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29,502
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44786
|
Discharge summary
|
report
|
Admission Date: [**2174-11-8**] Discharge Date: [**2174-11-13**]
Date of Birth: [**2119-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Tremulousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year-old man with a h/o alcohol abuse with prior episodes of
delirium tremens and withdrawal seizures, homelessness, chronic
Hep B/C and bipolar disorder who was recently discharged to an
inpatient psych facility presents with tremulousness, tachy to
140s, low grade temp to 100.9, hypertensive to 160s and ETOH
level of 169. Pt reports last drink was this am. He received a
total of Ativan 12mg in ED and vitals improved. Pt was
transferred to ICU for high level of nursing care in setting of
likely withdrawal.
.
On arrival to ICU pt was tremulous, but oriented and denying any
pain. He reports drinking approximately [**11-16**] quart of whiskey per
day, last drink was listerine this am. Today, after drinking
listerine, he was sitting down and started getting
uncontrollable jerking of extremities and stiffening of his
muscles. He is unsure if he lost consciousness at anytime, but
bystanders told him that he was foaming at his mouth and needed
to get medical attention. EMS was called and brought him into
the ED.
Past Medical History:
- alcoholism with history of delirium tremens
- hepatitis C, never treated
- bipolar disorder; history of self-inflicted lacerations and
benzo overdoses
- reported history of seizure disorder
- Hepatitis B, per OMR serology appears to be chronic infection
- History of subdural hematoma
Social History:
Mr. [**Known lastname 95814**] has been homeless for several months now. He has a
long history of alcohol abuse. He denies current tobacco use and
denies any history of any intravenous drug use; he admits to
using marijuana "back in the 70's." He was recently in
[**Location (un) 260**], Mass, where he had a job with the Chamber of
Commerence, but then lost his job, resumed drinking, and moved
to [**Location (un) 86**] where he has been homeless.
Family History:
He reports that both parents had esophageal cancer. He has a
sister with breast and skin cancer. He denies any family history
of alcohol abuse.
Physical Exam:
Temp:98.7 BP:115/77 HR:102 RR:12 O2sat: 96% on 2L
GEN: NAD, tremulous in all four extremities, eyes closed
HEENT: PERRLA, dry MM
NECK: no cervical lymphadenopathy, no jvd, no thyromegaly
RESP: CTA b/l with good air movement throughout
CV: frequent PVCs, otherwise mildy tachy, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: oriented x 3, 5/5 strength throughout, mild tremors, no
sensory deficits appreciated
Noted to be wearing hospital wrist band with name of
MD-Gurmarnik
Pertinent Results:
[**2174-11-8**] 08:40PM ASA-NEG ETHANOL-169* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2174-11-8**] 08:40PM ALBUMIN-5.3*
[**2174-11-8**] 08:40PM ALT(SGPT)-88* AST(SGOT)-66* ALK PHOS-65
AMYLASE-72 TOT BILI-0.6
[**2174-11-8**] 08:40PM estGFR-Using this
[**2174-11-8**] 08:40PM GLUCOSE-94 UREA N-12 CREAT-1.0 SODIUM-142
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-28 ANION GAP-19
[**2174-11-8**] 09:53PM PLT COUNT-221
[**2174-11-8**] 09:53PM NEUTS-70.1* LYMPHS-23.1 MONOS-2.0 EOS-3.7
BASOS-1.2
[**2174-11-8**] 09:53PM WBC-9.0# RBC-4.78 HGB-15.2 HCT-43.2 MCV-90
MCH-31.9 MCHC-35.3* RDW-14.6
[**2174-11-8**] 11:26PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2174-11-8**] 11:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2174-11-8**] 11:26PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2174-11-8**] 11:26PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2174-11-8**] 11:26PM URINE GR HOLD-HOLD
[**2174-11-8**] 11:26PM URINE HOURS-RANDOM
[**2174-11-8**] 11:26PM URINE HOURS-RANDOM
Brief Hospital Course:
55 y/o man h/o ETOH abuse & delirium tremens/withdrawal
seizures, homelessness, chronic hep B/C, and bipolar disorder
who was recently discharged to inpt Psych presents with symptoms
of ETOH withdrawal & some suicidal ideation.
.
#) Alcohol intoxication/withdrawal: Pt with h/o ETOH abuse & DTs
presents with tremulousness & autonomic instability. He was adm
to [**Hospital Unit Name 153**] for CIWA scale monitoring initailly, and required valium
q 3 hours initially to control his symptoms. His benzo
requirement was rapidly tapered down. He was transferred to the
medical floor on the evening of [**11-11**]. From this point forward,
he recieved approximately two doses of 5 mg of valium [**Hospital1 **] for
score greater than 10 on the CIWA scale, however, this was not
felt to be due to etoh withdrawal, as the scores were for his
tremor (felt by neurology to be "non physiologic" v. essential
tremor and not evidence of etoh withdrawal - see below), and for
anxiety, which has been a longstanding component of his
depression. He had no VS abnormalities to support etoh w/d
while on the medical [**Hospital1 **]. On [**11-13**] CIWA monitoring was
discontinued.
.
#) Bipolar disorder/Depression: pt has a long standing h/o
bipolar disorder, recently discharged to inpt psych on [**2174-10-21**].
Pt known to have mild cognitive deficits, some confabulation,
possibly related to Korsakoff vs depressive symptoms. On adm pt
was endorsing some SI but no clear plan. He was noted to be
wearing a hosp wrist band with adm date [**2174-11-3**] but couldn't
remember anything about this. 1:1 sitter was maintained for
active suicidality.
- held Escitalopram & Seroquel per psych recs
- continued Trileptal 300mg daily (mood stabilizind dose - not
an anti-epileptic)
- After etoh withdrawal and seizure workup and evaluation
completed (by [**11-13**]), psychitatry was informed that pt. had no
evidence of seizures or etoh withdrawal. He was then
re-evaluated by psychiatry who began looking for inpatient
psychiatric placement for ongoing treatment of his depression,
possibly to include ECT. [**Hospital1 **] 4 had bed for pt., transfer
there arranged.
.
#) Seizure disorder: unclear h/o seizure disorder - pt. states
he knows of no history of seizures that he can recall. Pt
managed on Oxycarbamazepine 300mg daily as outpatient - but this
was prescribed as a mood stabilizer only, not as an
antiepileptic. Given the report of seizure like acitivity seen
prior to admission to the hospital, CT head completed (negative)
and neurology consulted. Neurology felt there was no evidence
of seizure, and that his tremors were either "non-physiologic"
or essential tremor. The requested EEG, which was completed,
and had no evidence of epileptiform discharges. Neurology
signed off, and felt that no therapy for seizures was indicated.
During his hospitalization, no evidence of generalized or
complex seizure was seen, only the above mentioned tremor of the
right hand and foot, which was absent while sleeping, and went
away with volitional motions. Additionally, the pt. was noted
to be fully conversant and oriented during tremulous motions of
the hand and foot.
.
#) Chronic Hep B&C: h/o chronic hep C by serology, last viral
load was 4,890,000 IU/mL. HIV testing from [**10-21**] was negative.
Mild transaminitis noted on labs, but had been improved since
recent discharge and have essentially normalized during
hospitalization.
Medications on Admission:
Escitalopram 20 mg daily
Hexavitamin DAILY
Thiamine HCl 100 mg daily
Oxcarbazepine 300 mg daily (recently restarted)
Folic Acid 1 mg daily
Quetiapine 25 mg Tablet PO BID prn anxiety
Discharge Medications:
1. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Alcohol intoxication and withdrawal with report of seizure like
activity
Depression with suicidality
Essential tremor
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. Call your primary doctor or
report to the nearest Emergency Department for:
Suicidal thoughts
Fevers
Alcohol withdrawal
Followup Instructions:
With psychiatry as arranged (inpatient)
|
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48,439
| 104,741
|
41174
|
Discharge summary
|
report
|
Admission Date: [**2131-6-11**] Discharge Date: [**2131-6-28**]
Date of Birth: [**2046-6-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
L facial tumor
Major Surgical or Invasive Procedure:
Left facial resection and graft placement
PEG feeding tube placement
History of Present Illness:
CC: invasive advanced basal cell cancer causing discomfort
closing her mouth; some drooling of food because of the
retraction of her lips; difficulty in closing her eyes; some
tearing because of retraction of her lower eyelid and some pain
and discomfort in the cheek area itself and this ligament of her
face.
.
HPI: 85 year old woman with dementia and advanced erosive basal
cell
carcinoma involving the left cheek, nasal cavity, palate, and
lateral facial region. She was admitted for surgical resection
and will need a prosthesis and by a prosthodontist to have a
preliminary prosthesis made that will eventually shell the
defect and provide her some cosmesis.
Past Medical History:
Hypertension, anemia, renal failure, hypothyroidism,
hyperlipidemia, paranoid, dementia, and chronic psychosis.
Excision of left-sided facial carcinoma and type 2 diabetes, and
history of prior alcohol abuse.
Social History:
From the family, she says she and her husband
estranged from her family. Her husband recently died and they
used to travel all over the country in a trailer and they never
had a permanent place of residence. She is now in a
rehabilitation facility called Roscommon On The Parkway. No
other social history could be elicited from her. She does not
remember if she smokes or does have a history of alcohol abuse.
Family History:
None
Physical Exam:
VS: 96.2 128/84 HR 69 RR20 O2sat 95% on RA
General: Alert, oriented, mild respiratory difficulty with
audible wheeze, difficult to understand when she speaks.
HEENT: Sclera anicteric, dry MM, large defect on left cheek
extending to left orbit. Slight erythema at wound edge. no odor,
no sloughing tissue. Lips sutured midline.
Neck: supple, JVP 2-3 cm above clavicle
Lungs: mild crackles at bases bilaterally
CV: regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound tenderness or guarding, no organomegaly,
Gtube without dressing, ~10 in out of abd, clean dressing, no
erythema.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,
edema
Neuro: moving all extremities
Groin: minimal erythematous satellite lesions extended to
buttocks crease, labial folds
.
Pertinent Results:
Admit labs:
[**2131-6-11**] 04:00PM BLOOD WBC-17.8* RBC-4.08* Hgb-12.4 Hct-36.5
MCV-90 MCH-30.3 MCHC-33.9 RDW-12.8 Plt Ct-250
[**2131-6-11**] 04:00PM BLOOD Glucose-222* UreaN-17 Creat-0.9 Na-137
K-4.6 Cl-107 HCO3-22 AnGap-13
[**2131-6-11**] 04:00PM BLOOD Calcium-7.4* Phos-3.2 Mg-1.4*
[**2131-6-14**] 04:50AM BLOOD TSH-0.58
[**2131-6-14**] 04:50AM BLOOD T4-8.1 T3-52*
Cardiac enzymes:
[**2131-6-17**] 08:23AM BLOOD CK-MB-3 cTropnT-2.40*
[**2131-6-15**] 09:10PM BLOOD CK-MB-4 cTropnT-2.28*
[**2131-6-15**] 06:39PM BLOOD CK-MB-5 cTropnT-1.95*
[**2131-6-15**] 03:30AM BLOOD CK-MB-6 cTropnT-1.22*
[**2131-6-14**] 04:50AM BLOOD CK-MB-14* MB Indx-3.1 cTropnT-0.95*
UA
[**2131-6-23**] 09:12PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2131-6-23**] 09:12PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2131-6-23**] 09:12PM URINE RBC-6* WBC-25* Bacteri-FEW Yeast-FEW
Epi-1 TransE-<1
Discharge labs:
[**2131-6-26**] 07:30AM BLOOD WBC-12.6* RBC-3.18* Hgb-9.7* Hct-30.5*
MCV-96 MCH-30.6 MCHC-31.9 RDW-16.2* Plt Ct-503*
[**2131-6-26**] 07:30AM BLOOD Glucose-310* UreaN-34* Creat-1.1 Na-139
K-4.9 Cl-98 HCO3-30 AnGap-16
[**2131-6-22**] 05:45AM BLOOD ALT-16 AST-19 AlkPhos-55 TotBili-0.4
[**2131-6-26**] 07:30AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
URINE CULTURE (Final [**2131-6-25**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
YEAST. ~5000/ML. SECOND MORPHOLOGY.
Blood Culture:
Blood Culture, Routine (Final [**2131-6-22**]): NO GROWTH.
Blood Culture, Routine (Final [**2131-6-22**]): NO GROWTH.
Studies:
Portable CXR [**2131-6-22**]
FINDINGS: Patient's positioning compromises the quality of the
film as well as comparison with prior radiographs. However,
bilateral perihilar haziness with upper redistribution secondary
to mild pulmonary vascular congestion seems unchanged. The right
hemidiaphragm is elevated. A left lower lobe radiopacity is
stable from prior radiographs and likely represents moderate
atelectasis. No evidence of pneumothorax. Mild cardiomegaly is
stable.
IMPRESSION: Unchanged mild pulmonary edema. Bibasilar
atelectasis, left
worse than right.
Chest CT:
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is no
axillary,
mediastinal, or hilar lymphadenopathy. The pulmonary arteries
are well
opacified. There are no filling defects. A small left pleural
effusion is
identified. There is atelectasis in the right lower lobe. There
is left
lower lobe consolidation. A small amount of pericardial fluid is
noted. There are no lung nodules or masses. An NG tube is
identified.
Limited views of the upper abdomen demonstrate a normal
gallbladder, liver, and spleen. A 1.2 cm nodule in the left
adrenal gland measures 16 Hounsfield units, is thus
indeterminate but most consistent with an adenoma. A 3.5 cm
hypodense lesion in the right kidney at mid pole measures 13
Hounsfield units and is consistent with a cyst.
On bone windows there is loss of height of T12 and L1 and T9.
This is of
indeterminate age.
IMPRESSION:
1. No evidence of PE.
2. Consolidation in the left lower lobe concerning for
pneumonia. Small
pleural effusion.
3. Compression deformity of several lower thoracic vertebral
bodies and of L1 are of indeterminate age.
Abd Xray [**2131-6-22**]
FINDINGS: One supine portable view of the abdomen is provided. A
G-tube is
seen within the stomach. The bowel gas pattern shows some mildly
dilated
loops of small bowel consistent with an ileus. There are
multiple
calcifications noted, most predominantly within the aorta. The
lung bases
appear clear. There is no evidence of free air.
IMPRESSION: Bowel gas pattern consistent with an ileus.
PATHOLOGY: [**2131-6-11**] Maxillary Tissue
1. Left medial palatal margin (A):
Negative for carcinoma.
2. Left medial lip margin (B):
Negative for carcinoma.
3. Left inferior periorbital margin (C):
Atypical cells present; cannot exclude carcinoma.
Note: The atypical cells in the initial frozen section are
suspicious for carcinoma. The focus does not appear in the
permanent section of the remaining frozen tissue.
4. Left medial periorbital margin (D):
Negative for carcinoma.
5. Left superior medial periorbital margin (E):
Negative for carcinoma.
6. Left proximal inferior orbital nerve margin (F):
Small cluster of atypical basaloid cells within soft tissue
consistent with basal cell carcinoma, see note.
Note: There is a small focus at the edge of the permanent
section of the remaining frozen tissue. The focus did not
appear in the original frozen section which was diagnosed as
negative for carcinoma. The focus is within fat. The nerve is
uninvolved. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] has reviewed this case and concurs
with the diagnosis.
7. Additional margin, left inferior periorbital (G):
Small cluster of atypical basaloid cells consistent with basal
cell carcinoma, see note.
Note: There is a small focus at the edge of the permanent
section of the remaining frozen tissue. The focus did not
appear in the original frozen section which was diagnosed as
negative for carcinoma. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] has reviewed this case and
concurs with the diagnosis.
8. Coronoid process of left mandible (H-I):
Portion of bone and muscle; negative for carcinoma.
9. Posterior portion of left inferior turbinate (J):
Nasal mucosa; negative for carcinoma.
10. Total maxillectomy, left (K-AK):
-Basal cell carcinoma, infiltrative type, present at inferior
orbital rim margin (slides K, L, AH) see note.
-Hypertrophic actinic keratosis, not seen at the examined
specimen margins.
Note: There is perineural invasion (best observed in slide R)
and extension of tumor to underlying bone (best observed in
slides AD, AF). The tumor extends from the overlying epidermis
near the ulcer. In the superficial areas the tumor shows more
typical features of basal cell carcinoma including larger
nodules with peripheral palisading. As the tumor infiltrates
deeper, the cells are more pleomorphic with loss of palisading,
and some areas show infiltration of smaller nests with a marked
sclerotic stroma. There are focal areas showing an adenoid
pattern.
Brief Hospital Course:
This is an 85 yo F h/o HTN, DM, dementia with psychosis, basal
cell carcinoma admitted for surgical resection of basal cell
carcinoma of the left face. Surgical resection and Gtube
placement was performed [**6-11**] with post-op course complicated by
hypercapnia, aspiration PNA, tachycardia, hypernatremia, and
ARF.
Operative and post op course
Pt was admitted for surgical resection of large left facial
tumor. She underwent a resection of left facial tumor; partial
orbitectomy; partial palatectomy soft tissue face and cheek;
partial rhinectomy; local tissue rearrangment left eye. She
tolerated the procedure well, and was extubated, and brought to
the recovery room in stable condition. In the recovery room the
pt was desating to 80s% on room air, although remained stable
the entire time. On face mask and 12L her sat was 96%. cxr in
the PACU did not reveal pleural effusions, or any other acute
lung pathology. post-op labs were unchanged and wnl, except for
abg which was significant for a respiratory acidosis (PaCO2 61)
likely related to anesthesia. However, that pt was unable to
maintain saturation on room air, decision was made to send pt to
the ICU. Overnight in the ICU the pt remained npo with 100%
saturdation on non-rebreather. On POD#1, pt was weaned from
supplemental oxygen to room air. On room air saturdation was 92%
(baseline preop 94%). Pt was restarted on home medications,
continued on Unasyn, and tube feeds were started. In addition,
pt tolerated sips for comfort without coughing. On POD#2 pt was
transferred to the medical service after which she underwent the
following complications throughout her MICU and hospital stay:
hypercapnia, aspiration PNA, GIB, tachycardia, hypernatremia,
and ARF.
These problems were managed over the course of a prolonged
hospitalization to the point she was relatively stable with the
main underlying problems being poor airway control with high
aspiration risk and PEG tube management. Plan for discharge on
[**6-25**] when she had a minor aspiration event with respiratory
distress without hypoxia. That evening she also pulled her PEG
tube out. Goals of care were readdressed the following day with
the health care proxy who decided patient should be made DNR/DNI
and focus on comfort measures only and to avoid PEG tube
replacement.
Continued issues for this patient include:
1) Persistent aspiration risk: Patient must remain at atleast 45
degree angle to prevent aspiration. Pt allowed to have sips or
small bites of pureed solids for comfort if she requests. She is
written for concentrated liquid medications and suppositories as
routes of medication. She is written for morphine to be used
for respiratory distress.
2) Skin care: Patient has a hole at her G tube site which is
draining any oral intake and some gastric secretions also.
Barrier cream should be applied to the site twice daily with
good skin care. Pegs around the G tube site should fall off on
their own in [**2-23**] weeks, earlier removal may result in a
peritonitis.
3) Face care: Daily to qod facial cleansing with small
quantities of normal saline.
4) Pain control: Patient is written for round the clock tylenol
and prn morphine.
5) GOC: Patient is Comfort Measures Only and Do not hospitalize.
5) HCP: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 89691**] X123
.
Medications on Admission:
1. Alendronate 70mg weekly (sunday)
2. Citalopram 20mg daily
3. Ergocalciferol 50,000 units monthly
4. Erythromycin (0.5%) ointment 5mg/gm left eye daily
5. Glipizide XL 5mg daily
6. Labetalol 400mg PO BID
7. Levothyroxine 50mcg daily
8. Lisinopril 10mg daily
9. Olanzapine 2.5mg daily
10. Miralax 17gm/dose daily
11. Simvastatin 20mg nightly
12. Acetaminophen 650mg q6hrs
13. Aspirin 81mg daily
14. Calcium carbonate 500 mg (1250mg) tablet [**Hospital1 **]
15. Carboxymethylcellulsoe 1% drops 1 drop OS QID
16. Dextra 70-hypromellose 1 drop every 2 hours while awake
17. Colace 100mg [**Hospital1 **]
18. Mg hydroxide 400mg/5mL 30ml twice weekly Wed/Fri
19. Mg oxide 800mg daily
20. MVI
21. Senna 1 tablet nightly
22. Lacrilube one drop OS [**Hospital1 **]
Discharge Medications:
1. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QHS (once a day (at bedtime)).
2. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-19**]
Drops Ophthalmic Q1H (every hour).
3. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q6H (every 6 hours) as needed for
discomfort/agitation.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
discomfort from constipation.
5. acetaminophen 650 mg Suppository Sig: One (1) suppository
suppository Rectal every six (6) hours.
6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
Five (5) mg PO q2h as needed for pain or respiratory distress.
7. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Ten
(10) mg PO q2h as needed for severe pain or respiratory
distress.
Discharge Disposition:
Extended Care
Facility:
Roscommon on the Parkway - [**Location 1268**]
Discharge Diagnosis:
Primary Diagnosis
Basal Cell Carcinoma
Supraventricular tachycardia secondary to B-blockade withdrawal
Pneumonia
Secondary Diagnoses
Chronic kidney disease
Hypothyroidism
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 17926**],
It was a pleasure to take care of you. You were admitted to the
hospital for surgery to remove a cancer on your face. After the
surgery, you had a number of post surgical complications
including an arrythmia, a pneumonia, and a yeast infection on
the body. After all of this your health care proxy decided to
focus on comfort based care for management of your symptoms.
You had a feeding tube put in to protect your airway, but you
continued to pull it out and it was decided that we not replace
it. Your family decided that it may be best to focus on comfort
based care instead of aggressive medical treatments.
A number of medications have been changed. Please see the new
attached list.
Followup Instructions:
not needed
Completed by:[**2131-6-28**]
|
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icd9cm
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[
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[]
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[
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icd9pcs
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[
[
[]
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13940, 14013
|
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318, 389
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14239, 14239
|
2651, 3020
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|
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14417, 15153
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|
1783, 2632
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3037, 3610
|
264, 280
|
417, 1084
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14254, 14393
|
1106, 1316
|
1332, 1746
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,761
| 150,904
|
13899
|
Discharge summary
|
report
|
Admission Date: [**2148-4-26**] Discharge Date: [**2148-5-1**]
Date of Birth: [**2082-3-21**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old
woman with a history of coronary artery disease status post
recent stent to the right coronary artery, oxygen dependent,
chronic obstructive pulmonary disease, hypothyroidism
admitted to the Medical Intensive Care Unit for hypotension
requiring pressors. Four days prior to admission she
noted chills, which progressed to a fever of 101, fatigue and
malaise over the next few days. One day prior to admission
she had an appointment with her primary care physician who
prescribed [**Name9 (PRE) **] for presumed flare bronchitis. No increase
in cough or sputum. She noted sharp pain in her upper back
that radiated to her front and was alleviated with sublingual
nitroglycerin. That p.m. she noticed worsening chills,
fever, nausea, dry heaves and she went to an outside
hospital. There she was found to be hypotensive with a blood
pressure of 80/40 and put on a Dopamine drip. She denies
headache, abdominal pain. Last bowel movement was yesterday
a.m. No bright red blood per rectum. She has a rash on her
back. Abdominal ultrasound at the outside hospital was
without gallbladder thickening or gallstones. She has a
history of recent antibiotics with Levofloxacin for chronic
bronchitis.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post percutaneous transluminal coronary angioplasty and stent
to the right coronary artery in [**2148-3-20**]. No wall motion
abnormalities. EF of 60%. Capillary wedge pressure was 14.
2. Chronic obstructive pulmonary disease, which is oxygen
dependent. Most recent documented pulmonary function tests
are from [**2133**]. 3. Chronic low back pain status post
multiple back surgeries. 4. Hypothyroidism. 5. Status
post appendectomy at age 13.
MEDICATIONS ON ADMISSION: Aspirin 325 mg po q day,
Prednisone taper, Cardizem 20 po q day, Plavix 75 q.d.,
Lisinopril 5 q.d., Serevent and Protonix, Levoxyl .75
micrograms po q day, Flovent and Lipitor 20 po q.d.
ALLERGIES: Erythromycin, Penicillin, and Ceftin. Question
Ciprofloxacin and codeine.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97. Blood
pressure 85/47, which had increased to 127/52. Pulse 76 to
79. 95% sat on 2 liters. General, the patient is a pleasant
female lying flat and in no acute distress. HEENT mucous
membranes are moist. Pupils are equal, round and reactive to
light and accommodation. Extraocular movements intact.
Pharynx is benign. Neck has JVP of 4 to 5 cm. No Carotid
bruits. No thyromegaly. No nodules. Heart S1 and S2,
regular rate and rhythm. No murmurs, rubs or gallops. Lungs
decreased breath sounds bilaterally with no rales. Abdomen
soft, nondistended, tender to deep palpation in the right
upper quadrant. No hepatosplenomegaly. Rectal examination
she had hard stool in the vault, no fluctuance, nontender.
Guaiac negative. Extremities no clubbing, cyanosis or edema.
2+ dorsalis pedis pulses. Neurological alert and oriented
times three. Moves all four extremities.
LABORATORIES ON ADMISSION: White blood cell count 9.8,
hematocrit 34. Chem 7 within normal limits. ALT 149, AST
68, alkaline phosphatase 148, T bili 0.7. Her coags were
normal. CK was flat. Chest x-ray revealed increased lung
volumes, question right cardiophrenic increased opacity.
Electrocardiogram was normal sinus rhythm. Normal axis and
intervals normal with small Q waves in 2, 3 and AVF, early R
wave progression, flip T in V1 and V2.
HOSPITAL COURSE: 1. Pulmonary: She was started on
Levofloxacin for presumed pneumonia and she was diagnosed
with chronic obstructive pulmonary disease exacerbation. For
that she was continued on inhalers and given stress dose
steroids. The steroids were quickly tapered and she was
brought to the floor, however, after a few hours on the floor
she again became very short of breath and was transferred
back to the Medical Intensive Care Unit on the [**3-27**].
There she was again placed on stress dosed steroids and
continuous nebulizers, oxygen and did not require intubation.
She was called out to the floor again on [**2148-4-29**] and
started on very gradual Prednisone taper. She is currently on
po Prednisone at 60 mg po q day with plan to taper gradually.
On the floor she also began to have some blood streaked
sputum, which was sent for culture, however, contaminated and
other specimens were being attempted to be sent. She was
started on Singulair on transfer to the floor and Serevent
and Flovent were readded to her regimen. Also her outpatient
pulmonary function test results from [**2143**] were obtained and
because of the severity the plan was made for outpatient
pulmonary follow up.
2. Cardiovascular: The patient initially was placed on
telemetry and ruled out for myocardial infarction, because of
the hypotension. She did not receive pressors after
admission since her blood pressure had improved, however, her
blood pressure medications had been held and the Diltiazem
was eventually restarted on transfer to the floor.
3. Endocrine: She was continued on her Levoxyl and did not
have any elevated blood glucose on the steroids that she was
on.
4. Psychiatry: The patient also had significant anxiety
during this hospital course, which probably contributed to
her shortness of breath and tachycardia. These improved with
Xanax and Ativan was tried in addition without significant
improvement. However, frequent Xanax and frequent
reassurance seemed to be the best way to control her anxiety
attacks.
DISPOSITION: She was evaluated by physical therapy and they
felt she would benefit from a rehabilitation stay. She was
also seen by social work who dealt with some of her personal
issues with her family.
DISCHARGE PLAN: Transfer to rehabilitation, progressive
pulmonary rehab, chest physical therapy as needed, suctioning
as needed. Nebulizers as needed and teaching for inhalers.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, Prednisone
taper to be outlined on page one. Cardizem 20 mg po q day.
Lisinopril 5 mg po q day. Plavix 75 mg po q day. Serevent
two puffs b.i.d. Protonix 40 mg po q day. Levoxyl .75 mg po
q day. Flovent two puffs b.i.d., Lipitor 20 mg po q day.
Combivent nebulizers q four hours prn.
DISCHARGE DIAGNOSES:
1. Bronchitis.
2. Chronic obstructive pulmonary disease exacerbation.
3. Anxiety disorder.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. [**MD Number(1) 41641**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2148-5-1**] 10:42
T: [**2148-5-1**] 10:53
JOB#: [**Job Number 41642**]
|
[
"491.21",
"786.3",
"244.9",
"V45.82",
"458.9",
"300.00",
"782.1",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6412, 6774
|
6075, 6391
|
1960, 2257
|
3639, 5871
|
188, 1420
|
3199, 3621
|
5888, 6051
|
1443, 1933
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,653
| 124,966
|
49379
|
Discharge summary
|
report
|
Admission Date: Discharge Date: [**2172-3-10**]
Service:
CHIEF COMPLAINT: Shortness of breath and tachypnea.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old man
with an extensive past medical history including congestive
heart failure with an ejection fraction of 30%, severe
human immunodeficiency virus who presented with shortness of
breath and tachypnea.
The patient was recently discharged from [**Hospital1 346**] on [**2-27**] to [**Hospital1 **], at which
time he also presented with worsening dyspnea that was
attributed to congestive heart failure and treated with Lasix
avium-intracellulare in his sputum that was treated with
ethambutol, floxacillin, and azithromycin. Additionally, he
had pseudomonas positive wound culture and was
treated between [**2-21**] and [**3-2**].
Today, he was sent from [**Hospital1 **] for evaluation of shortness
of breath and increased respiratory rate for the last two
days.
REVIEW OF SYSTEMS: His review of systems was positive for a
temperature spike up to 101.4 on [**3-7**], and urinalysis was
positive for infection, treated with levofloxacin. On
admission, the patient denied chest pain, cough, nausea,
vomiting, and diarrhea. By report, chest x-ray was post for
edema and congestive heart failure, and the patient was
treated with Lasix earlier in the morning prior to admission.
While in the Emergency Department BiPAP was attempted without
much success.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction, status post coronary artery bypass graft in [**2149**]
and [**2153**]. Status post pacemaker placement in [**2168**].
2. Congestive heart failure with an ejection fraction of
30% to 35%; last echocardiogram on [**2-18**] with atrial
septal defect, moderate tricuspid regurgitation, moderate
pulmonary artery hypertension, decreased right ventricular
function, and left ventricular function of 30%.
3. Cervical nerve injury, status post percutaneous
endoscopic gastrostomy in [**2171-12-10**].
4. Peptic ulcer disease, status post upper gastrointestinal
bleed and history of gastroesophageal reflux disease.
5. Diverticulosis.
6. Arteriovenous malformation in the stomach and colon.
7. Parkinsonism.
8. Benign prostatic hypertrophy, status post transurethral
resection of prostate in [**2150**].
9. Status post cholecystectomy and appendectomy.
10. Chronic obstructive pulmonary disease (on home oxygen of
2 liters to 4 liters) with FEV of 31% of predicted and FVC of
63% of predicted in [**Month (only) 1096**] of last year.
10. Peripheral vascular disease.
11. Cerebrovascular accident in [**2165**].
12. .................... syndrome.
13. Cervical zoster.
14. Human immunodeficiency virus/acquired immunodeficiency
syndrome with a CD4 count of 248 in [**2172-1-10**] and a
viral load of less than 50.
15. Pulmonary aspergillosis in [**2161**].
16. Vitamin B12 and iron deficiency anemia.
ALLERGIES: PENICILLIN, NIFEDIPINE, QUINIDINE, PROCAINAMIDE,
DILTIAZEM, ACE INHIBITOR, and HYDRALAZINE.
SOCIAL HISTORY: The patient lives with his daughter ([**Name (NI) **])
who is health care proxy. [**Name (NI) **] reports no alcohol and a 100 to
150-pack-year tobacco smoking history.
MEDICATIONS ON ADMISSION: Combivir, nevirapine, vitamin C,
Neurontin, Atrovent, albuterol, Procrit, Pravachol, Flovent,
Ultrase, Bactrim, Fentanyl, Cozaar, subcutaneous heparin,
lactulose, digoxin, Risperdal, tube feeds, Fentanyl patch 25,
Flovent, Combivent, zinc, Protonix, Zocor, Mirapex,
oxycodone, Sinemet.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature of 100.8 rectally, respiratory rate of 30s to
40s, heart rate of 85, blood pressure of 122 to 181/35 to 48.
Generally, the patient was barely responsive to tactile
stimulation, laboring with his breathing. Head, ears, nose,
eyes and throat revealed pupils were round and reactive to
light. Pulmonary revealed there were bilateral crackles and
rhonchi. The patient was using accessory muscles with
ambulation. Cardiovascular revealed hyperdynamic heart. No
murmurs, rubs or gallops. The abdomen was nontender and
nondistended, with G-tube in site. Rectal was brown, which
was heme-positive. Extremities showed trace pretibial edema.
RADIOLOGY/IMAGING: Electrocardiogram was paced at 83.
Chest x-ray revealed congestive heart failure with pulmonary
edema, bilateral opacities (possibly edema of aspiration
pneumonia), emphysema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories at
[**Hospital1 **] revealed a white blood cell count of 4.7 (with a
differential of 52 neutrophils, 31 lymphocytes, and
4.9 eosinophils), hematocrit of 27.1 (down from a baseline of
approximately 26), platelet count of 322, mean cell volume
of 127, and an RDW of 23.4. Digoxin level of 1.7. INR
of 1.2, PTT of 32.7. Sodium of 137, potassium of 5.4,
chloride of 97, bicarbonate 38, blood urea nitrogen of 45,
creatinine of 0.8, glucose of 101. Amylase of 86, lipase
of 65, albumin was pending, calcium of 7.9, total bilirubin
of 0.4, ALT of 35, AST of 54, alkaline phosphatase of 101,
LDH of 239. Urinalysis was cloudy, trace blood, 5 to 10
white blood cells, 1+ leukocyte esterase. Arterial blood gas
at 1:45 was 7.26/90/286 on 100% nonrebreather; at 2:40 was
7.33/75/56 on 2 liters, satting 89%; at 4:50 was 7.21/97/164
on 3 liters, satting 100% on BiPAP of 10 X 5 and 30% oxygen.
His systolic blood pressure increased to 220, and his
respiratory rate decreased to 50s, with a decrease in his
oxygen saturation. Arterial blood gas at 6:20 p.m. showed
7.24/88/50, satting 88% on 2 liters.
HOSPITAL COURSE: In summary, the patient is an 82-year-old
with multiple medical problems including acquired
immunodeficiency syndrome, congestive heart failure (with an
ejection fraction of 30%), and chronic obstructive pulmonary
disease who came in with severe respiratory distress,
bilateral infiltrates, and hypercarbia, with mild hypoxia,
and fever.
After an extensive discussion with the daughter, the patient's
code status was changed to do not resuscitate/do not intubate. He
was transferred to the Intensive Care Unit for further
monitoring.
Overnight, his respiratory status deteriorated leading to a
progressive increase in his blood pressure. The patient
received 1 unit of packed red blood cells for his hematocrit
of 27, as well as antibiotics for pneumonia. Despite this
supportive care, the patient passed away at 4:10 in the
morning on [**2172-3-9**]. The immediate cause of death was
respiratory failure secondary to pneumonia, congestive heart
failure.
CONDITION AT DISCHARGE: Deceased.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Human immunodeficiency virus.
3. Pneumonia.
4. Peptic ulcer disease.
5. Chronic obstructive pulmonary disease.
6. Peripheral vascular disease.
7. Anemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. [**MD Number(1) 9562**]
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2172-3-10**] 04:55
T: [**2172-3-10**] 07:12
JOB#: [**Job Number **]
|
[
"428.0",
"276.2",
"285.29",
"486",
"518.84",
"792.1",
"707.0",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6655, 7123
|
3264, 5618
|
5637, 6608
|
6623, 6634
|
969, 1442
|
87, 123
|
152, 948
|
1465, 3050
|
3066, 3237
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,830
| 168,738
|
45204
|
Discharge summary
|
report
|
Admission Date: [**2169-11-11**] Discharge Date: [**2169-12-6**]
Service: MEDICINE
Allergies:
Aspirin / Percocet / Codeine / Nutren Pulmonary / Zosyn
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85yoW with h/o asthma, HTN, PVD, COPD, and MAT, recently
admitted to [**Hospital1 18**] [**Hospital Unit Name 153**] [**Date range (1) 96595**]/06 for sepsis in the setting
of pneumonia and UTI, and was also treated for decompensated
diastolic CHF, referred from [**Hospital **] Rehab for concern of
acute renal failure. She had been discharged on vancomycin and
meropenem, with course due to complete on [**2169-11-12**]. Today at
rehab her labs returned with a creatinine of 6.7 and [K+] 6.6.
On arrival to the [**Hospital1 18**] ED VS T 99.9 HR 107 BP 130/92 RR 16
97%on 2Lnc. In the ED patient's creatinine was at baseline 1.5,
however, she became acutely hypotensive with SBP in the 90s,
going as low as 80/37. She was also noted to have a T of 100.8R
and FS of 23 with lethargy. She was treated with 2 amps D50, 1L
NS iv fluids, and admitted. Lactate was not elevated. She was
also given levofloxacin 500mg iv x1. On presentation now she
denies having headache, chest pain, SOB, abdominal pain, nausea,
diarrhea, or dysuria. She continues to have a non-productive
cough, which she has had since her illness developed. She does
not take anything by mouth and has had a PEG for 3-4months for
feeding and medication administration.
Past Medical History:
1)Asthma > 5 hospitalization with no history of intubations. She
has been on steroids since the beginning of [**Month (only) 216**]. Prior to
this, she had been steroid free for the past 2 years. Recent
hospitalization with intubation complicated by MRSA pneumonia,
d/c on [**9-25**] to rehab, rehospitalized in early [**10-28**])Hypertension.
3)Steroid induced hyperglycemia. Discharged on insulin following
her [**Hospital1 **] admission.
4)Peripheral vascular disease, status post left fem-peroneal
bypass in [**2162**]
5)Multi-focal bacterial pneumonia.
6)Chronic obstructive pulmonary disease- PFT [**7-2**]- FVC 61% pred,
FEV1 56% pred, FEV1/FVC 92%, Reduced FVC related to gas
trapping, ~400 cc worse than PFT from one year ago.
7)Multi-focal atrial tachycardia.
8)Oral thrush.
9)Question left hilar mass.
10)Mult aspirations in past requiring now being on feeding tube
11)Hx. MRSA PNA
12) Bell's Palsy
13) UTI
14) GIB
Social History:
Denies history of smoking. Only social alcohol, ~3 drinks /week.
No other drug use. Widowed, with 3 children and 8 grandchildren.
Family History:
Asthma in her father
Physical Exam:
PE: T 97.1 HR 88 BP 144/82 RR 28 100%NRB; 97%2Lnc
GEN: lying at 30degrees, speaking full sentences, alert and
oriented, NAD
HEENT: right facial droop, PERRL, surgical pupils bilaterally,
OP clear with dry MM
Neck: supple, no LAD, JVP 9cm, soft tissue swelling bilaterally
supraclavicular
CV: PMI nondisplaced, RRR, no mrg
Resp: coarse bilaterally with coarse crackles throughout and
occasional bilateral wheeze, decreased at bases bilaterally
Abd: +BS, soft, NT, ND, PEG in place c/d/i
Ext: no edema, echymoses, anterior skin tears, 1+ DPs
bilaterally symmetric
Neuro: A&Ox3, CN II-XII intact with exception of right facial
droop, strength 5/5 BUE, [**2-28**] LLE, [**3-1**] R hip flexor, 3+/5 R foot
dorsi/plantar flexion. coordination intact FTN bilaterally with
slow deliberate movement. sensation intact to fine touch in the
BUE/BLE
Skin: pressure sores on sacrum. skin tears on anterior BLE
Pertinent Results:
Admission Labs [**2169-11-10**]:
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
.
GLUCOSE-30* UREA N-97* CREAT-1.5* SODIUM-136 POTASSIUM-5.4*
CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
.
WBC-10.1# RBC-3.33* HGB-10.9* HCT-33.0* MCV-99* MCH-32.7*
MCHC-32.9 RDW-18.3* PLT COUNT-323 NEUTS-74* BANDS-0 LYMPHS-11*
MONOS-13* EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
CXR PA and Lat [**2169-11-10**] Admission:
IMPRESSION: Partial interval clearing of known left lower lung
lobe consolidation.
.
LENIs [**2169-11-15**]: No evidence of DVT.
.
CXR [**11-13**]: IMPRESSION: AP chest compared to [**11-12**]:
Mild pulmonary edema which is new. There is also recurrence of
consolidation at both lung bases which could be atelectasis or
increasing moderate bilateral pleural effusion, but raises
concern for pneumonia. Heart is partially obscured by elevated
left hemidiaphragm but does not appear grossly enlarged. Tip of
left PIC catheter projects over the junction of the
brachiocephalic veins. Rightward displacement of the trachea at
the level of the aortic arch is due to tortuous head and neck
vessels as demonstrated by the CT of the chest on [**10-30**].
.
Chest CT [**2169-11-16**]:
1. As previously mentioned there is limited assessment for hilar
mass due to absence of intravenous contrast. If there is a
contraindication to iodinated contrast, the MRI of the chest
should be considered or a gadolinium injection in conjunction
with chest CT.
2. Worsening of left lower lobe atelectasis and development of
new scattered nodules and small areas of consolidation is highly
suspicious for recurrent aspirations. Infectious etiology is
superimposed on the recurrent aspirations cannot be excluded.
3. Small amount of ascites, unchanged.
.
Brief Hospital Course:
A/P: 85yoW with h/o COPD/Asthma, recurrent aspiration PNAs (s/p
g-tube placement), MAT, HTN, PVD, with recent admit for sepsis
in the setting of LLL pneumonia (MRSA by BAL) and UTI (resistant
pseudomonas), returned to hospital with hypoglycemia,
transferred to the ICU for recurrent episodes of hypoxemia,
likely secondary to mucous plugging/aspiration.
.
# Hypoxia: On the floor prior to MICU transfer, patient had 4
episodes over 72 hours of acute desaturation to 70-80's. During
these episodes she has become tachycardic to 120's and SBP has
dropped to 90's (diastolic CHF). She generally improves fairly
quickly to mid to upper 90's with supplemental oxygen (NC, face
mask, NRB). Triggers have included ?blood transfusion
(determined not to have been transfusion reaction) and pulmonary
toilet. These have occurred in the setting of intermittent low
grade fevers (99-101). EKGs are unchanged and LENIs negative
making ischemic or pulmonary embolis less likely. Acute event
precipitating [**Hospital Unit Name 153**] transfer likely [**12-29**] mucus plugging and/or
aspiration, on top of poor lung function at baseline from
aspiration PNA and LLL collapse. Sputum from [**11-20**] grew
Pseudomonas sensitive to Zosyn and MRSA and vanco, cipro, flagyl
changed to zosyn, vanco. Likely contribution of underlying
pneumonia. She was stable on 40% high flow O2 for most of her
MICU stay with persistent intermittent desaturations to high 80s
with subjective SOB. O2 sats improve with suctioning,
aggressive chest PT, nebulizers, and increase in FiO2. Following
improvement, she was quickly able to return to 40% O2. She was
quite deconditioned and was unable to clear her secretions which
was believed to have a significant contribution to
desaturations. Also possible contribution of volume overload and
was treated with diuresis. She was otherwise managed with
Advair, tiotropium, around the clock albuterol/atrovent nebs, as
well as prn albuterol nebs. She completed a 14 day course of
vancomycin on [**2169-11-30**]. Repeat sputum cultures showed rare GNRs.
She was continued on Zosyn to complete a 14 day course. She was
evaluated by Interventional Pulmonology for possible mini-trach
to aid in suctioning which the patient declined. However, her
oxygen requirement and secretions improved substantially. At the
time of discharge she had been stable on nasal cannula, had not
required deep suctioning in 3 days, and had no increased work of
breathing.
.
# Fever: Patient had low grade fevers since admission, without
leukocytosis or left shift. DDx was infection, atelectasis, and
much less likely malignancy. Possible sources of infection
included ?pna, candidal infection (oral thrush, groin
candidiasis and urinary yeast infection), PICC line infection,
g-tube infection, skin wounds. Pseudomonas UTI [**2169-10-29**] was
panresistant including resistance to meropenem. However, patient
was treated with meropenem with hope that high concentration in
urine would be adequate to eradicate infection and when admitted
with low grade fevers, no leukocytosis, and no left shift, she
had a clean UA and improved CXR. She finished her 14 day course
of vancomycin (for MRSA PNA) and meropenem (for pseudomonas UTI)
on [**11-12**] and they were discontinued on [**11-13**] in the AM. On
evening of [**11-13**] she had temp to 100.3 during transfusion and
cxr had ?RLL consolidation. She was restarted on tx for MRSA/asp
pna. Sputum culture grew MRSA and pseudomonas and was treated
with Zosyn and Vanco as above. Urine, stool, and blood cultures
were all negative throughout admission. She was afebrile at the
time of discharge off of all antibiotics.
.
# Asthma/COPD: She has distant smoking history with severe
reactive disease. Had persistent diffuse wheezing throughout
admission. Likely exacerbated by pneumonia. She was managed
with Advair, tiotropium, albuterol, and atrovent as above as
well as a steroid taper. She had received a 10 day taper of
steroids with her last dose of prednisone on [**11-24**], but steroids
were again restarted [**11-26**] as she was more bronchspastic. She
was initially restarted on Methylprednisolone 20 mg IV Q8H which
was then changed to 40 mg po prednisone. She completed 1 week of
40 mg prednisone which was then decreased to 30 mg daily. She
was discharged to complete a slow steroid taper.
.
# MAT: Patient with history of MAT, who came in not on a rate
controlling [**Doctor Last Name 360**] but has been controlled on diltiazem in the
past. During recent admissions she has been on 30mg QID but in
notes was on as high a dose as 90 QID. Patient has had several
episodes of tachycardia during hospitalization, especially
during hypoxemia. EKGs have all shown MAT with IVCD but no
ST-changes. She received diltiazem with minimal response and was
changed to verapamil. Verapamil was slowly uptitrated with
improvement in her tachycardia. Beta blockers were avoided in
setting of severe lung disease.
.
# Renal failure: Creatinine has been consistently elevated on
her multiple recent admissions and may reflect a new baseline
for her; appears to be 1.3-1.4. Her creatinine was slightly
elevated throughout admission but was otherwise stable. She did
have one jump in her creatinine thought to be secondary to
overdiuresis and then came back down with stoppage of her lasix.
However, she did havea significant increase in her BUN of
unknown etiology. Her standing lasix dose was stopped with
concern for overdiuresis.
.
# Anemia: Anemic at baseline, most recently hct running 29-32
and was stable at her baseline throughout admission.
.
# CHF: diastolic dysfunction on recent ECHO. Possibly
contributing to SOB. Her HR was managed with diltiazem and then
verapamil as above.
.
# Eosinophilia: Possible drug reaction. Began trending downward
(11->9->8.2->7.1) on [**11-23**]. Did improve off zosyn, but no other
signs of reaction to zosyn and seemed to start prior to zosyn
being started. She tolerated reinitiation of zosyn without
trouble. Eosinophils normalized without issue and remained
normal for the remainder of her admission.
.
# Steroid-Induced Diabetes: Patient's blood sugars are very
sensitive to steroids. She was discharged on a steroid taper and
standing long acting insulin. Patient developed hypoglycemia as
reason for admission in setting of not being on steroids,
standing insulin and having delays in her tube feeds. On
admission we discontinued her admission glargine 22U. However,
BGs increased with restart of steroids and lantus was restarted
and slowly uptitrated to obtain optimal BG control with
levels<150.
.
# Hilar Mass: seen on numerous non-contrast chest CT, not yet
characterized with contrast CT given poor renal function. Will
need biopsy once more stable and possible PET.
.
# Decubitus and stasis ulcer: managed per wound care recs.
.
# FEN: Strict NPO given history of aspiration. Probalance Full
strength; Goal rate: 50 ml/hr
.
# Code Status: Full code
.
# Contacts: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2916**] [**Telephone/Fax (1) 96596**]
Medications on Admission:
MVI liquid
Colace syrup [**Hospital1 **]
[**Doctor First Name **] 60mg daily
Advair 250/50 INH [**Hospital1 **]
Tiotropuim 1cap INH daily
Prevacid 30mg daily
Singulair 10mg daily
Lasix 60mg daily
Meropenem 500mg iv BID
Vancomycin 1g iv QOD
Neurontin 300mg daily
Lidoderm TP to right inner thigh, 12hr on/off
Lantus 22units QHS
Atrovent nebs TID
Tylenol prn
Milk of Mag prn
Dulcolax prn
Mylanta prn
Trazodone 50mg QHS prn sleeplessness
Ambien 10mg prn sleeplessness
Fibersource HN 50ml/hr continuous; flush with 100ml Q8hr
Discharge Medications:
1. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: Fifteen (15) PO BID
(2 times a day).
4. Fexofenadine 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
5. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Prevacid 30 mg Susp,Delayed Release for Recon [**Hospital1 **]: One (1)
PO once a day.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on/off.
8. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
9. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
every 4-6 hours as needed for SOB, wheezing.
10. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) puff Inhalation twice a day.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Verapamil 40 mg Tablet [**Last Name (STitle) **]: One [**Age over 90 8821**]y (140) mg PO
Q8H (every 8 hours).
13. Nitroglycerin 0.3 mg Tablet, Sublingual [**Age over 90 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. Zolpidem 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO HS (at bedtime)
as needed.
15. Insulin Glargine 100 unit/mL Solution [**Age over 90 **]: Fourteen (14)
units Subcutaneous at bedtime.
16. Prednisone 10 mg Tablet [**Age over 90 **]: Three (3) Tablet PO DAILY
(Daily): Take 3 tablets once daily for one week, followed by 2
tablets daily for one week, followed by one tablet daily
continuously until you see your pulmonologist.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
hyperkalemia
hypovolemia
Secondary:
resolving pseudomonal UTI (from last admission)
resolving MRSA pneumonia (from last admission)
Discharge Condition:
Stable. Satting fine on nasal canula
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml per day.
.
You came back into the hospital with dehydration, low blood
sugars and an elevated potasium. We rehydrated you and adjusted
your insulin and tube feeds.
.
We changed your furosemide back to 40mg every day. Please weigh
yourself daily. If you gain 2 or more pounds, please take an
extra 40mg dose of furosemide and check your weight again in the
morning. Repeat this for one day, then call a physician.
Followup Instructions:
Please follow up with the physicians at the rehab.
.
Please follow up with your PCP in the next 1-2 weeks.
|
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2,253
| 104,080
|
44338
|
Discharge summary
|
report
|
Admission Date: [**2110-4-2**] Discharge Date: [**2110-4-4**]
Date of Birth: [**2030-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
elective carotid stent
Major Surgical or Invasive Procedure:
carotid stents
History of Present Illness:
Mr. [**Known lastname 95068**] is a 79 year-old man with a history of a TIA about
3-4 years ago. On [**2110-3-8**], he was sitting at the breakfast table
when he an acute onset of decreased vision and blurriness in the
right eye. He was found to have approximately 75% stenosis of
his right carotid artery. He denies any slurred speech or right
sided weakness. There was no change in vision in the left eye.
A Carotid U/S on [**2109-7-23**] showed diffuse right ICA isoechoic wall
thickening
associated with a 60-69% ICA stenosis. Similar plaque on the
left, but to a lesser extent and unassociated with any
significant stenosis.
[**2109-7-26**] Echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. LV wall thickness, cavity size,
and systolic function normal (LVEF >55%).
[**2110-3-14**] Head/Brain/Carotid MRI/MRA: High grade stenosis
involving the right internal carotid artery just superior to the
common carotid bifurcation.
(+) HTN (+) hyperlipidemia (-) DM (-) cigarette smoking
Mf. denies claudication, PND, orthopnea, edema. He reports
occasional lightheadedness when he gets up too quickly.
ROS: (+) TIA (-) CVA (-) melana/GIB
Past Medical History:
prostate ca
right upper lobectomy for Stage I adencarcinoma of the lung
[**2109-8-5**]
right central retinal artery occlusion
carotid artery disease
left fem-[**Doctor Last Name **] bypass [**2096**] - per pt, no info found CCC
gallstones
TIA 3-4 years ago that lasted 20 seconds (slurred speech)
Social History:
He has been married 52 years.
Family History:
(-) FHx CAD
Physical Exam:
T 97.6, HR 49 BP 111/51 98% on RA, I/O 3800/1800
Gen: sleeping but pleasant and cooperative when awake
HEENT: MMM CN II-XII individually tested and intact except CN II
on the right which is chronic
Cor: RRR no M/R/G
Pulm: CTAB anteriorly
Abd: obese, soft NT ND
Ext: WWP, right groin with dressings C/D/I no hematoma or bruit,
DP 1+ bilaterally
Pertinent Results:
[**2110-4-4**] 05:35AM BLOOD WBC-5.2 RBC-3.93* Hgb-11.6* Hct-33.7*
MCV-86 MCH-29.5 MCHC-34.4 RDW-13.8 Plt Ct-192
[**2110-4-4**] 05:35AM BLOOD PT-13.4 PTT-25.6 INR(PT)-1.1
[**2110-4-4**] 05:35AM BLOOD Glucose-96 UreaN-19 Creat-1.2 Na-139
K-4.0 Cl-107 HCO3-27 AnGap-9
[**2110-4-3**] 02:03AM BLOOD CK(CPK)-61
[**2110-4-4**] 05:35AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
COMMENTS:
1. Retrograde access was obtained via the right common femoral
artery
for selective angiography of the subclavian, vertebral, and
carotid
arteries.
2. Limited resting hemodynamics revealed central hypertension
with
opening blood pressures of 180/74 mmHg.
3. Angiography demonstrated a type 1 aortic arch. Subclavian
arteries
were without angiographically significant, flow-limiting disease
or
gradient. The right common carotid artery was without flow
limiting
disease. The right internal carotid artery had an eccentric 90%
lesion
and filled the ACA and MCA. The right vertebral artery was small
and
totally occluded at the level of the basilar artery. The left
common
carotid arteyr and internal carotid artery were without
flow-limiting
disease. The left vertebral was without significant disease and
filled
the cerebellar circulation.
4. Successful placement of [**6-25**] x 40 mm AccuLink stent
postdilated with
a 4.5 mm balloon in the right internal carotid artery (ICA)
using
AccuNet filter distal embolic protection. Final angiography
demonstrated
a 20% residual stenosis, no angiographically apparent
dissection, and
normal flow (See PTCA Comments).
5. Successful placement of 6 French Angioseal device in right
femoral
arteriotomy without complications.
FINAL DIAGNOSIS:
1. Severe right internal carotid artery stenosis.
2. Successful placement of stent in right internal carotid
artery.
3. Successful use of filter embolic protection device.
4. Central hypertension.
5. Successful placement of Angioseal in right femoral
arteriotomy.
Brief Hospital Course:
Mr. [**Known lastname 95068**] is a 79 year-old man with a h/o TIA, recent right
eye vision
loss, high grade stenosis of the right ICA, referred for carotid
revascularization.
The carotid stents were placed without complication. The
patient's blood pressures were extremely labile overnight,
requiring both pressor support and intermittently labetolol
drip. As much as possible, his SBP was kept from 100-140. He was
also continued on plavix and aspirin. His neosynephrine was
weaned after one day and his blood pressure remained
normotensive with fewer swings. He was restarted on home
medications except for antihypertensives. Mr. [**Known lastname 95068**] was
discharged on day 2 with strict instructions to return to the
cath holding area for a blood pressure check and lab draw.
Medications on Admission:
Isordil 5mg TID
Lipitor 20mg daily
ASA 325mg daily
Plavix 75mg daily
Discharge Medications:
1. Aspirin 325 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. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
carotid stenosis
Discharge Condition:
stable
Discharge Instructions:
Please take aspirin and plavix.
Call your doctor for head ache, changes in vision, drooping
face, loss of sensation, weakness, or if there are any concerns
at all.
Come back to the cath lab holding area on Monday for a blood
pressure check and to have labs drawn.
Followup Instructions:
Provider: [**Name10 (NameIs) **] THORACIC MULTI SPEC-CC9 MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2110-4-17**] 2:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-9-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2111-2-16**] 2:15
Please call [**Last Name (LF) **],[**First Name3 (LF) **] L [**Telephone/Fax (1) 82541**] for an appointment in
the next 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"V10.46",
"401.9",
"997.91",
"V10.11",
"427.89",
"433.30",
"272.0",
"V70.7",
"V45.76",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5597, 5603
|
4282, 5071
|
336, 353
|
5663, 5671
|
2328, 3977
|
5984, 6795
|
1936, 1949
|
5190, 5574
|
5624, 5642
|
5097, 5167
|
3994, 4259
|
5695, 5961
|
1964, 2309
|
274, 298
|
381, 1550
|
1572, 1872
|
1888, 1920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,578
| 149,957
|
1383
|
Discharge summary
|
report
|
Admission Date: [**2185-8-4**] Discharge Date: [**2185-8-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Abdominal pain, coffee ground emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 8370**] is a [**Age over 90 **]yo female with PMH significant for CAD,
diastolic CHF, and diabetes. Per patient, she had dinner
yesterday evening. Following dinner she had abdominal pain which
she describes as indigestion like symptoms. She went to bed but
given persistence of pain she was brought to [**Hospital1 18**] ED via
ambulance. During her transport she had an episode of coffee
ground emesis.
.
In the ED her initial vitals were T 98.6 BP 129/58 AR 70 RR 16
O2 sat 97% RA. She received Protonix 40mg IV x1, Pepcid 20mg IV
x1, Zofran, D5W + 150meQ HCO3, and 1L NS. Patient was NG lavaged
with 500cc NS but coffee grounds did not clear. Patient's SBP
also dropped transiently to 70's and then quickly increased to
120's. No further episodes of hypotension since then.
.
Patient admits to feeling weak over the past week but denies any
dizziness, bloody/black tarry stools, or any other concerning
symptoms.
Past Medical History:
1. CAD, s/p MI [**5-23**] (no intervention)
2. CHF, EF > 55% (TTE [**5-24**])
3. HTN
4. NIDDM
5. Colon Ca, s/p resection [**9-22**]
6. Cellulitis
7. Osteoporosis
8. Urinary incontinence
Social History:
SH - Pt lives with her daughter at home, with PT and homemaker
services. She is widowed, has two adopted children. No
tobbaco/EtOH/drugs.
Family History:
FH - Mother died of MI, father died of prostate cancer
Physical Exam:
vitals T 97.3 BP AR 98 RR 14 O2 sat
Gen: Pleasant female,
HEENT: MMM
Heart: RRR, no m,r,g
Lungs: +crackles @ posterior lung bases
Abdomen: soft, distended, tympanitic, + bowel sounds, mildly
tender to palpation
Extremities: [**2-20**]+ bilateral edema, pulses difficult to palpate
given degree of swelling
Rectal: guiac negative
Pertinent Results:
[**2185-8-4**] 06:27PM WBC-6.9 RBC-3.29* HGB-10.4* HCT-30.8* MCV-94
MCH-31.7 MCHC-33.8 RDW-16.2*
[**2185-8-4**] 06:27PM PLT COUNT-237
[**2185-8-4**] 05:36AM URINE HOURS-RANDOM
[**2185-8-4**] 05:36AM URINE GR HOLD-HOLD
[**2185-8-4**] 05:23AM URINE TYPE-RANDOM COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-1.010
[**2185-8-4**] 05:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2185-8-4**] 04:17AM COMMENTS-GREEN TOP
[**2185-8-4**] 04:17AM HGB-11.9* calcHCT-36
[**2185-8-4**] 04:09AM WBC-8.9 RBC-3.47* HGB-11.3* HCT-32.8* MCV-95
MCH-32.4* MCHC-34.3 RDW-15.9*
[**2185-8-4**] 04:09AM NEUTS-84.1* BANDS-0 LYMPHS-13.7* MONOS-1.3*
EOS-0.7 BASOS-0.2
[**2185-8-4**] 04:09AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2185-8-4**] 04:09AM PLT SMR-NORMAL PLT COUNT-253
[**2185-8-4**] 01:19AM COMMENTS-GREEN TOP
[**2185-8-4**] 01:19AM K+-4.5
[**2185-8-3**] 11:53PM GLUCOSE-186* UREA N-53* CREAT-1.6* SODIUM-138
POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-29 ANION GAP-20
[**2185-8-3**] 11:53PM estGFR-Using this
[**2185-8-3**] 11:53PM ALT(SGPT)-15 AST(SGOT)-34 ALK PHOS-80
AMYLASE-111* TOT BILI-0.5
[**2185-8-3**] 11:53PM LIPASE-47
[**2185-8-3**] 11:53PM ALBUMIN-4.2
[**2185-8-3**] 11:53PM WBC-9.3# RBC-3.74* HGB-12.2 HCT-35.0* MCV-94
MCH-32.7* MCHC-35.0 RDW-16.0*
[**2185-8-3**] 11:53PM NEUTS-80.1* LYMPHS-17.0* MONOS-2.2 EOS-0.6
BASOS-0.1
[**2185-8-3**] 11:53PM PLT COUNT-261
Relevant Imaging:
1)CT scan abdomen/pelvis ([**2185-8-4**]): 1. Multiple dilated bowel
loops for which a small-bowel obstruction should be considered.
Although there is a small amount of fluid within small bowel
containing anterior abdominal wall hernia, transition point
likely lies in the
mid anterior abdomen. 2. Large hiatal hernia. 3. Marked
degenerative osteoarthritis and osteoporosis with compression
deformities of L1, L2, and L3.
CHEST (PA & LAT) [**2185-8-7**] 5:57 PM
No active pulmonary changes other than very small amount of left
lower lobe atelectasis.
ECG: ([**2185-8-4**])
Atrial fibrillation with controlled ventricular response. Low
limb lead
voltage. Right bundle-branch block. Compared to the prior
tracing
of [**2183-8-3**] atrial fibrillation has appeared.
Brief Hospital Course:
A/P: Ms. [**Known lastname 8370**] is a [**Age over 90 **]yo female with CAD, DM, and CHF who
presents with coffee ground emesis and possible SBO on CT scan.
.
MICU Course
-------------
Patient transfused and stabilized, transferred to floors. Please
see below for details.
General Wards Course
1)Coffee ground emesis: Suspected to have come from upper
gastrointestinal source though this could not be confirmed. GI
was involved in case and helped in management. Patient was given
2 units of packed red blood cells and [**Last Name (un) **]-gastric tube was
placed without any bloody fluids retrieved. She remained
hemodynamically stable with systolic blood pressures greater
than 100 and had GUAIAC negative stools in the floors. We held
aspirin as patient may have had gastric erosion causing bleeding
and platelet inhibition was inappropriate in setting of acute
bleeding. Will defer decision to re-start aspiring to outpatient
team.
2) Partial small bowel obstruction: Patient initially presented
with subjective complaint of nausea and abdominal pain. CT Scan
revealed dilated small bowel loops with air-fluid levels.
Patient decompressed well with nasogastric tube and began
passing both stool and gas without difficulty. No further
characterization of partial obstruction was performed as
symptoms resolved.
3)Coronary heart disease/ Congestive heart failure: Patient had
no chest pain during hospitalization and no changes were seen on
ECG. Aspirin and anti-hypertensive were held for bleeding and
resultant hypotension. Patient is discharged on Atenolol only as
she is no longer requiring any other antihypertensives.
4)Chronic renal insufficiency: Patient presented with creatinine
above her baseline, most likely secondary to pre-renal azotemia.
She was fluid replete and responded well with creatinine at time
of discharge of 1.2 and normal electrolytes.
5)Diabetes: Because patient was at NPO status during
hospitalization, we stopped oral antihyperglycemics and placed
her on an insulin sliding scale. Because she is being discharged
with a modified diet (see below) we will continue sliding scale
insulin until she resumes habitual eating. Defer further
management to outpatient team.
6)Dysphagia: Patient found to have significant difficulty
protecting her airway with witnessed chocking event. Speech and
swallow team was consulted and their impression is that there is
moderate dysphagia that can be reasonably managed with honey
thickened fluids and soft solids. Patient is being discharged
with these restrictions and speech pathology will continue to
assess patient at rehab facility.
7)Atrial fibrillation: Incidentally found on ECG during
admission, because of active bleeding patient is not a candidate
for anticoagulation at this point. Will defer further management
to primary care team.
8)FEN: Discharged on honey thickened liquids and soft solids,
please crush all pills and give with puree.
9)Prophylaxis: Patient placed on PPI
10)Communication: Contact person was her daughter throughout
admission.
11)Code: Patient remained full code throughout admission, status
confirmed with patient upon arrival to floor.
Medications on Admission:
Lasix 80mg PO QAM
Glyburide 1.25mg PO QPM, 2.5mg PO QAM
Atenolol 25mg PO daily
Lisinopril 2.5mg PO daily
Lipitor 40mg PO QHS
Isosorbide 60mg PO QHS
Levothyroxine 0.05 PO daily
ASA 81mg PO daily
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day. Tablet,
Delayed Release (E.C.)(s)
4. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding
scale Injection ASDIR (AS DIRECTED): Please see attached
sliding scale.
5. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
6. Vitamin B-12 1,000 mcg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO every other day.
7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
8. Theragran Capsule Sig: One (1) Capsule PO once a day.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain.
10. Nasacort AQ 55 mcg Aerosol, Spray Sig: One (1) puff Nasal
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY
1. UPPER GASTROINTESTINAL BLEED
2. DYSPHAGIA
3. ANEMIA
4. ATRIAL FIBRILLATION
SECONDARY
1. CONGESTIVE HEART FAILURE
2. URINARY INCONTINENCE
3. DIABETES
4. OSTEOPOROSIS
Discharge Condition:
Hemodynamically stable, tolerating thickened liquids, afebrile
and able to ambulate with assistance of walker.
Discharge Instructions:
You were admitted to the hospital because you were vomiting what
appeared to be bloddy fluid. We also found your abdomen to be
distended and were concerned about an obstruction in your
feeding track. During your hospitalization, we transfused you
with blood and monitored you for any more bleeding. Your
distension improved and you now have no signs of bleeding.
We also were concerned for your ability to swallow and performed
special studies to evaluate it. Though you are having some
problems, we believe we can help you by giving you thick liquids
and soft foods.
Please keep all doctor appointments and take all medications as
prescribed. If you develop any more vomiting, nausea, diarrhea,
or develop chest pain or shortness of breath or feel ill, please
call your primary care physician or come into the emergency
department for evaluation.
Followup Instructions:
Please call ([**Telephone/Fax (1) 6846**] to schedule an appointment with your
primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2 weeks of returning
home.
|
[
"535.41",
"733.00",
"V10.05",
"285.9",
"788.30",
"428.0",
"584.9",
"560.9",
"414.01",
"250.00",
"403.90",
"428.32",
"427.31",
"585.9",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8748, 8818
|
4416, 7569
|
297, 303
|
9039, 9152
|
2074, 3605
|
10050, 10253
|
1653, 1709
|
7814, 8725
|
8839, 9018
|
7595, 7791
|
9176, 10027
|
1724, 2055
|
221, 259
|
3623, 4393
|
331, 1271
|
1293, 1481
|
1497, 1637
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,104
| 198,207
|
43921
|
Discharge summary
|
report
|
Admission Date: [**2117-10-6**] Discharge Date: [**2117-10-9**]
Date of Birth: [**2058-12-19**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Portacath removal ([**2117-10-7**])
History of Present Illness:
This is a 58 year-old male with a history of pancreatic cancer
diagnosed [**11-5**] s/p whipple [**11-5**] who presents with fever to
102.8. Patient had a similar admission in [**8-6**] here for similar
reasons. Both times, the fever started shortly after port
access. During his admission in [**Month (only) **], no positive blood
cultures, negative urine cx, negative cxr, negative echo. Was
diagnosed with supraventricular tacchycardia and was given
adenosine and then lopressor to take at home. He was treated
with vanc and ceftriaxone and then ciprofloxacin and improved.
He usually feels ill about 48 hours after port access for
chemotherapy but it is unclear if this is the chemotherapy or
infection. The port was placed at [**Hospital1 112**] in [**Month (only) **]. On Monday,
he had his port accessed for labs and he began to feel like he
was "coming down with a cold" on tuesday afternoon. He went to
work today and around noon felt weak, developed abdominal pain
radiating to his left shoulder, one episode of vomiting and low
grade temp to 99. He went to the ED where his temp rose to 102.9
and he experienced rigors. He denies headache, meningismus, cp,
sob, cough, change in abd pain from baseline, diarrhea, change
in bowel habits, dysuria, rash, joint pain, hematochezia or
melena. No sick contacts. Traveled to [**State **] this weekend for
a conference but was only in hotels/airport. No hiking or
outdoor activities. Of note, his labs on monday for tumor lysis,
lfts were normal and crit was 34 per patient.
.
In the ED, vs were: 99.4 111 117/70 16 96% RA initially. Mild
epigastric tenderness. Guaic negative stool. Prostate exam
normal. UA negative. He received 4 liters IVF. CXR negative. HR
130s. EKG showed sinus tacchycardia. Received lovenox for ? PE
since he couldnt get CTA because of contrast allergy. Temp rose
to 102.8, gave tylenol. Received vanc and levaquin. Shortly
after receiving the abx, his lips swelled and he developed
hives. He received benadryl and pepcid and this resolved. He has
received those antibiotics multiple times in the past and has
never had a reaction. Of note, per wife, the vanco was given
slowly so red man syndrome less likely.
.
In the ICU, initial vs were: 99.6 103 125/78 90 20 93% RA.
Patient reported feeling better. Denied ha, dizziness, cp, palp,
sob, cough, abd pain, nausea, etc.
.
ROS: see hpi
Past Medical History:
Past Oncologic History:
- developed painless jaundice in [**11-5**]
- diagnosed with pancreatic adenocarcinoma
- underwent Whipple in [**11-5**] at [**Hospital1 2025**] -> had clear margins, but ?
of 2 positive lymph nodes
- complicated by intra-abdominal hemorrhage, hematoma/abscess
formation and sepsis which required multiple drainages
- treated with gemcitabine
- then 5FU continuous infusion, XRT (6 weeks) and low dose
gemcitabine
- XRT completed in [**5-6**]
- last dose of gemcitabine was the second week in [**Month (only) 462**]
(receives this with decadron)
.
Other PAST MEDICAL HISTORY:
- SVT
- restless leg syndrome
- BPH s/p TURP in end [**6-6**] -> had urinary obstruction/hydro
prior
- HTN
Social History:
Dr. [**Known lastname 94286**] is a faculty member here who specializes in HIV
vaccine research. He is married and his wife is also on faculty
here (neurology). No tobacco, etoh, drug use. Recent travel to
[**State **] without outdoor activities. No recent sick contacts.
Family History:
Father had CABG in his 60s, died of CAD at age [**Age over 90 **]
No family history of DM, lung disease, kidney disease
No family history of bleeding, clotting, cancer
Physical Exam:
Tmax: 37.7 ??????C (99.8 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 100 (100 - 115) bpm
BP: 138/88(100) {122/77(87) - 138/88(100)} mmHg
RR: 17 (17 - 23) insp/min
SpO2: 93%
Heart rhythm: SR (Sinus Rhythm)
Height: 63 Inch
GEN: Well-appearing, thin, no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MM dry, OP Clear, no thrush or oral lesions
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline, no meningismus
COR: tacchy, RR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs dullness at the R lung base, no W/R/R
ABD: Soft, mild tenderness in epigastrium, ND, +BS, no HSM, no
masses, no rebound or guarding, well-healed scar from whipple
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
BACK: no spinal tenderness
Pertinent Results:
.
[**2117-10-8**] MRI Abdomen
FINDINGS: The patient is status post Whipple with expected
postoperative
anatomy and anastomoses. There is expected pneumobilia. In
addition, there
is mild intrahepatic biliary ductal dilation, preferentially
within the left system, and also involving the posterior right
biliary duct which arises from the left system, an anatomic
variant. The pre-contrast study demonstrates even more prominent
left ductal dilation. There are equivocal areas of stenosis in
the peripheral left system without evidence of central stenosis,
although the evaluation of stenosis is limited by the presence
of pneumobilia. In the left lobe of the liver, there is subtle
hyperemia in the arterial phase without evidence of abnormality
in signal on the T2-weighted images suggestive of edema. No
enhancing liver lesions are identified. The gallbladder is
surgically absent. Nodularity of the right adrenal gland is
stable compared to the preoperative study. The left adrenal
gland and spleen appear unremarkable. The pancreatic parenchyma
enhances homogeneously. The pancreatic duct is not dilated. The
kidneys enhance and excrete contrast symmetrically without
hydronephrosis. There are bilateral nonenhancing renal cysts.
There is mild perinephric fluid bilaterally, right greater than
left. There is mild thickening of the right lateral conal fascia
which is probably postoperative. Small foci of blooming artifact
on the gradient-echo sequences within the mesentery near the
area of surgery are likely related to hemosiderin and
postoperative change. No evidence of new mass or lymphadenopathy
is appreciated. The signal within the bone marrow appeared to be
normal limits. The lung bases demonstrate small bilateral
pleural effusions and associated atelectasis, right greater than
left.
IMPRESSION:
1. Subtle hyperemia in the left lobe of the liver without
evidence of edema, fluid collection, or central biliary
stenosis. Equivocal stenosis in the periphery of the left
biliary system is difficult to evaluate given the presence of
pneumobilia. Findings could represent subclinical cholangitis,
given biliary anastomoses.
2. Bilateral small pleural effusions, right greater than left,
with
associated atelectasis.
3. Stable nodularity in the right adrenal gland, unchanged from
preoperative study.
[**2117-10-6**] 11:37PM GLUCOSE-125* UREA N-16 CREAT-1.2 SODIUM-140
POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-17* ANION GAP-15
[**2117-10-6**] 11:37PM CALCIUM-7.7* PHOSPHATE-3.2 MAGNESIUM-1.4*
[**2117-10-6**] 11:37PM TSH-2.4
[**2117-10-6**] 11:37PM WBC-12.2*# RBC-3.37* HGB-10.6* HCT-31.9*
MCV-95 MCH-31.5 MCHC-33.3 RDW-14.1
[**2117-10-6**] 11:37PM NEUTS-73* BANDS-22* LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2117-10-6**] 11:37PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2117-10-6**] 11:37PM PLT COUNT-197
[**2117-10-6**] 06:12PM COMMENTS-GREEN TOP
[**2117-10-6**] 06:12PM LACTATE-1.6
[**2117-10-6**] 02:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2117-10-6**] 02:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2117-10-6**] 02:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2117-10-6**] 01:53PM COMMENTS-GREEN TOP
[**2117-10-6**] 01:53PM LACTATE-3.1*
[**2117-10-6**] 01:40PM GLUCOSE-144* UREA N-23* CREAT-1.5* SODIUM-137
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
[**2117-10-6**] 01:40PM estGFR-Using this
[**2117-10-6**] 01:40PM ALT(SGPT)-57* AST(SGOT)-98* ALK PHOS-173* TOT
BILI-0.7
[**2117-10-6**] 01:40PM LIPASE-10
[**2117-10-6**] 01:40PM ALBUMIN-4.3
[**2117-10-6**] 01:40PM WBC-7.4# RBC-3.89*# HGB-12.5*# HCT-36.9*#
MCV-95 MCH-32.2* MCHC-33.9 RDW-14.1
[**2117-10-6**] 01:40PM NEUTS-93.6* LYMPHS-3.5* MONOS-0.6* EOS-2.2
BASOS-0.1
[**2117-10-6**] 01:40PM PLT COUNT-254
Brief Hospital Course:
58 year-old male with a history of pancreatic cancer who
presents with fever and tachycardia.
# Fever: Patient with fever to 102 and leukocytosis. This is
most likely an infectious in etiology. The differential includes
portacath infection given recent manipulation and timing of the
onset. The port was last accessed on monday. Blood cultures
drawn peripherally but not from port. The patient also report
abdominal pain and has h/o abdominal abscess, but patient has
had pain at baseline. CXR today showed haziness in R lower base
concerning for early pna vs pulmonary edema. UA negative
making pna and UTI unlikely. Pt has elevated liver enzymes that
were normal on monday per patient. Could be elevated in setting
of sepsis. No change in bowel habit, no signs of menigitis, no
murmur on exam to suggest endocarditis. Tick borne disease
unlikely as pt does not have any pets and does not do outdoor
activities at all. No new drugs to suggest drug fever. Empiric
broad spectrum antibiotics for possible line
infection/intrabdominal process: linezolid, cefepime and flagyl
given possible allergy to vanc and levaquin? MRI of abdomen was
performed and found no intrabdominal abscess but subclinic
cholangisit. ID was consulted and thought it was ok to discharge
him on PO Augmetin for one week to follow up with primary
providers.
.
# Tacchycardia: Patient's HR was consistently 110-120s here.
Patient's ekg was c/w sinus tacchycardia. He is mildly fluid
responsive. This could be due to sepsis as above. Pt high risk
for PE given onc hx, but no other signs of PE. Not anemic,
anxious or in pain. His BB was held.
.
# H/O SVT, currently sinus tacchycardia on ekg. Held metoprolol
given patient is febrile and may be peri-septic. Held BB at
discharge per patient request.
.
# ARF: likely prerenal in setting of possible sepsis
.
# Transaminitis: likely related to volume depletion and sepsis.
Since lfts were normal 2 days ago, liver abscess unlikely. Tbili
normal. Trended down.
.
# Anemia: crit at baseline to slightly higher. He is most likely
hemoconcentrated.
.
# Pancreatic cancer: defer to primary onc team
.
# Restless leg: cont mirapex
.
# HTN: hold lopressor
.
# GERD: cont prilosec
.
# General Care: replete lytes prn, IVF boluses prn MAP < 65,
npo given possible port removal in am, Access : portacath , one
[**Last Name (LF) **], [**First Name3 (LF) **] place another [**First Name3 (LF) **], PPx: prilosec, sub q heparin, bowel
regimen, Code: Full- confirmed, Discharged in good condition.
Comm: wife is Dr. [**Last Name (STitle) **] [**Numeric Identifier 94287**] pager.
Medications on Admission:
Mirapex 0.125 mg qhs
Prilosec 20 mg qhs
Lopressor 12.5mg PO BID
pancrease 2-3 tabs with meals
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs ().
4. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12 hr
Sig: One (1) Tablet Sustained Release 12 hr PO twice a day for 7
days.
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Sepsis from Port infection
.
Secondary Diagnosis:
Pancreatic Cancer
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with fevers a couple of days after having your
port accessed. Because of the concern of sepsis, you were
admitted to ICU were you were given broad spectrum antibiotics.
An MRI of your abdomen was peformed which ruled out a fluid
collection. You were seen by the ID specialists who feel it is
safe to send you home on oral antibiotics.
.
Your medication regimen remains the same except for we started
you on Augmentin XR twice a day for 7 days.
.
Please follow up with Dr. [**First Name (STitle) **], your oncologist.
.
If you develope any of the following, chest pain, shortness of
breath, palpatations, worsening of you abdominal pain, worsening
diarrhea, fevers or chills, or nausea and vomiting, please call
your doctor or go to your local emergency room.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **], your oncologist and Dr. [**Last Name (STitle) 2093**]
your primary care doctor.
Completed by:[**2117-10-9**]
|
[
"584.9",
"276.50",
"V10.09",
"038.9",
"530.81",
"E930.8",
"V15.3",
"401.9",
"996.62",
"E878.1",
"708.0",
"333.94"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
12237, 12243
|
8966, 11560
|
291, 328
|
12374, 12383
|
4996, 8943
|
13210, 13375
|
3762, 3932
|
11705, 12214
|
12264, 12264
|
11586, 11682
|
12407, 13187
|
3947, 4977
|
246, 253
|
356, 2725
|
12333, 12353
|
12283, 12312
|
3348, 3457
|
3473, 3746
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,362
| 151,053
|
33159
|
Discharge summary
|
report
|
Admission Date: [**2181-4-16**] Discharge Date: [**2181-4-18**]
Date of Birth: [**2158-5-11**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Levofloxacin
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Hyperkalemia, shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 76867**] is a very nice 22-year-old woman with MPGN
s/p renal transplant ([**7-12**]) and recurrent MPGN with removal of
transplanted kidney on [**2179-7-7**] who was on PD until [**2181-3-22**] when
she developed peritonitis and recently started on HD who comes
with chest pain and shortness of breath. She was in her usual
state of health until today around 8:00 AM when she woke up and
started with sudden dull retro-sternal chest pain [**7-17**] without
any radiation, associated with shortness of breath. She had
difficulty doing 1 flight of stairs having to slow down her
pace. Her symptoms did not change with position or activity, but
the pain is worse with deep breath. She had chills, did not take
her temperature and also reports non-productive cough. Since she
started HD she has been having bitemporal headache, which is
unchanged and improves with eccedrin. She has not had urine
output for >2 years. She has a glass of [**Location (un) 2452**] juice at least
daily, reports no change in her medications, no muscle
relaxants, changes in diet, having salt-replacement, diuretics,
steroids. She also denies muscle spasm, muscle cramps, etc.
Occasional dry mouth.
Of note, she was admitted on [**2181-3-22**] for abdominal pain and was
diagnosed with peritonitis with WBC [**Numeric Identifier 77069**] and 94% PMNs in her
peritoneal fluid. There were no bacteria seen in gram stain (at
[**Hospital1 18**]) and cultures are negative so far. She was treated with
Vanc/Ceftaz to complete a 2 week course. Her PD catheter was
pulled. The peritoneal cultures from [**Hospital6 2561**] came
back positve for paecilomyces lilanacus in [**12-9**] bottles from the
peritoneal fluid. She was seen by ID who thought it was a
contaminant and subsequent blood cultures have been negative.
The plan was to put PD catheter this week and go back to PD.
In the emergency room her initial VS were T 100.4? (recorded
10.4) F, HR 109 [**Doctor First Name **], BP 185/131 mmHg, RR 20 X', SpO2 100% in RA.
She was in NAD, chest CTAB, no murmurs, abdomen soft,
non-tender, guaiac negative. Her labs were significant for WBC
of 10.5 (85% PMNs, 8% L, no bands), HCT 26.9 at her baseline
(was 21 recently), PLT of 391, K 8.6, Na 142, Cl 100, CO2 26,
Glu 89, lactate 1.5. ECG showed peaked TW with QRS of 70 ms per
report (normal ECG upon review) and no S1Q3T3 or any signs of RV
strain. Patient was administered calcium gluconate 4g, Dextrose
50% 50mL with 10 U of R Insulin, Sodium Bicarbonate 50mEq,
Sodium Polystyrene Sulfonate, 8 mg of IV morphine and 10 mg of
IV compazine. Her repeat labs showed K of 6.7 with creatinine of
8.9 and BUN of 50, INR 1.2, PTT 27.7. Repeat ECG showed
worsening compared to prior (real peak TW), despite therapy. CXR
showed marked interstitial markings with bibaslilary alveolar
infiltrates. ER attendings thoguht that her clincal picture was
much more compatible with PE compared to healthcare acquired
pneumonia, so he tested her HCG was HCG:<5 and then she
underwent CT chest with contrast, which showed bilateral
ground-glass opacities without evidence of PE. Pt received
Levofloxacin in ER. She was very difficult access and they could
only place a 20G (required femoral stick for labs). Her VS prior
to transfer were HR 122 BPM, BP 167/114 mmHg, RR 25 X', SpO2 95%
RA.
Past Medical History:
1) MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post
transplant pt was doing well, but had rising Cr for two year. In
[**6-/2178**] pt presented with uncontrolled BP requiring ICU
admission for Isradipine drip. Repeat biopsy showed a type 1
MPGN. Negative HepC,HepB,[**Doctor First Name **], and renal U/S from NMEC showed
stable AVF. Her creatinine peaked to 4's and she was started on
steroids, prograf and cellcept. In [**1-/2179**], she required 3
sessions of HD through a right upper chest catheter. Creatinine
slowly recovered to 3.2. Plasmapheresis was then initiated with
plan to then treat with Rituximab. She only underwent 3 sessions
of pheresis. She is now transferred her care to Dr. [**Last Name (STitle) **]
at [**Hospital1 18**] to an adult clinic. Her transplant was removed on
[**2179-7-7**]. She was started on PD until [**2181-3-22**] when she developed
peritonitis and she was switched to HD (HD tunnelled line -
M/W/F - [**Location (un) 47**]).
2) Peripheral edema and abdominal striae [**1-9**] steroids
3) HTN [**1-9**] steroids and renal disease, multiple admissions for
Hypertensive emergency.
4) H/o Hemolytic Anemia
5) Migraines
Social History:
Lives at home with parents, brother and sister, college student
at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Drinks alcohol socialy,
drinking 1-2 drinks when she goes out (once a week). Denies
illicit drugs, tobacco.
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
VITAL SIGNS - Temp 100 F, BP 159/112 mmHg, HR 120 BPM, RR 12 X',
O2-sat 96% 1 L NC
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
not jaundiced (skin, mouth, conjuntiva), HD catheter looks clean
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
dry mucous membranes, no erythema in pharynx, no saddle nose
deformity, no lymphadenopathy
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - bibasilary crackles, mild ronchi bilateraly, good air
movement, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-11**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
Labs at Admission:
[**2181-4-15**] 08:30PM BLOOD WBC-10.5 RBC-2.75* Hgb-8.0* Hct-26.9*#
MCV-98 MCH-29.3 MCHC-29.9* RDW-18.0* Plt Ct-391
[**2181-4-15**] 08:30PM BLOOD Neuts-84.8* Lymphs-8.2* Monos-2.9 Eos-3.7
Baso-0.5
[**2181-4-15**] 11:31PM BLOOD PT-14.1* PTT-27.7 INR(PT)-1.2*
[**2181-4-15**] 11:00PM BLOOD UreaN-50* Creat-8.9*# Na-142 K-6.7*
Cl-104 HCO3-24 AnGap-21*
[**2181-4-15**] 11:00PM BLOOD CK(CPK)-21*
[**2181-4-16**] 02:59AM BLOOD ALT-7 AST-9 LD(LDH)-224 AlkPhos-106*
TotBili-0.1
[**2181-4-15**] 11:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2181-4-16**] 02:59AM BLOOD Albumin-3.1* Calcium-8.8 Phos-4.9* Mg-2.2
Iron Studies:
[**2181-4-16**] 06:49AM BLOOD Iron-12*
[**2181-4-16**] 06:49AM BLOOD calTIBC-204* VitB12-429 Folate-8.8
Ferritn-211* TRF-157*
Micro Data:
[**2181-4-16**] BLOOD CULTURE Blood Culture, Routine-
negative
[**2181-4-16**] MRSA SCREEN MRSA SCREEN- pending
[**2181-4-15**] BLOOD CULTURE Blood Culture, Routine-
negative
Imaging Studies:
CTA chest ([**2181-4-16**])
IMPRESSION:
1. No evidence of central, segmental or subsegmental pulmonary
embolism.
2. Multifocal mixed ground-glass opacities indicating pulmonary
edema, but
some small nodular opacities raise the possibility of
superimposed infection in the right clinical setting, atypical
etiologies including PCP are possible.
The study and the report were reviewed by the staff radiologist.
CXR PA and LAT ([**2181-4-16**])
The heart size is mildly enlarged. The aorta is tortuous. No
pneumothorax is detected. There are new bilateral perihilar and
bibasilar densities which are concerning for fluid
overload/heart failure. Small right pleural effusion is noted.
The dialysis catheter distal tip projects at the expected
location of the cavoatrial junction. The study and the report
were reviewed by the staff radiologist.
Brief Hospital Course:
Ms. [**Known firstname **] [**Known lastname 76867**] is a very nice 22-year-old woman with MPGN
s/p renal transplant ([**7-12**]) and recurrent MPGN with removal of
transplanted kidney on [**2179-7-7**] who was on PD until [**2181-3-22**] when
she developed peritonitis and recently started on HD who comes
with chest pain and shortness of breath.
# Hyperkalemia - Patient with known end-stage kidney disease
secondary to MPGN s/p failed kidney transplant, who was on PD
and recently had peritonitis and was switched to HD who had last
HD session last [**Month/Day/Year 2974**] at [**Location (un) 47**] without any complications
who came with a K of 8.6 and peaked TW on ECG without any
changes in the QRS. Pt already received Kayexelate, Ca
gluconate, Insulin/D50% and bicarbonate. No bowel movements yet.
No clear precipitant, no changes in medications, no missed HD
sessions, no ischemic areas, no hemolysis. RTA is very unlikely.
Her pneumonia (see below) may have precipitated her not to drink
fluids and hydrate herself and be hemoconcentrated. She
underwent HD on the first hospital day and continued HD during
the admission per her outpatient nephrologist. She will
follow-up for scheduled HD two days after discharge, per her
usual outpatient regimen.
# Healthcare Acquired Pneumonia (HCAP) - Pt with chest pain,
shortness of breath, slight leukocytosis with left-shift and
bilateral ground-glass opacities on CT scan without any evidence
of PE. She has received broad-spectrum antibiotics within the
last 90 days (finished Vanc/Cefepime on [**4-3**]) and has been
hospitalized >2 days in the last 3 months. Therefore she was
treated as HCAP with vancomycin, cefepime, and azithromycin (day
1 = [**4-15**]). When she improved clinically, the regimen was switched
over to azithromycin alone. She received in total three days of
intravenous broad-spectrum antibiotics and will complete a
five-day course of azithromycin.
# Chronic Kidney Disease - Patient is stage V CKD, followed by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 118**], who gets HD M/W/F at [**Location (un) 47**]. Her last PTH
was 80 at goal (Goal 150-300) on vitamin D, calcitriol and
phosphate binders as well as a calci-mimetic. Her outpatient
nephrology team was involved in her care during this admission
and assisted with hemodialysis orders.
# Hypertension - Patient with uncontrolled hypertension in the
setting of renal failure. Blood pressure was initially elevated
to 160s/110s and was treated with prn doses of labetalol. Given
that her blood pressures remained elevated even after fluid
removal in HD, she was started on labetalol and amlodipine. She
will continue these medicines until follow-up with her
outpatient nephrology team.
# Anemia - Patient with MCV 98 and MCH 29.3 and RDW 18.0 and HCT
at baseline of 26. Her home iron tablets were continued during
this admission.
# FEN - Regular renal low phosphate diet. Of note, patient
received diet teaching from the nutrition service during this
admission for low potassium, low phosphorous diet.
# Access - Peripheral IV x1.
# PPx -
-DVT ppx with heparin SQ
-Bowel regimen colace/senna
-Pain management with dilaudid IV given CKD
# Code - Full code.
# Dispo - ICU until K stable. Discharged home from the ICU on
the third hospital day.
# Contact - Mother [**Name (NI) 382**] [**Name (NI) 4489**] [**Name (NI) 76867**] [**Telephone/Fax (1) 76870**] and
[**Telephone/Fax (1) 76871**].
Medications on Admission:
Sevelamer 3200 mg PO TID w/meals
Calcitriol 0.25 mcg PO Daily
Cinacalcet 60 mg PO Daily
B Comple-Citamin C-Folic Acid 1 mg PO Daily
Docusate Sodium 100 mg PO BID PRN constipation
Senna 8.6 mg PO BID PRN Constipation
Percocet 5/325 mg PO q6hrs PRN pain
Diphenydramine HCL 25 mg PO q6 hrs PRN itching
Iron 325 mg Daily
Discharge Medications:
1. Sevelamer Carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itch / insomnia.
11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*0*
14. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
Pneumonia
Hyperkalemia
Hypertension
Secondary Diagnoses
End stage renal disease secondary to MPGN
Migraine headaches
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 treatment of high
potassium levels in the blood and also for pneumonia. You were
treated with a three-day course of intravenous antibiotics and
transitioned to oral antibiotics at the time of discharge. In
addition, we noticed that the blood pressure was elevated during
this admission and as a result we started two medicines for
better blood pressure control. You will have a dialysis session
on [**Telephone/Fax (1) 2974**].
We made the following changes to your medicines:
- we ADDED azithromycin. Please take three more days to complete
a five-day course.
- we ADDED labetalol for high blood pressure.
- we ADDED amlodipine for high blood pressure.
There were no other changes to your medicines.
In order to better control the potassium levels in the blood,
please try to stick to a low potassium diet. You received
teaching from the nutrition service during this admission to
help with a low potassium, low phosphorous diet.
Followup Instructions:
-hemodialysis on [**Last Name (LF) 2974**], [**4-20**] per your normal HD schedule
-[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2181-6-21**]
10:20
|
[
"585.6",
"V45.11",
"582.2",
"276.7",
"285.21",
"486",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13151, 13157
|
8080, 11540
|
319, 326
|
13337, 13337
|
6246, 7196
|
14483, 14684
|
5164, 5235
|
11907, 13128
|
13178, 13316
|
11566, 11884
|
13488, 14460
|
5250, 6227
|
245, 281
|
354, 3698
|
13352, 13464
|
3720, 4893
|
4909, 5148
|
7214, 8057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,150
| 109,091
|
32760
|
Discharge summary
|
report
|
Admission Date: [**2165-1-11**] Discharge Date: [**2165-1-16**]
Date of Birth: [**2095-2-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Niacin / Zetia / Lopid / Zestril / Benicar / Verapamil
/ Byetta / Avandia / Bactrim
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2165-1-11**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to Ramus, SVG to PDA)
History of Present Illness:
69 y/o female admitted to OSH with palpitations and treated for
SVT, Troponin was 0.82. Underwent cardiac cath which showed
severe coronary artery disease.
Past Medical History:
Hypertension, Hyperlipidemia, Diabetes, TAH, Cataract surgery
left eye, Vitreotomy, Bunion Removal
Social History:
Denies tobacco or ETOH use. Retired.
Family History:
Father died from MI at age 66.
Physical Exam:
VS: 69 18 166/60 5'3" 155lbs.
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB
Heart: RRR -c/r/m/g
Abd: Soft, NT, ND +BS, healed lower abd. incision
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2165-1-14**] CXR: Interval development of moderate hydropneumothorax
in the left lung. No other significant changes.
[**2165-1-14**] Echo: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is a trivial/physiologic pericardial
effusion.
[**2165-1-11**] Echo: PRE-BYPASS: 1. The left atrium is mildly dilated.
No spontaneous echo contrast is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. 2. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). 3. Right ventricular
chamber size and free wall motion are normal. 4. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. 5. Trivial mitral regurgitation is seen. A mobile
echogenic structure is noted attached to the posterior mitral
leaflet, flailing into the left atrium in systole possibly a
torn chordae. Some billowing of the A2 scallop is also seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced. 1. Biventricular function is preserved. 2. Aorta
is intact post decannulation. 3. Other findings are unchanged
[**2165-1-10**] 08:40AM BLOOD WBC-9.9 RBC-3.99* Hgb-11.7* Hct-33.4*
MCV-84 MCH-29.3 MCHC-35.0 RDW-12.4 Plt Ct-364
[**2165-1-13**] 02:00AM BLOOD WBC-13.4* RBC-2.84* Hgb-8.5* Hct-24.1*
MCV-85 MCH-30.0 MCHC-35.3* RDW-13.7 Plt Ct-133*
[**2165-1-16**] 04:55AM BLOOD WBC-12.3* RBC-2.57* Hgb-8.4* Hct-24.7*
MCV-96# MCH-32.5* MCHC-33.9 RDW-13.9 Plt Ct-181
[**2165-1-10**] 08:40AM BLOOD PT-11.3 PTT-23.8 INR(PT)-0.9
[**2165-1-14**] 02:23AM BLOOD PT-11.8 PTT-25.3 INR(PT)-1.0
[**2165-1-10**] 08:40AM BLOOD Glucose-146* UreaN-21* Creat-1.0 Na-144
K-4.1 Cl-104 HCO3-31 AnGap-13
[**2165-1-16**] 04:55AM BLOOD Glucose-62* UreaN-19 Creat-0.9 Na-138
K-4.6 Cl-103 HCO3-23 AnGap-17
[**2165-1-16**] 04:55AM BLOOD Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 76309**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**1-11**] she was brought
to the operating room where she underwent a coronary artery
bypass graft x 4. Please see operative report for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Later on operative day
she was weaned from sedation, awoke neurologically intact and
extubated. Post-operatively she required several blood
transfusions secondary to low HCT. On post-op day one she was
started on diuretics and beta blockers. She was gently diuresed
towards her pre-op weight. On post-op day two she had episodes
of atrial fibrillation and was given beta blockers and started
on amiodarone. She converted back to sinus rhythm. On post-op
day three she was transferred to the telemetry floor. Also on
this day her chest tubes were removed with post-pull chest x-ray
showing small bilateral apical pneumothoraces. Chest x-ray also
revealed possible pericardial effusion. On post-op day four
underwent echo which showed only a trivial effusion. She
remained in SR but will continue Amiodarone post-op. She worked
with physical therapy for post-op strength and mobility. On
post-op day five she was discharged to rehab.
Medications on Admission:
Lopressor 25mg [**Hospital1 **], Metformin 1000mg [**Hospital1 **], Diltiazem CD 120mg qd,
Aspirin 81mg qd, Glyburide 5mg [**Hospital1 **], MVI, Fish Oil, Calcium with
Vit. D
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. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 1 weeks.
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 400mg [**Hospital1 **] for 4 days. Then 200mg [**Hospital1 **] for 7
days. And finally, 200mg daily until stopped by cardiologist.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Post-operative Atrial Fibrillation
PMH: Hypertension, Hyperlipidemia, Diabetes
PSH: TAH, Cataract surgery left eye, Vitreotomy, Bunion Removal
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Hospital 409**] Clinic in 2 weeks on [**Hospital Ward Name 121**] 6
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 7047**] in [**1-13**] weeks
Dr. [**Last Name (STitle) **] in [**12-12**] weeks
Completed by:[**2165-1-16**]
|
[
"250.00",
"790.01",
"427.31",
"401.9",
"423.9",
"411.1",
"414.01",
"272.4",
"512.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"99.07",
"99.04",
"36.15",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
6095, 6150
|
3549, 4849
|
372, 476
|
6397, 6403
|
1196, 3526
|
6716, 6963
|
853, 885
|
5074, 6072
|
6171, 6376
|
4875, 5051
|
6427, 6693
|
900, 1177
|
320, 334
|
504, 661
|
683, 783
|
799, 837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,411
| 144,059
|
1019
|
Discharge summary
|
report
|
Admission Date: [**2188-9-23**] Discharge Date: [**2188-10-28**]
Date of Birth: [**2141-5-14**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Biaxin / Vancomycin / Haldol / Heparin Agents /
Flagyl
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
47 y/o female admitted for living related kidney transplant
Major Surgical or Invasive Procedure:
Living related kidney transplant
History of Present Illness:
47 y/o female with ESRD on hemodialysis, highly sensitized with
current desensitization protocol of IVIG and plasmapheresis now
admitted for kidney transplant from her sister. [**Name (NI) **] been in her
usual state of health, no fevers, chills or problems with
hemodialysis.
Past Medical History:
1) ESRD on HD Tues, Thurs, Sat; L
dialysis fistula
2) SLE: dx [**2173**], h/o lupus cerebri, membranous
glomerulonephritis, BOOP [**9-/2179**], Raynaud's, DIP arthritis,
avascular necorsis of hips and shoulder.
3) HTN
4) Dyslipidemia (not on any meds): [**12-9**] lipid panel wnl
5) Cardiomyopathy & CHF: normal cath in [**2183**]; TTE in [**9-8**] showed
EF 45%, 1+ MR, mild global left ventricular hypokinesis, LVH;
Exercise MIBI in [**9-8**] showed EF 62%
6) History of salmonella bacteremia
7) Gastritis: dx by EGD [**10/2185**]
8) Anemia: ? thallesemia, autoimmune hemolytic anemia
9) TTP/HUS
10) Thrombocytopenia/ITP
11) HSV [**2184-10-5**]
12) Cervical dysplasia LGSIL [**2180**]-[**2181**]
13) Breast DCIS
14) Adrenal crisis [**2184**] (was on chronic prednisone- finished in
[**8-8**])
15) Osteoporosis
16) h/o Hypothyroidism
17) Seizures
18) S/p hysterectomy for dysfunction uterine bleeding of [**Last Name (un) 6722**]
etiolgoy.
19) Pancreatitis [**2-7**] pancreatic divisum
20) status post cholecstectomy in [**2184-7-5**],
21) adrenal crisis in [**2184-6-5**]
Social History:
Lives with her brother. [**Name (NI) 1403**] part time as a bookkeeper and tax
preparer. No ETOH/Tob. Single.
Family History:
She reports a family history of lupus and autoimmune diseases.
Physical Exam:
On Admission:
VS: 99.3, 140/72, 80, 20, 100% RA Wt 55 kg Ht 5'4"
Gen: NAD, sitting up in bed, A&Ox3
HEENT: normocehphalic, atraumatic, no nodes palpated, no thrush
noted
CV: RRR, no M/R/G
Resp: Lungs CTA bilaterally
Abd: Soft, NT except for area in RUQ (not new), no scars noted,
+ BS
Extr: + femoral pulses, 2+ DP and Radial pulses, no edema noted.
LUArm AVF with + bruit and thrill. Dialyzed today and
experienced some extended bleeding post HD today. Dsg, CDI
Pertinent Results:
On Admission:
[**2188-9-23**] 10:20PM UREA N-30 CREAT-6.8 SODIUM-144 POTASSIUM-3.8
CHLORIDE-106 TOTAL CO2-29 ANION GAP-13
ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-97
CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.7 CHOLEST-36
TRIGLYCER-85
WBC-2.0* RBC-2.97* HGB-9.0* HCT-26.8* MCV-90 MCH-30.2 MCHC-33.5
RDW-21.6*
PLT SMR-VERY LOW PLT COUNT-62*
PT-14.6* PTT-46.5* INR(PT)-1.3*
Brief Hospital Course:
She underwent hemodialysis and then received rituximab. She was
plasmapheresed with ffp replacement then she received IVIG and
prograf per desensitization protocol. She was taken to the OR on
[**9-24**] for living related renal transplant placed on the right
side by Dr. [**First Name (STitle) **] [**Name (STitle) **] without complications. A JP was
placed. She received a reduced dose of ATG 50mg for wbc of 1.8
and solumedrol induction. EBL was 200cc. She produced urine
ranging between 250-500cc per hour. Preop creatinine was 8.1.
The creatinine trended down to 1.7 on pod 9. She did experience
right lateral leg numbness which was slightly swollen. A non-in
She received plasmapheresis x4 on subsequent days. ATG was
given x4. Prograf was continued at 2mg [**Hospital1 **] for level in the
11-12 range. Imuran was started at 50mg qd then increased to
75mg qd when wbc increased. Prednisone was tapered per protocol
then she was maintained on 25mg qd. Her platelet count was low
(62-51)postop.She received 1 unit PRBC on [**9-28**] for hct of 21.7.
Nephrology followed throughout this hospitalization making
recommendations which included increasing lopressor for elevated
BP. [**Last Name (un) **] followed for glucoses in the 113-168 range secondary
to steroids. Sliding scale insulin was recommended. On [**9-29**] she
had a temperature of 101.5. She was started on vanco and zosyn.
Her cline was changed over a wire without complications. Urine
culture was positive for 10-100,000 col enterococcus sensititive
to vanco. She received 4 days of iv vanco and zosyn then this
was switched to augmentin x2 days. A repeat urine culture was
negative.
A repeat crossmatch was sent and this was negative.
On [**9-29**], she complained of diarrhea. Stool was sent x 3 for
c.diff. These samples were negative. The JP was removed. She
had a small amount of drainage from this site. On pod 7 she c/o
pain in RLQ. An u/s demonstrated a fluid collection which was
successfully aspirated under u/s and a catheter was placed. This
fluid was sent for Approximately 130 cc of clear yellow fluid
with the appearance of urine, was removed. Culture was negative
for growth. Fluid from this drain was sent for creatinine which
was 1.4-1.8. Three days later a rpt u/s revealed no interval
change in the appearance of the arterial waveforms within the
transplanted kidney. The resistive indices range from 0.73 to
0.8. A fluid collection adjacent and deep to the transplanted
kidney was seen, measuring 7.0 x 5.6 x 5.4 cm. This was slightly
smaller. A pigtail drain was left in place. Initially, the
patient was to d/c home at this time with Pigtail drain in place
and finish Augmentin course. Creat at that time was 1.7. Renal
U/S shoewed good blood flow to the graft. On Post-op day 11 a
biopsy was performed that showed Glomerular and vascular changes
suggestive of thrombotic microangiopathy and patient was kept
for further hospitalization. Creatinine 3.8 at that time.
Patient received 2 more rounds of plasmapheresis and IVIG for a
total of 6 post transplant.
Abdominal wound from transplant was opened for drainage on [**10-9**].
Wound packed with NS wet to dry with good wound healing.
In spite of wound healing issues, immunosuppression changed from
Prograf to Rapamune for concern of Prograf toxicity to the
allograft.
On [**10-12**] patient was having some abdominal pain CT showed that
the pigtail drain appeared to be located laterally within the
collection. Patient underwent successful lysis of presumed
loculations within the perirenal transplant fluid collection,
with aspiration of all visible fluid in this collection. Fluid
analysis shows a creatinine content of 2.0 mg/dL. Gram stain and
culture were no growth.
Absolute CD3on [**10-13**] was 234. Patient continued to receive ATG.
Nadir of 0 on [**10-23**].
On [**10-14**] another allograft biopsy was performed. This was
consistent with acute cellular rejection, Banff Category 3. C4d
staining of peritubular capillaries was negative.
Following biopsy, the hematocrit was noted to have dropped to
19%, CT showed new subcapsular hematoma surrounding the
transplant kidney and extending into the right paracolic gutter.
Transfused with 2 units PRBCs with appropriate response.
On [**10-19**] patient spiked temp to 101.6. Blood cultures were
negative, however, she did grow Vanco resistant Enterococcus in
the urine. This was covered with Linezolid, continued on Zosyn,
Vanco d/c'd. ID was consulted and recommended Daptomycin. All
other antibiotics stopped at this time.
Blood pressure more elevated at this time, Metoprolol increased
to 100 mg TID.
Immunosuppresion: changed to Myfortic, Imuran d/c'd on [**10-22**]
Patient continued to improve and remained afebrile until
discharge home on [**10-28**].
Patient did have complaint of Right hip pain. X-ray on [**10-26**]:
Sclerosis and flattening suggestive of avascular necrosis of the
femoral head. Long-term steroid therapy may be the etiology.
Pigtail drain was left in to drainage.
Immunosuppression home course is Rapamycin 8 QD, Myfortic 360
[**Hospital1 **] and Pred 20
Final Absolute CD3 count on discharge was 57.
[**Last Name (un) **] followed blood sugars all during hospitalization, patient
on Lantus only for awhile and then changed to SS insulin with
adequate control, minimal insulin requirements by end of
hospitalization, sent home with no insulin coverage. Follow
blood sugars with outpatint labs.
VNA for dressing changes (abdomen still with minor NS wet-to-dry
[**Hospital1 **] changes) and med teaching
Medications on Admission:
Prograf 2'',Imuran 50', Valcyte 450', Omeprazole 20', Nifedipine
90', renagel 800 3 q meal, Metoprolol 100'', Folate 1mg',
nephrocap ', Fosamax 35 mg 1x/week, plaquenil ? dose, Nystatin 5
ml S&[**Name (NI) 6725**]
IS pta: prograf 2 [**Hospital1 **], imuran 75 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Continue as long as you are taking pain
medications, or as long as needed.
Disp:*60 Capsule(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).
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. Sirolimus 1 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
12. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Four (4) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
13. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO prn: q 3-4.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p living related kidney transplant
Discharge Condition:
Stable
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] if you experience any of the following:
Fever, chills, nausea, vomiting, diarrhea, inability to eat
Pain, redness or discharge from the incision
Any other symptoms concerning to you
Please have your labs drawn every Monday and Thursday and faxed
to [**Telephone/Fax (1) 697**]: CBC, Chem 10 Ca, Phos, AST, T bili, U/A and
trough Prograf level
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2188-10-30**] 3:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2188-11-3**] 3:40
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2188-11-3**] 4:40
Completed by:[**2188-11-4**]
|
[
"996.81",
"251.8",
"710.0",
"787.91",
"E932.0",
"733.42",
"582.81",
"457.8",
"446.6",
"998.32",
"693.0",
"599.0",
"998.12",
"403.90",
"780.39",
"428.0",
"E930.0",
"585.6",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"54.91",
"55.23",
"99.14",
"99.28",
"39.95",
"99.05",
"99.71",
"99.04",
"00.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10099, 10157
|
2925, 8478
|
390, 425
|
10238, 10247
|
2539, 2539
|
10678, 11119
|
1974, 2038
|
8792, 10076
|
10178, 10217
|
8504, 8769
|
10271, 10655
|
2053, 2053
|
291, 352
|
453, 731
|
2553, 2902
|
753, 1830
|
1846, 1958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,235
| 112,214
|
5839
|
Discharge summary
|
report
|
Admission Date: [**2150-3-4**] [**Month/Day/Year **] Date: [**2150-3-9**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with multiple recent admissions to [**Hospital1 18**] following fall on
[**2150-1-19**] with C1 fracture after a mechanical fall down stairs.
She was evaluated for surgery but was found to be nonoperable,
and was placed in a C-collar at least through [**4-19**] to be
followed up with Dr. [**First Name (STitle) 23161**]. She was also noted to have an
associated vertebral artery dissection and was treated
conservatively with aspirin, and a large retropharyngeal
hematoma. She was discharged to [**Hospital1 1501**] on [**1-27**].
.
On [**1-29**] she was seen in the ED after sliding out of a chair, but
the C1 fracture was stable. She was sent back to rehab, but was
noted to not be eating well and have a WBC count of 34k. She was
sent to [**Hospital3 **], then transferred to [**Hospital1 18**] on [**2150-2-4**] for
white count of 34K, significant dehydration, intraventricular
hemorrhage and question of colitis. Her hospital course was
complicated by C dif sepsis with hypotension requiring pressors,
acute renal failure, subdural hematoma (stable). She was
discharged to [**Hospital6 **] on [**2150-2-17**].
.
Today she was noted to have fevers to 101-102 and loose slightly
bloody stools. She was started on flagyl, then received empiric
vancomycin and imipenem and was transferred to the ED. In the
ED, she was noted to be tachycardic and febrile, and received
about 2 liters of fluids without improvement in her HR. She was
never hypotensive. They also gave her some ativan and haldol for
agitation. Cultures were drawn and she got additional 500 mg IV
flagyl and was admitted to the MICU service.
.
ROS: denies pain. Other ROS limited by hearing loss and mental
status.
.
Past Medical History:
Hypertension
Hypothyroidism
Osteoarthritis
Depression
Obesity
Urinary Incontinence
GERD
s/p Total TAH
C1 fracture [**12-28**]
subdural hematoma
ventricular hemorrhage
C.difficile colitis ([**1-28**])
Social History:
Pt has been widowed for 6 yrs and currently lives alone in her
home of 36 yrs. She has one daughter and four sons. Patient's
daughter visits daily, and she has two sons near by. Family is
close and supportive. Prior to recent trauma, patient was very
independent. - EtOH - denies
- Tob - denies
- IVDU - denies
Family History:
Noncontributory
Physical Exam:
V: T99.7 BP 135/35 P108 R26 90% 5L NC
Gen: lying in bed, moaning, opens eyes to voice
HEENT: pupils 1 mm, min reactive, MM dry
Neck: C collar in place, limits JVD assessment
Resp: crackles bilateral bases, no wheezes
CV: RRR nl s1s2 no MGR
Abd: soft NTND +BS
Ext: 2+ edema bilaterally
Neuro: responds to voice
Pertinent Results:
Imaging:
PORTABLE ABDOMEN [**2150-3-3**] 10:25 PM
IMPRESSION: Nonspecific but non-obstructive bowel gas pattern.
.
CHEST (PORTABLE AP) [**2150-3-3**] 10:21 PM
IMPRESSION: Bibasilar atelectasis with left pleural effusion.
Retrocardiac opacity likely represents combination of these two
processes, although underlying consolidation cannot be excluded.
.
CHEST (PORTABLE AP) [**2150-3-4**] 5:09 PM
IMPRESSION:
1. Moderate sized layering left pleural effusion, and small
right pleural effusion, both increased from [**2150-3-3**].
2. Increase in size and density of retrocardiac opacity, which
may be related to technical differences, but this area remains
suspicious for underlying consolidation or atelectasis.
.
CHEST (PORTABLE AP) [**2150-3-5**] 5:50 AM
IMPRESSION: Moderate bibasilar pleural effusions with increasing
size of the right effusion. Retrocardiac opacity suggests
atelectasis or consolidation.
.
CHEST (PORTABLE AP) [**2150-3-6**] 5:55 PM
IMPRESSION:
1. Unsatisfactory placement of Dobbhoff tube which is coiled in
the upper mediastinum. Recommend immediate removal.
2. Appearance of cardiomediastinal silhouette and lung fields
are not significantly changed compared to an hour prior.
These findings were discussed with the SICU nurse at the time of
this dictation.
.
CHEST (PORTABLE AP) [**2150-3-6**] 5:04 PM
IMPRESSION:
1. Intrabronchial placement of Dobbhoff tube. These results were
immediately called to the SICU.
2. Moderate bibasilar pleural effusions and persistent
retrocardiac opacity suggesting atelectasis versus
consolidation.
.
CHEST (PORTABLE AP) [**2150-3-7**] 10:41 AM
FINDINGS:
The tip of the NGT is well below the diaphragm and seen just to
the left of midline by the L4 vertebral body. Perhaps the chest
is obscured from view and the lower portions demonstrate some
atelectatic features.
.
CT HEAD W/O CONTRAST [**2150-3-8**] 3:56 PM
IMPRESSION: No significant interval change of left frontal
cerebral convexity subdural hematoma. Decrease in lateral
ventricle hemorrhage and frontal subgaleal hematomas.
.
PORTABLE ABDOMEN [**2150-3-8**] 11:17 AM
Supine views of the abdomen and pelvis demonstrate no evidence
of intestinal obstruction. Previously reported distended
air-filled loops of bowel have decreased in caliber since the
previous study.
.
CHEST (PORTABLE AP) [**2150-3-8**] 8:28 AM
Nasogastric tube remains in place terminating below the
diaphragm. Cardiac silhouette is enlarged but stable in size.
Bilateral pleural effusions have worsened, moderate on the right
and small-to-moderate on the left, with adjacent basilar
opacities that likely represent atelectasis.
.
Micro:
*[**2150-3-3**]*
Blood Culture: PENDING
Stool: C Diff positive
*[**2150-3-4**]*
Urine Culture: P. aeruginosa & VRE
MRSA Screen: negative
Stool: C diff positive
*[**2150-3-5**]*
Stool: C diff positive
Blood Culture: NGTD
PICC line tip culture: No growth
.
Labs:
[**2150-3-3**] 09:50PM BLOOD WBC-15.0* RBC-3.20* Hgb-9.8* Hct-29.6*
MCV-93 MCH-30.8 MCHC-33.3 RDW-18.8* Plt Ct-240#
[**2150-3-6**] 03:29AM BLOOD WBC-17.9* RBC-2.81* Hgb-8.6* Hct-26.3*
MCV-94 MCH-30.7 MCHC-32.8 RDW-17.5* Plt Ct-264
[**2150-3-9**] 06:10AM BLOOD WBC-20.4* RBC-3.08* Hgb-9.4* Hct-29.4*
MCV-95 MCH-30.5 MCHC-32.0 RDW-17.0* Plt Ct-380
[**2150-3-3**] 09:50PM BLOOD PT-12.2 PTT-26.6 INR(PT)-1.0
[**2150-3-6**] 03:29AM BLOOD PT-12.9 PTT-25.6 INR(PT)-1.1
[**2150-3-8**] 07:25AM BLOOD PT-13.2* PTT-24.5 INR(PT)-1.1
[**2150-3-3**] 09:50PM BLOOD Glucose-99 UreaN-28* Creat-0.8 Na-141
K-4.3 Cl-103 HCO3-30 AnGap-12
[**2150-3-5**] 03:27AM BLOOD Glucose-141* UreaN-27* Creat-0.9 Na-141
K-4.1 Cl-103 HCO3-30 AnGap-12
[**2150-3-9**] 06:10AM BLOOD Glucose-106* UreaN-37* Creat-1.2* Na-147*
K-4.2 Cl-109* HCO3-31 AnGap-11
[**2150-3-7**] 02:32AM BLOOD CK(CPK)-23*
[**2150-3-8**] 07:25AM BLOOD ALT-11 AST-14 LD(LDH)-306* AlkPhos-117
Amylase-32 TotBili-0.3
[**2150-3-8**] 07:25AM BLOOD Lipase-20
[**2150-3-3**] 09:50PM BLOOD Calcium-7.4* Phos-3.2 Mg-2.2
[**2150-3-6**] 03:29AM BLOOD Calcium-7.3* Phos-3.1# Mg-2.3
[**2150-3-9**] 06:10AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.4
[**2150-3-5**] 03:27AM BLOOD Triglyc-157*
[**2150-3-8**] 07:25AM BLOOD Osmolal-303
[**2150-3-7**] 02:32AM BLOOD TSH-11*
[**2150-3-7**] 02:32AM BLOOD Free T4-0.68*
Brief Hospital Course:
[**Age over 90 **]F with MMP including C difficle infection, UTI, PICC line
infection, PNA.
.
#) fever, elevated WBC - Patient was on multiple antibiotics to
treat C. diff, Pseudomonas/VRE UTI, Coag - staph PICC line
associated bacteremia, PNA and these were likely the causes of
her fevers and leuckocytosis. After discussion the family,
these measures were to be discontinued prior to [**Age over 90 **].
.
#) Respiratory distress: Patient with hypercarbic respiratory
distress. Patient is DNI and CPAP contraindicated at this time
as patient has some respiratory secretions. After discussion
with the family, it was determined that the patient definitively
not be intubated and she was not transferred to the MICU for
respiratory ventilation. RA saturations are 86-88%.
.
#) Mental status - AAOx3 intermittently in the MICU, although
while on the floor the patinet has been slightly responsive to
noxious stimulus. Family has been by the bedside and have
reassured us that this is not her baseline..
.
#) Paroxysmal atrial fibrillation - Likely in setting of
numerous infections. Patient was started on IV Lopressor for
rate control. This medication was held in the setting of
hypotension.
.
#) h/o C1 fracture - no new trauma since 1/[**2149**]. Patient has
been in hard collar and recommendations were to keep patient in
hard collar until [**2150-4-19**]. Given goals of comfort, patient will
be able to remove the collar. Patient does have scheduled
appointments with Neurosurgery in the upcoming months.
.
#) Hearing loss - appears at baseline. Patient with headphones
and microphone for communication.
.
#) hypothyroid - Synthroid was continued although TFTs were not
suggestive of such. This was likely due to decreased PO
absorption in the setting of C diff infection.
.
# Anemia - stable, acute GI bleed resolved at this point, will
continue to monitor.
.
# Depression - on Remeron 15 mg prior to admission but unable to
take po's.
.
# FEN - Family have decided not to undergo PEG placement as
this contradicts patient's wishes. Patient initially had an NGT
placed although this was removed by the patient on the day of
[**Month/Day/Year **].
.
.
After discussion with the patient's family, HCP, and medical
staff, all were in agreement that [**Known firstname **] [**Known lastname 23162**] was a suitable
candidate to [**Known lastname **] to hospice.
Medications on Admission:
imipenem 500 mg x1
vanco 1000 mg x 1
flagyl 500 mg po tid (start [**3-3**] for diarrhea)
lorazepam 0.5 mg po qhs, [**Hospital1 **] prn agitiation
TPN at 75/hour
heparin SQ TID
tylenol 1000 mg po q6h
calcium carbonate 500 mg po tid
hemorrhoidal ointment/hydrocort rectally
lansoprazole 30 mg po qd
levothyroxine 150 mcg po qd
miconazole topically [**Hospital1 **]
remeron 30 mg po qhs
vitamin d 800 units po qd
atrovent nebs Q6H prn
[**Hospital1 **] Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours).
5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q2H (every 2 hours) as needed.
6. Levothyroxine 50 mcg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
7. Nystatin 100,000 unit/g Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Lorazepam 0.5 mg IV Q6H:PRN agitation
10. Pantoprazole 40 mg IV Q24H
11. Morphine Sulfate 1 mg IV Q4H:PRN pain
12. Metoprolol 5 mg IV Q6H
please hold for SBP<100, HR<60
[**Hospital1 **] Disposition:
Extended Care
[**Hospital1 **] Diagnosis:
Primary Diagnosis: C. diff, Complicated Urinary tract infection,
Hypercarbic respiratory failure
.
Secondary Diagnoses:
Hypertension
Hypothyroidism
Osteoarthritis
Depression
Obesity
Urinary Incontinence
GERD
s/p Total TAH
C1 fracture [**12-28**]
subdural hematoma
ventricular hemorrhage
C.difficile colitis ([**1-28**])
[**Month/Year (2) **] Condition:
Afebrile, normotensive, tachycardic, nonambulatory, not
tolerating POs, nonresponsive
[**Month/Year (2) **] Instructions:
You were admitted with an infection and have been treated with
antibiotics.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. NEUROSURGERY WEST
Date/Time:[**2150-4-21**] 2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-4-21**] 1:00
Completed by:[**2150-3-10**]
|
[
"008.45",
"041.19",
"244.9",
"427.31",
"530.81",
"401.9",
"788.30",
"E878.1",
"599.0",
"041.7",
"715.90",
"V12.59",
"041.04",
"995.92",
"038.3",
"584.9",
"311",
"486",
"996.62",
"285.9",
"278.00",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7161, 9539
|
244, 251
|
2918, 7138
|
11674, 11943
|
2555, 2572
|
9565, 9999
|
2587, 2899
|
11215, 11651
|
199, 206
|
11052, 11067
|
10029, 11022
|
279, 1985
|
11114, 11194
|
11095, 11095
|
2007, 2209
|
2225, 2539
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,147
| 197,424
|
5823+55703
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-12-13**] Discharge Date: [**2112-12-17**]
Date of Birth: [**2038-5-20**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 74-year-old white male
with ischemic cardiomyopathy, paroxysmal atrial fibrillation,
atrial flutter, status post coronary artery bypass graft in
[**2100**] (3 vessels) brought into the hospital initially for an
During the electrophysiology study, he developed atrial
flutter spontaneously. After ablation of atrial flutter, he
developed left atrial tachycardia then atrial fibrillation.
Atrial fibrillation persisted despite ibutilide, ventricular rate
was approximately 40 BPM. The patient developed hypotension with
a systolic blood pressure in the 70s which responded to V
pacing and low dose dopamine infusion. A dual chamber pacemaker
was then placed. The patient developed monomorphic ventricular
tachycardia during V lead placement, and was shocked at 200
joules. At the end of the procedure the blood pressure remained
low when dobutamine was stopped. An echocardiogram revealed a
small pericardial effusion with no evidence of tamponade. RV
perforation was felt to have occurred probably during EPS/
ablation. A repeat echo 1 hour later revealed no increase in
size of the effusion, and no evidence of tamponade.
The patient was transferred to the Coronary Care Unit on
dopamine pressure support.
PAST MEDICAL HISTORY:
1. Inferior myocardial infarction in [**2100**].
2. Coronary artery bypass graft times three vessels in
[**2100**].
3. Paroxysmal atrial flutter.
4. Prior cerebrovascular accident; no residual neurologic
symptoms.
5. Peripheral vascular disease; status post
femoral-popliteal bypass.
6. Hypercholesterolemia.
7. Hepatitis C positivity.
8. Type 2 diabetes mellitus with neuropathy and
nephropathy.
9. Hypothyroidism.
10. Congestive heart failure.
11. Diabetic ulcers.
12. Sinus bradycardia.
MEDICATIONS ON ADMISSION: Medications on admission included
Coumadin 5 mg p.o. q.h.s., Prinivil 20 mg p.o. b.i.d.,
Lasix 160 mg p.o. q.a.m. and 80 mg p.o. q.p.m., Synthroid 75
mg p.o. q.d., terazosin 3 mg p.o. q.h.s., Imdur 60 mg p.o.
q.d., Tylenol as needed, folic acid 1 mg p.o. q.d.,
multivitamin, Humulin N 40 units b.i.d., Humulin R 5 units
b.i.d.
ALLERGIES: PENICILLIN (leads to hives).
SOCIAL HISTORY: He is a widower. He lives with daughter. A
former smoker. No alcohol. No drug use. He walks with a
cane.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with pulse of 100, blood pressure was
112/56, respiratory rate was 23, pulse oximetry was 94% on 2
liters, dopamine drip. In general, an elderly male,
lethargic but easily arousable. Alert and oriented times
three. Head, eyes, ears, nose, and throat examination
revealed mucous membranes were moist, edentulous. Pupils
were equal, round, and reactive to light. Extraocular
movements were intact. Neck revealed jugular venous
distention to 9 cm. No bruits. Cardiovascular examination
revealed a [**3-16**] holosystolic murmur at the left lower sternal
border. A regular rate and rhythm. Pulmonary examination
was clear to auscultation anteriorly. The abdomen was obese,
soft, nontender, and nondistended. Normal abdominal bowel
sounds. Extremities revealed no cyanosis, clubbing, or
edema. Feet were dry with multiple ulcers. Dorsalis pedis
and posterior tibialis pulses were dopplerable. Groin
revealed left venous sheath was in place. There was
ecchymosis present. No bruits. Right groin had dry blood,
no bruits.
PERTINENT LABORATORY DATA ON PRESENTATION: Initial
laboratory results revealed a white blood cell count
was 20.5, hematocrit was 35.1, platelets were 245. INR
was 1.4. Chemistry-7 revealed sodium was 141, potassium was
4.4, chloride was 104, bicarbonate was 22, blood urea
nitrogen was 43, creatinine was 1.2, and blood glucose
was 172. ALT was 19 and AST was 22. Hemoglobin A1c was 8.5,
thyroid-stimulating hormone was 3.3. Creatine kinase
was 897.
RADIOLOGY/IMAGING: Last catheterization in [**2112-11-8**]
showed severe 3-vessel disease, patent left internal mammary
artery to left anterior descending artery, and saphenous vein
graft to obtuse marginal. Pulmonary capillary wedge pressure
at the time was 10, ejection fraction was 40%, normal
right-sided pressures.
Initial electrocardiogram revealed atrial fibrillation of
about 63 beats per minute, left anterior descending artery
right bundle-branch block, left anterior vesicular block. No
acute ST changes. Q wave in II, III, and aVF. Poor R wave
progression.
INITIAL ASSESSMENT: This is a 74-year-old male with a
history of paroxysmal atrial flutter, status post inferior
myocardial infarction, status post ablation and pacemaker
placement complicated by multiple rhythms and right
ventricular perforation.
HOSPITAL COURSE:
1. CARDIOVASCULAR SYSTEM: (a) Pump: The patient had a
known ejection fraction of about 35% and hypotension after
pacemaker placement. He was started on dopamine. The
patient was slowly weaned off dopamine. All of his
antihypertensives were held initially.
The patient had a repeat echocardiogram the following morning to
evaluate for hemopericardium which was negative and showed a
decreased size of the pericardial effusion.
Once his blood pressure normalized, the patient was restarted
on ACE inhibitor and his usual Lasix regimen. The patient
tolerated this well.
(b) Rhythm: Status post biventricular pacemaker placement,
ventricularly paced. The patient was kept on telemetry. He
had no ectopic events. The patient was started on aspirin.
He was to be restarted on Coumadin at a later date. The
patient was to follow up in the Device Clinic. The patient
was also started on sotalol 80 mg p.o. b.i.d.
(c) Coronary arteries: The patient has known coronary
artery disease. A lipid panel was checked. ALT and AST were
within normal limits. The patient was started on Lipitor and
kept on folic acid during his hospital course.
2. PULMONARY SYSTEM: The patient's oxygen saturations were
stable during his hospital course. The patient had a cough
with greenish sputum which he said was chronic toward the end
of his hospital course. A chest x-ray was checked which was
negative for pneumonia.
3. RENAL SYSTEM: The patient with a known history of
chronic renal insufficiency. He had a stable blood urea
nitrogen and creatinine throughout his hospital course.
4. ENDOCRINE SYSTEM: The patient with known type 2 diabetes
mellitus. The patient was kept on his home doses of insulin.
He was also covered with fingersticks q.i.d. and a regular
insulin sliding-scale. The patient also had known
hypothyroidism. His Synthroid was continued.
6. GENITOURINARY SYSTEM: The patient had his terazosin for
blood pressure reasons. He initially had some urinary
retention with one liter of urine output once a Foley
catheter was placed. The Foley was able to be discontinued.
The patient had some questionable urinary incontinence toward
the end of his hospital course. The patient was to not take
terazosin on discharge to home; to restart at a later date.
7. OVERALL: The patient was lethargic initially in the
hospital course but brightened toward the end. The patient
was able to ambulate with Physical Therapy, and they felt
that [**Hospital 3058**] rehabilitation was needed, but the patient's
daughter refused and requested that he go home with [**Hospital6 3429**] and home Physical Therapy services; and
this was done.
DISCHARGE DIAGNOSES:
1. Status post atrial flutter ablation.
2. Status post pacemaker placement.
3. Type 2 diabetes mellitus.
4. Peripheral vascular disease.
5. Hepatitis C positivity.
6. Hypothyroidism.
7. Congestive heart failure.
MEDICATIONS ON DISCHARGE:
1. Lasix 160 mg p.o. q.a.m. and 80 mg p.o. q.p.m.
2. Enteric-coated aspirin 325 mg p.o. q.d.
3. Lisinopril 5 mg p.o. q.d.
4. Sotalol 80 mg p.o. b.i.d.
5. Sublingual nitroglycerin as needed (times three every 5
minutes).
6. Folic acid 1 mg p.o. q.d.
7. Multivitamin one tablet p.o. q.d.
8. Synthroid 75 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient was to follow up with the
Device Clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] in 1 week where he is
to get a repeat echocardiogram. In addition he will follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] (his PCP) and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23097**], his
cardiologist.
DISCHARGE STATUS: The patient was to be discharged to home
with [**Hospital6 407**] and Physical Therapy
services.
CONDITION AT DISCHARGE: Condition on discharge was good.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 8279**]
MEDQUIST36
D: [**2112-12-16**] 12:30
T: [**2112-12-17**] 05:12
JOB#: [**Job Number 21586**]
Name: [**Known lastname **], [**Known firstname 133**] Unit No: [**Numeric Identifier 3932**]
Admission Date: [**2112-12-13**] Discharge Date: [**2112-12-17**]
Date of Birth: [**2038-5-20**] Sex: M
Service:
This is a discharge summary addendum describing the hospital
course from [**12-16**] to [**12-17**]. The patient was not
discharged home because he needed another physical therapy
evaluation. Physical therapy reevaluation assessed that
patient was safe to be discharged to home with VNA and home
P.T. services. The patient had not been eating well during
the day and NPH was halved. He was given 25 units instead of
his normal 40 units. Patient still hypoglycemia during the
night with blood sugar as low as 44. Patient's blood sugar
rebounded after [**Location (un) 289**] juice and crackers.
Patient told on discharge to continue taking half of his
regular NPH dose and to monitor his blood sugars closely and
to call his regular physician to titrate up his insulin
p.r.n. Patient agreed to this plan. Patient to follow up
with echocardiogram next week and in device clinic in the
near future. Patient to call for device clinic appointment.
[**First Name4 (NamePattern1) 1197**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3933**]
Dictated By:[**Doctor First Name 3934**]
MEDQUIST36
D: [**2112-12-17**] 11:23
T: [**2112-12-19**] 12:42
JOB#: [**Job Number 3935**]
|
[
"997.1",
"423.9",
"070.54",
"428.40",
"427.31",
"998.2",
"427.1",
"788.20",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83",
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
7534, 7754
|
7780, 8104
|
1936, 2306
|
4854, 7513
|
8670, 10449
|
8125, 8655
|
149, 1375
|
1398, 1909
|
2323, 4836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,958
| 103,309
|
48523
|
Discharge summary
|
report
|
Admission Date: [**2146-12-1**] Discharge Date: [**2146-12-12**]
Date of Birth: [**2076-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2146-12-6**] Aortic Valve Replacement(21mm Pericardial) and Two
Vessel Coronary Artery Bypass Grafting(saphenous vein grafts to
diagonal and obtuse marginal arteries)
History of Present Illness:
This 70 year old male with 3 weeks of progressive shortness of
breath and productive cough. Presented to OSH in heart failure,
treated with Lasix, nebulizers and Prednisone with improvement.
With further workup, echocardiogram showed severe aortic
stenosis and cardiac catheterization revealed coronary artery
disease, additionally he had nonsustained ventricular
tachycardia. He was transferred for surgical evaluation.
Past Medical History:
insulin dependent Diabetes Mellitus
Hypertension
Chronic obstructive pulmonary disease
Acute systolic and diastolic heart failure
Anxiety
Aortic Stenosis
s/p Appendectomy
s/p Tonsillectomy
s/p Left wrist plating
Social History:
Lives with:significant other
[**Name (NI) 1139**]:3ppdxmany years
ETOH:none in 8 months-recovering
Family History:
non contributory
Physical Exam:
admission:
Pulse:87 Resp:20 O2 sat: 97% on 3L NC
B/P Right:122/47
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs rhonchi and expiratory wheezes bilat R>L
Heart: RRR [x] distant heart sounds [**3-19**] SEMurmur
Abdomen: Soft [x] obese, non-distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema1+ Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:+ecchymosis, no hematoma 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2146-12-12**] 04:50AM BLOOD WBC-11.8* RBC-2.69* Hgb-8.5* Hct-25.2*
MCV-94 MCH-31.7 MCHC-33.8 RDW-14.9 Plt Ct-207
[**2146-12-1**] 08:50PM BLOOD WBC-10.2 RBC-3.78* Hgb-11.8* Hct-35.8*
MCV-95 MCH-31.2 MCHC-32.9 RDW-14.0 Plt Ct-264
[**2146-12-12**] 04:50AM BLOOD Glucose-114* UreaN-30* Creat-1.1 Na-138
K-3.7 Cl-102 HCO3-32 AnGap-8
[**2146-12-11**] 04:50AM BLOOD Glucose-65* UreaN-38* Creat-1.3* Na-140
K-3.6 Cl-104 HCO3-28 AnGap-12
[**2146-12-1**] 08:50PM BLOOD Glucose-289* UreaN-31* Creat-0.9 Na-136
K-4.2 Cl-99 HCO3-28 AnGap-13
[**2146-12-1**] 08:50PM BLOOD ALT-35 AST-20 LD(LDH)-197 CK(CPK)-42*
AlkPhos-80 Amylase-29 TotBili-0.6
[**2146-12-4**] 11:15AM BLOOD %HbA1c-8.0* eAG-183*
[**2146-12-3**] 04:08PM BLOOD Type-ART Temp-37.2 pO2-85 pCO2-44 pH-7.44
calTCO2-31* Base XS-4 Intubat-NOT INTUBA
Brief Hospital Course:
Following transferred from the outside hospital for surgical
evaluation he underwent preoperative workup, including a
pulmonary consult due to his tobacco history. His steroids
started at the outside hospital were stopped and he was started
on Lasix for diuresis.
On [**2146-12-6**] he was taken to the Operating Room and underwent
aortic valve replacement and coronary artery bypass graft
surgery. Please see operative report for details, in summary he
had aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna Ease
pericardial tissue valve, coronary artery bypass grafting x2,
with reverse
saphenous vein graft to the second diagonal artery and the
obtuse marginal artery.
His bypass time was 118 minutes with a crossclamp of 97 minutes.
He tolerated the opration and was transferred to the cardiac
surgery ICU. He received vancomycin for perioperative
antibiotics.
He remained stable in the immediate post-op period, awoke
neurologically intact and was extubated. He remained in the
cardiac surgery ICU for several days post-operatively because
there were no beds available on the stepdown floor. All tubes,
lines, and drains were removed per cardiac surgery protocol.
Once on the stepdown floor he worked with Physical Therapy to
improve his strength and endurance. The remainder of his
hospital course was uneventful. His progress was somewhat slow
and it was felt he would benefit from a short rehabilitation
stay. On [**12-12**] he was cleared to be transferred to [**Hospital3 15644**]
Health Care Center for rehab. Lasix was continued at discharge
and can be discontinued when edema clears.
Medications on Admission:
Medications at home:
Temazepam 30 mg at bedtime
Lisinopril 40 mg daily
Symbicort 160 2 puffs [**Hospital1 **]
Spiriva inh 1 cap daily
Procardia 90 mg daily
Buspar 10 mg 4x day
Paxil 40 mg daily
Metformin 500 mg [**Hospital1 **]
Actos 40 mg daily
ativan 0.5mg prn
Outside hospital
Prednisone 60 mg daily
Metoprolol 12.5 mg TID
ASA 162 mg daily
Insulin NPH 12 units [**Hospital1 **], regular 5 units with each meal
Doxycycline 100 mg [**Hospital1 **]
Buspar 10 mg daily
Albuterol nebs
Atrovent nebs
Lisinopril 40 mg daily
Paxil 40 mg daily
Metformin 500 mg [**Hospital1 **]
Nicotine patch 21 mg daily
Procardia 90 mg daily
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet 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. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. paroxetine HCl 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. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 10
days.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
10. buspirone 10 mg Tablet Sig: One (1) Tablet PO four times a
day.
11. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
14. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): two tablets (400mg) twice daily for two weeks,
then one tablet (200mg) twice daily for two weeks, then one
tablets (200mg) daily until discontinued by physician.
15. NPH insulin human recomb 100 unit/mL Cartridge Sig: 12 units
Subcutaneous breakfast and dinner.
16. Humalog KwikPen 100 unit/mL Insulin Pen Sig: Five (5) units
Subcutaneous breakfast, lunch, dinner.
17. Humalog KwikPen 100 unit/mL Insulin Pen Sig: as directed
Subcutaneous ac & HS: 120-160-2 units ac, none HS;161-200-4
units ac,2units HS;201-240-6units ac,4unitsHS,241-280 ac,4units
HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Care - [**Location (un) 47**]
Discharge Diagnosis:
Aortic Stenosis
Coronary artery disease
s/p aortic valve replacement/coronary artery bypass grafts
Acute systolic and diasystolic heart failure
insulin dependent Diabetes Mellitus
Hypertension
Chronic obstructive pulmonary disease
Anxiety
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 2+ legs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] (for Dr [**Last Name (STitle) **] at [**Hospital1 **] Heart Center
([**Telephone/Fax (2) 6256**]) on Thursday, [**12-29**] at 9:15am
Cardiologist: Dr [**Last Name (STitle) 4610**] at [**Hospital1 **] Heart Center
([**Telephone/Fax (2) 6256**]) on [**1-10**] at 10am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 8593**] [**Name (STitle) 8592**] in [**5-16**] weeks ([**Telephone/Fax (1) 26318**])
**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:[**2146-12-12**]
|
[
"424.1",
"428.0",
"305.1",
"496",
"428.41",
"250.00",
"414.01",
"300.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
6952, 7040
|
2841, 4462
|
299, 471
|
7323, 7543
|
2020, 2818
|
8384, 9104
|
1293, 1312
|
5135, 6929
|
7061, 7302
|
4488, 4488
|
7567, 8361
|
4509, 5112
|
1327, 1999
|
240, 261
|
499, 924
|
946, 1160
|
1176, 1277
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,655
| 112,771
|
37627
|
Discharge summary
|
report
|
Admission Date: [**2166-10-3**] Discharge Date: [**2166-10-22**]
Date of Birth: [**2120-12-21**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Right sided open type IIIb tib-fib fracture with substantial
soft-tissue defect s/p motorcycle accident. Acute Osteomyelitis.
Major Surgical or Invasive Procedure:
[**2166-10-6**]: right distal tibia incision and drainage, ORIF fibula,
ex-fix of tibia, VAC dressing
[**2166-10-8**]: right tibia nail, antibiotic cement spacer, VAC
dressing
[**2166-10-13**]: incision and drainage, VAC dressing change
[**2166-10-15**]: right rectus free flap to right lower extremity soft
tissue defect and split thickness skin graft to right medial
ankle
History of Present Illness:
45 yo male s/p MCC vs. SUV T-bone ([**10-3**]) slid 40 feet on
pavement suffering right sided type IIIB tib/fib fracture with
substantial tissue loss over posterior and lateral calf.
