global left ventricular hypokinesis. On
admission the patient had no evidence of volume overload with
no jugular venous distention or rales on lung exam. The
patient had a chest x-ray on admission that showed bilateral
pleural effusions with potential consolidation in the right
lower lobe, representing either asymmetric pulmonary edema or
pneumonia. On the morning of hospital day two the patient
had an acute episode of respiratory distress with oxygen
saturation decreasing to 50 percent, respiratory rate in the
40s, hypertensive to 188/90 with heart rate of 125. The
patient was intubated and taken emergently to the cardiac
catheterization lab. On arrival to the cardiac
catheterization lab, the patient was noted to be hypotensive,
considered secondary to propofol given during his intubation.
The patient was started on a dopamine drip and an intra-
aortic balloon pump was placed. The patient's hemodynamics
revealed markedly elevated filling pressures with an RA
pressure of 16, RB pressure 69/12, PA pressure 69/20,
pulmonary capillary wedge pressure initially of 38. Once the
patient's intra-aortic balloon pump was placed and his heart
rate slowed, his pulmonary capillary wedge pressure improved
to 14. Cardiac output was noted to be markedly to 18.68 with
a cardiac index of 9.28. These numbers were difficult to
interpret in the setting of the dopamine drip. The patient's
cardiac catheterization showed no evidence of significant
coronary artery disease, though did reveal a 50 percent mid-
circumflex lesion that was stented. The etiology of the
patient's acute pulmonary edema was considered potentially
related to transient ischemia causing mitral valve
regurgitation and resulting in acute pulmonary edema. For
this reason, the patient received a stent in his left
circumflex artery. The patient was transferred back to the
CCU where his intra-aortic balloon pump was weaned and
discontinued. The patient's dopamine was also weaned and
discontinued. For the remainder of his hospitalization the
patient was given a beta blocker and ACE inhibitor, the doses
of which were titrated up as tolerated by his chest pain and
heart rate. The patient was evaluated with repeat
echocardiogram on [**2188-7-2**], that was significant for an
ejection fraction of 30 percent and overall moderate to
severely depressed left ventricular systolic function. The
etiology of the patient's multiple episodes of acute
pulmonary edema was considered likely secondary to
hypertension in the setting of severe diastolic dysfunction.
In addition, the patient was noted to have severe systolic
dysfunction. However, for the remainder of his
hospitalization and once off the intra-aortic balloon pump
and dopamine drip, the patient was treated with a beta
blocker and ACE inhibitor, the doses of which were titrated
up as tolerated by his blood pressure and heart rate. The
patient appeared to be well compensated throughout the
remainder of his hospitalization and required no additional
diuresis.
Coronary artery disease. As noted previously, the patient
was taken emergently to the cardiac catheterization lab on
hospital day two in the setting of respiratory failure and
emergent intubation. The patient's cardiac catheterization
was significant for elevated filling pressures. Coronary
angiography revealed a right dominant system with a 50
percent, mid-vessel, left, circumflex lesion, a distal, 50
percent, LAD lesion. There was no angiographically apparent
coronary artery disease in the RCA. The patient is status
post PTCA and Hepacoat stent placement to the left circumflex
lesion. He was continued on aspirin and Plavix throughout
the remainder of his hospitalization. As noted previously,
he was started on a beta blocker and ACE inhibitor, the doses
of which were titrated up as tolerated by his blood pressure
and heart rate.
Rhythm. The patient was noted to have several episodes of
asymptomatic, nonsustained ventricular tachycardia. The
patient remained hemodynamically stable throughout these
episodes. The electrophysiology consult service was
contact[**Name (NI) **] prior to discharge and recommended outpatient
followup one month after discharge. The patient will be
evaluated with a Holter monitor and cardiac MRI, the results
of which will be reviewed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], who will
see the patient one month after discharge. The patient was
noted to have sinus tachycardia for much of his
hospitalization despite large doses of beta blocker. It is
anticipated that the patient's beta blocker dose will be
titrated up as necessary by his outpatient cardiologist.
Diabetes mellitus. The patient's finger stick glucose levels
were noted to be somewhat poorly controlled throughout his
hospitalization. The patient's metformin was held on
admission secondary to concern for lactic acidosis in this
patient with severe heart failure. In addition, the
patient's Amaryl was held to avoid fluid retention. The
patient's glyburide dose was subsequently titrated up for
improved control of his blood sugars. It is anticipated that
the patient's diabetes will be followed closely as an
outpatient by his primary care physician. [**Name10 (NameIs) **] patient was
continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet with his finger stick glucoses
monitored q.i.d.
Acute renal failure. The patient was admitted to the outside
hospital with a creatinine of 1.3 which increased to 1.8 in
the setting of CHF and acute pulmonary edema. The patient's
creatinine improved throughout this hospitalization to 1.2
which is considered likely to be near his baseline. It is
likely that the patient has underlying hypertensive or
diabetic nephropathy.
Anemia. The patient was noted to have a hematocrit of 27 at
the outside hospital with guaiac positive stools. The
patient's hematocrit was stable throughout his entire
hospitalization here and repeat test of his stool was guaiac
negative. It is anticipated that the patient will be
evaluated with colonoscopy after discharge.
Pulmonary. As noted previously, the patient was intubated
for acute respiratory failure in the setting of acute
pulmonary edema. The patient's oxygen and ventilation were
optimal and he was quickly extubated. Repeat chest x-ray
performed prior to discharge revealed improvement in the
patient's congestive heart failure pattern seen on prior
studies. In addition, a superior mediastinal mass to the
left of the trachea was noted and considered to be possibly
secondary to a goiter or thyroid mass. The patient's thyroid
function tests were normal during this hospitalization and it
is anticipated that he will be evaluated with a chest CT as
an outpatient. The patient's primary care physician's office
was contact[**Name (NI) **] and this test is being ordered.
CONDITION ON DISCHARGE: Good. Oxygenating well in room air.
DISCHARGE STATUS: The patient is discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSES: CHF, systolic and diastolic
dysfunction, EF of 30 percent.
Status post PTCA/stent of the left circumflex artery.
Hypertension.
Diabetes mellitus type 2.
GI bleed.
Nonsustained ventricular tachycardia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.day.
2. Plavix 75 mg p.o. q.day.
3. Toprol XL 200 mg p.o. q.day.
4. Lisinopril 40 mg p.o. q.day.
5. Glyburide 10 mg p.o. q.day.
6. Tylenol one to two tablets p.o. q.four to six hours p.r.n.
7. Colace 100 mg p.o. t.i.d. p.r.n.
8. Senna one tablet p.o. b.i.d. p.r.n.
9. Pantoprazole 40 mg p.o. q.day.
FOLLOWUP: The patient has a followup appointment scheduled
with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on [**2188-7-23**],
at 9:00 o'clock a.m. Dr.[**Name (NI) 55512**] office will call the
patient if an earlier appointment becomes available. The
patient is encouraged to discuss his diabetes with his
physician and should be evaluated with a chest CT to evaluate
an unclear mediastinal mass seen on chest x-ray. The patient
should also be evaluated with colonoscopy as an outpatient.
The patient also has a followup appointment with his
outpatient cardiologist, Dr. [**Last Name (STitle) 8421**], on [**2188-7-16**], at
4:15 p.m. The patient's beta blocker and ACE inhibitor doses
will be titrated as necessary.
The patient has an appointment for a Holter monitor on
Tuesday, [**2188-8-5**], at 10:00 o'clock a.m. He will also
be evaluated with a cardiac MRI and will be contact[**Name (NI) **] by the
cardiac MRI office. After these tests, the patient has a
followup appointment with electrophysiologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 284**], on [**2188-8-18**], at 12:30 p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 12421**]
Dictated By:[**Last Name (NamePattern1) 12325**]
MEDQUIST36
D: [**2188-7-7**] 13:25:05
T: [**2188-7-7**] 14:36:41
Job#: [**Job Number 55513**]
|
[
"397.0",
"428.41",
"424.0",
"414.01",
"428.0",
"402.91",
"584.9",
"427.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.61",
"88.54",
"96.71",
"36.06",
"36.01",
"96.04",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
10334, 10541
|
10564, 12335
|
3068, 10173
|
2007, 3050
|
164, 1261
|
1284, 1769
|
1786, 1984
|
10198, 10312
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,156
| 130,504
|
652
|
Discharge summary
|
report
|
Admission Date: [**2167-4-28**] Discharge Date: [**2167-5-3**]
Date of Birth: [**2090-2-1**] Sex: F
Service: GEN [**Doctor First Name 147**]
ADMITTING DIAGNOSIS:
1. Pancreatic mass.
DISCHARGE DIAGNOSES:
1. Pancreatic mass.
PROCEDURES DURING ADMISSION:
1. Exploratory laparotomy, lysis of adhesions and
enucleation of a neuro-endocrine pancreatic mass.
HISTORY OF PRESENT ILLNESS: The patient is a 77 year old
female who presents with a history of a benign pancreatic
mass, which causes her significant abdominal pain. The
patient presents electively to have this resected.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Increased cholesterol.
3. Idiopathic hypertrophic subaortic stenosis with an
echocardiogram [**3-/2167**], revealing an ejection fraction of
greater than 55%.
PAST SURGICAL HISTORY:
1. Pancreatic resection in [**2155**].
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin.
2. Atenolol 125 mg p.o. twice a day.
3. Hydrochlorothiazide 25 mg p.o. q. day.
4. Zestril 40 mg p.o. q. day.
5. Prilosec 20 mg p.o. q. day.
6. Verapamil 240 mg p.o. twice a day.
PHYSICAL EXAMINATION: On examination the patient is awake
and alert in no apparent distress. Her heart is regular rate
and rhythm, S1, S2. Her lungs are clear to auscultation
bilaterally. Abdomen soft. She has a well healed midline
scar.
HOSPITAL COURSE: The patient was admitted to the hospital
on [**2167-4-28**], and taken to the Operating Room for
enucleation of the pancreatic mass and lysis of adhesions.
The patient tolerated the procedure well, however, in the
Post Anesthesia Care Unit she was noted to be extremely
somnolent. A blood gas revealed a pCO2 of 104. The patient
was followed closely. Given the fact that her blood gases
did not improve and it was thought that she had been
over-narcotized, the patient was electively intubated and
transferred to the Intensive Care Unit for further
monitoring.
She remained hemodynamically stable the this event, however,
her pH was significantly decreased, running from 7.04 to 7.1.
The patient's course in the Surgical Intensive Care Unit was
only notable for a transient rise in her liver function
tests. These, however, slowly trended down.
The patient was extubated and her respiratory status remained
good. She was started on her outpatient cardiac medications.
Her diet was fully advanced.
On [**2167-5-1**], the patient was transferred from the Intensive
Care Unit to the floor with intensive pulmonary toilet. Her
diet was advanced. A drain amylase was checked and revealed
a value of 3,724. Value was rechecked. This value trended
down, however, given the fact that the patient was stable,
her diet was advanced. She was tolerating p.o.
It was decided that she would be discharged home on her
preoperative medications on [**2167-5-3**], in stable condition.
She would also be discharged on:
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. She was told to follow-up with Dr. [**Last Name (STitle) 468**] in the office
and to call for a follow-up appointment.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2167-5-2**] 13:21
T: [**2167-5-2**] 16:01
JOB#: [**Job Number 4986**]
|
[
"211.6",
"E878.8",
"518.5",
"401.9",
"250.00",
"425.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"52.22",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
226, 379
|
2931, 2964
|
1390, 2908
|
2988, 3369
|
837, 1127
|
1150, 1371
|
409, 604
|
183, 205
|
626, 814
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,609
| 134,702
|
47528
|
Discharge summary
|
report
|
Admission Date: [**2159-8-18**] Discharge Date: [**2159-8-26**]
Date of Birth: [**2074-3-4**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Found Down
Major Surgical or Invasive Procedure:
Endotracheal intubation at OSH.
History of Present Illness:
85M with know history of EtOH use, found down in apt by EMS
after a 911 emergency call was made. Of note, when EMS arrived,
pt was alone in apartment, on the ground with no apparent
trauma. He was noted to have a very slow RR around [**3-29**], he was
only responsive to sternal rub. He was noted to be moving the R
side of his body only. FS was 190 at that time. No
incontinence, no tongue biting.
He was transferred to [**Hospital3 **] and when he was first
arrived he was hypotensive at 80/40 and tachycardic. He was
intubated for AMS. PE revealed left sided flaccid paralysis
with upgoing toes on left. Initial lactate at [**Hospital1 **] was 4.5,
WBC was 23K, BUN/Cr was 16 and 1.4, CK 169, LFTs and lipase
within normal limits, trop I <0.06. Of note his etoh level was
negative. He was briefly started on peripheral neo and fluid
resuscitated with 4L of crystalloid, at which point he became
normotensive.
A Head CT and C-spine films were unremarkable. Chest XR was
reportedly unremarkable as well. BNP was 100, UA with trace
ketones but otherwise bland.
Pt was started on vancomycin and zosyn for infection of unknown
etiology and transferred to [**Hospital1 18**] ED.
at [**Hospital1 18**]
vitals 120/80 NSR 70, afebrile, breathing at 14 on vent and
sating at 100% on 40% fio2. Fent/versed was switched to
propofol and two peripheral IVs were placed. When in ED it was
noted that his left arm flaccid, but now moving left lower
extremities. He was started on thiamine and folate as well. A
repeat lactate was 2.4.
lytes were significant for K of 5.6, normal cr, slightly anemic
at 11.5/35, leukocytosis of 15.9 with 93.4N, plt 195. Utox and
serum tox only + for benzos. LFTs unremarkable except alb of
3.4. Initial lactate at OSH was 4 and after 4L fluid
resuscitation lactate now 2.8.
Past Medical History:
inguinal hernia
spinal stenosis
transurethral resection of prostate
peptic ulcer disease
R hip frx in distant past
cholelithiasis
diverticulosis
cognitive impairment
Social History:
lives alone, but some level of baseline cognitive impairment.
- Tobacco:unknown
- Alcohol: yes, history of withdrawal unknown
- Illicits: no
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: 124/53, 84, 96% CPAP with PS of 5 and 50% O2
General: intubated
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-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: pupils are pinpoint, does not awake to voice, moving
lower extremities and RUE spontaneously, minimal to no movement
of LUE. Will withdraw to noxious stimuli, notably will not
withdraw with left extremity to noxious stimuli on left nail bed
rather will grimace and reach with right arm. Reflexes are all
2+. Toes are upgoing bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2159-8-18**] 03:00PM GLUCOSE-119* UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-20* ANION GAP-14
[**2159-8-18**] 03:00PM CALCIUM-7.5* PHOSPHATE-1.6* MAGNESIUM-1.7
[**2159-8-18**] 03:00PM WBC-12.4* RBC-3.45* HGB-11.5* HCT-34.8*
MCV-101* MCH-33.3* MCHC-33.0 RDW-13.0
[**2159-8-18**] 06:59AM LACTATE-2.8*
[**2159-8-18**] 06:50AM TSH-0.41
[**2159-8-18**] 06:50AM FREE T4-1.2
[**2159-8-18**] 06:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2159-8-18**] 06:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2159-8-18**] 06:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2159-8-18**] 06:50AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
IMAGING:
HEAD CT [**2159-8-18**]:
1. Findings consistent with a large right MCA territory region
of
ischemia/infarction, with an associated thrombus in the right
MCA M1 segment. These findings have progressed since the
earlier CT performed at [**Hospital1 **], [**Hospital3 4107**],
from approximately 10 hours ago. No hemorrhagic transformation.
Minimal leftward midline shift of normally midline structures
without central herniation.
MRI/MRA head [**2159-7-26**]:
Acute large MCA territory infarction on the right with petechial
hemorrhages along the subcortical white matter and cortex.
Poor flow-related enhancement in the right cervical and
intracranial ICA,
which could be on the basis of dissection. Recommend further
evaluation with a CTA.
Brief Hospital Course:
85M with h/o EtOH abuse, cognitive impairment found down by EMS
with AMS and left hemiparesis found to have clean tox screen,
leukocytosis and hypotension, intubated for airway protection.
Patient was found to have a large R MCA infarction and was
transferred to neuro ICU. He was monitored in the ICU and was
successfully extubated, but unfortunately suffered a likely
aspiration event in setting of emesis and had decreased level of
arousal again. Aspiration events were thought to be due to his
large stroke, and likely to be an ongoing problem requiring
tracheostomy and PEG placement for management. After a
discussion with patient's family members and his HCP (daughter
[**Name (NI) 4457**]), it was decided to make the patient's care focused on
comfort as he had made it clear that he did not want to be
resuscitated, intubated or have feeding tubes placed. His code
status was changed to comfort measures only. He was transferred
to the neurology floor and his symptoms were managed with
medications including morphine as needed for pain and
scopolamine to control secretions. He expired on [**2159-8-26**].
Medications on Admission:
Alprazolam 0.25 mg QID prn anxiety
omeprazole 20 mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
Large right middle cerebral artery infarction
Discharge Condition:
Expired
|
[
"V66.7",
"562.10",
"342.90",
"276.2",
"348.30",
"294.9",
"507.0",
"305.00",
"780.01",
"434.11",
"V49.86",
"724.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6304, 6313
|
5068, 6185
|
323, 356
|
6402, 6412
|
3451, 3451
|
2563, 2581
|
6334, 6381
|
6211, 6281
|
2596, 3432
|
273, 285
|
384, 2200
|
3467, 5045
|
2222, 2389
|
2405, 2547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,507
| 180,314
|
24800
|
Discharge summary
|
report
|
Admission Date: [**2144-12-17**] [**Month/Day/Year **] Date: [**2144-12-22**]
Date of Birth: [**2099-1-29**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
alcohol withdrawl
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 y.o. man, h/o alcoholism, homeless, was found intoxicated on
toilet at Border's. Patient does not remember events leading up
to this. He did drink a large amount of alcohol. Brought in by
EMS.
.
In the ED, initial vs: T97.3, BP 135/81, HR 110, RR 16, 98%ra.
He complained of left knee pain. X-ray knee was unremarkable.
ETOH level 401. He became tremulous in ED and was tachycardic
(sinus tach). CIWA protocol begun. He received at least 3 doses
of IV valium (~ 30mg) and admitted for acute alcohol withdrawl.
Past Medical History:
-Alcohol abuse for greater than 20 years (one period of 3.5
years of sobriety but recent worsening following a divorce three
months ago)- last drink last night at around [**10-14**] pm
-Alcohol withdrawal seizures approximately 6 months ago
-History of pericarditis status post pericardial window in
[**2139**]-[**2140**]
-Depression
Social History:
[**Year (4 digits) 4273**] illicit drug use. No tobacco use currently but remote
history of smoking 1 PPD* 8 years greater than 10 years ago.
Currently drinks 1 pint to one fifth of a gallon (750 ml) of
vodka daily. Recently divorced and unemployed secondary to
alcoholism. Previously was employed in nutrition at [**Hospital **]
Hospital. He is homeless and living [**Street Address(1) 29735**] shelter
Family History:
Notable for alcoholism in multiple aunts and uncles as well as
his mother.
Physical Exam:
PE on admission
vs: T 97.3, 122/78, HR 105, RR 16, 97%ra
gen: tremulous, otherwise no distress
heent: pupils equal. Dry mm
lungs: CTA b/l
heart: reg rhythm, tachy. no m/r/g
abd: +BS, soft, ND/NT
ext: Mild LE edema. 2+ DP pulses b/l
neuro: awake, alert. FNF intact although shaky (no dysmetria).
Reflexes intact
ms: mild left knee pain with flexion. No point tenderness. No
effusion. Small break in skin over the patella.
Pertinent Results:
[**2144-12-17**] 04:00AM BLOOD WBC-3.5* RBC-3.43* Hgb-11.1* Hct-32.1*
MCV-93 MCH-32.4* MCHC-34.7 RDW-14.8 Plt Ct-93*#
[**2144-12-20**] 04:17AM BLOOD WBC-2.9* RBC-3.32* Hgb-11.1* Hct-30.3*
MCV-91 MCH-33.3* MCHC-36.5* RDW-14.8 Plt Ct-94*
[**2144-12-17**] 04:00AM BLOOD Glucose-113* UreaN-5* Creat-0.5 Na-140
K-3.3 Cl-99 HCO3-26 AnGap-18
[**2144-12-19**] 04:07PM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-135
K-3.8 Cl-104 HCO3-21* AnGap-14
[**2144-12-22**] 06:45AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-138 K-4.0
Cl-102 HCO3-24 AnGap-16
[**2144-12-17**] 05:30PM BLOOD ALT-38 AST-89* LD(LDH)-238 AlkPhos-76
TotBili-1.3
[**2144-12-21**] 06:55AM BLOOD ALT-40 AST-74* AlkPhos-76 TotBili-1.2
[**2144-12-22**] 06:45AM BLOOD ALT-40 AST-62* AlkPhos-75 TotBili-0.9
[**2144-12-22**] 06:45AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8
[**2144-12-20**] 04:17AM BLOOD calTIBC-322 VitB12-700 Folate-12.8
Ferritn-195 TRF-248
[**2144-12-20**] 04:17AM BLOOD TSH-1.2
[**2144-12-20**] 04:17AM BLOOD CRP-7.0*
.
Imaging:
Knee XRay:
THREE VIEWS OF THE LEFT KNEE: There is no joint effusion,
fracture or
malalignment, and no radiopaque retained foreign body is
identified. Noted is mild spurring of the tibial spines with no
other degenerative change,
though the joint spaces are not well evaluated on these
non-weight-bearing
views.
IMPRESSION: No fracture or alignment abnormality.
.
CXR:
Lungs are fully expanded and clear. Mild loss of height in mid
thoracic
vertebral body, stable in one and increased slightly in the more
superior
since [**2141-10-15**], unchanged since [**2144-11-15**].
.
Abd Ultrasound:
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. No evidence of cirrhosis.
3. Normal size of spleen.
Brief Hospital Course:
45 M with history of EtOH abuse/withdrawal/DTs, admitted
[**2144-12-17**] for intoxication. He was transfered to MICU on [**12-20**]
with alcohol withdrawal and possible seizure. Patient brought in
by EMS on day of admission after found intoxicated at Border's.
Did not recall events leading up to this. Drinks 1 pint vodka
daily, reports last drink as [**12-16**] afternoon. EtOH level 401 on
admission. [**Month/Year (2) 4273**] other drug abuse.
.
Patient has had relatively uneventful hospital course until
transfer to MICU. Was receiving diazepam 10-20 mg IV Q2H prn
CIWA >10. [**12-17**]: 30 mg IV valium in ED and 40 IV valium on floor
(CIWAs [**8-15**]). [**12-18**]: 20 IV valium (CIWA [**7-15**]). [**12-19**]: 50 IV
valium prior to event and more following event (see below).
Tachycardic on admission (90s to low 100s), but today noted to
be more tachycardic (up to [**Street Address(2) 62474**] at one point on tele). CIWA
11 at 1:30 pm. Recalls walking back from BR today and then being
surrounded by medical staff. Per nursing report, he was having
significant degree of extremity tremulousness, unclear if
seizure occurred, seemed to maintain consciousness during entire
event. Shaky and anxious, [**Street Address(2) **] VH/AH. FSG 98. Received 60 mg
IV valium and 3 mg IV ativan and transferred to MICU for further
care.
.
In the MICU, has received 30 mg diazepam since 9:00 am.
Pancytopenia noted and thought to be [**3-7**] bone-marrow supression
from etoh toxicity. Abd U/S w/o cirrhosis or splenomegaly.
.
After transfer from the MICU, he again had a relatively
uneventful course on the floor. He did not require any valium
and was [**Doctor Last Name **] on the CIWA scale between 2 and 7, mostly for
anxiety. He had mild sweats at night, but his tremors improved.
He continued ot have some unsteadiness on his feet, likely from
minor cerebellar toxicity, but was ambulating on his own and
quite safe. PT evaluated him and thought he was safe to leave
independently.
.
As for his labs, his platelets starting increasing and were in
the normal range upon [**Doctor Last Name **]. He continued to have a
moderately low white count, but was trending upward towards
normal.
.
His pericarditis was symptom free upon [**Doctor Last Name **]. He did have
intermittent mild chest pain during the admission, but was at
his baseline. Continued his outpatient treatment with
[**Doctor Last Name **] and ibuprofen for now.
Medications on Admission:
1. Thiamine HCl 100 mg PO daily
2. Folic Acid 1 mg PO daily
3. Multivitamin PO daily
4. Quetiapine 50 mg PO QHS PRN insomnia
5. Ibuprofen 600 mg TID:PRN chest pain/pericarditis
6. [**Doctor Last Name 4147**] 1.2mg PO daily for chest pain/pericarditis
[**Doctor Last Name **] Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
5. [**Doctor Last Name 4147**] 0.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed for chest pain.
[**Doctor Last Name **]:*60 Tablet(s)* Refills:*0*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for chest pain, knee pain.
[**Doctor Last Name **]:*20 Tablet(s)* Refills:*0*
[**Doctor Last Name **] Disposition:
Home
[**Doctor Last Name **] Diagnosis:
1. Acute alcohol intoxication
2. Acute alcohol withdrawl
3. Percarditis
[**Doctor Last Name **] Condition:
Stable, SBPs in 110s, HR in 80s, not tremulous, slightly
unsteady on his feet, but ambulating on his own without
assistance.
[**Doctor Last Name **] Instructions:
You were admitted because of alcohol intoxication and later
alcohol withdrawl. You were treated with valium for withdrawl.
You also had chest pain which is due to your chronic
pericarditis. By the time of [**Doctor Last Name **] you were no longer
needing to take the valium and you were feeling better.
During your last hospitalization, you were given a referral for
alcohol treatment programs. We strongly recommend that you
attend this program.
Do not drink ANY alcohol. It is harmful to your health.
If you have chest pain, please take ibuprofen or [**Doctor Last Name **].
Call your doctor if you have any concerning symptoms.
Followup Instructions:
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Location (un) 16663**] Medical on [**2144-12-30**] at 10:30 AM. Phone
number is [**Telephone/Fax (1) 4326**].
Completed by:[**2144-12-22**]
|
[
"338.29",
"284.1",
"780.39",
"303.01",
"V60.0",
"571.1",
"291.0",
"427.89",
"423.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4048, 6489
|
300, 307
|
2181, 4025
|
8435, 8730
|
1647, 1724
|
6515, 8412
|
1739, 2162
|
243, 262
|
335, 851
|
873, 1209
|
1225, 1631
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,105
| 141,362
|
33655
|
Discharge summary
|
report
|
Admission Date: [**2115-4-11**] Discharge Date: [**2115-5-14**]
Date of Birth: [**2038-12-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
intubation, central line placement, arterial lines, PICC line
placement
History of Present Illness:
76 year old woman with history of seizure disorder, chronic
respiratory failure due to combination of pneumonia and poly
neuropathy referred to [**Hospital1 18**] for evaluation following potential
seizures and transient pulseless arrest. Prior to these events
(per her son), she was able to do breathing trials for several
hours at at time, mouth and speak words, move all 4 extremities,
and get OOB to chair. She was at [**Hospital **] Rehab on [**2115-4-10**] when
her vent started to alarm for desats to 60%. She was found to
have emesis around her trach site. She was suctioned then lost
her pulse on peripheral monitoring. She was pulseless for less
than a minute. She had spontaneous return of circulation. She
continued to have vomiting later that day with some blood seen.
She per report recovered to near her baseline according to her
son. She was started on timentin/flagyl. Also of note early on
[**2115-4-10**] she pulled out her foley with the baloon still inflated
and had subsequent hematuria. However in the morning of the day
of admission she was witnessed to have a seizure while being
cleaned. She recovered consciousness then had another seizure.
Keppra was started prior to transfer to [**Hospital1 18**]. She was admitted
to the ICU given chronic vent dependence.
.
Of note she was admitted to [**Hospital1 18**] from [**Date range (1) 77923**] for altered
mental status, pneumonia complicated by critical illness
neuropathy and had trach/G placed due to inability to wean from
the vent. She had 3 sequential days of EEG monitoring without
any events captured and only changes consistent with
encephalopathy were noted. In her discharge, her condition was
listed as "Ventilator dependent. Follows simple midline and
appendicular commands. Right CN VII palsy (chronic post polio)-
unable to close R eyelid. Upper extremities barely [**2-20**]
(antigravity) + motor impersistence. Withdraws lower extremities
to noxious stimulation in the plane of the bed. Intact deep
tendon reflexes throughout."
In the ED her initial vitals were 99.9 68 126/65 100% AC 450x14
60% PEEP 8.
She received NS bolus for transient sbp in mid 80s. Her lactate
was normal. She received vanc/ceftriaxone/azithromycin directed
at a pneumonia. Her EKG was interpreted as unchanged from
priors. Her ED course was notable for transient desat to 80%.
She was suctioned with moderate amount of mucous then returned
her sats to 100%.
Past Medical History:
seizure d/o
chronic vent dependence due to critical illness myopathy
chronic right sided pleural effusion
diastolic CHF (TTE [**2115-2-28**] EF >70%. diastolic dysfunction)
Polio as a child- residual R lower motor neuron CN VII palsy
(unable to fully close R eye)
Parkinson's disease
Hypercholesterolemia
Social History:
SH: prior to [**Month (only) 958**] hospital stay lived with her son and was
reasonably active. no cigarrettes in greater 40 years. rare
EtoH. has 2 children. Since previous hospitalization has been
vent dependent, and minimally active/responsive.
Family History:
No family history of neurologic disease.
Physical Exam:
Tmax: 35.9 ??????C (96.7 ??????F)
Tcurrent: 35.9 ??????C (96.7 ??????F)
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Respiratory
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 450 (450 - 450) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
PIP: 24 cmH2O
Plateau: 21 cmH2O
ABG: 7.40/44/433//2
Ve: 6.7 L/min
PaO2 / FiO2: 722
Physical Examination
General Appearance: No acute distress, chronically ill
Eyes / Conjunctiva: No(t) PERRL, left pupil 4->2mm. unable to
close left eye.
Head, Ears, Nose, Throat: Normocephalic, Poor dentition, trach
in place. Dry mucous membranes
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal, Widely split )
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : anteriorly), (Breath Sounds: Diminished: at bases),
vent water obscuring but otherwise clear anteriorly
Abdominal: Non-tender, Distended, bowel sounds sluggish. firm
stool filled colon in LLQ
Extremities: Right: Trace, Left: Trace, No(t) Cyanosis
Musculoskeletal: Unable to stand, flexion contractures at ankles
Skin: Cool, 1.5x1.5 sacral pressure ulcer/skin tear
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Noxious stimuli, Movement: No spontaneous movement,
No(t) Sedated, No(t) Paralyzed, Tone: Normal, right CN VII
palsy. Left corneal reflex intact. Tongue deviated to left. DTR
trace in biceps, patellars. no clonus.
Pertinent Results:
MRI/MRA of the brain:
1. Small acute infarct in the left posterior parietal white
matter.
2. Likely stenosis of the right posterior communicating artery.
.
.
Lumbar puncture:
Glucose: 66
Protein: 51
1WBC, 5RBC
Cultures negative
.
.
Sputum culture [**2115-4-18**]
25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2115-4-18**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 2 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
ACID FAST SMEAR (Final [**2115-4-17**]):
ACIDFAST BACILLI. MODERATE SEEN ON CONCENTREATED SMEAR.
GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD) (Final
[**2115-4-19**]):
NEGATIVE FOR M. TUBERCULOSIS BY MTD. AWAIT CULTURE RESULTS. MTD
PERFORMED AT [**State **] STATE LABORATORY, [**Location (un) **], MA
([**2115-4-18**]).
.
.
Sputum culture [**2115-4-27**]
GRAM STAIN (Final [**2115-4-26**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2115-4-29**]):
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
Echocardiogram [**2115-5-3**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is moderately
dilated with severe global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. No aortic regurgitation is
seen. Trivial mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is a small pericardial effusion.
Compared with the prior study (images reviewed) of [**2115-2-28**],
there is now severe RV systolic dysfunction with significant
tricuspid regurgitation and moderate to severe pulmonary
hypertension. There is a large pleural effusion.
Lower extremity ultrasound
Slightly limited evaluation as described above, but no evidence
of DVT
bilaterally. Absence of DVT in no way excludes the presence of a
PE.
Initial EEG
[**4-12**]:FINDINGS:
ABNORMALITY #1: Throughout the recording the background was slow
and
disorganized, typically in the 6 Hz frequency range in the
posterior
regions bilaterally and was interrupted by intermittent bursts
of
moderate amplitude generalized delta frequency slowing.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as this was a portable
study.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: No normal waking or sleeping morphologies were noted.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 84 beats per minute.
IMPRESSION: This is an abnormal portable EEG due to the slow and
disorganized background admixed with bursts of moderate
amplitude
generalized delta frequency slowing. This constellation of
findings is
consistent with a moderate encephalopathy and suggests
dysfunction of
bilateral subcortical or deep midline structures. There were no
areas
of prominent focal slowing, although encephalopathic patterns
can
sometimes obscure focal findings. There were no epileptiform
features
Repeat EEG:
[**2115-4-19**]:
FINDINGS:
ABNORMALITY #1: At the onset of the tracing, [**1-20**] Hz generalized
spike
and slow wave discharges were seen continually for several
minutes. The
technologist did not make any notation of clinical correlation.
The
discharges gradually decreased in amplitude and frequency until
a
somewhat disorganized [**3-23**] Hz mixed delta and theta frequency
background
was seen.
ABNORMALITY #2: As above, towards the end of the tracing, a slow
and
disorganized background was seen.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as the patient was
unable to
cooperate.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as the
test was
requested as a portable study.
SLEEP: No normal sleep or wake transitions were seen.
CARDIAC MONITOR: Demonstrated a generally regular rhythm with
average
rate of 84 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of near
continuous discharges consistent with nonconvulsive seizures at
the
beginning of the tracing, resolving into a slow and disorganized
background consistent with a moderate encephalopathy of toxic,
metabolic, or anoxic etiology.
Final EEG:
OBJECT: In pt bedside w/ video [**5-13**] to [**2115-5-14**].
FINDINGS:
PUSHBUTTON EVENTS: There was one pushbutton event recorded. This
pushbutton event was recorded with hemodialysis machinery turned
off.
EEG at this time demonstrates diffusely slowed background
rhythms in the
mixed delta and theta frequency range. There is no evidence of
clinical
or electrographic seizure at this time.
AUTOMATIC SEIZURE DETECTIONS: There were 24 files obtained. No
definite clinical or electrographic seizures were seen in these
files.
These files do reflect artifact from dialysis machinery and
other ICU
equipment.
AUTOMATIC SPIKE DETECTIONS: There were 18 files obtained. These
files
were reflective of artifact. No definite epileptiform discharges
were
seen.
ROUTINE TIME SAMPLING: No normal waking or sleep rhythms were
observed.
The EEG is obscured by hemodialysis artifact throughout
recording. At
times, when the hemodialysis machine was intentionally turned
off so we
could view the EEG, we see diffusely slowed generalized
background
rhythms in the admixed delta and theta frequency range with
occasional
bursts of generalized delta activity and more focal bursts of
left
hemisphere delta activity, as well. Intermittent epileptiform
discharges were also see with a bifrontal predominance and also
over the
left temporal region. No clinical or electrographic seizures
were
recorded.
SLEEP: The patient did not progress through normal stages of
sleep.
CARDIAC MONITOR: Demonstrated a generally regular rate and
rhythm.
IMPRESSION: This 24-hour video EEG telemetry captured no
clinical or
electrographic seizures. A number of the files were obscured at
times
by hemodialysis and other ICU equipment. At times, when
background
rhythms were easily viewed, we note generalized mixed frequency
slowing.
A few interictal discharges were also seen. This EEG is most
consistent
with a severe encephalopathy.
LABS:
[**2115-4-11**] 03:05PM PT-15.0* PTT-32.7 INR(PT)-1.3*
[**2115-4-11**] 03:05PM PT-15.0* PTT-32.7 INR(PT)-1.3*
[**2115-4-11**] 03:05PM PLT COUNT-282
[**2115-4-11**] 03:05PM NEUTS-70.6* LYMPHS-18.4 MONOS-9.0 EOS-1.1
BASOS-0.8
[**2115-4-11**] 03:05PM WBC-11.2* RBC-3.27* HGB-10.1*# HCT-30.5*#
MCV-93 MCH-30.9 MCHC-33.1 RDW-18.5*
[**2115-4-11**] 03:05PM PHENYTOIN-18.3
[**2115-4-11**] 03:05PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-2.6*
MAGNESIUM-2.7*
[**2115-4-11**] 03:05PM ALT(SGPT)-21 AST(SGOT)-46* CK(CPK)-291* ALK
PHOS-170* TOT BILI-0.3
[**2115-4-11**] 03:05PM GLUCOSE-83 UREA N-75* CREAT-1.5* SODIUM-138
POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-28 ANION GAP-17
[**2115-4-11**] 05:15PM URINE RBC-[**2-20**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
WBC RBC Hgb Hct RDW Plt Ct
[**2115-5-14**] 05:00AM 21.2* 2.65* 8.2* 25.0* 18.3* 39*1
Glucose UreaN Creat Na Cl HCO3
[**2115-5-14**] 11:19AM 249* 133 4.3 108 19* 10
HIT negative
Brief Hospital Course:
Hospital course by problem:
1- Non-convulsive status epilepticus/ neurologic : On admission
the patient's mental status deteriorated. She had been
responsive to voice, able to talk with her sons, have purposeful
movements etc, until about HD #9 where she began to decline,
eventually no longer responding to painful stimuli. A complete
work-up was done in consultation with neurology, including an
MRI of the brain, lumbar puncture, and 24 hour continuos EEG
monitoring. This work up revealed non-convulsive status
epilepticus of unknown etiology. Both her MRI and LP were
unrevealing. Several medications were tried to control her
status, including dilantin, keppra, and a midazolam drip.
Unfortunately she required a pentobarbital coma in addition to
dilantin and keppra to stop the seizure activity. Once she
remained seizure free for 24 hrs ([**4-27**]) we attempted to wean
this. She returned to status off of the pentobarbital, and was
thus placed back on it. During this course, the possibility of
Hashimoto's encephalitis was raised. In an effort to treat this
empirically, the patient was placed on high dose steroids.
Shortly after this therapy the patient was able to be weaned
from the pentobarbital coma. Her mental status did not improve
and she remained encephalopathic without response to pain or
other stimuli despite withdrawal of sedation, treatment of all
infections, and dialysis.
2. Respiratory failure: The etiology of her respiratory failure
is unknown, and was thought to be a chronic critical care
neuropathy vs. post-polio syndrome. She was to have a sural
nerve biopsy to help further delineate the underlying cause, but
due to her acute medical issues, this has been on hold. She has
been maintained on assist-controlled mechanical ventilation
through her tracheostomy tube throughout this admission. She
was unable to be weaned from the ventilator and developed a
pseudomonas pneumonia. This was treated with broad spectrum
antibiotics. Despite treatment, the patient had persistent
respiratory failure and thus additional antibiotics were added
based on recommendations by the ID consult team. Despite this,
the patient's respiratory status remained largely unchanged.
3. Recurrent pseudomonal pneumonias: Several times during this
admission, she was diagnosed with pseudomonal pneumonias.
Initially she was managed with cefepime for a seven day course.
When the pneumonia recurred we started double coverage with
cefepime and ciprofloxacin for a ten day course. All cultured
confirmed sensitivity to both antibiotics.
4. AFB colonization: She was found to have moderate AFB on her
smear. THis was confirmed to be non-TB. Given her chronic lung
disease, this was thought to be a colonization rather than an
infection
5. ?PE: We ordered an echocardiogram to assess her LV function,
which incidentally showed RV strain. We discussed the findings
with cardiology who felt that this was in fact [**Last Name (un) 13367**] sign.
We were unable to obtain a CT angiogram as a result of her
renal failure, and a V/Q scan would be non-optimal in the
setting of multifocal PNA and pleural effusions. LENI's were
negative. The decision was made to empirically anticoagulate
her with a heparin gtt. however, the patient had persistent
bleeding from the OG tube and line sites and the heparin was
held. Additionally, with drop in platelets, concern for HIT was
raised and a HIT antibody was sent (it returned after the
patient's death negative). Bleeding improved off the heparin
and the patient did not actually have signs of worsening clot
burden or PE clinically and thus it was assumed that off
treatment a PE large enough to cause RV strain would not be
silent clinically. Thus it was assumed that the RV strain was
likely not caused by PE.
6. Acute renal failure: Presumably secondary to ATN. Creatinine
continued to rise and the patient developed total renal
dysfunction without significant urine output, with electrolyte
abnormality and uremia. Complicated by a gap metabolic
acidosis presumably secondary to uremia. CVVH was initiated as
a short term trial to see if the patient's mental status would
improve. Diuresis was attempted with lasix gtt, diuril [**Hospital1 **],
with albumin o augment dleivery to tubules, this was not
effective. Patient remained approximately 35 liters positive.
After trial of dialysis for ~7 days, the patient had no recovery
of neurologic function. Thus it was deemed to be futile and was
stopped.
In the following several hours, the patient had persistent
hypotension that was treated with pressors and additional
fluids. However, the hypotension was not improved despite
maximal doses of pressors. The patient the began to become
bradycardic. Atropine was given, but the patient continued to
brady. Given that the prior decision was made to no initiated
CPR, the patient expired. The family was contact[**Name (NI) **] (after
several failed attempts to contact as the patient was
decompensating) and was able to see the patient shortly after
her death. An autopsy was declined.
Medications on Admission:
Dipyridamole 50mg DAILY
Fragmin 5,000 unit daily
Aspirin 325 mg DAILY
Thiamine HCl 100 mg DAILY
Zantac 150 mg [**Hospital1 **]
Folic Acid 1 mg DAILY
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Ophthalmic PRN
Eye patching Please tape and patch right eyelid closed each
night, apply moisturizing drops to avoid corneal ulceration.
Docusate Sodium 100 mg Liquid [**Hospital1 **]
Senna 8.8 mg/5 mL Syrup [**Hospital1 **]
Tobramycin-Dexamethasone 0.3-0.1 % Ophthalmic [**Hospital1 **]
Carbidopa-Levodopa 25-100 mg TID (3 times a day) PRN: rigidity
Ferrous Sulfate 300 mg/5 mL PO DAILY
Phenytoin 150 mg Tablet, Chewable [**Hospital1 **] please hold tube feedings
for 1
hour at time of dosing for adequate absorption.
Metoprolol Tartrate 100 mg QID
Acetaminophen 160 mg/5 mL Solution Q6H.
Calcium carbonate-vitamin D 600/400 daily
questran 4gm TID
Bacitracin TID:prn to G-tube and Trach
Bisacodyl 10 mg PR:prn
glycerin suppository daily:prn
ativan 1 mg q1h:prn
Milk of magnesium 30 mL q8:prn
levothyroxine 25 mcg daily
keppra 500 mg daily (started [**2115-4-11**])
Labetalol 800 mg TID
clonidine 0.1 mg daily
Saliva substitute 5mL TID
Beneprotein 1 scoop TID
Osmolite 1.5 tube feed
zofran 4mg q4:prn
Hydralazine 10 mg TID
Plavix 75 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest, acute. Possibly secondary to persistent shock
either cardiogenic or septic
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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|
[
[
[]
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[
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18263, 19504
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3531, 5117
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284, 296
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13173, 18237
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435, 2862
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2884, 3191
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3207, 3457
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,217
| 190,392
|
22526
|
Discharge summary
|
report
|
Admission Date: [**2134-7-18**] Discharge Date: [**2134-7-24**]
Date of Birth: [**2056-4-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
intubation x 1 day in MICU
Right internal jugular central line placed in MICU
Left midline placed by interventional radiology on [**2134-7-22**] - pt t
obe discharged with this line.
History of Present Illness:
Mr. [**Known lastname 23203**] is a 78 year old male with h/o HTN, AAA, CVA and TIA,
found slumped over in a chair, unresponsive with ?new L facial
droop at his nursing home this a.m. Of note, he was admitted 1
year ago in [**5-24**] with the exact same chief complaint,
additionally with slurred speech s/p reported fall and question
of incontinence. A head CT at the time was negative for acute
stroke, MRI showed chronic microvascular disease, an old left
thalamic lacunar infarct, and MRA with some moderate stenosis in
the proximal to mid portion of his basilar artery. His
neurologic deficits, thought to be a TIA, resolved, and he was
discharged on ASA 325 mg daily.
Report from the nursing home this morning is minimal. He was
reportedly found slumped on his side in a chair in his room,
minimally responsive. T 96, HR 60, BP 122/60. Sent to [**Hospital1 18**]
ED.
Vitals on arrival to the ED were T 101, HR 111, BP 155/48, RR
28, 96% on 2L O2. Given his fever, AMS, and a new petechial
rash that was noted, an LP was perfored: 3 WBC, 1 RBC, prot 47,
glucose 138. He was pan cultured and started on
ceftriaxone/vancomycin. UA negative. Head CT negative for
acute process. MRI head was negative for acute stroke, with
mild basilar artery stenosis and extensive white matter disease
seen on previous MRI that has progressed. He was tachypneic,
with ABG 7.46/30/60, subsequently intubated. Labs notable for
mild leukocytosis of 12.6, lactate 10; he had a central line
placed and was started on sepsis protocol, with lactate
decreasing to 8.6 then 2.8 with IVF. CK 2184, increasing to
5000, though MBI wnl. Trop 0.05. Amylase was 512, lipase 53,
CT abdomen with consolidation/atelectasis at L lung base,
otherwise no intra-abdominal source for fever.
Past Medical History:
TIA, chronic microvascular disease. See above.
HTN
AAA
vertebral compression fx s/p surgery
BPH
hx of removal of "skin tumor" on left face 40 years ago
Social History:
Smoked in the past, quit 50 years ago, came from [**Doctor Last Name **] house.
Family History:
Unknown
Physical Exam:
T 97.9, BP 147/71, HR 82, O2Sat 96, RR 19
GEN: NAD, intubated
HEENT: moist MM, Pupils 4mm, equal, reactive to light, JVP
difficult to evaluate [**12-23**] central line.
HEART: RR, normal rate, cresc-decresc murmur II/VI best heard
over RSB, no rubs or gallop.
LUNGS: anterior: mild, b/l crackles at the bases.
ABD: soft, nontender, nondistended, +BS
EXT: b/l symmetric, pitting 1+ edema, 2+DP
Skin: erythematous, indurated plaque with vesicles in T3
distribution over L side extending from sternum to mid-axillary
line. Also with petechial, nonblanching rash on dorsum of b/l
hands and feet.
NEURO: intubated, responsive to pain, turns his head to verbal
stimuli, normal muscle tone, 1+ reflexes b/l, no ankle reflexes
appreciated, plantars mute b/l.
Pertinent Results:
Admission labs:
Glucose-266* UreaN-25* Creat-1.5* Na-142 K-3.3 Cl-98 HCO3-20*
WBC-12.6* Hct-43.9 MCV-84 MCH-29.2 MCHC-34.8 RDW-14.0 Plt Ct-200
- Neuts-90.1* Bands-0 Lymphs-6.4* Monos-3.0 Eos-0.2 Baso-0.3
PT-13.1 PTT-23.6 INR(PT)-1.1
[**2134-7-18**] CK(CPK)-5108*
[**2134-7-18**] Fibrino-295
[**2134-7-19**] FDP-10-40
[**2134-7-20**] Fibrino-531*#
[**2134-7-20**] FDP-10-40
Hapto-134
[**2134-7-18**] ANCA-NEGATIVE B
[**2134-7-18**] [**Doctor First Name **]-NEGATIVE
[**2134-7-18**] CRP-58.8*
[**2134-7-18**] C3-98 C4-21
ESR 10
[**2134-7-20**] ALT-32 AST-48* LD(LDH)-215 CK(CPK)-1624* AlkPhos-50
Amylase-198* TotBili-0.7
[**2134-7-18**] Lipase-53
[**2134-7-18**] CK-MB-19* MB Indx-0.9 cTropnT-0.05*
[**2134-7-18**] CK-MB-37* MB Indx-0.7 cTropnT-0.05*
[**2134-7-18**] CK-MB-31* MB Indx-0.7 cTropnT-0.03*
[**2134-7-19**] Albumin-3.1*
[**2134-7-18**] Type-ART pO2-60* pCO2-30* pH-7.46* calHCO3-22 Base XS-0
Intubat-NOT INTUBA
[**2134-7-18**] Type-ART PEEP-5 pO2-122* pCO2-39 pH-7.41 calHCO3-26
Base XS-0 Intubat-INTUBATED
[**2134-7-18**] Lactate-10.3*
[**2134-7-18**] Lactate-2.8*
CSF: WBC-3 RBC-1* Polys-7 Lymphs-62 Monos-0 Macroph-31,
TotProt-47* Glucose-138
CSF culture - no growth
sputum culture x 2 - MRSA isolated
[**Doctor Last Name 3945**] culture - Cdiff negative
IMAGING:
Admission CXR:
1. Left lower lobe atelectasis and probable pleural effusion.
Pneumonia in this region cannot be excluded.
2. Minor linear atelectasis at the right lung base.
CT HEAD: Study somewhat limited by motion and streak artifact.
No definite evidence of acute infarction. Chronic small vessel
infarction.
MRI/MRI HEAD:
1) No evidence of acute infarction or an infectious process.
2) Multiple small foci of likely chronic hemorrhage within the
basal ganglia, corona radiata, and brainstem; the etiology is
most likely secondary to chronic hypertensive hemorrhages. Less
likely differential considerations would include amyloid
angiopathy and occult arteriovenous malformations.
3) Multifocal elevated T2/FLAIR signal suggesting chronic
microvascular infarction.
4) Moderate stenosis of the proximal basilar artery. The
cerebral vessels are otherwise unremarkable.
CT ABDOMEN:
1) No definite source of fever/infection identified.
2) Bibasilar consolidation/atelectasis; correlate with clinical
picture for possible early pneumonia.
3) Atypical appearing fluid filled structure adjacent to the
bladder, which may represent a bladder diverticulum or
neobladder; correlate with urologic/surgical history.
4) Simple right kidney cyst.
5) Left lateral chest wall subcutaneous edema, which is likely
dependent.
EKG: Sinus tachycardia, LAD, early R wave progression. Not
significantly changed from prior.
Brief Hospital Course:
A/P: 78 year old male with h/o HTN, AAA, CVA and TIA, p/w
lethargy, L facial droop (?old), found to have mild
leukocytosis, fever, lactate of 10, ?PNA on CXR and CT.
1) Sepsis: The patient was admitted to the [**Hospital Unit Name 153**] for code sepsis
based on elevated WBC count, elevated lactate, tachypneia. It
was felt that the likely source was PNA. His UA was negative,
CT abdomen negative for acute intra-abdominal process. LP
showed 3 wbc, normal fluid studies, making meningitis unlikely.
C. Diff negative. He was aggressively hydrated and lactate
dropped precipitously within the first 12 hours. He was started
on broad spectrum antibiotics - ceftriaxone and vancomycin, as
well as azithromycin to cover atypical pneumonia which was later
discontinued given low clinical suspicion. He remained afebrile
after the first day, with improvement in leukocytosis. He
remained hemodynamically stable, and in fact became hypertensive
by his 2nd hospital day. He was called out to the floors after
2 days in the ICU. On the floor the patient continued to
improve. He remained afebrile throughout and his sputum cultures
from the MICU grew MRSA. He was kept on IV vanco and ceftriaxone
and will be discharged with these medications to finish a 10 day
course.
It is unclear whether or not his PNA was the primary event, or
whether he had a viral syndrome with lethargy and resultant
aspiration pneumonia given the bilaterality of the pneumonia and
relative obtundation on admission. He was kept on aspiration
precautions on the floor. A swallow evaluation post-extubation
demonstrated good swallowing but difficulty handling his own
secretions. It was repeated on [**2134-7-23**] and the patient passed
swallow evaluation.
2) Hypoxic respiratory failure: He was intubated in the ED
secondary to concern for impending airway compromise given his
altered level of consciousness and borderline ABG. He was
maintained on AC for 1 day and extubated within 24 hours.
Pneumonia probably contributed to his initially mild A-a
gradient. His initial mild respiratory alkalosis was likely
secondary to early sepsis. He did well post-extubation. The
patient was kept on oxygen by nasal cannula while on the floor
and it was titrated down to room air with only occasional oxygen
prn.
3) Lethargy, facial droop: Given his normal CT and head MRI, as
well as relatively normal LP (3 WBC borderline), these symptoms
were felt most consistent with reexpression of an old lesion in
the setting of distant infection - especially since he presented
with the exact same clinical findings on last admit 1 year ago.
Per Dr. [**Last Name (STitle) **], his facial droop was actually not new. We
continued his daily ASA for stroke prophylaxis.
4) CK elevation: This was felt likely secondary to prolonged
down time, with possible viral infection. His MB index was
normal, therefore not likely cardiac. His head MRI was negative
for stroke, making intracranial source unlikely. His CK peaked
on the first night and declined with aggressive hydration.
5) Petechial rash: His INR rose to 3.0 on admission, therefore
his rash was thought possibly secondary to DIC, though his
fibrinogen and FDP, haptoglobin, LDH were all normal. Labs were
sent to rule out a vasculitis. [**Doctor First Name **], ANCA, C3, C4 were all
normal. CRP was markedly elevated, the significance of which is
uncertain in the setting of infection. His petechiae slowly
resolved, and his coags normalized.
6) Erythematous rashe on chest: In the MICU this was felt most
consistent with Zoster given the distribution and small
vesicles. He was placed on acyclovir. His rash also extended
down his L arm, which is atypical for zoster, however. This was
discussed throughout his stay, as the rash on the chest did not
represent a full dermatomal band, not extending all the way
medially or laterally, and ending where the arm covered the
chest. The floor team suggested possible contact dermatitis,
although the rash did not resolve at all throughout his stay.
Notably the rash only extended up to the arm/armpit area of the
chest, and the pt also had a veyr erythematous area under the
tape holding his R arm IV. It was decided to discontinue his
acyclovir as an outpatient given unlikely zoster presentation
and not improving. We will discharge him with hydrocortisone
cream [**Hospital1 **] applications to the chest rash. Please follow this
rash as an outpt for progression/improvement.
7) Increased Amylase: His amylase elevation on admission
prompted a CT abdomen which did not demonstrate a source. His
lipase was normal and his amylase trended down.
8) FEN: He was kept NPO while intubated and before obtaining
clearance by speech and swallow. On [**7-23**] the patient was
restarted on ground consistency heart healthy diet with thin
liquids. Meds were given in applesauce.
9) Code: Full - discussed with HCP during this admission.
10) PPx: Placed on SQ heparin, Pantoprazole while intubated.
11) Access: In the MICU, pt had a R IJ, which was d/c-ed on
arrival to floor. He then had a midline placed on [**2134-7-22**] for
administration of IV antibiotics which will extend through
discharge. Please d/c the patient's midline access after abx
course finished.
12) s/p fall - on his first day on the floor, the pt stood to
use the bathroom, became dizzy and disoriented, and fell. He
reports hitting his head on the floor, neuro exam was unchanged,
it was not thought to be necessary to get a head CT given
unchanged neuro status. Pt was placed on strict fall
precautions and PT evaluation was subsequently called.
12) pneumonia ppx - on the day of discharge the pt was given
pneumovax for pneumococcus prevention, as he is greater than 65
yo. His nursing home was called, who verified that according to
their records the pt had not received the vaccine, although they
could not verify longer than one year ago. Pt was unsure of his
status so vaccine was given.
Medications on Admission:
Aspirin 325mg QD
MVT QD
Atenolol 50mg QD
Hydrochlorothiazide 12.5mg QD
Vitamin D 400U QD
OYST-CAL-500 [**Hospital1 **]
Doxazosin 4mg QHS
FLomax 0.4mg QHS
Acetaminophen 325mg 2tbl Q4h prn for pain
Acetaminophen/ Diphenhydramin 1tabl QHS
Artificial tears
Discharge Medications:
1. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
1mL heparin flush in each lumen qDay and prn. Please inspect
site daily.
2. Ceftriaxone Sodium 1 g Piggyback Sig: One (1) gram
Intravenous once a day for 5 days.
3. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
q12 hours for 5 days.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
8. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
9. Oyst-Cal-500 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO at bedtime.
12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO q4h prn as needed
for pain.
13. Artificial Tears Drops Sig: [**11-22**] Ophthalmic as needed
as needed.
14. Hydrocortisone 1 % Cream Sig: One (1) application Topical
twice a day for 1-2 weeks: please apply topically to rash on
chest twice a day for 1-2 weeks as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
MRSA pneumonia
Discharge Condition:
fair
Discharge Instructions:
Please give pt IV antibiotics as directed. Please d/c the
patient's midline access after IV antibiotics are finished.
Please use care when using pt's line to avoid infection.
Please check the patient's vancomycin trough level to be sure it
is below 15 (to preserve renal function). It was due to be
checked at 10pm on [**2134-7-23**]. Vanco dose can be lowered by your
physician on staff if necessary for high level.
Please call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to follow up with patient within
the next 1-2 weeks.
Patient may return to all of his previous medications.
Please note that pt received the pneumovax (pneumococcus
vaccine) on [**2132-7-22**].
If you have fever, chills, shortness of breath, or chest pain
please call Dr. [**Last Name (STitle) **] or go to the emergency room.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] to schedule a follow up appt within [**11-22**]
weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Completed by:[**2134-7-24**]
|
[
"276.3",
"507.0",
"518.81",
"482.41",
"038.9",
"441.4",
"401.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13676, 13746
|
6139, 12098
|
339, 524
|
13805, 13812
|
3412, 3412
|
14684, 14934
|
2616, 2625
|
12402, 13653
|
13767, 13784
|
12124, 12379
|
13836, 14661
|
2640, 3393
|
276, 301
|
552, 2326
|
4889, 6116
|
3429, 4880
|
2348, 2503
|
2519, 2600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,546
| 140,996
|
45982
|
Discharge summary
|
report
|
Admission Date: [**2127-8-23**] Discharge Date: [**2127-8-29**]
Date of Birth: [**2063-11-28**] Sex: M
Service: MEDICINE
Allergies:
Nitroglycerin
Attending:[**First Name3 (LF) 33596**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 63 yo metastatic carcinoid, HTN, hyperlipidemia, s/p recent
admission to [**Hospital1 18**] (d/cd [**8-21**]) who presents with altered mental
status. Pt was admitted to [**Hospital1 **] [**2127-8-1**] with DOE and orthopnea.
Pt had a RLL PNA with b/l effusions (transudative on tap) and
CHF. He was found to have a decreased EF to 35-40%, and P-MIBI
showed moderate reversible defects in the apex and septum.
Cardiac catheterization on [**2127-8-15**] showed mild coronary artery
disease (prox RCA 40%, mid-LAD 50%, 20% stenosis at D2),
elevated RV and LV filling pressures, severely depressed EF,
moderate pulm HTN, mild aortic stenosis (mean gradient 10) with
a restrictive defect. Course was complicated by ARF secondary to
overdiuresis as well as contrast nephropathy, and shock liver.
.
Pt was transferred to [**Hospital 38**] Rehab from [**Hospital1 18**]. He developed
some altered mental status and confusion on [**2127-8-22**]. He also was
found to be hypoxic yesterday to 80s on RA with improvement with
diuresis. Today, pt desatted to 80% at rehab, "was blue in the
face", and had altered mental status. He was transferred to
[**Hospital6 33**]. Head CT report showed central and
peripheral atrophy, though no mass or hemorrhage. Pt was then
transferred here as most of his care is here. He was noted to be
A&O x 2 initially in ED, then x 0. He was able to speak small
amounts and follow commands initially.
.
In ED, VS: T: 101.6, HR: 94, BP: 126/52; RR:17; O2: 88RA, 100
4L.
An LP was performed and pt was given Ceftriaxone 2 grams IV x 1,
Vancomycin 1 gram IV x 1, Dexamethasone 13.5 mg IV x 1. Initial
ABG 7.55/29/123/26.
.
Of note, per daughters report, pt had confusion, paranoid
ideations in days prior to d/c from [**Hospital1 **] (no d/c summ yet). also
with this at rehab. Never had this before.
Past Medical History:
1. Metastatic carcinoid tumor, Dx'ed [**2123**], was on a study drug
for a year and a half (ended about a year ago) and was on
octreotide for a few months earlier this year but stopped
because of diarrhea
2. hypertension
3. hyperlipidemia
4. carotid endarterectomy [**2120**]
5. depression/anxiety
6. cellulitis 4 weeks ago, given Keflex IV at [**Hospital3 **], now resolved
7. DM2/prediabetic state: random blood sugar was high, was on
glyburide for a brief time but made his sugars low so stopped
8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI
9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and
[**7-1**])
Social History:
Lives alone, has two daughters
Distant tobacco use (25 pack-years, quit 30 years ago), distant
EtOH use (quit 28 yrs ago), no drugs
Family History:
Early CAD
Physical Exam:
PE:
T:99.3; BP: 124/46; HR: 72; RR: 33; O2: 99 3L
Gen: Unresponsive; can follow some verbal command
HEENT: Right pupil >left ~5:4 cm. reactive to light. Corneal
reflexes
intact. When light is shined in eye, eyes deviate to the left
upperward direction.
Neck: JVD ~8 cm to earlobe.
CV: III/VI systolic murmur best LLSB
Lungs: ?crackles at bases anteriorly. Good air movement.
Abd: Midline scar. Ecchymoses. +small masses under scar
Ext: No edema. DP 2+
Neuro: As per HEENT. Pt able to wiggle toes when asked. He is
nonverbal and cannot follow all commands. CN unable to be
tested.
Cannot follow command. +b/l clonus in LE. Babinski: left
upgoing?
right downgoing; Patellar reflexes 3+. Biceps, brachio [**1-29**].
Pertinent Results:
Radiology:
CXR- Cardiac silhouette enlarged. b/l hilar fullness. b/l
pleural effusions. Retrocardiac opacity in LLL.
.
Persantine MIBI [**2127-8-11**]-Moderate reversible defects in the apex
and septum. Hypokinesis of the septum and apex with a
calculated ejection fraction of 42%. Transient ischemic
dilatation of the left ventricle.
.
Blood:
[**2127-8-23**] 01:54PM NEUTS-76.5* LYMPHS-18.8 MONOS-4.0 EOS-0.3
BASOS-0.4
[**2127-8-23**] 01:54PM WBC-10.2 RBC-3.72* HGB-11.4* HCT-35.3* MCV-95
MCH-30.7 MCHC-32.4 RDW-15.0
[**2127-8-23**] 01:54PM ALT(SGPT)-57* AST(SGOT)-35 ALK PHOS-105
AMYLASE-44 TOT BILI-2.5*
[**2127-8-23**] 01:54PM GLUCOSE-112* UREA N-42* CREAT-1.7* SODIUM-135
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-24 ANION GAP-20
[**2127-8-23**] 02:04PM LACTATE-3.2*
[**2127-8-23**] 02:04PM PO2-123* PCO2-29* PH-7.55* TOTAL CO2-26 BASE
XS-4
[**2127-8-23**] 03:30PM AMMONIA-41
.
[**2127-8-29**] 06:03AM BLOOD WBC-7.8 RBC-3.51* Hgb-10.6* Hct-33.8*
MCV-96 MCH-30.2 MCHC-31.4 RDW-15.6* Plt Ct-218
[**2127-8-29**] 05:53PM BLOOD K-4.2
[**2127-8-29**] 06:03AM BLOOD Glucose-107* UreaN-62* Creat-1.6* Na-137
K-4.5 Cl-99 HCO3-27 AnGap-16
[**2127-8-29**] 11:32PM BLOOD ALT-22 AST-22 LD(LDH)-134 AlkPhos-75
Amylase-25 TotBili-0.9
[**2127-8-28**] 05:50AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-[**Numeric Identifier 78447**]*
[**2127-8-29**] 11:32PM BLOOD Albumin-1.9* Mg-2.4 UricAcd-7.3*
[**2127-8-23**] 08:28PM BLOOD Albumin-3.5 Calcium-9.1 Phos-5.7* Mg-1.9
[**2127-8-23**] 08:28PM BLOOD Osmolal-297
[**2127-8-27**] 05:16AM BLOOD TSH-10*
[**2127-8-29**] 06:03AM BLOOD T4-4.7 T3-42* calcTBG-0.98 TUptake-1.02
T4Index-4.8 Free T4-0.8*
[**2127-8-28**] 06:59AM BLOOD Type-ART Temp-37.7 pO2-86 pCO2-43 pH-7.38
calHCO3-26 Base XS-0 Intubat-NOT INTUBA
[**2127-8-29**] 08:22AM BLOOD Lactate-2.2*
.
CSF:
[**2127-8-23**] 04:35PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-4* POLYS-0
LYMPHS-75 MONOS-25
[**2127-8-23**] 04:35PM CEREBROSPINAL FLUID (CSF) PROTEIN-35
GLUCOSE-73 LD(LDH)-47
.
.
Brief Hospital Course:
BRIEF OVERVIEW:
63 yo male with metastatic carcinoid, HTN, DM, CHF, recently
discharged from [**Hospital1 18**] after prolonged course [**1-29**] pneumonia,
admitted to the ICU with MS changes, now with improving mental
status but continued edema and s/s heart failure R>L thought to
be from carcinoid heart. The patient was transfered to the
floor from the ICU as his mental status improved. He was
treated with diuretics for heart failure, placed on telemetry,
electrolytes monitored, and had good UOP after an initially poor
UOP. The patient appeared to be doing well and then went into V
Tach, V fib, and eventually died after a prolonged resuscitation
attempt.
.
1. Mental Status change - The differential diagnosis of etiology
of encephalopathic state was thought to include serotonin
syndrome, underlying pneumonia and bacteremia and acute renal
failure (consistent with asterixis). Encephalitis/ meningitis
was initially entertained, but was thought to be unlikely as CSF
was negative. The patient was found to becteremic by blood cx
on [**2127-8-23**] ([**3-31**] positive GPC). The pt was covered with
vancomycin. The cultures turned out to be growing MRSE and
vancomycin was continued. The patient remained afebrile and
cultures thereafter remained negative. SSRI was stopped to
prevent worsening of seratonin state. Ativan was initially used
on the floor to sedate the patient when he was agitated/anxious,
however this was held after one day as it was noted to increase
his sedation/confusion. As the patient diuresed, infection
cleared, and meds were held, he became more oriented and more
alert. Whereas he had some paranoia regarding CIA agents on
admission to the ICU and in the day prior, these delusions
resolved on transfer to the floor.
.
2. Fluid status- The patient was known to have an EF of 35% on
a prior echocardiogram. He had received a total of 5L of fluid
in the ICU to support pressure working under the assumption that
the patient was intravascularly dry but total volume overloaded.
Repeat echo showed an EF at this hospitalization of 20-25%.
Severe TR and elevated R-sided pressures were thought to be from
carcinoid heart. His lungs remained somewhat dull to
ausc/percussion, but he exhibited no crackles. Based on his
large JVD and edema and these lung findings, it was thought that
he continued to have the R heart failure physiology seen on echo
at this hospitalization and on cath at the past hospitalization.
On the floor, he was anxious initially and received ativan PRN
initially. Due to sedation effect, this was held starting on
[**8-27**]. Shortly after arriving on the floor, his breathing took
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6055**]-[**Doctor Last Name **] pattern and it was felt that he was volume
overloaded both intra and extra-vascularly. He was diuresed
with IV lasix at increasing doses with poor response. The
cardiology team was consulted and suggested initiation of IV
hydral and nitrates. These were started at low doses to
increase forward flow. The doses were titrated up over two
days, as was lasix until UOP increased. The pt was OOB to chair
on [**8-29**] with help from PT. He was mentating well and
continued to diurese. Goal diuresis was 0.5-1 L net negative
per day. By [**8-29**] he had reached that goal with fluid
restriction in place. [**Hospital1 **] labs were monitored to check
electrolytes during diuresis. The pt was put on telemetry to
monitor cardiac rhythm given extensive heart failure. On the
night of [**8-29**], the patient went into a poorly tolerated VT
which quickly degenerated into V Fib. A code blue was called
and resuscitation was attempted unsuccessfully for over 30
minutes. The patient was declared dead and the code blue was
called off.
.
3. [**Name (NI) 27812**] Pt continually had heart rates 90s-100s. He
remained afebrile. DDx was thought to include intravascular
volume depletion, PE, and anxiety. CT angio ruled out PE and
LENI's ruled out LE DVT. The patient was initially having BB
held but was restarted on BB at low dose when tx to the floor.
The HR remained somewhat fast. At that point, the pt was
thought to be tachycardic [**1-29**] CHF exacerbation in order to
maintain CO.
.
4.ARF- Creatinine baseline was 1.1 - 1.3. The patient had a
Creatinine between 1.5 and 2.0 at this hospitalization. It was
thought to be elevated due to poor forward flow in the setting
of low EF. However, the pt also received a PE protocol chest
CT, which may have further stressed the renal function. FeNA
was measured to be low consistent with a prerenal picture from
vol depletion or poor forward flow, and pointed away from ATN.
The creatinine seemed to peak in the ICU as more fluid was given
and began to descend as fluid was tapered. After arriving on
the floor, small amounts of lasix were given for diuresis with
poor response. UOP was low at 200-300cc/shift. There was a
second peak in the creatinine as diuresis was increased and
hydral/nitrates were added to the regimen. This was followed by
a trend downward as the patient's UOP increased on [**8-28**] and 2
so that he was reaching a goal of net 0.5 to 1 L negative. He
was taking PO well and had a 1-1.2L fluid restriction applied to
limit his intake of fluids.
.
5. Respiratory [**Name (NI) 97891**] Pt had a respiratory alkalosis on
admission. Breathing pattern was shallow and then apnic, but not
[**Last Name (un) **]-[**Doctor Last Name 6056**]. Likely [**1-29**] psychosis and fever. There was also a
gap acidosis in setting of elevated lactate, which resolved
prior to his arrival on the floor. On the morning of [**8-28**],
the [**Last Name (un) 6055**] [**Doctor Last Name **] respirations appeared more labored, O2 sat
dipped temporarily, and the patient appeared more somnolent.
ABG was done and revealed a normal blood gas. Lactate was
elevated, but decreased on a f/u with a venous lactate the next
day. Elevated lactate was thought to be due to hypoperfusion
diffusely rather than an infectious process as the pt was
afebrile.
.
5. DM2- The pt had known DM2 and was put on a diabetic diet and
a sliding insulin scale with regular insulin. Sugar was well
controlled.
.
7. [**Name (NI) 12329**] Pt was on beta blocker and lasix at home. In the ICU,
both were held for tachycardia of unknown etiology and proposed
intravascular volume depletion, respectively. BP was low in the
unit and the pt received fluids for support. By the time he was
transferred to the floor, he was normotensive and was started on
a BB for cardioprotection (low dose given heart failure). Lasix
was used to diurese and likely had little effect on BP.
Hydral/nitrates were started per cardiology recs and BB was
lowered
.
8. CAD-s/p MI in past. Continued baby ASA, statin. Held beta
blocker initially as above, and then restarted. The patient
initially ruled out for MI. He was monitored on telemetry.
.
9. Psychiatry- The patient has a history of depression and
anxiety. On Paxil as outpt, held as above secondary to possible
serotonin syndrome. Pt had been on medication long-term,
however, he may have had increased serotonin in system if
carcinoid has progressed. Pt was also having continued paranoid
ideations. However, was much improved and became cooperative
and less anxious appearing.
.
10. Carcinoid cancer- The patient had known metastasis to the
liver with evidence of carcinoid heart on catheterization. He
was on experimental protocols in past at [**Hospital1 112**]. He has been on
octreotide as an outpatient and had stopped. Restarting this
treatment was considered, but the family declined.
.
The patient died after unsuccessful resuscitation for
ventricular tachycardia that degenerated into ventricular
fibrillation.
.
Medications on Admission:
1. Paroxetine HCl 30 mg Tablet QD
2. Bisacodyl 10 mg Suppository QHS.prn
3. Insulin Regular Human 100 unit/mL as directed
4. Sodium Chloride 0.65 % Aerosol, [**12-29**] Sprays Nasal TID, prn
5. Docusate Sodium 100 mg Capsule PO BID
6. Aspirin 81 mg Tablet, QD
7. Pantoprazole Sodium 40 mg Tablet(E.C.) PO Q24H
8. Heparin Sodium (Porcine) 5,000 unit/mL TID sc.
9. Lactulose 10 g/15 mL, 30 ML PO Q8H prn
10. Furosemide 40 mg Tablet 1 PO BID
11. Toprol XL 25 mg Tablet Sustained Release QD PO
12. Atorvastatin Calcium 20 mg QD
Discharge Disposition:
Expired
Discharge Diagnosis:
The patient died in the hospital.
Discharge Condition:
Expired
Completed by:[**2127-9-1**]
|
[
"428.32",
"486",
"427.1",
"416.8",
"995.92",
"584.9",
"401.9",
"276.3",
"427.31",
"428.0",
"427.41",
"397.0",
"038.9",
"159.9",
"197.7",
"272.4",
"276.2",
"414.01",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.60",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14117, 14126
|
5771, 13543
|
298, 304
|
14203, 14240
|
3767, 5748
|
3001, 3013
|
14147, 14182
|
13569, 14094
|
3028, 3748
|
237, 260
|
332, 2158
|
2180, 2835
|
2851, 2985
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,749
| 148,320
|
28189
|
Discharge summary
|
report
|
Admission Date: [**2183-6-25**] Discharge Date: [**2183-6-30**]
Date of Birth: [**2142-6-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2183-6-25**] Minimal Invasive Off-Pump Coronary Artery Bypass Graft x
1 w/ Thorascopic LIMA Harvest
History of Present Illness:
41 y/o male with h/o HIV and +FH c/o chest pain. Had an abnormal
stress test and was then referred for a cardiac cath. There was
an attempt at stenting the LAD but failed. Now will undergo
surgical revascularization.
Past Medical History:
HIV, Hyperlipidemia, Asthma, Peripheral Neuropathy,
Gastroesophageal Reflux Disease, s/p Tonsillectomy, s/p cochlear
implant
Social History:
Quit smoking 2 weeks ago after [**11-19**] ppd x 28yrs. Social ETOH
drinker w/ approx. 1-2 drinks/wk.
Family History:
2 sisters with [**Name (NI) 5290**] in there 30's.
Physical Exam:
VS: 60 18 132/71 5'[**86**]" 172#
Gen: WDWN male in NAD
Skin: unremarkable
HEENT: EOMI, PERRL, poor dentitian
Neck: Supple, FROM, -JVD, -bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2183-6-25**] Echo: The left atrium is moderately dilated. The left
atrium is elongated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated. Right ventricular systolic function is
normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is a trivial/physiologic pericardial effusion. After
completion of the grafting, there is no significant change in
the echocardiographic examination.
[**6-30**] CXR: Small left apical pneumothorax as well as multiple
loculated left hydropneumothoraces appear unchanged.
Subcutaneous emphysema persists in the left chest wall. Heart
size, mediastinal and hilar contours are within normal limits.
Multifocal atelectasis in the left lung is unchanged as well as
a small right pleural effusion.
[**2183-6-25**] 04:34PM BLOOD WBC-16.9*# RBC-3.87* Hgb-12.0* Hct-34.0*
MCV-88 MCH-31.0 MCHC-35.2* RDW-14.7 Plt Ct-219
[**2183-6-30**] 09:00AM BLOOD WBC-7.3 RBC-3.38* Hgb-10.2* Hct-29.7*
MCV-88 MCH-30.3 MCHC-34.5 RDW-14.7 Plt Ct-291#
[**2183-6-25**] 06:40PM BLOOD PT-12.9 PTT-27.3 INR(PT)-1.1
[**2183-6-25**] 06:40PM BLOOD UreaN-14 Creat-0.9 Cl-106 HCO3-24
[**2183-6-30**] 09:00AM BLOOD Glucose-135* UreaN-19 Creat-1.1 Na-136
K-4.8 Cl-99 HCO3-28 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 68490**] was a same day admit and on [**6-25**] was brought to the
operating room where he underwent a minimal invasive off-pump
coronary artery bypass graft x 1. Please see operative report
for details. Following surgery he was transferred to the CSRU
for invasive monitoring in stable condition. Within 24 hours he
was weaned from sedation, awoke neurologically intact and
extubated. On post-op day one beta blockers and diuretics were
started and he was gently diuresed towards his pre-op weight. On
post-op day two he was transferred to the SDU for further care.
Initial chest x-ray during post-op period revealed a small
apical pneumothorax. Despite chest tubes remaining in place,
pneumothorax was still evident through post-op day four.
Therefore chest tubes were removed on post-op day four. Post
chest x-ray still revealed pneumothorax but with no increase in
size. He remained stable during these days while receiving
physical therapy for strength and mobility. On post-op day 5 he
was doing well and was discharged home with VNA services and the
appropriate follow-up appointments.
Medications on Admission:
Albuterol Neb q6hr, Albuterol INH, Aspirin 325mg qd, Atenolol
25mg qd, Chantix 1mg [**Hospital1 **], Flovent INH, Lexiva 700mg [**Hospital1 **], Lipitor
20mg qd, Marinol 10mg [**Hospital1 **], Norvir 100mg [**Hospital1 **], Omeprazole 20mg qd,
Videx EC 250mg qd, Viread 300mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*1*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*1*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
9. LEXIVA 700 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Marinol 10 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
11. Norvir 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
12. Videx EC 250 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*
13. Viread 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Cargegroup Home Care
Discharge Diagnosis:
Coronary Artery Disease s/p Minimal Invasive Off-Pump Coronary
Artery Bypass Graft x 1
PMH: HIV, Hyperlipidemia, Asthma, Peripheral Neuropathy,
Gastroesophageal Reflux Disease, s/p Tonsillectomy, s/p cochlear
implant
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**First Name (STitle) **] in [**11-19**] weeks
Dr. [**Last Name (STitle) **] in [**11-19**] weeks [**Telephone/Fax (1) 250**]
Wound check [**Hospital Ward Name **] 2 please schedule with RN [**Telephone/Fax (1) 3633**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2183-6-30**]
|
[
"530.81",
"355.9",
"512.1",
"493.90",
"272.4",
"V17.3",
"414.01",
"998.11",
"V08"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"34.21",
"99.07",
"89.60",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6101, 6152
|
3047, 4163
|
330, 434
|
6413, 6419
|
1331, 3024
|
6930, 7387
|
963, 1015
|
4492, 6078
|
6173, 6392
|
4189, 4469
|
6443, 6907
|
1030, 1312
|
280, 292
|
462, 680
|
702, 828
|
844, 947
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,490
| 118,160
|
49414+59176
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-8-9**] Discharge Date: [**2176-8-21**]
Date of Birth: [**2119-5-9**] Sex: F
Service: SURGERY
Allergies:
Demerol / Darvon / Darvocet-N 100 / Morphine / Percocet / Bee
Pollens
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
metastatic squamous cell carcinoma of the anus to liver,
identified on CT scan
Major Surgical or Invasive Procedure:
[**2176-8-9**]: Ex-lap, segment VI liver resection
[**2176-8-10**]: Celiac angiography via 6F [**Doctor Last Name **] 3 sheath and balloon
angioplasty for hepatic artery thrombosis
[**2176-8-16**]: Open cholecystectomy
History of Present Illness:
56y F with recurrent anal squamous cell CA s/p XRT, chemo, and
[**Month (only) **] ([**7-19**]). Postoperatively, on [**2175-9-4**], a CT scan
demonstrated no evidence of
metastatic disease, as did CT scans on [**9-10**] and [**1-9**],
[**2175**]. However, a followup CT scan on [**2176-4-1**] demonstrated
a new 5-
mm hypodensity that appeared to be in segment V of the liver,
too small to definitively characterize, but suspicious for a
metastatic lesion. On [**2176-4-3**] she developed a recurrent
small-bowel obstruction and was taken to the operating room for
exploratory laparotomy, lysis of adhesions for small-bowel
obstruction, and repair of a perineal hernia with DualMesh. A
followup CT scan on [**2176-5-5**] demonstrated that the lesion
in the right lobe had increased to 1.1 cm. She also developed a
recurrent small-bowel obstruction and on [**2176-5-17**] was taken
to the operating room for exploratory laparotomy, extensive
lysis of adhesions, removal of pelvic DualMesh, small- bowel
resection, and placement of drains and a pain pump. Following
this procedure she has had some difficulty eating and was
maintained on TPN. A CT scan on [**2176-6-2**] demonstrated no
change in the liver lesion. A followup CT scan on [**2176-7-19**]
demonstrated a 2.3-cm mass that is hypodense with a surrounding
rim of enhancement that was interpreted as being in Segment VII
of the liver, and a small cyst in Segment IV. The pelvic CT
demonstrated no change in the presacral soft tissue density and
areas of low density within the pelvis, some of which were
thought to represent simple adnexal structures. There were no
signs of small-bowel obstruction. The enlarging mass was
consistent with metastatic carcinoma and appeared to be
resectable. A decision was made to proceed with segemental
resection and she was admitted on [**2176-8-9**].
Past Medical History:
Squamous Cell Carcinoma of anal canal ([**2174**]) s/p chemo/XRT
Recurrent SBOs
Hypercholesterolemia
Hypothyroidism
Osteitis pubis, s/p inferior/superior pubic ramus fx([**6-17**])
Hypothyroidism
Depression
PSHx:
Ex-lap, lysis of adhesions for SBO ([**3-20**], [**5-20**])
[**Month (only) **] ([**7-19**])
Nissen fundoplication ([**2147**], [**2154**], and [**2161**])
Left mastoid type tympanoplasty ([**2164**])
Polyps removal from throat ([**2169**])
Rectus sheath repair ([**2171**])
Right cyst removal ([**2165**])
Social History:
She is engaged. She has no children. She is currently on
disability as manager of a gift shop at a hotel. No tobacco use.
Occasional alcohol use. No regular physical exercise program.
Family History:
No family history of cancer.
Physical Exam:
gen: no acute distress, comfortable, sitting up in chair
neuro: alert and oriented x3
cv: RRR, normal S1-S2, no murmurs
pulm: good aeration, CTA bilaterally
gi: soft, + tender RLQ, no rebound, no guarding, normoactive
bowel sounds, ostomy - pink, +gas, no stool output
ext: warm, pink, no edema
Pertinent Results:
[**2176-8-9**] 11:45AM GLUCOSE-156* UREA N-12 CREAT-0.5 SODIUM-143
POTASSIUM-4.6 CHLORIDE-111* TOTAL CO2-25 ANION GAP-12
[**2176-8-9**] 11:45AM ALT(SGPT)-676* AST(SGOT)-725* ALK PHOS-56 TOT
BILI-0.9
[**2176-8-9**] 11:45AM ALBUMIN-2.7* CALCIUM-7.9* PHOSPHATE-4.7*
MAGNESIUM-1.8
[**2176-8-9**] 11:45AM WBC-11.3*# RBC-3.68* HGB-11.2* HCT-32.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-16.6*
[**2176-8-9**] 11:45AM PT-12.9 PTT-29.3 INR(PT)-1.1
[**2176-8-9**] 09:24AM PO2-297* PCO2-37 PH-7.45 TOTAL CO2-27 BASE
XS-2
[**2176-8-9**] 09:24AM GLUCOSE-175* LACTATE-1.6 NA+-139 K+-4.1
CL--106 TCO2-25
[**2176-8-9**] 09:24AM HGB-11.1* calcHCT-33
Brief Hospital Course:
Admitted on [**2176-8-9**] and underwent segment VI liver resection and
IOUS which revealed a bilobed cystic necrotic mass in segment
VI, presumably representing a metastatic lesion with no other
nodule identified. Pathology revealed metastatic squamous cell
carcinoma (2.7 cm), moderately differentiated and consistent
with metastasis from the anal canal squamous cell carcinoma.
Carcinoma was present within 1.1 cm of the nearest medial
resection margin. Within the non-neoplastic liver specimen, mild
portal chronic inflammation, minimal portal fibrosis (trichrome
stain) and no stainable iron (iron stain) were documented.
Overall, the patient tolerated the procedure well and was
brought back to the floor with a thoracic epidural catheter for
post-operative analgesia, foley catheter, and JP drain x2.
Following the procedure, UOP was 50cc/hr with Foley in place
(Cr=0.6). BP was noted to be low (90s/60s) and patient was given
500cc bolus LR, otherwise she reported adequate pain control,
denied nausea/vomiting, and was tolerating sips. On POD#1, liver
function tests were elevated
(ALT=4282,AST=4295,AlkPhos=150,TBili=0.9), and thus a liver
ultrasound was obtained and labs were repeated. Ultrasound
revealed patent hepatic and portal veins, with appropriate
waveforms, yet decreased resistive indices in the main hepatic
artery and no definite intraparenchymal hepatic arterial flow.
Repeat LFTs were ALT=4319, AST=3688, AlkPhos=187. She was
subsequently referred for angiography and percutaneous
intervention. She underwent celiac angiography via 6F [**Doctor Last Name **] 3
sheath and balloon angioplasty. Thrombectomy of the hepatic
artery thrombus was achieved with QuickCat and ThromCat
catheters. The patient received Heparin IV 4000U and 1U pRBC,
sodium bicarbonate 150mEq (200cc bolus and then 100cc/hr x6h),
and mucomyst x4 doses. She was transferred to the SICU following
thrombolysis and a CT pelvis w/contrast and CTA abdomen w/and
w/o contrast were obtained to evaluate hepatic vessels and
possible contrast extravasation from the angioplasty. Findings
revealed: small pseudoaneurysm at the common hepatic artery
origin just distal to the take off the GDA, luminal narrowing of
the common and right hepatic artery origin consistent with
stenosis, patent intrahepatic right hepatic artery distal to
aforementioned area, no active extravasation of contrast,
possible small focal dissection involving the proximal GDA,
patent intrahepatic left hepatic artery, perfusion abnormalities
consistent with infarction involving segments VII and V with the
branch of right hepatic artery supplying these areas extending
to the resection margin, marked gallbladder luminal distension
and wall edema, and small bilateral effusions, right greater
than left, with adjacent compression atelectasis. The patient
remained hemodynamically stable yet was transferred to the ICU
for close monitoring. Serial Hct and LFTs were checked. Heparin
5000U SC bid was administered on POD#1 and changed to heparin
gtt on POD#2, which was then temporarily held on POD#3 in order
for the epidural to be removed and was then restarted following
catheter removal. Due to temperature of 101.7, she was started
on zosyn, vanco, and flagyl on POD #3, and blood and urine
cultures were taken. LFTs progressively trended down. The
patient reported passing flatus on POD#3 although no stool per
ostomy. She received 1u pRBC for Hct=26.8, which rose to 29.7.
She was then transferred to the floor on POD #4, continued on
aforementioned antibiotics, heparin gtt, and remainder of her
home medications. Foley and CVL remmained in place. At this
time, she was tolerating a regular diet, and medications were
switched to orals. She was initially placed on vicodin due to
percocet allergy, but then changed to po dilaudid due to
complaints of nausea despite zofran and compazine. In an effort
to alleviate nausea, ativan IV was administered which made the
patient extremely sleepy, disoriented, lethargic. On the evening
of POD #5, the patient sustained a mechanical fall after
attempting to get out of bed. She fell on her buttocks, no
trauma sustained. She did not hit her head. The following
morning, she received another dose of IV ativan (1mg) and again,
became increasing somnolent, confused, and incontinent. Ativan
was subsequently held; her home dose (0.5mg po q4-6hr) was given
later that evening on an as needed basis and IV ativan was
avoided. On POD #6 and #7, Fleet's enema per stoma was
administered due to no stool output x3 days; this resulted in
fecal output (pasty brown stool) and a softer abdomen. On POD#7,
CT abdomen - triphasic with arterial reconstruction was obtained
as followup to initial CT on [**2176-8-10**]. Findings revealed:
persistent hypoperfused areas in the right lobe of the liver,
appearance of gallbladder rupture/necrosis, patent portal and
splenic veins, focal stenosis of the common hepatic artery, and
an interval increase in size of the GDA aneurysm. Due to these
findings, she was taken back to the operating room and underwent
an open cholecystectomy on [**2176-8-16**]. She tolerated the procedure
well with no complications and was taken back to the floor
post-operatively. Her diet was advanced as tolerated and she was
encouraged to ambulate with assistance. She received Toradol and
Dilaudid IV for pain control, in addition to ativan po prn.
Heparin gtt was continued with goal INR 60-80. She was switched
to coumadin on POD #9/#1 and heparin gtt was continued until
discharge on [**2176-8-21**]. On discharge, she was tolerating a regular
diet, denied nausea, reported adequate pain control with tylenol
and ativan prn, and was ambulating independently. She was
discharged on coumadin 5mg daily in adddition to her previous
home medication regimen. Home nursing was arranged to assist
with JP and wound cares. She was scheduled to have PT, PTT, and
INR drawn on Thursday [**8-22**]. Followup in outpatient clinic
will be arranged during the week of [**9-2**] with Dr [**Last Name (STitle) **]; she
will be contact[**Name (NI) **] with the appointment date / time.
Medications on Admission:
Lipitor 20 mg po daily
Levoxyl 100 mcg po daily
Vitamin B6 and Vitamin B12
Caltrate 600mg po bid
Protonix 40mg po daily
Zyprexa 2.5mg po bid
Ativan 0.5mg po q4-6h prn
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*10 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
8. medication
Restart vitamin B6, vitamin B12, multivitamin, caltrate, zyprexa
and lipitor as per previous home regimen
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
please take only if instructed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Metastatic squamous cell carcinoma of the anus to the liver s/p
segmental (VI) liver resection, complicated by hepatic artery
thrombosis and necrotic gallbladder.
Discharge Condition:
stable
Discharge Instructions:
Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] if you experience
fever > 101.5, chills, nausea, vomiting diarrhea, constipation,
inability to take or keep down medications.
Monitor wound for redness, tenderness, drainage, bleeding
No heavy lifting x6weeks
[**Month (only) 116**] shower
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22956**] will contact you with your appointment date / time
with Dr [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 673**] if you have any
questions.
PT, PTT, INR to be checked on Thursday [**8-22**] by home nursing,
please fax results to [**Telephone/Fax (1) 697**] or call [**Telephone/Fax (1) 673**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Name: [**Known lastname 1114**],[**Known firstname 69**] Unit No: [**Numeric Identifier 16763**]
Admission Date: [**2176-8-9**] Discharge Date: [**2176-8-21**]
Date of Birth: [**2119-5-9**] Sex: F
Service: SURGERY
Allergies:
Demerol / Darvon / Darvocet-N 100 / Morphine / Percocet / Bee
Pollens
Attending:[**First Name3 (LF) 48**]
Addendum:
Prior to discharge on [**2176-8-20**], JP drain was removed. Due to
INR=3.1, the patient was instructed to hold PM coumadin dose
(5mg) on [**8-20**] and resume on Thursday, [**8-22**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2176-8-21**]
|
[
"V15.3",
"442.84",
"575.0",
"576.8",
"V55.3",
"197.7",
"444.89",
"244.9",
"272.0",
"997.79",
"997.4",
"573.4",
"V10.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"51.22",
"50.22",
"00.40",
"99.04",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
13282, 13494
|
4296, 10396
|
405, 626
|
11797, 11806
|
3633, 4273
|
12166, 13259
|
3271, 3301
|
10613, 11509
|
11611, 11776
|
10422, 10590
|
11830, 12143
|
3316, 3614
|
287, 367
|
654, 2507
|
2529, 3052
|
3068, 3255
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,450
| 122,507
|
51160+59326
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-3-17**] Discharge Date: [**2167-4-29**]
Date of Birth: [**2085-4-1**] Sex: M
Service: MEDICINE
Allergies:
Cholestyramine / Niacin / Iodine; Iodine Containing /
Ciprofloxacin / Heparin Agents
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
hypoxia/hypotension
Major Surgical or Invasive Procedure:
intubation/extubation/reintubation, trachostomy, HD line
placement, multiple central line placements, PEG tube placement,
intra-abdominal abscess drainage w/ pigtail placement
History of Present Illness:
81 yom CAD, pacemaker, reportedly in USOH until approx 2 weeks
PTA --> non-productive cough, persistent. No apparent fevers or
myalgias. Development of malaise, fatigue, generalized weakness
and reduced appetite prompted office visit to usual PCP (G.
[**Doctor Last Name **]) --> noted to be ill-appearing, mild resp. distress,
crackles on lung exam and BP= 68/40. Transported to [**Hospital1 18**] ER
for further evaluation.
In [**Hospital1 18**] ER, BP= 74/32 --> peripheral dopamine started. RIght
IJ central line placed (CVP=4) -- attempts at left IJ central
line placement. Received 5L NS, iv decadron. Anuric renal
failure. Dopamine substituted with Norepinephrine and then added
phenylephrine for persistent hypotension. Empirically received
Ceftriaxone, Azithromycin and Vanco (reportedly with Levoquin
allergy). Intubated (traumatic), and transferred to MICU
service for further evaluation and management.
Upon arrival to MICU, intubated, mechanically ventillated,
sedated. Vasopressin added as third vasopressor with good
effect. Remains anuric. Hypothermia (T= 94)
Past Medical History:
* CAD with hx of CABG in [**2146**] s/p multiple caths, most recently
in [**2157**] with stent to ramus intermedius
* CHB s/p DDD PCM, defibrillator in [**2160**]
* atrial fibrillation
* high cholesterol
* prostate cancer
* ocular melanoma
* CRI (baseline 2.8)
* gout
* OA
* GERD
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
Physical Exam:
Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 400 (400 - 400) mL
RR (Set): 25
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 60%
.
ICU Admission Exam:
General Appearance: No(t) Well nourished, No(t) No acute
distress, Overweight / Obese, No(t) Thin, No(t) Anxious, No(t)
Diaphoretic, Toxic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t)
Conjunctiva pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
Endotracheal tube, No(t) NG tube, OG tube
Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal,
No(t) Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t)
Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,
(Murmur: Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness
: ), (Breath Sounds: No(t) Clear : , Crackles : Bilateral, No(t)
Bronchial: , Wheezes : , No(t) Diminished: , No(t) Absent : ,
No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)
Distended, No(t) Tender: , No(t) Obese, Distended
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Musculoskeletal: No(t) Muscle wasting, Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: No(t) Attentive, Follows simple commands, Responds
to: Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful,
Sedated, No(t) Paralyzed, Tone: Normal
Pertinent Results:
[**2167-3-17**] 05:10PM NEUTS-94.6* LYMPHS-3.0* MONOS-2.3 EOS-0
BASOS-0.1
[**2167-3-17**] 05:10PM WBC-32.5*# RBC-3.09* HGB-10.1* HCT-30.2*
MCV-98 MCH-32.6* MCHC-33.3 RDW-16.9*
[**2167-3-17**] 05:10PM ALT(SGPT)-295* AST(SGOT)-305* ALK PHOS-150*
TOT BILI-4.2*
[**2167-3-17**] 09:32PM PT-24.8* PTT-42.9* INR(PT)-2.4*
[**2167-3-17**] 11:08PM LACTATE-1.3
CXR [**2167-3-17**]:
FINDINGS: There are marked dramatic changes from the prior scan
with at least three discrete foci of patchy opacity in the right
mid, right lower, and left lower lungs. There are less apparent
foci noted in the left mid and left upper lung zones as well.
There are changes consistent with prior median sternotomy and
CABG. An indwelling dual-chamber pacemaker is stable in course
and position. Numerous surgical clips are identified in the
right upper quadrant. No definite effusion or pneumothorax is
seen. The visualized osseous structures are otherwise
unremarkable.
IMPRESSION: Given history, the interval development of patchy
opacities in
the distribution described above are presumably multifocal
pneumonia.
Correlate clinically, and if indicated, continue with close
interval
surveillance.
[**2167-4-8**] UENI:
LEFT UPPER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and color and
pulse wave Doppler examination was performed over the left
internal jugular, subclavian, axillary, brachial, and basilic
veins, demonstrating normal flow, compressibility, respiratory
variation, and augmentation were unremarkable. No evidence of
intraluminal thrombus is seen. The cephalic vein is not seen.
IMPRESSION: No DVT seen in the left upper extremity. The
cephalic vein is
not well visualized, but the basilic vein remains patent.
[**2167-4-15**] CT ABDOMEN:
Fluid collection containing small bubbles of gas as described
above,
situated between the duodenum and pancreatic head and uncinate
process.
Differential considerations include perforation of a duodenal
ulcer or
duodenal diverticulum with resultant abscess. Much less likely,
given the
proximity of the pancreas, a pancreatic process such as an
infected pseudocyst (given the presence of gas) is a
differential consideration. No definite mass is identified.
.
[**2167-4-22**] CT Abdomen w/out IV contrast:
1. The pigtail catheters sits within an air and fluid collection
along the
medial aspect of the second portion of the duodenum in the
region of a
previously visualized duodenal diverticulum. This air and fluid
collection is smaller than on the prior study and currently
measures 5.3 x 2.9 cm.
2. New hypoattenuating lesions are seen in the periphery of the
right lobe of the liver as well as in the spleen. The
differential diagnosis for these findings together includes
infarcts. Additional etiologies that could explain the liver
findings include infectious causes such as cholangitis or
evolving hepatic abscesses. There is no drainable fluid
collection in the liver or spleen at this time.
3. Stable small amount of ascites in the perihepatic and
perisplenic regions which tracks along the right paracolic
gutter into the pelvis.
4. Unchanged large bilateral pleural effusions.
5. Colonic diverticulosis without evidence of diverticulitis.
6. Anasarca.
.
[**2167-4-23**] Renal U/S:
No hydronephrosis. Multiple small right renal cysts.
.
[**2167-4-25**] CT Abdomen w/ IV contrast:
1. Residual paraduodenal phlegmon with a pigtail in place.
2. Multiple hypodense areas in the liver and spleen. The liver
findings are again worrisome for small abscesses, although there
is no definite change and no drainable collection. Differential
considerations for the splenic lesions again include abscesses,
infarcts or both.
.
[**2167-4-27**] ECHO:
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. No masses
or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is severely depressed (LVEF= 20 %)
with global hypokinesis and regional akinesis of the inferior
wall. There is no ventricular septal defect. with depressed free
wall contractility. 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. No mass or vegetation is seen on the mitral valve.
Mild to moderate ([**2-13**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2167-4-6**], no
change.
.
Brief Hospital Course:
ICU Course:
#.Leukocytosis/fever ?????? The patient was admitted with septic
shock and had ongoing leukocytosis and fevers from the day of
admission. Sputum cultures from [**4-5**] showed pansensitive
serratia and klebsiella oxytoca and stool cultures were positive
for c.diff on [**4-8**] in the setting of prolonged antibiotic
administration. For the repeat PNA on the [**4-7**], there were not
significant radiographic findings, but with increased secretions
and needing to be placed back on the vent, started treating for
hospital aquired pneumonia with vanco/zosyn, until [**4-10**], when
repeat sputum cultures showed GNR. At this time, vancomycin was
switched from zosyn to meropenem. KUB did not show any evidence
of megacolon. For his C. diff infection, he was maintained on PO
Vancomycin and IV flagyl. This regimen should be continued for
14 days after all other antibiotics are discontinued.
In addition, on [**2167-4-16**] a CT Abdomen showed an intra-abdominal
air/fluid collection, adjacent to the duodenum, thought to be
the result of a ruptured duodenal diverticulum. Surgery was
consulted and did not want to take the patient to the O.R. This
collection was drained by Interventional Radiology and a pigtail
catheter was placed on [**2167-4-17**]. The collection grew pan-sensitive
serratia and fluconazole-sensitive [**Female First Name (un) **] parapsilosis. He was
started on fluconazole on [**4-16**] and cefepime on [**4-17**] for this
abscess.
A repeat CT was obtained on [**4-22**] to look for evolution of the
paraduodenal abscess, which showed new hypoattenuations in the
liver and spleen, possible consistent with ischemia or septic
infarct. None of these collections were large enough to drain,
and the patient was afebrile, so cefepime/fluconazole were
continued. The patient developed severe abdominal pain on the
morning of [**4-27**], and CT abdomen was again repeated, this time
with IV contrast, which showed persistent hypoattenuations in
the liver and spleen. An ECHO was repeated and was negative for
vegetations. Pain resolved with morphine and fentanyl. The
pigtail drain was clamped on [**4-29**] because it was draining
minimal amounts of clear green fluid.
#.Septic Shock/Hypotension: Initially hypotensive in setting of
septic shock. He had Early Goal Directed Therapy with Apache IV
score of 114. Initial sputum with GNRs and GPCs in pairs and
initial community-acquired PNA was treated. Then patient
developed what was thought to be hospital-acquired pneumonia as
well as c.diff colitis, and an intra-abdominal abscess. Daily
attempts were made to wean the patient from pressors once his
infections appeared adequately treated. His hypotension was
treated with levophed, midodrine, and vasopressin as needed. In
addition, as there was a question of a cardiogenic component to
his shock, given known low EF and low mixed venous O2
saturation, the patient had a trial of dobutamine, with no
improvement in his blood pressure. The patient had an A-line
placed, but developed arterial occlusion and A-line had to be
pulled. He was not able to have further invasive BP monitoring.
BP was monitored with lower UE and thigh cuff, and mental status
and serum lactate were used as parameters of tissue perfusion.
In order to maximize the patient's cardiac function, EP was
consulted on [**4-27**] to increase the patient's paced rate from
78->90. With a HR of 90, the patient was able to be weaned from
levophed. He was also restarted on digoxin, which he takes at
home, on [**4-29**].
.
#Respiratory failure/ARDS: In the setting of his hospital
acquired pneumonia, the patient developed ARDS. He had a
percutanous tracheostomy on [**4-1**] for ongoing mechanical
ventilation. As his pneumonia was treated, his pulmonary status
stabilized and each day he had pressure support trials, which he
tolerated for a few hours each day. His ongoing respiratory
failure was also likely due to CHF and fluid overload.
.
#Anemia ?????? Patient had severe anemia with hematocrits around 20
upon admission to the ICU. He was found to be super Coombs
positive and to have many antibodies to donor blood. In
addition, he has a component of anemia of chronic disease.
Hematology consult was obtained, and heme followed the patient
throughout his stay. Epogen 10000U 3x/week, iron, and folate
supplements were given consistently. In addition, daily
hemolysis labs were checked, which showed evidence of ongoing
low-grade DIC. Given the patient's antibodies, he was transfused
only for a goal Hct of 21%. A repeat Super-Coombs was done, and
the patient was found to be negative on repeat testing.
.
#LUE swelling ?????? The patient had 2 episodes of asymmetric LUE
swelling. He had 2 ultrasounds to evaluate for thromboses, which
were both negative. Strength and sensation were symmetric in R
and L arms. Despite negative LENIs, clinical suspicion for clot
remained very high. Swelling resolved without intervention.
.
#Dysphonia ?????? due to cuffed 8.0 trach, will change on [**4-13**] and
then get ENT consult as needed as outpatient, confirmed with ENT
and IP on [**2167-4-7**]. Got PMV on [**4-6**].
- Will hold off until resp status improves
.
#Coagulopathy: Patient had elevated PT/PTT and thrombocytopenia.
Coagulopathy likely mulifactorial, with components of shock
liver, low vitamin K absorption, and sub-acute DIC. Stool was
guaiac negative. The patient was found to be Heparin antibody
positive, and all heparin products were held. Serotonin Release
Antibody was negative, thereby confirming clinical suspicion
that patient did not have HIT. He was not anti-coagulated with
argatroban.
.
#Transaminitis: Likely due to shock liver in setting of
distributive picture with decreased EF. RUQ u/s shows known CBD
dialation, s/p chole. LFT??????s improving.
.
#Oliguric, acute on chronic ARF/Uremia: Baseline Cr 2.3.
Patient in ARF from acute tubular necrosis in setting of
hypotension. Patient was given CVVH through L femoral line then
HD. Renal pulled fem HD line with resolution of leukocytosis,
tip culture pending, but could suggest line infection. [**3-31**],
placed IR HD line on Tuesday with VIP port, non-tunneled since
was spiking. In the setting of ongoing pressor requirements, the
patient was maintained on CVVH until [**4-27**], when intermittent HD
was started per family request, as CVVH made the patient very
uncomfortable. He had a renal ultrasound which showed no
evidence of obstruction or hydronephrosis. He had a tunnelled
hemodialysis line placed on [**4-29**] with IR, and his Right IJ
central line was pulled.
.
#Mental Status: awake, following commands. Initially, mental
status did not immediately return once sedation removed because
of shock liver and decreased metabolism of sedatives on initial
presentation.
MS much improved, cont zyprexa as needed for agitation
.
#Coronary Artery Disease: The patient had a CABG in [**2146**] with
multiple PCI stent placements as well as AICD placement in [**2160**].
He was continued on ASA and statin, but all antihypertensives
were held in the setting of persistently low blood pressures.
Goal Hct was set at 21 rather than 25 due to significant issues
with transfusions, as above.
.
Hypoalbuminemia: decreased in the setting of sepsis
.
Nutrition: The patient had a PEG placed on [**4-3**] due to prolonged
intubation and need for prolonged tube feeds. This was advanced
to a G-J tube after the discovery of his para-duodenal abscess.
He was maintained on tube feeds.
.
On HOD 43, the patient returned from getting a tunneled catheter
in IR and had a witnessed run of ventricular tachycardia that
was caught on telemetry. It resolved spontaneously within [**2-13**]
minutes without intervention. A faint pulse was palpated in the
radial artery. The patient became unresponsive to voice. [**2-13**]
minutes later, the patient had another run of ventricular
tachycardia that was seen on EKG. During this episode, the
patient had no pulse. The blood pressure dropped to zero and no
CPR was performed as the patient was made DNR previously. The
patient was pronounced at 2218 on [**2167-4-29**].
Medications on Admission:
Allopurinol 200 mg daily
Amiodarone 200 mg daily
Atorvastatin 20 daily
Digoxin 125 mcg daily
Fexofenadine 50 mcg, 2 sprays each nostril daily
Furosemide 10 md every other day
Hytrin 2 mg qhs
Lisinopril 5 mg daily
Omeprazole 20 mg twice daily
Tylenol 650 mg tid prn pain
Aspirin 325 mg daily
MVI
Discharge Medications:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Septic shock
ARDS
community acquired pneumonia
ventilator associated pneumonia
acute on chronic renal failure requiring dialysis
Secondary:
chronic delayed hemolytic transfusion reaction with anemia
dysphonia secondary to prolonged intubation
Discharge Condition:
Expired
Discharge Instructions:
NONE
Followup Instructions:
NONE
Completed by:[**2167-4-29**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 17325**]
Admission Date: [**2167-3-17**] Discharge Date: [**2167-4-29**]
Date of Birth: [**2085-4-1**] Sex: M
Service: MEDICINE
Allergies:
Cholestyramine / Niacin / Iodine; Iodine Containing /
Ciprofloxacin / Heparin Agents
Attending:[**First Name3 (LF) 1015**]
Addendum:
The patient expired after a cardiopulmonary arrest. The previous
Discharge summary states that the patient was discharged to an
extended care facility. This was written in error.
Discharge Disposition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**]
Completed by:[**2167-6-25**]
|
[
"286.6",
"V45.02",
"038.49",
"283.10",
"428.0",
"530.81",
"V45.82",
"428.20",
"038.44",
"567.22",
"995.92",
"999.89",
"784.49",
"414.01",
"584.5",
"785.52",
"427.31",
"997.31",
"570",
"285.29",
"008.45",
"562.00",
"038.9",
"518.81",
"V45.81",
"585.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"46.32",
"99.04",
"96.6",
"38.93",
"99.07",
"39.95",
"43.11",
"38.91",
"54.91",
"38.95",
"96.72",
"31.1",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
18208, 18374
|
8711, 15283
|
364, 541
|
17496, 17505
|
3892, 8688
|
17558, 18185
|
2108, 2189
|
17155, 17161
|
17220, 17475
|
16836, 17132
|
17529, 17535
|
2204, 3873
|
305, 326
|
569, 1663
|
15298, 16810
|
1685, 1966
|
1982, 2092
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,599
| 113,444
|
40012+58343
|
Discharge summary
|
report+addendum
|
Admission Date: [**2117-9-29**] Discharge Date: [**2117-10-5**]
Service: CARDIOTHORACIC
Allergies:
aspirin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2117-9-29**] Aortic valve replacement with a 29-mm [**Company 1543**] Mosaic
Ultra bioprosthesis. Replacement of ascending aorta with a 30-mm
Dacron tube graft using deep hypothermic circulatory arrest
which included hemi-arch replacement.
History of Present Illness:
[**Age over 90 **] year old male known to our service (see previous notes) who
has a history of severe AS ([**Location (un) 109**] 0.8cm2), HTN, chronic GI
bleeding ([**1-6**] AVMs, UC) requiring frequent transfusion,
myelodysplastic syndrome s/p recent chemotherapy. He has been
undergoing work-up for potential aortic valve replacement and
asc. aorta repl. He first needed neuro clearance after new left
foot drop. Neuro decided foot drop is related to peroneal nerve
lesion. Given his complex GI history, he was also waiting GI
clearance and to make sure that his colitis was in control and
hopefully off steroids. Following cardiac surgery, it was
recommended that he have a colectomy because of the ulcerative
colitis and a large polyp that is almost to the anal verge.
There are multiple other polyps that are also adenomas. He now
presents again in clinic for further discussion of surgery.
Past Medical History:
- Severe aortic stenosis
- Hypertension
- Hyperlipidemia
- Systolic congestive heart failure
- Benign Prostatic Hypertrophy
- Ulcerative colitis with recurrent GI bleeding on sulfasalazine
- Gastric AVMs s/p GI bleed, admitted on [**2117-7-26**] to [**2117-7-28**]
- Myelodysplastic syndrome, tx with Vidaza [**Date range (1) 32684**]
- Prostate Cancer in [**2095**]'s
- Left foot drop - common peroneal nerve lesion, likely at the
fibular head. Wears foot orthosis and foot drop splint.
- s/p b/l cataract extraction and lens implants
Social History:
Race: Caucasain
Last Dental Exam: edentulous
Lives with: Wife
Occupation: Retired carpenter
Cigarettes: Smoked no [] yes [X] Hx:quit smoking 50 years ago
and smoked for 20 years
Other Tobacco use: Denies
ETOH: < 1 drink/week [X] [**1-11**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
Daughter - breast ca
Father - died at age 72 prostate Ca
Physical Exam:
Pulse: 85 Resp: 16 O2 sat: 99/RA
B/P 99/56
Height: 5'5" Weight: 75 kgs
General: Well-developed elderly male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [Xx] Irregular [] 3/6 systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema Trace
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/Left: systolic murmur radiating
Pertinent Results:
Echo [**2117-9-29**]: 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 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 normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Doppler parameters are most
consistent with Grade II (moderate) left ventricular diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. There is a
well-seated, well-functioning bioprosthetic valve in the aortic
position. No aortic regurgitation is seen. No paravalvular leak
is seen. There is a mean gradient of 7 mmHg across the aortic
valve at a cardiac index of 2.1. Mitral regurgitation is trace.
Tricuspid regurgitation is unchanged. The aorta is intact.
[**2117-10-4**] 05:45AM BLOOD WBC-4.3 RBC-2.85* Hgb-8.6* Hct-27.9*
MCV-98 MCH-30.2 MCHC-30.9* RDW-18.0* Plt Ct-219
[**2117-9-30**] 03:18AM BLOOD PT-14.4* PTT-33.3 INR(PT)-1.2*
[**2117-10-4**] 05:45AM BLOOD Glucose-100 UreaN-34* Creat-1.4* Na-140
K-4.3 Cl-104 HCO3-30 AnGap-10
[**2117-10-4**] 05:45AM BLOOD Mg-2.1
[**2117-10-5**] 06:05AM BLOOD UreaN-37* Creat-1.3* Na-142 K-4.4 Cl-105
[**2117-10-5**] 06:05AM BLOOD Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 14218**] was a same day admit after undergoing pre-operative
work-up prior to admission. On [**2117-9-29**] he was brought to the
operating room where he underwent an aortic valve replacement
and ascending aorta replacement. Please see operative report 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 2 the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. He was
seen by speech and swallow for a bedside evaluation and was
cleared for a regular diet. His rhythym was initially asystole
and then became nodal and eventually he was in a sinus rhythm in
the 60's. EP service was consulted. Low dose beta blocker was
initiated and titrated up and the patient tolerated this well.
He was gently diuresed toward his preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
(patient was in sinus rhythm in the 80's) after third dose of
beta blocker without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 6 the patient was
ambulating with assistance, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
[**Hospital 88006**] [**Hospital **] Rehab in [**Location (un) 38**] in good condition with
appropriate follow up instructions.
Medications on Admission:
AZACITIDINE [VIDAZA] - (Prescribed by Other Provider) - Dosage
uncertain
EPOETIN ALFA [PROCRIT] - (Prescribed by Other Provider) - 20,000
unit/mL Solution - 60,000 units twice a week
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 40 mg
Tablet - 0.5 (One half) Tablet(s) by mouth once a day
MESALAMINE [CANASA] - 1,000 mg Suppository - 1 Suppository(s)
rectally at bedtime
PREDNISONE - 7.5 mg Tablet - 1 Tablet(s) by mouth once a day as
directed
SULFASALAZINE [SULFAZINE] - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day
TERAZOSIN - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth once a day
Medications - OTC
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever.
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal HS (at bedtime).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP <100 or HR <60.
11. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
14. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 10 days.
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
Severe aortic stenosis s/p Aortic valve replacement
Dilated ascending aorta s/p Ascending aorta replacement
Past medical history:
- Hypertension
- Hyperlipidemia
- Systolic congestive heart failure
- Benign Prostatic Hypertrophy
- Ulcerative colitis with recurrent GI bleeding on sulfasalazine
- Gastric AVMs s/p GI bleed, admitted on [**2117-7-26**] to [**2117-7-28**]
- Myelodysplastic syndrome, tx with Vidaza [**Date range (1) 32684**]
- Prostate Cancer in [**2095**]'s
- Left foot drop - common peroneal nerve lesion, likely at the
fibular head. Wears foot orthosis and foot drop splint.
- s/p b/l cataract extraction and lens implants
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
Edema - 2+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on on [**11-8**] at 1:00pm
Cardiologist: Dr. [**Last Name (STitle) **] on [**10-15**] at 9:45a
Please call to schedule appointments with your
Primary Care Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 25693**] in [**3-9**] weeks [**Telephone/Fax (1) 25694**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2117-10-5**] Name: [**Known lastname 13949**],[**Known firstname **] Unit No: [**Numeric Identifier 13950**]
Admission Date: [**2117-9-29**] Discharge Date: [**2117-10-5**]
Date of Birth: [**2025-1-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
aspirin
Attending:[**First Name3 (LF) 1543**]
Addendum:
Terazosin 2 mg daily and Vitamin B12 added to patient's
discharge medications. Spoke to oncology service who
recommended follow up with outpatient oncologist for Procrit
dosing. Currently Hct is stable at 27.9 (baseline 28.9). Dr
[**Doctor Last Name 13951**] oncologist was called for appointment in 1
week. Rehab instructed to check Hct Q 3-4 days. Per oncology, no
danger in holding Procrit x 1 week during rehab stay
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] HealthCare Center at [**Location (un) **]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2117-10-5**]
|
[
"238.75",
"428.22",
"401.9",
"569.84",
"746.4",
"428.0",
"440.0",
"V70.7",
"441.2",
"272.4",
"424.1",
"556.9",
"426.0",
"355.3",
"736.79",
"V58.65",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"38.45",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
12316, 12559
|
5235, 6880
|
240, 484
|
9818, 10006
|
3080, 5212
|
10929, 12293
|
2303, 2361
|
7764, 9080
|
9154, 9262
|
6906, 7741
|
10030, 10906
|
2376, 3061
|
181, 202
|
512, 1411
|
9284, 9797
|
1987, 2287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,062
| 107,808
|
7469
|
Discharge summary
|
report
|
Admission Date: [**2121-12-7**] Discharge Date: [**2121-12-9**]
Date of Birth: [**2080-1-11**] Sex: F
Service: NEUROLOGY
Allergies:
Iodine
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Tingling of left side
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41 year old woman hx DM, TIA, 100% occlusion of the left
internal carotid artery, who was in her usual state of health
when she awoke at 4am, and shortly thereafter had acute onset of
tingling of the left fingers which marched up the left arm and
left face. She had tingling of the left leg. This quickly became
numbness. She had dysarthria. She felt heaviness of the left arm
and leg. Pt tried to stand up but she felt as if her left leg
was
shuffling and heavy. She sat back down. At 5:10am, she still had
tingling and heaviness of the left arm but the other symptoms
had
resolved.
Patient was taken to the [**Hospital1 18**] ED. NIHSS was 1 for left
pronator drift. Head CT showed a small bleed in the genu of the
right internal capsule. She had a SBP of 218/114. Patient was
given Labetalol 10mg iv once. Patient was admitted to ICU for BP
control.
ROS:
+tinnitus at times for 4 yrs
+floaters
+monocular diplopia s/p eval by Dr. [**Last Name (STitle) 27348**]
+lt sensitivity
+diarrhea and constipation alternating
+abd pain at times
+urinary urgency, occasional accidents (stress incont)
+occ. CP
+occ. palpitations
+occ. sob
+occ. DOE
Other ROS was negative
Past Medical History:
-CAD s/p MI at 37
-DM1 (retinopathy, neuropathy, nephropathy)
-autonomic dysfunction, s/p eval by autonomic team
-irritable bowel syndrom
-anemia
-depression
-migraines
-hypothyroidism
-recent TAH
-s/p CCY
-Acne
-ER visit [**8-8**] with same sx, thought to be possibly migraine vs
TIA
-prior [**Female First Name (ambig) 27349**]: [**7-8**] with BL LE heaviness and R-arm
heaviness;
She has had 2-3 episodes of right arm tingling, numbness and
right facial numbness and tingling
She describes sx as numbness and tingling starting in one finger
and spreading over minutes to including the whole hand and then
moving to the left side of the mouth - sx last 10 minutes total.
During the sx, when she tries to speak, speech is thick and
garbled, sometimes saying the wrong word in addition to
slurring,
and she has frustration with finding the right word -
comprehension is completely normal. This resolves within 10
minutes, and about 50% of the time she then experiences the
gradual onset of a throbbing, L-sided headache with photophobia,
mild phonophobia and nausea, sometimes with dry heaving, lasting
hours. She had an episode last week, and an episdode today -
compazine helped the headache.
patent extracranial R-ICA, with possible R-supraclinoid
narrowing; complete occlusion of the L-ICA; LVEF>55%, no PFO or
ASD; no dwi on MRI, but signs of small vessel disease
Social History:
She lives with husband and has a 4 year old son. She is a
homemaker. Denies smoking. Occ. etoh.
Family History:
No migraines, strokes, or seizures. Her father has DM and CAD.
Physical Exam:
VS: Tc 98.0 BP 218/114 to 167/101 P 114 R 16 O2 100%
Gen: WD/WN
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: regular rate and rhythm, no murmurs,
Abd: soft, non-distended, non-tender, no mass, positive bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert and oriented x3, fluent, intact comprehension,
intact naming, repetition, nowledge, follows crossed body
commands, no neglect
CN: visual fields full to confrontation, no papilledema, pupils
equal, round, and reactive,
extraocular movements intact, intact light touch, intact facial
strength and symmetry,
intact t/u/p, [**4-6**] SCM and trapezius
Motor: normal tone and bulk of all four extremities, no tremor
Mild pronator drift of the left arm
D B T WE WF
Left 5 5 5 5 5
Right 5 5 5 5 5
IP Q H DF PF
Left 5 5 5 5 5
Right 5 5 5 5 5
Sensory: intact light touch and pinprick of all four extremities
decreased vibration and proprioception of LE in a
stocking glove distribution
no extinction
negative Romberg
Reflex: T BR B K A toes
Left 2 2 2 2 2 down
Right 2 2 2 2 2 down
Coord: Intact finger-nose-finger, heel-shin bilaterally
Gait: deferred
Pertinent Results:
[**2121-12-7**] 06:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2121-12-7**] 06:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2121-12-7**] 05:46AM GLUCOSE-307* UREA N-35* CREAT-1.8* SODIUM-137
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2121-12-7**] 05:46AM estGFR-Using this
[**2121-12-7**] 05:46AM CK(CPK)-191*
[**2121-12-7**] 05:46AM cTropnT-<0.01
[**2121-12-7**] 05:46AM CK-MB-4
[**2121-12-7**] 05:46AM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2121-12-7**] 05:46AM WBC-7.0 RBC-5.09# HGB-13.8 HCT-43.1 MCV-85
MCH-27.1 MCHC-32.1 RDW-15.9*
[**2121-12-7**] 05:46AM NEUTS-54.1 BANDS-0 LYMPHS-32.8 MONOS-6.0
EOS-5.9* BASOS-1.2
[**2121-12-7**] 05:46AM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2121-12-7**] 05:46AM PLT COUNT-414
[**2121-12-7**] 05:46AM PT-11.2 PTT-22.9 INR(PT)-0.9
[**2121-12-8**] 05:44AM BLOOD %HbA1c-10.3*
[**2121-12-8**] 05:44AM BLOOD Triglyc-134 HDL-68 CHOL/HD-2.5 LDLcalc-77
[**2121-12-8**] 05:44AM BLOOD ALT-24 AST-30 LD(LDH)-211 CK(CPK)-80
AlkPhos-112 TotBili-0.3
CT head [**2120-12-7**]:
FINDINGS: There is a focal linear region of hyperattenuation
measuring 8 mm
in greatest dimension within the periventricular white matter
and involving
the lateral margin of the right internal capsule consistent with
acute
hemorrhage. There is a smaller adjacent focus. No significant
mass effect is
present. The major intracranial cisterns are preserved. There
is no
hydrocephalus.
No acute fracture is detected. The paranasal sinuses and
mastoid air cells
are clear except for mild mucosal thickening in the left
maxillary sinus.
IMPRESSION:
Two linear foci of hyperattenuation within the right corona
radiata
consistent with an acute parenchymal hemorrhage. No significant
mass effect
or midline shift is demonstrated.
MRI/MRA head [**2120-12-7**]:
Comparison is made with CT head on the same day and from MRI,
MRA performed
[**2121-4-22**] and [**2120-8-16**].
There is mucosal thickening and mucous retention cyst in the
left maxillary
sinus.
Acute hemorrhages are again noted in the right corona radiata,
unchanged from
the previous CT. There is no significant surrounding edema, or
mass effect.
There is no associated diffusion restriction. There is no
enhancement to
suggest an underlying lesion. There is lack of flow related
enhancement in
the left petrous and cavernous ICA and in the right supraclinoid
ICA. This is
unchanged from the prior report. There are multiple scattered
subcortical and
periventricular hyperintensities which likely represent small
vessel ischemic
sequela in this patient with diabetes.
IMPRESSION:
Small foci of hemorrhage in the right corona radiata with
minimal surrounding
edema and no midline shift.
Probable small vessel ischemic sequela related to underlying
diabetes in the
subcortical and periventricular white matter.
Lack of normal flow voids in the left petrous, cavernous and
supraclinoid ICA
and the right supraclinoid ICA, reportedly unchanged from prior
examination.
Images from the previous MRI from [**2120-8-16**] are pending at this
time.
ECG [**2120-12-7**]:
Sinus tachycardia. Poor R wave progression, probably a normal
variant.
Left ventricular hypertrophy by voltage criteria. Compared to
the previous
tracing of [**2121-6-23**] there is no significant diagnostic change.
Brief Hospital Course:
Given the patient's severe hypertension in the setting of
hemorrhage, the patient was admitted to ICU for BP control. Her
blood pressure was quickly controlled in the unit, and she was
called out to the floor for further management and observation.
MRI of the head showed a stable bleed, with no underlying mass
or vascular anomaly as the source for the right corona radiata
bleed. It also revealed stable (previously known) 100% left ICA
occlusion and an occlusion in the right supraclinoid ICA. Risk
stratification showed an A1C of 10.3 and a fasting lipid profile
with LDL 77 and HDL 65 while on lipitor 80 mg/d and zetia 10 mg
qod.
She was transferred out of the ICU to the floor on [**12-8**] and
observed for 24 hours. Overall, her exam had improved: she was
found to have left arm 5-/5 UMN pattern weakness (deltoid and
triceps, full distally) with pronator drift, and full strength
in the left leg, though still with a wide-based, slightly
cautious gait, favoring the right side. She was evaluated by PT
and OT and felt to be safe to go home with outpatient PT/OT.
She was restarted on her home dose of aspirin in addition to the
[**Month/Day (4) 4532**], considering her prior history, and the intracranial
hemorrhage was ultimately felt to be related to elevated ICP
with coughing, coupled with hypertension.
Medications on Admission:
Nortripyline 10mg qhs
Retin A 0.025%
Spectazole 1%
traZODONE HCl 50 mg PO HS
Escitalopram Oxalate 40 mg PO DAILY
Atorvastatin 80 mg PO DAILY
Doxycycline Hyclate 100 mg PO Q12H
Ezetimibe 10 mg PO QOD
Doxercalciferol 0.5 mcg PO DAILY
Aspirin 325 mg PO DAILY
Procardia 30mg qd
Toprol XL 50mg
Aranesp 0.3mL - off recently due to insurance problems
[**Name (NI) **] 75mg [**Name2 (NI) **] daily
Synthroid 50mcg po qday
Nitroglycerin 0.4mg prn cp
Reglan 10mg prn nausea (rarely takes)
Insulin pump - basal rate 13u
Hecterol 0.5mcg daily
RISS
Tesselon Perles
Xanax 0.25mg qhs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Retin-A 0.025 % Gel Sig: One (1) Topical once a day: or as
prior.
4. Spectazole 1 % Cream Sig: One (1) Topical once a day: or as
prior.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed: or as prior.
6. Escitalopram 20 mg Tablet Sig: Two (2) Tablet PO once a day.
7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
every twelve (12) hours: or as prior.
9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QODHS (every
other day (at bedtime)).
10. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Procardia XL 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One
(1) Tab,Sust Rel Osmotic Push 24hr PO once a day: or as prior.
13. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: or as prior.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual three times a day as needed for chest pain: for chest
pain as prior.
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
18. Insulin Pump IR1250 Kit Sig: One (1) Miscellaneous once
a day: use insulin pump as prior.
19. Hectorol 0.5 mcg Capsule Sig: One (1) Capsule PO once a day.
20. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: Regular insulin sliding scale as
prior.
21. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
22. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
25. Outpatient Physical Therapy
status post hemorrhagic infarct, needs PT for gait/balance
training
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Intracranial hemorrhage - right corona radiata
Discharge Condition:
Improved over admission - improved left sided strength, but with
residual weakness.
Discharge Instructions:
Please return to ER if weakness worsens, or if you have new
neurological symptoms including visual or hearing changes,
trouble speaking or swallowing, numbness, new weakness,
clumsiness, vertigo, or worsened walking. Please call if
headache worsens.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2121-12-16**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2122-1-23**] 11:20
Provider: [**First Name11 (Name Pattern1) 2747**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2122-5-12**] 10:00
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4390**] in [**1-6**]
weeks - call [**Telephone/Fax (1) 3070**] for appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2121-12-9**]
|
[
"433.10",
"413.9",
"564.1",
"536.3",
"357.2",
"412",
"250.51",
"244.9",
"V17.3",
"250.41",
"782.0",
"729.89",
"250.61",
"432.9",
"V58.66",
"V45.82",
"V58.67",
"414.01",
"401.9",
"V18.0",
"311",
"362.01",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12306, 12325
|
8103, 9430
|
290, 296
|
12416, 12502
|
4587, 8080
|
12801, 13602
|
3021, 3087
|
10050, 12283
|
12346, 12395
|
9456, 10027
|
12526, 12778
|
3102, 4568
|
228, 252
|
324, 1494
|
1516, 2889
|
2905, 3005
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,588
| 177,685
|
9119
|
Discharge summary
|
report
|
Admission Date: [**2205-11-25**] Discharge Date: [**2205-12-12**]
Date of Birth: [**2143-12-3**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Roxicet / Sirolimus
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
initiation of dialysis
Major Surgical or Invasive Procedure:
Tunneled line catheter placement
Dialysis
History of Present Illness:
Mr. [**Known lastname 2809**] is a 61 year old male with past medication history
significant for HBV/HCV cirrhosis s/p liver [**Known lastname **] in [**2194**],
CKD with proteinuria, medication induced polymyositis in [**2204**].
.
He was admitted to [**Hospital1 18**] from [**2205-11-6**] to [**2205-11-15**] for
peripheral neuropathy and worsening kidney function which was
thought to be related to tacrolimus toxicity. His
immunosuppression was switched from tacrolimus to Cellcept and
prednisone. Kidney biopsy did not show any etiology and he
continued to have worsening of his kidney function. He was
discharged to [**Hospital1 100**] house for neuro rehabilitation with close
renal follow.
.
He is admitted today for inititiation of dialysis.
Past Medical History:
Status post liver [**Hospital1 **] in [**2194**] secondary to hepatitis B &
C and alcohol abuse
Hepatic artery replacement [**2195**]
Asymptomatic strokes ([**2195**]: left corona radiata and posterior
putaminal infarct, periventricular white matter disease; [**8-12**]
MRI with evidence of chronic cerebellar infarcts)
Frontal gait disorder of unclear etiology
Stage IV chronic kidney disease
Central and obstructive sleep apnea (sleep study [**2203**])- not on
CPAP
Polymyositis of unclear etiology though possibly from tacrolimus
Seizure disorder
Paraproteinemia
Cataract removal
Retinal detachment
Inguinal hernia repair
Social History:
Patient lives with wife and pets (3 cats, 2 dogs). They have no
children. He denies current use of tobacco or EtOH. Says he has
smoked 2ppd for 40 years and quit 7 years ago. Also endorses
heavy drinking history (~30 years) and says he drank 6pack/day
at his worst. He quit EtOH use several years prior to
[**Year (4 digits) **]. H/o IVDU as per previous records. Walks w/ walker at
baseline.
Family History:
The patient is adopted. No known family history of stroke or
neurological disease.
Physical Exam:
Admission Physical Exam
Vital Signs: 97.3 119/77 68 18 95%RA
General: Thin male in no acute distess. He appears chronically
ill and has poor hygeine.
HEENT: PERRLA. EOMI. Anicteric. Supple neck without
lymphadenopathy
Chest: Normal respirations and breathing comfortably on room
air. He has rales at the bases bilaterally.
Heart: Regular rhythm. Normal S1, S2. III/VI HSM best heard at
base with radiation to the carotids.
Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Extremities: No edema. No rash
MSK: Joints with no redness, swelling, warmth, tenderness.
Normal ROM in all major joints.
Skin: No lesions, bruises, rashes.
Neuro: Alert, oriented x3. Speech and language are normal. CN
intact other than old left ptosis. No involuntary movements or
muscle atrophy. Normal tone in all extremities. Motor [**4-10**] in
upper and lower extremities bilaterally though his RLE is
somewhat weaker than left. His proximal muscles are not weaker
than his distal muscles. He is
too weak to stand without full assistance. Finger-to-nose
normal. No pronator drift. Gross sensation to light touch intact
in upper and lower extremities bilaterally.
Pertinent Results:
Admission Labs
[**2205-11-26**] 04:40AM BLOOD WBC-13.1* RBC-3.43* Hgb-10.9* Hct-32.1*
MCV-94 MCH-31.6 MCHC-33.8 RDW-14.1 Plt Ct-173
[**2205-11-26**] 04:40AM BLOOD Neuts-79.5* Lymphs-14.2* Monos-4.6
Eos-1.3 Baso-0.4
[**2205-11-25**] 07:20PM BLOOD Glucose-190* UreaN-113* Creat-7.5*#
Na-137 K-6.2* Cl-105 HCO3-19* AnGap-19
[**2205-11-26**] 04:40AM BLOOD ALT-57* AST-52* LD(LDH)-555* AlkPhos-70
TotBili-0.3
[**2205-11-26**] 04:40AM BLOOD Albumin-2.4* Calcium-8.0* Phos-4.7*
Mg-2.3
.
Cardiac Enzymes:
[**2205-12-5**] 01:55PM BLOOD CK-MB-11* MB Indx-10.5* cTropnT-0.38*
[**2205-12-5**] 08:44PM BLOOD CK-MB-25* MB Indx-17.9* cTropnT-0.45*
[**2205-12-6**] 05:25AM BLOOD CK-MB-49* MB Indx-21.9* cTropnT-0.66*
[**2205-12-7**] 04:45AM BLOOD CK-MB-23* MB Indx-19.7*
[**2205-12-8**] 06:30AM BLOOD CK-MB-12* cTropnT-0.63*
.
Discharge labs
.
([**2205-11-26**]): Successful placement of a right internal jugular
approach
tunneled hemodialysis catheter with its tip in the right atrium.
The catheter
is ready for use.
[**2205-12-11**] 05:31AM BLOOD WBC-10.0 RBC-3.74* Hgb-11.5* Hct-33.0*
MCV-88 MCH-30.7 MCHC-34.9 RDW-16.4* Plt Ct-118*
[**2205-12-8**] 06:30AM BLOOD Neuts-79.3* Lymphs-13.6* Monos-6.1
Eos-0.8 Baso-0.2
[**2205-12-11**] 05:31AM BLOOD PT-12.4 INR(PT)-1.0
[**2205-12-11**] 05:31AM BLOOD Glucose-75 UreaN-22* Creat-3.0* Na-138
K-3.8 Cl-104 HCO3-27 AnGap-11
[**2205-12-11**] 05:31AM BLOOD ALT-50* AST-48* AlkPhos-46 TotBili-0.4
[**2205-12-11**] 05:31AM BLOOD Calcium-7.2* Phos-2.4* Mg-1.7
[**2205-12-5**] 01:55PM BLOOD Triglyc-292* HDL-71 CHOL/HD-3.8
LDLcalc-142*
[**2205-12-8**] 06:30AM BLOOD Hapto-<5*
[**2205-12-4**] 01:10PM BLOOD Ammonia-3*
[**2205-11-29**] 06:00AM BLOOD PTH-523*
[**2205-11-26**] 11:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2205-12-11**] 05:31AM BLOOD tacroFK-2.1*
[**2205-11-26**] 11:25AM BLOOD HCV Ab-POSITIVE*
.
Imaging:
Cardiac ECHO [**2205-12-7**]: LEFT ATRIUM: Normal LA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Low normal LVEF. Beat-to-beat
variability on LVEF due to irregular rhythm/premature beats.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root. No 2D or Doppler
evidence of distal arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
AS (area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - body habitus.
Suboptimal image quality - patient unable to cooperate.
Cardiac Cath [**2205-12-5**]: 1. Coronary angiography in this left
dominant system demonstrated two vessel coronary artery disease.
The LMCA had no
angiographically apparent disease. The proximal LAD had a 60%
stenosis
and a calcific, thrombotic 90% mid stenosis. There were mild
irregularities throughout the LAD. The LCx had a seperate ostia
with
diffuse noncritical disease of up to 40%. The origin of the Cx
had a
60% stenosis on non-selective injection. The RCA was small,
non-dominant with mild, diffuse disease.
2. Resting hemodynamics revealed systemic arterial systolic and
diastolic hypertension with an aortic pressure of 189/130 mmHg.
3. Successful primary PCI of proximal LAD lesion with bare metal
stent.
4. Aspirin 81 mg daily.
5. Plavix 75mg daily for a minimum of 1 month.
6. Secondary prevention of coronary artery disease.
[**2205-11-29**]: CXR: FINDINGS: As compared to the previous radiograph,
the patient has received a double-lumen right-sided central
venous access line. The line is in correct position. There is no
evidence of complications and no evidence of infection. No
pleural effusions. Normal size of the cardiac silhouette.