Past Medical History:
chronic pancreatitis, GERD
Social History:
smokes 1.5 ppd, [**6-18**] drinks per week, construction worker
Family History:
non-contributory
Physical Exam:
Vitals: 99.7 98.5 130/98 18 96 RA
- general: NAD, A + O x 3
- pulm: CTAB, no WRR
- cardiac: RRR, no MRG
- abd: mild TTP, no R or G, incision CDI
- ext: right thigh donor site open to air, no drainage or signs
of infection,
abdominal free flap WWP with CR < 1 S, doppler +, mildly
edematous, STSG over
medial portion of right ankle good take without erythema or
discharge
Pertinent Results:
[**2166-10-3**] 09:20PM BLOOD WBC-12.2* RBC-3.77* Hgb-12.6* Hct-36.5*
MCV-97 MCH-33.4* MCHC-34.6 RDW-12.6 Plt Ct-163
[**2166-10-16**] 01:33AM BLOOD WBC-9.2 RBC-3.32* Hgb-10.4* Hct-30.9*
MCV-93 MCH-31.2 MCHC-33.6 RDW-13.6 Plt Ct-479*
[**2166-10-3**] 09:20PM BLOOD PT-11.1 PTT-19.6* INR(PT)-0.9
[**2166-10-3**] 09:20PM BLOOD Plt Ct-163
[**2166-10-14**] 01:45PM BLOOD PT-12.0 PTT-23.7 INR(PT)-1.0
[**2166-10-16**] 01:33AM BLOOD Plt Ct-479*
[**2166-10-3**] 09:20PM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-143
K-4.1 Cl-110* HCO3-21* AnGap-16
[**2166-10-16**] 01:40AM BLOOD Glucose-126* UreaN-10 Creat-0.7 Na-138
K-4.8 Cl-101 HCO3-26 AnGap-16
[**2166-10-4**] 03:38AM BLOOD Calcium-7.4* Phos-4.2 Mg-1.6
[**2166-10-16**] 01:40AM BLOOD Calcium-8.7 Mg-2.0
Brief Hospital Course:
Patient was admitted to the orthopedics-trauma service on
[**2166-10-3**] s/p motorcycle accident in which he suffered a type IIIb
tib-fib fracture of his right lower extremity with substantial
free tissue loss to his posterior-medial calf and multiple
non-operative right foot fractures. On [**10-3**] the patient was
taken by Dr. [**Last Name (STitle) 7376**] for [**MD Number(4) 84407**] of the right tibia fracture,
irrigation and debridement and application of a VAC dressing. On
[**2166-10-6**] the plastics service was consulted concerning coverage
of a substantial soft tissue defect on his right lower
extremity. On [**2166-10-6**] the plastics team began following the
patient, obtaining imaging as necessary for surgical planning of
the RLE wound. The patient remained with a vac covering the leg
wound and underwent several washouts of the site to ensure a
clean and non-infected surface ontowhich to place a free tissue
falp. On [**2166-10-15**] the pt was taken to the OR with plastics for a
rectus free flap to cover LE wound - the procedure went without
complication and a split thickness skin graft, taken from the
right lateral thigh, was used to cover the rectus muscle flap. A
large bolster was placed and the flap was followed
post-operatively with regular doppler ultrasounding of the
flap's pedicle. The patient had an uneventful post-operative
course transitioning to oral pain medications early and
tolerating a regular diet without problems. Following the
reconstruction, on post operative day 5 the patient began
dangling the leg from the side of the bed to slowly allow the
flap to fill with blood as it will in the anatomic position - he
tolerated this without event and has increased this dangling to
15 minutes/day. He was seen by physical therapy who helped him
to transition to using crutches and he proved agile in their
use. At the time of discharge the patient was taking PO dilaudid
and had adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: After each operation the patient was given IV fluids
until tolerating oral intake. His diet was advanced when
appropriate, which was tolerated well. He was also started on a
bowel regimen to encourage bowel movement. Foley was removed on
POD#4. He has been voiding without problem. Intake and output
were closely monitored.
ID: Post-operatively, the patient was started on IV cefazolin,
because the patient had been afebrile and had no signs of
infection, on POD 5 his antibiotics were discontinued. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. He is being discharged on Subq heparin as his mobility
is somewhat limited and should remain on this until he is
active.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. He
will go to [**Hospital3 **] facility.
Medications on Admission:
Amylase-lipase-protease
Ca carbonate
Vit D3
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*28 Capsule(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
Disp:*28 Tablet(s)* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily) for 30 days.
6. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO q 3 hours as needed
for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS): Please resume your usual home dose.
9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
QPM (once a day (in the evening)): Please continue this
medication until you leave rehab.
Disp:*30 syringes* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Open tib-fib fracture of right lower extremity with open
reduction internal fixation.
Free rectus flap and split thickness skin graft to fill in soft
tissue defect to right lower extremity.
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the emergency department
for any of the following:
- vomiting and cannot keep in fluids or your medications.
- shaking chills, fever greater than 101.5 (F) degrees or 38 (C)
degrees, increased redness, swelling or discharge from
incision,
chest pain, shortness of breath, or anything else that is
troubling
you.
- any serious change in your symptoms, or any new symptoms that
concern you.
- please resume all regular home medications and take any new
meds as
ordered.
- do not drive or operate heavy machinery while taking any
narcotic
pain medication. You may have constipation when taking
narcotic
pain medications (oxycodone, percocet, vicodin, hydrocodone,
dilaudid, etc.); you should continue drinking fluids, you may
take
stool softeners, and should eat foods that are high in fiber.
You will be non-weightbaring on your right lower extremity for
the next 2-3 weeks to ensure that your skin graft takes and that
your flap remains healthy. Continue to increase the dangling of
the leg by 5 minutes a day TID (starting at 15 min) - if the
flap looks overly dark and congested then re-elevate it. Please
also doppler the leg q8hrs for the next 4 days, please contact
MD if unable to find pulse.
You will need to follow up weekly at plastics clinic on Fridays.
Each visit your flap and graft will be evaluated and you will
gradually progress to more weight-baring on the extremity.
Please keep your right lower extremity dry until you follow up
at plastics clinic.
Followup Instructions:
You will need to follow up weekly at plastics clinic on Fridays.
Each visit your flap and graft will be evaluated and you will
gradually progress to more weight-baring on the extremity.
Please call the number below to schedule your appointment for
NEXT friday [**10-31**]. [**Telephone/Fax (1) 5343**]
Please also call Dr. [**Last Name (STitle) 1005**] to schedule an appointment with
his office for Orthopedic follow up: he can be reached at: ([**Telephone/Fax (1) 15940**]
|
[
"824.1",
"825.24",
"577.1",
"807.03",
"873.42",
"850.11",
"401.9",
"305.00",
"730.06",
"731.3",
"530.81",
"825.25",
"E812.2",
"305.1",
"825.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"83.43",
"84.56",
"79.66",
"79.07",
"78.18",
"78.37",
"86.69",
"78.17",
"83.82",
"79.67"
] |
icd9pcs
|
[
[
[]
]
] |
6872, 6942
|
2395, 5615
|
442, 822
|
7177, 7184
|
1617, 2372
|
8759, 9172
|
1181, 1199
|
5709, 6849
|
6963, 7156
|
5641, 5686
|
7208, 8736
|
1214, 1598
|
9183, 9239
|
277, 404
|
850, 1034
|
1056, 1084
|
1100, 1165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,870
| 185,244
|
24779
|
Discharge summary
|
report
|
Admission Date: [**2160-11-6**] Discharge Date: [**2160-11-18**]
Date of Birth: [**2097-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Stroke
Major Surgical or Invasive Procedure:
[**2160-11-11**] Single vessel coronary artery bypass grafting utilizing
the left internal mammary artery to left anterior descending
artery; with closure of patent foramen ovale by direct suturing.
History of Present Illness:
Mr. [**Name13 (STitle) 62436**] is a 63 year old male in history of two previous
strokes in [**Month (only) 116**] and [**2160-8-4**]. His only remaining deficit is
numbness in his left fifth [**Female First Name (un) 23217**] finger. He has been on
Coumadin since [**2160-5-4**]. A TEE in [**2160-8-4**] at the [**Hospital1 18**] was
notable for a patent foramen ovale with right-to-left passage of
agitated saline post Valsalva relsease. There was simple
atheroma in the aortic arch and descending thoracic aorta
without evidence of intracardiac thrombus. Further evaluation in
[**2160-8-4**] included a carotid ultrasound which found minimal
plaque in both internal carotid arteries and a brain MRI which
showed evidence of infarctions in the right hemisphere. There
was no evidence of aneurysm or obstruction. Based on the above
results, he was referred for cardiac surgical intervention.
Past Medical History:
Patent Foramen Ovale, Coronary artery disease, History of
Cerebral Vascular Attacks, Hypertension, Hyperlipidemia, History
of Nephrolithiasis, Prior Hernia repair
Social History:
No tobacco history. Denies excessive ETOH. Married with
children. Works at the [**Company 3596**]. Denies recreatinal drugs.
Family History:
Father had a stroke at age 69.
Physical Exam:
Vitals: T: afebrile, BP 100-110/60, P 61, RR 16, SAT 96% RA
General: Well develped male in no acute distress
HEENT: PERRl; sclera anicteric and non-injected; oropharynx
benign
Neck: supple, no JVD, no carotid bruits
Heart: regular rate, no murmur or rubs
Lungs: clear bilaterally
Abdomen: benign
Ext: warm, no edema
Pulses: 1+ distally
Neuro: alert and oriented; no focal deficits noted
Pertinent Results:
[**2160-11-17**] 07:20AM BLOOD WBC-10.8 RBC-3.20* Hgb-10.1* Hct-29.0*
MCV-91 MCH-31.7 MCHC-34.9 RDW-14.0 Plt Ct-305#
[**2160-11-6**] 04:52PM BLOOD WBC-7.7 RBC-4.42* Hgb-13.8* Hct-39.5*
MCV-89 MCH-31.1 MCHC-34.8 RDW-13.0 Plt Ct-203
[**2160-11-17**] 07:20AM BLOOD Glucose-135* UreaN-21* Creat-1.2 Na-139
K-4.8 Cl-101 HCO3-31 AnGap-12
[**2160-11-6**] 04:52PM BLOOD Glucose-124* UreaN-40* Creat-1.6* Na-138
K-5.0 Cl-98 HCO3-29 AnGap-16
[**2160-11-15**] 04:27PM BLOOD Calcium-8.7 Phos-2.9 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] was admitted for heparinzation and cardiac
catheterization which was performed [**11-7**]. Coronary
angiography revealed a right dominant system. The LMCA showed no
angiographically apparent flow-limiting stenoses. The LAD showed
a discrete 90% proximal stenosis without significant disease in
the rest of the LAD or diagnal system. The LCX and RCA showed no
apparent significant stenoses. Based on the above results,
surgical approach changes from minimally invasive to median
sternotomy. Mr. [**Known lastname 62437**] [**Last Name (Titles) **] course was otherwise
uneventful. He remained stable on intravenous Heparin.
On [**11-11**], Dr. [**Last Name (STitle) 1290**] performed single vessel coronary
artery bypass grafting with closure of PFO. Surgery was
uncomplicated and he was brought to the CSRU in stable
condition. Within 24 hours, he awoke neurologically intact and
was extubated without incident. He maintained stable
hemodynamics and transferred to the SDU on postoperative day
one. Most of his [**Last Name (STitle) **] medications were resumed. All
chest tubes and wires were removed without complication. Low
dose beta blockade was initiated and advanced as tolerated. He
worked daily with physical therapy and made steady progress. On
POD 2 his chest x-ray was reviewed and no significant
pneumothorax or acute pulmonary disease was appreciated, his
Chest tubes and mediastinal tubes were removed. Post procedural
chest x-rays demonstrated significant pneumothorax in the right
thorax. The patient remained asymptomatic and had no decrease
in his SpO2. He subsequently had a right thoracotomy with chest
tube placement and suction. He remained stable throughout his
procedure. Post procedural x-rays showed marked reduction of
his pneumothorax without any changes clinically. He progressed
rapidly during POD [**4-9**] with ambulation and the ability to climb
a flight of stairs without difficulty. On POD 7 his chest tube
was clamped and the patient was monitored for symptoms. A Chest
x-ray showed minimal residual right apical pneumothorax, he was
asymptomatic after clamping of the tubes. His chest tube was
removed without complication and an additional chest x-ray was
taken showing no change in a minimal apical pneumothorax and
possible minimal right mediastinal pneumothorax. At discharge,
his blood pressure was 102/60, heart rate was sinus in the 70's
with room air saturations of 95%. His discharge chest x-ray was
notable for residual right apical and right mediastinal
pneumothoracies without any clinical manifestations.
Mr[**Known lastname **] was discharged on [**2160-11-18**] in good condition to
home on a heart healthy diet with sternal precautions and
limited activity. His coumadin was discontinued in consulation
with Dr. [**Last Name (STitle) **] and he will be anticoagulated with Aspirin 325mg
po qd. He will follow up with Dr. [**Last Name (Prefixes) **] in four weeks,
Dr. [**Last Name (STitle) 911**] in two or three weeks, and Dr. [**Last Name (STitle) 62438**] in two
weeks.
Medications on Admission:
Aspirin 81 qd, Lisinopril 10 qd, HCTZ 25 qd, Lipitor 80 qd,
Warfarin 5 mg qd, Zetia 10 qd
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Patent Foramen Ovale, Coronary artery disease, History of
Cerebral Vascular Attacks, Hypertension, Hyperlipidemia, History
of Nephrolithiasis
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever, redness or drainage from incision, or weight
gain more than 2 pounds in one day or five pounds in one week.
No lifting more than 10 pounds.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**4-8**] weeks
Dr. [**Last Name (STitle) 62438**](PCP)in [**2-7**] weeks
Dr. [**Last Name (STitle) 911**] in [**2-7**] weeks [**Telephone/Fax (1) 920**]
Completed by:[**2160-11-18**]
|
[
"272.4",
"414.01",
"401.9",
"745.5",
"V12.59",
"V13.01",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"97.41",
"88.72",
"37.22",
"88.56",
"36.11",
"35.71",
"36.15",
"34.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6899, 6948
|
2765, 5833
|
329, 530
|
7134, 7141
|
2250, 2742
|
7493, 7716
|
1796, 1828
|
5974, 6876
|
6969, 7113
|
5859, 5950
|
7165, 7470
|
1843, 2231
|
283, 291
|
558, 1452
|
1474, 1638
|
1654, 1780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,975
| 178,167
|
7857
|
Discharge summary
|
report
|
Admission Date: [**2142-12-15**] Discharge Date: [**2143-1-1**]
Date of Birth: [**2105-6-2**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Zosyn
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
NG tube placement
PICC line placement
Central line placement
Intubation
History of Present Illness:
Mr. [**Known lastname 1007**] is a 37 year old male with history of idiopathic
pancreatitis who presents from [**Hospital 15405**] with necrotizing
pancreatitis. He initially presented on [**12-13**] with one day
history of severe abdominal pain/LLQ pain/epigastric pain
radiating to left scrotum. Also with nausea and dry heaves but
no emesis. Went to ED for evaluation and found to have elevated
amylase (424 --> 681) and lipase (1245 --> 1154). CT scan of
abdomen demonstrated significant necrotizing pancreatitis with
significant abnormal pleural fluid. Patient was hypotensive and
was on dopamine intially but weaned off after recieving
approximately 4L of IVF's over 2 days. He also become
tachycardic to 170's and was treated with lopressor 5mg IV,
repeated an unclear number of times. He also had a recurrent
fever (Tm 105) and was hypoxia with O2 sats in low 90's on 6-8L
high flow. He was seen by gastroenterology and treated with
aldactone 50 [**Hospital1 **] and lasix for ascites and to improve urine
output. He had been receiving dilaudid 2-4 mg IV Q2H prn for
pain. Because of the worsening CT scan on [**12-15**] and clinical
deterioration, patient transferred to [**Hospital1 18**] for further
management.
Pt arrived on floor looking comfortable and without respiratory
distress. Related no abdominal pain d/t pain meds. No chest
pain, SOB, or other discomforts. + fevers, no chills. No URI
sxs, no dysuria.
Past Medical History:
1)Idiopathic Pancreatitis - Seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] in [**2134**]
- First in [**2130**] after heavy ETOH, second [**2131**] after a car
accident and light ETOH, another after fatty foods (not ETOH),
another after ERCP (amylase range of 1800-[**2135**], pain relieved by
brief hospitalization).
- ERCP found a normal common bile duct and biliary system but
was unable to cannulate the pancreatic duct.
- MRCP with no pancreatic divisum ([**2134**])
- CF gene negative
2)Kidney Stones
3)GERD
4)UTI
5)Spinal stenosis s/p fusion in [**2123**]
6)HTN
7)Seasonal allergies
8)Ulnar nerve entrapment surgery in [**2132**]
Social History:
+tob, pt states no ETOH recently but told surgery that he drinks
a 6pk of beer a day and told attending 1 br/day on occasion. no
IVDU. lives at home with wife and 18mnth old child.
Family History:
Non-contributory
Physical Exam:
Gen: sleepy, arousable
Vitals: 101.3, 141/83, 120, 20, 98% on 50%
HEENT: PERRL, EOMI, anicteric sclera, MM dry, OP clear
Neck: supple, no LAD, no thyromegaly
Cardiac: tachy, regular, NL S1 and S2, no MRGs
Lungs: CTAB post, no crackles
Abd: distended, tense, tender in lower quadrants and epigastric,
+ascites and dullness, no caput or spiders, no asterixis, no HSM
Ext: warm, 2+ DP pulses, no C/C/E
Neuro: CN III-XII intact, MAE, alert to person, time, but
thought at [**Hospital3 **]
Pertinent Results:
Laboratory results:
[**2142-12-16**] 03:04AM BLOOD WBC-8.5 RBC-4.34* Hgb-13.1* Hct-38.0*
MCV-88 MCH-30.2 MCHC-34.5 RDW-14.2 Plt Ct-149*
[**2143-1-1**] 05:57AM BLOOD WBC-8.1 RBC-3.60* Hgb-10.6* Hct-31.9*
MCV-89 MCH-29.4 MCHC-33.1 RDW-13.6 Plt Ct-473*
[**2142-12-16**] 03:04AM BLOOD PT-13.5* PTT-36.1* INR(PT)-1.2*
[**2142-12-16**] 03:04AM BLOOD Glucose-153* UreaN-15 Creat-0.5 Na-142
K-4.0 Cl-111* HCO3-27 AnGap-8
[**2143-1-1**] 05:57AM BLOOD Glucose-70 UreaN-13 Creat-0.4* Na-136
K-4.1 Cl-100 HCO3-28 AnGap-12
[**2142-12-16**] 03:04AM BLOOD ALT-28 AST-53* LD(LDH)-472* AlkPhos-51
Amylase-552* TotBili-0.7
[**2143-1-1**] 05:57AM BLOOD ALT-37 AST-22 AlkPhos-244* Amylase-127*
TotBili-0.3
[**2142-12-16**] 03:04AM BLOOD Lipase-628*
[**2143-1-1**] 05:57AM BLOOD Lipase-95*
[**2142-12-16**] 03:04AM BLOOD Albumin-2.7* Calcium-7.4* Phos-1.0*
Mg-1.9
[**2143-1-1**] 05:57AM BLOOD Calcium-8.6 Phos-4.2
[**2142-12-18**] 02:30AM BLOOD VitB12-1299* Folate-11.5
[**2142-12-16**] 08:44PM BLOOD Triglyc-238*
CT scan abd/pelvis ([**2141-12-15**]): Severe pancreatitis, prominent
areas of nonengancement are seen involving the pancreas
suggestion possible necrotic changes (enhancement of head,
protion of tail, patchy through body). No interval change in
the extensive amount of fluid within the abdomen and pelvis.
Increased amount of pleural fluid. Liver with fatty
infiltration. Some minmal fatty sparing surrounding the
gallbladder and gallbladder is minimally dilated. Low density
foci throughout the spleen. One or two small stones in left
kidney and rounded hyperdensity in right kidney d/t small cyst.
Brief Hospital Course:
Mr. [**Known lastname 1007**] is a 37 year old male with h/o pancreatitis who
presents with necrotizing pancreatitis, now with delirium
suspected [**1-11**] alcohol withdrawal, although pt and family deny
alcohol use.
1)Necrotizing pancreatitis - 40% necrotized on admission CT scan
to our institution, with preservation of pancreatic head and
tail. Possible etiologies include ETOH, gallstones (none seen
on admission CT scan), obstruction (ruled-out with RUQ u/s),
hypertriglyceridemia (triglycerides only mildly elevated in
200s), hypercalcemia, drugs (unlikely; pt only taking atenolol
at home), infection, and trauma (no history of trauma). Most
likely ETOH, although patient and his family adamantly deny EtOH
other than a drink at [**Holiday **]. Repeat CT showed overall
improved appearance of pancreas although there is some
organization of pancreatic inflammation. He was initially kept
NPO with NGT to suction. He subsequently received post-pyloric
tube feeds while intubated, but pulled out his NGT following
extubation. As pancreatic enzymes trended downwards and his
clinical status improved, his diet was advanced. He also
completed a 7d course of Meropenem for necrotizing pancreatitis.
Surgery followed him closely throughout his hospital stay.
2)Fevers: Patient presented with persistent fevers throughout
his hospital stay. Daily blood and urine cultures were
unrevealing. Both pancreatitis and withdrawal can cause fever.
Ruled out acalculous cholecystitis with RUQ US. Patient also
presented with diarrhea, but c.diff was negative. He was
empirically started on Flagyl and Zosyn but the latter was
stopped due to development of a rash.
3)Delirium/? ETOH withdrawal: Per psychiatric evaluation and
high benzodiazepine requirement, acute mental status changes
likely secondary to EtOH withdrawal. Constellation of symptoms
includes tachycardia, tremulousness, agitation, coupled with a
history of recurrent pancreatitis. Head CT without intracranial
abnormalities. He was placed on empiric thiamine, folate, and
B12. The patient was intubated electively for airway protection
since he required large doses of sedatives. At time of discharge
his mental status had returned to baseline.
4)Respiratory: On admission, patient was tachypneic despite
large doses of BZDs for withdrawal and as a result, was
electively intubated. He was successfull extubated once his
clinical status improved and his BZD requirement was decreased.
Cxray showed large L pleural effusion, likely secondary to
pancreatitis.
5)Hyperglycemia: Likely new onset diabetes secondary to necrosis
of his pancreatic beta cells. Now with new insulin requirement
> 100 units per day while on TPN. He was initially maintained
on insulin gtt with increasing requirements but was transitioned
to a sliding scale as his clinical status improved. He no longer
required insulin at time of discharge.
6)HTN: Patient was started on low dose beta-blocker and was
discharged on Atenolol.
7)FEN: Patient was initially maintained on TPN and tube feeds.
Once he self d/c'ed his NGT his diet was slowly advanced with
help of nutrition. At time of discharge patient was able to
tolerate regular diet without any complications.
Medications on Admission:
Atenolol 50 mg PO QD
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing pancreatitis
Altered mental status
Respiratory failure
Hypertension
Hyperglycemia
Discharge Condition:
Stable
Discharge Instructions:
1)You are scheduled for an appointment with a
gastroenterologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**], for follow-up care for
your pancreatitis: [**2143-1-14**] 8:20am
2)Please schedule a follow-up appointment with your PCP [**Name Initial (PRE) 176**] 1
week of your discharge from the hospital.
3)Please take all medications as listed in your discharge
instructions. Your dose of Atenolol has been changed to 25mg
once daily.
4)Please avoid high contents of fat and carbohydrates in your
diet.
5)If you experience fevers, chills, sweats, abdominal pain,
nausea, vomiting, chest pain, shortness of breath or any other
concerning symptoms, please go to the Emergency Room or contact
your PCP [**Name Initial (PRE) 2227**].
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2143-1-14**] 8:20
|
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icd9cm
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290, 364
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2772, 3259
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236, 252
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392, 1833
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1855, 2523
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2539, 2723
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,322
| 181,695
|
1602
|
Discharge summary
|
report
|
Admission Date: [**2177-11-20**] Discharge Date: [**2177-12-5**]
Date of Birth: [**2137-9-14**] Sex: F
NOTE: This is a Discharge Summary for an admission ending in
death for Ms. [**Known firstname 9300**] [**Known lastname **].
HISTORY OF PRESENT ILLNESS: This was a 40-year-old Haitian
from [**Hospital 9301**] Hospital after a recent stay in the [**Hospital1 346**] [**Hospital Ward Name **] Intensive Care Unit on
[**9-27**] to [**11-18**].
She initially presented with complaints of headache,
anorexia, shortness of breath, and fevers. She was found to
have adult respiratory distress syndrome requiring paralytics
persistent hypotension requiring pressors on several
occasions; reportedly responsive to steroids. She was
treated with broad-spectrum antibiotics, antivirals, and
antifungals and developed acute renal failure secondary to
amphotericin. She required an insulin drip for glucose
control. She was eventually weaned mostly from ventilator
but did require a tracheostomy.
Her persistent fevers led to a repeat bronchoscopy which grew
herpes simplex virus. She had episodes of pulmonary edema
but related to volume resuscitation and tachycardia. An
esophagogastroduodenoscopy tube was placed for nutrition.
She was transferred to [**Last Name (un) 9301**] on [**11-18**]. On that day,
the patient was seen by Dr. [**Last Name (STitle) **] and was noted to be
hypotensive. Intravenous phenylephrine was started at
[**Last Name (un) 9301**] but apparently turned off for the ambulance ride.
On transfer, ambulance personnel noted difficulty bagging the
patient and stopped in the Emergency Department. There, she
was found to be hypoxic with a bradycardic arrest which
responded to epinephrine, atropine, and cardiopulmonary
resuscitation. She arrived in the [**Hospital Ward Name 332**] Intensive Care
Unit unresponsive.
PAST MEDICAL HISTORY:
1. Acquired immunodeficiency syndrome.
2. Cerebral toxoplasmosis.
3. Seizure disorder since [**2171**].
4. History of tuberculosis; status post isoniazid.
5. History of adult respiratory distress syndrome secondary
to pneumococcal sepsis.
6. History of methicillin-resistant Staphylococcus aureus
infection of decubitus ulcer.
7. Human papilloma virus infection.
8. Herpes simplex virus infection found on bronchoscopy on
[**11-10**].
9. History of candidal esophagitis.
10. Premature ovarian failure.
11. Hypoparathyroidism.
12. Hypotension.
13. Question Addison's disease.
14. Empty sellar syndrome.
15. Hypothyroidism.
MEDICATIONS ON ADMISSION:
1. [**Month (only) 9294**] 350 mg three times daily.
2. Vancomycin 1 g once daily.
3. Metronidazole 500 mg three times daily.
4. Sulfadiazine 500 mg four times daily.
5. Pantoprazole 40 mg once daily.
6. Prednisone 10 mg three times daily.
7. Leucovorin 10 mg once daily.
8. Ceftazidime 2 g once daily.
9. Amphotericin lipid complex 300 mg once daily.
10. Phenytoin 200 mg three times daily.
11. Pyrimethamine 50 mg once daily.
12. Levothyroxine 100 mg once daily.
13. Sertraline 75 mg once daily.
14. Regular insulin sliding-scale.
15. NPH insulin 30 units subcutaneously q.a.m. and 20 units
subcutaneously q.h.s.
16. Zolpidem 5 mg as needed.
17. Ativan as needed.
18. Morphine sulfate as needed.
ALLERGIES: PENICILLIN, reported to SULFA but known to
tolerate trimethoprim/Sulfamethoxazole, IMIPENEM (causing
thrombocytopenia), PENTAMIDINE.
SOCIAL HISTORY: The patient moved from [**Country 2045**] 15 years ago.
She has a husband and daughter. [**Name (NI) **] tobacco, alcohol, or
intravenous drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 101.1
axillary, heart rate was 115, blood pressure was 134/93 in
intravenous phenylephrine drip, respiratory rate was 24 on
pressor support ventilation 15 cm of water plus continuous
positive airway pressure of 5 cm of water, FIO2 of 1; oxygen
saturation was 100% on these settings, intravenous pressure
was 12. An overweight black female with tracheostomy. The
neck was supple without jugular venous distention or
lymphadenopathy. The lungs with coarse breath sounds
bilaterally. Heart was tachycardic with a regular rhythm and
normal heart sounds. Abdomen with a few bowel sounds, softly
distended, tympanitic, jejunostomy tube in place with no
apparent tenderness. Guaiac-negative green stool in rectal
bag. Extremities with 2+ distal pulses. No edema. The skin
appeared dry. Mucous membranes appeared dry.
Neurologically, she was responsive to painful stimuli, moved
all extremities spontaneously with 1+ biceps, patellar, and
Achilles reflexes. Bilateral upgoing toes.
PERTINENT LABORATORY VALUES ON PRESENTATION: Arterial blood
gas in the Emergency Department revealed pH was 6.4, PCO2 was
220, PO2 was 73, lactate was 12.4; improving to a pH of 7.07,
PCO2 of 100, and then to pH of 7.35, PCO2 of 46, with a
lactate of 2, and a PO2 of 87. Sodium was 139 and potassium
was 4.1. Hematocrit was 28. Ionized calcium was 1.14.
Laboratory data from [**Last Name (un) 9301**] on [**11-20**] revealed white
blood cell count was 20 (with 85 polymorphonuclear cells, 9
lymphocytes, and 6 monocytes), hematocrit was 22.5, and
platelets were 150. Sodium was 140, potassium was 4.4,
chloride was 107, bicarbonate was 22, blood urea nitrogen was
24, creatinine was 2.2, and blood glucose was 140. AST was
1.8, ALT was 24, alkaline phosphatase was 110, LDH was 322,
amylase was 45, lipase was 197. Calcium was 7.6, magnesium
was 1.3, phosphate was 4.7. Albumin was 1.8. Phenytoin
level was 5.2. Prothrombin time was 50.6. INR was 1.8.
Partial thromboplastin time was 33.1.
On arrival to the Intensive Care Unit white blood cell count
was 22.6, hematocrit was 26.4, and platelets were 158.
Prothrombin was 16.2, INR was 1.7, partial thromboplastin
time was 29.8. Sodium was 139, potassium was 3.2, chloride
was 104, bicarbonate was 22, blood urea nitrogen was 27,
creatinine was 1.8, and blood glucose was 183. AST was 25,
ALT was 11, LDH was 532. Creatine kinase was 36. Alkaline
phosphatase was 115, total bilirubin was 0.3. Calcium was
7.2, magnesium was 1.5, phosphate was 7.1. Albumin was 2.1.
Microbiology from last admission showed methicillin-resistant
Staphylococcus aureus growing from [**Month (only) **] on multiple
occasions and herpes simplex virus growing from
bronchoalveolar lavage several times.
RADIOLOGY/IMAGING: A chest x-ray revealed increased air
space disease with persistent interstitial disease, right
internal jugular catheter and right peripherally inserted
catheter in place. Tracheostomy in good position.
Electrocardiogram revealed sinus bradycardia at 27, with a
long P-R interval.
HOSPITAL COURSE: The patient's respiratory arrest was felt
to have a very broad differential. She received supportive
care with blood, urine, and [**Month (only) **] cultures. Broad-spectrum
antibiotics were continued and stress-dose steroids were
given for relative adrenal insufficiency. Pyrimethamine for
toxoplasmosis history and [**Month (only) **] for her herpes simplex
virus infection were continued.
Ms. [**Known lastname 9302**] decreased neurologic status was felt to be quite
concerning for anoxic brain injury. The Neurology Service
was consulted. A computed tomography scan of the head was
ordered as well as electroencephalogram. Dilantin was
reloaded for a low level.
Infectious Disease consultation recommended discontinuation
of [**Known lastname **]; which was done. Vancomycin, ceftazidime,
metronidazole, and ampicillin were continued.
The patient tolerated pressure support ventilation easily and
responded to furosemide for diuresis.
The Neurology consultation felt the patient to be minimally
responsive; likely due to anoxic brain injury. They agreed
with workup in progress and recommended re-evaluating
neurologic examination over several days to evaluate for
prognosis.
While ventilation was easy, the patient required
neuromuscular paralysis because she was continually biting
her tongue. After an oral airway was placed, it was possible
to discontinue paralysis, and the patient remained
comfortable on pressor support ventilation.
A lumbar puncture was attempted on [**11-22**] and failed.
It was noted that lumbar puncture had been attempted the week
prior with no success, and this procedure was not again
repeated after this attempt.
As sedation was weaned, the patient was able to open her eyes
intermittently and move purposefully, but had no meaningful
interaction. Pressor support was decreased to a certain
extent, but the patient was unable to become independent of
the ventilator. Levels of positive end-expiratory pressure
were required at all times for the patient's comfort. She
continued to receive occasional lorazepam for increased
agitation. Final report of electroencephalogram showed
minimal activity. The patient continued to have fevers
during the last week of [**Month (only) 1096**].
By [**11-26**], there was a high concern that the patient
would be in a persistent vegetative state. Discussions
continued with the family over the level of aggressiveness
the patient would want; and in the meantime, metabolic
abnormalities such as hyponatremia and anemia were addressed.
On [**11-28**], it was felt that the patient was likely to
remain in a persistent vegetative state, and the possibility
of withdrawal of life support was discussed with the family
on [**11-29**].
Extensive discussions were had with the patient's husband
[**Location (un) 4597**] from this time on. He understood that his wife had
suffered significant cortical anoxic brain injury and had a
poor prognosis for recovery. He stated at that time that he
wished for [**Known firstname 9300**] to have no further procedures; including no
lumbar puncture, new central venous access, arterial access,
lung biopsy, or blood products.
On [**11-25**], Ms. [**Known lastname 9302**] blood cultures grew methicillin-resistant
Staphylococcus aureus. Her husband was [**Name (NI) 653**] by the
pulmonary fellow (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9303**]) and informed that the
patient had a lethal blood infection which could only be
treated by changing her central intravenous access. Mr. [**Known lastname **]
[**Last Name (Titles) 9304**] that he understood, but affirmed his wishes to not
place any new central lines or perform invasive procedures.
Mr. [**Known lastname **] and his family were continually informed that the
medical team did not feel that further medical intervention
would improve Ms. [**Known lastname 9302**] prognosis or comfort, but for
several days the family remainder uncomfortable with
withdrawing life support.
On [**12-2**], the patient's family met with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 9303**] and with Dr. [**First Name (STitle) 9305**] [**Name (STitle) 9306**] from the Ethic Support
Service. At this time, all parties agreed to respect
[**Known firstname 9300**]'s prior wishes to not continue aggressive
interventions. On that day, [**Known firstname 9300**]'s care was changed to
focus on comfort; however, the family felt that [**Known firstname 9300**] was
comfortable on ventilator support and wished this to be
continued. All intravenous medications, fluids, and
laboratory draws were otherwise discontinued; including
intravenous phenylephrine. Morphine was ordered to
administered as needed for discomfort; however, the family
did not want prophylactic continuous morphine infusion.
The patient was continued with ventilatory support and as
needed morphine sulfate until [**12-5**]. On [**12-5**], a
Medical Intensive Care Unit house officer was called to
pronounce the patient's death at 6:29 p.m. Pupils were fixed
and dilated. No spontaneous heart beat or breathing.
Asystole by telemetry. The patient's husband [**Location (un) 4597**] was
called and notified at 6:40 p.m. A postmortem examination
was declined.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 8352**]
MEDQUIST36
D: [**2177-12-7**] 15:10
T: [**2177-12-9**] 08:23
JOB#: [**Job Number 9307**]
|
[
"042",
"427.5",
"276.1",
"038.11",
"255.4",
"518.81",
"996.62",
"518.5",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
2563, 3434
|
6715, 12251
|
275, 1867
|
1890, 2536
|
3450, 6697
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,784
| 136,351
|
25153
|
Discharge summary
|
report
|
Admission Date: [**2140-10-28**] Discharge Date: [**2140-11-2**]
Date of Birth: [**2066-3-15**] Sex: M
Service: SURGERY
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Fell down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 M s/p mechanical trip/fall onto L side @12.30pm; syncope
@16.30 for a few sec.; admitted at [**Hospital 1474**] hospital ER, no head
trauma -> CT head neg, CT [**Last Name (un) 103**]: L perinephric hematoma, ?splenic
lac; -> transfer [**Hospital1 18**]
Past Medical History:
HTN, prostate CA, s/p prostatectomy
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
on arrival to ED:
100.4 128/91 69 100%3L
General: no collar, no board
HEEENT: NCAT, PERRLA/EOMI, OPE, midface stable
Neck: Non tender
CVS: RRR, +s1/s2, chest stable
Pulm: CTAB, no crackles/wheezes
Abd: soft, NT, ?left sided distension, no ecchymosis
Ext: no stepoff/deformity, L elbow laceration
GU: trace guiac +, good rectal tone, no gross blood
Pertinent Results:
[**2140-10-28**] 09:57PM freeCa-1.05*
[**2140-10-28**] 09:57PM HGB-11.4* calcHCT-34 O2 SAT-96 CARBOXYHB-2.9
MET HGB-0.2
[**2140-10-28**] 09:57PM GLUCOSE-134* LACTATE-2.1* NA+-143 K+-4.8
CL--110 TCO2-23
[**2140-10-28**] 09:57PM PH-7.39 COMMENTS-GREEN TOP
[**2140-10-28**] 09:58PM URINE RBC-[**7-1**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2140-10-28**] 09:58PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-10-28**] 09:58PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.044*
[**2140-10-28**] 09:58PM PLT COUNT-218
[**2140-10-28**] 09:58PM WBC-7.8 RBC-3.44* HGB-11.3* HCT-31.5* MCV-92
MCH-32.7* MCHC-35.7* RDW-13.3
[**2140-10-28**] 09:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2140-10-28**] 09:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-10-28**] 09:58PM AMYLASE-46
[**2140-10-28**] 09:58PM UREA N-28* CREAT-1.2
RADIOLOGY Final Report
C-SPINE, TRAUMA [**2140-10-28**] 10:30 PM
C-SPINE, TRAUMA
Reason: fx
[**Hospital 93**] MEDICAL CONDITION:
74 year old man s/p fall
REASON FOR THIS EXAMINATION:
fx
INDICATION: 74-year-old man status post fall.
CERVICAL SPINE, MULTIPLE VIEWS: The vertebral body heights are
preserved. There is some disc space narrowing at the C5-C6 level
with anterior and posterior osteophytosis, consistent with
degenerative changes. There are no fractures or dislocations
visualized. The prevertebral soft tissue is unremarkable. A soft
tissue density in the upper Mediastinum. PA and lateral chest
radiograph is recommended for further evaluation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 21827**] [**Name (STitle) 21828**]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: TUE [**2140-11-1**] 9:14 AM
RADIOLOGY Final Report
CT PELVIS W/CONTRAST [**2140-10-29**] 2:54 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval splenic lac, perinephric hematoma
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
74 year old man s/p fall
REASON FOR THIS EXAMINATION:
eval splenic lac, perinephric hematoma
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE ABDOMEN AND PELVIS WITH THE ADMINISTRATION OF
INTRAVENOUS CONTRAST
INDICATION: 74-year-old male status post fall with splenic
laceration and perinephric hematoma.
TECHNIQUE: Contiguous 5 mm axial images were obtained from the
lung bases to the pubic symphysis with the administration of
intravenous contrast. Images were reformatted in the sagittal
and coronal planes.
FINDINGS: No prior examination for comparison. There are
bilateral calcified pleural plaques, compatible with prior
asbestos exposure. Small left-sided pleural effusion, and
atelectasis within the left lung base. No consolidation or
pulmonary mass in the visualized lung fields.
Evaluation of the liver demonstrates numerous hypodense lesions,
the largest measuring 1.5 cm within the liver dome, with central
density measurements of-5 Hounsfield units. Findings most
compatible with simple cysts, however, some of the smaller
lesions are too small to characterize. There is no intrahepatic
biliary ductal dilatation. There is a trace perihepatic fluid.
Calcified gallstones are identified.
There is minimal amount of low density fluid surrounding the
posterolateral aspect of the spleen. In addition, there is a
focal cleft within the posterolateral splenic body, which could
represent a tiny laceration, however, could represent normal
anatomic cleft. No active extravasation is seen.
There is a large left-sided perinephric hematoma, which measures
10.2 x 6.3 x 8.9 cm. There is anterior displacement of the left
kidney, however, no active extravasation is identified. The left
kidney opacifies well with contrast. The renal vein is patent,
and the collecting system is intact. The right kidney is grossly
normal. The pancreas and adrenal glands are normal.
There are no dilated loops of large or small bowel. No free
intraperitoneal gas. There is a small amount of fluid tracking
along the left pericolic gutter.
The patient is status post prostatectomy and nodal dissection,
with numerous clips within the pelvis. There is a Foley catheter
within a decompressed urinary bladder.
Small amount of fluid is identified within the right inguinal
ring.
Evaluation of osseous structures reveals degenerative change
amongst both hip joints, right side greater than left. There is
also degenerative change and osteophyte formation within the
thoracic and upper lumbar spine. No displaced rib fractures are
identified. Vertebral body height is preserved throughout.
IMPRESSION:
1. Large left perinephric hematoma with associated mass effect
on the left kidney. No active extravasation identified.
2. Possible tiny splenic laceration, without evidence of active
extravasation.
3. Gallstones.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2140-10-29**] 9:44 AM
CHEST (PA & LAT)
Reason: evaluate mediastinum with PA/lat CXR
[**Hospital 93**] MEDICAL CONDITION:
74 year old man with L perinehpric hematoma & splenic lac s/p
fall. Widened mediastinum on flat AP portable CXR.
REASON FOR THIS EXAMINATION:
evaluate mediastinum with PA/lat CXR
CHEST TWO VIEWS.
INDICATION: 74-year-old man with left perinephric hematoma.
COMMENTS: PA and lateral radiographs of the chest are reviewed.
No previous study is available for comparison.
There is small left pleural effusion associated with atelectasis
in the left lung base. The lungs are clear otherwise. The heart
and mediastinum are within normal limits.
There is question of pleural plaques in the lateral portion of
the right lung as well as right hemidiaphragm.
IMPRESSION: Small left pleural effusion and atelectasis in the
left lung base. Probable asbestos related pleural disease.
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: SUN [**2140-10-30**] 6:51 AM
Brief Hospital Course:
On arrival to [**Hospital1 18**] pt. was evaluated by the emergency
department and trauma surgery staff. Pt was imaged and found to
have a small splenic laceration and a large perinephric
hematoma. Pt was admitted to the trauma SICU for monitoring of
vital signs and serial hematocrits. During stay in TSICU,
hematocrits dropped to mid 20's, but then stabilized. Pt. was
transferred to the floor on bedrest and observed for a number of
days. Pt was ready for d/c when had one episode while climbing
stairs with PT of transient hypotension, lightheadedness and
oxygen desaturation & quickly recovered with addition of 2L o2.
Pt. was cleared by PT to return home. Pt was kept for one more
night in hospital for observation and was stable. Morning of d/c
crit was low but still in stable range, and pt. was offered a
blood transfusion for his anemia. Pt refused transfusion and
decided that he would return home without it being done. Pt made
aware that if there are any concerns or problems including any
signs/symptoms of increasing anemia or bleeding, he is to go to
the emergency room & to call [**Hospital1 18**] for the trauma team to adress
his concerns. Pt. d/c'd home with PCP follow up within 2 weeks
and trauma [**Doctor First Name **] follow up within 4 weeks.
Medications on Admission:
ASA, atenolol
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Fall
Left Large perinephric hematoma
Grade [**1-24**] splenic laceration
Discharge Condition:
stable
Discharge Instructions:
-Take your medications as perscribed
-If you have any concerns, please call the [**Hospital1 827**] trauma clinic at [**Telephone/Fax (1) 6946**]
-For the next two weeks, take a baby aspirin (81mg) daily
instead of your regular full strength aspirin (325mg)
-Follow up with your primary care physician and with the trauma
service for continued evaluation and treatment of your internal
injuries
--Do not partake in any activity that will result in trauma to
your abdomen. If you experience any symptoms of blood loss,
including but not limited to dizziness, fast heart rate, sudden
extreme fatigue, or feeling of faintness please proceed to the
emergency room. Please let those around you know that you have a
healing spleen injury and that if you pass out, you should be
taken to the closest emergency room immediately because you may
be bleeding internally.
Followup Instructions:
1) Please call to make a follow up appointment in 4 weeks in the
trauma surgery clinic: [**Telephone/Fax (1) 6946**]
2) Please call to make an appointment to repeat a CT scan of
your abdomen in 3 weeks (prior to your visit to the trauma
surgery clinic), particularly paying attention to your left
kidney and your spleen: [**Telephone/Fax (1) 327**]
2) Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up
appointment within 2 weeks of your hospital discharge.
|
[
"866.01",
"511.9",
"865.00",
"E888.9",
"501",
"V10.46",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8885, 8891
|
7140, 8411
|
280, 287
|
9008, 9017
|
1083, 2190
|
9925, 10437
|
681, 698
|
8475, 8862
|
6240, 6353
|
8912, 8987
|
8437, 8452
|
9041, 9902
|
713, 1064
|
231, 242
|
6382, 7117
|
315, 573
|
595, 632
|
648, 665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,424
| 180,671
|
31193
|
Discharge summary
|
report
|
Admission Date: [**2151-7-16**] Discharge Date: [**2151-7-20**]
Date of Birth: [**2098-2-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Submucosal mass of ascending colon
Major Surgical or Invasive Procedure:
lap converted to open R colectomy
History of Present Illness:
Mr. [**Known lastname 18721**] is a 53-year-old
gentleman who underwent a colonoscopy as workup for bright
red blood per rectum in [**2150-9-16**] that identified a 2 cm
submucosal lesion within the proximal transverse colon. This
was felt to be consistent with a lipoma, and the remainder of
the colonoscopy was unremarkable. A follow-up colonoscopy
this past [**Month (only) 116**] showed that this submucosal lesion had enlarged
to 4 cm and the overlying mucosa was normal. The lesion was
inked and the patient was referred to Dr. [**Last Name (STitle) **] for an
endoscopic ultrasound which was obtained this past [**Month (only) **]. This
showed a 2-3 cm submucosal mass in the ascending colon that
was heterogeneous and was felt to be consistent with a GI
stromal tumor or a carcinoid and not a lipoma. Accordingly, he
was referred to me for surgical resection. Given the fact
that he had no prior abdominal surgery as well as the fact
that he was obese, I recommended a laparoscopic-assisted partial
colectomy. He understood the risks and benefits of the procedure
and consented to proceed.
Past Medical History:
bipolar d/o, sleep apnea, gout/arthritis, GERD
Social History:
He is currently on disability, having formerly worked at a
factory in [**Location 4288**]. He has a 60-pack-year smoking history, but
quit approximately 20 years ago. He consumes 4-5 drinks per
week.
.
Family History:
+ hypercholesterolemia, + DM
Physical Exam:
v.s.s
A and O x 3, nad
rrr, no m/r/g
LSCTA bilat
soft, nt, nd, + bs
no c/c/e
Pertinent Results:
[**2151-7-20**] 06:20AM BLOOD WBC-8.4 RBC-3.00* Hgb-8.9* Hct-25.8*
MCV-86 MCH-29.5 MCHC-34.4 RDW-13.4 Plt Ct-231
[**2151-7-16**] 04:17PM BLOOD WBC-17.8*# RBC-3.80* Hgb-11.2* Hct-32.9*
MCV-87 MCH-29.5 MCHC-34.0 RDW-13.2 Plt Ct-233
[**2151-7-17**] 04:44AM BLOOD Neuts-91.2* Lymphs-3.6* Monos-4.7 Eos-0.4
Baso-0.1
[**2151-7-20**] 06:20AM BLOOD Plt Ct-231
[**2151-7-16**] 04:17PM BLOOD Plt Ct-233
[**2151-7-16**] 07:16PM BLOOD PT-13.0 PTT-22.7 INR(PT)-1.1
[**2151-7-20**] 06:20AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-143
K-3.7 Cl-105 HCO3-29 AnGap-13
[**2151-7-16**] 04:17PM BLOOD Glucose-208* UreaN-14 Creat-0.7 Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
[**2151-7-20**] 06:20AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.9
[**2151-7-16**] 04:17PM BLOOD Calcium-7.9* Phos-3.1 Mg-1.6
.
MRSA SCREEN (Final [**2151-7-19**]): No MRSA isolated.
Brief Hospital Course:
53 y/o M with PMHx of Bipolar Disorder and submucosal colonic
mass on who was admitted for elective laparoscopic colectomy
today. The procedure was complicated by significant bleeding and
it was converted to an open colectomy. Pt had approximately
1200cc of blood loss and received 4L of crystalloid intraop. Per
report, pt had a total of 200cc of urine output in the OR and
was mildly tachycardic to 115 in the PACU. Pt had an arterial
line and MAPs remained >65 without pressor requirement. There
was concern for blood loss and need for closer monitoring, thus
he was transferred to [**Hospital Unit Name 153**].
On arrival to the [**Name (NI) 153**], pt was complaining of mild nausea and
[**7-26**] pain that resolves entirely when he presses the PCA
dilaudid.
.
Once the pt was stable he was transferred to the floor. He was
maintained as NPO with IVF/PCA/FOLEY. With the return of bowel
function/flatus his diet was slowly advanced from sips to
regular. All home meds were restarted along with po pain meds.
The patient's lab values remained stable throughout the rest of
his stay.
All d/c paperwork was reviewd and questions answered.
Medications on Admission:
haldol 2.5 HS, prilosec 20'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks: do not take
more than 4000mg of acetaminophen in 24 hrs. .
Disp:*45 Tablet(s)* Refills:*0*
2. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
submucosal mass of the ascending colon
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
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 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* 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:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-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.
.
Followup Instructions:
1. Please call Dr.[**Name (NI) 12822**] office, [**Telephone/Fax (1) 7508**], to make a
follow up appointment in [**12-18**] weeks.
Completed by:[**2151-8-19**]
|
[
"530.81",
"998.11",
"274.9",
"285.1",
"211.3",
"V64.41",
"E878.6",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"45.93"
] |
icd9pcs
|
[
[
[]
]
] |
4451, 4457
|
2816, 3960
|
349, 385
|
4540, 4619
|
1964, 2793
|
6148, 6311
|
1821, 1852
|
4038, 4428
|
4478, 4519
|
3986, 4015
|
4643, 5785
|
5800, 6125
|
1867, 1945
|
275, 311
|
413, 1513
|
1536, 1584
|
1600, 1804
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,169
| 107,757
|
44981
|
Discharge summary
|
report
|
Admission Date: [**2103-7-11**] Discharge Date: [**2103-7-19**]
Date of Birth: [**2032-12-26**] Sex: F
Service: MEDICINE
Allergies:
Naprosyn
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
1. Mesenteric Angiography.
2. Enteroscopy w/ Cautery and Tattoo.
History of Present Illness:
This a 71 year old female with multiple medical problems
including recurrent GI bleed, coronary artery disease,
hypertension, diabetes mellitus type 2, gastritis,
hypercholesterolemia, chronic renal insufficiency and depression
who presents to the ED after finding her blood pressure to be
84/54 at home on the day of admission. Patient reports having
worsening dyspnea on exertion, dark stools, dizziness with
standing and chest pressure with walking x 3-4 days. Patient
has a history of upper GI bleed secondary to gastritis ([**4-27**])
and a negative workup for a duodenal neuro-endocrine tumor.
Most recent hospitalization for bleeding was secondary to small
bowel AVMs found on EGD. Denies changes in diet, fever/chills,
abdominal pain, recent alcohol consumption, nausea/vomitting or
recent trauma. Patient has been taking a baby ASA daily and iron
pills three times daily.
.
In the emergency room, the patient was found to have a Hct of
15.6 and HR or 61. She received intravenous fluids and 40 mg of
intravenous protonix. A nasogastric lavage was performed which
did not reveal an active bleed but also failed to produce bile.
Patient was tranfused two units of PRBCs and her Hct
subsequently rose to 23. GI was consulted and the patient was
admitted to medicine for further observation.
Past Medical History:
1. Gastritis
2. History of upper gastrointestinal bleed
3. Duodenal neural endocrine tumor, negative workup;
4. Coronary artery disease, status post percutaneous
transluminal coronary angioplasty in [**2095**]
5. Hypertension
6. Hypercholesterolemia
7. Type 2 diabetes
8. Chronic renal insufficiency, baseline 1.5 to 1.7
9. osteoarthritis
10. History of sarcoid, untreated
11. History of migraines
12. Status post appendectomy
13. Total abdominal hysterectomy/bilateral salpingo-oophorectomy
14. Status post parathyroid adenoma resection
15. Status post left wrist fusion
16. Status post small bowel resection in [**2077**]
17. History of small bowel bleed, s/p electrocauterization of
AVMs `04
18. History of hospitalization for intermittent small bowel
obstruction
Social History:
Former smoker, quit greater than 30 years
ago. Alcohol use, occasionally.
Family History:
Non-contributory
Physical Exam:
Vital signs on admission
afebrile, heart rate 68, pressure 155/64, breathing at 15, % on
room air. General: Alert and oriented, pleasant, no dyspnea and
no acute distress.
Head, eyes, ears, nose and throat, moist mucous
membranes,oropharynx clear. Lungs clear to auscultation
bilaterally.
Cardiovascular, regular rate with a II/VI systolic ejection
murmur at base radiating to carotids. No carotid bruits
auscultated. No jugulovenous pressure.
Abdominal examination, soft, nontender,nondistended. Hypoactive
bowel sounds.
Extremities, no cyanosis, clubbing or edema. Alert and oriented
times three.
No cranial nerve deficits.
Pertinent Results:
[**2103-7-11**] 02:30AM BLOOD WBC-4.3 RBC-1.58*# Hgb-4.6*# Hct-15.6*#
MCV-99*# MCH-29.4# MCHC-29.7* RDW-21.3* Plt Ct-208
[**2103-7-11**] 02:30AM BLOOD Neuts-76.5* Bands-0 Lymphs-17.1*
Monos-5.9 Eos-0.4 Baso-0.2
[**2103-7-11**] 02:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Schisto-1+ Stipple-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2103-7-11**] 02:30AM BLOOD PT-12.6 PTT-24.3 INR(PT)-1.0
[**2103-7-11**] 02:30AM BLOOD Glucose-192* UreaN-91* Creat-2.5* Na-138
K-4.1 Cl-103 HCO3-24 AnGap-15
[**2103-7-11**] 02:30AM BLOOD ALT-12 AST-42* LD(LDH)-414* CK(CPK)-51
AlkPhos-53 Amylase-121* TotBili-0.3
[**2103-7-11**] 02:30AM BLOOD Lipase-171*
[**2103-7-11**] 02:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2103-7-11**] 02:30AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.2 Mg-2.2
Cholest-113
[**2103-7-11**] 02:30AM BLOOD VitB12-204* Folate-18.8
[**2103-7-11**] 02:30AM BLOOD Triglyc-191* HDL-28 CHOL/HD-4.0
LDLcalc-47
[**2103-7-11**] 02:30AM BLOOD TSH-2.1
[**2103-7-11**] 03:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2103-7-11**] 03:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
EKG [**2103-7-11**]
Sinus rhythm, without diagnostic abnormality. Compared to the
previous tracing of [**2103-1-18**] T wave inversions are no longer
present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 176 102 428/444.85 66 -1 95
.
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2103-7-16**] 7:12 AM
Reason: embolize site of ooze in proximal jejenum.
IMPRESSION: Selective arteriography of the superior mesenteric
artery and jejunal branches demonstrated no evidence of
arteriovenous malformation or active hemorrhage.
.
ECHO [**2103-7-17**]
The left atrium is mildly dilated. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF 60%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
A/P: 71 year old female with multiple medical problems who
presented with GI bleed.
1. GIB: A push enteroscopy was performed that revealed melena in
the duodenum and fresh blood in the proximal jejunum 80-90 cm
from teeth. Copious irrigation and epinephrine injection failed
to halt the bleeding. On the floor her Hct dropped to 16 from 23
and the pt became tachycardic, so she was transferred to the
MICU.
.
In the MICU, patient received 4U and went from Hct of ~15 to low
30s. She received 1 more unit given cardiac status to bring
Hct>30. Upon transfer to MICU IR consulted for embolization,
however pt was unstable with MI. Cardiology saw patient on [**7-14**]
felt CEs were trending downward and recommended IR embolization
to stop bleed in proximal jejunum. Patient was subsequently
transferred to the medicine floor.
IR was unable to embolize the source of bleed and so patient
underwent repeat endoscopy with successful cauterization of the
site of bleed. The site was also tattooed. Patient received an
additional unit of PRBCs on the floor and her hematocrit
remained stable and she also was continued on protonix [**Hospital1 **].
.
2. NSTEMI- She developed chest pain and EKG showed ST depression
in V4-V6. Cardiac troponin peaked at 2.5. NSTEMI was likely
secdonary to demand ischemia with tachycardia in setting of her
GI bleed. She was started on BB. Plaxix and asapirin were held
given history of GI bleed. Cardiology saw patient on [**7-14**] felt
CEs were trending downward and recommended IR embolization to
stop bleed in proximal jejunum. A repeat ECHO on [**2103-7-17**] was
mainly unchanged aside from increased left ventricular
hypertrophy. Patient had remained chest pain free from the time
of tranfer from the MICU to the day of discharge.
.
3.HTN- On the floor, blood pressure was not as well controlled
off nitro drip and beta blocker. Patient was transitioned from
PO nitrates and hydralazine to beta blocker and [**Last Name (un) **].
.
4. Acute on CRI- Cr 2.5 on admission from baseline Cr 1.6-1.9.
Creaine was within baseline at 1.7 at time of discharge.
.
5. Hypernatremia- Was thought to be likely secondary to normal
saline boluses and free water loss. PO intake was encouraged
was resolved by time of discharge.
.
6. Anemia- patient was found to have iron deficiency anemia and
vitamin B12 deficient. Patient was started on vitamin B12
1000mcg oral supplementation QD.
6.PPX-pneumoboots, PPI [**Hospital1 **]
.
7.Code- full
Medications on Admission:
1) apirin 81mg QD
2) lipitor 10mg QD
3) [**Doctor First Name 130**] 60mg [**Hospital1 **]
4) celexa 40mg QD
5) clonidine 200mcg [**Hospital1 **]
6) cozaar 50mg QD
7) FeSO4 300mg TID
8) Flonase 50mcg one spray each nostril [**Hospital1 **]
9) Lasix 40mg QAM
10) Glipizide 5mg TID
11) Hydralazine 50mg 1.5 tabs QID
12) Lasix 20mg QHS
13) Nitrostat 0.3mg as needed
14) Norvasc 10mg QD
15) Protonix 40mg [**Hospital1 **]
Discharge Medications:
1. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO once a day.
Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2*
7. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Fe-Tabs 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
9. Citalopram Hydrobromide 40 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Principal:
1. Gastrointestinal bleed.
2. Non-ST elevation myocardial infarcation.
3. Acute Renal Failure.
4. Blood Loss Anemia.
5. Left Lower Lobe Pneumonia.
6. Vitamin B12 Deficiency.
Secondary:
1. Chronic Renal Insufficiency.
2. Hypertension.
3. Sarcoidosis.
4. Hypercholesterolemia.
5. Osteoarthritis.
6. Migraines.
7. Upper GI Bleed.
8. Duodenal Neuroendocrine Tumor.
9. CAD - Angioplasty Lcx [**10/2096**].
10. Diabetes Mellitus Type II.
11. Iron Deficiency Anemia.
13. s/p Parathryoid Adenoma Resection.
14. s/p Appendectomy.
15. s/p Small bowel resection.
16. s/p TAH-BSO.
Discharge Condition:
Good
Discharge Instructions:
Please take the medications listed below until you follow-up
with your primary care physician. [**Name10 (NameIs) 357**] do not resume your
outpatient medications unless they are listed below:
*1) Celexa (Citalopram Hydrobromide) 40 mg One Tablet by mouth
DAILY
2) Losartan Potassium (Cozaar) 50 mg One Tablet by mouth DAILY
*3) Calcium Carbonate 500 mg Chewable One (1) Tablet Chewable
three times daily W/MEALS
*4) Cholecalciferol (Vitamin D3) 400 unit Two Tablets by motuh
daily
*5) Pantoprazole Sodium (Protonix) 40 mg Delayed Release One (1)
Tablet by mouth daily
6) Lipitor 10 mg One (1) Tablet by mouth daily
*7) Glipizide 10 mg, Sust Release Osmotic Push One (1) Tab by
mouth daily
*8) Atenolol 25 mg Three (3) Tablet all together by mouth daily
9) Fe-Tabs (Iron) 325 (65) mg One (1) Tablet by mouth daily
*signify new doses for medications and prescriptions attached to
this discharge summary
[] Please call your PCP or return to the emergency room if you
experience chest pain, nausea or vomitting, shortness of breath
or any othter worrying symptoms.
Followup Instructions:
[] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14839**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:Tues [**2103-7-24**]
9:00am
[] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD GASTROENTEROLOGIST Where: [**Hospital Unit Name **] [**Location (un) **] SUITE 8E Phone:[**Pager number **]=[**Telephone/Fax (1) **] Date/Time: [**2103-8-1**]
1:15pm
[] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD CARDIOLOGY Where: [**Hospital 273**] CARDIOLOGY Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2103-8-21**] 10:30am
Completed by:[**2103-9-1**]
|
[
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"584.9",
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"486",
"V45.82",
"272.0",
"410.71",
"285.1",
"414.01",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.47",
"99.04",
"39.98"
] |
icd9pcs
|
[
[
[]
]
] |
9711, 9717
|
5725, 8191
|
277, 344
|
10342, 10349
|
3251, 5702
|
11466, 12154
|
2571, 2589
|
8658, 9688
|
9738, 10321
|
8217, 8635
|
10373, 11443
|
2604, 3232
|
229, 239
|
372, 1673
|
1695, 2464
|
2480, 2555
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,034
| 150,225
|
42081
|
Discharge summary
|
report
|
Admission Date: [**2174-11-2**] Discharge Date: [**2174-12-7**]
Service: SURGERY
Allergies:
adhesive tape
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Left lower extremity ischemia with ulceration and rest pain.
Major Surgical or Invasive Procedure:
[**2174-11-4**] - Left common femoral to peroneal artery bypass
with in situ saphenous vein. (Dr. [**Last Name (STitle) **]
[**2174-11-10**] - Exploratory laparotomy, extended right
hemicolectomy, ileostomy, and then gastrojejunostomy tube
placement. (Dr. [**First Name (STitle) **]
[**2174-11-30**] - Exploratory laparotomy
[**2174-11-29**] - ileoscopy, EGD
History of Present Illness:
Patient is a 87-year-old female with hyperlipidemia and history
of tobacco use presenting with a 3- month history of a left foot
ulceration and severe rest pain on that side. In the past
couple of weeks, she has started to have rest-pain symptoms on
the right as well. She states that she continued to have pain
while in bed and would find some relief by swinging her legs
over the edge of the bed. She had arteriography on [**2174-10-28**] which
showed long-segment occlusions of the left superficial femoral
artery and tibioperoneal trunk with single-vessel runoff. The
decision was made to bring the patient for an elective bypass
surgery.
Past Medical History:
PMH: Atrial fibrillation, Hypercholesterolemia, Tobacco use,
History of potential TIA which she describes as racing heart
rate but no focal neurologic deficit, history of arthritis,
history of gout
PSH: Surgery for hemorrhoids.
Social History:
Retired, lives independently but admits to increasing difficulty
with ambulation and mobility; uses a walker. Currently smokes
with past history of tobacco use. She has 1 alcoholic drink a
day.
Family History:
Non-contributory
Physical Exam:
PE on discharge:
patient had no breath sounds, no pulse, no gag reflex, there was
no heart beat, the pupils were fixed and non-reactive
Pertinent Results:
laboratory:
CBC
[**2174-11-2**] 08:20PM BLOOD WBC-5.0 RBC-3.20* Hgb-10.7* Hct-34.0*
MCV-106* MCH-33.4* MCHC-31.5 RDW-13.9 Plt Ct-136*
[**2174-11-9**] 06:40PM BLOOD WBC-14.1* RBC-3.15* Hgb-10.3* Hct-31.4*
MCV-100* MCH-32.8* MCHC-32.9 RDW-16.2*
[**2174-11-12**] 01:39AM BLOOD WBC-11.6* RBC-3.37*# Hgb-10.8*# Hct-32.9*
MCV-98 MCH-32.0 MCHC-32.8 RDW-17.1* Plt Ct-28*
[**2174-11-14**] 04:31AM BLOOD WBC-19.9* RBC-2.76* Hgb-8.8* Hct-27.8*
MCV-101* MCH-31.9 MCHC-31.7 RDW-17.1* Plt Ct-50*
[**2174-12-7**] 04:07AM BLOOD WBC-16.3* RBC-3.44* Hgb-10.9* Hct-35.6*
MCV-104* MCH-31.6 MCHC-30.5* RDW-21.0*
Coags:
[**2174-11-7**] 09:52AM BLOOD PT-30.3* PTT-50.3* INR(PT)-3.0*
[**2174-12-7**] 04:07AM BLOOD PT-20.1* PTT-49.1* INR(PT)-1.9*
[**2174-12-7**] 05:00AM BLOOD Plt Smr-LOW Plt Ct-131*
electrolytes:
[**2174-11-2**] 12:30PM BLOOD Glucose-116* UreaN-15 Creat-0.8 Na-141
K-4.3 Cl-102 HCO3-33* AnGap-10
[**2174-11-10**] 09:27AM BLOOD Glucose-116* UreaN-46* Creat-1.2* Na-139
K-3.3 Cl-103 HCO3-26 AnGap-13
[**2174-12-7**] 04:07AM BLOOD Glucose-155* UreaN-55* Creat-1.2* Na-138
K-4.4 Cl-109* HCO3-17* AnGap-16
LFTs:
[**2174-11-7**] 09:52AM BLOOD ALT-300* AST-1020* LD(LDH)-1314*
CK(CPK)-161 AlkPhos-128* Amylase-37 TotBili-2.2*
[**2174-11-10**] 09:27AM BLOOD ALT-171* AST-311* AlkPhos-99 TotBili-3.6*
[**2174-11-30**] 12:49AM BLOOD ALT-22 AST-47* CK(CPK)-30 AlkPhos-102
Amylase-29 TotBili-6.3*
[**2174-12-6**] 04:26AM BLOOD ALT-23 AST-87* LD(LDH)-161 CK(CPK)-16*
AlkPhos-277* Amylase-37 TotBili-10.6*
[**2174-12-7**] 04:07AM BLOOD ALT-21 AST-69* AlkPhos-243* TotBili-11.8*
lactate:
[**2174-11-14**] 02:23AM BLOOD Glucose-158* Lactate-4.0* Na-140 K-5.5*
Cl-113*
[**2174-11-14**] 02:56AM BLOOD Lactate-5.8*
[**2174-11-23**] 07:15PM BLOOD Glucose-148* Lactate-1.4 K-4.5
[**2174-12-6**] 09:11AM BLOOD Lactate-1.9
[**2174-12-7**] 07:06AM BLOOD Lactate-2.2*
imaging:
[**2174-11-7**] No evidence of hydronephrosis. Simple left renal
cyst.
[**2174-11-7**] CTA chest
1. No pulmonary embolus.
2. Large bilateral pleural effusions with adjacent compressive
atelectasis.
3. Splenic infarcts.
4. Mural thickening involving the cecum, ascending colon, and
distal ileum
concerning for bowel ischemia given cardiomegaly and extreme
calcification at
the origins of the celiac artery and SMA.
5. Imaging findings consistent with chronic pancreatitis.
6. Septated left adnexal lesion requiring further workup with
ultrasound when
the patient's condition is stabilized.
7. Surgical changes in the left inguinal region as described.
[**2174-11-9**] Liver US
1. No gallstones and no signs of cholecystitis. No biliary
dilatation.
2. Trace of ascites in the perihepatic space and small right
pleural
effusion.
[**2174-11-14**] CTA abdomen/pelvis
1. Interval increase to moderate right and small left pleural
effusions which
are simple in appearance.
2. Status post extended right hemicolectomy and ileostomy with
GJ tube in
place and moderate free fluid without evidence of
perforation/leak or ischemic
bowel.
3. Focal ectasia in the infrarenal abdominal aorta.
4. Septated left adnexal cyst for which followup ultrasound as
an outpatient
is still recommended.
5. Small left groin hematoma.
6. Findings compatible with chronic pancreatitis.
[**2174-11-23**] CXR
Persistent right lower lobe collapse.
[**2174-11-23**] CXR post-bronchoscopy
There has been interval resolution of right lower lobe collapse
compared to prior study performed one hour earlier. Small right
pneumothorax is
unchanged. Left lower lobe opacities are new a combination of
pleural
effusion and atelectasis, aspiration cannot be excluded. ET tube
is in
standard position. Cardiomediastinal contours are unchanged.
Increased
opacity in the left upper lobe is consistent with atelectasis.
Right basal
pigtail catheter is in place.
[**2174-11-23**] CTA abdomen/pelvis
1. New small bowel dilation with fluid-filled loops, most
consistent with an ileus.
2. No definite pneumatosis or secondary signs of mesenteric
ischemia. No
arterial or venous filling defects to suggest mesenteric
ischemia.
3. Small amount of ascites, slightly increased from prior exam.
4. New right pneumothorax, which is incompletely evaluated.
[**2174-12-4**] US gallbladder/ liver
1. Patent hepatic vasculature with appropriate direction of
flow.
2. Moderate amount of intra-abdominal ascites and bilateral
pleural
effusions.
[**2174-12-6**] CXR
1. New right upper lobe early complete collapse.
2. Moderate right pleural effusion and right lower lobe
atelectasis.
[**2174-12-6**] CXR post-bronchoscopy
1. Resolution of early complete right upper lobe collapse.
2. Still moderate right pleural effusion with associated
atelectasis.
ECHOACRDIOGRAPHY
[**2174-11-7**]
Right ventricular cavity enlargement with mild free wall
hypokinesis. Severe tricuspid regurgitation. Pulmonary artery
hypertension. Moderate mitral regurgitation. Normal left
ventricular cavity size with preserved global and regional
systolic function.
[**2174-11-14**] The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 5-10 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2174-11-30**]
the degree of TR seen has increased. LVEF and RVEF are similar.
[**2174-12-6**]
Dilated right ventricle with mild global hypokinesis. Severe
tricuspid regurgitation with likely underestimated pulmonary
arterial systolic pressure. Borderline LV function. Mild to
moderate mitral regurgitation.
[**2174-11-29**] EGD
Normal mucosa in the whole esophagus
Schatzki's ring
G-tube site without any ulceration. Tube passed through the
pylorus into the duodenum. There was mild gastritis in the
fundus and body of the stomach
Normal mucosa in the third part of the duodenum
Otherwise normal EGD to third part of the duodenum
[**2174-11-29**] ileoscopy
Friable, erythematous mucosa with superficial ulceration was
noted from ileostomy site to 20cm in. Beyond 20cm mucosa
appeared normal. These findings can be consistent with ischemia.
Otherwise normal colonoscopy to mid-ileum
Brief Hospital Course:
Patient presented for an elective left lower extremity bypass.
She tolerated the operation well. Post-operatively patient
experienced multiple complication.
neuro: Patient presented alert and oriented. During the periods
she was intubated she received minimal sedation and adequate
pain control, primarily fentanyl. She became less responsive on
[**12-4**] and her mental status declined progressively over the next
two days. On [**12-7**] she was not even responding to pain stimulus
while off any analgesics or sedatives.
CV: Patient has chronic atrial fibrillation in which she
remained during her hospitalization. She was initially
anticoagulated with Coumadin. The Coumadin was stopped on [**11-23**]
when a concern arose for bleeding from her ileostomy. There were
four echocardiogram performed during the stay. Patient was found
to have right ventricular hypokinesis which improved for a week
or so, then worsened again. She was also found to have severe
mitral and tricuspid regurgitation. The tricuspid regurgitation
has worsened throughout the stay. Patient remained
hemodynamically stable for greatest majority of her stay. She
required just transient vasopressor support during the two
periods when she experienced respiratory failure. Following the
episode of right upper lobe collapse on [**12-6**], she did not
recover her blood pressure despite the fluid resuscitation. She
was then started on vasopressors.
pulmonary: Patient has a history of smoking. Initially, she was
extubated following an operation. She experienced respiratory
failure likely following fluid overload. She experienced a
second episode of hypercapnic respiratory failure while in the
ICU and a third episode while on the floor. All together patient
was reintubated three times during this hospital stay. The last
time she was reintubated was on [**11-23**] and she has remained
intubated since. She experienced two episodes of right lower
lobe collapse, first one on [**11-23**] and the second one on [**12-6**].
Bronchoscopy was performed both times with satisfactory outcome.
The sputum and the BAL samples sent throughout the stay only
grew yeast. She was not suspected to have a respiratory
infectious process. She also had right pleural effusion which
was drained by the interventional pulmonology. The drain
remained in place for 13 days. The effusion reaccumulated since
the time of withdrawal, yet the choice was made not to replace
the chest tube.
GI: Patient experienced mesenteric ischemia following the
operation which was determined by the overall decline and
physical exam. She underwent and exploratory laparotomy with the
resection of the right colon which was necrotic, creation of
end-ileostomy and GJ tube placement. She recovered from the
operation. Several days later, the output from the ileostomy was
guaiac positive. The colonoscopy was done by surgery service and
no ischemia was seen. The ileoscopy was performed by the GI
service. There was a finding of the luminal ischemic changes of
the distal 20 cm of the ileum. There was no frank necrosis.
Patient lactate was persistently elevated in the range of [**1-27**]
and on physical exam appeared to be having pain. She was
intubated at that time on minimal sedation. She was again taken
to the OR for an exploratory laparotomy. No ischemia or necrosis
were found. All the viscera appeared viable on inspection. The
abdominal fascia was closed and the skin remained open secondary
to severe anasarca. Wound vac was applied to the area the day
following the operation. Shortly after the second exploration,
trophic tube feeds were started. Secondary to persistent and
rising hyperbilirubinemia tube feeds were stopped and TPN was
started. TPN was administered for 3 days only. Tube feeds were
reinitiated and advanced to goal for 2 days. The ileostomy
output became blood tinged and patient was declining, thus all
feeding was stopped. The right upper quadrant US was done on
[**12-4**] and showed contracted gallbladder, not consistent with any
infection or necrosis. The duplex of the liver was done. There
was no portal vein thrombosis.
GU: Patient presented with normal renal function. She produced
adequate urine until the last week of her hospitalization when
she became oliguric with the urine output as low as 6 cc/hr. She
never required hemodialysis. Her BUN rose to 55 on [**12-7**].
ID: Patient was treated empirically for intraabdominal
infection, was on ciprofloxacin and Flagyl. Following the second
abdominal exploration she was also started on vancomycin to
cover the open wound. She was started on fluconazole on [**12-3**]
after 3rd urine culture grew yeast. There were no culture
positive for bacterial growth.
heme: Patient received blood transfusion as necessary. She did
not experience any frank hemorrhage. Her INR rose as was likely
indicative of liver dysfunction.
endo: no issues
dispo: Patient was made CMO on [**12-7**] at 12:14 pm after Dr. [**Last Name (STitle) **]
had a discussion with the health care proxy.
Medications on Admission:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2174-12-7**]
|
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icd9pcs
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14134, 14143
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1987, 8530
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1831, 1834
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1848, 1968
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181, 244
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671, 1317
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
329
| 172,132
|
26354
|
Discharge summary
|
report
|
Admission Date: [**2154-4-5**] Discharge Date: [**2154-4-9**]
Date of Birth: [**2102-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
RUQ pain and fevers x 1 day
Major Surgical or Invasive Procedure:
ERCP s/p CBD stent
History of Present Illness:
51 yo male with Hep B and C s/p liver trx from [**Country **] 1 year ago
and now new dx of likely HCC now with fevers to 105, right upper
quadrant abdominal pain. Denies nausea, vomiting, or diarrhea.
He had similar presentation in [**3-20**]/0707 and underwent ERCP and
was found to have a stricture in the CBD exchange of stent.
ROS
No night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, rhinorrhea or congestion. Reported cough x 1
day. Denies shortness of breath. Denied chest pain or tightness,
palpitations. Has been having 2 bm/ day no change. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias
Past Medical History:
1. Hepatocellular carcinoma diagnosed in [**12/2152**] with multiple
tumors; patient was not a candidate for transplant in US so had
an orthotopic transplant in [**Country 651**] [**5-/2153**] - f/u by Dr. [**Last Name (STitle) 497**] the
liver center.
2. Hepatitis B, diagnosed in [**2149**] - last viral load:
undetectable [**2154-2-21**]
3. Hepatitis C, diagnosed in [**2149**] - viral load undetectable in
[**12-26**]
His hepatitis B surface antibody was positive in the range of
1:450 on [**2154-3-28**]. His last alpha-fetoprotein level was
53.2 with an L3 fraction of 44.1 on [**2154-2-21**]. His last
HBV viral load was nondetectable in [**2154-2-21**].
4. Subcapsular liver fluid collection status post biopsy on
[**2153-12-27**]
5. Recent CT imaging in [**3-27**] demonstrates multiple lung nodules
in lungs concerning for recurrence with AFP rising to >60 in
[**2-27**].
6. Recurrent c diff [**2154-2-11**] and [**2153-12-31**]
Social History:
He was a bus driver until the diagnosis of his hepatocellular
carcinoma. He has been in the US since [**2145-7-21**] and is
originally from [**Country 3992**]. He smoked half a pack a day for 35
years, but quit about 8 months ago. He denies any alcohol use or
any IV drug abuse. He has 4 children who are all healthy. He
lives at home with his wife and family.
Family History:
No family history of liver disease, diabetes, or cardiovascular
disease.
Physical Exam:
VS T 102 upon arrival to MICU and Tm = 105 in ED P = 117, BP =
146/70 RR O2Sat = 100% 3L
GENERAL: Diaphoretic but not in acute distress.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, 2/6 SEM at LUSB noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
Pertinent Results:
[**2154-4-5**] 01:30PM BLOOD WBC-5.4# RBC-4.08* Hgb-12.7* Hct-37.0*
MCV-91 MCH-31.0 MCHC-34.1 RDW-14.1 Plt Ct-144*
[**2154-4-6**] 05:16AM BLOOD WBC-6.7 RBC-3.81* Hgb-12.1* Hct-33.7*
MCV-89 MCH-31.8 MCHC-35.9* RDW-14.3 Plt Ct-118*
[**2154-4-7**] 01:22AM BLOOD WBC-3.2*# RBC-2.82*# Hgb-9.1* Hct-24.9*#
MCV-89 MCH-32.3* MCHC-36.5* RDW-14.3 Plt Ct-74*
[**2154-4-7**] 09:08AM BLOOD WBC-2.5* RBC-3.27* Hgb-10.4* Hct-30.1*
MCV-92 MCH-31.8 MCHC-34.5 RDW-13.9 Plt Ct-70*
[**2154-4-8**] 04:11AM BLOOD WBC-2.3* RBC-3.15* Hgb-10.0* Hct-28.2*
MCV-90 MCH-31.8 MCHC-35.5* RDW-14.2 Plt Ct-79*
[**2154-4-9**] 05:07AM BLOOD WBC-3.0* RBC-3.41* Hgb-10.7* Hct-30.1*
MCV-88 MCH-31.3 MCHC-35.4* RDW-14.3 Plt Ct-105*
[**2154-4-5**] 01:30PM BLOOD Glucose-109* UreaN-11 Creat-1.0 Na-135
K-4.7 Cl-100 HCO3-23 AnGap-17
[**2154-4-5**] 09:30PM BLOOD Glucose-132* Na-135 K-3.7 Cl-103 HCO3-21*
AnGap-15
[**2154-4-6**] 05:16AM BLOOD Glucose-112* UreaN-10 Creat-1.1 Na-136
K-3.6 Cl-105 HCO3-21* AnGap-14
[**2154-4-7**] 01:22AM BLOOD Glucose-121* UreaN-10 Creat-0.9 Na-138
K-3.4 Cl-111* HCO3-18* AnGap-12
[**2154-4-7**] 09:08AM BLOOD Glucose-116* UreaN-9 Creat-0.8 Na-140
K-3.6 Cl-113* HCO3-18* AnGap-13
[**2154-4-8**] 04:11AM BLOOD Glucose-97 UreaN-6 Creat-0.7 Na-139 K-3.7
Cl-111* HCO3-20* AnGap-12
[**2154-4-9**] 05:07AM BLOOD Glucose-119* UreaN-6 Creat-0.8 Na-141
K-3.6 Cl-112* HCO3-22 AnGap-11
[**2154-4-5**] 01:30PM BLOOD ALT-40 AST-73* Amylase-73 TotBili-0.6
[**2154-4-5**] 09:30PM BLOOD ALT-36 AST-53* LD(LDH)-274* AlkPhos-72
TotBili-0.9
[**2154-4-6**] 05:16AM BLOOD ALT-35 AST-48* LD(LDH)-273* AlkPhos-68
TotBili-1.1
[**2154-4-7**] 01:22AM BLOOD ALT-32 AST-44* AlkPhos-56 Amylase-70
TotBili-0.7
[**2154-4-7**] 09:08AM BLOOD ALT-31 AST-42* AlkPhos-54 Amylase-71
TotBili-0.5
[**2154-4-8**] 04:11AM BLOOD ALT-28 AST-35 AlkPhos-55 Amylase-67
TotBili-0.4
[**2154-4-9**] 05:07AM BLOOD ALT-26 AST-35 AlkPhos-65 TotBili-0.4
ERCP:
1.The major papilla was located in the second part of the
duodenum with an existing plastic stent within. 2.This was
removed and the papilla was cannulated to access the CBD.
3.Previous sphincterotomy was noted.
4.There was pus draining from the duct on removal of the stent.
5.The CBD was moderately dilated with an anastomotic stricture
as noted previously in the mid CBD.
5.The intrahepatic /CHD above the stricture were only mildly
dilated as previously.
6.The anastomotic stricture was dilated to 6mm using a hurricane
balloon.
7.Two Cotton [**Doctor Last Name **] biliary stents (10Fr x 10cm and 10 F X 12 cm)
were placed successfully across the stricture in the CBD.
8.There was good drainage of bile into the duodenum.
CT abd/pelvis:
1. No definite cause for abdominal pain or fever identified.
2. Biliary stent spans the length of the common duct. No
biliary ductal
dilatation.
3. Tiny amount of residual subcapsular fluid around the hepatic
dome is
significantly improved.
4. Fatty infiltration of the liver with areas of sparing.
5. No change in 4-mm nodules at the base of the right lower
lobe and lingula.
6. Long appendix with top normal caliber of 6mm appears similar
to [**2153-12-25**].
No periappendiceal inflammation or fluid.
RUQ u/s:
1. No abnormalities identified to explain the patient's
symptoms.
2. Redemonstration of 1.3-cm left hepatic lesion. Followup MRI
in four to six months from the prior MRI is recommended.
CXR: Heart size is normal, and there is no mediastinal or hilar
abnormality. The lungs are clear, and there is no pleural
effusion or pneumothorax.
CXR:
Brief Hospital Course:
51 yo man with Hep B/C cirrhosis and HCC s/p liver tx in [**Country 651**]
presents with ascending cholangitis. Now post-ERCP with changing
of biliary stent.
## Ascending cholangitis: pt s/p ERCP with changing of biliary
stent. Had frank pus draining after stent was pulled. Now on
levo, metronidazole. Changed to PO and discharged on 14-day
course. Pt remained afebrile and clinically stable afterward.
## Cirrhosis s/p liver tx: Has multiple pulmonary nodules
concerning for recurrent HCC. His MMF was held out of concern
for malignancy. His sirolimus was decreased to 2 qd, and his
prednisone was continued. He was scheduled for a PET-CT and f/u
with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 497**].
## Hep B: Continued entecavir
## Pulmonary nodules: ? HCC mets. Scheduled for outpt PET-CT and
f/u appointments with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 497**]. His MMF was
discontinued.
## Panctyopenia: ? immunosuppressives, Bactrim was discontinued
Medications on Admission:
Entecavir 0.5 mg qam
- rapamycin 3 mg qd
- CellCept [**Pager number **] mg b.i.d. d/c'ed yesterday to minimized the
amount of immunusuppression given recurrence of his cancer
- Bactrim single strength 1 tablet 3 times per week, M/W/F
- hepatitis B immunoglobulin with last shot on [**2154-3-6**], and s/p hep B IgG on [**2154-4-3**]
- Prilosec
- oxycodone 5 prn
Discharge Medications:
1. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
Disp:*33 Tablet(s)* Refills:*0*
3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ascending cholangitis
Secondary:
Cirrhosis s/p orthotopic liver transplant in [**Country 651**]
Chronic Hepatitis C
Chronic Hepatitis B
Hepatocellular carcinoma
Discharge Condition:
Afebrile, ambulatory, stable
Discharge Instructions:
You were admitted with fevers and abdominal pain. This was
likely from an infection in your transplant kidney that has been
treated with antibiotics.
Please take all of your medications as prescribed. We have
stopped your Bactrim and your Cellcept. You should not take
these medications unless told to do so specifically by Dr.
[**Last Name (STitle) 497**].
Please keep all of your follow-up appointments.
Please call your doctor or return to the hospital if you
experience fevers, abdominal pain, bleeding, chest pain,
shortness of breath or anything else concerning.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2154-4-18**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2154-4-18**] 9:30
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2154-4-19**]
12:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEPATOLOGY Date/Time:[**2154-5-1**] 8:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
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"038.9",
"576.1",
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"995.91",
"535.50",
"427.89",
"197.0",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.84",
"97.55",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
8736, 8742
|
6832, 7822
|
341, 361
|
8957, 8988
|
3301, 6809
|
9608, 10174
|
2417, 2493
|
8235, 8713
|
8763, 8936
|
7848, 8212
|
9012, 9585
|
3266, 3282
|
2508, 3170
|
274, 303
|
389, 1058
|
3185, 3249
|
1081, 2023
|
2039, 2401
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,451
| 114,843
|
36353
|
Discharge summary
|
report
|
Admission Date: [**2177-4-29**] Discharge Date: [**2177-5-13**]
Date of Birth: [**2110-4-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Hemoptysis
DVT
Major Surgical or Invasive Procedure:
PICC placement
Transfusion of packed red blood cells
Ventilator use (hooked up to tracheostomy)
IVC filter placement
IR coiling of laryngeal artery
Tooth extraction
History of Present Illness:
This is a 67 yo man w/ HTN, CVA, COPD, hyponatremia, EtOH abuse,
and SCC of the larynx s/p coil embolization of right inferior
thyroid artery for hypopharyngeal bleed [**3-/2177**], s/p tracheostomy
and PEG [**3-/2177**], recently discharged to rehab from MICU [**Location (un) **],
who was admitted to the floor on [**4-29**] for right LE DVT. His right
leg has become more warm and edematous, with mild pain, compared
to the left x3 days, and LENIs showed a right partially occluded
distal femoral and popliteal DVT. Given his recent bleed,
anticoagulation was not started, and he was transferred to [**Hospital1 18**]
for consideration of an IVC filter. Also completing course of
antibiotics for suspected aspiration pneumonia from prior
admission.
While on the floor early morning of [**4-30**] he started coughing and
was noted to have bleeding from his trache. He did not have any
respiratory difficulties, and ~150cc of blood was suctioned out
through the trach, the cuff was inflated for airway protection
and he was transfered to MICU green for monitoring. ENT saw the
patient, who was known to them, suspected bleeding from mass
on direct visualization. Pt was being taken down to IR for IVC
filter when he began to bleed again from his trach site. At
that time he was placed on the ventilator, paralyzed and
sedated. ENT packed his oral cavity. Pt then transported to IR
for IVC filter placement. Given that his bleeding has been
attributed to his mass, he is being transfered to the [**Hospital Ward Name **] ICU for ongoing care while he initiates XRT to his mass.
Hematocrit was stable and he was HD stable, so he is being
transferred to the ICU for closer airway monitoring.
Denies CP, SOB, palpitations, change in chronic productive
cough. No other bleeding. Denies fever, chills, dysuria.
Currently pain free.
Past Medical History:
Cerebrovascular accident, treated at [**Hospital1 2025**] [**2157**] with residual gait
weakness
Chronic obstructive pulmonary disease
Hypertension
Gout
Hyponatremia
SCC of the larynx diagnosed [**2177-3-31**], s/p coil embolization of
right inferior thryroid artery for hypopharangeal bleed
S/p tracheostomy and peg [**2177-4-1**] at [**Hospital1 34**]
EtOH abuse
Social History:
Former smoker quit at day of dx, EtOH 14 beers daily up until 1
month ago.
Family History:
Per report-lymphoma and lung ca.
Physical Exam:
GEN:Chronically ill appearing, pleasant, NAD, frequently
suctioning with yankauer
HEENT: nc/at MM dry OP clear with thick clear secretions
CV: Distant. RRR No m/r/g
Resp: Coarse rhonchorous BS throuhgout. No w/r
Abd: Soft. NTND +BS. No HSM
Ext: 2+RLE edema to upper calf with erythema. Trace edema LLE
Neuro: AAOx3. CM [**2-6**] intact. MAE.
Pertinent Results:
Labs at Admission:
[**2177-4-29**] 09:00PM BLOOD WBC-14.4* RBC-3.15* Hgb-9.6* Hct-28.5*
MCV-90 MCH-30.6 MCHC-33.8 RDW-13.9 Plt Ct-584*#
[**2177-5-1**] 04:06AM BLOOD Neuts-85.6* Lymphs-7.2* Monos-6.2 Eos-0.6
Baso-0.3
[**2177-4-29**] 09:00PM BLOOD PT-12.4 PTT-26.3 INR(PT)-1.0
[**2177-4-29**] 09:00PM BLOOD Glucose-93 UreaN-15 Creat-0.4* Na-128*
K-4.2 Cl-91* HCO3-30 AnGap-11
[**2177-4-29**] 09:00PM BLOOD Calcium-8.8 Phos-4.5 Mg-2.1 Iron-30*
[**2177-4-29**] 09:00PM BLOOD calTIBC-230* VitB12-GREATER TH
Folate-18.1 Ferritn-217 TRF-177*
[**2177-4-30**] 02:05AM BLOOD Osmolal-270*
[**2177-4-30**] 09:59PM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-50
pO2-170* pCO2-45 pH-7.43 calTCO2-31* Base XS-5
[**2177-5-1**] 10:17AM BLOOD Hgb-9.5* calcHCT-29
.
Imaging Studies:
[**4-30**] Procedure:
IMPRESSION: Prominent bilateral superior thyroidal arteries and
left inferior thyroidal artery supplying hypervascular
oropharyngeal mucosa.
Successful embolization of blood supply to hypervascular tumor
via the
bilateral superior thyroidal arteries and left inferior
thyroidal artery.
.
[**5-5**] Panorex:
read pending
.
[**5-5**] CT head:
IMPRESSION:
1. No acute intracranial process; specifically no evidence for
enhancing
masses. MR is more sensitive for the detection of small masses.
2. Bilateral maxillary sinus mucosal disease.
.
[**5-5**] CT neck:
IMPRESSION:
1. Extensive hypopharyngeal mass appearing similar to prior with
evaluation of supraglottic extension difficult.
2. No obvious lymphadenopathy.
3. Persistent left vertebral artery nonvisualization and plaque
in the left carotid bifurcation.
.
[**5-5**] CT Chest:
IMPRESSION:
1. New multifocal ground-glass opacity and consolidation in left
lung, mostly in the peribronchial and peripheral distribution,
with one wedge shaped peripheral opacity. Findings are
nonspecific but could be due to infection such as angioinvasive
fungus (for example, mucormycosis);
hemorrhage; or, alternatively, with history of DVT, this could
reflect infarct from non- visualized pulmonary embolism.
2. Thickening and calcification of the anterolateral wall of the
trachea and both mainstem bronchi, could be idiopathic or
related to relapsing
polychondritis. Diffuse bronchial wall thickening, slightly more
prominent on the left associated with left lower lobe mucoid
impaction could be related to infection or inflammation.
3. Minimal emphysema.
4. Moderate left and small right pleural effusion. Small
pericardial
effusion. Bibasilar atelectasis.
5. Enlargement of main pulmonary artery, suggesting possible
pulmonary
hypertension.
6. Severe calcifications of the left main coronary artery.
7. Secretions in the carina and both mainstem bronchi, which
could be blood in setting of tracheal bleed.
8. Please see separately dictated neck CT.
Brief Hospital Course:
Patient is a 67 year old man with history of HTN, CVA, COPD,
status post recent diagnosis of SCC of larynx status post coil
embolization of right inferior thyroid artery for hypopharyngeal
bleed [**3-/2177**], status post trach and PEG [**3-/2177**], recently
discharged to rehab approximately 1 month ago, who initially
presented and was admitted to the floor on [**4-29**] for right LE DVT,
with subsequent complicated hospital course for bleeding at
tracheostomy site.
# Bleeding from tracheostomy site: 24 hours after admission to
floor, patient was noted to have coughing and bleeding from his
tracheostomy site. This was initially managed by inflating the
cuff for airway protection, as well as transfer to the MICU
(initially to [**Hospital Ward Name **] MICU) for closer monitering. He also
received 2 units of packed RBC.
ICU course: Despite the cuff inflation, the patient had
intermittent bleeding from his tracheostomy site, requiring
placement on the ventilator. ENT was involved, and site was
packed (where patient was transiently on prophylactic
clindamycin). He went to IR for IVC filter placement to address
his DVT, at which time he also underwent coiling of a thyroid
artery.
Oncology was also involved during his hospital course, and he
was ultimately transferred from the [**Hospital Ward Name **] MICU to the [**Hospital Ward Name **] [**Hospital Unit Name 153**] for initiation of emergent radiation to be able to
stop the bleeding. He therefore underwent salvage radiation with
control of the bleeding, and was successfully weaned off the
ventilator, and currently remains stable on trach mask.
FLOOR COURSE: After stabilization in the ICU, patient was
transferred back to regular medical floor where bleeding
remained stable. Cancer was addressed as below.
# Right lower extremity deep venous thrombosis: Patient was
admitted to the floor on [**4-29**] for right lower extremity DVT. His
initial complaints were right leg pain, warmth, edema x 3 days,
with lower extremity ultrasound (performed at rehab)
demonstrating a right partially occluded distal femoral and
popliteal DVT. He was sent to [**Hospital1 18**] with above for
consideration of IVC filter (as no plans for anti-coagulation
given recent hypopharyngeal bleed). He successfully underwent
placement of IVC filter in IR on [**4-30**] without complication.
# Laryngeal Cancer: As above, complicated by recurrent bleeds,
now status post 2 coil artery embolizations, status post trach
and PEG. Oncology, radiation oncology, ENT involved early
during hospital course. Patient required dental work prior to
initiation of regular radiation therapy, and chemotherapy
waiting on regular radiation therapy.
Given this delay of therapy, panorex was obtained, dental
consult and maxillofacial surgery consults were obtained.
Patient underwent tooth extraction in OR on [**2177-5-8**], where
evaluation by ENT under anaesthesia was also performed.
Patient also underwent CT head/neck/chest for further evaluation
of the cancer.
Following the tooth extraction, radiation oncology and medical
oncology were consulted and recommended initiation of cetuximab
on [**5-15**] as well as radiation therapy, tentatively scheduled for
[**5-21**]. XRT treatments will be daily Monday through Friday for
seven weeks; he underwent radiation treatment planning in-house
before discharge. Cetuximab will be administered weekly by his
oncologists.
The patient should follow up with ENT (Dr. [**Last Name (STitle) 1837**] in [**2-26**]
weeks.
# Aspiration pneumonia: He has a history of aspiration PNA on
admission and completed a 10-day course of ceftaz and Vanco on
the day after admission.
# Hypertension: We continued his home lisinopril 40 mg daily.
# Anemia: Stable from recent baseline 25-28. Likely secondary
to bleed and inflammation. Iron studies suggest anemia of
chronic disease. Patient received 2 units pRBC on [**4-30**].
# Hyponatremia: Chronic, improved over the course of his
hospitalization.
# Chronic obstructive pulmonary disease: Continued home
nebulizers PRN.
# Status post cerebrovascular accident: There were no active
issues. He is not on aspirin due to bleeding risk.
# FEN: Tube feeds
# Code status: Full
Medications on Admission:
B12 1000 mcg IM qmonth
Folic acid 1
Lisinopril 40
Ranitidine 150 [**Hospital1 **]
Thiamine 100
Allopurinol 300
Mulitivitamin
Ceftazidime 1 q8 x 10 days for HAP, last day [**2177-4-30**]
Colace 100 [**Hospital1 **]
Vancomycin 1000 IV bid last day [**2177-4-30**]
? sq heparin
Dulcolax
Senna
Tylenol
Lorazepam 1mg IV q4PRN
Nebs prn
Oxycodone 5 q4 PRN
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
per PEG tube.
2. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily): per PEG tube.
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth care for 1 weeks.
5. Senna 8.8 mg/5 mL Syrup Sig: 8.8 MLs PO BID ().
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
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. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): per PEG tube.
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): per PEG tube.
10. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150)
mg PO BID (2 times a day): per PEG tube.
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): per PEG tube.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Right lower extremity DVT
Bleeding from tracheostomy site, acute blood loss anemia
Secondary:
SCC of larynx
Tracheostomy/PEG tube
COPD
Hypertension
Discharge Condition:
good, stable, managing secretions with suctioning, alert,
interactive
Discharge Instructions:
You were admitted to the hospital from rehab with DVT, but also
had complications with bleeding from your tracheostomy site.
You were stable at time of discharge.
Please take medications as directed.
Please follow up with appointments as directed.
Please contact physician if bleeding at tracheostomy site recurs
(bring to emergency room immediately), any respiratory distress,
fevers/chills, any other questions or concerns.
Followup Instructions:
Follow up with oncology (Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 1852**]). You have an
appointment on Thursday [**5-15**] at 11:30am at which point you
will be started on chemotherapy (cetuximab). Call Dr.[**Name (NI) 21829**]
office at [**0-0-**] or Dr.[**Name (NI) 22252**] office at [**Telephone/Fax (1) 22**]
with any questions.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2177-5-15**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2177-5-15**] 11:30
Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2177-5-15**] 1:00
Follow up with the ENT surgeons. Dr.[**Name (NI) 20390**] office was
contact[**Name (NI) **] for an appointment in [**2-26**] weeks, and they will call
your facility with the time and date. If they do not hear from
them, they can call his office at [**Telephone/Fax (1) 41**].
Follow up with your primary care physician 1-2 weeks asfter
discharge from rehab.
|
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icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.71",
"31.42",
"23.19",
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icd9pcs
|
[
[
[]
]
] |
11721, 11793
|
6021, 10244
|
287, 453
|
11995, 12067
|
3222, 3964
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233, 249
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2719, 2795
|
3981, 4335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,409
| 157,978
|
13496
|
Discharge summary
|
report
|
Admission Date: [**2194-3-27**] Discharge Date: [**2194-4-2**]
Date of Birth: [**2123-1-16**] Sex: F
Service: CARDIAC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 71-year-old
patient, who was referred to [**Hospital1 188**] after history of exertional chest pain and a positive
exercise treadmill test. The patient reports a one-year
history of stable exertional angina, which has resolved with
rest recently. The patient reports palpitations waking her
up at night.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Osteoporosis.
4. History of transient ischemic attacks.
5. Peripheral vascular disease.
6. Status post left CEA, [**2192**].
7. Status post tonsillectomy.
PREOPERATIVE MEDICATIONS:
1. Aspirin 325 mg p.o.q.d.
2. Fosamax 70 mg p.o.every week.
3. Lipitor 10 mg p.o.q.d.
4. Toprol XL 50 mg p.o.q.d.
5. Multivitamin.
6. Calcium.
7. Lorazepam p.r.n.
LABORATORY DATA: Laboratory data revealed the following:
White blood cell count 7.3, hematocrit 36, platelet count
159, sodium 141, potassium 4.6, chloride 104, bicarbonate 27,
BUN 15, and creatinine 0.8.
PREOPERATIVE PHYSICAL EXAMINATION: Examination revealed the
pulse of 66 regular rate and rhythm. Blood pressure 108/60
right arm; 118/76 on the left arm. HEENT: Unremarkable.
CHEST: Breath sounds normal without rales. EXTREMITIES:
Extremities without edema. ABDOMEN: Unremarkable. CARDIAC:
Regular rate and rhythm, normal S1 and S2 without murmur or
click.
HOSPITAL COURSE: The patient was taken for cardiac
catheterization on [**2194-3-27**]. Cardiac catheterization showed
left ventricular ejection fraction 55%, 60% to 70% ostial
left main; totally occluded LAD; 40% ostial left circumflex;
40% RCA.
The patient was taken to the operating room on [**2194-3-28**] with
Dr. [**Last Name (STitle) 70**] for a coronary artery bypass graft times three;
LIMA to the diagonal; SVG to LAD; SVG to OM. Please see
operative note for further details. The patient was
transferred to the Intensive Care Unit on a Neo-Synephrine
infusion in stable condition. The patient was weaned and
extubated from mechanical ventilation on her first
postoperative night. The patient required Neo-Synephrine
infusion through the first postoperative day. The patient
was weaned off Neo-Synephrine on the evening of postoperative
day #1. The patient was noted to have an air leak in her
chest tube on postoperative day #4, after which it was
discontinued. The patient was transferred out of the
Intensive Care Unit on postoperative day #2. The patient
began ambulating with the Department of Physical Therapy.
The patient's wire were removed on postoperative day #3. By
postoperative day #5, the patient was able to ambulate 500
feet and climb one flight of stairs without requiring oxygen.
The patient's vital signs remained stable. She was cleared
for discharge to home.
DISCHARGE PHYSICAL EXAMINATION: Neurologically, the patient
is awake, alert, oriented times three and neurological,
grossly intact. CARDIOVASCULAR: Regular rate and rhythm,
positive rub, no murmur. RESPIRATORY: Breath sounds are
decreased at the bilateral bases, right greater than left.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds. The patient is tolerating a regular diet. The
patient has had a bowel movement today. EXTREMITIES:
Minimal peripheral edema. Right lower extremity has Steri
Strips intact, groin and mid leg. There is mild ecchymosis
throughout the thigh. There is no erythema or drainage.
Sternum has Steri Strips intact; no erythema or drainage.
Sternum is stable without a click.
LABORATORY DATA: Laboratory data from [**2194-3-31**] revealed the
following: White blood cell count 8.4, hematocrit 28.9,
platelet count 91, sodium 139, potassium 4.6, chloride 102,
bicarbonate 29, BUN 11, creatinine 0.5, glucose 96. The
patient's weight on [**2194-4-2**] was 57.2 kg. Preoperatively,
the patient was 55.8 kg. Chest x-ray obtained on [**2194-4-1**]
showed a small right apical pneumothorax. After chest tubes
were removed, the patient was asymptomatic.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o.b.i.d.
2. Lasix 20 mg p.o.q.d. times seven days.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 10 mg mEq p.o.q.d.times seven days.
4. Enteric coated aspirin 325 mg p.o.q.d.
5. Colace 100 mg p.o.b.i.d.
6. Percocet 5/325 one to two tablets p.o.q.6h.p.r.n.
7. Ibuprofen 400 mg p.o.q.6h.p.r.n.
8. Lipitor 10 mg p.o.q.d.
9. Fosamax 70 mg p.o.every week.
10 The patient is to be discharged to home in stable
condition.
FOLLOW-UP CARE: The patient is to followup with her primary
care physician and her cardiologist in four weeks. The
patient is to followup with Dr. [**Last Name (STitle) 70**] in four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2194-4-2**] 09:55
T: [**2194-4-2**] 10:10
JOB#: [**Job Number 40843**]
|
[
"272.0",
"414.01",
"733.00",
"411.1",
"440.20",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.22",
"88.56",
"88.53",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4131, 5103
|
1516, 2911
|
753, 1144
|
2934, 4108
|
519, 727
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,772
| 195,718
|
1775
|
Discharge summary
|
report
|
Admission Date: [**2166-8-19**] Discharge Date: [**2166-8-23**]
Date of Birth: [**2112-12-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 yo female with hx of HTN, esophageal reflux, alcohol abuse,
and prior UGIB/hematemesis with mild esophagitis and duodenitis
presents with N/V found to have hematemesis, hyperglycemia, AG
acidosis, and [**Last Name (un) **].
She reports three days of malaise. She notes that she vomited
after eating Chinese food on Monday, and then had multiple
episodes of nausea with retching today. She then reports coffee
ground emesis with large volumes of bright red blood. She
reports RUQ abd dull ache after N/V which does not radiate to
her back, does not change with food intake, and is not
pleuritic. She has previously had hematemesis during an
admission in [**4-16**] at which point they noted a mild gastritis and
duodenitis.
She reports previously drinking 5-6 beers per day, and notes
that she has had to make many efforts to cut back. She now
denies daily drinking, but then notes that she has wine daily
with dinner and beer binges on the weekends. She had previoulsy
"been sick" from EtOH use. Denies eye openers, prior
withdrawal, prior DT's, trouble with the legal system or
problems at work as a result of drinking. She reports that her
last drink was this past weekend with 5-6 beers on Friday. She
also notes occaisional marijuana use, every day if available to
her, and sometimes multiple times per day. Last use on
Thursday. Reports that she uses because of upset stomach.
She has not taken any ibuprofen or NSAIDS recently. She denies
acid suppression therapy. She reports baseline diarrhea
secondary to IBS and lactose intolerance but reports more than
usual. She reports eating a chicken sandwhich today but was
unable to finish it. Overall, she has been eating less than
normal. In addition, she vomited up her medications she took
this morning. She went to see her PCP today who gave her zofran
and sent her to the ED.
In the ED, initial VS were 96.9 88 174/112 26 96% on RA. She
appeared very uncomfortable and had light brown emesis with
blood streaks. She was tender over the RUQ. She was given
protonix 40mg IV, zofran, morphine, and a total of 2L of NS.
Labs returned with WBC of 26 and [**Last Name (un) **] with a creatinine double
that of baseline. Her UA returned with ketones and glucose, so
she was started on D5NS with 40 of K given concern for alcoholic
ketoacidosis. Her FS were monitored with the last noted at 130.
GI was paged. A CT of the abdomen revealed dilated mid abdomen
loop of bowel ?focal ileus. Cipro/flagyl was started for ppx
for gut translocation in the setting of an UGIB. VS prior to
transfer were:
On arrival to the MICU, she reports nausea and retching with
NBNB emesis. She reports a dull ache over her RUQ without
radiation to the back.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies constipation, abdominal pain, or changes in bowel habits.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Alcohol abuse
UGIB found to have mild gastritis and duodenitis in [**4-16**]
Esophageal reflux
Colonic adenoma
Lactose intolerance
IBS
Hypertension
Ruptured Achilles tendon due to trauma - [**2165-2-5**]
Vocal Cord / Laryngeal Polyp
Benign endometrial biopsy+cervical polyp [**2162-3-11**]
BCC s/p Mohs to R ala
Social History:
She is a middle school physical ed teacher at [**Hospital1 **] but was
recently on disability given her ruptured achilles tendon.
Never smoker, drinks variable amounts per week. Occasional
marijuana. She denied other drugs but later admitted to
recreational cocaine use. She takes care of her mother who lives
downstairs and her father who lives in a nursing home.
Family History:
Mother with COPD/emphysema.
Father - Hyperlipidemia; Hypertension; Melanoma, Stroke,
alzheimers. Paternal Grandfather - [**Name (NI) **] [**Name2 (NI) 3730**].
Physical Exam:
On Admission:
Vitals: 98.4 99 179/109 24 96% on RA
General: Alert, oriented, anxious female moving around in bed
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, photosensitized skin
with erythema and multiple nevi, no spider angioma noted
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, mildly tender over epigastrium and RUQ,
non-distended, hepatomegaly, no splenomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, intention tremor
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
DISCHARGE:
VS - 98.1 141/99 83 20 97 ra
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Labs on Admission:
===================
[**2166-8-19**] 08:48PM BLOOD WBC-26.0*# RBC-4.75 Hgb-15.3 Hct-43.4
MCV-91 MCH-32.1* MCHC-35.2* RDW-13.0 Plt Ct-323
[**2166-8-19**] 08:48PM BLOOD Neuts-90.2* Lymphs-4.6* Monos-4.9 Eos-0.1
Baso-0.2
[**2166-8-19**] 08:48PM BLOOD PT-12.5 PTT-32.1 INR(PT)-1.2*
[**2166-8-19**] 08:48PM BLOOD Glucose-265* UreaN-24* Creat-1.5* Na-139
K-2.5* Cl-95* HCO3-18* AnGap-29*
[**2166-8-19**] 08:48PM BLOOD ALT-26 AST-25 AlkPhos-91 TotBili-1.4
[**2166-8-19**] 08:48PM BLOOD Lipase-12
[**2166-8-19**] 08:48PM BLOOD Albumin-5.7* Calcium-11.3* Phos-1.7*#
Mg-1.7
[**2166-8-19**] 08:48PM BLOOD Osmolal-301
[**2166-8-19**] 08:48PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2166-8-19**] 08:55PM BLOOD Lactate-7.1*
[**2166-8-19**] 10:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2166-8-19**] 08:57PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
Labs Prior to Discharge:
==========================
[**2166-8-23**] 05:50AM BLOOD WBC-9.7 RBC-4.60 Hgb-14.9 Hct-41.4 MCV-90
MCH-32.4* MCHC-35.9* RDW-12.5 Plt Ct-264
[**2166-8-23**] 05:50AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-139
K-3.2* Cl-99 HCO3-21* AnGap-22*
[**2166-8-23**] 05:50AM BLOOD Calcium-9.9 Phos-2.5* Mg-2.1
CT ABD:
1. No acute process of the abdomen and pelvis.
2. Stable liver cysts.
KUB [**2166-8-21**]: Nonspecific bowel gas pattern with no definite
evidence of ileus or obstruction.
EKG [**2166-8-20**]: Sinus rhythm. Non-specific ST-T wave changes
BLOOD CU;LTURES x 2 [**2166-8-19**]: PENDING
Brief Hospital Course:
Ms. [**Known lastname 10004**] is a 53 yo female with a hx of HTN, esophageal
reflux, alcohol abuse, and prior UGIB with mild esophagitis and
duodenitis who presented with N/V found to have hematemesis,
hyperglycemia, AG acidosis, and [**Last Name (un) **].
# Alcoholic ketoacidosis: Patient has a history of chronic
alcohol use and also had poor PO intake from nausea. When she
presented she had an anion gap acidosis, ketonuria, and
hypoperfusion-induced lactic acidosis. This resolved with fluid
repletion with D5NS. She was also given a banana bag. We
continued thiamine, folate, MVI. She did not score on CIWA for
the last 3 days of her admission.
# N/V/Hematemesis: This may have been drug related (alcohol and
marijuana in particular). Also may be
esophagitis/gastritis/duodenitis, gastroenteritis. Another
possibility is transient mesenteric ischemia from cocaine though
unlikely. Hematemesis may have been secondary to retching
([**Doctor First Name 329**]-[**Doctor Last Name **]) but is now resolved. No evidence of significant
blood loss to necessitate urgent endoscopy. We continued daily
oral [**Hospital1 **] PPI and arranged GI follow-up for EGD as outpatient
# Substance abuse: Patient's tox screen positive for cocaine and
opiates. She admits to using left over percocoet for foot pain,
also "licked the plate" of cocaine one week ago, denies
snorting. Social work was consulted and will continue outpt
support.
# [**Last Name (un) **]: Prerenal from volume depletion. Cr peaked at 1.5, which
returned to baseline with fluid repletion.
# Leukocytosis: Most likely secondary to stress response and
hemoconcentration. Infection unlikely given negative UA and CXR
with blood cultures pending. CT unrevealing. Cipro/Flagyl given
in ED which were not continued in the MICU.
# Elevated lactate: Most likely secondary to dehydration.
Resolved with IVF in ED.
TRANSITIONAL ISSUES:
1. NEEDS SUPPORT FOR ALCOHOL ABUSE/SUBSTANCE ABUSE COUNSELLING
2. OUTPT GI ENDOSCOPY [**Month (only) **] BE NEEDED
3. NEED TO BE ON THIAMINE, FOLATE RE-EVALUATED
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. Lorazepam 0.5 mg PO BID:PRN anxiety
2. Losartan Potassium 50 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. tazarotene *NF* 0.05 % Topical qhs
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Q12 Disp #*30 Tablet
Refills:*0
6. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*40 Tablet Refills:*0
7. Lorazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg 1 [**Hospital1 **] by mouth anxiety Disp #*10 Tablet
Refills:*0
8. tazarotene *NF* 0.05 % Topical qhs
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
10. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear
Alcohol Withdrawl
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital because of dehydration, narcotics,
and alcohol withdrawl. You improved with IV fluid hydration and
intermittent doses of valium to help with any withdrawl
symptoms. Your nausea improved with anti - nausea medications.
The blood in your vomit was thought to be from a small tear in
your esophagus called [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] - [**Doctor Last Name **] tear. The bleeding
spontaneously resolved and your blood counts remained stable.
You will need to see a gastroenterologist as an outpatient to
follow up on full resolution of the tear.
Followup Instructions:
Department: Primary Care
Name: [**First Name9 (NamePattern2) 10005**] [**Last Name (un) 10006**], PA for Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Thursday [**2166-8-28**] at 9:15 AM
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2261**]
Department: Gastroenterology
Name: Dr. [**First Name8 (NamePattern2) 10007**] [**Name (STitle) 10008**]
When: Dr. [**Last Name (STitle) 10009**] office is working on a follow up appointment
for you in 16-30 days after your hospital discharge. You will be
called by the office with your appointment date and time. If you
have not heard from the office in 2 business days please call
the number listed below.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
|
[
"271.3",
"291.81",
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"275.2",
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"305.50",
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"530.7",
"401.9",
"303.93",
"584.9",
"564.1",
"535.30",
"276.8",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10343, 10349
|
7136, 9018
|
317, 324
|
10482, 10482
|
5508, 5513
|
11267, 12189
|
4247, 4408
|
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3093, 3513
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266, 279
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352, 3074
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5527, 7113
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10497, 10609
|
3535, 3848
|
3864, 4231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,709
| 182,764
|
43000
|
Discharge summary
|
report
|
Admission Date: [**2179-7-13**] Discharge Date: [**2179-7-27**]
Date of Birth: [**2118-2-26**] Sex: M
Service: MEDICINE
Allergies:
Macrolide Antibiotics / Ambien
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
lower extremity weakness, paralysis, back pain
Major Surgical or Invasive Procedure:
C7-T10 laminectomy with washout [**2179-7-21**]
Intubation
Left trauma IJ central line
Right subclavian central line
Right arm arterial line
History of Present Illness:
Pt intubated and sedated on arrival to MICU, history obtained
from ED record and girlfriend. 61 yo male diabetic x 15 years
who presents to ED with bilateral lower extremity weakness and
back pain for the past 2 days. According to his girlfriend, pt
had been in his usual state of health except for a flare of his
neuropathy and gout on [**Hospital1 107**] day weekend, who developed right
sided back pain about two days ago after heavy lifting.
Yesterday the patient was unable to lie down and had to sit at
the side of his bed for about 24 hours. He was able to ambulate
to the bathroom at 9 am, but complained of "pain all over". He
had been prescribed Percocets following removal of a R callus by
podiatry, and took four of the percocet yesterday for pain
relief. This morning he was unable to get out of bed secondary
to loss of sensation in his feet, legs, and buttock region.
Typically ambulates limited distance with cane. His girlfriend
called 911 and he was taken to [**Hospital1 **] and transferred to ED
for further evaluation.
.
In the [**Name (NI) **], pt found to have a leukocytosis, febrile to 100.3
max. Concern for epidural abscess was raised given history of
diabetes. Neurosurgery and neurology were consulted, patient
found to have flaccid paraplegia, poor rectal tone, absent
reflexes in the legs, T4-T6 sensation level, and weak cough; rec
stat imaging at [**Hospital6 **] as pt body habitus
too large to fit into CT/MRI scanner here. Pt was electively
intubated for CT, sent to [**Hospital6 1708**], however,
because of his obesity, this was unable to be done as he could
not fit on the fluoro table, and a regular CT was done instead.
The patient was started on Vanc/ Zosyn along with 2 liters of
IVF and transferred to the MICU with plans to undergo an open
MRI at Shields MRI in [**Location (un) 583**].
Past Medical History:
Diabetes- insulin dependent x 15 years
MI 5 yrs ago
CABG x 4 5 years ago
Chronic back pain
neuropathy- unable to feel the bottom of his feet
gout
Social History:
quit ETOH after CABG, 2 PPD smoker x 5 years, retired [**Hospital1 **] rep,
has two sons but limited contact. Widowed 15 years ago, now
lives with his girlfriend.
Family History:
brother died of cancer, unknown cause
Physical Exam:
vitals: 179 kg/temp 99.4/bp 109/51/ hr 76/ 100%
vent settings: AC/ 100% FiO2/ 14/ 650-698/ PEEP 15
GEN: sedated, will respond to some questions, intubated, obese
HEENT: atraumatic, anicteric, pupils constricted but equal and
reactive
NECK: unable to appreciate JVP, no LAD
CV: soft precordium, RRR, no murmurs. CABG scar on chest
LUNGS: CTA B/L, distant BS
ABD: soft, nt, NABS, no organomegaly appreciated
EXT: warm, dry. DP pulses dopplerable. Lower extremities with
chronic venous stasis changes, dry, cracked skin.
Hyperpigmentation. Right callous on great toe, appears clean, no
frank pus
NEURO: arousable, responsive to some commands, no myoclonus,
toes mute bilaterally, unable to move extremities
Pertinent Results:
[**2179-7-13**] 09:55PM TYPE-ART TEMP-37.4 RATES-14/22 PEEP-15 O2-80
PO2-90 PCO2-51* PH-7.34* TOTAL CO2-29 BASE XS-0 AADO2-433 REQ
O2-74 INTUBATED-INTUBATED VENT-CONTROLLED
[**2179-7-13**] 09:10PM GLUCOSE-167* UREA N-34* CREAT-2.0* SODIUM-137
POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-26 ANION GAP-18
[**2179-7-13**] 09:10PM ALT(SGPT)-24 AST(SGOT)-49* LD(LDH)-239
CK(CPK)-3981* ALK PHOS-97 AMYLASE-27 TOT BILI-0.4
[**2179-7-13**] 09:10PM LIPASE-27
[**2179-7-13**] 09:10PM CK-MB-27* MB INDX-0.7 cTropnT-0.02*
[**2179-7-13**] 05:17AM LACTATE-1.6
[**2179-7-13**] 04:15AM GLUCOSE-167* UREA N-28* CREAT-1.5* SODIUM-136
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2179-7-13**] 04:15AM proBNP-950*
[**2179-7-13**] 04:15AM WBC-27.7* RBC-4.84 HGB-13.5* HCT-40.7 MCV-84
MCH-27.9 MCHC-33.2 RDW-17.5*
[**2179-7-13**] 04:15AM PLT COUNT-385
[**2179-7-13**] 09:10PM WBC-26.0* RBC-4.52* HGB-12.7* HCT-38.0*
MCV-84 MCH-28.0 MCHC-33.3 RDW-17.5*
[**2179-7-27**] 04:39AM BLOOD WBC-16.9* RBC-3.30* Hgb-9.6* Hct-27.8*
MCV-84 MCH-29.1 MCHC-34.4 RDW-17.3* Plt Ct-374
[**2179-7-23**] 03:44AM BLOOD Neuts-87.4* Lymphs-7.3* Monos-2.8 Eos-1.9
Baso-0.6
[**2179-7-27**] 04:39AM BLOOD Plt Ct-374
[**2179-7-21**] 11:28AM BLOOD Fibrino-732*
[**2179-7-27**] 04:39AM BLOOD UreaN-23* Creat-1.1 K-3.6
[**2179-7-26**] 12:01AM BLOOD CK(CPK)-157
[**2179-7-13**] 09:10PM BLOOD ALT-24 AST-49* LD(LDH)-239 CK(CPK)-3981*
AlkPhos-97 Amylase-27 TotBili-0.4
[**2179-7-25**] 04:19PM BLOOD CK-MB-4
[**2179-7-25**] 03:34AM BLOOD cTropnT-0.11*
[**2179-7-20**] 01:52PM BLOOD CK-MB-3 cTropnT-0.30*
[**2179-7-20**] 05:30AM BLOOD CK-MB-3 cTropnT-0.33*
[**2179-7-14**] 05:09AM BLOOD calTIBC-209* Hapto-417* Ferritn-293
TRF-161*
[**2179-7-16**] 10:40AM BLOOD Cortsol-49.6*
[**2179-7-25**] 04:01AM BLOOD Type-ART Temp-36.6 O2 Flow-4 pO2-60*
pCO2-39 pH-7.42 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2179-7-21**] 12:22PM BLOOD freeCa-1.10*
.
PICC LINE PLACMENT SCH [**2179-7-26**] 2:34 PM
IMPRESSION: Uncomplicated ultrasound-guided dual-lumen PICC line
placement via the right basilic venous approach. Final internal
length is 45 cm, with the tip positioned in the SVC seen on
portable chest radiograph. The line is ready to use.
.
Cardiology Report ECG Study Date of [**2179-7-22**] 1:11:52 PM
.
Sinus rhythm. Frequent ventricular premature beats. Left atrial
abnormality. Left axis deviation with left anterior fascicular
block. Right bundle-branch block. Low QRS voltage in the
precordial leads. Compared to the previous tracing of [**2179-7-20**]
frequent ventricular premature beats are more prominent.
.
CHEST (PORTABLE AP) [**2179-7-22**] 7:36 AM
.
Patient is markedly rotated. Endotracheal tube, left internal
jugular vein line, right subclavian line, and nasogastric tube
are probably unchanged; tip of nasogastric tube is not
visualized on this study. Vertical staple line, probably down
pt's back. Changes of CABG, with multiple broken cerclage wires.
Both extreme costophrenic angles are excluded from the study,
however, appearance of cardiomegaly and pulmonary vascular
congestion is similar to the previous study. No definite
pneumothorax. Probable small layering left pleural effusion.
.
ECHO Study Date of [**2179-7-16**] :
.
Conclusions:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Extremely limited study.
.
IMPRESSION: Unable to exclude endocarditis given extremely
limited views.
If clinically indicated, a transesophageal study could be done.
.
Brief Hospital Course:
A/P: 61 yo male with lower extremity paralysis and back pain
with C7-T8 epidural abscess s/p washout, laminectomy T2-T10 on
[**2179-7-21**].
.
# Epidural abscess. The patient underwent a T2-T10 washout,
laminectomy on [**2179-7-21**] by our neurosurgery service. He will
follow up with Dr. [**Last Name (STitle) **] in 4 weeks. He will need an outpatient
CT of his spine to assess interval improvement before his follow
up appointment with Dr. [**Last Name (STitle) **].
- Surveillance blood cultures have been negative since [**2179-7-13**]
and kast grew MSSA growth on [**7-13**]. On discharge, the patient was
on Nafcillin day 9 of antibiotics on [**2179-7-26**]. Total 6 weeks of
antibiotics.
- The patient remains afebrile, however, WBC still elevated but
stable at 16 on discharge.
.
# Respiratory failure:
- The patient was intubated electively for transport to his MRI
at Shields. He remained on the ventilator with a large PEEP
requirement whichw as felt to be secondary to his body habitus.
- He remained intubated for the OR on [**2179-7-21**]. Subsequently, he
was quickly extubated without further events.
- He has intermittent shortness of breath at baseline which was
felt to be secondary to atelectasis. He has a known diagnosis of
obstructive sleep apnea but did not use his BIPAP at home. He
may benefit from intermittent BIPAP at night at the rehab.
- On discharge, the patient was sat'ing 93% on 2 liters O2 with
a productive cough with no signs of CHF or infiltrate on chest
xray.
.
# Hypotension, unresponsive episode while intubated
- The patient had an episode of hypotension on [**2179-7-19**] while
intubated from SBP 130 to 80s that required IV bolus of fluid
and short run of neosynephrine to maintain his pressures. The
patient was intubated and sedated during this time. His fentanyl
and versed were immediately discontinued and narcan was
administered with good effect. It was felt that this episode was
secondary to oversedation with depots of sedatives in
subcutaneous fat that contributed to a cumulative overdose
despite the fact that the patient had not received additional
sedation during this time. EKG was unremarkable but the patient
did have a bump in his cardiac enzymes to 0.33 which remained
flat. He was not treated for ACS as this was felt to be
secondary to demand in the setting of hypotension that an acute
plaque burden.
.
# Leukocytosis- Felt to be secondary to his epidural abscess.
WBC 16-17 on discharge.
.
# Diabetes- insulin dependent x 15 years. Initially was on
lantus and HSSI which was later switched to insulin gtt while in
the ICU for tight blood sugar control.
- BS mid 100s on insulin gtt. [**Month (only) 116**] maintain peri-operatively for
now.
- He was continued on a sliding scale insulin and his lantus was
increased to 50 units glargine on [**2179-7-25**] with stable blood
sugars on discharge.
.
# Cardiac
1. Vessels- history of MI/ CABG x4. In the setting of a
hypotensive, unresponsive episode related to oversedation, the
patient was found to have an elevated troponin with no EKG
changes and flat at 0.33, 0.3. He had an episode of atypical
bilateral chest pain on [**2179-7-25**] with no associated symptoms that
was reproducible with palpation and worse with movement.
- [**Month (only) 116**] restart ASA 325 mg on 60-23-07 per neurosurgery.
-
.
2. Pump- EF >55%.
- The patient was diuresed towards the end of his stay with 20
mg IV lasix per day with -500 to 1 liter negative.
- Lasix 40 mg PO QD was restarted on [**2179-7-26**] upon discharge.
.
# FEN- diabetic, cardiac, monitor lytes.
.
# Proph- hep SQ TID, H2 blocker
.
# Access- A line- d/c'd, right subclavian central line dc'd,
left IJ double lumen placed [**2179-7-21**] - Dc'd on [**2179-7-26**]. PICC
placed by IR on [**2179-7-26**].
.
# Code- full, however, the patient expressed the desire with
[**State 622**] present to not experience a prolonged intubation
.
# [**Name (NI) 2638**] Brother [**Name (NI) **] [**Telephone/Fax (1) 92805**] and girlfriend
[**Name (NI) 622**] [**Telephone/Fax (1) 92806**] (HCP)
Medications on Admission:
Percocet, ASA, Zantac, Avapro.
Atenolol 25mg daily
Avapro 300mg qday
lasix 80mg daily
glucophage 100mg [**Hospital1 **]
lantus 90 units daily
lipitor 40mg daily
ASA
Percocet 5mg daily/prn
Talwin i tab daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
4. Nicotine 21 mg/24 hr Patch 24 hr Sig: [**2-9**] Patch 24 hrs
Transdermal DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
10. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours).
11. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. 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
14. Nafcillin 2 gm IV Q4H
Day 1 [**7-17**]
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
16. Heparin (Porcine) 10,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
20. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours).
21. Ipratropium Bromide 0.02 % Solution Sig: [**2-9**] Inhalation
Q4-6H (every 4 to 6 hours).
22. insulin
Sliding scale and lantus 50 QHS
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 **]
Discharge Diagnosis:
C7-T8 epidural abscess
Paraplegia
Discharge Condition:
Stable. On 2 liters O2 with sats of 93-97%
Discharge Instructions:
[**Month (only) 116**] resume aspirin 325 mg 7-14 days post-operative [**2179-7-21**].
Will continue IV nafcillin for at least a total of 6 weeks.
Follow up with Dr. [**Last Name (STitle) **] in 4 weeks.
Followup Instructions:
The patient should have his staples removed on [**2179-8-4**].
He should follow up with Dr. [**Last Name (STitle) **] in 4 weeks. Please call
[**Telephone/Fax (1) 92807**] to schedule this appointment.
The patient should have a CT of his spine prior to seeing Dr.
[**Last Name (STitle) **].
|
[
"E935.2",
"412",
"324.1",
"995.92",
"344.1",
"428.0",
"585.9",
"785.52",
"356.9",
"482.41",
"518.81",
"780.97",
"933.1",
"274.9",
"E912",
"V45.81",
"584.5",
"250.40",
"278.01",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"33.24",
"00.17",
"93.90",
"96.6",
"96.04",
"96.05",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
13333, 13393
|
7092, 11149
|
337, 480
|
13471, 13516
|
3486, 7069
|
13770, 14066
|
2707, 2746
|
11407, 13310
|
13414, 13450
|
11175, 11384
|
13540, 13747
|
2761, 3467
|
251, 299
|
508, 2341
|
2363, 2511
|
2527, 2691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,425
| 187,221
|
35503+58013
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-4-21**] Discharge Date: [**2185-4-30**]
Date of Birth: [**2116-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Retro-sternal burning
Major Surgical or Invasive Procedure:
[**2185-4-25**] Two Vessel Coronary Artery Bypass Grafting utilizing the
left internal mammary artery to left anterior descending artery,
with vein graft to obtuse marginal
History of Present Illness:
This is a 68 year old male who presented to [**Hospital6 **]
with retrosternal burning sensation, which was exertional. It
was reproduced on an exercise stress test, but there was no
evidence of ischemia. At the outside hospital, he underwent
cardiac catheterization which revealed a 90% ostial left
anterior descending artery lesion. He was then trasnferred to
[**Hospital1 18**] for possible cardiac surgical versus percutaneous
intervetnion. On admission, patient was chest pain free. No
other complaints. On review of systems, he denied 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 also
denied recent fevers, chills or rigors. All of the other review
of systems were negative.
Past Medical History:
Coronary Artery Disease, Stable Angina
Dylipidemia
Benign Prostatic Hypertrophy
Gastroesophogeal Reflux Disease
Social History:
Lives with his wife. Worked as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3456**] previously. Denies
tobacco. Drinks 1 glass wine per day.
Family History:
Mother died age 46- unknown. Father died at age 79 of heart
attack. Brother with liver disease. Brother died of cancer.
Physical Exam:
ADMISSION
VS: 97.4 131/77 66 18 96%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. No xanthalesma.
NECK: Supple with JVP flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 1/6 systolic murmur. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2185-4-22**] Echocardiogram:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**2185-4-27**] 07:10AM BLOOD WBC-9.5 RBC-2.94* Hgb-9.9* Hct-27.8*
MCV-95 MCH-33.7* MCHC-35.6* RDW-12.8 Plt Ct-154
[**2185-4-27**] 07:10AM BLOOD Glucose-129* UreaN-13 Creat-0.9 Na-140
K-5.1 Cl-104 HCO3-32 AnGap-9
[**2185-4-27**] 07:10AM BLOOD Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 61773**] was admitted to the cardiology service and ruled
out for myocardial infarction. Workup included an echocardiogram
which was notable for mild aortic stenosis. Ejection fraction
was normal between 55-60% and there was no other significant
valvular disease. After review of the cardiac catheterization,
it was decided that surgical intervention was a better option
than high-risk percutaneous procedure. While awaiting surgery,
he experienced repeat episode of chest pain for which he was
placed on intravenous Heparin. Preoperative course was otherwise
uneventful and he was cleared for surgery.
On [**4-25**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting surgery. For surgical details, please see operative
note. Given his inpatient stay was greater than 24 hours prior
to surgery, Vancomycin was utilized for perioperative antibiotic
coverage. Following the operation, he was brought to the CVICU
for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
maintained good hemodynamics and was started on low dose beta
blockade. His CVICU course was otherwise routine and he
transferred to the SDU on postoperative day one. Chest tubes
and pacing wires were discontinued without complication. The
patient made excellent progress post-operatively. By the time
of discharge on POD 4 he was ambulating freely, the wound was
healing and pain was controlled with oral analgesics.
Medications on Admission:
Atorvastatin 10 mg daily, ASA 81 mg daily
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) for 1 months.
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. 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*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
all care
Discharge Diagnosis:
Coronary Artery Disease - s/p Coronary Artery Bypass Grafting
Aortic Stenosis(Mild)
Dylipidemia
Benign Prostatic Hypertrophy
Gastroesophogeal Reflux Disease
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-8**] weeks, call for appt
Dr. [**Last Name (STitle) 29070**] in [**3-8**] weeks, call for appt
Dr. [**Last Name (STitle) 21448**] in [**3-8**] weeks, call for appt
Completed by:[**2185-4-29**] Name: [**Known lastname 12987**],[**Known firstname 12988**] Unit No: [**Numeric Identifier 12989**]
Admission Date: [**2185-4-21**] Discharge Date: [**2185-4-30**]
Date of Birth: [**2116-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Pt. was discharged on Dilaudid and Ibuprofen for pain.
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) for 1 months.
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Dilaudid 2mg PO q 4-6 hours PRN for pain.
9. Ibuprofen 600 mg PO q 6 hours PRN pain, take with food.
Discharge Disposition:
Home With Service
Facility:
all care
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2185-4-30**]
|
[
"276.8",
"424.1",
"780.62",
"600.00",
"413.9",
"414.01",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9072, 9234
|
3795, 5286
|
343, 518
|
6592, 6599
|
2703, 3772
|
7424, 8105
|
1692, 1813
|
8128, 9049
|
6412, 6571
|
5312, 5355
|
6623, 7401
|
1828, 2684
|
282, 305
|
546, 1368
|
1390, 1504
|
1520, 1676
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,485
| 130,176
|
37296
|
Discharge summary
|
report
|
Admission Date: [**2149-7-29**] Discharge Date: [**2149-8-9**]
Date of Birth: [**2080-5-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
Altered Mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 83931**] is a 69 YOM with metastatic melanoma to brain,
liver, lung, pancreas, and spine with chronic pain in his right
lower quadrant and low back secondary to metastases of the T12
vertebral body. He presents with increased agitation for one
day. His family brought him to the ED from home after he was
found to be more quiet/withdrawn than usual. Of note, he
recently was hospitalized in the begining of [**2149-6-26**] for pain,
altered mental status, and depression with SI. MRI of his head
at that time revealed progression of his disease and he was
discharged on [**Hospital1 **] Decadron as well as a percutaneous epidural
catheter, gabapentin, and multiple narcotics for pain control.
Since his discharge he has been complaining of lethargy,
dizziness, and exhaustion so his Gabapentin was recently
decreased with plans to taper seroids as well. He has been
undergoing radiation treatments in RI for the last 10 weeks.
.
In the ED initial vital signs were 98.6 110/86 85 18 96%
RA. He was initially found to be alert and oriented, but would
not cooperate on exam. He became progressively more difficult
to control and was given 5 mg haldol. Initial labs showed
mildly elevated lipase 62 and AST 46, hyponatremia to 126, and
hyperkalemia 5.4 with lactate 2.4. Redraw of the labs 4 hrs
later showed resolution in abnormalities of LFTs, K, and sodium
to 129. There was no elevated WBC count and the Hct was stable
at 39.8. CT head was limited due to motion and showed
progression of extensive numerous hyperdense lesions bilaterally
consistent with known metastatic melanoma. In addition, there
was a tiny focus of hyperdense material over the left parietal
lobe concerning for small amount of subarachnoid blood.
Neurosurgery was consulted and was not impressed with CT,
stating nothing to do. The Ed gave him 4 mg IV dexamethasone.
CXR showed small right pleural effusion and persistent right
middle lobe lung mass. The patient then developed emesis that
was brown with ? of blood. He was guiaic negative from below
and would not tolerate NG lavage. A KUB was obtained but was a
poor study therefore a CT torso was obtained. This showed no
acute intra-abd or pelvic process, but overall progression of
his metestatic disease. He was given 80 mg IV ppi. Repeat Hct
was stable at 39.6. In the scanner the pt ripped out his foley.
Urology was consulted and recommended over the phone to attempt
placing a 22 coude catheter.
.
During the patient's time in the ED he became progressively more
agitated and self destructive, wripping out lines and not
cooperating. He was given 5 mg of IV haldol, 3 mg dilaudid,
phenergan 12.5 mg, reglan which he initially responded to by
falling asleep. However during his trip to the CT scanner he
became more agitated. He was placed on 2 point restraints and
given 1 mg ativan with some effect. His oncologist, Dr. [**Last Name (STitle) 1729**]
was notified of his admission per ED. He was transferred to the
MICU given his agitation and high nursing requirement.
.
Review of Systems:
unable to obtain from pt
Past Medical History:
Past Oncologic History:
-- [**2123**] Dx melanoma from mole from his back. He then had wide
excision, and he did not have evidence of disease in the
subsequent years.
-- [**9-/2148**], he developed abdominal pain from a pulled muscles. A
CT of the abdomen on [**2148-10-31**] showed right lower lobe
pleura-based nodule, that on further CT of the chest showed
otehr pleura-based lesions.
-- He underwent a fine-needle biopsy on the largest lesion on
[**2149-1-2**] showing metastatic melanoma.
-- He saw the Biologics Group on [**2149-1-7**] and his BRAF V600E
mutation was positive. He was being screened for the R05185426
investigational drug and he was expected to start
treatment on [**2149-4-1**].
-- gadolinium-enhanced head MRI that showed a small enhancing
lesion in the right insula. There was no associated cerebral
edema and he does not have any neurological symptoms.
-- stereotactic radiosurgery to a small right temporal brain
metastasis on [**2149-3-31**] to 2,200 cGy at 77% isodose line, and
--- status post 2 monthly temozolomide from [**2149-4-16**] to
[**2149-5-13**],
--- status post Cyberknife radiosurgery on [**2149-5-6**] to a right
medial parietal and left cerebellar brain metastases, both to
2200 cGy at 79% isodose line, and
-- started ipilimumab on [**2149-6-3**].
--- missed his dose today ([**6-24**]) of Ipilimumab due to his
symptoms.
.
Other Past Medical History:
Hypercholesterolemia
Torn Abdominal Muscle
Social History:
Social History:
He does not smoke ciagrettes. He drinks alcohol
rarely. He does not use illicit drugs.
Lives with wife and daughter
Family History:
Family History:
His mother died at age 67 from unspecified
cancer. His father is alive at age [**Age over 90 **]; he has obesity,
cataracts, and macular degeneration. He has one sister and 2
brothers; one of the brothers has melanoma. He has an adopted
daughter who is healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GEN: calm with quivering chin, intermittant outbursts of moaning
and "help me"
VS: afebrile, 111 138/85 17 97% on nc
HEENT: MMM, no OP lesions, unable to assess pupils/pt not
cooperating, no cervical, supraclavicular LAD
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB on limited anterior exam
ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic
liver disease
LIMBS: No LE edema, no tremors or asterixis, no clubbing
SKIN: No rashes.coccyx pressure ulcer. Ulcer measures 0.5 x 0.4
cm.
NEURO: wiggles toes and squeezes hands, facial muscles
symetrical [**4-30**], follows verbal commands
On Discharge: Mental status - continues to be altered. Ulcer on
coccyx unchanged.
Pertinent Results:
ADMISSION LABS:
[**2149-7-29**] 03:58PM BLOOD WBC-10.9 RBC-4.17* Hgb-13.5* Hct-39.8*
MCV-96 MCH-32.3* MCHC-33.9 RDW-14.5 Plt Ct-145*
[**2149-7-29**] 03:58PM BLOOD Neuts-91.2* Lymphs-3.2* Monos-4.5 Eos-0.6
Baso-0.5
[**2149-7-29**] 03:58PM BLOOD PT-11.9 PTT-25.4 INR(PT)-1.0
[**2149-7-29**] 03:58PM BLOOD Plt Ct-145*
[**2149-7-29**] 03:58PM BLOOD ALT-24 AST-46* AlkPhos-50 TotBili-0.8
[**2149-7-29**] 03:58PM BLOOD Lipase-62*
[**2149-7-29**] 07:06PM BLOOD Lipase-33
[**2149-7-29**] 03:58PM BLOOD cTropnT-<0.01
[**2149-7-29**] 03:58PM BLOOD Calcium-8.0*
[**2149-7-29**] 04:31PM BLOOD K-3.0*
[**2149-7-29**] 04:04PM BLOOD Glucose-89 Lactate-2.4* Na-129* K-5.4*
Cl-91* calHCO3-26
CT TORSO WETREAD [**2149-7-30**]
No acute intra-abd or pelvic process. Increased right pleural
effusion w/
associated compressive atelectasis. Progression of diseaes with
new
metastatses and progression of others. At least 3 new hypodense
liver lesions.
Three new intraperitoneal nodules (2:61, 63, 70). Increased
right paraspinal mass. New sclerosis/slight anterior wedge
deformity of T11 vertebral body, tx change vs progression of
disease. Increased size of pancreatic head lesion.
Sigmoid diverticulosis.
CT HEAD [**2149-7-29**]
Limited study secondary to patient motion artifact
redemonstrating progression of extensive numerous hyperdense
lesions
bilaterally consistent with known metastatic melanoma. In
addition, there is a tiny focus of hyperdense material over the
left parietal lobe concerning for small amount of subarachnoid
blood.
Brief Hospital Course:
Mr. [**Known lastname 83931**] is a 69 YOM with metestatic melenoma with known mets
to his head and multiple other organs, on IV steroids who
presents with rapidly declining function over the past few weeks
and acute altered mental status for the past day and is found to
have hyponatremia and new left parietal finding concerning for
subarachnoid bleed. Patient was stablized while on OMED floor
with resolving hyponatremia, was on dexamethasone to reduce
intracranial inflammation. However the altered mental status did
not resolve.Patient expired on [**8-9**] likely secondary to
aspiration.
.
# Altered mental status: Likely caused by end stage metestatic
melenoma with known brain mets and progression seen thoughout
body on CT scan. Hyponatremia also in the differential, however,
unlikely to be the sole cause given improving and hyponatremia
seems minimal in comparison to the pt's severity of AMS. The SAH
seen on CT may be contributing, however neurosurgery does not
think so. Other DDX include evolving infection, meningitis,
hepatic encephalopathy, polypharmacy or toxic metabolic process.