[**2205-11-27**]: Upper extremity vein mapping: IMPRESSION: Patent right
upper arm cephalic vein with small diameters. Patent right
basilic vein with small diameters in the forearm and reasonable
diameters in the upper arm. Left cephalic vein thrombosis in the
upper arm. Left basilic vein with small diameters in the
forearm and moderate-to-large diameters in the upper arm.
[**2205-12-5**]: ECG: Sinus rhythm. One to two millimeter ST segment
elevation in leads V1-V4 concerning for acute myocardial
infarction. Q waves inferiorly with one half millimeter ST
segment elevation concerning for myocardial injury. ST segment
changes in high lateral and lateral leads concerning for
myocardial ischemia. Compared to the previous tracing earlier
the same day, the severity of the ST segment elevation in leads
V1-V2 is similar and there may be mild decrease in the extent of
elevations in leads V3-V4 with new T wave inversions consistent
with an evolving anteroseptal myocardial infarction. The
inferior ST segment elevations and ST segment changes are
consistent with ongoing myocardial ischemia. Clinical
correlation is suggested.
Microbiology:
H.Pylori [**2205-12-3**]: negative
Blood cultures [**2205-12-3**], [**2205-12-1**], [**2205-11-29**]: negative
Urine culture [**2205-11-30**]: negative
MRSA screen [**2205-12-5**]: negative
VRE screen [**2205-12-7**]: negative
Brief Hospital Course:
61 year old year old male with past medication history
significant for HBV/HCV cirrhosis s/p liver [**Month/Day/Year **] in [**2194**],
CKD with proteinuria, medication (tacrolimus vs interferon)
induced polymyositis in [**2204**] and Acute kidney injury on Chronic
kidney disease stage 3 thought be due to tacrolimus toxicity
admitted for initiation of dialysis. HD was tolerated well
however course was complicated by GI bleed and STEMI while on
HD.
#. ACUTE ON CHRONIC RENAL FAILURE leading to End Stage Renal
Disease: Likely progression of his underlying chronic kidney
disease. Switched off tacrolimus to Cellcept last admission,
although restarted tacrolimus and Cellcept dose reduced due to
elevation in liver enzymes . Tunneled line catheter was placed
with subsequent dialysis three days weekly. He tolerated HD
well aside from one episode of orthostasis (resolved with
temporarily holding his BP meds) and a STEMI (see below). He
will need to have care established with a renal/dialysis
physcian when he leaves the rehabilitation facility, preferably
near his home location. He previously saw Dr. [**Last Name (STitle) **]
(nephrology) at [**Hospital1 18**], however Dr. [**Last Name (STitle) 17253**] does not manage
outpatient dialysis patients.
.
# GI BLEED: On [**12-2**] he had a large melenatic stool. He was
started on IV pantoprazole, made NPO, and transfused 1u pRBCs
given slightly altered mental status. On [**12-3**] he had an EGD
which showed a duodenal ulcer (clipped and injected) as well as
[**Female First Name (un) **] esophagitis. He was last transfused [**2205-12-8**], but has
maintained a stable Hct >30 since then, without melena, and
remains hemodynamically stable. He was transitioned to PPI PO
BID which should be continued. Nystatin swish and swallow was
started for his esophagitis (note fluconazole not used due to
risk of hepatotoxicity and patient did not endorse dysphagia).
# STEMI: On [**2205-12-5**] during dialysis, he developed tachycardia
HR 150bpm but was completely asymptomatic. EKG revealed ST
elevations V3 and V4. CODE STEMI was called and the patient was
taken to the catheterization lab where a 90% LAD lesion was
found and a BMS was placed successfully. He was started on
aspirin, plavix, atorvastatin and restarted on his labetolol.
Note his aspirin dose was 81mg not 325mg due to his ongoing GI
bleed. He was not started on an ACE-I because his EF>50%. He
does not smoke. His cardiac enzymes peaked and downtrended. He
did not have any further chest pain.
#. HISTORY OF LIVER [**Date Range **] in [**2194**] due to alcohol/hepatitis
B & C: Tacrolimus restarted at low dose 0.5mg [**Hospital1 **], Cellcept
decreased to 500 mg po BID and he is now on prednisone 30/40
every other day for polymyositis. He should continue on Bactrim
SS daily while on prednisone. His liver enzymes improved while
on tacrolimus.
.
#. Polymyositis: Continued on prednisone 30 mg / 40 mg every
other day (as per neurology recommendation two weeks ago) for
his polymyositis which is clinically controlled per EMG. He
will follow up with Dr. [**Last Name (STitle) **] at which point his prednisone
should be tapered.
.
#. Seizure disorder/Epilepsy. Continued on oxcarbazepine at 150
mg [**Hospital1 **]
.
#. Hypertension: Well controlled on labetalol 200 mg po BID.
#. Depression: He initially expressed suicidal ideation to
housestaff and nursing staff. Psychiatry was consulted and
venlafaxine was increased to goal 150mg daily. Ritalin was also
added and titrated to goal 5mg qam and 5mg qnoon with
improvement in his mood.
.
# OSTEOPOROSIS: His alendronate will be restarted on discharge.
.
He was FULL CODE for this admission.
Medications on Admission:
1. folic acid 1 mg po qdaily
2. alendronate 35 mg po qweek
3. amlodipine 10 mg po qdaily
4. oxcarbazepine 150 mg po BID
5. prednisone 40 mg/30 mg po every other day
6. sulfamethoxazole-trimethoprim 800-160 mg po 3x week
(Tu/Th/Sa)
7. venlafaxine 75 mg Capsule, Sust. Release 24 hr po qdaily
8. labetalol 200 mg po BID
9. calcium acetate 667 mg Capsule po TID with meals
10. sodium bicarbonate 650 mg po BID
11. aspirin 81 mg po qdaily
12. calcium carbonate 200 mg (500 mg) po TID
13. mycophenolate mofetil 1000 mg po BID
14. multivitamin po qdaily
15. oxybutynin chloride 5 mg Tablet po qhs
16. Vitamin C 100 mg po qdaily
17. Toprol XL 5 mg po qhs
18. Bisacodyl 10 mg po qhs
19. lasix 40 mg po BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis
1. End state renal disease
2. Hepatitis B/hepatitis C/alcohol cirrhosis s/p liver
[**Hospital6 **] [**2194**]
3. Polymyositis
4. Upper GI bleed
5. STEMI
6. Esophageal candidasis
7. Seizure disorder
8. Hypertension
9. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 2809**],
You were admitted for initiation of dialysis. A tunneled
catheter line was placed with help of intervention radiology.
You tolerated dialysis well.
During your hospital stay you developed an ulcer in your small
intestines requiring several blood transfusions. You had an
endoscopy and the ulcer was clipped. You stopped bleeding and
your anemia improved.
During a hemodialysis session, your heart rate increased and you
had a heart attack. You were taken to the catheterization lab
immediately and a bare metal stent was placed in an artery in
your heart. You were started on Plavix and Aspirin. You MUST
continue to take your plavix to prevent a future heart attack.
Please do not stop this medication unless told to do so by your
cardiologist.
Please follow up with your physicians.
We made the following changes to your medications:
- STOP amlodipine
- INCREASE venlafaxine to 150mg daily
- STOP calcium acetate
- STOP sodium bicarbonate
- DECREASE mycophenylate mofetil to 500mg twice daily
- STOP Toprol XL
- STOP Lasix
- START Ritalin 5mg every morning and at noon
- START Tacrolimus 0.5mg twice daily
- START Sucralafate 1gm three times daily - wait 4 hours after
taking tacrolimus for the first dose
- START pantoprazole 40mg twice daily
- START atorvastatin 80mg daily
- START nephrocaps 1 tab daily
- START plavix 75mg daily
- START nystatin swish and swallow: 5mL four times daily
- START Insulin Sliding Scale as needed
- START Thiamine 100mg daily
- START B-complex vitamin with vit C: 1 tab daily
- STOP vitamin C
We wish you a speedy recovery.
Followup Instructions:
Department: [**Known lastname **]
When: MONDAY [**2205-12-16**] at 10:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2205-12-31**] at 2:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: THURSDAY [**2206-1-2**] at 1:30 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD [**Telephone/Fax (1) 541**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2205-12-12**]
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25,188
| 160,667
|
4023
|
Discharge summary
|
report
|
Admission Date: [**2147-2-24**] Discharge Date: [**2147-3-8**]
Date of Birth: [**2083-10-19**] Sex: F
Service: VSU
CHIEF COMPLAINT: Infected axillofemoral bypass graft.
HISTORY OF PRESENT ILLNESS: This 63 year old white female
who presented with infected right axillofemoral graft, who is
status post left aortofemoral bypass using left superficial
femoral vein graft via the retroperitoneal approach. The
patient originally had an aorto-[**Hospital1 **]-femoral bypass with Dacron
in [**2141-3-16**]. Since that time she has had multiple
complications with her original aorto-[**Hospital1 **]-femoral bypass which
has since been excised secondary to infection and since that
time has had multiple bypass procedures to restore flow to
the lower extremities. The patient is admitted post surgery
to the Surgical Intensive Care Unit for continued
postoperative care.
PAST MEDICAL HISTORY: Is significant for coronary artery
disease with an angioplasty, type 2 diabetes on oral agents,
hypertension, hypercholesterolemia.
PAST SURGICAL HISTORY: Multiple bypass vascular procedures,
left retroperitoneal to left femoral with nonreversed left
superficial vein graft on [**2147-2-24**]. A thrombectomy of the
right axillo-femoral-femoral graft on [**11-19**] and excision of
infected aorto-[**Hospital1 **]-femoral graft in [**9-19**], a right
axillofemoral to left profunda bypass with nonreversed
saphenous vein in [**2146-9-16**]. A right axillo to
profunda Dacron bypass with ligation of the common femoral
artery in [**2146-9-16**]. An aorto-[**Hospital1 **]-femoral bypass in
[**2141-3-16**].
ALLERGIES: Include codeine and Percocet.
OUTPATIENT MEDICATIONS ON ADMISSION: Included Lipitor,
Lisinopril, felodipine, Toprol, Glyburide, Coumadin which was
for graft patency was discontinued on 3//[**7-21**].
SOCIAL HISTORY: The patient denies alcohol or tobacco use.
FAMILY HISTORY: Is noncontributory.
ADMITTING PHYSICAL EXAMINATION: As the patient is intubated,
sedated, vital signs 98.1, 93/50, 36, 18, 99 percent O2
saturations. PAP is 28/16. CVP is 10. Cardiac output 7.3. SVR
832. Blood gases on assist control are 7.30, 43, 114, 22, -4.
Cardiovascular examination: Regular rate and rhythm with a
right internal jugular Cortis with Swan left brachial
arterial line. Lungs are clear to auscultation bilaterally.
Head, eyes, ears, nose and throat examination: Pupils are 3
to 2 bilaterally. Chest is with a well healed transverse
right upper chest incision. The abdomen has a well healed
midline laparotomy incision, left flank incision. Dressings
are clean, dry and intact. Palpable femoral-femoral graft
(suprapubic). Patient's abdomen is nontender, obese.
Extremities: The left medial thigh incision is clean, dry and
intact with a palpable graft. The right groin graft is
palpable with a fluctuant mass.
HOSPITAL COURSE: The patient underwent on [**2147-2-24**] a left
aortofemoral bypass using left superficial femoral vein for
an infected axillofemoral bypass. The patient tolerated the
procedure and was transferred to the Surgical Intensive Care
Unit for continued monitoring and care. Postoperative day one
there were no overnight events. The patient was alert and
followed commands. The pulse examinations were monophasic
dorsalis pedis and posterior tibialis bilaterally. The
incisions were clean, dry and intact. The abdominal
examination was unremarkable with bowel sounds. Postoperative
hematocrit was 30.0, BUN was 16, creatinine 0.7, lactate on
admission 6.9, on postoperative day 1 A.M. lactose was 5.1.
Her mixed venous O2 was 71 percent. Plans were wean Levophed,
continue assist control ventilation, continue n.p.o.,
maintain the urinary output of 40 cc per hour and remain in
the Surgical Intensive Care Unit. Postoperative day two the
patient desaturated with hypotensive episodes. She required
fluid and one unit of packed red blood cells. Blood cultures
and cortisol tests were ordered. She remained on Levophed and
propofol. Her maximum temperature was 100.4. Blood gases
7.44, 33, 78, 23, 0, on assist control 60 percent, 500
volume, 23 and 5. Her hematocrit remained stable. She
required repletion of her potassium and magnesium. Levophed
was weaned. Patient continued with diuresis. She continued on
Vancomycin, Flagyl and levofloxacin. She remained in the
Surgical Intensive Care Unit. Postoperative day three the
patient began to diurese. Her hematocrit after a total of
four units of packed red blood cells over the last 48 hours
32.6. BUN and creatinine remained stable. Examination:
Incisions were clean, dry and intact. Her pedal pulses were
biphasic and singles bilaterally. Lopressor was increased for
rate control. Plans were to wean to SIMV, remain n.p.o.
fluids KVO and she remained in the Surgical Intensive Care
Unit. Postoperative day number 4 the patient had no overnight
events, continued to diurese off intravenous Lasix drip,
temperature defervesced to 99.5. Her lactate was 1.0. Gases
on SIMV were 7.42, 38, 107, 25 and 0. Her hematocrit remained
stable at 33. BUN and creatinine were stable. Examination
remained unchanged. The incisions were clean, dry and intact
without erythema or hematoma. Antibiotics were continued and
the patient remained in the Surgical Intensive Care Unit.
On postoperative day four total parenteral nutrition was
instituted for nutritional support. Antibiotics were
continued. She remained intubated. Diuresis was continued.
Sputum cultures were sent. She remained in the Intensive Care
Unit. On [**2147-3-1**], postoperative day five her Swan-Ganz
catheter was converted to a triple lumen catheter without
difficulty. On postoperative day six there were no other
overnight events except for the change in the Swan catheter.
She continued to be diuresed on intravenous Lasix. Her x-ray
showed decreased size in the pleural effusion. She continued
on her Vancomycin. She remained intubated with nasogastric
tube in place. She remained in the Surgical Intensive Care
Unit. Postoperative day number seven the patient's maximum
temperature was 99.8. She continued on antibiotics. An
attempt would be made to wean to extubate. She continued on
Lopressor for blood pressure and rate control. Subcutaneous
heparin was continued. Insulin was increased for glycemic
control. She remained in the Intensive Care Unit.
On postoperative day eight, overnight events, patient was
extubated and she continued diuresis. She was 98 percent on
face mask with nasal cannula. Her lactate was 1.6, hematocrit
34.5, BUN and creatinine remained stable at 24 and 0.6. Her
pulse examination showed palpable pulses bilaterally. The
incisions were clean, dry and intact. Patient's abdominal
examination was unremarkable. She had not passed flatus.
Nasogastric tube was removed and patient was begun on clears.
Total parenteral nutrition was continued. Arterial line was
changed over a wire. Patient was transferred to the Vascular
Intensive Care Unit for continued monitoring and care on
postoperative day eight. Postoperative day nine she was
afebrile with a maximum temperature of 98.7. She was off the
Lasix drip and she required increase in her Lasix to 40
t.i.d. Insulin drip was continued for glycemic control.
Resident was called to see the patient at 1815. She
complained and noted that the left brachial line abruptly
lost tracing. The line was flushed without difficulty but
there is no tracing. The arterial line was removed and at
1850 the resident returned to the bedside because of the
patient complaining of left hand cool and numb. Evaluation
noted mild numbness on the anterior hand specific to nerve
distribution, capillary refill 3 to 4 seconds and the hand
was cool compared to the right hand with no cyanosis. Doppler
examination showed weak monophasic radial. No distal ulnar,
weak monophasic proximal ulnar. Weak monophasic brachial
distal to the arterial line site, a triphasic brachial
proximal to the arterial line site, palpable axillary graft.
The patient was heparinized with bolus and infusion. At 2200
the hand was slightly warmer, was non-cyanotic. The capillary
refill was 3 seconds. The right radial and ulnar pulses were
monophasic and the brachial was triphasic. On postoperative
day ten the patient's right hand had significantly improved
and the heparinization was discontinued. Patient was
transferred to the regular nursing floor on postoperative day
11. On postoperative day 12 repeat white count was taken
which was 16. The previous 24 hours it was 23. Urinalysis had
dirty urine. Urinalysis and culture and sensitivity were
sent. There were no other physical findings. Blood cultures
were sent which were not finalized but were so far no growth.
The patient was discharged in stable condition after being
evaluated by physical therapy being deemed safe to be
discharged to home. Patient will return on [**3-20**] for excision
of her aortofemoral graft. She will be discharged on
Levaquin and we will reinstitute her preadmission medications
including her Glucovance. The office will call the patient
with her preoperative instruction.
MEDICATIONS AT TIME OF DISCHARGE: Clonidine 0.1 mg 24 hour
patch q week q Thursday, aspirin 325 mg daily, metoprolol 50
mg b.i.d., levofloxacin 500 mg daily for a total of 16 days,
Lasix 20 mg daily was discontinued, oxycodone/acetaminophen
5/325 mg tablets 1 to 2 q 4 hours p.r.n., _________________
for analgesic control. Lipitor 20 mg at bedtime, Plendil 5 mg
sustained release was reinstituted. The
lisinopril/hydrochlorothiazide 20/12.5 mg was started and
Glucovance 5/500 tablets 3 times a day was reinstituted.
DISCHARGE DIAGNOSIS:
1. Axillofemoral graft infection.
2. Left hand ischemia resolved.
3. Lactic acidosis postoperatively resolved.
4. Postoperative blood loss anemia, corrected.
5. History of coronary artery disease, status post
angioplasty.
6. History of type 2 diabetes on oral agents, controlled.
7. History of hypercholesterolemia.
INSTRUCTIONS: The patient was instructed to continue the
levofloxacin until she returns for her surgery and Dr.[**Doctor Last Name 17754**] office will call her with instructions regarding
plans for surgical date and preoperative instructions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17755**], [**MD Number(1) 17756**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2147-3-8**] 13:54:44
T: [**2147-3-8**] 15:27:32
Job#: [**Job Number 17757**]
|
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[
[
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1917, 1948
|
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|
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|
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1070, 1678
|
1971, 2849
|
154, 192
|
221, 890
|
913, 1046
|
1856, 1900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,314
| 190,410
|
28014
|
Discharge summary
|
report
|
Admission Date: [**2175-6-28**] Discharge Date: [**2175-7-3**]
Date of Birth: [**2116-7-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**6-28**] CABG x 4
History of Present Illness:
58 yo male with recurrent chest discomfort and SOB. Cath showed
3VD, referred to Dr. [**Last Name (STitle) **] for CABG.
Past Medical History:
CAD
HTN
hyperlipidemia
obesity
herniated lumbar disc
depression
tonsillectomy
Social History:
lives alone, quit tob [**2154**], 3 etoh drinks per month
Family History:
father deceased from MI at age 38
Physical Exam:
NAD HR 65, BP 175/93
Lungs CTAB
RRR, no M/R/G
Abd Soft, NT, obese with umbilical hernia
extrem warm well perfused, - C/C/E
Pertinent Results:
[**2175-7-2**] 05:00AM BLOOD WBC-9.1 RBC-3.44* Hgb-11.0* Hct-30.7*
MCV-89 MCH-32.0 MCHC-35.9* RDW-15.1 Plt Ct-241
[**2175-7-1**] 04:08AM BLOOD WBC-11.6* RBC-2.97* Hgb-9.4* Hct-26.6*
MCV-90 MCH-31.7 MCHC-35.4* RDW-14.6 Plt Ct-182
[**2175-7-2**] 05:00AM BLOOD Plt Ct-241
[**2175-7-2**] 05:00AM BLOOD Glucose-103 UreaN-20 Creat-0.8 Na-140
K-4.7 Cl-103 HCO3-27 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 29224**] was taken to the operating room on [**2175-6-28**] where he
underwent a CABG x 4 (LIMA->LAD, SVG->Diag, SVG->OM, SVG->PDA).
He was transferred to the SICU in critical but stable condition.
He was extubated on POD # 1. He was weaned from his vasoactive
drips by POD # 2. He was transfused several times for an
unstable hematacrit which stabilized by POD #3, at which time he
was transferred to the floor. His hematacrit remained stable at
30 on POD #4. He was ready for discharge on POD # 5 when he was
cleared by physical therapy.
Medications on Admission:
ASA, atenolol, celebrex, cozaar, lamictal, aocor
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 3 days, then 400 mg daily for 1 week, then
200 daily ongoing.
Disp:*90 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
5 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
HTN
hyperlipidemia
obesity
depression
herniated lumbar disc
umbo hernia
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.
No lifting more than 10 pounds or driving.
Shower, no lotions, creams or powders to incision.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 5017**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2175-7-4**]
|
[
"414.01",
"401.9",
"272.4",
"722.10",
"553.1",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.07",
"36.15",
"99.04",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
3218, 3252
|
1227, 1790
|
277, 299
|
3368, 3376
|
837, 1204
|
3635, 3783
|
642, 678
|
1889, 3195
|
3273, 3347
|
1816, 1866
|
3400, 3612
|
693, 818
|
234, 239
|
327, 449
|
471, 551
|
567, 626
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,025
| 132,338
|
32641
|
Discharge summary
|
report
|
Admission Date: [**2102-11-27**] Discharge Date: [**2102-12-5**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Adenocarcinoma of sigmoid colon
Major Surgical or Invasive Procedure:
s/p LAR, divert transverese loop colostomy, takedown of bladder
History of Present Illness:
MR. [**Known lastname 76073**] is a [**Age over 90 **] y.o. gentleman with h/o prostate cancer,
cholecystolithiasis, h /o pancreatitis who was newly diagnosed
with rectal carcinoma. He was recently admitted ([**9-25**] to
[**2102-10-10**])to [**Hospital1 **] [**Location (un) 620**] for pancreatitis. He has a h/o
coffee-ground emesis prior to the [**Month (only) 321**] admission, chronic
constipation, occasional BRBPR since some years and occasional
dark, firm stools since one year. The patient reports that his
Guaiac's stool test was negative for several times. He was found
to have a sigmoid colon mass on CT scan.
Colonosopy and biospy showed adenocarcinoma of the sigma, CEA
level was 5.3
in [**Month (only) **], abdominal and pelvis CT revealed no evidence of
distant metastasis.
He was transferred to [**Hospital1 **] for continued Rehab and radiation
therapy to site of cancer after last admission. He underwent 1
week of radiation as recommended per Heme/Onco. He presents for
surgical resection of colon mass with Dr. [**Last Name (STitle) 1120**].
Past Medical History:
Prostate CA
HTN
Chronic constipation
s/p hernia repair
cholecystolithiasis
pancreatitis
s/p radiation for sigmoid colon mass
Social History:
Widower, lives alone, is independent. Retired electrician.
Former 4 P/Y smoker, quit ~50 years ago, does not use ETOH.
Supportive sister, [**Name (NI) **], who is patient's proxy.
Family History:
Noncontributory
Physical Exam:
On admission:
97.1 Pulse 74, BP 132/54, RR 16, 95%RA
Gen- no acute distress, alert and oriented
Card- RRR
Pulm- CTA b/l
Abd- soft, NT, ND, + bowel sounds
Extremities- no edema
Pertinent Results:
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2102-11-27**] 5:43 PM
Reason: please asses L IJ CVL [**Hospital 76074**]
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with s/p LAR, h/o PNA
Left IJ line is in the lower SVC. There is no pneumothorax or
pleural effusion. NG tube tip is in the stomach. Cardiac size is
top normal. The aorta is elongated. The lungs are clear.
Extensive bilateral pleural plaques are noted.
.
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2102-11-27**] 5:50 PM
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with distention
IMPRESSION: Nonspecific bowel gas pattern without evidence of
obstruction or ileus.
Pathology
Procedure date [**2102-11-27**]
DIAGNOSIS:
Rectosigmoid, resection (A-M):
1. Adenocarcinoma, see synoptic report.
2. Diverticulosis.
3. Focal acute cryptitis and reactive changes.
II. Additional sigmoid, resection (N-Q): Focal acute cryptitis
and reactive changes, no evidence of malignancy.
III. Colonic donuts (R): Focal acute cryptitis and reactive
changes. No evidence of malignancy
MACROSCOPIC
Specimen Type: Rectal/rectosigmoid resection (low anterior
resection).
Specimen Size Greatest dimension: 27.5 cm. Additional
dimensions: 8 cm x 3.5 cm.
Tumor Site: Rectum.
Tumor configuration: Exophytic (polypoid), ulcerating.
Tumor Size: Greatest dimension: 3 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues.
Regional Lymph Nodes: pN0
Lymph Nodes
Number examined: 15.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin: Uninvolved by invasive carcinoma: Distance of
tumor from closest margin: 215 mm.
Distal margin: Uninvolved by invasive carcinoma: Distance of
tumor from closest margin: 30 mm.
Circumferential (radial) margin: Uninvolved by invasive
carcinoma: Distance of tumor from closest margin: 12 mm.
Lymphatic Small Vessel Invasion: Absent.
Venous (large vessel) invasion: Absent.
Tumor border configuration: Infiltrating.
.
[**2102-12-2**] 06:55AM BLOOD WBC-7.3 RBC-3.09* Hgb-9.5* Hct-29.0*
MCV-94 MCH-30.9 MCHC-32.9 RDW-14.1 Plt Ct-215
[**2102-11-29**] 11:17AM BLOOD WBC-11.8*# RBC-2.95* Hgb-9.2* Hct-27.7*
MCV-94 MCH-31.2 MCHC-33.2 RDW-14.3 Plt Ct-165
[**2102-11-27**] 05:07PM BLOOD WBC-7.7 RBC-3.43* Hgb-10.7* Hct-31.9*
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.2 Plt Ct-187
[**2102-11-27**] 05:07PM BLOOD PT-13.3 PTT-27.6 INR(PT)-1.1
[**2102-12-2**] 06:55AM BLOOD Glucose-99 UreaN-24* Creat-0.9 Na-144
K-3.9 Cl-110* HCO3-29 AnGap-9
[**2102-11-27**] 05:07PM BLOOD Glucose-145* UreaN-17 Creat-0.9 Na-139
K-4.0 Cl-107 HCO3-22 AnGap-14
[**2102-11-30**] 06:11AM BLOOD CK(CPK)-125
[**2102-11-30**] 06:11AM BLOOD CK-MB-3 cTropnT-0.01
[**2102-12-2**] 06:55AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 76073**] [**Last Name (Titles) **] course required Urology assist to mobilize
bladder and ureterlysis secondary to inflammatory changes from
prostate cancer & treatment. His colorectal surgery was
uncomplicated.
.
Hypotension/Hypovolemia:He developed hypotension intra-op and
was successfully resuscitated with IV fluid. He was monitored in
the ICU overnight due to age and potential risk factors. He
remained stable, and was transferred to [**Hospital Ward Name **] following morning
for post-op care.
.
RESP/Pneumonia:He had bibasilar crackles with expiratory
wheezing post-op. Chest XRAY on [**2102-11-30**] revealed pneumonia. He
was otherwise afebrile with no evidence of leukocystosis. He was
started on IV levaquin, and switched to oral levaquin. He will
continue with this regimen for two more days.
.
Post-op Delirium: His baseline mental status is A/Ox3. He has
some underlying dementia and Parkinson's. His mental status
deteriorated a few days post-op likely due to fluid balace
shifts. He became agitated, pulling on medical equipment. Soft
restraints were applied for a few hours, and Zyprexa SC given
with effect. Geriatric Team was consulted. Recommendations
provided. He remained confused for a few days after Zyprexa with
increased sleepiness, and extrapyrimidal tremors related to
[**Last Name (un) 3562**]. Adjustments were made to medication regimen. His
mental status returned to baseline on [**2102-12-3**] with no further
changes.
.
ABD/Ostomy:His abdomen is currently soft, NT/ND with active
bowel sounds. His abdominal incision is OTA with Staples. The
stoma is pink & viable with drainage pouch intact. He has a RLQ
incision that continues to drain serous fluid requiring frequent
dressing changes to maintain dry. In addition, he has a few skin
tears proximal to this incision which requires dressing as well.
Please refer to ostomy/wound care RN recommendations.
.
NUT:He was NPO post-op. His diet was advanced as his bowel
function resumed. He was reverted back to NPO due to mental
status changes, and risk for aspiration. He was advanced to
regular food once his mental status cleared. He has been
tolerating a regular diet without complaints of nausea and/or
vomiting.
.
ELIM:A foley catheter inserted intra-op. The catheter remained
inserted for a few days post-op due to condition of bladder and
ureters intra-op. The foley was removed on [**2102-12-3**], and he was
able to urinate without difficulty. Flatus and stool production
was noted in ostomy pouch. He was seen per the ostomy RN who
provided teaching regarding care of stoma. His participation in
ostomy care is minimal. He is aware of the presence of the
ostomy, but has not been able to participate in care.
.
PAIN:His pain was managed with scheduled tylenol and IV Morphine
PRN post-op. He denies pain, and has not required any narcotics.
Tylenol has managed his pain well.
.
Mobility: He was evaluated per physical therapy, and recommended
to return to Rehab due to deconditioned physical state.
Medications on Admission:
MVI, protonix, , aquaphor to buttocks, colace, terazosin 4mg'
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
4. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for agitation.
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for
SOB/Wheeze.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
adenocarcinoma of sigmoid colon
Post-op hypotension
Post-op hypovolemia
Post-op delirium
.
Secondary:
Prostate CA-med treated, HTN, chronic constipation, s/p hernia
repair, cholelithiasis, pancreatitis, L Hip fx tx non-[**Doctor First Name **],
pneumonia
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-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.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 500mL to 1000mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) 1120**] in [**12-24**]
weeks.
2. Make a follow-up appointment with your primary care provider,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 951**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) **] in 1 week or as needed.
3. Follow-up with Heme/Oncology
|
[
"458.29",
"185",
"593.9",
"153.3",
"789.59",
"707.09",
"486",
"E879.9",
"275.3",
"564.00",
"401.9",
"998.89",
"154.0",
"293.0",
"276.52",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.02",
"45.76",
"38.93",
"48.62"
] |
icd9pcs
|
[
[
[]
]
] |
8942, 9021
|
5021, 8038
|
260, 326
|
9329, 9407
|
2012, 2140
|
11123, 11474
|
1781, 1798
|
8150, 8919
|
2571, 4998
|
9042, 9308
|
8064, 8127
|
9431, 10472
|
10487, 11100
|
1813, 1813
|
189, 222
|
354, 1419
|
1827, 1990
|
1441, 1567
|
1583, 1765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,412
| 182,142
|
31172
|
Discharge summary
|
report
|
Admission Date: [**2181-5-2**] Discharge Date: [**2181-5-15**]
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2181-5-8**]:
[**Street Address(2) 6158**]. [**Male First Name (un) 923**] Epic Supra Porcine Aortic Valve Replacement
Coronary Artery Bypass Graft Surgery with Left internal mammory
artery to the left anterior descending, reverse saphenouse vein
graft to the posterior descending artery
History of Present Illness:
This is an 88 year old female with known severe aortic stenosis.
notable for She was recently hospitalized at [**Hospital1 498**] for a fall
and underwent workup for anemia. Workup was negative for GI
bleed via colonoscopy/endoscopy. She is relatively asymptomatic
except for exertional leg discomfort. She denies dyspnea, chest
pain, syncope, presyncope, orthopnea, PND and pedal edema. Given
the severity of her aortic stenosis, she is now referred for
surgical evaluation.
Past Medical History:
Aortic Stenosis
Hypertension
Dyslipidemia
Peripheral Vascular Disease
Carotid Disease
Basilar artery aneurysm
History of sick sinus syndrome
s/p pacemaker implant
Osteoporosis
Lower Extremity Neuropathy
History of Syncope - last episode 2-3 years ago
History of Anxiety/panic disorder
Macular degeneration
Chronic Venous insufficiency
History of Colon Cancer
Anemia
s/p recent falls
Sigmoid diverticulosis/Small Gastric Ulcer - recently noted on
colonoscopy/endoscopy
History of Shingles
s/p Pacemaker Implantation [**2179**]
s/p Bilateral Total Knee Replacements
s/p Colon resection
s/p back surgery
s/p laparoscopic cholecystectomy
s/p cataract surgery
Social History:
-Tobacco history: 30 pack year history, quit in [**2139**].
-ETOH: Social
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
Pulse: 60 Resp: 16 O2 sat: 97%
B/P Right: 161/68 Left: 155/68
Height: 5'4" Weight: 152#
General: Elderly female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] - no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace
Varicosities: superfical varicosities noted on lower
extremities.
GSV appears suitable
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 1 - *****bilateral bruits****
DP Right: decreased Left: decreased
PT [**Name (NI) 167**]: decreased Left: decreased
Radial Right: 1 Left: 1
Carotid Bruit Right: none Left: yes
Pertinent Results:
[**2181-5-8**]: TTE
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage. No thrombus is seen in the
right atrial appendage No atrial septal defect is seen by 2D or
color Doppler. There is severe symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. LVEF=
60 %. Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the ascending aorta. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. The NCC is immobile and heavily calcified. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation.
POST-CPB: On infusion of Nitroglycerine. AV pacing. Well-seated
bioprosthetic valve in the aortic position. No AI. Gradient is
now peak 15 mmHg. [**Location (un) 109**] = 1.5 cm2. Normal biventricular systolic
function. Mild MR, TR as before. Aortic contour is normal post
decannulation.
[**2181-5-12**] 08:00AM BLOOD WBC-9.0 RBC-4.07* Hgb-11.8* Hct-36.2
MCV-89 MCH-28.9 MCHC-32.5 RDW-16.2* Plt Ct-344
[**2181-5-11**] 05:20AM BLOOD WBC-13.6* RBC-4.03* Hgb-11.9* Hct-36.1
MCV-90 MCH-29.5 MCHC-32.9 RDW-17.0* Plt Ct-303#
[**2181-5-12**] 08:00AM BLOOD Glucose-78 UreaN-35* Creat-0.9 Na-128*
K-4.4 Cl-91* HCO3-27 AnGap-14
[**2181-5-11**] 05:20AM BLOOD Glucose-148* UreaN-27* Creat-0.8 Na-132*
K-4.3 Cl-98 HCO3-27 AnGap-11
[**2181-5-14**] 06:25AM BLOOD WBC-9.9 RBC-3.93* Hgb-11.8* Hct-35.1*
MCV-89 MCH-30.1 MCHC-33.6 RDW-16.7* Plt Ct-411
[**2181-5-14**] 06:25AM BLOOD Glucose-108* UreaN-36* Creat-1.0 Na-132*
K-5.4* Cl-96 HCO3-28 AnGap-13
[**2181-5-14**] 06:25AM BLOOD WBC-9.9 RBC-3.93* Hgb-11.8* Hct-35.1*
MCV-89 MCH-30.1 MCHC-33.6 RDW-16.7* Plt Ct-411
[**2181-5-15**] 06:55AM BLOOD K-5.4*
[**2181-5-14**] 06:25AM BLOOD Glucose-108* UreaN-36* Creat-1.0 Na-132*
K-5.4* Cl-96 HCO3-28 AnGap-13
Brief Hospital Course:
This is an 88 year old female with know aortic stenosis and
peripheral vascular disease who initially presented with chest
pain. She underwent cardiac catherization and was found to have
2 vessel coronary artery disease. She had a preoperative workup
with included a hepatology consult for elevated transaminase.
Preoperative chest CT revealed multiple less than 3 mm lung
nodules for which follow up in one year is recommended.
She was brought to the Operating Room on [**5-8**] for aortic valve
replacement with a [**Street Address(2) 6158**]. [**Hospital 923**] Medical Biocor tissue valve
and a coronary artery bypass surgery x2 with left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the posterior descending artery. See
operative note for full details.
She weaned from bypass on Neo Synephrine and Propofol infusions.
She was weaned from all vasoactive medications and extubated on
post operative day 1 without incident. The EP service
interrogated her permanent pacemaker on the night of surgery and
parameters were good. She went into atrial fibrillation on
postoperative day 2 and was started on Amiodarone with
conversion to sinus rhythm. Her oral doses were decreased after
she was complaining of nausea. Beta blockers were begun as was
diuresis.
She was transferred to the step down unit in stable condition on
post operative day 3. Her Foley needed to be reinserted due to
urinary retention and was subsequently removed on postoperative
day 4 and passed her voiding trial. She has poor intake and was
started on nutritional supplements. Chest tubes and pacing
wires were removed per cardiac surgery protocol. She continued
to work with Physical Therapy to increase strength and
endurance. She developed recurrent atrial fibrillation on POD 5
with a ventricular rate of 100-120. Hydralazine was discontinued
and Lopressor increased.
She converted to sinus rhythm and remained there for 24 hours.
Coumadin was not begun. She was ready for discharge on [**5-15**] and
was discharged to [**Hospital3 **]. Arrangments were made for
outpatient followup. Medications are as listed elsewhere.
Medications on Admission:
Cilostazol 100 [**Hospital1 **]
Aggrenox 25/200 tabs, one tab twice daily
Alendronate 70 mg weekly
Citalopram 10 mg daily
Furosemide 20 mg daily
Gabapentin 600 mg QHS
Diltiazem 120 mg daily
Lorazepam 0.5mg prn
Pravastatin 40mg qd
Zolpidem 5mg prn Qhs
Metamucil one tsp daily
Vit. D/Calcium Carbonate
MVI
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. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constip.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever/pain.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
15. Psyllium Oral
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Aortic Stenosis
Coronary artery Disease
s/p aortic valve replacement
s/p coronary artery bypass grafts
hypertension
hyperlipidemia
s/p cholecystectomy
h/o colon cancer
s/p permanent transvenous pacemaker implant
chronic venous insufficiency
peripheral vaacular disease
cerebrovascular disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg (Left) - healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD ([**Telephone/Fax (1) 170**]) on:[**2181-6-14**] at
1:15
Please call to schedule:
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73577**] ([**Telephone/Fax (1) 73578**]) in [**1-13**] weeks
Cardiologist: Dr. [**Last Name (STitle) 73579**] [**Name (STitle) 73580**] in [**1-13**] weeks
Device Clinic at [**Hospital1 112**] in [**2-15**] weeks
**NEEDS CHEST CT FOLLOWUP IN 1 YEAR FOR MULTIPLE LUNG NODULE
FINDING**
**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:[**2181-5-15**]
|
[
"794.8",
"401.9",
"427.31",
"V43.65",
"459.81",
"443.9",
"788.29",
"428.0",
"424.1",
"518.89",
"355.8",
"733.00",
"414.01",
"362.50",
"272.4",
"428.31",
"V45.01",
"V10.05",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"88.56",
"39.63",
"36.11",
"35.21",
"36.15",
"88.53",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
9029, 9103
|
4998, 7160
|
244, 537
|
9440, 9653
|
2823, 4975
|
10495, 11243
|
1851, 1966
|
7515, 9006
|
9124, 9419
|
7186, 7492
|
9677, 10472
|
1981, 2804
|
194, 206
|
565, 1043
|
1065, 1722
|
1738, 1835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,798
| 140,591
|
5441
|
Discharge summary
|
report
|
Admission Date: [**2149-9-4**] Discharge Date: [**2149-9-13**]
Date of Birth: [**2078-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**9-4**] Aortic Valve Replacement (21mm CE tissue), Ascending Aorta
Replacement (28mm Gelweave graft)
[**2149-9-10**] left thoracentesis
History of Present Illness:
71 y/o female with h/o Aortic Stenosis now with worsening
dyspnea on exertion and chest tightness. Most recent echo
revealed severe aortic stenosis, mitral regurgitation, and
dilated ascending aorta. She was referred for surgical
intervention.
Past Medical History:
Aortic Stenosis
ascending Aortic Aneurysm
Mitral Regurgitation
Hypertension
Kyphoscoliosis
s/p Tubal ligation
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.
Physical Exam:
VS: stable.
Alert and oriented
Lungs clear to ausculation
Heart of regular rate and rhythm
Positive bowel sounds
2+ LE edema
Pertinent Results:
[**2149-9-8**] 05:30AM BLOOD Hct-33.9*
[**2149-9-7**] 07:39AM BLOOD Plt Ct-127*
[**2149-9-8**] 05:30AM BLOOD K-3.9
[**2149-9-7**] 07:39AM BLOOD Glucose-106* UreaN-28* Creat-0.7 Na-140
K-4.7 Cl-102 HCO3-31 AnGap-12
[**2149-9-11**] 09:30AM BLOOD WBC-6.4 RBC-3.92* Hgb-11.1* Hct-35.3*
MCV-90 MCH-28.4 MCHC-31.5 RDW-15.4 Plt Ct-236
[**2149-9-12**] 05:40AM BLOOD PT-14.1* PTT-32.8 INR(PT)-1.2*
[**2149-9-4**] 10:41AM BLOOD PT-16.8* PTT-72.9* INR(PT)-1.5*
[**2149-9-12**] 05:40AM BLOOD Glucose-111* UreaN-30* Creat-0.7 Na-140
K-4.3 Cl-95* HCO3-41* AnGap-8
[**2149-9-4**] 11:42AM BLOOD UreaN-15 Creat-0.4 Cl-120* HCO3-23
[**2149-9-12**] 05:40AM BLOOD Calcium-8.5 Mg-2.3
[**2149-9-5**] 03:20AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9
STUDY: Bedside semi-upright AP chest radiograph.
HISTORY: 71-year-old woman status post left thoracentesis.
COMPARISON: Comparison is made to chest radiograph from
[**2149-9-10**].
FINDINGS: There has been reaccumulation of moderate left-sided
pleural
effusion. Moderate right pleural effusion is also increased.
There is
associated bibasilar atelectasis. The lungs are otherwise clear.
Cardiac
silhouette is obscured by adjacent pleural effusions.
Mediastinal contours
are normal.
There are multiple sternotomy wires as well as midline thoracic
surgical
staples. There is moderate, unchanged scoliosis.
IMPRESSION:
1. Reaccumulation of bilateral moderate pleural effusions.
2. Otherwise, no significant change from past radiograph.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
The left atrium is elongated. The right atrium is moderately
dilated. There is severe symmetric left ventricular hypertrophy.
The left ventricular cavity is unusually small. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular free
wall is hypertrophied. The right ventricular cavity is mildly
dilated with normal free wall contractility. A bioprosthetic
aortic valve prosthesis is present. The prosthetic aortic valve
leaflets appear normal The transaortic gradient is normal for
this prosthesis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No pericardial effusion. Small, hypertrophied left
ventricle with hyperdynamic systolic function. Mildly dilated
right ventricle with normal systolic function.
Normally-functioning aortic valve bioprosthesis. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2149-7-16**],
stenotic aortic valve has been replaced with a bioprosthesis. LV
function is more vigorous, and amount of mitral and tricuspid
regurgitation has decreased. Pulmonary pressures are lower.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2149-9-11**] 16:19
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day of admission she
was brought directly to the operating room where she underwent
an aortic valve replacement and ascending aorta replacement.
Please see operative note for surgical details. Following
surgery she was transferred to the CVICU with invasive
monitoring on levophed and propofol drips in stable condition.
Within 24 hours she was weaned from pressors, sedation, awoke
neurologically intact and was extubated. She was transferred to
the floor on POD #2 to begin increasing her activity level.
Chest tubes and pacing wires removed per protocol.
On [**9-7**] evenings she developed atrial fibrillation and was given
a single dose of IV metoprolol to control the ventricular rate.
Amiodarone was begun (orally) and her rate remained controlled.
Electrolytes were normal during this time. Coumadin was started
48 hours later as she continued in paroxysmal atrial
fibrillation.
On [**9-9**] her O2 saturation was noted to drop into the mid 80's
when she was taken off oxygen. A CXR showed worsening of her
left pleural effusion and consolidation. Her left lung was
tapped for 700 ml or serosanguenous fluid. A "grapefruit sized
hematoma" was noted on her left thorax at the thoracentesis
puncture site. Chest x-ray and echocardiogram showed no acute
process.
She continued to improve and was cleared by physical therapy to
be discharged to rehab on [**2149-9-13**]. Patient needs to be on
coumadin and maintain INR>2 for atrial fibrillation
Medications on Admission:
Lisinopril 2.5mg qd, Lasix 20mg qd, Zantac 300mg qd, Tylenol #3
prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 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:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Lisinopril 2.5mg po daily
6. Coumadin 3 mg po daily (keep INR>2) for atrial fibrillation
Disp:*40 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Aortic Stenosis
Ascending Aortic Aneurysm
s/p Aortic Valve Replacement & Ascending Aortic Replacement
Hypertension
Kyphoscoliosis
Mitral regurgitation
tricuspid regurgitation
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 cardiac
surgery office 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) Keep wounds clean and dry, OK to shower and wash incision.
Gently pat the wound dry. Please shower daily. No bathing or
swimming for 1 month. No lotions, creams or powders to incision
until it has healed. Use sunscreen on incision if exposed to
sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 4 weeks.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr.[**Doctor Last Name 3733**] in [**1-19**] weeks
Dr. [**First Name (STitle) **] in [**12-18**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2149-9-13**]
|
[
"737.30",
"396.2",
"427.31",
"998.12",
"428.0",
"276.52",
"428.22",
"397.0",
"458.29",
"518.0",
"511.8",
"997.1",
"E878.2",
"441.2",
"285.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"34.91",
"38.45",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7119, 7218
|
4664, 6232
|
339, 479
|
7438, 7444
|
1275, 4641
|
8172, 8466
|
1033, 1115
|
6350, 7096
|
7239, 7417
|
6258, 6327
|
7468, 8149
|
1130, 1256
|
280, 301
|
507, 752
|
774, 892
|
908, 1017
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,311
| 136,786
|
53816
|
Discharge summary
|
report
|
Admission Date: [**2121-6-7**] Discharge Date: [**2121-7-2**]
Date of Birth: [**2045-7-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain and diaphoresis
Major Surgical or Invasive Procedure:
[**2121-6-16**] Urgent coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal, obtuse marginal, and posterior left
ventricular branch.
.
[**2121-6-27**] Placement of Right Percutaneous Nephrostomy Tube
History of Present Illness:
This is a 75 year old male with history of nephrolothiasis s/p
percutaneous nephrostomy tube placement for urosepsis
complicated by atrial fibrillation with RVR, and nowpresented
with chest pain and atrial fibrillation with RVR. He reports
that the morning of admission, aids at the rehab wererolling him
for a bath, when he had the acute onset of substernal chest
pressure, radiating down bilateral arms with associated
diaphoresis. He was given 2 SL NTG by EMS which improved pain
from [**10-22**] to [**2-21**]. In addition, he was noted by EMS to be
inatrial fibrillation with RVR. In the ED, patient was noted to
be in atrial fibrillation with RVR. He was admitted for further
evaluation and a cardiac catheterization was obtained and was
found to have coronary artery disease. He is now being referred
to cardiac surgery for revascularization.
Past Medical History:
- Coronary Artery Disease
- Diabetes
- Hypertension
- Chronic Systolic CHF (EF 35% on [**2121-5-8**])
- Atrial fibrillation on Coumadin
- Morbid Obesity
- Nephrolithiasis (since [**2069**])- recently obstructive causing
urosepsis, s/p right percutaneous nephrostomy tube placement
- s/p bilateral meniscal tears
- Positional vertigo
- Gout
- Right cataract surgery
Social History:
The patient lives with his wife [**Name (NI) **] in [**Location 110442**], MA,
however most recently he has been at [**Hospital 100**] Rehab, recently
transferred to [**Location (un) 169**]. He is a retired dry cleaning
machine manufacturerer
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
Father lost kidney due to stones
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS- 97.3 123/64 86 22 100% RA
GENERAL- obese male in NAD.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Oropharynx clear, no
lesions/exudate
NECK- Supple with JVP of 5 cm. Papular rash on neck
CARDIAC- Irregularly irregular, normal s1/s2, grade II/VI
systolic murmur best heard at LUSB, no radiation to carotids
LUNGS- CTA anteriorly, no crackles/wheezes
ABDOMEN- +BS, soft, NT, ND.
EXTREMITIES- WWP, no edema or cyanosis.
SKIN- Papular rash in folds of neck, dry skin on face. No stasis
dermatitis, ulcers, scars, or xanthomas.
Area surrounding percutaneous nephrostomy tube clean, no
erythema or exudate.
GU- foley in place draining clear/nonbloody urine.
Nephrostomy tube draining nonbloody urine with minimal sediment
No CVA tenderness bilaterally
PULSES-
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Coronary Catheterization [**2121-6-11**]:
1. Selective coronary angiography of this right dominant system
demonstrated severe left main and three vessel coronary artery
disease.
The LMCA had a distail 70% stenosis. The LAD had serial proxmal
and mid
vessel lesions up to 80% in narrowing. The distal vessel was
small with
diffuse disease. The LCx had a subtotal occlusion proximally.
The RCA
was a large ectactic vessel. There was a proximal 70% narrowing
with
diffuse moderate disease and severe disease of the small distal
branch
vessels. All vessels were heavily calcified.
2. Limited resting hemodynamics revaled elevated left
ventricular
filling pressure, with an LVEDP of 20 mmHg. There was no
transvavular
gradient to suggest aortic stenosis. There was normal systemic
blood
pressure, with a central aortic pressure of 124/73mmHg.
.
Carotid Series [**2121-6-13**]:
IMPRESSION: Less than 40% stenosis in the bilateral internal
carotid
arteries. Mild heterogeneous plaques are seen in the bilateral
proximal
internal carotid arteries.
.
Intra-op TEE [**2121-6-16**]:
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. There is moderate to severe regional left
ventricular systolic dysfunction with mid-apical anterior,
anteroseptal sever hypokinesis. Overall left ventricular
systolic function is moderately depressed (LVEF= 30-35 %). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. There are simple atheroma in the
ascending aorta. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Mild to moderate ([**1-13**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, posteriorly directed jet of
There is no pericardial effusion.
POST CPB: 1. Improverd global and focal LV systolic function
with persistent WMA's but of lesser severity. EF =35-40% 2. MR
is now mild. 3. No other change in valve structure and function
.
Chest CT Scan [**2121-7-1**]:
1. Postoperative changes from coronary artery bypass graft with
sternotomy noted and mild stranding of the superficial and
mediastinal soft tissues, likely postoperative in nature without
focal fluid collection. No evidence of osteomyelitis or
breakdown of the sternal wound. 2. Left greater than right
moderate pleural effusions with accompanying atelectasis and
right lower lobar consolidative opacity which may reflect
aspiration or developing pneumonia. 3. Moderate cardiomegaly
with coronary vascular disease, aortic valvular calcifications
and enlarged pulmonary artery suggesting pulmonary hypertension.
.
LABS
[**2121-7-2**] WBC-8.3 RBC-3.19* Hgb-9.0* Hct-28.9* RDW-15.3 Plt
Ct-433
[**2121-7-1**] WBC-7.7 RBC-2.99* Hgb-8.7* Hct-27.7* RDW-15.4 Plt
Ct-413
[**2121-6-30**] WBC-7.5 RBC-3.09* Hgb-9.0* Hct-28.8* RDW-15.4 Plt
Ct-386
[**2121-6-29**] WBC-9.1 RBC-2.92* Hgb-8.6* Hct-27.2* RDW-15.7* Plt
Ct-385
[**2121-6-28**] WBC-11.1* RBC-3.05* Hgb-8.7* Hct-28.5* RDW-15.6* Plt
Ct-332
[**2121-7-2**] PT-17.9* INR(PT)-1.7*
[**2121-7-1**] PT-24.8* INR(PT)-2.4*
[**2121-6-30**] PT-26.2* INR(PT)-2.5*
[**2121-6-29**] PT-24.7* INR(PT)-2.4*
[**2121-6-28**] PT-29.5* INR(PT)-2.8*
[**2121-7-2**] Glucose-113* UreaN-24* Creat-1.0 Na-132* K-4.9 Cl-97
[**2121-7-1**] Glucose-107* UreaN-25* Creat-1.0 Na-134 K-4.5 Cl-97
HCO3-32
06/18/12Glucose-88 UreaN-24* Creat-1.0 Na-133 K-4.4 Cl-97
HCO3-32 AnGap-8
[**2121-6-29**] Glucose-98 UreaN-27* Creat-1.0 Na-133 K-4.7 Cl-97
HCO3-31 AnGap-10
[**2121-6-28**] Glucose-106* UreaN-30* Creat-1.1 Na-137 K-4.5 Cl-101
HCO3-31
[**2121-6-26**] Glucose-110* UreaN-35* Creat-1.1 Na-135 K-4.2 Cl-100
HCO3-30
[**2121-6-25**] Glucose-108* UreaN-42* Creat-1.3* Na-136 K-4.2 Cl-100
HCO3-27
[**2121-6-22**] Glucose-107* UreaN-53* Creat-1.8* Na-140 K-4.2 Cl-103
HCO3-26
[**2121-7-2**] Mg-2.0
Brief Hospital Course:
MEDICAL COURSE:
75 yo M with h/o HTN, DMII, nephrolithiasis s/p right
percutaneous nephrostomy tube for obstructing calculus causing
urosepsis, afib on coumadin, now presenting with chest pressure
and diaphoresis with RVR with pseudomonal UTI.
PREOPERATIVE COURSE:
# Demand Ischemia/3-Vessel CAD s/p CABG: Patient was admitted
with chest pain which occurred in the setting of movement, and
on EMS arrival, was found to be in RVR. He had a mild troponin
leak to a peak level of 0.07 without elevation of CKMB and
without EKG changes. His chest pain was assessed as demand
ischemia caused by his Afib with rapid ventricular rate.
Patient had recent NSTEMI during prior admission and underwent
C. cath here which showed severe 3 vessel disease including a
70% left main lesion. He was medically managed with aspirin
325mg, atorvastatin 40mg daily, rate control with metoprolol
which was uptitrated to 100mg PO QID, and coumadin for his afib
in place of heparin. He was referred to cardiac surgery for
CABG, underwent unremarkable pre-CABG work-up including carotid
U/S and his coumadin was held and replaced with a heparin drip
as a bridge prior to surgery.
.
# Atrial fibrillation with RVR: During last admission, patient
had rapid rates with small amounts of activity, and his RVR on
this occasion occurred in the setting of lots of movement. He
had no evidence of pneumonia on CXR and d-dimer was negative, so
low suspicion for pulmonary embolism. He was monitored on
telemetry and his metoprolol was uptitrated to 100mg PO QID on
which he achieved good rate control. Patient had no ongoing
episodes of RVR during admission.
# Pseudomonas UTI: Patient had recent urosepsis secondary to
obstructive calculus in right kidney and patient now has right
percutaneous nephrostomy tube and foley catheter which puts him
at risk for UTI and pyelonephritis. He was initially started
broadly on vancomycin/ceftriaxone which was changed to cefepime
once urine culture grew pseudomonas. He was ultimately narrowed
to oral cipro once sensitivities were available and was treated
for a total 10-day course for complicated UTI with clearance of
his urine cultures.
SURGICAL COURSE:
On [**2121-6-16**], underwent four vessel coronary artery bypass grafting
by Dr. [**First Name (STitle) **]. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POSTOPERATIVE COURSE:
# Urosepsis/Sternal Wound Infection/Pneumonia: Experienced
fevers, pyuria and sternal drainage. Blood, urine and wound
cultures grew out Klebsiella pneumoniae. Followed by ID service
and intravenous antibiotics were titrated accordingly. At
discharge, antibiotics were Ertapenem and Vancomycin. Ertapenem
will be for approximately for 6 weeks. Just prior to discharge,
Vancomycin was added for 14 days for postoperative pneumonia
found on chest CT scan. PICC line will placed at [**Hospital 100**] rehab
and he will continue to followup with ID as outpatient. While at
rehab, patient will require weekly CBC with diff, BMP, LFT's,
ESR, CRP and BNP. Vancomycin will be titrated for a goal trough
between 15 - 20. During hospital stay, bedside debridement of
sternal wound was performed. At discharge, VAC dressing was in
place.
# Obstructive Nephrolithiasis: Underwent placement of a right
nephrostomy tube and will followup with Dr. [**First Name (STitle) **] [**Name (STitle) **] as
outpatient. At time of dicharge, Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] on vacation but
will contact patient at [**Hospital 100**] rehab upon his return. He is
currently scheduled for ureteroscopy with laser lithotripsy on
[**2121-8-12**].
# Atrial Fibrillation: Remained in a rate controlled atrial
fibrillation. Maintained on Amiodarone and Diltiazem. Warfarin
was dosed for a goal INR between 2.0 - 3.0.
# Disposition: Discharged to [**Hospital 100**] Rehab on postoperative day
16
Medications on Admission:
# aspirin 81 mg PO daily
# metoprolol succinate 200 mg PO daily
# lisinopril 2.5 mg PO daily
# warfarin 5 mg PO daily
# tamsulosin 0.4 mg PO qHS
# insulin glargine 100 unit/mL Solution 10 units SC qHS
# insulin aspart 100 unit/mL cartridge per sliding scale QACHS
# tramadol 50 mg PO BID prn pain
# miconazole nitrate 2 % Powder TOPICAL daily
# allopurinol 100 mg PO daily
# simethicone 80 mg PO q6-8h prn gas
Discharge Medications:
1. furosemide 10 mg/mL Solution Sig: Four (4) ml Injection [**Hospital1 **]
(2 times a day): 40mg IV twice daily.
2. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q
12H (Every 12 Hours) for 14 days: started [**2121-7-2**].
3. ertapenem 1 gram Recon Soln Sig: One (1) Intravenous Q24
hours () for 6 weeks: started [**2121-7-2**].
4. diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day): hold for SBP<95 or HR<85 .
5. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
6. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical HS
(at bedtime): apply to affected area.
11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. warfarin 1 mg Tablet Sig: 0.5 Tablet PO at bedtime: Take as
directed by MD. Daily dose may vary according to PT/INR. Goal
INR between 2.0 - 3.0.
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**6-20**]
hours as needed for pain, fever.
18. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
-Coronary Artery Disease, s/p CABG
-Postop Sternal Wound Infection, on VAC dressing
-Diabetes Mellitus
-Morbid Obesity
-Hypertension
-Systolic CHF (EF 35% on [**2121-5-8**])
-Atrial fibrillation on Coumadin
-Nephrolithiasis (since [**2069**])- recently obstructive causing
Klebsiella urosepsis, s/p right percutaneous nephrostomy tube
placement
-Postop Pneumonia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - VAC dressing in place
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:
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] [**2121-7-22**] at 1:00p
Cardiologist Dr. [**Last Name (STitle) 696**] [**Telephone/Fax (1) 62**] Date/Time:[**2121-8-7**] 10:00
Infectious Disease: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2121-7-18**] @ [**Hospital Unit Name **]
Basement
Urology: Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 4376**] - Dr. [**Last Name (STitle) **] [**First Name (STitle) **] contact
patient at [**Hospital 100**] Rehab with followup instructions
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 31293**] in [**4-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for afib
Goal INR [**2-14**]
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 4467**]
Results to phone fax ([**Telephone/Fax (1) 110443**]
.
***Also needs weekly CBC with diff, chem 7, LFT's, BNP, ESR and
CRP. Results should be faxed to [**Hospital1 18**] ID office at
[**Telephone/Fax (1) 1419**].*** Also check Vanco trough after 4th dose -
Vancomycin should be titrated for goal Vanco trough between 15 -
20.****
.
Please change VAC dressing every three days.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2121-7-2**]
|
[
"250.00",
"486",
"428.0",
"412",
"411.1",
"274.9",
"E879.6",
"428.22",
"278.01",
"V85.34",
"599.69",
"V58.61",
"041.3",
"427.31",
"730.28",
"E878.2",
"592.0",
"414.01",
"401.9",
"591",
"790.7",
"998.59",
"518.51",
"996.64",
"041.7",
"410.72",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"87.75",
"96.71",
"37.22",
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
13655, 13721
|
7440, 11395
|
334, 618
|
14128, 14268
|
3230, 5382
|
15056, 16702
|
2226, 2374
|
11855, 13632
|
13742, 14107
|
11421, 11832
|
14292, 15033
|
2414, 3211
|
268, 296
|
646, 1499
|
1521, 1888
|
1904, 2210
|
5392, 7417
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,402
| 173,999
|
8088
|
Discharge summary
|
report
|
Admission Date: [**2129-8-19**] Discharge Date: [**2129-8-26**]
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
Tagged RBC scan
Intubation
History of Present Illness:
Mr. [**Known lastname 2520**] is an 85 year old gentleman discharged from the CCU
service yesterday, returning with 2 episodes of painless
hematochezia, approximately 500mL while defecating at his
nursing home. He was found to have continued bleeding/BRBPR and
sent over to [**Hospital3 7571**]hospital. He was transfused 1 unit
of blood and 1.5 L with IVs placed and transferred to the [**Hospital1 18**]
ED.
.
In the ED, initial vs were: 88 86/54. Patient was given another
2 units of blood, 1.5L of NS to achieve hemodynamic stability.
Surgery and GI were consulted, 40 of Protonix was started. NG
tube placed coffee ground on initial suction with 2 lavages
negative thereafter. Difficult with sat monitoring, but high
90s on NRB. Given 40 Protonix x2. R Triple lumen placed.
Transfer VS: 96/63 (previous BPs: 123/103 103/66 96/64) 96 95%
NRB in AFIB with RBBB which appears to be a new rhythm.
.
On the floor, the patient is awake and confirms the story above,
although he intermittently falls asleep. He denies ever having
abdominal pain, chest pain or difficulty breathing.
.
Of note, the patient was discharged from the CCU service
yesterday after an admission for CHF and diuresis. Discharge
summary reviewed.
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:
Vitals: 93.7 axillary HR 88 BP 101/76 12 99% Facemask
General: Alert, oriented ill appearing gentleman
HEENT: Pale conjunctiva, oropharynx clear, coughing up tan
secretions, NG tube in place: Lavage clear
Neck: R IJ in place, JVP difficult to assess
Lungs: Inspiratory crackles in left side (Lat decub position),
expiratory fine rhonchi.
CV: S1 & S2 fast, irregular with a II/VI holosystoic murmur.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: BRB in rectal vault
GU: Foley in place
Ext: Cool, mild edema, pulses only obtainable by doppler.
Pertinent Results:
CT Abd and Pelvis [**2129-8-23**]
1. Status post aortobiiliac endostent placement with left common
iliac artery aneurysm repair. No definite evidence of endoleak
or aortoenteric fistula on this study.
2. No evidence of focal extravasation of contrast to suggest GI
bleed. If
clinical suspicion persists then nuclear medicine study can be
performed to determine site of bleed.
3. Large bilateral pleural effusions, ascites, and anasarca are
slightly
increased compared to [**2129-8-20**].
4. Hepatic cyst within the left lobe of the liver is stable
since [**2125**].
Bilateral renal cortical scarring is unchanged since most recent
prior.
5. Sclerotic foci of bilateral femoral heads may represent
avascular necrosis and are unchanged since the most recent
priors.
EGD [**2129-8-23**]
Erythema in the stomach compatible with gastritis
Erosions in the antrum
Erythema and friability and erosions in the duodenal bulb
compatible with duodenitis
Blood noted in proximal jejunum without active source of
bleeding noted.
Otherwise normal EGD to proximal jejunum
GI Bleeding Study [**2129-8-24**]
Dynamic blood pool images show extravascular activity noted in
the left lower quadrant throughout the initial thirty minutes
suggestive of brisk bleeding likely in the sigmoid colon.
Bleeding was first noticed within the first minute of dynamic
imaging.
[**2129-8-19**] 10:58PM HCT-35.3*
[**2129-8-19**] 06:08PM HCT-30.5*#
[**2129-8-18**] 04:25AM PT-14.8* PTT-33.1 INR(PT)-1.3*
Brief Hospital Course:
1) Shock/Hypotension/GI bleed: Was secondary to GI bleed and
likely cardiogenic shock with diastolic failure and severe MR,
other possible contributing sources were adrenal insufficiency
given chronic prednisone use and sepsis from urinary source.
The patient remained hypotensive despite 5 units of blood and 6L
of NS at initial presentation. IV access was maintained,
transfusions of PRBC were given for Hct <25, FFP>1.5.
Vancomycin, cefepime and flagyl were started for presumed
urosepsis, and were continued during MICU stay. Trauma line was
placed for faster fluid and blood repletion and hydrocortisone
was given.
Pt was followed by GI, vascular and surgery services. CTA did
not show active bleed or leak from endovascular graft.
Levophed and vasopressin were started to maintain MAP>65.
Patient was intubated on[**8-21**] for concern of inability to protect
airway and hcts and fluid status were stable until [**8-25**], when
there was evidence of a brisk GI bleed which was seen on tagged
RBC scan and embolized by IR, thought to be [**3-1**] diverticulosis,
and again on [**8-26**], for which 2 units of blood and one of FFP
were given. Pressors were titrated and fluid boluses were given
to maintain MAP, until the neighbors decided to initiate comfort
measures only on the afternoon of [**8-26**], after which all
interventions were discontinued except morphine drip and ativan.
Mr. [**Known lastname 2520**] died at 21:50 on [**8-26**].
.
2) Acute on chronic renal failure: Initial creatinine actual
represents an improvement from recent renal failure [**3-1**] heart
failure, but worsened after studies with contrast, the CTA and
IR, were done. Fluid boluses were given and Cr was trended
until CMO was initiated on [**8-26**].
.
4) Diastolic CHF/CAD: No evidence of new ischemia on EKG and
cardiac enzymes were stable. anticoagulation with Asa and
heparin were held
.
5) Atrial fibrillation, borderline rapid rate: Rate control with
fluids/blood as above, no anticoagulation was given.
Medications on Admission:
Acetaminophen 1g PO Q6 PRN
Aspirin 325mg PO Daily
Ciprofloxacin 500mg PO BID last day [**8-21**]
Docusate Sodium 100mg PO BID
Ferrous Sulfate 300mg PO Daily
Furosemide 80mg PO daily
Heparin (Porcine) SC TID
Mesalamine 800mg PO TID
Metolazone 2.5mg PO Daily
Metoprolol Tartrate 6.25mg PO TID
Pediatric Multivit-Iron-min [Multi-Vitamins W/Iron] PO daily
Prednisone 20mg PO Daily
Sennosides [Senna] PRN constipation
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
GI bleed, cardiopulmonary arrest
Discharge Condition:
expired
Completed by:[**2129-8-27**]
|
[
"428.33",
"714.0",
"789.59",
"V58.65",
"428.0",
"V45.81",
"285.1",
"785.51",
"578.9",
"255.41",
"427.31",
"443.9",
"496",
"518.81",
"599.0",
"403.90",
"416.8",
"584.5",
"280.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.47",
"45.13",
"38.91",
"96.04",
"96.72",
"44.44"
] |
icd9pcs
|
[
[
[]
]
] |
7336, 7345
|
4836, 6845
|
229, 261
|
7421, 7459
|
3334, 4813
|
2604, 2679
|
7308, 7313
|
7366, 7400
|
6871, 7285
|
2694, 3315
|
181, 191
|
289, 1515
|
1537, 2373
|
2389, 2588
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,411
| 124,999
|
19999
|
Discharge summary
|
report
|
Admission Date: [**2168-12-28**] Discharge Date: [**2169-1-2**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
emesis x 1 day
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **] y/o female with a PMH of colon cancer s/p
right colectomy who presented to the ED with a one-day history
of nausea and emesis. She dienied fever, chills, abdominal pain
and dysuria symptoms. She had a normal bowel movement the day
prior to admission but had not passed flatus.
Past Medical History:
cecal mass found on colonoscopy at osh (adenocarcinoma s/p R
colectomy [**6-/2168**])
diverticulosis
paroxysmal atrial fibrillation, h/o warfarin anticoagulation
aortic stenosis s/p valvuloplasty [**11-19**] (at that time, had clean
coronaries)
chf ef >55% from echo [**2165**]
retinal detachment
iron deficiency anemia (Fe 10, TIBC 514, B12 306, folate 12.4 at
OSH)
Social History:
daughter lives in area, pt lives by herself but has caregivers
who come in daily to help, denies etoh and smoking.
Family History:
non contributory
Physical Exam:
VS on admission ([**2168-12-26**]): 96.3 P85 BP112/62 R16 95%RA
Gen - NAD, A&Ox3
HEENT - MMM
Cardiac - RRR, 3/6 systolic creshendo murmur with neck rads
Lungs - CTA bilat.
[**Last Name (un) **] - bowel sounds present, soft, + distention, + tympanitic,
nontender, no rebound or guarding
Brief Hospital Course:
The patient presented to the ED where a nasogastric tube was
inserted for decompression. Thereafter, she was admitted to the
ICU for close monitoring. On HD#[**12-19**], the patient was noted to
have borderline sufficient urine output. She was supported with
bolus intravenous fluids as needed. By HD#3, the patient's bowel
function had still not returned despite nasogastric
decompression and bowel rest.
On HD#5, the patient went into atrial fibrillation with
resultant hypotension (SBP 70s). The patient denied chest pain,
shortness of breath, nausea, vomiting or diaphoresis. She was
cardioverted emergently and was restored to a normal sinus
rhythm after the third attempt. Her blood pressures were
restored with the normalization of her heart rhythm. She was
started on an amiodarone drip and was followed closely by the
cardiology service for the duration of her stay.
Plans were made to take her to the operating room for a
celiotomy and possible resection of bowel, but on HD#5, the
patient's bowel function returned. She passed flatus and had a
bowel movement. She continued to have persistent but improving
abdominal distention. Abdominal x-rays showed interval
improvement. On HD#6, she was tranferred out of the ICU to a
floor with telemetry. She continued to make interval
improvement. On HD#7, she converted to atrial fibrillation
again. The episode was asymptomatic, and the patient maintained
her systolic blood pressures in the 140s. She easily converted
to a sinus rhythm after beta blockade.
On HD#8, she was discharged home in stable condition with full
return of bowel function and with no abdominal distention. She
was tolerating a regular diet without issue. She was given
instructions to follow up with Dr. [**Last Name (STitle) **] in clinic and with
her cardiologist.
Medications on Admission:
furosemide 20mg po qd
pantoprazole 40mg po qd
potassium chloride 10mg po qd
metoprolol 25mg po BID
MVI
FeSO4
Discharge Medications:
The above medications and:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: start after 5 days of the other amiodarone and take
this lesser dose for 1 week.
Disp:*14 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Obstruction/a fib\n
Discharge Condition:
stable
Discharge Instructions:
Please resume you home medications for and again start the baby
aspirin. [**Name2 (NI) **] should see your cardiologist again this week and
discuss optimal therapy for atrial fibrilation as you are to
continue the amiodarone for one more week.
Followup Instructions:
F/ in 2 weeks in the office with Dr. [**Last Name (STitle) **], f/u this week with
you cardiologist
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2169-1-5**]
|
[
"427.31",
"560.9",
"V10.05",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3984, 3990
|
1466, 3266
|
234, 241
|
4053, 4062
|
4354, 4581
|
1122, 1140
|
3425, 3961
|
4011, 4032
|
3292, 3402
|
4086, 4331
|
1155, 1443
|
180, 196
|
269, 583
|
605, 973
|
989, 1106
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,775
| 142,961
|
40794
|
Discharge summary
|
report
|
Admission Date: [**2137-7-21**] Discharge Date: [**2137-8-13**]
Date of Birth: [**2102-12-12**] Sex: F
Service: MEDICINE
Allergies:
Bupropion / Lactose
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
Right percutaneous nephrostomy tube placement twice
Endoscopic Ultrasound
History of Present Illness:
Ms. [**Known lastname 53812**] is a 34 y.o. Female with Cerebral Palsy who presented
to [**Hospital 882**] hospital with 1 week of fevers, nausea, vomiting, rt
back pain.
Pt is poor historian s/p sedation. Obtained history from
peripheral sources. Per ED records from OSH it appears she
presented with 1 week of poor oral intake, 2 days of weakness, 1
week of nausea, vomiting, fevers. Her initial VS were noted to
be T 98.0, HR 87, RR 16, BP 117/56, Sat 97%. Labs were
significant for 24.9 WBC (9% Bands), Hgb/Hct 10.1/29.9, Plt 362.
Lytes showed 134/2.6/96/23/9/0.54/153. She received an U/S which
showed chronic high grade obstruction of the rt kidney with
large calculi within the renal collecting system 2.6-cm
associated with hydronephrosis in the right renal collecting
system suggesting pus. Urology was consulted however given her
scoliosis, back spasms a ureteral stent could not be feasibly
placed.
Per transfer summary pt was scheduled to go to [**Hospital1 112**] for perc
nephrostomy, unfortunately MICU/SICU beds were not available. At
1803 pt's BP dropped from 100s-110s systolics to 80s. Pt was
given IVF bolus and transferred to the ICU. There she was given
additional fluid to mantain BPs in the 90s. Urology at [**Hospital1 882**]
contact[**Name (NI) **] IR at [**Hospital1 18**] to transfer for emergent perc nephrostomy.
Pt received a total 4500cc with an output of 300cc urine. Pt was
given broad coverage with Zosyn 3.375mg IV x 2 (1230pm, 708pm),
Vancomycin 1gm IV x 1. She was also given Zofran 4mg x 1 for
nausea, Toradol for pain 30mg x 1. Her K was also noted to be
low at 2.6, replaced with 40 IV/40 PO KCL.
Given the pt's scoliosis and contractions anesthesia was called
for sedation. Her initial VS were notable for HR 80s, SBP 100s.
Pt was orientated x 3 and able to converse asking questions
about when she was going for the procedure. She was taken to IR
for percutaneous nephrostmoy, 60cc of pus was drained and sent
for cx, proximal obstruction compressed.
Past Medical History:
Cerebral Palsy
Choreoathetosis
Kidney Stone
Gallstones
Depression/Suicidality
Auditory Hallucinations
Social History:
Pt lives at home with caregiver, baseline uses a wheelchair.
Denies any tobacco, EtoH, recreational drug use.
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM:
VS: T 98.3 BP 121/71 HR 82 RR 18 O2 Sat 97%RA
GEN: Caucasian Female w/ scoliosis laying down in bed in NARD
HEENT: PERRL, EOMI, anicteric, MMM
CV: RR, II/VI non-radiating systolic murmur, no rubs or gallops
RESP: CTA b/l with good air movement throughout
ABD: Soft, no rigidity or rebound, mild distension, bs present
EXT: pt ntoed to have contractions, 2+ pitting edema of the BLEs
SKIN: no rashes
NEURO: Pt with contractions of upper and lower extremities. non
focal. Cn II-XII intact.
DISCHARGE EXAM (Pertinent findings):
VS: Tm 99.1 Tc 98.0 BP 113/74 HR 103 RR 20 SpO2 97%/RA
Physical exam:
GEN: Caucasian Female w/ scoliosis laying down in bed, appears
comfortable
ABD: soft/NT/slightly distended, +BS
EXT: pt noted to have contractions, 1+ pitting edema of the BLEs
SKIN: small amount of erythema surrounding PCN tube, no purulent
discharge
Pertinent Results:
Admission Labs:
[**2137-7-21**] 11:30PM GLUCOSE-95 UREA N-7 CREAT-0.5 SODIUM-136
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-19* ANION GAP-15
[**2137-7-21**] 11:30PM PT-14.4* PTT-41.5* INR(PT)-1.2*
[**2137-7-21**] 11:30PM WBC-27.9* RBC-2.95* HGB-9.0* HCT-27.6* MCV-94
MCH-30.4 MCHC-32.5 RDW-13.6
[**2137-7-21**] 11:30PM NEUTS-93* BANDS-3 LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2137-7-21**] 11:30PM ALBUMIN-2.0* CALCIUM-6.4* PHOSPHATE-2.0*
MAGNESIUM-1.5*
Discharge Labs:
Micro:
[**2137-7-22**] 2:30 am URINE,KIDNEY NEPHROSTOMY. RECEIVED IN A
SYRINGE.
**FINAL REPORT [**2137-7-28**]**
FLUID CULTURE (Final [**2137-7-28**]):
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..
DR. [**Last Name (STitle) 28883**] ([**Numeric Identifier 35492**]) REQUESTED WORK-UP OF ALL ORGANISMS
[**2137-7-25**].
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SECOND MORPHOLOGY.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ESCHERICHIA COLI
| | ESCHERICHIA
COLI
| | |
AMIKACIN-------------- <=2 S <=2 S
AMPICILLIN------------ <=2 S =>32 R =>32 R
AMPICILLIN/SULBACTAM-- <=2 S 8 S 4 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S 0.5 S
GENTAMICIN------------ <=1 S =>16 R =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 8 I 8 I
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2137-7-26**]): NO ANAEROBES ISOLATED.
BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2137-8-7**]**
Blood Culture, Routine (Final [**2137-8-7**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-7-24**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
C Diff ([**2137-7-27**]): Feces negative for C.difficile toxin A & B by
EIA.
Studies:
Percutaneous nephrostomy tube placement [**2137-7-21**]:
FINDINGS:
1. Severe hydronephrosis with cortical thinning. Low echoes
within the
pelvicaliceal system suggestive of purulent material.
2. Large greater than 2-cm stone within a mid-pole calix.
3. Occlusion of the proximal right ureter with no flow distal to
it.
4. Successful placement of a right 8 French x 25 cm Flexima
nephrostomy
catheter.
5. Grossly purulent urine sample sent for microbiologic
analysis.
6. Post-tube placement nephrostogram demonstrating occlusion of
the proximal
ureter.
IMPRESSION: Successful placement of a right-sided 8 French
nephrostomy tube in an obstructed renal pelvis. Urine purulent
with culture pending.
IR EVAL OF PICC PLACEMENT, NEPHROSTOMY TUBE [**2137-7-23**]:
FINDINGS:
1. Markedly abnormal right kidney demonstrating severe
hydronephrosis,
caliceal blunting consistent with chronic disease, and multiple
filling
defects consistent with stones.
2. Patient right nephrostomy tube in appropriate position.
3. Spinal rods consistent with history of scoliosis.
4. PICC replacement with tip in the lower SVC.
IMPRESSION:
1. Patent nephrostomy tube with markedly abnormal right kidney
consistent
with chronic hydronephrosis and caliceal blunting. The previous
ultrasound demonstrates severe cortical thinning. Low volume
urine production would be expected.
2. Replacement of a right-sided PICC with the tip in the lower
SVC. The tip is ready for use.
Anteriograde Urogram ([**2137-7-23**]):
1. Markedly abnormal right kidney demonstrating severe
hydronephrosis, caliceal blunting consistent with chronic
disease, and multiple filling defects consistent with stones.
2. Patient right nephrostomy tube in appropriate position.
3. Spinal rods consistent with history of scoliosis.
4. PICC replacement with tip in the lower SVC.
RENAL U/S [**2137-7-24**]:
CONCLUSION:
1. The pigtail catheter has resolved the marked right
hydronephrosis with
only minimal right upper pole caliectasis remaining. Several
large right
renal stones are noted, however.
2. Moderate right pleural effusion.
3. Right lower quadrant, moderate volume ascites.
4. No left renal stones or hydronephrosis noted. Simple cyst in
the left
upper pole.
CT ABD/PELVIS [**2137-7-24**]:
IMPRESSION:
1. Examination limited due to hardware artifact, but no definite
evidence of retroperitoneal hematoma.
2. Abdominal and pelvic ascites.
3. Status post right percutaneous nephrostomy tube placement
with a large
calculus in the right kidney along with an additional calculus
in the distal right ureter.
4. Cholelithiasis.
KUB [**2137-7-25**]: IMPRESSION: Unchanged size and location of the
previously seen renal calculi, with the larger stone being
within the right lower pole and the smaller stone in the distal
right ureter.
RUQ U/S [**2137-7-26**]:
IMPRESSION:
1. Moderate ascites. Right pleural effusion.
2. Cholelithiasis.
3. No ductal stones seen. The CBD is not dilated, measuring 3
mm.
CXR [**2137-7-26**]:
New nasogastric tube ends in the mid stomach. Moderate-to-large
right pleural effusion has grown since [**7-22**], while previous
pulmonary edema has improved. Persistent opacification at the
base of the left lung is probably residual edema and
atelectasis, though pneumonia is not excluded. Heart size is
normal. Right PIC catheter ends in the upper SVC. New right
upper quadrant drainage catheter has been added.
CTAP [**2137-7-26**]:
IMPRESSION:
1. Extremely limited study due to lack of intravenous contrast
and extensive streak artifacts from spinal fusion hardware.
Within this limitation, there is no significant change from
[**2137-7-24**] exam.
2. Small-to-moderate bilateral pleural effusions, right greater
than left,
with adjacent areas of compressive atelectasis, unchanged.
3. Stable appearance of moderate ascites.
4. Right renal calculus with percutaneous nephrostomy tube in
place,
unchanged in position. An additional right pelvic density may
represent an
obstructive right ureteral stone, stable.
5. Cholelithiasis.
CT HEAD W/O [**2137-7-26**]:
IMPRESSION:
Ex vacuo dilatation of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle is
likely related to a chronic process. No acute intracranial
process.
EEG [**2137-7-26**]:
IMPRESSION: This is an abnormal EEG due to the presence of a
slower
than average, disorganized background with periods of
generalized
voltage suppression seen. This pattern is consistent with a
moderate
encephalopathy of toxic, metabolic, or anoxic etiology. No
evidence of
ongoing or potential epileptogenesis was seen at the time of
this
recording.
Abd Ultrasound ([**2137-7-27**]):
1. Enlarged, hyperechoic, heterogenous pancreas, compatible with
known history of pancreatitis. No pancreatic duct dilation is
seen
2. 3-mm CBD. No ductal stone seen
3. Cholelithiasis, with no evidence of cholecystitis.
Gallbladder wall thickening likely secondary to third spacing
from neighboring ascites
4. Small amount of ascites
5. Mild intrahepatic bile duct dilation
CXR AP ([**2137-8-1**]):
1. Stable small bilateral effusions and atelectasis. No new
consolidation.
2. Mildly improved pulmonary vascular congestion.
RUQ US ([**2137-8-8**]):
1. Cholelithiasis with no sign of cholecystitis. No biliary
dilatation.
2. Scant trace of ascites and right pleural effusion.
3. No hydronephrosis on limited views of the kidneys. A large
right renal
stone is again noted.
Endoscopic ultrasound [**2137-8-8**]
EUS : Pancreas parenchyma was normal.
The main pancreatic duct was normal.
The bile duct was 3 mm and normal. The bile duct could not be
imaged at the level of the ampulla. Lack of biliary dilation
makes a distal CBD stone less likely.
Small amout of peri-gastric ascites was noted.
Discharge Labs:
CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2137-8-13**] 06:23 9.2 2.72* 8.3* 24.8* 91 30.3 33.3 17.1* 645
RENAL & GLUCOSE Glu Urea Creat Na K Cl HCO3 AnGap
[**2137-8-13**] 06:23 102*1 19 0.5 132* 4.6 100 25 12
Brief Hospital Course:
34 y.o. female with cerebral palsy who presented to [**Hospital 882**]
hospital with 1 week of fevers, nausea, vomiting and rt back
pain. She was found to have high grade obstruction of right
kidney with renal stones. Pt was transferred to [**Hospital1 18**] ICU after
developing hypotension from urosepsis [**2-27**] pyelonephritis with
percutaneous nephrostomy tube placed with IR and then placed on
antibiotics. Her MICU course was complicated by acute renal
failure, pancreatitis and altered mental status. Pt's urospesis
and altered mental status both improved on antibiotic treatment
(cipro), for which she completed a full fourteen day course.
Workup for pancreatitis revealed that the likely cause was
gallstone pancreatitis. EUS performed rather than ERCP given
that it is the safer procedure of the two to evaluate for ductal
stones or anatomic anomalies. The patient did have a 2nd episode
of pancreatitis which resolved within 1-2 days. The day prior to
discharge the nephrostomy tube was accidentally dislodged when
transferring the patient and it was replaced by IR.
# Urosepsis: Secondary to urinary tract infection, complicated
by renal stones and hydronephrosis. She was intermittently
hypotensive in the ICU, requiring boluses of fluid, but had no
pressor requirement. Pt had percutaneous drained placed with IR,
and was placed on antibiotics. Once species here resulted in
GNR's and proteus, Vancomycin was discontinued and she was
continued on Zosyn with the addition of IV Ciprofloxacin for
additional GNR coverage. Sensitivity data showed all 3 species
were sensitive to Cipro and therefore Zosyn was discontinued. IR
followed the pt, and did a fluoroscopic study given acute renal
failure (see below), which showed appropriate drainage/function
of the tube. Urology was consulted, and recommended no
intervention given concern for worsening sepsis with
lithotripsy. Given continued WBC count rise, ID was consulted
and recommended adjustment of abx to meropenem and continued
cipro. However, culture data grew E. coli sensitive to Cipro,
and Meropenem was discontinued. She clinically improved, and was
no longer hypotensive. She was to complete a 14 day course of
Ciprofloxacin that was finished on [**2137-8-5**]. Pt did have PCN
tube replaced by IR on [**8-12**] after it broke during pt transfer.
Per urology, plan for lithotripsy in [**1-27**] weeks after discharge.
Pt will then need to have PCN tube removed and will require
another 2 weeks of Cipro.
# Pancreatitis: Pt had two episodes of pancreatitis during
hospitalization with the likely etiology being gallstone
pancreatitis. The first episode was based on laboratory values
(elevated amylase/lipase), while the second episode was both
clinical with abdominal pain as well as having an extremely
elevated lipase. MRCP was considered but not done given metal
rods. ERCP team was consulted and decided that pt would benefit
best from an endoscopic ultrasound which showed a normal bile
and pancreatic duct with a normal pancreatic parenchyma.
Gastroenterology and ACS have been collaberating with team
during pts admission. Gastroenterology will plan to further
evaluate the pts CBD before ACS would evaluate for possible
cholecystectomy
# Toxic metabolic encephalopathy: Pt became altered in the ICU,
thought to be [**2-27**] medication effect with narcotics for pain
control, sepsis, and pain. She was given one dose of narcan in
the ICU when she was somnolent, which briefly improved her
mental status. However, she continued to be more somnolent. CT
head showed no acute process. EEG showed diffuse slowing, and no
epileptic foci. She continued to have intermittent delirium and
somnolence. She was started on Seroquel low doses for agitation.
On the floor morphine and benzos were held and her mental status
slowly improved back to baseline per family.
# Acute renal failure: Creatinine increased after nephrostomy
tube placed, with concern initially for continued obstruction.
However, fluoro study with IR reassuring for patent tube. DDx
included ATN given poor po intake, possible sepsis, and recent
Toradol use at OSH for pain. Urine lytes suggested intra-renal
etiology, possibly ATN. Her creatinine trended downward and was
normal on discharge.
# Leukocytosis: Elevated WBC persisted, most likely [**2-27**]
infection as discussed above. Blood cultures were negative, and
C. diff was negative as well. Her WBC was trended and initially
improved, but began to rise again. ID was consulted, and
recommended Meropenem pending cultures. As above, she was found
to have Cipro-sensitive E. Coli and abx were tailored to Cipro.
She remained afebrile and her WBC downtrended to to a normal
range at discharge.
# Anemia: Elevated ferritin, suggestive of inflammation. Hct
drifted down, but stools were brown guaiac positive. She was
transfused one unit of blood in the ICU, with appropriate Hct
bump.
Pt will be discharged to rehab facility with right nephrostomy
tube. Per urology the pt can follow up as an outpatient for
lithotripsy and tube removal (see appt with Dr. [**Last Name (STitle) 3748**]. After
removal the pt will require another 14 days of antibiotics. She
will also will follow up with gastroenterology ([**Doctor First Name 1948**] S.
[**Doctor Last Name **]), followed by ACS if surgery is necessary.
Medications on Admission:
Baclofen 20mg qAM, qNOON, 10mg qPM
Mirtazapine 30mg qHS (refill denied [**2136-12-26**], not actively
taking)
Trihexiphenidyl 2mg tid
Desonide Cream [**Hospital1 **]
Bacitracin Cream [**Hospital1 **]
Miralax daily
Meds on transfer:
Zosyn 3.375mg IV x 2 doses
Toradol 30mg
Vanc 1gm x 1
Zofran 4mg IV x 1
Discharge Medications:
1. trihexyphenidyl 2 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. baclofen 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. baclofen 10 mg Tablet Sig: Two (2) Tablet PO QAM, Q NOON ().
4. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
6. desonide Topical
7. bacitracin Topical
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Pyelonephritis, right
Obstructive nephrolithiasis s/p percutaneous nephrostomy tube,
right
Urosepsis
Gallstone pancreatitis
Toxic encephalopathy
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 53812**],
It was a pleasure taking care of you during your stay at
[**Hospital1 69**]. You were transferred here
with a kidney stone that was blocking the flow of your urine,
which eventually caused an infection. You were treated with
antibiotics that helped to cure your infection. You also had
some confusion, which we think was caused mainly by your
infection. You also developed inflammation of your pancreas
called pancreatitis, for which we were unable to find a definite
cause. You are stable for transfer to a rehab facility.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2137-8-20**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], 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: GASTROENTEROLOGY
When: TUESDAY [**2137-8-20**] at 10:40 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2137-8-27**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11307**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,060
| 123,945
|
24285
|
Discharge summary
|
report
|
Admission Date: [**2179-5-26**] Discharge Date: [**2179-6-1**]
Date of Birth: [**2144-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
etoh withdrawl
Major Surgical or Invasive Procedure:
none
History of Present Illness:
34 M with long time history of severe alcohol abuse and
withdrawl with prior seizure and DT. Last admitted to MICU
where required versed drip and up to 600 mg valium over first
day. Brought to ED by EMS after being found down. Last drink 1
am today: [**2-8**] gallon of vodka. Level 387 and having symptoms of
tremulousness. given 10 mg valium and sent to floor where
developed hypertension, tachycardia, and tactile hallucinations.
Given an additional 40 mg of vailum without improvement. Most
recent CIWA 34. Doesn't recall any head trauma or fall today.
CT head in ED showed no bleed. Last seizure was 3 days ago.
.
ROS: no chest pain, SOB, cough, fever, chills.
Past Medical History:
Polysubstance abuse
-- Required 170mg valium IV over 3 hours, then was placed on an
Ativan drip which started at 8mg/hr and was uptitrated to
20mg/hr. In the patient's first 24hours, he required 700mg IV
valium.
-- EtOh, heroin IVDU, klonopin
HCV, from IVDU
compartment syndrome RLE, [**2171**]
OCD and anxiety since childhood
depression, psychiatrist Dr. [**Last Name (STitle) 60521**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. H/O SI
with reportably tylenol overdose.
Social History:
Homeless for past 16 years; lives in [**Location **] common. Mother died
from complications of DM [**2162**]. Has not had contact with his
father/sister since [**2162**]. Was incarcerated for 9 months due to
possession charges. He also reports a history of almost every
infraction due to substance abuse. Hx of polysubstance abuse
including ETOH, cocaine, heroin, benzos. Current drug of choice
is ETOH; drinks 3 pints vodka a day. does not recall last use of
heroin and cocaine. Denies tobacco.
Family History:
mother died of complications of DM in '[**62**]. Father with
depression
and alcoholism
Physical Exam:
vs: 98.9, 160/80, p130, 22, 96% RA
heent: NC/AT, eomi, perrl
lungs: CTA b
cv: s1/s2, tachy regular, no m/r/g
abd: slight tender midepigastric and LLQ, soft, no rebound, nabs
ext: no edema, warm and dry
neuro: tremulous, tactile hallucinations (I feel cats scratching
my skin), answering questions appropriately. asking for a drink.
Pertinent Results:
CXR: normal
CT head: no subdural, cerebral atrophy.
[**2179-5-26**] 08:25AM BLOOD WBC-7.5# RBC-4.83 Hgb-14.6 Hct-41.9
MCV-87 MCH-30.3 MCHC-35.0 RDW-15.7* Plt Ct-166
[**2179-5-27**] 03:00AM BLOOD WBC-7.3 RBC-3.98* Hgb-12.2* Hct-34.9*
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.7* Plt Ct-113*
[**2179-5-30**] 08:06AM BLOOD WBC-8.9 RBC-3.65* Hgb-11.5* Hct-32.9*
MCV-90 MCH-31.5 MCHC-35.0 RDW-15.3 Plt Ct-151
[**2179-6-1**] 06:20AM BLOOD WBC-5.4 RBC-3.51* Hgb-11.2* Hct-31.9*
MCV-91 MCH-32.0 MCHC-35.2* RDW-15.8* Plt Ct-198
[**2179-6-1**] 06:20AM BLOOD Plt Ct-198
[**2179-5-27**] 03:00AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-139
K-3.9 Cl-102 HCO3-26 AnGap-15
[**2179-5-27**] 03:14PM BLOOD Glucose-146* UreaN-10 Creat-0.8 Na-136
K-3.7 Cl-100 HCO3-26 AnGap-14
[**2179-6-1**] 06:20AM BLOOD Glucose-118* UreaN-9 Creat-0.8 Na-142
K-3.7 Cl-105 HCO3-28 AnGap-13
[**2179-5-26**] 08:25AM BLOOD ALT-94* AST-208* AlkPhos-147*
Amylase-133* TotBili-0.6
[**2179-5-27**] 03:00AM BLOOD ALT-75* AST-182* AlkPhos-98 Amylase-99
TotBili-2.2*
[**2179-5-28**] 05:15PM BLOOD ALT-29 AST-23 AlkPhos-64 TotBili-0.1
[**2179-5-26**] 08:25AM BLOOD Lipase-159*
[**2179-5-27**] 03:00AM BLOOD Lipase-98*
[**2179-5-28**] 04:31AM BLOOD Lipase-61*
[**2179-5-26**] 08:25AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.8
[**2179-5-27**] 03:00AM BLOOD Albumin-3.9 Calcium-8.2* Phos-3.3 Mg-2.2
[**2179-5-31**] 06:35AM BLOOD Calcium-9.2 Phos-4.5# Mg-1.8
[**2179-5-28**] 04:31AM BLOOD calTIBC-263 Ferritn-256 TRF-202
[**2179-5-26**] 08:25AM BLOOD ASA-NEG Ethanol-387* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2179-5-26**] 08:35AM BLOOD Glucose-81 Na-149* K-4.2 Cl-102
calHCO3-32*
Brief Hospital Course:
34 M with h/o hep C admitted for alcohol withdrawal and
pancreatitis. He was initially admitted to the medical
intensive care unit, and was subsequently transferred to medical
service for continued monitoring during detox. He was treated
with benzodiazepenes during this admission for his withdrawal,
and was followed by the psychiatry service in consultation. He
was weaned off of large doses of benzodiazepenes by the time of
discharge, and will be able to continue his taper at the rehab.
Specific issues arriving during her stay are outlined as below:
.
# alcohol withdrawl: He was admitted to the ICU; he initially
required large amounts of benzodiazepines (>1000mg / day). He
was having tactile hallucinations as well as autonomic
instability earlier in this admission; none now. He is now
hemodynamically stable. He was initially treated with a CIWA
scale; psych evaluation recommended against a CIWA scale, as it
was difficult to determine withdrawal from benzo effect; much of
his tremor could be due to cerebellar atrophy. He is deemed safe
to leave AMA should he chose. He has been tapered to 10mg
valium q6h, now to 5mg valium q6h
-currently on valium 5 q6 with prn serquel for agitation. He
was kept on IVF until his PO intake was adequate. He had a
social work consult; He has said that he would like to be done
drinking. He was not tachycardic or hypertensive on the last
three days of his admission. The recommendation is to continue
his current regimen valium, and then, at the discretion of the
receiving institution, taper per CIWA scale. He was kept on
multivitamins, folate, thiamine.
.
# pancreatitis: Mild enzyme elevattion; likely from alcohol and
history of hepatitis C. Mild discomfort only remained after
leaving the ICU. His diet was advanced, and he had no nausea or
vomiting, and only mild abdominal pain. Amylase and lipase have
been trended and are now stable. He is tolerating PO diet
without nausea or vomiting.
.
# hepatitis: h/o hep C infection and alcoholic hepatitis c
AST/ALT ratio >1.5. Mild elevation, with trending down.
Asymptomatic. This was a stable issue during this admission.
.
# FEN: encouraged PO intake once out of acute withdrawal
symptoms. His electrolytes were repleted as needed.
.
#Anemia- partly dilutional but also likely nutritional component
given homeless and alcoholic. His albumin was 3.9; his MCV was
88. His iron panel was WNL. He did not require a blood
transfusion during this admission.
.
#PPx- Bowel regimen, Heparin subcutaneously, Vitamins
.
# Access: peripheral iv lines.
.
# Sedation: benzo for withdrawal
.
# Code: full
Medications on Admission:
Denies
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours: Dose of valium is per psychiatry recommendations. Please
begin to transition to prn CIWA >10. . Tablet(s)
7. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
Alcohol withdrawal
Hepatitis C
Pancreatitis
Polysubstance abuse
Discharge Condition:
Stable, ambulating, afebrile, normotensive, tolerating PO diet
Discharge Instructions:
If you experience any chest pain, difficulty breathing,
seizures, or passing out, please seek [**Hospital 61589**] medical
attention.
Please continue to take all medications as prescribed.
Please follow up with the [**Location (un) **] Health Clinic in about two
weeks.
Followup Instructions:
Please follow up with the [**Location (un) **] Health Clinic in about two
weeks. You can call [**Telephone/Fax (1) 6951**] to schedule an appointment.
|
[
"300.3",
"070.54",
"291.81",
"571.1",
"304.11",
"303.01",
"577.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7602, 7672
|
4154, 6765
|
286, 292
|
7780, 7845
|
2504, 2516
|
8165, 8320
|
2048, 2137
|
6822, 7579
|
7693, 7759
|
6791, 6799
|
7869, 8142
|
2152, 2485
|
232, 248
|
320, 994
|
2525, 4131
|
1016, 1517
|
1533, 2032
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,701
| 182,133
|
39144
|
Discharge summary
|
report
|
Admission Date: [**2200-4-3**] Discharge Date: [**2200-5-6**]
Date of Birth: [**2154-8-13**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Aldactone / Penicillins /
Bactrim
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Continuous venovenous hemodialysis
History of Present Illness:
45 y/o F with hx of HIV and hepatitis C cirrhosis s/p TIPS,
ascites, SBP and encephalopathy who is transferred from the
[**Doctor Last Name 3271**] [**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**] to the MICU for respiratory distress. The
patient was transferred from an OSH last night for hepato-renal
syndrome and SBP. She did well overnight except for transient
hypotension that responded to albumin infusion. She was
continued on cipro for SBP treatment and started on vanco for
broader coverage. This morning she was on 2L NC and had minimal
urine output. She was transferred to radiology for CXR and
ultrasound and after transport and lying flat, became tachypneic
and desatted requiring a NRB. She had an ABG on the floor of
7.20/40/79 and was in obvious distress. She was given one SLNG
for BP in 160s/110s and started on her diuretics. Her
respiratory status did not improve.
.
On the floor, she was placed on bipap and tolerated better
except for discomfort from the mask. She put out minimal urine
to the diuretics. She was unable to lie flat. She continues to
complain of shortness of breath. She denies chest pain, nausea,
vomiting, diarrhea. She is alert and arousable, but cannot
communicate due to the discomfort from the mask.
Past Medical History:
- HCV Cirrhosis - h/o ascites/hepatohydrothorax s/p TIPS,
encephalopathy, SBP
--liver biopsy in [**2195**] at [**Hospital6 86720**]
-Hepatitis C virus - tx with ribaviron and interferon
-HIV on HAART ([**9-1**] CD4 409, VL undetectable)
-Asthma
-Anemia
-COPD
-Aortic stenosis
-s/p tubal ligation in [**2179**]
-s/p throat biopsy with polyp removal in [**2197**] and again in [**2198**]
Social History:
Ms. [**Known lastname **] lives in [**Hospital1 40198**], [**State 350**] with her 26-year-old
daughter. She is now on disability; however, she used to work in
a cafeteria at [**Hospital1 40198**] Public School. No ETOH for 5 years, prior
was a social drinker. Tobacco: currently 3 cigarettes per day,
prior 1PPD since [**03**] yo. She states that she has never used any
intravenous drugs but she did smoke marijuana and experimented
with intranasal cocaine in her teens and early 20s.
Family History:
Mother died at the age of 62 from atherosclerosis and a
myocardial infarction. Her father passed away at 47 due to
morbid obesity and myocardial infarction.
Physical Exam:
General Appearance: Anxious, acute respiratory distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, bipap in place
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Crackles : 1/2 up lungs,
Wheezes : throughout all lung fields, audible without
stethoscope), moving air poorly; tachpneic
Abdominal: Soft, No(t) Non-tender, Distended, Tender: diffusely,
Obese, R bag draining peritoneal fluid
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, edematous in upper extremities as well
Skin: Cool, wrapped L leg
Neurologic: Follows simple commands, Responds to: Not assessed,
Oriented (to): , Movement: Purposeful, Tone: Not assessed
Pertinent Results:
[**2200-4-4**] 12:15AM BLOOD WBC-4.3# RBC-2.63* Hgb-8.3* Hct-25.4*
MCV-97# MCH-31.4 MCHC-32.5 RDW-21.7* Plt Ct-64*#
[**2200-4-4**] 12:15AM BLOOD PT-19.8* PTT-50.8* INR(PT)-1.8*
[**2200-4-4**] 12:15AM BLOOD Glucose-98 UreaN-51* Creat-2.9*# Na-127*
K-5.0 Cl-103 HCO3-17* AnGap-12
[**2200-4-4**] 12:15AM BLOOD ALT-16 AST-29 LD(LDH)-196 AlkPhos-65
TotBili-1.5 DirBili-0.7* IndBili-0.8
[**2200-4-4**] 12:15AM BLOOD Albumin-3.0* Calcium-8.2* Phos-7.2*#
Mg-1.6
[**2200-5-6**] 02:43AM BLOOD WBC-16.2* RBC-2.59* Hgb-8.6* Hct-24.8*
MCV-96 MCH-33.2* MCHC-34.7 RDW-29.2* Plt Ct-30*
[**2200-5-6**] 02:43AM BLOOD PT-85.0* PTT-116.8* INR(PT)-10.3*
[**2200-4-15**] 03:19PM BLOOD Fibrino-73*
[**2200-5-5**] 03:26AM BLOOD Glucose-165* UreaN-100* Creat-2.0* Na-143
K-4.0 Cl-118* HCO3-13* AnGap-16
[**2200-5-5**] 03:26AM BLOOD ALT-34 AST-110* LD(LDH)-589* AlkPhos-258*
TotBili-19.8*
[**2200-5-5**] 03:26AM BLOOD Calcium-8.5 Phos-7.9* Mg-2.2
.
Abdominal Ultrasound [**2200-4-4**]
IMPRESSION:
1. Patent TIPS shunt. Full assessment with velocities could not
be obtained
due to the patient's breathing difficulties. The left portal
vein is patent
with hepatopetal flow, with a large a patent umbilical vein.
2. No hydronephrosis; however, imaging of the kidneys is very
limited.
3. Small bilateral pleural effusion. No ascites identified.
.
ECHO [**2200-4-7**]
IMPRESSION: Mildly thickened trileaflet aortic valve with
minimal aortic stenosis. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Moderate tricuspid regurgitation. Mild
pulmonary artery systolic hypertension. Dilated ascending
aortal.
.
ECHO [**2200-4-25**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The estimated cardiac index is high (>4.0L/min/m2). Right
ventricular chamber size and free wall motion are normal. There
is mild aortic valve stenosis (valve area 1.2-1.9cm2). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**1-25**]+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
aortic stenosis. Mild to moderate mitral regurgitation. Moderate
tricuspid regurgitation. Mild pulmonary hypertension
.
EEG:
IMPRESSION: This is an abnormal video EEG study due to slowing
and
suppression of the background with GPEDs at approximately 1 Hz.
These
findings are suggestive of severe cortical and subcortical
dysfunction
and may be seen associated with non-convulsive status
epilepticus;
however, there was no evidence of non-convulsive status
epilepticus in
this study.
.
CT HEAD:
There is no evidence of hemorrhage, edema, masses, midline shift
or
infarction. The ventricles and sulci are normal in size and
caliber. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The previously
described
inspissated mucus in the right maxillary sinus is not seen on
the current
study. The paranasal sinuses are clear and well aerated. The
mastoid air
cells are clear bilaterally. No fractures or soft tissue
abnormalities are
detected. IMPRESSION: No acute intracranial process.
.
Abomdinal U/S:
1. Patent TIPS shunt with velocities in a reasonable range.
Three-month
followup is suggested. Flow in the left and right portal veins
is away from
the TIPS shunt. Patent umbilical vein is again noted.
2. Scant trace of ascites, insufficient for marking for
paracentesis.
3. Mild splenomegaly.
4. Gallbladder sludge. No biliary dilatation and no focal liver
lesion.
Brief Hospital Course:
This is a 45 year old female with Hep C cirrhosis, HIV on HAART,
admitted to [**Hospital1 18**] on [**2200-4-3**] with respiratory distress
due to volume overload requiring intubation and oliguric acute
renal failure likely due to hypotension and hepatorenal
syndrome. She had a prolonged hospital course complicated by
seizures likely secondary to her hepatic failure and uremia,
progressive deterioration in her liver and renal function,
coagulopathy, respiratory failure requiring intubation, and
hypotension requiring multiple vasopressor support. Multiple
services were involved in her care including renal for her renal
failure, liver for her hepatic failure, and neurology for her
seizures. Her condition deteriorated with multi-organ failure
and in agreement with the wishes of her family the goal of her
care was transitioned to patient comfort. She expired with her
family at her side. A post-mortem was offered and was declined.
.
Medications on Admission:
HOME MEDICATIONS:
-Amiloride 5mg twice daily
-Sustiva 600mg capsules qhs
-ethycrinic acid 25mg daily
-Lactulose 15ml 3 times a day
-Combivir 150 mg/300 mg twice daily
-Nadolol 40 mg daily
-Potassium chloride 20 mEq tablet daily
-Avelox 400mg daily
.
MEDICATIONS ON TRANSFER:
Albumin 142.5 g IV x1 at 11:20 on [**4-3**]
Albuterol MDI prn
Sustiva 600mg qhs
lactulose 20g Q12
levaquin 750mg Q48 hours
midodrine 10mg po tid
morphine 1-2mg iv q4 hours prn pain
octreotide 50mcg sq tid
vitamin k 10mg sq daily for three days (given on [**4-2**] and [**4-3**])
combivir 300/150 one tab [**Hospital1 **]
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver failure
Acute renal failure
Coagulopathy
hepatic enceaphalopathy
HCV
HIV
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"567.23",
"493.20",
"V08",
"276.2",
"584.5",
"780.39",
"572.3",
"789.59",
"585.9",
"287.5",
"304.23",
"572.4",
"599.0",
"349.82",
"784.3",
"995.92",
"276.1",
"584.9",
"V66.7",
"293.0",
"255.41",
"070.71",
"E936.3",
"785.52",
"486",
"780.01",
"244.9",
"782.4",
"424.1",
"276.6",
"518.81",
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"305.1",
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"041.3",
"V49.83",
"285.21",
"038.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"39.95",
"96.71",
"96.72",
"33.24",
"38.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9223, 9232
|
7598, 8542
|
345, 419
|
9354, 9364
|
3697, 6670
|
9421, 9432
|
2659, 2817
|
9190, 9200
|
9253, 9333
|
8568, 8568
|
9388, 9398
|
2832, 3678
|
8586, 8818
|
285, 307
|
447, 1729
|
6679, 7575
|
8843, 9167
|
1751, 2139
|
2155, 2643
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,339
| 117,002
|
50133
|
Discharge summary
|
report
|
Admission Date: [**2191-4-29**] Discharge Date: [**2191-5-6**]
Date of Birth: [**2114-12-19**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Iodine-Iodine Containing / Demerol /
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cipro Cystitis /
Iron Dextran Complex
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 year old female with h/o laxative abuse and dehydration,
personality disorder, nephrolithiasis with multiple UTI, Crohn's
disease c/b rectovaginal fistula who presents with 3 days of
weakness and poor po intake.
.
She has had multiple admissions in the setting of laxative use
and "inability to have a bowel movement" over the last several
weeks. She was admitted [**3-31**] with rectal pain and there was
concern for laxative abuse. She had profuse diarrhea and a
severe rectal ulcer and patient refused diverting ileostomy. She
refused to give up laxative use as she was "afraid of vomiting
up stool." She then went to [**Hospital1 3278**] [**2191-4-3**] and was treated for UTI
(Ecoli resistent to cipro, otherwise sensitive). She left AMA.
She then represented [**4-4**] with severe perianal rash and had
abdominal CT with focal enteritis without obstruction, bilateral
renal calculi with partial obstruction and ?pyelo. She was
treated with CTX and then left AMA. She was then admitted [**4-6**] to
[**4-7**] due to "inability to have a bowel movement" one morning. She
has been previously fired by the GI service. The public
health/city is also involved at home as reportedly she has stool
all over her house (per the ED).
.
In the ED, initial VS were 98.0 95 109/49 18 98%. EKG normal.
She had regular BMs in ED and was incontinent in the bed. Given
40 mEq PO potassium and given D5NS with 20 mEq K in 1L over 2
hours.
.
Currently, she requests colace, milk of magnesia, one glass of
warm water, and coffee immediately to keep her bowel movements.
She reports have 20-30BM/day in order to "keep from getting
obstructed." During this conversation, she is sitting in a pile
of liquid green stool. She also complains of abdominal pain that
she thinks is due to the potassium she received in the ED. She
states that without colace she will leave AMA. She reports she
came to the hospital due to feeling weak. She was able to eat
breakfast this morning, but just didn't have the appetite to eat
lunch or dinner.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Crohn's disease (s/p colon resection [**2150**] and rectal
stricture dilitation)
- Rectovaginal and intersphincteric fistula ([**10-7**])
- Diabetes Mellitus type 2
- Fibromyalgia
- h/o nephrolithiasis
- h/o rectal abscess
- Personality Disorder
Social History:
(per OMR and patient)
Patient lives alone with 24 hour private care.
Tobacco: quit 20 years ago
ETOH: none
Power of attorney and friend: [**Name (NI) **] [**Name (NI) 104641**] cell phone [**Telephone/Fax (1) 104642**]
Family History:
No family history with IBD. Dad died of pancreatic cancer.
Physical Exam:
GA: AOx3, thin and wasted in appearance
HEENT: PERRLA. dry mucouse membranes, No JVD
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. mild guarding, neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: dry
Rectum: area covered with brown liquid stool, peri-rectal area
erythematous but without deep ulceration
Neuro/Psych: delusional thought processes stating that without
constant laxative use she will become painfully constipated in
seconds, able to articulate that copious diarrhea is bad for her
health, but still requesting laxatives and stating she will
leave the hospital to use them if not given them here, also
fixated upon diet and idea that multiple physicians have taken
poor care of her in the past and that she is better able to care
for her health than they are
.
On Discharge:
97.8, 126/76 (126-154/74-89), 82 (82-92), 18, 100%RA
GENERAL: Cachectic female lying in bed, very concerned and
worried about not being helped
HEENT: EOMI, sclerae anicteric, MMM, OP clear.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
Back: no CVA tenderness
ABDOMEN: soft NT/ND, no HSM
EXTREMITIES: WWP, Patient has edematous hands and feet
bilaterally that are non-pitting, 2+ peripheral pulses.
SKIN: See rectum exam below
Rectum: did not allow me to examine this morning
Neuro/Psych: A&Ox3, CN II-XII intact.
Pertinent Results:
LABS:
CBC/DIF:
[**2191-4-29**] 04:25PM BLOOD WBC-7.9# RBC-3.41* Hgb-9.0* Hct-27.9*
MCV-82 MCH-26.2* MCHC-32.2 RDW-18.1* Plt Ct-501*
[**2191-5-1**] 09:15PM BLOOD WBC-19.7* RBC-2.62* Hgb-7.0* Hct-22.2*
MCV-85 MCH-26.7* MCHC-31.5 RDW-18.4* Plt Ct-395
[**2191-5-6**] 05:45AM BLOOD WBC-6.5 RBC-3.80* Hgb-10.6* Hct-33.6*
MCV-88 MCH-27.7 MCHC-31.4 RDW-19.1* Plt Ct-434
[**2191-5-1**] 09:15PM BLOOD Neuts-67 Bands-20* Lymphs-5* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2*
.
COAGS:
[**2191-4-30**] 12:50PM BLOOD PT-12.7 PTT-24.7 INR(PT)-1.1
[**2191-5-1**] 09:15PM BLOOD PT-14.5* PTT-27.3 INR(PT)-1.3*
.
CMP
[**2191-4-29**] 04:25PM BLOOD Glucose-121* UreaN-54* Creat-1.5* Na-134
K-3.2* Cl-93* HCO3-29 AnGap-15
[**2191-5-6**] 05:45AM BLOOD Glucose-70 UreaN-16 Creat-1.0 Na-143
K-3.9 Cl-117* HCO3-16* AnGap-14
[**2191-4-30**] 12:50PM BLOOD Albumin-2.4* Calcium-5.7* Phos-2.1*#
Mg-1.8
[**2191-5-6**] 05:45AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.4*
.
MiSC:
[**2191-5-3**] 05:40AM BLOOD calTIBC-159* Ferritn-266* TRF-122*
[**2191-5-1**] 09:15PM BLOOD TSH-1.3
[**2191-5-6**] 05:45AM BLOOD CRP-25.5*
#
#
#
################################################################
MICRO:
URINE CULTURE (Final [**2191-5-3**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
STOOL CULTURE: Negative
MRSA SCREEN: NEGATIVE
BLOOD CULTURE: NEGATIVE
BLOOD CULTURE: PENDING ([**2191-5-2**])
#######################################################
IMAGING:
ABD(upright and supine) [**2191-4-30**]:
There is extensive amount of content noted in the left upper
quadrant that
might be in the stomach or potentially in the left colon. There
is no
evidence of bowel loop obstruction or free air. No pathologic
air-fluid
levels were noted.
Staghorn calculus on the right and known left kidney calculus
are
redemonstrated.
.
CXR [**2191-5-1**]:
Mild pulmonary vascular engorgement is new. Lung volumes are
lower, compared to [**4-6**], but there is no focal consolidation
to suggest pneumonia. Mild interstitial pulmonary edema is new.
Pleural effusion is minimal if any. The heart is normal but
increased since [**4-6**]
.
RENAL U/S:
1. Similar large right staghorn calculus, resulting in mild
right
hydronephrosis.
2. Multiple tiny non-obstructive left renal calculi. No left
hydroureteronephrosis.
Brief Hospital Course:
A/P:
76 year old female with h/o laxative abuse and dehydration,
personality disorder, nephrolithiasis with multiple UTI, Crohn's
disease c/b rectovaginal fistula who presents with 3 days of
weakness and poor po intake found to be in acute renal failure
and hypokalemic
.
# Hypotension/Sepsis: Patient developed fever and hypotension
and was transferred to the MICU. She was started empirically on
Vanco/Cefepime given her history of recurrent UTIs, including
enterococcus and enterobacter and E. Coli. She had a positive
U/A and it was suspected that her known staghorn calculus was a
nidus of infection. The patient's blood pressure improved with
IVF boluses and antibiotics. She was stable to be transferred
back to the floor the following day. Eventually, her urine grew
out E. coli that was resistent to ciprofloxacin and renal U/S
was performed which revealed mild right hydropephrosis, right
staghorn calculus as well as small non-obstructing stones in the
left kidney. She was initially placed on ceftriaxone, but later
switched to cefpodoxime since patient refused IV antibiotics and
did not want a PICC line to be placed. She received a 7 day
course of Abx.
.
#. Diarrhea: Initially thought to be most likely related to
heavy use of laxatives and many stools at home, however, it
persisted after cessation of laxatives and concern for crohn's
flare. Dehydration from this problem and K loss in stool likely
causes of acute renal failure and hypokalemia. She was
constantly stooling on the floor and was in the ED, yet still
insisting to have laxatives. Pt found to have multiple bottles
of laxatives in her belongings at bedside. No real abdominal
pain to suggest flaring of her IBD. All laxatives were held and
stools sent for culture and c diff toxin. Laxative screen
ordered. Pt started on IVF to replace fluid loss and lytes were
repleted. Pt was not allowed to leave AMA as wanted to pursue
damaging behavior. Her diarrhea persisted and in spite of
holding all laxatives and ruling out for infectious process her
diarrhea persisted. She was on mesalamine during her hospital
stay, but there was concern for crohn's flare. Dr. [**Last Name (STitle) **] spoke
with the patient about different treatment options, but patient
refused any additional work-up give her history of Crohn's
disease. Also, given issues with non-compliance would be
hesitant about initiating treatment with immunosuppresants. We
discussed this with her at length, but it was ultimately decided
that she could be discharged with GI follow up in clinic.
.
# Psych: History of possible personality disorder. At this time
pt with delusions regarding need to take laxatives and delusions
leading her to self damaging behavior. Placement likely to be
needed as pt unable to care for self properly at home but
question if needs placement in a psych facility due to psych
issues. She was seen by psychiatry who felt that she was
acutely delirious, but as she improved they deemed her competent
to make her own decisions. She spoke with her HCP often, but
made decisions about her own care. She was started on zyprexa
2.5mg with PRN for increasing episodes of agitation. This
seemed to work well with relation to her delirium.
.
#. Acute renal failure: Likely related to volume depletion in
the setting of profound diarrhea. However, also had concerning
history of pyelo in the past with inadequate treatment courses
due to leaving hospital AMA. On admission had no CVA pain
although reported dysuria. UA not overwhelming for infection.
Urine culture showed E. Coli resistent to cipro. Urine lytes
showed indeterminate etiology. Kept on IVF and Cr trended down
re-inforcing diagnosis of pre-renal etiology. At the time of
discharge her creatinine was 1.0.
.
#. Hypokalemia: Most likely related to ongoing diarrhea.
Received KCL overnight. Laxatives held and pt monitored on tele
overnight. Her potassium remained stable and required minimal
repletion.
.
# Hypomagnesemia: Was 1.4 the day prior to and the day of
admission. She was refusing repletion and so was discharged
with a magnesium of 1.4.
.
#. H/o possible Pylonephritis: Has chronic staghorn calculi on
recent CT and recent treated with course of cefpodoxime. Urine
sent for culture and fever curve monitored. She had minimal
hydronephrosis and was not interested in a perc nephrostomy tube
even if she qualified for one. She was set up with an
outpatient Urology appointment for further management.
.
#. Crohn's Disease: Has refused ileostomy in the past and
doesn't take her mesalamine at home. Pt reports not taking home
mesalamine but was given on prior admissions and given during
this admission. [**Month (only) 116**] be having a crohns flare, but difficult to
manage as described above.
.
#. Rectal Breakdown: Refused to let some personelle examine the
site and had history of refusing treatment but agreed to wound
care evaluation at her last hospitalization. Wound care consult
was obtained and made recommendations, however, she would often
refuse to let nurses clean the site nor would she allow
phsyicians to monitor it daily.
.
#. Thrombocytosis: Likely reactive. Improved from previous
baseline.
.
#. Non-anion gap acidosis: Patient with persistent non-anion gap
acidosis. Likely secondary to ongoing diarrhea (as above).
TRANSITIONAL ISSUES:
Ongoing Diarrhea
Medications on Admission:
1. [**Last Name (un) **]-Max 500 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. mesalamine 250 mg Capsule, Extended Release Sig: Four (4)
Capsule, Extended Release PO QID (4 times a day).
3. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 10 days.
4. temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for insomnia.
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: One (1)
tablet, Chewable PO twice a day.
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
11. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety, sleep.
12. Zinc-220 220 (50) mg Capsule Sig: One (1) Capsule PO once a
day.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: HOLD FOR LOOSE STOOL.
Discharge Medications:
1. mesalamine 800 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO three times a day.
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
3. temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for insomnia.
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
10. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO DAILY (Daily).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
11. clonazepam 1 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)) as needed for anxiety.
12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5-1 Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
13. Zinc-220 220 (50) mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Failure to thrive
.
Secondary Diagnosis:
Crohn's disease (s/p colon resection [**2150**] and rectal stricture
dilitation)
Rectovaginal and intersphincteric fistula ([**10-7**])
Diabetes Mellitus type 2
H/o nephrolithiasis
Personality Disorder
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Bedbound.
Discharge Instructions:
You are being discharged from [**Hospital1 **]. You were admitted for weakness, poor food intake and
diarrhea. We stopped your laxatives and you continued to have
diarrhea. We think it is because of a crohn's flare. You were
started on mesalamine and your diarrhea continued. We think
that you should see a gastroenterologist for management of your
diarrhea and crohns as they may have some recommendations for
further treatment. we also found that you have a urinary tract
infection and are treating you for 8 days. You received 4 days
while here in the hospital and will receive 4 more days at home.
.
The following medication was STARTED:
mesalamine 1600mg by mouth every 8 hours
cefpodoxime 2gm by mouth for 4 more days (last dose [**2191-5-10**])
.
PLEASE STOP TAKING ALL LAXATIVES. YOU ARE HAVING MANY BOWEL
MOVEMENTS WITHOUT THEM AND IT IS NOT NECESSARY TO TAKE.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Location: [**Hospital **] MEDICAL CENTER
Address: [**State 11413**], [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 12802**]
Appointment: Friday [**2191-5-20**] 11:45am
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2191-5-18**] at 4:00 PM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"783.7",
"592.0",
"590.80",
"238.71",
"038.9",
"301.50",
"276.8",
"V49.86",
"301.22",
"555.1",
"276.51",
"569.41",
"995.91",
"275.41",
"275.2",
"305.91",
"584.9",
"275.3",
"276.2",
"250.00",
"787.91",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15719, 15777
|
7833, 13128
|
413, 419
|
16083, 16130
|
4698, 7810
|
17122, 17737
|
3186, 3247
|
14328, 15696
|
15798, 15798
|
13193, 14305
|
16220, 17099
|
3262, 4099
|
4113, 4679
|
13149, 13167
|
365, 375
|
447, 2661
|
15858, 16062
|
15817, 15837
|
16145, 16196
|
2683, 2933
|
2949, 3170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,863
| 141,130
|
35332
|
Discharge summary
|
report
|
Admission Date: [**2157-12-20**] Discharge Date: [**2158-1-5**]
Date of Birth: [**2107-10-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Transfer from OSH ([**Hospital3 **]) for evaluation of LLL
sleeve dehiscence
Major Surgical or Invasive Procedure:
1. Completion left pneumonectomy; tracheostomy tube change
2. Flexible bronchoscopy, BAL, tracheostomy tube change
History of Present Illness:
50M with reported "Stage II Lung CA" s/p lung resection with LLL
sleeve on [**2157-11-24**] at [**Hospital3 **] by Dr.[**Doctor Last Name **]. Patient
ventilator dependent immediately post-op. Underwent several
brochoscopies for mucous plugging. On [**12-10**] Bronchoscopy, staff
noted that LLL sleeve site seemed concerning for
dehiscence/tissue friability. Further bronchoscopies showed
worsening progression. He was transferred to [**Hospital1 18**] for further
management.
Past Medical History:
COPD, HTN, Anxiety
Social History:
Lives with cousin, good social support, social drinker,
ex-smoker (35 pack year hx), used to smoke pot
Family History:
Mother's side significant for lung CA, breast and uterine
CA, Father's side has CAD, no reported CA
Physical Exam:
VS: 98.9 60 105/50 16 91% on CPAP 25% PSV 12 PEEP 5
Gen: NAD, A+Ox3, supine on bed, tracheostomy in place
HEENT: EOMI, PERRL, trachostomy intact, no erythema, no LAD felt
CV: RRR, 2+ radial and DP pulses
Resp: expiratory wheezes right lung, little breath sounds on
left lung
prolonged expiratory phase
Abd: Soft, NT/ND, G-tube in place, no erythema
Ext: significant for clubbing, left shoulder staples c/d/i,
underlying "edema"/bulge is muscle not fluid
Pertinent Results:
[**2157-12-20**] 09:37PM BLOOD WBC-7.0 RBC-4.14* Hgb-11.8* Hct-34.1*
MCV-82 MCH-28.6 MCHC-34.7 RDW-18.1* Plt Ct-231
[**2157-12-24**] 02:07AM BLOOD WBC-21.4* RBC-3.87* Hgb-10.9* Hct-32.4*
MCV-84 MCH-28.1 MCHC-33.5 RDW-18.4* Plt Ct-212
[**2157-12-28**] 03:13AM BLOOD WBC-2.0* RBC-3.27* Hgb-9.0* Hct-27.8*
MCV-85 MCH-27.5 MCHC-32.4 RDW-17.4* Plt Ct-218
[**2158-1-1**] 02:55AM BLOOD WBC-11.8* RBC-3.08* Hgb-8.5* Hct-26.3*
MCV-86 MCH-27.8 MCHC-32.5 RDW-18.0* Plt Ct-268
[**2158-1-4**] 03:23AM BLOOD WBC-5.2 RBC-2.98* Hgb-8.6* Hct-24.9*
MCV-84 MCH-29.0 MCHC-34.7 RDW-19.1* Plt Ct-267
[**2158-1-1**] 02:55AM BLOOD PT-13.7* PTT-32.8 INR(PT)-1.2*
[**2158-1-1**] 02:55AM BLOOD Plt Ct-268
[**2157-12-20**] 09:37PM BLOOD Glucose-106* UreaN-12 Creat-0.4* Na-135
K-3.9 Cl-95* HCO3-34* AnGap-10
[**2157-12-24**] 02:07AM BLOOD Glucose-124* UreaN-15 Creat-0.4* Na-132*
K-4.3 Cl-94* HCO3-32 AnGap-10
[**2157-12-28**] 03:13AM BLOOD Glucose-123* UreaN-10 Creat-0.2* Na-135
K-4.0 Cl-92* HCO3-42* AnGap-5*
[**2158-1-1**] 02:55AM BLOOD Glucose-113* UreaN-14 Creat-0.3* Na-135
K-4.2 Cl-98 HCO3-35* AnGap-6*
[**2158-1-3**] 02:52AM BLOOD Glucose-114* UreaN-12 Creat-0.3* Na-137
K-4.4 Cl-97 HCO3-39* AnGap-5*
[**2157-12-22**] 02:07PM BLOOD ALT-29 AST-18 LD(LDH)-213 AlkPhos-93
Amylase-31 TotBili-0.9
[**2157-12-28**] 03:13AM BLOOD calTIBC-134* VitB12-766 Folate-6.8
Ferritn-863* TRF-103*
[**2158-1-2**] 02:50AM BLOOD calTIBC-182* Ferritn-592* TRF-140*
[**2157-12-23**] 09:45PM BLOOD Type-ART pO2-75* pCO2-54* pH-7.38
calTCO2-33* Base XS-4
[**2157-12-25**] 07:02AM BLOOD Type-ART pO2-104 pCO2-76* pH-7.28*
calTCO2-37* Base XS-5
[**2157-12-25**] 03:06PM BLOOD Type-ART Rates-/20 Tidal V-300 PEEP-5
FiO2-98 pO2-93 pCO2-71* pH-7.34* calTCO2-40* Base XS-8 AADO2-560
REQ O2-89 Intubat-INTUBATED Vent-SPONTANEOU Comment-CPAP 50% 1
[**2157-12-26**] 04:56PM BLOOD Type-ART Temp-37.4 PEEP-5 FiO2-35 pO2-73*
pCO2-67* pH-7.38 calTCO2-41* Base XS-10 Intubat-INTUBATED
[**2157-12-29**] 04:46AM BLOOD Type-ART Rates-/21 Tidal V-358 PEEP-5
FiO2-35 pO2-82* pCO2-66* pH-7.46* calTCO2-48* Base XS-18
Intubat-INTUBATED Vent-SPONTANEOU
[**2157-12-31**] 02:08AM BLOOD Type-ART pO2-139* pCO2-68* pH-7.33*
calTCO2-37* Base XS-7
[**2158-1-3**] 11:02AM BLOOD Type-ART pO2-56* pCO2-64* pH-7.40
calTCO2-41* Base XS-11
[**1-4**] ABG on discharge on following settings: CPAP 25%, PSV 12,
PEEP 5, with sats in 91-97%:
pH 7.44
pCO2 57
pO2 97
HCO3 40
BaseXS 11
[**12-21**] CT Airway: IMPRESSION:
1. Status post left lower lobectomy with severe narrowing of the
proximal
left main stem bronchus and distal complete obliteration as it
traverses the mediastinum. Correlation with bronchoscopy
recommended. 2. While evaluation of the operative bed is limited
without contrast, there is likely left hilar lymphadenopathy. 3.
Left upper lobe nodular peribronchial and septal thickening is
worrisome for lymphangitic spread of carcinoma. 4. 12 mm right
lower lobe solid nodule could represent a neoplastic deposit. 5.
Diffuse bilateral centrilobular ground- glass opacities and
multifocal consolidation could represent diffuse infection.
6. Moderate left pleural and small pericardial effusion. 7.
Slight comminution to posterolateral left fifth rib fracture is
in an appropriate location for postsurgical changes, but
correlation with surgical history is needed to exclude a
metastatic focus. 8. Linear densities around the tracheostomy
may represent secretions, though disruption of the tracheostomy
tube cannot be excluded.
[**12-22**] CXR S/p pneumonectomy IMPRESSION
Left pneumonectomy space is almost completely air filled with
only a small
amount of fluid. Cardiomediastinal contours are shifted towards
the left.
Left subclavian catheter terminates in superior vena cava and
tracheostomy
tube terminates in expected location of trachea. Within the
right hemithorax, a new band-like opacity has developed in the
right mid lung region, probably due to a combination of
atelectasis and intrafissural fluid. Subcutaneous emphysema is
present in the left chest wall. Larger gas collection is noted
in the lower left chest wall adjacent to an indwelling
left-sided chest tube.
[**1-4**] CXR (discharge CXR):
no evident change in the appearance of the left thorax status
post pneumonectomy with minimal residual air overlying the left
apex. Left PICC and tracheostomy tube are in expected and
unaltered positions. Right lung is unchanged with minimal
basilar atelectasis.
MICRO:
[**12-21**] Sputum: contaminant
[**12-21**] BAL: Klebsiella ([**Last Name (un) 36**] [**Last Name (un) 2830**], gent, bactrim)
[**12-22**] BAL: 2+ GPC, GNR sparse growth
[**12-22**] Pleural fluid: nothing on GS, NGTD
[**12-22**] Intercostal muscle flap: Klebsiella ([**Last Name (un) 36**] [**Last Name (un) 2830**], gent,
bactrim)
[**12-26**] Sputum: no growth final
[**12-26**] UCx: no growth final
[**12-26**] MRSA: negative
[**12-26**] CMV: negative
[**12-26**] RSV negative
[**12-26**] BCx: No growth final
[**1-2**] MRSA negative
Findings: Bronchial stump from previous operation was completely
dehisced. Chest was irrigated thoroughly with Betadiene,
Bacitracin, copious amounts of irrigation. Intercostal muscle
flap was used to cover the bronchial stump and fibrin glue was
used to cover all stumps (bronchial, PA, pulm vein). Did not
require any blood intraop
New bronchial resection margin was sent to pathology
.
PATH ([**12-22**])
L 5th Rib: No carcinoma seen
Completion Pneumonectomy: No carcinoma seen
New Bronchial Margin: No carcinoma seen
Brief Hospital Course:
The patient was admitted to the thoracic surgery service on
[**2157-12-20**] and had a completion left pneumonectomy and tracheostomy
tube change on [**2157-12-22**]. The patient tolerated the procedure well
and was transferred to the surgical ICU for further management.
Neuro: Post-operatively, the patient received a
hydromorphone/bupivacaine epidural with good effect and adequate
pain control. On POD#1 the patient was given enteric tube feeds
via G tube. On POD#3, the epidural was discontinued and the
patient was started on hydromorphone IV. The patient was
subsequently transitioned to oral pain medications on POD#12.
CV: A phenylephrine drip was initiated due to hypotension
experienced in POD#0. It was titrated to maintain a MAP>60. Once
the patient was weaned off the pressor, metoprolol was given to
control his heart rate. The patient was otherwise stable from a
cardiovascular standpoint; vital signs were routinely monitored
as per ICU protocols.
Pulmonary: Postoperatively, the patient was transferred to the
ICU from the PACU. Intraoperative findings included a bronchial
stump from a previous operation that was completely dehisced. An
intercostal muscle flap was used to cover the bronchial stump
and fibrin glue was used to cover all stumps (bronchial, PA,
pulm vein). A chest tube was inserted into the left chest and
put to water seal. A follow-up CXR showed postoperative changes:
Left pneumonectomy space almost completely air filled;
cardiomediastinal contours are shifted towards the left. On
POD#2 the chest tube was removed. Follow-up chest xray showed no
acute changes. On POD#3; the tracheostomy tube was changed due
to a cuff leak. On POD#7, the patient had an acute episode of
respiratory distress leading to an 02 desaturation into the 70s
during physical therapy. His respiratory secretions were
immediately suctioned and the Fi02 settings were increased to
100%. Chest XRay showed atelectasis vs aspiration pneumonitis.
Also on POD#7, the patient developed another air leak around his
trach. The Interventional Pulm service performed a flexible
bronchoscopy and changed the patient's tracheostomy tube ([**Last Name (un) 295**]
#8). The patient has been doing well since the last trach tube
change. The patient continues to be weaned from the ventilator.
His settings before D/C to rehab is CPAP 25% FiO2, PSV 12 PEEP 5
with sats in thhe 90-95%.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating PEG tube feeds. The patient's diet was advanced when
appropriate, which was tolerated well. The patient has a foley
to accurately monitor urine output while in the ICU setting.
Intake and output were closely monitored as per ICU protocol.
The patient received diuretic therapy as needed.
Heme: On admission, the patient's WBC was 7.0. On POD#4, a CBC
revealed a WBC of 1.7; with 43% neutrophils and 1% bands. The
granulocyte count was 790. Over the ensuing two days, the
patient's WBC remained at 2.0. The decision was made to start
the patient on filgastrim. The patient responded to the
filgrastrim therapy and at the time of discharge his WBC is near
his baseline level.
ID: During the hospital course, the patient had the following
positive cultures: [**12-21**] bronchoalveolar lavage postive for
Klebsiella (sensitive to meropenem); [**12-22**] bronchoalveolar lavage
with 2+ gram positive cocci on gram stain and gram negative rods
(rare growth) in culture; [**12-22**] intercostal muscle flap culture
that grew Klebsiella (sensitive to meropenem). The patient was
given two-week courses of meropenem and vancomycin for the
infections. To date no other microbiologic specimen have been
positive for microbes.
Prophylaxis: The patient was ordered for sequential compression
devices and subcutaneous heparin for DVT prophylaxis. He was
given PPI therapy for gastric ulcer prophylaxis. The patient was
also encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a diet via tube feeds, and
pain was well controlled.
Medications on Admission:
Proventil 2 puffs QID PRN, Advair 500/50 [**Hospital1 **], Spiriva 1 puff,
Lisinopril 5 mg PO qD
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*qsuff qsuff* Refills:*2*
4. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qsuff qsuff* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q2H (every 2 hours) as needed.
Disp:*qsuff qsuff* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*500 ML(s)* Refills:*0*
7. Lorazepam 0.5 mg IV Q6H:PRN
8. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day:
Crushed and via G-Tube. Capsule(s)
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day:
crushed via G-Tube. Tablet(s)
10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day): Crushed via G-Tube.
Disp:*60 Tablet(s)* Refills:*2*
11. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1)
Intravenous Q 8H (Every 8 Hours) for 2 days.
13. Meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 1 days.
Disp:*4 Recon Soln(s)* Refills:*0*
14. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day:
crushed via G-tube.
Discharge Disposition:
Extended Care
Facility:
Radius
Discharge Diagnosis:
Left bronchial anastomotic dehiscence with mediastinitis and
pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office at ([**Telephone/Fax (1) 1504**] if you
experience:
-Fever >101 or chills
-Increased cough, shortness of breath or sputum production
-Chest pain
-Difficulties breathing
-Incision develops drainage
-You may sponge bathe the first day. Afterwards you may shower.