However, inital labs do not support infection or hepatic cause.
Benzodiazepine given in the ED with good effect;patient was
switched to haldol 5 mg PRN Q 2 hr for sedation. He was also
covered with zyprexa 5mg in AM and 10mg in PM. During the
hospital course, he had intermittant agitation, fairly well
controlled on Zyprexa 5 mg qam and Zyprexa 10 mg qHS standing
doses. He was also started on Dexamethasone in case altered
mental status was due to cerebral edema, however this did not
improve his symptoms. Dexamethasone was tapered to 4 mg PO
daily and should be tapered and discontinued at inpatient
hospice. Final diagnosis is altered mental status due to
worsening of metastatic melanoma. On [**8-9**] patient was agitated,
was given morphine and that calmed him down. At 4pm vitals were
taken and he was found to be hypotensive and tachycardic, he
also sounded congested (and likely aspirated). Patient was
converted to comfort measures only and he expired soon after
that.
.
.
# Hyponatremia: Pt down to 121 day of transfer (from 128). Many
possible causes (SIADH vs salt wasting vs adrenal
insufficiency). - Random cortisol was 1.3. Patient was started
on dexamethasone, will taper to 4mg Dex Daily with plan to
further taper and discontinue at hospice. Hyponatremia resolved
prior to discharge with Na in high 130s for several days with
fluid restriction. Fluid restriction was discontinued with
stable sodium levels for several days prior to patient expiring.
.
.
# Metastatic Melanoma: End stage. Pt was receiving palliative
XRT. Patient was transitioned to palliative care while
inpatient.
.
# Ulcer on back: Ulcer remains unstageable but is improving in
size.
The ulcer measures 0.5 x 0.4 cm. Miconazole powder was applied
to the surrounding area.
The plan was to stabilize the patient and send him St. [**Doctor First Name 9893**],
a facility near his home, requested by his wife, to provide
inpatient hospice care. Unfortunately, the pt died before he
could be transferred.
Medications on Admission:
Dulcolax 5 mg EC 1-2 tabs PRN constipation
Dexamethasone 4 m [**Hospital1 **]
Escitalopram 20 mg Q day
Gabapentin 600 mg QID
Hydromorphone 4 mg tab PO Q 6 hr
Lactulose 15 ml TID for constipation
Lorazepam 0.5 mg 1-2 tabs QHS PRN insomnia
MV
Prochlorperazine 10 mg Q day
Temozolomide 100 mg TID
fentanyl patch 100 mg Q 72
Discharge Disposition:
Extended Care
Facility:
ST. [**Hospital 83932**] HOSPICE
Discharge Diagnosis:
altered mental status secondary to metastatic melanoma
Discharge Condition:
expired
Discharge Instructions:
-
-
Followup Instructions:
-
Completed by:[**2149-8-10**]
|
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"V15.82",
"197.0",
"272.0",
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"197.8",
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
]
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11153, 11212
|
7678, 8285
|
336, 342
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11311, 11321
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6131, 6131
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3447, 3474
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275, 298
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370, 3428
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6147, 7655
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8300, 10781
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4898, 4943
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4975, 5095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,601
| 115,903
|
38656
|
Discharge summary
|
report
|
Admission Date: [**2164-1-11**] Discharge Date: [**2164-1-25**]
Date of Birth: [**2111-6-2**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p ~20 ft fall
Major Surgical or Invasive Procedure:
[**2164-1-19**]
PROCEDURES:
1. Percutaneous endoscopic gastrostomy tube.
2. Open tracheostomy.
3. Placement of inferior vena cava filter.
History of Present Illness:
52 y/o male s/p fall off ~20 foot high scaffolding. Landed on
back on concrete. Positive LOC; he was taken to an area hsopital
and transferred to [**Hospital1 18**] for further care.
.
Past Medical History:
CAD, DM
Family History:
Noncontributory
Physical Exam:
Upon admission:
BP: 159 / 104 HR: 101-105 R 23 O2Sats: 100% NRB
Gen: Uncomfortable and complaining of severe back pain on back
board on CT table.
HEENT: Pupils: 3-2.5 EOMs intact
Neck: Trauma collar on
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake, but lethargic
Orientation: Oriented to self, date and president, confused
about
location states he is in [**State **] State.
Language: Speech fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2.5 mm
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-21**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2164-1-11**] 03:27PM K+-4.3
[**2164-1-11**] 03:27PM HGB-17.7 calcHCT-53
[**2164-1-11**] 03:10PM UREA N-15 CREAT-1.1
[**2164-1-11**] 03:10PM LIPASE-25
[**2164-1-11**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-1-11**] 03:10PM WBC-25.4* RBC-5.47 HGB-15.6 HCT-45.3 MCV-83
MCH-28.4 MCHC-34.4 RDW-13.7
[**2164-1-11**] 03:10PM PLT COUNT-278
[**2164-1-11**] 03:10PM PT-11.7 PTT-23.4 INR(PT)-1.0
[**2164-1-11**] 03:10PM FIBRINOGE-271
IMAGING:
[**2164-1-11**] CT head: 1. Minimal interval change in acute left
midbrain hemorrhage, now measuring 10 mm compared to 11 mm
previously. 2. Right temporal subarachnoid, intraparenchymal and
possible small subdural hematoma unchanged appearance. 3.
Hyperdense focus in the left frontal vertex may represent a
vessel; however, small focus of hemorrhage is not excluded.
.
[**2164-1-11**] CXR: Multiple left rib fractures. Subcutaneous emphysema
in right chest wall.
.
[**2164-1-11**] CT head: 1.1 cm focus of left brainstem acute
hemorrhage. Right temporal subarachnoid, intraparenchymal and
possible small subdural hematoma.
.
[**2164-1-11**] CT torso: Suboptimal reformatted images of the
thoracolumbar spine. If high clinical concern for spine
fracture, consider repeat study of the thoracolumbar spine. 2.
Left 2nd-7th rib fractures. Comminuted left clavicle fracture.
3. Right 1st rib costochondral diastasis, with associated
subcutaneous emphysema. Small right pneumothorax. 4. No evidence
of acute visceral injury in the abdomen or pelvis.
.
[**2164-1-11**] CT c-spine: WETREAD - No fx or malalignment.
Micro/Imaging:
[**2164-1-18**] LENIS neg b/l
[**2164-1-15**] BAL - R GS-3+PMNs,2+GPRs
[**2164-1-15**] BAL - L GS-3+PMNs,1+GPRs
[**2164-1-14**] sputum cx GS->25PMNs,1+GPCS
(pairs/clusters);Cx-Commensal Respiratory Flora
[**2164-1-14**] sputum cx cx GS->25PMNs,1+GPCS
(pairs/clusters);Cx-Commensal Respiratory Flora
[**2164-1-14**] sputum cx GS->25 PMNs,2+GPCs,2+GNRs,2+GPRs;Cx-Commensal
Respiratory Flora
[**2164-1-14**] BCx no growth
[**2164-1-14**] BCx no growth
[**2164-1-14**] UCx no growth
Brief Hospital Course:
He was admitted to the Trauma service. Neurosurgery was
consulted; he was admitted to the Trauma ICU where frequent
neurologic checks and serial head CT scans were followed. He was
loaded with Dilantin and remained on it for 10 days for seizure
prophylaxis; there were no seizures reported during his hospital
stay. His current mental status is awake, alert with
intermittent confusion likely related to delirium. He was given
intermittent doses of Ativan and Haldol for this. It is being
recommended that antipsychotic be used to treat his delirium vs.
benzodiazepines as this can worsen delirium.
He had chest tubes placed initially for his pneumothorax and
those have since been removed. Last chest xray on [**1-21**] revealed
some atelectasis; he is prescribed nebulizers prn.
He was also seen by ENT for left hemotympanum; he was prescribed
ear drops and should follow up with ENT as an outpatient.
The Pain Service was consulted for epidural analgesia due to his
rib fractures but recommended intravenous narcotics given that
at the time his cervical spine had not been cleared. He is
currently on an oral regimen and his pain appears to be
adequately controlled.
His left clavicle fracture was evaluated by Orthopedics and was
managed non operatively. he should not bear full weight on his
left arm. he will follow up as an outpatient.
He was evaluated by Physical therapy and is being recommended
for rehab after his acute hospital stay.
Medications on Admission:
[**Last Name (un) 1724**]: none
All: Codeine
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
5. Acetaminophen 500 mg/15 mL Liquid Sig: Fifteen (15) ML's PO
Q4H (every 4 hours) as needed for fever or pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO twice a day as needed for constipation.
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for Pain.
8. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: Four (4) drops Otic
twice a day for 8 days.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) neb Inhalation four times a day as needed for
shortness of breath or wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation four times a day as needed for shortness of breath or
wheezing.
12. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
s/p 20 foot Fall
Scalp laceration
Right subarachnoid hemorrhage
Intraparenchymal hemorrhage
Left [**12-25**] rib fractures
Small right pneumothorax
Comminuted left clavicle fracture
Respiratory failure
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were hospitalized following a ~20 ft fall where you
sustained a bleeding injury to your brain, rib fractures and a
fractures collar bone. Your injuries did not require surgery.
You did require 2 procedures where a tracheosotmy for breathing
was placed and a feeding tube was placed in your abdomen so that
you could receive nutrition. As you recover from your injuries
it is expected that the tracheostomy and feeding tube will be
able to be removed.
Followup Instructions:
Follow up in 1 month with Dr. [**Last Name (STitle) **], Neurosurgery for a repeat
head CT scan. Call [**Telephone/Fax (1) 1669**] for an appointment.
Follow up in 1 month with Dr. [**Last Name (STitle) **], Trauma surgery for
evalaution of your rib fractures, tracheosotmy and PEG removal.
Call [**Telephone/Fax (1) 2359**] for an appointment.
Follow up in [**Hospital **] clinic for an audiogram in 1 month, call
[**Telephone/Fax (1) 41**] for an appointment.
Follow up in 1 month in [**Hospital **] clinic with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], NP for your clavicle fracture, call [**Telephone/Fax (1) 1228**] for
an appointment.
Completed by:[**2164-2-9**]
|
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icd9cm
|
[
[
[]
]
] |
[
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[
[
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6980, 7062
|
4175, 5627
|
282, 422
|
7307, 7307
|
2044, 2564
|
7960, 8658
|
684, 701
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5723, 6957
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5653, 5700
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716, 718
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227, 244
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450, 637
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1228, 2025
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3039, 4152
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733, 1013
|
7322, 7457
|
659, 668
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,947
| 128,214
|
6249
|
Discharge summary
|
report
|
Admission Date: [**2103-12-17**] Discharge Date: [**2104-1-17**]
Date of Birth: [**2067-10-29**] Sex: F
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Admitted for Pancreas following Kidney ([**2102**])
Major Surgical or Invasive Procedure:
[**2103-12-19**]: Pancreas after kidney with duodenojejunostomy
[**2103-12-26**] x-ray laparotomy with transplant pancreatectomy
and wound debridement.
History of Present Illness:
Diabetes mellitus type 1 status post kidney transplant. Active
on pancreas list for PAK, currently on Prograf and Cellcept.
Denies fever or chills. Has a non-productive dry cough with
intermittent sore throat x 1 month. Occasional constipation.
Denies complaints regarding urine output. Blood sugar control
extremely variable (60-400). Has not taken Prograf on day of
admission.
Past Medical History:
ESRD
DM since age 7
Lupus
HTN
Kidney Tx from father [**2102**]
Retinopathy with laser Rx
C Section x 2
Social History:
Married with son
Family History:
N/C
Physical Exam:
VS: 98.0, 131/91, 101, 20, 97% wt 65.1
Gen: A+Ox3, sitting on bed, no fever or chills
HEENT: Oral mucosa pink/moist, no evidence of pharyngeal illness
Lungs: CTA Bilaterally
Card: RRR, no MRG
Abd: Soft, NT, ND, well healed scar R iliac fossa, + BS
Extr: no edema, + Radial, pedal and femoral pulses bilaterally
Pertinent Results:
On Admission:
GLUCOSE-97 UREA N-20 CREAT-0.9 SODIUM-139 POTASSIUM-4.6
CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
WBC-8.5 RBC-4.17* HGB-13.0 HCT-35.9* MCV-86 MCH-31.2 MCHC-36.3*
RDW-13.3
PLT COUNT-257
ALT(SGPT)-25 AST(SGOT)-18 LD(LDH)-144 ALK PHOS-88 AMYLASE-51 TOT
BILI-0.2
LIPASE-12
ALBUMIN-4.6 CALCIUM-10.2 CHOLEST-151
UCG-NEGATIVE
URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 BLOOD-NEG
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0-2 WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
Brief Hospital Course:
Diabetes mellitus type 1 status post kidney transplant now
admitted for PAK.
During the surgical procedure the pancreas pinked-up
immediately, and the duodenum began filling with exocrine
secretions. Once hemorrhage was controlled from the gland
itself, duodenojejunostomy completed. The jejunum was
anastomosed side-to-side to the duodenum. Patient extubated in
the OR. Please see op note for additional details.
In the immediate post op period the patient was transferred to
the ICU. It was noted that bladder pressure increased overnight,
and was also reintubated due to increasing respiratory distress
and hypotension.
Extubated on POD 3. Serial Abdominal exams revealed protuberant
abdomen, but softer and appropriately tender. Abdominal wound
intermittently had large amounts of sero-sang drainage when
patient coughed. Pancreas U/S showed the pancreas transplant
identified in the right mid abdomen with no discrete
peripancreatic collections. Ascites was noted. Arterial flow is
abnormal with a resistive index of one and no flow in diastole,
however, the entire graft is well vascularized and venous
outflow was normal. Arterial waveforms may reflect swelling due
to transplant pancreatitis.
Patient received ATG 100 intra-op and then 4 additional doses of
75 mg through POD 4 for a total of 5 doses. Continued on Prograf
and Cellcept. Creatinine had one bump to 1.9 on POD [**10-17**] but
otherwise remained around baseline of 1.0. Blood sugars were
variable with occasional BS > 200, but mostly 100-150. Amylase
and lipase initially elevated but returned to [**Location 213**] by POD 7.
Patient transferred to floor on POD 5.
Patients' abdomen was noted to be more distended, and on POD 6,
CT exam of abdomen showed: thrombus in the donor venous
anastomosis extending to the recipient inferior vena cava, as
well as likely compromised arterial supply to the transplanted
pancreas with findings suggestive of necrosis within the
pancreas head. Plan was to place an IVC filter with possible
thrombectomy/thrombolysis. Patient underwent uncomplicated
deployment of a Gunther tulip IVC filter via the right IJ
approach, with filter placed just above the IVC thrombus tip. If
removal of filter is considered, this would be best performed
within 2-3 weeks from now. (By [**2104-1-15**]) At the same time there
were failed attempts to opacify and catheterize the transplant
outflow vein. Patient was kept anticoagulated overnight and a
pancreatectomy of the transplant pancreas was performed on
[**2103-12-26**]. During the procedure, the pancreas was inspected on
the back table, it appeared to
be mainly a venous thrombosis. An organized clot at the Y graft
to SMA anastomosis was seen. The anastomoses themselves appeared
to be intact. Biopsy results showed
-Vascular thrombosis of major vessels, with transmural
hemorrhagic necrosis of donor duodenal wall.
-Mucosal ischemic necrosis involves both duodenal resection
margins.
-Pancreatic parenchyma with localized areas of necrosis and
acute inflammation, consistent with vascular ischemia.
Wound VAC was placed to the abdominal wound at the closure of
the pancreatectomy due to some necrotic subcutaeous tissue.
Patient was transferred back to the SICU following the
pancreatectomy.
CMV negative on [**2103-12-27**]
Patient complained of increased abdominal pain. CT exam of
abdomen on [**2104-1-7**] showed a 5 x 6 cm fluid collection with
enhancing wall in the right lower quadrant extending from the
level just inferior to the right lobe of the liver to the renal
transplant (in the old pancreas transplant bed). A second small
phlegmonous area was seen inferiorly and posteriorly to this
larger collection. Two small encapsulated fluid collections were
seen at the pancreatic arterial anastomotic site and adjacent to
the anterior abdominal wall as described above. On [**2104-1-8**],
drainage of collection resulted in 20 mL of serous sanguinous
fluid. A pigtail drain was left in place. Gram stain showed no
bacteria and cultures are negative after 48 hours. WBC was 225.
Amylase 19, T bili 1.7. A large clot was noted in the fluid.
Patient continued to improve. Diet advanced. Last day of TPN
[**2104-1-10**]
Coumadin therapy initiated on [**1-5**] due to thrombus and filter
placement. Patient will continue Coumadin as an outpatient.
On [**2104-1-11**] an unsuccessful attempt to retrieve the Gunther filter
was tried. The filter remains in at the time of discharge.
Patient continued to convalesce, started eating a bit better and
got blood sugars under control. Will continue on Lantus and
Humalog at home. [**Last Name (un) **] offered support during hospitalization
and is available for post care if patient requests.
Wound VAC changed on day of discharge. Will continue at home for
now. Assessment of need for continuing will be at outpatient
appointment. Wound appears well granulated but remains deep and
wide.
Will continue MMF and Prograf for immunosuppression for kidney
transplant.
Also sent home with Valcyte and Bactrim
Medications on Admission:
Prograf [**4-9**], Cellcept [**Pager number **]/750, Lisinopril 5', Humulin N 20 q AM,
Lantus 45u q AM, Humalog SS, Colace [**Hospital1 **] PRN
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO ONCE (Once).
Disp:*60 Tablet(s)* Refills:*0*
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times
a day) for 2 doses.
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-8**] Sprays Nasal
QID (4 times a day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Insulin Glargine 100 unit/mL Solution Sig: Thirty Eight (38)
units Subcutaneous once a day: Take in the morning.
12. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Please follow sliding scale.
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
DMI
S/P PAK with failed pancreas transplant due to thrombus
Discharge Condition:
Stable
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] if you experience:
-fever
-chills
-nausea, vomiting, inability to eat or keep medications down
-increase or change in nature of drainage from wound VAC
-low urine output
Continue Prograf and Cellcept as prescribed and have labs drawn
and faxed to [**Telephone/Fax (1) 697**] (Transplant office)
CBC, Chem 7, Ca, Phos, AST, T Bili, U/A and trough Prograf level
VNA will assist with wound VAC dressing changes, which should be
done every 3 days.
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2104-1-14**] 2:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2104-1-24**] 1:10
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2104-1-28**] 1:20
Completed by:[**2104-1-17**]
|
[
"789.5",
"998.12",
"362.01",
"250.61",
"996.81",
"996.86",
"428.0",
"357.2",
"577.0",
"453.8",
"250.41",
"518.5",
"599.0",
"710.0",
"584.5",
"403.90",
"250.51",
"453.2",
"444.89",
"V42.0",
"682.2",
"997.79",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.82",
"33.24",
"83.39",
"96.07",
"96.04",
"96.71",
"52.6",
"00.93",
"99.15",
"54.91",
"96.72",
"93.59",
"45.91",
"38.7",
"99.04",
"88.51"
] |
icd9pcs
|
[
[
[]
]
] |
8433, 8471
|
1982, 6985
|
321, 475
|
8575, 8584
|
1413, 1413
|
9118, 9566
|
1061, 1066
|
7180, 8410
|
8492, 8554
|
7011, 7157
|
8608, 9095
|
1081, 1394
|
230, 283
|
503, 884
|
1427, 1959
|
906, 1010
|
1026, 1045
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,946
| 194,405
|
43614
|
Discharge summary
|
report
|
Admission Date: [**2132-11-12**] Discharge Date: [**2132-11-28**]
Date of Birth: [**2066-2-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 93789**] is a 66-year-old
female status post coronary artery bypass graft in [**2119**],
where she had left internal mammary artery to left anterior
descending artery, right internal mammary artery to first
obtuse marginal, and saphenous vein graft to diagonal, who
presented with progressive angina.
An echocardiogram performed on [**2132-9-4**] showed evidence
of aortic stenosis with a mean gradient of 46 mmHg and a
valve area of approximately 0.8. The patient was
re-catheterized on [**2132-10-30**] due to the progressive
symptoms. Catheterization in [**2132**] showed a transaortic
gradient of 67, and an aortic valve area of 0.7, 80% left
main disease, 100% left anterior descending artery lesion,
80% circumflex disease, a 60% right coronary artery lesion.
The left internal mammary artery to left anterior descending
artery had an 80% stenosis at the touchdown point. The right
internal mammary artery to obtuse marginal was totally
occluded, and the superior vena cava to the diagonal was also
totally occluded.
REVIEW OF SYSTEMS: On review of systems, the patient only
complained of numbness in both feet. She had no history of
gastrointestinal bleed. No melena. No hematochezia.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Hypertension.
2. Hypercholesterolemia.
3. Peripheral vascular disease.
4. History of left subclavian stenosis.
5. Hypothyroidism.
6. Fibromyalgia.
7. Depression.
8. Asthma.
PAST SURGICAL HISTORY: (Past surgical history is significant
for)
1. Coronary artery bypass graft in [**2119**]; done by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 14714**].
2. Bilateral vein stripping in the past as well for
bilateral lower extremity varicosities.
ALLERGIES: She has a sensitivity to ISORDIL.
MEDICATIONS ON ADMISSION: Medications included
aspirin 325 mg p.o. q.d., Synthroid 0.1 mg p.o. q.d.,
Elavil 10 mg p.o. q.h.s., Effexor 75 mg p.o. q.a.m.,
Lopid 600 mg p.o. b.i.d., lisinopril 40 mg p.o. q.d.,
Lopressor 25 mg p.o. b.i.d., albuterol nebulizers as needed.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, blood
pressure was 160/80, with a heart rate of 65. Head, eyes,
ears, nose, and throat examination was unremarkable. Her
neck showed bilateral carotid bruits. The chest had a
well-healed midline scar. Heart had a regular rate and
rhythm. A 3/6 systolic ejection murmur at the left lower
sternal border was noted. Lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended. No hepatosplenomegaly. No masses. No bruits.
Extremities revealed peripheral pulses were not palpable,
dorsalis pedis and posterior tibialis pulses bilaterally.
Good capillary refill. The bilateral saphenectomy scar sites
were present.
AS[**Last Name (STitle) **]NT AND PLAN: This is a 66-year-old female with
severe aortic stenosis and significant occlusion of previous
bypass grafts, presenting with unstable angina who was
referred for aortic valve replacement and coronary artery
bypass graft with Dr. [**Last Name (Prefixes) **].
HOSPITAL COURSE: The patient underwent venous mapping and
carotid ultrasound. Ultimately, this preoperative carotid
ultrasound revealed a significant left carotid stenosis.
A consultation with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the Neurology Service
was obtained to assess how this could be dealt with
preoperatively. It turned out that the patient may have
suffered from a transient ischemic attack or stroke in the
past. She is a right-hand dominant female with multiple
stroke risk factors including angina, had been admitted for
the aortic valve replacement and coronary artery bypass
graft. She had a Duplex with the right internal carotid
artery stenosis of 60% to 69%, and the left internal carotid
artery stenosis of 80% to 99%.
Given the ultrasound findings, a magnetic resonance
angiography was obtained of the intracranial vessels. After
further evaluation of the left internal carotid artery
lesion, ultimately a left internal carotid artery stent had
to be placed preoperatively. This delayed the patient's
operation. The left internal carotid artery stent was placed
on [**2132-11-12**]. Because of the requirement for Plavix,
the patient was placed on Plavix. Her surgery was delayed
for one week. She remained on the C-MED Service on heparin,
Plavix, etcetera. She had no other issues or complications
during that time.
[**Last Name (STitle) 93790**], the patient went to the operating room on
[**2132-11-19**] where she underwent a coronary artery bypass
graft times three including a right radial artery graft to
the oblique marginal, a left radial artery graft to the right
posterior descending artery, and a left internal mammary
artery graft to the left anterior descending artery. She
also had an aortic valve replacement with 21-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. Dr. [**Last Name (Prefixes) **]
performed the procedure with the assistance of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 93791**]. The pericardium was left open. There was right
arterial line and right internal jugular Swan-Ganz catheter
which the patient left the room with. Two ventricular and
two atrial pacing wires were present, and there two
mediastinal chest tubes. The cross-clamp time was
approximately 136 minutes with the bypass time being 152
minutes. Mean arterial pressure leaving the room was 101
with a central venous pressure of 17, a PAD of 23, with a
pulmonary artery mean pressure of 25. She was in an AV paced
rhythm with a rate of 88. She left on Neo-Synephrine and
nitroglycerin.
Postoperatively, the patient was empirically ruled out by
cardiac enzymes. Her hematocrit postoperatively was 27.2,
with a blood urea nitrogen of 19, and creatinine of 0.6.
Coagulations were otherwise normal. The patient was
extubated, out of bed, and ambulating. Her nitroglycerin was
transitioned to Imdur orally and was started back on her
Plavix for the stent. In addition, aspirin was added to her
regimen. She was diuresed accordingly. She was receiving
perioperative vancomycin.
She developed a postoperative bifascicular block and was
evaluated with a Electrophysiology consultation. A repeat
electrocardiogram confirmed the postoperative bifascicular
block. An echocardiogram was performed showing effectively
no evidence significant change from the intraoperative
transesophageal echocardiogram which revealed a bioprosthetic
valve in the aortic position, trivial aortic insufficiency
within the combines of the valve with a calculated gradient
of 17 peak and 10 mm mean. She had preserved biventricular
systolic function with an ejection fraction estimated at
greater than 55%. Compared with the cardiopulmonary bypass
echocardiogram, there was more mitral regurgitation (now
mild-to-moderate) which again was unchanged.
Ultimately, Electrophysiology stated no pacemaker would be
required. The patient's conduction ultimately changed, and
she was ultimately in a sinus rhythm in the 70s by
postoperative four. Her hematocrit at this time was 29, with
a blood urea nitrogen of 11, and creatinine of 0.5. She was
out of bed ambulating. She was on Lasix 20 mg intravenously
b.i.d., and her wires were discontinued. She continued her
Imdur and Plavix. Once cleared by the Electrophysiology
Service, she was continued on her diuresis and sent to the
floor.
On postoperative day five (which was [**2132-11-24**]), she
was afebrile with a temperature of 98.4, and blood pressure
was 150/76. She was in sinus rhythm at 100, breathing at a
rate of 20, with an oxygen saturation of 96% on 4 liters
nasal cannula. She was clear to auscultation but decreased
at the base. She had a regular rate and rhythm, but was
somewhat fast. The abdomen was soft, nontender, and
nondistended. Extremities revealed no edema. The incision
was clean, dry, and intact with no drainage. She was
continued on Imdur, and continued on her Plavix, and her
Lasix diuresis. She was up and ambulating.
She was evaluated by the Physical Therapy Service who stated
the patient was quite mobile and doing well. She had
progressive dyspnea on exertion and expiratory wheezing. It
was felt this could be secondary to fluid overload and
possible bronchospasm. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], the patient's
primary care [**Last Name (NamePattern1) **], [**Name10 (NameIs) **] consulted to assist with the
management of this. She was given two separate doses of
40 mg of intravenous Lasix; both on [**2132-11-26**] and
[**2132-11-27**]; to which she responded well. Her
saturations were never below 95%, and her room air
saturations were approximately 89%. The 95% saturations
stated above were done on 3 liters nasal cannula.
Ultimately, the patient was given nebulizers and
bronchodilators as needed. The patient refused steroid
inhalers and ultimately was under continued assessment by
Dr. [**Last Name (STitle) 2450**]. Dr. [**Last Name (STitle) 2450**] did review the patient's medication list
prior to discharge, and all the medications which will follow
were chosen under his guidance and knowledge.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Lopressor 25 mg p.o. b.i.d.
3. Amitriptyline HCl 10 mg p.o. q.h.s.
4. Venlafaxine-XR 75 mg p.o. q.d.
5. Levothyroxine 100 mcg p.o. q.d.
6. Albuterol meter-dosed inhaler 2 puffs q.6h.
7. Atrovent meter-dosed inhaler 2 puffs q.4-6h. as needed.
8. Imdur 60 mg p.o. q.d. (to be continued for at one
month).
9. Gemfibrozil 600 mg p.o. b.i.d.
10. Percocet 5/325 one to two tablets p.o. q.4-6h. as
needed.
11. Colace 100 mg p.o. b.i.d.
12. Plavix 75 mg p.o. q.d. (to be continued for at least
three months).
13. Lasix 20 mg p.o. b.i.d. (times three days) then change
to Lasix 20 mg p.o. q.d. (times five days). Then Dr. [**Last Name (STitle) 2450**] to
reassess.
14. Potassium 20 mEq p.o. b.i.d. (times three days) then
change to potassium 20 mEq p.o. q.d. (times five days). Then
Dr. [**Last Name (STitle) 2450**] to reassess.
CONDITION AT DISCHARGE: Condition on discharge was stable,
afebrile, in sinus rhythm. No sternal drainage. She had
some slight expiratory wheezes; but otherwise had good lung
excursion, clear with no crackles. She had no lower
extremity edema. She had no evidence of jugular venous
distention.
DISCHARGE STATUS: Discharge disposition was to home with
[**Hospital6 407**]; to go home with her daughters in
[**Name (NI) 40198**].
DI[**Last Name (STitle) 408**]E FOLLOWUP/INSTRUCTIONS:
1. Her visiting nurse was to call Dr. [**Last Name (STitle) 2450**] in approximately
three to four days to update him on how her expiratory
wheezing and diuresis was progressing.
2. She should receive a wound check in approximately two
weeks here on [**Hospital Ward Name 121**] Two with the nurse practitioner [**First Name (Titles) **]
[**Last Name (Titles) **] assistant on call for that day.
3. She should follow up with Neurology attending (Dr. [**Last Name (STitle) **]
by calling telephone number [**Telephone/Fax (1) 657**] and be seen in
approximately one month from the time of discharge.
4. She was to continue her Plavix and aspirin as directed
for stent. She should see Dr. [**Last Name (Prefixes) **] in four weeks in
his clinic for a postoperative followup.
5. She was also to see Dr. [**Last Name (STitle) 2450**] in approximately one to two
weeks for followup so that her medications can be reviewed
and medications changed as needed.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2132-11-27**] 14:16
T: [**2132-11-27**] 15:28
JOB#: [**Job Number **]
cc:[**Doctor Last Name 93792**]
|
[
"458.2",
"433.10",
"790.01",
"411.1",
"426.53",
"414.02",
"276.6",
"424.1",
"414.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.12",
"36.15",
"39.61",
"39.64",
"89.68",
"88.41",
"38.93",
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
9455, 10342
|
2000, 3258
|
3277, 9428
|
1657, 1973
|
10357, 12074
|
1229, 1383
|
158, 1208
|
1406, 1633
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,193
| 134,118
|
16729
|
Discharge summary
|
report
|
Admission Date: [**2179-10-5**] Discharge Date: [**2179-10-8**]
Service: CARDIOTHORACIC
Allergies:
Heparin Agents / Ciprofloxacin
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
shortness of breath, respiratory distress, requiring intubation
Major Surgical or Invasive Procedure:
[**10-6**]: Rigid bronchoscopy.
2. Flexible bronchoscopy.
3. Balloon dilatation.
4. Metallic stent placement
History of Present Illness:
88M with metastatic esophageal cancer with erosion/compression
of trachea p/w SOB now intubated. Patient tranferred from [**Last Name (un) 1724**]
for Interventional Pulmonary evaluation, treatment and
procedure.
Past Medical History:
PMH: esophageal ca s/p radiation and chemo, MRSA pneumnia, c.
dif, anemia, hyponatremia, s/p G-tube
Physical Exam:
General-ill appearing elderly male in NAD, extubated.
HEENT- PERRLA/ EOMI, neck supple,
REsp- ronchi, no wheezing, good airation post procedure
COR- RRR
ABD-g-tube site, no erythema or discharge; soft, non-tender-
tubefeedings resumed
Ext- no edema, cyanosis.
Neuro- interactive, grossly intact
Pertinent Results:
[**2179-10-5**] 10:23PM PT-13.5* PTT-34.3 INR(PT)-1.2*
[**2179-10-5**] 10:23PM PLT COUNT-235
[**2179-10-5**] 10:23PM WBC-13.1* RBC-3.23* HGB-10.3* HCT-30.7*
MCV-95 MCH-31.9 MCHC-33.6 RDW-13.9
[**2179-10-5**] 10:23PM VANCO-11.1
[**2179-10-5**] 10:23PM calTIBC-190* FERRITIN-621* TRF-146*
[**2179-10-5**] 10:23PM ALBUMIN-3.4 CALCIUM-8.9 PHOSPHATE-2.3*
MAGNESIUM-2.3 IRON-29*
[**2179-10-5**] 10:23PM GLUCOSE-137* UREA N-14 CREAT-0.7 SODIUM-142
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-29 ANION GAP-11
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2179-10-7**] 04:37AM 12.0* 2.81* 9.0* 26.9* 96 32.1* 33.6 13.7
203
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2179-10-7**] 04:37AM 203
[**2179-10-7**] 04:37AM 14.0* 42.1* 1.2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2179-10-7**] 04:37AM 125* 7 0.6 137 3.7 105 27 9
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2179-10-7**] 04:37AM 77
CPK ISOENZYMES CK-MB cTropnT
[**2179-10-7**] 04:37AM NotDone1 0.04*2
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2179-10-7**] 04:37AM 8.1* 2.6* 2.0
HEMATOLOGIC calTIBC Ferritn TRF
[**2179-10-5**] 10:23PM 190* 621* 146*
ANTIBIOTICS Vanco
[**2179-10-5**] 10:23PM 11.11
1 UPDATED REFERENCE RANGE AS OF [**2179-9-22**] == REPRESENTS
THERAPEUTIC TROUGH
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat Vent
[**2179-10-7**] 06:44AM ART 116* 38 7.45 27 3
[**2179-10-7**] 01:03AM ART 38.1 /22 300 5 40 95 42 7.42 28 2
INTUBATED SPONTANEOU1
RADIOLOGY Preliminary Report
CT CHEST W/O CONTRAST [**2179-10-6**] 2:50 AM
Reason: [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
88 year old man with esophageal mass eroding into trachea
REASON FOR THIS EXAMINATION:
? amount of erosion
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Esophageal mass eroding into trachea. Question
amount of erosion.
TECHNIQUE: MDCT acquired images of the chest without the use of
intravenous contrast material. Images were displayed with 5- and
1.25-mm slice thickness in the axial plane.
FINDINGS: There is a soft tissue mass, subsuming the esophagus,
extending from the level of the thoracic inlet caudally at least
to the subcarinal level. The maximum dimensions in the axial
plane are 3.6 x 3.6 cm and at least 10 cm in craniocaudal
dimension. The inferior border of the mass is difficult to
determine as it is smoothly tapering. There is apparent invasion
of the posterior wall of the trachea over a segment of
approximately 7 cm. Inferior to the endotracheal tube, the
residual lumen measures 8 x 6 mm. The mass is inseparable from
the innominate artery as well as the aortic arch with possible
invasion of both vessel walls (no residual fat plane). There is
thickening along the posterior aspect of the right main stem
bronchus and bronchus intermedius, likely representing an
extension of the mass. No intraluminal invasion is apparent.
There are bilateral small pleural effusions and mild left
basilar compressive atelectasis. There is bronchiectasis and
surrounding peribronchial fibrotic thickening in the right upper
lobe of uncertain significance. This may represent post
radiation changes if there is a history of malignancy. The
patient is status post midline sternotomy, apparently performed
for treatment of motor vehicle accident trauma, according to the
CareWeb notes.
No acute pathology is seen in the partially visualized upper
abdominal organs. A 1-mm area of calcification on the most
inferior image slice in the left kidney may represent a
nonobstructing calculus or vascular calcification. The study is
not designed for evaluation of abdominal organs.
IMPRESSION:
1. Soft tissue mass centered around the upper esophagus,
inseparable from the innominate artery and tip of aortic arch
with likely extension into the wall of the right main stem
bronchus and bronchus intermedius. The mass is also invading the
posterior tracheal wall and causing luminal narrowing distal to
the endotracheal tube.
2. Bilateral small pleural effusions and mild left basal
atelectasis.
3. Bronchiectasis with peribronchial, likely chronic, thickening
in the right upper lobe of uncertain etiology. Is there a
history of radiation therapy?
4. Partially visualized stone or vascular calcification in the
left kidney.
CHEST (PORTABLE AP) [**2179-10-7**] 7:58 AM
Reason: r/o pneumo
[**Hospital 93**] MEDICAL CONDITION:
88 year old man with metastatic esophageal cancer and central
airway obstruction
REASON FOR THIS EXAMINATION:
r/o pneumo
AP CHEST, 8:32 A.M., [**10-7**]
HISTORY: Metastatic esophageal cancer. Central airway
obstruction.
IMPRESSION: AP chest compared to [**10-6**]:
Endotracheal tube has been removed, leaving a mild subglottic
edema. Tracheal stent at the level of the aortic arch is
unchanged in position, and the left lung volumes are lower, with
new left lower lobe atelectasis. Pulmonary vasculature is
engorged and cardiac size has increased, though still top
normal. Mediastinal contours are unchanged, although the extent
of the upper esophageal mass is not fully apparent on plain
radiographs. No pneumothorax. Pleural effusion, if any, is
minimal on the left.
Brief Hospital Course:
88M with met esophageal cancer c erosion/compression of trachea
p/w SOB now intubated.
Patient admitted [**2179-10-5**] to ICU for ongoing critical management.
Night of admission, CT of neck/chest done, pre-op for OR- rigid
bronchoscopy, possible stent placement.
HD#2- Maintained in ICU. To OR w/ Inter Pul for:Rigid
bronchoscopy, Flexible bronchoscopy,Balloon dilatation, Metallic
stent placement. Patient re-intubated into metallic stent post
procedure for overnight observation. Overnight course
significant for transient hypotension related to sedation,
treated w/ decreasing sedation, neo gtt/ IVF for 3hours. EKG-
no changes, enzymes flat. Hypotension resolved w/ d/c of
sedation in am prior to extubation. T- 100.6; Vanco
HD#3/PPD1- Patient stable in early am, sedation weaned w/o
complication. Pt extubated in controlled critical care setting
w/o complication, RR 20, sat 100% on.50 face tent. Hct 26.9
from 28.4 pre-op. Pt heomdynamically stable.
Pt stable post- procedure and ready for transfer back to
acute/critical referring facility.
99.2/98.4/84/108/48/16-20/100% .50 face tent. See pertinent
results for lab data.
Patient was transferred back to care under Dr. [**First Name4 (NamePattern1) 12056**] [**Last Name (NamePattern1) 634**] at
the ICU at [**Hospital6 2561**].
Medications on Admission:
prilosec, folic acid, lactinex, benadryl, tylenol, MOM,
[**Name (NI) 47319**], [**Name2 (NI) **], fentanyl patch, colace, percocet, duoneb
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) cc PO
BID (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q3-4H (Every 3 to 4 Hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
9. Pantoprazole 40 mg IV Q24H
10. Potassium Chloride 20 mEq / 250 ml D5W IV PRN K<4
11. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN Mg<2
12. Vancomycin HCl 1000 mg IV Q 12H
check after third dose
13. Metoprolol 5 mg IV Q4H
hold for hr<60 and sbp<100
14. Fentanyl Citrate 25-100 mcg IV Q2H:PRN
15. Ceftriaxone 1 gm IV Q24H
16. Insulin Regular Human 100 unit/mL Solution Sig: as dir units
Injection ASDIR (AS DIRECTED): sliding scale.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
metastatic esophageal cancer w/ erosion/compression of trachea.
PMH: esophageal ca s/p radiation and chemo, MRSA pneumnia, c.
difficile, anemia, hyponatremia, s/p G-tube.
Discharge Condition:
fair
Discharge Instructions:
Transfer back to [**Hospital6 2561**] to continuing on going
care.
Contact [**Name6 (MD) **] [**Name8 (MD) **], MD, [**Hospital1 18**], Interventional Pulmonary-
[**Telephone/Fax (1) 3020**] for any post procedure issues or questions
Followup Instructions:
Follow-up per instruction by [**Name6 (MD) **] [**Name8 (MD) **], MD, [**Hospital1 18**]-[**Telephone/Fax (1) 3020**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"285.9",
"150.8",
"518.81",
"599.0",
"V15.3",
"V44.1",
"276.1",
"V09.0",
"519.1",
"482.41",
"530.84",
"427.31",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"31.42",
"96.05",
"31.99",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9201, 9216
|
6558, 7851
|
307, 421
|
9431, 9438
|
1118, 2995
|
9720, 9933
|
8040, 9178
|
5764, 5845
|
9237, 9410
|
7877, 8017
|
9462, 9697
|
803, 1099
|
204, 269
|
5874, 6535
|
449, 664
|
686, 788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,386
| 167,797
|
41148
|
Discharge summary
|
report
|
Admission Date: [**2135-12-30**] Discharge Date: [**2136-1-16**]
Date of Birth: [**2068-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Exertional dyspnea
Major Surgical or Invasive Procedure:
[**2136-1-6**] - Urgent pump-assisted beating heart coronary artery
bypass graft x3: Left internal mammary artery to left anterior
descending artery, and saphenous vein grafts to obtuse marginal
and posterior descending arteries.
History of Present Illness:
67 year old male who presented to [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital with
systolic heart failure. An echocardiogram and nuclear stress
test showed an old large/inferior-lateral MI. He was referred
for a cardiac catheterization for further evaluation. He was
found to have multivessel disease upon catheterization. He was
transferred to [**Hospital1 18**] for further evaluation and
revascularization.
Past Medical History:
-Ischemic cardiomyopathy, LVEF=15-20% (3 heart failure
admissions
in [**Male First Name (un) 1056**] in 1 year)
-CAD status post large inferior MI [**2134**] (managed medically in
[**Male First Name (un) 1056**])
-CVA [**2134**]
-Bicuspid Aortic Valve
-IDDM
-Bilateral leg amputation secondary to peripheral arterial
disease (Right in [**2132**], Left in [**2134**])
-Chronic kidney disease
-Anemia
-Mild aortic stenosis
Social History:
Last Dental Exam: edentulous
Lives with:recently moved to US from [**Male First Name (un) 1056**]
Occupation:retired, previously worked in construction
Tobacco: denies
ETOH: denies
Family History:
non-contributory
Physical Exam:
Pulse: 80SR Resp: 20 O2 sat: 97%RA
B/P Right: Left: 114/75
Height: 5' (s/p bilat. BKA) Weight: 190lb ?
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] edentulous
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 none Varicosities: None [x]
Bilateral BKA
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: Left: NA
PT [**Name (NI) 167**]: Left: NA
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
ECHO [**2136-1-6**]
PREBYPASS: There is severe LV dilation and global hypokinesis of
the left ventricle with a calculated LVEF <20% by simpsons
method of discs, and a fractional area change of <20%. The right
ventricular cavity is moderately dilated, and there is a mild to
moderate decrease in RV systolic funciton. The aortic valve
leaflets are severely thickened/deformed, but there is a valve
area by continuity equation of 1.8 cm2 and by planimetry of
1.75cm2 cosistent with mild stenosis. There is decreased
systolic function with a decreased stroke volume across the AV,
therefore the gradients were all very low. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Mild TR and PI are
present. The interatrial septum is intact. There is no evidence
of clot in the left atrial appendage, although the velocities
measrued are less than 40 cm/sec. There is mild to moderate
descending thoracic aortic atherosclerosis. There is no
pericardial effusion.
POSTBYPASS: S/P CABG. Essentially unchanged. Mild improvement of
systolic function with inotrope administration
[**2136-1-2**] Carotid Duplex Ultrasound
Impression: Right ICA stenosis <40%. Left ICA stenosis <40%.
Renal Ultrasound [**2136-1-3**]
1. Normal-sized kidneys with no evidence of hydronephrosis.
2. Non-obstructive right upper pole stone versus stone in a
caliceal
diverticulum.
3. Bilateral cysts and a small AML in the upper pole of the left
kidney.
Brief Hospital Course:
Mr. [**Known lastname 7086**] was admitted to the [**Hospital1 18**] on [**2135-12-30**] for further
management of his coronary artery disease. He was worked-up in
the usual preoperative manner which included a carotid duplex
ultrasound which showed less then a 40% stenosis of the
bilateral internal carotid arteries. A renal consult was
obtaibed given his baseline creatinine was elevated at 1.6. An
ultrasound was obtained which showed normal-sized kidneys with
no evidence of hydronephrosis. It was believed that his chronic
kidney disease was due to his diabetes. On [**2136-1-6**], Mr. [**Known lastname 7086**]
was taken to the operating room where he underwent coronary
artery bypass grafting to three vessels. Please see operative
note for details. Postoperatively he was taken to the cardiac
surgical intensive care unit for monitoring. He was transfused
for postoperative anemia.
He developed ATN with a creatinine peak to 2.9- doown to 1.5 on
day of discharge.
Ace-I , betablocker and diuresis and statin therapies were
started and titrated to effect. Pacing wires and chest tubes
were removed per protocol. Mr. [**Known lastname 7086**] developed serosanguinous
drainage from the distal pole of his sternal incision. He was
started on IV cefazolin and changed to po keflex upon discharge
for 7 days.
He was cleared for discharge by Dr. [**First Name (STitle) **] on POD#10 to rehab
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] rehab in [**Location (un) 47**].
Medications on Admission:
Simvastatin 20mg Daily
Enalapril 10mg Daily
Carvedilol 12.5mg [**Hospital1 **]
Lasix 40mg Daily
Asprin 81mg Daily
Humalog insulin 70/30; 25 units every morning and every night
Saloftazol 100mg [**Hospital1 **]
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
7. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day:
decrease to daily dosing once sternal drainage resolves.
16. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Fifteen (15) units Subcutaneous twice a day.
17. insulin regular human 100 unit/mL Solution Sig: per
fingerstick units Injection before meals and at bedtime: dose
per fingerstick.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
-CAD status post large inferior MI [**2134**] (managed medically in
[**Male First Name (un) 1056**])
- Mild aortic stenosis
-Ischemic cardiomyopathy, LVEF=15-20% (3 heart failure
admissions
in [**Male First Name (un) 1056**] in 1 year)
-CVA [**2134**]
-Bicuspid Aortic Valve
-IDDM
-Bilateral leg amputation secondary to peripheral arterial
disease (Right in [**2132**], Left in [**2134**])
-Chronic kidney disease
-Anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or scant serosanguinous
drainage from mid point of sternal incision
Leg Left - healing well, no erythema or drainage.
No lower extremity edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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) **] [**2136-2-13**] at 1:00pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 77594**] in [**2-21**] weeks
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] in 3 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2136-1-16**]
|
[
"585.4",
"584.5",
"428.0",
"729.81",
"433.30",
"414.01",
"414.8",
"V12.54",
"V49.75",
"E878.2",
"285.9",
"412",
"599.0",
"997.5",
"250.40",
"746.4",
"424.0",
"433.10",
"V58.67",
"428.22",
"726.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7391, 7531
|
4028, 5524
|
328, 561
|
7997, 8285
|
2455, 4004
|
9174, 9814
|
1699, 1718
|
5784, 7368
|
7552, 7976
|
5550, 5761
|
8309, 9151
|
1733, 2436
|
270, 290
|
589, 1040
|
1062, 1484
|
1500, 1683
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,065
| 198,201
|
4220
|
Discharge summary
|
report
|
Admission Date: [**2116-2-8**] Discharge Date: [**2116-2-20**]
Date of Birth: [**2056-12-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
59 YOM with h/o NSCLC, CAD on aspirin presenting with melena,
nausea, vomiting. The patient reports having three episodes of
melena since this morning with nausea, vomiting but no
hematemesis. He also endorsed epigoastric pain and exertional
dyspnea and lightheadedness, but denied chest pain or syncope.
.
On arrival to the ED, the patient was noted to have SBP in the
50's with subsequent blood pressure in the room found to be
91/54. EKG reportedly showed NSR at 86 bpm and no acute ST
changes. The patient was type and crossed for 4 units PRBC. An
NG lavage showed immediate return of dark red clotted blood
which did not clear with 1L lavage. Guiac showed dark brown
floridly positive stool. He was started on a protonix drip with
a bolus and GI was consulted. Hct returned at 24 from a recent
baseline of 38. He was admitted to the MICU for further
evaluation. GI consult was initiated but did not see patient in
ED. Access: 1x16, 1x 18. He has not received blood. Interval
Vitals: Temp 98.1 HR 70 BP 100/68 Resp 18 O2 Sat 98%RA. Vitals
prior to transfer: T 97.7 HR 89 BP 102/48 RR 16 sat 100%RA.
.
of note, his recent medical history is as follows: He had
undergone catheterization in [**2115-5-5**], with two drug-eluting
stents placed. He has no cough. No shortness of breath. He
had a chest x-ray done as per his primary care physician. [**Name10 (NameIs) 6**]
abnormality was detected in the left upper lobe and a CT of the
chest was done on [**2116-1-3**]. He had a CT of the chest,
which revealed a 2.2 cm left upper lobe nodule as well as
mediastinal lymph node metastasis, skeletal metastasis,
lymphangitic carcinomatosis. He had a bronchoscopy with lymph
node biopsy on [**2116-1-17**]. Transbronchial biopsy of the
left upper lobe mass revealed adenocarcinoma of the lung, lymph
node station 4R, 4L, 7, and 11 were biopsied and revealed
adenocarcinoma. Prior to his biopsy, the prasugrel was stopped
and after the procedure, he was loaded with 60 mg of prasugrel
and then told to resume taking it at 10 mg daily. He had
pink-tinged sputum for several days after the biopsy and this
progressed to hemoptysis. On [**2116-1-22**], and [**2116-1-23**], he came to the emergency room with hemoptysis with no
intervention done at that time and he was discharged. This
patient had a PET CT, which revealed a 2.2 cm left upper lobe
nodule. There was also seen extensive FDG avid mediastinal,
hilar, and supraclavicular lymphadenopathy, osseous metastatic
involvement including lytic inferior sternal fracture at the
risk of pathologic fracture, and also several lytic and
sclerotic
lesions of the vertebrae, most prominent at T6.
.
On arrival to the MICU, the patient was stable, complaining of
no pain. The patient received 2U packed red cells and had an
EGD by GI which did not demonstrate an obvious source for
bleeding, but did have significant clot in stomach that was
unable to be totally cleared.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
- Newly diagnosed non-small cell lung cancer (metastatic)
- Coronary artery disease, status post cardiac catheterization
on [**2115-5-28**] with DES to the mLAD and dRCA. Catheterization
was done due to symptoms of dyspnea on exertion. No prior
history of MI.
-Dyslipidemia
-Impaired glucose tolerance test w/ Hgb A1c 6.2%
-Gastric esophageal reflux disease.
-Benign prostatic hypertrophy.
-Vitamin D deficiency
.
Oncological History:
.
- [**12/2115**]: developed right-sided chest pain. CXR was abnormal
and underwent CT on [**2116-1-3**] which showed a 2.2 cm left upper
lobe lung nodule as well as mediastinal lymph node metastases,
skeletal metastases and lymphangitic carcinomatosis.
- [**2116-1-17**]: bronchoscopy with lymph node biopsy. Transbronchial
biopsy of the left upper lobe mass was consistent with
adenocarcinoma of the lung. The carcinoma cells stained
positive for TTF-1 and negative for CK5/6, p63, and
thyroglobulin. Lymph node stations 4R, 4L, 7 and 11 were
biopsied and were all positive for adenocarcinoma.
- [**Date range (3) 18342**]: admission for hemoptysis in the setting of
receiving a 60 mg loading dose of Prasurgrel.
- [**2116-1-22**]: PET scan confirmed an FDG avid 2.2 cm left upper lobe
lung nodule. He was also seen to have extensive FDG avid
mediastinal, hilar, and supraclavicular lymphadenopathy, osseous
metastatic involvement included a lytic inferior sternal
fracture at the risk of pathologic fracture and also several
lytic and sclerotic lesions of the vertebrae, most prominent at
T6.
- [**2116-1-30**]: MRI T and L spine with extensive osseous metastases;
no cord compression.
Social History:
He is a nonsmoker and denies any secondhand smoke exposure. He
works as a mechanic at [**Hospital1 4601**] for the last 25 years. He
denies any known asbestosis or chemical inhalation. He will
drink a small cup of red wine about three times a week, but
denies any alcohol recently. He is married and lives with his
wife and one child. He is originally from [**Country 3992**] and moved
here in [**2084**]. Most of his family was killed in the [**Country 3992**] War.
Family History:
He does not know his family history as his parents died in the
[**Country 3992**] War and he does not know of any brothers or sisters that
he has.
Physical Exam:
Admission Physical Exam:
Vitals: T:98 BP:105/64 P:99 R: 18 O2:100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pale conjunctiva, 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: palor under the nails, perfused, 2+ pulses,
Neuro: CNII-XII intact
.
Discharge Physical Exam:
Vitals: 98.2 102/62 79 18 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pale conjunctiva, MMM, oropharynx
clear, EOMI, PERRL . Right eye medial sclera bleeding, not
injected.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally with decreased breath
sounds at the left base, no wheezes, rales, ronchi.
Thoracentesis site on the left CDI, bandage in place.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well-perfused, 2+ pulses, no edema
Neuro: CNII-XII intact
Pertinent Results:
Admission Labs:
[**2116-2-8**] 08:05PM BLOOD WBC-9.6# RBC-2.57*# Hgb-7.6*# Hct-24.2*#
MCV-94 MCH-29.7 MCHC-31.5 RDW-13.3 Plt Ct-248
[**2116-2-8**] 08:05PM BLOOD Neuts-74.4* Lymphs-21.3 Monos-3.1 Eos-0.8
Baso-0.3
[**2116-2-8**] 08:05PM BLOOD PT-13.4* PTT-25.2 INR(PT)-1.2*
[**2116-2-8**] 08:05PM BLOOD Glucose-169* UreaN-55* Creat-0.9 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
[**2116-2-8**] 08:05PM BLOOD Glucose-169* UreaN-55* Creat-0.9 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
[**2116-2-8**] 08:05PM BLOOD ALT-17 AST-17 AlkPhos-247* TotBili-0.1
[**2116-2-8**] 08:05PM BLOOD cTropnT-<0.01
[**2116-2-8**] 08:05PM BLOOD Albumin-2.9*
[**2116-2-8**] 08:05PM BLOOD D-Dimer-384
Interm Labs:
[**2116-2-8**] 11:47PM BLOOD calTIBC-142* Ferritn-177 TRF-109*
[**2116-2-8**] 11:47PM BLOOD Ret Aut-1.6
[**2116-2-8**] 08:05PM BLOOD D-Dimer-384
[**2116-2-8**] 08:05PM BLOOD cTropnT-<0.01
[**2116-2-9**] 03:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2116-2-8**] 11:47PM BLOOD Amylase-88
[**2116-2-9**] 03:48AM BLOOD ALT-15 AST-20 LD(LDH)-233 CK(CPK)-103
AlkPhos-173* TotBili-0.3
Pleural Fluid analysis:
[**2116-2-18**] 02:45PM PLEURAL WBC-275* RBC-1650* Polys-6* Lymphs-65*
Monos-0 Eos-1* Meso-3* Macro-5* Other-20*
[**2116-2-18**] 02:45PM PLEURAL TotProt-3.2 Glucose-126 LD(LDH)-233
Albumin-2.0 Triglyc-10
ADENOSINE DEAMINASE, PLEURAL 8.9 <9.2 U/L
POSITIVE FOR MALIGNANT CELLS, consistent with adenocarcinoma,
see note.
Cytogenetic analysis:
Test Information:
DNA was isolated from tissue with >50% tumor nuclei and analyzed
by polymerase chain reactions. For exon 19, capillary gel
electrophoresis is used to determine the size of the PCR
product.
For exon 21, a Taqman assay is used to determine the presence of
L858R point mutation.
RESULT:
Exon 19 PCR yielded 203 bp (wild type) product only.
Exon 21 PCR yielded both L858R and wild type sequence.
INTERPRETATION:
These results indicate a missense substitution of arginine for
leucine at codon 858 in EGFR exon 21 (L858R mutation). This
finding suggests a favorable response to treatment with a
targeted inhibitor of the EGFR tyrosine kinase. Other less
common, mutations in EGFR can be associated with either response
or resistance to therapy with a targeted inhibitor of the EGFR
tyrosine kinase. These include missense substitutions at codon
719 in exon 18 (responsive) and at codon 861 (L861Q) in exon 21
(responsive), insertions in exon 20 (primary resistance), and
T790M missense mutation in exon 20 (secondary resistance). These
mutations are not assessed by this test. Follow-up testing by
[**Location (un) 18343**] Sequencing is being performed by the Laboratory for
Molecular Medicine to assess these mutations, and will be
reported separately.
Discharge Labs:
[**2116-2-20**] 05:28AM BLOOD WBC-8.3 RBC-4.01* Hgb-12.0* Hct-35.5*
MCV-89 MCH-30.0 MCHC-33.9 RDW-13.6 Plt Ct-454*
[**2116-2-20**] 05:28AM BLOOD Glucose-96 UreaN-10 Creat-0.9 Na-142
K-4.7 Cl-104 HCO3-27 AnGap-16
[**2116-2-20**] 05:28AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.3
Microbiology:
[**2116-2-9**] HELICOBACTER PYLORI ANTIBODY TEST - NEGATIVE
[**2116-2-10**] URINE CULTURE - NEGATIVE
[**2116-2-10**] BLOOD CULTURE - NEGATIVE
[**2116-2-11**] BLOOD CULTURE - NEGATIVE
[**2116-2-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST -
NEGATIVE
[**2116-2-18**] BLOOD CULTURE - PENDING
[**2116-2-18**] URINE CULTURE - NEGATIVE
[**2116-2-18**] 2:45 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2116-2-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2116-2-21**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2116-2-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
Imaging:
EGD [**2-9**]:
Impression:
- Blood in the stomach
- Ulcer in the fundus (injection, thermal therapy)
- Diverticulum in the fourth part of the duodenum
- Otherwise normal EGD to third part of the duodenum
Recommendations:
- Cannot exclude possibility of another lesion underneath clot.
- Keep NPO and continue IV PPI drip
- Serial HCT
- Check H. pylori serology
CT Chest ([**2-17**]):
IMPRESSION:
1. Mixed interval changes, including: 1) enlarging left pleural
effusion, worsening pattern of lymphangitic carcinomatosis in
the left lung, and slight worsening of diffuse metastatic
skeletal lesions; 2) relatively stable left upper lobe nodule,
left hilar and supraclavicular nodes; and 3) stable to decreased
mediastinal lymph nodes.
2. New small right pleural effusion and slight increase in
pericardial effusion.
CXR ([**2-18**]):
FINDINGS: In comparison with study of [**2-11**], there has been
removal of pleural fluid from the left hemithorax. No evidence
of pneumothorax. Coalescent areas in the left upper and lower
zones could well reflect regions of consolidation. The right
lung is essentially clear.
Right IJ central catheter extends to the lower portion of the
SVC.
Brief Hospital Course:
59 YOM with h/o NSCLC, CAD on aspirin presenting with melena,
nausea, vomiting with signs suggestive of UGIB.
.
# UGIB: EGD performed by GI on admission showing large clot in
the fundus. A repeat EGD showed an underlying ulcer or gastric
tear. Patient was started on PPI drip IV and anticoagulation was
held. Repeat EGD allowed cauterization of this lesion. The
patient required 8 PRBC transfusions during hospitalization, the
last on [**2-13**]. When Hct stabilized, patient was advanced on diet
and transferred to the floor. On the floor his Hct remained
stable despite several episodes of melena and guaiac positive
stool. These were thought to represent old blood from the known
ulcer. He was found to be H pylori negative, so no triple
therapy was pursued.
# CAD: Coronary artery disease, status post cardiac
catheterization on [**2115-5-28**] with DES to the mLAD and dRCA.
Catheterization was done due to symptoms of dyspnea on exertion.
No prior history of MI, on anticoagulation. Prasagruel was held
due to GI bleed. Cardiology was consulted given the tradeoff
between bleeding risk and anti-coagulation. Plavix and aspirin
were restarted when bleeding was stabilized. Beta blockers were
also held during bleeding, and were not restarted on discharge
due to continued low blood pressure (SBP 110s).
# Pneumonia: The patient spiked a fever and was found to have a
lower lobe infiltrate. He was treated with vancomycin/cefepime
for a presumed aspiration HCAP with a 7 day course from [**2116-2-10**].
Blood cultures were negative. He was again febrile [**2-18**] to
101.5, concern for recurrent pneumonia, restarted
vanco/cefepime. Switched to [**Month/Year (2) **] [**2-19**] for planned 10 day
total course. Thoracentesis on [**2-18**] consistent with transudate,
likely parapneumonic. Gram stain no organisms.
# Non-small cell lung cancer (metastatic): Extensive FDG-avid
mediastinal, hilar, and supraclavicular lymphadenopathy, osseous
metastatic involvement including a lytic inferior sternal lesion
at risk of pathologic fracture and also several lytic and
sclerotic lesions of the vertebrae, most prominent at T6. The
patient complained of persistent [**2114-2-8**] chest pain with a
pleuritic component. This could be partially due to known
effusion. This was treated with Tylenol and improved during his
stay. Pleural fluid positive for adenocarcinoma. Mutation
analysis from lung biopsy previously performed revealed EGFR
mutation. The patient started erlotinib prior to discharge.
# Benign prostatic hypertrophy: Patient complaining of some
urinary symptoms (mostly retention). Terazosin was held due to
low BP (SBP 110s), may be restarted as an outpatient.
# Bleeding in eye: Patient presented [**2-18**] with burst capillary
in right eye. No foreign body sensation, no active bleeding.
Appears to be burst capillary [**2-6**] coughing. BP well-controlled.
Continue artificial tears.
# Impaired glucose tolerance test w/ Hgb A1c 6.2%. Diet
controlled, no finger sticks.
# Communication: Patient, [**Name (NI) **] HA (HCP, wife, [**Telephone/Fax (1) 18341**])
# CODE: DNR/DNI
TRANSITIONAL
- Moderate pericardial effusion seen on prior PET CT. Needs
outpatient follow-up.
- Resume atenolol and terazosin as blood pressure increases
Medications on Admission:
ATENOLOL 12.5 mg Tablet 0.5 Tablet(s) by mouth once daily
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 1 teaspoon by
mouth every evening as needed for cough
NITROGLYCERIN [NITROSTAT] 0.4 mg Tablet, Sublingual prn
PRASUGREL [EFFIENT] 10 mg Tablet once a day
ROSUVASTATIN [CRESTOR] 10 mg Tablet by mouth once a day
TERAZOSIN 5 mg Capsule by mouth once daily
ASPIRIN 325 mg by mouth once daily
DOCUSATE SODIUM 100 mg by mouth twice a day as needed for
constipation
FOLIC ACID 0.4 mg Tablet by mouth once a day
Discharge Medications:
1. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. folic acid 400 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. loperamide 2 mg Tablet Sig: 1-2 Tablets PO QID (4 times a
day) as needed for loose stool.
Disp:*100 Tablet(s)* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: no more than 4 grams per day.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
gastric ulcer
.
secondary:
coronary artery disease, s/p drug-eluting stent placement x2
NSCLC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You came to the hospital with several episodes
of dark black stool, nausea, and vomiting. You were found to
have gastrointestinal bleeding due to a large ulcer in your
stomach. This was treated with cauterization, after which your
bleeding stopped. Given your recent cardiac stent placement, we
worked with the Cardiology team to determine how to balance
anti-coagulation with bleeding risk.
We made the following changes to your medications:
- STOP codeine-guaifenesin cough syrup
- STOP atenolol and terazosin due to low blood pressure; Dr
[**Last Name (STitle) 3274**] may restart these medications as your blood pressure
rises
- STOP nitroglycerin
- STOP prasugrel
- START Plavix, a different blood thinner
- CHANGE aspirin to 81mg daily
- START pantoprazole twice a day to prevent gastric irritation
- START [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic, for a planned 7 day course
- START erlotinib, a chemotherapy for your lung cancer
- START loperamide (Immodium) for loose stools that can be a
side effect of erlotinib
Please follow-up with your treating physicians as listed below.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2116-2-25**] at 9:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2116-2-25**] at 9:00 AM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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4,802
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29317
|
Discharge summary
|
report
|
Admission Date: [**2162-1-11**] Discharge Date: [**2162-2-3**]
Date of Birth: [**2088-4-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with angioplasty and stenting
intra-aortic balloon pump
endotracheal intubation
History of Present Illness:
73-year old white male with PMH of afib and sciatica who
presents from [**Hospital3 4107**] with STEMI and vfib arrest. Around
9 AM of [**1-11**] during breakfast, pt had feeling of gaseous
discomfort and reportedly had diffuse chest pain with radiation
into both arms.
10:03 AM - [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] elevations precordium (no EKG, lead
strip), given beta blockade, morphine, [**First Name3 (LF) **], nitro, plavix 600,
set for transfer to [**Hospital1 **]. Trops(-), Cr 1.4, H/H, 12.6/38.3, HR
127-135, SBPs 111-132/80-89.
10:29 AM - Vfib arrest (on lead strips) w/subsequent CPR and
defib x5 cycles, with asystole and PEA. Received epinephrine x
3, atropine x 1, lidocaine drip.
11:00 AM transport to [**Hospital1 **] ED
11:20 Arrival [**Hospital1 **] - vfib arrest, continued CPR. Epi, atropine,
transcutaneously pace at 80. Transferred to cath lab.
11:52 arrives in cath lab, integrillin initiated
12:36 stent deployed
Past Medical History:
afib
Social History:
retired fire-fighter. no active smoking. lives with wife
Physical Exam:
Upon arrival to CCU:
85/50, 83, 96.8, AC 700 22, FiO2 80%, plat 22.
Intubated, sedated, pinpoint pupils, MMM
obese neck, no carotid bruits appreciated
cardiac: nsr, could not appreciate any murmurs [**3-12**] IABP
lungs: cta bil
pulses intact bil
no edema
Pertinent Results:
[**2162-1-11**] 02:57PM BLOOD WBC-26.5* RBC-4.65 Hgb-14.1 Hct-41.2
MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6 Plt Ct-408
[**2162-1-11**] 02:57PM BLOOD Glucose-230* UreaN-24* Creat-1.3* Na-137
K-4.7 Cl-110* HCO3-19* AnGap-13
[**2162-1-11**] 02:57PM BLOOD CK(CPK)-504*
[**2162-1-11**] 09:00PM BLOOD CK(CPK)-1174*
[**2162-1-12**] 04:56AM BLOOD CK(CPK)-1573*
[**2162-1-12**] 02:00PM BLOOD CK(CPK)-1714*
[**2162-1-12**] 08:51PM BLOOD CK(CPK)-1693*
[**2162-1-13**] 03:48AM BLOOD CK(CPK)-1512*
[**2162-1-15**] 01:10AM BLOOD CK(CPK)-[**2092**]*
[**2162-1-15**] 06:52AM BLOOD CK(CPK)-1602*
[**2162-1-17**] 05:30AM BLOOD CK(CPK)-283*
[**2162-1-11**] 02:57PM BLOOD CK-MB-65* MB Indx-12.9* cTropnT-1.10*
[**2162-1-11**] 09:00PM BLOOD CK-MB-135* MB Indx-11.5* cTropnT-2.30*
[**2162-1-12**] 04:56AM BLOOD CK-MB-112* MB Indx-7.1* cTropnT-3.20*
[**2162-1-12**] 02:00PM BLOOD CK-MB-56* MB Indx-3.3 cTropnT-2.26*
[**2162-1-12**] 08:51PM BLOOD CK-MB-31* MB Indx-1.8 cTropnT-2.14*
[**2162-1-13**] 03:48AM BLOOD CK-MB-19* MB Indx-1.3 cTropnT-1.84*
[**2162-1-15**] 01:10AM BLOOD CK-MB-114* MB Indx-5.9
[**2162-1-15**] 06:52AM BLOOD CK-MB-76* MB Indx-4.7
[**2162-1-16**] 05:34AM BLOOD CK-MB-20* MB Indx-3.2
[**2162-1-17**] 05:30AM BLOOD CK-MB-9
[**2162-1-14**] 04:25PM BLOOD ALT-112* AST-182* LD(LDH)-587*
CK(CPK)-1660* AlkPhos-73 TotBili-0.6
[**2162-1-16**] 05:34AM BLOOD ALT-80* AST-147* LD(LDH)-795*
CK(CPK)-628* AlkPhos-79 TotBili-0.8
[**2-1**]
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2162-2-2**] 04:23AM 16.0* 3.80* 11.6* 33.3* 88 30.6 34.9 15.0
373
.
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2162-2-2**] 04:23AM 98 25* 1.4* 139 4.8 102 30 12
.
Cardiac Cath [**1-11**]:
PTCA COMMENTS: The patient was emergently brought to the
catheterization
lab after undergoing cardiac arrest thrice at an outlying
hospital and
again en route to our facility. The patient was resuscitated in
the
emergency room and then brought to the cath lab after consulting
with
family members. Initial angiogram demonstrated proximal total
occlusion of the proximal LAD. Prior to proceeding with
intervention a
40cc IABP was placed for hemodynamic support for during and post
procedure afterload reduction and diastolic augmentation via
standard
technique through the righ common femoral artery.
It was planned to treat the lesion with PTCA and stenting.
Integrelin
was the anticoagulant used during the procedure. A 6FXB LAD 3.5
guide
catheter provided optimal support. The lesion was crossed with a
Choice
PT XS wire into the distal vessel. The lesion was pre-dilated
with a 2.0
x 12 Voyager balloon at low inflation and a Quick Cat extraction
catheter was then advanced across the lesion twice due to the
presence
of thrombus. A 3.0 x 28 Vision BMS was then deployed at 16 ATM
and post
dilated with a 3.0 x 20 Quantum Maverick at 20 ATM. Final
angiography
demonstrated no residual stenosis and no angiographic evidence
of
dissection, thrombus or perforation with TIMI III flow in the
distal
vessel. Patient left the lab on pressor support with Dopamine,
IABP,
intubated and responsive only to painful stimuli.
Conclusions:
1. Succesful primary PTCA and stenting of the RLADwith aa 3.0
BMS with
prior thrombectomy. Post dilated with a 3.0 NC balloon. The
final
angiogram demonstrated no residual stenosis with no angiographic
evidence of dissection, embolization or perforation with TIMI
III flow
in the distal vessel with grade 2 blush. (See PTCA comments)
FINAL DIAGNOSIS:
1. Cardiogenic shock s/p cardiac arrest
2. Successful primary PCI of the LAD.
.
ECHO [**1-11**] - Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is severe regional left
ventricular systolic dysfunction with near akinesis of all
segments except for the basal half of the inferior and
inferiolateral walls which are hypokinetic. No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
is normal with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Extensive regional left ventricular systolic
dysfunction c/w
proximal LAD/LM disease. Mild mitral regurgitation.
.
ECHO [**1-13**]: Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with mid to distal
anteroseptal/anterior/apical. Overall left ventricular systolic
function is moderately depressed. Transmitral Doppler and tissue
velocity imaging are consistent with Grade I (mild) LV diastolic
dysfunction. No apical thrombus seen (cannot exclude). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
Cardiac Cath [**1-15**]:
1. One vessel coronary artery disease due to sub-acute stent
thrombosis.
2. Severe elevation of right and left filling pressures.
3. AIVR and junctional tachycardia with drop in blood pressure
due to
rate and loss of syncrony.
4. Successful thrombetomy and angioplasty of a totally occluded
LAD with
restoration of TIMI 3 flow.
.
ECHO [**1-15**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. No masses or thrombi are seen in the
left ventricle. Overall left ventricular systolic function is
severely depressed with global hypokinesis and regional akinesis
of the septum, anterior wall and apex. Right ventricular
systolic function is borderline normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) 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 [**2162-1-13**], the overall LVEF is lower.
.
Echo [**1-18**]:
MEASUREMENTS:
EF 20% (nl >=55%)
LEFT VENTRICLE: Normal LV cavity size. Cannot exclude LV
mass/thrombus.
Severely depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior - akinetic; mid anterior - akinetic; basal
anteroseptal - akinetic; mid anteroseptal - akinetic; anterior
apex - akinetic; septal apex- akinetic; inferior apex -
akinetic; lateral apex - akinetic;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: No pericardial effusion.
.
Conclusions:
The left ventricular cavity size is normal. A left ventricular
mass/thrombus cannot be excluded. Overall left ventricular
systolic function is severely depressed. Resting regional wall
motion abnormalities include anteroseptal/anterior/apical
akinesis. Right ventricular chamber size and free wall motion
are normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2162-1-15**],
there is no
significant change.
.
MRI/MRA Head [**1-20**]:
FINDINGS: There are scattered, ill-defined regions of restricted
diffusion in the right frontoparietal cortex and right occipetal
lobe, with corresponding T2 and FLAIR signal hyperintensity.
Combined with mild hypodensity on corresponding CT in these
regions, the findings suggest subacute infarction. No additional
areas of restricted diffusion are seen. There is a tiny,
solitary focus of susceptibility artifact in the left external
capsule most consistent with hemorrhagic residuum. No
intracranial mass lesion, hydrocephalus, or shift of normally
midline structures are apparent.
There is mucosal thickening in maxillary sinuses, bilateral
scattered ethmoid air cells and bilateral sphenoid air cells,
possibly related to prior intubation or inflammatory process.
Fluid is also seen in bilateral mastoid air cells.
IMPRESSION:
1. Multiple right sided subacute infarcts in the right
frontoparietal and occipetal lobes - involvement of more than
one vascular territory suggests embolic phenomenon as the source
of infarction.
2. Sinus disease as described above.
MRA CIRCLE OF [**Location (un) **]: The major tributaries of the Circle of
[**Location (un) 431**] are patent. There is no area of significant stenosis or
aneurysmal dilatation. The basilar artery is slightly narrowed
at its origin. Irregularity along the cavernous portions of
bilateral internal carotid arteries is most consistent with
atherosclerosis.
IMPRESSION: No significant stenosis identified.
.
CT Chest w/o contrast [**1-30**]:
CT OF THE CHEST WITHOUT CONTRAST: Soft tissue window images
demonstrate several prominent mediastinal lymph nodes, the
largest measuring 11 mm in short axis diameter in the right
peritracheal region (series 3, image 9) and a second prominent,
but nonenlarged 8 mm lymph node (series 3, image 17). The
prominent pretracheal lymph node (series 3, image 18) contains
fat, and is likely benign. There is also a prominent AP window
lymph node measuring 16 x 30 mm (series 3, image 20). There are
bilateral pleural effusions, which are simple in appearance and
Hounsfield unit density measurements. No pericardial effusion is
seen. A density is seen along the course of the LAD, suggesting
placement of prior stents. There is a right PICC, with the tip
positioned in the distal SVC.
Lung window images demonstrate scattered areas of ground-glass
opacity bilaterally, and areas of interlobular septal thickening
at the lung bases independently. No focal consolidation or areas
of cavitation are identified. No pneumothorax is seen.
On the limited images of the superior portion of the abdomen,
the patient is status post cholecystectomy. Within the left lobe
of the liver in a subcapsular position, there is a 3.8 x 2.2 cm
mass (series 2, image 48), which demonstrates density of 50
Hounsfield units on this noncontrast study. Adjacent to this,
there is a smaller focal area of low attenuation measuring 13 x
9 mm. The visualized portions of the adrenal glands, spleen,
pancreas, upper kidneys, and stomach are within normal limits.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified. Degenerative changes are seen within the thoracic
spine.
IMPRESSION:
1. Bilateral pleural effusions, intralobular septal thickening,
and scattered areas of ground-glass opacity are consistent with
CHF and pulmonary volume overload. A superimposed atypical
infection is not entirely excluded. There is no evidence of
cavitation.
2. Several mildly prominent lymph nodes are noted within the
mediastinum, which can be seen in the setting of CHF and/or
infection.
3. There is a 3.8 cm subcapsular mass within the left lobe of
liver, which is not completely characterized on this study.
Further evaluation with an US or MRI is recommended.
.
Brief Hospital Course:
In brief, the patient is a 73 year old man who was transferred
from [**Hospital3 4107**] with an anterior STEMI complicated by
cardiogenic shock and VF arrest who was taken emergently to the
cath lab for revascularization, course complicated by in-stent
thrombosis and multiple extubations/re-intubations.
.
# CV:
CAD - Patient was transferred from OSH with STEMI, initially
loaded with plavix, acquired Vfib arrest resulting in multiple
rounds of CPR at OSH and enroute to [**Hospital1 **]. Patient transferred to
cath lab emergently (see results) with stent/iabp placement,
ECHO showing severe systolic dysfunction in anterior septal
region, LAD territory. Heparin was held post-cath for concern
for UGI due to NGT lavage with coffee grounds in ED with small
drop in hct. On HD#3, pt transferred to cath lab emergently for
ST elevations in anterior leads, found to have in-stent
thrombosis, thrombectomy and PTCA performed, IABP replaced,
heparin initiated, plavix loaded at 300mg, began 150mg qd.
Concern thrombosis [**3-12**] to inadequate plavix loading at OSH and
while in-house due to lavage and question of decreased PO
absorption. Patient was continued on his aspirin, statin, and
plavix (75mg [**Hospital1 **]) and also heparin drip over the course of his
stay. Two weeks post in-stent thrombosis, patient's heparin was
bridged with coumadin, with plan for continued anticoagulation.
Patient should also be continued on Plavix 75 mg PO BID for a
month and then uninterrupted for at least year and possible
longer. The course at that point should be discussed with
patient's cardiologist. Patient should continue his Lipitor 80
mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 325, Digoxin 0.625 QD, Metoprolol XL 50 mg QD, and
Plavix 75 mg PO BID x 30 days and then 75 mg QD thereafer.
Patient's captopril 25 mg TID was also switched to Lisinopril 15
mg QD.
PUMP - patient found to have EF of 20% with
anteroseptal/anterior/apical akinesis, was aggressively diuresed
on 40 IV lasix and will be d/c on Lasix 20 PO along with
spiranolactone. He should also be evaluated in [**5-14**] weeks for
SCD stratification with an echo, or alternatively, a signal
averaged EKG and cardiac MRI.
RHYTHM - Patient initially found to be in wide complex
tachycardia with VF arrest with subsequent afib/aflutter and
most recently with NSR with PAC. Patient's amiodarone was d/c
due to concern for amiodarone toxicity and he was continued on
digoxin. Patient will follow up in electrocardiology clinic.
# PULM: Patient's airway was initially preserved with intubation
and ventilator assistance in the setting of his cardiac code.
Patient self-extubated himself on the third hospital day, which
preceded his in-stent thrombosis and re-intubation. Patient was
extubated one additional time with consequent reintubation, most
likely secondary to mucus plugging or decreased respiratory
drive due to remaining sedating medications. As per history, no
intrinsic pulm disease was found to be limiting his pulmonary
functionality, RSBIs remained below 70 for days. Patient was
initiall treated for an aspiration pneumonia and then
transitioned to treatment for hospital acquired pneumonia, see
ID discussion. Due to some blood tinged sputum two weeks into
his hospital stay and abnormal findings on his chest xray, a
pulmonary consult was placed, with the recommendations to defer
on bronchoscopy and following clinically. On hospital day 16,
patient was successfully extubated without further complication
or reintubation. Patient was subsequently diagnosed with MRSA
ventilation associated pneumonia as confirmed by [**1-27**] sputum.
He was treated with 13 days of Vancomycin which was switched to
Linezolid on [**1-30**] for a 7 day course. Patient was also
empirically covered with Meropenem which was stopped after 7
days after no gram negative organisms were identified. Patient
remained afebrile although his WBC was slow to improve and
remained [**12-23**] upon discharge. Patient may have also had a
element of acute amiodarone toxicity which was contributing to
his continued oxygen requirement. Patient will require further
Physical therapy, spirometry and gradual titration of his oxygen
demand. Amiodarone as offending [**Doctor Last Name 360**] has been discontinued.
The infection is likely to be resolving as patient remained
afebrile without other source of leukocytosis. Patient will
need two further days of linezolid.
.
# GI: On hosptial day 1, patient had coffee ground emesis on
nasogastric suctioning, which prompted holding patient's heparin
administration. Protonix [**Hospital1 **] dosing was initiated. Throughout
his stay, patient did not have any melanotic stools or overt
bleeding from his uppper GI tract. While intubated, patient was
given tube feeds when appropriate, initially with increased
residuals, but then with improvement on an appropriate bowel
regimen. His hematocrit remained stable upon discharge on
30-35. He was conservatively managed.
.
# ID: Patient acquired a leukocytosis early in his hospital
course with a concurrent low grade temperature just below 100
degrees, save some intermittent spikes to 102. Patient's
panculture initially returned negative, save diptheroids on a
blood culture. Concern for aspiration pneumonia, patient was
initiated on levofloxacin and flagyl treatment. Patient's
multiple sputum cultures returned as MRSA and patient was
treatment for a hospital acquired pneumonia with vancomycin,
concurrently with cefepime. Due to woresning chest x-rays
during his course, infiltrative findings in the RLL and LML,
cefepime was changed to meropenem. Patient was continued on
vancomycin, then linezolid and short course of meropemen as
above. He remained afebrile throughout his stay without another
clear etiology of fevers.
.
# NEURO: Initially it was difficult to determine patient's
neurological functioning due to sedation. As patient was being
intermittently weaned off sedation, there was question whether
patient was appropriately moving his extremities and responding
appropriately, which prompted an MRI, revealing watershed
infarcts vs emboli in the right frontoparietal and occipital
lobes.t delayed. Continued concern for anoxic brain injury,
sequelae from notable infarcts on MRI, or more favorably,
lingering effects of sedating medications. Patient continue to
improve as far as short term memory and recall, with
intermittent delusions which may have been due to his strokes
and improving ICU psychosis. Patient was treated with Zyprexa
qHs and diazepam prn.
.
# f/u - patient will follow up with Dr. [**Last Name (STitle) **]/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
in [**Hospital **] clinic and with his PCP. [**Name10 (NameIs) **] is being d/c to acute rehab.
Medications on Admission:
warfarin
diltiazem?
no herbal supplements
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): for one month.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 days.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
13. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
ST elevation Myocardial Infarction
Systolic heart dysfunction (EF 30%)
Acute in stent thrombosis
Discharge Condition:
Stable. Asymptomatic.
Discharge Instructions:
Take all your medications as prescribed.
Followup Instructions:
ECHO in 4 weeks - [**2162-3-8**] 2pm in [**Location (un) 8661**] [**Location (un) 436**].
.
Follow up with your cardiologist - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2162-3-17**] @ 1pm in [**Hospital Ward Name 23**] [**Location (un) 436**]
cardiology clinic. You will need signal averaged EKG and cardiac
MRI to be performed as an outpatient. You will also have an
outpatient echo performed on [**2162-3-8**] at 2:00 pm prior to this
appointment with Dr. [**Last Name (STitle) **].
.
Follow up with your PCP regarding liver nodule as MRI was
recommended to follow it.
|
[
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"482.41",
"996.72",
"584.5",
"518.81",
"785.51",
"507.0",
"E942.0",
"401.9",
"410.11",
"427.31",
"786.3",
"V09.0",
"428.21",
"724.3",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"00.40",
"96.34",
"99.60",
"37.23",
"00.66",
"38.91",
"97.44",
"99.20",
"96.6",
"00.45",
"88.56",
"38.93",
"89.64",
"99.04",
"00.17",
"96.04",
"37.78",
"36.06",
"00.14",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
21245, 21326
|
13306, 20110
|
325, 430
|
21467, 21491
|
1850, 5337
|
21580, 22251
|
20203, 21222
|
21347, 21446
|
20136, 20180
|
5354, 13283
|
21515, 21557
|
1573, 1831
|
275, 287
|
458, 1454
|
1476, 1484
|
1500, 1558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,257
| 197,183
|
45699
|
Discharge summary
|
report
|
Admission Date: [**2156-10-18**] Discharge Date: [**2156-10-21**]
Date of Birth: [**2079-5-20**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 year old right handed man with history of alcohol abuse and
dementia (per record Korsakoff amnesia), as well as generalized
tonic clonic seizures (mainly related to alcohol withdrawal),
who was found at his [**Hospital3 **] facility around 7:20 a.m.
today seizing. Onset of seizure not witnessed, and he was last
seen normal the night before (per daytime nurse, night nurse not
available). Description of seizure not available per EMS notes
or nursing home staff, but was reportedly seizing on EMS
arrival, given 2 mg Ativan, after which seizure activity
stopped. Arrived at [**Hospital1 18**] around 8 a.m., where he was
post-ictal, with no response to voice but withdrawal to noxious
stimuli. There was less movement of the right side than left,
and upgoing toes bilaterally. He was seen by the attending 10
minutes later who noticed left eye deviation. He is DNR/DNI so
there was concern about giving him Ativan, but he received 0.5
mg with no effect. He then lost IV access, and about an hour
later a new IV was able to be started. At about 9:30 he
received another 0.5 mg Ativan and Neurology was consulted. He
likely had this left gaze deviation continuously in the
intervening time. He was also making shaking movements with his
left side that were concerning for seizure.
Mr. [**Known lastname 4318**] is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2442**] for his seizures.
His last seizure was in [**2155-2-18**], and may actually have
been syncope with 30 seconds of convulsive activity afterwards.
He had multiple prior seizures that were always in the setting
of alcohol withdrawal. When he first came to see Dr. [**Last Name (STitle) 2442**]
he was taking Depakote ER 1000 mg qHS, for behavioral problems.
[**Name (NI) 15110**] to concern for his future risk of seizures a morning dose of
500 mg was added. Seizures thought likely related to chronic
microvascular disease.
Past Medical History:
Hypertension
Hx old left pontine lacunar infarct, no residual weakness
Alcohol abuse
Dementia (?Korsakoff) - Lives in nursing home but apparently
fairly high functioning at baseline
Chronic Renal insufficiency
Anemia of Chronic Disease
Gout
Depression
Actinic Keratoses
Social History:
lives with wife at [**Hospital3 2558**]. The patient is a retired
police officer/firefighter. He has had many episodes for alcohol
use and has a distant tobacco history.
Family History:
Non-contributory
Physical Exam:
T Afebrile HR 111 BP 148/80 Pulse ox 97% on 10L NRB -> 94%
Gen 77 year old man lying in bed wearing NRB mask
HEENT mmm
Resp crackles at both bases
CV rr nl s1/s2 no murmurs audible
abd s/nt/nd
extrem no cyanosis, clubbing, edema
Neuro
MS: Eyes closed, no eye opening to voice or sternal rub.
Localizes to painful stimuli with left side. Does not follow
commands. No speech or vocalization.
CN: PERRL 3>2, Fixed eye and head deviation to left, unable to
doll to right. + corneals. No grimace to nasal tickle.
+flattening of right nasolabial fold. + gag.
MOTOR: Diminished tone on right side. Spontaneously moves left
side, purposefully. When stimulated and lifts left arm or leg
has high amplitude tremor, which is suppressible, and is
elicited by movement. Minimal movement of right side, flexes
hip and withdraws shoulder slightly to noxious stimuli
Reflexes: 2+ on left, Absent on right. Left plantar response
flexor, right is equivocal.
Sensation: grimaces to pain on right, purposefully moves and
localized to pain on left
Coord, Gait: Could not assess
Pertinent Results:
10/02/[**Numeric Identifier 97392**]:10a
Color Straw Appear Clear SpecGr 1.011 pH 6.5 Urobil Neg
Bili Neg
Leuk Neg Bld Tr Nitr Neg Prot Neg Glu Tr Ket Neg RBC 0-2
WBC 0-2 Bact Rare Yeast None Epi <1 Other Urine Counts
TransE: 0-2
[**2156-10-18**] 08:10a
130 96 37 187 AGap=23
4.4 15 2.4
Ca: 8.6 Mg: 2.1 P: 6.3 D
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Valproate: 49
8.7 > 11.3 < 200 D
33.0
N:84.9 Band:0 L:10.3 M:3.4 E:1.2 Bas:0.2 Anisocy: 1+ Macrocy: 1+
Plt-Est: Normal
Imaging:
Head CT: No acute infarct, hemorrhage, mass.
CXR: no acute cardiopulmonary process LLL pneumonia
EEG:
ABNORMALITY #1: Bursts of left hemisphere 4 Hz moderate
amplitude slowing was observed, lasting up to 20 seconds. These
periods were accompanied by left arm shaking while his head was
turned to the left.
ABNORMALITY #2: A poorly developed background with 6 Hz slowing
was observed throughout the recording, with decreased amplitude
over the
left hemisphere.
BACKGROUND: As above.
HYPERVENTILATION: Contraindicated.
INTERMITTENT PHOTIC STIMULATION: Portable EEG precluded photic
stimulation.
SLEEP: No sleep-wake transitions were noted.
CARDIAC MONITOR: A generally regular rhythm with an average rate
of 80 beats per minute was observed.
IMPRESSION: This is an abnormal EEG due to the poorly developed
background activity with decreased amplitude over the left
hemisphere. The decreased amplitude may suggest a diffuse left
subcortical dysfunction or an intervening tissue (such as a
subdural hemorrhage). The episodes of left upper extremity
shaking with associated left hemisphere 4 Hz rhythmic slowing
likely represents movement artifact, as the patient's head was
positioned with the left side against the bed. There was no
evolution to the rhythmic slowing and no epileptiform discharges
were noted.
EKG: Sinus bradycardia
First degree AV block
Inferior ST-T changes are nonspecific
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 0 90 426/435 0 12 9
Brief Hospital Course:
77 year old man with history of alcohol withdrawal seizures and
one possible seizure not in setting of withdrawal, now with over
two hours of forced left gaze and head deviation, and right
sided weakness. No recent illness, but had a dental procedure
on Friday for extraction of tooth. No evidence of new infarct,
bleed, or mass on head CT to explain the gaze deviation, likely
still seizing, right sided weakness could represent [**Doctor Last Name 555**]
paresis versus another intracranial process (e.g. infarct) that
is not yet evident on CT. After extensive discussion with ED
staff, and ED staff discussion with patient's family re: DNI
status, decision was made not to give
more benzos, although this would be the best acute treatment for
his seizure as it is the quickest-acting. There is however a
significant risk of respiratory depression and he definitely did
not want intubation nor does his family.
Patient was loaded with dilantin. Movements stopped, but patient
became very somnolent and minimally responsive. Patient was
admitted to the NeuroICU and then transferred to the floor.
NEURO: On exam and clinical history, patient is encephalopathic
with asterixis and course prox tremor. Continued valproic acid.
Avoided sedating medications.
ID: Infectious work-up was negative. Chest x-ray, urinanalysis,
WBC were normal. Patient subsequently was afebrile throughout
the hospital course.
ENDO: TSH and free T4 were suggestive of hypothyroidism. Pt was
started on a small dose of synthroid. He will follow-up with his
primary care physician for repeat thyroid function testing and
dose adjustment.
CODE STATUS:
DNR/DNI
Contact: son [**Telephone/Fax (1) 97393**], [**Telephone/Fax (1) 97394**]
Medications on Admission:
nifedipine ER 90 mg daily
omeprazole 20mg daily
depakote ER 500 mg qAM, 1000 mg qHS
estraderm patch 0.05 mg, one topically q Wed/Sat
Ferrous sulfate 325 mg daily
Zoloft 75 mg daily
Zyprexa 5 mg daily
Metoprolol 25 mg [**Hospital1 **]
Docusate 100 mg [**Hospital1 **]
Akwa tears ointment to left eye [**Hospital1 **]
Oyster shell with vitamins 500 tab
Trazodone 50 mg qHS
Bisacodyl 5 mg 2 tabs q12h
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Depakote ER 500 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO qAM.
6. Depakote ER 500 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO at bedtime.
7. estraderm patch Sig: 0.05 mg twice a week: please apply
once topically every wednesday and saturday.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
9. Zoloft 25 mg Tablet Sig: Three (3) Tablet PO once a day.
10. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. akwa tears ointment Sig: One (1) application twice a day:
please apply to left eye twice a day.
14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
16. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Os-Cal 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Seizure disorder
Hypothyroidism
Secondary diagnoses:
Hypertension
Hx old left pontine lacunar infarct, no residual weakness
Alcohol abuse
Dementia (?Korsakoff)
Chronic Renal insufficiency
Anemia of Chronic Disease
Gout
Depression
Actinic Keratoses
Squamous cell cancer of forearm and upper arm s/p excision
Discharge Condition:
stable, improved mentation. not seizing actively.
Discharge Instructions:
Please follow up with your primary care physician and
neurologist as scheduled below. Please take all medications as
prescribed. You have been started on Levothyroxine for low
thyroid hormone levels. Please have your primary care follow-up
with repeat thyroid function testing at follow-up. Otherwise,
there have been no changes in your meds.
If you experience high fever, chills, change in mental status or
any concerning symptoms, please call your doctor and go to the
nearest emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 608**] Please follow-up
with your primary care physician above within 1-2 weeks.
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2156-11-3**] 4:30
Provider: [**First Name11 (Name Pattern1) 306**] [**Last Name (NamePattern4) 7907**], MD Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2156-11-5**] 10:00
Completed by:[**2156-10-21**]
|
[
"244.9",
"274.9",
"285.21",
"403.90",
"345.80",
"585.9",
"291.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9463, 9533
|
5928, 7644
|
328, 335
|
9904, 9956
|
3910, 4441
|
10500, 11013
|
2794, 2813
|
8093, 9440
|
9554, 9554
|
7670, 8070
|
9980, 10477
|
2828, 3891
|
9627, 9883
|
280, 290
|
363, 2298
|
4450, 5905
|
9573, 9606
|
2320, 2591
|
2607, 2778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,745
| 195,349
|
4336+55570
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-9-24**] Discharge Date: [**2190-9-30**]
Date of Birth: [**2118-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath; chest discomfort
Major Surgical or Invasive Procedure:
[**2190-9-24**]
1. Aortic valve replacement with a size #23 [**Last Name (un) 3843**]-[**Doctor Last Name **]
Magna tissue valve.
2. Coronary artery bypass graft x2: Left internal mammary
artery to left anterior descending artery, and saphenous vein
graft to distal right coronary artery.
3. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
71M with multiple cardiac risk factors c/o shortness of breath
and chest discomfort recently. The patient was hospitalized
recently with an acute exacerbation of diastolic heart failure.
Echo showed moderate Aortic Stenosis and pulmonary hypertension.
Cath is performed today to further investigate the etiology of
his heart failure. This reveals 2 vessel CAD. He is referred
for surgical evaluation.
Past Medical History:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Pulmonary hypertension
Diastolic heart failure
Diabetes mellitus
AAA s/p endovascular repair in [**2186**]
Gout
Obesity
Sleep apnea
Aortic stenosis
Social History:
Lives with wife. Retired. Previously works as accountant. Now
volunteer as mentor on MWF. Smokes cigars occasionally. Drinks
[**2-1**] glasses of wine per week. Denies drug use.
Family History:
Mother with diabetes. No known history of MI, stroke, or cancer.
Physical Exam:
Admission Physical Exam:
Pulse: 48 B/P Right: Left: 111/62 Resp: 18 O2 sat: 91%RA
Height: 5'3" Weight: 189lb
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] distant Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] obese
Extremities: Warm [x], well-perfused [x] Edema [] _none_
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: NP Left:NP
Radial Right: cath site Left: 2+
Carotid Bruit no bruits
Discharge PE
VS 99.2 88 123/80 18 95%
Gen: NAD
Neuro: A&O x3, nonfocal exam
Pulm: CTA
CV: RRR, sternum stable-incision CDI
Abdm: soft, NT/softly distended/+BS
Ext: warm, well perfused. 1+ pedal edema bilat
Pertinent Results:
Echo 08/24/12LEFT ATRIUM: Dilated LA. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20
cm/s) LAA ejection velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. PFO is
present.
LEFT VENTRICLE: Mild symmetric LVH. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta. Complex (>4mm) atheroma in the ascending aorta.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS (area 1.2-1.9cm2). Moderate (2+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**2-1**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. Suboptimal image quality - poor echo windows. The
patient appears to be in sinus rhythm. Resting bradycardia
for the patient.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No thrombus is seen in the left atrial appendage.
A patent foramen ovale is present and is identified only by
agitated saline with valsalva release. No PFO was identified by
color doppler or agitated saline at rest.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%). Mild global dysfunction.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are complex (>4mm)
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets are
moderately thickened with calcification of the non coronry
cusp.There is mild aortic valve stenosis (valve area 1.4 cm2).
Moderate (2+) aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
Post bypass:
There is a well seated prosthetic valve in the aortic position
with no evidence of perivalvular leak. The peak and mean
gradients are 9 and 4 mm Hg respectively. There is no evidence
of aortic dissection. The estimated ejection fraction is
preserved and unchanged from prebypass.
No other new findings. Overall LVEF 45%.
[**2190-9-28**] 05:50AM BLOOD WBC-6.6 RBC-3.59* Hgb-10.7* Hct-33.4*
MCV-93 MCH-29.9 MCHC-32.2 RDW-14.5 Plt Ct-115*
[**2190-9-27**] 04:39AM BLOOD WBC-10.7 RBC-3.62* Hgb-11.1* Hct-33.8*
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.3 Plt Ct-98*
[**2190-9-26**] 06:00AM BLOOD WBC-13.2* RBC-3.39* Hgb-10.4* Hct-31.3*
MCV-92 MCH-30.6 MCHC-33.1 RDW-14.3 Plt Ct-74*
[**2190-9-28**] 05:50AM BLOOD Glucose-164* UreaN-29* Creat-1.4* Na-137
K-4.3 Cl-99 HCO3-28 AnGap-14
[**2190-9-27**] 04:39AM BLOOD Glucose-160* UreaN-21* Creat-1.6* Na-133
K-4.0 Cl-98 HCO3-27 AnGap-12
[**2190-9-26**] 06:00AM BLOOD Glucose-144* UreaN-15 Creat-1.3* Na-136
K-3.9 Cl-101 HCO3-27 AnGap-12
[**2190-9-25**] 01:45AM BLOOD Glucose-154* UreaN-18 Creat-1.3* Na-136
K-4.5 Cl-103 HCO3-23 AnGap-15
Brief Hospital Course:
The patient was brought to the Operating Room on [**2190-9-24**] where
the patient underwent Aortic valve replacement with a size #23
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve, Coronary artery bypass
graft x2: Left internal mammary artery to left anterior
descending artery, and saphenous vein graft to distal right
coronary artery. Endoscopic harvesting of the long saphenous
vein. See operative note for full details
Overall the patient tolerated the procedure well and
post-operatively was admitted to the CVICU in stable condition
for ongoing post-operative care and monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. He went into
a rate controlled atrial flutter on POD 2 and he was continued
on beta blockers with low dose oral Amiodarone started (rate
was 60's). He was in rate controlled atrial flutter for >24
hours and Coumadin was started. He received 2 mg Coumadin [**9-28**]
and [**9-29**] and INR goal was 2.0-2.5. Coumadin follow up was
arranged with PCP office for after discharge from rehab. He did
have some abdominal distention and KUB showed some dilated loops
of bowel but no ileus and he was given bowel medications with
good results. By the time of discharge on POD#6 the patient was
ambulating with assistance, the wound was healing well and pain
was controlled with oral analgesics. The patient was discharged
to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Rehab in good condition with appropriate
follow up instructions and appointments were advised.
Medications on Admission:
amlodipine 10mg daily, lipitor 40mg daily, bumetanide 0.5mg
daily, xalatan 0.005% 1gtt ou, lisinopril 40mg daily, metformin
500mg daily, toprol xl 50mg daily, viagra 100mg prn,
spironolactone 25mg daily, triamcinolone acetonide 0.1% topical
[**Hospital1 **] prn rash, aspirin 81mg daily, terbinafine 1% topical [**Hospital1 **] x 3
weeks, (allopurinol, colchicine and indomethacin prn gout
attacks
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Amiodarone 200 mg PO DAILY
8. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
9. Ranitidine 150 mg PO DAILY
10. Warfarin 2 mg PO DAILY16 Duration: 1 Doses
Take as directed for INR goal 2.0-2.5 for atrial fibrillation
11. Bumetanide 1 mg PO DAILY
x 7 days then resume 0.5 mg daily until further instructed by
cardiologist
12. Potassium Chloride 20 mEq PO DAILY
while on diuretics
13. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
`Coronary Artery Disease
Hypertension
Hyperlipidemia
Pulmonary hypertension
Diastolic heart failure
Diabetes mellitus
AAA s/p endovascular repair in [**2186**]
Gout
Obesity
Sleep apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2190-10-7**]
at 10:00am in in the [**Hospital **] Medical office building [**Hospital Unit Name **]
Surgeon: Dr [**First Name (STitle) **] on [**2190-10-26**] at 1:30p in in the [**Hospital **] Medical
office building [**Hospital Unit Name **]
Cardiologist: Dr.[**Doctor Last Name 3733**] on [**2190-10-15**] at 3:40pm [**Telephone/Fax (1) 62**]
and Date/Time:[**2190-11-5**] 11:40
Please call to schedule the following:
Primary Care: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2190-10-13**] 3:00pm in [**5-6**] weeks
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2190-9-30**]
Results to phone [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) **] at Dr.[**Name (NI) 11509**] office
[**Telephone/Fax (1) 18731**]
Fax [**Telephone/Fax (1) 13238**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2190-9-30**] Name: [**Known lastname 3049**],[**Known firstname **] Unit No: [**Numeric Identifier 3050**]
Admission Date: [**2190-9-24**] Discharge Date: [**2190-9-30**]
Date of Birth: [**2118-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
A prescription for 2mg coumadin daily with titration to achieve
an INR between [**3-5**] was written at the time of discharge for
post-operative atrial fibrillation.
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*50 Tablet Refills:*0
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Amiodarone 200 mg PO DAILY
8. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
9. Ranitidine 150 mg PO DAILY
10. Bumetanide 1 mg PO DAILY
x 7 days then resume 0.5 mg daily until further instructed by
cardiologist
11. Potassium Chloride 20 mEq PO DAILY
while on diuretics
12. MetFORMIN (Glucophage) 500 mg PO DAILY
13. Warfarin 2 mg PO ONCE Duration: 1 Doses
Dose coumadin daily for post-operative atrial fibrillation with
goal INR of [**3-5**]
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] - [**Location (un) 164**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2190-9-30**]
|
[
"250.00",
"428.0",
"V85.33",
"997.1",
"E878.2",
"424.1",
"278.00",
"272.4",
"427.32",
"428.32",
"414.01",
"401.9",
"416.8",
"274.9",
"327.23",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.11",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
13231, 13473
|
6028, 8058
|
349, 694
|
9581, 9737
|
2548, 6005
|
10526, 12375
|
1565, 1631
|
12398, 13208
|
9373, 9560
|
8084, 8483
|
9761, 10503
|
1671, 2529
|
271, 311
|
722, 1129
|
1151, 1352
|
1368, 1549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,026
| 175,782
|
14571
|
Discharge summary
|
report
|
Admission Date: [**2122-7-15**] Discharge Date: [**2122-7-21**]
Date of Birth: [**2065-6-6**] Sex: M
Service:
CHIEF COMPLAINT: Increasing shortness of breath.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 42982**] is a 57-year-old
male who was diagnosed with a silent MI in [**2122-1-20**],
based on an abnormal EKG. Thallium stress test was
subsequently performed, which was positive. Consequently,
the patient was taken to cardiac catheterization. Cardiac
catheterization on [**2122-6-19**] revealed left main 40% stenosis
LAD 100% occluded, ramus 95% stenosed, circumflex 20%
stenosis, right coronary artery 95% stenosed. Cardiac
echocardiogram on [**2122-5-12**] revealed an ejection fraction of
35% to 40% with multiple akinetic areas. Over the past
several months, Mr. [**Known lastname 42982**] also experienced nausea,
diaphoresis, and increasing shortness of breath. He has not
noticed any symptoms of chest pain. Mr. [**Known lastname 42982**] was
subsequently evaluated for CABG.
PAST MEDICAL HISTORY:
1. Non-Insulin-dependent diabetes mellitus.
2. CVA three years ago without residual deficit.
3. Myocardial infarction.
4. Gastroesophageal reflux disease.
5. Peripheral vascular disease.
6. Morbid obesity.
7. Peripheral neuropathy.
8. Status post left knee scope.
9. Repair of left second finger laceration.
FAMILY HISTORY: The patient's father is deceased from a MI
at the age of 61. Mother is deceased from CVA was the age of
54.
SOCIAL HISTORY: The patient does not use tobacco and is a
rate drinker. The patient is a high school English teacher.
MEDICATIONS:
1. Aspirin 325 mg p.o.q.d.
2. Mavik 1 q.d.
3. Toprol 50 q.d.
4. Glucophage 250 mg p.o.b.i.d.
5. Glucotrol XL 5 mg p.o.b.i.d.
6. Indocin 75 mg p.o.b.i.d.p.r.n. last dose was on [**7-8**].
ALLERGIES: The patient has no known drug allergies.
REVIEW OF SYSTEMS: Review of systems is negative, unless
otherwise, stated above.
PHYSICAL EXAMINATION: Examination revealed the following:
GENERAL: The patient is morbid obesity, well nourished. He
is 6 feet 1 inch and weighs 300 pounds. VITAL SIGNS: Heart
rate 82, blood pressure 145/87 right arm; 106/76 left arm.
He is afebrile. HEENT: Normocephalic, atraumatic. NECK:
Supple. CHEST: Chest was clear to auscultation bilaterally.
HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender,
nondistended. EXTREMITIES: Extremities were well perfused
with 1+ pedal edema. NEUROLOGICAL: Examination was
nonfocal.
HOSPITAL COURSE: Mr. [**Known lastname 42982**] was taken to the operating room
on [**2122-7-15**], where a CABG times three was performed. Graft
included LIMA to LAD, SVG to ramus, SVG to descending RCA.
Mr. [**Known lastname 42982**] [**Last Name (Titles) 8337**] surgery well and was transferred to the
Surgical Intensive Care Unit. He was weaned off drips and
hemodynamically monitored. He was extubated on postoperative
day #1 and stabilized. Chest tubes and pacing wires were
discontinued on postoperative day #3. The patient was
adequately fluid resuscitated and hemodynamically stable.
The patient was thus transferred to the floor. Mr. [**Known lastname 42982**]
recovered well while on the floor. He was taking good p.o.
diet and ambulating well, completing a level 5 physical
therapy assessment.
On postoperative #5, Mr. [**Known lastname 42982**] had a few episodes of
bigeminy and PVCs. He was asymptomatic and hemodynamically
stable during these incidents. He was monitored for the next
twenty-four hours without incident. Mr. [**Known lastname 42982**] was
consequently found to be stable to be discharged to his home
with the visiting nurse assistance.
Examination on discharge revealed the following: VITAL
SIGNS: Temperature maximum 98.6, temperature current 97.9,
blood pressure 105/52, pulse 69, respirations 18, oxygen
saturation 98% on room air, 1300 in and 1700 out. The
patient was normocephalic, atraumatic. Neck was supple.
Heart was regular rate and rhythm. Lungs were clear to
auscultation bilaterally. Incision was clean, dry, and
intact. Abdomen was soft, nontender, nondistended,
normoactive bowel sounds. There was trace edema in bilateral
lower extremities.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o.q.d.
2. Docusate 100 mg p.o.b.i.d.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.b.i.d. times 14 days.
4. Lasix 20 mg p.o.b.i.d. times 14 days.
5. Metoprolol 25 mg p.o.b.i.d.
6. Metformin 250 mg p.o.b.i.d.
7. Glucotrol XL 5 mg p.o.b.i.d.
8. Percocet 5/325 one to two tablets q.4h. to 6h.p.r.n.
pain.
FO[**Last Name (STitle) **]P CARE: Mr. [**Known lastname 42982**] is to follow up with Dr. [**Last Name (STitle) 37063**]
in three to four weeks. He is also to call Dr. [**Last Name (STitle) 37063**] to
discuss the diabetic regimen. The patient is also to follow
up with Dr. [**Last Name (Prefixes) **] in four weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged home with
[**Hospital6 **].
DIAGNOSIS: Status post coronary artery bypass graft times
three.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 12370**]
MEDQUIST36
D: [**2122-7-21**] 14:04
T: [**2122-7-21**] 14:15
JOB#: [**Job Number 42983**]
|
[
"412",
"530.81",
"427.31",
"443.9",
"250.00",
"278.01",
"414.01",
"427.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
1388, 1498
|
4246, 4940
|
2528, 4223
|
1987, 2510
|
1900, 1964
|
149, 1031
|
1053, 1371
|
1515, 1880
|
4965, 5370
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,787
| 162,965
|
7128+55812
|
Discharge summary
|
report+addendum
|
Admission Date: [**2114-12-27**] Discharge Date: [**2115-1-18**]
Date of Birth: [**2036-12-31**] Sex: M
Service: UROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6736**]
Chief Complaint:
Pt. returned to [**Location **] 5 days after being treated at [**Hospital1 18**] for
hematuria and conservative management of a small bladder
perforation from previous episode of fulgaration. Pt. presented
with hypotension, abdominal distension, and suspicion of
pneumonia.
Major Surgical or Invasive Procedure:
- placement of central line in 1)right groin 2)left subclavian
- s/p open cystotomy with bladder repair
- placement of Malecott supra pubic tube
History of Present Illness:
77 y/o M with history of CaP that underwent radiation therapy 5
years ago. Pt. then with three episodes of hematuria and clot
retention over past several months, two episodes managed at
[**Hospital1 18**] and one managed by the patient's primary urologist. Pt.
underwent fulgaration and cystoscopy by primary urologist prior
to presenting to [**Hospital1 18**]. On his second admission for hematuria
pt. underwent a cystoscopy and it was noticed that he had a
small bladder perforation. A retrograde cystogram was done and
indicated that the perf was not intraperitoneal. Pt. was
managed expectantly, hematuria decreased, and pt. was sent home
with a foley. Pt. returned this admission with hypotesion,
abdominal distention, and chest XR suspicious for pneumonia.
Past Medical History:
1. moderately differentiated prostatic adenocarcinoma of the
prostate, [**Doctor Last Name **] grade 3-4/5 of the left lobe s/p external beam
radiation '[**08**]
2. s/p urethotomy for membranous urethral stricture '[**12**]
3. HTN
4. NIDDM
5. s/p Left hip hemiarthroplasty '[**09**]
6. s/p right knee surgery
Social History:
married and lives at home
very involved family
Family History:
non-contrib
Physical Exam:
vitals: 96.8 59 103/59 20 94%ra
wd, wn, nad
ctab, no w/c/r
rrr, no m/r/g
soft, non-distended, non-tender, clean [**Last Name (un) 26535**]/dressing in place
over incision site
supra pubic tube and foley inplace - urine very light pink in
color with CBI off with no clotting noted
Bilateral lower extremities and scrotal area with minimal edema
Pertinent Results:
[**2115-1-12**] 07:30AM BLOOD WBC-6.1 RBC-2.88* Hgb-9.2* Hct-26.4*
MCV-92 MCH-31.8 MCHC-34.6 RDW-19.2* Plt Ct-205
[**2115-1-10**] 01:56AM BLOOD WBC-7.2 RBC-3.44* Hgb-10.5* Hct-31.8*
MCV-92 MCH-30.6 MCHC-33.1 RDW-16.3* Plt Ct-187
[**2115-1-9**] 05:50AM BLOOD WBC-7.8 RBC-3.24* Hgb-10.2* Hct-29.5*
MCV-91 MCH-31.6 MCHC-34.7 RDW-17.9* Plt Ct-221
[**2115-1-8**] 05:40AM BLOOD WBC-9.0 RBC-3.58* Hgb-10.9* Hct-32.4*
MCV-90 MCH-30.5 MCHC-33.8 RDW-16.0* Plt Ct-224
[**2115-1-7**] 05:52AM BLOOD WBC-8.1 RBC-3.59* Hgb-10.8* Hct-32.6*
MCV-91 MCH-30.3 MCHC-33.3 RDW-15.8* Plt Ct-243
[**2115-1-4**] 05:34AM BLOOD WBC-8.5 RBC-3.64* Hgb-11.4* Hct-32.8*
MCV-90 MCH-31.3 MCHC-34.7 RDW-16.6* Plt Ct-254
[**2115-1-3**] 05:11AM BLOOD WBC-9.0 RBC-3.63* Hgb-11.3* Hct-33.0*
MCV-91 MCH-31.1 MCHC-34.1 RDW-15.2 Plt Ct-226
[**2115-1-2**] 01:54AM BLOOD WBC-10.9 RBC-3.78* Hgb-11.6* Hct-32.7*
MCV-87 MCH-30.6 MCHC-35.4* RDW-15.5 Plt Ct-244
[**2114-12-31**] 08:00AM BLOOD Hct-33.9*
[**2114-12-31**] 12:49AM BLOOD Hct-31.1*
[**2114-12-30**] 09:03PM BLOOD Hct-32.7*
[**2114-12-30**] 05:39PM BLOOD WBC-12.2* RBC-3.76*# Hgb-11.6* Hct-33.0*#
MCV-88 MCH-30.7 MCHC-35.0 RDW-15.7* Plt Ct-179
[**2114-12-29**] 04:48AM BLOOD WBC-12.7* RBC-3.20* Hgb-9.8* Hct-28.8*
MCV-90 MCH-30.7 MCHC-34.1 RDW-16.2* Plt Ct-191
[**2114-12-28**] 05:34AM BLOOD WBC-16.8* RBC-3.49* Hgb-10.6* Hct-30.7*
MCV-88 MCH-30.5 MCHC-34.7 RDW-16.2* Plt Ct-171
[**2114-12-27**] 06:35AM BLOOD WBC-15.0* RBC-3.16* Hgb-10.2* Hct-27.4*
MCV-87 MCH-32.3* MCHC-37.3* RDW-16.5* Plt Ct-182
[**2114-12-26**] 10:25PM BLOOD WBC-12.7* RBC-3.81* Hgb-11.6* Hct-32.7*
MCV-86 MCH-30.6 MCHC-35.6* RDW-16.3* Plt Ct-228
[**2114-12-28**] 05:34AM BLOOD Neuts-89.8* Bands-0 Lymphs-7.6* Monos-2.2
Eos-0.3 Baso-0
[**2114-12-27**] 06:35AM BLOOD Neuts-71* Bands-15* Lymphs-7* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2114-12-26**] 10:25PM BLOOD Neuts-53 Bands-35* Lymphs-10* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2114-12-28**] 05:34AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
[**2114-12-27**] 06:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL
[**2114-12-26**] 10:25PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2115-1-12**] 07:30AM BLOOD Plt Ct-205
[**2115-1-10**] 01:56AM BLOOD Plt Ct-187
[**2115-1-9**] 05:50AM BLOOD Plt Ct-221
[**2115-1-6**] 05:36AM BLOOD Plt Ct-263
[**2115-1-4**] 05:34AM BLOOD Plt Ct-254
[**2115-1-3**] 05:11AM BLOOD Plt Ct-226
[**2115-1-2**] 01:54AM BLOOD Plt Ct-244
[**2115-1-2**] 01:54AM BLOOD PT-13.6* PTT-33.0 INR(PT)-1.2
[**2115-1-1**] 03:00AM BLOOD Plt Ct-224
[**2114-12-31**] 02:48AM BLOOD Plt Ct-187
[**2114-12-30**] 05:39PM BLOOD Plt Ct-179
[**2114-12-30**] 10:42AM BLOOD Plt Ct-182
[**2114-12-29**] 03:31PM BLOOD PT-13.4* PTT-42.9* INR(PT)-1.2
[**2114-12-29**] 04:48AM BLOOD Plt Ct-191
[**2114-12-28**] 11:26AM BLOOD PT-14.5* PTT-36.8* INR(PT)-1.4
[**2114-12-28**] 05:34AM BLOOD Plt Smr-NORMAL Plt Ct-171
[**2114-12-27**] 06:35AM BLOOD Plt Smr-NORMAL Plt Ct-182
[**2114-12-26**] 10:25PM BLOOD Plt Smr-NORMAL Plt Ct-228
[**2115-1-10**] 01:56AM BLOOD Glucose-129* UreaN-11 Creat-0.8 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
[**2115-1-9**] 03:30PM BLOOD K-4.1
[**2115-1-9**] 05:50AM BLOOD UreaN-11 Creat-0.7
[**2115-1-8**] 05:40AM BLOOD Glucose-118* UreaN-12 Creat-0.7 Na-137
K-3.9 Cl-104 HCO3-27 AnGap-10
[**2115-1-7**] 05:52AM BLOOD Glucose-102 UreaN-16 Creat-0.8 Na-137
K-3.9 Cl-105 HCO3-26 AnGap-10
[**2115-1-6**] 05:36AM BLOOD Glucose-135* UreaN-17 Creat-0.7 Na-136
K-3.9 Cl-106 HCO3-23 AnGap-11
[**2115-1-5**] 04:18PM BLOOD K-4.4
[**2115-1-4**] 03:02PM BLOOD UreaN-16 Creat-0.6 K-3.8
[**2115-1-4**] 05:34AM BLOOD Glucose-123* UreaN-16 Creat-0.6 Na-135
K-4.1 Cl-108 HCO3-22 AnGap-9
[**2115-1-3**] 02:39PM BLOOD UreaN-16 Creat-0.7 K-4.4
[**2115-1-3**] 05:11AM BLOOD Glucose-116* UreaN-17 Creat-0.7 Na-134
K-4.8 Cl-109* HCO3-19* AnGap-11
[**2115-1-2**] 01:54AM BLOOD Glucose-119* UreaN-13 Creat-0.6 Na-133
K-4.2 Cl-108 HCO3-17* AnGap-12
[**2115-1-1**] 03:00AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-132*
K-4.5 Cl-109* HCO3-18* AnGap-10
[**2114-12-31**] 08:00AM BLOOD Glucose-125* UreaN-13 Creat-0.7 Na-131*
K-4.4 Cl-106 HCO3-18* AnGap-11
[**2114-12-30**] 05:39PM BLOOD Glucose-128* UreaN-13 Creat-0.7 Na-131*
K-4.3 Cl-104 HCO3-20* AnGap-11
[**2114-12-30**] 10:42AM BLOOD Glucose-140* UreaN-15 Creat-0.7 Na-128*
K-4.1 Cl-104 HCO3-19* AnGap-9
[**2114-12-28**] 05:34AM BLOOD Glucose-140* UreaN-24* Creat-1.3* Na-129*
K-4.9 Cl-102 HCO3-17* AnGap-15
[**2114-12-26**] 10:25PM BLOOD ALT-18 AST-32 CK(CPK)-70 AlkPhos-141*
Amylase-19 TotBili-0.8
[**2114-12-26**] 10:25PM BLOOD Lipase-13
[**2114-12-27**] 06:35AM BLOOD CK-MB-4 cTropnT-<0.01
[**2114-12-26**] 10:25PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2115-1-12**] 07:30AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.6
[**2115-1-9**] 05:50AM BLOOD Albumin-2.4* Calcium-7.5* Phos-2.5*
Mg-1.8 Iron-25*
[**2115-1-8**] 05:40AM BLOOD Mg-1.9
[**2115-1-7**] 05:52AM BLOOD Mg-1.5*
[**2115-1-6**] 05:36AM BLOOD Mg-1.7
[**2115-1-5**] 04:18PM BLOOD Mg-1.9
[**2115-1-5**] 10:39AM BLOOD Mg-1.9
[**2114-12-31**] 08:00AM BLOOD Albumin-1.8* Calcium-7.6* Phos-2.8
Mg-3.0*
[**2114-12-31**] 02:48AM BLOOD Calcium-6.7* Phos-2.8 Mg-1.9
[**2114-12-30**] 10:42AM BLOOD Calcium-6.5* Phos-3.1 Mg-1.6
[**2114-12-29**] 04:48AM BLOOD Calcium-7.4* Phos-3.1 Mg-1.9 Cholest-55
[**2114-12-27**] 06:35AM BLOOD Calcium-7.3* Phos-4.6*# Mg-1.5*
[**2114-12-26**] 10:25PM BLOOD Albumin-2.6*
[**2115-1-9**] 05:50AM BLOOD calTIBC-147* Ferritn-102 TRF-113*
[**2114-12-29**] 04:48AM BLOOD Triglyc-58 HDL-21 CHOL/HD-2.6 LDLcalc-22
[**2114-12-29**] 04:48AM BLOOD Osmolal-271*
[**2114-12-26**] 10:25PM BLOOD HoldBLu-HOLD
[**2114-12-26**] 10:25PM BLOOD RedHold-HOLD
[**2115-1-9**] 05:50AM BLOOD PREALBUMIN-Test
CHEST (PA & LAT) [**2114-12-26**] 10:43 PM
PA AND LATERAL CHEST RADIOGRAPHS: There is atelectasis at the
right lung base. There is mild prominence of the pulmonary
vasculature, likely from poor inspiratory effort. The cardiac
and mediastinal contours are stable in appearance. No
pneumothorax is seen. No pleural effusion is seen. On the
lateral image only, there is an opacity, which is slightly
obscured secondary to blurring. The soft tissue and osseous
structures are stable.
IMPRESSION: Opacity on the lateral film in the costophrenic
angle, possibly representing a pneumonia.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
CT PELVIS W&W/O C [**2114-12-27**] 11:14 PM
IMPRESSION:
1. Interval development of a large amount of ascites.
2. There is no evidence of hydronephrosis or asymmetric renal
cortical enhancement.
3. Several hypodensities are again seen within the kidney, which
are too small to characterize.
4. Opacities within the lung bases are consolidative in
appearance and may represent a pneumonic process - clinical
correlation is recommended.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Cardiology Report ECHO Study Date of [**2114-12-28**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Height: (in) 65
Weight (lb): 201
BSA (m2): 1.98 m2
BP (mm Hg): 120/60
HR (bpm): 92
Status: Inpatient
Date/Time: [**2114-12-28**] at 15:03
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2005W506-0:46
Test Location: West Echo Lab
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Four Chamber Length: 5.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: 0.40 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.70
Mitral Valve - E Wave Deceleration Time: 175 msec
TR Gradient (+ RA = PASP): 18 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild
mitral
annular calcification. LV inflow pattern c/w impaired
relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2114-12-28**] 15:16.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CT PELVIS W/O CONTRAST [**2114-12-29**] 1:02 PM
CT PELVIS W/O CONTRAST; CT RECONSTRUCTION
Reason: CT cystolgram for extravasation of urine
[**Hospital 93**] MEDICAL CONDITION:
77 year old man h/o prostate ca s/p xrt with subsequent
hemorrhagic cystitis c/b bladder perforation (old?) now p/w
abdominal pain, new ascities with WBC >[**Numeric Identifier 7040**] Cr 1.8 growing
Ecoli.
REASON FOR THIS EXAMINATION:
CT cystolgram for extravasation of urine
CONTRAINDICATIONS for IV CONTRAST: None.
PROCEDURE: Pelvic CT with CT cystogram.
INDICATION: 77-year-old man with history of prostate cancer, S/P
XRT with subsequent hemorrhagic cystitis. H/O bladder
perforation with new ascites and abdominal pain. Assess
extravasation of urine.
IMPRESSION:
1. Bladder wall perforation in the right anterolateral aspect
with free extravasation of the contrast media through the
peritoneal cavity.
2. Diverticulosis.
The findings were discussed with Dr. [**Last Name (STitle) **] at the moment of
the interpretation of the study (6 p.m.)
Brief Hospital Course:
CC:[**CC Contact Info 26536**]
HPI: Mr. [**Known lastname 1005**] is a 77 year-old Spanish speaking male with a
history of prostate cancer s/p prostate irradiation in [**2108**], and
status post urethromtomy for a urethral stricture in [**2112**],
followed by an outside urologist. Over the past few months, he
has had recurrent gross hematuria, and underwent a cystoscopy
about a month ago with fulguration. He was recently admitted in
[**10/2114**] and again last week for similar complaints. During his
most recent admission, he underwent a cystoscopy with clot
evacuation, fulguration of the bladder mucose, and was found to
have a right lateral wall bladder perforation (likely old
injury), treated conservatively with foley drainage and abx.
While in hospital, he required 4 units of PRBCs for anemia. He
was discharged on [**2114-12-24**] with a foley and on Ciprofloxacin.
He reports that he had residual hematuria at the time of
discharge. This morning, he woke up to find his foley bag
filled, with worse hematuria and a few clots. He was seen by Dr.
[**Last Name (STitle) 770**] in the [**Hospital **] clinic today, who irrigated his foley without
difficulty. During the day, however, the patient reports
decreased urine output. He was seen by his VNA nurse, and was
found to have a low BP 80/60 (baseline 120/60). She advised him
to go to the ED. He endorses abdominal pain, which he has had
for >1 week, lower abdominal in location, non-radiating,
constant. No N/V. No change in BM. At home, his daughter reports
that he also had shortness of breath, and chills. No fever
(measured temperature). No chest pain. + cough since discharged
from the hospital, largely non-productive. + dizziness with
standing. Reportedly poor PO intake over the past days.
In ED, T98.9, HR 119, BP 100/49, RR 20, Sat 96% on RA. EKG with
new ST depression in I and aVL. CXR suspicious for pneumonia. He
was seen by urology. Irrigation of the foley was done without
difficulty. He was given one dose of Levofloxacin, ASA 325, and
hydrated.
EKG in ED: NSR, rate 88 bpm, LAD. LVH by voltage criteria. RBBB
(old), mild QT prolongation. Downsloping STs with TWI in I, aVL,
V2. No Qs. ST-T changes new versus [**2114-12-20**].
RELEVANT IMAGING DATA:
[**2114-12-26**] CXR: Opacity on the lateral film in the costophrenic
angle, concerning for pneumonia.
ASSESSMENT AND PLAN: 77 year-old Spanish male, with a h/o
prostate ca s/p external beam radiation, s/p urethrotomy for
stricture, with h/o hematuria s/p recent clot evacuation, now
with decreased UO and abdominal pain, ARF, and pneumonia.
1) Hemorrhagic cystitis: Seen by urology in the ED, appreciate
input. No indication for 3-way foley or CBI. Recommendation to
continue foley drainage, continue fluoroquinolone therapy (will
change to Levofloxacin to cover for both urinary and respiratory
organisms). No evidence of clot obstruction.
- Levofloxacin 500 mg PO QD
- Urology following. Continue foley drainage.
- Pt. had paracentesis on [**2114-12-28**] from which his fluid showed a
Cr. of 1.8. The pt. went for a CT cystogram the next day that
showed extravasation of contrast fluid into the peritoneal
cavity. The pt. remained stable otherwise and OR time was
arranged to repair the bladder perforation. on [**2114-12-30**] the
patient was taken to the OR for formal exploration and repair.
The pt. tolerated the procedure well and remained in the PACU
overnight where he received extensive hydration and two units of
PRBCs. Because we were unable to exutbate the patient he spent
the next three days in the SICU slowly being weaned from the
vent. Three days later he extubated without difficulty and was
transferred to the floor. The pt. slowly recovered on the
floor. He was continued on antibiotics for a total of 10 days,
gradually began eating a regular diet, slowly weaned off of
supplemental O2, and gained strength over the next two weeks.
Pt. worked with physical therapy was seen by nutrition and had
is urine output watched closely. The pt. had staples removed
from the cephalad portion of his incision on POD 10 and
subsequently the incision opened up. There was no evidence of
infection and the wound is now requiring TID wet to dry dressing
changes as it will close by secondary inteniton. The foley and
SPT remain in place and the pt. urine continues to be red. If
the tubes appear to be clogging or collecting a significant
amount of clots the pt. has been put back on CBI intermittently.
POD 14 the foley catheter became clogged and after attempted
flushing and removal of a significant amount of clots the foley
was taken out. It was replaced by a new 20 French two way foley
and the urine immediately became much more clear. POD 19 the
pt. was kept off of CBI with his urine continuing to be light
pink in color. The remainder of his staples were also removed
on POD 19. The pt. had received two units of PRBCs the day
before for a Hct of 24 and bumped to 31 and was feeling much
better. However, while giving the first unit of blood the pt.
felt short of breath. He received an additional dose of IV
lasix and his shortness of breath resolved. With the second
unit of blood the pt. was given lasix both pre- and post-doses
without complication. Pt. bleeding appears to have tapered and
the pt. is ready for discharge to rehab.
2) Abdominal pain: Etiology unclear until CT cystogram performed
and bladder perforation confirmed. Much improved after repair
and no return of ascites.
3) Bandemia: Infectious work-up to date remarkable for probable
pneumonia on CXR. Pt. was started on Levoquin initially and
switched to Aztreonam per ID recommendations. He completed a 10
day course of antibiotics because of the GN organisms seen in
the peritoneal tap and to treat the questionable pneumonia. Pt.
is currently not requiring antibiotic therapy.
4) CV: EKG with new ST depressions in I, aVL in setting of
relative hypotension. BP responding to IVF. Suspect low BP [**2-28**]
dehydration in setting of poor PO intake, continued Lisinopril
and HCTZ. Pt. ruled out for MI. Blood pressure continues to run
lower that pre-admission. He has been maintained on lopressor
25 [**Hospital1 **] as blood pressures permit. Are considering restarting
other antihypertensive medications as his recovery continues.
5) DM type 2: Hold Metformin and Glipizide for now. While in
the hospital the pt. has been maintained on a RISS requiring
between 4-10 units per day. Considering restarting antidiabetic
medications as the pt. appetite returns and his eating habits
return to normal.
6) Lower extremity edema - pt. post-surgery and resuscitation
has been placed on a standing order of lasix. This has helped
with decreasing his fluid load over the past week, however, the
pt. still is above his dry weight. He is to be continued on
Lasix 20mg PO for 7 more days (through [**2115-1-25**]). His BUN/Cr
and potassium levels have remained stable and he has not
required supplementation while taking the Lasix. He will,
however, require frequent lab checks to ensure his kidney
function does not become compromised.
Medications on Admission:
lipitor 20 '
glipizide 20/10
metformin 1000/500
lisinopril 20'
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for wheezing.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day). injection
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, T>101.5: no more than 4gm per
day.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
- h/o CaP s/p radiation therapy
- radiation cystitis
- s/p repair of perforated bladder
- diabetes
- hypertension
Discharge Condition:
- good
Discharge Instructions:
- no showers yet - may take sponge baths
- may eat a regular diet that is supplemented with protein
shakes
- should continue taking stool softeners as needed
- no narcotics, pt. should only take tylenol for pain relief
- should continue TID (wet to dry) dressing changes to abdomen
- continue to monitor urine output - will have clots and
occasionally be bloody for some time - please use CBI slowly as
needed to keep clots from forming
- continue PO lasix - only 20 po Qam for 7 more days
- will need three time a week BUN/Cr and Hct checks
- return to ED or call clinic if T>101.5, chills, nausea,
vomitting, chest pain, shortness of breath, inability to pass
urine, or any other concern
Followup Instructions:
- Pt. should call Dr.[**Name (NI) 825**] office to schedule a follow-up
appointment in 2 weeks. The number is ([**Telephone/Fax (1) 4276**].
***Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 **]: [**Telephone/Fax (1) 2756**] pager #[**Numeric Identifier 26537**]
with any questions or concerns***
Name: [**Known lastname **],[**Known firstname 4578**] A Unit No: [**Numeric Identifier 4579**]
Admission Date: [**2114-12-27**] Discharge Date: [**2115-1-18**]
Date of Birth: [**2036-12-31**] Sex: M
Service: UROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4580**]
Addendum:
Regarding the patient's bladder perforation: Pt. had previously
undergone radiation to the pelvic region for prostate cancer.
This causes radiation cystitis and weakening of the bladder
wall. The radiation cycstitis the pt. had already acquired most
likely lead to weakening of the patient's bladder wall,
subsequent perforation, and thus presentation with hematuria and
clot retention.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - Acute Rehab
[**Name6 (MD) **] [**Name8 (MD) 4581**] MD [**MD Number(2) 4582**]
Completed by:[**2115-1-30**]
|
[
"V10.46",
"458.0",
"276.2",
"285.1",
"998.32",
"276.6",
"596.6",
"041.4",
"458.29",
"250.00",
"276.51",
"273.8",
"998.11",
"909.2",
"567.29",
"789.5",
"595.82",
"584.9",
"403.90",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.48",
"54.91",
"57.18",
"38.93",
"57.89",
"39.98"
] |
icd9pcs
|
[
[
[]
]
] |
23258, 23456
|
13033, 20127
|
548, 695
|
21411, 21420
|
2304, 9701
|
22158, 23235
|
1908, 1921
|
20240, 21157
|
12156, 12363
|
21274, 21390
|
20153, 20217
|
21444, 22135
|
9727, 11867
|
1936, 2285
|
234, 510
|
12392, 13010
|
723, 1494
|
11899, 12119
|
1516, 1827
|
1843, 1892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,454
| 147,903
|
31862
|
Discharge summary
|
report
|
Admission Date: [**2175-6-6**] Discharge Date: [**2175-6-16**]
Date of Birth: [**2105-6-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hayfever / Pollen Extracts
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional angina
Major Surgical or Invasive Procedure:
[**2175-6-6**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to left anterior descending with vein
grafts to diagonal and right coronary artery)
History of Present Illness:
69 year old male seen originally in consultation by Dr. [**Last Name (STitle) **]
on [**2175-4-27**] at [**Hospital1 **]. He has a 10 year history of coronary
artery disease. He had angina again in [**2173**] with presumed
pericarditis, but a cardiac catherization revealed additional
coronary artery disease. He elected for further medical
management, but in the past few months, he developed exertional
angina. Catheterization in [**2175-3-19**] showed severe two vessel
coronary artery disease and surgical revascularization was
recommended.
Past Medical History:
coronary artery disease
hypertension
hyperlipidemia
pericarditis [**8-25**]
lumbar disc disease
gastroesophageal reflux disease
GI bleed [**2174**]
seasonal allergies
osteoarthritis neck
appendectomy
tonsillectomy
Social History:
Occupation: retired trucker
Lives with: wife
[**Name (NI) 1139**]:quit smoking [**2165**], cigar/pipesmoker
ETOH: rare
Family History:
Mother with CABG at 80
Physical Exam:
Vitals HR 60, b/p 124/76 weight 96.2 kg
General well nourished
Skin unremarkable
HEENT PERRLA, EOMI, anicteric sclera OP unremarkable
Neck Supple full ROM No JVD
Chest Clear to auscultation bilaterally
Heart RRR no murmur rub or gallop
Abdomen soft, nondistended, nontender
Extremities warm well perfused no edema, pulses palpable
Varicosities none
Neuro grossly intact, moves all extremities, nonfocal
Pertinent Results:
[**2175-6-16**] 06:00AM BLOOD WBC-9.2 RBC-3.49* Hgb-10.7* Hct-31.4*
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.9 Plt Ct-595*
[**2175-6-16**] 06:00AM BLOOD PT-23.1* INR(PT)-2.2*
[**2175-6-16**] 06:00AM BLOOD Glucose-95 UreaN-20 Creat-1.2 Na-137
K-4.5 Cl-104 HCO3-21* AnGap-17
Brief Hospital Course:
Admitted and was brought to the operating room for coronary
artery bypass graft surgery. See operative report for further
details. He received cefazolin for perioperative antibiotics.
He was transferred to the intensive care unit for hemodynamic
monitoring. On day of surgery he developed atrial fibrillation
and was started on amiodarone and converted to sinus rhythm. He
was weaned from sedation, awoke neurologically intact and was
extubated without complications. He was transfer to the floor
on post operative day one and remained there for the remainder
of his stay. Physical therapy worked with him on strength and
mobility. He continued to have atrial fibrillation and flutter.
He was started on coumadin and medications were adjusted,
stopping lopressor and placed on atenolol. He was started on
diltiazem since amiodarone was not effective, and amiodarone was
stopped. Keflex was begun for a left forearm phlebitis at an IV
site where amiodarone had been infusing. By post-operative day
ten he was ready for discharge to home on coumadin with a
follow-up appointment to be made with the electrophysiology
department.
Medications on Admission:
Atenolol 50mg QAM and 25mg QPM
Nitroglycerin patch 0.2mg daily
Norvasc 5mg daily
Enteric coated aspirin 325mg daily
Pravachol 80mg Monday-Wednesday-Friday
Pravachol 40mg Tuesday-Thursday-Saturday-Sunday,
Tricor 145mg daily
Protonix 40mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Pravachol 40 mg Tablet Sig: One (1) Tablet PO tuesday-
thrusday-saturday-sunday: then 80mg monday- wednesday-friday .
Disp:*45 Tablet(s)* Refills:*0*
5. Pravachol 80 mg Tablet Sig: One (1) Tablet PO
monday-wednesday-friday.
6. 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*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QAM.
Disp:*30 Tablet(s)* Refills:*2*
8. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO QPM.
Disp:*30 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days: Left forearm phlebitis.
Disp:*20 Capsule(s)* Refills:*0*
11. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. 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:*2*
13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
take 3mg daily or as directed by the office of Dr. [**Last Name (STitle) 12300**] phone
[**Telephone/Fax (1) 23002**].
Disp:*90 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
INR draw on [**6-17**] with results to Dr. [**Last Name (STitle) 12300**] phone [**Telephone/Fax (1) 23002**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Post operative atrial fibrillation
Upper extremity deep vein thrombosis
Gastroesophageal reflux disease
Osteoarthritis neck
Hypertension
Dyslipidemia
History of GI Bleed [**2174**]
Lumbar 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**]
PT/INR for coumadin dosing - goal INR 2.0-2.5 for atrial
fibrillation
First draw [**2175-6-17**] with results to Dr [**Last Name (STitle) 12300**] fax [**Telephone/Fax (1) 74720**].
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in [**2-21**] weeks, call [**Hospital1 **] heart center to
schedule follow up at Dr [**Last Name (STitle) **] clinic [**Telephone/Fax (1) 6256**]
Dr. [**Known firstname **] [**Last Name (NamePattern1) **] in [**2-21**] weeks [**Telephone/Fax (1) 6256**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12300**] in 1 week [**Telephone/Fax (1) 23002**]
PT/INR for coumadin dosing - goal INR 2.0-2.5 for atrial
fibrillation
First draw [**2175-6-17**] with results to Dr [**Last Name (STitle) 12300**] fax [**Telephone/Fax (1) 74720**].
Plan confirmed with Dr. [**Last Name (STitle) 12300**] on [**2175-6-8**].
Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (electrophysiology) in 1 month.
([**Telephone/Fax (1) 74721**].
Completed by:[**2175-6-16**]
|
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7,387
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13059
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Discharge summary
|
report
|
Admission Date: [**2188-3-1**] Discharge Date: [**2188-3-15**]
Date of Birth: [**2131-8-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
transfer from NEBH for SOB, possible need for cath given rising
troponin
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Coronary Artery Bypass Grafting
LIMA-->LAD, SVG-->OM, SVG-->PDA
History of Present Illness:
56 y/o male patient of Dr. [**Last Name (STitle) **] with HTN, hypercholesterolemia,
DM2, current smoking, PVD s/p Left CEA and totally occluded
[**Country **], with chest discomfort begining three weeks ago which he
describes as "stressed out feeing" right before the holidays.
Denies pain or associated symptomes of SOB, diasphoresis, light
headedness, nausea, or leg swelling. He has been chest dicomfort
free for the last several weeks since then, with the exception
of increased SOB, mostly at night, and increased leg swelling,
cough, and PND.
He presented to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39934**] office with SOB, cough, and
sputum production, was treated with antibiotics with no
resolution of symptomes, and had a CXR suggestive of pulm edema,
and so was referred to NEBH ambulatory services for evaluation.
He was admitted to NEBH for r/o MI, troponins 1.82 to 4.16 to
5.35 with CK 173 to 161 to 181. Started on asa, plavix, lovenox
and transferred for possible cath/CABG given rising troponins.
Denies chest pain currently. Denies SOB.
Past Medical History:
HTN
hypercholesterolemia
DM2
current smoking
PVD s/p Left CEA and totally occluded [**Country **]
Hypothyroidism
S/P Cholecystectomy
S/P Cervical Surgery
S/P B/L Knee Surgery
Social History:
Smoker of 35 years at 2 ppd. No recent alcohol use, but remote
history of frequent use.
Family History:
Father had MI at 65 years old.
Physical Exam:
General: Well appearing man in no distress. Approproately
responsive.
Vitals: T 96.2 BP 131/54 HR 61 RR 18 Sat 100% 1L O2 NC FS 58 Wt
110kg
HEENT: normal, anicteric sclera
Neck: Carotid bruits B/L R>L
Chest: Lungs with decreased breath sounds at bases, otherwise
clear
ABD: Scar over RUQ and above umbilicus, +bowel sounds, soft, NT,
ND, no organomegaly
EXT: No edema. Good femoral pulses B/L without bruits.
Pertinent Results:
INDICATIONS FOR CATHETERIZATION:
NSTEMI, low EF, 30 beats of monomorphic VT
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 6 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French angled pigtail catheter,
advanced
to the left ventricle through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 catheter, with manual contrast
injections.