No bathing/soaking/swimming for 6 weeks after the operation
-No driving while taking any form of narcotics.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call his
office at ([**Telephone/Fax (1) 1504**] to schedule an appointment.
Completed by:[**2158-1-5**]
|
[
"496",
"486",
"997.39",
"288.00",
"519.09",
"401.9",
"519.2",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.6",
"33.24",
"32.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13318, 13351
|
7299, 11385
|
398, 515
|
13466, 13475
|
1796, 7276
|
13928, 14099
|
1204, 1306
|
11532, 13295
|
13372, 13445
|
11411, 11509
|
13499, 13905
|
1321, 1777
|
282, 360
|
543, 1025
|
1047, 1067
|
1083, 1188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,944
| 128,911
|
22535
|
Discharge summary
|
report
|
Admission Date: [**2151-8-11**] Discharge Date: [**2151-9-9**]
Date of Birth: [**2085-7-1**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
anorexia, weight loss for 1 year, recurrent cholangitis with
history of bile duct injury.
Major Surgical or Invasive Procedure:
exploratory laparotomy, extensive adhesionolysis, open
cholecystectomy, central bile duct excision, roux-en-y
hepatoicojejunostomy, feeding J tube placement
History of Present Illness:
66-year-old gentleman has suffered from polio all of his life
and has significant scoliosis. More importantly, however, he
suffered a traumatic injury to the right upper quadrant from a
motor vehicle accident 30 years ago. The specifics of that
operation were available to me from his original surgeon, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58489**], at [**Hospital3 **] Hospital. At that time, Mr. [**Known lastname **]
had a significant right upper quadrant dissociation that
involved a duodenal laceration, a hepatic laceration, and a
complete transection of the common
bile duct. His portal vein and hepatic artery remained intact.
In the process of that operation, he coded on the table, and a
salvage drainage procedure for his biliary system was performed.
This consisted of a cholecystoenterostomy with a downstream
enteroenterostomy (omega loop).
Mr. [**Known lastname **] has done well through the years, but this summer
presented with fatigue, malaise, and evidence of active
cholangitis. He was quite ill and recovered from this, but
required a tracheostomy, as well as bilateral percutaneous
transhepatic drainage tubes. He was subsequently transferred
to the [**Hospital1 18**] in the middle of the summer for definitive
management of his biliary problem. It was found, at that point,
that he had evidence of high strictures in the hilum of the
common hepatic duct at the takeoff of each of the
right and left sides. Furthermore, it was unclear if there was
downstream strictures of his biliary drainage conduits, because
there was extreme distortion and dilation of all its components
including the bowel.
After extensive investigations and preparation in our system
over a 2 month period, it was decided to definitively operate on
Mr. [**Known lastname **]. He had multiple attacks of cholangitis and this
persisted even with the tube drainage on a couple of occasions.
We were unable to provide better nutrition
through TPN or tube feeds, in that his insurance company would
not allow for this approach. Therefore, for a 2 month period,
we had to rely on his own oral intake to gain back weight for
this chronically malnourished gentleman.
Finally, we were ready to proceed, and on [**8-13**], we went
to the operating room with the intention of an exploration of
the right upper quadrant and definitive resection of the
gallbladder, common bile duct, and repair
with a Roux-en-Y hepaticoenterostomy.
Past Medical History:
1. Motor vehicle accident in [**2116**] with hepatic laceration,
biliary tree disruption and pancreatitis
2. status post thoraco-abdominal repair of an extensive liver
laceration and he had a repair of the lacerated duodenum with
debridement of his pancreas and drainage and a
cholecystojejunostomy with a jejunojejunostomy in [**2116**].
3. history of right leg fracture
4. polio at age seven with initial total paralysis, iron lung,
quadraparesis
5. Recurrent cholangitis
6. T2-T9 fusion
7. Chronic malnutrition
8. scoliosis
Social History:
Lives with wife, non [**Name2 (NI) 1818**], non drinker
Family History:
non contributory
Physical Exam:
General: emaciated male in no apparent distress
Head and Neck: pupils were equally round and reactive to light.
Extraocular muscles and movements were intact.
Lungs: Breath sounds were noted to be decreased at the right
base.
Cardiovascular: normal S1 and S2, regular rate and rhythm
without murmurs, rubs or gallops.
Abdominal examination: positive bowel sounds. Soft, nontender
Musculoskeletal examination: within normal limits.
Neurologically intact throughout.
Pertinent Results:
1. Gallbladder (A-B):
a. Chronic active cholecystitis.
b. Small intestinal mucosa at opened end, with chronic
inflammation.
c. No tumor.
2. Bile duct (C-F):
a. Chronic active cholangitis, with fibrosis, diffuse.
b. No tumor.
3. Jejunal loop (G-N):
Segment of small intestine, within normal limits.
[**2151-8-20**]: Small bowel follow through:
IMPRESSION: High-grade partial small bowel obstruction affecting
the proximal jejunum. This is likely caused by the percutaneous
J-tube or an adhesion.
[**2151-8-20**]: T tube cholangiogram:
1. Patent outflow from the intrahepatic ducts with rapid
drainage into the
anastomosis and through the anastomosed small bowel loop.
2. Position of the sidehole of the left-sided biliary drain
under the skin
with leakage into the dressing. Removal of this tube since it
now does
not have any more function, and the junction between the liver
and anastomosed small bowel is widely patent.
CT Abdomen [**2151-8-27**]:
IMPRESSION:
1) Compared to the pre-operative CT exam of [**2151-7-15**], there is a
new intraperitoneal air/fluid collection in the prior location
of segments 8 and 4A of the liver. This raises concern for liver
necrosis in this region. Given the disproportionate amount of
air within this collection, and the proximity of the collection
to the adjacent air- filled bile ducts there is concern for
communication between the intrahepatic ducts and the collection.
A nuclear HIDA scan could be helpful in demonstrating
communication with the biliary tree.
2) Markedly dilated Roux limb, as described above, consistent
with an obstruction at the level of a surgical anastomosis.
3) New bilateral pleural effusions with adjacent bibasilar
consolidations. Please correlate clinically, as these findings
could represent pneumonias
Bilateral upper and lower extremity ultrasounds [**2151-8-22**]:
IMPRESSION: No deep venous thrombosis within the right common
femoral, superficial femoral, deep femoral, or popliteal veins.
IMPRESSION: No deep venous thrombosis in the right jugular,
subclavian, axillary, brachial, and basilic veins.
Upper GI [**2151-8-30**]:
IMPRESSION: Markedly distended loop of proximal small bowel,
including duodenum, and possibly a portion of proximal jejunum.
A small amount of contrast passage to normal appearing small
bowel is seen distally. There is no opacification of the
afferent loop. These findings are indicative of functional or
partial small bowel obstruction, possibly located at the
jejunojejunostomy site.
Discharge labs:
WBC-7.3 RBC-3.09* Hgb-9.6* Hct-29.6* MCV-96 MCH-31.2 MCHC-32.5
RDW-15.1 Plt Ct-314
Glucose-83 UreaN-23* Creat-0.4* Na-141 K-4.0 Cl-98 HCO3-40*
AnGap-7*
ALT-19 AST-27 AlkPhos-257* TotBili-0.3
Lipase-42
Calcium-8.9 Phos-1.9* Mg-2.0
Brief Hospital Course:
The patient was admitted ot the surgical intensive care unit
after the surgical procedure. Refer to surgical dictation for
full details. The patietn tolerated the procedure well, had an
estimated blood loss of 1400 cc and received 1875 in packed red
blood cells as well as 642 cc of Fresh frozen plasma. The
patient was maintained on a ventilator on post operative day 1
and was receiveing unasyn. His post operative hematocrit was
29.9, and the remainder of his laboratory evaluation was within
normal limits. Drainage from his two JP tubes as well as his T
tubes were recorded.
The patient required a 1 liter fluid bolus on post operative day
1 for decreased blood pressure. His ventilator was weaned on
post operative day 1. On postoperative day 2 the patients
perioperative antibiotics were scheduled to be stopped and half
strength tube feeds were begun. These were subsequently
advanced toward goal on post operative day 3. Diuresis was
begun to aid in vent weaning, and a spontaneous breathing trial
resulted in tachypnia and shallow breaths. Nutrition services
was consulted given the patients chronically malnourished state.
The patient was transitioned to trach collar during the day and
ventilator at night by post operative day 4, and then was
transitioned to trach mask. His NG tube was discontinued on
post operative day 5. The patient was also evaluated by
physical therapy at this point to help in recovering function in
his deconditioned state.
By post operative day 6 the patient was doing well and was
transferred to the floor. On post opeartative day 7 the patient
developed repeated vomiting followed by unresponsiveness. The
patient was gien phenergan and morphine during this time period.
When the patient was unresponsive, the patient continued to
have oxygen saturation in 97% with one transient decrease to
87-90%. The patient was placed on a vent mask, and received
narcan, and awoke and followed commands. The patient was
subsequently transfered back to SICU, an NG tube was placed and
the Tube feeds were stopped. He was placed back on the
ventilator and was started on levofloxacin and flagyl for
pneumonia. The patient spiked a fever on Post operative day 7
to 101.6 and was pan cultured for this. The patient also had
some low blood pressure and tachycardia and was bolused with IV
fluid. TPN was started on the patient as the tube feeds
continued to be held. The patient received aggressive pulmonary
toilet and received further fluid boluse on post operative day 8
for decreased urine output. A small bowel follow through
demonstrated partial small bowel obstruction. The left PTC was
pulled and tube feeds wer restarted on post operative day 9.
The ventilator was weaned on post operative days 9 and 10,
however the pressure support was eventually increased secondary
to low tidal volumes and increased respiratory rate. The
patient was passing flatus at this point. The PTC was
discontinued on post operative day 12, Tube feeds were advanced,
and TPN was stopped. He failed a NG tube clamping trial on post
operative day 13 secondary to high residuals. The patient was
transfused one unit of packed red blood cells for a low
hematocrit on post op day 14. He also required further fluid
bolus for low blood pressure. He was weaned from the vent
however and tolerated trach mask for 12 hours. The trach was
changed on post op day 16. He continued to be on antibiotics at
this point for a total 14 day course. By post operative day 17
the patient had tolerated better than 24 hours of continuous
trach mask trials.
The patient was transferred to the floor on post operative day
19 with a continued nasogastric tube in place. The patient was
having loose stools at this point but continued to have high NG
residuals and the possibility of and Afferent loop syndrome or
proximal stricture were entertained, given a dilated roux limb
on imaging and a question of narrowing at the J j Junction. The
patient had an endoscopy on [**8-31**]. There was a question
of a stricture in one of the jejunal limbs but it could not be
dilated. a repeat EGD on the 13th demonstrated no signs of
obstruction in either limb. His NG tube was removed by post
operative day 21. He was was recovering well and by post
operative day 21 the patient was ambulating around the halls,
had good pain control. He was kept NPO and continued to get his
tube feeds via a J tube. He continued to pass flatus and stool.
The patient was given sips of clears on post op day 23. The
patient was advanced to clears on Post operative day 24 and his
diet was subsequently advanced. Tube feeds were decreased and
set up to be run only at night. Case management reviewed the
case and plans were made for discharge with home services. He
was doing well and was discharged on [**8-11**] in stable
condition.
Medications on Admission:
protonix, cipro, flagyl
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours.
Disp:*100 Tablet(s)* Refills:*0*
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
-Severe malnutrition
-Hypotension/hypovolemia requiring fluid bolus
-Blood loss anemia requiring transfusion
-aspiration pnuemonia
-ventilatory failure
-Small bowel obstruction/ileus
-post operative fever
-status post exploratory laparotomy, extensive adhesionolysis,
open cholecystectomy, central bile duct excision, roux-en-y
hepatoicojejunostomy, feeding J tube placement
-Motor vehicle accident in [**2116**] with hepatic laceration,
biliary tree disruption and pancreatitis
-status post thoraco-abdominal repair of an extensive liver
laceration and he had a repair of the lacerated duodenum with
debridement of his pancreas and drainage and a
cholecystojejunostomy with a jejunojejunostomy in [**2116**].
-history of right leg fracture
-polio at age seven with initial total paralysis, iron lung,
quadraparesis
-Recurrent cholangitis
-T2-T9 fusion
Discharge Condition:
good
Discharge Instructions:
Maximize food intake.
Followup Instructions:
Patient to call and make appointment to be seen by Dr. [**Last Name (STitle) **]
|
[
"507.0",
"575.8",
"263.9",
"576.2",
"537.0",
"998.11",
"311",
"458.29",
"E929.0",
"E878.8",
"564.00",
"V44.0",
"908.1",
"575.11",
"V12.02",
"571.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.55",
"38.91",
"99.15",
"96.6",
"96.72",
"87.54",
"45.13",
"51.69",
"99.04",
"51.22",
"38.93",
"54.59",
"46.39",
"51.37"
] |
icd9pcs
|
[
[
[]
]
] |
12297, 12356
|
7001, 11844
|
421, 580
|
13253, 13259
|
4230, 6731
|
13329, 13413
|
3711, 3729
|
11918, 12274
|
12377, 13232
|
11870, 11895
|
13283, 13306
|
6747, 6978
|
3744, 4211
|
292, 383
|
608, 3070
|
3092, 3622
|
3638, 3695
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,342
| 171,013
|
55158
|
Discharge summary
|
report
|
Admission Date: [**2168-7-7**] Discharge Date: [**2168-7-19**]
Date of Birth: [**2099-11-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
S/P cardiac arrest
Major Surgical or Invasive Procedure:
Lung biopsy [**2168-7-18**]
History of Present Illness:
68 YOM with unknonw PMH found at the back of loading truck for
unknown amount of time by friends. AED placed and shock
indicated. NO rhythm strip. Had agonal breaths. EMS Arrived. No
more shocks aDVISED. ems SAID "BIZZARE WIDE COMPLEX" and
tachycardic. Went to OSH ([**Hospital1 2436**]) intubated and coold.
Continued to have wide complex tachy. Got ami x2 with amio gtt.
Life flight arrived and he was in NSR with LBBB.
.
Patient was Kept on Amio Gtt when arrived. A CXR showed RUL
consolidation which was interpreted as possible pulmonary
contusion. There was a concern for aspiration and started on
Levo and flagyl.
.
After discussion with the family he apparently had a cardiac
catheterization sometime in the last month at the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**] VA
for unknown reasons. His wife reports that there were "some
plaques" but nothing to put stents in. Incidentally he was found
to have a pulmonary nodule and a CT was reccomended. He refused
at the time and was scheduled to have scan in one month.
.
In the ED he is intubated and sedated. Cooling procol was
initiated.
.
REVIEW OF SYSTEMS
Deferred as patient is intubated and sedated
Past Medical History:
Nonischemic cardiomyopathy with severely reduced lv systolic
function
HTN
Tobacco dependance
Nephrolithiasis
LBBB
Social History:
-Tobacco history: 50 Pack year history
-ETOH: Occasional
-Illicit drugs: Drugs
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam
GENERAL: Intubated and sedated AAO X 0
HEENT: Large ecchymosis over left eye brow, some excoriations
over right cheek
NECK: In C collar
CARDIAC: S1 S2 No MRG
LUNGS: Audible inspiratory wheezes in bilateral apeices but
lodest over the RU lobe. Clear BS in the LLlobe
ABDOMEN: Soft cooling blanket in place so exam confounded.
EXTREMITIES: Cool 2+ pulses
Discharge Exam
General - room air; Vitals HR 70-89, BP 119-130/56-61, RR
18/min, O2 99% RA, Temp 97.7-98.1
HEENT: pupils equal; reactive to light
Neck: 3cm JVP
CV: H1 and H2 present; no murmurs
Resp: Lungs are clear to auscultation
GI: soft and nontender to palpation; bowels sounds presents
Extremities: peripheral pulses present; no ankle edema
Pertinent Results:
[**2168-7-7**] 03:15PM WBC-17.8* RBC-4.95 HGB-15.1 HCT-44.0 MCV-89
MCH-30.6 MCHC-34.4 RDW-13.3
[**2168-7-7**] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-7-7**] 03:33PM GLUCOSE-138* LACTATE-1.5 NA+-135 K+-5.3*
CL--104 TCO2-25
[**2168-7-7**] 03:15PM PT-30.1* PTT-47.0* INR(PT)-2.9*
[**2168-7-7**] 03:15PM cTropnT-0.10*
[**2168-7-7**] 03:15PM estGFR-Using this
[**2168-7-7**] 03:15PM UREA N-10 CREAT-1.2
Discharge labs
[**2168-7-19**] 01:20PM BLOOD WBC-7.1 RBC-3.94* Hgb-11.7* Hct-35.8*
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.3 Plt Ct-318
[**2168-7-19**] 01:20PM BLOOD Plt Ct-318
[**2168-7-19**] 01:20PM BLOOD PT-13.5* PTT-27.1 INR(PT)-1.3*
[**2168-7-19**] 01:20PM BLOOD Glucose-105* UreaN-6 Creat-1.3* Na-139
K-4.1 Cl-105 HCO3-25 AnGap-13
[**2168-7-13**] 05:07AM BLOOD ALT-29 AST-60* LD(LDH)-309* AlkPhos-49
TotBili-0.5
Brief Hospital Course:
68 year old man with idiopathic, non-ischemic dilated
cardiomyopathy s/p cardiac arrest and rewarming protocol
currently with newly discovered lung, liver and pancreatic
lesions concerning for malignancy.
# Pulmonary Nodule with perihilar lymphadenopathy:
The patient was found, incidentally to have a pulmonary nodule
with perihilar lymphadenopathy. Given his long smoking history
there was a concern for malignancy. After review of other
masses in abdomen, the lung nodule was deemed the best place for
initial biopsy. U/S and MRI was performed to assess Liver and
pancreatic lesions and it was felt, with conjunction of IP and
IR that biopsing the lung would be the best route. Patient went
for bronchial lung biopsy on [**7-18**] wihtout complications. Results
are pending at time of discharge
# Liver, and pancreatic lesions: An ultrasound was showed at
least 5 lesions in the liver suggestive of hemangiomas. An
abdominal MRI revealed multiple liver masses believed to be
benign cysts and others that are hemangiomas. One liver mass was
believed to be potentially malignant. The pancreatic tail lesion
was believed to be potentially malignant. After lung biopsy and
pending results, it will need to be determined whether to biopsy
the pancreas since the tail of the pancreas is more likely to be
a primary than metastatic. He will follow up with outpatient
oncology at the VA for a body PET-CT, brain MRI, PFTs, and
spirometry with DLCO (this will be set up with the patient's
cardiologist, Dr. [**Last Name (STitle) 77893**].
# Chronic Systolic Heart Failure: The patient has non-ischemic
idiopathic dilated cardiomyopathy with EF 15%; it is still
unknown as to primary etiology. Pt is on his home-dose
lisinopril 20mg and will leave on home dose Metoprolol Succinate
200mg daily. The electrophysiology service was consulted
regarding possibly ICD vs. life vest placement given PEA vs.
Vtach arrest. EP recommended Amiodarone over ICD or Life vest
as it has shown to be non-inferior to patients who are s/p
cardiac arrest in preventing further arrests. He will take
Amiodarone 200 mg [**Hospital1 **] for 1 month followed by 200 mg daily
indefinitely. This plan was discussed with the patient's
cardiologist, Dr. [**Last Name (STitle) 77893**], who agreed.
# Post-Obstructive Pneumonia: on Day 10 of
piperacillin-tazobactam and vancomycin.
Finished course [**7-18**]. Resolved upon discharge
# Afib: Will continue beta-blockers. Warfarin had been held
since early in the admission, first due to elevated INR and then
for upcoming procedures. Will continue the patient's warfarin
at discharge, but at a lower dose as he was both
supratherapeutic coming into the hospital and discharged on
amiodarone. We have contact[**Name (NI) **] the patient's cardiologist, Dr.
[**Last Name (STitle) 77893**], regarding the need for close INR follow-up.
# Anemia: The patient's admission hematocrit was 44.0 and his
discharge hematocrit was 35.8. His nadir was 29.5 on [**2168-7-13**]. No
obvious cause of a normocytic anemia was found and the patient's
stool was guaiac negative.
# Hypertension: The patient's lisinopril and metoprolol were
continued throughout his hospital course to good effect.
Transitional issues:
# Outpatient oncologic workup: He will follow up with outpatient
oncology at the VA for a body PET-CT, brain MRI, PFTs, and
spirometry with DLCO (this will be set up with the patient's
cardiologist, Dr. [**Last Name (STitle) 77893**].
# Atrial fibrillation requiring anticoagulation: We have
contact[**Name (NI) **] the patient's cardiologist, Dr. [**Last Name (STitle) 77893**], regarding the
need for close INR follow-up.
# Anti-arrhythmic therapy: The patient will take Amiodarone 200
mg [**Hospital1 **] for 1 month followed by 200 mg daily indefinitely. This
plan was discussed with the patient's cardiologist, Dr. [**Last Name (STitle) 77893**],
who agreed.
# The patient was instructed not to return to work until he sees
his outpatient cardiologist. The patient understood the risks
and confirmed that he will not drive his truck.
Transitional issues: Follow up on anemia as his Hct dropped
during the hospital course but rebounded at discharge.
Recommend check CBC once to ensure it has normalized.
Medications on Admission:
MEDICATIONS:
Lisinopril 20mg QD
Metoprolol 200mg QD
Warfarin 2mg QD
Discharge Medications:
1. Amiodarone 200 mg PO BID
2. Lisinopril 20 mg PO DAILY
Start on [**7-16**] and continue daily
3. Metoprolol Succinate XL 200 mg PO DAILY
Start in AM of [**7-16**]. Home dose. Will d/c tartrate for tomorrow.
Hold for SBP < 100 or HR < 60
4. Warfarin 1 mg PO DAILY at 4pm
Please follow up closely with your doctor, [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) 77893**], to
monitor your coumadin levels.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnoses:
-Chronic Cardiac systolic dysfunction after either pulseless
electrical activity orventricular tachycardia with arrest
-Lung, liver, and pancreatic masses
Secondary diagnoses:
-AFib
-HTN
Discharge Condition:
Fair. Ambulatory. Mental status intact.
Discharge Instructions:
Dr [**Last Name (STitle) **]. [**Known lastname 3952**],
You were admitted to the hospital because of cardiac arrest and
found to have lung, liver, and pancreatic masses. You were
briefly intubated with a breathing tube, but successfuly taken
off in the intensive care unit. The masses were better
characterized on MRI and it was felt that biopsy of the lung was
the best method for tissue diagnosis. A biopsy was taken Monday
[**7-18**] by an interventional pulmonlogist. Results are pending
and will be relayed to you after discharge. You are leaving on
your same blood pressure medications that you came in with:
Metoprolol 200 mg daily and lisinopril 20 mg daily. We have
also added a new medication called Amiodarone. The dose will be
amiodarone 200 mg twice a day for one month, then 200 mg once a
day indefinitely. You need to follow up with your cardiologist
at the VA Dr. [**Last Name (STitle) 112517**], regarding your coumadin dosing. Your
coumadin dose on discharge is 1mg, which is lower than when you
came in. Please continue 1mg until you see your cardiologist.
Followup Instructions:
Please make an appointment with your cardiologist, Dr. [**Last Name (STitle) 112517**],
by calling ([**Telephone/Fax (1) 112518**] and paging [**Numeric Identifier 112519**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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icd9cm
|
[
[
[]
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[
"38.91",
"38.93",
"33.24",
"89.19",
"96.72",
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icd9pcs
|
[
[
[]
]
] |
8397, 8446
|
3583, 6795
|
322, 351
|
8696, 8740
|
2685, 3560
|
9874, 10181
|
1815, 1931
|
7948, 8374
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8467, 8642
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7855, 7925
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8764, 9851
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1946, 2666
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8663, 8675
|
7680, 7829
|
264, 284
|
379, 1564
|
1586, 1702
|
1718, 1799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,276
| 169,170
|
30011
|
Discharge summary
|
report
|
Admission Date: [**2165-4-6**] Discharge Date: [**2165-4-13**]
Date of Birth: [**2104-8-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
bicyclist struck by motor vehicle
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yM bicyclist struck by MV @ 30 mph, with multiple L sided rib
Fx,
pulm contusion w/ ? PTX, and found to have small SAH on CT head.
Pt was medflighted from [**Hospital 13588**] hospital to [**Hospital1 18**].
Past Medical History:
High cholesterol
Social History:
He lives in [**Location 13588**]. He is married, he has two children. He
owns a biotech company.
Family History:
Negative for any malignancies
Physical Exam:
BP:176/P HR:54 R:16 O2Sats:98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ERRL 3->2.5 EOMs: full
Neck: c-spine immob (not cleared @ time of exam)
Lungs: CTA bilaterally, L rib TTP
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Back: TTP over upper L-spine
Pertinent Results:
[**2165-4-6**] 02:50PM BLOOD WBC-7.2 RBC-4.84 Hgb-14.4 Hct-41.0 MCV-85
MCH-29.9 MCHC-35.2* RDW-13.7 Plt Ct-256
[**2165-4-8**] 09:35AM BLOOD WBC-10.0 RBC-3.85* Hgb-11.7* Hct-32.7*
MCV-85 MCH-30.5 MCHC-36.0* RDW-13.8 Plt Ct-188
[**2165-4-6**] 02:50PM BLOOD PT-11.5 PTT-24.8 INR(PT)-1.0
[**2165-4-8**] 09:35AM BLOOD Plt Ct-188
[**2165-4-6**] 02:50PM BLOOD Fibrino-509*
[**2165-4-6**] 02:50PM BLOOD UreaN-18 Creat-0.9
[**2165-4-8**] 09:35AM BLOOD Glucose-100 UreaN-20 Creat-0.8 Na-137
K-4.3 Cl-101 HCO3-30 AnGap-10
[**2165-4-6**] 02:50PM BLOOD ALT-44* AST-41* AlkPhos-178* Amylase-22
TotBili-0.4
[**2165-4-8**] 09:35AM BLOOD ALT-28 AST-34 AlkPhos-120* TotBili-0.7
[**2165-4-6**] 02:50PM BLOOD Lipase-38
[**2165-4-6**] 02:50PM BLOOD Albumin-4.3 Calcium-9.5
[**2165-4-7**] 02:14AM BLOOD CEA-<1.0
[**2165-4-9**] 08:00PM BLOOD AFP-4.7
[**2165-4-7**] 02:14AM BLOOD CA [**76**]-9 -PND
[**2165-4-8**] 09:35AM BLOOD CHROMOGRANIN A-354.8 H
[**2165-4-8**] 01:30PM BLOOD SEROTONIN-811 H
[**2165-4-9**] 08:00PM BLOOD GASTRIN-PND
[**2165-4-9**] 08:00PM BLOOD INSULIN-PND
[**2165-4-10**] 08:23PM BLOOD GLUCAGON-PND
Brief Hospital Course:
Mr. [**Known lastname 71625**] is a 60-year-old male who was struck by a SUV while
riding his bicycle. He was wearing a helmet at the time and he
had no loss of consciousness, and he was transferred from
[**Location (un) 13588**] to [**Hospital1 69**] via [**Location (un) 7622**].
CT scan performed on [**4-6**] during trauma work up revealed small
subarachnoid hemorrhage of the head and also multiple L sided
rib fractures ([**3-3**])associated with small left- sided pleural
effusion and a small left-sided pneumothorax. He also had a L1
transverse process fx. CT scan of the torso incidentally
revealed multiple ring-enhancing liver lesions in all lobes of
the liver. The largest one measuring 5 x 5.5 cm. There was
also an area of terminal ileal thickening and a contiguous soft
tissue mesenteric mass measuring 9 mm associated with mesenteric
spiculation,
retraction, and calcification and multiple lymph nodes.
Dr. [**Last Name (STitle) **] from Heme/Onc was consulted as his CT scan results
were consistent with carcinoid tumor. The patient admits to
flushing and also diarrhea, and he also states that his flushing
is mostly precipitated after alcohol. In this situation, we
believe that a carcinoid tumor is very high in the differential.
Octreotide scan performed on [**2165-4-11**] showed multiple
Octreotide-avid lesions in both hepatic lobes. There is no
abnormal Octreotide uptake elsewhere, including the terminal
ilium.
On the day of discharge, the patient noted he had bilateral
lower extremity edema but no shortness of breath. This was most
likely to his initial fluid load on admission and decreased
activity. His lower extremities were nontender and LE US were
negative.
Mr [**Known lastname 71626**] acute issues while in house was pain associated with
his rib fxs, however, his pain is well controlled on oral pain
regimen at this point.
Medications on Admission:
lipitor
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 2 weeks.
Disp:*42 Capsule(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4 hours as
needed for pain for 5 days.
Disp:*70 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
-very small L parietal SAH
-mult L sided rib fxs #[**3-3**]
-L1 transverse process fx,
-pulmonary contusion
-mult ring-enhancing liver lesions likely metastatic dz
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or go to your local ED if you have the
following symptoms:
-fever
-vomiting
-severe pain uncontrolled with narcotic pain medications
-difficulties breathing
Do not drive while taking narcotic pain medications.
Followup Instructions:
1. Call Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 5562**] Hematology/Onc
for a follow up appointment
2. Call Dr.[**Name (NI) 6433**] office for a follow up appointment on [**4-30**] [**Telephone/Fax (1) 24689**]
|
[
"197.7",
"852.01",
"861.21",
"199.1",
"807.08",
"805.4",
"E813.6",
"272.0",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4730, 4736
|
2247, 4123
|
348, 355
|
4944, 4951
|
1125, 2224
|
5234, 5531
|
770, 801
|
4181, 4707
|
4757, 4923
|
4149, 4158
|
4975, 5211
|
816, 1106
|
274, 310
|
383, 597
|
619, 637
|
653, 754
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,164
| 124,219
|
51085
|
Discharge summary
|
report
|
Admission Date: [**2141-10-19**] Discharge Date: [**2141-10-30**]
Date of Birth: [**2066-5-23**] Sex: F
Service: NEUROLOGY
Allergies:
Latex / Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
stroke code
Major Surgical or Invasive Procedure:
Intravenous and intra-arterial tPA
History of Present Illness:
The pt is a 75 yo RH woman with a PMH of HTN, HLD, and CKD
not on HD. She was BIBA after falling at home around 7:50 pm.
She
recalls falling and then believes her difficulty with speech
started few minutes later. She is not aware of her L hemiplegia.
Per EMS her Bp was 202/104 and her BS was 123. Her rhythm strip
showed SR with a rate in the 70's. She was noted to have a dense
L hemiplegia and L facial droop. She was also reported to be
unable to communicate initially but then was dysarthric.
ROS: denies HA, CP, weakness, SOB
Past Medical History:
MH:
HTN
HLD
HISTORY RF
HISTORY RA
STATUS POST L4 5 DISC HERNIA REPAIR
STATUS POST EXCISION PITUITARY ADENOMOA
STATUS POST APPY, CCY, TAH OVARIAN CYST
STATUS POST EXPLORATORY LAP --ADHESION
S/P APPENDECTOMY
S/P CHOLECYSTECTOMY
S/P HYSTERECTOMY
S/P C-SECTION X3
S/P OVARIAN CYST REMOVAL
S/P EXPLORATORY LAPAROTOMY FOR ADHESIONS
S/P RHINOPLASTY
S/P LIPOSUCTION
S/P EXCISION OF PITUITARY MACROADENOMA
S/P EXPLOR LAP--ADHESIONS
S/P EXCISION PITUITARY MARCOADENOMA
S/P L4 5 DISC [**Doctor First Name 147**] [**2-/2126**]
S/P APPY, CCY, TAH
SPASTIC COLON S/P REMOVAL 3 BENIGN POLYPS
CATARACT SURGERY-bilateral
RECENT
Social History:
-married
-former tobacco
Family History:
-sister and mother died of colon CA
Physical Exam:
Vitals: T: AF P: 72 R: 16 BP:170/82 SaO2: 98% 2L NC
NIH SS: 16
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 1
3. Visual: 1
4. Facial palsy: 1
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 2
9. Best language: 0
10. Dysarthria: 1
11. Extinction and inattention: 2
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No pedal edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty but only
reads
the R half of the page. Speech was dysarthric. Able to follow
both midline and appendicular commands on the R only. There was
L
neglect and agnosia to hemiplegia.
CN
I: not tested
II,III: Pt does not cooperate with formal VF testing, but does
not blink to threat on the L. pupils 2.5mm->1.5 bilaterally,
discs show some AV nicking but fundi normal
III,IV,V: R gaze deviation but able to cross the midline, does
not abduct fully to the L. No nystagmus
V: no sensation to pin on L in V1-V3
VII: L facial droop w/o, symm forehead wrinkling
VIII: hears to voice bilaterally
IX,X: palate elevates but limited view
[**Doctor First Name 81**]: 4 bilaterally
XII: tongue protrudes midline
Motor: Normal bulk and tone; no asterixis or myoclonus. No
pronator drift on the R
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 0------------------
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 0------------------
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0 0 0 0 0 Extensor
R tr 1 tr 1 0 Flexor
-Sensory: No deficits to light touch, pinprick on the R. No
sensation to any modality on the L in face, arm or leg; +
extinction on the L
-Coordination: No dysmetria on FNF or HKS on the R.
-Gait: NA
Pertinent Results:
[**2141-10-19**] 10:00PM COMMENTS-GREEN TOP
[**2141-10-19**] 10:00PM HGB-11.8* calcHCT-35
[**2141-10-19**] 09:50PM cTropnT-<0.01
[**2141-10-19**] 09:50PM WBC-6.7 RBC-3.43* HGB-11.2* HCT-31.6* MCV-92
MCH-32.5* MCHC-35.3* RDW-17.1*
[**2141-10-19**] 09:50PM NEUTS-48.5* LYMPHS-41.5 MONOS-5.7 EOS-3.8
BASOS-0.5
[**2141-10-19**] 09:50PM PLT COUNT-278
[**2141-10-19**] 09:05PM PT-12.2 PTT-24.6 INR(PT)-1.0
[**2141-10-19**] 08:45PM GLUCOSE-105 UREA N-33* CREAT-1.5* SODIUM-135
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2141-10-19**] 08:45PM estGFR-Using this
[**2141-10-19**] 08:45PM ALT(SGPT)-19 AST(SGOT)-30 LD(LDH)-213
CK(CPK)-195* ALK PHOS-90 TOT BILI-0.2
[**2141-10-19**] 08:45PM CK-MB-5
[**2141-10-19**] 08:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-12.6
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-10-19**] 08:45PM WBC-8.0 RBC-3.34* HGB-10.9* HCT-30.6* MCV-92
MCH-32.5* MCHC-35.5* RDW-17.4*
[**2141-10-19**] 08:45PM PLT COUNT-335
[**2141-10-19**] 08:45PM SED RATE-20
Brief Hospital Course:
The pt is a 75 year-old RH woman with a PMH of HTN, HLD and CKD
who presented to the ED after a fall with abrupt onset L
hemiplegia, dysarthria and profound neglect. She has a R MCA M2
cut off by CTA with a significant MTT, consistent with a large
penumbra. IV tPA was given in ICU with nonsignificant
improvement. IA tPA and MERCI were administered with
considerable improvement in symptoms (improved strengh in left
side and dysarthria).
Patient developed a hematoma on L femoral site, the enlarged for
the first few days. The pseudo-aneurysm was followed-up closely
with US and by the vascular team. Patient received 1 U RBC
transfusion. H/H stabilized and no further intervention was
deemed necessary.
Patient was found to have afib, with a few episodes of rapid
afib controlled with diltiazen and metoprolol. Anti-coagulation
with coumadin was initiated.
Medications on Admission:
Metoprolol SR 25 mg 24 hr Tab Oral
1 Tablet Sustained Release 24 hr(s) Once Daily
Simvastatin 40 mg Tab Oral
1 Tablet(s) Once Daily
Terbinafine 250 mg Tab Oral
1 Tablet(s) Once Daily
Zolpidem 10 mg Tab Oral
1 Tablet(s) Once Daily, at bedtime
Hydrocodone-Acetaminophen 5 mg-500 mg Tab Oral
1 Tablet(s) Every 6 hours
Seroquel 100 mg Tab Oral
[**12-29**] Tablet(s) Once Daily, at bedtime
Alprazolam 1 mg Tab Oral
1 Tablet(s) Once Daily
Hyzaar 100 mg-25 mg Tab Oral
1 Tablet(s) Once Daily
Boniva 150 mg Tab Oral
1 Tablet(s) Once Daily
One Daily Multivitamin Tab Oral
1 Tablet(s) Once Daily
Vitamin D 1,000 unit Cap Oral
Unknown # of dose(s) unknown
Folic Acid 800 mcg Tab Oral
Unknown # of dose(s) unknown
Vitamin C 500 mg SR Cap Oral
Unknown # of dose(s) unknown
Discharge Medications:
1. Outpatient Lab Work
Please check INR M, W and F. Please, fax it over to
2. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: If pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right middle cerebral artery stroke
Discharge Condition:
Good
Discharge Instructions:
You were admitted with trouble speaking and weakness on the left
side of your body. You were found to have a stroke in the
territory of the right middle cerebral artery. You were given
medications intravenously and intra-arterially to unblock the
artery in the ICU. Your symptoms improved significantly after
that.
You developed a hematoma on the right femoral area which was
followed-up closely with ultrasonography and vascular experts.
You needed to receive 1 unit of blood transfusion because your
hematocrit was low.
The Neurology and Cardiology team opted for initiation of
anti-coagulation with coumadin because you have atrial
fibrilation which increase the risk for embolus that would cause
strokes.
You will need to check your INR level very frequently by VNS
which will be faxed over to your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2578**].
If you notice any change in your hematoma, call your doctor
immediately.
Followup Instructions:
Neurology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2141-11-8**] 3:30
PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2578**] on [**2141-11-15**] at 11:30 am ([**Telephone/Fax (1) 106096**])
Completed by:[**2141-10-31**]
|
[
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"434.11",
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icd9cm
|
[
[
[]
]
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[
"39.74",
"99.10",
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"00.40",
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] |
icd9pcs
|
[
[
[]
]
] |
7707, 7765
|
5105, 5967
|
303, 340
|
7845, 7852
|
4075, 5082
|
8886, 9242
|
1595, 1633
|
6790, 7684
|
7786, 7824
|
5993, 6767
|
7877, 8863
|
1648, 2448
|
252, 265
|
368, 903
|
2463, 4056
|
925, 1537
|
1553, 1579
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,962
| 168,649
|
29878
|
Discharge summary
|
report
|
Admission Date: [**2156-10-30**] Discharge Date: [**2156-11-3**]
Date of Birth: [**2092-8-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
SOB/DOE
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
64 M with history of HTN, HL, CAD, MI s/p DES presents with
worsening fatigue, CP, and DOE x 1 month. The shortness of
breath has worsened over the last few weeks, getting symptomatic
now when walking up stairs. He also experiences some associated
chest tightness and has an intermittent cough productive of
white sputum. Otherwise denies fevers, chills, nausea, vomiting.
ROS also positive for 20 lb weight loss over the last few
months.
.
In the ED, initial VS: 98.6 76 117/65 16 100%. Initial concern
was for PE. D-dimer was in the 4000s, so CTA was obtained which
was negative for PE, but found moderate pericardial effusion.
Cardiology evaluated the patient using bedside echo which showed
that there was no signs of right atrial or ventricular diastolic
collapse. Chronicity of this effusion is slightly unclear and so
decision was made to admit patient to cardiology service for
further monitoring. Morphine was not helpful in relieving
patient's chest discomfort, however toradol was. Vitals prior to
transfer to the floor were: 98.9 82 135/85 18 95% RA.
.
Currently, patient feels much better, still having very light
chest discomfort but otherwise is resting comfortably, not
having any difficulties with breathing
Past Medical History:
1. CAD as above acute MI in [**11-30**] sp stents (unknown where as no
report available)
2. Hyperlipidemia
3. Hypertension
4. mild CVA in [**2144**] no deficits
5. cholecystectomy
Social History:
The patient has a h/o smoking 1ppd x 30 yrs, for 6 weeks cut
back to 5 cig/day. Drinks 2 glasses of red wine per day
(5x/week). An administrator, married with one child
Family History:
Father with htn and heart disease died at 72
mother 74 died of cancer
sister MI, htn, DM 64
Physical Exam:
Admission Exam:
Pulsus: 8mmHg
VS: T 97-99 BP 90-116/40-60 HR 88-100 RR 18 O2 Sat 96% RA
GEN: NAD, comforatble
HEENT: EOMI, NCAT
NECK: Supple, thyroid non-tender, JVP 6cm above the RA
CV: Irreg Irreg, normal S1/S2, no S3/S4, no murmurs or rubs
PULM: CTAB, no incrased WOB
ABD: NTND, NABS
EXT: WWP, no c/c/e
NEURO: A/Ox3, CN II-XII intact. Non focal.
.
Discharge Exam:
Pulsus: 8mmHg
VS: T 98 BP 120-130/60-70 HR 70s RR 18 O2 Sat 96% RA
GEN: NAD, comforatble
HEENT: EOMI, NCAT
NECK: Supple, thyroid non-tender, JVP 6cm above the RA
CV: RRR, normal S1/S2, no S3/S4, no murmurs, gallops or rubs
PULM: CTAB, no incrased WOB
ABD: NTND, NABS
EXT: WWP, no c/c/e
NEURO: A/Ox3, CN II-XII intact. Non focal.
Pertinent Results:
Admission Labs:
[**2156-10-29**] 03:38PM BLOOD WBC-8.4 RBC-4.51* Hgb-10.6* Hct-33.8*
MCV-75* MCH-23.4* MCHC-31.3 RDW-15.2 Plt Ct-345
[**2156-10-29**] 03:38PM BLOOD Glucose-93 UreaN-17 Creat-1.0 Na-136
K-3.9 Cl-101 HCO3-24 AnGap-15
[**2156-10-29**] 03:38PM BLOOD cTropnT-<0.01
[**2156-10-30**] 07:04AM BLOOD CK-MB-1 cTropnT-<0.01
[**2156-10-29**] 06:31PM BLOOD D-Dimer-4205*
.
Discharge Labs:
[**2156-11-3**] 07:25AM BLOOD WBC-6.1 RBC-4.17* Hgb-9.8* Hct-31.3*
MCV-75* MCH-23.5* MCHC-31.3 RDW-15.0 Plt Ct-416
[**2156-11-1**] 07:00AM BLOOD Glucose-97 UreaN-13 Creat-1.0 Na-138
K-4.3 Cl-101 HCO3-28 AnGap-13
[**2156-11-1**] 07:00AM BLOOD LD(LDH)-177
[**2156-10-30**] 07:04AM BLOOD LD(LDH)-179 CK(CPK)-49
[**2156-10-30**] 07:04AM BLOOD CK-MB-1 cTropnT-<0.01
[**2156-10-29**] 03:38PM BLOOD cTropnT-<0.01
[**2156-11-1**] 07:00AM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.7 Mg-2.0
[**2156-11-1**] 07:00AM BLOOD RheuFac-18*
[**2156-10-31**] 02:41PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2156-10-31**] 05:35AM BLOOD dsDNA-NEGATIVE
[**2156-10-30**] 01:23PM OTHER BODY FLUID WBC-[**Numeric Identifier 22475**]* RBC-0 Hct,Fl-14.5*
Polys-76* Lymphs-21* Monos-3*
[**2156-10-30**] 01:23PM OTHER BODY FLUID TotProt-4.8 Glucose-78
LD(LDH)-842 Amylase-42 Albumin-2.8
[**2156-10-31**] 05:35AM BLOOD SM ANTIBODY-Neg
[**2156-10-31**] 05:35AM BLOOD ANTI-HISTONE ANTIBODY-Neg
.
CXR ([**2156-10-29**]):
The lungs are clear bilaterally with no areas of focal
consolidation. Small nodular densities overlying the left fifth
rib are again noted most consistent with bone islands as seen on
the prior chest radiographs with obliques. There are no areas of
focal consolidation to suggest pneumonia. There is no pleural
effusion or pneumothorax. There is mild cardiomegaly. The
mediastinal silhouette is unchanged.
IMPRESSION: Mild cardiomegaly, which is new since [**2155-1-27**]
study. No
evidence of pneumonia.
.
CTA ([**2156-10-29**]):
1. Moderate-sized pericardial effusion with faint enhancement of
the
pericardium. Pericarditis cannot be excluded.
2. No pulmonary embolism.
3. Moderate centrilobular emphysema. Multiple small pulmonary
nodules
measuring up to 3 mm. Followup chest CT in 12 months is
recommended.
.
TTE ([**2156-10-30**]):
Overall left ventricular systolic function is normal (LVEF>55%).
with RV normal free wall contractility. No mitral regurgitation
is seen. There is a moderate sized pericardial effusion
posteriorly (1.9cm) and small anterior effusion (0.9cm). No
right atrial diastolic collapse is seen. No right ventricular
diastolic collapse is seen.
.
TTE ([**2156-10-30**]):
Overall left ventricular systolic function is normal (LVEF>55%).
After pericardiocentesis there is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: Successful pericardiocentesis. Trivial residual
pericardial effusion without echocardiographic signs of
tamponade.
.
TTE ([**2156-10-31**]):
Overall left ventricular systolic function is normal (LVEF>55%).
There is a very small anterior pericardial effusion. There is a
larger focal pericardial vs. pleurial effusion posteriorly.
There are no echocardiographic signs of tamponade.
IMPRESSION: Small residual pericardial effusion. There is an
echolucent space near the left atrium that is probably a small
pleural effusion. No echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2156-10-30**] the
findings are similar.
.
TTE ([**2156-11-1**]):
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. There is abnormal
septal motion/position. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements.
IMPRESSION: Very small partiall echo filled pericardial effusion
with abnormal septal motion. No hemodynamic compromise, but the
abnormal septal motion raises the possibility of early
constriction. Pulmonary artery hypertension. Compared with the
prior study (images reviewed) of [**2156-10-31**], the findings are
similar (PA hypertension is now identified).
.
TTE ([**2156-11-3**]):
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is abnormal septal motion/position. There is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2156-11-1**],
the septal "bounce" is not as apparent on the current study. The
other findings are similar.
.
Pericardial Fluid Cytology ([**2156-10-30**]):
Rare atypical cells, cannot exclude reactive mesothelial cells.
.
Pericardial Fluid Cell Block ([**2156-10-30**]):
Rare atypical cells, cannot exclude reactive mesothelial cells.
Brief Hospital Course:
Priamry Reason for Admission: 64 M with h/o HTN, HL, CAD, MI s/p
DES presents with pericardial effusion of unknown etiology.
.
Active Problems:
.
# Pericardial Effusion: In the ED bedside TTE was negative for
tamponade physiology. On the morning of HD #1, the pts BP was
downtrending 120->110->90s and his HR was uptrending 80s->100s.
At this point the pt was bolused 500cc NS and repeat TTE showed
moderate pericardial effusion with brief RA diastolic collapse.
Given the pt's deteriorating VS, elective pericardiocentesis was
performed and 270 cc of serosanguinous pericardial fluid was
removed. The patient tolerated the procedure well. Repeat ECHO
after drain placement showed no significant reaccumulation of
pericardial fluid. The patient's drain was pulled on [**2156-10-31**] and
serial echos were obtained that showed small residual echodense
effusion with mild restrictive physiology. Clinically, the
patient stated he felt much better immediately post-procedure
and continued to improve throughout his course. He was started
on colchicine and ibuprofen for anti inflammatory effects with
symptomatic improvement. The patient's hydralazine was held due
to concern for hydralazine induced SLE that could account for
effusion; after d/c his anti-histone Ab returned negative. At
the time of d/c, he was able to ambulate without sx and felt
near his baseline.
TRANSITONAL ISSUES: The cause of his effusion is unclear at this
time and ongoing outpatient workup should be conducted to r/o
malignancy or other treatable cause. All autoimmune Ab labs were
negatuve. His effusion was clearly exudative based on lytes
criteria (see results).
.
# Atrial Fibrilation: On admission pt was noted to be in a-fib.
He has no known h/o a-fib, and it was felt his abnormal rhythm
was [**1-28**] periacrdial effusion. After pericardiocentesis, he
remained in NSR for the remainder of his course.
.
# Hypertension: While in the CCU, his antihypertensive
medications were initially held except for his Carvedilol
because of hypotension. However, on transfer from the CCU back
to the floor, the patient was restarted on amlodipine (dose
increased to 10 mg) and lisinopril 20 mg daily. Of note, his
hydralazine was discontinued, as there was some concern about
hydralazine induced SLE that could account for this effusion;
anti-histone Ab returned negative.
.
Chronic Problems:
.
# Weight loss - patient reports 20lb weight loss over last few
months. Has been evaluated by GI as outpatient because of guaiac
positive stool. GI workup has thus far been unrevealing with
negative EGD/[**Last Name (un) **].
TRANSITIONAL ISSUES: Pt should have ongoing outpatient workup
for malignancy given weight loss and exudative pericardial
effusion of unknown etiology
.
# HTN - We continued his amlodipine, carvedilol and lisinporil
and d/c'ed his hydralazine.
.
# HL - per patient, he was told by his PCP to stop taking
simvastatin, unclear why
.
TRANSITIONAL ISSUES:
Lung nodules seen on chest CT. On TTE, there was possible areas
calcfications in liver; will likely need outpatient RUQ u/s to
further evaluate. f/u with PCP and Cardiologist.
Medications on Admission:
AMLODIPINE 5mg daily
CARVEDILOL 50 mg [**Hospital1 **]
CLOPIDOGREL 75 mg daily
ECOTRIN 81 mg daily
HYDRALAZINE 50 mg TID
LISINOPRIL 20 mg daily
OMEPRAZOLE 20 mg daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 7 days.
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Chantix Starting Month Pak 0.5(11)-1(3X14) mg Tablets, Dose
Pack Sig: 1-2 Tablets, Dose Packs PO twice a day: as directed on
box.
Disp:*1 Dose Pack(s)* Refills:*0*
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Priamry:
Cardiac Tamponade
Secondary:
CAD s/p MI with DES ([**2152**])
HL
HTN
Anemia
h/o CVA ([**2144**])
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 634**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted because you were having
shortness of breath and chest pain due to fluid around your
heart. We performed a pericardiocentesis to remove the fluid. At
this time, it is unclear what caused your pericardial effusion.
Results of the tests performed during your hospitalizaion will
be sent to your primary care doctor and Cardiologist; it will be
important to follow up with your physicians to definitively
diagnose the cause of this problem.
During this hospitalization, the following changes were made to
your medications:
STARTED Ibuprofin 600mg by mouth 3 times a day x7 days
STARTED Colchicine 0.6 mg twice a day, continue until you see
your cardiologist
STOPPED Hydralazine 50mg by mouth three times a day
You have been given a prescription for Chantix to help you stop
smoking. You have tolerated this medication well in the past.
You will need to get the continuation pack from your PCP.
Thank you for allowing us to participate in your care.
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2156-11-8**] at 1:30 PM
With: DR. [**First Name8 (NamePattern2) 507**] [**Name (STitle) **] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 5768**]
Appt: [**11-16**] at 4pm
|
[
"401.9",
"423.9",
"783.21",
"V45.82",
"412",
"427.31",
"280.9",
"305.1",
"423.3",
"272.4",
"414.01",
"492.8",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
12225, 12231
|
8026, 10621
|
321, 341
|
12381, 12381
|
2830, 2830
|
13620, 14230
|
2004, 2098
|
11367, 12202
|
12252, 12360
|
11176, 11344
|
12532, 13597
|
3223, 8003
|
2113, 2464
|
2480, 2811
|
10972, 11150
|
274, 283
|
369, 1596
|
2847, 3207
|
12396, 12508
|
1618, 1800
|
1816, 1988
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,939
| 102,047
|
9543
|
Discharge summary
|
report
|
Admission Date: [**2174-8-30**] Discharge Date: [**2174-9-5**]
Date of Birth: [**2128-5-20**] Sex: F
Service: MEDICINE
Allergies:
Ceclor
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Persistent Fevers, Diffuse Arthralgias, Rash
Major Surgical or Invasive Procedure:
Central Line Placement
Femoral Dialysis Cath
A-Line
Intubation and Ventilator support
Sternal Bone Marrow Aspirate
CVVH
History of Present Illness:
46 yo F with PMH with PMh of diabetes, left internal carotid
artery aneurysm, status post coiling, Bell's palsy, sciatica,
s/p hysterectomy in [**2157**] for menorrhagia who presented to OSH
with fevers, chills, diffuse joint pains, muscle pain. The
patient reports that she was in [**Location (un) 32407**] from [**Date range (1) 32408**] when
on the morning of Sunday [**8-14**], when she was at her friend's
house, she had acute onset of a red confluent raised, itchy rash
that involved all apsects of her legs from the waist down, and
both of her arms from the shoulders down. She had never had a
rash like this before. That evening the patient had onset of
significant fevers and chills and over the next days developed
significant diffuse joint pain affecting all joints from her
shoulders, elbows, wrists fingers knees, ankles and toes with
associated diffuse muscle pain. She initially was seen as an
outpatient and reportedly started on a 1 week prednisone taper
(unclear if other meds initiated at that time also) The patient
had persistent symtoms and was admitted to Caritas Good [**Hospital 32409**]
medical center in [**Hospital1 1474**] with persistent fevers to 103, rash,
diffuse arthralgias. She underwent evaluation there including
numerous ID studies there, LP, MRI, TTE and multiple
rheumatologic studies which were all nondiagnostic to date. Due
to continued high fevers up to 104 at night, the patient was
started on vanc , levo and high dose steroids which rheum
reportedly diagnoisng adult onset JRA versus viral arthritis.
Past Medical History:
Diabetes
Left internal carotid artery aneurysm, status post coiling
Bell's palsy
Sciatica
S/p hysterectomy in [**2157**] for menorrhagia
Social History:
Patient lives in [**Hospital1 1474**]. Denies IVDA, tattoos, any significant
outdoor exposure in tick endemic areas. Patient reports travel
to [**Location (un) 5354**] in past. When she was in [**State 108**] she reports being
in the city the entire time. She was not in the everglades.
She has not been in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] region nor upstate NY
(sounded like she was in [**Location (un) 7349**], can clarify). Patient has been to
[**Male First Name (un) 1056**] of note, but denies being in the jungle. She
repeatedly denies being bitten by mosqitoes or any insect.
Family History:
Denies family history of arthritis or rheumatologic ailments.
Denies history of IBD.
Physical Exam:
Vitals: T 99.1 BP 98/54 HR 82 RR 18 O2sat 100%RA FS 276
HEENT: PERRL, anicteric, supple neck, no meningeal signs.
HEART: RRR with respiratory variation, nml s1s2, no m,r,g.
LUNGS: CTAB
ABD: +BS, soft, NT, ND
EXT: no pedal edema
DERM: Patient has dark erythematous macular rash on left
shoulder, appearance not consistent with hyperacute
presentation. Patient also has erythematous rash around the
base of her neck (patient reports more chronic for her).
LAD: No cervical axillary LAD detected. Inguinal LAD deferred.
NEURO: AAOx3, no evidence of encepthalopathy or meningeal signs,
patient had decreased bilateral hand grasp apparently secondary
to pain and weakness. [**3-5**] bilateral biceps strength. Full
extensive neuro exam to be performed tomorrow.
MSK: Patient without noted overt effusions or erythema of her
joints. Her wrists and fingers [**Last Name (un) **] most affected and tender
with some ROM exercises.
Pertinent Results:
[**2174-9-5**] 06:28AM BLOOD WBC-16.8* RBC-3.82* Hgb-10.6*# Hct-28.6*
MCV-75* MCH-27.7 MCHC-37.1* RDW-16.3* Plt Ct-32*
[**2174-9-5**] 06:28AM BLOOD Neuts-66 Bands-1 Lymphs-28 Monos-3 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
[**2174-9-5**] 06:28AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
[**2174-9-5**] 06:28AM BLOOD PT-26.2* PTT-140.8* INR(PT)-2.6*
[**2174-9-5**] 06:28AM BLOOD Fibrino-300
[**2174-9-5**] 06:28AM BLOOD Heparin-PND
[**2174-9-2**] 03:22PM BLOOD ACA IgG-PND ACA IgM-PND
[**2174-9-2**] 03:22PM BLOOD Lupus-PND AT III-PND ProtCFn-PND
ProtSFn-PND
[**2174-9-1**] 03:26PM BLOOD ACA IgG-5.2 ACA IgM-27.2*
[**2174-9-5**] 07:10AM BLOOD Glucose-96 UreaN-90* Creat-5.8*# Na-128*
K-4.3 Cl-88* HCO3-15* AnGap-29*
[**2174-9-5**] 07:10AM BLOOD ALT-2237* AST-[**Numeric Identifier 32410**]* LD(LDH)-[**Numeric Identifier 32411**]*
AlkPhos-685* TotBili-4.0*
[**2174-9-4**] 05:45AM BLOOD ALT-505* AST-1752* LD(LDH)-5375*
CK(CPK)-1625* AlkPhos-343* TotBili-4.1* DirBili-2.7* IndBili-1.4
[**2174-9-5**] 07:10AM BLOOD Albumin-1.5* Calcium-6.9* Phos-9.4*
Mg-2.0 UricAcd-12.0*
[**2174-9-3**] 05:01AM BLOOD Hapto-395*
[**2174-9-1**] 03:01PM BLOOD TSH-1.2
[**2174-9-2**] 05:55AM BLOOD Cortsol-73.0*
[**2174-9-2**] 02:15AM BLOOD Cortsol-44.2*
[**2174-9-2**] 12:42AM BLOOD Cortsol-39.0*
[**2174-9-1**] 03:01PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
[**2174-8-30**] 07:55PM BLOOD HCG-<5
[**2174-9-1**] 03:01PM BLOOD CRP-GREATER TH
[**2174-9-4**] 05:45AM BLOOD IgM-41
[**2174-9-1**] 06:56PM BLOOD PEP-AWAITING F IgG-595* IgA-124 IgM-59
IFE-PND
[**2174-9-4**] 05:45AM BLOOD C3-PND C4-PND
[**2174-9-1**] 03:01PM BLOOD C3-63* C4-2*
[**2174-9-1**] 02:55PM BLOOD HIV Ab-NEGATIVE
[**2174-9-1**] 03:01PM BLOOD HCV Ab-NEGATIVE
[**2174-9-5**] 06:37AM BLOOD Type-ART pO2-94 pCO2-28* pH-7.33*
calTCO2-15* Base XS--9
[**2174-9-5**] 06:37AM BLOOD Lactate-6.8*
[**2174-9-5**] 08:01AM BLOOD freeCa-0.92*
[**2174-9-4**] 02:14PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
[**2174-9-4**] 02:14PM BLOOD B-GLUCAN-PND
[**2174-9-3**] 09:56PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
[**2174-9-3**] 06:45AM BLOOD ADAMTS13 ACTIVITY AND INHIBITOR-PND
[**2174-9-2**] 11:07AM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND
[**2174-9-2**] 05:55AM BLOOD Q-FEVER (COXIELLA BURNETTI) ANTIBODY-PND
[**2174-9-2**] 05:55AM BLOOD LEPTOSPIRA ANTIBODY-PND
[**2174-9-2**] 05:55AM BLOOD BRUCELLA ANTIBODY, IGG, IGM-PND
[**2174-9-2**] 05:55AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
[**2174-9-1**] 06:56PM BLOOD HEPARIN DEPENDENT ANTIBODIES-PND
[**2174-9-1**] 03:01PM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG &
IGM)-Test
[**2174-9-1**] 03:01PM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-PND
Brief Hospital Course:
46 year-old female with fever, rash, arthralgias of unknown
origin with hospital course complicatedy by sepsis, respiratory
failure, and DIC.
1. DIC/sepsis/multisystem organ failure: Patient developed
fulminant DIC in setting of septic shock secondary to coag
negative Staph. Was also found to be weakly ACL IgM positive,
suggesting possible anti-phospholipid syndrome component.
Still's disease and HLH were also considered during admission,
and patient received skin biopsy and bone marrow biopsy during
admission. Patient during her hospital course received
meropenem and vancomycin empirically during admission, and was
maintained on levophed, vasopressin, and neosenephrine. She
also received multiple transfusions of cryoprecipitate, rAPC,
and heparin gtt during admission. Patient developed acute renal
failure and was on CVVH during admission. She was also found to
have a coagulopathy, thrombocytoepnia, and low fibrinogen
transfused with cryoglobulinemia and PRBCs.
2. Code status: As patient continued to deteriorate, multiple
family discussions resulted in decision to make patient CMO and
patient was extubated with pressors held. She died shortly
thereafter.
Medications on Admission:
MEDICATIONS (at home):
-Naproxen 500 mg PO Q12H
-Nicotine Patch 14 mg TD DAILY
-GlyBURIDE 2.5 mg PO DAILY
-Docusate Sodium 100 mg PO BID
-Acetaminophen 650 mg PO Q6H:PRN temp
-Milk of Magnesia 30 mL PO Q6H:PRN constipation
-Oxazepam 10 mg PO HS:PRN insomnia
.
MEDICATIONS (on transfer):
Vancomycin 1000 mg IV Q 12H
Sarna Lotion 1 Appl TP TID:PRN
Naproxen 500 mg PO Q12H
Doxycycline Hyclate 100 mg PO Q12H
Insulin SC (per Insulin Flowsheet)
Oxazepam 10 mg PO HS:PRN insomnia
Milk of Magnesia 30 mL PO Q6H:PRN constipation
Acetaminophen 650 mg PO Q6H:PRN temp
Nicotine Patch 14 mg TD DAILY
GlyBURIDE 2.5 mg PO DAILY
Docusate Sodium 100 mg PO BID
Discharge Medications:
Patient died
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient died
Discharge Condition:
Patient died
Discharge Instructions:
Patient died
Followup Instructions:
Patient died
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2174-9-5**]
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8548, 8557
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318, 439
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8613, 8627
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3900, 6611
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2847, 2933
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8511, 8525
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8578, 8592
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7842, 8488
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8651, 8665
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2948, 3881
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234, 280
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467, 2025
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2047, 2185
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,768
| 160,497
|
24119
|
Discharge summary
|
report
|
Admission Date: [**2127-4-28**] Discharge Date: [**2127-7-10**]
Date of Birth: [**2127-4-28**] Sex: M
Service: NB
HISTORY: [**Known lastname 6644**] [**Known lastname **] is a 29 3/7 weeks male infant
admitted to the Newborn Intensive Care Unit for issues of
prematurity. He was born to a 31 year-old gravida I, para 0
mother with estimated date of confinement of [**2127-7-11**].
Prenatal screens: Maternal blood type O positive, antibody
negative, RPR nonreactive, Rubella immune, hepatitis B
surface antigen negative. Prenatal course significant for
hypertension presented on Friday prior to delivery and
treated initially with p.o. labetalol, then IV labetalol and
hydralazine. No magnesium sulfate since all pregnancy-induced
hypertension laboratories were negative. Mother did receive
betamethasone on the Friday prior to delivery and was beta
complete at time of delivery. There was a normal fetal
ultrasound. Mom previously lived in [**State 108**], now moved to the
[**Location (un) 86**] area, around time of admission was looking for
housing. Currently works in a legal office. Today in
antenatal testing noted to have a biophysical profile of 4
out of 10 without movement. Mother's GBS status is unknown.
No maternal fever. Membranes were ruptured at delivery. In
setting of persistent hypertension and fetal concern elected
to deliver infant by cesarean section on [**4-28**] at 6:25
P.M. with Apgar scores 7 at one minute and 8 at five minutes
of age. He emerged with initial apnea requiring positive
pressure ventilation and intubation prior to transfer to the
Newborn Intensive Care Unit.
PHYSICAL EXAMINATION ON ADMISSION: Weight 965 grams (10th
percentile), head circumference 25.5 cm (10th to 25th
percentile). Infant on SIMV 40%, FIO2 with oxygen saturation
of 96%. Infant active, anterior fontanelle open and flat,
normal S1, S2, no murmur, breath sounds coarse bilaterally
and decreased bilaterally. Moderate intercostal and subcostal
retractions. Abdomen soft, nontender, nondistended,
extremities well perfused. Tone average for gestational age.
Testes palpable on left, not palpable on right. Patent anus,
spine intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: As
aforementioned, [**Known lastname 6644**] was intubated in the delivery room and
then transferred to the Newborn Intensive Care Unit. He
received one dose of servanda and then was extubated and
weaned to room air by day of life 2. He did require nasal
cannula oxygen starting on day of life 15 and successfully
weaned off of nasal cannula oxygen by day life 23. He was
started on caffeine citrate on day of life 1 for apnea of
prematurity. Caffeine citrate was discontinued on [**6-2**].
Apnea has resolved.
CARDIOVASCULAR: [**Known lastname 61301**] blood pressure has been stable
throughout his hospitalization. No boluses or pressors
required. A murmur was detected on day of life 24. An
echocardiogram at that time showed an atrial septal defect.
He has been uncompromised by the atrial septal defect and
will be followed by cardiology at [**Hospital3 1810**].
FLUID, ELECTROLYTES AND NUTRITION: Upon admission to the
Newborn Intensive Care Unit umbilical venous catheter was
placed and IV fluids of D10W were started at 80 cc per
kilogram per day. Enteral feeds were started on day of life 2
and he successfully advanced to full volume feeds of 24
calorie breast milk at 150 cc per kilogram per day on day of
life 11. Stools were found to be heme positive on day of life
11. He was made n.p.o. and started on ampicillin and
gentamicin at that time. KUB was nonspecific at that time.
Feeds were restarted on day of life 13 and advanced to 150 cc
per kilogram per day at 28 calories per ounce without
incident. [**Known lastname 6644**] again had bloody stools reappear on day of
life 23. KUB was abnormal at that time and a CBC suggestive
of infection. At that time he was started on ampicillin,
gentamicin and clindamycin. He remained n.p.o. and on
antibiotics for 14 days with presumed necrotizing
enterocolitis. He was restarted on feeds of Pregestimil on
day of life 37 and advanced to full volume by day of life 42.
Long term pan and limited IV access prompted a Broviac
catheter placement on day of life 29. The Broviac was in the
right leg and subsequently discontinued on day of life 43.
Trace heme positive stools resurfaced again on day of life
63. He was switched to Neocate formula and heme positive
stools resolved. He is currently p.o. feeding well with good
weight gain. Electrolytes have been within normal range
throughout his hospitalization. His discharge weight is 3100
grams. Length 49 cm. Head circumference 34 cm. He is going
home on iron supplementation.
GASTROINTESTINAL: [**Known lastname 6644**] was started under phototherapy on
day of life 1 for a bilirubin of 6.3. Phototherapy was
discontinued on day of life 5 with a rebound bilirubin of 1.5
on day of life 6.
HEMATOLOGY: [**Known lastname 61301**] blood type is A positive. He has
received 2 packed red blood cell transfusions during his
hospitalization. His last hematocrit on [**6-25**] was 33.8.
INFECTIOUS DISEASE: Upon admission to the newborn Intensive
Care Unit a CBC with differential and blood culture was
drawn. He had a white cell count of 4,000, hematocrit of 50,
platelet count of 193 with 16% polys and 0% bands. Blood
culture that was drawn at that time was negative and
antibiotics that were started upon admission were
discontinued after 48 hours. Ampicillin and gentamicin were
restarted on day of life 11 with re-emergence of heme
positive stools and then discontinued after 48 hours. CBC at
that time was unremarkable. Ampicillin, gentamicin and
clindamycin were started on day of life 22 with re-emergence
of bloody stools and abnormal KUB. CBC at that time showed a
white count of 5.6, a hematocrit of 27.9 with a platelet
count of 428,000 with 26% polys, 8% bands and 3% metas with
an I to T ratio of .3. Blood culture was negative. [**Known lastname 6644**]
received a 14 day course of ampicillin, gentamicin and
clindamycin. No further issues of infection after medical
neck watch was completed.