Left Ventriculography: was performed in the 30 degrees [**Doctor Last Name **]
projection,
using 33 ml of contrast injected at 11 ml/sec, through the
angled
pigtail catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.21 m2
HEMOGLOBIN: 14 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 15/16/9
RIGHT VENTRICLE {s/ed} 45/15
PULMONARY ARTERY {s/d/m} 45/18/28
PULMONARY WEDGE {a/v/m} 24/25/22
LEFT VENTRICLE {s/ed} 141/24
AORTA {s/d/m} 141/64/71
**CARDIAC OUTPUT
HEART RATE {beats/min} 55
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 38
CARD. OP/IND FICK {l/mn/m2} 7.3/3.3
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 680
PULMONARY VASC. RESISTANCE 66
**% SATURATION DATA (NL)
SVC LOW 70
PA MAIN 68
AO 88
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
LEFT VENTRICULOGRAPHY:
Volumetric data:
LV ejection fraction (nl 50%-80%). 25
Qualitative wall motion:
[**Doctor Last Name **]:
1. Antero basal - hypokinetic
2. Antero lateral - hypokinetic
3. Apical - hypokinetic
4. Inferior - hypokinetic
5. Postero basal - hypokinetic
Other findings:
Mitral valve was normal.
Aortic valve was normal.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA DISCRETE 50
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA DISCRETE 95
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DIFFUSELY DISEASED 70
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
12) PROXIMAL CX DISCRETE 70
13) MID CX DIFFUSELY DISEASED
13A) DISTAL CX DIFFUSELY DISEASED
14) OBTUSE MARGINAL-1 DISCRETE 95
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour41 minutes.
Arterial time = 0 hour25 minutes.
Fluoro time = 5.6 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 83 ml,
Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Fentanyl 25 mcg IV
Versed 0.5 mg IV
Lasix 20 mg IV
Cardiac Cath Supplies Used:
200CC MALLINCRODT, OPTIRAY 200CC
100CC MALLINCRODT, OPTIRAY 100CC
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system.
There was no angiographically apparent CAD in the LMCA. The LAD
had a
long diffusely diseased segment with a 70% stenosis. The LCX had
a 70%
proximal stenosis. The OM had a 95% origin stenosis. There was
moderate
diffuse distal disease in the LCx. The RCA had a 50% mid vessel
stenosis
and 95% bifurcation disease at the PDA and PL.
2. Hemodynamics on entry showed elevated filling pressures, mild
to
moderate pulmonary hypertension, and a normal cardiac output.
There was
no gradient across the aortic valve on pullback.
3. Left ventriculography showed a dilated ventricle which was
globally
hypokinetic.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate systolic and mild diastolic ventricular dysfunction.
3. Mild to moderate pulmonary hypertension.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) 10897**] B.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Cardiology Report ECG Study Date of [**2188-3-5**] 3:51:14 PM
Ectopic atrial rhythm. Ventricular premature beat with possible
pacemaker
fusion. Lone pacemaker spike in the third beat of the rhythm
strip. Consider
sensing malfunction.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
51 [**Telephone/Fax (3) 32880**]/446.86 -53 95 -157
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2188-3-7**] 12:47 PM
CHEST (PORTABLE AP)
Reason: PTX
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with increasing dyspnea s/p CABG now s/p R-IJ
change over wire and d/c CTs
REASON FOR THIS EXAMINATION:
PTX
CHEST, SINGLE AP FILM
History of CABG and increasing dyspnea with CV line change.
Status post CABG. Right jugular CV line is in the SVC. No
pneumothorax. The right costophrenic region is not included on
the film. There is opacity at the left base obscuring the left
hemidiaphragm consistent with atelectasis in the left lower lobe
and associated small left pleural effusion. Status post cervical
spine fusion.
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: [**First Name9 (NamePattern2) **] [**2188-3-7**] 2:55 PM
RADIOLOGY Final Report
CAROTID SERIES COMPLETE [**2188-3-4**] 3:40 PM
CAROTID SERIES COMPLETE
Reason: please eval for extent of carotid stenosis b/l
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with h/o PVD s/p left CEA and known [**Country **]
occlussion. ON exam with b/l carotid bruits R>L and diminsihed R
carotid pulse.
REASON FOR THIS EXAMINATION:
please eval for extent of carotid stenosis b/l
HISTORY: Status post left carotid endarterectomy with right
carotid occlusion.
TECHNIQUE: [**Doctor Last Name **] scale ultrasound, color Doppler, and spectral
Doppler interrogation of the extracranial carotid arteries were
performed.
RIGHT: No flow was demonstrated within the right internal
carotid artery. Peak systolic velocity in the right external
carotid artery was 193 cm/sec, common carotid artery 43 cm/sec.
Blood flow within the right vertebral artery was antegrade.
LEFT SIDE: Mild calcified plaques were noted at the origin of
the left internal carotid artery. Peak systolic velocities were
as follows: 112 cm/sec ICA, 71 cm/sec CCA, 132 cm/sec ECA. Blood
flow direction within the left vertebral artery was antegrade.
The ICA-CCA ratio on the left was 1.57.
IMPRESSION:
1. Right internal carotid artery is occluded.
2. Nonhemodynamically significant stenosis of less than 40% was
demonstrated in the left internal carotid artery.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 39935**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39936**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: WED [**2188-3-5**] 9:51 AM
Brief Hospital Course:
56 y/o male with HTN, hypercholesterolemia, current smoking,
DM2, PVD S/P L CEA and occluded [**Country **] presents from outside
hospital after completed MI with shortness of breath, was chest
pain free and ruled out for active ischemic event. He was
started on metoprolol and captopril. His shortness of breath
improved with diuresis (40 mg IV lasix QD). He had a 30 second
episode of monomorphic VT symptomatic with lightheadedness on
[**2188-3-3**]. He went for elective cath on [**2188-3-4**], which showed 3VD,
and so he was scheduled for CABG. He was started on amiodarone
for VT.
He was continued on his home regimen of 60 units 75/25 QD before
breakfast for DM2, but his evening dose of 60 units NPH was
halved for morning hypoglycemia.
He had a carotid US for his h/o PVD with CEA of left carotid and
known totally occluded [**Country **]. It showed 40% Left Stenosis and
totally occluded [**Country **]. He had an abnormally elevated TSH to 25,
but his free T4 was normal. We continued his home dose of
levothyroxine 300 mcg QD. He may need an EP study for possible
ablation of ventricular focus given his episode of monomorphic
VT as an Outpatient per Dr. [**Last Name (STitle) **]. He may also need an ICD given
his low EF an documented episode of symptomatic monomorphic VT.
Mr. [**Known lastname 3075**] [**Last Name (Titles) 1834**] cardiac catheterization where he was found
to have no angiographically apparent CAD in the LMCA. The LAD
had a long diffusely diseased segment with a 70% stenosis. The
LCX had a 70% proximal stenosis. The OM had a 95% origin
stenosis. There was moderate diffuse distal disease in the LCx.
The RCA had a 50% mid vessel stenosis and 95% bifurcation
disease at the PDA and PL. Given the severity of his disease,
the cardiac surgical service was consulted for surgical
revascularization. He was worked-up in the usual preoperative
manner. On [**2188-3-5**] he successfully [**Date Range 1834**] CABGx (LIMA->LAD,
SVG->PDA, SVG->OM). Afterward he was transferred to the Cardiac
surgery recovery unit in stable condition and awakened
neurologically intake. He was weaned from ventilator support,
extubated, and pressors were weaned. On POD 2 he was then
transferred to the cardiac stepdown unit for further recovery.
His chest tubes were removed without complication. He was
gently diuresed toward his preoperative weight with lasix. Beta
blockade, aspirin, and plavix were resumed. The physical therapy
service was consulted to assist with his postoperative strength
and mobility. Electrolytes were repleted as needed. On POD 3
his epicardial pacing wires were removed without complication.
The Electrophysiology service was consulted regarding history of
ventricular tachycardia that occurred preoperatively.
Consideration was given to performing an EP study with ablation
however due to his continued tenuous pulmonary status Dr. [**Last Name (STitle) **],
Mr. [**Known lastname 39937**] cardiologist elected to continue observation and
perform any further work up as an outpatient. Also on POD 3 he
began to complain of decreased sensation and flexion to his left
calf and shin. This was attributed to peroneal nerve injury
from fluid accumulation or positioning, for which the physical
therapy service gave an ankle foot orthotic. We will continue
watchful waiting for the return of his left lower extremity
function. If indicated further workup will be conducted as an
outpatient. He continued to improve his ability to ambulate
including climbing stairs without severe respiratory distress or
chest pain. His room air saturations improved to 98% despite
continuing to require combivent, albuterol, and advair. On POD
9 Mr. [**Known lastname 3075**] was at his preop weight with good exercise
tolerance, no SOB, or Chest pain. His blood pressure was
stable. His sternotomy and leg incision were clean, dry, and
intact, however he was placed on levaquin 500mg for seven days
due to sersanquinous drainage at the inferior portion of his
sternotomy. He was discharged to home on POD 9, with cardiac
diet, sternal precautions, and instructed to follow up with his
PCP and cardiologist in [**2-18**] weeks. He will follow up for a
wound check on Mon or Tues. at [**Hospital Ward Name 121**] 2. He will follow up with
Dr. [**Last Name (STitle) **] in four weeks.
Medications on Admission:
Home Meds:
Valium 5 mg TID
Humulin N 60 units QD at dinnertime
Humalog 75/25 60 units QD before breakfast
Levothyroxine 300mcg QD
Percocet 5mg/325mg [**2-18**] Q4H PRN
Additional Meds on transfer:
ASA 325 QD
Plavix 300 once
Nitro Paste 2inches
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*2*
13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs* Refills:*2*
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every 4-6 hours.
Disp:*qs qs* Refills:*2*
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day.
Disp:*qs 30* Refills:*2*
17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: One (1) 60
Subcutaneous qBreakfast.
Disp:*qs 30* Refills:*2*
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
60 Subcutaneous at bedtime.
Disp:*qs 30* Refills:*2*
19. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*qs ML(s)* Refills:*0*
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
care group
Discharge Diagnosis:
CAD, PVD s/p Left CEA, totally occluded [**Country **], Hypothyroidism,
s/p CCY, cervical injury, s/p Bilateral knee replacement with
intra-op brady arrest, IDDM, HTN, Hypercholesteremia
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever >101, redness or drainage from incision, or
weight gain more than 2 pounds in one day or five pounds in one
week.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] in four weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 5456**] in [**2-18**] weeks [**Telephone/Fax (1) 25798**]
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2394**] in [**2-18**] weeks
Completed by:[**2188-3-15**]
|
[
"443.9",
"428.0",
"416.8",
"410.71",
"414.01",
"401.9",
"250.00",
"272.0",
"305.1",
"427.1",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.53",
"39.61",
"88.56",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
16814, 16855
|
9706, 14036
|
393, 483
|
17086, 17093
|
2394, 2394
|
17463, 17729
|
1916, 1948
|
14332, 16791
|
8192, 8339
|
16876, 17065
|
14062, 14242
|
6288, 7277
|
17117, 17440
|
1963, 2375
|
5049, 6271
|
2427, 5030
|
281, 355
|
8368, 9683
|
511, 1596
|
1618, 1794
|
1810, 1900
|
14260, 14309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,750
| 145,131
|
41316
|
Discharge summary
|
report
|
Admission Date: [**2140-1-11**] Discharge Date: [**2140-1-13**]
Date of Birth: [**2090-11-9**] Sex: M
Service: NEUROLOGY
Allergies:
Keflex
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
The pt is a 49 year-old man with a history of CAD s/p stents,
DM, OSA and seizures who presents following several GTCs. As the
patient is currently intubated, history is obtained from EMS as
well as from the ED resident who had a brief conversation with
the patient's wife (currently on an airplane and not accessible
by phone). Apparently the patient was in town to give a talk,
and per his wife had only been sleeping 2-3 hours/night for the
past few nights. This morning he had [**3-29**] witnessed seizures,
reported to be generalized tonic clonic, each lasting [**2-27**]
minutes, with significant agitation in between. He was brought
to the ED by EMS, where he was reportedly extremely agitated,
requiring multiple people to restrain him. He was
initially given 4mg of IM Ativan, followed by 8mg of IV Ativan,
primarily for significant agitation. He was also given 500mg IV
Keppra given the report of seizure activity. He was then
intubated in order to sedate him enough to undergo further
studies.
According to his wife, he was first diagnosed with seizures in
[**Month (only) 116**] of this year. The seizures always occur at night while he
is sleeping, and consist of flexion of one arm and stiffening of
the other arm. He will have some post-ictal confusion
afterwards, but usually not the significant agitation that was
described today. The last seizure was reportedly in [**Month (only) 359**], at
which time his Keppra dose was increased. She did report that
he is not always fully compliant with his medication. The ED
resident was told that an extensive evaluation for his seizures
was done previously at [**Hospital1 **], however it is not clear what this
consisted of.
Intubated, unable to answer ROS. Per wife, patient has not
beeing sleeping much and always sleep less than several hours
nightly. His most recent seizure was in [**Month (only) 359**] and he was
diagnosed with epilepsy in [**2139-4-25**]. His seizures are always
nocturnal prior to this admission where he sometimes screams
followed by flexsion of one arm and extension of another. He
has had several episodes and upon evaluation, found to have
cardiac pathology hence initially thought to be cardiogenic. He
has had several (14) stents placed. His neurologist in
[**State **] is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Past Medical History:
1. CAD s/p multiple stents
2. DM
3. OSA
4. Seizures as above
Social History:
Rabbi and currently traveling/speaking circuit. Was due to go
to [**Hospital1 789**] [**1-12**] and [**Hospital1 614**] [**1-13**] then return to [**State **]
on [**1-14**]. Does not smoke. Lives with his wife.
Family History:
No seizures
Physical Exam:
Physical Exam: On admission
Vitals: T: 98.9 (axillary) P: 109 R: 16 BP: 164/90 SaO2: 100%
intubated
General: Intubated, agitated
HEENT: NC/AT. Conjunctival erythema.
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 C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Intubated, on 25 of propofol. Not following
commands or opening eyes spontaneously, but is making purposeful
movements towards the ETT if not restrained. Unable to stop
propofol, as patient becomes too agitated.
-Cranial Nerves: Pupils 4 to 2mm bilaterally. Intact corneals
and gag reflex. Negative oculocephalics.
-Motor/Sensory: Spontaneous purposeful movements of all
extremities with no asymmetry, reaching towards ETT and
withdrawing from painful stimuli.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Pertinent Results:
[**2140-1-13**] 06:05AM BLOOD WBC-9.2 RBC-4.19* Hgb-12.4* Hct-35.4*
MCV-85 MCH-29.5 MCHC-35.0 RDW-13.2 Plt Ct-179
[**2140-1-11**] 10:40AM BLOOD Glucose-118* UreaN-21* Creat-1.2 Na-138
K-3.9 Cl-103 HCO3-17* AnGap-22*
[**2140-1-11**] 10:40AM BLOOD cTropnT-<0.01
[**2140-1-12**] 02:03AM BLOOD Triglyc-63 HDL-46 CHOL/HD-2.3 LDLcalc-48
LDLmeas-53
[**2140-1-11**] 10:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
EKG:
Sinus tachycardia. Minor ST-T wave abnormalities. No previous
tracing available for comparison. Clinical correlation is
suggested.
CT Head on [**1-11**]:
1. No mass effect or extra-axial collection is seen. Asymmetric
density of
the left cerebellar tent is likely a normal variant but layering
hemorrhage is not excluded. Recommend comparison with priors and
attention on followup.
2. Empty [**Month/Year (2) **] which is hyperexpanded. If clinically indicated,
this could
be further evaluated with MRI.
3. Intubated state with mottled air and soft tissue filling the
nasal canals and posterior nasopharynx.
Repeat Head CT on [**1-13**]:
1. Slight decrease in size of thin left-sided subdural hematoma.
2. Acute on chronic sinus disease as described above.
3. Redemonstration of enlarged empty [**Month/Year (2) **].
MRI Head:
1. Small left-sided subdural hematoma.
2. Enlarged empty [**Month/Year (2) **].
Ankle/Hand x-ray: No fracture
EEG report pending at the time of discharge but no
spikes/discharges or evidence of seizures.
Brief Hospital Course:
Rabbi [**Known lastname 89944**] is a 49 year old man with extensive cardiac
history s/p 14 stents, diabetic (no longer on hypoglycemic
agents after losing 100 lbs) and seizure history who was
witnessed to have several seizures while giving a lecture. He
received total of 15mg of Ativan in the ED resulting in
respiratory depression warranting intubation. Hence he was
initially admitted to the ICU then was successfully extubated
the next day. Head CT showed small subdural hematoma likely
traumatic from the seizure and MRI showed no infarct or other
pathology. Repeat CT on the day of discharge showed mild
decrease in the subdural hematoma.
Patient was transferred to the neurology floor on [**1-12**] then
evaluated per physical therapist who found the patient to be
safe to be discharged without therapy or assistive device.
Patient also had an EEG while in the ICU which did not show any
seizure activities. He was already on Keppra 1500 mg [**Hospital1 **] for
seizure control and given the recent breakthrough seizures, he
was started on Lamotrigine 25 mg daily. The plan is to titrate
this up to 25 mg [**Hospital1 **] in 2 weeks. Our current plan is to further
increase the Lamictal to 50 mg [**Hospital1 **] 2 weeks after that then to
100 mg [**Hospital1 **] 2 weeks later. We are providing a prescription for
the first 4 weeks of this titration plan, and will leave the
further dose increases up to his outpatient neurologist, Dr.
[**First Name (STitle) **].
He also reported pain in both R wrist and ankle with some
swelling. X-ray with multiple views of wrist and hand were
negative as were X-rays of R ankle. This summary will be
provided to the family/patient upon discharge and will also be
faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 89945**], fax ([**Telephone/Fax (1) 89946**].
Medications on Admission:
Plavix
ASA 325mg
Amlodipine 5mg twice daily
Coreg 12.5mg [**Hospital1 **]
Keppra 1500mg [**Hospital1 **]
Imdur 30mg daily
Pletal 50mg [**Hospital1 **]
Discharge Medications:
1. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please start by taking one tablet daily for 2 weeks.
After the 2 weeks, please take 1 tablet twice a day. After that,
please see your outpatient neurologist for further medication
adjustment. .
Disp:*50 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for CAD.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for CAD/stents.
4. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO q6h prn as
needed for seizure.
Disp:*5 Tablet(s)* Refills:*0*
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
seizure d/o
subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital after having [**3-29**] witnessed generalized
seizures while giving a lecture, each seizure lasting several
minutes. You did not return to baseline in between seizures, but
rather was agitated. For this, you were given Ativan and
intubated for airway protection. You were then successfully
extubated without difficulty. You had a routine EEG during
admission; there were no active seizures noted during this
recording. At time of discharge, you were not having any
seizures.
A CT scan of your head upon arrival showed a thin left sided
subdural hematoma and a repeat CT, performed over 24 hours after
the initial, showed a slight decrease in the size of the
subdural. The CT also showed an enlarged empty [**Last Name (LF) **], [**First Name3 (LF) **] an MRI
was performed to further evaluate this. There was no evidence of
any mass on MRI.
You had soft tissue swelling and pain of your right wrist and
foot. X-rays were taken of your right hand and ankle; there were
no fractures on these X-rays.
You were started on Lamotrigine during this admission 25mg
daily. In two weeks from [**2140-1-12**], please increase to 25mg twice
daily. We will give you a prescription that will cover you
through this dose. Our current plan would then be to increase
the dose to 50mg twice daily two weeks later then finally to
100mg twice daily 2 weeks afterwards. We will leave these future
decisions to your outpatient neurologist. You are also given
presription for Ativan 1mg to take as instructed for seizures.
Followup Instructions:
Please follow-up with your Neurologist in [**State **] within [**12-27**]
weeks of discharge.
Completed by:[**2140-1-13**]
|
[
"V45.81",
"250.00",
"414.01",
"461.9",
"327.23",
"345.10",
"432.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8937, 8943
|
5714, 7580
|
277, 290
|
9017, 9017
|
4204, 5691
|
10722, 10847
|
3006, 3019
|
7781, 8914
|
8964, 8996
|
7606, 7758
|
9168, 10699
|
3797, 4185
|
3049, 3550
|
229, 239
|
318, 2674
|
9032, 9144
|
2696, 2759
|
2775, 2990
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,647
| 162,283
|
14038
|
Discharge summary
|
report
|
Admission Date: [**2123-5-2**] Discharge Date: [**2123-5-10**]
Service: MEDICINE
Allergies:
Furosemide
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
left hip fracture
Major Surgical or Invasive Procedure:
1) Intramedullary nailing left intertrochanteric hip fracture
with short gamma nail, 11 x 125 x 180.
2) Bronchoscopy
3) Blood transfusion
4) Central line placement
History of Present Illness:
The patient is an 83 year old man with a history of CAD s/p CABG
and stent to OM in [**2121**] on ASA/Plavix, ischemic CHF EF 25-30%
with AICD, HTN, DM2, PVD, RA on prednisone, HTN, who presented
to [**Hospital3 24768**] on [**2123-4-30**] after suffering a mechanical fall
at home. He reports that he was in his usual state of health
until [**2123-4-30**] when he tripped while emerging from the bathroom at
home. He was taken to [**Hospital3 24768**] where he was reportedly
found to have a left intertrochanteric fracture of his left
femur. Since he has an extensive cardiac history (for which he
has received his care here), he was transferred to [**Hospital1 18**] for
further management on [**2123-5-2**].
.
The patient underwent left femur fracture repair on [**5-5**]. His
post-operative course was complicated by RUL collapse. RUL
reinflated s/p bronchoscopy in OR. However, on POD#1 RLL
collapse noted and Pulmonary was consulted. Bronchoscopy was
performed on [**5-7**] and was notable for large mucous plug which
was suctioned from his bronchus.
.
On [**2123-5-6**], the patient spiked fevers to 103 and was started on
vanco/zosyn for presumed hospital-acquired pneumonia. Admission
WBC was 26.6.
.
On [**2123-5-7**], however, the patient began experiencing diarrhea and
was found to have C.diff negative stool with left-sided
abdominal pain. His WBC rose from 26 to near 79 with C. diff
toxin B positive. KUB yesterday without free air, however,
evidence of dilated bowel consistent with paralytic ileus.
However, toxic megacolon could not be excluded.
.
The patient is now on PO flagyl (day 2), IV vanco and zosyn (day
4) and the patient's symptoms improved marginally. He is still
having diarrhea.
.
Surgery was consulted on [**2123-5-9**] as well as oncology to assess
for acute leukemia given marked leukocytosis. Surgery felt the
KUB on [**2123-5-8**] was concerning for toxic megacolon and
recommended medical ICU for closer monitoring as well as CT
abdomen with oral contrast to assess further. NGT placed on
[**2123-5-9**].
.
In addition, the patient has developed acute on chronic renal
failure. Baseline Cr 1.2->2.5 now. The medical floor team
calculated his FeNa to be <1% and consistent with pre-renal
azotemia and the patient was given IVF. With fluid hydration,
the patient's O2 Sat's went from 96% to 88% on 4 liters and the
patient is now on 5 liters O2. CXR without evidence of CHF but
RLL and LLL atelectasis.
.
ID was consulted on [**2123-5-9**] for managment of C. diff colitis as
well as LLL pneumonia. Surgery recommended IV flagyl + PO
vancomycin. Renal was also consulted for worsening renal
function and felt the acute renal dysfunction was consistent
with ATN from sepsis. Urine lytes are pending. SBP 110s
(baseline 110s). Anti-hypertensives held on [**2123-5-9**] for concern
for sepsis. Lasix DC'd on [**2123-5-8**] with IVF hydration.
.
The patient was also noted to have trace guaiac positive stool
with mild hemoptysis post-bronch. Hct stable at 27 but
transfused 1 unit on [**2123-5-8**] with an appropriate bump to 30.
.
ROS:
Complains of shortness of breath, no chest pain, + chills, no
fevers. [**9-1**] abdominal pain on morphine PCA.
Past Medical History:
CAD s/p 5-v CABG (LIMA-LAD, SVG-D1, SVG-OM1, SVG-LPL, SVG-rPDA),
stent placed in SVG-LPL [**2120**], stent placed in graft to OM in [**Month (only) 116**]
[**2121**]; patent bypass grafts noted in [**5-/2122**]
s/p bilateral renal artery stenoses with stent placements
[**9-/2121**]
Systolic CHF, LVEF 25-30% s/p ICD placement in [**6-27**]
s/p L CEA
RA, on prednisone
PVD
type 2 diabetes, not on insulin
prostate CA treated with Lupron & radiation
macular hemorrhage
chronic renal insufficiency (baseline creatinine 1.2-1.5)
Social History:
Married, lives at home with his wife. [**Name (NI) **] is a retired engineer.
Has a 50 pack year smoking hx but none in past 10 years. No
alcohol. Has had asbestos exposure in the past.
Family History:
(+) [**Name (NI) 41900**] CAD, father died at age 47 of an MI
Physical Exam:
Exam:
T 1001. BP 106/50 HR 80 RR 18 Sat 100% on 5 liters O2 (g
Gen: NAD, lying flat in bed
HEENT: L>R proptosis (blind in left eye), OP clear, MMM
Neck: bilateral carotid bruits, JVP 7cm, no cervical/clavicular
lymphadenopathy
Chest: clear to auscultation throughout, no w/r/r
CV: rrr, nl s1s2, no m/r/g
Abd: Distended, diffusely tender, no rebound/guarding, decreased
bowel sounds
Extr: 2+ DP/PT/popliteal pulses bilaterally, full ROM in all
toes, no cyanosis or edema
Neuro: alert, appropriate, CN 2-12 intact, 5/5 strength in both
arms/feet
Pertinent Results:
XRAY LEFT HIP [**2123-5-2**]: There are moderate degenerative changes
of the left hip. There is a left intertrochanteric femur
fracture. Although the fracture is nondisplaced in the AP view,
slight anterior apex angulation and distraction of the anterrior
fracture line is seen on the true lateral view. There is
probable diffuse osteopenia. No other fracture is detected
involving the left femur. Dense vascular calcification and
surgical clips are noted. At the periphery of these films,
severe degenerative changes in the lower lumbar spine and
moderate degenerative changes of the right hip are noted.
IMRESSION: Left femoral intertrochanteric fracture, with slight
distraction and anterior apex angulation, but overall anatomic
alignment.
.
CT ABDOMEN [**2123-5-9**]: 1. Moderate circumferential bowel wall
thickening of the entire colon extending from rectum to cecum
with associated pericolonic inflammatory change and inflammation
of the associated mesentery. Findings are in keeping with the
patient's stated history of Clostridium difficile. Maximum
diameter of the transverse colon measures 7 cm. There is no
definite evidence for toxic megacolon, however this entity is
not entirely excluded.
2. Mild dilatation of the entire small bowel with no focal
transition point. Findings are suggestive of ileus.
3. Moderate distention of the gallbladder. If right upper
quadrant pain is present, right upper quadrant ultrasound could
be performed for further
characterization.
.
[**2123-5-10**] 03:11AM BLOOD WBC-86.2* RBC-3.31* Hgb-9.8* Hct-29.2*
MCV-88 MCH-29.5 MCHC-33.5 RDW-17.5* Plt Ct-241
[**2123-5-10**] 03:11AM BLOOD Neuts-82* Bands-10* Lymphs-1* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* Promyel-1*
[**2123-5-10**] 03:11AM BLOOD Glucose-95 UreaN-61* Creat-2.5* Na-139
K-3.9 Cl-106 HCO3-18* AnGap-19
.
[**2123-5-9**] 03:41PM BLOOD ALT-12 AST-26 AlkPhos-148* Amylase-19
TotBili-0.5
[**2123-5-10**] 03:11AM BLOOD Calcium-8.0* Phos-4.7* Mg-2.4
[**2123-5-9**] 03:41PM BLOOD Vanco-8.3*
[**2123-5-10**] 07:39AM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-43 pH-7.28*
calTCO2-21 Base XS--6
[**2123-5-10**] 07:39AM BLOOD Lactate-2.1*
.
CT ABDOMEN W/O CONTRAST [**2123-5-9**] 5:41 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: ABDOMINAL TENDERNESS, C DIFF. WHITE COUNT OF 85K, ?
TOXIC MEGACOLON
Field of view: 42.7
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with C.Diff, white count of 85K, abdominal
tenderness; pls perform with oral contrast
REASON FOR THIS EXAMINATION:
? toxic megacolon; pls perform with oral contrast
CONTRAINDICATIONS for IV CONTRAST: Acute Renal Failure;Acute
renal failure
CT OF THE ABDOMEN AND PELVIS
HISTORY: Clostridium difficile. Evaluate for obstruction or
megacolon.
TECHNIQUE: Following administration of oral contrast and without
intravenous contrast, multiple contiguous axial images were
obtained from the lung bases to the pelvis. There are no prior
examinations.
FINDINGS: Limited unenhanced images of the liver, adrenal
glands, spleen, and pancreas are unremarkable. Multiple
bilateral low-attenuation lesions are present within both
kidneys, the largest in the left lower pole measures 3 cm in
maximal diameter. An additional 8-mm hyperdense exophytic lesion
is present in the mid pole of the right kidney for which
ultrasound is recommended for further characterization. There is
distention of the gallbladder which is a nonspecific finding. If
right upper quadrant pain is present, ultrasound could be
performed for further characterization.
There is moderate circumferential bowel wall thickening
involving the entire colon from rectum to cecum. There is
associated mild pericolonic inflammatory change as well as
inflammatory change in the associated mesentery. Findings are in
keeping with the patient's stated history of Clostridium
difficile. Maximum diameter of the colon measures 7 cm as
measured in the transverse colon. There is no definite evidence
of toxic megacolon, however this is not entirely excluded. There
is dilatation of the entire small bowel measuring up to 3.4 cm
in diameter with no focal transition point. Findings are
consistent with ileus.
There are no enlarged pelvic or retroperitoneal lymph nodes.
There are no intraperitoneal free air or free fluid.
There is collapse and consolidation of dependent lung bases.
There are no suspicious bone lesions.
There is aneurysmal dilatation of the infrarenal abdominal aorta
measuring 3.5 cm in diameter. Bilateral renal artery stents are
present.
IMPRESSION:
1. Moderate circumferential bowel wall thickening of the entire
colon extending from rectum to cecum with associated pericolonic
inflammatory change and inflammation of the associated
mesentery. Findings are in keeping with the patient's stated
history of Clostridium difficile. Maximum diameter of the
transverse colon measures 7 cm. Toxic colitis is not entirely
excluded.
2. Mild dilatation of the entire small bowel with no focal
transition point. Findings are suggestive of ileus.
3. Moderate distention of the gallbladder. If right upper
quadrant pain is present, right upper quadrant ultrasound could
be performed for further characterization.
Brief Hospital Course:
The patient underwent left femur fracture repair on [**5-5**]. His
post-operative course was complicated by RUL collapse. RUL
reinflated s/p bronchoscopy in OR. However, on POD#1 RLL
collapse noted and Pulmonary was consulted. Bronchoscopy was
performed on [**5-7**] and was notable for large mucous plug which
was suctioned from his bronchus.
.
On [**2123-5-6**], the patient spiked fevers to 103 and was started on
vanco/zosyn for presumed hospital-acquired pneumonia. Admission
WBC was 26.6.
.
On [**2123-5-7**], however, the patient began experiencing diarrhea and
was found to have C.diff negative stool with left-sided
abdominal pain. His WBC rose from 26 to near 79 with C. diff
toxin B positive. KUB yesterday without free air, however,
evidence of dilated bowel consistent with paralytic ileus.
However, toxic megacolon could not be excluded.
.
The patient is now on PO flagyl (day 2), IV vanco and zosyn (day
4) and the patient's symptoms improved marginally. He is still
having diarrhea.
.
Surgery was consulted on [**2123-5-9**] as well as oncology to assess
for acute leukemia given marked leukocytosis. Surgery felt the
KUB on [**2123-5-8**] was concerning for toxic megacolon and
recommended medical ICU for closer monitoring as well as CT
abdomen with oral contrast to assess further. NGT placed on
[**2123-5-9**].
.
In addition, the patient has developed acute on chronic renal
failure. Baseline Cr 1.2->2.5 now. The medical floor team
calculated his FeNa to be <1% and consistent with pre-renal
azotemia and the patient was given IVF. With fluid hydration,
the patient's O2 Sat's went from 96% to 88% on 4 liters and the
patient is now on 5 liters O2. CXR without evidence of CHF but
RLL and LLL atelectasis.
.
ID was consulted on [**2123-5-9**] for managment of C. diff colitis as
well as LLL pneumonia. Surgery recommended IV flagyl + PO
vancomycin. Renal was also consulted for worsening renal
function and felt the acute renal dysfunction was consistent
with ATN from sepsis. Urine lytes are pending. SBP 110s
(baseline 110s). Anti-hypertensives held on [**2123-5-9**] for concern
for sepsis. Lasix DC'd on [**2123-5-8**] with IVF hydration.
.
The patient was also noted to have trace guaiac positive stool
with mild hemoptysis post-bronch. Hct stable at 27 but
transfused 1 unit on [**2123-5-8**] with an appropriate bump to 30.
.
The patient developed a distended abdomen with intense pain with
a history of C. diff with a KUB consistent with ileus. Surgery
was consulted and was concerned for toxic megacolon. A CT of the
A/P showed small bowel ileus and pancolitis with maximum 7 cm
dilation of the colon and could not exclude toxic megacolon.
.
The patient was transferred to the MICU for closer monitoring.
IV vancomycin was discontinued and the patient was continued on
PO vanco, IV flagyl and PR vancomycin. Surgery felt the patient
was not a good candidate for surgery given his comorbidities.
IVF were administered and antibiotics were administered to the
patient in the MICU but his pain and respiratory status
worsened. When the attending surgeon explained that the patient
was high operative risk, the patient and his family asked for
comfort only to be goal of care.
.
A morphine drip was initiated and all antibiotics and
medications not for comfort care discontinued.
The patient expired on [**2123-5-10**] with the family present.
Medications on Admission:
aspirin 81mg daily
glipizide 5mg daily
digoxin 0.25mg daily (except Thursday and Sunday)
fosinopril 10mg tid
isosorbide dinitrate 10mg tid
metoprolol 100mg qam, 50mg qpm
metolazone 2.5mg q48h
nitroglycerin 0.4mg SL prn
prednisone 10mg daily
clopidogrel 75mg daily
simvastatin 40mg daily
nifedipine 60mg qam, 30mg qpm
MVI
iron 65mg 1-2x per day
Glucosamine 1000 mg 1-2x/day
Lutein 6 mg 1-2x/day
Fish oil 1000 mg 1-2x/day
COQ-10 50 mg 1-2x/day
Acidophilus 2 caps daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Left hip fracture
Lung collapse
Pneumonia
Clostridium difficile colitis
Acute renal failure
Congestive heart failure
Type II Diabetes
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"584.5",
"V45.02",
"250.00",
"486",
"820.21",
"995.92",
"008.45",
"V10.46",
"519.19",
"E885.9",
"585.3",
"V58.65",
"E912",
"786.3",
"403.91",
"934.1",
"V45.81",
"560.1",
"038.9",
"518.0",
"714.0",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"33.24",
"79.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14156, 14165
|
10238, 13610
|
234, 399
|
14342, 14351
|
5026, 7381
|
14403, 14409
|
4383, 4446
|
14128, 14133
|
7418, 7520
|
14186, 14321
|
13636, 14105
|
14375, 14380
|
4461, 5007
|
177, 196
|
7549, 10215
|
427, 3614
|
3636, 4164
|
4180, 4367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,650
| 129,521
|
15554
|
Discharge summary
|
report
|
Admission Date: [**2123-8-3**] Discharge Date: [**2123-8-6**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female with a past medical history of hypertension,
hypercholesterolemia, and chronic renal insufficiency who was
in her usual state of health until [**2123-7-31**] when
she was admitted to [**Hospital 26200**] Hospital where she ruled
in for a myocardial infarction and was transferred to [**Hospital1 1444**] for cardiac catheterization,
who is now in the Coronary Care Unit after a large groin
bleed secondary to sheath difficulties.
The patient was in her usual state of health until [**2123-7-31**] when she presented to [**Hospital 26200**] Hospital with
7/10 substernal chest pain at rest with radiation to her left
arm and jaw. The pressure was not associated with nausea,
vomiting, shortness of breath, or diaphoresis.
At [**Hospital 26200**] Hospital, the patient was given
nitroglycerin, morphine, Lopressor, and aspirin with a
decrease in her blood pressure from 210/110 to 150/80. The
patient was started on a heparin drip and nitroglycerin drip,
and her enzymes peaked at a creatine kinase of 107, with a MB
fraction of 6.5, and a troponin of 1.7. The patient was
started 2B3A inhibitor.
On hospital day two, the patient was found to have a
decreased hematocrit from 35 to 27.5, as the patient
developed a large groin hematoma of her left upper extremity.
The patient was transfused 2 units of packed red blood cells
and was continued on anticoagulation. Of note, the patient's
partial thromboplastin time was greater than 250 at this
time.
Upon transfer to the [**Hospital1 69**],
the patient remained chest pain free. A cardiac
catheterization on the day of admission revealed a first
diagonal lesion with 90% stenosis, now status post
percutaneous transluminal coronary angioplasty.
The patient's post catheterization course was complicated by
the patient sitting up after the procedure with the falling
out of her femoral sheath. The patient had developed a right
inguinal hematoma. The patient was given Fentanyl for the
pain and was noted to have a brief period of hypotension with
a systolic blood pressure to the 50s and required transient
dopamine which was weaned prior to coming to the Coronary
Care Unit. The patient was then admitted to the Coronary
Care Unit for observation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Mitral valve prolapse.
4. She had a Zenker diverticulum; status post repair times
two.
5. Status post total abdominal hysterectomy.
MEDICATIONS ON TRANSFER: Lipitor 10 mg p.o. q.d., labetalol,
Excedrin, Vioxx, Ativan, and Prilosec.
ALLERGIES: There were no known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 620**] with her calico
cat. The patient is a retired librarian. The patient denies
tobacco and denies any alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on revealed the patient was afebrile with a blood pressure of
112/66, heart rate was 99 and regular, respiratory rate was
18, and oxygen saturation was 95% on 2 liters nasal cannula.
In general, the patient was resting comfortably in bed
supine. Her Head, eyes, ears, nose, and throat examination
revealed pupils were equal, round, and reactive to light.
Extraocular movements were intact. Mucous membranes were
moist. Her chest examination revealed clear to auscultation
bilaterally. Cardiovascular examination revealed normal
first heart sound and second heart sound. A regular rate and
rhythm. There was no third heart sound or fourth heart
sound. No murmurs, rubs, or gallops. Her abdomen was soft,
nontender, and nondistended. Normal active bowel sounds. Of
note, she had a large ecchymosis of her left arm and a right
thigh hematoma with a pressure dressing. Extremity
examination revealed no clubbing, no cyanosis, no edema.
Dorsalis pedis pulses were 2+ bilaterally. Her neurologic
examination revealed she was alert and oriented times three.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
from outside hospital revealed a Chemistry-7 which was within
normal limits with the exception of a creatinine of 1.1.
Hematocrit on admission was 38. INR was 1.3 and partial
thromboplastin time was 43.3. The patient had a peak
creatine kinase at the outside hospital of 137 and a troponin
of 1.7.
RADIOLOGY/IMAGING: Catheterization at [**Hospital1 190**] showed a right-dominant system. The left main
was normal. The left anterior descending artery with diffuse
narrowing proximally, mid lesion with up to 50% stenosis, a
90% occlusion of first diagonal. The left circumflex with
minimal irregularities and right coronary artery with minimal
irregularities. Intervention was percutaneous transluminal
coronary angioplasty.
Electrocardiogram on admission in the Coronary Care Unit
revealed a normal sinus rhythm at 87, with normal axis and
normal intervals. T wave inversions in leads I and aVL, V2
and V3. 1-mm ST depressions in V2 and V3.
Electrocardiogram status post cardiac catheterization
revealed a normal sinus rhythm at a rate of 91, normal axis
and normal intervals. T wave inversions in leads I, aVL, and
V2. 1-mm ST depressions in II, III, aVL, and V2 through V6.
Electrocardiogram at the outside hospital on [**8-1**] was
notable for a normal sinus rhythm at 84, normal axis and
normal intervals. T waves in leads in I, aVL, and V1 through
V6 with no ST changes.
IMPRESSION: The patient is an 83-year-old woman with cardiac
risk factors of hypertension and high cholesterol who
presented to an outside hospital with chest discomfort and
electrocardiogram changes.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was
transferred to [**Hospital1 69**] for
cardiac catheterization and is now status post
catheterization with percutaneous transluminal coronary
angioplasty of her first diagonal. The catheterization was
complicated by a right groin hematoma secondary to traumatic
loss of groin sheath.
The hospital course at the outside hospital was also notable
for a left arm hematoma in the setting of a supratherapeutic
partial thromboplastin time.
1. CARDIOVASCULAR SYSTEM: (a) Coronary artery disease:
The patient is status post percutaneous transluminal coronary
angioplasty to first diagonal. The patient was started on
Lopressor and captopril. Plavix, Integrilin, and heparin
were all held secondary to bleed. The patient was also
continued on a statin.
Her creatine kinases continued to trend downward throughout
her admission, and there were changes in her
electrocardiogram.
The patient was called out of the Coronary Care Unit on
hospital day two and was followed by the C-MED Service and
continued to do well and was discharged on hospital day
three.
(b) Pump: The patient had an ejection fraction of 55%
estimated from her left ventriculography. The patient was
continued on Lopressor and an ACE inhibitor and was titrated
up throughout her hospital stay as necessary.
(c) Rhythm: The patient was in a normal sinus rhythm.
There were no rhythm issues throughout this hospital stay.
2. HEMATOMA ISSUES: The patient was status post a large
right groin bleed. The patient had serial hematocrit checks,
and her hematocrit remained stable throughout her hospital
stay, and she required no transfusion of packed red blood
cells. Anticoagulation was held secondary to this issue.
3. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's
creatinine decreased to 0.9 at the time of discharge, and
there were no active issues.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post percutaneous transluminal coronary
angioplasty.
3. Right groin hematoma.
4. Gastroesophageal reflux disease.
5. Chronic renal insufficiency.
6. Hypercholesterolemia.
7. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Lipitor 10 mg p.o. q.d.
2. Atenolol 50 mg p.o. b.i.d.
3. Lisinopril 5 mg p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Prilosec 40 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**Last Name (STitle) 121**] at [**Hospital 26200**] Hospital.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 7944**]
MEDQUIST36
D: [**2123-12-21**] 20:27
T: [**2123-12-25**] 02:55
JOB#: [**Job Number 45022**]
|
[
"401.9",
"530.81",
"272.0",
"593.9",
"424.0",
"414.01",
"410.71",
"998.12",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.20",
"36.01",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
7684, 7918
|
7944, 8092
|
8126, 8536
|
5702, 7564
|
7579, 7663
|
114, 2362
|
2593, 2718
|
2384, 2567
|
2735, 5667
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,918
| 172,025
|
966
|
Discharge summary
|
report
|
Admission Date: [**2135-5-19**] Discharge Date: [**2135-5-26**]
Date of Birth: [**2083-7-12**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Percocet / Percodan / Celebrex
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
resection
History of Present Illness:
Patient is a 51 year old female with multiple medical problems
who presented to the [**Hospital1 18**] [**Name (NI) **] [**2135-5-18**] complaining of worsening
abdominal pain over the previous 36 hours. She described the
pain as sharp, constant and radiating to back and chest. She
also was naseauted and had bilious emesis for the last 24 hours.
No diarrhea.
Past Medical History:
pud/gerd
asthma
cad/cabg x 2
aortobifem [**2126**]
a/p c-sect [**2110**]
depression
s/p ccy and vent hernia repair [**2133**]
Social History:
lives with 24 yo daughter, + tob (35 pack years), occ etoh, no
drugs, works as clerk
Family History:
father died mi age 51, mother died lung cancer at 79
4 brothers with dm
Physical Exam:
97.1 96 168/58 18 99% RA
appears uncomfortable
tachy regular
lungs clear
abdomen soft, diffusely tender, with increase pain and focal
guarding in RUQ
rectal exam- heme negative with no masses
palpable femoral artery
palpable DP & PT bilaterally
Pertinent Results:
[**2135-5-18**] 02:50PM PLT COUNT-222
[**2135-5-18**] 02:50PM NEUTS-81.3* LYMPHS-15.0* MONOS-2.6 EOS-0.7
BASOS-0.4
[**2135-5-18**] 02:50PM WBC-15.2*# RBC-4.96 HGB-15.1 HCT-43.9 MCV-89
MCH-30.5 MCHC-34.5 RDW-13.2
[**2135-5-18**] 02:50PM ALT(SGPT)-19 AST(SGOT)-17 CK(CPK)-41 ALK
PHOS-99 AMYLASE-61 TOT BILI-0.3
[**2135-5-18**] 02:50PM ALT(SGPT)-19 AST(SGOT)-17 CK(CPK)-41 ALK
PHOS-99 AMYLASE-61 TOT BILI-0.3
[**2135-5-18**] CT: Pneumatosis intestinalis of the distal ileum and
thickening of
the tip of the cecum with associated portal venous and
mesenteric venous air
Brief Hospital Course:
Patient was evaluated by the surgical service the day of
presentation and then was emergently taken to the operating
room. Please see operative report for details. Post operatively,
patient was transferred to the SICU intubated and continued
emperic antibiotics. Cardiac echo was negative for source of
emboli. Patient was successfully extubated POD 1. Patient was
transferred to the floor POD 4. Diet was advanced slowly as
bowel function returned. Physical therapy was consulted and
followed patient through hospital course. Patient also started
coumadin on [**2134-5-23**] for history of atrial fibrillation and
possible embolic etiology of bowel ischemia. Patient was
discharged home on POD 7 tolerating general diet, ambulating
independently and pain controled on oral pain medication.
Patient was given perscription for coumadin and given
instructions to have coags drawn [**2135-5-27**]. Hospital course and
coumadin therapy was discussed with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6431**] prior to
discharge.
Medications on Admission:
advair
lipitor
ASA
norvasc
sublingual nitro PRN
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: do not take more than 4
grams of acetaminophen per day.
Disp:*50 Tablet(s)* Refills:*0*
2. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a
day: take the evening of [**5-26**] and then as instructed by nurse [**First Name (Titles) **] [**Hospital 6432**] [**Name Initial (PRE) **].
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
mesenteric ischemia of the ileum and right colon
atrial fibrillation
diabetes
peripheral vascular disease
coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Call doctor or go to emergency department for fever, chills,
naseau, vomiting, increase in redness or discharge from
incision.
[**Month (only) 116**] shower, no soaking incision in tub.
Resume prehospital medications and diet.
Followup Instructions:
Patient to call and make appointment to be seen in Dr.[**Name (NI) 6433**]
office [**6-14**].
Patient to have coags drawn [**Last Name (LF) 6434**], [**6-27**] and [**Hospital 6435**]
clinic. [**Doctor Last Name **],[**Month (only) 6436**] ([**Month (only) **]) 617
|
[
"V45.81",
"443.9",
"250.00",
"557.1",
"427.31",
"414.00",
"567.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.93",
"45.73",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
3542, 3548
|
1953, 2993
|
325, 337
|
3722, 3728
|
1351, 1930
|
4003, 4275
|
996, 1070
|
3091, 3519
|
3569, 3701
|
3019, 3068
|
3752, 3980
|
1085, 1332
|
271, 287
|
365, 727
|
749, 877
|
893, 980
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,580
| 193,887
|
6611
|
Discharge summary
|
report
|
Admission Date: [**2129-11-26**] Discharge Date: [**2129-12-28**]
Date of Birth: [**2077-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy
Internal Jugular Central line placement bilaterally
History of Present Illness:
52 y.o. male with morbid obesity, type II diabetes, obstructive
sleep apnea and CHF who contact[**Name (NI) **] his PCP this morning to say
that he was not feeling well. At that time he mentioned feeling
increasingly short of breath for approximately 3 days with
generalized malaise. It is unclear whether he was requiring
increased oxygen. At baseline he uses 2-5 L NC and is
prescribed CPAP but is non-compliant. His PCP called an
ambulance to transport him to the ED. Of note the patient was
recently admitted to the MICU on [**2129-11-12**] when he presented with
hypoxia (80% on RA) and required BIPAP. At that time it was
thought that his hypoxia was secondary to his obesity related
lung disease. He was extremely aggitated secondary to his
hypercarbia and signed himself out of the ICU AMA after only a
few hours.
.
In the ED his vitals were temp 99.4, HR 88, BP 138/88, RR 36
with an O2 sat of 88% on RA. He was noted to be extremely
aggitated and had difficulty responding to questions. He denied
chest pain, fevers, chills, cough, sputum production or
increasing oxygen requirement. He reported pain in abdomen but
was unable to describe the pain further and points to a site
beneath his panus. He denies nausea, vomiting, diarrhea, BRBPR.
He denied any dysuria or increased urinary frequency. He did
report increasing "shakiness" which worsened with his worsening
respiratory status. In the ED he received one dose of ativan
0.5 mg and was placed on BIPAP with an FiO2 of 0.5, pressure
support of 15 and a PEEP of 5.
.
On arrival to the ICU patient was increasingly aggiated and his
O2 sats were in the low 90s on BIPAP with 100% FiO2. Shortly on
arrival the patient desatted to the low 80s requiring emergent
intubation. ABG taken shortly prior to intubation was pH 7.07,
PCO2 141, O2 122.
Past Medical History:
Past Medical History:
1. Morbid obesity.
2. Hypertension.
3. Obstructive sleep apnea on CPAP 12 with 2 liters of
supplemental O2 (not currently using). On 5L nC at home.
4. Insulin-dependent diabetes (Followed at [**Last Name (un) **]. Seen by an
ophthalmologist once a year. He has not seen a podiatrist in
over two years. [**4-21**]: Hemoglobin A1c 8.6, urine albumin to
creatinine 31.6).
5. CHF (EF indeterminate on most recent Echo).
6. Polycythemia.
7. ? h/o COPD (he has never had pulmonary function testing).
8. Degenerative disc disease.
9. Diabetic neuropathy.
10. Venous stasis/leg ulcers.
11. Right knee with torn cartilage (?meniscal injury).
12. History of left hip pain status post fall one year ago using
Lidoderm patches.
13. Hyperlipidemia (Last cholesterol [**4-21**]: TC 157, TG 238, HDL
45, LDL 76)
.
Past Surgical History:
1. Status post splenectomy secondary to motor vehicle accident
(he is unclear of his vaccination status, he is not sure when he
last received the Pneumovax).
2. Status post vascular repair of his right groin (details
unclear).
Social History:
He is married, but is estranged from his wife. [**Name (NI) **] works
part-time for a property management company. He walks with a
cane at baseline He denies current tobacco use. He smoked
briefly for 2 years, however quit over 10 years ago. He drinks
EtOH occasionally. He has never been a heavy drinker. He denies
illicit drug use.
Family History:
Family History: His mother has hypertension. His father died
from complications of diabetes and hypertension. He did not have
coronary artery disease. He has four brothers, all which are
healthy. He has 2 boys aged 21 and 27, both healthy. His uncle
is status post heart transplant (details unknown).
Physical Exam:
VS T: 98.4 P 101 BP: 138/88 RR 25 O2Sat 94% on BIPAP w/Pressure
Support of 15 with a PEEP of 5 and FiO2 100%
GENERAL: Aggitated, confused, oriented to self, hospital
HEENT: PERRL, EOMI, oropharynx clear
Neck: Neck supple, unable to assess JVP secondary to body
habitus
Pulmonary: Distant breath sounds, no wheezes, rales, ronchi
appreciated
Cardiac: RRR, distant, no murmurs appreciated
Abdomen: obese, erythematous lower panus, complains of
tenderness but
Extremities: WWP, 2+ pulses, chronic venous stasis changes
bilaterally, 1+ edema bilaterally, no clubbing or cyanosis
Neurologic: + asterixis, otherwise non-focal
Pertinent Results:
Labs:
[**2129-11-26**] 07:48PM BLOOD WBC-13.0* RBC-6.33* Hgb-18.4* Hct-58.7*
MCV-93 MCH-29.1 MCHC-31.4 RDW-15.7* Plt Ct-266
[**2129-11-29**] 03:48AM BLOOD WBC-10.9 RBC-5.58 Hgb-15.7 Hct-49.1
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.0* Plt Ct-264
[**2129-12-2**] 03:50AM BLOOD WBC-12.6* RBC-5.15 Hgb-14.9 Hct-45.4
MCV-88 MCH-28.9 MCHC-32.7 RDW-16.1* Plt Ct-249
[**2129-12-5**] 04:23AM BLOOD WBC-11.3* RBC-4.76 Hgb-13.7* Hct-41.8
MCV-88 MCH-28.8 MCHC-32.8 RDW-15.9* Plt Ct-297
[**2129-12-8**] 03:00AM BLOOD WBC-17.0* RBC-4.75 Hgb-13.7* Hct-41.8
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.7* Plt Ct-365
[**2129-12-11**] 03:01AM BLOOD WBC-14.7* RBC-4.66 Hgb-13.5* Hct-40.8
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.9* Plt Ct-521*
[**2129-12-14**] 04:00AM BLOOD WBC-15.5* RBC-4.78 Hgb-13.4* Hct-41.5
MCV-87 MCH-28.1 MCHC-32.4 RDW-16.1* Plt Ct-534*
[**2129-12-15**] 04:36PM BLOOD Hct-41.0
[**2129-12-18**] 04:10AM BLOOD WBC-17.0* RBC-4.72 Hgb-13.5* Hct-41.4
MCV-88 MCH-28.5 MCHC-32.5 RDW-16.0* Plt Ct-430
[**2129-12-20**] 04:15PM BLOOD Hct-40.1
[**2129-12-22**] 06:53PM BLOOD Hct-37.8*
[**2129-12-25**] 03:32AM BLOOD WBC-16.8* RBC-4.70 Hgb-13.6* Hct-40.9
MCV-87 MCH-28.9 MCHC-33.3 RDW-16.1* Plt Ct-342
[**2129-12-27**] 03:27AM BLOOD WBC-16.2* RBC-4.71 Hgb-13.6* Hct-40.0
MCV-85 MCH-28.9 MCHC-34.0 RDW-16.0* Plt Ct-420
[**2129-11-26**] 07:48PM BLOOD Plt Smr-NORMAL Plt Ct-266
[**2129-11-30**] 03:20AM BLOOD Plt Ct-239
[**2129-12-6**] 02:27AM BLOOD Plt Ct-309
[**2129-12-11**] 03:01AM BLOOD Plt Ct-521*
[**2129-12-16**] 02:46AM BLOOD Plt Ct-438
[**2129-12-22**] 02:30AM BLOOD Plt Ct-345
[**2129-11-26**] 07:48PM BLOOD Glucose-159* UreaN-18 Creat-0.9 Na-141
K-5.2* Cl-100 HCO3-31 AnGap-15
[**2129-11-30**] 03:20AM BLOOD Glucose-158* UreaN-32* Creat-1.9* Na-137
K-4.7 Cl-97 HCO3-32 AnGap-13
[**2129-12-2**] 03:50AM BLOOD Glucose-123* UreaN-56* Creat-2.8* Na-134
K-4.6 Cl-98 HCO3-27 AnGap-14
[**2129-12-4**] 04:50AM BLOOD Glucose-208* UreaN-75* Creat-3.1* Na-137
K-5.4* Cl-101 HCO3-25 AnGap-16
[**2129-12-6**] 05:53PM BLOOD Glucose-132* UreaN-59* Creat-2.2* Na-144
K-4.6 Cl-108 HCO3-25 AnGap-16
[**2129-12-9**] 03:01AM BLOOD Glucose-170* UreaN-47* Creat-1.8* Na-147*
K-4.8 Cl-111* HCO3-28 AnGap-13
[**2129-12-13**] 02:41AM BLOOD Glucose-135* UreaN-44* Creat-1.3* Na-144
K-4.5 Cl-107 HCO3-28 AnGap-14
[**2129-12-17**] 03:00AM BLOOD Glucose-171* UreaN-37* Creat-1.1 Na-142
K-4.9 Cl-104 HCO3-28 AnGap-15
[**2129-12-21**] 10:45AM BLOOD Glucose-142* UreaN-33* Creat-1.3* Na-139
K-4.1 Cl-99 HCO3-30 AnGap-14
[**2129-12-25**] 03:32AM BLOOD Glucose-126* UreaN-23* Creat-1.1 Na-138
K-4.4 Cl-98 HCO3-31 AnGap-13
[**2129-12-27**] 03:27AM BLOOD Glucose-149* UreaN-27* Creat-1.1 Na-140
K-4.2 Cl-100 HCO3-30 AnGap-14
[**2129-12-22**] 02:30AM BLOOD PTH-13*
[**2129-12-4**] 02:15PM BLOOD Cortsol-11.3
[**2129-12-4**] 02:56PM BLOOD Cortsol-30.5*
[**2129-12-4**] 03:27PM BLOOD Cortsol-35.4*
[**2129-11-26**] 11:34PM BLOOD freeCa-1.27
[**2129-12-10**] 02:12PM BLOOD freeCa-1.30
.
Micro:
[**2129-11-27**] 12:22 am URINE Source: Catheter.
**FINAL REPORT [**2129-11-29**]**
URINE CULTURE (Final [**2129-11-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
.
[**2129-12-14**] 5:12 pm Staph aureus Screen Source: Nasal swab.
**FINAL REPORT [**2129-12-17**]**
Staph aureus Screen (Final [**2129-12-17**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin sensitivity performed by agar screen.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
OXACILLIN------------- R
.
[**2129-12-17**] 4:20 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2129-12-22**]**
GRAM STAIN (Final [**2129-12-17**]):
[**11-9**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2129-12-22**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2429**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
STAPH AUREUS COAG +. 2ND TYPE. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2429**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ <=1 S <=1 S
.
.
Imaging:
CHEST (PORTABLE AP) [**2129-11-26**] 7:10 PM
FINDINGS: Study is markedly limited secondary to
underpenetration due to the patient's large body habitus.
Evaluation of the upper lungs show no gross evidence for focal
consolidation or overt pulmonary edema, however the films are
limited. The mediastinum is prominent, however, it is unchanged
since the [**2129-11-12**], study. There is a catheter overlying
the mediastinum that is likely external to the patient. Clinical
correlation is recommended.
.
CHEST (PORTABLE AP) [**2129-11-28**] 3:45 AM
FINDINGS: Upright plain radiograph of the chest. Appearance of
right internal jugular line and ET tube is unchanged in position
and appropriate. ET tube is approximately 4.4 cm from the tip to
the carina. The cardiac silhouette again demonstrates
obscuration by a large left-sided pleural effusion. Pulmonary
vascular congestion appears stable. Interval increased aeration
of the left lung is identified.
IMPRESSION: ET tube stable in position. Increased aeration of
the left lung with stable pulmonary vascular congestion and
left-sided pleural effusion.
.
PORTABLE ABDOMEN [**2129-12-7**] 3:17 PM
FINDINGS: A single portable supine radiograph of the right side
of the patient was obtained. There is a small staple seen in the
left lower quadrant of this film. Due to the poor quality of
this film further analysis cannot be made at this time.
IMPRESSION: Unable to evaluate for ileus secondary to extremely
limited study.
.
CHEST (PORTABLE AP) [**2129-12-9**] 11:37 AM
IMPRESSION:
1. New left lower lobe and partial left upper lobe atelectasis,
likely due to mucous plugging. These findings were discussed
with Dr [**Last Name (STitle) 25272**].
2. Mild-to-moderate pulmonary edema.
.
CHEST (PORTABLE AP) [**2129-12-14**] 5:19 PM
IMPRESSION: Left internal jugular vein central venous line has
been retracted to level of left brachiocephalic vein and should
be advanced. This was discussed with Dr. [**Last Name (STitle) **] by telephone at
time of interpretation.
Similar appearance of left lower lobe opacity, representing
atelectasis and/or consolidation. Left pleural effusion.
Similar appearance of pulmonary vascular congestion.
.
CHEST (PORTABLE AP) [**2129-12-20**] 7:14 AM
IMPRESSION: AP chest compared to [**12-12**] through [**12-15**]:
The technical quality of the examination is limited by patient
motion.
There has been substantial increase in caliber of multiple
vascular structures, particularly both hila and the superior
mediastinum suggesting an increase in pulmonary vascular
resistance. No edema is seen in the right lung. Severe
consolidation has progressed on the left accompanied by a
probable small left pleural effusion.
ET tube is in standard placement. Nasogastric tube can be traced
into the stomach and out of view. A left-sided central venous
catheter deviates from the expected course of the left
brachiocephalic vein and is presumably in a smaller tributary
such as the left internal mammary, or has become extra-
vascular.
.
PORTABLE ABDOMEN [**2129-12-22**] 1:26 PM
SINGLE FRONTAL ABDOMINAL RADIOGRAPH: Only the central portion of
the abdomen is included in the study. Two linear radiopaque
foreign bodies are seen overlying the right SI joint. The prior
studies have been of such poor quality that it is not clear
whether these are new or old. The bowel gas pattern is
nonspecific with air and stool seen in the visualized ascending
and transverse colons. No clear evidence of retained needle.
.
CHEST (PORTABLE AP) [**2129-12-23**] 11:50 PM
SUPINE PORTABLE AP CHEST: Comparison is made to [**2129-12-22**]. Tracheostomy tube remains in unchanged position. The
Dobbhoff tube appears to have been advanced slightly and is now
in the gastric fundus. Assessment of the remainder of the heart
and lungs is extremely limited by patient's size. There is
equivocal worsening of pulmonary vascular engorgement, which
could reflect fluid overload/CHF. Unchanged
collapse/consolidation in the left lower lobe.
IMPRESSION: Lines/tubes as above. Possible worsening fluid
overload/CHF. Extremely limited study.
.
CHEST (PORTABLE AP) [**2129-12-27**] 2:47 AM
IMPRESSION: AP chest compared to [**12-13**] through [**12-24**]:
Tracheostomy tube has a standard appearance. Feeding tube ends
in the upper stomach. Mild edema most easily assessed in the
right lung has improved since [**12-24**]. Cardiac silhouette is
still large. Widening of the mediastinum is probably a
combination of fat deposition and vascular engorgement. Lateral
aspect of the left lower costal pleural surface is excluded from
the examination. The other pleural margins are normal.
.
.
Brief Hospital Course:
Assessment: Mr. [**Known lastname 25267**] is a 52-year-old male with morbid obesity,
insulin-dependent diabetes, hypertension, obstructive sleep
apnea, and CHF who presents with increasing shortness of breath
for three days.
.
Plan:
# Hypercarbic respiratory failure: On presentation the patient
was experiencing increased respiratory distress and aggitation.
Initial ABG on arrival to the MICU revealed a pH of 7.07 with a
PCO2 of 141. It was thought that his respiratory failure was
most likely secondary to obesity related lung disease,
obstructive sleep apnea and subsequent CO2 retention. The
patient has never had formal pulmonary function testing and his
baseline pulmonary disease is thus not entirely clear. Shortly
after arrival to the MICU the patient quickly dropped his oxygen
saturation to the 80s and became cyanotic. He required emergent
intubation. CXR following intubation was suggestive of an
infilatrate. He was started on vancomycin and levofloxacin for
broad coverage for community acquired pneumonia. His sputum
ultimately revealed gram positive cocci in pairs and short
chains. On hospital day 4 the patient developed acute renal
failure and his urine showed trace positive urine eosinophils.
Given concern for possible AIN his levofloxacin was switched to
ceftriaxone and completed a ten day course of antibiotics. The
patient required prolonged ventilatory support and during the
midst of his stay acquired a MRSA pneumonia that remained
refractory to 24 days of vancomycin treatment. Thus, he was
started on Linezolid to complete a 14-day course. Given the
patients respiratory presentation, it was deemed appropriate
that the patient would benefit from a tracheostomy in order to
bypass any pharyngeal obstruction contributing to his
obstructive hypercapneia. The patient underwent this procedure
without complication. After this procedure, the patient was
Weaning from the vent was difficult as the patient required
large amounts of PEEP in order to avoid desaturation. After
institution of the trach, the patient was able to be weaned
slowly from the vent from Assist Control to Pressure Support
Ventilation. His sedation was also weaned from continuous
Fentanyl/Midazolam drip to bolus sedation with haldol. He also
has had a fentanyl patch placed for sedation wean. The patient
was arousable, but still mildly sedated.
.
#Fevers: The patient intermittent spiked fevers while in the
ICU, and initially it was thought to be due to his pneumonia.
His fevers were refractory to a prolonged course of vancomycin,
and was subsequently switched to Linezolid for better lung
penetration. Prior to this medication switch the patient
underwent a traumatic Dobhoff placement in which there was an
estimated blood loss of approximately 700 cc of blood. ENT
packed the right nare and there was damage to his nasal septum.
Given this insult, and the intermittent fevers, it is likely
that the patient may have an occult infection in his sinuses.
He was not scanned and it is appropriate that continued fevers
may warrant the addition of a penicillin containing antibiotic.
.
# Acute Renal Failure: On hospital day four the patient
developed acute renal failure with elevated creatinine and
decreased urine output. Urine electrolytes were consistent with
prerenal etiology. Urine eosinophils were trace positive. It
was thought that the most likely etiology was prerenal azotemia
secondary to high levels of ventilatory PEEP decreasing his
cardiac output. Given the trace urine eosinophils AIN was also
a consideration. His levofloxacin and proton pump inhibitor
were stopped for this reason. As the patient's pressure
improved, the creatinine decreased in urine output increased.
This picture makes ATN secondary to hypotension and increased
intraabdominal pressures likely. With decreased PEEP and
increased diuresis the patient's ARF resolved and his Cr was at
baseline upon admission.
.
# Diabetes: The patient is a known insulin dependent diabetic.
Given his labile blood sugars [**Last Name (un) **] was consulted and he was
placed on an insulin drip to allow calculation of his basal
insulin requirement and control of FS while critically ill.
Upon cessation of the insulin drip, his insulin requirements
were adjusted as [**Last Name (un) 8337**] & his final dosing of Lantus upon
discharge was 75 lantus [**Hospital1 **], with additional coverage by a
Humulog Sliding scale.
.
# Hypertension: Home doses of antihypertensives were held on
admission. As his hemodynamics [**Hospital1 8337**] he was restarted on
captopril with good effect. He required no other
anti-hypertensives prior to admission.
.
# Hyperlipidemia: Continued his home dose of lipitor.
.
# CHF: Last echo unable to determine ejection fraction. Normal
BNP, no evidence of exacerbation on chest xray. He was diuresed
with lasix 20IV daily to [**Hospital1 **]; he still has evidence of CHF on
XRay.
.
# Prophylaxis: Heparin SC, H2 Blocker, Bowel Regimen including
intermittent dosing of PO narcan to counteract colonic slowing
due to opiate dosing.
.
# FEN: Tube feeds, IVF boluses to maintain urine output, monitor
electrolytes and replete as needed.
.
# Access: R PICC
.
# Code Status: Full Code
Medications on Admission:
Advair 250-50 mcg/Dose--1 puff inh twice a day
Albuterol 90 mcg/Actuation--1 puff inh q6hours prn
Aspirin-81 81 mg--1 tablet(s) by mouth once a day
Atorvastatin 80 mg--1 tablet(s) by mouth at bedtime
Cialis 5 mg--1 tablet(s) by mouth prn
Furosemide 40 mg--1 tablet(s) by mouth twice a day
Glipizide 10 mg--1 tablet(s) by mouth once a day
Humalog 100 unit/mL--50 units qac
Lantus 100 unit/mL--40 units at bedtime
Lidoderm 5 %(700 mg/patch)--apply to affected area q12hours prn
as needed for pain
Lisinopril 40 mg--1 tablet(s) by mouth once a day
Oxygen (2-5 L at baseline, CPAP for sleep)
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 1.5 Injection
TID (3 times a day).
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed for constipation.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal infection.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-17**] Sprays Nasal
TID (3 times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
16. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Ten (10)
ML PO TID (3 times a day).
17. insulin sliding scale
See attached sliding scale
18. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): please replace on [**12-28**] then
begin weaning by 25mcg each patch change.
19. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] prn for 3 days: Please use for Right nare bleeding.
20. Naloxone 1 mg/mL Syringe Sig: One (1) Injection TID (3
times a day) as needed for constipation for 3 days.
21. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
22. Famotidine in Normal Saline 20 mg/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours).
23. Haloperidol 3-5 mg IV Q4H:PRN agitation
24. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day) as needed for constipation.
25. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
26. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: Hypercarbic Respiratory Failure s/p
tracheostomy
.
Secondary Diagnoses:
1. Morbid obesity.
2. Hypertension.
3. Obstructive sleep apnea on CPAP 12 with 2 liters of
supplemental O2 (not currently using). On 5L nC at home.
4. Insulin-dependent diabetes (Followed at [**Last Name (un) **]. Seen by an
ophthalmologist once a year. He has not seen a podiatrist in
over two years. [**4-21**]: Hemoglobin A1c 8.6, urine albumin to
creatinine 31.6).
5. CHF (EF indeterminate on most recent Echo).
6. Polycythemia.
7. ? h/o COPD (he has never had pulmonary function testing).
8. Degenerative disc disease.
9. Diabetic neuropathy.
10. Venous stasis/leg ulcers.
11. Right knee with torn cartilage (?meniscal injury).
12. History of left hip pain status post fall one year ago using
Lidoderm patches.
13. Hyperlipidemia (Last cholesterol [**4-21**]: TC 157, TG 238, HDL
45, LDL 76)
Discharge Condition:
Afebrile, sedated, tolerating TFs
Discharge Instructions:
1. Please wean sedation with fentanyl patch and haldol as
needed.
2. Please return to the ED if the patient has any concerning
symptoms including, difficulty breathing or refractory fevers.
3. If the patient becomes febrile, there is likely an infection
within his sinuses that could be covered with Augmentin.
4. If there is bleeding from the right nare, please use Afrin
[**Hospital1 **] for 3 days.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2130-2-23**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2130-2-23**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] / DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2130-2-23**] 2:30
|
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"933.1",
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"999.9",
"784.7",
"357.2",
"599.0",
"276.7",
"518.84",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"33.23",
"21.01",
"43.11",
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"93.90",
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"96.6",
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icd9pcs
|
[
[
[]
]
] |
23770, 23836
|
15498, 20715
|
336, 414
|
24768, 24804
|
4682, 15475
|
25254, 25683
|
3739, 4026
|
21355, 23747
|
23857, 23857
|
20741, 21332
|
24828, 25231
|
3126, 3354
|
4041, 4663
|
23948, 24747
|
277, 298
|
442, 2260
|
23876, 23927
|
2304, 3103
|
3370, 3707
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,597
| 154,807
|
11707
|
Discharge summary
|
report
|
Admission Date: [**2147-12-22**] Discharge Date: [**2147-12-27**]
Date of Birth: [**2083-10-25**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 64 yaer old male
with a history of alcohol abuse, who was admitted with massive
upper gastrointestinal bleed, hypothermia and right-sided
aspiration pneumonitis versus pneumonia.
Mr. [**Known lastname 37048**] was found down, with his face, body and surroundings
covered in coffee- ground emesis. Liquor bottles were found
nearby. Emergency medical technicians were called.
Upon arrival of the emergency medical technicians, the patient
appeared cold within any evidence of bruises and with reactive
pupils. His initial blood pressure was noted to be 150/70, heart
rate 60, respiratory rate 8 to 10 per minute and oxygen
saturation 92% in room air. A large amount of fluid was
suctioned from his airway and the patient was found to be
lethargic but arousable. He was intubated in the field for
airway protection after being sedated with Versed and paralyzed
with succinylcholine. His fingerstick at the time was 106.
In the Emergency Room, the patient's vital signs remained stable.
His temperature was noted to be 34 degrees Celsius. Therefore, he
was given four liters of warm normal saline, warm blankets, and a
bear hugger. Repeat temperature within two hours was 34.7
degrees Celsius. Nasogastric suction was performed in the
Emergency Room, which revealed 1,400 cc of coffee-grounds, after
which the resulting fluid clear. There was no bright red blood.
The nasogastric lavage cleared after 450 cc of normal saline.
PAST MEDICAL HISTORY: 1. Coronary artery disease, status
post history of MI x2 per patient. 2. Noninsulin dependent
diabetes mellitus. 3. Hypercholesterolemia. 4. Depression. 5.
Alcohol abuse.
MEDICATIONS ON ADMISSION: The patient reports no medications
as an outpatient, however, discussion [**Street Address(1) 37049**] reveals
that the patient was taking Zoloft 50 mg p.o.q.d., Lipitor 40 mg
p.o.q.d. and an unknown hypertensive medication.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient reports three packs of cigarettes
smoked per day for an unknown quantity of time. The patient is
unable to clarify the current amount of alcohol used, but has a
history of alcohol abuse. He is homeless and has five brothers
who live in the nearby area, who also have significant alcohol
use.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 95 degrees, heart rate 70,
blood pressure 130/70, respiratory rate 16 and oxygen
saturation 99% on assist control with an FiO2 of 100%,
respiratory rate 16, tidal volume 650, PEEP 5.
Cardiovascular: Regular rate and rhythm, no murmur, rub or
gallop. Pulmonary: Good ventilation bilaterally, vesicular
breath sounds, right lower lobe crackles. Abdomen:
Nontender, mildly distended, positive bowel sounds, no
hepatosplenomegaly, question of ascites but no fluid wave.
Rectal: Occult blood negative. Neck: Supple, no
lymphadenopathy, no bruits. Head, eyes, ears, nose and
throat: Pupils equal, round, and reactive to light and
accommodation, no bruises, anicteric sclerae, moist mucous
membranes. Extremities: No edema, nontender, no clubbing,
bilateral palmar erythema, 2+ pulses times four. Skin:
General plethora, no spider angioma, no caput medusa.
Neurologic: Sedated, normal tone, moves all four
extremities, withdraws to pain, symmetric reflexes.
LABORATORY DATA: Admission white blood cell count was 12.9,
hematocrit 42.7, platelet count 280,000, differential with
79.6 polycytes, 16.2 lymphocytes and 2.8 monocytes, sodium
138, potassium 4.3, chloride 101, bicarbonate 24, BUN 30,
creatinine 1.6 and glucose 154. Toxicology screen was
positive for aspirin, positive for benzodiazepines, alcohol
422. Arterial blood gases: 7.22/58/310 on an FiO2 of 100%.
Electrocardiogram: Normal sinus rhythm, normal axis, normal
QRS, T wave inversions in V3, AVF and flat in V2, high J
point.
Chest x-ray: Patchy alveolar infiltrates in the right lung, no
effusion, no congestive heart failure, no cardiomegaly,
endotracheal tube at the carina level.
Head CT scan: No intracranial bleed, no skull or bone fractures,
presence of an old infarction in the right corona radiata.
HOSPITAL COURSE: The patient is a 64 year old male with a
history of alcohol abuse, who was admitted with massive coffee-
ground emesis, hypothermia, right-sided aspiration and mild acute
renal failure.
1. Gastrointestinal: The patient was noted to have a massive
coffee-ground emesis at the time of admission, with 1,400 cc of
coffee-grounds removed during nasogastric lavage, which cleared
after 450 cc of normal saline. There was felt to be a low
likelihood of variceal bleed or [**Doctor First Name **]-[**Doctor Last Name **] tear given the
absence of bright red blood.
The patient was given nothing by mouth and treated with
intravenous fluids. He was treated with intravenous Protonix
and two large bore intravenous lines were maintained at all
times. A gastroenterology consult was obtained, who recommended
an endoscopy. Endoscopy demonstrated grade III esophagitis in
the lower third of the esophagus and gastritis, but was an
otherwise normal esophagogastroduodenoscopy. The patient
tolerated the procedure without difficulty.
The patient's hematocrit remained stable throughout the course of
the hospital stay and he was felt to have no significant further
upper gastrointestinal bleeding. A Helicobacter pylori antibody
test was still pending at the time of discharge.
The patient was known to have a history of alcohol abuse, but his
initial liver function tests were found to be within normal
limits. Therefore, there was no further workup of liver
pathology. However, the patient was noted to have an elevated
amylase and lipase at the time of admission, which decreased over
the first few hospital days.
At the time of transfer from the Medical Intensive Care Unit
back to the floor, however, the patient was noted to have an
increase in his amylase and lipase to as high as 103. At this
point in time, the patient was complaining of mild abdominal
pain, however, he was able to tolerate clear liquids without any
difficulty.
The patient was treated with intravenous fluid hydration and
was kept on clears as tolerated. The patient will require
management of his pancreatitis over the next few days, with
evaluation for the need to make the patient nothing by mouth
as well as intravenous fluid hydration and pain management.
2. Pulmonary: The patient was intubated for airway
protection in the field and was thought to have secondary cold
induced bronchorrhea given the large amount of secretions
produced during the first few days in the Medical Intensive Care
Unit.
The patient was followed in the Intensive Care Unit with serial
arterial blood gases, which demonstrated appropriate oxygenation
and ventilation. He was extubated on Intensive Care Unit day
number two, which he tolerated without difficulty.
The patient's initial chest x-ray suggested a right lower lobe
consolidation consistent with aspiration pneumonia versus
pneumonitis. The patient was started on levofloxacin and
clindamycin to treat a possible aspiration pneumonia. A follow-
up chest x-ray in three days demonstrated improvement in the
lower lobe consolidation.
The patient was titrated on his oxygen as tolerated to maintain
oxygen saturations above 94%. At the time of this discharge
summary, the patient was still requiring completion of his
antibiotic therapy for aspiration pneumonia. He was 94% on room
air.
3. Cardiovascular: The patient was found to be hemodynamically
stable at the time of admission. There was no evidence for
congestive heart failure, however, he was followed closely during
his hydration. Aspirin and beta blockers were held given that
the patient presented with an upper gastrointestinal bleed.
Given the changes on the patient's electrocardiogram, and the
lack of a baseline, a CK/MB and troponin were checked, which were
found to be within normal limits. The patient responded well to
intravenous hydration and remained relatively stable during his
Medical Intensive Care Unit stay, with one episode of
hypotension, that responded well to approximately four hours of
Dopamine therapy. At the time of this discharge summary, the
patient has remained hemodynamically stable, without need of
pressors, for approximately 72 hours.
The patient has a history of hypertension as [**Street Address(1) 37050**] Inn
report, but his antihypertensive medication is unknown at this
time. The patient has had relatively normal blood pressures over
the course of the hospitalization. He may follow up for further
management of his hypertension [**Street Address(1) 29735**] Inn.
4. Renal: At the time of admission, the patient demonstrated
mild renal insufficiency, which was thought likely secondary to a
prerenal etiology of dehydration. He was treated with fluid
hydration, to which his creatinine responded quickly. The
patient maintained adequate urine output and had no further renal
issues over the course of the hospital stay.
5. Infectious disease: The patient was noted to have an
increased white blood cell count as well as a low temperature at
the time of admission. This was thought most likely secondary to
an aspiration pneumonia and the patient was started on
levofloxacin and clindamycin to cover for this infection. In
addition, the patient was pancultured, however urine cultures nor
blood cultures grew any specific bacteria. The patient responded
well to his antibiotic therapy, with a return of his white blood
cell count to normal limits and a return of a normal temperature.
The patient will complete a course of oral antibiotics.
6. Hematologic: The patient had a mildly low hematocrit at
the time of admission, thought secondary to his gastrointestinal
bleed. His hematocrit was followed twice a day over the first
few hospital days, with a plan to transfuse for a hematocrit less
than 30. The patient required transfusion of one unit of packed
red blood cells during his hospital stay. At the time of
discharge, the patient remained hemodynamically stable for well
over 72 hours.
7. Neurologic: The patient was found to be lethargic in the
field, however, his neurological examination was nonfocal and
a head CT scan obtained at the time of admission was negative.
His mental status changes were thought secondary to hypothermia
and alcohol intoxication. The patient was started on a CIWA
scale with Ativan, which did not seem to adequately control his
agitation. Therefore, he was switched to Valium.
At the time of transfer from the Medical Intensive Care Unit to
the floor, the patient was once again put on a CIWA scale using
Ativan, which adequately controlled his alcohol withdrawal.
8. Endocrine: A TSH was checked during this admission, which
was found to be within normal limits. The patient was thought to
have a history of noninsulin dependent diabetes mellitus per
discussion [**Street Address(1) 37049**] health care workers. The patient was
put on fingersticks four times a day and started on a regular
insulin sliding scale.
9. Fluids, electrolytes and nutrition: The patient was on
nothing by mouth at the time of admission, and his diet was
advanced as tolerated. When his amylase and lipase came back
elevated on [**2147-12-26**], suggesting development of a
pancreatitis, the patient was switched back to nothing by
mouth and then advanced to clears, which he tolerated without
difficulty. His electrolytes were followed on a daily basis and
repleted as needed. The patient was also started on MVI, folate
and thiamine supplementation.
10. Code status: The patient is full code.
DISCHARGE MEDICATIONS:
Protonix 40 mg p.o.b.i.d.
Thiamine 100 mg p.o.q.d.
Folate 1 mg p.o.q.d.
Multivitamin one p.o.q.d.
Lipitor 40 mg p.o.q.d.
Zoloft 50 mg p.o.q.d.
Albuterol meter dose inhaler two puffs q.4h.p.r.n.
Regular insulin sliding scale with fingersticks q.i.d.
Tylenol 650 mg p.o.q.6h.p.r.n.
Ativan 2 mg per CIWA scale.
CONDITION AT DISCHARGE: The patient was discharged in stable
condition.
FOLLOW-UP: The patient is to follow up at [**Street Address(1) 5904**] Clinic
and with his regular doctor.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2147-12-26**] 17:35
T: [**2147-12-26**] 17:35
JOB#: [**Job Number 37051**]
cc:[**Hospital 37052**]
|
[
"401.9",
"305.01",
"578.9",
"276.5",
"507.0",
"577.0",
"285.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11872, 12191
|
1850, 2130
|
4354, 11849
|
2476, 4336
|
12206, 12617
|
172, 1622
|
1645, 1823
|
2147, 2453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,542
| 190,725
|
3492
|
Discharge summary
|
report
|
Admission Date: [**2142-1-5**] Discharge Date: [**2142-1-8**]
Date of Birth: [**2066-6-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aldactone
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
75 yo F with h/o chronic GI bleed thought [**1-4**] small bowel
angiodysplasia requiring serial transfusions over several
months, cirrhosis with grade II varices, diastolic dysfunction,
COPD on home oxygen, DM admitted to ICU with hypotension after
paracentesis.
.
Patient underwent ultrasound guided paracentesis on [**2142-1-5**] and
had 5.3L fluid removed. Her starting HCt was 23.1 and she
recieved 1u PRBC prior to paracentesis. Her initial blood
pressure was 197/97. She was doing well until she went to the
bathroom 4 hour post tap when she suddenly became diaphoretic,
nauseaous and acutely dropped her blood pressure to 95/40 for
about 30 minutes. Her oxygenation remain stable at 98-99% on 3L
and her HR also remained stable at 80-90, T 96.9. SHe complained
of abdominal pain at that time which was relieved by bowel
movement. She denies chest pain/pressure/dizziness. She denies
diarrhea/vomiting/other blood loss within the past several
days.She had stat Hct, CXR and KUB. SHe was given another unit
of blood and fluid through 18gauge needle and her blood pressure
stabilized. Her Hct post 1u transfusion is 27. Her blood
pressure stabilized to 110s-140s. BS was 104. Pt was then
transfered to the MICU for observation. While in the MICU, Pt
remained stable received 4 units of packed RBCs with HCT
subsequently stablizing- currently 34. In addition, Pt has been
hypoglycemic and decision was made to hold her glyburide-
otherwise MICU course was uneventful.
.
On ROS, she reveals that she had not been sleeping well for the
past few days due to orthopnea. She claims that she has been
taking her lasix. She has been using her home 3L oxygen almost
all night for the past few nights. She denies ever having chest
pain. She denies cough/sputum/abdominal
pain/nausea/vomitng/urinary problems/dizziness/headahce in the
recent past.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 yo F with h/o chronic GI bleed thought [**1-4**] small bowel
angiodysplasia requiring serial transfusions over several
months, cirrhosis with grade II varices, diastolic dysfunction,
COPD on home oxygen, DM admitted to ICU with hypotension after
paracentesis.
.
Patient underwent ultrasound guided paracentesis on [**2142-1-5**] and
had 5.3L fluid removed. Her starting HCt was 23.1 and she
recieved 1u PRBC prior to paracentesis. Her initial blood
pressure was 197/97. She was doing well until she went to the
bathroom 4 hour post tap when she suddenly became diaphoretic,
nauseaous and acutely dropped her blood pressure to 95/40 for
about 30 minutes. Her oxygenation remain stable at 98-99% on 3L
and her HR also remained stable at 80-90, T 96.9. SHe complained
of abdominal pain at that time which was relieved by bowel
movement. She denies chest pain/pressure/dizziness. She denies
diarrhea/vomiting/other blood loss within the past several
days.She had stat Hct, CXR and KUB. SHe was given another unit
of blood and fluid through 18gauge needle and her blood pressure
stabilized. Her Hct post 1u transfusion is 27. Her blood
pressure stabilized to 110s-140s. BS was 104. Pt was then
transfered to the MICU for observation. While in the MICU, Pt
remained stable received 4 units of packed RBCs with HCT
subsequently stablizing- currently 34. In addition, Pt has been
hypoglycemic and decision was made to hold her glyburide-
otherwise MICU course was uneventful.
.
On ROS, she reveals that she had not been sleeping well for the
past few days due to orthopnea. She claims that she has been
taking her lasix. She has been using her home 3L oxygen almost
all night for the past few nights. She denies ever having chest
pain. She denies cough/sputum/abdominal
pain/nausea/vomitng/urinary problems/dizziness/headahce in the
recent past.
Past Medical History:
PMH:
1. Gastrointestinal bleed with chronic anemia. History of
extensive colonic diverticuli found on colonoscopy in [**2136**].
Multiple upper gastrointestinal AVMs detected on enteroscopy
and treated with electrocautery in [**2139-1-31**].
2. Congestive heart failure with diastolic dysfunction
diagnosed in [**2139-11-2**]. TTE in [**2139-11-2**]
revealed ejection fraction of greater then or equal to 55%
with 1+ mitral regurgitation and no wall motion
abnormalities. TTE on [**2141-2-27**] showed normal ventricular
thickness and function (LVEF>55%)
3. Portal hypertension.
3. Chronic obstructive pulmonary disease.
4. Diabetes type 2, 25 year history.
5. Hypertension.
6. Hypercholesterolemia.
7. Breast cancer status post right lumpectomy, chemotherapy
and radiation therapy.
8. Hypothyroidism
Social History:
Lives in [**Location 686**] with two adult children. Former head start
administrator. 20 pack year history, quit 4 years ago. No EtOH
or recent drug use. Of note, one of her daughters was murdered
15 years ago, and her adult son died of a drug overdose
recently.
Family History:
CAD
No fam h/o GI bleeding.
Physical Exam:
PHSICAL EXAMINATION
Tmax: TC: BP:157/53 P:93 RR:18 SaO2: xxx 3L
Gen- looks tired, but in no acute distress
HEENT- anicteric, EOMI, PERRLA, oral mucosa moist, neck supple,
no JVD
CV- distant heard sounds, ? ectopy, normal S1, S2, +S3, +S4, no
murmurs or rubs.
resp- decreased breath sounds throughout without crackles, no
accessory muscle use, slightly dyspneic.
abdomen- very distended, active bowel sounds, + fluid wave, +
tympany, no tenderness.
neuro- alert and oriented x3, CNII-XII intact, move all 4
extremity symmetrically.
extemity- 1+ pitting edema to ankles.
Pertinent Results:
[**2142-1-5**] 11:43PM HCT-34.7*#
[**2142-1-5**] 02:30PM GLUCOSE-138* UREA N-35* CREAT-1.5* SODIUM-142
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
[**2142-1-5**] 02:30PM CK(CPK)-68
[**2142-1-5**] 02:30PM CK-MB-NotDone cTropnT-<0.01
[**2142-1-5**] 02:10PM WBC-4.4 RBC-3.30* HGB-9.0* HCT-27.2* MCV-83
MCH-27.4 MCHC-33.1 RDW-16.5*
[**2142-1-5**] 02:10PM PLT COUNT-250
[**2142-1-5**] 10:00AM ASCITES WBC-335* RBC-325* POLYS-2* LYMPHS-7*
MONOS-0 MESOTHELI-1* MACROPHAG-90*
[**2142-1-5**] 07:40AM UREA N-34* CREAT-1.3* SODIUM-142
POTASSIUM-4.5
[**2142-1-5**] 07:40AM WBC-5.4 RBC-2.69* HGB-8.1* HCT-23.1* MCV-86
MCH-29.9 MCHC-34.8 RDW-16.3*
[**2142-1-5**] 07:40AM NEUTS-77.9* LYMPHS-9.8* MONOS-5.5 EOS-5.2*
BASOS-1.7
[**2142-1-5**] 07:40AM ANISOCYT-1+ MICROCYT-1+
[**2142-1-5**] 07:40AM PLT COUNT-202
Brief Hospital Course:
1. hypotension: currently resolved but may be due to a number of
reasons. Likely hypoglycemia in the setting of stress and liver
disease given diaphoresis and consistently low blood sugars
while in the unit; in addition there is likely a vasovagal
component as the pt had a peritoneal tap 4 hrs before
hypotensive episode with likely fluid shift and redistribution.
Patient also has known history of GIB, however, HCT is
responsive to transfusion of packed red blood cells. Sepsis
could also cause this picture but UA and blood cultures negative
so far. Pt has no ischemic EKG changes. No acute respiratory
changes to suggest PE. Pt's response to fluid resuscitation
while in the unit suggests relative hypovolemia/decreased tone.
Pt was transferred to the floor and remained clinically stable
without hypotension.
2. hypoglycemia- Pt's finger sticks were found to be in the 50s
and 60s while in the unit. She respond to glucose infusions and
have improved with resolution of hypotension. Concern for
hypoglycemia prompted the medical team to hold Glyburide while
on the floor. Her blood glucose has since improved and patient
will be discharged home on lower dose of Glyburide- 5 mgpoqd.
.
3. leukocytosis- pt likely has underlying chronic infection
given COPD- in addition underlying atelectasis and stress
response may explain transient leukocytosis. Leucocytosis has
since resolved.
.
4. diastolic dysfunction: Pt's medications were continued while
on the floor- Lasix, diltiazem, lisinopril, Metoprolol,
Atorvastatin
.
5. vaginal itch- pt complained or vaginal itch without
discharge. Likely candidal given underlying DM and was given
miconazole 2% powder. She experienced relief and will be
discharged to home with this prescription.
.
6. hypertension- BP relatively well controlled while in house
and was continued on diltiazem, lisinopril and metoprolol except
during hypotensive episode- when these medications were held.
.
7. angiodysplasia- Pt with HX of GI bleeds. Sandostatin was and
iron was continued while in the hospital.
.
8. cirrhosis with grade 2 varices- Patient underwent peritoneal
dialysis while in the hospital and experienced and episode of
hypotension and hypoglycemia- see above. Cirrhosis was
otherwise stable.
.
9. CRI(Cr 1.3-1.9)- Patient has chronic renal insufficiency and
because of this, medications were renally dosed. Her creatinine
remained stable at 1.3-1.5 despite episode of hypotension.
.
10. COPD- patient has COPD at baseline. Her COPD remain
clinically stable on 3L of oxygen and home regiment of
nebulizers.
.
11. diabetes- patient with persistent hypoglycemia in unit which
stabilized while on the floor. Glyburide held while on the
floor because of hypoglycemia while in the unit.
.
12. hypothyroidism- patient has baseline hypothyroidism and she
was continued Levoxyl
Medications on Admission:
phoslo
diltiazem 300mg QD
Levoxyl 0.075mg QD
calcitriol 0.25mg QD
lasix 40mg QD
protonix 40mg QD
lipitor 10mg QD
glyburide 10mg QAM, 5mg QPM
lisinopril 10mg QD
lorazepam 0.5mg Q12h
iron
sandostatin
albuterol
serevent
flovent
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
2. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12 () as
needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
12. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*1 Disk with Device(s)* Refills:*2*
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Disp:*1 1* Refills:*0*
15. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
Disp:*60 60* Refills:*2*
16. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnoses:
Transient hypotension, s/p paracentesis likely [**1-4**] fluid shifts
Hypoglycemia
Secondary diagnoses:
Chronic GIB [**1-4**] angiodysplasia
CHF
COPD
Cirrhosis
DM2
HTN
Hyperlipid
Hypothyroid
Laryngeal ca s/p xrt
Basal cell ca
Discharge Condition:
Good.
Stable. BP in 140-170 systolic.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Continue to take your medications. Your diabetes medication,
glyburide will be decreased, since your blood sugars in the
hospital were low.
Call your doctor or return to the emergency room if you develop
fevers, chills, nausea, vomiting, lightheadedness, chest pain,
difficulty breathing, or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care doctor:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7479**], MD Phone:[**Telephone/Fax (1) 7477**]
Date/Time:[**2142-1-22**] 9:00
Please follow up with your liver doctor:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2142-2-21**] 1:00
Completed by:[**2142-1-8**]
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|
4848, 5113
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Discharge summary
|
report
|
Admission Date: [**2190-1-25**] Discharge Date: [**2190-3-17**]
Date of Birth: [**2156-10-9**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache/SAH w/IVH
Major Surgical or Invasive Procedure:
[**2190-1-25**] EVD placement
[**2190-1-25**] Angiogram with coiling of R vertebral artery aneurysm
Mutliple bonchoscopies
[**2190-2-19**] TRACHEOSTOMY
[**2190-3-4**] PEG
midline placment right upper extremity
History of Present Illness:
33M who reports he had not been feeling well for the last few
days- c/o sore throat, minor headache, coughing. He then reports
that he experiencing the worse headache of his life this
morning,
went to lay down, had nausea then vomitted. Patient believes he
had +LOC prior to his mother finding him and calling EMS. He was
initially brought to [**Hospital1 **] and a Head CT showed extensive
SAH
w/IVH extension into the third and fourth ventricle.
Past Medical History:
HTN
Social History:
Single, lives with parents, denies tobacco, denies ETOH, denies
recreational drugs. Works out regularly.
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 3
[**Doctor Last Name **]: 4
GCS E: 3 V: 5 Motor: 6 = 14
O: T: 97.5 BP: 121/75 HR: 63 R 18 O2Sats 100% RA
Gen: WD/WN, lethargic, c/o pain.
HEENT: normocephalic
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: lethargic, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-27**] throughout. No pronator drift
Sensation: Intact to light touch
CT Head:
Extensive SAH along the sylvian fissure and cisterns, IVH
extension into the third and fourth ventricles, ventriclomegaly
noted.
ON DISCHARGE
He awakens easily or is found with eyes open spontaneously. He
makes eye contact with the examiner and follows commands. He is
oriented x [**2-25**]. He frequently gets the yr wrong but knows it is
winter when told it is [**Month (only) **]. Pupils are equal and reactive
/ he has a CN VI palsy on the right. EOM are otherwise intact.
No obvious facial asymmetry. He MAE and is antigravity. His
RLE is antigrvity but is recovering from motor weakness from
frontal infarcts appreciated on MRI. He discerns Right from
left and his naming is intact. He attempts to phonate with
passy muir valve. All of his incisions are well healed.
Pertinent Results:
CT HEAD W/O CONTRAST [**2190-1-25**]
1. Diffuse increase in subarachnoid hemorrhage concerning for
re-bleed or
continued subarachnoid hemorrhage. There has been interval
accumulation of
hemorrhage within the lateral ventricles bilaterally.
2. Interval placement of external ventricular drain with the tip
adjacent to the third ventricle. There has been some
decompression of the right lateral ventricle; however, the body
and anterior [**Doctor Last Name 534**] of the left ventricle appear increased in
size.
3. Diffuse unchanged cerebral edema.
CT HEAD W/O CONTRAST [**2190-1-25**]:
1. Interval vertebral artery coiling with stable appearance of
diffuse
subarachnoid and intraventricular hemorrhage.
2. There is stable effacement of the sulci diffusely with a
stable appearance of an external ventricular drain.
3. Interval increase in size of subgaleal hematoma in the region
of drain
placement.
4. There is no infarction noted.
ECHO [**2190-1-26**]:
The left atrium is normal in size. 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%). There
may be focal mid septal hypoknesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a
trivial/physiologic pericardial effusion.
HEAD CT W/O CONTRAST [**2190-1-26**]:
1. Status post right vertebral artery coiling, with diffuse
subarachnoid
hemorrhage and sulcal effacement as before. No increased
bleeding seen.
2. Intraventricular hemorrhage redemonstrated, with decreased
hydrocephalus compared to 13 hours prior. Unchanged position of
right intraventricular drainage catheter.
3. Hypodense areas now seen in left cerebellum may represent
developing areas of infarction.
HEAD CT W/O CONTRAST [**2190-1-26**]:
1. Further extension or redistribution of intraventricular
hemorrhage, now
filling the majority of the lateral ventricles, more markedly on
the left, as well as a crescentic area of acute hemorrhage
within the fourth ventricle.
2. Evolving left cerebellar hemispheric infarction.
3. Stable appearance of EVD.
4. Interval increase in the diffuse subarachnoid hemorrhage.
CT HEAD W/O CONTRAST [**2190-1-27**]:
1. Slightly decreased intraventricular hemorrhage.
2. Unchanged diffuse subarachnoid hemorrhage.
3. Stable cerebral edema and effacement of the basal cisterns
consistent with herniation, unchanged from most recent studies.
4. Evolving left cerebellar hemispheric and vermian infarction,
with no
definite new infarct.
EEG [**2190-1-28**]:
IMPRESSION: This EEG shows a fairly repetitive alternating
pattern
between what looks like a mild diffuse encephalopathy to more
significant slowing perhaps related to the intermittent use of
medication although it may also represent a combination of
increased
intracranial pressure and/or projected abnormalities. No clear
focal
epileptiform or sustained epileptiform discharges were
identified
although, on the trends analysis, there does appear to be
slightly more
right hemisphere abnormality than left.
CTA/P [**2190-1-28**]:
1. Unchanged non-contrast head CT showing residual diffuse
subarachnoid
hemorrhage, intraventricular hemorrhage, diffuse cerebral edema,
effacement of the basal cisterns consistent with herniation, and
evolving left cerebellar hemispheric and vermian infarction. No
new large vascular territory infarction or new hemorrhage seen.
2. CT perfusion with suggested decreased perfusion in the medial
left
cerebellar hemisphere, also consistent with infarction.
3. Status post coiling of left vertebral artery aneurysmal
dissection, with no contrast filling the visualized distal most
right vertebral artery.
4. Other major intracranial arteries including left PICA are
patent, however, due to streak artifact from the adjacent coils,
left PICA cannot be further characterized. Otherwise no definite
evidence of vasospasm.
CT Head [**2190-1-28**]:
IMPRESSION: Stable positioning of right frontal EVD with no new
intracranial hemorrhage, and no mass effect.
[**2190-1-29**]: MRI neck: CONCLUSION: Minor C5-6 disc protrusion. Left
cerebellar infarction.
[**2190-1-29**]: MRI brain: CONCLUSION: Multiple areas of evolving
infarction, including the cerebellum.
[**2190-1-31**]: IMPRESSION:
1. Unchanged appearance of diffuse subarachnoid hemorrhage.
2. Ventriculostomy catheter in right foramen of [**Last Name (un) 2044**], with
minimal decrease in biventricular hemorrhage.
ADDENDUM AT ATTENDING REVIEW: As noted in the body of this
report, there is continued evidence for the left cerebellar
infarct, without overt sign for increasing mass effect. A small
amount of hemorrhage also appears
redemonstrated approximating the medial margin of the thalamus
on the right side of the third ventricle.
[**2190-2-1**]: LE LENI's: IMPRESSION: No deep venous thrombosis in
right or left lower extremity.
[**2190-2-2**]: CT Brain/Perfusion: IMPRESSION:
1. Diffuse severe vasospasm worsened compared with the prior CTA
performed
[**2189-1-28**].
2. Slight decrease in the conspicuity of the diffuse
subarachnoid hemorrhage compared with the study on [**2190-1-31**]; stable intraventricular hemorrhage and the medial right
thalamic hemorrhage; no new intracranial hemorrhage is
demonstrated.
3. The ventriculostomy catheter is unchanged in position. The
ventricles are stable in size.
4. The CT perfusion demonstrates continued diminished blood
volume within the right occipital [**Doctor Last Name 352**] matter infarction
consistent with evolution. No new areas of abnormal perfusion
are demonstrated.
[**2190-2-5**]: CTA-IMPRESSION:
1. Slight decrease in subarachnoid and intraventricular
hemorrhage.
2. No vascular occlusion.
3. Persistent small caliber in anterior/posterior circulations
appears
unchanged.
[**2190-2-5**]: CT Torso-IMPRESSION:
1. Bilateral consolidations predominantly involving lower lobes,
with
moderate debris within the right main bronchus extending into
bronchus
intermedius and right lower bronchus. These findings suggest
aspiration,
likely with superimposed infection. Suggest endobronchial
suctioning or
bronchoscopy/suctioning to help clear this debris.
2. There are additional dependent patchy ground-glass opacities
bilaterally
in the other lobes, which may be infectious or inflammatory in
nature.
3. Increased main pulmonary artery diameter measuring 4 cm,
which may be
reflective of pulmonary hypertension.
4. Small pericardial effusion.
4. A 1.9 x 1.9 cm round hypodense lesion within the right upper
abdomen,
which may be hepatic or adrenal in origin. This lesion is not
fully
characterized on current exam. Further evaluation with MR
recommended on
non-emergent basis.
[**2190-2-11**] CTA chest
FINDINGS: The heart is normal in size. The pulmonary arteries
opacify
normally without evidence of filling defect to suggest pulmonary
embolism. The aorta opacifies normally without evidence of
dissection. The main pulmonary artery is enlarged measuring 3.8
cm in diameter. There is no mediastinal or hilar
lymphadenopathy. A central venous catheter is noted within the
SVC, but the tip is not identified secondary to dense contrast
material. Secretions are noted around the endotracheal tube
which terminates 5 cm above the carina. An NG tube is noted in
the esophagus terminating below the diaphragm. There is no
pericardial effusion. The tracheobronchial tree is patent to
level of the subsegmental bronchi bilaterally.
Again noted are bibasilar consolidations and worsening
ground-glass opacities with superimposed intralobular septal
thickening, consistent with a crazy paving appearance,
predominately affecting the bilateral upper lobes and right
middle lobe anteriorly. New small bilateral pleural effusions
are identified.
No bony lesions suspicious for malignancy are noted.
Although the study was not designed for subdiaphragmatic
evaluation, no
abnormalities are noted within the visualized upper abdomen.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Interval worsening of bibasilar consolidations and
ground-glass opacities with interlobular septal thickening
consistent with a crazy-paving appearance noted diffusely
throughout both lungs with new small bilateral pleural
effusions. Differential diagnosis includes ARDS, pneumonia,
hemorrhage, or aspiration. Clinical correlation is recommended.
3. Enlargement of the main pulmonary artery measuring 3.8 cm
which may
reflect pulmonary artery hypertension.
[**2190-2-15**] CXR
FINDINGS: In comparison with study of [**2-14**], there is little
change. Diffuse bilateral pulmonary opacifications again could
be consistent with widespread pneumonia, ARDS, or pulmonary
vascular congestion. Bilateral pleural effusions with
compressive atelectasis persist. Monitoring and support devices
remain in place.
[**2190-2-21**] CT Chest:
1. Overall slight improvement in the degree of consolidation,
especially in the upper lobes, with several areas now
demonstrating a more ground-glass appearance. However, in the
dependent region of the right upper lobe, there has been
progression from ground-glass opacity to a more consolidative
appearance which raises concern for infection, likely
superimposed on a background of ARDS.
2. Slight increase in the right-sided pleural effusion, stable
left-sided
pleural effusion.
3. Small pericardial effusion.
4. Indeterminate nodule in the right adrenal region is unchanged
since CT
torso of [**2190-2-5**].
ECHO [**2190-2-25**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 75%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are mildly thickened. The mitral valve
leaflets are elongated. There is borderline/mild posterior
leaflet mitral valve prolapse. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2190-1-26**], the findings are similar.
LENIS [**2190-2-27**]:
IMPRESSION: No evidence of DVT in either lower extremity.
CTA Head [**2190-2-28**]:
IMPRESSION:
1. No evidence of acute hemorrhage or ischemia.
2. Stable appearance of postoperative changes related to right
vertebral
artery coiling. Anterior circulation vessels appear normal in
caliber. The
basilar artery remains small in size.
3. Stable appearance of left cerebellar hypodensity
corresponding to left
PICA territorial infarct.
MRI Abdomen [**2190-3-12**]:
FINDINGS:
The lesion of interest corresponds to a 1.7 x 2.4-cm round
lesion in the right adrenal gland demonstrating significant loss
of signal on out-of-phase images (2:4), diagnostic of adrenal
adenoma. The left adrenal is unremarkable.
The exam is not tailored to assess the rest of the abdominal
organs, however, visualized liver, gallbladder, kidneys, spleen,
and pancreas are unremarkable.
IMPRESSION:
2.4-cm right adrenal adenoma.
CXR [**2190-3-13**]:
IMPRESSION: AP chest compared to [**3-7**] through 17:
Right lower lobe pneumonia has decreased over the past several
days, although it is stable since [**3-11**]. Left lung grossly
clear. Heart size normal. No pleural effusion. Tracheostomy tube
in standard placement.
Brief Hospital Course:
33 y/o M s/p WHO presents to ED. Head CT shows SAH with IV
extension. A CTA was ordered . Within an hour of initial
examination patient became more lethargic and was intubated.
Post-intubation, patient went into Vfib and had agonal
breathing, and was resuctitated. Patient was then noted to have
a narrow complex rhythm, intervention cardiology was called to
the ER but no intervention was indicated at that time. An EVD
was placed emergently for obstructive hydrocephalus in the ER
and patient was taken immediately to CT Head and angiogram where
his R vertebral artery aneurysm was coiled. The CTA was
cancelled given patient's clinical picture and was taken
directly to angiogram for intervention. Post-angio his Head CT
was stable, patient required frequent EVD flushes.
On [**1-26**]: Head CT was done which showed a a possible left
cerebellar infarct. Stroke neurology was consulted along with
cardiology for his cardiac arrest. Echocardiogram was done which
did not show any concern. TPA was used to flush EVD x 1 during
daytime. Patient was then placed on paralytics as he was
overbreathing the vent and had abnormal ABGs. A Heparin drip was
initiated post-angio. Overnight, he developed hypertension to
190s with elevated ICPs which were thought to be secondary to a
clot in the EVD. EVD flushed and TPA'd which did not help and a
Nicardipine drip was initiated to bring down his pressure with
no effect. He was then sent to head CT emergently to reassess
given his clinical picture and inability to get good exam due to
paralysis. His CT head showed increased IVH and worsening SAH so
the Heparin drip was turned off.
On [**1-27**]: During the early morning, patient became hypertensive
and tachycardic to 140s, then dropped blood pressures to
50s-70s. An ABG showed profound respiratory acidosis, pads were
placed in preparation for cardioversion. TV and RR increased to
blow off CO2, neo started for hypotension. With resolution of
respiratory acidosis, his HR decreased and BP stabilized. Neo
was quickly weaned off. During the day time he remained on
paralytics. He received a Dilantin 500 mg bolus for level of
7.4.
He remained stable throughtout the day.
On [**1-28**]: Repeat CTA/P was stable and showed interval decrease in
SAH and IVH. Paralytics were weaned off by the afternoon. Once
off paralytics the patient was following commands but no
movement to his [**Month/Day (4) **] were noted. In the evening, his EVD catheter
became disconnected, the RN immediately clamped the catheter and
Neurosurgery was called. The catheter was sterilly cut and
reattached. A head CT was done to ensure there was no
displacement of the catheter, the CT head showed no change in
position.
On [**1-29**]: His exam remained stable, but there remained to be no
movement to his [**Last Name (LF) **], [**First Name3 (LF) **] MRI Cspine was added to his MRI Brain.
The MRI of the brain showed multiple areas of infarct including
the cerebellum. The C-Spine MRI showed minor C5-6 disc
protrusion but no significant abnormalities.
On [**1-30**]: He was stable in the mornign and early afternoon however
in the evening he developed tachycardia to the 150's, and was
febrile to 104. The SICU team was unable to lower his
temperature or adequately control his hemodynamic status so he
was paralyzed and placed on the arctic sun cooling system.
Overnight into [**1-31**] his heart rate elevated to the 170's, he was
hypertensive to the 220's, and he was placed on a labetolol
drip. A CT scan of the head was obtained which was stable and
his fevers and hemodynamic status was broguht under control. He
was also started empirically on covereage for VAP.
On [**1-31**] into [**2-1**] patient developed respiratory distress and high
fevers and was placed back on the arctic sun and subsequently
needed to be paralyzed to control his shivering. His Chest xray
revealed a right lower and left lobe consolidation. His
Vancomycin level was found to be 3.3. His dose was increased.
He was sent for a CTA to r/o vasospasm and evolving strokes.
[**2-2**] CTA revealed moderate to severe basilar artery spasm,
patient was subsequently taken for a formal angiogram which
showed basilar vasosparm. In the setting of worsening PNA
without ET secreations, the ICU team performed a Bronchoscopy.
His antibiotics were changed to provide double coverage for GNR
to Cefepime and Cipro.
[**2-3**] CVP was 11 and was requiring fluid boluses to maintain
blood pressure goals (SBP 180-200). ICP's started elevating into
the 20's therefore the EVD was decreased to 15cmH20.
[**2-4**] patient continued to be febrile, paralyzed and sedated.
antibiotics were changed to flagyl per ICU recommendations. CSF
was sent for gram stain and culture. Patient was also requiring
boluses of neosenephrine after nimodipine was given.
[**2-5**] CTA head was ordered to evaluate status of vasospasm.
Hypertonic saline was started for Na of 129. A CT Torso was
requested to rule out infectious process due to the patient's
continued febrile state. He wbc peaked at approximately 42.
He was started on bromocriptine for control of neuroleptic
malignant syndrome. Ultimately his wbc came down and fevers
improved - his arctic sun was removed. He was started on
presedex and bronch'd again for secretions. He was extubated on
[**2-9**] and an EVD clamping trial was initiated. His hct was noted
to drop and stool guiacs were negative. He has a history of
ulcer and this was thought to be a potential cause. Gastric
lavage was negative for heme.
On the evening of the 19th patient developed respiratory
distress, became hypoxic and was re-intubated. An attempt was
made to diurese him without much improvement at which point he
was placed on a rotarest bed and sedated. His EVD was
discontinued after recieveing some platelets on the morning of
the 21st.
Neurologically he continued to improve however he is requiring
high peeps for ventilation. His Na level continued to drop and
he was restarted on 3%NS.
On [**2-16**], TCDs were done and NA levels were increased to 139,
3%NS was discontinued. On [**2-17**], ventilation wean was attempted,
but failed. He continues to be intubated with high PEEP. Exam
remained the same off sedation, he opens his eyes and follows
simple commands. Moves all extremities spontaneously except for
RLE. He is alert to self with yes/no questioning. His NA
continues to be within normal values.
On [**2-19**] he was s/p a trach. On [**2-20**] he had increased UOP
200-300 hr. He was unable to tolerate CPAP, placed back on CMV.
Stopped fludrocortisone as salt/K wasting, will allow him to
autoregulate. On [**2-21**] UOP began to slow down, serum NA/OSM and
urine NA/OSM remained stable. On [**2-22**] he was stable but still
demanding some sedation. R thoracentesis was done and
bronchoscopy w/ b/l BAL.
On [**2-23**] an endocrine c/s was obtained for hypokalemia and
question of an adrenal mass on CT. His methadone was increased,
initiated standing ativan. Cipro was added for double coverage
of pseudomonas. On [**2-24**], all sedation was discontinued and pt
placed on dex gtt/fentanyl gtt/seroquel PO. Weaning vent to PSV.
Endocrine workup pending for hypokalemia.
Overnight [**Date range (1) 37495**], patient's sedatives were discontinued and
patient became very agitated and restless. He was given multiple
different drugs without effect. He was started on Profolol and
Fentanyl. His morning EKG showed an increase in his QTc interval
and his Triglycerides were elevated. His profolol was
discontinued and patient was noted to be more agitated and
restless. A MICU consult was called.
On [**3-16**] patient was restarted on propofol and fentanyl drips
for his agitation, as an adjunct Zyprexa was started witn a
gradual increase daily. A psychiatry consult was obtained on [**3-2**]
to obtain input for ICU delerium and magagement. We contact[**Name (NI) **]
the patient's sister to [**Name2 (NI) 90289**] PEG placement. A general
surgeon will call the family to discuss the risks and benefits
of the procedure. His sedative meds were weaned off and patient
was put on Haldol [**Hospital1 **] standing.
On [**3-21**] he remained stable, he was less agitated and
remained on CPAP. Changes were made to patien't tube feed given
multiple episodes of vomiting due to gastric distention. His
tube feeds were double concentrated and he tolerated that well.
on [**2097-3-10**] he tolerated TM for 24 hours and neurologically
looked very bright with eyes open and for the first time to this
examiner he moved his right lower leg spontanously. He was
transferred to the floor on [**3-13**] where he remained stable. He
was able to have a PMV placed and is verbal. [**Date range (1) 86566**] he
remained stable and tolerating a trach mask.
He was seen by speech and swallow on [**3-16**] and passed with gorund
and nectar thickened liquids. Spironolactone was added for
better BP control and lisinopril increased to 30 mg daily. He
is currently dispo'd to [**Hospital 38**] rehab.
Medications on Admission:
lisinopril 5mg QD
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-24**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dryness.
5. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig:
One (1) PO TID (3 times a day).
6. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
7. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for fevers.
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. potassium chloride 10 mEq Capsule, Extended Release Sig:
Three (3) Capsule, Extended Release PO BID (2 times a day).
14. lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. lisinopril 10 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
16. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
19. HydrALAzine 10 mg IV Q6H:PRN SBP>160
hold for HR>100
20. 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.
21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
22. therapeutic multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
23. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
24. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
25. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
26. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
27. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
28. potassium chloride 20 mEq Packet Sig: One (1) Packet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
R Vertebral artery aneurysm
R vertebral artery dissection
Cardiac arrest
Obstructive Hydrocephalus
L cerebellar infart
Acute Inferior MI with troponin leak
Acute severe respiratory alkalosis
Acute respiratory acidosis
VAP pneumonia
dysphagia
ARDS
ACUTE ANEMIA requiring transfusion
ACUTE Hyponatremia requiring hypertonic saline.
Neuroloptic malignant syndrome
Acute Hypokalemia
adrenal adenoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
Followup Instructions:
?????? Please follow up with Dr. [**First Name (STitle) **] in 3 Months, you will
not need any imaging at that time.
You were diagnosed with an andrenal adenoma on MRI imaging
during your hospital stay. You will need to follow up with your
primary care physician and [**Name9 (PRE) 90290**] for this. The
endocrinolgy team would like to see you in the [**Hospital **] clinic in
one month. Please call Dr. [**Last Name (STitle) **] for an appointment: [**Telephone/Fax (1) 2384**].
Completed by:[**2190-3-17**]
|
[
"E849.7",
"331.4",
"293.0",
"333.92",
"348.5",
"276.8",
"443.24",
"E939.3",
"996.63",
"434.91",
"410.41",
"997.31",
"V49.87",
"E878.8",
"430",
"790.01",
"427.41",
"427.5",
"276.4",
"401.9",
"253.6",
"435.9",
"227.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"02.2",
"38.91",
"38.97",
"96.6",
"33.21",
"31.1",
"88.41",
"96.72",
"39.72",
"33.29",
"33.24",
"33.23",
"43.11",
"34.91",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
26418, 26515
|
14764, 23763
|
326, 538
|
26954, 26954
|
3196, 14741
|
27422, 27943
|
1183, 1202
|
23831, 26395
|
26536, 26933
|
23789, 23808
|
27132, 27399
|
1232, 1495
|
267, 288
|
566, 1016
|
1741, 2382
|
2391, 3177
|
26969, 27108
|
1038, 1044
|
1060, 1167
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,975
| 192,431
|
12333+12334
|
Discharge summary
|
report+report
|
Admission Date: [**2149-2-6**] Discharge Date: [**2149-2-27**]
Date of Birth: [**2149-2-6**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby Girl [**Name2 (NI) 1105**] [**Known lastname 38330**] [**Known lastname **] is the
600 gram product of a 24 [**5-27**] week triplet gestation born on
[**2149-2-6**] to a 27 year-old G2 P1 now 4 mom.
PRENATAL SCREENS: Blood type O positive, RPR nonreactive,
rubella immune, hepatitis surface antigen negative, GBS
unknown.
This pregnancy was notable for pregnancy induced hypertension
requiring delivery secondary to worsening laboratories. This
is a spontaneous triplet gestation with triplet II and [**Year (4 digits) 1105**]
monochorionic monoamniotic. Triplet II noted prenatally to
be IUGR.
ANTEPARTUM HISTORY: Significant for C section secondary to
triplet gestation. Rupture of membranes at delivery for
clear fluid. Infant delivered with active cry, spontaneous
respirations and good heart rate. The infant was intubated
in the Delivery Room at approximately five minutes of age
without complications and transported to the Neonatal
Intensive Care Unit. Apgars were 8 and 9 at one and five
minutes respectively.
PHYSICAL EXAMINATION ON ADMISSION: Weight 600 grams placing
her in the 25th percentile, length was 30.5 cm placing her in
the 10th percentile and head circumference was 22.5 cm
placing her in the 10th to 25th percentile. Anterior
fontanel long and flat. EG tube in place. No nasal flaring.
Eyes opened slightly on right. Cardiovascular regular rate
and rhythm. No murmur. Well profuse. Lungs good aeration,
slight crackles. Abdomen soft and flat. Extremities moves
all extremities. Neurological appropriate for gestational
age with good tone. Skin pink with skin appropriate for 24
and [**5-27**] week gestation infant.
HOSPITAL COURSE: 1. Respiratory: The infant was initially
intubated in the Delivery Room, received two doses of
Surfactant for management of respiratory distress syndrome.
Her initial ventilation settings were 20/5 with a rate of 25
100% O2. Her max ventilator settings were on high frequency
ventilation with a mean airway pressure of 17 and a delta P
of 26 and 60%. These are her current settings as of [**2149-2-26**]. Arterial blood gases on current settings of 735 for
a pH PCO2 55, PO2 51, total CO2 32 and base excess of 2.
2. Cardiovascular: Initially was started on Dopamine
following normal saline bolus for borderline blood pressure.
Her max Dopamine was 11 micrograms per kilogram per minute.
She was treated with Indomethacin times two courses the first
within day of life number three to four, the second day of
life fourteen to fifteen. Most recent echocardiogram on
[**2-25**] demonstrated a large PDA with a 15 mm gradient
with left to right flow. In light of the respiratory
compromise and the failed trial of Indomethacin times two
courses, is planned for a PDA ligation at [**Hospital3 1810**]
on [**2149-2-27**].
3. Fluid and electrolytes: Birth weight was 600 grams.
Head circumference was 22.5. Length was 30.5. Initially was
started on 140 cc per kilo per day of D5W. Her max total
fluid intake was 190 cc per kilo per day to support
electrolyte needs and fluid losses. Parenteral nutrition on
day of life number one and continued on parenteral nutrition.
She is currently on protein 3.5 grams per kilo. Total fluids
are 120 cc per kilo per day based on a weight of 700 grams.
She is on PND 14 with a half unit of heparin. She is getting
3 meqs of sodium per 100 cc and 2 meqs of potassium per 100
cc with half unit of heparin per cc and maximum acetate. Her
most recent set of electrolytes were on [**2149-2-26**],
134, 2.8, 99. A PICC line was placed on [**2-23**]. It is
in central location. Trophic feeds were initially started on
day of life eighteen and were empirically stopped in light of
ductus arteriosus on [**2-25**].
4. Gastrointestinal: Her max bilirubin was 4.6/0.3. She
continues on phototherapy secondary to no enteral intake with
her most recent bili on [**2-26**] of 2.8/0.4.
5. Hematology: Blood type is B positive. She has received
a total of 7 packed red blood cells transfusions during her
hospital course with her most recent on [**2149-2-25**].
Her hematocrit is 31. She received 20 cc per kilo per day
with a Lasix chaser.
6. Infectious disease: She initially received 48 hours of
Ampicillin and Gentamycin for sepsis risk factors. CBC was
negative and blood cultures remained negative at 48 hours and
antibiotics were discontinued on the [**3-11**]. She
also received 48 hours of Vancomycin and Gentamycin with a
negative CBC and negative blood cultures at 48 hours.
Antibiotics were discontinued on [**2-17**]. She has had no
further issues with sepsis during this hospital course.
7. Neurological: Head ultrasound was performed on day of
life one, six and eleven, all within normal limits. She is
scheduled for a one month follow up.
8. Social: The family is invested and involved with these
infants. The babies are not named at this time secondary to
cultural reasons. Triplet II who is the identical twin to
this baby passed on day of life number seven. A social
worker has been involved with this family and can be reached
at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Guarded.
DISCHARGE DISPOSITION: To [**Hospital3 1810**]. Name of
primary pediatrician not identified.
DISCHARGE DIAGNOSES:
20 day old former 24 and [**5-27**] week gestation infant, moderate
to severe respiratory distress syndrome, patent ductus
arteriosus, rule out sepsis status post, hyperbilirubinemia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36462**] M.D. [**MD Number(1) 36463**]
Dictated By:[**Last Name (NamePattern1) 38444**]
MEDQUIST36
D: [**2149-2-26**] 16:05
T: [**2149-2-27**] 07:55
JOB#: [**Job Number 38445**]
Admission Date: [**2149-2-6**] Discharge Date: [**2149-7-7**]
Date of Birth: [**2149-2-6**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Name2 (NI) 38446**] [**Known lastname 38330**]-[**Known lastname **], triplet number 3,
admitted to the Special Care Nursery from Labor and Delivery for
management of prematurity.
Mother is a 27-year-old gravida II, para I now IV woman, with
spontaneous triplet gestation. Prenatal screens included
blood type O positive, antibody screen negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
2. Intrauterine growth restriction of triplet number two due
to twin-to-twin transfusion
3. Pregnancy-induced hypertension.
She completed a course of betamethasone prior to delivery.
Delivered by cesarean section for worsening pregnancy-induced
hypertension. This triplet emerged active, crying, with a
heart rate greater than 100, given CPAP then intubated around
five minutes of age due to extreme prematurity and
respiratory distress. Apgar scores were 8 and 9 at one and
five minutes respectively.
PHYSICAL EXAMINATION: On admission, weight 600 grams (25th
percentile), length 30.5 cm (10th percentile), head
circumference 22.5 cm (10 to 25th percentile). Active, pink
infant, anterior fontanel soft, flat, left eye fused, right
eye slightly open, no clefts. Breath sounds with good
aeration, slight crackles. Regular rate and rhythm without
murmur. Abdomen soft, nondistended, no hepatomegaly, no
masses. Moves extremities well. Spine intact, no dimple.
Neurologic: Appropriate for gestational age.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: Received two doses of Survanta following
admission for respiratory distress syndrome. Initial
ventilator support pressures 20/5, rate of 20, 25%. On day
of life eight, was changed to high-frequency oscillatory
ventilation due to increasing ventilator support and bloody
secretions. Maximum mean airway pressure 17. Changed to
conventional ventilation on day of life 34, with maximum
support pressures 28/6, rate of 36, around 30 to 40%. Weaned
to CPAP on day of life 84, then to nasal cannula on day of
life 92, to room air on day of life 144 ([**2149-6-30**]). Recent blood
gas on [**7-6**] had a pH of 7.37, PCO2 54, PO2 39.
Hospital course notable for persistence of right upper lobe
opacity with development of necrotizing staphylococcus aureus
pneumonia. A bronchoscopy was done x 2 for pulmonary toilet
due to staphylococcus aureus pneumonia. The right main stem
bronchus and segmental bronchi to the right lower, middle and
upper lobes were noted to be occluded with purulent
secretions. During the bronchoscopy, large mucous plugs and
pus were removed. The infant was given aerosolized
tobramycin and Pulmozyme during the procedure.
Started diuretic therapy with lasix then Diuril alone for
chronic lung disease on day of life 34. Remains on Diuril
therapy.
Received caffeine citrate from day of life 38 to day of life
52. Last bradycardia and desaturation was on [**2149-5-30**].
2. Cardiovascular: Was treated for hypotension following
delivery with normal saline bolus x 2, then dopamine
infusion. Received dopamine from day of life zero to day of
life four.
Treated with dopamine again following patent ductus
arteriosus ligation from day of life 22 to day of life 30.
Additionally treated with four stress doses of
hydrocortisone. Once again required dopamine infusion from
day of life 54 to day of life 70 due to staphylococcus aureus
sepsis pneumonia.
A patent ductus arteriosus was treated with two courses of
Indocin without closure, requiring patent ductus arteriosus
ligation at [**Hospital3 1810**] on [**2149-2-27**] (day of life 21).
3. Fluids, electrolytes and nutrition: Initially maintained
on D-5-W, then total parenteral nutrition. Received fluids
by umbilical catheters initially, then by
percutaneously-inserted central catheter. Started trophic
feeds on day of life five, and advanced to 20 cc/kg/day on
day of life nine. Feedings were stopped on day of life ten
due to increased respiratory support and question of
infection. Feeds were restarted again on day of life 30, and
advanced to full feeds on day of life 39. Caloric density
was gradually increased to 32 calories/ounce with ProMod with
feeding tolerance. Was placed nothing by mouth again on day
of life 52 secondary to staphylococcus aureus sepsis
pneumonia and hypotension. Remained nothing by mouth until
day of life 70, when feeds were restarted. Advanced to full
feeds on day of life 82, then calories were increased to 32
calories/ounce by day of life 92. Due to nutritional
rickets, was given 6 calories/ounce of human milk fortifier
for additional calcium, phosphorus and vitamin D. Currently
is taking 150 cc/kg/day of breast milk enhanced with 4
calories/ounce of Neosure to equal 24 calories/ounce.
Is receiving all feeds by gavage due to microaspiration and
discoordination of suck, swallow. Has been gaining weight
well. Receiving supplemental potassium chloride secondary to
diuretic therapy. Most recent electrolytes on [**2149-7-6**] showed
a sodium of 136, potassium 4.9, chloride 98, and CO2 of 26.
Nutritional laboratories done on [**6-18**] showed a calcium of
9.7, phosphorus 6.3, albumin 3.9, alkaline phosphatase 475.
The maximum alkaline phosphatase on [**5-9**] was 1503.
Discharge weight 3915 grams (50 to 75th percentile), length
51 cm (50 to 75th percentile), head circumference 35.5 cm (50
to 75th percentile).
4. Gastrointestinal: Received phototherapy for indirect
hyperbilirubinemia. Peak bilirubin total 4.6, direct .3.
Developed direct hyperbilirubinemia around ten weeks of life
secondary to cholestasis associated with prolonged total
parenteral nutrition without enteral feeding. Highest direct
bilirubin 6.1. Was treated with phenobarbital and Actigall
from day of life 91 to day of life 126. Recent bilirubin on
[**6-18**], total .8, direct .4.
A video fluoroscopic swallow study was done on [**6-4**] showing
silent aspiration of thin and thick liquid with significant
discoordination of suck, swallow and breathe sequence. Has
been receiving only gavage feedings since that time. Gastrostomy
tube placed by Dr [**Last Name (STitle) 38447**] [**2149-7-1**]. Had a moderate to large
umbilical hernia, repaired during G tube placement on [**2149-7-1**].
Anti-reflux medication (Reglan and Zantac) initiated post-op.
5. Hematology: Infant's blood type is B positive. Received
a total of 16 packed red blood cell transfusions during this
hospitalization. The last packed red blood cell transfusion
was on [**2149-4-21**]. A recent hematocrit on [**2149-6-24**] was 37.4%, with
a reticulocyte count of 1.7%. Is receiving supplemental
iron.
Received a platelet transfusion on [**2149-3-5**] for a platelet
count of 77,000. Thrombocytopenia was due to sepsis and
resolved after one transfusion.
6. Infectious Disease: Received a 48 hour course of
ampicillin and gentamicin following birth for rule out
sepsis. CBC was normal. Blood culture was negative.
Received 48 hours of vancomycin and gentamicin from day of
life eight to day of life ten for rule out sepsis with a
negative blood culture and benign CBC. Received vancomycin
and gentamicin then switched to oxacillin for a total of
seven days of therapy from day of life 26 to day of life 32
for a tracheal aspirate that grew staphylococcus aureus.
Blood cultures was negative at that time. Received
vancomycin and gentamicin changed to oxacillin and gentamicin
for 32 days, then completed a total of 42 days with oxacillin
for staphylococcus aureus sepsis and pneumonia.
7. Orthopaedics. Seen by Orthopaedics from [**Hospital3 18242**] on [**2149-4-30**] for decreased movement of the left leg.
Was diagnosed with multiple fractures secondary to
nutritional rickets that included fractures of bilateral
proximal femurs, bilateral proximal humerus, and left distal
radius and ulna. Had a normal hip ultrasound on [**2149-5-28**].
Xrays done day prior to d/c for baseline; copies given to
parents.
8. Neurology: Head ultrasound was done on day of life one,
six, 11, one month, and 36 weeks corrected age, and all were
normal.
9. Sensory: Audiology: Hearing screening was performed
with automated auditory brain stem responses. Passed both
ears. Ophthalmology: Threshold retinopathy of prematurity
of the right eye was treated with laser therapy on [**2149-4-25**].
Threshold retinopathy of prematurity of the left eye was
treated with laser therapy on [**2149-5-15**] and then again on
[**2149-5-22**]. Most recent examination on [**2149-7-2**] showed resolution of
ROP bilaterally.
10. Psychosocial: Parents [**Known firstname 38448**] and [**Last Name (un) 38449**]. Brother is
[**Name (NI) **]. Have visited daily and are very involved. Triplet
number two died around a week of age. Triplet number one,
whose name is [**Name (NI) 38329**], was discharged home on [**2149-5-31**] and is
reportedly doing well. [**Hospital1 69**]
social work has been involved with the family. The contact
social worker is [**Name (NI) 4457**] [**Name (NI) 36244**], and she can be reached at
[**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: 151-day-old, now 46 2/7 weeks
corrected age, triplet with chronic lung disease but stable
in room air and diuretic therapy; with gastrostomy tube and on
antireflux medications.
DISCHARGE DISPOSITION: Home with family.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 2855**] [**Last Name (NamePattern1) **], [**Hospital 1426**]
Pediatrics, telephone number [**Telephone/Fax (1) 37802**].
CARE RECOMMENDATIONS:
1. Feeds: Breast milk 24 calories/ounce with 4
calories/ounce of Neosure via gastrostomy tube,100 cc q 4 hrs
over 1.5 hrs (150 cc/kg/day), nothing by mouth.
2. Medications: Diuril 75 mg pg [**Hospital1 **] (40 mg/kg/day), potassium
chloride 1.7 mEq pg [**Hospital1 **] (1 mEq/kg/day), Fer- in- [**Male First Name (un) **] 0.35cc pg
QD, Reglan 0.2mg pg TID, Zantac 8 mg pg q8 hrs.
3. Car seat position screening: passed.
4. State newborn screening status: Multiple state newborn
screens have been sent, with the last on [**2149-5-10**] and is
normal.
5. Immunizations received: Received hepatitis B
immunization and PCV-7 on [**2149-5-23**]. Received DTaP, HIB on
[**2149-5-24**]. Received IPV on [**2149-5-25**].
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointments:
a. Follow up with pediatrician Dr [**First Name (STitle) **] [**2149-7-9**].
b. Early Intervention referral made to [**Location (un) 86**] Regional Child
Development Center, telephone number [**Telephone/Fax (1) 38334**].
c. VNA referral to Care Group VNA, telephone number
[**Telephone/Fax (1) 37503**]. [**Location (un) 511**] Home Therapies to supply kangaroo
pump and pump set for feedings, telephone number 1-[**Telephone/Fax (1) 38450**].
d. Ophthalmology follow up with Dr. [**Last Name (STitle) 6955**] [**2149-10-30**] at 1pm,
telephone number [**Telephone/Fax (1) 38451**].
e. Orthopaedic followup with Dr [**Last Name (STitle) 38452**] in [**1-22**] months,
telephone [**Telephone/Fax (1) 38453**].
f. General Surgery, Dr [**Last Name (STitle) 38447**], [**2149-7-14**] at 2:15pm, telephone
number [**Telephone/Fax (1) 38454**].
g. Pulmonology, Drs [**Last Name (STitle) 37305**] and [**Name5 (PTitle) 38455**], in one month,
[**Telephone/Fax (1) 38456**].
h. [**Hospital3 1810**] infant follow up program in approximately
nine months, [**Telephone/Fax (1) 36479**].
DISCHARGE DIAGNOSIS:
1. AGA extremely premature female
2. Triplet number three
3. Respiratory distress syndrome, resolved
4. Hypotension, resolved
5. Patent ductus arteriosus status post ligation
6. Indirect hyperbilirubinemia, resolved
7. Direct hyperbilirubinemia, resolved
8. Rickets with multiple fractures
9. Dyscoordinated feeds with microaspiration
10. Rule out sepsis x 2
11. Staphylococcus aureus sepsis
12. Staphylococcus aureus pneumonia
13. Retinopathy of prematurity, both eyes, status post laser
14. Chronic lung disease, resolving
15. Apnea of prematurity, resolved
16. Anemia of prematurity, resolving
17. Gastroesophageal reflux
DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 50-563
Dictated By:[**Last Name (NamePattern1) 38457**]
MEDQUIST36
D: [**2149-6-25**] 02:59
T: [**2149-6-25**] 03:56
JOB#: [**Job Number 38458**]
|
[
"482.41",
"038.11",
"774.2",
"756.4",
"765.02",
"770.7",
"V34.01",
"769",
"747.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.56",
"34.92",
"38.85",
"96.6",
"96.04",
"96.72",
"99.15",
"99.21"
] |
icd9pcs
|
[
[
[]
]
] |
15368, 15574
|
5454, 7009
|
18191, 19080
|
1858, 5312
|
15596, 16324
|
7548, 15151
|
17082, 18170
|
7033, 7521
|
15166, 15344
|
16352, 17058
|
171, 1228
|
1243, 1840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,085
| 173,987
|
48721
|
Discharge summary
|
report
|
Admission Date: [**2156-5-16**] Discharge Date: [**2156-5-24**]
Date of Birth: [**2097-3-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Paxil
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
Briefly, 59 year old female with CAD s/p PCI stent x 2 in [**2149**]
and diastolic CHF, mechanical valve replacement and paroxysmal
atrial tachycardia admitted on [**2156-5-16**] for EP ablation. She was
admitted to the [**Hospital1 1516**] service for heparin bridge and coumadin
held in anticipation of procedure. She got the EP procedure
today and her atrial tachycardia was ablated. After the
procedure, she developed junctional bradycardia to the 50's. She
was reportedly given atropine without effect. She maintained her
BP's in the 80's to 90's. Then her bradycardia evolved to a
accelerated junctional escape to 80's. The cardiology fellow on
call did a bedside echo that did not show tamponade. She is
transferred to the CCU for closer monitoring.
.
Currently, she feels tired but does not have any specific
complaints. +LH, denies CP, SOB, palpiations.
Past Medical History:
Rheumatic fever at age 10.
Coronary artery disease status post PCI and stents x2 in [**2149**].
History of diastolic dysfunction with congestive heart failure.
History of mechanical mitral valve replacement in [**2140**].
History of paroxysmal atrial fibrillation s/p cardioversion in
[**2155**].
History of anxiety and depression.
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: .
Percutaneous coronary intervention, in [**2151**] anatomy as follows:
right dominant system with single vessel coronary artery
disease. The LMCA had a 20% stenosis. The LAD had mild diffuse
disease. The LCX had minimal luminal irregularities. The RCA had
a total occlusion in the previously placed mid-vessel stent.
Social History:
Lives alone in [**Location (un) 669**]. Close to son. [**Name (NI) **] alcohol or drugs.
Smokes [**1-28**] ppd. Has smoked for 40 years.
Family History:
Mother with diabetes and coronary artery disease.
Physical Exam:
VS - 95.1, 82, 98/46, 22, 100%2LNC
Gen: Lethargic but arousable and carries short conversation
appropriately
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple, neck veins pulsatile to ears but likely from TR
CV: RR, S1, S2. II/VI systolic murmur. No thrills, lifts. No S3
or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Soft faint crackles at
right base, no wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: PT 1+, cannot palpate DP pulse
Left: PT 1+, cannot palpate DP pulse
Pertinent Results:
[**2156-5-16**] 04:55PM BLOOD WBC-8.1 RBC-4.23 Hgb-12.7 Hct-36.8 MCV-87
MCH-30.0 MCHC-34.5 RDW-14.7 Plt Ct-193
[**2156-5-20**] 05:47AM BLOOD WBC-8.5 RBC-3.64* Hgb-10.9* Hct-31.8*
MCV-87 MCH-30.0 MCHC-34.5 RDW-14.6 Plt Ct-113*
[**2156-5-16**] 04:55PM BLOOD PT-28.1* PTT-150* INR(PT)-2.8*
[**2156-5-20**] 05:47AM BLOOD PT-17.0* PTT-56.5* INR(PT)-1.5*
[**2156-5-16**] 04:55PM BLOOD Glucose-140* UreaN-10 Creat-0.8 Na-137
K-3.5 Cl-101 HCO3-25 AnGap-15
[**2156-5-20**] 05:47AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-140
K-3.2* Cl-109* HCO3-23 AnGap-11
[**2156-5-16**] 04:55PM BLOOD Calcium-9.7 Phos-2.8 Mg-2.0
[**2156-5-20**] 05:47AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.9
[**2156-5-22**] 09:45AM BLOOD WBC-6.4 RBC-3.54* Hgb-11.0* Hct-31.3*
MCV-88 MCH-30.9 MCHC-35.0 RDW-14.9 Plt Ct-97*
[**2156-5-23**] 07:45AM BLOOD PT-19.1* PTT-59.5* INR(PT)-1.8*
[**2156-5-22**] 09:45AM BLOOD Glucose-141* UreaN-8 Creat-0.8 Na-140
K-3.6 Cl-104 HCO3-25 AnGap-15
[**2156-5-22**] 09:45AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
.
Cardiology Report ECG Study Date of [**2156-5-16**] 3:28:56 PM
ECG [**5-16**]:
Atrial tachycardia
Modest nonspecific ST-T wave changes suggested, but atrial
waveforms makes
assessment difficult
Since previous tracing of [**2156-4-20**], ventricular ectopy absent
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 172 78 396/420 65 71 33
.
ECG Study Date of [**2156-5-17**] 9:04:38 AM
Atrial tachycardia. Modest nonspecific ST-T wave changes
suggested, but atrial waveforms makes
assessment difficult. Since previous tracing of [**2156-5-16**], no
significant change
.
ECG Study Date of [**2156-5-18**] 12:17:10 PM
Sinus bradycardia. A-V conduction delay. Compared to the
previous tracing
of [**2156-5-17**] the rate has slowed. Otherwise, no diagnostic interim
change.
.
ECG Study Date of [**2156-5-18**] 11:51:38 PM
Junctional bradycardia with retrograde conduction as recorded
previously
on [**2156-5-18**]. No diagnostic interim change.
.
ECG Study Date of [**2156-5-19**] 7:20:44 AM
Junctional bradycardia with retrograde conduction and occasional
ventricular
ectopy. Otherwise, no diagnostic interim change
.
ECG Study Date of [**2156-5-20**] 9:16:46 AM
Junctional bradycardia with retrograde conduction and occasional
ventricular ectopy. Compared to the previous tracing of [**2156-5-19**]
no diagnostic interim change.
.
ECG Study Date of [**2156-5-21**] 8:31:10 AM
Junctional bradycardia with marked Q-T interval prolongation.
Compared to the previous tracing of [**2156-5-20**] no diagnostic
interval change.
.
Echo [**5-18**]:
The right atrium is dilated. The left ventricle is not well
seen. Overall left ventricular systolic function cannot be
reliably assessed. The aortic valve is not well seen. The mitral
valve leaflets are not well seen. A mitral valve prosthesis is
present. There is no pericardial effusion.
IMPRESSION: Limited study due to poor echo windows and focused
views. There is no pericardial effusion. The right atrium
appears dilated. The right ventricle may also be dilated.
Overall left ventricular systolic function is not well
visualized but is probably normal.
Compared with the prior study (images reviewed) of [**2156-4-21**],
the limited findings on the current study appear similar.
.
CHEST (PORTABLE AP) [**2156-5-18**] 10:49 PM
ADDENDUM:
Partially imaged sclerotic focus in proximal left humerus is
noted with apparent chondroid matrix. In the absence of
localized symptoms, this is most likely an enchondroma and less
likely a bone infarct. However, if there are symptoms in this
region, dedicated humeral radiographs would be recommended for
initial further assessment as communicated by phone to Dr. [**Last Name (STitle) **]
by phone on [**2156-5-19**].
There is no evidence of pneumothorax or pleural effusion.
Cardiomediastinal contours are unchanged, and lungs and pleural
surfaces remain clear.
.
CHEST (PORTABLE AP) [**2156-5-19**] 7:22 AM
IMPRESSION: AP chest compared to [**4-20**] and [**2156-5-18**]:
The lungs are clear. Patient has had median sternotomy. Heart is
overall top normal in size but both atria and possibly the right
ventricle are markedly dilated though unchanged since at least
[**2155-2-27**].
.
CHEST (PORTABLE AP) [**2156-5-22**] 7:52 AM
CHEST: A dual-chamber pacemaker is present with leads in
satisfactory position. There is no evidence of a pneumothorax.
The lung fields are clear. The cardiac size is within normal
limits. Previous CABG noted.
IMPRESSION: No pneumothorax, pacemaker lines in good position.
.
Brief Hospital Course:
ASSESSMENT AND PLAN [**2156-5-23**]:
Patient is a 59 year old female with CAD s/p stenting x2, and
mechanical mitral valve replacement [**2-28**] rheumatic fever and
known paroxysmal atrial flutter admitted for elective atrial
tachycardia ablation complicated by post-procedural junctional
bradycardia and hypotension, s/p pacer placement.
# Rhythm: The patient was admitted s/p atrial tachycardia
ablation. Post-procedure, she had bradycardia and hypotension.
She had a junctional rhythm in the 40's. Initially, she received
no ionotropes and was monitored on telemetry. The following day,
her sinus node had not yet recovered; she remained bradycardiac
and hypotensive and she was then started on dopamine. Beta
blockers, lasix, spironolactone and losartan were held. The
dopamine was weaned as her blood pressure improved. Coumadin was
held for pacemaker placement and she was maintained on heparin.
She had a mild groin bleed the day after ablation which resolved
with pressure. As she continued to have junctional bradycardia,
weakness and occasional dizziness, it was decided to place a
pacemaker. She underwent pacemaker placement without
complication. Beta blockers, lasix, spironolactone and losartan
were restarted. Coumadin was restarted and she was maintained
on heparin bridge. Her INR goal is 2.5 to 3.5. She was
discharged when her coumadin was above 2.0 with instructions to
continue her outpatient coumadin clinic.
#. CAD - History of 3 vessel disease requiring stenting of the
left main and the RCA. She was continued on statin and
metoprolol as above.
#. Pump - Last EF>55%, history of diastolic dysfunction with
chronic congestive heart failure. Lasix, valsartan,
spironolactone, metoprolol as above.
#. Valves - Mechanical mitral valve replacement in [**2140**] [**2-28**]
rheumatic fever and 3+ tricuspid regurgitation. Target INR
2.5-3.5 for mechanical valve. 3+ TR on recent ECHO. She
received heparin and coumadin as above.
#. HTN - She is to continue on Lasix, valsartan, spironolactone
and metoprolol as above. Metoprolol was decreased from 37.5mg
to 25mg [**Hospital1 **].
Medications on Admission:
Warfarin 5 mg daily - held [**5-14**]
Losartan 50 mg daily
Metoprolol tartrate 37.5 mg p.o. b.i.d.
Pravastatin 80 mg daily
Folic acid 1 mg daily
Lasix 20 mg daily
Lorazepam .5-1 mg q8h p.r.n.
Docusate sodium 100mg [**Hospital1 **]
Spironolactone 25mg daily
Discharge Medications:
1. Outpatient [**Hospital1 **] Work
Please check INR and fax results to Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] office.
Phone number: [**Telephone/Fax (1) 3581**]
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Junctional Bradycardia
Chronic Diastolic Congestive heart Failure
anticoagulation for mechanical valve
Discharge Condition:
Good, afebrile, ambulating
Discharge Instructions:
You were admitted to the hospital to undergo an ablative
procedure by the electrophysiology department, in an attempt to
eliminate your atrial fibrillation. This procedure was
complicated by a resulting slow heart rate, and low blood
pressure. You were admitted to the CCU for closer monitoring.
You received a pacemaker in order to maintain an adequate heart
rate and blood pressure.
.
Please continue to take your medications as prescribed. Your
metoprolol was decreased from 37.5mg twice a day to 25mg twice a
day. Please discuss titrating your metoprolol dose with your
primary care provider. [**Name10 (NameIs) 2172**] other medications remained the
same.
.
Your INR was 2.1 on discharge. Your goal is 2.5 to 3.5. Please
have your INR checked with your PCP on Wednesday [**2156-5-25**].
.
Please follow up as described below.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, fever over 102, or
any other concerning symptom.
Followup Instructions:
Please have your INR checked on Wednesday [**2156-5-25**] and fax
results to your PCP office for follow up.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2156-5-31**]
2:30
.
You will need to follow up with your PCP [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 3581**] on [**2156-6-10**] at 10am.
.
Please follow up with your cardiologist [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 5068**], on [**2156-6-15**] at 10am.
.
Please follow up with your cardiologist (electrophysiology for
your pacemaker) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 15500**] on [**2156-6-3**] at
9:20am.
.
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-11-1**] 3:10
|
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[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,267
| 181,448
|
48227
|
Discharge summary
|
report
|
Admission Date: [**2191-7-2**] Discharge Date: [**2191-7-12**]
Date of Birth: [**2138-3-6**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 53 year old female with history of PVD requiring bypass
procedures in both lower extremities, diabetes, and renal
failure on HD who presented with three days of pain on her lower
left leg. At rest and with no pressure, the pain was described
as "achy" [**3-8**]. However, with any pressure or movement, the pain
was described as sharp and [**9-7**]. She said it started at a level
just below her knee and radiated to the foot. Overall the pain
was worsening, and on the day of admission she could not walk.
Pain was constant and not alleviated by anything she did,
including taking "pain pills" she had from her recent procedure.
The pain interfered with falling asleep and also woke her at
night. Pt noted that her left leg swelled on the first day of
the pain. Pt recalled no recent trauma, bug bites, fevers,
chills, vomiting, nausea, or difficulty breathing. Of note, her
son was killed while at a friend's house on the first day that
she experienced the leg pain. She states the pain began before
that occurred. She notes that her appetite and sleep have been
poor. Since her bypass in [**Month (only) 116**], she has lived in a rehabilitation
facility.
.
In the last month, pt noted mood swings and a loss of memory.
She stated being forgetful of both recent and remote memories.
She mentioned it may be secondary to her medications.
Past Medical History:
renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA on CPAP
Gastroparesis
Ischemic colitis
Right thigh wound
LVH, EF 55%
COPD on 3-4L NC at home
Social History:
Denies illicit drug use. Denies smoking. Denies drinking
alcohol. Lives alone. Recent Stressor of her son fatally shot
this week.
Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.
Physical Exam:
ED Physical Examination
T 100.1 PO, HR 82, BP 149/43 RR 18, O2 sat 97% on 6L
.
Constitutional: Obese female laying in bed crying out in pain at
times.
.
Head/Eyes: NC/AT. PERRL, not icteric/no pallor.
.
ENT/Neck: MMM, clear oropharynx, no LAD.
.
Chest/Respiratory: Difficult to assess [**12-31**] habitus, poor effort,
but anteriorly clear.
.
CV: RRR, S1, S2, possible S4 gallop. No murmurs/rubs.
.
GI/Abdominal: Soft, Nt, ND, +BS.
.
GU: No flank pain.
.
MSK/Extremities/Back: + Left leg pain. Right thigh - wound vac
in place, draining little serosanguinous fluid. Multiple scars,
very tender to palp at left post calf. Pulses at dp Dopplerable
bilat.
.
Skin: no rashes/lesions. Dry, flaking feet. Fistula L arm, +
thrill. Left foot warm, full ROM toes, foot.
.
Neuro: A and Ox3. No focal deficits.
.
Psych: In pain, tearful.
Pertinent Results:
Admission Labs:
[**2191-7-2**] 10:30AM BLOOD WBC-12.1*# RBC-3.38* Hgb-10.6* Hct-33.2*
MCV-98# MCH-31.4 MCHC-31.9 RDW-21.7* Plt Ct-154
[**2191-7-2**] 10:30AM BLOOD Neuts-88.0* Lymphs-7.4* Monos-4.2 Eos-0.1
Baso-0.4
[**2191-7-2**] 10:30AM BLOOD PT-13.6* PTT-25.7 INR(PT)-1.2*
[**2191-7-2**] 10:30AM BLOOD Glucose-123* UreaN-8 Creat-5.0*# Na-143
K-4.4 Cl-100 HCO3-31 AnGap-16
[**2191-7-2**] 10:30AM BLOOD Calcium-8.7 Phos-2.4* Mg-1.8
[**2191-7-2**] 10:46AM BLOOD Lactate-1.6
[**2191-7-11**] 03:00PM BLOOD WBC-17.4* RBC-2.96* Hgb-9.4* Hct-28.9*
MCV-98 MCH-31.6 MCHC-32.3 RDW-21.0* Plt Ct-212
[**2191-7-10**] 06:30AM BLOOD Neuts-85.5* Lymphs-9.7* Monos-4.4 Eos-0
Baso-0.3
[**2191-7-11**] 03:00PM BLOOD Plt Ct-212
[**2191-7-11**] 03:00PM BLOOD Glucose-PND UreaN-PND Creat-PND K-PND
Cl-PND HCO3-PND
[**2191-7-10**] 06:30AM BLOOD Glucose-161* UreaN-22* Creat-6.9*# Na-139
K-5.6* Cl-96 HCO3-27 AnGap-22*
[**2191-7-10**] 06:30AM BLOOD Calcium-10.0 Phos-3.7 Mg-2.0
[**2191-7-7**] 05:50AM BLOOD %HbA1c-5.3#
BONE SCAN [**2191-7-8**] Clip # [**Clip Number (Radiology) 101633**]
Reason: ? CRPS B/L LOWER EXTREMITIES
Final Report
RADIOPHARMECEUTICAL DATA:
22.3 mCi Tc-[**Age over 90 **]m MDP ([**2191-7-8**]);
HISTORY: Left lower extremity pain and leukocytosis with concern
for possible
infection.
INTERPRETATION:
Whole body images of the skeleton were obtained in anterior and
posterior
projections. Coned down flow and static images of both distal
lower extremities
were also obtained. This study is somewhat limited by large
patient body
habitus. There is no focal abnormal uptake of the left lower
extremity to
suggest infection. Increase uptake of the right ankle is likely
due to
degenerative stress changes. The kidneys and urinary bladder
are visualized,
the normal route of tracer excretion.
IMPRESSION:
No abnormal uptake of the left lower extremity to suggest
infection.
CXR [**2191-7-6**]: INDICATION: End-stage renal disease with fever.
COMPARISON: [**2191-5-7**] and [**2191-5-14**].
PORTABLE SUPINE VIEW OF THE CHEST: Heart size at the upper
limits of normal.
There is right lateral and left lateral plate-like atelectasis.
There is
streaky left retrocardiac opacity. No overt pulmonary edema.
There is no
pneumothorax. The right costophrenic angle is not imaged. Left
costophrenic
angle is sharp.
IMPRESSION:
1. Bilateral plate-like areas of atelectasis in the lateral mid
lungs.
2. Streaky left retrocardiac opacity, favor atelectasis over
pneumonia.
LLEG XRAY [**2191-7-6**]:
HISTORY: 53 y/o woman with peripheral vascular disease and
requiring bypass of bilateral lower extremities. Patient with
right wound infection. Evaluate for osteomyelitis or fracture.
FINDINGS: There are no signs for acute fractures or
dislocations. There is
overall demineralization. Extensive vascular calcifications are
present. There is some flattening of the calcaneus posteriorly
without discrete fracture line. Vascular calcifications are seen
throughout the medial aspect of the lower extremity soft
tissues. The ankle mortise is preserved. There is no abnormal
soft tissue gas.
IMPRESSION:
No radiographic evidence for osteomyelitis or acute fracture.
R Calf U/S [**2191-7-5**]: CLINICAL INDICATION: Right calf abnormality
on MRI; varicosities vs. abscess.
COMPARISONS: Calf MR dated [**2191-7-3**].
FINDINGS: Multiple [**Doctor Last Name 352**]-scale and color Doppler images were
obtained in the
region of MR abnormality in the anteromedial calf subcutaneous
tissues. Images
revealing 1.4 x 1.2 x 1.0 cm complex cystic lesion without
definite flow
within or around it. The lesion contains floating echogenic
debris but no
solid nodular component.
IMPRESSIONS:
1. 1.4-cm subcutaneous complex cystic lesion, likely
representing a sebaceous
cyst. A small abscess would be considered less likely given the
absence of
associated vascularity. This appearance is not consistent with
a varicosity.
[**2191-7-3**] U/S Venous doppler to eval for DVT:
INDICATION: 53-year-old female with three-day history of leg
pain and
swelling. Please evaluate for popliteal DVT.
FINDINGS: Comparison is made to duplex ultrasound from [**2191-7-2**],
which
completely assessed the left common femoral and superficial
veins, but did not
assess the popliteal vein secondary to patient discomfort.
FINDINGS: Grayscale, color and pulse wave Doppler son[**Name (NI) 1417**]
were performed on the bilateral popliteal veins. Normal flow,
compressibility, waveforms, and augmentation are demonstrated.
Augmentation in the left popliteal fossa could not be
demonstrated secondary to patient discomfort. No intraluminal
thrombus is identified.
IMPRESSION: No evidence of DVT in the bilateral popliteal
veins.
Brief Hospital Course:
Assessment and Plan: 53 year old female with history of PVD
requiring bypass procedures in both lower extremities, diabetes,
and renal failure on HD who presented with three days of pain on
her lower left leg. Differential includes DVT, complex regional
pain syndrome, compartment syndrome, necrotizing fasciitis,
cellulitis, and diabetic neuropathy. In light of the very recent
death of her son, her [**Name2 (NI) 101634**] status is concerning and
may be contributing to her pain.
.
1. Lower leg pain. Her pain appears severe. In the setting of
recent surgery, increased immobilization, and obesity, the risk
for DVT is high. Complex regional pain syndrome is also
possible, given her recent procedures and emotional stress.
However, fever and elevated white count (12.1 WBC) raise the
concern for infection, especially because necrotizing fasciitis
can present with few objective physical signs. Compartment
syndrome and cellulitis are less of a concern due to lack of
obvious swelling and erythema. Diabetic neuropathy seems less
likely due to the pain's acute and severe nature. See also
problem 3.
- Control pain with oxycodone and acetaminophen; avoid dilaudid
and morphine because they caused her to have mental status
changes and agitation per discharge note from [**2191-5-17**] and
daughter's report.
- DVT could not be ruled out because the popliteal vein was not
assessed. There was no evidence of DVT in the left common
femoral vein and superficial femoral vein. Will start empiric
heparin.
- Blood cultures pending, pt on vancomycin and zosyn for wound
infections growing ESBL Klebsiella and MRSA. Continue Vanc/Zosyn
as an outpatient for a 14 day course, which is through [**2191-7-18**].
- Vascular Surgery following, will need PVRs of distal
extremeties and follow-up with Dr. [**Last Name (STitle) **] in [**11-30**] weeks.
- Podiatric Surgery following, will need to continue splints,
debridement cream, and follow-up with Dr. [**First Name (STitle) 3209**] in 1 week.
- Physical therapy will be necessary as an outpatient.
.
2. Right thigh wound vac. s/p vascular surgery on [**2191-3-31**] c/b
wound infection.
- Vascular Surgery following
- Monitor for signs of local infection.
- Will need wound care assistance as an outpatient.
- Continue Vanc/Zosyn as above as an outpatient for a 14 day
course, which is through [**2191-7-18**].
- Wound care: Aquacell silver with dry sterile dressing qDaily
.
3. Depression/coping. She has a history of depression, and her
29 year old son was shot and died three days prior to admission.
This is clearly and understandably affecting her. If no organic
cause can be found for the leg pain, consider psychologic
exacerbation or exaggeration of pain, or somatoform (pain)
disorder. Regardless of the leg pain, addressing her mood may be
therapeutic and necessary.
- Social work and psych consults done in hospital. On Seroquel.
- Will need continued psychiatry social work consultation as an
outpatient
.
4. Self-reported recent mental status changes. Etiology could be
medications. [**Month (only) 116**] also be related to her coping and depression.
- Psych and Social work as above.
.
5. O2 requirement. History of OSA on CPAP, COPD. Pt has no
respiratory complaints, but her respiratory rate was noted to be
24. Satting 94 on 2L NC. On 2-3L NC at home, CPAP at night but
unsure of her settings.
- Adjust O2 amount based on oximetry, may need 2 liters as an
outpatient.
- continue CPAP at night
- Oxygen requirement may be related to agitation; due to
peripheral vascular disease, difficult to get accurate Sp02
[**Location (un) 1131**]. No complaints or symptoms of shortness of breath.
.
6. Hypertension/Hyoptension. On the evening of [**7-11**], the patient
was admitted briefly to the MICU reported hypertension to SBP
260. Details: .
[**7-2**] to [**7-7**]: SBP 100-120 by automatic machine
[**7-8**] to [**7-10**]: SBP 80-90 by automatic machine
[**7-10**] 10pm: SBP 260 by doppler at wrist; SBP 130 by doppler at
brachial; SBP 80 at lower forarm by automatic machine.
Because it is unclear what the true BP is for this patient, she
is transferred to the MICU for assessment of the correct blood
pressure and for closer monitoring overnight. Overnight the
patient was asymptomatic. The patient is currently
asymptomatic. She has no headache, vision changes,
lightheadedness. She denies chest pain or shortness of breath.
Her true blood pressure is unclear, though likely approx 100s
systolic. Difficult to measure due to AV fistula in L arm and
new PICC in the R arm.
7. Diabetes. On admission, her fingerstick glucose was 152.
- Continue on home regimen and monitor FS.
.
8. End stage renal failure on hemodialysis.
- Renal to follow. HD schedule M-W-F per patient.
- Continue Vanc/Zosyn as above as an outpatient for a 14 day
course, which is through [**2191-7-18**]. Vanc is per HD protocol, Zosyn
is 2.25g q8hrs, PLUS 0.75 grams after dialysis.
.
9. LLE Bullae. Unclear etiology, Derm consulted in hospital.
They prefer to treat symptomatically and follow rather than bx
due to pt history of poor wound healing.
- will need derm f/u as outpatient.
- Wound care: Adaptic with dry sterile dressing qDaily
10. Right ankle wound - [**12-31**] PVD
- Wound care: Adaptiq with dry sterile dressing qDaily
11. Decubitus ulcer on coccyx stage 2
- Wound care: Wound gel with allevin change q3days
F/E/N: No fluids for now. Renal to follow electrolytes and
hemodialysis. Diabetic, renal diet.
.
PPx: Heparin, bowel regimen.
.
ACCESS: PICC in right arm, AV Fistula left arm.
.
CODE: FULL CODE
.
COMM: With [**Name2 (NI) **] amd Family
.
CONTACT: [**First Name8 (NamePattern2) **] [**Known lastname 37559**] [**Telephone/Fax (1) 101635**] (cell)
.
DISPO: To [**Hospital 100**] Rehab MACU
Medications on Admission:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-20 units
Subcutaneous ASDIR (AS DIRECTED).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 3 days: Stop date [**5-19**].
Disp:*3 Recon Soln(s)* Refills:*0*
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous
QHD per protocol for 2 days: stop day [**5-19**].
Disp:*2 bags* Refills:*0*
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift.
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
4. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for breakthrough pain.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl
Topical QID (4 times a day).
9. Insulin Lispro 100 unit/mL Solution Sig: 1-20 units
Subcutaneous qachs: take as directed for insulin sliding scale.
Disp:*100 units* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous once a day: at noon.
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed: hold for loose stools.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed for constipation.
20. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
QMOWEFR ([**Month/Year (2) 766**] -Wednesday-Friday).
21. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
22. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
23. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**11-30**]
nebs Inhalation Q4H (every 4 hours) as needed for SOB.
24. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
25. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
26. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
27. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
28. Vancomycin 1000 mg IV HD PROTOCOL
29. Antibiotic Regimen
Please continue course of Vancomycin and Zosyn through [**2191-7-18**].
30. Zosyn 2.25 g Recon Soln Sig: 2.25 grams Intravenous every
eight (8) hours: please also give 0.75 grams after dialysis in
addition to the standing doses.
Disp:*qs * Refills:*0*
31. Outpatient Lab Work
Please check vancomycin level before each dialysis
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Renal Failure
2. Peripheral Vascular Disease
3. Right lower extremity wound (thigh)
4. Right lower extremity wound (heel ulcer)
Discharge Condition:
stable
Discharge Instructions:
You were evaluated and treated for your leg pain, vascular
disease, and wound care. Please keep your follow-up
appointments as scheduled. Please follow your wound care
instructions and take your medications as prescribed. Call your
doctor or return immediately to the emergency department for any
shortness of breath, chest pain, leg pain uncontrolled by your
pain medications, or any other concerns.
Wound care instructions:
1. Right ankle wound - Change dressing daily. Wash wound with
sterile saline and dab dry, apply adaptiq to wound and cover
with dry sterile dressing.
2. Right thigh wound - Change dressing daily. Wash wound with
sterile saline and dab dry, apply aquacell silver and cover with
dry sterile dressing.
3. Decubitus ulcer over coccyx - Change dressing every 3 days.
Wash wound with sterile saline and dab dry. Apply allevin to
wound.
4. Left posterior knee bullae - Change dressing daily. Wash
wound with sterile saline and dab dry. Apply adaptiq with dry
sterile dressing.
Followup Instructions:
1. Please call your primary care physician to arrange [**Name9 (PRE) 702**]
this week.
2. Please call [**Hospital1 18**] Vascular Surgery (Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 2395**] to arrange follow-up in [**11-30**] weeks for a clinic
visit and non-invasive scans of your feet/ankles
3. Please call [**Hospital1 18**] Podiatry (Dr. [**First Name (STitle) 3209**] at [**Telephone/Fax (1) 543**] to
arrange follow-up in 1 week for a clinic visit and wound
re-check.
|
[
"V09.0",
"041.11",
"V45.1",
"707.07",
"309.0",
"496",
"709.8",
"729.5",
"707.03",
"V58.67",
"998.59",
"V10.52",
"585.6",
"327.23",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
18373, 18439
|
8001, 10360
|
283, 290
|
18614, 18623
|
3262, 3262
|
19674, 20162
|
2233, 2400
|
15380, 18350
|
18460, 18593
|
13789, 15357
|
18647, 19651
|
2415, 3243
|
230, 245
|
13336, 13763
|
318, 1667
|
3278, 7978
|
1689, 2069
|
2085, 2217
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,591
| 133,868
|
3617
|
Discharge summary
|
report
|
Admission Date: [**2137-5-21**] Discharge Date: [**2137-5-31**]
Date of Birth: [**2071-12-10**] Sex: M
Service: OMED
Allergies:
Penicillins / Valium / Morphine / Zithromax / Atenolol /
Cimetidine / Codeine / Cozaar / Imdur / Isordil / Vancomycin /
Pepcid / Prinivil / Propranolol / Toprol Xl / Clindamycin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
ischemic [**Hospital 16461**] transfer from surgery
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 16462**] is a 65-year-old male NSCL ca with a history of
coronary artery disease as well as short gut syndrome secondary
to bowel ischemia, on chronic TPN. He was
diagnosed with a right upper lobe lesion on [**2137-2-27**] by a CT
scan. CT-guided biopsy was consistent with poorly
differentiated
squamous cell carcinoma.
He is currently being treated with
chemoradiation with Taxol and carboplatin. His last dose of
the
chemotherapy was [**2137-5-16**] (single [**Doctor Last Name 360**] Taxol due to
thrombocytopenia) and his last scheduled dose of radiation
therapy is tomorrow.
Past Medical History:
Coronary artery disease status post a successful CABG in [**2124**]
as was well as several myocardial infarctions.
Postoperatively,
he suffered bowel ischemia requiring multiple surgery. An
embolus to the SMA required bowel resection resulting in
chronic
short gut syndrome and he is maintained on TPN.
2. Implanted ICD device.
3. History of atrial fibrillation.
4. Right lower extremity DVT on Lovenox.
5. lung ca as above
Social History:
He lives in [**Location 15005**] [**State 350**] with his wife,
daughter, and son-in-law. [**Name (NI) **] is having radiation treatment
closer to his home. He is a retired offset printer. He quit
tobacco 15 years ago following an extensive smoking history of
up
to 50-pack years. He denies alcohol use currently.
Family History:
Mother died from trauma, brother had lung
cancer, sister with breast cancer. Another brother suffered
from
[**Name (NI) 499**] cancer in his 60s. His father died of gastric cancer in
his 50s. Multiple family members have coronary artery disease.
Physical Exam:
GENERAL: [**Male First Name (un) 4746**] in NAD, AOx3
HEENT: PERRLA, EOMI, no oral lesions or thrush.
LUNGS: CTA x 2
CARDIOVASCULAR: systolic murmur II/VI
ABDOMEN: Soft, mild tenderness in left lower quadrant. There
is some evidence of rebound and
guarding. ICD device in the abdomen, hypoactive bowel sounds.
EXTREMITIES: 1+ right lower extremity edema to above the ankle.
Pertinent Results:
[**2137-5-21**] 03:15PM ALT(SGPT)-20 AST(SGOT)-23 CK(CPK)-26* ALK
PHOS-30* AMYLASE-58 TOT BILI-1.0
[**2137-5-21**] 03:28PM LACTATE-2.7*
[**2137-5-21**] 01:02PM GLUCOSE-112* UREA N-20 CREAT-0.7 SODIUM-139
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-32* ANION GAP-13
[**2137-5-21**] 01:02PM WBC-3.5* RBC-3.04* HGB-10.5* HCT-30.8*
MCV-102* MCH-34.7* MCHC-34.2 RDW-16.4*
Brief Hospital Course:
Pt was first admitted to surgery where pt was diagnosed with
bowel ischemia, it was treated conservatively and was
transferred to OMED for bowel rest and anticoagulation. The
reason for ischemia was undetermined but most likely a
mesenteric thrombosis (due to his history of multiple clots) or
due to atherosclerotic vessels (with one former episode of
mesenteric ischemia after cardiac surgery).
Discharge Medications:
1. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day) as needed for DVT prophylaxis.
Disp:*30 Tablet(s)* Refills:*1*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
3. Saline Flush 0.9 % Syringe Sig: [**11-30**] Injection as needed.
Disp:*20 syringe* Refills:*2*
4. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: Two (2) cc
Intravenous once a day as needed for line maintenance.
Disp:*30 syringe* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
ischemic bowel
Discharge Condition:
stable
Discharge Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**6-7**] at 10 am (9
[**Hospital Ward Name 23**])- at heme clinic, CT scan at 2 pm ([**Hospital Ward Name 452**] 3)
Please follow up with Dr. [**Last Name (STitle) 3274**] on Thurs [**6-13**]
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**6-7**] at 10 am (9
[**Hospital Ward Name 23**])- at heme clinic, CT scan at 2 pm ([**Hospital Ward Name 452**] 3)
Please follow up with Dr. [**Last Name (STitle) 3274**] on Thurs [**6-13**]
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2137-6-8**]
|
[
"414.01",
"V45.81",
"579.3",
"V12.51",
"289.81",
"427.31",
"V15.82",
"162.3",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
3965, 4026
|
3017, 3416
|
488, 495
|
4085, 4093
|
2626, 2994
|
4429, 4858
|
1954, 2208
|
3439, 3942
|
4047, 4064
|
4117, 4406
|
2223, 2607
|
396, 450
|
523, 1138
|
1160, 1599
|
1615, 1938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,546
| 181,171
|
5009
|
Discharge summary
|
report
|
Admission Date: [**2188-6-28**] Discharge Date: [**2188-7-3**]
Date of Birth: [**2112-8-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 20728**] is a 75 year old
woman from [**Hospital1 700**] admitted on [**2188-6-28**] for evaluation for the question of dialysis. The
patient was last admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] on [**2188-5-27**] for workup of new onset acute renal
failure, urosepsis, [**Last Name (un) 3696**] syndrome and chronic
ventilatory dependence. She was discharged to [**Hospital1 20731**] without dialysis as there was no indication
then for dialysis.
The patient's acute renal failure continued to worsen and she
had a question of altered mental status, leading to this
readmission, for workup of uremic encephalopathy and the
requirement of dialysis. The patient was transferred to the
Medical Intensive Care Unit because of ventilator dependence
at night.
ACTIVE ISSUES:
1. Acute renal failure: The patient had hyperkalemia on
admission, which resolved with a Kayexalate enema and Lasix.
She was evaluated by the renal service and started bedside
hemodialysis through a femoral line on [**2188-6-30**]. No
improvement of mental status was noticed after two days of
dialysis.
A family meeting was held on [**2188-6-29**] with the
patient's sister, who is her health care proxy, regarding the
goals of our care for the patient. We discussed at length
regarding the need for hemodialysis, the need for a permanent
catheter to be placed and regarding the overall prognosis of
Mrs. [**Known lastname 20728**]. The patient's family decided to give her a
trial of hemodialysis from her femoral line and observe what
benefit it will bring, then they will decide regarding
chronic hemodialysis. Mrs. [**Known lastname 20728**] had minimal mental status
improvement after two days of hemodialysis. The patient's
family decided on [**2188-7-1**] that they would not consent
to further procedures or hemodialysis and would want only
comfort measures for Mrs. [**Known lastname 20728**]. Hemodialysis was stopped
on [**2188-7-1**].
2. Ventilatory status: The patient was placed on 12 hours
off ventilator wean on her first day, and was noted to have
some apneic episodes and appear labored in her breathing. We
therefore placed her on 24 hour PSV then switched to AC in
order to better ventilate her and to rule out any hypoxia,
hypercarbia as a cause of her altered mental status. The
patient's family had decided on comfort measures only on
[**2188-7-2**]. The patient was then taken off the
ventilator that afternoon and given oxygen over her
tracheostomy mask. She was not to be put on ventilator
support from now on. The patient is to receive morphine if
she appears distressed from breathing.
3. Urinary tract infection: On admission, a urinalysis was
sent and the patient was found to have plenty of bacteria and
yeast in her urine. Later, the urine culture came back to
show Klebsiella pneumoniae, sensitive to Bactrim. The
patient is now treated, day number five of Bactrim DS on
discharge.
4. Diabetes/hyperglycemia: The patient had been
hyperglycemic during this admission, likely secondary to her
urinary tract infection. As the patient is now only comfort
measures, she is getting her daily NPH at the same dose as on
transfer, but no more daily fingersticks to check her blood
sugar level.
5. Nutrition: The patient is to receive no intravenous
fluids. She received 35 cc/hour of Nepro tube feeds and 250
cc of free water bolus through her nasogastric tube every
day. The family has not yet decided whether to stop tube
feeding her and to remove her nasogastric tube.
6. Altered mental status: A CT scan was performed for
further evaluation of possible causes of the patient's mental
status alteration and potential prognostication in terms of
neurological status. A CT scan of the head showed no acute
infarction or hemorrhage, with small vessel disease in the
periventricular white matter and an old putamen infarction.
7. Cardiovascular status: An echocardiogram was performed
to evaluate the cardiovascular status of Mrs. [**Known lastname 20728**].
Results showed a mildly dilated left atrium and right
atrium, otherwise no change from patient's echocardiogram on
[**2188-2-13**].
DISCHARGE DIAGNOSES:
Acute renal failure.
Diabetes mellitus.
Urinary tract infection.
Tracheostomy.
CODE STATUS: "Do Not Resuscitate"/"Do Not Intubate".
DISCHARGE MEDICATIONS:
Nepro tube feeds 35 cc/hour through nasogastric tube.
Synthroid 175 mcg via nasogastric tube q.d.
Lopressor 50 mg via nasogastric tube b.i.d.
Nystatin powder to inguinal rash b.i.d.
NPH 45 units s.c.b.i.d.
Bactrim DS one per nasogastric tube q.d.
Zantac 150 mg per nasogastric tube q.d.
Free water 250 cc per nasogastric tube q.i.d.
Morphine sulfate 1 to 5 mg s.c.q.1h.p.r.n. discomfort.
[**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**]
Dictated By:[**Name8 (MD) 20732**]
MEDQUIST36
D: [**2188-8-31**] 18:42
T: [**2188-9-2**] 10:54
JOB#: [**Job Number 20733**]
|
[
"263.9",
"428.0",
"599.0",
"V44.0",
"707.0",
"584.5",
"518.81",
"403.91",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.72",
"96.6",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
4420, 4555
|
4578, 5222
|
1044, 3786
|
155, 1029
|
3802, 4399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,012
| 104,482
|
9498
|
Discharge summary
|
report
|
Admission Date: [**2183-6-10**] Discharge Date: [**2183-6-18**]
Date of Birth: [**2109-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Myocardial Infarction
Major Surgical or Invasive Procedure:
[**2183-6-11**] - Cardiac Catheterization
[**2183-6-12**] - CABGx4 (Interal mammary to Left anterior descending
artery, Vein to Diagonal artery, vein to obtuse marginal artery,
vein to posterior descending artery)
History of Present Illness:
73M with h/o HTN, DMII, hyperlipidemia, GERD presents with 3
days of escalating exertional chest pressure. He clearly states
that he has been having the sensation of chest pressure/not
pain, over his anterior chest, non radiating which started with
exertion when he was mowing the lawn on Saturday. The pressure
is associated with bilateral elbow/arm muscular pain. He had a
prolonged episode today relieved with burping and pressing on
his stomach. He tells me that these symptoms started about three
months ago, off/on and getting progressively worse. The pressure
usually occurs with exertion and is relieved with drinking cold
water or sitting down. He is unclear how long these episodes
last but always resolve with the above measures. He denies any
nausea/vomiting/diaphoresis although may have been a little
sweaty on saturday during that episode. Also denies any abd
pain. He has normal bowel movements brown/tan color, never black
or frank blood. He has his last colonoscopy a few years ago at
[**Hospital1 **] [**Location (un) **] (no recors here). Currently he is CP free since he
has been lying down/sitting. ROS also negative for fever/chills,
+frequent cough with "upper respiratory problems". [**Name2 (NI) **]
orthopnea/pnd, but often sleeps with pillows due to GERD. GERD
symptoms are more burning in nature compared to these symptoms.
Effort tolerance unlimited although pressure sensation can occur
with minimal exertion, a few years ago walked 12 miles.
.
In the ED VS 97.7 77 147/96 16 98% RA. Given metoprolol 12.5 mg
po x 1, heparin per weight based protocol, ASA 81 mg x 1. EKG
NSR at 69, nl axis, nl intervals, S1Q3T3 pattern, no other ST-T
changes. (no old for comparison). Guaiac + clear mucus on
rectal.
.
He is now admitted for a cardiac catheterization and further
management of his cardiac disease.
Past Medical History:
- Diabetes--on metformin, recently decreased dose to 500 mg
daily due to rash; HbA1C 7.0 [**1-19**]
- Hypertension
- Hyperlipidemia.
- Arthritis of hands
- GERD
- HOH
- Myocardial Infarction
- Anxiety
Social History:
Lives with wife and daughter, still working for school with
disabled children, used to be in air force and worked for the
goverment. Quit smoking 7 years ago (prior smoked 2 ppd x 40
yrs), occasional etoh (1 drink every 2 weeks), no drugs.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father's side of family with CAD but all lived
to 80-90's. Mother's side died from stomach ulcers that became
cancerous (several members with same diagnosis). No other cancer
in family.
Physical Exam:
VS: T 98.2 BP 133/78 HR 62 RR 12 O2 96% RA Wt 183 lbs
Gen: elderly male in NAD, lying flat in bed, heavy beard,
frequently coughing.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with flat JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Distant heart sounds.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2183-6-10**] 08:00PM WBC-9.1 RBC-4.97 HGB-15.2 HCT-43.5 MCV-88
MCH-30.6 MCHC-34.9 RDW-13.3
[**2183-6-10**] 08:00PM GLUCOSE-120* UREA N-20 CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
[**2183-6-10**] 08:00PM CK-MB-6
[**2183-6-10**] 08:00PM cTropnT-0.06*
[**2183-6-10**] 08:00PM CK(CPK)-110
[**2183-6-10**] 09:30PM D-DIMER-1501*
.
EKG [**6-10**]: NSR at 69, nl axis, nl intervals, S1Q3T3 pattern, no
other ST-T changes. (no old for comparison).
.
CXR [**6-10**]: No acute cardiopulmonary process identified.
.
CTA [**6-11**]: No PE.
[**2183-6-11**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant system
demonstrated severe three (3) vessel coronary artery disease.
The left
main demonstrated no angiographic evidence of any flow limiting
lesions.
The left anterior descending artery was diffusely calcified
including a
70% proximal and 80% distal stenosis. The left circumflex was
diffusely
diseased including an 80% lesion at the origin of the vessel.
The right
coronary artery demonstrated a hazy 80-90% lesion in the
proximal
portion of the vessel along with mild diffuse disease throughout
the
remainder of the vessel.
2. LV ventriculography demonstrated a preserved left ventricle
function
with an ejection fraction of approximately 60%. The mitral
valve
appeared structurally normal without any significant
regurgitaition.
There was no significant pressure gradient across the aortic
valve upon
pullback from the left ventricle to the aorta.an elevated left
heart
filling pressure (LVEDP 24 mm Hg) along with a normal central
aortic
pressure (124/70 mm Hg).
[**2183-6-11**] ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
IMPRESSION: Preserved global and regional biventricular systolic
function. Mild mitral regurgitation with normal valve
morphology.
[**2183-6-13**] - CXR:
The pulmonary artery catheter has been removed with the right
internal jugular vascular sheath persisting. Mediastinal and
chest tubes have also been removed. Patient is status post
sternotomy and CABG with no significant change in the appearance
of the mediastinum. Lung volumes remain low and there is no
evidence of pneumothorax. Right upper lung field linear
atelectasis is unchanged. Layering left pleural effusion and
atelectasis persists. No evidence of overt failure.
Brief Hospital Course:
Mr. [**Known lastname 16745**] was admitted to the [**Hospital1 18**] on [**2183-6-10**] for further
management of his chest pain. He underwent a cardiac
catheterization which revealed severe three vessel disease.
Given these findings, the cardiac surgical service was consulted
for surgical management. Mr. [**Known lastname 16745**] was worked-up in the usual
preoperative manner and deemed suitable for surgery. On [**2183-6-12**],
Mr. [**Known lastname 16745**] was taken to the operating room where he underwent
coronary artery bypass grafting to four vessels. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. On postoperative day one,
Mr. [**Known lastname 16745**] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
Pressors were slowly weaned as tolerated. On postoperative day
two, Mr. [**Known lastname 16745**] developed atrial fibrillation which converted
back to normal sinus rhythm with intravenouos beta blocker and
repletion of his electrolytes. On postoperative day three, he
was treansferred to the step down unit for further recovery. He
was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. By post-operative day six
he was ready for discharge to home.
Medications on Admission:
HYDROCHLOROTHIAZIDE 12.5 mg--1 capsule(s) by mouth once a day
take w/ oj or banana
LIPITOR 10 mg--1 tablet(s) by mouth once a day
LISINOPRIL 40 mg--1 tablet(s) by mouth once a day
METFORMIN 500 mg--2 tab(s) by mouth q.day
PAXIL 20 mg--1 tablet(s) by mouth once a day
RANITIDINE HCL 150 mg--1 tablet(s) by mouth b.i.d.
RHINOCORT AQUA 32MCG--One spray/nostril every day
TRIAMCINOLONE ACETONIDE 0.1 %--apply twice a day as needed for
rash
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while taking percocet.
Disp:*60 Capsule(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
CAD s/p CABG
MI
Hypercholesterolemia
HTN
Diabetes Mellitus Type II
Anxiety
GERD
Pleurisy
Hearing Impaired
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Follow-up with Dr. [**Last Name (STitle) **] in [**2-15**] weeks. [**Telephone/Fax (1) 4775**]
Follow-up with cardiologist Dr. [**Last Name (STitle) **] in 2 weeks.
Call all providers for appointments.
Completed by:[**2183-6-18**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,978
| 198,761
|
5948
|
Discharge summary
|
report
|
Admission Date: [**2189-5-14**] Discharge Date: [**2189-5-26**]
Date of Birth: [**2114-5-12**] Sex: F
Service: MEDICINE
Allergies:
Magnesium Sulfate
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Chief Complaint: Dypnea
.
Reason for MICU transfer: For possible bronchoscopy
Major Surgical or Invasive Procedure:
Bronchoscopy on [**2189-5-14**]
History of Present Illness:
75 year-old with history of aortic stenosis/aortic regurgitation
([**Location (un) 109**] 0.8cm2), CAD with DES [**5-/2188**] on Plavix, PPM for AVB in
[**2184**], breast cancer in [**2153**], chronic hepatitis C and recent
admission for SVC syndrome s/p Y stent placement by IP now BIBA
from home with [**Year (4 digits) 9140**] cough and dyspnea. Patient initially
presented to PCP in [**Name9 (PRE) 547**] complaining of neck and facial
swelling. She was ultimately referred to allergy and ENT with a
neck CT ordered revealing SVC syndrome from extensive
mediastinal lymphadenopathy and chest CT showing a right
supraclavicular mass displacing the trachea and massive
mediastinal lympadenopathy. Given the CT findings, patient's
allergist called her to present to ED.
.
Had Dumon silicone Y stent placed by IP on Monday. She was
completely weaned off oxygen and had a normal ambulatory oxygen
saturation, so she was discharged home Tuesday morning. Patient
reports her breathing worsened throughout the day and she "felt
like she was drowning." Feels exhausted breathing through all
fluid, crackles with coughing. Feels she is getting weaker and
just breathing is making her very tired. Cough is productive of
mucous and occassional small amount of blood. No fevers, or
chills. No abdominal pain.
.
In the ED, initial vitals were 98.4 98 149/58 22 100% 12L. Exam
was significant for diffuse crackles and rhonchi in both lung
fields. Labs were significant for proBNP of 4048 and VBG of
7.49/43/78. Patient had CXR showing slighly worsened pulmonary
edema and RML collapse. Patient received lasix 10 mg IV,
albuterol/atrovent nebulizer treatments. She was also ordered
for vancomycin and cefepime given crackles on exam (although she
has not been febrile and no leukocytosis). Interventional
pulmonology was contact[**Name (NI) **] and recommended admission for possible
repeat bronch. Patient was admitted to ICU given high risk of
respiratory decompensation. Vitals on transfer are 98, 148/54,
96% on 4L, RR 27.
.
On arrival to the MICU, patient continues to complain of cough
and some mild dyspnea. The cough is the most bothersome
problem. [**Name (NI) **] fevers, chills, chest pain. No orthopnea.
Past Medical History:
Aortic stenosis undergoing CT SGY evaluation- critical AS,
planning for surgery this month
History of Complete Heart Block sp PPM [**6-/2185**]
Coronary artery disease: 40% RCA lesion in [**2184**], no stent placed
History of Pericarditis- prior to [**2184**]
Chronic Hepatitis C: stage II fibrosis per biopsy [**2186-10-22**]
History of Breast cancer [**2151**], s/p Lumpectomy and Radiation
therapy
Hypothyroidism
Osteoporosis/Osteopenia
History of Wrist Fracture
Pneumonia (recent)
[**Company 1543**] PPM placement in [**2184**] for 2:1 AV delay associated with
syncope
.
Past Surgical History: (per OMR)
- s/p [**Company 1543**] PPM [**2184**](Model # ADDRL1)
- s/p Bilateral Cataracts
- s/p Left Breast Lumpectomy
- s/p Laparoscopy for Endometriosis
- s/p Squamous Cell Removal
Social History:
lives alone, works as an artist(abstract art). Used to be very
active, but activities have been curtailed by symptomatic
shortness of breath. Still enjoys golf when able. Divorced, no
children.
- tobacco: former use, quit at the age of 60 - 30 yr history
- occassional ETOH use
- denies IVDA
Family History:
mother colon ca [**56**]'s
grandmother, sister with breast ca in 40s and 60s respectively
Father died in car accident
several relatives on maternal side have had valvular problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, audible breath sounds, speaking in
full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate, difficult to appreciate heart sounds given
loud rhonchi
Lungs: Diffuse rhonchi and crackles b/l
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, moving all extremities
.
DISCHARGE PHYSICAL EXAM:
General: Alert, oriented, audible breath sounds, speaking in
full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, no m/r/g
Lungs: Diffuse rhonchi and crackles b/l, improved since
admission
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, moving all extremities
Pertinent Results:
ADMISSION LABS:
-WBC-7.3 RBC-3.94* Hgb-12.7 Hct-38.7 MCV-98 MCH-32.2* MCHC-32.8
RDW-13.1 Plt Ct-142*
-Neuts-79.9* Lymphs-11.4* Monos-7.5 Eos-0.9 Baso-0.3
-PT-10.9 PTT-27.2 INR(PT)-1.0
-Glucose-140* UreaN-15 Creat-0.6 Na-138 K-3.5 Cl-99 HCO3-28
AnGap-15
-Calcium-9.4 Phos-2.9 Mg-1.8
-ALT-44* AST-57* AlkPhos-65 TotBili-0.4
-proBNP-4048*
-VENOUS BLOOD GAS: Type-[**Last Name (un) **] pO2-78* pCO2-43 pH-7.49* calTCO2-34*
Base XS-8 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
.
IMAGING
CXR [**2189-5-14**]
IMPRESSION:
1. Right middle lobe collapse. CT would be required to evaluate
airway
patency.
2. Mild CHF, with interstitial fluid and slight increase in
bilateral pleural effusions.
3. Stable bilateral paratracheal lymphadenopathy.
.
CT CHEST [**2189-5-18**]
1. Interval decrease in size of soft tissue encasing the
mediastinum. The
tracheal Y-stent has been placed in the interim, and remains
widely patent,
without extrinsic compression. The SVC remains markedly
narrowed, and is not significantly changed in appearance
compared with [**5-7**].
2. Interval increase in now moderate-sized bilateral pleural
effusions, with bibasilar atelectasis. Multiple foci of
irregular pleural thickening are noted, concerning for
lymphomatous implants. Ground-glass opacity within the anterior
segment of the right upper lobe abutting the minor fissure is
new compared with prior, is nonspecific. An 8-mm nodule in the
left upper lobe appears new.
3. Left breast mass, with adjacent surgical clips and skin
thickening, better evaluated with mammography.
.
Renal US [**2189-5-19**]
IMPRESSION: No evidence of hydronephrosis.
CT Chest ([**2189-5-24**]):
1. Persistent soft tissue encasement of the mediastinum with
unchanged severe narrowing of the SVC. Overall, soft tissue
density within the mediastinum appears unchanged compared to
recent prior examination.
2. Widely patent Y-stent within the distal trachea and main
stem bronchi. No extrinsic compression or narrowing.
3. Persistent small left pleural effusion with resolution of
prior right
pleural effusion.
4. Decreased density of prior ground glass opacities seen
within the right upper lobe suggesting interval improvement of
probable prior infectious or inflammatory process.
5. Resolution of prior 8-mm left upper lobe pulmonary nodule,
likely related to focal atelectasis or inflammation.
.
MICROBIOLOGY
Blood Cx [**5-14**]-NGTD
HCV VIRAL LOAD (Final [**2189-5-15**]):
4,129,314 IU/mL.
.
Sputum
GRAM STAIN (Final [**2189-5-16**]):
[**10-15**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2189-5-18**]):
MODERATE GROWTH Commensal Respiratory Flora.
.
Urine Cx
[**5-18**], [**5-19**]- NGTD
.
Pleural Fluid ([**2189-5-20**]):
The cytology specimen shows rare atypical epithelioid cells in a
background of reactive mesothelial cells, histiocytes, and
scattered predominantly small lymphocytes. Immunophenotypic
findings consistent with involvement by a kappa light chain
restricted B-cell lymphoma. Please correlate with
cytogenetics/FISH, cytology and clinical findings.
.
Pleural Fluid Cell Block ([**2189-5-20**]):
Immunohistochemical stains confirm the presence of many CD68+
histiocytes and mesothelial cells (Calretinin+, WT-1+). MOC31
and B72.3 are negative. Mammoglobin and GCDFP are
noncontributory. CD45 highlights background small lymphocytes
which are predominantly CD3+ T cells; CD20 stains rare B cells.
Overall, the morphologic and immunophenotypic findings support
the above diagnosis. See also the concurrent cytology specimen
(C12-17840T).
.
Urine Cytology ([**2189-5-20**]):
Atypical urothelial cells, present singly and in rare clusters.
.
FISH ([**2189-5-21**]):
FISH evaluation for a MYC rearrangement was performed on
nuclei with the LSI MYC Dual Color Break Apart
Rearrangement Probe ([**Doctor Last Name 7594**] Molecular) at 8q24 and is
interpreted as NORMAL. No rearrangement was observed in
100/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory
at [**Hospital1 18**]. Up to 4% of cells in normal samples can show
apparent MYC rearrangement using this probe set. A normal
MYC FISH finding can result from absence of a MYC
rearrangement, from an atypical MYC rearrangement, or from
an insufficient number of neoplastic cells in the
specimen.
.
FISH evaluation for an IGH@-BCL2 rearrangement was
performed on nuclei with the LSI IGH@/BCL2 Dual Color,
Dual Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for
IGH@ at 14q32 and BCL2 at 18q21 and is interpreted as
NORMAL. No rearrangement was observed in 100/100 nuclei,
which is within the the normal range established for these
probes in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 1%
of normal samples can show apparent IGH@-BCL2 rearragement
using this probe set. A normal FISH finding can result
from the absence of IGH@-BCL2 rearrragement, from a
variant IGH@-BCL2 rearrangement, or from an insufficient
number of neoplastic cells in the specimen.
.
These FISH tests were developed and their performance
determined by the [**Hospital1 18**] Cytogenetics Laboratory as
required by the CLIA '[**64**] regulations. They have not been
cleared or approved by the U.S. Food and Drug
Administration. The FDA has determined that such clearance
or approval is not necessary. These tests are used for
clinical purposes.
Brief Hospital Course:
Primary Reason for Admission: 74 year old woman with a h/o
breast cancer, right clavicular squamous cell carcinoma, chronic
HCV, and GERD with known large right infraclavicular mass
impinging on her esophagus, trachea, and SVC syndrome, s/p XRT,
recent transbronchial biopsy and Y-stent placement by IP, now
with [**Year (2 digits) 9140**] dyspnea.
.
ACTIVE ISSUES
.
# B Cell Lymphoma: Patient with mediastinal mass causing SVC
syndrome and tracheal compression. Heme/onc saw patient on HD1
and recommended biopsy to procure additional tissue to assist
with diagnosis. Patient's condition worsened on HD2 and
decision was made to start treatment, and in the ICU she was
started on prednisone/solumedrol and cytoxan. TLS labs were
monitored and pt was maintained on allopurinol daily. She was
seen by radiation oncology and started radiation therapy. A
femoral line was placed and the patient was started on [**Hospital1 **].
She improved and was called out to the BMT service. There, she
finished her [**Hospital1 **] and her femoral line was pulled. Final
pathology of her biopsy showed Lambda restricted CD10 positive
B-cell lymphoma.
.
# Dyspnea: Likely [**1-22**] mediastinal mass and Y-stent, along with
mild volume overload. Suspected lymphoma was causing tracheal
compression as well as SVC syndrome. She has associated RML
collapse suspect secondary to proximal obstruction. Pt was
continued on mucinex, sodium chloride nebs, and acetylcystein
nebs. On HD 2 patient had increasing air hunger and work of
breathing which nearly prompted intubation, but was avoided with
frequent nebulizers, morphine and lasix. She continued to have
difficulty clearing secretions which was likely due to the
tracheal stent. She has underlying CHF due to her AS with
evidence of [**Month/Day (2) 9140**] pleural effusions on CXR, and likely has
underlying COPD due to smoking history. No fever or
leukocytosis to suggest development of pneumonia and sputum
culture was unremarkable. The patient had a CT of her chest
which showed her Y stent was patent. IP did not recommend
removal. The patients respiratory status improved with diuresis
and she was called out to the floor on HD 4. However on HD 5 she
became acutely short of breath after receiving fluids. She was
given 40 mg IV lasix transferred to the [**Hospital Unit Name 153**]. She was duiresed
4L. She additionally underwent thoracentesis with removal of 1L
of clear yellow fluid. Cytology demonstrated clonal B cells (see
report). Respiratory status improved and she was weaned to room
air. She was then transferred to the BMT service where she
remained stable. CT chest was repeated and showed a patent Y
stent. Her cough improved and he was kept net neutral for the
remainder of her course. IP recommended leaving the stent in
place; she will f/u with IP on [**6-6**] for re-evaluation.
.
# Hematuria: The patient was noted to develop hematuria
concerning for hemorraghic cystitis. Urine was grossly bloody.
Urology was consulted and recommended continuous bladder
irrigation. Renal US was without evidence of hydronephrosis.
Urine cytology demonstrated few atypical urothelial cells,
present singly and in rare clusters. She was additionally
started initially on levofloxacin with transition to
ciprofloxacin for a 7 day course (empiric treatment of a
complicated UTI). Urine was noted to clear and CBI was
discontinued. She completed full course of Cipro for UTI; urine
cultures negative.
.
CHRONIC ISSUES:
.
# Critical Aortic Stenosis with AI/MR: Mild acute on chronic
exacerbation given increased edema/effusions on CXR. Patient
diuresed with improvement in dyspnea (see above). She should be
evaluated for AVR once medically stable.
.
# CAD: Proximal RCA 95% stenosis with DES to RCA 6/[**2187**].
Continue on aspirin/stain/beta blocker. Her home beta blockage
was increased to TID however her blood pressure did not tolerate
this change and the dose was decreased back to [**Hospital1 **]. Plavix had
been recently discontinued (in consultation with patient's
cardiologist) as it had been nearly one year since stent
placement.
.
# GERD: Continued omeprazole/sucralfate.
.
# Chronic HCV with transaminitis: No liver masses on abdominal
CT scan. Trended LFTs during admission.
.
# Hypothyroidism: Continued home levothyroxine.
.
# HLD: Continued atorvastatin 40 mg daily.
.
TRANSITIONS OF CARE: She was d/c'ed home with services. She will
f/u with Heme/Onc on [**5-27**] for ongoing management.
Medications on Admission:
atorvastatin 40 mg daily
aspirin 81 mg daily
levothyroxine 125 mcg
clobetasol 0.05% daily
furosemide 20 mg every other day
metoprolol succinate 25 mg daily
patanol 0.1% gtt [**Hospital1 **] PRN eye discomfort
omeprazole 20 mg daily
sucralfate 1 gram TID
cholecalciferol 400 units daily
mvi 1 tablet daily
calcium carbonate 500 mg [**Hospital1 **]
sodium chloride 3% nebs TID
acetylcysteine 20% nebs TID
mucinex 1200 mg [**Hospital1 **]
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. clobetasol 0.05 % Cream Sig: One (1) application Topical
twice a day as needed for rash.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO every other
day.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
7. Patanol 0.1 % Drops Sig: One (1) drop Ophthalmic twice a day
as needed for eye discomfort.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
13. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1)
nebulizer Intravenous three times a day as needed for
congestion.
14. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1)
Tablet, ER Multiphase 12 hr PO twice a day.
15. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*902 Tablet(s)* Refills:*0*
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
20. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
Disp:*1 bottle* Refills:*0*
21. filgrastim 300 mcg/mL Solution Sig: One (1) injection
Injection Q24H (every 24 hours) for 10 days: 7-10 days (to be
determined by Oncologist).
22. sodium chloride 2.65 % Aerosol, Spray Sig: One (1) nebulizer
Nasal three times a day as needed for shortness of breath or
wheezing.
23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
Disp:*15 treatments* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
1. Acute hypoxemic respiratory failure
2. Mediastinal B-cell lymphoma
3. Acute hematuria
.
Secondary Diagnoses:
1. Critical aortic stenosis
2. Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Bone Marrow Transplantation service at
[**Hospital1 69**] on [**Hospital Ward Name 1826**] 7 regarding
management of your shortness of breath in the setting of your
malignancy. You had a Y-stent placed by the Interventional
Pulmonology team which improved your breathing. You were feeling
improved at the time of discharge and will continue Neupogen
injections to improve your cell counts on discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or [**Hospital Ward Name 9140**] cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* You have pain that is not improving within 12 hours or is not
under control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
PLEASE NOTE THESE CHANGES IN YOUR MEDICATIONS:
.
* Upon admission, we ADDED:
START: Allopurinol 300 mg by mouth daily
START: Sulfamethoxazole-trimethoprim (Bactrim) 800-160 mg by
mouth daily
START: Acyclovir 400 mg by mouth every 8-hours
START: Senna 8.6 mg by mouth twice daily as needed; Colace 100
mg by mouth twice daily as needed; both for constipation
START: Nystatin 100,000 unit/mL suspension 5 mL by mouth three
times daily until thrush clears
START: Filgrastim (Neupogen) 300 mcg injections daily in the
[**Hospital **] clinic for 7-10 days
START: Albuterol nebulizer treatments Q4-6 hours as needed for
wheezing or shortness of breath
.
* This admission, we CHANGED: NONE
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: WEDNESDAY [**2189-5-27**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
.
Department: BMT/ONCOLOGY UNIT
When: THURSDAY [**2189-5-28**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
.
Department: [**Hospital **] MEDICAL GROUP
When: THURSDAY [**2189-5-28**] at 11:30 AM
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
.
[**2189-6-1**] 01:00p [**Last Name (LF) 3920**],[**First Name3 (LF) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC
Create Visit Summary
.
[**2189-6-1**] 01:00p BMT [**Apartment Address(1) 1641**] BMT CHAIRS & ROOMS
.
[**2189-6-1**] 12:30p [**Last Name (LF) 3919**],[**First Name3 (LF) **] E.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC
Create Visit Summary
.
[**2189-6-1**] 12:30p [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC
Create Visit Summary
.
[**2189-5-31**] 10:00a BED 1 (F)
FD [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
HEMATOLOGY/ONCOLOGY-7F
Create Visit Summary
.
[**2189-5-30**] 10:00a BED 1 (F)
FD [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
HEMATOLOGY/ONCOLOGY-7F
Create Visit Summary
.
[**2189-5-29**] 10:00a BED 2 (F)
FD [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
|
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icd9cm
|
[
[
[]
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"38.97",
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,602
| 108,451
|
11990
|
Discharge summary
|
report
|
Admission Date: [**2193-9-19**] Discharge Date: [**2193-9-25**]
Date of Birth: [**2124-5-26**] Sex: M
Service: SURGERY
Allergies:
lobster
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Abdominal Aortic Aneurysm
Major Surgical or Invasive Procedure:
PROCEDURE: Resection of juxtarenal aortic aneurysm.
History of Present Illness:
The patient is a 69-year-old male with an identified 5.7-cm
juxtarenal aortic aneurysm extending down just to the aortic
bifurcation.
Past Medical History:
PMHx:
-DJD spine
-CAD
-HTN- checks BP at home and states, SBP ~110/60 consistently
-Hyperlipidemia
-AAA, which was followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**]
-Trigger finger
-GERD - controlled with omeprazole
-Raynaud's
-bilateral cataracts
.
PSH:
-CABG x 4 vessel ([**2176**])
-tonsilectomy and adenoidectomy
-Left inguinal hernia repair approximately 10 years ago
Social History:
Smoke: 1.5 ppd (previously 2ppd) x 50 years
EtOH: daily glass of wine most nights; occassionally more on
social occassions, no recent episode of binge drinking
Drugs: none
Lives: [**Location (un) **], lives alone with cat, works as quality
technician
Family History:
No family history of GI issues or malignancies
FHx of heart disease, HTN, CAD
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 99.7 HR 65 BP 107/48 96% on RA.
Gen: Pleasant, NAD, AOx3
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No carotid bruits.
CV: RRR, normal S1,S2. No murmurs, rubs, clicks, or [**Last Name (un) 549**]
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. No palpable mass. Incision
c/d/i.
EXT: MAE, warm to touch. No c/c/e.
PULSE: Femoral palpable, DP and PT dopplerable bilaterally
Pertinent Results:
[**2193-9-24**] 06:58AM BLOOD WBC-5.8 RBC-3.52* Hgb-11.5* Hct-34.0*
MCV-97 MCH-32.6* MCHC-33.8 RDW-14.2 Plt Ct-150
[**2193-9-21**] 03:26AM BLOOD WBC-8.8 RBC-3.10* Hgb-10.3* Hct-29.3*
MCV-95 MCH-33.1* MCHC-35.0 RDW-15.1 Plt Ct-70*
[**2193-9-20**] 02:09AM BLOOD WBC-8.5 RBC-3.76* Hgb-12.2* Hct-35.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-15.4 Plt Ct-115*
[**2193-9-20**] 02:09AM BLOOD WBC-8.5 RBC-3.76* Hgb-12.2* Hct-35.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-15.4 Plt Ct-115*
[**2193-9-19**] 11:23AM BLOOD Hct-42.0 Plt Ct-135*
[**2193-9-23**] 03:00AM BLOOD PT-12.2 PTT-24.9 INR(PT)-1.0
[**2193-9-19**] 03:09PM BLOOD PT-15.1* PTT-32.9 INR(PT)-1.3*
[**2193-9-19**] 11:23AM BLOOD PT-14.8* PTT-31.9 INR(PT)-1.3*
[**2193-9-24**] 06:58AM BLOOD Glucose-109* UreaN-26* Creat-1.2 Na-142
K-3.7 Cl-105 HCO3-29 AnGap-12
[**2193-9-21**] 03:26AM BLOOD Glucose-117* UreaN-24* Creat-1.7* Na-135
K-4.5 Cl-104 HCO3-24 AnGap-12
[**2193-9-19**] 11:23AM BLOOD Glucose-142* UreaN-26* Creat-1.3* Na-141
K-5.6* Cl-114* HCO3-21* AnGap-12
[**2193-9-22**] 04:17AM BLOOD CK(CPK)-499*
[**2193-9-21**] 01:27PM BLOOD CK(CPK)-1074*
[**2193-9-21**] 09:58AM BLOOD CK(CPK)-1066*
[**2193-9-20**] 02:09AM BLOOD ALT-13 AST-34 LD(LDH)-350* AlkPhos-53
Amylase-32 TotBili-0.4
[**2193-9-19**] 11:23AM BLOOD ALT-10 AST-17 AlkPhos-68 TotBili-0.4
[**2193-9-22**] 01:22AM BLOOD CK-MB-2 cTropnT-<0.01
[**2193-9-21**] 01:27PM BLOOD CK-MB-3 cTropnT-<0.01
[**2193-9-21**] 09:58AM BLOOD CK-MB-3 cTropnT-<0.01
[**2193-9-19**] 11:23AM BLOOD CK-MB-3 cTropnT-<0.01
[**2193-9-23**] 03:00AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.2
[**2193-9-21**] 01:27PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2193-9-19**] 11:23AM BLOOD Albumin-2.8* Calcium-7.0* Phos-4.6*#
Mg-1.8
[**2193-9-20**] 02:05PM BLOOD Lactate-1.3
[**2193-9-19**] 09:16PM BLOOD Glucose-135* K-4.7
[**2193-9-19**] 09:16PM BLOOD freeCa-1.18
[**2193-9-19**] 10:30AM BLOOD freeCa-1.01*
CXR:
IMPRESSION:
1. Interval removal of the right internal jugular Swan-Ganz
catheter with the introducer remaining in place and having its
tip in the proximal SVC. Stable cardiac and mediastinal contours
in this patient status post median sternotomy for CABG. Patchy
bibasilar opacities, left greater than right in the setting of
low lung volumes most likely represents bibasilar atelectasis.
Small left pleural effusion. Low lung volumes with crowding of
the pulmonary vascularity and no overt pulmonary edema. No
pneumothorax.
Brief Hospital Course:
VASCULAR: The patient was admitted to the Vascular Surgery
Service on [**9-19**] and had a Juxta renal resection of AAA.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. EBL was roughly 2L and patient
received 3 units of RPBCs and 900cc of cell [**Doctor Last Name 10105**]
intraoperatively in addition to IVF. He tolerated the procedure
well without any difficulty or complication (reader referred to
operative note for details).
Post-operatively, he was transferred to the CVICU for further
stabilization and monitoring. He received 500cc of albumin and
IVF fluid for resuscitation but was otherwise hemodynamically
stable. He was kept in CV ICU for close monitoring with A-line,
PA Catheter, Foley, and Telemetry to monitor him during his
resuscitation and for fluid shifts.
He was then transferred to the VICU for further recovery. While
in the VICU he received monitored care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabilized from the acute setting of post operative care,
he was transferred to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. Staples were removed on POD 7 and replaced with
steri-strips. Incision remained c/d/i. He progressed with
physical therapy to improve her strength and mobility. He
continues to make steady progress without any incidents. He was
discharged home with VNA in stable condition.
Neuro: Pre - pt received a epidural catheter infusing the APS
solution. This was removed POD # 3. After removal the patient
received Dilaudid IV/PCA with good effect and adequate pain
control. When tolerating oral intake, the patient was transition
to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. Pt did have a new RBBB. A
cardiology consult was obtained. The RBBB was thought to be
caused by the PA catheter. After this was removed. Pt HR
returned to NSR. There is no sequelae for the event.
Pulmonary: Post operatively the patient required 02 via nasal
canula and face tent to provide adequate oxygenation. Patient
was actively diuresed and given nebulizers and the breathing
improved. At time of discharge, he was breathing on room air
without respiratory distress.
GI: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Before DC he is taking PO and had a
bowel movement.
GU: Foley was removed on POD#3. Intake and output were closely
monitored. Pt is urinating on DC.
ID: Pt received perioperative antibiotics. The patient's
temperature was closely watched for signs of infection. Sputum
culture revealed normal respiratory flora.
Heme: The patient received subcutaneous heparin during this
stay, This was stopped because of platelet drop to 70. A HIT was
sent this was negative. He was begun on aspirin before
discharge.
Prophylaxis: Pt was put on Pneumo Boots because of the
aforementioned platelet drop. He was encouraged to get up and
ambulate as early as possible.
At the time of discharge on POD#7, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 80 '; BUPROPION HCL - 150
ER';LISINOPRIL 10' METOPROLOL SUCCINATE - 50 ER'; OMEPRAZOLE
20'; ASPIRIN -325'; NIACIN 500'
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 10 days: prn for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO HS (at bedtime).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual x 3: with chest pain, call PCP if pain persists.
14. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]vna
Discharge Diagnosis:
juxtarenal aortic aneurysm.
CAD ; HTN ; Hyperlipidemia; GERD; Raynaud's ; diverticulosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**4-24**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-20**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8244**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2193-12-12**]
1:00
Call Dr [**Last Name (STitle) 11918**] office and schedule an appointment for 2
weeks. [**Telephone/Fax (1) 1393**]
|
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icd9cm
|
[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,975
| 147,212
|
50456
|
Discharge summary
|
report
|
Admission Date: [**2129-3-27**] Discharge Date: [**2129-4-5**]
Date of Birth: [**2053-10-3**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Atenolol / Ultram
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
AMS, R gaze deviation and nystagmus
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 75 year-old woman with a PMH of a prior L MCA
infarct ([**2124**]) with reported residual Wernicke's aphasia. She
also has a PMH of HTN, hypothyroidism, possible SSS s/p pacer
and
recent ARF. She was brought here this morning after being found
"unresponsive" at her NH.
I attempted to get further history from her NH as there was no
EMS transfer record. Per their report, she was last well the
evening prior. This morning she did not come down for breakfast,
[**Name6 (MD) **] the RN went to check on her at around 9:20 or 9:30. She found
her sitting without a facial droop, weakness or eye deviation
awake but "not really responding". She described her as opening
her eyes to voice and touch and mumbling but not understandably.
She was also not following commands. She seemed to be able to
mover her eyes laterally in both directions but not tracking.
She
was also noted to be "snoring" and puffing her cheeks. EMS was
called and she was brought here.
I attempted to reach her brother who is her HCP but there was
only a voice mail without an identifying name so I did not leave
a message. I also contact[**Name (NI) **] her PCP, [**Last Name (NamePattern4) **].[**Name (NI) 51133**] office, and
spoke briefly with the covering physician who could not provide
further details.
In our ED she was febrile to 101.8, HR in the 80's but her BP
ranged from 160-200/50's (wide pulse pressure). Her BS was 131.
She was given 1mg of ativan without effect. She was given
empiric
vanc and gent prior to LP.
Of note, Ms. [**Known lastname 28272**] was last discharged on [**3-4**] from [**Hospital1 18**]
after
an admission for ARF after prepping for a colonoscopy. Her Cr on
discharge was 1.0. She was last seen by neurology in [**2124**]. At
that time she was being evaluated for her recent stroke w/
residual aphasia but no clear evidence of weakness or other
focality.
Per her NH, at baseline she is somewhat dependant in her ADLS
and
has mild dementia (has meals, cleaning and meds done for her but
is able to feed herself). She walks with a walker and per their
report does not have weakness or speech impairments.
Past Medical History:
- Left MCA/temporal stroke -[**2124**]
- Wernicke's Aphasia
- Peripheral Arterial Disease
- Suspected sick sinus syndrome s/p pacer
- Status-post right femoral/anterior tibial bypass graft-[**2124**]
- Hypertension
- Hypothyroidism
- Psoriatic Arthritis
- Status post total abdominal hysterectomy
- History of basilar skull fracture status post fall
- Remote history of alcohol abuse
- Known/stable ulcerations in descending thoracic aorta
- Anemia
- Depression
Social History:
-She is retired, used to work as a clothes maker.
-Lives at [**Doctor Last Name **] House in [**Location (un) 86**] ([**Telephone/Fax (1) 105127**] (although per the
records [**Location (un) 583**] House Rehab)
-tobacco negative
-EtOH + per prior records
-drugs unknown
-PCP + [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**] [**Telephone/Fax (1) 608**]
Family History:
per prior notes
Thyroid disease and arthritis run in the family. Sister has
lupus.
Physical Exam:
Vitals: T: 101.8 PR P: 82 R: 16 BP: 165/55 - 200/50 SaO2: 100%
2L
NC
General: somnulant, snoring
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: rigid in all directions, no carotid bruits appreciated but
difficult to assess given loud snoring
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 edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: somnulant, does not respond to nox stim except
with L arm where she flexes slightly
CN
I: not tested
II,III: no blink to threat, pupils 5mm->3mm bilaterally, fundi
normal
III,IV,V: R gaze deviation with intermittent nystagmus and then
slow phase to the L but irregular.
V: + corneals & nasal tickle
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: face symmetric, + gag
[**Doctor First Name 81**]: UA
XII: UA
Motor: increased tone, L>R arm and leg. no spontaneous
movements,
L arm withdraws slightly to nox stim
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 1 up
R 2 2 2 2 2 up
-Sensory: as above
-Coordination: UA
-Gait: UA
Pertinent Results:
[**2129-4-4**] 01:39AM BLOOD WBC-5.5 RBC-2.91* Hgb-8.8* Hct-26.5*
MCV-91 MCH-30.3 MCHC-33.3 RDW-16.4* Plt Ct-256
[**2129-4-3**] 03:01AM BLOOD WBC-5.3 RBC-2.44* Hgb-7.4* Hct-22.4*
MCV-92 MCH-30.5 MCHC-33.2 RDW-15.9* Plt Ct-257
[**2129-4-2**] 01:59AM BLOOD WBC-5.6 RBC-2.50* Hgb-8.0* Hct-22.9*
MCV-92 MCH-31.9 MCHC-34.9 RDW-15.7* Plt Ct-232
[**2129-4-1**] 02:30AM BLOOD WBC-7.9 RBC-2.83* Hgb-8.6* Hct-25.7*
MCV-91 MCH-30.2 MCHC-33.4 RDW-15.7* Plt Ct-275
[**2129-3-31**] 02:26AM BLOOD WBC-6.7 RBC-2.50* Hgb-8.0* Hct-22.9*
MCV-92 MCH-32.0 MCHC-34.9 RDW-15.4 Plt Ct-239
[**2129-3-30**] 01:27AM BLOOD WBC-6.7 RBC-2.71* Hgb-8.6* Hct-24.7*
MCV-91 MCH-31.7 MCHC-34.7 RDW-15.5 Plt Ct-239
[**2129-3-29**] 02:13AM BLOOD WBC-8.5 RBC-2.85* Hgb-8.7* Hct-26.5*
MCV-93 MCH-30.7 MCHC-33.0 RDW-15.9* Plt Ct-239
[**2129-3-28**] 01:13PM BLOOD WBC-5.7 RBC-2.88* Hgb-9.4* Hct-26.7*
MCV-93 MCH-32.6* MCHC-35.0 RDW-15.4 Plt Ct-220
[**2129-3-28**] 04:00AM BLOOD WBC-6.4# RBC-3.29* Hgb-10.4* Hct-30.5*
MCV-93 MCH-31.5 MCHC-33.9 RDW-15.6* Plt Ct-223
[**2129-3-27**] 10:30AM BLOOD WBC-4.0 RBC-3.37* Hgb-10.4* Hct-31.9*
MCV-95 MCH-30.8 MCHC-32.5 RDW-15.6* Plt Ct-270
[**2129-3-27**] 10:30AM BLOOD Neuts-65.7 Lymphs-20.2 Monos-9.6 Eos-3.6
Baso-0.9
[**2129-4-4**] 03:13AM BLOOD PT-13.0 PTT-62.0* INR(PT)-1.1
[**2129-4-4**] 01:39AM BLOOD Plt Ct-256
[**2129-4-3**] 03:58PM BLOOD PTT-58.4*
[**2129-4-3**] 05:08AM BLOOD PTT-63.0*
[**2129-4-2**] 01:59AM BLOOD PT-13.9* PTT-44.2* INR(PT)-1.2*
[**2129-4-1**] 02:30AM BLOOD PT-14.3* INR(PT)-1.2*
[**2129-3-27**] 10:30AM BLOOD PT-13.3 PTT-25.8 INR(PT)-1.1
[**2129-4-4**] 01:39AM BLOOD Glucose-103 UreaN-20 Creat-0.7 Na-134
K-4.3 Cl-101 HCO3-28 AnGap-9
[**2129-4-3**] 03:01AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-132*
K-4.5 Cl-99 HCO3-28 AnGap-10
[**2129-4-1**] 07:33PM BLOOD K-4.5
[**2129-4-1**] 02:30AM BLOOD Glucose-107* UreaN-15 Creat-0.9 Na-130*
K-4.6 Cl-101 HCO3-23 AnGap-11
[**2129-3-31**] 08:51PM BLOOD K-3.9
[**2129-3-31**] 09:57AM BLOOD K-3.8
[**2129-3-31**] 02:26AM BLOOD Glucose-116* UreaN-17 Creat-1.1 Na-132*
K-4.2 Cl-103 HCO3-22 AnGap-11
[**2129-3-30**] 01:27AM BLOOD Glucose-116* UreaN-20 Creat-1.2* Na-128*
K-4.0 Cl-100 HCO3-21* AnGap-11
[**2129-3-29**] 12:42PM BLOOD Glucose-86 UreaN-20 Creat-1.3* Na-129*
K-3.7 Cl-101 HCO3-20* AnGap-12
[**2129-3-29**] 02:13AM BLOOD Glucose-137* UreaN-22* Creat-1.5* Na-132*
K-3.9 Cl-103 HCO3-19* AnGap-14
[**2129-3-28**] 01:13PM BLOOD Glucose-107* UreaN-18 Creat-1.2* Na-134
K-4.3 Cl-103 HCO3-21* AnGap-14
[**2129-3-28**] 04:00AM BLOOD Glucose-109* UreaN-17 Creat-1.1 Na-131*
K-4.1 Cl-99 HCO3-24 AnGap-12
[**2129-3-27**] 10:30AM BLOOD Glucose-99 UreaN-22* Creat-1.2* Na-139
K-4.5 Cl-105 HCO3-26 AnGap-13
[**2129-3-30**] 05:10PM BLOOD CK(CPK)-205*
[**2129-3-30**] 08:28AM BLOOD CK(CPK)-244*
[**2129-3-30**] 01:27AM BLOOD CK(CPK)-319*
[**2129-3-28**] 04:00AM BLOOD CK(CPK)-242*
[**2129-3-27**] 05:16PM BLOOD CK(CPK)-254*
[**2129-3-27**] 10:30AM BLOOD ALT-12 AST-26 CK(CPK)-125 AlkPhos-79
TotBili-0.6
[**2129-3-27**] 10:30AM BLOOD Lipase-38
[**2129-3-30**] 05:10PM BLOOD CK-MB-5 cTropnT-0.61*
[**2129-3-30**] 08:28AM BLOOD CK-MB-6 cTropnT-0.58*
[**2129-3-30**] 01:27AM BLOOD CK-MB-7 cTropnT-0.62*
[**2129-3-28**] 04:00AM BLOOD CK-MB-15* MB Indx-6.2* cTropnT-0.54*
[**2129-3-27**] 05:16PM BLOOD cTropnT-0.79*
[**2129-3-27**] 05:16PM BLOOD CK-MB-25* MB Indx-9.8*
[**2129-3-27**] 10:30AM BLOOD CK-MB-15* MB Indx-12.0*
[**2129-3-27**] 10:30AM BLOOD cTropnT-0.40*
[**2129-4-4**] 01:39AM BLOOD Albumin-2.4* Calcium-7.1* Phos-3.1 Mg-2.2
[**2129-4-3**] 03:01AM BLOOD Albumin-2.7* Calcium-7.6* Phos-1.9*
Mg-2.3
[**2129-4-2**] 01:59AM BLOOD Albumin-2.9* Calcium-7.9* Phos-1.8*
Mg-1.9
[**2129-4-1**] 02:30AM BLOOD Calcium-8.5 Phos-1.3* Mg-2.5
[**2129-3-31**] 02:26AM BLOOD Albumin-2.7* Calcium-9.1 Phos-2.0* Mg-2.0
[**2129-3-30**] 01:27AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.9 Mg-1.8
[**2129-3-29**] 12:42PM BLOOD Calcium-8.1* Phos-2.5* Mg-2.1
[**2129-3-29**] 02:13AM BLOOD Albumin-2.8* Calcium-7.3* Phos-2.8 Mg-1.6
[**2129-3-28**] 04:00AM BLOOD Albumin-3.4 Calcium-8.3* Phos-2.8 Mg-1.7
[**2129-3-27**] 10:30AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.2 Mg-2.2
[**2129-4-1**] 06:57AM BLOOD Osmolal-274*
[**2129-4-1**] 06:57AM BLOOD TSH-2.0
[**2129-3-28**] 04:00AM BLOOD TSH-0.25*
[**2129-4-1**] 06:57AM BLOOD Free T4-0.69*
[**2129-3-28**] 01:13PM BLOOD Free T4-1.2
[**2129-4-1**] 07:33PM BLOOD Vanco-29.7*
[**2129-4-1**] 06:57AM BLOOD Vanco-34.1*
[**2129-4-4**] 01:39AM BLOOD Phenyto-7.0*
[**2129-4-3**] 03:01AM BLOOD Phenyto-10.0
[**2129-4-2**] 01:59AM BLOOD Phenyto-12.5
[**2129-4-1**] 06:57AM BLOOD Phenyto-15.0
[**2129-3-31**] 02:26AM BLOOD Phenyto-15.3
[**2129-3-30**] 01:27AM BLOOD Phenyto-14.8
[**2129-3-29**] 02:13AM BLOOD Phenyto-12.6
[**2129-3-28**] 04:00AM BLOOD Phenyto-11.5
[**2129-3-27**] 08:24PM BLOOD Phenyto-<0.6*
[**2129-3-27**] 10:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2129-4-4**] 02:17AM BLOOD Type-ART pO2-174* pCO2-43 pH-7.41
calTCO2-28 Base XS-2
[**2129-4-2**] 02:24AM BLOOD Type-ART pO2-139* pCO2-38 pH-7.46*
calTCO2-28 Base XS-3
[**2129-4-1**] 04:34PM BLOOD Type-ART pO2-117* pCO2-34* pH-7.46*
calTCO2-25 Base XS-1
[**2129-3-31**] 09:55PM BLOOD Type-ART pO2-96 pCO2-36 pH-7.43
calTCO2-25 Base XS-0
[**2129-3-31**] 06:46AM BLOOD Type-ART pO2-153* pCO2-37 pH-7.39
calTCO2-23 Base XS--1
[**2129-3-30**] 06:47PM BLOOD Type-ART pO2-112* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
[**2129-3-30**] 11:43AM BLOOD Type-ART pO2-165* pCO2-36 pH-7.41
calTCO2-24 Base XS-0
[**2129-3-30**] 06:39AM BLOOD Type-ART pO2-187* pCO2-36 pH-7.40
calTCO2-23 Base XS--1
[**2129-3-30**] 01:37AM BLOOD Type-ART pO2-164* pCO2-36 pH-7.43
calTCO2-25 Base XS-0
[**2129-3-29**] 07:36PM BLOOD Type-ART pO2-87 pCO2-35 pH-7.37
calTCO2-21 Base XS--3
[**2129-3-29**] 05:15PM BLOOD Type-ART pO2-83* pCO2-35 pH-7.38
calTCO2-22 Base XS--3
[**2129-3-29**] 03:42PM BLOOD Type-ART pO2-69* pCO2-34* pH-7.38
calTCO2-21 Base XS--3
[**2129-3-28**] 01:49PM BLOOD Type-ART Temp-37.7 Rates-14/ Tidal V-450
PEEP-10 FiO2-50 pO2-130* pCO2-43 pH-7.32* calTCO2-23 Base XS--3
-ASSIST/CON Intubat-INTUBATED
Brief Hospital Course:
This 75 F was admitted with AMS, R gaze devaition and nystagmus
as outlined in the HPI. It was felt that she might be having a
seizure, however her bedside EEG's just showed global slowing.
Nonetheless, she was maintained on Dilantin and started on
Lamictal, to be weane up slowly and the dilantin to be taken off
when lamictal was therapeutic. Her course was complicated by
multiple infections, namely a UTI and PNA, and she received a
course of antibiotics. She also had an LP which showed some
WBC's, slightly out of proportion to RBC's and so she was
temporarily on acyclovir. However she developed ARF as a result
(also possibly as a result of IV contrast) and so acyclovir was
DC'd when no PLED's were appreciated on the EEG. She was
followed with serial CT scans, and one on [**3-30**] showed the
presence of what appeared to be a new infarct in the left
periventricular white matter. This coincided with a change in
her RUE motor exam (from flexion to extensor posturing) as well
as incidents of her heart rhythm going in and out of AF, and
thus she was started on a heparin gtt. In addition to AF with
RVR, she was noted to have episodes of pauses and required
transcutaneous pacing leads for several days. Her neurological
exam remained unchanged and when the family was approached about
performing a trach/PEG, they declined and decided to make her
CMO, and she passed away within 24 hours thereafter.
Medications on Admission:
HALOPERIDOL - 1 mg Tablet - Tablet(s) by mouth PRN
DOCUSATE SODIUM [COLACE] PRN
SENNA - PRN
PROZAC 20mg PO QDAZ
OLANZAPINE [ZYPREXA] - 2.5mg PO QHS
LEFLUNOMIDE [ARAVA] - 20 mg Tablet - one Tablet(s) by mouth once
a day
FOLIC ACID - 1 mg Tablet - Tablet(s) by mouth
MULTIVITAMIN Tablet - Tablet(s) by mouth
SIMVASTATIN - 80 mg Tablet - Tablet(s) by mouth
LEVOTHYROXINE - 75 mcg Tablet - one Tablet(s) by mouth once a
day
LOSARTAN [COZAAR] - 50 mg Tablet - PO QD
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
DIPYRIDAMOLE-ASPIRIN [AGGRENOX] - 25 mg-200 mg Cap, Multiphasic
Release 12 hr - 1 Cap(s) by mouth twice a day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - Tablet(s) by
mouth
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
encephalopathy likely secondary to seizure in context of prior
strokes.
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2129-4-5**]
|
[
"276.1",
"V45.01",
"438.11",
"294.8",
"441.2",
"486",
"427.81",
"443.9",
"311",
"592.0",
"401.9",
"427.31",
"780.39",
"599.0",
"E947.8",
"584.9",
"348.30",
"305.03",
"410.71",
"285.9",
"V45.89",
"434.11",
"438.89",
"593.2",
"696.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.23",
"96.6",
"03.31",
"96.04",
"87.03",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13103, 13112
|
10885, 12299
|
328, 334
|
13227, 13237
|
4796, 10862
|
13290, 13435
|
3393, 3478
|
13074, 13080
|
13133, 13206
|
12325, 13051
|
13261, 13267
|
3493, 4007
|
253, 290
|
362, 2493
|
4022, 4777
|
2515, 2980
|
2996, 3377
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,118
| 138,983
|
50149
|
Discharge summary
|
report
|
Admission Date: [**2183-7-26**] Discharge Date: [**2183-8-8**]
Date of Birth: [**2131-8-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vancomycin / Penicillins / Protamine / Quinidine Sulfate
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Paravalvular leak
Major Surgical or Invasive Procedure:
[**2183-7-31**] Redo sternotomy/mitral valve replacement (25/33 On-X
valve)/Repair of SVC
History of Present Illness:
Mrs. [**Known lastname 104673**] is a 51 year old female with presumed rheumatic
heart disease who has undergone multiple mechanical mitral valve
replacments in the past x 3. In [**2182-4-13**], she was
hospitalized with Pasteurella bacteremia/sepsis which was
further
complicated congestive heart failure. A transesophogeal
echocardiogram at that time revealed a new paravalvular leak
with
3+ mitral regurgitation.
Past Medical History:
Prosthetic Mitral Valve Regurgitation with Paravalvular Leak,
History of Rheumatic heart disease - s/p Mitral Valve
Replacements [**2155**], [**2158**], [**2161**](Bjork Shiley Valve), History of
Complete Heart Block - s/p Permanent Pacemaker
Implantation([**Company 1543**])[**2170**] and [**2172**], Diaslotic Congestive Heart
Failure, Paroxsymal Atrial Fibrillation, History of Pasteurella
Bacteremia secondary to Cat Scratch, Chronic Obstructive
Pulmonary Disease, History of GI Bleed [**2170**] and [**2182**] secondary
to Gastric Ulcer/Gastritis
Social History:
Denies tobacco for many years. Admits to 10 pack year history.
Drinks ETOH socially, denies excessive intake. Admits to cocaine
and marijuana in the past, last use over 7 years ago. Married
and currently lives with husband.
Family History:
No premature coronary artery disease
Physical Exam:
Physical Exam:
Vitals: T 98.7, BP 120/50, HR 96, RR 18, SAT 100 on room air
General: Thin, frail female in no acute distress
HEENT: oropharynx benign, EOMI, PERRL
Skin: well healed sternotomy and left groin incisions
Neck: supple, no JVD, no carotid bruits
Heart: irregular rate, normal s1s2, 4/6 systolic murmur radiates
throughout precordium
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: cool, 1+ edema bilaterally, bilateral varicosities noted
Pulses: 1+ distally
Neuro: nonfocal
Pertinent Results:
[**2183-8-7**] 05:55AM BLOOD WBC-4.1 RBC-2.48* Hgb-8.3* Hct-24.6*
MCV-99* MCH-33.4* MCHC-33.7 RDW-18.5* Plt Ct-197
[**2183-8-7**] 05:55AM BLOOD Glucose-93 UreaN-24* Creat-1.3* Na-132*
K-3.2* Cl-108 HCO3-22 AnGap-5*
[**2183-8-8**] 06:00AM BLOOD PT-26.1* PTT-94.5* INR(PT)-2.7*
Cardiology Report ECHO Study Date of [**2183-8-8**]
PATIENT/TEST INFORMATION:
Indication: Tamponade. S/p mitral valve replacement.
Height: (in) 63
Weight (lb): 127
BSA (m2): 1.60 m2
BP (mm Hg): 90/46
HR (bpm): 86
Status: Inpatient
Date/Time: [**2183-8-8**] at 11:15
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West [**Hospital Ward Name 121**] [**2-15**]
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.0 cm
Left Ventricle - Fractional Shortening: 0.49 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - Peak Velocity: 1.8 m/sec
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - Pressure Half Time: 42 ms
Mitral Valve - E Wave: 1.7 m/sec
Mitral Valve - E Wave Deceleration Time: 140 msec
TR Gradient (+ RA = PASP): *50 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2183-7-30**].
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Suboptimal technical quality, a focal LV wall motion
abnormality
cannot be fully excluded.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal
motion consistent with prior cardiac surgery.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets. No AR.
MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). MVR well
seated, with
normal leaflet/disc motion and transvalvular gradients. No MR.
[Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**1-14**]+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Small pericardial effusion. Effusion echo dense,
c/w blood,
inflammation or other cellular elements. No echocardiographic
signs of
tamponade.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions:
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets appear structurally normal with good leaflet excursion.
No aortic
regurgitation is seen. A bileaflet mitral valve prosthesis is
present. The
mitral prosthesis appears well seated, with normal disc motion
and
transvalvular gradients. No mitral regurgitation is seen. [Due
to acoustic
shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension.
There is a small (~ 1cm) circumferential partially echofilled
pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the prior study of [**2183-7-30**], the pericardial
effusion is new and
the mitral valve has been replaced with a normal functioning
bileaflet mitral
valve.
CLINICAL IMPLICATIONS:
Based on [**2183**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate prophylaxis IS recommended. Clinical decisions
regarding the need for
prophylaxis should be based on clinical and echocardiographic
data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2183-8-8**]
13:15.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2183-8-7**] 2:59 PM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
51 year old woman with redo MVR
REASON FOR THIS EXAMINATION:
evaluate effusion
REASON FOR EXAMINATION: Followup of a patient after mitral valve
replacement.
PA and lateral upright chest radiograph compared to serial chest
radiographs from [**7-31**] to [**8-5**].
The patient is after median sternotomy, mitral valve replacement
redo and presence of a previously obtained triscuspid
valvulopathy. The heart size appears to be gradually increasing
since [**7-31**] with predominantly increase of the right heart
although the left border of the heart is also more pronounced.
The lungs are otherwise clear except for chronic bibasilar
opacities. The pleural calcifications are again noted involving
both sides being more pronounced on the left.
The marked distention of the azygos vein which was not present
before, also favors right heart failure. The other explanation
might be the temponade etiology if there is a presence of large
pericardial effusion. The right pacemaker is again demonstrated
with its two leads terminating in right atrium and right
ventricle.
These findings were discussed with Dr. [**Last Name (STitle) 14777**]. Recommendation
to proceed with cardiac echo was obtained.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Brief Hospital Course:
Mrs. [**Known lastname 104673**] was admitted to the [**Hospital1 18**] on [**2183-7-26**] for surgical
management of her mitral valve disease. Coumadin was held and
heparin was started for anticoagulation for her mechanical
mitral valve. A dental consult was obtained for oral clearance
for surgery. After obtaining a panorex film and performing a
bedside exam, Mrs. [**Known lastname 104673**] was cleared for surgery from an oral
standpoint. Gentamycin and dicloxacillin were started per the
infectious disease service. This was empiric coverage of
Bartonella, Pasteurella and Coxiella given her recent treated
bacteremia. The electrophysiology service was consulted given
her permanent pacemaker. Her pacemaker was interoggated and
found to be functioning well and rarely needing to pace. Vitamin
K was used to reverse her INR. On [**2183-7-31**], when her INR reached
a safe range, Mrs. [**Known lastname 104673**] was taken to the operation room
where she underwent a fourth time redo sternotomy with
replacement of her mitral valve with a 25/33 On-X valve. Please
see operative note for details. Postoperatively she was taken to
the intensive care unit for monitoring. She was transfused for
postoperative anemia. On postoperative day one, Mrs. [**Known lastname 104673**]
awoke neurologically intact and was extubated. The
electrophysiology again interoggated her pacemaker and found it
to be functioning within normal limits. She was then transferred
to the step down unit for further recovery. Coumadin was resumed
for anticoagulation for her mechanical valve and chronic atrial
fibrillation. Dicloxacillin and gentamycin were continued per
the infectious disease service. She was gently diuresed towards
her preoperative weight. The physical therapy service was
consulted for assistance with her postoperative strength and
mobility. Argatroban was started for anticoagulation as a bridge
to coumadin. She was found to be HIT negative, argatroban was
stopped and she was started on heparin until INR therapuetic.
Digoxin was resumed for rate control of her chronic atrial
fibrillation. She continued to progress and was ready for
discharge home with services on postoperative day #8 in stable
condition. An echo on the day of discharge revealed a sm.
pericardial effusion without evidence of tamponade.
Medications on Admission:
1. Atenolol 100 mg
2. Disopyramide 100 mg [**Hospital1 **]
3. Spironolactone 50 mg
4. Folic Acid 1 mg
5. Hexavitamin
6. Furosemide 40 mg
7. Potassium Chloride 20 mEq [**Hospital1 **]
8. Digoxin 125 mcg 1 tab half tab(0.0625 mg) QMon and Fri.
9. Coumadin 5 mg Tablet
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
6. 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*
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day: until follow up with Dr. [**Last Name (STitle) 9404**].
Disp:*60 Capsule(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*80 Capsule, Sustained Release(s)* Refills:*0*
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
days: Take as directed by Dr. [**Last Name (STitle) 58**] for an INR goal of
[**3-15**].5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Paravalvular leak
PAF, COPD, GIB [**2170**] & [**2182**], MVR [**55**], 82, 85(bjork shiley), PPM 94
and 96, pasteurella bacteremia [**2-14**] cat scratch
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. [**Last Name (STitle) 58**] 1-2 weeks [**Telephone/Fax (1) 3329**]
Dr. [**Last Name (STitle) 1016**] 2-3 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks [**Telephone/Fax (1) 170**]
Wound check appointment - staple removal schedule with RN
[**Telephone/Fax (1) 3633**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 53840**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2183-8-20**] 12:00
Completed by:[**2183-8-8**]
|
[
"394.2",
"996.61",
"996.02",
"401.9",
"427.32",
"E849.8",
"V45.01",
"276.8",
"E849.7",
"E878.1",
"E870.0",
"305.23",
"496",
"416.8",
"998.2",
"427.31",
"305.63"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"38.93",
"39.32",
"89.64",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12971, 13028
|
8513, 10829
|
338, 430
|
13227, 13235
|
2303, 2634
|
13746, 14231
|
1710, 1748
|
11146, 12948
|
7034, 7066
|
13049, 13206
|
10855, 11123
|
13259, 13723
|
2660, 6422
|
1778, 2284
|
6445, 6803
|
281, 300
|
7095, 8490
|
458, 877
|
6835, 6997
|
899, 1452
|
1468, 1694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,621
| 114,450
|
7873+55889
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-5-23**] Discharge Date: [**2150-6-10**]
Date of Birth: [**2082-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Fever, altered mental status, and RLQ pain at rehab facility.
Major Surgical or Invasive Procedure:
[**2150-6-1**] nephrostogram with dilatation
[**2150-6-8**] nephrostogram
History of Present Illness:
Pt. is a 68 year-old male who presented to the ED with the
aforementioned complaints. His potassium level in the ED was
found to be 7.4 and his serum creatinine was 5.4 from a normal
baseline. The patient was emergently dialyzed, and an
obstruction was suspected. Prior to admission, the patient
underwent cadaveric renal transplant in [**12-27**] that was
complicated by proximal resection of the patient's ureter. A
nephrostomy tube was placed in the donor ureter shortly after
surgery and was removed on [**2150-5-21**].
Past Medical History:
DM2 x32 years
DM-associated retinopathy, nephropathy, and neuropathy.
CAD
ESRD
HTN
hypercholesterolemia
PVD
PSH:
s/p R ORIF hip [**2150-2-13**]
CRT [**2150-1-15**]
evac hematoma [**2150-1-16**]
nephrostomy tube [**2150-2-6**] for urinoma
CABG [**2143**]
Right fem-distal bypass
s/p R BKA
LUE AV fistula
Social History:
SOCIAL HISTORY: Significant for distant use of tobacco. He quit
in [**2143**]. No history of alcohol use or IV drug abuse. His wife
died of bone cancer. He has 6 children, all adults with an
eldest son with a history of diabetes. He has supportive family
in the area. He currently lives alone.
Family History:
Noncontributary
Physical Exam:
V/S: 98.9/P55/R20/BP137/53
Gen - cachectic male in NAD
Skin - L heel decubitus ulcer with eschar, no rashes
HEENT - NC/AT, EOMI, PERRL bilat., MMM, no palpable LAD
Cardiac - RRR, palpable thrill from L brachial AV fistula
Lungs - CTA bilat.
[**Last Name (un) **] - bowel sounds present, soft, NT, ND, no organomegaly
P.Vasc - 1/4 L d.p. and p.t. pulses, [**12-26**] palp. UE pulses bilat.,
no edema, no audible bruits
Musc/Skel - s/p R BKA, full active and passive ROM at L lower
extremity and upper extremities bilat.
Neuro - Gen - A&Ox3, appropriate speech and affect
CN - II-XII intact
Reflexex - 1+ at patella bilat., 1+ at brachiorad and
bicipital bilat.
Sensory - intact to light touch and temp at UE bilat, LE
bilat
Motor - 5/5 strength throughout
Cerebellar - + intention tremor
Gait - not assessed - pt. is s/p R BKA and without
prosthetic.
Pertinent Results:
[**2150-6-9**] 06:05AM BLOOD WBC-4.9 RBC-3.27* Hgb-9.0* Hct-28.1*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.6* Plt Ct-341
[**2150-6-9**] 06:05AM BLOOD WBC-4.9 RBC-3.27* Hgb-9.0* Hct-28.1*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.6* Plt Ct-341
[**2150-6-9**] 06:05AM BLOOD Glucose-97 UreaN-31* Creat-1.5* Na-139
K-5.8* Cl-111* HCO3-21* AnGap-13
[**2150-6-6**] 06:17AM BLOOD Glucose-71 UreaN-27* Creat-1.3* Na-140
K-4.9 Cl-110* HCO3-22 AnGap-13
[**2150-6-9**] 06:05AM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.4* Mg-1.6
[**2150-6-9**] 06:05AM BLOOD FK506-7.4
Brief Hospital Course:
Pt. was dialysed emergently upon arrival. His nephrostomy tube
reopened and allowed to drain. Pt's creatinine gradually
decreased to baseline levels over the course of admission with
hydration. Pt's blood glucose levels were initially high, but
were brought under good control with the help of the [**Last Name (un) **]
center. At the time of discharge, pt's blood glucose levels were
116-130.
[**5-29**]: Nutrition consult recommends Boost supplements
[**5-30**]: TSH, folate, B12 normal, urine output via foley catheter
and nephrostomy tube increased, creatinine continues to decrease
[**6-1**]: Nephrostogram with stomal dilation, tube still open and
draining well
[**6-2**]: Nephrostomy tube closed for trial, foley catheter draining
hematuria with clots. Foley removed.
[**6-3**]: Pt. refused replacement of foley,urethral clots stopped.
[**6-4**]: Urethral clots reappear,hematuria via nephro bag.
[**6-7**]: Pt. started Zoloft, tolerated well. Pt. began eating well.
[**6-8**]: Pt's Boost changed to Nepro supplements due to elevated
potassium levels, kayexalate given for asymptomatic
hyperkalemia.
[**6-8**]: Nephrostogram --> no vasovesicular fistula present.
[**6-9**]: Acute renal failure resolved, foley catheter draining more
that neprhostomy tube; pt. tolerates nephrostomy tube capping.
Pt. eating well. Pt.'s blood glucose levels in good control.
Medications on Admission:
tacrolimus 6 mg po bid
amlodipine 5 mg po qd
metoprolol 25mg po tid
fluoxetine 20 mg po qd
mycophenolate mofetil 1000mg po bid
valgancyclovir 450mg po qd
paantoprazole 40mg po qd
isosorbide dinitrate 60mg po qd
colace 100mg po bid
bactrim ss i po qd
CaCO3 100 mg po qid
nystatin 5 ml po qid
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): apply to scrotum then apply aloe vesta.
8. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times
a day).
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 20304**] Rehabilitation & Nursing Center - [**Location (un) 2498**]
Discharge Diagnosis:
hematoma/urinoma s/p cadaver kidney transplant complicated by
nephrostomy tube
DM type II
hypertension
depression
peripheral vascular disease.
Discharge Condition:
stable
Discharge Instructions:
call if fevers, chills, nausea, vomiting, inability to take
medications, inability to urinate, decreased urine output from
nephrostomy tube or if nephrostomy tube urine becomes more
bloody.
Change Nephrostomy tube dressing every day.
Labs once a week for cbc, chem 7, calcium, phosphorus, ast,
t.bili, albumin, urinalysis and trough prograf level. Fax
results to [**Hospital1 18**] [**Telephone/Fax (1) 697**]
Followup Instructions:
call [**Hospital1 18**] for follow up appointment in [**11-23**] weeks [**Telephone/Fax (1) 673**]
Completed by:[**2150-6-9**] Name: [**Known lastname 4971**],[**Known firstname **] Unit No: [**Numeric Identifier 4972**]
Admission Date: [**2150-5-23**] Discharge Date: [**2150-6-10**]
Date of Birth: [**2082-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2648**]
Addendum:
[**2150-6-10**] - Pt. tolerated discontinuation of foley catheter,
urinating without problems and with adequate output. Pt. to be
discharged to rehab. facility today.
Major Surgical or Invasive Procedure:
[**2150-6-1**] nephrostogram with dilatation
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4976**] Rehabilitation & Nursing Center - [**Location (un) 4977**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2150-6-10**]
|
[
"E878.2",
"250.60",
"995.91",
"599.0",
"401.9",
"250.50",
"443.9",
"996.81",
"997.5",
"599.7",
"311",
"038.9",
"276.7",
"E878.0",
"584.9",
"357.2",
"362.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.75",
"59.8",
"55.03",
"00.14",
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7311, 7573
|
3174, 4542
|
7241, 7288
|
6055, 6063
|
2614, 3151
|
6521, 7203
|
1663, 1680
|
4883, 5739
|
5889, 6034
|
4568, 4860
|
6087, 6498
|
1695, 2595
|
275, 338
|
480, 1007
|
1029, 1335
|
1367, 1647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,628
| 187,599
|
52525
|
Discharge summary
|
report
|
Admission Date: [**2184-3-17**] Discharge Date: [**2184-4-1**]
Date of Birth: [**2103-1-26**] Sex: M
Service: MEDICINE
Allergies:
Lovastatin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
[**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
Tunneled dialysis catheter removal and replacement
[**First Name3 (LF) **]
Attempted transesophageal echocardiogram
History of Present Illness:
81M Cantonese speaking PMH of ESRD, DM2, Afib on coumadin, CAD,
and gout presenting today with fevers. He was in his USOH until
yesterday afternoon after his HD session when he developed a
[**First Name3 (LF) **] to 102.5 while awaiting his ride home. He took tylenol and
contact[**Name (NI) **] his physician who recommended [**Name9 (PRE) **] evaluation but he
deferred until today. He was recently discharged from [**Hospital1 18**] on
[**2184-3-4**] after an admission for placement of a tunnelled HD
catheter and had been doing well. He notes fatigue but denied
any other symptoms including chest pain, shortness of breath,
cough, abdominal pain, nausea, vomiting, diarrhea, headache,
weakness, athraglias or arthritis. He has had no sick contacts
outside of his [**Date Range 13241**] sessions. He has been afebrile since
his [**Date Range **] yesterday but did take tylenol at home. Of note, the
patient was admitted [**Date range (1) 108495**] with [**Date range (1) **] of unknown
origin.
In the ED, VS 97.5 64 154/43 16 100%RA. Laboratories revealed
only renal insufficiency without evidence of a leukocytosis,
bandemia, or left shift. CXR showed no abnormality and blood
cultures were drawn. He received vancomycin 1gm in concern for a
catheter associated infection. He was seen by transplant surgery
and nephrology who agree with vancomycin and admission for
further evaluation.
Past Medical History:
1. Left arm hematoma.
2. End stage renal disease (on [**Date range (1) 13241**]).
3. Status post left brachiocephalic AV fistula placement
([**2182-10-16**]).
4. Status post revision of AV fistula x2.
5. Atrial fibrillation.
6. Diabetes mellitus type 2.
7. Hypertension.
8. Coronary artery disease.
9. History of enterococcal urosepsis.
10.History of [**Year (4 digits) **] or unknown origin.
11.History of gastric ulcer.
12.History of upper gastrointestinal (GI) bleed.
13.Obstructive sleep apnea.
14.Gout.
15.Carpal tunnel.
16.Status post left circumflex coronary artery stent in [**2180**].
17.Status post carpal tunnel release.
Social History:
Mr. [**Known lastname **] is Cantonese speaking. He lives at home with his wife.
[**Name (NI) **] has a remote 20-year history of tobacco smoking. He quit 20
years ago. No alcohol or illicit drug use
Family History:
Both parents deceased. Father had diabetes. He has 2 children
who are well and no siblings.
Physical Exam:
Vitals: T: 100.3 BP: 165/85 P: 87 RR: 20 SpO2: 100%RA
General: Awake, alert, NAD
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MMM, OP without
lesions
Neck: Supple, no JVD or carotid bruits appreciated
Pulm: CTAB without crackles, rhonchi, or wheezes
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: Soft, NT/ND, + BS, no masses or hepatomegaly noted.
Ext: No edema b/t, 1+ DP and PT pulses b/l, left arm well-healed
fistula site without thrill/bruit
Lymphatics: No cervical, supraclavicular, axillary, or inguinal
LAD
Skin: Right tunnelled catheter site without erythema or exudate,
multiple ecchymoses, no rashes
Neurologic: Able to relate history without difficulty per
interpretor, CN II-XII intact, MAEW
Pertinent Results:
Admission labs:
[**2184-3-17**] 04:00PM WBC-4.4 RBC-3.63* HGB-11.0* HCT-34.3* MCV-94
MCH-30.2 MCHC-32.0 RDW-16.3*
[**2184-3-17**] 04:00PM NEUTS-76.4* LYMPHS-16.9* MONOS-6.4 EOS-0.1
BASOS-0.3
[**2184-3-17**] 04:00PM PLT COUNT-212
[**2184-3-17**] 04:00PM GLUCOSE-134* UREA N-36* CREAT-3.7*#
SODIUM-139 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15
[**2184-3-17**] 10:04PM PT-25.6* INR(PT)-2.5*
.
Studies:
CHEST (PA & LAT) [**2184-3-17**]
FINDINGS: A right subclavian tunneled line is in standard
position. There is no evidence of infiltrate. The heart is
enlarged, but there is no evidence of volume overload or
pneumothorax. The aorta is tortuous and calcified.
IMPRESSION: No acute cardiopulmonary process.
.
TIB/FIB (AP & LAT) LEFT [**2184-3-19**]
FINDINGS: No evidence of acute fracture or other bone
abnormality. There is extensive calcification of vascular
structures throughout the leg, ankle, and foot, suggesting
underlying diabetes. Small inferior calcaneal spur.
.
MR ANKLE W/O CONTRAST LEFT [**2184-3-24**]
IMPRESSION:
1. Edema in the fat surrounding the Achilles with some mild
tendinosis of the Achilles tendon itself.
2. Mild degenerative change in the tibiotalar joint and mid
foot.
.
TTE (Complete) Done [**2184-3-23**]
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate regional
left ventricular systolic dysfunction with focal akinesis of the
inferior wall and moderate global hypokinesis of the remaining
segments (LVEF = 30-35 %). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened (especially the non-coronary cusp) 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. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild to moderate ([**12-17**]+) mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No valvular vegetations identified. Mild symmetric
left ventricular hypertrophy with regional left ventricular
systolic dysfunction c/w CAD. Mild/moderate mitral
regurgitation. Severe pulmonary hypertension.
.
TEE (Complete) Done [**2184-3-31**]
The TEE probe could not be passed into the esophagus due to the
patients inability to comply with swallowing instructions and
strong gag reflex. Anesthesia support is suggested for the
future.
.
CT TORSO W/CONTRAST [**2184-3-26**]
IMPRESSION:
1. No evidence of infectious source.
2. Increased bilateral pleural effusions are identified.
3. Sub-cm right thyroid nodule.
.
IN-111 WHITE BLOOD CELL STUDY [**2184-3-29**]
IMPRESSION: No scintigraphic evidence for a focal site of
infection.
.
CT HEAD W/O CONTRAST [**2184-3-31**]
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
81M Cantonese speaking PMH of ESRD, DM2, Afib on coumadin, and
CAD presenting after an episode of [**Month/Day/Year **] to 102.5 following
[**Month/Day/Year 13241**].
.
# [**Month/Day/Year **] of unknown origin: Infection was a concern as pt is
chronically on steroids for gout. Pt initially spiked fevers
with dialysis, and a line or line pocket infection was suspected
and he was started on vancomycin. However, bcxs prior to
initiation of antibiotics as well as subsequent blood cxs and HD
catheter tip culture were all negative. HD line was removed [**3-20**]
but pt continued to spike fevers. Vancomycin was discontinued
for suspected drug [**Month/Day (1) **]; however, fevers continued. The Renal
team also tried multiple dialysis membranes for concern of
dialysis membrane reaction; however, pt continued to spike. He
initially complained of L leg pain, and MRI of L ankle was
benign. Ultrasound of fistula did not show an abscess. ID was
consulted. The following studies were also sent and negative:
HBV VL, CMV VL, monospot, HIV, and strongyloides. CT torso did
not show obvious source of infection. He had an TTE that did
not show evidence of endocarditis, and TEE was attempted but the
probe could not be passed through the oropharynx. Tagged WBC
scan was neg. His methylprednisolone was even tapered to reveal
a possible infectious source. Oncologic causes were also
considered. He had slightly elevated LDH but had pan-scan did
not show any pathologic adenopathy to suggest lymphoma. SPEP was
without monoclonal spike. Pt's family deferred a bone marrow
biospy as they would not have pursued treatment.
Rheumatological causes were also considered. He has a history
of gout; however, his Rheumatologist had visited him and did not
find any affected joints at this time. [**Doctor First Name **], RF were WNL. The
cause of the [**Doctor First Name **] remains unknown.
.
# Atrial fibrillation with RVR: Pt was rate-controlled except
in the setting of fevers. He was continued on metoprolol, which
was titrated up as tolerated by his blood pressure. He was
continued on anticoagulation after placement of his new HD line.
.
# Hypertension: His blood pressure was labile. He was
continued on home metoprolol, imdur. A switch from metoprolol
to carvediolol was attempted but his blood pressure had fallen
with carvediolol, requiring IVF boluses. He was switched back
to metoprolol.
.
# Acute on chronic systolic congestive heart failure: On [**3-31**],
pt was noted to be acutely hypoxic and in pulmonary edema. This
was likely due to IVFs the pt had received during his episode of
hypotension as described above. He was transferred to the MICU
for emergent HD overnight. Unfortunately, his BP only tolerated
removal of 1L IVFs.
.
# Acute mental status changes: Pt was consistently less
responsive in the setting of his fevers. He was watched in the
MICU overnight for acute mental status changes. CT head was
negative. His narcotics were scaled back.
.
# ESRD on HD: Pt had long-standing renal impairment likely due
to diabetes. He continued HD on T/Th/Sa schedule, received epo
at HD, and continued on nephrocaps.
.
# CAD: Pt had a couple episodes of chest pain on [**3-27**] that were
relieved with NTG. EKG showed new T wave inversions. Troponin
was mildly elevated above baseline but CKs were flat. Cardiology
was consulted. Pt was placed on heparin gtt overnight to [**3-28**]
and was discontinued when his CEs trended down. This was likely
[**1-17**] demand ischemia. He was continued on ASA, BB, nitrate,
statin, plavix.
.
# Diabetes type 2: He was continue on home insulin regimen with
sliding scale insulin.
.
# Hypothyroidism: TSH was WNL and he was continued on his home
levothyroxine dose.
.
# Gout: This was not active. He was continued on
methylprednisolone and allopurinol.
.
# On [**3-31**], pt became acutely hypoxic and was found to be in
pulmonary edema as described above. He was started on a nitro
gtt and transferred to MICU for emergent HD. Unfortunately, his
BP only tolerated removal of 1L IVFs. At this time, the family
changed their goals of care to comfort. Pt was started on a
morphine gtt and transferred to the floor. He passed away on
[**2184-4-1**]. Pt's family declined an autopsy.
Medications on Admission:
1. Allopurinol 300 mg daily
2. Atorvastatin 10 mg daily
3. Calcitriol 0.25 mcg daily
4. Felodipine 10 mg daily
5. Folic Acid 1 mg daily
6. Isosorbide Mononitrate 30 mg daily
7. Levothyroxine 75 mcg daily
8. Methylprednisolone 8 mg daily
9. Metoprolol Tartrate 50 mg tid
10. Acetaminophen 325 mg prn
11. Coumadin 2.5 mg daily
12. Aspirin 81 mg daily
13. Levemir 16 units daily
14. Lactulose prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
[**Date Range **] of Unknown Origin
Atrial fibrillation
Acute on chronic systolic congestive heart failure
Chronic kidney disease, stage V
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"427.5",
"427.31",
"428.0",
"274.9",
"286.9",
"780.6",
"414.01",
"585.6",
"428.23",
"110.1",
"416.8",
"244.9",
"588.81",
"250.42",
"327.23",
"276.3",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11347, 11356
|
6609, 10875
|
293, 410
|
11538, 11543
|
3570, 3570
|
11595, 11601
|
2728, 2822
|
11319, 11324
|
11377, 11517
|
10901, 11296
|
11567, 11572
|
2837, 3551
|
230, 255
|
438, 1831
|
3586, 6586
|
1853, 2491
|
2507, 2712
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,104
| 176,991
|
40091
|
Discharge summary
|
report
|
Admission Date: [**2119-11-22**] [**Month/Day/Year **] Date: [**2119-12-8**]
Date of Birth: [**2068-8-7**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Found unresponsive.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
51 yo M with unknown past medical history found down by friends
yesterday AM. History based on chart review is extremely
limited. He was supposedly found unresponsive by his friends at
0800 yesterday AM and they went back to check on him last night
at 2200 and he was still unresponsive. EMS was called and he
was noted to have pinpoint pupils, coffee ground emesis in his
mouth, and coarse respirations. He was given narcan 4 mg IM in
field and taken to [**Hospital **] Hospital. Upon arrival T 99.5 P
113 RR 20 BP 184/111 and sating 94% on RA. He was noted to
"respond to pain but is restless." A handwritten sheet of paper
states he had 1000 cc of [**Location (un) 2452**] urine upon foley insertion and
labs notable for "CK 1000, lactate 3.4, Na 133, WBC 13, + etoh,
tox neg." He received propofol, lidocaine, etomidate,
vecuronium, succinylcholine, ativan, and dilantin 1g. CT head
showed a midbrain hematoma, SAH, and SDH, and was transferred to
[**Hospital1 18**] for further evaluation. He was seen by neurosurgery who
recommended neurology consult.
Past Medical History:
- Recently c/o "migraine-like HA" on left side of face for about
two months. Took unknown med with partial relief.
- History of heavy smoking, cut back recently.
- H/o Emphysema, on some inhaler(s) including albuterol (found
by EMS).
- Borderline hypertension without treatment.
- No prior h/o hospitalization, diabetes, dyslipidemia, no prior
medical complication from EtOH. No known h/o cardiac or
neurologic disease.
Social History:
Patient is visiting from PR, speaks only [**Country 12649**]. Lived at
cousin's house, but left [**2-28**] frequent drunkenness. Still working
at a laundromat in [**Location 17065**]. PCP is [**Name9 (PRE) 1557**] at [**Name9 (PRE) **] Med
Ctr.
Increased EtOH over the past year, up to 24 beers / day on
weekends. Drinks most every day, unsure how much. Moved from
cousin's house to rental with four other people from Central
America [**2-28**] drinking habit. Still smokes, but cut back recently.
No known history of drug abuse.
Family History:
Mom died of colon cancer at 39 years (refused colonoscopy, DRE
at PCP's office). Sister died of breast cancer. Grandfather with
DM, MI. Father (visiting) appears ill/cachectic, but denies Ca
or strokes, etc. Only says "bad circulation" on unknown meds.
Physical Exam:
[**Month/Day (2) **] Examination
Over the course of the admission, his vital signs remained
stable.
Mental status was significant for clarity of cognition - after
transfer to the floor he was clearly able to understand complex
language, instructions and understand complicated information,
all in Spanish. It seems that he cannot understand English. He
was alert, sometime taking a little while to arouse. Although it
is difficult to evaluate his affect fully, he does seem mildly
depressed.
Cranial nerves were significant for impaired eye movement: He
has a vertical skew deviation in mid-position, is able to move
both eyes vertically and can abduct the right eye, without being
able to move the left eye horizontally or adduct the right eye.
There was a left lower motor neuron pattern of facial weakness.
He has an upper motor neuron pattern of weakness on the right,
less so on the left. He can now hold his legs bend against
gravity if the heels are on the bed. He can move both hands with
the left arm antigravity and the right not yet antigravity. The
left hand is clumsy.
He presently cannot sit, let alone stand, without assistance.
Admission Examination
VS: T 98.7 BP 148/95 P 112 RR 18 99% on vent
Gen: lying in bed, intubated, off propofol
HEENT: small superficial abrasion on right forehead and right
upper shoulder.
CV: RRR, no murmurs
Pulm: CTA b/l
Abd: soft, nt, nd
Extr: no edema
Neuro: Eyes closed and unarousable to noxious stimuli. Skew
deviation of eyes with right eye displaced downward. Pupils 1.5
mm and minimally reactive. Does not blink to threat. Corneals
absent. Face appears symmetric. + cough and gag. No
spontaneous movement. Withdraws LUE to noxious, extensor
posturing to RUE noxious stimuli. Withdraws LLE > RLE. Trace
biceps and brachioradialis reflexes, 2+ patellar reflexes b/l,
toes mute
Pertinent Results:
[**2119-12-4**] 06:05AM BLOOD WBC-5.7 RBC-4.17* Hgb-14.1 Hct-42.5
MCV-102* MCH-33.8* MCHC-33.1 RDW-13.2 Plt Ct-369
[**2119-11-22**] 03:24AM BLOOD Neuts-86* Bands-0 Lymphs-8* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2119-12-4**] 06:05AM BLOOD PT-12.1 PTT-29.5 INR(PT)-1.0
[**2119-11-22**] 03:24AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2119-12-3**] 06:50AM BLOOD Glucose-115* UreaN-15 Creat-0.6 Na-140
K-4.2 Cl-103 HCO3-28 AnGap-13
[**2119-12-4**] 06:05AM BLOOD ALT-48* AST-66* LD(LDH)-595* AlkPhos-132*
TotBili-0.4
[**2119-12-3**] 06:50AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
[**2119-11-22**]
Sinus tachycardia. Peaked P waves and rightward P axis
consistent with right atrial abnormality. The T waves are tall
and peaked. Clinical correlation is suggested. No previous
tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
112 116 86 324/415 76 64 66
Initial head CT [**2119-11-22**]
There is a 15 x 18 mm intraparenchymal hemorrhage in the
midbrain extending down to the basis pontis, level of lower
middle cerebellar peduncle, with surrounding edema which is
essentially unchanged from the recent exam (13 x 18 mm). This is
associated with hemorrhage within the right quadrigeminal plate
and ambient cistern, subarachnoid hemorrhage in the right
occipital lobe and a 6 mm-thick right temporal extra-axial
hematoma. Also noted are multiple punctate foci of high density
at the [**Doctor Last Name 352**]-white junction in the right frontal lobe (102:52)
and the left frontovertex (102:58-9). While these may represent
cavernous hemangiomas, the presence of multi-compartment
hemorrhage, as well as the edema surrounding edema these foci is
concerning for diffuse axonal injury in the setting of trauma.
There is an incidental likely arachnoid cyst in teh left
posterolateral aspect of the posterior fossa, with minimal mass
effect on the subjacent cerebellar hemisphere. There is an air-
fluid level in the right maxillary sinus. The remaining sinuses
as well as the mastoid air cells are well aerated. No definite
fracture is seen.
IMPRESSION:
1. Midbrain/pontine parenchymal, right occipital subarachnoid
and right
temporal extra-axial hemorrhage, as described above.
2. Foci of high attenuation of the [**Doctor Last Name 352**]-white junction may
represent diffuse axonal injury, although cavernous angiomas are
a possibility.
Repeat Head CT [**2119-12-1**]
1. Hematoma involving the left dorsolateral aspect of the
brainstem at the
pontomesencephalic junction is unchanged from [**2119-11-29**].
2. Right parietal vertex subarachnoid hemorrhage is without
significant change from prior study.
MRI/MRA [**2119-11-22**]
IMPRESSION: 1. Mid brain hemorrhage is identified without
evidence of associated enhancement or abnormal flow voids. 2.
Foci of signal abnormality at the [**Doctor Last Name 352**]-white matter junction in
frontal lobes on diffusion images with two asmall area of blood
products in frontal [**Doctor Last Name 352**]-white matter junction and associated
small subdural hematoma on the right convexity and tentorium as
well as blood products along the subarachnoid space could be
related to trauma. Clinical correlation recommended.
MRA Head:
Head MRA demonstrates normal flow signal in the arteries of
anterior and
posterior circulation without stenosis, occlusion or an aneurysm
greater than 3 mm in size.
IMPRESSION: No significant abnormalities on MRA of the head.
Echocardiography [**2119-11-30**]
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: no obvious vegetations
Non-contrast head CT [**2119-12-1**]
1. Hematoma involving the left dorsolateral aspect of the
brainstem at the pontomesencephalic junction is unchanged from
[**2119-11-29**].
2. Right parietal vertex subarachnoid hemorrhage is without
significant change from prior study.
3. Stable small right frontal epidural hematoma. No new focus of
hemorrhage is noted.
Brief Hospital Course:
Brainstem Hemorrhage
Spontaneous hemorrhage into the medial brainstem with loss of
consciousness and distruption of function of descending motor
tracts and oculomotor control. Hemorrhage dissects into tissue,
resulting in neuropraxic axonal dysfunction, also due to
resulting edema. This can recover, as we have seen in this case.
Structures rostral to the brainstem and arousal nuclei of the
brainstem were largely unaffected, so it was not surprising that
the cognitive outcome in this case would be good. Motor function
improved, presumably with lessened functional disruption of
motor fibers passing into and through basis pontis. Oculomotor
function improved somewhat, but is still dramatically impaired.
Formal angiogram has not been performed in this case, with
vascular imaging at this time relying on MRA. No aneurysmal
dilations were seen (resolution 3 mm), but such an abnormality
may have been etiologic. On follow-up, we will consider again
further evulating cerebral vasculature. It is possible that such
an abnormality might have been singular. Hypertension may have
also contributed. We have commenced antihypertensive treatment.
Respirtory Failure
Owing to respiratory failure, secondary to brainstem hemorrhage,
he was initially intubated, but subsequently breathed well after
tracheostomy then extubation, using tracheal mask with enriched
oxygen between 35 and 50 %.
Nutrition
Difficulty swallow may have both descending control and
brainstem components. PEG tube placement was necessary,
uncomplicated, with subsequent successful at-goal tube feeds.
Cholestatic enzymes were noted sometime after intubation and
cessation of propofol which was attributed to tube feeds. Tube
feeds should now be changed to increased rate with daily hold.
Present rate is at 60 cc, and we would suggest increasing this
slightly for equivalent feeding with a short and lengthening
pause each day, perhaps until a 12 hour on, 12 hour off regimen
is reached. Please check liver function tests.
Cholestasis and Transaminitis
See Nutrition above. Abdominal ultrasound revealed normal
appearances, supporting the hypothesis that cholestatic enzymes
were secondary to tube feeds. See above for recommendations.
Urinary Tract Infection, Bacteremia, Pneumonia
Blood culture grew STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP, and
SPUTUM GRAM and CULTURE revealed HAEMOPHILUS INFLUENZAE,
BETA-LACTAMASE NEGATIVE. UA was dirty without culture. He was
covered by ceftriaxone, which ended at seven days upon
[**Year (4 digits) **].
Hypertension
Blood pressure has been well-controlled. Lisinopril was started.
Medications on Admission:
Albuterol inhaler only.
[**Year (4 digits) **] Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin with minerals Tablet Sig: One (1) Tablet PO
once a day.
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for
lubrication: [**Month (only) 116**] benefit from left eye patch at night.
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
TID (3 times a day).
13. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) as needed for copius secretions: Next
patch due on [**12-9**] afternoon.
14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): [**Month (only) 116**] be up-titrated to control back pain (given
immobility).
15. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
16. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
17. HydrALAzine 10 mg IV Q6H:PRN SBP > 160
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
[**Month (only) **] Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
[**Location (un) **] Diagnosis:
Primary
Intracerebral hemorrhage
Secondary
Hypertension
[**Location (un) **] Condition:
Mental Status: Clear and coherent. Unable to speak, but able to
understand complex language and ideas (in Spanish).
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
[**Location (un) **] Instructions:
You came to the hospital after been found unresponsive. This was
attributed to bleeding in your brain, specifically your
brainstem. You were admitted to the hospital for management,
which including placing an airway, feeding tube and controlling
your blood pressure. You are now stable from a medical point of
view, so we would recommend that you now transition to acute
rehabilitation.
Followup Instructions:
Please follow-up with [**Location (un) **]. [**Last Name (STitle) **] and [**Name5 (PTitle) 39380**] in clinic:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Name5 (PTitle) **] Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2120-1-17**] 1:00
Please also see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehabilitation.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
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icd9pcs
|
[
[
[]
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|
348, 355
|
4591, 9189
|
14585, 15086
|
2461, 2715
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|
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289, 310
|
13947, 13947
|
14174, 14562
|
383, 1452
|
13962, 14139
|
1474, 1897
|
1913, 2445
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,077
| 138,179
|
10110
|
Discharge summary
|
report
|
Admission Date: [**2143-11-2**] Discharge Date: [**2143-11-30**]
Date of Birth: [**2065-10-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Quinolones
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78F with hx of HTN, dCHF, COPD (?FEV1), CAD, CVA who presents to
the ED with weakness, increased wheezing, fever, shortness of
breath. Pt's family states that pt was in usual state of health
until 10 days prior to admission when she got a flu shot at her
PCP's office. Since that time, she has been weak, fatigued with
fevers/chills, nausea and vomiting. She states that she was
using her inhaler for shortness of breath and wheezing but it
wasn't helping. [**Name (NI) 1094**] son took her out to dinner on the night
prior to admission and notes that she looked well. She ate a
good dinner but afterwards, her son reports that she was more
wheezy than her baseline. He got concerned today when she did
not show up at her hair appointment. He went to her home and
found her sitting up in her chair, nauseous, weak and wheezing.
She had not yet taken her medications yet for the day. She was
also complaining of RUQ abdominal pain and short of breath. He
then took her to the ER.
.
At baseline, pt has a chronic cough productive of white sputum
which has not recently changed in color or frequency. She is
fully functional, lives alone, performs all of her ADLs, walks
without a walker. Her only residual deficit from her stroke is
right hand weakness and some word finding difficulties. At
baseline, she can only walk up 3-4 steps before getting short of
breath. She has no recent travel, no sick contacts though her
son recently had a cold. She coughs occasionally when she eats
and depending on what she is eating. She sleeps on one big
pillow at home and this has not changed. No recent medication
changes, no increase in her weight, no change in her diet. She
denies any diarrhea.
.
In ED, she was found to have a temp of 101 and O2 sat of 88% on
RA. She pt received ceftriaxone/azithro and flagyl for presumed
PNA. Pt was then noted to cough up a large amount of blood
streaked sputum though the next sputum was clear of blood.
Given concern for PE a CTA was ordered but pt was hydrated with
1L of NS over 2 hours prior to the study due to her cr of 1.8.
After the fluid bolus, pt became more hypoxic requiring a NRB
and then BiPAP which she did not tolerate. She received 20mg of
IV lasix x 2 to which she responded poorly to and she was
started on a nitro drip for hypertension to the 180s. She
continued to have increased work of breathing with a RR of 40
and she asked to be intubated. On the propofol, she dropped her
pressure to the 80s and she was given Narcan 1mg x 1. Her
pressure improved to the 100s. The CTA was cancelled given her
tenuous resp status and she was transferred to the [**Hospital Unit Name 153**].
Past Medical History:
* left carotid stenosis s/p CEA in [**2137**]
* hx of left hemisphere stroke in [**2137**]
* hypertension
* mild-to-moderate aortic stenosis
* CAD s/p stent in RCA and stent in OM1 in [**2137**]
* diastolic CHF (EF 70-80% on echo in [**2141**])
* COPD
* hx of prior intubations for resp distress
* hx of UGIB (H pylori pos) in [**2137**]
* hx of gallstone pancreatitis s/p cholecystectomy in [**2137**]
* hx of appendectomy
Social History:
no history of alcohol or current tobacco use but 2-3 packs per
day x 40 years, stopped in [**2137**]. She lives alone, performs all
her ADLs, drives. Son and daughter both live nearby
Family History:
grandmother having had valve disease; no hx of early CAD; no
family hx of blood clots
Physical Exam:
Exam: temp 101.6, BP 108/44, HR 107, R 19, O2 96% on AC
400/24/5/100%
ht 5'2", wt 160#
Gen: intubated, agitated, following commands
HEENT: MMM, PERRL
Neck: JVD not appreciable due to neck size
CV: regular, tachy, [**1-28**] holosystolic murmur at RUSB --> carotids
Chest: decreased breath sounds at bilateral bases, R>L; no
wheezing, no crackles heard
Abd: hypoactive bowel sounds, soft, nontender
Ext: no edema, 2+DP
Neuro: intubated but follows commands
Pertinent Results:
STUDIES:
EKG: NSR, nl axis, PRWP with Q waves in V1-V2; J point elevation
in V1 and V2; compared to prior from [**2137**], V1-V2 J-point is
higher
.
CXR Pa/Lat:
1. Persistent bilateral pleural effusions.
2. Advanced emphysema.
3. Bibasilar opacities, presenting scarring versus
atelectasis.
.
pCXR (after fluid bolus): increased interstitial markings
.
[**2143-11-4**] TTE:
1. The left atrium is mildly dilated. No atrial septal defect or
patent
foramen ovale is seen by 2D, color Doppler or saline contrast.
2. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%).
3. The aortic valve leaflets are moderately thickened. The
aortic valve is not well seen. There is mild aortic valve
stenosis. No aortic regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
5. There is moderate pulmonary artery systolic hypertension.
6. Comapred to the previous study of [**2142-11-9**], there is
probably no
significant change.
.
.
[**2143-11-16**] R UE USN: negative for thrombosis.
.
Brief Hospital Course:
Pt presented to [**Hospital Unit Name 153**] with stable SBP, though intubated
electively given increasing respiratory distress after IVF bolus
in anticipation of CTA to evaluate for PE.
.
.
# hypoxia: initial cause of hypoxia felt to be related to
pneumonia, which was exacerbated by component of CHF caused by
fluid hydration in anticipation of CTA to rule out PE in ED.
upon presentation to [**Hospital Unit Name 153**], plan was to treat with antibiotics
and gentle diuresis, however exact volume status was unclear,
and SBPs ranged in 80-90s, thus did not appear that pt would
tolerate diuresis. antibiotic regimen was broadened to from
ceftriaxoneazithro/flagyl to cefipime/azithromycin/flagyl [**11-5**]
after pt spiked fevers (100.4), and pt was treated with
albuterol and atrovent nebulizers for hypoxia. initial
hemoptysis was felt most likely [**1-24**] to chronic cough and
brochiectasis. flagyl was d/c'd 11/15 per ID recs, aspiration
felt unlikely.
.
pt's oxygenation initially did not change substantially with
variation in FiO2, raising concerning about shunt physiology,
possibly [**1-24**] pneumonia or CHF. A TTE was obtained which showed
normal EF, but E/A 0.7, mild MR (though this was felt to be
underestimated on TTE given her murmur), no intracaridac shunt
on bubble study. CT chest showed bilateral pulmonary
effusions, which were noted on prior CT. ID consult obtained on
[**11-3**] to evaluate for other sources of infection, however sense
was that the pulmonary process was most likely. thoracentesis
performed on [**11-8**] which was transudative with ~500 WBC felt
consistent with para-pneumonic effusion.
.
Pt continued to require ventilator support for hypoxia, though
by HD#5, her pneumonia seemed to be resolving (WBC trending
down, afebrile), and pulmonary edema [**1-24**] poor UOP was felt to be
an increasing cause of her hypoxia. She was started on lasix
gtt on [**11-6**]. this was initially limited by episodes of
hypotension, but was ultimately titrated up to 18 mg/hr on
[**11-16**], with only modest diuresis. Pt remained +9L on [**11-16**],
with CXR showing persistent pleural effusion/pulmonary edema.
.
On [**11-11**], pt was having low grade temps (100.0), with new
changes in sputum (thick yellow). Sputum cultures on [**11-5**]
showed GNR, on [**11-8**] and [**11-10**] showed pseudomonas. Pt was
witched from cefipime to meropenem given concern for resistent
gram negatives on [**11-11**]. Sputum initially cleared, but on [**11-16**]
changed again from white to yellow and thick. Given concern for
new VAP, low threshold to start vancomycin.
.
On HD#9 and again on HD#14 the possibility of tracheostomy/peg
was discussed with pt's daughter, who is amenable to plan,
though feels her mother may not have wanted trach. On HD#[**10-3**]
pt was transiently doing better on vent (on PS 14/10 - [**10-1**])
but was occasionally becoming uncomfortable. On [**11-15**] her
secretions Plan was to discuss with family again on [**11-18**],
before moving ahead with trach/peg. She coninued on multiple
antibiotics for pseudomonas colonization and septic physiology.
.
The patient was in fact extubated briefly, but required
re-intubation in setting of respiratory distress and a question
of septic physiology. She continued on antibiotics, and began
treatmen for sepsis when swan numbers showed evidence for this.
She alternated between septic and cardiogenic physiology and she
continued to get more and more volume overloaded. Attempts to
diurese were met with hypotension and low urine output.
Agitation was frequently an issue resulting in respiratory
discomfort and hypertension. Plans for a trach and peg were made
with surgery. However, after a lengthy discussion with family,
PCP, [**Name10 (NameIs) **] patient, it was decided that patient did not want to
continue aggressive medical care. Per the patient's and families
wishes, she was extubated and passed peacefully.
.
Medications on Admission:
diltiazem CR 240mg qd
aggrenox 1 tab [**Hospital1 **]
Lipitor 20mg qd
Zaroxylyn 2.5mg qd
lisinopril 5mg qd
Prevacid
Ritalin 5mg qd
Combivent 1 puff TID
Flovent 1-2x day
Serevent 1-2x day
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
sepsis
respiratory failure
renal failure
hypertension
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"511.9",
"482.1",
"785.52",
"518.81",
"428.33",
"585.9",
"285.29",
"584.5",
"425.1",
"577.0",
"995.92",
"438.20",
"038.9",
"786.3",
"486",
"401.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91",
"96.72",
"89.64",
"96.04",
"99.04",
"38.91",
"93.90",
"00.17",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9666, 9675
|
5457, 9400
|
307, 313
|
9783, 9793
|
4239, 5434
|
9846, 9990
|
3661, 3748
|
9637, 9643
|
9696, 9762
|
9426, 9614
|
9817, 9823
|
3763, 4220
|
255, 269
|
341, 2996
|
3018, 3443
|
3459, 3645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,939
| 166,737
|
42433+58528
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-3-10**] Discharge Date: [**2161-3-15**]
Date of Birth: [**2110-8-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Right atrial mass
Major Surgical or Invasive Procedure:
[**2161-3-11**]
1. Removal of right atrial mass.
2. Pericardial reconstruction using the CorMatrix product.
History of Present Illness:
This 50 year old Hispanic female has a history of colon/anal
cancer in [**2158**]
treated with chemotherapy and radiation. Recently, she
underwenta CT scan as part of her routine follow-up. The CT scan
revealed a mass in the right atrium suggestive of a myxoma. She
then underwent an echo which revealed a right atrial mass which
was thought to likely be a myxoma. She underwent a CT scan and
cardiac catheterization [**2161-2-20**] which showed no coronary artery
disease however multiple small pulmonary emboli were noted. She
was admitted for heparin bridge the night prior to surgery
Past Medical History:
Hypertension
Squamous cell cancer of the anus/colon s/p radiation/chemo [**2158**]
Mild hypercholesterolemia
Anemia
Depression
Recent diagnosis of Pulmonary emboli
Past Surgical History:
Tubal Ligation
Hickman catheter placement for chemotherapy - Left subclavian
Social History:
Race: Hispanic
Last Dental Exam: >= 1 Year ago
Lives with: Boyfriend
Occupation: Does not work
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [X] [**2-17**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
Family History: Multiple family members after the age of 55 with
heart disease
Physical Exam:
Physical Exam
BP: 141/89 Heart Rate: 60 Resp. Rate: 18
Saturation%: 100% RA
Height: 5'3" Weight: 96.3 lbs
General: AAO x 3 in NAD
Skin: Warm, Dry and intact. No lesions or rashes noted. Well
healed left subclavian incison 4cm.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in
fair repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit None appreciated
Pertinent Results:
[**2161-3-15**] 05:50AM BLOOD WBC-8.9 RBC-3.22* Hgb-9.7* Hct-28.2*
MCV-87 MCH-30.0 MCHC-34.4 RDW-14.5 Plt Ct-233
[**2161-3-13**] 04:23AM BLOOD WBC-13.5* RBC-3.25* Hgb-9.9* Hct-29.2*
MCV-90 MCH-30.6 MCHC-34.1 RDW-14.3 Plt Ct-193
[**2161-3-12**] 02:14AM BLOOD WBC-12.7* RBC-3.45* Hgb-10.7* Hct-31.1*
MCV-90 MCH-31.0 MCHC-34.4 RDW-14.1 Plt Ct-215
[**2161-3-15**] 05:50AM BLOOD PT-29.5* INR(PT)-2.8*
[**2161-3-14**] 05:50AM BLOOD PT-24.2* INR(PT)-2.3*
[**2161-3-13**] 04:23AM BLOOD PT-14.3* INR(PT)-1.3*
[**2161-3-11**] 01:27PM BLOOD PT-16.5* PTT-30.2 INR(PT)-1.6*
[**2161-3-11**] 03:28AM BLOOD PT-17.4* INR(PT)-1.6*
[**2161-3-15**] 05:50AM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-138
K-4.0 Cl-99 HCO3-30 AnGap-13
[**2161-3-14**] 05:50AM BLOOD Na-137 K-4.2 Cl-100
[**2161-3-13**] 04:23AM BLOOD Glucose-147* UreaN-16 Creat-0.9 Na-136
K-3.9 Cl-100 HCO3-28 AnGap-12
[**2161-3-12**] 02:14AM BLOOD Glucose-171* UreaN-19 Creat-1.0 Na-135
K-4.4 Cl-102 HCO3-24 AnGap-13
[**2161-3-11**] 07:49PM BLOOD Glucose-117* Na-140 K-4.4 Cl-108
[**2161-3-15**] 05:50AM BLOOD WBC-8.9 RBC-3.22* Hgb-9.7* Hct-28.2*
MCV-87 MCH-30.0 MCHC-34.4 RDW-14.5 Plt Ct-233
[**2161-3-15**] 05:50AM BLOOD Plt Ct-233
[**2161-3-15**] 05:50AM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-138
K-4.0 Cl-99 HCO3-30 AnGap-13
[**2161-3-15**] 05:50AM BLOOD Mg-2.1
[**2161-3-13**] 04:23AM BLOOD Mg-2.0
[**2161-3-10**] 05:52PM BLOOD Albumin-4.6 Calcium-9.7 Phos-3.2 Mg-2.0
PCXR [**3-12**]:
IMPRESSION: No pneumothorax. Interval extubation and removal of
an
orogastric tube. Small bilateral pleural effusions. New large
gastric bubble.
Brief Hospital Course:
This is a 50 year old female who has a history of colon/anal
cancer in [**2158**]
treated with chemotherapy and radiation. Recently, she underwent
a CT scan as part of her routine follow-up. The CT scan revealed
a mass in the right atrium suggestive of a myxoma. On [**3-10**] she
was admitted to the hospital for heparin bridge therapy. She was
brought to the operating room on [**2-/2078**] and underwent successful
excision of left atrial mass. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. On the floor she was tachycardic at times
and beta blocker was adjusted. Her lasix was discontinued as she
was below her preoperative weight and had no edema. She was
restarted on Coumadin and her INR was therapeutic at discharge.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 she was more confident about going home and was
ambulating without difficulty. Her wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home in good condition with appropriate follow up
instructions. At the time of her discharge her OR pathology
report was still pending and will need to be followed up on.