NEUROLOGY: [**Known lastname 6644**] has had normal head ultrasounds on [**5-7**]
and [**6-2**].
SENSORY: A hearing screen was performed with automated
auditory brain stem responses and Just has passed in both
ears.
OPHTHALMOLOGY: [**Known lastname 61301**] eyes was most recently examined on
[**6-30**] revealing mature retinal vessels. A follow up
examination is recommended in six months.
PSYCHOSOCIAL: [**Hospital1 69**] social
worker has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable on full volume feeds of
Neocate, gaining weight well. Temperatures stable in open
crib. Mature respiratory breathing pattern.
DISCHARGE DISPOSITION: To home with mother. Name of primary
pediatrician is Dr. [**First Name (STitle) **] of [**Hospital 1426**] Pediatrics. Phone #[**Telephone/Fax (1) 61302**].
CARE RECOMMENDATIONS: Feeds at discharge: Ad lib demand
feeds of Neocate 20 calories per ounce.
Medications: Ferrous sulfate supplementation.
Car seat position screening: [**Known lastname 6644**] did have a car seat test
and passed.
State Newborn Screen Status: Last state newborn screen was
sent on [**6-10**] and no abnormal results have been reported.
Immunizations received: [**Known lastname 6644**] received his first hepatitis B
vaccine on [**6-13**]. He received his first DTAP vaccine on [**6-26**]. He received Hib, IPV and PREVNAR vaccines on [**6-27**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: 1) Born at less than 32
weeks. 2) Born between 32 and 35 weeks with two of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, family abnormalities, or
school age siblings, or 3) With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life
immunization against influenza is recommended for household
contact and out of home caregivers.
Follow up appointments: [**Known lastname 6644**] will be followed by the GI
service at [**Hospital3 1810**]. He will have an appointment
at 1 month after discharge at the [**Hospital **] clinic, phone number [**Telephone/Fax (1) 61303**]. Cardiology will follow up in the [**Hospital1 **]
cardiology clinic at one year of age for his ASD, phone
number is [**Telephone/Fax (1) 37115**].
DISCHARGE DIAGNOSES:
1. Prematurity at 29 3/7 weeks.
2. Respiratory distress syndrome.
3. Apnea of prematurity.
4. Medical necrotizing enterocolitis.
5. Hyperbilirubinemia.
6. Atrial septal defect.
7. Umbilical hernia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2127-7-10**] 16:26:56
T: [**2127-7-10**] 18:03:08
Job#: [**Job Number 61304**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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icd9pcs
|
[
[
[]
]
] |
6871, 7029
|
8715, 9182
|
7052, 7058
|
2210, 6688
|
7072, 7603
|
7630, 8305
|
8329, 8694
|
1664, 2181
|
6713, 6847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,697
| 162,108
|
1225
|
Discharge summary
|
report
|
Admission Date: [**2107-7-25**] Discharge Date: [**2107-8-3**]
Date of Birth: [**2037-1-11**] Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone / Seroquel
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Right hemiarthroplasty
Evacuation of hematoma lateral hip, placement of deep drain and
superficial vacuum sponge
History of Present Illness:
This is a 70-year-old male with a history of mechanical aortic
valve replacement in [**2096-1-31**] (#25 CarboMedics valve) with an
INR
goal on warfarin of 2.5-3.5, Parkinson's disease
with dementia who was admitted for altered mental status and
failure to thrive
at home on [**2107-7-25**] and was noted to have a right subcapital
femoral neck fracture.
Past Medical History:
-Parkinson's disease with dementia
-Mechanical Aortic valve replacement, on Coumadin
-Hypertension
-Prostate CA s/p resection with Dr. [**Last Name (STitle) **]
[**Name (STitle) 7724**] Fistula (seeing [**Doctor Last Name 1120**]; applying Bacitracin)
Social History:
Uses a walker intermittently. Married, lives with wife who is
primary caretaker. Denies tobacco smoke. Drinks coffee [**11-28**]
times per day.
Family History:
Brother died of MI age 56
Physical Exam:
VS: 98 104/62 98 20 96RA
GENERAL: Frail man in NAD, occasionally speaks, waxing and
[**Doctor Last Name 688**] orientation
HEENT: Patient holds his neck in forward flexion (chin almost to
chest), with effort can extend backward to neutral position, can
rotate to left and right without difficulty, EOMI, sclerae
anicteric, oropharynx clear.
HEART: S1, S2, no murmurs auscultated, audible click appreciated
LUNGS: CTA bilaterally, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: Warm, well perfused. Radial and pedal pulses 2+.
Ecchymosis over R hip and R flank improving. Wound c/d/i
LYMPH: No cervical LAD.
NEURO: Drowsy, not oriented (knows name but thinks it is [**2086**]
and he is in [**Location (un) 7349**])
Pertinent Results:
[**2107-8-3**] 06:30AM BLOOD WBC-9.2 RBC-3.66* Hgb-11.2* Hct-32.4*
MCV-88 MCH-30.6 MCHC-34.6 RDW-13.8 Plt Ct-426
[**2107-8-2**] 06:15AM BLOOD WBC-9.1 RBC-3.74* Hgb-11.6* Hct-32.6*
MCV-87 MCH-31.0 MCHC-35.6* RDW-14.1 Plt Ct-321
[**2107-8-1**] 06:30AM BLOOD WBC-7.5 RBC-3.62* Hgb-10.9* Hct-32.0*
MCV-89 MCH-30.2 MCHC-34.2 RDW-13.8 Plt Ct-265
[**2107-7-28**] 04:55AM BLOOD Neuts-84.1* Lymphs-9.6* Monos-4.7 Eos-1.5
Baso-0.2
[**2107-8-3**] 06:30AM BLOOD PT-24.2* PTT-27.6 INR(PT)-2.3*
[**2107-8-2**] 06:15AM BLOOD PT-25.6* PTT-28.9 INR(PT)-2.4*
[**2107-8-3**] 06:30AM BLOOD Glucose-100 UreaN-18 Creat-0.7 Na-139
K-4.0 Cl-105 HCO3-28 AnGap-10
[**2107-8-2**] 06:15AM BLOOD Glucose-110* UreaN-15 Creat-0.6 Na-136
K-4.0 Cl-104 HCO3-26 AnGap-10
[**2107-8-1**] 06:30AM BLOOD Glucose-112* UreaN-13 Creat-0.7 Na-137
K-4.0 Cl-104 HCO3-27 AnGap-10
[**2107-8-2**] 06:15AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
Brief Hospital Course:
ASSESSMENT & PLAN: The patient is a 70-year-old man with a
history of Parkinson disease and falls who is presenting with
changes in behavior at home and a newly discovered right hip
fracture.
.
1. Right subcapital femoral neck fracture: Pt was not in pain
prior to operation, fracture was found due to fall at home and
inability to ambulate. His INR was reversed with PO vit K and
he was bridged to heparin prior to procedure. On [**7-26**] he went
to the OR for a right hip hemiarthroplasty. Postoperatively, he
had difficulty with extubation and required a course in the
TICU. During his post-op course, coumadin was restarted and the
pt developed a large hematoma in the wound bed requiring pRBCs
and surgical evacuation on [**7-28**]. Cardiology was consulted at
this point and recommended waiting 2 days prior to restarting
coumadin. He was transferred to the medical service on [**7-30**]
after restarting coumadin. He worked with PT and was able to
stand with assistance, although at his baseline he can ambulate
on his own with a walker. He will need aggressive PT and will
need follow-up with orthopedics.
.
2. Altered mental status: The patient's baseline is AOx2. Per
the wife, he was altered at home the day after his fall (more
confused, not taking POs). On admission to medicine originally,
he was AOx0-1, although he was quite alert. Post-operatively,
he was still AOx0 but less alert, and as his course continued he
became progressively more alert but still remained AOx1.
Infectious workup was negative throughout his course; he
remained afebrile, blood cx/ucx were negative, and he never
developed a leukocytosis or penia.
.
3. +Sputum culture: during his TICU stay, he had a sputum
culture from an ETT that was positive for MRSA. It is unclear
why this culture was performed, as he had no signs of infection
throughout his course. 2 CXR after this sample was obtained
were negative for infiltration; the pt never developed a fever
or leukocytosis. He was not treated in the TICU and by the time
he arrived on the medical floor, it was determined that he was
~5d after the culture was obtained and that in all likelihood he
was not infected. He was not treated for this culture during
this course.
.
4. Aortic valve replacement: Anticoagulation started [**7-30**]. After
his hematoma evacuation, he was restarted on coumadin 2.5 by the
ortho team. It is unclear why he did not resume his old dose.
However, he was resumed on 2.5 qd on the medical floor with INRs
in the low 2s (not consistently therapeutic above 2.5). He will
be discharged on 3mg QD and will need follow-up INRs to ensure
that he is within the therapeutic window of 2.5-3.5. It is
important that he be above 2.5 for his valve, and be less than
3.5 as his risk of bleeding and hematoma development in the
wound site would be quite high.
.
5. Parkinson disease and dementia: Continuing home regimen of
selegiline, carbidopa-levidopa, Exelon, and clozapine. On
admission, his citalopram was held due to his AMS and
citalopram's interaction with his selegiline. It was felt prior
to receiving general anesthesia that it would be best to d/c his
citalopram (low dose, unlikely to cause withdrawal). It was not
restarted afterwards, and should be left to his PCP to restart
at some point in the future.
.
6. Hypotension: on midodrine since last admission. No episodes
of hypotension during this admission.
.
7. Anal fistula: unclear etiology. Continued bacitracin
ointment [**Hospital1 **].
Medications on Admission:
1. selegiline HCl 5 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
2. selegiline HCl 5 mg Capsule Sig: One (1) Capsule PO NOON (At
Noon).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. warfarin 1 mg Tablet Sig: 3.5 Tablets PO QTUTHSA (TU,TH,SA).
6. warfarin 2 mg Tablet Sig: Two (2) Tablet PO QMoWeFrSu.
7. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
Q3H (every 3 hours).
8. clozapine 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
Daily ().
10. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
11. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Take during waking hours (not before bed).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Medications:
1. selegiline HCl 5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day, once in AM and once at noon).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
Q24H (every 24 hours).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
Q3H (every 3 hours).
11. clozapine 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO TID (3 times a day).
14. 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.
15. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right femoral neck fracture
Right hip wound hematoma
post operative blood loss anemia
post operative fluid volume deficit
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr [**Known lastname 7725**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted for confusion and found during your workup to have a
right hip fracture which was repaired by orthopedic surgery on
[**7-26**]. After the operation, you had bleeding into the surgical
site, which required a return trip to the OR for drainage.
Afterwards, you had a wound vacuum placed over the incision to
help facilitate healing which was removed prior to discharge.
You also had continued confusion during your hospital course
that was originally due to your hip fracture, and afterwards was
due to the anesthesia from your operations; this is common.
Please make the following changes to your medications:
Please STOP citalopram.
Please STOP your previous warfarin dosing.
Please START warfarin 3mg everyday. This will likely have to be
changed in the future, but your dose was lowered due to the risk
for further bleeding into your operation.
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Keep pin sites clean and dry.
-Sutures/staples will be removed at your first post-operative
visit.
Activity:
-Continue to be _ weight bearing on your left/right arm/leg.
-You should not lift anything greater than 5 pounds.
-Elevate right/left arm/leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
Followup Instructions:
Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A.
Specialty: INTERNAL MEDICINE
Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 7728**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge**
Department: ORTHOPEDICS
When: WEDNESDAY [**2107-8-10**] at 7:50 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2107-8-10**] at 8:10 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"E849.7",
"820.8",
"V10.46",
"294.10",
"998.12",
"V43.3",
"401.9",
"V58.61",
"285.1",
"331.82",
"737.10",
"565.1",
"E888.9",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
8783, 8855
|
3013, 4149
|
305, 420
|
9021, 9021
|
2097, 2990
|
10650, 11578
|
1259, 1286
|
7442, 8760
|
8876, 9000
|
6535, 7419
|
9198, 9891
|
1301, 2078
|
9920, 10160
|
244, 267
|
10173, 10627
|
448, 804
|
9036, 9174
|
826, 1080
|
1096, 1243
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,098
| 102,732
|
52950
|
Discharge summary
|
report
|
Admission Date: [**2141-5-2**] Discharge Date: [**2141-5-10**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname **] is an 82 year-old male with a history of diastolic
dysfunction, recent MRSA pneumonia, and asthma, who initially
presented on [**2141-5-1**] with a 1-day history of increased SOB,
productive cough and congestion.
On arrival to the ED, CXR showed moderate CHF. He was
empirically started on Vancomycin, CTX, Prednisone, and Lasix,
with some improvement. However, after several hours in the ED,
he became hypertensive, tachycardic, and hypoxemic, with
desaturation to the 80s. He was started on a nitro drip and
intubated. In ED, he was also noted to have anterolateral EKG
changes, with new TWI in I, aVL, and "pseudonormalization" of T
waves in V3-6. Enzymes elevated. He was admitted to the MICU for
further care.
Past Medical History:
1. Diastolic dysfunction
2. Hypertension
3. Asthma
4. History of bronchiolitis obliterans pneumonia ([**4-/2134**])
5. Chronic renal failure with baseline creatinine high 2s-low 3s
6. History of diverticular bleed, and upper GI bleed in 03/[**2140**].
EGD with gastric erosions.
7. Colonic adenoma
8. Giardia ([**3-/2137**])
9. CVA in [**2127**]
10. MRSA pneumonia in [**2-/2141**]
Social History:
He is originally from [**Country 4812**]. He lives with his daughter in
[**Name (NI) **].
Family History:
Non-contributory.
Physical Exam:
Physical examination at the time of transfer from the ICU:
VITALS: Tm 99.2/98.2, BP 110-140/50-60s, HR 60-70s, RR teens,
Sat 96-100% on face mask 0.50.
GEN: Appears comfortable, sitting in chair.
HEENT: Anicteric, MMM.
NECK: EJV distended, unable to assess JVP.
RESP: Bibasilar ronchi. Bilateral expiratory wheezes.
CVS: RRR. Normal S1, S2. Heart exam limited secondary to breath
sounds.
GI: BS NA. abdomen soft, non-tender.
EXT: Without edema.
Pertinent Results:
Relevant laboratory data on admission:
CBC [**2141-5-2**]:
WBC-17.1*# RBC-3.43* HGB-9.8* HCT-29.1* MCV-85 MCH-28.6
MCHC-33.7 RDW-16.0*
NEUTS-81* BANDS-3 LYMPHS-10* MONOS-6 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
Chemistry:
GLUCOSE-179* UREA N-39* CREAT-2.9* SODIUM-132* POTASSIUM-5.3*
CHLORIDE-98 TOTAL CO2-19* ANION GAP-20
CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.4*
Coagulation:
PT-13.9* PTT-24.8 INR(PT)-1.2*
Microbiology:
[**2141-5-9**] URINE negative
[**2141-5-4**] URINE CULTURE negative
[**2141-5-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{MORAXELLA CATARRHALIS, PRESUMPTIVE IDENTIFICATION} INPATIENT
[**2141-5-2**] URINE CULTURE negative
[**2141-5-2**] BLOOD CULTURE negative
Other data: HbA1c and PTH pending.
Relevant imaging data:
[**2141-5-2**] CXR: Moderate CHF
[**2141-5-2**] CXR: NG tube, worsened CHF
[**2141-5-2**] CXR: ETT, persistent pulmonary edema
ECHO [**2141-5-2**]: LV thickness normal. Moderate regional LV
systolic dysfunction. Overall LVEF is moderately depressed (LVEF
35%). Resting regional wall motion abnormalities include mid to
distal septal and apical akinesis. RV normal. Aortic valve
leaflets are mildly thickened and there is focal calcification
of the noncoronary cusp. No AS. Mild AR. [**12-19**]+ MR. Compared to
prior, worse EF, new WMA. E/A 1.60.
[**2141-5-3**] CXR: Moderately severe pulmonary edema has changed in
distribution but not in overall severity, accompanied by
persistent small left and small-to-moderate right pleural
effusion and borderline cardiomegaly. ET tube in standard
placement.
[**2141-5-4**] CXR: Markedly improved CHF.
[**2141-5-9**] CXR: Small bilateral plerual effusions, with RLL
atelectasis.
Brief Hospital Course:
82 year-old male with CHF, CRI, prior GI bleed (both upper and
lower), admitted with respiratory failure. His hospital course
will reviewed by problems.
1. Respiratory failure: His acute decompensation was felt most
consistent with flash pulmonary edema, requiring intubation.
While in the ICU, he was diuresed with IV Lasix, switched to
oral Lasix with good results. He was also continued empirically
on Vancomycin and CTX for coverage of CAP. Sputum gram stain
returned positive for GN diplococci, and culture eventually grew
Moraxella catarrhalis. Vancomycin was discontinued on [**2141-5-5**].
He self-extubated on [**2141-5-4**], and did well thereafter. He
completed a 7-day course of CTX on [**2141-5-8**] for Morazella in his
sputum. Please see below for further details on his CHF
management.
2. CAD: His cardiac enzymes on admission were noted to be
trending up, and an EKG was concerning for "pseudonormalization"
of T waves in V3-6 versus 04/[**2140**]. It is of note that cardiac
enzymes were not obtained in [**3-/2141**] in the setting of these
changes. He was briefly started on heparin, which was
discontinued in the setting of a hematocrit drop and probable
demand ischemia rather than ACS. An echo was obtained on
[**2141-5-2**], which revealed new systolic dysfunction with EF 35%,
with mid to distal septal and apical akinesis. Cardiology was
consulted. Review of his records indicated a recent echo with
preserved systolic function in 03/[**2140**]. He was felt to have
likely had a recent anterior MI, with superimposed
demand/subendocardial ischemia. He was deemed a poor
catheterization candidate given his stage IV CKD, and medical
management was advised. His troponin continued to rise in the
ICU, but CK was trending down. He was continued on ASA and
statin. Toprol was changed to Metoprolol (not renally cleared),
which was titrated up. He was started on Captopril while in the
ICU, subsequently discontinued in the setting of an acute rise
in his creatinine. Hydralazine and Isordil were subsequently
started (lower dose than before admission).
3. CHF: As noted above, he was found to have new systolic
dysfunction, felt likely secondary to a recent anterior MI. In
addition, he likely has a component of diastolic dysfunction.
His acute presentation was felt secondary to flash pulmonary
edema, and he responded well to diuresis. He was weaned off
oxygen, and was saturating well on room air at the time of
discharge. He was placed back on Lasix 40 mg daily. Please note
that while in the hospital, his oral Lasix was transiently held
in the setting of hyponatremia, which improved after holding
Lasix for 48 hours. His sodium and creatinine will need to be
closely monitored as an out-patient. He needs to remain on Lasix
from a cardiac standpoint. He was also discharged oh Hydralazine
25 mg PO QID and Imdur 30 mg daily for afterload reduction
(acute rise in creatinine with Captopril).
3. GI bleed: While in the hospital, he was noted to have guaiac
positive stools, associated with a hematocrit drop to 24 on
[**2141-5-2**] (albeit also in the setting of a short course of IV
heparin). He was transfused 2 units of PRBCs on that day. Review
of his recent data indicated an EGD in [**2-/2141**] remarkable for
gastric erosion. He was placed on PRotonix 40 mg twice daily
(initially IV then PO), and Carafate PO QID. His hematocrit
remained stable thereafter, and further work-up was not pursued.
4. CRI: Patient with known CKD with fluctuating creatinine at
baseline, followed by Dr. [**Last Name (STitle) 3271**] as an out-patient. While in
the hospital, his creatinine rose to a peak of 4.2, at one point
with concomitant hyperkalemia and hyperphosphatemia. He was
started on CaCO3 and Sevelamer, with correction of his
hyperphosphatemia. A recent renal U/S in [**2-/2141**] was remarkable
for thin cortices suggestive of parenchymal disease. Prior lab
data were also remarkable for known nephrotic range proteinuria,
negative SPEP/UPEP in [**2139**]. The renal service was consulted on
[**2141-5-9**] for further advice, with an impression of probable
hypertensive nephrosclerosis possibly also with superimposed
FSGS. He had no indication for acute hemodialysis, although it
is likely that he will need long-term hemodialysis in the near
future. His family, however, is very reluctant to consider it.
Follow-up appointment scheduled with Dr. [**Last Name (STitle) 118**] in Nephrology
per Dr. [**Last Name (STitle) 1860**]. PTH pending at the time of discharge.
5) Hyponatremia: On [**2141-5-7**], his sodium was noted to drop to
127. His Lasix was held for 48 hours, with eventual improvement
in his sodium to 131. Urine lytes revealed UNa 25, Uosm 371,
Uurea 646. He was also placed on fluid restriction 1000 mL. He
will need close out-patient follow-up of his sodium and
creatinine. Lasix was restarted at the time of discharge (40 mg
daily).
6) Leukocytosis: His WBC was noted to rise slightly again on
[**2141-5-9**]. A repeat U/A was negative, and a repeat CXR showed
only RLL atelectasis without clear infiltrate. His WBC was back
down to normal on [**2141-5-10**].
7) Hematuria: While in the hospital, he was noted to have
microscopic hematuria. He will need further work-up as an
out-patient.
Medications on Admission:
Albuterol inhaler
Fluticasone inhaler
Salmeterol inhaler
Clonidine TD 0.1 mg
Lasix 40 mg daily
Imdur 60 mg daily
Amlodipine 10 mg daily
Lipitor 10 mg daily
Protonix
Toprol 50 mg daily
Hydralazine 50 mg PO QID
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: [**12-19**]
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
11. 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*
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Congestive heart failure
Probable coronary artery disease
Chronic kidney disease
Hyponatremia
Tracheobronchitis
Gastrointestinal bleeding
Discharge Condition:
Patient discharged home in stable condition, with stable
saturation on room air.
Discharge Instructions:
Please weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight > 3
lbs.
Adhere to 2 gm sodium diet. Fluid Restriction: 1000 mL.
Please note that we have made some changes to your medications.
Please take all medications as prescribed. Briefly, we have
decreased Imdur to 30 mg daily. We have stopped Toprol and
started Metoprolol 100 mg three times daily. We have stopped
Amlodipine. We have finally decreased the dose of Hydralazine to
25 mg four times daily. In addition, please take a full dose
aspirin (325 mg) daily.
We have started 2 medications for your kidneys which help keep
the phosphate level in your body within normal limits. They are
calcium carbonate and Sevelamer. Please take them as prescribed.
You will need close follow-up of your blood work as an
out-patient. In addition, please see below for recommended
follow-up appointments.
Please return to the ED or call your PCP if you develop chest
pain, worsening shortness of breath, or if you notice black or
bloody stools.
Followup Instructions:
1. Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an
appointment to be seen within the next 2 weeks. It is important
that you [**Last Name (Titles) **] this appointment.
2. You also have a scheduled appointment with Dr. [**Last Name (STitle) 118**]
(Nephrology) on Tuesday [**5-16**] at 0830 in the morning. His
office is located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Clinical
center, in Medical Specialties.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2141-5-10**]
|
[
"410.71",
"599.7",
"276.1",
"398.91",
"518.81",
"585.4",
"396.3",
"482.83",
"403.91",
"578.9",
"493.90",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11001, 11059
|
3772, 9023
|
241, 267
|
11241, 11324
|
2067, 2092
|
12381, 12987
|
1567, 1586
|
9282, 10978
|
11080, 11220
|
9049, 9259
|
11348, 12358
|
1601, 2048
|
181, 203
|
295, 1038
|
2106, 3749
|
1060, 1443
|
1459, 1551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,739
| 145,682
|
7664
|
Discharge summary
|
report
|
Admission Date: [**2136-5-3**] Discharge Date: [**2136-5-6**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 80 year old male with
coronary artery disease status post non-ST elevation
myocardial infarction on [**2136-4-23**] presenting with
non-sustained ventricular tachycardia and syncope. His past
medical history is significant for coronary artery disease
status post two stents to the left anterior descending,
percutaneous coronary intervention without stent to the D1
and stent to the obtuse marginal 2, end-stage renal disease
on hemodialysis, hypertension, hypercholesterolemia,
hyperthyroidism, and Factor IV Leiden mutation.
He was in his usual state of health until [**4-19**] when he
was found unresponsive by his daughter who felt he possibly
had taken too much Trazodone. He was taken to an outside
hospital and found to have "non-sustained ventricular
tachycardia" responsive to lidocaine. He was noted to have a
non-ST elevation myocardial infarction with troponin of 8.4.
He was transferred to [**Hospital1 69**]
for catheterization. The catheterization found two vessel
disease with a 70% mid-left anterior descending with a
percutaneous transluminal coronary angioplasty and stent, a
D1 at 80% treated with cutting balloon, a left circumflex
with 80% obtuse marginal 1 that was percutaneous transluminal
coronary angioplastied and stented and a left ventricular
ejection fraction of 41% with anterior and lateral and apical
hypokinesis.
Yesterday he was seen in the primary care physician's office
and noted palpitations and was set up for a Holter and
electrophysiology appointment as an outpatient. Today at
hemodialysis, he again noted palpitations and was sent to the
Emergency Room. In the Emergency Room, he was noted to have
an episode of syncope, however, was not on the monitor at the
time. He was placed on the monitor and had several runs of
polymorphic R on T ventricular tachycardia, approximately 10
to 15 beats. This is symptomatic with palpitations and hot
flashes.
He spontaneously converted each time and received no shocks.
He was given magnesium sulfate 2 grams intravenous as well as
lidocaine 100 mg bolus and 2 mg per minute drip thereafter.
He was admitted to the Cardiac Care Unit with plans of
placement for an implantable cardioverter-defibrillator. At
the time of being seen by the Cardiac Care Unit staff, he had
no complaints.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post non-ST elevation
myocardial infarction on [**4-19**]. Please see the details of
the catheterization in his catheterization report dated [**4-23**].
2. Prostate cancer.
3. End-stage renal disease on hemodialysis.
4. Hypertension.
5. Hyperlipidemia.
6. Hypercholesterolemia.
7. Hyperthyroidism.
8. Gout.
9. Factor IV Leiden mutation, heterozygous with history of
bilateral superficial thrombosis.
MEDICATIONS:
1. Lisinopril 10 mg once daily.
2. Aspirin 325 mg once daily.
3. Metoprolol 50 mg once daily.
4. Lipitor 20 mg once daily.
5. Coumadin 1 mg once daily.
6. ............ 0.25 mg once daily.
7. Casodex 50 mg once daily.
8. Renagel 800 mg once daily.
9. Nephrocaps.
10. Colace 100 mg twice a day.
11. Allopurinol.
12. Ativan.
13. Leuprolide injection q month.
ALLERGIES: Codeine which causes nausea and vomiting.
FAMILY HISTORY: Notable for coronary artery disease.
SOCIAL HISTORY: History of tobacco, quit 38 years ago, 50
pack year history. Denies any alcohol. He lives with his
daughter and ambulates with a cane.
PHYSICAL EXAMINATION: General: He is a pleasant, elderly
gentleman in no apparent distress. Vital signs: Temperature
98.4 F, pulse 56 and regular, blood pressure 138/45,
respiratory rate 16, oxygen saturation rate 97% on 2 liters.
Head, eyes, ears, nose and throat: Normal cephalic,
atraumatic, pupils are equal, round, and reactive to light,
extraocular movements intact, sclera anicteric, moist mucous
membranes. Neck: Supple, no jugular venous pressure,
notable hepatojugular reflux. Lungs: Bibasilar rales, no
wheezes, breathing non-labored. Cardiovascular: Regular
rate and rhythm, normal S1 S2, no murmurs. Abdomen: Soft,
non-tender, non-distended with normal active bowel sounds.
Extremities: No edema, 2+ pulses dorsalis pedis. ..........
was noted to have a bruit and palpitations, thrill but no
erythema. Neurological: Alert and oriented times three,
mood appropriate, cranial nerves 2 through 12 grossly intact.
LABS: White blood count 11.1 with normal differential;
hematocrit 31.2; platelets 249; coags within normal limits;
sodium 143; potassium 5.1; chloride 99; bicarbonate 29; BUN
23; creatinine 3.1; glucose 59; calcium 9.4; magnesium 1.9;
phosphatase 2.3; TSH pending; electrocardiogram at 3:42 p.m.
showed sinus bradycardia with 58 beats per minute, normal
axis, and left bundle branch block and prolonged QT. At 4:53
he was noted to be sinus bradycardia, 57 beats per minute
with a normal axis and left bundle branch block and prolonged
QT. Telemetry showed R on T polymorphic ventricular
tachycardia. Chest x-ray was negative for infiltrate or
congestive heart failure.
HOSPITAL COURSE: This is an 80 year old male with a history
of coronary artery disease status post NSTEMI with a recent
catheterization with stent to the left anterior descending,
obtuse marginal with a percutaneous coronary angioplasty to
D1 and ejection fraction of 41% with symptomatic polymorphic
R on T VT. Given his syncope and ventricular tachycardia
noted in the Emergency Room, he was admitted to the Cardiac
Care Unit on a lidocaine drip. The following morning he was
taken to the Electrophysiology Laboratory and had an
implantable cardioverter-defibrillator implanted without
complications. He was then transferred back to the cardiac
floor for further monitoring. The following morning, he was
noted on telemetry to be pacing 75. He had no complaints at
that time. A chest x-ray confirmed placement of the
implantable cardioverter-defibrillator with leads in place.
He was given routine antibiotics prophylactically and was
discharged on [**5-6**] with recommendations to follow-up in
the device clinic in one week.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home with follow-up in
Electrophysiology Device Clinic in one week.
DISCHARGE DIAGNOSIS:
1. Syncope.
2. Non-sustained ventricular tachycardia.
DISCHARGE MEDICATIONS:
1. Lisinopril 10 mg once daily.
2. Aspirin 325 mg once daily.
3. Metoprolol 50 mg once daily.
4. Lipitor 20 mg once daily.
5. Coumadin 1 mg once daily.
6. ............ 0.25 mg once daily.
7. Casodex 50 mg once daily.
8. Renagel 800 mg once daily.
9. Nephrocaps.
10. Colace 100 mg twice a day.
11. Allopurinol.
12. Ativan.
13. Leuprolide injection q month.
FOLLOW-UP: He will follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], as well as in the
Electrophysiology Device Clinic within one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 14434**]
MEDQUIST36
D: [**2137-1-20**] 16:14
T: [**2137-1-22**] 19:25
JOB#: [**Job Number 27877**]
|
[
"410.72",
"286.3",
"V45.82",
"414.01",
"599.0",
"403.91",
"244.9",
"272.0",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"37.94",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
6191, 6289
|
3324, 3362
|
6390, 7269
|
6310, 6367
|
5150, 6169
|
3540, 5132
|
114, 2406
|
2428, 3307
|
3379, 3517
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,258
| 196,695
|
7362
|
Discharge summary
|
report
|
Admission Date: [**2195-7-21**] Discharge Date: [**2195-7-28**]
Date of Birth: [**2118-5-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Mitral insufficiency/endocarditis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 77 yo man wtih h/o CAD, PVD presented to OSH on
[**2195-7-16**] with confusion and urinary incontinence. Per wife was
having low grade fevers at home prior to admission. he developed
confusion and urinary incont 1 day PTA to OSH. MRI showed
multiple acute strokes in the brain and blood cultures from [**7-16**]
and 19 grew e. faecalis. he was started on Ampicillin and
vancomycin on [**2195-7-18**]. Echo showed 1.7 cm vegetation on mitral
valve. Patient seen by ID and abx changed to Ampicillin and
Gentimicin. The source of this endocarditis appears to be a UTI
he had in [**Month (only) 205**] of this year which grew out enterococcus on
culture.
.
Pt had 9/10 chest pain prior to transfer to [**Hospital1 **]. he was given
nitro paste 1 inch, IV lopressor and placed on nrb. This am, he
denies chest pain, sob, palpatations, abd pain, N/V. He is on NC
4L and satting 92%.
Past Medical History:
CAD MI in [**2187**], [**2188**], stented in [**2188**] at Deaconness (no report
in computer)
PVD
DM
Hyperlipidemia
HTN
Oxygen dependent COPD
Aortoilliac atherosclerotic disease
Left iliac aneurysm with no repair.
Social History:
Lives at home with his wife. retired [**Name2 (NI) 27127**] man. NO pets.
quit smoking in [**2153**]. denies etoh
Family History:
NC
Physical Exam:
VS: T 95.7 BP 149/76 HR 97 O2 98% on NRB
gen-sleeping, well-appearing , NAD
HEENT- NC, AT, anicteric, no injections, OP clear, MMM
Cor- [**2-2**] HSM at apex
lungs- bibasilar crackles and wheezes, overall poor aeration
with prolonged exp
abd- +bs, soft nt nd no masses or hsm, umbilibical
hernia-reducible
extrem- pedal pulses 2+bl, no edema or splinter hemorrhages
neuro- cn2-12 intact, strength and sensation normal, cerebellar
signs normal no pronator drift and nl finger to nose
A+O x 2 did not know date.
Pertinent Results:
[**2195-7-22**] 06:35AM BLOOD WBC-10.1 RBC-3.36* Hgb-10.2* Hct-30.1*
MCV-90 MCH-30.3 MCHC-33.9 RDW-13.7 Plt Ct-161
[**2195-7-22**] 06:35AM BLOOD Glucose-112* UreaN-22* Creat-1.1 Na-137
K-3.9 Cl-99 HCO3-32 AnGap-10
[**2195-7-22**] 06:35AM BLOOD ALT-45* AST-27 LD(LDH)-339* CK(CPK)-25*
AlkPhos-111 Amylase-39 TotBili-0.8
[**2195-7-22**] 06:35AM BLOOD Albumin-3.0* Calcium-9.6 Phos-3.7 Mg-2.2
[**2195-7-22**] 12:33AM BLOOD Type-ART pO2-71* pCO2-54* pH-7.40
calTCO2-35* Base XS-6
echo:
The left atrium is moderately dilated. Overall left ventricular
systolic
function is normal (LVEF>55%). Tissue velocity imaging E/e' is
elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
right
ventricular free wall is hypertrophied. The aortic root is
mildly dilated. The
aortic valve leaflets are moderately thickened. There is no
aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are
moderately thickened and there is mild to moderate mitral inflow
gradient.
There are large echodense structures associated with the mitral
valve that are
consistent with calcification and probable vegetation (although
prior study
not available to assess acuity of findings). Mild to moderate
([**12-1**]+) mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] There is severe pulmonary artery systolic
hypertension. There
is no pericardial effusion.
[**2195-7-24**] 01:46AM BLOOD WBC-29.4*# RBC-3.19*# Hgb-10.0*#
Hct-29.5*# MCV-93 MCH-31.5 MCHC-34.0 RDW-14.3 Plt Ct-198#
[**2195-7-24**] 06:23AM BLOOD WBC-38.0* RBC-3.26* Hgb-9.8* Hct-29.4*
MCV-90 MCH-30.1 MCHC-33.3 RDW-14.3 Plt Ct-196
[**2195-7-25**] 03:54AM BLOOD WBC-20.9* RBC-3.05* Hgb-9.7* Hct-27.5*
MCV-90 MCH-31.9 MCHC-35.3* RDW-15.0 Plt Ct-138*
[**2195-7-26**] 05:03AM BLOOD WBC-23.2* RBC-2.88* Hgb-8.9* Hct-26.0*
MCV-90 MCH-31.0 MCHC-34.4 RDW-15.2 Plt Ct-159
[**2195-7-24**] 12:03AM BLOOD Neuts-80.1* Lymphs-16.7* Monos-2.7
Eos-0.4 Baso-0.1
[**2195-7-26**] 05:03AM BLOOD PT-21.6* PTT-34.4 INR(PT)-2.1*
[**2195-7-26**] 05:03AM BLOOD Glucose-147* UreaN-63* Creat-5.7* Na-128*
K-5.6* Cl-97 HCO3-22 AnGap-15
[**2195-7-25**] 03:02PM BLOOD Glucose-137* UreaN-53* Creat-4.4* Na-131*
K-4.9 Cl-96 HCO3-20* AnGap-20
[**2195-7-25**] 03:54AM BLOOD Glucose-154* UreaN-47* Creat-3.7*# Na-134
K-4.2 Cl-97 HCO3-24 AnGap-17
[**2195-7-24**] 06:23AM BLOOD Glucose-193* UreaN-33* Creat-1.9* Na-136
K-4.8 Cl-99 HCO3-22 AnGap-20
[**2195-7-24**] 12:37AM BLOOD Glucose-162* UreaN-30* Creat-1.6* Na-139
K-5.0 Cl-101 HCO3-16* AnGap-27*
[**2195-7-26**] 05:03AM BLOOD ALT-3455* AST-1829* AlkPhos-172*
TotBili-1.5
[**2195-7-25**] 03:54AM BLOOD ALT-4872* AST-4263* LD(LDH)-2383*
AlkPhos-152* TotBili-1.7*
[**2195-7-24**] 06:23AM BLOOD ALT-5290* AST-7350* LD(LDH)-[**Numeric Identifier **]*
CK(CPK)-425* AlkPhos-124* TotBili-1.5
[**2195-7-24**] 12:37AM BLOOD ALT-3921* AST-3616* LD(LDH)-8875*
CK(CPK)-188* AlkPhos-118* TotBili-0.9
[**2195-7-24**] 10:03PM BLOOD CK-MB-10 MB Indx-2.3
[**2195-7-24**] 02:01PM BLOOD CK-MB-14* MB Indx-3.0 cTropnT-1.10*
[**2195-7-24**] 06:23AM BLOOD CK-MB-16* MB Indx-3.8 cTropnT-0.85*
[**2195-7-24**] 12:37AM BLOOD CK-MB-3 cTropnT-0.37*
[**2195-7-26**] 05:03AM BLOOD Calcium-9.2 Phos-6.4*# Mg-2.6
[**2195-7-24**] 06:23AM BLOOD Calcium-9.2 Phos-4.5# Mg-2.3
[**2195-7-26**] 11:01AM BLOOD Type-ART pO2-164* pCO2-32* pH-7.36
calTCO2-19* Base XS--6
[**2195-7-26**] 09:09AM BLOOD Type-ART pO2-64* pCO2-33* pH-7.37
calTCO2-20* Base XS--4
[**2195-7-24**] 03:42AM BLOOD Lactate-7.9*
BILAT LOWER EXT VEINS PORT [**2195-7-25**] 12:40 PM
BILAT LOWER EXT VEINS PORT
Reason: PEA ARREST, EVAL FOR DVT
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with CHF, s/p PEA arrest, unable to get CTA
REASON FOR THIS EXAMINATION:
evaluate for DVT
INDICATION: 77-year-old man with CHF status post PEA arrest
evaluate for DVT.
There are no prior studies for comparison.
.
BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: Bilateral femoral
lines limit evaluation of the common femoral veins. Grayscale,
color, and Doppler son[**Name (NI) 1417**] of the right and left superficial
femoral and popliteal veins demonstrate normal compressibility,
waveforms, color flow, and augmentation. There is no evidence of
intraluminal thrombus.
IMPRESSION:
1. No DVT in the superficial femoral or popliteal veins. The
common femoral veins were not able to be evaluated.
CT HEAD W/O CONTRAST [**2195-7-24**] 2:21 PM
CT HEAD W/O CONTRAST
Reason: eval for new emboli to brain vs. bleeding of existing
emboli
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with known enterococcus endocarditis with emboli
to brain now s/p code with bradycardia and complete heart block
REASON FOR THIS EXAMINATION:
eval for new emboli to brain vs. bleeding of existing emboli.
CONTRAINDICATIONS for IV CONTRAST: acute renal failure
REASON FOR EXAMINATION: History of known enterococcus
endocarditis with emboli to the brain. Evaluate for new emboli
and/or bleeding to the brain.
TECHNIQUE: Head CT without intravenous contrast with contiguous
5-mm axial images from the skull vertex to the base.
No prior head CT for comparison. Compared to the MR of [**2195-7-23**].
FINDINGS: There is no evidence of acute intracranial hemorrhage.
There are multiple areas of hypodensity in both [**Doctor Last Name 352**] and white
matter of both cerebral hemispheres, and more predominantly so,
in the cerebellum. These most likely represent embolic infarct,
and are greater in number than the infarcts seen on MR of
[**2195-7-23**]. In addition, not seen on the MR done the day before, is
loss of [**Doctor Last Name 352**]-white matter differentiation consistent with
generalized brain swelling. There is a chronic lacune in the
head of the left caudate nucleus. There is no shift of midline
structures or hydrocephalus.
IMPRESSION:
1. Findings consistent with multiple embolic infarcts
bilaterally above and, more predominantly, below the tentorium,
more in number than on MR of [**2195-7-23**].
2. No evidence of acute intracranial hemorrhage.
3. Generalized brain swelling, new from MR of [**2195-7-23**].
.
MR HEAD W & W/O CONTRAST [**2195-7-23**] 11:31 AM
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: eval for emboli
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with endocarditis
REASON FOR THIS EXAMINATION:
eval for emboli
MRI SCAN OF THE BRAIN WITH GADOLINIUM ENHANCEMENT
HISTORY: Endocarditis. Evaluate for emboli.
TECHNIQUE: Multiplanar T1- and T2-weighted gadolinium-enhanced
brain imaging.
COMPARISON STUDIES: None.
FINDINGS: The conventional images are poor quality due to
patient motion. However, they are sufficient to demonstrate
innumerable foci of elevated T2 signal, nearly all 1 cm or less
in size within the white matter of both cerebral hemispheres.
There are likely a few additional T2 hyperintense lesions within
the pons and inferior aspect of the right cerebellar hemisphere
but motion artifacts render such interpretation more
problem[**Name (NI) 115**]. Several of the lesions, most notably a 1 cm lesion
in the posterior left thalamic/caudate nucleus region, show
elevated signal on diffusion-weighted images; however, only one
of these appears to have correspondingly abnormal signal on the
ADC map. This latter lesion, therefore, could represent an area
of acute brain ischemia while the other lesions are subacute to
chronic in age. Again, these latter lesions presumably are the
remnants of chronic infarcts.
The gadolinium enhanced images unfortunately also are motion
degraded. There do appear to be at least two tiny areas of
contrast enhancement deep within sulci of the left temporal
lobe, with the third area, similar in size within the left
occipital lobe. The enhancement pattern may be either
leptomeningeal or involve new portions of the cerebral gyri. If
leptomeningeal, either an inflammatory/infectious or neoplastic
etiology could be considered. If gyral, a broad range of
abnormalities, including multiple areas of infarction,
inflammatory, post-traumatic and less likely neoplastic disease
could be considered. There is no hydrocephalus or shift of
normally midline structures. There were no areas of abnormal
susceptibility seen within the brain parenchyma. The surrounding
osseous and soft tissue structures do not display additional
abnormalities.
CONCLUSION: Numerous T2 hyperintense foci, at least one of which
is abnormal on the ADC map. In all probability, multiple small
vessel infarctions would be the most reasonable diagnosis.
Leptomeningeal and/or gyral abnormalities within the left
temporal and occipital lobe, with differential diagnosis as
discussed above.
MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **] AND ITS TRIBUTARIES.
TECHNIQUE: Three-dimensional time-of-flight imaging with
multiplanar reconstructions.
FINDINGS: The study is of poor quality due to patient motion.
Granting these limitations, the major vascular tributaries of
the circle of [**Location (un) 431**] appear patent. No overt evidence for the
presence of an aneurysm or vascular malformation, or
hemodynamically significant area of stenosis is identified.
However, it is to be emphasized that the quality of this study
is, at best, marginal.
.
RADIOLOGY Final Report
CAROTID SERIES COMPLETE [**2195-7-22**] 1:31 PM
CAROTID SERIES COMPLETE
Reason: eval for stenosis pre MVR
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with endocarditis
REASON FOR THIS EXAMINATION:
eval for stenosis pre MVR
CAROTID SERIES COMPLETE.
REASON: Preop mitral valve replacement.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries. There is mild plaque noted in the proximal ICA
bilaterally.
On the right, peak systolic velocities are 65, 40, and 355
cm/sec in the ICA, CCA, and ECA respectively. This is consistent
with less than 40% ICA stenosis.
On the left, peak velocities are 55, 52, and 51 cm/sec in the
ICA, CCA, and ECA respectively. This is consistent with less
than 40% ICA stenosis.
There is antegrade vertebral flow bilaterally.
IMPRESSION: Bilateral less than 40% carotid stenosis.
.
CTA ABD W&W/O C & RECONS [**2195-7-22**] 3:30 PM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
Reason: please eval for seeding of left iliac aneurysm
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
Pt is a 77 yo male with enterococcus endocarditis with left
iliac aneursym.
REASON FOR THIS EXAMINATION:
please eval for seeding of left iliac aneurysm
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: Enterococcus endocarditis. Left iliac aneurysm.
Assess for seeding.
TECHNIQUE: Volumetric CT imaging of the abdomen and pelvis was
performed before and after administration of 200 cc of Optiray
IV contrast. Multiplanar reformatted images including 3D
reconstructions were made.
COMPARISON: None.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There are small
bilateral pleural effusions with intralobular septal thickening
and ground-glass opacity in both lower lobes. There is no
pericardial effusion. Dense calcifications are present about the
mitral valve annulus.
No focal hepatic lesions are identified. The patient is status
post cholecystectomy. There are multiple peripheral areas of
decreased attenuation in the spleen, many of which are wedge
shaped. There are multiple low- density lesions throughout both
kidneys which are incompletely assessed, along with areas of
heterogeneous attenuation/cortical thinning. There is no
hydronephrosis. There is a rounded 15 x 13 mm fat- density
nodule in the left adrenal gland. There is diffuse dilatation of
the pancreatic duct in the body and tail, and to a lesser degree
in the head. There is a lobulated low-density cystic mass within
the body which measures 13 x 21 mm. Similar smaller lesions are
present in the tail and uncinate process. The stomach and small
bowel are unremarkable without evidence of bowel wall
thickening. There is no ascites.
CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: There is rectus
diastasis with a large lower abdominal wall fat, colon, and
bladder containing ventral hernia in the midline. Foley catheter
and air are present within the bladder. There are diffuse
colonic diverticula but no evidence of acute diverticulitis.
There is no free fluid in the pelvis or pathological inguinal or
pelvic nodal enlargement.
Severe degenerative changes are seen within the spine. No lytic
or sclerotic lesions are identified.
AORTIC CT ANGIOGRAPHY: There is a moderate diffuse
atherosclerotic plaque involving the abdominal aorta. There is
complete occlusion of the proximal celiac artery, which is
reconstituted by pancreaticoduodenal arcade collaterals. There
is a partially replaced left hepatic artery which supplies
segments [**Doctor First Name 690**] and II. Segments III and IVb are supplied
conventionally. There is severe atherosclerotic disease
involving the splenic artery, which is very tortuous. No
discrete emboli are visualized within the arteries.
Atherosclerotic plaque involves the SMA, but the vessel remains
patent. No intraluminal filling defects are identified within
the main SMA or its proximal branches. There is no portal venous
air. The inferior mesenteric artery is enlarged but patent.
Multiple enlarged lumbar collateral vessels are also present on
the right. There is complete occlusion of the right common iliac
artery at the origin, with filling of the internal iliac via
lumbar collaterals, which reconstitute the external iliac artery
on the right. The origin of the left common iliac artery is
severely narrowed, and there is severe post-stenotic dilatation
measuring up to 2.5 cm in greatest axial dimension. This tapers
down to normal caliber at the level of the bifurcation where
both the internal and external iliac arteries on the left are
normal in caliber. There is moderate diffuse disease involving
both iliac systems.
CT RECONSTRUCTIONS: Coronal and sagittal reformatted images show
complete occlusion of the proximal celiac axis with
reconstitution by pancreaticoduodenal arcades. The
reconstructions were essential in evaluating vascular anatomy.
IMPRESSION:
1. Multiple splenic infarcts. Given history of endocarditis, the
infarcts could be bland or infectious.
2. Complete occlusion of proximal celiac axis with
reconstitution by pancreaticoduodenal arcades, indicating
chronic occlusion.
3. Complete occlusion of the right common iliac artery with
reconstitution from lumbar collaterals via the internal iliac
artery.
4. Severe narrowing of origin of left common iliac artery with
severe post- stenotic aneurysmal dilatation measuring up to 2.5
cm. No mural thrombus or evidence of wall thickening/mycotic
aneurysm.
5. Multiple low-density areas in both kidneys and areas of
irregular perfusion. Areas of infarction cannot be completely
excluded, particularly in the left renal mid pole.
6. Diffuse dilatation of main pancreatic duct with multiple
cystic lesions in pancreas. The largest is in the body measuring
13 x 21 mm. Findings are consistent with diffuse IPMT. Six-month
followup with MRI is recommended.
7. 15-mm left adrenal myelolipoma.
8. Large ventral hernia containing nonincarcerated colon and
bladder.
Brief Hospital Course:
Pt is a 77 yo male with pmhx CAD S/P stent in [**2188**], HTN, DM,
hyperlipidemia, COPD who presents to OSH with urinary
incontinence and confusion found to have acute infarcts probably
septic emboli from endocarditis as demonstrated on
echocardiogram. On admission, the patient was continued on
ampicillin and gentamicin, which had been started at the outside
hospital. His chest pain was worked up for ischemic cause with
EKG and cycling cardiac enzymes, which were negative. He was
placed on telemetry and continued on beta-blocker, statin,
aspirin, and oxygen. Cardiothoracic surgery and infectious
diseases were consulted regarding management of his
endocarditis. Transthoracic echocardiogram was also performed to
evaluate the vegetation. To evaluate for septic emboli, an MRI
of the brain, CT of the abdomen and carotid ultrasound were
ordered (see results section).
On [**7-23**], the patient developed tachycardia at roughly 2100
followed by sinus bradycardia at 2300. In the context of sinus
bradycardia he developed complete heart block and became
asystolic. A code was called and he was not responsive to
atropine and epinephrine x three rounds. CPR was continued and
transcutaneous pacing was successful in reestablishing a pulse.
He was asystolic for approximately 12 minutes during the code.
He was started on dopamine and norepinephrine drips and
transferred to the cardiac intensive care unit. He was sedated
with propofol.
The patient was not in complete heart block following the code
and his AV conduction system was intact on transfer to the unit
as assessed by EKGs. The differential diagnosis for his arrest
was considered to be hypoxia, possibly due to pulmonary
embolism, vs. further septic emboli to brain causing respiratory
suppression or vagal response, vs. transient effect of
endocarditis (considered less likely because of location of
abscess on mitral valve and recovery of conduction system).
In the cardiac care unit his problems were managed as follows:
Cardiac rhythm: A temporary pacing lead was placed via internal
jugular vein approach. The patient demonstrated no further heart
block and was pacer independent, so the lead was removed on day
#3. The patient had some episodes of nonsustained ventricular
tachycardia, which decreased after he was weaned off the
dopamine.
Cardiac Valves: The patient's endocarditis was managed as
described in the ID section below. A transesophageal
echocardiogram was considered not necessary for management
decisions. Cardiac surgery followed the patient and considered
him to be not a candidate for surgery.
.
Cardiac Pump: The patient was initially on levophed and dopamine
and the dopamine was weaned off. Vasopressin was briefly used
for additional pressure support. The patient had evidence of
heart failure prior to code, and his pulmonary edema and
effusions worsened over his stay. The patient's cardiac failure
was exacerbated by poor renal function, leading to volume
overload.
Infectious disease: At the time of transfer, the patient was on
ampicillin and gentamicin for E. Faecalis endocarditis
(sensitivities per OSH microbiology data), which was switched to
Unasyn and gent on [**7-26**] after blood cultures from [**7-24**] grew
Klebsiella pneumonia that was resistant to ampicillin but
sensitive to unasyn. His Unasyn was renally dosed and his gent
troughs were followed. His gentamicin levels were
supratherapeutic as renal failure progressed. Head CT post
arrest revealed more infarcts in brain, consistent with septic
emboli, indicating that patient was continuing to disperse
emboli from endocarditis. The patient also had positive sputum
culture for gram negative rods.
.
# Respiratory
The patient was maintained on a ventilator with assist control
throughout his stay in the unit. He demonstrated some
spontaneous breathing over the ventilation. His oxygen
saturation remained adequate. After arriving at the unit, he had
a chest x-ray that was suspicious for pulmonary embolism but
could not confirm with CTA due to IV infiltration. Lower
extremity dopplers were negative.
.
# Neuro
The patient was asystolic for at least 12 minutes which likely
led to anoxic brain injury. Immediately following code, he was
not responsive to voice or painful stimuli, his pupils were
sluggishly reactive to light, his corneal reflex was intact, but
other reflexes were not elicited. He demonstrated no spontaneous
movements. He was sedated to allow for optimal respiration.
Neurology was consulted and obtained an EEG. A repeat head CT
on [**7-28**] showed progression of infarcts with global edema and
early infarct. The patient's family decided to stop all
interventions at this pointand the patient was made comfort
measures only. He died shortly thereafter on [**2195-7-28**].
.
# Renal
The patient's creatinine rose from admission at 1.0 to 5.6 on
[**7-26**]. He was oliguric, making 100 ccs or less of urine. His
urine output did not respond to fluids. His renal failure was
considered likely the result of acute tubular necrosis due to
hypotensive event. Elevated potassium levels were managed with
kayexelate. Renal was consulted
.
# Elevated LFTs: The patient's AST and ALT rose to greater than
5000, considered likely due to shock liver. His INR was
elevated, thought to be a result of liver failure. Liver enzymes
were followed over the course of stay.
.
# Type2DM: The patient's blood sugars were controlled with
sliding scale insulin.
.
# Nutrition
- Tube feeds were started on [**7-25**] and initially had high
residuals for which standing dose of reglan was ordered. The
patient's residuals improved and he continued with tube feeds.
.
# Code Status: DNR
......
On [**7-28**] a repeat head CT showed increasing edema and early
herniation. The family decided to stop all interventions and
the patient was made comfort measures only. he died shortly
thereafter on a morphine gtt.
.
Medications on Admission:
ASA 81
hytrin 5 QD
glyburide 2.5 mg QD
lopresor 25 QD
kcl 20 mg QD
lovastatin 40 mg QD
albuterol MDI 2 puff QID
folate 1 mg QD
lasix 20 mg QD
clarinex 5 mg QD
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
Pt died [**2195-7-28**]
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"427.5",
"491.21",
"444.89",
"434.11",
"518.81",
"414.01",
"584.5",
"250.00",
"412",
"428.0",
"421.0",
"442.2",
"999.9",
"790.7",
"443.9",
"348.1",
"511.9",
"570",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"99.69",
"96.6",
"38.91",
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
23696, 23705
|
17575, 23460
|
349, 355
|
23751, 23776
|
2208, 5986
|
23827, 23832
|
1658, 1662
|
23669, 23673
|
12680, 12756
|
23726, 23730
|
23486, 23646
|
23800, 23804
|
1677, 2189
|
276, 311
|
12785, 17552
|
383, 1273
|
1295, 1511
|
1527, 1642
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,096
| 122,349
|
17326
|
Discharge summary
|
report
|
Admission Date: [**2119-5-11**] Discharge Date: [**2119-5-18**]
Date of Birth: [**2100-1-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 19-year-old
unrestrained driver with question loss of consciousness in a
high speed rollover motor vehicle crash transferred from
[**Hospital 48386**] Hospital. [**Location (un) 2611**] coma score was 15. Hemodynamically
stable. Noted to have a L1 burst fracture on CT scan,
complains of back pain.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Patient is not on any medications.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She smokes a half a pack per day.
Occasional EtOH.
LABORATORIES ON ADMISSION: White count of 17.9, hematocrit
39, 201 for platelets, 134 for sodium, 4.4 potassium, 101
chloride, 11 BUN, 0.6 creatinine, amylase 26. Fibrinogen
227. Urinalysis was negative. Tox screen was positive for
opiates that was in urine. Serum tox was negative. PT was
13.3, PTT was 24.7 and 1.2 for INR.
X-RAYS: C spine was negative for x-ray. Pelvis was
negative.
PHYSICAL EXAMINATION: Temperature of 97.3, blood pressure
131/68, pulse of 68, respirations 16, and 97% on room air.
The patient is awake, alert, and oriented times three.
Pupils are equal, round, and reactive to light and
accommodation. Moving all extremities. No numbness or
tingling. Regular rhythm and rate. Lungs are clear
bilaterally. Neurologic examination: The patient is awake,
alert, and oriented times three. Cranial nerves II through
VII were intact. Motor strength was [**3-27**] in bilateral upper
and lower extremities. Sensation was intact throughout to
light touch. Rectal tone was normal.
CT scan showed a L1 burst fracture.
Patient was admitted to the Intensive Care Unit, where she
had an amylase and lipase checked daily. Her hematocrit was
watched twice a day. She was placed on log roll precautions.
Needs to be kept on flat bed rest and a TLSO brace was
ordered. Social Work did see patient on admission.
On the [**3-12**], the patient was neurologically intake,
continued on log roll precautions and flat bed rest. Vital
signs were normal limits. Hematocrit was 37.8. Amylase was
24. Coags were PT 13.7, INR was 1.2. Lipase was 14.
Patient's MRI from the 19th showed a L1 burst fracture with
80% loss of vertebral body height and 70% canal compromise.
On the [**3-12**], Dr. [**Last Name (STitle) 1327**] discussed with the patient
that her fracture was unstable with a significant risk of
deformity and progression and development of radiculopathy.
He discussed the indications for surgery with the patient
including a retroperitoneal approach versus the use of
titanium cage plate device, and autologous vertebral rib
graft. The risks and benefits were explained to the patient
and she was eager to proceed with the surgery.
On the [**3-13**], the patient was transferred to the
Surgery Floor, where she continued to be neurologically
intact, was using a Morphine PCA pump, was fair to good
relief of her pain.
On [**2119-5-15**], patient was brought to the operating room, where
she had a L1 vertebrectomy via retroperitoneal approach. She
had placement of TPS hardware and fusion of T12 to T2. She
had no complications intraoperatively, and was monitored in
the recovery room and transferred to the surgical floor
postsurgery.
Her assessment immediately after surgery is patient was
awake, alert, oriented x3. Her motor strength was [**3-27**], and
she had a nasogastric tube in place, and also a chest tube
placed. Those are both functioning without problems. She
had a J-P in her neck. Her dressing was dry and clean.
On postoperative day one, which was [**2119-5-16**], the patient was
awake, alert, comfortable. Both the nasogastric and chest
tubes were putting out serosanguinous fluid out of the chest
tube and same with the J-P. The patient had standing films
done on [**5-16**], AP and lateral of her lumbar region, which
showed good alignment. She was seen by Physical Therapy, who
recommended gait training, functional mobility training,
patient education, and discharge planning.
On the [**3-17**], patient's Foley catheter was
discontinued. Her J-P was discontinued, and her nasogastric
tube was discontinued. She was tolerating a normal diet, and
began to ambulate by the 24th and 25th with Physical Therapy.
On the [**3-17**], her PCA pump was discontinued. Her
Foley was discontinued. Her nasogastric tube was
discontinued. Her chest tube was left at 20 cm of suction.
she was started on oxycodone acetaminophen [**11-24**] po prn with
good relief. Her IV antibiotics were also stopped. Patient
was discharged home on [**2119-5-18**].
DISCHARGE INSTRUCTIONS: She should follow up with Dr. [**Last Name (STitle) 1327**]
in one month. She should have her staples removed 10 days
from discharge. She should return back if she has fever
greater than 101, redness that is spreading, increased pain,
chest tightness, numbness, or tingling, or weakness anywhere.
She should not get her staples wet. She should not lift
anything greater than 5 pounds.
Patient was discharged neurologically intact with no decrease
in motor strength. No residual paresthesias.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2119-6-28**] 15:14
T: [**2119-7-3**] 13:02
JOB#: [**Job Number 48503**]
|
[
"805.4",
"E816.1",
"722.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"77.89"
] |
icd9pcs
|
[
[
[]
]
] |
4735, 5491
|
523, 618
|
1107, 1431
|
156, 469
|
715, 1084
|
1456, 4710
|
492, 499
|
635, 700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,989
| 122,501
|
47541
|
Discharge summary
|
report
|
Admission Date: [**2155-4-13**] Discharge Date: [**2155-4-18**]
Date of Birth: [**2083-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Ventricular fibrillation, syncope
Major Surgical or Invasive Procedure:
DC cardioversion on [**2155-4-13**]
History of Present Illness:
The patient is a 71 year old male with a h/o CAD s/p CABG 6'[**52**]
(**), CHF with EF of <20%, DMII and HTN who presented to [**Hospital1 18**]
after a vfib arrest in the field s/p cardioversion. The patient
was in his usual state of health the morning of presentation
when he suddenly felt chest discomfort, felt lightheaded and
dizzy and collapsed to the floor but did not lose consciousness.
EMS was called who found the patient to be in ventricular
tachycardia that turned into v fib. The patient was shocked and
returned to [**Location 213**] sinus rhythm.
Past Medical History:
DMII
HTN
CAD s/p silent MI and CABG [**2152-6-26**] (LIMA->LAD, SVG->OM1,
SVG->rPDA)
Gout
h/o SVT
Thrombocytopenia, anemia of unknown origin - followed at [**Hospital1 756**]
h/o Bell's palsy
h/o trigeminal neuralgia
Social History:
The patient formerly smoked [**3-28**] ppd x 35 years. He denies any
EtOH. He is currently retired.
Family History:
nc
Pertinent Results:
ECHO [**4-14**]
IMPRESSION: Biventricular cavity enlargement with severe global
biventricular systolic dysfunction (LVEF <20%) c/w diffuse
process (toxin, metabolic etc. - cannot exclude multivessel
CAD). Moderate mitral regurgitation. Mild aortic regurgitation.
Compared with the prior study (tape reviewed) of [**2152-9-12**], the
left ventricular cavity is more dilated with similar ventricular
function. Right ventricular cavity enlargement is now present
with more prominent free wall hypokinesis. The severity of
mitral and aortic regurgitation are slightly increased
(previously trace AR).
.
CATH [**4-16**]
LMCA 40%prox, LCX 80%OM1 80%upper pole OM1, RCA 60% mid RCA w/
good flow to PL and large AM, LIMA-LAD patent, SVG-PDA patent,
SVG-OM patent
No interventions
FINAL: 3vd CAD, elevated LVEDP, Patent SVG x 2 and LIMA
Brief Hospital Course:
Patient was admitted from ED to CCU in stable condition in
normal sinus rhythm and pain free. He underwent catheterization
without intervention (3vd CAD, elevated LVEDP, Patent SVG x 2
and LIMA) and an echocardiogram (increased biventricular
dilatation, LVEF <20%, inc free wall hypokinesis). He ruled out
for an MI by enzymes. EP placed an ICD on HD 3 which he
tolerated well. His medications were adjusted; warfarin
decreased, amiodarone added, keflex x 1day post discharge,
lopressor d/c'd and coreg added. He was discharged on HD4 after
having inpatient pulmonary function tests to monitor amiodarone
effects, the results of which Dr [**Last Name (STitle) **] will follow. He will
have his renal function and INR coags checked 6days after
discharge, and Dr [**Last Name (STitle) **] will follow results and adjust meds as
needed. Patient also has a followup appt with the Device clinic
in one week and then will make an appointment for followup with
Dr [**Last Name (STitle) 2357**] (EP).
Medications on Admission:
coumadin 5-7.5 (started [**8-26**] decrease his risk for
intracardiac thromboses), celebrex 200BID PRN, Lopressor 75BID,
Avandia 2 qd, lasix 20-40 QD, allopurinol 300bid, gylburide
1.25QD, captopril 6.25 TID, lipitor 5, ASA 162
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take for stool softening while taking percocet.
[**Month/Year (2) **]:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
4. Aranesp 300 mcg/0.6 mL Syringe Sig: One (1) Injection once a
week: per your hematologist and primary care physician.
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
you may take two tablets a day if you notice increased swelling
of your legs or >3lb wt gain over a day, but you may only
increase max three times a week.
6. Glyburide 2.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
7. Rosiglitazone Maleate 2 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 days.
[**Month/Year (2) **]:*4 Capsule(s)* Refills:*0*
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
[**Month/Year (2) **]:*60 Tablet(s)* Refills:*0*
10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet, Chewable(s)* Refills:*0*
12. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
[**Doctor First Name **]:*30 Tablet(s)* Refills:*0*
14. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
[**Doctor First Name **]:*30 Tablet(s)* Refills:*0*
15. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 1 weeks: then decrease the dose to two tablets
just once a day until further notice from your doctor.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ventricular tachycardia/ fibrillation
ICD-pacer placement
hypertension
diabetes
hyperlipidemia
congestive heart failure
Discharge Condition:
good
Discharge Instructions:
-no vigorous activity
-heart healthy and diabetic diet
-no driving for 6 months!! very strict per EP doctors
-MEDICATION: you will continue to take the medications you were
on before hospitalization. Changes are as below:
1. METOPROLOL discontinued- take Coreg (carvedilol) instead as
directed.
2. COUMADIN (warfarin) dose has been decreased because of
interactions with other medications, take as directed.
3. AMIODARONE will be taken three times a day for one week after
discharge ([**4-25**]) than decreased to only once a day.
4. your ASPIRIN dose has been decreased to 81mg per day
5. you must take an antibiotic KEFLEX for 24hrs after discharge.
-Call the Device Clinic to speak to an electrophysiologist (EP
doctor) if your defibrillator shocks you or if you have
prolonged noticable palpitations or if you lose consciousness
again.
-Call Dr [**Last Name (STitle) **] if you have any chest pain, shortness or breath,
increasing weight or leg swelling, or any other concerns
Followup Instructions:
You will need to have your INR and renal function tested on
Thursday [**4-24**] at your normal [**Doctor Last Name 54135**] St lab- they should have
recieved a requisition sheet and a fax number from Dr [**Last Name (STitle) **] so
that he can get the results. You will need INR, BUN, Creatinine
blood work.
Also, you have an appointment next friday to have your
defibrillator checked. Provider DEVICE CLINIC Where: [**Hospital 273**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time: [**2155-4-25**]
1:00
While you are at the Device clinic (above), please make an
appointment to see Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2357**] (electrophysiology) for
continued management of your ICD.
Followup with Dr [**Last Name (STitle) **] within one month, call for an
appointment.
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10012**]
|
[
"287.5",
"414.01",
"401.9",
"396.3",
"238.7",
"593.9",
"250.00",
"427.41",
"427.5",
"398.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"99.04",
"88.56",
"37.94",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
5409, 5467
|
2226, 3225
|
348, 385
|
5631, 5637
|
1374, 2203
|
6670, 7607
|
1351, 1355
|
3503, 5386
|
5488, 5610
|
3251, 3480
|
5661, 6647
|
275, 310
|
413, 977
|
999, 1218
|
1234, 1335
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,202
| 169,694
|
7106
|
Discharge summary
|
report
|
Admission Date: [**2115-12-9**] Discharge Date: [**2115-12-26**]
Date of Birth: [**2050-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**12-10**]- [**Month/Year (2) **] w/ stent placement, sphincterotomy
[**12-10**]- intubation, mechanical ventilation
11/27- trans-esophageal echocardiogram
History of Present Illness:
65 year-old gentleman w morbid obestity and history of
cholecytsitis s/p perc chole tube at [**Hospital **] Hospital in [**9-25**]
transferred here from [**Hospital **] Hospital with recurrent RUQ pain
and concern for cholecystitis or cholangitis. Patient is poor
historian, but describes off and on pain over past 2 months,
with worsening pain associated with nausea and vomiting since
last week. Was seen on [**12-4**] for RUQ pain with essentially
normal work-up. Re-presented
today with severe pain and nausea/vomiting, hypotensive in ?new
afib with elevated transaminases, alk phos and bilirubin.
Treated with 2L IVF and Levaquin and transferred here to [**Hospital1 18**]
ED. On arrival here, hypotensive with SBPs in 80's, tachycardic
in Afib, mentating well. Treated with 2L IVF, Flagyl and
Vancomycin, R IJ central line placed by ED resident. Converted
to
sinus rhythm in ED, pressures improved. Admitted to West SICU on
[**12-9**], transferred to [**Hospital Unit Name 26481**] on [**12-10**] for [**Month/Year (2) **]. [**Month/Year (2) **] revealed
multiple gallstones in CBD and large amounts of purulent
drainage; CBD stent was place and sphincterotomy performed.