Medications on Admission:
Coumadin - "2 tablets" daily (? dose) Last dose [**2161-3-5**]
ATENOLOL - 50 mg Tablet once a day
BUSPIRONE 7.5 mg Tablet twice a day
HYDROCHLOROTHIAZIDE 25 mg once a day
OMEPRAZOLE 20 mg Capsule once a day
Discharge Medications:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. buspirone 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain: prn for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*1*
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take 2.5 mg tonight and then as directed for INR 2.0-3.0.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Academy Manor of [**Location (un) 7658**] - [**Location (un) 7658**]
Discharge Diagnosis:
right atrial mass
s/p removal of right atrial mass
h/o squamous cell anal/colon cancer- s/p radiation &
chemotherapy
s/p tubal ligation
h/o pulmonary emboli
hypertension
hypercholesterolemia
depression
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Recommended Follow-up:
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2161-4-6**] at 1:15pm
Cardiologist: Dr.[**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**] on [**2161-4-1**] at 9:30am
Office to call patient for wound check appointment
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 91871**]in [**4-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication pulmonary emboli
Goal INR 2.0-3.0
First draw [**3-16**]
Results to phone fax (Dr. [**Last Name (STitle) 29070**] has managed Coumadin in
past) - will call office to follow Coumadin [**Telephone/Fax (1) 37284**]
Completed by:[**2161-3-15**] Name: [**Known lastname 2729**],[**Known firstname **] Unit No: [**Numeric Identifier 14463**]
Admission Date: [**2161-3-10**] Discharge Date: [**2161-3-15**]
Date of Birth: [**2110-8-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1543**]
Addendum:
As stated previously in the patients history of present illness,
Ms [**Known lastname **] is a 50 year old Hispanic female with a history of
colon/anal cancer in [**2158**] treated with chemotherapy and
radiation. Followed at outside facility, during routine followup
she underwent a CT scan, which revealed a mass in the right
atrium suggestive of a myxoma. Subsequent work-up included an
echocardiogram which also revealed rt atrial mass possibly myoma
and she was referred to cardiac surgery. As part of the initial
screen a CTA of chest was obtained it revealed acute pulmonary
emboli in the right lower and left lower branches of the
pulmonary artery. Her PCP was [**Name (NI) 178**] and anticoagulation
therapy was initiated. She was brought to [**Hospital1 **] for heparin bridge
prior to surgical removal of the mass on [**2-/2078**].
The pathology report described the mass as "The "mass" appears
to be primarily an old thrombus with areas of calcification".
Anticoagulation for pulmonary embolism was reinstituted post
operatively. Ms [**Known lastname **] was discharged to rehabilitation on [**3-15**] at
that time her INR was 2.8, her coumadin levels were to be
followed by her cardiologist
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2161-5-1**]
|
[
"V12.55",
"272.0",
"212.7",
"311",
"415.19",
"V15.3",
"401.9",
"285.9",
"V10.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"37.49",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11201, 11407
|
4113, 5766
|
326, 436
|
7546, 7702
|
2505, 4090
|
8649, 11178
|
1650, 1715
|
6024, 7182
|
7321, 7525
|
5792, 6001
|
7726, 8626
|
1262, 1341
|
1730, 2486
|
269, 288
|
464, 1053
|
1075, 1239
|
1357, 1618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,294
| 106,608
|
11373
|
Discharge summary
|
report
|
Admission Date: [**2197-11-21**] Discharge Date: [**2197-12-19**]
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old
woman, who was here, visiting her nephew from [**State 2690**]. In the
middle of the night, she got up to go to the bathroom and
opened the basement door, instead of the bathroom door, and
fell down the stairs. The patient was intubated at the
to two minutes. This was preceded by combative behavior.
The head CT revealed an intraparenchymal bleed and left
subarachnoid bleed with a question of midline shift. The
head CT also revealed right skull fracture from the parietal
occipital juncture, extending to the skull, base, and foramen
Magnum; also with left temporal attenuation, may be an
interparenychmal hemorrhage and left frontal-lobe density
HOSPITAL COURSE: The patient was admitted to the ICU. The
patient had a vent drain placed. The patient was sent to the
surgical ICU for close monitoring.
PAST MEDICAL HISTORY: The patient has a past medical history
of hypertension for which she was taking Atenolol and Vasotec
prior to admission to the hospital. The patient has no other
past medical history.
PAST SURGICAL HISTORY: The patient has no other past
surgical history.
On arrival to the ER the GCS score was 70. She had no other
obvious injuries.
PHYSICAL EXAMINATION: On examination, the heart rate was 69,
blood pressure 141/62, temperature 96.8, respiratory rate 16,
saturation 99%. Pupils were 4:6 on the left and 4:3 and
brisk on the right. She had hemotympanum on the right, large
right scalp laceration. She was intubated and sedated,
following no commands and not responding to pain.
Repeat head CT on [**11-22**] showed contusion and subarachnoid
hemorrhage, left anterior temporal, interparenchymal
hemorrhages, right frontal lobe hemorrhage, left greater than
right and right subdural hematoma, which was small. The
cervical spine films revealed a C6 fracture. The patient
also had thoracic spine films, which revealed a T3 fracture.
PHYSICAL EXAMINATION: Neurological examination on [**2197-11-23**]
revealed that the patient was still intubated. She had
partial localization of the left upper extremity and question
of extension posturing on the right upper extremity and brisk
withdrawal of the lower extremities. Pupils were 3 down to 2
bilaterally. Head CT revealed partial blossoming of the
frontal bleed. The patient CTA of the brain, which showed no
evidence of aneurysm for cause of subarachnoid blood.
On [**2197-11-25**], the patient's sputum culture came back with
gram-negative rods. The patient was started on
Ciprofloxacin. Neurologically, pupils equal, round, and
reactive, but withdrawing in the upper extremities and
flexing in the lower extremities bilaterally. The patient
was on CPAP at 40%.
On [**2197-11-26**], neurological examination revealed the
following: Pupils remained 4-mm and reactive bilaterally.
She has an impaired corneal on the right and intact corneal
on the left, positive gag, positive cough. The patient was
unresponsive, except to withdrawal on all four extremities to
nail bed pressure. Minimal spontaneous movement noted and
the patient did open eyes half way with logrolling. The
patient was unable to focus on the examination. The ICP
drain remains in place at 20 cm above the tragus with ICPs 17
to 20. The patient was loaded on Dilantin on admission and
Dilantin was continued until [**2197-12-11**], when it was
discontinued. The ICP drain remained in place until
[**2197-12-5**]. The patient was fitted, TLSO brace arrived. The
patient was in TLSO brace at all times, head of the bed
greater than 45 degrees. While in bed, the patient should be
logrolled only. The patient was treated with Acyclovir for
herpes zoster on her lips. She also had yeast in her urine,
for which she received a full treatment of Diflucan. She was
also treated for an MRSA pneumonia.
Currently, the patient is receiving IV Vancomycin, 1-gram IV
q 12 hours and p.o. Levaquin 500 mg p.o.q.d.
The patient was Oxacillin from [**11-21**] to [**12-5**], Ciprofloxacin
from [**11-21**] to [**12-6**], Diflucan from [**12-4**] to [**12-9**] and
Ceftazidime from [**12-7**] to the current time. The patient had
tracheostomy tube and PEG tube on [**2197-12-7**]; tracheostomy
mask at 40% on [**2197-12-11**]. Neurologically, as of [**2197-12-18**],
the patient opened her eyes; was able to say her name;
moving the upper extremities strongly; lower extremities
flexing minimally to pain. The patient remained at flat bed
rest, otherwise, in TLSO brace. The patient is having a MRI
of the thoracic and cervical spine on [**2197-12-18**]; results
pending.
MEDICATIONS ON DISCHARGE:
1. Atenolol 100 mg p.o.q.d.
2. K-Dur 20 mg per G-tube q.d.
3. Vancomycin 1-g IV b.i.d., which was started on
[**2197-12-7**].
4. Levaquin 500 mg per G-tube q.d. begin on [**2197-12-8**].
5. Salt tabs per G-tube q.d., 2-g.
6. NPH Insulin, two units subcutaneously q.m. and q.p.m.
7. Nystatin powder to the groins.
8. Promote tube feeding at 60 cc per hour via her J-tube.
The patient has a Passy-Muir valve for her tracheostomy. She
was on log-roll precautions whenever the brace is off. The
brace must be on at all times if head of bed is greater than
45 degrees or patient is out of bed. C-collar must remain in
place due to the C6 fracture at all times for twelve-week
total. The patient is on MRSA precautions for the MRSA in
her sputum.
The patient is being transferred to an acute hospital in
[**State 2690**] with followup rehabilitation postoperatively and
followup with the neurosurgeon in [**Location (un) 36413**], TX.
The patient's condition was stable at the time of discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2197-12-18**] 13:36
T: [**2197-12-18**] 13:34
JOB#: [**Job Number 36414**]
|
[
"518.81",
"E880.9",
"805.2",
"401.9",
"482.41",
"112.2",
"804.22",
"805.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"43.11",
"02.2",
"38.7",
"31.1",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4725, 5966
|
821, 961
|
1194, 1323
|
2053, 4699
|
984, 1170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,522
| 143,145
|
54559
|
Discharge summary
|
report
|
Admission Date: [**2132-7-2**] Discharge Date: [**2132-7-9**]
Date of Birth: [**2058-11-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
gait instability
Major Surgical or Invasive Procedure:
Left craniotomy [**2132-7-4**]
History of Present Illness:
This is a 73 year old man with a 1 month history of increasing
gait instability. He was seen in ED recently and had whole
spine MRI which was unremarkable. He was being worked up for
possible Parkinson's Ds. and had MRI brain this morning showing
large L SDH and the patient was advised to come to the ED for
evaluation. Upon questioning patient does admit to slip and
fall on ice hitting head in [**2132-3-10**] followed by MVA 3 days
later with car being totalled. He did not seek medical
attention for either episode.
Past Medical History:
PMHx:HTN, 3 stents [**5-12**] yr ago, s/p colectomy for fecalith,
subtotal prostatectomy for BPH, macular degeneration, recent
catarct removal OS, needs OD done
Social History:
Social Hx:nonsmoker, lives on [**Hospital3 4298**] but relocating
to
[**Location (un) 86**] area, invovled family, retired RN
Family History:
nc
Physical Exam:
PHYSICAL EXAM: u[pin admission
O: T:97 BP: 144/95 HR:84 R 18 O2Sats99 ra
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: L surgical 4mm reactive, R 3mm reactive
EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-9**] objects at 5 minutes.
Language: Speech fluent with good comprehension and
repetition.Has some difficulty with word finding when describing
history.Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils L surgical 4mm reactive, R 3mm reactive to light.
Visual fields are full.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-11**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes:
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
Exam at Discharge:
Nonfocal. Right pupil surgical and asymmetric to left, but
reactive. MAE [**6-11**]. No drift. Ambulating with a cane. Head
incision C/D/I
Pertinent Results:
MRI Brain [**2132-7-2**]:
Large extra-axial heterogeneous collection overlying the entire
left hemisphere likely represents a complex, multi-aged subdural
hematoma,
with a large multiloculated component filling the left middle
cranial fossa with posterior and superior displacement of the
temporal lobe with mass effect as detailed above. It is unclear
to what extent there may be underlying left anterior temporal
encephalomalacia. The majority of enhancement is thin peripheral
and dural-based, with a more focal plaque-like and nodular area
of enhancement overlying one of the cystic cavities which is
most likely reactive, and an underlying is unlikely. However,
neurosurgical evaluation and continued followup is recommended.
There is subfalcine and uncal hernaition on the left. Prominent
cisterna magna with hypoplastic vermis in the spectrum of
Dandy-Walker variant is also noted. The findings were discussed
with the emergency department at the time of dictation, at 0930
hours on [**2132-7-2**], also subsequently discussed with the
patient's neurologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2132-7-2**] 09:30 7.2 5.28 15.3 47.2 90 29.1 32.5 13.7 361
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2132-7-2**] 09:30 65.9 22.3 7.4 3.8 0.6
BASIC COAGULATION PT PTT INR Plt Ct
[**2132-7-2**] 09:30 12.9 26.9 1.1 361
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2132-7-2**] 09:30 106 20 0.9 139 4.6 106 23 15
CT head [**7-4**]:
1. Status post left frontotemporal craniotomy for evacuation of
left subdural collection with interval increase in acute
subdural blood within the left temporal convexity and temporal
fossa compared to the prior study.
2. Moderate amount of pneumocephalus within the bifrontal and
left temporal regions causing slightly more prominent gyral and
sulcal effacement.
CT head [**7-5**]:
The patient is status post left craniotomy, with a drain
catheter
tracking superiorly along the convexity to the vertex. Unchanged
hyperdense material pools around the catheter, compatible with
hemorrhage from procedure. The degree of pneumocephalus is
similar, small in the left frontal region and small-to-moderate
in the right frontal region. The previously noted "[**Location 95867**]"
sign (widening of the interhemispheric fissure and space at the
tips of the frontal lobes) has significantly improved.
Residual left subdural fluid and blood is stable in extent. The
left temporal lobe remains displaced posteriorly with sulcal
effacement. Effacement of the frontal [**Doctor Last Name 534**] of the left lateral
ventricle remains mild, and its temporal [**Doctor Last Name 534**] remains
compressed. A 3-mm rightward shift of midline structures is
unchanged.
CT head [**7-6**]:
No significant interval change.
Brief Hospital Course:
Patient was admitted to ICU for close monitoring with Q1hr
neurologic evaluations and work up for the OR including platelet
transfusion. He was taken to the OR on [**7-4**] for a left
Craniotomy. He had a subdural drain in place post-op and was
returned to the ICU. His Keppra was increased to 1g [**Hospital1 **].
Platelets were given. On [**7-5**] a post-o pCT head was stable.
Seroquel was started for sundowning behavior. On [**7-6**], his
confusion improved. His drain was discontinued. Repeat CT was
again stable. He was transferred to the floor with telemetry.
The Geriatric service was consulted on [**7-6**]. Seroquel was
restarted, and the Pepcid and Foley were removed. PT and OT were
consulted. It was felt that he would benefit from rehab
services. Per the family, he was starting to exhibit signs of
dementia prior to this medical event/admission. He was cleared
for home by PT on [**2132-7-8**]. A VNA home safety evaluation was
ordered. He was discharged home [**2132-7-9**].
Medications on Admission:
Medications prior to admission:lisinopril, asa, plavix,
seroquel(self dc'd 1 month ago), simvastation (self dc'd), MVI
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain,fever: max 4g/24hrs.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q PM ().
13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left SDH and cyst
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You are ok to resume taking your Plavix and Aspirin. Please
contact us with any change in headaches or mental status
?????? You have been prescribed an anti-seizure medicine, Keppra,
take it as prescribed.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call for an appointment for removal of your staples due
[**7-16**].
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2132-7-9**]
|
[
"852.21",
"348.0",
"V45.82",
"518.0",
"E888.9",
"997.39",
"293.0",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
7928, 7947
|
5705, 6700
|
334, 367
|
8009, 8009
|
2744, 5682
|
9593, 10033
|
1263, 1267
|
6869, 7905
|
7968, 7988
|
6726, 6726
|
8162, 9570
|
1297, 1520
|
6757, 6846
|
2585, 2725
|
278, 296
|
395, 920
|
1873, 2571
|
8024, 8138
|
942, 1104
|
1120, 1247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,241
| 184,318
|
24246
|
Discharge summary
|
report
|
Admission Date: [**2173-8-13**] Discharge Date: [**2173-8-16**]
Date of Birth: [**2139-9-13**] Sex: M
Service: MEDICINE
Allergies:
Betadine
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33 M w/ h/o HTN, admitted 1 year ago to [**Hospital1 18**] with hypertensive
urgency, presented to ED with c/o worsening dyspnea over several
weeks, found to have BP 230s/168. Patient states he has been on
labetalol and HCTZ in the past for blood pressure control, but
that he has had a lapse in health care coverage and has not been
able to afford pills since [**Month (only) 116**] of this year. Although he had a
"head cold" a few weeks ago, he denies having any fevers or
taking pseudoephedrine for the last several months. He denies
taking any cocaine. He denies chest pain, blurry vision,
headaches, confusion, or back pain.
.
Pt c/o episodes of dyspnea over several weeks. He reports
episodes come on acutely when he is "just sitting there." The
most he exerts himself is when he climbs a flight of stairs, and
he has not noticed dyspnea or chest pain when climbing the
stairs. +orthopnea, +paroxysmal nocturnal dyspnea, +lower
extremity edema, which he says has gotten worse today but has
been increasing over several weeks. Of note, he does have a h/o
childhood asthma, hasn't used inhalers for years, denies
nighttime cough.
.
In the ED, the patient's VS were T 95, BP 232/163, HR 114, RR
14, O2 100%. He was given Hydralazine 10mg IV x 1, then placed
on nitro gtt and labetalol gtt with decrease in BP to 171/114
over 3 hours. He also received ASA 325 and Morphine 4mg IV x 1.
He was initially given 1L of NS, but when CXR was noted to be
consistent with CHF, he was given 20mg IV lasix with 1200ml
urine output.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, or syncope. He does note dyspnea, paroxysmal
nocturnal dyspnea, orthopnea, and ankle edema as mentioned
above.
Past Medical History:
- Hypertension with hypertensive urgency x 1 in past
- Chronic renal insufficiency with baseline Cr 1.5
- Acute disseminated encephalomyelitis - per [**Hospital1 18**] records,
diagnosed at [**Hospital1 2025**], p/w photophobia and was sore from his L-ear to
his scapula; s/p craniotomy with biopsy and 5 week hospital
stay, recovered completely, no neurological symptoms since
- Bacteremia - [**Hospital3 **] [**9-3**], per patient from
eczema skin wound. Hospitalization [**2172-7-7**] for Group G
streptococcal bactermia.
- Eczema
- Childhood asthma--has not been on inhalers in years
- Allergic rhinitis
- Rotator cuff injury
.
ALLERGIES: Betadine--rash
Social History:
Social history is significant for the presence of current
tobacco use: 1-2PPD x 10 years. Patient denies alcohol abuse,
though he indiciates there have been times when he had to cut
back on his drinking. He works as a bartender. +tattooes done by
a friend, reports they are done under sanitary conditions.
Denies ever abusing IV drugs or cocaine. Lives with roommates.
Family History:
There is a family history of premature coronary artery disease:
mother [**Name (NI) 61530**] with CAD in her 40s. Father and sisters healthy.
Mother has DM that resolved after gastric bypass. Denies other
family h/o DM, HTN, or CAD.
Physical Exam:
VS: T 96.3, BP 156/102, HR 86, RR 16, O2 90% on RA, 145 kg
Gen: Obese African American male, appears comfortable without
respiratory distress, affect somewhat aloof, but cooperative.
HEENT: Old scar on head from brain biopsy. Sclera anicteric.
PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Funduscopic exam: no papilledema or hemorrhages noted.
Neck: Supple with JVP to angle of jaw at 30 degrees.
CV: Difficult to appreciate PMI in this obese man. RR, normal
S1, S2. S4 noted, no S3. No murmur appreciated.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles noted at bases
b/l, no wheeze.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No clubbing. No femoral bruits. +2 pitting pretibial edema
b/l to [**12-1**]-way up legs.
Skin: Multiple tattooes on arms b/l. Patches or
scarring/lichenification with depigmentation on feet and lower
extremities b/l.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: A + O x 3, CN II-XII intact, Motor 5/5 strength proximal
and distal UE and LE b/l, bulk and tone symmetric b/l, DTRs +2
b/l UE and LE throughout, toes downgoing b/l, Sensation grossly
intact to light touch throughout, Finger to Nose intact both
right and left arm.
Pertinent Results:
EKG demonstrated NSR with appropriate axis and intervals, LVH,
ST elevations in V1-V4 and T wave inversions in I, aVL, V4-V6.
?Left atrial enlargement (biphasic P wave in V1). The T wave
inversions appear new as change compared with prior dated
[**2172-7-19**].
.
Relevant labs:
WBC 12.9 with left shift
K 3.7, Cr 2.3
BNP 2499
CK 585 -> 474
MB 12 -> 12
Trop T 0.05 -> 0.02
[**2173-8-15**] 04:45AM BLOOD WBC-8.6 RBC-3.76* Hgb-12.2* Hct-35.8*
MCV-95 MCH-32.5* MCHC-34.2 RDW-15.2 Plt Ct-196
[**2173-8-14**] 04:39AM BLOOD PT-12.5 PTT-29.8 INR(PT)-1.1
[**2173-8-15**] 04:45AM BLOOD Glucose-77 UreaN-31* Creat-2.2* Na-143
K-3.9 Cl-107 HCO3-28 AnGap-12
[**2173-8-14**] 04:39AM BLOOD %HbA1c-5.0
[**2173-8-14**] 04:39AM BLOOD Triglyc-88 HDL-60 CHOL/HD-2.9 LDLcalc-97
[**2173-8-14**] 04:39AM BLOOD TSH-0.84
.
CXR in ED [**8-13**]:
1. Findings consistent with interstitial pulmonary edema.
Please correlate with the patient's symptoms.
2. Apparant cardiac enlargement is likely related to volume
overload, although pericardial effusion cannot be excluded.
3. Right basilar opacity, though probably in part atelectatic,
may also represent consolidation.
.
CXR [**2173-8-14**]:
Improvement in the right lower lobe patchy opacity and decrease
in the
interstitial markings since the prior examination. Persistent
cardiac
enlargement.
.
Echo [**2173-8-14**]:
The left and atrium are moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. Regional and global left
ventricular function is preserved. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging
are consistent with Grade II (moderate) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild to moderate ([**12-1**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Brief Hospital Course:
33yo man with h/o hypertension and poor access to medical care
presents with hypertensive emergency and signs of congestive
heart failure as well as possible acute on chronic renal
failure.
.
# HTN:
Mr. [**Known lastname **] blood pressure was acutely controlled with
labetalol IV and then switched to oral labetalol after the first
night in the hospital. His EKG and his cardiac enzymes did not
show evidence for MI. At the time of discharge, he was given a
prescription for labetalol, and he was given a follow-up
appointment with a PCP at [**Hospital1 18**].
.
Patient has chronic HTN for which he has had difficulty
obtaining medicines. Given that he has a h/o difficult to treat
HTN on multiple medicines according to prior discharge
summaries, it would be reasonable to consider secondary causes
of HTN. His TSH was normal, and his aldosterone was pending at
the time of discharge. Given his obesity, it would be
recommended to pursue evaluation for OSA as an outpatient.
.
# CHF- acute diastolic heart failure:
Patient was clinically found to be in heart failure upon
presentation. Upon review of his chart, there is no evidence of
heart failure in the past, and echo showed preserved systolic
function. He responded well to diuresis with lasix, and his
dyspnea and lower extremity edema improved. He was discharged
on lasix.
.
# EKG changes:
Patient had slightly increased cardiac enzymes and ST/T
abnormalities consistent with LVH and demand ischemia in the
setting of hypertension. To assess his risk factors for
coronary disease, his lipids were checked (LDL 97, HDL 60) and
his A1C was sent (5.0%). He will have follow-up with his PCP.
.
# Acute Renal Failure on Chronic Renal Insufficiency (baseline
Cr 1.5):
The patient's creatinine continued to be high at 2.2 throughout
his admission. It was felt that he most likely had hypertensive
nephropathy, and he was educated about the importance of
controlling his blood pressures in order to preserve his renal
function. Follow-up was arranged with nephrology evening
clinic.
.
# Elevated WBC:
Although the patient had an elevated white count on admission,
he did not develop fevers. His white count resolved without
antibiotics.
.
# Respiratory distress:
Patient initially presented with chief complaint of shortness of
breath. He had no further dyspnea once he was diuresed. Given
his childhood history of asthma and his current smoking, his PCP
can consider checking pulmonary function tests as appropriate.
.
# Poor access to medical care:
Patient was educated about the importance of treating his
hypertension. He now has insurance through his job, and he
agreed to come to [**Hospital1 18**] for follow-up with a new PCP and
nephrologist.
Medications on Admission:
no prescription meds
Claritin PRN
.
Denies taking herbal medicines or supplements
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Outpatient Lab Work
Please go to [**Hospital 191**] clinic in the [**Hospital Ward Name 23**] building during the week
of [**8-23**] to have your blood drawn: CBC, retic count, Iron,
Transferrin, Ferritin, Sodium, Potassium, Chloride, Bicarb, BUN,
Cr, and Glucose.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: hypertensive emergency
Secondary Diagnoses: Hypertension, acute renal failure, chronic
renal insufficiency
Discharge Condition:
good, blood pressure improved to 120s to 150s systolic
Discharge Instructions:
You came into the hospital because of shortness of breath. Your
blood pressure was very high in the emergency room and improved
with medications. You also had evidence of kidney disease which
appears to be a chronic problem.
1. Please take all your medications as prescribed. This is very
important to do regularly to prevent your high blood pressure
from damaging your heart and kidneys.
2. Please attend all follow-up appointments as listed below.
3. You will need to go to [**Hospital 191**] clinic in 1 week to get your blood
drawn. We will give you a prescription to bring with you for
the blood draw.
4. Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, decreased urine,
fevers, or any other concerning symptom.
Followup Instructions:
1. Nephrology (Kidney doctor). Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 60**] Date/Time:[**2173-8-23**] 7:00 Go to [**Hospital Ward Name 23**] [**Location (un) **]; please call and reschedule if this is a bad time
2. Primary care doctor. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2173-8-26**] 2:30. [**Hospital Ward Name 23**] building.
3. Please go to the [**Hospital Ward Name 23**] building and have your blood drawn
next week; bring your prescription with you.
Completed by:[**2173-8-19**]
|
[
"701.2",
"428.0",
"584.9",
"305.1",
"493.90",
"585.9",
"401.0",
"V17.3",
"428.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10719, 10725
|
7370, 10090
|
289, 296
|
10897, 10954
|
5143, 7347
|
11774, 12456
|
3489, 3723
|
10222, 10696
|
10746, 10746
|
10116, 10199
|
10978, 11751
|
3738, 5124
|
10811, 10876
|
230, 251
|
324, 2404
|
10766, 10789
|
2426, 3085
|
3101, 3473
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,204
| 114,209
|
40963
|
Discharge summary
|
report
|
Admission Date: [**2159-4-30**] Discharge Date: [**2159-5-5**]
Date of Birth: [**2117-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Fever, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41 year old male with DMI c/b retinopathy, ESRD s/p renal and
pancreas tranplant in [**2149**], on immunosuppresion who has been
having 2 days of fever and generalized weakness and headache.
He resides in prison and an inmate noted that he was stumbling
to get out of the bathroom and collapsed. He was caught and did
not hit the floor. He did not lose consciousness. He was
brought to the clinic at the prison by where he was noted to
have a temp of 104.9, HR of 130s at (approx: 8pm on [**4-29**]). His
indwelling foley at that time was draining "dark amber colored"
urine. On [**4-27**], he had moved from one unit of the prison to
another unit as he had a "respiratory illness", vitals at the
time were HR of 70s, BP of 104/60's, not orthostatic. Since
then he has been having lethargy and staying in bed. He does
complain of occasional RUQ pain. Of note he has a chronic
indwelling catheter for urinary retention, diagnosed recently.
.
Of note, he had a recent admission at [**Hospital3 **] from
[**Date range (1) 61876**]/[**2158**] for presistent N/V/abd pain for 4-5 days prior.
Creatinine documented at that time was 2. Per d/c summary, he
had CT scan of abd and pelvis on [**4-8**] which showed no abnormality
to explain abd pain. He was treated for urinary retention,
placed on tamsulosin for dystonic bladder and discharged with a
foley. His pancrease and kidney are connected to bladder, thus,
he has chronic metabolic acidosis [**1-3**] bicarb excreted into
urine, he is taking outpatient NaHCO3 and was give Isotonic
bicarb in NS during that admission. He had a f/u appt with Dr.
[**Last Name (STitle) 43125**] on [**2159-5-2**].
.
He was tranfered from prison to [**Hospital1 498**] ED. At OSH ED he was
found to have a temp to 103.3 and had a positive UA and a CXR
was done that was clear. He was given Vancomycin 1g, Gent
100mg, zosyn 3.325mg and hydrocortisone 200mg and tylenol. He
was given dilaudid for pain. He was then tranfered to [**Hospital1 18**] ED
for further work-up.
.
At [**Hospital1 18**] ED initial vitals were: 97.0 90 128/75 20 94%. He was
noted to be diffusely diaphoretic and occasional somnolent
although he could be aroused and woken up. His renal transplant
site was normal and did not have any erythema or fluccuance. He
requires translator, but was appropriate. Pt denied abdomainl
pain. Labs significant for bicarb of 8, K of 6.7, Na 122, WBC
of 23, lactate of 1.5, creatinine of 3.1, INR of 1.6. Given the
fact that he had a headache an LP was planned. However the
patient refused an LP as he had one in the past and did not want
it. In addition to the antibiotics given at OSH ED he was given
ceftriaxone 2g iv, Insulin/D50, Calcium, and 4L of NS.
.
On the floor, he is tachycardiac and rigoring.
Past Medical History:
Urinary retention
blodder stone removal vai cycstocopy in [**2153**]
chronic metabolic acidosis
legally blind in the let eye
DM type 1 c/b retinopathy, nephropathy s/p kidney and pancreas
transplant in [**2149**] at [**Location (un) 10866**].
Transplant-related erythrocytosis
HLD
HTN
GERD
L. Kidney soft tissue mass
Social History:
incarcerated at [**Last Name (un) **]. No current use of tobacco, etoh, or
ivdu.
Family History:
Grandfather had throat cancer
Physical Exam:
Admission Vitals
Vitals: T: 103 BP: 130/60 P: 140 R: 25 O2:100% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, diffusely
blanching erythema.
Neck: supple, JVP not elevated, no LAD, +
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Vitals: T: 97.8 Tmax: 99.1 BP: 142/80 (114-142) P: 64 (58-64)
R: 18 (18-20) O2: 94-99% RA
Fingersticks: 102->103->134->117
General: Alert, oriented, no acute distress. Afebrile.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no meningismus, no
tenderness to palpation over spine
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no
tenderness over transplanted kidney in LLQ.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
ADMISSION LABS:
.
[**2159-4-30**] 02:15AM BLOOD WBC-23.5* RBC-6.42* Hgb-17.7 Hct-57.8*
MCV-90 MCH-27.6 MCHC-30.6* RDW-17.1* Plt Ct-153
[**2159-4-30**] 02:15AM BLOOD Neuts-88* Bands-0 Lymphs-1* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2159-4-30**] 02:15AM BLOOD PT-18.0* PTT-38.1* INR(PT)-1.6*
[**2159-4-30**] 02:15AM BLOOD Glucose-130* UreaN-53* Creat-3.1* Na-122*
K-6.7* Cl-111* HCO3-8* AnGap-10
[**2159-4-30**] 08:35AM BLOOD Albumin-3.0* Calcium-10.7* Phos-4.9*
Mg-1.9
.
DISCHARGE LABS:
[**2159-5-5**] 06:51AM BLOOD WBC-5.8 RBC-5.38 Hgb-14.8 Hct-47.0 MCV-87
MCH-27.4 MCHC-31.4 RDW-17.3* Plt Ct-161
[**2159-5-5**] 06:51AM BLOOD Neuts-61.9 Lymphs-27.3 Monos-8.1 Eos-2.5
Baso-0.2
[**2159-5-5**] 06:51AM BLOOD Plt Ct-161
[**2159-5-5**] 06:51AM BLOOD Glucose-99 UreaN-22* Creat-1.6* Na-142
K-4.0 Cl-110* HCO3-22 AnGap-14
[**2159-5-3**] 05:50AM BLOOD ALT-26 AST-25 AlkPhos-56 TotBili-0.2
[**2159-5-5**] 06:51AM BLOOD Lipase-119*
[**2159-5-5**] 06:51AM BLOOD Calcium-9.4 Phos-2.1* Mg-1.5*
[**2159-5-5**] 06:51AM BLOOD tacroFK-19.0
[**2159-5-5**] 06:51AM BLOOD rapmycn-12.3
IMAGING STUDIES:
TRANSPLANT U/S:
1. Left lower quadrant renal transplant, with no hydronephrosis,
but elevated segmental arterial resistive indices measuring 0.80
to 0.87.
2. Pancreatic transplant possibly seen within the right lower
quadrant, with possible ductal dilation althought this could
also represent bowel with thickened walls. If there remains a
high concern for an acute process, a CT examination should be
considered.
3. No focal fluid collections.
TRANSTHORACIC ECHOCARDIOGRAM [**5-3**]:
IMPRESSION: No echocardiographic evidence of endocarditis. Mild
symmetric LVH. Normal regional and global biventricular systolic
function. The valves are well seen without significant
regurgitation making endocarditis unlikely.
CONTRAST CT ABDOMEN AND PELVIS AND NON-CONTRAST CHEST CT [**5-4**]:
No intrathoracic, abdominal or pelvic evidence of infectious
etiology.
Dilatation of the left native proximal ureter with high-density
material and abnormal soft tissue density just inferior to the
dilated ureter which could represent a ureteric process or lymph
node, possibly causing obstruction of the native proximal
ureter. Further evaluation with MR urogram should be considered.
Air within the non-dependent portion of the urinary bladder may
be related to prior instrumentation and clinical correlation is
recommended.
CXR:
No previous images. The right PICC tip is in the upper portion
of
the right atrium and should be pulled back about 3 cm for
optimal placement. This information has been telephoned to the
IV nurse by the resident on call at 9:40 a.m. on [**5-5**]. (this was
done to PICC line)
.
Micro:
[**4-30**] Blood:
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 1 S
.
[**4-30**] Urine:
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
Brief Hospital Course:
41-year-old man with diabetes and ESRD s/p pancreas and kidney
transplant now with fevers, GPC bacteremia, pyuria, and
leucocytosis, presumably transplant pyelonephritis.
.
# Fevers/UTI/Bacteremia: Patient started on emperic vancomycin
and zosyn [**4-30**]. UTI . Patient did have dental work several
weeks ago, thus endocarditis was also on the differential.
Foley catheter was switched out. ID was consulted and
recommended staying on zosyn/vancomycin until speciation.
Abdominal US negative for fluid collection. Blood culture grew
enterococcus and urine grew e coli and enterococcus. Zosyn
transitioned to PO cipro on [**5-2**] and vancomycin transitioned
ampicillin on [**5-3**] in response to sensitivities. TTE was normal
with good quality study. The patient was feeling clinically
well by [**5-2**] except for headache and several episodes of loose
stool [**5-1**]. C-diff toxin negative x2 and diarrhea and headache
resolved. Patient continued to spike fevers evening of [**5-2**] and
[**5-3**]. Further urine/blood cultures as well as contrast abdominal
and non-contrast chest CT scan, BK virus and adenovirus urine
and blood studies were sent for fever work-up. CT scan was
negative for infectious process, and patient remained afebrile
following 22:05 on [**5-4**]. Plan is for 2 weeks total of amp until
[**5-15**] for bactermia and course of cipro for UTI to end [**5-7**].
.
# ARF: Cr from recent baseline of 2.0 up to 3.1 on admission.
Likely prerenal from UTI and spesis. Improved with fluids to
2.4 on [**5-1**] and he had appropriate urine output. With clinical
improvement, his Cr continued to fall to 1.6 on day of
discharge. Of note, patient received IV contrast for CT scan on
[**5-4**]. He was pre-hydrated. Please monitor for worsening ARF
after discharge.
# Transplant: Continued on sirolimus and tacrolimus. Was
followed by renal transplant service throughout stay. Levels of
sirolimus and tacrolimus were slightly low on admission,
suggesting the patient missed meds recently. Following 24hr
troughs were [**Month/Day (4) 25486**] 5.2-5.7 and rapamycin 7.5-7.9. Ultrasound
showed increased arterial indicies read as concerning for mild
rejection, but renal team did not feel this was the case. Of
Note: his PPI dose was doubled on this admission, which can
increase levels of tacrolimus.
.
# Urinary Retention: Had foley in place on admission, which was
changed for clean foley initially. He had a planned outpatient
voiding trial on [**5-2**], so foley was removed on [**5-2**] and patient
was able to void. Post-void residual on [**5-3**] was 108cc. He was
continued on flomax.
.
# HyperK: Given D50/Insulin, kayalxylate, calcium, 6-liter IV
NS. K+ trended down over 24 hours and remained stable.
.
# Metabolic acidosis: Secondary to infection and pancreatic
excretion, continued on home bicarb repletion 650mg TID but the
patient's levels fell to 12, on renal reccomendations, increased
to 1950mg PO TID and levels stablized in the normal range. This
should be his new dose and his electrolytes should be checked
two days after discharge. Then should then be checked as you
deem appropriate.
.
# Diarrhea: had 4 episodes watery stool on day 1 and additional
infrequent episodes. C. diff stool toxins were negative x 2.
Stool culture [**5-3**] negative for salmonella, shigella, enteric
GNRs and campylobacter.
.
#Headache: Patient complained of neck, shoulder and occipital
soreness starting day 1 of hospitalization, this was most MSK
pain likely secondary to sleeping position. Tylenol was
inadequate for controlling this pain, but resolved with
oxycodone 5mg Q6hr PRN while inpatient. Patient did not have
significant analgesia needs by [**5-4**]. This should not be
continued on discharge.
.
# Diabetes Mellitus: The patient is s/p pancreatic transplant
with no insulin requirement at home; was slightly hyperglycemic
here most likley due to infection. H received low doses of
insulin per sliding-scale regimen while inpatient.
.
# GERD: Continued on omeprazole, but dose doubled to 40mg PO
daily on [**5-3**] in response to ongoing complaints of heartburn by
the patient. This has been known to ocassionally interact with
tacrolimus, so please check dose to make sure it is stable on
Monday. He did get good relief on the higher dose of
omeprazole.
.
# Transplant-related erythrocytosis: HCT 58 at admission, in 40s
since IV fluid hydration. Baseline is around 50 and he receives
periodic phlebotomy as an outpatient. The acute elevation may
have been secondary to dehydration. HCT remained in high 40s
after hospital day 1, no intervention aside from IV hydration
and frequent laboratory draws.
.
# Hyperlipidemia: Continued on simvastatin.
Medications on Admission:
Aspirin 81mg
Fludricortisone 0.1mg TID
Methylprednisolone 4mg daily
Omeprazole 20mg daily
Simvastatin 20mg daily
Tamsulosin 0.4mg daily
Sirolimus 3mg daily
Tacrolimus 2mg [**Hospital1 **]
Sodium Bicarbonate 650mg TID
Bactrim 400/80 M/W/F
PCN VK 500mg Q6H for 6 days (completed on [**4-17**])
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO M W F ().
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
10. methylprednisolone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. sodium bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: LAST DOSE: AM of [**5-7**].
14. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
15. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 2 weeks: First dose: PM [**5-3**].
Continue for 2 weeks total. Last day [**5-17**].
16. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 68789**] [**Hospital 16843**] Campus
Discharge Diagnosis:
Primary:
Urinary Tract Infection with sepsis
Discharge Condition:
Vital Signs Stable
Mental Status: Alert and Oriented
Ambulates at will
Discharge Instructions:
You were admitted to the hospital after feeling weak and having
fevers for several days. You had developed new kidney failure.
It was found that you had a urinary tract infection. Bacteria
were found in your urine and in your blood. You received
antibiotics intravenously and orally and your infection began to
clear and your kidney function improved. You will need to be on
two weeks of IV antibiotics. We also increased your dose of
bicarb and ompeprazole. Omeprazole can sometimes interact with
your [**Last Name (LF) 25486**], [**First Name3 (LF) **] please make sure to have your levels checked.
Followup Instructions:
Follow-up with outpatient urology providers for urinary
retention
Will continue IV Ampicillin for total of 2 weeks. Should have
labs checked at least weekly to monitor infection. Infectious
disease follow-up with possible trans-esophogeal endocardiogram
if he develops new fevers.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2159-5-6**]
|
[
"V42.83",
"584.9",
"276.2",
"530.81",
"289.0",
"E878.0",
"362.01",
"041.4",
"276.51",
"585.6",
"250.40",
"995.91",
"272.4",
"784.0",
"038.0",
"996.81",
"787.91",
"788.29",
"041.04",
"250.50",
"590.80",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15096, 15172
|
8430, 13140
|
321, 327
|
15261, 15280
|
4908, 4908
|
15989, 16402
|
3580, 3611
|
13483, 15073
|
15193, 15240
|
13166, 13460
|
15358, 15966
|
5407, 5987
|
3626, 4889
|
265, 283
|
355, 3124
|
4924, 5391
|
15295, 15334
|
3146, 3465
|
3481, 3564
|
6005, 8407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,547
| 187,227
|
40457
|
Discharge summary
|
report
|
Admission Date: [**2174-5-10**] Discharge Date: [**2174-5-17**]
Date of Birth: [**2094-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aortic Stenosis and Coronry Artery Disease
Major Surgical or Invasive Procedure:
[**2174-5-11**]: Aortic Valve Replacement (27 mm Porcine) and Coronary
Artery ByPass x 2 (LIMA->LAD, SVG->OM)
History of Present Illness:
This is a 79 year old male with known aortic stenosis and murmur
most of his life. Over the last 4 months, he has began to
experience exertional angina. His angina does improve with rest.
In addition he complains of fatigue and
lightheadedness. Most recent echocardiogram in [**2173-12-25**]
revealed progressive aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6cm2 and
mean gradient of 76mmHg. Given the above findings, he has been
referred for aortic valve replacement.
Past Medical History:
- Coronary Artery Disease
- Aortic Stenosis
- Dyslipidemia
- Benign Prostatic Hypertrophy
- Melanoma of Face
- Macular Degeneration, s/p Avastin Therapy
Past Surgical History
- Ulcer repair
- Appendectomy
Social History:
Lives with: Wife in [**Name2 (NI) **]
Occupation: Retired Carpenter
Tobacco: 10 PYH, quit 40 years ago
ETOH: Denies
Family History:
No premature coronary artery disease
Physical Exam:
Admission: Physical Exam
Pulse: 71 Resp: 18 O2 sat: 100%
B/P 136/48
Height: 68 inches Weight: 155 lbs
General: Well-developed, well-nourished male in no acute
distress
Skin: Dry [X] [**Name2 (NI) 5235**] [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Nl S1-S2, Murmur [**2-27**] late peaking systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]Well healed incision along right abdomen
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Small varicosities on distal right lower extremity
Neuro: Grossly [**Month/Day (4) 5235**] [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: Transmitted murmur
Pertinent Results:
Echo: [**2174-5-11**]
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aortic Valve - Peak Gradient: *96 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 46 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**12-26**] T): 2.6 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Borderline normal RV systolic function.
[**Month/Day (2) **]: Mildly dilated ascending [**Month/Day (2) 5236**]. Simple atheroma in
descending [**Month/Day (2) 5236**].
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Moderate to severe (3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%), with septal hypokinesis and with borderline normal free
wall function. The ascending [**Month/Day (2) 5236**] is mildly dilated.
There are simple atheroma in the descending thoracic [**Month/Day (2) 5236**].
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Moderate
to severe (3+) aortic regurgitation is seen.
Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient was initially AV-Paced, then no longer paced, on no
inotropes.
There is a well-seated bioprosthetic aortic valve with no leak
and no AI. Mean residual gradient = 10 mmHg.
Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Preserved biventricular systolic fxn
with septal hypokinesis. The SGC is at the PA bifurcation.
[**2174-5-16**] 04:40AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.6* Hct-28.1*
MCV-90 MCH-31.0 MCHC-34.3 RDW-14.2 Plt Ct-140*
[**2174-5-14**] 06:20AM BLOOD WBC-12.2* RBC-3.37* Hgb-10.3* Hct-29.8*
MCV-88 MCH-30.6 MCHC-34.7 RDW-14.5 Plt Ct-102*
[**2174-5-16**] 04:40AM BLOOD Glucose-150* UreaN-31* Creat-0.8 Na-134
K-3.6 Cl-99 HCO3-28 AnGap-11
[**2174-5-13**] 05:00AM BLOOD Glucose-161* UreaN-23* Creat-0.7 Na-131*
K-4.4 Cl-99 HCO3-25 AnGap-11
Brief Hospital Course:
The patient was brought to the operating room on [**2174-5-11**] where
the patient underwent Aortic Valve Replacement (27 mm Porcine)
and Coronary Artery ByPass x 2 (LIMA->LAD, SVG->OM) and repair
of LAA laceration. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Episode of RAF
110's with hypotension converted to sinus rhythm following
Amiodarone bolus and Magnesium 2 gms.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically [**Date Range 5235**]
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. Episode of
nausea and vomiting which resolved with antiemetics. The patient
was transferred to the telemetry floor for further recovery. He
developed urinary retention. Foley was re-inserted and Flomax
started, which was changed to Cardura at home dose. He voided
following 2nd attempt of foley removal. His Lopressor was
decreased and lasix decreased with hypotenstion. 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 6 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home with VNA services in good
condition with appropriate follow up instructions.
Medications on Admission:
Simvastatin 20mg daily, Cardura 8mg daily, Aspirin 325mg daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours for 1 months: then as directed by
cardiologist.
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:*2*
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain. Tablet(s)
6. Cardura 8 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*1 1* Refills:*0*
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Lopressor 50 mg Tablet Sig: One-half Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 5 days.
Disp:*5 Tablet, ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
- Coronary Artery Disease
- Aortic Stenosis
- Dyslipidemia
- Benign Prostatic Hypertrophy
- Melanoma of Face
- Macular Degeneration, s/p Avastin Therapy
Past Surgical History
- Ulcer repair
- Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on Wed [**5-25**] at
10:00 AM
Surgeon Dr. [**Last Name (STitle) **] on [**6-9**] at 1:00pm
Cardiologist: Dr. [**Last Name (STitle) 10543**] on [**6-14**] at 2:00pm
Follow up with PCP Dr [**Last Name (STitle) 10543**] [**Telephone/Fax (1) 4475**] for urologic issues and
follow up with Urologist as needed
**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:[**2174-5-17**]
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74,421
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46787
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Discharge summary
|
report
|
Admission Date: [**2166-8-21**] Discharge Date: [**2166-8-28**]
Date of Birth: [**2102-12-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tegretol / Dilaudid
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Leg weakness
Major Surgical or Invasive Procedure:
[**2166-8-22**]
Right thoracentesis
[**2166-8-22**]
1. Right VATS, right thoracotomy and decortication.
2. Flexible bronchoscopy with bronchoalveolar lavage
[**2166-8-26**]
Right AC PICC
History of Present Illness:
Mr. [**Known lastname 4114**] is very pleasant 63 year old manw ith a PMH notable
for congenital hydrocephalus, HTN, OSA, seizure disorder, and
gait instability, who presents with weakness after standing.
Of note, the patient was in this hospital in early [**Month (only) 116**] with a
finding of a right sided pleural effusion status post a fall; he
had a pigtail placed and subsequently also had a VATS, with an
effusion that was characterized as exudative. He was treated for
a CAP as well as that time with Levofloxacin.
He presented to his PCP's office today because his wife [**Name (NI) **]
was concerned he was anemic. His wife says his PCP says that his
HGB at that time was 8.4. At PCP's office, was also reported
guiaic positive, prompting her to recommend an ED evaluation.
When he left his PCP's office with his wife with a plan to go to
[**Hospital1 **], on the wa to the hospital they stopped off a a store, and
when he tried to leave the car he said that his legs became very
weak, and that he fell to the ground. He denied any LOC, any
[**Last Name (LF) 99291**], [**First Name3 (LF) 691**] lightheadedness or any dizziness. He denied
feeling any palpitations in his chest.
Per the wife, he has been having increasing numbers of falls at
home, increasing urinary incontience, and has been more confused
recently. He is currently AAOx3. He has also had an increasing
number of falls; he feel two nights ago while in the bathtub,
without LOC, but with some possible body trauma. He also
indicates that he has fallen in the past 3 weeks as well.
His neurologist is at [**Hospital1 2025**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9063**]. Per patient, he has
been evaluated for a VP shunt, but has never been felt to
clinically need one; his last CT scan was 6 months ago, but
unclear what this showed.
The patient denies any history of coagulopathy or liver disease.
He denies drinking enough to be visisted by that "dark [**Doctor Last Name **]"
cirrhosis.
In the ED, initial vitals 97.6 90 86/53 16 95% RA
Exam notable for being guiaic positive.
Labs notable for WBC 25.3, HCT 26.3, Plt 748, MCV 66, INR 1.6,
Alb 2.8, but a negative tropinin x 1 and a normal lactate.
The pt underwent an EKG with NSR, and a CXR which was
preliminarily read as right lower lobe opacity with associated
effusion, likely representing atelectasis. He received
CeftriaXONE 1 g, and Azithromycin 500 mg. He also recieved 2 L
NS and 40 mg IV Pantoprazole. Vitals prior to transfer were
Pulse: 93, RR: 16, BP: 117/59, O2Sat: 99% RA.
On transfer to floor, he endorses some mild shortness of breath.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Congenital hydrochephalus
- Hypertension
- OSA x 30 years
- ? etoh over use
- Seizure disorder
- gait instability after MVC in [**2161**]
Social History:
Married with one child. His wife is a psychologist -Dr.
[**First Name (STitle) 2405**]. Has worked as business lawyer. Denies tobacco (past
smoker, quit '[**25**]), no illicit drugs. Reports that he drinks 2-3
beers per week.
Family History:
No seizures, migraines, neuropathy. No diabetes. Mother with
hydrocephalus. Father with lung cancer, CVA, CAD.
Physical Exam:
VS - T98.2 BP 112/58 HR 88 RR 24 96% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - Strabismus of the right eye (old), PERRL, sclerae
anicteric, MMM
NECK - supple, no JVD
LUNGS - decreased BS at the right base, without crackles, to
2/3s up the lung. Resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - Notable for 2x3 cm hematomas (3) on the left back
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-14**] throughout, gait not assessed
RECTAL - Guiaic positive black stool, firm in the rectal vault,
not tarry
Pertinent Results:
[**2166-8-21**] 02:40PM WBC-25.3*# RBC-3.98* HGB-7.8* HCT-26.3*
MCV-66* MCH-19.6* MCHC-29.7* RDW-16.4*
[**2166-8-21**] 02:40PM NEUTS-88.5* LYMPHS-6.5* MONOS-4.6 EOS-0.1
BASOS-0.1
[**2166-8-21**] 02:40PM PLT COUNT-748*
[**2166-8-21**] 02:40PM PT-17.2* PTT-30.1 INR(PT)-1.6*
[**2166-8-21**] 02:40PM ALBUMIN-2.8* IRON-9*
[**2166-8-21**] 02:40PM ALT(SGPT)-17 AST(SGOT)-32 ALK PHOS-74 TOT
BILI-0.3
[**2166-8-21**] 02:40PM GLUCOSE-101* UREA N-17 CREAT-1.3* SODIUM-133
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-13
[**2166-8-21**] Head CT
1. Persistent but stable massive probable non-communicating
ventriculomegaly.
2. No definite evidence to suggest normal pressure
hydrocephalus.
3. Unchanged left posterior fossa arachnoid cyst.
[**2166-8-21**] Chest CT :
Moderate loculated right pleural effusion that is high in
density suggesting residual hemothorax. There appears to be
also peripheral pleural thickening
[**2166-8-22**] RUQ US :1. No findings to suggest the presence of
cirrhosis.
2. Small simple left renal cyst.
3. Right pleural effusion.
[**2166-8-25**] CXR :
Findings remain stable compared to the previous study with the
exception of increased air with the soft tissues of the right
lateral chest wall.
[**2166-8-26**] CXR :
As compared to the previous radiograph, the patient has
received a
new right PICC line. The tip of the line is difficult to
visualize but
appears to project over the right atrium. To ensure correct
position in the mid-to-lower SVC, pullback by 3-4 cm is
recommended. ( done )
Cultures :
[**2166-8-22**] 12:41 pm PLEURAL FLUID
GRAM STAIN (Final [**2166-8-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2166-8-25**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2166-8-26**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 99292**] @ 10:17 AM ON
[**2166-8-24**].
FUSOBACTERIUM NUCLEATUM. SPARSE GROWTH. BETA LACTAMASE
NEGATIVE.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2166-8-22**] 10:30 pm FLUID,OTHER PYOTHORAX.
GRAM STAIN (Final [**2166-8-23**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2166-8-23**] AT
0055.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2166-8-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final [**2166-8-27**]):
FUSOBACTERIUM NUCLEATUM. MODERATE GROWTH.
BETA LACTAMASE NEGATIVE.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2166-8-25**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2166-8-22**] 11:20 pm TISSUE EMPYEMA CAVITY *.
GRAM STAIN (Final [**2166-8-23**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2166-8-26**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2166-8-25**]):
NO FUNGAL ELEMENTS SEEN.
ACID FAST SMEAR (Final [**2166-8-23**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
Brief Hospital Course:
Pt was admitted for eval of R pleural effusion, anemia and
elevated INR in setting of NPH and multiple falls:
# Microcytic anemia:
Thought to be [**3-13**] possible GIB (colonoscopy [**2165-12-27**] showed
diverticulosis, EGD [**2162**] showed a medium hiatal hernia, polyp in
the cardia). Pt was guiac positive. He was evaluated by the
Hematology service and iron studies and peripheral smears were
evaluated. They felt that he had a combines iron deficiency
anemia along with anemia of chronic inflammation. He was
transfused with a total of 5 units of prbc during this admission
and his hematocrit has been stable at 29 for the last 3 days.
The GI service will plan to bring him back as an out patient for
endoscopy. He will also need his hematocrit followed weekly
along with iron therapy. His aspirin has been held.
# Leukocytosis: His admission WBC was 25K and he had blood and
urine cultures which were negative. The Interventional
Pulmonary service was consulted for a thoracentesis due to the
findings of a right pleural effusion on chest CT. The
thoracentesis was done but the fluid was viscous and Thoracic
Surgery was consulted for a right VATS decortication.
He was taken to the Operating Room on [**2166-8-22**] for a right VATS
decortication. He required thoracotomy due to multiple loculated
pockets and a dense empyema cavity not amenable to VATS. He
tolerated the procedure well and maintained stable hemodynamics.
He required 2 units of blood intraop and maintained stable BP
and urine output. His chest tubes were placed to suction for 48
hours.
Following recovery in the PACU he was transferred to the
Surgical floor for further management. He was treated with
Cipro, Vancomycin and Cefepime post op pending cultures. The
pleural fluid cultures grew Fusobacterium nucleatum (also
present on
[**7-3**]). His WBC continued to decline and he remained afebrile.
His chest tubes were draining minimally and were placed to
individual pleurostat tubes for easier ambulation. These tubes
will be gradually backed out to assure the cavity has
decompressed. His thoracotomy incision is healing well and his
staples should be removed on [**2166-9-2**]. He is saturating at 97%
off of oxygen and needs encouragement in using his Incentive
spirometer.
The Infectious Disease service followed him closely and will
also follow him in their clinic. He was switched to ceftriaxone
2 Gm IV q 24 hours on [**2166-8-26**] and will be on that for 2 weeks
via his PICC line. He will then start Cefpodoxime 400 mg
orally [**Hospital1 **] for 2 weeks from [**2166-9-10**] thru [**2166-9-23**]. He will also
continue Flagyl 500 mg PO TID thru [**2166-9-23**]. The PICC line can be
removed following his last dose of Ceftriaxone. He will need
weekly CBC's followed. See page 1 for FAX info.
# Hydrocephalus: he has a history of congenital hydrocephalus
and his wife endorses symptoms consistent with NPH. Unclear the
degree to which this has been worked up as an outpatient,
although sounds as though this may be fairly extensive. the
patient endorses the fact that he has been evaled for a VP
shunt, but has never felt the need for it. The Neurology service
was consulted for a full evaluation and assessment of his recent
decline with multiple falls, incontinence and gait disturbance.
They felt that his exam showed bilateral frontal lobe
dysfunction along with a depressed mood. An MRI was done to
evaluate any frontal lobe lesions but upon review by the
Neurology service he had only findings of hydrocephalus. He
will be evaluated as an out patient by the Cognitive Neurology
service and in the interim should undergo physical therapy and
occupational therapy. He should also be followed by Psychiatry
either his own or if possible, at the rehab.
# Coagulopathy: INR was elevated on admission at 1.6 despite
patient not on Coumadin. Albumin is low, which could suggest
either nutritional deficiency versus liver disease. His LFT's
were normal as was a RUQ US. He was treated with Vitamin K when
it rose to 1.8 and currently it is 1.4. His appetite has been
modest. He will need to improve his nutrition possibly with
protein shakes and his albumin and transferrin should be
followed.
After a long complicated hospital stay he was transferred to
rehab on [**2166-8-27**] and will follow up in the Thoracic Clinic in a
week for chest tube advancement.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Pantoprazole 20 mg PO Q24H
2. Valsartan 40 mg PO DAILY
3. LaMOTrigine 200 mg PO BID
4. Duloxetine 90 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. traZODONE 100 mg PO HS
7. Enablex *NF* (darifenacin) 15 mg Oral QHS
8. Donepezil 10 mg PO HS
9. Adderall *NF* (amphetamine-dextroamphetamine) 20 mg Oral QAM
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Calcium Carbonate 1000 mg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO DAILY
14. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Adderall *NF* 20 mg Oral QAM Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
2. Calcium Carbonate 1000 mg PO DAILY
3. Donepezil 10 mg PO HS
4. Enablex *NF* (darifenacin) 15 mg Oral QHS
5. Ferrous Sulfate 325 mg PO BID
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. LaMOTrigine 200 mg PO BID
8. traZODONE 100 mg PO HS
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 1000 mg PO Q6H pain >4
11. CeftriaXONE 2 gm IV Q24H
thru [**2166-9-9**]
12. Docusate Sodium 100 mg PO BID
13. Heparin 5000 UNIT SC TID
14. 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.
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H fusobacterium nucleatum
thru [**2166-9-23**]
18. Multivitamins W/minerals 1 TAB PO DAILY
19. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
20. Senna 1 TAB PO BID:PRN constipatoin
21. Amlodipine 10 mg PO DAILY
22. Duloxetine 90 mg PO DAILY
23. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
24. Cefpodoxime Proxetil 400 mg PO Q12H
Start [**2166-9-10**] thru [**2166-9-23**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 100**] SeniorLife
Discharge Diagnosis:
Right empyema
Acute blood loss anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital for further work after a
syncopal episode. Your WBC was elevated and your chest xray
showed a large opacification in the right chest, possibly from
infected fluid. You also had a low blood pressure and some
blood in your stool.
* The fluid collection in your chest required surgical treatment
and currently you are improving. You will however need long
term antibiotics and the chest tubes will slowly be backed out.
* The Infectious Disease service will follow you closely while
you are on antibiotics and you will also need to folow up with
the gastroenterologist as an out patient to evaluate the blood
in your stool. Currently your blood count has been stable.
* The Neurology service also followed you in the hospital to try
to evaluate the reason for your frequent falls. An MRI of the
brain was done....
* The Hematology service also followed you due to elevated
clotting factors. You will need to have your blood tests
followed closely and increasing your nutrition will also be
important.
* You will spend some time in rehab prior to returning home to
increase your mobility in a safe manner.
* Continue to eat well and stay well hydrated.
* If you develop any increased pain, shortness of breath, high
fevers or any other new symptoms that concern you, please call
Dr. [**Last Name (STitle) **].
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2166-9-9**] at 2:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], 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: INFECTIOUS DISEASE
When: THURSDAY [**2166-9-11**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], 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: [**Hospital **] [**Hospital 11099**] CLINIC
When: TUESDAY [**2166-9-30**] at 10:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 40119**]
Building: None [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department : Infectious Disease [**Telephone/Fax (1) 457**]
Tuesday [**2166-10-7**] at 11:15 AM
Dr. [**Last Name (STitle) 438**]
[**Hospital Ward Name 517**], [**Hospital Unit Name **], [**Last Name (NamePattern1) **] Voston, Basement
level
Please call Cognitive Neurology at [**Telephone/Fax (1) 99293**] to schedule
a follow up appointment in [**3-14**] weeks.
Please call your Psychiatrist to arrange a follow up following
discharge from rehab.
Completed by:[**2166-8-28**]
|
[
"294.10",
"345.90",
"799.59",
"263.9",
"401.9",
"510.9",
"781.2",
"285.29",
"V85.1",
"331.19",
"530.81",
"V15.82",
"269.0",
"273.8",
"742.3",
"600.01",
"790.92",
"458.8",
"285.1",
"327.23",
"041.84",
"792.1",
"780.2",
"V15.88",
"788.30",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.06",
"96.56",
"33.22",
"34.51",
"38.97",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
14705, 14762
|
8385, 12770
|
299, 490
|
14844, 14844
|
4711, 6763
|
16401, 17979
|
3827, 3941
|
13412, 14682
|
14783, 14823
|
12796, 13389
|
15029, 16378
|
3956, 4692
|
8121, 8121
|
8154, 8362
|
247, 261
|
518, 3404
|
8069, 8084
|
14859, 15005
|
3426, 3567
|
3583, 3811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,735
| 106,977
|
34402
|
Discharge summary
|
report
|
Admission Date: [**2179-8-5**] Discharge Date: [**2179-8-12**]
Date of Birth: [**2140-5-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Multiple intracranial hemorrhages, s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
39 y/o male transferred from [**Hospital6 4620**] after
being brought to there after a fall in a bathroom. He was at a
work meeting (visiting from the UK) and it is unclear if he was
standing or sitting when he fell. Apparently he vomitted before
going into the bathroom. He had been drinking the previous
night. He was seated on a toilet when he fell. Pt was found by
EMT with vomit on the floor. Patient was confused and has giving
multiple reasons for having head injury.
Past Medical History:
non-contributory
Social History:
Married resides in UK with wife and small children. Here in the
US on business trip. Social ETOH.
Family History:
non-contributory
Physical Exam:
On Admission:
O: T:100.7 BP:130/88 HR: 67 R 25 O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-21**] EOMs 3cm hematoma left occiput but no
laceration; blood in right nare no
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Prefers eyes closed but awwake and alert,
cooperative with exam, normal
affect.
Orientation: Oriented to person, and date thought he was in the
UK.
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-24**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger,
Pertinent Results:
Admission CT [**8-5**]:
NON-CONTRAST HEAD CT: A large focus of parenchymal hemorrhagic
contusion is noted in the left cerebellar hemisphere measuring
approximately 1.6 x 2.5 cm. There is surrounding edema and a
small amount of extra-axial blood along the occipital bone.
There is a nondisplaced fracture of the left occipital bone
extending along the skull base into the posterior wall of the
left jugular foramen as well as the foramen magnum.
There is bifrontal subarachnoid hemorrhage, subdural hematomas,
and a small amount of parenchymal contusion which measure up to
approximately 1 cm in the left frontal lobe. The subdural
hematoma measures up to 5 mm in the right frontal convexity and
up to 4 mm along the right temporal lobe. Subdural hematoma is
also noted layering along the anterior falx and extending up to
the vertex. There is effacement of sulci in the right cerebral
hemisphere due to the subarachnoid blood, also seen within the
right sylvian fissure. There is no intraventricular hemorrhage,
though there is a slightly increased density of the CSF within
the suprasellar cistern which likely reflects a small amount of
admixed blood. In addition, there are locules of air within the
suprasellar cistern compatible with pneumocephalus and likely
originating from a fracture of the sphenoid sinus. Blood is
noted within the right sphenoid sinus, though fracture is not
clearly seen. There is likely a fracture of the clivus, though
one is not definitively identified. Given the slight asymmetry
in scanning, it is difficult to assess for subfalcine
herniation. A 3-mm shift of the septum pellucidum to the left is
noted, though this may be related to patient's position. There
is patency of the basilar cisterns.
Non-Contrast HCT [**8-10**]:
FINDINGS: There is no change in the subdural hemorrhage. There
is resolution of blood of the subarachnoid hemorrhage noted on
the previous scan. The right cerebellar hemorrhagic contusion is
stable, with associated regional mass effect, mildly effacing
the fourth ventricle and perimesencephalic cistern as previously
mentioned on the scan, unchanged from the previous scan. There
is no uncal or transtentorial herniation. Evolution of of
bifrontal hemorrhagic contusions. There is blood in the sphenoid
sinus, as noted before, on the right side, which is now less
dense and decreased in size. The non-displaced fracture of the
left occipital bone is described on head CT, [**2179-8-5**]. The
tonsils were slightly low, unchanged from the previous scan.
Labs:
[**2179-8-5**] 02:50PM BLOOD WBC-13.5* RBC-4.66 Hgb-13.8* Hct-39.1*
MCV-84 MCH-29.5 MCHC-35.1* RDW-12.6 Plt Ct-167
[**2179-8-11**] 06:12AM BLOOD WBC-5.9 RBC-4.70 Hgb-13.6* Hct-39.2*
MCV-83 MCH-28.9 MCHC-34.6 RDW-13.2 Plt Ct-188
[**2179-8-5**] 02:50PM BLOOD Glucose-145* UreaN-8 Creat-0.9 Na-145
K-4.0 Cl-106 HCO3-23 AnGap-20
[**2179-8-11**] 06:12AM BLOOD Glucose-115* UreaN-16 Creat-0.9 Na-140
K-3.7 Cl-100 HCO3-28 AnGap-16
[**2179-8-11**] 06:12AM BLOOD Phenyto-10.1
[**2179-8-5**] 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2179-8-11**] 06:12AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.3
Brief Hospital Course:
Patient was admitted via the emergency department on [**2179-8-5**]
after being transferred from [**Location (un) 65053**] Hospital to be
evaluated for multiple intracranial hemorrhages after a fall of
unclear etiology, thought to be alcohol induced. Given the
patient's age and presentation, he was admitted to the ICU for 1
hour neurochecks monitoring. After three days of uneventful
monitoring in the ICU, he was transferred to floor status. He
was evaluated by physical therapy daily to assist in is
management of intracranial hemorrhages, and to be evaluated for
any gait issue. He was determined to be appropriate to be
discharged home on [**8-12**]. He was given medical clearance to
partake in international flight to return home to the UK with
instructions to follow up with a neurosurgeon there in
approximately one month.
Medications on Admission:
None.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-20**]
Tablets PO Q6H (every 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple traumatic Intracranial Hemorrhages
Discharge Condition:
Neurologically 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, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
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.
Followup Instructions:
Follow up in UK with a neurosurgeon and get an CT of head in 4
weeks.
Completed by:[**2179-8-12**]
|
[
"851.40",
"E884.6",
"E849.6",
"801.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7112, 7118
|
5722, 6559
|
360, 367
|
7206, 7230
|
2548, 2585
|
8243, 8344
|
1043, 1061
|
6615, 7089
|
7139, 7185
|
6585, 6592
|
7254, 8220
|
1076, 1076
|
277, 322
|
395, 872
|
1716, 2529
|
2594, 5699
|
1090, 1387
|
1402, 1700
|
894, 912
|
928, 1027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,242
| 197,808
|
12354
|
Discharge summary
|
report
|
Admission Date: [**2192-7-23**] Discharge Date: [**2192-7-24**]
Date of Birth: [**2138-8-3**] Sex: M
Service: [**Hospital Unit Name 153**]
CHIEF COMPLAINT: Transfer for endoscopic retrograde
cholangiopancreatography.
HISTORY OF PRESENT ILLNESS: The patient is a 53 year-old
gentleman with metastatic lung cancer with known mets to the
pancrease who presents with biliary obstruction. He is
status post common bile duct stent several months ago for the
same obstruction. He has been doing well until about two
weeks prior to presentation here when he noted the onset of
abdominal pain,anorexia and constipation. He was admitted to
[**Hospital3 **] on [**2192-7-15**] by their report. His
constipation was adequately treated with medication. He was
noted to become hypotensive and have abnormal liver function
tests, which were normal on admission. He did require blood
pressure support was transferred to the Intensive Care Unit
at [**Hospital1 3494**] for further care. At that time he was found to
hve blood cultures positive for enterococcus. An ultrasound
revealed dilated common bile ducts. The patient was
transferred to the [**Hospital1 69**] for
endoscopic retrograde cholangiopancreatography. He was
treated with antibiotics including Zosyn and blood pressure
support including neo-synephrine. On arrival the patient was
complaining of shortness of breath and right upper quadrant
pain.
PAST MEDICAL HISTORY: Lung cancer with mets to the liver and
pancrease diagnosed in [**2192-2-20**]. He is status post
radiation therapy and chemotherapy. Left lung abscess
diagnosed approximately one month prior to admission. This
has required bronchoscopy in the past and had been monitored
over the last month. He has hypertension, history of deep
venous thrombosis three months ago, history atrial
fibrillation.
MEDICATIONS ON TRANSFER: Zosyn, Colace, Senna, Lactulose,
neo-synephrine drip, Digoxin, vitamin K, subQ and morphine
prn.
ALLERGIES: Sulfa and codeine.
SOCIAL HISTORY: He is a former heavy smoker approximately
eight pack years. His primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 38490**].
PHYSICAL EXAMINATION: His temperature was 100.0. Heart rate
of 109. Blood pressure 90/48, breathing at 18, 100% on 2
liters nasal cannula and a shovel mask. In general, he is
cachectic older male in some respiratory distress, but able
to speak in full sentences with the use of accessory
respiratory muscles. HEENT pupils are equal, round and
reactive to light. Extraocular movements intact. Right IJ
is in place. Neck is supple without lymphadenopathy. Lungs
are clear on the right and nearly absent on the left. Heart
is irregular, tachycardic, 3 out of 6 systolic murmur at the
right upper sternal border. Abdomen is soft, nondistended.
There is significant right upper quadrant tenderness.
Extremities are 2+ edema bilaterally with right greater then
left. Neurologically intact.
LABORATORIES ON PRESENTATION AT [**Hospital1 **]: White blood cell count 23.9, hematocrit 28.1,
platelets 119, sodium 135, K 2.9, chloride 99, bicarb 26, BUN
7, creatinine 0.5 and glucose is 70, INR 8, ALT 104, AST 96,
alkaline phosphatase 993, T bili 3.8, albumin 1.6, digoxin
level of 1.5. Arterial blood gas revealed a pH of 7.51, PCO2
35 and PO2 of 113. Chest x-ray revealed left sided white out
with a few air fluid levels and a shift of the trachea to the
right. An electrocardiogram was atrial fibrillation at 129
with 1 to [**Street Address(2) 1766**] depressions in V4 through V6, which is
unchanged from his electrocardiograms at the outside
hospital.
HOSPITAL COURSE: 1. Infectious disease: The patient had
enterococcus bacteremia likely from a biliary source. He was
treated with Ampicillin, Levofloxacin and Flagyl and the
endoscopic retrograde cholangiopancreatography service was
consulted. The patient also had a large likely left sided
lung abscess that was evaluated by CAT scan during his stay.
During his second hospital day the patient underwent
endoscopic retrograde cholangiopancreatography, which he
tolerated well, although later during this procedure his
blood pressure dropped and he did require increasing amounts
of neo-synephrine as well as the addition of Levophed. After
the procedure the patient was noted to become increasingly
bradycardic. At 4:34 the afternoon of [**7-24**], the
patient was noted to have an asystolic arrest. Due to the
patient's DNR status, which was discussed multiple times
during his length of stay, CPR was not initiated. He did
receive epinephrine and atropine. The patient's brother was
notified as well as his primary care physician. [**Name Initial (NameIs) **] post was
declined.
DISCHARGE DIAGNOSES:
1. Asystole.
2. Cholangitis.
3. Metastatic lung cancer.
4. Sepsis.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Last Name (NamePattern1) 36649**]
MEDQUIST36
D: [**2192-7-24**] 17:22
T: [**2192-7-31**] 06:02
JOB#: [**Job Number 38491**]
|
[
"V10.11",
"038.49",
"576.1",
"427.31",
"197.8",
"263.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4824, 5132
|
3727, 4803
|
2268, 3709
|
174, 236
|
265, 1427
|
1875, 2005
|
1450, 1849
|
2022, 2245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,434
| 158,261
|
15070
|
Discharge summary
|
report
|
Admission Date: [**2189-1-27**] Discharge Date: [**2189-2-2**]
Date of Birth: [**2129-9-17**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old female
with hepatitis B and C, child class C cirrhosis, diabetes,
history of IV drug abuse who initially presented to an
outside hospital ED on [**1-26**] after being found unresponsive
at home by a friend. EMS arrived and found the patient to
have a fasting fingerstick glucose of 21. The patient is
given Glucose and brought to [**Hospital3 44023**]. In the ED, the
patient had a witnessed fever for which he was given Ativan,
glucose for persistent hypoglycemia with improvement in
patient's mental status in approximately two hours. Unclear
[**Name2 (NI) 44024**] events for unresponsiveness other than
hypoglycemia. Urine tox at [**Hospital3 1280**] was negative. CT Scan
of the head was negative for massive bleeding. Sodium was
found to be 122 and ammonia also 122.
The patient was admitted to the MICU at the outside hospital
with hypotension with SVP in the 80s and 90s. Treated with
IV fluid bolus without improvement in blood pressure or urine
output. Hyponatremia was treated with IV normal saline and
Lasix without improvement in urine output. Abdominal
paracentesis was done and removed 5 liters of fluid which
gram stain was negative for organisms, 35 white blood cells,
six polys and 514 red blood cells. She was given 20 grams of
Albumin IV times one paracentesis. She was also given
Levaquin 500 mg IV times one for UTI.
The patient was then transferred to [**Hospital1 190**] for further care. Upon transfer, the patient
was noted to have worsening in her liver function with an AST
rise from 59 to 88 and ALT from 34 to 38. T bilirubin from
3.5 to 4.7 and INR from 1.6 to 2.1. The patient was also
noted to be coagulopathic and treated with vitamin K 10 mg
p.o. times. Abdominal ultrasound to evaluate for pelvic
portal vein thrombosis which was consistent with liver
cirrhosis, no focal masses, no thrombosis, large ascites.
It was determined there was no further need for paracentesis.
The patient was continued on Lactulose. Neomycin had been
started at an outside hospital and that was discontinued.
The patient was determined to be in oliguric renal failure
likely prerenal with a pheno of 0.2 and urine sodium of 18 in
the setting of liver disease, but not severe enough to be
felt to be hepatorenal syndrome.
Lasix and Spironolactone were held on admission. Patient
given an IV of normal saline as well as Albuterol 50 grams
times one with improvement in urine output. The patient is
also noted to have a hematocrit of 22 on admission, guaiac
negative.
PAST MEDICAL HISTORY:
1. Hepatitis C and Hepatitis B, child class C cirrhosis,
history of ascites, encephalopathy, cordal gastropathy,
esophageal varices grade II. Patient has recently been
removed from the transplant list due to lack of social
support.
2. Diabetes.
3. Depression.
4. History of urinary tract infection.
5. History of coag negative staphylococcus bacteremia
secondary to PICC line infection.
6. History of SVP with e.coli in [**8-1**].
7. Known history of polysubstance abuse including heroin.
8. Status post CCY in [**2180**].
9. Hiatal hernia.
10. Echo on [**11-1**] showed an ejection fraction of greater than
60%, 1+ MR, 2+ TR, mild pulmonary hypertension. An ETT MIBI
in [**10-1**] was normal.
MEDICATIONS ON TRANSFER:
1. Regular insulin sliding scale.
2. Protonix 40.
3. Lasix 30 cc t.i.d.
4. Tylenol p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient lives alone, widowed with five
children. Is disabled. Use to work as a substance abuse
counselor. No alcohol. Positive tobacco one pack per week.
FAMILY HISTORY: Pancreatic carcinoma, hypertension and
myocardial infarction.
PHYSICAL EXAMINATION: On admission temperature 98.5
F, blood pressure 107/47, heart rate 93, respiratory rate 18,
O2 saturation 100% on room air. In general patient is lying
supine in bed in no apparent distress. Ins and outs are 1240
in and 945 out. Pupils are equal, round and reactive to
light and accommodation with scleral icterus. Oropharynx
clear. Mucous membranes dry, no lymphadenopathy, no jugular
venous distention. Cardiac: S1, S2, regular rate and rhythm
There is a II/VI systolic ejection murmur. Lungs clear to
auscultation bilaterally. Abdomen: Soft, mildly distended,
bowel sounds positive. No hepatosplenomegaly. Extremities:
3+ pitting edema to above the knee bilaterally.
LABORATORY DATA ON ADMISSION: White blood cell count of 5.5,
hematocrit 24.8, platelets 94. Sodium 125, potassium of 4.1,
chloride 98, CO2 21, BUN 29, creatinine 1.7 down from 2.2 on
admission. Glucose of 114, ALT 34, AST 36, phos 123, t
bilirubin 6.3, LD 196. Blood cultures grew out one of four
bottles gram positive cocci in pairs and clusters.
Echo was [**2189-1-28**] showed left atrium to be mildly dilated,
left ventricular cavity size within normal limits, ejection
fraction of greater than 55%. Right ventricle systolic
function normal, 1+ MR, 3+ TR, mild pulmonary hypertension,
no effusion.
HOSPITAL COURSE:
1. GASTROINTESTINAL: Liver, she is felt to be in worsening
liver failure in the setting of progressive of cirrhosis.
Encephalopathy was well controlled with Lactulose. Further
bowel decontamination with Neomycin and Flagyl was
discontinued after the patient was transferred from the
outside hospital. Patient's mental status remained
relatively slow, however she had no signs of acute
encephalopathy such as asterixis.
It is unclear whether this is the patient's baseline, a mild
encephalopathy not correctable with Lactulose or perhaps some
sort of permanent neurologic damage which occurred in the
setting of hypoglycemia and seizure.
2. HEMATOLOGY: The source of the patient's decrease in
hematocrit was never found. Patient's hemolysis labs were
negative. She was consistently guaiac negative. She
required six units of blood throughout the hospitalization
bringing her hematocrit up to 30 prior to discharge. The
patient was continued on vitamin K 5 mg p.o. q.d. without
significant change in her INR which remained between 1.9 and
2.0 throughout hospitalization. Despite this, she was not
found to have a bleeding tendency on repeat paracentesis or
on central line removal.
Repeat paracentesis was done and removed approximately 600 ml
of cloudy white fluid. It was found to be negative for
indices for SVP and no evidence of significant hemorrhage.
Gram stain was negative. Cytology is pending at this time.
3. INFECTIOUS DISEASE: Patient was running low grade fevers
in the range of 99 to 100. Over this time, she developed
central line erythema, warmth and tenderness. Cultures drawn
from the line grew one out of four bottles of gram positive
cocci in clusters and pairs. It is unclear whether this is
contamination at this time, however central line has been
removed and patient is currently afebrile and asymptomatic.
She was not given any antibiotics during hospitalization.
4. RENAL: Patient had what was thought to be prerenal
failure. She was given IV fluids and renal function
continued to improve throughout hospitalization. Creatinine
prior to discharge was done to 1.1, close the patient's
baseline of approximately 0.8. Would avoid NSAIDS and ACE
inhibitors in the future.
5. ENDOCRINE: This patient was maintained on regular
insulin sliding scale. Her glucoses were well controlled.
6. FLUIDS, NUTRITION AND ELECTROLYTES: Her sodium improved
to 131 without further intervention. This maintained its
level even after starting diuretics of Aldactone 100 mg p.o.
q.d. and Lasix 80 mg p.o. q.d. late in the hospitalization.
DISPOSITION: To rehab as PT evaluated patient and found her
unsteady. They feel she is not safe to be discharged to home
at this time.
DISCHARGE DIAGNOSES:
1. Hepatitis B and hepatitis C.
2. Liver cirrhosis, child's class C.
3. Hyponatremia.
4. Hypoglycemia.
5. Anemia requiring multiple blood transfusions.
6. Diabetes.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Lactulose 30 cc p.o. q.i.d. to t.i.d. p.r.n. for three
plus bowel movements per day.
3. Regular insulin sliding scale.
4. Aldactone 100 mg p.o. q.d.
5. Lasix 80 mg p.o. q.d.
CONDITION ON DISCHARGE: Patient is discharged to rehab
insulin stable condition.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2189-2-2**] 13:56
T: [**2189-2-2**] 14:05
JOB#: [**Job Number **]
|
[
"571.5",
"599.0",
"070.32",
"070.54",
"789.5",
"572.2",
"276.1",
"424.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3796, 3859
|
7930, 8102
|
8125, 8336
|
5192, 7909
|
3882, 4582
|
188, 2717
|
4597, 5175
|
3470, 3603
|
2739, 3445
|
3620, 3779
|
8361, 8704
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,845
| 193,777
|
35594
|
Discharge summary
|
report
|
Admission Date: [**2200-3-11**] Discharge Date: [**2200-3-18**]
Service: NEUROSURGERY
Allergies:
Codeine / Morphine / Egg
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
transferred to [**Hospital1 18**] with a SDH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 16072**] is an 86yo F who fell today now presenting with a
parafalcine SDH. She was attending a routine outpatient appt at
[**Hospital3 4107**] where she slipped on some [**Doctor Last Name 5691**] on an incline,
fell and struck the left side of her face. She did not lose
consciousness. She was evaluated at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where left
supraorbital laceration was sutured and head CT revealed a 4mm L
frontal--> para falcine subdural hemorrhage. Neck CT revealed
multilevel DJD with canal stenosis, no fracture. At present pt
feels head is "heavy" and feels fatigued. No headache. No
diplopia, dysphagia, no difficulty producing or comprehending
speech. No focal weakness, numbness, paresthesia. no bowel or
bladder dysfunction. She now feels nauseated, which is new since
the fall this afternoon.
On general ROS, + generalized fatigue since MI in [**December 2199**].
+
DOE, no SOB at present, no CP. no orthopnea. no rash, no f/c, no
abd pain, no diarrhea. no myalgia or new arthralgia.
Past Medical History:
MI- [**2199-12-30**]- s/p stent x2 at [**Hospital1 **]
HTN
Hypercholesterolemia
Osteoporosis
Social History:
Lives with sister, nonsmoker, no ETOH. Has not left the
house much since her MI. ++ fatigue with exertion.
Family History:
non-contributory
Physical Exam:
Exam upon admission:
T: 99.6 BP: 199/68 HR: 78 R 18 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: R supraorbital laceration s/p suturing. OP clear.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. soft midsystolic [**3-7**] murmur.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils surgical, but equally round and reactive to light, 2
to 1 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk. inc tone bilateral LE's. No abnormal
movements, tremors. Strength full power [**6-3**] throughout. No
pronator drift
Sensation: Intact to light touch, slight reduction of
proprioception, normal pinprick and vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 0 1
Toes upgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Gait- deferred.
Pertinent Results:
CT- [**2200-2-8**]- from [**Hospital1 **]- small parafalcine SDH.
Head CT [**3-11**]:
CT HEAD WITHOUT CONTRAST: A small subarachnoid hemorrhage is
within a sulcus of the left Sylvian fussure. Apparent thickening
of the falx cerebri likely represents a small amount of subdural
hemorrhage. No other intracranial hemorrhage is identified.
There is no shift of normally midline structures or evidence of
acute major vascular territorial infarct. Moderate
periventricular white matter hypodensities consistent with
chronic small vessel ischemic changes. Atherosclerotic
calcifications involve the cavernous carotids and intracranial
vertebral arteries bilaterally. Ventricular and sulcal caliber
appear age appropriate. The surrounding osseous structures
demonstrate no
fracture. The paranasal sinuses and mastoid air cells appear
well aerated.
IMPRESSION:
1. Small focus of left Sylvian subarachnoid hemorrhage.
2. Small subdural hemorrhage along the falx is likely.
Head CT [**3-12**]:
FINDINGS: Small focal hyperdensity in the left sylvian fissure
is unchanged. Previously noted falcine thickening is less
apparent on current examination, though there is decreased
thickening along the falx, but with persistent hyperdensity
along the tentorium, could represent some redistribution of
previously noted subdural hemorrhage.
IMPRESSION: No new hemorrhage seen.
Brief Hospital Course:
The patient was admitted s/p fall while on her way to an
outpatient appointment in [**Hospital1 **]. She had a SDH which was
revealed on head CT. The patient did have some confusion while
she was hospitalized. At times she thought she was in a hotel.
By [**3-18**] she was improved and was oriented x 3. Normally, she
lives at home with her sister. Currently her sister is also
hospitalized due to a car accident. The patient is unable to go
home at this time due to cognitive function. She will be
discharged to the same rehab facility as her sister. Hopefully
they will be be able to return home within 2 weeks. The patient
was evaluated by PT and OT. PT cleared her but OT recommended 24
hour supervision.
Medications on Admission:
Fosamax 70mg PO q week
?Zelodin
Digoxin ? dose
Celebrex
gabapentin
Lisinopril
Plavix 75mg daily
Simvastatin
Metoprolol
Aspirin 325mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] Health Care
Discharge Diagnosis:
SDH
Discharge Condition:
stable
Discharge Instructions:
General 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.
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 Dr.[**Name (NI) 9034**] office in 4 weeks with a non-contrast
CAT scan of the head. Call [**Telephone/Fax (1) 1669**] to make an appointment.
Completed by:[**2200-3-18**]
|
[
"414.01",
"E885.9",
"873.42",
"412",
"V45.82",
"852.21",
"272.0",
"401.9",
"733.00",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6229, 6287
|
4593, 5303
|
281, 288
|
6334, 6343
|
3206, 4570
|
7335, 7521
|
1638, 1656
|
5493, 6206
|
6308, 6313
|
5329, 5470
|
6367, 7312
|
1671, 1678
|
197, 243
|
316, 1380
|
2265, 3187
|
1692, 1973
|
1988, 2249
|
1402, 1497
|
1513, 1622
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,422
| 167,175
|
4193
|
Discharge summary
|
report
|
Admission Date: [**2153-7-6**] Discharge Date: [**2153-7-12**]
Date of Birth: [**2110-7-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2153-7-6**] Aortic valve replacement with a size 27-mm St. [**Male First Name (un) 923**]
mechanical valve. Tricuspid valve repair with a size 34 [**Doctor Last Name **]
MC3 ring.
History of Present Illness:
42 year old female who is originally from [**Country 4194**], has a history
of a bicuspid aortic valve with aortic stenosis. She had a prior
catheterization in [**2149**] which revealed normal coronary arteries
with a calculated aortic valve area of
0.9cm2 and a peak to peak gradient of 41mmHg across the aortic
valve. Also in [**2149**] she was evaluated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
repeated syncopal episodes and it was felt that her syncope was
vasovagal in nature. She has had mild dyspnea on exertion over
the last 2.5 years that became significantly worse about a month
ago. She was previously able to climb two flights of stairs
before stopping and now she has to stop after half a flight due
to shortness of breath. She is also experiencing new onset
central mid chest pressure with exertion which radiates to her
neck. This occurs associated with dyspnea, lightheadedness and
diaphoresis. She also reports feeling easily fatigued over the
last few weeks and has had several episodes of paroxysmal
nocturnal dyspnea. She has continued to have syncopal and
presyncopal episodes occurring sporadically. She is unable to
say how often. She was referred for cardiac catheterization
followed by surgical evaluation for an aortic valve replacement.
Past Medical History:
Bicuspid aortic valve with aortic stenosis
new onset CHF/cardiomyopathy
Hypercholesterolemia
Seasonal allergies
Syncope
Social History:
Lives with:husband and 13 year old son
Occupation:Not currently working. Previously worked as a house
cleaner
Cigarettes: Smoked no [x]
Other Tobacco use:denies
ETOH: denies
Illicit drug use:denies
Family History:
noncontributory
Physical Exam:
Pulse:94 Resp:14 O2 sat:100/RA
B/P Right:86/64 Left:92/63
Height:5'7" Weight:161 lbs
General:NAD, alert and cooperative
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 [] II/VI SEM Murmur across
precordium[]
grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact []
Pulses:
Femoral Right: +1 Left:+1
DP Right: +2 Left:+2
PT [**Name (NI) 167**]:+1 Left:+1
Radial Right: +1 Left:+1
Carotid Bruit Right/Left:murmur radiates to both carotids
Pertinent Results:
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. The right atrium is markedly dilated.
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with akinetic
inferior wall and dyskinetic inferior septum. The remaining left
ventricular segments are also modelrately hypokinetic. The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to XX cm from the incisors. The aortic valve is bicuspid. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is moderate thickening of the mitral
valve chordae. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The tricuspid
valve leaflets fail to fully coapt. Severe [4+] tricuspid
regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Marginally improved global and focal LV systolci function ith
background inotropic support
2. Thereis a mechanical [**Hospital1 **]-leaflet valve in aortic positon, Well
seated and stable, with good leaflet excursion/ Trace to mild
valvular AI jets which are consistent with signature
regurgitation jets of these valves. No apprecaible transaortic
gradient
3. An aanuloplasty ring is identified in the tricuspid position.
Well seated and stable with good leaflet excursion. Trace
tricuspid regurgitation and no evidence of trisuspid stenosis.
4. MR is now mild.
5. Unchanged right ventricular systolic function.
6. Intact aorta
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2153-7-6**] 15:34
[**2153-7-10**] 04:20AM BLOOD WBC-9.7 RBC-3.33* Hgb-8.6* Hct-25.8*
MCV-78* MCH-25.9* MCHC-33.4 RDW-16.5* Plt Ct-164
[**2153-7-10**] 04:20AM BLOOD PT-19.3* PTT-64.9* INR(PT)-1.8*
[**2153-7-9**] 10:40AM BLOOD Glucose-99 UreaN-25* Creat-0.8 Na-135
K-3.9 Cl-99 HCO3-30 AnGap-10
[**Known lastname **],[**Known firstname 18263**] [**Medical Record Number 18264**] F 42 [**2110-7-20**]
Radiology Report CHEST (PA & LAT) Study Date of [**2153-7-9**] 2:19 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2153-7-9**] 2:19 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 18265**]
Reason: r/o inf, eff
Final Report
INDICATION: Patient with atrial valve replacement and tricuspid
valve ring.
Evaluate for progression of pneumothorax and pleural effusions.
COMPARISON: Pre-op radiograph from [**2153-6-28**] and portable
radiographs
from [**2153-7-8**].
TECHNIQUE: PA and lateral chest x-ray.
FINDINGS: Poor lung expansion with interval improvement of
pulmonary edema
and pulmonary vascular congestion. The widened vascular pedicle
of the
mediastinum has improved considerably as well. There is
persistent
right-sided pleural effusion with concurrent atelectasis.
Pneumonia cannot be
excluded and should be considered in the right clinical setting.
A small
right apical pneumothorax is present. No pleural effusion or
pneumothorax are
observed in the left lung field. Stable moderate cardiomegaly.
Sternotomy
wires are intact and aortic and tricuspid valve rings are
present.
IMPRESSION: Interval improvement of pulmonary vascular
congestion and
pulmonary edema. Decreased mediastinal widening. Persistent
right-sided
pleural effusion with attendant atelectasis.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Admitted [**7-6**] and underwent surgery with Dr. [**First Name (STitle) **]. Transferred
to the CVICU in stable condition on titrated epinephrine,
phenylephrine and propofol drips. Extubated later that day and
transferred to the floor on POD #1 to begin increasing her
activity level. Gently diuresed toward her preop weight.
Coumadin started for mechanical AVR and bridged with IV heparin
until therapeutic. Chest tubes and pacing wires removed per
protocol. She was anticoagulated with heparin and coumadin and
was discharged with an INR of 2.4 on 3 mgs of coumadin.
Continued to make good progress and cleared for discharge to
home with VNA on POD #6. First INR check will be [**2153-7-13**] with
results faxed to [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **]-[**Telephone/Fax (1) 18266**]. All f/u
appts were advised.
Medications on Admission:
lasix 40 mg daily
amoxicillin prn dental
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: Continue with lasix 40 mg PO daily after [**Hospital1 **] dose
complete. .
Disp:*0 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day) for 10 days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
10. warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 2 days: Take as directed by Dr. [**Last Name (STitle) **] for and INR to
2.5-3.0.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Aortic stenosis and bileaflet s/p AVR
Tricuspid regurgitation s/p TV repair
Acute on Chronic systolic heart failure
Hypercholesterolemia
Seasonal allergies
Syncope
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+ LE edema 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**
Labs: PT/INR for Coumadin ?????? indication mechanical AVR
Goal INR 2.5-3
First draw day after discharge....................
Results to phone fax ................................
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 766**] [**7-30**] at 1:45pm [**Hospital Ward Name **] 2A
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-8**] at 1:00pm
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 2427**] in [**3-20**] weeks [**Telephone/Fax (1) 250**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical AVR
Goal INR 2.5-3
First draw day after discharge: [**2153-7-13**]
Results to phone fax [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **]-[**Telephone/Fax (1) 18266**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2153-7-12**]
|
[
"512.1",
"272.4",
"428.23",
"746.4",
"997.1",
"427.41",
"E878.1",
"396.2",
"E849.7",
"397.0",
"428.0",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.14",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
9234, 9293
|
6895, 7743
|
329, 514
|
9501, 9697
|
2991, 4300
|
10805, 11765
|
2222, 2239
|
7834, 9211
|
9314, 9480
|
7769, 7811
|
9721, 10782
|
2254, 2972
|
269, 291
|
542, 1846
|
1868, 1990
|
2006, 2206
|
4311, 6872
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,208
| 197,031
|
51133
|
Discharge summary
|
report
|
Admission Date: [**2173-9-7**] Discharge Date: [**2173-9-11**]
Date of Birth: [**2124-7-4**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Mental Status Change
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
49 yo caucasian male w/ PMHx significant for metastatic [**First Name3 (LF) 499**]
cancer to liver s/p colectomy and liver resection brought to the
unit for worsening mental status. Per wife, pt had become more
confused over the last few days. He has been verbal but
forgetful needing frquent reminding/orienting. 1 week earlier
pt had a low grade fever. Last few days had one episode of
chills. No N/V/diarrhea. Started on thorazine for hiccups on
[**9-6**]. This morning had to ask wife what he was going to the
hospital for. The patient was brought to the hospital today for
an elective ERCP for elevated LFTS. Pt had a metal stent placed
in [**4-25**]. Pt had dilation and stenting of common bile duct that
had become obstructed due to tumor. He tolerated the procedure
well and was then transferred to the floor. Wife states that he
has been in poor mental status ever since the procedure.
Past Medical History:
1. Metastatic [**Date Range 499**] cancer (dx [**2163**]) s/p rectosigmoidectomy -
mets to liver s/p resection, lung mets s/p chemo/xrt
2. Malignant biliary obstruction s/p metal stent placement [**2171**],
revision [**4-25**] (metal stent)
3. DVT/PE [**10-24**] has been anticoagulated on coumadin, held for
ERCP
Social History:
Lives at home in [**Location (un) **] (waterfront) with wife and three children
ages 24, 14, 12. Worked as a police officer in [**Location (un) 86**]. No
history of tobacco or alcohol.
Family History:
Father - [**Name (NI) **] cancer
Mother - Stroke
Various aunts and uncles with cancer hx
Physical Exam:
PE on transfer to floor ([**9-8**]):
VITALS T max 97.7 103/62 (88-103/41-62) 86 (77-94) [**10-5**]
96-100%2L FS 177-160-136-124-100 (most recent 100) receiving 1
unit/hr on sepsis protocol I/O after MN: 2439/2690 (net +6L
over 24h)
GEN: tired, chronically ill appearing, eyes closed, noticably
jaundiced
HEENT: dark yellow skin, +scleral icterus, EOMI, MMD, yellow
tender scale on tongue
Neck:
CV: irregular [**2-22**] occasional PVCs; tele reviewed
Lungs: decreased bs bilaterally, ?crackles in right mid lung
Abd: soft, distended, +BS, tender to palpation diffusely,
+voluntary guarding, no rebound. +foley with dark urine.
Ext: w/wp, 2+ DP pulses bilaterally, 5/5 strength, sensation
grossly intact to light touch. +mild asterixis
Neuro: somnolent but responsive, oriented x3.
Pertinent Results:
Pre-procedure labs ([**9-7**]):
[**2173-9-7**] 09:15AM ALT(SGPT)-159* AST(SGOT)-109* ALK PHOS-607*
AMYLASE-40 TOT BILI-19.7*
[**2173-9-7**] 09:15AM LIPASE-42
[**2173-9-7**] 09:15AM WBC-14.3*# RBC-3.54* HGB-9.0*# HCT-27.8*#
MCV-78*# MCH-25.3*# MCHC-32.3 RDW-23.4*
[**2173-9-7**] 09:15AM PLT SMR-VERY LOW PLT COUNT-61*#
[**2173-9-7**] 09:15AM PT-14.9* PTT-26.0 INR(PT)-1.4
ERCP ([**9-7**]):
Metal stent in biliary duct found in major papilla.
Stricture within metal stent in CBD suggestive of tumor
ingrowth.
Large amounts of stones and sludge extracted.
New stent placed in CBD.
Post-procedure labs:
CBC
[**2173-9-7**] 10:25PM WBC-17.9* RBC-3.11* HGB-7.9* HCT-24.3*
MCV-78* MCH-25.3* MCHC-32.4 RDW-23.6*
[**2173-9-7**] 10:25PM NEUTS-91.5* BANDS-0 LYMPHS-5.3* MONOS-3.0
EOS-0.1 BASOS-0.1
[**2173-9-7**] 10:25PM PLT COUNT-53*
Chemistries
[**2173-9-7**] 10:25PM GLUCOSE-177* UREA N-36* CREAT-1.3* SODIUM-135
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-11
[**2173-9-7**] 10:25PM CALCIUM-6.6* PHOSPHATE-2.2* MAGNESIUM-2.0
LFTs
[**2173-9-7**] 10:25PM ALT(SGPT)-131* AST(SGOT)-104* ALK PHOS-465*
TOT BILI-17.6*
[**Last Name (un) **] Stim
[**2173-9-7**] 10:25PM BLOOD Cortsol-16.0
[**2173-9-7**] 11:47PM BLOOD Cortsol-16.6
[**2173-9-8**] 12:34AM BLOOD Cortsol-18.4
Other
[**2173-9-7**] 10:54PM BLOOD Fibrino-394 D-Dimer-[**2118**]*
[**2173-9-7**] 10:54PM BLOOD FDP-0-10
[**2173-9-7**] 10:25PM BLOOD Ret Aut-1.6
[**2173-9-8**] 01:32PM BLOOD Ammonia-48*
Blood Cultures
[**2173-9-7**] 10:26 pm BLOOD CULTURE
**FINAL REPORT [**2173-9-12**]**
AEROBIC BOTTLE (Final [**2173-9-12**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES.
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
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA OXYTOCA
| | SERRATIA
MARCESCENS
| | |
AMPICILLIN/SULBACTAM-- 4 S <=2 S
CEFAZOLIN------------- <=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
CEFUROXIME------------ <=1 S <=1 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S <=0.25 S <=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S 2 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
ANAEROBIC BOTTLE (Final [**2173-9-12**]):
REPORTED BY PHONE TO [**Last Name (NamePattern4) 106163**] [**2173-9-8**] @11:40AM.
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
KLEBSIELLA OXYTOCA.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2173-9-7**] 10:25 pm BLOOD CULTURE
**FINAL REPORT [**2173-9-11**]**
AEROBIC BOTTLE (Final [**2173-9-11**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES (pan
sensitive as above).
SERRATIA MARCESCENS. FINAL SENSITIVITIES (pan sensitive
as above).
CXR ([**9-9**]):
IMPRESSION:
1. Tip of intravenous line in SVC. No pneumothorax.
2. Cardiomegaly with patchy opacities, representing congestive
heart failure and patchy pulmonary edema.
3. Increased opacity in left lower lobe, suggesting either
atelectasis or pneumonia.
4. Multiple ill-defined nodular opacities in bilateral lungs,
most likely representing metastatic disease. Further evaluation
by CT scan may be helpful if clinically indicated .
Labs on discharge:
CBC
[**2173-9-11**] 06:45AM BLOOD WBC-14.2* RBC-4.54* Hgb-12.1* Hct-35.4*
MCV-78* MCH-26.5* MCHC-34.1 RDW-23.7* Plt Ct-85*
[**2173-9-10**] 05:39AM BLOOD Neuts-96* Bands-0 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-9-11**] 06:45AM BLOOD Plt Ct-85*
Coags
[**2173-9-11**] 06:45AM BLOOD PT-23.5* INR(PT)-3.5
[**2173-9-10**] 05:39AM BLOOD PT-25.6* INR(PT)-4.1
Chemistries
[**2173-9-11**] 06:45AM BLOOD Glucose-163* UreaN-32* Creat-1.1 Na-144
K-3.0* Cl-111* HCO3-22 AnGap-14
LFTs
[**2173-9-11**] 06:45AM BLOOD ALT-85* AST-29 AlkPhos-528* Amylase-41
TotBili-17.9*
LENIs ([**9-11**])
IMPRESSION: No evidence of DVT within both lower extremities.
Brief Hospital Course:
1. Hypotension/GNR sepsis: The patient had his ERCP on [**9-7**]
after which he was started on broad spectrum antibiotics
(Amp/Gent/Levo). That evening his blood pressure was found to
be 80/50. He was given 1.5 liters of fluid and his BP imrpoved
to 90/60. A left subclavial line was placed and her was
transferred to the ICU where he received more hydration and 2
units of PRBCs. His HCT was stable and he remained afebrile.
Blood cultures were sent, and the following day 3/4 bottles grew
out gram negative rods (klebsiella, serratia) which were pan
sensitive. He was continued on broad spectrum coverage with
Amp/Gent/Flagyl. The hypotension was most likely from
cholangitis/procedure, but could have been exacerbated by his
liver disease and meds (thorazine, ERCP sedatives). Once
transferred to the floor, he continued to receive antibiotics
and IV fluid for sepsis. However, on [**9-8**] a CXR showed
pulmonary edema/CHF and IV fluids were discontinued. At this
point the patient was tolerating fluids by mouth and remained
well hydrated. On [**9-10**] (Abx day 4) the patient's creatinine
bumped to 1.1 from 0.6 and given gentamycin's nephrotoxicity, it
was discontinued and ciprofloxacin was started. The antibiotics
were transitioned to oral dosing. The patient was discharged on
a 10 day course of Amoxicillin, Cipro, and Flagyl.
2. Biliary obstruction: The patient initally had a total
bilirubin of 19.7 on [**9-7**], prior to his ERCP. Post ERCP his
total bilirubin rose to 21.8 on [**9-9**]. The ERCP fellow felt that
this could be due to sepsis and liver metastasis and not
necessarily indicative of a re-occlusion of the stented area.
The following day, the tbili trended downward to 15.3, and the
patient was noticable less jaundiced. He was discharged with a
total bilirubin of 17.9, possibly a new baseline for this
patient per ERCP.
3. Respiratory: The patient had a difficult lung exam secondary
to poor air movement. Crackles were auscultated in the right
mid lung upon transfer to the floor, and the following day a CXR
was ordered to better evaluate the lungs; it showed stable
nodules (mets) but also seemed c/w pulmonary edema. The patient
did not appear to be in respiratory distress, and had stable
vitals and good oxygen saturations. However, given concern for
fluid overload, IV fluids were held. He was not started on
diuretics. The following day LENIs were ordered to rule out a
DVT/PE and were negative. The patient was discharged with a
stable respiratory exam and good oxygen saturations.
4. Adrenal Insufficiency: Cosyntropin stimulation test on [**9-7**]
was positive for adrenal insufficiency. Therefore the patient
was empirically started on stress-dose steroids and
mineralocorticoids but these were stopped on [**9-9**] as BP elevated
appropriately. He maintained a stable BP for the rest of his
hospitalization.
5. Mental Status Changes: The patient presented to his ERCP
appointment already having had some mental status changes from
baseline. This was likely multifactorial, including but not
limited to: medications, liver disease, and later sepsis. When
evaluated post-ERCP he was somnolent and poorly oriented. Upon
transfer to the unit, his narcotics were held and he was given
IVF. Once he had been adequately hydrated in the ICU his mental
status rapidly cleared, and he returned to his baseline. On
[**9-9**], he reported that he was in increased pain [**2-22**] his
narcotics being held (he usually takes oxycontin 50mg [**Hospital1 **] at
home). He was started on 30mg oxycontin with morphine IV for
breakthrough and tolerated this well with improved pain control.
On [**9-10**] his pain regimen was changed: his oxycontin was
increased to 40mg [**Hospital1 **] and his morphine IV was switched to
oxycodone orally for breakthrough. His pain was well controlled
on discharge.
6. Thrombocytopenia: The patient had a normal platelet count on
[**8-28**] at 175. On the morning of [**9-7**] his platelets were low at
61; that evening post ERCP, they were 53. They were followed
each morning and improved over the next several days. He did
not have any bleeding. On discharge the patient's platelets
were 85.
7. Anemia: The patient had a chronic anemia with a hematocrit in
the low 30s for several months. Prior to this, in [**2171**], his
hematocrit was normal. His hematocrit was followed during his
hospitalization and was stable. He was discharged with a HCT of
35.4.
8. Decreased UOP: The day of his ERCP the patient had a very
poor urine output, likely secondary to sepsis and intravascular
volume depletion. On transfer to the unit a foley catheter was
placed and he was agressively hydrated with a return of good
UOP. The foley was discontinued on [**9-10**]. He was discharged
with a creatinine of 1.1; earlier in the hospitalization it had
been as low as 0.6 though pre-ERCP, the morning of [**9-7**], it had
been 1.3. Gentamycin was thought to perhaps have played a role
in the creatinine bump from 0.6 to 1.1 so it was discontinued
and ciprofloxacin started as above.
9. DVT/PE: The patient was on chronic anticoagulation with
coumadin, which was stopped prior to his procedure. He has a hx
of DVT but in light of anemia and low platelets he was only
placed on pneumoboots. He was stable with no evidence of
DVT/PE, and had a negative bilateral LENI on the day of
discharge. Even though his anticoagulation had been stopped,
his INR increased initially during hospitalization to 4.1. No
vitamin K was given as he had a h/o PE. It was trending down on
discharge at 3.5. His anticoagulation was not reinitiated on
discharge, but may be in the future as an outpatient.
10. Metastatic [**Date Range 499**] cancer (liver, lung): pt w/ disseminated
disease. He was not a candidate for further treatment. Pain
medications were added back during hospitalization after being
initially held, his pain was well controlled on discharge.
11. PVCs: The patient had what was thought to be an irregular
heart beat, therefore, and EKG was checked revealing sinus
rhythm with PVCs.
12. Access: The patient had a R subclavian line placed on the
evening of [**9-7**] just before transfer to the unit. Additionally
he had peripheral access. His central line was removed without
difficulty on [**9-10**].
13. FEN: The patient was kept NPO in the unit and hydrated
intravenously. Once on the floor his diet was slowly advanced
and on discharge he was tolerating an oral diet. IVF was
discontinued when his CXR showed evidence of pulmonary edema
(see above).
14. Proph: The patient had pneumoboots, but was not given
heparin SQ given his low platelets. He was maintained on a ppi
and had a RISS qid. Nystatin swish and swallow was added to his
oral fluconazole for treatment of thrush.
15. Code: The patient and family decided that his code status
would be mechanical ventilation and pressors but no CPR.
Medications on Admission:
Coumadin
Oxycodone
MSIR
Fluconazole
Dexamethasone
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Gram negative rod sepsis
2. Common bile duct obstruction
3. Thrombocytopenia
4. Anemia
5. Metastatic [**Hospital3 499**] cancer
Discharge Condition:
Stable, tolerating an oral diet, ambulatory
Discharge Instructions:
Please continue to take all of your medications as prescribed.
Please continue with your Antibiotics Ciprofloxacin, Flagyl, and
amoxicillin for 10 more days. Please also continue to take
Protonix 40 mg daily.
Please continue your Oxycontin dose at 40 mg twice daily and
discontinue your thorazine since this was contributing to your
mental status changes. Continue with your Fluconazole for now,
but would discuss with your PCP when to discontinue this
medication.
Please return to the ED or call your PCP if you experience any
fevers >101 or chills, nausea or vomiting, worsening abdominal
pain not alleviated with your pain meds, worsening confusion.
Followup Instructions:
Please follow-up with your PCP on [**Name9 (PRE) 766**] Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 30837**]
so that you can be seen within this week.
|
[
"584.9",
"995.92",
"197.0",
"428.0",
"197.7",
"287.5",
"576.1",
"038.49",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"99.04",
"51.88",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14872, 14923
|
7865, 14772
|
329, 335
|
15098, 15143
|
2745, 7158
|
15846, 16007
|
1828, 1918
|
14944, 15077
|
14798, 14849
|
15167, 15823
|
1933, 2726
|
269, 291
|
7177, 7842
|
363, 1271
|
1293, 1608
|
1624, 1812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,569
| 197,451
|
12890
|
Discharge summary
|
report
|
Admission Date: [**2184-3-18**] Discharge Date: [**2184-5-13**]
Date of Birth: [**2131-3-30**] Sex: M
Service: MEDICINE
Allergies:
Benadryl Allergy / Ambisome / Flomax
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy x 2
History of Present Illness:
Mr. [**Known lastname 39623**] is a 52-year-old male with a history of AML who
is now day +120 status post a myeloablative sequential unrelated
double cord blood transplant. He developed shortness of breath
at 5 a.m. with paroxysmal coughing spasms. His wife states that
he was awake for most of the night with unrelenting dry,
non-productive cough that had been worsening over the past 3
days. He suddenly became unresponsive and per his wife fell
forward and turned blue. His wife immediately called EMS and
gave rescue breaths in the few minutes before their arrival.
Per her report, he had not had any fevers, chills, diarrhea, or
productive cough. She had noted some shakes in the middle of
the night but states that he did not feel cool or warm to the
touch. Patient had reported increased lower extremity edema the
prior day. His recent abdominal pain and nausea had improved
over the previous days since he had been switched from
Tacrolimus to Cyclosporine.
.
In the ambulance, he received nitroglycerin x 2 and Lasix 40 mg.
On arrival BP 200/90, RR 30, SpO2 78% on RA. ABG 7.4/39/49.
He denied chest pain. SpO2 improved to 80% on 15L NRB. He was
intubated and was treated with ASA 325 mg, levofloxacin 750 mg,
rocephin 1 gram. It was felt that he went flashed with fluid
resuscitation, and he was started on a nitroglycerin drip. He
was sedated and paralyzed with succinyl choline and propofol.
BP's 132-179/76-100 with HR 118-124. He was transfered to the
[**Hospital1 18**] ED.
.
On arrival to our ED, Tm 102.2, BP 104/55, HR 96, SpO2 100% on
ACC with TV 550 x 22, FiO2 100%, PEEP 5. ABG 7.27/50/87.
Nitroglycerine gtt was discontinued. He received Tylenol 1000
mg PR, 2 mg IV dexamethasone, Vanc 1 gram, and Zosyn 2.25 gram.
Repeat ABG was 7.23/53/127. Blood culture x 1 was drawn.
Past Medical History:
1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+120. Day 100 bone marrow biopsy showed no
diagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares initially maintained on
anidulafungin after being on posaconazole for several months in
an effort to "rest" his liver. This was switched to
voriconazole
when he developed epistaxis and sinus tenderness in the side of
prior disease. He has remained on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Cardiomyopathy of unclear etiology. The patient underwent a
cardiac MRI in [**7-/2182**] prior to chemotherapy and was noted to
have an ejection fraction of 45%-50%. Most recent TTE [**6-19**]
with preserved systolic function EF>55%.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses ([**8-/2182**])
Social History:
The patient is married and lives with his wife [**Name (NI) 2048**] in
[**Location (un) 620**], [**State 350**]. He has 4 children. He previously worked
as a mechanic until [**2173**], and then he worked at a car
dealership. The patient has a history of tobacco use and notes
that he smoked one-half pack per day x30 years. He uses alcohol
occasionally; however, is not drinking at this time. He denies
use of illicit drugs.
Family History:
The patient's parents are alive. His father has hypertension, a
h/o CAD status post three-vessel CABG, and sarcoidosis. He notes
that his mother is in good health. He has one brother and two
sisters who are all alive and well. He notes that his
grandmother was diagnosed with a type of cancer. He denies any
family history of bleeding disorders.
Physical Exam:
Vital Signs
Tmax: 37.1 ??????C (98.8 ??????F)
Tcurrent: 37.1 ??????C (98.8 ??????F)
HR: 89 (88 - 91) bpm
BP: 120/64(82) {120/64(82) - 125/68(353)} mmHg
RR: 24 (22 - 25) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Ventilator mode: CMV/ASSIST
Vt (Set): 550 (550 - 550) mL
RR (Set): 22
PEEP: 15 cmH2O
FiO2: 100%
Physical Examination
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG
tube
Lymphatic: Cervical WNL, Supraclavicular WNL, thick neck
Cardiovascular: (S1: Normal), (S2: Normal), unable to assess JVP
due to thickness of neck
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases bilaterally, Rhonchorous: scattered, in all
fields)
Abdominal: Soft, Non-tender, quiet bowel sounds
Extremities: Right: 1+, Left: 1+ edema
Skin: Warm, well-perfused
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
Pertinent Results:
ADMISSION LABS
[**2184-3-18**] 09:45AM BLOOD WBC-6.0 RBC-3.03* Hgb-10.1* Hct-31.2*
MCV-103* MCH-33.3* MCHC-32.4 RDW-14.7 Plt Ct-52*
[**2184-3-18**] 09:45AM BLOOD Neuts-78.6* Lymphs-12.8* Monos-7.2
Eos-1.1 Baso-0.3
[**2184-3-18**] 04:32PM BLOOD PT-15.6* PTT-34.8 INR(PT)-1.4*
[**2184-3-18**] 09:45AM BLOOD Glucose-164* UreaN-32* Creat-1.8* Na-133
K-5.0 Cl-104 HCO3-21* AnGap-13
[**2184-3-22**] 04:48AM BLOOD Glucose-140* UreaN-75* Creat-3.0* Na-142
K-5.3* Cl-107 HCO3-21* AnGap-19
[**2184-3-18**] 09:45AM BLOOD ALT-11 AST-22 LD(LDH)-244 CK(CPK)-32*
AlkPhos-127* TotBili-0.8
[**2184-3-18**] 09:45AM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-6884*
[**2184-3-22**] 07:12AM BLOOD VitB12-311 Folate-2.6
[**2184-3-29**] 04:40AM BLOOD Hapto-161
[**2184-3-18**] 08:31PM BLOOD Cortsol-8.0
DISCHARGE LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2184-5-13**] 12:10AM 5.2 3.05* 10.5* 33.6* 110* 34.2* 31.1
18.7* 52*1
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso
[**2184-5-13**] 12:10AM 72.4* 19.6 5.7 2.0 0.3
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2184-5-13**] 12:10AM 289* 32* 0.9 137 4.6 103 25 14
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos TotBili
[**2184-5-12**] 12:00AM 32 15 232 115 0.3
PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
[**2184-4-25**] 12:00AM HYPOGAMMAG1 376* 59* 124 NO MONOCLO2
MICROBIOLOGY
galactomannan and B-glucan were negative on 4 separate dates
[**2184-5-11**] Immunology (CMV) CMV Viral Load-NEG
[**2184-5-7**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-5-3**] Immunology (CMV) CMV Viral Load-FINAL NEG
[**2184-4-28**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-4-28**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-4-26**] Immunology (CMV) CMV Viral Load-NEG
[**2184-4-20**] Immunology (CMV) CMV Viral Load-NEG
[**2184-4-19**] URINE URINE CULTURE-NEG
[**2184-4-18**] STOOL OVA + PARASITES-NEG
[**2184-4-17**] STOOL OVA + PARASITES-NEG
[**2184-4-17**] STOOL OVA + PARASITES-NEG
[**2184-4-17**] URINE URINE CULTURE-NEG
[**2184-4-16**] STOOL OVA + PARASITES-NEG
[**2184-4-14**] 8:55 pm URINE
**FINAL REPORT [**2184-4-17**]**
URINE CULTURE (Final [**2184-4-17**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
[**2184-4-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
LEGIONELLA CULTURE-FINAL; Immunoflourescent test for
Pneumocystis jirovecii (carinii)-FINAL; FUNGAL CULTURE-FINAL
INPATIENT -NEG
[**2184-4-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-NEG
[**2184-4-10**] Immunology (CMV) CMV Viral Load-NEG
[**2184-4-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
LEGIONELLA CULTURE-FINAL INPATIENT NEG
[**2184-4-9**] URINE Legionella Urinary Antigen -NEG
[**2184-4-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-4-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-4-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-30**] URINE URINE CULTURE-NEG
[**2184-3-30**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-30**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-29**] ASPIRATE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
FUNGAL CULTURE-FINAL INPATIENT NEG
[**2184-3-29**] 1:59 pm ASPIRATE Source: Sinus.
**FINAL REPORT [**2184-4-12**]**
GRAM STAIN (Final [**2184-3-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2184-3-31**]):
OROPHARYNGEAL FLORA ABSENT.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES PERFORMED ON REQUEST..
FUNGAL CULTURE (Final [**2184-4-12**]): NO FUNGUS ISOLATED.
[**2184-3-29**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-27**] Rapid Respiratory Viral Screen & Culture Rapid
Respiratory Viral Antigen Test-FINAL; VIRAL CULTURE-FINAL
INPATIENT NEG
[**2184-3-27**] Influenza A/B by DFA - Bronch Lavage DIRECT INFLUENZA
A ANTIGEN TEST-NEG; DIRECT INFLUENZA B ANTIGEN TEST-NEG
[**2184-3-27**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; Immunoflourescent test
for Pneumocystis jirovecii (carinii)-FINAL; FUNGAL
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE-FINAL; VIRAL CULTURE: R/O
CYTOMEGALOVIRUS-FINAL INPATIENT NEG
[**2184-3-27**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-27**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
FUNGAL CULTURE-FINAL INPATIENT NEG
[**2184-3-27**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-FINAL; BLOOD/AFB CULTURE-PENDING INPATIENT
[**2184-3-27**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-27**] URINE URINE CULTURE-NEG
[**2184-3-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE NEG;
FUNGAL CULTURE-NEG
[**2184-3-26**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-26**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-26**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-26**] URINE URINE CULTURE-FINAL INEG
[**2184-3-25**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-25**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-25**] URINE URINE CULTURE-FINAL NEG
[**2184-3-25**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB NEG;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-NEG; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-NEG
[**2184-3-25**] Immunology (CMV) CMV Viral Load-NEG
[**2184-3-25**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-NEG
[**2184-3-24**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-24**] URINE URINE CULTURE-NEG
[**2184-3-24**] STOOL OVA + PARASITES-NEG
[**2184-3-22**] STOOL OVA + PARASITES-NEG
[**2184-3-22**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL INPATIENT NEG
[**2184-3-22**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; MICROSPORIDIA STAIN-FINAL;
CYCLOSPORA STAIN-FINAL; Cryptosporidium/Giardia (DFA)-FINAL;
CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL; VIRAL CULTURE-FINAL
INPATIENT NEG
[**2184-3-21**] ASPIRATE Immunoflourescent test for Pneumocystis
jirovecii (carinii)-NEG
[**2184-3-21**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-21**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-21**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL; VIRAL
CULTURE-FINAL INPATIENT
[**2184-3-19**] Rapid Respiratory Viral Screen & Culture Rapid
Respiratory Viral Antigen Test-FINAL; VIRAL CULTURE-FINAL
INPATIENT NEG
[**2184-3-19**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; Immunoflourescent test
for Pneumocystis jirovecii (carinii)-FINAL; FUNGAL
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE-FINAL; VIRAL CULTURE: R/O
CYTOMEGALOVIRUS-FINAL INPATIENT NEG
[**2184-3-19**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-19**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-NEG
[**2184-3-19**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-18**] 1:11 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2184-4-1**]**
GRAM STAIN (Final [**2184-3-19**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2184-3-22**]):
RARE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
[**2184-3-18**] BLOOD CULTURE BARTONELLA BLOOD CULTURE-NEG
[**2184-3-18**] URINE URINE CULTURE-NEG
[**2184-3-18**] URINE Legionella Urinary Antigen -NEG
[**2184-3-18**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-18**] Influenza A/B by DFA Rapid Respiratory Viral Antigen
Test-FINAL; VIRAL CULTURE-FINAL INPATIENT NEG
[**2184-3-18**] Immunology (CMV) CMV Viral Load-NEG
[**2184-3-18**] BLOOD CULTURE Blood Culture, Routine-NEG
.
HERPES 6 DNA PCR, QUANTITATIVE
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Virus 6 DNA, Quantitative Real-Time PCR
Herpes Virus 6 DNA, QN PCR <500
<500 copies/mL
This test was developed and its performance characteristics have
been
determined by Focus Diagnostics. Performance characteristics
refer to
the analytical performance of the test. This test is performed
pursuant
to a license agreement with [**Doctor Last Name **] Molecular Systems, Inc. The
quantitative
range of this assay is 500 - 2,000,000 HHV-6 DNA copies/mL
.
HERPESVIRUS 6 IGG & IGM ANTIBODY PANEL
Test Result Reference
Range/Units
HERPESVIRUS 6 IGM <1:20 <1:20
HERPESVIRUS 6 IGG 1:40 H <1:10
INTERPRETATION: PAST INFECTION
STRONGYLOIDES ANTIBODY,IGG
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Strongyloides Antibody, IgG ([**Doctor First Name **])
Strongyloides IgG <1.00
<1.00
Interpretive Criteria
<1.00 Antibody Not Detected
> or = 1.00 Antibody Detected
IMAGING STUDIES
[**2184-3-18**] LENI: IMPRESSION: No evidence of DVT.
[**2184-3-18**] TTE:
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic arch is mildly dilated. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is a small to moderate sized pericardial effusion. There
are no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2183-10-22**], a small-to-moderate pericardial effusion is
now present.
EKG: Sinus rhythm. Normal tracing. Compared to the previous
tracing of [**2183-12-12**] the rate is slightly slower and limb lead
voltage is lower. Clinical
correlation is suggested.
[**3-19**] CXR portable-IMPRESSION: Improving pulmonary opacifications,
most likely representing decreasing pulmonary edema.
CT CHEST [**2184-3-26**] : Within limits of the study without contrast,
the heart and great vessels are within normal limits.
Mediastinal and hilar lymph nodes have decreased in size
compared to prior examination. There are moderate bilateral
pleural effusions and associated lower lobe atelectasis.
Separate from this, there are patchy areas of opacities in the
lower lobes as well as the left upper lobe, lingula, and right
upper lobe. No pulmonary edema is identified. Endotracheal,
central venous catheter, and nasogastric tube are in unchanged
position. Visualized portions of the upper abdomen are
unremarkable.
IMPRESSION:
1. Patchy multifocal opacities consistent with pneumonia.
2. Moderate bilateral pleural effusions and bilateral lower lobe
atelectasis.
3. No evidence of pulmonary edema. Small amount of pericardial
fluid and ascites.
CT CHEST W/O CONTRAST [**2184-4-16**] 11:11 AM
FINDINGS: Diffuse lung parenchymal abnormalities have
progressed, including areas of consolidation, ground-glass
attenuation, and poorly defined nodules. The areas of
consolidation have a striking subpleural distribution except for
at the lung bases where they are combined bronchovascular and
subpleural in distribution. Areas of ground-glass attenuation
are more variable in distribution, and poorly defined nodules
are predominantly peribronchovascular. Within the lower lungs,
there is also smoothly marginated septal thickening present. A
small amount of retained secretions are present within the
central airways, but there are no suspicious lesions.
Numerous mediastinal lymph nodes are again demonstrated with
slight increase in size. For example, a right paratracheal lymph
node at the level of the aortic arch is now 13 mm compared to 10
mm, and a lower right paratracheal lymph node at the level of
the carina now measures 16 mm in short axis and previously
measured 15 mm. Bilateral hilar nodes appear similar allowing
for difficulty in measurement due to absence of intravenous
contrast. Heart is normal in size. Moderate-sized dependent
posterior pericardial effusion has slightly increased, and small
dependent pleural effusions have minimally decreased on the
right and minimally increased on the left.
Examination is not specifically tailored to evaluate the
subdiaphragmatic region, but a small incompletely imaged cyst in
the right lobe of the liver is incidentally noted as well as
diffuse increased attenuation of the liver. Adrenal glands are
normal. Please note that absence of intravenous and oral
contrast reduced sensitivity of CT for detecting abdominal
abnormalities.
Subcutaneous 17-mm diameter round lesion in the upper right
posterior chest wall appears unchanged. There are no acute
skeletal abnormalities. Incidental note is made of an apparent
hemangioma in the lower thoracic spine as well as an area of
disc calcification.
IMPRESSION:
1. Worsening of widespread lung parenchymal abnormalities, with
combined subpleural and peribronchovascular distributions. The
differential diagnosis is broad, but cryptogenic organizing
pneumonia is a likely contributing diagnosis. However, the
severity of abnormalities in the lower lungs and the presence of
associated septal thickening raise the concern for a secondary,
coexisting process such as atypical infection or edema.
2. No change in subcutaneous soft tissue nodule in upper right
chest wall. This could potentially represent a sebaceous cyst,
but correlation with physical exam findings is suggested for
initial further assessment if the diagnosis is not already known
clinically.
CT CHEST W/O CONTRAST [**2184-4-26**] 10:14 AM
IMPRESSION:
1. Improvement of the widespread lung parenchymal abnormalities
including ground-glass opacities, peribronchovascular
infiltrates, and subpleural consolidation. The improvement is
more pronounced in the ventral segments of the lung. The left
pleural effusion has completely resolved while the right pleural
effusion has persisted.
CT HEAD W/O CONTRAST [**2184-5-4**] 10:39 PM
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or acute vascular territorial infarction. Ventricles and
sulci are normal in size and configuration. There is no
fracture. There is mild mucosal thickening in the bilateral
maxillary sinuses.
IMPRESSION: No acute intracranial process. Please note that MRI
with diffusion-weighted imaging is more sensitive for the
detection of acute brain ischemia.
MR/A HEAD W & W/O CONTRAST [**2184-5-5**] 4:17 PM
FINDINGS: There is no hemorrhage, infarct, or edema. No abnormal
signal intensity within the brain parenchyma. There is no
abnormal enhancement.
Increased signal on the post-contrast images (series16, im 14)in
the internal auditory canals can be real or due to 3T scanner
effect as this is not identifiable on post contrast MRA neck
images.
MRA OF THE BRAIN: The intracranial vertebral and internal
carotid arteries and their major branches are normal with no
evidence of stenosis, occlusion, or aneurysm.
MRA OF THE CAROTIDS AND VERTEBRAL ARTERIES: Carotid and
vertebral arteries are visualized from the origins to the
intracranial courses. No stenosis or occlusion identified. The
distal ICA measures 5 mm on the right and 4 mm on the left.
Soft tissues demonstrate a T1 hypointense, T2 hyperintense ovoid
well-defined structure within the soft tissues at the right
cranial vertex measuring approximately 1.7 x 0.9 cm.
IMPRESSION:
1. No acute infarction.
2. Increased signal on post contrast images of brain in the
internal auditory canals can be real or artifactual related to
3T scanner effect amd is not associated with increased FLAIR
signal or seen on postcontrast MRA neck images. Clinical
correlation and if necessary LP can be useful.
3. No focal flow limiting stenosis, occlusion or aneurysm more
than 3mm within the resolution of MRA.
4. Well-defined nodule in the subcutaneous tissues of the
parietal vertex, which may represent a sebaceous cyst, lymph
node, or nodule of uncertain etiology.
PERSANTINE MIBI [**2184-5-7**]
INTERPRETATION:
Left ventricular cavity size is mildly dilated.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 49%.
IMPRESSION: Normal myocardial perfusion on scintigraphy. Mildly
dilated left
ventricular cavity size. LVEF 49%.
STRESS Study Date of [**2184-5-7**]
EXERCISE RESULTS
RESTING DATA
EKG: SINUS, PROM. VOLT.
HEART RATE: 80 BLOOD PRESSURE: 118/64
PROTOCOL /
STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
1 0-4 0.142MG/ KG/MIN 90 98/60 8820
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 54
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: This 53 year old man was referred to the lab for
evaluation of chest pain. The patient was infused with 0.142
mg/kg/min
of dipyridamole over 4 minutes. No arm, neck, back or chest
discomfort
was reported by the patient throughout the study. There were no
ST
segment changes during the infusion or in recovery. The rhythm
was
sinus with no ectopy. Appropriate hemodynamic response to the
infusion.
The dipyridamole was reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
Brief Hospital Course:
53 yo male with history of AML, s/p cord blood transplant who
presented in early [**Month (only) 958**] with ARDS of unclear etiology requiring
intubation. He was called out to the floor after stablilization.
Floor course was complicated by increasing hypoxia so he was
readmitted to the ICU for increasing respiratory distress/ARDS,
found to have BOOP, treated with high dose steroids after which
he made steady improvements and continued to make progress on
the floor. Hospital course by problem:
# ACUTE RESPIRATORY DISTRESS SYNDROME: Upon admission, the
patient was started on broad spectrum antibiotic treatment in
order to treat an infectious process responsible for a clinical
picture consistent with ARDS. Antibiotics included vancomycin,
cefepime, levofloxacin, as well as bactrim and voriconozole.
The patient was followed by infectious disease during this
course, with coverage of antibiotics eventually being changed to
vanc/meropenem/levofloxacin/flagyl as well as prophylactic doses
of voriconozole and atovaquone. The patient underwent a
bronchoscopy, and BAL was sent. All work up for infectious
etiology was unrevealing. There was some concern that the ARDS
was secondary to rare cyclosporine toxicity, which had been
intiated 3 days prior to presentation, however this was later
felt not to be the case. This medication was weaned, and
ultimatly discontinued. The patient was noted to have pleural
effusions and gross body volume overload in the setting of ARF
with an elevated BNP upon admission, but was an unlikely primary
source of patients respiratory decompenstation. Patient
remained intubated from [**2184-3-18**] to [**2184-3-30**]. Patient was
difficult to wean from the vent, possibly due to a VAP, but
process was facilitated through continued diuresis and
adjustments in antibiotics. Since extubation patient breathed
comfortably on NC. Prior to transfer to the medical floor
vancomycin and cefepime had been discontinued. He completed an
empiric course of levaquin on [**4-8**]. He was volume overloaded on
transfer and diuresis was continued with 100mg IV lasix daily.
On [**4-3**] the patient briefly desated to 88% on 6L NC and required
NRB, occurred in the setting of [**10-22**] chest pain. The patient
was given additional diuresis, morphine and sl ntg and recovered
to previous O2 requirement of 6L. CEs were negative. No ECG
changes during event. Over the course of the next few days, he
remained stable from a pulmonary standpoint with a requirement
of 6L NC. On [**4-9**], the patient transiently desaturated to 90% on
6L with mild shortness of breath. He was afebrile and
hemodynamically stable. CT chest revealed increased diffuse
bilateral peribronchovascular infiltrates as compared to
previous. Cefepime (d/c'd on [**4-10**]) and azithromycin (d/c'd on
[**4-12**]) were added for empiric coverage of hospital-acquired
pneumonia. He was switched to levofloxacin on [**4-11**]. Pulmonary
and ID were consulted. His oxygenation status continued to
deteriorate and he desatted frequently to the 70-80s on 6L with
only minimal exertion. He had some transient improvement with
lasix. TTE on [**4-12**] revealed a normal EF with mild hypokinesis of
the basal to mid inferior segments of the LV, which had been
seen on a prior TTE on [**4-2**]. On the morning of [**4-13**], the patient
became hypoxic to 86% and required NRB to maintain sats in the
low-mid 90s. EKG was unchanged. CXR appeared more volume
overloaded. He received lasix 80mg IV, atrovent neb, SLN and was
transferred to the unit. The etiology of his respiratory
distress was unclear with the differential including BOOP, ILD,
and CHF. Infection was felt to be less likely.
.
Pt was transferred back to the ICU for repeated desaturations on
RA to the low 80s, with the concern for either a cardiogenic or
pulmonary process. Cardiology was consulted and recommended
maximizing medical management given the context of pt's AML. LAD
calcifications were noted on Chest CT, suggesting coronary
artery disease. Pt was therefore placed on metoprolol titrated
to maintain HR in the 70s, as well as ASA 81mg QOD. Pt also
responded well to furosemide IV diuresis.
.
CT chest revealed likely BOOP, and pt was started on
methylprednisolone IV with planned slow taper. He tolerated the
taper well, and was weaned eventually to 1-2L O2. He was
transitioned to prednisone and discharged on 20mg prednisone po
BID, which he should continue for 2 weeks until he follows up
with his pulmonologist Dr. [**Last Name (STitle) 4507**]. At that point he will have a
follow up Chest CT and PFTs and Dr. [**Last Name (STitle) 4507**] will advise on plan
for further taper. He should continue the atrovent/spiriva and
prn albuterol nebs. He is being discharged to a pulmonary rehab
facility.
.
# Coronary artery disease: The patient had an episode of
nausea/diaphoresis in ICU and was evaluated with EKG that showed
non-specific changes. CE's negative. CT chest showed
calcifications of the LAD. Cardiology felt impression most
consistent with angina and recommended continuation of aspirin
and beta-blocker. Had been poorly tolerant of beta-blockade
thought secondary to sleep disordered breathing, dose was
decreased to 100mg TID. Further decreased in setting of
transient facial numbness/weakness on [**5-4**] and improved since
then. P-MIBI on [**5-7**] showed no ECG changes, and normal
myocardial perfusion on scintigraphy, mildly dilated left
ventricular cavity size with mild depression of systolic
function (LVEF 49%). He was continued on ASA qod given
thrombocytopenia and Metoprolol 75mg TID (adjust as needed)
given episode of facial weakness/numbness thought to be [**2-14**] to
relative hypotension. Goal SBP of 120's. Addition of
statin/acei can be discussed as an outpatient.
.
#Facial Weakness/numbness and Altered Mental Status: Patient had
a transient episode of facial weakness and numbness with AMS on
[**5-4**]. VSS, finger stick normal. Neuro evaluated and felt it was
unlikely to be TIA/Stroke. MRI/MRA negative. Most likely was due
to poor perfusion in setting of relative hypotension (SBP upper
90's). He had no further episodes.
.
# ID: An extensive infectious workup for the etiology of the
patient's ARDS was unrevlealing. While intubated, the patient
developed persistent fevers. His Hickman line site showed no
evidence of infection. Lower extremity ultra-sound showed no
evidence of DVT, and CT of chest showed a question of a
multifocal pneumonia. Additionally, patient had CT of the
sinuses, which had a question of sinusitis. ENT was not
markedly empressed by CT, and an aspirate was sent and has been
negative to date. He was followed by ID during the
hospitalization. Given concern that the fevers may be
medication related, antibiotics have been systemacilly
discontinued. The meropenem was d/c'd on [**3-30**], and the vanc and
flagyl were stopped on [**3-31**]. His levaquin was discontinued on
[**4-4**]. He defervesced and his respiratory status improved with
treatment BOOP as above.
.
# H/O LEUKEMIA, ACUTE s/p cord blood transplantation for AML.
Concern that ARDS was secondary to GVH prophylactic medation
cyclosporine. Patient was admitted with supertherapeutic
levels. The dose was tapered, and ultimatly discontinued. The
patient was started on tacrolimus on [**3-31**] and then was held in
the ICU. He was continued on cellcept which is being slowly
tapered. He is currently on a daily regimen of 500mg qam, 250mg
qnoon, 500mg qpm. This should be decreased to 500mg [**Hospital1 **] on
[**2184-5-15**]. His oncologist Dr. [**First Name (STitle) **] will adjust as necessary at his
follow up appointment. He was continued on prophylactic regimen
of voriconozole, atovaquone, and acylovir.
.
# RENAL FAILURE, ACUTE: The patient presented with ARF, and over
intial days had a rising Cr to a peak of 3.0 with oliguric renal
production. Renal was consulted, who felt that ARF was seondary
to cyclosporine toxicity, as patient was admitted with
supratherapeutic levels of near 400. Patients renal function
improved as dose was lowered. He was grossly fluid overloaded
due to aggressive fluid hydration with oliguria, and has
required diuresis to help mobilize fluid. After aggressive
diuresis on the regular medical floor, his creatinine again
increased to a peak of 1.7. Urine electrolytes were consistent
with a pre-renal etiology and creatinine improved after diuresis
was held.
.
# h/o ASPERGILLUS INFECTION: The patient has a history of sinus
aspergillosis, on Voriconazole home regimen. Glucan &
galactomannin neg. Pt developed new fevers & Head CT on [**3-26**]
reported L sphenoid sinusitis, d/w ENT, very subtle & nothing to
drain, performed nasal washing & sent aspirate for fungal
culture to r/o fungal infections. Continued home voriconozole
regimen.
.
# Thrombocytopenia: Patient remained at baseline levels of
around 50 throughout hospitalziation.
.
#. PROPHYLAXIS pneumoboots/ambulation for DVT prophylaxis, PPI
given high dose steroids, Atovaquone, acyclovir, voriconazole
.
# Ulcer: Site: Mid inner aspect right and left buttock. Pt has
acquired healing stage II pressure ulcers while inpatient
secondary to friction and sheer. There are small and circular in
size, pink wound bed with surrounding skin intact. There is no
drainage or odor to these wounds. Upon d/c they are scabbed over
and healing.
Care: Daily and prn cleansing. Barrier cream applied daily and
prn.
.
#. CODE - full
.
Dispo- pulm rehab, outpatient pulm f/u with CT chest/PFTs and
outpatient oncology follow up
Medications on Admission:
Ursodiol 300 mg [**Hospital1 **]
Acyclovir 400 mg TID
Atovaquone 1500 mg daily
Sulcralfate 1 g QID
Protonix 40 mg [**Hospital1 **]
Labetolol 100 mg [**Hospital1 **]
Doxazosin 4 mg qHS
Cyclosporine 100 mg [**Hospital1 **]
Lorazapam 0.5-1 mg PRN nausea
Zyprexa 5 mg daily PRN nausea
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Atovaquone 750 mg/5 mL Suspension [**Last Name (STitle) **]: 1500 (1500) mg PO
DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
6. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO DAILY (Daily).
7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day) as needed.
8. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a
day) as needed.
9. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day).
11. Voriconazole 200 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO Q12H (every
12 hours).
12. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
15. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO EVERY OTHER DAY (Every Other Day).
16. Sucralfate 1 gram Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
17. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day:
adjust per pulmonologist recs.
18. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2)
Tablet, Chewable PO Q 12H (Every 12 Hours).
19. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
20. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) neb Inhalation Q4H (every 4 hours) as needed.
21. Acyclovir 200 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO Q8H (every
8 hours).
22. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for flatulence.
23. Nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED) as needed for chest
pain.
24. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3
times a day).
25. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day).
26. Mycophenolate Mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily) for 2 days: at noon.
27. Ursodiol 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
28. Ondansetron 4 mg IV Q8H:PRN
29. Heparin Flush (10 units/ml) 2 mL IV PRN
10 ml NS followed by 2 ml of 10 units/ml heparin (20 units
heparin) to each lumen daily and PRN. Inspect site every shift.
30. Heparin Flush Hickman (100 units/ml) 2 mL IV DAILY:PRN
10 mL NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
31. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Fifty Two (52)
units Subcutaneous at bedtime: adjust [**Name8 (MD) **] MD recs.
32. Insulin Aspart 100 unit/mL Cartridge [**Name8 (MD) **]: per sliding scale
Subcutaneous breakfast, lunch, dinner: FS 0-70 mg/dL, give [**1-14**]
amp D50; 71-120 , 0 u; 121-160, 2u; 161-200, 4u; 201-240, 6u;
241-280, 8u; 281-320, 10u; 321-360, 12u; 361-400, 14u; >400 [**Name8 (MD) 138**]
MD .
33. Insulin Aspart 100 unit/mL Cartridge [**Name8 (MD) **]: as instructed
Subcutaneous at bedtime: FS 0-70 mg/dL, give [**1-14**] amp D50; 71-120
, 0 u; 121-160, 1u; 161-200, 1u; 201-240, 3u; 241-280, 4u;
281-320, 6u; 321-360, 8u; 361-400, 10u; >400 [**Name8 (MD) 138**] MD .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8629**]
Discharge Diagnosis:
1. Acute myelogenous leukemia
2. Hypoxic respiratory failure due to ARDS and bronchiolitis
obliterans organizing pneumonia
3. Diabetes secondary to steroids
4. Atypical chest pain
5. Mild chronic systolic heart dysfunction
6. ICU neuropathy and myopathy
7. transient facial weakness of unknown etiology
8. coronary artery disease
Discharge Condition:
VSS, on 1LO2, breathing comfortably, lungs clear, ambulates with
assistance
Discharge Instructions:
You were admitted to the hospital with respiratory failure
thought due to ARDS/BOOP. You were treated with broad spectrum
antibiotics (vancomycin, cefepime, levoflox, bactrim,
voriconazole, then vanc, meropenem, levoflox, flagyl) and you
were started on high dose steroids with good response, and are
now being tapered slowly. Please continue to take prednisone
20mg po BID until your appointment with Dr. [**Last Name (STitle) 4507**] in 2 weeks.
He will discuss decreasing the dose further at that time. You
will need to have a repeat Chest CT without contrast before the
appointment as scheduled. Please continue to take PCP and fungal
prophylaxis (atovaquone and fluconazole) as prescribed. Please
continue to take montelukast 10mg daily and nebulizers as
prescribed. Please continue to take pantoprazole as prescribed
as this will protect your stomach in the setting of high dose
steroids.
.
You were also noted to have chest pain with deep breaths. You
had a stress test which was negative for ischemic changes or
perfusion defects. You had an echocardiogram which showed mildly
depressed ejection fraction (50%) which indicates you have mild
chronic systolic heart dysfunction. Please continue to take
aspirin as precribed, every other day, as well as the metoprolol
as prescribed. Monitor your weight daily and report weight gain
of >3lbs to the doctor.