Post-[**Month/Year (2) **] was extubated, had increased work of breathing/
difficulty oxygenating and was re-intubated. Due to hypotension
with CVPs not responding to multiple fluid boluses, levophed was
initiated. Currently, pt is sedated w/ propofol and intubated on
AC, Vt 600 x 20, PEEP 8 & FiO2 50%.
Past Medical History:
obesity
DM
cholecystitis
HTN
Social History:
SW patient's APN: [**First Name5 (NamePattern1) 26482**] [**Last Name (NamePattern1) 26483**] [**Telephone/Fax (1) 26484**] at Elder Service
Plan of [**Location (un) 1121**], there is no next of [**Doctor First Name **]. The patient moved
from [**First Name11 (Name Pattern1) 6171**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 15935**] years ago, and has no family here. He is
mobile at home in a wheelchair, but has poor baseline
respiratory status. He also does not take his insulin
appropriately.
Family History:
unknown
Physical Exam:
VS: afebrile, HR 76 BP 138/78 RR 20 (set) SaO2 98% on vent
settings
GEN: morbidly obese short (4'9) gentleman, intubated,
sedated but opening his eyes to voice
HEENT: no scleral icterus or chemiosis
CV: regular rate and rhythm, distant heart sounds
Lungs: decreased bibasilar breath sounds, coarse ventilated
breaths
Abd: morbidly obese, massive pannus almost covering his knees
soft, hypoactive BS, grimaces w palpation of abd, esp RUQ but
cannot accurately assess pain
Ext: chronic venous stasis changes, well-perfused 2+ DP,PT
pulses B/L
Pertinent Results:
blood cultures from
[**12-20**] and [**12-21**] pending at discharge
discharge labs ([**2115-12-25**])
5.8>28.2<263
PT 16.8, INR 1.5, peak at 2.7 on [**12-24**] (from one dose of
coumadin)
Ca 8.1, Phos 4.5, Mg 1.8
139/3.5/106/28/17/1.6<171
LFTs decreased to ALT 23, AST 25, AlkPhos 128, Amylase 32, TB
1.0, lipase 47 as of [**12-24**]
ABG [**12-24**] 7.49/37/86
Vit B12 825, Folate 10.8
TSH 1.2
TGs peaked at 799, down to 363 as of [**10-20**]
[**2115-12-9**] 08:12PM LACTATE-2.0
[**2115-12-9**] 08:02PM CK(CPK)-44
[**2115-12-9**] 07:35PM cTropnT-<0.01
[**2115-12-9**] 07:35PM LIPASE-23
[**2115-12-9**] 08:02PM DIGOXIN-<0.2*
[**2115-12-9**] 07:35PM PT-15.4* PTT-24.1 INR(PT)-1.4*
[**12-26**]
TIBC 198, Ferritin 263, Iron 152
MICRO:
[**12-9**] blood cx: GPC in clusters
IMAGING: CT abd: mild fat stranding extending from gallbladder
to anterior abdominal wall, indicating tract associated w
previous
cholecystostomy tube. No loculated collections or abcess. mildly
thickened gallbladder wall. No stones. No intrahepatic biliary
dilation
[**2115-12-10**]: [**Month/Day/Year **] Report-- Pus discharge in the major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in complete opacification. The procedure was
mildly difficult
There were filling defects that appeared like sludge and stones
in the main duct and common hepatic duct. The quality of the
images obtained was severely reduced due to the patient's body
habitus. A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire. [**3-20**]
stones and a large amout of pus were extracted successfully
using a 11.5 mm RX balloon. 5cm by 10FR double pig tail biliary
stent was placed successfully. (sphincterotomy, stone
extraction, stent placement)
[**2115-12-13**]: TEE Report- No atrial septal defect is seen by 2D or
color Doppler. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 40 cm from the incisors. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. No masses or vegetations are seen
on the tricuspid valve. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetation, masses or abscess.
[**2115-12-23**] CT head without contrast
Interpretation of the study is significantly limited by motion.
Within this limitation, there is no evidence of hemorrhage,
edema, large
masses, mass effect, or infarction. Prominence of ventricles and
sulci are
noted consistent with global volume loss. No acute fractures are
identified.
Mucosal retention cyst is noted in bilateral maxillary sinuses
and the right sphenoid sinus.
Brief Hospital Course:
Mr. [**Known lastname 26485**] is a 65-year old morbidly obese gentleman with a
history of diabetes, who was admitted to the ICU for cholangitis
s/p [**Known lastname **] with stent placement and sphincterotomy, complicated by
hypotension, sepsis, respiratory failure and acute renal
insufficiency.
#. SEPSIS/ HYPOTENSION/corneybacterium and [**Known lastname 8974**] bacteremia: Upon
presentation from [**Known lastname **], Mr. [**Known lastname 26485**] was hypotensive requiring
Levophed. Blood cultures showed 4/4 bottles positive for gram
positive cocci, so Vancomycin was started empirically in
addition to Zosyn. Speciation revealed [**Last Name (LF) 8974**], [**First Name3 (LF) **] Zosyn was
discontinued, and Vanc changed to nafcillin. Source of [**First Name3 (LF) 8974**]
bacteremia was unclear, but could be related to previous
percutaneous cholecystostomy tube placed at [**Hospital **] hospital.
Bedside TEE was done on [**12-13**] to rule out endocarditis, and did
not show any valvular vegetations. The patient continued to
have fevers once his hypotension resolved, and blood cultures
from [**12-5**] and [**12-17**] arterial line grew out corynebacterium
species. He was consequently restarted on Vancomycin on [**2115-12-20**]
for a planned 2 week course. His dose at discharge was 750mg IV
Q12H. He will need a vancomycin trough each morning until at a
stable dose. Nafcillin was stopped on [**2115-12-25**] after a two-week
course from last negative blood culture.
#. RESPIRATORY FAILURE: Was intubated for his [**Date Range **] and did not
tolerate post-procedure extubation due to fatigue and poor
effort, so was re-intubated in ICU on assist control settings.
Respiratory failure was likely secondary to acute lung injury/
ARDS-like picture as PAO2/FiO2 ~246 and had B/L fluffy
infiltrates on CXR. Respiratory distress was also secondary to
body habitus- he has short inspiratory phase and prolonged
expiration with massive rebound of his pannus which could cause
ventilator to deliver additional breaths. On [**12-13**], a trial of
pressure support was started, initially he was apneic and
required assist-control, but as settings were altered to
increase PCO2 (as patient likely has resting hypercarbia due to
body habitus, small lung volumes), patient did better. He was
extubated on [**2115-12-18**] without complication. He was gradually
weaned off oxygen and was satting high 90s on RA as of [**12-26**].
#. ACUTE RENAL INSUFFICIENCY: Etiology of renal insufficiency
was likely secondary to acute tubular necrosis from poor renal
perfusion during hypotension. Urine electrolytes and sediment
were consistent with this diagnosis. Creatinine rose, plateaued
and then decreased as patient went from anuric phase to
producing about 50-100cc/hr urine. He was given multiple fluid
boluses during the initial phase of his renal insufficiency
which had some component of volume depletion- however, fluid
boluses were not given as he reached anuric phase. His renal
function continued to improve, he was seen by the renal consult
service who determined he did not need hemodialysis and would
recover on his own. His renal function improved and he
underwent a post-ATN diuresis. His creatinine did occassionally
increase with diuresis and was 1.6 as of [**12-26**].
#. HYPERTENSION: Patient's blood pressures were difficult to
control. He was diuresed actively from [**Date range (1) 26486**]. He was
restarted on home amlodipine on [**12-15**]. Hydralazine and
Labetolol PO were added to his regimen however SBPs remained
high. Patient dropped his pressures on a nitro gtt on [**12-17**] so
this was stopped. He was gradually restarted on home regimen
including olmesartan, amlodipine, and lisinopril. He was also
started on metoprolol (home beta blocker not on formulary). As
of [**12-25**] his blood pressure was better controlled on oral
olmesartan, amlodipine, lisinopril and metoprolol. He
occasionally required doses of prn IV hydralazine for SBPs in
200s.
#. Altered Mental Status/Delirium: Post-extubation, the patient
had waxing and [**Doctor Last Name 688**] mental status consistent with [**Doctor Last Name 361**].
This was felt to be multifactorial, possibly secondary to
prolonged sedation during intubation versus ICU psychosis. Per
his SW, he is oriented at baseline but not high-functioning. He
received several doses of anti-psychotic medications for
agitation at night, Haldol working the best. A CT of his head
on [**12-23**] was not revealing. Lab workup including TSH, B12,
folate, were unremarkable and patient was started on a three day
course of thiamine. He was evaluated by neurology who
recommended an MRI (though realized that this would have to be
done in another facility given his need for an open MRI). A
psychiatry consult was done and their recommendations were to
continue haldol for agitation associated with delirium, as well
as quetiapine 25-50mg if haldol alone does not decrease his
agitation.
#. UTI: Pt. was started on Cipro on [**12-23**] for a planned 7 day
course for a complicated UTI.
#. Atrial Fibrillation: Had episode of paroxysmal Atrial
fibrillation with rapid ventricular response on [**12-21**], which
converted to sinus after administration of IV and PO metoprolol.
Per chart review, the patient has had this issue in the past.
He was started on heparin gtt and coumadin, which was stopped
after further chart review; the patient has a history of poor
medical compliance and a history of falls and was felt to be a
poor coumadin candidate. He was continued on PO metoprolol for
rate control. On [**12-24**] the patient had aflutter which was
unresponsive to metoprolol 20mg IV and diltiazem boluses and
drip. He was chemically converted with Amiodarone and started
on an Amiodarone drip which was continued until discharge. Due
to his body habitus, it was decided to give him an IV amiodarone
load greater than typical. Plan was to continue amiodarone
400mg PO BID until he has received 5 grams total. At discharge,
he has received 1590mg of amiodarone. He needs 3410mg more of
amiodarone, so should be continued on amiodarone 400mg PO BID
for 4 more days to end at 11:59pm at [**2115-12-30**]. If after his
load is stopped, he converts back into atrial
fibrillation/flutter, he should be restarted on his IV drip. He
should then be continued on amiodarone 400mg po bid for 1
additional week to be tapered to a goal of 200mg po daily. He
was felt to be a poor candidate for anticoagulation given his
outpatient records and risk of fall. He had one episode of
Aflutter with RVR after being started on the amiodarone drip
which was responsive to 10mg IV metoprolol.
#. CHOLANGITIS ?????? Pt. was followed by [**Month/Day/Year **] team who recommended
likely biliary stent pull around the first week of [**2116-1-17**].
#. IRON DEFICIENCY ANEMIA - He was persistently anemic during
this hospitalization. He had a hematocrit of 27-30 which was
felt to be most likely iron deficiency anemia. Iron studies at
discharge showed a mild [**Doctor First Name **]. He was started on iron as an
outpatient.
#. EMESIS: Patient had an episode of vomiting on [**2115-12-25**] after a
large meal. He was started on an IV PPI and his vomit was
gastroccult positive. His hematocrit remained stable during
this episode and he should not be given large meals after
discharge. The new iron pill may make his stool look dark.
#. CODE: Presumed full
#. Contact: Pt. does not have close friends or family to help
him make medical decisions per his social worker. At baseline,
patient uses a wheelchair.
Medications on Admission:
LANTUS 30u [**Hospital1 **]
ADVAIR 250/50 1 puff [**Hospital1 **]
IRON 325 [**Hospital1 **]
Vit C 250 [**Hospital1 **]
MVI daily
LASIX 10 qAM
GLIMEPIRIDE 8 daily
BYSTOLIC (nebivolol) 10mg daily
OMEPRAZOLE 10mg [**Hospital1 **]
COLACE 100mg [**Hospital1 **]
DUONEB Q4HRS PRN
BENICAR 40mg DAILY
LISINOPRIL 40mg DAILY
SIMVASTATIN 20mg DAILY
AMLODIPINE 10mg DAILY
METFORMIN 1000mg [**Hospital1 **]
SERTRALINE 100mg [**Hospital1 **]
MAGNESIUM CITRATE [**1-18**] bottle prn
GLYBURIDE 2.5mg [**Hospital1 **]
MIRALAX
SENNA
FLUTICASONE nasal spray daily
Discharge Medications:
1. Haldol 5 mg/mL Solution Sig: One (1) mg Injection three times
a day as needed for agitation: use only if not taking PO.
2. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) INJ
Injection TID (3 times a day).
13. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation.
14. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Insulin sliding scale
see copy of insulin sliding scale
Fingerstick QACHS
Bedtime Glargine 30 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-100 0 Units 0 Units 0 Units 0 Units
101-150 2 Units 2 Units 2 Units 0 Units
151-200 4 Units 4 Units 4 Units 2 Units
201-250 6 Units 6 Units 6 Units 3 Units
251-300 8 Units 8 Units 8 Units 4 Units
301-350 10 Units 10 Units 10 Units 5 Units
351-400 12 Units 12 Units 12 Units 6 Units
17. Pantoprazole 40 mg IV Q24H
18. Ciprofloxacin 400 mg IV Q12H
D1: [**2115-12-23**], plan for 7 day course
19. Ondansetron 8 mg IV Q6H:PRN nausea
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
21. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
23. Amiodarone 0.5 mg/min IV INFUSION
24. Vancomycin 750 mg IV Q 12H
25. 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.
26. Outpatient Lab Work
Vancomycin trough daily starting before the dose the morning of
[**2115-12-27**] until level is therapeutic at 15-20.
Daily electrolytes (sodium, potassium, chloride, bicarb, BUN,
creatinine, magnesium) until kidney function improving and there
is no need for potassium or magnesium repletion. These
electrolytes should be repleted to potassium of 4 and magnesium
of 2.
27. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Final Diagnoses:
Cholangitis
Sepsis secondary to bacteremia
Atrial fibrillation
Atrial flutter
Hypertension
Diabetes Mellitus type 2
Urinary Tract Infection
Acute Kidney Injury
Obesity
Discharge Condition:
Mental Status:Confused - always
Activity Status:Out of Bed with assistance to chair or
wheelchair, not ambulatory
Level of Consciousness:Lethargic but arousable
Hemodynamically stable
Discharge Instructions:
You were admitted to the hospital for cholangitis and underwent
[**Location (un) **] and had subsequent sepsis leading to intubation. You were
extubated and then reintubated. You had a long hospital course
in the ICU; you are being sent to an extended care facility
because of your complicated medical problems and inability to
care for yourself at home. Your active medical problems include
[**Name2 (NI) 361**], atrial fibrillation, hypertension, poorly controlled
diabetes mellitus and bacteremia for which you are receiving IV
antibiotics.
Followup Instructions:
You have an appointment for the removal of your bile duct stent
on [**2116-1-21**]:
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2116-1-21**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2116-1-21**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"576.1",
"790.7",
"599.0",
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"280.9"
] |
icd9cm
|
[
[
[]
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[
"96.04",
"51.85",
"96.72",
"51.87",
"38.93",
"88.72"
] |
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|
[
[
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6360, 13972
|
338, 496
|
18207, 18207
|
3201, 6337
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2615, 2624
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14567, 17855
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17999, 17999
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13998, 14544
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18417, 18966
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2639, 3182
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18016, 18186
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284, 300
|
524, 2012
|
18221, 18393
|
2034, 2064
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2080, 2599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,689
| 166,437
|
2909
|
Discharge summary
|
report
|
Admission Date: [**2187-12-30**] Discharge Date: [**2188-1-5**]
Date of Birth: [**2129-12-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
Mr. [**Known lastname **] is a 55 year old Creole speaking man with multiple
myeloma on Velcade and Cytoxan and s/p failing renal transplant
[**11-7**] on tacrolimus and currently on HD who presented to the ED
on [**12-30**] with dyspnea and non-productive cough. He developed a
"high fever" and chills with a nonproductive cough on [**12-29**] and
came in to the ED after developing dyspnea [**12-30**]. He had chest
discomfort with coughing, but no pleuritic pain and no
hemoptysis. No known sick contacts or recent travel, denies h/o
+PPD but not sure when this last was done. He had received in
influenza vaccination [**11-7**]. Had been hospitalized [**Date range (1) 14048**].
.
Review of systems negative for sweats, abdominal discomfort,
nausea, vomiting, diarrhea, myaglias, arthralgias, rhinitis,
sore throat, headache.
.
In the ED, vitals were T 102.4 P 105 Bp 185/91 RR 16 O2 94% on
room air. His chest film showed a RLL opacity and he was started
empirically on vancomycin, ceftazidime, and levofloxacin. Due to
tachypnea 20-30[**Hospital **] transferred to [**Hospital Unit Name 153**] for close observation.
Admission labs notable for WBC 2.1 (57% polys no bands) and
lactate of 2.7.
Past Medical History:
1. Multiple myeloma diagnosed [**11-7**]
- s/p cytoxan and high dose decadron end of [**11-7**]
- currently on on velcade/cytoxan q2wks. last seen in clinic
[**12-28**] cytoxan held for WBC 1.5, velcade given however
2. s/p DDRT [**2187-11-3**], graft failing now back on HD
- on tacrolimus, cellcept held in setting of cyclophosphamide tx
- still makes some urine
3. h/o ESRD secondary to HTN on HD from [**2183**]-[**2187**] thought at
that time to be [**2-2**] HTN
4. s/p L AVF [**2-3**]
5. HTN
6. Hepatitis B
7. Hordeolum
Social History:
4 children, supportive in [**Location (un) 86**] area. He lives with a friend
and does not work. He had been a preacher, last job was cab
driver 4 years ago. He has never smoked, denies any alcohol
usage. States he has never used illicts.
Native language Haitian Creole. His son [**Name (NI) **] [**Name (NI) **] is his HCP.
Immigrated to the US ~ [**2160**], lived in [**Location 2848**] ~5 months then but
in [**Location (un) 86**] otherwise without residence elsewhere in US.
No pets at home.
Family History:
noncontributory
Physical Exam:
Exam [**Location (un) 3242**] floor [**12-31**]
Tmax 102.8 (4:30pm [**12-30**] in ED) T 99.6 P 96 BP 126/71 RR 22 O2
95% RA
General: Appears older than stated age, coughing occasionally in
mild respiratory distress
HEENT: Sclera white, conjunctiva pale, moist mucus membranes, no
thrush or other oral lesions. R eyelid slight swollen
Neck: No cervical or supraclavicular adenopathy
Pulm: Speaking in full sentences. No dullness to percussion,
+rhonchi, +crackles L>R
CV: Regular rate S1 S2 II/VI systolic murmur
Abd: Soft, +bowel sounds, mild tender epigastrium and over
allograft in LLQ
Extrem: Warm, well perfused, tr ankle edema. Fistula L forearm
with palpable thrill.
Neuro: Alert, interactive, moving all extremities with no gross
deficits
Derm: Skin warm to touch, no rash
Pertinent Results:
[**2187-12-30**] 03:39PM BLOOD WBC-2.1* RBC-2.91* Hgb-8.7* Hct-27.7*
MCV-95 MCH-29.9 MCHC-31.4 RDW-21.0* Plt Ct-197
[**2187-12-30**] 06:00PM BLOOD PT-12.6 PTT-31.3 INR(PT)-1.1
[**2187-12-30**] 03:39PM BLOOD Glucose-78 UreaN-27* Creat-6.9* Na-139
K-4.6 Cl-97 HCO3-32 AnGap-15
[**2187-12-30**] 03:39PM BLOOD ALT-22 AST-15 AlkPhos-73 Amylase-76
TotBili-0.3
[**2187-12-30**] 03:39PM BLOOD Albumin-3.4 Calcium-9.8 Phos-2.8 Mg-1.9
[**2187-12-30**] 03:39PM BLOOD Lipase-89*
[**2187-12-31**] 06:05AM BLOOD WBC-4.7# RBC-2.61* Hgb-7.8* Hct-24.9*
MCV-95 MCH-29.7 MCHC-31.2 RDW-19.9* Plt Ct-148*
[**2187-12-31**] 06:05AM BLOOD Gran Ct-3570
[**2187-12-31**] 04:58AM BLOOD Glucose-83 UreaN-36* Creat-7.8* Na-136
K-5.1 Cl-97 HCO3-29 AnGap-15
[**2187-12-31**] 04:58AM BLOOD ALT-17 AST-12 LD(LDH)-203 AlkPhos-66
Amylase-47 TotBili-0.3
[**2187-12-31**] 04:58AM BLOOD Lipase-30
[**2187-12-31**] 04:58AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
[**2187-12-31**] 04:58AM BLOOD Vanco-14.9
[**2187-12-31**] 06:05AM BLOOD FK506-2.1*
[**2187-12-30**] 03:13PM BLOOD Glucose-77 Lactate-2.7* Na-145 K-4.5
Cl-95*
.
DISCHARGE LABS [**2188-1-5**]
WBC 18.4, Hb/Hct 8.5/27.7, Plts 173
BUN 25, Cr 7.7 (pre-dialysis)
FK506 trough 12.2
.
IMAGING:
[**12-30**] CXR AP: Study is limited by respiratory motion. Relative
to the prior examination, right internal jugular approach
central venous catheter has been removed. There is a patchy
opacity in the right lower lobe, highly suspicious for
pneumonia. Volume status has normalized since the prior
examination. Again noted is a tortuous aorta. The cardiac
silhouette remains enlarged but stable. No definite pleural
effusion or pneumothorax is seen. IMPRESSION: Limited
examination, highly suspicious for right lower lobe pneumonia.
If clinically feasible, PA and lateral views in the radiology
suite are recommended for better characterization.
[**12-31**] CXR PA/LAT:
FINDINGS: In comparison with study of [**12-30**], there is again an
area of patchy opacification in the right lower lobe, highly
suspicious for pneumonia given the clinical history of
immunesuppression. Enlargement of the cardiac silhouette with
some increase in pulmonary venous pressure persists.
[**1-3**] Lspine plain films
AP AND LATERAL LUMBAR SPINE: There is spondylosis of the L5
vertebral body without evidence of spondylolisthesis. No
discrete bony lesions are identified within the imaged bones to
account for the patient's pain. The remaining vertebral body and
intervertebral disc space heights are preserved. Sacroiliac
joints are normally aligned. A catheter projecting over the
right acetabulum represents a pigtail catheter extending along
the course of the ureter, as seen on prior CT scan. Multiple
calcifications in the right lower quadrant likely represent
central calcifications from prior right renal transplant.
IMPRESSION: No discrete osseous lesion within the imaged lumbar
spine to account for the patient's symptoms. L5 spondylosis
without spondylolisthesis, unchanged since [**2187-11-27**].
Micro
********* BLOOD CULTURES PENDING DATE OF DISCHARGE [**2188-1-5**]
1/5 blood culture [**2-2**] no growth as of [**2188-1-6**]
[**1-3**] blood culture no growth as of [**2188-1-6**]
1/2 blood culture no growth as of [**2188-1-6**]
*********
[**12-31**] urine legionella antigen negative
[**12-31**] blood [**2-2**] cx negative
[**12-31**] sputum >10epis
[**12-30**] urine cx negative
[**12-30**] blood [**2-2**] negative
Brief Hospital Course:
1. Pneumonia: Due to his initial tachypnea and fever he was
admitted to the [**Hospital Unit Name 153**] for close monitoring. He was initially
treated empirically with broad spectrum antibiotics including
vancomycin, levofloxacin, and ceftazidime due to recent
hospitalization. Antibiotic treatment lead to rapid improvement
in his respiratory status and fever curve. He was maintaining
oxygen saturations in mid-high 90's on room air at time of
discharge. Cultures remained negative at time of discharge, and
his outpatient providers should follow up on the final results.
A bacterial etiology due to an encapsulated organism such as
pneumococcus seemed most likely. It was felt that his persistent
leukocytosis at time of discharge reflected his treatment with
neupogen as clinically he was much improved from a respiratory
standpoint. He will continue levofloxacin to complete a 14 day
course of treatment.
.
2. Multiple myeloma: The patient was restarted on his
cyclophosphamide and velcade on [**2188-1-4**]. He will have close
followup in oncology clinic. Prophalaxis with acyclovir and
bactrim was continued. Neupogen was discontinued prior to
discharge.
.
3. ESRD, s/p renal transplant: The patient's Cellcept had been
held while on Cytoxan but was restarted in hospital after
discussion with Nephrology, prior to restarting his Cytoxan on
[**2188-1-4**]. He tacrolimus levels were adjusted per Nephrology and he
will need to have a trough rechecked on Monday [**2188-1-7**]. Dialysis
was continued during his hospitalization, last done the day of
discharge [**2188-1-5**]. He was continued on his phosphate binder. He
will follow up with Dr. [**Last Name (STitle) **] from Nephrology. Per renal,
dialysis sessions should be conservative in regards to volume
removed.
.
4. Hypertension: He continued his home regimen metoprolol and
amlodipine.
.
5. Chest pain and back pain: The patient complained of chest and
low back discomfort overnight [**2188-1-3**]. A cardiac etiology of the
chest pain was thought unlikely given unchanged EKG and
reproducibility of chest discomfort with palpation over the
right throax. His right sided chest discomfort was more likely
related to the known right sided pneumonia. In regards to his
back pains, he had no neurologic findings concerning for cord
compression and plain films of his lumbar spine revealed no
fracture or other acute pathology. He was started on a fentanyl
patch with oxycodone prn breakthrough for pain relief.
Medications on Admission:
Medications: per OMR
Docusate Sodium 100 mg PO BID
Amlodipine 10 mg PO DAILY
Omeprazole 20 mg PO once a day
Nystatin 500,000 unit/mL Suspension PO QID
Oxycodone 5 mg Tablet PO Q6H as needed for pain.
Acylovir 400 mg PO DAILY
Toprol XL 75 mg [**Hospital1 **] (though conflicting note states pt is on
lopressor 75 mg [**Hospital1 **])
Trimethoprim-Sulfamethoxazole 80-400 mg One Tablet PO DAILY
Calcium Acetate 1334 mg PO TID W/MEALS
MVI
Tacrolimus 8 mg PO twice a day
Doxazosin 2 mg PO HS
Zofran prn
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea.
13. Multivitamin Oral
14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
16. Tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO twice a day.
Disp:*360 Capsule(s)* Refills:*2*
17. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours: First patch applied in
hospital Saturday [**2187-1-5**]. Change patch on Tuesday [**2187-1-8**].
Disp:*10 patches* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
dprimary
1. pneumonia
secondary
1. multiple myeloma
2. s/p kidney transplant
3. renal failure chronic, dialysis dependent
Discharge Condition:
Good, breathing room air and in no respiratory distress,
afebrile
Discharge Instructions:
You came to the hospital because of fever, cough, and dyspnea.
You had an Xray of your lungs that showed you had an infection
of your lungs (pneumonia). You were treated with antibiotics
with improvement in your symptoms.
You will need to continue taking an antibiotic, levofloxacin,
for treatment of your pneumonia. Please take the entire course
of levofloxacin even if you are feeling well.
The dose of the medicine used to protect your transplanted
kidney, tacrolimus, was decreased to 6mg twice a day by your
kidney doctors. You need to have a blood test drawn on Monday
[**2188-1-7**] to check that the level of the kidney medicine is at the
right level. Take your tacrolimus at 8pm on Sunday [**2188-1-6**] and
have your blood drawn 12 hours later at 8am on Monday [**2188-1-7**]
BEFORE you take your morning dose of tacrolimus. Please do not
take the Monday morning dose of tacrolimus before the blood draw
because the medicine levels measured in the blood will not be
accurate.
Please continue taking all of your other medicines as directed
and follow up with your primary care doctor Dr. [**Last Name (STitle) 14049**]
[**Telephone/Fax (1) 14050**] , oncology (cancer) doctors [**Last Name (NamePattern4) **]. [**Last Name (STitle) 877**] and Dr.
[**First Name (STitle) **] [**Telephone/Fax (1) 14051**] , and with your kidney doctor Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 14052**].
Call Dr. [**Last Name (STitle) 877**] [**Telephone/Fax (1) 14051**] and seek medical attention if you
develop:
** worsened cough, shortness of breath, high fevers (greater
than 101 farenheit), shaking chills, drenching sweats, or other
symptoms that worry you
Followup Instructions:
Please call Dr.[**Name (NI) 14053**] office at [**Telephone/Fax (1) 14052**] on [**2188-1-7**] to set
up an appointment for management of your kidney disease.
Please keep the following appointments
Oncology
Monday [**1-7**] [**Hospital Ward Name 23**] 7 at 12pm with Dr. [**First Name (STitle) **] and Dr.
[**Last Name (STitle) 877**] [**Telephone/Fax (1) 14051**]
Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 1641**] Date/Time:[**2188-1-7**] 12:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2188-1-7**] 12:00
Orthopedics
Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2188-1-14**] 1:30
|
[
"403.91",
"486",
"203.00",
"584.9",
"996.81",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11528, 11586
|
6964, 9439
|
351, 366
|
11752, 11820
|
3506, 6941
|
13536, 14321
|
2673, 2691
|
9989, 11505
|
11607, 11731
|
9465, 9966
|
11844, 13513
|
2706, 3487
|
284, 313
|
394, 1594
|
1616, 2143
|
2159, 2657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,390
| 133,103
|
25351
|
Discharge summary
|
report
|
Admission Date: [**2133-9-29**] Discharge Date: [**2133-9-30**]
Date of Birth: [**2066-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Carotid stenting
History of Present Illness:
67yoM O2-dependant COPD, htn, DMII, ?syncopal hx admitted for
coronary angiography, found to have L/R-ICA disease, now s/p
R-ICA stenting x2, admitted to CCU for BP control.
In past 2 months, outpt PCP noted carotid bruits, sent for
carotid u/s [**9-23**], showed 70-90% R-ICA stenosis, 91-99% L-ICA
stensosis. CTA neck [**9-24**] showed >90% post-bifurcation long
segment stenosis of R-ICA and near complete occlusion of post
bifurcation LCA.
In [**Hospital1 18**] cath lab, verbal report - 100% L-ICA stenosis, R-ICA
95% stenosis with multiple ulcerations and dissections of R-ICA
artery with collaterals from external carotid artery. Two stents
placed in R-ICA with adequate post-placement flow. Pt had 10
minute period in which he could not identify his location, which
resolved.
On ROS per report, pt reports mult episodes of passing out that
occurred about 3 years ago?. Presently, feels well, denies focal
numbness/weakness/visual changes, denies claudication, edema,
orthopnea, PND, CP.
Past Medical History:
1. COPD, on home oxygen 2L continuously
2. Anxiety
3. Depression
4. Sleep apnea: cpap
5. acute renal failure
6. Diabetes Type II
7. Hypertension
8. Appendectomy
9. Tonsillectomy
10. Back surgery
[**36**]. CAD s/p ptca [**35**] yrs BU
12. ? seizures
13. ? syncope
14. Atrial fibrillation s/p cardioversion (?[**8-18**] at [**Hospital1 **])
15. Parasympathetic nervous system dysfunction
16. "Unusual syndrome of abnormal sensation/movement in penis
Social History:
Pt retired (used to work for oxygen device company) and lives
with his mother in [**Name (NI) 13360**]. Has 5 children ages 43 to 30
years old. Previously smoked 3-4 packs/day x 45 years gradually
decreasing for past 8 years to ~6 cigs/day. Patient states he
quit alcohol 30 years ago. Prior crack/cocaine x 2 yrs. Quit a
few yrs ago. Pt informed that he cannot drive himself to the
procedure and he is going to make arrangements to
have his brother bring him in and pick him up.
Family History:
Mother CABG [**14**], alive 92. Father died at of pancreatic cancer at
age 72.
Physical Exam:
VS: T 98, BP 98/60, HR 71, RR 16, 98%ra
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ D
Pertinent Results:
[**2133-9-29**] 07:57PM
TYPE-ART O2 FLOW-2.5 PO2-85 PCO2-52* PH-7.34* TOTAL
CO2-29 BASE XS-0 O2 SAT-94
[**2133-9-29**] 04:40PM CK(CPK)-165 CK-MB-5
WBC-6.1 RBC-3.70* HGB-11.7* HCT-36.0* MCV-97 MCH-31.6 MCHC-32.5
RDW-15.0
NEUTS-53.9 LYMPHS-33.0 MONOS-6.8 EOS-5.8* BASOS-0.5 PLT
COUNT-217
C.CATH Study Date of [**2133-9-29**]
COMMENTS:
1. Limited angiography of the left carotid artery demonstrated
99%
stenosis of the left ICA with fillign of the MCA only.
Angiography of
the right brachiocephalic trunk demonstrated 50% right
subclavian artery
stenosis, patent vertebral artery and 95% long ulcerated,
dissected
stenosis of the right ICA.
2. Successful angioplasty and stenting of the right ICA with a
8.0x40mm
Protege stent and a 6.0x20mm Acculink stent that were
postdilated to
4.5mm. Final angiography revealed no residual stenosis, no
angiographically apparent dissection and good flow.
FINAL DIAGNOSIS:
1. 99% left ICA stenosis, 95% right ICA stenosis, and 50% right
subclavian stenosis.
2. Successful PTCA and stenting of the right ICA.
ECG Study Date of [**2133-9-29**] 3:13:14 PM
Baseline artifact
Sinus rhythm Slight ST-T wave changes suggested but baseline
artifact makes assessment difficult Since previous tracing of
[**2133-4-21**], ventricular ectopy absent but otherwise baseline
artifact makes comparison difficult
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 [**Telephone/Fax (3) 63415**]/418 71 65 51
Brief Hospital Course:
The patient is a 67yo man with a history of O2-dependent COPD,
hypertension, DMII, and syncopal history who presented for
carotid angiography on [**9-29**].
# PVD/CAD - The patient was admitted for carotid stenting.
Angiography revealed a left ICA with 99% stenosis and a 95% long
ulcerated, dissected stenosis of the right ICA. The patient
underwent angioplasty and stenting of the right ICA with a
8.0x40mm
Protege stent and a 6.0x20mm Acculink stent. There was no
residual stenosis and no
angiographically apparent dissection. The patient was monitored
in the ICU for blood pressure control and neurologic evaluation.
He was felt to be stable and at his neurologic baseline. He
was continued on aspirin, Plavix, statin was discharged with
instructions to follow-up with Dr. [**Last Name (STitle) **] as an outpatient.
# Rhythm - The patient had a history of Afib s/p cardioversion.
EKG's were difficult to interpret in the setting of baseline
artifact, however it was felt that the patient may benefit from
further anticoagulation. He was discharged on Coumadin and
instructed to follow up with his primary care physician for INR
monitoring.
# DM - The patient was discharged on his home regimen of
Glyburide and Avandia
# Hypertension - The patient was continued on his home regimen
of metoprolol, lisinopril and amlodipine.
# Hypercholesterolemia - The patient was continued on ezetemibe
and atorvastatin.
# COPD/OSA - The patient was continued on Advair, albuterol nebs
prn and CPAP overnight.
# Tobacco Abuse - The importance of smoking cessation was
stressed and the patient was given information on tobacco
cessation resources.
# Code - FULL
Medications on Admission:
1. Advair disc 250/50 2 puffs [**Hospital1 **]
2. Albuterol/atrovent nebulizer 4 times daily
3. Amlodipine 2.5mg daily
4. Aspirin 325mg daily
5. Avandia 4mg daily
6. Clorezepate 7.5mg 2 pills 3 times daily
7. Effexor 75mg [**Hospital1 **]
8. Gemfibrizol 600mg daily
9. Glipizide 2.5mg daily
10. Lisinopril 10mg daily
11. Metoprolol succinate 50mg [**Hospital1 **]
12. Omega 3 tid
13. Uroxatral 10mg daily
14. Vitamin b12 1daily
15. Plavix 75mg daily
16. Lipitor 40mg daily
17. Lidocaine 2 % solution PRN
18. Lidociaine 4% liquid PRN
19. lidocaine 5% cream PRN
20. Lidocaine patch PRN
Discharge Medications:
1. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2)
puffs Inhalation twice a day.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO once a day.
6. Clorazepate Dipotassium 15 mg Tablet Sig: One (1) Tablet PO
three times a day.
7. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
12. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO qd ().
13. Vitamin B-12 Oral
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
17. Outpatient Lab Work
Please check INR on [**Last Name (LF) 2974**], [**10-2**] and call in results to
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. Office number: [**Telephone/Fax (1) 3183**].
18. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*150 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Carotid stenosis
.
Secondary Diagnoses:
Peripheral vascular disease
Coronary artery disease
Diabetes
Hypertension
Hypercholesterolemia
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for stenting of your carotid artery. This
occurred without complication. We have started you on coumadin
for your carotid disease. You will need to get frequent blood
draws to adjust the dosage of your coumadin. You will need to
coordinate this with either visiting nurses or with Dr. [**Doctor Last Name 63416**] office. His office number is [**Telephone/Fax (1) 3183**]. Please
get your coumadin level drawn early on [**Telephone/Fax (1) **] so Dr. [**Last Name (STitle) 6700**]
gets the results and can tell you how much coumdadin to take on
[**Last Name (STitle) 2974**]. You will need to follow up with Dr. [**Last Name (STitle) **] as well. Dr.
[**Last Name (STitle) **] will contact you to make that appointment.
.
Please continue the remainder of your medications.
.
Please stop smoking. Information regarding smoking cessation was
given to you on admission.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **]. He will contact you with an
appointment time. His clinic number is [**Telephone/Fax (1) 62**].
Completed by:[**2134-5-20**]
|
[
"433.30",
"305.1",
"440.20",
"V46.2",
"272.0",
"327.23",
"433.10",
"250.00",
"412",
"414.01",
"401.9",
"496",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"00.46",
"00.40",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
8716, 8771
|
4788, 6453
|
334, 353
|
9031, 9040
|
3269, 4164
|
9979, 10160
|
2364, 2444
|
7088, 8693
|
8792, 8792
|
6479, 7065
|
4181, 4765
|
9064, 9956
|
2459, 3250
|
8851, 9010
|
275, 296
|
382, 1379
|
8811, 8830
|
1401, 1850
|
1866, 2348
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,024
| 174,163
|
6518
|
Discharge summary
|
report
|
Admission Date: [**2178-6-26**] Discharge Date: [**2178-7-3**]
Date of Birth: [**2109-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Heparin Agents / Lovenox / Adhesive Bandages
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left fibrothorax.
Major Surgical or Invasive Procedure:
[**2178-6-26**] Left thoracotomy and total pulmonaryn decortication
including parietal pleurectomy, flexible bronchoscopy with
bronchoalveolar lavage.
History of Present Illness:
Mr. [**Known lastname **] is a 68-year-old gentleman who has had bilateral
recurrent pleural effusions. He had a decortication on the right
to address this which
revealed significant fibrothorax and trapped lung. He has had
this same process affecting his left hemithorax and, therefore,
we consented him for decortication to prevent recurrent
effusion. He also has significant dyspnea and it was unclear
whether relief of his fibrothorax may improve his
dyspnea though that was a possibility though not guaranteed.
Past Medical History:
1. Bicuspid aortic valve, status post St. [**Male First Name (un) 923**] mechanical aortic
valve replacement in [**2160**]
2. Atrial fibrillation diagnosed since [**2175-9-17**],
currently on Coumadin therapy
Social History:
Significant for the absence of current tobacco use. daily ETOH
[**1-21**] drinks per day.
Family History:
There is no family history of premature coronary artery disease
or sudden death. +grandfather with MI and DM
Physical Exam:
VS: T 97.6 HR 88 Afib SBP 116/64 Sats: 97% RA
General: walking in halls in no distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: irregular, good click
Resp: decreased breath sounds on right, faint crackles LLL
GI: benign
Extr: warm no edema
Incision: Left thoracotomy site clean mild erythema around
margin, cool no discharge
Neuro: non-focal
Pertinent Results:
[**2178-6-30**] WBC-4.2 RBC-2.65* Hgb-9.1* Hct-27.2 Plt Ct-153
[**2178-6-29**] WBC-5.6 RBC-2.80* Hgb-9.6* Hct-28.5* Plt Ct-143*#
[**2178-6-26**] WBC-5.6# RBC-4.55* Hgb-15.9 Hct-47.0 Plt Ct-118*
[**2178-6-29**] Glucose-137* UreaN-16 Creat-1.0 Na-139 K-3.8 Cl-102
HCO3-29
[**2178-6-26**] Glucose-138* UreaN-22* Creat-0.9 Na-139 K-3.9 Cl-106
HCO3-25
[**2178-6-29**] Calcium-8.7 Phos-2.8 Mg-2.2
Culture Pleural Fluid [**2178-6-26**] no growth
CXR:
[**2178-7-2**] There is a minimal millimetric apical medial
pneumothorax. Signs of tension are not present. Small left basal
pleural
effusion that is unchanged. Also unchanged is the right-sided
pleural
effusion. The preexisting rib fracture is less well recognized
than on the
previous exam. The size of the cardiac silhouette is unchanged.
[**2178-6-29**] 1. Persistent small bilateral pleural effusion, mild
left basal atelectasis and costal pleural thickening, but no
pneumothorax.
[**2178-6-27**] IMPRESSION: Left lower lobe new retrocardiac opacity
consistent with interval development of atelectasis that might
be accompanied by pleural effusion. Interval improvement of
subcutaneous air. The left fifth posterior rib fracture is most
likely post-surgical.
[**2178-7-3**] 06:20AM BLOOD WBC-4.8 RBC-2.94* Hgb-10.2* Hct-30.1*
MCV-102* MCH-34.6* MCHC-33.8 RDW-15.0 Plt Ct-226
[**2178-7-3**] 06:20AM BLOOD Plt Ct-226
[**2178-7-3**] 06:20AM BLOOD PT-18.3* INR(PT)-1.7*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2178-6-26**] for Left thoracotomy and
total pulmonary
decortication including parietal pleurectomy, flexible
bronchoscopy with bronchoalveolar lavage. He was transferred to
SICU intubated.
Pulmonary: He was extubated on [**2178-6-27**]. He required aggressive
pulmonary toilets and nebs and diuresis. His oxygen saturation
on 1 Lites high 90's which dropped to the high 89's with
ambulation. His oxygenation improved over the course of his
hospitalization, RA saturations 97% RA He continued on his home
CPAP at night.
Chest tubes: 3 28 french chest-tubes: basilar, posterior &
anterior apical remained on suction until [**2178-6-30**] then placed
to water-seal. The drainage was serousanguiounous. They were
removed on [**2178-7-2**]. He was followed by serial chest films which
revealed atelectasis/sm effusion.
Cardiac: He was hypotensive immediately postop with a good
response to neo and volume. He was started on his home
medications for atrial fibrillation.
Heme: We was restarted on his fondaparinox on [**2178-6-28**] for his
mechanical valve. He chest tube drainaged was monitored for
bleeding which none occurred. He was then restarted on his
warfarin [**2178-6-30**] for a goal INR 2.0-3.0
Renal: Administered lasix with 1.8 Liter output. Renal function
remained normal.
FEN: Electrolytes were repleted as needed. He tolerated a
regular diet.
Pain: His epidural was managed by acute pain with good pain
control which was removed on [**2178-6-27**]. His pain was well
controlled via Dilaudid PCA converted to PO pain medication.
Disposition: Plan home with VNA. He will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
atenolol 25 mg daily, folic acid 1 mg daily, furosemide 20 mg
[**Hospital1 **], probenecid 500 mg [**Hospital1 **], isosorbide mononitrate 30 mg daily,
warfarin 5/2.5 mg alternating.
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Probenecid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO as directed: Goal
INR 2.0-3.0.
9. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily): stop when INR > 2.0.
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Left fibrothorax
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage
-Chest tube site remove dressing Saturday and cover with a
bandaid until healed
-You may shower on Saturday. No tub bathing or swimming for 6
weeks
-No driving while taking narcotics
-Walk 4-5 times a day for 10 mins increased to goal of 30 mins
daily
Warfarin: Take Fonadarinux until INR 2.0 or greater
Warfarin continue home dose as previous
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**7-16**] 2:00 pm on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Follow-up with Dr. [**Last Name (STitle) 2912**] [**Telephone/Fax (1) 25005**] for further warfarin
doses. INR Goal 2.0-3.0. Please have your Blood drawn on
Monday and call Dr.
[**Last Name (STitle) 2912**] for further warfarin doses.
Completed by:[**2178-7-3**]
|
[
"287.5",
"511.0",
"427.31",
"518.0",
"V58.61",
"V12.04",
"276.3",
"V43.3",
"305.01",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.51"
] |
icd9pcs
|
[
[
[]
]
] |
6201, 6263
|
3379, 5089
|
343, 497
|
6324, 6333
|
1933, 3356
|
6929, 7478
|
1402, 1512
|
5322, 6178
|
6284, 6303
|
5115, 5299
|
6357, 6906
|
1527, 1914
|
285, 305
|
525, 1045
|
1067, 1278
|
1294, 1386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,091
| 159,750
|
47165
|
Discharge summary
|
report
|
Admission Date: [**2129-11-24**] Discharge Date: [**2129-11-26**]
Date of Birth: [**2058-10-1**] Sex: M
Service: MEDICINE
Allergies:
Niacin
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Left internal carotid stenosis
Major Surgical or Invasive Procedure:
Left internal carotid artery stent placement
History of Present Illness:
71 year old man has a history of hypertension,
hyperlipidemia, tobacco abuse, coronary artery disease s/p prior
RCA stenting and carotid artery disease s/p right ICA stenting
at [**Hospital3 **]??????s hospital in [**2125-12-12**], with asymptomatic
70-79% L ICA stenosis admitted for elective angiography, L ICA
stent.
He also has a known left carotid stenosis that has been
followed by Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] from neurology. In [**2129-7-12**] he
underwent routine
screening of his carotids and was found to have progression in
the stenosis on the left side. He has been completely
asymptomatic. He is now being referred for angiography/stenting.
Past Medical History:
Hypertension
Hyperlipidemia
CAD, s/p RCA DES [**8-16**]
PVD, asymptomatic carotid artery disease s/p [**Country **] stenting in
[**2125-12-12**]??????s, now with progressive moderate
to severe left ICA disease
Lumbar spinal stenosis/back pain with mild residual weakness of
his left leg (s/p physical therapy and steroid injection)
Cataracts
Remote history of nephritis
GERD
Right hernia repair
Appendectomy
Tonsillectomy
BPH
Social History:
-Tobacco history: smoked upto 1.5 packs a day for over fifty
years. He currently smokes 8-10cigarettes per day. Wife also
smokes
-ETOH: rare
-Illicit drugs: denies
Married, 2 grown children
Family History:
Mother died suddenly at a young age, cause unknown
Father died of PE after cardiac surgery
Physical Exam:
VS: T=afeb BP=112/44 HR=65 RR=12 O2 sat= 98% RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, no JVD. Carotid bruits b/l.
CARDIAC: RRR, normal S1, S2. Soft systolic murmur at USB. No
thrills, lifts. No S3 or S4.
LUNGS: Enlarged A-P diameter, resps unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND, +BS.
EXTREMITIES: No c/c/e. Inguinal dressing C,D,I. No hematomas or
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.Small
cherry hemangiomas on chest.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Neuro: CN 2-12 intact. Strength: [**5-16**] proximal and distal muscles
of b/l UEs. Distal LE strength 5/5. Sensory exam to light touch
equal bilaterally. FNF intact.
Pertinent Results:
[**2129-11-26**] 05:59AM BLOOD WBC-8.0 RBC-3.13* Hgb-9.5* Hct-26.8*
MCV-86 MCH-30.5 MCHC-35.6* RDW-13.2 Plt Ct-210
[**2129-11-25**] 02:57AM BLOOD PT-13.5* PTT-36.7* INR(PT)-1.2*
[**2129-11-26**] 05:59AM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-139
K-3.9 Cl-107 HCO3-24 AnGap-12
[**2129-11-24**] 06:39PM BLOOD CK(CPK)-59
[**2129-11-26**] 05:59AM BLOOD Mg-1.9
[**2129-11-25**] 02:57AM BLOOD Mg-1.7 Cholest-99
[**2129-11-25**] 02:57AM BLOOD Triglyc-164* HDL-30 CHOL/HD-3.3
LDLcalc-36
Brief Hospital Course:
71 year old male with history of CAD s/p DES to RCA, Righ ICA
stent, L ICA stenosi, admitted s/p L ICA stent.
#Carotid Stenosis - Pt admitted s/p stent placement in left ICA
stent, which he tolerated well. Pt was hypotensive post op
(thought to be secondary to vagal stimulation from stent)
requiring transient phenylephrine post op to keep SBP between
100 and 160. Pt had regular checks of his neurologic status,
which remained normal for every 2-4 hour checks by nursing
staff, cardiac team and neurology consult. Pt was continued on
ASA, plavix and a statin, while blood pressure medications and
Flomax were held. Pt was instructed to restart his BP meds
several days after discharge.
# [**Name (NI) 30294**] Pt was continued on his finasteride but flomax held while
hypotensive.
# [**Name (NI) 14983**] Pt was continued on home PPI regimen
Medications on Admission:
Plavix 75mg daily every morning
Finasteride 5mg daily every evening
HCTZ 25mg daily every morning
Lisinopril 40mg daily every morning
Metoprolol XL 100mg, 1.5 tablets every morning
Zocor 80mg daily every evening
Aspirin 81mg daily every morning
Flomax 0.4mg daily every evening
Pepcid OTC prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop unless instructed to by your cardiologist.
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: restart on [**11-29**].
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
restart on [**11-29**].
7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day: restart on [**11-29**].
8. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day: restart on [**11-29**].
9. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for heartburn.
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid artery stenosis
Coronary artery disease
Discharge Condition:
Stable. Off pressors > 12 hours. Ambulating. Normal neuro
exam.
HR 69 BP 113/49
Discharge Instructions:
You were admitted for a procedure to increase blood flow through
the carotid arteries, that deliver blood to the brain. As an
effect of this procedure your blood pressures were low and you
were given medications to increase your blood pressures. This
medication was stopped, but you should wait three days before
starting medications that lower your blood pressure.
You have a new, higher dose of 325 mg of enteric coated aspirin
that you should take.
Please stop smoking as this greatly increases your risk of heart
and vascular disease. Information was given to you on admission
regarding smoking cessation.
Followup Instructions:
You will need to call Dr.[**Name (NI) 3101**] office at [**Telephone/Fax (1) 62**] to
arrange a follow-up appointment in the next 1-2 weeks.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2130-2-1**] 3:40
Completed by:[**2129-11-27**]
|
[
"433.10",
"272.4",
"401.9",
"458.29",
"414.01",
"V45.82",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"00.45",
"88.41",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
5437, 5443
|
3331, 4181
|
300, 347
|
5535, 5621
|
2828, 3308
|
6281, 6602
|
1755, 1847
|
4525, 5414
|
5464, 5514
|
4207, 4502
|
5645, 6258
|
1862, 2809
|
230, 262
|
375, 1082
|
1104, 1531
|
1547, 1739
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,305
| 123,147
|
33892
|
Discharge summary
|
report
|
Admission Date: [**2142-10-2**] Discharge Date: [**2142-10-11**]
Date of Birth: [**2117-2-6**] Sex: F
Service: MEDICINE
Allergies:
Magnesium / Latex / Salicylate / Benzocaine
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
fever, knee pain
Major Surgical or Invasive Procedure:
L knee washout
intubation
extubation
transesophageal echocardiogram
History of Present Illness:
Ms. [**Known lastname 1637**] is a 25 yo F with PMH of severe persistent asthma
with multiple prior intubations, IVDA, septic arthritis
presenting with two days of fever and knee pain. She reports
that on the evening prior to presentation she developed fever
to 102 and swelling of her left knee. Two days prior to that
she reports falling out of a car and cutting her hand on the
ground which became progressively more swollen and painful. She
does also endorse injecting heroin into her right antecubital
fossa one week ago but denies sharing needles. Of note, details
of her history change when asked at different times or by
different interviewers.
She also endorses history of cellulitis in her left leg two
months ago at [**Hospital **] hospital for which she was treated with
antibiotics. [**Doctor Last Name **] reports that the infection started in her
foot and spread upward. She denies having to have her left knee
tapped at that time.
In the ED, initial vs were: T 101 P 146 BP 105/64 R 18 O2 sat
94% RA. She had drainage of a 2x2 cm abscess on her left hand
which was packed in the ED. She was evaluated by orthopedics
due to concern for septic joint and she had drainage of
reportedly purulent material from her left knee. She was given
6L NS IV and had 3L urine output in ED. She was also given
morphine 4mg IV, zosyn 4mg IV, tylenol 1 g po, levofloxacin
750mg IV, ativan 0.5mg IV, vancomycin 1g IV.
Past Medical History:
Severe persistent asthma - multiple intubations
chronic sinusitis
opiod dependence
s/p bilateral knee replacements for osteonecrosis [**2-26**] long term
prednisione use (R knee [**9-1**], left knee [**1-1**])
hypogammaglobulinemia
hepatitis c
tobacco abuse
-spontaneous PTX in [**5-2**]
-s/p R VATS/bleb resection and pleurectomy at [**Hospital 8**] Hospital
in [**2141-6-25**]
osteopenia by xray
Social History:
She endorses recent injection of heroin in the past week and
reports that prior to this she had been clean for about two
years. She does have history of injection drug use and cocaine
use in the past.
Tobacco: She endorses smoking [**1-26**] PPD currently and has been
smoking for the past 10 years.
Family History:
Mother - breast cancer
[**Name (NI) **] - asthma and hyperthyroidism
Physical Exam:
Vitals: T: 98.1 BP: 92/64 P:95 R:21 O2: 97% RA
General: awake, alert and oriented
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
no roths spots
Neck: supple, JVP not elevated, no LAD
Lungs: decreased air movement, scattered squeaks in the upper
air fields, no crackles
CV: regular, tachycardic(after nebs), normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: left knee with clean dry surgical site with staples in
place. +edema, but not erythema. Mild tenderness to palpation.
Good ROM. Good pulses.
Pertinent Results:
[**2142-10-2**] knee X ray: In comparison with the study of [**8-29**],
there has been placement of a total knee prosthesis without
evidence of hardware-related complication. There is substantial
soft tissue swelling in the suprapatellar region. It is unclear
whether this could merely represent postoperative change, since
the date of the surgical procedure is not known. If
postoperative changes should have been resolved by this time,
the possibility of an acute inflammatory process must be
seriously considered given the clinical history.
[**2142-10-2**] chest x ray pa / lat: No acute intrathoracic process.
[**2142-10-2**] hand x ray: Osteopenia, for which additional workup is
strongly recommended (perhaps beginning with bone mineral
measurements). If this patient has no underlying obvious
etiology, the differential would include osteogenesis
imperfecta.
[**2142-10-3**] transthoracic echocardiogram: Suboptimal study due to
patient decision not to allow for study completion. Possible
very small vegetation on the posterior mitral leaflet. If
clinically indicated, a follow-up transthoracic study with color
Doppler and apical images and/or a TEE is suggested to better
assess the possible posterior mitral leaflet abnormality
[**2142-10-3**] transthoracic echocardiogram: The left atrium and right
atrium are normal in cavity size. The interatrial septum is
aneurysmal. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen (clip [**Clip Number (Radiology) **]). The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2142-10-3**], the
previously noted mobile echodensity on the posterior mitral
leaflet is no longer seen . Mild mitral regurgitation is now
seen (not previously assessed).If the clinical suspicion for
endocarditis is moderate or high, a TEE would be better able to
define the mitral valve morphology and severity of mitral
regurgitation.
[**2142-10-4**] transesophageal echocardiogram: The left atrium and
right atrium are normal in cavity size. The interatrial septum
is aneurysmal. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen (clip [**Clip Number (Radiology) **]). The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2142-10-3**], the
previously noted mobile echodensity on the posterior mitral
leaflet is no longer seen . Mild mitral regurgitation is now
seen (not previously assessed). If the clinical suspicion for
endocarditis is moderate or high, a TEE would be better able to
define the mitral valve morphology and severity of mitral
regurgitation.
Time Taken Not Noted Log-In Date/Time: [**2142-10-2**] 12:26 pm
SWAB (L) THUMB.
**FINAL REPORT [**2142-10-6**]**
GRAM STAIN (Final [**2142-10-2**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2142-10-6**]):
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Left Knee joint fluid also grew group A beta hemolytic
streptococcus, as did [**4-28**] blood cultures from [**2142-10-2**].
Brief Hospital Course:
septic shock, septic arthritis, prosthetic joint: the patient
was initially admitted with septic shock, was on pressors and
weaned. she was started on broad spectrum antibiotics until
cultures returned with group A strep bactermia. At that time
she was transitioned to penicillin and clindamycin. Clindamycin
was in case she had toxic shock, this was discontinued on
[**2142-10-6**] as she was no longer pressor dependent. Her bacteremia
was detected on [**2142-10-2**] and subsequent blood cultures had cleared
(pending as of [**2142-10-6**]). Her L knee joint fluid and L thumb
abscess also grew group A strep. Had knee washout and
replacement, [**2142-10-4**]. Plastic surgery I&D to thumb. She will
need 6 weeks of penicillin. She had a TEE without evidence of
endocarditis. Needs weekly labs, ID and ortho f/u. CPM 0-100 as
tolerated. Staples out two weeks from discharge from [**Hospital1 18**].
POLYSUBSTANCE ABUSE: The patient was initially noted to be
extremely agitated with acute illness. This cleared. She is
stable on seroquel at night. Prn clonapin. Also needs narcotic
pain meds weaned off over 6 weeks.
ASTHMA: Asthma exacerbation on admission. Severe persistent
asthma with multiple (> 20) intubations in the past. She is not
compliant with her meds and was intubated due to respiratory
failure. She was extubated successfully on [**10-5**] and her asthma
had improved with bronchodilators alone, given her sepsis
steroids were not added. she is stable now on her home meds, but
still has wheezing on exam, but is moving air well. this is her
baseline. She will need f/u with her pulmonologist at [**Hospital1 18**], Dr.
[**Last Name (STitle) **] that can be set up upon her discharge from rehab or
ealier if needed.
PROPHYLAXIS: She was started on lovenox 40mg sc daily for ppx
after her knee washout and will need this for 3 weeks post op.
MRSA+: was found in her record with unclear actual source. MRSA
negative in all cultures at our hospital and negative MRSA
screen. Consider repeating MRSA screens x 3 to remove
precautions.
sinus tachycardia: the patient frequently tachycardic after
neb/inh treatments.
Hepatitis C chronic: antibody +, VL 7700. will f/u with ID. HIV
neg.
Medications on Admission:
Medications (confirmed by local pharmacy):
1) Advair 500/50 b.i.d.
2) Albuterol inhaler (Proair) up to 4 times daily.
3) Theophylline SR 450 mg once daily.
4) Spiriva 18 micrograms once daily. (not filled)
5) Singulair 10 mg once daily.
6) Dilaudid 4 mg p.o. q4hr (unclear if currently getting this)
7) DuoNebs p.r.n. (she uses this approximately once a week).
8) Prilosec 20 mg once daily.
9) Calcium/vitamin D.
10) seroquel 100mg qhs (not filled)
11) Clonidine (not confirmed by pharmacy)
12) Xopenex (not filled)
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): until [**10-24**].
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth pain.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for dyspnea, wheezing.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain: should be weaned over 6 weeks.
13. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: Four
(4) Million units Injection Q4H (every 4 hours) for 5 weeks: do
not stop medication until instructed by [**Hospital **] clinic at [**Hospital1 18**].
14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
septic arthritis, prosthetic joint
Discharge Condition:
good
Discharge Instructions:
Patient was admitted with group A strept infection of her
prosthetic knee. Needs 6 weeks on antibiotics. Also needs PT for
right knee with CPM 0-100 degrees as tolerated. Lovenox for 3
weeks post op and staple removal in 2 weeks. Needs f/u with [**Hospital **]
clinic and ortho clinic during 6 week course and appointments
with PCP and pulmonary(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) after discharge from
rehab.
Followup Instructions:
ID follow up
- anticipate 6 weeks IV PEN G from [**10-2**] and then 6 months of oral
therapy pending clinical course
- we will arrange follow up in ID clinc with Dr. [**First Name (STitle) **] [**Name Initial (MD) **]
[**Name8 (MD) **], MD or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-27**] weeks
- check weekly cbc diff bun cr lfts while on IV antibiotics and
fax all lab results to Infectious disease R.Ns. at ([**Telephone/Fax (1) 18871**]
- all questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**] or to
on [**Name8 (MD) 138**] MD in when clinic is closed.
Provider [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2142-10-31**] 3:45
PCP([**Doctor Last Name **]) and pulm([**Doctor Last Name **]) f/u after discharge from rehab.
|
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icd9cm
|
[
[
[]
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[
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"96.71",
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icd9pcs
|
[
[
[]
]
] |
12658, 12731
|
8311, 10525
|
321, 390
|
12810, 12817
|
3338, 8288
|
13311, 14310
|
2603, 2673
|
11100, 12635
|
12752, 12789
|
10551, 11077
|
12841, 13288
|
2688, 3319
|
265, 283
|
418, 1848
|
1870, 2269
|
2285, 2587
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,152
| 155,412
|
30143
|
Discharge summary
|
report
|
Admission Date: [**2189-3-29**] Discharge Date: [**2189-4-18**]
Date of Birth: [**2115-8-21**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Antipsychotic Drug
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Left hip pain.
Major Surgical or Invasive Procedure:
Blood transfusion.
Left hip ORIF.
Cardiac catheterization.
History of Present Illness:
73 year-old male with history of CAD, HTN, CHB with PPM, PAF on
coumadin who suffered a fall forward "onto all fours" per wife
in Bahamas on [**Name (NI) 2974**]. He did not have any head trauma. The
patient complained of left hip pain. The patient was med
flighted to [**Location (un) 71836**], where he was diagnosed with a proximal femur
fracture, then transferred to [**Hospital1 18**]. On arrival in the ED, noted
to be hemodynamically stable, but hematocrit was 21.9 (unknown
baseline). INR was 1.3; he had last taken warfarin the day
preceding his fall.
.
The patient's wife states that at baseline he walks on level
surfaces without difficulty, but she has noted he is having
increasing SOB. When asked if she thought he could climb two
flights of stairs with a bag of groceries, she says that he
would have to stop and rest for shortness of breath.
.
The patient states he has anginal pain when he gets aggrevated,
and has been needing to use his nitrostat more frequently of
late.
.
Review of systems otherwise negative in detail.
Past Medical History:
1. Pacer placed post-MI for complete heart block, replaced x2
most recently [**2-/2188**]
2. Paroxysmal atrial fibrillation, on coumadin
3. Hypertension
4. Early Alzheimer's dementia
5. Depression/anxiety
6. Left femoral fracture
7. ? Hodgkin's Lymphoma
8. ? TIA
Social History:
Lives with wife in [**Name (NI) 3844**]. Rare alcohol use; history of
tobacco use, but quit a number of years ago.
Family History:
Non-contributory.
Physical Exam:
VS: 98 140/76 101 18 99 2L
Pale, anxious, nad.
HEENT Face symmetric, MMM, pale-appearing. EOMI, PERRL
COR:Tachy, reg, [**4-14**] HSM with radiation to carotids. No R/G
PULM:CTA thoughout
ABD:Soft, tender bilateral lower quadrants, BS +, no rebound or
guarding, no hsn, audible abdominal aortic bruit.
EXT:No edema, lle in ace wrap thoughout.
NEURO:Alert, anxious, oriented to person, place.
Pertinent Results:
FEMUR /KNEE/HIP LEFT [**2189-3-29**]
IMPRESSION: Oblique fracture of the proximal left femur
involving the lesser trochanter and proximal femoral diaphysis.
.
CT ABDOMEN/PELVIS W/O CONTRAST [**2189-3-29**]
IMPRESSION:
1. Tiny bilateral pleural effusions and bibasilar atelectasis.
2. Bilateral renal lesions, the larger are consistent with
cysts, several subcentimeter lesions are too small to
characterize. There is a 1.6-cm high- density lesion at the
upper pole of the left kidney, which is not completely
characterized. Further evaluation with ultrasound or MRI is
recommended. Differential diagnosis includes hemorrhagic cyst or
renal cell carcinoma.
3. Suprarenal abdominal aortic aneurysm.
4. Left femoral fracture extending from the femoral neck down to
the proximal femur, this fracture is significantly displaced and
there is a large left thigh hematoma involving nearly the entire
rectus femoris muscle. There is also a left knee joint effusion.
.
Transthoracic echocardiogram [**2189-3-31**]
Conclusions:
Technically suboptimal study.
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is mild to moderate regional left
ventricular systolic dysfunction with focal akinesis of the
basal half of the inferolateral wall and hypokineis of the
distal half of the septum and anterior wall and apex. Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. No aortic regurgitation is seen.
The mitral valve is not well seen. No definite mitral
regurgitation is identified. There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
multivessel CAD.
.
Transthoracic echocardiogram [**2189-4-3**]
Left Ventricle - Ejection Fraction: 30% to 40% (nl >=55%)
The left atrium is elongated. Left ventricle is mildly
hypertrophied.. There is moderate regional left ventricular
systolic dysfunction. There is Akinesis of the basal and mid
posterior wall. There is hypokinesis of the basal inferior wall.
There is hypokisis of the distal antieror and septal walls and
the apex. Overall, the function and wall motion does not appear
appreciably changed from the previous (limited) transthoracic
study of [**2189-3-31**]. The right ventricular cavity is moderately
dilated. Right ventricular systolic function is borderline
normal. There are complex (mobile) atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(area 1.2-1.9cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation or stenosis is seen. The tricuspid valve leaflets
are mildly thickened. Findings relayed to surgical team at
bedside at the time of the exam.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2189-4-4**]
No pulmonary embolism. Small bilateral pleural effusions with
associated dependent bibasilar lung atelectasis. Nonspecific
patchy ground glass attenuation throughout both lungs, which is
worse in the right upper lobe. Findings may represent early
infection or pulmonary edema. Wedge fracture of a single mid
thoracic vertebral body.
.
Tranesophagel echocardiogram [**2189-4-4**]
Conclusions:
Right ventricular chamber size and free wall motion are normal.
Compared with the prior study (images reviewed) of [**2189-3-31**],
the right
ventricular function is similar. Please see prior echocardiogram
for full
study. This was a limited examination.
.
C.CATH Study Date of [**2189-4-15**]
*** Not Signed Out ***
BRIEF HISTORY: 73 year old male with coronary artery disease
status
post two remote myocardial infarction who presented with a hip
fracture
and NSTEMI. Echocardiogram revealed an LVEF of 35% with wall
motion
abnormalities consistent with rPDA and mid-LAD disease.
Catheterization
deferred prior to hip surgery but now referred to the cath lab
prior to
resuming physical rehabilitation.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the left ventricle through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: gms %
FICK
**PRESSURES
LEFT VENTRICLE {s/ed} 158/14
AORTA {s/d/m} 158/72/100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 50
6) PROXIMAL LAD DISCRETE 50
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 DISCRETE 70
10) DIAGONAL-2 DISCRETE 60
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 19 minutes.
Arterial time = 16 minutes.
Fluoro time = 4.6 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 55 ml
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Fentanyl 50mcg
Nahc03 75cc/hr
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
two vessel disease. The LMCA had a heavily calcified 50% distal
stenosis
but with a large caliber lumen. The LAD had a calcified 50%
ostial
lesion but no significant disease distally. There was a small D1
branch
with a 70% stenosis and a 60% focal lesion in D2. The LCx was
free of
significant stenoses. The RCA was chronically occluded
proximally and
filled via left to right collaterals.
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with an LVEDP of 14mmHg. There was moderate
systemic
arterial hypertension with an aortic SBP of 158mmHg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Mild diastolic left ventricular dysfunction.
.