.
While you were in the ICU you developed lower extremity weakness
and tingling. Neurology evaluated you and felt you had ICU
neuropathy and myopathy. You should continue to work with
physical therapy to regain your strength.
.
While in the hospital it was also noted that your blood sugars
were high. This likely was exacerbated by steroids, but could
suggest underlying insulin resistance. Please continue to take
the lantus and insulin sliding scale as ordered. Your doctor
will adjust the doses as needed based on your insulin
requirements. You should have your fasting blood sugars checked
as an outpatient once you have finished your steroid course.
.
Continue to take cellcept (mycophenolate) 500mg qam, 250mg qnoon
and 500mg qpm on [**5-13**] and [**5-14**]. Beginning [**2184-5-15**] reduce this to
500mg [**Hospital1 **] (500mg twice a day).
.
Please take all medications as prescribed. Please go to all
follow up appointments.
.
If you develop fever, shortness of breath, chest pain, cough,
bleeding, light headedness, mental status changes, or any other
concerning symptoms, please call your doctor or come to the
hospital.
Followup Instructions:
Please go to [**Hospital Ward Name 23**] [**Location (un) **] for a chest CAT SCAN
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2184-5-26**] 10:30. Please arrive at
10:15. Do not eat or drink anything for 3 hours prior to the
study.
.
Pulmonary follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**], ([**Telephone/Fax (1) 3554**], on Wed
[**5-26**], at 2pm. Please show up at 1:30 pm as you will go to the
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2184-5-26**]
1:40, before the appointment.
.
Please go to your scheduled appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2184-5-21**] 10:30; Provider: [**Name10 (NameIs) 674**] [**Name8 (MD) 39626**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-5-21**] 10:30.
.
Please come to the oncology clinic again the following week
(week of [**5-24**]) as instructed by Dr. [**First Name (STitle) **].
Completed by:[**2184-5-13**]
|
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icd9cm
|
[
[
[]
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[
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] |
icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,689
| 174,737
|
45994
|
Discharge summary
|
report
|
Admission Date: [**2190-9-2**] Discharge Date: [**2190-9-20**]
Date of Birth: [**2117-7-15**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Codeine / Bactrim DS / IV Dye, Iodine
Containing / Levofloxacin / Lipitor / Shellfish / Sulfa
(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
"altered mental status."
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
This is a 73 yo WF with a PMHx of breast cancer originally
diagnosed in [**2160**] with recurrence 6 months ago, s/p recent
bilateral mastectomy c/b infection and removal of expanders, now
with pseudomonas osteomyelitis who now p/f home with subacute
changes in MS and increased problems ambulating.
.
The patient was discharged for the plastic surgery service about
2 months ago for surgical treatment for complications related to
her bilateral mastetomy. She was re-admitted several weeks ago
for a delayed closure of her wounds. Her most recent tissues
culture from her chest grew pan-sensitive pseudomonas. She is
on vancomycin and cefipme therpay, end date is [**2190-9-29**]. The
patient had been at home for the last several weeks and the
family notes a slow decline in mental functioning. They report
she is slower to answer questions and has a poor attention span.
They thinks her metal function started to decline noticably as
she was diagnosed with her second breast cancer in 2/[**2190**]. They
did note that she has some level of forgetfulness at baseline.
The day of admission, the patietn had decreased ability to
ambulate with a walked like she had been able to previously, so
they presented to the hospital. They denied falls and the
patietn denies dysequilibrium or vertigo. The patient has had
problems taking in po [**3-17**] to increased nausea and vomiting of
clear liquid. The patient family notes she is on many
medications and that her pain medications and reglan may have
been changed recently. Per the ED notes, reglan was added
recently.
.
In the ED they got a HCT which was negative for acute processes
and a CXR that was negative except for her picc was in her RIJ.
The patients labs were signifcant for acidosis with a bicarb of
14, a normal lactate and a creatinine of 1.8. There the patient
was AAOX2.
When the patient arrived to the floor she had no complaints.
She denied pain, cp, sob, f/c. The plastic surgery team
evalauted the patietn and probed her wound and got pus like
drainage from the patient right chest. She had minimal pain
during the procedure.
Past Medical History:
PMH:
1) Left breast cancer [**2160**]
-carcinoma of the left breast diagnosed in [**2160**]
-At that time, she was treated with breast conserving surgery
including an axillary dissection, chemotherapy, and adjuvant
radiation therapy.
-She has had no further problems with her breast until [**2-/2190**]
when Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a wire localized right breast
biopsy for a mammographic abnormality, which demonstrated
microcalcifications associated with benign breast lobules. An
initial core biopsy had demonstrated calcifications associated
with a sclerosed fibroadenoma and lobular carcinoma in situ
-new left breast ca, the pathology of which was the same as her
initial breast ca over 20 yrs ago
-there was 1 positive sebtinel node, Her-2 neg
-In [**Month (only) 956**] she [**Month (only) 1834**] a bilateral mastectomy
with expanders placed
-her post op course was complicated by a significant cellulitis
of both surgical sights, requiring surgical intervention and
removal of expanders
2) L squamous cell carcinoma
3) Hypertension
4) Hyperlipidemia
5) Hypothyroidism
6) Arthritis
7) Diverticulitis s/p sigmoidectomy
Past Surgical History:
1) [**2190-4-15**] Bilateral breast debridement
2) [**2190-3-30**] Bilateral total simple mastectomies
3) [**2183**] Sigmoidectomy for diverticulitis
4) [**2180-7-11**] arthroscopy with major synovectomy and thermal
chondroplasty of right knee
5) [**2180-1-25**] operative arthroscopy with partial medial
meniscectomy and debridement
6) [**2179-8-18**] Wire localized right breast biopsy
7) [**2178-4-13**] Excision of cyst on buttocks
8) [**2175-9-15**] Removal of distal radius pin
9) [**2175-7-24**] Closed reduction of the right distal radius
fracture,
external fixator application of right wrist, percutaneous K-wire
placement of right distal radius
10) [**2165**] Left breast lumpectomy and chemoradiation
11) [**2153**] C-section
12) [**2135**] Appendectomy
13) [**2123**] Tonsillectomy
Social History:
Cigarettes-denied, EtOH rare social.
Family History:
negative for breast and ovarian cancer.
Physical Exam:
Admission Physical Exam:
.
VS 98.6, 138/62, 67, 16, 97 RA
General: patient is easily arousable, AAOX3-knows she is in the
hospital, knows the month, unsure of the year, throughts are
somewhat tangential and sometiems does not answer questions
appropirately
HEENT: CN 2-12 grossly intact, mmm, no lad
Endo: no obvious thyroid masses
CV: 3/6 systolic murmur
Lungs: CTAB no wrr
Abdomen: positive bs, obese but not TTP, liver and spleen not
palpable, no rebound
Extremities:
UE:5/5 strength, pulses 2+ and equal, sensation grossly intact
LE:4+/5 strength, pulses 2+ and equal, sensation grossly intact,
2+ pitting ble edema
Neuro:
-strength equal, slightly decreased per above
-reflexes 1+ and equal
-sensation grossly intact
-unable to participate in cerebellar exam
-mental status per above, able to answer some simple questions
but is tangential
ICU Admission Exam:
Vitals: T 98.9, BP 168/61, HR 92, RR 27, SpO2 97% on 8L
Ventimask
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest wall: Dressing in place, non-tender, bilateral mastectomy
sutures clean.
Lungs: Increased work of breathing, tachypnea. Bibasilar
crackles. Wheezing audible without stethoscope, upper airway.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, well perfused. Distal pulses 2+. Lower extremity
edema 1+ bilaterally at ankles.
DERM: Sacral decub ulcer, healing incision on right mid-back.
.
Discharge Physical Exam:
.
VS 97.8, 132/78, 72, 18, 97 RA
General: AOx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest wall: Dressing in place, non-tender, bilateral mastectomy
sutures clean.
Lungs: Increased work of breathing, tachypnea. Bibasilar
crackles. Wheezing audible without stethoscope, upper airway.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, well perfused. Distal pulses 2+. Lower extremity
edema 1+ bilaterally at ankles.
Neuro: non-focal
.
Pertinent Results:
Admission Labs:
.
[**2190-9-2**] 12:15PM URINE HOURS-RANDOM
[**2190-9-2**] 12:15PM URINE GR HOLD-HOLD
[**2190-9-2**] 12:15PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2190-9-2**] 12:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
[**2190-9-2**] 12:15PM URINE RBC-1 WBC-21* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2190-9-2**] 12:15PM URINE AMORPH-FEW
[**2190-9-2**] 12:15PM URINE MUCOUS-RARE
[**2190-9-2**] 10:12AM LACTATE-1.0 K+-4.1
[**2190-9-2**] 10:05AM GLUCOSE-84 UREA N-34* CREAT-1.8* SODIUM-133
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-14* ANION GAP-19
[**2190-9-2**] 10:05AM estGFR-Using this
[**2190-9-2**] 10:05AM ALT(SGPT)-3 AST(SGOT)-12 LD(LDH)-226 ALK
PHOS-93 TOT BILI-0.2
[**2190-9-2**] 10:05AM LIPASE-10
[**2190-9-2**] 10:05AM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-1.4*
[**2190-9-2**] 10:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-9-2**] 10:05AM WBC-8.4 RBC-3.54* HGB-10.4* HCT-33.2* MCV-94
MCH-29.4 MCHC-31.3 RDW-16.2*
[**2190-9-2**] 10:05AM NEUTS-83.3* LYMPHS-6.3* MONOS-3.7 EOS-5.7*
BASOS-1.0
[**2190-9-2**] 10:05AM PLT COUNT-353
.
Pertinent Labs:
.
[**2190-9-3**] 07:05AM BLOOD freeCa-1.25
[**2190-9-3**] 11:17AM BLOOD Type-ART pO2-273* pCO2-26* pH-7.28*
calTCO2-13* Base XS--12
[**2190-9-14**] 03:47AM BLOOD Type-ART pO2-43* pCO2-38 pH-7.51*
calTCO2-31* Base XS-6
[**2190-9-2**] 10:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-9-18**] 05:47AM BLOOD CRP-31.1*
[**2190-9-5**] 06:00AM BLOOD T4-3.4*
[**2190-9-4**] 05:45AM BLOOD TSH-8.0*
[**2190-9-3**] 06:00AM BLOOD Ammonia-34
[**2190-9-7**] 06:00AM BLOOD Triglyc-151*
[**2190-9-3**] 06:00AM BLOOD VitB12-272 Folate-5.3
.
Discharge Labs:
.
[**2190-9-20**] 06:00AM BLOOD WBC-6.5 RBC-3.23* Hgb-9.8* Hct-28.7*
MCV-89 MCH-30.2 MCHC-34.0 RDW-15.2 Plt Ct-375
[**2190-9-20**] 06:00AM BLOOD Plt Ct-375
[**2190-9-20**] 02:00PM BLOOD Glucose-121* UreaN-49* Creat-1.3* Na-135
K-5.3* Cl-99 HCO3-26 AnGap-15
[**2190-9-20**] 02:00PM BLOOD Calcium-10.1 Phos-4.2 Mg-2.2
.
MICRO/PATH:
.
Blood culture [**9-2**]: No growth
Abscess Culture [**9-2**]: Pseudomonas Aeruginosa pan-sensitive
Blood culture x 2 [**9-4**]: No growth
Urine Culture [**9-4**]: Yeast 10k-100k orgs/ml
Stool Cdiff [**9-6**]: Negative
Stool Cdiff [**9-7**]: Negative
MRSA Screen [**9-8**]: Negative
Urine Culture [**9-10**]: No growth
Urine Culture [**9-14**]: No growth
Urine Legionella Antigen [**9-14**]: Negative
Stool Cdiff [**9-14**]: Negative
.
IMAGING:
.
Chest Portable [**9-14**]
IMPRESSION:
1.Mild interval progression of pulmonary edema
2.New left upper lung opacity which could potentially represent
a focus of
consolidation or may be from the summation shadows of the ribs
and scapula. Lateral radiograph is suggested for further
evaluation.
3. Unchanged bilateral minimal pleural effusions
.
CXR PA/LAT [**9-2**]
IMPRESSION:
1. Right PICC terminates in the right neck - likely within the
internal
jugular vein and should be repositioned.
2. Mild congestive heart failure. No pneumonia.
.
CT Head [**9-2**]
1. No acute intracranial hemorrhage. Note that MRI is more
sensitive for
detection of metastases and mass lesions.
2. Bifrontal prominence of CSF space could reflect bifrontal
atrophy, chronic small subdural hematomas, or CSF hygromas.
.
MR [**Name13 (STitle) 430**] [**9-4**]
1. No acute intracranial abnormality; specifically, there is no
evidence of an acute ischemic event.
2. No secondary finding to specifically suggest intracranial
metastatic
disease on this non-enhanced examination.
3. Relatively marked symmetric prominence of the bifrontal
extra-axial CSF
spaces, most likely representing severe bifrontal cortical
atrophy.
.
CT Chest [**9-3**]
1. Extensive irregularity and sclerosis of the sternum since the
prior study, concerning for progression of osteomyelitis with
soft tissue stranding anterior to the sternum.
2. No focal fluid collections or tracking soft tissue air with
soft tissue
inflammatory changes in the left greater than right chest wall
possibly
reflecting associated soft tissue infection.
3. Right greater than left pleural effusions.
4. Right middle lobe nodules similar in size, although perhaps
slightly
[**Hospital1 2824**] than on the prior study, can be followed in three to six
months with a followup chest CTA.
5. Mild pulmonary edema with small bilateral effusions.
6. Lucent lesion in the left glenoid could reflect degenerative
subchondral cystic change. However, metastasis cannot be fully
excluded.
.
CXR [**9-7**]
Pulmonary edema, if present, is mild. There is substantial
opacification of the right lower lung, probably collapsed. On
the left, there may be a moderate pleural effusion and basal
consolidation is not excluded. Heart is mildly-to-moderately
enlarged, and there is mild mediastinal venous engorgement.
Right PICC line ends in the upper right atrium.
.
CXR [**9-9**]
Mild left lower lobe atelectasis or pneumonia. Vascular
congestion has improved.
.
ECHO [**9-3**]
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears grossly normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal study. No valvular
pathology or pathologic flow identified.
.
RENAL US [**9-3**]
No hydroureteronephrosis or renal stone.
.
LUB [**9-3**]
Unremarkable abdominal x-ray. No evidence of free air.
.
Brief Hospital Course:
This is a 73 yo WF with a PMHx of breast cancer with new primary
diagnosed [**2-/2190**] s/p bialteral mastecomy c/b sternal and rib
osteomyelitis who was on IV abx at home who now p/w altered
mental status and decreased ability to abulate with a walker and
persistent n/v, found to have 3/6 systolic murmur, ARF (Cr 1.8),
metabolic acidosis (bicarb 14), and only able to answer simple
questions with tangential thoughts.
.
Active Diagnoses:
.
#Altered mental status: The etiology of Mrs.[**Known lastname 69032**] altered
mental status was likely multifactorial but predominately a
result of delirium given her serious medical illnesses. We
tested for reversible causes of AMS including B12 and folate
levels which were wnl's, CT head which was negative for
intracranial processes, UA and urine cultures which were
negative for UTI, and reduced her doses of CNS-depressing
medications including her fentanyl patch, gabapentin, and
benadryl. We continued to treat her underlying skin/wound
infection of IV vanc and cefepime and her mental status
gradually improved until she became alert, oriented, conversant,
and demanding for discharge home.
.
#Pseudomonas osteomyelitis of chest: She remained afebrile
during the admission but had immunosuppression from
chemotherapy, metastatic disease, and malnutrition. She was
treated with IV vanc and cefepime and was followed closely by
plastics for evlauation of her wounds and removal of her wound
drains. Her urine and blood cultures remained negative
throughout admission but her wound abscess grew pan-sensitive
pseudomonas. Her TTE was negative for vegetations as well. Stool
Cdiff antigen test was negative x 2. Her infection was monitored
with weekly CRP/ESR levels which remained severely elevated.
During her admission she was switched to daptomycin and
meropenem per ID recs. She was followed closely by ID and
continued on IV antibiotics on discharge with follow-up
established in the [**Hospital **] clinic for final antibiotic course
determination to be made as an outpatient. Per the plastics
team, she will need further severe surgical debridement if she
is able to become healthy enough to tolerate such an operation
in the future.
.
#[**Last Name (un) **]: Pt with [**Last Name (un) **] that was assessed to be pre-renal or as a
result of interstitial nephritis from her IV cefepime. She had
an elevated BUN/Cr ratio and trace urine Eos. Her ACEI and home
diuretics were held and she was given good amounts of continuous
IV fluids and her Cr level fell towards baseline down to 1.3
from 2.3 earlier in her hospital course.
.
#Metabolic Acidosis, Anion Gap +: She had a widened anion gap
metabolic acidosis early in her hospital course but with a
normal lactate level thought to be related to her smoldering
pseudomonas osteomyelitis. We continued treatment of her
underlying infection and this resolved.
.
#Malnutrition: This patient was found to have low-low normal
albumin levels with a pre-albumin wnl's. She however, had
significant nausea and occasional vomiting and had difficulty
tolerating food by mouth. She was treated with TPN for much of
her admission yet as her mental status improved her nausea began
to fade and she was able to tolerate a better diet. She was
discharged home without TPN as it was determined that her risk
of developing further infection given her widespread pseudomonal
osteomyelitis was quite high and her appetite and PO intake was
rapidly improving.
.
ICU Course:
Mrs. [**Known lastname **], a 73 year old lady with Pseumonal osteomyelitis and
soft tissue infection s/p breast resections, was transferred to
the East ICU on [**9-8**] after developing respiratory distress on
the floor with a concern for anaphylaxis. Her ICU course was
also complicated by hypertension, acute kidney injury, altered
mental status and anemia.
.
# Respiratory Distress: Floor team was concerned that the
patient had developed anaphylaxis to meropenem, as she had
recently begun that antibiotic for treatment of her Pseudomonal
osteomyelitis and soft tissue infection. On arrival to the ICU
however, her history, exam, labs (elevated BNP [**Numeric Identifier **]) and chest
x-ray (vascular congestion) seemed most consistent with
pulmonary edema in the setting of uncontrolled hypertension.
For her suspected allergic reaction, her meropenem was
discontinued, and she was treated with ranitidine and
albuterol/iprotropium nebulizers. For her pulmonary edema, she
was diuresed with furosemide IV. She responded with good UOP
and improved exam. Her blood pressure was also controlled.
Prior to transitioning back to the floor, the patient was
challenged with meropenem and carefully monitored for signs of
anaphylaxis. She tolerated the meropenem challenge, and was
continued on meropenem along with daptomycin for treatment of
her sternal osteomyelitis. Patient acutely developed anxiety,
but [**3-17**] AMS patient was unable to explain symptoms. CE cycled
and negative; EKG without acute ST/T wave changes. CXR done at
the time consistent with pulmonary edema. She was diuresed and
given 10mg IV hydralazine and her symptoms seemed to improve.
.
# Pseudomonal Wound Infection: Infectious Disease and Plastic
Surgery continued to follow the patient in the ICU. She was
continued on vancomycin and cefepime for treatment of her wound
infection, until she passed the meropenem challenge. Wound care
and dry dressings were done per the advice of the Plastic
Surgery team. On discharge from the ICU, the patient's
antibiotic regimen was meropenem and daptomycin.
.
# Hypertension: The patient's blood pressures remained elevated
in the ICU; however, some elevation was attributed to the fact
that there was significant external pressure on her leg blood
pressure cuff. This pressure was likely falsely elevating her
readings. Home lisinopril was held [**3-17**] elevated sCr. She was
treated with amlodipine 10mg qDay and hydralazine 10mg TID, as
well as IV furosemide for diuresis. We tolerated leg blood
pressures of SBP 150-170, so that her kidneys would remain
well-perfused.
.
# [**Last Name (un) **]: Elevated creatinine persisted while in the ICU. Renal
team continued to follow and believed that her urine sediment
was consistent with ATN. Volume status, urine output, and
electrolytes were monitored, and her medications were
renally-dosed.
.
# Altered Mental Status: The patient reportedly had subacute
mental status changes at home with confusion and impaired gait
which prompted her presentation. Several deliriogenic meds,
including Fentanyl patch, were stopped on admission to the
hospital or shortly after. In the ICU, she continued to have
waxing and [**Doctor Last Name 688**] confusion and impaired attention consistent
with delirium. She seemed to have a better mental status with
her family present in the room. Her Ativan was changed from qHS
to [**Hospital1 **], and other delirogenic medications were avoided.
.
# Anemia: The patient's Hct was low, but stable at her recent
baseline prior to hospitalization. Her CBC was trended and
stools Guaiac'd to monitor.
Transitional/Follow-up Issues:
-F/u w/ primary breast surgeon: will need more surgery to remove
osteomyelitis of sternum but not until she is more stable, ~6
weeks. Follow-up was set up with the ID team to tailor and
determine her final antibiotic course as an outpatient.
Medications on Admission:
1. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily)-will hold
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for burning pain, anterior right chest.
Disp:*63 Capsule(s)* Refills:*1*
8. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal
Q72H (every 72 hours) as needed for cancer pain.
Disp:*10 patches* Refills:*1*
9. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal
every seventy-two (72) hours as needed for cancer pain.
Disp:*10 patches* Refills:*1*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000)
mgs Intravenous Q 24H (Every 24 Hours): Last dose to be given on
[**2190-9-29**].
Disp:*7 IV bags* Refills:*6*
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. cefepime 2 gram Recon Soln Sig: Two (2) gms Injection Q8H
(every 8 hours): Last dose to be given on [**2190-9-29**].
Disp:*21 IV bags* Refills:*6*
Discharge Medications:
1. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 15 days.
Disp:*30 Recon Soln(s)* Refills:*0*
2. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 15 days.
Disp:*8 Recon Soln* Refills:*0*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*1 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
Disp:*1 * Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Disp:*30 Capsule(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. 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*
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
11. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*14 Tablet, Rapid Dissolve(s)* Refills:*0*
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: hold for sedation.
Disp:*7 Tablet(s)* Refills:*0*
13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
16. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
Disp:*240 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
Please obtain blood and check CBC and Chem 10 (including
magnesium, calcium, and phosphate)
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Pseudomonal osteomyelitis
pulmonary edema
hypertension
acute kidney injury
delirium
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure caring for you. You were admitted with altered
mental status and were found to have an infection in the site of
your prior mastectomies, and kidney damage. We are treating your
infection with antibiotics and your kidney function is
improving.
.
We made the following changes to your medications:
-START Meropenem 1g IV every 12 hours
-START Daptomycin 400mg IV every 48 hours
-START Hydralazine 10mg, 2 tablets, by mouth every 6 hours
-START Amlodipine 10mg by mouth daily
-START Hydrochlorothiazide 25mg by mouth daily
-START Omeprazole 20mg by mouth daily
-START Metoclopramide 10mg by mouth four times daily as needed
for nausea
-START Zofran 8mg by mouth every eight hours as needed for
nausea
-START Compazine 10mg by mouth every six hours as needed for
nausea
-START Ativan 0.5mg by mouth every four hours as needed for
anxiety
-START Dilaudid 2mg by mouth every four hours as needed for pain
-STOP Triamterene
-STOP Lisinopril
-STOP Gabapentin
-STOP Fentanyl patches
-STOP Cefepime
-STOP Vancomycin
Please make sure to eat as much as you can by mouth to keep up
your nutritional status. Also, please make sure to follow up
with your primary care doctor sometime this week for repeated
lab work and follow-up. You will have to discuss with him the
possibility of returning to your original blood pressure
medications once your kidney function improves. Please also
continue your IV antibitoics until your appointment with Dr.
[**Last Name (STitle) **] on [**10-5**]. We wish you a speedy recovery.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2190-10-5**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 97917**],MD
[**Last Name (Titles) 90499**]: Primary CAre
Location: PERSONAL MDS, LLC
Address: [**Location (un) **] [**Apartment Address(1) 97918**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 95663**]
When: [**Last Name (LF) 766**], [**9-27**] at 10:30am
Completed by:[**2190-10-12**]
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Discharge summary
|
report+report+report
|
Admission Date: [**2110-10-2**] Discharge Date: [**2110-11-4**]
Service: TRA
HISTORY OF PRESENT ILLNESS: An 84 year old male intoxicated
status post fall from 6 feet downstairs with questionable
loss of consciousness. He was noted to have been drinking
excessively and to have suffered a head trauma in this
incident. The patient is currently disoriented in the trauma
SICU, with CAT scan that showed C5 lamina and spinous process
fracture and vertebral foramen fracture around C5. Due to
concern for vertebral artery Neurosurgery requested MRI, MRA,
and C-spine at this time.
PAST MEDICAL HISTORY: Of note, the patient's past medial
history consist of prostate cancer, therapy with Lupron,
history of lymphoma, hypertension, and history of alcohol
abuse. He is known to take at home Toprol XL, Aspirin,
Ativan, Zyprexa and Depakote.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.2 degrees
Fahrenheit, heart rate 76, blood pressure 146/64, respiratory
rate 14, breathing 99 percent 3 liters nasal cannula.
GENERAL APPEARANCE: He is noted to be intoxicated and in no
apparent distress.
NEUROLOGICAL: Pupils are equal, round and reactive to light.
Extraocular movements intact. The patient is disoriented,
inebriated. Appropriate neuro examination at this time is
noted to be difficult. The patient is not following commands.
Speech fluent but nonsensical. Not oriented. It is difficult
to examine this patient secondary to the patient not
following commands. Pupils 3 to 2 and sluggish. He moves
all four extremities. Upper extremities move spontaneously.
Lower extremities withdraw to pain. Toes were downgoing
bilaterally. Normal reflexes throughout were noted.
CARDIOVASCULAR: Normal S1 and S2 with regular rate and
rhythm. No murmurs, rubs or gallops.
CHEST: Lungs are clear to auscultation bilaterally without
wheezes, rales or rhonchi.
ABDOMINAL: Non-distended with normal active bowel sounds.
Soft and nontender throughout with no rebound or guarding.
HOSPITAL COURSE: The patient was admitted for further
observation and study and then was transferred to the Trauma
SICU at this time. The patient was receiving q 1 neuro
checks at this time and was wearing a hard cervical collar.
He was on a propofol drip at this time and a Solu-Medrol
drip. He was to receive an MRI/ MRA of the spine.
Endotracheal tube was required to proceed with his MRI with a
plan to extubate when the study is completed. Arterial blood
gases drawn and a chest x-ray was performed. The patient was
placed on intravenous fluids and NPO at this time and regular
insulin sliding scale. A Foley catheter was also placed. The
patient was placed on Pepcid, subcutaneous heparin,
Pneumoboots, thiamine folate and Ativan 0.5 mg intravenous,
b.i.d.
On hospital day No. 2, [**2110-10-3**], the patient
remained in the trauma SICU and was continued on the Solu-
Medrol drip at this time. The patient was noted to be
withdrawing his legs to pain still. He was also noted to have
decreased breath sounds at the bases. The patient was also
placed on prophylaxis for alcohol withdrawal and the patient
also was extubated at this time without incident. It was
determined that the patient was currently at risk for re-
intubation and would need two feeds for nutrition at this
time and a OG tube was placed for this purpose. The patient
was also seen by ophthalmology on hospital day 2, consulted
to evaluate for globe orbital floor fracture on the left and
noted to be only reactive to noxious stimuli. Plastic
surgery was also consulted at this time to assess for
possible repair of this fracture. Also of note there was no
evidence of entrapment at this time. Also of note on
hospital day No. 2, a central venous line was placed in the
left subclavian vein in a sterile fashion. The patient
tolerated this procedure well. The patient's MRI, MRA showed
cord enhancement and then on the left it was noted that the
vertebral artery was not visible. CT angiogram also showed a
stenotic vertebral artery. The patient at this time was
started on a Heparin drip with a goal PTT of 40 to 60. The
patient was noted still to be having significant lower
extremity weakness bilaterally. The patient was also on an
insulin drip at this time for elevated blood glucose on
finger sticks.
An AA line was placed on hospital day 3, [**2110-10-4**]
and on hospital day No. 4, [**2110-10-5**], the patient had
an official read of CAT scan of his head and facial CT as
follow up. There was noted to be no change. There was a left
inferior orbital fracture with no signs of entrapment. Tube
feeds were started. Haldol was given for agitation and
Zyprexa and valproate were discharged at this time. The
patient was still tachycardic and hypertensive at this time
with blood pressure up to 180/70 and heart rate into the
120's. The patient was changed to Dobhoff tube on hospital
day 4, [**2110-10-5**] and on hospital day 4, also of note
the patient was neurologically improved according to the
neurosurgical team who saw him in the afternoon. He was noted
to be interacting more at this time and the patient was
cleared to begin physical therapy, to be out of bed and on
hospital day No. 5 the patient was noted to have a
temperature of 101.3 and cultures were sent and labetalol was
required to control his systolic blood pressure. Also of
note the patient was started on Vancomycin and Zosyn for
hospital acquired pneumonia. He was noted to have coarse
breath sounds at this time and on chest x-ray was noted to be
largely unchanged with some signs of infiltrate.
On hospital day No. 5, [**2110-10-6**], in the mid morning
at approximately 7:45 a.m. health officers were called to the
bedside for decreased blood pressure and decreased mental
status. The patient was noted to be less arousable. The
patient briefly went into pulseless electrical activity at
this time as the team was preparing was intubation and
compressions were started. The patient was given 0.5 mg of
atropine x 1. Epinephrine was given, etomidate and
succinylcholine were administered for intubation purposes and
C-spine immobilization was maintained at all times. An
endotracheal tube was placed and good coloration was noted.
Breath sounds were noted to be equal bilaterally. Trauma
team was notified that the airway was regained and of the
prior events. Blood pressure at this time was noted to dip
down into the 60's and 70's systolically. Levophed was
briefly started but blood pressure soon returned to the 200
and Levophed was promptly discontinued. The patient was then
taken for repeat head CAT scan. The patient was given
morphine and Ativan and was noted to have a blood pressure of
150 systolically in the CT scanner. The patient was moving
all extremities but not following commands. CAT scan showed
no changes at this time and he was seen by neurosurgery who
requested a CT angiogram to assess vertebral arteries. Dr.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 93809**], MD, was noted to be present for the entire
resuscitation in the Trauma Surgical Intensive Care Unit. CT
angiogram showed stable occlusion of the vertebral artery at
this time. The plan was for the patient to have blood
pressure greater than 150 at all times systolically and
heparin was continued with a goal PTT of 40 to 60.
On hospital day No. 6, [**2110-10-7**], the patient
continued to be tachycardic and hypertensive and was
requiring Lopressor, hydralazine and labetalol drip now. The
patient was now awake and agitated on the vent. The patient
also had Dobhoff still at this time. Levophed was stopped at
this time as the patient was not requiring pressors to
maintain blood pressure above 150 systolically. Nutrition
throughout this stay continued to provide the recommendations
for tube feeds and these were followed accordingly.
On hospital day No. 7, [**2110-10-8**], the patient was
noted to have grown on culture strep viridans from his blood,
likely oropharyngeal flora in his sputum, Enterococcus in his
urine that was Pen sensitive. His central line tip was
cultured at this time. Infectious Disease was also consulted
during the stay on hospital day No. 7, [**2110-10-8**], who
suggested there were possibly multiple etiologies of his
fever, possibly from the sinus, from his lines, and from
positive blood culture. They agreed with the current regimen
of antibiotics of Vancomycin and Zosyn to provide broad
coverage and should cover the likely pathogens.
On hospital day No. 8, [**2110-10-9**], the patient had a
transthoracic echocardiogram that showed no vegetations or
any signs of regurgitation or other valve abnormalities with
a plan to also have a transesophageal echocardiogram
performed. The patient was switched to Fentanyl patch at
this time. Foley placement was performed and decongestants
were added for left maxillary sinus opacity. The patient was
recultured for a temperature spike to 101.9. The patient was
placed back on Levophed for systolic blood pressure greater
than 150 with a plan to discuss with neurosurgery how long
these blood pressure parameters were necessary. Versed was
also added as needed. The patient also had a hematocrit
dropped to 23.5 during this time and received two units of
packed red blood cells. The patient's morphine and Haldol
were stopped at this time and antibiotics were continued for
strep viridans, and bacteremia.
On hospital day No. 9, [**2110-10-10**], the patient's
hematocrit was noted to drop to 19 and urine output having
decreased with persistent tachycardia. At this time Neo-
Synephrine was also added and then weaned off. Heparin was
stopped at this time and the patient then received 5 units of
packed red blood cells overnight. Tube feeds were on hold at
this time. The patient was also seen by Neurology on this
date who recommended not using pressors to maintain a target
systolic blood pressure and suggested continuing to treat
sepsis and hemorrhage and to use fluid boluses if needed
They also suggested to consider an MRI with diffusion to
assess whether the patient has in fact sustained an acute
infarct. Infectious Disease continued to recommend the using
Vancomycin and Zosyn at this time. Also of note on this
hospital day No. 9, Otolaryngology was consulted to perform a
tap on a left maxillary sinus that was known to be built up
with fluid if the patient is now positive blood cultures with
sinus, possibly suspected as a source, At this time it was
determined that this patient's bleed was likely
retroperitoneal in nature in the study of recent trauma and
anticoagulation and the patient continued to be
hemodynamically labile suggesting a possible central nervous
system process.
On hospital day No 10, [**2110-10-11**], the patient
continued to have labile blood pressure ranging from the 70's
to the 210's. The patient was on q4 hematocrit checks. A
right femoral ultrasound was also performed at this time to
rule venous pseudoaneurysm and anticoagulation was reassessed
in the background of this bleed with need for anticoagulation
for left vertebral artery thrombosis. The MRI/ MRA of
[**10-11**], of the head and neck showed no obvious
infarction.
On hospital day No. 11, [**2110-10-12**], Vancomycin was
stopped and Lopressor was added for blood pressure control
and urine catecholamines were also sent at this time to try
to explain these possible sudden rises in blood pressure.
The patient's hematocrit at this time was noted to be 24.8
and regular hematocrit checks were continued. The patient was
transfused one unit at this time of packed red blood cells.
The patient now had his left maxillary sinus taps, 2 cc of
blood tinged fluid was removed and sent for culture and
sensitivity. The patient's temperature had now gone up to
101.9. Also on this date, the left subclavian central venous
line was changed due to the likelihood of possible infection.
On hospital day No. 12, [**2110-10-13**], penicillin was
started by strep viridans in his blood. Levofloxacin was also
started on enterococcus that grew back in the urine and
angiography was planned for the morning. Tube feeds were
held. Hematocrit was stable at this time between 25.2, and
26.3 on this date. Metoprolol was then given orally 2 twice
day and [**2110-10-13**], the patient also received
transesophageal echocardiogram that revealed no vegetations
and no significant valvular abnormalities or regurgitations.
The patient was then started on aspirin after discussion with
Neurosurgical and Trauma teams. The patient's hematocrit
continued to be stable. Penicillin was also stopped at this
time and tube feeds were restarted since angiography did not
take place. Maxillary sinus fluid was noted to be positive
for Enterococcus at this time and the antibiotics given at
this time were vancomycin and Levofloxacin. Penicillin had
been stopped.
On hospital day No. 15, [**2110-10-16**], a family meeting
was arranged in order to discuss the possibility of a
tracheostomy and percutaneous endoscopic gastrostomy to be
done. Clonidine was also added at this time for further blood
pressure control and angiography was still being planned at
this time. CAT scan at this time was noted to show no acute
infarcts and the MRI/ MRA of [**10-11**], of the head and
neck showed no obvious infarction.
No [**2110-10-17**], hospital day No. 16, the patient was
weaned off of all pressors and was having problems with
agitation and accompanied hypertension and tachycardia that
evening. The patient required Haldol, morphine and Versed.
The patient was denying pain and was noted to be able to
follow commands. Sputum was found to be Methicillin-
Resistant Staphylococcus Aureus positive. The patient also
then required being placed back on Levophed for blood
pressure systolic in the 60's that was not temporarily
related to sedation and then Levophed was discharged again as
the patient's blood pressure rebounded appropriately. The
patient was also seen by Physical Therapy at this time who
suggested it would require one to three more weeks to
progress strengthening and to weaning from vent.
On hospital day No. 17, [**2110-10-18**], the patient
required two more units of packed red blood cells for a
hematocrit of 22.9, with a plan to obtain abdominal CAT scan
if this hematocrit continued to drop. Lopressor and
Clonidine were increased at this time and blood pressure
decreased down to the 80s around 10 p.m. that evening.
Antibiotics were changed to a Linezolid from Vancomycin due
to Methicillin-Resistant Staphylococcus Aureus in sputum.
On [**2110-10-19**], the patient was given Lasix 20 mg twice
a day. The patient was unable to be kept negative in terms
of inputs and outputs due to episodes of hypotension. The
patient was still not able to be weaned off the endotracheal
tube at this time and then on [**2110-10-20**], the patient
was continued on diuresis as tolerated with a plan for
possible tracheostomy at this time. At this time the staff
was still waiting for daughter's consent for the tracheostomy
and another family meeting was brought about. The Social
Work Team's, Patient Relations and Ethics Committee were
notified. Levaquin was also stopped at this time. The
patient was also more hypertensive and the evening dose of
Lasix was held and the patient received a small fluid bolus.
It was felt determined to be wise to let this patient attempt
autodiuresis at his own pace for a period of time.
On hospital day No. 21, [**2110-10-22**], Levofloxacin was
restarted for Pen sensitive Klebsiella grown out of sputum.
Consent was now obtained for tracheostomy and percutaneous
endoscopic gastrostomy. Tube feeds were held appropriately at
midnight.
On [**2110-10-23**], the patient received percutaneous
tracheostomy and this was placed without difficulty and under
direct visualization with the endoscope, they were able to
using appropriate wire technique. A G-tube was placed. The
patient tolerated the procedure well. A chest x-ray was
obtained. The patient was noted to have a bout of
hypotension at 80/50 and the patient received bolus of Neo-
Synephrine to which he responded well.
On hospital day No. 23, [**2110-10-24**], physical therapy
and occupational therapy continued to work with the patient.
The patient was noted to need spinal rehab placement once he
was weaned to the tracheal mask and was assessed for pap
smear of valve when appropriate. The patient continued to be
evaluated by physical therapy and occupational therapy at
this time who suggested the patient would likely need a
significant rehabilitation stint before being able to return
to a home setting and on [**2110-10-25**], hospital day 24,
the patient's central line was removed and the patient was
placed on all oral medications. Pressor support was
gradually weaned and sputum gram stain at this time showed no
organisms. Arterial line was also discharged at this time.
The patient was continued on Levofloxacin and Linezolid.
On hospital day 25, [**2110-10-26**], the patient was given
Lasix once and was received Impact at 75 cc which was his
goal rate. He was continued on Fentanyl patch and Haldol prn
and morphine as needed. On [**2110-10-27**], the patient was
noted to have desaturations to 80 percent with tachycardia at
120 and blood pressure to 200/100. The patient was noted to
be unresponsive with rhythmic facial eye movements and
decreased breath sounds at the bases. Saturations were noted
to improve with ventilation. The patient received Ativan.
The patient then became responsive after 5 minutes with
oxygen saturations to 100 percent, heart rate to 60 and
systolic blood pressure to 150's. The patient was noted to
also still have large amounts of secretions at this time from
his tracheostomy but they were noted to be easily
expectorated. The patient continued to receive Lasix for
gentle diuresis after that was added as the patient still had
mild wheezes and on Albuterol. The patient also received a
bedside swallow and pap smear of valve of valve evaluation at
this time. The patient tolerated this well with good oxygen
saturations and no respiratory distress and without excessive
secretion interference. The patient was noted to be in
limited orientation at this time. Detailed instructions were
given to always deflate the cuff prior to placing the valve
and to monitor oxygen saturations and respirations while
valve was in place. The patient was not to sleep with the
valve in place as well.
On hospital day No. 27, [**2110-10-28**], final reads were
obtained of the CAT scan of the patient's head following this
prior episode of diaphoresis and unresponsiveness, and
rhythmic eyelid movement. CAT scan of the head was negative
for any new significant pathology. EEG studies showed no
seizure activity. The patient had to receive fluid and Neo-
Synephrine drip basically for hypotensive episode. The
patient was continued on a ventilator. The patient also had
lower extremity non-invasive studies performed that ruled out
deep vein thrombosis.
On hospital day No. 28, [**2110-10-29**], the patient was now
being actually screen for rehabilitation and was started on
Verapamil. Diuresis was continued with Lasix with goal that
the patient be 1 liter negative in terms of input and
outputs. The patient was continued with pressor support at
this time.
On hospital day No. 29, [**2110-10-30**], Infectious
Disease, stated that it would be best to give this patient
Linezolid for 14 days. There were no new cultures over the
last 5 days and on [**2110-10-30**], the patient had CT
angiogram that showed bilateral pulmonary emboli and the
patient was then started on anticoagulation with Lovenox.
On hospital day 31, [**2110-11-1**], the patient continued
to tolerate his pap smear valve well. The patient received
the flue vaccine at this time. The patient was noted to be
continually diuresing well and now noted to be down to his
initial dry weight. The patient was continued on Lovenox at
this time for pulmonary embolus. The pulmonary emboli were
noted to be in the left upper lobe and right lower lobe.
Oxygen saturations continued to be at 100 percent at this
time.
On hospital day No, 32, [**2110-11-2**], MRI/ MRA was
requested by Neurosurgery to look for further possible
thrombus in the cerebral circulation. This was unable to be
done due to inability to inflate the trachea at this time.
This was then changed by respiratory. Coumadin was also
started at this time with goal of anticoagulation. The
patient was also restarted on metoprolol at 25 mg b.i.d and
blood pressure range was still noted to be 130 to 190
systolically over 50 to 90 diastolically.
On hospital day No. 33, [**2110-11-3**], MRI/ MRA had been
attempted again the prior evening without success. The
patient was on 5 mg of Coumadin at this time, taking it once
a day with Lovenox to be taken until the INR was in the
therapeutic range. A chest x-ray was performed the prior day
that revealed atelectasis but no signs of congestive heart
failure. Sputum continued to grow gram positive cocci and
gram negative rods. The patient was still being treated with
Levofloxacin and Linezolid with a goal at this time still to
obtain MRI/ MRA. The patient was now actively screened for
rehabilitation and noted to have received a bed for [**2110-11-4**], and on [**2110-11-3**], in the evening the
patient received his MRI/ MRA that revealed no further
thrombus in the cerebral circulation and on [**2110-11-4**], hospital day No. 34, the patient was noted to be
stable. Vital signs were stable. The patient was on Trach
mask at this time saturating well, using the pap smear valve
and tolerating this well. This was noted to be not
decreasing his oxygen saturations or causing any shortness of
breath. The patient now had a bed available at [**Hospital1 **] in
[**Hospital 1319**] Rehab Hospital.
Throughout this stay the patient was in the Trauma Surgical
Intensive Care Unit and Neurosurgery teams were in good
contact with the patient's family with the daughter acting as
this [**Hospital 228**] healthcare proxy.
On [**2110-11-4**], the patient was discharged to the
rehabilitation facility at this time. He was receiving tube
feeds and was noted to be increasing interactive and was
actively engaging in conversation and was following all
commands. He was sitting up at his bed and in the chair. His
spirits were noted to be improved. The patient was eager to
be discharged to rehabilitation facility.
DISCHARGE DIAGNOSIS: The patient is status post fall likely
due to intoxication. Left orbital medial and inferior wall
fracture, thrombosed right vertebral artery, possible right
vertebral artery dissection, fractures of cervical vertebrae
No. 5 and bilateral lamina fractures, spinous process
fracture of cervical vertebrae No. 5 and right vertebral
foraminal fracture, Klebsiella pneumonia, Methicillin-
Resistant Staphylococcus Aureus pneumonia, urinary tract
infection with Enterococcus, right lower lobe pulmonary
embolus, left upper lobe pulmonary embolus, nasopharyngeal
lymphoma, prostate cancer, mood disorder, alcoholism.
DISCHARGE MEDICATIONS:
1. Verapamil 60 mg po q 8 hours.
2. Warfarin 5 mg po qhs.
3. Lovenox 80 mg subcutaneously q 12 hours.
4. Insulin per sliding scale in fixed dose.
5. Ipratropium bromide meter dose inhaler, 2 puff inhaled qid
prn.
6. Potassium chloride 40 mEq po as needed for potassium less
than 4.
7. Clonidine 0.2 mg po tid.
8. Albuterol one to two puffs inhaled q4 hours.
9. Fentanyl patch 25 ug per hour to be changed q 72 hours.
10. Dulcolax 10 mg pr daily prn.
11. Milk of magnesia 30 ml po q 6 hours prn.
12. Colace 100 mg po b.i.d.
13. Tylenol 325 to 650 mg po/ PR q 4 to 6 hours prn.
14. Potassium phosphate 15 mmol/ 250 ml intravenous as
needed for phosphate less than 3.6 to be infused over 6
hours.
15. Calcium gluconate 2 grams for calcium less than 1.12
as needed.
16. Magnesium sulfate.
DISCHARGE INSTRUCTIONS: The patient to follow up with Trauma
clinic in 2 weeks and for appointment to be scheduled. The
patient to follow up with Neurosurgery and Neurology.
Further follow up plans to be detailed in an addendum to this
discharge summary.
DISPOSITION: The patient to be discharged to rehabilitation
facility, [**Hospital3 7**], at this time on [**2110-11-4**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16263**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2110-11-3**] 21:01:33
T: [**2110-11-4**] 00:45:36
Job#: [**Job Number 93810**]
Admission Date: [**2110-10-2**] Discharge Date: [**2110-11-5**]
Service: TRA
HOSPITAL COURSE ADDENDUM: This is an addendum to the prior
hospital course dictated on [**2110-11-3**]. The patient
was not discharged, according to that prior discharge summary
on [**2110-11-4**], but was rather discharged on [**2110-11-5**]. There were no new significant events during this
interval. Of note, in the prior discharge summary it stated
that the patient received an MRA/MRI on the evening of
[**2110-11-3**]. This did not end up occurring. After
much discussion, it was determined that it would not be in
the best interest of the patient's safety, and that the
benefits of obtaining this study would not outweigh the
risks, and thus it was not pursued at this time. The patient
was stable on the day of discharge, was afebrile, was
receiving tube feeds at this time and sips of clear liquids,
and the patient was due to be discharged to [**Hospital3 6373**] facility.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg-650 mg po q 4-6 h to be put down the
tube.
2. Colace 150 mg/15 ml, to receive 10 ml po bid.
3. Milk of Magnesia 30 ml q 6 h prn.
4. Dulcolax 10 mg per rectal once daily.
5. Albuterol 1-2 puffs q 4 h, 90 mcg per actuation
aerosolization.
6. Clonidine 0.2 mg po tid.
7. Ipratropium bromide 18 mcg per actuation 2 puffs qid prn.
8. Warfarin 1 mg tablets, to start off taking 5 mg a night
with goal INR of [**12-23**].5 for anticoagulation for pulmonary
emboli.
9. Regular insulin sliding scale as directed. This will be
included in the discharge packet.
10.Verapamil 80 mg po q 8 h.
11.Lasix 20 mg po once daily prn to keep inputs and outputs
even. Only give if needed.
12.Patient to receive tube feeds of Promote with fiber at
full-strength with a rate of 75 ml/h, this being the goal
rate. Hold feeding for residuals of greater than 200 ml,
which are to be checked q 4 h, and flush q 4 h with 100 ml of
water. The patient can have sips of clears and clear liquids
as tolerated.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16263**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2110-11-5**] 11:30:03
T: [**2110-11-5**] 11:54:10
Job#: [**Job Number 93811**]
Unit No: [**Unit Number 93812**]
Admission Date: [**2110-10-12**]
Discharge Date: [**2110-11-13**]
Sex: M
Service:
ADDENDUM: This is an addendum to the prior hospital course,
dictated on [**2110-11-5**]. The patient was not
discharged on the 15th according to plan. Instead, he was
transferred from the Trauma Surgical Intensive Care Unit to
the surgical [**Hospital1 **] on [**2110-11-6**] to continue to evaluate the
patient for tachycardia. He was started on Levofloxacin for
pneumonia on [**2110-11-6**]. He spiked a temperature to 101.4 on
[**2110-11-7**] and a chest x-ray at that time showed a stable left
lower lobe opacity with a worsening right lower lobe opacity.
Sputum cultures from that time were growing out Klebsiella
and Staph aureus. The patient was started on Vancomycin on
[**2110-11-7**] in addition to his Levofloxacin. The patient again
spiked a fever on [**2110-11-9**] to a temperature of 101.0. Repeat
sputum cultures were sent and repeat chest x-ray showed no
change. He was continued on Levofloxacin and Vancomycin and
his white blood cell count at that time was 14.3. On
[**2110-11-10**], the patient remained afebrile and his white blood
cell count came down but he had an episode of respiratory
distress from large amounts of secretions in his trache. He
was transferred at that time from the surgical [**Hospital1 **] to the
neurologic step-down unit. The patient had a repeat swallow
study on [**2110-11-12**], which he did not pass and so he was placed
on aspiration precautions and made n.p.o.
On [**2110-11-11**], the patient remained afebrile and his heart rate
and blood pressure were better controlled. His trache tube
was changed on that same day. On [**2110-11-13**], he remained
afebrile. Vital signs were stable and white count was 13.4.
At this point, he was deemed stable enough to be transferred
to a high care long term facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. (INT)
Dictated By:[**Last Name (NamePattern4) 6394**]
MEDQUIST36
D: [**2110-11-13**] 10:32:41
T: [**2110-11-13**] 10:49:21
Job#: [**Job Number 93813**]
|
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icd9cm
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2013, 22468
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23987, 25595
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877, 1995
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617, 854
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,885
| 111,068
|
24073
|
Discharge summary
|
report
|
Admission Date: [**2192-2-9**] Discharge Date: [**2192-2-24**]
Date of Birth: [**2142-7-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
from OSH for workup of pancreatic mass
Major Surgical or Invasive Procedure:
Whipple
History of Present Illness:
The patient is a 49 yo M who is being transferred from [**Hospital1 1474**]
for further workup of a pancreatic mass. He originally
presented to his PCP for [**Name Initial (PRE) **] 1 week h/o fatigue, nausea, and a
12lb weight loss over a one week period. He further reports
intermittent RUQ abdominal pain over the past week. Decreased
PO intake over this time frame. He denied fevers, chills,
vomiting, diarrhea, or observed skin changes.
On admission to the OSH, AP 726, AST 303, ALT 122, TB 6.3, DB
2.5, Alb 3.2, INR 1.2, triglycerides [**2186**]. A RUQ U/S was
performed which showed a slightly increased common bile duct
diameter, but was otherwise unremarkable. An MRCP was then
performed which showed a suspicious lesion at the head of the
pancreas which is concerning for pancreatic carcinoma. A
decision was made to tranfer the patient to a tertiary care
center. During his stay at the OSH, he was started on bactrim
for an asymptomatic UTI. A flu shot and pneumovax were given at
the OSH.
Patient was subsequently transferred to the [**Hospital1 18**] for further
work-up and treatment.
Past Medical History:
PMH:
MI,
HTN,
35 pack-year smoker
PSH:
R CEA ([**7-18**]),
knee scope,
?SFA angioplasty
Social History:
The patient lives in [**Location 1475**] in an apartment with his wife
and 1 [**Name2 (NI) **] daugther. no other children. Drinks 4-5 beers per day
until 1 week priorago. Per OSH records patient has drank more
heavily in the past. He smoked 2 ppd x 40 years, he quit 1
month ago. Grew up on a farm.
Family History:
Father with liver cirrhosis from ETOH use
Physical Exam:
VS - 98.7 108/60 80 16 100%RA
General - lying in bed, pleasant caucasion male, jaundiced
HEENT - PERRL, EOMI, icteric
Neck - supple, no JVP
CV - RRR, 2/6 systolic murmur best heard at LUSB
Chest - good air sounds b/l; minimal scattered wheezes
throughout
Abd - soft, NT/ND, no caput, no hepatosplenomegaly, large healed
midline scar
Ext - no edema; + clubbing of fingers bilaterally
Skin - jaundiced
Pertinent Results:
Imaging:
[**2192-2-9**] U/S (at OSH) - findings suggests fatty infiltration of
the liver. small granuloma within the spleen. pancreas not
well seen due to bowel gas. common bile duct normal (5mm).
[**2192-2-9**] MRCP (at OSH) - no evidence of gallstones, borderline
dilatation of common bile duct and mild dilatation of the
pancreatic dict without ductal stones seen. abnormal
heterogeneous enhancing infiltrative changes are seen in the
enlarged pancreatic head and uncinate process. these changes
could represent pancreatic carcinoma, but differentiation from
changes due to chronic pancreatitis is difficult.
Labs (OSH):
Admission to OSH --> AP 726, AST 303, ALT 122, TB 6.3, DB 2.5,
Alb 3.2, INR 1.2.
[**2192-2-10**] CT-A:
1. Findings most consistent with pancreatic carcinoma. There
is no biliary
or pancreatic duct dilatation. There is an accessory right
hepatic artery
which is encased by tumor. The main right hepatic artery and
left hepatic
arteries are normal as are the proper and common hepatic
arteries.
2. No evidence of distant metastases.
3. Diffuse atherosclerosis. Aortobifemoral bypass graft is
patent. There is
marked mural thrombus present within the proximal SMA, but the
distal SMA is
patent.
[**2192-2-13**] P-MIBI:
1. Normal myocardial perfusion. 2. Normal left ventricular
cavity
size and function. 3. LVEF of 71%.
No anginal symptoms or ischemic ST segment changes.
[**2192-2-10**] 05:10AM BLOOD WBC-6.4 RBC-3.24* Hgb-10.7* Hct-30.6*
MCV-95# MCH-32.9* MCHC-34.8 RDW-17.1* Plt Ct-104*
[**2192-2-16**] 04:32PM BLOOD WBC-11.8* RBC-3.42* Hgb-10.7* Hct-31.3*
MCV-92 MCH-31.2 MCHC-34.0 RDW-19.5* Plt Ct-343
[**2192-2-19**] 02:36AM BLOOD WBC-16.9* RBC-2.78* Hgb-8.6* Hct-25.6*
MCV-92 MCH-31.0 MCHC-33.6 RDW-17.8* Plt Ct-439
[**2192-2-22**] 05:04AM BLOOD WBC-10.7 RBC-3.08* Hgb-10.0* Hct-27.9*
MCV-91 MCH-32.3* MCHC-35.7* RDW-17.2* Plt Ct-556*
[**2192-2-18**] 04:21AM BLOOD Neuts-85.0* Lymphs-9.8* Monos-4.1 Eos-0.8
Baso-0.2
[**2192-2-10**] 05:10AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0
[**2192-2-18**] 04:21AM BLOOD PT-15.2* PTT-29.7 INR(PT)-1.4*
[**2192-2-21**] 02:46AM BLOOD PT-14.0* PTT-26.6 INR(PT)-1.2*
[**2192-2-10**] 05:10AM BLOOD Glucose-105 UreaN-4* Creat-0.7 Na-134
K-3.3 Cl-103 HCO3-24 AnGap-10
[**2192-2-17**] 03:48AM BLOOD Glucose-110* UreaN-5* Creat-0.6 Na-134
K-4.1 Cl-103 HCO3-24 AnGap-11
[**2192-2-20**] 03:01AM BLOOD Glucose-100 UreaN-6 Creat-0.5 Na-136
K-3.8 Cl-98 HCO3-30 AnGap-12
[**2192-2-24**] 04:43AM BLOOD Glucose-120* UreaN-6 Creat-0.4* Na-135
K-3.4 Cl-105 HCO3-22 AnGap-11
[**2192-2-10**] 05:10AM BLOOD ALT-61* AST-108* LD(LDH)-147 AlkPhos-507*
TotBili-2.9*
[**2192-2-14**] 06:20AM BLOOD ALT-21 AST-35 AlkPhos-280* TotBili-1.1
[**2192-2-17**] 11:42AM BLOOD Lipase-20
[**2192-2-10**] 05:10AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7
[**2192-2-16**] 06:18AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8
[**2192-2-24**] 04:43AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.8
[**2192-2-12**] 08:00AM BLOOD calTIBC-199* Ferritn-573* TRF-153*
[**2192-2-18**] 12:25PM BLOOD Cortsol-13.9
[**2192-2-18**] 02:04PM BLOOD Cortsol-20.0
[**2192-2-10**] 05:10AM BLOOD CA [**05**]-9 -Test
[**2192-2-10**] 09:22AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-12* pH-8.0 Leuks-NEG
[**2192-2-10**] 09:22AM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.010
[**2192-2-10**] 09:22AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**Known lastname **],[**Known firstname **] [**2142-7-7**] 49 Male [**Numeric Identifier 61225**]
[**Numeric Identifier 61226**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: GALLBLADDER, WHIPPLE SPECIMEN.
Procedure date Tissue received Report Date Diagnosed
by
[**2192-2-16**] [**2192-2-16**] [**2192-2-21**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma??????
Previous biopsies: [**-5/2637**] CAROTID PLAQUE
DIAGNOSIS
I. Gallbladder: Chronic cholecystitis.
II. Pancreaticoduodenectomy, partial pancreatectomy:
1. Multiple foci of fat necrosis primarily involving
peripancreatic adipose tissue.
2. Unremarkable duodenum, common bile duct, and pancreas.
3. Two reactive lymph nodes.
Brief Hospital Course:
The pt. presented from an outside hospital for further workup of
a newly-diagnosed pancreatic mass. A CT-A scan done here at the
[**Hospital1 18**] identified a low density mass at the uncinate process;
accessory R hepatic artery was encased by tumor but no evidence
for distant mets. Surgery was consulted, and an ERCP, which had
been pending, was postponed to proceed with the Whipple
procedure without a formal tissue diagnosis. As part of the
pre-op workup, the pt. had a normal P-MIBI on [**2-13**] and nl CXR
and U/A. Treatment of the pt's coronary artery disease was
continued with aspirin and metoprolol while the pt. was in the
hospital.
.
In addition to the pancreatic mass, the pt. also presented with
a transaminitis. pt's liver enzyme levels trended down lower
each day and normalized before his surgery.
.
While here, the pt. spiked a fever to 102.5. Because of concern
for cholangitis/sepsis, the pt. was started on ampicillin,
levofloxacin, and metronidazole. Urine and blood cultures were
negative, and antibiotics were discontinued after 3 days.
.
The pt. also presented with a normocytic anemia. Iron studies
most consistent with anemia of chronic inflammation: Fe low
normal, decreased TIBC, increased ferritin. Because the pt's
hematocrit drifted lower while in the hospital, he was
transfused with 2 units PRBCs the day before surgery, which he
tolerated without incident.
.
Although the pt. had a history of high alcohol intake, he did
not require the CIWA scale while in the hospital. As
prophylaxis, he was given thiamine and folate during his stay in
the hospital.
.
Patient was taken to the OR on [**2-16**] for a pylorus
sparing pancreaticoduodenectomy (for more operative details see
dictated operative report). Patient tolerated the procedure well
and was transferred to the PACU extubated. Post-operatively,
patient became hypotensive and febrile to 103. Epidural was
stopped and patient was transitioned to a PCA for pain control.
He was aggressively fluid resuscitated. Neosynephrine drip was
started for BP control. On POD 1 patient was weaned off of
neosynephrine and blood pressures stabilized in 90-100 range. He
continued to spike fevers. On the evening of POD 2 patient
developed increased work of breathing and de saturations into
80's. On exam, wet crackles were appreciated. CVP was [**6-21**]
range. Lasix was administered with good diuresis. CXR was
obtained and showed bilateral lower lobe processes concerning
for aspiration pneumonia vs. ARDS and pulmonary congestion,
pulmonary edema. EKGs were normal. ABG was 7.32/55/73/31/1.
During the next several days his pulmonary status and blood
pressures stabilized and started to improve. All urine and blood
cultures were without growth. Cortisol stimulation test was
normal. Aggressive pulmonary toilet was continued as patient
required frequent suctioning for excessive mucus production.
On POD 6 patient was transferred to a regular floor. He
continued to be stable. His diet was advanced without
complications. He was continued on Protonix and Reglan.
He was discharged home in good condition with JP drain in place
and instructions for follow-up with Dr. [**Last Name (STitle) 468**] in clinic.
Medications on Admission:
Medications at OSH:
ASA 81mg
Thiamine
Folate
Bactrim
Medications at Home:
ASA
Diovan
Darvan
Atenolol
Lipitor (recently stopped)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
Disp:*1 tube* Refills:*2*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Head of pancreas mass
Discharge Condition:
good
Discharge Instructions:
please seek meical attention if you experience fever > 101.5,
severe nausea, vomitting, or pain, or a very large increase in
drain output
please take all meds as prescribed
please care for your JP and change the dressing as shown by your
nurses
Followup Instructions:
please follow up with [**Doctor Last Name 468**] ([**Telephone/Fax (1) 2835**]) in 1 week to have
staples removed.
Completed by:[**2192-2-24**]
|
[
"412",
"496",
"280.9",
"576.2",
"305.00",
"276.8",
"V17.3",
"577.1",
"575.11",
"783.21",
"401.9",
"V12.59",
"511.9",
"458.29",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"45.13",
"99.04",
"52.7",
"51.22",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
11118, 11124
|
6733, 9944
|
350, 359
|
11190, 11197
|
2431, 6710
|
11492, 11638
|
1951, 1995
|
10124, 11095
|
11145, 11169
|
9970, 10024
|
11221, 11469
|
10045, 10101
|
2010, 2412
|
272, 312
|
387, 1497
|
1520, 1613
|
1629, 1935
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,720
| 193,253
|
52206
|
Discharge summary
|
report
|
Admission Date: [**2101-2-14**] Discharge Date: [**2101-2-19**]
Date of Birth: [**2028-6-4**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Niacin / Tape
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
taxus stent > ISR of the SVG > RCA
EGD
Blood transfusion
Colonoscopy
History of Present Illness:
72 M with h/o CAD s/p CABG, HTN, high cholesterol who reports
about 5 weeks of worsening angina with exercise and rest.
Normally he is able to walk 2.5miles 3 times a week but has been
unable to do this for the past 3 weeks. The CP occurrs 2-3 times
a day and many times at night over the past 2 weeks. He has been
SOB wiht basic activities like picking up clothing. He also c/o
PND.
.
ROS: As above. No claudication, edema, lightheadedness,
abdominal pain, or black or bloody stools.
Past Medical History:
1. CAD:
--s/p CABG '[**77**] with LIMA-D1, SVG-PDA, SVG-OM with re-do CABG in
[**2092**] with SVG-PDA and SVG-OM. His last cardiac catheterization
was on [**2100-9-6**] that revealed 40% LM, total occlusion of LAD,
RCA, and LCX. Patent LIMA-D1, TO SVG-OM, and 90% mid stenosis
of SVG-RCA that was stented with Cypher 3.5x18mm.
2. CHF, ischemic systolic failure with diastolic relaxation
dysfxn; EF 35% with inferolateral, distal septal HK with apical
AK. 1+MR. [**First Name (Titles) 213**] [**Last Name (Titles) **].
3. HTN
4. Hypercholesterolemia
5. s/p PPM for sick sinus syndrome
6. Hemorrhoids
7. Diverticulosis
8. Chronic Low Back Pain
9. Sicca syndrome
10. Pulmonary embolus (age 31) - was driving long distance
11. Atrial fibrillation
Social History:
SOCIAL HX:
-Married, lives with wife
-quit [**Name (NI) **] 40+ years ago
-Drinks glass of wine with dinner
-no other drug use
-Pt is vegetarian but eats fish.
Family History:
M: MI, CVA, Maternal uncles w/ CAD and MIs in 40s-50s
F: CVA
no known cancer history in family
Physical Exam:
temp 99.3, bp 100/55, hr 70, rr12, spo2 100% ra
I/O: 3000/1150 x16h
gen: well
heent: conjuctiva pink, eomi, perrla
cv: s1/s2, rrr, no m/r/g appreciated. carotids brisk upstroke,
jvp 6cm
lungs: ctab
abd: mild LLQ discomfort, soft, no rebound, no HSM
ext: no edema, dp 2+, warm and dry
neuro: a&ox3, MAE
Pertinent Results:
[**2101-2-14**] 10:05PM POTASSIUM-3.9
[**2101-2-14**] 10:05PM CK(CPK)-28*
[**2101-2-14**] 10:05PM CK-MB-NotDone
[**2101-2-14**] 10:05PM PLT COUNT-191
[**2101-2-14**] 04:18PM PLT COUNT-202
[**2101-2-14**] 11:55AM CK(CPK)-35*
[**2101-2-14**] 11:55AM CK-MB-NotDone cTropnT-<0.01
[**2101-2-14**] 10:10AM INR(PT)-1.2*
.
Cardiology Report C.CATH Study Date of [**2101-2-14**]
*** Not Signed Out ***
BRIEF HISTORY: 72 year old male with multiple CAD history
referred for
cardiac catheterization in the setting of worsening chest pain
at night.
He had CABG in [**2077**] with LIMA-D1, SVG-PDA, SVG-OM with re-do
CABG in
[**2092**] with SVG-PDA and SVG-OM. His last cardiac catheterization
was on
[**2100-9-6**] that revealed 40% LM, total occlusion of LAD, RCA, and
LCX.
Patent LIMA-D1, TO SVG-OM, and 90% mid stenosis of SVG-RCA that
was
stented with Cypher 3.5x18mm.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class II, stable.
Prior CABG
[**2077**] & [**2092**]. Prior PTCA [**2100-9-6**].
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French angled pigtail catheter,
advanced
to the left ventricle through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 catheter, with manual contrast
injections.
Graft Angiography: of 2 saphenous vein bypass grafts was
performed using
a 6 French right [**Last Name (un) 2699**] catheter, with manual contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
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
AORTA {s/d/m} 121/65/88
**CARDIAC OUTPUT
HEART RATE {beats/min} 61
RHYTHM SINUS
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 100
12) PROXIMAL CX NORMAL
13) MID CX DISCRETE 50
13A) DISTAL CX DIFFUSELY DISEASED
14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED
15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED
16) OBTUSE MARGINAL-3 DIFFUSELY DISEASED
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 2 DISCRETE 100
**PTCA RESULTS
SVBG
**BASELINE
STENOSIS PRE-PTCA 100
COLLATERAL GRADE (0-2) 0
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH 6F MP
GUIDEWIRES CHOICE P
INITIAL BALLOON (mm) 3.5
FINAL BALLOON (mm) 4.0
# INFLATIONS 2
MAX PRESSURE (PSI) 360
**RESULT
STENOSIS POST-PTCA 0
DISSECTION (0-4) 0
SUCCESS? (Y/N) Y
PTCA COMMENTS: Initial angiography showed a totally occluded
SVG-RCA. We planned to recanalize the graft. Eptifibatide was
given
prophylactically. A 6 French MP guide provided good support. The
lesion
was crossed with a Choice PT wire and a distal injection showed
in-stent
restenosis with minimal thrombus. The wire was then exchanged
for a
GuardWire which was inflated in the distal graft. Next, a 3.5x24
mm
Taxus DES was deployed at 18 atm. and post-dilated with a 4.0x13
mm
Powersail balloon at 24 atm. Final angiography showed no
residual
stenosis, no dissection and TIMI 3 flow. The patient left the
lab in
stable condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour52 minutes.
Arterial time = 0 hour52 minutes.
Fluoro time = 14 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 100
ml, Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 3500 units IV
Other medication:
Fentanyl 50mcg
Adenosine 6000mcg IC
Integrillin 13.6cc bolus
Integrillin 12cc/hr gtt
TNG 0.2mg SL
Plavix 600mg
Midazolam 0.5mg
Cardiac Cath Supplies Used:
- [**Company **], CHOICE PT [**Name (NI) **], 182CM
4 GUIDANT, POWERSAIL, 13
- CORDIS, MPA 1 SH (90CM)
- [**Company **], ULTRAFUSE X
150CC MALLINCRODT, OPTIRAY 150CC
- [**Company **], GUARD WIRE PLUS OTW
- [**Company **], TAXUS EXPRESS 2 OTW, 08
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
native three vessel disease. The LMCA had mild disease. The LAD
and RCA
were chronically occluded. The LCX had mid 50% stenosis, giving
collaterals to occluded RCA and OM.
2. Selective vein graft angiography demonstrated occluded mid
SVG-RCA.
The SVG-OM was not engaged due to known chronic occlusion.
3. The LIMA to LAD was not engaged.
4. Successful stenting of the SVG-RCA with a 3.5 mm Taxus
drug-eluting
stent, which was post-dilated to 4.0 mm.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Chronic occlusion of SVG-OM. Mid occlusion fo SVG-RCA.
3. Successful stenting of the SVG-RCA.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **]
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] J.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2101-2-15**] 7:38 PM
CHEST (PORTABLE AP)
Reason: pulm edema? admitting MICU CXR.
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with GIB and CHF
REASON FOR THIS EXAMINATION:
pulm edema? admitting MICU CXR.
INDICATION: 72-year-old with GI bleed and CHF, admission chest
x-ray, question pulmonary edema.
SINGLE AP UPRIGHT PORTABLE CHEST: Compared to [**2094-4-20**],
right-sided pacer is seen with its leads unchanged in position.
Median sternotomy wires intact. Heart size is within normal
limits. The lungs are clear, without evidence of pneumonia or
congestive heart failure.
IMPRESSION: No evidence of congestive heart failure.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: TUE [**2101-2-15**] 10:31 PM
.
Cardiology Report ECHO Study Date of [**2101-2-15**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. S/p taxus stent ? ICD
placement
Height: (in) 68
Weight (lb): 165
BSA (m2): 1.89 m2
BP (mm Hg): 103/49
HR (bpm): 94
Status: Inpatient
Date/Time: [**2101-2-15**] at 13:40
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W021-0:00
Test Location: West [**Hospital Ward Name 121**] [**12-17**]
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.4 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.7 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.67
Mitral Valve - E Wave Deceleration Time: 176 msec
TR Gradient (+ RA = PASP): *28 to 29 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.9 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
This study was compared to the report of the prior study (images
not
available) of [**2097-9-13**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire
is seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall
normal LVEF (>55%).
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
hypo; basal inferior - hypo; mid inferior - hypo; basal
inferolateral - hypo;
mid inferolateral - akinetic; anterior apex - hypo; septal apex
- hypo;
inferior apex - hypo; lateral apex - akinetic;
RIGHT VENTRICLE: RV not well seen. Normal RV chamber size.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate
[[**11-15**]+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Resting
regional wall motion abnormalities include inferior and
inferolateral hypokinesis and distal septal and apical
hypokinesis. The anterior wall is not well visualized but
appears hypokinetic distally. Estimated left ventricular
ejection fraction ~35%?. Right ventricular chamber size is
normal. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the report of
the prior study (images unavailable for review) of [**2097-9-13**],
left ventricular systolic function may be similar to slightly
improved.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2101-2-15**] 15:13.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
.
EGD Wednesday, [**2101-2-16**]:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
Conscious sedation anesthesia. The patient was placed in the
left lateral decubitus position and an endoscope was introduced
through the mouth and advanced under direct visualization until
the second part of the duodenum was reached. Careful
visualization of the upper GI tract was performed. The procedure
was not difficult. The patient tolerated the procedure well.
There were no complications.
Findings: Esophagus: Normal esophagus.
Stomach: Contents: Scant clotted blood was seen in the fundus.
No active bleeding. Mucosa: Diffuse continuous erythema and
congestion of the mucosa with no bleeding were noted in the
antrum. These findings are compatible with mild gastritis.
Excavated Lesions A few non-bleeding erosions were noted in the
antrum and fundus.
Duodenum: Mucosa: Localized continuous erythema and congestion
of the mucosa with no bleeding were noted in the duodenal bulb
compatible with mild duodenitis.
Impression: Blood in the fundus Erythema and congestion in the
duodenal bulb compatible with mild duodenitis Erosions in the
antrum and fundus
Erythema and congestion in the antrum compatible with mild
gastritis
Recommendations: Protonix 40 mg Twice daily
Serial hematocrits.
Prep for colonoscopy with 4L golytely for colonoscopy tomorrow.
Additional notes: The attending physician was present during the
entire procedure.
.
Colonoscopy Report [**Hospital1 **]
[**Hospital Ward Name 517**]
Small hemorrhoids small polyp at 67 cm Diverticulosis
Diverticulosis
Date: [**Last Name (LF) 2974**], [**2101-2-18**] Endoscopist(s): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**], MD
[**First Name (Titles) **] [**Last Name (Titles) 9890**], MD (fellow)
Patient: [**Known firstname 3075**] [**Known lastname **]
Ref. Phys.:
Birth Date: [**2028-6-4**] (72 years) Instrument: PCF 160AL
ID#: [**Numeric Identifier 108003**]
Medications: Midazolam 1.5mg
Fentanyl 75 micrograms
Indications: GI Bleeding
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
conscious sedation. The patient was placed in the left lateral
decubitus position and the colonoscope was introduced through
the rectum and advanced under direct visualization until the
cecum was reached and the ileo-cecal valve was identified.
Careful visualization of the colon was performed as the
colonoscope was withdrawn. The colonoscope was retroflexed
within the rectum. The procedure was not difficult. The quality
of the preparation was poor. Visualization of the cecum and some
parts of colon was poor. The patient tolerated the procedure
well. The digital exam was normal. There were no complications.
Limitations: Poor preparation when the cecum and other parts of
colon were reached.
Findings:
Contents: Stool was found in the throughout colon.
Protruding Lesions A single sessile 4 mm non-bleeding polyp of
benign appearance was found in the proximal transverse at 67cm.
Small non-bleeding grade 1 internal hemorrhoids were noted.
Excavated Lesions Multiple non-bleeding diverticula with mixed
openings were seen in the sigmoid and descending
colon.Diverticulosis appeared to be severe.
Impression: Diverticulosis of the sigmoid and descending colon
Polyp at 67cm in the proximal transverse
Stool in the throughout colon
Grade 1 internal hemorrhoids
No active bleeding, small avms could have been missed. Bleeding
may have been secondary to diverticulosis which has now
resolved.
Recommendations: Colonoscopy in 1 year, for resection of polyp
which was not removed since patient is on aspirin and plavix.
History: 72 year old male with CAD s/p cath and stent placement,
GIB in setting of anticoagulation (ASA, Plavix, Heparin and
Integrillin)
Additional notes: The attending physician was present for entire
procedure.
_________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**], MD
_________________________________
[**Name6 (MD) **] [**Name8 (MD) 9890**], MD (fellow) Case documented on
[**2101-2-18**] 2:26:46 PM
Patient: [**Known firstname 3075**] [**Known lastname **] ([**Numeric Identifier 108003**])
Brief Hospital Course:
1. CAD: At cardiac cath he was found to have a 100% stenosis in
SVG-RCA graft. Underwent thrombectomy with protection device
then [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] stent. Received integrillin x18h and loaded with
plavix 600mg. Initially restarted on coumadin and continued on
aspirin 325mg. Peri-procedure also received 40mg po prednisone
x2 doses. Had another episode of his usual angina after transfer
to the floor with nonspecific ECG changes and no change in CE.
Briefly on NTG gtt but then gtt d/c'd with no return of CP.
Pacemaker rate adjusted (decreased to 70) given thought that
this could be contributing.
.
2. GIB: In the evening after his cath, he felt felt dizzy when
standing, and the next morning large dark bloody stools with
large clots. Hct drop from 37.5 to 26. got 1 unit and continued
to drop to 24 but remained HD stable. 1 liter NG lavage no blood
but no bile back. BP stable with good urine output. Had prior
colonoscopy [**1-15**] yrs ago showing diverticulosis and no polyps.
Never had bloody stools for years. Prior attributed to
hemorrhoids which ceased after banding. No hematemesis. Left
lower quad discomfort mild. No appetite. No nausea. No recent
change in stools. No weight loss or low grade temps.
Transferred to MICU for overnight observation, then back to
floor after EGD and stable hcts. Started on protonix [**Hospital1 **],
continued ASA/plavix but stopped coumadin. Seen by GI with EGD
(mild gastritits/duodenitis, some erosions, no active bleeding
but blood in fundus) and colonoscopy (no active bleeding, small
avms could have been missed. Bleeding may have been secondary to
diverticulosis which has now resolved).
.
3. CHF: mixed systolic and diastolic heart failure. ischemic in
origin. Improvement in LVEF possibly from recent
revascularization. Restarted BB once hct stable and for episode
of CP.
.
4. Rhythm: sick sinus s/p PPM; seen by EP for 5-beat run of VT
and now 100% A-paced. A lead sensing threshold very high. Needs
new A lead but needs ICD anyway and wil likely get for EF<35%
with CAD and NSVT. Underlying paroxysmal atrial fibrillation.
Coumadin and BB held.
.
5. HTN - Held BP meds given GIB, then restarted imdur and BB. Pt
had transient low BP day meds restarted; suspect combination of
medications, low hct and NTG gtt. Asymptomatic. Per wife, SBP at
home often low 90s. Pt reports that imdur (120mg QD) is a new
medication change. D/c'd on imdur 60mg QD.
.
6. PE - distant past. Had been on coumadin, held for cath and
then for GIB.
.
Communication: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Known lastname **],wife (phone: [**Telephone/Fax (1) 108004**])
Medications on Admission:
ALL:
niacin (rash)
Dye (hives)
no shellfish allergy
.
coumadin 7.5mg M/F/F, 5mg Tu/Th/Sa/[**Doctor First Name **]
plavix 75mg PO QD
ASA 325mg PO QD
Lipitor 10mg PO QD
Captopril 6.25mg PO BID
Coreg 6.25mg PO QAM, 3.125mg PO QPM
Imdur 120mg PO QD
Zantac 150mg PO QD
MVI
Coenzyme Q 100mg PO QD
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).
Disp:*30 Tablet(s)* Refills:*9*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*3*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO as directed:
take 1 tab in the morning, and [**11-15**] tab at night.
Disp:*60 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
CAD
ischemic CMP
HTN
dyslipidemia
GI bleed
Discharge Condition:
Good
Discharge Instructions:
Activity and wound care as per post angioplasty instructions.
Continue all current medications, including uninterrpted plavix
for a minimum of 6 months due to taxus stents.
Stop taking coumadin.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1500 cc per day
Of note, your imdur dose was lowered to 60mg per day. Also, you
were started on lisinopril. You should discuss your medications
with Dr. [**Last Name (STitle) **] in 1 week.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] for a follow-up appointment next week. His phone
number is [**Telephone/Fax (1) 10012**]. You will need a repeat echocardiogram in
approximately 8 weeks; he will arrange this.
You will need a repeat colonoscopy in 1 year.
|
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"272.4",
"428.40",
"996.72",
"424.0",
"401.9",
"211.3",
"427.1"
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icd9cm
|
[
[
[]
]
] |
[
"00.66",
"36.07",
"00.45",
"88.56",
"45.23",
"37.22",
"99.04",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
21240, 21246
|
17130, 19807
|
311, 382
|
21333, 21340
|
2293, 3180
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21893, 22155
|
1859, 1956
|
20149, 21217
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7851, 7884
|
21267, 21312
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19833, 20126
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7212, 7814
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21364, 21870
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8768, 12458
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1971, 2274
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5746, 7195
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3213, 5727
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261, 273
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7913, 8742
|
410, 896
|
12490, 17107
|
918, 1665
|
1681, 1843
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,621
| 130,819
|
41279
|
Discharge summary
|
report
|
Admission Date: [**2177-4-15**] Discharge Date: [**2177-4-18**]
Date of Birth: [**2113-12-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
Tracheal Intubation
History of Present Illness:
Mr [**Known lastname **] is a 63 yo M w/ h/o COPD, CAD MI [**58**] s/p cabg '[**66**]
admitted [**2177-4-15**] sof SOB x1 month after found to have an O2 sat
in the 70's at his PCP's office. Patient reports that 1-2 years
ago he stopped taking all of his inhaler medications and that he
had been fine from a COPD perspective. He denies having any
fevers, chills, PND or orthopnea prior to seeing his PCP. [**Name10 (NameIs) **]
his PCP's office her was sent to the ED (on [**2177-4-15**]).
In the [**Name (NI) **] pt was afebrile, tachycardic and 99% on 4L O2. He has
a CXR which showed a question of a retrocardiac opacity. CTA
was negative for PE, but did show diffuse tree in [**Male First Name (un) 239**] opacities.
Patient was given empiric vancomycin, ceftriazone,
azithromycin, tamiflu and solumedrol. However, in the ED he
became agitated and a blood gas showed a pCO2 of >100, so he was
intubated and sent to the ICU.
In the ICU, he improved on the ventilator. His antibiotics were
narrowed to just levo on [**4-16**]. In addition, his flu swab
returned negative and his tamiflu was stopped. His sputum Cx is
still pending. Patient's blood gas on morning of [**4-17**] was
7.37/66/121 on FIO2 40% 5/5, so he was then weaned to 5/0 for
several hrs prior to extubation which happened on morning of
[**4-17**]. On transfer to the floor he was on 2L NC and satting
91-93%. Of note, his atenolol had been held in the ICU, and he
was also borderline tachycardic in the 90's at transfer.
.
Upon transfer to the floor, patient became tachycardic to the
140's, but was asymptomatic with BP stable in the 130's. He was
given back his home PO dose of atenolol 50mg QD and aslo IV
metoprolol 5mg x1 and HR went back to low 100's. He remained
asymptomatic throughout, and EKG at HR of 140's showed ?
aflutter, which resolved when pt's rate was better controlled.
Past Medical History:
-HL
-s/p MI in [**2158**], s/p PTCA and then CABG x 3 [**Hospital1 112**] [**2166**]
-COPD
-?sleep apnea
Social History:
60 pack year smoking history but quit age 40
Family History:
Alcoholism Father
[**Name (NI) 3730**] Mother
[**Name (NI) **]: throat cancer
CAD/PVD Maternal Grandmother
Asthma Mother
Diabetes - Type II Mother
Psychiatric Illness - [**Name (NI) **] Mother
Physical Exam:
ADMISSION PHYSICAL EXAM:
General Appearance: No acute distress
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4, No(t) Rub, (Murmur: No(t) 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), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Wheezes : , No(t)
Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: No(t) Attentive, Responds to: Not assessed,
Movement: Not assessed, Sedated, Tone: Not assessed
DISCHARGE PHYSICAL EXAM:
VS: Tm 99.1, Tc97.4, BP 99/67 (99-138/67-88), 70 (67-124), 22
(22-26), 94% on 1.5L (92-94% on 1.5L)
GENERAL - well-appearing elderly man in NAD, comfortable,
appropriate
HEENT - EOMI, sclerae anicteric, MM mildly dry, OP clear, no
teeth in page
LUNGS - poor air movement bilaterally, lungs sound tight with
occ. faint end expiratory wheezes
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - trace edema to ankles bilaterally
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-15**] throughout, sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS
[**2177-4-15**] 02:10PM BLOOD WBC-10.2 RBC-4.37* Hgb-15.1 Hct-43.7
MCV-100* MCH-34.5* MCHC-34.5 RDW-13.3 Plt Ct-327
[**2177-4-17**] 04:30AM BLOOD WBC-11.5*# RBC-3.49* Hgb-12.1* Hct-36.0*
MCV-103* MCH-34.6* MCHC-33.5 RDW-13.6 Plt Ct-268
[**2177-4-15**] 02:10PM BLOOD Neuts-71* Bands-6* Lymphs-8* Monos-12*
Eos-1 Baso-1 Atyps-0 Metas-1* Myelos-0
[**2177-4-15**] 02:10PM BLOOD Glucose-95 UreaN-21* Creat-0.9 Na-135
K-4.5 Cl-93* HCO3-34* AnGap-13
[**2177-4-15**] 02:10PM BLOOD ALT-15 AST-23 LD(LDH)-230 AlkPhos-92
TotBili-0.4
[**2177-4-16**] 04:24AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.3
DISCHARGE LABS
[**2177-4-18**] 06:00AM BLOOD WBC-10.7 RBC-3.91* Hgb-13.1* Hct-40.8
MCV-105* MCH-33.6* MCHC-32.2 RDW-13.5 Plt Ct-263
[**2177-4-18**] 06:00AM BLOOD Glucose-83 UreaN-24* Creat-0.9 Na-142
K-4.8 Cl-99 HCO3-38* AnGap-10
MRSA SCREEN (Final [**2177-4-17**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
CTA Chest [**2177-4-15**] - 1. Widespread tree-in-[**Male First Name (un) 239**] nodular opacities
most compatible with a small airways infectious process.
Mediastinal and bilateral hilar lymphadenopathy is likely
reactive. 2. No pulmonary embolism or aortic dissection.
Echo [**2177-4-16**] - The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
focal hypokinesis of the basal inferior septum and
inferior/inferolateral walls. The remaining segments contract
normally (LVEF = 45-50 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-12**]+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Mild to moderate mitral regurgitation. Moderate pulmonary
hypertension. Preserved right ventricular function.
Brief Hospital Course:
63 yo man with history of COPD/emphysema and CAD who presented
with shortness of breath and hypoxemia and was admitted to the
ICU with hypercarbic respiratory failure.
# Hypoxemic and Hypercarbic Respiratory Failure - Intubated in
the ED in setting of PCO2 > 100 and agitation. He was then
admitted to the MICU for further management. CT Chest showed
diffuse tree in [**First Name5 (NamePattern1) 239**] [**Last Name (NamePattern1) 89881**] concerning for underlying infection
that likely triggered COPD exacerbation (not on medications > 1
year). Patient was started on high dose IV steroids, Levoquin
for probable CAP, and Oseltamivir pending flu rule out. Flu was
negative, and oseltamavir stopped. Ventilation improved on vent
and Mr. [**Known lastname **] was extubated after less than 48 hours on
mechanical ventiliation. He was transferred to floor for
further management where he was continued on levo for a 5 day
course, and trantitioned to an oral prednisone taper (60, 60,
40, 40, 20, 20, 10, 10 stop). He was continued on duonebs with
good effect. His ambulatory O2 sat on RA was 87-94% during a
full loop of the hospital floor, and 96% at rest. He was sent
home with an Rx for nebs, a neb machine, albuterol inhaler, the
rest of his levo course and the rest of his steroid taper.
# COPD exacerbation: pt with multiple tree in [**Male First Name (un) 239**] signs on CT
suggestive of small airways infectious process, likely causing
COPD exacerbation. Possible CAP, though no focal consolidation
noted. Patient treated with ABx and steroids as above in
addition to nebs. His O2 sat goal was 88-93% given likely
chronic CO2 retention.
# CAD s/p MI in [**2166**] - Initially held atenolol while intubated
in setting of COPD exacerbation. Restarted medications when
tolerating PO.
.
# Tachycardia: occurred on transfer from ICU to floor, likely
from having atenolol held in the ICU. After 5mg IV metoprolol
and home dose atenolol pt no longer tachycardic. Pt
asympromatic throughout tachycardia. We continued his home dose
atenolol and monitored him on tele, but there were no other tele
events.
.
# CAD s/p MI: pt's atenolol, ASA and statin were held while pt
intubated, then ASA restarted on c/o from ICU, and atenolol and
simvastatin restarted soon after.
# CODE: Full code
# CONTACT: sister [**Name (NI) 382**] [**Telephone/Fax (1) 89882**], and alternative contact is
girlfriend [**Name (NI) **] [**Name (NI) 13275**] [**Telephone/Fax (1) 89883**]
PENDING LABS RESULTS:
[**2177-4-15**]: Blood culture
[**2177-4-15**]: Blood culture
TRANSITIONAL CARE ISSUES: Patient will need a f/u appt with a
pulmonary specialist. However, his insurance won't cover this
unless his PCP refers him. We instructed the patient to bring
this up with his PCP at his [**Name Initial (PRE) **]/u appt.
Medications on Admission:
SIMVASTATIN 20 MG TAB 1 tablet every evening for cholesterol
ATENOLOL 50 MG TAB TAKE ONE TABLET DAILY
ADVAIR DISKUS 250 MCG-50 MCG/DOSE FOR INHALATION
(FLUTICASONE/SALMETEROL) 1 inhalation twice daily and rinse your
mouth thoroughly afterward
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER Take [**1-12**]
inhalations every 4-6 hrs as needed; rinse mouthpiece at least
once per week.
VITAMIN D 1,000 UNIT TAB (CHOLECALCIFEROL) 1 tablet daily
CIALIS 5 MG TAB (TADALAFIL) 1 tablet one hour before sex; to be
given as single dose and not to be taken more than once daily
ASPIRIN 81 MG TAB
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. prednisone 10 mg Tablet Sig: 1-6 Tablets PO once a day for 7
days: Take 60mg (6 x10mg pills) on [**4-19**], take 40mg (4 x10mg
pills) on [**4-22**], take 20mg (2 x10mg pills) on [**4-24**]),
take 10mg (1 x10mg pills) on [**4-26**] then stop.
.
Disp:*20 Tablet(s)* Refills:*0*
4. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day: rinse your mouth thoroughly afterwards.
Disp:*1 diskus* Refills:*2*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-12**] inhalations Inhalation every 4-6 hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*1*
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
Disp:*112 nebs* Refills:*0*
7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days: Please take this on [**4-19**], then stop.
Disp:*1 Tablet(s)* Refills:*0*
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*112 nebs* Refills:*0*
9. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
10. Cialis 5 mg Tablet Sig: One (1) Tablet PO 1 hour prior to
intercourse.
11. Nebulizer Machine
Patient will require a nebulizer machine for his albuterol and
ipratropium nebulizers.
12. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: COPD exacerbation
Secondary:
community-acquired pneumonia
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were seen in the hospital for a COPD exacerbation caused
most likely by a virus. You were sent to the Intensive Care
Unit and intubated. You improved quickly after you were put on
antibiotics and steroids and were extubated and sent to the
regular medicine floor. You will need 1 more day of antibiotics
and you will take steroids until [**4-25**]. You will see your PCP in
the next 1-2 weeks (you will be contact[**Name (NI) **] with an appointment),
and at this appointment you need to ask to be seen by a
pulmonologist (lung doctor) in the future. Please take your
inhalers and nebulizer treatments. Do not stop taking them again
as this will put you at risk for needing to return to the
hospital, serious injury and death.
We made the following changes to your medications:
1) We STARTED you on PREDNISONE. Take 60mg (6 x10mg pills) on
[**4-19**], take 40mg (4 x10mg pills) on [**4-22**], take 20mg (2 x10mg
pills) on [**4-24**]), take 10mg (1 x10mg pills) on [**4-26**]
then stop.
2) We STARTED you on LEVOFLOXACIN 750mg. You will only take 1
pill tomorrow then you are done with antibiotics.
3) We STARTED you on ALBUTEROL NEBULIZERS every 6 hours as
needed for shortness of breath. We will be sending you home
with a prescription for a nebulizer machine.
4) We STARTED you on IPRATROPIUM NEBULIZERS every 6 hours as
needed for shortness of breath.
5) We CONTINUED your ALBUTEROL inhaler and sent you home with a
new prescription for this. Take 102 inhalations every 4-6 hours
as needed for shortness of breath.
6) We CONTINUED your ADVAIR DISKUS and sent you home with a new
prescription for this. Take 1 inhalation twice daily and rinse
your mouth afterwards.
Please continue to take your other medications as directed.
If you experience any of the below listed Danger Signs please
call your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Name: HUNT,[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 88505**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within
1-2 weeks. You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above.
**Please discuss with your PCP the need to see a Pulmonologist
at this appointment**
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"491.21",
"414.00",
"V15.82",
"486",
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"272.4",
"785.0",
"327.23",
"E941.3",
"518.81",
"412"
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
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icd9pcs
|
[
[
[]
]
] |
11722, 11728
|
6547, 9113
|
325, 346
|
11863, 11863
|
4350, 6524
|
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|
2461, 2773
|
10010, 11699
|
11749, 11842
|
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|
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265, 287
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9139, 9365
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374, 2251
|
11878, 11990
|
2273, 2380
|
2396, 2443
|
3702, 4331
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,561
| 191,544
|
24509+57402
|
Discharge summary
|
report+addendum
|
Unit No: [**Numeric Identifier 61951**]
Admission Date: [**2183-5-6**]
Discharge Date: [**2183-5-16**]
Date of Birth: [**2108-5-31**]
Sex: M
Service: VSU
CHIEF COMPLAINT: Failed right vascular graft with a
nonhealing right 5th toe ulceration.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman
with a recent known bypass graft in [**Month (only) 958**] (followed by Dr.
[**Last Name (STitle) 61952**] from [**Hospital3 **] in [**Location (un) 7661**]). He performed the initial
surgery. The patient developed an ulcer in the left big toe
that was not hearing. Dr. [**Last Name (STitle) 61952**] did an ultrasound which
showed a failing graft, and the patient was referred to Dr.
[**Last Name (STitle) 1391**] for an arteriogram with possible intervention.
PAST MEDICAL HISTORY: Peripheral vascular disease, BPH,
history of hypertension (controlled), history of GERD,
history of depression, history of anemia, and a history of
chronic renal insufficiency.
PAST SURGICAL HISTORY: Bypass graft to the left lower
extremity, amputation of the 3rd, 4th, and 5th right toes,
amputation of 2nd, 3rd, 4th, 5th left toes, cataract
extraction.
REVIEW OF SYSTEMS: Negative except for frequency. The
patient is on Lasix.
ALLERGIES: PENICILLIN but does not know the reaction.
MEDICATIONS ON ADMISSION: Include Lasix 40 mg daily,
atenolol 50 mg daily, Protonix 40 mg daily, Flomax 0.4 mg
daily, Norvasc 5 mg daily, potassium chloride 20 mEq daily,
Coumadin (which was discontinued on [**2183-5-2**]), aspirin
325 mg daily, Paxil 25 mg daily, zinc 50 mg daily, vitamin C
500 mg daily, multivitamin tablet daily, Procrit 40,000 units
every Thursday.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] uses a
walker. He does not need assist with ADLs. He has former
tobacco use, but quit 25 years ago. He admits to occasional
alcohol.
FAMILY HISTORY: Mother and father are both deceased. Mother
died of [**Name (NI) 2481**]. Father died of prostate carcinoma. He
has a sister living and well.
PHYSICAL EXAMINATION ON ADMISSION: This is an elderly white
male in no acute distress. Lying in bed and comfortable.
HEENT exam is unremarkable. The lungs are clear to
auscultation bilaterally. Heart is a irregular regular rhythm
with a systolic ejection murmur of [**4-9**]. Abdominal exam is
unremarkable. Extremity exam shows well-healed bilateral toe
amputations. The toes are with cyanotic changes. The feet are
cool to touch bilaterally. The DP pulse are absent. The PT
pulses are monophasic signals bilaterally. There is a dry
eschar of 2 x 2 cm on the right 1st toe.
HOSPITAL COURSE: The patient was admitted to the vascular
service under the care of Dr. [**Last Name (STitle) 1391**]. Routine laboratories
were obtained. White count was 9.0, hematocrit was 36.9, and
platelets were 257. BUN was 46, creatinine was 3.0, K was
3.5. Urinalysis showed 3 to 5 RBCs. Leukocyte negative.
Nitrite negative. A chest x-ray showed a small right pleural
effusion versus pleural thickening. EKG was normal sinus
bradycardic rhythm with no acute ischemic changes.
The patient was prehydrated for anticipated arteriogram. He
received Mucomyst and sodium bicarbonate per protocol. On
[**5-7**] he underwent an arteriogram via the left femoral
artery. Abdominal, aortic, and pelvic vessels were imaged
with right leg runoff which demonstrated an occluded graft
with diseased PFA with collaterals which filled the popliteal
artery and mildly diseased posterior tibial peroneal artery
with an occluded anterior tibial without filling of the
dorsalis pedis. The patient had no post angio complications.
His BUN and creatinine remained stable. He was prepared for
surgery and on [**2183-5-9**] underwent a left femoral above-
knee popliteal bypass graft using 7 mL of PTFE. The patient
tolerated the procedure well and had a palpable PT pulse at
the end of the procedure.
Immediately postoperatively the patient developed a wound
hematoma, and the patient returned to the OR for hematoma
evacuation. He tolerated the procedure well and was
transferred to the PACU in stable condition. Intraoperatively
with the second operation the patient had an episode of sinus
bradycardia with hypotension. Fluid resuscitation was given
with improvement in the patient's systolic blood pressure.
Cardiology was consulted. They felt that it was probably
related to hypovolemia and beta blockade. Recommendations
were to adjust his atenolol to 25 mg daily to metoprolol 25
mg b.i.d. or metoprolol IV 2.5 mg q.6h. Electrolytes were
repleted. No other intervention or recommendations, and to
maintain a hematocrit of greater than 30.
On postoperative day 1, the patient had no further events
overnight. Hematocrit was 28 post 2 units of packed red blood
cells. The wound was stable. The patient remained on bedrest,
and hematocrit was monitored. Physical therapy was requested
to see the patient on postoperative day 2, and at that time
they felt he would be able to be discharged to home when
medically ready. The patient was noted to have a rise in his
creatinine from 3.0 to 3.3 on postoperative day 2. He was
continued on Lasix 40 b.i.d., and his Coumadin was
reinstituted. The patient had a T-max of 100.4 on
postoperative day 2, and a chest x-ray was obtained which was
unremarkable. A urinalysis and urine culture were sent. The
chest x-ray was unremarkable. Blood cultures were obtained
which were unremarkable and urine culture and sensitivity
were negative.
On postoperative day 3, the patient was continued on
vancomycin and levofloxacin. Anticoagulation and
coumadinization were continued. Heparin was discontinued when
the patient reached a therapeutic state of greater than 2.0,
he continued to show incremental increases. The patient's
anticoagulation was monitored and required a significant
adjustment in his Coumadin dosing. He was very sensitive to
his Coumadin. His INR has peaked. The patient's creatinine
peaked at 3.7 on [**2183-5-13**]. On [**2183-5-15**] creatinine
began to show a downward trend and was 3.4. Baseline
creatinine on admission was 3.1. The remainder of the
hospital course was unremarkable. The patient was waiting for
final evaluation regarding suitability for discharge to home
versus rehab from physical therapy. Case management was aware
of the patient's status and began screening for rehab. As of
[**2183-5-15**] we are awaiting final decision from PT and
screening process.
MEDICATIONS ON DISCHARGE: Atenolol 50 mg daily, Protonix 40
mg daily, tamsulosin 0.4 mg daily, amlodipine 5 mg daily,
aspirin 325 mg daily, paroxetine 20 mg daily, ascorbic acid
500 mg daily, multivitamin capsule 1 daily, Epogen 10,000
units (every Monday, Wednesday, and Friday), zinc sulfate 220-
mg capsule daily, Darvocet-N 100/650 tablets 1 q.6h. p.r.n.
(for pain), acetaminophen 325-mg tablets 1 to 2 q.4-6h.
p.r.n., Lasix 40 mg daily, Coumadin (dose will be determined
at the day of discharge).
DISCHARGE INSTRUCTIONS: INR should be monitored until the
patient is in the steady therapeutic rate; goal INR is 2.0 to
3.0. The patient may ambulate essential distances. He may
take a shower. He should not drive until seen in followup by
Dr. [**Last Name (STitle) 1391**]. Skin clips should remain in place until seen in
followup.
DISCHARGE DIAGNOSES:
1. Peripheral vascular disease with failed graft and right
1st toe ulceration.
2. Postoperative sinus bradycardia with hypotension;
corrected.
3. Postoperative wound hematoma.
4. Postoperative blood loss anemia; transfused.
5. History of benign prostatic hyperplasia.
6. History of hypertension.
7. History of depression.
8. History of anemia.
9. History of chronic renal insufficiency.
10. History of gastroesophageal reflux disease.
MAJOR SURGICAL INTERVENTION AND PROCEDURES PERFORMED:
1. Arteriogram with right leg runoff via the left femoral
artery on [**2183-5-7**].
2. A left femoral-to-popliteal bypass graft with PTFE on [**5-9**], [**2182**].
3. A left leg hematoma evacuation on [**2183-5-9**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2183-5-15**] 12:50:11
T: [**2183-5-15**] 13:36:32
Job#: [**Job Number 61953**]
Name: [**Known lastname 11169**],[**Known firstname **] Unit No: [**Numeric Identifier 11170**]
Admission Date: [**2183-5-6**] Discharge Date: [**2183-5-20**]
Date of Birth: [**2108-5-31**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 231**]
Addendum:
Pt had extended stay in hospital form original discharge date.
Pt had an INR of 7.7 on [**2183-5-14**]. Pt coumadin was stopped. His INR
was allowed to go into the range od [**1-9**]. On discharge pt INR is
2.0.
PT also had a bump in his creat to 3.7. Pt creat on discharge is
3.1. Pt has CRI, this is his baseline.
Discharge Disposition:
Home With Service
Facility:
TLC/STAFF BUILDERS
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2183-5-20**]
|
[
"998.12",
"427.89",
"440.23",
"280.0",
"707.15",
"458.29",
"997.1",
"593.9",
"996.74",
"401.9",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"88.48",
"99.04",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
8961, 9167
|
1880, 2044
|
7283, 8938
|
6451, 6928
|
1316, 1662
|
2618, 6424
|
6953, 7262
|
1000, 1156
|
1176, 1289
|
178, 251
|
280, 775
|
2059, 2600
|
798, 976
|
1679, 1863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,493
| 162,158
|
15924
|
Discharge summary
|
report
|
Admission Date: [**2199-4-5**] Discharge Date: [**2199-4-10**]
Date of Birth: [**2134-11-28**] Sex: M
Service:
ADMISSION DIAGNOSIS: Coronary artery disease, ejection
fraction of 35%
DISCHARGE DIAGNOSES:
1. Coronary artery disease, ejection fraction of 35%
2. Status post coronary artery bypass graft x3 ([**2199-4-5**])
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
male with a two year history of shortness of breath status
post a positive stress test in [**2198-10-14**]. The
patient subsequently underwent cardiac catheterization in
[**2198-11-13**] which revealed two vessel coronary artery
disease and a decreased ejection fraction as well as also had
an echocardiogram which revealed an ejection fraction of 35%.
The patient was subsequently recommended to undergo coronary
artery bypass grafting. He now presents for his
revascularization surgery.
PAST MEDICAL HISTORY:
1. Hypertension
2. Obesity
3. Type II diabetes mellitus
4. Hemorrhoids
5. Gastroesophageal reflux disease
6. Depression
7. .................
8. Psoriasis
9. Sleep apnea
10. Bilateral carpal tunnel syndrome
11. Left bundle branch block
PAST SURGICAL HISTORY:
1. TURP approximately 20 years ago
2. Bilateral inguinal hernia repairs approximately 20 years
ago
MEDICATIONS:
1. Terazosin 5 mg qd
2. Atenolol 50 mg qd
3. Zestril 5 mg qd
4. Lasix 20 mg qd
5. Serzone 150 mg [**Hospital1 **]
6. Naprosyn 500 mg [**Hospital1 **]
7. Zantac 150 mg [**Hospital1 **]
ALLERGIES: PENICILLIN CAUSES HIVES.
PHYSICAL EXAMINATION ON ADMISSION:
GENERAL: Middle age elderly man in no acute distress.
VITAL SIGNS: Heart rate is ..............., blood pressure
154/79. Height is 5 foot 6 inches. Weight 215 pounds.
HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic,
atraumatic. Pupils equal, round and reactive to light.
Extraocular muscles are intact. Throat is clear.
NECK: Supple, midline. No masses or lymphadenopathy. There
is a slightly pronounced thyroid.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm with a possible 1 to
2/6 systolic ejection murmur.
ABDOMEN: Soft, nontender, nondistended with no masses or
organomegaly.
EXTREMITIES: Warm, nondistended, nonedematous x4. Positive
for psoriatic plaques bilaterally.
NEUROLOGIC: Grossly intact with no focal motor or sensory
deficits.
LABS: The patient had preoperative labs on [**2199-3-27**]. CBC
8.7/15.3/44.2/213. PT is 13.1, INR 1.1, PTT 30.1.
Chemistries: 141/4.2/101/26/19/1.0/110. ALT 17, AST 22,
alkaline phosphatase 111, total bilirubin 0.8. Type and
screen performed [**2199-3-27**].
IMAGING: Preoperative chest x-ray showed some mild left
ventricular enlargement, but no other significant acute
processes.
HOSPITAL COURSE: The patient was admitted or coronary artery
bypass graft. On [**2199-4-5**], the patient was taken to the
Operating Room and had a coronary artery bypass graft x3 with
left internal mammary artery to the LAD, saphenous vein graft
to the OM and positive saphenous vein graft and left radial
to the diagonal artery.
The patient was extubated on postoperative day 0 without
incident. His postoperative course was largely unremarkable.
On postoperative day #2, the patient was transferred from the
Intensive Care Unit floor. Here, he worked with physical
therapy and was initially seen to be fairly unmotivated and
with a blunt affect. They are restarting his antidepressant
medication nefazodone 150 mg [**Hospital1 **]; the patient had a marked
improvement. He responded well to diuresis and physical
therapy. Ultimately, the patient was discharged on
postoperative day #5 tolerating a regular diet and adequate
pain control on po pain medications and having been cleared
for home by physical therapy. He experienced no more dyspnea
or acute shortness of breath exacerbations.
PHYSICAL EXAMINATION ON DISCHARGE:
GENERAL: No acute distress.
VITAL SIGNS: 99.1, heart rate 80, blood pressure 154/88,
respirations 20, 90% on room air.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. There is no
sternal click or drainage. He has 1+ peripheral edema.
NEUROLOGIC: Grossly intact.
DISCHARGE LABS: CBC 11.9/12.0/35.1/210. Chemistries
139/4.2/100/27/28/1.1/141. Calcium is 8.4, magnesium 2.0,
phosphate 3.2.
DISCHARGE CONDITION: Good
DISPOSITION: Home
DIET: Cardiac and diabetic
MEDICATIONS:
1. Imdur 60 mg qd
2. Aspirin 325 mg qd
3. Serzone 150 mg [**Hospital1 **]
4. Lasix 20 mg [**Hospital1 **] x7 days, then resume home dose 20 mg qd
5. Potassium chloride 20 milliequivalents [**Hospital1 **] x7 days
6. Lopressor 100 mg [**Hospital1 **]
7. Lisinopril 5 mg qd
8. Zantac 150 mg [**Hospital1 **]
9. Percocet 5/325 1 to 2 q4h prn
10. Colace 100 mg [**Hospital1 **]
INSTRUCTIONS: The patient is to follow up with cardiologist
in one to two weeks' time. He should follow up with Dr.
[**Last Name (STitle) 70**] in six weeks. He is encouraged to continue
incentive spirometry as well as ambulation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 14041**]
MEDQUIST36
D: [**2199-4-10**] 08:55
T: [**2199-4-10**] 08:59
JOB#: [**Job Number 45664**]
|
[
"530.81",
"413.9",
"414.01",
"786.05",
"692.9",
"311",
"780.57",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4347, 5339
|
225, 345
|
2772, 3877
|
4213, 4325
|
1185, 1551
|
153, 204
|
3891, 4196
|
374, 895
|
1565, 2754
|
917, 1162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,089
| 169,634
|
32977
|
Discharge summary
|
report
|
Admission Date: [**2181-8-30**] Discharge Date: [**2181-9-2**]
Date of Birth: [**2132-2-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 year old female with autoimmune hepatitis, RA who complains
of fever/chills, and weakness. Patient with two days of fever to
102 and bilateral flank/lateral abd pain(atraumatic). No midline
back pain. Diagnosed with a pansensitive E.coli UTI 2 weeks ago
with c/o pelvic pressure and dysuria, now s/p treatment with
Keflex for 10 days. She represented to her PCP office yesterday
and told she had diminished renal function and was instructed to
f/u at the office again today. She complained of back pain,
fever, weakness, and chills. Since yesterday the fever has been
constant and measured from 99 - 102 with associated cough with
some clear phlegm production. She also reports light headedness
and headache upon standing. The back pain is only present upon
standing and walking and cannot be reproduced with palpation.
Motrin was not helpful in alleviating her symptoms. She has not
eaten solid food today because of the nausea though she denies
emesis. She reports noting some increased edema, but denies CP,
SOB, sweating, or change in sleep patterns. She also reports
some symptoms of dysuria and increased pelvic pressure similar
to her symptoms with the previous UTI but denies changes in
frequency, color, or hematuria. She also notes ongoing leakage
as a result of her longstanding urine incontinence problems. She
denies changes in bowel movement frequency, color, or
consistency. Vital signs at PCP visit today:102.9 BP: 112/73 HR:
123 Resp: 96% RA. She has been downtitrating prednisone since
[**7-24**] (pt self-dc'd prednisone) and uptitrating 6-MP.
.
ED course: Initial vitals: 103.1 124 106/63 16 99%/ra. Labs
notable for UA negative, WBC 10.5 w normal differential, creat
1.0. Imaging: CXR nl, CT abd/pelvis with contrast was
unremarkable. She was given vancomycin 1000mg, and metronidazole
500mg. Also administered stress dose steroids and 2 L of NS
until around 2200 when she became hypotensive to sbp 70s. She
was given 100mg of hydrocort and additional liter of NS(total
3L). Transfer vitals: T 97.8, HR 76, BP 82/42 (sbp 91), RR 14,
O2 97%RA. Access 18g x2. No foley catheter.
.
On the floor, pt feels improved since this AM. She has not taken
her prednisone for 3 days (rx ran out). Cough began 3 days ago
and febrile illness began yesterday. Her back pain was b/l low
back pain. She endorses anterior mild nonreproducible chest
pressure, nausea (resolved), low back pain (resolved), cough
productive of sputum, and stiff neck/headache. She denies SOB,
wheezing, hemoptysis. CP is not relieved with positional change
and not pleuritic. No photophobia. Denies sick contacts or
recent hospitalizations. Pt has been working up until today.
Mild dysuria - improved since administration of keflex. Denies
hematuria. Endorses poor po intake x3 days.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denies shortness of breath, or
wheezing. Denies palpitations, or weakness. Denies vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
POSITIVE PPD 795.5M
GOITER 240.9AQ
ARTHRITIS - RHEUMATOID 714.0G
URINARY INCONTINENCE - MIXED 788.33M
MENOPAUSE 627.2AU
OBESITY UNSPEC 278.00J
AUTOIMMUNE HEPATITIS
.
Past Surgical History:
DELIVERY - C SECT W/ OB CARE
ANTERIOR COLPORRHAPHY, SUBURETHRAL SLING
Social History:
Lives with her daughter. [**Name (NI) 1403**] in a laundry service for a hotel.
Originally from [**Country **]. Son away working and living alone.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Stroke Father deceased
[**Name2 (NI) **]ardial infarction [Other] Mother deceased
[**Name2 (NI) 3730**] - Breast
Comment: paternal great aunt
Physical Exam:
Admission Physical Exam
Vitals: T:97.9 BP:97/50 P:77 R: 16 O2: 99/RA
Gen: pleasant, hispanic obese female, lying in bed, cushingoid
appearance
Derm: Fine, red, macular rash on chest, abdomen and back,
bruising over L flank, large erythematous nontender macules on L
flank
HEENT: PERRL, no nystagmus, EOMi, OP wo lesions
NECK: supple, no cervical or supraclavicular LAD
CV: RRR, no murmurs, rubs or gallops
Lungs: CTAB
Abdomen: Soft, NT, nondistended, +BS, no cva tenderness
Ext: 1+ edema in b/l lower extremeties, distal pulses intact,
warm
Neuro: CN II-XII grossly intact
Discharge Physical Exam
VS: 98.4 98/58 72 18 100RA
1080/250+BRP, BMx1
GENERAL: pleasant woman appearing stated age, resting
comfortably, NAD
HEENT: NC/AT, PERRL, sclerae anicteric, MMM, OP clear
NECK: supple, no cervical LAD, no JVD
HEART: RRR, normal S1-S2, no r/m/g
LUNGS: CTAB, no wheezes/rales/rhonchi, good air movement
ABDOMEN: bowel sounds present, soft/NT/ND, no suprapubic
tenderness, no organomegaly, no rebound/guarding
BACK: no midline tenderness, no CVA tenderness
EXTREMITIES: warm, well-perfused, no cyanosis or edema, 2+
peripheral pulses
SKIN: several erythematous macular lesions on RLQ, right flank
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-26**] throughout, sensation grossly intact throughout, patellar
reflexes 2+ and symmetric, toes downgoing
Pertinent Results:
[**2181-8-30**] 09:10PM LACTATE-1.1
[**2181-8-30**] 08:32PM URINE HOURS-RANDOM
[**2181-8-30**] 08:32PM URINE UCG-NEGATIVE
[**2181-8-30**] 05:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2181-8-30**] 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2181-8-30**] 04:08PM LACTATE-2.1*
[**2181-8-30**] 03:55PM GLUCOSE-129* UREA N-7 CREAT-1.0 SODIUM-128*
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-25 ANION GAP-12
[**2181-8-30**] 03:55PM estGFR-Using this
[**2181-8-30**] 03:55PM ALT(SGPT)-51* AST(SGOT)-44* LD(LDH)-414* ALK
PHOS-54 TOT BILI-1.3
[**2181-8-30**] 03:55PM LIPASE-36
[**2181-8-30**] 03:55PM TSH-0.49
[**2181-8-30**] 03:55PM TSH-0.49
[**2181-8-30**] 03:55PM WBC-10.5 RBC-4.36 HGB-14.6 HCT-38.6 MCV-89
MCH-33.4* MCHC-37.8* RDW-16.0*
[**2181-8-30**] 03:55PM NEUTS-77.0* LYMPHS-18.2 MONOS-3.3 EOS-1.0
BASOS-0.4
[**2181-8-30**] 03:55PM PLT COUNT-128*
[**2181-8-31**] 03:44AM BLOOD WBC-6.7 RBC-3.75* Hgb-12.7 Hct-34.3*
MCV-92 MCH-34.0* MCHC-37.1* RDW-15.4 Plt Ct-122*
[**2181-9-1**] 01:05PM BLOOD WBC-14.9*# RBC-4.02* Hgb-13.3 Hct-36.6
MCV-91 MCH-33.2* MCHC-36.4* RDW-15.7* Plt Ct-173
[**2181-9-1**] 01:05PM BLOOD Neuts-91.3* Lymphs-7.3* Monos-1.3*
Eos-0.1 Baso-0.1
[**2181-8-31**] 03:44AM BLOOD PT-14.6* PTT-28.1 INR(PT)-1.3*
[**2181-8-31**] 03:44AM BLOOD Plt Ct-122*
[**2181-8-31**] 03:44AM BLOOD Glucose-132* UreaN-6 Creat-0.8 Na-142
K-3.5 Cl-111* HCO3-22 AnGap-13
[**2181-9-1**] 01:05PM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-136
K-3.7 Cl-104 HCO3-24 AnGap-12
[**2181-8-31**] 03:44AM BLOOD ALT-41* AST-37 AlkPhos-43 TotBili-0.8
[**2181-9-1**] 01:05PM BLOOD Calcium-8.8 Phos-2.3* Mg-2.1
[**2181-9-2**] 08:15AM BLOOD WBC-11.7* RBC-4.08* Hgb-13.4 Hct-37.4
MCV-92 MCH-32.9* MCHC-35.9* RDW-16.4* Plt Ct-176
[**2181-9-2**] 08:15AM BLOOD Plt Ct-176
[**2181-9-2**] 08:15AM BLOOD Glucose-85 UreaN-11 Creat-0.8 Na-141
K-3.7 Cl-105 HCO3-30 AnGap-10
[**2181-9-2**] 08:15AM BLOOD ALT-38 AST-26 AlkPhos-55 TotBili-0.5
[**2181-9-2**] 08:15AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1
Imaging:
chest xray: no acute cardiopulmonary process.
.
CT abd/pelvis with contrast: No acute intraabdominal process
with normal kidneys, appendix, gallbladder and pancreas
.
EKG: Compared to report of EKG (no image avail) from [**9-/2170**],
sm inferior q waves and nonspecific T wave changes in V1-V3.
Unclear significance of diffuse ST elevations in II, III, F,
V4-V6. T waves peaked in II.
Urine cultures were skin and gential contamination.
Sputum culture was inconclusive as bad sample.
Pending:
Respiratory viral swab was preliminary negative, culture
pending.
Blood cultures were pending
HIV consent obtained and is pending.
EBV panel is pending.
MRSA screen pending
Brief Hospital Course:
49y F hx of autoimmune hepatitis, RA on steroids/6MP presenting
with cough, malaise, fever, back pain, and admitted to MICU for
hypotension.
.
# Hypotension: Likely related to underlying infection despite
negative imaging. [**Month (only) 116**] be related to the prior UTI. Her
immunosuppressive medications increases our suspicion of and
underlying infection cause and may explain the observed normal
white count. Likely component of adrenal insufficiency given
chronic pred use and recent self discontinuation x 3 days -
supported by hyponatremia. BP stable now in high 90s systolic
with MAP>60 on arrival to the floor. Given clinical stability
overnight and high suspicion for adrenal insufficiency, her
broad spectrum abx were discontinued. She was continued on
stress dose steroids overnight and transitioned to home
prednisone dose on HD1. She did not require pressors or
additional fluid boluses once she reached the MICU. Patient was
transferred to the medicine floor with stable BPs. During her
stay on the floor BPs were stable.
.
# Fever: Likely infectious (bacterial vs viral etiology). Given
immunosuppression with steroids and 6-MP, may not manifest
leukocytosis. Increased risk of infection given concomitant
prednisone and 6-MP. Fine macular rash on torso could be related
to infectious etiology and more likely viral exanthem.
Respiratory viral swab was preliminary negative, culture
pending. Blood cultures were pending but negative to date by
discharge, Urine cultures were skin and gential contamination.
Lactate normalized prior to arrival to floor. Sputum culture was
inconclusive as bad sample. Repeat chest xray did not show
progression or new findings after receiving IVF in the ED. HIV
consent obtained and is pending. EBV panel is pending. Broad
spectrum antibiotics quickly narrowed to levofloxacin with
clinical improvement. GIven immunosuppression and septic
presentation she will complete an empiric 10 day course of
levofloxacin.
.
# productive cough: CXR unremarkable, Sputum culture was
inconclusive as above, symptoms improved in house. Pt placed on
empiric 10 day course of levofloxacin.
.
# [**Doctor First Name 48**]: Baseline creat 0.7 - noted to be 1.2 prior PCP visit now
down to baseline after fluids overnight - most likely prerenal
azotemia related to poor po intake prior to hospitalization.
Creatinine stable at discharge.
.
# autoimmune hepatitis: On prednisone and mercaptopurine. Slight
transaminitis - unclear significance, could be inflammatory
although given recently initiated 6-MP, would confirm prior
hepatitis w/u with PCP. [**Name10 (NameIs) 9026**] were trended and normalized by time
of discharge.
Transitional issues.
Respiratory viral swab was preliminary negative, culture
pending.
Blood cultures were pending
HIV consent obtained and is pending.
EBV panel is pending.
MRSA screen pending
Consider outpatient starting Bactrim for PCP prophylaxis, pt
briefly on this medication in ICU but not discharged on
medication.
Patient started on Ca/Vit D as on chronic steroids. However
check TSH as levothyroxine and Ca have interaction.
Patient started on Omeprazole for ppx as on chronic steroids.
Patient placed on 10 day course of levofloxacin (last day
[**2181-9-10**])
Medications on Admission:
Prednisone 10 mg Oral Tablet 4 tabs in am, 2 tablets with supper
Mercaptopurine (PURINETHOL) 50 mg Oral Tablet [**12-24**] tablet po qam
for one week then i po qam
Levothyroxine 75 mcg Oral Tablet TAKE ONE TABLET DAILY
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
4. mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
7. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days: 10 days total, but started [**2181-9-1**] so last
day [**2181-9-10**].
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Fever, hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 1391**],
It was a pleasure seeing you during your admission to [**Hospital1 18**]. You
were admitted for fevers and some low blood pressure. You take
prednisone and mercaptopurine for your rheumatoid arthritis
which puts you at risk for infections. You also had missed
several days of your prednisone. You were briefly admitted to
our ICU and watched, with improvement of your blood pressures
and temperature. You were then sent to the medicine floor.
You also had a chest xray and a CAT scan of your abdomen which
were both reassuring without signs of acute infection.
Initially you were put on strong IV antibiotics, but as your
urine and blood cultures have been negative, we switched you to
an oral antibiotic called Levofloxacin which you should take for
10 days total (last day [**2181-9-10**]).
You should discuss with your outpatient doctor if you should
start taking Bactrim, an antibiotic for prophylaxis against
possible lung infections for people who take immunosuppressing
drugs. You were briefly on this medication in the hospital but
are not being discharged on this medication.
Changes to medication:
START Levofloxacin (last day [**2181-9-10**])
START Pantoprazole (for prophylaxis against ulcers, which can
happen especially for people on prednisone)
START Calcium (please get your thyroid levels checked as calcium
can interact with levothyroxine)
START vitamin D
Followup Instructions:
Please call your primary care physician [**Name9 (PRE) 76022**],[**Name9 (PRE) 8694**] [**Name Initial (PRE) **].
[**Telephone/Fax (1) 2115**] to schedule an appointment for next week regarding
your hospitalization.
Please call your rheumatologist to schedule an appointment for
next week regarding your hospitalization.
Completed by:[**2181-9-2**]
|
[
"571.42",
"714.0",
"458.9",
"780.60",
"788.33",
"240.9",
"795.5",
"593.9",
"278.00",
"255.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12693, 12699
|
8387, 11623
|
315, 321
|
12762, 12762
|
5598, 8364
|
14353, 14705
|
4012, 4191
|
11894, 12670
|
12720, 12741
|
11649, 11871
|
12913, 14330
|
3708, 3780
|
4206, 5579
|
3139, 3496
|
264, 277
|
349, 3120
|
12777, 12889
|
3518, 3685
|
3796, 3996
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,520
| 137,247
|
21098
|
Discharge summary
|
report
|
Admission Date: [**2204-1-23**] Discharge Date: [**2204-1-28**]
Date of Birth: [**2141-10-24**] Sex: F
Service: SURGERY
Allergies:
Codeine / Tramadol
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
L popliteal transection
Major Surgical or Invasive Procedure:
Left above-knee popliteal to below-knee popliteal bypass using
PTFE, left leg fasciotomy, exploration of right greater
saphenous vein.
History of Present Illness:
62F transferred from an OSH after undergoing a L TKR. The
popliteal artery was transected during the procedure. On exam
she had no pulses distal to this point so she was sent
emergently by helicopter to our hospital to undergo repair of
this injury.
Past Medical History:
Past medical history includes hypertension, osteoarthritis, and
status post cholecystectomy and hysterectomy.
Social History:
Denies EtOH, tobacco, or illicit drug use
Family History:
non-contributory
Physical Exam:
T 98.7 HR 83 BP 119/83 RR 19 SaO2 98% 3L
Gen: NAD
chest: CTAB
CV: RRR, -MRG
Abd: Morbidly obese, soft, NT, ND, +BS
RLE - normal sensation, 5+ motor strength, normal capillary
refill, palpable DP and PT pulses
LLE - L knee in bandage, ischemic L foot w decreased sensation
and strength, absent capillary refill, no palpable pulses below
the knee
Pulses:
fem [**Doctor Last Name **] DP PT
R palp palp palp palp
L palp - - -
Pertinent Results:
7.1 > 29.8 < 161
CTA RIGHT AORTA/BIFEM/ILIAC ([**2204-1-23**]):
1. Streak artifact from bilateral total knee arthroplasties
limits assessment of the above knee popliteal arteries. However,
except for a wisp of minimal opacification within the left
tibioperoneal trunk, there is non-opacification of the arterial
vasculature below the popliteal fossa, including the below knee
popliteal, the anterior tibial, posterior tibial, and peroneal
arteries. Findings are compatible with the patient's history of
transection of the left popliteal artery with absent flow distal
to the popliteal fossa.
2. Colonic diverticular disease.
3. Subcentimeter hypodensities within both kidneys, not fully
characterized, but likely cysts.
4. Status post cholecystectomy and gastric bypass. Two
radiopaque densities are noted within the region of the
gallbladder fossa, which could represent retained stones within
the cystic duct.
KNEE X-RAY ([**2204-1-23**]): Status post constrained left knee
prosthesis in good alignment without evidence of periprosthetic
fracture.
ECG ([**2204-1-23**]): Baseline artifact. Sinus rhythm with atrial
premature beats. Early R wave progression. ST-T wave
abnormalities. Since the previous tracing of [**2197-8-16**] the rate is
faster and artifact is more prominent.
Brief Hospital Course:
Patient was admitted to the Vascular Surgery service and taken
emergently to the OR for left above-knee popliteal to below-knee
popliteal bypass using PTFE, left leg fasciotomy, exploration of
right greater saphenous vein after having experienced popliteal
artery transection during a total knee replacement. Her
post-operative course was uncomplicated. She was initially
admitted to the VICU and was transferred to the floor on
post-operative day 2. She had palpable pulses post-op which
continued throughout the course of her hospital stay. Her CK
was initally elevated due to ischemic muscle damage and she was
aggressively fluid resuscitated. Her Cr was 0.4-0.5 throughout
her hospital stay. Her CK peaked at 2700 and progressively
decreased and her IV fluids were discontinued. Due to the
aggressive hydration she was fluid overloaded and was given IV
lasix with good diuresis for 3 days. She was started on CPM per
orthopaedic surgery recommendations on post-operative day 2 and
on post-operative day 3 her activity and movement was
unrestricted from a vascular surgery perspective. She was also
started on lovenox as a bridge to coumadin per orthopaedic
surgery recommendations.
At time of discharge her pain was well controlled, she was
tolerated a regular diet, was working with PT on the CPM machine
per protocol and she was voiding spontaneously. Her INR was 1.3
at time of discharge and she will continue lovenox as a bridge
to therapeutic coumadin.
Medications on Admission:
diltiazem 120mg XL daily, prevacid 20mg daily, percocet PRN
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
6. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): Please administer until
coumadin is therapeutic. injection
7. Prevacid 15 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**] in [**Hospital1 3597**] NH
Discharge Diagnosis:
Left popliteal artery transection during left total knee
replacement at outside hospital
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:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????You should get up out of bed every day and gradually increase
your activity each day
??????Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
??????Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
??????Elevate your leg above the level of your heart (use [**2-9**] pillows
or a recliner) every 2-3 hours throughout the day and at night
??????Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
??????You will probably lose your taste for food and lose some weight
??????Eat small frequent meals
??????It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
??????No driving until post-op visit and you are no longer taking
pain medications
??????Unless you were told not to bear any weight on operative foot:
??????You should get up every day, get dressed and walk
??????You should gradually increase your activity
??????You may up and down stairs, go outside and/or ride in a car
??????Increase your activities as you can tolerate- do not do too
much right away!
??????No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
??????You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
??????Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
??????Take all the medications you were taking before surgery, unless
otherwise directed
??????Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
??????Redness that extends away from your incision
??????A sudden increase in pain that is not controlled with pain
medication
??????A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????Temperature greater than 100.5F for 24 hours
??????Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
1. You have an appoitment with DR. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD on
[**2204-2-16**] at 1:45pm. Phone:[**Telephone/Fax (1) 2625**]
|
[
"V43.65",
"998.89",
"459.89",
"V58.61",
"728.89",
"E870.0",
"715.96",
"E878.2",
"276.7",
"276.69",
"V45.86",
"998.2",
"401.9",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.98",
"39.29",
"83.14"
] |
icd9pcs
|
[
[
[]
]
] |
5096, 5170
|
2772, 4247
|
303, 440
|
5303, 5303
|
1461, 2749
|
8177, 8358
|
932, 950
|
4357, 5073
|
5191, 5282
|
4273, 4334
|
5486, 7750
|
7776, 8154
|
965, 1442
|
240, 265
|
468, 722
|
5318, 5462
|
744, 856
|
872, 916
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,585
| 116,287
|
18111
|
Discharge summary
|
report
|
Admission Date: [**2145-2-27**] Discharge Date: [**2145-3-11**]
Date of Birth: [**2064-10-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
GNR bacteremia
Major Surgical or Invasive Procedure:
Continuous Bladder Irrigation
Central Line Placement
History of Present Illness:
80M history of DM2, HTN, prostate CA 8 yrs ago sp brachytherapy,
recent admission to NEBH on [**2145-2-8**] for TKR for osteoarthritis
who presents from rehab for a fever to 103 this morning and was
subsequently sent to the [**Hospital1 18**] ER.
In the ED inital vitals were, 07:56 10 101.8 116 115/63 18 96%
RA. There has been no swelling or drainage at the surgical site.
He endorses feeling fine but did have chills and sweats.
Patient had HR in 150s initially on monitor that then decreased
after 45 seconds. EKG (per ED read) showed sinus tachycardia
with frequent PACs, no overt ischemic changes. His rate
subsequently decreased, but then while he spiked a fever, his HR
went to 140-150s with subsequent drop in blood pressure to
90/50s and then consistent SBP 80s despite IVF. They then
discovered Tele showed new onset A fib HR 140-150s. He was give
10mg IV dilt once and HR improved to 120s. Also given 4 L NS. UA
was positive and CBC showed WBC 12 with 93 Neuts. He was then
started on vancomycin 1 gm IV and zosyn 4.5 g IV in addition to
acetaminophen 1000 mg. R IJ was placed for hypotension despite
IVF rescusitation with initiation of levophed infusion at 0.1 to
maintain BPs.
CXR showed Right internal jugular catheter tip terminates at the
approximate level of the cavoatrial junction. Very slight
increase in pulmonary vascular prominence is consistent with
interval intravenous hydration. No pneumothorax detected.
Labs were significant for initial lactate 2.5 --> 2.3 (after 3 L
IVF). UA: SG 1.014, LE large, blood large, protein 100, RBC 38,
WBC > 182, many bacteria, 0 epi with many WBC clumps. Chem
significant for BUN 34, Cr 3.0 (pre-op Cr at NEBH was 1.9). AG
18. WBC 11.7, Hct 30.7, Plats 500.
Ortho was consulted in the ED regarding the knee, they recc
imaging.
Most recent Vitals prior to transfer: 98.3, HR 140, RR 33, 96%
RA, 117/63 on levophed 0.1mcg/kg/min.
Admit to [**Hospital Unit Name 153**] for urosepsis.
On arrival to the ICU, pt is tachy to 150s, dyspneic, able to
talk in sentences. Says he feels "great." Denies any history of
A fib with RVR. Says he has been drinking normally, thinks his
urine ouput is normal. Denies any difficulty starting his
stream. No abd pain, no diarrhea, no chest pain, no pneumonia.
Past Medical History:
Prostate CA sp brachytherapy - 8 yrs ago
HTN
DM2
osteoarthritis sp TKA
Social History:
non smoker, no ETOH. Lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] alone. WIdow. 1
daughter, 5 grandchildren.
Family History:
no FH of heart disease of cancer
Physical Exam:
Admission Exam:
Vitals: afebrile, HR 144, 134/67, RR 22, 100%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pale appearing
Neck: supple, JVP not elevated, no LAD
Lungs: Anteriorly: Clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining cloudy urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Exam:
AVSS breathing comfortably on room air
Lungs: Anteriorly: Clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear urine
Pertinent Results:
===================
LABORATORY RESULTS
===================
Admission Labs:
WBC-11.7* RBC-3.54* Hgb-10.6* Hct-30.7* MCV-87 RDW-12.9 Plt
Ct-500*
--Neuts-93* Bands-4 Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
PT-15.7* PTT-24.7* INR(PT)-1.5*
Glucose-218* UreaN-84* Creat-3.0* Na-133 K-3.6 Cl-94* HCO3-21*
ALT-32 AST-39 AlkPhos-262* TotBili-0.8
Lipase-24 cTropnT-0.04* CK-MB-3 cTropnT-0.06*
Calcium-8.5 Phos-3.8 Mg-2.2 TSH-0.90
Lactate-2.5*
=============
MICROBIOLOGY
=============
Micro:
Blood Culture, Routine (Final [**2145-3-3**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES STRAIN 1.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI. FINAL SENSITIVITIES STRAIN 2.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI. FINAL SENSITIVITIES STRAIN 3.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | ESCHERICHIA
COLI
| | |
AMPICILLIN------------ 4 S 4 S 4 S
AMPICILLIN/SULBACTAM-- 4 S 4 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 <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
Aerobic Bottle Gram Stain (Final [**2145-2-27**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 2202 ON
[**2-27**] - 4I.
GRAM NEGATIVE ROD(S).
URINE CULTURE (Final [**2145-3-1**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
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---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood Cultures ([**2-28**] and [**3-1**]): NGTD
==============
OTHER STUDIES
==============
Imaging:
[**2-27**] CXR: Portable chest radiograph demonstrates interval
placement of a right central venous line with tip terminating at
the cavoatrial junction. No pneumothorax evident. Otherwise,
exam is unchanged with persistence of the left lower lung faint
opacity, morel likely atelectasis although developing
consolidation/pneumonia not excluded.
[**2-27**] knee xray: No acute fracture or dislocation. Possible small
suprapatellar joint effusion. Status post right knee replacement
without evidence of hardware complication.
[**3-1**] Renal U/S:
FINDINGS:The kidneys measures 11cm. There is no evidence of
hydronephrosis, renal masses or nephrolithiasis bilaterally. The
corticomedullary differentiaion is well preserved. The bladder
is collapsed around a Foley catheter.
IMPRESSION: No evidence of hydronephrosis.
[**3-1**] LENI: IMPRESSION:
No evidence of deep venous thrombosis in bilateral lower
extremities.
[**3-1**] ECHO:
The left atrium is elongated. The estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thicknesses and
cavity size are normal. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved global
biventricular systolic function. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Mild mitral and tricuspid regurgitation. Borderline
pulmonary hypertension.
[**2-28**]: RUQ U/S:
IMPRESSION: Normal right upper quadrant ultrasound.
CT Head W/O Contrast [**2145-3-7**]:
IMPRESSION: No evidence of hemorrhage or infarction. If there
are concerns
for intracranial infection an MR with contrast will be far more
sensitive.
Discharge Labs:
[**2145-3-11**] 03:29AM BLOOD WBC-6.0 RBC-3.08* Hgb-9.0* Hct-27.4*
MCV-89 MCH-29.3 MCHC-32.9 RDW-15.9* Plt Ct-150
[**2145-3-11**] 03:29AM BLOOD PT-17.8* INR(PT)-1.7*
[**2145-3-11**] 03:29AM BLOOD Glucose-101* UreaN-22* Creat-1.8* Na-140
K-3.1* Cl-108 HCO3-22 AnGap-13
[**2145-3-5**] 07:05AM BLOOD ALT-534* AST-74* LD(LDH)-258* CK(CPK)-58
AlkPhos-291* TotBili-0.6
[**2145-3-10**] 05:37AM BLOOD Mg-1.5*
Brief Hospital Course:
80M with history of DM2, HTN, prostate CA sp brachytherapy,
recent admission to NEBH on [**2145-2-8**] for TKR for arthritis who
presented from rehab for a fever, tachycardia, hypotension,
consistent with septic shock.
ACTIVE ISSUES BY PROBLEM:
# Septic Shock secondary to E. Coli septicemia: leukocytosis,
fever, tachycardia, and hypotension requiring pressors, and
elevated lactate and creatinine on admission, consistent with
septic shock. Urine looked grossly infected, so urosepsis
suspected. He was started on cefepime and vancomycin for broad
coverage. Levophed was started in the ED, however this was
changed to neosynephrine on arrival in the ICU in order to
better control atrial fibrillation with RVR (see below).
Multiple fluid boluses were given, however blood pressures
continued to remain low, so neo was uptitrated. Lactate rose
from 2.3 to 7.2 within hours of arrival. Blood cultures grew
GNRs in [**5-5**] bottles within 12 hours, and urine culture also grew
GNRs (e.coli), confirming high grade bacteremia from urosepsis.
Pressors were able to be discontinued on [**2-28**]. Blood pressures
remained acceptable afterward, with intermittent need for fluid
boluses during ICU stay. After speciation of the blood and
urine, we changed ciprofloxacin. Ciprofloxacin transitioned to
ceftriaxone on [**2145-3-7**] out of concern ciprofloxacin could be
contributing to delirium. This should continue through [**2145-3-14**].
A PICC line was placed on [**2144-3-9**].
.
# Chest Pain/ Melena/ Black Esophagus/ Candidal esophagitis:
Patient had one episode of melena in the ICU but no further and
Hct stable. He did, however, report chest pain worse with
eating and thus on transfer to floor there was concern for ulcer
or other acute GI process. EGD on [**2145-3-5**] showed black
esophagus, likely due to ischemia in the context of hypotension
and hypoperfusion while he was septic. He was managed
supportively with [**Hospital1 **] PPI, sucralfate, and fluconazole for
likely [**Female First Name (un) **] esophagitis. He did well and chest pain
resolved. He had no signs of bleeding with advancement of diet
back to full (he was made NPO) or with initiation of
anticoagulation. His fluconazole was changed to po on [**2145-3-8**]
with plan to continue this through [**2145-3-14**]. He should continue
on oral nystatin swish and swallow x 2 weeks after cessation of
systemic antibiotics. He should have a repeat EGD in [**5-7**] weeks.
- When odynaphagia improves, transition from IV to PO PPi
# Acute toxic metabolic encephalopathy: The patient had
confusion in the ICU with disorientation that was thought
attributed to critical illness. He showed gradual improvement.
Head CT showed no acute injury (concern for watershed infarcts
given other signs of hypoperfusion injury) and work up for other
sources of infection including UA and repeat blood cultures was
negative. MRI was discussed with patient's HCP/daughter but it
seemed unlikely to change management as hypoperfusion injury
would be largely supportive and patient would require sedation
for MRI which may further worsen his delirium.
- At the time of discharge, the patient was at his mental
baseline per his daughter.
# Atrial fibrillation: No previous history of afib, acute
development likely secondary to sepsis. Troponin slightly
elevated, however likely due to demand ischemia from tachycardia
and renal failure, no new ST changes on ECG. On arrival in the
ICU, levophed was stopped in case this was contributing/driving
the Afib with RVR. He was also given verapamil 2.5 mg IV then
metoprolol 5 mg IV with good control of heart rate (dropped from
130s-->80s), however remained in atrial fibrillation. Given his
CHADS score of 3, he was started on a heparin gtt for
anticoagulation which was stopped after he developed melena and
hematuria. After several days of improvement his heparin drip
was restarted without overt bleeding and warfarin was restarted.
Given ongoing use of abx, fluconazole and poor po intake, his
warfarin/INR will need to be checked/followed VERY carefully.
Goal INR [**3-5**]. Last dose of 1mg given on [**3-10**]. Recommend
increasing to 2mg daily starting [**3-11**].
- Given the AF was in the setting of sepsis, the patients new
B-blocker and Calcium Channel blocker could be titrated down and
his home SBP meds restarted (once his Cr is close to baseline)
# Hematuria: Thought to be related to UTI in a patient with a
friable bladder post-radiation and anti-coagulation. Required
foley placement with CBI, which clotted a few times. Eventually
transitioned off CBI with plan for outpatient urology followup.
Urology was consulted and they recommended outpatient cystoscopy
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] and proceding with systemic
anticoagulation despite "pink colored" urine. They stated if
patient again developed clots to reconsult them and they would
reconsider inpatient cystoscopy. Foley was continued due to
skin excoriation in perineum.
- Urine was clear on [**2145-3-11**]. Consider discontinuation of foley
later on [**3-11**] or on [**3-12**].
# Acute Renal Failure: Likely acute on chronic as baseline Cr
1.9 per NEBH records and he had protein in UA. Cr was 2.3 at
rehab on the day of admission, was elevated to 3.0 on
presentation. Likely etiologies include pre-renal hypovolemia vs
ATN from sepsis vs post-obstructive process in pt with hsitory
of prostate CA. Renal US showed no acute pathology. After
transfer to floor patient had progresive improvement of his Cr
as likely acute tubular necrosis resolved.
** On discharge Cr is 1.8**
# Anion gap then non-anion gap metabolic acidosis: Anion gap 19
on admission, likely secondary to lactic acidosis and acute
renal failure. His gap closed but remained with hyperchloremic
metabolic acidosis likely secondary to normal saline volume
resuscitation.
***This resolved after fluid resuscitation stopped and patient
able to eat. On discharge was ****
# Shock liver: Patient had markedly elevated LFTs at
presentation likely due to hypoperfusion and shock liver. These
dramatically improved after hemodynamics were corrected.
# Malnutrition/Poor po's: With acute illness, odynophagia in
the acute setting (with necrotic esophagus) though this latter
seems to have resolved, patient's po intake has been very poor.
His diet was liberalized to allow for him to eat whatever suited
him. He requires encouragement to take any po's.
INACTIVE ISSUES BY PROBLEM:
# Anemia: HCT 31, although appears to be higher then recent 27.
Likely reflective of recent ortho surgery and blood loss.
**Hct on d/c is 27**
# S/p TKR: Ortho saw pt in ED, felt knee healing well, signed
off. Knee film unremarkable.
# DM2: Held glipizide 10mg. Started on glarine 10U and ISS
# HTN: Given hypotension, held home antihypertensives while in
house (amlodipine 10mg) as pt was being treated with b-blocker
and calcium channel blockers.