Labwork on admission:
[**2189-3-29**] 01:50AM WBC-8.4 RBC-2.44* HGB-7.9* HCT-21.9* MCV-90
MCH-32.3* MCHC-36.0* RDW-13.8
[**2189-3-29**] 01:50AM PLT COUNT-232
[**2189-3-29**] 01:50AM NEUTS-81.1* LYMPHS-11.7* MONOS-6.4 EOS-0.7
BASOS-0.1
[**2189-3-29**] 01:50AM PT-14.8* PTT-29.2 INR(PT)-1.3*
[**2189-3-29**] 01:50AM GLUCOSE-96 UREA N-31* CREAT-1.7* SODIUM-137
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
[**2189-3-29**] 01:50AM CK(CPK)-973*
[**2189-3-29**] 01:50AM CK-MB-11* MB INDX-1.1 cTropnT-0.02*
[**2189-3-29**] 09:40AM CK(CPK)-836*
[**2189-3-29**] 09:40AM CK-MB-10 MB INDX-1.2 cTropnT-0.02*
[**2189-3-29**] 01:08PM CK(CPK)-803*
[**2189-3-29**] 01:08PM CK-MB-9 cTropnT-0.02*
.
Labwork on discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2189-4-17**] 05:52AM 11.7* 3.08* 9.6* 28.8* 94 31.4 33.5 16.0*
473*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2189-4-17**] 05:52AM 83 22* 1.2 139 3.9 102 28 13
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2189-4-18**] 09:20AM 25.0* 38.1* 2.5*
Brief Hospital Course:
73 year-old with history of CAD now s/p fall who presented with
left femur fracture and chest pain.
.
The patient presented with an oblique left femur fracture which
required surgical correction by orthopedic surgery. However,
given elevated troponins, echocardiogram with multiple wall
motion abnormalities in the setting of low EF (35%), and
patient's complaints of chest pain on admission, the patient's
surgery was postponed until cardiac risk assessment was
completed. The patient was initially maintained with ASA, Nitro
patch, metoprolol, SL NTG, and morphine PCA pump with resolution
of chest pain. The risk of peri-operative cardiovascular event
was estimated at about 20%. The patient lacked capacity; the
patient's wife and son consented to proceed with the high-risk
surgery.
.
The patient's hematocrit was maintained >28 with blood
transfusions as needed. The patient's warfarin was initially
held given the amount of blood loss and need for surgery.
.
On [**2189-4-1**], the patient had a pin placed with 15 pounds of
traction by orthopedic surgery at the bedside. He was taken to
the OR on [**2189-4-3**].
.
The patient was noted to be hypotensive post-operatively
[**2189-4-3**]. He was maintained on phenylephrine gtt for his
hypotension. There was some concern for new elevations in his
cardiac enzymes and he was transferred to the CCU team for
further care. Once in the CCU, his phenylephrine was
discontinued and he was started on peripheral dopamine for blood
pressure support. He was noted to be hypoxic and in sinus
tachycardia to the 120s. The source of his shock was initially
unclear (sepsis vs cardiogenic shock vs secondary to pulmonary
embolus), and a Swan-Ganz catheter was placed under fluoroscopic
guidance. The Swan numbers showed elevated right-sided
pressures and a narrow pulse pressure which was concerning for
PE. He was started on a heparin gtt, electively intubated, and
underwent a CT angiography which showed no evidence of PE as
above.
.
The etiology of hypotension was not entirely clear but PA
catheter numbers were not consistent with cardiogenic shock; the
shock was presumed secondary to sepsis from MRSA pneumonia and
postoperative hypovolemia. Further CCU course significant for
supportive care initially including pressors and IVF. After
fluid resuscitation, pressors were weaned several days later.
After hemodynamic stability, the patient was extubated without
difficulty. The patient completed a 7-day course of Zosyn and a
14-day course of vancomycin started [**2189-4-4**] for MRSA in the
sputum and [**2-12**] blood cultures with S. faecium.
.
Prior to transfer to the floor, the patient had a pulseless
polymorphic VT/VF arrest with QT prolongation. The patient
received one shock at 300 J and returned to sinus rhythm. The
arrest was believed secondary to QT prolongation from haldol.
The patient's pacemaker rate was increased to 90 to decrease the
QT interval. The patient should not receive any QT prolonging
agents in the future. The patient's cardiac enzymes were stable
and ischemia was not believed to be responsible for the
patient's arrhythmia. The patient was intubated for airway
protection during the arrest but extubated easily the day after.
The patient does not require ICD placement for this reversible
etiology of VT arrest. The patient was evaluated for ICD
placement because of his depressed EF, but this was not further
pursued because of the patient's decreased mental status.
.
The day prior to transfer, the patient became hypotensive in the
setting of atrial fibrillation with rapid ventricular rate. The
patient's pacemaker was adjusted from DDD to DDI with good
effect. The patient was started on metoprolol for rate control.
.
The day of transfer to the floor, the patient received
diagnostic/therapeutic cardiac catheterization to evaluate for
ischemia given the history of NSTEMI early in his hospital
course. The report is as above; there were no intervenable
lesions.
.
The patient is discharged to rehab for further physical therapy
post ORIF. The patient is discharged with a cardiac regimen
consisting of ASA, plavix, BB, ACEI, and statin. The patient
was restarted on coumadin for paroxysmal atrial fibrillation and
should receive INR checks regularly at least twice weekly until
stable to ensure that INR is at goal [**3-14**]. The patient is taking
tylenol and tramadol as needed for left hip pain.
.
Of note, the patient had a diagnosis of early Alzheimer's
dementia prior to admission. The patient was oriented times one
to three during admission, in general becoming more disoriented
at night.
.
The patient should follow-up decreasing the pacemaker rate in
the future if the QTc is back to normal range and should have
pacemaker interrogation per his primary cardiologist. He should
have follow-up imaging to reassess the probable renal cysts seen
on CT abdomen as above. The patient should have further
management of COPD diagnosed on chest X-ray as needed.
Medications on Admission:
Diltiazem 360 SR
Irbesartan 150
Trazodone 12.5 hs prn
Aricept 5
Nameda 10 [**Hospital1 **]
Warfarin 3 mg for 5 d/wk, 1.5 mg 2 other days
Zocor 40 Q HS
Nitrostat prn
Toprol XL 100
Protonix 40
Effexor XL 75
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
[**Month (only) 116**] repeat x2.
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Until warfarin therapeutic.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
10. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
13. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Apply Velley
Discharge Diagnosis:
Primary:
1. Left hip fracture status post ORIF
2. Septic shock secondary to hospital-acquired pneumonia
3. Cardiac arrest secondary to ventricular tachycardia with
prolonged QT
4. Coronary artery disease status post NSTEMI is peri-operative
period
5. Congestive heart failure, EF 30-40%
.
Secondary:
1. Pacer placed post-MI for complete heart block, replaced x2
most recently [**2-/2188**]
2. Paroxysmal atrial fibrillation, on coumadin
3. Hypertension
4. Early Alzheimer's dementia
5. Depression/anxiety
6. Chronic obstructive pulmonary disease per CXR
7. Left femoral fracture
8. ? Hodgkin's Lymphoma
9. ? TIA
Discharge Condition:
Afebrile, vital signs stable. INR 2.5.
Discharge Instructions:
You were hospitalized with a left femur fracture. You underwent
surgery to repair this. You are being discharged to a rehab
facility for physical therapy.
.
While hospitalized, you had a cardiac arrest from QT
prolongation from haldol. You should discontinue Effexor, as it
can increase the QT interval. You should check with your
physician before starting any new medications. You should never
take any medications that prolong the QT interval. You pacemaker
rate was increased to 90 to decrease the QT interval and you
should recheck this with your cardiologist.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, or any other concerning
symptoms.
.
Please take your medications as prescribed.
- For your heart, you should take:
-- Aspirin 325 mg once daily
-- Plavix 75 mg once daily
-- Metoprolol 25 mg twice daily
-- Lisinopril 5 mg once daily
-- Simvastatin 40 mg once daily
-- Warfarin 3 mg once daily
-- Please have INR checked every two to three days at rehab with
goal INR [**3-14**] until stable values obtained
.
Please call your cardiologist, Dr. [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) **], at
[**Telephone/Fax (1) 16827**] to schedule a follow-up appointment within two
weeks of your discharge from the rehab center.
Followup Instructions:
Please call your cardiologist, Dr. [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) **], at
[**Telephone/Fax (1) 16827**] to schedule a follow-up appointment within two
weeks of your discharge from the rehab center.
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25,385
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Discharge summary
|
report+report+addendum
|
Admission Date: [**2193-7-30**] Discharge Date: [**2193-8-5**]
Date of Birth: [**2135-12-13**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
woman who presented with a severe headache to the Emergency
Room with no trauma. She went to an outside hospital. On
the way there, she became syncopal and unresponsive.
Subsequently was intubated for airway protection with no
focal weakness. No numbness or tingling. Positive
photophobia at the outside hospital.
PAST MEDICAL HISTORY: Hypothyroidism and
hypercholesterolemia.
MEDICATIONS ON ADMISSION: Synthroid, Prevacid, Pravachol,
and Fosamax.
ALLERGIES: The patient has an allowing to AMOXICILLIN.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
intubated. Neurologically, not following commands. No eye
opening to voice. The pupils were 2 mm down to 1 mm and
sluggishly reactive. She had positive corneal's bilaterally.
She had a positive gag. She withdrew all four extremities
equally to noxious stimulation.
RADIOLOGY: A computer tomography and computed tomography
angiogram of the head showed moderate subarachnoid hemorrhage
with mildly enlarged lateral ventricles. No mass effect, and
no shift. A question of a left internal carotid artery
bifurcation aneurysm and right middle cerebral artery
aneurysm.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Intensive Care Unit for close neurologic observation. She
was started on Dilantin/nimodipine and was taken to angio.
On [**7-31**], she went to angio where she underwent an
arteriogram. The patient's angio confirmed a right internal
carotid artery and a left middle cerebral artery aneurysm.
The patient was taken to the operating room on [**7-31**] for a
right frontotemporal parietal craniotomy for clipping of
aneurysms. There were no intraoperative complications.
Postoperatively, the patient was monitored in the Intensive
Care Unit. On chest x-ray on [**7-30**], she had some mild
interstitial edema. On postoperative check she was sedated
on propofol. She had a vent drain in that put out 40 cc.
Her pupils were 4 mm down to 3 mm and briskly reactive
bilaterally. She had a positive cough. She had some
movement to stimulation in the upper extremities - right
greater than left - and minimal movement in the bilateral
lower extremities to stimulation.
On [**8-1**], the patient continued to be sedated on propofol.
She did not open her eyes. She was moving the right side
greater than the left side to stimulation. On [**8-1**], the
patient was taken back to angio which showed good clipping of
the aneurysms without residual of the aneurysm, and no
evidence of vasospasm. The [**Location (un) 1661**]-[**Location (un) 1662**] drain was pulled,
and the vent drain remained in place. Post procedure, off
propofol, the patient moved spontaneously on the right.
Localized briskly in the right upper extremity. Localized 50
percent in the left upper extremity, and the toes were
downgoing bilaterally. She briskly withdrew the lower
extremity on the right and minimally on the left lower
extremity. The groin showed no hematoma, and her pedal
pulses were strong.
On [**8-3**], the patient had transcranial Doppler studies
which showed normal flow on the left side but was
nondiagnostic on the right. The patient remained intubated
with some spontaneous move of the right upper extremity. The
pupils were equal and reactive.
On [**8-4**], the patient spiked to 102.8. The patient was
fully cultured. On [**8-4**], TCD showed high flow on the
right side. The patient was started on levofloxacin for gram-
negative rods in her sputum.
The patient had a repeat head computer tomography on [**8-5**]
which was stable. There were no changes. Neurologically,
the patient continued to be stable with no change in her
neurologic status. She continued to move the right side
spontaneously, the left side less so. [**8-5**], Infectious
Disease was consulted due to the patient's persistent fevers.
The patient currently being covered with vancomycin,
levofloxacin, and Flagyl for broad spectrum coverage.
No definite source was identified on [**2193-8-6**] following
cerebrospinal fluid cultures, sputum cultures, and urine
cultures.
On [**8-7**], a chest x-ray showed left lower lobe retrocardiac
opacity. A right upper quadrant ultrasound showed a liver
cyst. Lower extremity noninvasive studies showed no evidence
of deep venous thrombosis. A head computer tomography on
[**8-5**] showed no change. The patient continued to be
febrile with no apparent source. Infectious Disease
continued to follow.
On [**2193-8-9**] the patient spiked to 101.5. Infectious
Disease continued to follow and aztreonam was added to
intravenous antibiotic coverage for suspected multifocal
pneumonia likely secondary to aspiration. Continued on
levofloxacin, and vancomycin, and Flagyl despite not really
responding to this regimen. The patient had a tracheostomy
placed without complications.
The patient had a computed tomography angiogram done on [**8-10**] that showed bilateral pneumonia, left lower lobe collapse,
and right middle lobe consolidation. Also had an abdominal
computer tomography which was negative. On [**8-8**], the
patient also grew out Pseudomonas and was treated; that is
why the aztreonam was added for Pseudomonas in her sputum and
blood. On [**8-10**], the patient had a bronchoscopy, and
samples were sent. The patient was continued on aztreonam.
The levofloxacin was discontinued, and gentamicin was added
for double coverage for Pseudomonas bacteremia in the sputum.
On [**8-11**], the patient had a head computer tomography that
showed no change. A chest x-ray showed continued bilateral
pneumonia. On [**8-12**], the pupils were 3.5 mm down to 3 mm on
the right and 3.5 mm down to 3 mm on the left. The patient
had somewhat of a disconjugate gaze. Localized on the right
upper extremity. The left upper extremity had slight
internal rotation, and she withdrew the lower extremities -
left greater than right. Neurologic examination was
basically unchanged. A computer tomography showed a decrease
in the size of the ventricles.
On [**8-13**], the patient continued to spike temperatures up to
101.2. She was discontinued on vancomycin, gentamicin, and
aztreonam. Cultures continued to show Pseudomonas
bacteremia. The Flagyl was discontinued. There was a slight
improvement in the white count and chest x-ray. On [**8-13**],
the patient underwent an angiogram which showed some evidence
of vasospasm that was treated with papaverine. She had
vasospasm in the basilar artery, right anterior cerebral
artery, the right middle cerebral artery, and the right
posterior cerebral artery. Treated with papaverine for the
vasospasm in the right internal carotid artery. The patient
remained trached on the ventilator. On neurologic
examination, opening her eyes to voice, localizing in the
right upper extremity, extended the left upper extremity,
withdrew the lower extremities. No groin hematoma, and her
pedal pulses were positive post angio. The sensitivities on
the Pseudomonas the patient had developed became resistant to
aztreonam, so the aztreonam was discontinued. The patient
remained on vancomycin and gentamicin, and cefepime was
started on [**8-13**].
On [**8-14**], neurologically she opened her eyes, localizing
briskly in right upper, slight flexion on the left, and
slight withdraw to stimulation in the lower extremities. Her
pupils were 5 mm down to 4.5 mm. The patient had developed a
rash which was felt to be contact dermatitis; however,
Dilantin was discontinued and the patient was started on
Depakote.
On [**8-1**], there was evidence of Neisseria meningitis in the
sputum; however, Infectious Disease felt that this was
colonization and did not require treatment or precautions.
On [**8-16**], the patient continued to spike temperatures
despite being on vancomycin, gentamicin, and cefepime. A
chest x-ray was done to assess pleural effusions, question of
effusions. The patient continued on intravenous vancomycin,
gentamicin, and cefepime for antibiotic coverage.
On [**8-17**], her chest x-ray was improved with a small left
pleural effusion and continued left lower lobe consolidation.
The patient had a skin test sent for possible [**Female First Name (un) 564**] on her
skin. She had a rash in the high moisture areas of her skin.
On [**8-18**], neurologically the patient opened her eyes
spontaneously. She withdrew the left side greater than the
right. She was continued not to follow commands, withdraw in
the lower extremities. Infectious Disease felt that the skin
rash that the patient had was not [**Female First Name (un) 564**] and that it could
be vancomycin since that was the longest running antibiotic
she had been on. So, that was discontinued. The patient
remained on the gentamicin and cefepime.
On [**8-19**], received a Pulmonary consultation due to her
prolonged infiltration on chest x-ray and continued need for
ventilatory support.
On [**8-20**], the drain was raised to 20 cm above the tragus.
The head computer tomography showed no change, and chest x-
ray was improving. The patient had been on Diamox for two
days for diuresis. Continued on gentamicin and cefepime for
antibiotic coverage. On [**2193-8-20**] the drain was clamped.
The patient spiked a temperature again to 102.4. Continued
on gentamicin and cefepime. Most recent cultures from [**8-19**] continued to show Pseudomonas in the sputum. Urine was
still no growth. Cerebrospinal fluid cultures continued to
remain negative. The last positive blood culture was on [**8-9**] - which was Pseudomonas. She had a head computer
tomography after drain being clamped which showed a slight
interval increase in ventricular size. Nimodipine was
discontinued and HHH therapy for treatment of vasospasm was
backed off on - on [**2193-8-22**]. Neurologically, the
patient continued to open her eyes to voice but not follow
commands. Localization in the right upper extremity. Slight
localization in the left upper extremity.
Again on [**8-23**], a repeat head computer tomography showed
slightly enlarged ventricles. The left vent drain was left
in place but continued to be clamped. On [**8-23**], the vent
drain was opened due to the enlarged ventricles. The patient
was tolerating trach mask and off the ventilator.
Neurologically, not opening her eyes. Localizing the right
upper, slight flexion in the left upper, and withdrawing the
lower extremities - left greater than right. Gaze was not
conjugate. Her pupils were 4 mm down to 3.5 mm on the right
side and 4 mm and trace reactive on the left. She did have a
lateral gaze.
On [**8-25**], a head computer tomography showed no change.
On [**2193-8-27**] the patient was taken back to the operating
room for a cranioplasty. There were no intraoperative
complications, and postoperative vital signs were stable.
The patient opened her eyes spontaneously. She withdrew in
the upper extremity. Localized in the right upper extremity.
Slight localization in the left upper extremity and withdrew
her lower extremities. She remained neurologically
unchanged.
The drain was removed on [**2193-8-29**] without incident. A
head computer tomography on [**8-28**] showed small subadjacent
epidural fluid collection with no change in the
intraparenchymal hemorrhage.
On [**2193-8-1**] the patient had a percutaneous endoscopic
gastrostomy tube placed without complications. She remained
neurologically unchanged. A repeat head computer tomography
on [**8-31**] showed unchanged appearance of the epidural fluid
collection. Most recent sputum culture from [**8-22**]
continued to show Pseudomonas. Urine showed no growth.
Blood cultures from the 14th and the 18th were negative.
Cerebrospinal fluid continued to be negative. Clostridium
difficile was negative as well. The patient had her head
computer tomography on [**2193-9-2**] which continued to show
the epidural fluid collection. The fluid collection was
tapped, and the patient's head was wrapped.
DISCHARGE DISPOSITION: The patient was evaluated by
rehabilitation and found to require an acute rehabilitation
stay.
MEDICATIONS ON DISCHARGE: Gentamicin 340 mg intravenously
q.24h.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2193-9-2**] 11:08:35
T: [**2193-9-2**] 12:18:49
Job#: [**Job Number 56263**]
Admission Date: [**2193-7-30**] Discharge Date:[**2193-9-3**]
Date of Birth: [**2135-12-13**] Sex: F
Service: NSU
MEDICATIONS ON DISCHARGE:
1. Sodium chloride 1 gram p.o. t.i.d.
2. Valproic acid 500 mg p.o. t.i.d.
3. Metoprolol 25 mg p.o. b.i.d.
4. Famotidine 20 mg p.o. q.12h.
5. Loperamide 2 mg p.o. q.i.d. prn.
6. Heparin 5000 units subQ q.12h.
7. Insulin-sliding scale.
CONDITION ON DISCHARGE: Patient's condition was stable at
the time of discharge.
FOLLOW-UP INSTRUCTIONS: She will follow up with Dr. [**Last Name (STitle) 1132**] in
one month with a repeat head CT.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2193-9-2**] 11:10:03
T: [**2193-9-2**] 11:42:15
Job#: [**Job Number 56264**]
Name: [**Known lastname 10549**], [**Known firstname 153**] Unit No: [**Numeric Identifier 10550**]
Admission Date: [**2193-7-30**] Discharge Date: [**2193-9-9**]
Date of Birth: [**2135-12-13**] Sex: F
Service: NSU
ADDENDUM:
HOSPITAL COURSE: The patient's neurostatus on [**9-2**] was
unchanged. The head CT this morning shows the fluid
collection around the skull flap has been worsening. Dr.
[**Last Name (STitle) 365**] aspirated the fluid from above the skull and specimen
was sent for culture. Head was wrapped with a dry dressing,
currently intact and without drainage. The patient remained
afebrile. On [**9-3**], the patient was taken to the OR. Her
preoperative diagnosis was epidural fluid collection.
Postoperative diagnosis was the same. Procedure was a JP
drain placement in the epidural area. Surgeon was Dr. [**Last Name (STitle) 365**],
and he was assisted by Dr. [**Last Name (STitle) **]. There were no
complications, and the patient received 800 cc of IV fluid.
Postoperative check, the patient's vital signs were stable.
Temperature was 98.3 degrees, her heart rate was 84, her
blood pressure was 141/76, respirations were 15, and her SpO2
was 100 percent on room air. Her CVP was 22 at that time.
On physical exam, the patient opens her eyes to stimulation.
Her pupils are reactive, brisk, 5 mm to 4 mm. She localizes
her upper extremity to noxious stimuli, slight withdrawal of
the lower extremity to pain.
The patient was stable, and her [**Location (un) 2021**]-[**Location (un) 2022**] drain is set to
bulb suction. On [**2193-9-4**], the patient opens her eyes to
stimulation. Her pupils are reactive bilaterally. She
localizes her upper extremity to pain and withdraws her
lower extremities to stimuli. Labs on [**2193-9-4**] were all
stable with slightly reduced hematocrit of 29.7. The patient
was on vancomycin for prophylaxis pending cultures.
On the night of [**2193-9-5**], JP drain put out 50 cc of bloody
serosanguinous fluid. On [**2193-9-5**], the patient was
neurologically stable. All of her labs were stable. Her
vancomycin trough level was 14.3. Physical examination
remained unchanged. A PICC line was placed without
complications. On [**2193-9-5**], the patient remained stable.
All labs were stable. Vital signs were stable. Her pupils
were 3.5 with trace reactivity. She opens her eyes to
stimuli and localizes her upper extremity left greater than
the right. No movement in the right leg, withdraws her left
lower extremity.
On [**2193-9-6**], the patient is neurologically stable. Physical
examination, she opens her eyes to stimulation with a
disconjugate gaze. Her pupils were 4 to 3 bilaterally.
Localizes her upper extremity, withdraws her lower extremity
left greater than the right. Her labs were stable. Her
hematocrit has come up to 31.8. We planned to discontinue
the drain at this time after discussing with Dr. [**Last Name (STitle) 365**].
On [**2193-9-7**], her neurostatus was unchanged. Her head CT scan
done and a JP drain was removed by Dr. [**First Name (STitle) **] today. Head
incision was intact with staples and all JP site clean and
dry. Vancomycin was discontinued at this time. Her physical
examination, her pupils are 4 mm. On [**2193-9-8**], the patient
remained neurologically stable. All of her vital signs were
stable. Her labs were stable. Pupils were 4 mm and
reactive. There was no sign of fluid collection. Flexes 30
degrees right upper extremity to pain, localizes on the left,
bilaterally withdraws her lower extremities. Plan at this
time is to have a head CT, and we will discuss transfer to
the floor with Dr. [**Last Name (STitle) 365**].
On [**2193-9-9**], neurosurgically, the patient is with all vital
signs stable. She is awake and does not follow commands.
Withdraws bilateral lower extremities to pain, localizes
upper extremity. She is neurologically stable at this time
and is to have a head CT followed by possible discharge
tomorrow.
[**Name6 (MD) **] [**Last Name (NamePattern4) 2483**], [**MD Number(1) 2484**]
Dictated By:[**Last Name (NamePattern1) 10242**]
MEDQUIST36
D: [**2193-9-9**] 13:47:54
T: [**2193-9-9**] 16:52:20
Job#: [**Job Number 10551**]
|
[
"435.8",
"041.7",
"433.10",
"276.3",
"518.81",
"482.1",
"437.3",
"790.7",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"02.2",
"99.04",
"88.41",
"39.51",
"01.09",
"02.03",
"96.72",
"38.93",
"31.29",
"86.09",
"96.6",
"38.91",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
12152, 12249
|
12729, 12965
|
605, 1337
|
13699, 17692
|
1366, 12128
|
165, 513
|
13073, 13681
|
536, 578
|
12990, 13048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,372
| 131,918
|
2552
|
Discharge summary
|
report
|
Admission Date: [**2194-10-21**] Discharge Date: [**2194-10-23**]
Date of Birth: [**2155-8-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Pollen Extracts / Mold Extracts
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5723**]
.
CHIEF COMPLAINT: PCN desensitization
.
REASON FOR MICU ADMISSION: PCN desensitization
Major Surgical or Invasive Procedure:
PICC Line Placement
History of Present Illness:
HPI: 39 yo M with HIV CD4 354, viral load <75 as of [**10-9**], recent
diagnosis of anal HSV s/p treatment and recent diagnosis of
neurosyphillis on LP [**10-17**] presenting electively for admission
for penicillin desensitization. Allergic to PCN and
cephalosporins but is unclear of what the reaction. Patient
presented [**2194-10-9**] with anal pain and bloody muco-purulent
discharge. Exam at that time revealed a posterior perianal ~ 6mm
ulceration and anoscopic exam showed a muco-purulent discharge.
He was treated with po Acyclovir 400mg tid for 10 days and given
Azithromycin 2gm po to cover for HSV, GC and chlamydia in this
probable PCN allergic and cephalosporin allergic patient.
Culture of the anal anal was negative for GC but viral culture
was positive HSV. RPR done at that visit came back positive at a
titer of 1:256 and patient was started on Doxycycline 100mg [**Hospital1 **]
pending LP which was done on [**2194-10-17**].
.
In the ED, initial VS: 98.90 97 152/81 100% on RA. C/o headache.
Placed 20G IV.
.
Currently, patient denied headache, phonophobia, photophobia,
double vision, or N/V/D. Reported going to the eye doctor one
month ago for visual disturbances and was diagnosed with central
serous retinopathy. Reported subjective chills in past couple of
days but has been afebrile when he took his temperature. Also
endorsed recently increased fatigue and letharg in past couple
days.
.
ROS: Denies fever, chills, night sweats, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-HIV last CD4 count 354
-anal HSV [**10-9**]
-central serous retinopathy [**10-9**] therefore stopped intranasal
steroids
-Impetigo
-Condyloma acuminatum
-allergic rhinitis
-esophageal reflux
-sinusitis [**7-24**]
-hypertriglyceridemia
-molluscum contagiosum
-cellultis of finger
-pterygium
-Anal CIS
-elbow pain/fracture
-rective airway disease
-chronic leg pain
-back pain
Social History:
Currently works for [**University/College **] in systems managing, non smoker,
ETOH 3times/month, admits to occasional recreational drug use.
Not currently in a relationship but MSM not always using
protection.
Family History:
father with CAD, aunt and uncle with diabetes
Physical Exam:
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : bilateral)
Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)
Distended, Tender: RLQ without rebound or guarding
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Not assessed
Pertinent Results:
LP [**2194-10-17**]: colorless, clear, WBC 12 RBC 0 Neutrophils 0%
Lymphocytes 84%, monocytes 16% eosinophils 0% total protein 92
glucose 51
VDRL: 1:2
.
[**10-9**] RPR: 1:256, FTA-abs reactive
[**10-9**] GC culture/rectal: negative
[**10-9**] Rectal HSV swab: positive
Brief Hospital Course:
# Neurosyphillis: Found on screening RPR and +VDRL in LP. He
completed penicillin desensitization protocol in ICU, and
currently is on IV Penicillin G 3 million units IV every four
hours for 10 to 14 days after desensitization for treatment of
syphillis. Epipen at bedside. PICC line was placed and
verified. Had significant panic attack following PICC line
placement, and received 1 mg of ativan. He described an episode
of chest discomfort associated with infusion and some panic. ECG
was nonischemic, and there was a reproducible nature to the
discomfort.
Following the ativan, the patient was lethargic and was
transferred to the floor overnight. The following morning, he
was awake, alert, and stable for discharge home.
Medications on Admission:
-Viread 300mg PO daily
-Ziagen 600mg PO daily
-Reyataz 300mg PO daily
-Norvir 100mg PO daily
-Astelin 137 mcg/spray [**Hospital1 **]
-Guaifenesin 100mg PO BID
-zyrtec 10mg PO daily
-acyclovir 400mg PO TID
-doxycycline 100mg [**Hospital1 **] for 14 days from [**10-10**]
Discharge Medications:
1. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Astelin 137 mcg Aerosol, Spray Sig: One (1) INH Nasal twice a
day.
6. Guaifenesin 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day.
7. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Mucinex D 60-600 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO daily ().
9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours) for 1 days.
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*200 ML(s)* Refills:*0*
11. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
Sig: Fifty (50) mL Intravenous Q4H (every 4 hours): last day =
[**2194-11-4**].
Disp:*4200 mL* Refills:*0*
12. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) pen
Intramuscular once application for severe allergic reaction for
1 months: if develop severe allergic reaction, use 1 injection
and call 911. .
Disp:*2 pens* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
Primary Diagnosis:
1. Penicillion Desensitization
2. Neurosyphilis
Secondary Diagnosis:
1. HIV
2. HSV
Discharge Condition:
Stable. Afebrile.
Discharge Instructions:
You were admitted to the Intensive Care Unit for penicillin
desensitization. You tolerated this protocol well without any
complications. You were started on IV penicillin for your
infection. You will need to continue IV penicillin for 14 days.
You also had a PICC line placed for these IV antibiotics.
Please take all your medications as prescribed. The following
changes have been made to your medications:
- Please take Acyclovir 400mg PO TID for one more day (last day
[**10-23**])
- Please take Penicillin G Potassium 3 million units IV q4 hours
(last day [**2194-11-4**]) through your PICC line.
Please keep your medical appointments.
If you have any of the following, please call your doctor or go
to the nearest Emergency Room: fever>101, chest pain, shortness
of breath, abdominal pain, or any other concerning symptoms.
Followup Instructions:
Wednesday, [**2194-10-29**] 12:40 PM with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**], MD
Please call [**Telephone/Fax (1) 5723**] to reschedule. This is an appointment
for follow up.
|
[
"054.9",
"V08",
"094.9",
"V07.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6372, 6438
|
4066, 4795
|
505, 526
|
6584, 6603
|
3772, 4043
|
7488, 7700
|
2856, 2903
|
5115, 6349
|
6459, 6459
|
4821, 5092
|
6627, 7465
|
2918, 3753
|
397, 467
|
554, 2214
|
6548, 6563
|
6478, 6527
|
2236, 2612
|
2628, 2840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,273
| 188,555
|
11441
|
Discharge summary
|
report
|
Admission Date: [**2153-4-2**] Discharge Date: [**2153-4-16**]
Date of Birth: [**2099-7-20**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Lisinopril
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Neck pain, right hilar mass
Major Surgical or Invasive Procedure:
Bronchoscopy with tissue biopsy
PICC line placement
History of Present Illness:
Mr. [**Known lastname 19688**] is a 53-year-old gentleman with a history of
Alport's Syndrome s/p cadaveric renal transplant in [**2147**], PCP
pneumonia in [**2151**], PPD+ who presented to [**Hospital 8**] Hospital with
right-sided neck pain, cough productive of bloody sputum, and
shortness of breath on [**2153-3-31**]. Noncontrast CT chest revealed a
mass at the right hilum that was obstructing his right upper
lobe; also with 2 subcentimeter nodules in LUL concerning for
satellite nodules, RUL consolidation concerning for
post-obstructive pneumonia, mediastinal adenopathy. Noted to
have purulent sputum. Increased hypoxia with ABG 7.33/42/60 on
4LNC.
He was initially treated for post-obstructive pneumonia with
cefepime/azithromycin, switched to ceftriaxone after urine
legionella negative. He developed an increasing oxygen
requirement of 30L/min of high flow O2. Given concern for TB,
AFB sent (negative x1, pending x2).
Regarding right hilar mass, bronchoscopy postponed due to
increasing oxygen requirement. Per oncology consultation,
concern for NSCLC vs SCLC vs post-transplant lymphoproliferative
disease. Hospital course also complicated by hypercalcemia
improved with IVF and pamidronate, delirium suspected secondary
to infection/malignancy.
Of note, the patient recently traveled to Aruba.
Before transfer, the patient's vitals were: T:98.8(101 in AM)
HR:91 BP: 131/69 RR:20 O2:97% on high flow O2 (30 liters).
On arrival to [**Hospital1 18**] ICU, patient reports feeling better. Dyspnea
improved. Persistent wet cough. No fever/chills. Review of
systems otherwise limited secondary to malfunctioned hearing
aids.
Past Medical History:
past medical history
- Alport's Syndrome s/p cadaveric renal transplant (Cr in [**2150**]:
1.8)
- bilateral hearing loss
- diverticulosis
- hypertension
- hyperlipidemia
- PCP pneumonia last year, on Bactrim prophylaxis
- h/o depression treated with nortriptyline
- BPH
- h/o alcohol abuse
- Chronic renal insufficiency (baseline creatinine 1.6-2.0)
- Dermatofibroma
past surgical history
- cadaveric kidney transplant right iliac fossa
- peritoneal dialysis catheter placement
- tonsillectomy
Social History:
Originally from [**Country 480**]. Quit smoking in [**2150**] (2.5 pack-year
history), has since started again. Formerly drank five alcoholic
beverages daily. Works as nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 8**] Hospital. Divorced,
with one adult daughter. Travelled to Aruba [**Date range (3) 36564**].
Family History:
Unable to obtain.
Physical Exam:
99.5, 98, 138/67, 23, 99% facemask
General: Comfortable; repeatedly pulls at facemask
HEENT: Bilateral hearing aids; pupils pinpoint, difficult to
assess for reactivity; moist mucous membranes; oropharynx is
clear
Neck: No LAD at neck or supraclavicular; without distended neck
veins
Lungs: Diffuse rhonchi, R>L; poor air movement on right,
slightly better on left; occasional expiratory wheezes
CV: Tachycardic; normal S1/S2; no murmurs appreciated
Abdomen: Soft, nontender, not distended
Ext: No inguinal lymphadenopathy; thin; warm, well-perfused,
radial and DP pulses 2+ and symmetric
Neuro: Upper extremity strength 5/5 and symmetric; pupils
constricted with minimal reactivity; moves lower extremity
Pertinent Results:
Admission labs:
[**2153-4-3**] 01:50AM BLOOD WBC-12.6*# RBC-3.26* Hgb-10.4* Hct-31.6*
MCV-97# MCH-31.9# MCHC-32.9 RDW-14.1 Plt Ct-409
[**2153-4-3**] 03:26PM BLOOD WBC-10.9 RBC-3.27* Hgb-10.1* Hct-31.2*
MCV-95 MCH-30.9 MCHC-32.4 RDW-14.6 Plt Ct-481*
[**2153-4-4**] 05:08AM BLOOD WBC-9.6 RBC-3.31* Hgb-9.8* Hct-31.0*
MCV-94 MCH-29.6 MCHC-31.6 RDW-14.3 Plt Ct-571*
[**2153-4-3**] 01:50AM BLOOD Glucose-152* UreaN-15 Creat-1.5* Na-135
K-4.9 Cl-102 HCO3-23 AnGap-15
[**2153-4-4**] 01:28PM BLOOD Glucose-127* UreaN-14 Creat-1.3* Na-142
K-3.8 Cl-103 HCO3-24 AnGap-19
[**2153-4-3**] 01:50AM BLOOD ALT-67* AST-26 LD(LDH)-3084* AlkPhos-295*
TotBili-0.4
[**2153-4-4**] 05:08AM BLOOD ALT-46* AST-22 LD(LDH)-2392* AlkPhos-292*
TotBili-0.6
[**2153-4-3**] 01:50AM BLOOD Albumin-3.3* Calcium-12.0* Phos-2.5*
Mg-1.3* UricAcd-7.4*
[**2153-4-3**] 01:50AM BLOOD tacroFK-13.9
[**2153-4-3**] 11:09PM BLOOD tacroFK-20.4*
[**2153-4-4**] 08:26AM BLOOD tacroFK-12.1
[**2153-4-3**] 09:45AM BLOOD freeCa-1.59*
Microbiology:
[**2153-4-3**] Blood cx: negative
[**2153-4-3**] Urine cx: negative
[**2153-4-3**] Sputum cx: commensal organisms
[**2153-4-5**] Tissue (lymph node from bronch): Coag negative staph in
broth only
[**2153-4-5**] BAL: 1+ PMN on gram stain, otherwise negative
[**2153-4-6**] blood cx:
[**2153-4-6**] Urine cx: negative
[**2153-4-10**] Pleural fluid: negative
[**2153-4-10**] blood cx:
[**2153-4-10**] urine cx:
Radiology Studies:
Head CT: [**3-31**]
IMPRESSION:
1. No evidence of an acute pathologic intracranial process.
2. Opacification of bilateral mastoid air cells and middle ears.
Please
correlate clinically to exclude mastoiditis and otitis media.
CXR [**3-31**]:
1. Findings are concerning for right hilar mass with
post-obstructive
consolidation in the right upper lobe. Additional opacity in the
right
paratracheal region, likely represents mediastinal
lymphadenopathy.
Recommended CT of the chest with contrast if this has not been
performed
before
2. Mild overhydration.
[**2153-4-9**] LENI: IMPRESSION: No evidence of DVT.
[**2153-4-10**] CTA Chest: IMPRESSION:
1. No evidence of pulmonary embolism.
2. Significant interval progression of disease. Worsening
poststenotic
opacification involving the right upper lobe. New near subtotal
collapse of the right lower lobe and a worsened now severe in
size right pleural effusion. Associated compression of the right
main stem bronchi and distal branches and the right main
pulmonary artery. Extensive adenopathy.
3. Newly developed moderate left effusion.
4. Multiple hypoattenuating liver lesions, incompletely assessed
and a soft tissue lesion is seen abutting the left hemidiaphragm
that in given setting of disease is highly concerning for
metastasis.
5. Circular area of low attenuation seen in the right atrium
that is probably caused by venous inflow from non-opacified
inferior vena caval blood, although the possibility of thrombus
still exists.
Brief Hospital Course:
Mr. [**Name13 (STitle) 36565**] is a 53 year old gentleman with Alport's Syndrome
s/p cadaveric renal transplant in [**2147**], PPD+, and PCP [**Name Initial (PRE) 1064**]
[**2151**] who was admitted with respiratory distress in the setting
of a new right hilar mass.
.
#. Hypoxic respiratory failure: Likely multifactorial, including
right hilar mass compression of right upper lobe bronchus, RUL
pneumonia. Despite immunosuppression and elevated LDH, PCP less
likely based on CT chest findings. Patient was treated with 14
days of Vancomycin and Zosyn for post-obstructive pneumonia (day
1 = [**2153-4-1**]). Sputum GS and culture showed polymicrobial
infection, which grew only commensal organisms. Ruled out for
TB with 3 induced sputums (2 expectorated at outside hospital, 1
induced at [**Hospital1 18**]). Quantiferon gold assay for TB was negative.
He was weaned off of oxygen and was satting well on room air on
discharge from the ICU [**2153-4-4**]. After bronchoscopy [**2153-4-5**] he
again desaturated twice to O2 sats in the low 80s, but improved
quickly and was able to be weaned off of oxygen quickly. This
was thought to be due to mucous plugging as his CXR was
unchanged, so he was started on guaifenesin 1200mg [**Hospital1 **]. His
respiratory status was stable for several days, however he was
persistently tachycardic, would desaturate with ambulation and
had low-grade fevers. LENI's were negative and his EKG
unchanged. [**2153-4-9**] he had an increased oxygen requirement in the
setting of aggressive fluids for hypercalcemia, and a CTA chest
was done. No PE seen, but his hilar mass had grown and he had
large effusions. The effusion was drained [**2153-4-10**] by
interventional pulmonology showing an exudate. Cytology was
pending. The patient was stable on 3-4L O2 on transfer to the
oncology service for XRT.
#. Right hilar mass: Concern for malignancy vs infection vs less
likely inflammatory. Given hemoptysis, known PPD+, and
immunosuppression TB also a possibility. Sarcoid, amyloid less
likely given that she has been on immunosuppression. Patient
underwent bronchoscopy by IP after he was ruled out for TB for
which tissue from a cervical lymph node and brushings from the
large mass were sampled. Final pathology results showed a poorly
differentiated adenocarcinoma. Initially the plan was for
outpatient work-up, but the patient's respiratory status
worsened and [**2153-4-9**] showed interval worsening of the mass.
Heme/onc and radiation oncology were consulted. He was
initiated on XRT and transferred to the oncology service
[**2153-4-10**]. On [**4-14**], Mr. [**Known lastname 19688**] became hypotensive to SBP 80s on
the floor. He was given 500cc IVF bolus with SBP increase to
90s. SBP then decreased to 80s and ICU transfer was requested.
Patient was evaluated on the floor and was noted to be
somnolent, but awoke to verbal stimulation. Patient denied any
pain, sob, chest pain, dizziness or LH. SBP noted to be 110.
Patient was then transferred to East ICU for further management.
In the ICU, pt was on NRB and had both audible and palpable
rhonchi B/L. Pt was confirmed DNR/ DNI after extensive
discussions with his two health care proxies, who were nurses he
worked with at [**Hospital 8**] Hospital. His respiratory status and
cognitive function continued to decline rapidly, and a family
meeting was held in the presence of his daughter, health care
proxies, friends and the pulmonary fellow Dr. [**Last Name (STitle) **]. It was
then decided on the morning of [**4-15**], that pt's care would be
focused primarily on comfort. Morphine gtt was initiated and pt
passed comfortably at 0130 on [**4-16**] in the presence of his loved
ones. The cause of death was rapid respiratory compromise from a
very aggressive poorly differentiated adenocarcinoma of the
lung, which may have been especially aggressive in the setting
of pts post-transplant immunosuppression.
#. Hypercalcemia: PTH low at 10, phos low normal and PTHrp
negative at [**Hospital 8**] hospital, making bony mets the most likely
source of hypercalcemia. Patient was given pamidronate 45mg on
[**2153-4-1**] at [**Hospital 8**] Hospital. He was treated with IVFs and
lasix and his calcium improved to 10.3. 25-0H Vitamin D level
was low, and 1,25-OH vitamin D levels were pending. His
hypercalcemia initially improved with IV fluids and lasix in the
ICU, and was stable with PO intake on arrival to the floor
[**2153-4-3**]. His calcium then trended up and he was restarted on IV
fluids (NS 200cc/hr) with PRN lasix (typically 60-80mg IV
total/day). He was started on daily calcitonin [**4-7**] and
pamidronate was re-dosed [**2153-4-8**].
.
# Altered Mental Status: Patient often with hallucinations in
ICU. Likely multifactorial in setting of hypercalcemia,
infection. Consideration of chronic effects of alcohol on mental
status vs. alcohol withdrawal given patient is a heavy drinker
(reportedly abstinent). Head CT negative for bleed or
metastases. Infection and hypercalcemia treated as above. Mental
status continued to deteriorate, likely in the setting of
malignancy.
#. Chronic kidney disease s/p cadaveric transplant: Patient was
transplanted by [**Hospital1 18**] in [**2147**]. Per review of OSH records,
baseline creatinine 1.6-2.0. Continued tacrolimus, myophenolate
per home regimen. Renal transplant was consulted and followed pt
in house. They titrated his tacrolimus as needed to maintain
therapeutic levels and continued mycophenolate and Bactrim ppx.
Medications on Admission:
- Tacrolimus (Prograf) 2mg [**Hospital1 **]
- Myfortic 180mg PO BID
- Simvastatin 80mg PO daily
- Bactrim DS 800-160 PO daily
- Atenolol 50mg PO daily
- Losartan 50mg PO daily
- Norvasc 10mg PO daily
- Flomax 0.4mg PO daily
- Folic acid 1mg PO daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory distress
Right hilar mass
Adenocarcinoma of the lung
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2153-4-17**]
|
[
"511.81",
"162.3",
"518.81",
"486",
"786.3",
"795.5",
"275.42",
"780.1",
"V66.7",
"V42.0",
"196.1",
"759.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.04",
"92.29",
"33.24",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
12464, 12473
|
6619, 11306
|
308, 361
|
12582, 12591
|
3681, 3681
|
12647, 12685
|
2911, 2930
|
12432, 12441
|
12494, 12561
|
12157, 12409
|
12615, 12624
|
2945, 3662
|
241, 270
|
389, 2033
|
5116, 6596
|
3697, 5107
|
11321, 12131
|
2055, 2551
|
2567, 2895
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,824
| 101,776
|
14050
|
Discharge summary
|
report
|
Admission Date: [**2105-8-11**] Discharge Date: [**2105-8-12**]
Date of Birth: [**2034-12-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70yo man w/ h/o CAD s/p CABG, h/o afib, ETOH cirrhosis, DM, who
presented to an OSH on [**2105-8-4**] w/ a perforated small bowel,
underwent enterectomy & end-ileostomy on [**2105-9-5**], post-op course
complicated by renal failure, ileus, worsening hepatic failure
and mental status changes. He is being transferred to [**Hospital1 18**] for
evaluation of his multi-organ failure--there was question of him
having hepatorenal syndrome.
Summary of OSH Course:
- Pt p/w abd pain. Initially treated conservatively w/ IVF and
levo/ flagyl. However, his pain persisted and lactate up to 6.1.
- Pt went for ex lap, which reportedly revealed perforated small
bowel. He underwent enterectomy w/ end ileostomy.
- Post-op he was extubated. However, he had increasing
respiratory distress and required intermittent Bipap. On day of
transfer, he was requiring persistent Bipap due to hypoxemia:
ABG 7.48/30/68--on 50% Fi02 on Bipap. He was intubated prior to
transfer to [**Hospital1 18**].
- Pt described as having MS changes w/ possible hepatic
encephalopathy. He reportedly Opened eyes, responded
"intermittently" to voice.
- He developed acute renal failure of unclear cause. His bumped
from 0.48 to 1.58 post-op. OSH was unable to be measure crt on
last day or two of his OSH stay [**1-17**] elevated bili. Renal US w/
no hydro (per erport).
- Pt described as having post-op ileus for which an NGT placed.
He was started on TPN b/c ileus.
- LFTs notable for Tbili 20.8, up from 6.8 on admission. Direct
bili 14.9. AST 85, ALT 49. INR 2.1. Alb 2.4.
- Pt noted to have ascites w/ bacteroides uniformis (few) and
rare clostridium species (not perfringens) growing in it.
- Cdiff test positive from [**2105-8-4**]--day of pt's admission,
suggesting he had it prior to presenting.
- Pt treated with flagyl/levo from outset of hospital stay
([**8-4**]) and zosyn was added (? [**8-11**])
- Had afib w/ rates up to 140s. Was getting dig for this.
- Trop 0.11. EKG unchanged from prior.
- Pt developed hypotension. He was started on levophed. Serum
cortisol 22.1 (unclear if random level). Lactic acid 2.9 prior
to transfer.
- Plt 29K (chronically low--for years)
- Pt noted to have coagulopathy w/ INR 2.1
- Got re-intubated by EMS, AC 550x10/5/100%; on levophed,
Past Medical History:
- CAD s/p CABG
- DM
- ETOH cirrhosis
- Colon cancer s/p resection & radiation
- Chronic thrombocytopenia & ? leukonpenia
- Group B strep sepsis of unknown source in [**4-20**]
- AAA
- HTN
- Hypercholesterolemia
-GERD
-Esophagitis
- Echo [**6-22**] (OSH) nml LV function, LVH & biatrial enlargement.
Mild MR, Mild to mod TR, mild to mod PAH. (EF 64% on MIBI [**6-22**])
- EGD [**6-22**] showed "diffuse mild inflation at GE junction--not
biopsied--and gastritis.
- Colonscopy rectal polyp (rsected
Social History:
Married. Lives w/ wife on [**Name (NI) **]. Works 3day/wk in butcher shop.
Has grown kids. Drinks 4 gins /day. Former smoker
Family History:
nc
Physical Exam:
VS: T: 95.6 HR: 105 BP: 117/62 (on 0.25 levophed) Sat: 92% on AC
550x14, 5, 100%
Gen: NAD, when sedation wears off pt follows one step commands &
shakes his head "no" when asked if he is in pain.
HEENT: NCAT, PERRL, sclera icteric
Neck: Supple, no LAD, no JVD
CV: distant hrt sounds; nml S1/S2, no m/r/g
Resp: course breath sounds b/l anteriorly
Abdomen: Distended but Soft, absent BS, NT, vertical ~midline
surgical incision w/ areas open space where fluid is leaking out
(?[**Last Name (un) 12949**] fell out in those areas), fluid draining appears
serosanguinous. Ostomy draining serosainguinous fluid
Ext: No c/c/e. DP pulses are 2+ bilaterally
Neuro: A + O x 3, CN II-XII grossly intact, Motor [**4-20**] both upper
and lower extremities
Skin: Pink, warm, no rashes
Brief Hospital Course:
70 year-old man with CAD s/p CABG, PAF, reported cirrhosis from
ETOH abuse, and chronic thrombocytopenia, POD#7 s/p enterectomy
& end-ileostomy for small bowel perforation, who is transferred
with multiorgan failure.
.
# Shock: Pt presented from OSH already on one pressor with
evidence for multisystem organ failure including ARF. Had been
intubated prior to transport. On arrival pt rapidly
decompensated with hypotension refractory to IVF and eventually
maxed out on 4 pressors. He was treated broadly with
antibiotics, daptomycin, ceftazadime, PO vancomycin, IV flagyl.
His lactate continued to elevated and he stopped making urine. A
family meeting was held during the day when pt's pressures could
not be maintained on max presssors and fluids. The decision was
made not to withdraw care but it was agreed that CPR would not
be indicated. The patient passed away with his family present
at [**2026**].
Medications on Admission:
Dig 0.25mg
Toprol Xl 50mg
ASA 81
PRotonix 40mg
? Glyburide
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Multiorgan failure
Discharge Condition:
Expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"427.31",
"570",
"785.52",
"272.0",
"414.00",
"560.1",
"530.81",
"250.00",
"303.90",
"995.92",
"572.2",
"584.9",
"V66.7",
"V10.05",
"571.2",
"286.7",
"038.9",
"287.5",
"V45.81",
"V15.3",
"518.5",
"401.9",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5162, 5171
|
4107, 5020
|
323, 329
|
5240, 5249
|
5305, 5315
|
3292, 3296
|
5130, 5139
|
5192, 5219
|
5046, 5107
|
5273, 5282
|
3311, 4084
|
277, 285
|
357, 2611
|
2633, 3133
|
3150, 3276
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,881
| 172,454
|
25225
|
Discharge summary
|
report
|
Admission Date: [**2104-9-24**] Discharge Date: [**2104-9-30**]
Date of Birth: [**2051-3-24**] Sex: M
Service: MEDICINE
Allergies:
Colchicine / Protein Powder
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Joint pains, RUQ pain
Major Surgical or Invasive Procedure:
EGD [**9-30**]
History of Present Illness:
Pt is a 53 yo M with PMH of metastatic esophageal cancer (liver,
lung, bone mets), known LE DVT on lovenox, ESRD [**2-2**] IgA s/p
renal transplant who presented with diffuse arthralgias and
RUQ/pleuritic chest pain. Pt did not take lovenox over last 24
hrs as was feeling unwell. Was seen at OSH ED last weekend with
complaint of itchy eyes, itchy palms, lip and tongue swelling.
Started on prednisone 60mg with taper over 3 days. He developed
severe arthralgias several days prior to admission. Otherwise
denies fever, chills, abdominal pain, chest pain, cough, sputum,
HA, rash.
In the ED, VS: Tm 102. CTA revealed acute PE involving segmental
branches to RLL and RUL PNA. Bedside ECHO revealed no RV strain.
EKG showed sinus tach 130s. Received vanco, cefepime. Started on
heparin gtt. Also 2L IVF and multiple [**Month/Day (2) 4319**] of dilauded for
pain. Pt was transferred to [**Hospital Unit Name 153**] for further management.
Past Medical History:
Gastric ulcer as above
endstage renal disease due to IgA nephropathy
kidney transplant [**2091**] and [**2101**]
status post right arm AVF
avascular necrosis of the bilateral hips, cataracts status post
extraction, gout, squamous cell carcinoma of the face x3
status post umbilical hernia repair
status post ventral hernia repair mass
Social History:
Lifetime nonsmoker. He is a civil engineer
working in tunnel building. He lives with his wife and three
children. He drinks occasionally and notes no exposure to
asbestos or radiation.
Family History:
Mother had a CVA, father had CHF, had a
grandfather with gastric cancer.
Physical Exam:
VS: T 98.4 HR 136 BP 147/97 RR 17 99% RA
GEN: Middle aged man in acute distress, moaning in pain from
joints.
HEENT: EOMI, PERRL, anicteric
NECK: supple, no [**Doctor First Name **],
CHEST: Decreased BS at RML field anteriorly
CV: Tachycardic, S1S2, loud III/VI systolic murmur best at apex
ABD:Soft, NT, ND, +BS
EXT: warm, no c/c/e. No joint swelling or erythema. LLE> RLE;
LLE also warm
SKIN: No rashes
NEURO: CN II-XII intact, Strength 5/5, normal sensation; toes
downgoing bilaterally
Pertinent Results:
=========
Labs
=========
[**2104-9-24**] 12:30PM PLT COUNT-278#
[**2104-9-24**] 12:30PM NEUTS-79.0* LYMPHS-17.8* MONOS-2.4 EOS-0.6
BASOS-0.2
[**2104-9-24**] 12:30PM WBC-6.9# RBC-3.16* HGB-9.4* HCT-29.6* MCV-94#
MCH-29.9 MCHC-31.8 RDW-19.7*
[**2104-9-24**] 12:30PM URIC ACID-5.5
[**2104-9-24**] 12:30PM LIPASE-14
[**2104-9-24**] 12:30PM ALT(SGPT)-35 AST(SGOT)-25 ALK PHOS-176* TOT
BILI-0.5
[**2104-9-24**] 12:30PM estGFR-Using this
[**2104-9-24**] 12:30PM GLUCOSE-105 UREA N-19 CREAT-1.0 SODIUM-131*
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-25 ANION GAP-14
[**2104-9-24**] 12:50PM LACTATE-2.9*
[**2104-9-24**] 12:50PM COMMENTS-GREEN TOP
[**2104-9-24**] 01:15PM PT-12.2 PTT-31.4 INR(PT)-1.0
[**2104-9-24**] 03:30PM URINE RBC-[**3-5**]* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2104-9-24**] 03:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2104-9-24**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2104-9-24**] 10:58PM PT-14.0* PTT-93.8* INR(PT)-1.2*
[**2104-9-24**] 10:58PM HCT-23.3*
=========
Radiology
=========
CTA Chest [**9-24**] - IMPRESSION: 1. Findings consistent with acute
pulmonary embolism. 2. Right upper lobe pneumonia. 3. Interval
increase in size of multiple pulmonary nodules. 4. Interval
increase in size of hypodense liver lesions. 5. Findings
consistent with known esophageal carcinoma post-stenting.
.
Knee XR bilateral [**9-25**] - Mild osteoarthritis. No radiographic
evidence of gout or avascular necrosis.
.
CXR [**9-25**] -
Cavitating ill-defined density in the right upper lobe
suggestive of pneumonic consolidation, however, a neoplasm
cannot be entirely excluded and follow up to clearance is
recommended.
.
CXR [**9-26**] - Two AP views were brought to our review, but note is
made that both of them do not include part of the right upper
lobe. Within the limitation of this radiograph, the impression
is that there is an improvement of the right upper lobe as well
as left lower lobe opacities consistent with resolution of
infectious process/aspiration. No other abnormalities are seen
within the limitation of this limited radiograph.
.
CXR [**9-28**] - Both extent and the density of the previous right
upper lobe
opacity has markedly decreased. On today's examination, only
subtle remnant opacities are seen. The other lung parenchyma
still displays subtle opacities in the left lung, at the level
of the hilus and in projection on the left costophrenic sinus. A
linear opacity is seen in the right upper lobe. The lateral
radiograph displays the peripheral esophageal stent.
========
Cardiology
========
TTE [**9-25**] - The left atrium is elongated. The estimated right
atrial pressure is 0-5 mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal for the patient's body size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. The mitral
valve leaflets have normal thickness. The mitral valve leaflets
are elongated. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. There is systolic anterior motion of the mitral valve
leaflets. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
small pericardial effusion.
Compared with the prior study (images reviewed) of [**2104-9-24**],
the mild resting LVOT gradient and valvular systolic anterior
motion of the mitral valve are more apparent. No vegetations
identified, but the image quality was suboptimal. If clinically
indicated, a TEE would be recommended for assessment of
endocarditis.
.
EGD [**9-30**]: Localized erythematous mucosa with edema and
friability noted in the esophagus adjacent to the proximal
border of the metal stent. No frank ulceration or active
bleeding noted. The mucosa in the upper third of the esophagus,
proximal to the stent was nodular. This could represent tumor,
reactive process or less likely varices.
Brief Hospital Course:
ASSESSMENT: Mr. [**Known lastname 36365**] 53 yo M with PMH of metastatic
esophageal cancer (liver, lung, bone mets), known LE DVT on
lovenox, ESRD [**2-2**] IgA s/p renal transplant who presented with
diffuse arthralgias and RUQ/pleuritic chest pain and found to
have PE and RUL pna. Also had an episode of hematemesis vs
coffee ground emesis in ED prior to admission.
.
.
## Pulmonary Embolism: Patient developed embolism in setting of
known DVT and missing a dose of lovenox at home (although
unclear as this may not represent Lovenox failure, as he had a
known DVT at the time which could have embolized). Patient
contines to be hemodynamically stable and saturating well on RA.
TTE did not demonstrate right heart strain which suggests that
the PE is likely small. Very difficult management given recent
hematemesis, but likely benefits of anticoagulation outweigh
risks of holding lovenox given no more episodes of hematemesis
since ED. He was sent home to continue his old Lovenox dose
with specific instructions not to miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
.
## RUL pna: Pna reported on CTA Chest as well as multiple CXR.
Given recent admission to the hospital in the last month, will
continue to treat for HAP. Cefepime and vancomycin were
discontinued at the time of discharge, as his chest x-ray had
resolved, suggesting no infectious process was present.
.
## Upper GIB: Per report patient had 200-300 cc hematemesis in
ED. Upon further questioning patient had a small amout of black
vomitus that was no gross blood but more consistent with coffee
ground emesis. This was in the setting of a heparin bolus which
was likely responsible for some worsening of chronic bleeding
from esophageal tumor. Also known to have gastric ulcers that
could be responsible. No further episodes since event in ED. PPI
was continued and serial Hcts were performed to r/o acute bleed.
EGD was performed and demonstrated no bleeding source; no
intervention was performed.
.
## Hyponatremia: Na corrected now. Possible SIADH in setting of
malignancy. Serum Osm normal and FeNA 1.
.
## Arthralgias: Symmetric joint involvement of LEs. No effusion
or erythema on exam. Reports this is not like usual gout flair.
No eosiniphilia. No cyanosis of extremities so unlikely
mircoemboli. UA negative. Could be viral infection,
rheumatologic disorder. Allergic to colchicine. Knee xr negative
for avascular necrosis in setting of steroids.
.
## ESRD s/p renal transplant: Continued rapamune, dexemathasone.
Continue bactrim ppx.
.
## Esophageal Cancer: Management per Dr. [**Last Name (STitle) **].
.
## PUD: Potentially etiology of coffee ground emesis in ED.
Continued PPI.
.
## HTN: Off meds at home. They were held in the hospital in the
setting of questionable hemodynamic instability.
.
## OSA: On CPAP at home. Continued in house.
.
## Dyslipidemia: Off meds. Continued to hold.
Medications on Admission:
Lovenox 80mg q12
Protonix 40 t.i.d.
Bactrim one daily
Rapamune four milligrams daily
ranitidine 150 mg b.i.d.
dexamethasone 4 mg daily
Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO three times a day.
3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
6. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H () as
needed for nausea.
9. Lovenox Subcutaneous
10. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
11. Dexamethasone 1 mg Tablet Sig: as directed Tablet PO once a
day for 3 days: Please take 3 tablets(3mg) on [**10-1**], please take
2(2mg) tablets [**10-2**], and then take 1 tablet(1mg) on [**10-3**].
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
pulmonary embolism
Upper GI Bleed
.
Secondary:
Pneumonia, esophageal cancer, gastric ulcer, IGA nephropathy s/p
kidney transplant, AVN of bilateral hips, HTN, hyperlipidemia,
gout
Discharge Condition:
Stable
Discharge Instructions:
You presented to the hospital with pain and shortness of breath.
You were found to have a blood clot in your lungs and you were
treated with lovenox to thin your blood. You were also found to
have a pneumonia and were treated with antibiotics. You had one
episode of bloody vomit and an upper endoscopy was performed on
[**2104-9-30**]. Your stent was found to be intact and there was no
frank ulceration or active bleeding noted.
.
Please continue lovenox at 90mg Subcutaneous every 12 hours.
Please take the dexamethasone steroid taper as directed. The
rest of your medication regimen remain the same.
.
Please seek immediate medical attention for fevers, chills,
cough, increased sputum production, shortness of breath, loss of
conciousness, or any other change in your baseline health
status.
.
You have an appointment with radiation oncology Dr.[**Last Name (STitle) **] on
[**Hospital Ward Name 23**] [**Location (un) 442**] on [**2104-10-7**] at 8:00am.
.
You have an appointmemt with Dr. [**Last Name (STitle) **] your oncologist
Phone:[**0-0-**] on [**2104-10-9**] at 2:00pm.
Followup Instructions:
You have an appointment with radiation oncology Dr.[**Last Name (STitle) **] on
[**Hospital Ward Name 23**] [**Location (un) 442**] on [**2104-10-7**] at 8:00am.
Provider [**Name9 (PRE) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2104-10-9**] 2:00
Provider [**Name9 (PRE) 2105**] [**Name9 (PRE) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2105-2-23**] 1:00
|
[
"585.6",
"272.4",
"276.1",
"197.7",
"453.40",
"327.23",
"486",
"531.90",
"274.9",
"578.9",
"150.8",
"719.40",
"198.5",
"415.19",
"403.91",
"V42.0",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11214, 11220
|
7046, 9948
|
308, 325
|
11463, 11472
|
2473, 7023
|
12605, 13018
|
1873, 1948
|
10134, 11191
|
11241, 11241
|
9974, 10111
|
11496, 12582
|
1963, 2454
|
247, 270
|
353, 1293
|
11260, 11442
|
1315, 1651
|
1667, 1857
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,793
| 139,549
|
21346
|
Discharge summary
|
report
|
Admission Date: [**2121-4-3**] Discharge Date: [**2121-4-5**]
Date of Birth: [**2049-8-3**] Sex: M
Service: SURGERY
Allergies:
Plavix / Coumadin / Statins-Hmg-Coa Reductase Inhibitors /
Vicodin
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
carotid artery stenosis
Major Surgical or Invasive Procedure:
R CEA
History of Present Illness:
Pt with known Right carotid artery stenosis. sl;ight
progression, which warrants surgery
Past Medical History:
PMHx:
CAD - cardiac cath [**4-28**] - RCA patent stents minimal dz LM, LAD,
LCx
Dislipidemia
PAF
HTN
AAA (h/o prior repair in '[**10**] now with supragraft aneurysm)
Non small cell lung cancer s/p chemo/XRT/RULobectomy with brain
mets
CVA [**2108**] with right sided involvement
OA
Diverticuli
prostate cancer
kidney stones
traumatic hip dislocation in [**2063**], status post fusion
Hepatits A
Heart murmur NOS
depression/anxiety
PSHx:
s/p Hartmann's then colostomy reversal '[**07**]
s/p right upper lung lobectomy [**2112**]; LUL VATWR [**11-24**]
s/p left occipital craniotomy [**8-23**]
s/p AAA repair [**2110**]
s/p radical prostatectomy [**2109**]
s/p ventral hernia repait [**2109**]
s/p left hip fusion [**2063**]
s/p right TKR [**2117**]
s/p Herniorrhaphy in [**2075**] with recurrent midline and left flank
incisional hernias
s/p appendectomy
s/p tonsillectomy
Social History:
Former pack a day smoker; quit 6 years ago
Denies ETOH at present ("heavy" drinker about 15 years ago)
He lives part-time in [**Location (un) 86**] with his current wife and part-time
in [**Name (NI) 37452**] where he owns a home. He is independent in
adls. He is a high school graduate, currently retired. He has
two daughters in their 20's from his first marriage.
used to work with restaurant equipment
Family History:
Atherosclerotic cardiovascular disease, prostate and colon
cancer, and hypertension
His father died at 64 of a "[**Last Name **] problem" that the patient does
not recall, and his mother died at 42 of rheumatic fever.
Sister died of colon cancer at a young age
Physical Exam:
Physical Exam:
Vitals- 97.9, 72, 115/57, 17, 96%RA
Gen: WDWN chronically ill-appearing elderly gentleman in no
acute distress.
CV: RRR
Lungs: CTA bilat
Abd: obese, soft, no m/o, tender over incision site
Incision: clean/dry/intact, no signs of erythema, hematoma or
swelling
Extremities: Warm and well perfused without edema bilat. He has
had bilateral hip surgeries and his left foot is externally
rotated and about 4" shorter than the right.
Pulses: Femoral - palp bilat DP - palp on left, dop on right PT
- dop bilat
Pertinent Results:
[**2121-4-4**] 03:32AM BLOOD WBC-5.5 RBC-3.64*# Hgb-11.0*# Hct-34.2*
MCV-94 MCH-30.2 MCHC-32.2 RDW-14.7 Plt Ct-116*
[**2121-4-4**] 03:32AM BLOOD Glucose-121* UreaN-23* Creat-0.9 Na-138
K-4.5 Cl-108 HCO3-23 AnGap-12
[**2121-4-4**] 03:32AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
Cardiovascular Report ECG Study Date of [**2121-4-3**] 7:22:52 PM
Artifact is present. Sinus bradycardia. The P-R interval is
prolonged.
The Q-T interval is prolonged. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2121-3-31**] ventricular ectopy
is no longer present and the Q-T interval is longer.
CK(CPK)-94
Brief Hospital Course:
The patient was admitted to the Vascular Surgical Service for
evaluation and treatment of carotid artery stenosis. Pt had
successfull RCEA.
After a brief, uneventful stay in the PACU, the patient arrived
on the floor NPO, on IV fluids and antibiotics, with a foley
catheter, and PO pain control. The patient was hemodynamically
stable.
Neuro: The patient received PO pain medications with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched 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.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge on POD 2, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. His surgical site staples
were removed and steri-strips were placed.
Medications on Admission:
atenolol 37.5', ASA 81', lisinopril 20', fish oil, vitamin D3
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
carotid artery stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery to remove a
blockage of your right carotid artery.
We have started you on crestor for your cholesterol and a full
strength aspirin. Please follow up with Dr. [**Last Name (STitle) **] for dosage
adjustments and monitoring.
Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
Followup Instructions:
Department: VASCULAR SURGERY
When: MONDAY [**2121-5-12**] at 3:00 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2121-5-12**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2121-4-5**]
|
[
"250.00",
"433.10",
"272.4",
"414.01",
"V12.54",
"427.31",
"401.9",
"V10.11",
"V10.46",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
6026, 6032
|
3274, 5300
|
347, 355
|
6100, 6100
|
2636, 3251
|
8625, 9201
|
1810, 2075
|
5412, 6003
|
6053, 6079
|
5326, 5389
|
6251, 8602
|
2105, 2617
|
284, 309
|
383, 473
|
6115, 6227
|
495, 1370
|
1386, 1794
|
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