# Prostate CA: appears to be in remission, sp brachytherapy.
.
TRANSITIONAL ISSUES:
Full Code
Daughter ([**Doctor First Name **]) [**Telephone/Fax (1) 50108**]
Verbal signout over the phone was given to the patients PCP
prior to discharge to rehab.
Pt will need to be followed for new onset of AF in regards to
anticoagulation.
Medications on Admission:
HCTZ 25mg
Glargine 10 U
ISS at rehab with humalog
MVT
Amlodipine 10mg
tylenol 1000mg
simvastatin 20mg
colace
bisacodyl
MOM
[**Name (NI) **]
Discharge Medications:
1. CeftriaXONE 1 gm IV Q24H
Switched from ciprofloxacin on [**2145-3-7**]. End date: [**2145-3-14**]
2. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
3. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
4. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Last day [**3-14**].
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): swish and swallow last day [**2145-3-28**] .
8. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
9. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
12. Ondansetron 4-8 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses:
Urosepsis complicated by bacteremia with E. coli
Shock Liver
Acute Renal failure likely secondary to acute tubular necrosis
Acute toxic/metabolic encephalopathy
Hematuria
Atrial Fibrillation
Secondary Diagnoses:
Diabetes Mellitus type 2
History of prostate cancer
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:
You were admitted with a severe bloodstream infection that
originated in the urine. You were treated with antibiotics,
fluids, and drugs to help your blood pressure and you improved.
While your blood pressure was low you sustained injury to your
liver, kidneys, and esophagus that are all improving. You will
need time to recover from this severe illness and to continue to
rehabilitate from your knee surgery. You will be discharged to
a rehabilitation facility to complete this recovery.
Your medications have been changed. Please take all medications
as prescribed and keep all discharge appointments.
Followup Instructions:
Please make an appointment to follow-up with your PCP post
discharge
|
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3,703
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|
45055
|
Discharge summary
|
report
|
Admission Date: [**2173-8-16**] Discharge Date: [**2173-8-21**]
Service: MEDICINE
Allergies:
Bactrim / Procardia / Sulfa (Sulfonamides) / Sulfamethoxazole /
Trimethoprim
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Sleep Study
Fluoroscopic swallow study
History of Present Illness:
This is an 87 year old man with history of Diabetes Mellitus,
Hypertension, diverticulosis status post partial colectomy,
depression, CKD, vascular dementia, Parkinsonism, and status
post pacemaker who presented to the ED from [**Hospital 100**] Rehab for
unresponsiveness. At 6:45AM, patient was noted to be in
respiratory distress, O2 sat was 91%, and was placed on NRB. A
nurse walking by had noted that he was tachypneic and called a
code blue. Pulse was recorded as 81, BP 100/50, O2 sat 100% on
NRB. ABG: 7.21/101/92. Glucose 242. Received Lasix 60 mg IV.
.
In the ED: V/S afebrile, BP 110/50, RR 20s on NRB O2 sat 91%.
Patient was placed on BiPAP. Nitro gtt was started for CHF but
SBP in 80s so it was stopped. Given hypoxia, concern was for PE.
Bilateral LENIS were done which was negative. Pt received
vancomycin, ceftriaxone, and levaquin. Head CT was neg. for
bleed. Patient was then transferred to MICU for further
management. Patient was non-communicative at time of exam and
history was obtained from medical record and from family report.
.
Of note, patient was just discharged yesterday from [**Hospital1 18**] for
hypoxia/CHF exacerbation. Patient presented on that admission
with SpO2 76% on NRB and an arterial blood gas of 7.34/66/53. He
was started on BiPap (FiO2 60%, PEEP 5, PS 10) with improvement
of O2 sat to 90-100% which was weaned over several hours. PE was
on the differential during this last hospitalization as he has
history of RA thrombus so TTE was done which showed no thrombus,
LENIS were also negative. He was started on Lasix and was weaned
down to 4L NC on discharge.
.
On review of symptoms, family denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. Denies recent fevers,
chills or rigors. He has a chronic raspy cough per the daughter.
[**Name (NI) **] of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations. Daughter is not aware of any dyspnea on exertion,
orthopnea. She has noted that he had ankle edema ("elephant
legs") in the late winter and early spring and had asked [**Hospital1 100**]
Senior Life to start the patient on Lasix. Daughter denies any
syncope or presyncope. He has poor functional capacity at
baseline.
Past Medical History:
1. Type 2 DM
2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter
3. HTN
4. Diverticulosis, s/p partial colectomy
5. Depression
6. CRI (baseline Cr 1.3-1.7)
7. Parkinson's disease
8. Vascular dementia
9. Pacemaker c/b lead thrombus. Previously followed by Dr [**Last Name (STitle) **]
for "episodic unreponsiveness." This resolved with pacemaker
adjustment. Recently seen by Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] for
the thrombus, anticoagulation deferred for h/o falls, unsteady
gait, and confusion.
11. s/p hip fracture requiring ORIF in [**3-/2172**] with a
complicated medical course including hypoxic respiratory
failure.
12. Chronic diastolic dysfunction.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient resides at
[**Hospital 100**] Rehab.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 96.0 ax, BP 126/62, HR 78, RR 24, O2 100% on BiPap 15/5
Gen: Unresponsive.
HEENT: NCAT. Sclera anicteric. Constricted pupils. MMM.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No murmurs noted.
Chest: No accessory muscle use. Decreased breath sounds
throughout, diffuse rhonchi. No crackles, wheezes.
Abd: Normoactive, soft, NT/ND, No HSM. No abdominial bruits.
Ext: No femoral bruits. Trace pedal edema bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: Minimally responsive to sternal rub.
.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
.
.
On discharge exam not significantly changed except patient's
mental status has considerably improved. Vital signs stable and
within normal limits (no further supplementary oxygen
requirement). Alert and Oriented *2 (not to date) and
responding to some questions appropriately though confused with
others. Conversational. Lungs clear to auscultation
bilaterally.
Pertinent Results:
<b>LABORATORY RESULTS<B>
=======================
Labs on Admission
WBC-7.2 RBC-4.27* Hgb-12.5* Hct-37.9* MCV-89 Plt Ct-130*
PT-13.0 PTT-28.5 INR(PT)-1.1
Glucose-198* UreaN-43* Creat-1.8* Na-144 K-3.8 Cl-99 HCO3-36*
AnGap-13
.
ABG on [**2173-8-16**]: ART Rates-/25 PEEP-5 FiO2-35 pO2-76* pCO2-78*
pH-7.30* calTCO2-40* Base XS-8 Intubat-NOT INTUBA
.
ABG on [**2173-8-18**]:ART pO2-76* pCO2-62* pH-7.41 calTCO2-41* Base
XS-11 Intubat-NOT INTUBA
.
Labs on Discharge
WBC-6.7 RBC-4.20* Hgb-12.1* Hct-38.2* MCV-91 Plt Ct-159
Glucose-205* UreaN-42* Creat-1.7* Na-145 K-4.3 Cl-100 HCO3-39*
AnGap-10
ALT-15 AST-15 LD(LDH)-107 AlkPhos-62 TotBili-0.3
Calcium-9.4 Phos-3.1 Mg-2.4
.
Cardiac Enzymes:
Trop: 0.03-0.02-0.02
CK-MB: [**3-19**]-ND
.
.
.
<b>RADIOLOGY<B>
===============
CT HEAD on [**2173-8-16**]
IMPRESSION:
No acute intracranial pathology. Atherosclerotic disease and old
lacunar-type infarcts as described above.
.
CT Chest on [**2173-8-18**]
IMPRESSION:
1. Technically limited CT due to submaximal inspiratory level
and respiratory motion. No substantial change in atelectasis
involving the majority of right lower lobe adjacent to an
elevated right hemidiaphragm. High-attenuation foci peripherally
could potentially represent aspirated barium if the patient has
had a prior oral contrast examination.
2. No short interval change in pseudoaneurysm since recent CTA.
.
.
<B>OTHER STUDIES<b>
Video Swallow Study [**2173-8-20**]:
SUMMARY:
Pt presents with mild-moderate oropharyngeal dysphagia as
described above. There was premature spillage of liquids and
swallow initiation delay which resulted in silent aspiration of
thin liquids before and during the swallow and laryngeal
penetration of nectar thick liquids during the swallow. Pt was
not sensate to aspiration and did not produce spontaneous cough.
Treatment techniques were not effective in reducing penetration
or aspiration. Pt also presented with prolonged mastication of
solids. This represents a decline in swallow function since
pt's
most recent videoswallow study, performed on [**2173-6-2**] while pt
was
at [**Hospital6 459**].
Based on these deficits, I recommend a PO diet of ground solids
and nectar thick liquids at this time. Pt should have PO meds
whole in puree. Pt is still at risk for intermittent aspiration
with nectar thick liquids due to laryngeal penetration, though
it
was not observed on our study. However, I believe it is worth
trialing this diet in hopes that these restrictions will have a
positive effect on pt's respiratory symptoms. If there is
continued concern for aspiration on this diet, repeat
videoswallow study is recommended with consideration of further
restricting pt's liquid intake.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4, mild-moderate dysphagia.
RECOMMENDATIONS:
1. PO diet: ground solids, nectar thick liquids
2. PO meds whole in puree
3. Supervision and assistance with meals as needed to maintain
standard aspiration precautions.
4. If there is continued concern for aspiration on this diet,
repeat videoswallow study is recommended with consideration of
further restricting pt's liquid intake.
.
Sleep Study from [**2173-8-20**]:
IMPRESSION:
This was an abnormal portable polysomnogram. There was
presumptive evidence of significant nocturnal hypoventilation
and
hypoxemia in the form of persistently low oxygen saturations.
Moreover, there were evidence for severe chemoreflex-mediated
sleep-disordered breathing.
.
Suggest empiric trial of nocturnal BiPAP 12/6 with backup rate
of
8 breaths per minute and 2L/min of oxygen. If he tolerates
this,
he can go home with this.
Brief Hospital Course:
The patient is an 87 year old man with a history of Diabetes,
Hypertension, diastolic CHF, status post pacemaker, CKD,
Parkinson's, and vascular dementia who presented for
unresponsiveness and was found to be in hypercarbic respiratory
failure.
.
# Acute mental status changes: On arrival the patient was
minimally responsive to sternal rub and did not withdraw
extremities to pain. Given the ABG obtained at the outside
facility the likely cause of his unresponsiveness was
hypercarbic respiratory failure. Urine tox for opiates was
negative and a head CT showed no acute process. There were no
signs of infection as the patient was afebrile, had no
localizing symptoms, and had no leukocytosis. BiPAP was started
and patient's mental status resolved with improving ABG's over
the next two to three days so that on day of discharge he was at
his baseline mental status.
.
# Respiratory failure: Pt was in hypercarbic respiratory failure
at [**Hospital1 100**]. There was strong suspicion he is a CO2 retainer at
baseline as also had elevated CO2's during last hospitalization.
The cause of this was difficult to elucidate. Initially, we
screened for pharmacologic causes of altered mental status, but
the urine tox screen was negative. Pramipexole and Trazodone
were both potentially sedating medications so trazodone was
stopped and pramipexole dose was halved. Other etiologies of
potential respiratory failure were also pursued. Pulmonary was
consulted and the general pulmonary team didn't think there was
a primary pulmonary process for this problem, especially with
negative chest CT. Concern was also raised for aspiration, as
patient seemed to be choking on thin liquids. Speech and
swallow performed a fluoroscopic swallow evaluation and did did
document dysphagia, but patient was already on aspiration
precautions as an outpatient so an acute aspiration episode was
considered a less likely cause of respiratory failure. Another
etiology pursued was sleep apnea as the patient had a history of
snoring. Sleep consult was obtained and inpatient sleep study
showed central sleep apnea pattern and recommended BiPAP.
Finally, to screen for possible causes of central sleep apnea,
neurology was consulted and said Parkinsonism or vascular
dementia are possible but unlikely causes of central apnea.
Patient was thus treated empirically with BiPAP and discharged
with prescription for this therapy.
.
# Pump: Patient has history of diastolic dysfunction and
inadequate control of his diastolic heart failure was considered
one possible contributing factor to his respiratory failure.
Thus, over the course of the hospitalization we worked to
optimize heart failure therapy titrating the patient's diuretic
and beta blocker as well as adding an ACE inhibitor for better
control of blood. Patient was initially diuresed about one and
a half liters then kept at relatively neutral fluid balance
therafter.
.
# CAD/Ischemia: EKG showed possible new T wave inversions at
admission but cardiac enzymes flat and never significant. ACS
considered extremely unlikely as cause for acute respiratory
decompensation and no further work-up was pursued.
.
# Rhythm: Patient was in NSR throughout hospitalization but
bizarre wide complex rhythm obtained from pacemaker recording.
EP evaluated and thought unlikely to be afib and was probably an
unusual sinus rhythm. The patient was followed on telemetry
throughout his hospitalization and had no clinically significant
dysrhythmias.
.
# Diabetes Mellitus Type II: The patient was maintained on
sliding scale insulin and was reasonably well controlled in the
hospital.
.
# Chronic Kidney Disease (baseline Cr 1.3-1.7): Patient remained
at stable Cr throughout addition of ACEi and other modifications
to HTN regimen. No acute issues.
.
# Parkinson's disease/Vascular Dementia/Depression: Very unclear
history of the exact etiologies of these processes. Unclear if
Parkinson's disease vs Parkinsonism as consequence of vascular
dementia. Patient's Pramipexole initially weaned down due to
fear of sedation but neurology said this could worsen dysphagia
so he was returned to his admission dose. Psychiatric
medications continued at home doses.
.
The patient was NPO initially but as his mental status cleared
he was allowed to eat. Liquids were thickened and he had ground
solids per Speech and Swallow reccs. he was maintained on SC
heparin for DVT prophylaxis. He was DNR but 1 shock was
allowed, which was confirmed by the [**Hospital 228**] health care
proxies. He was discharged to [**Hospital 100**] Rehab MACU after
stabilized on new medication regimen and probable cause of
hypercarbic episodes was discovered.
Medications on Admission:
Bupropion 75 mg [**Hospital1 **]
Calcium Carbonate 500 mg [**Hospital1 **]
Vitamin D3 400 DAILY
Citalopram 20 mg DAILY
Donepezil 10 mg PO HS
Ferrous Sulfate 325 mg DAILY
Pramipexole 0.25 mg PO TID
Docusate Sodium 100 mg [**Hospital1 **]
Bisacodyl 10 mg DAILY
Senna 8.6 mg [**Hospital1 **] PRN
Aspirin 325 mg DAILY
Glipizide 5 mg DAILY
Trazodone 25 mg qHS
Isosorbide Mononitrate 10 mg [**Hospital1 **]
Metoprolol Succinate 100 mg DAILY
Potassium Chloride 10 mEq PO MWF.
Cephalexin 500 mg Q24H
Iron 325 mg PO DAILY
Vitamin C 100 mg Daily
Vitamin B-12 1,000 mcg/mL SQ qMonthly
Melatonin 4 mg PO qHS.
Lasix 60 mg Daily
Discharge Medications:
1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
once a month.
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual
q 5 minutes x3 as needed for chest pain.
14. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
15. Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO every
six (6) hours.
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
17. Melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
22. BiPAP
Nasal CPAP w/PSV (BIPAP) Inspiratory pressure: 12 cm/h2o
Expiratory pressure: 6 cm/h2o Backup rate: 8 bth/min Supp O2: 2
L/min
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses:
===================
Sleep Apnea
Diastolic Heart Failure
.
Secondary Diagnoses:
====================
1. Diabetes Mellitus, type 2
2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter
3. Hypertension
4. Diverticulosis, s/p partial colectomy
5. Depression
6. Chronic Kidney Disease (baseline Cr 1.3-1.7)
7. Parkinson's disease
8. Vascular dementia
9. Pacemaker placed for "episodic unreponsiveness," which
resolved with pacemaker adjustment
10. s/p hip fracture requiring ORIF in [**3-/2172**] with a
complicated medical course including hypoxic respiratory
failure.
Discharge Condition:
Comfortable, not requiring O2, tolerating P.O.'s
Discharge Instructions:
You were admitted to the hospital because you were confused and
not thinking well. We believe this was due to you having low
oxygen in your blood and high carbon dioxide due to not
breathing adequately. This was most likely due to the fact that
you stop breathing when you sleep in addition to a bit a bit of
a worsening of your heart failure.
.
Your medications have been changed. You have been started on
LISINOPRIL, a medication to help control your blood pressure.
Your METOPROLOL XL dose was also increased to better control
your blood pressure. Your FUROSEMIDE (LASIX) dose has been
decreased in order to protect you from the combined affect of it
and LISINOPRIL on your kidneys. Your TRAZODONE has been stopped
as this medication might worsen your breathing at night.
.
You have also been started on BiPAP, a treatment to help your
breathing at night. This intervention should help you continue
to breathe adequately throughout the night and prevent episodes
of low oxygen and high carbon dioxide in the blood such as those
that brought you into the hospital.
.
Please keep all scheduled appointments as these are important to
maintain your health.
.
Please adher to a 2 gm sodium/day diet. Please call your doctor
or report to the ED if you have chest pain, shortness of breath,
Fever to 101 F, increased swelling of your legs, or any other
disturbing changes to your health.
Fluid Restriction:
Followup Instructions:
Gastroenterology:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-12-2**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2173-12-2**] 1:45
.
Cardiology:
You have a follow up scheduled for Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**9-20**] at 11am on [**Hospital Ward Name 23**] 7. His office can be reached at
[**Telephone/Fax (1) 62**]
.
You will need to follow up in sleep clinic in four to six weeks
to talk about how you're doing on BiPAP. Sleep clinic can be
reached at([**Telephone/Fax (1) 9525**].
|
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21,469
| 187,617
|
47513
|
Discharge summary
|
report
|
Admission Date: [**2142-5-14**] Discharge Date: [**2142-5-21**]
Date of Birth: [**2083-1-15**] Sex: M
Service: MED ONCOLO
HISTORY OF PRESENT ILLNESS: This is a 59 year old male with
a recently diagnosed pancreatic cancer in [**2142-1-6**],
who is status post chemotherapy, who presented to the
Emergency Department today with complaints of worsening
dyspnea on exertion, new onset of orthopnea and generalized
weakness in the setting of mild bright red blood per rectum.
His dyspnea on exertion began on Thursday and has been
progressively worsening such that he is no longer able to
climb a flight of stairs. No association with chest pain,
nausea, vomiting, diaphoresis. He has also had new onset of
orthopnea and is now sleeping in a recliner. He reports
generalized weakness since Saturday. He reports orthostatic
symptoms, dizziness when getting up out of chair.
He has no documented coronary artery disease but had an
exercise treadmill test with nuclear imaging in [**2140-1-7**] with moderate reversible inferior perfusion defect. His
last echocardiogram was also in [**2140-10-6**] with left
atrial enlargement, normal ejection fraction, minimal aortic
stenosis, one plus mitral regurgitation, one plus tricuspid
regurgitation.
Per the patient he was started on by mouth Lasix, unspecified
doses, last week, for fluid in his lungs. He reports not
feeling greatly shortness of breath at that time and that the
Lasix was started for radiographic findings rather than
symptoms. His dose was increased over the weekend because of
this progressive shortness of breath and he was told to go to
the Emergency Room on Monday if he did not improve.
He has had intermittent bright red blood per rectum for six
months, usually on toilet paper and sometimes in the stool.
The bleeding is small in amount and chronic. He denies any
melena.
REVIEW OF SYSTEMS: He denies fevers, chills, headache, upper
respiratory infection symptoms or cough. He does have a
chronic intermittent right upper quadrant pain, especially
after eating. He denies diarrhea, constipation, or
straining; no dysuria.
In the Emergency Room, he had a blood pressure of 75/46 and
an oxygen saturation of 87% on room air on arrival. His
rectal examination showed a small amount of red blood. A
nasogastric lavage showed bilious fluid. Initial hematocrit
was 17 with a potassium of 1.7. He received three liters of
normal saline, one unit of fresh frozen plasma, 40 mEq of
potassium by mouth and 40 mEq of potassium intravenously. He
was noted to be in atrial flutter with a controlled rate. He
was transferred to the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Pancreatic cancer first diagnosed in [**2142-1-6**],
after presenting with painless jaundice and acholic stools.
His CT scan showed a pancreatic mass. A biopsy showed
adenocarcinoma. He had metastatic lesions to the liver with
near complete portal vein obstruction, mild ductal dilatation
of the common bile duct and intrahepatic duct, ascites on a
CT scan from [**2142-4-5**]. He is status post Gemcitabine now
undergoing Gemcitabine and Cisplatin for chemotherapy.
2. Hodgkin's Disease diagnosed 30 years ago, status post
chest radiation therapy and splenectomy.
3. Prostate cancer diagnosed six years ago status post
radiation therapy.
4. Chronic obstructive pulmonary disease.
5. Hypertension.
6. Hypothyroidism.
7. Candidal esophagitis.
8. Gastritis.
9. Status post bilateral carotid endarterectomies.
MEDICATIONS ON ADMISSION:
1. Accupril 5 mg p.o. q. day.
2. Albuterol 2 puffs every four hours as needed.
3. Amoxicillin two grams before dental visits.
4. Enteric-coated aspirin 81 mg a day.
5. Cardizem 300 mg once every day.
6. Flovent two puffs twice a day.
7. Isosorbide mononitrate 60 mg once a day.
8. Levoxyl 88 micrograms p.o. q. day.
9. Lipitor 10 mg p.o. q. day.
10. Plavix 75 mg p.o. q. day.
11. Serevent two puffs twice a day.
12. Theophylline 200 mg three times a day.
13. Reglan with meals.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] used to work in
manufacturing. He has three children in the [**Location (un) 86**] area. He
is a former smoker tho quit 13 years ago. Minimal alcohol
use.
FAMILY HISTORY: Sister with breast cancer.
PHYSICAL EXAMINATION: Temperature 98.6 F.; heart rate 84
laying down and 109 sitting up; blood pressure 102/49 laying
down, 98/46 sitting up; respiratory rate 24; 97% on three
liters. In general, alert, very pleasant, in no acute
distress. No pallor. HEENT: Pupils are equal, round and
reactive to light. Scleral icterus. Oropharynx mild thrush.
Neck with jugular venous pressure of about 8 to 9
centimeters. No lymphadenopathy or thyromegaly. Heart is
regular rate and rhythm, I/VI high pitched systolic murmur at
the left lower sternal border, no gallop. Lungs are clear to
auscultation bilaterally. Abdomen is soft, nondistended,
tender in the right upper quadrant. No percussion tenderness
or rebound. Normoactive bowel sounds. Rectal in the
Emergency Department showed red blood. Extremities had no
edema.
LABORATORY: White blood cell count of 8.0, hematocrit of
17.2, platelets of 181. Sodium of 143, potassium 1.7,
chloride of 122, bicarbonate of 15, BUN of 13, creatinine
0.3, glucose of 54. INR of 1.9, PT of 17.
Calcium of 3.6, magnesium of 0.8, ALT of 60, AST of 41,
alkaline phosphatase 264. Total bilirubin of 2.5.
Chest x-ray showed bibasilar atelectasis, no pneumonia. An
EKG showed atrial flutter with a rate in the 100s. Normal
axis, but [**Street Address(2) 2914**] depressions in V4 through V6 with T
wave inversions and no evidence of heart strain.
He had a chest CT scan with angiography done which showed
multiple bilateral pulmonary emboli and possible pulmonary
metastatic disease.
ASSESSMENT: This is a 59 year old male with a recently
diagnosed pancreatic cancer who presents with shortness of
breath found to have pulmonary emboli on chest CT scan, also
with concurrent bright red blood per rectum.
HOSPITAL COURSE BY SYSTEM:
1. PULMONARY: The patient had multiple bilateral pulmonary
emboli. At first it was not clear given his bright red blood
per rectum whether or not he should be started on
anti-coagulation, however, GI was called, who advised to get
an esophagogastroduodenoscopy and colonoscopy within the next
few hours after his admission and defer any anti-coagulation
until after that.
Thus, the patient underwent a colonoscopy and nothing was
seen and he was then started on heparin and Coumadin until
his INR became therapeutic. At the time of his discharge,
the patient's INR was therapeutic on Coumadin alone.
The patient was also seen to have a question of a pneumonia
based on a follow-up chest x-ray. He was started on
Levofloxacin and received a five day course.
For his chronic obstructive pulmonary disease, the patient
was continued on Salmeterol inhalers, ipratropium inhalers
and fluticasone inhalers. At the time of his discharge, his
room air oxygen saturation was 95% sitting, although 87%
ambulatory. Thus, he was sent home with home oxygen.
2. GASTROINTESTINAL: As mentioned prior, the patient was
admitted with some bright red blood per rectum. The patient
underwent a colonoscopy by the Gastrointestinal Service, who
did not find any lesions. Thus, it was thought that he was
likely having these bleeds secondary to radiation proctitis.
He was transfused appropriately and his hematocrit
stabilized.
3. CARDIOVASCULAR: The patient had a history of presumed
coronary artery disease as he had had a prior positive stress
test in the past and has been placed on Imdur to prevent any
symptoms of chest pain. The patient demonstrated atrial
flutter and he had been on Diltiazem to help control his
rate. No further changes were made. He was ruled out for a
myocardial infarction.
The patient has a history of hypercholesterolemia and was
continued on Atorvastatin. The patient's blood pressure was
not elevated while he was hospitalized, thus, his usual home
Accupril was held. It was thought that he would follow-up
with his primary care physician when he would have his blood
pressure rechecked and it would be determined whether he
would need his Accupril or not.
4. ENDOCRINE: The patient has a history of hypothyroidism.
He was continued on his levothyroxine.
DISCHARGE DIAGNOSES:
1. Pancreatic cancer.
2. Chronic obstructive pulmonary disease.
3. Hypertension.
4. Hypothyroidism.
5. Pulmonary emboli.
6. Pneumonia.
7. Atrial flutter.
8. Candidal esophagitis.
9. Gastritis.
DISCHARGE MEDICATIONS:
1. Warfarin 5 mg p.o. q. h.s.
2. Fluticasone 110 micrograms two puffs inhaled twice a day.
3. Levothyroxine 88 micrograms p.o. q. day.
4. Atorvastatin 10 mg p.o. q. day.
5. Pantoprazole 40 mg p.o. q. day.
6. Ipratropium two puffs inhaled four times a day.
7. Diltiazem 50 mg p.o. four times a day.
8. Phexofenadine 60 mg p.o. twice a day.
9. Salmeterol two puffs twice a day.
10. Imdur 60 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient should follow-up with his primary care
physician regarding his Accupril as his blood pressure was
not elevated in the hospital. Of note, his long-acting
Cardizem was changed to a four times a day Diltiazem as his
blood pressure had been on the low side and we felt that the
patient should not be taking a sustained release tablet if he
was feeling lightheaded; this can be also followed up by his
primary care physician.
2. The patient needs home oxygen with ambulation.
3. He needs his INR drawn by Visiting Nurses Association
services and fax the results to Dr.[**Name (NI) 8949**] office.
4. The patient should follow-up with Dr. [**Last Name (STitle) **] on
Thursday, [**5-24**]. He should have his INR checked on
Tuesday, [**5-22**], and Saturday [**5-26**]. This is very
important since patient had been on Levofloxacin in the
hospital which can effect the level of Coumadin metabolism,
thus altering the INR level.
5. The patient should call Dr.[**Name (NI) 8949**] office to verify
and confirm his appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], M.D. [**MD Number(1) 8654**]
Dictated By:[**Last Name (NamePattern4) 26118**]
MEDQUIST36
D: [**2142-5-27**] 17:19
T: [**2142-5-27**] 20:51
JOB#: [**Job Number 100460**]
|
[
"486",
"578.9",
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"397.0",
"427.32",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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4292, 4320
|
8417, 8620
|
8643, 9058
|
3521, 4055
|
9082, 10401
|
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|
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|
1892, 2650
|
173, 1872
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,732
| 196,123
|
22146
|
Discharge summary
|
report
|
Admission Date: [**2105-11-7**] Discharge Date: [**2105-11-17**]
Date of Birth: [**2059-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Acetaminophen overdose with encephalopathy.
Major Surgical or Invasive Procedure:
-Mechanical Ventilation
-Dobhoff tube placement
-Sub-clavian line placement
History of Present Illness:
46-y.o. female went to dinner with mother on [**2105-11-3**], she
stayed with mother that evening, next morning [**2105-11-4**] she left
a note to mother to let her sleep in, mother left for errands
and returned to find her lying unresponsive with bottles of
seroquel, campral, lithium, clonidine, sumatriptan, tylenol PM,
and topamax. Also found open bottle of vodka, one teaspoon
gone, next to patient. Mother called EMS, patient brought to
[**Hospital3 **] Hospital, and she was intubated for airway protection.
.
Initially she was unresponsive to painful stimuli. Her best
mental status was in the following few days, during which she
was following commands. However this morning, she stopped
following commands. It is unclear if she was off sedation
completely, as she had been on propofol gtt, which was stopped
at 5am, resumed at 9:30am, and last exam timed at 10:30am.
.
She was found to have acetaminophen level of 403 -> 532.9([**11-4**])
-> 13.5 ([**11-6**]), and has trended downwards to 9.8 on transfer.
Initially worsening transaminitis up to ALT 2509 / AST 7009,
improving since. INR 1.8 -> 2.0 -> 1.5 (on transfer). Lactic
acid 9.1 -> 1.8 (HD#2).
Past Medical History:
H/o EtOH abuse, sober for 17 years involved in AA with relapse
in [**2104**] (per OMR note [**2104-7-15**]), drank a lot of vodka x 2 years
prior to last 5 weeks which she has spent in [**Hospital3 **] with
mother (clinical social worker), migraines, bipolar disorder
(uncontrolled, recent psych admission at [**Hospital1 1774**]), depression.
.
Past Surgical History:
Facial surgery, knee surgery.
Social History:
Denies recreational drug use. Married but separated, marital
problems, husband has restraining order against patient for
charges of assault and battery. Lived in [**Location **], but for
last 5 weeks was living in [**Hospital3 **] with mother.
Family History:
No known family history of suicidal behavior.
Physical Exam:
Physical Exam On Admission:
T: 101.7 P: 101 BP: 123/61 RR: 25 O2sat: 98% CMV 500x14/5 @
50%
General: awake, NAD
HEENT: NCAT, EOMI, anicteric, PERRL
Heart: RRR
Lungs: CTAB, normal excursion, intubated
Abdomen: soft, NT, ND
Neuro: GCS 9T (E4, V1T, M4), not following commands
Extremities: WWP, 1+ peripheral edema, 2+ B radial/DP pulses
.
ON DISCHARGE:
Vitals: 98.7, 158/96 (145/87), 76, 95RA
General: Patient appears hyperalert, with wide pupils, constant
movement, darting glances, pressured speech and [**Last Name (un) 15970**] mood.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal, no
asterixis
Pertinent Results:
---------------
ADMISSION LABS:
---------------
[**2105-11-7**] 08:06PM WBC-5.6 RBC-3.54* HGB-11.5* HCT-33.2* MCV-94
MCH-32.5* MCHC-34.6 RDW-15.4
[**2105-11-7**] 08:06PM NEUTS-79.4* LYMPHS-9.0* MONOS-4.4 EOS-6.6*
BASOS-0.5
[**2105-11-7**] 08:06PM PLT COUNT-129*
[**2105-11-7**] 08:06PM PT-18.0* PTT-41.8* INR(PT)-1.6*
[**2105-11-7**] 08:06PM GLUCOSE-90 UREA N-19 CREAT-1.2* SODIUM-147*
POTASSIUM-3.3 CHLORIDE-119* TOTAL CO2-18* ANION GAP-13
[**2105-11-7**] 08:06PM ALT(SGPT)-2095* AST(SGOT)-3128* LD(LDH)-641*
ALK PHOS-106* TOT BILI-1.5
[**2105-11-7**] 08:06PM LIPASE-292*
[**2105-11-7**] 08:06PM ACETMNPHN-NEG
--------
IMAGING
---------
MR head [**2105-11-8**]:
1. No evidence of intracranial abnormality.
2. Incidental note of opacification of the bilateral mastoid,
sphenoid, and posterior ethmoid air cells.
.
[**11-12**] LENIs;
IMPRESSION:
No right or left lower extremity DVT
.
[**11-12**] CXR:
FINDINGS: As compared to the previous radiograph, the patient
has been
extubated. The nasogastric tube and the left subclavian access
line are in unchanged position. The signs indicative of fluid
overload have decreased in the interval. There is a remnant left
and right medial basal atelectasis, partially with air
bronchograms. Borderline size of the cardiac silhouette. No
pleural effusions. No newly appeared parenchymal opacities. No
pneumothorax.
[**11-8**] Liver US:
1. Grossly unremarkable liver with patent hepatic vasculature,
normal Doppler
waveforms, and appropriate directional flow.
2. Cholelithiasis without evidence of acute cholecystitis.
[**11-13**] VIDEO SWALLOW:
FINDINGS: Barium passes freely through the oropharynx and
esophagus without evidence of obstruction. There was no gross
aspiration, but minimal penetration with thin liquids. For
details, please refer to speech and swallow division note in
OMR.
IMPRESSION: Minimal penetration with thin liquids. No gross
aspiration.
-------------
DISCHARGE LABS
-------------
[**2105-11-14**] 06:37AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.0* Hct-31.5*
MCV-96 MCH-30.4 MCHC-31.8 RDW-14.7 Plt Ct-364
[**2105-11-14**] 11:50AM BLOOD Na-142 K-3.7 Cl-113*
[**2105-11-14**] 06:37AM BLOOD Glucose-116* UreaN-4* Creat-0.6 Na-147*
K-3.6 Cl-117* HCO3-23 AnGap-11
[**2105-11-14**] 06:37AM BLOOD ALT-196* AST-56* AlkPhos-116* TotBili-0.7
[**2105-11-12**] 04:13AM BLOOD Lipase-281*
[**2105-11-14**] 06:37AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9
[**2105-11-7**] 11:07PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
Brief Hospital Course:
46yo W with a history of poorly managed bipolar disorder,
alcoholism and recent life stressors with intentional
polypharmacy overdose including tylenol and ?lithium now with
resolving liver failure, hepatic encephalopathy, and toxic
pancreatitis.
.
#Hyperchloremic Hypernatremia: The pt was persistently
hypernatremic during the current admission with sodium ranging
from 147-166 and was unresponsive to DDAVP suggesting
nephrogenic diabetes insipidus likely from chronic lithium use.
Her hypernateremia was initially treated with free water boluses
via NG tube and D5W infusions. Once patient was able to take POs
she was given free access to fluids and by consuming in excess
of 5L of water a day was able to autoregulate her sodium in the
normal range. Lytes will be checked on [**11-24**] and sent to
patient's PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 57843**]).
.
#Acetaminophen overdose/Liver Failure: The pt presented with
acetaminophen o/d with subsequent liver failure. Pt was treated
with NAC for several days with improvement of LFTs and INR. NAC
was discontinued and LFTs were trended and continued to
normalize with normal synthetic . She was initially evaluated
by transplant surgery, but upon correction of her LFTs did not
require transplant. Psychiatry was consulted and recommended
admission to inpatient psychiatry facility once medically clear.
She was monitored with a 1:1 sitter after extubation. She
continued to have down trending LFTs and return of normal
synthetic function over the course of her stay. LFTs should be
collected on [**11-24**] and results sent to patient's PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 57843**]). She will require follow up in
hepatology clinic in [**3-12**] weeks for revaluation of LFTs and
overall clinical status.
.
#Toxic Pancreatitis: Pt with elevated lipase however clinically
without signs/symptoms consistent with pancreatitis. It was
felt that this was related to her toxic ingestions. Tube feeds
were slowly advanced as the patient's lipase and LFTs
normalized. She was able to consume a regular diet by the time
of discharge. This issue had resolved by the time of discharge,
but will be followed up in hepatology clinic. Lipase will be
drawn on [**11-24**] and results sent to patient's PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 57843**]).
.
# Cough: patient with dry cough after extubation and CXR that
was not concerning for pneumonia. Felt to be secondary to
airway irritation from endotracheal tube and doboff device.
Patient was given cough suppression with dextrometrophan and
cephecol. Was improving at the time of discharge with no
evidence of infection.
.
#Hypoxia. Patient was initially transferred to [**Hospital1 18**] while
intubated presumably for airway protection. She was initally
difficult to extubate secondary to continued hypoxemia. CXR
demonstrated a RLL finding concerning for aspiration pneumonia
vs pneumonitis. Patient was briefly covered with broad spectrum
antibiotics that were discontinued once respiratory status
improved and there were no systemic signs of infection. Patient
was transferred from the TSICU to the MICU on a 50% facemask and
CXR with mild to moderate pulmonary edema patient diuresised
with lasix 10mg IV x1 with good effect. Additional work-up
included negative LENIs. Prior to transfer to patient saturating
93-95% on RA which improved to 98% on RA at the time of
discharge.
.
# AMS: per surgical team, pt was very sluggish after extubation.
Likely multifactorial with components of delirium,
hypernatremia, and continued circulating sedatives given hepatic
metabolism. As [**Hospital 228**] clinic status improved so did her
mental status and by the time of discharge patient was alert and
oriented, but with evidence of hypomania.
.
# Suicidial Ideation: patient presented with tylenol overdose
and acute hepatic failure. She was evaluated by psychiatry who
felt that she should be admitted to an inpatient psych facility
once medically clear. Patient met with social work and expressed
regrets for her actions, but still appeared to lack much
insight. She was with symptoms of hypomania including pressured
speech, darting glances, psychomotor agitation, tangential
thoughts and labile affect.
.
# Bipolar: patient's lithium ER 450 mg [**Hospital1 **] and quetiapine 100
mg QHS were held while in the hospital and had not been
restarted at the time of transfer with plan for inpatient
psychiatry providers to restart appropriate medications. She
was with symptoms of hypomania including pressured speech,
darting glances, psychomotor agitation, tangential thoughts and
labile affect at the time of discharge. She had not been started
on any pschyoactive medications at the time of discharge, but
had no contraindications to restarting lithium if her pscyiatry
providers deem fit.
.
# HTN: Patient was diagnosed with essential hypertension with
BPs in the 130-140s and was started on HCTZ 12.5 mg. She will
need continued follow up by her primary care doctor for
treatment of this chronic medical issue.
.
# Headaches: Patient's topiramate 100 mg [**Hospital1 **] was initially held
on admission in the setting of her acute liver failure. Once
discharged from the ICU and LFTs had normalized patient began
having headaches similar to her typical migraines. She was
given Imitrex 50 mg PRN which extinguished these migraines. She
was restared on 50 mg topiramate [**Hospital1 **] at the time of discharge
and may have this up titrated in 5 days to a final dose of 100
mg [**Hospital1 **]. Patient was also written for 50 mg Imitrex PRN at the
time of discharge. Patient has follow up in headache clinic
on [**3-1**] for follow up.
.
TRANSLATIONAL ISSUES:
-Patient was discharged holding her lithium and quetiapine,
these or similar medications will need to be restarted by
psychiatry.
-Patient clinically hypomanic at the time of discharge
-Please check Chem-10, LFTs, Lipase on [**11-24**] and send to
patient's PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 57843**]).
-Patient will have follow up of her LFTs and Pancreatic enzymes
in [**3-12**] weeks with hepatology.
-Patient will need unrestricted access to water in order to
maintain her Na in a normal range
-Patient's topiramate will need to be uptitrated to 200 mg [**Hospital1 **]
in 5 days.
Medications on Admission:
-lithium ER 450 mg [**Hospital1 **],
-quetiapine 100 mg QHS
-sumatriptan 100 mg PRN headache
-topiramate 200 mg [**Hospital1 **]
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: [**6-16**]
MLs PO Q6H (every 6 hours) as needed for cough.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. sumatriptan succinate 100 mg Tablet Sig: One (1) Tablet PO
PRN as needed for migraine headache: to be given if patient
complains of migraine headache. .
6. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 57844**] [**Hospital **]
Discharge Diagnosis:
-Acetaminophen induced liver failure
-Nephrogenic Diabetes Insipidis
-Bipolar disorder
-Depression
-hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory.
Discharge Instructions:
Ms. [**Known lastname 3175**],
It was a pleasure taking care of you while you were in the
hospital. You were admitted for a tylenol overdose. Your liver
was badly damaged by the tylenol and you treated by our
transplant surgeons, but ultimately you improved and you did not
require a transplant. You were also found to have a problem
with your kidney as a result of the lithium you had been taking.
You will need to stay well hydrated to make sure your sodium
levels stay in a safe range. You were also diagnosed with
hypertension and started on a medication called
hydrochlorathizide.
The following changes were made to your medications:
-STOP lithium ER 450 mg twice daily
-STOP quetiapine 100 mg at night
-STOP topiramate 200 mg twice daily
-STOP sumatriptan 50 mg as need for migranes
-START Hydroclorothiazide 12.5 mg daily
-START Dextrometrophan-Guaifenesin 10 ml every six hours as
needed
-START Miconazole powder as needed
-START topiramate 100 mg twice daily and to increase to 200 mg
twice daily on [**2105-11-19**].
-CONTINUE sumatriptan 100 mg as need for migraines
Followup Instructions:
Please call [**Telephone/Fax (1) 57843**] to schedule an appointment with your
PCP, [**Name10 (NameIs) **] [**Last Name (STitle) **] when you are discharged from the hospital.
Department: HMFP COMP HEADACHE CENTER
When: MONDAY [**2106-3-1**] at 4:15 PM
With: [**First Name8 (NamePattern2) 3049**] [**Last Name (NamePattern1) 3050**], MD [**Telephone/Fax (1) 3051**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: RADIOLOGY
When: FRIDAY [**2106-8-6**] at 7:00 AM
With: MAMMOGRAPHY IN [**Location (un) 2788**] [**0-0-**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"E849.0",
"577.0",
"965.4",
"570",
"E950.3",
"401.9",
"276.0",
"V61.09",
"518.81",
"507.0",
"969.8",
"E950.0",
"296.40",
"572.2",
"588.1",
"296.50",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"38.91",
"87.69",
"96.71",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13518, 13582
|
5996, 12633
|
349, 427
|
13739, 13739
|
3439, 3455
|
14983, 15755
|
2327, 2374
|
12813, 13495
|
13603, 13718
|
12659, 12790
|
13875, 14960
|
2017, 2048
|
2389, 2403
|
2744, 3420
|
266, 311
|
455, 1626
|
3471, 5973
|
2417, 2730
|
13754, 13851
|
1648, 1994
|
2064, 2311
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,725
| 135,297
|
21657
|
Discharge summary
|
report
|
Admission Date: [**2200-4-21**] Discharge Date: [**2200-4-25**]
Date of Birth: [**2152-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48M w/ severe COPD (FEV1 19% predicted [**1-27**]) on home oxygen,
type 2 dm, now being admitted to [**Hospital Unit Name 153**] for resp distress presumed
secondary to COPD excerbation.
Pt reports USOH until approximately 4 days ago when noted
increased cough from baseline productive of clear sputum. No
fevers, chills, chest pain, shortness of breath, wheezing. Had
not been using albuterol nebulizers and has continued to use
tobacco. Apparently, prescribed Levaquin by pulmonologist and
had reported some improvement. However, in the day leading to
admission, developed increased nasal congestion/rhinorrhea with
susbequent sob. Reports chest tightness with inspiration. Of
note, had not been using flonase. Denies sick contact. [**Name (NI) **]
nausea, vomitting, abdominal pain.
Sought ED evaluation where noted to be febrile to 100.6,
tachycardic to 110 and hypertensive to 155/84, tachypneic to
20's and satting 96% 4L in moderate resp distress with
difficulty speaking full sentences. Had BC drawn, labs notable
for leukocytosis to 9K. ABG 7.36/52/195 on 100%NRB. Received
Ceftriaxone, Azithromax, Prednisone 60, and continous nebs, and
transferred to [**Hospital Unit Name 153**] for further monitoring.
Currently, pt reports mild improvement in shortness of breath
since arrival at ED.
Past Medical History:
1. COPD excerbation, FEV1 19% predicted [**1-27**] on home oxygen (2
liters rest/ 4 liters activity). Reports sat of 95% at baseline
2. type 2 dm (aic 6.4 [**12-30**])
3. depression
4. de Quervain's tenosynovitis
Social History:
Social: retired consultant in [**Hospital1 8**] living with sister,
heavy tobacco history (34 pack years with 1 ppd x 34 years but
w/ several years at 3 packs per day), occasional etoh, no ivda
Family History:
Multiple family members with DM
Brother with [**Name2 (NI) 499**] cancer
No family history of lung disease
Physical Exam:
VS - 134/77, 112, 88-94% on Heliox + Continous Neb
HEENT - + accessory muscle use during respiration, no LAD, OP
clear, sclerae conjunctivae deep red.
LUNGS - poor air entry diffusely. Diffuse rhonchi and coarse
sounds. + Crackles at L base rising [**11-26**] way up
HEART - tachycardic; unable to assess for murmurs
ABD - soft, NT, ND, BS+
EXT - wwp. + clubbing, + soft consistency over fingernail beds.
NEURO - non focal
Pertinent Results:
[**2200-4-21**] 09:30PM BLOOD WBC-9.0 RBC-5.01 Hgb-14.4 Hct-42.6 MCV-85
MCH-28.7 MCHC-33.8 RDW-13.3 Plt Ct-196
[**2200-4-22**] 06:09AM BLOOD WBC-5.2 RBC-4.48* Hgb-13.0* Hct-39.3*
MCV-88 MCH-29.0 MCHC-33.1 RDW-13.5 Plt Ct-159
[**2200-4-23**] 06:45AM BLOOD WBC-8.7# RBC-4.75 Hgb-13.4* Hct-40.5
MCV-85 MCH-28.2 MCHC-33.0 RDW-13.4 Plt Ct-183
[**2200-4-21**] 09:30PM BLOOD Neuts-74.3* Bands-0 Lymphs-18.3 Monos-5.7
Eos-1.4 Baso-0.4
[**2200-4-21**] 09:30PM BLOOD Glucose-111* UreaN-22* Creat-1.0 Na-142
K-4.3 Cl-105 HCO3-27 AnGap-14
[**2200-4-22**] 06:09AM BLOOD Glucose-279* UreaN-17 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-22 AnGap-17
[**2200-4-23**] 06:45AM BLOOD Glucose-192* UreaN-14 Creat-0.7 Na-142
K-4.5 Cl-103 HCO3-31 AnGap-13
[**2200-4-21**] 10:41PM BLOOD Type-ART pO2-195* pCO2-52* pH-7.36
calHCO3-31* Base XS-3
.
CXR [**2200-4-21**]: Note is made of paucity of the vessels in upper
lobes, representing severe emphysema. Again note is made of
faint opacity in lower lobe, which may represent early pneumonia
if the patient has fever, however, the finding is equivocal.
Again note is made of right basilar atelectasis and blunting of
the right costophrenic angle, unchanged compared to the prior
study. Cardiac and mediastinal contours are unchanged.
IMPRESSION: Severe emphysema. Faint opacity in left lower lobe,
which may represent early pneumonia if the patient has fever.
Please correlate clinically, and if necessary, please repeat PA
and lateral chest radiograph.
.
CXR [**4-22**]:
IMPRESSION: AP chest compared to chest imaging study since
[**2199-9-9**], most recently [**4-21**]:
Bullous emphysema is severe. There is no substantial atelectasis
or evidence of pneumonia. Minimal interstitial abnormality in
the lingula may be chronic, since it is less severe than the
appearance on [**2199-11-7**] when the patient was in mild
congestive heart failure. Heart is normal size. There is no
pneumothorax or appreciable pleural effusion.
Brief Hospital Course:
A/P: 48M w/ severe COPD on home O2, type 2dm, now being admitted
for COPD exacerbation.
.
1. COPD exercabtion: The patient was admitted to ICU for close
monitoring. CXR did not reveal any pneumonia and the patient
remained afebrile and no leukocytosis in the ICU and on the
floor. In ICU, the patient was continued on azithromycin, iv
steroids, aggressive nebulizer treatment as well as Spiriva,
Advair, Flonase, [**Doctor First Name **], and Afrin. The patient was transferred
to the floor in a stable condition the day after admission. The
patient was switched to po prednisone and continued all other
medications. The patient's pulmonary status gradually improved.
The patient finished 5 day course of azithromycin and is to
finish 2 week prednisone taper and continue maintenance
prednisone 10mg every other day until he follows up with his
pulmonologist (Dr. [**Last Name (STitle) 56979**]. The patient is to receive
outpatient pulmonary rehabilitation/physical therapy. Smoking
cessation counseling was given. At the time of discharge, pt's
ambulatory sat was 97% on 4L (ambulatory sat baseline at 95% on
4L NC) and satting 95-100% on 2L at rest, which is his basline.
.
2. Tachycardia: Was secondary to respiratory distress and
continous nebs. Tachycardia improved with less frequent
albuterol nebs.
.
3. DM: Held oral hypoglycemics while npo and restarted once good
PO intake.
.
4. Depression: continued Lexapro and Bupropion.
.
5. FEN: Gentle ivf while npo w/ resp distress and then restarted
diabetic diet.
.
6. Prophylaxis: PPI, bowel regimen, sc heparin
Medications on Admission:
Atrovent 17 mcg 2 puffs [**Hospital1 **]
albuterol prn
Flonase 2 spray [**Hospital1 **]
glucophage xr 500 [**Hospital1 **]
lexapro 10 qd
loratidine 10 qd prn
Adavair 250/50 [**Hospital1 **]
Discharge Medications:
1. O2
Oxygen 2-4L continuous to keep O2 sat>90
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal once a day.
7. Prednisone 10 mg Tablet Sig: see other instructions Tablet PO
once a day: Take 4 tablets daily on [**4-26**], then 3 tablets [**Date range (1) 3047**],
2 tablets [**Date range (1) 3048**] then 1 tablet [**Date range (1) 1163**], then 1 tablet every
other day until you see Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*1*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
11. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
13. Pulmonary rehabilitation
Outpatient pulmonary physical therapy/rehabilitation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Chronic obstructive pulmonary disease exacerbation
Secondary diagnosis:
Depression
Discharge Condition:
Stable, O2 sat at 95-100 on 2L O2 via nasal cannula and
ambulatory O2 sat at 97% on 4L.
Discharge Instructions:
Please return to emergency department or call your doctor if you
develop chest pain, worsening shortness of breath, fever,
chills, or any other worrisome symptoms. Take medications as
instructed and keep your follow-up appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2200-5-5**] 3:40
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2200-5-5**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2200-5-5**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**6-30**] 03:00p PHONE:
[**Telephone/Fax (1) 250**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"427.89",
"V46.2",
"491.21",
"250.00",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8033, 8039
|
4654, 6229
|
317, 324
|
8185, 8275
|
2686, 4631
|
8557, 9199
|
2118, 2226
|
6470, 8010
|
8060, 8060
|
6255, 6447
|
8299, 8534
|
2241, 2667
|
274, 279
|
352, 1652
|
8151, 8164
|
8079, 8130
|
1674, 1890
|
1906, 2102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,031
| 132,948
|
11485
|
Discharge summary
|
report
|
Admission Date: [**2143-10-11**] Discharge Date: [**2143-10-16**]
Date of Birth: [**2077-12-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with
a history of small cell lung cancer who was last treated with
Taxol and carboplatin ten days prior to admission. The
patient was originally admitted to [**Hospital6 2561**] with
a three day history of shortness of breath, fatigue and
(baseline 31-35) with an INR of 3.6. An nasogastric tube
lavage was negative by report. The patient at that time
received two units of FFP and two units of packed red blood
cells with an increase in hematocrit up to 20 percent.
Patient was subsequently transferred to [**Hospital6 649**].
In the Emergency Room, she had a temperature of 101.1 and a heart
rate in the 130s and signs and symptoms of congestive heart
failure. She was given 60 mg of Lasix and then transferred to the
Medical Intensive Care Unit.
In the Medical Intensive Care Unit, she was started on
Levaquin for pneumonia and also given four additional units
of packed red blood cells.
On the day of admission, the patient underwent an endoscopy
which showed a prepylorus ulcer with coffee ground but no
active bleeding.
LABS ON ADMISSION: CBC: White blood cell count 11,
hemoglobin and hematocrit of 7.1 and 21.1 and platelets of
155. Her chemistry panel was as follows: Sodium 140,
potassium 3.6, chloride 101, bicarbonate 31, BUN and
creatinine of 22 and 0.6 and glucose of 120, calcium 8.2,
magnesium of 1.8 and alkaline phosphatase of 3.3. Her LDH
was 455 and her CK was 38. Her lipase was 5. The patient's
post transfusion hematocrit was 30.1%.
HOSPITAL COURSE: Given the patient's past medical history of
mitral valve and aortic valve replacement and the patient had
previously been on Coumadin 5 mg q.d. times six days and then
off on Sundays and given her history of mechanical valve,
patient was started on a heparin drip on hospital day number
one. She proceeded with anticoagulation. She was started on
her Coumadin on hospital day number two and her INR on the
day of discharge was in therapeutic range at 2.8. The
patient's hematocrit on discharge is stable at 26 vital sign.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: The patient for INR and hematocrit checks. In
addition the patient will see her usual primary care
physician/hematologist/oncologist, Dr. [**Last Name (STitle) 10653**], at the
[**Hospital 36653**] Clinic on Thursday.
The patient will be discharged to home on the following
medications:
DISCHARGE MEDICATIONS;
1. Protonix 40 mg q.d. (a letter was sent home with the
patient for her to provide to her insurance. She said their
would be difficulty in her obtaining Protonix).
2. Coumadin 5 mg q.d. times six days and off on Sundays.
3. Ativan 0.5 mg po t.i.d.
4. Levaquin 500 mg t.i.d. times one more day.
5. Combivent inhaler.
DISCHARGE DIAGNOSIS: Gastrointestinal bleed.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-983
Dictated By:[**Name8 (MD) 4872**]
MEDQUIST36
D: [**2143-10-18**] 13:33
T: [**2143-10-18**] 13:33
JOB#: [**Job Number **]
|
[
"162.9",
"486",
"287.5",
"428.0",
"531.40",
"V45.81",
"V43.3",
"280.0",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
2907, 3153
|
1675, 2202
|
158, 1224
|
1239, 1657
|
2227, 2885
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,795
| 117,624
|
46916
|
Discharge summary
|
report
|
Admission Date: [**2102-10-6**] Discharge Date: [**2102-10-9**]
Date of Birth: [**2060-7-15**] Sex: M
Service: NEUROLOGY
Allergies:
Lactose / Lamictal / Geodon / Percocet / Codeine / Oxcarbazepine
/ Heparin Agents / Tegretol
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**First Name8 (NamePattern2) 2855**] [**Known lastname **] is well known to neurology service. He was
recently admitted to neurology EMU for seizure management and
was
discharged yesterday. He was discharged on clonopin
0.25/0.25/0.5
as seizure med and was taken off other AEDs (including dilantin
and zonegran). Today, he came to ED again for evaluation of
anxiety. He was seen by neurology and psych and the plan was
discussed with Dr. [**Last Name (STitle) 851**] who suggested addition of
zonegran 100/200 from today. He was evaluated and was being
admitted to psych service today. At 5 pm, he had sudden onset
generalised seizure that lasted for about 3 mins. He was
unresponsive and became cyanotic. he needed to have mask
ventilation for few mins before he picked up on the saturation.
He was giavn ativan 2 mg. He was post ictal and was confused
afterwards and was oriented to place only.
ROS- unable to obtain
Past Medical History:
1. Seizure disorder, complex partial seizures (neonatal anoxia
vs. primary generalized)
epilepsy.
2. Psychogenic non-epileptic seizures
3. s/p resection of left frontal AVM
4. PTSD related to history of sexual assault
5. Irritable bowel syndrome
6. Insomnia
7. Depression, h/o suicide attempts and psychiatric
hospitalization
8. Hemorrhoids
9. History of head injury and concussion in [**2086**]
10. History of bulimia
11. Asthma
12. Cognitive disorder, NOS
13. Borderline personality disorder
14. Hydrocele
.
Past Psychiatric History: Per OMR notes, historical dx of
borderline personality disorder, PTSD, bulimia, and previous
suicide attempts
Social History:
Lives alone. Works as jewelry designer. Denies tobacco, alcohol,
drug use.
Family History:
Per record, maternal grandmother and cousin have h/o seizures.
Notable also for schizophrenia, depression, alcoholism, and
stroke.
Physical [**Year (4 digits) **]:
Vitals: T: 98 118 140/99 14 98
General: drowsy
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft,
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: drowsy and opened eyes to command and then
closes
back. does not take part in conversation. He could only tell
that
"I am in [**Hospital3 **]" but other than that was not oriented to
time or person. Other MS [**First Name (Titles) **] [**Last Name (Titles) 99517**] due to inattention and
drowsiness.
CN
I: not tested
II,III: VFF to confrontation, pupils 5mm->3mm bilaterally
III,IV,V: EOMI, no ptosis. No nystagmus
VII: Face symmetric
VIII: responds to voice on both sides
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**5-17**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Moves all limbs symmetric, individual [**Month/Day (1) **] limited owing
to inattantion and cooperation
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 3 3 Mute
R 2 2 2 3 3 Mute
-Sensory: withdraws to pain in all limbs
-Coordination: not tested
-Gait: not tested
Pertinent Results:
[**2102-10-6**] 05:25PM WBC-11.1*# RBC-5.66 HGB-17.2 HCT-49.3 MCV-87
MCH-30.3 MCHC-34.8 RDW-14.2
[**2102-10-6**] 05:25PM PLT COUNT-254
[**2102-10-6**] 05:25PM NEUTS-64.9 LYMPHS-28.3 MONOS-5.0 EOS-0.3
BASOS-1.6
[**2102-10-6**] 05:25PM PT-14.6* PTT-22.6 INR(PT)-1.3*
[**2102-10-6**] 05:25PM GLUCOSE-159* UREA N-22* CREAT-1.2 SODIUM-143
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-16* ANION GAP-29*
[**2102-10-6**] 05:34PM LACTATE-9.6*
[**2102-10-6**] 05:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2102-10-6**] 07:45PM bnzodzpn-NEG
EEG (last week)(LTM): routine and automated sampled EEG does
show some suspicious left posterior frontal/anterior temporal
interictal epileptiform activity, particularly late in the
recording session on the
routine record rather than on the spike detection algorithm.
There is
also some asymmetric slowing over the left central frontal
region in the
theta bandwidth early in the recording that seemed to normalize
later.
The breach phenomenon is still present.
Brief Hospital Course:
42 yo M with L frontal AVM s/p resection, seizure d/o,
non-epileptic seizures, borderline personality disorder,
depression, recent admit for 1 week LTM monitoring, and
dischatged a few hours prior to returning to ED. He was
discharged off all AEDs except Klonopin and was on outpatient
EEG monitoring. He returned in the middle of the night following
his discharge with events he felt concerning for seizures. There
was no change on the few hours that were recorded on his
outpatient EEG monitoring. While in the ED, he had 3 minute
event of cyanosis and poor responsiveness and was admitted to
the ICU overnight. It was unclear if this event in [**Name (NI) **] was a
seizure or non-epileptic event; however, he was started on
Zonegran 400 mg daily. He was also continued on his Klonopin
0.5/1/0.5. The plan was to re-monitor him on EEG prior to
discharge; however, prior to having this arranged, he absconded.
Medications on Admission:
clonopin 0.25/0.25/0.5
zonegran 100/200 started this am
nexium 20 [**Hospital1 **]
advair
lexapro 20 [**Hospital1 **]
abilify 2 QHS
Vit D2
verapamil SR 120 [**Hospital1 **]
Discharge Medications:
Pt. Absconded
Discharge Disposition:
Home with Service
Discharge Diagnosis:
pt. absconded
Discharge Condition:
pt. absconded
Discharge Instructions:
pt. absconded
Followup Instructions:
pt. absconded
Completed by:[**2102-10-30**]
|
[
"V11.3",
"564.1",
"309.81",
"455.6",
"275.42",
"301.83",
"300.4",
"780.52",
"V45.89",
"346.90",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5838, 5857
|
4662, 5576
|
363, 369
|
5914, 5929
|
3598, 4639
|
5991, 6036
|
2102, 2606
|
5800, 5815
|
5878, 5893
|
5602, 5777
|
5953, 5968
|
315, 325
|
397, 1324
|
2621, 3579
|
1346, 1993
|
2009, 2086
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
627
| 172,013
|
17548+56870
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-1-25**] Discharge Date:
Date of Birth: [**2056-8-2**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 64 year old female
transferred from [**Hospital 48951**]Hospital to [**Hospital Ward Name 332**] Intensive
Care Unit at [**Hospital1 69**] on
[**2121-1-25**]. The patient was originally admitted to the outside
hospital on [**2121-1-20**], after the acute onset of abdominal
pain. The patient was in her usual state of health until
this day around 5:00 p.m. when the patient developed the
acute onset of epigastric pain and violent nonbloody emesis
after eating a meal of macaroni and cheese. The patient
states that the pain was ten out of ten, did not radiate to
her back, but did radiate to her bilateral flanks. It was
associated with increased shortness of breath, no chest pain,
light-headedness or syncope.
The patient's husband called 911. When she was taken to the
outside hospital, her amylase was 3861, white blood cell
count 23.0, hematocrit 45.0, normal liver function tests.
The patient had temperature of 98.2, blood pressure 135/72,
respiratory rate 18, oxygen saturation 98% ? In room air.
The patient had an abdominal CT which showed mild acute
pancreatitis with no gallstones or other pancreatic
complications. The right upper quadrant ultrasound was done
that revealed no evidence of gallstones (suboptimal study).
The patient then had a repeat abdominal CT on [**2121-1-23**], which
showed necrosis of the pancreatic head with peripancreatic
inflammatory changes. The amylase had trended down to the
80s over four days and the patient also had significant
decrease in her abdominal pain.
The patient was transferred to [**Hospital1 188**] on [**2121-1-25**], for question of endoscopic retrograde
cholangiopancreatography as well as for failing respiratory
status at the outside hospital. The patient had a chest
x-ray that showed bilateral pleural effusions, status post
aggressive intravenous fluids. The patient was noted to have
increased wheezing on physical examination. She was given 20
mg intravenous Lasix with good effect. The patient was also
given stress dose steroids of Solu-Medrol, however, she had
hallucinations from this. Her paO2 was 61 mmHg.
PHYSICAL EXAMINATION: Temperature is 98.6, pulse 112, blood
pressure 134/81, respiratory rate 31, oxygen saturation 88 to
90% on four liters of oxygen via nasal cannula. Weight 84.5
kilograms. In general, she is a pleasant female in no
apparent distress, speaking full sentences, despite
tachypnea. Head, eyes, ears, nose and throat examination -
mucous membranes are dry. The oropharynx is clear. The
pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Anicteric
sclera. Neck - no jugular venous distention, no bruits, no
thyromegaly. Pulmonary - diffuse severe end expiratory
wheezes with fair air movement, mild bibasilar crackles,
increased inspiratory and expiratory ratio. Abdomen is soft,
positive bowel sounds, nontender, question mildly distended,
no rebound or guarding. Extremities - no cyanosis, clubbing
or edema, 1+ dorsalis pedis pulses. Neurologic - The patient
is alert and oriented times three. Mini mental status
examination - 28/30. Cranial nerves II through XII are
intact. Motor is [**4-7**], [**3-8**] right upper extremity. Sensation
intact.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease, ?
2. Coronary artery disease, status post non Q wave
myocardial infarction in [**2115-7-5**], with left bundle branch
block.
3. Congestive heart failure with a reported ejection
fraction of 40% in [**2114**]. Peak CK 213 with MB of 18.
4. Cardiac catheterization [**2115-8-5**], showed apical
hypokinesis, no significant coronary artery disease.
5. Left thalamic cerebrovascular accident [**2119-11-4**],
with mild right upper extremity greater than right lower
extremity weakness.
6. No history of hyperlipidemia, gallstones or alcohol use.
MEDICATIONS AT HOME: Norvasc 10 mg p.o. once daily.
MEDICATIONS HERE:
1. Hydralazine 20 mg intravenous q6hours.
2. Enalapril 0.625 mg intravenous q6hours.
3. Clonidine 0.1 mg patch.
4. Norvasc 10 mg p.o. once daily which has been held.
5. Nitroglycerin drip.
6. Haldol and Ativan p.r.n.
7. Morphine intravenous.
8. Imipenem 500 mg intravenous q6hours.
9. Famotidine 20 mg intravenous q12hours.
10. Heparin subcutaneous 5000 units three times a day.
11. The patient had been on Gentamicin and Zosyn from
[**2121-1-20**], to [**2121-1-23**]. On [**2121-1-23**], the patient's antibiotics
were changed to Imipenem.
12. Albuterol and Atrovent nebulizers q2hours p.r.n.
13. Serevent two puffs twice a day.
14. Flovent two puffs twice a day.
15. Ocean Spray nasal solution p.r.n.
16. Dulcolax p.r.n.
ALLERGIES: No known drug allergies. However, Solu-Medrol
has caused hallucinations.
SOCIAL HISTORY: The patient is married with three children
and lives in [**Location 48952**] and runs a restaurant with her husband.
She is a two pack per day smoker for her whole life. No
alcohol use or intravenous drug use.
FAMILY HISTORY: Questionable history of pancreatic fibrosis
in two or three sisters at an early age leading to early
deaths. Mother with lung cancer. Father with hypertension,
cerebral hemorrhage.
LABORATORY DATA: At the outside hospital, white blood cell
count 18.0 prior to transfer. Arterial blood gases 7.42, 35,
61 and went to 7.41, 43, 68, went to 7.39, 41, 66. Blood
culture showed no growth to date. On [**2121-1-21**], amylase was
3861, trended down to 94. Lipase 862 and trended down to
153. CK 168, MB 2.7, troponin 0.02 but then increased her
troponin to 0.18. CK 198, MB 9.5.
Electrocardiogram - left bundle branch block, pulse 112.
Laboratory data at [**Hospital1 69**]
included white blood cell count 23.0, hematocrit 40.2,
platelet count 258,000, MCV 88. Prothrombin time 13.8, INR
1.3, partial thromboplastin time 23.8. Sodium 142, potassium
3.3, chloride 106, bicarbonate 28, blood urea nitrogen 14,
creatinine 0.6, glucose 135. Amylase 68, lipase 27.
Differential on white blood cell count revealed neutrophils
91%, no bands, 6% lymphocytes, 3% monocytes, 0.1%
eosinophils. Calcium 8.9, magnesium 2.0, phosphorus 2.5,
albumin 3.1. ALT and AST 24, total bilirubin 0.4, alkaline
phosphatase 126, LDH 496. Cholesterol 174, LDL 107, HDL 42.
Arterial blood gases revealed on five liters nasal cannula
7.46/41/55 with a bicarbonate of 30. Lactate 1.3. Potassium
3.3, free calcium 1.26. At 7:53 p.m. on 70% face mask, the
patient had arterial blood gases of 7.47/38/80, bicarbonate
of 28.
Urinalysis revealed specific gravity 1.005, large blood,
negative leukocyte esterase and nitrites, 5 white blood
cells, trace ketone, 423 red blood cells, no epithelial
cells.
Chest x-ray - mild cardiomegaly, interstitial markings with
congestive heart failure.
HOSPITAL COURSE:
1. Pancreatitis - The patient with history of necrotizing
pancreatitis of unclear etiology. Normal liver function
tests, amylase and lipase and hematocrit of 40.2. Unclear
family history of childhood pancreatic fibrosis but at the
time of presentation, the patient is 64 years old and this
may be unrelated acute event. The patient may have passed a
gallstone given her age, gender, clinical history with acute
onset of severe pain after a fatty meal.
The patient was continued on Imipenem for necrotizing
pancreatitis which was discontinued on [**2121-1-29**]. The patient
was kept NPO except for most medications and ice chips. She
did not require placement of nasogastric tube. The patient
initially was able to tolerate gradually increasing diet
including sips which was then advanced to full clears and
soft solids. However, on [**2121-1-31**], the patient noted
epigastric tenderness to light palpation after eating and the
patient was again made NPO. The patient continued to do well
after she was made NPO with a goal of restarting clears on
[**2121-2-2**].
The patient was continued on TPN throughout her hospital
course with the long term plan being that the patient will
likely need TPN for at least seven to ten days postdischarge
in order to meet her full nutritional needs assuming that she
will be able to tolerate gradually increasing p.o. The
patient continued to have amylase and lipase that were within
normal limits. However, her LDH and alkaline phosphatase did
remain elevated at 465 and 173, respectively. The patient's
hematocrit was 38.5 on [**2121-2-1**].
Long term plans for gastrointestinal follow-up would include
touch base with the Gastroenterology service to assess length
of TPN as well as question of endoscopic retrograde
cholangiopancreatography at some later date as an outpatient
once acute episode of pancreatitis has resolved.
2. Pulmonary - The patient initially had bilateral pleural
effusions likely secondary to congestive heart failure and
volume overload as well as potential third spacing of fluid
from her pancreatitis. The patient never required intubation
and was maintained on mask ventilation and eventually
titrated down to nasal cannula and currently saturating 94%
in room air with no subjective shortness of breath.
3. Congestive heart failure - The patient had an
echocardiogram which showed an ejection fraction of 55% with
1+ mitral regurgitation, no evidence of pericardial effusion.
4. Hypertension - The patient continued to have labile
hypertension throughout her hospital course. The patient was
started on a regimen of Metoprolol and Norvasc which were
gradually titrated. However, while the patient was NPO, the
patient's Norvasc was held and Metoprolol was continued and
is currently at a dose of Metoprolol 100 mg p.o. three times
a day. However, once the patient is able to tolerate p.o.
she should be restarted on her Norvasc 10 mg p.o. once daily.
Both of these medications can be titrated down to maintain a
good blood pressure.
5. Ileus - The patient has an ileus, however, she gradually
had an improving abdominal examination, positive flatus and
then began to pass stool with ability to tolerate her p.o.
medications.
6. Infectious disease - The patient had an increased white
blood cell count that was persistently elevated in the 20s
and remained relatively stable, however, gradually started to
increase to 26 and 25. The patient had a Clostridium
difficile toxin sent as she had been experiencing significant
loose stools and it was positive for evidence of Clostridium
difficile. The patient was then started on Flagyl 500 mg
p.o. three times a day. This was started on [**2121-1-29**]. The
patient will need a full fourteen day course for this
infection.
The patient had complete resolution of her diarrhea after the
start of Flagyl. She remained afebrile.
7. Psychiatry - The patient had Intensive Care Unit delirium
and required p.r.n. Haldol while she was in the Intensive
Care Unit. She did not require any restraints and was not
receiving any narcotics at the time. After transfer to the
Medicine floor, the patient did quite well and had no further
episodes of delirium.
8. Access - The patient had a right IJ that was placed on
[**2121-1-23**], at the outside hospital. This was discontinued on
[**2121-1-28**]. The patient had a PICC line placement for long
term TPN.
9. Disposition - The patient is full code. Her family is
quite involved including her husband and her children.
Family can be reached at [**Telephone/Fax (1) 48953**]. In addition, her
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], is also very available and
involved in her care. The patient was seen by physical
therapy who deemed that she would need rehabilitation. The
patient is in the process of being screened and referred to
various facilities. The patient will require TPN at the time
of discharge for at least one week most likely.
CONDITION ON DISCHARGE: Stable. The patient is not at her
functional baseline, however, with resolution of her acute
medical condition, it is likely that she will improve to her
baseline functional status.
MEDICATIONS ON DISCHARGE:
1. Sodium Chloride 0.65% nasal spray for dryness.
2. Flomax 110 mcg two puffs twice a day.
3. Tylenol rectal suppository p.r.n. fever or pain.
4. Dulcolax 10 mg rectal suppository q.h.s p.r.n.
constipation.
5. Nicotine 14 mg a day patch.
6. Miconazole Powder 2% to groin once daily.
7. Norvasc 10 mg p.o. once daily if the patient on p.o.
8. Metoprolol 100 mg p.o. three times a day.
9. Benadryl 25 mg p.o. q6hours p.r.n. rash. Please
discontinue this medication if the patient is not still
experiencing rash.
10. Flagyl 500 mg p.o. once daily for a full course of two
weeks. This was started on [**2121-1-29**] and it should be
completed on [**2121-2-14**].
DISCHARGE DIAGNOSES:
1. Necrotizing pancreatitis.
2. Labile hypertension.
3. Respiratory distress secondary to congestive heart
failure and bilateral pleural effusions from volume overload.
[**First Name8 (NamePattern2) **] [**Doctor First Name 1775**],[**Doctor Last Name **] 12.ADF
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2121-2-1**] 17:53
T: [**2121-2-1**] 18:21
JOB#: [**Job Number 48954**]
Name: [**Known lastname 9090**], [**Known firstname **] Unit No: [**Numeric Identifier 9091**]
Admission Date: [**2121-1-25**] Discharge Date: [**2121-2-6**]
Date of Birth: [**2056-8-2**] Sex: F
Service: A-Cove
ADDENDUM: This is a Discharge Summary Addendum to the
previously dictated Discharge Summary on this patient which
outlines the [**Hospital 1325**] hospital course from [**2121-1-31**]
until the day of discharge on [**2121-2-6**].
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PANCREATITIS ISSUES: The patient continued to do quite
well, and her pancreatitis gradually resolved. The patient
had persistent elevated LD and alkaline phosphatase but
normalization of liver function tests.
The patient was able to gradually have advancement of her
diet to the point where she was able to tolerate a full
regular diet at the time of discharge. The patient's total
parenteral nutrition ran until [**2121-2-5**] and was
discontinued at the time of discharge.
The patient had an abdominal computed tomography on [**2121-2-5**] that showed an enlarged pancreas with peripancreatic
fluid collections with focal under-perfusion of the
pancreatic head which has now resolved when compared to prior
abdominal computed tomography. Persistent peripancreatic
stranding and fluid collection, consistent with pancreatitis.
Given the patient's subjective improvement and resolution of
abdominal pain and ability to tolerate full oral intake,
these changes were thought to be consistent with her clinical
course and resolving pancreatitis.
The abdominal computed tomography on [**2-5**] also revealed
evidence of portal vein thrombosis which was new and not seen
on prior computed tomography. There was a filling defect in
the main portal vein; consistent with a recent diagnosis of
pancreatitis.
An abdominal ultrasound with Doppler studies was performed to
assess the degree of portal vein thrombosis and flow. The
intrahepatic portal venous system demonstrated normal
hepatopetal flow without evidence of intrahepatic thrombosis.
The left and right hepatic veins demonstrated normal
hepatofugal flow without evidence of thrombosis with a normal
triphasic wave form. The hepatic arteries also demonstrated
normal wave forms. Within the extrahepatic portal vein,
extending from the confluence with the splenic vein, there
was 3.2-cm area of nonocclusive clot which appeared to occupy
just over 50% of the cross sectional area of the portal vein.
The gallbladder appeared unremarkable. These changes were
consistent with the nonocclusive extrahepatic portal vein
thrombosis found on the abdominal computed tomography.
These findings were discussed with the Gastroenterology
Service who was continuing to follow the patient. Current
data suggests that anticoagulation for this would be
warranted, given that we do not known whether it is acute or
chronic. However, it is new compared to prior studies in the
past two to three weeks. The patient was placed on Lovenox
and Coumadin for anticoagulation. She was likely be on this
for at least three to six months. The patient will have
followup with the Gastroenterology Service, and an
appointment has been made for her with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9092**] in
the next month. In addition, an abdominal ultrasound will be
repeated to assess for the degree of portal vein thrombosis.
These findings were discussed with the patient's primary care
physician (Dr. [**First Name (STitle) 5992**] who will arrange for outpatient
surgical consultation for a potential cholecystectomy.
2. PULMONARY ISSUES: The patient initially was found to
have bilateral pleural effusions as well as congestive heart
failure after initial volume resuscitation for her
pancreatitis.
Subsequently, she did quite well and was taken off nasal
cannula and was saturating around 94% to 96% on room air.
The patient did continue to have mild low-grade temperatures
as well as a cough and a persistently elevated white blood
cell count.
Given these findings, a chest x-ray was repeated which
revealed a moderate sized right pleural effusion that was new
compared to a prior pleural effusion. It was also on the
right side; which was inconsistent with changes that would be
expected from spread of pancreatic fluid, which would
normally appear on the left.
The patient underwent a right thoracentesis with drainage of
approximately 500 cc of straw-colored fluid. This fluid was
sent for analysis and was found to have 1+ gram-positive
cocci with negative cultures.
The Pulmonary Interventional Service was involved in the
thoracentesis and determined that based on these findings, as
well as the exudative nature of the effusion, the patient
should be treated with antibiotics for at least two weeks.
The patient was started on levofloxacin 500 mg p.o. q.d.
which will be continued for a total of 2-week course.
The pleural fluid had a white blood cell count of 993, a red
blood count of 565, 7% polys, 89% lymphocytes, 1% monocytes,
1% eosinophils, and 2% mesothelial cells. The total protein
was 2.7, a glucose of 124, a LDH of 267, an amylase of 23,
and an albumin of 1.5, and pH was 7.41. Gram stain revealed
1+ gram-positive cocci in pairs. Fluid culture revealed no
growth; both anaerobic and other cultures. The cytology was
negative for malignant cells and showed only reactive
mesothelial cells, macrophages, lymphocytes, and neutrophils.
A chest computed tomography was performed to evaluate for
loculated fluid collection, consolidation, and size of right
pleural effusion after her pleural tap. This revealed an
interval reduction in the size of the right pleural effusion,
partial re-expansion of the right lower lobe, with discoid
atelectasis, and patchy ground-glass opacities that persisted
in the right lower lobe, likely representing evolving
re-expansion; however, a right lower lobe infiltrate cannot
be excluded.
The patient will follow up with the Pulmonary Interventional
Service with whom she has an appointment scheduled on [**2121-2-19**] at 2 p.m. in [**Hospital1 **] 207. The patient will have a
chest x-ray done by her primary care physician prior to this
appointment and bring the film to this appointment.
3. HYPERTENSIVE ISSUES: The patient had gradual improvement
in her blood pressures with blood pressures ranging from 120
to 130 systolic at the time of discharge on metoprolol 100 mg
p.o. t.i.d. and Norvasc 10 mg p.o. q.d.
The patient will have her blood pressure followed up by her
primary care physician and subsequent adjustment in
medications as needed.
4. INFECTIOUS DISEASE ISSUES: The patient was still
completing her course of Flagyl for her Clostridium difficile
infection. The patient has had a gradual decrease in her
white blood cell count; however, it was elevated at 16 at the
time of discharge.
5. ACCESS ISSUES: The patient had her peripherally inserted
central catheter line discontinued prior to discharge, as she
will no longer need total parenteral nutrition.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. As mentioned above, the patient was to follow up with the
Interventional Pulmonary Service as well as the
Gastroenterology Service here at [**Hospital1 4242**].
2. The patient was also to follow up with her primary care
physician on [**Name9 (PRE) 228**].
3. The patient was also to have an outpatient surgical
consultation for a cholecystectomy.
4. The patient was to have visiting nurses to administer her
Lovenox on the day of discharge ([**2121-2-6**]) as well as
[**2121-2-7**].
5. She will be continued on Coumadin 5 mg p.o. q.d. for two
additional days and then have her INR checked on [**2121-2-8**] by the visiting nurses with the results sent to Dr.
[**First Name (STitle) 5992**] who will then adjust her Coumadin for a goal INR of 2
to 3.
CONDITION AT DISCHARGE: The patient was stable at the time
of discharge.
MEDICATIONS ON DISCHARGE: (Her final discharge medications
included)
1. Sodium chloride nasal spray as needed (for nasal
dryness).
2. Flovent 110-mcg 2 puffs inhaled b.i.d.
3. Dulcolax as needed.
4. Nicotine patch.
5. Miconazole powder.
6. Norvasc 10 mg p.o. q.d.
7. Metoprolol 100 mg p.o. t.i.d.
8. Flagyl 500 mg p.o. t.i.d. (this will be completed on
[**2121-2-12**]).
9. Levofloxacin 500 mg p.o. q.d. (for another 12 days).
10. Ipratropium bromide meter-dosed inhaler 1 puff inhaled
q.6h. as needed.
11. Lovenox 80 mg b.i.d. (second dose on [**2121-2-6**] and
[**2121-2-7**]).
12. Benadryl as needed (for rash).
13. Coumadin 5 mg p.o. q.d. (times two days).
14. Coumadin 3 mg p.o. q.d. (starting on [**2121-2-8**]; dose
adjusted based on INR with a goal of 2 to 3).
NOTE: Also send the patient's primary care physician (Dr.
[**First Name (STitle) 5992**] a copy of the original Discharge Summary as well as
this Addendum.
[**First Name8 (NamePattern2) 77**] [**First Name4 (NamePattern1) 1495**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8396**]
Dictated By:[**Name8 (MD) 4791**]
MEDQUIST36
D: [**2121-2-6**] 18:16
T: [**2121-2-6**] 19:24
JOB#: [**Job Number 9093**]
cc:[**Name2 (NI) 9094**]
|
[
"577.0",
"486",
"453.8",
"428.0",
"560.1",
"511.1",
"496",
"428.30",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5130, 6901
|
12831, 13740
|
21202, 22447
|
6918, 11906
|
20340, 21110
|
4013, 4884
|
13774, 20307
|
2269, 3377
|
21125, 21175
|
142, 2246
|
3399, 3991
|
4901, 5113
|
11931, 12115
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,990
| 168,571
|
49274
|
Discharge summary
|
report
|
Admission Date: [**2173-9-15**] Discharge Date: [**2173-9-27**]
Date of Birth: [**2098-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Losartan
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Tracheostomy tube placement
PEG placement
Oral surgery: dental extraction
Tongue nodule biopsy
femoral CVL
Internal Jugular CVL
History of Present Illness:
Ms [**Known lastname 103090**] is a 75F with a PMH s/f subglottic edema from
multiple intubations, HTN, DM, and ESRD, who was found
unresponsive at her nursing home today. Per the patient's
daughter and nurse [**First Name8 (NamePattern2) **] [**Name (NI) 2299**] [**Last Name (NamePattern1) **], she had been in her USOH,
which included mild stridor since her recent discharge from
[**Hospital1 18**]. Starting on Sunday ([**9-12**]), her daughter noticed she
seemed more "out of breath" than usual. She was started on
albuterol/ipratropium with good effect. On Wednesday [**9-15**] the
patient became acutely uncomfortable, complaining that something
was "stuck in her throat". She was noted to be restless,
stridorous, and clutching her throat at the time. She was given
a one-time dose of benadryl, and suddenly dropped her O2 sats to
87% on 6L NC, became unresponsive and "limp". She maintained a
pulse throughout. EMS was called and the patient was
transferred to [**Hospital1 18**]. Of note, the patient was stopped on
lisinopril/valsartan on her last admission for concern that
angioedema may have contributed to her stridor. She was
restarted on valsartan on [**9-13**] when her symptoms worsenened.
In the emergency department the patient was afebrile, SBPs
ranged from 198-240, HR in the 50s, RR 15. She was started on a
labetalol drip for hypertension. She was intubated for airway
protection and was noted to have a difficult airway. Serum tox,
cardiac enzymes, CBC were all wnl. A head CT, CXR, CT neck and
torso were completed and were all grossly wnl, except for a
non-perfusing left vertebral artery. She was given 1g of CTX,
1g of vancomycin, and 500mg of metronidazole despite not having
fevers, leukocytosis or any focal signs of infection. She was
pan cultured. She was noted to have coffee ground emesis
through her OG tube, with guiac negative stools, and was given
40mg of IV pantoprazole.
Past Medical History:
1. End stage renal disease
-On HD MWF
-Recently admitted in [**8-/2173**] with pseudoaneurysm at LUE fistula
s/p excision.
-Now with a right subclavian tunneled HD line
2. Vascular dementia s/p CVA
-MRA with narrowing diffusely of BL MCA's and left A1
-A+O x1 at baseline
3. HTN
4. Type 2 Diabetes Mellitus
5. Osteoarthritis
6. Subglottic laryngeal edema: confirmed on bronchoscopy [**8-/2173**]
Social History:
Lives at the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. No tobacco, ETOH, or drug use.
Daughter is involved in care.
Family History:
NC
Physical Exam:
Per admit to the ICU
T=100.8... BP=187/79... HR=73... RR=14... O2=100% on AC 500x14,
FiO2 100% and PEEP of 5
GENERAL: Intubated, sedated
HEENT: NCAT, Pupils miotic bilaterally, macroglossia, edematous
lips
CARDIAC: Regular rhythm, normal rate, no murmurs
LUNGS: coarse ventilated breath sounds, no stridor heard at the
upper airway
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Cool, 1+ radial, DP, PT pulses
SKIN: Sacral decubitus ulcer
Pertinent Results:
LABS ON ADMISSION:
CBC: WBC 6.6, Hct 32.2, Plt 265
[**2173-9-15**] GLUCOSE-155* LACTATE-1.9 NA+-138 K+-4.9 CL--91*
TCO2-34*
[**2173-9-15**] ALT(SGPT)-22 AST(SGOT)-26 LD(LDH)-243 CK(CPK)-113 ALK
PHOS-123* TOT BILI-0.2
[**2173-9-15**] LIPASE-18
[**2173-9-15**] CK-MB-5 cTropnT-0.17*
[**2173-9-15**] ASA-NEG ACETMNPHN-NEG tricyclic-NEG
[**2173-9-15**] PT-14.3* PTT-26.8 INR(PT)-1.2*
[**2173-9-15**] URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-TR
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-TR
[**2173-9-15**] URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0
.
.
.
IMAGING:
CT Head ([**9-15**]): 1. No acute intracranial hemorrhage. Please note,
MRI is more sensitive for the detection of acute ischemia. 2.
Persistent, partial opacification of the mastoid air cells.
.
CTA neck/chest ([**9-15**]): 1. Interval development of the left
vertebral artery distal segment occlusion, with distal
reconstitution just proximal to the basilar artery. 2. Apparent
thrombosis of the distal right subclavian vein around the CV
catheter with extensive collateralization in the right chest. 3.
No evidence of pulmonary embolism or aortic dissection.
4. Interval worsening of right lower lobe consolidation and
pleural
effusions. 5. Paranasal sinus disease better evaluated on the
recent head CT. 6. Chronic right internal jugular occlusion with
extensive thoracic
collaterals. Patent left brachiocephalic stent.
.
CT Sinus ([**9-24**]):
1. Pansinusitis with evidence of acute-on-chronic inflammatory
change; the
findings appear most marked involving the sphenoid sinuses and
their lateralrecesses, bilaterally. The left ostiomeatal
complex, and bilateral fronto-and spheno-ethmoidal recesses
appear occluded.
2. There is no evident involvement of the intracranial or
intraorbital
compartments. 3. Very poor dentition as described, with findings
strongly suggestive of periapical abscess involving a left
maxillary molar and, perhaps, right maxillary incisor with
evident cortical breakthrough. These findings should be closely
correlated with detailed oral examination (as performed by the
Dental service). 4. Opacified mastoids, bilaterally, with fluid
in the right middle ear cavity, which may relate to the
combination of prolonged intubation and supine positioning;
however, an inflammatory component cannot be excluded.
.
CXR on admit: Right perihilar consolidation, likely pneumonia.
Moderate right pleural effusion. F/u CXRs do not confirm PNA.
.
MICRO:
Blood, urine, sputum cx NGTD
CDiff neg x1
.
Trends:
WBC: 6.6-> 7.8
HCT: 32->29
Discharge Chem panel:
[**2173-9-27**] 08:45AM BLOOD ESR-85*
[**2173-9-27**] 08:45AM BLOOD Glucose-263* UreaN-34* Creat-5.6*# Na-134
K-4.2 Cl-95* HCO3-24 AnGap-19
Brief Hospital Course:
1)Respiratory distress: The patient has a history of subglottic
laryngeal edema of unclear etiology, and likely causes included
angioedema from ACE/[**Last Name (un) **] vs. history of multiple intubations.
This episode occured temporally after being restarted on
Valsartan so angioedema was on the differential but given
history of multiple recent intubations, laryngeal edema was
thought to be the most likely etiology. CTA chest was negative
for PE or any other acute process. She was started on steroids
on admission which were stopped after a brief course. Decision
was made for tracheostomy and PEG tube placement. Family was in
agreement with this plan and the patient tolerated the procedure
well; she was able to be weaned to a trach collar over the
following two days. Patient was transferred to the floor and
continued to do well from respiratory standpoint, satting 100%
on the trach collar with supplemental oxygen. Speech and
swallow saw her in consult and she was fitted for a PM valve
with good results. There was no further respiratory distress
noted during her hospital course.
- we recommend avoiding ARBs and ACEi in the future given
possible contribution to resp issues
- Will complete antibiotic course for ? pneumonia although no
culture data or CXR data to clearly support this.
- trach collar care to be continued at rehab
- Can use PM valve as tolerated to assist with speech
- followup with pulmonary to assess trach and eval for any edema
.
2)Fevers/leukocystosis: A few days into admission, the patient
started spiking temperatures with a mildly elevated WBC. There
was concern for line infection given R femoral line that was
placed in the emergency room. VAP was also on the differential
but was thought to be unlikely given short duration of
intubation. The femoral line was d/c'ed and sent for culture
which was negative. She was empirically started on Vancomycin
for a planned 8 day course. Several days later, the pt spiked
again and was noted to develop loose stools. Her covereage was
broadened to emperic Flagyl for possible C.Diff as well as
Levaquin. C. diff cultures were negative X1. Patient had a CT
scan of the sinuses which showed extensive sinusitis as well as
possible dental abscesses. She was seen in consult by OMFS who
felt that she would benefit from extraction of the diseased
teeth. She was taken to the OR on [**2173-9-26**] and 10 teeth were
extracted; a small tongue nodule was also biopsied. After
transfer from the MICU to the floor, the patient remained
afebrile. Vancomycin was continued for an 8-day course
(finished [**2173-9-27**]), and levo/flagyl were continued for a planned
10 day course (to be finished [**2173-10-2**]).
.
3)Hypertensive urgency: Patient initially presented with
elevated blood pressures in the emergency room. She was
transiently started on a Labetolol gtt and then transitioned to
an oral regimen of PO Labetolol and clonidine (hydralazine also
used transiently). Low dose amlodipine was added to her regimen
as well. Her blood pressure was well controlled on these agents
throughout her hospital stay.
- recommend avoiding [**Last Name (un) **] and ACEi
.
4)Coffee ground emesis: Patient presented with coffee ground
emesis on admission which quickly resolved. Stools were guiac
negative. The pt has prior history of gastritis resulting in an
UGIB, however no further intervention was persued on this
admission. Hematocrits remained stably low at the patient's
baseline (around 30) throughout her hospital stay.
- continued on H2 blocker during stay
.
5)ESRD: Renal was consulted during patient's admission. She was
continued on HD on her regular schedule (Tu/Th/Sat). The pt is
known to have thrombosis around the distal portion of her HD
line, for which renal has currently elected not to treat. There
is a possibility the pt may be anticoagulated in the future,
pending further evaluation by the renal team.
- discuss with outpt nephrologist regarding indication for
anticoagulation for thrombosis.
.
6)Type II DM: She was continued on NPH at half dose while NPO as
well as insulin sliding scale. Her blood sugars were well
controlled.
.
7)FEN: Patient was started on tube feeds after she was
intubated. Nurses noted high residuals so she was started on
standing Reglan with mild improvement. She then had a PEG tube
placed and tolerated subsequent feeding well. Speech and
swallow saw her in consult and she passed a PO trial and was
started on a diet of pureed solids and thin liquids in addition
to tube feeds per S/S recommendations.
.
8) PPX: Patient was kept on bowel regimen, heparin SC.
.
9) Contact: daughter [**Name (NI) **] [**Name (NI) 103090**] ([**Telephone/Fax (1) 103274**]. Patient is
Creole speaking; daughter speaks [**Name2 (NI) 483**].
.
10) Psych/neuro: Pt's home meds of celexa, namenda, and
risperdal were not continued while in the ICU given use of other
sedating meds. We restarted the risperdal on the floor and
recommend monitoring for delirium/psychosis. Consider
restarting namenda and celexa after d/w PCP. [**Name10 (NameIs) **] does become
slightly delirious on occasion at nights and even needed
restraints at one point.
.
11) Access: difficult IV access. Has HD line for dialysis
.
12) Code: Full, discussed with daughter (HCP)
.
13) Wound care: has sacral decubitus. Wound care per nursing.
Medications on Admission:
Amlodipine 5mg daily
Labetalol 200mg [**Hospital1 **]
Diovan 40mg daily- re-started on [**9-13**]
Simvastatin 40mg daily
Prilosec 20mg daily
NPH 6 units [**Hospital1 **]
Celexa 10m daily
Risperdal 0.25mg daily
Cinacalcet 50mg daily
Namenda 5mg qhs
Albuterol/ipatropium nebs
Bowel regimen
Phoslo 667 two tabs TID
Discharge Medications:
1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday): Please hold for SBP <100 or
HR <55.
Disp:*4 Patch Weekly(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Six (6)
units Subcutaneous Once at breakfast, once at dinner: Please
take 6 units at breakfast and 6 units at dinner once every day.
7. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days: Please take one tablet on [**9-22**], and
[**10-3**].
Disp:*3 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: Please take one tablet twice a day
from [**Date range (1) 103275**].
Disp:*10 Tablet(s)* Refills:*0*
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig:
variable units Subcutaneous four times a day: routine insulin
sliding scale as needed.
12. Risperdal 0.25 mg Tablet Sig: One (1) Tablet PO once a day.
13. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
injection Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Laryngeal Edema causing acute respiratory failure
Dental infection now s/p extraction
Thrombosis of HD line - plan to hold on anticoagulation for now
Hypertension: s/p new medication regimen
Possible [**Last Name (un) **] and ACEi allergies
Secondary:
ESRD on HD qTues, Thurs, Sat
Type II Diabetes mellitus
Vascular dementia s/p CVA
Osteoarthritis
Discharge Condition:
Stable, satting well on trach collar, afebrile
Discharge Instructions:
You were admitted to the hospital because of unresponsiveness
and difficulty breathing. We think this is likely due to a
combination of swelling in your airway from previous times when
you had a breathing tube as well as possible medication side
effect of swelling from one of your diuretics. In the hospital,
we needed to put in a breathing tube so that your airway would
function properly. We did a surgery to insert a tube through
your airway (tracheostomy tube) so that you would not need to be
on the ventillator, and also placed a feeding tube so that you
would get adequate nutrition. You had some fevers and were put
on several antibiotics. We think the cause of the fevers was
most likely a dental infection, and the oral surgeons did an
operation to remove some diseased teeth which may have been
causing you to have these fevers. After your operation, you did
well and had no more fevers, and you did well with breathing on
the trach collar.
Please take all medications as directed. Please call your PCP
if you have any difficulty breathing, notice your neck is
swelling up, have any mouth or tooth pain, or have high
fevers/chills or other symptoms which are concerning to you. If
your PCP is not available, please come to the nearest emergency
room.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week; please f/u results
of tongue nodule biopsy with your PCP at this appointment
Please follow up with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] in
interventional pulmonary on Tuesday [**10-26**] at 8:30am. Office in
[**Hospital Ward Name 121**]/[**Hospital1 **] 116, patient will need transportation from rehab to
[**Hospital1 18**]. Phone:[**Telephone/Fax (1) 3020**]
|
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19,851
| 157,454
|
44299
|
Discharge summary
|
report
|
Admission Date: [**2125-5-7**] Discharge Date: [**2125-5-15**]
Date of Birth: [**2061-2-21**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Codeine / Nortriptyline
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
Left femoral line placement
History of Present Illness:
Mr. [**Known lastname 7493**] is a 64yo man with HIV, hepatitis C, ESRD on HD, DM2,
who lives at a nursing home, where he was found to have mental
status canges this morning being minimally responsive. He was
sent to our ER where he was found to have a FS of 14. (By report
FS at the nursing home was 278). He was given 1 amp D50 with
good effect, and Narcan x 1 with reportedly "better effect." The
patient was kept on a D5 drip to maintain his FS in the 70s in
the ER. He was admitted to the [**Hospital Unit Name 153**] for frequent FS monitoring.
Vital signs were stable in the ER. L femoral line was placed on
arrival. CXR showed likely aspiration or widespread pneumonia
and the pt was started on vancomycin/Zosyn/azithro. MICU course
also notable for sinus tachycardia, improved with hydration and
addition of a beta-blocker. Troponin of 0.30 is below levels
checked early in [**Month (only) 547**] of 0.35.
.
The patient has no complaints at present except for his chronic
upper and lower extremity pain which he says has not been
treated at his nursing home. He states that he asked a friend to
bring him two [**Name (NI) 94991**] yesterday but claims he did not take
these. He also has many complaints about his treatment at his
nursing home, where he thinks that he is poorly cared for and
that they do not like him because he "complains too much." He
believes he has gotten his usual doses of insulin only and
denies any oral hypoglycemics or new pills which looked
different to him. He states that he currently feels at his new
baseline.
.
Pt has HD on TThSa through R femoral line. He is on coumadin for
history of clotted HD lines.
Past Medical History:
1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**].
2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy,
charcot foot, nephropathy, and ? mild retinopathy.
2) ESRD on Hemodialysis and graft infections,
thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues,
thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] /
Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**]
3) [**Female First Name (un) 564**] esophagitis
4) Hepatitis C: genotype IB-> last viral load [**8-/2124**] 175,000
5) Congestive heart failure: echocardiogram [**10/2123**] w/ EF 60%.
6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and
circumcision during hospitalization.
7) Hypertension
8) Hypercholesterolemia
9) LE Diabetic ulcers
10) Herpes zoster of the left mandibular distribution of the
trigeminal nerve. [**2115**]
11) R suprapatellar abscess: [**2115**].
12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**]
13) Obesity
15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative
colonoscopies.
16) Anemia: [**2117**]. Started Epogen.
18) Colonic Polyps
19) Gastritis with large hiatal hernia.
20) Lipodystrophy
21) Charcot foot: dx in [**9-12**].
22) Colonic AVM: seen on [**3-8**] colonoscopy on the ileocecal
valve. Treated with thermal therapy. At that time was also
offerred hormonal therapy, but this was deferred.
23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No
abnormalities on CT chest in [**2121**].
24) MRSA- grew out from culture from L anterior chest wound, s/p
I+D
25) Peripheral neuropathy: on a narcotics contract
26) Diastolic CHF: [**2-/2125**] TTE: LV cavity is unusually small.
Hyperdynamic LV systolic fxn (EF >75%(, trivial MR,
trivial/physiologic pericardial effusion
27) Thrombosis of dialysis line, on chronic anti-coagulation
28) Emphysema
Social History:
Hx of tobacco abuse (quit 20 yrs ago), alcohol abuse
(quit >20 yrs ago) and heroin and cocaine abuse (quit >20 yrs
ago). Has a girlfriend who visits him frequently and is involved
in his care. Recently lost his home after several
hospitalizations and has been in ECF but hopes to return home to
his girlfriend.
Family History:
Noncontributory
Physical Exam:
Tc 97.3, bpc 139/105, HR 95, resp 20, 95% RA
Gen: African American male, NAD
HEENT: anicteric, nl conjunctiva, OMMM, OP clear, neck supple,
No LAD
Cardiac: RRR, no M/R/G appreciated
Pulm: (+) crackles at bases bilaterally
Chest: right chest wall abscess site with small amt purulent
drainage, non-tender.
Abd: obese, soft, NT
Ext: Cool [**Last Name (un) **] bilaterally, (+) muscle wasting in lower
extremities bilaterally. Right dorsal great toe ulcer, shallow
Neuro: falls asleep during conversation (pt's girlfriend reports
this is his baseline).
Pertinent Results:
[**2125-5-7**] CXR: Left lung consolidation has improved substantially
over nine hours, indicating this was most likely asymmetric
edema. Lungs are otherwise clear. Lateral aspect of the right
lower hemithorax is excluded from the examination, but the
remaining pleural surfaces are normal. Large hiatus hernia
noted.
.
[**2125-5-8**] ECG: Sinus tachycardia @ 106. Low limb lead QRS voltage.
Early precordial QRS transition. Modest non-specific right
precordial/anterior T wave changes. Prolonged QTc interval.
These findings are non-specific but clinical correlation is
suggested. Since the previous tracing of [**2125-4-11**] sinus
tachycardia is present, further T wave changes are seen and QTc
interval appears prolonged.
.
[**2125-5-9**] CXR: The heart size is large but unchanged in size. The
large hiatal hernia is again demonstrated. The lungs are clear
with no new infiltrates. The pleural surfaces are smooth and
there is no sizable pleural effusion.
.
[**2125-5-10**] ECG: Sinus rhythm
Early precordial QRS transition - is nonspecific
Diffuse nonspecific ST-T wave abnormalities with prolonged Q-Tc
interval -
cannot exclude in part drug/metabolic/electrolyte effect
Clinical correlation is suggested
Since previous tracing of [**2125-5-8**], sinus tachycardia absent,
further ST-T wave abnormalities seen and Q-Tc interval is
prolonged
.
[**2125-5-11**] CHEST U.S. RIGHT: Partial interval resolution of fluid
collection in the right upper chest with residual 4.8 x 0.9 x
1.0 cm fluid collection of mixed echogenicity, which could
represent hematoma.
.
[**2125-5-7**] 12:10PM BLOOD WBC-10.0 RBC-3.65* Hgb-11.6* Hct-37.6*
MCV-103* MCH-31.9 MCHC-30.9* RDW-22.8* Plt Ct-232
[**2125-5-7**] 12:10PM BLOOD Neuts-82.9* Lymphs-12.0* Monos-3.6
Eos-1.2 Baso-0.3
[**2125-5-7**] 12:10PM BLOOD Hypochr-3+ Anisocy-3+ Macrocy-3+
Microcy-1+
[**2125-5-7**] 12:10PM BLOOD Plt Ct-232
[**2125-5-7**] 12:10PM BLOOD PT-28.1* PTT-49.1* INR(PT)-2.9*
[**2125-5-7**] 12:10PM BLOOD Glucose-112* UreaN-30* Creat-6.2*# Na-138
K-4.3 Cl-97 HCO3-30 AnGap-15
[**2125-5-7**] 12:10PM BLOOD estGFR-Using this
[**2125-5-7**] 12:10PM BLOOD ALT-6 AST-12 CK(CPK)-15* AlkPhos-75
Amylase-30 TotBili-0.9
[**2125-5-7**] 12:10PM BLOOD Lipase-11
[**2125-5-7**] 12:10PM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2125-5-7**] 12:10PM BLOOD Calcium-10.4* Phos-5.9*# Mg-2.4
[**2125-5-7**] 01:13PM BLOOD Lactate-1.8
[**2125-5-7**] 12:16PM BLOOD Glucose-103 Na-140 K-4.3 Cl-97*
calHCO3-35*
[**2125-5-8**] 03:20AM BLOOD TSH-4.5*
[**2125-5-10**] 05:29AM BLOOD WBC-4.7 RBC-3.62* Hgb-11.8* Hct-38.0*
MCV-105* MCH-32.7* MCHC-31.2 RDW-21.8* Plt Ct-248
[**2125-5-10**] 05:29AM BLOOD Plt Ct-248
[**2125-5-10**] 05:29AM BLOOD PT-32.1* PTT-82.3* INR(PT)-3.4*
[**2125-5-10**] 05:29AM BLOOD Glucose-74 UreaN-24* Creat-6.0*# Na-137
K-3.9 Cl-96 HCO3-27 AnGap-18
[**2125-5-10**] 05:29AM BLOOD CK(CPK)-12*
[**2125-5-7**] 12:10PM BLOOD Lipase-11
[**2125-5-10**] 05:29AM BLOOD CK-MB-3 cTropnT-0.25*
[**2125-5-10**] 05:29AM BLOOD Calcium-9.7 Phos-4.6* Mg-1.9
[**2125-5-10**] 05:29AM BLOOD VitB12-991* Folate-14.0
[**2125-5-10**] 05:29AM BLOOD Free T4-1.1
[**2125-5-10**] 05:29AM BLOOD Cortsol-15.8
[**2125-5-10**] 05:29AM BLOOD Vanco-24.4*
.
[**5-11**] Wound CX
GRAM STAIN (Final [**2125-5-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2125-5-13**]): NO GROWTH
Brief Hospital Course:
1) Hypoglycemia/Type II diabetes: Patient was only on a sliding
scale at his [**Hospital1 1501**]; no long-acting insulin or oral agents. [**Month (only) 116**]
have been related to infection (see below), in combination with
ESRD (decreased clearance of endogenous insulin) and impaired
gluconeogenesis (decreased muscle mass reducing substrate, known
HCV). The endocrinology service was consulted, who recommended a
liberal sliding scale, frequent small meals. A nutrition consult
was obtained to help instruct patient regarding the difference
between simple and complex carbohydrates. His a.m. cortisol was
normal, not suggestive of adrenal insufficiency. His TSH was
elevated but his free T4 was normal; this can be repeated in 6
wks as an outpatient. The patient should also follow-up with
ophthalmology as an outpatient.
2) Mental status change: Most likely related to hypoglycemia and
narcotics. He improved to his baseline rapidly. His methadone
dose was decreased to 10 mg daily. Given obesity, he is at risk
for obstructive sleep apnea, and an outpatient sleep study may
be considered.
3) Pneumonia: Rapid resolution of airspace opacity following
admission suggests some component of pulmonary edema. The
patient completed a 7 day course of antibiotics and, at time of
discharge, his pulmonary status was stable.
4) HIV: CD4 614 on [**2125-4-13**]. The patient was continued HAART
5) Peripheral neuropathy: The patient's methadone dose was
reduced given prolonged QTC and oversedation; he was continued
on percocet per narcotic contract (2 mg PO q8h prn)
6) ESRD: The patient continued Tues/Thurs/Sat dialysis. Given
his history of thrombosis, he was continued on anticoagulation
(goal INR [**2-10**])
7) Right chest wall abscess: The patient has a history of MRSA
right chest wall abscess at the setting of prior dialysis line.
He has required drainage/VAC dressing in the past. Given
continued purulent drainage noted, a chest ultrasound was
obtained, which showed residual (decreased) fluid collection.
The surgery service was consulted, who did not recommend repeat
drainage given the collection's reduced size and the healing
difficulties that the patient had after the last drainage. He
will complete a 14 day of vancomycin, dosed at dialysis for
levels <15.
8) Prolonged QTc/EKG changes: Troponin levels were lower than
patient's values from last admission, not suggestive of active
ischemia. The patient's methadone dose was decreased, as this
could be contributing to prolonged QTC.
9) Hypertension: The patient's metoprolol dose was increased for
improved blood pressure control.
Medications on Admission:
protonix 40mg po daily
lamivudine 100mg po qday
cymbalta 30mg po qday
ritonavir 100mg po bid
colace 100mg po bid
indinavir 400mg po bid
metoprolol 25mg po bid
methadone 10mg po bid
heparin sc
epo 20,000 sc qwk at HD
stavudine 20mg po qday
dulcolax pr qday prn
albuterol 2 pufs q6h prn
compazine 10mg q6h prn nausea
per OMR percocet 5 per day in narcotic ocntract but not on ECF
med list
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (3) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lamivudine 100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Month/Day (3) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Ritonavir 100 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO BID (2 times
a day).
5. Docusate Sodium 100 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO BID (2
times a day).
6. Indinavir 400 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO BID (2 times
a day).
7. Metoprolol Tartrate 50 mg Tablet [**Month/Day (3) **]: 1.5 Tablets PO TID (3
times a day).
8. Methadone 10 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (3) **]: 1-2 Tablets PO
Q8H PRN (): hold for oversedation.
10. Stavudine 20 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO Q24H (every
24 hours).
11. Warfarin 2.5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO HS (at
bedtime).
12. Atorvastatin 10 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
13. Vancomycin 1,000 mg Recon Soln [**Month/Day (3) **]: One (1) gram Intravenous
at dialysis for 5 days: as needed if vanco level <15
(Course to be completed on [**5-20**]).
14. Insulin Lispro (Human) 100 unit/mL Solution [**Month/Year (2) **]: see
attached U Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary: change in mental status
Secondary: hypoglycemia, chest wall abscess, pneumonia,
peripheral neuropathy, hypertension, end stage renal disease,
HIv, hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a low blood sugar, a questionable
pneumonia (for which you completed a course of antibiotics) and
a right chest wall abscess.
1) Please take all medications as prescribed
2) Please follow-up as indicated below.
3) Please come to the emergency room or see your primary care
physician if you develop persistent low blood sugars, fevers,
chills, cough, or other symptoms that concern you.
Do not take insulin unless your sugars are >200.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD (PCP) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2125-5-23**] 10:10
2. You have an appointment scheduled with Dr. [**Last Name (STitle) **] at the
[**Hospital **] [**Hospital 464**] clinic on Friday, [**2125-5-18**] at 4:00.
3. Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
(Podiatry) Date/Time:[**2125-5-30**] 1:30
|
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icd9cm
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,272
| 132,957
|
510
|
Discharge summary
|
report
|
Admission Date: [**2161-11-21**] Discharge Date: [**2161-12-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Tracheostomy
Central Line Placement
History of Present Illness:
This is a 84 y/o with h/o ESRD, A fib, who comes to the
Emergency Department after being found on HD with increasing
shortness of breath. Patient found to be 10L positive, but they
were unable to take enough fluid off so they took off 2L.
Patient describes that over the last few weeks, she has been
feeling a little more short of breath. She reports one "big
pillow" orthopnea and cannot lie flat due to shortness of
breath. No PND. Pt is non-ambulatory so it is difficult to tell
how far she can walk before getting SOB.
She denies any fever, cough, diarrhea, chest pain, chills,
nausea, vomit. Of note, pt was recently admitted for debridement
of her heel ulcers. Also, of note, pt recently had a PMIBI that
was negative for ischemia and showed an EF of 60%.
Past Medical History:
1. ESRD on HD since [**2149**] (Dr. [**Last Name (STitle) 1860**];
2. MRSA bacteremia from fistula [**5-10**]
2. Atrial Fibrillation
3. Renal Mass on CT since [**2159**]
4. Right Hip Erosive Arthritis; now s/p R hip
surgery(hemiarthroplasty) complicated by mental status changes
and decreased BP
5. Osteoporosis
6. Anemia
7. Asthma
8. GERD
9. Hypertension
10. PVD/Heel Ulcers - refusing angio
11. C.Diff [**8-10**] treated with Flagyl. C.Diff positive on [**9-19**] at
nursing home.
12. Poor PO Intake
13. Depression
14. Low Phos, Mag, and Potassium
15. b/l non-healing heel ulcers
16. Ischemic left leg
Social History:
Pt currently lives at rehab center but prior to fracture lived
alone in [**Location (un) 86**] with a house cleaner who comes several times a
week to clean her house. Pt reports quiting smoking 8 years ago.
However, the patient does have a 60+ pack year history of
smoking. Pt has occasional alcohol use.
Family History:
Noncontributory.
Physical Exam:
98.6 BP 126/70 HR 84 RR 30 Sats 100%
General: Patient in non aparent distress
HEENT: Dry mucosa, JVD 7 cm, neck supple
Heart: iregularly irregular. Systolic eyection murmur in the
apex [**2-8**]
Lungs: Decrease breath sounds bilaterally. dullness to
percussion on the left side. poor air movement.
Abdomen: BS+, g-tube in place, soft, non tender, non distended.
Extremities: 3+ edema to mid thighs; + sacral edema; skin ulcers
on bilateral heels - no s/s of infection (erythema/pururlence),
but with tenderness to palpation. Pt has pain to palpation over
L>R hip that is chronic. RUE with chronic edema
Changes on Discharge exam"
trach in place.
Face with some baseline asymmetry but elevates symetrically for
smile, brow raise.
RUE still edemetous but HD fistula working, decreased
tenderness, appearance c/w lymphedema of arm.
Pertinent Results:
[**2161-10-20**]
MIBI: IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left
ventricular cavity size and function. LVEF of 60%.
.
[**2161-11-21**]
LEFT DECUBITUS AND LATERAL RADIOGRAPHS: Again seen is a
left-sided PICC line terminating in the SVC. Large left pleural
effusion with associated atelectasis is again seen. A small
right-sided pleural effusion and associated atelectasis is seen.
Osseous structures remain unstable. Note is made of a calcified
aorta. Heart and mediastinal contours cannot be adequately
evaluated secondary to the pleural effusion.
IMPRESSION:
1. Large left pleural effusion with associated atelectasis.
2. Small right pleural effusion with associated atelectasis
.
[**2161-11-21**] ultrasound negative for DVT RUE
.
CT HEAD: IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Probable thick secretions within the posterior nasopharynx.
Clinically correlate.
.
CXR [**2161-12-9**]:
INDICATION: Tube placement.
There has been interval placement of a tracheostomy tube, which
terminates at approximately the level of the thoracic inlet. The
cuff appears slightly wider than the adjacent tracheal lumen
suggesting mild overdistention. There is no evidence of
pneumomediastinum or pneumothorax, and there has otherwise been
no significant interval change in appearance of the chest with
the exception of the tube placement compared to the prior study
of one day earlier.
.
ECHO [**11-24**]:
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is dilated. Right ventricular systolic
function is borderline normal. [Intrinsic right ventricular
systolic function may be more depressed given the severity of
tricuspid regurgitation.] The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
[**2162-11-24**] CTA CHEST:
IMPRESSION:
1. No evidence of pulmonary embolism, retroperitoneal
hemorrhage, or intra- abdominal abscess.
2. Moderate bilateral pleural effusions unchanged from the prior
study. Small pericardial effusion, and small amount of ascites
fluid. Findings are consistent with anasarca.
3. Heavy coronary and aortic calcifications.
4. Atrophic kidneys with bilateral cysts, consistent with
end-stage renal disease. Some low-density lesions of the kidneys
are not fully characterized.
.
LABS:
[**2161-11-21**] 11:40AM BLOOD WBC-8.6 RBC-3.70* Hgb-10.8* Hct-34.7*
MCV-94 MCH-29.3 MCHC-31.3 RDW-17.7* Plt Ct-308#
[**2161-12-7**] 03:25AM BLOOD WBC-15.9* RBC-3.19* Hgb-9.0* Hct-28.0*
MCV-88 MCH-28.2 MCHC-32.2 RDW-17.9* Plt Ct-493*
[**2161-12-16**] 02:18AM BLOOD WBC-9.5 RBC-3.31* Hgb-9.6* Hct-30.0*
MCV-91 MCH-28.9 MCHC-31.9 RDW-18.7* Plt Ct-391
.
[**2161-11-21**] 11:40AM BLOOD PT-15.8* PTT-47.2* INR(PT)-1.7
[**2161-12-16**] 02:18AM BLOOD PT-13.8* PTT-79.3* INR(PT)-1.3
.
[**2161-11-21**] 11:40AM BLOOD Glucose-104 UreaN-18 Creat-1.5*# Na-141
K-3.5 Cl-96 HCO3-35* AnGap-14
[**2161-12-16**] 02:18AM BLOOD Glucose-108* UreaN-39* Creat-2.8* Na-138
K-5.0 Cl-101 HCO3-27 AnGap-15
.
[**2161-11-23**] 01:00PM BLOOD ALT-13 AST-16 LD(LDH)-203 CK(CPK)-82
AlkPhos-268* TotBili-0.2
[**2161-12-1**] 03:06AM BLOOD ALT-9 AST-16 LD(LDH)-165 AlkPhos-202*
TotBili-0.2
.
[**2161-11-23**] 01:00PM BLOOD CK-MB-NotDone cTropnT-.36*
[**2161-11-23**] 11:01PM BLOOD CK-MB-NotDone cTropnT-0.35*
.
[**2161-12-16**] 02:18AM BLOOD Calcium-10.1 Phos-2.0* Mg-2.1
.
[**2161-12-6**] 02:56AM BLOOD calTIBC-113* Ferritn-518* TRF-87*
.
[**2161-11-22**] 09:24PM BLOOD TSH-3.1
[**2161-12-11**] 12:12PM BLOOD PTH-46
[**2161-12-1**] 03:06AM BLOOD Cortsol-10.9
[**2161-12-1**] 01:00PM BLOOD Cortsol-20.7*
[**2161-12-1**] 01:30PM BLOOD Cortsol-23.6*
.
[**2161-12-7**] 03:25AM BLOOD Vanco-17.7*
.
.
[**2161-12-11**] 02:59PM BLOOD Type-ART pO2-120* pCO2-51* pH-7.37
calHCO3-31* Base XS-3
[**2161-12-14**] 06:28PM BLOOD Type-ART Temp-36.2 Rates-/14 Tidal V-350
PEEP-5 FiO2-40 pO2-179* pCO2-48* pH-7.39 calHCO3-30 Base XS-3
Intubat-INTUBATED
[**2161-12-15**] 03:26AM BLOOD Type-ART Temp-36.2 pO2-106* pCO2-53*
pH-7.37 calHCO3-32* Base XS-4
Brief Hospital Course:
OVERVIEW: This is a 84 y/o female with h/o ESRD on HD, PAF on
anticoagulation who came in with increasing shortness of breath
and a new pleural effusion.
.
# Shortness of Breath: The patient developed shortness of
breath prior to transfer to the medical ICU. On transfer, she
was intubated for hypercarbic respiratory failure. The
differential diagnosis of this SOB included cardiac causes (MI,
worseing CHF), and pulmonary (pna, pleural effusion, COPD). EKG
showed no acute changes and enzymes ruled her out for MI. BNP
was [**Numeric Identifier 4244**], suggesting CHF, but Echocardiogram revealed EF 50-55%
MR1+, TR 2+. She did not appear grossly volume overloaded and
HD was continued, though it was occasionally suboptimal due to
hypotension. Pleural effusions decreased in size with continued
HD and were too small to tap. In the end, her resp failure was
thought to be due to multiple causes including CHF with
overload, underlying COPD, and deconditioning. There was no
overt evidence of PNA, though she had an elevated white count
and a stable retrocardiac opacity and was treated with a course
of antibiotics. It was thought possible that she had early
sepsis and she was treated emperically with vanco, ceftaz and
flagyl. She had one culture showing proteus (sputum [**11-23**]) but
no other positive culture data. HD was continued with good
response, but the pt was not able to wean from the ventilator.
HCP was [**Name (NI) 653**] and felt she would want at least medium term
trach to facilitate weaning. Failure to wean from vent was
thought to be due to the same underlying causes that led to her
respiratory failure.
- patient is to continue on ventilatory support via trach and is
to transfered to an acute rehab for further wean.
.
# Cardiovascular:
Pump: patient with EF> 50% so CHF likely diastolic. The pt was
on pressors for a majority of her ICU stay, but these were
discontinued days prior to discharge. Prior to her discharge
she began to become hypertensive and metoprolol was added back
into her regimen. We control BP with home meds; 1.5L fluid
restriction, low salt diet, daily weights, strict Is/Os.
Patient during her stay continued to gradually get fluid off
through HD with improvement in her pulmonary oxygen
requirements.
- Patient however remains positive throughout her stay in the
ICU and may benefit from further volume diuresis via HD.
.
Rhythm: Pt has A-fib with adequate rate control, stable
hemodynamically;
Patient is to continue amiodarone-metoprolol. Metoprolol can be
titrated up as possible. Patient was previously on coumadin and
was on heparin during this hospitalization. She has been
restarted on coumadin. She is currently being bridged to
coumadin.
-she will need daily INR until >1.9, when heparin can be d/c'd.
Thereafter, she will need qod INR until stable and weekly
monitoring thereafter.
.
CAD: neg MIBI as above, ROMI'd at this hospitalization by
enzymes, no EKG changes. No active issues. Cont on ASA,
metoprolol.
.
#. Anemia: Chronic issue in setting of chronic renal failure.
Basline mid to high 30s. Cont epo at dialysis.
.
#. Heel ulcers. currently with no evidence of infection; Patient
attended by wound care nurse while in house; vit C and zinc to
continue.
- will need monitoring, wound care
.
#. ESRD: patient on receiving HD Tu,Th,Sat.
- cont nephrocaps and phoslo and epo with HD as above.
- monitor electrolytes
.
# GERD - Continued on protonix 40mg QD
.
#. COPD/Asthma - continued on combivent
.
# FEN: Pt with G-tube [**1-7**] poor po intake. Consult nutrition re
tube feed recs, Boost.
# Hypotension - The etiology was unclear - she had an
appropriate response to [**Last Name (un) 104**] stim test, wbc increased, and she
was thought to have early sepsis. However, she had large fluid
shifts with HD, which caused her BP to decrease most markedly.
As her course and volume status stabilized. Levophed was weaned
off 4days prior to discharge and her BP remained stable and she
was started on low dose metoprolol and tolerated this well..
- cont metoprolol
.
#MS changes - On transfer to the MICU, she had MS changes. She
had a negative head CT and it was thought that she had MS
changes due to hypercarbia. The ddx also included TIA b/c the pt
briefly had L sided weakness. She was noted to have some
baseline facial asymmetry, but elevates her palate, brow, and
smile symmetrically.
The MS [**First Name (Titles) 4245**] [**Last Name (Titles) 4246**] when her respiratory status improved
with intubation.
.
## FEN - Probalance at 65cc/hr continuous.
.
## CODE - DNR/DNI. [**Last Name (un) 4247**] designated as HCP. ([**First Name4 (NamePattern1) 4248**] [**Last Name (NamePattern1) 4249**] -
[**Telephone/Fax (1) 4250**]). The pt is also well known to Dr.
[**Last Name (STitle) 4251**], her PCP (who acted as interim HCP for a week early
during this hospital course.
.
## PPX - lansoprazole, pneumoboots, heparin gtt
.
## Contact - [**First Name4 (NamePattern1) 4248**] [**Last Name (NamePattern1) 4249**], [**Last Name (un) **], is HCP.
.
## Dispo - To [**Hospital1 1501**] today. Goal is weaning from vent.
Medications on Admission:
Amiodarone 200mg/day
Nephrocaps 1/day
Albuterol INh
Atrovent Inh
Protonix 40mg/day
Warfarin 0.5 mg/day
Phoslo 667 TID
Toprol Xl 25mg/day
Epo 5500 UNITS on HD tid/week
Zemplar (paricalcitol)
Venofer: once week/HD
- recently on levaquin for PNA and flagyl for c diff??
Discharge Medications:
1. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 200 mg PO
BID: prn.
7. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
10. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-20 units
Subcutaneous ASDIR (AS DIRECTED): as per sliding scale.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Resp. Failure
Sepsis
ESRD
Discharge Condition:
To vent rehab on PS to facilitate vent weaning.
Discharge Instructions:
Please return to the hospital if you develope shortness of
breath, chest pain, or have any other concerns.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**6-14**] days.
Completed by:[**2161-12-16**]
|
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icd9cm
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|
1758, 2065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,115
| 183,654
|
49284+59166
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-12-10**] Discharge Date: [**2191-12-20**]
Date of Birth: [**2118-1-9**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Chief complaint is chest pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 25731**] is a 73-year-old
male with a past medical history significant for prostate
cancer (status post radical prostatectomy in [**2183**]), who was
in [**State 108**] in the middle of [**Month (only) 1096**] when during a daily walk
he began having chest pain associated with dry heaves.
This pain was relieved by rest. He reported never having
experienced this type of pain before and denied any
associated shortness of breath.
He returned to [**State 350**] where he saw his primary care
physician who sent him for a stress test, which was done at
the [**Hospital6 2561**]. This revealed septal ischemia
with ST segment changes on electrocardiogram.
The patient underwent cardiac catheterization on [**2191-12-9**] which showed severe 3-vessel coronary artery disease.
He denies dysuria, fevers, chills, nausea, vomiting, renal
problems, or claudication.
The patient was found not to have had a myocardial infarction
by enzymes at [**Hospital6 2561**]. He was found to have
mild chronic renal insufficiency with a baseline creatinine
of 1.5.
PAST MEDICAL HISTORY:
1. Prostate cancer.
2. Hypercholesterolemia.
3. Mild chronic renal insufficiency.
PAST SURGICAL HISTORY:
1. Radical prostatectomy in [**2183**].
2. Open reduction/internal fixation of the right ankle.
MEDICATIONS ON ADMISSION: Medications on admission included
[**Doctor First Name **].
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Mr. [**Known lastname 25731**] had a prior history of tobacco
use; approximately 10 pack years, which he had quit
approximately 10 years ago. He states that he has one
alcoholic drink per night.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: The initial physical
examination revealed Mr. [**Known lastname 25731**] was found to have a
temperature of 98.3 degrees Fahrenheit, heart rate was 62 (in
sinus rhythm), and blood pressure was 107/50, with an oxygen
saturation of 90% on room air. In general, he was in no
acute distress. On cardiovascular examination he was found
to have a regular rate and rhythm. Normal first heart sound
and second heart sound. No murmurs, rubs, or gallops. His
lungs were clear to auscultation bilaterally. His abdomen
was soft, nontender, and nondistended, with a well-healed
prostatectomy scar. His extremities showed a small amount of
edema around the right ankle. Otherwise, they were warm,
dry, and well perfused. His pulse examination showed 2+
palpable femoral, popliteal, dorsalis pedis, and posterior
tibialis pulses bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed his complete blood count was significant
for a white blood cell count of 6.1 and hematocrit was 35.9.
Chemistry-7 showed sodium was 137, potassium was 3.8,
chloride was 106, bicarbonate was 23, blood urea nitrogen was
20, creatinine was 1.3, and blood glucose was 152.
RADIOLOGY/IMAGING: The patient had an electrocardiogram from
the [**Hospital6 2561**] which showed flipped T waves in
leads III, aVR, and V1. There were no signs of acute
ischemia by electrocardiogram.
The patient also had a carotid ultrasound which showed no
evidence of carotid artery plaques.
A chest x-ray was done which was clear and showed no
abnormalities.
HOSPITAL COURSE: Mr. [**Known lastname 25731**] was admitted to the
Cardiothoracic Surgical Intensive Care Unit on [**2191-12-10**] where he was started on Lopressor, aspirin, and a
heparin drip. The patient did well during the subsequent two
days with no issues.
On [**12-12**], the patient was taken to the operating room
where he underwent a coronary artery bypass graft times four
under general endotracheal intubation. Please refer to the
dictated Operative Note for full details of this procedure.
In summary, the patient had a left internal mammary artery to
the left anterior descending artery graft as well as
saphenous vein grafts to the posterior descending artery and
obtuse marginal arteries.
The patient tolerated the procedure well, and following
surgery was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. At this time, he was
being A-paced at a rate of 74 beats per minute and came to
the Intensive Care Unit on a Neo-Synephrine drip as well as a
propofol drip.
He did well overnight with Neo-Synephrine being titrated to
maintain a systolic blood pressure of greater than 140. He
required continued use of propofol for sedation, but did
appropriately follow commands.
On postoperative day one, he did require 4 liters of lactated
Ringer's, 500 cc of Hespan as well as 2 units of packed red
blood cells for labile blood pressures. He was continued on
a Neo-Synephrine drip at that time. He was extubated later
on postoperative day one which he tolerated without incident.
At this time, he continued to have moderate amounts of
serosanguineous drainage from his chest tubes as well as an
air leak. He was able to maintain his blood pressure and
heart rate without being paced, and a slow wean of his
Neo-Synephrine drip was begun.
Later on postoperative day two, Mr. [**Known lastname 25731**] went into a
rate atrial fibrillation with a heart rate up into the 130s.
He was given intravenous Lopressor as well as intravenous
magnesium and amiodarone. His Neo-Synephrine drip, which had
been weaned off, was subsequently restarted. At this time,
he was rate controlled with a heart rate in the low 100s and
in atrial fibrillation. However, shortly thereafter, he
converted back into a normal sinus rhythm with a heart rate
in the 70s, and he remained there throughout the rest of the
shift. He did require a small amount of Neo-Synephrine to
maintain his systolic blood pressure above 100.
It was noted early on postoperative day three that he no
longer had an air leak from his chest tubes. Later on
postoperative day three, the patient's arterial line and
chest tubes were removed. He was out of bed to the chair for
the first time, and he subsequently ambulated with
assistance. He remained in a normal sinus rhythm throughout
that day.
On postoperative day four, the patient was deemed ready and
stable for transfer to the regular floor. The patient
continued to do quite well after arrival to the floor. He
remained in almost sinus rhythm with no further episodes of
ectopy. He did quite well working with physical therapy,
ambulating multiple times a day with assistance.
On postoperative day number ten, it was felt that the patient
was stable and ready for discharge from the hospital. He was
doing extremely well from a cardiopulmonary standpoint. It
was, however, felt in conjunction with physical therapy, that
the patient would benefit from and require a short stay at a
rehabilitation facility to help further build increased
strength and mobility.
At the time of discharge, he was afebrile with a heart rate
of 80, in sinus rhythm, and a blood pressure of 90/60, with a
room air oxygen saturation of 92%. He was alert and oriented
to person, place, and time. He moved all extremities and
followed commands. His heart showed a regular rate and
rhythm with normal S1, S2, and no murmurs. His sternum was
stable, and his sternal incision was healing nicely with no
erythema or drainage. His lungs were clear to auscultation
bilaterally. His abdomen was soft, nontender, nondistended,
with no hepatosplenomegaly or other palpable masses. He
continued to have approximately 1+ lower extremity and pedal
edema, for which he was continuing to be diuresed.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg b.i.d.
2. Lasix 20 mg b.i.d. times ten days.
3. Potassium chloride 20 mEq b.i.d. for ten more days.
4. Colace 100 mg by mouth twice per day.
5. Aspirin 325 mg p.o. q.d.
6. Percocet one to two tablets every four to six hours as
needed for pain.
7. Zantac 150 mg b.i.d.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To an extended care facility.
DIET: Cardiac Heart Healthy diet.
ACTIVITY: Should be as tolerated, but the patient will
require assistance for ambulation, and further physical
therapy to help build increased strength and mobility.
FOLLOW-UP: Mr. [**Known lastname 25731**] should follow-up with his
cardiologist in the next one to two weeks. He should also
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in four weeks time. He
should also follow-up with his primary care physician in
approximately three to four weeks. An appointment will be
made for him to be seen in the [**Hospital 409**] Clinic here at [**Hospital6 1760**] in the next one to two weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft times three on [**2191-12-12**] with an ejection
fraction of 55%.
2. Prostate cancer, status post radical prostatectomy.
3. Hypercholesterolemia.
4. Brief episode of atrial fibrillation postoperatively
which resolved with medication and has not recurred.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2191-12-20**] 08:35
T: [**2191-12-20**] 09:11
JOB#: [**Job Number **]
Name: [**Known lastname 4419**], [**Known firstname **] Unit No: [**Numeric Identifier 16715**]
Admission Date: [**2191-12-10**] Discharge Date: [**2191-12-20**]
Date of Birth: [**2118-1-9**] Sex: M
Service:
ADDENDUM: The patient continued to do quite well after
arrival to the floor. He remained in almost sinus rhythm
with no further episodes of ectopy. He did quite well
working with physical therapy, ambulating multiple times a
day with assistance.
On postoperative day number ten, it was felt that the patient
was stable and ready for discharge from the hospital. He was
doing extremely well from a cardiopulmonary standpoint. It
was, however, felt in conjunction with physical therapy, that
the patient would benefit from and require a short stay at a
rehabilitation facility to help further build increased
strength and mobility.
At the time of discharge, he was afebrile with a heart rate
of 80, in sinus rhythm, and a blood pressure of 90/60, with a
room air oxygen saturation of 92%. He was alert and oriented
to person, place, and time. He moved all extremities and
followed commands. His heart showed a regular rate and
rhythm with normal S1, S2, and no murmurs. His sternum was
stable, and his sternal incision was healing nicely with no
erythema or drainage. His lungs were clear to auscultation
bilaterally. His abdomen was soft, nontender, nondistended,
with no hepatosplenomegaly or other palpable masses. He
continued to have approximately 1+ lower extremity and pedal
edema, for which he was continuing to be diuresed.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg b.i.d.
2. Lasix 20 mg b.i.d. times ten days.
3. Potassium chloride 20 mEq b.i.d. for ten more days.
4. Colace 100 mg by mouth twice per day.
5. Aspirin 325 mg p.o. q.d.
6. Percocet one to two tablets every four to six hours as
needed for pain.
7. Zantac 150 mg b.i.d.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To an extended care facility.
DIET: Cardiac Heart Healthy diet.
ACTIVITY: Should be as tolerated, but the patient will
require assistance for ambulation, and further physical
therapy to help build increased strength and mobility.
FOLLOW-UP: Mr. [**Known lastname **] should follow-up with his
cardiologist in the next one to two weeks. He should also
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in four weeks time. He
should also follow-up with his primary care physician in
approximately three to four weeks. An appointment will be
made for him to be seen in the [**Hospital 4011**] Clinic here at [**Hospital6 5442**] in the next one to two weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft times three on [**2191-12-12**] with an ejection
fraction of 55%.
2. Prostate cancer, status post radical prostatectomy.
3. Hypercholesterolemia.
4. Brief episode of atrial fibrillation postoperatively
which resolved with medication and has not recurred.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern4) 16716**]
MEDQUIST36
D: [**2191-12-20**] 08:44
T: [**2191-12-20**] 06:54
JOB#: [**Job Number 16717**]
|
[
"593.9",
"427.31",
"V10.46",
"411.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
1899, 3533
|
11087, 11384
|
12154, 12766
|
1568, 1667
|
3551, 7779
|
1442, 1541
|
174, 206
|
235, 1311
|
1333, 1419
|
1684, 1881
|
11409, 12133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,615
| 161,125
|
21893
|
Discharge summary
|
report
|
Admission Date: [**2187-3-17**] Discharge Date: [**2187-3-22**]
Date of Birth: [**2105-7-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 F w/ htn, hypercholesterolemia, AF on coumadin p/w 2 weeks
dry cough, runny nose, nasal congestion and feeling run down.
Over last few days, more SOB. Also c/o HA, quite severe, but
denied focal neuro signs. Came to ED, where CXR shows infiltrate
on the lateral view. CT revealed no ICH. BP was elevated to
180/100 and after IV hydral 25mg, improved to 150/90. On
admission, pt felt tired, but denied fevers, chills, SOB,
dizziness, SSCP. Tolerating PO's and is not dizzy on ambulation.
In ED, receied levaquin 500PO and hydral 25 IV.
Past Medical History:
Recent mild diverticulitis
Recent C. diff infection (OSH--positively confirmed by daughter)
HTN
Hypercholesterolemia (was on Atorvastatin but this was d/c'd
secondary to myopathy)
Afib on Coumadin
Cognitive Dysfunction
Hypothyroidism
Chronic leg pain (starting in right gluteal region and radiating
down right leg)
Not up to date per daughter on screening
Social History:
She is married and lives with her husband. Daughter is also a
caregiver and is a nurse, and lives in apartment above.
Family History:
Brother with [**Name2 (NI) **] dx'd in his 40s
Physical Exam:
PE: 96.7 HR 73-110 BP 121-166/79-90 94% 4L n/c
Gen: NAD, A&O X3
Heent: EOMI, PERRL
Neck: No LAD + JVD to Jaw
Heart: Irregular, No mrg.
Lungs: crackles [**12-5**]-way up
Abd: +BS, S/NT/ND
Ext: No edema
Pertinent Results:
ECG [**3-18**]: AF at 111 bpm, borderline LAD, no ST-T deviation,
unchanged from admission
.
CXR [**3-18**]: Development of increased interstitial markings
consistent with edema. Interval improvement in left basilar
infiltrate.
CXR [**3-17**]: Left lower lobe consolidation.
.
CT head: Neg
.
[**12-19**] CXR: B pleural effusions; flash pulm edema. No discrete
consolidation seen
.
ECHO [**3-20**]:
The left atrium is dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is normal (LVEF>55%). The aortic
root is moderately dilated athe sinus level. The aortic valve
leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion. Compared with
the prior study (images reviewed) of [**2186-12-19**], findings are
similar. Estimated pulmonary artery systolic pressure is now
slightly lower.
.
[**2187-3-17**] 09:30PM PT-29.6* PTT-32.0 INR(PT)-3.1*
[**2187-3-17**] 09:30PM PLT COUNT-237
[**2187-3-17**] 09:30PM WBC-10.2 RBC-4.90 HGB-12.9 HCT-39.0 MCV-80*#
MCH-26.2* MCHC-33.0 RDW-16.5*
[**2187-3-17**] 09:30PM cTropnT-<0.01
[**2187-3-17**] 09:30PM CK(CPK)-47
[**2187-3-17**] 09:30PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2187-3-17**] 09:30PM UREA N-32* CREAT-1.4* SODIUM-137
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
Brief Hospital Course:
Ms. [**Name14 (STitle) 57139**] is a 81 yo F with A fib who presented with URI
symptoms, CXR evidence of a small LLL pneumonia, rapid a fib and
HTN. She was admitted to the floor and during the day on [**3-18**]
she received intermittent doses of metoprolol 5mg IV for HR in
120s as well as IVF totaling ~1.5L. ~4:20pm, she was suddenly
noted to have an O2 sat of 84% on 3L and subsequently was 91% on
NRB. Her lung exam was noted to be more rhoncorous. She was also
hypertensive to the 180s-190s. CXR showed flash pulmonary edema.
ABG was 7.39/33/51 on NRB. She received 20mg IV lasix with good
UOP (although she was incontinent of urine so exact amount not
recorded). A Foley was placed. She was ordered for Vanc and CTX
IV and nitro paste was applied. Repeat ABG was 7.4/34/81. She
was then transferred to the ICU
.
In the ICU her ABX cvg was narrowed to levoquin and Ms.
[**Known lastname 56855**] remained afebrile w/o leukocytosis. Her CXR
subsuquently looked more like CHF. She diuresed 1.7L since ICU
admission with improvement in hypoxia; also her metoprolol and
diltiazem were increased with improvement in HTN and heart rate.
She also ruled out for MI with negative cardiac enzymes x 3.
At this point she was trasnferred back to the floor where her
care was continued. with diltiazem 45 qid and metoprolol 75 tid
for her HTN and rapid a fib; she was furhter diuresed about 1 L
with improvement in her oxygen requirement although she did have
a waxing and [**Doctor Last Name 688**] oxygen requirement . With regards to her
pneumonia, she remained afebrile without leukocytosis. She
completed a 5day course of antibiotics in-house but was still
bothered by a cough.
Ms [**Known lastname 56855**] has also had some confusion, vivid dreams, and
hallucinations since admission. She was not agitated at all and
was award of her hallucinations. She states that she sometimes
has the same symptoms at home, although according to her
daughter they were worse in-house. Sedating medications were
withheld and her levaquin was changed to cefpodoxime because of
the frequent neurologic side effects of this medication. She
also had significant reversal of day and night cycle and some
delerium although she remained oriented at all times.
Physical therapy worked with the patient and cleared her for
home with PT and walker, but because of the patient's lingering
oxygen requirement the decision was made to send her to rehab.
Medications on Admission:
dilt 120 daily
lisinopril 5 daily
metoprolol 25 [**Hospital1 **]
levoxyl 100
aricept 0.10
paxil 20
neurontin 100
coumadin 2mg (Saturday, Sunday, Tuesday, Thursday; otherwise
3mg)
asa 81
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
6. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough for 2 weeks.
Disp:*60 Capsule(s)* Refills:*0*
9. Rolling Walker
rolling walker
10. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 3 days.
11. Coumadin 3 mg Tablet Sig: One (1) Tablet PO q wed and fri.
12. Coumadin 2 mg Tablet Sig: One (1) Tablet PO q sat, sun,
tues, thurs.
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
pneumonia
flash pulmonary edema
afib
dementia/delerium
Discharge Condition:
AFVSS
Discharge Instructions:
You were admitted to the hospital because of a pneumonia and
while you were here you had some congestive heart failure in the
setting of high blood pressure and rapid heart rate. Those
problems are now better. You will need to finish a 10-day
course of antibiotics (you will have 3 days left). If you have
any fevers, chills, worsening cough, difficulty breathing please
seek medical attention.
If you notice a rapid heart rate, are light headed, or have
difficulty breathing please see your doctor.
We have increased the dose of your toprol, diltiazem, and
lisinopril. Please fill these prescriptions. YOu will
follow-up with [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 715**] (a nurse practitioner in Dr. [**Name (NI) 57410**] office next week to go over these changes).
Please weigh yourself daily; if you gain more than 3 lbs please
tell your doctor.
Followup Instructions:
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2187-4-2**] 10:20
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2187-4-26**]
10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2187-3-27**] 10:30
|
[
"428.0",
"585.9",
"V45.82",
"530.81",
"V58.61",
"799.02",
"244.9",
"272.0",
"486",
"427.31",
"276.2",
"403.90",
"414.01",
"300.00",
"272.4",
"428.30",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7326, 7423
|
3528, 5971
|
321, 328
|
7522, 7530
|
1713, 1990
|
8462, 8899
|
1429, 1477
|
6208, 7303
|
7444, 7501
|
5997, 6185
|
7554, 8439
|
1492, 1694
|
276, 283
|
356, 896
|
1999, 3505
|
918, 1277
|
1293, 1413
|
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